case management of acls handouts - power point 879

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ACLS 2005 Update ACLS 2005 Update

The Essentials The Essentials

WhistlerWhistler -- September 2006September 2006

ACLS 2005 Update ACLS 2005 Update

The Essentials The Essentials

WhistlerWhistler -- September 2006September 2006

Dr. John PawlovichDr. John Pawlovich

Fraser Lake, BCFraser Lake, BC

CCFP, Assistant Clinical Professor UBCCCFP, Assistant Clinical Professor UBC



Main ConceptsMain Concepts 2005 ACLS2005 ACLSMain ConceptsMain Concepts 2005 ACLS2005 ACLS



The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:

1.1. improve delivery of effective chest compressionsimprove delivery of effective chest compressions

2.2. single compressionsingle compression--toto--ventilation ratio (30:2)ventilation ratio (30:2)(except newborns)(except newborns)

3.3. each rescue breath should be given over 1 secondeach rescue breath should be given over 1 secondto produce visible chest riseto produce visible chest rise

4.4. single shock followed by immediate CPR without single shock followed by immediate CPR without pulse or rhythm check for VF/ PVT cardiac arrest pulse or rhythm check for VF/ PVT cardiac arrest

5.5. AED use in children (1 AED use in children (1--8 years)8 years)

1.1. improve delivery of effective chest compressionsimprove delivery of effective chest compressions

2.2. single compressionsingle compression--toto--ventilation ratio (30:2)ventilation ratio (30:2)(except newborns)(except newborns)

3.3. each rescue breath should be given over 1 secondeach rescue breath should be given over 1 secondto produce visible chest riseto produce visible chest rise

4.4. single shock followed by immediate CPR without single shock followed by immediate CPR without pulse or rhythm check for VF/ PVT cardiac arrest pulse or rhythm check for VF/ PVT cardiac arrest

5.5. AED use in children (1 AED use in children (1--8 years)8 years)



HighHigh--quality CPR saves lives!!quality CPR saves lives!!HighHigh--quality CPR saves lives!!quality CPR saves lives!!



Important PointsImportant Points

RateRate

DepthDepth

ReleaseRelease

Five key

aspectsto Great

CPR

Five key

aspectsto Great

CPR

!!

UninterruptedUninterrupted Ve

ntilatio

n Ve

ntilatio

n



Coronary Perfusion Pressure

(CPP)

Coronary Perfusion Pressure

(CPP) = (aortic pressure right atrial pressure)

M AJOR DETERMIN ANT FOR SURVI VAL IS CPP

Highly correlated to ROSC

When CPR is paused, CPP falls quickly

When CPR is restarted, it takes 3-6

compressions to reestablish the previous CPP

= (aortic pressure right atrial pressure)

M AJOR DETERMIN ANT FOR SURVI VAL IS CPP

Highly correlated to ROSC

When CPR is paused, CPP falls quickly

When CPR is restarted, it takes 3-6

compressions to reestablish the previous CPP



Compression

� Compression of heart & lungs

� Increased intrathoracic

pressure

Decompression

� Refilling of heart & lungs

� Decreased intrathoracic

pressure

� Negative with full recoil

Compression-DecompressionCompression-Decompression



One Universal CompressionOne Universal Compression--toto--Ventilation VentilationRatio for All Lone RescuersRatio for All Lone Rescuers

One Universal CompressionOne Universal Compression--toto--Ventilation VentilationRatio for All Lone RescuersRatio for All Lone Rescuers

2005 (New):2005 (New): 30:2 for all lone rescuers30:2 for all lone rescuers

2000 (Old):2000 (Old): 15:2 adults, 5:1 child and infant.15:2 adults, 5:1 child and infant.

Why:Why: ByBy--stander CPR is on the order of 30% or less.stander CPR is on the order of 30% or less.Simplify guidelines to increase bystander CPR.Simplify guidelines to increase bystander CPR.

2005 (New):2005 (New): 30:2 for all lone rescuers30:2 for all lone rescuers

2000 (Old):2000 (Old): 15:2 adults, 5:1 child and infant.15:2 adults, 5:1 child and infant.

Why:Why: ByBy--stander CPR is on the order of 30% or less.stander CPR is on the order of 30% or less.Simplify guidelines to increase bystander CPR.Simplify guidelines to increase bystander CPR.



Defibrillation (VF/ PVT): 1 Shock, ThenDefibrillation (VF/ PVT): 1 Shock, ThenImmediate CPR (NO pulse check, NOImmediate CPR (NO pulse check, NO

rhythm check)rhythm check)

Defibrillation (VF/ PVT): 1 Shock, ThenDefibrillation (VF/ PVT): 1 Shock, ThenImmediate CPR (NO pulse check, NOImmediate CPR (NO pulse check, NO

rhythm check)rhythm check)

SINGLE SHOCK = MORE CPR

CONTINUE CPR WHILE M ACHINECH ARGES

SINGLE SHOCK = MORE CPR

CONTINUE CPR WHILE M ACHINECH ARGES



RationaleRationale -- 1 Shock followed by Immediate1 Shock followed by ImmediateCPRCPR

RationaleRationale -- 1 Shock followed by Immediate1 Shock followed by ImmediateCPRCPR

1.1. The rhythm analysis by current AEDs afterThe rhythm analysis by current AEDs aftereach shock typically results ineach shock typically results in 37 sec 37 sec delaydelay

in CPRin CPR2.2. first shock eliminates VF in more than 85% of first shock eliminates VF in more than 85% of cases. If first shock fails, resumption of CPR iscases. If first shock fails, resumption of CPR islikely more beneficiallikely more beneficial

3.3. it takes several minutes for a normal heart it takes several minutes for a normal heart rhythm to return and more time for the heart rhythm to return and more time for the heart to create blood flow after VF is eliminated.to create blood flow after VF is eliminated.CPR can bridge that gap.CPR can bridge that gap.

4.4. Immediate CPR after defibrillation is not Immediate CPR after defibrillation is not

harmful.harmful.

1.1. The rhythm analysis by current AEDs afterThe rhythm analysis by current AEDs aftereach shock typically results ineach shock typically results in 37 sec 37 sec delaydelay

in CPRin CPR2.2. first shock eliminates VF in more than 85% of first shock eliminates VF in more than 85% of cases. If first shock fails, resumption of CPR iscases. If first shock fails, resumption of CPR islikely more beneficiallikely more beneficial

3.3. it takes several minutes for a normal heart it takes several minutes for a normal heart rhythm to return and more time for the heart rhythm to return and more time for the heart to create blood flow after VF is eliminated.to create blood flow after VF is eliminated.CPR can bridge that gap.CPR can bridge that gap.

4.4. Immediate CPR after defibrillation is not Immediate CPR after defibrillation is not

harmful.harmful.



Changes in Advanced Life SupportChanges in Advanced Life Support



Pulseless Rhythm



Main Concept Main Concept Main Concept Main Concept

priority is good CPR with minimallypriority is good CPR with minimallyinterruptioninterruption

Insertion of an advanced airwayInsertion of an advanced airway not not a higha highprioritypriority

In presence of advanced airway, continuousIn presence of advanced airway, continuous

compressions (~100 per minute) withcompressions (~100 per minute) withasynchronous ventilation (~8asynchronous ventilation (~8--10/ min) (~110/ min) (~1breath every 6breath every 6--8 seconds).8 seconds).

minimize interruptions in chest minimize interruptions in chest

compressions!!!compressions!!!

priority is good CPR with minimallypriority is good CPR with minimallyinterruptioninterruption

Insertion of an advanced airwayInsertion of an advanced airway not not a higha highprioritypriority

In presence of advanced airway, continuousIn presence of advanced airway, continuous

compressions (~100 per minute) withcompressions (~100 per minute) withasynchronous ventilation (~8asynchronous ventilation (~8--10/ min) (~110/ min) (~1breath every 6breath every 6--8 seconds).8 seconds).

minimize interruptions in chest minimize interruptions in chest

compressions!!!compressions!!!



DefibrillationDefibrillation General concept General concept DefibrillationDefibrillation General concept General concept Immediate defibrillation if witnessed arrest andImmediate defibrillation if witnessed arrest and

AED available AED available

Compressions before defibrillation if unwitnessedCompressions before defibrillation if unwitnessedor arrival at the sceneor arrival at the scene >4>4--5 minutes.5 minutes.

One shockOne shock followed by immediate CPRfollowed by immediate CPR(beginning with chest compressions)(beginning with chest compressions)

rhythm check after 5 cycles of CPR or 2 minutesrhythm check after 5 cycles of CPR or 2 minutes

Immediate defibrillation if witnessed arrest andImmediate defibrillation if witnessed arrest and AED available AED available

Compressions before defibrillation if unwitnessedCompressions before defibrillation if unwitnessedor arrival at the sceneor arrival at the scene >4>4--5 minutes.5 minutes.

One shockOne shock followed by immediate CPRfollowed by immediate CPR(beginning with chest compressions)(beginning with chest compressions)

rhythm check after 5 cycles of CPR or 2 minutesrhythm check after 5 cycles of CPR or 2 minutes



0 2 4 6 8 10 12 14 16 18 20

Arrest Time (min)

Circulatory

Phase

ElectricalPhase

MetabolicPhase

Shock CPR ?

Importance of CPRThree-Phase Model

Importance of CPRThree-Phase Model



Importance of CPRPriming the Pump



DefibrillationDefibrillation Energy settingEnergy settingDefibrillationDefibrillation Energy settingEnergy setting

For adult defibrillation:For adult defibrillation:

monophasic manual defibrillator 360J;monophasic manual defibrillator 360J;

biphasic with truncated exponentialbiphasic with truncated exponentialwaveform 150waveform 150--200J;200J;

biphasic with rectilinear waveform 120J;biphasic with rectilinear waveform 120J;

biphasic unknown type 200J.biphasic unknown type 200J.

For adult defibrillation:For adult defibrillation:

monophasic manual defibrillator 360J;monophasic manual defibrillator 360J;

biphasic with truncated exponentialbiphasic with truncated exponentialwaveform 150waveform 150--200J;200J;

biphasic with rectilinear waveform 120J;biphasic with rectilinear waveform 120J;

biphasic unknown type 200J.biphasic unknown type 200J.



1shock versus 3 stacked shocks

1shock versus 3 stacked shocks

� BIPHASIC eliminates VF after firstshock >90%

� AED requires 90 secs for 3 shocks (i.e.NO CPR FOR 90 SECONDS)

� Interruptions in chest compressions are

harmful� 1 Shock strategy may be preferable

� BIPHASIC eliminates VF after firstshock >90%

� AED requires 90 secs for 3 shocks (i.e.NO CPR FOR 90 SECONDS)

� Interruptions in chest compressions are

harmful� 1 Shock strategy may be preferable



Drug AdministrationDrug AdministrationDrug AdministrationDrug Administration I V or IO drug administration is preferred to ETTI V or IO drug administration is preferred to ETT

routeroute

Drugs should be delivered during CPR as soon asDrugs should be delivered during CPR as soon aspossible after rhythm checks.possible after rhythm checks.

timing of drug administration is less important thantiming of drug administration is less important thanthe need to minimize interruptions in chest the need to minimize interruptions in chest

compressionscompressions

I V or IO drug administration is preferred to ETTI V or IO drug administration is preferred to ETTrouteroute

Drugs should be delivered during CPR as soon asDrugs should be delivered during CPR as soon aspossible after rhythm checks.possible after rhythm checks.

timing of drug administration is less important thantiming of drug administration is less important thanthe need to minimize interruptions in chest the need to minimize interruptions in chest

compressionscompressions



Major changes in ACLS drugsMajor changes in ACLS drugsMajor changes in ACLS drugsMajor changes in ACLS drugs

VF/ pVT/ asystole/ PEA VF/ pVT/ asystole/ PEA

epinephrine q3epinephrine q3--5 min5 min Vasopressin X 1 may replace either the first or Vasopressin X 1 may replace either the first or

second dose of epinephrine.second dose of epinephrine.

VF/ pVT VF/ pVT

Amiodarone (Class IIb) Amiodarone (Class IIb)

Lidocaine (indeterminate)Lidocaine (indeterminate)

VF/ pVT/ asystole/ PEA VF/ pVT/ asystole/ PEA

epinephrine q3epinephrine q3--5 min5 min Vasopressin X 1 may replace either the first or Vasopressin X 1 may replace either the first or

second dose of epinephrine.second dose of epinephrine.

VF/ pVT VF/ pVT

Amiodarone (Class IIb) Amiodarone (Class IIb)

Lidocaine (indeterminate)Lidocaine (indeterminate)



Antiarrhythmics Antiarrhythmics No evidence that giving any antiarrythmic

drug routinely during cardiac arrest increases

rate of survival to hospital discharge In comparison with placebo and lidocaine, the

use of amiodarone in shock-refractory VFimproves the short-term outcome of survival

to hospital admission

No evidence that giving any antiarrythmicdrug routinely during cardiac arrest increases

rate of survival to hospital discharge In comparison with placebo and lidocaine, the

use of amiodarone in shock-refractory VFimproves the short-term outcome of survival

to hospital admission



Use of Advanced AirwaysUse of Advanced AirwaysUse of Advanced AirwaysUse of Advanced Airways

LM A and Combitube should be considered (ClassLM A and Combitube should be considered (ClassIIa).IIa).

Advanced airway may be placed several minutes Advanced airway may be placed several minutesinto the resuscitationinto the resuscitation

clinical assessment plus a device such as ETCOclinical assessment plus a device such as ETCO22 or EDD toor EDD toconfirm ETT placement (Class IIa).confirm ETT placement (Class IIa).

LM A and Combitube should be considered (ClassLM A and Combitube should be considered (ClassIIa).IIa).

Advanced airway may be placed several minutes Advanced airway may be placed several minutesinto the resuscitationinto the resuscitation

clinical assessment plus a device such as ETCOclinical assessment plus a device such as ETCO22 or EDD toor EDD toconfirm ETT placement (Class IIa).confirm ETT placement (Class IIa).



Bradycardia & Tachycardia



Arrhythmia with pulse Arrhythmia with pulse Arrhythmia with pulse Arrhythmia with pulse symptomatic bradycardiasymptomatic bradycardia

atropine 0.5mg I V (max 3mg)atropine 0.5mg I V (max 3mg)

Isoproterenol eliminatedIsoproterenol eliminated TachycardiaTachycardia

summarized in a single algorithmsummarized in a single algorithm

branch points then become narrow versus widebranch points then become narrow versus widecomplex, and regular versus irregular rhythmscomplex, and regular versus irregular rhythms

polymorphic VT should be treated as VF withpolymorphic VT should be treated as VF withhighhigh--energy unsynchronized defibrillationenergy unsynchronized defibrillation

symptomatic bradycardiasymptomatic bradycardia

atropine 0.5mg I V (max 3mg)atropine 0.5mg I V (max 3mg)

Isoproterenol eliminatedIsoproterenol eliminated TachycardiaTachycardia

summarized in a single algorithmsummarized in a single algorithm

branch points then become narrow versus widebranch points then become narrow versus widecomplex, and regular versus irregular rhythmscomplex, and regular versus irregular rhythms

polymorphic VT should be treated as VF withpolymorphic VT should be treated as VF withhighhigh--energy unsynchronized defibrillationenergy unsynchronized defibrillation



Post Post--resuscitation Stabilizationresuscitation StabilizationPost Post--resuscitation Stabilizationresuscitation Stabilization

Vasoactive support Vasoactive support

Hypothermia

Hypothermia cooled to 32cooled to 32ooCC--3434ooC for 12C for 12--24 hours when the24 hours when the

initial rhythm was VF (Class IIa).initial rhythm was VF (Class IIa).

may be beneficial for patients with nonmay be beneficial for patients with non--VF VF

arrests inarrests in-- or out or out--of of--hospital (Class IIb).hospital (Class IIb).

Glycemic controlGlycemic control

Vasoactive support Vasoactive support

Hypothermia

Hypothermia cooled to 32cooled to 32ooCC--3434ooC for 12C for 12--24 hours when the24 hours when the

initial rhythm was VF (Class IIa).initial rhythm was VF (Class IIa).

may be beneficial for patients with nonmay be beneficial for patients with non--VF VF

arrests inarrests in-- or out or out--of of--hospital (Class IIb).hospital (Class IIb).

Glycemic controlGlycemic control



SUMM AR Y SUMM AR Y of of

AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINESSUMM AR Y SUMM AR Y of of

AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINES

Push hard and push fast with Push hard and push fast withadequate recoil and minimaladequate recoil and minimal

interruptionsinterruptions

Push hard and push fast with Push hard and push fast withadequate recoil and minimaladequate recoil and minimal

interruptionsinterruptions



SUMM AR Y SUMM AR Y of of

AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINESSUMM AR Y SUMM AR Y of of

AH A ECC 2005 GUIDELINES AH A ECC 2005 GUIDELINES

Eff ective ACLS begins with highEff ective ACLS begins with high--quality quality BLS...particularly highBLS...particularly high--quality CPR! quality CPR!

The potential eff ects of any drugs or ACLS The potential eff ects of any drugs or ACLS therapy on outcome from VF SCA arr esttherapy on outcome from VF SCA arr est ar e dwarf ed by the pot ential eff ects of ar e dwarf ed by the pot ential eff ects of hi ghhi gh--qualit y CPR.qualit y CPR.

Eff ecti ve ACLS begins with hi ghEff ecti ve ACLS begins with hi gh--qualit y qualit y BLS...particularl y hi ghBLS...particularl y hi gh--qualit y CPR! qualit y CPR!

T he pot ential eff ects of an y drugs or ACLS T he pot ential eff ects of an y drugs or ACLS therapy on outcome from VF SCA arr est therapy on outcome from VF SCA arr est ar e dwarf ed by the pot ential eff ects of ar e dwarf ed by the pot ential eff ects of hi ghhi gh--qualit y CPR.qualit y CPR.

case management of acls handouts - power point 879

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