acls december 2005

8/7/2019 Acls December 2005

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CARDIOPULMONARYCARDIOPULMONARY

RESUSCITATIONRESUSCITATION

&&

EMERGENCYEMERGENCY

CARDIOVASCULAR CARECARDIOVASCULAR CARE

DECEMBER 2005 GUIDELINESDECEMBER 2005 GUIDELINES


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Classification of RecommendationsClassification of Recommendations

and Level of Evidenceand Level of Evidence CLASS I: Benefit>>>RiskCLASS I: Benefit>>>RiskProcedure/Rx/Diagnostic Test should be doneProcedure/Rx/Diagnostic Test should be done

CLASS IIa: Benefit>>RiskCLASS IIa: Benefit>>RiskProcedure/Rx/Diagnostic Test reasonable to performProcedure/Rx/Diagnostic Test reasonable to perform

CLASS IIb: Benefit=RiskCLASS IIb: Benefit=Risk Procedure/Rx/Diagnostic may be consideredProcedure/Rx/Diagnostic may be considered Optional vs expert recommendationOptional vs expert recommendation

CLASS III: Risk>BenefitCLASS III: Risk>BenefitProcedure/Rx/Diagnostic should not be performed/harmfulProcedure/Rx/Diagnostic should not be performed/harmful


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New RecommendationsNew Recommendations

2 breaths2 breaths chest compressionschest compressions

All breaths (mouthAll breaths (mouth--mouth, mouthmouth, mouth--bag, bagbag, bag--mask)mask)given over 1 secgiven over 1 sec see chest risesee chest rise

Longer uninterrupted chest compressionLonger uninterrupted chest compressionCompression:Breath (30:2)Compression:Breath (30:2)

Push hard and push fast (100/minute)Push hard and push fast (100/minute)

2 min of compression before rhythm/pulse check2 min of compression before rhythm/pulse checkin pulseless arrestin pulseless arrest

Pulseless VF/VT: 1 shock (instead of stacked)Pulseless VF/VT: 1 shock (instead of stacked)


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CPR

Compress at the center of the chest at theCompress at the center of the chest at thenipple linenipple line

Compress the chest approximately 1.5Compress the chest approximately 1.5--22inches using heel of handsinches using heel of hands


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Electrical TherapiesElectrical TherapiesAutomated Electrical Defibrillators(AED), Defibrillation,Automated Electrical Defibrillators(AED), Defibrillation,

Cardioversion, PacingCardioversion, Pacing

Immediate CPR until defibrillator availableImmediate CPR until defibrillator available

11--Shock vs 3Shock vs 3--shock sequenceshock sequenceNo studies humans/animals comparing the twoNo studies humans/animals comparing the two

Animal studies: long interruptions in CPR assoc w/Animal studies: long interruptions in CPR assoc w/postpost--resuscitation myocardial dysfunction and decr.resuscitation myocardial dysfunction and decr.survivalsurvival

RCT: interruptions in CPR assoc w/ decr. probabilityRCT: interruptions in CPR assoc w/ decr. probabilityof conversion of VF to another rhythmof conversion of VF to another rhythm

33--Shock: 37 sec delay before 1Shock: 37 sec delay before 1ststcompressioncompression

11--Shock: efficacy of conversion >90% (biphasicShock: efficacy of conversion >90% (biphasicdefibrillators)defibrillators)


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Monophasic vs Biphasic DefibrillatorsMonophasic vs Biphasic Defibrillators

11stst--shock efficacy of monophasic < 1shock efficacy of monophasic < 1stst--shockshockefficacy of biphasicefficacy of biphasic

Goal: delivery of current through chest to theGoal: delivery of current through chest to the

heart to depolarize myocardial cells and eliminateheart to depolarize myocardial cells and eliminateVF/VTVF/VTMonophasic:Monophasic:

delivers current of one polaritydelivers current of one polarity 11--shock 360Jshock 360J

Biphasic :Biphasic :


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AEDAED

Only useful for shockable rhythmsOnly useful for shockable rhythms If implantable medical device (pacemaker, AICD)If implantable medical device (pacemaker, AICD)

place 1 inch awayplace 1 inch away

Do NotDo Notplace on transdermal medicationplace on transdermal medicationdevicesdevicesburns, decrease energy to heartburns, decrease energy to heart Individual wet/diaphoreticIndividual wet/diaphoreticdrydry Decreasing impedanceDecreasing impedance

Shave chest hairShave chest hairConductive gelConductive gel

Arched placement of AED in OArched placement of AED in O22--rich environmentrich environmentcan spark firescan spark fires


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Synchronized CardioversionSynchronized Cardioversion

Shock delivery timed with QRS complexShock delivery timed with QRS complex Indicated for Rx of unstable tachyarrhythmiasIndicated for Rx of unstable tachyarrhythmias

associated with organized QRS complex and aassociated with organized QRS complex and aperfusing rhythmperfusing rhythm

Rx unstable SVTRx unstable SVTReentryReentry

Atrial FibrillationAtrial Fibrillation mono=100mono=100--200J, bi=100200J, bi=100--120J120J

Atrial flutterAtrial flutter mono=50mono=50--100J, bi=100100J, bi=100--120J120J

U

nstable monomorphic VTU

nstable monomorphic VT

100J, bi=100100J, bi=100--120J120JNOT effectiveNOT effective

Junctional tachycardiaJunctional tachycardia

Ectopic/multifocalEctopic/multifocal--atrial tachycardia (automatic focus)atrial tachycardia (automatic focus)

Shocks to automatic focus can further increase HRShocks to automatic focus can further increase HR


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PacingPacing

Symptomatic bradycardiaSymptomatic bradycardia

RCT: Asytolic patients and pacingRCT: Asytolic patients and pacing

No improvent in survivalNo improvent in survivalClass IIIClass III


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Medication for Arrest RhythmsMedication for Arrest Rhythms

VASOPRESSORS

No controlled trials demonstrating increasedrate of neurologically intact survival tohospital discharge

Evidence that Vasopressor agents favors initialROSC


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EPINEPHRINEEPINEPHRINE

AlphaAlpha--adrenergic vasoconstrictor propertiesadrenergic vasoconstrictor propertiesincreases coronary and CPP during CPRincreases coronary and CPP during CPR

BetaBeta--adrenergic properties controversial asadrenergic properties controversial asthey may increase myocardial work andthey may increase myocardial work andreduce subendocardial perfusionreduce subendocardial perfusion

1mg dose vs High dose NSS in 81mg dose vs High dose NSS in 8--RCTRCT

1mg dose Q 31mg dose Q 3--5 min5 min CLASS IIBCLASS IIB


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VASOPRESSINVASOPRESSIN

NonNon--adrenergic peripheral vasoconstrictoradrenergic peripheral vasoconstrictor

Coronary and renal vasoconstrictorCoronary and renal vasoconstrictor

MetaMeta--analysis of 5analysis of 5--RCT NSS between EPIRCT NSS between EPI

and VP for ROSC, 1and VP for ROSC, 1--hour survival, 24hour survival, 24--hrhr--survival, or survival to hospital d/csurvival, or survival to hospital d/c

Dose: 40 UnitsDose: 40 Units


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ATROPINEATROPINE Reverses the cholinergic mediated decrease in HR,Reverses the cholinergic mediated decrease in HR,

SVR, BPSVR, BP

No prospective controlled studies supporting itsNo prospective controlled studies supporting itsuse in Asystole/ PEAuse in Asystole/ PEA

Retrospective review: intubated pts w/ refractoryRetrospective review: intubated pts w/ refractoryasystole (in the field)asystole (in the field) increased survival toincreased survival tohospital admissionhospital admission

Caution in ACS/AM

I as may Incr HR and worsenCaution in ACS/AM

I as may Incr HR and worsenischemiaischemiaMay not be effective in cardiac transplant patientsMay not be effective in cardiac transplant patients

as the transplanted heart lacks vagal innervationas the transplanted heart lacks vagal innervation Dose: 1mg Q 3Dose: 1mg Q 3--5 min (max 3mg)5 min (max 3mg)


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AmiodaroneAmiodarone

Affects Na, K, CaAffects Na, K, Ca--channels, alpha and betachannels, alpha and beta--adrenergic blocking propertiesadrenergic blocking properties

RCT (in the field): Amio vs Placebo vs LidoRCT (in the field): Amio vs Placebo vs LidoIncreased survival to hospital admission (SS)Increased survival to hospital admission (SS)

Improved defibrillator response (SS)Improved defibrillator response (SS)

Initial: 300mg, then 150mgInitial: 300mg, then 150mg

***(SS) Statistically Significant***(SS) Statistically Significant


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MagnesiumMagnesium

Observational studiesObservational studies termination oftermination of

TorsadesTorsades

11--2g in 502g in 50--100cc D5W over 5100cc D5W over 5--20min20min


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ETT MedicationsETT Medications

NAVELNALOXONE

ATROPINE

VASOPRESSIN

EPIN

EPHRIN

ELIDOCAINE

***Dose at 2-2.5 x normal


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VF/VTVF/VT

Most critical intervention during 1Most critical intervention during 1ststminminImmediate bystander CPR w/ min interruptions inImmediate bystander CPR w/ min interruptions in

chest compressions and Defib ASAPchest compressions and Defib ASAP Class 1Class 1

11--shock instead of 3shock instead of 3--shocks (stacked)shocks (stacked)


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PULSELESS ARRESTPULSELESS ARRESTVF/VTVF/VT

1ST-shock (M=360J, B=120-200J) CPR X 2 minutes 1-shock

Epi 1mg Q 3-5min OR Vasopressin 40U 1-shock Amiodarone 300mg (then 150) OR

lidocaine 1-1.5mg/kg x 1 (then 0.5 - 0.75 mg/kg x 2)

Magnesium 2 gms IV for Torsades

***CPRRHYTHM CHECKSHOCK


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PULSELESS ARRESTPULSELESS ARREST

ASYSTOLE/PEA

CPR x 2 min Epi 1mg Q 3-5 min OR VP 40U

CPR x 2 minutesAtropine 1 mg Q 3-5 minutes (max 3 doses) for

asystole or slow PEA

***CPR: PUSH HARD , PUSH FAST(100 COMPRESSIONS PER MINUTE )

***1 DOSE VP SUBSTITUTES 2 DOSES OF EPI


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PULSELESS ARRESTPULSELESS ARRESTPULSELESS ELECTRICAL ACTIVITY (PPULSELESS ELECTRICAL ACTIVITY (PEA)

6 Hs

Hypovolemia

HypoxiaHydrogen ion (acidosis)

Hypo-/Hyperkalemia

Hypoglycemia

Hypothermia

5 Ts

Toxins

TamponadeThrombosis (coronary or

pulmonary)

Tension PTx

Trauma


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Symptomatic BradycardiaSymptomatic Bradycardia

HR


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TachyarrythmiaTachyarrythmia

NarrowComplexQRS0.12

VT

SVT with aberrancy


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Narrow ComplexNarrow Complex

RegularVagal Maneuver

Adenosine 6, 12, 12

**If converts:reentrantSVT

If not converted:CCB, BB,

Amio (EF


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Wide ComplexWide Complex

VT or Uncertain rhythmVT or Uncertain rhythm

Amiodarone 150mgAmiodarone 150mg

Synchronized cardioversionSynchronized cardioversion

AF+WPW (preAF+WPW (pre--excited AF)excited AF)

Amiodarone 150mgAmiodarone 150mg

AVOID: adenosine, Digoxin, Diltiazem,AVOID: adenosine, Digoxin, Diltiazem,VerapamilVerapamil


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ReviewReview

Pulseless VF/VTPulseless VF/VTCPR, 120J, CPRCPR, 120J, CPREPI/VPEPI/VPCPR,AirwayCPR,AirwayAmio 300Amio 300CPR X 2 min then shockCPR X 2 min then shock

Asystole/PEAAsystole/PEAEpi, AtropineEpi, Atropine

Symptomatic BradycardiaSymptomatic BradycardiaTCP, Atropine, Epi/Dopa, TCPTCP, Atropine, Epi/Dopa, TCP

Narrow Complex Tachycardia:Narrow Complex Tachycardia:

Vagal, Adenosine, CCB/BB/AmioVagal, Adenosine, CCB/BB/Amio Wide Complex TachycardiaWide Complex Tachycardia

AmioAmio


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58yo female with DM, HTN, found unresponsive, No Pulse


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65 yo male with CODE BLUE, unresponsive and no palpable pulse


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76 yo female with acute SOB and complaints of mild CP


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50 yo male with HTN, DM, heroine abuse, CRI on HD found

down and without palpable pulses


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acls december 2005

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