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Advanced Cardiac Life Support PowerPoint Presentation

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Slide 1-

ACLS Systematic approach to assessment and management of cardiopulmonary emergencies Continuation of Basic Life Support Resuscitation efforts aimed at restoring spontaneous circulation and retaining intact neurologic function ABCD 1
Slide 2-

The AAA’s Assess the patient Establish unresponsiveness Check pulse, respirations Activate EMS Call for help AED Get an AED (automated external defibrillator) 2
Slide 3-

Primary Survey (BLS) Airway Breathing Circulation Defibrillation Always assess and manage before moving on to the next step! 3
Slide 4-

Airway Open the airway Head tilt-chin lift Jaw thrust Wellcome Photo Library, Wellcome Photos Wellcome Photo Library, Wellcome Photos 4
Slide 5-

Breathing Look, Listen and Feel Give 2 rescue breaths Watch for appropriate chest rise and fall U.S. Navy photo by Photographer's Mate 3rd Class Jesse Praino, Wikimedia Commons 5
Slide 6-

Circulation Check for a pulse Start CPR 30 compressions/ 2 respirations Compressions more important than respirations! U.S. Navy photo by Mass Communication Specialist Seaman Gabriel S. Weber, Wikimedia Commons 6
Slide 7-

Defibrillation Know your AED Universal steps: Power ON Attach electrode pads Analyze the rhythm Shock (if advised) Ernstl, Wikimedia Commons 7
Slide 8-

Defibrillation Most frequent initial rhythm in witnessed sudden cardiac arrest is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) which rapidly deteriorates into VF The only effective treatment for VF is electrical defibrillation Probability of successful defibrillation diminishes rapidly over time VF rapidly converts to asystole if not treated 8
Slide 9-

Early Defibrillation = Increased Survival Source unknown 9
Slide 10-

Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos NEJM Vol 343 (17) October 26, 2000 Used AEDs on 105 patients with Ventricular Fibrillation 53% survived to discharge (back to casino) Previously, less than 5% survive 10
Slide 11-

Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest NEJM 2004 Community based trial of AED deployment and layperson training. 30 in AED group versus 15 survivors in CPR only group to hospital discharge Average age of survivor - 69.8 years Study cost - $9.5 million 11
Slide 12-

Secondary Survey (ACLS) Airway Breathing Circulation Differential Diagnosis Assess and manage at each step before moving on! 12
Slide 13-

Airway Maintain airway patency Head tilt-chin lift/jaw thrust Oro- or nasopharyngeal airway Advanced airway management ETT Combitube LMA Ignis, Wikimedia Commons 13
Slide 14-

Breathing Assess adequacy of oxygenation and ventilation Provide supplemental oxygen Confirm proper airway placement Secure tube 14
Slide 15-

Circulation Assess/monitor cardiac rhythm Establish IV access Give medications as appropriate for rhythm and BP Fluid resuscitation Minimize interruption of compressions to maximize survival. 15
Slide 16-

Differential Diagnosis Look for and treat any reversible cause of arrest 16
Slide 17-

Basic Rhythm Analysis 17
Slide 18-

Basic Rhythm Analysis Rate – too fast or too slow? Rhythm – regular or irregular? Is there a normal looking QRS? Is it wide or narrow? Are P waves present? What is the relationship of the P waves to the QRS complex? 18
Slide 19-

Rhythm Analysis Lethal vs non-lethal? Shockable vs. non-shockable? Too fast vs too slow? Symptomatic vs. asymptomatic? 19
Slide 20-

Lethal Rhythms Shockable (Defibrillation) Ventricular fibrillation Pulseless ventricular tachycardia Non-shockable Asystole Pulseless electrical activity 20
Slide 21-

Non-Lethal Rhythms Too fast (tachycardias) Sinus Supraventricular (including a-fib/flutter) Ventricular Too slow (bradycardias) Sinus Heart block (1°, 2°, 3° AV block) 21
Slide 22-

What is a Symptomatic Dysrhythmia? Any abnormal rhythm that produces signs or symptoms of hypoperfusion Chest Pain/ischemic EKG changes Shortness of Breath Decreased level of consciousness Syncope/pre-syncope Hypotension Shock - decreased Uop, cool extremities, etc. Pulmonary Congestion/CHF 22
Slide 23-

Name that rhythm… 23
Slide 24-

63 yo man with a witnessed collapse while mowing the lawn What is the rhythm? What is the management? Chikumaya, Wikimedia Commons 24
Slide 25-

Ventricular Fibrillation Rapid and irregular No normal P waves or QRS complexes Jer5150, Wikimedia Commons 25
Slide 26-

VF / Pulseless VT Primary Survey - ABC Secondary Survey - ABC Source unknown 26
Slide 27-

ACLS Algorithm Primary Survey Shock – 360 J Secondary Survey Vasopressor - Epi or Vasopressin IV Shock 360J Antiarrhythmic – Amiodarone, Lidocaine or Magnesium Sulfate IV Shock 360J 27
Slide 28-

79yo man s/p NSTEMI What is the rhythm? What is the management? Glenlarson, Wikimedia Commons 28
Slide 29-

Ventricular Tachycardia Rapid and regular No P waves Wide QRS complexes Ksheka, Wikimedia Commons 29
Slide 30-

Ventricular Tachycardia Monomorphic VT Polymorphic VT 30 Ksheka, Wikimedia Commons Displaced, Wikimedia Commons
Slide 31-

Ventricular Tachycardia Assume any wide complex tachycardia is VT until proven otherwise SVT with aberrant conduction may also have wide QRS complexes Attempt to establish the diagnosis Ischemia risk and VT go together 31
Slide 32-

Treatment of VT If pulseless - follow VF algorithm If stable try anti-arrhythmics Amiodarone Lidocaine Procainamide? If patient has a pulse, but is unstable or not responding to meds - shock 32
Slide 33-

Treatment of VT Anti-arrhythmics are also pro-arrhythmic One antiarrhythmic may help, more than one may harm Anti-arrhythmics can impair an already impaired heart Electrical cardioversion should be the second intervention of choice 33
Slide 34-

60yo diabetic man with chest pain What is the rhythm? What is the management? Knutux, Wikimedia Commons 34
Slide 35-

Normal Sinus Rhythm Regular rate and rhythm Normal P waves and QRS Evaluate for cause of chest pain and monitor for change in rhythm Knutux, Wikimedia Commons 35
Slide 36-

40 yo woman found down, pulseless and apneic What is the rhythm? What is the management? Masur, Wikimedia Commons 36
Slide 37-

Pulseless Electrical Activity Any organized (or semi-organized) electrical activity in a patient without a detectable pulse Non-perfusing Treat the patient NOT the monitor Find and treat the cause!!!!! 37
Slide 38-

PEA and Asystole Secondary Survey - ABCD Primary Survey - ABC Source unknown 38
Slide 39-

PEA 39
Slide 40-

Find and Treat the Cause Non-shockable rhythm The most effective treatment is to find and fix the underlying problem Rama, Wikimedia Commons 40
Slide 41-

So what causes PEA? #1 cause of PEA in adults is hypovolemia #1 cause in children is hypoxia/respiratory arrest Other causes? 41
Slide 42-

The H’s and T’s Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyper-/hypokalemia Hypothermia Hypoglycemia (rare) Toxins Tamponade Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma 42
Slide 43-

Treat the H’s and T’s Hypovolemia Volume – IVF, PRBC’s Hypoxia Oxygenate/Ventilate Hydrogen ion (acidosis) Sodium bicarbonate Hyperventilation Hyper-/hypokalemia Sodium bicarbonate Insulin/glucose Calcium Hypothermia Warm -- invasive Hypoglycemia Dextrose Toxins Check levels Charcoal Antidotes Tamponade pericardiocentesis Tension pneumothorax Needle decompression Tube thoracostomy Thrombosis (coronary or pulmonary) Thrombolytics OR/cath lab Trauma 43
Slide 44-

19yo man with palpitations What is the rhythm? What is the management? Displaced, Wikimedia Commons 44
Slide 45-

Supraventricular Tachycardia Rapid (usually 150-250 bpm) and regular P waves cannot be positively identified QRS narrow Displaced, Wikimedia Commons 45
Slide 46-

Treatment of Stable SVT Consider vagal maneuvers Carotid sinus massage Valsalva Eyeball massage Ice water to face Digital rectal exam Adenosine 6 mg, 12 mg, 12 mg 46
Slide 47-

Treatment of Unstable SVT Electrical Cardioversion Cardioversion is not defibrillation Use defibrillator in “sync” mode prevents delivering energy in the wrong part of the cardiac cycle (R on T phenomenon) 47
Slide 48-

Electrical Cardioversion Energy level – somewhat controversial 100 J→200J→300J→360J Atrial flutter may convert with lower energy 50J For polymorphic VT – start with 200J The EP guys tend to start with 360J 48
Slide 49-

Electrical Cardioversion Be prepared Patient on monitor, IV, Oxygen Suction ready and working Airway supplies ready Pre-medicate whenever possible Conscious sedation Electrical shocks are painful! 49
Slide 50-

Tachycardia Treat the patient NOT the monitor!!! 50
Slide 51-

Stable Tachycardias Narrow complex? Regular rhythm Sinus tachycardia SVT AV nodal reentry Irregular rhythm Atrial fibrillation Atrial flutter Wide complex? Uncertain rhythm – assume VT Narrow complex tachycardia with aberrancy Ventricular tachycardia Monomorphic or polymorphic 51
Slide 52-

56 yo woman with shortness of breath and chest pain What is the rhythm? What is the management? J. Heuser, Wikimedia Commons 52
Slide 53-

Atrial fibrillation/flutter May be rapid Irregular (fib) or more regular (flutter) No P waves, narrow QRS James Heilman, MD, Wikimedia Commons J. Heuser, Wikimedia Commons 53
Slide 54-

Atrial fibrillation/flutter Treatment based on patient’s clinical picture Unstable = Immediate electrical cardioversion Stable Control the rate Diltiazem Esmolol (not if EF < 40%) Digoxin Provide anticoagulation Treat the patient NOT the monitor!!! 54
Slide 55-

78yo man found down, pulseless and apneic, unknown duration What is the rhythm? What is the management? D Dinneen, Wikimedia Commons 55
Slide 56-

Asystole Is it really asystole? Check lead and cable connections. Is everything turned on? Verify asystole in another lead. Maybe it is really fine v-fib? D Dinneen, Wikimedia Commons 56
Slide 57-

68 yo woman with h/o hypertension presents with dizziness What is the rhythm? What is the treatment? Mysid, Wikimedia Commons 57
Slide 58-

Sinus Bradycardia Slow and regular Normal P waves and QRS complexes Mysid, Wikimedia Commons 58
Slide 59-

Bradycardias Many possible causes Enhanced parasympathetic tone Increased ICP. Hypothyroidism Hypothermia Hyperkalemia Hypoglycemia Drug therapy 59
Slide 60-

Bradycardias Treat only symptomatic bradycardias Ask if the bradycardia causing the symptoms Recognize the red flag bradycardias Second degree type II block Third degree block 60
Slide 61-

Source unknown 61
Slide 62-

Transcutaneous pacing Class I for all symptomatic bradycardias Always appropriate Doesn’t always work Technique Attach pacer pads Set a rate to 80 bpm Turn up the juice (amps) until you get capture Painful – may need sedation / analgesia 62
Slide 63-

Transvenous Pacing Invasive Time-consuming to establish Skilled procedure Better long-term than transcutaneous May have better capture than transcutaneous pacing 63
Slide 64-

Bradycardia Treatment Medications Vagolytic Atropine Adrenergic Epinephrine Dopamine 64
Slide 65-

What if the same patient had this rhythm? What is the rhythm? What is the treatment? Jer5150, Wikimedia Commons 65
Slide 66-

Junctional Escape Slow and relatively regular No P waves Narrow QRS Arises from site near the junction of the atria and ventricles Jer5150, Wikimedia Commons 66
Slide 67-

29 yo asymptomatic female What is the rhythm? What is the management? 67 Steven Fruitsmaak, Wikimedia Commons
Slide 68-

1° AV block Regular rate and rhythm Normal P wave with long PR interval (>0.2msec/1 big box) Normal QRS 68 Steven Fruitsmaak, Wikimedia Commons
Slide 69-

58yo asymptomatic woman What is the rhythm? What is the management? Jer5150, Wikimedia Commons 69
Slide 70-

2° AV Block - Type I aka Wenckebach Regular rate and rhythm Normal P waves and QRS complexes Increasing PR interval until QRS dropped Jer5150, Wikimedia Commons 70
Slide 71-

80 yo man with syncope What is the rhythm? What is the management? Jer5150, Wikimedia Commons 71
Slide 72-

2° AV Block – Mobitz Type II Regular atrial rate with normal P wave Consistent PR interval Random QRS dropped Jer5150, Wikimedia Commons 72
Slide 73-

Another 80 yo man with syncope What is the rhythm? What is the management? MoodyGroove, Wikimedia Commons 73
Slide 74-

3° AV Block Normal P waves Normal QRS No relationship between P and QRS aka complete heart block MoodyGroove, Wikimedia Commons 74
Slide 75-

Know When To Stop With return of spontaneous circulation No ROSC during or after 20 minutes of resuscitative efforts Possible exceptions include near-drowning, severe hypothermia, known reversible cause, some overdoses DNR orders presented Obvious signs of irreversible death 75
Slide 76-

Take Home Points Assess and manage at every step before moving on to the next step Rapid defibrillation is the ONLY effective treatment for VF/VT Search for and treat the cause Treat the patient not the monitor Reassess frequently Minimize interruptions to chest compressions 76
Slide 77-

Special thanks to: Steve Kronick, MD and Suzanne Dooley-Hash, MD for contributing slides and content for this lecture. 77