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ACLS
1. RC (UK)
RESUSCITATION COUNCIL (UK)
RESUSCITATION COUNCIL
(QAT)
ADVANCED LIFE SUPPORT
2/15/2003 , 1
INTRODUCTION
Dr.Montaser Ismail
MRCP, Arab Board of Cardiology
2. RC (UK)
Cardiovascular Disease
• In Europe cardiovascular disease accounts for
40% of all deaths < 75 yrs
• In QAT cardiovascular disease accounts for 29%
of all deaths all ages.
• One third of all people developing an MI die
before reaching hospital
• Presenting rhythm in most of these cases is
VF/VT
• In-hospital cardiac arrest more likely non-VF/VT
2
11. RC (UK)
Breathing inadequacy
Symptoms and signs
• Short of breath,
anxious, irritable
• Decrease in
conscious level
• Tachypnoea
• Cyanosis
Action
• Oxygen
• Ventilatory support
• Treat underlying
cause where possible
11
12. RC (UK)
Cardiac abnormalities:
Acute Coronary Syndromes
Clinical syndromes form spectrum
of the same disease process:
Unstable angina
↓
Non-Q wave myocardial infarction
↓
Q wave myocardial infarction
12
13. RC (UK)
Immediate treatment in all
acute coronary syndromes
• “MONA”
–Morphine (or diamorphine)
–Oxygen
–Nitroglycerine (GTN spray or tablet)
–Aspirin 300 mg orally
(crushed/chewed)
13
14. RC (UK)
Patients with ST segment
elevation MI or MI with LBBB
Early coronary reperfusion therapy:
• Thrombolytic therapy
–streptokinase
–alteplase
• Percutaneous transluminal coronary
angioplasty (PTCA)
• Coronary artery bypass surgery (CABG)
14
16. RC (UK)
Which patients?
• Cardiac arrest or other important
arrhythmias
• Chest pain
• Heart failure
• Collapse / syncope
• Shock / hypotension
• Palpitations
16
17. RC (UK)
How to monitor the ECG (1):
Monitoring leads
• 3-lead system
approximates to I, II, III
• Colour coded
• Remove hair
• Apply over bone
• Lead setting (II)
• Gain
17
18. RC (UK)
How to monitor the ECG (2):
Defibrillator paddles
• Suitable for “quick-
look”
• Movement artefact
• Risk of spurious
asystole
18
19. RC (UK)
How to monitor the ECG (3):
Adhesive monitoring electrodes
• “Hands-free”
monitoring and
defibrillation
19
21. RC (UK)
12-lead ECG
• 3D electrical activity from heart
• More sophisticated ECG
interpretation
• ST segment analysis
21
22. RC (UK)
• Depolarisation
initiated in SA node
• Slow conduction
through AV node
• Rapid conduction
through Purkinje
fibres
Basic electrocardiography (1)
22
24. RC (UK)
How to read a rhythm strip
1. Is there any electrical activity?
2. What is the ventricular (QRS) rate?
3. Is the QRS rhythm regular or irregular?
4. Is the QRS width normal or prolonged?
5. Is atrial activity present?
6. How is it related to ventricular activity?
24
25. RC (UK)
ECG rhythm interpretation
• Effective treatment often possible
without precise ECG diagnosis
• Haemodynamic consequences of any
given rhythm will vary
• Treat the patient not the rhythm
25
26. RC (UK)
What is the ventricular rate?
• Normal 60-100 min-1
• Bradycardia < 60 min-1
• Tachycardia > 100 min-1
Rate = 300
Number of large squares between
consecutive QRS complexes*
* At standard paper speed of 25 mm sec-1
, 5 large squares = 1 second
26
27. RC (UK)
Is the QRS rhythm regular or
irregular?
• Unclear at rapid heart rates
• Compare R-R intervals
• Irregularly irregular = AF
27
28. RC (UK)
Is the QRS width normal or
prolonged?
• Normal QRS:
–< 0.12 s (< 3 small squares)
–originates from above bifurcation of
bundle of His
28
29. RC (UK)
• Prolonged QRS (> 0.12 s) arises from:
–ventricular myocardium, or
–supraventricular with aberrant
conduction
Is the QRS width normal or
prolonged?
29
30. RC (UK)
A broad complex tachycardia
should be assumed to be
ventricular in origin unless there
is a very good reason to suspect
otherwise.
30
31. RC (UK)
Is atrial activity present?
• P waves (leads II and V1)
• Rate, regularity, morphology
• Flutter waves
• Atrial activity may be revealed by
slowing QRS rate with adenosine
31
33. RC (UK)
How is atrial activity related
to ventricular activity?
• Consistent, fixed PR interval
• Variable, but recognisable pattern
• No relationship - atrioventricular
dissociation
33
38. RC (UK)
Mechanism of defibrillation
• Definition
“The termination of fibrillation or
absence of VF/VT at 5 seconds after
shock delivery”
• Critical mass of myocardium
depolarised
• Natural pacemaker tissue resumes
control
38
39. RC (UK)
Defibrillation
Success depends on delivery
of current to the myocardium
Current flow depends upon:
• Electrode position
• Transthoracic impedance
• Energy delivered
• Body size
39
44. RC (UK)
Manual Defibrillation
Relies upon:
• Operator recognition of
ECG rhythm
• Operator charging
machine and delivering
shock
• Can be used for
synchronised
cardioversion
44
45. RC (UK)
Defibrillator Safety
• Never hold both paddles in one hand
• Charge only with paddles on
casualty’s chest
• Avoid direct or indirect contact
• Wipe any water from the patient’s
chest
• Remove high-flow oxygen from zone
of defibrillation
45
46. RC (UK)
Synchronised cardioversion
• Convert atrial or ventricular tachyarrhythmias
• Shock synchronised to occur with the R wave
• Short delay after pressing discharge buttons -
keep defibrillator electrodes in place
• Conscious patients: sedation or anaesthesia
• Check mode if further shock/s required
46
50. RC (UK)
Biphasic Defibrillators
• Require less energy for defibrillation
– smaller capacitors and batteries
– lighter and more transportable
• Repeated < 200 J biphasic shocks
have higher success rate for
terminating VF/VT than escalating
monophasic shocks
50
52. RC (UK)
Common causes of airway
obstruction
• Upper Airway
–tongue
–soft tissue oedema, foreign
material
–blood, vomit
• Larynx
–laryngospasm, foreign material
• Lower Airway
–secretions, oedema, blood52
53. RC (UK)
Recognition of airway
obstruction
• LOOK for chest/abdominal
movement
• LISTEN at mouth and nose for
breath
sounds, snoring, gurgling
• FEEL at mouth and nose for
expired air53
61. RC (UK)
Mouth to mask
ventilation
Advantages:
• Avoids direct person to
person contact
• Decreases potential for
cross infection
• Allows oxygen
enrichment
Limitations:
• Maintenance of airtight61
63. RC (UK)
Ventilation using self inflating
bag
Advantages
• Avoids direct person to person
contact
• Allows oxygen supplementation –
up to 85%
• Can be used with facemask, LMA,
Combitube, tracheal tube
64. RC (UK)
Ventilation using self inflating
bag
Limitations
When used with a facemask:
• Risk of inadequate ventilation
• Risk of gastric inflation
• Need two persons for optimal use
64
67. RC (UK)
The Laryngeal Mask
Airway
Advantages
• Rapidly and easily inserted
• Variety of sizes
• More efficient ventilation than
facemask
• Avoids the need for laryngoscopy
67
68. RC (UK)
The Laryngeal Mask
Airway
Limitations
• No absolute guarantee against
aspiration
• Not suitable if very high inflation
pressures needed
• Unable to aspirate airway
72. RC (UK)
Tracheal Intubation
Advantages
• Allows ventilation with up to 100% O2
• Isolates airway, preventing aspiration
• Allows aspiration of the airway
• Alternative route for drug
administration
72
73. RC (UK)
Limitations
• Training and experience essential
• Failed insertion, oesophageal
placement
• Potential to worsen cervical cord or
head injury
Tracheal Intubation
74. RC (UK)
Needle
Cricothyroidotomy
Indication
• Failure to provide an airway by
any other means
Complications
• Malposition of cannula
– Emphysema
– Haemorrhage
– Oesophageal perforation
• Hypoventilation
• Barotrauma
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93. RC (UK)
Assess
Rhythm
+/- Check Pulse
VF/VT
Defibrillate X 1
CPR 2 min
Ventricular Fibrillation/
Pulseless Ventricular
Tachycardia
94. RC (UK)
• Deliver 1 shocks in <
30 seconds
• Continue CPR for 2
minutes regardless.
VF / VT
SHOCK maximum
(200 – 360) joules
95. RC (UK)
During CPR
Correct reversible causes
If not already:
• check electrodes, paddle position and
contact
• attempt / verify: airway & O2
i.v. access
• give epinephrine every 3-5 min (every other
cycle of CPR)
Consider:
amiodarone, atropine / pacing, buffers
96. RC (UK)
Chest compressions,
airway and ventilation
• Secure airway:
–tracheal tube
–LMA
–Combitube
• Once airway secured, do not
interrupt chest compressions for
ventilation
97. RC (UK)
Intravenous access and drugs
VF/VT
• Central veins versus peripheral
• Epinephrine 1 mg i.v. or 2-3 mg
tracheal tube
• Consider amiodarone 300 mg if
VF/VT persists after 3rd shock
• Alternatively - lidocaine 100 mg
• Consider magnesium 8 mmol
101. RC (UK)
Asystole
• Confirm:
–check leads - view via leads I and II
–check gain
• Epinephrine 1 mg every 3-5 minutes
• Atropine 3 mg i.v. or 6 mg via tracheal tube
(once)
102. RC (UK)
Pulseless electrical activity
• Exclude/treat reversible causes
• Epinephrine 1 mg every 3-5 minutes
• Atropine 3 mg if PEA with rate < 60 min-1
107. RC (UK)
Aim: the maintenance of normal sinus
rhythm and a cardiac output
adequate for perfusion of vital
organs
Continued resuscitation:
circulation
107
111. RC (UK)
Post Resuscitation Care
Chest X-ray
• Fractured ribs, pneumothorax,
aspiration, sub-diaphragmatic gas
• Tracheal tube
• CVP line
• Chest drain
• Nasogastric tube
• Pacing wire
111
112. RC (UK)
Transfer of the patient
Aim: to facilitate a safe transfer of the
patient between the site of
resuscitation and an appropriate
place of definitive care (critical care
area)
112
113. RC (UK)
Supporting relatives
• Clear explanation of what they will
see
• Clear explanation of the events
leading to the arrest
• Direct not to interfere
• Use simple language
• Ensure they are supported by a
member of the team
113
114. RC (UK)
Dealing with the
recently bereaved
• Early contact with one person,
usually a nurse
• Provision of a suitable room
• Recognising the grief response
• Encouraging and arranging
viewing of the body
• Establishing religious
requirements114
115. RC (UK)
Dealing with the
recently bereaved
Possible responses to grief:
• Acute emotional distress
• Anger
• Denial
• Guilt
• Catatony
115
