Adult Advanced Cardiovascular Life Support Emergency Procedures in PT
BLS Can be learned & practiced by the general public Includes: CPR First Aid (e.g. choking relief) Use of AED ACLS Used by healthcare professionals Includes: Use of meds to treat emergency heart-related conditions and stroke BLS Treatment using intubation, bag-mask ventilations, ECG/EKG
Advanced CV Life Support (ACLS) prevent cardiac arrest treat cardiac arrest improve outcomes of patients who achieve (ROSC) ** after cardiac arrest
Key Changes in 2010 ACLS Guidelines 2005 2010 Use clinical assessment plus additional confirmation methods (eg, ETCO2 detector, esophageal detector devices (EDD) Continuous quantitative waveform capnography Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high-quality CPR
Key Changes in 2010 ACLS Guidelines 2005 2010 Atropine 1 mg q 3 5 min (give atropine if PEA rate < 60) Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole. There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC.
Key Changes in 2010 ACLS Guidelines Atropine, Epinephrine 2005 2010 Chronotropic drug infusions for symptomatic and unstable bradycardia. Adenosine for stable undifferentiated regular monomorphic wide-complex tachycardia.
Part 1: Adjuncts for Airway Control and Ventilation
Bag-Mask Ventilation Airway Adjuncts Advance Airways
Bag-Mask Ventilation All healthcare providers should be familiar with the use of the bag-mask device. it is NOT recommended for a lone provider. AND used by a trained and experienced provider.
Bag-Mask Ventilation How to use it? One provider opens the airway and seals the mask to the face while the other squeezes the bag. helpful when placement of an advanced airway is delayed or unsuccessful
Airway Adjuncts Oropharyngeal airways Nasopharyngeal airways
Airway Adjuncts Oropharyngeal airways not for pts with cardiac arrest Prevent tongue from occluding the airway used for unconscious pts with no cough or gag reflex
Airway Adjuncts Nasopharyngeal airways useful in pts with airway obstruction or those at risk for developing one e.g clenched jaw used in pts with known or suspected basal skull fracture or severe coagulopathy
Advance Airways Supraglottic Airways Endotracheal Intubation Automatic Transport Ventilators
Advanced Airways Supraglottic Airways designed to maintain an open airway and facilitate ventilation can be inserted without interrupting compressions E.g. LMA, Combitube, Laryngeal tube
Esophageal-Tracheal Tube Advantages: Isolation of airway Reduced risk of aspiration More reliable ventilation Ease of training compared to endotracheal tube Complications*: compared to B-M ventilation Esophageal trauma (e.g. lacerations, bruising) Subcutaneous emphysema
Laryngeal Tube Advantages: same with Combitube PLUS more compact and less complicated to insert (up to esophagus)
Laryngeal Mask Airway Advantages: More secure and reliable means of ventilation Less regurgitation compared to B-M Alternative to endotracheal intubation when there is unstable neck injury or positioning for intubation is impossible
Endotracheal Intubation once considered the optimal method of managing the airway during cardiac arrest Complications: Trauma to oropharynx Interruption of compression and ventilation Hypoxemia d/t prolonged intubation attempts Unrecognized tube misplacement/ displacement
Endotracheal Intubation Indications: inability of the provider to ventilate the unconscious patient adequately with a bag and mask and the absence of airway protective reflexes (coma or cardiac arrest)
Endotracheal Intubation Application during CPR limit interruptions to no more than 10 seconds compressions should be interrupted only for the time required by the intubating provider to visualize the vocal cords and insert the tube (less than 10 seconds)
Summary All basic and advanced healthcare providers should be able to provide ventilation with a bag-mask device during CPR. Airway control with an advanced airway is a fundamental ACLS skill. Prolonged interruptions in chest compressions should be avoided during advanced airway placement.
Part 2: Management of Cardiac Arrest
Review of Cardiac Arrest Causes: Ventricular Fibrillation (VF) Pulseless Ventricular Tachycardia (VT) Pulseless Electric Activity (PEA) Asystole
Review of Cardiac Arrest Causes: VF disorganized electric activity VT organized electric activity Do not generate significant forward blood flow PEA organized with absent/insufficient mechanical activity to give detectable pulse Asystole absent ventricular activity w/ or w/o atrial activity
ACLS Cardiac Arrest Algorithm. Neumar R W et al. Circulation 2010;122:S729-S767 Copyright American Heart Association
ACLS Cardiac Arrest Circular Algorithm. Neumar R W et al. Circulation 2010;122:S729-S767 Copyright American Heart Association
The foundation of successful ACLS is high-quality CPR, and, for VF/pulseless VT, attempted defibrillation within minutes of collapse.
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