2. 65-year old male come to ED with c/o several episodes of syncope. Upon
attending the patient, he complains of chest pain.
BP: 70/33, RR 28, PR 128
What is your next management?
Case Scenario 1
3. A 45-year-old woman with a history of palpitations develops light-headedness
and palpitations. She is alert and oriented.
BP is 138/84. Pulse is 150.
What is your next management?
Case Scenario 2
4. You attend a 56-year-old diabetic woman with dizziness and sudden onset of chest
pain. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac
monitor documents the rhythm below. She is receiving oxygen at 4 L/min by nasal
cannula and an IV has been established.
What is your next management?
Case Scenario 3
5. A 40 year-old man is brought to your tertiary ED after being found unconscious.
PR no pulse
What is your next management?
Case Scenario 4
6. Overview
1. The BLS survey
2. High quality cardiopulmonary resuscitation
(CPR)
3. The ACLS Survey
4. The ACLS algorithms
5. Immediate post-cardiac arrest care
6. Case scenario
7. AHA 2010 Adult Chain of Survival
1. Immediate recognition of cardiac arrest and
activation of emergency response system
2. Early CPR with emphasis on chest
compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care
8. Systematic Approach
If the patient appears unconscious:
- Use the BLS survey for initial management
- Proceed with ACLS survey for more advanced
assessment and treatment
If the patient appears conscious:
- Use the ACLS Survey for initial management
9.
10.
11. Key changes from the 2005 BLS Guidelines
⢠Immediate recognition of cardiac arrest based on
assessing unresponsiveness and absence of normal
breathing
⢠âLook, listen and feelâ removed from the BLS algorithm
⢠Sequence change from ABC to CAB
⢠Healthcare providers continue effective chest
compressions until return of spontaneous circulation or
termination of resuscitative efforts
12. High quality cardiopulmonary resuscitation (CPR)
⢠Compress the chest hard and fast âPush hard, Push fastâ
- Compress the center of the chest with at least 100
compressions per minute at a depth of at least 2 inches
⢠Allow complete chest recoil after each compression
⢠Minimize interruptions in compressions (10 seconds or
less)
⢠Switch providers about every 2 minutes to avoid fatigue
⢠Avoid excessive ventilation
13. The ACLS survey
(A) Airway: Maintain airway and use advanced airway if needed.
Ensure confirmation of placement of an advanced airway and secure
the advanced airway device.
(B) Breathing: Give bag-mask ventilation, provide supplemental
oxygen, and avoid excessive ventilation. Also, adequacy of ventilation
and oxygenation should be monitored during this step.
(C) Circulation: Obtain IV access, attach ECG leads, identify and
monitor arrhythmias, giving fluids if needed, and use defibrillation if
appropriate.
(D) Differential diagnosis: Look for reversible causes and contributing
factors for the emergency.
14.
15. Effective Resuscitation Team Dynamics
Members of the resuscitation
team
- Team leader
- Airway or ventilator
- Defibrillator
- Compressor
- Medicator
- Recorder or observer
Elements of an effective team
- Closed loop communication
- Clear messages
- Clear roles and responsibilities
- Knowing one limitation
- Knowledge sharing
- Constructive intervention
- Reevaluation and summarizing
- Mutual respect
16. ACLS scenario
1. Respiratory arrest
2. Cardiac arrest (Pulseless arrest)
- VF / Pulseless VT
- Asystole or PEA
3. Bradycardia
4. Tachycardia â Unstable and stable
17. The ACLS cases: Respiratory arrest
⢠Management of respiratory arrest includes
both BLS and ACLS interventions
⢠Interventions include:
- Giving supplementary oxygen
- Opening the airway
- Providing basic ventilation
- Using basic airway adjuncts (OPA and NPA)
- Suctioning
18. The ACLS cases: Respiratory arrest
Airway device Ventilation during
cardiac arrest
Ventilation during
respiratory arrest
Bag-mask 2 ventilations after every
30 compressions
1 ventilation every 5 to 6
seconds
(10 to 12 breaths per
minute)
Any advanced airway 1 ventilation every 6 to 8
seconds
(8 to 10 breaths per
minute)
Providing Ventilation with an Advanced Airway
- Laryngeal mask airway
- Laryngeal tube
- Esophageal-tracheal tube
- Enotracheal tube
Once an advanced airway is in place, chest compressions are no
longer interrupted for ventilations
19. The ACLS cases:
Cardiac arrest
There are 4 rhythms seen in
pulseless cardiac arrest:
1. Pulseless Ventricular
Tachycardia (VT)
2. Ventricular Fibrillation (VF)
3. Asystole
4. Pulseless Electrical Activity
(PEA)
24. DEFIBRILLATOR
1. Attach electrodes to patientâs chest and turn on
2. Analyse the rhythm ?shockable
3. Apply coupling agent or pads to patientâs chest
4. Select energy level â 200Joule
5. Apply paddles to chest
6. Charge the paddles
7. The âClearâ chant
8. Check monitor again
9. Discharge shock and return paddles to machine
31. 65-year old male come to ED with c/o several episodes of syncope. Upon
attending the patient, he complains of chest pain.
BP: 70/33, RR 28, PR 128
What is your next management?
Case Scenario 1
32. A 45-year-old woman with a history of palpitations develops light-headedness
and palpitations. She is alert and oriented.
BP is 138/84. Pulse is 150.
What is your next management?
Case Scenario 2
33. You attend a 56-year-old diabetic woman with dizziness and sudden onset of chest
pain. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac
monitor documents the rhythm below. She is receiving oxygen at 4 L/min by nasal
cannula and an IV has been established.
What is your next management?
Case Scenario 3
34. A 40 year-old man is brought to your tertiary ED after being found unconscious.
PR no pulse
What is your next management?
Case Scenario 4
ventricular tachycardia with pulse, unstable
Syncronised cardioversion; mode 100 J
SVT
Second degree heart block Mobitz type II
Pulseless VT
The 5 links in the adult Chain of Survival
A strong Chain of Survival can improve chances of survival and recovery for victims of heart attack, stroke and other emergencies
The systematic approach requires healthcare providers to determine the patientâs level of consciousness
How do you check responsiveness?
(BLS)
-Check for absent/abnormal breathing (look at chest)
-No more than 10 seconds
The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR
When the BLS survey is complete or if the patient is conscious and responsive, the responder should conduct the ACLS survey with a focus on identifying and treating the underlying cause(s) of the patientâs problem.
The ACLS Survey uses the ABCD model to systematize the ACLS process
5 basic airway skills: 1.) Head tilt-chin lift; 2.) Jaw thrust without head extension for possible cervical spine injury; 3.) Mouth-to-Mouth ventilation; 4.) Mouth-to-Barrier device (using a pocket mask); and 5.) Bag-mask ventilation.
Ventilation rates
post-cardiac arrest care is now the 5th link in the AHA adult chain of survival
post-cardiac arrest care requires an integrated multidisciplinary approach.
Check level of consciousness- follow command
To protect the brain and other organs, the resuscitation team should induce therapeutic hypothermia in patient who fails to follow commands- target T of 32 to 34C for a period of 12 to 24h
Tissue perfusion
instability
ventricular tachycardia with pulse, unstable
Syncronised cardioversion; mode 100 J