Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 1
DR. Alireza Abootalebi Assistant Professor Of Emergency Medicine Isfahan Univercity Of Medical Science 2
Pulseless Arrest 3
4 rhythms produce pulseless cardiac arrest: Ventricular fibrillation (VF) Rapid ventricular tachycardia (VT) Pulseless electrical activity (PEA) Asystole 4
Survival from these arrest rhythms requires both : Basic life support (BLS) and Advanced cardiovascular life support (ACLS) 5
For victims of witnessed VF arrest, prompt bystander : 1.CPR 2.Early defibrillation can significantly increase the chance for survival to hospital discharge. 6
In comparison, typical ACLS therapies, such as: insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge. 7
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Central line access is not needed in most resuscitation attempts. Drugs typically require 1 to 2 minutes to reach the central circulation when given via a peripheral vein but require less time when given via central venous access. 9
peripheral venous route: 1. Follow with a 20 ml bolus of IV fluid 2. Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation. 10
Intraosseous (IO) cannulation provides access to a noncollapsible venous plexus, enabling drug delivery similar to that achieved by central venous access. 11
If IV and IO access cannot be established, some resuscitation drugs may be administered by the endotracheal route 12
E T route: Lidocaine Epinephrine Atropine Naloxone Vasopressin 13
The optimal endotracheal dose of most drugs is unknown, but typically the dose given by the endotracheal route is 2 to 2.5 times the recommended IV dose. 14
Providers should dilute the recommended dose in 5 to 10 ml of water or normal saline 15
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ACLS Cardiac Arrest Algorithm 2010 Neumar, R. W. et al. Circulation 2010;122:S729-S767 Copyright 2010 American Heart Association
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complete cessation of myocardial electrical activity End-stage rhythm Asystole should always be confirmed in at least two limb leads It may be difficult to distinguish between extremely fine VF and asystole 22
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PEA is defined as non-coordinated groups of electrical activity of the heart (other than VT/VF) without a palpable pulse: EMD + pseudo EMD EMD = Electro Mechanical Dissociation : no myocardial contractions occur Pseudo-EMD : myocardial contractions occur but no pulse can be palpated 25
Idioventricular rhythms Ventricular escape rhythms Postdefibrillation idioventricular rhythms Brady-asystolic rhythms Agonal rhythms 26
Global myocardial dysfunction Papillary muscle and myocardial wall rupture Primary supraventricular tachycardia (SVT ( Hypovolemia, tension pneumothorax, pericardial tamponade, and massive PE 27
ASYSTOLE/PEA MANAGEMENT Patients who have either asystole or PEA will not benefit from defibrillation attempts A vasopressor (epinephrine or vasopressin) may be administered at this time. Epinephrine can be administered approximately every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may be substituted for either the first or second epinephrine dose (2010) 28
2015 Recommendation Vasopressin in combination with epinephrine offers no advantage as a substitute for standarddose epinephrine in cardiac arrest. The removal of vasopressin has been noted in the Adult Cardiac Arrest Algorithm. 29
2015 Recommendation It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (ie, during CPR with an advanced airway This simple single rate for adults, children, and infants rather than a range of breaths per minute should be easier to learn, remember, and perform. 30
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1. Ventricular rate is greater than 200 beats/min. 2. QRS structure displays an undulating axis, with the polarity of the complexes appearing to shift about the baseline. 3. Occurrences are often in short episodes of less than 90 seconds, although sustained runs can be seen. 39
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ACLS Cardiac Arrest Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767 Copyright 2010 American Heart Association
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Treatable Causes of Cardiac Arrest: The H's and T's 1. Hypoxia 2. Hypovolemia 3. Hydrogen Ion (Acidosis) 4. Hypo/ Hyper Kalemia 5. Hypothermia 1. Toxins 2. Tamponad (cardiac) 3. Tension Pneumothorax 4. Thrombosis (coronary) 5. Thrombosis (pulmonary) 48
2015 Recommendation There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT. 49
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Emphasis on effective chest compression One universal compression-toventilation 30/2 Recommendation for 1-second breaths during all CPR 51
Rescuers should change compressors every 2 min Compression should ideally be interrupted only for rhythm check and shock delivery 52
Providers do not attempt a pulse or check the rhythm after shock delivery Drug should be delivered during CPR, as soon as possible after rhythm check 53
Antiarrhythmics: Amiodarone is preferred to lidocaine, but either is acceptable Deliver 1 shock, then immediate CPR and NO check pulse 54
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1-Epinephrine 2-Atropine 3-Amiodarone 4-Lidocaine 5-Magnesium 56
When VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer magnesium sulfate at a dose of 1-2 g diluted in 10 ml D5W IV/IO push, typically over 5-20 minutes 57
When torsades is present in the patient with pulses, the same 1-2 g is mixed in 50 to 100 ml of D5W and given as a loading dose. It can be given more slowly (eg, over 5 to 60 minutes IV) 58
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Resuscitation of the Pregnant Patient
Key Points During resuscitation there are two patients, mother & fetus The best hope of fetal survival is maternal survival Consider the physiologic changes due to pregnancy
Successful resuscitation of a pregnant woman & survival of the fetus require prompt & excellent CPR with some modifications in techniques By the 20th week of gestation, the gravid uterus can compress the IVC & aorta, obstructing venous return & arterial blood flow Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side
Defibrillation Defibrillate using standard ACLS defibrillation doses There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus If fetal or uterine monitors are in place, remove them before delivering shocks
Summary Defibrillation & medication doses used for resuscitation of the pregnant woman are the same as those used for other adults Rescuers should consider the need for ER Caesarian Delivery as soon as the pregnant woman develops cardiac arrest Rescuers should be prepared to proceed if the resuscitation is not successful within 4 minutes
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DEFIBRILLATION
Some AEDs will automatically switch themselves on when the lid is opened 68
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Stand clear Deliver shock 71
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defibrillation
CPR prior to defibrillation Lack of success for in-hospital resuscitation appears to result from delays in time to first shock from collapse.
Defibrillation Equipment
List of Materials for Defibrillation Defibrillator/ECG monitor Handheld defibrillation electrodes quick-look paddles Patient interface cables; multifunctional for ECG monitoring and defibrillation Electrodes and pads for ECG signal acquisition and defibrillation Conductive gel (not ultrasound gel)
Additional Equipment (Pertinent to VF/VT) ACLS Medications Epinephrine Vasopressin Amiodarone Lidocaine Magnesium sulfate Procainamide Atropine Miscellaneous IV access equipment, central line kits, and the like
Code cart with defibrillation equipment.
Remember the longer VF persists, the harder it is to defibrillate
Multifunction defibrillator/monitor
Defibrillator monitor capable of 12-lead ECG/cardioversion/pacing/limited ECG interpretation.
Defibrillator Types
Defibrillators (operational characteristics) Manual Semiautomated fully automatic
Monophasic damped sinusoidal (MDS) and monophasic truncated exponential(mte) waveforms
Biphasic waveforms.
no specific waveform has been proved to be superior to another regarding survival from SCA or for the return of spontaneous circulation biphasic waveforms have been shown to be more efficient in achieving first-shock termination of VF than monophasic waveforms.
Monophasic Defibrillators/Energy Selection an energy level of 360 J be used for the first shock
Biphasic Defibrillators An optimal energy level for first-shock for VF has not been established, several studies have demonstrated that using relatively low energy of 200 J or less
Manual Defibrillation with Paddles Select DEFIB Unit automatically defaults to first shock setting To change energy setting, use UP/DOWN ARROWS Press CHARGE on the panel or on the apex handle
Manual Defibrillation with Paddles Apply electrolyte gel to the paddles and apply paddles to chest Make sure everyone is clear When SHOCK button lights, place paddles on chest with 25 lb pressure and simultaneously press SHOCK on both paddles
Correct position for electrode/paddle placement
Use of quick-look paddle electrodes for rhythm (ECG) determination and defibrillation
Front/back position of electrodes on patient (alternate position).
Complications soft tissue injury myocardial injury Cardiac dysrhythmias multifunctional electrode pads better applicators for electrode gels have decreased the potential for soft tissue injuries such as burns to the chest biphasic defibrillation
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