Cardiovascular Critical Care II
Patient Case
M.G., a 58-year-old woman with a history of chronic osteoarthritis and peptic ulcer disease, is admitted to
the MICU with hypovolemic shock caused by a suspected bleeding gastric ulcer. Endoscopy is performed,
confirming the gastric ulceration. The ulcer is cauterized, and M.G. is stabilized. On ICU day 2, M.G.
becomes lethargic, hypoxic, and subsequently pulseless. The MICU team is summoned, and the monitor
reveals VF. Resuscitation efforts begin, and the ACLS algorithm is followed. The patient will receive amio-
darone. Which general principles are most accurate regarding amiodarone administration for M.G.’s VF
arrest?
tracheal route.
time is shorter than with other routes.
endotracheal route.
shorter than with other routes.
Management of VF/pVT (Figure 1): Defibrillation (summary, details available previously in the
IHCA and OHCA chain of survival: Defibrillation section)
When VF/pVT detected, CPR should continue until defibrillator (either manual or automatic)
charging period is over.
ii.
It is strongly recommended that CPR be performed while the defibrillator is readied because
chest compressions can deliver oxygen and potentially unload the ventricles, increasing the
likelihood that a perfusing rhythm will return after shock is delivered.
iii.
Because intentionally delaying defibrillation for CPR has mixed results, it cannot currently be
recommended.
iv.
Once defibrillator is charged, patient is “cleared” (ensuring all members of the resuscitation
team are no longer in contact with the patient).
Shock is delivered, and CPR is immediately resumed, beginning with chest compressions.
| (a) | Pulse check is delayed until 2 minutes of CPR is given. |
|---|---|
| (b) | Pause for rhythm and pulse check (less than 10 seconds); continue CPR, if necessary. |
vi.
If biphasic defibrillator is available:
| (a) | Provider should use manufacturer’s recommended energy dose (e.g., 120–200 J). |
|---|---|
| (b) | If information unavailable, the maximum dosing can be considered. |
| (c) | Second and subsequent defibrillator energy dosages should be equivalent, and consideration |
should be made for escalating energy doses, if possible.
vii.
If monophasic defibrillator is the only available defibrillator:
| (a) | Initial energy dose should be 360 J. |
|---|---|
| (b) | Second and subsequent defibrillator energy dosages should be 360 J. |
viii.
If VF/pVT is terminated by defibrillation and reoccurs, resulting in an arrest, the successful
energy dosage used previously should be considered.
ix.
Change of multimodal defibrillator from automatic to manual mode may result in fewer
interruptions of CPR but also an increased frequency of inappropriate shocks (Resuscitation
2007;73:131-6; Resuscitation 2007;73:212-20).