Advanced Cardiovascular Life Support (Acls)
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Transcript of Advanced Cardiovascular Life Support (Acls)
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ADVANCED CARDIOVASCULAR LIFE
SUPPORT (ACLS)
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Core knowledge and skills in ACLS
Airway management and endotracheal intubation Recognition and therapy of the major ACLS
emergency conditions
Electrical therapy and emergency pacing
Acute coronary syndrome and stroke
Intravenous and invasive therapeutics andmonitoring technique
Cardiac arrhythmias
Cardiovascular pharmacology
Management of special resuscitation situation
Postresuscitation care
Toxicology
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Classes of Recommendation
Class I: always acceptable, proven safe, anddefinitely useful
Class II: acceptable, safe, and useful Class IIa: consider standard of care, intervention of
choice Class IIb: consider standard of care, optional or
alternative interventions
Class Indeterminate: still be recommended foruse, but evidence is lacking
Class C: unacceptable, may be harmful
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Primary-Secondarysurvey approach to ECC
Primary survey : first A-B-C-D(BLS
action)Airway, Breathing, Circulation, Defibrillation
Secondary survey : second A-B-C-D
Airway, Breathing, Circulation,
Differential diagnosis
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Algorithms for
Treatment of Cardiac
Arrest
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ILCOR Universal/International ACLS Algorithm AduAdult Advanced Cardiovascular Life Support
Adult Cardiac Arrest
BLS algorithmIf appropriate
Precordial thum p i f appropriate
Attach defibrillator/monitor
Assess rhythm
Check pulse +/-
VF/VT
AttemptDefibrillation 3
As necessary
CPR
1 minute
Non-VF/VT
CPR
1 minute
Consider causes that are
potentially reversible
HypovolemiaHypoxia
Hydrogen ion acidosis
Hyper-/hypokalemia, other metabolic
Hypothermia
Tablet (drug OD, acidosis
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary (ACS)
Thrombosis, pulmonary (embolism)
During CPR
Check electrode/paddle Airway:tracheal tube placement
VF/VT refractoryto initial shocks:
- Epinephrine1mg IV, q 3 - 5 min.
or
- Vasopressin40 U IV
non-VF/VTrhythm:
- Epinephrine1 mg IV, q 3 - 5 min.
Buffers, antiarrhythmics, pacing
Search for reversible causes
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Comprehensive ECC Algorithm AduAdult Advanced Cardiovascular Life Support
Person collapse, Possible cardiac arrest,Assess responsiveness
Primary ABCD Survey (Begin BLS Algorithm) Activate emergency response system, Call for defibrillator
A Assess breathing (open airway, look, listen, and feel)
B Give 2 slow breaths, C Assess pulse, if no pulse C Start chest compressionsD Attach monitor/defibrillator when available
Unresponsive
Not Breathing
CPR continue
Assess rhythm
No Pulse
Attempt defibrillation
(up to 3 shocks if VF persists)
VF/VT
Non-VF/VT
(asystole or PEA)
Non-VF/VT
CPR for1 minute
CPR up to3 minutes
Secondary ABCD Survey
Airway: airway device, Breathing: ventilation,oxygenationCirculation: intravenous access; Drugs, pacing
Non-VF/VT patients:Epinephrine1mg IV, q 3-5 min.VF/VT patients:Vasopressin40 U IV
or Epinephrine1 mg IV q 3 - 5 min.Differential Diagnosis
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Ventricular Fibrillation/Pulseless Ventricular Tachycardia Adu(VF/VT) Algorithm Adult Advanced Cardiovascular Life Support
Primary ABCD SurveyCheck responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, Breathing: provide positive-pressure ventilations
C Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulseless VT, up to 3 times
(200J, 200 to 300J, 360J, or equivalent biphasic) if necessary
Rhythm after first 3 shocks?
Persistent or recurrent VF/VT
Secondary ABCD Survey
A Airway: place airway device
B Breathing: confirm airway device
placement
B Breathing: secure airway device;
B Breathing: confirm effective
oxygenation and ventilation
C Circulation: IV accessC Circulation: monitor rhythm
C Circulation: drugs
D DifferentialDiagnosis: search
for reversible causes
Epinephrine1mg IV, q 3-5 min. orVasopressin40 u IV
Resume attempt to defibrillate
1 360 J (or equivalent biphasic) within 30-60 sec.
antiarrhythmics:Amiodarone(IIb), l idocaine(indeterminate),magnesium(IIbif hypomagnesemic state),
procainamide(IIb for intermittent/recurrent VF/VT).Consider buffers.
Resume attempt to defibrillate
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Mechanism with Monophasic wave(Extension of Refractoriness)
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Synchronization
of Repolarization
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Defibrillation success factor
Patient factors
duration of pre-shock VF andCPR
functional status of myocardium
acid-base balance, hypoxia,
drug
Operational factors
time to defibrillationtransthoracic impedance
paddle position, optimal energy
P l l El t i l A ti it
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Pulseless Electrical Activity AduAdult Advanced Cardiovascular Life Support
Primary ABCD SurveyFocus: basic CPR and defibrillation
Check responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulseless VT
Pulseless Electrical Activity
(PEA = rhythm on monitor, without detectable pulse)
Consider causes that are potentially reversible HypovolemiaHypoxiaHydrogen ion acidosisHyper-/hypokalemia, other metabolicHypothermia
Tablet (drug OD, acidosis)Tamponade, cardiacTension pneumothoraxThrombosis, coronary (ACS)Thrombosis, pulmonary (embolism)
Epinephrine1mg q 3-5 min. Atrop ine1mg IV (if PEA rate is s low), q 3 - 5 min.
Secondary ABCD Survey
A Airway: place airway device,B Breathing: confirm airway device placement
B Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilation
C Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugs
D DifferentialDiagnosis: search for reversible causes
A t l Th Sil t H t Al ith
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Asystole: The Silent Heart Algorithm AduAdult Advanced Cardiovascular Life Support Figure
Asystole
Primary ABCD SurveyFocus: basic CPR and defibrillation
Check responsiveness, Activate emergency response system, Call for defibrillatorA Airway: open the airway, B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions, C Confirm true asystoleD Defibrillation: assess for and shock VF/pulseless VTRapid scene survey: any evidence personnel should notattempt resuscitation
Secondary ABCD Survey
A Airway: place airway device,B Breathing: confirm airway device placementB Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilationC Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugsD DifferentialDiagnosis: search for reversible causes
Epinephrine1mg IV q 3-5 min.
Transcutaneous pacing:If considered, perform immediately
Atrop ine1mg IV,repeat every 3 to 5 minutes
up to a total dose of 0.04mg/kg
Asystole persistsWithhold or cease resuscitative efforts?
Consider qualify of resuscitation? Atypical clinical features present? Support for cease-efforts protocols in place?
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Intravenous Techniques During
ACLS
Routes of Drug Delivery:
Intravenous
Intratracheal
IntraosseousIntracardiac
Preferred IV route:
Antecubital vein
Central vein
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Objectives of ACLS
pharmacology Correction of hypoxia
ROSC and adequate blood pressure
Promotion of optimal cardiac function
Treatment of arrhythmias
Relief of pain
Correction of acidosis
Treatment of heart failure
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Pharmacology in ACLS Primary agents : agents for full cardiac arrest
oxygen, epinephrine, vasopressin,
amiodarone, atropine etc
Secondary agents : agents for AMI &complications
inotropic agents, vasodilators, adrenergicblockers, diuretics, thrombolytic agents
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EpinephrineMechanism Increase of SVR by alpha-adrenergic effect
Increase of CoPP and CPP
myocardial oxygen requirement
Class Indeterminate
- No survival benefit vs placebo- Increase in 24 hr mortality with high-dose
Dosage during CPR
standard : 1 mg q 3-5min.
intermediate : 2- 5 mg
escalating : 1- 3 - 5 mghigh : 0.1 mg/kg
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Vasopressin
Stimulation of smooth muscle V1 receptors
Increase in CPP, vital organ blood flow, median
frequency of VF, and cerebral oxygen delivery
No beta-adrenergic activity Class IIb for VF/VT cardiac arrest: 40 U IV
bolus
Class indeterminate for PEA or asystole
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AtropineMechanism enhancement of SA node
automaticity enhancement of & AV node
conduction
Indications: symptomatic bradycardia* role in AV block* bradyasystolic cardiac arrest
Dosage
: 0.5 - 1.0 mg in non-cardiac arrestup to 3 mg in cardiac arrest
*paradoxical response
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Amiodarone
Class III antiarrhythmic agent
Effects on sodium, potassium, and calcium channels
Alpha- and beta-adrenergic blocking effect
Class IIb for refractory VF/VT, stable VT, polymorphic VT,
wide-complex tachycardia of uncertain origin Class IIa for an adjunct to electrical cardioversion of
refractory PSVTs and pharmacologic cardioversion of AF
Class IIb for preexcited atrial arrhythmias
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LidocaineMechanism Reduction of the slope of phase 4
depolarization, elevation of fibrillationthreshold
No effect in contractility, conduction, atrialarrhythmogenesis
Indicationstreatment of VT or VF: Class indeterminateprevention of ventricular arrhythmias
Dosage
1.0 - 1.5 mg/kg(bolus during CPR)2 - 4 mg/min. (maintenance)
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Sodium bicarbonateAcid-Base balance during CPR Veno-aterial paradox during CPR
* three-part acid-base abnormality CO2 producing buffer solution
* limited elimination of CO2 during CPR
Indicationspreexisting metabolic acidosis,hyperkalemia, tricyclic or phenobarbitaloverdose
Dosage : 1 mEq/kgAdverse effect
tissue/intracellular acidosis, alkalemia,hyperosmolarity, impaired O2 delivery
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Algorithms for Treatment
of Life-Threatening
Conditions
Bradycardia Algorithm (Patient Not in Cardiac Arrest) Adu
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y g ( )Adult Advanced Cardiovascular Life Support
Bradycardia
Slow (Absolute bradycardia = rate
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Indications of emergency
cardiac pacing Hemodynamically unstable
bradyarrhythmias
Pause- or bradycardia-dependent
ventricular rhythms Termination of malignant supraventricular
or ventricular tachyarrhythmias
Bradyasystolic cardiac arrest
Prophylactic pacing in AMI
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Contraindications to ECP
Severe hypothermia
Brady-asystolic CA of more than 20 minutesduration
Pediatric CA due to respiratory origin
The Tachycardias: Overview Algorithm Adu
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Adult Advanced Cardiovascular Life Support
Evaluate patientstable or unstable? serious signs or symptoms? due to tachycardia?
Stable patients: no serious signs or symptomsInitial assessment identifies 1 or 4 types of tachycardias
Unstable patients: serious signs or symptoms
Establish rapid heart rate as cause of signs and symptoms Rate related signs and symptoms occur at many rates->Prepare forimmediate cardioversion
1. Atrial fibrillationAtrial flutter
4. Stable monomorphic Vand.or polymorphic VT
2. Narrow-complextachycardia
3. Stable wide-complextachycardia: unknown type
Evaluation focus:clinically unstable?Cardiacfunction?,WPW?Duration 48 hours?
Attempt to specific DxECG, Clinical information Vagal maneuvers Adenosine
Attempt to specific DxECG, Esophageal lead Clinical information
Treatment focus: clinical evaluation1.Treat unstable patient urgently2.Control the rate, convert the rhythm3.Provide anticoagulation
Diagnostic efforts yield Ectopic atrial tachycardia Multifocal atrial tachycardia PSVT
Treatment ofAtrial
Fibrillation/Atrial flutter
Treatment of SVT)Confirmed
SVTWide-complextachycardia ofunknown type
ConfirmedStableSVT
Treatment Stable
monomorpand
polymorphVT
DC cardioversion or Procainamide orAmiodarone if EF >40%
DC cardioversion or Amiodaroneif EF
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Adult Advanced Cardiovascular Life Support
Control Rate Convert Rhythm
Norm al LVEFLVEF
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Adult Advanced Cardiovascular Life Support
Narrow-Complex SupraventricularTachycardia, Stable
Attempt therapeutic diagnostic maneuver
Vagal stim ulation
Adenos ine
Junctional tachycardia
No DC cardioversion!Amiodaroneb-blocker Ca2+channel blocker
No DC cardioversionAmiodarone
Preserved
EF
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Adult Advanced Cardiovascular Life Support
Stable Ventricular Tachycardias:
Monomorphic and Polymorphic?
Monomorphic VT
Is cardiac function impaired?
Polymorphic VT
Is QT baseline interval prolonged?
Note!May go direct ly to
cardioversion
Normal function Poor ejection fraction NormalProlonged
Medications: any one Procainamide
SotalolOther acceptableAmiodarone Lidocaine
Amiodarone
150mg IV bolus over 10 minutesorLidocaine
0.5 60 0.75 mg/kg IV pushThen use
Synchronized cardioversion
Cardiac functionimpaired2
Normal baseline QT intervalTreat ischemia
Correct electrolyteMedications: any oneb-Blockers orLidocaine orAmiodarone orProcainamideorSotalol
Long baseline QT intervalCorrect abnormal electrolyte
Medications: any oneMagnesium Overdrive pacing Isoproterenol Phenytoin Lidocaine
Electrical Cardioversion Algorithm AduAd lt Ad d C di l Lif S t
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Adult Advanced Cardiovascular Life Support
TachycardiaWith serious signs and symptoms
If ventricular rate is >150 bpm, prepare forimmediatecardioversion. May give brief trial of medications based onspecific arrhythmias. Immediate cardioversion is generally notneeded if heart rate is 150 bpm.
Have available at bedside Oxygen saturation monitor Suction device IV line
Intubation equipment
Steps for synchronized Cardioversion1. Consider sedation.
2. Turn on defibrillator
(monophasic or biphasic)
3. Attach leads
4. Synchronization
5. Select energy
6. Apply gel to paddles
7. Position paddle on patient8. Charge
9. Announce Clear
10. Discharge
11. Check monitor and patient
Premedicate whenever possible
Synchro nized cardioversion
Ventricular tachycardia Paroxysmal supraventricular
tachycardia Atrial fibrillation Atrial flutter
100 J, 200 J,300 J, 360 Jmonophasic energydose (or clinicallyequivalent biphasicenergy dose)
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Transthoracic Impedance Electrode composition/ size
Energy selected
Electrode-skin coupling material
No & interval of previous shocks Phase of respiration
Inter-electrode distance
Contact pressure
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Energy requirements Ventricular fibrillation
Ventricular tachycardia
Atrial fibrillation
Atrial flutter
PSVT
200-200-360
100-200-360
100-200-360
50-100-200
50-100-200
Acute Pulmonary Edema, Hypotension, Shock AduAdult Advanced Cardiovascular Life Support
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Adult Advanced Cardiovascular Life Support
Clinical signs: Shock, hypotension,congestive heart failure, acute pulmonary edema
Most likely problem?
Acute pulmonary edema Volume problem Pump problem Rate problem
Bradycardiaalgorithm
Tachycardalgorithm
1st-Acute pulmonary edema FurosemideIV 0.5 to 1.0mg/kgMorphineIV 2 to 4 mgNitroglycerinSLOxygen/intubation as needed
AdministerFluids Blood transfusions Cause-specific interventionsConsidervasopressors Blood
pressure?
Systolic BPBP defines2nd line ofaction (seebelow)
Systolic BP100 mmHg
Norepinephrine0.5 to 30 mg/min IV
Dopamine5 to 15 mg/kg perminute IV
Dobutamine2 to 20 mg/kg perminute IV
Nitroglycerin10 to 20 mg/min IV
Consider Ni t ropruss ide0.1 to
5.0 mg/kg per minute2ndAcute pulmonary edemaNitroglycerin/nitroprusside if BP >100 mmHgDopamone if BP = 70 to 199 mmHg, signs/symptoms of shockDobutamine if BP >100 mmHg, no signs/symptoms of shock
Further diagnosis/therapeutic considerations: IABP, PA catheter, Angiography, etc
A t M di l
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Acute MyocardialInfarction
Community early activation of EMS
EMS system
oxygen / IV / cardiac monitor / vital signsNTG, narcoticsnotification of ED, rapid transportprehospital screening of thrombolytic therapy12-lead ECG, analysis, transmissioninitiation of thrombolytic therapy
Emergency departmentDoor-to-drug team protocol approach(triage, decision making)
Assessmentvital signs/ECG/ historydecision for Thrombolysis
Treatmentoxygen / NTG / morphineaspirin/ heparin/ beta-blockerthrombolytic agents
Ischemic Chest Pain Algorithm AduAdult Advanced Cardiovascular Life Support
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pp
Chest pain
suggestive of ischemia
Immediate assessment:
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pp
Assess the initial ECG
within 10 minutes of arrival.
ST segment
elevationor new LBBB
ST segment depression/
dynamic T-wave inversion:strong ly susp ic ious for ischemia
Nondiagnostic ornormal ECG
ST elevation 1 mm in 2 or morecontiguous leads
New or presumably new LBBB(BBB obscuring ST-segment analysis)
ST depression >1 mm Marked symmetrical T-waveinversion in multiple precordial leads
Dynamic ST-T changes with pain
ST depression 0.5 to 1 mm T-wave inversion or flattened inleads with dominant R waves
Normal ECG
90% of patients with ischemic-typechest pain and ST-segmentelevation will develop new Q wavesor positive serum markers for AMI.
Patients with hyperacute T wavesbenefit when AMI diagnosis is certain.Repeat ECG may be helpful.
Patient with ST depression in earlyprecordial leads who have posterior MIbenefit when AMI diagnosis is certain.
High-risk subgroup with increasedmortality Persistent symptoms, recurrentischemia
Diffuse or widespread ECGabnormalities
Depressed LV function Congestive heart failure Serum marker release: positivetroponin or CK-MB+
Heterogeneous group: rapidassessment needed by Serial ECGs ST-segment monitoring Serum cardiac markersFurther risk assessment helpfu Perfusion radionuclide imaging Stress echocardiography
Reperfusion therapy
Aspirin
Heparin (if using fibrin-specific lytics)
b-Blockers, Nitrates as indicated
Antithrombin therapy with heparin
Antiplatelet therapy with aspirin
Glycoprotein IIb/IIIa inhibitors
b -Blockers, Nitrates
Aspirin, Other therapy as appropr
Patients with positive serum
markers, ECG changes, or func-
tional study: manage as high risk
Algorithm for Suspected Stroke AduAdult Advanced Cardiovascular Life Support
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EMS assessment and actionsImmediate assessments Cincinnati
Prehospital Stroke ScaleLos Angeles Prehospital Stroke Screen
Alert hospital to possible stroke patientRapid transport to hospital
Suspected Stroke
Detection
Dispatch
DeliveryDoor
Immediate general assessment:
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Initial therapy for all patients Remove wet garments, Protect against heat loss and wind chill (use blankets and insulating equipment) Maintain horizontal position, Avoid rough movement and excess activity, Monitor core temperature Monitor cardiac rhythm1
Assess resp onsiveness, breathing, and pulse
What is core temp erature? Start CPRDefibri l lateup to a maximum of 3 shocks Attempt, confirm, secure airway warm, humid oxygen(42 to 46)2
IV access, Infuse warm normal saline (43)2
34 to 36 (mild hypothermia) Passive rewarming Active external rewarming
30 to 34 (moderate hypothermia) Passive rewarming
Active external rewarming of truncal areasonly1,3
What is core temp erature?
35 Return of spontaneous circulation or Resuscitative effort cease
30
Continue CPR Withhold IV medications Limit shocks for VF/VTto maximum of 3
Transport to hospital
Continue CPR Give IV medications asindicated (but space atlonger than standardinterval)
repeat defibrillation
for VF/VT as coretemperature rises
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Invasive monitoring /
Therapeutics Arterial cannulation
continuous monitoring of arterial pressure
blood samping
Bedside pulmonary artery catheterization
hemodynamic variables and cardiacoutput
sampling of mixed venous blood
Therapeutics
Pericardiocentesis, EmergencyThoracostomy
Open cardiac massage
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Prolonged Life Support
Goals
Postresuscitation intensive care /
monitoring
Cerebral resuscitation
Identification of the cause of CA
Prevention of recurrence
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Cerebral Resuscitation
Brain-orient noncerebral organ systemperfusion pressure, oxygenation,Normal ventilation, correction of acidosis,body temperature, hemodilution,immobilization/sedation, anticonvulsant
therapy, Brain-specific therapies
barbiturate, calcium channel blockers,free radical scavengers, free iron chelators,excitatory amino acid receptor blocker,
prostaglandin synthesis blockers
G l B i O i t d I t i
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General Brain-Oriented Intensive
Care Normotension: MAP, 90 - 100 mm Hg Normocapnea: PaCO2, 35 - 40 mm Hg
Moderate hyperoxia: PaO2 around 100 mm Hg
Arterial pH 7.3 - 7.5
Immobilization, Sedation, Anticonvulsants asneeded
Normothermia, aggressive treatment ofhyperthermia
Nutritional support started by 48 hours Osmotherapy if indicated