cpr 2000

CPR 2000Dr. THANAPONG HONGPROMYATI

Adult Cardiac Arrest

BLS algorithmif appropriate

Precordial thumb if appropriate

Attach defibrillator/monitor

Assess rhythm

Figure 1. ILCOR Universal/International ACLS Algorithm.

1

2

Assess rhythm

Check pulse+/-

During CPR• Check electrode/paddle position and contact• Attempt to place, confirm, secure airway• Attempt and verify IV access• Patients with VF/VT refractory to initial shocks: - Epinephrine 1 mg IV, every 3-5 min or - Vasopressin 40 U IV, single dose, 1 time only• Patients with non-VF/VT rhythm: - Epinephrine 1 mg IV, every 3-5 min• Consider: buffers, antiarrhythmics, pacing• Search for and correct reversible cause

VF/VT Non-VF/VT

CPR up to3 minCPR for

1 min

Attemptdefibrillation

*3 as necessary


5,6

43

3

Consider causes that are potentially reversible

•“Tablet” (drug OD,accidents)• Temponade, cardiac• Tension pneumothorax• Thrombosis, coronary (ACS)• Thrombosis, pulmonary (embolism)

• Hypovolemia• Hypoxia• Hydrogen ion-acidosis• Hyper-/Hypokalemia• Hypothermia


7

• Person collapses• Possible cardiac arrest• Assess responsiveness

Begin Primary ABCD Survey(Begin BLS Algorithm)

• Activate emergency response system• Call for defibrillator• A Assess breathing (open airway, look, listen, and feel)

Unresponsive

No Breathing• B Give 2 slow breaths• C Assess pulse, if no pulse• C Start chest compressions• D Attach monitor/defibrillator when available

No pulseFigure 2. Comprehensive ECC Algorithm.

1

1

• CPR continues• Assess rhythm

Secondary ABCD Survey• Airway: attempt to place airway device• Breathing: confirm and secure airway device, ventilation, oxygenation• Circulation: gain intravenous access; give adrenergic agent; consider antiarrhythmics, buffer agents, pacingNon-VF/VT patients:- Epinephrine 1 mg IV, repeat every 3-5 minVF/VT patients:- Vasopressin 40 U IV, single dose, 1 time onlyor- Epinephrine 1 mg IV, repeat every 3-5 min• Differential Diagnosis: search for and treat reversible cause

Attempt defibrillation(Up to 3 shock if VF persists)

Non-VF/VT(asystole or PEA)

CPR for1 min

CPR up to3 min

Figure 2. Comprehensive ECC Algorithm.

2 3

4,5

No pulse

Primary ABCD SurveyFocus: basic CPR and defibrillation

• Check responsiveness• Activate emergency response system

• Call for defibrillator A Airway:open the airway

B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions

D Defibrillation: assess for and shock VF/pulesless VT, up to 3 times (200J,200-300J,360J, or equivalent biphasic) if necessary

Rhythm after first 3 shocks?

Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.

1

Secondary ABCD SurveyFocus: more advanced assessments and treatments

A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.C Circulation:• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.D Differential Diagnosis: Search for and treat identified reversible causes.

Persistent or recurrent VF/VT


2

Epinephrine 1 mg IV push, repeat every 3 to 5 minutesor

Vasopressin 40 U IV, single dose, 1 time only

Resume attempts to defibrillate1*360J (or equivalent biphasic) within 30 to 60 sec.

Consider antiarrhythmics:amiodarone (IIb), lidocaine (Indeterminate),magnesium (IIb if hypomagnesemic state),

procainamide (IIb for intermittent/recurrent VF/VT).Consider buffers.

3

4

Resume attempts to defibrillate 5


Antiarrhythmics & Buffer• Amiodarone 300(class IIb) mg IV push (cardiac arres

VVVVVVVVVVVV VV VVVVVVV VVVVVVVV VVV VVVVVVVVVVV V) / , 1 5 0 . 2 .f a second dose of mg IV Max cumulative dose

2 2 4 .g over hr• Lidocaine - (class Indeterminate) 1 .0 1 .5 mg/kg IV p

VV V VV V V VV VV V V VV VVV VVVVVVV V. 3 5 3ose of mg/kg.

• Magnesium sulfate 1 2to g IV in polymorphic VT (tor sades de pointes) and suspected hypomagnesemic state.

• Procainamide 30mg/min in refractory VF (Max total d VV VVVVVVVVVV VVV VVV VVVVV V VVVVV: 1 7 /)

• Sodium bicarbonate 1mEq/kg IV is indicated for seve ral conditions known to provoke sudden cardiac arrest.

PULSELESS ELECTRICAL ACTIVITY(PEA = Rhythm on monitor, without detectable pules)



• Call for defibrillator A Airway:open the airway

B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulesless VT

Figure 4. Pulseless Electrical Activity Algorithm.


A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.

C Circulation:• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.• -Assess for occult blood flow (“pseudo EMT”)D Differential Diagnosis: Search for and treat identified reversible causes.

Figure 4. Pulseless Electrical Activity Algorithm. - EMD=electro mechanical dissociation

Review for most frequent causes

• Hypovolemia• Hypoxia• Hydrogen ion-acidosis• Hyper-/Hypokalemia• Hypothermia

• “Tablet” (drug OD,accidents)• Temponade, cardiac• Tension pneumothorax• Thrombosis, coronary (ACS)• Thrombosis, pulmonary (embolism)

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

Atropine 1 mg IV (if PEA rate is slow),repeat every 3-5 minutes as need, to a total dose of 0.04 mg/kg

Figure 4. Pulseless Electrical Activity Algorithm.

2

3

1

Asystole



• Call for defibrillatorA Airway:open the airway

B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions Confirm true asystoleD Defibrillation: assess for VF/pulesless VT; shock if indicateRapid scene survey: any evidence personnel should not attempt resuscitation?

Figure 5. Asystole: The Silent Heart Algorithm.

1


A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.C Circulation:• Confirm true asystole• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.D Differential Diagnosis: Search for and treat identified reversible causes.


2,3

Transcutaneous pacingIf considered, perform immediately

4

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

5

Atropine 1 mg IV,repeat every 3 to 5 minutesup to a total of 0.04 mg/kg

6

Asystole persistsWithhold or cease resuscitation efforts?• Consider quality of resuscitation?• Atypical clinical features present?• Support for cease-efforts protocols in place?

7,8,9


• Confirm true asystole- Check lead and cable connection- Monitor power on?- Monitor gain up ?- Verify asystole in another lead

• Review the quality of the resuscitation attempt- Was there an adequate trial of BLS? of ACLS? Has the team done the following:- Achieved tracheal intubation?- Performed effective ventilation?- Shocked VF if present?- Obtained IV access?- Given epinephrine IV? Atropine IV?- Ruled out or corrected reversible causes?- Continuously documented asystole >5 to 10 min after all of the above have been accomplished?

• Reviewed for atypical clinical features?- Not a victim of drowning or hypothermia?- No reversible therapeutic or illicit drug overdose?

8

7

2

Bradycardia• Slow (absolute bradycardia = rate<60bpm• Relatively slow (rate less than expected relative to underlying condition or cause)Primary ABCD Survey

• Assess ABCs• Secure airway noninvasively• Ensure monitor/defibrillator is available

Secondary ABCD Survey• Assess secondary ABCs (invasive airway management needed?)• Oxygen-IV access-monitor-fluids• Vital sign, pulse oximeter, monitor BP• Obtain and review 12 lead ECG• obtain and review portable Chest x-ray• Problem-focused history• Problem-focused physical examination• Consider cause (differential diagnoses)

Figure 6. Bradycardia Algorithm.

Serious sign or symptom?Due to the bradycardia?

Type II second-degree AV blockor

Third-degree AV block?

Intervention sequence• Atropine 0.5-1.0 mg• Transcutaneous pacing if available• Dopamine 5-20 ug/kg per min• Epinephrine 2-10 ug/min

Observe

• Prepare for transvenous pacer• If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

Figure 6. Bradycardia Algorithm.

1,2

3,4,56

7

No Yes

No Yes

• If the patient has serious sign or symptoms, make sure th ey are related to the slow rate.

• Cl i ni cal mani f est at i ons i ncl ude- Symptoms(chestpain, shortnessof br eat h, decr ease l evel of consci ousness)- Signs (low blood pressure, shock, pulmonary congestion , CHF)

• If the patient is symptomatic, do not delay transcutaneou s pacing while awaiting IV access or for atropine to take e

ff ect• Denervatedtransplantedheartswillnot r esponse t o at r opi ne. Go at once paci ng, cat ech

olamineinfusion, or bot h.• - Nevertreatt he combi nat i on of t hi r d degr ee hear t bl ock and ven

tricular escape beats with lidocaine (or any agent that su ppresses ventricular escape rhythms)

1

2

3

4

6

Evaluate patient• Is patient stable or unstable?• Are there serious signs or symptoms?• Are signs and symptoms due to tachycardia?

Unstable patient: serious signs or symptoms• Establish rapid heart rate as cause of signs and symptoms• Rate related signs and symptoms occur at many rates, seldom < 150 bpm

• Prepare for immediate cardioversion (see algorithm)

Stable patient: no serious signs and symptoms• Initial assessment identified 1 of 4 type of tachycardia• Atrial fibrillation/flutter• Narrow-complex tachycardia• Stable wide-complex tachycardia: unknown type• Stable monomorphic VT and/or polymorphic VT

Figure 7. The Tachycardia Overview Algorithm.

Stable Unstable

1. Atrial fibrillation Atrial flutter

Evaluation focus, 4 clinical features:1. Patient clinical unstable?2. Cardiac function impaired?3. WPW present?4. Duration<48 or >48 hours?

Treatment focus: clinical evaluation1. Treat unstable patient urgently2. Control the rate3. Convert the rhythm4. Provide anticoagulationTreatment of atrial

fibrillation/atrial flutter(See following table)


2. Narrow-complex tachycardia

Attempt to establish a specific diagnosis• 12 lead ECG• Clinical information• Vagal maneuvers• Adenosine

Diagnosis effort yield• Ectopic atrial tachycardia• Multifocal atrial tachycardia• Paroxysmal supraventricular tachycardia

Treatment of SVT(see narrow-complex

tachycardia algorithm)Figure 7. The Tachycardia Overview Algorithm.

3. Stable wide-complex tachycardia: unknown type

4. Stable monomorphic VT and/or polymorphic VT

Attempt to establish a specific diagnosis• 12-lead ECG• Esophageal lead• Clinical information

Treatment of SVT

(see narrow- complex

tachycardia algorithm)

Wide-complex tachycardia of unknown type

ConfirmedSVT

Confirmedstable VT

Dc cardioversionor

Procainamideor

Amiodarone

Dc cardioversionor

Amiodarone

Ejection fraction< 40% Clinical CHF

Preservedcardiac function


Treatment of stable

monomorphic and

polymorphic VT (see stable VT: monomorphic

and polymorphic algorithm)

Duration<48Hrs Duration>48Hrs or UnknownConsider• DC cardioversionUse only 1 of the Class IIa following agents (see note below):• Amiodarone• Ibutilide• Flecainide• Propafenone• Procainamide• For additional drugs that are Class IIb recommendation, see Guidelines or ACLS text

• NO DC cardioversion!• Note: Conversion of AF to NSR with drugs or shock may cause embolization of atrial thrombi unless patient has adequate anticoagulation.• Use antiarrhythmic agents with extreme caution if AF>48 hours’ duration (see note below). or

Note:If AF>48hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anti coagulation because of possible embolic complications. Use only 1 of the following agents:

• Digoxin (ClassIIb)• Diltiazem (ClassIIb)

• Amiodarone(ClassIIb)

1. Control Rate2. Control Rhythm

AF/flutter with• Normal heart• Impair heart• WPW

Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.Use only 1 of the following agents (see note below):• Calcium channel blockers (ClassI)• B-Blockers (ClassI)• For additional drugs that are ClassIIb recommendations, see Guideline or ACLS text

Consider• DC cardioversion or• Amiodarone (ClassIIb)

Delayed cardioversion Anticoagulation * 3 weeks at proper levels• Cardioversion, then• Anticoagulation * 4 weeks more or Early cardioversion• Begin IV heparin at once• TEE to exclude atrial clot. then• Cardioversion within 24 h. then• Anticoagulation * 4 more weeks• Anticoagulation as described above, following by• DC cardioversion

Normal cardiac function

Impaired heart (EF<40% or CHF)

Control of Rate and Rhythm (Continued From Tachycardia Overview)

Duration<48Hrs Duration>48Hrs or Unknown

Consider• DC cardioversion or• Primary antiarrhythmic agents Use only 1 of the following agents (see note below**):

1. Control Rate 2. Control RhythmAF/flutter with• Normal heart• Impair heart• WPW

Heart FunctionPreserved

Impaired HeartEF<40% or CHF

WPWNote: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.• DC cardioversion or• Primary antiarrhythmic agents Use only 1 of the following agents (see note below):

Class III (can be harmful)• Adenosine• B-Blockers• Calcium blockers• Digoxin

Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.• DC cardioversion or• Amiodarone (ClassIIb)

•Amiodarone (ClassIIb)• Flecainide (ClassIIb)• Procainamide (ClassIIb)• Propafenone (ClassIIb)• Sotalol (ClassIIb)

•Amiodarone (ClassIIb)• Flecainide (ClassIIb)• Procainamide (ClassIIb)• Propafenone (ClassIIb)• Sotalol (ClassIIb)

Class III (can be harmful)• Adenosine• B-Blockers• Calcium blockers• Digoxin

• Anticoagulation as described above, following by• DC cardioversion

Control of Rate and Rhythm (Continued From Tachycardia Overview)

Priority order:• Ca2+ Channel blocker• B-Blocker• Digoxin• DC cardioversion• Consider procainamide, amiodarone, sotalolPriority order:

• No DC cardioversion• Amiodarone• Diltiazem

• No DC cardioversion• Amiodarone

• No DC Cardioversion• Amiodarone• B-Blocker• Ca2+ channel blocker

• No DC cardioversion• Ca2+ channel blocker• B-Blocker• Amiodarone• No DC cardioversion• Amiodarone• Diltiazem

Preserved

Preserved

Preserved

EF<40%, CHF

EF<40%, CHF

EF<40%, CHF

Junctional tachycardia

Paroxysmal supraventricular tachycardia

Ectopic or multifocal atrial tachycardia

Attempt therapeutic diagnosis maneuver• Vagal stimulation• Adenosine

Narrow-Complex SupraventricularTachycardia, Stable

Figure 8. Narrow-Complex Supraventicular Tachycardia Algorithm.

Stable Ventricular TachycardiaMonomorphic or Polymorphic?

Monomorphic VT• Is cardiac function impaired?

Polymorphic VT• Is QT baseline interval prolonged?

Medications: any one• Procainamide• SotalolOther acceptable• Amiodarone• Lidocaine

Normal baseline QT interval• Treat ischemia• Correct electrolytes

Medications: any one• - B Blocker or• Lidocaine or• Amiodarone or• Procainamide or• Sotalol

Long baseline QT interval• Correct abnormal electrolytes

Medications: any one• Magnesium• Overdrive pacing• Isoproterenol• Phenytoin• Lidocaine

Amiodarone• 150 mg IV bolus over 10 min. or

Lidocaine• 0.5 to 0.75 mg/kg IV push. Then

use• Synchronized cardioversion

Normal function Poor ejection fraction Normal baselineQT interval

Prolong baseline QT interval

(suggests torsades)

Note!May go directly to

cardioversion

Figure 9. Stable Ventricular Tachycardia (Monomorphic or Polymorphic) Algorithm.

Tachycardiawith serious signs and symptoms related to the tachycardia

150If ventricular rate is > bpm, prepare for immediate VVV VVVV VVVVV VVVVV VV VVVVVVVVVVV VVVVV VV.

VVVVVVVVVVVV VVVVVVVVV VVVVVVVVVVVVV VV VVVVVVVVV VVV. need if heart rate is <= 150 bpm.

Have available at bedside•oxygen saturation monitor•IV line•Intubation equipment

VVVVVVVVVVV VVVVVVVV VVVVVVVV

Synchronized cardioversion•ventricular tachycardia•Paroxysmal supraventriculartachycardia•Atrial fibrillation•Atrial flutter

100200 300 , 360J J monophasic energy dose

VVVVVVVV VVVVVVVVVV ( biphasic energy dose)

Figure 10. Synchronized Cardioversion Algorithm.

cpr 2000

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