ACLS

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ACLS

  1. 1. RC (UK) RESUSCITATION COUNCIL (UK) RESUSCITATION COUNCIL (QAT) ADVANCED LIFE SUPPORT 2/15/2003 , 1 INTRODUCTION Dr.Montaser Ismail MRCP, Arab Board of Cardiology
  2. 2. RC (UK) Cardiovascular Disease • In Europe cardiovascular disease accounts for 40% of all deaths < 75 yrs • In QAT cardiovascular disease accounts for 29% of all deaths all ages. • One third of all people developing an MI die before reaching hospital • Presenting rhythm in most of these cases is VF/VT • In-hospital cardiac arrest more likely non-VF/VT 2
  3. 3. RC (UK) Chain of Survival 3
  4. 4. RC (UK) CAUSES AND PREVENTION OF CARDIORESPIRATORY ARREST 2/15/2003 , 4
  5. 5. RC (UK) Causes of cardiorespiratory arrest 1. Airway obstruction • CNS depression • Blood, vomit, foreign body • Trauma • Infection, inflammation • Laryngospasm • Bronchospasm 5
  6. 6. RC (UK) Causes of cardiorespiratory arrest 2. Breathing inadequacy • Decreased respiratory drive –CNS depression • Decreased respiratory effort –neurological lesion –muscle weakness –restrictive chest defect • Pulmonary disorders –pneumothorax, lung pathology6
  7. 7. RC (UK) Causes of cardiorespiratory arrest 3. Cardiac abnormalities Primary • Ischaemia • Myocardial infarction • Hypertensive heart disease • Valve disease • Drugs • Electrolyte abnormalities Secondary • Asphyxia • Hypoxaemia • Blood loss • Septic shock 7
  8. 8. RC (UK) Recognition of patients at risk • History, examination, investigations • Clinical indicators of deterioration before in-hospital cardiac arrest in 80% –tachypnoea –tachycardia –hypotension –reduced conscious level 8
  9. 9. RC (UK) Medical Emergency Team (MET) Calling Criteria • Airway -threatened • Breathing –Respiratory arrest –RR < 5 or RR >36 • Circulation –cardiac arrest –PR < 40 or PR >140 –Systolic BP < 90 • Neurology –sudden fall in GCS > 2 • Any other worries RR = respiratory rate PR = pulse rate 9
  10. 10. RC (UK) Airway obstruction Symptoms and signs • Difficulty breathing, distressed, choking • Shortness of breath • Stridor, wheeze, gurgling • See-saw respiratory pattern Actions • Suction, positioning • BLS manoeuvres • Advanced airway intervention 10
  11. 11. RC (UK) Breathing inadequacy Symptoms and signs • Short of breath, anxious, irritable • Decrease in conscious level • Tachypnoea • Cyanosis Action • Oxygen • Ventilatory support • Treat underlying cause where possible 11
  12. 12. RC (UK) Cardiac abnormalities: Acute Coronary Syndromes Clinical syndromes form spectrum of the same disease process: Unstable angina ↓ Non-Q wave myocardial infarction ↓ Q wave myocardial infarction 12
  13. 13. RC (UK) Immediate treatment in all acute coronary syndromes • “MONA” –Morphine (or diamorphine) –Oxygen –Nitroglycerine (GTN spray or tablet) –Aspirin 300 mg orally (crushed/chewed) 13
  14. 14. RC (UK) Patients with ST segment elevation MI or MI with LBBB Early coronary reperfusion therapy: • Thrombolytic therapy –streptokinase –alteplase • Percutaneous transluminal coronary angioplasty (PTCA) • Coronary artery bypass surgery (CABG) 14
  15. 15. RC (UK) CARDIAC MONITORING & RHYTHM RECOGNITION 2/15/2003 , 15
  16. 16. RC (UK) Which patients? • Cardiac arrest or other important arrhythmias • Chest pain • Heart failure • Collapse / syncope • Shock / hypotension • Palpitations 16
  17. 17. RC (UK) How to monitor the ECG (1): Monitoring leads • 3-lead system approximates to I, II, III • Colour coded • Remove hair • Apply over bone • Lead setting (II) • Gain 17
  18. 18. RC (UK) How to monitor the ECG (2): Defibrillator paddles • Suitable for “quick- look” • Movement artefact • Risk of spurious asystole 18
  19. 19. RC (UK) How to monitor the ECG (3): Adhesive monitoring electrodes • “Hands-free” monitoring and defibrillation 19
  20. 20. RC (UK) 12-lead ECG 20
  21. 21. RC (UK) 12-lead ECG • 3D electrical activity from heart • More sophisticated ECG interpretation • ST segment analysis 21
  22. 22. RC (UK) • Depolarisation initiated in SA node • Slow conduction through AV node • Rapid conduction through Purkinje fibres Basic electrocardiography (1) 22
  23. 23. RC (UK) Basic electrocardiography (2) • P wave = atrial depolarisation • QRS = ventricular depolarisation (< 0.12 s) • T wave = ventricular repolarisation 23
  24. 24. RC (UK) How to read a rhythm strip 1. Is there any electrical activity? 2. What is the ventricular (QRS) rate? 3. Is the QRS rhythm regular or irregular? 4. Is the QRS width normal or prolonged? 5. Is atrial activity present? 6. How is it related to ventricular activity? 24
  25. 25. RC (UK) ECG rhythm interpretation • Effective treatment often possible without precise ECG diagnosis • Haemodynamic consequences of any given rhythm will vary • Treat the patient not the rhythm 25
  26. 26. RC (UK) What is the ventricular rate? • Normal 60-100 min-1 • Bradycardia < 60 min-1 • Tachycardia > 100 min-1 Rate = 300 Number of large squares between consecutive QRS complexes* * At standard paper speed of 25 mm sec-1 , 5 large squares = 1 second 26
  27. 27. RC (UK) Is the QRS rhythm regular or irregular? • Unclear at rapid heart rates • Compare R-R intervals • Irregularly irregular = AF 27
  28. 28. RC (UK) Is the QRS width normal or prolonged? • Normal QRS: –< 0.12 s (< 3 small squares) –originates from above bifurcation of bundle of His 28
  29. 29. RC (UK) • Prolonged QRS (> 0.12 s) arises from: –ventricular myocardium, or –supraventricular with aberrant conduction Is the QRS width normal or prolonged? 29
  30. 30. RC (UK) A broad complex tachycardia should be assumed to be ventricular in origin unless there is a very good reason to suspect otherwise. 30
  31. 31. RC (UK) Is atrial activity present? • P waves (leads II and V1) • Rate, regularity, morphology • Flutter waves • Atrial activity may be revealed by slowing QRS rate with adenosine 31
  32. 32. RC (UK)32
  33. 33. RC (UK) How is atrial activity related to ventricular activity? • Consistent, fixed PR interval • Variable, but recognisable pattern • No relationship - atrioventricular dissociation 33
  34. 34. RC (UK) Heart Block: First Degree 34
  35. 35. RC (UK) Heart Block: Second Degree Möbitz Type I (Wenckebach) Block Möbitz Type II Block 35
  36. 36. RC (UK) Heart Block: Third Degree • Site of pacemaker: –AV node 40 - 50 min-1 –Ventricular myocardium 30 - 40 min-1 36
  37. 37. RC (UK) DEFIBRILLATION 2/15/2003 , 37
  38. 38. RC (UK) Mechanism of defibrillation • Definition “The termination of fibrillation or absence of VF/VT at 5 seconds after shock delivery” • Critical mass of myocardium depolarised • Natural pacemaker tissue resumes control 38
  39. 39. RC (UK) Defibrillation Success depends on delivery of current to the myocardium Current flow depends upon: • Electrode position • Transthoracic impedance • Energy delivered • Body size 39
  40. 40. RC (UK) Transthoracic Impedance Dependent upon: • Electrode size • Electrode/skin interface • Contact pressure • Phase of respiration • Sequential shocks 40
  41. 41. RC (UK)41
  42. 42. RC (UK)42
  43. 43. RC (UK)43
  44. 44. RC (UK) Manual Defibrillation Relies upon: • Operator recognition of ECG rhythm • Operator charging machine and delivering shock • Can be used for synchronised cardioversion 44
  45. 45. RC (UK) Defibrillator Safety • Never hold both paddles in one hand • Charge only with paddles on casualty’s chest • Avoid direct or indirect contact • Wipe any water from the patient’s chest • Remove high-flow oxygen from zone of defibrillation 45
  46. 46. RC (UK) Synchronised cardioversion • Convert atrial or ventricular tachyarrhythmias • Shock synchronised to occur with the R wave • Short delay after pressing discharge buttons - keep defibrillator electrodes in place • Conscious patients: sedation or anaesthesia • Check mode if further shock/s required 46
  47. 47. RC (UK)
  48. 48. RC (UK) Automated external defibrillators • Analyse cardiac rhythm • Prepare for shock delivery • Specificity for recognition of shockable rhythm close to 100% 48
  49. 49. RC (UK) Automated external defibrillators Advantages: • Less training required –no need for ECG interpretation • Suitable for “first-responder” defibrillation • Public access defibrillation (PAD) programs 49
  50. 50. RC (UK) Biphasic Defibrillators • Require less energy for defibrillation – smaller capacitors and batteries – lighter and more transportable • Repeated < 200 J biphasic shocks have higher success rate for terminating VF/VT than escalating monophasic shocks 50
  51. 51. RC (UK) AIRWAY MANAGEMENT AND VENTILATION  2/15/2003 , 51
  52. 52. RC (UK) Common causes of airway obstruction • Upper Airway –tongue –soft tissue oedema, foreign material –blood, vomit • Larynx –laryngospasm, foreign material • Lower Airway –secretions, oedema, blood52
  53. 53. RC (UK) Recognition of airway obstruction • LOOK for chest/abdominal movement • LISTEN at mouth and nose for breath sounds, snoring, gurgling • FEEL at mouth and nose for expired air53
  54. 54. RC (UK) Opening the airway • Head tilt • Chin lift • Jaw thrust • CAUTION! – cervical spine injury 54
  55. 55. RC (UK) Head Tilt and Chin Lift 55
  56. 56. RC (UK) Jaw Thrust 56
  57. 57. RC (UK) Suction 57
  58. 58. RC (UK) Simple airway adjuncts
  59. 59. RC (UK) Oropharyngeal Airway
  60. 60. RC (UK) Nasopharyngeal Airway
  61. 61. RC (UK) Mouth to mask ventilation Advantages: • Avoids direct person to person contact • Decreases potential for cross infection • Allows oxygen enrichment Limitations: • Maintenance of airtight61
  62. 62. RC (UK) Bag-valve-mask, 2-person ventilation 62
  63. 63. RC (UK) Ventilation using self inflating bag Advantages • Avoids direct person to person contact • Allows oxygen supplementation – up to 85% • Can be used with facemask, LMA, Combitube, tracheal tube
  64. 64. RC (UK) Ventilation using self inflating bag Limitations When used with a facemask: • Risk of inadequate ventilation • Risk of gastric inflation • Need two persons for optimal use 64
  65. 65. RC (UK) Advanced Airway Management
  66. 66. RC (UK) The Laryngeal Mask Airway
  67. 67. RC (UK) The Laryngeal Mask Airway Advantages • Rapidly and easily inserted • Variety of sizes • More efficient ventilation than facemask • Avoids the need for laryngoscopy 67
  68. 68. RC (UK) The Laryngeal Mask Airway Limitations • No absolute guarantee against aspiration • Not suitable if very high inflation pressures needed • Unable to aspirate airway
  69. 69. RC (UK) The Laryngeal Mask Airway Fig 1 Fig 2 Fig 3
  70. 70. RC (UK) The Laryngeal Mask Airway
  71. 71. RC (UK) Tracheal Intubation
  72. 72. RC (UK) Tracheal Intubation Advantages • Allows ventilation with up to 100% O2 • Isolates airway, preventing aspiration • Allows aspiration of the airway • Alternative route for drug administration 72
  73. 73. RC (UK) Limitations • Training and experience essential • Failed insertion, oesophageal placement • Potential to worsen cervical cord or head injury Tracheal Intubation
  74. 74. RC (UK) Needle Cricothyroidotomy Indication • Failure to provide an airway by any other means Complications • Malposition of cannula – Emphysema – Haemorrhage – Oesophageal perforation • Hypoventilation • Barotrauma 74
  75. 75. RC (UK) Cardiac Arrest Rhythms and ALS Universal Treatment Algorithm
  76. 76. RC (UK)
  77. 77. RC (UK) Ventricular fibrillation • Bizarre irregular waveform • No recognisable QRS complexes • Random frequency and amplitude • Unco-ordinated electrical activity • Coarse / fine • Exclude artifact – movement – electrical interference
  78. 78. RC (UK)
  79. 79. RC (UK)
  80. 80. RC (UK) Pulseless ventricular tachycardia • Monomorphic VT –Broad complex rhythm –Rapid rate –Constant QRS morphology • Polymorphic VT –Torsade de pointes
  81. 81. RC (UK)
  82. 82. RC (UK)
  83. 83. RC (UK) Asystole • Absent ventricular (QRS) activity • Atrial activity (P waves) may persist • Rarely a straight line trace • Consider fine VF
  84. 84. RC (UK)
  85. 85. RC (UK)
  86. 86. RC (UK) Pulseless Electrical Activity • Clinical features of cardiac arrest • ECG normally associated with an output
  87. 87. RC (UK) Cardiac Arrest Precordial Thump if appropriate BLS Algorithm if appropriate Attach Defib-Monitor Assess Rhythm +/- Check Pulse VF/VT Non-VF/VT Defibrillate X 1 CPR 2 min CPR 2 min During CPR Correct reversible causes If not already: •check electrodes, paddle position and contact •attempt / verify airway & O2 i.v. access •give epinephrine every 3 min Consider: amiodarone, atropine / pacing buffers Potential reversible causes: •Hypoxia •Hypovolaemia •Hypo/hyperkalaemia & metabolic disorders •Hypothermia •Tension pneumothorax •Tamponade •Toxic/therapeutic disorders •Thrombo-embolic & mechanical obstruction Universal ALS Algorithm
  88. 88. RC (UK)
  89. 89. RC (UK) Precordial thump • Indication: –witnessed or monitored cardiac arrest
  90. 90. RC (UK) Cardiac Arrest Precordial Thump if appropriate BLS Algorithm if appropriate Attach Defib-Monitor Assess Rhythm +/- Check Pulse VF/VT Non-VF/VT
  91. 91. RC (UK) Look Listen & Feel X 10 seconds
  92. 92. RC (UK) 30 : 2
  93. 93. RC (UK) Assess Rhythm +/- Check Pulse VF/VT Defibrillate X 1 CPR 2 min Ventricular Fibrillation/ Pulseless Ventricular Tachycardia
  94. 94. RC (UK) • Deliver 1 shocks in < 30 seconds • Continue CPR for 2 minutes regardless. VF / VT SHOCK maximum (200 – 360) joules
  95. 95. RC (UK) During CPR Correct reversible causes If not already: • check electrodes, paddle position and contact • attempt / verify: airway & O2 i.v. access • give epinephrine every 3-5 min (every other cycle of CPR) Consider: amiodarone, atropine / pacing, buffers
  96. 96. RC (UK) Chest compressions, airway and ventilation • Secure airway: –tracheal tube –LMA –Combitube • Once airway secured, do not interrupt chest compressions for ventilation
  97. 97. RC (UK) Intravenous access and drugs VF/VT • Central veins versus peripheral • Epinephrine 1 mg i.v. or 2-3 mg tracheal tube • Consider amiodarone 300 mg if VF/VT persists after 3rd shock • Alternatively - lidocaine 100 mg • Consider magnesium 8 mmol
  98. 98. RC (UK) *or biphasic equivalent VF/VT (continued) • Epinephrine every 3-5 minutes • Consider bicarbonate 50 mmol if pH < 7.1 • Consider paddle positions Shock maximum (200 – 360) J
  99. 99. RC (UK) Non-VF/VT CPR 2 min Assess Rhythm +/- Check Pulse Asystole Pulseless Electrical Activity
  100. 100. RC (UK) Potential reversible causes: •Hypoxia •Hypovolaemia •Hypo/hyperkalaemia & metabolic disorders •Hypothermia •Tension pneumothorax •Tamponade •Toxic/therapeutic disorders •Thrombo-embolic & mechanical obstruction
  101. 101. RC (UK) Asystole • Confirm: –check leads - view via leads I and II –check gain • Epinephrine 1 mg every 3-5 minutes • Atropine 3 mg i.v. or 6 mg via tracheal tube (once)
  102. 102. RC (UK) Pulseless electrical activity • Exclude/treat reversible causes • Epinephrine 1 mg every 3-5 minutes • Atropine 3 mg if PEA with rate < 60 min-1
  103. 103. RC (UK) POST RESUSCITATION CARE 2/15/2003 , 103
  104. 104. RC (UK) The return of spontaneous circulation is the first step in the continuum of resuscitation 104
  105. 105. RC (UK) Post Resuscitation Care The goal: • Normal cerebral function • Stable cardiac rhythm • Adequate organ perfusion 105
  106. 106. RC (UK) Continued resuscitation: airway and breathing Aim: to ensure a clear airway, adequate oxygenation and ventilation 106
  107. 107. RC (UK) Aim: the maintenance of normal sinus rhythm and a cardiac output adequate for perfusion of vital organs Continued resuscitation: circulation 107
  108. 108. RC (UK) Continued resuscitation: neurological assessment • Glasgow Coma Scale • Pupils • Limb tone and movement • Posture 108
  109. 109. RC (UK) Further assessment Monitoring • History • ECG • Pulse oximetry • Blood pressure • End tidal carbon dioxide • Urine output • Temperature 109
  110. 110. RC (UK) Further assessment Investigations • Full blood count • Biochemistry • 12-lead ECG • Chest X-ray • Arterial blood gases 110
  111. 111. RC (UK) Post Resuscitation Care Chest X-ray • Fractured ribs, pneumothorax, aspiration, sub-diaphragmatic gas • Tracheal tube • CVP line • Chest drain • Nasogastric tube • Pacing wire 111
  112. 112. RC (UK) Transfer of the patient Aim: to facilitate a safe transfer of the patient between the site of resuscitation and an appropriate place of definitive care (critical care area) 112
  113. 113. RC (UK) Supporting relatives • Clear explanation of what they will see • Clear explanation of the events leading to the arrest • Direct not to interfere • Use simple language • Ensure they are supported by a member of the team 113
  114. 114. RC (UK) Dealing with the recently bereaved • Early contact with one person, usually a nurse • Provision of a suitable room • Recognising the grief response • Encouraging and arranging viewing of the body • Establishing religious requirements114
  115. 115. RC (UK) Dealing with the recently bereaved Possible responses to grief: • Acute emotional distress • Anger • Denial • Guilt • Catatony 115
  116. 116. RC (UK) ‫لــكـــم‬ ‫شكــــرا‬ Thank You

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