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A32 Anesthesia
Appendices Toronto Notes 2019 Advanced Cardiac Life Support Guidelines
1
2 VF/pVT
Adult Cardiac Arrest
Start CPR
• Give oxygen
• Attach monitor/defibrillator
CPR Quality
• Push hard (≥2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil
• Minimize interruptions in compressions • Avoid excessive ventilation
• Rotate compressor every 2 min, or
sooner if fatigued
• If no advanced airway,
30:2 compression-ventilation ratio • Quantitative waveform capnography – If PETCO2 <10 mmHg, attempt to
improve CPR quality • Intra-arterial pressure
– If relaxation phase (diastolic) pressure <20 mmHg, attempt to improve CPR quality
Shock Energy
• Biphasic: Manufacturer recommenda- tion (e.g. initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered
• Monophasic: 360 J Drug Therapy
• Epinephrine IV/IO Dose: 1 mg every 3-5 min
• Amiodarone IV/IO Dose:
– First dose: 300 mg bolus – Second dose: 150 mg
Advanced Airway
• Endotracheal intubation or supraglottic advanced airway
• Waveform capnography to confirm and monitor ET tube placement
• Once advanced airway in place, give 1 breath every 6 sec (10 breaths/min) with continuous chest compressions
• Pulse and blood pressure
• Abrupt sustained increase in PETCO2
(typically ≥40 mmHg)
• Spontaneous arterial pressure waves
with intra-arterial monitoring
Reversible Causes
– Hypovolemia
– Hypoxia
– Hydrogen ion (acidosis) – Hypo-/hyperkalemia
– Hypothermia
– Tension pneumothorax – Tamponade, cardiac
– Toxins
– Thrombosis, pulmonary – Thrombosis, coronary
Yes
• IV/IO access
Rhythm shockable?
9 Asystole/PEA
No
No
No
3 4
SHOCK
CPR 2 min
Rhythm shockable?
Yes
10
CPR 2 min
6
7
capnography
Rhythm shockable?
No
CPR 2 min
• Treat reversible causes
Rhythm shockable?
Yes
5 SHOCK
CPR 2 min
• Epinephrine every 3-5 min • Consider advanced airway,
capnography
Rhythm shockable?
Yes
SHOCK
CPR 2 min • Amiodarone
• Treat reversible causes
• IV/IO access
• Epinephrine every 3-5 min • Consider advanced airway,
11
8
Figure 19. Adult cardiac arrest algorithm
• If no signs of return of spontaneous circulation (ROSC), go to 10 or 11
• If ROSC, go to Post-Cardiac Arrest Care
Go to 5 or 7
No
Yes
Reprinted with permission: Link, M. S., Berkow, L. C., Kudenchuk, P. J., Halperin, H. R., Hess, E. P., Moitra, V. K., ... & White, R. D. (2015). Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015, 132(18 suppl 2), S444-S464. ©2015 American Heart Association, Inc.
Return of Spontaneous Circulation (ROSC)