Advanced Cardiovascular
Life Support (ACLS)
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
2010 ACLS Guidelines
Science updates
to CPR and ECC
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Basic Life Support
ACLS
Acute Coronary
Syndrome
Electrical
Therapies
CPR Techniques
and Devices
Stroke
Ethical Issues
Education,
Implementation,
and Teams
The road to change
Evidence Evaluation Process
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International consensus
Extensive review of resuscitation literature
Peer-reviewed studies
Rigorous disclosure and management of conflicts of
interest
BLS Survey
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Chest Compressions
High Quality
Chest
Compressions
“push hard
and
push fast”
High-Quality Chest Compression
To deliver effective chest
compressions, you must:
• Rate: at least 100/minute
• Depth:
• 2 inches [5 cm] in adults and children
• 1.5 inches [4 cm] infants
• Allow full chest recoil
• Minimize interruptions
• Avoid excessive ventilation
Compression Depth At Least 2 Inches
For adults, at
least 2 inches
(5 cm)
Compression -to- ventilation ratio
Questions?
Change “A-B-C” to “C-A-B”
Chest compressions
Chest compressions
and early defibrillation.
Elimination of Look, Listen, and Feel
Cricoid Pressure During Ventilation
Not Recommended
Definition of Cricoid
Pressure
Cricoid pressure is a technique
of applying pressure to the
victim’s cricoid cartilage to push
the trachea posteriorly and
compress the esophagus against
the cervical vertebrae. Cricoid
pressure can prevent gastric
inflation and reduce the risk of
regurgitation and aspiration
during bag mask ventilation, but
it may also impede ventilation.
BLS Survey
First
Then
Check simultaneously:
1) Responsiveness
2) Breathing
If victim unresponsive and not
breathing:
1) Activate emergency response system
2) Retrieve AED if available
3) If no pulse felt within 10 seconds, begin CPR
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Advanced
Cardiovascular Life
Support
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Overview
Advanced
Cardiovascular Life
Support
Simplified Cardiac
Arrest Algorithm
Monitoring to
Optimize CPR
Post-Cardiac Care
Airway Management
Simplified ACLS Algorithm
Adult arrest algorithm
ACLS Cardiac Arrest Algorithm
Neumar, R. W. et al. Circulation
2010;122:S729-S767
Tachycardia Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
Bradycardia Algorithm
Neumar, R. W. et al. Circulation 2010;122:S729-S767
Questions?
Capnography Recommendation
Capnography Waveform
Capnography to confirm endotracheal tube placement.
Capnography to monitor effectiveness of resuscitation efforts.
Ineffective chest
compressions
indicated by
Pressure of end tidal
CO2 (PETCO2)
New Medication Protocols
Symptomatic Arrhythmias
Medication Recommendations
PEA/asystole
Epinephrine IV/IO Dose: 1 mg every 3-5 minutes
Vasopressin IV/IO Dose: 40 units can replace first or
second dose of epinephrine
Amiodarone IV/IO Dose: First dose: 300 mg bolus.
Second dose: 150 mg.
Tachycardia
Adenosine IV Dose: First dose: 6 mg rapid IV push; follow
with NS flush.
Second dose: 12 mg if required.
Symptomatic or
unstable bradycardia
Atropine IV Dose:
First dose: 0.5 mg bolus
Repeat every 3-5 minutes
Maximum: 3 mg
OR
Dopamine IV Infusion:
2-10 mcg/kg per minute
OR
Epinephrine IV Infusion:
2-10 mcg per minute
Organized Post-Cardiac Care
Improved Survival
Hemodynamic
Neurologic
Metabolic
Effect of Hypothermia on Prognostication
Positive results from
therapeutic hypothermia
Oxygen Saturation
Oxygen Saturation
Special Resuscitation Situations
Asthma
Anaphylaxis
Pregnancy
Morbid obesity
Pulmonary embolism
Electrolyte imbalance
Ingestion of toxic substances
Trauma
Accidental hypothermia
Avalanche
Drowning
Electric shock/lightning strikes
Percutaneous coronary intervention
Cardiac tamponade
Cardiac surgery
Acute Coronary
Syndromes
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
ACS
The primary goals of therapy for
patients with ACS include the need to:
• Reduce the amount of myocardial necrosis
• Prevent major adverse cardiac events
• Treat acute, life-threatening complications
Systems of Care for Patients With
ST-Elevation Myocardial Infarction (STEMI)
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• Educational programs
• EMS protocols
• ED & hospital transports
STEMI Systems of Care
Triage to Capable Hospital
Cardiac Catheterization
Questions?
Electrical Therapies
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Electrical Therapy
Defibrillation
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Cardioversion
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Pacing
Healthcare Provider AED Recommendations
AED Use in Children Includes Infants
One-Shock Protocol Versus
Three-Shock Sequence
1-shock defibrillation protocol followed by immediate CPR
Defibrillation Waveforms and Energy Levels
200 J
Pediatric Defibrillation
2 J/kg
Fixed and Escalating Energy
Joules
400
350
300
250
200
150
100
50
0
Escalating Energy Levels
Electrode Placement
Anterior-lateral
Anterior-posterior
Anterior-left infrascapular
Anterior-right infrascapular
Defibrillation With Implanted
Cardioverter Defibrillator
Anterior-posterior
or
Anterior-lateral
Synchronized Cardioversion
Energy Doses
Supraventricular Tachycardias
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Initial biphasic energy
dose of 50-100 J
Ventricular Tachycardia
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Monophasic or biphasic
waveform cardioversion
shocks at initial energy
of 100 J
Fibrillation Waveform Analysis
The value of VF waveform analysis to
guide defibrillation management during
resuscitation is uncertain.
CPR Techniques and
Devices
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Recommended Devices
No resuscitation device
other than a
defibrillator
has consistently
improved long-term
survival from out-ofhospital cardiac arrest.
Use of Precordial Thump Not
Recommended
Definition of
Precordial Thump
The precordial thump is a
CPR technique used by
healthcare professionals
in the initial response to a
witnessed cardiac arrest
when no defibrillator is
immediately available.
Stroke
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Stroke Care
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Detection
Dispatch
Delivery
Door
Data
Decision
Drug
Disposition
Stroke-Prepared Hospital
rtPA Guidelines
Patients Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset
Inclusion Criteria
• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms <3 hours before beginning treatment
• Age ≥18 years
Exclusion Criteria
• Head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
• Evidence of active bleeding on examination
• Acute bleeding diathesis, including but not limited to
− Platelet count <100 000/mm3
− Heparin received within 48 hours, resulting in aPTT >upper limit of normal
− Current use of anticoagulant with INR >1.7 or PT >15 seconds
• Blood glucose concentration <50 mg/dL (2.7 mmol/L)
• CT demonstrates multilobar infarction (hypodensity >¹⁄³ cerebral hemisphere)
Relative Exclusion Criteria
Recent experience suggests that under some circumstances—with careful consideration and
weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative
contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative
contraindications is present:
• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Seizure at onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)
Stroke Unit Care
Magnitude of benefits from treatment in a stroke unit
are comparable to magnitude of effects achieved with rtPA.
Management of Hypertension
Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke
Patients Who Are Potential Candidates for Acute Reperfusion Therapy
Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:
• Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1, or
• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes, maximum 15 mg per hour;
when desired blood pressure is reached, lower to 3 mg per hour, or
• Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA.
Management of blood pressure during and after rtPA or other acute reperfusion therapy:
Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every
30 minutes for 6 hours, and then every hour for 16 hours.
If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:
• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or
• Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour every 5-15 minutes, maximum
15 mg per hour
If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.
Questions?
Ethical Issues
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Ethical issues relating to resuscitation are complex.
Terminating
Resuscitative Efforts
in Adults with Out-ofHospital Cardiac
Arrest (OHCA)
 Arrest not witnessed by EMS
provider or first responder
 No ROSC after three
complete rounds of CPR and
AED analyses
 No AED shocks
were delivered
“ALS termination of resuscitation” rule was established to
consider terminating resuscitative efforts prior to ambulance
transport if all of the following criteria are met:
 Arrest not witnessed
 No bystander CPR
was provided
 No ROSC after
complete ALS care
in the field
No shocks
were delivered
Prognostic Indicators in the Adult Post-Arrest Patient Treated
with Therapeutic Hypothermia
v
Education,
Implementation, and
Teams
2010 Heart and Stroke Foundation of
Canada Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC)
Learn and Live
Chain of Survival
Thank you.