ALSALSAdvanced Life Support

Simonetta TesoroDipartimento di Medicina Clinica e Sperimentale

Sezione di Anestesia, Analgesia e Terapia IntensivaDir. Prof. Vito Aldo Peduto

Università degli Studi di Perugia

HOSPITAL CARDIAC ARREST

• Fewer than 20% of patients suffering an in-hospital cardiac arrest will survive to go home. Most survivors have monitored VF arrest (primary myocardial ischaemia) and receive immediate defibrillation

• Cardiac arrest in patients in unmonitored ward areas isn’t usually caused by primary cardiac disease but by a progressive physiological deterioration, involving hypoxia and hypotension and it is usually non-shockable. The survival to hospital discharge is very poor.

The records of patients who have a cardiac arrest often contain evidence of unrecognised,unrecognised, or untreated, breathing and circulation problems.breathing and circulation problems.

European Resuscitation Council Guidelines 2005

IN-HOSPITAL CARDIAC ARREST

• Hipoxia and incorrect use of oxygen therapy

• Fluid and electrolyte balance

• Poor analgesia

• Lack knowledge about drug doses

• Failure to monitor patients

EARLY WARNING SCORINGEWS

Early warning scoring systems allocate points to routine vital signs measurements

on basis of their derangement from an arbitrarily agreed normal range.

May be used to call ward doctors or critical care out-reach teams to the patient.

THE IMPORTANCE OF EARLY RECOGNITION AND TREATMENT OF CRITICALLY ILL PATIENTS

TO PREVENTTO PREVENT CARDIAC ARREST

MEDICAL EMERGENCY TEAMMET

It is a team that responds, not only to patient in cardiac arrest, but also to

those with acute physiological deterioration

The MET usually comprises medical and nursing staff from intensive care

and general medicine

GUIDELINES FOR PREVENTION OF IN-HOSPITAL CARDIAC ARREST

• Provide care for patients who are critically ill in appropriate areas.

• Critically ill patients need regular observation of vital signs.

• Use EWS to identify patients at risk of clinical deterioration.

• The hospital should have a MET capable of responding to acute clinical crises avaible 24h per day

• Identify patients for whom cardiopulmonary arrest is an anticipated terminal event and in whom CPR is inappropriate

• Ensure accurate audit of cardiac arrest, “false arrest”, unexpected deaths and unanticipated ICU admissions

STEPS FOR STEPS FOR SUCCESSFUL SUCCESSFUL

RESUSCITATIONRESUSCITATION1. Early recognitionrecognition of the emergency and

calling for help.calling for help.2. Early bystander CPRCPR: immediatemmediate CPR

can double or triple survival.3. Early defibrillationdefibrillation: CPR + defibrillation

within 3-5 min can produce survival rates as high as 49-75%. Each minute of delay in defibrillation reduces the probability of survival to discharge by 10-15%.

4. Early Advanced Life SupportAdvanced Life Support and post resuscitation care: the quality of treatment affects outcome.

GUIDELINESGUIDELINES

Based on the document 2005 International Consensus on

Cardiopulmonary Resuscitations and Emergency Cardiovascular Care Science

with Treatment Recommendations. November 2005

• American Heart Association (AHA)• European Resuscitation Council (ERC)• Italian Resuscitation Council (IRC)• International Liaison Commitee on

Resuscitation (ILCOR)

CHAIN OF SURVIVALCHAIN OF SURVIVAL Cummins 1991…..

GOLD STANDARDGOLD STANDARD • GOOD NEUROGICAL OUTCOME

BLS-DBLS-D ALSALS

CHAIN OF SURVIVALCHAIN OF SURVIVAL Cummins 1991…..

• ALSALS: AAdvanced LLife SSupport

• ACLSACLS: AAdult CCardiac LLife Support

ALSALSFOR

NO LAY RESCUERNO LAY RESCUER

HOSPITAL RESUSCITATION

CHECK THE VICTIM FOR A RESPONSE: gently shake his shoulders and ask loudly:”are you all right?”

SHOUT FOR HELP

AA = AirwayOPEN THE AIRWAY

HEAD TILT AND CHIN LIFT

•Place your hand on his forehead and gently tilt his head back keeping your thumb.

•With your fingertips under the point of the victim’s chin, lift the chin to open the airway.

JAW THRUST

The rescuer’s index and other fingers are placed behind the angle of the mandible.Using the thumbs, the mouth is open

slightly by downward displacement of the chin

INSERTION OF OROPHARYNGEAL AIRWAY

AIRWAY OBSTRUCTION

1.1. LOOK-LISTEN-FEELLOOK-LISTEN-FEEL

In partial obstruction air entry is diminished and usually noisy.

Inspiratory stridor is caused by obstruction at the laryngeal level or above

• GURGLING is caused by liquid or semisolid foreign material

• SNORING arises when the pharynx is partially occluded by the soft palate or epiglottis

• CROWING is sound of laryngeal spasm

BB = Breathing

• LL = LOOKLOOK chest movement

• LL = LISTENLISTEN at the victim’s mouth for breath sounds

• FF = FEELFEEL for air on your cheek

…1,2, 3, 4, 5, 6, 7, 8, 9, 10

HE IS BREATHING

NO MORE THAN 10 NO MORE THAN 10 SS

IF HE IS BREATHING NORMALLYNORMALLY• Turn him into the recovery position• Chek for continued breathing

DO NOT CONFUSE BARELY BARELY

BREATH NOISY BREATH NOISY GASPSGASPS WITH

NORMAL BREATHING

• LL = LOOKLOOK chest movement

• LL = LISTENLISTEN at the victim’s mouth for breath sounds

• FF = FEELFEEL for air on your cheek

…1,2, 3, 4, 5, 6, 7, 8, 9, 10

HE ISN’T BREATHING

NO MORE THAN 10 NO MORE THAN 10 SS

CHEST COMPRESSION• Place the heel of one hand in the centre of the

victim’s chest; place the heel of your hand on top of the first hand. Interlook the fingers of your hands. Ensure that pressure is not applied over the victim’s ribs. Do not apply any pressure over the upper abdomen or the bottom end of bony sternum

• Position yourself vertically above the victim’s chest and, with your arm straight

• Press down on the sternum 4-5 cm.• After each compression, release all the

pressure on the chest without losing contact between your hands and the sternum

• Take approxmately the same amuont of time for compression and relaxation. Minimise interruptions in chest compression.

GUIDELINES CHANGES

1.Increase the number of chest compressions 30:2

2.No cheking carotid pulse

3.One-shock versus three-shock sequence

4.Time of adrenaline

Coronary Artery Perfusion Pressure Improves With Longer Series of

Chest Compressions in Adult VictimsCoronary Artery Pressure at 5:1 Coronary Artery Pressure at 5:1

ratioratio

Pressure at 15:2 ratioPressure at 15:2 ratio

GUIDELINES CHANGES

1.Increase the number of chest compressions 30:2

2.No cheking carotid pulse

3.One-shock versus three-shock sequence

4.Time of adrenaline

CHECK CIRCULATION• If the patient has NO signs of life –lack of

movement, normal breathing, coughing- start CPR

• Those experienced in clinical assessment should assess the CAROTID PULSE whilst simultaneously looking for signs of lif for not more than 10 s

If there is doubt start CPR immediately

MUST BE AVOID DELAY IN MUST BE AVOID DELAY IN DIAGNOSISDIAGNOSIS !

VENTILATION

BAG-MASK BAG-MASK VENTILATIONVENTILATION

• One person holds the facemask in place using a jaw thrust with both hands

• An assistant squeezes the bag

MOUTH TO MASK VENTILATION

10 BREATHS min10 BREATHS min-1-1

DO NOT DO NOT HYPERVENTILATEHYPERVENTILATE

DD = Defibrillation

DEFIBRILLATORS

• Automated External Defibrillators AEDAutomated External Defibrillators AED The defibrillators assess the rhythm with waveform

analysis and give automatically a shock.• Manual defibrillatorsManual defibrillators

It is used healthcare rescuers because they have to do diagnosis and give a shock. It’s used for

synchronised cardioversion• Semi-autometed external defibrillator Semi-autometed external defibrillator

The defibrillators assess the rhythm with waveform analysis and the rescuer has to give a shock.

ELECTRODE POSITION

Apply paddles or self-adhesive pads to the chest

SEQUENCE FOR USE OF AN AED 1. MAKE sure you, the victim and any bystanders are

safe.2. If the victim is unresponsive and not breathing

normally, send someone for the AED and to call for an ambulance.

3. Start CPR according to the guidelines for BLS4. As soon as the defibrillator arrives:

-switch on the defibrillator and attach the electrode pads-ensure that no body touches the victim while the AED is unlysing the rhythm

5. If a shock is indicated: push shock button as directed 6. If no shock indicated: immediately resume CPR 7. Continue until:

-qualifield help arrives and takes over-the victim starts to breathe normally-you become exhaustead

AED ALGORITHM

GUIDELINES CHANGES

1.Increase the number of chest compressions 30:2

2.No cheking carotid pulse

3.One-shock versus three-shock sequence

4.Time of adrenaline

PRECORDIAL THUMPConsider giving a single precordial thump when

cardiac arrest is confirmed rapidly after a witnessed, sudden collapse and a defibrillator is

not immediatele to hand.

Using the ulnar edge of a tightly cleneched fist, deliver a sharp impact to the lower half of the

sternum from a height of about 20 cm.

A precordial thump is most likely to be successful in converting VT to sinus rhythm.

Successful treatment of VF is much less likely: if it was given within the first 10 s of VF

SOMMINISTRATION ROUTE

• INTRAVENOUS: drugs injected perperipherally must be followed by a flush of at least 20 ml.insertion of central venous catheter requires interrumpion of CPR

• TRACHEAL ROUTE: if intravenous can’t be established.Unpredictable plasma concentration are achieved and equipotent dose is unknown.DOSE: three to ten times higher diluited in 10 ml

HOSPITAL RESUSCITATION

ADRENALINE • Adrenaline is the first drug used in cardiac

arrest of any aetiology: it is included in the ALS ALGORITHM for use

1 mg every 3-5 min of CPR1 mg every 3-5 min of CPR

• Its primary efficacy is due to its alpha-adrenergic vasoconstrictive effects causing systemic vasoconstriction, which increases coronary and cerebral perfusion pressures.

• The beta adrenergic actions of adrenaline increases miocardial oxygen consumption, ectopic ventricular arrhythmias and transient hypoxaemia due to pulmonary arteriovenous shunting.

CPR 2 min - SHOCK CPR 2 min - SHOCK CPR 2 min – ADRENALINE - SHOCKCPR 2 min – ADRENALINE - SHOCK

GUIDELINES CHANGES

1.Increase the number of chest compressions 30:2

2.No cheking carotid pulse

3.One-shock versus three-shock sequence

4.Time of adrenaline

AMIODARONEIt is a membrane-stabilising anti-arrhythmic drug that increase

the duration of the the action potential

• INDICATIONINDICATION Refractory VF/VT Heamodynamically stable ventricular tachycardia (VT)

and other resistant tachyarrhythmia

• DOSEDOSE

300 mg in 20 ml dextrose 5%300 mg in 20 ml dextrose 5%

• ADVERSE EFFECTSADVERSE EFFECTS

May be arrhythmogenic

Hypothension

Bradycardia

LIDOCAINE

Until 2000 it was the antiarrhytmic drug of choiceNow it is recommended only when amiodarone is

unavailable• DOSEDOSE

1-1.5 mg/kg1-1.5 mg/kgAdditional bolus 50 mg

Max 3 mg/kg during first h

Its half-life is prolonged during cardiac arrestIt is less effective in the presence of hypokalaemia

and hypomagnesaemia

MAGNESIUM SULPHATEIt is an important constituent of many enzyme and

improves the contractile response of the stunned myocardium

• INDICATIONINDICATION Shock-refractory VF in the presence of possible

hypomagnesaemia Ventricular tachyarrhythiamias in the presence of

possible hypomagnesaemia Torsades de pointes Digoxin toxicity

• DOSEDOSE2 g in 1-2 min2 g in 1-2 min

It may be repeated after 10-15 min

ATROPINE

• INDICATIONINDICATIONAsystolePulseless electrical activity (PEA) with a rate

<60 min-1

Sinus, atrial or nodal bradycardia when the haemodynamic condition of the patient is unstable

• DOSEDOSE

3 mg ev3 mg ev

SODIUM BICARBONATEThe best treatment of acidemia in cardiac arrest is

chest compression

NOT INDICATED DURING CPR:NOT INDICATED DURING CPR:– It exacerbates intracellular acidosis– It causes generation of carbon dioxide– It produces a negative inotropic effect on ischaemic myocardium– It presents a large, osmotically active, sodium load– It produces a shift to the left in the oxygen dissociation curve, further

inhibiting release of oxygen to the tissues.

Following resuscitation from cardiac arrest, consider giving small doses of sodium bicarbonate50 ml of an 8.4% solution

CONSIDER SODIUM BICARBONATE:CONSIDER SODIUM BICARBONATE:– Life-threatening hyperkalaemia/ cardiac arrest associated

hyperkaelemia– Severe metabolic acidosis– Tricyclic overdose

VF and VT pulselessVF and VT pulseless

LIDOCAINA now recommended only when amiodarone is unavailable / in refractory FV-VT

1-1.5 mg/kg ev1-1.5 mg/kg ev

1 additional bolus dose max 3 mg/kg

AMIODARONE CLASSE IIb

300 mg ev

additional bolus ev 150 mg dose max 2.2 gr in 24 h

MgSO4 CLASSE IIb

1-2 gr ev

• shock-refractory VF + HypoMgSO4

• Ventricular tachyarrhythmias + HypoMgSO4

• Torsades de pointes + HypoMgSO4

PROCAINAMIDE CLASSE IIb nella FV/TV recidivante/intermittente

30 mg/min dose max 17 mg/kg

ACCETTATA MA NON RACCOMANDATA PER LUNGHI TEMPI DI SOMMINISTRAZIONE

BRADYCARDIBRADYCARDIAA