Today’s morning report was cancelled as a result of a code blue, which represented
an excellent learning experience. The patient was originally admitted with sepsis,
and had a end-stage
renal disease on dialysis. She had
become progressively hypotensive and hypoxic over the previous 24 hours, and
was breathing agonally with a very low pressure when the code was called. Upon
initiating rhythm monitoring, she was in ventricular fibrillation. She received high-quality CPR, two shocks, an
epinephrine bolus and an amiodarone bolus.
She was intubated with rapid reflux into the ETT of pink, frothy sputum
suggestive of decompensated heart failure.
This resulted in a return of spontaneous circulation (ROSC). As is commonly the case, she remained
hypotensive following the arrest, requiring an infusion of dopamine,
norepinephrine, and boluses of phenylephrine and epinephrine.
This case has multiple
learning points:
· Code blues are as much about management and
leadership than they are about medical knowledge. Our code leader promptly entered the room,
introduced himself and his role, and took control of the situation. The priorities
at the beginning of a code are to check for a pulse, organize rhythm and vital
sign monitoring, initiate CPR if appropriate, and maintain an airway through
bag-mask ventilation and ultimately an advanced airway. During the code, Mike and the rest of the
time exemplified good communication strategies which include the following:
o
Loud and
clear introductions
o
Clear
sharing of the though process of the code, what the next steps are, and asking
for suggestions
o
Closed-loop
communication (e.g. “Please give 1mg of epinephrine and let me know when it’s
in”) on the part of the code blue leader, and team members
o
Assigning
tasks to particular individuals, using names if possible
o
Voicing
concerns about safety transporting a patient with unstable vital signs or an
unstable airway
· Given the rapidity of the ROSC, this code blue
became more about post-arrest care than about the algorithm itself. This part of things is less well-taught,
because critical care physicians usually intervene at this point. There a couple of points to mention here:
o
Therapeutic
hypothermia (which involves maintaining a core temperature between 32-34C) was
recommended for all patients with out-of-hospital VF/VT arrest, and most other
comatose patients post-arrest in the 2010 ACLS guidelines. After multiple trials, the 2015 ECC
post-arrest guidelines now recommend a term called targeted temperature management rather than therapeutic
hypothermia, largely because prevention of pyrexia (T 36C) has been shown to be
equivalent to hypothermia. The 2015 AHA
post-arrest guidelines echo the same thoughts.
o
The
guidelines are not specifically clear, but targeted temperature management may
mean anywhere from 32C to 36C. UpToDate
suggests a lower temperature selection in patients with deeper coma following
arrest (no motor function) and a higher temperature selection (36C) in patients
with some motor function but not obeying commands.
o
Pressors
are something we don’t use often on medicine, but can be your best friend
during a cardiac arrest. There is a vasoplegia
that follows an arrest, so regardless of its cause, you almost always need
them.
§ Do you need a central line to use pressors?
No. It is preferred because it allowed
infusion of higher concentrations of vasoactive agents, and peripheral IVs tend
to extravasate those compounds which can lead to tissue necrosis. In an emergency without a central line,
peripheral pressors is OK. The fastest
way to obtain access if needed is with an intraosseous line.
§ What pressor is the best? That depends on what
you want:
· Phenylephrine (Neosynephrine®) – this is a pure
alpha agonist typically used in boluses rather than infusions. Expect a huge afterload increase, blood
pressure rise, and reflex bradycardia.
Make a vial of 100ug/mL by mixing a 10mg vial (how the drug comes) into
a 100cc minibag of NS. Use every
100-500ug every 2-3 minutes.
· Norepinephrine (Levophed®) – this is our most
common pressor infusion and is probably the best for undifferentiated
shock. It has 7:1 alpha:beta effect, and
raises pressure with a small amount of inotropy. It can be mixed in peripheral or central
concentrations and has doses of 0-0.35ug/kg/min.
· Dopamine – this is premixed on crash carts and can be given through a peripheral
IV. Depending on the concentration, it
has different effects. Very low doses
(“renal dose”) are classically associated with increased renal perfusion and
reductions in BP. As doses increase,
beta effect predominates, and at doses over 20ug/kg/min, alpha effect
predominates.
· Epinephrine – acts on all receptors. Premixed in 1:10,000 (code vials of
1mg). This gives you equal alpha and
beta effect and is great for patients with bradycardia. Use a full milligram ONLY for a pulseless
patient. Use 100-200ug (1-2cc) of the
code vial for a quick increase in blood pressure and heart rate. Infusions can be used for bradycardia at
1-10ug/min.
· Others such as dobutamine (Dobutrex®),
isoproterenol (Isuprel®) and vasopressin are used in specific situations (see
reference below from Overgaard et al).
Further Reading:
Overgaard, C. B.,
& Džavík, V. (2008). Inotropes and vasopressors review of physiology and
clinical use in cardiovascular disease. Circulation, 118(10),
1047-1056.
Peberdy, M. A.,
Callaway, C. W., Neumar, R. W., Geocadin, R. G., Zimmerman, J. L., Donnino, M.,
... & Hoek, T. L. V. (2010). Part 9: Post–Cardiac arrest care 2010 American
Heart Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 122(18 suppl 3), S768-S786.
Holzer, M. (2010).
Targeted temperature management for comatose survivors of cardiac arrest. New
England Journal of Medicine, 363(13), 1256-1264.
Link, M. S., Berkow,
L. C., Kudenchuk, P. J., Halperin, H. R., Hess, E. P., Moitra, V. K., ... &
White, R. D. (2015). Part 7: Adult Advanced Cardiovascular Life Support 2015
American Heart Association Guidelines Update for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation, 132(18 suppl 2),
S444-S464.
Image Credit: www.hitleadersandnews.com
No comments:
Post a Comment