ADVANCED CARDIAC LIFE SUPPORT(ACLS) – 2015

Dr. Md. Mashiul AlamResidentUniversity Cardiac CenterBSMMU

ADVANCED CARDIAC LIFE SUPPORT Advanced cardiac life support or advanced

cardiovascular life support (ACLS) refers to a setof clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.

IMPORTANCE OF BLS IN ACLS

ACLS is built heavily upon the foundation of BLS

COMPONENT OF HIGH QUALITY CPR IN BLS Scene safety:1. Make sure the environment is safe for

rescuers and victim Recognition of cardiac arrest:1. Check for responsiveness2. No breathing or only gasping ( ie, no normal

breathing)3. No definite pulse felt within 10 secs ( Carotid

or femoral pulse)(Breathing and pulse check can be performed

simultaneously within 10 secs)

Activation of emergency response system:If alone with no mobile phone, leave the victim

to activate the emergency response system and get the AED before beginning CPR

Otherwise, send someone and begin CPR immediately; use the AED as soon as it is available

In case of unwitnessed collapse of children or infant give CPR for 2 mins before leaving the victim and getting the AED then resume CPR

Chest compression-Adult- 30:2Children or infant- 30:2 if one rescuer 15:2 if more than one

rescuer Compression rate: 100-120/ min Compression depth: Adult- at least 5 cmChildren or infant- at least 1/3rd AP diameter of

chest

Hand placement:Adult - 2 hands on the lower half of the

sternumChildren – 1 or 2 hands on the lower half of the

sternumInfants – 2 fingers or 2 thumb defending of the

number of rescuers Chest recoil: allow full recoil of chest after each

compression; do not lean on the chest after each compression.

Minimizing interruption: Limit interruptions in chest compressions to less than 10 secs.

A CHANGE FROM A-B-C TO C-A-B

BLS DON’TS OF ADULT HIGH-QUALITY CPR

1. compression rate slower than 100/ min or faster than 120/min

2. Compression depth less than 5 cm or greater than 6 cm

3. Lean on the chest between compression 4. Interrupt compressions for greater than 10

secs 5. Provide excessive ventilation- ie, too many

breaths or breaths with excessive force

ADULT ADVANCED CARDIOVASCULAR LIFE SUPPORT

RECONGNITION OF ARRYTHMIALethal or non lethal

Symptomatic or asymptomatic

Stable or unstable

Shockable or unshockable

Shockable

VTMonomorphic or

polymorphicVF

Fine or Coarse VF

Unshockable

AsystolePEA- pulseless electrical

activity or EMD- electromechanical dissociation

MEANWHILE… Minimize interruption in CPR- alternate CPR

provider every 2 minutes as continued Chest compression may fatigue the provider leading to ineffective compression

Maintain an orchestra of activity between physician, nurse and other health care provider (Ward boy)

Check airway patency- consider oropharyngeal tube placement if tongue fell back.

Arrange for endotracheal tube/ maximize oxygen delivery

VT/ VFDeliver single defibrillitor shock

VT/V

F re

cursCPR-2 mins

Check rhythm

VT/V

F re

cursDeliver single shock- if VT /VF persist---CPR 2 mins and give EPINEPHRINE 1 mg

VT/V

F re

cursContinue CPR 2 min

VT/V

F re

cursAmiodarone/ Lidocaine/ Magnesium sulfate

V T / V F r e c u r s

Defibrillate: Drug---Shock---Drug----Shock

ELECTRODE PLACEMENT4 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).

DEFIBRILLATION Biphasic wave form: 120- 200 J Monophasic wave form: 360 J AED- device specific

Failure of a single adequate shock to restore a pulse should be followed by continued CPR and second shock delivered after five cycles of CPR

If cardiac arrest still persist- patient is intubated and IV/IO access achieved

Defibrillation Sequence● Turn the AED on.● Follow the AED prompts.● Resume chest compressions immediately after the shock(minimize interruptions).

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

ASYSTOLE/PEAContinue CPR

(Intubate and

establish IV

access)

Identify and

RX reversi

ble causes

Continue

CPR if asystole/PEA

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

AIRWAY AND VENTILATIONS Opening airway – Head tilt, chin lift or jaw thrust, in

addition explore the airway for foreign bodies, dentures and remove them. Consider oropharyngeal tube placement.

The Health care provider should open the airway and give rescue breaths with chest compressions

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)

BREATHING DEVICES Plastic oropharyngeal airways Esophageal obturators Ambu bag- usual method for continuing

breathing in hospital before ET tube can be inserted.

Endotracheal tube

PHARMACOTHERAPY

ROUTES OF ADMINISTRATIONPeripheral IV – easiest to insert during CPR,

must followed by 20 ml NS pushCentral IV – fast onset of action, but do not

wait or waste time for CV lineIntraosseous – alternative IV route in peds, also

in AdultIntratracheally (down an ET tube)- not

recommended now a days

Oxygen• FIO2 100%• Assist Ventilation• O2 Toxicity should not be a concern during ACLS

IV FluidsVolume Expanders• crystalloids , e.g. Ringer’s lactate, N/S

Amiodarone (Cordarone)• Indications:– Like Lidocaine – Vtach, Vfib• IV Dose:– 300 mg in 20-30 ml of N/S or D5W– Supplemental dose of 150 mg in 20-30 ml of N/S orD5W– Followed with continuous infusion of 1 mg/min for 6 hours than .5mg/min to a maximum daily dose of 2grams• Contraindications:– Cardiogenic shock, profound Sinus Bradycardia, and 2nd and 3rd degree blocks that do not have apacemake

Lidocaine• Indications:– PVCs, Vtach, Vfib– Can be toxic so no longer given prophylactically• IV dose :– 1-1.5 mg/kg bolus then continuous infusion of 2-4mg/min– Can be given down ET tube• Signs of toxicity:– slurred speech, seizures, altered consciousness

Magnesium• Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes• Dose:– 1-2 grams over 2 minutes• Side Effects– Hypotension– Asystole

Propranolol/ Esmolol• Beta blocker that may be useful for Vfib and Vtach that has not responded to othertherapies– Very useful for patients whose cardiac emergency was precipitated by hypertension– Also used for Afib, Aflutter, & PSVT

Epinephrine• Because of alpha, beta-1, and beta-2 stimulation, it increases heart rate, stroke volume and bloodpressure– Helps convert fine vfib to coarse Vfib– May help in asystole– Also PEA and symptomatic bradycardia• IV Dose:– 1 mg every 3-5 minutes– May increase ischemia because of increased O2 demand by the heart

Vasopressin (ADH)- is out according to 2015 guidelines for ACLS

Sodium Bicarbonate• Used for METABOLIC acidosis / hyperkalemia

– Airway and ventilation have to be functional• IV Dose:– 1 mEq/kg– If ABGs, [BE] x wt in kg/6• Side effects:– Metabolic alkalosis– Increased CO2 production

MONITORING DURING CPRPhysiologic 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

Quantitative waveform capnography If Petco2 <10 mm Hg, attempt to improve

CPR qualityIntra-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

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

ACTION IN TIME CAN SAVE A LIFE!!!

THANK YOU