Chain of survival Advanced Life Support Guidelines 2015 (ACLS) MUDr. L. Dadák ARK, FN u sv. Anny Success in CPR / crisis technical skills: – – – – –  non-technical skills  Success in CPR / crisis technical skills: – algorithm = plan – airway management – compressions – drugs (O2, Epi, amiodaron..) – care after ROSC  non-technical skills – communication  Stress additional effect Communication "To say" doesn't mean "to hear". "To hear" does not mean „to understand“. „To understand“ does not mean "to do" P. give epinephrine! … Epinephrine is given. © ACLS ERC Action linked phrases  No consciousness No puls  VF  Shock delivered  asystoly/PEA  ROSC  bring the resuscitation cart! start compressions! charge defibrilator! start compressions! start compressions! BP+12 EKG... Hunt E.A.,et al. A novel approach to life support training using “actionlinked phrases”, Resuscitation, Vol.86, January 2015, 1-5; https://doi.org/10.1016/j.resuscitation.2014.10.007 Debriefing Thanks  Emotions  Questions  +Δ Feedback for the future Success in CPR / crisis technical skills: – algorithm = plan – airway management – compressions – drugs (O2, Epi, amiodaron..) – care after ROSC  non-technical skills – communication  Primary survay D R ' S A B C D E ACLS 2010 Primary survay (Primární vyšetření) Danger  Response '  Send for HELP  Airway  Breathing  Circulation  Disability  Exposure / everything else  ACLS 2010 Danger A+B+C in 10s? A+B+C in 10s? A+B+C in 10s? Alive ? Oxygen ● Monitoring (SpO2, EKG, BP) ● Vein ● Alive ? Oxygen ● Monitoring (SpO2, EKG, BP) ● Vein ● Success in CPR / crisis technical skills: – algorithm = plan – airway management – compressions – drugs (O2, Epi, amiodaron..) – care after ROSC  non-technical skills – communication  Compressions Compressions  count laudly 20 - 25 - 30 Compressions Change regularly 2010..2015 VF/ VT VENTRICULAR Fibrillation Ventricular fibrillation ● electrical instability of heart muscle (ischemia, hypothermia) sings: ● pulselessness Th: defibrillation, adrenalin, (vasopressin) Amiodarone after 3rd shock 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 – 300 - 360J 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 15 ms Impedance of Th 70 – 80 ohms ● ● Skin burns "stand clear" order Asystole ● isoelectric line Pulseless Electrical Activity (bezpulzová elektrická aktivita = elektromechanická disociace) ● 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." ● ● ● ((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 ● ● ● 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 LM Intubation ● ● ● ● ● Laryngoskope Magill pincers tracheal tubes Introducer syringe rarely: ● bronchoscope Oxygen ● ● 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 ● ● ● ● 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 ● ● 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 Monitoring during ACLS ● ● ● ● 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: ● ● ● restored vital functions asystole for “20” minutes new information – when not to start After recovery of circulation The moment of greatest vulnerability is the instant immediately after victory. Napoleon Bonaparte After recovery of circulation ● ● ● ● ● ● ABCDE + Stabilisation of vital functions Diagnosis and treatment of the reason of arrest Hypo? Normo thermia 32 – 36°C for 12 – 24 h (better neurological outcome) Potasium Intubation, Mandatory Ventilation, NasoGastric tube sedation, Convulsion therapy