introduction to advanced cardiac life support · acls algorithm •primary survey •shock – 360...
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Project: Ghana Emergency Medicine Collaborative
Document Title: Advanced Cardiac Life Support
Author(s): Rocky Oteng (University of Michigan), MD 2012
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ACLS
• Systematic approach to assessment and management of cardiopulmonary emergencies
• Continuation of Basic Life Support• Resuscitation efforts aimed at restoring
spontaneous circulation and retaining intact neurologic function
ABCD3
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The AAA’s
• Assess the patient– Establish unresponsiveness– Check pulse, respirations
• Activate EMS– Call for help
• AED– Get an AED (automated external defibrillator)
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Primary Survey (BLS)
• Airway• Breathing• Circulation• Defibrillation
Always assess and manage before moving on to the next step!
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Airway
• Open the airway– Head tilt-chin lift– Jaw thrust
Wellcome Photo Library, Wellcome Photos
Wellcome Photo Library, Wellcome Photos
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Breathing
• Look, Listen and Feel
• Give 2 rescue breaths
• Watch for appropriate chest rise and fall
U.S. Navy photo by Photographer's Mate 3rd Class Jesse Praino, Wikimedia Commons7
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Circulation
• Check for a pulse• Start CPR
– 30 compressions/
2 respirations
• Compressions more important than respirations!
U.S. Navy photo by Mass Communication Specialist Seaman Gabriel S. Weber, Wikimedia Commons8
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Defibrillation
• Know your AED
• Universal steps:1. Power ON
2. Attach electrode pads
3. Analyze the rhythm
4. Shock (if advised)
Ernstl, Wikimedia Commons 9
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Defibrillation
• Most frequent initial rhythm in witnessed sudden cardiac arrest is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) which rapidly deteriorates into VF
• The only effective treatment for VF is electrical defibrillation
• Probability of successful defibrillation diminishes rapidly over time
• VF rapidly converts to asystole if not treated
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Early Defibrillation = Increased Survival
Source unknown 11
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Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in
Casinos
• NEJM Vol 343 (17) October 26, 2000• Used AEDs on 105 patients with Ventricular
Fibrillation• 53% survived to discharge (back to casino)• Previously, less than 5% survive
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Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest
• NEJM 2004• Community based trial of AED deployment and
layperson training.• 30 in AED group versus 15 survivors in CPR
only group to hospital discharge• Average age of survivor - 69.8 years• Study cost - $9.5 million
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Secondary Survey (ACLS)
• Airway• Breathing• Circulation• Differential Diagnosis
• Assess and manage at each step before moving on!
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Airway
• Maintain airway patency– Head tilt-chin lift/jaw thrust– Oro- or nasopharyngeal airway
• Advanced airway management– ETT– Combitube– LMA
Ignis, Wikimedia Commons 15
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Breathing
• Assess adequacy of oxygenation and ventilation• Provide supplemental oxygen• Confirm proper airway placement• Secure tube
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Circulation
• Assess/monitor cardiac rhythm• Establish IV access• Give medications as appropriate for rhythm and
BP• Fluid resuscitation• Minimize interruption of compressions to
maximize survival.
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Differential Diagnosis
• Look for and treat any reversible cause of arrest
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Basic Rhythm Analysis
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Basic Rhythm Analysis
• Rate – too fast or too slow?• Rhythm – regular or irregular?• Is there a normal looking QRS? Is it wide or
narrow?• Are P waves present?• What is the relationship of the P waves to the
QRS complex?
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Rhythm Analysis
Lethal vs non-lethal?
Shockable vs. non-shockable? Too fast vs too slow?
Symptomatic vs. asymptomatic?
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Lethal Rhythms
• Shockable (Defibrillation)– Ventricular fibrillation– Pulseless ventricular tachycardia
• Non-shockable– Asystole– Pulseless electrical activity
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Non-Lethal Rhythms
• Too fast (tachycardias)– Sinus– Supraventricular (including a-fib/flutter)– Ventricular
• Too slow (bradycardias)– Sinus– Heart block (1°, 2°, 3° AV block)
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What is a Symptomatic Dysrhythmia?
• Any abnormal rhythm that produces signs or symptoms of hypoperfusion– Chest Pain/ischemic EKG changes– Shortness of Breath– Decreased level of consciousness– Syncope/pre-syncope– Hypotension– Shock - decreased Uop, cool extremities, etc.– Pulmonary Congestion/CHF
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Name that rhythm…
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63 yo man with a witnessed collapse while mowing the lawn
What is the rhythm?What is the management?
Chikumaya, Wikimedia Commons 26
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Ventricular Fibrillation
• Rapid and irregular• No normal P waves or QRS complexes
Jer5150, Wikimedia Commons 27
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VF / Pulseless VT
Primary Survey - ABC
Secondary Survey - ABC
Source unknown 28
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ACLS Algorithm
• Primary Survey• Shock – 360 J• Secondary Survey• Vasopressor - Epi or Vasopressin IV• Shock 360J• Antiarrhythmic – Amiodarone, Lidocaine or
Magnesium Sulfate IV• Shock 360J
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79yo man s/p NSTEMI
What is the rhythm?What is the management?
Glenlarson, Wikimedia Commons 30
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Ventricular Tachycardia
• Rapid and regular• No P waves• Wide QRS complexes
Ksheka, Wikimedia Commons 31
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Ventricular Tachycardia
• Monomorphic VT
• Polymorphic VT
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Ksheka, Wikimedia Commons
Displaced, Wikimedia Commons
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Ventricular Tachycardia
• Assume any wide complex tachycardia is VT until proven otherwise– SVT with aberrant conduction may also have wide
QRS complexes
• Attempt to establish the diagnosis– Ischemia risk and VT go together
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Treatment of VT
• If pulseless - follow VF algorithm• If stable try anti-arrhythmics
– Amiodarone– Lidocaine– Procainamide?
• If patient has a pulse, but is unstable or not responding to meds - shock
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Treatment of VT
• Anti-arrhythmics are also pro-arrhythmic• One antiarrhythmic may help, more than one
may harm• Anti-arrhythmics can impair an already impaired
heart• Electrical cardioversion should be the second
intervention of choice
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60yo diabetic man with chest pain
What is the rhythm?What is the management?
Knutux, Wikimedia Commons 36
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Normal Sinus Rhythm
• Regular rate and rhythm• Normal P waves and QRS• Evaluate for cause of chest pain and monitor for
change in rhythm
Knutux, Wikimedia Commons 37
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40 yo woman found down, pulseless and apneic
What is the rhythm?
What is the management?
Masur, Wikimedia Commons 38
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Pulseless Electrical Activity
• Any organized (or semi-organized) electrical activity in a patient without a detectable pulse
• Non-perfusing
• Treat the patient NOT the monitor• Find and treat the cause!!!!!
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PEA and AsystoleSecondary Survey - ABCD
Primary Survey - ABCSource unknown 40
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PEA
A t r o p i n e 1 m g I V Pi f P E A i s s l o w
E p i n e p h r i n e 1 m g I V Pr e p e a t e v e r y 3 - 5 m i n u t e s
S e a r c h f o r a n d T r e a t C a u s e s
S e c o n d a r y S u r v e y
P r i m a r y S u r v e y
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Find and Treat the Cause
• Non-shockable rhythm • The most effective treatment is to find and fix
the underlying problem
Rama, Wikimedia Commons 42
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So what causes PEA?
• #1 cause of PEA in adults is hypovolemia• #1 cause in children is hypoxia/respiratory
arrest
• Other causes?
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The H’s and T’s
• Hypovolemia• Hypoxia• Hydrogen ion (acidosis)• Hyper-/hypokalemia• Hypothermia • Hypoglycemia (rare)
• Toxins• Tamponade• Tension pneumothorax• Thrombosis (coronary or
pulmonary)• Trauma
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Treat the H’s and T’s• Hypovolemia
– Volume – IVF, PRBC’s• Hypoxia
– Oxygenate/Ventilate• Hydrogen ion (acidosis)
– Sodium bicarbonate– Hyperventilation
• Hyper-/hypokalemia– Sodium bicarbonate– Insulin/glucose– Calcium
• Hypothermia – Warm -- invasive
• Hypoglycemia – Dextrose
• Toxins– Check levels– Charcoal– Antidotes
• Tamponade– pericardiocentesis
• Tension pneumothorax– Needle decompression– Tube thoracostomy
• Thrombosis (coronary or pulmonary)– Thrombolytics– OR/cath lab
• Trauma
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19yo man with palpitations
What is the rhythm?What is the management?
Displaced, Wikimedia Commons 46
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Supraventricular Tachycardia
• Rapid (usually 150-250 bpm) and regular• P waves cannot be positively identified• QRS narrow
Displaced, Wikimedia Commons 47
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Treatment of Stable SVT
• Consider vagal maneuvers– Carotid sinus massage– Valsalva– Eyeball massage– Ice water to face– Digital rectal exam
• Adenosine– 6 mg, 12 mg, 12 mg
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Treatment of Unstable SVT
• Electrical Cardioversion• Cardioversion is not defibrillation• Use defibrillator in “sync” mode
– prevents delivering energy in the wrong part of the cardiac cycle (R on T phenomenon)
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Electrical Cardioversion
• Energy level – somewhat controversial• 100 J→200J→300J→360J• Atrial flutter may convert with lower energy
– 50J
• For polymorphic VT – start with 200J• The EP guys tend to start with 360J
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Electrical Cardioversion
• Be prepared– Patient on monitor, IV, Oxygen– Suction ready and working– Airway supplies ready
• Pre-medicate whenever possible– Conscious sedation– Electrical shocks are painful!
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Tachycardia
L o t s o f o p t i o n sb a s e d o n r h y t h m
S t a b l e ?
S h o c k
U n s t a b l e ?
E v a l u a t e P a t i e n t
• Treat the patient NOT the monitor!!!
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Stable Tachycardias
• Narrow complex?– Regular rhythm
• Sinus tachycardia• SVT• AV nodal reentry
– Irregular rhythm• Atrial fibrillation • Atrial flutter
• Wide complex?– Uncertain rhythm –
assume VT– Narrow complex
tachycardia with aberrancy
– Ventricular tachycardia• Monomorphic or
polymorphic
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56 yo woman with shortness of breath and chest pain
What is the rhythm?
What is the management?
J. Heuser, Wikimedia Commons 54
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Atrial fibrillation/flutter
• May be rapid• Irregular (fib) or more regular (flutter)• No P waves, narrow QRS
James Heilman, MD, Wikimedia Commons
J. Heuser, Wikimedia Commons
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Atrial fibrillation/flutter• Treatment based on patient’s clinical picture
– Unstable = Immediate electrical cardioversion– Stable
• Control the rate– Diltiazem– Esmolol (not if EF < 40%)– Digoxin
• Provide anticoagulation
• Treat the patient NOT the monitor!!!
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78yo man found down, pulseless and apneic, unknown duration
What is the rhythm?What is the management?
D Dinneen, Wikimedia Commons 57
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Asystole
• Is it really asystole?• Check lead and cable connections.• Is everything turned on?• Verify asystole in another lead.• Maybe it is really fine v-fib?
D Dinneen, Wikimedia Commons 58
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68 yo woman with h/o hypertension presents with dizziness
What is the rhythm?
What is the treatment?
Mysid, Wikimedia Commons 59
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Sinus Bradycardia
• Slow and regular• Normal P waves and QRS complexes
Mysid, Wikimedia Commons 60
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Bradycardias
• Many possible causes– Enhanced parasympathetic tone – Increased ICP. – Hypothyroidism – Hypothermia – Hyperkalemia – Hypoglycemia – Drug therapy
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Bradycardias
• Treat only symptomatic bradycardias– Ask if the bradycardia causing the symptoms
• Recognize the red flag bradycardias– Second degree type II block– Third degree block
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Source unknown 63
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Transcutaneous pacing
• Class I for all symptomatic bradycardias• Always appropriate• Doesn’t always work• Technique
– Attach pacer pads– Set a rate to 80 bpm– Turn up the juice (amps) until you get capture
• Painful – may need sedation / analgesia
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Transvenous Pacing
• Invasive• Time-consuming to establish• Skilled procedure• Better long-term than transcutaneous• May have better capture than transcutaneous
pacing
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Bradycardia Treatment
• Medications– Vagolytic
• Atropine
– Adrenergic• Epinephrine• Dopamine
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What if the same patient had this rhythm?
What is the rhythm?
What is the treatment?
Jer5150, Wikimedia Commons 67
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Junctional Escape
• Slow and relatively regular• No P waves• Narrow QRS• Arises from site near the junction of the atria and ventricles
Jer5150, Wikimedia Commons 68
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29 yo asymptomatic female
What is the rhythm?What is the management?
69Steven Fruitsmaak, Wikimedia Commons
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1° AV block
• Regular rate and rhythm• Normal P wave with long PR interval (>0.2msec/1 big
box)• Normal QRS
70Steven Fruitsmaak, Wikimedia Commons
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58yo asymptomatic woman
What is the rhythm?What is the management?
Jer5150, Wikimedia Commons 71
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2° AV Block - Type I
• aka Wenckebach• Regular rate and rhythm• Normal P waves and QRS complexes• Increasing PR interval until QRS dropped
Jer5150, Wikimedia Commons 72
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80 yo man with syncope
What is the rhythm?What is the management?
Jer5150, Wikimedia Commons 73
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2° AV Block – Mobitz Type II
• Regular atrial rate with normal P wave• Consistent PR interval• Random QRS dropped
Jer5150, Wikimedia Commons 74
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Another 80 yo man with syncope
What is the rhythm?
What is the management?
MoodyGroove, Wikimedia Commons 75
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3° AV Block
• Normal P waves• Normal QRS• No relationship between P and QRS• aka complete heart block
MoodyGroove, Wikimedia Commons 76
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Know When To Stop
• With return of spontaneous circulation • No ROSC during or after 20 minutes of
resuscitative efforts– Possible exceptions include near-drowning, severe
hypothermia, known reversible cause, some overdoses
• DNR orders presented• Obvious signs of irreversible death
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Take Home Points
• Assess and manage at every step before moving on to the next step
• Rapid defibrillation is the ONLY effective treatment for VF/VT
• Search for and treat the cause• Treat the patient not the monitor• Reassess frequently• Minimize interruptions to chest compressions
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Special thanks to:Steve Kronick, MD andSuzanne Dooley-Hash, MDfor contributing slides and content for this lecture.
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