Transcript Advanced Cardiac Life Support 2000

Advanced Cardiac Life Support
2004
Mark I. Langdorf, MD, MHPE, FACEP
Professor or Clinical Emergency Medicine
Chair and Associate Residency Director
University of California, Irvine
ACLS History
• Sixth iteration of guidelines since 1966
• Second that is evidence based
• First that incorporates international
perspective
Evidence Based Guidelines
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Search the international literature
Determine level of each piece of evidence
Graded each study for quality
Integrate all evidence into final class
recommendation
Classes of Recommendations
• Class I: always acceptable, proven safe and
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definitely useful
Class IIa: acceptable, reasonably prudent,
intervention of choice by experts
Class IIb: acceptable, safe and useful, within
standard of care, optional or alternative
by experts
Interderminate: inadequate research to decide
Class III: evidence for benefit lacking, or harmful
Chain of Survival
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Recognize early warning signs
Activate EMS
Basic CPR
Defibrillation
Airway and ventilation
Intravenous medications
Public Access Defibrillation: PAD
• Goal: AEDs used by laypersons everywhere
• Most effective cardiac intervention
• Shown to be cost effective (cost per life year
saved)
• Response time goal is 3 to 5 minutes
– Police
– Fire
– Casino
– Airlines
– First responders
• Survival rates up to 49% from primary ventricular
fibrillation
Sequence of Events
• 50% of patients with CAD first present with
sudden death
• Sequence:
– Decades of atherosclerotic buildup
– Plaque rupture or erosion
– Platelet adhesion
– Occluding thrombus
– Severe ischemia
– Irritable myocardium
– Ventricular fibrillation
– Collapse and sudden death
Adult BLS: Recent Changes
• Phone first (no CPR unless drowned,
trauma or overdose)
• BLS should transport to ED capable of IV
thrombolysis for MI and stroke
– Within 30 minutes for MI
– Within 60 minutes for stroke
BLS Sequence Changes
• 10cc/kg tidal volume without oxygen
• 6-7 cc/kg with supplemental oxygen
• Prevent gastric insufflation: deliver over 2
seconds
• Lay rescuers don’t check pulses before
chest compressions, healthcare workers do
• Compression rate 100/minute
• 15:2 ratio for 1 and 2-rescuer CPR
Prehospital Care for ACS
• Oxygen is routine
• Aspirin en route: 160-325mg
• Nitroglycerin
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Be careful with Viagra
Need SBP >90
3 sprays q 3-5 minutes
Morphine if 3 sprays don’t relieve pain
12 lead ECG under study
Prehospital Stroke Care
• Determine time of onset and GCS
• Perform prehospital stroke scale
– Cincinnati PSS: sensitivity 72%
– Los Angeles PSS: 93% sensitivity, 97%
specificity
• LAPSS
– Age > 45
– No seizures
– Duration < 24 hours
– Ambulatory at baseline
– Glucose 60-400
– Obvious asymmetry of face/grip/arm strength
ACLS Changes for 2000
• Wide complex tachycardia: Amiodarone
and procainamide before lidocaine and
adenosine (IIb)
• Stable V tach (and torsades): Amiodarone
and sotalol preferred (IIa)
• Bretylium not available (IIb)
• Lidocaine: evidence poor for benefit for vfib and v-tach (indeterminate)
ACLS Changes for 2000
• V-fib/pulseless V-tach: evidence for all
antiarrhythmics weak. Amiodarone preferred (IIb)
• Magnesium still IIb for torsades de pointes
(polymorphic ventricular tachycardia)
• Vasopressin: may be more effective than
epinephrine in cardiac arrest (IIb)
– 40 units IV only once
– Epinephrine still class IIb
• High-dose epinephrine: no benefit (indeterminate)
Defibrillation: Biphasic
• Will become the norm
• As effective at lower energy
– 150 biphasic = 200 monophasic
– No need for escalating energy levels (joules)
• Transthoracic impedance declines with
subsequent shocks
• Repeat same energy = success
Shock Energies: Recommended
• Still 200/200-300/360 joules for v-fib
/pulseless v-tach
• Atrial fibrillation: 100-200
• Atrial flutter/PSVT 50 to start
• Ventricular tachycardia
– Monomorphic (usual) 100 joules
– Polymorhpic (torsades de pointes) 200 joules
Other Defibrillator Points:
• Synchronize for any perfusing rhythm
– Avoids precipitating ventricular fibrillation
– Hold buttons down
• Check two leads for asystole
– If no ventricular fibrillation noted, defibrillation
not effective
• Lead disconnect can simulate asystole
Cardiac Arrhythmias
• Check the patient, not the rhythm
• Perfusion is most important
• Wide complex tachycardias are ventricular
tachycardia
– Odds 75/25 ventricular/supraventricular
– Older (>45 yo)
– Sicker (previous MI or coronary disease)
– Treat the worst, first
• 12 ECG criteria not reliable enough to distinguish
Rhythms to recognize
• Normal sinus rhythm
• Atrio-ventricular (AV) blocks
– 1st degree(not important)
– 2nd degree
• Type I (Wenkebach)
• Type II (dangerous)
– 3rd degree (complete, AV disassociation)
• Premature complexes
– Atrial (no pause)
– Ventricular (compensatory pause)
Rhythms to Recognize
• Ventricular tachycardia
– Monomorphic
– Polymorphic (Torsades de pointe)
• Ventricular fibrillation
• Asystole (confirm)
Tachyarrhythmias
• Narrow QRS complex (<120 msec)
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Sinus
Atrial fibrillation
Atrial flutter
Atrial tachycardia (digoxin toxicity)
Multifocal atrial tachycardia (COPD)
AV nodal re-entrant tachycardia (PSVT)
Junctional tachycardia
Tachyarrhythmias
• Wide QRS (>120 msec)
– Ventricular tachycardia (usually 160 msec)
– Supraventricular tachycardia with aberrant
conduction (usually not this wide)
• 12 lead if stable
• Mr. Edison if not
Show Rhythm Strips
Routes for Drug Administration
• Evidence for effectiveness for all drugs is weak
• Drugs are secondary interventions
• Peripheral still first choice
– flush with NS
– 1-2 minutes to central circulation
• If no response to drugs and defibrillation
– Consider central line
• Internal jugular (IJ) preferred (or
supraclavicular subclavian)
• Femoral less preferred
– Avoid non-compressible sites if possible
Tracheal Administration
• N-a-v-e-l still holds: drugs for the ET tube
– Narcan
– Atropine
– Valium
– Epinephrine
– Lidocaine
• Amiodarone/vasopressin not yet studied, so avoid
• Dilute in 10cc/bag vigorously
• 2-2.5 times the IV dose for all meds
Wide Complex Tachycardias:
Stable
• Must be regular and fast (>120)
• Must be uniform (one QRS morphology)
• No signs of impaired perfusion
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Mental status normal
No chest pain or CHF
Skin signs warm and dry
Systolic BP > 90 mm Hg
• Obtain 12 lead ECG if stable
Wide Complex Tachycardias:
Stable
• Procainamide first line if ventricular function
normal (sotalol) (both IIa)
• Amiodarone (IIb) (150mg over 10 minutes) or
Lidocaine (.5-.75mg/kg IVP) if poor EF (<40%)
• If ineffective:
– Synchronized cardioversion (100/200/300/360
joules)
– No repeat drug doses recommended
• Bottom line:
– Normotensive: procainamide
– Hypotensive: cardiovert
Polymorphic Ventricular
Tachycardia
• Recurrent bouts
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– Usually terminate spontaneously, or
– Degenerate into v-fib
Stop offending meds that prolong QT interval
Correct hyopcalcemia/hypomagnesemia
Magnesium 2-4 grams IVP (shortens QT)
Transcutaneous pacer (“overdrive pacing”)
– Rate >100 if no ischemia
– Shortens QT, reduces recurrence
V-fib/Pulseless V-tach
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This is easy!
Defib three times ASAP (200/300/360)
ABCs
Epi 1mg IV every 3-5 minutes, or
Vasopressin 40 units IVP, once
– Then Epi same as usual
• Amiodarone (IIb) 300mg IVP (second dose
if recurrent V-fib 150 mg)
Look for Cause!
• Hypovolemia
• Hypoxia
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– ETT/02 hooked up/pneumothorax/CO
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Acidosis
Hypo/hyperkalemia
Cardiac tamponade
Tension pneumothorax
Coronary thrombosis
Massive pulmonary embolism
Langdorf’s Silly Mnemonic
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Shock, shock, shock (defibrillation three times)
All Breathing Counts (airway, breathing, circulation)
EVerybody (epinephrine OR vasopressin)
Shocks (defib)
Americans (amiodarone)
Shock (defib)
Europeans (epinephrine again)
Shock (defib)
Latin Americans (lidocaine)
Shock (defib)
Sodium Bicarbonate: Indications
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No changes
Hyperkalemia (class I)
Pre-existing acidosis (class IIa)
TCA overdose (class IIa)
ASA overdose (class IIa)
Prolonged arrest (class IIb)
Return of spontaneous circulation (class IIb)
NOT in hypoxic, lactic acidosis cardiac arrest!
Pressors: Epinephrine
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Alpha effects confer benefit
Increases systemic vascular resistance
Increases aortic root pressure
Perfuses coronaries
Perfuses brain at expense of body
Escalating or high doses without demonstrable
benefit
• Potent pressor for hypotension (1mg in 500cc at 210 micrograms/min)
Pressors: Norepinephrine
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Potent alpha and beta agonist
Indicated for severe hypotension (SBP < 70)
Dose 1-30 micrograms/min
Extravasation: infiltrate 5-10 mg of
phentolamine
Pressors: Dopamine
• Precursor of norepinephrine
• Alpha and beta adrenergic agonist
• Indicated with hypotension and bradycardia
(raises SBP and HR)
• Dose 5-20 micrograms/min after cardiac
arrest
– 5-10 primarily beta stimulation
– 10-20 additional potent alpha effect
Pressors: Dobutamine
• Potent beta-1 selective ventricular inotrope
• Use for severe systolic dysfunction
• Reflex tachycardia due to peripheral
vasodilation
• 5-20 micrograms/min