ACLS Algorithm Flashcards
How many breaths do you give with a bag/mask AND with an artificial airway?
Bag/mask = 30:2 (however at SPHs, it’s whenever you can get a breath in, so 1 breath every 6 seconds on the upstroke of compression.
Artificial airway: 1 breath every 6 seconds (10 breaths per minute) on the upstroke of compression.
Bagging with 100% O2.
How many compressions per minute?
100-120 compressions per minute
which two ECG rhythms are shockable?
Pulseless Ventricular Tachycardia
Ventricular fibrillation.
These are non-perfusing rhythms so we need CPR as well.
which two ECG rhythms are non-shockable
Pulseless electrical activity (PEA)
Asystole
These are non-perfusing rhythms so we need CPR as well.
what is PEA?
Pulseless electrical activity.
An organized rhythm without enough contraction to produce a palpable pulse/BP. You cannot defibrillator this
what is asystole?
Complete absence of cardiac activity, there is not pulse, no CO. You cannot defibrillator this
Where do the defibrillator pads go?
Right upper chest and Left midaxillary
What are the differences between monophonic and biphasic shock?
Monophasic - 360 Joules. Shock is given in ONE direction, requires more energy.
Biphasic - 120-200 Joules. Shock delivered in two vectors. Uses less energy, less damage to heart.
*All defibrillators are biphasic now.
What does it mean if the ETCO2 drops <10 mmHg?
Compressor fatigue - time to switch compressions
What does an abrupt rise in ETCO2 >40 mmHg mean?
ROSC = return of spontaneous circulation
What are some ways you know you got ROSC?
- ETCO2 abruptly increases >40 mmHg.
- Pt starts gagging on airway (you at HOB will be looking for this).
- Pulse or BP
- Spontaneous arterial pressure waves intra-arterial monitoring
T/F: You should only use end tidal once the artificial airway is in place
FALSE!
Also use it with your bagger! You can get ROSC before you intubate
Pt is in pulseless Vtach or VFib, how many shocks are given before the first dose of Epi?
2
How long does CPR go for until the rhythm is reassessed?
2 minutes
What is the dosing for Epi?
1 mg every 3-5 mins
The pt was in Vtach and now they are in asystole - what do you do?
NO MORE DEFIBRILLATION
Continue providing breaths (30:2 bag/mask or 1 breath every 6 seconds with airway) and continue CPR.
Epi every 3-5 mins.
1 mg Epi –> CPR 2 mins –> check rhythm, repeat if needed.
What is the dosage for Amiodarone?
First bolus = 300 mg
2nd bolus = 150 mg
What is the dosage for lidocaine?
1st dose = 1-1.5 mg/kg
2nd dose = 0.5-0.75 mg/kg
*Ryan said Lidocaine is no longer used in ACLS.
what are the 5 H’s for reversible causes? How would you treat them?
- Hypovolemia (i.e. was the pt bleeding? vomiting? Melena?) - Treat with normal saline and find the source of bleeding
- Hypothermia (<35 degrees) - warm pt with warm fluids and heated blankets.
- Hypoxia (i.e. not breathing for a period of time, drowning) - establish an airway and 100% O2
- Hydrogen Ion (acidosis) caused by long period of hypoxemia - Give Bicarb
- Hypokalemia/Hyperkalemia (due to vomiting/diarrhea) - for hypokalemia Tx with K+. For hyperkalemia Tx with insulin, glucose and Ca2+ (shifts K+ into cells, out of blood).
what are the 5 T’s for reversible causes? How would you treat them?
- Tension pneumothorax (i.e. due you see tracheal deviation, decrease A/E, asymmetrical chest rise?) - Tx with thoracentesis, and then chest tube. Use US to find.
- Tamponade, cardiac (usually occurs with crush injuries) - Dx with US - Tx with pericardiocentesis
- Toxins - Dx with toxin screen, Hx - Tx with reversal agent (Narcan for opioid, Flumazenil for Benzos).
- Thrombosis, pulmonary - Dx with CT/PEA, D-dimer
- Thrombosis, cardiac - go to Cath lab
* *note: thombolytics are not usually used for thrombosis in ACLS bc brain bleeds during an arrest are likely.
Where does thoracentesis occur?
2nd intercostal space, midclavicular
Where does a chest tube go?
4rth intercostal space, midaxillary
Factors that determine termination of the algorithm
- duration of arrest >30 mins without a perfusing rhythm
- asystole t/o the entire arrest
- prolonged time b/w estimated time of arrest and initiation of resuscitation
- pt age and comorbidities (cancer, very old)
- absence of brain reflexes
- ETCO2 < 10 mmHg for 20 mins
- no ROSC after 3 doses of Epi
What to do when you get ROSC
- Manage a/w - early placement of ETT
- Manage resp parameters - Start 10 bpm, SpO2 92-98%, PaCo2 35-35 mmHg
- Manage hemodynamic parameters - SBP > 90 mmHg, MAP > 65 mmHg
Then obtain a 12 lad ECG
Initiate temp management (if we think the pt has brain hypoxia) with TTM (targeted temp management)
What is TTM?
Targeted temp management.
It’s induced hypothermia (32-36 degrees for 24 hrs after ROSC).
It reduces the brains O2 demand and decreased cerebral metabolism.
use cooling blankets, ice packs and cooled solutions through central catheters
