ACLS basics and STEMIs

Physiologic ADULT pt criteria for determination of when to act:

-Airway Compromise -RR <6/min -RR >30/min -HR <40/min -HR >140/min -SBP <90 -*Symptomatic HTN* -Unexpected dec. in LOC -*Unexplained Agitation* -*Seizure* -Significant dec. in Urine Output

SAMPLE S/sx includes:

-Breathing difficulty -Tachypnea and Tachycardia -Fever/headache -Abd pain -Bleeding

SAMPLE Event includes:

-Events leading to current illnesses/injury -Hazards at scene -Treatment during interval onset of disease/injury -Estimated time of onset

For a pt with a STEMI the goals of reperfusion are:

-First medical contact to balloon inflation within 90 minutes -door to drug (fibrinolytics) within 30 minutes of arrival

The secondary assessment involves the differential diagnosis. This involves obtaining:

-Focused medical Hx -Searching for/Treating reversible causes (H&Ts)

SAMPLE Past Medical Hx includes:

-Health Hx -Fam Hx -significant underlying medical conditions -past surgeries -Immunization status

The systematic approach consists of:

-Initial impression (visualization/scene safety) -BLS assessment -Primary assessment (ABCs, Disability, Exposure) -Secondary Assessment (SAMPLE/focused Hx, H'S, T'S)

SAMPLE Last Meal includes:

-Last time & nature of last intake of liquid/food

Administration explanation (4):

-Leadership -Measurement -Continuous improvement -Number of code team members

SAMPLE Allergies includes:

-Medication, allergies, foods, latex -Associated reactions

SAMPLE Medications includes:

-Pt medications (OTC, vitamins, inhalers, herbals) -Last doses & times -Meds that can be found in the pt's home

Quality explanation (5):

-Rate, depth, and recoil -Minimizing interrupt -Switching compressors -Avoiding excess ventilation -Use of a feedback device

SAMPLE consists of:

-Signs and symptoms -Allergies -Medications -Past medical Hx -Last meal consumes -Events

One of the measures of a high-performance team is the ability to achieve:

-Specific performance metrics -High chest compression fraction (CCF)

what are the components of high-quality CPR?

-Switching compressors q 2 minutes -avoiding excessive ventilation -compression depth of 2 inches (5cm) -Complete chest recoil after each compression -interruptions <10seconds

Which are the elements of a system of care?

-System -Patient Outcome -Processes -Structure

The T's:

-Tension Pneumothorax -Tamponade -Toxins -Thrombosis Pulmonary -Thrombosis Coronary

Timing explanation (5):

-Time to first compression -time of first shock -CCF ideally greater than 80% -Minimizing preshock pause -Early EMS response time

Attach monitor/defibrillator for which arrhythmias or cardiac arrest rhythms?

-Ventricular Fibrillation (VF) -Pulseless Ventricular Tachycardia (pVT) -Asystole -Pulseless electrical Activity (PEA)

-A patient without dyspnea has signs of ACS. -There are no obvious signs of HF. -You assess a noninvasively monitored oxyhemoglobin saturation What is the oxygen saturation threshold below which supplemental oxygen would be required?

90%

Only give Nitro if the pt's SBP is > ___mmHg or no lower than ____mmHg below their known BP baseline.

90mmHg; 30mmHg

AVPU is a quick tool used to assess neurological status and stands for?

A-Alert V- Voice P-Painful U-Unresponsive

what is the first link in the out-of-hospital cardiac arrest (OHCA) chain of survival?

Activation of emergency responses

what defines Chest Compression Fraction (CCF)?

Actual chest compression time/ total code time

Coronary Perfusion Pressure (CPP)=

Aortic *Diastolic* Pressure MINUS *Right* Atrial *diastolic* Pressure

Ventricular Fibrillation deteriorates to?

Asystole

what is the most effective way to treat Ventricular Fibrillation?

CPR then *Electrical Defibrillation*

In-patient cardiac arrest is often preceded by?

Changes in the pt's vital signs.

15 seconds before pausing compressions at the end of each 2--minute cycle, high-performance teams should:

Check for a pulse, precharge the defibrillator, and be prepared to deliver a shock in 10 seconds or less.

Aspirin is absorbed better when ____ rather than when it is ____.

Chewed, swallowed

which member of a high-performance team has the responsibility for assigning roles?

Team Leader

While performing the BLS assessment, you initiate high-quality CPR and assist ventilation w/ a bag-mask device. The AED does not recommend a shock. Which action in the Primary Assessment should you preform first?

Determine if the pt's airway is patent

Which action is part of the secondary assessment of a conscious patient?

Formulate a different diagnosis

The purpose of the Rapid Response Team (RRT) or Medical Emergency Team (MET) is to..

Improve pt outcomes by identifying and treating early clinical deterioration

What is the primary purpose of the CPR Coach on a resuscitation team?

Increasing CPR quality

What is the first step in the systematic approach to patient assessment?

Initial impression

Nitroglycerin reduces ____ and ____ preload through peripheral arterial and venous dilation

Left ventricular and right ventricular

which is the best example of a role of a team member?

Prepared to fulfill their role responsibilities

monitor CPR quality with:

Quantitative waveform capnography

what should be used to monitor the the effectiveness of airway placement?

Quantitative waveform capnography

what is the advantage of a systematic approach to patient assessment?

Reduces the chances of missing important signs and symptoms

How do interruptions in chest compressions negatively impact survival after cardiac arrest?

Decrease Coronary Perfusion Pressure (CPP)

What is the most common symptom of Myocardial infarction and ischemia?

Retrosternal chest pain

Element "Patient Outcome" includes what 3 things?

Satisfaction, safety, quality

If you find NO breathing or only gasping, & NO pulse within 10 seconds what do you do?

Start CPR and begin chest compressions

4 elements of an integrated system of care:

Structure, Processes, System, and patient outcomes

What are signs of clinical deterioration that would prompt the activation of a rapid response system?

Symptomatic HTN, Seizure, Unexplained Agitation

Pulseless Ventricular Tachycardia deteriorates to?

Ventricular Fibrillation

What is a common initial rhythm in out-of-hospital witnessed sudden cardiac arrest?

Ventricular Fibrillation (VF)

Only give drugs after..

Verbally confirming the order with the team leader.

Ventricular Fibrillation definition:

When the heart quivers and does not pump blood

The H's:

_Hypovolemia -Hypoxia -Hydrogen Ion (acidosis) -Hypo/Hyperkalemia -Hypothermia

Continuous quantitative waveform capnography provides a measure of what and why?

an indirect measure of the cardiac output during chest compressions because the amount of CO2 exhaled is associated with the amount of blood that passes through the lungs.

In a patient with an arterial line, a reasonable surrogate for CPP is:

arterial relaxation or diastolic pressure

When switching compressors the second compressor should:

come in behind the first compressor so he/she has the same view of the team and defibrillator

what is a step in the closed-loop communication?

confirming task completion before assigning another task

What is one of the most important determinants of survival from cardiac arrest?

The interval from collapse to defibrillation

What happens when teams rapidly assess and intervene when patients have abnormal vital signs?

The number of in-hospital cardiac arrests decreases.

To function effectively, a high performance team needs to focus on (4 things):

Timing, Quality, Coordination, and Administration

What is the primary purpose of the RRT or MET?

To improve patient outcomes by identifying and treating early clinical deterioration

Early CPR can ____ the survival rate from a witnessed sudden cardiac arrest?

double or triple

What is the only intervention that can restore an organized rhythm in patients with ventricular fibrillation?

early and effective defibrillation

ETCO2 is used to

estimate tissue perfusion and quality of chest compressions

Which demographic group experiencing acute coronary syndromes is more likely to present without chest pain?

females

Among others, which of the following factors has been associated with improved survival in pts with cardiac arrest?

immediate high-quality CPR

You can only achieve high chest compression fraction (CCF) by:

minimizing pauses during high-quality CPR

What is the best example of a role of the team leader?

models excellent team behavior

which high-performance team member is part of the resuscitation triangle? timer/recorder team leader monitor/defibrillator/CPR coach IV/IO/Medications

monitor/defibrillator/ CPR coach

Which high-performance team member is part of the resuscitation triangle?

monitor/defibrillator/CPR coach

Element "Structure" includes what 3 things?

people, education, equipment

Element "System" includes what 3 things?

programs, organization, culture

Element "Process" includes what 3 things?

protocols, policies, procedures

Coordination explanation (1):

team members working together and being proficient in their roles

The chain of Survival is a metaphor used to organize and describe:

the integrated set of time-sensitive coordinated actions necessary to maximize survival

When pressing the shock button, the defibrillator operator should face what?

the patient NOT the machine

Which compressor should resume compressions after a defibrillator shock?

the same compressor

the "circulation" assessment step in the BLS assessment includes:

-attaching ECG leads -establish IV or IO access -give appropriate drugs to manage rhythms -assess for perfusion issues

The Disability assessment of the BLS assessment includes:

-checking neurological function -assess for responsiveness -LOCs -Pupil dilation

CPR compression inches and rate

-compress 2 inches -rate of 100-120/min -30:2

CPR Coach (supports performance of high-quality BLS skills)

-coordinates initiation of CPR -Coaches to improve quality chest compressions -coaches to improve high quality ventilations -states guideline targets -minimizes length of pauses in compressions

In addition to decreased IHCA, what are some of the other benefits of implementing a rapid response system?

-decreased in total hospital length of stay -decreased ICU length of stay

Consider these 4 agents in pts with ischemic-type chest discomfort:

-if O2 sats <90% start O2 at 4L & titrate -Aspirin 162-325 -Nitro -Morphine IV if Nitro doesn't help -consider P2Y inhibitors

Team Leader Role (focuses on comprehensive pt care)

-organizes the group -Monitors individual performance of the team -backs up team members -trains and coaches -facilitates understanding -focuses on comprehensive pt care -Places advanced airway

If the pt HAS a pulse start rescue breathing at ___ breath every ___ seconds. Check pulse every ___ minutes.

1 breath 6 seconds 2 mintues

BLS Assessment:

1. assess the scene & "Are you okay?!" 2.Shout for help & activate the emergency response system to get an AED 3.Check for breathing

Try to limit interruptions for defibrillator or rhythm analysis to no longer than:

10 seconds

what is the maximum amount of time you should simultaneously perform the pulse and breathing checks?

10 seconds

for cardiac arrest patients administer what % oxygen?

100% oxygen

a CPP of ___ or greater must be achieved during CPR.

15mmHg

Switching compressors between cycles of every ___ minutes is best

2

For every minute that passes between collapse and defibrillation, the chance of survival from a witnessed VF sudden cardiac arrest declines by what percent WITH CPR?

3-4% per minute

Ventricular Fibrillation is most likely to develop within the first ___ hours after onset of symptoms?

4

Anterior MI, the ST segment is ___mm.

4.5mm

check for absent or abnormal breathing by scanning the chest rise and fall for at least ____ seconds but no longer than ____seconds.

5---10

Feel for a pulse for __ to__ seonds

5-10 seconds

Inferior MI, the ST segment is ___mm.

5.0mm

Only give Nitro if the HR is between ___ and ___.

50 to 100.

During CPR, chest compression fraction (CCF) should be at least ___% and ideally greater than ____%.

60% 80%

How quickly does the chance of survival decline for every minute of defibrillation delay in patients with VF who do not receive CPR?

7-10%