Professional Documents
Culture Documents
Overview
Goal = review major changes to CPR, ALS, electrical therapies, cardiac arrest, arrythmia algorithms, post resusc care Briefly review some Landmark papers.
AEDs, ACS, CVA, toxicology and other special resusc situations not included
Global Comments
BACK TO THE BASICS
Increased emphasis on CPR Decreased emphasis on drugs
SIMPLER
Consistent ratios for CPR Less algorithms (PEA/Asystole out) Tachycardia much simpler
EVIDENCE BASED
Nice to see Landmark papers incorporated. Recognition of importance of survival to discharge vs survival to admission
CPR/BLS
Circulation 2005;112:IV-19-34IV-
Age definitions
Neonatal age applies to baby deliver up until they leave hospital Different age cut offs for Lay rescuers
<1year, 1-8 year, >8 year (Lay rescuer) <1year, 1-adolescent, >adolescent to adult (HCP)
Synchronicity
Unsynchronized ventilation/compression after advanced airway placed
ED Interruptions in Compressions
Transfer to ED bed Pulse checks Placing patient on the monitor and defibrillator Rhythm checks Vascular access Airway management Defibrillation Drug delivery Bedside ultrasound ABG draw Physical examination Changeover of compressor
ACLS 2005
Compress/ Ventilation ratio Single Layperson Double Layperson Single HCP Double HCP Adult/ Adolescent 30:2 30:2 30:2 30:2 Child 30:2 30:2 30:2 15:2 Infant 30:2 30:2 30:2 15:2
After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)
ACLS 2005
Compress/ Ventilation ratio Single Layperson Double Layperson Single HCP Double HCP Adult/ Adolescent 30:2 30:2 30:2 30:2 Child 30:2 30:2 30:2 15:2 Infant 30:2 30:2 30:2 15:2
After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)
Circulation 2005;112:IV-19-34IV-
Electrical Therapies
Circulation 2005;112:IV-19-34IV-
Defibrillators
Monophasic
Biphasic
Rectilinear
Truncated Exponential
Lifepak
12 and 20 are both biphasic (truncated exponential)
1st shock
360J
120J
150J
200J
Subsequent shocks
360J
= or > 120J
= or > 150J
= or > 200J
Lifepak 12 and 20
Timing of Defibrillation
NNT
16 10
5.5
Survival to d/c
Response < 5min Response > 5min
Timing of Defibrillation
ACLS 2005 Recommendation
CPR X 5 cycles of 30:2 (about 2 min) recommended for out-of-hospital VF arrest
Response time > 4-5 minutes Unwitnessed
ALS
Circulation 2005;112:IV-19-34IV-
CPR 30:2 until defibrillator ready One shock, not three 150J (not 360J) Lifepak 12/20 CPR X 2min right after shock (no rhythm check) Timing of intubation not specified Timing of vasopressor not specified Epinephrine 1mg or vasopressin 40IU Timing of antiarrythmic not specified Amiodarone 300mg or Lidocaine 1.5 mg/kg
PL Amio
Why Vasopressin?
Or why not
Vasopressin
Wenzel. NEJM 2004. 350(2). P 105-113.
DBRCT, N= 1186 Out-of-hospital vfib/PEA/asystole Vasopressin 40IU vs Epinephrine 1mg Survival all patients AVP EPI
Admission Discharge 36% 10% 31% 10%
P
.06 .99
Survival Asystole
Admission Discharge
AVP
29% 4.7%
EPI
20% 1.5%
NNT
.02 .04 31
ALS Tachy/Brady
Circulation 2005;112:IV-19-34IV-
Bradycardia Algorithm
Circulation 2005;112:IV-67-77IV-
Bradycardia Notes
No major changes Increased emphasis on early pacing for unstable patients Atropine unlikely to work with infranodal blocks/escape rhythms
2nd degree type II AVB 3rd degree AVB Wide QRS escape rhythm
Tachycardia Algorithm
General Comments
Much simpler Cardiac function/Ejection Fraction decision branches removed Less drugs listed at each box Less emphasis on trying to distinguish Vtach vs SVT + aberrancy Nice approach ..
STABLE
UNSTABLE Cardiovert
Narrow
Wide
Regular
Irregular
Regular
Irregular
Circulation 2005;112:IV-67-77IV-
Amiodarone Cardioversion
Torsades
AFIB + BBB
AFIB + WPW
Adenosine for SVT+a Procaine a 1st line option Lidocaine NOT 1st line Sotalol NOT 1st line
AFIB + WPW
Tijunelis. CJEM 2005. Vol7(4)p. 262-5.
Literature review of Afib + WPW treated with amiodarone No controlled studies 10 case reports 7/10 developed Vfib or unstable VT
AMIODARONE NOT SAFE for AFIB +WPW CARDIOVERSION is the treatment of choice
Induced Hypothermia:
NEJM Feb 2002 --what is the evidence?
Austrian Study
RCT, N=136 Witnessed VF/pulseless VT Excluded: Sats < 85%, hypotension > 30 min, coagulopathy, etc 32-34 degrees X 24hrs Result cool warm NNT Neurofn 6mo 55% 39% 6 Mortality 6mo 41% 55% 7
Australian Study
RCT, N=77 Initial VF rhythm then comatose Excluded: SBP<90 despite epi, non-primary-cardiac etiologies 33 degrees X 18hrs Result cool warm NNT Survival 49% 26% 4
Circulation 2005;112:IV-19-34IV-
5.0%
5.1%
p.83