ACLS Update – 2005 recommendations Management of Cardiac Arrest
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ACLS Update – 2005 recommendations Management of Cardiac Arrest ??? 2006.01.05
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Introduction Pulseless cardiac arrest: ventricular fibrillation (VF), rapid ventricular tachycardia (VT), pulseless electrical activity (PEA), Asystole Survival : basic life support (BLS) and advanced cardiovascular life support (ACLS). The foundation of ACLS : good BLS care, beginning with prompt high-quality bystander CPR for VF/pulseless VT, attempted defibrillation within minutes of collapse.
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For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.
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Access for Medications: Correct Priorities During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.
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Central Versus Peripheral Infusions Central line access is not needed in most resuscitation attempts. Peripheral IV, IO (class IIa) Endotracheal (liodcaine, epinephrine, atropine, naloxone, vasopressin): lower ROSC 2 – 2 ½ x dose Epinephrine 3 – 10 x dose Diluted to 5 – 10 ml
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ACLS Pulseless Arrest Algorithm
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia Witnessed arrest: 2 breaths ? defibrillator not witnessed: 5 cycles of CPR
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia 1 shock Biphasic 120 – 200 J Monophasic 360 J
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia 5 cycles (2 mins of CPR) after the 1st shock then rhythm checking
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia CPR – RHYTHM CHECK – CPR* -- SHOCK
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia Antiarrhythmic (e.g. amiodarone) after 2 to 3 shocks
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Ventricular Fibrillation/ Pulseless Ventricular Tachycardia
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Asystole and Pulseless Electrical Activity Identify and treat a reversible cause
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Asystole and Pulseless Electrical Activity NOT interrupt CPR
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Medications for Arrest Rhythms Epinephrine and Vasopressin Epinephrine 1 mg every 3 to 5 mins Vasopressin 40 U substituted for the first or second dose of epinephrine Atropine 1 mg IV every 3 to 5 mins if asystole persists
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Medications for Arrest Rhythms Amiodarone 300 mg IV/IO, can be followed by one dose of 150 mg IV/IO Lidocaine Lower rates of ROSC and higher incidence of asystole 1 to 1.5 mg/kg IV, additional 0.5 to 0.75 mg/kg IV at 5- to 10-min interval Magnesium Torsades de points (irregular/polymorphic VT associated with prolonged QT 1 to 2 g diluted in 10 mL D5W IV/IO push, 5 to 20 min
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Potentially Beneficial Therapies Fibrinolysis When pulmonary embolus is suspected
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Interventions Not Supported by Outcome Evidence Pacing in arrest Not recommended at this time Procainamide in VF & pulseless VT The use is supported by retrospective study Norepinephrine Equivalent to epinephrine in the initial resuscitation but associated with worse neurologic outcome
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Interventions Not Supported by Outcome Evidence Precordial thump Not recommended for BLS providers Class indeterminate for ACLU providers Electrolyte therapies Magnesium: Torsades de points Routine administration of IV fluids: insufficient evidence
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Summary Prevent pulseless: good ACLS begins with high-quality BLS During resuscitation rescuers must provide good chest compressions (adequate rate and depth), allow complete recoil of the chest between compressions, minimize interruptions in chest compressions. avoid provision of excessive ventilation Resuscitation drugs have not been shown to increase rate of survival to hospital discharge, and none has the impact of early and effective CPR and prompt defibrillation.
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For victims of witnessed VF arrest, prompt bystander CPR and earlyDuring cardiac arrest, basic CPR
For victims of witnessed VF arrest, prompt bystander CPR and earlyDuring cardiac arrest, basic CPR and early defibrillation are of primary importance, ...