PowerPoint Template
Download
Report
Transcript PowerPoint Template
2010년 AHA
심폐소생술 가이드라인 설명회
Electrical Therapies
한림대학교 강동성심병원 응급의학과 조규종
Early defibrillation
Critical to survival from sudden cardiac arrest
VF: the most frequent initial rhythm in witnessed SCA
(41% in King County, 52% in Tucson)
The treatment for VF: electrical defibrillation
Success of defibrillation: diminishes rapidly over time
VF tends to deteriorate to asystole within a few minutes
CPR alone: no effect
대한심폐소생협회
CPR + Defibrillation: Critical Combination
Collapse to CPR Interval (min)
Larsen MP et al. 1993
Valenzuela TD et al. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model.
Circulation. 1997;96:3308 –3313.
대한심폐소생협회
Two critical questions
CPR before defibrillation ?
Shock First Versus CPR First
number of shocks before resumes CPR ?
1-Shock Protocol Versus 3-Shock Sequence
대한심폐소생협회
Integrate CPR and AED Use
Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation
in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.
대한심폐소생협회
Shock First vs. CPR First
Swine VF model
Pre-shock 90s CPR in Seattle
(Prolong VF: O2, energy source ↓ )
Berg RA et al. Crit Care Med 2004;32:1428-9
Cobb LA et al. JAMA. 1999;281:1182–1188.
Importance of high-quality CPR
대한심폐소생협회
Shock First vs. CPR First – 2005 AHA
Witnessed arrest
AED / Defibrillator as soon as possible
Not witnessed arrest
Pre-shock CPR (5 cycles, 2min) (Class IIb)
EMS response interval > 4-5 min: consider pre-shock CPR
Insufficient evidence in-hospital cardiac arrest
대한심폐소생협회
Shock First vs. CPR First
Who
Design
Intervention
(witnessed VF)
Baker PW et al.
RCT
(2008 Circulation)
Jacobs IG et al.
Survival
CI
(shock, CPR)
Pre-shock CPR
17.1 vs. 10.3%
0.56 (0.25-1.25)
5.1 vs. 4.2%
0.81 (0.25-2.64)
P = 0.048
(3 min)
RCT
(2005 Emerg Med Australas)
Pre-shock CPR
(1.5 min)
Hayakawa M et al.
Retrospective
Pre-shock CPR until
30 day CPC 1-2
(2009 Am J Emerg Med)
before/after
permission
14 vs. 28%
There is insufficient evidence to recommend pre-shock CPR
대한심폐소생협회
Shock First vs. CPR First – 2010 AHA
Not witnessed arrest
CPR should be performed while checking the ECG &
preparing for defibrillation (class I, LOE B)
In-hospital cardiac arrest
Insufficient evidence, Defibrillation should be < 3min
Team concept, simultaneous approach
(Pre-shock CPR + preparing for defibrillation)
대한심폐소생협회
1-Shock vs. 3-Shock – 2005 AHA
VF/pulseless ventricular tachycardia (VT)
1 shock and immediately CPR (Class IIa)
Do not check the rhythm or pulse after shock (Class IIb)
Check the rhythm after 5 cycles of CPR
First-shock efficacy & energy level
Biphasic > monophasic defibrillator
Monophasic 360J defibrillation (expert consensus)
대한심폐소생협회
1-Shock vs. 3-Shock – change effect
C:V ratio = 15:2
Rea TD et al. Circulation 2006;114:2760-5
대한심폐소생협회
Defibrillation success vs. Hands-off time
Observation: 868 shocks in 156 prehospital VF patients
Eftesol T et al. Circulation 2002;105:2270-3
대한심폐소생협회
1-Shock vs. 3-Shock – 2010 AHA
VF/pulseless ventricular tachycardia (VT)
1 shock and immediately CPR (Class IIa, LOE B)
Do not after-shock rhythm check (Class I, LOE B)
Minimize hands-off time before shock (Class IIa, LOE C)
Immediate shock without rescue breathing (Class IIa, LOE B)
First-shock efficacy & energy level
Biphasic > monophasic defibrillator
Monophasic 360J defibrillation (expert consensus)
대한심폐소생협회
Defibrillation Waveforms
Defibrillation
Delivery of current through the chest to depolarize myocardial cells
and eliminate VF (300 – 500 millisec.)
Lowest effective energy needed to terminate VF
Shock success: termination of VF for at least 5 sec.
Monophasic waveform defibrillators
Deliver current of one polarity
Biphasic waveform defibrillators
Almost all AEDs and manual defibrillators today
대한심폐소생협회
Types of waveforms
A
40
20
-10
0
4
8
12
msec
amp
Peak currents
대한심폐소생협회
Monophasic vs. Biphasic defibrillator
RCT: 150J biphasic AED vs. 200-360J monophasic AED
Schneider T et al. Circulation 2000;102:1780-7
대한심폐소생협회
Monophasic vs. Biphasic defibrillator
Lower-energy biphasic waveform shocks (≤ 200 J)
Equivalent or higher shock success (1st success rate > 90%)
RCTs: short-term outcome ↑, no survival change
No specific energy recommendation
Multiphasic waveforms defibrillator
Triphasic, quadriphasic waveform vs. biphasic waveform
Lack of human study
대한심폐소생협회
Biphasic defibrillation – AHA 2010
Safe & efficient biphasic defibrillation
Biphasic defibrillator > monophasic defibrillator
부재 시 Monophasic defibrillator 사용 가능 (Class IIb, LOE B)
Manufacturer’s recommended energy dose (Class I, LOE B)
모를 때 defibrillation at maximal dose (Class IIb, LOE C)
Pediatric biphasic defibrillation
Initial 2 J/kg (success rate 48%), 2 - 4 J/kg (Class IIa, LOE C)
2 J/kg, 4 J/kg, consider < 10 J/kg or adult maximum dose
(Class IIb, LOE C)
대한심폐소생협회
Fixed and Escalating Energy
Commercially available biphasic AEDs
either fixed or escalating energy levels
Optimal energy level : unknown
Definitive recommendation : not possible
Selected First shock
Manufacturer’s recommendation: 120 J to 200 J
Subsequent shock
At least equivalent or higher (Class IIb, LOE C)
대한심폐소생협회
Current-based Defibrillation
Defibrillation
Delivery of current to the heart
Energy based defibrillation: variable current due to thoracic impedance
Current based defibrillation: encouraged
Optimal current for defibrillation: under investigation (30-40 A)
Lerman BB et al. J Am Coll Cardiol 1988;12:1259-64
대한심폐소생협회
Electrode Placement
Anterior - both infrascapular
4 pad positions: reasonable for defibrillation (Class IIa, LOE B)
Apex-anterior: default placement (Class IIa, LOE C)
Lateral pad: under the breast
대한심폐소생협회
Electrode Placement
Implantable ICD / Pacemaker
Avoid placing the pad over the device (Class IIb, LOE C)
Transdermal medication patch
Do not place pads directly
Remove patches and wipe (Class IIb, LOE C)
Water
Wipe chest before attaching pads (Class IIb, LOE C)
Victim on snow or ice
AEDs can be used (Class IIb, LOE C)
Very hairy chest
Remove some hair
대한심폐소생협회
Electrode size & Transthoracic Impedance
Adult : 8 – 12 cm in diameter (Class IIa, LOE C)
Small electrode (4.3cm)
Harmful, myocardial necrosis
Use the largest pads without overlap.
Transthoracic impedance
Adult : 70 – 80 ohm
Use conductive materials to reduce impedance
: gel pads, electrode paste with paddles, self-adhesive pads
대한심폐소생협회
AED (Automated External Defibrillator)
PAD (public access defibrillation) Programs
Since 1995, AHA recommended
Early CPR & shock delivery by AEDs & trained lay rescuers
AHA Recommendations
Organizing, planning
Training of anticipated rescuers / frequent retraining/practice
Link with the local EMS system
Process of continuous quality improvement
대한심폐소생협회
AED (Automated External Defibrillator)
Successful PAD Programs
Survival of OHCA ↑
Time from collapse to delivery of 1st shock (< 3~5min)
Airports, Casinos
1st responder programs with police officers
Targeted public area (recreation center, shopping mall, office
building, community center etc.)
General public area
대한심폐소생협회
Nationwide dissemination of AEDs
AEDs 9,906
AEDs 88,265
Kitamura T et al. N Eng J Med 2010;362:994-1004
대한심폐소생협회
Community-based PAD programs
Reasonable AED location
At least 1 OHCA every 2 yrs (Europe) or 5 yrs (USA)
At least 1 predicted OHCA during the study period
(>250 adults over 50 yrs, present for >16 hrs/day)
every 100m2
Folke F et al. Circulation 2009;120:510-7
대한심폐소생협회
PAD programs – 2010 AHA
CPR & AED use by first responders (Class I, LOE B)
Public location where SCA is likely to occur (Class I, LOE B)
Airports, casinos, sports facilities
Plan to reduce time from collapse to shock (Class IIa, LOE B)
Establish response plan, train & retrain likely responders,
Maintain equipments, coordinate local EMS systems
Continuous Quality Improvement (Class IIa, LOE C)
Performance of the emergency response plan
Responder performance, Patients outcome
AED function, Battery and Electrode pad status
Home AED: no survival benefit (only one study)
대한심폐소생협회
Automated Rhythm Analysis
Microprocessors
: Frequency, Amplitude, Slope or Wave morphology Integration
(Shock: VF, monomorphic VT, polymorphic VT)
Other check
loose electrodes, poor electrode contact,
spontaneous movement of the patient, quality of CPR
대한심폐소생협회
AED Use in Children
Ventricular fibrillation in children
Less common than adults (5 – 15 %)
AED Use in children
Biphasic AED > Monophasic AED
2 - 4 J/kg (Class IIa, LOE C), initial 2 J/kg for easy teaching
4 J/kg or higher (<10 J/kg) for subsequent attempts (Class IIb, LOE C)
1 - 8 yrs: pediatric dose attenuation (Class IIa, LOE C)
(Use standard AED if not have this system)
< 1 yr: manual defibrillator > pediatric AED > standard AED
(Class IIb, LOE C)
대한심폐소생협회
In-Hospital Use of AEDs
No randomized trials, limited evidence
In-hospital use of AED (Class IIb, LOE C)
Goal : early defibrillation ≤ 3 min. from collapse
In areas where staff have no rhythm recognition skills or
defibrillators are used infrequently
Training & monitoring
First-responding personnel
Collapse-to-shock intervals and resuscitation outcomes
대한심폐소생협회
Fibrillation Waveform Analysis
Aims
To predict success of defibrillation by analyzing VF waveform
The value of VF wave form analysis
Uncertain to guide defibrillation management (Class IIb, LOE C)
“defibrillate” asystole is beneficial ?
Not useful to shock asystole (Class III, LOE B)
대한심폐소생협회
Fire Hazard
Several case reports
By sparks from poorly applied defibrillator paddles
O2-enriched atmosphere (disconnected ventilator)
Avoid defibrillation in an O2-enriched atmosphere (Class IIb, LOE C)
Self-adhesive defibrillation pads with good contact
To minimize the risk of sparks during defibrillation
Use gel pad for manual paddles
Risk for sparks with the pastes and gels (Class IIb, LOE C)
대한심폐소생협회
Synchronized Cardioversion
Shock delivery timed with the QRS complex
Indication
SVT - reentry, atrial fibrillation / flutter / tachycardia
Monomorphic VT
Not effective : Automatic focus
Junctional tachycardia, multifocal atrial tachycaria
Not used : only defibrillation
VF, pulseless VT, polymorphic (irregular) VT
대한심폐소생협회
Synchronized cardioversion - SVT
Biphasic energy dose, adult (Class IIa, LOE A)
Atrial fibrillation: 120 to 200 J (increase stepwise fashion)
Atrial flutter & other SVT: 50 to 100 J (increase stepwise fashion)
Monophasic energy dose, adult (Class IIa, LOE B)
Atrial fibrillation : begin 200 J (increase stepwise fashion)
Cardioversion of SVT in children (Class IIb, LOE C)
Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)
대한심폐소생협회
Synchronized cardioversion - VT
Adult monomorphic VT (Class IIb, LOE C)
Monophasic or biphasic 100 J (increase stepwise fashion)
Child monophasic VT (Class I, LOE C)
Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)
Any doubt: monomorphic or polymorphic VT
Do not shock delivery, perform unsynchronized defibrillation
대한심폐소생협회
Pacing – 2010 AHA
Not recommended for asystole (Class III, LOE B)
Symptomatic bradycardia
Prepare TCP (Transcutaneous pacing)
Immediate pacing
Not respond to atropine (Class IIa, LOE B)
Severely symptomatic bradycardia (Class IIb, LOE C)
Transvenous pacing
Not respond to drugs or TCP (Class IIa, LOE C)
대한심폐소생협회
Maintaining Devices
Maintain devices in a state of readiness (Class I, LOE C)
User checklists
To reduce equipment malfunction
To reduce operator errors
To properly maintain defibrillator or power supply
대한심폐소생협회
Summary – 2010 AHA
The recommendations for electrical therapies
to improve survival from SCA / life-threatening arrhythmias
Whenever defibrillation is attempted
High-quality CPR to minimize interruptions in chest compressions
Immediate resumption of chest compressions after shock delivery
Single shock + immediate CPR for VF
Use of biphasic waveforms
Further data is needed to refine recommendations for energy
levels
대한심폐소생협회