advanced cardiovascular life support (acls)

7/27/2019 Advanced Cardiovascular Life Support (Acls)

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ADVANCED CARDIOVASCULAR LIFE

SUPPORT (ACLS)


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Core knowledge and skills in ACLS

Airway management and endotracheal intubation Recognition and therapy of the major ACLS

emergency conditions

Electrical therapy and emergency pacing

Acute coronary syndrome and stroke

Intravenous and invasive therapeutics andmonitoring technique

Cardiac arrhythmias

Cardiovascular pharmacology

Management of special resuscitation situation

Postresuscitation care

Toxicology


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Classes of Recommendation

Class I: always acceptable, proven safe, anddefinitely useful

Class II: acceptable, safe, and useful Class IIa: consider standard of care, intervention of

choice Class IIb: consider standard of care, optional or

alternative interventions

Class Indeterminate: still be recommended foruse, but evidence is lacking

Class C: unacceptable, may be harmful


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Primary-Secondarysurvey approach to ECC

Primary survey : first A-B-C-D(BLS

action)Airway, Breathing, Circulation, Defibrillation

Secondary survey : second A-B-C-D

Airway, Breathing, Circulation,

Differential diagnosis


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Algorithms for

Treatment of Cardiac

Arrest


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ILCOR Universal/International ACLS Algorithm AduAdult Advanced Cardiovascular Life Support

Adult Cardiac Arrest

BLS algorithmIf appropriate

Precordial thum p i f appropriate

Attach defibrillator/monitor

Assess rhythm

Check pulse +/-

VF/VT

AttemptDefibrillation 3

As necessary

CPR

1 minute

Non-VF/VT

CPR

1 minute

Consider causes that are

potentially reversible

HypovolemiaHypoxia

Hydrogen ion acidosis

Hyper-/hypokalemia, other metabolic

Hypothermia

Tablet (drug OD, acidosis

Tamponade, cardiac

Tension pneumothorax

Thrombosis, coronary (ACS)

Thrombosis, pulmonary (embolism)

During CPR

Check electrode/paddle Airway:tracheal tube placement

VF/VT refractoryto initial shocks:

- Epinephrine1mg IV, q 3 - 5 min.

or

- Vasopressin40 U IV

non-VF/VTrhythm:

- Epinephrine1 mg IV, q 3 - 5 min.

Buffers, antiarrhythmics, pacing

Search for reversible causes


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Comprehensive ECC Algorithm AduAdult Advanced Cardiovascular Life Support

Person collapse, Possible cardiac arrest,Assess responsiveness

Primary ABCD Survey (Begin BLS Algorithm) Activate emergency response system, Call for defibrillator

A Assess breathing (open airway, look, listen, and feel)

B Give 2 slow breaths, C Assess pulse, if no pulse C Start chest compressionsD Attach monitor/defibrillator when available

Unresponsive

Not Breathing

CPR continue

Assess rhythm

No Pulse

Attempt defibrillation

(up to 3 shocks if VF persists)

VF/VT

Non-VF/VT

(asystole or PEA)

Non-VF/VT

CPR for1 minute

CPR up to3 minutes

Secondary ABCD Survey

Airway: airway device, Breathing: ventilation,oxygenationCirculation: intravenous access; Drugs, pacing

Non-VF/VT patients:Epinephrine1mg IV, q 3-5 min.VF/VT patients:Vasopressin40 U IV

or Epinephrine1 mg IV q 3 - 5 min.Differential Diagnosis


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Ventricular Fibrillation/Pulseless Ventricular Tachycardia Adu(VF/VT) Algorithm Adult Advanced Cardiovascular Life Support

Primary ABCD SurveyCheck responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, Breathing: provide positive-pressure ventilations

C Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulseless VT, up to 3 times

(200J, 200 to 300J, 360J, or equivalent biphasic) if necessary

Rhythm after first 3 shocks?

Persistent or recurrent VF/VT


A Airway: place airway device

B Breathing: confirm airway device

placement

B Breathing: secure airway device;

B Breathing: confirm effective

oxygenation and ventilation

C Circulation: IV accessC Circulation: monitor rhythm

C Circulation: drugs

D DifferentialDiagnosis: search

for reversible causes

Epinephrine1mg IV, q 3-5 min. orVasopressin40 u IV

Resume attempt to defibrillate

1 360 J (or equivalent biphasic) within 30-60 sec.

antiarrhythmics:Amiodarone(IIb), l idocaine(indeterminate),magnesium(IIbif hypomagnesemic state),

procainamide(IIb for intermittent/recurrent VF/VT).Consider buffers.

Resume attempt to defibrillate


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Mechanism with Monophasic wave(Extension of Refractoriness)


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Synchronization

of Repolarization


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Defibrillation success factor

Patient factors

duration of pre-shock VF andCPR

functional status of myocardium

acid-base balance, hypoxia,

drug

Operational factors

time to defibrillationtransthoracic impedance

paddle position, optimal energy

P l l El t i l A ti it


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Pulseless Electrical Activity AduAdult Advanced Cardiovascular Life Support

Primary ABCD SurveyFocus: basic CPR and defibrillation

Check responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulseless VT

Pulseless Electrical Activity

(PEA = rhythm on monitor, without detectable pulse)

Consider causes that are potentially reversible HypovolemiaHypoxiaHydrogen ion acidosisHyper-/hypokalemia, other metabolicHypothermia

Tablet (drug OD, acidosis)Tamponade, cardiacTension pneumothoraxThrombosis, coronary (ACS)Thrombosis, pulmonary (embolism)

Epinephrine1mg q 3-5 min. Atrop ine1mg IV (if PEA rate is s low), q 3 - 5 min.


A Airway: place airway device,B Breathing: confirm airway device placement

B Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilation

C Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugs

D DifferentialDiagnosis: search for reversible causes

A t l Th Sil t H t Al ith


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Asystole: The Silent Heart Algorithm AduAdult Advanced Cardiovascular Life Support Figure

Asystole

Primary ABCD SurveyFocus: basic CPR and defibrillation

Check responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions, C Confirm true asystoleD Defibrillation: assess for and shock VF/pulseless VTRapid scene survey: any evidence personnel should notattempt resuscitation


A Airway: place airway device,B Breathing: confirm airway device placementB Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilationC Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugsD DifferentialDiagnosis: search for reversible causes

Epinephrine1mg IV q 3-5 min.

Transcutaneous pacing:If considered, perform immediately

Atrop ine1mg IV,repeat every 3 to 5 minutes

up to a total dose of 0.04mg/kg

Asystole persistsWithhold or cease resuscitative efforts?

Consider qualify of resuscitation? Atypical clinical features present? Support for cease-efforts protocols in place?


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Intravenous Techniques During

ACLS

Routes of Drug Delivery:

Intravenous

Intratracheal

IntraosseousIntracardiac

Preferred IV route:

Antecubital vein

Central vein


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Objectives of ACLS

pharmacology Correction of hypoxia

ROSC and adequate blood pressure

Promotion of optimal cardiac function

Treatment of arrhythmias

Relief of pain

Correction of acidosis

Treatment of heart failure


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Pharmacology in ACLS Primary agents : agents for full cardiac arrest

oxygen, epinephrine, vasopressin,

amiodarone, atropine etc

Secondary agents : agents for AMI &complications

inotropic agents, vasodilators, adrenergicblockers, diuretics, thrombolytic agents


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EpinephrineMechanism Increase of SVR by alpha-adrenergic effect

Increase of CoPP and CPP

myocardial oxygen requirement

Class Indeterminate

- No survival benefit vs placebo- Increase in 24 hr mortality with high-dose

Dosage during CPR

standard : 1 mg q 3-5min.

intermediate : 2- 5 mg

escalating : 1- 3 - 5 mghigh : 0.1 mg/kg


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Vasopressin

Stimulation of smooth muscle V1 receptors

Increase in CPP, vital organ blood flow, median

frequency of VF, and cerebral oxygen delivery

No beta-adrenergic activity Class IIb for VF/VT cardiac arrest: 40 U IV

bolus

Class indeterminate for PEA or asystole


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AtropineMechanism enhancement of SA node

automaticity enhancement of & AV node

conduction

Indications: symptomatic bradycardia* role in AV block* bradyasystolic cardiac arrest

Dosage

: 0.5 - 1.0 mg in non-cardiac arrestup to 3 mg in cardiac arrest

*paradoxical response


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Amiodarone

Class III antiarrhythmic agent

Effects on sodium, potassium, and calcium channels

Alpha- and beta-adrenergic blocking effect

Class IIb for refractory VF/VT, stable VT, polymorphic VT,

wide-complex tachycardia of uncertain origin Class IIa for an adjunct to electrical cardioversion of

refractory PSVTs and pharmacologic cardioversion of AF

Class IIb for preexcited atrial arrhythmias


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LidocaineMechanism Reduction of the slope of phase 4

depolarization, elevation of fibrillationthreshold

No effect in contractility, conduction, atrialarrhythmogenesis

Indicationstreatment of VT or VF: Class indeterminateprevention of ventricular arrhythmias

Dosage

1.0 - 1.5 mg/kg(bolus during CPR)2 - 4 mg/min. (maintenance)


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Sodium bicarbonateAcid-Base balance during CPR Veno-aterial paradox during CPR

* three-part acid-base abnormality CO2 producing buffer solution

* limited elimination of CO2 during CPR

Indicationspreexisting metabolic acidosis,hyperkalemia, tricyclic or phenobarbitaloverdose

Dosage : 1 mEq/kgAdverse effect

tissue/intracellular acidosis, alkalemia,hyperosmolarity, impaired O2 delivery


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Algorithms for Treatment

of Life-Threatening

Conditions

Bradycardia Algorithm (Patient Not in Cardiac Arrest) Adu


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y g ( )Adult Advanced Cardiovascular Life Support

Bradycardia

Slow (Absolute bradycardia = rate


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Indications of emergency

cardiac pacing Hemodynamically unstable

bradyarrhythmias

Pause- or bradycardia-dependent

ventricular rhythms Termination of malignant supraventricular

or ventricular tachyarrhythmias

Bradyasystolic cardiac arrest

Prophylactic pacing in AMI


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Contraindications to ECP

Severe hypothermia

Brady-asystolic CA of more than 20 minutesduration

Pediatric CA due to respiratory origin

The Tachycardias: Overview Algorithm Adu


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Adult Advanced Cardiovascular Life Support

Evaluate patientstable or unstable? serious signs or symptoms? due to tachycardia?

Stable patients: no serious signs or symptomsInitial assessment identifies 1 or 4 types of tachycardias

Unstable patients: serious signs or symptoms

Establish rapid heart rate as cause of signs and symptoms Rate related signs and symptoms occur at many rates->Prepare forimmediate cardioversion

1. Atrial fibrillationAtrial flutter

4. Stable monomorphic Vand.or polymorphic VT

2. Narrow-complextachycardia

3. Stable wide-complextachycardia: unknown type

Evaluation focus:clinically unstable?Cardiacfunction?,WPW?Duration 48 hours?

Attempt to specific DxECG, Clinical information Vagal maneuvers Adenosine

Attempt to specific DxECG, Esophageal lead Clinical information

Treatment focus: clinical evaluation1.Treat unstable patient urgently2.Control the rate, convert the rhythm3.Provide anticoagulation

Diagnostic efforts yield Ectopic atrial tachycardia Multifocal atrial tachycardia PSVT

Treatment ofAtrial

Fibrillation/Atrial flutter

Treatment of SVT)Confirmed

SVTWide-complextachycardia ofunknown type

ConfirmedStableSVT

Treatment Stable

monomorpand

polymorphVT

DC cardioversion or Procainamide orAmiodarone if EF >40%

DC cardioversion or Amiodaroneif EF


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Control Rate Convert Rhythm

Norm al LVEFLVEF


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Narrow-Complex SupraventricularTachycardia, Stable

Attempt therapeutic diagnostic maneuver

Vagal stim ulation

Adenos ine

Junctional tachycardia

No DC cardioversion!Amiodaroneb-blocker Ca2+channel blocker

No DC cardioversionAmiodarone

Preserved

EF


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Stable Ventricular Tachycardias:

Monomorphic and Polymorphic?

Monomorphic VT

Is cardiac function impaired?

Polymorphic VT

Is QT baseline interval prolonged?

Note!May go direct ly to

cardioversion

Normal function Poor ejection fraction NormalProlonged

Medications: any one Procainamide

SotalolOther acceptableAmiodarone Lidocaine

Amiodarone

150mg IV bolus over 10 minutesorLidocaine

0.5 60 0.75 mg/kg IV pushThen use

Synchronized cardioversion

Cardiac functionimpaired2

Normal baseline QT intervalTreat ischemia

Correct electrolyteMedications: any oneb-Blockers orLidocaine orAmiodarone orProcainamideorSotalol

Long baseline QT intervalCorrect abnormal electrolyte

Medications: any oneMagnesium Overdrive pacing Isoproterenol Phenytoin Lidocaine

Electrical Cardioversion Algorithm AduAd lt Ad d C di l Lif S t


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TachycardiaWith serious signs and symptoms

If ventricular rate is >150 bpm, prepare forimmediatecardioversion. May give brief trial of medications based onspecific arrhythmias. Immediate cardioversion is generally notneeded if heart rate is 150 bpm.

Have available at bedside Oxygen saturation monitor Suction device IV line

Intubation equipment

Steps for synchronized Cardioversion1. Consider sedation.

2. Turn on defibrillator

(monophasic or biphasic)

3. Attach leads

4. Synchronization

5. Select energy

6. Apply gel to paddles

7. Position paddle on patient8. Charge

9. Announce Clear

10. Discharge

11. Check monitor and patient

Premedicate whenever possible

Synchro nized cardioversion

Ventricular tachycardia Paroxysmal supraventricular

tachycardia Atrial fibrillation Atrial flutter

100 J, 200 J,300 J, 360 Jmonophasic energydose (or clinicallyequivalent biphasicenergy dose)


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Transthoracic Impedance Electrode composition/ size

Energy selected

Electrode-skin coupling material

No & interval of previous shocks Phase of respiration

Inter-electrode distance

Contact pressure


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Energy requirements Ventricular fibrillation

Ventricular tachycardia

Atrial fibrillation

Atrial flutter

PSVT

200-200-360

100-200-360

100-200-360

50-100-200

50-100-200

Acute Pulmonary Edema, Hypotension, Shock AduAdult Advanced Cardiovascular Life Support


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Clinical signs: Shock, hypotension,congestive heart failure, acute pulmonary edema

Most likely problem?

Acute pulmonary edema Volume problem Pump problem Rate problem

Bradycardiaalgorithm

Tachycardalgorithm

1st-Acute pulmonary edema FurosemideIV 0.5 to 1.0mg/kgMorphineIV 2 to 4 mgNitroglycerinSLOxygen/intubation as needed

AdministerFluids Blood transfusions Cause-specific interventionsConsidervasopressors Blood

pressure?

Systolic BPBP defines2nd line ofaction (seebelow)

Systolic BP100 mmHg

Norepinephrine0.5 to 30 mg/min IV

Dopamine5 to 15 mg/kg perminute IV

Dobutamine2 to 20 mg/kg perminute IV

Nitroglycerin10 to 20 mg/min IV

Consider Ni t ropruss ide0.1 to

5.0 mg/kg per minute2ndAcute pulmonary edemaNitroglycerin/nitroprusside if BP >100 mmHgDopamone if BP = 70 to 199 mmHg, signs/symptoms of shockDobutamine if BP >100 mmHg, no signs/symptoms of shock

Further diagnosis/therapeutic considerations: IABP, PA catheter, Angiography, etc

A t M di l


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Acute MyocardialInfarction

Community early activation of EMS

EMS system

oxygen / IV / cardiac monitor / vital signsNTG, narcoticsnotification of ED, rapid transportprehospital screening of thrombolytic therapy12-lead ECG, analysis, transmissioninitiation of thrombolytic therapy

Emergency departmentDoor-to-drug team protocol approach(triage, decision making)

Assessmentvital signs/ECG/ historydecision for Thrombolysis

Treatmentoxygen / NTG / morphineaspirin/ heparin/ beta-blockerthrombolytic agents

Ischemic Chest Pain Algorithm AduAdult Advanced Cardiovascular Life Support


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pp

Chest pain

suggestive of ischemia

Immediate assessment:


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pp

Assess the initial ECG

within 10 minutes of arrival.

ST segment

elevationor new LBBB

ST segment depression/

dynamic T-wave inversion:strong ly susp ic ious for ischemia

Nondiagnostic ornormal ECG

ST elevation 1 mm in 2 or morecontiguous leads

New or presumably new LBBB(BBB obscuring ST-segment analysis)

ST depression >1 mm Marked symmetrical T-waveinversion in multiple precordial leads

Dynamic ST-T changes with pain

ST depression 0.5 to 1 mm T-wave inversion or flattened inleads with dominant R waves

Normal ECG

90% of patients with ischemic-typechest pain and ST-segmentelevation will develop new Q wavesor positive serum markers for AMI.

Patients with hyperacute T wavesbenefit when AMI diagnosis is certain.Repeat ECG may be helpful.

Patient with ST depression in earlyprecordial leads who have posterior MIbenefit when AMI diagnosis is certain.

High-risk subgroup with increasedmortality Persistent symptoms, recurrentischemia

Diffuse or widespread ECGabnormalities

Depressed LV function Congestive heart failure Serum marker release: positivetroponin or CK-MB+

Heterogeneous group: rapidassessment needed by Serial ECGs ST-segment monitoring Serum cardiac markersFurther risk assessment helpfu Perfusion radionuclide imaging Stress echocardiography

Reperfusion therapy

Aspirin

Heparin (if using fibrin-specific lytics)

b-Blockers, Nitrates as indicated

Antithrombin therapy with heparin

Antiplatelet therapy with aspirin

Glycoprotein IIb/IIIa inhibitors

b -Blockers, Nitrates

Aspirin, Other therapy as appropr

Patients with positive serum

markers, ECG changes, or func-

tional study: manage as high risk

Algorithm for Suspected Stroke AduAdult Advanced Cardiovascular Life Support


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EMS assessment and actionsImmediate assessments Cincinnati

Prehospital Stroke ScaleLos Angeles Prehospital Stroke Screen

Alert hospital to possible stroke patientRapid transport to hospital

Suspected Stroke

Detection

Dispatch

DeliveryDoor

Immediate general assessment:


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Initial therapy for all patients Remove wet garments, Protect against heat loss and wind chill (use blankets and insulating equipment) Maintain horizontal position, Avoid rough movement and excess activity, Monitor core temperature Monitor cardiac rhythm1

Assess resp onsiveness, breathing, and pulse

What is core temp erature? Start CPRDefibri l lateup to a maximum of 3 shocks Attempt, confirm, secure airway warm, humid oxygen(42 to 46)2

IV access, Infuse warm normal saline (43)2

34 to 36 (mild hypothermia) Passive rewarming Active external rewarming

30 to 34 (moderate hypothermia) Passive rewarming

Active external rewarming of truncal areasonly1,3

What is core temp erature?

35 Return of spontaneous circulation or Resuscitative effort cease

30

Continue CPR Withhold IV medications Limit shocks for VF/VTto maximum of 3

Transport to hospital

Continue CPR Give IV medications asindicated (but space atlonger than standardinterval)

repeat defibrillation

for VF/VT as coretemperature rises


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Invasive monitoring /

Therapeutics Arterial cannulation

continuous monitoring of arterial pressure

blood samping

Bedside pulmonary artery catheterization

hemodynamic variables and cardiacoutput

sampling of mixed venous blood

Therapeutics

Pericardiocentesis, EmergencyThoracostomy

Open cardiac massage


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Prolonged Life Support

Goals

Postresuscitation intensive care /

monitoring

Cerebral resuscitation

Identification of the cause of CA

Prevention of recurrence


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Cerebral Resuscitation

Brain-orient noncerebral organ systemperfusion pressure, oxygenation,Normal ventilation, correction of acidosis,body temperature, hemodilution,immobilization/sedation, anticonvulsant

therapy, Brain-specific therapies

barbiturate, calcium channel blockers,free radical scavengers, free iron chelators,excitatory amino acid receptor blocker,

prostaglandin synthesis blockers

G l B i O i t d I t i


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General Brain-Oriented Intensive

Care Normotension: MAP, 90 - 100 mm Hg Normocapnea: PaCO2, 35 - 40 mm Hg

Moderate hyperoxia: PaO2 around 100 mm Hg

Arterial pH 7.3 - 7.5

Immobilization, Sedation, Anticonvulsants asneeded

Normothermia, aggressive treatment ofhyperthermia

Nutritional support started by 48 hours Osmotherapy if indicated

advanced cardiovascular life support (acls)

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