ACLS Update 2005 recommendations Management of Cardiac Arrest

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ACLS Update 2005 recommendations
Management of Cardiac Arrest

• ??? 2006.01.05

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Introduction

• Pulseless cardiac arrest
• ventricular fibrillation (VF),
• rapid ventricular tachycardia (VT),
• pulseless electrical activity (PEA),
• Asystole
• Survival basic life support (BLS) and advanced
  cardiovascular life support (ACLS).
• The foundation of ACLS
• good BLS care,
• beginning with prompt high-quality bystander CPR
• for VF/pulseless VT, attempted defibrillation
  within minutes of collapse.

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• For victims of witnessed VF arrest, prompt
  bystander CPR and early defibrillation can
  significantly increase the chance for survival to
  hospital discharge. In comparison, typical ACLS
  therapies, such as insertion of advanced airways
  and pharmacologic support of the circulation,
  have not been shown to increase rate of survival
  to hospital discharge.

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Access for Medications Correct Priorities

• During cardiac arrest, basic CPR and early
  defibrillation are of primary importance, and
  drug administration is of secondary importance.
• Few drugs used in the treatment of cardiac arrest
  are supported by strong evidence. After beginning
  CPR and attempting defibrillation, rescuers can
  establish intravenous (IV) access, consider drug
  therapy, and insert an advanced airway.

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Central Versus Peripheral Infusions

• Central line access is not needed in most
  resuscitation attempts.
• Peripheral IV, IO (class IIa)
• Endotracheal (liodcaine, epinephrine, atropine,
  naloxone, vasopressin) lower ROSC
• 2 2 ½ x dose
• Epinephrine 3 10 x dose
• Diluted to 5 10 ml

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ACLS Pulseless Arrest Algorithm
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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia

• Witnessed arrest 2 breaths ? defibrillator
• not witnessed 5 cycles of CPR

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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia

• 1 shock
• Biphasic 120 200 J
• Monophasic 360 J

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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia

• 5 cycles (2 mins of CPR) after the 1st shock then
  rhythm checking

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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia

• CPR RHYTHM CHECK CPR -- SHOCK

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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia

• Antiarrhythmic (e.g. amiodarone) after 2 to 3
  shocks

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Ventricular Fibrillation/ Pulseless Ventricular
Tachycardia
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Asystole and Pulseless Electrical Activity

• Identify and treat a reversible
• cause

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Asystole and Pulseless Electrical Activity

• NOT interrupt CPR

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Medications for Arrest Rhythms

• Epinephrine and Vasopressin
• Epinephrine 1 mg every 3 to 5 mins
• Vasopressin 40 U substituted for the first or
  second dose of epinephrine
• Atropine
• 1 mg IV every 3 to 5 mins if asystole persists

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Medications for Arrest Rhythms

• Amiodarone
• 300 mg IV/IO, can be followed by one dose of 150
  mg IV/IO
• Lidocaine
• Lower rates of ROSC and higher incidence of
  asystole
• 1 to 1.5 mg/kg IV, additional 0.5 to 0.75 mg/kg
  IV at 5- to 10-min interval
• Magnesium
• Torsades de points (irregular/polymorphic VT
  associated with prolonged QT
• 1 to 2 g diluted in 10 mL D5W IV/IO push, 5 to 20
  min

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Potentially Beneficial Therapies

• Fibrinolysis
• When pulmonary embolus is suspected

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Interventions Not Supported by Outcome Evidence

• Pacing in arrest
• Not recommended at this time
• Procainamide in VF pulseless VT
• The use is supported by retrospective study
• Norepinephrine
• Equivalent to epinephrine in the initial
  resuscitation but associated with worse
  neurologic outcome

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Interventions Not Supported by Outcome Evidence

• Precordial thump
• Not recommended for BLS providers
• Class indeterminate for ACLU providers
• Electrolyte therapies
• Magnesium Torsades de points
• Routine administration of IV fluids insufficient
  evidence

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Summary

• Prevent pulseless good ACLS begins with
  high-quality BLS
• During resuscitation rescuers must
• provide good chest compressions (adequate rate
  and depth),
• allow complete recoil of the chest between
  compressions,
• minimize interruptions in chest compressions.
• avoid provision of excessive ventilation
• Resuscitation drugs have not been shown to
  increase rate of survival to hospital discharge,
  and none has the impact of early and effective
  CPR and prompt defibrillation.

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Thanks for your attention