Advanced Cardiac Life Support ACLS lecture

Advanced Cardiac Life Support and Basic life Support

1. Advanced Cardiovascular Life Support (ACLS) Presented by : Dr. Asmaa Jumaa Falih, PhD in Adult Nursing

2. Structure and Function of the Heart

3. Structure of the Lungs

4. Introduction BLS : providing care to a choking victim or to someone who needs cardiopulmonary resuscitation (CPR). ACLS (advanced cardiac life support) : an orderly approach to providing advanced emergency care to a patient who is experiencing a cardiac-related problem Cardiac monitoring Intravenous fluids and medications Advanced airway adjuncts

5. Introduction… Cardiac arrest -Abrupt cessation of cardiac function resulting in loss of effective circulation. Cardiovascular collapse -is Sudden loss of effective circulation due to cardiac and/or peripheral vascular factors Sudden cardiac death -is Sudden unexpected death attributed to cardiac arrest.

6. Adult chain of survival 2015 : Separate Chains of Survival have been recommended that identify the different pathways of care for patients who experience cardiac arrest in the hospital as distinct from out-of-hospital settings

7. “Chain of Survival” out-of-hospital cardiac arrest (OHCA) Immediate recognition of cardiac arrest and activation of the emergency response system Early CPR that emphasizes chest compressions Rapid defibrillation if indicated Effective advanced life support Integrated post cardiac arrest care Recovery*

8. “Chain of Survival” in-hospital cardiac arrest (IHCA) Surveillance for cardiac arrest Activate code (multidisciplinary team) Initiate CPR by professional providers Early defibrillation Integrated post cardiac arrest care Recovery*

9. Adult B asic L ife S upport (BLS)

10. B asic L ife S upport Used for patients with life-threatening illness or injury before the patient can be given full medical care Generally used in the pre-hospital setting, and can be provided without medical equipment Generally does not include the use of drugs or invasive skills

11. 1/14/2025 ACLS-2021 G.C. 12

12. Resuming CPR immediately after a shock is more likely to be beneficial than another shock. ACLS-2021 G.C.

13. Chest compression

14. Chest compression At least 5 cm (2inches) Full chest recoil

15. Chest compression 100-120 compression per minute

16. Airway Head tilt Chin lift

17. Jaw thrust for suspected C-spine injury

18. Breathing

19. Be sure to open the airway adequately with a head tilt–chin lift, lifting the jaw against the mask and holding the mask against the face, creating a tight seal. ACLS-2021 G.C. Do not over ventilate (i.e., give too many breaths per minute or too large volume per breath).

20. BLS Dos and Don’ts of Adult High-Quality CPR Rescuers Should Rescuers Should Not perform chest compressions at a rate of 100-120/min Compress at a rate slower than 100/min or faster than 120/min Compress to a depth of at least 2 inches (5 cm) Compress to a depth of less than 2 inches (5 cm) or greater than 2.4 inches (6 cm) Allow full recoil after each compression Lean on the chest between compressions Minimize pauses in compressions Interrupt compressions for greater than 10 seconds Ventilate adequately (2 breaths after 30 compressions, each breath delivered over 1 second, each causing chest rise) Provide excessive ventilation ( ie , too many breaths or breaths with excessive force)

21. AED (Automated External Defibrillator) Power on, AED Stick paddle according to the picture The machine will analyze whether to shock or not. If the device can give shock press the shock button

22. AED (Automated External Defibrillator) press the power button and turn the AED on AED ON

23. AED (Automated External Defibrillator) Attach pad to sternum /apex

24. AED (Automated External Defibrillator ) Connect the electrode pad cable to the electrode cable of the machine.

25. AED (Automated External Defibrillator) The analyzer will report on the monitor what kind of ECG it is and recommend it. Defibrillation If the ECG is of type VF or VT Do not touch the patient as the machine will misread the EKG. If the EKG is VF or VT type, it will provide a power charge. If the EKG is an asystole, the machine will continue CPR for 2 minutes and then analyze the EKG again.

26. AED (Automated External Defibrillator) Press to shock!

27. A dvanced C ardiovascular L ife S upport: ACLS

28. Team Work

29. ACLS... These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri cardiac arrest care- Airway management Ventilation CPR compressions Defibrillation Medications

30. 1-AIRWAY MANAGEMENT Maintain patient airway using the head-tilt, chin-lift. Rescue breathing can be mouth-to-mouth breathing. Or airway management by equipment

31. Mouth to Mouth breath To provide mouth-to-mouth breaths to an adult or child : Use the head tilt-chin lift to hold the victim’s airway open. Using the hand on the victim’s forehead that is maintaining the head tilt-chin lift, pinch the victim’s nose closed using the thumb and index finger. Inhale a regular breath, then cover the victim’s mouth with your own, creating a tight seal. Give one breath over 1 second, watching to see if the chest rises. If the chest doesn’t rise as you give the breath, repeat the head tilt-chin lift. Give a second breath over 1 second and watch for chest rise. If the second breath fails to go in, go immediately to chest compressions.

32. 2-VENTILATION In the absence of an advanced airway during CPR, current guidelines based on very limited evidence recommend two positive pressure breaths after every 30 chest compression. These breaths should be of an inspiratory time of 1 s and produce a visible chest wall rise.

33. 3-CPR COMPRESSIONS CPR is an emergency procedure consisting of chest compressions often combined with artificial ventilation. Chest compressions for adults between 5cm and 6cm deep and a rate at least 100 to 120 per minute. Chest compression to breathing ratios is set at 30 to 2 in adults

34. CPR with advanced airway Once an advanced airway is in place, there is no longer a need to pause compressions to deliver breaths. it means that air is reliably delivered to the lungs, regardless of whether a rescuer is applying force to the chest at the same time a breath is being delivered. Advanced airways include: Laryngeal mask airways (LMAs) Supraglottic airway (Combitube or King LT) Endotracheal (ET) tube When an advanced airway is in place, compressions are delivered at a rate of 100-120 compressions per minute. Breaths are delivered over 1 second simultaneously at a rate of 1 breath every 6 seconds (10-12 breaths per minute).

35. 4-Defibrillation Defibrillation is the non-synchronized delivery of a shock randomly during the cardiac cycle in arrhythmias. A defibrillator is a device that is used to deliver a shock to eliminate an abnormal heart rhythm.

36. Defibrillation We paralyze the heart, to let S. A. Node to start working again The delay in DC >>>the sever the arrhythmia >>> less favorable prognosis & less responsive to treatment. Synchronized Cardio-version: used to convert Atrial or ventricular tach., shock synchronized to occur with the R wave of the ECG rather than with the T wave . Asynchronized Cardio-version: at any ECG phase & it can cause ventricular fibrillation.

37. Cont.. Mechanism of action: 1. Monophasic:-- receive single burst, 1 pad to another & don’t come back. 2. Biphasic :-- less Jules (electric shock waves move from 1 pad to the other then go in reverse direction).

38. Defibrillation Types of Biphasic Defibrillator:-- 1. Manual (which we are using). 2. Shock Advisor (for non-expert people),with big electrodes they can read the rhythm then talk or write the order to be done. 3. Automated External (you just connect it to the patient & it will work & calculate the electric wave by it self & when to give it).

39. Shock Energy Biphasic: Biphasic delivery of energy during defibrillation is more effective than older monophasic waveforms. Initial dose of 120 to 200 J; if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses should be considered. Monophasic: 360 J

40. Defibrillator

41. Defibrillator 1. Right of the upper sternum below the clavicle 2. left 5 th IC space ant. Axillary's line. Technique : 1. A pply pressure to the paddle [10kg] to decrease thoracic impedance (the distance by pr. The fat). 2. keep the defibrillator paddles at least 12.5 cm from the pace maker if there is. 3. Keep oxygen flow away from paddle and area of the patient’s bed ; and place them at least 3.5 to 4 feet away from the patient’s chest. 4. Don’t remove the paddle until 3 DC shock performed.

42. 5-MEDICATIONS Adrenaline(all types of cardiac arrest) 1mg every 3-5 min. Amiodarone (VF,VT)- 1st dose:300mg IV bolus, 2nd dose 150mg. Lidocaine (if amiodarone is not available) Sodium bicarbonate (only if cardiac arrest is associated with hyperkalemia or tricyclic anti- depressent overdose) Calcium gluconate.

43. Drug therapy for VF/VT Vasopressin combined with epinephrine may be considered in cardiac arrest, but it offers no advantage as a substitute for epinephrine alone. Epinephrine : 1 mg IV q 3-5 min while CPR is performed continuously

44. Management of specific arrythmias VF/PVT -Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are life-threatening cardiac rhythms that result in ineffective ventricular contractions. VF is a rapid quivering of the ventricular walls that prevents them from pumping not synchronized with atrial contractions. VT is a condition in which the ventricles contract more than 100 times per minute.

45. VF and pulseless VT are both shockable rhythms. Antiarrhythmic drugs are considered after a second unsuccessful defibrillation attempt in anticipation of a third shock. Little survival benefit in refractory VF or pulseless VT. Amiodarone -First-line anti arrhythmic agent given during cardiac arrest. Considered for VF or pulseless VT unresponsive to CPR, defibrillation, vasopressor therapy Lidocaine may be considered if amiodarone is not available. The recommended dose of lidocaine is 1.0 to 1.5 mg/kg IV/IO for the first dose and 0.5 to 0.75mg/kg IV/IO for a second dose if required. Magnesium sulfate 2 g IV, followed by a maintenance infusion for polymorphic VT

46. Pulseless Arrest

47. shock Amiodarone 300 mg----150 mg 5 Hs, 5Ts Hypovolemia Hypoxia Hydrogen ions (acidosis) Hyper/ hypokalemia Hypothermia Toxins Tamponade Tension PTX Thrombosis (coronary) Thrombosis (pulmonary) Pulse/BP EtCO2>40 mmHg A-line wave form

48. BRADYCARDIA WITH PULSE

49. Unstable bradycardia

50. TACHYCARDIA WITH PULSE

51. Unstable Tachycardia Narrow regular 50-100 j Narrow irregular 120-200 j (mono 200j) Wide regular 100 j Wide irregular DF

52. TERMINATION OF RESUSCITATIVE EFFORTS  Duration of resuscitative effort >20 minutes without a sustained perfusing rhythm Initial EKG rhythm of asystole . Prolonged interval between estimated time of arrest and initiation of resuscitation. Patient age and severity of comorbid disease. Absent brainstem reflexes . Normothermia . From objective endpoints best predictor of outcome may be the end-tidal carbon dioxide (EtCO 2 <10 mmHg) level following 20 minutes of resuscitation.

53. PROGNOSIS Poor prognostic features in patients with SCA who survive until admission Persistent coma after CPR Hypotension, pneumonia, and/or renal failure after CPR Need for intubation or pressors History of class III or IV heart failure and Older age Greater likelihood of survival to hospital discharge Witnessed arrest Ventricular tachycardia or ventricular fibrillation as initial rhythm Pulse regained during first 10 minutes of CPR Despite advances in the treatment of heart disease, the outcome of patients experiencing sudden cardiac arrest (SCA) remains poor.

54. References Harrison Principles of Internal Medicine, 20th ed Up to date 2018 2019 and 2020 AHA Guidelines Update for CPR and ECC 2015 ECC Guidelines Journals ACLS provider hand book