Transcript CPR 2000 - Chiang Mai University

CPR 2000
Dr. THANAPONG HONGPROMYATI
Adult Cardiac Arrest
BLS algorithm
if appropriate
1
Precordial thumb if appropriate
Attach defibrillator/monitor
Assess rhythm
Figure 1. ILCOR Universal/International ACLS Algorithm.
2
Assess rhythm
3
Check pulse+/-
VF/VT
During CPR
Attempt 3
defibrillation
*3 as
necessary
CPR for
1 min
4
Non-VF/VT
5,6
•
•
•
•
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
Figure 1. ILCOR Universal/International ACLS Algorithm.
CPR up to
3 min
Consider causes that are potentially reversible
• Hypovolemia
• Hypoxia
• Hydrogen ion-acidosis
• Hyper-/Hypokalemia
• Hypothermia
7
•“Tablet” (drug OD,accidents)
• Temponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary (ACS)
• Thrombosis, pulmonary (embolism)
Figure 1. ILCOR Universal/International ACLS Algorithm.
• Person collapses
• Possible cardiac arrest
• Assess responsiveness
Unresponsive
Begin Primary ABCD Survey 1
(Begin BLS Algorithm)
• Activate emergency response
system
• Call for defibrillator
• A Assess breathing (open
airway, look, listen, and feel)
No Breathing
1
• B Give 2 slow breaths
• C Assess pulse, if no pulse
• C Start chest compressions
• D Attach monitor/defibrillator
when available
No pulse
Figure 2. Comprehensive ECC Algorithm.
No pulse
• CPR continues
• Assess rhythm
Attempt defibrillation 2
Non-VF/VT 3
(Up to 3 shock if VF persists)
(asystole or PEA)
Secondary ABCD Survey
4,5
• 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, pacing
CPR up to
CPR for
Non-VF/VT patients:
3 min
1 min
- Epinephrine 1 mg IV, repeat every 3-5 min
VF/VT patients:
- Vasopressin 40 U IV, single dose, 1 time only
or
- Epinephrine 1 mg IV, repeat every 3-5 min
• Differential Diagnosis: search for and treat
reversible cause
Figure 2. Comprehensive ECC Algorithm.
Primary ABCD Survey
Focus: basic CPR and defibrillation
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
A Airway:open the airway
B Breathing: provide positive-pressure ventilations
C 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
Persistent or recurrent VF/VT
Secondary ABCD Survey
Focus: more advanced assessments and treatments
A Airway: Place airway device as soon as possible
B 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.
Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.
2
Epinephrine 1 mg IV push, repeat every 3 to 5 minutes
or
Vasopressin 40 U IV, single dose, 1 time only
Resume attempts to defibrillate
1*360J (or equivalent biphasic) within 30 to 60 sec.
4
Consider antiarrhythmics:
amiodarone (IIb), lidocaine (Indeterminate),
magnesium (IIb if hypomagnesemic state),
procainamide (IIb for intermittent/recurrent VF/VT).
Consider buffers.
Resume attempts to defibrillate
5
Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.
3
Antiarrhythmics & Buffer
• Amiodarone (class IIb) 300 mg IV push (cardiac arrest
dose) If VF/pulseless VT recurs, consider administration of
a second dose of 150 mg IV. Max cumulative dose 2.2 g over
24 hr.
• Lidocaine (class Indeterminate) 1.0 - 1.5 mg/kg IV push.
Consider repeat in 3 to 5 min to a max cumulative dose of 3
mg/kg.
• Magnesium sulfate 1 to 2 g IV in polymorphic VT
(torsades de pointes) and suspected hypomagnesemic state.
• Procainamide 30 mg/min in refractory VF (Max total dose:
17 mg/kg) is acceptable but not recommended
• Sodium bicarbonate 1 mEq/kg IV is indicated for several
conditions known to provoke sudden cardiac arrest.
PULSELESS ELECTRICAL ACTIVITY
(PEA = Rhythm on monitor, without detectable pules)
Primary ABCD Survey
Focus: basic CPR and defibrillation
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
A
B
C
D
Airway:open the airway
Breathing: provide positive-pressure ventilations
Circulation: give chest compressions
Defibrillation: assess for and shock VF/pulesless VT
Figure 4. Pulseless Electrical Activity Algorithm.
Secondary ABCD Survey
Focus: more advanced assessments and treatments
A Airway: Place airway device as soon as possible
B 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
1
• “Tablet” (drug OD,accidents)
• Temponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary (ACS)
• Thrombosis, pulmonary (embolism)
Epinephrine 1 mg IV push, 2
repeat every 3 to 5 minutes
3
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.
Asystole
Primary ABCD Survey
Focus: basic CPR and defibrillation
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
A Airway:open the airway
B Breathing: provide positive-pressure ventilations
C Circulation: give chest compressions
Confirm true asystole
D Defibrillation: assess for VF/pulesless VT; shock if indicate
Rapid scene survey: any evidence personnel should not attempt
resuscitation?
Figure 5. Asystole: The Silent Heart Algorithm.
1
Secondary ABCD Survey
Focus: more advanced assessments and treatments
A Airway: Place airway device as soon as possible
B 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 pacing
If 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 minutes
up to a total of 0.04 mg/kg
6
7,8,9
Asystole persists
Withhold or cease resuscitation efforts?
• Consider quality of resuscitation?
• Atypical clinical features present?
• Support for cease-efforts protocols in place?
Figure 5. Asystole: The Silent Heart Algorithm.
• Confirm true asystole 2
-
Check lead and cable connection
Monitor power on?
Monitor gain up ?
Verify asystole in another lead
7
• 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?
8
• Reviewed for atypical clinical features?
- Not a victim of drowning or hypothermia?
- No reversible therapeutic or illicit drug overdose?
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? 1,2
Due to the bradycardia?
Yes
No
Type II second-degree AV block
or
Third-degree AV block?
No
Observe
6
3,4,5
Intervention sequence
• Atropine 0.5-1.0 mg
• Transcutaneous pacing if
available
• Dopamine 5-20 ug/kg per min
• Epinephrine 2-10 ug/min
Yes
• Prepare for transvenous pacer7
• If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed
Figure 6. Bradycardia Algorithm.
1
• If the patient has serious sign or symptoms, make sure they
are related to the slow rate.
2
• Clinical manifestations include
- Symptoms (chest pain, shortness of breath, decrease level
of consciousness)
- Signs (low blood pressure, shock, pulmonary congestion,
CHF)
3• If the patient is symptomatic, do not delay transcutaneous
pacing while awaiting IV access or for atropine to take
effect
4
• Denervated transplanted hearts will not response to
atropine. Go at once pacing, catecholamine infusion, or both.
6
• Never treat the combination of third-degree heart block
and ventricular escape beats with lidocaine (or any agent
that suppresses ventricular escape rhythms)
Evaluate patient
• Is patient stable or unstable?
• Are there serious signs or symptoms?
• Are signs and symptoms due to tachycardia?
Stable
Stable patient: no serious
signs and symptoms
• Initial assessment
identified 1 of 4 type of
tachycardia
Unstable
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
• 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.
• Prepare for immediate
cardioversion (see algorithm)
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 evaluation
1. Treat unstable patient urgently
2. Control the rate
3. Convert the rhythm
4. Provide anticoagulation
Treatment 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
Confirmed
SVT
Treatment of
SVT
(see narrowcomplex
tachycardia
algorithm)
Wide-complex
tachycardia of
unknown type
Preserved
cardiac function
Dc cardioversion
or
Procainamide
or
Amiodarone
Confirmed
stable VT
Ejection fraction
< 40% Clinical CHF
Dc cardioversion
or
Amiodarone
Treatment of
stable
monomorphic and
polymorphic VT
(see stable VT:
monomorphic and
polymorphic
algorithm)
Figure 7. The Tachycardia Overview Algorithm.
Control of Rate and Rhythm (Continued From Tachycardia Overview)
AF/flutter with
• Normal heart
• Impair heart
• WPW
1. Control Rate
2. Control Rhythm
Duration<48Hrs
Duration>48Hrs or Unknown
Consider
• NO DC cardioversion!
• DC cardioversion • Note: Conversion of AF to NSR
Use only 1 of the with drugs or shock may cause
embolization of atrial thrombi
Class IIa
Normal
following agents unless patient has adequate
cardiac
(see note below): anticoagulation.
Use
only
1
of
the
following
agents
function
• Use antiarrhythmic agents with
• Amiodarone
(see note below):
extreme caution if AF>48 hours’
• Ibutilide
• Calcium channel blockers (ClassI)
duration (see note below). or
• Flecainide
• B-Blockers (ClassI)
• Propafenone
Delayed cardioversion
• For additional drugs that are
• Procainamide
Anticoagulation * 3 weeks at
ClassIIb recommendations, see
• For additional
proper levels
Guideline or ACLS text
drugs that are
• Cardioversion, then
Class IIb
• Anticoagulation * 4 weeks more
recommendation,
or
see Guidelines or
Early cardioversion
ACLS text
• Begin IV heparin at once
Note:If AF>48hours’ duration, use
• TEE to exclude atrial clot. then
agents to convert rhythm with extreme
• Cardioversion within 24 h. then
caution in patients not receiving
• Anticoagulation * 4 more weeks
adequate anti coagulation because of
Consider
Impaired heart
• Anticoagulation as described
possible embolic complications.
• DC cardioversion above, following by
(EF<40% or
Use only 1 of the following agents:
or
CHF)
• DC cardioversion
• Digoxin (ClassIIb)
• Amiodarone
• Amiodarone
• Diltiazem (ClassIIb)
(ClassIIb)
(ClassIIb)
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.
Control of Rate and Rhythm (Continued From Tachycardia Overview)
AF/flutter with
• Normal heart
• Impair heart
• WPW
WPW
1. Control Rate
Heart Function
Preserved
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
• Primary antiarrhythmic agents
Use only 1 of the
following agents (see
note below):
•Amiodarone
(ClassIIb)
• Flecainide
(ClassIIb)
• Procainamide
(ClassIIb)
• Propafenone
(ClassIIb)
• Sotalol (ClassIIb)
Class III (can be
harmful)
• Adenosine
• B-Blockers
• Calcium blockers
• Digoxin
Impaired Heart
EF<40% or CHF
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)
2. Control Rhythm
Duration<48Hrs
Consider
• DC cardioversion
or
• Primary antiarrhythmic agents
Use only 1 of the
following agents (see
note below**):
•Amiodarone
(ClassIIb)
• Flecainide
(ClassIIb)
• Procainamide
(ClassIIb)
• Propafenone
(ClassIIb)
• Sotalol
(ClassIIb)
Class III (can be
harmful)
• Adenosine
• B-Blockers
• Calcium blockers
• Digoxin
Duration>48Hrs or Unknown
• Anticoagulation as described
above, following by
• DC cardioversion
Narrow-Complex Supraventricular
Tachycardia, Stable
Attempt therapeutic diagnosis maneuver
• Vagal stimulation
• Adenosine
Preserved
EF<40%, CHF
Junctional tachycardia
Preserved
Paroxysmal supraventricular
tachycardia
Ectopic or multifocal
atrial tachycardia
• No DC Cardioversion
• Amiodarone
• B-Blocker
• Ca2+ channel blocker
• No DC cardioversion
• Amiodarone
Priority order:
• Ca2+ Channel blocker
• B-Blocker
• Digoxin
• DC cardioversion
• Consider procainamide,
amiodarone, sotalol
EF<40%, CHF
Priority order:
• No DC cardioversion
• Amiodarone
• Diltiazem
Preserved
• No DC cardioversion
• Ca2+ channel blocker
• B-Blocker
• Amiodarone
EF<40%, CHF
• No DC cardioversion
• Amiodarone
• Diltiazem
Figure 8. Narrow-Complex Supraventicular Tachycardia Algorithm.
Stable Ventricular Tachycardia
Monomorphic or Polymorphic?
Monomorphic VT
• Is cardiac function impaired?
Normal function
Note!
May go directly to
cardioversion
Poor ejection fraction
Medications: any one
• Procainamide
• Sotalol
Other acceptable
• Amiodarone
• Lidocaine
Normal baseline
QT interval
Normal baseline QT interval
• Treat ischemia
• Correct electrolytes
Medications: any one
• B-Blocker or
• Lidocaine or
• Amiodarone or
• Procainamide or
• Sotalol
Amiodarone
• 150 mg IV bolus over 10 min. or
Lidocaine
• 0.5 to 0.75 mg/kg IV push. Then use
• Synchronized cardioversion
Figure 9. Stable Ventricular Tachycardia (Monomorphic or Polymorphic) Algorithm.
Polymorphic VT
• Is QT baseline interval prolonged?
Prolong baseline
QT interval
(suggests torsades)
Long baseline QT interval
• Correct abnormal electrolytes
Medications: any one
• Magnesium
• Overdrive pacing
• Isoproterenol
• Phenytoin
• Lidocaine
Tachycardia
with serious signs and symptoms related to the tachycardia
If ventricular rate is > 150 bpm, prepare for immediate
cardioversion. May give brief trial of medications based on
specific arrhythmias. Immediate cardioversion is generally not
need if heart rate is <= 150 bpm.
Have available at bedside
•oxygen saturation monitor
•IV line
•Intubation equipment
Premedicate whenever possible
Synchronized cardioversion
•ventricular tachycardia
•Paroxysmal supraventricular
tachycardia
•Atrial fibrillation
•Atrial flutter
Figure 10. Synchronized Cardioversion Algorithm.
100J, 200J
300J, 360J
monophasic energy dose
(or clinical equivalent
biphasic energy dose)