American Heart Association BLS/ACLS/PALS Update Janet Smith.
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Transcript of American Heart Association BLS/ACLS/PALS Update Janet Smith.
American Heart Association BLS/ACLS/PALS Update
Janet Smith
Forget everything you know
Instructor Goals
Incorporate the previous changes from 2001 & present 2005 revisionsLess number of algorithmsReview Acute Pulmonary Edema, Hypotension, & Shock combined algorithms, & Hypothermia algorithmStroke algorithm less busy & ACS not much change
February 24, 2006 - Rollout
First session BLS changesSecond session ACLS & PALS updateBegin new test – revised 2005Handbook of Emergency Cardiovascular Care – includes Guidelines CPR/ECC 2005. Nice addition cardiac markers, Treatment w/ Non-ST-segment Elevation MI
Instructor Objectives
Fit the course to your needsAdult learners need positive reinforcement & deal well with scenariosUnderstand the exam (new & improved)What is your environment
Student Objectives
Discuss new basic life support guidelines Discuss patient assessment & surveyDiscuss the use of ACLS drugsStations: Determine competencyDiscuss the ethical considerations in resuscitation
What type of course do you need?
Recertification versus full courseUtilize your study guides or “cheat sheets”Review pretest written examProvide scenarios
ACLS goals
Emphasis on trained & equipped Health Care Professional (HCP), but only in conjunction with trained lay rescuer & reduce time to CPR and shock delivery & obtain ultimate successEffective ACLS begins with high-quality CPR
Drug changes 2005
Most drug doses are the same as those recommended in 2000 – except use Atropine 0.5 mg IV for Bradycardia. May repeat to a total of 3 mg. Epinephrine or dopamine may be administered while waiting for a pacemaker
Early intervention & effective CPR
5 major changes 2005 guidelines
Emphasis on, & recommendations to improve, delivery of effective chest compressionsA single compression-to-ventilation ratio for all single rescuers for all victims (except newborns)
5 major changes 2005 guidelines
Recommendation that each rescue breath be given over 1 second & should produce visible chest riseA new recommendation that single shock, followed by immediate CPR, be used to attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every 2 minutes
5 major changes 2005 guidelines
Endorsement of the 2003 ILCOR recommendations for use of AEDs in children 1 to 8 years old (and older); use a child dose-reduction system if available
5 major changes continued: AED – teaching point
Some AED’s have shown to be very accurate in recognizing pediatric shockable rhythms & may be used with regular adult pads
Age Definition
“Child” CPR guidelines apply to victims 1 year to the onset of puberty (about 12 – 14 years old)Chest compressions are recommended if the heart rate is less than 60 per minute with signs of poor perfusion
Effective chest compressions
“push hard & push fast” & chest compress the chest @ a rate of about 100 per minute (except newborns)Use 1 or 2 hands with a child (Use technique that gives best results)Allow the chest to recoilLimit interruptions in chest compression
Effective chest compressions
Chest compressions create a small amount of blood flow to vital organs – the better the chest compressions (adequate rate, depth, & allowing for recoil) the more blood flow is produced
Copyright ©1996 American Heart Association
Idris, A. H. et al. Circulation 1996;94:2324-2336
Arterial and central venous pressure waveforms during external closed chest compression
Universal Compression-to-Ventilation – all lone rescuers
One universal compression-to-ventilation ratio for all lone rescuers: Single compression to ventilation ration of 30:2 for single rescuers of victims of all agesTeaching point: Simplify CPR & increase blood flow to the heart
1-Second breaths during all CPR
All breaths should be given over 1 second w/ significant volume to achieve visible chest riseTeaching point: During CPR, blood flow to the lungs is much less than normal, so the victim needs less ventilation than normal
Review of BLS guidelines
Determine if you require BLS proof prior to your course
Basic Life Support – Teaching concepts
Early bystander CPR can double or triple the victim’s survival from VF & Sudden cardiac arrest (SCA)CPR plus defibrillator within 3 – 5 minutes of collapse can produce survival rates as high as 49% to 75%
Basic Life Support – Calling for help
Lone Healthcare provider: Sudden collapse – Phone 911 & get an AED available & then return to victim to begin CPRUnresponsive victim w/ likely drowning – deliver about 5 cycles (about 2 minutes) of CPR prior to phoning 911 to get the AED & then return to CPR
Lone Healthcare Provider/CPR
Scenario: Patient unresponsive & non-breathing the Lone Healthcare provider will give 2 rescue breaths & then feel a pulse for no more than 10 seconds. If no pulse – begin compression Adult: 30:2Child: 15:2 (two rescuers)
HCP- Rescue breathing
Deliver rescue breath over 1 secondRescue breathing for a victim w/pulse
Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than normal & not as effective as compressions
Chest compressions – components
Adult: Center chest & @ nipple line & 1 ½ to 2 inches using heel of both hands & lower half of sternum
Child: 1/3 to ½ depth of chest & using heel of one handRate: 100 on all patients
HCP Chest compressions
Compression during CPR & NO advanced airway is present:
Deliver cycles of compressions 30:2Compression during CPR & advanced airway IS present: No longer use cycles or pausing for rescue breathing. Deliver 100 compressions/minute w/ 8-10 breaths/minute
Lay Rescuers CPR – may include information with your course
Lay rescuers should immediately begin cycles of chest compressions after delivering 2 rescue breaths in the unresponsive victim. Lay rescuers are not taught to assess for pulse or sings or circulationResearch notes that the lay public has a difficult time locating the correct place for palpation
Defibrillation
One shock followed by immediate CPR beginning w/ chest compressions & 5 cycles or 2 minutesMonophasic: 360 J Biphasic: 150 to 200 J
AED Review
Use the model for teaching & state the proper order -4-Universal steps: Power AED Attach to victim Analyze rhythm Deliver shock if indicated
Use of the AED
Use adult pads on adultsUse AED after 5 cycles of CPR (out of hospital)No recommendation for infants < 1 year of ageChildren 1 to 8 Use an AED with pediatric dose-attenuator
Electrical Therapies
Defibrillation involves delivery of current through the chest & to the heart to depolarize myocardial cells & eliminate VFMonophasic – Deliver current to one polarity & higher energy levelBiphasic – Lower energy & are more in current use
Management of Pulseless Arrest
5 cycles or 2 minutes or uninterrupted CPR & should resume immediately after deliver 1 shockPulse & rhythm are NOT checked after shock
Management of cardiac arrest
Drug administration is of 2nd importanceNO IV access: Lidocaine, epinephrine, atropine, narcan, & vasopression are absorbed via the trachea w/typical dose 2 to 2 ½ times the recommended IV dose & should dilute with water or NS Administer drugs during CPR
HCP- Rescue breathing
Deliver rescue breath over 1 secondRescue breathing for a victim w/pulse
Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than normal & not as effective as compressions
Airway management - review & observe student performance
Demonstrate the BVMIntubation techniquesSecondary confirmation techniquesSecuring the ETTC-Spine precautions & trauma5-point chest exam
Airway & C-spine management
Use head tilt-chin lift technique to open the airway of trauma victim unless cervical spine injury is suspectedTeaching point: Jaw thrust is a difficult maneuver & may not be an effective way to open the airway
Airway station – Use BVM
Anyone providing prehospital care for adult, children, or infants should be trained to deliver effective oxygenation & ventilationThe use of BVM should be considered to be the primary method of venilatory support, especially if transport times are short
Airway Management – Issues to discuss during the station:
BVM can be as effective as ETTA study noted 25% intubations were found to have esophageal/pharyngeal tube placementSecondary confirmation involves the use of end-tidal CO2 detectorsReview tube holder & LMA
Verify correct ETT placement
To reduce the risk of esophageal misplacement or displacement – Confirm the placement immediately after insertion, in the transport vehicle, & whenever the patient is moved
Acute Coronary Syndromes - goals
Reduce the amount of myocardial necrosis & preserve LV functionPrevent Major adverse cardiac events “MACE”Review new ACS algorithm
Acute Coronary Syndromes
M – O – N – A = Same RxEach minute the patient is in VF has 10% decrease of chance of survivalEMS: Monitor, support ABCs, CPR, & defibrillationGoal: Door-balloon 90 minutes & Door- needle 30 minutes
Stroke
Intravenous tPA who meet (NINDS) is administered by physicians w/ defined protocol, knowledgeable team, & institutional commitmentStroke patients should be admitted to Stroke Units
Acute Ischemic Stroke
Lower blood sugar (> 200mg/dL)Orders urgent CT Scan < 25 minutesReads CT scan < 45 minutesIf scan shows ICH/SAH call Neurosurgery If no hemorrhage, continues protocolSymptom onset > 3 hours?
Algorithm Review
Treatment of Wide Complex Tachycardias
ACLS providers should make a reasonable attempt to distinguish hemodynamically stable VT from SVT with aberrancy. History of CAD suggest ventricular origin. Obtain a 12-lead (when possible) & note the QRS yet accuracy requires experience
Tachycardia with Pulses
Treatment summarized in a single algorithm – Immediate synchronized cardioversion for unstable patientNarrow versus Wide Complex – Control rate (Diltiazem review)Treat contributing factors
Unstable Tachycardia/Cardioversion
Primary & Secondary ABCsD = Determine DefibrillationDetermine Sedatives & AnalgesicsKnow rapid infusion of antiarrhythmic agentsPost cardioversion careChange unsynchronized mode
Pulseless Arrest VF/VT
5 cycles of CPR prior to defibrillation & minimize interruptions Deliver 1 shock (120 or 200j) & resume CPR immediatelyEpinephrine 1mg or vasopressin 40 U IV/IO to replace 1st dose of EpinephrineMay shock either 200j (unknown biphasic device) or 360j
Asystole/PEA
Attach monitor/defibrillatorShockable Epinephrine & Vasopressin Consider Atropine 1 mg IV/IO for asystole or slow PEA rate
Asystole
Advanced airway controlEstablish IV – Epinephrine & AtropineConsider TCP (start @ once)Consider differential diagnosisLook for specific causes – The H’s & T’s with new addition
Pulseless Electrical Activity
Primary & SecondaryAirway controlIV access – Epinephrine 1 mg IVPAtropine 1 mg IVP (if rate is slow)6 H’s & 5 T’sAct upon differential diagnosis when reasonable
Correct contributing factors
HypovolemiaHypoxiaHydrogenHypo/HyperkalemiaHypoglycemiaHypothermia
ToxinsTamponadeTension pneumoThrombosis (coronary or pulmonary)Trauma
Bradycardia
Prepare TCP without delayRecognize 2nd & 3rd Degree BlocksAtropine 0.5 mg IV while waiting TCP (total dose 3mg)Epinephrine 2 to 10 mcg/min or Dopamine infusion 2 to 10 mcgSearch contributing factors
Medication Review
Anti-arrhythmic agents
Lidocaine – Alternative to AmiodaroneAdenosine – Slow AV nodal conductionProcainamide – Supraventricular arrhythmias & VT 20 mg/min total 17mg/kgAmiodarone – Is effective with SVT because it alters conduction through the accessory pathway
Dobutamine
Indication – Pump problems (CHF, Pulmonary congestion) SBP 70 to 100 mm Hg & no signs of shock
Precautions – May cause tachyarrhythmias, fluctuations in blood pressure, headache, & nausea2 to 20 mcg/kg/minute
Dopamine
Second-line drug for symptomatic bradycardia (after atropine)Use for hypotension SBP , 70 to 100 mm Hg) with signs & symptoms of shockCorrect hypovolemia with volume replacement2 to 20 mcg/kg/minute
Amiodarone
Recurrent VF & recurrent hemodynamically unstable VTRequires several time consuming steps for administration (Glass ampule, etc)Cardiac arrest: 300 mg IV initial dose & ONE 150 mg IVP in 3-5 minutesRecurrent Ventricular arrhythmias: 150 mg IV over 10 minutes
Magnesium
Use in cardiac arrest only if Torsades de Pointes is suspected or Hypomagnesaemia is present
Life-threatening digitalis toxicity1-2 g over 5 -20 min
Diltiazem
Indications: To control ventricular rate in atrial fibrillation & atrial flutterRate control: 15 to 20 mg (0.25 mg/kg) IV over 2 minutesCaution: Avoid in patient receiving or Beta blockers, B/P may drop due to peripheral vasodilation
Epinephrine
Cardiac arrest: VF, Pulseless VT, Asystole, PEASymptomatic bradycardia: after atropine & an alternative infusion to dopamineDose: IV/IO 1 mg (10 mL of 1:10,000) every 3-5 minutes
Vasopressin
Indications: Alternative pressor to epinephrine in treatment of adult shock-refractory VFDose: 40 U IV/IO push may replace either first or second dose of epinephrine
Fibinolytic Agents (Activase, tPA)
Indications: For AMI in Adults – ST elevation ( > 1 mm in 2 leads) or new
LBB, in context of S & S of AMI, Time of onset of symptoms < 12 hoursIndications: For Acute Ischemic Stroke
Focal neurologic deficits, Absence of Intracerbral or SAH on CT, & non-improving symptoms < 3 hours onset
“Flat Line Protocol”
The sensitivity or “gain” displayed on the monitor is one of the important things to check or confirm true asystole. Check the POWER (on/off)Battery supply & lead select (if set to paddles)
Postresuscitation support
Vasoactive supportInduced hypothermia cooled to 32 to 34C for 12 to 24 hours after ROSCAce Inhibitors: Reduces mortality & CHF with AMI (Angiotensin or ACE is a chemical that causes the heart to contract such as Vasotec)
Ethical Considerations
Do not resuscitateFamily presence – Let the family view all of your care & include in decision making if possibleFamily & staff grief counselingCISD assistance
The written exam
Review EID & hypopharyngeal intubation (esophageal)Hypovolemia easy to treatPrehospital asystole = drug overdoseNon-contrast CTReview Retavase & HeparinCVA v insulin-induced hypoglycemia
The written exam
Cannot be open book or use of notesBe prepared to deal with the student that challenges the exam or the answersHow do you deal with the student who fails the exam?
What can you expect in the course
Decreased lecturesMore “hands on”Role-playScenario reviewGroup involvement
Questions?