ACLS Flashcards
BLS Primary Survey What is The First things You Do
Scene Safety
Check Response
Check for Breathing
Activate the emergency response system
BLS-Circulation
Feel for carotid pulse for 5-10 seconds
Begin CPR if you do not feel a pulse
30 compressions
BLS-Breathing
Give Two Breaths
BLS-DEFIBRILLATION
if no pulse attach AED/manual defibrillator as soon as it arrives
BLS Primary Survey
BLS survey focuses on early CPR and early defibrillation
Remember to assess and perform the appropriate action
BLS-Activation of the Emergency Response System
Adults and Adolescence
If you are alone with no mobile phone leave the victim to activate the response system and get the AED before beginning CPR
Otherwise send someone and begin CPR immediately use the AED as soon as it is available
BLS-Activation of the Emergency Response System
Infants and Children where the arrest has been witnessed
If you are alone with no mobile phone leave the victim to activate the response system and get the AED before beginning CPR
Otherwise send someone and begin CPR immediately use the AED as soon as it is available
BLS-Activation of the Emergency Response System
Infants and Children where the arrest has not been witnessed
Give 2 minutes of CPR, then leave the victim to go activate the emergency response system.
Return to the child or infant and resume CPR use the AED as soon as it is available
BLS Compression to Ventilation Ratio With an Advanced Airway
Continuous compression at a ratio of 100-120 beats/min
Give 1 breath every 6 seconds (10 breath/min)
BLS Compression to Ventilation Ratio Without an Advanced Airway
Infants and Children
1 Rescuers-30:2
2 Rescuers-15:2
BLS Compression to Ventilation Ratio Without an Advanced Airway
Adults and Aldoscents
1 or 2 rescuers
30:2
What should your compression rate be with CPR
100-120/ min
Compression depth for adults
2 inches
5 cm
Compression depth for Children
At least one third AP diameter of chest
About 2 inches (5 cm)
Compression Depth for Infants
At least one-third AP of the chest
About 1 1/2 inches (4 cm)
Respiratory Arrest
Patient has a pulse but is not breathing
10-12 bpm (1 every 5-6 seconds)
Cardiac Arrest BVM
30 compression to 2 breaths
Cardiac Arrest- Advanced Airway
100 compression per minute with minimal interruptions (<10 seconds)
8-10 bpm (~1 breath every 6-8 seconds)
Why do we only give breath at a slow rate with an advanced airway
We are trying to avoid excessive ventilation so that we can ensure that the patent has enough oxygen well also avoiding vasoconstriction
ACLS Survey-Breathing
When indicated give oxygen
Assess the adequacy of oxygenation/ventilation
Waveform capnography
Look for adequate chest rise
ACLS Survey-Airway
Maintain airway patency (open airway, OPA, NPA)
Advanced airway when indicated
Airway confirmation
ACLS-Circulation
Begin with 30 compression before you begin breaths in order to improve blood flow
Monitor CPR Quality
Obtain IV/IO access
ECG monitoring; rhythm assessment
Give drugs/fluid bolus as indicated
ACLS-Differential Diagnosis
Search for and treat reversible causes (Hs and Ts)
Quality of Chest Compression
Push hard and fast-If you are pushing hard and fast and getting effective chest compression you should have some CO2 on the capnography
Aim for a rate between 100-120 bpm
The depth you are aiming for is 2 inches (5 cm) but not more than 2.4 inches (6 cm)
Allow for full recoil
Switch providers every 2 minutes
Avoid interruptions
Is An Advanced Airway Indicated?
An advanced airway should only be used when indicated not as an automatic response
An advanced airway is considered any type of artificial airway (LMA, ETT)
Do not interrupt chest compression to establish an advanced airway
Confirmation of airway-Waveform capnography
Securing
PetCO2 and CPR
If PetCO2 is <10 mmHG you need to improve your CPR
Airway for Unconscious Patient
OPA
NPA
Head Tilt Chin Lift
Jaw Thurst
Breathing for cardiac arrest
100% O2
This may change in the future
Titrate O2 for SpO2 ≥ 94
Avoid Excessive Ventilation
Will push air into the stomach
May result in vasoconstriction which will reduce blood flow
Breathing With Advanced Airway
When an advanced airway is in place you can give breath one every 6-8 seconds
H with Differential Diagnosis
- Hypovolemia
- Hypoxia
- Hydrogen Ion (acidosis)
- Hyper/Hypokalemia
- Hypoglycemia
- Hypothermia
T with Differential Diagnosis
Toxins
Tampnade (cardiac)
Tension pneumothorax
Thrombosis-Coronary and pulmonary
Trauma
What are the Different Routes of Administration for Medication
In order of how they should use
- IV
- IO
- ETT
IV Route of Administration
Peripheral
Most preferred route of access
Give by bolus injection unless otherwise specified
Follow with 20 cc bolus NS; raise extremity
IO Route of Administration
Sternal (FAST)/ Tibial
Preferred over ETT route
Any drug that can be given IV can be given IO
When you go through the sternum IO route it will make it hard to do chest compression
ETT Route of Access
NAVEL drugs
Optimal dosage not known
Typical dose: 2 to 2.5 times the IV dose
Navel Drugs
Naloxon
Atropine
Valium
Epinephrine
Lidocaine
Epinephrine
This is a vasopressor
Will improve initial ROSC but does not affect overall survival and discharge rates
Amiodarone vs. Lidocaine
Amiodarone will increase short term survival when compared to a placebo or lidocaine
Amiodarone can cause amiodarone lung which is a restrictive lung disease and will also cause smurf syndrome
Atropine Vs. Pacing
Atropine is the first line drug used for acute symptomatic bradycardia
Failure to respond is an indication for TCP, even though the use of epi and dopamine may be successful and can be used to temporarily until pacing is started
When should you not use Atropine
Do NOT rely on Atropine in Mobitz Type II or 3° heart blocks
Transcutaneous Pacing should be started immediately when
There is no response to atropine
Atropine is unlikely to be effective or IV access is not quickly available
The patient is severely symptomatic
TCP-How to Adjust
Place the pads on the patient
If able you should sedate the pt
Set the rate
Set the current
When may you not be able to sedate the pt
When they are already very hypotensive
TCP-Setting the Rate
60/min to start and can be adjusted once pacing has been established
Most patients will improve with rates of 60-70 ppm
Setting the Current (mA) for TCP
- Incrementally increase until capture has been noted and then increase by 2 mA further for a safety margin
- Assess for mechanical capture has been notes
- Check via the femoral pulse
- We check through the femoral pulse because if we check with the carotid pulse we pay just be feeling the large muscle contracting with the electricity
- Check via the femoral pulse
- Assess response to the treatment/clinical status
- If BP is still low try to increase set rate
Mechanical Capture
When you have mechanical capture you will have a pulse with every single beat
Stable Vs. Unstable Pt
When a patient is stable we will tend to not do anything and instead consult will cardiology
When a patient is unstable (symptomatic) we will begin treatment
What is the first thing you should do when a patient is pulseless
CPR
Which rhythms are shockable
VF
pVT
What Should You Do after you give the shock
Do CPR for 2 min
Give epinephrine every 3-5 min
Consider advanced airway
Check capnogrphy
You Have given the shock a second time
do CPR for 2 min
amiodarone- You first give a vasopressor (epi) and then you give an antiarrhythmic (amiodarone)
The rhythm is not shockable
Continue CPR for 2 min before you do another rhythm check
Give epinephrine
Consider advance airway
Think and reversible causes
CPR and Intra arterial pressure
If diastolic pressure is <20 mmHg then you should improve CPR quality
Shock Energy for Defibrillation
BiPhasic
Manufacturer recommendation
Initial dose 120-200 J
If unknown use max available
Shock Energy for Defibrillation
Monophasic
360 J
Epinephrine IV/IO Dose
1 mg every 3-5 min
Amiodarone IV/IO dose
First dose is 300 mg
Second dose is 150 mg
Return of Spontaneous Circulation (ROSC)
Pulse and blood pressure
Abrupt sustained increase in PET (typically >40 mmHg)
Spontaneous arterial pressure waves with intra-arterial monitoring
Adult Tachycardia with Pulse Algorithm
Is the Persistent Tachycardia Causing
Hypotension
Altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
Adult Tachycardia with Pulse Algorithm
1st Steps
Identify and Treat Underlying Cause
Maintain airway and assist breathing if needed
Oxygen is needed
Cardiac monitor, BP, and oximetry
Adult Tachycardia with Pulse Algorithm
Treatment for Symptomatic Tachycardia
Synchronized Cardioversion
Consider sedation
If regular and narrow complex consider adenosine
Adult Tachycardia with Pulse Algorithm
Not Symptomatic and Has a narrow QRS
QRS is <0.12
IV Access and ECG
Vagal manuver
Adenosine-if regular and monomorphic
beta blockers and calcium blockers
expert consultation
Adult Tachycardia with Pulse Algorithm
Not Sympomatic and Has a Wide QRS
QRS is >0.12
IV Access and ECG
Adenosine0if regular and monomorphic
Antiarrhythmic infusion
expert consultation
Synchronized Cardioversion Doses
Wide Irregular
Defibrillation dose (not synchrnized)
Synchronized Cardioversion Doses
Wide Regular
100 J
Synchronized Cardioversion Doses
Narrow Irregular
120-200 J Biphasic
200 J Monophasic
Synchronized Cardioversion Doses
Narrow Regular
50-100J
Adenosine IV Dose
The first dose is 6 mg rapid infusion
Follow with NS flush
Second dose is 12 mg if required
What are your option for an antiarrhythmic infusion for stable wide QRS Tachycardia
Procainamide
Amiodarone
Procainamide Dose
20-50 mg/min
When to stop Procainamide
arrhythmia has been supressed
hypotension
QRS increase >50%
Max dose of 17 mg/kg has been reached
Maintanence infusion of Procainamide
1-4 mg/min
When to Avoid Procainamide
Prolonged QT or CHF
Amiodarone IV
First dose is 150 mg over 10 min
Repeat as needed
Maintanence infusion or 1 mg/min for first 6 hour
Cardioversion for Unstable Monomorphic VT
Biphasic
120-200J
Cardioversion for Polymorphic Vt
Defibrillation Dose
Cardioversion for Unstable SVT Atrial Flutter
Biphasic
120-200J
Cardioversion for Unstable Atrial Fibrillation
Biphasic
120-200J
Bradycardia with a pulse algorithm
What to do when symptomatic and atropine is ineffective
Dopamine
Epinephrine
Expert consultation
Tranvenous pacing
Bradycardia with a pulse algorithm
What to do when symptomatic
Atropine
Bradycardia with a pulse algorithm
What to do when not symptomatic
Monitor and observe
Dopamine IV Dose
infusion rate of 2-20 mcg/kg per min
Titrate to response
Taper slow
Atropine IV Dose
First dose is 0.5 mg bolus
Repeat every 3-5 min
max 3 mg
Epinephrine IV Infusion
2-10 mcg per min
titrate to response
Early Defibrillation
Will not restart the heart
Will temporarily stun the heart and terminate all electrical activity including VF and VT
If the heart is still viable the normal pacemakers may resume electrical activity
Why is Early Defib so important?
The interval from collapse to defib is one of the most important determinants of survival from cardiac arrest!
The shock is more likely to work than the vasopressor so it is a higher prority
Cardioversion vs. Defibrillation
With synchronized cardioversion we are delivering the shock before the down slope of the T wave
On the upslope is the refractory phase and on the down slope if another action potential came the heart muscle could depolarize but it would not be optimal
Post-cardiac Arrest Algorithm
Optimize Ventilation and Oxygenation
Maintain SpO2 of 94%
Consider advanced airway and waveform capnography
Do not hyperventilate
Post Cardiac Arrest Algorithm
Hypotension
Want to treat hypotension (SBP <90mmHg)
give IV/IO bolus
Vasopressor infusion
Consider treatable causes
Post Cardiac Arrest Algorithm
Was a STEMI or AMI suspected
Consider coronary reprefusion
Post Cardiac Arrest Algorithm
Do they follow commands
Yes-Continue to advanced critical care
No-Initiate targeted temperature management
Acute Coronary Syndrome
Immediate ED General Treatment
If SpO2 is <90% start oxygen at L/min and titrate
Aspirin 160-325 mg
Nitroglycerin sublingual or spray
Morphine IV is pt is in discomfort that is not relieved through nitroglycerin