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Guidelines for Emergency Cardiovascular Care
Aka: Guidelines for Emergency Cardiovascular Care
- See Also
- Cardiopulmonary Resuscitation
- Background
- Emergency Resuscitation has been significantly updated in 2000, 2005, 2010
- Broad evidence based changes
- Guidelines applied Internationally
- Applied across all Resuscitation courses
- Basic Life Support: Cardiopulmonary Resuscitation
- Advanced Cardiac Life Support
- Pediatric Advanced Life Support
- ACLS guidelines 2010 focuses on Cardiac Compressions as the first line intervention
- New Mnemonic is 'C-A-B'
- First-responders start compressions without a pulse check to minimize delays
- Cardiac Compressions should be hard and fast, interrupted only for <10 seconds for rhythm checks and Defibrillation
- Active Compression-Decompression devices (ACD-CPR, e.g. Lucas ) can be considered where available, however insufficient evidence in 2010
- Protocol: Basic Life Support Changes
- No pulse check before starting CPR
- Laypersons inaccurately identify pulseless patient
- Automatic Electrical Defibrillator (AED)
- Public access Defibrillator emphasized
- Early Defibrillation critical for survival in arrest
- Bag Valve Mask Ventilation emphasized
- Pre-hospital providers should be skilled with BVM
- Endotracheal Intubation de-emphasized
- Tidal Volumes decreased to 50% (6-7 ml/kg)
- Chest Compressions
- Mainstay of Resuscitation
- All patients (child and adult) are compressed 100/min
- Cardiac Compressions should be hard and fast
- Ratio of Chest Compressions to ventilations
- One and two rescuer ratio are now both 30:2
- Exception: CPR in children by 2 health care providers is at a ratio of 15:2
- Protocol: Advanced Cardiac Resuscitation Changes
- Antiarrhythmic Drugs
- Bretylium no longer included in recommendations
- Amiodarone is preferable to Lidocaine usage
- Vasopressin is alternative to Epinephrine in Ventricular Fibrillation
- No Epinephrine used within 20 minutes of dose
- In practice, Vasopressin is often not available
- Sotalol is a new option for Ventricular Tachycardia
- Epinephrine
- High dose Epinephrine de-emphasized (may be harmful)
- Epinephrine is recommended in most of the ACLS cardiac guidelines 2010 (recommendation 2B)
- See Epinephrine regarding questions of efficacy in Cardiac Arrest since the 2010 ACLS guidelines
- New emphasis on use of one Antiarrhythmic
- Contrast to prior Antiarrhythmic soups
- Pro-arrhythmic effects increase with poly-drugs
- Acute Coronary Syndrome
- Pre-hospital 12 lead Electrocardiogram
- Pre-hospital triaging to Fibrinolytic candidate
- Early Fibrinolysis in Acute Myocardial Infarction
- Antiplatelet drugs (in addition to Aspirin 325 mg)
- Indications
- Patients likely to go to angiogram
- Unstable Angina
- Non-ST elevation MI
- Options (choose one per local catheter lab protocol)
- Clopidogrel 300 mg once or
- GP IIB IIIA Inhibitors
- Acute Ischemic Stroke (Code-Stroke)
- Indicated for patients meeting the NIH stroke score guidelines and no contraindications
- Intravenous tPA within 3 hours of symptom onset
- Do not use intravenous tPA beyond 3 hours of symptoms
- Endotracheal Intubation must be performed correctly
- Providers must be skilled (>6 intubations per year)
- Consider alternative airway management if not skilled
- Esophageal-tracheal Combitube (ETC)
- Laryngeal Mask Airway (LMA)
- Confirm endotracheal placement with End-Tidal CO2
- Use commercial tube holder
- Cocaine induced emergencies
- Ventricular Dysrhythmias
- Sodium Bicarbonate
- Alpha adrenergic blockers
- Acute Coronary Syndrome
- Benzodiazepines
- Nitrates
- Alpha adrenergic blockers
- Inappropriate Medications
- Non-selective Beta-Blockers (selective also)
- References
- Cardiopulmonary Resuscitation Guidelines
- http://www.circulationaha.org
- (2010) Guidelines for CPR and ECC [PubMed]
- (2005) Circulation 112(Suppl 112):IV [PubMed]
- (2000) Circulation, 102(Suppl I):86-9 [PubMed]