als algorithm lecture

ALS Subcommittee 2010

ARRHYTHMIA TREATMENT

ALGORITHMS


OBJECTIVES

Upon completion of this session, you will be able to:

List the 4 arrhythmias leading to cardiac arrest

State the treatment algorithms for VF/ pulseless VT, PEA and Asystole

Understand the principles of management of tachy and brady arrythmias


Cardiac Arrest

Occurs with one of 4 arrhythmias:

ventricular fibrillation (VF)

pulseless ventricular tachycardia (VT)

pulseless electrical activity (PEA)

asystole

HYDROGEN ION HYPOXIA HYPOTHERMIA HYPOVOLEMIA HYPO/HYPERKALEMIA HYPOGLYCEMIA

TAMPONADE, CARDIAC TENSION PNEUMOTHORAX THROMBOSIS, Pulmonary THROMBOSIS, Coronary TOXIN

•Danger •Responsiveness •Shout for help

1. DANGER 2. RESPONSIVENESS 3. SHOUT FOR HELP AND DEFIBRILLATOR 4. AIRWAY OPENING 5. BREATHING 6. CHEST COMPRESSION

CARDIOPULMONARY RESUSCITATION Push hard 5cm deep, Push fast 100 per minute Minimize interruption of chest compression Allow complete chest recoil Do NOT hyperventilate Compression to ventilation ratio 30:2 if not intubated DEFIBRILLATION 360J for monophasic, 120-200J for biphasic IV or IO ACCESS DRUGS IV Adrenaline 1 mg push IV Vasopressin 40 U (as first or second drug after Adrenaline IV AMIODARONE 300mg bolus, 150 mg second dose

1. DANGER 2. RESPONSIVENESS 3. SHOUT FOR HELP AND DEFIBRILLATOR 4. AIRWAY OPENING 5. BREATHING 6. CHEST COMPRESSION

CARDIOPULMONARY RESUSCITATION Push hard 5cm deep, Push fast 100 per minute Minimize interruption of chest compression Allow complete chest recoil Do NOT hyperventilate Compression to ventilation ratio 30:2 if not intubated IV or IO ACCESS DRUGS IV Adrenaline 1 mg push IV Vasopressin 40 U (as first or second drug after Adrenaline IV AMIODARONE 300mg bolus, 150 mg second dose

Hydrogen ion Hypoxia Hypothermia Hypovolemia Hypo/hyperkalemia Hypoglycemia

Trauma Tension pneumothorax Thrombosis(coronary) Thrombosis(pulmonary) Tamponade


Causes: H’s and T’s

• Hypoxia

• Hypokalemia/hyperkalemia

• Hypothermia

• Hypovolemia

• Hydrogen ions (acidosis)

• Hypoglycemia


Causes: H’s and T’s ….cont

• Tamponade

• Thrombosis (pulmonary)

• Thrombosis (coronary)

• Toxins

• Tension pneumothorax

ALS Subcommittee

2010

Pericardial Tamponade

• Chest x-ray

–Widened mediastinum

–Pneumo- or hemothorax

• Electrical alternans

•Note rounded bottle shape to left side of heart


Right Left

A: Air under tension in left thorax

A

Pleural margin; partial lung

collapse

Tension Pneumothorax


Asystole Algorithm

Adrenaline 1 mg IV push, repeat every 3 to 5 minutes,

Vasopression 40U may replace 1 dose of adrenaline

If Asystole persists Withhold or cease resuscitation efforts?

•Consider quality of resuscitation? •Atypical clinical features present? •Search for DNR order


Pulse Algorithm

• Bradycardia

• Tachycardia

– Narrow Complex

– Wide Complex

ATROPINE 0.5mg to 3mg OR DOPAMINE 5 to 10mcg.kg.min OR

ADRENALINE 2-10 mcg/kg/min

Assess clinically

Identify and treat underlying cause

Ensure airway patency Oxygen supplement Cardiac monitor Establish IV access Perform 12 lead ECG

Hemodynamic instability - Hypotension - altered mental status - signs of shock - acute heart failure


Tachyarrhythmia

Is patient stable or unstable?

Patient has serious signs or symptoms? Chest pain (ischemic? possible ACS?)

Shortness of breath (lungs getting ‘wet’? possible CCF?)

Low blood pressure (orthostatic? dizzy? lightheaded?)

Decreased level of consciousness (poor cerebral perfusion?)

Clinical shock (cool and clammy? peripheral vasoconstriction?)

Are the signs and symptoms due to the rapid heart rate?


Management of Tachyarrhythmia

• Stable

– Treat with IV drugs

• Unstable

– Cardioversion

Unstable, with serious signs or symptoms

ie : Heart failure, SBP<90, In shock

Tachycardia Algorithm

Immediate synchronised cardioversion

Narrow Complex Tachycardia

•Assess: Responsiveness • ECG monitor •Shout: Help/defibrillator • Assess vital signs •Assess: ABC • Review history •Administer oxygen • Perform physical exam •Establish IV • Do 12 Lead ECG

Wide Complex Tachycardia

Polymorphic VT

Yes

No


Postresuscitation Stabilisation

• Support of `stunned’ myocardium - may require vasoactive support

• Keep hypothermic (32-34°C) for VF or non VF arrest for 12 to 24h

• Maintain strict glucose control (4 - 6mmol/l)

• Monitor clinical signs


SUMMARY

• Effective ALS begins with high quality CPR

• Uninterrupted high quality chest compressions improve outcome – Rhythm check, rescue breath, even drug administration

should NOT interrupt compressions

• Early recognition & treatment of arrhythmias give the best chance of survival

• Search for treatable causes of PEA

• Post-resuscitation period is important

• Know algorithms well


THANK YOU NATIONAL COMMITTEE ON RESUSCITATION TRAINING

SUBCOMMITEE FOR ADVANCED LIFE SUPPORT

Dr Tan Cheng Cheng

Dr Luah Lean Wah

Dr Ismail Tan

Dr Wan Nasrudin

Dr Chong Yoon Sin

Dr Priya Gill

Dr Ridzuan bin Dato’ Mohd Isa

Dr Thohiroh Abdul Razak

Dr Adi Osman

als algorithm lecture

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