ACLSPast, Present & Future

Dr FT Lee

A&E, PMH

2004

http://pmh-acls2004.tripod.com

Do s

• Brief review of main points

• Case presentation

• Future development

Don’t s

• Review of Algorithms

History

• Originated in Nebraska in early 1970

History

• Organised in Hong Kong by Hong Kong Society of Emergency Medicine and surgery since 1991

• Case-based small group teaching since 1994

• A two days workshopwith hands on experience

Cardiac arrest?

• Breathing 氣

• Beating 血

Pulse check

• no more than 10 sec

• Start chest compression

if you are unsure

Cardiac Arrest

• Ventricular fibrillation/

Pulseless Ventricular Tachycardia

• Asystole

• Pulseless Electrical Activity(PEA)

Early defibrillation

• The most frequent initial rhythm in sudden cardiac arrest is VF

• Chance of successful defibrillation reduced 10% each minute

Chain of survival

Early access Early CPR Early Early ACLS

Defibrillation

Pulse +ve

• Tachycardia 快

• Bradycardia 慢

Tachycardia (P > 100/min)

• Wide complex– QRS >0.12 s (3 small squares)

• Narrow complex– QRS < 0.12 s

Bradycardia (P< 60/min)

• Sinus

• Heart Block– 1st, 2nd and 3rd

Pulse +ve

STABLE

?

Unstable

• Shock

• SOB

• Severe chest pain

• Impaired consciousness

Unstable

• Electrical therapy

Stable

• Drug

Drugs

• Adrenaline/Vasopressin• Amiodarone

– 300mg iv bolus in VF/pulseless VT– 150mg ivi over 10 min in stable tachycardia– Maintenance infusion 1mg/min for 8hrs then 0.

5mg/min for 16 hours

• ATP/Verapamil/Diltiazem• Atropine

Is life so simple?

Case 1

• AE 04026XXX(X)• Mr Au, M/57,• 19:58, 3/2004

• C/O: Chest pain since 18:00 with radiation to neck & back, sweating +ve

• PH: HT, Gout

• BP: 182/73, P: 99/min reg, RR: 14/min • SaO2: 96% (RA)

• Triage as Cat III (20:00)

• ECG ordered

• Seen at 20:46 (46mins after triage)

• Diagnosed as Angina

• O2, TNG, Aspirin and Heparin block ordered

• Patient disappeared at 20:55, 20:56, 20: 58, 21:00, 21:03.

• Reappeared at 21:05

• Developed generalized seizure on receiving treatment

• Valium 10mg iv given

• Seizure stopped

• Cardiac monitor

• Defibrillation 200J

Asystole Adrenaline 1mg

VF

Defibrillation 300J

Asystole

Amiodarone 300mg iv bolusAdrenaline 1mg iv

SR

• Patient semi conscious

• Intubated under RSI

• Admitted to ICU

• Extubated in ICU and discharged from medical ward

Happy Ending

Beating Heart

with a

Thinking Mind

Case 2

• AE04097XXX(X)

• Ms Ou F/28, 16:24 10-04

• Tourist from Thailand to China

• C/O: Chest discomfort since 14:30

• PH: VSD

• P/E: BP: 115/64, P: 119/min, RR:14/min

• GCS: 15

• Cat II

• Dormicum 5mg iv

• Synchronized cardioversion 100J

SR

• Amiodarone 150mg iv stat

150mg in 100ml over 1 hour

• Admitted to CCU

• DAMA 2 days after

Case 3

• AE04071XXX(X)

• Ms Siu F/82, 09:56, 8-04

• C/O: Increase dizziness in the morning. Fell onto ground for 3 times.

• PH: HT, gout

• P/E:

• BP: 95/50 (R/C 95/60) P:60 reg

• Fully conscious

• Cat III

• Amiodarone 150mg in 100ml D5 ivi over 30mins

• Convert back to SR

• BP: 107/50, P:82/min

Case 4

• AE01134XXX(X)

• Mr Cheng M/17, 17:48, 12-01

• C/O: LOC at 15:00 for 2mins, Left chest pain, sweating, palpitation

• PH: good

• P/E:

• BP: 95/51, P150/min, RR: 22/min,

• SaO2: 100% (RA), GCS:15

• Cat II

What next?

• Chest drain inserted

• 1.4 litre of blood drained

• 1 litre of NS given

• Admit to surgery

Case 5

• AE04102XXX(X)

• Mr Cheng M/75, 18:26, 11-04

• C/O: sudden onset of chest pain and SOB

• P/E: In distress, sweating

• BP: 106/51, P:71/min, RR: 40/min

• SaO2: 87% with O2

• CXR: APO

• TNG, Aspirin were given

What next?

Intubate or TCP?

• Intubation was done under RSI

• Developed cardiac arrest after Suxamethonium was given

• CPR, Atropine and Adrenaline

• Pulse returned transiently

• Put on TCP

• Develop cardiac arrest again

• No response to resuscitation

• Certified dead 1 hour after

A sad ending

ACLS

A means or the end?

Exceptions

• VF in Hypothermia

• Tachycardia in TCA overdose

• Arrhythmia in hyperkalemia

• Bradycardia or Heart block in Ca channel blocker or -blocker overdose

Treat the patient Not the ECG !

The Road Ahead

Future

• Biphasic defibrillation

• Antiarrhythmics

Biphasic defibrillation

Biphasic defibrillation

Biphasic defibrillation

Biphasic defibrillation

• Positive evidence supports a statement that initial low-energy (150-J), nonprogressive (150 J-150 J-150 J), impedance-adjusted biphasic waveform shocks for patients in out-of-hospital VF arrest are safe, acceptable, and clinically effective

(Circulation. 1998;97:1654-1667.)

Biphasic defibrillation

• Less energy

• More efficacy

• Less myocardial damage

• Class IIA recommendation

for VF/pulseless VT

Biphasic defibrillation

• What energy level for defibrillation?

• Is escalating energy necessary?

• Recommendations– 150J, 150J, 150J– 120J, 150J, 200J (Zoll)– 200J, 300J, 360J (Medtronic)

Biphasic Synchronized cardioversion

• What energy level?– 50J, 100J, 120J, 150J, 200J (Zoll)– 50J, 100J, 200J, 300J 360J (Medtronic)

Drugs

• Vasopressin– Lack of evidence base

• Amiodarone– Effective drugs– Long term S/E

Questions & comments