BLS/ACLS/PALS/ATLS Flashcards
Adult BLS Algorithm for Healthcare Providers
- Unresponsive (No breathing or no normal breathing, ie, only gasping)
- Activate emergency response system, get AED/defibrillator
- Check pulse - definite pulse within 10 seconds?
3A. Definite pulse - give 1 breath every 5 to 6 seconds, recheck pulse every 2 minutes
3B. No pulse -> 4. - Begin cycles of 30 compressions and 2 breaths
- AED/Defibrillator arrives
- Check rhythm - shockable?
- If shockable, give 1 shock and resume CPR immediately for 2 minutes, then check rhythm again
- If not shockable, resume CPR immediately for 2 minutes. Check rhythm every 2 minutes and continue until ALS providers take over or victim starts to move
Define high-quality CPR
Rate at least 100/min and not faster than 120/min
Compression depth at least 2” (5cm) but no more than 2.5” (6cm)
Allow complete chest recoil after each compression
Minimize interruptions in chest compression (10 seconds or less)
Avoid excessive ventilation
Rotate compressor every 2 minutes, or sooner if fatigued
If no advanced airway, 30:2 compression-ventilation ratio. If advanced airway, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions
If using quantitative waveform capnography - if PETCo2 <10 mmHg, attempt to improve CPR quality
If relaxation phase (diastolic pressure) <20 mmHg, attempt to improve CPR quality
Adult Cardiac Arrest Algorithm
- Start CPR (give O2, attach monitor/defibrillator) - is rhythm shockable?
- VF/pVT (yes) [if no, #9]
- Shock
- CPR for 2 minutes, obtain IV/IO access. Assess rhythm.
- If shockable, shock.
- CPR for 2 minutes. Give epinephrine every 3-5 minutes. Consider advanced airway/capnography. Assess rhythm.
- If shockable, shock.
- CPR for 2 minutes. Give amiodarone. Treat reversible causes.
- Asystole/PEA
- CPR for 2 minutes, obtain IV/IO access, epinephrine every 3-5 minutes, consider advanced airway, capnography. Check rhythm.
- If not shockable, CPR for 2 minutes, treat reversible causes. Check rhythm.
If at any point rhythm is shockable, go to #5 or #7.
If ROSC, go to post-cardiac arrest care.
Shock energy for defibrillation?
Biphasic - manufacturer recommendation (eg, initial dose of 120-200 J). If unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.
Monophasic - 360 J
Dose of epinephrine (IV/IO)?
1 mg every 3-5 minutes
Dose of amiodarone (IV/IO)?
First dose - 300 mg bolus
Second dose - 150 mg bolus
Define ROSC?
Pulse and blood pressure
Abrupt sustained increase in PETCO2 (typically 40+ mmHg)
Spontaneous arterial pressure waves with intra-arterial monitoring
Reversible causes?
Hypovolemia Hypoxia Hydrogen ions (acidosis) Hypo/hyperkalemia Hypothermia (Hypoglycemia) Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis (pulmonary) Thrombosis (coronary)
Adult Bradycardia with a Pulse Algorithm
- Assess appropriateness of clinical condition. HR typically <50/min if bradyarrhythmia
- Identify and treat underlying cause. Maintain patent airway; assist breathing as necessary. O2 if hypoxemic. Cardiac monitor to identify rhythm. Monitor blood pressure and oximetry. IV access. 12-lead ECG if available; don’t delay therapy.
- Persistent bradyarrhythmia causing hypotension? Acutely AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
- If no, monitor and observe.
- If yes, give atropine. If ineffective, move to transcutaneous pacing OR dopamine infusion OR epinephrine infusion
- Consider expert consultation or transvenous pacing
Atropine IV doses?
First dose: 0.5 mg bolus
Repeat every 3-5 minutes
Maximum 3 mg
Dopamine IV infusion?
Usual rate is 2-20 mcg/kg per minute. Titrate to patient response; taper slowly.
Epinephrine IV infusion?
2-10 mcg/minute infusion. Titrate to patient response
Adult tachycardia algorithim?
- Assess appropriateness for clinical condition. HR typically 150+/min in tachyarrhythmia
- Identify and treat underlying cause. Maintain patient airway; assist breathing as necessary. O2 if hypoxemia. Cardiac monitor to identify rhythm; monitor BP and oximetry
- Persistent tachyarrhythmia causing hypotension? Acutely AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
- If yes, synchronized cardioversion (consider sedation. If regular narrow complex, consider adenosine while preparing for cardioversion)
- If no, is the QRS wide? (0.12+ seconds)
- If yes, get IV access and 12-lead EKG if available. Consider adenosine only if regular and monomorphic. Consider antiarrhythmic infusion. Consider expert consultation.
- If no, IV access and 12-lead EKG if available. Vagal maneuvers. Adenosine if regular. Beta-blocker or CCB. Consider expert consultation
Initial recommended doses for synchronized cardioversion?
Narrow regular: 50-100 J
Narrow irregular: 120-200 J biphasic or 200 J monophasic
Wide regular: 100 J
Wide irregular: defibrillation dose (not synchronized)
Adenosine IV doses for synchronized cardioversion?
First dose: 6 mg rapid IV push followed by NS flush
Second dose: 12 mg if required
Antiarrhythmic infusion options for stable wide-QRS tachycardia?
Procainamide IV
Amiodarone IV
Sotalol IV
Procainamide IV dose?
20-50 mg/minute until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given
Amiodarone IV dose?
First dose: 150 mg over 10 minutes, repeat as needed if VT recurs
Follow by maintenance infusion of 1 mg/minute for first 6 hours
Sotalol IV dose?
100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QTc
What tasks should be assigned during a code?
Compressions Airway/BVM Defibrillator IV insertion and medications Recorder
Team leader tasks?
Ensure high quality CPR at all times
Analyze rhythm while chest compressions are held
Recognize rhythm
Duration of resuscitation?
No evidence for a “correct” duration of resuscitation; after 20-30 minutes, possibility of ROSC becomes extremely small
After achieving ROSC, what should be considered?
Therapeutic hypothermia
Proper positioning for chest compressions?
Fingers interlaced, elbows locked, heal of hand between nipples on mid-sternum
Primary actions in cardiopulmonary arrest?
- Perform BLS primary survey
- Obtain finger stick blood sugar
- Perform ACLS secondary survey
Aspects of BLS primary survey?
- Is the airway open? Head tilt-chin lift or jaw thrust (if trauma is suspected)
- Initiate rescue breathing with BVM ventilation if not adequately breathing
- Check carotid pulse for at least 5 seconds (max 10 seconds). If no pulse, initiate CPR.
- Defibrillation
Aspects of ACLS secondary survey?
- Airway - head tilt-chin lift, jaw thrust, oropharyngeal airway, or nasopharyngeal airway; endotracheal intubation if indicated (do not delay defibrillation)
- Breathing - adequacy of oxygenation and ventilation should be confirmed by assessing rise and fall of the chest, auscultation of equal breath sounds, absence of breath sounds over the epigastrum, monitoring end-tidal CO2 using capnometry or capnography, secure ET tube and confirm position with CXR, monitor pulse ox
- Circulation - IV or IO access, monitor, appropriate drugs per ACLS guidelines
Optimal dosing of drugs administered endotracheally has not been established, but ___x the IV route is generally accepted.
2-2.5
ACLS drugs safe for endotracheal administration?
NAVEL Naloxone Atropine Vasopressin Epinephrine Lidocaine
DDx for cardiac arrest
Hypovolemia Hypoxia H+ (Acidosis) Hypothermia Hyperkalemia (or other electrolyte abnormality)
Tension pneumothorax Tamponade (cardiac) Toxins (OD) Trauma Thrombosis (ACS or PE)
Work-up of cardiac arrest?
H&P EKG ABG Lytes CXR US
Initiation of mild hypothermia (cooling to 32-34 C) has been demonstrated to decrease the 6 month mortality rate and lead to improved functional recovery at hospital discharge. What are the inclusion criteria for therapeutic hypothermia?
Patient resuscitated after out-of-hospital witnessed arrest with VT/VF as initial rhythm
Resuscitation initiated by EMS within 5-15 minutes of arrest
No more than 60 minutes from collapse to ROSC
Persistent coma after ROSC
Adult age
Endotracheal intubation and MV
Contraindications to therapeutic hypothermia?
Severe cardiogenic shock (SBP<90) despite fluids and inotropes Cause of coma other than cardiac arrest (OD, CVA) Pregnancy Known coagulopathy Life-threatening arrhythmias Initial temperature <30C Pre-existing DNR status Pediatric patients
Initial actions in trauma patient?
- Assess primary survey with focus on ABCDEs
- Address problems with any portion of the survey before moving on
- Log roll the patient
- XR (AP chest, AP pelvis) and FAST
- Secondary survey
- Resuscitation and stabilization
Primary survey in trauma patient?
Airway maintenance with C-Spine protection
Breathing and ventilation
Circulation with hemorrhage control/shock assessment
Disability (neuro status)
Exposure/Environmental control
Airway management in trauma patient?
- Judge the airway - have the patient speak to you to establish patency and to evaluate for voice change and stridor. Is there evidence of pooling secretions or cyanosis?
- If intact, look for problems which may cause the patient to lose the airway in the near future -> facial injury causing obstruction or bleeding, laryngeal fractures, expanding hematomas, GCS of 9 or less (requires intubation)
- If not intact -> act
- Always maintain C-spine immobilization
- Jaw thrust to establish patency
- Consider NP or OP airway during BVM
- Rapid sequence intubation
- Evaluate neck for landmarks associated with cricothyroidotomy and for SubQ emphysema or tracheal deviation
Breathing in trauma patient?
Patent airway DOES NOT mean adequate ventilation, which requires functioning lungs, chest wall, and diaphragm
Inspect - look for cyanosis, JVD (tension PT, cardiac tamponade), asymmetric movement of the chest (flail chest), accessory muscle use (tension PT), or open chest wounds (open PT)
Auscultate - listen for stridor (upper airway injury), lung breath sounds (PT or hemothorax)
Percuss - hyperresonance (PT) or dullness (hemothorax), subQ emphysema (airway injury), paradoxical movements (flail chest), crepitence and point tenderness (rib fractures), bruising (pulmonary contusion)
Why is tension pneumothorax so serious?
Formation of one-way valve at point of rupture in the lung -> air becomes trapped in the pleural cavity between the chest wall and lung, builds up, puts pressure on the lung, prevents full inflation
Hypotension develops due to increased intrathoracic pressure decreasing preload, loss of L heart blood flow due to loss of pulmonary vasculature to affected lung, compression of mediastinum
Rx tension pneumothorax?
14-16 gauge long angiocath inserted at midclavicular line in the second intercostal space over the 3rd rib to avoid the neurovascular bundle
Presentation of massive hemothorax?
Systemic or pulmonary vessel disruption leads to >1500 mL blood loss initially and 400 cc/hr for 2 hours
Neck veins expected to be flat but may be full due to supine position or associated tension PT or tamponade. Consider in those in sohck with no breath sounds and/or percussion dullness
Rx massive hemothorax?
Place large (36 F) chest tube and possible trip to OR for hemorrhage control
Circulation management in trauma?
Establish that the patient is getting adequate tissue perfusion and oxygenation
Control any active hemorrhage with direct pressure
Feel for pulses
If a radial pulse is palpable, it suggests a systolic BP of at least ___. If the femoral or carotid is palpable, these suggest a systolic BP of at least ___.
80; 60
What types of patients may not mount a tachycardic response to shock?
Neurogenic shock
Beta-blockers, CCBs
Elderly, children, young adults
Conditioned athletes start with a lower basal level (doubled resting heart rate of 45-50 shows a falsely reassuring HR of 90-100)
ATLS classifications of hemorrhagic shock (define by HR, BP, findings)
Class I: normal to fast HR, normal BP, no specific findings
Class II: normal to fast HR, normal to low BP, narrowed pulse pressure
Class III: fast HR, low BP, altered mentation
Class IV: fast HR, low BP, obtunded
ATLS classifications of hemorrhagic shock (blood loss and treatment)?
Class I: <15% blood loss, NS
Clas II: 15-30% blood loss, NS
Class III: 30-40% blood loss, NS + blood products
Class IV: >40% blood loss, NS + blood products
Disability assessment in trauma?
Quick check of neuro status - use the AVPU scale
Alert - fully awake
Voice - responds when verbally addressed (response can be verbal, motor, or with eyes)
Pain - makes a response on any of the three component measurements only when pain stimuli is delivered
Unresponsive - no eye, motor, or voice response to voice or painful stimuli
Gross motor/sensory exam to determine if CNS is intact (simple, not a full neuro exam)
Assess pupils (uncal herniation - blown pupil)
Log roll patient using spinal immobilization to palpate spine for step-offs or pain
GCS?
Eyes: Spontaneous (4), loud voice (3), pain (2), none (1)
Verbal: Oriented (5), Confused (4), Inappropriate words (3), Incomprehensible sounds (2), no sounds (1)
Motor: Obeys (6), Localizes to pain (5), Withdraws to pain (4), Abnormal flexion posturing (3), Abnormal extension posturing (2), None (1)
Assess Exposure/Environment in trauma patient?
Completely disrobe patient to assess for any hidden injury
Keep patient warm to prevent coagulopathy
Secondary Survey - history?
AMPLE history: Allergies Medications Past illnesses Last meal Events/environment/mechanism of injury
Secondary survey - physical?
Head to toe directed assessment focusing on:
- Head/CNS Trauma
- Motor Strength/Grading
- Facial Trauma
- C-spine/Neck exam
- Chest
- Abdomen
- Pelvis
- Perineum, Rectum, and Genital Exam
- MSK
Head/CNS trauma physical exam?
Skull fractures Axonal injuries Contusion Concussion Hemorrhage
Battle’s sign (ecchymosis behind ear, indicates basilar skull fracture)
Raccoon eyes (periorbital ecchymosis without edema, indicates skull fracture)
Cervical spine/neck trauma patient exam?
Blunt trauma - crushed larynx, tracheal disruption, expanding hematoma, esophageal leak
Penetrating trauma - injury to major vascular structures, pharynx, larynx, trachea, esophagus
Flexion, extension, rotational injuries may injur spine
Obstruction 2/2 trauma may be due to direct trauma to larynx or neck - may have inspiratory stridor (supraglottic) or expiratory stridor (subglottic), muffled voice, difficulty handling secretions
What must be done to clear the C-spine and remove the collar?
Alert and not intoxicated Absence of neck pain Absence of midline neck tenderness Absence of distracting injury Absence of sensory or motor complaint
Chest trauma patient physical exam?
Inspect for obvious injuries with consideration for mechanism
Palpate for subcutaneous emphysema and chest wall stability
Percuss for dullness or hyperresonance
Auscultate for diminished breath sounds
Some life threatening conditions to the chest in a trauma patient?
Tracheobronchial tree disruption (subQ emphysema) -> chest tube with failure of lung to inflate (persistent air leak), may need 2nd tube or OR
Pulmonary contusion (mild hypoxia that worsens after fluid resuscitation) -> Dx on CXR or CT, Rx by proper O2, ventilation, normovolemia
Blunt cardiac injury - abnormal EKG, echo with hypokentic heart; medicate dysrhythmias
Traumatic aortic disruption - rapid acceleration or deceleration injury, may be immediately fatal, widened mediastinum on CXR, confirm with CT or CTA, surgery
Flail chest - moves in opposite direction, disrupts normal negative-pressure ventilatory mechanisms
Abdomen trauma patient exam?
Bruising patterns (Cullen’s sign of periumbilical bruising, Grey-Turner’s sign of blank bruising, both associated with retroperitoneal hemorrhage, or seat belt sign)
Auscultate for absent or tympanic bowel sounds
Palpate and percuss for rebound tenderness, guarding, or diffuse dullness
Re-evaluate frequently
Pelvic trauma patient exam?
Pain/instability on palpation, unequal leg lengths
Can hide severe hemorrhage
Rx - stabilize by wrapping a sheet around it (compress), longitudinal traction, pelvic binders
GU exam in trauma patient?`
Examine perineum for contusions, scrotal hematomas, lacerations, or blood at the meatus
Rectal exam - diminished tone
Prostate - high-riding can be a sign of a pelvic fracture or urethral injury
Rectal wall integrity, gross blood
MSK trauma patient exam
Distal perfusion and neurovascular status (worry about compartment syndrome - pallor, pain, paresthesia, poikilothermia, pulselessness)
Diagnostic studies in trauma?
Tye and crossmatch CBC ABG and lactate BMP UA EtOH EKG if indicated AP chest and pelvic XR C-spine XR (lateral, AP, odontoid, oblique views)
CT FAST XR EKG Retrograde urethrogram if concern for urethral injury
