American Heart Association BLS/ACLS/PALS Update

Janet Smith

Forget everything you know

Instructor Goals

Incorporate the previous changes from 2001 & present 2005 revisionsLess number of algorithmsReview Acute Pulmonary Edema, Hypotension, & Shock combined algorithms, & Hypothermia algorithmStroke algorithm less busy & ACS not much change

February 24, 2006 - Rollout

First session BLS changesSecond session ACLS & PALS updateBegin new test – revised 2005Handbook of Emergency Cardiovascular Care – includes Guidelines CPR/ECC 2005. Nice addition cardiac markers, Treatment w/ Non-ST-segment Elevation MI

Instructor Objectives

Fit the course to your needsAdult learners need positive reinforcement & deal well with scenariosUnderstand the exam (new & improved)What is your environment

Student Objectives

Discuss new basic life support guidelines Discuss patient assessment & surveyDiscuss the use of ACLS drugsStations: Determine competencyDiscuss the ethical considerations in resuscitation

What type of course do you need?

Recertification versus full courseUtilize your study guides or “cheat sheets”Review pretest written examProvide scenarios

ACLS goals

Emphasis on trained & equipped Health Care Professional (HCP), but only in conjunction with trained lay rescuer & reduce time to CPR and shock delivery & obtain ultimate successEffective ACLS begins with high-quality CPR

Drug changes 2005

Most drug doses are the same as those recommended in 2000 – except use Atropine 0.5 mg IV for Bradycardia. May repeat to a total of 3 mg. Epinephrine or dopamine may be administered while waiting for a pacemaker

Early intervention & effective CPR

5 major changes 2005 guidelines

Emphasis on, & recommendations to improve, delivery of effective chest compressionsA single compression-to-ventilation ratio for all single rescuers for all victims (except newborns)

5 major changes 2005 guidelines

Recommendation that each rescue breath be given over 1 second & should produce visible chest riseA new recommendation that single shock, followed by immediate CPR, be used to attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every 2 minutes

5 major changes 2005 guidelines

Endorsement of the 2003 ILCOR recommendations for use of AEDs in children 1 to 8 years old (and older); use a child dose-reduction system if available

5 major changes continued: AED – teaching point

Some AED’s have shown to be very accurate in recognizing pediatric shockable rhythms & may be used with regular adult pads

Age Definition

“Child” CPR guidelines apply to victims 1 year to the onset of puberty (about 12 – 14 years old)Chest compressions are recommended if the heart rate is less than 60 per minute with signs of poor perfusion

Effective chest compressions

“push hard & push fast” & chest compress the chest @ a rate of about 100 per minute (except newborns)Use 1 or 2 hands with a child (Use technique that gives best results)Allow the chest to recoilLimit interruptions in chest compression

Effective chest compressions

Chest compressions create a small amount of blood flow to vital organs – the better the chest compressions (adequate rate, depth, & allowing for recoil) the more blood flow is produced

Copyright ©1996 American Heart Association

Idris, A. H. et al. Circulation 1996;94:2324-2336

Arterial and central venous pressure waveforms during external closed chest compression

Universal Compression-to-Ventilation – all lone rescuers

One universal compression-to-ventilation ratio for all lone rescuers: Single compression to ventilation ration of 30:2 for single rescuers of victims of all agesTeaching point: Simplify CPR & increase blood flow to the heart

1-Second breaths during all CPR

All breaths should be given over 1 second w/ significant volume to achieve visible chest riseTeaching point: During CPR, blood flow to the lungs is much less than normal, so the victim needs less ventilation than normal

Review of BLS guidelines

Determine if you require BLS proof prior to your course

Basic Life Support – Teaching concepts

Early bystander CPR can double or triple the victim’s survival from VF & Sudden cardiac arrest (SCA)CPR plus defibrillator within 3 – 5 minutes of collapse can produce survival rates as high as 49% to 75%

Basic Life Support – Calling for help

Lone Healthcare provider: Sudden collapse – Phone 911 & get an AED available & then return to victim to begin CPRUnresponsive victim w/ likely drowning – deliver about 5 cycles (about 2 minutes) of CPR prior to phoning 911 to get the AED & then return to CPR

Lone Healthcare Provider/CPR

Scenario: Patient unresponsive & non-breathing the Lone Healthcare provider will give 2 rescue breaths & then feel a pulse for no more than 10 seconds. If no pulse – begin compression Adult: 30:2Child: 15:2 (two rescuers)

HCP- Rescue breathing

Deliver rescue breath over 1 secondRescue breathing for a victim w/pulse

Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute

Teaching point: Less ventilation than normal & not as effective as compressions

Chest compressions – components

Adult: Center chest & @ nipple line & 1 ½ to 2 inches using heel of both hands & lower half of sternum

Child: 1/3 to ½ depth of chest & using heel of one handRate: 100 on all patients

HCP Chest compressions

Compression during CPR & NO advanced airway is present:

Deliver cycles of compressions 30:2Compression during CPR & advanced airway IS present: No longer use cycles or pausing for rescue breathing. Deliver 100 compressions/minute w/ 8-10 breaths/minute

Lay Rescuers CPR – may include information with your course

Lay rescuers should immediately begin cycles of chest compressions after delivering 2 rescue breaths in the unresponsive victim. Lay rescuers are not taught to assess for pulse or sings or circulationResearch notes that the lay public has a difficult time locating the correct place for palpation

Defibrillation

One shock followed by immediate CPR beginning w/ chest compressions & 5 cycles or 2 minutesMonophasic: 360 J Biphasic: 150 to 200 J

AED Review

Use the model for teaching & state the proper order -4-Universal steps: Power AED Attach to victim Analyze rhythm Deliver shock if indicated

Use of the AED

Use adult pads on adultsUse AED after 5 cycles of CPR (out of hospital)No recommendation for infants < 1 year of ageChildren 1 to 8 Use an AED with pediatric dose-attenuator

Electrical Therapies

Defibrillation involves delivery of current through the chest & to the heart to depolarize myocardial cells & eliminate VFMonophasic – Deliver current to one polarity & higher energy levelBiphasic – Lower energy & are more in current use

Management of Pulseless Arrest

5 cycles or 2 minutes or uninterrupted CPR & should resume immediately after deliver 1 shockPulse & rhythm are NOT checked after shock

Management of cardiac arrest

Drug administration is of 2nd importanceNO IV access: Lidocaine, epinephrine, atropine, narcan, & vasopression are absorbed via the trachea w/typical dose 2 to 2 ½ times the recommended IV dose & should dilute with water or NS Administer drugs during CPR

HCP- Rescue breathing

Deliver rescue breath over 1 secondRescue breathing for a victim w/pulse

Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute

Teaching point: Less ventilation than normal & not as effective as compressions

Airway management - review & observe student performance

Demonstrate the BVMIntubation techniquesSecondary confirmation techniquesSecuring the ETTC-Spine precautions & trauma5-point chest exam

Airway & C-spine management

Use head tilt-chin lift technique to open the airway of trauma victim unless cervical spine injury is suspectedTeaching point: Jaw thrust is a difficult maneuver & may not be an effective way to open the airway

Airway station – Use BVM

Anyone providing prehospital care for adult, children, or infants should be trained to deliver effective oxygenation & ventilationThe use of BVM should be considered to be the primary method of venilatory support, especially if transport times are short

Airway Management – Issues to discuss during the station:

BVM can be as effective as ETTA study noted 25% intubations were found to have esophageal/pharyngeal tube placementSecondary confirmation involves the use of end-tidal CO2 detectorsReview tube holder & LMA

Verify correct ETT placement

To reduce the risk of esophageal misplacement or displacement – Confirm the placement immediately after insertion, in the transport vehicle, & whenever the patient is moved

Acute Coronary Syndromes - goals

Reduce the amount of myocardial necrosis & preserve LV functionPrevent Major adverse cardiac events “MACE”Review new ACS algorithm

Acute Coronary Syndromes

M – O – N – A = Same RxEach minute the patient is in VF has 10% decrease of chance of survivalEMS: Monitor, support ABCs, CPR, & defibrillationGoal: Door-balloon 90 minutes & Door- needle 30 minutes

Stroke

Intravenous tPA who meet (NINDS) is administered by physicians w/ defined protocol, knowledgeable team, & institutional commitmentStroke patients should be admitted to Stroke Units

Acute Ischemic Stroke

Lower blood sugar (> 200mg/dL)Orders urgent CT Scan < 25 minutesReads CT scan < 45 minutesIf scan shows ICH/SAH call Neurosurgery If no hemorrhage, continues protocolSymptom onset > 3 hours?

Algorithm Review

Treatment of Wide Complex Tachycardias

ACLS providers should make a reasonable attempt to distinguish hemodynamically stable VT from SVT with aberrancy. History of CAD suggest ventricular origin. Obtain a 12-lead (when possible) & note the QRS yet accuracy requires experience

Tachycardia with Pulses

Treatment summarized in a single algorithm – Immediate synchronized cardioversion for unstable patientNarrow versus Wide Complex – Control rate (Diltiazem review)Treat contributing factors

Unstable Tachycardia/Cardioversion

Primary & Secondary ABCsD = Determine DefibrillationDetermine Sedatives & AnalgesicsKnow rapid infusion of antiarrhythmic agentsPost cardioversion careChange unsynchronized mode

Pulseless Arrest VF/VT

5 cycles of CPR prior to defibrillation & minimize interruptions Deliver 1 shock (120 or 200j) & resume CPR immediatelyEpinephrine 1mg or vasopressin 40 U IV/IO to replace 1st dose of EpinephrineMay shock either 200j (unknown biphasic device) or 360j

Asystole/PEA

Attach monitor/defibrillatorShockable Epinephrine & Vasopressin Consider Atropine 1 mg IV/IO for asystole or slow PEA rate

Asystole

Advanced airway controlEstablish IV – Epinephrine & AtropineConsider TCP (start @ once)Consider differential diagnosisLook for specific causes – The H’s & T’s with new addition

Pulseless Electrical Activity

Primary & SecondaryAirway controlIV access – Epinephrine 1 mg IVPAtropine 1 mg IVP (if rate is slow)6 H’s & 5 T’sAct upon differential diagnosis when reasonable

Correct contributing factors

HypovolemiaHypoxiaHydrogenHypo/HyperkalemiaHypoglycemiaHypothermia

ToxinsTamponadeTension pneumoThrombosis (coronary or pulmonary)Trauma

Bradycardia

Prepare TCP without delayRecognize 2nd & 3rd Degree BlocksAtropine 0.5 mg IV while waiting TCP (total dose 3mg)Epinephrine 2 to 10 mcg/min or Dopamine infusion 2 to 10 mcgSearch contributing factors

Medication Review

Anti-arrhythmic agents

Lidocaine – Alternative to AmiodaroneAdenosine – Slow AV nodal conductionProcainamide – Supraventricular arrhythmias & VT 20 mg/min total 17mg/kgAmiodarone – Is effective with SVT because it alters conduction through the accessory pathway

Dobutamine

Indication – Pump problems (CHF, Pulmonary congestion) SBP 70 to 100 mm Hg & no signs of shock

Precautions – May cause tachyarrhythmias, fluctuations in blood pressure, headache, & nausea2 to 20 mcg/kg/minute

Dopamine

Second-line drug for symptomatic bradycardia (after atropine)Use for hypotension SBP , 70 to 100 mm Hg) with signs & symptoms of shockCorrect hypovolemia with volume replacement2 to 20 mcg/kg/minute

Amiodarone

Recurrent VF & recurrent hemodynamically unstable VTRequires several time consuming steps for administration (Glass ampule, etc)Cardiac arrest: 300 mg IV initial dose & ONE 150 mg IVP in 3-5 minutesRecurrent Ventricular arrhythmias: 150 mg IV over 10 minutes

Magnesium

Use in cardiac arrest only if Torsades de Pointes is suspected or Hypomagnesaemia is present

Life-threatening digitalis toxicity1-2 g over 5 -20 min

Diltiazem

Indications: To control ventricular rate in atrial fibrillation & atrial flutterRate control: 15 to 20 mg (0.25 mg/kg) IV over 2 minutesCaution: Avoid in patient receiving or Beta blockers, B/P may drop due to peripheral vasodilation

Epinephrine

Cardiac arrest: VF, Pulseless VT, Asystole, PEASymptomatic bradycardia: after atropine & an alternative infusion to dopamineDose: IV/IO 1 mg (10 mL of 1:10,000) every 3-5 minutes

Vasopressin

Indications: Alternative pressor to epinephrine in treatment of adult shock-refractory VFDose: 40 U IV/IO push may replace either first or second dose of epinephrine

Fibinolytic Agents (Activase, tPA)

Indications: For AMI in Adults – ST elevation ( > 1 mm in 2 leads) or new

LBB, in context of S & S of AMI, Time of onset of symptoms < 12 hoursIndications: For Acute Ischemic Stroke

Focal neurologic deficits, Absence of Intracerbral or SAH on CT, & non-improving symptoms < 3 hours onset

“Flat Line Protocol”

The sensitivity or “gain” displayed on the monitor is one of the important things to check or confirm true asystole. Check the POWER (on/off)Battery supply & lead select (if set to paddles)

Postresuscitation support

Vasoactive supportInduced hypothermia cooled to 32 to 34C for 12 to 24 hours after ROSCAce Inhibitors: Reduces mortality & CHF with AMI (Angiotensin or ACE is a chemical that causes the heart to contract such as Vasotec)

Ethical Considerations

Do not resuscitateFamily presence – Let the family view all of your care & include in decision making if possibleFamily & staff grief counselingCISD assistance

The written exam

Review EID & hypopharyngeal intubation (esophageal)Hypovolemia easy to treatPrehospital asystole = drug overdoseNon-contrast CTReview Retavase & HeparinCVA v insulin-induced hypoglycemia

The written exam

Cannot be open book or use of notesBe prepared to deal with the student that challenges the exam or the answersHow do you deal with the student who fails the exam?

What can you expect in the course

Decreased lecturesMore “hands on”Role-playScenario reviewGroup involvement

Questions?