acls

Advanced Cardiovascular Life Support (ACLS)

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

2010 ACLS Guidelines

Science updates to CPR and ECC

• Basic Life Support

• ACLS• Acute Coronary

Syndrome• Electrical

Therapies• CPR Techniques

and Devices• Stroke• Ethical Issues• Education,

Implementation, and Teams

• International consensus • Extensive review of resuscitation literature• Peer-reviewed studies• Rigorous disclosure and management of conflicts of

interest

The road to change

BLS Survey

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

High Quality Chest Compressions

“push hard and

push fast”

Chest Compressions

To deliver effective chest compressions, you must:

•Rate: at least 100/minute•Depth:

• 2 inches [5 cm] in adults and children• 1.5 inches [4 cm] infants

•Allow full chest recoil•Minimize interruptions•Avoid excessive ventilation

High-Quality Chest CompressionHigh-Quality Chest Compression

For adults, at least 2 inches (5 cm)

Compression Depth At Least 2 InchesCompression Depth At Least 2 Inches

Compression -to- ventilation ratio

Questions?

Change “A-B-C” to “C-A-B”Change “A-B-C” to “C-A-B”

Chest compressions and early defibrillation.

Chest compressions

Elimination of Look, Listen, and FeelElimination of Look, Listen, and Feel

Cricoid pressure is a technique of applying pressure to the victim’s cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebrae. Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag mask ventilation, but it may also impede ventilation.

Definition of Cricoid Pressure

Cricoid Pressure During Ventilation Not RecommendedCricoid Pressure During Ventilation Not Recommended

Check simultaneously:1)Responsiveness2)Breathing

If victim unresponsive and not breathing:1)Activate emergency response system2)Retrieve AED if available3)If no pulse felt within 10 seconds, begin CPR

First

Then

BLS SurveyBLS Survey

16 16

Advanced Cardiovascular Life Support

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Simplified Cardiac Arrest Algorithm

Monitoring to Optimize CPR

Post-Cardiac CareAirway Management

Advanced Cardiovascular Life Support

Overview

Simplified ACLS AlgorithmSimplified ACLS Algorithm

Adult arrest algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

ACLS Cardiac Arrest Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Tachycardia Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Bradycardia Algorithm

Questions?

Capnography RecommendationCapnography Recommendation

Capnography to confirm endotracheal tube placement.

Capnography to monitor effectiveness of resuscitation efforts.

Capnography Waveform

Pressure of end tidal CO2 (PETCO2)

Ineffective chest compressionsindicated by

PEA/asystole

Medication RecommendationsSymptomatic Arrhythmias

New Medication ProtocolsNew Medication Protocols

Epinephrine IV/IO Dose: 1 mg every 3-5 minutesVasopressin IV/IO Dose: 40 units can replace first or second dose of epinephrineAmiodarone IV/IO Dose: First dose: 300 mg bolus.Second dose: 150 mg.

Atropine IV Dose:First dose: 0.5 mg bolusRepeat every 3-5 minutesMaximum: 3 mg

ORDopamine IV Infusion:2-10 mcg/kg per minute

OREpinephrine IV Infusion:2-10 mcg per minute

Adenosine IV Dose: First dose: 6 mg rapid IV push; follow with NS flush.Second dose: 12 mg if required.

Tachycardia

Symptomatic or unstable bradycardia

Organized Post-Cardiac CareOrganized Post-Cardiac Care

Improved Survival

Effect of Hypothermia on PrognosticationEffect of Hypothermia on Prognostication

Oxygen Saturation

Oxygen SaturationOxygen Saturation

Special Resuscitation SituationsSpecial Resuscitation Situations

Acute Coronary Syndromes

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

• Reduce the amount of myocardial necrosis• Prevent major adverse cardiac events• Treat acute, life-threatening complications

ACS

Systems of Care for Patients WithST-Elevation Myocardial Infarction (STEMI)

STEMI Systems of Care

Triage to Capable Hospital

Cardiac Catheterization

Questions?

Electrical Therapies

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Defibrillation | Cardioversion | Pacing

Electrical Therapy

Healthcare Provider AED RecommendationsHealthcare Provider AED Recommendations

AED Use in Children Includes InfantsAED Use in Children Includes Infants

1-shock defibrillation protocol followed by immediate CPR

One-Shock Protocol Versus Three-Shock SequenceOne-Shock Protocol Versus Three-Shock Sequence

Defibrillation Waveforms and Energy LevelsDefibrillation Waveforms and Energy Levels

200 J

Pediatric DefibrillationPediatric Defibrillation

2 J/kg2 J/kg

Fixed and Escalating EnergyFixed and Escalating Energy

Escalating Energy Levels

Joules

Electrode PlacementElectrode Placement

Anterior-lateralAnterior-lateral

Anterior-posteriorAnterior-posterior

Anterior-left infrascapularAnterior-left infrascapular

Anterior-right infrascapularAnterior-right infrascapular

Defibrillation With Implanted Cardioverter DefibrillatorDefibrillation With Implanted Cardioverter Defibrillator

Anterior-posterior or

Anterior-lateral

Anterior-posterior or

Anterior-lateral

Ventricular Tachycardia Supraventricular Tachycardias

• Initial biphasic energy dose of 50-100 J

• Monophasic or biphasic waveform cardioversion shocks at initial energy of 100 J

Synchronized CardioversionSynchronized Cardioversion

Energy Doses

The value of VF waveform analysis to guide defibrillation management during resuscitation is uncertain.

Fibrillation Waveform AnalysisFibrillation Waveform Analysis

CPR Techniques and Devices

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Recommended Devices

No resuscitation device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.

The precordial thump is a CPR technique used by healthcare professionals in the initial response to a witnessed cardiac arrest when no defibrillator is immediately available.

Definition of Precordial Thump

Use of Precordial Thump Not RecommendedUse of Precordial Thump Not Recommended

Stroke

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Stroke CareStroke Care

• Detection

• Dispatch

• Delivery

• Door

• Data

• Decision

• Drug

• Disposition

Stroke-Prepared HospitalStroke-Prepared Hospital

rtPA GuidelinesrtPA Guidelines

Inclusion Criteria• Diagnosis of ischemic stroke causing measurable neurologic deficit• Onset of symptoms <3 hours before beginning treatment• Age ≥18 yearsExclusion Criteria• Head trauma or prior stroke in previous 3 months• Symptoms suggest subarachnoid hemorrhage• Arterial puncture at noncompressible site in previous 7 days• History of previous intracranial hemorrhage• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)• Evidence of active bleeding on examination• Acute bleeding diathesis, including but not limited to

− Platelet count <100 000/mm3− Heparin received within 48 hours, resulting in aPTT >upper limit of normal− Current use of anticoagulant with INR >1.7 or PT >15 seconds

• Blood glucose concentration <50 mg/dL (2.7 mmol/L)• CT demonstrates multilobar infarction (hypodensity >¹⁄³ cerebral hemisphere)Relative Exclusion CriteriaRecent experience suggests that under some circumstances—with careful consideration andweighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relativecontraindications. Consider risk to benefit of rtPA administration carefully if any one of these relativecontraindications is present:

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)• Seizure at onset with postictal residual neurologic impairments• Major surgery or serious trauma within previous 14 days• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)• Recent acute myocardial infarction (within previous 3 months)

Patients Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset

Magnitude of benefits from treatment in a stroke unit are comparable to magnitude of effects achieved with rtPA.

Stroke Unit CareStroke Unit Care

Management of HypertensionManagement of Hypertension

Potential Approaches to Arterial Hypertension in Acute Ischemic StrokePatients Who Are Potential Candidates for Acute Reperfusion Therapy

Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:• Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1, or• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour; when desired blood pressure is reached, lower to 3 mg per hour, or• Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA.

Management of blood pressure during and after rtPA or other acute reperfusion therapy:Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours.

If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or• Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour

If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Questions?

Ethical Issues

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Ethical issues relating to resuscitation are complex.

Arrest not witnessed by EMS provider or first responder

No ROSC after three complete rounds of CPR and AED analyses

No AED shocks were delivered

Terminating Resuscitative Efforts in Adults with Out-of-Hospital Cardiac Arrest (OHCA)

Arrest not witnessed No bystander CPR

was provided No ROSC after

complete ALS care in the field

No shocks were delivered

“ALS termination of resuscitation” rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met:

v

Prognostic Indicators in the Adult Post-Arrest Patient Treated with Therapeutic Hypothermia

Education, Implementation, and Teams

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Learn and LiveLearn and Live

Chain of Survival

Thank you.