ACLS OverviewACLS Overview

Kevin Mikielski, DOKevin Mikielski, DO

January 16, 2007January 16, 2007

Initial Evaluation and Initial Evaluation and ManagementManagement

Initial Evaluation and ManagementInitial Evaluation and Management

Immediately call for backup and crash cartImmediately call for backup and crash cart Keep your coolKeep your cool Assess for responsivenessAssess for responsiveness Promptly feel for pulsePromptly feel for pulse

Don’t waste timeDon’t waste time Won’t harm patient by doing CPR if they have a pulseWon’t harm patient by doing CPR if they have a pulse DEFINITELY WILL NOT HELP PATIENT IF YOU DEFINITELY WILL NOT HELP PATIENT IF YOU

THINK YOU FEEL A PULSE BUT THEY ARE THINK YOU FEEL A PULSE BUT THEY ARE ACTUALLY PULSELESSACTUALLY PULSELESS

Happens 10-20% of the time to usHappens 10-20% of the time to us

Initial Evaluation and ManagementInitial Evaluation and Management

Start CPR immediately if no pulseStart CPR immediately if no pulse Chest compressions are much more important than Chest compressions are much more important than

ventilation, especially initiallyventilation, especially initially Critical to maintain cerebral and coronary perfusionCritical to maintain cerebral and coronary perfusion Increases the likelihood of successful debrillation of VF Increases the likelihood of successful debrillation of VF Compress with base of hand over lower sternumCompress with base of hand over lower sternum

1.5 to 2 inches of compression1.5 to 2 inches of compression Rate of 100/minuteRate of 100/minute Avoid interruption of compressions; if need to cease compressions, Avoid interruption of compressions; if need to cease compressions,

be brief and resume promptlybe brief and resume promptly Begin ventilations with Ambu bag at ratio of 30:2Begin ventilations with Ambu bag at ratio of 30:2 Intubate but do not delay defibrillations in order to Intubate but do not delay defibrillations in order to

intubateintubate Once intubated, ventilate at 8-12 breaths per minuteOnce intubated, ventilate at 8-12 breaths per minute Do not overventilate as this results in decreased cardiac output Do not overventilate as this results in decreased cardiac output

and possibly pneumothoraxand possibly pneumothorax

Initial Evaluation and ManagementInitial Evaluation and Management

Quickly analyze rhythm on telemetry or Quickly analyze rhythm on telemetry or defibrillatordefibrillator

Determine if rhythm is suitable for Determine if rhythm is suitable for defibrillationdefibrillationNeed to have an underlying rhythm to Need to have an underlying rhythm to

“shock”“shock”

Defibrillation vs Defibrillation vs CardioversionCardioversion

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Defibrillation is form of cardioversionDefibrillation is form of cardioversionAlso known as “unsynchronized” Also known as “unsynchronized”

cardioversioncardioversion ““Shocks” immediately without sensing Shocks” immediately without sensing

underlying rhythmunderlying rhythmCardioversion is also referred to as Cardioversion is also referred to as

synchronized cardioversion because it synchronized cardioversion because it “senses” the underlying rhythm and delivers “senses” the underlying rhythm and delivers shock at peak of R wave to avoid shocking at shock at peak of R wave to avoid shocking at time to result in R on T phenomenon and time to result in R on T phenomenon and subsequent VFsubsequent VF

How does How does defibrillation/cardioversion work?defibrillation/cardioversion work?

Does not “shock” heart back to normal Does not “shock” heart back to normal rhythmrhythm

Induces asystoleInduces asystoleAllows heart’s normal intrinsic pacemakers Allows heart’s normal intrinsic pacemakers

to dischargeto dischargeMay take seconds to minutesMay take seconds to minutesMay have period of PEA or asystole following May have period of PEA or asystole following

shocksshocks

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Best positioning of pads in APBest positioning of pads in AP Usually position pads or paddles over sternum Usually position pads or paddles over sternum

and apexand apex If attempting defibrillation, make sure that mode If attempting defibrillation, make sure that mode

is set to UNSYNCHRONIZED cardioversionis set to UNSYNCHRONIZED cardioversion If in Synch mode, nothing will happenIf in Synch mode, nothing will happen

If attempting cardioversion, make sure mode is If attempting cardioversion, make sure mode is set to SYNCHRONIZED cardioversionset to SYNCHRONIZED cardioversion May need to hold/press button for a few seconds until May need to hold/press button for a few seconds until

R waves are sensedR waves are sensed

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Energies utilized depend on type of deviceEnergies utilized depend on type of device Monophasic deviceMonophasic device

At our institutionAt our institution Defibrillation: 360 JDefibrillation: 360 J Cardioversion:Cardioversion:

A fib-100 JA fib-100 J PSVT, A flutter-50JPSVT, A flutter-50J ““Stable” VT-100 JStable” VT-100 J

Biphasic deviceBiphasic device Lower Joules because device determines impedence Lower Joules because device determines impedence

and adjusts energy deliveredand adjusts energy delivered

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Defibrillator rhythmsDefibrillator rhythmsPulseless VTPulseless VTVentricular fibrillationVentricular fibrillationTorsades de PointesTorsades de Pointes

Cardioversion rhythmsCardioversion rhythmsAtrial fibrillationAtrial fibrillationAtrial flutterAtrial flutterPSVTPSVT ““Stable” VTStable” VT

Defibrillation vs CardioversionDefibrillation vs Cardioversion

DO NOT SHOCK:DO NOT SHOCK: BRADYCARDIABRADYCARDIA ASYSTOLEASYSTOLE

Unless you think it may be fine ventricular fibrillationUnless you think it may be fine ventricular fibrillation

SINUS TACHYCARDIASINUS TACHYCARDIA PULSELESS ELECTRICAL ACTIVITYPULSELESS ELECTRICAL ACTIVITY

Avoid cardioversion in patients with atrial Avoid cardioversion in patients with atrial fibrillation who are on digoxin and are fibrillation who are on digoxin and are hypokalemichypokalemic May precipitate VF or asystoleMay precipitate VF or asystole

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Immediately resume CPR following Immediately resume CPR following defibrillationdefibrillationMay have period of asystole or PEA following May have period of asystole or PEA following

defibrillationdefibrillationConstantly assess rhythmConstantly assess rhythmCheck for pulse in 2-3 minutesCheck for pulse in 2-3 minutes

Defibrillation vs CardioversionDefibrillation vs Cardioversion

Be aggressive with pressors/fluidsBe aggressive with pressors/fluidsRemember to obtain stat labs/EKG/CXRRemember to obtain stat labs/EKG/CXRGo with patient to ICU as many patients Go with patient to ICU as many patients

“recode”“recode”

RhythmsRhythms

VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA

VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA

VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA

VENTRICULAR FIBRILLATIONVENTRICULAR FIBRILLATION

VENTRICULAR FIBRILLATIONVENTRICULAR FIBRILLATION

Torsades de PointesTorsades de Pointes

TORSADES DE POINTESTORSADES DE POINTES

ASYSTOLEASYSTOLE

Pulseless Electrical ActivityPulseless Electrical Activity Immediately need to think Immediately need to think

of causes of causes HypovolemiaHypovolemia HypoxiaHypoxia HypothermiaHypothermia Hyper or hypokalemiaHyper or hypokalemia Severe acidosisSevere acidosis Massive PEMassive PE Massive MIMassive MI TamponadeTamponade Tension pneumothoraxTension pneumothorax Drug overdoseDrug overdose

TCAs, antiarrhythmics, digoxinTCAs, antiarrhythmics, digoxin

No indication for No indication for pacing based on pacing based on current guidelinescurrent guidelines

Case StudiesCase Studies

Case 1Case 1

58 year old female 58 year old female Hx of CAD Hx of CAD LVEF 15%LVEF 15%Sitting in chair and feels “weak”Sitting in chair and feels “weak”Nursing student is there are sees patient Nursing student is there are sees patient

start to seizestart to seizeMonitor shows:Monitor shows:

Case 2Case 2

42 year old AA male42 year old AA male Hx of end-stage renal disease on HDHx of end-stage renal disease on HD

Has missed HD for past weekHas missed HD for past week

Presents to ED feeling “weak” and “sick”Presents to ED feeling “weak” and “sick” Vital signs: BP 80/40, P 130 (sinus), RR 22Vital signs: BP 80/40, P 130 (sinus), RR 22

““Funny sound” on cardiac auscultationFunny sound” on cardiac auscultation Several PVCs on monitorSeveral PVCs on monitor Suddenly becomes unresponsive and pulselessSuddenly becomes unresponsive and pulseless EKG shows:EKG shows:

Case 3Case 3

42 year old AA male42 year old AA male Hx of end-stage renal disease on HDHx of end-stage renal disease on HD

Has missed HD for past weekHas missed HD for past week

Presents to ED feeling “weak” and “sick”Presents to ED feeling “weak” and “sick” Vital signs: BP 80/40, P 130 (sinus), RR 22Vital signs: BP 80/40, P 130 (sinus), RR 22

Several PVCs on monitorSeveral PVCs on monitor Suddenly becomes unresponsive and pulselessSuddenly becomes unresponsive and pulseless EKG shows:EKG shows:

Case 4Case 4

56 yo female56 yo female Admitted to ICU with midepigastric discomfort Admitted to ICU with midepigastric discomfort

and nausea with vomitus x 1and nausea with vomitus x 1 Diagnosed with pancreatitis in ERDiagnosed with pancreatitis in ER Amylase 250, lipase 200; liver enzymes okAmylase 250, lipase 200; liver enzymes ok

Hemodynamically stable but HR periodically in Hemodynamically stable but HR periodically in 50s with 150s with 1stst degree AV block per ER doctor; no degree AV block per ER doctor; no acute ST segment changesacute ST segment changes

EKG reveals:EKG reveals:

The next morning:The next morning:BP 60/30, P 40BP 60/30, P 40

Case 5Case 5

70 yo white male70 yo white male Hx CABGHx CABG Admitted with chest pain and dyspneaAdmitted with chest pain and dyspnea

Troponin 14; EKG NS ST/T changesTroponin 14; EKG NS ST/T changes

Sx improved with asa, plavix, heparin, integrillin, Sx improved with asa, plavix, heparin, integrillin, metoprolol, ntg gttmetoprolol, ntg gtt

Awaiting transfer for LHC/SCAAwaiting transfer for LHC/SCA Suddenly becomes unresponsive in ICU and Suddenly becomes unresponsive in ICU and

telemetry shows:telemetry shows:

Weak PulseWeak Pulse

No pulseNo pulse

PulsePulse

PulsePulse

Case 6Case 6

32 year old white female32 year old white femaleSmokerSmokerPOD 1 following TAH w BSO develops POD 1 following TAH w BSO develops

mild dyspnea and “a funny feeling in my mild dyspnea and “a funny feeling in my chest”chest”

Vital signs stable; mild fever 100 FVital signs stable; mild fever 100 FSymptoms improved with nebulizer and Symptoms improved with nebulizer and

O2O2Probably secondary to atelectasisProbably secondary to atelectasis

Next day develops worsening dyspnea Next day develops worsening dyspnea with SaO2 of 88% on 4Lwith SaO2 of 88% on 4L

BP 86/54 and Pulse 130; RR 22BP 86/54 and Pulse 130; RR 22CXR: Probable RLL atelectasis vs infiltrateCXR: Probable RLL atelectasis vs infiltrateEKG reveals:EKG reveals:

Twenty minutes later, she collapses Twenty minutes later, she collapses and is pulseless . . .and is pulseless . . .

No pulseNo pulse

PulsePulse

Case 7Case 7

78 yo admitted with severe nausea, 78 yo admitted with severe nausea, abdominal pain, and diarrheaabdominal pain, and diarrhea

Baseline EKG reveals sinus rhythm with Baseline EKG reveals sinus rhythm with 11stst degree AV block, RBBB and LAFB degree AV block, RBBB and LAFB

Occasional brief “pauses” on monitor Occasional brief “pauses” on monitor when abdominal pain increaseswhen abdominal pain increases

Develops intractable nausea and Develops intractable nausea and abdominal painabdominal painVital signs BP 70/45, P 32Vital signs BP 70/45, P 32

PulsePulse

PulsePulse

Case 8Case 8

25 yo white female25 yo white femaleOn Behavioral Health floorOn Behavioral Health floorOn Risperdal, Haldol, AmitryptylineOn Risperdal, Haldol, AmitryptylineDevelops palpitationsDevelops palpitationsHemodynamically stableHemodynamically stable

Weak PulseWeak Pulse

End of LectureEnd of Lecture

Thank you for your attendance.Thank you for your attendance.