Advance Cardiac Life Support

Trinity University of Asia (St. Luke s College of Nursing)

CPR Milestones 1966 1973 1979 1985 1992 2000 2005 2010 1st conference on CPR AHA Guidelines for ACLS 3rd conference 4th conference 5th conference ILCOR (International Liaison Committee on Resuscitation) Guidelines 2000 for CPR and ECCInternational Consensus on Science Guidelines 2005 for CPR and ECC 2010 AHA Guidelines for CPR and ECC

CPR Statistics Sudden Cardiac Arrest EMS treats nearly 300,000 victims of out-of-hospital cardiac arrest each year in the U.S. Less than eight percent of people who suffer cardiac arrest outside the hospital survive. Sudden cardiac arrest can happen to anyone at any time. Many victims appear healthy with no known heart disease or other risk factors. Sudden cardiac arrest is not the same as a heart attack. Sudden cardiac arrest occurs when electrical impulses in the heart become rapid or chaotic, which causes the heart to suddenly stop beating. A heart attack occurs when the blood supply to part of the heart muscle is blocked. A heart attack may cause cardiac arrest. Cardiopulmonary Resuscitation (CPR) Less than one-third of out-of-hospital sudden cardiac arrest victims receive bystander CPR. Effective bystander CPR, provided immediately after sudden cardiac arrest, can double or triple a victim s chance of survival. The American Heart Association trains more than 12 million people in CPR annually, including healthcare professionals and the general public. The most effective rate for chest compressions is 100 compressions per minute the same rhythm as the beat of the BeeGee s song, Stayin Alive. Automated External Defibrillators (AEDs) Unless CPR and defibrillation are provided within minutes of collapse, few attempts at resuscitation are successful. Even if CPR is performed, defibrillation with an AED is required to stop the abnormal rhythm and restore a normal heart rhythm. New technology has made AEDs simple and user-friendly. Clear audio and visual cues tell users what to do when using an AED and coach people through CPR. A shock is delivered only if the victim needs it. AEDs are now widely available in public places such as schools, airports and workplaces.

Essentials of ACLS CORE of ACLS Concepts y Cerebral Resuscitation is the most important goal! y Returning the patient to the pre-arrested level of neurological functioning y Cardio-Pulmonary-Cerebral resuscitation (CPCR) had been proposed to replace CPR Focuses on Airway and Ventilation, Basic CPR, Defibrillation of Ventricular fibrillation and Drugs The probability of survival declines with each passing minute of cardiopulmonary compromise Medical conditions that lead to cardiac arrest must be identified as quickly as possible (e.g. AMI) The chain of survival applies in all settings. Good ACLS requires a careful thought about when to start and when to stop resuscitative

y y y y y efforts.

The Chain of Survival

The corepurpose of ACLS&ECC To provide effective care ASAP, aim for a rapid restoration of spontaneous circulation and give the best chance of recovery, thus it would include: > Pre-arrest cares, >CPR(BLS & ACLS) & ECC, and > Post-resuscitation cares. ACLS: y impacts multiple key links in the chain of survival that include: y interventions to prevent cardiac arrest y treat cardiac arrest, and y improve outcomes of patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest. y ACLS interventions aimed at preventing cardiac arrest include: y airway management y ventilation support, and y treatment of bradyarrhythmias and tachyarrhythmias. y For the treatment of cardiac arrest, ACLS interventions build on the basic life support (BLS) foundation of: y immediate recognition and activation of the emergency response system y early CPR, and y rapid defibrillation to further increase the likelihood ROSC with drug therapy, advanced airway management, and physiologic monitoring. y Following ROSC, survival and neurologic outcome can be improved with integrated post cardiac arrest care. The Basics ACLS always starts with BLS! Are you OK? Is the patient conscious?

Call for help. Do C-A-B Circulation- check pulse, start CPR!Airway- Is it open? Breathing- moving air?

Defibrillation- if VF or pulseless VT

Drugs Given Via ET Tube Narcan Vasopressin Epinephrine Lidocaine Preferred route is IV/IO If given via ET Tube, double the dose except Vasopressin (insufficient evidence torecommend a dose)

ACLS CORE DRUGS

Epinephrine (Adrenaline) Mechanism of Action - and -adrenergic activity Indication(s) y VF / pulseless VT unresponsive to defibrillation o ACLS Class IIb Recommendation y Asystole / PEA o ACLS Class Indeterminate Recommendation y Symptomatic bradycardia, severe hypotension, & anaphylaxis Standard dose = 1 mg every 3-5 minutes Follow each dose with saline flush May be given via ET tube (double the dose) High dose / Escalating dose No longer recommended No improvement of survival or neurological outcomes May contribute to post-tx myocardial dysfunction Epinephrine Drip Initiate at 1 mcg/min, titrate to hemodynamic endpoint(2-10 mcg/min)

Precautions

Mechanism of Action Naturally occurring antidiuretic hormone Acts as non-adrenergic peripheral vasoconstrictor Direct stimulation of smooth muscle V1 receptors Does not increase myocardial O2 consumption (No beta effects) Levels higher in patients who survive CPR Indication(s) - VF / pulseless VT unresponsive to defibrillation o ACLS Class IIb Recommendation) - Asystole / PEA o ACLS Class Indeterminate Recommendation) Vasodilatory shock (i.e. septic shock) May be helpful in prolonged arrest (Longer half-life than epinephrine) Dose is 40 units IV x1 dose alternative to 1st or 2nd dose of epinephrine Re-dosing (Class Indeterminate) If no response in 10-20 minutes, resume epinephrine, do not repeat doses of vasopressin Re-dosing vasopressin seems rational, but is not supported by human-data. Some practitioners will re-dose vasopressin, this is not supported by ACLS recommendations. Precautions Hypertension, Tremor Myocardial Ischemia, Angina Increased peripheral vascular resistance Overdose treatment is supportive Consider osmotic diuretics if severe overdose Miscellaneous Provided as 20 unit/mL ampule Lidocaine Mechanism of Action Depresses diastolic depolarization & automaticityin the ventricles Indication(s) Persistent or recurrent VF / pulseless VT o ACLS Class Indeterminate Recommendation o Most useful in sustained VF / pulseless VT orwide-complex tachycardia of unknown origin Perfusing arrhythmias Cardiac Arrest (VF/pulseless VT) given as 1 1.5 mg/kg IV initially Repeat doses of 0.5 0.75 mg/kg ( of initial dose) IV every 5-10 min for a total of 3 doses (or) 3 mg/kg May give via ET tube (double the dose) Lidocaine Drip Start at 1-4 mg/min to achieve levels of 1.5 6 mcg/mL Reduce maintenance infusion if hepatic impairment Constant ECG monitoring is necessary w/ infusions Precautions Bradycardia, hypotension, heart block, sinus nodedepression, N/V, double vision, dyspnea Excessive drowsiness is a sign of high blood levels leading to seizures, loss of consciousness, coma Stop infusion immediately, draw levels Adenosine (Adenocard)

Will not convert atrial tachycardias or VT as reentry not involving the AV or sinus node 6 mg rapid IV push (over 1-3 seconds) followed by immediate saline flush push May repeat with 12 mg bolus (x1-2) if no conversion Precautions Transient bradycardia (asystole!), ventricular ectopy, flushing, dyspnea, and chest pain Caution in patients prone to bradycardia or conduction defects without pacemaker Miscellaneous (drug interactions) Reduce dose to 3 mg Dispyridamole, Carbamazepine, Cardiac Transplant, CVL Admin Dose at 12 mg Theophylline, Caffeine M.O.N.A. for ACS Morphine: 2-4 mg Repeat dose of 2-8 mg every 5-15 min as needed Do not use if patient hypovolemic Oxygen: 100% Assist with myocardial oxygen demands Nitroglycerin: 0.4 mg tablet SL every 5 min x3 Reduces preload Aspirin: 325 mg tablet (chewable) Remember: MONA greets all patients

Medication Overdose Naloxone (Narcan) Reverses opiate activities, including respiratory depression from natural & synthetic opioids 0.4 2 mg every 2-3 min up to 10 mg Duration of 20-60 min, typically shorter than most opioids so will need repeat doses May be given via the ET tube (double the dose) Flumazenil (Romazicon) Reverses sedative effects of benzodiazepines Does not reverse respiratory depression with BZD 0.2 mg over 15 sec, repeat in 1 min intervals up to 1 mg Duration of ~60 minutes, repeat as needed

Classification of VF/VT Persistent (shock resistant): persists after multiple shocks Refractory: persists after shocks, CPR, airway, AND drugs Recurrent: returns after a successful intervention

Summary : Ten Commandments for ACLS

1. Do good CPR: do CPR when indicated, refrain when not indicated, and do well 2. Highest priority is the primary survey & hunt for VF 3. The next highest priority is the secondary survey 4. Know the defibrillator! : familiarize and do daily maintenance check 5. Search for reversible or treatable causes. 6. Know the ECC medications: Why? , When? , How? , and Watch out?!? 7. Be a good team: conductor or member 8. Practice the phase response resuscitation format: anticipation/entry/resuscitation/ maintenance/ family notification/ transfer/critique 9. Determine code status in advance 10. Learn and practice the most difficult resuscitation skills*: when not to start CPR when to stop CPR how to tell the family members how to talk with your colleagues

REFERENCES: Circulation Supplement (October 18, 2010) Currents in Emergency Cardiovascular Care Handbook of Emergency Cardiovascular Care (American Heart Association)

Let no man's ghost return to say your training let him down

For the Greater Glory of God (Ad Majoreim Dei Gloriam)