Advance Cardiac Life Support

Advance Cardiac Life Support Christian Gallardo, MD

CPR Milestones • • • • • •

1966 1973 1979 1985 1992 2000

1st conference on CPR AHA Guidelines for ACLS 3rd conference 4th conference 5th conference. ILCOR Guidelines 2000 for CPR and ECC International Consensus on Science

Essentials of ACLS • CORE of ACLS Concepts – Cerebral Resuscitation is the most important goal! • Returning the patient to the prearrested level of neurological functioning • Cardio-Pulmonary-Cerebral resuscitation (CPCR) – had been proposed to replace CPR

– Focuses on Airway and Ventilation, Basic CPR, Defibrillation of Ventricular fibrillation and Drugs

Essentials of ACLS – The probability of survival declines with each passing minute of cardiopulmonary compromise – Medical conditions that lead to cardiac arrest must be identified as quickly as possible (e.g. AMI) – The chain of survival applies in all settings. – Good ACLS requires a careful thought about when to start and when to stop resuscitative efforts.

The Chain of Survival

Acute Coronary Syndrome (ACS) • 52% deaths of AMI occurs out of the hospital within the 1st hour after the onset of symptoms (chest discomfort, nausea, SOB etc)

Stroke • Number 3 killer and leading cause of severe, long term disability • EMS provider should be trained to suspect stroke, rapid dispatch of EMS and rapid delivery to a hospital capable of providing acute stroke care

Adult BLS Algorithm

Adult BLS Algorithm

Adult BLS Algorithm

•Push hard, push fast (rate of 100 compressions per minute), allow complete chest recoil between compressions (Do not bend elbows!!) •Compress in the center of the chest at the nipple line (2 fingers width above the xyphoid process) •Compress the chest approximately 11⁄2 to 2 inches, using the heel of both hands •Minimize interruptions in chest compressions

Adult BLS Algorithm

Automated External Defibrillator

Adult Basic Life Support • Recovery Position – For unresponsive adult victims who have normal breathing – Should be stable, near a true lateral position, with the head dependent and no pressure on the chest to impair breathing

ACLS Algorithm

ACLS Pulseless Arrest Algorithm

ACLS Pulseless Arrest Algorithm When using a bagmask device (ie, no advanced airway is in place), the rescuer should deliver a tidal volume sufficient to produce chest rise (approximately 6 to 7 mL/kg or 500 to 600 mL) over 1 second

ACLS Pulseless Arrest Algorithm

ACLS Pulseless Arrest Algorithm

ACLS Bradycardia Algorithm

ACLS Bradycardia Algorithm

ACLS Bradycardia Algorithm

ACLS Tachycardia Algorithm

ACLS Tachycardia Algorithm

ACLS Tachycardia Algorithm

ACLS Tachycardia Algorithm

ACLS Tachycardia Algorithm

ACLS Tachycardia Algorithm

Electrical Cardioversion

Electrical Cardioversion Algorithm

Electrical Cardioversion Algorithm Initial Energy Levels for synchronized cardioversion: • 50J: Atrial flutter and SVT • 100J: AF and Monomorphic VT • Polymorphic VT (Torsade): Synchronize is impossible, treat as VF and deliver a high energy synchronize shock (360J)

Defibrillation Injuries Gibbs et al Am J Emerg Med 3/90 arm touching side of rail hand contact with gel checking femoral pulse holding bag mask thumb in contact with breast leg touching stretcher arc from paddle to electrode hands over paddle electrode crack in paddle pt’s arm between MD’s legs discharge with paddles on head

-tingling arm x 30 min -sore arm -thrown clear of patient -shock to fingers -shock to hand -shock to leg -burn to hand and patient -shock to arms -PVC’s, muscle spasms -contusion to groin -LOC x 5 min, burns

Case Discussions & Summary

Emergency Case 1 • A 64 y/o male came in at the ER. Relative claims that patient suddenly had lost of consciousness 3 mins ago. What will you do? •Assess patient: Get Vital Signs •Administer Oxygen •Hook to Defibrillator

Emergency Case 1 • Patient has no pulse and is cyanotic. Then you check the rhythm. It revealed:

Emergency Case 2 • Patient comes in due to palpitations and chest discomfort. BP= 60/40 CR= 189 RR= 28. You administer oxygen and hooked the patient to a defibrillator. Rhythm reveled:

Emergency Case 2 • Initial Energy Levels for synchronized cardioversion: – 50J: Atrial flutter and SVT – 100J: AF and Monomorphic VT

Emergency Case 3 • Patient comes in due to palpitations and shortness of breath. Patient is unconscious. BP= 60/40 CR= 190 RR= 28. You administer oxygen and hooked the patient to a defibrillator. Rhythm reveled:

Torsade de Pointes

Emergency Case 3 Torsade de Pointes • Do synchronize cardioversion 360J (for unstable patients). • Do it for 3 to 4x. If still not converted, consider Magnesium. – How to give: 1-2 g diluted in 50 - 100 ml D5W administer over 5 to 60 minutes followed by an infusion of 0.5 – 1.0 g (4 to 8 mEq) per hour.

Emergency Case 4 • Patient comes in due to chest heaviness of about 1 week. BP= 100/60, RR= 18. Oxygen was given. ECG revealed:

Acute Coronary Syndrome Algorithms

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm

Fibrinolytic Checklist

Fibrinolytic Therapy

Acute Coronary Syndrome

Acute Coronary Syndrome

Acute Coronary Syndrome

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm

Acute Coronary Syndrome Algorithm