acls.dr.young

8/12/2019 ACLS.dr.Young

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AHA

ACLS

Guideline

UpdateAmericanHeartAssociationAdvance

Cardiac

Life

Support


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OutofHospitalCardiacArrestDatain

HongKong(Ref:HKJEM,HKMJ2002)15%patientdiebecauseofACS

5 18%initialrhythmisVF

70 90%initialrhythmisasystole

14%can

be

survival

to

admission

to

A&E

0.5 3%canbesurvivaltodischarge

42 80%witnessarrest

12%citizenlearnedCPR

15%BystanderCPRrate


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Out of hospital cardiac arrest

2005 (PWH): * Most of OHCA happens at home

* Bystander CPR ~15.3%

* Most common 1st rhythm identified: asystole;

VF/VT only 18%

* Overall survival 0.8% (VF/VT: 11.8%, Asystole

0%)

* Median time of 1st shock: 14 minutes; Median

time of arrival to hospital: 33 minutes


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In-hospital cardiac arrest

2007 (PWH)

* Most occurred in non-monitored area * Initial rhythm mostly asystole (52%)

* Only 8% VF/VT; (40% PEA)

* Overall survival rate 5%

* Survival rate higher in monitored area (9% vs 4%),

respiratory arrest (61% vs 3%), Initial rhythm VF/VT

(13% vs 4%)


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2006 (Taiwan)

* overall 18% STD (Survival to Discharge)

2009 (USA)

* VF survival rate 8-40% depending on the region

2002(HK)

0.53%can

be

survival

to

discharge

!!

i.e.themortalityofOHCAinHKis97 99%!!

Why??Delayinrestorationofnormalrhythmand

circulation.


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Howtoimprove??Call999 12minAmbulanceofficer arrivedwitha

defibrillator(equippedsince1990s)

Evidence:

75%

VF

can

be

revived

if

defibrillation

within3min.

PublicaccessAEDsaved50%morelivesfromOHCA

TheHKCC

AED

Program

since

2008:

increase

public

awareness,promotelaypersontraininginBLSandcoordinateAEDinstallationinsuitablelocation

ResuscitationCouncil

of

Hong

Kong

established

in

May2012(Titleofthe1st scientificmeeting:PublicAccessDefibrillation)


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Incardiacarrest...NewChainsofsurvival

Survival fromcardiacarrestrequires:

Rapid,highqualityBLS(Mostchange)

Earlydefibrillation

for

VF/

pulseless

VT

(effort

to

improve)

SystematicACLSinterventions,with

BasisonhighqualityCPR,withminimallyinterruptedchest

compression

ContinuousmonitoringofCPRquality

Drug/advancedairway/underlyingcauses

Rhythm

based

algorithms Integratedpostcardiacarrestcare(NewLink)


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OddsRatiosforSurvivaltoHospitalDischarge

AssociatedwithSelectedFactorsOriginalArticlefromTheNewEnglandJournalofMedicine AdvancedCardiacLifeSupportin

OutofHospitalCardiacArrest.Aug12,2004

Howimportantofeachring?

1st

Link:

early

access

by

bystander:

4.42nd Link:earlyCPRbybystander: 3.7

3rd Link:defibrillationin


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BLSClip


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Push hard

(Depth >5cm)

Push fast

(Rate >100min)

Ensurecomplete

chest recoil

Minimally

interrupted

chestcompression

Avoid

hyperventilation(ventilate 8 10/min)

(decrease survival rate)

Rotatecompressor

every 2 mins.(avoid fatigue)

Compression:

Ventilation

30:2(Vs old 15:2)

High Quality

CPR

BLS


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Physiologyofcirculationduring

standardCPR

C.O.(cardiacoutput):depressed1030%

Brainbloodflow:depressed20%

Coronarybloodflow:5 15%

Lowerlimbs

and

Abd

visceral

flow:


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CA B (OldA B C)1. Check

for

responsiveness

and

breathing

2.CallforhelpandgettheAED

3.Checkthepulse

4. Give30

chest

compressions

(step

1to

3done

in

10

seconds)

5.Opentheairwayandgive2breaths

6. Resumecompressions

(Evidenceshows

that

compressions

are

the

critical

element

in

adultresuscitation.IntheABCsequence,compressionsareoftendelayed.Layrescuersdifficulttoassessbreathing.)

Circulation 2008; 117:2162-2167

Resuscitation 2008; 78: 119-126

Change of BLS


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Change of BLSContinuous

Chest

Compression

(CCC)

or

called

HandsonlyCPRisasgoodasconventionalCPRfornonmedicalbystanders***(2008)

Handsonly

CPR

better

than

no

CPR

Why?? Studieshaveshownthat:

bystandersaremorewillingtostartresuscitationifmouthtomouth

ventilationare

not

require.

(now

only

25%

cardiac

arrest

patient

receives

bystanderCPRinUS)(15%inHK)

CCCiseasytolearn.

Passivechestrecoilprovideairexchange.

Arterialoxygenstoresdepletein4mininCCC.

Exceptrespiratoryarrest.eg.COpoisoning,severeasthma,drowningetc.inwhichconventionalCPRshouldbeemploy


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Alternativetechniqueanddevices

Severalalternativetechniqueanddevicestoconventional

manual

CPR

Efficacyreportedinspecificsettings

No

alternative

technique

or

devices

in

routine

useconsistentlyshowedsuperiorityoverconventionalmanualCPR***

BLS


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LUCAS LundUniversity

CardiopulmonaryAssist

System

LUCASvsmanualCPR:equivalentandsafe

Experimental

studies

shown

improvement

of

perfusion

pressuretothebrainandheart.

2randomisedpilotstudiesinoutofhospitalcardiac

arrestpatients

have

not

shown

improved

outcome.


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AEDAutomatedExternal

DefibrillatorDefibrillationistheonlyrhythmspecificintervention

thatincrease

chance

of

survival

to

hospital

discharge

UseAEDimmediatelyonceavailable

Compulsory

a

period

of

CPR

before

using

AED

(old)

is

notrecommend.


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Outcomesofrapiddefibrillationby

securityofficers

after

cardiac

arrest

in

casinos.NEJM2000

105patients

in

VF

in

32

Las

Vegas

Casinos

3.5+/2.9minfromcollapsetoattachAED

4.4+/2.9minfromcollapsetofirstshock

9.8+/4.3minfromcollapsetoarrivalofEMT

74%survivaliffirstdefib3min


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Maxiumdose

of

Defib?

HKJEM2005.AcaseofpersistentandrecurrentVF

withsuccessful

resuscitation

and

good

neurological

outcome

Case:49/M,retrosternalchestpain,witnessarrestinA&EwithVF.

Totalshocks:22(21inA&E,1inICU)

Dx:

AMI

DConD10,goodneurologicaloutcome


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ACLSClip


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ACLS:4Categories

of

Change

CardiacarrestAlgorithm

ImmediatePostCardiacarrestCareAlgorithm

AirwayManagement

Synchronized

Cardioversion


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Emphasize

the

importance

of

high

quality

CPR

Theonlyrhythmspecifictherapythatis

proventoincreaseSTDisdefibrillation

ACLSactions(vascularaccess,medication

deliveryand

advanced

airway

placement)

shouldnotinterruptCPRandDefibrillation


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Other ACLS therapies: medication and

advanced airway, improve the chance of

ROSC, but not the chance of STD

Further evaluation of the role of thesetherapies is necessary, especially with the

higher-quality CPR and better post-arrest

care re-emphasis after 2010

Cardiac arrest algorithm 2010


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Cardiacarrestalgorithm2010

GOOD

ACLS

bases

on

GOOD

BLS

Monitoring CPR quality


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MonitoringCPR

quality


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MonitoringCPRquality

Physiologicalparameters

EndtidalCO2(PETCO2)

CorrelatewithcardiacoutputandmyocardialbloodflowduringCPR


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EndtidalCO2(PETCO2)

ConsiderthepresenceofROSC(ReturnOf

Spontaneous

Circulation),

if

PETCO2

abruptly

increasestoandsustainedat3540mmHg

PETCO2persistently


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Airwaymanagement

Airway management


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Airwaymanagement

Advancedairway

placement

in

cardiac

arrest

should

not

delay

initialCPRanddefibrillationforVF

Optimaltimingofadvancedairwayplacementduringresuscitation

undefined

Interruptionofchestcompression(ideally


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Airwaymanagement

ETtube

Supraglotticairways

LMALaryngealTube

Noevidencethatadvancedairwayimprovessurvival

inout

of

hospital

cardiac

arrest

C h


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Capnography

Recommendedfor

ConfirmingandmonitoringcorrectplacementofETtube,(inadditiontoclinicalassessment)

MonitoringCPR

quality

DetectingROSC

Capnography


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Capnography

Confirmation of tube placement

Monitoring of CPR quality and detecting ROSC

PETCO2 persistently 35-

40mmHg

Drug therapy


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Drugtherapy


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Associated with increased rate of ROSC

and survival to hospital admission, but not

increased rate of neurologically intact

survival to hospital discharge

IV/IO/ET access


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IV/IO/ETaccess

LessimportantthanhighqualityCPR

Performwithout

interrupting

chest

compression

Insufficientevidencetospecifytheoptimaltimeand

sequence

of

drugs

administration

during

cardiac

arrest

ProvideIOaccessifIVaccessnotreadilyavailable

ETroute

only

if

IV

and

IO

access

cant

be

established


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Rhythmbased Algorithm


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2005 2010


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VF/

Pulseless

VTDefibrillationimprovessurvival

Emphasize:

1shockevery2mins.

Minimizehands

off

time

Continuechestcompressionwhilechargingdefibrillator

ResumeCPR

immediately

after

shock

delivery

without

pulse/

rhythm

check


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VF/

Pulseless

VT Energydose

120200J,accordingtomanufacturersrecommendation(Biphasic)

Subsequentenergy

level

equivalent

or

higher

360J(Monophasic)


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VF/PulselessVT

Nochangeinmedication

Adrenaline

Vasopressin

Antiarrhythmicagent

Amiodarone

(Lignocaine)

MgSO4(ForTdPonly)


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VF/PulselessVT

Precordialthump

Roleincardiacarrestuncertain

Maybeconsideredforwitnessed,monitoredVF/

pulselessVT

when

adefibrillator

is

not

readily

availableforuse

PEA/ Asystole


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PEA/AsystoleAtropine

Therapeuticbenefitunlikely

Searchforunderlying

causesin

PEA

(5H5T)

Hypervolemia

Hypoxia

Hydrogenion

(acidosis)

Hypo(hyper)kalemia

Hypothermia

Tensionpneumothorax

Tamponade,cardiac

Toxins

Thrombosis,

pulmonaryThrombosis,coronary

B d di


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Bradycardia

2005 2010

B d di


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BradycardiaAtropine

as

first

line

Ifatropinefail:

TCP

as

temporizing

measure

Alternative:dopamine,

adrenaline


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Tachycardia

2005 2010

Tachycardia


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TachycardiaImmediate

synchronized

cardioversionforunstabletachyarrhythmia

120200J

for

AF

100JformonomorphicVT

50100J

for

atrial

flutter/

other

SVT

Unsynchronizedshockforunstable

polymorphicVT

T h di


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TachycardiaATPcanbeconsideredfor

undifferentiatedregular,monomorphicwidecomplextachycardia(ClassIIb,LOEB)


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PostCardiac

Arrest

Care

P t C di A t C


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PostCardiacArrestCareIncreasingevidencethat

asystematicmulti

disciplinarypost

cardiac

arrestcareafterROSCincreaseslikelihoodof

neurologicallyintact

survivaltohospitaldischarge


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The only interventiondemonstrated to improve

neurologically intact

recovery

Therapeutic Hypothermia


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TherapeuticHypothermia

Inductionofhypothermia(3234)for1224hoursfor

thoseremain

comatose

after

ROSC,

with

initial:

OutofhospitalVFarrest(ClassI)

Inhospitalarrestofanyrhythm(ClassIIB)

Outof

hospital

asystole/

PEA

(Class

IIB)


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SupplementaryO2

after

ROSC

WeanFiO2whenSaO2100%

Titratesupplementary

oxygen

to

maintain

SaO2

94%

99%


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GlycemicControl

Hyperglycemiaassociatedwithhighermortalityand

worsenedneurological

outcome

Maintainserumglucoselevel810mmol/L


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SeizureManagement

Seizuremayoccurin520%ofcomatosecardiacarrest

victimsafter

ROSC

EEGfordiagnosisandfrequentmonitoringincomatosepatientsafterROSC(ClassI,LOEC)


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Stroke


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Stroke

Stroke


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Stroke

Dedicatedstrokeunit

Improve1yearsurvivalrate,functionaloutcomeandQuality

of

Life

for

stroke

patients

Fibrinolytictherapy(IVrtPA)forischemicstroke

Time

is

Brain

the

earlier,

the

better FDAapprovedifrtPAisusedwithin3 hours ofstroke

onsetineligiblestrokepatients


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AcuteCoronary

Syndrome

Acute Coronary Syndrome


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AcuteCoronarySyndrome

Whatisnew?

Alarge

registry

showed

an

association

between

morphine andUA/NSTEMIandincreasedmortality

NomoreroutineMONA:startO2ifSaO2


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AcuteCoronarySyndrome

Timeismuscle:AMI


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Whereto

take

the

course?

HospitalAuthorityAccident&EmergencyTraining

Centrewww3.ha.org.hk/aetc

Location:TangShiuKinHospital,WanChai

Whatarethecourses?


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Coursesfor

health

care

professional

AdvancedStrokeLifeSupport(ASLS) HospitalProvider

AmericanHeartAssociation(AHA)BasicLifeSupport(BLS)Provider/Renewal

AHA

Advanced

Cardiac

Life

Support

(ACLS)

Provider

/Renewal

AHAPediatricAdvancedLifeSupport(PALS)

Provider/Renewal

AmericanAcademyofPediatricNeonatalResuscitationProgram(NRP)

InternationalTraumaLife

Support

(ITLS)

Advanced


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SimulatedAccident

&

Vehicle

Extrication

(SAVE)

(ITLSAccess)

EmergencyManagementofSevereBurns(EMSB)

AHAECG(singleleadforcardiacmonitoring)

VenousCannulation&Bloodtakingfornurse

CrewResource

Management

12leadECGInterpretationfornurses

Transportation andRetrievalofIllpatient(TRIP)

UnderstandingEmergency

X

Ray

(For

Health

Care

Professional)

Emergency

DeliveryCare

(ED)

Hospital

Provider


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QuestionsandComments?

acls.dr.young

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