Episode 96 Beyond ACLS Cardiac Arrest – Live from EMU Conference 2017

This is EM Cases Episode 96 - Beyond ACLS Cardiac Arrest - Live from EMU Conference 2017 with Jordan Chenkin. I had the privilege of speaking at Canada's largest EM Conference, North York General's Emergency Medicine Update Conference. This year they celebrated their 30th conference in Toronto and rather than give a standard plenary talk, we decided to do a live podcast. Jordan Chenkin (who heads up the University of Toronto EM POCUS program and who has taught at the EM Cases Course as well as many other EM conferences), joined me in discussing 3 areas where your cardiac arrest management can be optimized beyond the ACLS protocols: refractory ventricular fibrillation, optimized pulse checks and PEA arrest. In these 3 areas, we show videos of a code team performing the ACLS way and then contrasted that with videos of optimized approaches. This meant that a video format had to used for the podcast. So, we are excited to share the first ever video podcast on EM Cases! Blog post by Anton Helman Month, May 2017 Cite this podcast as: Helman, A, Chenkin, J. Beyond ACLS Cardiac Arrest - Live from EMU Conference 2017. Emergency Medicine Cases. May, 2017. https://emergencymedicinecases.com/episode-99-highlights-emu-2017/. Accessed [date]. SHOCK REFRACTORY VF 1. Minimize the perishock pause  Stop chest compressions only to assess for defibrillation and to defibrillate. Perishock pauses <20 s in the early resuscitation period are associated with survival to discharge when compared to episodes with peri-shock pause ≥40 s. Tips to minimize the perishock pause: * Pre-charge the defibrillator during chest compressions * Count down before pausing for a shock so that the shock is delivered in between chest compressions and the hands come off the chest only momentarily * Use a look-through monitor whereby the cardiac rhythm can be identified while chest compressions are ongoing 2. Dual Shock Therapy for Refractory Ventricular Fibrillation Dual Shock Therapy ("double defib" or "double sequential defib") involves defibrillating patients who are refractory to multiple defibrillations with 2 defibrillators at the same time or within seconds of each other, one with pads set up in the traditional anterior positions and the other set up with anterior-posterior pad positions. A recent observational case series showed improved rates of ROSC with dual shock therapy with one patient surviving to hospital discharge. An RCT in 1989 by Bardy randomized patients with refractory ventricular fibrillation to dual vs single shock therapy and found no significant difference in ROSC. Despite the lack of definitive evidence that dual shock therapy improves survival, we recommend attempting it when other avenues have been exhausted in the patient with refractory ventricular fibrillation. https://www.youtube.com/watch?v=Ov-BBUhKdJU 3. Stop Epinephrine after 3 doses or lower the dose During refractory ventricular fibrillation and VF storm there is a huge catecholamine surge that contributes to the refractoriness. Rather than adding more catecholamine with epinephrine, our experts recommend stopping the epinephrine after 3 doses or lowering the dose in ventricular fibrillation. Some experts believe that the dose of 1mg every 3-5 minutes that is recommended in the guidelines is too high, is too frequently given and may be detrimental. Epinephrine,