Transcript Shock to the Heart: A Pharmacist`s Role in the Code Team

Shock to the Heart:
A Pharmacist’s Role
in the Code team
Tyler Osgood PharmD
Pharmacist
St. Luke’s Boise Regional Medical Center
03/06/16
Disclosures

The presenter for this continuing education activity has
reported no relevant financial contributions
Objectives
• Describe the role of each member of the code team while focusing
on the pharmacist’s role
• Discuss ways to be prepared for various code situations
• Distinguish basic cardiac rhythms and the ACLS algorithms
associated with the ACLS algorithm associated with them
• Describe the differences between the 2010 and 2015 AHA ACLS
guidelines
Code Team Roles
1) Respiratory Therapy
2) Respiratory Therapy
3) Medication Nurse
4) Pharmacist
5) Team Leader
6) Compressions
7) Backup Compressions
8) Recorder
9) Administrative Support
10)Ancillary Support
http://www.medscape.org/viewarticle/481221
11)Primary Care Nurse
Pharmacists Role
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Assist with distribution of
medications and supplies
available on the crash cart
Obtain additional medications
from pharmacy as needed
Prepare and label medications
for administration as needed
Provide drug information as it
relates to drug compatibilities,
administration, allergies, etc
Pertinent Algorithms
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
H's
&
T's
Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
Cardiac Arrest
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
First Decision Point
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
Rhythm Test
1
2
3
4
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
Intravenous
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Peripheral IV is preferred
unless central line is
already available
Directions:
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Give by bolus injection
unless otherwise
specified
Flush with 20mL bolus
of IV fluid
Elevate extremity for 10
– 20 seconds
Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
Intraosseous
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Can be established in all
age groups
Usually takes 30 – 60
seconds
Preferred over
endotracheal route
Any ACLS drug or fluid
given IV may be given IO
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Endotracheal
• Narcan
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• Atropine
• Vasopressin
• Epinephrine
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• Lidocaine
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Optimal dose of most
drugs unknown
Typically 2 – 2.5 times
the IV route
Dilute dose in 5 – 10 ml
of sterile water or NS
Inject directly into ET
tube
Should we be flushing?
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
Epinephrine
• Dose: 1 mg IV/IO q 3 – 5 minutes during
cardiac arrest
• 2 – 2.5 mg endotracheal dose
• Pearls:
• Prepare dose prior to it being called
• Remember flush with 20 ml IV fluid and
elevate limb for 10 – 20 seconds
• Available in 1:10,000 and 1:1,000
concentrations
• Used in both VF, pVT, Asystole, and PEA
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Amiodarone
• Consider for treatment of VF or
pVT unresponsive to
defibrillation, CPR, and
vasopressor therapy
• Dosing:
• 1st Dose: 300 mg IV/IO push
• 2nd Dose: 150 mg IV/IO push
• Pearls:
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Amiodarone kit
No utility in asystole, or PEA
May be given as bolus
May be given independent of
timing of last dose of
epinephrine
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Vasopressin?
• No longer included in 2015 guidelines
• Old Dose: 40 units IV/IO push to replace
either 1st or 2nd dose of epinephrine
• Pearls:
• Medication should only be given once
during cardiac arrest per old algorithms
• Medication was removed from the
guidelines for simplicity while not showing
any superiority to epinephrine
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
Special Circumstances
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Asthma
Anaphylaxis
Pregnancy
Morbidly obese
Pulmonary embolism
Electrolyte disturbances
Drowning
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Trauma
Toxicity
Hypothermia
Avalanche victims
During PCI
After cardiac surgery
Cardiac tamponade
Eric J. Lavonas et al
Pregnancy
• Key Points:
• Epinephrine is preferable to
vasopressin in light of MOA
• Routine sodium bicarb is still a
• H’s and T’s (BEAU-CHOPS)
bad idea (even worse here)
• Bleeding
• If the fundus is above the
• Embolic causes
umbilicus left uterine
• Anesthetic complications
displacement may relieve
• Uterine atony
aortocaval compression
• Cardiac disease
• Hand placement for
compressions in same position
• Hypertension
• Other: think standard H’s and T’s • Energy requirements for
defibrillation and drug doses are
• Placenta abruptio/previa
the same as a normal adult
• Sepsis
• Cesarean delivery indicated if
ROSC not achieved within 4
minutes
Carolyn M Zelop et al. Cardiopulmonary Arrest in Pregnancy.
Methamphetamine Overdose
• Keys to Success:
• Fluid resuscitation with
large volumes of NS
• Correction of metabolic
acidosis with sodium
bicarbonate
• Do we have any
concerns with
epinephrine use under
this circumstance?
https://adapaproject.org/bbk_temp/tikiindex.php?page=Leaf%3A+How+
do+nerves+communicate+with+each+other%3F
Edward W. Boyer et al. Methamphetamine intoxication
Pulmonary Embolism
• Patient is admitted to the ICU with the diagnosis of
pulmonary embolism.
• Patient is hypotensive on norepinephrine and
severely hypoxic
• Echocardiogram shows right ventricular strain
• The plan is to administer thrombolytics, however
during intubation the patient loses a pulse.
• What are your thoughts on thrombolytic therapy?
Absolute contraindications
Prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within three months (excluding stroke within three hours*)
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Relative contraindications
History of chronic, severe, poorly controlled hypertension
Severe uncontrolled hypertension on presentation (SBP >180 mmHg or DBP >110 mmHg)
History of ischemic stroke more than three months prior
Traumatic or prolonged (>10 minute) CPR or major surgery less than three weeks
Recent (within two to four weeks) internal bleeding
Noncompressible vascular punctures
Recent invasive procedure
For streptokinase/anistreplase - Prior exposure (more than five days ago) or prior allergic reaction to these agents
Pregnancy
Active peptic ulcer
Pericarditis or pericardial fluid
Current use of anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) >1.7 or
prothrombin time (PT) >15 seconds
Age >75 years
Diabetic retinopathy
Victor F Tapson, MD. Fibrinolytic therapy in acute pulmonary embolism and lower extremity deep vein thrombosis
Most Common Regimens
Alteplase Dose
Reference
100 mg over 2 hours
FDA labeling
0.6mg/kg ideal body weight over 2
minutes
Levine M., et al Chest. 1990 Dec; 98 (6)
1473 – 9
0.6mg/kg (max 50 mg) over 15 minutes
1.) Goldhaber SZ et al. Chest 1994 Sep;
106 (3) 718-24, 2.) Sors H, et al. Chest.
1994 sep; 106 (3) 712-7
50 mg bolus x 2 (30 min apart)
Ruiz-Bailen M, et al. Resuscitation 2001
Oct;51(1): 97-101
15 mg bolus followed by 85 mg infusion
over 90 minutes
Kurkciyan I, et al. Arch Intern Med. 2000
May 22; 160 (10): 1529-35
100 mg over 15 minutes
Cavallaro F, et al. Acta anaesthesiol
Scand. 2009 Mar; 53(3):400-2
Adapted from Top of Your License’ Code Response Alexander H. Flannery Pharm.D. BCPS
Key Updates to Guidelines
• Vasopressin was removed from the Cardiac Arrest algorithm
for simplicity in light of no superiority to epinephrine
• Compression rate updated to 100 – 120/min during BLS/ACLS
• For those with unshockable rhythm, it may be reasonable to
administer epinephrine as soon as feasible
• Utilization of steroids in cardiac arrest is controversial however
intra-arrest vasopressin, epinephrine, and methylprednisolone
and post arrest hydrocortisone may be considered
• Cardiac arrest in pregnancy: if the fundus is at or above the
level of the umbilicus left uterine displacement may relieve
aortocaval compression
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American
Heart Association Guidelines Update Cardiopulmonary Resuscitation
New Wild Things in the
Literature
Vasopressin, Steroids, Epinephrine
Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically
favorablesurvival after in-hospital cardiac arrest: a randomized clinical trial.
Vasopressin, Steroids, Epinephrine
VSE
Control OR (95% CI)
P value
All patients
ROSC of > 20 min
83.9%
65.9%
2.98
(1.39 – 6.40)
0.005
Survival to discharge with
CPC 1 or 2
13.9%
5.1%
3.28
(1.17 – 9.20)
0.020
3.74
(1.20 – 11.62)
0.020
Patients with post-resuscitation shock
Survival to discharge with
CPC 1 or 2
21.1%
8.2%
Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically
favorable survival after in-hospital cardiac arrest: a randomized clinical trial.
PARAMEDIC2 Trial
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RCT in UK (Universities of Warwick and Surrey)
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Epinephrine vs. Placebo
Planned enrollment: 8,000
Primary outcome: 30 day survival
What really is the role of drugs?
http://www2.warwick.ac.uk/fac/med/resear
ch/hscience/ctu/trials/critical/paramedic2/
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Atropine
• Indications:
• First drug for symptomatic sinus
bradycardia
• May be beneficial in presence of
some AV nodal block
• Likely will not help with PEA or
asystole
• Will not work for Mobitz Type II
second degree heart block
• Dosing:
• 0.5 mg IV q 3 – 5 min as needed
• Max total dose: 3 mg or 0.04 mg/kg
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Transcutaneous Pacing
• Indications:
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Hemodynamically unstable bradycardia
Symptomatic sinus bradycardia
Mobitz type II second degree AV block
Third degree heart block
New left, right, or alternating BB or
bifascicular block
• Pearls:
• Contraindicated in severe hypothermia and
asystole
• Do not assess carotid pulse to confirm
mechanical capture
• Analgesia and sedation for patient comfort
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Dopamine
• Indications:
• Second-line drug for symptomatic bradycardia
• Hypotension with signs of shock
• Precautions
• Correct hypovolemia before initiating
• Use with caution in cardiogenic shock with CHF
• May cause tachyarrythmias/excessive
vasoconstriction
• Do not mix with sodium bicarbonate
• Dosing: 2- 10 mcg/kg/min titrated to response
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Epinephrine
• Indications:
– Second-line drug for symptomatic bradycardia
– Hypotension with signs of shock
• Precautions
– Increased myocardial O2 demand
– High doses may be necessary in some
poisonings
• Dosing: 2- 10 mcg/min titrated to response
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Rhythm Test
1
2
3
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Rhythm Test
1
2
3
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Unstable Tachyarrythmias
• 2 keys to management
• Rapid recognition that the patient is symptomatic or unstable
• Rapid recognition that the symptoms are caused by tachycardia
• Drugs: Not typically indicated. Immediate cardioversion
recommended.
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Narrow QRS Tachyarrythmia
Pearls
• Vagal maneuvers
• Will terminate 25% of SVTs
• Adenosine
• May cause bronchospasm
• Will terminate ~90% of reentry arrhythmias
• Will not terminate Afib or Aflutter
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Adenosine
• Initial Bolus: 6 mg given rapidly over 1 – 3 seconds
followed by NS bolus of 20 ml then elevate the extremity
• Optional 3 mg starting dose:
• Patients on dipyridamole or carbamazepine
• Heart transplant patients
• Patients receiving through a central line
• Second bolus: 12 mg can be given after 1 – 2 minutes if
needed
• Injection technique:
• Watch rhythm strip during administration
• Draw dose and flush in 2 separate syringes
• Push as fast as possible followed by flush
Precautions: In irregular, polymorphic wide-complex tachyarrhythmias, adenosine is
contraindicated and may cause deterioration.
Transient periods of sinus bradycardia or ventricular ectopy are common
Field JM, Hazinski MF et al. 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
Wide QRS Tachyarrhythmia Pearls
• A wide-complex tachycardia may represent either VT or a
supraventricular rhythm with abnormal conduction
• Remember think hemodynamic stability
• Determine if rhythm is regular or irregular
• Avoid AV nodal blocking agents in patients with preexitation
• Adenosine, CCBs, Digoxin, B-blockers
• Some experts proceed straight to electrical cardioversion
others begin with antiarrhythmic agents
• Amiodarone
• Procainamide: Avoid if prolonged QTC or CHF
• Sotalol: Avoid if prolonged QTC
Leonard I Ganz et al. Approach to the management
of wide QRS complex tachycardias.
Pertinent Algorithms
Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
What Can We Do?
• Announce yourself and your role
• Speak up and push for meaningful interventions
• Expand your comfortability
• Infusion pumps
• Medical equipment
• Rhythm interpretation
• Know your crash cart
• Both Medication and Medical Equipment
• Think of your H's and T's
• Think ahead and prepare medications prior to being called
when appropriate
Questions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Asthma
Anaphylaxis
Pregnancy
Morbidly obese
Pulmonary embolism
Electrolyte disturbances
Trauma
Toxicity
Hypothermia
Drowning
Electric shock
Avalanche victims
During PCI
After Cardiac Surgery
References
Robert W. Neumar et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update
Cardiopulmonary Resuscitation and Emergency Cardiovascular care. Circulation.
Field JM, Hazinski MF et al. 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2010
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2005;
Mentzelopoulos SD et al. Vasopressin, steroids, and epinephrine and neurologically favorable
survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013
Alexander H. Flannery. Top of Your License' Code Response: Elevating the Pharmacist Role 2015 Midyear
Clinical Meeting & Exhibition.
Carolyn M Zelop et al. Cardiopulmonary Arrest in Pregnancy. UpToDate. Retrieved January 2016.
http://www.uptodate.com/home
http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/
Terry L. Vanden Hoek et al. Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010
Eric J. Lavonas et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association
Guidelines Update Cardiopulmonary Resuscitation and Emergency Cardiovascular care. Circulation.
References
Edward W. Boyer et al. Methamphetamine intoxication UpToDate. Retrieved January 2016.
http://www.uptodate.com/home
Leonard I Ganz et al. Approach to the management of wide QRS complex tachycardias. UpToDate.
Retrieved January 2016 http://www.uptodate.com/home
Alexander H. Flannery et al. Top of Your License Code Response: Elevating the Pharmacists Role. ASHP
Midyear Clinical Meeting. December 7, 2015
Victor F Tapson, MD. Fibrinolytic therapy in acute pulmonary embolism and lower extremity deep vein
thrombosis. UpToDate. Retrieved January 2016 http://www.uptodate.com/home