Algorithm on Shock, hypotension and CHF

Acute Pulmonary Edema, Hypotension, & Shock Algorithm

Clinical Signs: shock, hypoperfusion, CHF, acute pulmonary edema

Most likely problem?



Acute Pulmonary Edema


Volume problemVolume problem Pump problemPump problem Rate problemRate problem

1st – Acute Pulmonary Edema•Furosemide IV 0.5 – 1mg/kg•Morphine IV 2 – 4mg•NTG SL•Oxygen/intubation if needed


Administer•Fluids•Blood transfusion•Cause specific interventionsConsider vasopressors


BradycardiaSee algorithm


TachycardiaSee algorithm


Blood Pressure?Blood Pressure?

Acute Pulmonary Edema, Hypotension, & Shock AlgorithmAcute Pulmonary Edema, Hypotension, & Shock Algorithm








1st – Acute Pulmonary Edema•Furosemide•Iv 0.5 – 1mg/kg•Morphine IV 2 – 4mg•NTG SL•Oxygen/ intubation if needed













1st – Acute Pulmonary Edema




Systolic BPBP defines 2nd line of action


Systolic BP<70mm Hg

Signs & symptoms of

shock

Systolic BP<70mm Hg

Signs & symptoms of

shock

Systolic BP70 – 100mmHgSigns/symptoms of shock


Systolic BP70 – 100mm HgNo signs/symptoms of shock


Systolic BP> 100mm Hg


•Norepinephrine0.5 – 30 ug/min IV

•Dopamine5 – 15

ug/Kg/min IV

•Dobutamine2 – 20 ug/Kg/min IV

•Nitroglycerin10 – 20 ug/min IVConsider•Nitroprusside 0.1 – 5 ug/Kg/min

2nd-Acute Pulmonary edema•NTG/ nitroprusside if BP > 100mm Hg•Dopamine if BP= 70 – 100 mm Hg, Shock•Dobutamine if BP > 100mm Hg, No shock

Further diagnostic & therapeutic considerations•Pulmonary artery catheter•Intra-aortic balloon pump•Angiography for AMI/ ischemia

•28 Y/O, female, G2P1 in active labor•BP 160/100, CR=115/m•Sudden dyspnea after delivery of

placenta•(+) crackles both lung fields•Cold clammy extremity•Pulse oximeter: 60-70%

CASE # 1

• 12 lead EKG = ST, LAE, RAD; Tall R in V1, V2 Persistent S = V5,V6

• Chest X-Ray = Straightened LA border = Kerly B lines

• Blood-streaked, frothy sputum• Bluish nail beds• Heart: (+) opening snap;

irregularly irregular rhythm(+) diastolic rumble at the apex

1st – Acute Pulmonary Edema•Furosemide IV 0.5 – 1mg/kg•Morphine IV 2 – 4mg•NTG SL•Oxygen/ intubation if needed


Acute Pulmonary EdemaAcute Pulmonary Edema


• 60 Y/O, M, Smoker• Unconscious• Intubated/ambubagging• BP = 60 palpatory HR = 112/min

T=38 oC• C/L = (+) crackles BLF• Skin = cold, clammy

CASE #2

•BP = 70/40mmHg, CR = 110/min

•Still with crackles both MLF to Base

•Skin = cold, clammy•Elevated total CK, (+) troponin-T, CKMB 10X normal

•BP = 90/60mmHg, CR = 115/min

•EKG = ST elevation V1-V4•Skin/Lungs = Status Quo

•BP = 160/100mmHg•Still with crackles•Further ST segment elevation V1-V4

•Chest pain

Pump problemPump problem


Systolic BP<70mm Hg

Signs & symptoms of

shock

Systolic BP<70mm Hg

Signs & symptoms of

shock








•Dopamine5 – 15

ug/Kg/min IV


•Nitroglycerin10 – 20 ug/min IVConsider•Nitroprusside 0.1 – 5 ug/Kg/minFurther diagnostic &

therapeutic considerations•Pulmonary artery catheter•Intra-aortic balloon pump•Angiography for AMI/ ischemia

CASE # 3

• 35 Y/O, Male, Alcoholic• BP = 80 palpatory; CR = 120/min• Pale conjunctivae; pale nail beds• (+) Melena• (+) Hematamesis• Faint Pulse

• BP = 80 Palpatory• JVP = Angle of mandible• C/L = clear• Irritable; 5-pillow orthopnea• EKG: ST elevation II, III, AVF

ST elevation V4R, V3R Tall R in V1 2o AVB Mobitz I

Volume problemVolume problem














































Systolic BP<70mm Hg

Signs & symptoms of

shock

Systolic BP<70mm Hg

Signs & symptoms of

shock








•Dopamine5 – 15

ug/Kg/min IV


•Nitroglycerin10 – 20 ug/min IVConsider•Nitroprusside 0.1 – 5 ug/Kg/min


Further diagnostic & therapeutic considerations•Pulmonary artery catheter•Intra-aortic balloon pump•Angiography for AMI/ ischemia

Acute Coronary Syndrome Algorithm

Acute Coronary Syndromes

Primary Goals of Therapy

• Reduce the amount of myocardial necrosis that occurs in patients with MI, preserving LV function and preventing heart failure.

• Prevent major adverse cardiac events (MACE): death, nonfatal MI, and need for urgent revascularization.

• Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT),

symptomatic bradycardias, and unstable tachycardias.

Copyright ©2005 American Heart Association

Acute Coronary Syndromes Algorithm






Pulseless Cardiac Arrest Algorithm

Pulseless Cardiac Arrest

• Four rhythms produce pulseless cardiac arrest: - Ventricular fibrillation (VF)

- Rapid ventricular tachycardia (VT) - Pulseless electrical activity (PEA) - Asystole

• Survival from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS).

ACLS Pulseless Arrest AlgorithmACLS Pulseless Arrest Algorithm

Ventricular Fibrillation/ Pulseless Ventricular Tachycardia

• Deliver 1 shock then resume CPR immediately ( 5 cycles or 2 min)– 200 J (biphasic) for the first shock and an equal or

higher shock dose for the 2nd & subsequent shocks

• Check rhythm• Continue CPR while defibrillator is charging• Deliver shock

Providers should give 1 shock rather than 3 successive shocks which were previously recommended

First shock success rate is high

CPRCPRRHYTHM RHYTHM CHECKCHECK CPRCPR

SHOCKSHOCK


ACLS Pulseless Arrest Algorithm


ACLS Pulseless Arrest Algorithm

• If VF / pulseless VT persists after delivery of 1-2 shocks plus CPR– Give a vasopressor (epinephrine every 3-5 min) or one dose of

vasopressin

• When VF/ pulseless VT persists after 2-3 shocks plus CPR & vasopressor– Consider anti-arrhythmics such as amiodarone or lidocaine



• Minimize interruptions in chest compressions because they reduce coronary perfusion pressure.

• Establishing IV access should not interfere with CPR & delivery of shocks.

• Drugs should be administered ASAP before or after shock delivery.

• Drug doses should be prepared before the rhythm check.

• Rhythm checks should be very brief.

• Pulse checks should generally be performed if an organized rhythm is established. If there is any doubt, resume CPR.


Asystole & Pulseless Electrical Activity (PEA)• Pulseless electrical activity (PEA)

– Encompasses pseudo-electromechanical dissociation, idioventricular rhythm, ventricular escape rhythms, postdefibrillation idioventricular rhythms and bradyasystolic rhythms

– Often caused by reversible causes

• Does not benefit from defibrillation attempts• Perform high-quality CPR with minimal

interruptions• Continuous chest compressions 100/min• Two rescuers should change compression roles

every 2 minutes• Epinephrine can be administered every 3-5 min

Asystole & Pulseless Electrical Activity (PEA)

Medications for Arrest Rhythms

• Vasopressors

– No placebo-controlled trials have shown increased rate of neurologically intact survival to hospital discharge

Medications for Arrest Rhythms – VF/ Pulseless VT

• Epinephrine– Alpha-adrenergic effects can increase coronary &

cerebral perfusion pressure during CPR– Beta-adrenergic effects may increase myocardial work

& reduce subendocardial perfusion– No evidence to show that it improves survival– Dose: 1 mg every 3 -5 min (2-2.5 mg via endotracheal

route

• Vasopressin– Nonadrenergic peripheral vasoconstrictor that causes

coronary & renal vasoconstriction– No statistically significant differences between

vasopressin & epinephrine for return of spontaneous circulation (ROSC), 24-hour survival or survival to hospital discharge

– Dose: 40 U IV/IO

Medications for Arrest Rhythms – VF/ Pulseless VT

• Vasopressors– May consider giving vasopressin for asystole but insufficient

evidence in PEA

– Epinephrine 1mg every 3-5 min

• Atropine– Reverses cholinergic-mediated decreases in heart rate, systemic

vascular resistance & BP

– No prospective studies to support its use in asystole/ PEA

– Dose: 1 mg IV every 3 -5 min ( maximum of 3mg)

Medications for Arrest Rhythms – Asystole & PEA

• Amiodarone– Affects Na, K and Ca channels as well as alpha and

beta adrenergic blocking properties– May be administered for VF or pulseless VT

unresponsive to CPR, shock & vasopressor– Dose: 300 mg IV/IO followed by 150 mg IV/IO

Medications for Arrest Rhythms – Antiarrhythmics

• Lidocaine– Alternative anti-arrhythmic to Amiodarone– No proven short-term or long-term efficacy in cardiac

arrest– Initial dose: 1-1.5 mg/kg IV, then 0.5 – 0.75 mg/kg IV

push every 5 -10 minutes ( maximum dose of 3 mg/kg)


• Magnesium– Effectively terminates torsades de pointes– Not effective in irregular/ polymorphic VT in patients

with normal QT– Dose: 1-2 g in 10 ml D5W IV/IO push over 5-20min– When with pulse, 1-2 g in 50-100 ml D5W


Interventions not Supported by Outcome Evidence

• Pacing in arrest• Procainamide in VF and Pulseless VT• Norepinephrine• Precordial thump for VF/ pulseless VT• Electrolyte therapies in arrest rhythms (Magnesium)• Routine administration of IV fluids during arrest

Thank you for your attention !

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Algorithm on Shock, hypotension and CHF