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Advanced Cardiac Life Support

Advanced Cardiac Life Support. N.Tavakoli Assistant professor Department of Emergency Medicine Iran University of Medical Sciences. Chain of Survival. Early ACCESS. Early CPR. Early DEFIB. Early ACLS. Drug Administration Route. Peripheral Venous Central Venous Endotracheal

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Advanced Cardiac Life Support

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  1. Advanced Cardiac Life Support N.Tavakoli Assistant professor Department of Emergency Medicine Iran University of Medical Sciences

  2. Chain of Survival EarlyACCESS EarlyCPR EarlyDEFIB EarlyACLS

  3. Drug Administration Route • Peripheral Venous • Central Venous • Endotracheal • Intraosseous • Intra cardiac

  4. Central IV access • More rapid drug delivery • Ability to perform invasive monitoring • More time consuming • More experience • Risk of complication is greater • Internal jugular or supraclavicular are preferred

  5. Peripheral IV access • Antecubital or external Jugular are the first choice • Administer drugs -By rapid bolus followed 20cc of IV fluid -Elevation of the extremity

  6. ُEndotracheal Route • ‘’L –E – A –N’’ can be given via tracheal tube .Lidocaine, Atropine, Epinephrine, Naloxan • 2-2.5 times the recommended dosage • Should be diluted in 10 cc N/S • Temporarily holding chest compression • Injecting drug through a cannula while delivering several deep breath

  7. Intra cardiac Route • Only when other routes are not readily available • During Open- chest CPR • Heart can be directly visualized

  8. Pharmacologic Agentsin ACLSfor shock-refractory VT/VF • Epinephrine • 1 mg intravenously every 3 -5 minutes • a higher dose (0.2 mg/kg) is acceptable, but not recommended,

  9. Epinephrine • Indications (When & Why?) • Increases: • Heart rate • Force of contraction • Conduction velocity • Peripheral vasoconstriction • Bronchial dilation VF / Pulseless VT

  10. Epinephrine • Dosing (How?) • 1 mg IV push; may repeat every 3 to 5 minutes • May use higher doses (0.2 mg/kg) if lower dose is not effective • Endotracheal Route • 2.0 to 2.5 mg diluted in10 mL normal saline VF / Pulseless VT

  11. Epinephrine • Dosing (How?) • Alternative regimens for second dose (Class IIb) • Intermediate: 2 to 5 mg IV push, every 3 to 5 minutes • Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart • High: 0.1 mg/kg IV push, every 3 to 5 minutes VF / Pulseless VT

  12. Epinephrine • Precautions (Watch Out!) • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand • Do not mix or give with alkaline solutions • Higher doses have not improved outcome & may cause myocardial dysfunction VF / Pulseless VT

  13. Vasopressin • Indications (When & Why?) • Used to “clamp” down on vessels • Improves perfusion of heart, lungs, and brain • No direct effects on heart VF / Pulseless VT

  14. Vasopressin • Dosing (How?) • One time dose of 40 units only • May be substituted for epinephrine • Not repeated at any time • May be given down the endotracheal tube • DO NOT double the dose • Dilute in 10 mL of NS VF / Pulseless VT

  15. Vasopressin • Precautions (Watch Out!) • May result in an initial increase in blood pressure immediately following return of pulse • May provoke cardiac ischemia VF / Pulseless VT

  16. Atropine Sulfate • Indications (When & Why?) • Should only be used for bradycardia • Relative or Absolute • Used to increase heart rate Pulseless Electrical Activity

  17. Atropine Sulfate • Dosing (How?) • 1 mg IV push • Repeat every 3 to 5 minutes • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS • Maximum Dose: 0.04 mg/kg Pulseless Electrical Activity

  18. Atropine Sulfate • Precautions (Watch Out!) • Increases myocardial oxygen demand • May result in unwanted tachycardia or dysrhythmia Pulseless Electrical Activity

  19. Amiodarone • Indications (When & Why?) • Powerful antiarrhythmic with substantial toxicity, especially in the long term • Intravenous and oral behavior are quite different • Has effects on sodium & potassium VF / Pulseless VT

  20. Amiodarone • Dosing (How?) • Should be diluted in 20 to 30 mL of D5W • 300 mg bolus after first Epinephrine dose • Repeat doses at 150 mg VF / Pulseless VT

  21. Amiodarone • Precautions (Watch Out!) • May produce vasodilation & shock • May have negative inotropic effects • Terminal elimination • Half-life lasts up to 40 days VF / Pulseless VT

  22. Lidocaine • Indications (When & Why?) • Depresses automaticity • Depresses excitability • Raises ventricular fibrillation threshold • Decreases ventricular irritability VF / Pulseless VT

  23. Lidocaine • Dosing (How?) • Initial dose: 1.0 to 1.5 mg/kg IV • For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg • A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable • Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS VF / Pulseless VT

  24. Lidocaine • Dosing (How?) • Maintenance Infusion • 2 to 4 mg/min • 1000 mg / 250 mL D5W = 4 mg/mL • 15 mL/hr = 1 mg/min • 30 mL/hr = 2 mg/min • 45 mL/hr = 3 mg/min • 60 mL/hr = 4 mg/min VF / Pulseless VT

  25. Lidocaine • Precautions (Watch Out!) • Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction • Discontinue infusion immediately if signs of toxicity develop VF / Pulseless VT

  26. Magnesium Sulfate • Indications (When & Why?) • Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state • Refractory VF • VF with history of ETOH abuse • Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose VF / Pulseless VT

  27. Magnesium Sulfate • Dosing (How?) • 1 to 2 g  (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push VF / Pulseless VT

  28. Magnesium Sulfate • Precautions (Watch Out!) • Occasional fall in blood pressure with rapid administration • Use with caution if renal failure is present VF / Pulseless VT

  29. Procainamide • Indications (When & Why?) • Recurrent VF • Depresses automaticity • Depresses excitability • Raises ventricular fibrillation threshold • Decreases ventricular irritability VF / Pulseless VT

  30. Procainamide • Dosing (How?) • 30 mg/min IV infusion • May push at 50 mg/min in cardiac arrest • In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable • Maximum total dose: 17 mg/kg VF / Pulseless VT

  31. Procainamide • Dosing (How?) • Maintenance Infusion • 1 to 4 mg/min • 1000 mg / 250 mL of D5W = 4 mg/mL • 15 mL/hr = 1 mg/min • 30 mL/hr = 2 mg/min • 45 mL/hr = 3 mg/min • 60 mL/hr = 4 mg/min VF / Pulseless VT

  32. Procainamide • Precautions (Watch Out!) • If cardiac or renal dysfunctionis present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min • Remember Endpoints of Administration VF / Pulseless VT

  33. Vasopressin • an acceptable alternative, recommended • a single intravenous dose of 40 U is given once (half life is 10 - 20 min versus 3 - 5 min with epinephrine) • in a controlled trial of patients with out-of-hospital VF who received either vasopressin or epinephrine; those treated with vasopressin had higher rates of survival to hospital admission (70 vs 35 %, p = 0.06) and survival at 24 hours (60 vs 20 %, p = 0.02)

  34. Other Cardiac Arrest Drugs

  35. Calcium Chloride • Indications (When & Why?) • Known or suspected hyperkalemia (eg, renal failure) • Hypocalcemia (blood transfusions) • As an antidote for toxic effects of calcium channel blocker overdose • Prevent hypotension caused by calcium channel blockers administration Other Cardiac Arrest Drugs

  36. Calcium Chloride • Dosing (How?) • IV Slow Push • 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose • 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers Other Cardiac Arrest Drugs

  37. Calcium Chloride • Precautions (Watch Out!) • Do not use routinely in cardiac arrest • Do not mix with sodium bicarbonate Other Cardiac Arrest Drugs

  38. Sodium Bicarbonate • Indications (When & Why?) • Class I if known preexisting hyperkalemia • Class IIa if known preexisting bicarbonate-responsive acidosis • Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation • Class III  (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation) Other Cardiac Arrest Drugs

  39. Sodium Bicarbonate • Dosing (How?) • 1 mEq/kg IV bolus • Repeat half this dose every 10 minutes thereafter • If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration) Other Cardiac Arrest Drugs

  40. Sodium Bicarbonate • Precautions (Watch Out!) • Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest • Not recommended for routine use in cardiac arrest patients Other Cardiac Arrest Drugs

  41. Factors Influencing Survival • the rhythm associatedwith the arrest • whether the collapse was witnessed • adequacy of CPR • age /underlying health of the patient rate of hospital discharge (ages 90s 4.4% 80s 9.4% <80 19% )

  42. ACLS and arrhythmias

  43. Tachycardia sudden onset of rapid heart rate what do you do?

  44. Tachycardia ALWAYS CHECK THE PATIENT FIRST • Check for a pulse • Check the blood pressure • Make a diagnosis

  45. Tachycardia Case 1 On ward, sudden onset of palpitations • Does the patient have a pulse? Yes • What is the blood pressure? 60/20 Is the patient “stable” or “unstable”?

  46. Definition of “Unstable”presence of any one of: • Low blood pressure • Short of Breath • Chest pain • Lightheaded • CHF

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