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UPDATES IN ADVANCED LIFE SUPPORT
DR AHMAD JAMAL MOKHTAR ASMIC 2013
ADULT
PAEDIATRIC
• References • Introduction • History • What are new? • Guidelines 2005 vs Guidelines 2010 • Closing
• UK resuscitation council, 2005 • UK resuscitation council, 2010 • 2010 ERC ALS Guidelines : The Science Behind the Changes • The New Zealand Resuscitation Council and Australian
Resuscitation Council combined updated ALS guidelines, 2010.
• Why need updates? To improve out‐comes. • Who are the target audience? These guidelines apply to healthcare professionals
trained in ALS techniques.
• Guidelines 2010 adheres to the same general principles as Guidelines 2005, but incorporates some important changes.
• 2005 Defibrillation CPR first Strategy Fine VF Drugs Adrenaline
• 2010 Defibrillation Drugs Airway Ultrasound Post Resuscitation care
Defibrillation
2005 • CPR first.
2010 • In addition Emphasizing on chest
compression before airway management.
Defibrillation
2005 • Do not delay Out of hospital cardiac
arrest, attended but un‐witnessed by EMS, give CPR for 2 min (~ 5 cycles at 30:2) before defibrillation.
Both out‐of‐hospital cardiac arrest witnessed by EMS and in‐hospital cardiac arrest
2010 • Minimal interruption in
high‐quality chest compressions.
Continue chest compressions while charging defibrillator.
Chest compressions are paused briefly only to enable specific interventions.
Defibrillation
Defibrillation
Defibrillation
2010 The 2005 recommendation
for a specified period of CPR before out‐of‐hospital defibrillation following cardiac arrest un‐witnessed by the EMS has been removed.
Defibrillation
2005 • VF/pulseless VT
(shockable) Treat with a single shock,
followed by immediate resumption of CPR (30 compressions to 2 ventilations).
Do not reassess the rhythm or feel for a pulse.
After 2 min of CPR, check the rhythm and give another shock (if indicated).
2010 Single shock is
recommended for both witnessed and unwitnessed arrests
Stacked shocks only for VF/pulseless VT occurring in the CCL or immediate post cardiac surgery.
The role of the precordial thump is de‐emphasised.
Fist and electrical pacing not recommended in asystolic cardiac arrest.
Defibrillation
2005 • Biphasic energy Initial at 150‐200 J.
Subsequent shocks at 150‐360 J.
• Monophasic at 360 J for both initial and subsequent shocks.
2010 • Biphasic at 200 J for all shocks
unless clinical evidence of other energy level for a specific device.
Self‐adhesive defibrillation pads offer advantages (facilitating pacing, charging during CPR, safety [eg. removing risk of fires]).
• Monophasic at 360 J for all shocks.
Defibrillation
Defibrillation
• 2005 & 2010 In doubt about whether the rhythm is asystole or fine VF do NOT attempt defibrillation; instead, continue chest compression and ventilation.
Drugs
2005 • Adrenaline & VF/VT cardiac
arrest Give adrenaline 1 mg IV if
VF/VT persists after a second shock.
Repeat the adrenaline every 3‐5 min thereafter if VF/VT persists.
2010 • Adrenaline & VF/VT cardiac
arrest Adrenaline 1 mg is given once
chest compressions have restarted after the third shock and then every 3‐5 min (during alternate cycles of CPR).
• In non‐shockable rhythm, immediately give 1 mg adrenaline then every 3–5 min: “alternate cycles of CPR”.
Drugs
• Timing of drug administration Now recommended at the time of recommencement of CPR. This to separate the timing of drug delivery from attempted
defibrillation. It is hoped that this will result in more efficient shock delivery
and less interruption in chest compressions.
Drugs
• 2010 (additional) Amiodarone 300 mg is also given after the third shock. Atropine is no longer recommended for routine use in
asystole or pulseless electrical activity (PEA).
Drugs
• 2010 (additional) Delivery of drugs via a tracheal tube is no longer
recommended If intravenous (IV) access cannot be achieved give drugs by
the intraosseous (IO) route.
Airway
• 2010 (additional) Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruption to chest compressions.
Airway
• 2010 (additional) A supraglottic airway device may be considered as an alternative to bag‐mask ventilation during
cardiopulmonary resuscitation, for definitive airway management during cardiac arrest as a backup or rescue airway in a difficult or failed tracheal
intubation.
Airway
• 2010 (additional) Increased emphasis on the use of capnography for confirmation and continually monitoring tracheal tube
placement (in addition to clinical assessment), Monitoring quality of CPR To provide an early indication of return of spontaneous
circulation (ROSC).
Ultrasound
• 2010 (additional) The potential role of ultrasound imaging during ALS is
recognised. To assist in detection of potentially reversible causes.
Post resuscitation care
• 2010 (additional) There is recognition that implementation of a
comprehensive, structured post‐resuscitation treatment protocol may improve survival in cardiac arrest victims after ROSC.
There is much greater detail and emphasis on the treatment of the post cardiac arrest syndrome.
The potential harm of hyperoxaemia after ROSC is achieved. Titrate inspired oxygen to achieve a SaO2 of 94 ‐ 98%.
Post resuscitation care
Post resuscitation care
There is increased emphasis on the use of primary percutaneous coronary intervention in appropriate, but comatose, patients with sustained ROSC after cardiac arrest.
Use of therapeutic hypothermia now includes comatose survivors of cardiac arrest associated initially with non‐shockable rhythms as well as shockable rhythms. The lower level of evidence for use after cardiac arrest from nonshockable rhythms is acknowledged.
The recommendation for glucose control has been revised: in adults with sustained ROSC after cardiac arrest, blood glucose values >10 mmol/ l should be treated but hypoglycaemia must be avoided.
Post resuscitation care
Post resuscitation care
More emphasis on identifying underlying cause or associated injuries, and managing them accordingly
Prognostication
• 2010 (additional) It is recognised that many of the accepted predictors of poor
outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia.
• Guidelines 2010: Early detection and prevention of cardiac arrest CPR to commence with chest compressions. Fallibility of pulse check even in the hands of
clinicians.
Minimally‐interrupted high‐quality chest compressions throughout any ALS intervention.
Efficient and timing of defibrillation with less interruption in chest compressions.
Adequacy of ventilation.
Comprehensive post‐resuscitation treatment protocol .
Therapeutic hypothermia.