case management of acls handouts - power point 879
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8/6/2019 Case Management of ACLS Handouts - Power Point 879
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ACLS 2005 Update ACLS 2005 Update
The Essentials The Essentials
WhistlerWhistler -- September 2006September 2006
ACLS 2005 Update ACLS 2005 Update
The Essentials The Essentials
WhistlerWhistler -- September 2006September 2006
Dr. John PawlovichDr. John Pawlovich
Fraser Lake, BCFraser Lake, BC
CCFP, Assistant Clinical Professor UBCCCFP, Assistant Clinical Professor UBC
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Main ConceptsMain Concepts 2005 ACLS2005 ACLSMain ConceptsMain Concepts 2005 ACLS2005 ACLS
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The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:
1.1. improve delivery of effective chest compressionsimprove delivery of effective chest compressions
2.2. single compressionsingle compression--toto--ventilation ratio (30:2)ventilation ratio (30:2)(except newborns)(except newborns)
3.3. each rescue breath should be given over 1 secondeach rescue breath should be given over 1 secondto produce visible chest riseto produce visible chest rise
4.4. single shock followed by immediate CPR without single shock followed by immediate CPR without pulse or rhythm check for VF/ PVT cardiac arrest pulse or rhythm check for VF/ PVT cardiac arrest
5.5. AED use in children (1 AED use in children (1--8 years)8 years)
1.1. improve delivery of effective chest compressionsimprove delivery of effective chest compressions
2.2. single compressionsingle compression--toto--ventilation ratio (30:2)ventilation ratio (30:2)(except newborns)(except newborns)
3.3. each rescue breath should be given over 1 secondeach rescue breath should be given over 1 secondto produce visible chest riseto produce visible chest rise
4.4. single shock followed by immediate CPR without single shock followed by immediate CPR without pulse or rhythm check for VF/ PVT cardiac arrest pulse or rhythm check for VF/ PVT cardiac arrest
5.5. AED use in children (1 AED use in children (1--8 years)8 years)
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HighHigh--quality CPR saves lives!!quality CPR saves lives!!HighHigh--quality CPR saves lives!!quality CPR saves lives!!
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Important PointsImportant Points
RateRate
DepthDepth
ReleaseRelease
Five key
aspectsto Great
CPR
Five key
aspectsto Great
CPR
!!
UninterruptedUninterrupted Ve
ntilatio
n Ve
ntilatio
n
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Coronary Perfusion Pressure
(CPP)
Coronary Perfusion Pressure
(CPP) = (aortic pressure right atrial pressure)
M AJOR DETERMIN ANT FOR SURVI VAL IS CPP
Highly correlated to ROSC
When CPR is paused, CPP falls quickly
When CPR is restarted, it takes 3-6
compressions to reestablish the previous CPP
= (aortic pressure right atrial pressure)
M AJOR DETERMIN ANT FOR SURVI VAL IS CPP
Highly correlated to ROSC
When CPR is paused, CPP falls quickly
When CPR is restarted, it takes 3-6
compressions to reestablish the previous CPP
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Compression
� Compression of heart & lungs
� Increased intrathoracic
pressure
Decompression
� Refilling of heart & lungs
� Decreased intrathoracic
pressure
� Negative with full recoil
Compression-DecompressionCompression-Decompression
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One Universal CompressionOne Universal Compression--toto--Ventilation VentilationRatio for All Lone RescuersRatio for All Lone Rescuers
One Universal CompressionOne Universal Compression--toto--Ventilation VentilationRatio for All Lone RescuersRatio for All Lone Rescuers
2005 (New):2005 (New): 30:2 for all lone rescuers30:2 for all lone rescuers
2000 (Old):2000 (Old): 15:2 adults, 5:1 child and infant.15:2 adults, 5:1 child and infant.
Why:Why: ByBy--stander CPR is on the order of 30% or less.stander CPR is on the order of 30% or less.Simplify guidelines to increase bystander CPR.Simplify guidelines to increase bystander CPR.
2005 (New):2005 (New): 30:2 for all lone rescuers30:2 for all lone rescuers
2000 (Old):2000 (Old): 15:2 adults, 5:1 child and infant.15:2 adults, 5:1 child and infant.
Why:Why: ByBy--stander CPR is on the order of 30% or less.stander CPR is on the order of 30% or less.Simplify guidelines to increase bystander CPR.Simplify guidelines to increase bystander CPR.
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Defibrillation (VF/ PVT): 1 Shock, ThenDefibrillation (VF/ PVT): 1 Shock, ThenImmediate CPR (NO pulse check, NOImmediate CPR (NO pulse check, NO
rhythm check)rhythm check)
Defibrillation (VF/ PVT): 1 Shock, ThenDefibrillation (VF/ PVT): 1 Shock, ThenImmediate CPR (NO pulse check, NOImmediate CPR (NO pulse check, NO
rhythm check)rhythm check)
SINGLE SHOCK = MORE CPR
CONTINUE CPR WHILE M ACHINECH ARGES
SINGLE SHOCK = MORE CPR
CONTINUE CPR WHILE M ACHINECH ARGES
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RationaleRationale -- 1 Shock followed by Immediate1 Shock followed by ImmediateCPRCPR
RationaleRationale -- 1 Shock followed by Immediate1 Shock followed by ImmediateCPRCPR
1.1. The rhythm analysis by current AEDs afterThe rhythm analysis by current AEDs aftereach shock typically results ineach shock typically results in 37 sec 37 sec delaydelay
in CPRin CPR2.2. first shock eliminates VF in more than 85% of first shock eliminates VF in more than 85% of cases. If first shock fails, resumption of CPR iscases. If first shock fails, resumption of CPR islikely more beneficiallikely more beneficial
3.3. it takes several minutes for a normal heart it takes several minutes for a normal heart rhythm to return and more time for the heart rhythm to return and more time for the heart to create blood flow after VF is eliminated.to create blood flow after VF is eliminated.CPR can bridge that gap.CPR can bridge that gap.
4.4. Immediate CPR after defibrillation is not Immediate CPR after defibrillation is not
harmful.harmful.
1.1. The rhythm analysis by current AEDs afterThe rhythm analysis by current AEDs aftereach shock typically results ineach shock typically results in 37 sec 37 sec delaydelay
in CPRin CPR2.2. first shock eliminates VF in more than 85% of first shock eliminates VF in more than 85% of cases. If first shock fails, resumption of CPR iscases. If first shock fails, resumption of CPR islikely more beneficiallikely more beneficial
3.3. it takes several minutes for a normal heart it takes several minutes for a normal heart rhythm to return and more time for the heart rhythm to return and more time for the heart to create blood flow after VF is eliminated.to create blood flow after VF is eliminated.CPR can bridge that gap.CPR can bridge that gap.
4.4. Immediate CPR after defibrillation is not Immediate CPR after defibrillation is not
harmful.harmful.
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Changes in Advanced Life SupportChanges in Advanced Life Support
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Pulseless Rhythm
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Main Concept Main Concept Main Concept Main Concept
priority is good CPR with minimallypriority is good CPR with minimallyinterruptioninterruption
Insertion of an advanced airwayInsertion of an advanced airway not not a higha highprioritypriority
In presence of advanced airway, continuousIn presence of advanced airway, continuous
compressions (~100 per minute) withcompressions (~100 per minute) withasynchronous ventilation (~8asynchronous ventilation (~8--10/ min) (~110/ min) (~1breath every 6breath every 6--8 seconds).8 seconds).
minimize interruptions in chest minimize interruptions in chest
compressions!!!compressions!!!
priority is good CPR with minimallypriority is good CPR with minimallyinterruptioninterruption
Insertion of an advanced airwayInsertion of an advanced airway not not a higha highprioritypriority
In presence of advanced airway, continuousIn presence of advanced airway, continuous
compressions (~100 per minute) withcompressions (~100 per minute) withasynchronous ventilation (~8asynchronous ventilation (~8--10/ min) (~110/ min) (~1breath every 6breath every 6--8 seconds).8 seconds).
minimize interruptions in chest minimize interruptions in chest
compressions!!!compressions!!!
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DefibrillationDefibrillation General concept General concept DefibrillationDefibrillation General concept General concept Immediate defibrillation if witnessed arrest andImmediate defibrillation if witnessed arrest and
AED available AED available
Compressions before defibrillation if unwitnessedCompressions before defibrillation if unwitnessedor arrival at the sceneor arrival at the scene >4>4--5 minutes.5 minutes.
One shockOne shock followed by immediate CPRfollowed by immediate CPR(beginning with chest compressions)(beginning with chest compressions)
rhythm check after 5 cycles of CPR or 2 minutesrhythm check after 5 cycles of CPR or 2 minutes
Immediate defibrillation if witnessed arrest andImmediate defibrillation if witnessed arrest and AED available AED available
Compressions before defibrillation if unwitnessedCompressions before defibrillation if unwitnessedor arrival at the sceneor arrival at the scene >4>4--5 minutes.5 minutes.
One shockOne shock followed by immediate CPRfollowed by immediate CPR(beginning with chest compressions)(beginning with chest compressions)
rhythm check after 5 cycles of CPR or 2 minutesrhythm check after 5 cycles of CPR or 2 minutes
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0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
ElectricalPhase
MetabolicPhase
Shock CPR ?
Importance of CPRThree-Phase Model
Importance of CPRThree-Phase Model
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Importance of CPRPriming the Pump
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DefibrillationDefibrillation Energy settingEnergy settingDefibrillationDefibrillation Energy settingEnergy setting
For adult defibrillation:For adult defibrillation:
monophasic manual defibrillator 360J;monophasic manual defibrillator 360J;
biphasic with truncated exponentialbiphasic with truncated exponentialwaveform 150waveform 150--200J;200J;
biphasic with rectilinear waveform 120J;biphasic with rectilinear waveform 120J;
biphasic unknown type 200J.biphasic unknown type 200J.
For adult defibrillation:For adult defibrillation:
monophasic manual defibrillator 360J;monophasic manual defibrillator 360J;
biphasic with truncated exponentialbiphasic with truncated exponentialwaveform 150waveform 150--200J;200J;
biphasic with rectilinear waveform 120J;biphasic with rectilinear waveform 120J;
biphasic unknown type 200J.biphasic unknown type 200J.
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1shock versus 3 stacked shocks
1shock versus 3 stacked shocks
� BIPHASIC eliminates VF after firstshock >90%
� AED requires 90 secs for 3 shocks (i.e.NO CPR FOR 90 SECONDS)
� Interruptions in chest compressions are
harmful� 1 Shock strategy may be preferable
� BIPHASIC eliminates VF after firstshock >90%
� AED requires 90 secs for 3 shocks (i.e.NO CPR FOR 90 SECONDS)
� Interruptions in chest compressions are
harmful� 1 Shock strategy may be preferable
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Drug AdministrationDrug AdministrationDrug AdministrationDrug Administration I V or IO drug administration is preferred to ETTI V or IO drug administration is preferred to ETT
routeroute
Drugs should be delivered during CPR as soon asDrugs should be delivered during CPR as soon aspossible after rhythm checks.possible after rhythm checks.
timing of drug administration is less important thantiming of drug administration is less important thanthe need to minimize interruptions in chest the need to minimize interruptions in chest
compressionscompressions
I V or IO drug administration is preferred to ETTI V or IO drug administration is preferred to ETTrouteroute
Drugs should be delivered during CPR as soon asDrugs should be delivered during CPR as soon aspossible after rhythm checks.possible after rhythm checks.
timing of drug administration is less important thantiming of drug administration is less important thanthe need to minimize interruptions in chest the need to minimize interruptions in chest
compressionscompressions
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Major changes in ACLS drugsMajor changes in ACLS drugsMajor changes in ACLS drugsMajor changes in ACLS drugs
VF/ pVT/ asystole/ PEA VF/ pVT/ asystole/ PEA
epinephrine q3epinephrine q3--5 min5 min Vasopressin X 1 may replace either the first or Vasopressin X 1 may replace either the first or
second dose of epinephrine.second dose of epinephrine.
VF/ pVT VF/ pVT
Amiodarone (Class IIb) Amiodarone (Class IIb)
Lidocaine (indeterminate)Lidocaine (indeterminate)
VF/ pVT/ asystole/ PEA VF/ pVT/ asystole/ PEA
epinephrine q3epinephrine q3--5 min5 min Vasopressin X 1 may replace either the first or Vasopressin X 1 may replace either the first or
second dose of epinephrine.second dose of epinephrine.
VF/ pVT VF/ pVT
Amiodarone (Class IIb) Amiodarone (Class IIb)
Lidocaine (indeterminate)Lidocaine (indeterminate)
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Antiarrhythmics Antiarrhythmics No evidence that giving any antiarrythmic
drug routinely during cardiac arrest increases
rate of survival to hospital discharge In comparison with placebo and lidocaine, the
use of amiodarone in shock-refractory VFimproves the short-term outcome of survival
to hospital admission
No evidence that giving any antiarrythmicdrug routinely during cardiac arrest increases
rate of survival to hospital discharge In comparison with placebo and lidocaine, the
use of amiodarone in shock-refractory VFimproves the short-term outcome of survival
to hospital admission
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Use of Advanced AirwaysUse of Advanced AirwaysUse of Advanced AirwaysUse of Advanced Airways
LM A and Combitube should be considered (ClassLM A and Combitube should be considered (ClassIIa).IIa).
Advanced airway may be placed several minutes Advanced airway may be placed several minutesinto the resuscitationinto the resuscitation
clinical assessment plus a device such as ETCOclinical assessment plus a device such as ETCO22 or EDD toor EDD toconfirm ETT placement (Class IIa).confirm ETT placement (Class IIa).
LM A and Combitube should be considered (ClassLM A and Combitube should be considered (ClassIIa).IIa).
Advanced airway may be placed several minutes Advanced airway may be placed several minutesinto the resuscitationinto the resuscitation
clinical assessment plus a device such as ETCOclinical assessment plus a device such as ETCO22 or EDD toor EDD toconfirm ETT placement (Class IIa).confirm ETT placement (Class IIa).
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Bradycardia & Tachycardia
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Arrhythmia with pulse Arrhythmia with pulse Arrhythmia with pulse Arrhythmia with pulse symptomatic bradycardiasymptomatic bradycardia
atropine 0.5mg I V (max 3mg)atropine 0.5mg I V (max 3mg)
Isoproterenol eliminatedIsoproterenol eliminated TachycardiaTachycardia
summarized in a single algorithmsummarized in a single algorithm
branch points then become narrow versus widebranch points then become narrow versus widecomplex, and regular versus irregular rhythmscomplex, and regular versus irregular rhythms
polymorphic VT should be treated as VF withpolymorphic VT should be treated as VF withhighhigh--energy unsynchronized defibrillationenergy unsynchronized defibrillation
symptomatic bradycardiasymptomatic bradycardia
atropine 0.5mg I V (max 3mg)atropine 0.5mg I V (max 3mg)
Isoproterenol eliminatedIsoproterenol eliminated TachycardiaTachycardia
summarized in a single algorithmsummarized in a single algorithm
branch points then become narrow versus widebranch points then become narrow versus widecomplex, and regular versus irregular rhythmscomplex, and regular versus irregular rhythms
polymorphic VT should be treated as VF withpolymorphic VT should be treated as VF withhighhigh--energy unsynchronized defibrillationenergy unsynchronized defibrillation
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Post Post--resuscitation Stabilizationresuscitation StabilizationPost Post--resuscitation Stabilizationresuscitation Stabilization
Vasoactive support Vasoactive support
Hypothermia
Hypothermia cooled to 32cooled to 32ooCC--3434ooC for 12C for 12--24 hours when the24 hours when the
initial rhythm was VF (Class IIa).initial rhythm was VF (Class IIa).
may be beneficial for patients with nonmay be beneficial for patients with non--VF VF
arrests inarrests in-- or out or out--of of--hospital (Class IIb).hospital (Class IIb).
Glycemic controlGlycemic control
Vasoactive support Vasoactive support
Hypothermia
Hypothermia cooled to 32cooled to 32ooCC--3434ooC for 12C for 12--24 hours when the24 hours when the
initial rhythm was VF (Class IIa).initial rhythm was VF (Class IIa).
may be beneficial for patients with nonmay be beneficial for patients with non--VF VF
arrests inarrests in-- or out or out--of of--hospital (Class IIb).hospital (Class IIb).
Glycemic controlGlycemic control
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SUMM AR Y SUMM AR Y of of
AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINESSUMM AR Y SUMM AR Y of of
AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINES
Push hard and push fast with Push hard and push fast withadequate recoil and minimaladequate recoil and minimal
interruptionsinterruptions
Push hard and push fast with Push hard and push fast withadequate recoil and minimaladequate recoil and minimal
interruptionsinterruptions
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SUMM AR Y SUMM AR Y of of
AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINESSUMM AR Y SUMM AR Y of of
AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINES
Eff ective ACLS begins with highEff ective ACLS begins with high--quality quality BLS...particularly highBLS...particularly high--quality CPR! quality CPR!
The potential eff ects of any drugs or ACLS The potential eff ects of any drugs or ACLS therapy on outcome from VF SCA arr esttherapy on outcome from VF SCA arr est ar e dwarf ed by the pot ential eff ects of ar e dwarf ed by the pot ential eff ects of hi ghhi gh--qualit y CPR.qualit y CPR.
Eff ecti ve ACLS begins with hi ghEff ecti ve ACLS begins with hi gh--qualit y qualit y BLS...particularl y hi ghBLS...particularl y hi gh--qualit y CPR! qualit y CPR!
T he pot ential eff ects of an y drugs or ACLS T he pot ential eff ects of an y drugs or ACLS therapy on outcome from VF SCA arr est therapy on outcome from VF SCA arr est ar e dwarf ed by the pot ential eff ects of ar e dwarf ed by the pot ential eff ects of hi ghhi gh--qualit y CPR.qualit y CPR.
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