DEC 2011 UG

 To describe concepts of BLS and Acls

 To identify conditions for resucitations
 To describe steps used in BLS/ACLS
 To understand ACLS algorithms and perform
ACLS.
 CPR+better setup and expertise, otherwise
the activity and goal is the same -facilitating
recovery of cardiac arrest victim.
ABC-openness of airway, presence of breathing
effort, presence of pulse or heart activity
 Conceptual difference from acute trauma
care (Not arrest situation)
 Primary T. survey-ABCDE
 Secondary T. survey-thorough evaluation
 One day BLS training is must.
 One hour lecture of ACLS and two days practical
training.
 Examination(Pretest,post test,practical)
 Group
-CPR
-V fib/pulseless tachycardia
-tachycardia
-Bradycardia, asystole/PEA
 Examination (Pretest,post test,practical)
 Survival of prehospital arrest 2-
5% in USA/Canada.
 (95% die before hospital)
 Arrest in hospital up to 17%
 V fib-survival is reported 7-40%
 The best way to improve
survival is to standardize the
care for out of the hospital
victims.
 SCD-death due to cardiac causes heralded by
abrupt loss of consciousness in an individual
with/without known preexisting heart disease.
 CA (cardiac arrest)-Abrupt cessation of cardiac
pump function which may be reversed by prompt
intervention.
 Cardiovascular collapse-acute loss of effective
blood flow to distal organs.
structural
 coronary artery disease
 myocardial hypertrophy
 dilated cardiomyopathy
 valvular heart disease
 electrophysiological abnormalities

Functional
 electrolyte abnormalities,hypoxia,acidoses
 Mostly the causes of SCD are
Vfib/tac,PEA,and asystole.
2004 Anna Story 8
 Ventricular fibrillation
 Ventricular tachycardia

 Polymorphic ventricular tachycardia

 BLS-is provided by CPR where artificial
circulation and breathing are given.
 CPR is delivered through chest compression
and artificial breathing with specific ratios.

 Objective -to circulate oxygenated blood to

the brain and other organs until the heart
rhythm recovers and/or medical support
arrives.
1.Decades ago 4-5:1
2.The last decade
15:2(one rescuer)
3. AHA 2005 guidelines 30:2(one rescuer)
4. AHA 2010- “A-B-C” “C-A-B”
In VF or pulseless ventricular tachycardia(VT) the
critical elements of CPR have been shown to be
chest compressions and early defibrillation. More
victims receive CPR and evidences show
comparable or better outcomes.
 Integration of AED’s(automated external defibilator)
 Continue CPR until –casualty responds
-AED is available
-medical help is available

-Attach electrodes
-On-off
-Analyze button
-Shock after clearing.
Goals
 Achieve adequate ventilation
 Control cardiac arrhythmias
 Stabilize BP and cardiac out put.
 Restore organ perfusion

Strategy
 Defibrillation/cardioversion or pacing
 Intubation with endotrachial tube
 IV line insertion and initiation of drugs
• passage of an electrical current of sufficient
magnitude to depolarize a critical mass of myocardium
and restoration of coordinated electrical activity
(Phase I) for V fib and Pulseless ventricular tachy.
• Biphasic defibrilator 200J,Monophasic 360J while in
AED: Joules are device adjusted. ICD and wearable
used ambulatory situations.

• Preparation,select energy,charge,discharge

• In AED Turn on, Apply the pad, wait while machine

analyzes, shock if shockable.
pesumCPR immediately-5 cycles(30:2)-2’
Defibrillation
 Immediate defibrilation should proceed others
 200J 300J 360J(3 defibrilations)
 Epinephrine 1 mg after failed defibrillation ?

-can be repeated after 3-5 minutes.

 Continue defibrillation
 Preocrdial thump???- anecdotal reports of
successful "thump-version" of asystole, VF, and
VT
 Shock Shock Shock Shock

CPR CPR CPR CPR CPR

2 min 2 min 2 min 2 min 2 min
30:2 30:2 30:2 30:2 30:2

Drug Drug Drug

Drug indication Dosage

Epinephrine VF 1mg q 3-5 mins during CPR

(Vasopressin Pulseless VT Followed with 20 mL flush
one dose is Asystole -Can be given via ETT 2- 2.5
alternative) PEA mg diluted in 10 mL N/S
Symptomatic bradycardia High-dose epinephrine was
not found to improve survival
(N Eng. J Med 1992;327:1045

Amiodarone -Shock refractory/recurrent Cardiac Arrest: 300 mg IV/IO

VF/Pulseless VT with 20-30 mL D5W push,150
-Polymorphic VT , Adjunct to mg IV push repeat in 3-5’
cardioversion of SVT/PSVT -stable wide complex tachy-
Termination of MAT 150mg iv in 10’.
Lidocaine Alt to amiodarone in cardiac 1-1.5 mg/kg IV/IO, in 5- 10
arrest from VF/VT mins
Stable monomorphic VT with MAX: 3 doses or total 3 mg/kg
Magnesium CA in Torsades de In arrest: 1-2 g, diluted in 10 ml
ulfate Pointes suspected or D5W, IV/IO over
Hypomagnesemia, 5-20 minutes
Digitalis toxicity

Atropine Symptomatic Sinus 0.5 mg IV q 3-5 mins

Brady,2nd °(I) AV Bl.,- MAX dose: 0.04 mg/kg (total 3
2nd line for asystole mg)
/PEA 1 mg IV/IO push q 3-5 mins

Adenosine First drug for most forms 6 mg rapid IV push, follow with
of narrow tachy. Safe 20 ml N/s; repeat
and effective in dose of 12 mg in 1- 2 mins
pregnancy. Up to 3rd dose of 12 mg

Diltiazem/ Control ventricular rate DT-15-20 mg IV over 2

Verapamil in A Fib and A Flutter or Mins or Verap 5mg
MAT may repeat in 15 mins at 20-25
mg of DT.
 Airway techniques- bag valve ventilation,
supraglotic rescue system, ETT, surgical
airway intervention.
 New ACLS guidelines de-emphasize advanced
airway techniques.
 If bag-valve mask (BVM) ventilation is
adequate, insertion of and advanced airway
may be deferred or not necessary.
 Maintain airway patency in unconscious
patients by use of a head tilt-chin lift,
oropharyngeal airway or nasopharyngeal
airway.
 Asystole-a flat line with no clear electrical
actiivty ,it is usually due to chronic illness
(Fine v fib and loose connection D/D)
 organized rhythm without a palpable pulse.
PEA along with asystole make up half of the
Pulseless Arrest Algorithm with VF and VT
consisting of the other half.
 Both Asystole and PEA usually have poor
outcomes.
 CPR.
 If identified treat etiologies.
 Adrenaline/vassopresin can be given.
 5H(hypoxia,hypovolemia,hypokalemia/
hyperkalemia,hydorgen/
acidosis,hypothermia),

 5T(Toxins,tamponade,thromboembolism,Tensi
on PT, trauma)
 Defibrillation not successful, Atropine is also
Questioned.
 Therapeutic hypothermia(32-34°C)
 Hemodynamic optimization(hypotension MX)
 Ventilation optimization(Sao2≥94%)
 Immediate coronary reperfusion with PCI
(percutaneous coronary intervention)
 Moderate glycemic control measures should
be implemented to maintain glucose levels
from 144-180 mg/dL to avoid hypoglycemia)
 Team Leader – organizes the group, monitors
individual performance of team members,
models excellent team behavior, trains and
coaches, facilitates understanding and focuses
on comprehensive patient care.
 Team Member – must be proficient to perform
skills within their scope of practice. They are
clear about their role assignment
 Team Dynamics and Communication-Closed
loop communication,Clear messages, Clear
roles and responsibilities, Knowing one’s
limitations, Constructive intervention.
 Drugs-ready ,even in a syringe
 IV line,vigo
 Air way adjuncts ready
 Defibrillator charged
 Hard board for resucitation
 Team formulated
 Trainings and simulations
• This algorithm outlines the assessment and
management of a patient with
symptomatic bradycardia
 Bradycardia
Heart rate <60bpm and
inadequate for clinical
condition

•Maintain patent airway; assist breathing as

needed
•Give oxygen
•Monitor ECG (identify rhythm), blood
pressure, oximetry
•Establish IV access
 Signs or symptoms of poor perfusion
caused by the bradycardia?
(eg, acute altered mental status, ongoing chest
pain, hypotenension, or other signs of shock)

Adequate Poor
Perfusion Perfusion
Observe/
Monitor •Prepare for transcutaneous pacing;
•Prepare for transcutaneous pacing; use
without delay for high-degree block (type II
second-degree block or third-degree AV block)
•Consider atropine 0.5mg IV while awaiting
pacer. May repeat to a total dose of 3mg. If
ineffective begin pacing
•Consider epinephrine (2-10ug/min) or
dopamine (2-10ug/kg per minute) infusion
while awaiting a pacer or if pacing ineffective
•Prepare for transvenous pacing
•Treat contributing causes(5H,5T)
 Stable-Beta blockers,calcium channel
blockers,amiodarone)
 Unstable with hypotension and shock-
cardioversion with 100-200J(there is risk of
embolism)
Yes