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ARC ALS Guidelines UPDATE (2011)

ARC ALS Guidelines UPDATE (2011). Dr Tony Eliseo Emergency Specialist RAH ED. Contents. 2011 ARC changes to BLS 2011 ARC changes to ALS. BLS flow chart. BLS Changes. Recognising Cardiac Arrest Focus on unresponsiveness & absent or abnormal breathing. BLS Changes.

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ARC ALS Guidelines UPDATE (2011)

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  1. ARC ALS GuidelinesUPDATE (2011) Dr Tony Eliseo Emergency Specialist RAH ED Australasia EMed

  2. Contents • 2011 ARC changes to BLS • 2011 ARC changes to ALS Australasia EMed

  3. BLS flow chart Australasia EMed

  4. BLS Changes • Recognising Cardiac Arrest • Focus on unresponsiveness & absent or abnormal breathing Australasia EMed

  5. BLS Changes • If unwilling/unable to perform rescue breathing, then perform compression only CPR • New focus on maintenance of good quality CPR i.e. change “compressor” every 2 minutes • Minimise interruptions to chest compressions Australasia EMed

  6. BLS Changes • Recognised need for refresher training for individuals not performing resuscitation on a regular basis • Recommended that individuals trained in CPR should refresh their skills at least yearly Australasia EMed

  7. Cardiac arrest • Compressions→ approximately 1/3 chest • Rate 100/min – no benefit from >120/min • Compression: ventilation ratio before the airway is secured = 30:2 ie avoid simultaneous compressions and breaths • After an advanced airway = 6 - 10 ventilations/minute without pausing (1 breath every 15 compressions) Australasia EMed

  8. ARC Guideline 11.2 Australasia EMed

  9. Assess rhythm • To perform rhythm check/assess rhythm • This means charging defib with chest compressions continuing. Everyone else stands clear • Then ceasing chest compressions for the rhythm check • If a shockable rhythm is seen – deliver shock and recommence CPR immediately • Adrenaline 1mg, after 2nd shock and after every 2nd cycle • Amiodarone after 3rd shock Australasia EMed

  10. Performing CPR with defibrillation • Manual defibrillator – NOT AED • Safe to charge while chest compressions continue • Recommence/start CPR immediately after shock, irrespective of apparent electrical success • Monophasic = 360 joules for all shocks • Biphasic = 200 joules for all shocks Australasia EMed

  11. Non-shockable rhythm • Defibrillation not indicated – dump charge and assess for signs of life • if no signs of life continue CPR • Adrenaline 1 mg immediately, then every 2nd cycle • Emphasis on CPR & ALS interventions i.e. IV access, advanced airway & drugs Australasia EMed

  12. Reversible causes – 4H’s and 4T’s • Hypoxaemia • Hypovolaemia • Hyper/hypokalaemia & metabolic disorders • Hypo/hyperthermia • Tension pneumothorax • Tamponade • Toxins/poisons/drugs • Thrombosis-pulmonary/coronary Australasia EMed

  13. Single shock and precordial thump protocol • Single shock strategy (no stacked shocks) • Precordial thump is no longer recommended for VF • May be considered in monitored, pulseless patient in VT if a defib is not immediately available Australasia EMed

  14. Medications in Cardiac Arrest No medication has been shown to improve long-term outcomes after cardiac arrest. • 1st preference :IV administration Must flush with 20ml-30 mls fluid & compressions • 2nd preference :Intra-osseous • 3rd preference :Endotracheal • De emphasising the ET route Give at the time of recommencing CPR Australasia EMed

  15. Medications in Cardiac Arrest • Adrenaline • Non-shockable rhythm – immediately then every 2nd cycle • Shockable – after 2nd shock then every alternate cycle of CPR • Amiodarone – after 3rd cycle of CPR • Atropine – no longer used • Sodium bicarbonate – no longer regularly used • Fibrinolytics - adult patients with cardiac arrest proven or suspected pulmonary embolism Australasia EMed

  16. Monitoring during CPR – End Tidal CO2 • Wave form capnography confirms ETT placement • Quantitative measurement of end tidal CO2→ CO, early indicator for ROSC • Low values of end tidal CO2 assoc with low probability of survival • May be beneficial → feedback on effectiveness or quality of chest compressions Australasia EMed

  17. Post Resuscitation Care ABCDE Approach Optimise cerebral perfusion Prevent cardiac arrhythmias Manage 4H’s and 4T’s Australasia EMed

  18. Post Resuscitation Care • Airway • Breathing • Continue respiratory support • Aim for Sats 94-98% - avoid hyperoxaemia • Avoid hyperventilation • Circulation • Aim for SBP 100 mmHg Australasia EMed

  19. Post Resuscitation Care • Disability • Treat BSL >10 mmol/L • Avoid BSL <4 mmol/L • Angiography + PCI • If STEMI or new LBBB following ROSC Australasia EMed

  20. Therapeutic hypothermia – 32-34°C • Recommendation for routine use for comatose survivors of out of hospital cardiac arrest due to VF • Consideration for use in survivors of arrest of any rhythm for in and out of hospital cardiac arrest Australasia EMed

  21. Questions? Australasia EMed

  22. Summary • Changes to BLS and ALS make it easier to teach + in line with international research • BLS – good quality CPR • ALS – minimise interruptions to chest compressions • Adrenaline every alternate cycle • Monitoring during CPR with End Tidal CO2 • Quality Post Resuscitation Care Australasia EMed

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