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ACLS Past, Present & Future Dr FT Lee A&E, PMH 2004 http://pmh-acls2004.tripod.com
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Do s Brief review of main points Case presentation Future development
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Don’t s Review of Algorithms
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History Originated in Nebraska in early 1970
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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
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Cardiac arrest? Breathing 氣 Beating 血
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Pulse check no more than 10 sec Start chest compression if you are unsure
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Cardiac Arrest Ventricular fibrillation/ Pulseless Ventricular Tachycardia Asystole Pulseless Electrical Activity(PEA)
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Early defibrillation The most frequent initial rhythm in sudden cardiac arrest is VF Chance of successful defibrillation reduced 10% each minute
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Chain of survival Early accessEarly CPREarlyEarly ACLS Defibrillation
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Pulse +ve Tachycardia 快 Bradycardia 慢
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Tachycardia (P > 100/min) Wide complex –QRS >0.12 s (3 small squares) Narrow complex –QRS < 0.12 s
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Bradycardia (P< 60/min) Sinus Heart Block –1 st, 2 nd and 3rd
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Pulse +ve STABLE ?
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Unstable Shock SOB Severe chest pain Impaired consciousness
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Unstable Electrical therapy
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Stable Drug
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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
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Is life so simple?
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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
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BP: 182/73, P: 99/min reg, RR: 14/min SaO2: 96% (RA) Triage as Cat III (20:00) ECG ordered
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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
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Developed generalized seizure on receiving treatment Valium 10mg iv given Seizure stopped
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Cardiac monitor
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Defibrillation 200J Asystole Adrenaline 1mg VF Defibrillation 300J Asystole Amiodarone 300mg iv bolus Adrenaline 1mg iv SR
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Patient semi conscious Intubated under RSI Admitted to ICU Extubated in ICU and discharged from medical ward
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Happy Ending Beating Heart with a Thinking Mind
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Case 2 AE04097XXX(X) Ms Ou F/28, 16:24 10-04 Tourist from Thailand to China C/O: Chest discomfort since 14:30 PH: VSD
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P/E: BP: 115/64, P: 119/min, RR:14/min GCS: 15 Cat II
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Dormicum 5mg iv Synchronized cardioversion 100J SR Amiodarone 150mg iv stat 150mg in 100ml over 1 hour
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Admitted to CCU DAMA 2 days after
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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
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P/E: BP: 95/50 (R/C 95/60)P:60 reg Fully conscious Cat III
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Amiodarone 150mg in 100ml D5 ivi over 30mins Convert back to SR BP: 107/50, P:82/min
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Case 4 AE01134XXX(X) Mr Cheng M/17, 17:48, 12-01 C/O: LOC at 15:00 for 2mins, Left chest pain, sweating, palpitation PH: good
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P/E: BP: 95/51, P150/min, RR: 22/min, SaO2: 100% (RA), GCS:15 Cat II
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What next?
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Chest drain inserted 1.4 litre of blood drained 1 litre of NS given Admit to surgery
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Case 5 AE04102XXX(X) Mr Cheng M/75, 18:26, 11-04 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
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CXR: APO TNG, Aspirin were given
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What next? Intubate or TCP?
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Intubation was done under RSI Developed cardiac arrest after Suxamethonium was given CPR, Atropine and Adrenaline
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Pulse returned transiently Put on TCP Develop cardiac arrest again No response to resuscitation Certified dead 1 hour after
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A sad ending
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ACLS A means or the end?
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Exceptions VF in Hypothermia Tachycardia in TCA overdose Arrhythmia in hyperkalemia Bradycardia or Heart block in Ca channel blocker or -blocker overdose
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Treat the patient Not the ECG !
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The Road Ahead
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Future Biphasic defibrillation Antiarrhythmics
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Biphasic defibrillation
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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;97:1654-1667.)
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Biphasic defibrillation Less energy More efficacy Less myocardial damage Class IIA recommendation for VF/pulseless VT
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Biphasic defibrillation What energy level for defibrillation? Is escalating energy necessary? Recommendations –150J, 150J, 150J –120J, 150J, 200J (Zoll) –200J, 300J, 360J (Medtronic)
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Biphasic Synchronized cardioversion What energy level? –50J, 100J, 120J, 150J, 200J (Zoll) –50J, 100J, 200J, 300J 360J (Medtronic)
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Drugs Vasopressin –Lack of evidence base Amiodarone –Effective drugs –Long term S/E
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Questions & comments
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