195445265-Acls

Advanced Cardiovascular

Life Support (ACLS)

2010 Heart and Stroke Foundation of

Canada Guidelines for Cardiopulmonary

Resuscitation (CPR) and Emergency

Cardiovascular Care (ECC)

2010 ACLS Guidelines

Science updates to CPR and ECC

• Basic Life Support

• ACLS

• Acute Coronary Syndrome

• Electrical Therapies

• CPR Techniques and Devices

• Stroke

• Ethical Issues

• Education, Implementation, and Teams

Evidence Evaluation Process

• International consensus • Extensive review of resuscitation literature • Peer-reviewed studies • Rigorous disclosure and management of conflicts of

interest

The road to change

BLS Survey





High Quality Chest Compressions

“push hard and push fast”

Chest Compressions

To deliver effective chest compressions, you must: • Rate: at least 100/minute • Depth:

• 2 inches [5 cm] in adults and children • 1.5 inches [4 cm] infants

• Allow full chest recoil • Minimize interruptions • Avoid excessive ventilation

High-Quality Chest Compression

For adults, at least 2 inches (5 cm)

Compression Depth At Least 2 Inches

Compression -to- ventilation ratio

Questions?

Change “A-B-C” to “C-A-B”

Chest compressions

and early defibrillation.

Chest compressions

Elimination of Look, Listen, and Feel

Cricoid pressure is a technique

of applying pressure to the

victim’s cricoid cartilage to push

the trachea posteriorly and

compress the esophagus against

the cervical vertebrae. Cricoid

pressure can prevent gastric

inflation and reduce the risk of

regurgitation and aspiration

during bag mask ventilation, but

it may also impede ventilation.

Definition of Cricoid Pressure

Cricoid Pressure During Ventilation Not Recommended

Check simultaneously: 1) Responsiveness 2) Breathing

If victim unresponsive and not breathing: 1) Activate emergency response system 2) Retrieve AED if available 3) If no pulse felt within 10 seconds, begin CPR

First

Then

BLS Survey

Advanced

Cardiovascular Life

Support





Simplified Cardiac Arrest Algorithm

Monitoring to Optimize CPR

Post-Cardiac Care

Airway Management

Advanced Cardiovascular Life Support

Overview

Simplified ACLS Algorithm

Adult arrest algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

ACLS Cardiac Arrest Algorithm


Tachycardia Algorithm


Bradycardia Algorithm

Questions?

Capnography Recommendation

Capnography to confirm endotracheal tube placement.

Capnography to monitor effectiveness of resuscitation efforts.

Capnography Waveform

Pressure of end tidal CO2 (PETCO2)

Ineffective chest compressions indicated by

PEA/asystole

Medication Recommendations Symptomatic Arrhythmias

New Medication Protocols

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.

Atropine IV Dose:

First dose: 0.5 mg bolus

Repeat every 3-5 minutes

Maximum: 3 mg

OR

Dopamine IV Infusion:

2-10 mcg/kg per minute

OR

Epinephrine IV Infusion:

2-10 mcg per minute

Adenosine IV Dose: First dose: 6 mg rapid IV push; follow

with NS flush.

Second dose: 12 mg if required.

Tachycardia

Symptomatic or unstable bradycardia

Organized Post-Cardiac Care

Hemodynamic Neurologic Metabolic

Improved Survival

Effect of Hypothermia on Prognostication

Positive results from therapeutic hypothermia

Oxygen Saturation

Oxygen Saturation

Asthma

Anaphylaxis

Pregnancy

Morbid obesity

Pulmonary embolism

Electrolyte imbalance

Ingestion of toxic substances

Trauma

Accidental hypothermia

Avalanche

Drowning

Electric shock/lightning strikes

Percutaneous coronary intervention

Cardiac tamponade

Cardiac surgery

Special Resuscitation Situations

Acute Coronary

Syndromes





The primary goals of therapy for patients with ACS include the need to:

• Reduce the amount of myocardial necrosis • Prevent major adverse cardiac events • Treat acute, life-threatening complications

ACS

Systems of Care for Patients With ST-Elevation Myocardial Infarction (STEMI)

1 • Educational programs

2 • EMS protocols

3 • ED & hospital transports

STEMI Systems of Care

Triage to Capable Hospital

Cardiac Catheterization

Questions?

Electrical Therapies





Defibrillation | Cardioversion | Pacing

Electrical Therapy

Healthcare Provider AED Recommendations

AED Use in Children Includes Infants

1-shock defibrillation protocol followed by immediate CPR

One-Shock Protocol Versus Three-Shock Sequence

Defibrillation Waveforms and Energy Levels

200 J

Pediatric Defibrillation

2 J/kg

Fixed and Escalating Energy

0

50

100

150

200

250

300

350

400

Escalating Energy Levels

Joules

Electrode Placement

Anterior-lateral

Anterior-posterior

Anterior-left infrascapular

Anterior-right infrascapular

Defibrillation With Implanted Cardioverter Defibrillator

Anterior-posterior or

Anterior-lateral

Ventricular Tachycardia Supraventricular Tachycardias

• Initial biphasic energy dose of 50-100 J

• Monophasic or biphasic waveform cardioversion shocks at initial energy of 100 J

Synchronized Cardioversion

Energy Doses

The value of VF waveform analysis to guide defibrillation management during resuscitation is uncertain.

Fibrillation Waveform Analysis

CPR Techniques and

Devices





Recommended Devices

No resuscitation device other than a

defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.

The precordial thump is a CPR technique used by healthcare professionals in the initial response to a witnessed cardiac arrest when no defibrillator is immediately available.

Definition of Precordial Thump

Use of Precordial Thump Not Recommended

Stroke





Stroke Care

• Detection

• Dispatch

• Delivery

• Door

• Data

• Decision

• Drug

• Disposition

Stroke-Prepared Hospital

rtPA Guidelines

Inclusion Criteria

• Diagnosis of ischemic stroke causing measurable neurologic deficit

• Onset of symptoms <3 hours before beginning treatment

• Age ≥18 years

Exclusion Criteria

• Head trauma or prior stroke in previous 3 months

• Symptoms suggest subarachnoid hemorrhage

• Arterial puncture at noncompressible site in previous 7 days

• History of previous intracranial hemorrhage

• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)

• Evidence of active bleeding on examination

• Acute bleeding diathesis, including but not limited to

− Platelet count <100 000/mm3

− Heparin received within 48 hours, resulting in aPTT >upper limit of normal

− Current use of anticoagulant with INR >1.7 or PT >15 seconds

• Blood glucose concentration <50 mg/dL (2.7 mmol/L)

• CT demonstrates multilobar infarction (hypodensity >¹⁄³ cerebral hemisphere)

Relative Exclusion Criteria

Recent experience suggests that under some circumstances—with careful consideration and

weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative

contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative

contraindications is present:

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)

• Seizure at onset with postictal residual neurologic impairments

• Major surgery or serious trauma within previous 14 days

• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)

• Recent acute myocardial infarction (within previous 3 months)

Patients Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset

Magnitude of benefits from treatment in a stroke unit are comparable to magnitude of effects achieved with rtPA.

Stroke Unit Care

Management of Hypertension

Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke

Patients Who Are Potential Candidates for Acute Reperfusion Therapy

Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1, or

• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour;

when desired blood pressure is reached, lower to 3 mg per hour, or

• Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA.

Management of blood pressure during and after rtPA or other acute reperfusion therapy:

Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every

30 minutes for 6 hours, and then every hour for 16 hours.

If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:

• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or

• Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour every 5-15 minutes, maximum

15 mg per hour

If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Questions?

Ethical Issues





Ethical issues relating to resuscitation are complex.

Arrest not witnessed by EMS provider or first responder

No ROSC after three complete rounds of CPR and AED analyses

No AED shocks were delivered

Terminating Resuscitative Efforts in Adults with Out-of-Hospital Cardiac Arrest (OHCA)

Arrest not witnessed No bystander CPR

was provided No ROSC after

complete ALS care in the field

No shocks were delivered

“ALS termination of resuscitation” rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met:

v

Prognostic Indicators in the Adult Post-Arrest Patient Treated with Therapeutic Hypothermia

Education,

Implementation, and

Teams 2010 Heart and Stroke Foundation of




Learn and Live

Chain of Survival

Thank you.

195445265-Acls

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