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ACLS CE Part II of III
ACLS in Acute Coronary Syndromes
Prepared and presented by
Marc Imhotep Cray, M.D.
Objectives
• Review the importance of CPR / BLS in ALCS (AHA BLS guidelines)
• Describe the relationship of the chain of survival to successful resuscitation of the cardiac arrest patient
• Discuss the interventions required to ensure good outcomes with Return of Spontaneous Circulation
2
Heart Disease
• Cardiovascular disease is the number one cause of death in the U.S., and many times the first indication of this disease is an acute coronary event
• Cardiac arrest is the most severe manifestation of an acute coronary syndrome, and with rapid intervention EMS providers can make the difference between life and death
3
Heart Disease(2)
•While EMT will occasionally be called to a patient who is in cardiac arrest, or to a patient who goes into cardiac arrest at scene or en route to the hospital…
•More often the call will be to a responsive patient who has signs and symptoms—particularly chest discomfort or pain—that may be caused by heart disease
4
Heart Disease (3)
•Not every cardiac arrest is preceded by chest pain or discomfort, nor do all patients with chest discomfort or pain proceed to cardiac arrest, but for those who do, rapid intervention is vital
Without it, such patients will almost surely die
•As such, EMT are taught they must be prepared to treat all patients with signs and symptoms of cardiac compromise as cardiac emergencies
5
American Heart Association Facts 7 to 8 million people a year seek treatment for chest
pain.
Of these, 2 million will actually have a cardiac condition that affects the coronary arteries.
About 1.5 million will suffer a heart attack.
500,000 of these heart attack patients will die.
250,000 of these patients will die within the first hour of symptom onset.
6
Definition of ACLS
Advanced cardiac life support or advanced
cardiovascular life support (ACLS) refers to a set
of clinical interventions for the urgent treatment of
cardiac arrest, stroke and other life-threatening
medical emergencies, as well as the knowledge
and skills to deploy those interventions.
From: http://en.wikipedia.org/wiki/Advanced_cardiac_life_support
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ACLS Guidelines •American Heart Association (AHA) and International Liaison
Committee on Resuscitation (ILCR) performs a science
review every five years and publishes an updated set of
recommendations and educational materials
•ACLS guidelines were last updated by the American Heart
Association and the International Liaison Committee on
Resuscitation in 2010
•New ACLS guidelines focus on BLS as the core component
of ACLS
See: Berg RA et.al. “Part 5: Adult basic life support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care”. Circulation. 2010;122(suppl 3):S685–S705.
http://circ.ahajournals.org/content/122/18_suppl_3/S685
8
“Current Guidelines”
2010 American Heart Association (AHA) Guidelines
for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiovascular Care (ECC)
2010 AHA Guidelines for CPR and ECC Access the full 2010 AHA Guidelines for CPR & ECC, published in the journal Circulation on October 18, 2010.
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Importance of BLS in ACLS
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Importance of BLS in ALS BASIC LIFE SUPPORT ACLS is built heavily upon the foundation of BLS New AHA ACLS guidelines focus on BLS as the core component of ACLS
See: Berg RA et.al.. “Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S685–S705. http://circ.ahajournals.org/content/122/18_suppl_3/S685
11
Adult CPR
1. Make sure the scene is SAFE!
2. Check responsiveness and breathing
3. If alone call 9-1-1 and get an AED
4. Check for a pulse and if no pulse present begin CPR
•Always start CPR with Compressions First!
12
Chest Compressions
Always start CPR with Compressions First!
• Push hard and fast • Rate should be at least 100
per minute • Provide 30 compressions
then 2 breaths • Make sure the chest is
allowed to re-expand completely at the end of each compression
13
CPR Chest compressions and breaths are the same for
adults, child, and infant if you are alone
◦ Adult age starts at the onset of puberty
◦ (12-14 years of age)
◦ Child is age 1 year to the onset of puberty ◦ Infant is anyone under the age of 1year
14
Adult CPR 5. Open the airway with head tilt-chin lift
6. Place the mask on the patient’s face
7. Use the E-C clamp technique
8. Deliver each breath over 1 second
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Relationship of chain of survival to successful resuscitation of cardiac
arrest patient
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AHA ECC Adult Chain of Survival
The links in the new AHA ECC Adult Chain of Survival are
as follows:
1. Immediate recognition of cardiac arrest and activation of the
emergency response system
2. Early CPR with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care
Source: 2010 AHA Guidelines for CPR and ECC
17
Interventions required to ensure good outcomes with Return of
Spontaneous Circulation
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Immediate Post Arrest Care –Return of Spontaneous Circulation (ROSC) (1)
• Optimize ventilation and oxygenation
• O2 Saturation > 94%
• Advanced Airway
–10-12 per minute
• PETCO2 35-40 mm/Hg
• Do not hyperventilate
– < cerebral perfusion
–Oxygen toxic
19
Immediate Post Arrest Care –Return of Spontaneous Circulation (ROSC)(2)
– Treat hypotension (SBP <90 mm Hg)
• Fluid Bolus –1-2 liters
• Vasopressors
–Epinephrine 0.1-0.5 mcg/kg/minute
–Dopamine 5-10 mcg/kg/minute
20
Immediate Post Arrest Care –Return of Spontaneous Circulation (ROSC)(3)
– Induced Hypothermia
• If not following commands
• Improved neurological recovery
• 32º - 34º C for 12-24 hours
– Coronary reperfusion
• If STEMI
• May do concurrently with hypothermia
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Cardiac Arrest • Few cardiac arrest patients survive outside a hospital
without a rapid sequence of events
– Chain of survival:
• Early recognition and activation of EMS
• Immediate bystander CPR
• Early defibrillation
• Early advanced cardiac life support
• Integrated post-arrest care
22
Early CPR
• Why is CPR Important
– Studies have shown that the general population will start CPR only 1/3 of the time and only 15% of that total is done correctly
– Chest Compressions can be started within 18 seconds of arriving at the patient, whereas airway management first can delay compressions by 1-2 minutes or more
– CPR prolongs the period during which defibrillation can be effective
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Rationale for Early Defibrillation
• Ventricular fibrillation is the most frequent rhythm found in cardiac arrest
• Defibrillation is the most effective treatment for VF
• Probability of successful defibrillation diminishes with time
• VF will lead to asystole quickly without proper treatment
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Early Defibrillation Impacts Survival
• EMS has the most opportunity to perform CPR, so we should be good at performing good, quality CPR
“Hearts and Brains are going to die” Peter Safar MD
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Adult Cardiac Arrest AHA ACLS Managements Guidelines
ACLS in Acute Coronary Syndromes
Reference: O'Connor, RE et.al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 10: Acute Coronary Syndromes Available at http://circ.ahajournals.org/content/122/18_suppl_3/S787.full
ACLS GUIDELINES
Adult Cardiac Arrest
"2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science". Circulation 122 (18 Suppl 3).
November 2010.
doi:10.1161/CIRCULATIONAHA.110.970889.
Adult Cardiac Arrest Protocol V-Fib / Pulseless V-Tach (1)
1. Initiate CPR and attach monitor/defibrillator 2. Defibrillate at 360j or equivalent biphasic shock 3. Resume CPR immediately following defibrillation
and continue for 2 minutes
(9 STEP Sequence)
Adult Cardiac Arrest Protocol V-Fib / Pulseless V-Tach (2)
4. Initiate vascular access; manage airway 5. Reevaluate rhythm; defibrillate if needed;
resume CPR 6. Administer Epinephrine 1mg every 3-5
minutes
Adult Cardiac Arrest Protocol V-Fib / Pulseless V-Tach (3)
7. Defibrillate if needed; resume CPR 8. Administer Amiodarone 300mg; may repeat
at 150 mg IV/IO in 5 minutes if needed. 9. Continue cycles of CPR and defibrillation as
needed
Adult Cardiac Arrest Protocol Asystole / PEA
1. Initiate CPR and attach monitor/defibrillator
2. Initiate vascular access; manage airway
3. Administer Epinephrine 1mg every 3-5 minutes
4. Consider possible causes and treatments
• “H’s and T’s”
Reversible Causes – H’s and T’s
• Hypovolemia (Volume infusion)
• Hypoxia (Ventilation and oxygenation)
• Massive Myocardial Infarction (Volume infusion)
• Tension Pneumothorax (Needle decompression)
• Acidosis/Hyperkalemia (Hyperventilation)
• Drug Overdose (Refer to appropriate protocol)
• Hypothermia (Refer to appropriate protocol)
• Pericardial Tamponade (Rapid transport)
• Massive Pulmonary Embolism (Ventilation, Volume infusion)
34
End of ACLS CE Part II THANK YOU FOR YOUR ATTENTION
See Part III •Defibrillation and ACLS Drug Therapy
References and further study next slide
References and further study: 1. Berg et.al. 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science Part 5: Adult Basic
Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
Available at: http://circ.ahajournals.org/content/122/18_suppl_3/S685
2. Neumar,RW et.al. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care SciencePart
8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
Available at: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full
3. 2010 AHA Guidelines for CPR and ECC
4. O'Connor, RE et.al. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 10: Acute Coronary Syndromes
Available at http://circ.ahajournals.org/content/122/18_suppl_3/S787.full
35
• ACLS Precourse Self-Assessment Test • ACLS Supplementary Materials • ACLS Core Drugs • ACLS Science Overview Video BLS for Healthcare Providers Videos • Adult 1-Rescuer CPR Demo • Adult Compressions • Adult Breaths With Mask • Adult Compressions and Breaths • Adult Assessment • Adult Rescue Breathing With Bag Mask • Adult 2-Rescuer CPR Demo • Adult 2-Rescuer CPR and AED Demo • Adult 2-Rescuer CPR With an Advanced Airway
© 2006 American Heart Association
Compiled and served by University of Minnesota
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