CPR ACLS Recertjuliomodified

ACLS/CPR In-service : 

ACLS/CPR In-service Presented by: Instructors Julio P. Diaz and/or Chad N. Bird

Slide 2: 

The annual number of out-of-hospital cardiac arrest in North America is about 0.55 per 1000 population (or about 1 person out of 2000) Statistically with a population of approximately 750,000, Gwinnett is looking at about 375 out-of-hospital cardiac arrests this year. About 60 percent of unexpected cardiac deaths are treated by emergency medical services Studies show that HIGH quality CPR is what saves lives!!! What is HIGH quality CPR?

Important Points : 

Important Points Five key aspectsto high quality CPR !

Coronary Perfusion Pressure (CPP) : 

Coronary Perfusion Pressure (CPP) Aortic pressure – right atrial pressure=CPP MAJOR DETERMINANT FOR SURVIVAL IS CPP (the heart must be perfused) Highly correlated to ROSC When CPR is paused, CPP falls quickly When CPR is restarted, it takes several compressions to reestablish the previous CPP

Compression-Decompression : 

Compression Compression of heart & lungs Delivers blood to Brain and peripheral vasculature. Decompression Refilling of heart & lungs Delivers blood to the heart Compression-Decompression

One person vs. Two personCompression to Ventilation Ratio : 

One person vs. Two personCompression to Ventilation Ratio Adults 30:2 Children 30:2 Infants 30:2 Adults 30:2 Children 15:2 Infants 15:2

It’s still A, B, then C : 

It’s still A, B, then C Yes, it’s still airway, breathing, then circulation, but advanced airways such as ETT have taken a back seat to good uninterrupted CPR. If OPA/NPA or Combitube is maintaining the airway, leave it in. Intubation generally requires a pause in CPR which is harmful to the patient, so consider Combitube or a King Airway (coming to Gwinnett Soon).

Slide 10: 

Each rescue breath should be given over 1 second. Just enough to produce chest rise will do. Shorter Breaths decrease interruption in CPR. AVOID HYPERVENTILATION!! When you do have an advanced airway in place, ventilations should be about 1 every 6-8 seconds.

Check, and Re-check your airway : 

Check, and Re-check your airway When advanced airway is in place (especially ETT), you should confirm it as many ways as you can. Direct Visualization, BS, absent epigastric sounds, aspirator, Easy Cap CO2 detector, Capnography

NO MORE STACKED SHOCKS : 

NO MORE STACKED SHOCKS SINGLE SHOCK = MORE CPR

Rationale : 

Rationale The average time for an AED to deliver three stacked shocks is 90 seconds. THAT’S 1 ½ MINUTES WITHOUT CPR If the first shock does not eliminate VF, resumption of CPR is likely more beneficial It takes several minutes for a normal heart rhythm to return and more time for the heart to create a decent pressure after VF is eliminated. CPR can bridge that gap. Immediate CPR after defibrillation is not harmful.

When to De-Fib? : 

When to De-Fib? Obviously when they’re in V-fib or PVT Shock immediately if you witness the arrest and you have a monitor or AED readily available. If it is un-witnessed, do two minutes or 5 cycles of GOOD CPR.

Importance of CPR : 

Importance of CPR Rather than treating all “shockable” rhythms with direct countershock, the current model of VF arrest suggests that the optimal treatment changes over time. While the treatment for VF in the first 4 minutes is still a shock, very few out of hospital cardiac arrest patients are reached in this phase. The notable exception is witnessed arrest patients, who should always be shocked immediately. The optimal therapy after 10+ minutes, when the metabolic phase is reached, is still unknown. It is worth pointing out that the morphology of VF appears to change over time, which is an observation that most EMS providers have made before.

Importance of CPRPriming the Pump : 

Importance of CPRPriming the Pump These VF tracings demonstrate the priming effect from an electrophysiological perspective. As pointed out with the 3-phase model schematic, the morphology of VF changes as time passed. The VF at 1 min is well within the electrical phase, with greater amplitude and median frequency. After 8 min, the morphology is very different; a shock at this point would likely be unsuccessful in producing return of spontaneous circulation (ROSC). However, after only 90 sec of chest compressions, the morphology looks similar to the “fresh” VF on the left.

Defibrillation – Energy setting : 

Defibrillation – Energy setting Adult defibrillation: Monophasic defibrillator 360j, and keep at 360j. Biphasic type 200j, and keep at 200j. (unless manufacturer recommends otherwise).

Drug Administration : 

Drug Administration IV or IO drug administration is preferred to ETT route. Drugs should be delivered early during CPR so you can circulate the drug, but timing of drug administration is less important than the need to minimize interruptions in chest compressions

What if you can’t get a line? : 

What if you can’t get a line? ETT route is better than no route at all!!! With the advancement of adult IO, soon there will be other options for drug administration.

Antiarrhythmics : 

Antiarrhythmics No evidence that giving any antiarrythmic drug routinely during cardiac arrest increases rate of survival to hospital discharge You should probably remember this for some reason (hint hint)

Slide 23: 

Algorhythms

Symptomatic Bradycardia : 

Symptomatic Bradycardia ABC’s, O2, IV, Monitor. Atropine 0.5-1mg IV. (Do not delay pacing to start an IV). Pace @ 70bpm. Start @ 50mA and increase by 5 or 20 mA increments until capture. Consider Dopamine drip 2-10mcg/kg/min. Epi-drip 2-10mcg/min if the patient has sever clinical symptoms.

Bradycardia Considerations : 

Bradycardia Considerations If the patient is stable, monitor en-route. Be prepared for them to get worse though. Atropine may not work in high degree heart blocks. Atropine given at doses lower than 0.5mg can produce paradoxical bradycardia.

Tachycardic Rhythms : 

Tachycardic Rhythms Wide vs. Narrow Stable vs. Unstable

Wide Complex TachStable……………Unstable : 

Wide Complex TachStable……………Unstable ABC’s, O2, IV, ECG Cordarone 150mg over 10 minutes. (Use soluset, put 150mg in 100ml of NS). Contact Med Control ABC’s, O2, IV, ECG If conscious, consider sedation with Versed. Cardiovert @ 100j

Narrow Complex TachStable…………...Unstable : 

Narrow Complex TachStable…………...Unstable ABC’s, O2, IV, ECG Consider Vagal Maneuvers Adenosine 6, 12, 12 Contact Med Control ABC’s, O2, IV, ECG If conscious, consider sedation with Versed Cardiovert @ 100j

What makes a patient unstable? : 

What makes a patient unstable? Use all you findings about a patient. LOC, breathing effort, skin CTM, BP. Patients c/o CP, SOB may be or become unstable rapidly. Be prepared!

Asystole/PEA : 

Asystole/PEA ABC’s, O2, IV, ECG, CPR (30:2 for 2 min) Epinephrine 1mg 1:10,000 (2mg 1:1,000 ETT) Atropine 1mg (2mg ETT). If in PEA, give atropine if rate is <60. Consider causes: see next slide

Causes of Asystole/PEA : 

Causes of Asystole/PEA Hypovolemia (Fluid Challenge) Hypoxia (Ventilate with O2) Tension Pneumo (Decompress) Hypothermia (Warming) OD (Narcan) Acidosis (Bi-Carb) Hyperkalemia (Bi-Carb) Cardiac Tamponade PE Massive MI (R.I.P.)

V-fib/PVT : 

V-fib/PVT ABC’s, O2, IV, ECG, CPR (30:2 for 2 min) D-fib @ 200j 2 min CPR, ETT/Combitube, Epi 1mg 1:10,000 IV, Cordarone 300mg IV D-fib @ 300j CPR (30:2 for 2 min) D-fib @ 360j CPR (30:2 for 2 min), Lidocane 1.5mg/kg IV or 150mg Cordarone

Cardiac Chest Pain : 

Cardiac Chest Pain ABC’s, O2, IV, ECG ASA 324mg PO 12-lead NTG if not Inferior or contraindicated 2-4mg Morphine High Diesel Drip Contact Med Control for more Morphine or Valium Notify facility of STEMI

Pulmonary Edema : 

Pulmonary Edema ABC’s, O2, IV (KVO if unclear BS), ECG Sit the patient up 12-lead If BP >110, give NTG 0.4mg SL X3 q3-5 Morphine 2-4mg Contact Med Control

SUMMARY : 

SUMMARY Effective ACLS begins with good basic skill and high-quality CPR! The potential effects of any drugs or other ACLS therapy on VF SCA are dwarfed by the potential effects of high-quality CPR.