ACLS and Cardiac Management Guidelines

CPR Guidelines

  • Depth and Rate of Compressions: Compress at 2-2.4 inches deep, at a rate of 100-120 beats per minute (BPM).
  • Minimize Interruptions: Allow full recoil of the chest during compressions.
  • Ventilation:
    • Without Endotracheal Tube (ETT): use 30:2 compressions to mask vent.
    • With ETT: delta compressors every 2 minutes, administer breaths every 6-8 seconds.
Code Blue Procedure
  • Initiate Code Blue:
    • Dial 6-3333 or press the blue button on the wall.
    • Call for defibrillator, backboard, and ambu bag.
  • Monitoring: Telemetry, defibrillator pads, continuous oxygen, and blood pressure cuff.
  • Rhythm Check: Perform immediately after pads are applied, for both witnessed and unwitnessed arrests.
Maternal Code Blue Algorithm

  • Evidence Review: Utilize AHA 2020 ACLS and ILCOR 2020 guidelines for evidence evaluation.

  • Patient Check: Assess circulation (pulse), airway, and breathing (C-A-B).

  • Cardiac Arrest Management:

    • If no pulse detected within 10 seconds, differentiate between PEA/Asystole vs. VT/VF.
    • For VT/VF: Defibrillation - Biphasic 120-200J.
Pharmacological Interventions
  • Epinephrine: 1mg every 3-5 minutes.
  • Antiarrhythmics: Consider administering Amiodarone, Lidocaine, or Magnesium Sulfate.
  • Return of Spontaneous Circulation (ROSC): Defined by:
    1. Pulse and blood pressure recovery.
    2. Sustained ETCO2 greater than 40.
    3. Spontaneous waves on arterial line.
Post-Arrest Care / Targeted Temperature Management (TTM)
  • Start CPR if no pulse is detected.
  • Thrombolytics for suspected Pulmonary Embolism during a code:
    • Alteplase (tPA):
    • For Pulseless: 50mg IV/IO over 2 min, repeat if necessary.
    • For Pulse Present: 100mg infusion over 2 hours.
  • Contraindications for thrombolysis:
    • Prior intracranial hemorrhage, significant head trauma, or active bleeding.
ECMO for Cardiac Arrest
  • ECMO Activation: Contact ECMO team within 10 minutes of code initiation.
  • MGH Code Roles:
    • Code Leader: Senior staff on duty.
    • Code Whisperer: Consult SAR/PMS.
Reversible Causes of Cardiac Arrest (H&Ts)
  • Hypovolemia, Hypoxia, Acidosis, Electrolyte Imbalances, Hypothermia, Thrombosis, Tension Pneumothorax, Cardiac Tamponade, Toxins.
Maternal Code Considerations (ABCDEFGH)
  • Logistics: Prioritize IV access (or IO), order STAT labs including ABG, CBC, BMP, LFTs, lactate, coags, etc.
  • Monitoring: Utilize wave capnography during CPR, targeting ETCO2 of >20 mmHg.
  • Prognostication: If ETCO2 <10 mmHg after 20 minutes of CPR, consider poor outcomes.
  • Pregnancy Considerations: Use left lateral uterine displacement, initiate IVs above the diaphragm, and prepare for perimortem delivery if applicable.
Quick Guide: Dosing
  • Defibrillation: Use biphasic settings. Repeat shocks at same or increased dose if necessary.
  • Epinephrine: Administer 1mg q3-5m.
  • Amiodarone: First dose 300mg; second 150mg.
  • Magnesium Sulfate: If torsades, give 1-2g over 15 minutes.
  • Hyperkalemia: Administer Calcium Gluconate or Calcium Chloride, Bicarb, Dextrose with Insulin as necessary.
  • Naloxone: 2mg IV for pulseless cases; lower doses (0.2-1 mg IV) for apneic patients with a pulse.

Targeted Temperature Management After Cardiac Arrest

  • Rationale: Avoid hyperthermia post-resuscitation; it worsens neurological outcomes and damages neurons.
    • Goal: Maintain temperatures at 33°C vs. normothermia at 36°C.
    • Hypothermia: Recommended to improve neurologic outcomes.
    • Normothermia: No significant differences noted in mortality or neurological outcomes post-arrest.
  • Duration of TTM:
    • 33°C for 24 hours, with rewarming strategy to 36°C for an additional 48 hours.