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Advanced cardiac life support(ACLS) guidelines - 2010

Advanced cardiac life support(ACLS) 2015

Dr. Md. Mashiul AlamResidentUniversity Cardiac CenterBSMMU

Advanced cardiac life support Advanced cardiac life support or advancedcardiovascular life support (ACLS) refers to a setof 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.

Importance of BLS in ACLS

ACLS is built heavily upon the foundation of BLS

Component of high quality CPR in BLSScene safety:Make sure the environment is safe for rescuers and victimRecognition of cardiac arrest:Check for responsivenessNo breathing or only gasping ( ie, no normal breathing)No definite pulse felt within 10 secs ( Carotid or femoral pulse)(Breathing and pulse check can be performed simultaneously within 10 secs)

Activation of emergency response system:If alone with no mobile phone, leave the victim to activate the emergency response system and get the AED before beginning CPR Otherwise, send someone and begin CPR immediately; use the AED as soon as it is availableIn case of unwitnessed collapse of children or infant give CPR for 2 mins before leaving the victim and getting the AED then resume CPR

Chest compression-Adult- 30:2Children or infant- 30:2 if one rescuer 15:2 if more than one rescuerCompression rate: 100-120/ minCompression depth: Adult- at least 5 cmChildren or infant- at least 1/3rd AP diameter of chest

Hand placement:Adult - 2 hands on the lower half of the sternumChildren 1 or 2 hands on the lower half of the sternumInfants 2 fingers or 2 thumb defending of the number of rescuersChest recoil: allow full recoil of chest after each compression; do not lean on the chest after each compression.Minimizing interruption: Limit interruptions in chest compressions to less than 10 secs.

A Change From A-B-C to C-A-B

BLS donts of adult high-quality CPR

1. compression rate slower than 100/ min or faster than 120/min 2. Compression depth less than 5 cm or greater than 6 cm 3. Lean on the chest between compression 4. Interrupt compressions for greater than 10 secs 5. Provide excessive ventilation- ie, too many breaths or breaths with excessive force

Adult advanced cardiovascular life support

Recongnition of arrythmia

MeanwhileMinimize interruption in CPR- alternate CPR provider every 2 minutes as continued Chest compression may fatigue the provider leading to ineffective compressionMaintain an orchestra of activity between physician, nurse and other health care provider (Ward boy)Check airway patency- consider oropharyngeal tube placement if tongue fell back.Arrange for endotracheal tube/ maximize oxygen delivery

Vt/ vf

Electrode Placement4 pad positions anterolateral, anteroposterior,anterior-left infrascapular, and anterior-rightinfrascapular

For adults, an electrode size of 8 to 12 cm is reasonable (Class IIa, LOE B). Any of the 4 pad positions is reasonable for defibrillation (Class IIa, LOE B).

DefibrillationBiphasic wave form: 120- 200 JMonophasic wave form: 360 JAED- device specific

Failure of a single adequate shock to restore a pulse should be followed by continued CPR and second shock delivered after five cycles of CPR

If cardiac arrest still persist- patient is intubated and IV/IO access achieved

Defibrillation Sequence Turn the AED on. Follow the AED prompts. Resume chest compressions immediately after the shock(minimize interruptions).

1-Shock Protocol Versus 3-Shock Sequence Evidence from 2 well-conducted pre/post design studies suggested significant survival benefit with the single shock defibrillation protocol compared with 3-stacked-shock protocols

If 1 shock fails to eliminate VF, the incremental benefit of another shock is low, and resumption of CPR is likely to confer a greater value than another shock

Asystole/PEA

Treatable Causes of Cardiac Arrest: The Hs and Ts Hs Ts

Hypoxia ToxinsHypovolemia Tamponade (cardiac)Hydrogen ion(acidosis) Tension pneumothoraxHypo-/hyperkalemia Thrombosis, pulmonaryHypothermia Thrombosis, coronary

Airway and Ventilations Opening airway Head tilt, chin lift or jaw thrust, in addition explore the airway for foreign bodies, dentures and remove them. Consider oropharyngeal tube placement.

The Health care provider should open the airway and give rescue breaths with chest compressions

Rescue breathsBy mouth-to-mouth or bag-mask Deliver each rescue breath over 1 second Give a sufficient tidal volume to produce visible chest rise Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations After advanced airway is placed, rescue breaths given asynchronus with ventilation 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute)

Breathing devicesPlastic oropharyngeal airwaysEsophageal obturatorsAmbu bag- usual method for continuing breathing in hospital before ET tube can be inserted.Endotracheal tube

Pharmacotherapy

Routes of AdministrationPeripheral IV easiest to insert during CPR, must followed by 20 ml NS pushCentral IV fast onset of action, but do not wait or waste time for CV lineIntraosseous alternative IV route in peds, also in AdultIntratracheally (down an ET tube)- not recommended now a days

Oxygen FIO2 100% Assist Ventilation O2 Toxicity should not be a concern during ACLS

IV FluidsVolume Expanders crystalloids , e.g. Ringers lactate, N/S

Amiodarone (Cordarone) Indications: Like Lidocaine Vtach, Vfib IV Dose: 300 mg in 20-30 ml of N/S or D5W Supplemental dose of 150 mg in 20-30 ml of N/S orD5W Followed with continuous infusion of 1 mg/min for 6 hours than .5mg/min to a maximum daily dose of 2grams Contraindications: Cardiogenic shock, profound Sinus Bradycardia, and 2nd and 3rd degree blocks that do not have apacemake

Lidocaine Indications: PVCs, Vtach, Vfib Can be toxic so no longer given prophylactically IV dose : 1-1.5 mg/kg bolus then continuous infusion of 2-4mg/min Can be given down ET tube Signs of toxicity: slurred speech, seizures, altered consciousness

Magnesium Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes Dose: 1-2 grams over 2 minutes Side Effects Hypotension Asystole

Propranolol/ Esmolol Beta blocker that may be useful for Vfib and Vtach that has not responded to othertherapies Very useful for patients whose cardiac emergency was precipitated by hypertension Also used for Afib, Aflutter, & PSVT

Epinephrine Because of alpha, beta-1, and beta-2 stimulation, it increases heart rate, stroke volume and bloodpressure Helps convert fine vfib to coarse Vfib May help in asystole Also PEA and symptomatic bradycardia IV Dose: 1 mg every 3-5 minutes May increase ischemia because of increased O2 demand by the heart

Vasopressin (ADH)- is out according to 2015 guidelines for ACLSSodium Bicarbonate Used for METABOLIC acidosis / hyperkalemia

Airway and ventilation have to be functional IV Dose: 1 mEq/kg If ABGs, [BE] x wt in kg/6 Side effects: Metabolic alkalosis Increased CO2 production

Monitoring During CPRPhysiologic parametersMonitoring of PETCO2 (35 to 40 mmHg)Coronary perfusion pressure (CPP) (15mmHg)Central venous oxygen saturation (ScvO2)

Abrupt increase in any of these parameters is a sensitive indicator of ROSC that can be monitored without interrupting chest compressions

Quantitative waveform capnographyIf Petco2