ADVANCED CARDIAC LIFE SUPPORT

TUAN HAIRULNIZAM TUAN KAMAUZAMAN Emergency Physician/Senior lecturer Department of Emergency Medicine Universiti Sains Malaysia

OBJECTIVE OF COURSE
To acquire the knowledge of ACLS To acquire the skills of ACLS To encourage systematic and efficient teamwork in resuscitation To assess ACLS competency

Rhythm

BLS

Airway

ACLS
Algorithm

Electrical therapy

Drug

Teaching method
Scenario run-tru

Megacode practise

Megacode demo

Skill stations
Lecture

Assessment
Assessment Theory Practical Max mark awarded 50% 50%

Passing mark = 50%

ACLS ALGORITHM
TUAN HAIRULNIZAM TUAN KAMAUZAMAN Emergency Physician/Senior lecturer Department of Emergency Medicine Universiti Sains Malaysia

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ACLS DRUG THERAPY

General principle
Second priority to defib and good chest compression only in SECONDARY SURVEY All antiarrthmic is pro-arrthymic!! LIMIT TO ONE CHOICE OF DRUG ONLY All resus drug to be given tru least resistant IV access. Best given diluted with IV saline push.

Adrenaline
Class Sympatomimetic - on alpha and beta receptor Presentat Clear solution 1ml/vial 1:1000 conc 1 ion mg Usage Cardiac arrest (VT/VF/asystole/PEA), anaphylaxis, bronchospasm, local vasoconc. Dosage 10 ml/1mg/1:10000 conc every 3-5 mins in CA

Adrenaline - action
CVS Positive inotrop/chronotrop (1) Coronary vasodilate (2) Peripheral vasoconstrict (1) Bronchodilator (2) Decrease renal blood flow

Resp GU

Metabolic Blood sugar/FFA

Amiodarone
Class Anti-arrthymic- class III affects sodium, potassium, calcium channel and and receptor VF/pulseless VT not responding to shock, stable tachyarrthia 300 mg IV bolus in cardiac arrest followed by 150 mg bolus second dose; 150 mg IV over 10 mins in stable tachycardia followed by 1 mg/min BP, bradycardia, corneal microdeposits, pulm toxicity, photosensitivity

Usage Dosage

Adverse effect

Adenosine
Class Usage Purine neucloside antiarrthmic acts on adenosine receptor First line in stable narrow/wide complex tachy

Dose
Adverse effects Precautious

6mg -12mg-12mg IV fast bolus (rapid metabolism by red blood cells) followed by 20 cc flush
Transient bradycardia/asystole/complete heart block, bronchospasm, angina Asthma/COAD, theophyline

Sodium bicarbonate
Class Electrolyte imbalance agent/elementary substance

Usage
Dose

Severe metabolic acidosis, hyperkalaemia

1 mEq/kg slow IV

Adverse effects
Precautious

Metabolic alkalosis, hypernatraemia, pontine myelinosis, hypocalcaemia, hypokalaemia, paradoxical intracellular acidosis
Inactivate inotrpoe, reduce efficacy of defibrillation

Verapamil
Class Usage Dose Adverse effects Calcium channel blocker- Class IV antiarrthmic Narrow complex tachyC/I in wide complex tachy 2.5-5 mg IV slow bolus repeated every 15-30 mins to a total of 20 mg Dizziness, first/second degree heart block, heart failure

Precautious

Impaired vetricular function/ heart failure

Magnesium sulphate
Class Elementary substance

Usage
Dose

Hypomagnesemia, torsede de pointes

2g IV slow bolus in hypomagnesemia/torsedes de pointes

Adverse effects
Precautious

Hypermagnesemia, CNS depressant, smooth/skeletal muscle reduced contractility

Hypotension, breathing difficulties, heart block

Dopamine
Class Catecholamine, inotrope

Usage
Dose

Low cardiac output, shock

<5 g/kg/min: Dopamine-1 receptor 5-10 g/kg/min: -1 receptor >10 g/kg/min : receptor BW x 3 in 50 cc DS: x ml/hr = x mcg/kg/min Low dose: hypotension; high dose: ectopic beat, hypertension, angina

Adverse effects Precautious

Phaechromocytoma, extravesation = gangrene,

Thank you

POST RESUSCITATION CARE

DR TUAN HAIRULNIZAM TUAN KAMAUZAMAN Pakar / Pensyarah Kanan Jabatan Perubatan Kecemasan Universiti Sains Malaysia

Introduction
Post cardiac arrest care has significant potential to reduce early mortality caused by hemo- dynamic instability and later morbidity and mortality from multiorgan failure and brain injury. ROSC and surviving cardiac arrest with good brain function is TWO DIFFERENT THING!! Most death first 24 hrs post arrest.

Objective of post-resus care

Control body temperature to optimize survival and neuro- logical recovery Identify and treat ACS Optimize mechanical ventilation to minimize lung injury Reduce the risk of multiorgan injury and support organ function if required

Ventilation and oxygenation

Maintain ETCO2 35-40 mmHg
Indication of tube placement and blood flow

Keep PaCO2 40-45 mmHg

To prevent cerebral vasodilatation Not to hyperventilate can cause auto-PPEP and cerebral ischaemia!!

CXR detect complication of resuscitation Maintain SPO2 > 94% and PAO2 ~ 100 mmHg
Reduced FiO2 as tolerated

Hemodynamics
Ensure all IV line functioning Frequent BP and arterial line
Keep MAP >65; SBP >90 mmHg

Treat hypotension
Fluid therapy IV dopa, dobu, nored, adrenaline for effect !!

Other parameters: CVP, serum lactate < 2 mmol/L

Cardiovascular
Continuous cardiac monitoring
To detect arrthmia No prophylactic drug indicated

12-lead ECG detcet ACS ASAP!! Treat ACS strep/PCI Bedside ECHO
Detect structural abnormalities, cardiomyopathy

Neurological
Ensure core body temperature 32-34 degrees
(to maintain 12-24 hrs starting immediately after ROSC)- esp beneficial after out-of-hospital VF

Serial neurological outcome

Gag, cough, pupillary reflex, response to verbal/stimulation

EEG monitoring if comatose

To detect seizure

Sedation is acceptable BUT try not to paralyze

Metabolic
Serial lactate keep <2 mmol/L Serum potassium 3.5-4.5 mmol/L Urine output 0.5-1.0 ml/kg/hr Treat hypo/hyperglycaemia

Thank you

ACLS SCENARIO RUN-THROUGH

DR TUAN HAIRULNIZAM TUAN KAMAUZAMAN Pakar / Pensyarah Kanan Jabatan Perubatan Kecemasan Universiti Sains Malaysia

SCENARIO 1
You are doing your weekly shopping in a mall one day when suddenly an elderly gentleman fall down and collapsed in front of you.

What is your immediate action? What is the possible cause of unconsciousness in this patient?

This is rhythm on AED..

What is the diagnosis? What is your immediate action?

You continue to perform CPR with the help of paramedic. What is the indication to stop CPR? Would you bring back this patient back to hospital?

SCENARIO 2
You are working in ED one day when your paramedic brings in an unconscious elderly lady. CPR is ongoing,endotracheal tube insitu, 2 large bore IV access is inserted. Name 2 important things you would do at this time.

During the 2 minutes interval this is the rhythm shown

What would be your immediate action now?

After the next 2 minutes interval, this is the rhythm shown

What would be your immediate action? What would be your drug of choice to give to the patient now? Discuss your post-resuscitation management.

SCENARIO 3
A 26 years old Malay gentleman present to you with acute onset of shortness of breath Discuss the oxygen delivery system of your choice How would you investigate this patient?

ABG result
pH 7.12 pO2 65 mmHg pCO2 55 mmHg SPO2 80% HCO3 20 mmol/L Serum lactate 4 mmol/L

Interprate the ABG result.

The patient suddenly becomes more drowsy and later unconscious in front of you. What is your immediate action?

This is the ECG shown

What is your diagnosis? How would you investigate the cause of unconsciousness?

On echocardiography, massive pericardial effusion is detected. How would you manage this patient?

SCENARIO 4
You received a 56-years old patient in your ED complaining of shortness of breath What is your immediate action?

This is the rhythm shown

Please analyze this rhythm. What is your diagnosis? What is the treatment choices of this condition and how would you prepare the patient for this treatment?

Thank you