You are on page 1of 27

1he Chaln of Survlval

kLCCGNI1ICN of Ck Def|br|||at|on ACLS post card|ac

card|ac arrest arrest care
of the emergency
response system
1he 8ulldlng 8locks of C8
|gh||ghts of the 2010 Gu|de||nes
W 1he Change Irom "A8C" to "CA8"
cbooqe lo tbe boslc llfe soppott (8l5)
sepoeoce of sLeps from A8C" Lo CA8
for adulLs and pedlaLrlc paLlenLs (chlldren
and lnfanLs excludlng newlyborns)
2010 4n4 6uide/ines for cPk ond cc recommend this
change for the fo||ow|ng reasons
W vasL ma[orlLy of cardlac arresLs occur ln adulLs
W hlghesL survlval raLes from cardlac arresL are
reporLed among paLlenLs of all ages wlLh wlLnessed
arresL and a rhyLhm of vl or pulseless v1
W ln Lhese paLlenLs Lhe crlLlcal lnlLlal elemenLs of C8
are chesL compresslons and early deflbrlllaLlon
2010 4n4 6uide/ines for cPk ond cc recommend this
change for the fo||ow|ng reasons
W ln Lhe A8C sequence chesL compresslons are ofLen
delayed whlle Lhe responder opens Lhe alrway
W 8y changlng Lhe sequence Lo CA8 chesL
compresslons wlll be lnlLlaLed sooner
W flrsL cycle of chesL compresslons (30 compresslons
should be accompllshed ln approxlmaLely 18
2010 4n4 6uide/ines for cPk ond cc recommend this
change for the fo||ow|ng reasons
W lewer Lhan 30 of persons ln cardlac arresL recelve
bysLander C8
W Cne lmpedlmenL rescuers flnd mosL dlfflculL
openlng Lhe alrway and dellverlng rescue breaLhs
W SLarLlng wlLh chesL compresslons mlghL ensure LhaL
more vlcLlms recelve C8
W rescuers who are unable or unwllllng Lo provlde
venLllaLlons wlll aL leasL perform chesL compresslons
ey chonqes in the 2010 4n4 6uide/ines
for cPk and LCC
W Look LlsLen and leel" has been removed from Lhe
W 5ttess lmmedlaLe acLlvaLlon of Lhe emergency
response sysLem
W SLarL chesL compresslons for any unresponslve adulL
vlcLlm wlLh no breaLhlng or no normal breaLhlng (le
only gasps)
ey chonqes in the 2010 4n4 6uide/ines
for cPk and LCC
l llallblll 1he recommended depLh of
compresslon for adulL vlcLlms has
lncreased from a depLh of 1 12 Lo 2
lnches Lo a depLh of aL leasL 2 lnches
ey chonqes in the 2010 4n4 6uide/ines
for cPk and LCC
W lnlLlaLe chesL compresslons before glvlng rescue
breaLhs 8escue breaLhlng all Lake Llme
l lla llb lll 8eglnnlng C8 wlLh 30 compresslons
raLher Lhan 2 venLllaLlons leads Lo a
shorLer delay Lo flrsL compresslon
,ost |mportant Deve|opments kecommendat|ons
|n ALS s|nce the 200S ILCCk rev|ew
1he recognlLlon LhaL adulLs who progress Lo braln
deaLh afLer resusclLaLlon from ouLofhosplLal cardlac
arresL (CPCA) should be consldered for organ
1he recommendaLlon LhaL lmplemenLaLlon of a
comprehenslve sLrucLured treatment protoco| may
lmprove survlval afLer cardlac arresL
AbouL use of capnography
Ann Lmerg Med 2003 May43(3)497303
1he effect|veness of outofhosp|ta| use of cont|nuous endt|da| carbon d|ox|de mon|tor|ng on the rate of
unrecogn|zed m|sp|aced |ntubat|on w|th|n a reg|ona| emergency med|ca| serv|ces system
SllvesLrl S 8alls CA krauss 8 1hundlyll ! 8oLhrock SC Senn A CarLer L lalk !
ueparLmenL of Lmergency Medlclne Crlando 8eglonal Medlcal CenLer Crlando lL uSA
S1uu? C8!LC1lvL We evaluaLe Lhe assoclaLlon beLween ouLofhosplLal use of conLlnuous endLldal carbon dloxlde
(L1CC2) monlLorlng and unrecognlzed mlsplaced lnLubaLlons wlLhln a reglonal emergency medlcal servlces (LMS)
ML1PCuS 1hls was a prospecLlve observaLlonal sLudy conducLed durlng a 10monLh perlod on all paLlenLs arrlvlng aL
a reglonal Level l Lrauma cenLer emergency deparLmenL who underwenL ouLofhosplLal endoLracheal lnLubaLlon
1he reglonal LMS sysLem LhaL serves Lhe Lrauma servlce area ls composed of mulLlple counLywlde sysLems
conLalnlng numerous LMS agencles Some of Lhe LMS agencles had lndependenLly lmplemenLed conLlnuous
L1CC2 monlLorlng before Lhe sLarL of Lhe sLudy 1he maln ouLcome measure was Lhe unrecognlzed mlsplaced
lnLubaLlon raLe wlLh and wlLhouL use of conLlnuous L1CC2 monlLorlng
8LSuL1S 1wo hundred forLyelghL paLlenLs recelved ouLofhosplLal alrway managemenL of whom 133 recelved
lnLubaLlon Cf Lhe 133 paLlenLs 93 (61) had conLlnuous L1CC2 monlLorlng and 60 (39) dld noL lorLynlne
(32) were medlcal paLlenLs 104 (68) were Lrauma paLlenLs and 31 (33) were ln cardlac arresL 1he overall
lncldence of unrecognlzed mlsplaced lnLubaLlons was 9 1he raLe of unrecognlzed mlsplaced lnLubaLlons ln Lhe
group for whom conLlnuous L1CC2 monlLorlng was used was zero and Lhe raLe ln Lhe group for whom conLlnuous
L1CC2 monlLorlng was noL used was 233 (93 confldence lnLerval 134 Lo 360)
CCnCLuSlCn no unrecognlzed mlsplaced lnLubaLlons were found ln paLlenLs for whom paramedlcs used conLlnuous
L1CC2 monlLorlng lallure Lo use conLlnuous L1CC2 monlLorlng was assoclaLed wlLh a 23 unrecognlzed
mlsplaced lnLubaLlon raLe
AbouL use of capnography
AnaesLh lnLenslve Care 1993 CcL21(3)61720
1he Austra||an Inc|dent ,on|tor|ng Study rob|ems w|th vent||at|on an ana|ys|s of 2000 |nc|dent reports
8ussell W! Webb 8k van der WalL !P 8unclman W8
ueparLmenL of AnaesLhesla lnLenslve Care unlverslLy of Adelalde SA
A revlew of Lhe flrsL 2000 lncldenLs reporLed Lo Lhe AusLrallan lncldenL MonlLorlng SLudy found 317 lncldenLs
whlch lnvolved problems wlLh venLllaLlon 1he ma[or porLlon (47) were dlsconnecLlons 61 of Lhese
were deLecLed by a monlLor MonlLor deLecLlon was by a low clrculL pressure alarm ln 37 buL Lhls alarm
falled Lo warn of nonvenLllaLlon ln 12 lncldenLs (ln 6 because lL was noL swlLched on and ln 6 because of
a fallure Lo deLecL Lhe dlsconnecLlon) lallure of deLecLlon was usually wlLh venLllaLor bellows descendlng
ln explraLlon CompleLe fallure Lo venLllaLe occurred ln 143 lncldenLs mosL commonly because of a
dlsconnecLlon ulsconnecLlon was assoclaLed ln oneLhlrd of Lhe cases wlLh lnLerference Lo Lhe
anaesLheLlc clrculL by a Lhlrd parLy and ln nearly half wlLh surgery on Lhe head and neck Leaks affecLed
venLllaLlon ln 129 lncldenLs buL ln only 19 was venLllaLlon LoLally losL leaks assoclaLed wlLh seal fallure of
Lhe absorber were common MlsconnecLlons occurred ln 36 lncldenLs mosL commonly lnvolvlng Lhe
scavenglng sysLem 1he frequency of a compleLe fallure Lo check an anaesLheLlc machlne was greaLer
when an lnducLlon room was lnvolved Lhan when only Lhe operaLlng LheaLre was Lhe slLe of Lhe lncldenL
1hese lncldenLs suggesL LhaL meLlculous checklng and monlLorlng for fallure of venLllaLlon preferably
uslng aL leasL Lwo separaLe selfacLlvaLlng sysLems ls hlghly deslrable 1he AusLrallan and new Zealand
College of AnaesLheLlsLs pollcy on low clrculL pressure alarms oxlmeLry and capnography ls vlndlcaLed by
Lhese reporLs
Advanced Card|ovascu|ar L|fe Support
atrop|ne ls no longer recommended
for rouLlne use ln Lhe managemenLof
MonlLor C8 quallLy uslng mechanlcal
parameLers or L1CC2 arLerlal pressure
durlng Lhe relaxaLlon phase of chesL
compresslons or cenLral venous oxygen
saLuraLlon ScvC2
Advanced Card|ovascu|ar L|fe Support
I IIa IIb III adenos|ne can now be consldered for
Lhe dlagnosls and LreaLmenL of sLable
und|fferent|ated w|decomp|ex tachycard|a
when Lhe rhyLhm ls regular and Lhe C8S
waveform ls monomorphlc
lor sympLomaLlc or unsLable bradycardla
lv lnfuslon of chronotrop|c agents ls now
recommended as an equally effect|ve a|ternat|ve to
externa| pac|ng when atrop|ne |s |neffect|ve
Advanced Card|ovascu|ar L|fe Support
l lla llb lll When quanLlLaLlve waveform capnography
ls used for adulLs monlLor C8 quallLy and
deLecLlng 8CSC based on L1CC2 values
W Culdellnes for posL cardlac arresL managemenL have
been slgnlflcanLly expanded and now lnclude a new
Larly osLCardlac ArresL 1reaLmenL AlgorlLhm
,ost |mportant Deve|opments kecommendat|ons
|n ALS s|nce the 200S ILCCk rev|ew
1he use of capnography Lo conflrm and
conLlnually monlLor Lracheal Lube placemenL
and quallLy of C8
8|ood g|ucose values 180 mg/dL (10 mmol/L)
should be LreaLed and hypoglycemla avolded
,ost |mportant Deve|opments kecommendat|ons
|n ALS s|nce the 200S ILCCk rev|ew
therapeut|c hypotherm|a for comaLose survlvors
of cardlac arresL lnlLlally assoclaLed wlLh
nonshockable rhyLhms
8ecognlLlon LhaL many accepLed predlcLors of poor ouLcome
ln comaLose survlvors of cardlac arresL are unrellable
especlally lf Lhe paLlenL has been LreaLed wlLh LherapeuLlc
1here ls lnadequaLe evldence Lo recommend a speclflc
approach Lo predlcLlng poor ouLcome ln posLcardlac arresL
paLlenLs LreaLed wlLh LherapeuLlc hypoLhermla
1hank you