1. 1 Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

2. 2 Pulseless Arrest

3. 4 rhythms 4 rhythms produce pulseless cardiac arrest: Ventricular fibrillation (VF) Rapid ventricular tachycardia (VT) Pulseless electrical activity (PEA) Asystole 3

4. Survival from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS). 4

5. witnessed VF arrest For victims of witnessed VF arrest, prompt bystander : 1. CPR 1. CPR 2. Early defibrillation 2. Early defibrillation can significantly increase the chance for survival to hospital discharge. 5

6. In comparison, typical ACLS therapies, such as: insertion of advanced airways and pharmacologic support of the circulation, not increase ROSC but have not been shown to increase rate of survival to hospital discharge. 6

7. 7

8. Central line access Central line access is not needed in most resuscitation attempts. 1 to 2 minutes peripheral vein Drugs typically require 1 to 2 minutes to reach the central circulation when given via a peripheral vein but require less time when given via central venous access. 8

9. peripheral venous route: 1. Follow with a 20 ml bolus of IV fluid 2. Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation. 9

10. Intraosseous (IO) cannulation provides access to a noncollaps-ible venous plexus, enabling drug delivery similar to that achieved by central venous access. 10

11. endotracheal route If IV and IO access cannot be established, some resuscitation drugs may be administered by the endotracheal route 11

12. Lidocaine Lidocaine Epinephrine Epinephrine Atropine Atropine Naloxone Naloxone Vasopressin Vasopressin 12 E T route:

13. The optimal endotracheal dose of most drugs is unknown,but typically the dose given by the endotracheal route is 2 to 2.5 times the recommended IV dose. 13

14. dilute Providers should dilute the recommended dose in 510mL 5 to 10 mL of water or normal saline 14

15. 15

16. 16

17. 17

18. 1. Hypoxia 2. Hypovolemia 3. Hydrogen Ion (Acidosis) 4. Hypo/ Hyper Kalemia 5. Hypothermia 1. Toxins 2. Tamponad (cardiac) 3. Tension Pneumothorax 4. Thrombosis (coronary) 5. Thrombosis (pulmonary) 18

19. 19

20. 20

21. complete cessation of myocardial electrical activity End-stage rhythm َ Asystole should always be confirmed in at least two limb leads It may be difficult to distinguish between extremely fine VF and asystole 21

22. 22

23. PEA is defined as non-coordinated groups of electrical activity of the heart (other than VT/VF) without a palpable pulse: EMD + pseudo EMD EMD = Electro Mechanical Dissociation : no myocardial contractions occur Pseudo-EMD : myocardial contractions occur but no pulse can be palpated 23

24. Idioventricular rhythms Ventricular escape rhythms Postdefibrillation idioventricular rhythms Brady-asystolic rhythms Agonal rhythms 24

25. 25

26. Global myocardial dysfunction Papillary muscle and myocardial wall rupture Hypovolemia, tension pneumothorax, pericardial tamponade, and massive PE 26

27. Patients who have either asystole or PEA will not benefit from defibrillation attempts A vasopressor (epinephrine ) may be administered at this time. Epinephrine can be administered approximately every 3 to 5 minutes during cardiac arrest 27 ASYSTOLE/PEA MANAGEMENT

28. 28

29. 29

30. 30

31. 31

32. 32

33. 33

34. When supplementary oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR 34

35. In intubated patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts, but it should not be used in isolation 35

36. if the arterial relaxation “diastolic” pressure is <20 mm Hg, it is reasonable to consider trying to improve quality of CPR by optimizing chest compression parameters or giving a vasopressor or both 36

37. 37

38. 38

39. 39

40. 40

41. 41

42. 42

43. 43

44. 44

45. 45

46. 46

47. 47

48. Emphasis on effective chest compression One universal compression-to- ventilation 30/2 Recommendation for 1-second breaths during all CPR 48

49. Rescuers should change compressors every 2 min Compression should ideally be interrupted only for rhythm check and shock delivery 49

50. Providers do not attempt a pulse or check the rhythm after shock delivery Drug should be delivered during CPR, as soon as possible after rhythm check 50

51. Antiarrhythmics: Amiodarone is preferred to lidocaine, but either is acceptable 1 shock NO check pulse Deliver 1 shock, then immediate CPR and NO check pulse 51

52. 52

53. 1-Epinephrine 2-Amiodarone 3-Lidocaine 4-Magnesium 53

54. magnesium sulfate When VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer magnesium sulfate at a dose of 1 - 2 g diluted in 10 mL D5W IV/IO push 54

55. in 50 to 100 mL of D5W When torsades is present in the patient with pulses, the same 1 - 2 g is mixed in 50 to 100 mL of D5W and given as a loading dose. It can be given more slowly (eg, over 20 to 60 minutes IV) 55

56. 56

57. 57

59. During resuscitation there are two patients, mother & fetus The best hope of fetal survival is maternal survival Consider the physiologic changes due to pregnancy

60. 60

61. Successful resuscitation of a pregnant woman & survival of the fetus require prompt & excellent CPR with some modifications in techniques By the 20th week of gestation, the gravid uterus can compress the IVC & aorta, obstructing venous return & arterial blood flow Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side

62. 62

63. Defibrillate using standard ACLS defibrillation doses There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus If fetal or uterine monitors are in place, remove them before delivering shocks

64. Defibrillation & medication doses used for resuscitation of the pregnant woman are the same as those used for other adults Rescuers should consider the need for ER Caesarian Delivery as soon as the pregnant woman develops cardiac arrest Rescuers should be prepared to proceed if the resuscitation is not successful within 4 minutes

65. 65

66. BLS treatment of cardiac arrest in asthmatic patients is unchanged Standard ACLS guidelines should be followed Auto PEEP tension pneumothorax 66

67. 67

68. management of cardiac arrest secondary to anaphylaxis should be treated with standard BLS and ACLS Airway The intramuscular (IM) administration of epinephrine Fluid Resuscitation Vasopressors 68

69. Adjuvant use of antihistamines (H1 and H2 antagonist), inhaled -adrenergic agents, and IV corticosteroids has been successful in management of the patient with anaphylaxis and may be considered in cardiac arrest due to anaphylaxis 69

70. 70

71. CPR for drowning victims should use the traditional A-B-C approach in view of the hypoxic nature of the arrest The first and most important treatment of the drowning victim is the immediate provision of ventilation. 71

72. Attempts to remove water from the breathing passages by any means other than suction (eg, abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous 72

73. As soon as the unresponsive victim is removed from the water, the rescuer should open the airway, check for breathing, and if there is no breathing, give 2 rescue breaths that make the chest rise Victims in cardiac arrest may present with asystole, PEA, or pulseless VT/VF. For treatment of these rhythms, follow the appropriate ACLS guideline s 73

74. AED? Cervical imobilization? 74

75. 75

78. 78 Some AEDs will automatically switch them- selves on when the lid is opened

79. 79

80. 80

81. 81 Stand clear Deliver shock

82. 82 302 30 2

83. 83 30 2

84. 84

85. defibrillation

87. The most effective treatment of VF is timely defibrillation early defibrillation :defined as defibrillation under 4 minutes of onset successful defibrillation implies delivering the appropriate amount of current or energy to the fibrillating myocardium, such that the chaotic electrical activity is terminated and a supraventricular perfusing rhythm is established

88. CPR prior to defibrillation Lack of success for in-hospital resuscitation appears to result from delays in time to first shock from collapse.

90. Defibrillator/ECG monitor Handheld defibrillation electrodes “quick-look” paddles Patient interface cables; multifunctional for ECG monitoring and defibrillation Electrodes and pads for ECG signal acquisition and defibrillation Conductive gel (not ultrasound gel)

92. always kept in a constant state of readiness Wherever possible, the defibrillator,patient cables, quick-look electrode paddles and ECG and defibrillation electrodes and pads should be preconnected and labeled to facilitate application to the patient members of the designated resuscitation team should check the equipment at the beginning of their clinical shifts

96. Manual Semiautomated fully automatic

99. Monophasic or 99 Biphasic

100. no specific waveform has been proved to be superior to another regarding survival from SCA or for the return of spontaneous circulation biphasic waveforms have been shown to be more efficient in achieving first-shock termination of VF than monophasic waveforms.

101. first type introduced still available in various patient care settings MDS waveform for defibrillation an energy level of 360 J be used for the first shock

102. Defibrillator today are primarily biphasic an output waveform that flows back and forth between the electrodes more successful defibrillation shock /less energy / better first-shock defibrillation success an optimal energy level for first-shock for VF has not been established, several studies have demonstrated that using relatively low energy of 200 J or less

103. device-specific effective waveform dose range biphasic rectilinear waveform 120 J unaware of waveform dose range, a consensus default of 200 J should be used for the initial shock

104. CHILDREN? 104

105. Attach Electrodes to patient Select DEFIB Unit automatically defaults to first shock setting determined in Configuration (typically 120J, 150J, 200J) To change energy setting, use UP/DOWN ARROWS. Selected energy is displayed as “DEFIB xxxJ SEL” Press CHARGE Make sure everyone is clear When SHOCK button lights, press SHOCK

106. Select DEFIB Unit automatically defaults to first shock setting To change energy setting, use UP/DOWN ARROWS Press CHARGE on the panel or on the apex handle Apply electrolyte gel to the paddles and apply paddles to chest Make sure everyone is clear When SHOCK button lights, place paddles on chest with 25 lb pressure and simultaneously press SHOCK on both paddles

110. Asystole or Fine VF 110

111. 111

112. 112 Post–Cardiac Arrest Care

113. 113

114. 114 Ventilation Hemodynamics Cardiovascular Neurological Metabolic