Advanced Cardiovascular Life Support (ACLS)

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

2010 ACLS Guidelines

Science updates to CPR and ECC

Basic Life Support ACLS Acute Coronary Syndrome Electrical Therapies CPR Techniques and Devices Stroke Ethical Issues Education, Implementation, and Teams

The road to change

Evidence Evaluation Process

International consensus Extensive review of resuscitation literature Peer-reviewed studies Rigorous disclosure and management of conflicts of interest

BLS Survey

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Chest Compressions High Quality Chest Compressions push hard and push fast

High-Quality Chest Compression

To deliver effective chest compressions, you must:

Rate: at least 100/minute Depth: 2 inches [5 cm] in adults and children 1.5 inches [4 cm] infants Allow full chest recoil Minimize interruptions Avoid excessive ventilation

Compression Depth At Least 2 Inches

For adults, at least 2 inches (5 cm)

Compression -to- ventilation ratio

Questions?

Change A-B-C to C-A-B

Chest compressions

Chest compressions and early defibrillation.

Elimination of Look, Listen, and Feel

Cricoid Pressure During Ventilation Not Recommended

Definition of Cricoid Pressure

Cricoid pressure is a technique of applying pressure to the victims cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebrae. Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag mask ventilation, but it may also impede ventilation.

BLS Survey

First

Check simultaneously:
1) Responsiveness 2) Breathing

Then

If victim unresponsive and not breathing:

1) Activate emergency response system 2) Retrieve AED if available 3) If no pulse felt within 10 seconds, begin CPR

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Advanced Cardiovascular Life Support

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Overview
Advanced Cardiovascular Life Support

Simplified Cardiac
Arrest Algorithm Monitoring to Optimize CPR Post-Cardiac Care Airway Management

Simplified ACLS Algorithm

Adult arrest algorithm

ACLS Cardiac Arrest Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Tachycardia Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Bradycardia Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Questions?

Capnography Recommendation
Capnography Waveform

Capnography to confirm endotracheal tube placement.

Capnography to monitor effectiveness of resuscitation efforts.

Ineffective chest compressions indicated by

Pressure of end tidal

CO2 (PETCO2)

New Medication Protocols

Symptomatic Arrhythmias Medication Recommendations
Epinephrine IV/IO Dose: 1 mg every 3-5 minutes Vasopressin IV/IO Dose: 40 units can replace first or second dose of epinephrine Amiodarone IV/IO Dose: First dose: 300 mg bolus. Second dose: 150 mg.
Adenosine IV Dose: First dose: 6 mg rapid IV push; follow with NS flush. Second dose: 12 mg if required. Atropine IV Dose: First dose: 0.5 mg bolus Repeat every 3-5 minutes Maximum: 3 mg OR Dopamine IV Infusion: 2-10 mcg/kg per minute OR Epinephrine IV Infusion: 2-10 mcg per minute

PEA/asystole

Tachycardia
Symptomatic or unstable bradycardia

Organized Post-Cardiac Care

Improved Survival

Hemodynamic

Neurologic

Metabolic

Effect of Hypothermia on Prognostication

Positive results from therapeutic hypothermia

Oxygen Saturation

Oxygen Saturation

Special Resuscitation Situations

Asthma Anaphylaxis Pregnancy Morbid obesity Pulmonary embolism Electrolyte imbalance Ingestion of toxic substances Trauma Accidental hypothermia Avalanche Drowning Electric shock/lightning strikes Percutaneous coronary intervention Cardiac tamponade Cardiac surgery

Acute Coronary Syndromes

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

ACS

The primary goals of therapy for patients with ACS include the need to:
Reduce the amount of myocardial necrosis Prevent major adverse cardiac events Treat acute, life-threatening complications

Systems of Care for Patients With ST-Elevation Myocardial Infarction (STEMI)

Educational programs EMS protocols ED & hospital transports

2
3

STEMI Systems of Care

Triage to Capable Hospital

Cardiac Catheterization

Questions?

Electrical Therapies
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Electrical Therapy
Defibrillation | Cardioversion | Pacing

Healthcare Provider AED Recommendations

AED Use in Children Includes Infants

One-Shock Protocol Versus Three-Shock Sequence

1-shock defibrillation protocol followed by immediate CPR

Defibrillation Waveforms and Energy Levels

200 J

Pediatric Defibrillation

2 J/kg

Fixed and Escalating Energy

Joules

400 350 300 250 200 150 100

50
0

Escalating Energy Levels

Electrode Placement

Anterior-lateral Anterior-posterior Anterior-left infrascapular Anterior-right infrascapular

Defibrillation With Implanted Cardioverter Defibrillator

Anterior-posterior or Anterior-lateral

Synchronized Cardioversion

Energy Doses
Supraventricular Tachycardias Ventricular Tachycardia

Initial biphasic energy dose of 50-100 J

Monophasic or biphasic waveform cardioversion shocks at initial energy of 100 J

Fibrillation Waveform Analysis

The value of VF waveform analysis to guide defibrillation management during resuscitation is uncertain.

CPR Techniques and Devices

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Recommended Devices

No resuscitation device other than a

defibrillator
has consistently improved long-term survival from out-ofhospital cardiac arrest.

Use of Precordial Thump Not Recommended Definition of Precordial Thump

The precordial thump is a CPR technique used by healthcare professionals in the initial response to a witnessed cardiac arrest when no defibrillator is immediately available.

Stroke

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Stroke Care

Detection Dispatch Delivery Door Data Decision Drug Disposition

Stroke-Prepared Hospital

rtPA Guidelines
Patients Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset
Inclusion Criteria Diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms <3 hours before beginning treatment Age 18 years Exclusion Criteria Head trauma or prior stroke in previous 3 months Symptoms suggest subarachnoid hemorrhage Arterial puncture at noncompressible site in previous 7 days History of previous intracranial hemorrhage Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Evidence of active bleeding on examination Acute bleeding diathesis, including but not limited to Platelet count <100 000/mm3 Heparin received within 48 hours, resulting in aPTT >upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 seconds Blood glucose concentration <50 mg/dL (2.7 mmol/L) CT demonstrates multilobar infarction (hypodensity > cerebral hemisphere) Relative Exclusion Criteria Recent experience suggests that under some circumstanceswith careful consideration and weighing of risk to benefitpatients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative contraindications is present: Only minor or rapidly improving stroke symptoms (clearing spontaneously) Seizure at onset with postictal residual neurologic impairments Major surgery or serious trauma within previous 14 days Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months)

Stroke Unit Care

Magnitude of benefits from treatment in a stroke unit are comparable to magnitude of effects achieved with rtPA.

Management of Hypertension
Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke Patients Who Are Potential Candidates for Acute Reperfusion Therapy
Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg: Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1, or Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour; when desired blood pressure is reached, lower to 3 mg per hour, or Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA. Management of blood pressure during and after rtPA or other acute reperfusion therapy: Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours. If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg: Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Questions?

Ethical Issues
2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Ethical issues relating to resuscitation are complex.

Terminating Resuscitative Efforts in Adults with Out-ofHospital Cardiac Arrest (OHCA)

Arrest not witnessed by EMS

provider or first responder No ROSC after three complete rounds of CPR and AED analyses No AED shocks were delivered

ALS termination of resuscitation rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met:

Arrest not witnessed No bystander CPR

was provided No ROSC after complete ALS care in the field No shocks were delivered

Prognostic Indicators in the Adult Post-Arrest Patient Treated with Therapeutic Hypothermia

Education, Implementation, and Teams

2010 Heart and Stroke Foundation of Canada Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)

Learn and Live

Chain of Survival

Thank you.