Ventricular Fibrillation Pulseless Ventricular Tachycardia: Difference between revisions

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==Section 4 - CARDIAC 4.08==
==Section 4 - CARDIAC==
=== VENTRICULAR FIBRILLATION /PULSELESS VENTRICULAR TACHYCARDIA===
===4.08 CARDIAC ARREST - VENTRICULAR FIBRILLATION /PULSELESS VENTRICULAR TACHYCARDIA===


* Precordial thump if witnessed and monitored.
* Initiate 5 cycles of CPR (30:2) for approximately 2 minutes to allow blood to circulate and continue throughout resuscitation, minimizing interruptions. Assist ventilations with OXYGEN @ 100% via BVM. DO NOT HYPERVENTILATE!
* DEFIBRILLATION @ 120J-200J Biphasic.
* Initial defibrillation amount may depend on the patient. Size (small/large), medical history (healthy/cardiac history) or the amount of time the patient has been down. Witnessed arrest with bystander CPR may require less joules verses 5 minute down time may require more.
* Proceed to next step only if V-fib / pulseless V-Tach persists. If rhythm converts, follow appropriate Practice Parameters.
* Resume CPR immediately for 5 cycles. Check for pulse and rhythm change. Continue CPR (5 cycles) alternating with the following interventions:
* Ventilate (Intubation or BVM) using an inline EtCO2 device and establish IV or IO as able. 
*'''DO NOT HYPERVENTILATE THE PATIENT.'''
* [[Adrenergics|EPINEPHRINE]] 1:10,000 1 mg IV or IO. Repeat [[Adrenergics|EPINEPHRINE]]every 3 - 5 minutes of continued arrest. OR [[Hormones Vitamins|VASOPRESSIN]] 40 units IV or IO (once) and follow with [[Adrenergics|EPINEPHRINE]]every 3 - 5 minutes.
* DEFIBRILLATION @ 120J-300J Biphasic.
* [[Antiarrhythmics|LIDOCAINE]] 1 to 1.5 mg / kg IVP. May repeat every 5-10 minutes to a maximum of 3 mg/Kg.
* DEFIBRILLATION @ 120J-360J Biphasic.
* [[Electrolytes|MAGNESIUM SULFATE]] 2 gm IVP only if suspected Polymorphic VT (Torsades de pointes). Hypomagnesemic state (chronic alcohol, diuretic use).
* DEFIBRILLATION @ 120J-360J Biphasic.
* [[Electrolytes|SODIUM BICARBONATE]] 1 mEq/kg IVP if suspected, HYPERKALEMIA (e.g. dialysis patient), or Tricyclic antidepressant OD
* DEFIBRILLATION @ 120J-360J Biphasic.


Ventricular Fibrillation (VF) and Pulseless V-Tach (VT) focuses in the correction of the dysrhythmia into a pulse producing rhythm. Consider all possible reversible causes for cardiac arrest utilizing a national recommended mnemonic of “H’s and T’s”:


''If V-Fib converts to a pulse-producing non-heart block supraventricular rhythm, administer a [[Antiarrhythmics|LIDOCAINE]] bolus and drip 1-4 mg/min.''
{| class="wikitable"
|-
! H’s !! T’s
|-
| Hypovolemia|| Tension Pneumothorax
|-
| Hypoxia|| Tamponade, cardiac
|-
| Hydrogen Ion (acidosis)|| Toxins or Tablets (overdose)
|-
| Hypo/hyperkalemia|| Thrombosis, pulmonary
|-
| Hypothermia|| Thrombosis, cardiac
|}
In addition, also consider the following:
{| class="wikitable"
|-
| Hypoglycemia|| Trauma
|}


====When the Patient found in cardiac arrest:====
* Initiate BLS algorhythm with 5 cycles of high quality CPR (push hard/push fast)
** Minimum of 100 compressions per minute, minimize interruptions
** Compression rate of 30:2 for approximately 2 minutes
** Depth of compression of at least 2 inches
** Initiate the use of a mechanical compression device if available
* Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
* Attach cardiac monitor – Evaluate the cardiac rhythm
** VF/VT Present – deliver a DEFIBRILLATION 120-200j biphasic
* Continue high quality CPR/Ventilations for 2 minutes
* Establish intravenous access via IV or IO
* Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
** Do not interrupt compressions to place an advanced airway
** Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
* Administer [[Adrenergics|EPINEPHRINE 1:10,000]] 1 mg IV / IO – repeat every 3-5 minutes of arrest
'''OR'''
* Administer [[Hormones Vitamins|VASOPRESSIN]] 40 units IV / IO – replaces the first or second dose of epinephrine
** Vasopressin is a one-time dose
** Do not stop CPR to administer medications
* Reassess for circulation every two minutes
** VF/VT Present – deliver a DEFIBRILLATION 300-360j biphasic
** Subsequent shocks should be at the higher dose selected
* Administer [[Antiarrhythmics|LIDOCAINE]] 1 to 1.5 mg/kg IVP. May repeat every 5-10 minutes to a maximum of 3 mg/Kg
** If VF/VT converts to a pulse-producing non-heart block supraventricular rhythm, administer a LIDOCAINE DRIP 1-4 mg/min
** In patients over age 70 or in those with known hepatic disease, reduce [[Antiarrhythmics|LIDOCAINE]] boluses at 0.25 mg/kg every 3 minutes to a maximum of 1.5 mg/kg
* Administer [[Electrolytes|MAGNESIUM SULFATE]] 2 gm IVP only if suspected Polymorphic VT (Torsades de pointes) or hypomagnesemic state (chronic alcohol, diuretic use)
* Administer [[Electrolytes|SODIUM BICARBONATE]] 1 mEq/kg IVP if suspected, HYPERKALEMIA (e.g. dialysis patient), or Tricyclic antidepressant OD


''In patients over age 70 or in those with known hepatic disease, administer [[Antiarrhythmics|LIDOCAINE]] boluses at 0.25 mg / kg every 3 minutes until maximum of 1.5 mg / kg administered.
'''If patient combative post resuscitation, refer to [[Analgesia and Sedation|ANALGESIA / SEDATION PARAMETER (2.04)]]'''
''


 
'''''Deliver all Defibrillations at 360 Joules in any patient who has had an Automatic Implanted Cardioverter Defibrillator (AICD) shock. (Use Anterior/Posterior position if possible for Defibrillator Pads - Do not place pads over device).'''''
'''If patient combative post resuscitation, refer to [[Analgesia and Sedation|ANALGESIA / SEDATION PARAMETER]] (2.04)'''
*Consider sedation in patient experiencing cardioversion or defibrillation by their own AICD.
 
* Leave copy of ECG at ER on any patient with implanted device.
 
''Deliver all Defibrillations at 360 Joules in any patient who has had an Automatic Implanted Cardioverter Defibrillator (AICD) shock. (Use Anterior/Posterior position if possible for Defibrillator Pads - Do not place pads over device).  
''
*''Consider sedation in patient experiencing cardioversion or defibrillation by their own AICD.''
 
* ''Leave copy of ECG at ER on any patient with implanted device.''

Revision as of 17:10, 3 May 2012

Section 4 - CARDIAC

4.08 CARDIAC ARREST - VENTRICULAR FIBRILLATION /PULSELESS VENTRICULAR TACHYCARDIA

Ventricular Fibrillation (VF) and Pulseless V-Tach (VT) focuses in the correction of the dysrhythmia into a pulse producing rhythm. Consider all possible reversible causes for cardiac arrest utilizing a national recommended mnemonic of “H’s and T’s”:

H’s T’s
Hypovolemia Tension Pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen Ion (acidosis) Toxins or Tablets (overdose)
Hypo/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia Trauma

When the Patient found in cardiac arrest:

  • Initiate BLS algorhythm with 5 cycles of high quality CPR (push hard/push fast)
    • Minimum of 100 compressions per minute, minimize interruptions
    • Compression rate of 30:2 for approximately 2 minutes
    • Depth of compression of at least 2 inches
    • Initiate the use of a mechanical compression device if available
  • Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
  • Attach cardiac monitor – Evaluate the cardiac rhythm
    • VF/VT Present – deliver a DEFIBRILLATION 120-200j biphasic
  • Continue high quality CPR/Ventilations for 2 minutes
  • Establish intravenous access via IV or IO
  • Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
    • Do not interrupt compressions to place an advanced airway
    • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)
  • Administer EPINEPHRINE 1:10,000 1 mg IV / IO – repeat every 3-5 minutes of arrest

OR

  • Administer VASOPRESSIN 40 units IV / IO – replaces the first or second dose of epinephrine
    • Vasopressin is a one-time dose
    • Do not stop CPR to administer medications
  • Reassess for circulation every two minutes
    • VF/VT Present – deliver a DEFIBRILLATION 300-360j biphasic
    • Subsequent shocks should be at the higher dose selected
  • Administer LIDOCAINE 1 to 1.5 mg/kg IVP. May repeat every 5-10 minutes to a maximum of 3 mg/Kg
    • If VF/VT converts to a pulse-producing non-heart block supraventricular rhythm, administer a LIDOCAINE DRIP 1-4 mg/min
    • In patients over age 70 or in those with known hepatic disease, reduce LIDOCAINE boluses at 0.25 mg/kg every 3 minutes to a maximum of 1.5 mg/kg
  • Administer MAGNESIUM SULFATE 2 gm IVP only if suspected Polymorphic VT (Torsades de pointes) or hypomagnesemic state (chronic alcohol, diuretic use)
  • Administer SODIUM BICARBONATE 1 mEq/kg IVP if suspected, HYPERKALEMIA (e.g. dialysis patient), or Tricyclic antidepressant OD

If patient combative post resuscitation, refer to ANALGESIA / SEDATION PARAMETER (2.04)

Deliver all Defibrillations at 360 Joules in any patient who has had an Automatic Implanted Cardioverter Defibrillator (AICD) shock. (Use Anterior/Posterior position if possible for Defibrillator Pads - Do not place pads over device).

  • Consider sedation in patient experiencing cardioversion or defibrillation by their own AICD.
  • Leave copy of ECG at ER on any patient with implanted device.
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