Download Advanced Cardiac Life Support

Advanced Cardiac Life
Support
N.Tavakoli
Assistant professor
Department of Emergency Medicine
Iran University of Medical Sciences
Chain of Survival
Early
ACCESS
Early
CPR
Early
DEFIB
Early
ACLS
Drug Administration Route
 Peripheral
Venous
 Central Venous
 Endotracheal
 Intraosseous
 Intra cardiac
Central IV access
 More
rapid drug delivery
 Ability to perform invasive monitoring
 More time consuming
 More experience
 Risk of complication is greater
 Internal jugular or supraclavicular are
preferred
Peripheral IV access
 Antecubital
or external Jugular are the first
choice
 Administer drugs
-By rapid bolus followed 20cc of IV fluid
-Elevation of the extremity
Endotracheal Routeُ
 ‘’L
–E – A –N’’ can be given via tracheal
tube .
Lidocaine, Atropine, Epinephrine, Naloxan
 2-2.5 times the recommended dosage
 Should be diluted in 10 cc N/S
 Temporarily holding chest compression
 Injecting drug through a cannula while
delivering several deep breath
Intra cardiac Route
 Only
when other routes are not readily
available
 During Open- chest CPR
 Heart can be directly visualized
Pharmacologic Agents in
ACLS
for shock-refractory VT/VF
 Epinephrine


1 mg intravenously every 3 -5 minutes
a higher dose (0.2 mg/kg) is acceptable, but
not recommended,
Epinephrine
 Indications

(When & Why?)
Increases:
• Heart rate
• Force of contraction
• Conduction velocity


Peripheral vasoconstriction
Bronchial dilation
VF / Pulseless VT
Epinephrine
 Dosing



(How?)
1 mg IV push; may repeat every 3 to 5
minutes
May use higher doses (0.2 mg/kg) if lower
dose is not effective
Endotracheal Route
• 2.0 to 2.5 mg diluted in 10 mL normal saline
VF / Pulseless VT
Epinephrine
 Dosing

(How?)
Alternative regimens for second dose (Class
IIb)
• Intermediate: 2 to 5 mg IV push, every 3 to 5
minutes
• Escalating: 1 mg, 3 mg, 5 mg IV push, each dose
3 minutes apart
• High: 0.1 mg/kg IV push, every 3 to 5 minutes
VF / Pulseless VT
Epinephrine
 Precautions



(Watch Out!)
Raising blood pressure and increasing heart
rate may cause myocardial ischemia, angina,
and increased myocardial oxygen demand
Do not mix or give with alkaline solutions
Higher doses have not improved outcome &
may cause myocardial dysfunction
VF / Pulseless VT
Vasopressin
 Indications



(When & Why?)
Used to “clamp” down on vessels
Improves perfusion of heart, lungs, and brain
No direct effects on heart
VF / Pulseless VT
Vasopressin
 Dosing




(How?)
One time dose of 40 units only
May be substituted for epinephrine
Not repeated at any time
May be given down the endotracheal tube
• DO NOT double the dose
• Dilute in 10 mL of NS
VF / Pulseless VT
Vasopressin
 Precautions


(Watch Out!)
May result in an initial increase in blood
pressure immediately following return of pulse
May provoke cardiac ischemia
VF / Pulseless VT
Atropine Sulfate
 Indications

(When & Why?)
Should only be used for bradycardia
• Relative or Absolute

Used to increase heart rate
Pulseless Electrical Activity
Atropine Sulfate
 Dosing




(How?)
1 mg IV push
Repeat every 3 to 5 minutes
May give via ET tube (2 to 2.5 mg) diluted in
10 mL of NS
Maximum Dose: 0.04 mg/kg
Pulseless Electrical Activity
Atropine Sulfate
 Precautions


(Watch Out!)
Increases myocardial oxygen demand
May result in unwanted tachycardia or
dysrhythmia
Pulseless Electrical Activity
Amiodarone
 Indications



(When & Why?)
Powerful antiarrhythmic with substantial
toxicity, especially in the long term
Intravenous and oral behavior are quite
different
Has effects on sodium & potassium
VF / Pulseless VT
Amiodarone
 Dosing

(How?)
Should be diluted in 20 to 30 mL of D5W
• 300 mg bolus after first Epinephrine dose
• Repeat doses at 150 mg
VF / Pulseless VT
Amiodarone
 Precautions



(Watch Out!)
May produce vasodilation & shock
May have negative inotropic effects
Terminal elimination
• Half-life lasts up to 40 days
VF / Pulseless VT
Lidocaine
 Indications




(When & Why?)
Depresses automaticity
Depresses excitability
Raises ventricular fibrillation threshold
Decreases ventricular irritability
VF / Pulseless VT
Lidocaine
 Dosing




(How?)
Initial dose: 1.0 to 1.5 mg/kg IV
For refractory VF may repeat 1.0 to 1.5 mg/kg
IV in 3 to 5 minutes; maximum total dose, 3
mg/kg
A single dose of 1.5 mg/kg IV in cardiac arrest
is acceptable
Endotracheal administration: 2 to 2.5 mg/kg
diluted in 10 mL of NS
VF / Pulseless VT
Lidocaine
 Dosing

(How?)
Maintenance Infusion
• 2 to 4 mg/min
• 1000 mg / 250 mL D5W = 4 mg/mL




15 mL/hr = 1 mg/min
30 mL/hr = 2 mg/min
45 mL/hr = 3 mg/min
60 mL/hr = 4 mg/min
VF / Pulseless VT
Lidocaine
 Precautions


(Watch Out!)
Reduce maintenance dose (not loading dose)
in presence of impaired liver function or left
ventricular dysfunction
Discontinue infusion immediately if signs of
toxicity develop
VF / Pulseless VT
Magnesium Sulfate
 Indications




(When & Why?)
Cardiac arrest associated with torsades de
pointes or suspected hypomagnesemic state
Refractory VF
VF with history of ETOH abuse
Life-threatening ventricular arrhythmias due to
digitalis toxicity, tricyclic overdose
VF / Pulseless VT
Magnesium Sulfate
 Dosing

(How?)
1 to 2 g (2 to 4 mL of a 50% solution) diluted
in 10 mL of D5W IV push
VF / Pulseless VT
Magnesium Sulfate
 Precautions


(Watch Out!)
Occasional fall in blood pressure with rapid
administration
Use with caution if renal failure is present
VF / Pulseless VT
Procainamide
 Indications





(When & Why?)
Recurrent VF
Depresses automaticity
Depresses excitability
Raises ventricular fibrillation threshold
Decreases ventricular irritability
VF / Pulseless VT
Procainamide
 Dosing




(How?)
30 mg/min IV infusion
May push at 50 mg/min in cardiac arrest
In refractory VF/VT, 100 mg IV push doses
given every 5 minutes are acceptable
Maximum total dose: 17 mg/kg
VF / Pulseless VT
Procainamide
 Dosing

(How?)
Maintenance Infusion
• 1 to 4 mg/min
• 1000 mg / 250 mL of D5W = 4 mg/mL




15 mL/hr = 1 mg/min
30 mL/hr = 2 mg/min
45 mL/hr = 3 mg/min
60 mL/hr = 4 mg/min
VF / Pulseless VT
Procainamide
 Precautions


(Watch Out!)
If cardiac or renal dysfunction
is present, reduce maximum total dose to 12
mg/kg and maintenance infusion to 1 to 2
mg/min
Remember Endpoints of Administration
VF / Pulseless VT
 Vasopressin



an acceptable alternative, recommended
a single intravenous dose of 40 U is given once
(half life is 10 - 20 min versus 3 - 5 min with
epinephrine)
in a controlled trial of patients with out-of-hospital
VF who received either vasopressin or
epinephrine; those treated with vasopressin had
higher rates of survival to hospital admission (70
vs 35 %, p = 0.06) and survival at 24 hours (60 vs
20 %, p = 0.02)
Other Cardiac Arrest Drugs
Calcium Chloride
 Indications




(When & Why?)
Known or suspected hyperkalemia (eg, renal
failure)
Hypocalcemia (blood transfusions)
As an antidote for toxic effects of calcium
channel blocker overdose
Prevent hypotension caused by calcium
channel blockers administration
Other Cardiac Arrest Drugs
Calcium Chloride
 Dosing

(How?)
IV Slow Push
• 8 to 16 mg/kg (usually 5 to 10 mL) IV for
hyperkalemia and calcium channel blocker
overdose
• 2 to 4 mg/kg (usually 2 mL) IV for prophylactic
pretreatment before IV calcium channel blockers
Other Cardiac Arrest Drugs
Calcium Chloride
 Precautions


(Watch Out!)
Do not use routinely in cardiac arrest
Do not mix with sodium bicarbonate
Other Cardiac Arrest Drugs
Sodium Bicarbonate

Indications (When & Why?)




Class I if known preexisting hyperkalemia
Class IIa if known preexisting bicarbonate-responsive
acidosis
Class IIb if prolonged resuscitation with effective
ventilation; upon return of spontaneous circulation
Class III (not useful or effective) in hypoxic lactic
acidosis or hypercarbic acidosis (eg, cardiac arrest
and CPR without intubation)
Other Cardiac Arrest Drugs
Sodium Bicarbonate
 Dosing



(How?)
1 mEq/kg IV bolus
Repeat half this dose every 10 minutes
thereafter
If rapidly available, use arterial blood gas
analysis to guide bicarbonate therapy
(calculated base deficits or bicarbonate
concentration)
Other Cardiac Arrest Drugs
Sodium Bicarbonate
 Precautions


(Watch Out!)
Adequate ventilation and CPR, not
bicarbonate, are the major "buffer agents" in
cardiac arrest
Not recommended for routine use in cardiac
arrest patients
Other Cardiac Arrest Drugs
Factors Influencing
Survival
• the rhythm associated with the
arrest
• whether the collapse was
witnessed
• adequacy of CPR
• age / underlying health of the
patient
ACLS and arrhythmias
Tachycardia
sudden onset of rapid heart
rate
what do you do?
Tachycardia
ALWAYS CHECK THE PATIENT FIRST
1. Check for a pulse
2. Check the blood pressure
3. Make a diagnosis
Tachycardia
Case 1
On ward, sudden onset of palpitations
1. Does the patient have a pulse? Yes
2. What is the blood pressure? 60/20
Is the patient “stable” or “unstable”?
Definition of “Unstable”
presence of any one of:
1.
2.
3.
4.
5.
Low blood pressure
Short of Breath
Chest pain
Lightheaded
CHF
Unstable Tachycardia




goal is to slow down rate or
convert to sinus rhythm
drugs or electrical cardioversion is
used
usually cardioversion if unstable
Electrical Shock





defibrillation or
cardioversion (= “synchronized”)
action: resets all activity to zero
good for tachycardia (non-sinus)
good for ventricular fibrillation (VF)
Electrical Shock





defibrillation or
cardioversion (= “synchronized”)
NOT USED FOR:
sinus rhythm
bradycardia
asystole
Case #2
Alarm on ECG monitor makes noise!!
Case #2



Patient is awake and
talking
Diagnosis?
ECG lead is disconnected
ECG shows artifact
Case #3
Alarm on ECG monitor makes noise!!
Case #2



Try to wake up. Does not wake up
Check for breathing. No breathing.
Check for pulse. No pulse.
What is the diagnosis?
What do you do?
Ventricular Fibrillation (VF)

What is the cure for VF?
DEFIBRILLATION
EARLY defib. has higher
success
SHOCK SOON, SHOCK OFTEN

VF


Drugs
improve success of defibrillation (the cure)
do NOT cure VF



lidocaine
procainamide
amiodarone
VF
What is the cardiac output in VF?
 Zero. There is no circulation
What MUST occur at all times?
 CPR … unless defib. is
happening.
How do you manage ventilation?
 bag-mask and early intubation
VF Summary







Start CPR … and only stop to shock
Intubate
Defibrillation is the most important!!!
Drug
shock
drug
shock
Case #4
BP 60/30
Diagnosis?
Treatment?
Case #4: Sinus Bradycardia
Treatment: increase heart rate!
Methods:
1. atropine (probably successful)
2. pacing (thoracic skin paddles)
3. dopamine infusion
Case #5
BP 60/30
Diagnosis?
Treatment?
3rd Degree Block (Bradycardia)
Treatment: increase heart rate!
Methods:
1. atropine (probably NOT successful)
2. pacing (thoracic skin paddles)
3. dopamine infusion
Case # 6

BP: 120/80 , no chest pain , no rales , alert
Diagnosis?
Treatment?