Advanced Cardiac Life Support (ACLS) MUDr. L. Dadák ARK, FN u sv. Anny Introduction ● The most common cause of death is a heart attack. ● A disturbance in the electrical rhythm of the heart called ventricular fibrillation. ● Because up to 80% of all cardiac arrests occur in the home, you are most likely to perform CPR on a family member or loved one. Obr: AIM front wall + septum What is CPR? Combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest. lBasic Life Support = Základní neodkladná resuscitace lAdvanced Cardiac Life Support = Rozšířená neodkladná resuscitace ! http://circ.ahajournals.org/ 1. Rescuers should phone ER for unresponsive adults before beginning CPR. Exceptions: Provide CPR first for adult victims of submersion, trauma and drug intoxication. 2. Rescuers should provide about one minute of CPR for infants and children up to age 8 before calling ER. 4. Lay rescuers will no longer be taught a pulse check. The signal for lay rescuers to begin chest compressions is the absence of signs of circulation (normal breathing, coughing or movement) in response to the two rescue breaths. 5. The compression rate for adult CPR is increased to about 100 per minute. 6. The compression-to-ventilation ratio for CPR for victims age 1 or older is 30 compressions to 2 breaths for one or two rescuers. 7. Chest-compression-only CPR is recommended ONLY when the rescuer is unwilling or unable to perform mouth-to-mouth rescue breathing. Efectiveness of ACLS ● 1/3 Cardiac Output ● O2 for metabolic need of brain Evaluation of CPR ● resumption of circulation ● Successful CPR - sociologic aspect - return to taxpayer Basic Life Support 2005 DR ABC ● Danger ● Response ● Airway ● Circulation ● Breathing BLS /basic life support/ A - airway B - breathing C - circulation ACLS /advanced cardiac life support/ D - drugs and fluids E - ECG F - fibrilation treatment Advanced Cardiac Life Support = BLS + ● A+ B: ● Oxygen ● Intubation ● Positive Pressure Ventilation ● C: ● Vein access, drugs, fluids ● Therapy of fibrilation Danger Danger ● Location: car, fire, gas, ... ● Biologic – bld of victim Response – Evaluation of consciousness ● Shake & Shout !! shoulder !! ● unconsciousness = no reaction to word, pain, dilatated pupils If correct ABC: ● pupils ● symetrie? ● mydriasis ● miosis ● reaction to light ● movements of eyes ● Meningeal symptoms Evaluation of breathing: ● movement of chest ● expirated gas - free airway ● frequency Skin color: ● pink ● cyanotic Signs of airway obstruction Breathing ● haed titl ● inspiration 1s. insp. exp. ratio 1:1 ● frequency 10/min. ● Vt 600 ml ● ? movement of chest, expiration Most common errors: l delays in diagnosing respiratory or cardiac arrest l failure to establish a patent airway l delays in instituting BLS promptly; l inadequate ventilation (eg, poor seal around mouth or nose, failure to deliver the initial two full breaths, or inadequate amount of expired-air pressure generated to cause chest movements) Airway Problem = obstruction ● relaxed tongue and neck muscles in an unconscious person ● forein body Solution: ● head tilt-chin lift ● airway ● laryngeal mask ● combitube ● intubation ● coniotomy Esmarch: ● Head tilt ● Chin lift ● Mouth open Airway LM Combitube Intubation ● Laryngoskope ● Magill pincers ● tracheal tubes ● Introducer ● syringe ● broncho- fibroskoscope Intubation: direct laryngoscopy - view: tonque epiglotis vocal cords recessus piriformis plica aryepigottica tuberculum corniculatum zadní komisura Coniotomy ● urgent preservation of airways ● lig. cricothyreoideum (lig. conicum) B – breathing ACLS positive pressure ventilation ● bug („ambu“), holding mask by 1 or 2 hands ● (ventilator – Volume Control Ventilation) ● 6 ml/kg; 10/min, fiO2 100% ● ACLS 2 breaths ● inspiration 1sratio – 2 : 30 - ventilated by mask no ratio = 10 : 100 – advanced airway ● Oxygen ● as high FiO2 as possible ● Hypoxia and acidosis contra efectivness of elektric and farmakologic therapy Top-less CPR ● opening of airway and chest compressions without breathing to casualty ● risk of infection Circulation ● pulsations on central arteries (a.carotis; a.femoralis) ● NEVER - periferal – wrist art. ● NEVER – (heart rate) ● NEVER – blood pressure ● NEVER - (capilary refill ) Chest compressions ● Rescuer should stand or kneel next to victim's side. ● Find the tip of the breastbone = xyphoid process ● 2 fingers up to danger spot ● Place heel of 1 hand on lower sternum and other hand on top of hand ● Apply pressure only with heel of hand straight down on sternum with arms straight and elbows locked into position so entire weight of upper body is used to apply force. ● During relaxation all pressure is removed but hands should not lose contact with chest wall. ● Sternum must be depressed 5 cm in average adult (palpable pulse when SBP >50 mm Hg) ● Duration of compression should equal that of relaxation. ● Compression rate should be 100/min. Adequacy of chest compressions ● is judged by palpation of carotid or femoral pulse (palpable pulse primarily reflects Systolic Blood Pressure). C – circulation Signs of circulation = pulsations ● a. carotis communis ● a. femoralis children ● a. brachialis Theory of heard pump x Theory of thoracic pump Ratio 2005 compressions : breaths ● adult nonintubated 30 : 2 ● adult intubated 100:10 ● child + medical pers. 15:2 ● newborn 3:1 Drugs - administration Intravenously – periferal cath. - v. jugul. externa - v. femoralis - central v. cath. - v. subclavia - v. jugul. interna ● Add 20ml i.v of fluids to move the drug. ● Effect in 1 min Drugs administration 2. Endotrachealy – ONLY 4: ● adrenalin ● atropin ● naloxon ● lidokain 3. (Intraoseal access - children) Epinephrine = Adrenalin Alfa effect = raise diastolic pressure - raise brain, heart perfusion pressure Beta effect - raise contractility - change of type of fibrillation D: 1 mg i.v. a 3 min 2 mg E.T. a 3 min Vasopressin Vasoconstriction, direct stimulation of V1 receptor smooth muscle = elevation of TK without β aktivity – no effect on consumption of O2 in heart „long“ halftime - 20 min. I: alternativly to Adrenalin (VF, PEA, asystolia) D: 40 j (1x) Amiodarone (CORDARONE) ● antiarytmic drug I: ● recurent VF D: ● 5mg/kg (150mg iv.) Fluids ● Bolus of 20ml after each dose = movement of drug ● Acute bleeding – rubt. AAA, EUG; Types: ● Crystaloids – Ringer, Hartman, physiol. sol. ● Coloids – Gelatina, HAES = stark ● Glc – do NOT use – wrong neurology result Asystole ..... Check me in another lead, then let's have a cup of TEA." ● {T = Transcutaneous Pacing} ● E = Epinephrine ● A = Atropine Pulseless electrical activity are guided by the letters P-E-A ● Problem (H, T) ● Epinephrine ● Atropine VENTRICULAR Fibrillation Ventricular fibrillation ● electrical instability of heart muscle (ischemia, hypothermia) sings: ● pulselessness Th: defibrillation, adrenalin, vasopressin amiodarone Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better ● (Please = precordial thrump) ● Shock 200J bifasic / 360J mono ● EVerybody = Epinephrine / Vasopressin ● And = Amiodarone ● Let's = Lidocaine ● Make = Magnesium ● Patients = Procainamide ● Better = Bicarbonate Defibrillation ● Defibrillation sends a high energy DC electric shock through the heart, stopping it momentarily. The sinoatrial node should then take over and a coordinated rhythm restart. However, ventricular fibrillation often recurs so multiple shocks are used routinely. Position of electrodes: Energy: Joule (Watt × sec.) heard - ONLY 4%/ monophasic shock 360 J biphasic shock 200 J internal shock 25 - 35 J Biphasic versus monophasic ● Monophasic defibrillation delivers a charge in only one direction. ● Biphasic defibrillation delivers a charge in one direction for half of the shock and in the electrically opposite direction for the second half. Defibrillation Voltage 1,5 – 3 kV Current 30 – 40 A Time 1 ms Impedance of Th 70 – 80 ohms ● Skin burns ● "stand clear" order After recovery of circulation ● Stabilisation of vital functions (circulation, ventilation, AB) ● Diagnosis and treatment of reason of cardiac arrest ● Hypotermia 32 – 34 °C for 12 – 24 h (better neurological outcome) When to start? Not to start? ● end stage disease, no prognosis ● trauma with no hope for life (decapitation) ● signs (indication) of death (patch, Tonelli sign) ● time factor (15 – 30 minutes from stop of circulation to your arrival), temperature, age. When stop CPR: ● restored vital functions ● doctor takes care of victim ● no power to continue with CPR