ACLS Past, Present & Future Dr FT Lee A&E, PMH

Do s Brief review of main points Case presentation Future development

Don’t s Review of Algorithms

History Originated in Nebraska in early 1970

History Organised in Hong Kong by Hong Kong Society of Emergency Medicine and surgery since 1991 Case-based small group teaching since 1994 A two days workshop with hands on experience

Cardiac arrest? Breathing 氣 Beating 血

Pulse check no more than 10 sec Start chest compression if you are unsure

Cardiac Arrest Ventricular fibrillation/ Pulseless Ventricular Tachycardia Asystole Pulseless Electrical Activity(PEA)

Early defibrillation The most frequent initial rhythm in sudden cardiac arrest is VF Chance of successful defibrillation reduced 10% each minute

Chain of survival Early accessEarly CPREarlyEarly ACLS Defibrillation

Pulse +ve Tachycardia 快 Bradycardia 慢

Tachycardia (P > 100/min) Wide complex –QRS >0.12 s (3 small squares) Narrow complex –QRS < 0.12 s

Bradycardia (P< 60/min) Sinus Heart Block –1 st, 2 nd and 3rd

Pulse +ve STABLE ?

Unstable Shock SOB Severe chest pain Impaired consciousness

Unstable Electrical therapy

Stable Drug

Drugs Adrenaline/Vasopressin Amiodarone –300mg iv bolus in VF/pulseless VT –150mg ivi over 10 min in stable tachycardia –Maintenance infusion 1mg/min for 8hrs then 0.5mg/min for 16 hours ATP/Verapamil/Diltiazem Atropine

Is life so simple?

Case 1 AE 04026XXX(X) Mr Au, M/57, 19:58, 3/2004 C/O: Chest pain since 18:00 with radiation to neck & back, sweating +ve PH: HT, Gout

BP: 182/73, P: 99/min reg, RR: 14/min SaO2: 96% (RA) Triage as Cat III (20:00) ECG ordered

Seen at 20:46 (46mins after triage) Diagnosed as Angina O2, TNG, Aspirin and Heparin block ordered Patient disappeared at 20:55, 20:56, 20: 58, 21:00, 21:03. Reappeared at 21:05

Developed generalized seizure on receiving treatment Valium 10mg iv given Seizure stopped

Cardiac monitor

Defibrillation 200J Asystole Adrenaline 1mg VF Defibrillation 300J Asystole Amiodarone 300mg iv bolus Adrenaline 1mg iv SR

Patient semi conscious Intubated under RSI Admitted to ICU Extubated in ICU and discharged from medical ward

Happy Ending Beating Heart with a Thinking Mind

Case 2 AE04097XXX(X) Ms Ou F/28, 16: Tourist from Thailand to China C/O: Chest discomfort since 14:30 PH: VSD

P/E: BP: 115/64, P: 119/min, RR:14/min GCS: 15 Cat II

Dormicum 5mg iv Synchronized cardioversion 100J SR Amiodarone 150mg iv stat 150mg in 100ml over 1 hour

Admitted to CCU DAMA 2 days after

Case 3 AE04071XXX(X) Ms Siu F/82, 09:56, 8-04 C/O: Increase dizziness in the morning. Fell onto ground for 3 times. PH: HT, gout

P/E: BP: 95/50 (R/C 95/60)P:60 reg Fully conscious Cat III

Amiodarone 150mg in 100ml D5 ivi over 30mins Convert back to SR BP: 107/50, P:82/min

Case 4 AE01134XXX(X) Mr Cheng M/17, 17:48, C/O: LOC at 15:00 for 2mins, Left chest pain, sweating, palpitation PH: good

P/E: BP: 95/51, P150/min, RR: 22/min, SaO2: 100% (RA), GCS:15 Cat II

What next?

Chest drain inserted 1.4 litre of blood drained 1 litre of NS given Admit to surgery

Case 5 AE04102XXX(X) Mr Cheng M/75, 18:26, C/O: sudden onset of chest pain and SOB P/E: In distress, sweating BP: 106/51, P:71/min, RR: 40/min SaO2: 87% with O2

CXR: APO TNG, Aspirin were given

What next? Intubate or TCP?

Intubation was done under RSI Developed cardiac arrest after Suxamethonium was given CPR, Atropine and Adrenaline

Pulse returned transiently Put on TCP Develop cardiac arrest again No response to resuscitation Certified dead 1 hour after

A sad ending

ACLS A means or the end?

Exceptions VF in Hypothermia Tachycardia in TCA overdose Arrhythmia in hyperkalemia Bradycardia or Heart block in Ca channel blocker or  -blocker overdose

Treat the patient Not the ECG !

The Road Ahead

Future Biphasic defibrillation Antiarrhythmics

Biphasic defibrillation

Positive evidence supports a statement that initial low-energy (150-J), nonprogressive (150 J-150 J-150 J), impedance-adjusted biphasic waveform shocks for patients in out- of-hospital VF arrest are safe, acceptable, and clinically effective (Circulation. 1998;97: )

Biphasic defibrillation Less energy More efficacy Less myocardial damage Class IIA recommendation for VF/pulseless VT

Biphasic defibrillation What energy level for defibrillation? Is escalating energy necessary? Recommendations –150J, 150J, 150J –120J, 150J, 200J (Zoll) –200J, 300J, 360J (Medtronic)

Biphasic Synchronized cardioversion What energy level? –50J, 100J, 120J, 150J, 200J (Zoll) –50J, 100J, 200J, 300J 360J (Medtronic)

Drugs Vasopressin –Lack of evidence base Amiodarone –Effective drugs –Long term S/E

Questions & comments