R195/03/31

Chain of Survival

Early Access Early Defibrillation

Early CPR Early Advanced care

Outline

Major changes of 2005 AHA guidelines in defibrillation and ALS

BLS Management of tachycardia Management of pulseless arrest

- VFSCA:

:

,

-

-30:2-CPR-

-15:2-()CPR--

Push fast: 100 Push hard: 1.5-2 Chest recoil: complete chest wall recoil No interruption!

Shock First or CPR First

Witnessed sudden cardiac arrest: AED as soon as possible.

Not witnessed SCA: 5 cycles of CPR before checking ECG and attempting defibrillation.

1-Shock or 3-Shock

Interruption of chest compression No published human or animal studies

compared 1-shock protocol with 6-stacked shock protocol.

Animal study: frequent or long interruption of chest compression post-resuscitation myocardial dysfunction, reduced survival rate!

1-Shock or 3-Shock

Interruption of chest compression: decreased probability of conversion of VF to another rhythm

Chest compression by healthcare providers: only 51-76% of total CPR time.

3-shock protocol delays up to 37 seconds between the first shock to fist post-shock compression.

1-shock + immediate CPR!

Tachycardia

First Step

Tachycardia :

?

SSS synchronized, sedation, shock 100, 200, 300, 360 PSVT: 50J AF : 50J Af : 100J Monomorphic VT 100J Polymorphic VT: 200J (Vf

VT

QRS R

QRS

T Vf

12 lead EKG

QRS ( =0.12

n-QRS ST, PSVTAf, AF, MAT

w-QRS VT, unknown originAf+ aberrancy

Af+ WPWpolymorphic VT Torsades de pointes

QRS

n-QRS ST underlyingPSVT adenosine 6-12-12

Af, AF, MAT control rateDiltiazem -bloker

Sinus Tachycardia

Sinus Tachycardia

HR>100

Painanalgesia Anxietysedation Hyperdynamic state-blockade Hypovolemiavolume replacement

PSVT

PSVT Vagal maneuver Adenosine 6mg (ClassI)

12mg 12mg

(1-3)20mlsaline 3mg :

(ClassIIa) Verapamil 2.5-5mg iv 2 Diltiazem 15-20mg(0.25 mg/kg) iv2 -bloker COPDCHF

Verapamil1. 15-305mg10mg

Max: 20mg2. 155mg

30mg

Diltiazem1520mg25mg(0.35 mg/kg)5-15mg/h

Atrial Flutter

AtrialAtrial FibrillationFibrillation

A.fib: Evaluation and Treatment

1. ?3. WPW ?4. 48 ?

1. 2. ( Control rate )3. ( Convert rhythm)4.

QRS : VT Amiodarone

SVT with aberrancy Adenosine

: Af with aberrancy AfAf with WPW Amiodaronepolymorphic VT AmiodaronePolymorphic VTtorsades de pointes Mg

Wide-Complex Tachycardia

MonomorphicMonomorphic VTVT

VT:VT:Amiodarone

Polymorphic VTPolymorphic VT

VT: VT: QT interval QT interval ?: amiodarone treat ischemia, correct e-: correct electrolytes: Magnesium,

overdrive pacing, isoproterenol, QT interval

Wolff-Parkinson-White Syndrome

WPW with A.fibrillationAmiodarone

What kinds of anti-arrhythmic drugs are harmful to this condition?

AABBCCD D

Amiodarone 150mg IVF 10 6 hr 1mg/min

18 hr 0.5mg/min500ml run 34ml/hr (6)

17ml/hr (18)500ml run 50ml/hr

25ml/hr

2.2g/24hrs (15) 10150mg IVF

MgSO4 MgSO4 1-2g

Torsades de pointes (class IIa)

pulse : D5W 10ml IF 5-20minpulse torsades D5W 100ml IF 5-60min

y

*ABC**()*

QRS

QRS

**Adenosine 6IV12IV12

(A.fib)(AF)(MAT)**(Diltiazem-Blockers-BlockersCHF)

(reentry SVT)**Adenosine(Diltiazem-Blockers)

(AF)(EAT)(JT)

*(Diltiazem-Blockers-Blockers

)**

(VT)

*Amiodarone150 IV 10

2.2g/24hr*

(SVT+Aberrancy)*Adenosine (7)

(A.fib+Aberrancy)*(11)(A.fib+WPW)** (AdenosineDigoxinDiltiazemVerapamil)*(Amiodarone150 IV 10)

torsades de pointes (Magnesium , 1~2g 5~60)

6 12

13 147

8

9 10

11

*4

***

6H-/6T-()()

Summary

1. 2. 12 lead EKGQRS3.

QRS

n-QRS ST underlyingPSVT adenosine 6-12-12

Af, AF, MAT control rateDiltiazem -bloker

QRS : VT Amiodarone

SVT with aberrancy Adenosine

: Af with aberrancy AfAf with WPW Amiodaronepolymorphic VT AmiodaronePolymorphic VTtorsades de pointes Mg

SSS synchronized, sedation, shock 100, 200, 300, 360

PSVT: 50J AF : 50J Af :100J monomorphic VT 100J Polymorphic VT: 200J (Vf

Pulseless Arrest

Pulseless Arrest

1. VF2. Pulseless VT3. PEA4. Asystole

1. CPR VF / pulseless VT

2. CPR PEA / asystole

CPR5cycle

360J200J (120~200J)

1. (biphasic)85%VF!

2. PEA CPR!

CPRCPR

On endo 30:2 100/min

8~10/min

(rhythm pulse)

pulse1.VF/pulseless VT (CPR)2.Asystole/PEA CPR

pulse ROSC (post-R care)

Bosmin: 1mg / 3~5 Vasopressin: 40UBosmin)

Amiodarone 300mg IV then 150mg IV

Lidocaine 1-1.5mg/kg then0.5-0.75mg/kg

Max: 3mg/kg

MgSO4 1-2g (D5W 10ml IF 5-20min)(Torsades de pointes) class IIapulse torsades D5W 100ml IF 5-60min

CPR

2005!

Summary (VF/pulseless VT) S-CPR-endo S: 360J C: CPR Epi 1mg -SC SCcheck Vaso 40 -SC Amio 300-SC Amio 150-SC Lido 1.5mg/kg- SC Lido 0.75mg/kg-SC Lido 0.75mg/kg-SC Mg 2g -SC

Asystole/PEA

CPR Bosmin 1mg 3~5 Vasopressin 40U

Bosmin)

Atropine 1mg 3~5(Max: 3mg)

2005: Vassopressin Asystole/PEA ! 40U!

PEA

6H-/

6T-()()

Pulseless Arrest

BLSCPR

/

Asystole/PEAVF/VT

CPRIV/IOVasopreesor*Epinephrine 1 IV/IO 3~5 Vasopreessin 40U IV/IO Epinephrine

Atropine 1 IV/IOAsystolePEA 3~5(3)

*(120~200(J))200(J)*AED*360(J)CPR

CPR

*()200(J)*AED*360(J)CPR

CPR

1

2

3 9

410

5

6

11

CPR

CPR IV/IOVasopreesor*Epinephrine 1 IV/IO 3~5 Vasopreessin 40U IV/IO Epinephrine

Atropine 1 IV/IOAsystolePEA 3~5(3)

(120~200(J))200(J)*AED*360(J)CPR

CPR

*()200(J)*AED*360(J)CPRIV/IOCPRVasopreesor()*Epinephrine 1 IV/IO 3~5 *Vasopreessin 40U IV/IO Epinephrine

*Asystole10*10*

4

CPR

CPR

CPR

5

6

11

1312

7

8

CPP

CPR

IV/IOCPRVasopreesor()*Epinephrine 1 IV/IO 3~5 *Vasopreessin 40U IV/IO Epinephrine

*Asystole10*10*

4

CPR

*()200(J)*AED*360(J)CPRCPR() Amiodarone(300 IV/IO 150 IV/IO ) Lidocaine(1~1.5 /0.5~0.75 / IV/IO33 /) Torsades de pointesMagnesium 1~2g IV/IOCPR5

CPR

1312

7

8

CPP*(100/)***CPR3025 (2)**

*CPR8~10*2

*6H-/6T-()()

Chain of SurvivalOutline- Shock First or CPR First1-Shock or 3-Shock1-Shock or 3-Shock1-shock + immediate CPR!TachycardiaFirst StepQRSSinus TachycardiaSinus TachycardiaPSVTPSVTAtrial FlutterAtrial FibrillationA.fib: Evaluation and TreatmentQRS Wide-Complex TachycardiaMonomorphic VTPolymorphic VTWolff-Parkinson-White SyndromeWPW with A.fibrillationAmiodaroneAmiodaroneMgSO4SummaryQRSQRS Pulseless ArrestPulseless ArrestSummary (VF/pulseless VT)Asystole/PEAPEA