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Basic and Advanced Life Support
- 1. An Overview: Basic and Advanced Life Support 2005 K.S. Chew Emergency Medicine Department School of Medical Sciences UniversiF Sains Malaysia
- 3. IntroducFon • “ResuscitaFon is most successful if defibrillaFon is performed in about 5 minutes aLer collapse” • AHA Guidelines 2005
- 5. IntroducFon • “In many communiFes, the Fme interval from EMS call to EMS arrival is 7 – 8 minutes or longer. • This means that in the first minutes aLer collapse, the vicFm’s chance of survival is in the hands of bystanders.” • AHA Guidelines 2005
- 6. IntroducFon • “Many SCA vicFms can survive if bystanders act immediately while VF is sFll present, but successful resuscitaFon is unlikely once the rhythm deteriorates to asystole” – AHA Guidelines 2005
- 7. CPR Facts • “About 75 percent to 80 percent of all out‐of‐ hospital cardiac arrests happen at home, so being trained to perform cardiopulmonary resuscitaFon (CPR) can mean the difference between life and death for a loved one.” • AHA Guidelines 2005
- 8. CPR Facts • “EffecFve bystander CPR, provided immediately aLer cardiac arrest, can double a vicFm’s chance of survival” – AHA Guidelines 2005
- 9. The Magnitude of the Problem (WHO , 2002)
- 11. IntervenFons that Improve Survival • The intervenFons that unquesFonably contribute to improved survival aLer cardiac arrest are 1. Early defibrillaFon for VF/pulseless VT 2. Prompt effecFve bystander BLS
- 12. Chain of Survival • Early RecogniFon and AcFvaFon (EducaFon) – Recognize signs of life – Recognize symptoms of ACS – Recognize symptoms of stroke (FAST) – Occasional gasping IS NOT breathing
- 13. Chain of Survival • Early EffecFve Bystander CPR – Every minute without CPR, survival chance decrease 7% to 10% – With bystander CPR, the decrease in survival is 3‐4%
- 14. Chain of Survival • Early DefibrillaFon – CPR plus defibrillaFon within 3 – 5 min produce survival rates as high as 49% ‐ 75% – In first few minutes aLer successful defibrillaFon, asystole or bradycardia maybe present (ineffecFve pumping)
- 15. Chain of Survival • Early ACLS and post‐resuscitaFon care – Not as important as early effecFve bystander CPR and early defibrillaFon
- 16. “Push Hard, Push Fast” EffecFve CPR • Compress at a rate of about 100 compression per minute • Depth of 1½ to 2 inches (approximately 4 to 5 cm) • Allow chest to recoil completely aLer each compression – To improve venous return – Reduce intrathoracic pressure – Improve coronary perfusion
- 17. Coronary Artery Perfusion Pressure Improves With Longer Series of Chest Compressions in Adult VicFms
- 18. Minimal InterrupFons During Chest Compression • Ideally, compressions should only be interrupted for A. VenFlaFon (unFl an advanced airway is placed) B. Rhythm check C. Shock delivery
- 19. One Single RaFo • VenFlaFon: Compression raFo of 30:2 for all (adults, children and infants) • ExcepFons 1. Two healthcare providers performing CPR for a child and infant 2. For newborns
- 20. One SHOCK versus THREE STACKED SHOCKS Guidelines 2000 Guidelines 2005 For VF/Pulse‐less VT, give For witnessed VF/ pulse‐ three stacked shocks less VT, ONE SHOCK only, without interrupFons (NO followed by immediate CPR) in between CPR without pause to check pulse
- 21. Four Reasons Why Single Shock With Immediate CPR 1. High first shock efficacy 2. Post terminaFon iniFal non‐perfusing rhythm (PEA or asystole) 3. Prolonged interrupFon to CPR (29‐37 seconds) if giving stacked shocks and pulse check 4. Even if a perfusing rhythm is already restored, giving chest compressions does not increase the chance of VF recurring
- 23. PaFent brought in Dead or alive? Dead Alive CPR started? No Start CPR? stable? Yes No Yes Shockable rhythm? No Refer and treat Yes accordingly Consider CPR & Defib CPR Electrical therapy
- 24. Cardiac Arrest Rhythms • Shockable rhythms – Ventricular fibrillaFon – Ventricular tachycardia • Non‐shockable rhythms – Asystole – Pulseless electrical acFviFes (all other rhythms)
- 26. Steps DR ABCD • D = Danger • R = Response • A = Airway • B = Breathing • C = CirculaFon • D = DefibrillaFon if indicated
- 27. Response
- 28. Call for Help
- 29. Open Airway
- 30. Check Breathing
- 31. Agonal Breathing • Occurs shortly aLer the heart stops in up to 40% of cardiac arrests • Described as barely, heavy, noisy or gasping breathing • Recognise as a sign of cardiac arrest
- 33. Check Pulse and Chest Compressions if No Pulse
- 34. PosiFon of hands
- 35. RaFo 30:2 30 2
- 37. Step 1: On AED
- 40. Step 4: Warning Others Not to Touch PaFent and Deliver Shock
- 41. Resume CPR 30 2
- 42. Recovery PosiFon
- 44. CPR • Chest compression with mouth‐to‐mouth breathing • Chest compression with mask‐to‐mouth breathing • Chest compression only (without rescue breathing)
- 45. Pocket Masks
- 47. Chew KS, Yazid MNA. The willingness of final year medical and dental students to perform bystander cardiopulmonary resuscitaBon in an Asian community Int J Emerg Med. 2008;1(4):301‐09.
- 48. Chew KS, Yazid MNA. The willingness of final year medical and dental students to perform bystander cardiopulmonary resuscitaBon in an Asian community Int J Emerg Med. 2008;1(4):301‐09.
- 49. Chew KS, Yazid MNA. The willingness of final year medical and dental students to perform bystander cardiopulmonary resuscitaBon in an Asian community Int J Emerg Med. 2008;1(4):301‐09.
- 50. Hands‐Only CPR • On March 31, 2008, the American Heart AssociaFon changed its guidelines to include hands‐only CPR, a new version using chest compressions only. • Hands‐only CPR is intended for untrained rescuers and only for witnessed cardiac arrest.
- 51. Sayre MR, Berg RA, Cave DM, Page RL, Pops J, White RD. Hands‐only (compression‐only) cardiopulmonary resuscitaFon: a call to acFon for bystander response to adults who experience out‐of‐hospital sudden cardiac arrest: a science advisory for the public from the American Heart AssociaFon Emergency Cardiovascular Care Commipee. CirculaFon. 2008 Apr 22;117(16):2162‐7.
- 52. Hands‐Only CPR • “Bystanders who witness the sudden collapse of an adult should immediately call 9‐1‐1 and start what we call Hands‐Only CPR. This involves providing high‐quality chest compressions by pushing hard and fast in the middle of the vicBm’s chest, without stopping unBl emergency medical services (EMS) responders arrive….” • Michael Sayre, M.D., chair of the statement wriFng commipee and associate professor in the Ohio State University Department of Emergency Medicine in Columbus.
- 55. Clinical Approach To Arrhythmias • Treat the paFent, not the rhythm • Two essenFal quesFons: • Is the paFent in cardiac arrest? – CaroFd Pulse check 10 secs – Signs of life • Is the paFent stable? – Signs of hemodynamic instablity – drowsy, chest pain, pulmonary edema, SBP<90 for adults
- 56. PaFent brought in Dead or alive? Dead Alive CPR started? No Start CPR? stable? Yes No Yes Shockable rhythm? No Refer and treat Yes accordingly Consider CPR & Defib CPR Electrical therapy
- 61. The drugs to be given at this Note that by this stage are vasopressors Fme, if 3rd shock is required, it is the DRUG →SHOCK→ CPR sequence. It is the same sequence thereaLer
- 63. When Should Drugs Be Administered? • Inadequate evidence to idenFfy an opFmal number of CPR cycles and defibrillaFon before drugs. • IF VF/VT persists aLer delivery of 1 – 2 shocks plus CPR, give a vasopressor (adrenaline every 3 – 5 min during cardiac arrest; one dose of vasopressin may replace either first or second dose of adrenaline)
- 64. Note: • DO NOT interrupt CPR to give medicaFons • Administer drugs DURING CPR, as soon as aLer rhythm is rechecked • Can be administered before or aLer shock delivery
- 65. DefibrillaFon • DefibrillaFon • Monophasic ‐ single shock 360 J • Biphasic ‐ depends on waveform; by default 200 J
- 66. Types of Defibrillator Waveforms and Energy • It is the transmyocardial current flow that defibrillates (not the energy) • Monophasic – Monophasic Damped Sinusoidal Waveform – Monophasic Truncated ExponenFal Waveform • Biphasic – Biphasic Truncated ExponenFal Waveform – RecFlinear Biphasic Waveform
- 67. Dose for Biphasic Waveform Device • Refer to manufacturers’ recommendaFons • If manufacturers’ recommendaFons not available, use 200 J for first shock • This 200 J default energy is a consensus default dose and not the ideal dose • This has been chosen because it falls within the reported range of selected doses that are effecFve for first and subsequent shocks
- 68. Types of Waveform A – MTE B – BTE A – RLB B – BTE
- 69. Oxygen Safety and DefibrillaFon • In an oxygen enriched atmosphere, sparking from poorly applied defibrillator paddles can cause a fire Minimize risk by • Take off any oxygen mask or nasal cannula and place them at least 1 m away from paFent’s chest • Leave the venFlaFon bag connected to tracheal tube or other airway adjunct
- 70. Oxygen Safety and DefibrillaFon • If paFent is on a venFlator, leave the venFlator tubing (breathing circuit) connected to the tracheal tube • Minimize risk of sparks by use of self‐adhesive pads than manual paddles
- 81. Pads PosiFon
- 83. Shock first or CPR first? • Most criFcal intervenFons during the first minutes of VF or pulseless VT: – immediate bystander CPR with minimal interrupFon in chest compressions – DefibrillaFon • Shock first or CPR first?
- 84. Shock first or CPR first? If • Witnessed arrest + defibrillator available ON SITE, then defibrillate immediately • Otherwise, CPR first
- 85. Why? • If VF/pulseless VT been present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. • A brief period of chest compressions can deliver oxygen and energy substrates to increase the likelihood that a perfusing rhythm will return aLer shock delivery.
- 86. Rhythm and Pulse Check Rhythm checks should be brief Pulse checks should be performed only if an organized rhythm is observed.
- 88. Cardiac Arrhythmias Two most important quesFons: 1. Is the paFent dead or alive? – Dead per ALS algorithm – Alive go to quesFon 2 2. If the paFent is alive, is the paFent stable or unstable? – Unstable electrical therapies – Stable further invesFgaFons
- 89. When the Arrhythmias is Unstable Four main signs 1. Signs of low cardiac output – systolic hypotension < 90 mmHg, altered mental status 2. Excessive rates: <40/min or >150/min 3. Chest pain 4. Heart failure • If unstable, electrical therapy: cardioversion for tachyarrhythmias, pacing for bradyarrhythmias
- 90. Electrical therapies • Tachyarrhythmias – cardioversion • Bradyarrhythmias – electrical pacing – Transcutaneous pacing – Transvenous pacing • Temporary • Permanent
- 91. DefibrillaFon • DefibrillaFon • Monophasic ‐ single shock 360 J • Biphasic ‐ depends on waveform; by default 200 J
- 92. Cardioversion • SynchronizaFon with R waves rather than T wave • Because VF can be induced if a shock is delivered during relaFve refractory period of cardiac cycle
- 93. DefibrillaFon Cardioversion Synchronised on the R Not synchronised wave For periarrest For cardiac arrest tachyarrhythmias (unstable) Higher energy joules Lower energy joules No escalaFng energy for Escalate for next shock next shock (100 ‐ 200 ‐ 300 ‐ 360J)
- 94. Cardioversion CondiFons Joules with monophasic defibrillator Atrial FibrillaFon Start with 200 J (Too high, e.g. 360 J may cause myocardial damage) Atrial Fluper Start with 100 J Ventricular Tachycardia Start with 200 J Supraventricular Tachycardia Start with 100 J
- 95. • Cardioversion up to 3 apempts • But if first cardioversion fails to restore NSR, and paFent remains unstable, give IV amiodarone 300 mg loading over 20 min; then re‐apempt • Serial DC shocks not appropriate for recurrent paroxysms of AF, esp with ongoing precipitaFng factors like sepsis • Cardioversion does not prevent subsequent arrhythmias – for recurrent, treat them with drugs
- 96. Wide Complex Tachycardias • Generally most wide complexes tachycardias are ventricular in origin • But, some wide complexes are due to supraventricular in origin • If not sure whether the rhythm is ventricular origin or supraventricular origin, then treat as ventricular origin
- 98. If the tachyarrhythmias are stable……
- 99. Tachyarrhythmias • For stable tachyarrhythmias, we need to further decide whether it is NARROW QRS or WIDE QRS • For each type, further divide into – Regular – Irregular
- 100. Tachyarrhythmias • Narrow QRS tachyarrhythmias – Regular • Sinus Tachycardia, PSVT, atrial fluper with regular AV conducFon – Irregular • Atrial FibrillaFon, Atrial fluper with variable AV Block • Wide (Broad) QRS tachyarrhythmias – Regular • Ventricular Tachycardia, SVT with BBB – Irregular • Polymorphic VT, AF with BBB
- 101. Management of Narrow Complex Tachycardia • Vagal maneuver – Valsalva maneuver is the most effecFve – Blow into a 20ml syringe with enough force to push back the plunger • Adenosine • Successful terminaFon pf a tachyarrhythmias by vagal maneuver or adenosine indicates that it is almost certainly AVNRT or AVRT.
- 102. Atrio‐Ventricular Tachyarrhythmias • AVNRT versus AVRT • AVNRT = atrioventricular nodal reentrant tachycardia – Due to reentrant circuit loop formed by 2 pathways, slow and fast, in the AV node (micro‐ reentry) • AVRT = atrioventricular reentrant tachycardia – Due to a large re‐entry circuit caused by an aberrant myocardial accessory pathways or bypass tracts
- 103. Atrio‐Ventricular Tachyarrhythmias AVNRT AVRT Micro‐reentry due to two pathways within Macro‐reentry due to an accessory the AV Node pathways or bypass tracts Affects all ages, but associated with IHD, Tends to present at earlier age than RheumaFc HD, etc AVNRT; male: female = 2:1; seen in WPW; also associated with Ebstein anomaly Most common form of Paroxysmal SVTs 2nd most common form of PSVTs Causes rapid, almost simultaneous Called orthodromic AVRT if anterograde depolarizaFon of both ventricles and atria conducFon through normal His‐Purkinje pathway and retrograde conducFon through accessory pathway Called anFdromic if anterograde conducFon through accessory pathway; retrograde conducFon through normal pathway
- 104. Atrio‐Ventricular Tachyarrhythmias AVNRT AVRT QRS complex typically narrow and regular; Orthodromic rate 120 – 250bpm Because ventricle depolarizaFon occurs along normal pathway, QRS narrow. Because atrial depolarizaFon and Because atria depolarized late along ventricle depolarizaFon occur accessory pathway, P wave follows QRS simultaneously, P wave maybe “buried” ; complex; or visible just aLer or immediately before Difficult to differenFate from AVNRT QRS complex AnFdromic Because ventriicles are aberrantly depolarized, a bizarre wide QRS complex tachycardia results; difficult to differenFate from VT or SVT with aberrancy
- 107. AV nodal reentrant tachycardia. In yellow, is evidenced the P wave that falls aLer the QRS complex.
- 113. Note • 3 of more consecuFve PVCs = VT • <30 seconds of VT = non sustained VY • >30 seconds of VT = sustained VT • Non sustained VTs do not require treatment • Torsades de pointes – a type of polymorphic VT with a cyclical papern of alternaFng electrical polarity and amplitude
- 114. Torsades de Pointes Torsade de pointes. The rhythm is iniFated by an R‐on‐T phenomenon. The rate is extremely fast, with changing QRS morphologies and axis. The QRS complexes change smoothly in amplitude, giving the appearance they are “twisFng” around a central axis. Most commonly occurs in paFents with prolonged QT interval, due to many causes: • Drug‐induced: tricyclic anFdepressants, procainamide, sotalol, amiodarone, ibuFlide, dofeFlide, some anFpsychoFcs, digoxin, some long‐acFng anFhistamines • Electrolyte and metabolic alteraFons (hypomagnesemia is the prototype) • Inherited forms of long QT syndrome • Acute ischemic events (see Pathophysiology)
- 115. Bradyarrhythmias
- 117. When the Arrhythmias is Unstable Four main signs 1. Signs of low cardiac output – systolic hypotension < 90 mmHg, altered mental status 2. Excessive rates: <40/min or >150/min 3. Chest pain 4. Heart failure • If unstable, electrical therapy: cardioversion for tachyarrhythmias, pacing for bradyarrhythmias
- 119. Four Rhythms at Risk of Developing Asystole 1. Recent asystole 2. Mobitz II 2nd degree AV Block 3. Complete Heart Block (especially with broad QRS or iniFal heart rate <40/min) 4. Ventricular standsFll more than 3 sec For these, consider also electrical therapy
- 120. 2nd Degree AV Block • 2nd degree Mobitz type 1 the block is at AV Node OLen transient Maybe asymptomaFc • 2nd degree Mobitz type 2 Block most oLen below AV node, at bundle of His or BB May progress to 3rd degree AV block
- 121. Other Topics
- 122. Pre‐cordial Thump • No prospecFve studies so far • RaFonale is to convert mechanical energy to electrical energy • In all sucessful cases, the thump was given within first 10s • More likely to be successful in converFng VT to sinus rhythm • Much less likely for VF
- 123. Pre‐cordial Thump • Consider as an opFon for witnessed, sudden collapse and defibrillator NOT immediately available • Thump may cause deterioraFon: – Rate acceleraFon of VT – Conversion of VT to VF – Complete Heart Block – Asystole
- 124. Pre‐cordial Thump • Only by trained healthcare providers immediately confirm cardiac arrest • Use ulnar edge of Fghtly clenched fist • Deliver a sharp impact to the lower half of the sternum from a height of 20 cm • ALer that, immediately retract the fist
- 125. Four Features SuggesFve Ventricular Origin • Concordance Polarity • Fusion beats and Capture beats • Bizzare QRS complexes • AV DissociaFon
- 126. Concordance Polarity
- 128. AV DissociaFon