Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CPR 2000 Dr. THANAPONG HONGPROMYATI Adult Cardiac Arrest BLS algorithm if appropriate 1 Precordial thumb if appropriate Attach defibrillator/monitor Assess rhythm Figure 1. ILCOR Universal/International ACLS Algorithm. 2 Assess rhythm 3 Check pulse+/- VF/VT During CPR Attempt 3 defibrillation *3 as necessary CPR for 1 min 4 Non-VF/VT 5,6 • • • • Check electrode/paddle position and contact Attempt to place, confirm, secure airway Attempt and verify IV access Patients with VF/VT refractory to initial shocks: - Epinephrine 1 mg IV, every 3-5 min or - Vasopressin 40 U IV, single dose, 1 time only • Patients with non-VF/VT rhythm: - Epinephrine 1 mg IV, every 3-5 min • Consider: buffers, antiarrhythmics, pacing • Search for and correct reversible cause Figure 1. ILCOR Universal/International ACLS Algorithm. CPR up to 3 min Consider causes that are potentially reversible • Hypovolemia • Hypoxia • Hydrogen ion-acidosis • Hyper-/Hypokalemia • Hypothermia 7 •“Tablet” (drug OD,accidents) • Temponade, cardiac • Tension pneumothorax • Thrombosis, coronary (ACS) • Thrombosis, pulmonary (embolism) Figure 1. ILCOR Universal/International ACLS Algorithm. • Person collapses • Possible cardiac arrest • Assess responsiveness Unresponsive Begin Primary ABCD Survey 1 (Begin BLS Algorithm) • Activate emergency response system • Call for defibrillator • A Assess breathing (open airway, look, listen, and feel) No Breathing 1 • B Give 2 slow breaths • C Assess pulse, if no pulse • C Start chest compressions • D Attach monitor/defibrillator when available No pulse Figure 2. Comprehensive ECC Algorithm. No pulse • CPR continues • Assess rhythm Attempt defibrillation 2 Non-VF/VT 3 (Up to 3 shock if VF persists) (asystole or PEA) Secondary ABCD Survey 4,5 • Airway: attempt to place airway device • Breathing: confirm and secure airway device, ventilation, oxygenation • Circulation: gain intravenous access; give adrenergic agent; consider antiarrhythmics, buffer agents, pacing CPR up to CPR for Non-VF/VT patients: 3 min 1 min - Epinephrine 1 mg IV, repeat every 3-5 min VF/VT patients: - Vasopressin 40 U IV, single dose, 1 time only or - Epinephrine 1 mg IV, repeat every 3-5 min • Differential Diagnosis: search for and treat reversible cause Figure 2. Comprehensive ECC Algorithm. Primary ABCD Survey Focus: basic CPR and defibrillation • Check responsiveness • Activate emergency response system • Call for defibrillator A Airway:open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulesless VT, up to 3 times (200J,200-300J,360J, or equivalent biphasic) if necessary Rhythm after first 3 shocks? Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm. 1 Persistent or recurrent VF/VT Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: Place airway device as soon as possible B Breathing: • Confirm airway device placement by exam plus confirmation device. • Secure airway device; purpose-made tube holders preferred. • Confirm effective oxygenation and ventilation. C Circulation: • Establish IV access. • Identify rhythm; monitor. • Administer drugs appropriate for rhythm and condition. D Differential Diagnosis: Search for and treat identified reversible causes. Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm. 2 Epinephrine 1 mg IV push, repeat every 3 to 5 minutes or Vasopressin 40 U IV, single dose, 1 time only Resume attempts to defibrillate 1*360J (or equivalent biphasic) within 30 to 60 sec. 4 Consider antiarrhythmics: amiodarone (IIb), lidocaine (Indeterminate), magnesium (IIb if hypomagnesemic state), procainamide (IIb for intermittent/recurrent VF/VT). Consider buffers. Resume attempts to defibrillate 5 Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm. 3 Antiarrhythmics & Buffer • Amiodarone (class IIb) 300 mg IV push (cardiac arrest dose) If VF/pulseless VT recurs, consider administration of a second dose of 150 mg IV. Max cumulative dose 2.2 g over 24 hr. • Lidocaine (class Indeterminate) 1.0 - 1.5 mg/kg IV push. Consider repeat in 3 to 5 min to a max cumulative dose of 3 mg/kg. • Magnesium sulfate 1 to 2 g IV in polymorphic VT (torsades de pointes) and suspected hypomagnesemic state. • Procainamide 30 mg/min in refractory VF (Max total dose: 17 mg/kg) is acceptable but not recommended • Sodium bicarbonate 1 mEq/kg IV is indicated for several conditions known to provoke sudden cardiac arrest. PULSELESS ELECTRICAL ACTIVITY (PEA = Rhythm on monitor, without detectable pules) Primary ABCD Survey Focus: basic CPR and defibrillation • Check responsiveness • Activate emergency response system • Call for defibrillator A B C D Airway:open the airway Breathing: provide positive-pressure ventilations Circulation: give chest compressions Defibrillation: assess for and shock VF/pulesless VT Figure 4. Pulseless Electrical Activity Algorithm. Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: Place airway device as soon as possible B Breathing: • Confirm airway device placement by exam plus confirmation device. • Secure airway device; purpose-made tube holders preferred. • Confirm effective oxygenation and ventilation. C Circulation: • Establish IV access. • Identify rhythm; monitor. • Administer drugs appropriate for rhythm and condition. • Assess for occult blood flow (“pseudo-EMT”) D Differential Diagnosis: Search for and treat identified reversible causes. Figure 4. Pulseless Electrical Activity Algorithm. EMD=electro-mechanical dissociation Review for most frequent causes • Hypovolemia • Hypoxia • Hydrogen ion-acidosis • Hyper-/Hypokalemia • Hypothermia 1 • “Tablet” (drug OD,accidents) • Temponade, cardiac • Tension pneumothorax • Thrombosis, coronary (ACS) • Thrombosis, pulmonary (embolism) Epinephrine 1 mg IV push, 2 repeat every 3 to 5 minutes 3 Atropine 1 mg IV (if PEA rate is slow), repeat every 3-5 minutes as need, to a total dose of 0.04 mg/kg Figure 4. Pulseless Electrical Activity Algorithm. Asystole Primary ABCD Survey Focus: basic CPR and defibrillation • Check responsiveness • Activate emergency response system • Call for defibrillator A Airway:open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions Confirm true asystole D Defibrillation: assess for VF/pulesless VT; shock if indicate Rapid scene survey: any evidence personnel should not attempt resuscitation? Figure 5. Asystole: The Silent Heart Algorithm. 1 Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: Place airway device as soon as possible B Breathing: • Confirm airway device placement by exam plus confirmation device. • Secure airway device; purpose-made tube holders preferred. • Confirm effective oxygenation and ventilation. C Circulation: • Confirm true asystole • Establish IV access. • Identify rhythm; monitor. • Administer drugs appropriate for rhythm and condition. D Differential Diagnosis: Search for and treat identified reversible causes. Figure 5. Asystole: The Silent Heart Algorithm. 2,3 Transcutaneous pacing If considered, perform immediately 4 Epinephrine 1 mg IV push, repeat every 3 to 5 minutes 5 Atropine 1 mg IV, repeat every 3 to 5 minutes up to a total of 0.04 mg/kg 6 7,8,9 Asystole persists Withhold or cease resuscitation efforts? • Consider quality of resuscitation? • Atypical clinical features present? • Support for cease-efforts protocols in place? Figure 5. Asystole: The Silent Heart Algorithm. • Confirm true asystole 2 - Check lead and cable connection Monitor power on? Monitor gain up ? Verify asystole in another lead 7 • Review the quality of the resuscitation attempt - Was there an adequate trial of BLS? of ACLS? Has the team done the following: - Achieved tracheal intubation? - Performed effective ventilation? - Shocked VF if present? - Obtained IV access? - Given epinephrine IV? Atropine IV? - Ruled out or corrected reversible causes? - Continuously documented asystole >5 to 10 min after all of the above have been accomplished? 8 • Reviewed for atypical clinical features? - Not a victim of drowning or hypothermia? - No reversible therapeutic or illicit drug overdose? Bradycardia • Slow (absolute bradycardia = rate<60bpm • Relatively slow (rate less than expected relative to underlying condition or cause) Primary ABCD Survey • Assess ABCs • Secure airway noninvasively • Ensure monitor/defibrillator is available Secondary ABCD Survey • Assess secondary ABCs (invasive airway management needed?) • Oxygen-IV access-monitor-fluids • Vital sign, pulse oximeter, monitor BP • Obtain and review 12 lead ECG • obtain and review portable Chest x-ray • Problem-focused history • Problem-focused physical examination • Consider cause (differential diagnoses) Figure 6. Bradycardia Algorithm. Serious sign or symptom? 1,2 Due to the bradycardia? Yes No Type II second-degree AV block or Third-degree AV block? No Observe 6 3,4,5 Intervention sequence • Atropine 0.5-1.0 mg • Transcutaneous pacing if available • Dopamine 5-20 ug/kg per min • Epinephrine 2-10 ug/min Yes • Prepare for transvenous pacer7 • If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed Figure 6. Bradycardia Algorithm. 1 • If the patient has serious sign or symptoms, make sure they are related to the slow rate. 2 • Clinical manifestations include - Symptoms (chest pain, shortness of breath, decrease level of consciousness) - Signs (low blood pressure, shock, pulmonary congestion, CHF) 3• If the patient is symptomatic, do not delay transcutaneous pacing while awaiting IV access or for atropine to take effect 4 • Denervated transplanted hearts will not response to atropine. Go at once pacing, catecholamine infusion, or both. 6 • Never treat the combination of third-degree heart block and ventricular escape beats with lidocaine (or any agent that suppresses ventricular escape rhythms) Evaluate patient • Is patient stable or unstable? • Are there serious signs or symptoms? • Are signs and symptoms due to tachycardia? Stable Stable patient: no serious signs and symptoms • Initial assessment identified 1 of 4 type of tachycardia Unstable Unstable patient: serious signs or symptoms • Establish rapid heart rate as cause of signs and symptoms • Rate related signs and symptoms occur at many rates, seldom < 150 bpm • Atrial fibrillation/flutter • Narrow-complex tachycardia • Stable wide-complex tachycardia: unknown type • Stable monomorphic VT and/or polymorphic VT Figure 7. The Tachycardia Overview Algorithm. • Prepare for immediate cardioversion (see algorithm) 1. Atrial fibrillation Atrial flutter Evaluation focus, 4 clinical features: 1. Patient clinical unstable? 2. Cardiac function impaired? 3. WPW present? 4. Duration<48 or >48 hours? Treatment focus: clinical evaluation 1. Treat unstable patient urgently 2. Control the rate 3. Convert the rhythm 4. Provide anticoagulation Treatment of atrial fibrillation/atrial flutter (See following table) Figure 7. The Tachycardia Overview Algorithm. 2. Narrow-complex tachycardia Attempt to establish a specific diagnosis • 12 lead ECG • Clinical information • Vagal maneuvers • Adenosine Diagnosis effort yield • Ectopic atrial tachycardia • Multifocal atrial tachycardia • Paroxysmal supraventricular tachycardia Treatment of SVT (see narrow-complex tachycardia algorithm) Figure 7. The Tachycardia Overview Algorithm. 3. Stable wide-complex tachycardia: unknown type 4. Stable monomorphic VT and/or polymorphic VT Attempt to establish a specific diagnosis • 12-lead ECG • Esophageal lead • Clinical information Confirmed SVT Treatment of SVT (see narrowcomplex tachycardia algorithm) Wide-complex tachycardia of unknown type Preserved cardiac function Dc cardioversion or Procainamide or Amiodarone Confirmed stable VT Ejection fraction < 40% Clinical CHF Dc cardioversion or Amiodarone Treatment of stable monomorphic and polymorphic VT (see stable VT: monomorphic and polymorphic algorithm) Figure 7. The Tachycardia Overview Algorithm. Control of Rate and Rhythm (Continued From Tachycardia Overview) AF/flutter with • Normal heart • Impair heart • WPW 1. Control Rate 2. Control Rhythm Duration<48Hrs Duration>48Hrs or Unknown Consider • NO DC cardioversion! • DC cardioversion • Note: Conversion of AF to NSR Use only 1 of the with drugs or shock may cause embolization of atrial thrombi Class IIa Normal following agents unless patient has adequate cardiac (see note below): anticoagulation. Use only 1 of the following agents function • Use antiarrhythmic agents with • Amiodarone (see note below): extreme caution if AF>48 hours’ • Ibutilide • Calcium channel blockers (ClassI) duration (see note below). or • Flecainide • B-Blockers (ClassI) • Propafenone Delayed cardioversion • For additional drugs that are • Procainamide Anticoagulation * 3 weeks at ClassIIb recommendations, see • For additional proper levels Guideline or ACLS text drugs that are • Cardioversion, then Class IIb • Anticoagulation * 4 weeks more recommendation, or see Guidelines or Early cardioversion ACLS text • Begin IV heparin at once Note:If AF>48hours’ duration, use • TEE to exclude atrial clot. then agents to convert rhythm with extreme • Cardioversion within 24 h. then caution in patients not receiving • Anticoagulation * 4 more weeks adequate anti coagulation because of Consider Impaired heart • Anticoagulation as described possible embolic complications. • DC cardioversion above, following by (EF<40% or Use only 1 of the following agents: or CHF) • DC cardioversion • Digoxin (ClassIIb) • Amiodarone • Amiodarone • Diltiazem (ClassIIb) (ClassIIb) (ClassIIb) Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications. Control of Rate and Rhythm (Continued From Tachycardia Overview) AF/flutter with • Normal heart • Impair heart • WPW WPW 1. Control Rate Heart Function Preserved Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications. • DC cardioversion or • Primary antiarrhythmic agents Use only 1 of the following agents (see note below): •Amiodarone (ClassIIb) • Flecainide (ClassIIb) • Procainamide (ClassIIb) • Propafenone (ClassIIb) • Sotalol (ClassIIb) Class III (can be harmful) • Adenosine • B-Blockers • Calcium blockers • Digoxin Impaired Heart EF<40% or CHF Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications. • DC cardioversion or • Amiodarone (ClassIIb) 2. Control Rhythm Duration<48Hrs Consider • DC cardioversion or • Primary antiarrhythmic agents Use only 1 of the following agents (see note below**): •Amiodarone (ClassIIb) • Flecainide (ClassIIb) • Procainamide (ClassIIb) • Propafenone (ClassIIb) • Sotalol (ClassIIb) Class III (can be harmful) • Adenosine • B-Blockers • Calcium blockers • Digoxin Duration>48Hrs or Unknown • Anticoagulation as described above, following by • DC cardioversion Narrow-Complex Supraventricular Tachycardia, Stable Attempt therapeutic diagnosis maneuver • Vagal stimulation • Adenosine Preserved EF<40%, CHF Junctional tachycardia Preserved Paroxysmal supraventricular tachycardia Ectopic or multifocal atrial tachycardia • No DC Cardioversion • Amiodarone • B-Blocker • Ca2+ channel blocker • No DC cardioversion • Amiodarone Priority order: • Ca2+ Channel blocker • B-Blocker • Digoxin • DC cardioversion • Consider procainamide, amiodarone, sotalol EF<40%, CHF Priority order: • No DC cardioversion • Amiodarone • Diltiazem Preserved • No DC cardioversion • Ca2+ channel blocker • B-Blocker • Amiodarone EF<40%, CHF • No DC cardioversion • Amiodarone • Diltiazem Figure 8. Narrow-Complex Supraventicular Tachycardia Algorithm. Stable Ventricular Tachycardia Monomorphic or Polymorphic? Monomorphic VT • Is cardiac function impaired? Normal function Note! May go directly to cardioversion Poor ejection fraction Medications: any one • Procainamide • Sotalol Other acceptable • Amiodarone • Lidocaine Normal baseline QT interval Normal baseline QT interval • Treat ischemia • Correct electrolytes Medications: any one • B-Blocker or • Lidocaine or • Amiodarone or • Procainamide or • Sotalol Amiodarone • 150 mg IV bolus over 10 min. or Lidocaine • 0.5 to 0.75 mg/kg IV push. Then use • Synchronized cardioversion Figure 9. Stable Ventricular Tachycardia (Monomorphic or Polymorphic) Algorithm. Polymorphic VT • Is QT baseline interval prolonged? Prolong baseline QT interval (suggests torsades) Long baseline QT interval • Correct abnormal electrolytes Medications: any one • Magnesium • Overdrive pacing • Isoproterenol • Phenytoin • Lidocaine Tachycardia with serious signs and symptoms related to the tachycardia If ventricular rate is > 150 bpm, prepare for immediate cardioversion. May give brief trial of medications based on specific arrhythmias. Immediate cardioversion is generally not need if heart rate is <= 150 bpm. Have available at bedside •oxygen saturation monitor •IV line •Intubation equipment Premedicate whenever possible Synchronized cardioversion •ventricular tachycardia •Paroxysmal supraventricular tachycardia •Atrial fibrillation •Atrial flutter Figure 10. Synchronized Cardioversion Algorithm. 100J, 200J 300J, 360J monophasic energy dose (or clinical equivalent biphasic energy dose)