2005 CPR & ECC

GUIDELINES
Schedule
 BLS
 ACLS
 Pulseless Arrest
 Bradycardia
 Tachycardia
Chain of survival
 Early recognition of the emergency and
activation of EMS
 Early bystander CPR
 Early delivery of shock with defibrillator
 Early advanced life support followed by
post-resuscitation care
Basic Life Support
BASIC
LIFE
SUPPORT
Basic Life Support

No movement or response

PHONE 911 or emergency number

GET AED
Or send second rescuer (if available) to do this
 Basic Life Support

Open AIRWAY, Check BREATHING

If not breathing, give 2 BREATHS that make chest rise

 Basic Life Support

Definite Give 1 breath every

If no response, check pulse: 5 to 6 seconds
Pulse
Do you DEFINITELY feel
pulse within 10 seconds? Recheck pulse every
2 minutes

No Pulse
Basic Life Support

Give cycles of 30 COMPRESSIONS and 2 BREATHS

until AED/defibrillator arrives, ACLS providers take over,
or victim starts to move

Push hard and fast (100/min) and release completely

Minimize interruptions in compressions
Basic Life Support

AED/defibrillator ARRIVES
 Basic Life Support
Check rhythm
Shockable rhythm?

Shockable Not Shockable

Resume CPR immediately

for 5 cycles
Give 1 shock
Resume CPR immediately Check rhythm every 5 cycles
for 5 cycles Continue until ACLS
providers take over or
victim starts to move
Advanced Cardiac Life
Support
Management of Pulseless Arrest
The focus in the algorithms
 Witnessed VF/ pulseless VT:
 Increased survival to discharge with early
CPR/Shock
 Not with advanced airway and pharmacologic
support
 Asystole/PEA:
 Dismal survival overall
 Identify and treat reversible cause/factors.
 Good Basic Life Support
 Push hard and fast (100 compressions/min)
 Ensure full chest recoil
 One cycle = 30 compressions then 2 breaths
 5 cycles = 2 minutes
 Avoid hyperventilation
 Secure airway and confirm placement during
rhythm checks
 After advanced airway: no pauses for breath,
8-10 breaths/min, check rhythm every 2 minutes
Shockable Not Shockable
 Give 5 cycles CPR

No
Shockable

VT/VF

Give 5 cycles CPR

No
Shockable
Asystole/PEA
Give 5 cycles CPR

Not Shockable Shockable

 Reversible Causes / Factors:
 Hypovolemia  Toxins
 Hypoxia  Tamponade
 Hydrogen ion  Tension
(acidosis) pneumothorax
 Hypo/hyperkalemia  Thrombosis (coronary)
 Hypothermia  Thrombosis (pulm)
 Hypoglycemia  Trauma
 Limit Interruptions in CPR
 Chest compressions are crucial
 Oxygen and energy substrate to myocardium
 Increase chance that rhythm returns
 Shock may be more effective after CPR
 A few seconds can increase shock success
 Only stop for breaths, rhythm check, or 1 shock
 Do not stop for IV access/drug
administration/intubation
If 1 is good, 2 should be better…
 Success rate is high for first shock
 Better defibrillators
 Minimize CPR interruptions to maintain
coronary perfusion pressure
Continuous Chest Compressions

Kern et al Circulation 2002

How many joules per shock?
 Consensus Guidelines:
 Monophasic: 360J
 Biphasic ‘default’ dose: 200J
 Each biphasic manufacturer is different:
 Check machine
 Display effective dose on front of
defibrillator!
Do I need a central line?
 Not mandatory
 Do not interrupt CPR
 Options: PIV/IO/ETT
 If PIV/IO and still no spontaneous
circulation, consider central line
When to Stop?
 You must make a conscientious
and competent effort to
resuscitate
 Good clinical judgment
 Respect for human dignity
Summary:
1: Start CPR Early
2: 1 Shock Early
3: Good CPR
4: Good CPR
5: Good CPR
6: IV access, drugs, advanced airway
Management of Symptomatic
Bradycardia
Bradycardia
 Generally defined as HR<60/min

 Slow HR may be normal for some

patients and HR>60 may be
inadequate for others

 Decision to treat based on HR that

is inadequate for perfusion
 BRADYCARDIA
BRADYCARDIA
Heart rate <60min and
Heart rate <60min and
inadequate for clinical condition
inadequate for clinical condition

•Maintain patent airway; assist breathing as needed

•Maintain patent airway; assist breathing as needed
•Give oxygen
•Give oxygen
•Monitor EKG (identify rhythm), blood pressure, oximetry
•Monitor EKG (identify rhythm), blood pressure, oximetry
•Establish IV access
•Establish IV access

Signs or symptoms of poor perfusion caused by bradycardia?

Signs or symptoms of poor perfusion caused by bradycardia?
(e.g acute altered mental status, ongoing chest pain, hypotension or other signs of shock)
(e.g acute altered mental status, ongoing chest pain, hypotension or other signs of shock)

Adequate Poor
Perfusion Perfusion
Observe/Monitor •Prepare for transcutaneous pacing;
Observe/Monitor •Prepare for transcutaneous pacing;
use without delay for higher-degree
use without delay for higher-degree
block (type II 2ndnddegree or 3rdrddegree
block (type II 2 degree or 3 degree
block)
block)
•Consider atropine 0.5 mg while
•Consider atropine 0.5 mg while
awaiting pacer. May repeat to a total
awaiting pacer. May repeat to a total
dose of 3 mg. If ineffective, begin
dose of 3 mg. If ineffective, begin
pacing
Reminders pacing
Reminders •Consider epinephrine (2 to 10
•If PEA results, go to PEA algorithm •Consider epinephrine (2 to 10
•If PEA results, go to PEA algorithm mcg/min) or dopamine (2 to 10
•Search for & treat possible contributing factors: mcg/min) or dopamine (2 to 10
•Search for & treat possible contributing factors: mcg/kg/min) infusion while awaiting
mcg/kg/min) infusion while awaiting
pacer or if pacer ineffective
pacer or if pacer ineffective

•Prepare for transvenous pacing

•Prepare for transvenous pacing
•Treat contributing causes
•Treat contributing causes
•Consider expert consultation
•Consider expert consultation
Atropine
 0.5 mg every 3-5 min
 Max dose 3 mg
 Doses <0.5 mg may cause paradoxical
slowing of HR (centrally mediated)
 Atropine should not delay
implementation of external pacing for
patients with poor perfusion
Atropine

 Use with caution in presence of acute

coronary ischemia or MI
 In transplanted heart, atropine may be
ineffective
Transcutaneous Pacing

 Start immediately for high degree blocks

 Limitations
 Painful
 Failure to capture
Transcutaneous Pacing

 Verify capture
 Reassess patient’s condition
 Use appropriate analgesia & sedation
 If ineffective, use transvenous pacing
Alternative Drugs to Consider
 NOT first line treatment

 May be considered if atropine is

ineffective & as temporizing
measure before initiating pacing
Epinephrine
 Epinephrine infusion may be used for
bradycardia & hypotension after
atropine or if pacing fails

 Start infusion rates @ 2 -10 mcg/min

Dopamine
 May be used alone or with
epinephrine

 Start infusion rates @ 2 -10

mcg/kg/min
Summary
 Observe/Monitor the stable patient
 Transcutaneous pacing and atropine
are the first-line interventions
 Search for and treat the causes
Management of Tachycardia
The QRS Complex
 QRS complex- narrow or wide?
 Narrow:
 Sinus tachycardia
 Atrial fibrillation
 Atrial flutter
 AV nodal reentry (AVNRT)
 Junctional tachycardia
 Multifocal atrial tachycardia
The QRS Complex
 Wide complex tachycardia
 Ventricular tachycardia

 Pre-excited atrial

fibrillation (WPW with afib)

 Atrial fibrillation with

aberrancy
 Polymorphic VT
Summary
 Stable versus unstable
 Be able to distinguish sinus, narrow SVT and
wide complex tachycardias
 Know how to treat and rate control
 Know the difference between cardioversion
and defibrillation
OVERVIEW

 Management of Symptomatic
Bradycardia
 Management of Tachycardia
 Management of Cardiac Arrest
Symptomatic Bradycardia
Tachy
BASIC
LIFE
SUPPORT
MANAGEMENT
OF
CARDIAC
ARREST
Management of Cardiac
Arrest
Management of Cardiac
Arrest
Objectives of Post-Resuscitation
Care

 Optimize cardiopulmonary function and systemic perfusion, especially

perfusion to the brain
 Transportation of patient to ED and subsequently to an appropriate
critical care unit
 Identify precipitating causes of arrest
 Institute prevention of recurrence
 Institute measures that improve long-term and neurologically intact
survival
Post-Resuscitation Support :
Induced Hypothermia
 Temperature Regulation
 Hypothermia both permissive and active
induction might play a role in post-
resuscitation care.
 2 Randomized clinical trials evaluating
induced hypothermia after return of
spontaneous circulation showed improved
outcome
 The Hypothermia after Cardiac
Arrest Study Group
 A multicenter trial of 273 patients resuscitated after
cardiac arrest who were randomly assigned to
undergo therapeutic hypothermia (target
temperature, 32°C to 34°C, measured in the bladder)
over a period of 24 hours or to receive standard
treatment with normothermia. The assessment of the
outcome was blinded
 Hypothermia After Cardiac Arrest Study Group. Mild
therapeutic hypothermia to improve the neurologic
outcome after cardiac arrest. NEJM. 2002
The Hypothermia after Cardiac
Arrest Study Group

Outcomes Hypothermic Normothermic

Group Group

Favorable
Neurologic 55% 39%
(RR 1.40; 95%)

Mortality at 6
months 41% 55%
(RR 0.74; 95%)
Treatment of Comatose Survivors of Out-of-
Hospital Cardiac Arrest with Induced
Hypothermia

 A randomized controlled trial of 77 patients who

remained comatose after out-of hospital
resuscitation were assigned to undergo
hypothermia (with the core body temperature
reduced to 33°C within 2 hours after the return
of spontaneous circulation and maintained at
that temperature for 12 hours) or normothermia.
Treatment of Comatose Survivors of Out-of-
Hospital Cardiac Arrest with Induced
Hypothermia

 Good outcome defined as discharge home

or to a rehabilitation facility were achieved
in 49% of hypothermic group compared to
26% in the normothermic group. (P=0.046)
Hypothermia
 Unconscious patient should be cooled
to 32-34 C for 12 to 24 hours following
out-of-hospital arrest with return of
spontaneous circulation from an initial
rhythm of VF.
Questions???