advanced cardiac life support

Advanced Cardiac Life Advanced Cardiac Life Support Support

N.TavakoliN.TavakoliAssistant professorAssistant professor

Department of Emergency Medicine Department of Emergency Medicine Iran University of Medical SciencesIran University of Medical Sciences

EarlyACCESS

EarlyCPR

EarlyDEFIB

EarlyACLS

Chain of Survival

Drug Administration RouteDrug Administration Route

Peripheral VenousPeripheral Venous Central VenousCentral Venous EndotrachealEndotracheal IntraosseousIntraosseous Intra cardiacIntra cardiac

Central IV accessCentral IV access

More rapid drug deliveryMore rapid drug delivery Ability to perform invasive monitoringAbility to perform invasive monitoring More time consumingMore time consuming More experienceMore experience Risk of complication is greaterRisk of complication is greater Internal jugular or supraclavicular are Internal jugular or supraclavicular are

preferredpreferred

Peripheral IV accessPeripheral IV access

Antecubital or external Jugular are the first Antecubital or external Jugular are the first choicechoice

Administer drugs Administer drugs -By rapid bolus followed 20cc of IV fluid -By rapid bolus followed 20cc of IV fluid -Elevation of the extremity -Elevation of the extremity

�ُ�ُEndotracheal RouteEndotracheal Route

‘’‘’L –E – A –N’’ can be given via tracheal L –E – A –N’’ can be given via tracheal tube .tube .Lidocaine, Atropine, Epinephrine, NaloxanLidocaine, Atropine, Epinephrine, Naloxan

2-2.5 times the recommended dosage 2-2.5 times the recommended dosage Should be diluted in 10 cc N/SShould be diluted in 10 cc N/S Temporarily holding chest compressionTemporarily holding chest compression Injecting drug through a cannula while Injecting drug through a cannula while

delivering several deep breathdelivering several deep breath

Intra cardiac RouteIntra cardiac Route

Only when other routes are not readily Only when other routes are not readily availableavailable

During Open- chest CPRDuring Open- chest CPR Heart can be directly visualizedHeart can be directly visualized

Pharmacologic AgentsPharmacologic Agents in in ACLSACLS

for shock-refractory VT/VFfor shock-refractory VT/VF EpinephrineEpinephrine

1 mg intravenously every 3 -5 minutes1 mg intravenously every 3 -5 minutes a higher dose (0.2 mg/kg) is acceptable, but a higher dose (0.2 mg/kg) is acceptable, but

not recommended,not recommended,

EpinephrineEpinephrine

Indications Indications (When & Why?)(When & Why?) Increases:Increases:

• Heart rateHeart rate• Force of contractionForce of contraction• Conduction velocityConduction velocity

Peripheral vasoconstrictionPeripheral vasoconstriction Bronchial dilationBronchial dilation

VF / Pulseless VT


Dosing Dosing (How?)(How?) 1 mg IV push; may repeat every 3 to 5 1 mg IV push; may repeat every 3 to 5

minutesminutes May use higher doses (0.2 mg/kg) if lower May use higher doses (0.2 mg/kg) if lower

dose is not effectivedose is not effective Endotracheal RouteEndotracheal Route

• 2.0 to 2.5 mg 2.0 to 2.5 mg diluted indiluted in 10 mL10 mL normal saline normal saline

VF / Pulseless VT


Dosing Dosing (How?)(How?) Alternative regimens for second dose (Class Alternative regimens for second dose (Class

IIb)IIb)• Intermediate:Intermediate: 2 to 5 mg IV push, every 3 to 5 2 to 5 mg IV push, every 3 to 5

minutesminutes• Escalating:Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 1 mg, 3 mg, 5 mg IV push, each dose

3 minutes apart3 minutes apart• High:High: 0.1 mg/kg IV push, every 3 to 5 minutes 0.1 mg/kg IV push, every 3 to 5 minutes

VF / Pulseless VT


Precautions Precautions (Watch Out!)(Watch Out!) Raising blood pressure and increasing heart Raising blood pressure and increasing heart

rate may cause myocardial ischemia, angina, rate may cause myocardial ischemia, angina, and increased myocardial oxygen demandand increased myocardial oxygen demand

Do not mix or give with alkaline solutionsDo not mix or give with alkaline solutions Higher doses have not improved outcome & Higher doses have not improved outcome &

may cause myocardial dysfunctionmay cause myocardial dysfunction

VF / Pulseless VT

VasopressinVasopressin

Indications Indications (When & Why?)(When & Why?) Used to Used to “clamp”“clamp” down on vessels down on vessels Improves perfusion of heart, lungs, and brainImproves perfusion of heart, lungs, and brain No direct effects on heartNo direct effects on heart

VF / Pulseless VT


Dosing Dosing (How?)(How?) One time dose of 40 units onlyOne time dose of 40 units only May be substituted for epinephrineMay be substituted for epinephrine Not repeated at any timeNot repeated at any time May be given down the endotracheal tubeMay be given down the endotracheal tube

• DO NOTDO NOT double the dose double the dose• Dilute in 10 mLDilute in 10 mL of NS of NS

VF / Pulseless VT


Precautions Precautions (Watch Out!)(Watch Out!) May result in an initial increase in blood May result in an initial increase in blood

pressure immediately following return of pulsepressure immediately following return of pulse May provoke cardiac ischemiaMay provoke cardiac ischemia

VF / Pulseless VT

Atropine SulfateAtropine Sulfate

Indications Indications (When & Why?)(When & Why?) Should only be used for bradycardiaShould only be used for bradycardia

• Relative or AbsoluteRelative or Absolute Used to increase heart rateUsed to increase heart rate

Pulseless Electrical Activity


Dosing Dosing (How?)(How?) 1 mg IV push 1 mg IV push Repeat every 3 to 5 minutesRepeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) May give via ET tube (2 to 2.5 mg) diluted in diluted in

10 mL10 mL of NS of NS Maximum Dose: 0.04 mg/kgMaximum Dose: 0.04 mg/kg



Precautions Precautions (Watch Out!)(Watch Out!) Increases myocardial oxygen demandIncreases myocardial oxygen demand May result in unwanted tachycardia or May result in unwanted tachycardia or

dysrhythmiadysrhythmia


AmiodaroneAmiodarone

Indications Indications (When & Why?)(When & Why?) Powerful antiarrhythmic with substantial Powerful antiarrhythmic with substantial

toxicity, especially in the long term toxicity, especially in the long term Intravenous and oral behavior are quite Intravenous and oral behavior are quite

different different Has effects on sodium & potassiumHas effects on sodium & potassium

VF / Pulseless VT


Dosing Dosing (How?)(How?) Should be diluted in 20 to 30 mL of D5WShould be diluted in 20 to 30 mL of D5W

• 300 mg bolus after first Epinephrine dose300 mg bolus after first Epinephrine dose• Repeat doses at 150 mgRepeat doses at 150 mg

VF / Pulseless VT


Precautions Precautions (Watch Out!)(Watch Out!) May produce vasodilation & shockMay produce vasodilation & shock May have negative inotropic effectsMay have negative inotropic effects Terminal eliminationTerminal elimination

• Half-life lasts up to 40 daysHalf-life lasts up to 40 days

VF / Pulseless VT

LidocaineLidocaine

Indications Indications (When & Why?)(When & Why?) Depresses automaticityDepresses automaticity Depresses excitabilityDepresses excitability Raises ventricular fibrillation thresholdRaises ventricular fibrillation threshold Decreases ventricular irritability Decreases ventricular irritability

VF / Pulseless VT

LidocaineLidocaine

Dosing Dosing (How?)(How?) Initial dose: 1.0 to 1.5 mg/kg IVInitial dose: 1.0 to 1.5 mg/kg IV For refractory VF may repeat 1.0 to 1.5 mg/kg For refractory VF may repeat 1.0 to 1.5 mg/kg

IV in 3 to 5 minutes; maximum total dose, 3 IV in 3 to 5 minutes; maximum total dose, 3 mg/kgmg/kg

A single dose of 1.5 mg/kg IV in cardiac arrest A single dose of 1.5 mg/kg IV in cardiac arrest is acceptableis acceptable

Endotracheal administration: 2 to 2.5 mg/kg Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mLdiluted in 10 mL of NS of NS

VF / Pulseless VT

LidocaineLidocaine

Dosing Dosing (How?)(How?) Maintenance InfusionMaintenance Infusion

• 2 to 4 mg/min2 to 4 mg/min

• 1000 mg / 250 mL D5W = 4 mg/mL1000 mg / 250 mL D5W = 4 mg/mL 15 mL/hr = 1 mg/min15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min60 mL/hr = 4 mg/min

VF / Pulseless VT

LidocaineLidocaine

Precautions Precautions (Watch Out!)(Watch Out!) Reduce maintenance dose (not loading dose) Reduce maintenance dose (not loading dose)

in presence of impaired liver function or left in presence of impaired liver function or left ventricular dysfunctionventricular dysfunction

Discontinue infusion immediately if signs of Discontinue infusion immediately if signs of toxicity developtoxicity develop

VF / Pulseless VT

Magnesium SulfateMagnesium Sulfate

Indications Indications (When & Why?)(When & Why?) Cardiac arrest associated with torsades de Cardiac arrest associated with torsades de

pointes or suspected hypomagnesemic statepointes or suspected hypomagnesemic state Refractory VFRefractory VF VF with history of ETOH abuseVF with history of ETOH abuse Life-threatening ventricular arrhythmias due to Life-threatening ventricular arrhythmias due to

digitalis toxicity, tricyclic overdosedigitalis toxicity, tricyclic overdose

VF / Pulseless VT


Dosing Dosing (How?)(How?) 1 to 2 g (2 to 4 mL of a 50% solution) diluted 1 to 2 g (2 to 4 mL of a 50% solution) diluted

in 10 mL of D5W IV pushin 10 mL of D5W IV push

VF / Pulseless VT


Precautions Precautions (Watch Out!)(Watch Out!) Occasional fall in blood pressure with rapid Occasional fall in blood pressure with rapid

administrationadministration Use with caution if renal failure is presentUse with caution if renal failure is present

VF / Pulseless VT

ProcainamideProcainamide

Indications Indications (When & Why?)(When & Why?) Recurrent VFRecurrent VF Depresses automaticityDepresses automaticity Depresses excitabilityDepresses excitability Raises ventricular fibrillation thresholdRaises ventricular fibrillation threshold Decreases ventricular irritabilityDecreases ventricular irritability

VF / Pulseless VT


Dosing Dosing (How?)(How?) 30 mg/min IV infusion 30 mg/min IV infusion May push at 50 mg/min in cardiac arrestMay push at 50 mg/min in cardiac arrest In refractory VF/VT, 100 mg IV push doses In refractory VF/VT, 100 mg IV push doses

given every 5 minutes are acceptablegiven every 5 minutes are acceptable Maximum total dose: 17 mg/kgMaximum total dose: 17 mg/kg

VF / Pulseless VT


Dosing Dosing (How?)(How?) Maintenance InfusionMaintenance Infusion

• 1 to 4 mg/min1 to 4 mg/min

• 1000 mg / 250 mL of D5W = 4 mg/mL1000 mg / 250 mL of D5W = 4 mg/mL 15 mL/hr = 1 mg/min15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min60 mL/hr = 4 mg/min

VF / Pulseless VT


Precautions Precautions (Watch Out!)(Watch Out!) If cardiac or renal dysfunctionIf cardiac or renal dysfunction

is present, reduce maximum total dose to 12 is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/kg and maintenance infusion to 1 to 2 mg/minmg/min

Remember Endpoints of AdministrationRemember Endpoints of Administration

VF / Pulseless VT

VasopressinVasopressin an acceptable alternative, recommended an acceptable alternative, recommended a single intravenous dose of a single intravenous dose of 40 U40 U is given once is given once

(half life is 10 - 20 min versus 3 - 5 min with (half life is 10 - 20 min versus 3 - 5 min with epinephrine)epinephrine)

in a controlled trial of patients with out-of-hospital in a controlled trial of patients with out-of-hospital VF who received either vasopressin or VF who received either vasopressin or epinephrine; those treated with vasopressin had epinephrine; those treated with vasopressin had higher rates of survival to hospital admission (70 higher rates of survival to hospital admission (70 vs 35 %, p = 0.06) and survival at 24 hours (60 vs vs 35 %, p = 0.06) and survival at 24 hours (60 vs 20 %, p = 0.02)20 %, p = 0.02)

Other Cardiac Arrest DrugsOther Cardiac Arrest Drugs

Calcium ChlorideCalcium Chloride

Indications Indications (When & Why?)(When & Why?) Known or suspected hyperkalemia (eg, renal Known or suspected hyperkalemia (eg, renal

failure)failure) Hypocalcemia (blood transfusions)Hypocalcemia (blood transfusions) As an antidote for toxic effects of calcium As an antidote for toxic effects of calcium

channel blocker overdosechannel blocker overdose Prevent hypotension caused by calcium Prevent hypotension caused by calcium

channel blockers administrationchannel blockers administration

Other Cardiac Arrest Drugs


Dosing Dosing (How?)(How?) IV Slow PushIV Slow Push

• 8 to 16 mg/kg (usually 5 to 10 mL) IV for 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker hyperkalemia and calcium channel blocker overdoseoverdose

• 2 to 4 mg/kg (usually 2 mL) IV for prophylactic 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockerspretreatment before IV calcium channel blockers



Precautions Precautions (Watch Out!)(Watch Out!) Do not use routinely in cardiac arrestDo not use routinely in cardiac arrest Do not mix with sodium bicarbonateDo not mix with sodium bicarbonate


Sodium BicarbonateSodium Bicarbonate

Indications Indications (When & Why?)(When & Why?) Class I if known preexisting hyperkalemiaClass I if known preexisting hyperkalemia Class IIa if known preexisting bicarbonate-responsive Class IIa if known preexisting bicarbonate-responsive

acidosisacidosis Class IIb if prolonged resuscitation with effective Class IIb if prolonged resuscitation with effective

ventilation; upon return of spontaneous circulationventilation; upon return of spontaneous circulation Class III (not useful or effective) in hypoxic lactic Class III (not useful or effective) in hypoxic lactic

acidosis or hypercarbic acidosis (eg, cardiac arrest acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)and CPR without intubation)



Dosing Dosing (How?)(How?) 1 mEq/kg IV bolus1 mEq/kg IV bolus Repeat half this dose every 10 minutes Repeat half this dose every 10 minutes

thereafterthereafter If rapidly available, use arterial blood gas If rapidly available, use arterial blood gas

analysis to guide bicarbonate therapy analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate (calculated base deficits or bicarbonate concentration)concentration)



Precautions Precautions (Watch Out!)(Watch Out!) Adequate ventilation and CPR, not Adequate ventilation and CPR, not

bicarbonate, are the major "buffer agents" in bicarbonate, are the major "buffer agents" in cardiac arrest cardiac arrest

Not recommended for routine use in cardiac Not recommended for routine use in cardiac arrest patientsarrest patients


Factors Influencing Factors Influencing SurvivalSurvival

• the rhythm associatedthe rhythm associated with the arrestwith the arrest

• whether the collapse was witnessedwhether the collapse was witnessed

• adequacy of CPRadequacy of CPR

• age /age / underlying health of the patientunderlying health of the patient

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

ACLS and arrhythmiasACLS and arrhythmias

TachycardiaTachycardia

sudden onset of rapid heart ratesudden onset of rapid heart rate

what do you do?what do you do?


ALWAYS CHECK THE PATIENT FIRSTALWAYS CHECK THE PATIENT FIRST

1.1. Check for a pulseCheck for a pulse

2.2. Check the blood pressureCheck the blood pressure

3.3. Make a diagnosisMake a diagnosis


Case 1Case 1

On ward, sudden onset of palpitationsOn ward, sudden onset of palpitations

1.1. Does the patient have a pulse? YesDoes the patient have a pulse? Yes

2.2. What is the blood pressure? 60/20What is the blood pressure? 60/20

Is the patient “stable” or “unstable”?Is the patient “stable” or “unstable”?

Definition of “Unstable”Definition of “Unstable”presence of any one ofpresence of any one of::

1.1. Low blood pressureLow blood pressure

2.2. Short of BreathShort of Breath

3.3. Chest painChest pain

4.4. LightheadedLightheaded

5.5. CHFCHF

Unstable TachycardiaUnstable Tachycardia

goal is to slow down rate orgoal is to slow down rate or convert to sinus rhythmconvert to sinus rhythm

drugs or electrical cardioversion is drugs or electrical cardioversion is usedused

usually cardioversion if unstableusually cardioversion if unstable

Electrical ShockElectrical Shock

defibrillationdefibrillation or or cardioversioncardioversion (= “synchronized”) (= “synchronized”) action: resets all activity to zeroaction: resets all activity to zero

good for tachycardia (non-sinus)good for tachycardia (non-sinus) good for ventricular fibrillation (VF)good for ventricular fibrillation (VF)

Electrical ShockElectrical Shock

defibrillationdefibrillation or or cardioversioncardioversion (= “synchronized”) (= “synchronized”)

NOT USED FOR:NOT USED FOR: sinus rhythmsinus rhythm bradycardiabradycardia asystoleasystole

Case #2Case #2

Alarm on ECG monitor makes noise!!Alarm on ECG monitor makes noise!!

Case #2Case #2

Patient is awake and Patient is awake and talkingtalking

Diagnosis?Diagnosis? ECG lead is disconnectedECG lead is disconnected ECG shows artifactECG shows artifact

Case #3Case #3

Alarm on ECG monitor makes noise!!Alarm on ECG monitor makes noise!!

Case #2Case #2 Try to wake up. Does not wake upTry to wake up. Does not wake up Check for breathing. No breathing.Check for breathing. No breathing. Check for pulse. No pulse.Check for pulse. No pulse.

What is the diagnosis?What is the diagnosis?

What do you do?What do you do?

Ventricular Fibrillation (VF)Ventricular Fibrillation (VF)

What is the cure for VF?What is the cure for VF?

DEFIBRILLATIONDEFIBRILLATION

EARLY defib. has higher EARLY defib. has higher successsuccess

SHOCK SOON, SHOCK OFTENSHOCK SOON, SHOCK OFTEN

VFVF

DrugsDrugs improve success of defibrillation (the cure)improve success of defibrillation (the cure) do NOT cure VFdo NOT cure VF

lidocainelidocaine procainamideprocainamide amiodaroneamiodarone

VFVF

What is the cardiac output in VF?What is the cardiac output in VF? Zero. There is no circulationZero. There is no circulation

What MUST occur at all times?What MUST occur at all times? CPR … unless defib. is CPR … unless defib. is

happening.happening.

How do you manage ventilation?How do you manage ventilation? bag-mask and early intubationbag-mask and early intubation

VF SummaryVF Summary

Start CPR … and only stop to shockStart CPR … and only stop to shock IntubateIntubate Defibrillation is the most important!!!Defibrillation is the most important!!! DrugDrug shockshock drug drug shockshock

Case #4Case #4

BP 60/30BP 60/30

Diagnosis?Diagnosis?

Treatment?Treatment?

Case #4: Sinus BradycardiaCase #4: Sinus Bradycardia

Treatment: increase heart rate!Treatment: increase heart rate!

Methods:Methods:

1.1. atropine (probably successful)atropine (probably successful)

2.2. pacing (thoracic skin paddles)pacing (thoracic skin paddles)

3.3. dopamine infusiondopamine infusion

Case #5Case #5

BP 60/30BP 60/30



33rd Degree Block (Bradycardia)rd Degree Block (Bradycardia)Treatment: increase heart rate!Treatment: increase heart rate!

Methods:Methods:

1.1. atropine (probably NOT successful)atropine (probably NOT successful)

2.2. pacing (thoracic skin paddles)pacing (thoracic skin paddles)

3.3. dopamine infusiondopamine infusion

Case # 6Case # 6

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



advanced cardiac life support

Documents

iv push

time dose

lower dose

nsmaximum dose

minutesa higher dose

dose class iibintermediate

myocardial ischemia

blood pressure