Advanced cardiac life support
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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

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Advanced Cardiac Life Support

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Advanced Cardiac Life Support

N.Tavakoli

Assistant professor

Department of Emergency Medicine

Iran University of Medical Sciences


Chain of Survival

EarlyACCESS

EarlyCPR

EarlyDEFIB

EarlyACLS


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 Route

  • ‘’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 Agentsin ACLSfor 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 in10 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 dysfunctionis 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 associatedwith the arrest

  • whether the collapse was witnessed

  • adequacy of CPR

  • age /underlying health of the patient

    rate of hospital discharge (ages 90s 4.4% 80s 9.4% <80 19% )


ACLS and arrhythmias


Tachycardia

sudden onset of rapid heart rate

what do you do?


Tachycardia

ALWAYS CHECK THE PATIENT FIRST

  • Check for a pulse

  • Check the blood pressure

  • Make a diagnosis


Tachycardia

Case 1

On ward, sudden onset of palpitations

  • Does the patient have a pulse? Yes

  • What is the blood pressure? 60/20

    Is the patient “stable” or “unstable”?


Definition of “Unstable”presence of any one of:

  • 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:

  • atropine (probably successful)

  • pacing (thoracic skin paddles)

  • dopamine infusion


Case #5

BP 60/30

Diagnosis?

Treatment?


3rd Degree Block (Bradycardia)

Treatment: increase heart rate!

Methods:

  • atropine (probably NOT successful)

  • pacing (thoracic skin paddles)

  • dopamine infusion


Case # 6

  • BP: 120/80 , no chest pain , no rales , alert

    Diagnosis?

    Treatment?


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