Advanced Cardiovascular Life Support (ACLS)
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
2010 ACLS Guidelines
Science updates to CPR and ECC
• Basic Life Support
• ACLS• Acute Coronary
Syndrome• Electrical
Therapies• CPR Techniques
and Devices• Stroke• Ethical Issues• Education,
Implementation, and Teams
• International consensus • Extensive review of resuscitation literature• Peer-reviewed studies• Rigorous disclosure and management of conflicts of
interest
The road to change
BLS Survey
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
High Quality Chest Compressions
“push hard and
push fast”
Chest Compressions
To deliver effective chest compressions, you must:
•Rate: at least 100/minute•Depth:
• 2 inches [5 cm] in adults and children• 1.5 inches [4 cm] infants
•Allow full chest recoil•Minimize interruptions•Avoid excessive ventilation
High-Quality Chest CompressionHigh-Quality Chest Compression
For adults, at least 2 inches (5 cm)
Compression Depth At Least 2 InchesCompression Depth At Least 2 Inches
Compression -to- ventilation ratio
Questions?
Change “A-B-C” to “C-A-B”Change “A-B-C” to “C-A-B”
Chest compressions and early defibrillation.
Chest compressions
Elimination of Look, Listen, and FeelElimination of Look, Listen, and Feel
Cricoid pressure is a technique of applying pressure to the victim’s cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebrae. Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag mask ventilation, but it may also impede ventilation.
Definition of Cricoid Pressure
Cricoid Pressure During Ventilation Not RecommendedCricoid Pressure During Ventilation Not Recommended
Check simultaneously:1)Responsiveness2)Breathing
If victim unresponsive and not breathing:1)Activate emergency response system2)Retrieve AED if available3)If no pulse felt within 10 seconds, begin CPR
First
Then
BLS SurveyBLS Survey
16 16
Advanced Cardiovascular Life Support
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Simplified Cardiac Arrest Algorithm
Monitoring to Optimize CPR
Post-Cardiac CareAirway Management
Advanced Cardiovascular Life Support
Overview
Simplified ACLS AlgorithmSimplified ACLS Algorithm
Adult arrest algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
ACLS Cardiac Arrest Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
Tachycardia Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
Bradycardia Algorithm
Questions?
Capnography RecommendationCapnography Recommendation
Capnography to confirm endotracheal tube placement.
Capnography to monitor effectiveness of resuscitation efforts.
Capnography Waveform
Pressure of end tidal CO2 (PETCO2)
Ineffective chest compressionsindicated by
PEA/asystole
Medication RecommendationsSymptomatic Arrhythmias
New Medication ProtocolsNew Medication Protocols
Epinephrine IV/IO Dose: 1 mg every 3-5 minutesVasopressin IV/IO Dose: 40 units can replace first or second dose of epinephrineAmiodarone IV/IO Dose: First dose: 300 mg bolus.Second dose: 150 mg.
Atropine IV Dose:First dose: 0.5 mg bolusRepeat every 3-5 minutesMaximum: 3 mg
ORDopamine IV Infusion:2-10 mcg/kg per minute
OREpinephrine IV Infusion:2-10 mcg per minute
Adenosine IV Dose: First dose: 6 mg rapid IV push; follow with NS flush.Second dose: 12 mg if required.
Tachycardia
Symptomatic or unstable bradycardia
Organized Post-Cardiac CareOrganized Post-Cardiac Care
Improved Survival
Effect of Hypothermia on PrognosticationEffect of Hypothermia on Prognostication
Oxygen Saturation
Oxygen SaturationOxygen Saturation
Special Resuscitation SituationsSpecial Resuscitation Situations
Acute Coronary Syndromes
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
• Reduce the amount of myocardial necrosis• Prevent major adverse cardiac events• Treat acute, life-threatening complications
ACS
Systems of Care for Patients WithST-Elevation Myocardial Infarction (STEMI)
STEMI Systems of Care
Triage to Capable Hospital
Cardiac Catheterization
Questions?
Electrical Therapies
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Defibrillation | Cardioversion | Pacing
Electrical Therapy
Healthcare Provider AED RecommendationsHealthcare Provider AED Recommendations
AED Use in Children Includes InfantsAED Use in Children Includes Infants
1-shock defibrillation protocol followed by immediate CPR
One-Shock Protocol Versus Three-Shock SequenceOne-Shock Protocol Versus Three-Shock Sequence
Defibrillation Waveforms and Energy LevelsDefibrillation Waveforms and Energy Levels
200 J
Pediatric DefibrillationPediatric Defibrillation
2 J/kg2 J/kg
Fixed and Escalating EnergyFixed and Escalating Energy
Escalating Energy Levels
Joules
Electrode PlacementElectrode Placement
Anterior-lateralAnterior-lateral
Anterior-posteriorAnterior-posterior
Anterior-left infrascapularAnterior-left infrascapular
Anterior-right infrascapularAnterior-right infrascapular
Defibrillation With Implanted Cardioverter DefibrillatorDefibrillation With Implanted Cardioverter Defibrillator
Anterior-posterior or
Anterior-lateral
Anterior-posterior or
Anterior-lateral
Ventricular Tachycardia Supraventricular Tachycardias
• Initial biphasic energy dose of 50-100 J
• Monophasic or biphasic waveform cardioversion shocks at initial energy of 100 J
Synchronized CardioversionSynchronized Cardioversion
Energy Doses
The value of VF waveform analysis to guide defibrillation management during resuscitation is uncertain.
Fibrillation Waveform AnalysisFibrillation Waveform Analysis
CPR Techniques and Devices
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Recommended Devices
No resuscitation device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.
The precordial thump is a CPR technique used by healthcare professionals in the initial response to a witnessed cardiac arrest when no defibrillator is immediately available.
Definition of Precordial Thump
Use of Precordial Thump Not RecommendedUse of Precordial Thump Not Recommended
Stroke
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Stroke CareStroke Care
• Detection
• Dispatch
• Delivery
• Door
• Data
• Decision
• Drug
• Disposition
Stroke-Prepared HospitalStroke-Prepared Hospital
rtPA GuidelinesrtPA Guidelines
Inclusion Criteria• Diagnosis of ischemic stroke causing measurable neurologic deficit• Onset of symptoms <3 hours before beginning treatment• Age ≥18 yearsExclusion Criteria• Head trauma or prior stroke in previous 3 months• Symptoms suggest subarachnoid hemorrhage• Arterial puncture at noncompressible site in previous 7 days• History of previous intracranial hemorrhage• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)• Evidence of active bleeding on examination• Acute bleeding diathesis, including but not limited to
− Platelet count <100 000/mm3− Heparin received within 48 hours, resulting in aPTT >upper limit of normal− Current use of anticoagulant with INR >1.7 or PT >15 seconds
• Blood glucose concentration <50 mg/dL (2.7 mmol/L)• CT demonstrates multilobar infarction (hypodensity >¹⁄³ cerebral hemisphere)Relative Exclusion CriteriaRecent experience suggests that under some circumstances—with careful consideration andweighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relativecontraindications. Consider risk to benefit of rtPA administration carefully if any one of these relativecontraindications is present:
• Only minor or rapidly improving stroke symptoms (clearing spontaneously)• Seizure at onset with postictal residual neurologic impairments• Major surgery or serious trauma within previous 14 days• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)• Recent acute myocardial infarction (within previous 3 months)
Patients Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset
Magnitude of benefits from treatment in a stroke unit are comparable to magnitude of effects achieved with rtPA.
Stroke Unit CareStroke Unit Care
Management of HypertensionManagement of Hypertension
Potential Approaches to Arterial Hypertension in Acute Ischemic StrokePatients Who Are Potential Candidates for Acute Reperfusion Therapy
Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:• Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1, or• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour; when desired blood pressure is reached, lower to 3 mg per hour, or• Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA.
Management of blood pressure during and after rtPA or other acute reperfusion therapy:Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours.
If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or• Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour
If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.
Questions?
Ethical Issues
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Ethical issues relating to resuscitation are complex.
Arrest not witnessed by EMS provider or first responder
No ROSC after three complete rounds of CPR and AED analyses
No AED shocks were delivered
Terminating Resuscitative Efforts in Adults with Out-of-Hospital Cardiac Arrest (OHCA)
Arrest not witnessed No bystander CPR
was provided No ROSC after
complete ALS care in the field
No shocks were delivered
“ALS termination of resuscitation” rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met:
v
Prognostic Indicators in the Adult Post-Arrest Patient Treated with Therapeutic Hypothermia
Education, Implementation, and Teams
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
Learn and LiveLearn and Live
Chain of Survival
Thank you.
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