ACLS

4 Steps in BLS Assessment

(1) Check responsiveness (2) Activate the emergency response system and obtain a AED (3) Circulation (4) Defibrillation

SAMPLE

(S) signs and symptoms (A) allergies (M) medications (P) past illnesses (L) last oral intake (E) events leading up to present illness

Atropine for Symptomatic Bradycardia

- 1mg every 3-5 minutes/4 minutes - max dose = 3mg

Emergent Bradycardia Rhythms

- 2nd degree heart block type II - 3rd degree heart block - Most important tx is atropine and transcutaneous pacing

Dopamine infusion for Bradycardia

- 5-20mcg/kg/min

Toxins

- Accidental overdose: Some of the most common include: tricyclics, digoxin, betablockers, and calcium channel blockers - Cocaine is the most common street drug that increases incidence of pulseless arrest. - Physical signs include bradycardia, pupil symptoms, and other neurological changes - Poison control can be utilized to obtain information about toxins and reversing agents

ACLS Bradycardia Drugs

- Atropine 0.5mg IV push to repeat every 3-5min. Max: 3mg - Dopamine infusion: 2-20mcg/kg/min - Epi infusion: 2-10mcg/min

Hypo/Hyperkalemia

- Both a high and low K+ can cause cardiac arrest - Signs of high K+ include taller, peaked T-waves and widening of the QRS complex - Signs of low K+ include flattened T-waves, prominent U-waves and possibly widened QRS complex - Never give undiluted intravenous potassium

Interventions for comatose patient

- Brain CT - EEG monitoring

Thrombosis (lungs: massive PE)

- Can rapidly lead to respiratory collapse and sudden death - ECG signs of PE: Narrow QRS Complex and rapid heart rate Physical signs: No pulse felt with CPR, distended neck veins, positive d-dimer test, prior positive test for DVT or PE. Treatment: surgical intervention) pulmonary thrombectomy) and fibrinolytic therapy.

Thrombosis (heart: acute, massive MI)

- Causes acute myocardial infarction. - ECG signs: 12 lead ECG with ST-segment changes, T-wave inversions, and/or Q waves. - Physical signs: elevated cardiac markers on lab tests, and chest pain/pressure - Treatments: use of fibrinolytic therapy, PCI (percutaneous coronary intervention) - The most common PCI procedure is coronary angioplasty with or without stent placement.

Advanced Airways

- Combitube - LMA (laryngeal mask airway) - laryngeal tube - ET tube (endotracheal tube) - continuous chest compressions can be given once an advanced airway is placed - Give 1 breath every 6 seconds (10 breaths per minute)

Hypoxia

- Deprivation of an adequate oxygen supply can be a significant contributing cause of cardiac arrest - Ensure that the airway is open - Ensure adequate ventilation, and bilateral breath sounds - Ensure oxygen supply is connected properly

ACLS Cardiac Arrest Drugs

- Epinephrine: 1mg - Amiodarone: - 1st dose: 300mg - 2nd dose: 150mg

Tamponade

- Fluid build-up in the pericardium results in ineffective pumping of the blood which can lead to pulseless arrest. - ECG symptoms: Narrow QRS complex and rapid heart rate - Physical signs: jugular vein distention (JVD), no pulse or difficulty palpating a pulse, and muffled heart sounds - Perform: pericardiocentesis to reverse.

Management of Respiratory Arrest

- Give oxygen - Open the airway - Provide basic ventilation - Provide respiratory support with the use of artificial airways (OPA and NPA) - Suction to maintain a clear airway - Maintain airway with advanced airways

ACLS Bradycardia Symptoms

- Hypotension - Altered mental status - Signs of shock - Ischemic chest discomfort - Acute heart failure

Tachyarrhythmia Symptoms

- Hypotension - Altered mental status - Signs of shock - Ischemic chest discomfort - Acute heart failure

H's and T's

- Hypovolemia - Hypoxia - Hydrogen ion (acidosis) - Hyper-/Hypokalemia - Hypothermia - Toxins - Tamponade (cardiac) - Tension pneumothorax - Thrombosis (coronary and pulmonary)

Refractory Unstable Tachycardia

- ID underlying cause - Consider need to increase energy levels for next cardioversion - Consider administering anti arrhythmic drug - Consider expert consultation

Hypothermia

- If a patient has been exposed to the cold, warming measures should be taken. - Core temp. should be raised above 86 degree F and 30 degree C as soon as possible. - The patient may not respond to drug or electrical therapy while hypothermic.

Suctioning

- Limit oral and endotracheal suctioning to 10 seconds or less to reduce the risks of hypoxemia - monitor HR as oropharyngeal suctions can cause vagal stimulation and result in bradycardia

Hypovolemia

- Loss of fluid volume in the circulatory system - Look for obvious blood loss - Most important intervention is to obtain IV access and administer IV fluids - Use a fluid challenge to determine if the arrest is related to hypovolemia

Loss of Tone in the Throat Muscles

- Most common cause of airway obstruction in a patient that is unresponsive - Can cause the tongue to fall back and obstruct the airway - prevented with the head tilt-chin lift or jaw thrust maneuver (in patient with suspected spinal injury)

Hydrogen ion (acidosis)

- Obtain an arterial blood gas to determine respiratory acidosis - Provide adequate ventilations - Use sodium bicarbonate to prevent metabolic acidosis if necessary

Waveform Capnography Change

- Quantitative waveform capnography with a bag-mask device to confirm and monitor CPR quality is now recommended - Used in Cardiac Arrest

ACLS Algorithm #2: Bradiacardia

- Seen when HR <50/min - Priority: ID and tx underlying cause - Maintain patent airway, assist breathing if necessary - Apply oxygen if needed, monitor O2 - Apply cardiac monitor and BP - IV access - 12-lead ECG - Bradyarrhythmia Symptoms: Yes - Give atropine - If atropine is ineffective: - Trancutaneous pacing - Dopamine or epinephrine infusion may be used as an alternate to TCP - Consider: expert consultation and transvenous pacing if other efforts are ineffective - Bradyarrhythmia Symptoms: No - Monitor and Observe

ACLS Algorithm #3: Tachycardia

- Seen with HR>/= 150 Priority: ID and tx underlying cause - Maintain patent airway, assist breathing if necessary - Apply oxygen if needed, monitor O2 - Apply cardiac monitor and BP - Tachyarrhythmia Symptoms: Yes - Synchronized Cardioversion - Consider sedation - May use adenosine for regular narrow complex tachyarrthymia - Tachyarrhythmia Symptoms: No - Is the QRS Wide >/= 0.12 sec: Yes - Start IV and 12-lead ECG - May use adenosine only if regular and monomorphic - Consider antiarrhythmic infusion - Consider expert consultation - Is the QRS Wide >/= 0.12 sec: No - Start IV and 12-lead ECG - Vagal Maneuvers - Adenosine (if rate is regular) - Beta Blocker or Calcium Channel Blocker - Consider expert consultation Antiarrhythmics that may be considered: Amiodarone, Procainamide, Sotalol

ACLS Algorithm #1: Cardiac Arrest

- Shout for Help/Activate Emergency Response - Start CPR, Give Oxygen, Attach Monitor/Defibrillate - Shockable Rhythm: YES - SHOCK - pVT/VF - CPR 2 minutes/5 cycles - Obtain IV/IO access - ***Shockable Rhythm: Yes - CPR 2 min/5 cycles - Epi every 4 min - Consider advanced airway - Capnography - Shockable Rhythm: Yes - CPR 2 min/5 cycles - Amiodarone - Tx reversible causes - Start over at *** - *Shockable Rhythm: No - PEA/Asystole - CPR 2 minutes/5 cycles - Obtain IV/IO access - Epi every 4 minutes - Consider advanced airway - Shockable Rhythm: No - CPR 2 minutes/5 cycles - Treat reversible causes - NO ROSC = go to * - Shockable Rhythm: Yes = go to ***

Tension Pneumothorax

- Tension pneumothorax shifts in the intrathroacic structure and can rapidly lead to cardiovascular collapse and death. - ECG signs: Narrow QRS complexes and rapid heart rate - Physical signs: JVD, tracheal deviation, unequal breath sounds, difficulty with ventilation, and no pulse felt with CPR. - Treatment: Needle decompression

Amiodarone and lidocaine Change

- considered equivalent in the tx of ventricular fibrillation or pulseless ventricular tachycardia - Used in Cardiac Arrest

Hyperventilation

- def.: providing too many breaths per minute or too large of a volume per breath during ventilation - should be avoided during respiratory arrest - may lead to increased intrathoracic pressure, decreased venous return to the heart, diminished cardiac output, and increased gastric inflation

Breaths per Minute

- for patients with a perfusing rhythm deliver 1 breath every 6 seconds.

Cardioversion Recommendation

- instruct you to refer to your specific device's recommended energy level to maximize first shock success

nasopharyngeal airway

- may be used on an unconscious and semiconscious patient - indicated if a pt has a massive trauma around the mouth or wiring of the jaws

Wide QRS complex, irregular rhythm

- use unsynchronized cardioversion (a.k.a. defibrillation) for unstable, wide QRS complex, tachycardia if the rhythm is irregular

Respiratory Arrest breath/sec

1 breath every 6 seconds with bag-mask device

During the Primary Assessment when assessing (B)breathing, how should supplementary oxygen be delivered?

1. Administer 100% oxygen for cardiac and respiratory arrest patients 2. For ACS keep O2 sat ≥ 90% 3. Other than cardiac and respiratory arrest, administer oxygen to achieve an O2 saturation value of 95-98% by pulse oximetry 4. For post-cardiac arrest care keep O2 sat 92-98%

To of Emergencies

1. Check patient responsiveness 2. Activate EMS 3. Get AED 4. Perform CABD's

While conducting the BLS Assessment, you should do all of the following except:

1. Check patient responsiveness 2. Activate emergency response system 3. Start an IV **** 4. Get an AED

5 Basic Airway Skills

1. Head tilt-chin lift 2. Jaw thrust without head extension for possible cervical spine injury 3. Mouth-to-mouth ventilation 4. Mouth-to-barrier device (use a pocket mask) 5. Bag-mask ventilation

Success of any resuscitation attempt is built on:

1. High quality CPR 2. Defibrillation when required by the patients ECG rhythm

When performing the Airway Assessment portion of the Primary Assessment, the following questions should be asked:

1. Is the airway patent? 2. Is an advanced airway indicated?

Interventions emphasized in post-cardiac arrest

1. Manage airway 2. Manage Respiratory parameters 3. Manage hemodynamic parameters

When providing BLS/ACLS to a known or suspected cervical spine trauma which of the following is NOT correct when attempting to open the airway?

1. Open the airway using the jaw thrust without head extension. 2. Use a head tilt-chin lift maneuver if the jaw thrust is not effective. 3. Use manual restriction to stabilize the head 4. **Use an immobilization device to stabilize the head

AED Use

1. Patient is not responsive 2. Patient is not breathing 3. Patient has no pulse

What is true about chest compressions?

1. Push hard and fast 2. Ensure full chest recoil 3. Minimize interruptions in chest compression 4. Switching chest compressors every 2 minutes to avoid fatigue 5. Avoiding excessive ventilation

Secondary Assessment

1. Searching for underlying cases (H's & T's) 2. If possible - Focused Medical History (SAMPLE)

Effective resuscitation team dynamics would include all of the following statements except which one:

1. Team leaders and team members should have clear, closed-loop communication. 2. Team members inform the team leader when a task begins or ends. 3. **Team members do not question team leaders orders even if doubt exists. 4. Team leaders define all roles of team members in the clinical setting.

What is true about the oropharyngeal airway(OPA):

1. The OPA keeps the airway open during bag-mask ventilation. 2. The OPA can stimulate coughing and gagging. 3. The OPA can prevent the patient from biting on an ET tube. 4. An OPA should not be used in a conscious or semiconscious patient because it may stimulate gagging and vomiting

Good team dynamics requires:

1. knowledge sharing 2. knowing one's limitations 3. clear roles and responsibilities

Examples of advanced airway adjuncts

1. laryngeal tube 2. laryngeal mask airway 3. combitube 4. endotracheal tube

When performing BLS/ACLS you should avoid all of the following except:

1. prolonged rhythm analysis 2. frequent pulse checks 3. taking too long to give rescue breaths to the patient 4. **keeping the patients airway open

The goal of BLS interventions for a patient in respiratory or cardiac arrest is to:

1. restore effective oxygenation 2. restore effective ventilation 3. restore or support effective circulation

The single-dose administration for atropine within the bradycardia algorithm changed from 0.5 mg to ______.

1.0mg max dose administration of 3 mg remains the same

During CPR with an advanced airway in place the compression rate is:

100 -120/min

Epinephrine Dosage Change

1mg every 4 minutes or 3-5min - Used in Cardiac Arrest

During CPR with no advanced airway in place the compression-to-ventilation ratio is:

30:2

The dopamine infusion rate for the treatment of bradycardia is now ____ mcg/kg/min.

5-20

For patients experiencing respiratory arrest with a perfusing rhythm, deliver rescue breaths at 1 breath every ____ seconds.

6 seconds

The oxygen saturation during the post-cardiac arrest phase should now be maintained on a range from _________

92-98%

Primary Assessment

ABCDE (A) Airway: If needed, use advanced airway -- confirm placement and secure (B) Breathing: Bag-mask ventilation, supplemental O2 and monitoring O2 (C) Circulation: IV assess, ECG, ID arrhythmias, use fluids and defib if needed (D) Disability: Neuro assess, LOC, pupils (AVPU -alert, voice, painful, unresponsive) (E) Exposure: Remove clothing, Look for trauma, bleeding, burns or medical alert bracelets

Supplemental O2

Acute coronary syndrome (ACS) - Provide if pt is dyspneic or hyoxemic, has obvious signs of HF or O2 is less than 90% or unknown Post-cardiac arrest care - Maintain O2 92-98% Stroke and general care - Maintain O2 great than 94%

Unstable Tachyarrhythmia tx

Always use cardioversion

Which of the following is the correct sequence of steps for BLS CPR?

C-A-B circulation, airway, breathing

ventricular fibrillation tx

CPR and AED (Defibrillation)

CPR after defibrillation

CPR may be needed after successful defibrillation since spontaneous rhythms after defib may not always produce adequate perfusion for several minutes.

Elements for effective resuscitation and good team dynamics

Closed-loop communications clear messages clear roles and responsibilities Knowing one's limitations knowledge sharing constructive intervention reevaluation and summarizing mutual respect.

The most important intervention with witnessed sudden cardiac arrest is:

Early defibrillation

(True or False) Within the cardiac arrest algorithm, lidocaine remains an alternative, only if, amiodarone is not available.

False

Adenosine IV Dose

First dose: 6mg rapid IV push and NS flush Second dose: 12mg if needed

During the stabilization phase of post-cardiac arrest care, programs should include the management of these three things. Management of airway, management of respiratory parameters, and management of _____________ parameters.

Hemodynamic

Synchronized Cardioversion Doses

Initial recommended doses: - Narrow regular: 50-100 J - Narrow irregular: 120-200 biphasic or 200 J monophasic - Wide regular: 100 J - Wide irregular: defibrillation dose (not synchronized)

During the (C) circulation portion of the Primary Assessment, the following actions are carried out:

Obtain IV access Attach ECG leads Monitor rhythm Give medications to manage rhythm Give IV/IO fluids if needed

During CPR after an advanced airway is in place, which of the following is true:

One breath every 6 seconds should be given

Adjuncts to Bag-mask ventilation

Oropharyngeal and nasopharyngeal airway may be used as adjuncts to improve the effectiveness of patient ventilation

Assessment/Reassessment Reminder

Remember to assess first then perform appropriate actions, and after each action...reassess

After providing a shock with an AED you should:

Start CPR, beginning with chest compressions

Interruptions in chest compressions should be limited to no longer than _____seconds.

Ten

When checking for a carotid pulse during CPR you should take no longer than ______seconds before restarting CPR

Ten

(True or False) The systematic approach with a person in cardiac arrest should include the BLS Assessment and the Primary Assessment?

True

(True or False) There is now an option to provide Epinephrine 1 mg every 4 minutes as a midrange to the every 3-5 minute interval.

True

For conscious patients who may need more advanced assessment and management techniques, healthcare providers should conduct the Primary Assessment first?

True

ACLS

advanced cardiac life support

Prior to 2020, the AHA only recommended waveform capnography after endotracheal tube placement. Now, the American Heart Association recommends waveform capnography with the use of what ____________.

bag-mask device

The most important algorithm to know for adult resuscitation is:

cardiac arrest

Respiratory Arrest

cessation of breathing

CABD

compressions, airway, breathing, defibrillation

In the Primary Assessment of the systematic approach to ACLS, the D stands for:

disability Perform a general neurological assessment which should include assessment of responsiveness, level of consciousness, and pupil reflex. AVPU acronym may help. (Alert, Voice, Painful, Unresponsive).

The BLS Assessment focuses on:

early CPR and early defibrillation

The purpose of a Rapid Response Team is:

improve patient outcomes by identifying and treating early clinical deterioration

Oxygenation post-cardiac arrest range

maintain oxygen range from 92%-98%

What is performed BEFORE the BLS assessment?

make sure the scene is safe

Bag-mask ventilation

most common method of providing positive-pressure ventilation

oropharyngeal airway

only used on unconscious patient because it can stimulate gag reflex and cause vomiting in conscious patient

Examples of basic airway adjunct

oropharyngeal airway

Blood, secretions and vomit

primary causes of an obstructed airway in unconscious patient who has a basic airway maintained - use suctioning to prevent this

Typically, suctioning attempts in ACLS situations should be:

ten seconds or less

Which of the following best describes how to select the proper size of an (OPA) oropharyngeal airway?

the OPA should be the length from the corner of the mouth to the angle of the mandible.

In the trauma patient with a suspected neck injury,

use jaw thrust without head extension. Because maintaining a patent airway and providing ventilation are priorities, use a head tilt-chin lift maneuver if the jaw thrust is not effective....Use manual spinal motion restriction rather than immobilization devices. Manual spinal immobilization is safer.