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Advanced cardiac life support at emergency department

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Sarah Ajose

Introduction:Advanced cardiac life support(ACLS) or advanced cardiovascular life support refers to a set of clinical interventions for urgent treatment of cardiac arrest and other life- threadening medical emergencies,as well as the knowledge and skills to deploy those interventions. American heart association ( AHA) protocols are considered to be gold standard ACLS protocols, and it gets reviewed every 5 years. ACLS is build heavily upon the foundation of BLS ( Basic life support ). Definition:Advanced cardiac life support, advanced cardiovascular life support refers to a set of clinical guidelines for the urgent and emergent treatment of life- threating cardiovascular conditions that will cause or have caused cardiac medicatios, and techniques. AHA adult chain of survival:Immediate recognition of cardiac arrest and condition of the emergency response system. Early CPR with emphasis on chest compressions. Rapid defibrillation. Effective advanced life support. Integrated post- cardiac arrest care. Components of high quality CPR in BLS:SCENE SAFETY Make sure the environment is safe for rescuers and victim. RECOGNITION OF CARDIAC ARREST Check for responsiveness No breathing or only gasping ( no normal breathing ) No definitive pulse left with in 10 secs ( cartoid or femoral pulse ) Breathing and pulse check can be performed with in 10 secs Activation of emergency activation system: If done with no mobile phone, leave the victim to activate the emergency response system and get the AED before beginning CPR. Otherwise, send someone and begin CPR immediately, use the AED as soon as it is available. Chest compression 30 : 2 Compression rate 100 - 120 / min Compression depth -- at least 5 cm or 2 inches Hand placement - 2 hands on the half of the sternum Chest recoil- allow full chest recoil Minimize interruptions - < 30 secs ( Early defibrillation and early CPR for treatable arrhythmias remains the corner stone of ACLS) CPR quality: Push hard ( at least 2 inches (5 cm) and fast (100- 120/min) and allow complete chest recoil. Minimize interruptions in compressions. Avoid excessive ventilation. Change compressor every 2 minutes, or sooner if fatigued. If no advanced airway, 30:2 compression : ventilation ratio. Quantitative waveform capnography. If PETCO2 is low of decreasing reassess CPR quality Defibrillation:Biphasic:- Manufacturer recommendations (eg: initial dose of ( 20 -200 j); if unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered. Mono phasic: 360 j DRUG THERAPY: Epinephrine IV/IO Dose: 1mg every 3-5 minutes Amiodarone IV/IO Dosew : First dose 300mg bolus, second dose 150 mg. Lidocaine IV/IO dose : First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg. Advanced airway: Endotracheal intubation or supraglottic advanced airway Waveform capnography or capnometry to confirm and monitor ET tube/ Placement. Once advanced airway in place, give 1 breath every 6 seconds ( 10 breaths

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ADVANCED CARDIAC LIFE SUPPORT SUBMITTED BY SATHESHWARI N II YR MSC N
INTRODUCTION Advanced cardiac life support(ACLS) or advanced cardiovascular life support refers to a set of clinical interventions for urget treatment of cardiac arrest and other life- threadening medical emergencies,as well as the knowledge and skills to deploy those interventions. American heart association ( AHA) protocols are considered to be gold standard ACLS protocols, and it gets reviewed every 5 years. ACLS is build heavily upon the foundation of BLS ( Basic life support ).
DEFINITION Advanced cardiac life support, advanced cardiovascular life support refers to a set of clinical guidelines for the urgent and emergent treatment of life- threating cardiovascular conditions that will cause or have caused cardiac medicatios, and techniques.
AHAADULT CHAIN OF SURVIVAL Immediate recognition of cardiac arrest and condition of the emergency response system. Early CPR with emphasis on chest compressions. Rapid defibrillation. Effective advanced life support. Integrated post- cardiac arrest care.
COMPONENTS OF HIGH QUALITY CPR IN BLS SCENE SAFETY Make sure the environment is safe for recuers and victim. RECOGNITION OF CARDIAC ARREST Check for responsiveness No breathing or only gasping ( no normal breathing ) No definitive pulse left with in 10 secs ( cartoid or femoral pulse ) Breathing and pulse check can be performed with in 10 secs
ACTIVATION OF EMERGENCY RESPONSE SYSTEM If done with no mobile phone, leave the victim to activate the emergency response system and get the AED befre beginning CPR. Otherwise, send someone and begin CPR immediately, use the AED as soon as it is available. 1. Chest compression 30 : 2 2. Compression rate 100 - 120 / min 3. Compression depth -- at least 5 cm or 2 inches 4. Hand placement - 2 hands on the half of the sternum 5. Chest recoil- allow full chest recoil 6. Minimize interuptions - < 30 secs ( Early defibrillation and early CPR for treatable arrhythmias remains the corner stone of ACLS)
ACLS ALGORITHM
IN HOSPITAL CARDIAC ARREST (IHCA)
OUT HOSPITAL CARDIAC ARREST (OHCA)
Advanced cardiac life support at emergency department
CPR QUALITY Push hard ( at least 2 inches (5 cm) and fast (100- 120/min) and allow complete chest recoil. Minimize interuptions in compressions. Avoid excessive ventilation. Change compresser every 2 minutes, or sooner if fatiqued. If no advanced airway, 30:2 compression : ventilation ratio. Quantitative waveform capnography. If PETCO2 is low oe decreasing reassess CPR quality
ADVANCED SHOCK ENERGY FOR DEFIBRILLATION Biphasic:- Manufacturer recommendations (eg: initial dose of ( 20 -200 j); if unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered. Mono phasic: 360 j DRUG THERAPY: a) Epinephrine IV/IO Dose: 1mg every 3-5 minutes b) Amiodarone IV/IO Dosew : First dose 300mg bolus, second dose 150 mg. c) Lidocaine IV/IO dose : First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg.
ADVANCED AIRWAY Endotrachial intubation or supraglottic advanced airway Waveform capnography or capnometry to confirm and monitor ET tube/ Placement. Once advanced airway in place, give 1 breath every 6 seconds ( 10 breaths/ min) with continous chest compressions.
RETURN OF SPONTANEOUS CIRCULATION (ROSC) Pulse and blood pressure Abrupt sustained increase in PETCO2 ( typically 40 mm Hg) Spontaneous arterial pressure wave with intra arterial pressure
REVERSIBLE CAUSES 5 H Hypovolemia Hypoxia Hydrogen ion ( acidosis) Hypo, Hyperkaelemia Hypothermia 5 T Tension pneumothorax Tanponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary
KEY PRINCIPLES OF HIGH QUALITY CPR(ACLS) Intervensions that cannot be performed while CPR is in progress (eg.defibrillator). sufficient chest compressions 5 cm depth 100-200 beats per min compression rate and allow complete chest recoil. Single biphasic defibrillation - VF/ PVT (pulseless) Withoutadvanced airway 30: 2 compression Ventilation- 6 to 8 breaths / minute in intubated patients (one full breath over 1-2 seconds) to prevent hyperventilation. Do not stop compression until defibrillation fully charged. Rapidly identify the cause of non- shockable arrest (PEA, Asystole).
CONTD... Irreversible causes 5 ts, 5 hs are to be corrected rapidly. Definitive airway management may be delayed if there is adequate recue breahing without an advanced airway in place. A blindly inserted supraglottic airway (eg. laryngeal mask airway, combitube laryngeal tube, can be placed without interupting chest compressions. Provide adequate ventilation in modt casese and reduce the risk of aspiration as compared to bag- m,ask ventilation. Attempets at intubation should last no longer than 10 seconds.
MANAGEMENT OF ARRHYTHMIAS VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA 1. Early defibrillation is the most critical action in the resuscitaion effort, followed by the performance of excellent CPR. 2. Manage potentially treatable underlying causes as appropriate. 3. Decreased time in defibrillation improves the likelihood of successful conversion to a perfusing rhythm and patient survival. Biphasic- 100-120 J- ventricular fibrillation Monophasic 360 J - pulseless ventricular tachycardia
1. Epinephrine 1mg IV every 3 - 5 min (while CPR) 2. Vasopressin (40 units/ IV) first and second close of epinephrine. 3. Amiodarone ( 300mg IV with a repeat dose of 150 mg IV as indicated) 4. lodocaine ( 1- 1.5mg/kg/ IV then 0.5 - 0.75 mg/kg every 5 to 10 minutes. 5. Magnesiumsulphate 2g IV followed by a manintaience infusion
ASYSTOLE/ PEA Complete absence of demonstrable electrical and mechanical cardiac activity is asystole. PEA - pulseless electrical activity is defined as any one of a heterogenous group of organised electrocardiographic rhythms without sufficient mechanical conraction of the heart to produce a palpable pulse or measurable blood pressure. Treat irreversible caueses. Atropine is no longer recommended.
BRADYCARDIA Assess appropriateness for clinical condition. HR typically < 50 min in brady arrhythmia Identify and treat underlying cause. 1. Maintain patent airway, assist breathing as necessary 2. Oxygen (if hypoxaemia) 3. Cardiac monitor ti idebtify rhythm, Monitor blood pressure and oximetry 4. IV access 5. 12 lead ECG if available, dont delay therapy 6. consider possible hypoxia and toxicologic causes 7. Persistent bradyarrhythmia causing ( hypotension, acutely altered mental status)
No signs of shock No Ischemic chest discomfort Acute heart failure Atropine if atropine ineffective Transcutaneous pacing and /or Dopamine infusion or epinephrine infusion Consider Expert consultation Transvenous pacing M o n i t o r & o b s e r v e
DRUG DOSES Atropine IV infusion First dose: 1 mg bolus Repeat every 3-5 minutes Maximum 3 mg Dopamine IV dose Uusual infusion rate is 5- 20 mcg/ kg per minute. titrate to patient response slowly. Epinephrine 2- 10 mcg per minute infusion Titrate to patient response Causes- MI, drugs toxicity ( CCB, BB, digoxin), hypoxia, electrolyte abnormality.
TACHYCARDIA Assess appropriateness for clinical condition HR typically 150 / min if tachy arrhythmias. DRUG DOSES Adenosin IV doses 1st dose 6mg rapid IV push- follow with NS flush 2 nd dose 12 mg if required Antiarrhythmic infusions for stsble wide QR tachycardia Procainamide IV dose 20-50 mg/min until arrhythmia suppressed. Amiodarone 1st dose 150 mg over 10 minutes, repeat as needed. Sotalol IV dose 100 mg ( 1.5mg/kg) over 5 minutes.
POST CARDIAC ARREST CARE
TERMINATION OF RESUSCITATION Factors influencing the decision to stop resuscitative efforts include:- 1. Duration of resusitative effort > 30 min without sustained perfusing rhythm. 2. Initial electrocardiographic rhythm of asystole. 3. Prolonged interval between estimated time of arrest and initiation of resuscitation. 4. Patient age and severity of comorbid disease. 5. Absence of brain steam reflexes 6. Normothermic. 7. EFCO2 < 10 mmhg even after > 20 minutes of resuscitation.
Advanced cardiac life support at emergency department

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Advanced cardiac life support at emergency department

  • 1. ADVANCED CARDIAC LIFE SUPPORT SUBMITTED BY SATHESHWARI N II YR MSC N
  • 2. INTRODUCTION Advanced cardiac life support(ACLS) or advanced cardiovascular life support refers to a set of clinical interventions for urget treatment of cardiac arrest and other life- threadening medical emergencies,as well as the knowledge and skills to deploy those interventions. American heart association ( AHA) protocols are considered to be gold standard ACLS protocols, and it gets reviewed every 5 years. ACLS is build heavily upon the foundation of BLS ( Basic life support ).
  • 3. DEFINITION Advanced cardiac life support, advanced cardiovascular life support refers to a set of clinical guidelines for the urgent and emergent treatment of life- threating cardiovascular conditions that will cause or have caused cardiac medicatios, and techniques.
  • 4. AHAADULT CHAIN OF SURVIVAL Immediate recognition of cardiac arrest and condition of the emergency response system. Early CPR with emphasis on chest compressions. Rapid defibrillation. Effective advanced life support. Integrated post- cardiac arrest care.
  • 5. COMPONENTS OF HIGH QUALITY CPR IN BLS SCENE SAFETY Make sure the environment is safe for recuers and victim. RECOGNITION OF CARDIAC ARREST Check for responsiveness No breathing or only gasping ( no normal breathing ) No definitive pulse left with in 10 secs ( cartoid or femoral pulse ) Breathing and pulse check can be performed with in 10 secs
  • 6. ACTIVATION OF EMERGENCY RESPONSE SYSTEM If done with no mobile phone, leave the victim to activate the emergency response system and get the AED befre beginning CPR. Otherwise, send someone and begin CPR immediately, use the AED as soon as it is available. 1. Chest compression 30 : 2 2. Compression rate 100 - 120 / min 3. Compression depth -- at least 5 cm or 2 inches 4. Hand placement - 2 hands on the half of the sternum 5. Chest recoil- allow full chest recoil 6. Minimize interuptions - < 30 secs ( Early defibrillation and early CPR for treatable arrhythmias remains the corner stone of ACLS)
  • 8. IN HOSPITAL CARDIAC ARREST (IHCA)
  • 9. OUT HOSPITAL CARDIAC ARREST (OHCA)
  • 11. CPR QUALITY Push hard ( at least 2 inches (5 cm) and fast (100- 120/min) and allow complete chest recoil. Minimize interuptions in compressions. Avoid excessive ventilation. Change compresser every 2 minutes, or sooner if fatiqued. If no advanced airway, 30:2 compression : ventilation ratio. Quantitative waveform capnography. If PETCO2 is low oe decreasing reassess CPR quality
  • 12. ADVANCED SHOCK ENERGY FOR DEFIBRILLATION Biphasic:- Manufacturer recommendations (eg: initial dose of ( 20 -200 j); if unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered. Mono phasic: 360 j DRUG THERAPY: a) Epinephrine IV/IO Dose: 1mg every 3-5 minutes b) Amiodarone IV/IO Dosew : First dose 300mg bolus, second dose 150 mg. c) Lidocaine IV/IO dose : First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg.
  • 13. ADVANCED AIRWAY Endotrachial intubation or supraglottic advanced airway Waveform capnography or capnometry to confirm and monitor ET tube/ Placement. Once advanced airway in place, give 1 breath every 6 seconds ( 10 breaths/ min) with continous chest compressions.
  • 14. RETURN OF SPONTANEOUS CIRCULATION (ROSC) Pulse and blood pressure Abrupt sustained increase in PETCO2 ( typically 40 mm Hg) Spontaneous arterial pressure wave with intra arterial pressure
  • 15. REVERSIBLE CAUSES 5 H Hypovolemia Hypoxia Hydrogen ion ( acidosis) Hypo, Hyperkaelemia Hypothermia 5 T Tension pneumothorax Tanponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary
  • 16. KEY PRINCIPLES OF HIGH QUALITY CPR(ACLS) Intervensions that cannot be performed while CPR is in progress (eg.defibrillator). sufficient chest compressions 5 cm depth 100-200 beats per min compression rate and allow complete chest recoil. Single biphasic defibrillation - VF/ PVT (pulseless) Withoutadvanced airway 30: 2 compression Ventilation- 6 to 8 breaths / minute in intubated patients (one full breath over 1-2 seconds) to prevent hyperventilation. Do not stop compression until defibrillation fully charged. Rapidly identify the cause of non- shockable arrest (PEA, Asystole).
  • 17. CONTD... Irreversible causes 5 ts, 5 hs are to be corrected rapidly. Definitive airway management may be delayed if there is adequate recue breahing without an advanced airway in place. A blindly inserted supraglottic airway (eg. laryngeal mask airway, combitube laryngeal tube, can be placed without interupting chest compressions. Provide adequate ventilation in modt casese and reduce the risk of aspiration as compared to bag- m,ask ventilation. Attempets at intubation should last no longer than 10 seconds.
  • 18. MANAGEMENT OF ARRHYTHMIAS VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA 1. Early defibrillation is the most critical action in the resuscitaion effort, followed by the performance of excellent CPR. 2. Manage potentially treatable underlying causes as appropriate. 3. Decreased time in defibrillation improves the likelihood of successful conversion to a perfusing rhythm and patient survival. Biphasic- 100-120 J- ventricular fibrillation Monophasic 360 J - pulseless ventricular tachycardia
  • 19. 1. Epinephrine 1mg IV every 3 - 5 min (while CPR) 2. Vasopressin (40 units/ IV) first and second close of epinephrine. 3. Amiodarone ( 300mg IV with a repeat dose of 150 mg IV as indicated) 4. lodocaine ( 1- 1.5mg/kg/ IV then 0.5 - 0.75 mg/kg every 5 to 10 minutes. 5. Magnesiumsulphate 2g IV followed by a manintaience infusion
  • 20. ASYSTOLE/ PEA Complete absence of demonstrable electrical and mechanical cardiac activity is asystole. PEA - pulseless electrical activity is defined as any one of a heterogenous group of organised electrocardiographic rhythms without sufficient mechanical conraction of the heart to produce a palpable pulse or measurable blood pressure. Treat irreversible caueses. Atropine is no longer recommended.
  • 21. BRADYCARDIA Assess appropriateness for clinical condition. HR typically < 50 min in brady arrhythmia Identify and treat underlying cause. 1. Maintain patent airway, assist breathing as necessary 2. Oxygen (if hypoxaemia) 3. Cardiac monitor ti idebtify rhythm, Monitor blood pressure and oximetry 4. IV access 5. 12 lead ECG if available, dont delay therapy 6. consider possible hypoxia and toxicologic causes 7. Persistent bradyarrhythmia causing ( hypotension, acutely altered mental status)
  • 22. No signs of shock No Ischemic chest discomfort Acute heart failure Atropine if atropine ineffective Transcutaneous pacing and /or Dopamine infusion or epinephrine infusion Consider Expert consultation Transvenous pacing M o n i t o r & o b s e r v e
  • 23. DRUG DOSES Atropine IV infusion First dose: 1 mg bolus Repeat every 3-5 minutes Maximum 3 mg Dopamine IV dose Uusual infusion rate is 5- 20 mcg/ kg per minute. titrate to patient response slowly. Epinephrine 2- 10 mcg per minute infusion Titrate to patient response Causes- MI, drugs toxicity ( CCB, BB, digoxin), hypoxia, electrolyte abnormality.
  • 24. TACHYCARDIA Assess appropriateness for clinical condition HR typically 150 / min if tachy arrhythmias. DRUG DOSES Adenosin IV doses 1st dose 6mg rapid IV push- follow with NS flush 2 nd dose 12 mg if required Antiarrhythmic infusions for stsble wide QR tachycardia Procainamide IV dose 20-50 mg/min until arrhythmia suppressed. Amiodarone 1st dose 150 mg over 10 minutes, repeat as needed. Sotalol IV dose 100 mg ( 1.5mg/kg) over 5 minutes.
  • 26. TERMINATION OF RESUSCITATION Factors influencing the decision to stop resuscitative efforts include:- 1. Duration of resusitative effort > 30 min without sustained perfusing rhythm. 2. Initial electrocardiographic rhythm of asystole. 3. Prolonged interval between estimated time of arrest and initiation of resuscitation. 4. Patient age and severity of comorbid disease. 5. Absence of brain steam reflexes 6. Normothermic. 7. EFCO2 < 10 mmhg even after > 20 minutes of resuscitation.