Advanced Cardiovascular Life Support (ACLS).pptx

discusses the basic and Advanced Life support according to the AHA guidelines.
ACLS, BLS, defibrillation and Advanced medications at Adama Hospital medical college ICU

1. Advanced Cardiovascular Life Support (ACLS) Presenter: Dr. Rebil Heiru IM R3 Moderators: Dr Endashaw Abebe (Internist, Assistant Professor) & Dr Dejene ( Anestheologist , Assistant professor)

2. Outline Introduction BLS ACLS Pulseless Arrest Bradycardia Tachycardia Post cardiac arrest care Take Home message

3. 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

4. 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.

5. 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

6. “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*

7. “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*

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

9. 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

10. unresponsesive Breathing and pulse 30:2 x 5 cycle Call for help and AED Pulse :breathing 5-6 sec No pulse : CPR

11. 6/29/2021 ACLS-2021 G.C. 14

12. Resuming CPR immediately after a shock is more likely to be beneficial than another shock. 6/29/2021 ACLS-2021 G.C. 15

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. 6/30/2021 ACLS-2021 G.C. 22 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. A dvanced C ardiovascular L ife S upport: ACLS Pulseless Arrest Bradycardia with Pulse Tachycardia with Pulse

29. Team Work

30. 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. 6/30/2021 ACLS-2021 G.C. 37

31. 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. 6/30/2021 ACLS-2021 G.C. 38

32. 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). 6/30/2021 ACLS-2021 G.C. 39

33. 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). 6/30/2021 ACLS-2021 G.C. 40

34. 6/30/2021 ACLS-2021 G.C. 41 CPR should be resumed immediately after shock delivery.

35. 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 6/30/2021 ACLS-2021 G.C. 42

36. Cont.. 6/30/2021 ACLS-2021 G.C. 43

37. Defibrillator

38. 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.

39. Drug therapy for VF/VT 6/30/2021 ACLS-2021 G.C. 46 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

40. 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. 6/30/2021 ACLS-2021 G.C. 47

41. 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 6/30/2021 ACLS-2021 G.C. 48

42. Pulseless Arrest

43. 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

44. BRADYCARDIA WITH PULSE

45. Unstable bradycardia

46. TACHYCARDIA WITH PULSE

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

48. Quantitative Waveform Capnography Confirmation and monitoring ETT placement Evaluating the effectiveness of chest compressions ETCO2 value is at least 10-20 mmHg. Identification of ROSC Failure to achieve an ETCO2of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR decide to end resuscitative efforts but should not be used in isolation

49. C apnography R ecommendation

50. CPR Quality Quantitative waveform capnography If Petco2<10 mm Hg, attempt to improve CPR quality Intra-arterial pressure If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality

51. SPO2 SBP >90 mmHg MAP>65 mmHg BT 32C-36C at least 24 hr

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. 6/29/2021 ACLS-2021 G.C. 60

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54. 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 6/29/2021 ACLS-2021 G.C. 62 Despite advances in the treatment of heart disease, the outcome of patients experiencing sudden cardiac arrest (SCA) remains poor.

55. Factors identified predicting a lower likelihood of survival to hospital discharge: Longer duration of overall resuscitation efforts & Multiple resuscitation efforts Success is best for VT (25–30%), worse for VF and poor for PEA and asystole (<5%). Although advances in CPR and post-resuscitation care have improved survival rates after cardiac arrest, 90% of patients will not survive to be discharged from the hospital. Of those that survive, ~20% are left with severe neurologic and/or physical disability 6/29/2021 ACLS-2021 G.C. 63

56. Neuroprognostication Hypoxic Ischemic brain injury…. Leading cause of death in OHCA

57. The score for all variables in a patient should be summed interpreted using the following categories: Good Outcome Following Attempted Resuscitation; Very low likelihood of survival (<1%) Score of 24 or greater. Low likelihood of survival (1 to 3%) Score 14 to 23. Average likelihood of survival (>3 to 15%) Score –5 to 13. Higher than average likelihood of survival (>15%) – Score –15 to –6. GO-FAR score to predict neurologically intact survival-following IHCA Variable GO-FAR score Neurologically intact or with minimal deficits at admission _15 Major trauma 10 Acute stroke 8 Metastatic or hematologic cancer 7 Septicemia 7 Medical non-cardiac diagnosis 7 Hepatic insufficiency 6 Admit from skilled nursing facility 6 Hypotension or hypoperfusion 5 Renal insufficiency or dialysis 4 Respiratory insufficiency 4 Pneumonia 1 Age, yr (70-74),(75-79),(80-84),(>85). (2,5,6,11) 6/29/2021 ACLS-2021 G.C. 65

58. Prevention Beta-adrenergic blockers ACEI, aldosterone antagonists, and angiotensin-receptor/ neprilysin inhibitors Coronary artery bypass grafting For patients whose disease continues to confer substantial risk of sustained VT or VF on optimal medical therapy, an ICD is recommended. Communicate with family and loved ones throughout resuscitative efforts Allow family to be present during resuscitative efforts, if appropriate Assess likely outcome, based on scientific evidence 6/29/2021 ACLS-2021 G.C. 66 ETHICAL CONSIDERATION

59. TOP 10 TAKE-HOME MESSAGES FOR ADULT CARDIOVASCULAR LIFE SUPPORT 1. On recognition of a cardiac arrest event, and promptly activate the emergency response system and initiate CPR. 2. Performance of high-quality CPR 3. Early defibrillation with concurrent high-quality CPR. 4. Administration of epinephrine with concurrent high-quality CPR. 5. Recognition that all cardiac arrest & specialized mgt for each diseases

60. Cont … 6. Activation of emergency care and high quality CPR in OHCR due to opioid poisoning 7. Post–cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, MDT treatment. 8. Prompt initiation of targeted temperature management 9. Accurate neurological prognostication 10.Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation.

61. Thank you!

62. 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 6/30/2021 ACLS-2021 G.C. 70