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ACLS in 2013 The science behind the changes

ACLS in 2013 The science behind the changes. Michele Vicari-Christensen DNP ARNP August 17 th 2013. Objectives. Discuss the recent changes in ACLS Understand the scientific rationale for the changes presented Explain the use of capnography and hypothermia

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ACLS in 2013 The science behind the changes

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  1. ACLS in 2013The science behind the changes Michele Vicari-Christensen DNP ARNP August 17th 2013

  2. Objectives Discuss the recent changes in ACLS Understand the scientific rationale for the changes presented Explain the use of capnography and hypothermia Explore the rationale for key pharmacological changes in the algorithms 5) Illustrate the Chain of Survival

  3. CPR CPR Quality-Concensus Statement Circulation June 2013 Must use a systematic approach to assess and treat arrest and acutely ill or injured patients for optimum care which includes: -High quality CPR -Capnography -Hypothermia -Optimal glycemic control -Appropriate algorithms and pharmolcological agents 2) Goal of any resuscitative action is return of spontaneous circulation (ROSC) and neurological preservation

  4. Worldwide there are > 135 million cardiovascular death annuallyGlobally, the incidence of out of hospital cardiac arrest ranges from 20-140K/110K in the USSurvival ranges from 2-11% in the USThese statistics establish cardiac arrest as one of the most lethal public health problems in the US taking more lives than colorectal cancer, breast cancer, prostate cancer, influenza, pneumonia auto accidents HIV firearms and house fires combined

  5. The American Heart Association (AHA) recommends focusing primarily on effective cardiac compressions during resuscitative efforts

  6. Importance of compressions-5 critical components 1) Minimize any interruptions in effective chest compressions. 2) Provide compressions of adequate rate and depth 3) Avoid leaning between compressions 4) Allow complete chest recoil after each compression 5 Avoid excessive ventilation

  7. CPR survival is dependent on adequate myocardial oxygen delivery and myocardial blood flow: Chest compression fraction (CCF) of >80%-minimal interruptions Chest compression rate of 100-120 Compression depth of 50 mm or 2 inches in adults (1/3 anterior, posterior dimension of chest No Leaning causes lack of recoil Excessive ventilation decreases depth and recoil

  8. Push it to the limit

  9. Monitoring the effects of CPR:Cardiac perfusion pressure (CPP)of>20 mmHg-defined by arterial end diastolic pressure minus central venous pressure (CVP). Requires and arterial line and a central line during CPRCapnography-ET CO2 of > 20 mmHg

  10. The AHA recommends the use of capnography to monitor the effectiveness of chest compressions during CPR in the intubated patient

  11. CapnographyWhat is waveform capnography ? Quantitative waveform capnography is the continuous, noninvasive measurement and graphical display of end-tidal carbon dioxide/ETCO2 (also called PetCO2). Capnography uses a sample chamber/sensor placed for optimum evaluation of expired CO2. The inhaled and exhaled carbon dioxide is graphically displayed as a continuous waveform on the monitor along with its corresponding numerical measurement

  12. Capnography Circulation. Blood must be moving in order to deliver CO2 from the tissues to the alveoli. Circulation requires blood, an effective heartbeat and blood pressure. Preload plus afterload equals circulation. Mimic in compressions. In the acute setting, PetCO2 is a function of cardiac output Ventilation. Air must move in and out of the alveoli effectively to get rid of carbon dioxide and other waste products, and to inhale fresh oxygen.

  13. Capnography Qualitative waveform capnography (PETC02) provides a quality measure for CPR Optimal goal for CPR is PETC02 of 35-40 mmHg equates to same as when ROSC If PET Co2 is < 10 mmHg attempt to improve CPR-a PetC02 is 10 or less after initiation of ACLS is associated with poor outcomes.

  14. The AHA recommends the use of hypothermia in the treatment of neurological injury post cardiac arrest in the field from Pulseless Electrical Activity, Ventricular Fibrillation and Asystole

  15. Hypothermia The new guidelines recommend cooling comatose adult patients with ROSC after out of hospital VF, PEA and Asystole cardiac arrest to 32-34 degrees C (89-93 degrees F) for up to 12-24 hours

  16. Moderate hypothermia used since 1950 to protect the brain from global ischemia-lowers cerebral metabolic rate for oxygen (CMRO2) by 6% for every degree.Reduces cerebral histological deficits associated with reperfusion injury :-less mitochondrial damage, -decreased free radical production-less excitatory amino acid release -less calcium shifts-less neural cell apoptosis

  17. Methods:1) External coolingblankets, ice , wet towels and fanning, cooling helmet2)Intravenous30 cc/kg of crystalloid at 4 C over 30 minutes3) Peritoneal lavage4) Pleural lavage5) ECMO Side Effects and Complications Higher Systemic Vascular Resistance, Pneumonia Lower Cardiac Index Hyperglycemia Coagulopathy Arrythmias Skin Breakdown

  18. The AHA recommends optimal glycemic control for neurological recovery post ACLS intervention.

  19. Glycemic control Target glycemic control 10 144-180 mg/dl in an adult patients after cardiac arrest and ROSC. Avoid lower blood sugars in ranges of 80-110 mg/dl

  20. Hyperglycemia causes cerebral microvascular changes and brain edema that quickly lead to neuronal death Hypoglycemia causes cerebral cellular fuel deprivation and cellular death as well as an increase in cerebral cellular excitability and seizures.

  21. The AHA recommends the appropriate algorithm with recommended pharmacological agents

  22. Sodium Bicarbonate

  23. NAHC03 Henderson-Hasselbalch Equation Regulation of Carbonic Acid/Bicarbonate buffer pair

  24. Atropine 1) Parasympatholytic agent. Research supports only effective utilization is in symptomatic bradycardia 2) There is no benefit in pulseless electrical activity or asystole

  25. The AHA recommends implementation of the Chain of Survival for ACS and CVA both in the field and in the hospital

  26. Chain of Survival ACLS extends to Acute Coronary Syndrome and Cerebral Vascular Accidents

  27. In hospital survival from cardiac arrest is 20% from 7a-11p and declines to < 15% from 11p-7a

  28. The majority of published data in the form of before and after studies of Rapid Response teams have reported 17-65% drop in the rates of cardiac arrest after teams were developed

  29. References Guidelines for CPR and ECC (2010). American Heart Association. Field et al. (2010). Executive Summary- American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. (2010). Circulation. November 2, 2010; pp. S640-S729. CPR Quality-Improving Cardiac Resuscitation Outcomes Both inside and Outside the Hospital: A Concensus Statement from the American Heart Association. (2013).Circulation. June 25, 2013. pp. 1-19

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