ACLS Update
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Transcript of ACLS Update
Audience Survey
• Who has been certified in ACLS in last 3 years?
• Who was certified before then?• Anyone ever give bystander CPR or CPR
in the field?• When was last time you participated in a
Code Blue that had a really good outcome?
Audience Opinions
• Who thinks that CPR works?• Can you actually save anyone?• Would you initiate CPR as a bystander?• Who has talked to Ann Lockhart or Elise
Lewis about their experience on the reservoir run?
Grim Statistics for Code Blue
• Return of spontaneous circulation (ROSC) of about 40% - 60%
• Survival to hospital discharge of at most 15%
• Long term (3 year) survival ~40% OF the 15% that are discharged
• Long-term survival after successful in hospital cardiac arrest resuscitation American Heart Journal - Volume 153, Issue 5 (May 2007)
• Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. - Dumot JA - Arch Intern Med - 23-JUL-2001; 161(14): 1751-8 (From NIH/NLM MEDLINE)
38 YO Asian Male Homicide Detective
• Rides road bike total of 250 miles during week of 10/5/08
• Goes for easy 3 mile training run w/ other officers 10/15/08
• Stretches post run; reaching for the sky is the last thing he remembers until waking in the ER
What Happened While He was Asleep?
• Collapsed forward, striking head and face• Pale, unresponsive, pulseless• Companion officers start EXCELLENT
CPR• SRFD on scene in less than 3 minutes,
defibrillator pads placed, rhythm checked…
V-Fib Arrest
• Shock w/ 120 Joules• Continue EXCELLENT CPR (How do we know it was excellent?)
• Check pulse, check rhythm – carotid pulse present, sinus rhythm
• Transport to Santa Rosa Memorial Hospital
• In ER trauma bay, patient becomes alert, speaks coherently, and complains of being very sore
Epilogue
• Patient goes to cardiac catheter where he is diagnosed with severe 3 vessel disease
• Undergoes 3 Vessel CABG• EP study demonstrates need for
implantable defibrillator• His friends take CPR and get their own
cholesterol checked
Excellent CPR: Hard and Fast
• New ratio is 30:2• Chest compressions are more important
than rescue breaths• Compressions delivered at 100/minute
(staying alive, staying alive, ah, ah, ah…)• Ventilations 8-10/minute – slower than you
think
Rhythm Check
• There is only one question…
• To shock, or not to shock• V-Fib or pulseless V-Tach • SHOCK• PEA or Asystole • MEDS AND CONTINUED CPR
NEW: KEEP DOING CPR!
• After delivering a shock, resume CPR for 2 minutes before checking rhythm again
• Simultaneously check for pulse• Resume CPR while defibrillator charges, if
need to shock again
Drugs Work
• NO MORE ET Tube administration• IV access or IO access as soon as
possible• Epinephrine/Vasopressin Q3-5 minutes• Amiodarone after Epi/Vasopressin;
Lidocaine also OK, but now out of favor and not in field protocols
Vasopressin
Indicated for V-Fib, V-Tach, PEA, Asystole;Give ONLY ONCE• 40 Units IV/IO instead of 1st or 2nd dose of
Epinephrine• NOT for responsive (talking) patients with
known CAD
Epinephrine
First line drug for ALL pulseless rhythms• 10 ml of 1:10,000 solution -- bolus• 1 mg in 500 ml of NaCl or D5W @
1microgram/min, titrate to effect
Amiodarone
Give for V-Fib or pulseless V-Tach• 1st dose: 300 mg IV/IO• 2nd dose: 150 mg IV/IO• Infuse: 0.5 mg/min x 18 hours
Atropine
Symptomatic bradycardia or SLOW PEA• PEA, Asystole: 1mg IV/IO Q3-5 min• Bradycardia: 0.5mg IV/IOQ3-5 min, PRN• Note that dose < 0.5mg can cause
paradoxical bradycardia
72 YO Caucasian Family Doctor
• Swimming, per his usual at the local pool• Not feeling up to par, decides he should
get out• Wakes up in ICU• What happened?
By stander CPR
• Oral surgeon swimming in same lane starts poor quality CPR
• 2 ER nurses, having breakfast @ poolside shove surgeon out of way and start excellent CPR
• Paramedics arrive, and deliver 2 shocks in field between continued CPR, establishing a line and intubating
• Transport to ER – CPR continuing
ER Code Blue
• On arrival to ER, rhythm remains VFib• Shock in ER and Amiodarone bolus• Rhythm converts to sinus• Transferred to ICU• Implantable defibrillator placed