Downloaded 121 times
![CPR Quality
• Push hard (>=2inches [5cm]) and fast (>=100/min) and allow complete chest recoil
• Minimize interruptions in compressions
• Avoid excessive ventilation
• Rotate compressor every 2 minutes
• If no advanced airway, 30:2 compression-ventilation ratio
• Quantitative waveform capnography
-If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality
Return of spontaneous Circulation (ROSC)
• Pulse and blood pressure
• Abrupt sustained increase in PETCO2 (typically>40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial monitoring
Shock Energy
• Biphasic: Manufacturer recommendation (120-200 J);if unknown, use maximum available. Second and subsequent
doses should be equivalent, and higher doses may be considered.
• Drug Therapy
• Monophasic:360 J
• 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.
Advanced Airway
• Supraglottic advanced airway or endotracheal intubation
• Waveform capnography to confirm and monitor ET tube placement
• 8-10 breaths per minute with continuous chest compressions
Reversible causes
• Hypovolemia -Tension pneumothorax
• Hypoxia -Tamponade, cardiac
• Hydrogen Ion (acidosis) - Toxins
• Hypo-/hyperkalemia -Thrombosis,pulmonary
• Hypothermia -Thrombosis,coronary](https://image.slidesharecdn.com/cpruptodate2-141020034707-conversion-gate01/75/acls-11-2048.jpg)
Uploaded byMurad Karajah
acls
This document summarizes guidelines for emergency medicine training in resuscitation. It discusses adult cardiopulmonary resuscitation, including a focus on high-quality chest compressions. It also reviews the treatment of cardiac arrest, including defibrillation and drug therapy. Additional sections cover bradycardia, tachycardia, cardiac rhythms like atrial fibrillation and flutter, and management approaches.
More Related Content
acls
- 1. EMERGENCY MEDICINE TRAINING RESUSCITATION Presented By: Dr. Murad Karajah Thursday,1st of Dec,2011
- 2. Adult Cardiopulmonary Resuscitation • Survival from in-hospital cardiac arrest has been reported to be 17% • The survival is dependent on the actions of many people, acting as a team The most important new recommendation chest compressions. And change A-B-C to C-A-B
- 3. Adult Cardiopulmonary Resuscitation patients with a witnessed VF arrest, or time is< 5 minutes, ear ly def ibr i l lat ion is the prefer red However, in patients un witnessed VF arrest, or an arrest of unclear length of time Ini t ial CPR has been shown to improve outcomes
- 4. The New GuidelinesRecommend It is now recommended that rescuers should make chest compressions , at a rate at least 100 compressions per minute Another recent change to the guidelines for CPR has been the recommendation of a ratio of 30 compressions to 2 ventilations The only exception is for rescuer CPR delivered to newborn and pt with respiratory arrest . The chest compressions should depress the adult sternum at least 2 inches, rather than the previous recommendation of 1 ½ to 2 inches
- 5. The New GuidelinesRecommend • If an advanced airway is in place delivery of respirations should occur without pauses in compressions at a rate of 8–10 per minute
- 6. The New GuidelinesRecommend Airway Management And Ventilation • Rescue breathing and airway management are of less importance than uninterrupted chest compressions • Insertion of (ETT) may not be the critical airway/ventilation management intervention • All breaths, whether delivered by (BVM) or advanced airway device should be done over 1 second and at a rate of approximately 12BPM. Hyperventilation should be avoided
- 7. Approach To CardiacArrest And Life-Threatening Arrhythmias • Cardiac arrest is characterized by an abrupt LOC because of absence of blood flow • The most common electrical mechanisms of cardiac arrest are the ventricular tachyarrhythmia's
- 8. Adult BLS HealthcareProviders • Patient unresponsive or gasping First: call help or send some one to do this Second: check pulse if present give 1 breath q 5 sec check P q 2 min no pulse start Compression 30 then 2 breath 3d check rhythm- if shockable give one shock then CPR 2 min not shockable start CPR 2 min then check again rhythm until patient start to move or ALS provider take over Un Shockable rhythm – a systole – pulseless electrical activity
- 9. Adult Cardiac ArrestShout for help/active EMS START CPR GIVE O2 ATTACH MONITOR ASYSTOLE PEA VF/VT SHOCK RHYTHM SHOCHABLE CPR 2 min EPINEPHRINE every 3-5 min Consider advanced AW Give shock then CPR for 2 min Iv access YES YES NO NO CPR 2 min Iv epinephrine every 3-5 min Consider advanced AW CHECK RHYTHM TREAT REVERSIBLE CAUSE If rhythm shockable give 3d shock Then start amiodarone Treat reversible cause Rhythm SHOCKABLE CPR
- 10. Post Cardiac ArrestCare After return to spontaneous circulation optimize ventilation and oxygenation by O2 sat < 94% Don’t hyperventilate Considered intubation Treat hypotension give IV fluids bolus If no response give vasopressore infusion Do ECG 12 leads Patient not follow commands consider induced hypothermia Signs of AMI cardiac reperfusion is indicated
- 11. CPR Quality •Push hard (>=2inches [5cm]) and fast (>=100/min) and allow complete chest recoil • Minimize interruptions in compressions • Avoid excessive ventilation • Rotate compressor every 2 minutes • If no advanced airway, 30:2 compression-ventilation ratio • Quantitative waveform capnography -If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality Return of spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in PETCO2 (typically>40 mm Hg) • Spontaneous arterial pressure waves with intra-arterial monitoring Shock Energy • Biphasic: Manufacturer recommendation (120-200 J);if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered. • Drug Therapy • Monophasic:360 J • 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. Advanced Airway • Supraglottic advanced airway or endotracheal intubation • Waveform capnography to confirm and monitor ET tube placement • 8-10 breaths per minute with continuous chest compressions Reversible causes • Hypovolemia -Tension pneumothorax • Hypoxia -Tamponade, cardiac • Hydrogen Ion (acidosis) - Toxins • Hypo-/hyperkalemia -Thrombosis,pulmonary • Hypothermia -Thrombosis,coronary
- 12. Adult Bradycardia yes symptomatic NO No symptoms Just observation Under monitor symptoms: Hypotension Mental changes Shock Chest pain Acute heart failure HR >50 bpm Identify the cause Started ABCs IV access Give O2 Monitor ECG 12 Leads Give atropine If not effective transfer for pacing Or adrenalin Or dopamine
- 13. Adult Tachycardia WithPulse Wide QRS < 0.12 Synchronized cardioversion yes NO NO YES IDENTIFY AND TREAT UNDERLYING CAUSE ABCS O2 therapy Iv access BP monitoring Symptoms : Hypotension Chest pain Mental status changes Shock IHD Acute heart failure Considered adenosine Antiarrhythmic IV access Vagal maneuver B blocker Ca blocker HR<150
- 14. Doses/Details Synchronized Cardioversion Initial recommended doses: • Narrow regular: 50-100 J • Narow irregular: 120-200 J biphasic or 200 J monophasic • Wide regular: 100J • Wide irregular: defibrillation close (NOT synchronized) Adenosine IV Dose First dose: 6 mg rapid IV push: follow with NS flush. Second dose:12 mg if required. ______________________________________ Antiarrhythmic Infusions for Stable Wide=QRS Tachycardia Procainamide IV Dose: 20-50 mg/min until arrhythmia suppressed. hypotension ensues. QRS duration increases>50%.or maximum dose 17 mg/kg given. Maintenance infusion:1-4 mg/min. Avoid if prolonged QT or CHF. Amiodarone IV Dose: First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours. Sotalol IV Dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.
- 15. Approach to patientwith arrhythmia Identify and treat underlying cause Maintain patent airway: assist breathing as necessary Oxygen if hypoxic Cardiac monitor Monitor blood pressure Iv access 12 leads ECG don't delay therapy
- 16. Persistent tachyarrhythmia causing • Hypotension • • Acute altered mental status • • Acute heart failure • Ischemic heart disease • Signs of shock
- 17.
- 18. First degree AVBlock • Causes Medication Ischemic heart disease Hypothyroidism • Sinus bradycardia • P wave before QRS • PR interval < 0.2 sec
- 19. Second Degree AVBlock: Type 1 – Wenkenbach Causes Inferior MI Digoxin toxocity P • consists of progressive prolongation of the PR interval until a nonconducted P wave occurs PR
- 20. Second-Degree AV Block,Type II • Most patients will require permanent pacemaker • the PR interval remains constant with intermittent conduction of atrial impulses Conduction block below the AV node.
- 21. Third Degree AVBlock: Complete AV Block • These patients require transvenous pacer placement for stabilization • occurs when there is no AV conduction. P waves • and QRS complexes exist independently of each other • ventricular escape beats typically occur at a rate of about 40 beats/min.
- 22. Sinus Tachycardia Causesinclude • pain, fear, anxiety, • fever, hypovolemia, • pulmonary embolism, hyperthyroidism, • CHF, ischemia, • sepsis, • alcohol, nicotine, caffeine, catecholamine's, atropine, anticholinergic toxicity, and herbal weight • accelerated sinus node discharge at a rate Higher than 100 beats/min. Normal • P wave • PR interval, and • QRS complex
- 23. SVT – SupraventricularTachycardia CAUSES • IHD • catecholamine's, • COPD, digoxin toxicity, rheumatic heart disease, • (MVP), alcohol, electrolyte abnormalities, • accessory pathways such as (WPW). • ectopic pacemaker or reentry Most SVTs are AV nodal reentrant tachycardia's • narrow QRS complexes • P waves are often absent
- 24. Management of SVT • Carotid massage • A denosine, • Beta blockers, • Calcium-channel blockers, • Amiodarone, • Procainamide, • Synchronized cardioversion. If the patient’s condition is unstable
- 25. Atrial Fibrillation Causes • hypertension, • rheumatic heart disease, • coronary artery disease hyperthyroidism, • COPD, • CHF, and • alcohol intoxication • multiple areas of atrial myocardium continuously Discharging and contracting The atrial rate is between 400 and 600 • ventricular contraction rate <100 beats/min, it is • termed atrial fibrillation with rapid ventricular response
- 26. Management of atrialfibrillation If the duration of atrial fibrillation is less than 48 hours or no thrombus is present on TEE - Treatment • chemical (pharmacological) • or electrical cardioversion. If the patient’s condition is unstable, immediate sedation and synchronized cardioversion is indicated(100–200 J is usually effective). If the duration of AF more than 48 hrs the treatment focused to rate control • Calcium-channel blockers and beta blockers are first-line agents • Then plan for cardioversion after 3-4 wk of anticoagulation
- 27. Atrial Flutter Causes • CAD • AMI. • CHF, • pulmonary embolus • myocarditis, • digoxin toxicity • a localized area of ectopy in the atrium • regular atrial rate between 250 and 350 beats/min • The degree of AV block is usually 2:1 but may be greater
- 28. Management of flutter • Treatment is directed at controlling the ventricular rate. Calcium-channel blockers and beta blocker are first-line • Chemical and electrical cardioversion may also be considered. If • the patient’s condition is unstable, immediate sedation and synchronized • cardioversion is indicated (0.5–1 J/kg is usually effective).
- 29. Ventricular Tachycardia (Monomorphic) Polymorphic Ventricular Tachycardia – Torsade de • Pointes • VT occurs when more than three depolarization's occur from a ventricular focus. • VT less than 30 seconds duration is termed nonsustained ventricular tachycardia. • QRS complex is generally wide and regular • rate higher than 100 beats/min (usually 150–200)
- 30. Management of VT • The most common causes of VT are ischemic heart disease . Other common causes include • MVP, HOCM, hypoxia, electrolyte abnormalities, • Treatment is administered according to ACLS guidelines. • Amiodarone and lidocaine are first-line agents for stable VT. • Magnesium, procainamide, and bicarbonate can also be considered • for refractory VT. If the patient’s condition is unstable, immediate sedation and synchronized cardioversion are indicated.
- 31. VENTRICULAR FIBRILLATION •Treatment is administered according to ACLS guidelines. • there are no organized depolarization or contractions of the ventricles.
- 32. ACUTE CORONARY SYNDROM Symptoms suggest IHD Emergency assessment :out clinic Monitor-IV access- bed rest Aspirine-O2 therapy – nitroglycerin – morphine Obtain ECG – If ST elevation transfer urgent to hospital If considering fibrinolysis give prehospital Time should be recorded ED assessment- <10 min review rapid history ,physical exam , ECG, Monitor, cardiac enzyme,O2 Portable x ray , coagulation study Review complete fibrinolytic checklist Treatment in the emergency department : O2 therapy >94% , morphine , NTG , ASA
- 33. ECG finding Normalor non specific changes ST or new LBBB Strongly suggest acute myocardial injury ST or T wave inversion High risk for unstable angina or NSTEMI Start therapy Don’t delay reperfusion Trop or high risk patient consider early invasive strategy if : Recurrent chest pain Recurrent st depression Ventricular tachycardia Hemodynamic instability Signs of heart failure Observation Serial ECG Enzymes Non invasive <12hr Time of cardiac test symptoms <12 hr Reperfusion Door to Pallone PCI 90 min Door to fibrinolysis 30 min Start treatment by -NTG - -Heparin -ASA - B blocker - Clopidogrel - ACEI/ARB Statin therapy Any changes consider invasive test
- 34. ADULT SUSPECTED STROK Candidate for Fibrinolytic Consult neurologist& Neurosurgery Need admission SIGNS&SYMPTOMS Active EMS ASSESSMENT AND ACTION ABCs and give o2 Obtain iv access Check glucose Obtain 12 leads ECG Order if possible urgent brain CT Alert hospital Hemorrhagic Yes Ischemia No CT showed bleeding Give Rtpa And give ASA Heparin after 24 h Yes No ASA
- 35.
Editor's Notes
- #4 the energy depleted myocardial cells, following a prolonged VF arrest,