Part 6: Advanced Cardiovascular Life Support
2000; Lippincott Williams & Wilkins; Volume: 102; Issue: suppl_1 Linguagem: Inglês
10.1161/circ.102.suppl_1.i-136
ISSN1524-4539
AutoresAll who respond to cardiorespiratory emergencies should arrive well trained in a simple, easy-to-remember approach. The ACLS Provider Course teaches the, to emergency cardiovascular care. This memory aid describes sets of steps, With each step the responder performs an, and then, if the assessment so indicates,
Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeCirculationVol. 102, No. suppl_1Part 6: Advanced Cardiovascular Life Support Free AccessOtherDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherDownload EPUBPart 6: Advanced Cardiovascular Life Support Section 7: Algorithm Approach to ACLS Emergencies Originally published22 Aug 2000https://doi.org/10.1161/circ.102.suppl_1.I-136Circulation. 2000;102:I-136–I-165Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 22, 2000: Previous Version of Record 7A: Principles and Practice of ACLSKey Principles in the Application of ACLSThe Importance of TimeThe passage of time drives all aspects of ECC. The final outcomes are determined by the intervals between collapse or onset of the emergency and the delivery of basic and advanced interventions.1A2A The probability of survival declines sharply with each passing minute of cardiopulmonary compromise. Some interventions, like basic CPR, slow the rate at which this decline in probability occurs. CPR makes this contribution by supplying some blood flow to the heart and brain. Some single interventions, such as tracheal intubation, clearing an obstructed airway, or defibrillating a heart in VF, are sufficient alone to restore a beating heart. For all of these interventions, independently sufficient or simply contributory, the longer it takes to administer these therapies, the lower the chances of benefit.The "Periarrest" PeriodEmergency cardiovascular care no longer focuses only on the patient in cardiac arrest. Emergency care providers cannot narrow their objectives to only the arrest state. They must recognize and treat effectively those patients "on their way to a cardiac arrest" and those recovering in the immediate postresuscitation period. Once these patients are identified, ECC personnel must be able to rapidly initiate appropriate therapy. If responders treat critical conditions properly in this "periarrest" or "prearrest" period, they can prevent a full cardiopulmonary arrest from occurring.Consequently, the international ACLS recommendations present the science-based clinical guidelines and some educational material for these periarrest conditions:Acute coronary syndromesAcute pulmonary edema, hypotension, and shockSymptomatic bradycardiasStable and unstable tachycardiasAcute ischemic strokeImpairments of rate, rhythm, or cardiac function in the postresuscitation period (by definition a periarrest/prearrest condition)Other parts of the ECC and CPR guidelines present guidelines for more specific causes of cardiac arrest, such as electrolyte abnormalities, drug toxicity or overdoses, and toxic ingestions.Never Forget the PatientResuscitation challenges care providers to make decisions quickly and under pressure. Providers must occasionally limit their focus for a brief time to a specific aspect of the resuscitative attempt: getting the IV infusion line started, placing the tracheal tube, identifying the rhythm, and remembering the "right" medication to order. But rescuers constantly must return to an overall view of each resuscitative attempt. The flow diagrams or algorithms focus the learner on the most important aspects of a resuscitative effort: airway and ventilation, basic CPR, defibrillation of VF, and medications suitable for a particular patient under specific conditions.Code Organization: Using the Primary and Secondary ABCD Surveys The International PerspectiveMany approaches to code organization exist. The section that follows describes the approach taught in AHA courses for ACLS and pediatric resuscitation. This does not imply that methods of code organization used in other countries are incorrect or less successful.Why Is Training in ACLS Intentionally Multidisciplinary?An understandable tendency exists internationally to separate the highly trained professional from less skilled personnel during ACLS training. Such a practice, however, would jeopardize one of the most important objectives of resuscitation training. This objective is to have each member of the multidisciplinary response team know and understand the skills and roles of each of the other team members. An accomplished senior physician may claim, "I already know the resuscitation guidelines and already possess the psychomotor skills. Why must I attend a learning session with less trained responders who are not authorized to perform tracheal intubation, start an IV drip, or order medications?" An experienced instructor might respond in several ways, but the response should remind the expert that he or she must still work with the entire responding team. The expert must know what the other team members can and cannot perform so that attempted resuscitation proceeds smoothly, quietly, and effectively.Of even greater importance, the ACLS team member who possesses the lowest level of professional training will attend future resuscitative attempts as a critical quality control agent. Nurses, for example, who work in critical care and emergency care areas may not perform intubation or defibrillation in some settings, but they can detect with surprising speed and accuracy when other team members attempt the procedure incorrectly! In American hospitals, particularly academic teaching centers, nurses prevent innumerable medical mishaps during resuscitative attempts. They gently (and sometimes not so gently) point out when the tracheal tube is misplaced, the IV line has become a subcutaneous line, CPR is inadequate, or the medication ordered was incorrect or wrongly dosed.While emergency personnel are encouraged to know and experience the role of team leader, training should concentrate on the team aspects of resuscitative efforts. The course of resuscitative attempts may be complex and unpredictable. Indeed, a good resuscitation team has been likened to a fine symphony orchestra.3A The team recognizes the team leader for broad skills of organization and performance. They recognize the individual team member for specific performance skills. Like an orchestra, all are performing the same piece, polished by practice and experience, with attention to both detail and outcome. There is no excuse for a disorganized and frenetic code scene.The team leader should be decisive and composed. The team should stick to the ABCs (airway, breathing, and circulation) and keep the resuscitation room quiet so that all personnel can hear without repetitious commands. Team members shouldState the vital signs every 5 minutes or with any change in the monitored parametersState when procedures and medications are completedRequest clarification of any ordersProvide primary and secondary assessment informationThe team leader should communicate her or his observations and should actively seek suggestions from team members. Evaluation of airway, breathing, and circulation should guide the efforts whenever the vital signs are unstable, when treatment appears to be failing, before procedures, and for periodic clinical updates.The next section describes the Primary and Secondary ABCD Surveys. This aide-mémoire provides an easily remembered listing of the content and sequence of the specific assessment and management steps of a resuscitative attempt.The Primary and Secondary ABCD SurveysAll who respond to cardiorespiratory emergencies should arrive well trained in a simple, easy-to-remember approach. The ACLS Provider Course teaches the Primary and Secondary Survey Approach to emergency cardiovascular care. This memory aid describes 2 sets of 4 steps: A-B-C-D (8 total steps). With each step the responder performs an assessment and then, if the assessment so indicates, a management.Conduct the Primary ABCD SurveyThe Primary ABCD Survey requires your hands (gloved!), a barrier device for CPR, and an AED for defibrillation. The Primary ABCD Survey assesses and manages most immediate life threats:Airway: Assess and manage the Airway with noninvasive techniques.Breathing: Assess and manageBreathing with positive-pressure ventilations.Circulation: Assess and manage the Circulation, performing CPR until an AED is brought to the scene.Defibrillation: Assess and manageDefibrillation, assessing the cardiac rhythm for VF/VT and providing defibrillatory shocks in a safe and effective manner if needed.Conduct the Secondary ABCD SurveyThis survey requires medically advanced, invasive techniques to again assess and manage the patient. The rescuer attempts to restore spontaneous respirations and circulation to the patient and when successful, continues to assess and manage the patient until relieved by appropriate emergency professionals. In brief: resuscitate, stabilize, and transfer to higher-level care.Airway: Assess and manage. Advanced rescuers manage a compromised airway by placing a tracheal tube.Breathing: Assess and manage. Assess adequacy of breathing and ventilation by checking tube placement and performance; correct all problems detected. Manage breathing by treating inadequate ventilation with positive-pressure ventilations through the tube.Circulation: Assess and manage the circulation of blood and delivery of medications by —Starting a peripheral IV line —Attaching ECG leads to examine the ECG for the most frequent cardiac arrest rhythms (VF, pulseless VT, asystole, and PEA) —Administering appropriate rhythm-based medicationsDifferential Diagnosis: Assess and manage the differential diagnoses that you develop as you search for, find, and treat reversible causes.The Resuscitation Attempt as a "Critical Incident": Code Critique and DebriefingAfter any resuscitation attempt team members should perform a code critique. In busy emergency or casualty departments, carving out the necessary few minutes can be difficult. The lead physician, however, should assume responsibility to gather as many team members as possible for at least a pause to reflect. This debriefing provides feedback to prehospital and in-hospital personnel, gives a safe venue to express grieving, and provides an opportunity for education. Table 1 provides information on critical incident stress debriefing.An alternative approach to critical stress debriefing is presented by Kenneth V. Iserson, MD, in his book Pocket Protocols:Notifying Survivors About Sudden, Unexpected Deaths,4A from which the excerpt in Table 2 is adapted.Family Presence in the Resuscitation AreaIn a number of countries, hospitals have begun to allow family members and loved ones to remain in the resuscitation suite during procedures and actual resuscitative efforts. Evaluations of these programs, pioneered by critical care and emergency nurses, have confirmed a remarkable level of approval and gratitude by participating family members. These evaluations, mostly in pediatric cases, have noted significant reduction in posttraumatic stress and self-reports of a greater sense of resolution and fulfillment. In the 2000 pediatric resuscitation guidelines, family presence in the resuscitation area has a Class IIb positive recommendation. Provision must be made for a professional to accompany the family members during these observed attempts, to direct positioning, to answer questions, and to explain procedures. In addition, the accompanying professional can observe for signs of acute discomfort in the family members and can end the observations.We lack sufficient evidence about family presence during adult resuscitations, but this is simply due to an absence of research in adults. Success in such programs for adults is predictable, provided that the professionals involved demonstrate the same high level of care and concern as shown by nurses and social workers involved in pediatric resuscitative attempts.Ethics and the Clinical Practice of BLS and ACLS: Do Resuscitation Efforts "Fail"?Of major importance, but often neglected in the rush to learn all of advanced resuscitation training, we must not forget the resuscitation team and team members, as well as the surviving friends and relatives. As soon as you declare death for the arrest victim, you immediately acquire a new set of patients—the family, friends, and loved ones of the person who dies (see Table 3).Remember that when the heart or brain of a person in arrest cannot be restarted, do not use the word fail. The team did not fail to restore the heartbeat, nor did the heart itself fail to respond to the efforts. Instead think in terms of an attempt to restore a "heart too good to die"5A rather than a "heart too sick to live."6A At the start, however, the clinical reality is unknown; caregivers have no way of knowing the status of suddenly arrested hearts when they arrive on the scene of a cardiac emergency.In the past we used the phrase "give a trial of CPR"; the only way to recognize "too good to die" versus "too sick to live" was to give the patient a rapid, aggressive evaluation period of BLS and ACLS. If spontaneous circulation did not return quickly, then we assumed that the verdict in the trial of CPR was "person at the end of his or her life." In such a situation continued resuscitative efforts are inappropriate, futile, undignified, and demeaning to both patient and rescuers. "Part 2: Ethical Aspects of CPR and ECC" provides an ethical framework with which to consider resuscitative efforts and presents specific recommendations for prehospital and in-hospital care providers.Circulation. 2000;102(suppl I):I-136–I-165. Table 1. Recommendations for Resuscitation Team Critique and DebriefingAsk team members to assemble soon after the event. With few exceptions all team members should be present.Gather the group in a private place if possible. Use the resuscitation room if available. State the purpose: "We want to have a brief review (debriefing) of our resuscitative attempt."Start with a review of the events and conduct of the code. "Let's start from the arrival of the paramedics. Could (nurse) review our sequence of interventions?"State the algorithm or protocol that should have been followed; discuss what was actually done; discuss why there were any variations. "So this was an out-of-hospital VF arrest treated by the medics. When we assumed care, what protocol was indicated? How well did we do?"Analyze the decisions and actions that were done correctly and effectively. Discuss decisions that may have been incorrect; discuss any actions that were performed less than optimally. Allow free discussion. "When the patient's pulse was restored it seemed like everyone left the room. Only (nurse) was in the room when Mr. (patient) rearrested. Who wants to explain that delay?"All team members should share their feelings, anxieties, anger, and possible guilt. "I feel upset because when the admitting team arrived they were really obnoxious, demanding a lot of tests and x-rays. They made me feel that we had done a bad job."Ask for recommendations or suggestions for future resuscitative attempts. "How can we do this better the next time?" (Nurse:) "I think we should not call the admitting team until the patient is completely stable and ready to go upstairs."Inform team members unable to attend the debriefing of the process followed, the discussion generated, and the recommendations made. "Chuck, we are going to implement that plan to allow family members in the code room during the resuscitation. I know you have been opposed to that. What if we designate our social worker to stay at the side of the family members the entire time they are near the resuscitation?"The team leader should encourage team members to contact him or her if questions arise later. Table 2. Critical Incident Stress Debriefing of Professionals: A Simplified ProtocolThere are 4 sequential aspects to critical incident stress debriefing (CISD). These are the on-scene debriefing, the initial defusing, the formal CISD, and the follow-up CISD. Not all 4 aspects are always used, however.On-Scene or Near-Scene DebriefingThis is performed by an officer, chaplain, or health professional knowledgeable in both CISD and the operations of the team. This individual primarily watches for the development of any signs of acute stress reactions. Rather than a formal debriefing, it is mainly a period of aware observation.Initial DefusingPerformed within a few hours of the incident, this is a situation in which participants have an opportunity to discuss their feelings and reactions in a positive and supportive atmosphere. This discussion may be led by a senior officer or health professional familiar with CISD who has good interpersonal skills, or it may have no leader at all and be a spontaneous interaction among team members. It is best done through a mandatory team meeting.The key to success at this stage is to maintain a supportive rather than a critical atmosphere, to keep comments confidential, and to ban comments that are tough, insensitive, or could be construed as "gallows humor." If this is not done, it will quickly end any sharing feelings among team members.Formal CISDTypically led by a mental health professional familiar with CISD, these formal sessions are held within 24 to 48 hours after the incident. Specially trained public and private CISD teams now exist throughout the United States, Canada, and in many other countries. Many of these are associated with local or regional police or fire departments (who can also be contacted to locate other competent teams).These sessions often follow a standard format by first laying out the noncritique and confidentiality ground rules. Then the participants are asked to describe themselves and key activities during the incident, their feelings during the incident and at present, and any unusual symptoms they experienced or are experiencing.Participants may be asked to explore linkages between the event and past events, nonjudgmentally describe others' actions (to help describe their own actions), and describe their own and the group's successes during the incident. The facilitator then describes typical posttraumatic stress disorder (PTSD) symptoms and finally suggests an activity to help them regain a sense of purpose and unity (such as attending the memorial service for the victims). During this session, the leader also tries to identify those who may need more intensive counseling.Follow-Up CISDNot always or even frequently done, these sessions are held from several weeks to months after the incident. They can be held to resolve specific group issues or more often to help specific individuals. (When held on an individual basis, these are essentially psychological counseling sessions.)Groups who will encounter events triggering PTSD in the course of their work must have this service available before it is needed. Individuals providing these counseling services may themselves be subject to PTSD, and, if so, should also undergo debriefing.Additional ResourcesFor more information to assist professionals working with PTSD victims, contact the National Center of PTSD at telephone 802-296-5132, e-mail [email protected], or website http://www.dartmouth.edu/dms/ptsd/Clinicians.htm or the Post Traumatic Stress Resources web page at http://www.long-beach-va-gov/ptsd/stress.htm.From Pocket Protocols—Notifying Survivors About Sudden, Unexpected Deaths, pages 64–65. ©1999 by Kenneth V. Iserson, MD, and published by Galen Press, Ltd, Tucson, AZ, www.galenpress.com. Table 3. Conveying News of a Sudden Death to Family MembersCall the family if they have not been notified. Explain that their relative has been admitted to the Emergency Department and that the situation is serious. Survivors should not be told of the death over the telephone.Obtain as much information as possible about the patient and the circumstances surrounding the death. Carefully go over the events as they happened in the Emergency Department.Ask someone to take family members to a private area. Walk in, introduce yourself, and sit down. Address the closest relative.Briefly describe the circumstances leading to the death. Go over the sequence of events in the Emergency Department. Avoid euphemisms such as "he's passed on," "she's no longer with us," or "he's left us." Instead, use specific phrases and words such as "death," "dying," or "dead." "Your mother died quietly, without suffering. …" "Her death was quiet and peaceful. …"Allow time for the shock to be absorbed. Make eye contact, touch, and share. Convey your feelings with a phrase such as "You have my (our) sincere sympathy" rather than "I (we) are sorry."Allow as much time as necessary for questions and discussion. Go over the events several times to make sure everything is understood and to facilitate further questions.Allow the family the opportunity to see their relative. If equipment is still connected, let the family know.Know in advance what happens next and who will sign the death certificate. Physicians may impose burdens on staff and family if they fail to understand policies about death certification and disposition of the body. Know the answers to these questions before meeting the family.Enlist the aid of a social worker or the clergy if not already present.Offer to contact the patient's attending or family physician and to be available if there are further questions. Arrange for follow-up and continued support during the grieving period. Table 4. The Algorithm Approach to Emergency Cardiac CareThese guidelines use algorithms as an educational tool. They are an illustrative method to summarize information. Providers of emergency care should view algorithms as a summary and a memory aid. They provide a way to treat a broad range of patients. Algorithms, by nature, oversimplify. The effective teacher and care provider will use them wisely, not blindly. Some patients may require care not specified in the algorithms. When clinically appropriate, flexibility is accepted and encouraged. Many interventions and actions are listed as "considerations" to help providers think. These lists should not be considered endorsements or requirements or "standard of care" in a legal sense. Algorithms do not replace clinical understanding. Although the algorithms provide a good "cookbook," the patient always requires a "thinking cook."The following clinical recommendations apply to all treatment algorithms:· First, treat the patient, not the monitor.Algorithms for cardiac arrest presume that the condition under discussion continually persists, that the patient remains in cardiac arrest, and that CPR is always performed.· Apply different interventions whenever appropriate indications exist.The flow diagrams present mostly Class I (acceptable, definitely effective) recommendations. The footnotes present Class IIa (acceptable, probably effective), Class IIb (acceptable, possibly effective), and Class III (not indicated, may be harmful) recommendations.Adequate airway, ventilation, oxygenation, chest compressions, and defibrillation are more important than administration of medications and take precedence over initiating an intravenous line or injecting pharmacological agents.Several medications (epinephrine, lidocaine, and atropine) can be administered via the tracheal tube, but clinicians must use an endotracheal dose 2 to 2.5 times the intravenous dose.With a few exceptions, intravenous medications should always be administered rapidly, in bolus method.After each intravenous medication, give a 20- to 30-mL bolus of intravenous fluid and immediately elevate the extremity. This will enhance delivery of drugs to the central circulation, which may take 1 to 2 minutes.Last, treat the patient, not the monitor.Download figureDownload PowerPoint Figure 1. ILCOR Universal/International ACLS Algorithm.Download figureDownload PowerPoint Figure 2. Comprehensive ECC Algorithm.Download figureDownload PowerPoint Figure 2A. Primary and Secondary ABCD SurveysDownload figureDownload PowerPoint Figure 3. Ventricular Fibrillation/Pulseless VT Algorithm.Download figureDownload PowerPoint Figure 4. Pulseless Electrical Activity Algorithm.Download figureDownload PowerPoint Figure 5. Asystole: The Silent Heart Algorithm.Download figureDownload PowerPoint Figure 6. Bradycardia Algorithm.Download figureDownload PowerPoint Figure 7. The Tachycardia Overview Algorithm.Download figureDownload PowerPoint Figure 7B. Control of Rate and Rhythm (Continued from Tachycardia Overview)Download figureDownload PowerPoint Figure 7C. Control of Rate and Rhythm (Continued from Tachycardia Overview)Download figureDownload PowerPoint Figure 8. Narrow-Complex Supraventricular Tachycardia Algorithm.Download figureDownload PowerPoint Figure 9. Stable Ventricular Tachycardia (Monomorphic or Polymorphic) Algorithm.Download figureDownload PowerPoint Figure 10. Synchronized Cardioversion Algorithm. References 1A Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett P, Becker L, Bossaert L, Delooz H, Dick W, Eisenberg M, et al, Task Force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style [see comments]. Ann Emerg Med.1991; 20:861–874.CrossrefMedlineGoogle Scholar2A Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the "chain of survival" concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation.1991; 83:1832–1847.CrossrefMedlineGoogle Scholar3A Burkle FM Jr, Rice MM. Code organization. Am J Emerg Med.1987; 5:235–239.CrossrefMedlineGoogle Scholar4A Iserson KV. Pocket Protocols for Notifying Survivors About Sudden Unexpected Deaths. Tuscon, Ariz: Galen Press, Ltd; 1999.Google Scholar5A Beck C, Leighninger D. Reversal of death in good hearts. J Cardiovasc Surg.1962; 3:357–375.Google Scholar6A Safar P, Bircher N. Cardiopulmonary Cerebral Resuscitation: World Federation of Societies of Anaesthesiologists International CPCR Guidelines. Philadelphia, Pa: WB Saunders Co; 1988.Google ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & Wilkins2208200022082000220820007B: Understanding the Algorithm Approach to ACLSOrigin of the ACLS AlgorithmsThe first ACLS "algorithms" appeared in the 1986 ECC and CPR Guidelines.1B These outlines of the 4 algorithms presented the interventions for the 4 arrest rhythms, using double-spaced lines of type connected by vertical arrows. Since those first primitive algorithms, diagrams have been a major tool to depict critical observations, critical actions, and critical decision points in resuscitation. Since 1986 similar algorithms have been published by the Resuscitation Councils of Europe (1992)2B3B and in southern Africa (1995).4B5B6B7B In the years since 1986 a variety of algorithmic approaches emerged. Differences have been in design and detail, not in science or clinical recommendations. Each set of ACLS algorithms contained information on the same general principles of resuscitation but presented it in a unique style with varying amounts of detail and very different target audiences.4B5BThe Structure of the AlgorithmsAll resuscitation algorithms depict both observation and action steps. These steps typically alternate. The observation steps serve as a series of decision-making points or "decision nodes." You identify the problems present at the decision node and then select the proper action to take. The alternating observation and decision steps in the algorithms closely resemble the alternating "assess-manage" steps fundamental to emergency care and resuscitation.In 2000 in this set of algorithms, we have given all observational boxes curved corners and all action boxes square corners. The treatment of every resuscitation emergency can be mapped into this assess-manage series of steps, with repeating loops and reassessment.The Philosophy of the AlgorithmsThe algorithms have grown to mean different things to different resuscitation councils around the world. They mean different things to the training networks within those resuscitation councils. In some resuscitation councils the algorithms were designed to distill essential information about identification and treatment of a problem to its essence—such a concise display targets the novice practitioner and encourages the expert to provide his or her own detail or additional information. Such an approach was favored by Dr Walter Kloeck, National Chairman of the Resuscitation Councils of Southern Africa. Dr Kloeck's sparse, clean design aimed to depict the most common assessments and actions performed for the vast majority of patients. These algorithms were designed for the beginning or student learner of CPR, ECC, and ACLS. This elegantly simple style of teaching materials has come to dominate the teaching materials of many international resuscitation councils.7BAt the same time, within the AHA the algorithms came to be used by instructors and experienced clinicians as teaching tools. The training network began to request inclusion of more and more detail to address a wider variety of clinical situations with more and more information for the clinician and for the ACLS instructor. Thes
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