Advanced Life Support - Guidelines 2015 (ACLS)

MUDr. L. Dadák ARK, FN u sv. Anny

Primary survay
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Danger Responce = Unresponsive Send for HELP A+B+C … in 10 seconds … start Chest compressions

2010

VF/ VT

VENTRICULAR Fibrillation

Ventricular fibrillation
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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
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(Please = precordial thrump) Shock 200J bifasic / 360J mono EVerybody = Epinephrine / Vasopressin And = Amiodarone Let's = Lidocaine Make = Magnesium Patients = Procainamide Better = Bicarbonate

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Defibrillation
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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 – 300 - 360J internal shock 25 - 35 J

Biphasic versus monophasic
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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 15 ms Impedance of Th 70 – 80 ohms
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Skin burns "stand clear" order

Asystole
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isoelectric line

Pulseless Electrical Activity
(bezpulzová elektrická aktivita = elektromechanická disociace)
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complex, line, complex

Asystole
The worst situation

• Diagnosis on ECG monitor – flat line • Airway management - hypoxia • Adrenalin 1 mg i.v. á 3 min. children 10 μg/kg

Asystole ..... Check me in another lead, then let's have a cup of TEA."
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((T = Transcutaneous Pacing)) ex 2005 E = Epinephrine ((A = Atropine)) ex 2010

Pulseless Electrical Activity
reasons:
• Hypovolemia • Hypoxia • H+ acidosis • Hyper/hypocalemia • Hypothermia

PEA - reasons:

• „Tablets“ (overdose) • Cardiac Tamponade • Tension pneumothorax • Trombosis of C.a. • Trombosis of a.pulm. (embolie)

Pulseless electrical activity are guided by the letters P-E-A
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Problem (H, T) Epinephrine (atropin) ex2010

Co je to?

Co je to?

Co je to?

Co je to?

Co je to?

Co je to?

Asystole ?? low amplitude VF ??

Asystole ?? low amplitude VF ??


if in doubt - asystoly

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 ● ratio – 2 : 30 - ventilated by mask “no ratio” = 10 : 100 – advanced airway

Advanced Airway
100% O2, flow 10lpm Supraglotic devices:

Capnography

http://vanessajunkin.files.wordpress.com/2013/06/waveform.jpg

Capnography

http://vanessajunkin.files.wordpress.com/2013/06/waveform.jpg

Capnography

EtCO2 <1.33 kPa (10 mmHg) after 20 min of CPR is associ-ated with a poor outcome

Oxygen
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as high FiO2 as possible – during compressions Hypoxia and acidosis contra efficiency of electric and pharmacology therapy

Hyperoxemia after recovery of circulation is harmfull SpO2 .. 94%

Ratio 2005..2015
compressions : breaths adult nonintubated 30 : 2 adult intubated 100:10 child 30:2 - 2medical = team 15:2 newborn 3:1

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Drugs - administration
Intravenously – periferal cath. - v. jugul. externa - v. femoralis - central v. cath. - v. subclavia - v. jugul. interna Intraoseal access - children ● Add 20ml i.v of fluids to move the drug. ● Effect in 1 min

drugs of VF
• after 3 defibrilation: • Adrenalin 1 mg i.v. á 3 min. children 10 μg/kg • Antiarhythmics: Amiodaron 5 mg/kg 300 mg i.v.
rd

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

Fluids
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Bolus of 20ml after each dose = movement of drug Acute bleeding – rubt. AAA, EUG;

Types:
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Crystaloids – Ringer, Hartman, physiol. sol. Coloids – Gelatina, HAES = stark Glc – do NOT use – wrong neurology result

Monitoring during ACLS
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Clinical signs: breathing efforts, movements and eye open-ing ECG: Pulse checks when there is an ECG rhythm compatible with an output can be used to identify ROSC, but may not detect pulses in those with low cardiac output states and a low blood pressure Capnometry

When stop CPR:
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restored vital functions asystole for “20” minutes new information – when not to start

After recovery of circulation
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ABCDE + Stabilisation of vital functions Diagnosis and treatment of the reason of arrest Hypothermia 32 – 36°C for 12 – 24 h (better neurological outcome) Potasium Intubation, Mandatory Ventilation, NasoGastric tube sedation, Convulsion