cpr 2000
DESCRIPTION
CPR 2000. Dr. THANAPONG HONGPROMYATI. Adult Cardiac Arrest. BLS algorithm if appropriate. Precordial thumb if appropriate. Attach defibrillator/monitor. Assess rhythm. 1. 2. Figure 1. ILCOR Universal/International ACLS Algorithm. Assess rhythm. 3. 4. Check pulse+/-. VF/VT. - PowerPoint PPT PresentationTRANSCRIPT
CPR 2000Dr. THANAPONG HONGPROMYATI
Adult Cardiac Arrest
BLS algorithmif appropriate
Precordial thumb if appropriate
Attach defibrillator/monitor
Assess rhythm
Figure 1. ILCOR Universal/International ACLS Algorithm.
1
2
Assess rhythm
Check pulse+/-
During CPR• Check electrode/paddle position and contact• Attempt to place, confirm, secure airway• Attempt and verify IV access• Patients with VF/VT refractory to initial shocks: - Epinephrine 1 mg IV, every 3-5 min or - Vasopressin 40 U IV, single dose, 1 time only• Patients with non-VF/VT rhythm: - Epinephrine 1 mg IV, every 3-5 min• Consider: buffers, antiarrhythmics, pacing• Search for and correct reversible cause
VF/VT Non-VF/VT
CPR up to3 minCPR for
1 min
Attemptdefibrillation
*3 as necessary
Figure 1. ILCOR Universal/International ACLS Algorithm.
5,6
43
3
Consider causes that are potentially reversible
•“Tablet” (drug OD,accidents)• Temponade, cardiac• Tension pneumothorax• Thrombosis, coronary (ACS)• Thrombosis, pulmonary (embolism)
• Hypovolemia• Hypoxia• Hydrogen ion-acidosis• Hyper-/Hypokalemia• Hypothermia
Figure 1. ILCOR Universal/International ACLS Algorithm.
7
• Person collapses• Possible cardiac arrest• Assess responsiveness
Begin Primary ABCD Survey(Begin BLS Algorithm)
• Activate emergency response system• Call for defibrillator• A Assess breathing (open airway, look, listen, and feel)
Unresponsive
No Breathing• B Give 2 slow breaths• C Assess pulse, if no pulse• C Start chest compressions• D Attach monitor/defibrillator when available
No pulseFigure 2. Comprehensive ECC Algorithm.
1
1
• CPR continues• Assess rhythm
Secondary ABCD Survey• Airway: attempt to place airway device• Breathing: confirm and secure airway device, ventilation, oxygenation• Circulation: gain intravenous access; give adrenergic agent; consider antiarrhythmics, buffer agents, pacingNon-VF/VT patients:- Epinephrine 1 mg IV, repeat every 3-5 minVF/VT patients:- Vasopressin 40 U IV, single dose, 1 time onlyor- Epinephrine 1 mg IV, repeat every 3-5 min• Differential Diagnosis: search for and treat reversible cause
Attempt defibrillation(Up to 3 shock if VF persists)
Non-VF/VT(asystole or PEA)
CPR for1 min
CPR up to3 min
Figure 2. Comprehensive ECC Algorithm.
2 3
4,5
No pulse
Primary ABCD SurveyFocus: basic CPR and defibrillation
• Check responsiveness• Activate emergency response system
• Call for defibrillator A Airway:open the airway
B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions
D Defibrillation: assess for and shock VF/pulesless VT, up to 3 times (200J,200-300J,360J, or equivalent biphasic) if necessary
Rhythm after first 3 shocks?
Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.
1
Secondary ABCD SurveyFocus: more advanced assessments and treatments
A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.C Circulation:• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.D Differential Diagnosis: Search for and treat identified reversible causes.
Persistent or recurrent VF/VT
Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.
2
Epinephrine 1 mg IV push, repeat every 3 to 5 minutesor
Vasopressin 40 U IV, single dose, 1 time only
Resume attempts to defibrillate1*360J (or equivalent biphasic) within 30 to 60 sec.
Consider antiarrhythmics:amiodarone (IIb), lidocaine (Indeterminate),magnesium (IIb if hypomagnesemic state),
procainamide (IIb for intermittent/recurrent VF/VT).Consider buffers.
3
4
Resume attempts to defibrillate 5
Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.
Antiarrhythmics & Buffer• Amiodarone 300(class IIb) mg IV push (cardiac arres
VVVVVVVVVVVV VV VVVVVVV VVVVVVVV VVV VVVVVVVVVVV V) / , 1 5 0 . 2 .f a second dose of mg IV Max cumulative dose
2 2 4 .g over hr• Lidocaine - (class Indeterminate) 1 .0 1 .5 mg/kg IV p
VV V VV V V VV VV V V VV VVV VVVVVVV V. 3 5 3ose of mg/kg.
• Magnesium sulfate 1 2to g IV in polymorphic VT (tor sades de pointes) and suspected hypomagnesemic state.
• Procainamide 30mg/min in refractory VF (Max total d VV VVVVVVVVVV VVV VVV VVVVV V VVVVV: 1 7 /)
• Sodium bicarbonate 1mEq/kg IV is indicated for seve ral conditions known to provoke sudden cardiac arrest.
PULSELESS ELECTRICAL ACTIVITY(PEA = Rhythm on monitor, without detectable pules)
Primary ABCD SurveyFocus: basic CPR and defibrillation
• Check responsiveness• Activate emergency response system
• Call for defibrillator A Airway:open the airway
B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressionsD Defibrillation: assess for and shock VF/pulesless VT
Figure 4. Pulseless Electrical Activity Algorithm.
Secondary ABCD SurveyFocus: more advanced assessments and treatments
A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.
C Circulation:• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.• -Assess for occult blood flow (“pseudo EMT”)D Differential Diagnosis: Search for and treat identified reversible causes.
Figure 4. Pulseless Electrical Activity Algorithm. - EMD=electro mechanical dissociation
Review for most frequent causes
• Hypovolemia• Hypoxia• Hydrogen ion-acidosis• Hyper-/Hypokalemia• Hypothermia
• “Tablet” (drug OD,accidents)• Temponade, cardiac• Tension pneumothorax• Thrombosis, coronary (ACS)• Thrombosis, pulmonary (embolism)
Epinephrine 1 mg IV push,repeat every 3 to 5 minutes
Atropine 1 mg IV (if PEA rate is slow),repeat every 3-5 minutes as need, to a total dose of 0.04 mg/kg
Figure 4. Pulseless Electrical Activity Algorithm.
2
3
1
Asystole
Primary ABCD SurveyFocus: basic CPR and defibrillation
• Check responsiveness• Activate emergency response system
• Call for defibrillatorA Airway:open the airway
B Breathing: provide positive-pressure ventilationsC Circulation: give chest compressions Confirm true asystoleD Defibrillation: assess for VF/pulesless VT; shock if indicateRapid scene survey: any evidence personnel should not attempt resuscitation?
Figure 5. Asystole: The Silent Heart Algorithm.
1
Secondary ABCD SurveyFocus: more advanced assessments and treatments
A Airway: Place airway device as soon as possibleB Breathing: • Confirm airway device placement by exam plus confirmation device.• Secure airway device; purpose-made tube holders preferred.• Confirm effective oxygenation and ventilation.C Circulation:• Confirm true asystole• Establish IV access.• Identify rhythm; monitor.• Administer drugs appropriate for rhythm and condition.D Differential Diagnosis: Search for and treat identified reversible causes.
Figure 5. Asystole: The Silent Heart Algorithm.
2,3
Transcutaneous pacingIf considered, perform immediately
4
Epinephrine 1 mg IV push,repeat every 3 to 5 minutes
5
Atropine 1 mg IV,repeat every 3 to 5 minutesup to a total of 0.04 mg/kg
6
Asystole persistsWithhold or cease resuscitation efforts?• Consider quality of resuscitation?• Atypical clinical features present?• Support for cease-efforts protocols in place?
7,8,9
Figure 5. Asystole: The Silent Heart Algorithm.
• Confirm true asystole- Check lead and cable connection- Monitor power on?- Monitor gain up ?- Verify asystole in another lead
• Review the quality of the resuscitation attempt- Was there an adequate trial of BLS? of ACLS? Has the team done the following:- Achieved tracheal intubation?- Performed effective ventilation?- Shocked VF if present?- Obtained IV access?- Given epinephrine IV? Atropine IV?- Ruled out or corrected reversible causes?- Continuously documented asystole >5 to 10 min after all of the above have been accomplished?
• Reviewed for atypical clinical features?- Not a victim of drowning or hypothermia?- No reversible therapeutic or illicit drug overdose?
8
7
2
Bradycardia• Slow (absolute bradycardia = rate<60bpm• Relatively slow (rate less than expected relative to underlying condition or cause)Primary ABCD Survey
• Assess ABCs• Secure airway noninvasively• Ensure monitor/defibrillator is available
Secondary ABCD Survey• Assess secondary ABCs (invasive airway management needed?)• Oxygen-IV access-monitor-fluids• Vital sign, pulse oximeter, monitor BP• Obtain and review 12 lead ECG• obtain and review portable Chest x-ray• Problem-focused history• Problem-focused physical examination• Consider cause (differential diagnoses)
Figure 6. Bradycardia Algorithm.
Serious sign or symptom?Due to the bradycardia?
Type II second-degree AV blockor
Third-degree AV block?
Intervention sequence• Atropine 0.5-1.0 mg• Transcutaneous pacing if available• Dopamine 5-20 ug/kg per min• Epinephrine 2-10 ug/min
Observe
• Prepare for transvenous pacer• If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed
Figure 6. Bradycardia Algorithm.
1,2
3,4,56
7
No Yes
No Yes
• If the patient has serious sign or symptoms, make sure th ey are related to the slow rate.
• Cl i ni cal mani f est at i ons i ncl ude- Symptoms(chestpain, shortnessof br eat h, decr ease l evel of consci ousness)- Signs (low blood pressure, shock, pulmonary congestion , CHF)
• If the patient is symptomatic, do not delay transcutaneou s pacing while awaiting IV access or for atropine to take e
ff ect• Denervatedtransplantedheartswillnot r esponse t o at r opi ne. Go at once paci ng, cat ech
olamineinfusion, or bot h.• - Nevertreatt he combi nat i on of t hi r d degr ee hear t bl ock and ven
tricular escape beats with lidocaine (or any agent that su ppresses ventricular escape rhythms)
1
2
3
4
6
Evaluate patient• Is patient stable or unstable?• Are there serious signs or symptoms?• Are signs and symptoms due to tachycardia?
Unstable patient: serious signs or symptoms• Establish rapid heart rate as cause of signs and symptoms• Rate related signs and symptoms occur at many rates, seldom < 150 bpm
• Prepare for immediate cardioversion (see algorithm)
Stable patient: no serious signs and symptoms• Initial assessment identified 1 of 4 type of tachycardia• Atrial fibrillation/flutter• Narrow-complex tachycardia• Stable wide-complex tachycardia: unknown type• Stable monomorphic VT and/or polymorphic VT
Figure 7. The Tachycardia Overview Algorithm.
Stable Unstable
1. Atrial fibrillation Atrial flutter
Evaluation focus, 4 clinical features:1. Patient clinical unstable?2. Cardiac function impaired?3. WPW present?4. Duration<48 or >48 hours?
Treatment focus: clinical evaluation1. Treat unstable patient urgently2. Control the rate3. Convert the rhythm4. Provide anticoagulationTreatment of atrial
fibrillation/atrial flutter(See following table)
Figure 7. The Tachycardia Overview Algorithm.
2. Narrow-complex tachycardia
Attempt to establish a specific diagnosis• 12 lead ECG• Clinical information• Vagal maneuvers• Adenosine
Diagnosis effort yield• Ectopic atrial tachycardia• Multifocal atrial tachycardia• Paroxysmal supraventricular tachycardia
Treatment of SVT(see narrow-complex
tachycardia algorithm)Figure 7. The Tachycardia Overview Algorithm.
3. Stable wide-complex tachycardia: unknown type
4. Stable monomorphic VT and/or polymorphic VT
Attempt to establish a specific diagnosis• 12-lead ECG• Esophageal lead• Clinical information
Treatment of SVT
(see narrow- complex
tachycardia algorithm)
Wide-complex tachycardia of unknown type
ConfirmedSVT
Confirmedstable VT
Dc cardioversionor
Procainamideor
Amiodarone
Dc cardioversionor
Amiodarone
Ejection fraction< 40% Clinical CHF
Preservedcardiac function
Figure 7. The Tachycardia Overview Algorithm.
Treatment of stable
monomorphic and
polymorphic VT (see stable VT: monomorphic
and polymorphic algorithm)
Duration<48Hrs Duration>48Hrs or UnknownConsider• DC cardioversionUse only 1 of the Class IIa following agents (see note below):• Amiodarone• Ibutilide• Flecainide• Propafenone• Procainamide• For additional drugs that are Class IIb recommendation, see Guidelines or ACLS text
• NO DC cardioversion!• Note: Conversion of AF to NSR with drugs or shock may cause embolization of atrial thrombi unless patient has adequate anticoagulation.• Use antiarrhythmic agents with extreme caution if AF>48 hours’ duration (see note below). or
Note:If AF>48hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anti coagulation because of possible embolic complications. Use only 1 of the following agents:
• Digoxin (ClassIIb)• Diltiazem (ClassIIb)
• Amiodarone(ClassIIb)
1. Control Rate2. Control Rhythm
AF/flutter with• Normal heart• Impair heart• WPW
Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.Use only 1 of the following agents (see note below):• Calcium channel blockers (ClassI)• B-Blockers (ClassI)• For additional drugs that are ClassIIb recommendations, see Guideline or ACLS text
Consider• DC cardioversion or• Amiodarone (ClassIIb)
Delayed cardioversion Anticoagulation * 3 weeks at proper levels• Cardioversion, then• Anticoagulation * 4 weeks more or Early cardioversion• Begin IV heparin at once• TEE to exclude atrial clot. then• Cardioversion within 24 h. then• Anticoagulation * 4 more weeks• Anticoagulation as described above, following by• DC cardioversion
Normal cardiac function
Impaired heart (EF<40% or CHF)
Control of Rate and Rhythm (Continued From Tachycardia Overview)
Duration<48Hrs Duration>48Hrs or Unknown
Consider• DC cardioversion or• Primary anti- arrhythmic agents Use only 1 of the following agents (see note below**):
1. Control Rate 2. Control RhythmAF/flutter with• Normal heart• Impair heart• WPW
Heart FunctionPreserved
Impaired HeartEF<40% or CHF
WPWNote: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.• DC cardioversion or• Primary anti- arrhythmic agents Use only 1 of the following agents (see note below):
Class III (can be harmful)• Adenosine• B-Blockers• Calcium blockers• Digoxin
Note: If AF>48 hours’ duration, use agents to convert rhythm with extreme caution in patients not receiving adequate anticoagulation because of possible embolic complications.• DC cardioversion or• Amiodarone (ClassIIb)
•Amiodarone (ClassIIb)• Flecainide (ClassIIb)• Procainamide (ClassIIb)• Propafenone (ClassIIb)• Sotalol (ClassIIb)
•Amiodarone (ClassIIb)• Flecainide (ClassIIb)• Procainamide (ClassIIb)• Propafenone (ClassIIb)• Sotalol (ClassIIb)
Class III (can be harmful)• Adenosine• B-Blockers• Calcium blockers• Digoxin
• Anticoagulation as described above, following by• DC cardioversion
Control of Rate and Rhythm (Continued From Tachycardia Overview)
Priority order:• Ca2+ Channel blocker• B-Blocker• Digoxin• DC cardioversion• Consider procainamide, amiodarone, sotalolPriority order:
• No DC cardioversion• Amiodarone• Diltiazem
• No DC cardioversion• Amiodarone
• No DC Cardioversion• Amiodarone• B-Blocker• Ca2+ channel blocker
• No DC cardioversion• Ca2+ channel blocker• B-Blocker• Amiodarone• No DC cardioversion• Amiodarone• Diltiazem
Preserved
Preserved
Preserved
EF<40%, CHF
EF<40%, CHF
EF<40%, CHF
Junctional tachycardia
Paroxysmal supraventricular tachycardia
Ectopic or multifocal atrial tachycardia
Attempt therapeutic diagnosis maneuver• Vagal stimulation• Adenosine
Narrow-Complex SupraventricularTachycardia, Stable
Figure 8. Narrow-Complex Supraventicular Tachycardia Algorithm.
Stable Ventricular TachycardiaMonomorphic or Polymorphic?
Monomorphic VT• Is cardiac function impaired?
Polymorphic VT• Is QT baseline interval prolonged?
Medications: any one• Procainamide• SotalolOther acceptable• Amiodarone• Lidocaine
Normal baseline QT interval• Treat ischemia• Correct electrolytes
Medications: any one• - B Blocker or• Lidocaine or• Amiodarone or• Procainamide or• Sotalol
Long baseline QT interval• Correct abnormal electrolytes
Medications: any one• Magnesium• Overdrive pacing• Isoproterenol• Phenytoin• Lidocaine
Amiodarone• 150 mg IV bolus over 10 min. or
Lidocaine• 0.5 to 0.75 mg/kg IV push. Then
use• Synchronized cardioversion
Normal function Poor ejection fraction Normal baselineQT interval
Prolong baseline QT interval
(suggests torsades)
Note!May go directly to
cardioversion
Figure 9. Stable Ventricular Tachycardia (Monomorphic or Polymorphic) Algorithm.
Tachycardiawith serious signs and symptoms related to the tachycardia
150If ventricular rate is > bpm, prepare for immediate VVV VVVV VVVVV VVVVV VV VVVVVVVVVVV VVVVV VV.
VVVVVVVVVVVV VVVVVVVVV VVVVVVVVVVVVV VV VVVVVVVVV VVV. need if heart rate is <= 150 bpm.
Have available at bedside•oxygen saturation monitor•IV line•Intubation equipment
VVVVVVVVVVV VVVVVVVV VVVVVVVV
Synchronized cardioversion•ventricular tachycardia•Paroxysmal supraventriculartachycardia•Atrial fibrillation•Atrial flutter
100200 300 , 360J J monophasic energy dose
VVVVVVVV VVVVVVVVVV ( biphasic energy dose)
Figure 10. Synchronized Cardioversion Algorithm.