Advanced Cardiac Life Support N.Tavakoli Assistant professor Department of Emergency Medicine Iran University of Medical Sciences

Early ACCESS Early CPR Early DEFIB Early ACLS Chain of Survival

Drug Administration Route  Peripheral Venous  Central Venous  Endotracheal  Intraosseous  Intra cardiac

Central IV access  More rapid drug delivery  Ability to perform invasive monitoring  More time consuming  More experience  Risk of complication is greater  Internal jugular or supraclavicular are preferred

Peripheral IV access  Antecubital or external Jugular are the first choice  Administer drugs -By rapid bolus followed 20cc of IV fluid -Elevation of the extremity

ُEndotracheal Route  ‘’L –E – A –N’’ can be given via tracheal tube. Lidocaine, Atropine, Epinephrine, Naloxan  times the recommended dosage  Should be diluted in 10 cc N/S  Temporarily holding chest compression  Injecting drug through a cannula while delivering several deep breath

Intra cardiac Route  Only when other routes are not readily available  During Open- chest CPR  Heart can be directly visualized

Pharmacologic Agents in ACLS for shock-refractory VT/VF  Epinephrine 1 mg intravenously every 3 -5 minutes 1 mg intravenously every 3 -5 minutes a higher dose (0.2 mg/kg) is acceptable, but not recommended, a higher dose (0.2 mg/kg) is acceptable, but not recommended,

Epinephrine  Indications (When & Why?) Increases: Increases: Heart rateHeart rate Force of contractionForce of contraction Conduction velocityConduction velocity Peripheral vasoconstriction Peripheral vasoconstriction Bronchial dilation Bronchial dilation VF / Pulseless VT

Epinephrine  Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline2.0 to 2.5 mg diluted in 10 mL normal saline VF / Pulseless VT

Epinephrine  Dosing (How?) Alternative regimens for second dose (Class IIb) Alternative regimens for second dose (Class IIb) Intermediate: 2 to 5 mg IV push, every 3 to 5 minutesIntermediate: 2 to 5 mg IV push, every 3 to 5 minutes Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apartEscalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart High: 0.1 mg/kg IV push, every 3 to 5 minutesHigh: 0.1 mg/kg IV push, every 3 to 5 minutes VF / Pulseless VT

Epinephrine  Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Higher doses have not improved outcome & may cause myocardial dysfunction VF / Pulseless VT

Vasopressin  Indications (When & Why?) Used to “clamp” down on vessels Used to “clamp” down on vessels Improves perfusion of heart, lungs, and brain Improves perfusion of heart, lungs, and brain No direct effects on heart No direct effects on heart VF / Pulseless VT

Vasopressin  Dosing (How?) One time dose of 40 units only One time dose of 40 units only May be substituted for epinephrine May be substituted for epinephrine Not repeated at any time Not repeated at any time May be given down the endotracheal tube May be given down the endotracheal tube DO NOT double the doseDO NOT double the dose Dilute in 10 mL of NSDilute in 10 mL of NS VF / Pulseless VT

Vasopressin  Precautions (Watch Out!) May result in an initial increase in blood pressure immediately following return of pulse May result in an initial increase in blood pressure immediately following return of pulse May provoke cardiac ischemia May provoke cardiac ischemia VF / Pulseless VT

Atropine Sulfate  Indications (When & Why?) Should only be used for bradycardia Should only be used for bradycardia Relative or AbsoluteRelative or Absolute Used to increase heart rate Used to increase heart rate Pulseless Electrical Activity

Atropine Sulfate  Dosing (How?) 1 mg IV push 1 mg IV push Repeat every 3 to 5 minutes Repeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: 0.04 mg/kg Maximum Dose: 0.04 mg/kg Pulseless Electrical Activity

Atropine Sulfate  Precautions (Watch Out!) Increases myocardial oxygen demand Increases myocardial oxygen demand May result in unwanted tachycardia or dysrhythmia May result in unwanted tachycardia or dysrhythmia Pulseless Electrical Activity

Amiodarone  Indications (When & Why?) Powerful antiarrhythmic with substantial toxicity, especially in the long term Powerful antiarrhythmic with substantial toxicity, especially in the long term Intravenous and oral behavior are quite different Intravenous and oral behavior are quite different Has effects on sodium & potassium Has effects on sodium & potassium VF / Pulseless VT

Amiodarone  Dosing (How?) Should be diluted in 20 to 30 mL of D5W Should be diluted in 20 to 30 mL of D5W 300 mg bolus after first Epinephrine dose300 mg bolus after first Epinephrine dose Repeat doses at 150 mgRepeat doses at 150 mg VF / Pulseless VT

Amiodarone  Precautions (Watch Out!) May produce vasodilation & shock May produce vasodilation & shock May have negative inotropic effects May have negative inotropic effects Terminal elimination Terminal elimination Half-life lasts up to 40 daysHalf-life lasts up to 40 days VF / Pulseless VT

Lidocaine  Indications (When & Why?) Depresses automaticity Depresses automaticity Depresses excitability Depresses excitability Raises ventricular fibrillation threshold Raises ventricular fibrillation threshold Decreases ventricular irritability Decreases ventricular irritability VF / Pulseless VT

Lidocaine  Dosing (How?) Initial dose: 1.0 to 1.5 mg/kg IV Initial dose: 1.0 to 1.5 mg/kg IV For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS VF / Pulseless VT

Lidocaine  Dosing (How?) Maintenance Infusion Maintenance Infusion 2 to 4 mg/min2 to 4 mg/min 1000 mg / 250 mL D5W = 4 mg/mL1000 mg / 250 mL D5W = 4 mg/mL 15 mL/hr = 1 mg/min 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min 60 mL/hr = 4 mg/min VF / Pulseless VT

Lidocaine  Precautions (Watch Out!) Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Discontinue infusion immediately if signs of toxicity develop Discontinue infusion immediately if signs of toxicity develop VF / Pulseless VT

Magnesium Sulfate  Indications (When & Why?) Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state Refractory VF Refractory VF VF with history of ETOH abuse VF with history of ETOH abuse Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose VF / Pulseless VT

Magnesium Sulfate  Dosing (How?) 1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push 1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push VF / Pulseless VT

Magnesium Sulfate  Precautions (Watch Out!) Occasional fall in blood pressure with rapid administration Occasional fall in blood pressure with rapid administration Use with caution if renal failure is present Use with caution if renal failure is present VF / Pulseless VT

Procainamide  Indications (When & Why?) Recurrent VF Recurrent VF Depresses automaticity Depresses automaticity Depresses excitability Depresses excitability Raises ventricular fibrillation threshold Raises ventricular fibrillation threshold Decreases ventricular irritability Decreases ventricular irritability VF / Pulseless VT

Procainamide  Dosing (How?) 30 mg/min IV infusion 30 mg/min IV infusion May push at 50 mg/min in cardiac arrest May push at 50 mg/min in cardiac arrest In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable Maximum total dose: 17 mg/kg Maximum total dose: 17 mg/kg VF / Pulseless VT

Procainamide  Dosing (How?) Maintenance Infusion Maintenance Infusion 1 to 4 mg/min1 to 4 mg/min 1000 mg / 250 mL of D5W = 4 mg/mL1000 mg / 250 mL of D5W = 4 mg/mL 15 mL/hr = 1 mg/min 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min 60 mL/hr = 4 mg/min VF / Pulseless VT

Procainamide  Precautions (Watch Out!) If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min Remember Endpoints of Administration Remember Endpoints of Administration VF / Pulseless VT

 Vasopressin an acceptable alternative, recommended an acceptable alternative, recommended a single intravenous dose of 40 U is given once (half life is min versus min with epinephrine) a single intravenous dose of 40 U is given once (half life is min versus min with epinephrine) in a controlled trial of patients with out-of-hospital VF who received either vasopressin or epinephrine; those treated with vasopressin had higher rates of survival to hospital admission (70 vs 35 %, p = 0.06) and survival at 24 hours (60 vs 20 %, p = 0.02) in a controlled trial of patients with out-of-hospital VF who received either vasopressin or epinephrine; those treated with vasopressin had higher rates of survival to hospital admission (70 vs 35 %, p = 0.06) and survival at 24 hours (60 vs 20 %, p = 0.02)

Other Cardiac Arrest Drugs

Calcium Chloride  Indications (When & Why?) Known or suspected hyperkalemia (eg, renal failure) Known or suspected hyperkalemia (eg, renal failure) Hypocalcemia (blood transfusions) Hypocalcemia (blood transfusions) As an antidote for toxic effects of calcium channel blocker overdose As an antidote for toxic effects of calcium channel blocker overdose Prevent hypotension caused by calcium channel blockers administration Prevent hypotension caused by calcium channel blockers administration Other Cardiac Arrest Drugs

Calcium Chloride  Dosing (How?) IV Slow Push IV Slow Push 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers Other Cardiac Arrest Drugs

Calcium Chloride  Precautions (Watch Out!) Do not use routinely in cardiac arrest Do not use routinely in cardiac arrest Do not mix with sodium bicarbonate Do not mix with sodium bicarbonate Other Cardiac Arrest Drugs

Sodium Bicarbonate  Indications (When & Why?) Class I if known preexisting hyperkalemia Class I if known preexisting hyperkalemia Class IIa if known preexisting bicarbonate-responsive acidosis Class IIa if known preexisting bicarbonate-responsive acidosis Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation) Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation) Other Cardiac Arrest Drugs

Sodium Bicarbonate  Dosing (How?) 1 mEq/kg IV bolus 1 mEq/kg IV bolus Repeat half this dose every 10 minutes thereafter Repeat half this dose every 10 minutes thereafter If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration) If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration) Other Cardiac Arrest Drugs

Sodium Bicarbonate  Precautions (Watch Out!) Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest Not recommended for routine use in cardiac arrest patients Not recommended for routine use in cardiac arrest patients Other Cardiac Arrest Drugs

Factors Influencing Survival the rhythm associated with the arrest the rhythm associated with the arrest whether the collapse was witnessed whether the collapse was witnessed adequacy of CPR adequacy of CPR age / underlying health of the patient age / underlying health of the patient rate of hospital discharge (ages 90s 4.4% 80s 9.4% <80 19% )

ACLS and arrhythmias

Tachycardia sudden onset of rapid heart rate what do you do?

Tachycardia ALWAYS CHECK THE PATIENT FIRST 1. Check for a pulse 2. Check the blood pressure 3. Make a diagnosis

Tachycardia Case 1 On ward, sudden onset of palpitations 1. Does the patient have a pulse? Yes 2. What is the blood pressure? 60/20 Is the patient “stable” or “unstable”?

Definition of “Unstable” presence of any one of: 1. Low blood pressure 2. Short of Breath 3. Chest pain 4. Lightheaded 5. CHF

Unstable Tachycardia  goal is to slow down rate or  convert to sinus rhythm  drugs or electrical cardioversion is used  usually cardioversion if unstable

Electrical Shock  defibrillation or  cardioversion (= “synchronized”)  action: resets all activity to zero  good for tachycardia (non-sinus)  good for ventricular fibrillation (VF)

Electrical Shock  defibrillation or  cardioversion (= “synchronized”) NOT USED FOR:  sinus rhythm  bradycardia  asystole

Case #2 Alarm on ECG monitor makes noise!!

Case #2  Patient is awake and talking Diagnosis?  ECG lead is disconnected  ECG shows artifact

Case #3 Alarm on ECG monitor makes noise!!

Case #2  Try to wake up. Does not wake up  Check for breathing. No breathing.  Check for pulse. No pulse. What is the diagnosis? What do you do?

Ventricular Fibrillation (VF)  What is the cure for VF? DEFIBRILLATION  EARLY defib. has higher success SHOCK SOON, SHOCK OFTEN

VF Drugs  improve success of defibrillation (the cure)  do NOT cure VF lidocaine lidocaine procainamide procainamide amiodarone amiodarone

VF What is the cardiac output in VF?  Zero. There is no circulation What MUST occur at all times?  CPR … unless defib. is happening. How do you manage ventilation?  bag-mask and early intubation

VF Summary  Start CPR … and only stop to shock  Intubate  Defibrillation is the most important!!!  Drug  shock  drug  shock

Case #4 BP 60/30 Diagnosis?Treatment?

Case #4: Sinus Bradycardia Treatment: increase heart rate! Methods: 1. atropine (probably successful) 2. pacing (thoracic skin paddles) 3. dopamine infusion

Case #5 BP 60/30 Diagnosis?Treatment?

3rd Degree Block (Bradycardia) Treatment: increase heart rate! Methods: 1. atropine (probably NOT successful) 2. pacing (thoracic skin paddles) 3. dopamine infusion

Case # 6  BP: 120/80, no chest pain, no rales, alert Diagnosis?Treatment?