Introduction To Advanced Cardiac Life Support (ACLS - 2008) :Introduction To Advanced Cardiac Life Support (ACLS - 2008) Dr Saber A Malak M.B.B.Ch, M.Sc, Diploma (Card) MRCP-UK


ACLS Reading Sources: :ACLS Reading Sources: AHA Guidelines published in the Circulation supplement Dec 2005: http://circ.ahajournals.org/content/vol112/24_suppl/ American Heart Association ACLS Provider Manual


ILCOR :ILCOR International Liaison Committee on Resuscitation American Heart Association (AHA) European Resuscitation Council (ERC) Heart and Stroke Foundation of Canada (HSFC) Resuscitation Council of Southern Africa (RCSA) Australia and New Zealand Council on Resuscitation (ANZCOR) Inter American Heart Foundation (IAHF) Japan Resuscitation Council (JRC) – International observer to ILCOR


ILCOR Advisory Statements :ILCOR Advisory Statements


Key Issues in ACLS 2005 :Key Issues in ACLS 2005 Airway CPR Defibrillation Drug therapy Post-resuscitation management Special Situations


Stop the Killer :Stop the Killer Sudden Cardiac Arrest (SCA) is the number one killer in USA.  SCA claims ~ one life every 90 seconds.....over 1,000 lives every day.   50% of SCA deaths in men, and 63% in women, occur in people with no prior symptoms of heart disease.   A person who suffers SCA outside of a hospital has only a 5% chance of survival


ACLS Course: :ACLS Course: Arrest scenarios VF Pulseless VT Asystole PEA Pre-arrest scenarios Tachyarrhythmias Bradyarrythmias Ischemia Stable Angina Unstable Angina MI Stroke


Chain of Survival :Chain of Survival


Priorities :Priorities Of primary importance: Prompt CPR Early Defibrillation for VF/VT Of secondary importance: Insertion of advanced airway IV Access and Drug administration


Chances of survival with time :Chances of survival with time


Early defibrillation :Early defibrillation When defibrillation is delivered within one minute, survival rates can be as high as 90%. If defibrillation is delivered in less than 5 minutes, survival can be as high as 50%. For every minute that passes prior to receiving defibrillation, a victim's chance of survival declines by about 10%. After 10 minutes chances of survival are near zero. Automated Electrical Defibrillator (AED)


The Basics :The Basics ACLS always starts with BLS! “Are you OK?” Is the patient conscious? Call for help. Do primary survey: ABCD Airway- Is it open? Breathing- moving air? Look, Listen, and Feel Circulation- check pulse, start CPR! Defibrillation- if VF or pulseless VT


Algorithm for basic life support for adults :Algorithm for basic life support for adults


Quick BLS Review :Quick BLS Review Give 2 rescue breaths. Each breath over 1 second, enough to make the chest rise. Check the pulse for minimum of 5 seconds but no longer than 10 seconds. If no pulse or unsure, start CPR! Compression to ventilation ratio 30:2; after advanced airway no need to interrupt compressions (Rate 100/m)


BLS Key Concepts :BLS Key Concepts Avoid Hyperventilation (Do not ventilate too fast or too much volume) Push hard and fast, allow complete chest recoil, minimal interruptions Compress chest depth of 1.5 to 2 inches at a rate of 100 compressions per minute Resume CPR immediately after shock. Interruption in CPR for rhythm check should not exceed 10 seconds


BLS Key Concepts :BLS Key Concepts Chest compression should not be interrupted except for: (coronary perfusion pressure) Shock delivery Rhythm check Ventilation (until an advanced airway is inserted) Do not interrupt CPR: To insert cannula or to give drugs To listen to the heart or to take BP??? Waiting for charging the Defibrillator To rotate personnel


Equipments for ventilation in BLSOropharyngeal and nasopharyngeal airways :Equipments for ventilation in BLSOropharyngeal and nasopharyngeal airways


CPR Skill Chart :CPR Skill Chart


Secondary Survey: ABCD :Secondary Survey: ABCD Airway- Is an advanced airway needed? If yes, then ETT/LMA/Combitube Breathing- Tube placed correctly? Secured? Is there adequate oxygenation and ventilation? Circulation- What is the rhythm? Is there IV access? Drugs? Differential diagnosis? Find potential reversible causes of arrest.


Advanced AirwaysOnce advanced airway in place, don’t interrupt chest compression for ventilation and avoid over ventilation 8-10 breaths/m :Advanced AirwaysOnce advanced airway in place, don’t interrupt chest compression for ventilation and avoid over ventilation 8-10 breaths/m Endotracheal Tube Laryngeal Mask Airway LMA Combitube


Slide 22:Arrest Rhythms Shockable rhythms: VF Pulseless VT Non shockable rhythms: PEA Asystole Electrical therapies in ACLS Cardiversion / Defibrillation for Tachyarrhythmias Unsynchronized = defibrillation (Uses higher energy levels and delivers shock immediately) Synchronized delivers shock at peak of QRS complex (Avoids delivering shock during repolarization) Pacing for brady arrhythmias


VF/ Pulseless VT :VF/ Pulseless VT Witnessed arrest: 2 rescue breaths then Defibrillate Unwitnessed arrest: 5 cycles of CPR (2 min) then Defibrillate 200 Joules for biphasic machines 360 Joules for monophasic machines Single shock (not 3 shocks) followed by CPR No gap between chest compression and shock delivery


Defibrillation technique :Defibrillation technique


How to give drugs? :How to give drugs? Peripheral line (long circulation time 1-2 min, IV Bolus followed by 20 ml NS flush and elevate limb x 10-20 sec) Central venous line (CVC) (time consuming, relative C/I to fibrinolysis if required) Intraosseous (IO) cannulation (safe and effective alternative to peripheral IV access – class IIb) Endotracheal (ET) administration ( Less reliable, 2-2 ½ IV dose, in 5-10 ml D5W or NS)


Slide 26:Drugs that can be given by ETT NAVVEL Narcan Atropine Valium Vasopressin Epinephrine Lidocaine Use at least 2 – 2 ½ x the dose, chase it with 5 – 10 ml saline, and ventilate. Now IO access is emphasized over ET if IV is not available.


What is the optimal drug therapy for VF? :What is the optimal drug therapy for VF? Does the use of intravenous amiodarone improve survival? prevent recurrent dysrhythmias compared with other anti-dysrhythmia agents? Eleven article reviewed 6 since 2002 Reasonable evidence exists to support a Class IIa. A new formulation of amiodarone (Amio-Aqueous) is associated with comparably small rates of hypotension when compared with lidocaine.


Drug Therapy - Amiodarone :Drug Therapy - Amiodarone Existing human studies favor amiodarone in shock-resistant VF/VT. Class IIa recommendation after defibrillation and administration of a vasopressor in shock-resistant VF/VT. Evidence does not support the use of amiodarone in the setting of hypothermic VF/VT.


Drug Therapy - Norepinephrine :Drug Therapy - Norepinephrine Norepinephrine should be class indeterminate in the therapy of cardiac arrest. Not superior to epi Not compared to vasopressin


Drug Therapy - vasopressin :Drug Therapy - vasopressin Out of the 1219 patients in the study, 732 failed the first 2 doses of study drug. The patients in the vasopressin arm then received subsequent epi, while the epi-arm patients received more epi. The combination of vaso and epi provided significantly better outcomes Vasopressin and asystole (retrospective comparison) Patients who received vasopressin and epinephrine had a significantly increased likelihood of ROSC and having a pulse on arrival to the emergency department (Guyette et al. 2004)


Differential Diagnosis:6 Hs & 6 Ts of PEA and Asystole :Differential Diagnosis:6 Hs & 6 Ts of PEA and Asystole Hypovolemia Hypoxia Hydrogen ions (acidosis) Hyper/ hypokalemia Hypothermia Hypoglycemia Toxins (like drug OD) Tamponade Tension PTX Thrombosis (coronary) Thrombosis (pulmonary) Trauma


Hypokalemia: flat ST segments :Hypokalemia: flat ST segments See a normal EKG…


Hypokalemia: Prominent U waves :Hypokalemia: Prominent U waves


Hyperkalemia: peaked T waves :Hyperkalemia: peaked T waves See a normal EKG…


Treatment of Hyperkalemia :Treatment of Hyperkalemia Antagonize membrane effects of K + IV Calcium: onset 1-2 min, duration 30-60 min Drive K+ into cells Insulin (remember to give with glucose!) Beta agonists (high dose) – like albuterol Remove K+ from the body Kayexalate- binds K+ in gut, onset 1-2 hours Diuretics- only work if renal function remains Hemodialysis- depends on availability


Electrical alternans: the EKG finding of tamponade :Electrical alternans: the EKG finding of tamponade


Treatment of Tamponade: :Treatment of Tamponade: Pericardiocentesis


Tension Pneumothorax :Tension Pneumothorax


Treatment of Tension PTX :Treatment of Tension PTX Oxygen Insert a large-bore (ie, 14-gauge or 16-gauge) needle into the second intercostal space (above the third rib!), at the midclavicular line.


General Rule for PEA rhythms :General Rule for PEA rhythms Narrow QRS complex: more likely noncardiac cause like low volume or low vascular tone Wide QRS complex: most likely due to a cardiac cause, drug toxicity, or electrolye abnormality


ECG lead placement :ECG lead placement


What is this rhythm? :What is this rhythm?


Asystole Protocol :Asystole Protocol Check another lead Is it on paddles? Adjust the gain Power on? Check lead and cable connections


Hypothermia :Hypothermia ILCOR Advisory statement (2003): Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34°C for 12-24 hrs when the initial rhythm was ventricular fibrillation (VF). Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrests.


Hypothermia :Hypothermia Cooling: Retard enzymatic rxns, suppress production of free radicals Reduction of O2 demand in low-flow regions Inhibition of excitatory NT synthesis Protection of membrane fluidity Reduction of intracellular acidosis Decrease in cerebral edema and ICP


Slide 47:Two independent studies utilized surface cooling on intubated, paralyzed patients vs. standard of care Multi-center, prospective, randomized trial in Australia* 77 pts: 43 hypothermia, 34 control 33°C x 12 hours following resuscitation from cardiac arrest Good neurologic outcome : 49% of cooled, 26% of controls (p=.046) Multi-center, prospective, randomized trial in Europe ** 275 pts: 137 hypothermia, 138 control 32°C to 34°C x 24 hours Good neurologic outcome in: 55% of cooled, 39% of controls (p=.009) Mortality 41% in cooled vs 55% control, P=.02 *NEJM 2002; 346: 557-63 ** NEJM 2002; 345: 549-56


Techniques to Induce Hypothermia :Techniques to Induce Hypothermia Surface cooling techniques Slow and imprecise Cumbersome Limited in depth with non-paralyzed patient Lavage Moderately invasive and uncomfortable Slow and imprecise IV infusions Limited volumetric capacity Cardiopulmonary bypass Invasive and resource intensive


key concepts Revisited… :key concepts Revisited… Avoid Hyperventilation Push hard and fast, allow complete chest recoil, minimal interruptions Compress chest depth of 1.5 to 2 inches at a rate of 100 compressions per minute Compression to ventilation ratio 30:2, after advanced airway no need to interrupt compression Turing defibrillator on… Sinus tachycardia… Closed loop communication… 6 Hs and 6 Ts…