1. ACLS Past, Present & Future Dr FT Lee A&E, PMH 2004 http://pmh-acls2004.tripod.com

2. Do s Brief review of main points Case presentation Future development

3. Don’t s Review of Algorithms

4. History Originated in Nebraska in early 1970

5. History Organised in Hong Kong by Hong Kong Society of Emergency Medicine and surgery since 1991 Case-based small group teaching since 1994 A two days workshop with hands on experience

6. Cardiac arrest? Breathing 氣 Beating 血

7. Pulse check no more than 10 sec Start chest compression if you are unsure

8. Cardiac Arrest Ventricular fibrillation/ Pulseless Ventricular Tachycardia Asystole Pulseless Electrical Activity(PEA)

9. Early defibrillation The most frequent initial rhythm in sudden cardiac arrest is VF Chance of successful defibrillation reduced 10% each minute

10. Chain of survival Early accessEarly CPREarlyEarly ACLS Defibrillation

11. Pulse +ve Tachycardia 快 Bradycardia 慢

12. Tachycardia (P > 100/min) Wide complex –QRS >0.12 s (3 small squares) Narrow complex –QRS < 0.12 s

13. Bradycardia (P< 60/min) Sinus Heart Block –1 st, 2 nd and 3rd

14. Pulse +ve STABLE ?

15. Unstable Shock SOB Severe chest pain Impaired consciousness

16. Unstable Electrical therapy

17. Stable Drug

18. Drugs Adrenaline/Vasopressin Amiodarone –300mg iv bolus in VF/pulseless VT –150mg ivi over 10 min in stable tachycardia –Maintenance infusion 1mg/min for 8hrs then 0.5mg/min for 16 hours ATP/Verapamil/Diltiazem Atropine

19. Is life so simple?

20. Case 1 AE 04026XXX(X) Mr Au, M/57, 19:58, 3/2004 C/O: Chest pain since 18:00 with radiation to neck & back, sweating +ve PH: HT, Gout

21. BP: 182/73, P: 99/min reg, RR: 14/min SaO2: 96% (RA) Triage as Cat III (20:00) ECG ordered

23. Seen at 20:46 (46mins after triage) Diagnosed as Angina O2, TNG, Aspirin and Heparin block ordered Patient disappeared at 20:55, 20:56, 20: 58, 21:00, 21:03. Reappeared at 21:05

24. Developed generalized seizure on receiving treatment Valium 10mg iv given Seizure stopped

25. Cardiac monitor

26. Defibrillation 200J Asystole Adrenaline 1mg VF Defibrillation 300J Asystole Amiodarone 300mg iv bolus Adrenaline 1mg iv SR

27. Patient semi conscious Intubated under RSI Admitted to ICU Extubated in ICU and discharged from medical ward

28. Happy Ending Beating Heart with a Thinking Mind

29. Case 2 AE04097XXX(X) Ms Ou F/28, 16:24 10-04 Tourist from Thailand to China C/O: Chest discomfort since 14:30 PH: VSD

30. P/E: BP: 115/64, P: 119/min, RR:14/min GCS: 15 Cat II

32. Dormicum 5mg iv Synchronized cardioversion 100J SR Amiodarone 150mg iv stat 150mg in 100ml over 1 hour

33. Admitted to CCU DAMA 2 days after

34. Case 3 AE04071XXX(X) Ms Siu F/82, 09:56, 8-04 C/O: Increase dizziness in the morning. Fell onto ground for 3 times. PH: HT, gout

35. P/E: BP: 95/50 (R/C 95/60)P:60 reg Fully conscious Cat III

37. Amiodarone 150mg in 100ml D5 ivi over 30mins Convert back to SR BP: 107/50, P:82/min

39. Case 4 AE01134XXX(X) Mr Cheng M/17, 17:48, 12-01 C/O: LOC at 15:00 for 2mins, Left chest pain, sweating, palpitation PH: good

40. P/E: BP: 95/51, P150/min, RR: 22/min, SaO2: 100% (RA), GCS:15 Cat II

42. What next?

44. Chest drain inserted 1.4 litre of blood drained 1 litre of NS given Admit to surgery

45. Case 5 AE04102XXX(X) Mr Cheng M/75, 18:26, 11-04 C/O: sudden onset of chest pain and SOB P/E: In distress, sweating BP: 106/51, P:71/min, RR: 40/min SaO2: 87% with O2

48. CXR: APO TNG, Aspirin were given

49. What next? Intubate or TCP?

50. Intubation was done under RSI Developed cardiac arrest after Suxamethonium was given CPR, Atropine and Adrenaline

51. Pulse returned transiently Put on TCP Develop cardiac arrest again No response to resuscitation Certified dead 1 hour after

52. A sad ending

53. ACLS A means or the end?

54. Exceptions VF in Hypothermia Tachycardia in TCA overdose Arrhythmia in hyperkalemia Bradycardia or Heart block in Ca channel blocker or  -blocker overdose

55. Treat the patient Not the ECG !

56. The Road Ahead

57. Future Biphasic defibrillation Antiarrhythmics

58. Biphasic defibrillation

61. Positive evidence supports a statement that initial low-energy (150-J), nonprogressive (150 J-150 J-150 J), impedance-adjusted biphasic waveform shocks for patients in out- of-hospital VF arrest are safe, acceptable, and clinically effective (Circulation. 1998;97:1654-1667.)

62. Biphasic defibrillation Less energy More efficacy Less myocardial damage Class IIA recommendation for VF/pulseless VT

63. Biphasic defibrillation What energy level for defibrillation? Is escalating energy necessary? Recommendations –150J, 150J, 150J –120J, 150J, 200J (Zoll) –200J, 300J, 360J (Medtronic)

64. Biphasic Synchronized cardioversion What energy level? –50J, 100J, 120J, 150J, 200J (Zoll) –50J, 100J, 200J, 300J 360J (Medtronic)

65. Drugs Vasopressin –Lack of evidence base Amiodarone –Effective drugs –Long term S/E

66. Questions & comments