Page 669 - Cardiac Nursing

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C HAPTER 2 7 / Sudden Cardiac Death and Cardiac Arrest 645
DISPLAY 27-4 The Algorithm Approach to Emergency Cardiac Care
The American Heart Association Guidelines use algorithms as an educational tool. They are an illustrative method to
summarize information. Providers of emergency care should view algorithms as a summary and a memory aid. They pro-
vide ways to treat a broad range of patients. Algorithms by nature oversimplify. The effective teacher and care provider
uses them wisely, not blindly. Some patients may require care not specified in the algorithms. When clinically appropriate,
flexibility is accepted and encouraged. Many interventions and actions are listed as “considerations” to help providers
think. These lists should not be considered endorsements or requirements or “standard of care” in a legal sense.
Algorithms do not replace clinical understanding. Although the algorithms provide a good “cookbook,” the patient always
requires a “thinking cook.”
The following clinical recommendations apply to all treatment algorithms:
• First, treat the patient, not the monitor.
• Algorithms for cardiac arrest presume that the condition under discussion continually persists, that the patient remains
in cardiac arrest, and that CPR is always performed. The foundation of ACLS is good BLS.
• Apply different interventions whenever appropriate indications exist.
• Priorities during cardiac arrest are CPR with proper ventilation and chest compressions, and defibrillation. Administration
of medications and insertion of an advanced airway are considered secondary importance.
• Providers may establish interosseous (IO) cannulation for IV fluids, drug administration and blood sampling if IV access is
available (class IIa). If IV and IO access cannot be established some drugs can be given via the endotracheal route
(lidocaine, epinephrine, atropine, naloxone, and vasopressin). Drugs given into the trachea have decreased absorption,
and should be given in doses 2 to 2.5 times the recommended IV dose.
• With a few exceptions, intravenous medications should always be administered rapidly, by a bolus method.
• After each intravenous medication, give a 20- to 30-mL bolus of intravenous fluid and immediately elevate the extremity.
This will enhance delivery of drugs to the central circulation, which may take 1 to 2 minutes.
• Last, treat the patient, not the monitor.
From American Heart Association. (2005). American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Supplement to Circulation,
112 (Suppl. IV), IV-19–IV-34.
and potential cause for the arrest. If VF or pulseless VT is present, should be initiated immediately after the shock. 32,33 Although
the left side of the algorithm should be followed. If electrical studies comparing one shock to three shocks have not been con-
activity is present without a pulse, or asystole is present then the ducted, evidence shows that interruption of chest compression
right side of the algorithm should be followed. decreases coronary perfusion. With previous algorithms that
Cardiac arrest should be managed by an ACLS team composed called for three-stacked shocks, there was noted to be a delay of
of a team leader and one or more team members. Priorities for nearly 40 seconds to the time CPR was resumed. 4,46,47 Delays in
resuscitation are: resuming CPR longer than 15 to 20 seconds have been shown to
be a predictor of low survival, decreased myocardial function, and
■ Effective CPR: minimizing interruptions of chest compressions
poor neurological outcome. 48,49
and pushing hard and fast. Always ventilate not hyperventilate.
■ Assess—then perform appropriate action. The VF and pulseless VT algorithm directs rescuers to give ei-
ther epinephrine or a one-time dose of vasopressin after the sec-
■ Rapid, early defibrillation for VF or pulseless VT.
ond shock and five cycles of CPR if the patient remains in VF/VT.
■ Vasopressin single dose or epinephrine given every 3 to 5 min-
Vasopressors remain an extremely important drug for patients in
utes to maintain coronary and cerebral perfusion.
■ Differential diagnosis: search for and treat any reversible causes. cardiac arrest. The beneficial effects of both vasopressin (non-
adrenergic vasopressor) and epinephrine (adrenergic vasopressor)
during cardiac arrest come from vasoconstriction, which increases
VF and Pulseless VT aortic diastolic pressure, coronary perfusion pressure, and coro-
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In an unwitnessed arrest, the most critical intervention in the first nary blood flow. 32,33 Studies have not shown improved outcome
few minutes of VF or pulseless VT is immediate CPR for at least using high-dose or escalating doses of epinephrine. The epineph-
2 minutes, followed by rapid defibrillation. Providers should give rine dose remains 1 mg intravenous/intraosseus every 3 to 5 min-
one shock, rather than the three-stacked shocks that were recom- utes. 4,32,33
mended from previous versions of ACLS. Immediate CPR in- An antiarrhythmic drug can be considered after the second cycle
creases survival, and provides blood flow to the brain and heart, of CPR, ventilations, and defibrillations. There is no evidence that
which keeps the heart in VF (as opposed to asystole) for a longer giving antiarrhythmic drugs during cardiac arrest increases survival
period. Defibrillation allows the normal pacemakers of the heart to hospital discharge, and the optimal number of cycles before drug
to restart after interrupting fibrillatory electrical activity. 4,45 After administration has not been determined. 32,33 Amiodarone has been
the single shock, CPR should be resumed immediately, beginning shown to increase survival to hospital admission when compared
with compressions. with lidocaine or a placebo (Display 27-5) and is a first-line antiar-
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In a witnessed arrest, CPR should be started immediately, and rhythmic drug for shock-refractory VT or VF (class IIb). 32,50,51
a shock should be delivered as soon as VF/VT has been confirmed Lidocaine is an alternative antiarrhythmic, but has no proven short-
and a defibrillator is available. It is not necessary to perform the or long-term efficacy in cardiac arrest. Lidocaine is given an indeter-
2 minutes of CPR prior to the shock for a witnessed arrest. CPR minate classification of recommendation. 32 Magnesium has been