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Copy of ACLS 2010 Updates
Transcript of Copy of ACLS 2010 Updates
UPDATES Spend no more than 10 seconds
checking for a pulse. Presented by:
Dr. Ma. Ivy D. Lozada 2010 ACLS Guidelines-CPR High quality CPR continues to be of primary importance in optimizing outcomes. Compression Quality Emphasis is being placed on high quality CPR with compressions of adequate depth (2-2 1/2?) and rate, allowing complete chest recoil. Compression pauses Minimization of the interval between stopping chest compressions and shock delivery should be encouraged. Data collected has indicated that minimizing the pause between compressions and shock improves the chances of shock success. Ventilation Excess ventilation can have detrimental effects on the patient who is in cardiac arrest or other low-blood-flow states. Therefore excessive ventilation should be avoided. Team Delegation Emphasized Improved outcomes for ACLS are expected when ACLS is performed by an integrated team of highly trained rescuers. Having a team of highly trained rescuers allows for efficient management of the many tasks performed by healthcare providers during a resuscitation attempt. Thus, training should focus on building the team as each member arrives or quickly delegating roles when multiple rescuers are present. Sequence Change from ABC to CAB Per the 2010 Guidelines, it is reasonable for the in-hospital healthcare provider to tailor the sequence of rescue actions to the most likely cause of arrest. ACLS Key Emphasis Points for Training The 2010 AHA ACLS/BLS Guidelines included several points that the AHA felt needed to be emphasized during BLS and ACLS training. Below is a brief summary of these key emphasis points. -Early recognition of sudden cardiac arrest is of primary importance. It is not uncommon for there to be an abnormal presentation of sudden cardiac arrest which may cause a rescuer confusion and thus delay CPR. Training should include identifying unusual presentations of sudden cardiac arrest so that chest compressions are not delayed.
-Minimize Interruptions in chest compressions. Any unnecessary interruptions in chest compressions decreases CPR effectiveness.
-Minimize the importance of pulse checks. Assessment of a pulse can be very difficult during emergency situations, and often leads to a delay in initiation or continuation of CPR. Chest compressions delivered to patients who are later found not to have been in cardiac Electrical Therapy Changes and Review The 2010 AHA ACLS/BLS guidelines have been updated to reflect new data on the use of pacing in bradycardia, and on cardioversion and defibrillation for tachycardia rhythm disturbance. The following is a list of the most important points. 2010 ACLS Guidelines and Airway Management The 2010 ACLS Guidelines included several changes regarding airway management. Below is a summary of the most significant changes in airway management dynamics: 1.The use of quantitative waveform capnography (QWC) for confirmation and monitoring of endotracheal tube placement is considered a class 1 recommendation. It has been determined that the most reliable method of confirming and monitoring correct placement of an endotracheal tube was QWC. Colormetric ETCO2 devices should only be used “when waveform capnography is not available.
2.The use of supraglottic advanced airways (laryngeal mask airway (LMA), esophageal-tracheal tube (combitube), laryngeal tube) continues to be supported as an alternative to endotracheal intubation for airway management during CPR. When providers are trained in the use of supraglottic airway devices, these devices have been show to be just as effective as a BVM or ET tube for delivery of ventilations.
3.The routine use of cricoid pressure during airway management of patients in cardiac arrest is no longer recommended. Reasons for this include reduced effectiveness of ventilations and interference with placement of a supraglottic airway or intubation. Healthcare Provider BLS Acute Coronary Syndromes (ACS) • Reducing the amount of myocardial necrosis that occurs in patients with acute myocardial infarction, thus preserving left ventricular function, preventing heart failure, and limiting other cardiovascular complications
• Preventing major adverse cardiac events death, nonfatal myocardial infarction, and the need for urgent revascularization.
• Treating acute, life-threatening complications of ACS such as VF, pulseless VT, unstable tachycardia., and symptomatic bradycardias. Stroke •Because cardiac arrest victims may present with a short period of seizure-like activity or agonal gasps that may confuse potential rescuers, dispatchers should be specifically trained to identity these presentations of cardiac arrest to improve cardiac arrest recognition.
•Dispatchers should instruct untrained lay rescuers to provide Hands-Only CPR for adults with sudden cardiac arrest.
•Refinements have been made to recommendations for immediate recognition and activation of the emergency response system once the health care provider identifies the adult victim who is unresponsive with no breathing, no normal breathing or only gasping. The healthcare provider briefly checks for no breathing, no normal breathing or only gasping when the provider checks responsiveness. The provider then activates the emergency response system and retrieves the AED (or sends someone to do so). The healthcare provider should not spend more than 10 seconds checking for pulse, and if a pulse is not definitely felt within 10 seconds. should begin CPR and use the AED when available.
•"Look, listen, and feel for breathing” has been removed from the algorithm.
•Increased emphasis has been placed on high-quality CPR and compressions of adequate rate and depth, allowing complete chest recoil between compressions, minimizing interruptions in compressions, and avoiding excessive ventilation. •Use of cricoid pressure during ventilations is generally not recommended.
•Rescuers should initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression.
•Compression rate is modified to at least 100/min from approximately 100/min.
•Compression depth tot adults has been slightly altered to at least 2 inches (about 5 cm) from the previous recommended range of about 1 to 2 inches (4 to 5 cm)
•Continued emphasis has been placed on the need to reduce the time between the last compression and shock delivery and the time between shock delivery and resumption of compressions immediately after shock delivery.
•There is an increased focus on using a team approach during CPR. These changes are designed to simplify training for the healthcare provider and to continue to emphasize the need to provide early and high-quality CPR for victims of cardiac arrest. cont. • The time-sensitive nature of stroke care requires the establishment of local partnerships between academic medical centers and community hospitals. The concept of a "stoke-prepared" hospital has emerged with the goal of ensuring that best practices for stroke care (acute and beyond) are offered in an organized fashion throughout the region. Additional work is needed to expand the leach of regional stroke networks.
• Each EMS system should work within a regional stroke system of care to ensure prompt triage and transport to a stroke hospital when possible. • Although blood pressure management is a component of the ED care of stroke patients, unless the patient is hypotensive (systolic blood pressure <90 mm Hg), prehospital treatment of blood pressure is not recommended
• A glowing body of evidence indicates improvement in 1-year survival rate, functional outcomes. and quality of life when patients hospitalized with acute stoke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke.
• Guidelines for indications, contraindications, and cautions when considering use of recombinant tissue plasminogen activator (rtPA) have been updated to be consistent with the American Stroke Association and AHA-recommendations • Although a higher likelihood of good functional outcome is reported when patients with acute ischemic stroke receive rtPA within 3 hours of stroke symptom onset treatment of carefully selected patients with acute ischemic stroke with IV rtPA between 3 and 4.5 hours after symptom onset has also been shown to improve clinical outcome; however, the degree of clinical benefit is smaller than that achieved with treatment within 3 hours. At present, the use of IV OPA within 3 to 4.5 hours after symptom onset has not been approved by the US Food and
• Recent studies showed that stroke unit care is superior to care on general medical wards, and the positive effects of stroke unit care can persist for years. The magnitude of benefits from treatment in a stroke unit is comparable to the magnitude of effects achieved with IV rtPA.
The table for management of hypertension in stroke patients has been updated. cont. The most dramatic change in the 2010 AHA CPR guidelines for ACLS and BLS is a change in the basic life support sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adult and pediatric patients (excluding newborns).
This change occurred due to the fact that the vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia. (VT). In these patients, the critical elements of CPR have been shown to be chest compressions and early defibrillation. This change in sequence will ensure that chest compressions will be initiated sooner and should only cause a minimal delay in ventilation until completion of the first cycle of chest compressions (approx. 18 seconds for 30 chest compressions)
Starting with chest compressions may ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions. 1. Adenosine can now be considered for the diagnosis and treatment of stable undifferentiated wide-complex tachycardia when the rhythm is regular and the QRS waveform is monomorphic.
2. IV infusion of chronotropic agents is now recommended as an equally effective alternative to external pacing when atropine is ineffective.
3. Atropine is no longer recommended for routine use in the management of PEA and asystole. 2010 ACLS Guidelines-Management of Symptomatic Arrhythmias Advanced Cardiac Life Support (ACLS) • 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 pulseless electrical activity (PEA) and asystole.
• Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradyrcardia.
• Adenosine is recommended as safe and potentially effective for both treatment and diagnosis in the initial management of undifferentiated regular monomorphic wide complex tachycardia
• Systematic post-cardiac arrest Care after ROSC should continue in a critical care unit with expert multidisciplinary management and as of the neurologic and physiologic status of the patient. This often includes the use of therapeutic hypothermia. 1. Full integration of AED’s into a system of care is critical to the Chain of Survival in public places outside hospitals.
2. The 1-shock protocol for VF has not been changed.
3. Rescuers should minimize the interval between stopping compressions and delivering shocksand should resume CPR immediately after the shock delivery
4. Biphasic waveforms have been shown to be more effective than monophasic waveforms in cardioversion and defibrillation. Emphasis should be placed on the use of the biphasic waveform.
5. In both defibrillation and cardioversion, if the initial shock fails, providers should increase the dose in a stepwise fashion.
6. Pacing is not recommended for patients in asystolic cardiac arrest.
7. Healthcare providers should be prepared to initiate pacing in patients with bradyarrhythmias in the event the heart rate does not respond to atropine or other chronotropic (rate accelerating) drugs. Thank you.