Dr yonas ppt for ACLS for residents of emergency
- 1. Yonas ( ECCM R-1) Advisor Dr. Mohammed ( ECCM consultant)
- 2. Objectives Introduction ABCD of ACLS Cardiac arrest rhythms Post cardiac arrest algorithm Updates on ACLS
- 3. To explain causes of cardiac arrest To list down ABCD of ACLS To identify cardiac arrest rhythms To explain cardiac arrest and post cardiac arrest algorithm To mention updates on ACLS
- 4. Cardiac arrest(CA)- defined by triad of ◦ unconsciousness ◦ Apnea ◦ pulselessness ACLS- is advanced support given to a patient with Cardiac arrest ACLS - is a series of evidence-based responses simple enough to be committed to memory and recalled under moments of stress 4/21/2024 4
- 5. The goal of ACLS is to achieve the best possible outcome for whom experiencing a life-threatening event ACLS guideline updated every 5 years The recent updated ACLS guide line is the 2020
- 6. ◦ 6.8 to 8.5 million people/year throughout the world sustain cardiac arrest ◦ More than 70% of these occur out of hospital ◦ Annual incidence of OHCA is 140/100,000 ◦ VT and VF are the initiating event in about 80% of the patient above
- 7. Survival rate of victims of sudden cardiac arrest For OHCA is ≈ 5 percent For IHCA is 22.3% to 25.5% Patients with VF/VT have 10-15 times more chance of surviving than those suffering from PEA/Asystole. For every minute delay in defibrillation, survival decreases by 10%.
- 10. Differential diagnosis Investigate other causes of non responsiveness, look for reversible causes (5Hs and 5Ts)
- 11. When encountering an individual who is “down,” Make sure the scene is safe before approaching the individual and conducting the BLS or ACLS Survey Apply chain of survival
- 14. Basic airway materials ◦ Nasopharyngeal ◦ Orophryngeal Advanced airway equipment ◦ laryngeal mask airway ◦ laryngeal tube ◦ esophageal-tracheal tube ◦ endotracheal tube Suctioning
- 15. To support and restore effective ◦ Oxygenation ◦ ventilation ◦ circulation ROSC (Return of spontaneous circulation) is an intermediate goal of ACLS
- 16. Three basic theories for how pressure gradients and flow are produced during closed chest cardiac massage; 1. Cardiac pump theory 2. Thoracic pump theory 3. Abdominal pump theory 4/21/2024 16
- 17. Rate 100- 120 per min Depth 5 cm - 6 cm with each down-stroke Allow for complete chest recoil between compressions Minimize interruptions between chest compressions If multiple rescuers are available, rotate the task of compressions every 2 minutes. 4/21/2024 17
- 18. Give Breaths after 30 compression Breaths should be delivered over one second Adult:30 compression :2 breathing Child:15 compresion:2 breathing
- 19. Defibrillation is the therapeutic use of electric shock in cardiac arrest to depolarize the entire myocardium Defibrillation should be done as soon as it is available in shockable rhythm Two types of AED exit Biphasic defibrillators (120 to 200 J). Monophasic defibrillation is 360 J. Place one pad on upper right side and the other on the chest a few inches below the left arm.
- 20. Stopping all compressions and patient movement is recommended Rescuer(s) should not be in contact with the patient move the patient to a safe area and dry the body before delivering Remove all metallic objects and nitroglycerin patches from the patient Remove all direct sources of oxygen to avoid fire Do not allow the conducting gel to spread to within 5 cm of the other For internal pacemaker, the pads are placed well away (12.5 cm or 5 inches)
- 23. Drug doses are the same whether by IV, IO or Central line Drugs are adjunct Good CPR, Early Defib and Ventilation are the corner stone
- 26. Endogenous catecholamine Provides the most benefit within the first 15 to 20 minutes Used in ◦ VF or pulseless VT unresponsive to initial shock ◦ PEA and Asystole Standard dose ◦ 1 mg diluted in 10mL IV push repeat q 3 - 5 min
- 27. Class III antiarrhythmic drug Use in Cardiac arrest for: Persistent VT/VF after defibrillation and epinephrine Given only for shockable rhythem For pulseless VT/VF dose is 300mg IV followed by 20 mL NS flush Give another 150 mg if there is no response to the first dose
- 28. is a class I antidysrhythmic drug. It reduces automaticity, suppresses ventricular ectopy Is the second-choice drug after amiodarone the dose was an IV bolus of 1 to 1.5 mg/kg. A second bolus of 0.5 to 0.75 mg/kg if the rhythm persisted
- 32. • Team dynamics • Clear communication between team leaders and team members • know your own clinical limitations • Only take on tasks you can perform successfully. • Clearly state when you need help • mutual respect, knowledge sharing, constructive criticism • follow-up discussion (debriefing) after the event
- 36. Traditional monitoring ◦ Pulse palpations and ECG Modern monitoring ◦ Quantitative wave capnography ◦ Central venous oxygen saturation ◦ Coronary perfusion pressure
- 37. 1, Waveform capnography Used to measure end-tidal carbon dioxide (EtCO2) ETCO2 is the partial pressure of carbon dioxide(co2) at the end of an exhaled breath It reflects cardiac output and pulmonary blood flow
- 38. ETCO2- is used to Monitoring ventilation rate during CPR Monitoring the quality of chest compressions during CPR Identifying ROSC during CPR ◦ If ETco2<<10mmhg ROSC is unlikely ◦ If ETco2 increase abrubtly to 35to40 mmhg is indicator of ROSC Prognostication during CPR. ◦ PECO2<<<10 mmHg after 20 min of CPR is associated with a poor outcome in observational studies
- 39. 2, Central venous oxygen saturation Measured by using oximetric tipped central venous catheter placed in superior vena cava or pulmonary artery Normal range-60%-80% If the scvo2 is less than 30%, rosc is unlikely
- 40. 3, Coronary perfusion pressure/arterial relation pressure The pressure gradient between the aorta and the right atrium during the ‘diastolic’ portion of chest compression not commenly used because time is needed to insert the pressure-measuring catheters. Increased CPP correlates with both myocardial blood flow and ROSC If CPP less than 20mmhg-ROSC unlikely
- 44. Systemic cooling of resuscitated adult cardiac arrest for 24 hours following return of spontaneous circulation. It can dramatically improve survival and neurologic outcomes. controversy exists regarding the appropriate “target temperature” for post arrest care. most protocols aim for a core temperature of 32°C to 36°C.
- 48. Post cardiac arrest goals
- 52. persistent or recurrent despite three shocks from a defibrillator, three rounds of epinephrine, and use of an antiarrhythmic. Rx - Change defibrillation strategy -Vector-change (VC) defibrillation -Double sequential external defibrillation
- 53. • Double sequential external defibrillation (DSED), the technique of providing rapid Sequential shocks from two defibrillators with defibrillation pads placed in two different planes (anterior-lateral and anterior- posterior) • has been studied for decades in the Electrophysiology laboratory for use in patients with refractory atrial or VF • Vector-change (VC) defibrillation, the technique of switching defibrillation pads from the Anterior-lateral to the anterior-posterior position • offers the theoretical potential to defibrillate a portion of the ventricle that may not be completely defibrillated by pads in the standard Anterior-lateral position Defibrillation for Refractory VF
- 55. Vasopressin alone or with methylprednisolone in combination with epinephrine Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that is unresponsive to defibrillation Routine administration of calcium, sodium bicarbonate, and magnesium for cardiac arrest is not recommended. ECMO for patients with cardiac arrest refractory to standard ACLS is reasonable when equipment and trained staff are available Coronary angiography should be performed emergently for all cardiac arrest patients with suspected cardiac arrest and ST-segment elevation on electrocardiography
- 56. During post-arrest temperature control, a constant temperature between 32°C and 37.5°C should be maintained Patients with spontaneous hypothermia after ROSC unresponsive to verbal commands should not routinely be actively or passively rewarmed faster than 0.5°C per hour Seizure activity should be treated Organ donation should be considered in all patients resuscitated from cardiac arrest who meet neurological criteria for death or before planned withdrawal of life-sustaining therapies.
- 57. Indications to consider cessation of resuscitation: ◦ Duration of resuscitative effort >30 minutes without a sustained perfusing rhythm ◦ Unwitnessed collapse with an initial ECG rhythm of asystole ◦ Prolonged interval between time of collapse and initiation of cardiopulmonary resuscitation (CPR) ◦ Patient age, severe comorbid disease, or prior functional dependence
- 58. Hypothermia Drowning Toxicological arrest Asthma (need to correct dynamic hyperinflation) Pregnancy prior to resuscitative caesarean section Young people who have persistent VF until reversible factors have been fixed) or therapeutic options exhausted 4/21/2024 58
- 59. Judith E. Tintinalli et al, Tintinalli’s Emergency Medicine A Comprehensive Study Guide,9th edition 2020 Ron M. Walls et al , Rosen’s emergency medicine: concepts and clinical practice, 10th edition, 2023 Karl disque, Advanced cardiac life support, providers hand book,2021 Jonathan Elmer, advanced cardiac life support in adults, Up-to- date 2024 ACLS algorithms, American heart association,2020 https://www.acc.org/Latest-in-Cardiology/ten-points-to- remember/2023/12/21/16/43/2023-aha-adult-acls
Editor's Notes
- #28: Give after the 3rd shock
- #30: PEA-is any organized/ semiorganized rhythm without pulse
- #46: Because coagulopathy and bleeding can result from lowering of core body temperature, patients with clinically significant bleeding at the time of arrest or who have arrested from penetrating trauma are generally excluded from targeted temperature management, although therapeutic anticoagulation is not a contraindication. Note the inclusion of a category of clinical items that would not preclude the use of therapeutic hypothermia. These represent issues commonly asked about by practitioners but should not represent exclusion criteria. Abbreviations: DNI = do not intubate; DNR = do not resuscitate; GCS = Glasgow Coma Scale; ROSC = return of spontaneous circulation. ∗Criteria that are controversial and may vary from hospital to hospital.
- #48: Bradycardia is very common and often pronounced (heart rate <50 beats/min) with induction, but usually is of little clinical consequence and requires no treatment.31 Tachyarrhythmias, atrial fibrillation, and nonsustained ventricular tachycardia are uncommon unless core body temperature is <32°C (89.6°F). QTc prolongation has been observed, so continuous cardiac monitoring and interval ECGs are necessary.54 Shivering can impede the lowering of body temperature. A variety of treatment approaches to shivering exist, the most definitive being neuromuscular blockade. Bleeding can be exacerbated by lowered core temperature but occurs in <5% of cases.31,55 Hypokalemia and hypomagnesemia can result from intracellular shifts and diuresis mediated by lowered core temperature.
- #55: https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2023/12/21/16/43/2023-aha-adult-acls