The International Liaison Council (Committee) of Resuscitation (ILCOR)

Transcription

1 CPR GUIDELINES

2 It is our pleasure to present to you this work as a result of team work of the national CPR committee at the Saudi Heart Association (SHA). We adapted the 2010 guidelines as per The International Liaison Council (Committee) of Resuscitation (ILCOR) which was published October, We modified some of the items of 2005 guidelines and kept some as it is depending on our national need in the kingdom of Saudi Arabia. As an example, the sequence of A.B.C in children and infants should not change because most common cause of child and/or infant arrest is respiratory, so respiratory assessment should take place at the beginning. Reviewing the international resuscitation science since 2010 till 2012, there is a great emphasis on the early CPR and early defibrillation which make difference between life and death, good outcome and bad outcome of in hospital CPR. there is also a great emphasis on CPR awareness to the community through the skillful programs.

3 National CPR Committee Members

4 ADVANCED LIFE SUPPORT Unresponsive? Not breathing or only occasional gasps Call Resuscitation Team CPR 30:2 Attach defibrillator/monitor Minimize interruptions AED Assesses Rythm Shockable (VF /Pulseless VT) Return Of Spontaneous Circulation No Shock Advised 1 Shock Immediately resume: CPR 30:2 for 2 min Minimize interruptions Immediate Post Cardiac Arrest Treatment - Use ABCDE approach. - Controlled Oxygenation and ventilation lead ECG. - Treat precipitating cause. - Temperature control / Therapeutic hypothermia. - Entidal Co2 monitoring. Immediately resume: CPR 30:2 for 2 min Minimize interruptions DURING CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway In place Vascular access intravenous, intraosseous) Give epinephrine every 3-5 min Amiodarone 300 mg IV bolus for refractory VF/pulseless VT Correct reversible causes REVERSIBLE CAUSES Hypoxia Hypervolemia Hypo- / hyperkalemia / metabolic Hypothermia Thrombosis - coronary or pulmonary Tamponade - cardiac Toxins Tension pneumothorax

5 ACS ALGORITHM (DIAGNOSES) Patient with clinical signs & symptoms of ACS 12 Lead ECG ST Elevation 0.1 mv In 2 adjacent limb leads and/ or 0.2 mv in adjacent chest leads or (presumably) new LBBB Other ECG alterations (or normal ECG) STEMI = NSTEMI if troponins (T or I) positive = UA if troponins remain negative Non-STEMI-ACS High risk - Dynamic ECG changes - ST depression - Hemodynamic/rhythm Instability - Diabetes mellitus

6 ACS ALGORITHM (TREATMENT) ECG Pain Relief Nitroglycerin if systolic BP > 90 mmhg ± Morphine (repeated doses) of 3-5 mg until pain free Antiplatelet Treatment 16o-325mg Acetylsalicylic acid chewed tablet mg Clopidogrel according to strategy* OXYGEN THERAPY if Spo2 < 94 % STEMI Non-STEMI-ACS Thrombolysis preferred if: No contraindications and inappropriate delay to PCI PCI preferred if: Within the time window & availability of highly specialized center. Contraindications for thrombolytic therapy, cardiogenic shock (or severe left ventricular failure) According to risk stratification: Antiplatelet therapy Antianginal therapy Antithrombin therapy Serial cardiac enzymes Reperfusion for high risk

7 BRADYCARDIA ALGORITHM YES Atropine 500mcg IV Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, Sp02, record12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities) Assess for evidence of instability signs: 1. Shock 2. Syncope 3. Myocardial ischemia 4. Heart failure NO Satisfactory Response? NO Interim Measure: Atropine 500 mcg IV Repeat to maximum of 3 mg Isoprenaline 5 mcg/min Epinephrine 2-10 mcg/min Alternative drugs* OR Dopamine/dobutamine infusion (alternative to transcutaneous pacing) Transcutaneous pacing Seek Expert help Arrange transvenous pacing YES YES Risk of Asystole? - Recent asystole - Mobitz 2 AV block - Complete heart block with broad QRS - Ventricular pause > 3s NO Observe * Alternatives include: Aminophylline Dopamine Glucagon (if beta-blocker or calcium channel blocker overdose)

8 TACHYCARDIA ALGORITHM (WITH PULSE) Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, Sp02,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities Unstable Assess for evidence of instability signs: 1. Shock 2. Syncope 3. Myocardial ischemia 4. Heart failure Stable Synchronized DC Shock* Up to 3 attempts Amiodarone 300 mg IV over min & repeat shock; followed by: Darone 900 mg over 24 h Irregular Seek Expert Help Possibilities Include: AF with bundle branch block treat as for narrow complex Pre-excited AF consider amiodarone Polymorphic VT (e.g. torsades de pointes give magnesium 2 g over 10 min Broad Broad QRS Is QRS regular? Regular If Ventricular Tachycardia: Amiodarone 300 mg IV over min; then 900 mg over 24 h If previously confirmed SVT with bundle branch block or (uncertain monomorphic rhythm): Give adenosine as for regular narrow complex tachycardia Use vagal maneuvers Adenosine 6 mg rapid IV bolus; If unsuccessful give 12 mg; If unsuccessful give further 12 mg. Monitor ECG continuously Normal sinus rhythm restored? YES Regular Is QRS narrow (< 0.12 sec)? Narrow QRS Is QRS regular? Irregular narrow complex tachycardia Probable atrial fibrillation Control rate with: B-Blocker or diltiazem Consider digoxin or amiodarone If evidence of heart failure Anticoagulate If duration > 48h NO Narrow Irregular Seek Expert Help *Attempted electrical cardioversion is always undertaken under sedation or anesthesia Probable re-entry PSVT: Record 12 lead ECG in sinus rhythm If recurs, give adenosine again & consider choice of antiarrhythmic prophylaxis Possible atrial flutter Control rate (e.g. B-Blocker)

9 PAEDIATRIC ADVANCED LIFE SUPPORT Unresponsive? Not breathing or only occasional gasps CPR (2 initial breaths then 15:2) Attach defibrillator/ monitor Minimize interruptions Assesses Rythm Shockable (VF /Pulseless VT) Return Of Spontaneous Circulation No Shock Advised (PEA/Asystole) 1 Shock 4 J/Kg Immediately resume: CPR for 2 min Minimize interruptions Immediate Post Cardiac Arrest Treatment - Use ABCDE approach - Controlled Oxygenation and ventilation - Investigations - Treat precipitating cause - Temperature control - therapeutlc hypothermia - Entidal Co2 monitoring Immediately resume: CPR for 2 min Minimize interruptions DURING CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway In place Vascular access intravenous, intraosseous) Give epinephrine every 3-5 min Amiodarone 5mg / kg IV bolus for refractory VF/pulseless VT Correct reversible causes REVERSIBLE CAUSES Hypoxia Hypervolemia Hypo- / hyperkalemia / metabolic Hypothermia Thrombosis - coronary or pulmonary Tamponade - cardiac Toxins Tension pneumothorax

10 NEWBORN LIFE SUPPORT Dry the Baby Remove any wet towels & cover Start the clock or note the time Assess (tone), Breathing & Heart Rate Birth 30 sec If gasping or not breathing Open the airway 60 sec Give 2 inflation breaths Consider Sp02 monitoring Re-assess If no increase in heart rate Look for chest movement If chest not moving Recheck head position Consider two-person airway control or other airway manoeuvres Repeat inflation breaths Acceptable* pre-dudalsp02 2 min:60% 3 min :70% 4 min:80% 5 min :85% 10 min:90% Consider Sp02 monitoring Look for a response If no increase in heart rate Look for chest movement When the chest is moving If the heart rate is not detectable or slow (< 60) Start chest compressions 3 compressions to each breath Reassess heart rate every 30 seconds If the heart rate is not detectable or slow (< 60) Consider venous access and drugs

11 PERFORMANCE Sheets

12 ACLS PERFORM AIRWAY Teaching Testing NAME: Batch#: DATE: Skills Station 1: Airway Adjuncts and Intubation Objectives: On completion of Testing Station 2, the student will have demonstrated the ability to perform or demonstrate the following: 1. Ventilate adult manikin using mouth-to-mask technique. (Each participant must have his or her own mask; masks must not be shared.) 2. Insert esophageal airway into adult intubation manikin and provide effective ventilation. 3. Intubate trachea of adult intubation manikin with endotracheal tube and assess that both lungs can be inflated simultaneously. 4. Intubate trachea of adult intubation manikin with endotracheal tube while esophageal airway is in place. 5. Intubate trachea of infant intubation manikin with endotracheal tube and assess that both lungs can be inflated simultaneously. Time Skills Pass Fail A. Mouth-to-Mask Ventilation W ith Supplemental Oxygen 1. Connect oxygen line with 10L flow. 30 sec 2. Establish airway by head - tilt. 3. Insert oropharyngeal airway with proper technique. 4. Establish seal with mask. 5. Ventilate mouth-to-mask & record 800ml minimumtidal volume on recording manikin at least three times in 15 seconds. B. Esophageal Airway (or use optional PTL airway, with appropriate procedure for insertion) 20 sec 1. Assume ventilation is in progress. 2. Grasp jaw between thumb and index finger and lift upward, but keep mouth open; do not hyperextend neck. 3. With mask attached, insert tubeinto mouth and place it so that the curvature is the same as that of the pharynx. 4. Advance into esophagus and seal mask firmly over mouth and nose. 5. Ventilate and see if chest rises - inflate cuff with 35 - ml syringe. 6. Check placement of esophageal airway by visualizing lung inflation with each ventilation and by auscultating both sides of chest and over stomach with stethoscope.

13 C. Adult Intubation 35 sec 40 sec 30 sec 1. Assume ventilation is in progress. 2. Connect laryngoscope blade and handle; check light: check cuff on endotracheal tube. 3. Hold laryngoscope in left hand. 4. Insert laryngoscope in right side of mouth, moving tongue to the left. 5. Visualize epiglottis, then vocal cords. 6. Insert ETT (endotracheal tube). 7. Inflate cuff with 4-6 ml of air. 8. Check placement of ETT by ventilating, visualizing lung inflations, and auscultating both sides of chest and over stomach with stethoscope. D. intubation of Trachea with Esophageal Airway in Place 1. Esophageal airway is in place. 2. Intubate trachea. 3. Ventilate through endotracheal tube. 4. Remove esophageal airway. E. Infant Intubation 1. Assume ventilation is in progress. 2. Connect laryngoscope blade and handle; check light. 3. Hold laryngoscope in left hand. 4. Insert laryngoscope in right side of mouth, moving tongue to left. 5. Visualize epiglottis, then vocal cords. 6. Insert endotracheal tube. 7. Check placement of tube by mouth-to-tube or bag-to-tube ventilation, observing chest movement and auscultating chest and over stomach with stethoscope. Overall Grade (circle one) Instructor Pass Fail

14 ACLS PERFORM IV Teaching Testing NAME: batch #: DATE: Skills Station 2: PLACEMENT OF INTRAVENOUS FLUID LIFE LINE, PERIPHERAL AND CENTRAL VEINS OBJECTIVES: On completion of Station 4, the student will be able to: 1. Describe the surface markings and the technique for insertion of an intravenous cannula into: a) A peripheral vein b) A femoral vein c) An internal jugular or subclavian vein 2. Assemble the components of an intravenous infusion lifeline. 3. Describe the surface markings and the technique for insertion of aninteroseous (IO) cannula into the shaft of a leg. NOTE: Learning during practice is enhanced by utilizing the illustrations from the paper which demonstrate each approach. Once the student has learned the site of the venipunctureand the angles of approach for cannulation of central veins and can demonstrate such on a model, he should practice on a cadaver and finally actually perform these techniques on a living patient under supervision until the procedure can be performed safely and efficiently. Only then can he be considered "certified" to perform central venipuncture. Knowledge of these performance criteria is only the first step toward acquiring such a skill. Choose one of each of the following: verbalize and demonstrate landmarks rather than actually doing venipuncture: 1) Peripheral vein; 2) Femoral vein; and 3) Internal jugular (one approach) or subclavian. TIME CRITERIA PASS FAIL I PERIPHERAL VEINS 60 Sec. A. ARMS OR LEGS 1. Apply tourniquet proximally. 2. Locate vein and cleanse the overlying skin with alcohol or povidone - iodine. 3. Anesthetize the skinif a large bore cannula is to be inserted in an awake patient. 4. Hold vein in place by applying pressure on vein distal to the point of entry. 5. Puncture the skin with bevel of needle upward about ½ to 1 6. Centimeter from the vein and enter the vein either from the side or from above. 7. Note blood return and advance the catheter either over or through the needle, depending on which type of catheter - needle device is employed. Remove the tourniquet. 8. Withdraw and remove the needle and attach the intravenous tubing. 9. Cover the puncture site with povidone iodine -ointment and a sterile dressing and tape in place, excluding the point of connection of the intravenous tubing.

15 60 Sec. B. EXTERNAL JUGULAR II. 1. Patient in supine, at least 150 head down position, head turned away toward opposite side. 2. Cleanse skin, use lidocaine if patient awake and large bore needle used 3. Align needle in the direction of the vein with the point aimed toward the ipsilateral shoulder. 4. Make venipuncture midway between angle of jaw and midclavicular line; "tourniqueting" the vein lightly with one finger above the clavicle. 5. Note blood return. 6. Advance catheter and remove needle; attach to IV tubing. 7. Cover puncture site and affix catheter in place CENTRAL VEINS 60 Sec. A. FEMORAL 1. Cleanse the overlying skin with povidone-iodine;this is especially important in this site because the danger of contamination is great. If the puncture is being performed electively, shave the hair around the area. 2. Locate the femoral artery either by its pulsation or by finding the midpoint of a line drawn between the anterior superior iliac spine and the symphysis pubis. 3. Infiltrate the skin with lidocaine if the patient is awake. 4. Make the puncture with the needle attached to a 5 or 10 milliliter syringe two fingerbreadths below the inguinal ligament, medial to the artery, directing the needle cephalad at a 4-5 degree angle with the skin or frontal plane (some prefer to enter at a 9-0 degree angle) until the needle will go no further. 5. Maintain suction on the syringe and pull the needle back slowly until blood appears in the syringe, indicating that the lumen of the vein has been entered. 6. Remove the syringe and insert catheter with the needle more parallel to the frontal plane. 7. Withdraw the needle, leaving the catheter in place. 8. Connect to intravenous tubing. 9. Cover the puncture site with povidone- iodine ointment and a steri dressing and secure the catheter and tubing in place.

16 60 Sec. B. SUBCLAVIAN, INFRACLAVICULAR APPROACH 1. Patient in supine, at least 150 head down position, head turned away. 2. Cleanse skin, use lidocaine if patient awake. 3. Introduce needle attached to a syringe I centimeter below the junction of the middle and medial thirds of the clavicle. 4. Hold the syringe and needle parallel to the frontal plane(the plane of the back of the patient). 5. Direct the needle medially, slightly cephalad, and posteriorly behind the clavicle toward the posterior superior angle of the sternal end of the clavicle. 6. Establish a good point of reference by firmly pressing the fingertip into the suprasternal notch to locate the deep side of the superior angle of the clavicle and directing the course of the needle slightly behind the fingertip. 7. Advance needle while withdrawing plunger of syringe. 8. When blood appears and vein entered, rotate bevel of needle caudally; remove syringe and insert catheter to predetermined depth. 9. Remove needle and connect catheter to IV tubing. 10. Cover puncture site, and affix catheter in place. 60 Sec. C. INTERNAL JUGULAR, POSTERIOR APPROACH 1. Patient in supine, at least 15 0 head down position, head turned away. 2. Cleanse skin, use lidocaine if patient awake. 3. Introduce the needle under the sternomastoid muscle near the junction of the middle and lower thirds of the lateral (posterior) border (5 centimeters above the clavicle or just above where the external jugular vein crosses the sternomastoid muscle). 4. Aim the needle caudally and ventrally (anteriorly) toward the suprasternal notch at an angle of 45 degrees to the sagittal and horizontal planes and with 15-degree forward angulation in the frontal plane. 5. The vein should be entered within 5 to 7 centimeters. 6. Advance needle while withdrawing plunger of syringe. 7. When blood appears and vein entered, remove syringe and insert catheter to predetermined depth. 8. Remove needle and connect catheter to IV tubing. 9. Cover puncture site, and affix catheter in place.

17 60 Sec. D. INTERNAL JUGULAR, MIDDLE OR CENTRAL ROUTE 1. Patient in supine, at least 15 0 head down position, head turned away. 2. Cleanse skin, use lidocaine if patient awake. 3. Introduce needle attached to syringe in the center of triangle formed by two lower heads of sternomastoid muscle and clavicle. 4. Direct needle caudally, parallel to sagittal plane, at 30 -posterior angle with frontal plane. 5. If vein is not entered, withdraw needle and redirect it 5 to 10 degrees laterally. 6. Advance needle while withdrawing plunger of syringe. 7. When blood appears and vein entered, remove syringe and insert catheter to predetermined depth. 8. Remove needle and connect catheter to IV tubing. 9. Cover puncture site, and affix catheter in place. 60 Sec. E. INTERNAL JUGULAR, ANTERIOR APPROACH 7 minutes 1. Patient in supine, at least 15 0 head down position, head turned away. 2. Cleanse skin, use lidocaine if patient awake. 3. Place the left index and middle fingers (if from the right side) 3 centimeters lateral to the mid - sternal line; the carotid artery is retracted medially away from the anterior border of the sternomastoid. 4. Introduce the needle at the midpoint of this anterior border (5 centimeters above the clavicle and 5 centimeters below the angle of the mandible). 5. Forming a posterior angle of 30 to 45 degrees with the frontal plane, direct the needle caudally toward the ipsilateral nipple and toward the junction of the middle and medial thirds of the clavicle. 6. Advance needle while withdrawing plunger of syringe. 7. When blood appears and vein entered, remove syringe and insert catheter to predetermined depth. 8. Remove needle and connect catheter to IV tubing. 9. Cover puncture site, and affix catheter in place. Instructors (s): (check) Pass Fail (check) Pass Fail

18 INTRAOSSEOUS INFUSION INTRODUCTION: Bone shaft acts as non-collapsible vein through which medication & fluids can be given. It is an old procedure but become popular recently. It is not the first choice. A rigid needle is Inserted into the cavity of a long bone. Indications: Used for critical situations when a peripheral IV is unable to be obtained. Initiate it after 90 seconds or three unsuccessful IV attempts. SITES: STEPS OF INTRODUCTION OF MEDICATIONS: 1. Select the medication and prepare equipment. 2. Palpate the puncture site and prepare with an antiseptic solution. 3. Make the puncture. 4. Aspirate to confirm proper placement. 5. Aspirate to confirm proper placement. 6. Connect the IV Tubing. 7. Administer the medication. 8. Monitor the patient for effects. COMPLICATIONS: - Fracture - Infiltration - Growth plate damage - Complete insertion - Pulmonary embolism - Infection - Thrombophlebitis - Air embolism - Circulatory overload - Allergic reaction CONTRAINDICATIONS TO INTRAOSSEOUS PLACEMENT: - Fracture to tibia or femur on side of access. - Osteogenesis imperfecta congenital bone disease resulting in fragile bones. - Osteoporosis. - Establishment of a peripheral IV line.

19 ACLS PERFORM MEGACODE Teaching Testing NAME: batch #: DATE: Objectives: On completion of Testing Station 4, during a -5minute scenario, the Team Leader will have performed as follows: 1. Supervised and directed arrest team in a sequence that would lead to successful resuscitation. 2. Monitored arrest team to insure that his/her directions were correctly carried out. 3. Correctly diagnosed arrhythmias and made proper treatment decisions. 4. Operated a defibrillator in the counter shockor cardio versionmode as appropriate and interposed it into team activity in a safe and proper sequence. 5. Prescribed the appropriate drug(s) in correct dosage. 6. Ordered and interpreted lab data. Skills (Team Leader) Pass Fail Supervision and leadership Proper sequencingincluding BLS skills Monitoring other team members Rhythm diagnosis Defibrillator operation Drugs Ordering and interpretation of lab data Overall Grade (Circle one) Instructor Pass Fail