2010 Advance Cardiac Life Support

8/6/2019 2010 Advance Cardiac Life Support

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Advance Cardiac Life SupportTrinity University of Asia (St. Lukes College of Nursing)

CPR Milestones

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

victims 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 BeeGees 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 andrestore 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.


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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 functioningy Cardio-Pulmonary-Cerebral resuscitation (CPCR) had been proposed to replace

CPR

y Focuses on Airway and Ventilation, Basic CPR, Defibrillation of Ventricular fibrillation and Drugsy The probability of survival declines with each passing minute of cardiopulmonary compromisey Medical conditions that lead to cardiac arrest must be identified as quickly as possible (e.g. AMI)y The chain of survival applies in all settings.y Good ACLS requires a careful thought about when to start and when to stop resuscitativeefforts.

The Chain of Survival


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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 arresty treat cardiac arrest, andy 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 managementy ventilation support, andy 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 systemy early CPR, andy 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 postcardiacarrest 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


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Drugs Given Via ET Tube

Narcan Preferred route is IV/IO

Vasopressin

Epinephrine

Lidocaine

ACLS CORE DRUGS

Epinephrine (Adrenaline)

Mechanism of Action

- - and -adrenergic activity Indication(s)

y VF / pulseless VT unresponsive to defibrillationo ACLS Class IIb Recommendation

y Asystole / PEAo 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

If given via ET Tube, double the dose

except Vasopressin (insufficient

evidence torecommend a dose)


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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

oACLS Class Indeterminate Recommendation

o Most useful in sustained VF / pulseless VT orwide-complex tachycardia of unknownorigin

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)


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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


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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)

Documents

2010 Advance Cardiac Life Support