ACLS update
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The document summarizes recommendations for protocols in adult advanced life support (ALS) based on ANZCOR and international resuscitation guidelines. It outlines: 1) Using the ALS algorithm to manage all adults requiring advanced resuscitation 2) Prioritizing high-quality CPR and minimizing time to defibrillation for cardiac arrest patients 3) Minimizing interruptions to compressions during ALS interventions
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ACLS update
- 2. ANZCORGuideline11.2–ProtocolsforAdult AdvancedLifeSupport.(June 2017) Recommendations 1. That the Adult ALS algorithm be used as a tool to manage all adults who require advanced life support. 2. Good quality CPR and reducing time to defibrillation are the highest priorities in resuscitation from sudden cardiac arrest. 3. Rescuers should aim to minimise interruptions to CPR during any ALS intervention.
- 4. CPR • Depth: 5cm • Rate: 100-120bpm • Minimise interruptions • Cycle every 2 minutes or more frequently of required • ETCO2 < 10mmHg = inadequate compressions
- 9. VF
- 10. Shockable CPR 2 minutes CPR for 2 minutes Amiodarone 300mg IV/IO CPR for 2 minutes 1mg Adrenaline IV/IO (1 in 1000) Then every 2nd cycle • 200 J shock (biphasic) • Recommended it is reasonable to increase energy level for subsequent shocks.
- 11. Non shockable
- 13. Non shockable 1mg Adrenaline IV/IO (1 in 1000) CPR 2 minutes CPR 2 minutes
- 14. Reversible causes • Hypoxaemia • Hypovolaemia • Hyper/hypokalaemia & metabolic disorders • Hypo/hyperthermia • Tension pneumothorax • Tamponade • Toxins / poisons / drugs • Thrombosis-pulmonary / coronary 4 H’s & 4 T’s
- 17. Cardioversion Rhythm Energy level (biphasic) Atrial fibrillation 120-200 J (synchronised) Atrial flutter 50-100 J (synchronised) SVT 50-100 J (synchronised) Pulsed VT 100 J (synchronised) VF/Pulseless VT 200 J (consider increasing if unsuccessful)
- 18. Summary • All cardiac arrests should follow the ALS algorithm • Good quality CPR with minimal interruptions including • Resuscitate with 100% O2 • Early defibrillation • Consider higher energy levels if 1st shock unsuccessful
- 19. References • Soar J, Callaway C, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, on behalf of the Advanced Life Support Chapter Collaborators. Part 4: Advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e71– e120 • Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.027]. 2010;81(1, Supplement 1):e93-e174. • Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.AULink MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE SOCirculation. 2010;122(18 Suppl 3):S706. • Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729. • Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA 2017; 317:494.
Notas do Editor
- https://resus.org.au/guidelines/
- Other management priorities during CPR: • Minimise interruptions to CPR during ALS interventions [Class A; LOE III-2]. • Administer 100% oxygen when available (CoSTR 2015 weak recommendation, very low quality evidence).3 • Obtain intravenous or intra-osseous access [Class A; LOE II]. • Consider airway adjuncts, but attempts to secure the airway should not interrupt CPR for more than 5 seconds [Class A; Expert consensus opinion]. • Waveform capnography should be used to confirm airway placement and monitor the adequacy of CPR (CoSTR 2015 strong recommendation, low quality evidence).3 • Adrenaline should be administered every second loop (approximately every 4 minutes) [Class A; Expert consensus opinion]. • Other drugs/electrolytes should be considered depending on the individual circumstances [Class A; Expert consensus opinion]. End tidal CO2<10 = poor CPR
- 100% O2 Attempts to secure airway should not interrupt compressions for >5secs
- Other management priorities during CPR: • Minimise interruptions to CPR during ALS interventions [Class A; LOE III-2]. • Administer 100% oxygen when available (CoSTR 2015 weak recommendation, very low quality evidence).3 • Obtain intravenous or intra-osseous access [Class A; LOE II]. • Consider airway adjuncts, but attempts to secure the airway should not interrupt CPR for more than 5 seconds [Class A; Expert consensus opinion]. • Waveform capnography should be used to confirm airway placement and monitor the adequacy of CPR (CoSTR 2015 strong recommendation, low quality evidence).3 • Adrenaline should be administered every second loop (approximately every 4 minutes) [Class A; Expert consensus opinion]. • Other drugs/electrolytes should be considered depending on the individual circumstances [Class A; Expert consensus opinion]. End tidal CO2<10 = poor CPR
- Monomorphic VT Uniform broad QRS
- ANZCOR suggests that if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy to the maximum available for subsequent shocks (CoSTR 2015 weak recommendation, very low quality evidence).3 Precordial thump – witnessed VT (not VF) not on Defibrilator Stacked shocks – 3 sequential shocks if witnessed VT on defibriltor usually in cath lab
- 10ml of 10% Calcium chloride – hypoCa, HyperK, Ca channel blocker OD Mg – TdP, HypoK, dig toxicity, HypoMg Bicarb – Metabolic Acidosis, Arrest >15mins, Hyper K, TCA OD
- Amioderone: 150mg over 10 mins then infusion (900mg/24hrs), Bolus can be repeated or