BLS ACLS 2015 - rameshhospitals.com · CARDIOPULMONARY RESUSCITATION Cardiopulmonary resuscitation...

BLS ACLS 2015

•Moderator: Dr. Abhijit Paul

•Presenter: Dr.B.V.Ramesh

CARDIOPULMONARY RESUSCITATION

Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve chance of survival following cardiac arrest

Out-of-Hospital Cardiac Arrest (OHCA) -75% occur at home and approx. 50% unwitnessed -Only 10.8% survivalIn-Hospital Cardiac Arrest (IHCA) -Survival is 22.3% to 25.5%


Cardiopulmonary arrest : Absence of palpable pulse in large artery, unconsciousness, apnoea with a dilated pupil, skin grey and cold with bluish mottling.

Mainly due to –1.Ventricular Fibrillation(VF) or Ventricular Tachycardia without

cardiac output (pVT)

2.Pulseless Electrical Activity(PAE) or Mechanical asystole

3.Electrical Asystole


Ventricular Fibrillation(VF)

Pulseless Ventricular Tachycardia(pVT)


Ventricular Fibrillation(VF) and Pulseless Ventricular Tachycardia(pVT):

-may be caused by transient focal myocardial ischemia caused by Hypotension or Vasospasm

-Shockable rhythms and Completely reversible

-Defibrillation or Electrical counter shock is the most effective method to terminate


Pulse less Electrical Activity(PAE) or Mechanical asystole:

Heterogenous group of rhythmsIdioventricular rhythmsVentricular Escape rhythms Postdefibrillation idioventricular rhythmsSinus rhythm

Nonshokable rhythm


Most common causes of PEA

They are potentially reversible

H’s T’s

Hypovolemia Tension pneumothoraxHypoxia Tamponade (cardiac)Hydrogen ion (acidocis) ToxinsHyper-/ hypokalemia Thrombosis(pulmonary)Hypothermia Thrombosis(coronary)


Asystole : Is a cardiac arrest rhythmNo electrical activity on ECGFlat line ECG is not “True Asystole”

Rule outLoose leadsLeads not connected to the patientLeads not connected to the DefibrillatorNo powerSignal gain is too low

Non shockable RhythmEpinephrine can be used followed by CPR


BRAIN can withstand hypoxic insult only for 4 minutes-Establishing an artificial circulation and respiration is immediately

important

-Best results are obtained with BLS within eight minutes

BRAIN is an important factor in continuing resuscitation and Treatment-Resuscitated person without functioning brain is of no use-Hence CPR is also known as Cardio Pulmonary and Cerebral

Resuscitation (CPCR)


Resuscitation is in three phases:1.Basic Life Support (BLS)

A - Airway controlB - Breathing supportC - Circulation support

2.Advanced Cardiac life support (ACLS)D - DrugsE - ElectrocardiographyF - Fibrillation treatment

3.Prolonged Cardiac life support (PCLS)G - Gauging (Prognosis)H - Human mentation (Cerebral outcome)I - Intensive care (multiple organ failure)

ADULT CHAINS OF SURVIVAL

Basic Life Support

Basic Life SupportADULT CHAINS OF SURVIVAL

PEDIATRIC CHAIN OF SURVIVAL

-Prevention of cardiac arrest-Early bystander high quality CPR-Activation of ERS-Effective Advanced Life Support-Integrated Post Cardiac Arrest Care

Basic Life Support

STEPS OF BLS

-Verify scene safety

-Check for Responsiveness

-Activate ERS

-Check for the Pulse and Breathing simultaneously

-Start CPR

Basic Life Support

Major Change in the SequenceFrom A B C C A B

AIRWAYBREATHINGCHEST COMPRESSION

CHEST COMPRESSIONAIRWAYBREATHING

Basic Life Support

Significant NEW and UPDATED recommendations-Rate of chest compression : 100-120/min-Depth of Compression : at least 5 cm or 2 inches

upper limit is 6 cm or 2.4 inches-Chest compression fraction : as high as possible

target of at least 65%-Preshock or postshock pauses : as short as possible-Routine use of passive ventilations is not recommended-Provide chest compressions and ventilations to all patients-Advanced airway : one breath at an interval of 6 sec 10 breaths per

minutes -Suspected opioid addiction with respiratory arrest : give Naloxone

Basic Life Support

Significant NEW and UPDATED recommendationsSHOCK FIRST vs CPR FIRST

For Witnessed adult cardiac arrestAED is immediately availableDefibrillator be used as soon as possible

For Unwitnessed adult cardiac arrestAED is NOT immediately availableInitiate CPR Defibrillator be used as soon as available

Basic Life Support

Basic Life SupportSummary of High- Quality CPR Components

Basic Life SupportSummary of High-Quality CPR Components

Basic Life SupportAdult Cardiac Arrest Algorithm - 2015

Basic Life SupportAdult Cardiac Arrest Circular Algorithm - 2015

Basic Life SupportOpioid-Associated Life Threatening Emergency(Adult) Algorithm – New 2015

2015 Recommendations for ACLS include :•Use of Epinephrine•Avoid Vasopressin•Use of Steroids•Use of Lidocaine•Use of Amiodarone•Use of β-blockers•ETCO2 for Prediction of failed Resuscitation•Extracarporeal CPR

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS)

2015 Recommendations for ACLS

Use of Epinephrine-As early as possible

-For non shockable rhythm

-Standard dose 1mg every 3-5 min

-Higher dose not recommended for routine use


Avoid Vasopressin-no advantage as a substitute for Epinephrine

- no advantage in combination with Epinephrine

-removed from Adult Cardiac arrest Algorithm 2015


Use of Steroids-Steroids may provide some benefit when combined with vasopressin

and epinephrine for IHCA

-Routine use not recommended

-Intra-arrest Methyleprednesolone

-Post-arrest Hydrocartisone considered

-In OHCA patients uncertain benefit


Use of Antiarrhythmic drugsThe role of these drugs during and after cardiac arrest yet to be shown to

increase the survival or improve neurologic outcome in cardiac arrest due to VF or pVT.

-Amiodarone may be considered in VF or pVT unresponsive to CPR, defibrillation and vasopressor therapy

-Lidocaine may be an alternative

- β-blockers may be considered immediately after ROSC from cardiac arrest due to VF or pVT


Use of Magnesium-Routine use of Magnesium is not recommended

in Adult patients for VF or pVT


ETCO2 for Prediction of failed Resuscitation

-Low ETCO2 in intubated patient after 20 min of CPR is extremely poor chance of ROSC

- This parameter alone should not be considered for terminate resuscitation


Extracorporeal CPRExtracorporeal techniques and Invasive Perfusion Devices may be

considered

-can prolong viability, if implemented rapidly

-provide time to treat potentially reversible conditions

-to support patient while waiting for cardiac transplantation

-Highly expensive


Other Devices

Impedance Threshold Devices(ITD)Mechanical Chest Compression Devices

are NOT recommended for routine use.

2015 Recommendations for ACLSOxygenation and Ventilation during CPR

-Bag-Mask device or Advanced airway may be used.

-IF Advanced air way is used 1 breath at an interval of 6 sec (10bpm) andchest compressions at a rate of at least 100 per minute without pause for breaths

-Use maximum feasible inspired Oxygen during CPR.

This does not apply to ROSC

2015 Recommendations for ACLSMonitoring during CPR

-Continued emphasis on Physiologic monitoring during CPR

-Continuous wave form Capnography is recommended.

-Ultrasound (cardiac or non-cardiac) may be considered.

-U/s should not interfere with standard cardiac treatment protocol

-used as an adjunct to standard patient evaluation


Defibrillation-If using Manual Defibrillator capable of escalating energies, higher

energy for second or subsequent shocks may be considered

-Single shock strategy is preferred to stacked shocks

2015 Recommendations for ACLSPOST CARDIAC ARREST CARE

Hemodynamic goals

-Avoid Hypotension

-Treat Hypotension

-If SBP is <90 mm of Hg or

-MAP is <65 mm of Hg


Coronary Angiography (CAG)-OHCA patients-suspected cardiac origin with ST elevation-Emergency CAG

- OHCA patients-suspected cardiac origin without ST elevation- electrically and hemodynamically unstable comatose- Emergency CAG

-reasonable to perform CAG in post cardiac arrest patients weather awake or comatose


Targeted Temperature Control (TTM) -previously known as Therapeutic Hypothermia

- in patients with ROSC and no return of consciousness

-Temperature 320C to 360C (900 -970 F) is maintained


Targeted Temperature Control (TTM) -for at least 24 hrs after achieving target temperature

-Actively prevent fever after TTM

-mortality is 35% less in TTM group

- in children it is unclear whether hypothermia is beneficial


Oxygenation -use highest Oxygen concentration available

-until Arterial oxyhemoglobin saturation or PaO2 measuring is available

-After measuring titrate FiO2 to maintain oxyhemoglobin saturation 94% or greater


Prognostication- time for prognosticate poor neurological outcome is after 72 hrs of

normothermia in patients treated with TTM

-paralysis and sedation could be a confounder

- time for prognosticate poor neurological outcome is after 72 hrs after ROSC in patients NOT treated with TTM


Organ Donation

-All patients who are resuscitated from cardiac arrest but who progress to death or brain death

-All Patients who do not achieve ROSC

- Who would otherwise have resuscitation terminated are potential organ donor Where rapid organ recovery programs exists

CARDIAC ARREST IN PREGNANCY

To provide high-quality CPR and Relief of Aortocaval compression

2015 -Left uterine displacement manually

2010 -Left uterine displacement manually-If this is unsuccessful-Left lateral wedge of 270 to 300 using a wedge under pelvis

High quality CPR is critically important and left lateral tilt is incompatible with high quality CPR

CARDIAC ARREST IN PREGNANCY – EMERGENCY CESARIAN DELIVERY

-In Nonsurvival maternal trauma -maternal pulselessness

-In which resusctative efforts are unsuccesful-there is no maternal ROSC

Perimortem Cesarian Delivery (PMCD) is considered at 4minutes Clinical decision to perform PMCD is complex and depends on :

-Variability in practitioner and team training-Patient factors-cause of arrest, gestational age of the fetus-System resources

PEDIATRIC BASIC LIFE SUPPORT AND CPR QUALITYThe changes for paediatric BLS parallels changes in Adult BLS

-Reaffirming the change in sequence A-B-C to C-A-B

-New algorithms in Cell phone era 1 and multiple rescuer CPR

-Establishing upper limit for depth of compression in adolescents-6 cms

Chest compressions at a rate of 100 to 120/min

-Strongly reaffirming the ratio compressions to ventilation in paediatric age group - C-A-B sequence has not been changed

PEDIATRIC BASIC LIFE SUPPORT AND CPR QUALITYSingle rescuer Pediatric Algorithm

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PEDIATRIC BASIC LIFE SUPPORT AND CPR QUALITY Two or more rescuers Pediatric Algorithm

BLS ACLS 2015 - rameshhospitals.com · CARDIOPULMONARY RESUSCITATION Cardiopulmonary resuscitation...

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