ACLS- 2005 New Guidelines

2006 ACLS
1. 2005 American Heart Association AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) . 4-5 . 2005 .

2.

3.

4.

(ACS) 2005 .
2005 .

5.

Chain of Survival

2005 American Heart Association AHA) Guidelines

for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)

2005 International Consensus on Science and Treatment Recommendations for CPR and ECC
1. Participants () Over 375 experts from the American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada (HSFC), Resuscitation Council of Southern Africa (RCSA), the Australia and New Zealand Council on Resuscitation (ANZCOR), and the InterAmerican Heart Foundation 2. Time table (2005 ) C2005 conference: Jan., March Writing conference Publication: Resuscitation and Circulation in Nov 2005.

ASSESS THE QUALITY OF EACH STUDY & Determine the Level of Evidence (2005 )
L. of Evidence Definitions (See manuscript for full details)

Level 1
Level 2

Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Randomized clinical trials with smaller or less significant treatment effects

Level 3
Level 4 Level 5

Prospective, controlled, non-randomized, cohort studies

Historic, non-randomized, cohort or case-control studies Case series: patients compiled in serial fashion, lacking a control group

Level 6
Level 7 Level 8

Animal studies or mechanical model studies

Extrapolations from existing data collected for other purposes, theoretical analyses Rational conjecture (common sense); common practices accepted before evidence-based guidelines

DETERMINE THE CLASS OF RECOMMENDATION

CLASS
Class I Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful

CLINICAL DEFINITION
Always acceptable, safe Definitely useful Proven in both efficacy & effectiveness Must be used in the intended manner for proper clinical indications Safe, acceptable Clinically useful Not yet confirmed definitively

REQUIRED LEVEL OF EVIDENCE

One or more Level 1 studies are present (with rare exceptions) Study results consistently positive and compelling Most evidence is positive Level 1 studies are absent, or inconsistent, or lack power No evidence of harm

Class IIa: Acceptable and useful Good evidence provides support

Class IIb: Acceptable and useful Fair evidence provides support

Safe, acceptable Clinically useful Considered treatments of choice

Safe, acceptable Clinically useful Considered optional or alternative treatments Unacceptable Not useful clinically May be harmful. Research just getting started. Continuing area of research No recommendations until further research

Generally higher levels of evidence Results are consistently positive

Generally lower or intermediate levels of evidence Generally, but not consistently, positive results No positive high level data Some studies suggest or confirm harm. Minimal evidence is available Higher studies in progress Results inconsistent, contradictory Results not compelling

Class III: Not acceptable, not useful, may be harmful Indeterminate

The most significant changes

1. Simplify CPR instruction ( ) 2. Increase the number of chest compression delivered per minute ( ) 3. Reduce interruptions in chest compressions during CPR ( )

New Developments()
1. Elimination of lay rescuer assessment of signs of circulation
( )

2. Simplification of instructions for rescue breaths: over 1 second with sufficient volume to achieve visible chest rise
( : 1 , )

3. Elimination of lay rescuer training in rescue breathing without chest compressions ( ) 4. Universal compression-to-ventilation ratio
(: =30: 2) 5. Modification of the definition of pediatric victim( )

New Developments ()
6. Emphasis on the importance of chest compression
( )

CPR before defibrillation ( ) Minimize interruption of chest compression (pulse check, drug administration, reassessment of the patient, insertion of an advanced airway( ) Only 1 shock followed immediately by CPR (1
)

Increased emphasis on the importance of ventilation and deemphasis on the importance of using high concentration of oxygen for the newborn( ) New first aid recommendations

Effect of Interrupting Compression

Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:246570. Vascular Pressure during CPR CPP of First and Last Compression

Effect of Interruption of Chest Compression

Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation.Circulation 2002;106:368-72

Return of Spontaneous Circulation

Total Duration of CPR

A Reality of Rescuer CPR

100 80 60 40 20 0
Time to 1st compression (s) Pause for breathing (s) No. compression delivered

93 Comp-only Standard

37 12 0 14

43

Arterial Oxygen Saturation and Carotid Oxygen Delivery (Compression-only vs 30:2 Compression/Ventilation)
3.8 Comp-only 30:2 C-V 3.1 3 2 1 0.4 0 1 min. CPR 3 min. CPR 1.7

Arterial oxygen saturation

Carotid oxygen delivery

Compression-only CPR vs Standard CPR

100 80

% Survival

60 60 40 20 0 Comp-only Standard 50

Impact of interruption of chest compression

Recommendation Minimizing the interruption interval during resuscitation should be accentuated during BLS training for layman and bystanders and the interruption of CPR should be minimized during use of an AED.

Defibrillation First (1990-1993) vs CPR First (1994-1996)

50
% Survival

1990-1993

1994-1996

40 30 20 10 0 1 2 3 4 5 >5 First Unit Arrival Interval (min.)

CPR First vs Defibrillation First A Randomized Trial

% Discharged from Hospital

50 40 30 20 10 0 < 5 min. > 5 min. First Responder Arrival Time 4 23 22 CPR first Defibrillation first 29

CPR and VF Waves

Defibrillation first vs CPR first

8 min. untreated VF, 90 sec CPR

Should CPR be delivered before attempted defibrillation?

Recommendation: Immediate defibrillation is the treatment of choice for VF/VT cardiac arrest where the duration of the VF/VT is likely to be shorter than 5 minutes. In UNWITNESSED adult out-of-hospital cardiac arrest victims of VF (or with long response time intervals), 5 cycles of CPR before attempting defibrillation has the potential to improve ROSC and survival to hospital discharge

Optimal Compression/Ventilation Ratio

PaO2 and PaCO2

Neurologic Outcome

Hyperventilation Reduces Survival

Simulation of C:V Ratio

Expert rescuer Breathing time<5s

Lay rescuer Breathing time<16s

Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical conditions: a physiological and mathematical analysis.Resuscitation. 2002;54(2):147-57.

Recommendations for the preferred CPR compression-ventilation ratio?

1. CV ratio of 30:2 is recommended by experts consensus (Class IIa) 2. In infants and children, 2 rescuers (healthcare provider) should use a ratio of 15:2 (Class IIb) 3. For neonate, 90 compression and 30 ventilation per minute should be achieved. 4. With advanced airway, no interruption of chest compression / ventilation with 8-10 breaths per minute. 5. Tidal volume of 500-600 ml (6-7ml/kg)

Defibrillation Waveforms
(MDS vs BTE)

Shock Success and Waveforms

154 patients undergoing electrophysiologic testing or receiving an implantable defibrillator

'n' (total 154) 1st Shock 61 (90%) efficacy

200J Mono 68

130J Biphasic 47
39 (83%)

200J Biphasic 39
39 (100%)

Optimizing waveforms and energy level in defibrillation

Recommendation

Biphasic waveform shocks: 200 J

Monophasic waveform shocks: 360 J

No CPR Time During AED Defibrillation

Probability of ROSC and Hand-off Time

PROSC

Hand-off time (sec)

One Shock vs Three Initial Shocks

Recommendation

In settings of out-of-hospital cardiac arrest, the AED algorithm should be limited to one shock rather than pausing to provide three shocks between each minute of CPR .
Class I - Definitely recommended

Major changes in defibrillation:

3. 1. sudden witnessed collapse with an AED on site (for victims 1 year of age) 2. 4-5 sudden collapse is >4 to 5 minutes after the call.

3. 1 5(2)

Major changes in defibrillation:

4. - using a monophasic manual defibrillator is 360 J. - using a biphasic manual defibrillator is 150 J to 200 J for a biphasic truncated exponential waveform or 120 J for a rectilinear biphasic waveform. 5. The second dose should be the same or higher. If the rescuer does not know the type of biphasic waveform in use, a default dose of 200 J is acceptable.

5. Reaffirmation of 2003 ILCOR statement that AEDs may be used in children 1 to 8 years of age (and older). For children 1 to 8 years of age, rescuers should use an AED with a pediatric dose-attenuator system if one is available. 6. Elements of successful community lay rescuer AED

programs were revised. (, , :class I)

7. Instructions for shocking VT were clarified. -polymorphic VT VF unsynchronized shock

What did NOT change

1. The initial dose for attempted defibrillation for infants and children using a monophasic or biphasic manual defibrillator. First dose 2 J/kg; second and subsequent doses 4 J/kg. 2. The dose for synchronized cardioversion for infants and children.

3. The dose for synchronized cardioversion for supraventricular arrhythmias and for stable, monomorphic VT in adults.

Major changes in ACLS include

1. Emphasis on high-quality CPR.
See information in the BLS for Healthcare Providers section, particularly rescue breaths with chest compressions and emphasis on chest compression depth and rate, chest wall recoil, and minimal interruptions.
2. Increased information about use of LMA

and esophageal-tracheal combitube (Combitube). Use of endotracheal intubation is limited to providers with adequate training and opportunities to practice or perform intubations.

( :class I)

3. Confirmation of endotracheal tube placement requires both clinical assessment and use of a device (eg, exhaled CO2 detector, esophageal detector device). Use of a device is part of (primary) confirmation and is not considered secondary confirmation. 4. The Reorganized algorithm for treatment of pulseless arrest include VF / pulseless VT, asystole, and PEA.

The priority skills and interventions during cardiac arrest are BLS skills, including effective chest compressions with minimal interruptions.

5. If an advanced airway is inserted, rescuers should no longer deliver cycles of CPR.

-Insertion of an advanced airway may not be a high

priority. - Chest compressions should be delivered continuously

(100 per minute) and rescue breaths delivered at a rate

of 8 to 10 breaths per minute (1 breath every 6 to 8 seconds). Providers must organize care to minimize interruptions in chest compressions for rhythm

check, shock delivery, advanced airway insertion,

or vascular access.

6. Intravenous or intraosseous (IO) drug administration is preferred to endotracheal administration.

( : LEAN,Vasopressin IV/IO )

7. Treatment of VF / pulseless VT :
To attempt defibrillation, 1 shock is delivered (see Defibrillation for defibrillation doses using

monophasic or biphasic waveforms) followed immediately by CPR (beginning with chest compressions). Rescuers should minimize interruptions in chest compressions and particularly minimize the time between compression and shock delivery, and shock delivery and resumption of compressions.

 Compressions should ideally be interrupted only for rhythm checks and shock delivery. while the defibrillator is charging. Then compressions.

Providers do not attempt to palpate a pulse or check the rhythm after shock delivery. If an organized rhythm is apparent during rhythm check after 5 cycles (about 2 minutes) of CPR, the provider checks a pulse.

 Drugs should be delivered during CPR, as soon as possible after rhythm checks.
If a third rescuer is available, that rescuer should prepare drug doses before they are needed. If a rhythm check shows persistent VF/VT, the appropriate vasopressor or antiarrhythmic

The timing of drug delivery is less important than is the need to minimize interruptions in chest compressions.

 Vasopressors are administered when an IV/IO line is in place, typically if VF or pulseless VT persists after the first or second shock. - Epinephrine may be given every 3 to 5 minutes. -A single dose of vasopressin may be given to replace either the first or second dose of epinephrine. Antiarrhythmics may be considered after the first dose of vasopressors (typically if VF or pulseless VT persists after the second or third shock). Amiodarone is preferred to lidocaine, but either is acceptable.

8. Treatment of asystole/pulseless electrical activity : epinephrine may be administered every 3 to 5 minutes. One dose of vasopressin may replace either the first or the second dose of epinephrine. 9. Treatment of symptomatic bradycardia : the recommended atropine dose is now 0.5 mg IV, may repeat to a total of 3 mg. Epinephrine or dopamine may be administered while awaiting a pacemaker.
10. Treatment of symptomatic tachycardia : a single simplified algorithm includes some but not all drugs that may be administered. The algorithm indicates therapies intended for use in the in-hospital setting with expert consultation available.

11. Postresuscitation stabilization

requires support of vital organs, with the anticipation of

postresuscitation myocardial dysfunction. Some reliable prognostic indicators have been reported. (vasoactive support, , ) 12. Avoid hyperthermia for all patients after resuscitation. Consider inducing hypothermia if the patient is unresponsive but with an adequate blood pressure following resuscitation. ( )

Things that did NOT change in ACLS include the following:

1. Most drug doses are the same as those recommended in 2000 (one exception noted above.atropine for bradycardia).
2. The need to search for and treat reversible causes of

cardiac arrest and failure to respond to resuscitation attempts. These contributing factors are referred to as the 5Hs (hypovolemia, hypoxia, hydrogen ion, hypoglycemia,
hypo - hyperkalemia, hypothermia) and 5Ts (toxins,tamponade, tension pneumothorax,thrombosis [includescoronary or pulmonary], trauma [hypovolemia]) These are listed in the ACLS and PALS algorithms.

Cardiopulmonary Arrest

Priorities
Airway and ventilation Early High Quality CPR until defibrillator arrives

Recognition of ECG rhythm

Early defibrillation (1 shock-CPR-1shock) Use of pressor agents and antiarrhythmics Differential and treat underlying cause

The ACLS Approach

Primary Survey
A - Airway: open the airway B - Breathing: positive pressure
ventilation( 1)

C - Circulation: signs of circulation

Chest compressions AED

D - Defibrillation: monitor and defibrillate:

Ventricular fibrillation or pulseless ventricular tachycardia

A- Airway
Manual opening of the airway Evaluate breathing

B- Breathing
Provide two slow breaths(1/1)
500 - 600 ml ( , )

Evaluate breathing

C-Circulation
Perform CPR until AED is available 100 compression/minute 30-2 Compression ventilation ratio
One and two rescuer CPR

Attach AED

D - Defibrillation
Attach AED Defibrillation X 1
For VF: Shock-CPR 5- -Shock

CPR, ACLS

Automated External Defibrillator

Power on (CPR) Attach electrodes (CPR) Analyze (clear) CPR Shock (clear)

POWER ON

SHOCK

SURVIVAL
100 90 80 % 70 60

Larsen MP, et al. Emerg Med 1993;22:1652-58

Ann

Chances of success reduced 7% to 10% each minute

Success 50
40 30

20
10
0 1 2 3 4 5 6 7 8 9

Time

The ACLS Approach

CPR

A - Airway: advanced airway

B - Breathing: primary confirmation
additional confirmation

C - Circulation: IV, medications D - Differential: identify and treat cause

A- Airway
Airway device
Laryngeal Mask Airway Esophageal-tracheal combitube

Endotracheal intubation -

B- Breathing
Evaluate breathing
Primary confirmation (ETCO2, EDD) Additional confirmation

Continuous monitoring

C-Circulation
IV /IO therapy Medications Fluids

Epinephrine
Treatment recommendations Epinephrine, 1 mg IV, given every 3 to 5 minutes, is generally accepted as useful in cardiac arrest from all rhythms although no human trials have compared epinephrine to placebo Regarding high-dose epinephrine (up to 0.2 mg/kg): Giving more than 1 mg as the first dose of epinephrine has not been shown to be harmful and might provide benefit. (Class I Indeterminate). If standard doses of epinephrine have failed to bring about return of spontaneous circulation, high-dose epinephrine may be useful. (Class IIb regarding ROSC, Class Indeterminate regarding intact neurologic recovery.) If high-dose epinephrine is given, the dosing interval after highdose epinephrine before a next dose of epinephrine should be about 5

Vasopressin vs Epinephrine
(n=1186)
50 46 34

% Admitted to Hospital

40 30 20 10 0

VF PEA Asystole 29

43 31
*p=0.02

20

Vasopressin Initial Rhythm

Epinephrine

Wenzel V, Krismer AC, Arntz HR, et al: A comparison of vasopressin and epinephrine for out-ofhospital cardiopulmonary resuscitation. N Engl J Med 2004; 350:105-113

Recommendation for CPR drug

Epinephrine 1 mg IV/IO, Repeat 3 to 5 min. (Class IIb) Or May give 1 dose of vasopressin 40 U IV/IO (Class indeterminate) to replace first or second dose of epinephrine For All CA rhythm(VF,Asystole, PEA)

D-Differential
Treat cause Treat rhythm
VF/ VT

PEA

Asystole

Algorithms for Treatment of Cardiac Arrest

Adult BLS Healthcare Provider Algorithm

No movement or response Phone emergency number, Get AED Open AIRWAY, check BREATHING Give 2 BREATHS Check pulse within 10 sec Definite pulse Give 1 breath every 5 to 6 sec. Recheck pulse every 2 min.

No pulse
Give 30 COMPRESSIONS and 2 BREATHS AED/defibrillator ARRIVES

Check rhythm/Shockable rhythm? Shockable Give 1 shock Resume CPR immediately for 5 cycles Not Shockable Resume CPR immediately for 5 cycles Check rhythm every 5 cycles

ACLS Pulseless Arrest Algorithm

Pulseless arrest BLS, Oxygen, monitor/defibrillator

Check rhythm/Shockable rhythm? Shockable Not Shockable

VF/VT
Give 1 shock Resume CPR immediately Give 5 cycles of CPR Check rhythm Shockable rhythm?

Asystole/PEA

Resume CPR immediately for 5 cycles Give vasopressor Consider atropine Give 5 cycles of CPR Check rhythm Shockable rhythm? Not Shockable Shockable

Shockable
Give 5 cycles of CPR Give 1 shock Resume CPR immediately Give vasopressor

Not Shockable

Follow VF/VT Asystole/PEA:go to algorithm algorithm Give 5 cycles of CPR If pulse present, begin postresuscitation care Check rhythm Shockable rhythm? Not Shockable During CPR Shockable Do correct CPR Give 1 shock Minimize interruption Resume CPR immediately Search for and treat possible Give antiarrhythmics (Amiodarone or lidocaine) contributing factors: 5H and 5T

/
Ventricular Fibrillation/
Pulseless Ventricular Tachycardia

Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/VT) Algorithm

Adult Adult Advanced Cardiovascular Life Support

Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, Breathing: provide positive-pressure ventilations( ) C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulseless VT, up to 1 times (120-200J equivalent biphasic, 360J monophasic) if necessary Resume CPR immediately (5cycle)

Persistent or recurrent VF/VT 1shock & Continue CPR ( ) During CPR Push hard & fast Ensure full chest recoil Minimize interruptions in chest com. (: -30: 2 , 5 cycle = 2) avoid hyperventilation Secure airway & confirm placement ( , 8-10/ - 2 ) (5H & 5T ) Epinephrine 1mg IV, q 3-5 min. or Vasopressin 40 u IV (CPR
, , ) CPR immediately (5cycle)

Resume attempt to 1shock & CPR ( ) after 5 cycle CPR. Resume CPR immediately (5cycle) after 1shock (CPR , , ) CPR immediately (5cycle) antiarrhythmics: Amiodarone (IIb), lidocaine (indeterminate), magnesium (IIb if hypomagnesemic state),

Resume attempt to defibrillate

VF/VT
1 Shock 5cycle CPR 1 Shock

VF/VT
Epinephrine 1 mg every 3 to 5 minutes or Vasopressin 40 U 1 dose only

VF/VT
Amiodarone
300 mg IV bolus Consider Second dose of 150 mg

Lidocaine
1 to 1.5 mg/kg IV bolus Consider Second dose ( 0.5-0.75mg /kg 3 3mg/kg)

VF/VT Other Drugs

Magnesium sulfate
1-2 gms IV bolus Polymorphic VT (torsades de pointes) or Hypomagnesemic states

3-5 1

1 mg 40 IU : 300 mg : 150 mg

1.0-1.5 mg/kg 3 mg/kg ( )

0.5-0.75 mg/kg ( )

Torsades de pointes 1-2 g

5-15

 Pulseless Electrical Activity

1

Pulseless Electrical Activity

Adult Adult Advanced Cardiovascular Life Support

Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, Breathing: provide positive-pressure ventilations( ) C Circulation: give chest compressions attach monitor/defibrillatorwhen available : check rhythm-shockable or not shockable

(PEA = rhythm on monitor, without detectable pulse) Resume CPR immediately (5cycle) When IV/IO available, give vasopressor Epinephrine 1mg IV/IO, repeat every 3 to 5 min. Or may give 1 dose of Vasopressin 40U IV/IO to replace first or second dose of epinephrine Consider Atropine 1mg IV/IO (if PEA rate is slow) repeat every 3 to 5 min(up to 3 doses) Give 5 cycle CPR Not shock. check rhythm-shockable or not shockable shockable Go to VF/VT

PEA=

if asystole Asys. al. if PEA PEA al. if pulse present-begin postresuscitation

During CPR Push hard & fast , Ensure full chest recoil, Minimize interruptions in chest com. (: -30: 2 , 5 cycle = 2) avoid hyperventilation , Secure airway & confirm placement ( , 8-10/ - 2 ) (5H & 5T )

PEA
Epinephrine 1 mg every 3 to 5 minutes or may give 1 dose of Vasopressin 40U IV/IO to replace first or second dose of epinephrine Atropine if bradycardic PEA(less than 60 / )

PEA Treat Cause

6 Hs Hypovolemia Hypoxia (O2) Hydrogen ion (Ph) Hyper/hypokalemia (K+) Hypothermia Hypoglycemia

5 Ts Tablets (Drugs) Tamponade Tension pneumothorax Thrombosis, MI Thrombosis, (pulmonary embolism)

Asystole
Search for cause (2 , ,) DNR, advanced directives Family at bedside

Pulseless Electrical Activity

Adult Adult Advanced Cardiovascular Life Support

Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, Breathing: provide positive-pressure ventilations( ) C Circulation: give chest compressions attach monitor/defibrillatorwhen available : check rhythm-shockable or not shockable

(Asystole)

Resume CPR immediately (5cycle) When IV/IO available, give vasopressor Epinephrine 1mg IV/IO, repeat every 3 to 5 min. Or may give 1 dose of Vasopressin 40U IV/IO to replace first or second dose of epinephrine Consider Atropine 1mg IV/IO repeat every 3 to 5 min(up to 3 doses) if asystole Asys. al. if PEA PEA al. if pulse present-begin postresuscitation Give 5 cycle CPR check rhythm-shockable or not shockable

Asystole persists Withhold or cease resuscitative efforts? Consider qualify of resuscitation? Atypical clinical features present?(: Iib) Support for cease-efforts protocols in place?

Not shock.

shockable

Go to VF/VT

During CPR Push hard & fast , Ensure full chest recoil, Minimize interruptions in chest com. (: -30: 2 , 5 cycle = 2) avoid hyperventilation , Secure airway & confirm placement ( , 8-10/ 2 )

Asystole
1

Asystole
Transcutaneous pacing (2005 ) Epinephrine 1 mg every 3 to 5 minutes Atropine 1 mg every 3 to 5 minutes
Total .04mg/kg


Cardiac Arrhythmias (with pulse)
Pre-arrest or Post-arrest

Cardiac Arrhythmias (with pulse)

Pre-arrest or Post-arrest

Priorities
Invasive airway only if needed Oxygen, IV, monitor, fluids Vital signs, pulse-ox, monitor BP 12 lead ECG History and physical Differential, include electrolytes and toxicology

Bradycardia Algorithm (Patient Not in Cardiac Arrest)

Adult Adult Advanced Cardiovascular Life Support

Bradycardia
Serious signs or symptoms related to slow rate:
Decreased level of consciousness Shortness of breath Chest pain Low blood pressure Shock Pulmonary congestion Congestive heart failure

Bradycardia
Transcutaneous pacing(class I) Atropine 0.5 IV(TCP )
Max 3mg(.04 mg/kg)- TCP

Dopamine 2 to 10 g/kg/min (class IIb) (TCP , TCP,Atropine ) Epinephrine 2 to 10 g/min(class IIb)

(TCP ,
TCP, Atropine )

Bradycardia
Second degree type II, or third degree block(TCP )
Transvenous pacemaker

Treat contributiong causes (AMI., Myocarditis, e. disturbances ) Consider expert consultation

Unstable Tachycardias
Tachyarrhythmia with serious signs or symptoms
Immediate synchronized cardioversion if symptoms attributable to arrhythmia (rate at least 150) Full monitoring Sedation if possible

ACLS Tachycardia Algorithm

Tachycardia with pulse
Airway, Breathing, Oxygen Monitor ECG, BP, Oxymetry Identify and treat reversible causes IV access 12 lead ECG Is QRS narrow(<0.12 sec)?

Stable

Is patient stable?
Wide>0.12 sec

Unstable

Perform immediate synch. Cardioversion

Narrow QRS
Is rhythm regular?

Wide QRS
Is rhythm regular? (expert consultation)

Regular Vagal maneuver Adenosine

Does rhythm convert?

Irregular Regular Atrial fibrillation Atrial flutter Mutifocal atrial tachycardia: Diltiazem B-blockers Treat causes Does not convert Atrial flutter Ectopic atrial tachycardia Junctional tachycardia: Diltiazem B-blockers Treat causes Ventricular tachycardia Uncertain rhythm: Amiodarone Prepare sync. Cardioversion SVT with aberrancy: Adenosine

Irregular Atrial fibrillation wit aberrancy: Treat as irregular narrow tachycardia

Convert SVT: Diltiazem B-blockers

Pre-excited atrial fibrillation: expert consultation, avoid AV blocking agents (adenosine, verapamil, b-blockers, dogoxin) Consider antiarrhythmics (amiodarone)
Recurrent polymorphic VT: Exepert consultation Torsades de pointes: magnesium

Reminders If pulseless, go to pulseless arrest rhythm Search for and treat possible contributing factors: Hypovolemia Toxins Hypoxia Tamponade, cardiac Hydrogen ion (acidosis) Tension pneumothorax Hypo-/hyperkalemia Thrombosis, coronary Hypoglycemia Thrombosis, pulmonary Hypothermia Trauma (hypovolemia, IICP)

 2005
. .
* (. ., .12 )

PSVT( )
. . . . 6 mg (13) . 20 ml . 1-2 12 mg . . , . dipyridamole, carbamazepine (3 mg) .

 Acute Coronary Syndromes

1

Learning Objectives
At the end of Case 6 be able to ACS(acute coronary syndromes) (Ischemic Chest Pain) Algorithm . ( the Why? (actions), When? (indications), How? (dose), and Watch Out! (precautions)

Learning Objectives (contd)

At the end of Case 6 be able to ST-segment . ST-segment . localization of infarct, injury, and ischemia . .


: : , , , : 0.5 mm (0.05 mV) ST T (2 mm)
: CK-MB

TIMI score
65 1 (, , , , ) 3 1 7 1 24 2 1 CK-MB 1 0.5 mm ST (20 ) 1 50% 1
* TIMI (Thrombolysis in Myocardial Ischemia) * 0-1: low risk, 2-3: intermediate risk, 5 : high risk

 , AMI
1. 48 (20) 2. ,, 3, 75 3. 0.5mmST , 4. : , CK-MB


, , , , (, , , )


AMI 4 V.Fib. ( 5%) 5 EMT 2. ( out-of-hospital ECG) 12 (5) ST AMI. 3. (out-of-hospital fibrinolysis) 1 20% EMS 30-6 1.

Ischemic Chest Pain Algorithm ( )

Acute Coronary Syndromes algorithm()

Ischemic chest discomfort
EMS assessment and care and hospital preparation Monitor, support ABCs, Prepare for CPR/defibrillation Oxygen, aspirin, nitroglycerin, and morphine Obtain 12 ECG if available. If ST-elevation: Notify receiving hospital with transmission or interpretation Begin fibrinolytic checklist Notified hospital: mobilize hospital resources to respond to STEMI

Immediate ED assessment (<10 min.) Check vital signs/oxygen saturation IV access, obtain/review 12-lead ECG History/physical exam Review/complete fibrinolytic checklist Obtain cardiac marker levels, electrolytes and coagulation studies Obtain portable chest X-ray (30<min)

Immediate ED general treatment Oxygen at 4L/min Aspirin 160-325 mg Nitroglycerin Morphine IV

Review initial 12-lead ECG

ST elevation or New LBBB

Adjunctive treatment (B-blockers, clopidogrel, heparin)

ST depression or dynamic T wave change

Adjunctive treatment (NTG, B-blockers, clopidogrel, heparin, Glycoprotein IIb/IIIa inhibitor)
>12 hrs yes

Normal or non-diagnostic ECG

? High or intermediate risk or ? Troponin positive
no

Time from onset of symptoms

12 hrs

Admit to monitored bed Assess risk status

Admission to ED chest pain unit or to monitored bed in ED Serial cardiac markers Repeat ECG tracing or monitoring Consider stress test
yes

Reperfusion strategy Reperfusion by PCI (goal: 90 min) Reperfusion with thrombolytics (goal: 30 min) Continue adjunctive therapies and ACE inhibitor/ARB within 24 hrs HMG Co A reductase inhibitor (Statin therapy)

Early invasive strategy for high-risk patient Refractory ischemic chest pain Recurrent/persistent ST deviation Ventricular tachycardia Hemodynamic instability Signs of pump failure Continue adjunctive therapies and ACE inhibitor/ARB within 24 hrs HMG Co A reductase inhibitor (statin therapy)

? Develop high or intermediate risk criteria or ? troponin-positive

no

If no evidence of ischemia or infarction, can discharge with follow-up

Assess Initial 12-Lead ECG Findings

ST elevation or new or presumably new LBBB: strongly suspicious for injury ST-elevation AMI

ST depression or dynamic T-wave inversion: strongly suspicious for ischemia High-risk unstable angina/ nonST-elevation AMI

Nondiagnostic ECG: absence of changes in ST segment or T waves Intermediate/low-risk unstable angina

Classify patients with acute ischemic chest pain into 1 of the 3 groups above within 10 minutes of arrival.

1. ST (ST-elevation myocardial infarction: STEMI) 1 mm (0.1 mV) ST 2

2. ST (non-ST elevation myocardial infarction: NSTEMI) 0 . 5 mm (0.05 mV) ST T (20 ) 0.5 mm ST

3. ST T (non-diagnostic ECG) 0.5 mm (0.05 mV) ST 0.2 mV T


(unfractionated heparin) (Low-molecular-weight heparin)) Glycoprotein(GP) IIb/IIIa inhibitors (ACE inhibitor) (Statin : HMG Co. A. )

(clopidogrel)
- 2005 -

adenosine diphosphate receptor . 300 mg ST 4 , ST , , . , ST , , , , 75 ST .


(Statins; HMG Coenzyme A Reductase Inhibitors)
- 2005 -

, 24

Nitroglycerin: Actions
Decreases pain of ischemia Increases venous dilation Decreases venous blood return to heart Decreases preload and cardiac oxygen consumption Dilates (coronary arterie)s) Increases cardiac collateral flow coronary arteries O X

 (sublingual) () .

 , , .

 , .

Nitroglycerin: Dose
Sublingual: 0.3 to 0.4 mg; repeat every minutes Spray inhaler: 2 metered doses at 5-minute intervals IV infusion: 12.5 to 25 g bolus, 10 to 20 g/min infusion, titrated

 5 2-3 .

Nitroglycerin: Indications
Class I: First 24 to 48 hours in patients with ST-segment elevation or depression including
LV failure (acute pulmonary edema or CHF) Elevated BP (especially with signs of LV failure) Large anterior infarction Persistent ischemia

Suspected ischemic chest pain Unstable angina (change in angina pattern) Acute pulmonary edema (if BP >90 mm Hg systolic) X O 90

 . 90 mmHg , () .

 100 mmHg 25 mmHg .

 10% .

 90 mmHg .

 . .

1. , 2. , 3. , 4. .

 (tachyphylaxis) 24-48 . 6 .


. . .

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 1-3 mg 1-5 , 5-15 .

 . . - Naloxone


, . .

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 (metoprolol).

 5 mg 2-5
100 mmHg 60

 () 2 .


, .


cyclooxygenase thromboxane A2 . .

 160 mg , 1 160-325 mg .

(unfractionated heparin)
(antithrombin ) .

 (conformational) .

 Q . . .

 . tissue plasminogen activator(tPA) .

 (nonselective) urokinase streptokinase .

 , , , .

 60U/kg(4000U/kg) 12U/kg( 1000 U/kg) . activated partial thromboplastin time 1.5-2.0 . ( PTT: 60-70, APTT: 20-35 )

 , , , , .

 (Low-molecular-weight heparin)
(unfractionated) (depolymerization) .

 , () .

 -- , - .

 (unfractionated) factor Xa .

 . , partial thromboplastin time .

 (unfractionated) , .

 Glycoprotein(GP) IIb/IIIa inhibitors

Glycoprotein IIb/IIIa inhibitor Glycoprotein IIb/IIIa .

 Glycoprotein IIb/IIIa () , glycoprotein IIb/IIIa .

 . glycoprotein IIb/IIIa inhibitor .

Glycoprotein IIb/IIIa inhibitor

1. glycoprotein IIb/IIIa (monoclonal) (antibody), 2. glycoprotein IIb/IIIa (eptifibatide), 3. glycoprotein IIb/IIIa inhibitor glycoprotein IIIb/IIIa (tirofiban) .

 Glycoprotein IIb/IIIa inhibitor , .

 IIb/IIIa , . IIb/IIIa abciximab ST ( , , , , ) , (, , ) .

, abciximab .

 , glycoprotein IIb/IIIa inhibitor ST (, , ) .

ACE Inhibitors
Mechanism of action
Reduces BP by inhibiting angiotensinconverting enzyme (ACE) Alters post-AMI LV remodeling by inhibiting tissue ACE Lowers peripheral vascular resistance by vasodilatation Reduces mortality and CHF from AMI

Fibrinolytic Therapy
Breaks up the fibrin network that binds clots together Indications: ST elevation >1 mm in 2 or more contiguous leads or new LBBB or new BBB that obscures ST

Time of symptom onset must be <12 hours Caution: fibrinolytics can cause death from brain hemorrhage

Agents differ in their mechanism of action, ease of preparation and administration; cost; need for heparin 5 agents currently available: alteplase (tPA, Activase), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase)


. 12 , 12 ST . .

, 24 . 24 ST .
. 1 . 1 . 3 .


12 20 2 0.1 mV ST


1. 1. 180 mmHg 110 mmHg 2. 2. 1 3. (INR 2.0 ), 4. 2-4 5. 3 3. 6. 10 7. 4. 8. 2-4 9. (, streptokinase) 5. 10. 11. 12.

ST ( )

1.
2. () 3. ST

4.
5. , 6. 2 7. 6


Routes of Drug Delivery: Intravenous() Intraosseous() Intratracheal() Preferred IV route: Antecubital vein() Central vein()

Objectives of ACLS pharmacology

Correction of hypoxia ROSC and adequate blood pressure Promotion of optimal cardiac function Treatment of arrhythmias Relief of pain Correction of acidosis Treatment of heart failure

Pharmacology in ACLS
Primary agents : agents for full cardiac arrest oxygen, epinephrine, vasopressin, amiodarone, atropine etc Secondary agents : agents for AMI & complications inotropic agents, vasodilators, adrenergic blockers, diuretics thrombolytic agents

Epinephrine
Class Indeterminate - - 24 : 1 mg q 3-5min. : 2- 5 mg : 1- 3 - 5 mg : 0.1 mg/kg

Vasopressin
V1 , , Class indeterminate( ): 40 U IV bolus Class indeterminate(, )

Amiodarone
sodium, potassium, and calcium channel Class IIb: , , , wide-QRS Class IIa: 40% Class IIb:

Atropine
: 0.5 mg : 1.0 mg

 (Acute Stroke)

 Acute Ischemic Stroke

. , . .

Phase 1:
Recognize stroke signs and symptoms Be able to use either the Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen Appreciate importance of rapid transport to ED Appreciate importance of notifying ED before arrival Know the differences between ischemic and hemorrhagic stroke( )

() ?
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(stroke): .

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60 . . (
.)

3 (, , ).



1,000 1 45-54 : 1.4 55-64 : 4.1 65-74 : 9.1 75-84 : 15.2 >85 : 27.0


10 46.6, 36.7 (1996)

10 74.7 (71.0, 78.4)

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1. .
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3. .

Cincinnati Prehospital stroke Scale

3 Components: Facial droop (ask patient to show teeth and smile) Arm drift (ask patient to extend arms, palms down, with eyes closed) Speech (ask patient to say You cant teach an old dog new tricks)

Look for abnormalities.

 (Details of Facial Droop)

4 3 2 1

Details of Arm Drift

 ?
() () ( )

 (1)

 (2)

 (amaourosis fugax)

 .
. . 119 .

Acute Stroke Algorithm( )

Identify signs of possible stroke Critical EMS assessments and actions Support ABCs, give oxygen if needed Perform prehospital stroke assessment Establish time when patient last known normal Transport: consider triage to a center with a stroke unit, consider bringing a witness Alert hospital Check glucose if possible Immediate general assessment and stabilization Assess ABCs, vital signs Provide oxygen if hypoxemic Obtain IV access and blood samples, Check glucose, treat if indicated Perform neurologic screening assessment Activate stroke team Order emergent CT scan of brain/ Obtain 12-lead-ECG Immediate nerurologic assessment by stroke team or designee Review patient history Establish symptom onset Perform neurologic exam (NIHSS, Canadian Neurologic Scale) Does CT scan show any hemorrhage?

No hemorrhage
Probable acute ischemic stroke; consider fibrinolytic therapy Check for fibrinolytic exclusions Repeat neurologic exam: are deficits rapidly improving to normal?

Hemorrhage
Consult neurologist or neurosurgeon; Consider transfer if not available

Patient remains candidate for fibrinolytic therapy?

Not candidate

Administer aspirin

Candidate
Review risks/benefits with patient and family: If acceptable Give tPA No anticoagulants or antiplatelet treatment for 24 hours

Begin stroke pathway Admit to stroke unit if available Monitor BP; treat if indicated Monitor neurologic status; emergent CT if deterioration Monitor blood glucose; treat if needed Initiate supportive therapy; treat comorbidities

Algorithm for Suspected Stroke ( )