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Advanced Cardiac Life Support 2004

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  1. Advanced Cardiac Life Support 2004 Mark I. Langdorf, MD, MHPE, FACEP Professor or Clinical Emergency Medicine Chair and Associate Residency Director University of California, Irvine

  2. ACLS History • Sixth iteration of guidelines since 1966 • Second that is evidence based • First that incorporates international perspective

  3. Evidence Based Guidelines • Search the international literature • Determine level of each piece of evidence • Graded each study for quality • Integrate all evidence into final class recommendation

  4. Classes of Recommendations • Class I: always acceptable, proven safe and definitely useful • Class IIa: acceptable, reasonably prudent, intervention of choice by experts • Class IIb: acceptable, safe and useful, within standard of care, optional or alternative by experts • Interderminate: inadequate research to decide • Class III: evidence for benefit lacking, or harmful

  5. Chain of Survival • Recognize early warning signs • Activate EMS • Basic CPR • Defibrillation • Airway and ventilation • Intravenous medications

  6. Public Access Defibrillation: PAD • Goal: AEDs used by laypersons everywhere • Most effective cardiac intervention • Shown to be cost effective (cost per life year saved) • Response time goal is 3 to 5 minutes • Police • Fire • Casino • Airlines • First responders • Survival rates up to 49% from primary ventricular fibrillation

  7. Sequence of Events • 50% of patients with CAD first present with sudden death • Sequence: • Decades of atherosclerotic buildup • Plaque rupture or erosion • Platelet adhesion • Occluding thrombus • Severe ischemia • Irritable myocardium • Ventricular fibrillation • Collapse and sudden death

  8. Adult BLS: Recent Changes • Phone first (no CPR unless drowned, trauma or overdose) • BLS should transport to ED capable of IV thrombolysis for MI and stroke • Within 30 minutes for MI • Within 60 minutes for stroke

  9. BLS Sequence Changes • 10cc/kg tidal volume without oxygen • 6-7 cc/kg with supplemental oxygen • Prevent gastric insufflation: deliver over 2 seconds • Lay rescuers don’t check pulses before chest compressions, healthcare workers do • Compression rate 100/minute • 15:2 ratio for 1 and 2-rescuer CPR

  10. Prehospital Care for ACS • Oxygen is routine • Aspirin en route: 160-325mg • Nitroglycerin • Be careful with Viagra • Need SBP >90 • 3 sprays q 3-5 minutes • Morphine if 3 sprays don’t relieve pain • 12 lead ECG under study

  11. Prehospital Stroke Care • Determine time of onset and GCS • Perform prehospital stroke scale • Cincinnati PSS: sensitivity 72% • Los Angeles PSS: 93% sensitivity, 97% specificity • LAPSS • Age > 45 • No seizures • Duration < 24 hours • Ambulatory at baseline • Glucose 60-400 • Obvious asymmetry of face/grip/arm strength

  12. ACLS Changes for 2000 • Wide complex tachycardia: Amiodarone and procainamide before lidocaine and adenosine (IIb) • Stable V tach (and torsades): Amiodarone and sotalol preferred (IIa) • Bretylium not available (IIb) • Lidocaine: evidence poor for benefit for v-fib and v-tach (indeterminate)

  13. ACLS Changes for 2000 • V-fib/pulseless V-tach: evidence for all antiarrhythmics weak. Amiodarone preferred (IIb) • Magnesium still IIb for torsades de pointes (polymorphic ventricular tachycardia) • Vasopressin: may be more effective than epinephrine in cardiac arrest (IIb) • 40 units IV only once • Epinephrine still class IIb • High-dose epinephrine: no benefit (indeterminate)

  14. Defibrillation: Biphasic • Will become the norm • As effective at lower energy • 150 biphasic = 200 monophasic • No need for escalating energy levels (joules) • Transthoracic impedance declines with subsequent shocks • Repeat same energy = success

  15. Shock Energies: Recommended • Still 200/200-300/360 joules for v-fib /pulseless v-tach • Atrial fibrillation: 100-200 • Atrial flutter/PSVT 50 to start • Ventricular tachycardia • Monomorphic (usual) 100 joules • Polymorhpic (torsades de pointes) 200 joules

  16. Other Defibrillator Points: • Synchronize for any perfusing rhythm • Avoids precipitating ventricular fibrillation • Hold buttons down • Check two leads for asystole • If no ventricular fibrillation noted, defibrillation not effective • Lead disconnect can simulate asystole

  17. Cardiac Arrhythmias • Check the patient, not the rhythm • Perfusion is most important • Wide complex tachycardias are ventricular tachycardia • Odds 75/25 ventricular/supraventricular • Older (>45 yo) • Sicker (previous MI or coronary disease) • Treat the worst, first • 12 ECG criteria not reliable enough to distinguish

  18. Rhythms to recognize • Normal sinus rhythm • Atrio-ventricular (AV) blocks • 1st degree(not important) • 2nd degree • Type I (Wenkebach) • Type II (dangerous) • 3rd degree (complete, AV disassociation) • Premature complexes • Atrial (no pause) • Ventricular (compensatory pause)

  19. Rhythms to Recognize • Ventricular tachycardia • Monomorphic • Polymorphic (Torsades de pointe) • Ventricular fibrillation • Asystole (confirm)

  20. Tachyarrhythmias • Narrow QRS complex (<120 msec) • Sinus • Atrial fibrillation • Atrial flutter • Atrial tachycardia (digoxin toxicity) • Multifocal atrial tachycardia (COPD) • AV nodal re-entrant tachycardia (PSVT) • Junctional tachycardia

  21. Tachyarrhythmias • Wide QRS (>120 msec) • Ventricular tachycardia (usually 160 msec) • Supraventricular tachycardia with aberrant conduction (usually not this wide) • 12 lead if stable • Mr. Edison if not

  22. Show Rhythm Strips

  23. Routes for Drug Administration • Evidence for effectiveness for all drugs is weak • Drugs are secondary interventions • Peripheral still first choice • flush with NS • 1-2 minutes to central circulation • If no response to drugs and defibrillation • Consider central line • Internal jugular (IJ) preferred (or supraclavicular subclavian) • Femoral less preferred • Avoid non-compressible sites if possible

  24. Tracheal Administration • N-a-v-e-l still holds: drugs for the ET tube • Narcan • Atropine • Valium • Epinephrine • Lidocaine • Amiodarone/vasopressin not yet studied, so avoid • Dilute in 10cc/bag vigorously • 2-2.5 times the IV dose for all meds

  25. Wide Complex Tachycardias: Stable • Must be regular and fast (>120) • Must be uniform (one QRS morphology) • No signs of impaired perfusion • Mental status normal • No chest pain or CHF • Skin signs warm and dry • Systolic BP > 90 mm Hg • Obtain 12 lead ECG if stable

  26. Wide Complex Tachycardias: Stable • Procainamide first line if ventricular function normal (sotalol) (both IIa) • Amiodarone (IIb) (150mg over 10 minutes) or Lidocaine (.5-.75mg/kg IVP) if poor EF (<40%) • If ineffective: • Synchronized cardioversion (100/200/300/360 joules) • No repeat drug doses recommended • Bottom line: • Normotensive: procainamide • Hypotensive: cardiovert

  27. Polymorphic Ventricular Tachycardia • Recurrent bouts • Usually terminate spontaneously, or • Degenerate into v-fib • Stop offending meds that prolong QT interval • Correct hyopcalcemia/hypomagnesemia • Magnesium 2-4 grams IVP (shortens QT) • Transcutaneous pacer (“overdrive pacing”) • Rate >100 if no ischemia • Shortens QT, reduces recurrence

  28. V-fib/Pulseless V-tach • This is easy! • Defib three times ASAP (200/300/360) • ABCs • Epi 1mg IV every 3-5 minutes, or • Vasopressin 40 units IVP, once • Then Epi same as usual • Amiodarone (IIb) 300mg IVP (second dose if recurrent V-fib 150 mg)

  29. Look for Cause! • Hypovolemia • Hypoxia • ETT/02 hooked up/pneumothorax/CO poisoning • Acidosis • Hypo/hyperkalemia • Cardiac tamponade • Tension pneumothorax • Coronary thrombosis • Massive pulmonary embolism

  30. Langdorf’s Silly Mnemonic • Shock, shock, shock (defibrillation three times) • All Breathing Counts (airway, breathing, circulation) • EVerybody (epinephrine OR vasopressin) • Shocks (defib) • Americans (amiodarone) • Shock (defib) • Europeans (epinephrine again) • Shock (defib) • Latin Americans (lidocaine) • Shock (defib)

  31. Sodium Bicarbonate: Indications • No changes • Hyperkalemia (class I) • Pre-existing acidosis (class IIa) • TCA overdose (class IIa) • ASA overdose (class IIa) • Prolonged arrest (class IIb) • Return of spontaneous circulation (class IIb) • NOT in hypoxic, lactic acidosis cardiac arrest!

  32. Pressors: Epinephrine • Alpha effects confer benefit • Increases systemic vascular resistance • Increases aortic root pressure • Perfuses coronaries • Perfuses brain at expense of body • Escalating or high doses without demonstrable benefit • Potent pressor for hypotension (1mg in 500cc at 2-10 micrograms/min)

  33. Pressors: Norepinephrine • Potent alpha and beta agonist • Indicated for severe hypotension (SBP < 70) • Dose 1-30 micrograms/min • Extravasation: infiltrate 5-10 mg of phentolamine

  34. Pressors: Dopamine • Precursor of norepinephrine • Alpha and beta adrenergic agonist • Indicated with hypotension and bradycardia (raises SBP and HR) • Dose 5-20 micrograms/min after cardiac arrest • 5-10 primarily beta stimulation • 10-20 additional potent alpha effect

  35. Pressors: Dobutamine • Potent beta-1 selective ventricular inotrope • Use for severe systolic dysfunction • Reflex tachycardia due to peripheral vasodilation • 5-20 micrograms/min