Anda di halaman 1dari 68

Advanced Cardiac Life Support

Judith Maely Kong-Tarrazona, RN

Created by Judith Maely Kong-Tarrazona

4 Chains
Early recognition of emergency and activation of EMS Early bystander CPR Early defibrillation: CPR plus defibrillation within 3 to 5 minutes of collapse can produce survival rates as high as 49% to 75%.

Early advanced life support followed by postresuscitation care delivered by healthcare providers.

Created by Judith Maely Kong-Tarrazona

Core Concepts of ACLS


Knowledge and Skills
Devices and procedures: Indications Precautions Proper Use Pharmacologic Agents: Actions, Indications, Dosing and Precautions
Judith Maely Kong-Tarrazona, RN

Core Concepts of ACLS


The Brain
- Cerebral Resuscitation is the most important goal Cardio-pulmonary-cerebral Resuscitation (CPCR)

Judith Maely Kong-Tarrazona, RN

Core Concepts of ACLS


The Patient
- the algorithms focus on the most important aspects of resuscitative care suitable for a particular patient NEVER FORGET the PATIENT

Judith Maely Kong-Tarrazona, RN

Core Concepts of ACLS


Basic Life Support
- ACLS is just the other end of BLS

BLS
Open Airway
Adequate Ventilation Mechanical Circulation

ACLS
Recognition of CP/CV Emergency Defibrillation
Advanced Airway Mgt
Rhythm Appropriate IV Meds
Judith Maely Kong-Tarrazona, RN

Core Concepts of ACLS


Time
- The longer it takes to perform some interventions, the lower the chances of benefits

The Cause
- must be identified as quickly as possible to start appropriate therapy immediately
Judith Maely Kong-Tarrazona, RN

Core Concepts of ACLS


The CHAIN of SURVIVAL
Early Access Early CPR Early Defibrillation Early ACLS

CPR

ACCESS

DEFIB

ACLS

Judith Maely Kong-Tarrazona, RN

Head-tilt, Chin-lift
The

fingers of one hand are placed underneath the mandible, gently lifting upward in an anterior direction.

Judith Maely Kong-Tarrazona, RN

Jaw-Thrust

Advantage: decreased risk of hyper-extending the neck. 1. Distinguish the edge of the jaw below the ears one hand on each side of the head. 2. Displace the mandible forward by applying a steady forward-andupwards movement to lift the jaw. 3. The thumbs are then utilised to slightly open the mouth by gently pressing downwards on the chin.
Judith Maely Kong-Tarrazona, RN

Breathing
LOOK (at rise and fall
of the chest)

LISTEN (for breath


sounds)

FEEL (for air)

Judith Maely Kong-Tarrazona, RN

Rescue Breaths
Pinch the nose Take 1 normal breath Make a good seal with your mouth Blow until there is visible chest rise
Judith Maely Kong-Tarrazona, RN

Airway Adjuncts

Face Mask

OroPharyngeal Airway (OPA)


Judith Maely Kong-Tarrazona, RN

Judith Maely Kong-Tarrazona, RN

Airway Adjuncts

Naso Pharyngeal Airway

Laryngeal Mask Airway (LMA)


Judith Maely Kong-Tarrazona, RN

Airway Adjuncts

Edotracheal Tube (ETT)

Laryngoscope
Judith Maely Kong-Tarrazona, RN

Intubation

Judith Maely Kong-Tarrazona, RN

Adult Basic Life Support


1

No movement or response
2

Call for Help, Get AED


3

Open AIRWAY

Check BREATHING
4

If NOT, Give 2 BREATHS


Judith Maely Kong-Tarrazona, RN

Adult Basic Life Support


5

No Response, Check Pulse (only for 10 seconds)


w/ PULSE NO PULSE
5A

Give 1 breath / 5 sec


Check pulse q 2

Give cycles of 30 Compressions and 2 Breaths Until AED arrives or ALS takes over Push HARD and FAST (100/min)
Judith Maely Kong-Tarrazona, RN

Adult Basic Life Support


7

AED / Defibrillator arrives


8

Check Rhythm

Shockable Rhythm?

Give 1 Shock

Resume CPR immediately for 5 cycles

Resume CPR immediately for 5 cycles


Judith Maely Kong-Tarrazona, RN

10

Judith Maely Kong-Tarrazona, RN

During CPR
Push

hard and fast (100/min) Ensure full recoil Minimize interruptions in chest compressions 1 cycle = 30 compressions : 2 breaths 5 cycles = 2 minutes Avoid hyperventilation

Judith Maely Kong-Tarrazona, RN

During CPR
Secure

airway and confirm placement After an advanced airway is in place, rescuers no longer deliver CPR in cycles Give continuous compressions without pausing for ventilations Give 8-10 ventilations per minute Check rhythm every 2 minutes Rotate compressors every 2 minutes within rhythm checks
Judith Maely Kong-Tarrazona, RN

During CPR
Search

for and treat possible contributing Toxins Tamponade (Cardiac) Tension pneumothorax Thrombosis Trauma

factors: Hypovolemia Hypoxia H+ ion (acidosis) Hypo-hyperkalemia Hypoglycemia Hypothermia

Judith Maely Kong-Tarrazona, RN

Defibrillation
1. 2. 3. 4.

The most frequent initial rhythm in witnessed SCA is VF The treatment for VF is electrical defibrillation The probability of successful defibrillation diminishes rapidly over time VF tends to deteriorate to asystole within a few minutes
Judith Maely Kong-Tarrazona, RN

Defibrillation: Shock first vs. CPR first


When an AED is available on site: USE AED ASAP!

Out-of-hospital SCA: Give 5 cycles of CPR then use AED (analyze rhythm)

Judith Maely Kong-Tarrazona, RN

DefibrillationProtocols
Single Shock at 360J followed by 5 cycles of CPR (ECC 2005) Sternal-apical electrode placement Charge and change sync settings Chant for clearance Deliver the shock with 20 lbs of weight Resume CPR immediately
Judith Maely Kong-Tarrazona, RN

ECG Recognition

Judith Maely Kong-Tarrazona, RN

ACLS Core Cases

Created by Judith Maely Kong-Tarrazona

Case 1: AED Algorithm

Universal Steps for AED Operation: POWER ON Attach Electrode Pads Analyze the Rhythm Clear the victim and press the SHOCK button

1. 2. 3. 4.

Judith Maely Kong-Tarrazona, RN

AED Algorithm
1

Unresponsive 911 - AED


UNRESPONSIVE
2

Start ABCDs
NOT BREATHING
3B

YES, BREATHING
3A

Adequate Breathing: Recovery Position

Give 1 breath / 5sec Check Circulation

Inadequate Breathing: Give 1 breath / 5sec


Judith Maely Kong-Tarrazona, RN

AED Algorithm
NO CIRCULATION
4

Perform CPR until AED arrives (30:2)


5

Use AED Power ON, Attach electrodes, Analyze, SHOCK!


After 3 shocks or after any no shock indicated: Check for circulation No circulation, continue CPR Then press analyze (Continue up to 3 times)
6
Judith Maely Kong-Tarrazona, RN

Case 2: Pulseless
1

Arrest

BLS Algorithm: Call for Help, CPR O2 when available Attach to monitor Check Rhythm Shockable Rhythm?
SHOCKABLE NOT SHOCKABLE
9 2

VF/VT

Asystole / PEA
Judith Maely Kong-Tarrazona, RN

What is this?

Judith Maely Kong-Tarrazona, RN

What is this?

Judith Maely Kong-Tarrazona, RN

What is this?

Judith Maely Kong-Tarrazona, RN

SHOCKABLE
3A

VF/VT

Give 1 SHOCK Biphasic 200J Monophasic 360J Resume CPR Immediately!


Give 5 cycles of CPR*

Check Rhythm Shockable Rhythm?


Judith Maely Kong-Tarrazona, RN

SHOCKABLE
6

Continue CPR while charging Give 1 SHOCK Resume CPR immediately! Give EPINEPHRINE (1mg IV) q 3-5 min or 1 dose VASOPRESSIN 40 u IV
Give 5 cycles of CPR*

Check Rhythm Shockable Rhythm?


Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE

Epinephrine
Cardiac Arrest from VF or pulseless VT unresponsive to initial shocks Asystole PEA Initial Dose: 1mg IV; repeat every 3-5 min Infusion: 1mg/500ml NSS or D5W
Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE

Vasopressin
Alternative to Epinephrine PEA Shock 40 mg IV bolus single dose

Judith Maely Kong-Tarrazona, RN

SHOCKABLE
8

Continue CPR while charging Give 1 SHOCK, Resume CPR immediately! Consider antiarrhythmics AMIODARONE (300 mg IV once, then additional 150 mg IV once) or LIDOCAINE 1-1.5 mg/kg 1st dose then 0.50.75 mg IV [max=3mg/kg] Consider MAGNESIUM loading dose 1-2 g IV for Torsades de pointes After 5 cycles, go back to box 5
Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology Anti-arrhythmics


Amiodarone
Alters conduction through the accessory pathway

Persistent VF or VT after defibrillation SVT 150 mg IV bolus over 10 min followed by 1 mg/min infusion for 6 hours then 0.5 mg/min
Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology Anti-arrhythmics


Lidocaine
automaticity Ventricular Tachycardia Ventricular Fibrillation Initial: 1-1.5 mg/kg Infusion: 30-50 ug/kg/min
Judith Maely Kong-Tarrazona, RN

Check Rhythm Shockable Rhythm?

Judith Maely Kong-Tarrazona, RN

ASYSTOLE / PEA

10

Resume CPR immediately for 5 cycles When IV/IO available Give EPINEPHRINE (1mg IV) q 3-5 min or 1 dose VASOPRESSIN 40 u IV (to replace 1st or 2nd dose of Epinephrine) Consider ATSO4 1mg IV/IO for asystole or slow PEA Repeat q 3-5 min up to 3 doses
Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology Anti-arrhythmics


Atropine
Enhanced sinus node automaticity; AV Conduction

Symptomatic bradycardia 1st degree AV Block Mobitz Type 1 AV Block Asystole or PEA
0.5-1 mg IV in 5-min interval TOTAL= 3mg
Judith Maely Kong-Tarrazona, RN

Give 5 cycles of CPR*

Check Rhythm Shockable Rhythm?


SHOCKABLE
13

11

NOT SHOCKABLE

Go to Box 4

12

If Asystole go to Box 10 If with electrical activity, check pulse, no pulse, go to Box 10 If with pulse, proceed to postresuscitation care

Judith Maely Kong-Tarrazona, RN

Case 3: Bradycardia

Algorithm

Judith Maely Kong-Tarrazona, RN

Case 3: Bradycardia

Algorithm

Judith Maely Kong-Tarrazona, RN

Case 3: Bradycardia
1

Algorithm
Bradycardia Heart rate < 60 bpm and inadequate for clinical condition
2

Maintain patent airway, assist breathing as needed Give O2 Monitor ECG, BP, oximetry Establish IV line

Judith Maely Kong-Tarrazona, RN

S/S of poor perfusion r/t bradycardia?


POOR PERFUSION
4

ADEQUATE PERFUSION
4A

Observe / Monitor

Prepare for Transcutaneous Pacing

Consider ATSO4 0.5 mg while awaiting pacer max dose = 3 mg Consider EPINEPHRINE 2-10ug/min or DOPAMINE 2-10 ug/kg/min
Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE

Dopamine
Hypotension Post-resuscitation Shock 5-20 ug/kg/min

Dopaminergic Effect 2-4 ug/kg/min Inotropic Effect 5-10 ug/kg/min -receptor effect 10-20 ug/kg/min
Judith Maely Kong-Tarrazona, RN

Prepare for Transvenous Pacing Treat contributing causes Consider expert opinion

Judith Maely Kong-Tarrazona, RN

Case 4: Tachycardia
1

Algorithm
Tachycardia with pulses

Assess and support ABCs as needed Give O2 Monitor ECG, BP, oximetry Identify and treat reversible causes

Judith Maely Kong-Tarrazona, RN

SYMPTOMS PERSIST
3

Is patient stable? Unstable symptoms: altered mental status ongoing chest pain hypotension or signs of shock
STABLE UNSTABLE

Establish IV access Obtain 12-lead ECG

Perform immediate SYNCHRONIZED CARDIOVERSION*


Judith Maely Kong-Tarrazona, RN

Is QRS Narrow?
WIDE
6

NARROW
6

Is Rhythm Regular?

Wide Complex QRS: Is Rhythm Regular?

REGULAR
11

IRREGULAR

Irregular Narrow Complex Tachycardia (Afib, AF, MAT) Consider expert consultation Control rate: DILTIAZEM, BBLOCKERS
Judith Maely Kong-Tarrazona, RN

Irregular Narrow Complex Tachycardia

Judith Maely Kong-Tarrazona, RN

Irregular Narrow Complex Tachycardia

Judith Maely Kong-Tarrazona, RN

Regular Narrow Complex Tachycardia


REGULAR

Judith Maely Kong-Tarrazona, RN

REGULAR
7

Attempt Vagal Maneuvers Give ADENOSINE 6mg rapid IV push with NSS flush If rhythm does not convert, give 12mg May repeat after 12 mg dose once
8

Does rhythm convert?


DOES NOT CONVERT

CONVERTS

Judith Maely Kong-Tarrazona, RN

Cardiovascular Pharmacology Anti-arrhythmics


Adenosine
Slows AV nodal conduction

Narrow complex tachycardias SVT 6mg IV bolus over 1-3 sec Followed by 20ml saline flush Repeat at 12 mg IV within 1-2 min
Judith Maely Kong-Tarrazona, RN

CONVERTS
9

DOES NOT CONVERT

Re-entry SVT

Observe for recurrence Treat recurrence with ADENOSINE or DILTIAZEM or BBLOCKERS

AF, Ectopic Atrial Tachycardia, or Junctional Tachycardia) Control rate: DILTIAZEM, B-BLOCKERS Treat underlying cause Consider expert consultation
Judith Maely Kong-Tarrazona, RN

10

WIDE
6

Wide Complex QRS: Is Rhythm Regular?


IRREGULAR
14

REGULAR

VT or uncertain rhythm AMIODARONE 150 mg IV over 10 mins Repeat as needed to maximum dose of 2.2g/24 hours Prepare for CARDIOVERSION

13

If Afib, with aberrancy, Go to Box11 If pre-excited atrial tachycardia avoid AV nodal blocking agents (ADENOSINE, DIGOXIN, DILTIAZEM, VERAPAMIL)
Judith Maely Kong-Tarrazona, RN

Case 5: Stroke
1

Management

Identify signs of possible STROKE

EMS Assessment Support ABCs; Give O2 as needed Perform Pre-hospital Stroke Assessment * Establish time patient last known normal Alert hospital Check Glucose is possible
Judith Maely Kong-Tarrazona, RN

Immediate general assessment and stabilization * Assess ABCs, vital signs * Provide O2 if hypoxemic * Obtain IV access and blood samples * Perform neurologic screening assessment * Activate stroke team * Order emergent CT scan of brain * Obtain 12-lead ECG

Judith Maely Kong-Tarrazona, RN

Immediate neurologic assessment by stroke team or designee * Review patient history * Establish symptom onset * Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale

Judith Maely Kong-Tarrazona, RN

5 Does

CT Scan show hemorrhage?


HEMORRHAGE
7 Consult

NO HEMORRHAGE
6 Probable

Acute Ischemic

Stroke Consider FIBRINOLYTIC THERAPY * Check for fibrinolytic therapy * Repeat neurologic exams: are deficits rapidly improving to normal?

neurologist or neurosurgeon; consider transfer if not available

Judith Maely Kong-Tarrazona, RN

8 Patient

remains candidate for fibrinolytic therapy?


CANDIDATE
10 Review

NOT A CANDIDATE
9 Administer

risks/benefits with patient and family: if acceptable * Give tPA * No anticoagulants or antiplatelet treatment for 24 hours

ASPIRIN

Judith Maely Kong-Tarrazona, RN