AHA Guidelines ACLS

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AHA GuidelinesACLS
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COMMUNICATIONS!!

• Change
• Know your protocols
• Know the standards (algorithms)
• Be flexible
• Your patient probably did not read the ACLS manual

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Conventional Wisdom
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Scientific Review and Consensus

• ILCOR considered over 350 literature based
  reviews of specific resuscitation related
  questions
• There were more questions than answers

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Stacked shocks vs. single shock
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A Balancing ActChanging recommendations

• Change is bad
• Every time guidelines change, basic skills must
  be relearned
• Changes based on weak data may undermine the
  integrity of the process
• Guidelines 2000 Epinephrine Class indeterminate
• Vasopressin Class 2b
• Guidelines 2005 Epinephrine Class 2b
• Vasopressin Class indeterminate

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A Balancing ActChanging recommendations

• Change is good
• New skills save lives
• New data demands new recommendations

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Consensus

• Consensus may not be the right thing if there is
  definitive data.
• When is consensus best?
• Consensus works when it takes something
  everybody knows and makes it something
  everybody agrees to do.
• Quote from Developing Consensus in Emergency
  Medicine Information Technology AEM 11/04

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Guidelines 2005Everything is simpler
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Goal Review changes in ACLS

• Reviewing ACLS is impossible without an overview
  of CPR
• CPR will be taught as an integral part of every
  ACLS course
• The goal is to use CPR to increase the efficacy
  of defibrillation to achieve a perfusing rhythm

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Why the emphasis on CPR
0 1 2 3 4 5 6
7 8 9 10 11 12
13 14 Minutes

Electrical Circulatory
Metabolic Phase Phase
Phase
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CPR Overview
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Why 302 ?

• Good Data (Aufderheide, Abella and others) that
  we do too many ventilations.
• Universal agreement that we need to decrease
  ventilations.
• NO data directly comparing compression
  ventilation ratios
• Most wanted to see a unified pediatric/adult ratio

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Changes to CPR training

• All courses (BLS, ACLS, PALS) will teach CPR as
  part of core course
• Mega-codes will incorporate real time CPR with
  retesting for improper performance
• Rapid rate with full chest recoil is emphasized
• Rate of 302 compression to ventilation with BVM
• 100 compressions unsynchronized to 8-10
  ventilations controlled airway

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Compressions

• Research indicates- 2 minutes of CPR prior to
  first defibrillation for a non witnessed cardiac
  arrest
• Prime the ATP pump
• Otherwise VFIB will go to
• Asystole or PEA
• Dont interrupt compressions
• Stopping compressions for 4 seconds
• Reduces Coronary Perfusion Pressure (CPP) to
  Zero.
• Studies show we stop TOO long.

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Compressions

• Every other intervention ( except defibrillation)
  in cardiac arrests should be
• Considered an adjunct to chest compressions.
• Rotation of the cardiac compressor should be
  every 2 minutes

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More on the Airway

• Bag-Mask ventilation is emphasized
• ..all healthcare providers should be trained in
  delivering effective oxygenation and ventilation
  with a bag and mask.
• Definitive airway may be delayed
• Rescuers may defer insertion of an advanced
  airway until the patient fails to respond to
  initial CPR and defibrillation attempts

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Defibrillation

• Stacked shocks are eliminated. Start with maximum
  energy setting
• Concept
• There is no data to support any number of stacked
  shocks
• Biphasic defibs have increased conversion
  efficacy (gt90 in electrical phase)
• Delays in time between last compression and shock
  significantly change shock efficacy

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Combining CPR and Defibrillation
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Why not check rhythm post shock?

• In theory
• PEA or asystole are common for a brief period
  post shock
• Ischemic myocardium is likely to develop
  recurrent ventricular fibrillation
• CPR has not been shown to be detrimental even in
  the patient with a pulse.

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What does rhythm check mean?

• Exactly that
• Look at the rhythm.
• If organized do pulse check
• If not resume CPR without pulse check

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The combined algorithm
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Drug Therapy Administration

• Route of administration
• IV/IO
• Intraosseous is now a recommended route of
  administration (IIa)
• Endotracheal administration ONLY if IV/IO cannot
  be established (still 2-2.5 times IV dose)

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Drug Therapy
Give Vasopressor
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Drug Therapy

• Vasopressors
• Epinephrine Upgraded from class indeterminate
  to class 2b.
• Vasopressin Downgraded from 2b to class
  indeterminate
• Epinephrine is recommended in ALL pulseless
  arrests
• Vasopressin may replace 1st or 2nd of
  epinephrine. Timing does NOT change

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Drug Therapy

• One large study showed no difference in survival
  between epinephrine and vasopressin and a trend
  to better ROSC with both
• Epinephrine is the established vasopressor
• Because vasopressin effects have not been shown
  to differ from those of epinephrine in cardiac
  arrest one dose of vasopressin may replace..

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Combining CPR and Defibrillation
Consider Antiarrythmic
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Drug Therapy

• CONSIDER Antiarrhythmics
• Amiodarone 300 mg IV/IO once then consider
  additional 150 mg IV/IO once.
• OR
• Lidocaine 1-1.5 mg/kg first dose then 0.5-0.75
  mg/kg maximum 3 doses or 3mg/kg
• Consider Magnesium 1-2 gm for torsades de pointes
• There is no evidence that any antiarrhythmic
  drug increases survival to hospital discharge.

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Protocol

• V FIB - PULSELESS V TACH
• Initial Intervention
• Identify absence of pulse and respirations.
• CPR for 2 minutes if unwitnessed arrest.
• Defibrillate
• Witnessed Arrest
• EKG or paddles for "Quick Look." Determine V fib
  or V tach.
• Defibrillate 200 J (Biphasic defibrillator) 360J
  (Monophasic defibrillator)
• Children 2 J/kg first shock 4 J/kg subsequent.
• Unwitnessed Arrest
• 2 minutes of CPR then defibrillate as per above
• I.V. balanced salt solution, TKO. ET Tube, 100
  O2.(maintain EtCO2 of 30-40)

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Protocol

• V FIB - PULSELESS V TACH (cont.)
• Drug Therapy - (CPR for 2 minutes then
  defibrillate after each drug given).
• Initial drug (adults only)
• Vasopressin 40 units IV, single dose one time
  only
• After 3-5 minutes
• Epinephrine 1.0 mg IV or IO. Repeat every 3-5
  minutes prn
• Children 0.01mg/kg initial and subsequent doses

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Protocol

• V FIB - PULSELESS V TACH (cont.)
• If V-Fib persists, administer antiarrhythmic (If
  ET CO2 gt 10)
• Amiodarone 300 mg IV/IO bolus, repeat 150 mg IV
  bolus in 3-5 minutes prn. Children 5 mg/kg IV/IO
  bolus
• If Amiodarone contraindicated Lidocaine 1.5 mg/kg
  IV/IO bolus, repeat 0.75 mg/kg bolus in 3-5
  minutes prn max 3 mg/kg. Children 1 mg/kg
• If multifocal WCT (Torsades) or Magnesium
  deficiency suspected
• Magnesium Sulfate 2 gm bolus I.V. (dilute in 50cc
  D5W wide open) Children 25-50 mg/kg
• Continuously monitor effectiveness of CPR and
  oxygenation. May repeat defibrillation current,
  as appropriate, after each 2 min of CPR (5
  cycles).

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Protocol

• V FIB - PULSELESS V TACH (cont.)
• Supraventricular rhythm greater than 60/minute
  with pulses
• Utilize an infusion rate of the drug associated
  with restoration of a stable rhythm. If no
  antiarrhythmic given treat symptomatically.(Reduce
  maintenance dose only if impaired liver or heart
  chf, etc )
• Bradycardia
• Atropine 0.5 mg I.V. repeat as needed every 2-3
  minutes (3mg total).
• Epinephrine per protocol
• Dopamine drip per protocol

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Other Pulseless Rhythms
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PEA and Asystole

• The recommended dose of atropine for cardiac
  arrest is 1 mg IV/IO. Maximum 3 mg. (Class
  indeterminate)
• No pacing in asystole
• Several randomized controlled trials failed to
  show benefit from attempted pacing for asystole.
  At this time use of pacing for patients in
  asystolic cardiac arrest is not recommended.

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Protocol

• Asystole
• Identify absence of pulse and respirations.
• CPR for 2 mins
• Apply EKG Leads. Determine asystole in two leads.
• I.V. TKO with balanced salt solution
• ET tube, 100 O2.
• Electrical Therapy
• Consider immediate transcutaneous pacemaker if
• Perfusing Bradycardia converting to asystole
  during resuscitation
• Asystole due to Adenocard administration

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Protocol

• Asystole
• Drug Therapy
• Initial drug (adults only)
• Vasopressin 40 units IV, single dose one time
  only
• After 3-5 minutes
• Epinephrine 1.0 mg I.V. or IO. Repeat every 3-5
  minutes prn Children 0.01mg/kg initial and
  subsequent doses
• Atropine 1mg I.V. or IO q 3-5 minutes to max
  3mg. Child 0.02 mg/kg.
• If rhythm is restored, follow appropriate
  protocols e.g., fibrillation, bradycardia,
  hypotension, etc. If asystole persists, consider
  termination of efforts.

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Protocol

• Pulseless Electrical Activity
• Identify absence of pulse and respirations.
• CPR for 2 mins.
• EKG paddles or leads. Determine presence of PEA
  (electrical rhythm without pulses).
• Continue CPR for 2 mins
• I.V. volume challenge with 300-500 cc. balanced
  salt solution
• ET tube, 100 O2

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Protocol

• Pulseless Electrical Activity (cont.)
• Drug Therapy
• Initial drug (adults only)
• Vasopressin 40 units IV, single dose one time
  only
• After 3-5 minutes
• Epinephrine 1.0 mg I.V. or IO. Repeat every 3-5
  minutes prn Children 0.01mg/kg initial and
  subsequent doses
• If bradycardia, Atropine 1 mg I.V., may repeat q
  3-5 minutes to max 3mg.
• If witnessed event, consider Transcutaneous
  Pacemaker
• Continuously monitor effectiveness of CPR and
  oxygenation

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The combined algorithm
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The Combined Algorithm
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The combined algorithm
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VF/Pulseless VT

• Use of vasopressor
• Use of amiodarone vs. lidocaine vs. magnesium
• Use of vasopressor

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PEA and Asystole

• Use of vasopressor
• Consider Atropine 1 mg for Slow PEA or Asystole
• Use of vasopressor

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When Do You Stop?

• When youre tired?
• After 20 minutes?
• ?????

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Bradycardia
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Bradycardia

• Dopamine dosing
• Guidelines 2000 Dopamine 5-20 µg/kg/min
• Guidelines 2005 Dopamine 2-10 µg/kg/min
• NO explanation in text. Why
• Consultation with editors/authors
• For simplification we decided to have a single
  dose for dopamine and epinephrine ?????
• (µg/kg/min vs. µg/min)
• BUT does it make sense

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Bradycardia
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Bradycardia

• Does the change make sense
• No new data. The choice is editorial
• Pro Simpler
• Con Change for the sake of change
• Consensus strikes again
• The skilled provider can start at the appropriate
  dose

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Diagnosis?
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What Is This Rhythm?
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What Is This Rhythm?
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Diagnosis?
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What Is This Rhythm?
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Tachycardia
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Tachycardia
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Tachycardia
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Tachycardia

• Is amiodarone the ONLY drug for WCT?
• NO!
• Procainamide, sotolol, ibutilide, lidocaine and
  magnesium are discussed in the text.
• The intent is to provide a BASIC framework to
  manage the majority of situations
• In the complex patient, the intent is to allow
  experts to tailor the treatment to the patient
  and situation.
• A patient on amiodarone with VT due to
  thyrotoxicosis induced by amiodarone should not
  receive more amiodarone

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Protocol

• Tachydysrhythmias
• Ventricular Tachycardia - (stable) with adequate
  perfusion.
• O2 High flow.
• I.V.
• 12 Lead prn (prior to and after
  treatment/conversion))
• Amiodarone 150 mg over 10 minutes Repeat 150 mg
  after 10 minutes if VT recurs
• IF VT persists, cardiovert as in unstable VT.
• If VT refractory, or Torsade or TCA OD, Magnesium
  Sulfate 2 grams I.V. slow (5-20 min. dilute in
  50-100 cc D5W).

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Protocol

• Tachydysrhythmias (cont.)
• Ventricular Tachycardia - (unstable- hypotension,
  CHF, chest pain, SOB)
• O2 high flow.
• I.V.
• Versed 2.5-5 mg I.V. as needed.
• Synch cardiovert 100, 200, 300, 360j monophasic,
  OR 100, 150, 200, 200 j biphasic) Peds 0.5
  j/kg, 1 j/kg prn
• If recurrent VT or persistent
• Amiodarone, per protocol above
• OR
• Magnesium Sulfate, per protocol above

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Protocol

• Tachydysrhythmias (cont.)
• Wide-Complex Tachycardia (WCT) of uncertain type
  (SVT vs. VT)
• STABLE
• O2 high flow
• I.V. .
• 12 Lead prn (prior to and after
  treatment/conversion))
• Amiodarone 150 mg bolus over 10 minutes repeat q
  10 mins prn
• If WCT rhythm persists, cardiovert as needed as
  if unstable.
• UNSTABLE (see definition above)
• Cardiovert as per unstable V.T.

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Protocol

• Tachydysrhythmias (cont.)
• Supraventricular (Narrow Complex) Tachycardia
• ATRIAL FIB/FLUTTER NO HYPOTENSION w/ rapid
  ventricular rate
• I.V 12 Lead as in above stable rhythms
• Diltiazem 0.25 mg/kg (maximum 20 mg) given slow
  over 2 mins. Avoid in patients taking B-blockers
• After 15 mins. may repeat at 0.35 mg/kg (maximum
  25 mg)
• If conversion, 10mg/hr drip
• If hypotension after administration, fluids as
  appropriate and Calcium 250 mg
• ATRIAL FIBRILLATION/FLUTTER - unstable with rapid
  ventricular rate
• Cardiovert synchronized at 100,200,300,360 J.
  monophasic 100, 150, 200, 200j biphasic
• Peds 0.5 j/kg, 1 j/kg prn
• (Versed sedation as needed)

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Protocol

• Tachydysrhythmias (cont.)
• Supraventricular Tachycardia (cont.)
• PSVT, nodal tachycardia, PAT etc.
• If stable, attempt vagal maneuvers
• Cough, valsalva
• Carotid sinus massage
• Establish bilateral carotid, no bruits do right
  CSM, wait 1 minute do left CSM if right
  unsuccessful.
• If PSVT persists Adenocard
• Contraindication 2?block/3?block, allergy, KNOWN
  WPW.
• Caution asthma, pregnancy, and pt. on
  Tegretol/Dipyridamole
• Ineffective in A-fib/A-flutter

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Protocol

• Tachydysrhythmias (cont.)
• Supraventricular Tachycardia (cont.)
• If PSVT persists stable, i.e. NO hypotension w/
  rapid ventricular rate
• Diltiazem 0.25 mg/kg (maximum 20 mg) given slow
  over 2 mins. Avoid in patients taking B-blockers
  after 15 mins. may repeat at 0.35 mg/kg (maximum
  25 m
• If conversion, 10mg/hr drip
• If hypotension after administration administer
  fluids as appropriate and Calcium 250 mg
• If hypotensive, fluid challenge 200-300 cc
  balanced salt.
• Contraindication pulmonary edema
• If Unstable
• synchronized Cardioversion at 100, 200, 300,
  360j monophasic 50, 100, 150, 200 biphasic
• Peds 0.5j/kg, 1j/kg prn
• Versed sedation, as needed

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Summary ACLS Drugs

• Vasopressin
• Positive epy effects (augment CPP) without epy
  side effects
• 1 dose 40 unit to replace first or second dose of
  epinephrine
• Studies show most effectiveness in Asystole, PEA
  and VF/VT no pulse.
• Higher BP and HR post arrest if used
• Can be given ET ( not preferred)
• Amiodarone
• Handicapped by extreme difficulty in giving for
  emergencies
• Most Effective in cardiac arrest with heart
  history
• Only 2 doses in cardiac arrest (300mg, 150mg)
• Must ALWAYS be diluted
• DO NOT administer with other drugs that prolong
  QT
• Cannot go down the tube
• 150mg over 10 minutes every 10 minutes as needed
• Maint. Drip _at_ 1 mg/min

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Summary ACLS Drugs

• Atropine
• Relieves bradycardia,
• Ineffective if bradycardia is from
• Hypoxia
• Ischemia
• 1 mg for patients without pulse
• 0.5mg for patients with a pulse
• Lidocaine
• Effective in cardiac arrest with NO heart history
• Increases the electrical energy required to
  defibrillate by more than 50
• Used if Amiodarone is contraindicated
• Can be given by ET

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Summary ACLS Drugs

• Magnesium
• Must be diluted
• Given over 5-20 minutes in cardiac arrest
• 5- 60 minutes in Torsades with a pulse
• Life threatening ventricular arrythmias due to
  digitalis toxicity
• Tricyclic OD, Torsades, hypomagnesemia
• Caution in renal failure patients
• ET drugs discouraged
• IO or IV preferred
• Glucagon
• TX Betablocker and Ca Channel Toxicity

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Summary ACLS Drugs

• Adenosine
• 6, 12, 12 mg stable patient
• 12,12,18 for stable patient on theophyllin or
  caffeine OD
• 3 mg for dipyridamole (persantine), tegretol,
  heart transplant (denervated heart)
• Monophasic versus Biphasic

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New Post-Resuscitation Care

• Optimize tissue perfusion, especially for the
  brain
• Induction of mild hypothermia (33-34 C for 12-24
  hours
• During resuscitation spontaneous cooling occurs
  to 35 C
• Improves neurologic recovery
• Low blood pressure within 2 hours
• Associated with poor neuro outcomes

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Questions?