Studying ACLS
List 4 advanced airway pieces of equipment
* laryngeal mask airway *the laryngeal tube *the esophageal-tracheal tube *ET tube
To ensure the success of post-cardiac arrest care, healthcare providers must do what?
* optimize the patient's hemodynamic and ventilation status * initiate therapeutic hypothermia * provide immediate coronary reperfusion with PCI * institute glycemic control * provide neurologic care and prognostication and other structured interventions
What vasopressors used during cardiac arrest?
*Epinephrine: 1 mg IV/IO (repeat every 3 to 5 minutes) *Vasopressin: 1 dose of 40 units IV/IO may replace either the first or second dose of epinephrine
What are the important points about using the IO route for delivery of drugs
*IO access can be established in all age groups *IO access often can be achieved in 30 to 60 seconds *the IO route of administration is preferred over the endotracheal route *any ACLS drug or fluid that is administered IV can be given IO
When an IV is established, how should hypotension be treated?
*IV bolus - 1-2 L normal saline or lactated Ringer's. If therapeutic hypothermia is indicated or will be performed, you may use 4 degree C fluids *Epinephrine .1-.5 mcg/kg per minute IV infusion titrated to achieve a minimum SBP of >90mmHg or a mean arterial pressure of >65mmHg *Dopamine 5-10 mcg/kg per minute IV infusion titrated to achieve a minimum SBP of >90mmHG or a mean arterial pressure of >65mmHG *Norepinephrine .1-.5 mcg/kg per minute IV infusion titrated to achieve a minimum SPC of >90 mmHg or a mean arterial pressure of >65mmHg
What type of rhythms might be seen in a case of VF/Pulseless VT
*VF *VT *Artifact that looks line VF *New left bundle branch block
When assessing breathing using the ACLS survey what questions are you asking yourself?
*are ventilation and oxygenation adequate? *are quantitative waveform capnography and oxyhemoglobin saturation monitored?
What are the steps of an adult in cardiac arrest using an AED and drugs when rhythm is not shockable?
*before beginning - shout for help/activate emergency response 1) Start CPR - give oxygen, attach monitor/defibrillator 2) No shockable rhythm - Asystole/PEA 3) CPR 2 minutes - IV/IO access, Epinephrine every 3-5 minutes, consider advanced airway, capnography 4) No shockable rhythm 5) CPR 2 minutes - treat reversible causes
What are the first 8 steps of an adult in cardiac arrest using an AED and drugs when rhythm is shockable?
*before beginning - shout for help/activate emergency response 1) Start CPR - give oxygen, attach monitor/defibrillator 2) Yes rhythm is shockable - VF/VT 3) Deliver shock 4) CPR 2 minutes - IV/IO access 5) Yes, rhythm is shockable - deliver shock 6) CPR 2 minutes - Epinephrine every 3-5 min, consider advanced airway, capnography 7) Yes, rhythm is shockable - deliver shock 8) CPR 2 minutes - amiodarone - treat reversible causes
What is the role of the team member?
*clear about role assignments *prepared to fulfill their role responsibilities *well practiced in resuscitation skills *knowledgeable about the algorithms *committed to success
What are drugs use if VF/Pulseless VT
*epinephrine *norepinephrine *vasopressin *amiodarone *lidocaine *magnesium sulfate *dopamine *oxygen
What are 3 common types of fixation errors?
*everything is okay *this and only this is the correct path *anything but this
What is the guidelines when administering a drug by peripheral venous route
*give the drug by bolus infection unless otherwise specified *follow with a 20mL bolus of IV fluid *evaluate the extremity for about 10 to 20 seconds to facilitate delivery of the drug to the central circulation
When assessing Airway in the ACLS survey what questions are you asking yourself?
*is the airway paten? *is an advanced airway indicated? *is proper placement of airway device confirmed? *is tube secured and placement reconfirmed frequently?
What does the team leader do?
*organizes the group *monitors individual performance of team members *backs up team members *models excellent team behavior *trains and coaches *facilitates understanding *focuses on comprehensive patient care
What is an essential role of the team leader is monitoring and reevaluating what?
*the patient's status *interventions that have been performed *assessment findings
What is the physiologic criteria for adult patinets to activate a RRT
*threatened airway *respiratory rate <6 or >30 breaths per minute * HR <40/min or >140/min *systolic BP <90mmHG *symptomatic HTN *unexpected decrease in LOC *unexplained agitation *seizure *significant fall in urine output *subjective concern about the patient
What are the questions to ask when assessing for circulation in the ACLS survey
*what is the cardiac rhythm *is the patient with a pulse unstable? *is defibrillation or cardioversion indicated? *are chest compression effective? *is ROSC present? *has IV/IO access been established? *are medications needed for rhythm or BP *does the patient need volume (fluid) for resuscitation
What question should be asked if thinking about the differential diagnosis
*why did this patient develop symptoms or arrest? *is there a reversible cause that can be treated?
How much Epinephrine should you give during CPR
1 mg IV/IO - repeat every 3 to 5 minutes
How much and how is lidocaine administered
1 to 1.5 mg/kg IV/IO first does, then .5-.75 mg/kg IV/IO at 5 to 10 minute intervals, to a maximum dose of 3 mg/kg
What are ventilations during a respiratory arrest with bag mask or advanced airway
1 ventilation every 5 to 6 seconds (10 to 12 breaths per minute)
What are the steps of action for a person in respiratory arrest?
1) Check responsiveness - :"are you okay?" and scanning the chest for movement (5-10second) 2)Activate the emergency response system/get AED 3)Circulation - check the carotid pulse (5-10seconds) - if no pulse start with chest compressions (30:2) 4)Defibrillation - if no pulse check for shockable rhythm
what are the 4 universal steps to starting the AED?
1) Power on the AED 2) Attach electrode pads 3) Analyze rhythm 4) be sure to clear the patient (DO NOT TOUCH the patient)
List the steps of adult immediate post cardiac arrest care
1) Return of spontaneous Circulation (ROSC) 2) Optimize ventilation and oxygenation 3) Treat hypotension (SBP ,90mmHg) 4) Follow commands? If yes -- STEMI or suspicion of AMI If No -> 5) consider induced hypothermia 6) STEMI or suspicion of AMI If yes, 7) Coronary reperfusion --> 8) Advanced Critical care If no, -- 8) Andvanced Critical Care
What are the simplified steps for Adult BLS HCP?
1) unresponsive (no breathing or no normal breathing) 2) activate emergency response --> send someone to get AED 3) check pulse 4) start CPR 5) check rhythm/shock if indicated (repeated every 2 minutes)
What 3 ways can you monitor the adequacy of ventilation and oxygenation
1)clinical criteria (chest rise and cyanosis) 2)quantitative waveform capnography 3)oxygen saturation
List the 6 action as appropriate during the circulation assessment
1)monitor CPR quality 2)attach monitor/defibrillator for arrhythmias or cardiac arrest rhythms 3) defibrillation/cardioversion 4)obtain IV/IO access 5)give appropriate drugs to manage rhythm and BP 6)give IV/IO fluids if needed
To pause in CPR to conduct a rhythm check should not exceed how many seconds?
10 seconds
How much and how is amiodarone administered
300mg IV/IO bolus, then consider and additional 150mg IV/IO once
What is the target temperature of cooling patients?
32 to 34 degrees Celsius for 12 to 24 hours
How much Vasopressin should you give during CPR
40 units IV/IO - may substitute for the first or second dose of epinephrine
Which drug has been shown to increase short-term survival to hospital admission?
Amiodarone
What is an very important saying to remember when performing the BLS survey
Assess....then perform appropriate action
What does VF deteriorate to?
Asystole
What is the most effective way to treat VF
Electrical defibrillation - delivery of a shock to stop the VF
What are the most common causes of PEA starting with the letter H?
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyper-/Hypokalemia Hypothermia
What rhythms are included to define PEA?
Idoventricular rhythms ventricular escape rhythms postdefibrillation idoventricular rhythms sinus rhythm
Does vasopressin have an alpha-adrenegic effect as well?
NO, it is a nonadrenergic peripheral vasoconstrictor
Dopamine is a chemical precursor to what drug
Norepinephrine that stimulates the heart through both alpha- and beta- adrenergic receptors
What is the preferred route of drug and fluid administration
Peripheral IV
What does PEA stand for?
Pulseless Electrical Activity - any organized rhythm without a pulse
What does ROSC stand for?
Return Of Spontaneous Circulation
What does pulseless VT rapidly deteriorates to?
V-Fib
what is the common initial rhythm witnessed out of hospital sudden cardiac arrest?
V-Fib
Can you administer drugs during CPR and/or should you stop CPR to administer drugs?
Yes administer drugs during CPR and DO NOT STOP CPR to administer drugs
If amiodarone is not available, then what
administer lidocaine
What is epinephrine thought to stimulate during cardiac arrest?
adrenegric receptors, producing vasoconstriction, increasing BP, and HR, and improving perfusion pressure to the brain and heart
What does amiodarone affect on cellular level?
affects sodium, potassium and calcium channels. it also has alpha- and beta-adrenergic blocking properties
When should you conduct a rhythm check?
after 2 minutes of CPR or 5 cycles
Where is the NPA placed?
airflow between the nares and the pharynx
What drug is the first line drug given as a antiarrhythmic drug during cardiac arrest
amiodarone
Name 3 Antiarrhytmic agents commonly used
amiodarone lidocaine magnesium sulfate
Remember that pulseless VT is treated with-----
an immediate high-energy shock, where as magnesium is an adjunctive agent used to prevent recurrent or treat persistent VT associated with torsades de pointes
What is the key assessment to check in order to use the OPA?
an intact cough or gag reflex
What does vasopressin increase?
arterial blood pressure because it is a nonadrenergic peripheral vasoconstrictor
What is something you want to avoid while helping deliver oxygen
avoid excessive ventilation
why is excessive ventilations harmful
because it increases intra-thoracic pressure, decreases venous return to the heart, and diminishes cardiac output. it may also cause gastric inflation and predispose the patient to vomiting and aspiration of gastric contents
What is the major determinant of CO2 delivery to the lungs?
cardiac output
What do vasopressors optimize
cardiac output and blood pressure
What are 2 vasopressors you can give during CPR?
epinephrine and vasopressin
How should you monitor the patient's core temperature during induced hypothermia?
esophageal thermometer, a bladder catheter in nonanuric patients, or a pulmonaryartery catheter
When giving a dose of drugs peripherally what should you remember to do?
follow each dose given by peripheral injection with a 20mL flush of IV fluid and elevate the extremity above the level of the heart for 10 to 20 seconds
How much and how should magnesium sulfate be administered
for tosades de pointes, loading dose 1 to 2g IV/IO diluted in 10mL (D5W, normal saline) given as IV/IO bolus, typically over 5 to 20 minutes
When should you consider using amiodarone?
for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor
What is rescue breathing amount for someone in respiratory arrest with pulse
give 1 breath every 5 to 6 seconds (10 to 12 breaths per minute)
If an advanced airway is in place and compressions are being performed, what is the rate of ventilating?
give 1 breath every 6-8 seconds (~8 to 10 breaths per minute)
what are the priorities during cardiac arrest
high quality CPR and early defibrillation
What should the quantitative waveform capnography look like
if PETCO2 is <10mmHG, attempt to improve CPR quality
When should CPR be improved when looking at intra-arterial pressure
if the relaxation phase [diastolic] pressure is <20mmHG
when is an OPA used?
in patients who are at risk for developing airway obstruction form the tongue or from relaxed upper airway muscles
When should the OPA not be used?
in the conscious or semiconscious patient
What does vasoconstriction do during CPR
increases cerebral and coronary blood flow by increasing mean arterial pressure and aortic diastolic pressure
What are secondary importance during a cardiac arrest
insertion of an advanced airway and drug administration
What is PETCO2?
is the partial pressure of end-tidal CO2, a measure of the amount of carbon dioxide present in the exhaled air
what question will the AED answer?
is the rhythm shockable? VF or pulseless VT
What is amiodarone given first during a cardiac arrest
it has been clinically demonstrated that it improves the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT
What is meant by comatose?
lack of meaningful response to verbal commands
What is another name of norepinephrine?
levaraterenol
What drug is given if amiodarone is not available?
lidocaine
what is the most common cause of upper airway obstruction in the unconscious/unresponsive patient
loss of tone in the throat muscles
What medication to consider if torsades de pointes associated with a long QT interval
magnesium sulfate
What kind of patient can the NPAs be used in
may be used in conscious or semiconscious patients
What does NPA stand for?
nasopharyngeal airway
What will hypothermia help improve physically or neurologically
neurologic recovery after cardiac arrest
what does OPA stand for
oropharyngeal airway
What is the main drug to use for respiratory arrest?
oxygen
Why is epinephrine used during resuscitation?
primarily for its alpha-adrenergic effects (vasoconstriction)
When should you recheck the patient in respiratory arrest?
recheck the pulse every 2 minutes
what does rtPA represent?
recombinant tissue plasminogen activator
What might magnesium sulfate terminate or prevent?
recurrent torsades de pointes in patients who have a prolonged QT interval during a normal sinus rhythm
What is respiratory arrest?
respirations are completely absent or clearly inadequate to maintain effective oxygenation and ventilation. A pulse is present
what should you assume if you have a patient with multiple trauma, head injury, and facial trauma
spine injury
How long should you take to check for a pulse when rescue breathing?
take at least 5 seconds but no more than 10 seconds for a pulse check
What is "fixation error"
team leaders may become trapped in a specific treatment or diagnostic approach
What is end tidal CO2 (PETCO2)?
the concentration of carbon dioxide in exhaled air at the end of expiration
What does the heart do when VF is present?
the heart quivers and does not pump blood
What is a good practice for the team leader?
to summarize the patient's status, interventions, and assessment findings out loud in a periodic update to the team.
Can you place an advanced airway while chest compressions are going on?
yes
Do you give supplementary oxygen for cardiac or other types of patients?
yes - 100% oxygen for cardiac arrest patients and other to titrate to achieve >94% O2 pulse ox
