Introduction To Advanced Cardiac Life Support (ACLS - 2010)

ACLS Reading Sources:

AHA Guidelines published in the Circ ulation supplement Dec 2005:

http://circ.ahajournals.org/content/vol1 12/24_suppl/

American Heart Association ACLS Provider Manual

ILCOR
International Liaison Committee on Res uscitation

American Heart Association (AH

A) European Resuscitation Council ( ERC) Heart and Stroke Foundation of C anada (HSFC) Resuscitation Council of Souther n Africa (RCSA) Australia and New Zealand Coun cil on Resuscitation (ANZCOR) Inter American Heart Foundation (IAHF) Japan Resuscitation Council (JR C) International observer to ILCOR

ILCOR Advisory Statements Key Issues in ACLS 2005

Airway CPR Defibrillation Drug therapy Postresuscitation management Special Situations

Stop the Killer

Sudden Cardiac Arrest (SCA) is the numb er one killer in USA. SCA claims ~ one life every 90 seconds... ..over 1,000 lives every day.

50% of SCA deaths in men, and 63% in w omen, occur in people with no prior sympto ms of heartdisease. A person who suffers SCA outside of a h ospital has only a 5% chance of survival

ACLS Course:

Arrest scenarios

VF Pulseless VT Asystole PEA

Pre-arrest scenarios

Tachyarrhythmias Bradyarrythmias

Ischemia

Stable Angina Unstable Angina MI Stroke

Chain of Survival Priorities

Of primary importance:

Prompt CPR Early Defibrillation for VF/VT

Of secondary importance:

Insertion of advanced airway IV Access and Drug administration

Chances of survival with time

Early defibrillation
When defibrillation is delivered within one mi nute, survival rates can be as high as 90%.

If defibrillation is delivered in less than 5 min utes, survival can be as high as 50%. For every minute that passes prior to receivi ng defibrillation, a victim's chance of survival dec lines by about10%. After 10 minutes chances of survival are nea r zero.

Automated Electrical Defibrillator (AED)

The Basics
ACLS always starts with BLS! Are you OK? Is the patient conscious? Call for help. Do primary survey: ABCD Airway- Is it open? Breathing- moving air? Look, Listen, and Feel Circulation- check pulse, start CPR!

Defibrillation- if VF or pulseless VT
Algorithm for basic life support for adult s

Quick BLS Review

Give 2 rescue breaths. Each breath over 1 second, enough to make the che st rise.

Check the pulse for minimum of 5 se conds but no longer than 10 seconds. If no pulse or unsure, start CPR!

Compression to ventilation ratio 30:2 ; after advanced airway no need to interr upt compressions (Rate 100/m)

BLS Key Concepts

Avoid Hyperventilation (Do not ventil ate too fast or too much volume)

Push hard and fast, allow complete c hest recoil, minimal interruptions

Compress chest depth of 1.5 to 2 inc hes at a rate of 100 compressions per m inute

Resume CPR immediately after shoc k. Interruption in CPR for rhythm check should not exceed 10 seconds

BLS Key Concepts

Chest compression should not be interrupt ed except for: (coronary perfusion pressur e) Shock delivery Rhythm check Ventilation (until an advanced airway is inserted) Do not interrupt CPR: To insert cannula or to give drugs To listen to the heart or to take BP?? ? Waiting for charging the Defibrillator To rotate personnel

Equipments for ventilation in BLS Oropharyngeal and nasopharyngeal airways CPR Skill Chart

Secondary Survey: ABCD

AirwayIs an advanced airway needed? If yes, t hen ETT/LMA/Combitube

BreathingTube placed correctly? Secured? Is the re adequate oxygenation and ventilation ?

CirculationWhat is the rhythm? Is there IV access? Drugs?

Differential diagnosis? Find potential reversible causes of arrest.

Advanced Airways
Once advanced airway in place, dont interrupt chest compression for ventilation and avoid over ventilation 8-10 breaths/m

Endotracheal Tube

Laryngeal Mask Airway LMA

Combitube

Arrest Rhythms

Shockable rhythms:

VF Pulseless VT

Non shockable rhythms:

PEA Asystole

Electrical therapies in ACLS

Cardiversion / Defibrillation for Tachyarrhythmias

Unsynchronized = defibrillation (Uses higher energy levels and delivers shock immediately) Synchronized delivers shock at peak of QRS complex (Avoids delivering shock during repolar ization)

Pacing for brady arrhythmias

VF/ Pulseless VT
Witnessed arrest:

2 rescue breaths then Defibrillate

Unwitnessed arrest:

5 cycles of CPR (2 min) then Defibrillate

200 Joules for biphasic machines 360 Joules for monophasic machines Single shock (not 3 shocks) followed by CP No gap between chest compression and sho

ck delivery

Defibrillation technique

11. Return to ALS algorithm for further steps

"Check pulse"

10. Check for output if rhythm change

9. Check ECG rhythm

"Shocking now"

8. Press paddle buttons simultaneously

"Stand clear"

7. Ensure noone is in contact with anything touching the patient

"Charging"

6. Charge to required energy level

5. Select non-synchronized (VF) setting

4. Check ECG rhythm and confirm no pulse

3. Apply paddles

2. Place coupling pads/gel in correct position

1. Switch on.

Announcements

Action

Defibrillation Sequence

How to give drugs?

Peripheral line

(long circulation time 1-2 min, IV Bolus followed by 20 ml NS flush and elevate limb x 10-20 sec)

Central venous line (CVC) Intraosseous (IO) cannulation

(time consuming, relative C/I to fibrinolysis if required)

(safe and effective alternative to peripheral IV access class IIb)

Endotracheal (ET) administration

( Less reliable, 2-2 IV dose, in 5-10 ml D5W or NS)

Drugs that can be given by ETT

NAVVEL
Narcan Atropine Valium Vasopressin Epinephrine Lidocaine Use at least 2 2 x the dose, chase it with 5 10 ml saline, and ventilate. Now IO access is emphasized over ET if IV is not available.

What is the optimal drug therap y for VF?

Does the use of intravenous amiodar one

improve survival?

prevent recurrent dysrhythmias compa red with other anti-dysrhythmia agents?

Eleven article reviewed

6 since 2002

Reasonable evidence exists to suppor t a Class IIa.

A new formulation of amiodarone (Ami

oAqueous) is associated with comparably s mall rates ofhypotension when compared with lidocaine.

Drug Therapy - Amiodarone

Existing human studies favor ami odarone in shock-resistant VF/VT.

Class IIa recommendation after defi brillation and administration of a vasop ressor inshock-resistant VF/VT.

Evidence does not support the us e of amiodarone in the setting of hyp othermicVF/VT.

Drug Therapy - Norepinephrine

Norepinephrine should be class in determinate in the therapy of cardiac arrest.

Not superior to epi Not compared to vasopressin

Drug Therapy - vasopressin

Out of the 1219 patients in the stu dy, 732 failed the first 2 doses of stud y drug.

The patients in the vasopressin arm then received subsequent epi, while th e epi-arm patientsreceived more epi. The combination of vaso and epi pr ovided significantly better outcomes

Vasopressin and asystole (retrospect ive comparison)

Patients who received vasopressin an d epinephrine had a significantly increase d likelihood of ROSCand having a pulse o n arrival to the emergency department

(Guyette et al. 2004)

Differential Diagnosis: 6 Hs & 6 Ts of PEA and Asystole

Hypovolemia

Hypoxia Hydrogen ions (acidosis) Hyper/ hypokalemia Hypothermia Hypoglycemia Toxins (like drug OD) Tamponade Tension PTX Thrombosis (coronary) Thrombosis (pulmonary) Trauma

HYPOKALEMIA: FLAT ST SEGM ENTS

See a normal EKG

HYPOKALEMIA: PROMINENT U WAVES

HYPERKALEMIA: PEAKED T WA VES

See a normal EKG

TREATMENT OF HYPERKALEMI A

Antagonize membrane effects of K +

IV Calcium: onset 1-2 min, duration 30-

60 min

Drive K+ into cells

Insulin (remember to give with glucose!) Beta agonists (high dose) like albuterol

Remove K+ from the body

Kayexalate- binds K+ in gut, onset 1Diureticsonly work if renal function remains Hemodialysis- depends on availability

2 hours

ELECTRICAL ALTERNANS: THE EKG FINDING OF TAMPONADE TREATMENT OF TAMPONADE:

PERICARDIOCENTESIS

TENSION PNEUMOTHORAX TREATMENT OF TENSION PTX

Oxygen

Insert a large-bore (ie, 14gauge or 16gauge) needle into the second intercost al space (above the third rib!), at the mid clavicular line.

GENERAL RULE FOR PEA RHYT HMS

Narrow QRS complex: more likely no ncardiac cause like low volume or low v ascular tone

Wide QRS complex: most likely due t o a cardiac cause, drug toxicity, or electr olye abnormality

ECG LEAD PLACEMENT WHAT IS THIS RHYTHM? ASYSTOLE PROTOCOL

Check another lead Is it on paddles? Adjust the gain Power on? Check lead and cable connections

Hypothermia

ILCOR Advisory statement (2003):

Unconscious adult patients with sp ontaneous circulation after out-ofhospital cardiac arrestshould be coole d to 32-34C for 1224 hrs when the initial rhythm was vent ricular fibrillation(VF).

Such cooling may also be beneficia l for other rhythms or inhospital cardiac arrests.

Hypothermia

Cooling: Retard enzymatic rxns, suppress pro duction of free radicals Reduction of O2 demand in lowflow regions Inhibition of excitatory NT synthesis Protection of membrane fluidity Reduction of intracellular acidosis Decrease in cerebral edema and ICP
Two independent studies utilized surface co oling on intubated, paralyzed patients vs. standa rd of care Multicenter, prospective, randomized trial in Australia *

77 pts: 43 hypothermia, 34 control

33C x 12 hours following resuscitation fro m cardiac arrest

Good neurologic outcome : 49% of cooled, 26% of controls (p=.046)

Multicenter, prospective, randomized trial in Europe * *

275 pts: 137 hypothermia, 138 control 32C to 34C x 24 hours

Good neurologic outcome in: 55% of coole d, 39% of controls (p=.009) Mortality 41% in cooled vs 55% control, P =.02

*NEJM 2002; 346: 557-63 ** NEJM 2002; 345: 549-56

Techniques to Induce Hypothermia

Surface cooling techniques

Slow and imprecise Cumbersome

Limited in depth with nonparalyzed patient

Lavage

Moderately invasive and uncomfortabl Slow and imprecise Limited volumetric capacity Invasive and resource intensive

IV infusions

Cardiopulmonary bypass

KEY CONCEPTS REVISITED

Avoid Hyperventilation Push hard and fast, allow complete c hest recoil, minimal interruptions Compress chest depth of 1.5 to 2 inc hes at a rate of 100 compressions per m inute Compression to ventilation ratio 30:2 , after advanced airway no need to interr uptcompression

Turing defibrillator on Sinus tachycardia Closed loop communication 6 Hs and 6 Ts

Book, readings, benefits of ACLS as a 2nd year

Give 2 rescue breaths. Each breath over 1 second, enough to make the chest rise. Do not venti late too fast or too much volume. Check the pulse for minimum of 5 seconds but no longer th an 10 seconds. If unsure, start CPR! Immediately resume CPR after defibrillation.

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Resume CPR immediately after shock. Interruption in CPR for rhythm check should not exceed 10 seconds

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Assess breathing by seeing chest rise, O2 saturation, capnometry, physical exam

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The drugs that can be given via ET tube.

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PEA doesnt necessarily mean there is no organized electrical activity. There could be any rhyt hm on the strip, and you can use that to narrow down your differential.

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Treatment: rapid but controlled infusion of potassium

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Normal potassium: 3.5 - 5.5 mEq/L Calcium decreases myocardial excitability and normalized the gradient of the resting potential Kayexalate binds K+ in the bowel

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Electrical alternans: the EKG finding of tamponade

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Alligator clip on needle. If see ST changes stop because you went into myocardium

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White on right, smoke above fire, green is grass, fire burns wood and makes smoke Brown goes 5th ICS midclavicular line

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External defibrillator

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Resume CPR immediately after shock. Interruption in CPR for rhythm check should not exceed 10 seconds