7/30/2019 201081015844

1/44

1

Advanced Cardiac L ife Support

ACLS COURSE

CPR Provider Manual12/2003

7/30/2019 201081015844

2/44

2

Advanced Life Support in perspective

Chain of survival:

1. Early access to emergency services [911].2. Early Basic life Support [by hands only].

3. Early defibrillation .

4. Early Advanced Life Support.

7/30/2019 201081015844

3/44

3

Causes & prevention of Cardio

respiratory arrest

Definition:A respiratory arrest is when breathingstops (apnea). A cardiac arrest is when the heart

stops contracting & pumping blood.

Causes:

1. Airway problems.2. Breathing problems.

3. Cardiovascular problems.

7/30/2019 201081015844

4/44

4

Airway Obstruction

Complete airway obstruction will rapidly result in

cardiac arrest.

Partial airway obstruction may lead to cerebral or

pulmonary edema , hypoxic brain damage as wellas cardiac arrest .

Causes of airway obstruction [blood, vomitus ,

F.B., direct throat / face trauma , CNSdepression, epiglottitis , epileptic fit,bronchialsecretions ,

mucosal edema, laryngeospasm ,bronchospasm].

7/30/2019 201081015844

5/44

5

Cardiac Abnormalities

Primary causes [ventr icular f ibr i l lation] :

1. Ischemia.

2. M.I.3. Drugs [digoxin , quinidine , phenothiazide ,

tricyclic antidepressant].

4. Alcohol abuse.5. Acidosis .

6. Abnormal electrolytes conc.[Ca, Mg & K].

7/30/2019 201081015844

6/44

6

Secondary causes of cardiac abnormal ities:1.asphyxia.

2. Apnea.

3. Acute sever blood loss.4. Acute pulmonary edema.

5. Suffocation.

6. Hypoxemia , anemia , hypothermia , end-

stage septic shock are having longer heart effect.

7/30/2019 201081015844

7/44

7

Prevention:

1. History, examination & investigation when

needed.

2. Breathing problems is pre cardio respiratory

arrest clinical abnormalities.

3. Hypotension , confusion , restlessness lethargy

& L.O.C. should be considered .

4. Metabolic abnormalities particularly acidosis.

5. Consider ICU admission in your plan.

7/30/2019 201081015844

8/44

8

Risks to The Rescuer

The rescuershould neverplace him self indangerwhile saving the patients life.

In case ofpoisonings [organophosphates ]that is easily absorbed via the rescuer skin &respiratory tract.

Infections [HIV , HBV , Cutaneous TBshigellosis , salmonella , meningeococcalmeningitis & herpes simplex virus ].

7/30/2019 201081015844

9/44

9

Management of The Airway

Basic techniques:

1. Head tilt [ respiratory tract in one straight line ].

2. Chin left.3. Jaw thrust [take tongue with its base & the only technique

done in suspected cervical spine injury patient ].

Types of airways:

1. Oral.

2. Naso-pharyngeal [ clenched jaw or maxillofacial injuries ].

7/30/2019 201081015844

10/44

10

Ventilation

Face mask: [ 45 - 50% if more than 6 L/m ].

Nasal Cannulae: [ 30 - 35% on 3 L/m].

Ventorie: [ 2490% ]. Non re-breathing mask: [ 90% ].

Laryngeal mask airway: [100% ].

Endo tracheal tube: [100% ]. Needle cricothyroidotomy: [full neck extension ,

feel the cricoid & prick 0.5 cm below it ].

7/30/2019 201081015844

11/44

11

Cardiac Monitor ing & rhythm

Recognition

Remember:Treat the patient not the ECG.

A normal HR is defined as 60100 b/m , a rate

below 60 is known as bradycardia & a rate of100 is known as tachycardia.

Rhythms causing cardiac arrest:

1. Supra-ventricular tachycardia [ above bundleof His bifurcation ].

2. Ventricular tachycardia [distal to bifurcation].

7/30/2019 201081015844

12/44

12

Supra-ventr icular tachycardia:1. Atrial fibrillation: [absent P wave & normal

QRS complex].

2.Atrial flutter: [there is P wave but saw tooth inappearance & rate more than 200/m (250-300/m)

with regular QRS complex].

3.supra-ventricular tachycardia: [ you might findP wave or not , because it might start from A/V

node ].

7/30/2019 201081015844

13/44

13

Ventr icular tachycardia:

1.wide QRS complex.

2. rare more than 100/m.3. may sustain for morethan 30 seconds (take itseriously). But if it was for less than 30 seconds itmight be d.t. lytes imbalance or hypoxia.

Ventricular F ibri ll ation :

1. no pulse.

2. ECG show absent QRS & T wave & replaced by

cont., very rapid, bizarre, irregular appearance ofapparently random frequency & amplitude.

7/30/2019 201081015844

14/44

14

Drugs & Their delivery

Priori ty in drug delivery :

1. central line [30 seconds].

2. Peripheral line [5 minutes].

3. E.T. Tube [but we double or triple the IV dose].

4. Intra Cardiac[ not used any more]:a) technically difficult.

b) while doing the procedure CPR should stopped.

c) high rate of complications:1.coronary laceration.

2.intra mural injections.

3.pneumothorax.

7/30/2019 201081015844

15/44

15

Adrenaline:

[1/1000 & 1/10000 conc.].

Atropine:

[parasympatholytic , block thevagal nerve & affect SAN & AVN].

Calcium:[indication]

1. Pre-existing hyperkalemia

2. Hypocalcaemia.3. Calcium Chunnel blocker toxicity.

7/30/2019 201081015844

16/44

16

NaHCO3:

[Toxicity]

1. Exacerbate intra cellular acidosis.2. - ve inotropic effect on ischemic myocardium.

3. Increase Na load [C.I. in brain edema].

4. Shift Oxygen dissociation curveto the left.[Indications]

1. hyperkalemia.

2. pre-existing metabolic acidosis (PH

7/30/2019 201081015844

17/44

17

Mg:

[ Indication]

1. Suspected hypomagnesaemia.

2. Refractory V.F.

Adenosine :

[ Indication]

1. Drug of choice for SVT.

2. Slow A-V conduction .

3. Half life 10 to 15 sec.

4. Shouldn't be diluted [push & flush].

7/30/2019 201081015844

18/44

18

Verapamil:

[Indication]

1. Reduce AVN conductivity.

2. Only can be used in definite SVT

3. Dilute & give slowly.

Amiodarone:

1. Increase duration of action potention in atrial

& ventricular myocardium, Q-T interval is

prolonged .

2. given via central cath. /wide pore cannulae.

7/30/2019 201081015844

19/44

19

3. Should be diluted in G/W 50 cc & to be

given over 10 min.

[Side Effects]

1. photo-sensitivity.2. hepatic & pulmonary infiltrates.

3. peripheral neuropathy .

4. corneal micro-deposits.5. thyroid function disturbances.

7/30/2019 201081015844

20/44

20

Lignocaine:

[Indication]

1. ventricular tach. (metabolites in liver).2. dose 1 mg/kg loading then 2-4mg/min drip.

[Toxicity]

1. confusion.2. drowsiness.

B. blockers:

1. 2nd line of SVT treatment.

2. Given carefully after Verapamil.

7/30/2019 201081015844

21/44

21

Vasopressin:

Single dose of 40 units as alternation to

adrenaline in Ventricular Fibrillation or pulseless ventricular tachycardia.

7/30/2019 201081015844

22/44

22

Defibrillation

We paralyze the heart, to let S. A. Node to start

working again .

The delay in DC >>>the sever the arrhythmia

>>> less favorable prognosis & less responsive

to treatment.

Types:

1. Synchronized Cardio-version.

2. A synchronized Cardio-version.

7/30/2019 201081015844

23/44

23

1. Synchronized Cardio-version:

if is used to convert Atrial or ventricular tach., it is

important that the shock is synchronized to occurwith the R wave of the ECG rather than with the Twave.

2. A synchronized Cardio-version:

it will shock at any ECG phase ,& it can causeventricular fibrillation.

Mechanism of action:

1. Monophasic:receive single burst, 1 pad to another & dont comeback.

2 Bi h i

7/30/2019 201081015844

24/44

24

2. Biphasic :

less Jules (electric shock waves move from 1 pad to

the other then go in reverse direction).

Types of Biphasic Defibri l lator:

1. Manual (which we are using).2. Shock Advisor(for non-expert people),with big

electrodes they can read the rhythm then talk or

write the order to be done.3. Automated External (you just connect it to the

patient & it will work & calculate the electric wave

by it self & when to give it).

7/30/2019 201081015844

25/44

25

Position:

1. Right of the upper sternum below the clavicle

2. left 5th inter-costal space ant. Axillary's line.

Technique:

1. apply pressure to the paddle [10kg] to decrease

thoracic impedance (the distance by pr. The fat).2. keep the defibrillator paddles at least 12.5 cm from the

pace maker if there is.

3. Keep oxygen flow away from from paddle (not to kill

the patient by burning instead of arrest)

4. Dont remove the paddle until 3 DC shock performed.

7/30/2019 201081015844

26/44

26

Treatment of Algor ithms

During CPR:

[If not already]

1. Check electrode/paddle position & contact.

2. Attempt/verify airway ,oxygen & IV access.3. Give adrenaline every 3 minutes (cycle).

4. Consider :

a. Anti-arrhythmic.

b. Atropine.

7/30/2019 201081015844

27/44

27

[Correct Reversible causes (4 Hs & 4Ts)]

1. Hypoxia.

2. Hypovolemia.

3. Hypo/Hyperkalemia & metabolic disorders.4. Hypothermia.

5. Tensionpneumothorax.

6. Tamponade.7. Toxic/Therapeuticdisturbances.

8. Thrombo-embolic/mechanical obstruction.

7/30/2019 201081015844

28/44

28

Management of VF /pulse-less VT

I n each CPR cycle we provide:

1mg adrenaline IV.

3 DC shocks (200, 200, & 360joules).

1 minute CPR.

Then after 1 min. CPR 3 DCshocks (each 360 joules)+ 1

minute CPR & adrenaline.

7/30/2019 201081015844

29/44

29

Algor ithm for management of non

VF /VT rhythmsIn case of a systole there is norule of DC shock unless fineVF.

1mg adrenaline + 3mgatropine.(USA)

3mg atropine but 0.5mg every3 min & total of 3mg + 1mgadrenaline in each cycle.

Post DC shock heart can enterinto a systole for 15 sec. Thenreturn to normal.

7/30/2019 201081015844

30/44

30

Cardiac Arrest in special

CircumstancesHypothermia.

Near drowning.

Pregnancy.

Poisoning.

Electrocution.

Anaphylaxis.

Acute severe asthma.

7/30/2019 201081015844

31/44

31

Hypothermia

Hypothermia exist when the body core temp. falls below 35C. (A&B) with high conc. Warm O2.

(C) palpate a major artery for a minimum of 1 minute before

concluding that there is no C.O.P.

As body temp. falls sinus bradycardia A.F. V.F. finallya systole. When core temp < 30C ; VF will not respond to

cardioversion or drugs. Arrhythmias other than VF tend to revert

spontaneously as the core temp rises [in open heart surgery when

we rise temp 33C the heart rate pick up systole & sinus rhythm].

Rewarming:

1) Remove cold wet clothing ASAP & cover with blankets.

2) Warm bathes (40C).

7/30/2019 201081015844

32/44

32

Severe hypothermia (

7/30/2019 201081015844

33/44

33

Near Drowning

Associated with hypothermia & beadycardia.

Defined as asphyxiation in fluid (water).

Respiratory arrest 1ry event & cardiac arrest is 2ry event.

BLS & ALS shouldnt be less than 45 min.

Placed horizontally & head down ( to prevent aspiration &regurgitation).

In 10% of cases no fluid is aspirated (dry drowning due tospasm).

Hospitalization is needed for:- Secondary pulmonary edema.

- ARDS (aspirated fluid).

Patient can be discharged after 6 hrs if clinically, ABG, CXR

normal.

7/30/2019 201081015844

34/44

34

Pregnancy

Two people to resuscitate.

Causes of maternal cardiac arrest:

- Hemorrhage.

- Pulmonary embolism.

- Amniotic fluid embolism.

- Placental abruption.

- Eclampcia. After 5 minutes of unsuccessful in-hospital resuscitation,

emergency C/S is indicated to save the fetus (in the 3rd trimester

of pregnancy).

7/30/2019 201081015844

35/44

35

Poisoning

A.B.C. & NO mouth to mouth breathing.

Increase risk of pulmonary edema, aspiration, earlyintubation is recommended in thermal injury & airway

burns.

Arrhythmias commonly results from the ingestion of drugs

with negative inotropic action (treatment is with positiveinotropic drugs i.e. adrenaline & dobutamine).

7/30/2019 201081015844

36/44

36

Antidote:- OpiodXNaloxone 1.2mg

- BradyarrhythmiaXatropine 2mg orisoprenaline 10-100ug/min.

- B.blockersXglucagon 5mg IV.

- Organophosphate insecticidesX high-dose atropine.

- CyanidesXdicobalt edetate.

- Digoxin toxicityXdigoxin specific FAB.

Pass NGT & lavage stomach from ingested toxins & give activated

charcoal.

7/30/2019 201081015844

37/44

37

Electrocution

The severity of injury depends on the area & the magnitude &the path of the current.

Electricity tends to pass along muscles, nerves & vessels. It maytherefore paralyze the respiratory muscles or disturb themyocardium, leading to respiratory or cardiac arrest (V.Fibrillation, immediate asystole, extra pace maker).

Electrocution is like a bullet goes in & out, but if it remains in it

will settle at the heart. Those who have survived an electric shock should be monitored

in hospital if they have suffered (L.O.C, cardiac arrest, ECGabnormalities, contact injury)

7/30/2019 201081015844

38/44

38

Anaphylaxis Due to (insect bite, food, blood products & drugs)IgE Anti bodies

histamine release increase vascular permeability & peripheral V.D.(

decrease V.R. & C.O.P.) sudden collapse & death.

Anaphylactoid reaction (there is no IgE mediators & no previous

sensitization).

Resuscitation with:

1) 100% oxygen.

2) Adrenaline (if stridor, wheeze or respiratory distress) 0.5cc 1/1000 I.M. &

repeat Q5 minutes if no clinical improvement is clear.

3) CPR or ALS.4) Antihistamines.

5) Hydrocortisone.

6) IV Colloids.

7/30/2019 201081015844

39/44

39

Acute Severe Asthma

Normal or low PCO2.

Resuscitated with:1) ABGs.

2) Intubation.

3) Exclude pneumothorax & consider open cardiacmessage.

Resist arrhythmias in case of metabolic disorders.

7/30/2019 201081015844

40/44

40

Peri-arrest Arrhythmias complications of M.I. & in certain circumstances

may also precede ventricular fibrillation, named :1. Bradycardia.

2. Broad complex tachycardia (90% ventricular in origin).

3. Narrow complex tachycardia (90%atrial in origin).

Principle of treatment:

1. How is the patient ?

2. What is the arrhythmia ?

Three options available in the immediate treatment ofarrhythmias:

1. Cardio-version.

2. Anti-arrhythmic & other drugs.

3. Cardiac pacing.

7/30/2019 201081015844

41/44

41

Bradycardia:

blood pressure < 90 mmHg.

Broad complex tachycardia:

1) Pulse sedationsynchronize DC shock

2) Pulseless no C.O.P. VF/VT.

Narrow complex tachycardia:1)AF > 130 b/min ask help BP < 90 mmHg synchronized

DC shock.2) Vagal maneuver adenosine ask help BP

7/30/2019 201081015844

42/44

42

Cardiac Pacing

SAN(60 - 70 beats/minute).

AVN(40 -50 beats/minute) [narrow QRS].

His/Purkinje fibers(30 beats/minute) [wide QRS].

N.B.

In open heart surgery the pace maker should be 100

beats/minute to over come SAN.

7/30/2019 201081015844

43/44

43

Arti f icial pacemakers classif ication:

Non-invasive:Percussion pacing (decrease HR decrease COP).

Transcutaneous pacing (stickers).

Invasive:

Temporary transvenous pacing (central line placed in Rt.ventricle).

Permanent implanted pacing (catheter with patery).

Implantable cardioverter defibrillators.

7/30/2019 201081015844

44/44