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25.01.2016 admin
You must have JavaScript enabled in your browser to utilize the functionality of this website. The Guidelines continue to recommend running through the H’s and T’s in order to arrive at a specific diagnosis and guide treatment in PEA arrest.
This new way of thinking about PEA combines initial ECG morphology with the clinical scenario to guide the clinician to the most likely causes, and offer further diagnostic certainty using point of care ultrasound (POCUS).
Our experts caution that this approach should be used only when a highly skilled ultrasonographer is present and in a way that does not interrupt high quality chest compressions. While we know that intra-arrest antiarrhythmic medications may improve rates of ROSC in ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) arrests, there has never been a trial to show improvements in long term survival with any antiarryhthmic medication. When it comes to giving antiarrhythmic medication post-ROSC, there is only one RCT of lidocaine post arrest which showed a decrease in the incidence of recurrent VF. The Guidelines state that “there is inadequate evidence to support the routine use of lidocaine after cardiac arrest. We will need to wait for the results of the ROC-ALPS trial to give us a more clear idea of whether or not we should be using antiarrhythmics intra-arrest or post-arrest.
In the ED the decision to terminate resuscitation is multi-factorial and there is no absolute time cut off.
For patients who receive multiple doses of epinephrine during cardiac arrest resuscitation, if ROSC is achieved, then the patient’s BP tends to be high in the first few minutes. As an adjunct or replacement of manual pulse checks: rather than depending on manual pulse checks (which have been shown to be inaccurate) to determine ROSC, an arterial line placed early after cardiac arrest can instantly determine whether ROSC is present or not and hence minimize the chest compression pause time. The literature clearly shows that patients with an initial rhythm of Vfib or showing ongoing signs of STEMI on ECG should be considered for emergency PCI. For all other patients (those without VFib or STEMI), it is unclear which patients should be transferred for PCI. One of our experts suggests that any patient in whom a cardiac cause is suspected and no other cause is apparent should be considered for emergency PCI. Again, similar to the decision to terminate resuscitation, multiple factors should be taken into consideration in deciding whether or not to activate the cath lab. An elevated Troponin: A ROC paper that is currently under peer review as of November 2015 shows a clear association between a higher serum troponin level and a PCI amenable lesion as well as improved outcomes.

The Guidelines stipulate that Targeted Temperature Management (TTM) should be initiated for ALL post arrest patients who achieve a ROSC, and it’s up to your intensivist what the target temperature should be between 32 and 36 degrees. It is important to understand that the control arm in the TTM trial still actively cooled patients, just not to the same degree as the 32 degree arm. A pre-hospital RCT in 2013 compared immediate 2L boluses of cooled saline vs in-hospital cooling and showed an increased rate of re-arrest and acute heart failure in the pre-hospital group that received immediate large boluses of cooled NS. About Us Emergency Medicine Cases (EM Cases) is a free online medical education podcast & medical blog dedicated to providing online emergency medicine education & CME for physicians, residents, students, nurses & paramedics.
Good post-arrest care involves maintaining blood pressure and cerebral perfusion, adequate sedation, cooling and preventing hyperthermia, considering antiarrhythmic medications, optimization of tissue oxygen delivery while avoiding hyperoxia, getting patients to PCI who need it, and looking for and treating the underlying cause. The first key step is to distinguish between narrow complex and wide complex PEA, with POCUS being used to help differentiate the causes of narrow complex PEA in particular.
Ideally, a designated team member provides the specific POCUS role independent of the other team members.
Having an arterial line in place will detect this loss of circulation sooner than standard BP monitors or manual pulse checks. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. Effect of prehospital induction of mild hypothermia on 3-month neurological status and 1-year survival among adults with cardiac arrest: long-term follow-up of a randomized, clinical trial. We are Canada's most listened to emergency medicine podcast with thousands of listeners and well over one million podcast downloads since 2010.
Hence, our experts recommend that if lidocaine is given intra-arrest and ROSC is achieved, then it is reasonable to continue a lidocaine infusion post-ROSC.
It is therefore recommended by many critical care experts to start vasopressors early in the post-arrest phase and target a MAP of 65 in order to maintain adequate cerebral perfusion pressure.

Morrison recommends to wait a few minutes after ROSC to let the heart settle and then start cooled IV saline in small boluses. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine, the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute and is on the advisory board of The Teaching Institute. Our Advisory Board includes prominent leaders in the faculty of the University of Toronto Divisions of Emergency Medicine.
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After listening to part 1, my friend Scott Weingart of EMCrit asked me if he could chime in to give us his take on the controversies discussed in this series; and of course, I obliged.
If a central line has not been placed yet soon after ROSC, it is safe to start vasopressors in a peripheral IV until central access has been obtained.
Helman in a round-table, case-based discussion on key practice changing clinical emergency medicine topics, which are then carefully edited to maximize your learning. Our Guest Experts, Canada's brightest minds in emergency medicine, are carefully chosen for each episode topic.
So in this episode we discuss the controversies in post-arrest care with some of the most important researchers in ACLS and co-authors of The Guidelines as well as one of the most influential critical care educators in the world.
Morrison offer us their opinion on the new simplified approach to diagnosing the underlying cause of PEA arrests. I was so impressed with the quality that I purchased a second one to keep around for other purposes.

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