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Adult Advanced Cardiovascular Life Support 2015

American Heart Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care

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DR. Alireza Abootalebi

Assistant Professor Of Emergency Medicine Isfahan Univercity Of

Medical Science

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Pulseless Arrest

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pulseless cardiac arrest:

Ventricular fibrillation (VF)

Rapid ventricular tachycardia (VT)

Pulseless electrical activity (PEA)

Asystole

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Survival from these arrest rhythms requires both :

Basic life support (BLS)

and

Advanced cardiovascular life support (ACLS)

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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.

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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.

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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.

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Intraosseous (IO) cannulation provides access to a noncollaps-ible venous plexus, enabling

drug delivery similar to that achieved by central venous access.

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If IV and IO access cannot be established, some resuscitation drugs may be administered by the endotracheal route

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Lidocaine

Epinephrine

Atropine

Naloxone

Vasopressin

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E T route:

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.

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Providers should dilute the recommended dose in

5 to 10 mL of water or normal saline

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Copyright ©2010 American Heart Association

Neumar, R. W. et al. Circulation 2010;122:S729-S767

ACLS Cardiac Arrest Algorithm 2010

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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

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Idioventricular rhythms

Ventricular escape rhythms

Postdefibrillation idioventricular rhythms

Brady-asystolic rhythms

Agonal rhythms

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Global myocardial dysfunction

Papillary muscle and myocardial wall rupture

Primary supraventricular tachycardia (SVT (

Hypovolemia, tension pneumothorax, pericardial tamponade, and massive PE

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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)

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ASYSTOLE/PEA MANAGEMENT

Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest .

The removal of vasopressin has been noted in the Adult Cardiac Arrest Algorithm.

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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.

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2015 Recommendation

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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.

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Copyright ©2010 American Heart Association

Neumar, R. W. et al. Circulation 2010;122:S729-S767

ACLS Cardiac Arrest Circular Algorithm

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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)

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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 .

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2015 Recommendation

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Emphasis on effective chest compression

One universal compression-to-ventilation 30/2

Recommendation for 1-second breaths during all CPR

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Rescuers should change compressors every 2 min

Compression should ideally be interrupted only for rhythm check and shock delivery

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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

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Antiarrhythmics: Amiodarone is preferred to lidocaine , but either is acceptable

Deliver 1 shock , then immediate CPR and NO check pulse

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1-Epinephrine

2-Atropine

3-Amiodarone

4-Lidocaine

5-Magnesium

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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

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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)

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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

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Some AEDs will automatically switch them-selves on when the lid is opened

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Stand clear

Deliver shock

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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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