Background: Epinephrine remains a staple in cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA). However, the optimal dose, timing, and route of administration are still unknown. Standard dosing of epinephrine is 1mg every 3 to 5 minutes via the intravenous (IV) or intraosseous (IO) route. IO lines are quicker to establish and have a higher first-attempt success rate compared to IV access. Rapid placement and ease of use minimizes delays for critical patients requiring quick access. The literature, although methodologically limited, is mixed about the use of IV vs IO access for epinephrine in OHCA....Read More
Hey there REBEL Cast listeners, Salim Rezaie here. For me and I am sure many COVID-19 has been quite the whirlwind. So much information, so little time to process all of it. Meanwhile, many of us are on the frontlines having to take care of these patients. Personally, I have never been so wrong, so many times about a single disease process. What I say today, may be different tomorrow. This podcast was recorded on April 3rd, 2020 so any information that comes out after this, might change the viewpoints that are expressed today.
The protected code blue is designed to keep your staff safe when managing a patient with COVID-19 who has a sudden cardiac arrest. You will continue to do high quality CPR, defibrillation (if indicated), give code medications, and BVM with airway management, now with a drape. I’m going to outline a suggested plan for how to conduct a protected code blue at your hospital. You will need to modify it to fit your hospitals requirements....Read More
The American Heart Association (AHA) released a focused update in 2019, for advanced cardiovascular life support (ACLS) guidelines, to addend those published in 2017 and 2018 for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care. These recommendations were based on evidence identified by the 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR). This ACLS Update addresses three main concerns:
Background Information: Refractory ventricular fibrillation (RVF) is a complication of cardiac arrest defined as ventricular fibrillation (VF) that does not respond to three or more standard defibrillation attempts.1,2 Patients with RVF during their cardiac arrest have a mortality of up to 97%.3,4 Double external defibrillation (DED) involves the use of a second defibrillator providing an additional shock in a sequential or simultaneous manner. The left ventricle (LV), being the most posterior part of the heart and the furthest away from the anterolateral electrode pads, have led some to hypothesize that utilizing an anterior-posterior pad placement (ie. Changing the vector) is what accounts for DED’s success. Some theorize that the increase in amount of energy from two defibrillations as opposed to one is what’s needed to reach the LV. There are also theories suggesting that the sequential administration of the shocks, more effectively lowers the defibrillation threshold of the cardiac myocytes and thus leads to a more successful conversion of VF. In spite of these many theories, the intervention of DED has been studied for decades in the electrophysiology lab and widely discussed in the literature through case reports and meta-reviews. These case reports have shown success and a recent meta-review of 39 patients who received DED showed that 25% of them were discharged neurologically intact with Cerebral Performance Category (CPC) scores of 2 or less indicating normal recovery/mild disability or moderate disability but able to independently perform activities of daily living.5-10 While this literature is promising, DED is a highly variable intervention and there are still many unknown factors which continue to cause debate and controversy. The role of vector direction via pad placement, the role of a pulse interval in energy deliverance and the efficacy in method of delivering DED sequentially vs simultaneously continues to remain unclear. 6-11 The authors of this pilot RCT (DOSE VF) wished to answer some of these questions by first determining the feasibility and safety of performing a full RCT. In doing so, they used alternate defibrillation strategies such as vector changes and double external sequential defibrillation (DSED) in treating RVF.12...Read More