Advanced Cardiac Life Support 2004

Mark I. Langdorf, MD, MHPE, FACEP

Professor or Clinical Emergency Medicine

Chair and Associate Residency Director

University of California, Irvine

ACLS History

• Sixth iteration of guidelines since 1966

• Second that is evidence based

• First that incorporates international perspective

Evidence Based Guidelines

• Search the international literature

• Determine level of each piece of evidence

• Graded each study for quality

• Integrate all evidence into final class recommendation

Classes of Recommendations

• Class I: always acceptable, proven safe and definitely useful

• Class IIa: acceptable, reasonably prudent, intervention of choice by experts

• Class IIb: acceptable, safe and useful, within standard of care, optional or

alternative by experts• Interderminate: inadequate research to decide• Class III: evidence for benefit lacking, or harmful

Chain of Survival

• Recognize early warning signs

• Activate EMS

• Basic CPR

• Defibrillation

• Airway and ventilation

• Intravenous medications

Public Access Defibrillation: PAD• Goal: AEDs used by laypersons everywhere• Most effective cardiac intervention• Shown to be cost effective (cost per life year saved)• Response time goal is 3 to 5 minutes

– Police – Fire– Casino– Airlines– First responders

• Survival rates up to 49% from primary ventricular fibrillation

Sequence of Events• 50% of patients with CAD first present with

sudden death• Sequence:

– Decades of atherosclerotic buildup– Plaque rupture or erosion– Platelet adhesion– Occluding thrombus– Severe ischemia– Irritable myocardium– Ventricular fibrillation– Collapse and sudden death

Adult BLS: Recent Changes

• Phone first (no CPR unless drowned, trauma or overdose)

• BLS should transport to ED capable of IV thrombolysis for MI and stroke– Within 30 minutes for MI– Within 60 minutes for stroke

BLS Sequence Changes

• 10cc/kg tidal volume without oxygen• 6-7 cc/kg with supplemental oxygen• Prevent gastric insufflation: deliver over 2

seconds• Lay rescuers don’t check pulses before

chest compressions, healthcare workers do• Compression rate 100/minute• 15:2 ratio for 1 and 2-rescuer CPR

Prehospital Care for ACS

• Oxygen is routine• Aspirin en route: 160-325mg• Nitroglycerin

– Be careful with Viagra– Need SBP >90– 3 sprays q 3-5 minutes– Morphine if 3 sprays don’t relieve pain– 12 lead ECG under study

Prehospital Stroke Care

• Determine time of onset and GCS• Perform prehospital stroke scale

– Cincinnati PSS: sensitivity 72%– Los Angeles PSS: 93% sensitivity, 97% specificity

• LAPSS– Age > 45– No seizures– Duration < 24 hours– Ambulatory at baseline– Glucose 60-400– Obvious asymmetry of face/grip/arm strength

ACLS Changes for 2000

• Wide complex tachycardia: Amiodarone and procainamide before lidocaine and adenosine (IIb)

• Stable V tach (and torsades): Amiodarone and sotalol preferred (IIa)

• Bretylium not available (IIb) • Lidocaine: evidence poor for benefit for v-

fib and v-tach (indeterminate)

ACLS Changes for 2000

• V-fib/pulseless V-tach: evidence for all antiarrhythmics weak. Amiodarone preferred (IIb)

• Magnesium still IIb for torsades de pointes (polymorphic ventricular tachycardia)

• Vasopressin: may be more effective than epinephrine in cardiac arrest (IIb)– 40 units IV only once– Epinephrine still class IIb

• High-dose epinephrine: no benefit (indeterminate)

Defibrillation: Biphasic

• Will become the norm

• As effective at lower energy– 150 biphasic = 200 monophasic– No need for escalating energy levels (joules)

• Transthoracic impedance declines with subsequent shocks

• Repeat same energy = success

Shock Energies: Recommended

• Still 200/200-300/360 joules for v-fib /pulseless v-tach

• Atrial fibrillation: 100-200

• Atrial flutter/PSVT 50 to start

• Ventricular tachycardia– Monomorphic (usual) 100 joules– Polymorhpic (torsades de pointes) 200 joules

Other Defibrillator Points:

• Synchronize for any perfusing rhythm– Avoids precipitating ventricular fibrillation– Hold buttons down

• Check two leads for asystole– If no ventricular fibrillation noted, defibrillation not effective

• Lead disconnect can simulate asystole

Cardiac Arrhythmias

• Check the patient, not the rhythm• Perfusion is most important• Wide complex tachycardias are ventricular

tachycardia – Odds 75/25 ventricular/supraventricular– Older (>45 yo)– Sicker (previous MI or coronary disease)– Treat the worst, first

• 12 ECG criteria not reliable enough to distinguish

Rhythms to recognize

• Normal sinus rhythm• Atrio-ventricular (AV) blocks

– 1st degree(not important)– 2nd degree

• Type I (Wenkebach)• Type II (dangerous)

– 3rd degree (complete, AV disassociation)• Premature complexes

– Atrial (no pause)– Ventricular (compensatory pause)

Rhythms to Recognize

• Ventricular tachycardia– Monomorphic– Polymorphic (Torsades de pointe)

• Ventricular fibrillation

• Asystole (confirm)

Tachyarrhythmias

• Narrow QRS complex (<120 msec)– Sinus– Atrial fibrillation– Atrial flutter– Atrial tachycardia (digoxin toxicity)– Multifocal atrial tachycardia (COPD)– AV nodal re-entrant tachycardia (PSVT)– Junctional tachycardia

Tachyarrhythmias

• Wide QRS (>120 msec)– Ventricular tachycardia (usually 160 msec)– Supraventricular tachycardia with aberrant

conduction (usually not this wide)

• 12 lead if stable

• Mr. Edison if not

Show Rhythm Strips

Routes for Drug Administration• Evidence for effectiveness for all drugs is weak• Drugs are secondary interventions• Peripheral still first choice

– flush with NS– 1-2 minutes to central circulation

• If no response to drugs and defibrillation– Consider central line

• Internal jugular (IJ) preferred (or supraclavicular subclavian)

• Femoral less preferred– Avoid non-compressible sites if possible

Tracheal Administration

• N-a-v-e-l still holds: drugs for the ET tube– Narcan– Atropine– Valium– Epinephrine– Lidocaine

• Amiodarone/vasopressin not yet studied, so avoid• Dilute in 10cc/bag vigorously• 2-2.5 times the IV dose for all meds

Wide Complex Tachycardias: Stable

• Must be regular and fast (>120)• Must be uniform (one QRS morphology)• No signs of impaired perfusion

– Mental status normal– No chest pain or CHF– Skin signs warm and dry– Systolic BP > 90 mm Hg

• Obtain 12 lead ECG if stable

Wide Complex Tachycardias: Stable

• Procainamide first line if ventricular function normal (sotalol) (both IIa)

• Amiodarone (IIb) (150mg over 10 minutes) or Lidocaine (.5-.75mg/kg IVP) if poor EF (<40%)

• If ineffective:– Synchronized cardioversion (100/200/300/360 joules)– No repeat drug doses recommended

• Bottom line:– Normotensive: procainamide– Hypotensive: cardiovert

Polymorphic Ventricular Tachycardia

• Recurrent bouts– Usually terminate spontaneously, or– Degenerate into v-fib

• Stop offending meds that prolong QT interval• Correct hyopcalcemia/hypomagnesemia• Magnesium 2-4 grams IVP (shortens QT)• Transcutaneous pacer (“overdrive pacing”)

– Rate >100 if no ischemia– Shortens QT, reduces recurrence

V-fib/Pulseless V-tach

• This is easy!• Defib three times ASAP (200/300/360)• ABCs• Epi 1mg IV every 3-5 minutes, or• Vasopressin 40 units IVP, once

– Then Epi same as usual

• Amiodarone (IIb) 300mg IVP (second dose if recurrent V-fib 150 mg)

Look for Cause!

• Hypovolemia• Hypoxia

– ETT/02 hooked up/pneumothorax/CO poisoning

• Acidosis• Hypo/hyperkalemia• Cardiac tamponade• Tension pneumothorax• Coronary thrombosis• Massive pulmonary embolism

Langdorf’s Silly Mnemonic

• Shock, shock, shock (defibrillation three times)• All Breathing Counts (airway, breathing, circulation)• EVerybody (epinephrine OR vasopressin)• Shocks (defib)• Americans (amiodarone)• Shock (defib)• Europeans (epinephrine again)• Shock (defib)• Latin Americans (lidocaine)• Shock (defib)

Sodium Bicarbonate: Indications

• No changes

• Hyperkalemia (class I)

• Pre-existing acidosis (class IIa)

• TCA overdose (class IIa)

• ASA overdose (class IIa)

• Prolonged arrest (class IIb)

• Return of spontaneous circulation (class IIb)

• NOT in hypoxic, lactic acidosis cardiac arrest!

Pressors: Epinephrine

• Alpha effects confer benefit• Increases systemic vascular resistance• Increases aortic root pressure• Perfuses coronaries• Perfuses brain at expense of body• Escalating or high doses without demonstrable

benefit• Potent pressor for hypotension (1mg in 500cc at 2-

10 micrograms/min)

Pressors: Norepinephrine

• Potent alpha and beta agonist

• Indicated for severe hypotension (SBP < 70)

• Dose 1-30 micrograms/min

• Extravasation: infiltrate 5-10 mg of phentolamine

Pressors: Dopamine

• Precursor of norepinephrine• Alpha and beta adrenergic agonist• Indicated with hypotension and bradycardia

(raises SBP and HR)• Dose 5-20 micrograms/min after cardiac

arrest– 5-10 primarily beta stimulation– 10-20 additional potent alpha effect

Pressors: Dobutamine

• Potent beta-1 selective ventricular inotrope

• Use for severe systolic dysfunction

• Reflex tachycardia due to peripheral vasodilation

• 5-20 micrograms/min