1. Advanced Cardiac Life Support 2004
Mark I. Langdorf, MD, MHPE, FACEP
Professor or Clinical Emergency Medicine
Chair and Associate Residency Director
University of California, Irvine

2. ACLS History Sixth iteration of guidelines since 1966
Second that is evidence based
First that incorporates international perspective

3. Evidence Based Guidelines
Search the international literature
Determine level of each piece of evidence
Graded each study for quality
Integrate all evidence into final class recommendation

4. Classes of Recommendations
Class I: always acceptable, proven safe and definitely useful
Class IIa: acceptable, reasonably prudent, intervention of choice by experts
Class IIb: acceptable, safe and useful, within standard of care, optional or alternative by experts
Interderminate: inadequate research to decide
Class III: evidence for benefit lacking, or harmful

5. Chain of Survival Recognize early warning signs Activate EMS Basic CPR
Defibrillation
Airway and ventilation
Intravenous medications

6. Public Access Defibrillation: PAD
Goal: AEDs used by laypersons everywhere
Most effective cardiac intervention
Shown to be cost effective (cost per life year saved)
Response time goal is 3 to 5 minutes
Police
Fire
Casino
Airlines
First responders
Survival rates up to 49% from primary ventricular fibrillation

7. Sequence of Events
50% of patients with CAD first present with sudden death
Sequence:
Decades of atherosclerotic buildup
Plaque rupture or erosion
Platelet adhesion
Occluding thrombus
Severe ischemia
Irritable myocardium
Ventricular fibrillation
Collapse and sudden death

8. Adult BLS: Recent Changes
Phone first (no CPR unless drowned, trauma or overdose)
BLS should transport to ED capable of IV thrombolysis for MI and stroke
Within 30 minutes for MI
Within 60 minutes for stroke

9. BLS Sequence Changes 10cc/kg tidal volume without oxygen
6-7 cc/kg with supplemental oxygen
Prevent gastric insufflation: deliver over 2 seconds
Lay rescuers don’t check pulses before chest compressions, healthcare workers do
Compression rate 100/minute
15:2 ratio for 1 and 2-rescuer CPR

10. Prehospital Care for ACS
Oxygen is routine
Aspirin en route: mg
Nitroglycerin
Be careful with Viagra
Need SBP >90
3 sprays q 3-5 minutes
Morphine if 3 sprays don’t relieve pain
12 lead ECG under study

11. Prehospital Stroke Care
Determine time of onset and GCS
Perform prehospital stroke scale
Cincinnati PSS: sensitivity 72%
Los Angeles PSS: 93% sensitivity, 97% specificity
LAPSS
Age > 45
No seizures
Duration < 24 hours
Ambulatory at baseline
Glucose
Obvious asymmetry of face/grip/arm strength

12. ACLS Changes for 2000
Wide complex tachycardia: Amiodarone and procainamide before lidocaine and adenosine (IIb)
Stable V tach (and torsades): Amiodarone and sotalol preferred (IIa)
Bretylium not available (IIb)
Lidocaine: evidence poor for benefit for v-fib and v-tach (indeterminate)

13. ACLS Changes for 2000
V-fib/pulseless V-tach: evidence for all antiarrhythmics weak. Amiodarone preferred (IIb)
Magnesium still IIb for torsades de pointes (polymorphic ventricular tachycardia)
Vasopressin: may be more effective than epinephrine in cardiac arrest (IIb)
40 units IV only once
Epinephrine still class IIb
High-dose epinephrine: no benefit (indeterminate)

14. Defibrillation: Biphasic
Will become the norm
As effective at lower energy
150 biphasic = 200 monophasic
No need for escalating energy levels (joules)
Transthoracic impedance declines with subsequent shocks
Repeat same energy = success

15. Shock Energies: Recommended
Still 200/ /360 joules for v-fib /pulseless v-tach
Atrial fibrillation:
Atrial flutter/PSVT 50 to start
Ventricular tachycardia
Monomorphic (usual) 100 joules
Polymorhpic (torsades de pointes) 200 joules

16. Other Defibrillator Points:
Synchronize for any perfusing rhythm
Avoids precipitating ventricular fibrillation
Hold buttons down
Check two leads for asystole
If no ventricular fibrillation noted, defibrillation not effective
Lead disconnect can simulate asystole

17. Cardiac Arrhythmias Check the patient, not the rhythm
Perfusion is most important
Wide complex tachycardias are ventricular tachycardia
Odds 75/25 ventricular/supraventricular
Older (>45 yo)
Sicker (previous MI or coronary disease)
Treat the worst, first
12 ECG criteria not reliable enough to distinguish

18. Rhythms to recognize Normal sinus rhythm Atrio-ventricular (AV) blocks
1st degree(not important)
2nd degree
Type I (Wenkebach)
Type II (dangerous)
3rd degree (complete, AV disassociation)
Premature complexes
Atrial (no pause)
Ventricular (compensatory pause)

19. Rhythms to Recognize Ventricular tachycardia Ventricular fibrillation
Monomorphic
Polymorphic (Torsades de pointe)
Ventricular fibrillation
Asystole (confirm)

20. Tachyarrhythmias Narrow QRS complex (<120 msec) Sinus
Atrial fibrillation
Atrial flutter
Atrial tachycardia (digoxin toxicity)
Multifocal atrial tachycardia (COPD)
AV nodal re-entrant tachycardia (PSVT)
Junctional tachycardia

21. Tachyarrhythmias Wide QRS (>120 msec) 12 lead if stable
Ventricular tachycardia (usually 160 msec)
Supraventricular tachycardia with aberrant conduction (usually not this wide)
12 lead if stable
Mr. Edison if not

22. Show Rhythm Strips

23. Routes for Drug Administration
Evidence for effectiveness for all drugs is weak
Drugs are secondary interventions
Peripheral still first choice
flush with NS
1-2 minutes to central circulation
If no response to drugs and defibrillation
Consider central line
Internal jugular (IJ) preferred (or supraclavicular subclavian)
Femoral less preferred
Avoid non-compressible sites if possible

24. Tracheal Administration
N-a-v-e-l still holds: drugs for the ET tube
Narcan
Atropine
Valium
Epinephrine
Lidocaine
Amiodarone/vasopressin not yet studied, so avoid
Dilute in 10cc/bag vigorously
2-2.5 times the IV dose for all meds

25. Wide Complex Tachycardias: Stable
Must be regular and fast (>120)
Must be uniform (one QRS morphology)
No signs of impaired perfusion
Mental status normal
No chest pain or CHF
Skin signs warm and dry
Systolic BP > 90 mm Hg
Obtain 12 lead ECG if stable

26. Wide Complex Tachycardias: Stable
Procainamide first line if ventricular function normal (sotalol) (both IIa)
Amiodarone (IIb) (150mg over 10 minutes) or Lidocaine (.5-.75mg/kg IVP) if poor EF (<40%)
If ineffective:
Synchronized cardioversion (100/200/300/360 joules)
No repeat drug doses recommended
Bottom line:
Normotensive: procainamide
Hypotensive: cardiovert

27. Polymorphic Ventricular Tachycardia
Recurrent bouts
Usually terminate spontaneously, or
Degenerate into v-fib
Stop offending meds that prolong QT interval
Correct hyopcalcemia/hypomagnesemia
Magnesium 2-4 grams IVP (shortens QT)
Transcutaneous pacer (“overdrive pacing”)
Rate >100 if no ischemia
Shortens QT, reduces recurrence

28. V-fib/Pulseless V-tach
This is easy!
Defib three times ASAP (200/300/360)
ABCs
Epi 1mg IV every 3-5 minutes, or
Vasopressin 40 units IVP, once
Then Epi same as usual
Amiodarone (IIb) 300mg IVP (second dose if recurrent V-fib 150 mg)

29. Look for Cause! Hypovolemia Hypoxia
ETT/02 hooked up/pneumothorax/CO poisoning
Acidosis
Hypo/hyperkalemia
Cardiac tamponade
Tension pneumothorax
Coronary thrombosis
Massive pulmonary embolism

30. Langdorf’s Silly Mnemonic
Shock, shock, shock (defibrillation three times)
All Breathing Counts (airway, breathing, circulation)
EVerybody (epinephrine OR vasopressin)
Shocks (defib)
Americans (amiodarone)
Shock (defib)
Europeans (epinephrine again)
Latin Americans (lidocaine)

31. Sodium Bicarbonate: Indications
No changes
Hyperkalemia (class I)
Pre-existing acidosis (class IIa)
TCA overdose (class IIa)
ASA overdose (class IIa)
Prolonged arrest (class IIb)
Return of spontaneous circulation (class IIb)
NOT in hypoxic, lactic acidosis cardiac arrest!

32. Pressors: Epinephrine
Alpha effects confer benefit
Increases systemic vascular resistance
Increases aortic root pressure
Perfuses coronaries
Perfuses brain at expense of body
Escalating or high doses without demonstrable benefit
Potent pressor for hypotension (1mg in 500cc at 2-10 micrograms/min)

33. Pressors: Norepinephrine
Potent alpha and beta agonist
Indicated for severe hypotension (SBP < 70)
Dose 1-30 micrograms/min
Extravasation: infiltrate 5-10 mg of phentolamine

34. Pressors: Dopamine Precursor of norepinephrine
Alpha and beta adrenergic agonist
Indicated with hypotension and bradycardia (raises SBP and HR)
Dose 5-20 micrograms/min after cardiac arrest
5-10 primarily beta stimulation
10-20 additional potent alpha effect

35. Pressors: Dobutamine Potent beta-1 selective ventricular inotrope
Use for severe systolic dysfunction
Reflex tachycardia due to peripheral vasodilation
5-20 micrograms/min