Training transcript describing an update to shockable-rhythm cardiac arrest protocols (V-fib and V-tach). It emphasizes early use of amiodarone, introduces esmolol for refractory/shock-resistant electrical storm cases, and provides step-by-step esmolol dosing and infusion preparation for Palm Beach County Fire Rescue. The content stresses high-quality CPR and that medications play a secondary role.
Questions this video answers
100 mg in 10 mL
40 mg IV push (0.5 mg/kg referenced, protocol uses 80 kg reference)
Withdraw remaining 60 mg (6 mL) into a 50 mL bag, label, use a 15-drop set, and run at 1.25 drops/sec (5 drops/4 sec) until rhythm resolves.
After administering 450 mg of amiodarone.
No — the protocol specifies not administering epinephrine in refractory cases.
Am.
Alright, now it's time to go over our shockable rhythm cardiac arrest protocol update. So for shockable rhythm, as you recall, we added esmolol into the mix this year and we're also changing where and when we give amiodarone. Again, V fib is a lot of electrical activity going on. Epinephrine, when you give epinephrine raises electrical activity. And in our folks who are shock resistant, V fib, epinephrine could theoretically actually make them worse. And you might want to do the opposite of epinephrine, which, which is a beta blocker, which is where esmolol comes in. So let me explain how we're gonna go through this. In the Alps trial, it was a study using amiodarone and lidocaine and pre hospital cardiac arrest. What we found was that if you used amiodarone early on and witnessed V fib there was a small benefit to it. So it turns out that if you're going to give a drug like amiodarone, it's best to give it right up front early on because if you gave it late, eh, it didn't really make any difference. So you're going to see amiodarone really kind of move up the scale as a first line drug for your shockable rhythms. After of course you do all the important things which is push at the right rate, breathe at the right rate, et cetera, don't pause for anything. That's really what saves lives. So all the medications are a small role in all the cardiac arrest stuff, but add some little bits to it. So amioderador you're going to see is a first line drug, epinephrine. Remember I mentioned that epinephrine can cause some problems if you already have coronary artery disease, while V fib. A lot of our V fib patients have coronary artery disease because again, we think that there's a chance epinephrine could make them actually a little bit worse, depending on what the underlying cause is. These are the folks that we feel have something called electrical storm. An electrical storm means too much electrical activity in the heart, which is why your shock's not working. And the way we deal with that is we have to deal with decrease the amount of electricity going on in the heart and we give them a beta blocker which is basically the brakes on the whole electrical system. And that's the opposite of what epinephrine does. So now that's the point where the captains who will be carrying the esmolol will come in and start them on the esmolol at that point.
Now let's talk a little bit about the administration of esmolol. And you're only going to find this in one particular protocol for Palm Beach County Fire Rescue, and that is in the refractory V fib and V tach. So let's just get the terminologies and definitions straight before we get started. There's recurrent V fib and V tach. And recurrent V fib and V tach is basically when you press the shock button and the rhythm changes, goes to pea, goes to asystole, and then later on in the cardiac arrest, the V fib or V tach comes back. Refractory is when you push the shock button and you give the antiarrhythmic amiodrone. It doesn't go away. That is the definition of refractory. So just think a little bit about your in laws. Everybody has the in laws come over to your house and you love to have them come visit, but you always want them to go home. That's a recurrent situation. Refractory is when your in laws decide to move in with you. So remember, recurrent, they come and go. Refractory is they're there to stay. So how do we treat this refractory case? Well, one, we're not going to be administering epinephrine to the patient. Two, we're going to be doing something called double sequential defibrillation after the 450mg of amiodarone. And and then what we've added into the protocol is esmolol. Now esmolol comes packaged in 100mg and 10mls. So the dose that we came up with, the actual recommendation, is 0.5 milligrams per kilogram. But Dr. Schefke is not a big believer of using actually weight based medication and making you guys come up with this formula and pretend like you know how much the patient weighs. So we just picked an 80 kilogram patient. So for the 80 kilogram patient, and that's the way the protocol is written, the the dose is 40mg IV push. So like I said, it's 10mg per ML. You're going to pull off four MLS and that's going to be how much you administer as an IV push during the cardiac arrest. Now if the refractory V fib and V tach goes away, well, great, you don't have to give any more medication. But if it hasn't gone away yet. We still have 60 milligrams left in this vial. During that time, you're going to go ahead and remove the remaining 6mls 60mg and insert it into your 50cc bag. You're going to make sure that you put your medication label on this and you're going to use your 15 drop set, just like you do for every other 10 minute infusion that we have listed in Palm Beach County Fire Rescues protocols. You're going to go ahead and put the 15 drop set on. You're going to go ahead and set the drip chamber to 1.25 drops every one second, or five drops every four seconds, and you're going to go ahead and administer the entire bag until the refractory V fib v tach goes away.
