Advanced Cardiac Life SupportAdvanced Cardiac Life Support (ACLS)(ACLS) MUDr. L. DadákMUDr. L. Dadák ARK, FN u sv. AnnyARK, FN u sv. Anny http://www.med.muni.cz/~ldadak/iiihttp://www.med.muni.cz/~ldadak/iii IntroductionIntroduction The most common cause of death is a heart attack.The most common cause of death is a heart attack. A disturbance in the electrical rhythm of the heartA disturbance in the electrical rhythm of the heart called ventricular fibrillation.called ventricular fibrillation. Because up to 80% of all cardiac arrests occur inBecause up to 80% of all cardiac arrests occur in the home, you are most likely to perform CPR on athe home, you are most likely to perform CPR on a family member or loved one.family member or loved one. Obr: AIM front wall + septumObr: AIM front wall + septum What is CPR?What is CPR? Combination of rescue breathing and chestCombination of rescue breathing and chest compressions delivered to victims thought to be incompressions delivered to victims thought to be in cardiac arrest.cardiac arrest. Basic Life Support = Základní neodkladnáBasic Life Support = Základní neodkladná resuscitaceresuscitace Advanced Cardiac Life Support = RozšířenáAdvanced Cardiac Life Support = Rozšířená neodkladná resuscitaceneodkladná resuscitace http://circ.ahajournals.org/http://circ.ahajournals.org/ 1. Rescuers should phone ER for unresponsive adults before beginning CPR.1. Rescuers should phone ER for unresponsive adults before beginning CPR. Exceptions: Provide CPR first for adult victims of submersion, trauma and drugExceptions: Provide CPR first for adult victims of submersion, trauma and drug intoxication.intoxication. 2. Rescuers should provide about one minute of CPR for infants and children up to2. Rescuers should provide about one minute of CPR for infants and children up to age 8 before calling ER.age 8 before calling ER. 4. Lay rescuers will no longer be taught a pulse check. The signal for lay rescuers to4. 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,begin chest compressions is the absence of signs of circulation (normal breathing, coughing or movement) in response to the two rescue breaths.coughing or movement) in response to the two rescue breaths. 5. The compression rate for adult CPR is increased to about5. The compression rate for adult CPR is increased to about 100100 per minute.per minute. 6. The compression-to-ventilation ratio for CPR for victims age 1 or older is6. The compression-to-ventilation ratio for CPR for victims age 1 or older is 3030 compressions to 2 breathscompressions to 2 breaths for one or two rescuers.for one or two rescuers. 7. Chest-compression-only CPR is recommended ONLY when the rescuer is7. Chest-compression-only CPR is recommended ONLY when the rescuer is unwilling or unable to perform mouth-to-mouth rescue breathing.unwilling or unable to perform mouth-to-mouth rescue breathing. Efectiveness of ACLSEfectiveness of ACLS 1/3 Cardiac Output1/3 Cardiac Output O2 for metabolic need of brainO2 for metabolic need of brain Evaluation of CPREvaluation of CPR resumption of circulationresumption of circulation Successful CPR -Successful CPR - sociologic aspect -sociologic aspect return to taxpayerreturn to taxpayer Basic Life Support 2005Basic Life Support 2005 DR ABCDR ABC DangerDanger ResponseResponse AirwayAirway CirculationCirculation BreathingBreathing BLS /basic life support/BLS /basic life support/ A - airwayA - airway B - breathingB - breathing C - circulationC - circulation ACLS /advanced cardiac life support/ACLS /advanced cardiac life support/ D - drugs and fluidsD - drugs and fluids E - ECGE - ECG F - fibrilation treatmentF - fibrilation treatment AAdvanceddvanced CCardiacardiac LLifeife SSupportupport = BLS += BLS + A+ B:A+ B: OxygenOxygen IntubationIntubation Positive Pressure VentilationPositive Pressure Ventilation C:C: Vein access, drugs, fluidsVein access, drugs, fluids Therapy of fibrilationTherapy of fibrilation DangerDanger DangerDanger Location:Location: car, fire, gas, ...car, fire, gas, ... Biologic ­ bld of victimBiologic ­ bld of victim Response ­ Evaluation of consciousnessResponse ­ Evaluation of consciousness Shake & ShoutShake & Shout !! shoulder !!!! shoulder !! unconsciousness = no reaction to word, pain,unconsciousness = no reaction to word, pain, dilatated pupilsdilatated pupils If correct ABC:If correct ABC: pupilspupils symetrie?symetrie? mydriasismydriasis miosismiosis reaction to lightreaction to light movements of eyesmovements of eyes Meningeal symptomsMeningeal symptoms Evaluation of breathing:Evaluation of breathing: movement of chestmovement of chest expirated gasexpirated gas - free airway- free airway frequencyfrequency Skin color:Skin color: pinkpink cyanoticcyanotic Signs of airway obstructionSigns of airway obstruction BreathingBreathing haed titlhaed titl inspiration 1s.inspiration 1s. insp. exp. ratio 1:1insp. exp. ratio 1:1 frequency 10/min.frequency 10/min. Vt 600 mlVt 600 ml ? movement of chest, expiration? movement of chest, expiration Most common errorsMost common errors:: delays in diagnosing respiratory or cardiac arrestdelays in diagnosing respiratory or cardiac arrest failure to establish a patent airwayfailure to establish a patent airway delays in instituting BLS promptly;delays in instituting BLS promptly; inadequate ventilation (eg, poor seal around mouth orinadequate ventilation (eg, poor seal around mouth or nose, failure to deliver the initial two full breaths, ornose, failure to deliver the initial two full breaths, or inadequate amount of expired-air pressure generatedinadequate amount of expired-air pressure generated to cause chest movements)to cause chest movements) AirwayAirway Problem = obstructionProblem = obstruction relaxed tongue and neck muscles in an unconsciousrelaxed tongue and neck muscles in an unconscious personperson forein bodyforein body Solution:Solution: head tilt-chin lifthead tilt-chin lift airwayairway laryngeal masklaryngeal mask combitubecombitube intubationintubation coniotomyconiotomy Esmarch:Esmarch: Head tiltHead tilt Chin liftChin lift MouthMouth oopenpen AirwayAirway LMLM CombitubeCombitube IntubationIntubation LaryngoskopeLaryngoskope Magill pincersMagill pincers tracheal tubestracheal tubes IntroducerIntroducer syringesyringe broncho-broncho- fibroskoscopefibroskoscope Intubation:Intubation: * prepare instruments (ventilate) * position of patient * (anestezie / unconsciousness) * direct laryngoscopy * introduce Tr tube * fill baloon * check possition * fix tube direct laryngoscopy - view:direct laryngoscopy - view: tonquetonque epiglotisepiglotis vocal cordsvocal cords recessus piriformisrecessus piriformis plica aryepigotticaplica aryepigottica tuberculum corniculatumtuberculum corniculatum zadní komisurazadní komisura ConiotomyConiotomy urgent preservation ofurgent preservation of airwaysairways lig. cricothyreoideumlig. cricothyreoideum (lig. conicum)(lig. conicum) B ­ breathingB ­ breathing ACLSACLS positive pressure ventilationpositive pressure ventilation bug (,,ambu"), holding mask by 1 or 2 handsbug (,,ambu"), holding mask by 1 or 2 hands (ventilator ­ Volume Control Ventilation)(ventilator ­ Volume Control Ventilation) 6 ml/kg; 10/min, fiO2 100%6 ml/kg; 10/min, fiO2 100% ACLS 2 breathsACLS 2 breaths inspiration 1sratio ­ 2 : 30 - ventilated by maskinspiration 1sratio ­ 2 : 30 - ventilated by mask no ratio = 10 : 100 ­ advanced airwayno ratio = 10 : 100 ­ advanced airway OxygenOxygen as high FiO2 as possibleas high FiO2 as possible Hypoxia and acidosis contra efectivness of elektricHypoxia and acidosis contra efectivness of elektric and farmakologic therapyand farmakologic therapy Top-less CPRTop-less CPR opening of airway and chest compressions withoutopening of airway and chest compressions without breathing to casualtybreathing to casualty risk of infectionrisk of infection CirculationCirculation pulsations on central arteriespulsations on central arteries (a.carotis; a.femoralis)(a.carotis; a.femoralis) NEVER - periferal ­ wrist art.NEVER - periferal ­ wrist art. NEVER ­ (heart rate)NEVER ­ (heart rate) NEVER ­ blood pressureNEVER ­ blood pressure NEVER - (capilary refill )NEVER - (capilary refill ) Chest compressionsChest compressions Rescuer should stand or kneel next to victim's side.Rescuer should stand or kneel next to victim's side. Find the tip of the breastbone = xyphoid processFind the tip of the breastbone = xyphoid process 2 fingers up to danger spot2 fingers up to danger spot Place heel of 1 hand on lower sternum and other hand on top of handPlace 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 withApply pressure only with heel of hand straight down on sternum with arms straight and elbows locked into position so entire weight of upperarms straight and elbows locked into position so entire weight of upper body is used to apply force.body is used to apply force. During relaxation all pressure is removed but hands should not loseDuring relaxation all pressure is removed but hands should not lose contact with chest wall.contact with chest wall. Sternum must be depressed 5 cm in average adult (palpable pulseSternum must be depressed 5 cm in average adult (palpable pulse when SBP >50 mm Hg)when SBP >50 mm Hg) Duration of compression should equal that of relaxation.Duration of compression should equal that of relaxation. Compression rate should be 100/min.Compression rate should be 100/min. Adequacy of chest compressionsAdequacy of chest compressions is judged by palpation of carotid or femoral pulseis judged by palpation of carotid or femoral pulse (palpable pulse primarily reflects Systolic Blood(palpable pulse primarily reflects Systolic Blood Pressure).Pressure). C ­ circulationC ­ circulation Signs of circulation = pulsationsSigns of circulation = pulsations a. carotis communisa. carotis communis a. femoralisa. femoralis childrenchildren a. brachialisa. brachialis Theory of heard pump x Theory ofTheory of heard pump x Theory of thoracic pumpthoracic pump Ratio 2005Ratio 2005 compressions : breathscompressions : breaths adult nonintubatedadult nonintubated 30 : 230 : 2 adult intubatedadult intubated 100:10100:10 child + medical pers.child + medical pers. 15:215:2 newbornnewborn 3:13:1 Drugs - administrationDrugs - administration Intravenously ­ periferal cath.Intravenously ­ periferal cath. - v. jugul. externa- v. jugul. externa - v. femoralis- v. femoralis - central v. cath. - v. subclavia- central v. cath. - v. subclavia - v. jugul. interna- v. jugul. interna Add 20ml i.v of fluids to move the drug.Add 20ml i.v of fluids to move the drug. Effect in 1 minEffect in 1 min Drugs administrationDrugs administration 2. Endotrachealy ­ ONLY 4:2. Endotrachealy ­ ONLY 4: adrenalinadrenalin atropinatropin naloxonnaloxon lidokainlidokain 3. (Intraoseal access - children)3. (Intraoseal access - children) * 2 ­ 2,5 x higher dose than i.v. * Volume (10 ml FR) Epinephrine = AdrenalinEpinephrine = Adrenalin Alfa effect =Alfa effect = raise diastolic pressureraise diastolic pressure - raise brain, heart perfusion pressure- raise brain, heart perfusion pressure Beta effect - raise contractilityBeta effect - raise contractility - change of type of fibrillation- change of type of fibrillation D:D: 1 mg i.v. a 3 min1 mg i.v. a 3 min 2 mg E.T. a 3 min2 mg E.T. a 3 min VasopressinVasopressin Vasoconstriction, direct stimulation of V1 receptorVasoconstriction, direct stimulation of V1 receptor smooth muscle = elevation of TKsmooth muscle = elevation of TK without aktivity ­ no effect on consumption of O2 inwithout aktivity ­ no effect on consumption of O2 in heartheart ,,,,long" halftime - 20 min.long" halftime - 20 min. I: alternativly to Adrenalin (VF, PEA, asystolia)I: alternativly to Adrenalin (VF, PEA, asystolia) D: 40 j (1x)D: 40 j (1x) ˇ I: - sinus bradycardia - a-v block - asystolia * D: to 4 mg i.v. ,,D" Atropin Amiodarone (CORDARONE)Amiodarone (CORDARONE) antiarytmic drugantiarytmic drug I:I: recurent VFrecurent VF D:D: 5mg/kg (150mg iv.)5mg/kg (150mg iv.) ˇ local anaesthetic * I: - VES - VT - reccurent VF after defibrillation D: bolus 1mg/kg max. 3 mg/kg ,,D" Lidokain FluidsFluids Bolus of 20ml after each dose = movement of drugBolus of 20ml after each dose = movement of drug Acute bleeding ­ rubt. AAA, EUG;Acute bleeding ­ rubt. AAA, EUG; Types:Types: Crystaloids ­ Ringer, Hartman, physiol. sol.Crystaloids ­ Ringer, Hartman, physiol. sol. Coloids ­ Gelatina, HAES = starkColoids ­ Gelatina, HAES = stark Glc ­ do NOT use ­ wrong neurology resultGlc ­ do NOT use ­ wrong neurology result Copyright 2005 American Heart Association ILCOR Universal Cardiac Arrest Algorithm (AHA) ˇ Diagnosis on ECG monitor ­ flat line * 2 breaths, chest compressions, ... * Intubation, i.v. * Adrenalin 1 mg i.v. á 3 min. children 10 g/kg * Atropin up to 4 mg i.v. (0,04 mg/kg) * check for electrical activity and pulsations Asystolia The worst situation Asystole ..... Check me in another lead,Asystole ..... Check me in another lead, then leťs have a cup of TEA."then leťs have a cup of TEA." {T = Transcutaneous Pacing}{T = Transcutaneous Pacing} E = EpinephrineE = Epinephrine A = AtropineA = Atropine ˇ Hypovolemia * Hypoxia * H acidosis * Hyper/hypocalemia * Hypothermia + Pulseless Electrical Activity reasons: PEA - reasons: * ,,Tablets" (overdose) * Cardiac Tamponade * Tension pneumothorax * Trombosis of C.a. * Trombosis of a.pulm. (embolie) Pulseless electrical activity are guided by thePulseless electrical activity are guided by the letters P-E-Aletters P-E-A Problem (H, T)Problem (H, T) EpinephrineEpinephrine AtropineAtropine VENTRICULAR FibrillationVENTRICULAR Fibrillation Ventricular fibrillationVentricular fibrillation electrical instability of heart muscleelectrical instability of heart muscle (ischemia, hypothermia)(ischemia, hypothermia) sings:sings: pulselessnesspulselessness Th: defibrillation,Th: defibrillation, adrenalin, vasopressinadrenalin, vasopressin amiodaroneamiodarone Please Shock-Shock-Shock, EVerybodyPlease Shock-Shock-Shock, EVerybody Shock,Shock, And Leťs Make Patients BetterAnd Leťs Make Patients Better (Please = precordial thrump)(Please = precordial thrump) Shock 200J bifasic / 360J monoShock 200J bifasic / 360J mono EVerybody = Epinephrine / VasopressinEVerybody = Epinephrine / Vasopressin And = AmiodaroneAnd = Amiodarone Leťs = LidocaineLeťs = Lidocaine Make = MagnesiumMake = Magnesium Patients = ProcainamidePatients = Procainamide Better = BicarbonateBetter = Bicarbonate ˇ Adrenalin 1 mg i.v. á 1 min. children 10 g/kg (Vazopresin 40 j (1x)) * Antiarhythmics: Lidokain 1,5 mg/kg Amiodaron 5 mg/kg 300 mg slowly i.v. VF DefibrillationDefibrillation Defibrillation sends a high energy DC electric shockDefibrillation sends a high energy DC electric shock through the heart, stopping it momentarily. Thethrough the heart, stopping it momentarily. The sinoatrial node should then take over and a coordinatedsinoatrial node should then take over and a coordinated rhythm restart. However, ventricular fibrillation oftenrhythm restart. However, ventricular fibrillation often recurs so multiple shocks are used routinely.recurs so multiple shocks are used routinely. Position of electrodes:Position of electrodes: Energy:Energy: Joule (Watt × sec.)Joule (Watt × sec.) heardheard - ONLY 4%/- ONLY 4%/ monophasic shockmonophasic shock 360 J360 J biphasic shockbiphasic shock 200 J200 J internal shockinternal shock 25 - 35 J25 - 35 J Biphasic versus monophasicBiphasic versus monophasic MonophasicMonophasic defibrillation delivers adefibrillation delivers a charge in only onecharge in only one direction.direction. Biphasic defibrillationBiphasic defibrillation delivers a charge in onedelivers a charge in one direction for half of thedirection for half of the shock and in theshock and in the electrically oppositeelectrically opposite direction for the seconddirection for the second half.half. DefibrillationDefibrillation VoltageVoltage 1,5 ­ 3 kV1,5 ­ 3 kV CurrentCurrent 30 ­ 40 A30 ­ 40 A Time 1 msTime 1 ms Impedance of Th 70 ­ 80 ohmsImpedance of Th 70 ­ 80 ohms Skin burnsSkin burns "stand clear" order"stand clear" order After recovery of circulationAfter recovery of circulation Stabilisation of vital functions (circulation,Stabilisation of vital functions (circulation, ventilation, AB)ventilation, AB) Diagnosis and treatment of reason of cardiac arrestDiagnosis and treatment of reason of cardiac arrest Hypotermia 32 ­ 34 °C for 12 ­ 24 hHypotermia 32 ­ 34 °C for 12 ­ 24 h (better neurological outcome)(better neurological outcome) WhenWhen to start?to start? Not to start?Not to start? end stage disease, no prognosisend stage disease, no prognosis trauma with no hope for life (decapitation)trauma with no hope for life (decapitation) signs (indication) of death (patch, Tonelli sign)signs (indication) of death (patch, Tonelli sign) time factor (15 ­ 30 minutes from stop of circulation totime factor (15 ­ 30 minutes from stop of circulation to your arrival), temperature, age.your arrival), temperature, age. When stop CPR:When stop CPR: restored vital functionsrestored vital functions doctor takes care of victimdoctor takes care of victim no power to continue with CPRno power to continue with CPR