Basic Life Support and Advance Cardiac Life Support Prepared by: AUGUST P. MALABANAN, RN Objectives 1. Students will be able to develop proficiency in providing BLS care, including prioritizing chest compressions and all the dynamics of Basic Life Support 2. Student will develop knowledge in managing cardiac arrest until return of spontaneous circulation (ROSC), termination of resuscitation, or transfer of care. 3. Student will be able to describe specific assessment and management of cardiac arrest patient using AHA ACLS Protocols 4. Student will be able to describe Post Cardiac Arrest Care standards. Lecture Outline • Cardiovascular Anatomy Quick Review • Basic Life Support • Advanced Cardiac Life Support – – – – Cardiopulmonary Resuscitation Airway Management Pharmacologic Management Electric Therapy • Post Cardiac Arrest Care Anatomy Quick Review!!! Functions of the Heart •Pumping oxygenated blood to the other body parts. •Pumping hormones and other vital substances to different parts of the body. •Receiving deoxygenated blood and carrying metabolic waste products from the body and pumping it to the lungs for oxygenation. •Maintaining blood pressure. Basic Life Support BLS (Basic Life Support) is a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel, such as emergency medical technicians, and by qualified bystanders. Indication of BLS • • • • Cardiac Arrest Respiratory Arrest Drowning Choking 1 2 3 4 5 Verifying if Scene is Safe. • Removing any potential hazard that could impact your ability to help someone else – Hazards could be something very obvious – traffic, downed power lines, smoke, or fire. – Hazards could be something small that you could miss – a wet or slippery floor, broken glass or sharp objects. – Hazards could also be your personal safety. It’s dark, you think you see someone lying on the ground a distance away. Is it safe for you to go check on them? Maybe, maybe not. Checking for Responsiveness First tap the victim and shout “HEY! HEY! Are you OK?” If they do not respond, shout for help. Activate the emergency response system. If you are alone, retrieve an AED and other emergency equipment. Send someone to get it if others are available. Assessment of Breathing and Pulse • check for absent or abnormal breathing by watching the chest for movements for 5 to 10 seconds. • Simultaneously check the carotid pulse for a minimum of 5 seconds—but no more than 10 seconds—to determine if there is a pulse present. • It’s important to minimize delay in starting CPR, so take no more than 10 seconds to assess the patient. Possible Responses • If the victim has a pulse and is breathing normally, monitor them until emergency responders arrive. • If the victim has a pulse but is breathing abnormally, maintain the patient’s airway and begin rescue breathing. Administer one breath every 5 to 6 seconds, not exceeding 10 to 12 breaths per minute. • If no breathing and Pulse Begin CPR. How to open Airway and Give Rescue Breathes • To open the airway, place 1 hand on the casualty's forehead and gently tilt their head back, lifting the tip of the chin using 2 fingers. • Use the fingers of one hand to pinch the person’s nostrils shut. This helps to prevent air from escaping through their nose. • Cover their mouth with yours, forming a seal so that air doesn’t escape. • Give rescue breaths by gently breathing into their mouth. A rescue breath should last about 1 second. Aim to give a rescue breath every 5 to 6 seconds. This is about 10 to 12 breaths per minute. • Check to see if the person’s chest rises as you give the first rescue breath. If it doesn’t, repeat step 2 (open the airway) before giving additional rescue breaths. • Continue giving rescue breaths until emergency medical services (EMS) arrives or the person begins breathing normally on their own. CPR • Cardiopulmonary Resuscitation • is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. • If a pulse is not identified within 10 seconds, immediately begin administering CPR, starting with chest compressions. Compressions should occur at a rate of 100 to 120 compressions per minute, with a depth of 2 inches. Use a compression-to-ventilation ratio of 30 compressions to 2 breaths. High Quality CPR Push Fast : Rate of 100 compressions per minute Push Hard: 1/3 the AP diameter of the chest or approximately 1 ½ inches (Infants) and 2 inches in Child Allow complete chest recoil Minimize Interruptions Avoid excessive ventilation Chest Compression to Ventilation Ratio Single Rescuer : 30 Compression is to 2 ventilation Multiple Rescuer: 15 Compression is to 2 ventilation If with advanced airway every 3 seconds. Use of AED • is a portable electronic device that automatically diagnoses the lifethreatening cardiac arrhythmias of ventricular fibrillation (VF) and pulseless ventricular tachycardia Advance Cardiac Life Support Advance Cardiac Life Support • often referred to by its acronym, "ACLS", refers to a set of clinical algorithms for the urgent treatment of cardiac arrest, stroke, myocardial infarction (also known as a heart attack), and other lifethreatening cardiovascular emergencies. Components of ACLS – – – – Cardiopulmonary Resuscitation Airway Management Pharmacologic Management Electric Therapy Airway Management Airway Management • Airway management in ALCS is different from BLS as the provider use advance devices to aid patient’s breathing Devices BAG VALVE MASK LMA Insertion Pharmacologic Management and Electrical Therapy Review of Meds Epinephrine • Classification : alpha- and beta-adrenergic agonists (sympathomimetic agents) Atropine Sulfate Class : parasympatholytic, Antimuscarinic, Anticholinergic Dopamine Class : Inotropic Agents Amiodarone Class : antiarrhythmics Atenolol Class : Beta-Blocker Digoxin Class :digitalis glycosides Lidocaine Class : Local Anesthetic and anti arrhythmic Diltiazem Class : calcium-channel blockers. Types of Rhythm • • • • PEA – Pulseless Electrical Activity asystole Bradycardia Tachycardia – Narrow-complex SVT – Stable V-Tach (monomorphic or polymorphic) PEA – Pulseless Electrical Activity • refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 55% of people in cardiac arrest. Management Pharmacologic Electric Therapy 1. Epinephrine – 1mg IV every 3-5 None minute 2. Atropine Sulfate – 1 mg IV every 3 to 5 minutes (max dose of 0.4 mg/kg) Asystole Management Pharmacologic Electric Therapy 1. Epinephrine – 1mg IV every 3-5 None minute 2. Atropine Sulfate – 1 mg IV every 3 to 5 minutes (max dose of 0.4 mg/kg) 3. Sodium bicarbonate 1 mEq/kg Bradycardia • means your heart rate is slow. • < 60 BPM Management Pharmacologic Electric Therapy 1. Atropine IV 0.5-1.0mg (Push) 2. Dopamine 5 to 20 ug/kg/min (Drip) 3. Epinephrine 2 to 10 ug/min (Drip) 1. Transcutaneous Pacing Atrial Fibrillation and Atrial Flutter • Atrial fibrillation is an irregular and often rapid heart rate that can increase your risk of strokes, heart failure and other heart-related complications. • Atrial flutter is similar to atrial fibrillation, a common disorder that causes the heart to beat in abnormal patterns. Management Pharmacologic Electric Therapy 1. Adenosine 6mg Rapid IV and 12mg Rapid IV 2. Procainamide 20-50mg/min until arrhythmia suppressed, Hypotension, increase of 50% in QRS Duration (max of 17mg/kg. 3. Amiodarone – 150mg IV over 10 minutes (1 mg/min for 6 hours drip) 4. Satalol 100mg (1.5 mg/kg) over 5 minutes Synchronized Cardioversion Narrow Regular: 50J to 100J Narrow Irregular: 120-200J Wide regular : 200J Wide Irregular : Defibrilation Narrow Complex - SVT • is a dysrhythmia originating at or above the atrioventricular (AV) node and is defined by a narrow complex • Usually with a rate of > 150 BPM. 3 types • Junctional Tachycardia • Paroxysmal SVT • Multifocal Atrial tachycardia Sample Pharmacologic Electric Therapy 1. Adenosine 6mg IV then 12mg IV for 2 more doses 2. Amiodarone 150mg IV then 300mg IV as Drip for 6 hours 3. Atenolol– 5mg IV over 5 minutes 4. Digoxin – 0.25 mg IV (max of 1mg/day) 5. Diltiazem - 0.25 mg/kg IV None Pulseless V-tach and V-Fib • Ventricular tachycardia (VT or V-tach) is a type of abnormal heart rhythm, or arrhythmia. It occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood. • Ventricular fibrillation is a type of abnormal heart rhythm (arrhythmia). During ventricular fibrillation, disorganized heart signals cause the lower heart chambers (ventricles) to twitch (quiver) uselessly. As a result, the heart doesn't pump blood to the rest of the body. Pharmacologic Electric Therapy 1. Amiodarone – 300mg IV once then Defibrilation – Start at 120J or 200J max 150mg for succeeding dose of 360J using Biphasic Defibrilator (200 to 2. Epinephrine 1mg IV every 3 to 5 360 J using Monophasic Defib) minutes 3. Lidocaine – 1mg to 1.5mg/kg, then 0.5 to .75mg/kg IV/IO (max of 3 doses) 4. Magnesium- loading dose of 1 to 2 mg for Torsades de pointes Post Cardiac Arrest Care Post cardiac Arrest Care when there is defined ROSC or Return of Spontaneous Circulation 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System 1. Targeted Temperature Management • For protection of the brain and other organs, hypothermia is a helpful therapeutic approach in patients who remain comatose (usually defined as a lack of meaningful response to verbal commands) after ROSC. • 32°C to 34°C for 12 or 24 hours beginning minutes to hours after ROSC. • Can be done thru superficial cooling or core temperature control • Possible Problems – Coagulopathy – Arrhythmias – and hyperglycemia 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System Organ-Specific Evaluation and Support • Pulmonary System • Sedation After Cardiac Arrest • Cardiovascular System Organ-Specific Evaluation and Support • Pulmonary System • Sedation After Cardiac Arrest • Cardiovascular System Pulmonary System • Essential diagnostic tests in intubated patients include a chest radiograph and arterial blood gas measurements. • Evaluation of a chest radiograph should verify the correct position of the endotracheal tube and the distribution of pulmonary infiltrates or edema and identify complications from chest compressions • Providers should adjust mechanical ventilator support based on the measured oxyhemoglobin saturation, blood gas values, minute ventilation (respiratory rate and tidal volume), and patient-ventilator synchrony. • ABG • • • • Maintain a 94% O2 Saturation Adjustment of O2 support No over ventilation RR of 12 to 20, ETCO2 of 35 to 45 mmhg Organ-Specific Evaluation and Support • Pulmonary System • Sedation After Cardiac Arrest • Cardiovascular System Sedation After Cardiac Arrest • Patients with coma or respiratory dysfunction after ROSC are routinely intubated and maintained on mechanical ventilation for a period of time, which results in discomfort, pain, and anxiety. • Shorter-acting medications that can be used as a single bolus or continuous infusion are usually preferred. Organ-Specific Evaluation and Support • Pulmonary System • Sedation After Cardiac Arrest • Cardiovascular System Cardiovascular System • The clinician should evaluate the patient's 12lead ECG and cardiac markers after ROSC • Used of PCI (Percutaneous Coronary Intervention) 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Vasoactive drugs may be administered after ROSC to support cardiac output, especially blood flow to the heart and brain. Drugs may be selected to improve heart rate (chronotropic effects), myocardial contractility (inotropic effects), or arterial pressure (vasoconstrictive effects), or to reduce afterload (vasodilator effects). Do not mix vasoactive agents with NaHCo3 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System Modifying Outcomes From Critical Illness • Glucose Control • Steroids • Hemofiltration Glucose Control Strategies to target moderate glycemic control (144 to 180 mg/dL [8 to 10 mmol/L]) may be considered in adult patients with ROSC after cardiac arrest. Attempts to control glucose concentration within a lower range (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) should not be implemented after cardiac arrest due to the increased risk of hypoglycemia Steroids • Corticosteroids have an essential role in the physiological response to severe stress, including maintenance of vascular tone and capillary permeability. Hemofiltration. • Hemofiltration has been proposed as a method to modify the humoral response to the ischemic-reperfusion injury that occurs after cardiac arrest. IDENTIFY REVERSIBLE CAUSES 1. 2. 3. 4. 5. Targeted Temperature Management Organ-Specific Evaluation and Support Vasoactive Drugs for Use in Post–Cardiac Arrest Patients Modifying Outcomes From Critical Illness Central Nervous System Central Nervous System • The pathophysiology of post–cardiac arrest brain injury involves a complex cascade of molecular events that are triggered by ischemia and reperfusion and then executed over hours to days after ROSC • Clinical manifestations of post–cardiac arrest brain injury include coma, seizures, myoclonus, various degrees of neurocognitive dysfunction (ranging from memory deficits to persistent vegetative state), and brain death. • Seizure Management • Neuroprotective Drugs Seizure Management • An EEG for the diagnosis of seizure should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after ROSC • Use of anti-seizure drugs such as thiopental, diazepam. Neuroprotective Drugs • Lamotrigine • Citicholine • Magnessium Sulfate TAKE HOME • • • • On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms. • • • Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions Post–cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes. Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome. References • https://www.ahajournals.org/doi/full/10.1161 /circulationaha.110.971002 • https://coastalcpr.com/scene-safety/ • https://resources.acls.com/free-resources/blsalgorithms/adult-cardiac-arrest • https://www.healthline.com/health/rescuebreathing#for-child-or-infant