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Advanced Cardiac Life Support
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Basic Cardiac Life Support
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Definitions of death
Clinical death means that the heartbeat and breathing have stopped. This process is reversible.
Biological death is permanent, cellular damage due to lack of oxygen, the brain cells are the most sensitive to the lack of oxygen.
Brain damage occurs after 4 minute of cardio-respiratory arrest.
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CPR It is the simple procedures which prevent
circulatory and/or respiratory arrest or insufficiency prompt intervention.
These simple procedures include: Open and clear airway Mouth to mouth breathing (through
a barrier) OR bag-mask ( Ambu-baging )
External cardiac compression
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Basic knowledge
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Basic knowledge External cardiac compression give 25% of
original Cardiac Output. It contract around 70 times/min, every
contraction ejects 70 ml of blood, so minute Cardiac Output is around 5 L/min. ( at rest).
Respiratory center is located in the brain which is stimulated by the level of the arterial carbon dioxide.
Adult respiratory rate is about 12-15 times/min.
Room air contain 21%O2 – our expiration contain 16% O2
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To start CPR
The patient is Unresponsive Breathlessness Pulselessness
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Chain Of Survival ( Sequences of action linked together too tightly with no gap )
Activate code blue Start CPR until Defibrillator and team
arrive Defibrillation if indicated Advanced cardiac life support actions
to be followed i.e. intubation, IV line for fluids and drugs etc….
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Principles of Defibrillation Electric shock will terminate
ventricular fibrillation by transmural current flow
Entire myocardium is depolarised into refractoriness. The SA node, as the fastest pacemaker, may resume pacing function
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Safe Defibrillation
To avoid accidental shocks to rescuer and patient injury
Safe environment, away from pooled water or metal surface under patient or rescuer
Apply conductive material Turn on defibrillator, select
energy and charge defibrillator Proper electrode placement Apply firm pressure on electrodes
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Make sure no smearing of conductive gel
Remove transdermal patches Keep paddles >12 cm away from
implanted cardiac pacemakers Make sure no personnel are
directly in contact with the patient, clearing chant
Ensure VF or pulseless VT Depress both discharge buttons
simultaneously and deliver the electric shock
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Defibrillation Energy
Adults200J 200/300J 360J 360J
thereafter (monophasic)Non-escalating 150J (biphasic)
Children2J/kg 2-4J/kg 4J/kg 4J/kg
thereafter
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Some Determinants of Defibrillation Dose Chest impedance Electrode size and location Type of waveform Disease, drugs, metabolic
state of the subject
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Factors Reducing Transthoracic Impedance Appropriate electrode size Coupling medium between
electrodes and chest wall Repeated shocks Expiratory phase of
respiration Electrode-chest wall contact
pressure (>10 kg) Post-cardiac surgery
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Electrode Size
diameter of electrode impedance and defibrillation
thresholdIn animals:
8 cm : 71% defib success12.8 cm : 88% defib success
Very large electrodes impedance, but… in current density
defibrillation successInadequate contact with chest
wall
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Coupling Medium
Electrode paste (e.g. Redux paste)Electrode paste resulted in
significantly lower impedance than the disposable defibrillation pads. No difference in defibrillation success.
Beware of paste spread across the chest wall during CPR
Disposable coupling pads (e.g. Defib-Pads)
Adhesive pads
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Self-adhesive pads
AdvantagesProphylactic placement in high
risk patientsLess interference with external
cardiac massageIncorrect coupling gel avoidedBetter operator safety
DisadvantagesSpecial connectionLack of firm pressureHigh impedanceHairy skin
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Electrode Position
Proper polarity facilitates ECG interpretation. It does not affect success of defibrillation
Three acceptable positionsSternal-apicalLeft-anterior-posteriorApical –posterior
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Sternal-apical
Below the outer right clavicle Cardiac apex
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Left-anterior-posterior
Anterior apex just left of palpable cardiac apex
Back inferior to the left scapula
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Apical–posterior
Left ventricular apex Back inferior to the left
scapula
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If VF Persists:
Secure airway, ventilatory and circulatory support, IV access
Appropriate medications to maintain myocardial and cerebral viability
Detect and treat potentially reversible underlying causes
Resume defibrillation attempts After each minute of CPR, or after
each medication The best prospects for restoring a
perfusing rhythm still remain with defibrillation
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Scope of ACLS
Basic life support ECG monitoring, interpretation and
arrhythmia recognition Advanced equipment and techniques
for ventilation and circulation Therapies for respiratory or cardiac
arrests Treatment of acute coronary
syndromes Treatment with tPA for eligible
stroke patients
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Scope of ACLS
Basic life support ECG monitoring, interpretation and
arrhythmia recognition Advanced equipment and techniques
for ventilation and circulation Therapies for respiratory or cardiac
arrests Treatment of acute coronary
syndromes Treatment with tPA for eligible stroke
patients
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International Guidelines 2005 Conference on Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care
ال تنسونا من صالح دعائكم
إخوانكمفي منتديات كل
الطب
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The 3 Unequivocally Effective Interventions Basic cardiopulmonary
resuscitation Oxygenation and ventilation
of the lungs through a patent secure airway
Defibrillation for ventricular fibrillation or pulseless ventricular tachycardia
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Advanced Equipment & Techniques for Ventilation
& Circulation
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Airway Adjuncts
Oropharyngeal airways Nasopharyngeal airways Laryngeal mask airway
64-100% success Combitube
69-100% success Cuffed oropharyngeal
airways (COPA) Suction devices
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Combitube
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Endotracheal Intubation
Optimal airwaySecure and clear airwayProtect airwayNo gastric inflationDrugBronchial toilet
Need 3 minutes of preoxygenation Ventilation should not be
interrupted for > 30 seconds Cricoid pressure Use of stylet or gum elastic bougie Confirm and secure tube position
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Breathing
FiO2 of 1.0 Manual resuscitators or
ventilators 12-15 breaths/minute Tidal Volume
10-12 ml/kg, if intubated6-7 ml/kg, if not
unintubated
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Circulation
Closed chest compression at 100/minute
Open chest CPR should be restricted to operating theatre and selected instances of penetrating thoracic injury
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Specific Drug Therapy
Meticulous, systematic review reveals that relevant, valid, and credible evidence to confirm a benefit due to these agents simply does
NOT exist.
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Routes of Drug Administration Peripheral veins Central veins Tracheal Intraosseous Intracardiac
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Peripheral Venous Route
Peak effect 1.5-3 min. after injection at antecubital fossa
IV push20 ml NS flush after drug
injection circulation time by 40% Comparable to drug delivery
through a central vein
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Central Venous Route
Faster, higher peak concentration and more potent effect compared to peripheral injection
Should be used if it is already in situ
Inserting a central line is associated with problems of interrupting CPR, bleeding arterial puncture and air embolism
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Tracheal Route
Second line route due to impaired absorption and unpredictable pharmacodynamics
Need 2-3 times the IV dose, diluted to at least 10 ml in 0.9% NS
Non-ionic drugs only:adrenalin, atropine, lignocaine and
naloxone NEVER calcium or sodium
bicarbonate
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Intracardiac Route
NOT recommended May produce pneumothorax,
injury to a coronary artery and prolonged interruption of cardiac massage.
Inadvertent injection into the myocardium may produce intractable arrhythmias
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Drugs for Resuscitation
VasopressorsAdrenalineVasopressin
Other AgentsAtropineBuffer agentsCalcium
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Adrenaline
Adrenaline 1 mg (10 ml of 1:10,000 dilution) IV boluses every three minutes until pulse returns
Short half life of 3-5 minutes -effect (vasoconstriction)
aortic pressure to maintain myocardial and cerebral blood flow
Cautions: solvent abuse, cocaine and other sympathomimetic drugs
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Vasopressin
40 U IV: powerful vasoconstriction V1 receptors in smooth muscle Longer half-life of 10-20 minutes If there is no response 10-20 min.
after 40 U of IV vasopressin, resume epinephrine 1 mg IV push every 3 to 5 minutes
Used in VF/VT ? role in asystole or PEA
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Antiarrhythmic DrugsDrug Fibrillatio
n threshold
Defibrillation threshold
Proarrhythmo-genicity
Quinidine ++ +++ +
Procainamide
++ 0 +
Flecainide ++ +++ +
Lignocaine ++ + +
Bretylium ++ - +
Amiodarone ++ - 0/+
Verapamil + ++ 0
Diltiazem + ++ 0
Nifedipine + 0 0
Adrenergic agents
- 0 +
Beta-blockers
++ + 0
Sotolol + - +
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Antiarrhythmic DrugsDrug Fibrillatio
n threshold
Defibrillation threshold
Proarrhythmo-genicity
Quinidine ++ +++ +
Procainamide
++ 0 +
Flecainide ++ +++ +
Lignocaine ++ + +
Bretylium ++ - +
Amiodarone ++ - 0/+
Verapamil + ++ 0
Diltiazem + ++ 0
Nifedipine + 0 0
Adrenergic agents
- 0 +
Beta-blockers
++ + 0
Sotolol + - +
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Drugs for Persistent VF
AmiodaroneClass IIbRapid infusion of 300 mg in 20-
30 ml NS IV push (cardiac arrest dose)
If VF/pulseless VT recurs, Supplementary doses of 150 mg
IV by rapid infusionFollowed by 1 mg/min for 6 hours
and then 0.5 mg/minMaximum daily dose of 2 g
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Lignocaine Class indeterminate Initial bolus of 1.0-1.5 mg/kgAdditional bolus of 0.5-0.75 mg/kg Maximum total of 3 mg/kgMaintenance infusion of 1-4 mg/min
Magnesium sulphate1-2 g diluted in 100 ml D5 over
1-2 minutesClass IIb in torsades de pointes or
suspected hypomagnesaemia or severe refractory VF
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Atropine
Good for haemodynamically significant bradycardia from high vagal tone, hypoxia or nodal ischaemia
? For asystole or PEA 1 mg up to 3 doses or
single dose of 3 mg will produce a fully vagolytic effect
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Buffer Agents
8.4% sodium bicarbonate solution
Initial dose of 1 mEq/kg Problems
Left shift of Hb dissociation curveParadoxical intracerebral acidosisHigh osmolality and Na loadInactivate simultaneously
administered catecholamines
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Indications of NaHCO3
Class I Preexisting hyperkalemiaPexisting bicarbonate-responsive
acidosis
Alkaline diuresis; overdose of tricyclic antidepressant, aspirin, etc.
Class IIbLong arrest interval
In intubated and ventilated patientsOn return of circulation
Class IIIHypercarbic acidosis
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Calcium
Only used in hypocalcaemia, hyperkalaemia and calcium antagonist overdose
10% CaCl2 at 2-4 mg/kg repeated as necessary at 10-minute intervals
Worries regarding the role of Ca++ in ischaemic cell damage during reperfusion to the heart and the brain
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UniversalAdvanced
Life Support
Algorithm
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The Universal Advanced Life Support Algorithm Two arrest rhythms
VF/Pulseless VT Ventricular fibrillationPulseless ventricular
tachycardiaNon-VF/VT
Pulseless electrical activityAsystole
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VF / Pulseless VT
VF: commonest primary arrest rhythm
VF/VT: 85% to 95% of the survivors from cardiac arrest
Pulseless VT deteriorates rapidly to VF and treatment is identical to that of VF
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Management of VF / Pulseless VT Electrical defibrillation is the
most effective treatment for VF
CPR unlikely to convert VF Speed of defibrillation is the
major determinant of success of VF treatment Survival rates after VF arrest
7-10 %/min
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In-hospital Cardiac Arrest
• 1325 Resuscitation attempts using 1997 Guidelines• Updated from: Gwinnutt C et al. Resuscitation 1998; 37: S64
VF/VT EMD/Asystole
Number 422 (32%) 903 (68%)
ROSC 298 (71%) 344 (38%)
Survive discharge
179 (42%) 58 (6%)
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Cardiac Arrest Time before Defibrillation
Yakaitis et al. Crit Care Med 1982;8:157-163.
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Defibrillation Energy
Balance between electrical injury and efficiency of defibrillation
Damage related to the peak current, not the energy delivered
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Defibrillation Energy
Weaver et al. N Engl J Med 1982;307:1101
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Morbidity & Mortality
Dahl et al. Circulation 50:956. Ehsani et al. Am J Cardiol 37:12.Warner et al. Arch Pathol 99:55.
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Transthoracic Impedance
70-80 (range 15-143) impedance current Current-based defibrillation
30-40A MDS
(sec)Duration*(ohms)Resistance(joules)Energy
Current
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Defibrillation vs. Cardioversion
Defibrillation
Electric shock delivered without synchronization with ECG activity
Used in VF or pulseless VT
Synchronized Cardio-version
Electric shock delivered with synchronization with R wave to avoid the R on T phenomenon
Used in unstable tachyarrhytmias other than VF or pulseless VT
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Non-VF/VT
RhythmsUniversalAdvanced
Life Support Algorithm
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Non-VF/VT Rhythms
Defibrillation is NOT indicated Prognosis much poorer than VF/VT Secure basic life support, airway,
oxygen, ventilation, IV access Detect and treat potentially
reversible conditions Consider:
Atropine: 3 mg bolus given once or 1 mg bolus to a maximum of 3 mg
Pacing if P waves are present
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Pulseless Electrical Activity (PEA) Absence or undetectable mechanical
activity in the presence of coordinated electrical activity
Includes Pseudo-EMD Idioventricular rhythmsVentricular escape rhythmsPostdefibrillation idioventricular rhythmsBradyasystolic rhythms
Rhythm of survival if a reversible cause of PEA is identified and treated appropriately
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Possible Underlying Reversible Causes
H’s Hypovolemia Hypoxia Hydrogen ion
(acidosis) Hyperkalemia/
hypokalemia/ metabolic disorders
Hypothermia/ hyperthermia
T’s Toxins/tablets
(drug overdose)
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary
Thrombosis, pulmonary
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Asystole
Primary rhythm in up to 25% inhospital arrests
Most commonly seen in outpatients with VF who have not been resuscitated successfully
Low survival rate 1-2 out of 100 cardiac arrests
Identify and treat a reversible cause
Consider “not starting” and “when to stop”
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Post-resuscitation Care
CNS is most vulnerable for ischaemic-hypoxic damage during cardiac arrest
ICU or CCU admission Avoid and correct hypotension,
hypoxia, hypercarbia, electrolyte imbalance, hypoglycaemia and hyperglycaemia
Control convulsions with anticonvulsants
No drugs have been demonstrated to reduce cerebral complications
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In Summary
Perform CPR at all times for pulseless patients
Defibrillate VF/VT until it is no longer present
Gain airway control and provide adequate oxygenation and ventilation
Give IV boluses of epinephrine
Correct reversible causes
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UniversalAdvanced
Life Support
Algorithm
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Possible Underlying Reversible Causes
H’s Hypovolemia Hypoxia Hydrogen ion
(acidosis) Hyperkalemia/
hypokalemia/ metabolic disorders
Hypothermia/ hyperthermia
T’s Toxins/tablets
(drug overdose)
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary
Thrombosis, pulmonary
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Reference
Circulation. 2000; 102 (Suppl 1):I-1-384.
The 1998 European Resuscitation Council guidelines for adult advanced life support. BMJ: 1998; 316:1863-1869.
ILCOR advisory statement. Circulation. 1997;95(8):2172-2210.
BJA, 1997; 79:149-213. (Postgraduate educational issue, resuscitation)