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ADVANCED CARDIAC LIFE

SUPPORT(ACLS) - 2010

Speaker – Dr Omar Kamal


DNB anaesthesiology
ADVANCED CARDIAC LIFE SUPPORT
 ACLS impacts multiple key links in the chain of
survival that include interventions to prevent
cardiac arrest, treat cardiac arrest, and improve
outcomes of patients who achieve return of
spontaneous circulation (ROSC) after cardiac
arrest

 Interventions aimed at preventing cardiac arrest


include airway management, ventilation support,
and treatment of bradyarrhythmias and
tachyarrhythmias.
AHA ADULT CHAIN OF SURVIVAL
1. Immediate recognition of cardiac arrest and
activation of the emergency response system
2. Early CPR with an emphasis on chest
compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care
CARDIOPULMONARY RESUSCITATION
(CPR)

 Cardiopulmonary resuscitation (CPR) is a series


of life saving actions that improve the chance of
survival following cardiac arrest
KEY CHANGES FROM THE
2005 BLS GUIDELINES
● Immediate recognition of SCA based on assessing
unresponsiveness and absence of normal breathing
● “Look, Listen, and Feel” removed from the BLS
algorithm
● Encouraging Hands-Only (chest compression
only) CPR
● Sequence change CAB rather than ABC
● Health care providers continue effective chest
compressions/ CPR until return of spontaneous
circulation or termination of resuscitative efforts
● Increased focus on high-quality CPR

● Continued de-emphasis on pulse check for health


care providers

● A simplified adult BLS algorithm is introduced


with the revised traditional algorithm
A CHANGE FROM A-B-C TO C-A-B
CHEST COMPRESSIONS

 Chest compressions consist of forceful rhythmic


applications of pressure over the lower half of the
sternum.

 Technique ..?
MONITORING DURING CPR
Physiologic parameters
 Monitoring of PETCO2 (35 to 40 mmHg)
 Coronary perfusion pressure (CPP) (15mmHg)

 Central venous oxygen saturation (ScvO2)

 Abrupt increase in any of these parameters is a


sensitive indicator of ROSC that can be
monitored without interrupting chest
compressions
Quantitative waveform capnography
 If Petco2 <10 mm Hg, attempt to improve CPR
quality
Intra-arterial pressure
 If diastolic pressure <20 mm Hg, attempt to
improve CPR quality
 If ScvO2 is < 30%, consider trying to improve the
quality of CPR
HIGH QUALITY CPR

 Chest compressions of adequate rate 100/min


 A compression depth of at least 2 inches (5 cm)
in adults and in children, a compression depth of
at least 1.5 inches [4 cm] in infants
 Complete chest recoil after each compression,

 Minimizing interruptions in chest compressions

 Avoiding excessive ventilation

 If multiple rescuers are available, rotate the task


of compressions every 2 minutes.
AIRWAY AND VENTILATIONS
 Opening airway – Head tilt, chin lift or jaw thrust

 The untrained rescuer will provide Hands-Only


(compression-only) CPR

 The Health care provider should open the airway


and give rescue breaths with chest compressions
RESCUE BREATHS
 By mouth-to-mouth or bag-mask
 Deliver each rescue breath over 1 second

 Give a sufficient tidal volume to produce visible


chest rise
 Use a compression to ventilation ratio of 30 chest
compressions to 2 ventilations
 After advanced airway is placed, rescue breaths
given asynchronus with ventilation
 1 breath every 6 to 8 seconds (about 8 to 10
breaths per minute)
CARDIAC ARREST
 Cardiac arrest can be caused by 4 rhythms:

1. Ventricular fibrillation(VF),
2. Pulseless ventricular tachycardia (VT),
3. Pulseless electric activity (PEA), and
4. Asystole.

How to recognise cardiac arrest ..?


TREATABLE CAUSES OF CARDIAC
ARREST: THE H’S AND T’S
H’s T’s

 Hypoxia Toxins
 Hypovolemia Tamponade (cardiac)
 Hydrogen ion(acidosis) Tension pneumothorax
 Hypo-/hyperkalemia Thrombosis, pulmonary
 Hypothermia Thrombosis, coronary
DEFIBRILLATION
 Defibrillation is defined as termination of VF for
at least 5 seconds following the shock.

 Early defibrillation remains the cornerstone


therapy for ventricular fibrillation and pulseless
ventricular tachycardia
ELECTRODE PLACEMENT
4 pad positions
 anterolateral,

 anteroposterior,

 anterior-left infrascapular, and

 anterior-rightinfrascapular

 For adults, an electrode size of 8 to 12 cm is


reasonable (Class IIa, LOE B).
 Any of the 4 pad positions is reasonable for
defibrillation (Class IIa, LOE B).
 Defibrillation Sequence
● Turn the AED on.
● Follow the AED prompts.
● Resume chest compressions immediately after the
shock(minimize interruptions).

Shock Energy
 Biphasic : Manufacturer recommendation
(eg, initial dose of 120-200 J), if unknown, use
maximum available.
 Second and subsequent doses should be
equivalent, and higher doses may be considered.
 Monophasic : 360 J
1-SHOCK PROTOCOL VERSUS 3-SHOCK
SEQUENCE
 Evidence from 2 well-conducted pre/post design
studies suggested significant survival benefit
with the single shock defibrillation protocol
compared with 3-stacked-shock protocols

 If 1 shock fails to eliminate VF, the incremental


benefit of another shock is low, and resumption of
CPR is likely to confer a greater value than
another shock
DRUG THERAPY
1. Peripheral IV Drug Delivery
2. IO Drug Delivery - IO cannulation provides
access to a noncollapsible venous plexus
3. Central IV Drug Delivery - It can be used to
monitor ScvO2 and estimate CPP during CPR,
both of which are predictive of ROSC
4. Endotracheal Drug Delivery - lidocaine,
epinephrine, atropine, naloxone, and
vasopressin
 Dose : 2 to 2 ½ times the recommended IV dose
VASOPRESSORS
Drug Therapy
 Epinephrine IV/IO Dose: 1 mg every 3-5 minutes

 Vasopressin IV/IO Dose: 40 units can replace


first or second dose of epinephrine
 Amiodarone IV/IO Dose: First dose: 300 mg
bolus. Second dose: 150 mg.
KEY CHANGES FROM THE 2005 ACLS
GUIDELINES
 Continuous quantitative waveform capnography
is recommended

 Cardiac arrest algorithms are simplified and


redesigned to emphasize the importance of high
quality CPR

 Atropine is no longer recommended for routine


use in the management of pulseless electrical
activity (PEA)/asystole
 Increased emphasis on physiologic monitoring to
optimize CPR quality and detect ROSC

 Chronotropic drug infusions are recommended as


an alternative to pacing in symptomatic and
unstable bradycardia.

 Adenosine is recommended as a safe and


potentially effective therapy in the initial
management of stable undifferentiated regular
monomorphic wide-complex tachycardia
CARDIAC ARREST ASSOCIATED
WITH PREGNANCY
 The overall maternal mortality rate was
calculated at 13.95 deaths per 100 000
maternities.
 There were 8 cardiac arrests with a frequency
calculated at 0.05 per 1000 maternities, or
1:20 000.
 The frequency of cardiac arrest in pregnancy is
on the rise with previous reports estimating the
frequency to be 1:30 000 maternities

 Department of Health, Welsh Office, Scottish Office. Report on


confidential enquiries into maternal deaths in the United Kingdom 2000–
2002. London (UK): The Stationery Office; 2004.
CAUSES

B – Bleeding/ DIC
E – Embolism( pulmonary, coronary , amniotic )
A – Anesthetic complications
U – Uterine atony

C – Cardiac disease( MI/Aortic


dissection/Cardiomyopathy)
H – Hypertension ( Pre eclampsia/ Eclampsia )
O – Other reversible causes
P – Placenta praevia/ abruptio
S -- Sepsis
RECOMMENDATION FOR EMERGENCY
CAESAREAN SECTION

Recommendation
 When the gravid uterus is large enough to cause
maternal hemodynamic changes due to
aortocaval compression,
 emergency caesarean section should be
considered, regardless of fetal viability
 Several case reports of emergency cesarean section in
maternal cardiac arrest indicate a return of
spontaneous circulation or improvement in maternal
hemodynamic status only after the uterus has been
emptied.

 In a case series of 38 cases of perimortem cesarean


section, 12 of 20 women for whom maternal outcome
was recorded had return of spontaneous circulation
immediately after delivery.

McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of


successful outcomes in association with perimortem Caesarean delivery.
Br J Anaesth. 2009;103:406–409.
 Synchronised cardioversion - shock delivery that
is timed (synchronized) with the QRS complex
 Narrow regular : 50 – 100 J

 Narrow irregular : Biphasic – 120 – 200 J and


Monophasic – 200 J
 Wide regular – 100 J

 Wide irregular – defibrillation dose

 Adenosine : 6 mg rapid iv push, follow with NS


flush.. Second dose 12 mg
INITIAL OBJECTIVES OF POST– CARDIAC
ARREST CARE

 Optimize cardiopulmonary function and vital organ


perfusion.

 After out-of-hospital cardiac arrest, transport


patient to an appropriate hospital with a
comprehensive post–cardiac arrest treatment

 Transport the in-hospital post– cardiac arrest


patient to an appropriate critical-care unit

 Try to identify and treat the precipitating causes of


the arrest and prevent recurrent arrest
THANK YOU

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