The concentration of adrenaline in ACLS/Cardiac Arrest Resuscitation is -
Ans- D Epinephrine is a commonly used medication in the emergency department for the management of anaphylaxis and cardiac arrest. Administering this drug can be confusing as the dosage and concentration are different for each indication. The "allergy epi" 1:1000 concentration is 10 times more concentrated than the "cardiac epi". The "allergy epi" is delivered IM while the "cardiac epi" is delivered IV. This difference leads to an increased risk of error as the incorrect epinephrine dosage, concentration, or route can have disastrous consequences for patients including coronary dissection, infarction, and ventricular arrhythmias (1-3). Here is a little saying to easily remember the dosage and concentration of epinephrine in both anaphylaxis and cardiac arrest... Anaphylaxis and Epinephrine Dosage LESS (volume) is MORE (concentrated) Less (0.5cc) is More (1:1000) Use 1/2 ml of 1:1000 epinephrine and deliver it into the muscle (IM). This will deliver a total of 0.5mg of epinephrine IM. Cardiac Arrest and Epinephrine Dosage MORE (volume) is LESS (concentrated) More (10cc) is Less (1: 10,000) Use 10cc of 1: 10,000 epinephrine and give it intravenously (IV). This will deliver 1mg of epinephrine IV. References Kanwar M, Irvin CB, Frank JJ, et al. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med. 2010. Apr;55(4):341-4 Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World J Emerg Med. 2013;4(4):245-51 Campbell RL, Bellolio MF, Kuntson BD, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract. 2015 Jan-Feb;3(1):76-80 Epinephrine is the primary drug used in the cardiac arrest algorithm. It is used for its potent vasoconstrictive effects and also for its ability to increase cardiac output. Epinephrine is considered a vasopressor. Indications for ACLS Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart. Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by: Increasing heart rate Increasing heart muscle contractility Increasing conductivity through the AV node Epinephrine is used in the cardiac arrest algorithm as a direct IV push and also in the bradycardia algorithm as an infusion. See the respective algorithm pages for more information about their use in each. Routes During ACLS, epinephrine can be given 3 ways: intravenous; intraosseous, and endotracheal tube Dosing Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes. IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The infusion should run at 2-10 micrograms/min (titrated to effect). IV infusion for post-cardiac arrest hypotension: The dosing is 0.1-0.5 mcg/kg/min (for example a 70kg adult: 7-35 mcg/min would be given). Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube. Epinephrine should be used with caution in patients suffering from myocardial infarction since epinephrine increases heart rate and raises blood pressure. This increase in HR and BP can increase myocardial oxygen demand and worsen ischemia. Note: There is no clinical evidence that the use of epinephrine, when used during cardiac arrest, increases rates of survival to discharge from the hospital. However, studies have shown that epinephrine and vasopressin improve rates of ROSC (return of spontaneous circulation). Adult Basic Life Support Algorithm for Healthcare Providers In the algorithm for adult basic life support, emphasis is placed upon immediate recognition of cardiac arrest and the implementation of efficient compressions and early defibrillation. To immediately recognize cardiac arrest, the healthcare provider is trained to assess for unresponsiveness and/or an absence of breathing or presence of abnormal breath sounds. Laypersons should be instructed to use hands-only CPR. This approach calls for continuous compressions at a rate of 100-120 per minute. CPR should be continued by a healthcare provider until return of spontaneous circulation (ROSC) or until termination of efforts. High quality CPR emphasizes adequate depth and number of chest compressions. The pulse check has been deemphasized, and the guidelines recommend a pulse check for no less than 5 seconds and no more than 10 seconds. An integrated team approach includes simultaneous compressions and rescue breathing. Rhythm detection should take place as soon as an AED or defibrillator is available, with subsequent shock, as indicated, as the survival rate from ventricular fibrillation and pulseless ventricular tachycardia ranges from 5% to 50%, and decreases with an increase in the length of time to the first shock. When a victim is unresponsive to a tap on the chest (ask "Are you ok?"), then the healthcare provider should observe the victim for breathing for 5 to 10 seconds. If respirations are present, the victim should be attached to a cardiac monitor. Otherwise, the healthcare provider (HCP) should activate EMS and retrieve the AED by himself or by sending a second rescuer. The pulse check is the third step in the algorithm. The pulse should be checked for no less than 5 seconds and no more than 10 seconds. If there is a definite pulse, then rescue breathing should be done for one second every six seconds with a recheck every 2 minutes. If the victim does not have a pulse, or there is a question as to whether it is present, then compressions should be initiated at the rate of 30:2, with 2 breaths every 30 compressions. Compressions should be provided at a rate of 100-120/min. When the AED or defibrillator is available, then the HCP should check the victim's rhythm. If it is shockable, then 1 shock should be given with immediate CPR instituted for 2 minutes, beginning rapidly (within seconds) of the shock. If the rhythm is not shockable, then the HCP should administer CPR for 2 minutes and recheck the rhythm every 2 minutes. Continue CPR until ALS is available. High quality chest compressions: Position patient on hard surface in supine position Minimal interruptions for ventilation 18 seconds per cycle Adequate speed of compressions: >100/minute Adequate depth of compressions: 2-2.4" (5-6cm) Allow complete recoil of chest Do not over ventilate Breathing devices include a ONE WAY VALVE FACE MASK. Deliver breath over one second. Watch the chest rise. A BAG VALVE MASK is an additional device to deliver breaths. Hold the mask in place with the EC clamp technique and lift the jaw to open the airway. Squeeze the bag for one second while watching for the rise and fall of the chest. Basic Life Support Sequence Step Lay Rescuer Not Trained Lay Rescuer Trained Healthcare Provider 1 Ensure scene safety. Ensure scene safety. Ensure scene safety. 2 Check for response. Check for response. Check for response. 3 Shout for nearby help. Phone or ask someone to phone 9-1-1 (the phone or caller with the phone remains at the victim's side, with the phone on speaker). Shout for nearby help and activate the emergency response system (9-1-1, emergency response). If someone responds, ensure that the phone is at the side of the victim if at all possible. Shout for nearby help/activate the resuscitation team; can activate the resuscitation team at this time or after checking breathing and pulse. 4 Follow the dispatcher's instructions. Check for no breathing or only gasping; if none, begin CPR with compressions. Check for no breathing or only gasping and check pulse (ideally simultaneously). Activation and retrieval of the AED/emergency equipment by either the lone healthcare provider or by the second person sent by the rescuer must occur no later than immediately after the check for no normal breathing and no pulse identifies cardiac arrest. 5 Look for no breathing or only gasping, at the direction of the dispatcher. Answer the dispatcher's questions, and follow the dispatcher's instructions. Immediately begin CPR, and use the AED/ defibrillator when available. 6 Follow the dispatcher's instructions. Send the second person to retrieve an AED, if one is available. When the second rescuer arrives, provide 2-person CPR and use AED/defibrillator. AED indicates automated external defibrillator; and CPR, cardiopulmonary resuscitation.
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