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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 - PowerPoint PPT Presentation
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Advanced Cardiac Life Advanced Cardiac Life Support Support
N.TavakoliN.TavakoliAssistant professorAssistant professor
Department of Emergency Medicine Department of Emergency Medicine Iran University of Medical SciencesIran University of Medical Sciences
EarlyACCESS
EarlyCPR
EarlyDEFIB
EarlyACLS
Chain of Survival
Drug Administration RouteDrug Administration Route
Peripheral VenousPeripheral Venous Central VenousCentral Venous EndotrachealEndotracheal IntraosseousIntraosseous Intra cardiacIntra cardiac
Central IV accessCentral IV access
More rapid drug deliveryMore rapid drug delivery Ability to perform invasive monitoringAbility to perform invasive monitoring More time consumingMore time consuming More experienceMore experience Risk of complication is greaterRisk of complication is greater Internal jugular or supraclavicular are Internal jugular or supraclavicular are
preferredpreferred
Peripheral IV accessPeripheral IV access
Antecubital or external Jugular are the first Antecubital or external Jugular are the first choicechoice
Administer drugs Administer drugs -By rapid bolus followed 20cc of IV fluid -By rapid bolus followed 20cc of IV fluid -Elevation of the extremity -Elevation of the extremity
�ُ�ُEndotracheal RouteEndotracheal Route
‘’‘’L –E – A –N’’ can be given via tracheal L –E – A –N’’ can be given via tracheal tube .tube .Lidocaine, Atropine, Epinephrine, NaloxanLidocaine, Atropine, Epinephrine, Naloxan
2-2.5 times the recommended dosage 2-2.5 times the recommended dosage Should be diluted in 10 cc N/SShould be diluted in 10 cc N/S Temporarily holding chest compressionTemporarily holding chest compression Injecting drug through a cannula while Injecting drug through a cannula while
delivering several deep breathdelivering several deep breath
Intra cardiac RouteIntra cardiac Route
Only when other routes are not readily Only when other routes are not readily availableavailable
During Open- chest CPRDuring Open- chest CPR Heart can be directly visualizedHeart can be directly visualized
Pharmacologic AgentsPharmacologic Agents in in ACLSACLS
for shock-refractory VT/VFfor shock-refractory VT/VF EpinephrineEpinephrine
1 mg intravenously every 3 -5 minutes1 mg intravenously every 3 -5 minutes a higher dose (0.2 mg/kg) is acceptable, but a higher dose (0.2 mg/kg) is acceptable, but
not recommended,not recommended,
EpinephrineEpinephrine
Indications Indications (When & Why?)(When & Why?) Increases:Increases:
• Heart rateHeart rate• Force of contractionForce of contraction• Conduction velocityConduction velocity
Peripheral vasoconstrictionPeripheral vasoconstriction Bronchial dilationBronchial dilation
VF / Pulseless VT
EpinephrineEpinephrine
Dosing Dosing (How?)(How?) 1 mg IV push; may repeat every 3 to 5 1 mg IV push; may repeat every 3 to 5
minutesminutes May use higher doses (0.2 mg/kg) if lower May use higher doses (0.2 mg/kg) if lower
dose is not effectivedose is not effective Endotracheal RouteEndotracheal Route
• 2.0 to 2.5 mg 2.0 to 2.5 mg diluted indiluted in 10 mL10 mL normal saline normal saline
VF / Pulseless VT
EpinephrineEpinephrine
Dosing Dosing (How?)(How?) Alternative regimens for second dose (Class Alternative regimens for second dose (Class
IIb)IIb)• Intermediate:Intermediate: 2 to 5 mg IV push, every 3 to 5 2 to 5 mg IV push, every 3 to 5
minutesminutes• Escalating:Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 1 mg, 3 mg, 5 mg IV push, each dose
3 minutes apart3 minutes apart• High:High: 0.1 mg/kg IV push, every 3 to 5 minutes 0.1 mg/kg IV push, every 3 to 5 minutes
VF / Pulseless VT
EpinephrineEpinephrine
Precautions Precautions (Watch Out!)(Watch Out!) Raising blood pressure and increasing heart Raising blood pressure and increasing heart
rate may cause myocardial ischemia, angina, rate may cause myocardial ischemia, angina, and increased myocardial oxygen demandand increased myocardial oxygen demand
Do not mix or give with alkaline solutionsDo not mix or give with alkaline solutions Higher doses have not improved outcome & Higher doses have not improved outcome &
may cause myocardial dysfunctionmay cause myocardial dysfunction
VF / Pulseless VT
VasopressinVasopressin
Indications Indications (When & Why?)(When & Why?) Used to Used to “clamp”“clamp” down on vessels down on vessels Improves perfusion of heart, lungs, and brainImproves perfusion of heart, lungs, and brain No direct effects on heartNo direct effects on heart
VF / Pulseless VT
VasopressinVasopressin
Dosing Dosing (How?)(How?) One time dose of 40 units onlyOne time dose of 40 units only May be substituted for epinephrineMay be substituted for epinephrine Not repeated at any timeNot repeated at any time May be given down the endotracheal tubeMay be given down the endotracheal tube
• DO NOTDO NOT double the dose double the dose• Dilute in 10 mLDilute in 10 mL of NS of NS
VF / Pulseless VT
VasopressinVasopressin
Precautions Precautions (Watch Out!)(Watch Out!) May result in an initial increase in blood May result in an initial increase in blood
pressure immediately following return of pulsepressure immediately following return of pulse May provoke cardiac ischemiaMay provoke cardiac ischemia
VF / Pulseless VT
Atropine SulfateAtropine Sulfate
Indications Indications (When & Why?)(When & Why?) Should only be used for bradycardiaShould only be used for bradycardia
• Relative or AbsoluteRelative or Absolute Used to increase heart rateUsed to increase heart rate
Pulseless Electrical Activity
Atropine SulfateAtropine Sulfate
Dosing Dosing (How?)(How?) 1 mg IV push 1 mg IV push Repeat every 3 to 5 minutesRepeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) May give via ET tube (2 to 2.5 mg) diluted in diluted in
10 mL10 mL of NS of NS Maximum Dose: 0.04 mg/kgMaximum Dose: 0.04 mg/kg
Pulseless Electrical Activity
Atropine SulfateAtropine Sulfate
Precautions Precautions (Watch Out!)(Watch Out!) Increases myocardial oxygen demandIncreases myocardial oxygen demand May result in unwanted tachycardia or May result in unwanted tachycardia or
dysrhythmiadysrhythmia
Pulseless Electrical Activity
AmiodaroneAmiodarone
Indications Indications (When & Why?)(When & Why?) Powerful antiarrhythmic with substantial Powerful antiarrhythmic with substantial
toxicity, especially in the long term toxicity, especially in the long term Intravenous and oral behavior are quite Intravenous and oral behavior are quite
different different Has effects on sodium & potassiumHas effects on sodium & potassium
VF / Pulseless VT
AmiodaroneAmiodarone
Dosing Dosing (How?)(How?) Should be diluted in 20 to 30 mL of D5WShould be diluted in 20 to 30 mL of D5W
• 300 mg bolus after first Epinephrine dose300 mg bolus after first Epinephrine dose• Repeat doses at 150 mgRepeat doses at 150 mg
VF / Pulseless VT
AmiodaroneAmiodarone
Precautions Precautions (Watch Out!)(Watch Out!) May produce vasodilation & shockMay produce vasodilation & shock May have negative inotropic effectsMay have negative inotropic effects Terminal eliminationTerminal elimination
• Half-life lasts up to 40 daysHalf-life lasts up to 40 days
VF / Pulseless VT
LidocaineLidocaine
Indications Indications (When & Why?)(When & Why?) Depresses automaticityDepresses automaticity Depresses excitabilityDepresses excitability Raises ventricular fibrillation thresholdRaises ventricular fibrillation threshold Decreases ventricular irritability Decreases ventricular irritability
VF / Pulseless VT
LidocaineLidocaine
Dosing Dosing (How?)(How?) Initial dose: 1.0 to 1.5 mg/kg IVInitial dose: 1.0 to 1.5 mg/kg IV For refractory VF may repeat 1.0 to 1.5 mg/kg For refractory VF may repeat 1.0 to 1.5 mg/kg
IV in 3 to 5 minutes; maximum total dose, 3 IV in 3 to 5 minutes; maximum total dose, 3 mg/kgmg/kg
A single dose of 1.5 mg/kg IV in cardiac arrest A single dose of 1.5 mg/kg IV in cardiac arrest is acceptableis acceptable
Endotracheal administration: 2 to 2.5 mg/kg Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mLdiluted in 10 mL of NS of NS
VF / Pulseless VT
LidocaineLidocaine
Dosing Dosing (How?)(How?) Maintenance InfusionMaintenance Infusion
• 2 to 4 mg/min2 to 4 mg/min
• 1000 mg / 250 mL D5W = 4 mg/mL1000 mg / 250 mL D5W = 4 mg/mL 15 mL/hr = 1 mg/min15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min60 mL/hr = 4 mg/min
VF / Pulseless VT
LidocaineLidocaine
Precautions Precautions (Watch Out!)(Watch Out!) Reduce maintenance dose (not loading dose) Reduce maintenance dose (not loading dose)
in presence of impaired liver function or left in presence of impaired liver function or left ventricular dysfunctionventricular dysfunction
Discontinue infusion immediately if signs of Discontinue infusion immediately if signs of toxicity developtoxicity develop
VF / Pulseless VT
Magnesium SulfateMagnesium Sulfate
Indications Indications (When & Why?)(When & Why?) Cardiac arrest associated with torsades de Cardiac arrest associated with torsades de
pointes or suspected hypomagnesemic statepointes or suspected hypomagnesemic state Refractory VFRefractory VF VF with history of ETOH abuseVF with history of ETOH abuse Life-threatening ventricular arrhythmias due to Life-threatening ventricular arrhythmias due to
digitalis toxicity, tricyclic overdosedigitalis toxicity, tricyclic overdose
VF / Pulseless VT
Magnesium SulfateMagnesium Sulfate
Dosing Dosing (How?)(How?) 1 to 2 g (2 to 4 mL of a 50% solution) diluted 1 to 2 g (2 to 4 mL of a 50% solution) diluted
in 10 mL of D5W IV pushin 10 mL of D5W IV push
VF / Pulseless VT
Magnesium SulfateMagnesium Sulfate
Precautions Precautions (Watch Out!)(Watch Out!) Occasional fall in blood pressure with rapid Occasional fall in blood pressure with rapid
administrationadministration Use with caution if renal failure is presentUse with caution if renal failure is present
VF / Pulseless VT
ProcainamideProcainamide
Indications Indications (When & Why?)(When & Why?) Recurrent VFRecurrent VF Depresses automaticityDepresses automaticity Depresses excitabilityDepresses excitability Raises ventricular fibrillation thresholdRaises ventricular fibrillation threshold Decreases ventricular irritabilityDecreases ventricular irritability
VF / Pulseless VT
ProcainamideProcainamide
Dosing Dosing (How?)(How?) 30 mg/min IV infusion 30 mg/min IV infusion May push at 50 mg/min in cardiac arrestMay push at 50 mg/min in cardiac arrest In refractory VF/VT, 100 mg IV push doses In refractory VF/VT, 100 mg IV push doses
given every 5 minutes are acceptablegiven every 5 minutes are acceptable Maximum total dose: 17 mg/kgMaximum total dose: 17 mg/kg
VF / Pulseless VT
ProcainamideProcainamide
Dosing Dosing (How?)(How?) Maintenance InfusionMaintenance Infusion
• 1 to 4 mg/min1 to 4 mg/min
• 1000 mg / 250 mL of D5W = 4 mg/mL1000 mg / 250 mL of D5W = 4 mg/mL 15 mL/hr = 1 mg/min15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min60 mL/hr = 4 mg/min
VF / Pulseless VT
ProcainamideProcainamide
Precautions Precautions (Watch Out!)(Watch Out!) If cardiac or renal dysfunctionIf cardiac or renal dysfunction
is present, reduce maximum total dose to 12 is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/kg and maintenance infusion to 1 to 2 mg/minmg/min
Remember Endpoints of AdministrationRemember Endpoints of Administration
VF / Pulseless VT
VasopressinVasopressin an acceptable alternative, recommended an acceptable alternative, recommended a single intravenous dose of a single intravenous dose of 40 U40 U is given once is given once
(half life is 10 - 20 min versus 3 - 5 min with (half life is 10 - 20 min versus 3 - 5 min with epinephrine)epinephrine)
in a controlled trial of patients with out-of-hospital in a controlled trial of patients with out-of-hospital VF who received either vasopressin or VF who received either vasopressin or epinephrine; those treated with vasopressin had epinephrine; those treated with vasopressin had higher rates of survival to hospital admission (70 higher rates of survival to hospital admission (70 vs 35 %, p = 0.06) and survival at 24 hours (60 vs vs 35 %, p = 0.06) and survival at 24 hours (60 vs 20 %, p = 0.02)20 %, p = 0.02)
Other Cardiac Arrest DrugsOther Cardiac Arrest Drugs
Calcium ChlorideCalcium Chloride
Indications Indications (When & Why?)(When & Why?) Known or suspected hyperkalemia (eg, renal Known or suspected hyperkalemia (eg, renal
failure)failure) Hypocalcemia (blood transfusions)Hypocalcemia (blood transfusions) As an antidote for toxic effects of calcium As an antidote for toxic effects of calcium
channel blocker overdosechannel blocker overdose Prevent hypotension caused by calcium Prevent hypotension caused by calcium
channel blockers administrationchannel blockers administration
Other Cardiac Arrest Drugs
Calcium ChlorideCalcium Chloride
Dosing Dosing (How?)(How?) IV Slow PushIV Slow Push
• 8 to 16 mg/kg (usually 5 to 10 mL) IV for 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker hyperkalemia and calcium channel blocker overdoseoverdose
• 2 to 4 mg/kg (usually 2 mL) IV for prophylactic 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockerspretreatment before IV calcium channel blockers
Other Cardiac Arrest Drugs
Calcium ChlorideCalcium Chloride
Precautions Precautions (Watch Out!)(Watch Out!) Do not use routinely in cardiac arrestDo not use routinely in cardiac arrest Do not mix with sodium bicarbonateDo not mix with sodium bicarbonate
Other Cardiac Arrest Drugs
Sodium BicarbonateSodium Bicarbonate
Indications Indications (When & Why?)(When & Why?) Class I if known preexisting hyperkalemiaClass I if known preexisting hyperkalemia Class IIa if known preexisting bicarbonate-responsive Class IIa if known preexisting bicarbonate-responsive
acidosisacidosis Class IIb if prolonged resuscitation with effective Class IIb if prolonged resuscitation with effective
ventilation; upon return of spontaneous circulationventilation; upon return of spontaneous circulation Class III (not useful or effective) in hypoxic lactic Class III (not useful or effective) in hypoxic lactic
acidosis or hypercarbic acidosis (eg, cardiac arrest acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)and CPR without intubation)
Other Cardiac Arrest Drugs
Sodium BicarbonateSodium Bicarbonate
Dosing Dosing (How?)(How?) 1 mEq/kg IV bolus1 mEq/kg IV bolus Repeat half this dose every 10 minutes Repeat half this dose every 10 minutes
thereafterthereafter If rapidly available, use arterial blood gas If rapidly available, use arterial blood gas
analysis to guide bicarbonate therapy analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate (calculated base deficits or bicarbonate concentration)concentration)
Other Cardiac Arrest Drugs
Sodium BicarbonateSodium Bicarbonate
Precautions Precautions (Watch Out!)(Watch Out!) Adequate ventilation and CPR, not Adequate ventilation and CPR, not
bicarbonate, are the major "buffer agents" in bicarbonate, are the major "buffer agents" in cardiac arrest cardiac arrest
Not recommended for routine use in cardiac Not recommended for routine use in cardiac arrest patientsarrest patients
Other Cardiac Arrest Drugs
Factors Influencing Factors Influencing SurvivalSurvival
• the rhythm associatedthe rhythm associated with the arrestwith the arrest
• whether the collapse was witnessedwhether the collapse was witnessed
• adequacy of CPRadequacy of CPR
• age /age / underlying health of the patientunderlying health of the patient
rate of hospital discharge (ages 90s rate of hospital discharge (ages 90s 4.4%4.4% 80s 80s 9.4%9.4% <80 <80 19%19% ) )
ACLS and arrhythmiasACLS and arrhythmias
TachycardiaTachycardia
sudden onset of rapid heart ratesudden onset of rapid heart rate
what do you do?what do you do?
TachycardiaTachycardia
ALWAYS CHECK THE PATIENT FIRSTALWAYS CHECK THE PATIENT FIRST
1.1. Check for a pulseCheck for a pulse
2.2. Check the blood pressureCheck the blood pressure
3.3. Make a diagnosisMake a diagnosis
TachycardiaTachycardia
Case 1Case 1
On ward, sudden onset of palpitationsOn ward, sudden onset of palpitations
1.1. Does the patient have a pulse? YesDoes the patient have a pulse? Yes
2.2. What is the blood pressure? 60/20What is the blood pressure? 60/20
Is the patient “stable” or “unstable”?Is the patient “stable” or “unstable”?
Definition of “Unstable”Definition of “Unstable”presence of any one ofpresence of any one of::
1.1. Low blood pressureLow blood pressure
2.2. Short of BreathShort of Breath
3.3. Chest painChest pain
4.4. LightheadedLightheaded
5.5. CHFCHF
Unstable TachycardiaUnstable Tachycardia
goal is to slow down rate orgoal is to slow down rate or convert to sinus rhythmconvert to sinus rhythm
drugs or electrical cardioversion is drugs or electrical cardioversion is usedused
usually cardioversion if unstableusually cardioversion if unstable
Electrical ShockElectrical Shock
defibrillationdefibrillation or or cardioversioncardioversion (= “synchronized”) (= “synchronized”) action: resets all activity to zeroaction: resets all activity to zero
good for tachycardia (non-sinus)good for tachycardia (non-sinus) good for ventricular fibrillation (VF)good for ventricular fibrillation (VF)
Electrical ShockElectrical Shock
defibrillationdefibrillation or or cardioversioncardioversion (= “synchronized”) (= “synchronized”)
NOT USED FOR:NOT USED FOR: sinus rhythmsinus rhythm bradycardiabradycardia asystoleasystole
Case #2Case #2
Alarm on ECG monitor makes noise!!Alarm on ECG monitor makes noise!!
Case #2Case #2
Patient is awake and Patient is awake and talkingtalking
Diagnosis?Diagnosis? ECG lead is disconnectedECG lead is disconnected ECG shows artifactECG shows artifact
Case #3Case #3
Alarm on ECG monitor makes noise!!Alarm on ECG monitor makes noise!!
Case #2Case #2 Try to wake up. Does not wake upTry to wake up. Does not wake up Check for breathing. No breathing.Check for breathing. No breathing. Check for pulse. No pulse.Check for pulse. No pulse.
What is the diagnosis?What is the diagnosis?
What do you do?What do you do?
Ventricular Fibrillation (VF)Ventricular Fibrillation (VF)
What is the cure for VF?What is the cure for VF?
DEFIBRILLATIONDEFIBRILLATION
EARLY defib. has higher EARLY defib. has higher successsuccess
SHOCK SOON, SHOCK OFTENSHOCK SOON, SHOCK OFTEN
VFVF
DrugsDrugs improve success of defibrillation (the cure)improve success of defibrillation (the cure) do NOT cure VFdo NOT cure VF
lidocainelidocaine procainamideprocainamide amiodaroneamiodarone
VFVF
What is the cardiac output in VF?What is the cardiac output in VF? Zero. There is no circulationZero. There is no circulation
What MUST occur at all times?What MUST occur at all times? CPR … unless defib. is CPR … unless defib. is
happening.happening.
How do you manage ventilation?How do you manage ventilation? bag-mask and early intubationbag-mask and early intubation
VF SummaryVF Summary
Start CPR … and only stop to shockStart CPR … and only stop to shock IntubateIntubate Defibrillation is the most important!!!Defibrillation is the most important!!! DrugDrug shockshock drug drug shockshock
Case #4Case #4
BP 60/30BP 60/30
Diagnosis?Diagnosis?
Treatment?Treatment?
Case #4: Sinus BradycardiaCase #4: Sinus Bradycardia
Treatment: increase heart rate!Treatment: increase heart rate!
Methods:Methods:
1.1. atropine (probably successful)atropine (probably successful)
2.2. pacing (thoracic skin paddles)pacing (thoracic skin paddles)
3.3. dopamine infusiondopamine infusion
Case #5Case #5
BP 60/30BP 60/30
Diagnosis?Diagnosis?
Treatment?Treatment?
33rd Degree Block (Bradycardia)rd Degree Block (Bradycardia)Treatment: increase heart rate!Treatment: increase heart rate!
Methods:Methods:
1.1. atropine (probably NOT successful)atropine (probably NOT successful)
2.2. pacing (thoracic skin paddles)pacing (thoracic skin paddles)
3.3. dopamine infusiondopamine infusion
Case # 6Case # 6
BP: 120/80 , no chest pain , no rales , alertBP: 120/80 , no chest pain , no rales , alert
Diagnosis?Diagnosis?
Treatment?Treatment?