acls in 2013 the science behind the changes
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ACLS in 2013The science behind the changes
Michele Vicari-Christensen DNP ARNPAugust 17th 2013
Objectives1) Discuss the recent changes in ACLS2) Understand the scientific rationale
for the changes presented3) Explain the use of capnography and
hypothermia4) Explore the rationale for key pharmacological changes in the algorithms5) Illustrate the Chain of Survival
CPRCPR Quality-Concensus Statement Circulation June 2013
1) Must use a systematic approach to assess and treat arrest and acutely ill or injured patients for optimum care which includes:
-High quality CPR -Capnography -Hypothermia -Optimal glycemic control -Appropriate algorithms and pharmolcological
agents
2) Goal of any resuscitative action is return of spontaneous circulation (ROSC) and neurological preservation
Worldwide there are > 135 million cardiovascular death annually
Globally, the incidence of out of hospital cardiac arrest ranges from 20-140K/110K in the US
Survival ranges from 2-11% in the US
These statistics establish cardiac arrest as one of the most lethal public health problems in the US taking more lives than colorectal cancer, breast cancer, prostate cancer, influenza, pneumonia auto accidents HIV firearms and house fires combined
The American Heart Association (AHA) recommends focusing primarily on effective cardiac compressions during
resuscitative efforts
Importance of compressions-5 critical components
1) Minimize any interruptions in effective chest compressions.
2) Provide compressions of adequate rate and depth
3) Avoid leaning between compressions4) Allow complete chest recoil after each
compression5 Avoid excessive ventilation
CPR survival is dependent on adequate myocardial oxygen delivery and myocardial blood flow:
Chest compression fraction (CCF) of >80%-minimal interruptions
Chest compression rate of 100-120
Compression depth of 50 mm or 2 inches in adults (1/3 anterior, posterior dimension of chest
No Leaning causes lack of recoil
Excessive ventilation decreases depth and recoil
Push it to the limit
Monitoring the effects of CPR:
Cardiac perfusion pressure (CPP)of>20 mmHg-defined by arterial end diastolic pressure minus central venous pressure (CVP). Requires and
arterial line and a central line during CPR
Capnography-ET CO2 of > 20 mmHg
The AHA recommends the use of capnography
to monitor the effectiveness of chest
compressions during CPR in the intubated patient
CapnographyWhat is waveform capnography ?
Quantitative waveform capnography is the continuous, noninvasive measurement and graphical display of end-tidal carbon dioxide/ETCO2 (also called PetCO2).
Capnography uses a sample chamber/sensor placed for optimum evaluation of expired CO2. The inhaled and exhaled carbon dioxide is graphically displayed as a continuous waveform on the monitor along with its corresponding numerical measurement
CapnographyCirculation. Blood must be moving in order to deliver CO2 from the tissues to the alveoli. Circulation requires blood, an effective heartbeat and blood pressure. Preload plus afterload equals circulation. Mimic in compressions.
In the acute setting, PetCO2 is a function of cardiac output
Ventilation. Air must move in and out of the alveoli effectively to get rid of carbon dioxide and other waste products, and to inhale fresh oxygen.
Capnography1) Qualitative waveform capnography
(PETC02) provides a quality measure for CPR
2) Optimal goal for CPR is PETC02 of 35-40 mmHg equates to same as when ROSC
3) If PET Co2 is < 10 mmHg attempt to improve CPR-a PetC02 is 10 or less after initiation of ACLS is associated with poor outcomes.
The AHA recommends the use of hypothermia in the treatment of neurological injury post cardiac
arrest in the field from Pulseless Electrical Activity, Ventricular Fibrillation and Asystole
Hypothermia
The new guidelines recommend cooling comatose adult patients with ROSC after out of hospital VF, PEA and Asystole cardiac arrest to 32-34 degrees C (89-93 degrees F) for up to 12-24 hours
Moderate hypothermia used since 1950 to protect the brain from global ischemia-lowers cerebral metabolic rate for oxygen (CMRO2)
by 6% for every degree.
Reduces cerebral histological deficits associated with reperfusion injury :
-less mitochondrial damage, -decreased free radical production-less excitatory amino acid release
-less calcium shifts-less neural cell apoptosis
Methods:1) External cooling
blankets, ice , wet towels and fanning, cooling helmet2)Intravenous
30 cc/kg of crystalloid at 4 C over 30 minutes3) Peritoneal lavage
4) Pleural lavage5) ECMO
Side Effects and ComplicationsHigher Systemic Vascular Resistance,
PneumoniaLower Cardiac Index
HyperglycemiaCoagulopathy
ArrythmiasSkin Breakdown
The AHA recommends optimal glycemic control for neurological recovery post ACLS intervention.
Glycemic control1)Target glycemic control 10
144-180 mg/dl in an adult patients after cardiac arrest and ROSC.
2)Avoid lower blood sugars in ranges of 80-110 mg/dl
Hyperglycemia causes cerebral microvascular changes and brain edema
that quickly lead to neuronal death
Hypoglycemia causes cerebral cellular fuel deprivation and cellular death as well as an increase in cerebral cellular
excitability and seizures.
The AHA recommends the appropriate algorithm with recommended
pharmacological agents
Sodium Bicarbonate
NAHC03
Henderson-Hasselbalch EquationRegulation of Carbonic Acid/Bicarbonate
buffer pair
Atropine
1) Parasympatholytic agent. Research
supports only effective utilization is in symptomatic bradycardia
2) There is no benefit in pulseless
electrical activity or asystole
The AHA recommends implementation of the Chain of Survival for ACS and CVA both in the field and in the hospital
Chain of Survival
ACLS extends to Acute Coronary Syndrome and Cerebral Vascular
Accidents
In hospital survival from cardiac arrest is 20% from 7a-11p and declines to <
15% from 11p-7a
The majority of published data in the form of before and after
studies of Rapid Response teams have reported 17-65% drop in the rates of cardiac
arrest after teams were developed
ReferencesGuidelines for CPR and ECC (2010). AmericanHeart Association.
Field et al. (2010). Executive Summary- American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. (2010). Circulation. November 2, 2010; pp. S640-S729.
CPR Quality-Improving Cardiac Resuscitation Outcomes Both inside and Outside the Hospital: A Concensus Statement from the American Heart Association. (2013).Circulation. June 25, 2013. pp. 1-19
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