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Advanced cardiac life support(acls)



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ACLS - update and review
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Advanced cardiac life support(acls)

  1. 1. ADVANCED CARDIAC LIFE SUPPORT(ACLS) - 2010 Speaker – Dr Omar Kamal DNB anaesthesiology
  2. 2. ADVANCED CARDIAC LIFE SUPPORT  ACLS impacts multiple key links in the chain of survival that include interventions to prevent cardiac arrest, treat cardiac arrest, and improve outcomes of patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest  Interventions aimed at preventing cardiac arrest include airway management, ventilation support, and treatment of bradyarrhythmias and tachyarrhythmias.
  3. 3. AHA ADULT CHAIN OF SURVIVAL 1. Immediate recognition of cardiac arrest and activation of the emergency response system 2. Early CPR with an emphasis on chest compressions 3. Rapid defibrillation 4. Effective advanced life support 5. Integrated post–cardiac arrest care
  4. 4. CARDIOPULMONARY RESUSCITATION (CPR)  Cardiopulmonary resuscitation (CPR) is a series of life saving actions that improve the chance of survival following cardiac arrest
  5. 5. KEY CHANGES FROM THE 2005 BLS GUIDELINES ● Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing ● “Look, Listen, and Feel” removed from the BLS algorithm ● Encouraging Hands-Only (chest compression only) CPR ● Sequence change CAB rather than ABC ● Health care providers continue effective chest compressions/ CPR until return of spontaneous circulation or termination of resuscitative efforts
  6. 6. ● Increased focus on high-quality CPR ● Continued de-emphasis on pulse check for health care providers ● A simplified adult BLS algorithm is introduced with the revised traditional algorithm
  8. 8. CHEST COMPRESSIONS  Chest compressions consist of forceful rhythmic applications of pressure over the lower half of the sternum.  Technique ..?
  9. 9. MONITORING DURING CPR Physiologic parameters  Monitoring of PETCO2 (35 to 40 mmHg)  Coronary perfusion pressure (CPP) (15mmHg)  Central venous oxygen saturation (ScvO2)  Abrupt increase in any of these parameters is a sensitive indicator of ROSC that can be monitored without interrupting chest compressions
  10. 10. Quantitative waveform capnography  If Petco2 <10 mm Hg, attempt to improve CPR quality Intra-arterial pressure  If diastolic pressure <20 mm Hg, attempt to improve CPR quality  If ScvO2 is < 30%, consider trying to improve the quality of CPR
  11. 11. HIGH QUALITY CPR  Chest compressions of adequate rate 100/min  A compression depth of at least 2 inches (5 cm) in adults and in children, a compression depth of at least 1.5 inches [4 cm] in infants  Complete chest recoil after each compression,  Minimizing interruptions in chest compressions  Avoiding excessive ventilation  If multiple rescuers are available, rotate the task of compressions every 2 minutes.
  12. 12. AIRWAY AND VENTILATIONS  Opening airway – Head tilt, chin lift or jaw thrust  The untrained rescuer will provide Hands-Only (compression-only) CPR  The Health care provider should open the airway and give rescue breaths with chest compressions
  13. 13. RESCUE BREATHS  By mouth-to-mouth or bag-mask  Deliver each rescue breath over 1 second  Give a sufficient tidal volume to produce visible chest rise  Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations  After advanced airway is placed, rescue breaths given asynchronus with ventilation  1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute)
  14. 14. CARDIAC ARREST  Cardiac arrest can be caused by 4 rhythms: 1. Ventricular fibrillation(VF), 2. Pulseless ventricular tachycardia (VT), 3. Pulseless electric activity (PEA), and 4. Asystole. How to recognise cardiac arrest ..?
  15. 15. TREATABLE CAUSES OF CARDIAC ARREST: THE H’S AND T’S H’s T’s  Hypoxia Toxins  Hypovolemia Tamponade (cardiac)  Hydrogen ion(acidosis) Tension pneumothorax  Hypo-/hyperkalemia Thrombosis, pulmonary  Hypothermia Thrombosis, coronary
  16. 16. DEFIBRILLATION  Defibrillation is defined as termination of VF for at least 5 seconds following the shock.  Early defibrillation remains the cornerstone therapy for ventricular fibrillation and pulseless ventricular tachycardia
  17. 17. ELECTRODE PLACEMENT 4 pad positions  anterolateral,  anteroposterior,  anterior-left infrascapular, and  anterior-rightinfrascapular  For adults, an electrode size of 8 to 12 cm is reasonable (Class IIa, LOE B).  Any of the 4 pad positions is reasonable for defibrillation (Class IIa, LOE B).
  18. 18.  Defibrillation Sequence ● Turn the AED on. ● Follow the AED prompts. ● Resume chest compressions immediately after the shock(minimize interruptions). Shock Energy  Biphasic : Manufacturer recommendation (eg, initial dose of 120-200 J), if unknown, use maximum available.  Second and subsequent doses should be equivalent, and higher doses may be considered.  Monophasic : 360 J
  19. 19. 1-SHOCK PROTOCOL VERSUS 3-SHOCK SEQUENCE  Evidence from 2 well-conducted pre/post design studies suggested significant survival benefit with the single shock defibrillation protocol compared with 3-stacked-shock protocols  If 1 shock fails to eliminate VF, the incremental benefit of another shock is low, and resumption of CPR is likely to confer a greater value than another shock
  20. 20. DRUG THERAPY 1. Peripheral IV Drug Delivery 2. IO Drug Delivery - IO cannulation provides access to a noncollapsible venous plexus 3. Central IV Drug Delivery - It can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC 4. Endotracheal Drug Delivery - lidocaine, epinephrine, atropine, naloxone, and vasopressin  Dose : 2 to 2 ½ times the recommended IV dose
  21. 21. VASOPRESSORS Drug Therapy  Epinephrine IV/IO Dose: 1 mg every 3-5 minutes  Vasopressin IV/IO Dose: 40 units can replace first or second dose of epinephrine  Amiodarone IV/IO Dose: First dose: 300 mg bolus. Second dose: 150 mg.
  22. 22. KEY CHANGES FROM THE 2005 ACLS GUIDELINES  Continuous quantitative waveform capnography is recommended  Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high quality CPR  Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole
  23. 23.  Increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC  Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia.  Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia
  24. 24. CARDIAC ARREST ASSOCIATED WITH PREGNANCY  The overall maternal mortality rate was calculated at 13.95 deaths per 100 000 maternities.  There were 8 cardiac arrests with a frequency calculated at 0.05 per 1000 maternities, or 1:20 000.  The frequency of cardiac arrest in pregnancy is on the rise with previous reports estimating the frequency to be 1:30 000 maternities  Department of Health, Welsh Office, Scottish Office. Report on confidential enquiries into maternal deaths in the United Kingdom 2000–2002. London (UK): The Stationery Office; 2004.
  25. 25. CAUSES B – Bleeding/ DIC E – Embolism( pulmonary, coronary , amniotic ) A – Anesthetic complications U – Uterine atony C – Cardiac disease( MI/Aortic dissection/Cardiomyopathy) H – Hypertension ( Pre eclampsia/ Eclampsia ) O – Other reversible causes P – Placenta praevia/ abruptio S -- Sepsis
  26. 26. RECOMMENDATION FOR EMERGENCY CAESAREAN SECTION Recommendation  When the gravid uterus is large enough to cause maternal hemodynamic changes due to aortocaval compression,  emergency caesarean section should be considered, regardless of fetal viability
  27. 27.  Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation or improvement in maternal hemodynamic status only after the uterus has been emptied.  In a case series of 38 cases of perimortem cesarean section, 12 of 20 women for whom maternal outcome was recorded had return of spontaneous circulation immediately after delivery. McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. 2009;103:406–409.
  28. 28.  Synchronised cardioversion - shock delivery that is timed (synchronized) with the QRS complex  Narrow regular : 50 – 100 J  Narrow irregular : Biphasic – 120 – 200 J and Monophasic – 200 J  Wide regular – 100 J  Wide irregular – defibrillation dose  Adenosine : 6 mg rapid iv push, follow with NS flush.. Second dose 12 mg
  29. 29. INITIAL OBJECTIVES OF POST– CARDIAC ARREST CARE  Optimize cardiopulmonary function and vital organ perfusion.  After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment  Transport the in-hospital post– cardiac arrest patient to an appropriate critical-care unit  Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest
  30. 30. THANK YOU