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

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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

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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

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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

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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.

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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

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“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

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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!

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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

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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

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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

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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

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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

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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

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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)

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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

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• 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