Advanced Cardiac Life Support 2000

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Advanced Cardiac Life Support 2000

• Mark I. Langdorf, MD, MHPE, FACEP
• University of California, Irvine

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ACLS History

• Sixth iteration of guidelines since 1966
• Second that is evidence based
• First that incorporates international perspective

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Evidence Based Guidelines

• Search the international literature
• Determine level of each piece of evidence
• Graded each study for quality
• Integrate all evidence into final class
  recommendation

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Classes of Recommendations

• Class I always acceptable, proven safe and
  definitely useful
• Class IIa acceptable, reasonably prudent,
  intervention of choice by experts
• Class IIb acceptable, safe and useful, within
  standard of care, optional or alternative by
  experts
• Inderminateinadequate research to decide
• Class III evidence for benefit lacking, or
  harmful

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Chain of Survival

• Recognize early warning signs
• Activate EMS
• Basic CPR
• Defibrillation
• Airway and ventilation
• Intravenous medications

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Public Access Defibrillation PAD

• Goal AEDs used by laypersons everywhere
• Most effective cardiac intervention
• Shown to be cost effective (cost per life year
  saved)
• Response time goal is 3 to 5 minutes
• Police
• Fire
• Casino
• Airlines
• First responders
• Survival rates up to 49 from primary vfib

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Sequence of Events

• 50 of patients with CAD first present with
  sudden death
• Sequence
• Decades of atherosclerotic buildup
• Plaque rupture or erosion
• Platelet adhesion
• Occluding thrombus
• Severe ischemia
• Irritable myocardium
• Ventricular fibrillation
• Collapse and sudden death

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Adult BLS Recent Changes

• Phone first (no CPR unless drowned, trauma or
  overdose)
• BLS should transport to ED capable of IV
  thrombolysis for MI and stroke
• Within 30 minutes for MI
• Within 60 minutes for stroke

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BLS Sequence Changes

• 10cc/kg tidal volume without oxygen
• 6-7 cc/kg with supplemental oxygen
• Prevent gastric insufflation deliver over 2
  seconds
• Lay rescuers dont check pulses before chest
  compressions, healthcare workers do
• Compression rate 100/minute
• 152 ratio for 1 and 2-rescuer CPR

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Prehospital Care for ACS

• Oxygen is routine
• Aspirin en route 160-325mg
• Nitroglycerin
• Be careful with Viagra
• Need SBP 90
• 3 sprays q 3-5 minutes
• Morphine if 3 sprays dont relieve pain
• 12 lead ECG under study

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Prehospital Stroke Care

• Determine time of onset and GCS
• Perform prehospital stroke scale
• Cincinnati PSS sensitivity 72
• LAPSS 93 sensitivity, 97 specificity
• LAPSS
• Age 45
• No seizures
• Duration
• Ambulatory at baseline
• Glucose 60-400
• Obvious asymmetry of face/grip/arm strength

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ACLS Changes for 2000

• Wide complex tachycardia Amiodarone and
  procainamide before lidocaine and adenosine (IIb)
• Stable V tach (and torsades) Amiodarone and
  sotalol preferred (IIa)
• Bretylium not available (IIb)
• Lidocaine evidence poor for benefit for v-fib
  and v-tach (indeterminate)

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ACLS Changes for 2000

• V-fib/pulseless V-tach evidence for all
  antiarrhythmics weak. Amiodarone preferred (IIb)
• Magnesium still IIb for torsades
• Vasopressinmay be more effective than epi in
  cardiac arrest (IIb)
• 40 units IV only once
• Epinephrine still class IIb
• High-dose epi no benefit (indeterminate)

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Defibrillation Biphasic

• Will become the norm
• As effective at lower energy
• 150 biphasic 200 monophasic
• No need for escalating joules
• Transthoracic impedance declines with subsequent
  shocks
• Repeat same energy success

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Shock Energies Recommended

• Still 200/200-300/360 joules for v-fib /pulseless
  v-tach
• A-fib 100-200
• A-flutter/PSVT 50 to start
• V-tach
• Monomorphic (usual) 100 joules
• Polymorphic (torsades) 200 joules

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Other Defibrillator Points

• Synchronize for any perfusing rhythm
• Avoids precipitating v-fib
• Hold buttons down
• Check two leads for asystole
• If no fibrillation noted, defibrillation not
  effective
• Lead disconnect can simulate asystole

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Cardiac Arrhythmias

• Check the patient, not the rhythm
• Perfusion is most important
• Wide complex tachycardias are v-tach
• Odds 75/25
• Older (45 yo)
• Sicker (previous MI or CAD)
• Treat the worst, first
• 12 ECG criteria not reliable enough

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Rhythms to recognize

• Normal sinus rhythm
• AV blocks
• 1st (not important)
• 2nd
• Type I (Wenkebach)
• Type II (dangerous)
• 3rd degree (complete, AV disassociation)
• Premature complexes
• Atrial (no pause)
• Ventricular (compensatory pause)

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Rhythms to Recognize

• V-tach
• Monomorphic
• Polymorphic (Torsades de pointe)
• V-fib
• Asystole (confirm)

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Tachyarrhythmias

• Narrow QRS (
• Sinus
• Atrial fibrillation
• Atrial flutter
• Atrial tachycardia (digoxin toxicity)
• Multifocal atrial tachycardia (COPD)
• AV nodal re-entrant tachycardia (PSVT)
• Junctional tachycardia

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Tachyarrhythmias

• Wide QRS (120 msec)
• Ventricular tachycardia (usually 160 msec)
• Supraventricular tachycardia with aberrant
  conduction (usually not this wide)
• 12 lead if stable
• Mr. Edison if not

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Show Rhythm Strips
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Routes for Drug Administration

• Evidence for all effectiveness for all drugs is
  weak
• Drugs are secondary interventions
• Peripheral still first choice
• flush with NS
• 1-2 minutes to central circulation
• If no response to drugs and defibrillation
• Consider central line
• IJ preferred (or supraclavicular subclavian)
• Femoral less preferred
• Avoid non-compressible sites if possible

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Tracheal Administration

• Navel still holds
• Narcan
• Atropine
• Valium
• Epinephrine
• Lidocaine
• Amiodarone/vasopressin not yet studied, so avoid
• Dilute in 10cc/bag vigorously
• 2-2.5 times the IV dose for all meds

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Wide Complex Tachycardias Stable

• Must be regular and fast (120)
• Must be uniform (one QRS morphology)
• No signs of impaired perfusion
• Mental status normal
• No chest pain or CHF
• Skin signs warm and dry
• Systolic BP 90 mm Hg
• Obtain 12 lead ECG if stable

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Wide Complex Tachycardias Stable

• Procainamide first line if ventricular function
  normal (sotalol) (both IIa)
• Amiodarone (IIb) (150mg over 10 minutes) or
  Lidocaine (.5-.75mg/kg IVP)if poor EF (
• If ineffective
• Cardiovert (100/200/300/360 joules)
• No repeat drug doses recommended
• Bottom line
• Normotensive procainamide
• Hypotensive cardiovert

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Polymorphic V-tach

• Recurrent bouts
• Usually terminate spontaneously, or
• Degenerate into v-fib
• Stop offending meds that prolong QT interval
• Correct hyopcalcemia/hypomagnesemia
• Magnesium 2-4 grams IVP (shortens QT)
• Transcutaneous pacer (overdrive pacing)
• Rate 100 if no ischemia
• Shortens QT, reduces recurrence

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V-fib/Pulseless V-tach

• This is easy!
• Defib three times ASAP (200/300/360)
• ABCs
• Epi 1mg IV every 3-5 minutes, or
• Vasopressin 40 units IVP, once
• Then Epi same as usual
• Amiodarone (IIb) 300mg IVP (second dose if
  recurrent V-fib 150 mg)

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Look for cause

• Hypovolemia
• Hypoxia
• ETT/02 hooked up/pneumothorax/CO poisoning
• Acidosis
• Hypo/hyperkalemia
• Cardiac tamponade
• Tension pneumothorax
• Coronary thrombosis
• PE

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Mnemonic

• Shock, shock, shock
• All Breathing Counts
• EVerybody
• Shocks
• Americans
• Shock
• Europeans
• Shock
• Latin Americans
• Shock

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Bicarbonate Indications

• No changes
• Hyperkalemia (I)
• Pre-existing acidosis (IIa)
• TCA overdose (IIa)
• ASA overdose (IIa)
• Prolonged arrest (IIb)
• Return of spontaneous circulation (IIb)

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Pressors Epinephrine

• Alpha effects confer benefit
• Increases systemic vascular resistance
• Increases aortic root pressure
• Perfuses coronaries
• Perfuses brain at expense of body
• Escalating or high doses without demonstrable
  benefit
• Potent pressor for hypotension (1mg in 500cc at
  2-10 micrograms/min)

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Pressors Norepinephrine

• Potent alpha and beta agonist
• Indicated for severe hypertension (SBP
• Dose 1-30 micrograms/min
• Extravasation infiltrate 5-10 mg of phentolamine

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Pressors Dopamine

• Precursor of norepinephrine
• Alpha and beta adrenergic agonist
• Indicated with hypotension and bradycardia
  (raises SBP and HR)
• Dose 5-20 micrograms/min after cardiac arrest
• 5-10 primarily beta stimulation
• 10-20 additional potent alpha effect

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Pressors Dobutamine

• Potent beta-1 selective ventricular inotrope
• Use for severe systolic dysfunction
• Reflex tachycardia due to peripheral vasodilation
• 5-20 micrograms/min