ADVANCED ADVANCED CARDIAC LIFE SUPPORT TUAN HAIRULNIZAM TUAN KAMAUZAMAN Emergency Physician/Senior lecturer Department of Emergency Medicine Universiti Sains Malaysia
OBJECTIVE OF COURSE •
To acquire the knowledge of ACLS
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To acquire the skills of ACLS
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To encourage encourage systematic and and efficient effici ent teamwork in resuscitation To assess ACLS competency
Rhythm
BLS
Airway
ACLS Electrical therapy
Algorithm
Drug
Teaching method
Megacode demo Skill stations Lecture
Scenario run-tru
Megacode practise
Assessment Assessment
Max mark awarded
Theory
50%
Practical
50%
Passing mark = 50%
ACLS ALGORITHM TUAN HAIRULNIZAM TUAN KAMAUZAMAN Emergency Physician/Senior lecturer Department of Emergency Medicine Universiti Sains Malaysia
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ACLS DRUG THERAPY
General principle •
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Second priority to defib and good chest compression – only in SECONDARY SURVEY All antiarrthmic is pro-arrthymic!! – LIMIT TO ONE CHOICE OF DRUG ONLY All resus drug to be given g iven tru least resistant IV access. Best given diluted with IV saline push.
Adrenaline Class
Sympatomimetic Sympatomimetic - on alpha and beta receptor
Presentat Clear solution 1ml/vial 1:1000 conc 1 ion mg Usage
Cardiac arrest (VT/VF/ (VT/VF/asystole/PEA), asystole/PEA), anaphylaxis, bronchospasm, local vasoconc.
Dosage
10 ml/1mg/1:10000 ml/1mg /1:10000 conc every 3-5 mins in CA
Adrenaline - action CVS
Positive inotrop/chronotrop (β1) Coronary vasodilate (α2) Peripheral vasoconstrict (α1)
Resp
Bronchodilator (β2)
GU
Decrease renal blood flow
Metabolic
Blood sugar/FFA
Amiodarone Class
Anti-arrthymicAnti-arrthymic- class III – affects affects sodium, potassium, calcium channel and α and β receptor
Usage
VF/pulseless VF/pulseless VT not responding to shock, stable tachyarrthia
Dosage
300 mg IV bolus in cardiac arrest followed by 150 mg bolus second dose; 150 mg IV over 10 mins in stable tachycardia followed by 1 mg/min
Adverse effect
BP, bradycardia, corneal microdeposits, pulm toxicity, photosensitivity
Adenosine Class
Purine neucloside antiarrthmic – acts on adenosine receptor
Usage
First line in stable narrow/wide narrow/wi de complex tachy
Dose
6mg -12mg-12mg IV fast fast bolus (rapid metabolism by red blood cells) followed followed by 20 2 0 cc flush
Adverse effects
Transient bradycardia/asystole/complete heart block, bronchospasm, angina
Precautious
Asthma/COAD, Asthma/COAD, theophyline
Sodium bicarbonate bicarbonate Class
Electrolyte imbalance agent/elementary agent/elementary substance
Usage
Severe metabolic acidosis, hyperkalaemia
Dose
1 mEq/kg slow IV
Adverse effects
Metabolic alkalosis, hypernatraemia, pontine myelinosis, myelinosis, hypocalcaemia, hypocalcaemia, hypokalaemia, paradoxical paradoxical intracellular intracellular acidosis
Precautious
Inactivate Inactivate inotrpoe, reduce efficacy of defibrillation
Verapamil Class
Calcium channel blocker- Class IV antiarrthmic
Usage
Narrow complex tachyC/I in wide complex tachy
Dose
2.5-5 mg IV slow bolus repeated every 15-30 mins to a total of 20 mg
Adverse effects
Dizziness, first/second first/second degree heart block, heart failure
Precautious
Impaired vetricular function/ heart failure failure
Magnesium sulphate Class
Elementary substance
Usage
Hypomagnesemia, torsede de pointes
Dose
2g IV slow bolus in hypomagnesemia/torsedes hypomagnesemia/torsedes de pointes
Adverse effects
Hypermagnesemia, CNS depressant, smooth/skeletal smooth/skeletal muscle reduced contractility
Precautious
Hypotension, breathing difficulties, heart block
Dopamine Class
Catecholamine, inotrope
Usage
Low cardiac output, shock
Dose
<5
g/kg/min: Dopamine-1 receptor
5-10 g/kg/min: -1 receptor >10 g/kg/min : receptor
BW x 3 in 50 cc DS: x ml/hr = x mcg/kg/min Adverse effects
Low dose: hypotension; high dose: ectopic beat, hypertension, angina
Precautious
Phaechromocytoma, extravesation extravesation = gangrene,
Thank you
POST RESUSCITATION CARE
DR TUAN HAIRULNIZAM TUAN KAMAUZAMAN Pakar / Pensyarah Kanan Jabatan Perubatan Kecemasan Universiti Sains Malaysia
Introduction •
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Post – cardiac arrest care has significant sig nificant potential to reduce early mortality caused by hemo- dynamic instability and later morbidity and mortality from multiorg mu ltiorgan an failure and brain injury. injury. ROSC and surviving cardiac arrest arrest with good brain function is TWO DIFFERENT THING!! Most death first 24 hrs post arrest.
Objective of post-resus care •
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Control body temperature to optimize survival and neuro- logical recovery Identify and treat ACS Optimize mechanical ventilation to minimize lung injury Reduce the risk of multiorgan injury and support organ function if required
Ventilation and oxygenation oxygenation •
Maintain ETCO2 35-40 mmHg –
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Keep PaCO2 40-45 mmHg –
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Indication of tube placement and blood flow To prevent cerebral vasodilatation Not to hyperventilate – can cause auto-PPEP and cerebral cerebral ischaemia!! is chaemia!!
CXR – detect complication of resuscitation resuscitation Maintain SPO2 > 94% and PAO2 ~ 100 mmHg –
Reduced FiO2 as tolerated tolerated
Hemodynamics •
Ensure all IV line functioning
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Frequent BP and arterial line –
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Keep MAP >65; SBP >90 mmHg
Treat hypotension –
Fluid therapy
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IV dopa, dobu, nored, adrenaline for for α effect !!
Other parameters: CVP, serum lactate < 2 mmol/L
Cardiovascular •
Continuous cardiac monitoring –
To detect arrthmia
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No prophylactic drug indicated
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12-lead ECG detcet ACS ASAP!!
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Treat ACS – strep/PCI
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Bedside ECHO –
Detect structural abnormalities, cardiomyopathy
Neurological •
Ensure core body temperature 32-34 degrees (to maintain 12-24 hrs starting immediately after ROSC)- esp beneficial after out-of-hospital VF
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Serial neurological outcome –
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EEG monitoring if comatose –
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Gag, cough, pupillary reflex, reflex, response to verbal/stimulation To detect dete ct seizure seizure
Sedation is acceptable BUT try not to paralyze paralyze
Metabolic •
Serial lactate keep <2 mmol/L
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Serum potassium 3.5-4.5 mmol/L
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Urine output 0.5-1.0 ml/kg/hr
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Treat hypo/hyperglycaemia
Thank you
ACLS SCENARIO RUN-THROUGH RUN-THROUGH
DR TUAN HAIRULNIZAM TUAN KAMAUZAMAN Pakar / Pensyarah Kanan Jabatan Perubatan Kecemasan Universiti Sains Malaysia
SCENARIO 1 You are doing your weekly shopping in a mall one day when suddenly an elderly gentleman fall down and collapsed in front of you. •
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What is your immediate action? What is the possible cause of unconsciousness in this patient?
This is rhythm on AED..
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What is the diagnosis?
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What is your immediate action?
You continue to perform CPR with the help of paramedic. •
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What is the indication ind ication to stop stop CPR? Would you bring back this patient back to hospital?
SCENARIO 2 You are working in ED one day when your paramedic brings in an unconscious elderly lady. lady. CPR is ongoing,endotracheal ong oing,endotracheal tube insitu, 2 large bore IV access is inserted. •
Name 2 important things you would do at this time.
During the 2 minutes interval interval this is the rhythm shown
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What would be your immediate action now?
After the next 2 minutes interval, this is the rhythm shown
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What would be your immediate action? What would be your drug of choice to give to the patient now? Discuss your post-resuscitation post-resuscitation management.
SCENARIO 3 A 26 years old Malay gentleman present to you with acute onset of shortness of breath •
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Discuss the oxygen delivery system of your choice How would you investigat investigate e this patient?
ABG result… pH 7.12 pO2 65 mmHg pCO2 55 mmHg SPO2 80% HCO3 20 mmol/L Serum lactate 4 mmol/L •
Interprate the ABG result.
The patient suddenly becomes more drowsy and later unconscious in front of you. •
What is your immediate action?
This is the ECG shown…
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What is your diagnosis? How would you investigat investigate e the cause of unconsciousness?
On echocardiography echocardiography,, massive pericardial peri cardial effusion is detected . •
How would you manage this patient?
SCENARIO 4 You received a 56-years old patient in your ED complaining of shortness of breath •
What is your immediate action?
This is the rhythm shown…
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Please analyze this rhythm. What is your diagnosis? What is the treatment choices of this condition and how would you prepare the patient for this treatment?
Thank you
