S Rhythm displays organized electrical activity (not VF/pulseless VT) s Seldom as organized as. Page 10; PEA Algorithm, page 100. Prepare for immediate cardioversion (see algorithm). Dopamine 5 to 20 µg/kg per minute. CASE 4: PULSELESS ELECTRICAL ACTIVITY. ▫ Now included in new Pulseless Arrest Algorithm. ▫ Identify and treat. Dosages for Dopamine 2-10 ug/kg/min. Notes to the ILCOR Universal/International ACLS Algorithm. This is discussed in detail in the section on pulseless electrical activity. These patients need volume expansion, norepinephrine, dopamine, or some combination of the three. Cardiovascular 6: Pulseless Electrical Activity Portal Pulseless electrical activity (PEA) is a condition rather than an arrhythmia. It is defined by the presence of a rhythm but the absence of a detectable pulse. The advent of bedside cardiac ultrasound has identified patients in whom cardiac activity is clearly present, but no peripheral pulse is palpable. This has cast doubt on the notion that PEA necessarily represents an uncoupling of electrical and mechanical activity. Rather, PEA can be thought of as a form of deep shock, and indeed, the list of conditions that cause PEA overlaps considerably with that of causes of shock. People in PEA can be resuscitated if a reversible cause of PEA is identified and treated appropriately. Therefore, the primary emphasis of the PEA algorithm is to find and treat the cause of the PEA. Reversible Causes 1: 5 Hs and 5 Ts Hs Ts Hypoxia Tablets/Toxins Hypovolemia Tamponade Hydrogen ion (acidosis) Tension pneumothorax Hypo/Hyperthermia Thrombosis, Coronary (ACS) Hypo/Hyperkalemia Thrombosis, Pulmonary (embolism) Causes and Treatment Hypovolemia: This is the most common cause of PEA. Hypovolemia may be due to hemorrhage or fluid loss. ![]() Treatment consists of adequate volume infusion. Hypoxia from any cause: Treatment consists of adequate ventilation. Cardiac tamponade such that occurs in trauma, renal failure, or thoracic malignancy. Treatment consists of pericardiocentesis. Tension pneumothorax may be spontaneous, follow trauma, or occur in a patient with severe asthma or on a ventilator. Appropriate treatment consists of needle decompression followed by chest tube insertion. Hypothermia: Treatment involves re-warming and prolonged resuscitation. Patients are not considered dead until they are warm and dead. Massive pulmonary embolus (Thrombosis, pulmonary): Treatment requires heroic use of fibrinolytics and possible surgical embolectomy. Captain sim c 130 crack. Drug overdoses (Tablets) such as those involving tricyclics, digitalis, beta blockers, and calcium channel blockers. Treatment includes deactivating drugs, using antidotes, removing excess drug(s) from the body as able. Hyperkalemia: This occurs in patients on dialysis, with severe diabetes, or in renal failure. Treatments include sodium bicarbonate, regular insulin, dextrose, calcium chloride, Kayexalate, and furosemide. If these measures fail or if the patient experiences complications, use dialysis. Pre-existing acidosis (Hydrogen ion): Treatment includes maximizing oxygen and ventilation, correcting the underlying problem, and, if the pH is low, administering sodium bicarbonate. If the patient is intubated, use hyperventilation. Massive acute MI (Thrombosis, coronary (ACS): Treatment requires aggressive management of cardiogenic shock with BP support utilizing balloon pump and possible early intervention with angioplasty or cardiac surgery. Prediction of Cause and Prognosis Based on QRS Width in PEA: Narrow complex PEA has a better prognosis than wide complex PEA. Wide complex PEA, especially with a slow ventricular rate, has a particularly poor prognosis. These rhythms are frequently associated with malfunction of the myocardium or the cardiac conduction system. This rhythm tends to be the last electrical activity of a dying myocardium. Windows XP Service Pack 3 ISO includes all previously released updates for the operating system. Install windows xp usb syslinux package from santa. Windows XP UI soon became the most user friendly OS that any ordinary person can use it easily. Severe hyperkalemia, hypothermia, hypoxia, preexisting acidosis, massive acute MI, and a large variety of drug overdoses may be associated with wide complex PEA. Overdoses of tricyclic antidepressants, beta blockers, calcium channel blockers, digitalis, and many other agents ordinarily produce a slow, wide-complex PEA. Narrow complex PEA indicates a normal myocardium being severely stressed by a serious process. Conditions such as severe hypovolemia, large pulmonary embolus, cardiac tamponade, severe infection, or tension pneumothorax are frequent causes for narrow complex PEA. In each of these cases, treatment of the underlying cause is essential to the success of treating the PEA. General Approach to PEA 1: Initial Patient Treatment (Focus on CPR and defibrillation if indicated.) • Effective CPR • Assess for VF/pulseless VT, shock if indicated. • Monitor for rhythm and O2 saturation. • Assess for any reason not to continue resuscitation (ie, DNR order, signs of death) Focus on advanced treatment modalities1: • Secure adequate airway. • Confirm airway device placement (EID, clinical assessment). Pulseless Electrical Activity OverviewNote: The use of an end-tidal CO2 detector may not be accurate in cardiac arrest. • Establish IV access. • Consider bedside echocardiography to detect cardiac contractility. Patients with detectable contractility have a greater probability of survival and require a more aggressive approach. These patients need volume expansion, norepinephrine, dopamine, or some combination of the three. • Patients with bradycardia may benefit from early transcutaneous pacing. • Consider an IV fluid bolus challenge. • Perform a careful search for any treatable cause and if found, aggressively treat as appropriate. • Give drugs appropriate for rhythm and condition. Drug Use for PEA Resuscitation 2: Epinephrine: The recommended dose is 1 mg IV/IO push every 3 to 5 minutes. (Class indeterminate) If this approach fails, a higher dose of epinephrine (up to 0.2 mg/kg) may be used but is not recommended. 1 PEDS: 0.01 mg/kg IV/IO or 0.1 mg/kg ET. (If used ET use 1: 1000 preparation.) Vasopressin: One dose of vasopressin (40 units IV) is acceptable (Class IIb) in place of first or second dose of epinephrine. ( PEDS: not recommended in pediatric patients.) Atropine: The use of atropine in PEA may be helpful if the electrical activity is slow (either an absolute bradycardia. These patients may have both pump (cardiogenic) and volume problems. Fluid bolus NS of up to 500 cc. If the patient does not respond, consider the need for further fluid boluses or for sympathomimetics. Pulseless Electrical ActivityNorepinephrine with inotropic and vasoconstrictive properties is useful for BP 70 mm Hg. A combination of norepinephrine and dopamine may be needed. Administering pressor agents by central line is preferred but is not always possible to accomplish. Angioplasty and intra-aortic counterpulsation in patients with acute MI and cardiogenic shock may be lifesaving. References • ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
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