2015 Guidelines and Changes BLS: Agonal gasps are considered a sign of cardiac arrest. Check breathing and pulse simultaneously. Chest compressions at 100-120 per minute. (Compressions depth decreases as rate increases.) Chest compression depth at least 2 (-2.4) inches. Allow full chest recoil. (Chest recoil creates a relative negative intrathoracic pressure and promotes venous return.) Minimize pauses in compressions. Defib as soon as possible. Do CPR until defib ready for use. 1 breath every 6 seconds with advanced airway. 1 breath every 6 seconds for all airways! Some discussion of compression fraction with desired 60-80% range. Use a feedback device to monitor rate and depth of compressions. Cardiac Arrest: Epinephrine 1 mg IV q 3-5 minutes for cardiac arrest. (Vasopressin removed for simplicity; no demonstrable benefit from giving both epi and vasopressin.) Give Epi as soon as possible after the onset of cardiac arrest due to non-shockable rhythm. In intubated patients, failure to achieve an ETCO2 of > 10 mmHg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts. Post arrest: Targeted temperature management (not induced hypothermia) after ROSC: For patients lacking meaningful response to verbal commands 32-36 ° C for 24 hours Pre-hospital cooling with rapid infusion of cold fluids is not recommended. (No benefit and potential increased risk of complications.)
Transcript
2015 Guidelines and Changes
BLS:
Agonal gasps are considered a sign of cardiac arrest.
Check breathing and pulse simultaneously.
Chest compressions at 100-120 per minute. (Compressions depth decreases as rate increases.)
Chest compression depth at least 2 (-2.4) inches.
Allow full chest recoil. (Chest recoil creates a relative negative intrathoracic pressure and promotes venous return.)
Minimize pauses in compressions.
Defib as soon as possible. Do CPR until defib ready for use.
1 breath every 6 seconds with advanced airway. 1 breath every 6 seconds for all airways!
Some discussion of compression fraction with desired 60-80% range.
Use a feedback device to monitor rate and depth of compressions.
Cardiac Arrest:
Epinephrine 1 mg IV q 3-5 minutes for cardiac arrest. (Vasopressin removed for simplicity; no demonstrable benefit from giving both epi and vasopressin.)
Give Epi as soon as possible after the onset of cardiac arrest due to non-shockable rhythm.
In intubated patients, failure to achieve an ETCO2 of > 10 mmHg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts.
Post arrest:
Targeted temperature management (not induced hypothermia) after ROSC:
For patients lacking meaningful response to verbal commands
32-36 ° C for 24 hours
Pre-hospital cooling with rapid infusion of cold fluids is not recommended. (No benefit and potential increased risk of complications.)
Chest Pain:
May chew 1 adult or 2 low-dose aspirins if suspected ACS and no allergy to ASA. The bioavailability of enteric coated aspirin is similar to non–enteric-coated when chewed and swallowed.36 Thus, there is no longer the restriction to use non–enteric-coated aspirin, as long as the aspirin is chewed before swallowing. STEMI: If O2 sat < 90%, apply 4 L/min (which is different than the other algorithms of O2 sat > 94%.) Dopamine 2-20 mc/kg/min for hypotension but 2-10 mc/kg/min in ROSC. NSTEMI has been changed to NSTE-ACS
4 American Heart Association
Figure 2. Adult Cardiac Arrest Algorithm.
5
ACLS Cardiac Arrest Algorithm UpdateThe ACLS Adult Cardiac Arrest Algorithm and the ACLS Adult Cardiac Arrest Circular Algorithm were updated to include lido-caine as an alternative antiarrhythmic to amiodarone for treatment of shock-refractory VF/pVT. The lidocaine dose was added within the algorithm’s Drug Therapy box, and a minor edit was made in the CPR Quality box as detailed in the next sections.Changes to the Adult Cardiac Arrest Algorithm—2018 Update. Within the VF/pVT branch of the algorithm, lidocaine was add-ed as an alternative to amiodarone in Box 8. In the algorithm’s CPR Quality box, the fourth bullet text was changed from “Rotate compressor every 2 minutes, or sooner if fatigued” to “Change compressor every 2 minutes, or sooner if fatigued.” Within the al-
gorithm’s Drug Therapy box, the lidocaine dose was added as an alternative to amiodarone in the second bullet text.Changes to the Adult Cardiac Arrest Circular Algorithm—2018 Update (Figure 3). Within the circle, under “Drug Therapy,” the last drug was changed from “Amiodarone for refractory VF/VT” to “Amiodarone or lidocaine for refractory VF/pVT.” Within the algorithm’s CPR Quality box, the fourth bullet text was changed from “Rotate compressor every 2 minutes, or sooner if fatigued” to “Change compressor every 2 minutes, or sooner if fatigued.” Within the algorithm’s Drug Therapy box, the lidocaine dose was added as an alternative to amiodarone in the second bullet text.
2016 STUDY GUIDE St. David’s Institute for Learning
Advanced Cardiac Life Support (ACLS) for Healthcare Providers
Key Principles for BLS & AED:
o Effective, high quality compressions are the most important aspect in effective CPR! o HARD & FAST o Allow complete recoil between compressions o NEVER INTERRUPT COMPRESSIONS FOR LONGER THAN 10 SECONDS- interruption reduces blood
pressure and coronary perfusion pressure o Maintain a compression rate of 100-120/minute
o Control Ventilations: Do not hyperventilate; Hyperventilation interferes with effective compressions o Deliver breaths over 1 second to obtain visible chest rise –not too deep! o Count the seconds between breaths to control rate – a breath given every 5-6 seconds
o AED is limited to 1 shock: o Apply AED while still delivering compressions o Stop compressions only when AED says, “Analyzing rhythm…Do not touch the patient.” o DO NOT STOP COMPRESSIONS WHILE AED IS CHARGING. o Shock when prompted then IMMEDIATELY resume 5 cycles of CPR (30:2) WITHOUT A PULSE CHECK. o After 5 cycles of CPR THEN check breathing & pulse.
o Unconscious Foreign Body Airway Obstruction: o If unable to ventilate, reposition head & reattempt ventilation o Look in mouth for foreign object & remove if seen o Begin compressions at ratio of 30:2 breaths o Reexamine mouth for foreign object after each 2 minutes of compressions.
Airway Management with Intubation:
o Ensure a patent (open) airway o Ventilate (mouth to mouth or with artificial airway & bagging) when spontaneous breathing is
inadequate or absent o Provide supplemental O2 to achieve an O2 sat of > 94%. o Perform continuous assessment of airway & ventilation o Respiratory arrest may progress to cardiac arrest if patient doesn’t receive ventilation and oxygenation.
Recommended Ventilation Rates (watch for obvious chest rise):
o With Advanced Airway in place: 10/minute (1 breath every 5-6 seconds) Higher rates may result in decreased cerebral blood flow Higher volumes increase the risk of gastric insufflations without improving oxygenation Do not synchronize breaths with chest compressions
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100 chest compressions & 8-10 breaths/minute Bag Mask Ventilation:
o 10-12 / minute ( 1 breath every 5-6 seconds) Apneic Patient with Pulse:
o ETCO@ is a rapid & reliable method to detect life-threatening conditions (malpositioned tracheal tubes, unsuspected ventilator failure & circulatory failure)
o ETCO2 shows how much CO2 is released with expiration o Poor circulation (during CPR = ineffective chest compressions) causes little CO2 to be released
ETCO2 values are low Ineffective CPR may produce ETCO2 of < 10 mm Hg; use to assess CPR quality
o When pulse returns (ROSC), more CO2 is released ETCO2 values rises
o Target ventilations to maintain ETCO2@ of 35-40 mm Hg
Oropharyngeal Airways:
o Used to hold the tongue away from the posterior wall of the pharynx o Use only on unconscious patient with no gag/cough reflex (otherwise might cause vomiting)
Measure angle of mandible to corner of mouth to determine correct size Insert with airway upside down & rotate into position after the tip approaches the posterior wall
of the pharynx After correct placement, check for respirations. If none present ventilate with bag.
Nasopharyngeal Airways:
o Designed to keep the tongue away from the back of the throat o Better tolerated than oral airways; may be used with conscious or unconscious patients o May cause laryngospasm and vomiting, but generally well tolerated
Measure from tip of nose to the earlobe for correct size. Lubricate with water soluble gel Bevel should point at nasal septum Gently advance airway into one nostril along natural curve.
• If resistance felt, gently roll between fingers while trying to advance • If unable to fully insert, try other nostril
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Bag-Valve-Mask Devices:
o Best performed by 2 people (one to maintain seal, 1 to ventilate) o Difficult to use effectively (requires adequate training / practice) o Capable of delivering close to 100% with high O2 flow rates o Does not provide a greater tidal volume than mouth to mask o To Use:
Open airway with head tilt – chin lift if no trauma to head/neck Place V shaped end of mask over bridge of nose Apply gentle pressure around the mask to obtain seal around nose & mouth Ventilate by squeezing bag 10-12 times/minute
Advanced Airways:
o Endotracheal Intubation is the preferred method for airway control. o When advanced airway in place:
DO NOT SYNCHRONIZE COMPRESSIONS AND VENTILATIONS Ventilate with 10 breaths / minute and perform 100-120 compressions / minute
Intubation Supplies:
• Endotracheal tube o Open at both ends o Distal end attached to pilot balloon (helps to indicate cuff is inflated) o Tubes come in several sizes 7.0-8.0 for women; 8.0-8.5 for men
• Laryngoscope o Handle (holds batteries) o Blades (with light bulb)
Straight (tip used to lift epiglottis) Curved (tip fits into vallecula, indirectly opening epiglottis)
• Stylet o Malleable, plastic coated o Use is optional o Helps to conform the ET tube to any desired shape o The end of stylet must be recessed at least ½ inch from tip of ET tube.
• Other Supplies o 10cc Syringe for Cuff Inflation o Water Soluble lubricant o Suction unit with pharyngeal rigid suction tip o Tape or an ETT holder
Ties that tightly compress the neck can obstruct venous return from the brain. Assess for adequate Circulation!
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Intubation Procedure
• Check your equipment • Check cuff on ETT to be sure it holds air by inflating with syringe, gently squeezing cuff • Deflate cuff by aspirating all air with the syringe (Lubricate tube if desired) • Place patient in sniffing position (head extended, neck flexed) • Check bulb on blade (light comes on) • Open mouth with R hand (crossed fingers technique) • Hold Laryngoscope in L hand • Insert blade into mouth and advance toward base of tongue. • STOP CHEST COMPRESSIONS NOW
o Visualize the vocal cords o Place tube into R corner of mouth and advance it through and 1 inch beyond
the vocal cords (tube passed beside blade) o Remove stylet o Inflate cuff with volume required to occlude airway (10 ml of air)
• RESUME CHEST COMPRESSIONS • Confirm placement of tube
o Auscultate the epigastrium & lung fields = confirmation by exam o Watch for chest rise & fall as sign of ventilation o Secondary Survey = confirmation by device
Confirmation Device = ETCO2 detector or Esophageal detector bulb Esophageal Detector Bulb is the LEAST ACCURATE CONFIRMATION METHOD Confirm oxygenation and ventilation with O2 or CO2 monitoring
• Secure ETT with tape or commercial tube holder • INTUBATION ATTEMPT SHOULD TAKE NO LONGER THAN 30 SECONDS (preferably less
than 15 seconds). If not successful w/in 30 seconds, abort attempt, ventilate w/100% O2 for 15-30 seconds & try again.
• Cricoid Pressure is not routinely recommended o May impede ventilation or placement of the advanced airway.
• Laryngoscope is never to be used as a fulcrum for “prying” on the teeth
Complications
• Esophageal Intubation o Stomach gurgling heard with no chest expansion o Absent breath sounds o Deflate cuff, remove tube, ventilate w/100% O2 for 15-30 sec & try intubation
again. • Right Mainstem Intubation
o Tube is advanced too far into trachea o Check for bilateral breath sounds o If breath sounds absent on the L, deflate cuff, pull tube back 1-2 cm & reinflate
cuff. o Reassess breath sounds
Post ETT placement: After auscultation & confirmation with device---verify with CXR
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• Evidence shows airways are dislodged up to 14% of time with patient transport or movement
• Continuous O2 Sat or End Tidal CO2 monitoring needed to detect airway dislodgement
ET Suctioning
• Removes secretions • Use sterile disposable catheter • Ventilate & pre-oxygenate with 100% O2 • Insert suction catheter into ET tube (without closing the side opening & causing vacuum) • Advance to level of the carina • Suction only on way out—DO NOT SUCTION FOR LONGER THAN 10 SECONDS • Close the side hole to apply suction while slowly withdrawing the catheter with a
rotating motion
Other Advanced Airways (not tested in class)
Combitube (ETC: Esophageal Tracheal Combitube)
o Double lumen airway with 2 inflatable balloon cuffs o Does not require visualization of vocal cords to insert o Once inflated, 1 balloon anchors the tube, the other isolates the airway o Ventilations may be given through either lumen depending upon location of
distal tip; it may be in the esophagus or trachea
Laryngeal Mask Airway (LMA)
o Tube w/ inflatable mask-shaped cuff o Mask shape cuff seals the larynx o Does not require visualization of vocal cords to insert o Better than facemask as regurgitation is less likely o Use in unconscious patients
Devices for Checking Placement / Monitoring ET Placement
Continuous Waveform Capnography
Most reliable method for confirming/monitoring correct ET tube placement
After ROSC, target range for ETCO2 is 35-40 mm Hg
CO2 Detectors
o Color changes from purple to yellow indicating proper placement o False negatives caused by:
Low blood flow & O2 delivery to lungs Pulmonary Embolus Contamination with gastric secretions IV Epinephrine may decrease CO2 If no CO2 detected, use another device
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Esophageal Detector Device (EDD)
o Bulb is compressed & attached to ET tube & released Suction pulls tissue against tip of tube and bulb does not expand
o Misleading results caused by: Morbid Obesity Late Term Pregnancy Status Asthmaticus Copious Secretions
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BLS – Defibrillation
BLS Survey: 1. Establish Unresponsiveness/ abnormal or absent breathing
(Agonal gasps are a likely indicator of cardiac arrest) 2. Call for help and an AED 3. Check carotid pulse and breathing for 5-10 seconds
• If no pulse or unsure of pulse begin chest compressions (at least 100/minute) • Compress at least 2 inches • Allow complete chest recoil between compressions • Switch chest compressors every 2 minutes to avoid fatigue • CPR can provide small amount of blood to heart & brain
4. Defibrillate as soon as AED Arrives • Continue chest compressions while pads are applied and AED is CHARGING.
Shortening the interval between the last compression and the shock by even a few seconds can improve shock success.
• Immediately resume chest compressions after defibrillation • Defibrillation is most effective treatment for V Fib • Probability of success decreases over time; defib ASAP! Deliver compressions & breaths at rate of 100-120 compressions/min followed by 2 breaths Do not initiate resuscitation if a safety threat TO YOU is present.
AED: Automated External Defibrillator 1. ATTACH AED ONLY to patients who are PULSELESS & APNEIC 2. Safety:
a. Clear area with call & visual check (no one touching patient) before delivering shock b. Oxygen should not be flowing/blowing across the victims chest during defibrillation (can cause
flash fire) c. Switch from AED to manual defibrillator ASAP. Rhythm analysis with AED may result in
prolonged interruption in chest compressions. If pad connectors not compatible, use adapter or switch pads quickly (minimizing interruptions to chest compressions).
3. Troubleshooting a. If AED fails to promptly analyze rhythm, DO CHEST COMPRESSIONS b. If patient in water / wet:
Pull out of water, wipe chest to dry, attach electrodes c. If on snow or ice, immediately use AED without delay.
Single health care providers may tailor the sequence of rescues action to the most likely cause of arrest.
• Sudden collapse most likely due t sudden cardiac arrest. Call for help, attach AED, then provide CPR. • If arrest due to hypoxia, give 2 minutes of CPR before activating the emergency response system.
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Ventricular Fibrillation (VF)/Pulseless V Tach (VT)
V-Fib (Ventricular Fibrillation) = Disorganized ventricular activity 1. No Cardiac Output (no effective pumping action) 2. Patient is PULSELESS & UNCONSCIOUS 3. Monitor shows no identifiable QRS complexes and the pattern is irregular and chaotic.
May be mimicked by artifact on monitor---treat the patient, not the monitor!
VT (Ventricular Tachycardia) 1. Wide QRS complexes (> 0.12 seconds in width) 2. Regular Rhythm 3. Rate 100-200 4. If P waves present they are disassociated with QRS complexes 5. Can mimic / look like artifact on monitor---Treat the Patient not the Monitor! 6. If patient in VT & PULSELESS---Treat as V-Fib!
V-Fib Pulseless VT: 1. Begin compressions (at least 100 / minute) 2. Give 100% oxygen in cardiac arrest 3. Attach monitor/defibrillator 4. Defibrillate VF or pulseless VT ASAP
Two types of Defibrillators
1. Monophasic (current delivered between paddles in only 1 direction—apex to sternal paddle) Initial Setting: Use 360 Joules
2. Biphasic (shock delivered from apex to sternum & then back to apex)
1. Uses less energy 2. May cause less cardiac dysfunction 3. Some models have lower maximum levels: 200-250 joules 4. Initial Setting: Use 200 Joules
Review of Defibrillator Use/ Settings
a. Select Energy Level
ii. Monophasic = 360 J iii. Biphasic = 200 J
b. Charge Defibrillator – continue chest compressions while charging c. Press Discharge Button(s) d. Safety Precautions:
i. Move Ambu Bag or turn off O2 before delivering shock 1. O2 flowing/blowing across chest may result in fire 2. Pads preferred over paddles to reduce the risk of arcing
ii. Clear the area before shocking:
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1. Call Clear in audible voice 2. Visually assess/clear the field by looking head to toe then toe to head (no one
touching patient) 3. Deliver shock
Pads provide faster defibrillation
iii. Pad Placements: • Right Sternal Border & at 5th intercostal space anterior axillary line (apex of heart) • Both pads bi-axillary • One pad L lateral chest & other on R or L upper back
e. V Fib is considered REFRACTORY if it does not convert with defibrillation
5. IV Fluids / Drugs a. NS fluid of choice. May use Lactated Ringers (LR) b. Volume not appropriate for all patients c. Antecubital is IV access of choice unless central line already available
i. IO (intraosseous ) preferred if no peripheral IV ii. Central lines are difficult to place during BLS so peripheral is preferred
Administering Drugs in Cardiopulmonary Arrest: iii. Bolus Therapy only; give drugs rapidly iv. Follow bolus with 20-30 mL IV fluids v. Elevate IV extremity for 10-20 seconds if peripheral IV site
vi. Some drugs may be given via ET Tube 1. Result in lower blood concentrations than IV or IO 2. ET absorption of drugs is poor and optimal drug dosing is not known
vii. Method for administering drugs via ETT 1. Give while compressions stopped for rhythm analysis 2. Instill 2-2.5 times the IV dose 3. Drug should be diluted in 10cc NS 4. Ventilate (bag) the patient 5. Resume Chest Compressions
viii. Remember to acknowledge when all meds are given to “close the communication loop” (Example: “Epi is in!”)
ix. Drugs that may be given via ETT 1. Atropine (2-3 mg) 2. Epinephrine (2 – 2.5 mg) 3. Lidocaine (2-4 mg/kg)
x. First Drug in ALL Cardiac Arrests: Vasoconstrictor or Vasopressor to increase blood flow to heart and brain
Epinephrine---Dose 1 mg IV or IO 1. Give every 3-5 minutes throughout resuscitation until rhythm changes 2. First line agent in all forms of cardiac arrest (VF, pulseless VT, PEA, Asystole)
xi. Antiarrhythmic Medications 1. Amiodarone 300 mg IVP
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a. Repeat dose of 150 mg in 3-5 minutes for persistent or recurrent VF/pulseless VT
2. Lidocaine 1-1.5 mg/kg if Amiodarone is unavailable a. Repeat dose 0.5 - 0.75 mg/kg every 5-10 minutes b. Max dose = 3 mg/kg c. Few hemodynamic side effects d. Reduce loading (not maintenance) dose if impaired liver function or LV
dysfunction 3. Magnesium Sulfate 1-2 gm diluted in 10 ml D5W IV
a. Given in cardiac arrest when patient has: i. Torsades de Pointes
ii. Known Hypomagnesemia iii. May also give Mag after Lidocaine in refractory VF and in V
arrhythmias w/dig toxicity.
6. ACLS Sequence: Rhythm Check – Shock – CPR – Rhythm Check – Shock – CPR - Drug 7. After 2 minutes of an organized rhythm, check for a pulse.
a. Presence of Pulses = Return of Spontaneous Circulation (ROSC). 8. If patient fails to respond to Defibrillation, Epinephrine & Antiarrhythmic Therapies,
D/C efforts & notify family.
Post Arrest Care
1. Optimize ventilation & oxygenation: Ensure airway open & protected a. Keep O2 Sats > 94% b. Begin ventilation at 10 breaths/minute; target ETCO2 to 35-40 mm Hg c. Use waveform capnography to monitor ETT placement and ROSC.
2. Treat Hypotension: Hypotension = SBP < 90 mmHg
a. Give 1-2 L of NS or LR i. Use COLD IV FLUID to induce hypothermia
b. Vasopressor to increase BP i. Epinephrine 0.1 - 0.5 mcg/kg/min
ii. Dopamine 5 - 10 mcg/kg/min iii. Norepinephrine 0.1 - 0.5 mcg/kg/min
3. Does the 12 lead EKG show STEMI? a. IF YES:
i. To Cath Lab for Reperfusion (at reperfusion capable/PCI facility) 4. Assess LOC: Does the patient follow commands?
b. If NO: i. Induce Targeted Temperature Management (TTM) to 32-34° C for 24 hours ii. Begin TTM ASAP (in ED & continue in Cath Lab/ICU)
iii. TTM is the only intervention documented to improve neurologic recovery after cardiac arrest. There is no evidence to support continued prophylactic administration of antiarrhythmic meds once the patient achieves ROSC.
ACS: ACUTE CORONARY SYNDROME: Acute necrosis of the heart muscle caused by inadequate blood & oxygen supply
Goals of Therapy for ACS
1. Identify patients with STEMI (ST Segment Myocardial Infarction) and triage for early reperfusion 2. Relief of ischemic chest discomfort 3. Treat complications such as VF, symptomatic Brady / tachyarrythmias
Clinical Symptoms Associated with Coronary Artery Occlusion (Symptoms represent varying degrees of coronary artery occlusion)
1. ST Elevation MI (STEMI) 2. Non ST Elevation MI (NSTEMI) 3. Sudden cardiac death can occur with each of these syndromes 4. Presenting Signs/Symptoms
a. Chest pain/discomfort i. May spread to shoulders. Neck arm or jaw or into back or between shoulder blades
ii. Often Described as: 1. Crushing 2. Pressure 3. Squeezing 4. Fullness
b. SOB i. May be sudden & unexplained
ii. May occur with/without chest discomfort c. N/V d. Diaphoresis e. Fatigue f. Elderly, Diabetics & Women more likely to present
• in unusual/atypical manner • without classic symptoms • with vague/nonspecific complaints
5. Transport suspected ACS pts to ER using 911 ambulance for immediate assessment & treatment
IMMEDIATE ASSESSMENT “O2 – IV – Monitor” (complete in < 10 minutes) 1. Vital Signs 2. O2 Saturation; if < 90% apply O2.(Note: < 90% in ACS; < 94% in other situations) 3. Obtain IV access (1-2 IV lines) 4. Draw blood for Cardiac Markers, lytes & coags 5. 12 Lead EKG
a. Single EKG cannot be relied upon to exclude diagnosis of ACS b. St Elevation > 1-2 mm indicates acute ischemia
i. Must be seen in 2 or more contiguous leads (leads showing same region) ii. ST elevation is an ACUTE change
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c. Q waves indicate INFARCTION i. ST segment may/may not be elevated with Q waves
1. Q waves with ST elevation indicate RECENT event 2. Q waves with no St elevation indicates OLD infarct
6. Brief targeted history (focus is on eligibility for fibrinolytics)
a. Onset of pain i. Defined as continuous, persistent discomfort
ii. If “on/off” stuttering pattern to pain, onset is time patient decided to seek care b. Duration c. Use of concurrent meds d. History of Trauma (< 2 weeks) e. History of Surgery (< 2 weeks) f. History of Bleeding
7. Brief Physical Assessment a. Breath Sounds (pulmonary congestion?) b. Heart Sounds (Extra Sounds Heard?) c. Bruits d. Evidence of Trauma/Bleeding
8. Review Fibrinolytic Check List; indicate identified contraindications 9. If in Hospital when symptoms of ACS begin
a. To identify ACS & prevent deterioration: i. Call Rapid Response Team or
ii. Medical Emergency Team (MET)
Immediate General Treatment – call a Rapid Response or Medical Emergency Team for rapid assessment and early treatment
1. MONA greets all patients a. Oxygen
i. If O2 sat < 90% , dyspnea or heart failure: 1. Start O2 @ 4 l/m 2. Titrate to maintain O2 sat >90%
b. Aspirin i. 160-325 mg chew & swallow
1. ASA associated with decreased mortality after MI 2. Interferes with platelet aggregation
c. Nitroglycerine (NTG) i. Decreases O2 demand of the myocardium
ii. Give SL or Spray if BP ≥ 90 iii. Avoid NTG if Inferior MI or Right Ventricular Failure, hypotension or recent (within 48
hours) phospohodiesterase inhibitor use (sildenafil, vardenafil) d. Morphine
i. Decreases preload and afterload ii. 2-4 mg IV if pain unrelieved by NTG
2. Get 12 lead EKG
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a. Identify ST Elevation MI (STEMI--indicates complete occlusion of coronary artery) b. Identify Depression (NSTEMI) c. Consider adjunctive treatments but DO NOT DELAY REPERFUSION
3. Time from onset of symptoms < 12 hours? If Yes ---Select Reperfusion Strategy a. The earlier therapy begins, the better the outcome b. Greatest benefit for survival & LV function occurs when therapy begins within 3 hours c. Significant benefit may occur when therapy started up to at least 12 hours after onset of
symptoms 4. Reperfusion Strategies:
a. PCI- Percutaneous Coronary Intervention (Coronary angioplasty with/without a stent) i. Targeted Time Goal: ED Door to Balloon inflation 90 minutes
b. Fibrinolytics i. Used when:
1. Complaint consistent with ischemic type pain 2. ST Elevation ≥ 1mm in 2 or more contiguous leads on 12 leak EKG 3. No contraindications present in patient
ii. Types 1. rtPA: Ateplase 2. Reteplase (Retavase) 3. Tenecteplase
iii. Targeted Time Goal: ED Door to Needle 30 minutes Disposition of the patient:
1. Admission to ICU/CCU/IMC 2. Cath Lab for PCI
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BRADYCARDIA Bradycardia – Heart rate less than 60 beats/minute Priorities / Management: – call a Rapid Response or Medical Emergency Team for rapid assessment and early treatment
a. Initial Assessment (“VS- O2 – IV – Monitor”) i. Maintain patent airway
ii. Assist breathing as needed iii. O2 if hypoxemic / O2 Sat monitor iv. IV access v. Monitor to ID rhythm
vi. Vital Signs vii. 12 Lead EKG
b. Serious Signs / Symptoms due to Bradycardia i. Hypotension
ii. Altered mental status iii. Signs of shock iv. Ischemic chest discomfort v. Acute heart failure
c. If Patient is asymptomatic with adequate perfusion i. OBSERVE & MONIITOR
d. If Patient is Symptomatic i. Atropine 0.5 mg IV (maximum total dose 3 mg)
ii. Prepare for TCP (Transcutaneous Pacemaker) if atropine ineffective e. If patient is hypotensive and demonstrates no response/improvement to atropine and/or
pacing: 1. Dopamine 2-20mcg/kg/min IV Titrate to SBP of 90 mm Hg 2. Epinephrine 2-10 mcg/min IV as a continuous infusion - Titrate to SBP of 90 mm Hg
2. Use of TCP (Transcutaneous Pacing)
a. Indications: i. Symptomatic Bradycardia
ii. No response to Atropine iii. Second Degree Type II or Third Degree AVB
b. Procedure: i. Obtain Defibrillator with pacing option
ii. Place the hands free pacing pads 1. Anterior (V3 position- avoid breast tissue) 2. Posterior (Directly below L scapula)
iii. Connect pacing pads to pacing cable iv. Attach pacing cable to pacemaker/defibrillator v. Turn rate to desired rate (usually 60 b/m)
vi. Increase MA (output) until capture is obtained 1. Capture Indicator– Pacer spike is immediately followed by a wide QRS
vii. Ensure pulse is present and corresponds to paced rate viii. Assess for presence of symptoms; provide sedation/analgesia for pain control.
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ix. If TCP ineffective—plan for Transvenous Pacing and obtain expert consultation.
PEA (Pulseless Electrical Activity): PEA = a PULSELESS patient whose electrical cardiac rhythm SHOULD PRODUCE A PALPABLE PULSE
1. Has been called Electromechanical Dissociation (EMD) in past 2. Pacing not appropriate for PEA because patient already has an electrical rhythm (heart is “pacing” itself already).
a. Problem in PEA is that the heart muscle is not or cannot respond to the electrical impulse/stimulation. 3. Identified by seeing SVT, 2nd Degree, Type II AVB, AF on monitor but PT is PULSELESS 4. Priorities / Management of PEA
a. CPR b. IV/IO access c. Vasopressor (Epinephrine)
i. Epi is a vasoconstrictor which preserves coronary & cerebral blood flow. 5. Treatment of PEA
a. Identify Cause for the PEA (5H’s & 5T’s)
H’s T’s
Hypovolemia Toxins (Tablets) – Drug Overdose
Hypoxemia Tamponade – Cardiac
Hydrogen ion - Acidosis Tension Pneumothorax
Hyperkalemia / Hypokalemia Thrombosis – Coronary
Hypothermia Thrombosis - Pulmonary
i. Hypovolemia (most common cause of PEA)
1. Causes/Symptoms of Hypovolemia a. Fluid/Blood loss b. Flat neck veins c. Poor pulse with CPR d. Rapid, narrow complex rhythm
2. Treat with Volume Expansion ii. Hypoxemia (common cause of PEA)
1. Causes/Associated history a. History of respiratory problems b. Difficult intubation or ventilation
2. Symptoms a. Slow heart rate b. Cyanosis / pallor c. Changes in LOC / restlessness / lethargy
3. Treatment is Oxygenation & troubleshooting ventilation problems a. Assess placement of ETT, O2 supply, Volume & frequency of ventilations
iii. Hydrogen Ion Acidosis 1. Causes / Associated history
a. Diabetes b. Renal Failure
2. In most codes this is a combination of respiratory & metabolic acidosis a. Usually corrected once perfusion restored
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3. Treatment a. Initial treatment is ALWAYS to increase rate of respirations & administer
Oxygen b. Na Bicarb may be given if pre-existing acidosis
iv. Hyperkalemia 1. Causes/ Associated History
a. Renal patient b. Excessive potassium supplementation c. Diabetes
a. Renal patient b. Vomiting / Diarrhea c. Diuretic therapy (Lasix) without adequate potassium supplementation
2. Symptoms a. Muscle cramps / weakness b. Flat T waves
3. Treatment a. Potassium replacement b. Magnesium if in Cardiac Arrest
vi. Hypothermia 1. Causes / Associate history
a. History of exposure to drugs b. Alcohol c. Diabetes d. Near drowning, e. Sepsis
2. Treatment a. Rewarm the patient (remember the old adage: “They’re not dead until
they’re WARM & dead”) i. Hypothermic heart may be unresponsive and drug metabolism is
reduced ii. Avoid unnecessary movements, drugs & procedures until patient is
warm iii. Warm packs iv. Heated, humidified O2 v. Infusion of warm NS via central line.
vii. Toxins 1. Symptoms/ Associated history
a. Prolonged QT b. Bradycardia c. Pupil changes d. Tricyclic antidepressants (they are cardiotoxic / myocardial depressants)
2. Treatment
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a. Intubation b. Lavage c. Activated Charcoal d. Lactulose e. Specific antidotes for the identified toxin
viii. Cardiac Tamponade 1. Causes / Associate history
a. History of trauma b. Recent CPR/MI/Viral illness c. Renal failure d. Thoracic malignancy
2. Symptoms a. Narrow complex QRS; RAPID rate b. Distended neck veins c. Poor pulse / no pulse with CPR d. Increased heart rate e. Increased CVP f. Pulsus Paradoxus (decrease of > 10 mm Hg in SBP on inspiration) g. Muffled heart tones h. Pericardial Rub i. Increased heart size on Xray
3. Treatment a. Pericariocentesis
i. Needle inserted at the 5th intercostals space at L sterna border ix. Tension Pneumothorax
1. Causes/ Associated history a. History of trauma b. Recent central line insertion c. Recent CPR
2. Symptoms a. Narrow complex QRS; SLOW rate b. Distended neck veins c. No pulse / poor pulse with CPR d. Tracheal deviation e. Unequal breath sounds f. Difficulty ventilating patient
3. Treatment a. Needle Decompression b. Placement of Chest tube
x. Thrombosis (Coronary) 1. Causes/ Associated history
a. Clot lodging in coronary artery b. CAD, hyperlipidemia, angina
2. Symptoms a. Chest pain b. Abnormal 12 lead EKG
i. ST elevation ii. Q waves
iii. T wave inversions 3. Treatment
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a. PCI with stent for reperfusion b. Fibrinolytic therapy
xi. Thrombosis (Pulmonary) MASSIVE PE 1. Causes/ Associated history
a. May occur suddenly in otherwise healthy person; long period of sitting increases risk
b. DVT 2. Symptoms
a. Narrow complex rhythm with rapid rate b. No pulse with CPR c. Distended neck veins
3. Treatment a. Surgical embolectomy b. Fibrinolytic
4. Prognosis is POOR 6. If Return of Spontaneous Circulation (ROSC) initiate post cardiac arrest care protocol. 7. If no ROSC, stop resuscitative efforts. 8. Notify family.
ASYSTOLE:
Asystole = Absence of electrical activity (“flatline”) 1. When you see Asystole on the monitor---Check for other causes of a flat EKG
a. Loose leads b. Size control set too small
2. Priorities of Management a. Rapid Scene Survey (for evidence resuscitation should not be attempted)
i. DNR order ii. Signs of death such as rigor mortis
iii. Threat to safety of rescuers b. BLS
i. Establish unresponsiveness ii. Call for help & AED
iii. Check carotid pulse and breathing for 5-10 seconds iv. If no pulse or unsure of pulse, begin chest compressions v. When IV/IO available, give Vasopressor
Epi 1 mg IVP q 3-5 minutes c. Do not give Atropine for Asystole. It is unlikely to have a therapeutic effect. d. Differential Diagnosis (5H’s / 5T’s) to identify possible causes of asystole. e. DO NOT SHOCK Asystole
i. Shocking “stuns” the heart and produces a profound parasympathetic discharge ii. May eliminate the possibility for spontaneous cardiac activity
f. Do Not Pace Asystole i. Pacing asystole is not effective.
g. Withhold or stop resuscitative efforts if: i. Prolonged duration of resuscitative efforts (factor associated with poor outcomes)
ii. No reversible situations such as hypothermia or drug overdose can be identified. iii. ETCO2 < 10 mm Hg after 20 minutes of CPR.
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Tachycardia Stable & Unstable
TACHYCARDIA Tachycardia = Heart rate > 100 b/m
1. ACLS algorithms treat HR > 150 b/m 2. Rhythms seen with Tachycardia
a. A Fib b. A Flutter c. SVT (Re-entry Supraventricular Tachycardia) d. Monomorphic VT e. Polymorphic VT f. Wide Complex of uncertain type (could be SVT or VT)
3. Identification of rhythm a. Rhythm regular / irregular? b. Is QRS wide or narrow? c. Does patient have pulse? (If NO- Treat as VF)
4. Is patient symptomatic? (Unstable?) a. Signs & symptoms of instability
i. Hypotension ii. Acutely altered metal status / LOC
iii. Signs of shock (diaphoretic, pale, clammy, ect.) iv. Chest pain/ ischemic chest discomfort v. Acute heart failure
5. If unstable – Synchronized CARDIOVERSION a. Unstable = patient has a pulse and at least one of above symptoms of instability b. Drugs are not used to manage UNSTABLE Tachycardia c. Establish IV (& give analgesia/sedation if time and patient condition allows) d. If no pulse, defibrillate!
6. Cardioversion = synchronized shock delivered on the R wave of the cardiac cycle a. Use same paddle / pad placement as for defibrillation
i. Sternum = R sternal border below clavicle ii. Apex = 5th intercostals space, anterior axillary line
b. Press SYNC button prior to delivery of each cardioversion shock c. Check that defibrillator is flagging each QRS (required for delivery of shock at correct moment in cycle) d. Press & hold SHOCK button or both discharge buttons until energy delivered
Unstable rhythms and Energy levels for Synchronized Cardioversion Unstable A fib 120-200, 300, 360 Joules Unstable SVT, Atrial flutter 50 to 100 Joules
Unstable Monomorphic VT 100, 200, 300, 360 Unstable polymorphic VT Treat as VF with high energy shock
***Remember: VT without a pulse is treated as VF***
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Stable Tachycardias = no signs of instability present
1. Signs & symptoms of instability; a. Hypotension b. Acutely altered metal status / LOC c. Signs of shock (diaphoretic, pale, clammy, ect.) d. Chest pain/ ischemic chest discomfort e. Acute heart failure
2. Treatment: a. Obtain 12 lead EKG b. Start IV c. Attempt vagal maneuvers
3. If Stable: Identify Type of tachycardia a. Is QRS narrow (< .12 seconds)?
i. All narrow complex tachycardias originate above the ventricle ii. Types of Narrow Complex Tachycardias
1. Sinus Tach a. Regular Rhythm b. HR 100 – 180 c. Caused by external influences on the heart (fever, anxiety, blood loss & pain) d. Gradual onset & gradual termination e. Vagal maneuver may slow heart rate but only temporarily f. Cardioversion contraindicated g. Treat cause (fever, pain, blood loss, anxiety, etc.)
2. SVT (Supraventricular Tachycardia) a. Re-entry rhythm; one impulse travels in a circle repeatedly depolarizing the heart b. Cardioversion is used to depolarize all the heart cells simultaneously which breaks
the re-entry cycle. c. Regular Rhythm d. Rate > 150 b/m e. P waves difficult to identify f. PR difficult to identify due to fast rate & hidden P waves g. QRS are all alike; 0.04-0.11 seconds
3. Atrial Fibrillation i. Irregular Rhythm
iii. Converting the Narrow Complex Tachycardias 1. Vagal Maneuvers
a. Stimulates the vagus nerve which slows the heart rate b. Will terminate 25% of SVT c. Cough, Gag or Valsalva d. Carotid Massage
i. Contraindicated in those at risk for carotid atherosclerosis ii. Avoid in late middle age & elderly patients
iii. Can break re-entry SVT iv. Performed only by Physicians
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2. Adenosine a. Slows conduction through the AV node b. Eliminates 90% of re-entry arrhythmias within 2 minutes c. Slows ventricular rate to identify A Flutter & A Fib d. Has a short half life (<10 seconds) e. May cause angina, hypotension, bronchospasm, acceleration of accessory
pathway conduction f. DOSE: 6 mg IVP (slam) over 1-3 seconds
i. Follow immediately with 20 ml flush ii. Elevate arm.
iii. Wait 1-2 minutes iv. 12 mg IVP over 1-3 seconds
3. Did rhythm convert? a. If YES:
i. Probably re-entry SVT ii. Watch for recurrence
1. Treat with Adenosine, calcium channel blocker or beta blocker if recurs.
iii. Calcium Channel Blocker 1. Diltiazem 15-20 mg IV over 2 minutes (0.25 mg/kg) 2. May repeat in 15 minutes 20-25 mg (0.35mg/kg) 3. Watch for hypotension 4. Do not give with IV beta blocker; may cause hypotension
iv. Beta Blocker 1. “LOL” drugs (metoprolol. Atenolol, propranolol, esmolol,
labetalol) 2. Used to slow ventricular rate (response)
b. If NO i. Possibly Atrial Flutter, Ectopic Atrial tachycardia (MAT) or Junctional
Tach ii. Obtain Expert consultation for diagnosis & treatment
Wide Complex Tachycardias = QRS > .12 seconds
4. Regular Rhythm / Monomorphic VT / Uncertain Rhythm a. VT = Wide & fast b. P waves absent or dissociated c. PR = None d. QRS > 0.12 seconds (wide) e. Regular rhythm with rate > 100 b/m (generally between 150-200 b/m)
5. Start IV 6. Consider antiarrhythmic infusion
a. Procainamide 20-50 mg /min IV until: i. Arrhythmia suppressed
ii. Hypotension iii. QRS increases by 50% or more
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iv. Max dose of 17 mg/kg given v. Maintenance dose: 1-4 mg/min
vi. Avoid if prolonged QT or CHF b. Amiodarone 150 mg diluted in 50-100 ml D5W over 10 minutes (15 mg/min)
i. May repeat 150 mg every 10 minutes as needed ii. Mix 900 mg in 500 ml D5W for continuous infusion
1. 1 mg/min over 6 hours (then 0.5 mg / min over 18 hrs) iii. Max dose 2.2 Gm in 24 hours iv. No dosage adjustment for elderly v. May cause vasodilation, hypotension, bradycardia, negative inotropic
effects vi. May prolong the QT Interval---avoid if QT already prolonged
vii. Do not use with Procainamide (both may increase the QT interval) c. Sotolol
i. 100 mg over 5 minutes ii. Avoid if prolonged QT
7. Obtain Expert Consultation 8. Prepare for elective synchronized Cardioversion
iv. Torsades de Pointes with a pulse a. Magnesium sulfate
i. Loading dose of 1 to 2 Gm mixed in 50 to 100 mL D5W or NS over 5 to 60 minutes IV
ii. Follow with 0.5 to 1 Gm per hour IV (titrate to control Torsades)
STROKE
Stroke Assessment F – Facial droop – have patient show teeth or smile A – Arm – one arm does not move or drifts down S – Speech - slurred, uses wrong words or is unable to speak T – Time – note time of symptom onset and call 911 or Rapid Response Team Check VS, O2 sat, 12 lead ECG. Check blood glucose as hypoglycemia may mimic signs of a stroke; treat if indicated. Establish time of onset (time Last Known Well)
If transporting to hospital, alert the hospital prior to arrival Stat Head CT without contrast (Complete within 25 minutes of hospital arrival) If head CT negative (normal), stroke is embolic (due to clot) and fibrinolytics may be used.
Begin fibrinolytics ASAP and within 1 hour of hospital arrival; within 3 hours of symptom onset If head CT positive (shows bleeding in brain), fibrinolytic is contraindicated; transfer to ICU CT scan is urgent. If scanner not working, promptly transfer patient to another facility for CT scan.
Revised 5/25/16
St. David’s Institute 5/16
ACLS St. David's Megacode Critical Actions Evaluation Checklists BLS and AED Checklist Name _________________________________________
Critical Performance Steps Completed Comments
Patient was talking while being assessed and now appears unresponsive.
1. Checks for responsiveness — shake and shout.
2. Activates emergency response system/calls for AED
3. Checks carotid pulse and looks for normal breathing—at least 5/less than 10 seconds
4. Locates proper hand position— lower half of sternum
5. Delivers compressions (>2 inches) at least 100/min.—30 compressions in 15 - 18 seconds
6. Gives 2 breaths—1 second each—within 5-10 seconds. Visible chest rise with each breath.
7. Resumes compressions in < 10 seconds.
8. Second rescuer arrives with AED, 1st rescuer continues CPR while AED applied
9. Second rescuer turns on AED.
10. Second rescuer selects proper AED pads and places pads correctly
11. When indicated, second rescuer clears victim to analyze—visible and verbal check
12. Second rescuer clears victim to shock/ presses shock button (within 45 sec of AED arrival)
13. Second rescuer immediately resumes chest compressions after 1 shock
14. Second rescuer delivers cycle of compressions at correct rate of at least 100/min.
15. First rescuer delivers 2 breaths using bag and mask at the end of each 30 compression cycle.
Instructor Signature:______________________________________ IP:_____ Pass:_____ Retest:_____ Airway Management Checklist – Pt has pulse but is apneic.
1. Insert oropharyngeal airway correctly
2. Insert nasopharyngeal airway correctly
3. Use Bag/Mask ventilator appropriately — delivers breath over 1 second. Basic airway : 10 - 12/min (once every 5-6 seconds) (Advanced airways: 8-10 ventilations/min or every 6-8 seconds)
Administer Atropine 0.5 mg IV while awaiting pacemaker
Verbalize need for transcutaneous pacing Demonstrate pad placement Set rate at 60 Increase mA until capture Verify capture (spike followed by a wide QRS) OR Dopamine IV 2-20 mcg/kg/min OR Epinephrine IV 2-10 mcg/min
III. Recognize change in rhythm (Change rhythm to VFib)
Charge to 200 J biphasic (or 360 monophasic)
Call clear and visually clear before shock; delivers shock
Immediately resume CPR after shock for 5 cycles
Appropriate airway management (BVM or advanced airway acceptable)
Stop CPR for rhythm check (Continues in VF)
Charge to 300 J biphasic (or 360 monophasic)
Call clear and visually clear before shock; delivers shock
Immediately resume CPR after shock for 5 cycles
Epinephrine 1 mg IV/IO
Stop CPR
Check rhythm (Continues in VFib)
J Britt 5/2016 St. David’s Institute
Critical Performance Steps Completed Comments
Call clear and visually clear patient
Give 1 shock (200 or greater if biphasic; 360 for monophasic)
Immediately resume CPR for 5 cycles
Give Amiodarone 300 mg IV
Pause CPR for rhythm check
IV. Recognize change in rhythm (Change rhythm to Asystole)
Resume CPR
Verbalize potentially reversible causes of PEA/Asystole (H’s and T’s) – Must be able to name all 10:
5. Recognize change in rhythm (Change rhythm to NSR with a pulse)
Identify Return Of Spontaneous Circulation (ROSC)
Assess BP, O2 sat, 12 lead ECG, lab tests
Verbalize need for endotracheal intubation and waveform capnography to optimize ventilation and oxygenation
Treat hypotension (SBP < 90)
Assess LOC: Patient follows commands? If no, consider targeted temp management
Assess 12 lead ECG: STEMI? If yes, to cath lab for coronary reperfusion
Transfer to ICU
Instructor Signature:______________________________________ IP:_____ Pass:_____ Retest:_____ Second Attempt Signature:____________________________________ Pass:_____ Unsuccessful:_____
1
ACLS Rhythm Handout St. David’s Institute for Learning
As interpretation of cardiac rhythms is a vital part of using the appropriate algorithm, this handout was created to emphasize the key points of rhythms seen in ACLS. It is intended only as a study aid and not as a complete source of information. Please see the ACLS text for additional information concerning rhythms. ECG Changes with Acute MI
Note the normal waveform in the top box. STEMI is characterized by ST segment elevation in two or more contiguous leads. ST Elevation = current of injury An acute change
• PR >.20 sec; constant • Regular • QRS’ alike; .04-.12 sec • P waves normal
4
2nd Degree AV Block Type I or Wenckebach
• PR progressively longer until QRS is dropped (Wide, wider, widest, block….) • P waves normal • QRS normal • Irregular • Rate varies
2nd Degree AV Block Type II or Mobitz II
• More Ps than QRS’ • PR interval is constant • Irregular • Rate varies • QRS’ alike; .04-.12 seconds • May progress to 3rd degree block; plan for pacemaker
