ACLS

Aspirin

-160-325 mg of non-enteric coated. Have patient chew them -Give if pt has not taken ASA, allergy, or GI bleeding

Systematic Approach

-If pt appears unconscious - Use BLS Assessment for initial evaluation - Then use Primary and Secondary assessments for more advanced evaluation and treatment -If patient appears conscious - Use the Primary Assessment for initial evaluation

Elements of Effective High-Performance Team Dynamics

1. Clear Roles and Responsibilities 2. Knowing Your Limitations 3. Constructive Interventions 4. Knowledge Sharing 5. Summarizing and Reevaluating 6. Closed-Loop Communication 7. Clear Messages 8. Mutual Respect

Door to PCI Goal

90 minutes if at non-PCI-capable hospital, 120 minutes

Bag-Mask Ventilation

Deliver approximately 600 mL tidal volume to produce chest rise over 1 second

Cornerstone of managing bradycardia

Differential beween S/S that are caused by the slow HR vs those that are unrelated Correctly diagnose presence and type of AV blocks Use Atropine as 1st line drug of choice Decide when to intimate Transcutaneous pacing (TCP) Decide when to start Eii or dopamine Know when to cal expert consult In addition: You must know the techniques and cautions for using TCP

Inclusion Criteria for fibrinolytic

Dx of ischemic stroke causing neuro deficits Onset of symptoms <3 hours Age >18 years

Mainstay tx for STEMI

Early reperfusion therapy achieved with primary PCI or fibrinolytic

Knowledge Sharing

Encourage an environment of knowledge sharing. Ask for good ideas for DDX. As if anything has been overlooked.

Clear Roles and Responsibilities

Every member should know his/her role and responsibilities.

Cincinnati Prehospital Stroke Scale

Facial droop (have patient smile or try to show teeth) Arm Drift (have patient close eyes and hold both arms out, with palms up) Abnormal speech (have the patient say "you can't teach an old dog new tricks")

Reperfusion goals for STEMi patients

Fibrinolytic within 30 minutes of arrival or perform PCI within 90 minutes of arrival

No Hemorrhage

Fibrinolytic, but if C/I give ASA

Excessive ventilation can cause

Gastric inflation Regurgitation and aspiration Increased intrathoracic pressure Decreased venous return to heart Diminished cardiac output and survival

Administer O2 and drugs for ACS/Suspected STEMI

Oxygen Aspirin Nitroglycerin Opiates (e.g. Morphine)

How to select proper size OPA

Place OPA against side of face, when flange of OPA is at corner of moth, the tip should be at the angle of the mandible

H's & T's

Potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions

If Hemorrhage is present

Pt not candidate for fibrinolytic

STEMI Chain of Survival

Rapid recognition and reaction to STEMI warning signs Rapid EMS dispatch and transport and prearrival notification to receiving hospital Rapid assessment and dx in the ED (or cath lab) Rapid treatment

Stroke Chain of survival

Rapid recognition and reaction to stroke warning signs Rapid EMS dispatch Rapid EMS system transport and prearrival notification Rapid diagnosis and tx in hospital

Exposure

Remove clothing to perform a physical exam, looking for obvious sings of trauma, bleeding, burns, unusual markings, or medical alert brackets

Summarizing and Reevaluating

Summarize information out load in a periodic update to the team. Review status of resuscitation attempt an announce plans for next steps

Check Responsiveness

Tap and shout "Are you ok?"

Leadership Roles

Team Leader IV/IO Medications Timer/Recorder

T's

Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis (pulmonary) Thrombosis (coronary)

Nasopharyngeal Airway (NPA)

Used as alternative to OPA May be used in conscious, semiconscious or unconscious patients

Oropharyngeal Airway (OPA)

Used in unconscious patient if chin lift or jaw thrust fails Should NOT be used in conscious or semiconscious patient

Persistently low PETCO2 values less than 10mmHg

suggest ROSC is less likely to occur

Nitroglycerin

- 1 SL tablet or spray every 3-5 minutes. -May repeat does twice (3 total doses) - Administer only if hemodynamically stable - SBP >90 mmHg or now lower than 30 mmHg below baseline - HR is 50-100/min Contraindications: - Inferior wall MI and RV infarction - Hypotension, bradycardia, or tachycardia - Resecent phosphodiesterase inhibitor use

Atropine

0.5 mg IV may repeat to a total dose of 3 mg

Magnesium Sulfate

1-2 g IV/IO diluted in 10 mL (D5W, NS) given as IV/IO bolus, typically over 5 to 20 minutes

8 D's of Stroke Care

1. Detection 2. Dispatch 3. Delivery 4. Door 5. Data 6. Decision 7. Drug/Devices 8. Disposition

NINDS in-hospital goals for assessment of suspect stroke

1. Immediate general assessment by the stroke team, emergency physical , or expert within 10 minutes of arrival, order surgery non contrast CT 2. Neurologic assessment by stroke team or designee and CT scan performed in 25 minutes of hospital arrival 3. Interpretation of the CT scan within 45 minutes of ED arrival 4. initial of fibrinolytic therapy in appropriate patients, within 1 hour of hospital arrival and 3 hours from symptom onset 5. Door to admission time of 3 hours

Labetalol dose

10-20 mg IV over 1-2 minutes, may repeat X 1

Door to Fibrinolytics

30 minutes

Amiodarone Dose

300 mg IV/IO bolus, then consider additional 150 mg IV/IO once Class III Antiarrhythmic

Exclusion Criteria for Fibrinolytic 3-4.5 hr

Age >80 Severe Stroke (NIHSS score >25) Taking oral anticoagulant regardless of INR History of both DM and prior ischemic stroke

The Primary Assessment

Airway Breathing Circulation Disability Exposure

Antiarrhythmics

Amiodarone Lidocaine Magnesium Sulfate

Coronary Perfusion Pressure (CPP)

Aortic relaxation (diastolic) pressure - Right atrial relaxation (diastolic) pressure

Soft Suctioning

Aspiration of thin secretions fro oropharynx and nasopharynx Performing intratracheal suctioning Suctioning thought in-place airway (ie NPA) to access back of pharynx in pt with clenched teeth

Immediate General Assessment and Stabilization

Assess ABCs Provide Oxygen Establish IV access and obtain blood samples Check Glucose Perform Neuro exam Activate stroke team Order CT scan Obtain 12 lead EKG

Hypertension managent in rtPA candidates

Blood pressure must be 185 mmHg or less systolic and 110 mmHg or less Diastolic to limit risk of bleeding

Non contrast CT Scan

Can differentiate between ischemic and hemorrhagic stroke. Most important test for a patient with acute stroke

Ventilation rate of Advanced airway device

Cardiac Arrest: Once every 6 seconds Respiratory Arrest: Once very 5-6 seconds

Respiratory Arrest

Cessation of breathing. Usually caused by events such as drowning or head injury . Provide tidal volume approx 500-600 mL (6-7 mL/kg)

BLS Assessment

Check Responsiveness Shout for nearby help/activate Emergency response/AED/defibrillator Check breathing and pulse Defibrillation

Check breathing and pulse

Check for absent or abnormal breathing by looking or scanning the chest for monument. for about 5-10 seconds Pulse check should be performed simultaneously with breathing check to minimize delay in detection of cardiac arrest and initiation of CPR Check pulse for 5-10 sec If no pulse within 10 sec begin CPR with chest compressions If there is a pulse start rescue breathing at 1 breath every 5-6 seconds. Check pulse every 2 minutes

Disability

Check for neuro function Quickly assess responsiveness, Level of consciousness, pupil dilation AVPU: Alert, Voice, Painful, Unresponsive

The 1st 10 minutes of assessing and stabilizing patient

Check vitals Establish IV Brief focused H&P Complete fibrinolytic checklist Obtain labs EKG Portable Chest x-ray (less than 30 minutes after patients arrival in ED)

Respiratory Distress

Clinical state characterized by abnormal respiratory rate or effort

Respiratory Failure

Clinical state of inadequate oxygenation, ventral or both. Often the end stage of Respiratory Distress.

Fibrinolytic Agent

Clot buster, administered to pt with J-point ST segment elevation >2mm in leads V2 and V3, and 1 mm or more in all other leads or by new LBBB examples: rTPA, reteplase, tenecteplase

Hypovolemia

Common cause of PEA, initially produces a rapid narrow-complex tachycardia, and typically increases diastolic and decreased systolic pressure. As blood loss continues, blood pressure drops, eventually becoming undetectable, but narrow QRS complexes and rapid rate continue (PEA)

How to select proper size NPA

Compare butter circumference of NPA with inner aperture of nare. Length of NPA should be same as distance from tip of patients nose to the earlobe.

Chest Compression Concepts

Compression of at least 2 inches Compress the chest at rate of 100-120/min Allow compete chest recoil after each compression

Resuscitation Triangle Roles

Compressor AED/Monitor/Defibrillator Airway

Monitor Blood Glucose

Consider giving IV or SQ insulin when glucose is greater than 185 mg/dL

Breathing

Give O2 when indicated Maintain O2 Sat of 94% or greater Monitor adequacy of ventilation and oxygenation Avoid excessive ventilation

Closed-Loop Communications

Give clear message, orders, or assignments to team members. Receive clear response from team members Listen for conformation of response

Morphine

Given for chest discomfort unresponsive to nitro

Lidocaine Dose

Given if Amiodarone is unavailable 1-1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg IV/IO at 5-10 minute intervals Max dose of 3 mg/kg

Fibrinolytic Therapy

Given to adults with acute ischemic stroke within 3 hours of onset of symptoms, or within 4.5 hours of onset of symptoms for selected patients

Symptomatic Bradycardia

HR less than 50 w/ symptoms

Exclusion criteria for Fibrinolytic

Head trauma or stroke w/i 3 months Symptoms of subarachnoid bleed Arterial puncture in previous 7 days History of previous intracranial hemorrhage Elevated BP (>185 SBP and >110 DBP) Active internal bleeding Acute bleeding diathesis Glucose <50 CT demonstrates multi lobar infarction

H's

Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypothermia

Most common causes of Pulseless Electrical Activity (PEA)

Hypovolemia and Hypoxemia

Nicardipine

IV 5mg/hr, titrate up to 2.5 mg/h every 15-20 minutes, max 15 mg/hr

Defibrillation

If no pulse, check for shockable rhythm Provide shocks as indicated Follow each show immediately with CPR beginning with compressions

NSTE-ACS

Ischemic ST-segment depression 0.5 mm or greater or dynamic T-wave inversion w/ pain or discomfort

Major types of Stroke

Ischemic Stroke- MC Hemorrhagic stroke

Knowing Your Limitations

Know your limitations, team leader should also know your limitations. Ask for advice when unsure.

Medications for treatment of HTN in stroke pt

Labetalol Nicardipine

Types of Advanced Airway devices

Laryngeal mask airway Laryngeal tube Esophageal-tracheal tube ET tube

Constructive Intervention

Leader may need to intervene if action may be inappropriate at the time. It should be tactful. Avoid confrontation.

In Asystole consider stopping CPR if ETCO2 is

Less than 10 mmHg after 20 minute of CPR

Airway

Maintain patent airway in unconscious patient using head tilt-chin lift, OPA or NPA Used advanced airway management if needed

Circulation

Monitor CPR quality - Quantitative waveform capnography. if PETCO2 <10 mmHg, attempt to improve CPR quality Attach monitor/defibrillator Provide defibrillator/cardioversion Obtain IV/IO Give appropriate drugs Give IV/IO fluids as needed Check glucose and temp Check perfusion issues

Rigid Suctioning

More effective suction of the oropharynx, particularly if there is thick particulate matter (vomit)

How long do you try to limit interruptions in chest compressions

No longer than 10 seconds

Low-/intermediate-risk ACS

Normal or non diagnostic changes in T segment or T wave that are inconclusive and return future risk stratification St-segment deviation in either direction of less that 0.5 mm or T-wave inversion less than or equal 2mm.

EKG

Obtain within 10 minutes of arrival and assess the patient It is the center of decision pathway in management of ischemic chest discomfort and the only means to identify a STEMI

ROSC

Return of Spontaneous Circulation

STEMI

ST-segment elevation in 2 or more contiguous leads or new LBBB. J-joint elevation greater than 2mm in leads V2 and V3 and 1mm or more in all other leads by new or presumed new LBBB 2.5 mm in men younger than 40 1.5 mm in all women

Mutual Respect

Share a mutual respect for each other and work together

Shout for nearby help/activate Emergency response/AED/defibrillator

Shout for nearby help activate emergency response system Get and AED if one is available, or send someone to get one

Sudden spike in ETCO2 of 35-40 mmHG

Suggest ROSC has occurred

When is ROSC most likely to occur

When CPP of 15 mmHg or greater was achieved during CPR

Clear Message

concise communication spoke with distinctive speech in controlled tone of voice

Oxygen

give if O2<90%

Secondary Assessment

involves differential diagnosis, including focused history and search for underlying case. SAMPLE: Signs/Symptoms, Allergies, Medications, PMH, Last meal consumed, Events

Inclusion Criteria for fibrinolytic 3-4.5 hr

ischemic stroke with neuro deficit Onset of symptoms 3-4.5 hours before tx