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Cardiac arrest is a leading cause of death, with over 300,000 cases annually in the United States alone. As clinical pharmacists and members of the emergency response team, having a strong working knowledge of the pharmacological agents utilized in advanced cardiovascular life support (ACLS) is imperative. When cardiac arrest strikes, immediate recognition and prompt initiation of evidence-based ACLS protocols is crucial. Pharmacists play a pivotal role in preparing and administering ACLS medications, guiding appropriate drug selection, and ensuring medication safety throughout resuscitation efforts. This subtopic will provide a practical approach to integrating pharmacists into ACLS and optimizing medication use in cardiac arrest situations. We will discuss classifications of cardiac arrest rhythms, ACLS treatment algorithms, pharmacotherapy considerations for each rhythm type, and special therapeutic situations. By understanding the pharmacological principles underlying ACLS, clinical pharmacists can help improve patient outcomes during these critical events.
Cardiac Arrest Basics
- Cardiac arrest involves the sudden cessation of cardiac mechanical activity, identified by unresponsiveness, absence of normal breathing, and lack of a palpable pulse.
- It is categorized based on presenting heart rhythm:
- Ventricular fibrillation (VF): Chaotic ventricular activity
- Pulseless ventricular tachycardia (pVT): Rapid regular ventricular rhythm
- Asystole: Complete absence of electrical activity
- Pulseless electrical activity (PEA): Electrical activity without mechanical contractions
- Causes of cardiac arrest include ischemia, electrolyte disturbances, toxins, respiratory failure, and circulatory obstruction. These disrupt the heart’s electrical conduction system.
Understanding the classification of cardiac arrest rhythms is crucial, as it guides appropriate pharmacotherapy during ACLS.
Cardiac arrest is a life-threatening medical emergency characterized by the sudden cessation of cardiac mechanical activity. It is identified by the absence of a palpable pulse, unresponsiveness, and the absence of normal breathing. Rapid recognition and immediate initiation of Advanced Cardiovascular Life Support (ACLS) protocols are crucial in improving patient outcomes.
During ACLS, the clinical pharmacist plays a vital role as a member of the healthcare team. They are responsible for various tasks, including preparing ACLS medications, providing drug information and protocol guidance, ensuring medication safety, and documenting medication use and response. By integrating pharmacists into ACLS, medication use can be optimized, and patient outcomes can be improved.
The foundation of ACLS lies in the performance of high-quality cardiopulmonary resuscitation (CPR) and early defibrillation, when indicated. CPR involves continuous chest compressions and artificial ventilation to maintain blood circulation and oxygenation to vital organs. Defibrillation, the delivery of an electrical shock to the heart, is performed to restore normal cardiac rhythm in cases of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).
ACLS protocols are based on the specific rhythm identified during cardiac arrest and guide the subsequent steps of resuscitation. The two primary categories of rhythms in ACLS are ventricular fibrillation/pulseless ventricular tachycardia and asystole/pulseless electrical activity.
In the case of ventricular fibrillation and pulseless ventricular tachycardia, the ACLS algorithm involves immediate chest compressions, defibrillation, and the administration of medications such as epinephrine. The healthcare team, including the clinical pharmacist, must ensure proper medication preparation, correct dosing, and comply with the recommended algorithm for rhythm analysis, defibrillation, and medication administration.
For asystole and pulseless electrical activity, the ACLS algorithm focuses on continuous chest compressions, immediate administration of epinephrine, and the identification and treatment of underlying causes. The clinical pharmacist contributes by preparing and administering medications, as well as assisting with identifying and managing the underlying issues. For example, they may suggest fluid boluses for hypovolemia, glucose for hypoglycemia, sodium bicarbonate for severe acidosis, and specific antidotes for toxidromes.
- As ACLS team members, pharmacists play a vital role through responsibilities such as:
- Preparing ACLS medications during codes
- Providing drug information and protocol guidance
- Assisting with medication administration and safety
- Suggesting appropriate pharmacotherapy tailored to situation
- Documenting medication use and response