ACLS

systematic approach

initial assessment

BLS assessment

primary assessment

secondary assessment

initial assessment

visual appearance of the patient

scene safety

conscious vs unconscious

if patient is conscious upon initial assessment, what assessment comes next?

move to primary assessment followed by secondary assessment

if patient is unconscious upon initial assessment, what assessment comes next?

BLS assessment followed by primary then secondary assessment

BLS assessment

check responsiveness

activate ERS and send to get AED

check breathing and pulse

no pulse no breathing = CPR, check rhythm/shock if indicated; check pulse every 2 minutes

pulse present but not breathing normally = rescue breaths (1 every 6 seconds)

pulse present and breathing normally = primary assessment

primary assessment

A- airway; patency, OPA/NPA, proper placement of artificial airway

B- breathing; adequate ventilation and oxygenation, waveform capnography, O2 sat, supplemental oxygen if needed

C- circulation; CPR quality, IV/IO access, medications, temperature, perfusion, color, defibrillation

D- disability; neuro function, glucose level, LOC, pupils, responsiveness, AVPU

E- exposure; remove clothing for physical exam, look for signs of trauma, bleeding, bruising, medical alert bracelets, etc

secondary assessment

S- signs and symptoms
A- allergies
M- medications; what and when
P- past medical hx
L- last meal; what and when
E- events; leading up to current illness/injury

H’s and T’s

look for underlying cause

H’s and T’s

potential underlying causes of cardiac arrest and emergent cardiopulmonary conditions

H: hypotension, hypothermia, hypovolemia, hypokalemia, hyperkalemia, hypoxia, hydrogen ions (acidosis)

T: tension pneumothorax, tamponade (cardiac), thrombosis (coronary), thrombosis (pulmonary), toxins

what are the 2 most common underlying and potentially reversible causes of PEA?

hypovolemia and hypoxia

airway management

ensure airway is open and clear

can use the head tilt chin lift maneuver or a jaw thrust to open the airway

suction airway immediately to clear secretions, blood, foreign body, etc

may need to use airway adjuncts

OPA and NPA

airway adjuncts that can be placed to open the airway

OPA- usually for pts who are unconscious or have no gag reflex

NPA- conscious or unconscious pts with or without a gag reflex

how to measure OPA: place against cheek and measure from corner of the mouth to the tip of the mandible

how to measure NPA: measure from the tip of the nose to the earlobe

these devices provide a clear path for ventilation and suctioning

watch for chest rise and listen for breath sounds after placement

use of a bag mask

ensure mask completely covers mouth and nose without covering the eyes or extending below the chin

position yourself directly above the patient’s head and use the E-C clamp technique

lift the jaw toward the mask and slightly tilt head back to open the airway

squeeze the back to deliver one breath over 1 second; ventilate once every 6 seconds

look for chest rise to ensure proper ventilation

deliver volume just enough to see chest rise and do not ventilate too quickly

the most effective way is to use two people so one can hold the mask with both hands and the other can squeeze the bag

acute coronary syndromes

plaque formation in the coronary arteries

can cause varying degrees of coronary occlusion

includes: unstable angina, NSTEMI, STEMI

sudden cardiac death may occur with any of these syndromes

NSTEMI

non ST elevation myocardial infarction

partial occlusion of a coronary artery

nonspecific or no ECG changes may be seen

other ECG changes: ST segment depression, T wave inversion

STEMI

ST elevation myocardial infarction

occurs when the coronary artery is completely blocked

ECG changes: ST segment elevation in 2 or more leads on a 12 lead

more serious

usually develops after a ruptured plaque or erosion results in an acute blood clot that blocks a coronary artery

stable vs unstable angina

stable: occurs with exertion, but is relieved by rest or medications

unstable: occurs even at rest and is not relieved by medications

what can operators tell patients to do while waiting for EMS for ACS?

chew 162-325mg of aspirin (non EC)

do not give if pt has an active or recent GI bleed

do not give if there is an allergy

pre hospital ACS

12 lead ECG- speeds up dx and shortens time to reperfusion

oxygen- provide supplemental oxygen if SpO2 is less than 90%

determine symptoms

take patients with a STEMI to the nearest hospital that performs PIC

what is PCI?

percutaneous coronary intervention

use of a catheter to open the blocked artery

nitroglycerin for ACS

reduces ischemic chest discomfort

1 sublingual tablet every 5 minutes- total of 3 doses max for ongoing s/s

only use if SBP is greater than 90 and the HR is 50-100

contraindications: hypotension, tachycardia, bradycardia, recent phosphodiesterase inhibitor use, right ventricular infarction

no pain relief after nitro can lead to use of opioids

morphine for ACS

used if nitro does not relieve pain

can also use fentanyl

caution in pts with unstable angina

monitor RR and BP

reperfusion goals for STEMI patients

providing PCI within 90 minutes after first medical contact or fibrinolytics being administered within 30 minutes of ED arrival

adjunctive tx for ACS

LMWH or heparin

IV nitro

beta blockers

ACE inhibitors

bivalirudin

P2Y12 inhibitors

glycoprotein inhibitors

initial drug therapy for ACS

oxygen- if needed

aspirin- 162-325mg chewed

nitroglycerin

morphine/fentanyl- if needed

ACS algorithm

assess ABCs and prepare for CPR and defibrillation

administer oxygen if needed and aspirin to chew; may also need nitro/morphine

obtain 12 lead

STEMI = start adjunctive therapies as indicated, do not delay reperfusion tx; if time from onset of s/s is less than 12 hours pt needs PCI within 90 mins or fibronylitics within 30 mins; cath lab ASAP

NSTEMI = needs invasive tx if chest comfort persists, ST deviation persists, there is VT, hemodynamic instability, or signs of HF; these pts also can get heparin, nitro, etc

stroke

ischemic or hemorrhagic

ischemic stroke= stops blood flow to the brain, sudden onset of s/s, more common

hemorrhagic stroke= blood vessel ruptures and causes blood to leak into the brain cavity and cause pressure on the surrounding tissue

8 D’s of stroke care

detection- rapid recognition of stroke s/s

dispatch- early activation and dispatch of EMS or rapid response

delivery- rapid stroke identification, management, triage, transport, and pre hospital notification by EMS or rapid response

door- ED/imaging suite triage and immediate assessment by stroke team

data- rapid clinical evaluation, labs, and imaging

decision- establishing stroke dx and choosing best tx option

drug/device- admin of thrombolytics and/or EVT if available

disposition- rapid admission to stroke unit or critical care unit or transfer to facility with EVT

warning s/s of stroke

sudden weakness or numbness of the face, armk, or leg, especially on one side of the body

trouble speaking or understanding

sudden trouble seeing in one or both eyes

sudden trouble walking

dizziness, loss of balance or coordination

sudden severe h/a with no known cause

sudden confusion

stroke algorithm

assess ABCs, oxygen if needed, activate stroke protocol, stroke screen and severity, establish time of onset, glucose test, IV access, CT or MRI asap

no hemorrhage = thrombolytics

thrombolytic candidate = administer and consider EVT if a candidate

no candidate = consider EVT

EVT candidate = transport to cath lab or other facility, admit to neuro icu

no candidate = stroke unit or higher level of care

critical time periods for stroke

IV thrombolytics asap; 3 hours of symptom onset

EVT should be done asap for LVO or if thrombolytics are not an option within 24 hours within 24 hours of LKN

CT or MRI within 20 minutes of arrival

what is EVT?

endovascular therapy

a guidewire is fed through the clot followed by a sheath

the guidewire is removed, and when the sheath is pulled away coils are deployed within the blood vessel

this crushes the clot and restores blood flow immediately

the coils are removed from the vessel and brings the clot with them

optimal stroke recovery guidelines

control blood glucose

manage temperature

manage blood pressure

bradycardia algorithm with no compromise

HR 50 or less with symptoms → determine if there is cardiopulmonary compromise

cardiopulmonary compromise = hypotension, altered mental status, signs of shock, ischemic chest discomfort, acute heart failure

no compromise = identify and tx the underlying cause, support ABCs, consider O2, obtain 12 lead, observe

symptomatic bradycardia algorithm

HR 50 or less with signs of cardiopulmonary compromise

cardiopulmonary compromise = hypotension, signs of shock, altered mental status, ischemic chest discomfort, acute heart failure

compromise present = maintain patent airway, provide O2, assist breathing with positive pressure ventilation if needed, attach cardiopulmonary monitor, monitor pulse

persits? —> no = support ABCs, identify and tx cause, observe, 12 lead

persists? —> yes = atropine, if not working try transcutaneous pacing and/or dopamine/epi infusion; expert consult and transvenous pacing

cardiac arrest = cardiac arrest algorithm

tachycardia = tachycardia algorithm

what medications are given for symptomatic bradycardia?

1st- atropine

atropine 1mg bolus repeated every 3-5 minutes with a max dose of 3mg

2nd- transcutaneous pacing and/or dopamine or epi infusion

dopamine IV infusion of 5-20mcg/kg per minute titrated to pt response; taper slowly

epinephrine IV infusion of 2-10mcg per minute infusion titrated to pt response

what is atropine?

tx of symptomatic bradycardia

anticholinergic

blocks action of the vagus nerve = heart rate increases

what is TCP?

transcutaneous pacing

uses electrodes on the pts chest to deliver an electrical impulse that overrides the natural pacemaker functions of the heart

an external pacemaker

what is dopamine?

stimulates the beta 1 adrenoceptors = improved myocardial contractility, increased SA node rate, and enhanced impulse conduction

types of bradycardia

sinus bradycardia

first degree AV block

second degree AV block (type I or type II)

third degree AV block

what is sinus bradycardia?

the heart is beating too slow, but the electrical signal is normal

normal P waves, PR interval, and rhythm

no s/s = no tx

s/s = tx = atropine, TCP, dopamine/epi IV infusion

what is a first degree AV block?

the electrical message gets through, it just takes longer than normal

every P wave has a QRS after it

PR interval longer than .20 seconds

rhythm is usually regular

no s/s = no tx = monitor

usually no tx needed

second degree AV block type I

mobitz type I or wenckebach

each electrical message takes longer to get through until one get blocked

P waves continue regularly

PR interval progressively gets longer

a QRS is eventually dropped

then the pattern repeats

longer, longer, longer, drop —> now you have a wenckebach

s/s = atropine or pacing

second degree AV block type II

mobitz type II

electrical messages usually get through at the same speed until one suddenly gets dropped

P waves continue regularly

PR intervals stay the same for conducted beats

a QRS is suddenly missing from a P wave

same, same, same, drop

can lead to complete heart block —> needs pacing

third degree AV block

complete heart block

the most dangerous

no electrical messages get from the atria to the ventricles, so the top and bottom chambers beat independently

P waves and QRS are not together, they are completely on their own

pacing needed asap

types of tachycardia

sinus tachycardia (usually unstable tachycardia is at least 150)

atrial fibrillation

atrial flutter

narrow complex tachycardia (SVT)

monomorphic ventricular tachycardia

polymorphic ventricular tachycardia

wide complex tachycardia of uncertain type

what is sinus tachycardia?

normal electrical conduction, just fast

normal P waves and rhythm

QRS may be narrow

no s/s = no tx

s/s = cardioversion, adenosine, procainamide, amiodarone

what is narrow complex tachycardia (SVT)?

racing heart beat

often 150-250

P waves may not even be seen due to rapid QRS complexes

rhythm is usually regular

QRS are narrow

stable tx = vagal maneuvers, adenosine, cardioversion if needed

unstable tx = cardioversion, adenosine, antiarrhythmic

what is atrial fibrillation?

atria quiver instead of pump effectively

rate can be slow, normal, or rapid

no distinct, consistent P waves

irregularly irregular rhythm

QRS usually narrow

RVR = cardioversion

stable = anticoagulants, beta blockers

what is atrial flutter?

the atria flutter in a rapid pattern

P waves look like sawtooth waves

can be regular or irregular rhythm

usually has a narrow QRS

unstable = cardioversion

stable = anticoagulants, beta blockers

what is monomorphic ventricular tachycardia?

ventricles take over as the pacemaker and fire rapidly, blood not being pumped to body effectively

looks like mountains

pulse and stable = amiodarone, procainamide

pulse and unstable = cardioversion

no pulse = CPR, defibrillate, cardiac arrest algorithm

what is polymorphic ventricular tachycardia?

often torsades de pointes or similar

defibrillation, magnesium

what is ventricular fibrillation?

ventricles quiver

no pulse

CPR, defibrillation

cardiac arrest algorithm

tachycardia with a pulse algorithm

maintain patent airway, oxygen and breathing assist as needed, cardiac monitoring, BP and SpO2 monitoring, IV access, 12 lead

causing: hypotension, altered mental status, signs of shock, ischemic chest discomfort, acute HF

no = look for wide QRS (.12 or longer) = vagal maneuvers, adenosine, BB, CCB

yes = synchronized cardioversion (sedation), adenosine if regular and monomorphic, antiarrhythmic

refractory = tx underlying cause, increase energy level, add antiarrhythmic

bradycardia = bradycardia algorithm

cardiac arrest = cardiac arrest algorithm

drugs for tachycardia

cardioversion with sedation when possible (versed)

adenosine 6mg rapid IV push followed with NS flush for first dose

if second dose is needed, 12mg rapid IV push with NS flush

only use adenosine if rhythm is regular and monomorphic

procainamide 20-50mg until arryhtmia is suppressed, hypotension ensues, QRS duration increases over 50%, or the maximum dose of 17mg/kg is given

maintenance infusion is 1-4mg/min

amiodarone 150mg over 10 minutes for first dose, repeat as needed

maintenene infusion of 1mg/min needed for next 6 hours

what is synchronized cardioversion?

uses a sensor to deliver a shock synced with the R wave

what is adenosine?

slows conduction through the AV node

cardiac arrest algorithm

high quality CPR, bag mask, attach monitor/defibrillator

shockable rhythm = VF and pulseless VT

not shockable = asystole and PEA

shockable cardiac arrest algorithm

high quality CPR, bag mask ventilation, attach monitor/defibrillator

deliver a shock as soon as defibrillator is available

continue CPR for 2 minutes —> establish IV/IO access

rhythm/pulse check

VF or pulseless VT = another shock and resume CPR —> 1mg epi every 3-5 mins; consider and advanced airway with capnography

rhythm and pulse check

shockable rhythm = another shock, CPR, and an antiarrhythmic (amiodarone or lidocaine) —> tx of reversible causes

check pulse and rhythm again after 2 minutes

present = repeat until ROSC

what is epinephrine?

vasoconstrictor which increases cerebral and coronary blood flow

increases MAP and aortic diastolic pressure

non shockalbe cardiac arrest algorithm

high quality CPR, bag mask ventilation, attach monitor/defibrillator

1mg epi every 3-5 minutes; consider an advanced airway with capnography

still not shockable = CPR for 2 minutes, tx underlying cause

repeat until ROSC

cardiac arrest medications

epi 1mg every 3-5 minutes

amiodarone 300mg bolus first dose

second dose 150mg or lidocaine

lidocaine first dose at 1-1.5mg/kg

second dose 0.5-0.75mg/kg

post cardiac arrest algorithm

ROSC obtained

assess airway; place or exchange artificial airway as needed and confirm placement

use the lowest inspired O2 concentration that will maintain SpO2 of 90-98; if SpO2 is unknown deliver 100% O2

tx of hypotension when MAP is less than 65 —> IV fluid bolus of NS or LR and may need pressors

tx of any reversible causes that could have caused cardiac arrest and still persist after ROSC

12 lead ECG asap

tx of arrest etiologies and compliactions

assess pt when weaning from sedation and/or neuromuscular blocks if able

follows commands? —> no = ongoing critical care (temp control, EEG, coronary angiography, multimodal prognostication)

follows commands —> yes = ongoing critical care and monitoring