ACLS

Epinephrine dosing & frequency for VF/Pulseless VT & asystole

-1 mg IV/IO, repeat every 3-5 minutes -Follow each dose with a 20 mL NS flush and raise arm for 10-20 seconds

Oxygen dosing

-4 L/min via NC, maintain O2 sat >90% -If in cardiac arrest: 15 L/min

Third Degree Heart Block (Complete)

-A-V Dissociation: Block at AV node or His Bundle or block of both bundle branches -An ectopic rhythm takes over despite the continue atrial rhythm (idio -atrial, -junctional, -ventricular): Usually junctional with narrow QRS; Patients may experience transient syncope until the ventricular pacing begins (Stoke Adams Syndrome).

Morphine use

-ACS: for chest pain refractory to NTG

Heparin use

-Adjunct to fibrinolytics and PCI for ACS -LV mural thrombus -Atrial fibrillation -PE prophylaxis for patients on prolonged bed rest and heart failure complicating MI (can use lovenox in some situations too)

ACLS Secondary Survey of respiratory arrest

-Airway: Head tilt-chin lift or OPA or NPA, Advanced airway (LMA, Combitube, ET tube) -Breathing: Continue ventilations, Confirm placement of advanced airway, Secure airway device -Circulation: Obtain IV/IO access, Attach EKG leads, Identify and monitor for arrhythmias, Give fluids if indicated -Differential Diagnosis: Search for, find, and treat, reversible causes

ACLS Secondary Survey

-Airway: maintain airway, consider advanced airway device -Breathing: ventilate the patient with or without advanced airway -Circulation: obtain IV/IO access, assess EKG rhythm, give drugs and IVF's as indicated -Differential Dx: search for, find, and treat reversible causes

Which patients get oxygen?

-Any suspected cardiopulmonary event -Complaints of shortness of breath or suspect ischemic chest pain -Suspected stroke

Effects on early defib on survival

-Approximate survival rate from non-hospital cardiac arrest: ~5% -Approximate survival rate from non-hospital cardiac arrest suffered in a facility that have AED's available: ~50%

Cause of First Degree AV block

-Block Delayed impulse conduction through AV node -Usually innocuous

Cause of Second Degree Type I (Mobitz I) (Wenckebach)

-Block above bundle of His (usually level of AV node)

Initial mgmt of respiratory arrest

-Check responsiveness and quickly note if no breathing or agonal respirations -Activate the emergency response system -Check pulse: At least 5 seconds, but no longer than 10 seconds -Open the airway -Check breathing: If not breathing, give 2 breaths (1 second per breath & chest must visibly rise) -If no pulse, attach AED or defibrillator -Ventilate: 1 breath every 5-6 seconds = 10-12 breaths per minute** -Recheck pulse every 2 minutes

Initial mgmt of Ventricular fibrillation treated with CPR and AED

-Circulation: check for a carotid pulse --> If no pulse, perform cycles of compressions and ventilations (30:2) until AED arrives -Airway: open the airway -Breathing: If not breathing or breathing is inadequate, give 2 rescue breaths using a barrier device -Defibrillation: attach AED and follow prompts *Resume CPR IMMEDIATELY after defib, even if a normal rhythm is restored! (Do NOT perform a pulse or rhythm check --> AED will prompt a rhythm check again after 2 minutes)

BLS Primary Survey

-Compressions: check pulse (no longer than 10s), perform compressions -Airway: open the airway -Breathing: provide ventilations -Defibrillation: deliver shocks as indicated with AED or manual defibrillator

High-Quality CPR technique

-Cycles of 30 compressions to 2 ventilations* -Compress chest at a depth of 2 inches* & allow chest to recoil completely -Push hard and fast (rate of at least 100 compressions per minute*) & minimize interruptions -In 2 rescuer CPR, rotate compressors every 2 minutes (5 cycles of CPR) to minimize fatigue and maximize quality of compressions -Once an advanced airway is in place, continuous CPR and ventilations* (try to ventilate as chest is rising)

Second Degree Type II (Mobitz II) characteristics

-Fixed P-R interval with intermittent dropped QRS -There is a P for every QRS, But not a QRS for every P -QRS may be widened (if blocked below -not at - the bundle of His)

Acute Coronary Syndromes Mgmt

-Focused H&P -Vitals -IV -12-lead EKG within 10 minutes of arrival -Fibrinolytic checklist -Cardiac markers, electrolytes, coags -Portable CXR within 30 minutes of arrival -MONA: Oxygen, Aspirin, Nitroglycerin, morphine

Nitroglycerin caution

-Hypotension, tachycardia, bradycardia, inferior MI, Right ventricular MI, or recent phosphodiesterase inhibitor use (Viagra)

Mgmt of ACS if normal or non-diagnostic EKG

-If high risk or troponin positive: follow course for NSTEMI -If not high risk and troponin negative: complete serial cardiac enzymes with EKGs, monitor EKG rhythm, consider stress test

When should you terminate efforts during asystole?

-In general, if no ROSC at any time during or following 20 minutes of cumulative BLS and ACLS, continued efforts are very unlikely to be successful -Only special situations, such as hypothermia or drug overdose, could warrant more prolonged efforts (cannot be pronounced dead until warm & dead)

Second Degree Type I (Mobitz I) (Wenckebach)

-Increasingly prolonged P-R interval until QRS is dropped -P wave falls in refractory period of ventricles and fails to conduct impulse to ventricles -QRS width normal

Mimickers of asystole

-Loose leads -Not connected to patient -Not connected to defibrillator/monitor -No power -Signal gain turned too low -Isoelectric VF/VT or true asystole

Third Degree Heart Block (Complete) characteristics

-No relationship between P waves and QRS complexes -"PR interval" varies

Aspirin dosing and routes of adminisration

-PO 324 mg (chewable= 81mgx4) -Rectal ASA suppositories if N/V, active PUD, other UGI disorders

First Degree AV block characteristics

-Prolonged and fixed P-R interval (>0.20 sec, or more than 1 big block) -1 P : 1 QRS -QRS width ( < .12 sec, Narrow)

Nitroglycerin route of admin & frequency

-SL every 3-5 minutes up to 3 doses prn chest pain -Routine IV NTG not beneficial: Useful in patients with CP refractory to SL or spray NTG and morphine, pulmonary edema or hypertension complicating STEMI

Nitroglycerin formulations

-SL, spray, IV, gel paste

Which patients get Nitroglycerin?

-Systolic BP >90 mmHg (or 30 mmHg below baseline) and heart rate 50-100 bpm --> check BP & have IV line in place before giving! -Used for unstable angina and CHF - vasodilates, including coronary vessels

Mgmt of stable tachycardia if QRS wide and regular

-VT or uncertain: Amiodarone, prepare for synchronized cardioversion -If SVT with aberrancy: adenosine

PR interval duration

0.12 to 0.20

Atropine dosing for bradycardia

0.5 mg IV every 3-5 minutes, may repeat to max of 3 mg

Initial mgmt of VF/Pulseless VT

1. BLS: call for help, give CPR 2. Attach monitor/defibrillator when available 3. Shock ONCE* (Monophasic: 360 J, Biphasic: 120-200 J, AED is device specific) 4. Give 5 cycles (2 minutes) of CPR 6. Check rhythm/pulse 7. If still shockable rhythm, SHOCK ONCE 8. RESUME CPR (5 cycles) immediately after shock: Obtain IV or IO access & Give epinephrine or vasopressin 9. Check rhythm/pulse 10. If shockable rhythm, SHOCK ONCE RESUME CPR (5 cycles) immediately after shock: Consider antiarrhythmics (Amiodarone, Lidocaine) or magnesium

Asystole mgmt

1. BLS: call for help, perform CPR 2. Attach monitor/defibrillator when available 3. Resume CPR (5 cycles) 4. Obtain IV/IO access: Takes priority over advanced airway procedures, give epinephrine or vasopressin 5. Check rhythm 6. Resume CPR (5 cycles) *Attempting pacing or defibrillation not helpful

Mgmt of ACS if STEMI or new LBBB

1. Beta-blocker, clopidogrel, Heparin 2. If symptom onset < 12 hours, reperfuse: -Door-to-balloon time (PCI) goal less than 90 minutes -Door-to-needle time (fibrinolytics) goal 30 minutes -ACE-I or ARB -HMG CoA reductase inhibitor (statin) 3. If symptoms > 12 hours, admit: -High risk patients: early invasive strategy (cath, revascularize) within 48 hours, ACE-I or ARB, HMG CoA reductase inhibitor -If not high risk, cardiology to risk-stratify

Bradycardia mgmt

1. Maintain airway 2. Assist breathing as needed 3. IV, O2, monitor 4. If inadequate perfusion (symptomatic bradycardia): -Prepare for transcutaneous PACING (TCP): Use without delay if Mobitz II or third degree heart blocks (can go straight to chronotropic drugs as alternative) -Consider ATROPINE -Consider EPINEPHRINE or DOPAMINE infusion -Treat contributing causes (6 H's, 5 T's)

Routes of access for fluid and drug administration

1st: IV (intravenous) 2nd: IO (intraosseous)* 3rd: endotracheal (LEAN)

Dopamine dosing for symptomatic bradycardia

2-10 mcg/kg/min

Epinephrine dosing for symptomatic bradycardia

2-10 mcg/min

Morphine route of admin, dosing, and frequency

2-4 mg IV (over 1-5 minutes) every 5-30 minutes Repeat dose: 2-8 mg at 5- to 15-minute intervals

Amiodarone dosing for VF/PVT

300 mg IV/IO x 1, then 150 mg IV/IO x 1

Vasopressin dosing for VF/PVT & when can it be used?

40 U IV/IO once, can replace 1st or 2nd dose of epinephrine in VF/Pulseless VT algorithm (NOT both)

QRS complex duration

<0.12 sec

Factors that negate the initiation of resuscitative efforts

ASYSTOLE IN LEADS I, II, and III, plus: -Rigor Mortis (stiffness) or -Morbid Lividity (pooling of blood in dependent region) or -Decapitation (no head) or -Signs of Decay (yuck) -"Stiff, Smelly, or Segmented" -Valid DNR order with no family objection

Beta-blockers use

Administer to every suspected MI or unstable angina in the absence of contraindications

Morphine effects

Anxiolytic, analgesic, produces venodilation, which reduces LV preload and oxygen requirements

NOT shockable rhythms in pulseless arrest

Asystole Pulseless Electrical Activity (PEA)

How to confirm advanced airway placement

Auscultation - stomach End-tidal CO2 detector Esophageal detector device (EDD) Wave form capnography--ideal*

What is the target organ of CPR?

Brain - without the brain, everything else is useless

When should advanced airways be used?

Can and should be deferred until patient fails to respond to CPR and defibrillation or until return of spontaneous circulation*

Unstable angina diff dx

Chest pain <---> Acute Myocardial Infarction Shortness of breath <---> Congestive Heart Failure, Pulmonary congestion Decreased level of consciousness <---> Shock, Low blood pressure CHILD: CP, CHF; Hypotension; Ischemia/infarction; LOC decreased; Dyspnea

What should you communicate to others prior to starting defib?

Clearing chant: -Warn others that a shock will be delivered -Do not take more than 5 seconds -"I'm clear. You're clear. Everybody's clear!"

Can you give amiodarone to a patient with frequent unifocal PVCs and an underlying rate of 46 bpm?

Do NOT give amiodarone! PVC's are acting in a compensatory fashion for the slow heartrate. To remove them would cause him harm. Give oxygen and treat the underlying bradycardia!!!

T/F When defibrillating a patient with an implanted mechanical pacemaker, it is important to shock over the device in order to restore its functionality

False - Avoid defibrillating or cardioverting directly over an implanted pacemaker (but usually in upper L chest)

T/F Second Degree Type II (Mobitz II) usually doesn't progress to third degree block

False - Usually progresses quickly to complete heart block

Mgmt of stable tachycardia if QRS narrow and regular

Give adenosine: -If converts, probable reentry SVT -If does not convert, possible atrial flutter, atrial tach, junctional tach: Control rate (diltiazem, beta-blockers) & treat underlying cause

What is "Symptomatic bradycardia"?

Heart rate is slow Patient has symptoms The symptoms are due to the slow heart rate

Differential Diagnosis of cardiac arrest

Hypovolemia Hypoxia Hydrogen ions (acidosis) Hyper-/hypokalemia Hypoglycemia Hypothermia Toxins (tablets) Tamponade (cardiac) Tension pneumothorax Thrombosis (cardiac and pulmonary) Trauma

Initial work up of stable tachycardia

IV 12-lead EKG

Goal of Acute Coronary Syndromes Mgmt

Identification of STEMI and triage for early reperfusion therapy (Fibrinolytics or percutaneous coronary intervention)

Techniques for using AED/Defibrillator in a wet patient

If IN water, pull them out If wet, dry them quickly If lying in snow or a small puddle, proceed as usual

Effects of hyperventilation

Increases intrathoracic pressure Decreases venous return to the heart Diminishes cardiac output (Want SpO2 at 99% - ventilating but not overventilating)

Reference lead

Lead II - Main axis of heart is down and to left & lead II most simulates this

For what rhythms is atropine ineffective?

Mobitz II or complete heart block

What should you consider if patient comes in with CP that is not relieved taking 3 of their own NTG?

NTG goes bad quickly, especially if exposed to light - Maybe it's not good anymore

Mgmt of ACS if STEMI or unstable angina

Nitroglycerin Beta-blockers Clopidogrel Heparin Glycoprotein IIb/IIIa inhibitor Admit and assess risk status

Does a patient in Vfib have a pulse?

No

If the patient has a pulse do you need to start CPR?

No

Will atropine be effective in a heart transplant patient?

No - During heart transplantation the nerves (in particular the Vagus nerve) to the heart are cut and do not respond autonomic nervous stimuli. Atropine is a parasympatholytic and won't influence the heart rate.

Pulseless Electrical Activity (PEA) mgmt

P roblem search E pinephrine A: 1. BLS: call for help, perform CPR 2. Attach monitor/defibrillator when available 3. Resume CPR immediately (5 cycles): Obtain IV/IO access, Epinephrine or Vasopressin 4. Check pulse/rhythm 5. If still in PEA, resume CPR (5 cycles) 6. Check pulse/rhythm

How do you know Second Degree Type I (Mobitz I) (Wenckebach) isn't sinus block?

P waves --> Do not confuse with sinus block (No P, QRS, or T waves in pause)

Techniques for using AED/Defibrillator in a patient with a hairy chest

Perform rapid chest waxing! Shave if still bear-like Put on new pads

Does a patient in Vtach have a pulse?

Potentially

Mgmt of stable tachycardia if QRS narrow and irregular

Probable A.Fib or possible atrial flutter or MAT" -Consider expert consult -Control rate (diltiazem, beta-blockers)

Mnemonic for tachycardia mgmt

Pulse and awake--drugs they must take! Pulse and a "nap"--ZZZZZAP!

Represents depolarization

QRS complex

What should you do if you feel a 'crunching' sensation as you compress the sternum during CPR?

Reassess your hand position and continue: -Probably cracked some ribs or popped the costal cartilages -Do NOT stop doing CPR or get CXR first -Do NOT move your hand position over the xiphoid process ever!

Stable tachycardia narrow EKG rhythms

Reentry SVT, atrial tach, atrial flutter, junctional tach

10 Core Cases

Respiratory Arrest Ventricular fibrillation treated with CPR and AED Ventricular fibrillation/Pulseless Ventricular Tachycardia Pulseless Electrical Activity (PEA) Asystole Acute Coronary Syndrome Bradycardia Unstable Tachycardia Stable Tachycardia Acute Stroke

Clopidogrel use

STEMI and "dynamic T-wave inversion" (NSTEMI and UA)

Mnemonic for initial mgmt of VF/Pulseless VT

Shock, Shock, Everybody, Shock, And, Live

PEA etiology mnemonic

The rhythm is not MATCH(X4)ED by a pulse! M = Myocardial infarction (massive acute) A = Acidosis (severe) T = Tension pneumothorax C = periCardial tamponade H = Hypoxia (severe) H = Hypothermia H = Hypovolemia H = Hyperkalemia E = pulmonary Embolism D = Drug overdose

T/F Mobitz I Usually progresses to Mobitz II or complete

True (progressively more involved blocking of ventricular conduction)

T/F Avoid too many breaths or too large a volume per breath during ventilation

True - avoid excessive ventilation

T/F Bradycardia can be functional or relative

True - heart rates insufficient or inappropriate for patients clinical situation

T/F If a patient has a patch do not place any pads overmedication patches

True - remove and wipe area clean if necessary

Stable tachycardia wide EKG rhythms

V. Tach or uncertain, SVT with aberrancy, A. fib with abberancy, pre-excited A. Fib (AF + WPW), torsades de pointes (seek expert consult)

Shockable rhythms in pulseless arrest

Ventricular fibrillation Pulseless ventricular tachycardia

How do you apply EKG Leads?

WHITE to the right Smoke (BLACK) over fire (RED)

Clopidogrel contraindication

active PUD

Contraindications of aspirin

allergy or recent GI bleeding

Beta-blockers cautions

asthmatics, diabetics, heart failure

What med shouldn't you administer IV beta-blockers with?

calcium channel blockers

Symptoms of bradycardia

chest discomfort or pain, shortness of breath, decreased LOC, weakness, fatigue, lightheadedness, dizziness, presyncope or syncope

Beta-blockers contraindication

cocaine-induced ACS

Signs of bradycardia

hypotension, orthostatic hypotension, pulmonary congestion on exam or CXR, frank CHF or pulmonary edema, bradycardia-related, frequent PVC's or VT

Clopidogrel dosing

initial dose is 300 mg po

For every ____ that passes between collapse and defibrillation (witnessed VF sudden cardiac death), there is a 7-10% per minute decline in chance of survival

minute (Bystander CPR reduces this decline to 3-4%)