ADVANCED CARDIAC LIFE

SUPPORT(ACLS) - 2010

Speaker – Dr Omar Kamal

DNB anaesthesiology

ADVANCED CARDIAC LIFE SUPPORT

ACLS impacts multiple key links in the chain of

survival that include interventions to prevent cardiac

arrest, treat cardiac arrest, and improve outcomes

of patients who achieve return of spontaneous

circulation (ROSC) after cardiac arrest

Interventions aimed at preventing cardiac arrest

include airway management, ventilation support,

and treatment of bradyarrhythmias and

tachyarrhythmias.

AHA ADULT CHAIN OF SURVIVAL

1. Immediate recognition of cardiac arrest and

activation of the emergency response system

2. Early CPR with an emphasis on chest

compressions

3. Rapid defibrillation

4. Effective advanced life support

5. Integrated post–cardiac arrest care

CARDIOPULMONARY RESUSCITATION (CPR)

Cardiopulmonary resuscitation (CPR) is a series of

life saving actions that improve the chance of

survival following cardiac arrest

KEY CHANGES FROM THE

2005 BLS GUIDELINES

● Immediate recognition of SCA based on assessing

unresponsiveness and absence of normal breathing

● “Look, Listen, and Feel” removed from the BLS

algorithm

● Encouraging Hands-Only (chest compression only)

CPR

● Sequence change CAB rather than ABC

● Health care providers continue effective chest

compressions/ CPR until return of spontaneous

circulation or termination of resuscitative efforts

● Increased focus on high-quality CPR

● Continued de-emphasis on pulse check for health

care providers

● A simplified adult BLS algorithm is introduced with

the revised traditional algorithm

A CHANGE FROM A-B-C TO C-A-B

CHEST COMPRESSIONS

Chest compressions consist of forceful rhythmic

applications of pressure over the lower half of the

sternum.

Technique ..?

MONITORING DURING CPR

Physiologic parameters

Monitoring of PETCO2 (35 to 40 mmHg)

Coronary perfusion pressure (CPP) (15mmHg)

Central venous oxygen saturation (ScvO2)

Abrupt increase in any of these parameters is a

sensitive indicator of ROSC that can be monitored

without interrupting chest compressions

Quantitative waveform capnography

If Petco2 <10 mm Hg, attempt to improve CPR

quality

Intra-arterial pressure

If diastolic pressure <20 mm Hg, attempt to improve

CPR quality

If ScvO2 is < 30%, consider trying to improve the

quality of CPR

HIGH QUALITY CPR

Chest compressions of adequate rate 100/min

A compression depth of at least 2 inches (5 cm) in

adults and in children, a compression depth of at

least 1.5 inches [4 cm] in infants

Complete chest recoil after each compression,

Minimizing interruptions in chest compressions

Avoiding excessive ventilation

If multiple rescuers are available, rotate the task of

compressions every 2 minutes.

AIRWAY AND VENTILATIONS

Opening airway – Head tilt, chin lift or jaw thrust

The untrained rescuer will provide Hands-Only

(compression-only) CPR

The Health care provider should open the airway

and give rescue breaths with chest compressions

RESCUE BREATHS

By mouth-to-mouth or bag-mask

Deliver each rescue breath over 1 second

Give a sufficient tidal volume to produce visible

chest rise

Use a compression to ventilation ratio of 30 chest

compressions to 2 ventilations

After advanced airway is placed, rescue breaths

given asynchronus with ventilation

1 breath every 6 to 8 seconds (about 8 to 10

breaths per minute)

CARDIAC ARREST

Cardiac arrest can be caused by 4 rhythms:

1. Ventricular fibrillation(VF),

2. Pulseless ventricular tachycardia (VT),

3. Pulseless electric activity (PEA), and

4. Asystole.

How to recognise cardiac arrest ..?

TREATABLE CAUSES OF CARDIAC ARREST:

THE H’S AND T’S

H’s T’s

Hypoxia Toxins

Hypovolemia Tamponade (cardiac)

Hydrogen ion(acidosis) Tension pneumothorax

Hypo-/hyperkalemia Thrombosis, pulmonary

Hypothermia Thrombosis, coronary

DEFIBRILLATION

Defibrillation is defined as termination of VF for at

least 5 seconds following the shock.

Early defibrillation remains the cornerstone therapy

for ventricular fibrillation and pulseless ventricular

tachycardia

ELECTRODE PLACEMENT

4 pad positions

anterolateral,

anteroposterior,

anterior-left infrascapular, and

anterior-rightinfrascapular

For adults, an electrode size of 8 to 12 cm is

reasonable (Class IIa, LOE B).

Any of the 4 pad positions is reasonable for

defibrillation (Class IIa, LOE B).

Defibrillation Sequence

● Turn the AED on.

● Follow the AED prompts.

● Resume chest compressions immediately after the shock(minimize interruptions).

Shock Energy

Biphasic : Manufacturer recommendation (eg, initial dose of 120-200 J), if unknown, use maximum available.

Second and subsequent doses should be equivalent, and higher doses may be considered.

Monophasic : 360 J

1-SHOCK PROTOCOL VERSUS 3-SHOCK

SEQUENCE

Evidence from 2 well-conducted pre/post design

studies suggested significant survival benefit with

the single shock defibrillation protocol compared

with 3-stacked-shock protocols

If 1 shock fails to eliminate VF, the incremental

benefit of another shock is low, and resumption of

CPR is likely to confer a greater value than another

shock

DRUG THERAPY

1. Peripheral IV Drug Delivery

2. IO Drug Delivery - IO cannulation provides

access to a noncollapsible venous plexus

3. Central IV Drug Delivery - It can be used to

monitor ScvO2 and estimate CPP during CPR,

both of which are predictive of ROSC

4. Endotracheal Drug Delivery - lidocaine,

epinephrine, atropine, naloxone, and vasopressin

Dose : 2 to 2 ½ times the recommended IV dose

VASOPRESSORS

Drug Therapy

Epinephrine IV/IO Dose: 1 mg every 3-5 minutes

Vasopressin IV/IO Dose: 40 units can replace first

or second dose of epinephrine

Amiodarone IV/IO Dose: First dose: 300 mg bolus.

Second dose: 150 mg.

KEY CHANGES FROM THE 2005 ACLS

GUIDELINES

Continuous quantitative waveform capnography is

recommended

Cardiac arrest algorithms are simplified and

redesigned to emphasize the importance of high

quality CPR

Atropine is no longer recommended for routine use

in the management of pulseless electrical activity

(PEA)/asystole

Increased emphasis on physiologic monitoring to

optimize CPR quality and detect ROSC

Chronotropic drug infusions are recommended as

an alternative to pacing in symptomatic and

unstable bradycardia.

Adenosine is recommended as a safe and

potentially effective therapy in the initial

management of stable undifferentiated regular

monomorphic wide-complex tachycardia

CARDIAC ARREST ASSOCIATED

WITH PREGNANCY

The overall maternal mortality rate was calculated at 13.95 deaths per 100 000 maternities.

There were 8 cardiac arrests with a frequency calculated at 0.05 per 1000 maternities, or 1:20 000.

The frequency of cardiac arrest in pregnancy is on the rise with previous reports estimating the frequency to be 1:30 000 maternities

Department of Health, Welsh Office, Scottish Office. Report on confidential enquiries into maternal deaths in the United Kingdom 2000–2002. London

(UK): The Stationery Office; 2004.

CAUSES

B – Bleeding/ DIC

E – Embolism( pulmonary, coronary , amniotic )

A – Anesthetic complications

U – Uterine atony

C – Cardiac disease( MI/Aortic

dissection/Cardiomyopathy)

H – Hypertension ( Pre eclampsia/ Eclampsia )

O – Other reversible causes

P – Placenta praevia/ abruptio

S -- Sepsis

RECOMMENDATION FOR EMERGENCY CAESAREAN

SECTION

Recommendation

When the gravid uterus is large enough to cause

maternal hemodynamic changes due to aortocaval

compression,

emergency caesarean section should be

considered, regardless of fetal viability

Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation or improvement in maternal hemodynamic status only after the uterus has been emptied.

In a case series of 38 cases of perimortem cesareansection, 12 of 20 women for whom maternal outcome was recorded had return of spontaneous circulation immediately after delivery.

McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery.

Br J Anaesth. 2009;103:406–409.

Synchronised cardioversion - shock delivery that is

timed (synchronized) with the QRS complex

Narrow regular : 50 – 100 J

Narrow irregular : Biphasic – 120 – 200 J and

Monophasic – 200 J

Wide regular – 100 J

Wide irregular – defibrillation dose

Adenosine : 6 mg rapid iv push, follow with NS

flush.. Second dose 12 mg

INITIAL OBJECTIVES OF POST– CARDIAC

ARREST CARE

Optimize cardiopulmonary function and vital organ

perfusion.

After out-of-hospital cardiac arrest, transport patient

to an appropriate hospital with a comprehensive

post–cardiac arrest treatment

Transport the in-hospital post– cardiac arrest patient

to an appropriate critical-care unit

Try to identify and treat the precipitating causes of the

arrest and prevent recurrent arrest

THANK YOU