Advance Cardiac Life support for Family Physician · Cardiovascular Care Coronary angiography 1....

Advance Cardiac Life support for Family Physician

P i t s u c h a S a n g u a n w i t

E m e r g e n c y D e p a r t m e n t

R a m a t h i b o d i H o s p i t a l

2 9 M a y 2 0 1 9

Outline

▪ System of care Cardiopulmonary resuscitation

▪ Basic life support

▪ Advance cardiac life support ▪ Cardiac arrest algorithm ▪ Tachycardia algorithm ▪ Bradycardia algorithm

▪ Post cardiac arrest care

▪ New and Updated Recommendations

▪ CPR device

▪ Measure effort Resuscitation outcome

▪ In-hospital cardiac arrest

Systems of care of cardiopulmonary resuscitation

Question 1

▪ทมีใดมหีนา้ที ่ประเมนิและรกัษาผูป่้วย ป้องกนัไมใ่หผู้ป่้วยอาการแย่ลงและป้องกนั In-hospital cardiac arrest

a) EMS team

b) CPR team

c) Critical care team

d) Rapid response team

e) Lay rescuer team

Cardiopulmonary resuscitation (CPR)

▪ Series lifesaving action to improve survival

after cardiac arrest

▪ Depend on

Rescuer

Patient

Resource

How to achieve early and effective CPR

System-specific Chain of Survival

Resuscitation : link Community to Ems to hospital

Out of hospital cardiac arrest

Medical emergency Team And rapid response team

▪ Management of life threatening emergencies requires integration of multidisciplinary team

▪ IHCA: 80% hospital patient had abnormal vital sign up to 8 hr. before arrest

Critical care team

Code (CPR) team

Rapid response

team

The systematic approach

Initial Impression (provider visually checks while approaching patient)

Conscious patient

(appearance)

BLS assessment

Unconscious Patient (appearance)

Secondary assessment

Primary assessment

Scene safety

Basic life support (BLS) assessment

Question 2

▪ ขอ้ใดเหมาะสมทีสุ่ดกบั “Minimize interrupt the chest compression in adult”?

a) Rhythm analysis immediately after defibrillation

b) check pulse at least 10s for analyze rate and fullness

c) Give compression and ventilation ratio 15:2

d) Do not switch role; compression and ventilation until compressor fatigue

e) Avoid Unnecessarily move patient

Lay Rescuer Not Trained: Follow dispatcher’s instructions. Lay Rescuer Trained: check if no breathing or only gasping;,begin CPR

Respiratory arrest drowning., head injury

5-10s

AED analyze as soon as possible

Q 2min -check pulse -check rhythm(AED) -switch roll

Adult BLS assessment for health care provider

Check responsive

• Tap shoulder

Shout for help/

activate EMS; get AED

Check breathing and pulse

CPR

30:2

defibrillation

1.Chest Compression Rate

▪ Rate - Depth - Recoil - Position

▪ Rate In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/min (Class IIa, LOE C-LD)

▪ physiologic studies ▪ Compression rate 120/min ได ้blood flow ดทีี่สุด โดยวดัend-tidal CO2

Circulation 2012;125:3004-3012

Crit Care Med 2015;43(4):840–848

Circulation 2012;125:3004-3012

125/min probability of ROSC สูงสุด (p = 0.012) probability of survival to D/C ไมม่นียัยทางสถติิ

Crit Care Med 2015;43(4):840–848

likelihood of survival : compression rate 100 – 119 มากที่สุด If rate > 119 จะไดค้วามลกึในการกดที่นอ้ยลง

2. Compression Depth

▪ During manual CPR,

▪ chest compressions depth at least 5 cm for an average adult, while avoiding depths greater than 6 cm (Class I, LOE C-LD)

Compression - Increase cardiac output - Increase cerebral perfusion

mean compression depth was divided into three categories <50 mm, 50-60 mm, >60 mm, increase injuries of 28%, 27% and 49% (p = 0.06).

Resuscitation 84 (2013) 760–765

3.Chest Wall Recoil

▪ Allow full chest wall recoil for adults in cardiac arrest (Class IIa, LOE C-LD)

Decompression - Filling Heart (venous return) - Perfuse coronary a. blood flow

4.Chest compression: position

▪ position hands for chest compressions on lower half of the sternum in adults with cardiac arrest (Class IIa, LOE C-LD)

Resuscitation. 2013;84:1203–1207

5.Minimizing Interruptions in Chest Compressions

▪ Pauses chest compressions should be as short as possible (Class I, LOE C-LD).

▪ goal of chest compression fraction as high as possible, with a target ≥60% (Class IIb, LOE C-LD).

Coronary perfusion pressure

Coronary perfusion pressure (CPP)

▪ Coronary perfusion pressure is aortic relaxation (diastolic pressure)

▪ ROSC did not occur unless CPP > 15 mmHg

▪ Minimize interrupt ,no longer than 10s

▪ Avoid ▪ Prolong rhythm analysis

▪ Inappropriate check pulse ▪ To long to give breathing

▪ Unnecessarily move patient

Compression-to-Ventilation Ratio

▪ Compression-to-ventilation ratio of 30:2 for adults in cardiac arrest (Class IIa, LOE C-LD).

Layperson—Compression-Only CPR Versus Conventional CPR: BLS

▪ Dispatchers should provide chest compression–only for OHCA (Class I, LOE C-LD).

▪ For lay rescuers, ▪ compression–only alternative to conventional CPR (Class IIa,LOE

C-LD).

▪ For trained lay rescuers, ▪ reasonable to provide ventilation add to chest compressions

(Class IIa, LOE C-LD).

Layperson—Compression-Only CPR Versus Conventional CPR: BLS

RCT

Not different

Advance cardiac life support

Question 3

▪ ชาย 60 ปี หมดสตบินสะพานลอย พลเมอืงดนี ามาส่งทีโ่รงพยาบาล นอนไม่รูส้กึตวั แรกรบัตดิ EKG monitor ไดด้งัภาพ ท่านจะท าอย่างไรต่อไปเป็นล าดบัแรก

a) Defibrillation 200 J

b) Oxygen mask with bag 10 LPM, Keep O2 sat > 94%

c) Check pulse

d) Synchronized cardioversion 100 J

e) EKG 12 leads

ACLS 2018

ACLS 2018

Shockable

-early defibrillation

-high quality CPR

-5H 5T

Non Shockable

-early epinephrine

-high quality CPR

-5H 5T

Shock1

Pump

Shock2

Pump, epinephrine

Shock3 Pump, amiodarone or lidocaine

Q 2min -check pulse

-check rhythm -switch roll

Adult Recommendations

•Use of antiarrhythmic drugs during resuscitation from adult VF/pVT cardiac arrest

• Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to

defibrillation.

• Routine magnesium for cardiac arrest is not recommended in adult patients. may be

considered for torsades

• Insufficient evidence routine β- blocker or lidocaine within the first hour after ROSC.

Question 4

What’s ROSC of EtCo2

a) .

b) .

c) .

d)

e)

ETCO2

• partial pressure of exhaled Co2 at end of expiration

• determined • CO2 production

• alveolar ventilation (V)

• pulmonary blood flow.(Q)

• During cardiac arrest • ETCO2 levels reflect cardiac output by chest compression.

• Low ETCO2: inadequate cardiac output

• but ETCO2 levels can also be low • bronchospasm, mucous plugging of the ETT, kinking of the ETT,

alveolar fluid in the ETT, hyperventilation

New and Updated Recommendations ACLS

1. Maximal inspired oxygen during CPR, but not apply after ROSC.

2. Physiologic monitoring during CPR may be useful • waveform capnography

• Arterial relaxation diastolic pressure

• arterial pressure monitoring

• central venous oxygen saturation

for optimize CPR quality, guide vasopressor therapy, and detect ROSC (Class IIb, LOE C-EO).

New and Updated Recommendations

▪ 3.Recommendations for ultrasound during cardiac arrest

Cardiac Tamponade LV D-shape = PE

New and Updated Recommendations

4. Continuous waveform capnography remained a Class I

▪ recommendation for confirming placement ETT.

▪ Ultrasound was added for confirmation of ETT

ETT dislodge, cardiac arrest ROSC

New and Updated Recommendations

5. Vasopressin was removed from ACLS Cardiac Arrest Algorithm as a vasopressor therapy (increase coronary vasoconstriction)

6. Non-shockable rhythm, epinephrine as soon as feasible

New and Updated Recommendations

7.Prognostication during CPR

▪ Low PEtco2 in intubated patients after 20 minutes of CPR associated with failure of resuscitation.

▪ not be used in isolation and not used in non-intubated patients.

New and Updated Recommendations

8. ECPR

▪ veno-arterial extracorporeal membrane oxygenation, may considered an alternative conventional CPR for refractory cardiac arrest reversible cause

H

A

S

I A

SVT w aberrancy

Vagal maneuver

▪ Carotid sinus massage

Adenosine

▪ Adenosine 6 mg IV rapid push (Right antecubital vein) double syringe technique ถา้ไม ่convert ใน 1-2 นาท ีให ้adenosine 12 mg IV

▪ ลด dose เหลอื 3 mg กลุม่ทีไ่ดร้บัยา ▪ Dipyridamole

▪ Carbamazepine

▪ heart transplant

▪ ใหท้าง central line

Synchronize cardioversion

▪ Consider sedation

▪ After synchronize: check patient as soon as possible

H

A

S

I A

Pacing- defibrillation Pad

Transcutaneous pacing

▪ Mode: Syn/Asyn, demand/Fix

▪ Rate: 60-70 ppm

▪ Output:มากกวา่ค่าทีน่อ้ยทีสุ่ด สามารถ pacing ไดท้กุตวั ประมาณ 10mA

post cardiac arrest care

Question 5

▪ ขอ้ใดถกูตอ้งมากทีสุ่ดเกี่ยวกบัการดูแลผูป่้วย Post cardiac arrest

a) แนะน าใหท้ า hyperventilation ทกุราย

b) แนะน าให ้Monitor PEtCO2 ทกุราย

c) แนะน าให ้load isotonic solution 1-2 L ในผูป่้วยทกุรายที ่SBP<90mmHg

d) แนะน าใหท้ า PCI ในผูป่้วยทกุรายทีไ่มต่อบสนองตามค าส ัง่ หลงักลบัมามชีพีจร

e) แนะน าใหท้ า Targeted temperature management ไดต้ ัง้แต่จดุเกดิเหต ุ

ROSC -คล า pulseได ้/วดั BP ได ้

-EtCo2 sustain -Pulse wave on arterial line

Post cardiac arrest care system of care

▪ Post cardiac arrest care syndrome

Reperfusion response

Systematic ischemia

Myocardial dysfunction

Brain injury

Post cardiac arrest care Multidisciplinary management

Targeted temperature management(TTM)

Hemodynamic and ventilation optimization

-

Immediate coronary reperfusion

Neurologic care and prognostication

prognostic delay at least 72h. after

Cardiovascular Care Coronary angiography

1. OHCA suspected cardiac etiology of arrest and ST elevation (Class I, LOE B-NR).

2. adult comatose after OHCA of suspected cardiac origin but without ST elevation (Class IIa, LOE B-NR).

3. post–cardiac arrest patients for whom coronary angiography is indicated whether comatose or awake (Class IIa, LOE C-LD).

Targeted Temperature Management

▪ selecting and maintaining a constant temperature between 32ºC and 36ºC during TTM (Class I, LOE B-R).

▪ maintained at least 24 hrs (Class IIa, LOE C-EO).

▪ against routine prehospital cooling after ROSC with rapid infusion of cold intravenous fluids (Class III: No Benefit, LOE A)

▪ prevent fever in comatose patients after TTM

Hemodynamic and ventilation optimization

▪ Hemodynamic ▪ MAP > 65 mmHg หรือ SBP > 90 mmHg

▪ optimize blood pressure, cardiac output, systemic perfusion

▪ Correct hypotension: fluid bolus, dopamine 5-10 mcg/kg/min, NE 0.1-0.5 mcg/kg/min, epinephrine 0.1-0.5 mcg/kg/min

▪ Monitor EKG

▪ Ventilation optimization ▪ keep o2 sat 94%(avoid toxicity)

▪ avoid excessive hyperventilation,

▪ Normocarbia

▪ Ventilator setting :TV 6-8 ml/kg, plateau pressure < 30 cmH2O

CPR device

Question 6

▪ ขอ้ใดถกูตอ้งเกี่ยวกบั CPR device

a) Impedance Threshold Device (ITD) เพิม่ อตัรารอดชวีติเมือ่ใชร่้วมกบั conventional CPR

b) Automatic compression ―Lucas‖ ใชห้ลกัการ circumferential chest compression

c) Automatic compression ―autopulse‖ ใชร่้วมกบั Impedance Threshold Device (ITD) สามารถเพิม่ อตัรารอดชวีติ

d) Automatic compression good survival outcome than manual chest compressions

e) Automatic compression can used in limited rescuers setting

Impedance Threshold Device (ITD)

▪ ลกัษณะเป็น pressure-sensitive valve ใชต่้อเขา้กบั ▪ facemask, supraglottic airway, endotracheal tube:

▪ limits air entry into the lungs during decompression phase, increase negative intrathoracic pressure improve venous return

▪ Routine use as an adjunct during conventional CPR is not recommended. (Class III: No Benefit, LOE A)

▪ not demonstrate benefit or harm when use ITD when use ITD conventional CPR.

Active Compression-Decompression CPR and Impedance Threshold Device

▪ Not support the routine use of ACD-CPR+ITD as an alternative to conventional CPR.

▪ combination may alternative in settings with available equipment and properly trained personnel. (Class IIb, LOE C-LD)

ResQ Trial: important limitations, lack of blinding, different CPR feedback, lack of CPR quality assessment, early termination.

Mechanical Chest Compression Devices

▪ 1. Piston Device automated compressed

▪ gas- or electric-powered compresses the chest at a set rate. Some incorporate a suction cup

▪ The Lund University Cardiac Arrest System (LUCAS)

▪ LUCAS-2 ม ีsuction cup เพือ่ ให ้active compression decompression (ACD-CPR)

Mechanical Chest Compression Devices

▪ 2. Load-Distributing Band (LDB) device, LCD-CPR circumferential chest compression device composed of a pneumatically or electrically actuated constricting band and backboard

▪ Autopulse

Autopulse & manual Lucus & manual

Survival to discharge not different

Mechanical Chest Compression Devices

▪ Not demonstrate benefit with piston devices for chest compressions versus manual chest compressions

▪ may alternative use by trained personnel. (Class IIb, LOE B-R)

▪ considered in specific settings ▪ limited rescuers,

▪ prolonged CPR, during hypothermic arrest,

▪ moving ambulance,

▪ angiography suite,

▪ during preparation ECPR, (Class IIb, LOE C-EO)

Measure effort the resuscitation outcome

▪ Real time feedback CPR

▪ Compression rate

▪ Depth

▪ Recoil

▪ Chest compression fraction

CPR feedback device

ZOLL, CPR Dashboard™

TruCPR(physiocontrol)

Smart phone base CPR feedback (APP)

2013 by the American College of Emergency Physicians

Resuscitation training combined real-time audiovisual feedback associated improved CPR quality, survival, and favorable functional outcomes after out-of-hospital cardiac arrest.

(E-series; ZOLL Medical, Chelmsford, MA) with Food and Drug Administration–approved

▪ Real-time Feedback

▪ Mechanical Chest Compression

▪ Timely Vascular Access: Intraosseous (IO) access offers an invaluable alternative to peripheral and central venous catheters.

▪ Capnography

CHEST 2017

Automatic External Defibrillator

▪ ประกาศ กพฉ. ก าหนดใหก้ารใช ้

AED เป็นการปฐมพยาบาล สามารถใชไ้ดโ้ดยบคุคลท ัว่ไป ลง

วนัที ่๒๒ เมษายน พ.ศ. ๒๕๕๘

บคุคลท ัว่ไปในประเทศไทยไดร้บั

อนุญาตใหใ้ชเ้ครื่อง AED ได ้แลว้ ถอืเป็นส่วนหนึ่งของการปฐม

พยาบาลระหวา่งรอความช่วยเหลอื

จากแพทย ์

In-Hospital Cardiac Arrest IHCA

In-hospital cardiac arrest (IHCA)

▪ Cardiac arrest (code) team (in-hospital)

▪ Rapid assessment, monitor quality CPR

▪ Cardiac arrest team unlikely to prevent arrest

▪ Best way to improve chance of survival; to prevent it (cardio-pulmonary failure)

Rapid response system

▪ More than half of in-hospital cardiac arrest are from respiratory failure or hypovolemic shock; physiologic change such as ▪ Tachypnea

▪ Tachycardia

▪ hypotension

▪ Rapid response team ▪ system to identify and treat early clinical deterioration; to

improve patient outcome by bringing critical care expert to patient

Rapid response system

▪ Specific physiologic criteria as apart of early warning sign system ▪ Threatened airway

▪ RR<6 or >30/min

▪ HR<40 or 140/min

▪ Systolic BP <90 mmHg

▪ Symptomatic hypertension

▪ Unexplained decrease level of consciousness

▪ Unexplained agitation

▪ Seizure

▪ Significant fall of urine output

▪ Subjective concern about the patient

Rapid response system

▪ Medical emergency teams(METs) and Rapid response teams(RRTs)

▪ established for early intervention in patients who deterioration to prevent IHCA

Nishijima et al. Journal of Intensive Care (2016) 4:12

Knowledge Gaps in Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

T h e 2 0 1 5 I n t e r n a t i o n a l C o n s e n s u s o n C P R a n d E m e r g e n c y C a r d i o v a s c u l a r C a r e S c i e n c e W i t h T r e a t m e n t R e c o m m e n d a t i o n s ( C o S T R ) p u b l i c a t i o n

T h e I n t e r n a t i o n a l L i a i s o n C o m m i t t e e o n R e s u s c i t a t i o n ( I L C O R ) c o n s e n s u s 2 0 1 8

the International Liaison Committee on Resuscitation (ILCOR) preparation Basic life support Advance life

support

Post arrest care

BLS • PAD system

configuration

• Dispatcher

recognition

• pre arrival

instruction protocols

• CPR quality

ALS • Tracheal

intubation during

CPR

• vasopressor in

cardiac arrest

• Physiologic

targets in PAC,

• Post-ROSC

angiography

• neuroprognostic

ation

Education-

Implementat

ion-Team

• Retraining interval

• Leadership and Team

training

• Social medial

strategies

• Implementation of

resuscitation guide

line

Question 1

▪ทมีใดมหีนา้ที ่ประเมนิและรกัษาผูป่้วย ป้องกนัไมใ่หผู้ป่้วยอาการแย่ลงและป้องกนั In-hospital cardiac arrest

a) EMS team

b) CPR team

c) Critical care team

d) Rapid response team

e) Lay rescuer team

Question 2

▪ ขอ้ใดเหมาะสมทีสุ่ดกบั “Minimize interrupt the chest compression in adult”?

a) Rhythm analysis immediately after defibrillation

b) check pulse more than 10s for analyze rate and fullness

c) Give compression and ventilation ratio 15:2

d) Do not switch role; compression and ventilation until compressor fatigue

e) Avoid Unnecessarily move patient

Question 3

▪ ชาย 60 ปี หมดสตบินสะพานลอย พลเมอืงดนี ามาส่งทีโ่รงพยาบาล นอนไม่รูส้กึตวั แรกรบัตดิ EKG monitor ไดด้งัภาพ ท่านจะท าอย่างไรต่อไปเป็นล าดบัแรก

a) Defibrillation 200 J

b) Oxygen mask with bag 10 LPM, Keep O2 sat > 94%

c) Check pulse

d) Synchronized cardioversion 100 J

e) EKG 12 leads

Question 4

What’s ROSC of EtCo2

a) .

b) .

c) .

d)

e)

Question 5

▪ ขอ้ใดถกูตอ้งมากทีสุ่ดเกี่ยวกบัการดูแลผูป่้วย Post cardiac arrest

a) แนะน าใหท้ า hyperventilation ทกุราย

b) แนะน าให ้Monitor PEtCO2 ทกุราย

c) แนะน าให ้load isotonic solution 1-2 L ในผูป่้วยทกุรายที ่SBP<90mmHg

d) แนะน าใหท้ า PCI ในผูป่้วยทกุรายทีไ่มต่อบสนองตามค าส ัง่ หลงักลบัมามชีพีจร

e) แนะน าใหท้ า Targeted temperature management ไดต้ ัง้แต่จดุเกดิเหต ุ

Question 6

▪ ขอ้ใดถกูตอ้งเกี่ยวกบั CPR device

a) Impedance Threshold Device (ITD) เพิม่ อตัรารอดชวีติเมือ่ใชร่้วมกบั conventional

b) Automatic compression ―Lucas‖ ใชห้ลกัการ circumferential chest compression

c) Automatic compression ―autopulse‖ ใชร่้วมกบั Impedance Threshold Device (ITD) สามารถเพิม่ อตัรารอดชวีติ

d) Automatic compression good survival outcome than manual chest compressions

e) Automatic compression can used in limited rescuers setting

Take home message

▪ Basic life support: scene safe, call 1669 get AED, quality CPR

▪ Advance cardiac life support ▪ Early defib in shockable, early epinephrine in non shockable

▪ High quality CPR& CO2 monitoring

▪ No vasopressin

▪ 5H5T

▪ Post cardiac arrest care: consider PCI& TTM, multidisciplinary, organ support for post cardiac arrest syndrome

▪ New and Updated Recommendations: Lidocain alternative to VF,pVT

▪ Inhospital cardiac arrest : prevent arrest, early warning score& rapid respond team

▪ Thanks You