A.C.L.S. for health care providers

1. Shree sahjanand institute of nursing,
ADVANCED CARDIAC LIFE SUPPORT
A.C.L.S.
PRESENTED BY :-
Mr. AKRAM KHAN
M.S.N. (HOD)
ASST. PROFESSOR
SSIN, BHAVNAGAR

2. Introduction
• Healthcare providers use a systematic approch to
assess and treat arrest and acutely ill or injured
patients for optimum care.
• The goal of the resuscitation team’s interventions for
a patient in respiratory or cardiac arrest is to support
and restore effective oxygenation, ventilation, and
circulation with return of intact neurologic function.

3. Definitions…
• Cardiopulmonary resuscitation (CPR) is a series of
life saving actions that improve the chance of
survival following cardiac arrest
• ADVANCED CARDIAC LIFE SUPPORT
(ACLS):
• refers to a form of management to the cardiac
arrest victims through the use of techniques such as
endo-tracheal intubations, administration of drugs,
cardiac monitoring, defibrillation and
electrocardiogram interpretation.

4. Statistical data
• 2016 Out-of-Hospital Cardiac Arrest
Incidence: More than 350,000
Bystander CPR (overall): 46.1%
Survivor rate* (overall): 12%
2016 In-Hospital Cardiac Arrest
Incidence: 209,000
Survival Rate Adult*: 24.8%
Survival Rate Children: N/A
• (by A.H.A.)

5. BLS Key Concepts
• Avoid Hyperventilation (Do not ventilate too fast or
too much volume)
• Push hard and fast, allow complete chest recoil,
minimal interruptions
• Compress chest depth of 1.5 to 2 inches at a rate of
100 compressions per minute
• Resume CPR immediately after shock. Interruption
in CPR for rhythm check should not exceed 10
seconds

6. BLS Key Concepts
Chest compression should not be interrupted except
for:
• Shock delivery
• Rhythm check
• Ventilation (until an advanced airway is inserted)
Do not interrupt CPR:
• To insert cannula or to give drugs
• To listen to the heart or to take BP???
• Waiting for charging the Defibrillator
• To rotate personnel

7. Chances of survival with time

8. Advanced cardiac life support
• ACLS impacts multiple key links in the chain of
survival that include interventions to prevent cardiac
arrest, treat cardiac arrest, and improve outcomes of
patients who achieve return of spontaneous
circulation (ROSC) after cardiac arrest
• Interventions aimed at preventing cardiac arrest
include airway managemeant, ventilation support,
and treatment of bradyarrhythmias and
tachyarrhythmias.

9. AHA Adult Chain of Survival
1. Immediate recognition of cardiac arrest and
activation of the emergency response system
2. Early CPR with an emphasis on chest
compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care

10. Cardiopulmonary resuscitation
(CPR)
• Cardiopulmonary resuscitation
(CPR) is a series of life saving
actions that improve the chance of
survival following cardiac arrest

13. Key changes from the
2005 BLS Guidelines
● Immediate recognition of SCA based on assessing
unresponsiveness and absence of normal breathing
● “Look, Listen, and Feel” removed from the BLS
algorithm
● Encouraging Hands-Only (chest compression only)
CPR
● Sequence change CAB rather than ABC
● Health care providers continue effective chest
compressions/ CPR until return of spontaneous
circulation or termination of resuscitative efforts

14. A Change From A-B-C to C-A-B

15. o 2017 (New): “Look, listen, and feel” was removed
from the CPR sequence. After delivery of 30
compressions, the lone rescuer opens the victim’s
airway and delivers 2 breaths.
• 2005 (Old): “Look, listen, and feel” was used to
assess breathing after the airway was opened.
• 2017 (New): Initiate chest compressions before
ventilations.
• 2005 (Old): The sequence of adult CPR began
with opening of the airway, checking for normal
breathing, and then delivery of 2 rescue breaths
followed by cycles of 30 chest compressions and
2 breaths.

16. • 2017 (New): It is reasonable for lay rescuers and
healthcare providers to perform chest compressions
at a rate of at least100/min.
• 2005 (Old): Compress at a rate of about 100/mi
• 2017 (New): The adult sternum should be depressed
at least 2 inches (5 cm).
• 2005 (Old): The adult sternum should be depressed
approximately 1. to 2 inches (approximately 4 to 5
cm).n

17. • 2005 (Old): Cricoid pressure should be used only if
the victim is deeply unconscious, and it usually
requires a third rescuer not involved in rescue
breaths or compressions
• 2017(new):routine use of cricoid pressure in
cardiac arrest is not recommended.

18. Cricoid Pressure
18
Thyroid
Cartilage
Cricoid

19. 2005 to 2017 changes
Component of
CPR
2005 ECC
recommendatio
ns
2017 ECC
Recommendati
ons
DEPTH OF
COMPRESSION
1 ½ - 2 inches Greater than 2
inches
RATE 100 /MINUTE At least 100
/MIN
VENTILATION 8-10 /MINUTE 8-10 /MINUTE
CHEST RECOIL 100% 100%
INTURUPTIONS Minimized Less than 10
seconds goal
PULSE CHECK HCP Only HCP only,
Checking for
“DEFNITE pulse”.

20. • 2017 (New): The precordial thump should not be
used for un witnessed out-of-hospital cardiac arrest.
The precordial thump may be considered for patients
with witnessed, monitored, unstable VT (including
pulse less VT) if a defibrillator is not immediately
ready for use, but it should not delay CPR and shock
delivery

21. Summary of Key Issues and Major
Changes
• The major changes in advanced cardiovascular life support
(ACLS) for 2010 include the following:
• • Quantitative waveform capnography is recommended for
confirmation and monitoring of endotracheal tube placement
and CPR quality.
• • The traditional cardiac arrest algorithm was simplified and
an alternative conceptual design was created to emphasize
the importance of high-quality CPR.
• • There is an increased emphasis on physiologic monitoring
to optimize CPR quality and detect ROSC.
• • Atropine is no longer recommended for routine use in the
management of pulse less electrical activity (PEA)/asystole.

22. Capnography Recommendation
• 2017 (New): Continuous quantitative waveform
capnography is now recommended for intubated
patients throughout the per arrest period. When
quantitative waveform capnography is used for
adults, applications now include recommendations
for confirming tracheal tube placement and for
monitoring CPR quality and detecting ROSC based
on end-tidal carbon dioxide (PETCO2) values .

23. • 2010 (New): Advanced life support training should
include training in teamwork.
• Why: Resuscitation skills are often performed
simultaneously, and healthcare providers must be able
to work collaboratively to minimize interruptions in
chest compressions. Teamwork and leadership skills
continue to be important, particularly for advanced
courses that include ACLS and PALS providers

26. Monitoring During CPR
Physiologic parameters
• Monitoring of PETCO2 (35 to 40 mmHg)
• Coronary perfusion pressure (CPP)
(15mmHg)
• Central venous oxygen saturation (ScvO2)
• Abrupt increase in any of these parameters
is a sensitive indicator of ROSC that can be
monitored without interrupting chest
compressions

27. Quantitative waveform capnography
• If Petco2 <10 mm Hg, attempt to
improve CPR quality
Intra-arterial pressure
• If diastolic pressure <20 mm Hg,
attempt to improve CPR quality
• If ScvO2 is < 30%, consider trying to
improve the quality of CPR

30. HIGH QUALITY CPR
• Chest compressions of adequate rate 100/min
• A compression depth of at least 2 inches (5
cm) in adults and in children, a compression
depth of at least 1.5 inches [4 cm] in infants
• Complete chest recoil after each compression,
• Minimizing interruptions in chest
compressions
• Avoiding excessive ventilation
• If multiple rescuers are available, rotate the
task of compressions every 2 minutes.

31. CHEST COMPRESSIONS

32. Chest compressions
• Chest compressions consist of
forceful rhythmic applications of
pressure over the lower half of the
sternum.
• Technique ..?

33. Decompression Phase
back
Maintain contact with the skin at your fingertips while you
lift the heel of your hand off the chest. This will assure that
the chest wall recoils completely after each compression
and maximizes the formation of the vacuum that promotes
filling of the heart.

34. Compression Rate (at least 100 / Minute)
• Rate per minute is NOT a function of “speed” of compressions
only, but a function of both speed ands minimizing no-flow periods
(discussed later) for a total compressions/minute.
• Compressions rates as high as 130 resulted in favorable outcomes
• Compression rates <87/minute saw rapid drop off in ROSC.
•
• NEW RECOMMENDATION: At LEAST 100/minute.
• Better too fast than too slow.

35. Compression DEPTH (At least 2 inches)
• Previous studies show that only about 27% of compressions
were deep enough (Wik, 2005)
• 0% (none) were too deep.
• NEW GIUDELINES: The adult sternum should be depressed
at least 2 inches (5 cm) , with chest compression and chest
recoil/relaxation times approximately equal

36. Compression Rate…
Percent segments
within 10 cpm
of AHA Guidelines
31 %
36.9%
Abella, et al 2005 Circulation
76 %
75 %
58 %
42%

37. Complete RELEASE/RECOIL
• Complete Recoil essential to reduce intrathoracic pressure
between compressions.
• Reducing recoil improves hemodynamic in arrest, and improves
Coronary Perfusion Pressure (CPP)
• Incomplete chest wall recoil can be reduced during CPR by
using electronic recording devices that provide real-time
feedback.

38. Active Compression-Decompression CPR
(ACD-CPR)
• Small studies showed improvement, but
a Cochrane Meta- review of over 1000
patients did not.
• ACD-CPR may be considered for use
when providers are adequately trained
and monitored (Class IIb, LOE B).

39. Mechanical Piston Devices
• L.U.C.A.S., THUMPER, ETC
• In 3 Studies the use of a mechanical piston device for
CPR improved end-tidal CO2 and mean arterial
pressure during adult cardiac arrest resuscitation.
• No long term benefit over manual CPR discovered
(yet)
• There is insufficient evidence to support or refute the
routine use of mechanical piston devices in the
treatment of cardiac arrest.
• Use of such devices during specific cercumstances
when manual CPR is difficult may be done (Class IIb,
LOE C).

41. INTURRUPTIONS
• Pausing for procedures
– intubation, IV, pulse check, etc.).
• Pausing for rhythm analysis.
• Pausing to charge, clear, and shock.

42. KEY POINT:
“…High-quality CPR is important
not only at the onset but
throughout the course of
resuscitation. Defibrillation and
advanced care should be interfaced
in a way that minimizes any
interruption in CPR.”
AHA 2010 Guidelines

43. • Coronary vessel injury
• Diaphragm injury
• Hemopericardium
• Hemothorax
• Interference with ventilation

44. • Liver injury
• Myocardial injury
• Pneumothorax
• Rib fractures
• Spleen injury
• Sternal fracture

45. AIRWAY

46. Airway and Ventilations
• Opening airway – Head tilt, chin lift or
jaw thrust
• The untrained rescuer will provide Hands-
Only (compression-only) CPR
• The Health care provider should open the
airway and give rescue breaths with chest
compressions

47. Airway
• Assess the airway, ensuring it is
- open
- clear
• Jaw thrust can be used
• Look in mouth for obstruction
– teeth, tongue, vomit, foreign
object
• Ensure airway is clear
– If airway obstructed with fluid
(vomit or blood) roll patient
onto their side & clear airway
or use suction if available

48. AIRWAY

49. Rescue breaths
• By mouth-to-mouth or bag-mask
• Deliver each rescue breath over 1 second
• Give a sufficient tidal volume to produce visible
chest rise
• Use a compression to ventilation ratio of 30
chest compressions to 2 ventilations
• After advanced airway is placed, rescue breaths
given asynchronus with compression
• 1 breath every 6 to 8 seconds (about 8 to 10
breaths per minute)

50. OPEN AIRWAY
Head tilt, chin lift + jaw thrust

51. Opening the Airway
Jaw thrust
51
Head tilt–chin lift

52. The Oropharyngeal Airway

53. Malposition of
Oropharyngeal Airway
53
Too short

55. Mouth to pocket mask

56. Pocket-Mask Devices
56
1-way valve
Port to attach O2 source

57. Mouth-to-Mask Ventilation
57
Fingers: jaw thrust upward Fingers: head tilt–chin lift

58. Bag-Mask Ventilation
• Key—ventilation volume: “enough to
produce
obvious chest rise”
58
1-Person:
difficult, less effective
2-Person:
easier, more effective

59. Bag/Valve/Mask

60. Equipment for Intubation
• Laryngoscope with
several blades
• Tracheal tubes
• Malleable stylet
• 10-mL syringe
• Magill forceps
• Water-soluble lubricant
• Suction unit, catheters, and tubing
60

61. Curved Blade Attaches to
Laryngoscope Handle
61

62. Curved Blade Attached to
Laryngoscope Handle
62

63. Straight-Blade Laryngoscope
Inserted Past Epiglottis
63

64. Aligning Axes of Upper
Airway
64
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
C
BA
B
C
Trachea
Pharynx
Mouth
A

65. Securing the Airway
Perform chest compressions with a 30:2
compression to ventilation ratio
back
The head tilt-chin lift with a good 2-
handed face mask seal will provide
adequate ventilations in most cases.
Do not delay or interrupt
compressions early in CPR for a
secure airway.

66. CPR and Rescue Breathing
with a Bag-Valve Mask (BVM)
1
When squeezing the bag, use one hand
and only bring the fingertips together.
DO NOT increase volume!
back

67. Rescue Breathing after
Intubation
DO NOT pause chest compressions to
deliver breaths after tube placement.
back

68. Esophageal-Tracheal Combitube
68
A = esophageal obturator; ventilation into trachea through side openings = B
C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
Distal End
Proximal End
B
C
D
E
F
G
H
A

69. Combitube

70. Esophageal-Tracheal Combitube
Inserted in Esophagus
70
A = esophageal obturator; ventilation into
trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at
level of teeth
D
A
D
B F
H

71. Advanced Airways
Once advanced airway in place, don’t interrupt chest
compression for ventilation and avoid over ventilation 8-10
breaths/m
Endotracheal Tube
Laryngeal
Mask Airway
LMA
CombitubeLaryngoscope

72. Laryngeal Mask Airway
LMA

73. Laryngeal Mask Airway
(LMA)
The LMA is an adjunctive airway that
consists of a tube with a cuffed mask-like
projection at distal end.
73

74. LMA Introduced Through
Mouth Into Pharynx
74

75. LMA in Position
Once the LMA is in position, a clear, secure airway is
present.
75

76. Anatomic Detail
76

77. Cricoid Pressure (Really???)
• Cricoid pressure in no arrest patients may offer some measure of
protection to the airway from aspiration and gastric insufflation
during bag-mask ventilation.
• However, it also may impede ventilation and interfere with
placement of a supraglottic airway or intubation.
• If cricoid pressure is used in special circumstances during cardiac
arrest, the pressure should be adjusted, relaxed, or released if it
impedes ventilation or advanced airway placement.
• The routine use of cricoid pressure in cardiac arrest is not
recommended .

78. FiO2 (During Arrest)
• Use of 100% inspired oxygen
(FIO21.0) as soon as it becomes
available is reasonable during
resuscitation from cardiac arrest .

79. FiO2 (post arrest)
• Increasing Data that hyper-oxia may increase
incidence of poor neurological outcomes and
increased pulmonary injury.
• Exact FiO2 recommendations have not been
determined.
• In the post arrest phase, if equipment is
available, titration of FiO2 to SPO2 04% is
recommended .

80. Passive O2 delivery during arrest
• Passive O2 delivery via ETT has been reviewed.
• In theory, because ventilation requirements are lower than
normal during cardiac arrest, oxygen supplied by passive
delivery is likely to be sufficient for several minutes after
onset of cardiac arrest with a patent upper airway.
• The studies involved resulted in improved outcomes., but
it is unsure what role (if any) passive O2 had.
• At this time there is insufficient evidence to support
the removal of ventilations from CPR performed by
ACLS providers.

81. ETT
• There are no studies directly addressing the timing
of advanced airway placement and outcome during
resuscitation from cardiac arrest.
• Although insertion of an endotracheal tube can be
accomplished during ongoing chest compressions,
intubation frequently is associated with interruption
of compressions for many seconds.
• Placement of a supraglottic airway is a reasonable
alternative to endotracheal intubation and can be
done successfully without interrupting chest
compressions.

82. ETT (Moral of story)
• There are two pitfalls of ETT placement:
– 1- Interruption of CPR
– 2- Poor Placement practices.
• Therefore, Place during CPR if possible,
and optimize first attempt (bougie, etc)
• If you CANT do this, then use a
supraglottic airway.
– If you cant do this, perhaps you should not be
a paramedic? Hmmmmmm……

83. Confirmation:
Tracheal Tube Placement
End-tidal colorimetric CO2 indicators
83

84. Compression-Ventilation Ratio
• Ventilation rate = 12/min
• Compression rate = 78/min.
• Large amplitude waves = ventilations.
• Small amplitude waves = compressions.
• Each strip records 16 seconds of time

85. Reality Sucks…
• Compression: Ventilation Ratio 2:1
• 47-48 Breaths a minute
47 Nails in a coffin!

86. Prolonged Ventilations
• 􀂃Ventilation Duration = 4.36 seconds / breath
• 􀂃Ventilation Rate = 11 breaths / minute
• 􀂃% time under Positive Pressure = 80%

87. DECREASING
VENTILATION
• CPR with Advanced Airway: 8 – 10
breaths/minute
• Post-resuscitation: 10 – 12/min

88. Cardiac arrest
• Cardiac arrest can be caused by 4 rhythms:
1. Ventricular fibrillation(VF),
2. Pulseless ventricular tachycardia (VT),
3. Pulseless electric activity (PEA), and
4. Asystole.
How to recognise cardiac arrest ..?

91. Treatable Causes of Cardiac
Arrest: The H’s and T’s
H’s T’s
• Hypoxia Toxins
• Hypovolemia Tamponade (cardiac)
• Hydrogen ion(acidosis) Tension pneumothorax
• Hypo-/hyperkalemia Thrombosis, pulmonary
• Hypothermia Thrombosis, coronary

92. Electrical alternans: the EKG
finding of tamponade

93. Treatment of Tamponade:PERICARDIOCENTESIS

94. Tension Pneumothorax

95. Treatment of Tension PTX
• Oxygen
• Insert a large-bore (ie, 14-gauge or
16-gauge) needle into the second
intercostal space (above the third
rib!), at the midclavicular line.

97. Cardiac arrest
• Cardiac arrest can be caused by 4
rhythms:
1. Ventricular fibrillation(VF),
2. Pulseless ventricular tachycardia
(VT),
3. Pulseless electric activity (PEA),
and
4. Asystole.

98. Arrest Rhythms
Shockable rhythms:
• VF
• Pulseless VT
Non shockable rhythms:
• PEA
• Asystole
Electrical therapies in ACLS
Cardiversion / Defibrillation for
Tachyarrhythmias
• Unsynchronized = defibrillation
(Uses higher energy levels and
delivers shock immediately)
• Synchronized delivers shock at
peak of QRS complex (Avoids
delivering shock during
repolarization)
Pacing for brady arrhythmias

99. Pre‐cordial Thump
• • No prospective studies so far
• • Rationale is to convert mechanical
energy to electrical energy
• • In all successful cases, the thump
was given within first 10s
• • More likely to be successful in
converting VT to sinus rhythm
• • Much less likely for VF

100. Pre‐cordial Thump
• • Consider as an option for
witnessed, sudden collapse and
defibrillator NOT immediately
available
• • Thump may cause deterioration:
• – Rate acceleration of VT
• – Conversion of VT to VF
• – Complete Heart Block
• – A systole

101. Pre‐cordial Thump
• • Only by trained healthcare
providers immediately confirm
cardiac arrest
• • Use ulnar edge of tightly clenched
fist
• • Deliver a sharp impact to the lower
half of the sternum from a height of
20 cm
• • After that, immediately retract the
fist

102. Defibrillation
• Defibrillation is defined as
termination of VF for at least 5
seconds following the shock.
• Early defibrillation remains the
cornerstone therapy for ventricular
fibrillation and pulseless ventricular
tachycardia

103. ‘
• Defibrillation Sequence
● Turn the AED on.
● Follow the AED prompts.
● Resume chest compressions immediately after the
shock(minimize interruptions).
Shock Energy
• Biphasic : Manufacturer recommendation (eg,
initial dose of 120-200 J), if unknown, use
maximum available.
• Second and subsequent doses should be equivalent,
and higher doses may be considered.
• Monophasic : 360 J

106. Defibrillation technique
Defibrillation Sequence
Action Announcements
1. Switch on.
2. Place coupling pads/gel in correct position
3. Apply paddles
4. Check ECG rhythm and confirm no pulse
5. Select non-synchronized (VF) setting
6. Charge to required energy level "Charging"
7. Ensure no-one is in contact with anything touching
the patient
"Stand clear"
8. Press paddle buttons simultaneously
"Shocking
now"
9.eturn to ALS algorithm for further steps

107. CAUTION IN USE OF AED
• Don’t apply pads over pacemakers
• Don’t apply pads over skin
patches/medications
• Be cautious around water
• NEVER attach to anyone not in cardiac
arrest

108. Do I check for a pulse after I deliver a
shock ?

109. 1
No stacked shocks
No pulse check after shock
Single shock will be followed by 2 minutes
of CPR, then pulse check, and re-analyze if
necessary
Defibrillation
These measures reduce “no flow time”. Why is it
important to reduce the amount of time when
compressions are not performed?

110. What next ?
• Commence CPR immediately
after delivering the shock
• Use a ratio of 30 compressions to
2 breaths
• Follow the voice prompts &
continue CPR until signs of life
return

111. 1-Shock Protocol Versus 3-
Shock Sequence
• Evidence from 2 well-conducted pre/post
design studies suggested significant survival
benefit with the single shock defibrillation
protocol compared with 3-stacked-shock
protocols
• If 1 shock fails to eliminate VF, the
incremental benefit of another shock is low,
and resumption of CPR is likely to confer a
greater value than another shock

112. Cardiac arrest
• Cardiac arrest can be caused by 4
rhythms:
1. Ventricular fibrillation(VF),
2. Pulseless ventricular tachycardia
(VT),
3. Pulseless electric activity (PEA),
and
4. Asystole.

113. VF/ Pulseless VT
Witnessed arrest:
• 2 rescue breaths then
• Defibrillate
Unwitnessed arrest:
• 5 cycles of CPR (2 min) then
• Defibrillate
• 200 Joules for biphasic
machines
• 360 Joules for monophasic
machines
• Single shock (not 3 shocks)
followed by CPR
• No gap between chest
compression and shock
delivery

114. Ventricular Fibrillation
Fine VF
Coarse VF

115. Ventricular Fibrillation
Rate Cannot be determined, because there are no
discernible waves or complexes to measure
Rhythm Rapid and chaotic, with no pattern or regularity
P waves Not discernible
PR interval Not discernible
QRS duration Not discernible

117. Ventricular Tachycardia
• Treat the following as VF:
– Pulse less monomorphic VT
– Pulse less polymorphic VT

118. Polymorphic Ventricular
Tachycardia
Rate 150 to 300 beats/min; typically 200 to 250 beats/min
Rhythm May be regular or irregular
P waves None
PR interval None
QRS 0.12 sec or more; there is a gradual alteration in the
amplitude and direction of the QRS complexes; a
typical cycle consists of 5 to 20 QRS complexes

119. Monomorphic Ventricular
Tachycardia
Rate 101 to 250 beats/min
Rhythm Essentially regular
P waves Usually not seen; if present, they have no set
relationship with the QRS complexes that appear
between them at a rate different from that of the VT
PR interval None
QRS 0.12 sec or more; often difficult to differentiate
between the QRS and the T wave

120. Monomorphic Ventricular
Tachycardia
• Signs and symptoms associated with
VT vary.
– Sustained VT does not always produce
signs of hemodynamic instability.
• VT may occur with or without
pulses.
• Treatment is based on signs and
symptoms and the type of VT.

123. What is this rhythm?

125. Asystole Protocol
• Check another lead
• Is it on paddles?
• Power on?
• Check lead and cable connections

126. Asystole (Cardiac Standstill)
Rate Ventricular usually not discernible, but atrial activity may
be seen (i.e., “P-wave” asystole)
Rhythm Ventricular not discernible, atrial may be discernible
P waves Usually not discernible
PR interval Not measurable
QRS Absent

127. “P-Wave” Asystole
Asystole

128. Pulseless Electrical Activity
• Pulseless electrical activity exists
when organized electrical activity
(other than VT) is present on the
cardiac monitor but the patient is
apneic and pulseless.

129. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 129
The Resuscitation Team

130. Goals of the Resuscitation
Team
• To re-establish spontaneous
circulation and respiration
• To preserve vital organ function
during resuscitation
• Your responsibility to the patient
continues until patient care is
transferred to a team with equal or
greater expertise.

131. Critical Tasks of Resuscitation
1. Chest compressions
2. Airway management
3. ECG monitoring and defibrillation
4. Vascular access and medication
administration

132. Team Leader Responsibilities
• Assesses the patient
• Orders emergency care in accordance with protocols
• Considers reasons for cardiac arrest
• Supervises team members
• Evaluates the adequacy of chest compressions
• Ensures that the patient receives appropriate oxygen therapy
• Evaluates the adequacy of ventilation
• Ensures safe and correct defibrillation, when it is indicated

133. Team Leader Responsibilities
• Ensures the correct choice and placement of vascular
access
• Confirms proper positioning of an advanced airway
• Ensures correct drug, dose, and route of
administration
• Ensures the safety of all team members
• Problem solves
• Decides when to terminate resuscitation efforts

134. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. 134
Team Member Responsibilities

135. Airway Team Member
 Manual airway maneuvers
 Oral airway
 Nasal airway
 Oxygen-delivery devices
 Bag-mask ventilation
 Suctioning
 Advanced airway placement
 If within scope of practice
 Waveform capnography, exhaled
carbon dioxide detector, and
esophageal detector device

136. Cardiopulmonary Resuscitation
Team Member
• The ACLS or BLS team member
who is responsible for CPR must be
able to do the following:
– Properly perform CPR
– Provide chest compressions of adequate
rate, force, and depth in the correct
location

137. Electrocardiography/Defibrillat
ion Team Member
• Synchronized versus unsynchronized shocks
• Pad or paddle placement
• Safety precautions
• Indications for and complications of
transcutaneous pacing
• Problem solving with regard to equipment failure

138. key concepts Revisited…
• Avoid Hyperventilation
• Push hard and fast, allow complete chest recoil,
minimal interruptions
• Compress chest depth of 1.5 to 2 inches at a rate of
100 compressions per minute
• Compression to ventilation ratio 30:2, after
advanced airway no need to interrupt compression
• Turing defibrillator on…
• 5 Hs and 5 Ts…

139. Epinephrine
 Indications
 Cardiac arrest
 VF; VT; a systole; PEA
 Symptomatic bradycardia
 After atropine; alternative to dopamine
 Severe hypotension
 When atropine and pacing fail; hypotension
accompanying bradycardia; phosphodiesterase
enzyme inhibitors
 Anaphylaxis; severe allergic reactions
 Combine with large fluid volume; corticosteroids;
antihistamines

140. Epinephrine
 Precautions
 May increase myocardial ischemia, angina, and oxygen
demand
 High doses do not improve survival; may be detrimental
 Higher doses may be needed for poison/drug induced
shock
 Dosing
 Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min.
 High dose up to 0.2 mg/kg for specific drug OD’s
 Infusion of 2-10 mcg/min.
 Endotracheal of 2-2.5 times normal dose
 SQ/IM 0.3-0.5 mg

141. Vasopressors
Drug Therapy
• 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.

142. Key changes from the 2005
ACLS Guidelines
• Continuous quantitative waveform
capnography is recommended
• Cardiac arrest algorithms are simplified and
redesigned to emphasize the importance of
high quality CPR
• Atropine is no longer recommended for
routine use in the management of pulseless
electrical activity (PEA)/asystole

143. • Increased emphasis on physiologic
monitoring to optimize CPR quality and
detect ROSC
• Chronotropic drug infusions are
recommended as an alternative to pacing in
symptomatic and unstable bradycardia.
• Adenosine is recommended as a safe and
potentially effective therapy in the initial
management of stable undifferentiated
regular monomorphic wide-complex
tachycardia

146. • Synchronised cardioversion - shock delivery that
is timed (synchronized) with the QRS complex
• Narrow regular : 50 – 100 J
• Narrow irregular : Biphasic – 120 – 200 J and
Monophasic – 200 J
• Wide regular – 100 J
• Wide irregular – defibrillation dose
• Adenosine : 6 mg rapid iv push, follow with NS
flush.. Second dose 12 mg

147. initial objectives of post–
cardiac arrest care
• Optimize cardiopulmonary function and vital
organ perfusion.
• After out-of-hospital cardiac arrest, transport
patient to an appropriate hospital with a
comprehensive post–cardiac arrest treatment
• Transport the in-hospital post– cardiac arrest
patient to an appropriate critical-care unit
• Try to identify and treat the precipitating
causes of the arrest and prevent recurrent arrest

151. CAUSESE
B – Bleeding/ DIC
E – Embolism( pulmonary, coronary , amniotic )
A – Anesthetic complications
U – Uterine atony
C – Cardiac disease( MI/Aortic
dissection/Cardiomyopathy)
H – Hypertension ( Pre eclampsia/ Eclampsia )
O – Other reversible causes
P – Placenta praevia/ abruptio
S -- Sepsis

152. Recommendation for
emergency caesarean section
Recommendation
• When the gravid uterus is large enough to cause
maternal hemodynamic changes due to aortocaval
compression,
• emergency caesarean section should be
considered, regardless of fetal viability

153. THANK YOU