advance cardiac supp

7/27/2019 Advance Cardiac Supp

1/32

IntroductionToAdvanced Cardiac LifeSupport (ACLS - 2010)

ACLS Reading Sources:

AHA Guidelines published in the Circulation supplement Dec 2005: http://circ.ahajournals.org/content/vol1

12/24_suppl/

American Heart AssociationACLS Provider Manual
http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/http://circ.ahajournals.org/content/vol112/24_suppl/


2/32

ILCOR

International Liaison Committee on Resuscitation

American Heart Association (AH

A)

European Resuscitation Council (ERC) Heart and Stroke Foundation of Canada (HSFC) Resuscitation Council of Souther

n Africa (RCSA) Australia and New Zealand Council on Resuscitation (ANZCOR) Inter American Heart Foundation(IAHF) Japan Resuscitation Council (JRC) International observer to ILCOR


3/32

ILCOR Advisory StatementsKey Issues in ACLS 2005

Airway CPR Defibrillation Drug therapy Post-resuscitation management Special Situations

Stop the Killer

Sudden Cardiac Arrest (SCA) is the numb

er one killer in USA.

SCA claims ~ one life every 90 seconds...

..over 1,000 lives every day.


4/32

50% of SCA deaths in men, and 63% in w

omen, occur in people with no prior sympto

ms of heartdisease.

A person who suffers SCA outside of a h

ospital has only a 5% chance of survivalACLS Course:

Arrest scenarios VF Pulseless VT Asystole PEA

Pre-arrest scenarios Tachyarrhythmias

Bradyarrythmias

Ischemia


5/32

Stable Angina Unstable Angina MI Stroke

Chain of SurvivalPriorities

Of primary importance: Prompt CPR Early Defibrillation for VF/VT

Of secondary importance: Insertion of advanced airway IV Access and Drug administration

Chances of survival with time

Early defibrillation

When defibrillation is delivered within one mi

nute, survival rates can be as high as 90%.


6/32

If defibrillation is delivered in less than 5 min

utes, survival can be as high as 50%.

For every minute that passes prior to receiving defibrillation, a victim's chance of survival dec

lines by about10%. After 10 minutes chances of survival are nea

r zero.

Automated Electrical Defibrillator (AED)The Basics

ACLS always starts with BLS! Are you OK? Is the patientconscious? Call for help. Do primary survey: ABCD

Airway- Is it open?Breathing- moving air? Look, Listen,and FeelCirculation- check pulse, start CPR!


7/32

Defibrillation- if VF or pulseless VTAlgorithm for basic life support for adult

sQuick BLS Review

Give 2 rescue breaths. Each breath

over 1 second, enough to make the che

st rise.

Check the pulse for minimum of 5 se

conds but no longer than 10 seconds. If

no pulse or unsure, start CPR!

Compression to ventilation ratio 30:2

; after advanced airway no need to interr

upt compressions (Rate 100/m)

BLS Key Concepts


8/32

Avoid Hyperventilation (Do not ventil

ate too fast or too much volume)

Push hard and fast, allow complete c

hest recoil, minimal interruptions

Compress chest depth of 1.5 to 2 inc

hes at a rate of 100 compressions per m

inute

Resume CPR immediately after shock. Interruption in CPR for rhythm check

should not exceed 10 seconds

BLS Key Concepts


9/32

Chest compression should not be interrupted except for: (coronary perfusion pressur

e) Shock delivery Rhythm check Ventilation (until an advanced airwayis inserted)

Do not interrupt CPR: To insert cannula or to give drugs To listen to the heart or to take BP???

Waiting for charging the Defibrillator

To rotate personnelEquipments for ventilation in BLSOropharyngeal and nasopharyngealairwaysCPR Skill ChartSecondary Survey: ABCD


10/32

Airway-

Is an advanced airway needed? If yes, t

hen ETT/LMA/Combitube

Breathing-

Tube placed correctly? Secured? Is the

re adequate oxygenation and ventilation

?

Circulation-

What is the rhythm? Is there IV access?

Drugs?

Differential diagnosis? Find potential

reversible causes of arrest.Advanced Airways

Once advanced airway in place, dont interrupt chest

compression for ventilation and avoid over ventilation

8-10 breaths/m


11/32

Endotracheal Tube

Laryngeal Mask AirwayLMA

Combitube

Arrest Rhythms

Shockable rhythms: VF Pulseless VT

Non shockable rhythms: PEA Asystole

Electrical therapies in ACLS


12/32

Cardiversion / Defibrillation for Tachyarrhythmias Unsynchronized = defibrillation (Uses higher

energy levels and delivers shock immediately)

Synchronized delivers shock at peak of QRS

complex (Avoids delivering shock during repolar

ization)

Pacing for brady arrhythmias

VF/ Pulseless VT

Witnessed arrest: 2 rescue breaths then Defibrillate

Unwitnessed arrest:

5 cycles of CPR (2 min) then

Defibrillate


13/32

200 Joules for biphasic machines 360 Joules for monophasic machines Single shock (not 3 shocks) followed by CP

R No gap between chest compression and sho

ck deliveryDefibrillation technique

11. Return to ALS algorithm for further steps

"Check pulse"

10. Check for output if rhythm change


14/32

9. Check ECG rhythm

"Shocking now"

8. Press paddle buttons simultaneously

"Stand clear"

7. Ensure no-

one is in contact with anything touching the patient

"Charging"

6. Charge to required energy level


15/32

5. Select non-synchronized (VF) setting

4. Check ECG rhythm and confirm no pulse

3. Apply paddles

2. Place coupling pads/gel in correct position

1. Switch on.


16/32

Announcements

Action

Defibrillation SequenceHow to give drugs?

Peripheral line(long circulation time 1-2 min, IV Bolus followed by 20

ml NS flush and elevate limb x 10-20 sec) Central venous line (CVC)

(time consuming, relative C/I to fibrinolysis if required) Intraosseous (IO) cannulation

(safe and effective alternative to peripheral IV access

class IIb) Endotracheal (ET) administration

( Less reliable, 2-2 IV dose, in 5-10 ml D5W or NS)

Drugs that can be given by ETT


17/32

NAVVEL

NarcanAtropineValiumVasopressinEpinephrineLidocaine

Use at least 2

2 x the dose, chase it with 5

10 ml saline, and ventilate.

Now IO access is emphasized over ET if IVis not available.What is the optimal drug therapy for VF?


18/32

Does the use of intravenous amiodar

one improve survival? prevent recurrent dysrhythmias compa

red with other anti-dysrhythmia agents? Eleven article reviewed

6 since 2002 Reasonable evidence exists to suppor

t a Class IIa. A new formulation of amiodarone (Ami

o-

Aqueous) is associated with comparably s

mall rates ofhypotension when compared

with lidocaine.

Drug Therapy - Amiodarone

Existing human studies favor ami

odarone in shock-resistant VF/VT.


19/32

Class IIa recommendation after defi

brillation and administration of a vasop

ressor inshock-resistant VF/VT. Evidence does not support the us

e of amiodarone in the setting of hyp

othermicVF/VT.

Drug Therapy - Norepinephrine

Norepinephrine should be class in

determinate in the therapy of cardiac

arrest. Not superior to epi Not compared to vasopressin

Drug Therapy - vasopressin


20/32

Out of the 1219 patients in the study, 732 failed the first 2 doses of stud

y drug. The patients in the vasopressin arm

then received subsequent epi, while th

e epi-arm patientsreceived more epi. The combination of vaso and epi pr

ovided significantly better outcomes Vasopressin and asystole (retrospective comparison)

Patients who received vasopressin an

d epinephrine had a significantly increase

d likelihood of ROSCand having a pulse o

n arrival to the emergency department

(Guyette et al. 2004)

Differential Diagnosis:6 Hs & 6 Ts of PEA andAsystole

Hypovolemia


21/32

Hypoxia Hydrogen ions (acidosis) Hyper/ hypokalemia Hypothermia Hypoglycemia

Toxins (like drug OD) Tamponade Tension PTX Thrombosis (coronary) Thrombosis (pulmonary)

Trauma

HYPOKALEMIA: FLAT ST SEGMENTS

See a normal EKGHYPOKALEMIA: PROMINENT UWAVES
http://normal+12+lead+ekg/http://normal+12+lead+ekg/http://normal+12+lead+ekg/http://normal+12+lead+ekg/


22/32

HYPERKALEMIA: PEAKED T WAVES

See a normal EKGTREATMENT OF HYPERKALEMIA

Antagonize membrane effects of K+

IV Calcium: onset 1-2 min, duration 30-

60 min

Drive K+

into cells Insulin (remember to give with glucose!) Beta agonists (high dose)

like albuterol

Remove K+

from the body
http://normal+12+lead+ekg/http://normal+12+lead+ekg/http://normal+12+lead+ekg/http://normal+12+lead+ekg/


23/32

Kayexalate- binds K+

in gut, onset 1-

2 hours Diuretics-only work if renal function remains

Hemodialysis- depends on availability

ELECTRICAL ALTERNANS: THEEKG FINDING OF TAMPONADETREATMENT OF TAMPONADE:

PERICARDIOCENTESISTENSION PNEUMOTHORAXTREATMENT OF TENSION PTX

Oxygen


24/32

Insert a large-bore (ie, 14-

gauge or 16-

gauge) needle into the second intercostal space (above the third rib!), at the mid

clavicular line.

GENERAL RULE FOR PEA RHYTHMS

Narrow QRS complex: more likely no

ncardiac cause like low volume or low v

ascular tone

Wide QRS complex: most likely due t

o a cardiac cause, drug toxicity, or electr

olye abnormalityECG LEAD PLACEMENT

WHAT IS THIS RHYTHM?ASYSTOLE PROTOCOL


25/32

Check another lead Is it on paddles? Adjust the gain Power on? Check lead and cable connections

Hypothermia

ILCOR Advisory statement (2003):

Unconscious adult patients with sp

ontaneous circulation after out-of-

hospital cardiac arrestshould be coole

d to 32-34C for 12-24 hrs when the initial rhythm was vent

ricular fibrillation(VF). Such cooling may also be beneficia

l for other rhythms or in-

hospital cardiac arrests.

Hypothermia


26/32

Cooling: Retard enzymatic rxns, suppress pro

duction of free radicals Reduction of O

2demand in low-

flow regions Inhibition of excitatory NT synthesis Protection of membrane fluidity Reduction of intracellular acidosis Decrease in cerebral edema and ICP Two independent studies utilized surface co

oling on intubated, paralyzed patients vs. standa

rd of care Multi-center, prospective, randomized trial in Australia

* 77 pts: 43 hypothermia, 34 control 33C x 12 hours following resuscitation fro

m cardiac arrest Good neurologic outcome : 49% of cooled,

26% of controls (p=.046)


27/32

Multi-

center, prospective, randomized trial in Europe *

* 275 pts: 137 hypothermia, 138 control 32C to 34C x 24 hours Good neurologic outcome in: 55% of coole

d, 39% of controls (p=.009) Mortality 41% in cooled vs 55% control, P

=.02 *NEJM 2002; 346: 557-63 ** NEJM 2002; 345: 549-56

Techniques to Induce Hypothermia

Surface cooling techniques Slow and imprecise Cumbersome Limited in depth with non-

paralyzed patient Lavage


28/32

Moderately invasive and uncomfortabl

e Slow and imprecise

IV infusions Limited volumetric capacity

Cardiopulmonary bypass Invasive and resource intensive

KEY CONCEPTS REVISITED

Avoid Hyperventilation Push hard and fast, allow complete chest recoil, minimal interruptions Compress chest depth of 1.5 to 2 inc

hes at a rate of 100 compressions per m

inute Compression to ventilation ratio 30:2, after advanced airway no need to interr

uptcompression


29/32

Turing defibrillator on Sinus tachycardia Closed loop communication 6 Hs and 6 Ts

Book, readings, benefits of ACLS as a 2nd

year

2

Give 2 rescue breaths. Each breath over 1 second, enough to make the chest rise. Do not venti

late too fast or too much volume. Check the pulse for minimum of 5 seconds but no longer th

an 10 seconds. If unsure, start CPR! Immediately resume CPR after defibrillation.

14

Resume CPR immediately after shock. Interruption in CPR for rhythm check should not exceed

10 seconds


30/32

17

Assess breathing by seeing chest rise, O2 saturation, capnometry, physical exam

21

The drugs that can be given via ET tube.

27

PEA doesnt necessarily mean there is no organized electrical activity. There could be any rhyt

hm on the strip, and you can use that to narrow down your differential.

32

33


31/32

Treatment: rapid but controlled infusion of potassium

34

35

Normal potassium: 3.5 - 5.5 mEq/L

Calcium decreases myocardial excitability and normalized the gradient of the resting potentialKayexalate binds K+ in the bowel

36

Electrical alternans: the EKG finding of tamponade

37

Alligator clip on needle. If see ST changes stop because you went into myocardium


32/32

38

White on right, smoke above fire, green is grass, fire burns wood and makes smokeBrown goes 5

thICS midclavicular line

42

External defibrillator

45

Resume CPR immediately after shock. Interruption in CPR for rhythm check should not exceed

10 seconds

advance cardiac supp

Documents