als algorithm lecture
TRANSCRIPT
ALS Subcommittee 2010
ARRHYTHMIA TREATMENT
ALGORITHMS
ALS Subcommittee 2010
OBJECTIVES
Upon completion of this session, you will be able to:
List the 4 arrhythmias leading to cardiac arrest
State the treatment algorithms for VF/ pulseless VT, PEA and Asystole
Understand the principles of management of tachy and brady arrythmias
ALS Subcommittee 2010
Cardiac Arrest
Occurs with one of 4 arrhythmias:
ventricular fibrillation (VF)
pulseless ventricular tachycardia (VT)
pulseless electrical activity (PEA)
asystole
HYDROGEN ION HYPOXIA HYPOTHERMIA HYPOVOLEMIA HYPO/HYPERKALEMIA HYPOGLYCEMIA
TAMPONADE, CARDIAC TENSION PNEUMOTHORAX THROMBOSIS, Pulmonary THROMBOSIS, Coronary TOXIN
•Danger •Responsiveness •Shout for help
1. DANGER 2. RESPONSIVENESS 3. SHOUT FOR HELP AND DEFIBRILLATOR 4. AIRWAY OPENING 5. BREATHING 6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION Push hard 5cm deep, Push fast 100 per minute Minimize interruption of chest compression Allow complete chest recoil Do NOT hyperventilate Compression to ventilation ratio 30:2 if not intubated DEFIBRILLATION 360J for monophasic, 120-200J for biphasic IV or IO ACCESS DRUGS IV Adrenaline 1 mg push IV Vasopressin 40 U (as first or second drug after Adrenaline IV AMIODARONE 300mg bolus, 150 mg second dose
1. DANGER 2. RESPONSIVENESS 3. SHOUT FOR HELP AND DEFIBRILLATOR 4. AIRWAY OPENING 5. BREATHING 6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION Push hard 5cm deep, Push fast 100 per minute Minimize interruption of chest compression Allow complete chest recoil Do NOT hyperventilate Compression to ventilation ratio 30:2 if not intubated IV or IO ACCESS DRUGS IV Adrenaline 1 mg push IV Vasopressin 40 U (as first or second drug after Adrenaline IV AMIODARONE 300mg bolus, 150 mg second dose
Hydrogen ion Hypoxia Hypothermia Hypovolemia Hypo/hyperkalemia Hypoglycemia
Trauma Tension pneumothorax Thrombosis(coronary) Thrombosis(pulmonary) Tamponade
ALS Subcommittee 2010
Causes: H’s and T’s
• Hypoxia
• Hypokalemia/hyperkalemia
• Hypothermia
• Hypovolemia
• Hydrogen ions (acidosis)
• Hypoglycemia
ALS Subcommittee 2010
Causes: H’s and T’s ….cont
• Tamponade
• Thrombosis (pulmonary)
• Thrombosis (coronary)
• Toxins
• Tension pneumothorax
ALS Subcommittee
2010
Pericardial Tamponade
• Chest x-ray
–Widened mediastinum
–Pneumo- or hemothorax
• Electrical alternans
•Note rounded bottle shape to left side of heart
ALS Subcommittee 2010
Right Left
A: Air under tension in left thorax
A
Pleural margin; partial lung
collapse
Tension Pneumothorax
ALS Subcommittee 2010
Asystole Algorithm
Adrenaline 1 mg IV push, repeat every 3 to 5 minutes,
Vasopression 40U may replace 1 dose of adrenaline
If Asystole persists Withhold or cease resuscitation efforts?
•Consider quality of resuscitation? •Atypical clinical features present? •Search for DNR order
ALS Subcommittee 2010
Pulse Algorithm
• Bradycardia
• Tachycardia
– Narrow Complex
– Wide Complex
ATROPINE 0.5mg to 3mg OR DOPAMINE 5 to 10mcg.kg.min OR
ADRENALINE 2-10 mcg/kg/min
Assess clinically
Identify and treat underlying cause
Ensure airway patency Oxygen supplement Cardiac monitor Establish IV access Perform 12 lead ECG
Hemodynamic instability - Hypotension - altered mental status - signs of shock - acute heart failure
ALS Subcommittee 2010
Tachyarrhythmia
Is patient stable or unstable?
Patient has serious signs or symptoms? Chest pain (ischemic? possible ACS?)
Shortness of breath (lungs getting ‘wet’? possible CCF?)
Low blood pressure (orthostatic? dizzy? lightheaded?)
Decreased level of consciousness (poor cerebral perfusion?)
Clinical shock (cool and clammy? peripheral vasoconstriction?)
Are the signs and symptoms due to the rapid heart rate?
ALS Subcommittee 2010
Management of Tachyarrhythmia
• Stable
– Treat with IV drugs
• Unstable
– Cardioversion
Unstable, with serious signs or symptoms
ie : Heart failure, SBP<90, In shock
Tachycardia Algorithm
Immediate synchronised cardioversion
Narrow Complex Tachycardia
•Assess: Responsiveness • ECG monitor •Shout: Help/defibrillator • Assess vital signs •Assess: ABC • Review history •Administer oxygen • Perform physical exam •Establish IV • Do 12 Lead ECG
Wide Complex Tachycardia
Polymorphic VT
Yes
No
ALS Subcommittee 2010
Postresuscitation Stabilisation
• Support of `stunned’ myocardium - may require vasoactive support
• Keep hypothermic (32-34°C) for VF or non VF arrest for 12 to 24h
• Maintain strict glucose control (4 - 6mmol/l)
• Monitor clinical signs
ALS Subcommittee 2010
SUMMARY
• Effective ALS begins with high quality CPR
• Uninterrupted high quality chest compressions improve outcome – Rhythm check, rescue breath, even drug administration
should NOT interrupt compressions
• Early recognition & treatment of arrhythmias give the best chance of survival
• Search for treatable causes of PEA
• Post-resuscitation period is important
• Know algorithms well
ALS Subcommittee 2010
THANK YOU NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
Dr Tan Cheng Cheng
Dr Luah Lean Wah
Dr Ismail Tan
Dr Wan Nasrudin
Dr Chong Yoon Sin
Dr Priya Gill
Dr Ridzuan bin Dato’ Mohd Isa
Dr Thohiroh Abdul Razak
Dr Adi Osman