Michele Vicari-Christensen DNP ARNP August 17 th 2013

1) Discuss the recent changes in ACLS 2) Understand the scientific rationale for the changes presented 3) Explain the use of capnography and hypothermia 4) Explore the rationale for key pharmacological changes in the algorithms 5) Illustrate the Chain of Survival

CPR Quality-Concensus Statement Circulation June ) Must use a systematic approach to assess and treat arrest and acutely ill or injured patients for optimum care which includes: -High quality CPR -Capnography -Hypothermia -Optimal glycemic control -Appropriate algorithms and pharmolcological agents 2) Goal of any resuscitative action is return of spontaneous circulation (ROSC) and neurological preservation

1) Minimize any interruptions in effective chest compressions. 2) Provide compressions of adequate rate and depth 3) Avoid leaning between compressions 4) Allow complete chest recoil after each compression 5 Avoid excessive ventilation

CPR survival is dependent on adequate myocardial oxygen delivery and myocardial blood flow: Chest compression fraction (CCF) of >80%-minimal interruptions Chest compression rate of Compression depth of 50 mm or 2 inches in adults (1/3 anterior, posterior dimension of chest No Leaning causes lack of recoil Excessive ventilation decreases depth and recoil

Quantitative waveform capnography is the continuous, noninvasive measurement and graphical display of end-tidal carbon dioxide/ETCO2 (also called PetCO2). Capnography uses a sample chamber/sensor placed for optimum evaluation of expired CO2. The inhaled and exhaled carbon dioxide is graphically displayed as a continuous waveform on the monitor along with its corresponding numerical measurement

Circulation. Blood must be moving in order to deliver CO2 from the tissues to the alveoli. Circulation requires blood, an effective heartbeat and blood pressure. Preload plus afterload equals circulation. Mimic in compressions. In the acute setting, PetCO2 is a function of cardiac output Ventilation. Air must move in and out of the alveoli effectively to get rid of carbon dioxide and other waste products, and to inhale fresh oxygen.

1) Qualitative waveform capnography (PETC02) provides a quality measure for CPR 2) Optimal goal for CPR is PETC02 of mmHg equates to same as when ROSC 3) If PET Co2 is < 10 mmHg attempt to improve CPR-a PetC02 is 10 or less after initiation of ACLS is associated with poor outcomes.

The new guidelines recommend cooling comatose adult patients with ROSC after out of hospital VF, PEA and Asystole cardiac arrest to degrees C (89-93 degrees F) for up to hours

Side Effects and Complications Higher Systemic Vascular Resistance, Pneumonia Lower Cardiac Index Hyperglycemia Coagulopathy Arrythmias Skin Breakdown

1) Target glycemic control mg/dl in an adult patients after cardiac arrest and ROSC. 2) Avoid lower blood sugars in ranges of mg/dl

Hypoglycemia causes cerebral cellular fuel deprivation and cellular death as well as an increase in cerebral cellular excitability and seizures.

Henderson-Hasselbalch Equation Regulation of Carbonic Acid/Bicarbonate buffer pair

1) Parasympatholytic agent. Research supports only effective utilization is in symptomatic bradycardia 2) There is no benefit in pulseless electrical activity or asystole

ACLS extends to Acute Coronary Syndrome and Cerebral Vascular Accidents

Guidelines for CPR and ECC (2010). American Heart Association. Field et al. (2010). Executive Summary- American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. (2010). Circulation. November 2, 2010; pp. S640-S729. CPR Quality-Improving Cardiac Resuscitation Outcomes Both inside and Outside the Hospital: A Concensus Statement from the American Heart Association. (2013).Circulation. June 25, pp. 1-19