ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS)

Core knowledge and skills in ACLS

Airway management and endotracheal intubation Recognition and therapy of the major ACLS emergency conditions Electrical therapy and emergency pacing Acute coronary syndrome and stroke Intravenous and invasive therapeutics and monitoring technique Cardiac arrhythmias Cardiovascular pharmacology Management of special resuscitation situation Postresuscitation care Toxicology

Classes of Recommendation
Class I: always acceptable, proven safe, and definitely useful Class II: acceptable, safe, and useful
Class IIa: consider standard of care, intervention of choice Class IIb: consider standard of care, optional or alternative interventions

Class Indeterminate: still be recommended for use, but evidence is lacking Class C: unacceptable, may be harmful

Primary-Secondary survey approach to ECC

Primary survey : first A-B-C-D(BLS action)
Airway, Breathing, Circulation, Defibrillation

Secondary survey : second A-B-C-D

Airway, Breathing, Circulation, Differential diagnosis

Algorithms for Treatment of Cardiac Arrest

ILCOR Universal/International ACLS Algorithm

Adult Advanced Cardiovascular Life Support

Adult

Adult Cardiac Arrest

Consider causes that are potentially reversible Hypovolemia Hypoxia Hydrogen ion acidosis Hyper-/hypokalemia, other metabolic Hypothermia Tablet (drug OD, acidosis Tamponade, cardiac Tension pneumothorax Thrombosis, coronary (ACS) Thrombosis, pulmonary (embolism) BLS algorithm If appropriate During CPR Check electrode/paddle Airway:tracheal tube placement VF/VT refractory to initial shocks: - Epinephrine 1mg IV, q 3 - 5 min. or - Vasopressin 40 U IV non-VF/VT rhythm: - Epinephrine 1 mg IV, q 3 - 5 min. Buffers, antiarrhythmics, pacing Search for reversible causes

Precordial thump if appropriate Attach defibrillator/monitor Assess rhythm Check pulse +/-

VF/VT Attempt Defibrillation 3 As necessary CPR 1 minute

Non-VF/VT

CPR 1 minute

Comprehensive ECC Algorithm

Adult Advanced Cardiovascular Life Support

Adult

Person collapse, Possible cardiac arrest, Assess responsiveness Unresponsive Primary ABCD Survey (Begin BLS Algorithm) Activate emergency response system, Call for defibrillator A Assess breathing (open airway, look, listen, and feel) Not Breathing B Give 2 slow breaths, C Assess pulse, if no pulse C Start chest compressions D Attach monitor/defibrillator when available No Pulse CPR continue Assess rhythm

VF/VT

Non-VF/VT Non-VF/VT (asystole or PEA)

Attempt defibrillation (up to 3 shocks if VF persists) CPR for 1 minute

Secondary ABCD Survey Airway: airway device, Breathing: ventilation, oxygenation Circulation: intravenous access; Drugs, pacing Non-VF/VT patients: Epinephrine 1mg IV, q 3-5 min. VF/VT patients: Vasopressin 40 U IV or Epinephrine 1 mg IV q 3 - 5 min. Differential Diagnosis

CPR up to 3 minutes

Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/VT) Algorithm Adult Advanced Cardiovascular Life Support
Primary ABCD Survey Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulseless VT, up to 3 times (200J, 200 to 300J, 360J, or equivalent biphasic) if necessary Rhythm after first 3 shocks? Persistent or recurrent VF/VT Epinephrine 1mg IV, q 3-5 min. or Vasopressin 40 u IV A B B B C C C D Secondary ABCD Survey Airway: place airway device Breathing: confirm airway device placement Breathing: secure airway device; Breathing: confirm effective oxygenation and ventilation Circulation: IV access Circulation: monitor rhythm Circulation: drugs Differential Diagnosis: search for reversible causes

Adult

Resume attempt to defibrillate 1 360 J (or equivalent biphasic) within 30-60 sec. antiarrhythmics: Amiodarone (IIb), lidocaine (indeterminate), magnesium (IIb if hypomagnesemic state), procainamide (IIb for intermittent/recurrent VF/VT). Consider buffers. Resume attempt to defibrillate

Mechanism with Monophasic wave (Extension of Refractoriness)

Synchronization of Repolarization

Defibrillation success factor

Patient factors duration of pre-shock VF and CPR functional status of myocardium acid-base balance, hypoxia, drug Operational factors time to defibrillation transthoracic impedance paddle position, optimal energy

Pulseless Electrical Activity

Adult Advanced Cardiovascular Life Support

Adult

Pulseless Electrical Activity (PEA = rhythm on monitor, without detectable pulse)

Primary ABCD Survey Focus: basic CPR and defibrillation Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulseless VT Secondary ABCD Survey Airway: place airway device,B Breathing: confirm airway device placement Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilation Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugs Differential Diagnosis: search for reversible causes

A B C D

Consider causes that are potentially reversible Hypovolemia Tablet (drug OD, acidosis) Hypoxia Tamponade, cardiac Hydrogen ion acidosis Tension pneumothorax Hyper-/hypokalemia, other metabolic Thrombosis, coronary (ACS) Hypothermia Thrombosis, pulmonary (embolism) Epinephrine 1mg q 3-5 min. Atropine 1mg IV (if PEA rate is slow), q 3 - 5 min.

Asystole: The Silent Heart Algorithm

Adult Advanced Cardiovascular Life Support

Adult Figure 5

Asystole

Primary ABCD Survey Focus: basic CPR and defibrillation Check responsiveness, Activate emergency response system, Call for defibrillator A Airway: open the airway, B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions, C Confirm true asystole D Defibrillation: assess for and shock VF/pulseless VT Rapid scene survey: any evidence personnel should not attempt resuscitation

A B C D

Secondary ABCD Survey Airway: place airway device,B Breathing: confirm airway device placement Breathing: secure airway device, B Breathing: confirm effective oxygenation/ventilation Circulation: IV access, C Circulation: monitor rhythm, C Circulation: drugs Differential Diagnosis: search for reversible causes

Transcutaneous pacing: If considered, perform immediately Epinephrine 1mg IV q 3-5 min. Atropine 1mg IV, repeat every 3 to 5 minutes up to a total dose of 0.04mg/kg

Asystole persists Withhold or cease resuscitative efforts? Consider qualify of resuscitation? Atypical clinical features present? Support for cease-efforts protocols in place?

Intravenous Techniques During ACLS

Routes of Drug Delivery: Intravenous Intratracheal Intraosseous Intracardiac Preferred IV route: Antecubital vein Central vein

Objectives of ACLS pharmacology

Correction of hypoxia ROSC and adequate blood pressure Promotion of optimal cardiac function Treatment of arrhythmias Relief of pain Correction of acidosis Treatment of heart failure

Pharmacology in ACLS
Primary agents : agents for full cardiac arrest oxygen, epinephrine, vasopressin, amiodarone, atropine etc
Secondary agents : agents for AMI & complications inotropic agents, vasodilators, adrenergic blockers, diuretics, thrombolytic agents

Epinephrine
Mechanism Increase of SVR by alpha-adrenergic effect Increase of CoPP and CPP myocardial oxygen requirement Class Indeterminate - No survival benefit vs placebo - Increase in 24 hr mortality with high-dose Dosage during CPR standard : 1 mg q 3-5min. intermediate : 2- 5 mg escalating : 1- 3 - 5 mg high : 0.1 mg/kg

Vasopressin
Stimulation of smooth muscle V1 receptors Increase in CPP, vital organ blood flow, median frequency of VF, and cerebral oxygen delivery No beta-adrenergic activity Class IIb for VF/VT cardiac arrest: 40 U IV bolus Class indeterminate for PEA or asystole

Atropine
Mechanism enhancement of SA node automaticity enhancement of & AV node conduction Indications : symptomatic bradycardia * role in AV block * bradyasystolic cardiac arrest Dosage : 0.5 - 1.0 mg in non-cardiac arrest up to 3 mg in cardiac arrest *paradoxical response

Amiodarone
Class III antiarrhythmic agent Effects on sodium, potassium, and calcium channels Alpha- and beta-adrenergic blocking effect Class IIb for refractory VF/VT, stable VT, polymorphic VT, wide-complex tachycardia of uncertain origin Class IIa for an adjunct to electrical cardioversion of refractory PSVTs and pharmacologic cardioversion of AF Class IIb for preexcited atrial arrhythmias

Lidocaine
Mechanism Reduction of the slope of phase 4 depolarization, elevation of fibrillation threshold No effect in contractility, conduction, atrial arrhythmogenesis Indications treatment of VT or VF: Class indeterminate prevention of ventricular arrhythmias Dosage 1.0 - 1.5 mg/kg(bolus during CPR) 2 - 4 mg/min. (maintenance)

Sodium bicarbonate
Acid-Base balance during CPR Veno-aterial paradox during CPR * three-part acid-base abnormality CO2 producing buffer solution * limited elimination of CO2 during CPR Indications preexisting metabolic acidosis, hyperkalemia, tricyclic or phenobarbital overdose Dosage : 1 mEq/kg Adverse effect tissue/intracellular acidosis, alkalemia, hyperosmolarity, impaired O2 delivery

Algorithms for Treatment of Life-Threatening Conditions

Bradycardia Algorithm (Patient Not in Cardiac Arrest)

Adult Advanced Cardiovascular Life Support

Adult

Bradycardia Slow (Absolute bradycardia = rate<60 bpm) or Relatively slow

Primary ABCD Survey Assess ABCs, Secure airway noninvasively, Ensure monitor.defibrillator is available Secondary ABCD Survey Assess secondary ABCs (invasive airway management needed?) Oxygen-IV access-monitor-fluids, Vital signs, pulse oximeter, monitor BP Obtain and review 12-lead ECG, Problem-focused history, Problem-focused physical examination Consider causes (differential diagnosis) Serious signs or symptoms? No Type II 2o AV block or 3o AV block Yes Intervention sequence Atropine 0.5 - 1.0 mg, Dopamine 5 - 20 mg/kg/min. Transcutaneous pacing if available Epinephrine 2 to 10 mg/min

No Observe

Yes Prepare for transvenous pacer If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

Indications of emergency cardiac pacing

Hemodynamically unstable bradyarrhythmias Pause- or bradycardia-dependent ventricular rhythms Termination of malignant supraventricular or ventricular tachyarrhythmias Bradyasystolic cardiac arrest Prophylactic pacing in AMI

Contraindications to ECP
Severe hypothermia Brady-asystolic CA of more than 20 minutes duration Pediatric CA due to respiratory origin

The Tachycardias: Overview Algorithm

Adult Advanced Cardiovascular Life Support

Adult

Evaluate patient stable or unstable? serious signs or symptoms? due to tachycardia? Stable Stable patients: no serious signs or symptoms Initial assessment identifies 1 or 4 types of tachycardias Unstable Unstable patients: serious signs or symptoms Establish rapid heart rate as cause of signs and symptoms Rate related signs and symptoms occur at many rates ->Prepare for immediate cardioversion

1. Atrial fibrillation Atrial flutter

2. Narrow-complex tachycardia

3. Stable wide-complex tachycardia: unknown type

4. Stable monomorphic VT and.or polymorphic VT

Evaluation focus: clinically unstable?Cardiac function?,WPW? Duration <48 or >48 hours?

Attempt to specific Dx ECG, Clinical information Vagal maneuvers Adenosine

Attempt to specific Dx ECG, Esophageal lead Clinical information

Treatment focus: clinical evaluation 1.Treat unstable patient urgently 2.Control the rate, convert the rhythm 3.Provide anticoagulation

Diagnostic efforts yield Ectopic atrial tachycardia Multifocal atrial tachycardia PSVT Confirmed SVT Wide-complex tachycardia of unknown type Confirmed Stable SVT Treatment of Stable monomorphic and polymorphic VT

Treatment of Atrial Fibrillation/ Atrial flutter

Treatment of SVT)

DC cardioversion or Procainamide or Amiodarone if EF >40%

DC cardioversion or Amiodarone if EF <40%

Atrial Fibrillation/Flutter
Adult Advanced Cardiovascular Life Support

Adult

Control Rate Normal LVEF LVEF<40% or CHF

Convert Rhythm Duration<48 hrs DC cardioversion Amiodarone Ibutilide Flecainide Procainamide Propafenone (class IIa) Duration>48 hrs

Normal Cardiac Function

Ca2+ channel blocker b-blocker (class I)

LVEF<40% or CHF

Digoxin, Diltiazem, Amiodarone (class IIb) DC cardioversion Or Amiodarone Flecainide Procainamide Propafenone Sotalol (class IIb)

DC cardioversion or Amiodarone (Class IIb)

No DC cardioversion Delayed cardioversion with anticoagulation Early cardioversion after TEE and anticoagulation

WPW

DC cardioversion or Amiodarone (Class IIb)

DC cardioversion Or Amiodarone Flecainide Procainamide Propafenone Sotalol (class IIb)

Adenosine Ca2+ channel blocker b-blocker Digoxin (Class III)

Narrow Complex Tachycardias

Adult Advanced Cardiovascular Life Support

Adult

Narrow-Complex Supraventricular Tachycardia, Stable Attempt therapeutic diagnostic maneuver Vagal stimulation Adenosine Preserved Junctional tachycardia EF <40%, CHF No DC cardioversion! Amiodarone b-blocker Ca2+ channel blocker No DC cardioversion Amiodarone Priority order: Ca2+ channel blocker b-blocker, Digoxin DC cardioversion Consider procainamide, amiodarone, sotalol Priority order: No DC cardioversion Amiodarone, Digoxin, Diltiazem No DC cardioversion Ca2+ channel blocker b-blocker Amiodarone No DC cardioversion Amiodarone Diltiazem

Preserved Paroxysmal supraventricular tachycardia EF <40%, CHF

Ectopic or mutifocal atrial tachycardia

Preserved EF <40%, CHF

Stable Ventricular Tachycardias: Monomorphic and Polymorphic

Adult Advanced Cardiovascular Life Support

Adult

Stable Ventricular Tachycardias: Monomorphic and Polymorphic?

Monomorphic VT Is cardiac function impaired? Normal function Poor ejection fraction

Note! May go directly to cardioversion

Polymorphic VT Is QT baseline interval prolonged? Normal Prolonged

Medications: any one Procainamide Sotalol Other acceptable Amiodarone Lidocaine

Normal baseline QT interval Treat ischemia Correct electrolyte Medications: any one b-Blockers or Lidocaine or Amiodarone or Procainamide or Sotalol Cardiac function impaired2 Amiodarone 150mg IV bolus over 10 minutes or Lidocaine 0.5 60 0.75 mg/kg IV push Then use Synchronized cardioversion

Long baseline QT interval Correct abnormal electrolyte Medications: any one Magnesium Overdrive pacing Isoproterenol Phenytoin Lidocaine

Electrical Cardioversion Algorithm

Adult Advanced Cardiovascular Life Support

Adult

Tachycardia With serious signs and symptoms

If ventricular rate is >150 bpm, prepare for immediate cardioversion. May give brief trial of medications based on specific arrhythmias. Immediate cardioversion is generally not needed if heart rate is 150 bpm.
Have available at bedside Oxygen saturation monitor Suction device IV line Intubation equipment Premedicate whenever possible

Steps for synchronized Cardioversion 1. Consider sedation. 2. Turn on defibrillator (monophasic or biphasic) 3. Attach leads 4. Synchronization 5. Select energy 6. Apply gel to paddles 7. Position paddle on patient 8. Charge 9. Announce Clear 10. Discharge 11. Check monitor and patient

Synchronized cardioversion Ventricular tachycardia Paroxysmal supraventricular tachycardia Atrial fibrillation Atrial flutter

100 J, 200 J, 300 J, 360 J monophasic energy dose (or clinically equivalent biphasic energy dose)

Transthoracic Impedance
Electrode composition/ size Energy selected Electrode-skin coupling material No & interval of previous shocks Phase of respiration Inter-electrode distance Contact pressure

Energy requirements
Ventricular fibrillation 200-200-360 Ventricular tachycardia 100-200-360 100-200-360 Atrial fibrillation 50-100-200 Atrial flutter 50-100-200 PSVT

Acute Pulmonary Edema, Hypotension, Shock

Adult Advanced Cardiovascular Life Support

Adult

Clinical signs: Shock, hypotension, congestive heart failure, acute pulmonary edema Most likely problem? Acute pulmonary edema 1st-Acute pulmonary edema Furosemide IV 0.5 to 1.0 mg/kg Morphine IV 2 to 4 mg Nitroglycerin SL Oxygen/intubation as needed Volume problem Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors Pump problem Bradycardia algorithm Blood pressure? Rate problem Tachycardia algorithm

Systolic BP Systolic BP Systolic BP Systolic BP Systolic BP BP defines <70 mmHg 70 to 100 mmHg 70 to 100 mmHg >100 mmHg 2nd line of Signs/symptoms Signs/symptoms No Signs/symptoms action (see of shock of shock of shock below) Nitroglycerin Norepinephrine Dopamine Dobutamine 10 to 20 mg/min IV 0.5 to 30 mg/min IV 5 to 15 mg/kg per 2 to 20 mg/kg per Consider minute IV minute IV Nitroprusside 0.1 to 5.0 mg/kg per minute IV 2nd Acute pulmonary edema Nitroglycerin/nitroprusside if BP >100 mmHg Dopamone if BP = 70 to 199 mmHg, signs/symptoms of shock Dobutamine if BP >100 mmHg, no signs/symptoms of shock Further diagnosis/therapeutic considerations: IABP, PA catheter, Angiography, etc

Acute Myocardial Infarction

Community early activation of EMS oxygen / IV / cardiac monitor / vital signs NTG, narcotics notification of ED, rapid transport prehospital screening of thrombolytic therapy 12-lead ECG, analysis, transmission initiation of thrombolytic therapy EMS system

Emergency department

Door-to-drug team protocol approach (triage, decision making) Treatment oxygen / NTG / morphine aspirin/ heparin/ beta-blocker thrombolytic agents

Assessment vital signs/ECG/ history decision for Thrombolysis

Ischemic Chest Pain Algorithm

Adult Advanced Cardiovascular Life Support

Adult

Chest pain suggestive of ischemia

Immediate assessment: <10 minutes vital signs, O2 saturation, IV access, ECG Hx/P/E focus on eligibility for fibrinolytic therapy Electrolyte/coagulation studies, CXR(<30 minutes)

Immediate general treatment MONA greets all patients (Morphine, Oxygen, Nitroglycerin, Aspirin)

Assess initial 12-lead ECG

Immediate assessment /treatment (MONA), including initial 12-lead ECG and review for fibrinolytic therapy indications and contraindications.

ST elevation or new or presumably new LBBB: strongly suspicious for injury ST-elevation AMI Start adjunctive treatments : b -blocker, NTG, Heparin IV ACE inhibitors (after 6 hours or when stable) Time from onset of symptoms?

ST depression or dynamic T-wave inversion: strongly suspicious for ischemia High-risk unstable angina/ non-ST-elevation AMI

Nondiagnostic ECG: absence of changes in ST segment or T waves Intermediate/low-risk unstable angina Yes Meets criteria for UA or New-onset angina? Or TNT positive? No Admit to ED chest pain unit: Serial cardiac markers, ECG/continuous ST monitoring Consider imaging study Clinically stable No Yes Evidence of ischemia or infarction No Discharge / follow-up

Start adjunctive treatments Heparin (UFH/LMWH) Aspirin, NTG Glycoprotein IIb/IIIa receptor inhibitors b- blockers >12hours Assess clinical status High-risk patient: symptoms, Recurrent ischemia, low LVEF Widespread ECG changes Prior AMI, PCI, CABG catheterization: Revascularization PCI or CABG

<12hours Cardiogenic shock: Select a reperfusion PCI,If PCI is not strategy available, ibrinolytics Fibrinolytic therapy selected Front-loaded alteplase Goal: door-to-drug <30 minutes

Primary PCI selected Door-to-balloon inflation 9030 minutes

Attempt CCU/monitored bed

Acute Coronary Syndromes

Adult Advanced Cardiovascular Life Support

Adult

Assess the initial ECG within 10 minutes of arrival.

ST segment elevation or new LBBB

ST elevation 1 mm in 2 or more contiguous leads New or presumably new LBBB (BBB obscuring ST-segment analysis) 90% of patients with ischemic-type chest pain and ST-segment elevation will develop new Q waves or positive serum markers for AMI. Patients with hyperacute T waves benefit when AMI diagnosis is certain. Repeat ECG may be helpful. Patient with ST depression in early precordial leads who have posterior MI benefit when AMI diagnosis is certain. Reperfusion therapy Aspirin Heparin (if using fibrin-specific lytics) b-Blockers, Nitrates as indicated

ST segment depression/ dynamic T-wave inversion: strongly suspicious for ischemia

ST depression >1 mm Marked symmetrical T-wave inversion in multiple precordial leads Dynamic ST-T changes with pain High-risk subgroup with increased mortality Persistent symptoms, recurrent ischemia Diffuse or widespread ECG abnormalities Depressed LV function Congestive heart failure Serum marker release: positive troponin or CK-MB+ Antithrombin therapy with heparin Antiplatelet therapy with aspirin Glycoprotein IIb/IIIa inhibitors b -Blockers, Nitrates

Nondiagnostic or normal ECG

ST depression 0.5 to 1 mm T-wave inversion or flattened in leads with dominant R waves Normal ECG Heterogeneous group: rapid assessment needed by Serial ECGs ST-segment monitoring Serum cardiac markers Further risk assessment helpful Perfusion radionuclide imaging Stress echocardiography

Aspirin, Other therapy as appropriate Patients with positive serum markers, ECG changes, or functional study: manage as high risk

Algorithm for Suspected Stroke

Adult Advanced Cardiovascular Life Support

Adult

Detection Dispatch Delivery Door

Suspected Stroke

EMS assessment and actions Immediate assessments Cincinnati Prehospital Stroke Scale Los Angeles Prehospital Stroke Screen Alert hospital to possible stroke patient Rapid transport to hospital

Immediate general assessment:<10 minutes Assess ABCs, vital signs, O2 IV access: blood samples (CBC, electrolytes, coagulation studies, blood sugar), 12-lead ECG general neurological screening----Alert Stroke Team: neurologist, radiologist, CT technician

Neurological assessment: <25 minutes history, onset (<3 hours required for fibrinolytics), P/Exam Neurological examination:consciousness (Glasgow Coma Scale) stroke severity (NIH Stroke Scale or Hunt and Hess Scale) Noncontrast CT scan <25 minutes, Read CT scan <45 minutes Lateral cervical spine x-ray (comatose/history of trauma)

ICH or SAH on CT? Data No Yes Consult neurosurgery Blood on LP Initiate actions for acute hemorrhage Reverse any anticoagulants and reverse any bleeding disorder Monitor neurological condition Treat hypertension in awake patients Initiate supportive therapy, Consider admission and anticoagulation Consider alternative diagnosis

Probable acute ischemic stroke CT exclusions, Neurological exam Review fibrinolytic exclusions and patient data: symptom >3 hours?

Decision

No to all of above

SAH suspected- Lumbar puncture No blood on LP

Patient remains candidate for Fibrinolytic therapy? Drug No Yes

Begin fibrinolytic treatment (door-to-treatment goal <60 minutes): Monitor neurological status & BP; treat as indicated No anticoagulants or antiplatelet treatment for 24 hours

Hypothermia Algorithm
Adult Advanced Cardiovascular Life Support

Adult

Initial therapy for all patients Remove wet garments, Protect against heat loss and wind chill (use blankets and insulating equipment) Maintain horizontal position, Avoid rough movement and excess activity, Monitor core temperature Monitor cardiac rhythm1

Assess responsiveness, breathing, and pulse What is core temperature?

34 to 36 (mild hypothermia) Passive rewarming Active external rewarming 30 to 34 (moderate hypothermia) Passive rewarming Active external rewarming of truncal areas only1,3

Start CPR Defibrillate up to a maximum of 3 shocks Attempt, confirm, secure airway warm, humid oxygen (42 to 46)2 IV access, Infuse warm normal saline (43)2 What is core temperature? <30 Continue CPR Withhold IV medications Limit shocks for VF/VT to maximum of 3 Transport to hospital >30 Continue CPR Give IV medications as indicated (but space at longer than standard interval) repeat defibrillation for VF/VT as core temperature rises

<30 (severe hypothermia) Active internal rewarming sequence Active internal rewarming Warm IV fluids (43) Warm, humid oxygen (42 to 46) Peritoneal larvage (KCL-free fluid) Extracorporeal rewarming Esophageal rewarming tubes4 Continue internal rewarming until Core temperature >35 Return of spontaneous circulation or Resuscitative effort cease

Invasive monitoring / Therapeutics

Arterial cannulation continuous monitoring of arterial pressure blood samping Bedside pulmonary artery catheterization hemodynamic variables and cardiac output sampling of mixed venous blood Therapeutics Pericardiocentesis, Emergency Thoracostomy Open cardiac massage

Prolonged Life Support

Goals Postresuscitation intensive care / monitoring Cerebral resuscitation Identification of the cause of CA Prevention of recurrence

Cerebral Resuscitation
Brain-orient noncerebral organ system perfusion pressure, oxygenation, Normal ventilation, correction of acidosis, body temperature, hemodilution, immobilization/sedation, anticonvulsant therapy, Brain-specific therapies barbiturate, calcium channel blockers, free radical scavengers, free iron chelators, excitatory amino acid receptor blocker, prostaglandin synthesis blockers

General Brain-Oriented Intensive Care

Normotension: MAP, 90 - 100 mm Hg Normocapnea: PaCO2, 35 - 40 mm Hg Moderate hyperoxia: PaO2 around 100 mm Hg Arterial pH 7.3 - 7.5 Immobilization, Sedation, Anticonvulsants as needed Normothermia, aggressive treatment of hyperthermia Nutritional support started by 48 hours Osmotherapy if indicated