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Advanced Cardiovascular Life Support (ACLS) 2010 GUIDELINES

Dr Raana Ansari Resident Medicine Medical Unit II

BLS SURVEY

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:

Allow full chest recoil Minimize interruptions Avoid excessive ventilation

2 inches [5 cm] in adults and children 1.5 inches [4 cm] infants

Compression -to- ventilation ratio

Change A-B-C to C-A-B

Because CPR begins with chest compressions, the experts also recommended removal of Look, listen, and feel from the initial assessment. The healthcare provider briefly checks for breathing when checking responsiveness to detect signs of cardiac arrest. Following delivery of 30 compressions, the lone rescuer opens the victims airway and delivers 2 breaths. With an advanced airway in place, chest compressions can be continuous at a rate of at least 100/minute and no longer cycled with ventilations.

Elimination of Look, Listen, and Feel

About 8-10 breaths should be delivered per minute that is about one breath every 6-8 seconds. Excessive ventilation should be avoided.

Cricoid Pressure During Ventilation Not Recommended


Cricoid pressure is a technique of applying pressure to the victims 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

Advanced Cardiovascular Life Support


Attach the patient to
cardiac monitors

Advance airway
access(e.g. Endotracheal intubation)

Establish IV/IO access


(for medication)

The new algorithm also emphasizes the fact that ACLS actions should be organized around uninterrupted periods of CPR. A new circular algorithm is introduced to represent a two-minute continuous cycle of CPR and defibrillation.

New Medication Protocols


Symptomatic Arrhythmias 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. Adenosine IV Dose: First dose: 6 mg rapid IV push; follow with NS flush. Second dose: 12 mg if required.

Tachycardia

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

New Medication Protocols


There are several important changes regarding management of symptomatic arrhythmias in adults. Atropine is not recommended for routine use in the management of PEA/asystole and has been removed from the ACLS Cardiac Arrest algorithm. The treatment of PEA/asystole is now consistent in the ACLS and PALS recommendations and algorithms. For treatment of tachycardia:
Adenosine is recommended in the initial diagnosis and treatment of undifferentiated regular monomorphic wide complex tachycardia. This is also consistent in ACLS and PALS recommendations.

It is important to note that adenosine should not be used for irregular wide complex tachycardias, as it may cause degeneration of the rhythm to VF. For the treatment of adults with symptomatic and unstable bradycardia, chronotropic drug infusions are recommended as an alternative to pacing.

Capnography Recommendation
Continuous quantitative waveform capnography is now recommended for intubated patients throughout the periarrest period Capnography Recommended for:
confirming tracheal tube placement for monitoring CPR quality detecting ROSC based on end-tidal carbon dioxide (PETCO2) values

Capnography Recommendation

Capnography Recommendation.
Ineffective chest compressions indicated by
Pressure of end tidal
CO2 (PETCO2)

Once circulation is restored, monitor systemic oxygen saturation. It may be reasonable, when equipment is available, to titrate oxygen administration to maintain an oxyhemoglobin saturation greater than 94%. Provided equipment is available, once ROSC is achieved, adjust the FiO2 to the minimum concentration needed to achieve transcutaneous or arterial oxygen saturation greater than 94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery. Since an oxygen saturation of 100% may correspond to a PaO2 anywhere between about 80 and 500 mmHg, in general it is appropriate to wean the FiO2 for a saturation of 100%, provided the oxyhemoglobin saturation can be maintained at above 94%

The key to improving survival from sudden cardiac arrest early defibrillation integrated with highquality CPR

Evidence from two new studies suggests significant survival benefit with single shock defibrillation protocol compared with three 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.

This fact, combined with the data from animal studies documenting harmful effects from interruptions to chest compressions and human studies suggesting a survival benefit with a 1-shock protocol, supports the recommendation of single shocks, followed by immediate CPR rather than stacked shocks for attempted defibrillation.

Data from both out-of-hospital and in-hospital studies indicate that biphasic waveform shocks at energy settings comparable to or lower than 200 J monophasic shocks have equivalent or higher success for termination of VF. The optimal energy for first-shock biphasic waveform defibrillation has not been determined. No specific waveform characteristic for either monophasic or biphasic is consistently associated with a greater incidence of ROSC or survival to hospital discharge after cardiac arrest. .

Biphasic waveform shock configurations differ among manufacturers, and none have been directly compared in humans with regard to their relative efficacy. Because of such differences in waveform configuration, providers should use the manufacturers recommended energy dose for its respective waveform. If the manufacturers recommended dose is not known, defibrillation at the maximal dose of 200 J may be considered.