ADVANCED DR WOLDESENBET

CARDIAC LIFE
(MPH, Associate
professor of
Emergency and
SUPPORT(ACLS) critical care )
OUTLINE
Introduction
Monitoring quality of CPR
Defibrillation
Drugs for cardiac arrest
Advanced airway
Rhythm-Based Management of Cardiac Arrest
Post cardiac arrest care
 INTRODUCTION
Every year, 6.8 to 8.5 million persons throughout the world
sustain cardiac arrest
About 70% of cardiac arrests occur out of hospital
Cardiac arrest can be caused by 4 rhythms
Chain of survival: the structured emergency care system
concept for treatment of cardiac arrest
- Early Access, Early CPR, Early Defibrillation, and Early
Advanced Care
High-quality CPR is fundamental to the management of all
cardiac arrest rhythms
BLS Healthcare Provider Adult Cardiac Arrest
Algorithm—2015 Update
CPR QUALITY
MONITORING
ACLS: A set of clinical interventions for the urgent treatment of
cardiac arrest
ACLS provides recommendations regarding:
- optimizing circulation
- airway management
- cardiac rhythm management via defibrillation
and/or administration of medications, and
- stabilization of the patient’s condition
Once cardiac arrest occurs, only about 20% of patients who
have an in-hospital cardiac arrest will survive to go home
DEFIBRILLATION AND
CARDIOVERSION
Defibrillation is the delivery of a shock randomly during
the cardiac cycle:
- so coordinated contractions can occur
- to terminate a nonperfusing rhythm
Indications include VF and pulseless VT
Cardioversion is the delivery of energy that is
synchronized to the QRS complex
- to allow a normal sinus rhythm to restart
 DEFIBRILLATION…
Untreated VF deteriorates to asystole in about 15 minutes
For every minute delay in defibrillation, survival decreases
by 7 % to 10%
If delay to defibrillation exceeds 12 minutes, survival is of the
order of 0% to 5%
Most successful treatment for v-fib is defibrillation!
All published studies support the effectiveness (85%–98%) of
biphasic shocks using 200 J or less for the first shock.
Metoba et al (2010) Circulation
Device
 Most defibrillators are energy-based (Mono > Biphasic)
Energy Dose for Subsequent Shocks
(a fixed energy dose vs escalating higher doses)

Single Vs Stacked shocks

A single-shock strategy (as opposed to stacked shocks)
is reasonable for defibrillation(Class IIa, LOE B-NR)
Avoid prolonged pauses (>10 seconds)
to CPR when performing defibrillation
 Several alternative positions for
defibrillatin paddles or pads

- Antero-apical position
- Anteroposterior position
- Apex-posterior position
For monophasic defibrillators begin
with an initial 360-J shock
For biphasic waveforms deliver the first
shock with an energy of at least 150 J
 DRUGS AND FLUIDS FOR
CARDIAC
Drugs are an adjunct in ARREST
the management of cardiac arrest
patients
The effectiveness of standard resuscitative drugs on ROSC and
survival to hospital discharge has not been well demonstrated
Vasopressors
 Epinephrine
 vasopressin

Antiarrhythmics
 Amiodarone
 Lidocaine
 Magnesium
 Procainamide
 Beta blockers

Steroids
Epinephrine
- peripheral vasoconstriction, which improves cerebral and
coronary blood flow
Epinephrine seems to improve short-term survival
Dose: 1mg IV/IO q 3-5 minutes
High-dose epinephrine have not resulted in increased long-
term survival
Used mainly to treat cardiac arrest from:
- VF or pVT unresponsive to the initial shock
- asystole, PEA, and profoundly symptomatic bradycardia

Timing: It may be reasonable to administer

epinephrine as soon as feasible after the onset of
cardiac arrest due to an initial non- shockable rhythm.
(Class IIb, LOE C-LD)
Vasopressin
peripheral vasoconstrictor without chronotropic or inotropic
effects
Dose: 40 IU IV
No advantage as a substitute for epinephrine or when used in
combination with epinephrine
 ANTI-ARRHYTHMICS
For refractory VF/ pVT (persistent or recurring after one or
more shock)
- to facilitate restoration and maintenance of a spontaneous
perfusing rhythm in concert with termination of VF/ VT by
defibrillation
Don’t increase long term survival or survival with good
neurologic outcome
but may increase rates of hospital admission and ROSC
Amiodarone
It causes coronary and peripheral artery vasodilation
A class 3 antiarrhythmic (prolong repolarization and refractory
period)
Also has class 1b and class 4 effect
It is more effective than lidocaine for improving short-term
survival
Its main use in cardiac arrest is for persistent VT or VF
after defibrillation and epinephrine
IV initial dose 300 mg , second dose 150 mg
Lidocaine
A class 1b drug
Less effective than amiodarone in OHCA but similar
effects in survival to discharge
- First dose 1-1.5 mg/kg IV
- Repeat 0.5- 0.75 mg/kg q 5-10 minutes (max
cumulative dose 3mg/kg)
- Start infusion (1-4 mg/minute) after ROSC
- Infusion concentration (1000/2000mg in 250ml
D5W ,i.e. 4 mg/mL or 8 mg/ml)
Magnesium (for torsades de pointes)
A direct vasodilator
Regulates sodium, potassium and calcium flow across
membranes (reduced SA node impulse generation and
slowed impulse conduction)
Doesn’t improve rate of ROSC regardless of the
presenting rhythm
1-2 g IV over 15 minutes after defibrillation
 2015 RECOMMENDATIONS -
UNCHANGED
Amiodarone may be considered for VF/pVT that is unresponsive
to CPR, defibrillation, and a vasopressor therapy. (Class IIb, LOE
B-R)
Lidocaine may be considered as an alternative to amiodarone
for VF/pVT that is unresponsive to CPR, defibrillation, and
vasopressor therapy. (Class IIb, LOE C-LD)
The routine use of magnesium for VF/pVT is not recommended
in adult patients.(Class III: No Benefit, LOE B-R)
 Steroids (methylprednisolone, during arrest/ hydrocortisone,
post)
In IHCA, combination with vasopressin, epinephrine, and
methylprednisolone and postarrest hydrocortisone improved
ROSC and survival to hospital discharge--needs further study
to recommend as a routine

Vs

For patients with OHCA, use of steroids

during CPR is of uncertain benefit. (Class
ANTIARRHYTHMIC DRUGS
AFTER
RESUSCITATION: AFTER ROSC
The only studied drugs are beta blockers(metoprolol/
bisoprolol) and lidocaine
There is inadequate evidence to support the routine
use of lidocaine or a -blocker after cardiac arrest
But may be considered immediately after ROSC or
early after hospitalization from cardiac arrest due to
VF/pVT respectively
INTERVENTIONS NOT
RECOMMENDED FOR
ROUTINE USE DURING
CARDIAC ARREST
Atropine
Sodium carbonate
Calcium
Fibrinolysis
Pacing
ADVANCED AIRWAY

No difference in outcome as compared to bag mask

ventilation
Consider when bag mask is inadequate or as a
stepwise approach to airway management
Selection of which method to use depends on the skill
and experience of the person doing the CPR
- ETT or SGA (Supraglottic airway devices)
RHYTHM-BASED MANAGEMENT
OF CARDIAC ARREST

VF and pulseless VT

- are nonperfusing rhythms emanating from the ventricles
- early rhythm identification, defibrillation, and CPR are the
mainstays of treatment
- treat reversible causes
- If VF or pVT persists after at least one attempt at defibrn
and 2 minutes of CPR, give epinephrine
- antiarrhythmic drugs:
If the patient has ROSC, post–cardiac arrest care
should be started
ASYSTOLE AND PULSELESS
ELECTRICAL ACTIVITY
Asystole: a complete absence of detectable ventricular
electrical activity
PEA: electrocardiographic rhythms without sufficient
mechanical contraction of the heart to produce a
palpable pulse or measurable BP
Are non-perfusing rhythms
Successful management depends on excellent CPR,
vasopressors, and rapid reversal of underlying causes
IT IS CRUCIAL TO IDENTIFY AND TREAT
POTENTIAL SECONDARY CAUSES OF
ASYSTOLE OR PEA AS RAPIDLY AS
POSSIBLE
- AFTER INITIATING CPR, TREAT
REVERSIBLE CAUSES AS APPROPRIATE
AND ADMINISTER EPINEPHRINE
Neither asystole nor PEA responds to defibrillation
Atropine is no longer recommended for the treatment of
asystole or PEA
Cardiac pacing is not recommended for routine use in cardiac
arrest(C III, LOE B)
BRADYCARDIA
Heart rate < 60 beats per minute
Symptomatic bradycardia generally entails rates < 50
bpm
If bradycardia produces signs and symptoms of
instability, the initial treatment is atropine.
(Class IIa, LOE B)
TACHYCARDIA
A rate of >100 beats per minute
Symptomatic tachycardia generally involves rates over
150 beats per minute, unless underlying ventricular
dysfunction exists
If not hypotensive, the patient with a regular
narrow-complex SVT may be treated with
adenosine while preparations are made for
synchronized cardioversion. (Class IIb, LOE C)
Figure 4: Adult Tachycardia With a
Pulse Algorithm
 POST CARDIAC
ARREST
Post–cardiac CARE
arrest care is a critical component of ALS
Most deaths occur during the first 24 hours after cardiac arrest
Issues to be addressed include:
Determining and treating the cause of cardiac arrest
Minimizing brain injury
Managing cardiovascular dysfunction
Managing problems that may arise from global ischemia and
reperfusion injury
Cardiovascular care
Acute interventions
- Emergent coronary angio for OHCA and ST elevation on
ECG
- reasonable for selected unstable patients who are
comatose after OHCA but without ST elevation
- Post CA patients who have indication for coronary angio
regardless of LOC
Hemodynamic Goals
- Avoid and immediately correct hypotension (SBP <90, MAP
<65)
Temperature management
Lowering brain temp during the first few hours after CA
reduces the risk of neurologic injury
REC. Comatose adult patients with ROSC after cardiac
arrest have TTM (Class I, LOE B-R for VF/pVT OHCA; for
non-VF/pVT (ie, “nonshockable”) and in-hospital
cardiac arrest). (Class I, LOE C-EO)
- a constant temperature 32ºC - 36ºC during TTM
Avoid hyperthermia
Respiratory care
-Maintain Pco2 within the normal physiologic limit (35 to
45 mmHg)
 Lower targets to treat cerebral edema
 Higher targets in ALI or high airway pressures

- Use an FIo2 that maintains oxygen saturation greater than or equal to 94

- If difficult to measure SpO2 due to peripheral vasoconstriction send for PaO2
to adjust the FiO2
Neurologic care
 EEG should be promptly done and interpreted to diagnose seizure activity
and monitored(frequently/continiously) in comatose patients
 Once identified treat according to recommendations for other causes of
status epilepticus

Glucose control
 No specific target range of serum glucose is recommended (uncertain
benefit)
REFERENCES
2015 AHA Guidelines Update for CPR and ECC
Uptodate 21.6
Tintinallis emergency medicine, 8th ed.
ERC Guidelines for Resuscitation 2015
Harrison’s Principles of IM, 19th ed.