Provided by Life Support Education August 2013 ACLS HELPFUL HINTS Provided by Life Support Education August 2013

Patient Assessment - Conscious Patient Initial Assessment ABC’s 12 Lead EKG Expert Consult Consider Oxygen with O2 sat < 94% SAMPLE History

SAMPLE Signs & Symptoms Allergies Medications Past Pertinent Medical History Last Oral Intake Events Leading Up to Event

Patient Assessment - Stable Considerations for patients with perfusing rhythms who are Stable ABC’s V/S Oxygen if Hypoxic Monitor Peripheral IV Access

Patient Assessment - Stable Bradycardic Patients – HR <50 usually for treatment Monitor patient for change in mental status Any Bradycardia that is symptomatic needs treatment with Atropine 0.5 mg (maximum dose – 3 mg) Pressors – Epinephrine 2 – 10 mcg/min Dopamine 2 – 10 mcg/kg/min Pacing

Patient Assessment - Stable Tachycardic Patients – Sinus Tach 100-150 bpm ABC’s 12 Lead EKG Treatable Causes (H’s & T’s)

H’s & T’s Hypoxia Hypovolemia Hydrogen Ions (Acidosis) Hypo/Hyperkalemia Hypothermia Hypoglycemia - not included Tension Pneumothorax Tamponade – Cardiac Thrombosis – Cardiac Thrombosis – Pulmonary Toxins Trauma – Separate Considerations

Patient Assessment - Stable Narrow complex tachycardia – (SVT) – Supraventricular Tachycardia Rate >150 – 220 bpm ABC’s 12 Lead EKG Expert Consult Vagal Maneuvers Adenosine 6 mg - 12 mg Elective Synchronized Cardioversion

Patient Assessment - Stable Wide complex tachycardia – Ventricular Tachycardia ABC’s 12 Lead EKG Expert Consult Amiodarone 150 mg/100cc D5W or NS Administer over 10 minutes Adenosine 6 mg - 12 mg - 12 mg Elective Synchronized Cardioversion

Acute Coronary Syndrome Substernal Chest Pain – Radiation – SOB Patient History ASA 160 mg – 325 mg for ACS 12 Lead EKG SL NTG - Hold if right ventricular infarct suspected Hold if taken phosphodiesterase inhibitors within 48 hours Hold for severe bradycardia or tachycardia Hold if systolic BP 90 mmHg or less

Acute Coronary Syndromes Peripheral IV Access for medication administration Morphine if chest pain continues Preparation for PCI

Suspected Stroke Weakness – facial droop – pronator drift ABC’s Oxygen if needed IV Access Glucose testing – fingerstick – lab Neurologic screening include time of symptom onset Activate Stroke Team/Transport to Stroke Center

Suspected Stroke Patient History Patient Stable - Head CT Scan – (R/O - Ischemic vs. Hemorrhagic) 12-Lead EKG rtPA Candidate (Yes/No)

Patient Assessment - Conscious Patient Initial Assessment ABC’s 12 Lead EKG Expert Consult Consider Oxygen with O2 sat < 94% SAMPLE History

Patient Assessment – Unstable Patients with perfusing rhythms who are Unstable Atropine 0.5 mg if V/S indicate bradycardia/hypotension Airway management if not breathing and heart rate decreasing

Patient Assessment – Unstable Synchronized Cardioversion indicated for SVT and/or VT with hypotension Sedation if time

Synchronized Cardioversion Narrow Complex Tachy or Atrial Flutter – 50 – 100 joules Atrial Fibrillation – 120 – 200 joules Wide Complex Tachy – 100 joules

Patients in Respiratory Arrest Patent Airway – (Yes/No) Agonal Respirations Ventilations – 1 every 5 – 6 seconds (10 – 12/min) Advanced Airway Indicated – (Yes/No)

Airway Management Relief of FBAO in Unresponsive Victim BVM Use Chest compressions – Look in Mouth – Attempt Ventilations BVM Use OPA (oropharyngeal airway) or NPA (nasopharyngeal airway) Proper Placement of Advanced Airway

Airway Management Cricoid Pressure ETT/King/LMA – Continuous compressions without pauses for ventilations Ventilations: 1 every 6 – 8 seconds (8-10 BPM) Suction if needed on withdrawal and for 10 seconds or less Advanced airway verified – Listen Colormetric CO2 Device Waveform Capnography Cricoid Pressure Do not use if it impedes ventilation or advanced airway placement Not recommended in cardiac arrest airway management

Oxygenation vs. Ventilation Oxygenation- Amount of Oxygen in the blood Prolonged high concentrations may cause oxygen toxicity SaO2 of 100% may equal PO2 of 800 Maintain SaO2 at 94-99% Ventilation-Rate at which we ventilate Hyperventilation decreases venous return which decreases blood flow to the heart and lungs. Hyperventilation causes cerebral vasoconstriction which decreases cerebral blood flow.

Why not hyperventilate? When we breath normally…. It is negative-pressure ventilation Helps venous return to the heart When we stop breathing…… Lose benefit of negative pressure and venous return

Why not hyperventilate? When Delivering Positive Pressure Ventilations… Prevents venous return Every ventilation increases intrathoracic pressure for 2 seconds

Effect of Ventilation on Venous Return

Effect of Ventilation on Venous Return

Capnography What it tells us: ET Tube placement PETCO2 < 10-ROSC unlikely (need to improve CPR technique) Abrupt sustained increase in waveform - ROSC Note: there will be a transient rise in PETCO2 following Bicarb. Administration> do not mistake this for more effective CPR or return of spontaneous circulation (ROSC)

Capnography Useful for Intubation- not a must if able to ventilate Compression effectiveness (if PETCO2 less than 10 need to improve compressions) Airway- ET Tube placement verification Pulse- ROSC (sudden increase in waveform) Intubation- not a must if able to ventilate But….. Better CPR Use of Capnography

Capnography for ROSC 70 55 40 25 10 mm Hg [1 Minute Interval] Capnography is used for verification of advance airway and for indication of return of spontaneous circulation (ROSC) during CPR. Capnography tracing displaying the PETCO2 in mm Hg on the vertical axis over time. This patient is intubated and receiving CPR. Note that the ventilation rate is approximately 8 to 10 breaths per minute. The initial PETCO2 is less than 12.5 mm Hg during the first minute, indicating very low blood fl ow. The PETCO2 increases to between 12.5 and 25 mm Hg during the second and third minutes, consistent with the increase in blood flow with ongoing resuscitation. Return of spontaneous circulation (ROSC) occurs during the fourth minute. ROSC is recognized by the abrupt increase in the PETCO2 (visible just after the fourth vertical line) to over 40 mm Hg, which is consistent with a substantial improvement in blood fl ow. 4 5

The UnConscious Patient

Patient Assessment - Unconscious Check Responsiveness Observe chest for breathing Call for help & ask for AED if available Check Pulse (5 – 10 seconds) Begin Chest Compressions if Needed

Patients in Cardiac Arrest CPR Produces blood flow through coronary arteries to the heart Never interrupt for more than 10 seconds Prolonged interruptions in compressions can be fatal for victim Shockable Rhythm vs. Non-Shockable Rhythm Shockable- VF & Pulseless VT (Torsade-de-pointes) Non-Shockable – PEA & Asystole

CPR Interventions Compression rate – “at least” 100/minute Depth of Compressions – 2 inches (at least) Allow for complete chest recoil after each compression Rotate Compressors every 2 minutes Continue compressions while defibrillator charges Ratio – 30:2 until advanced airway inserted

CPR Interventions Paddles vs. Pads Withholding or Terminating CPR Pads – more rapid defibrillation Paddles – circumstances where pads cannot be used Burns/surgeries/other considerations Withholding or Terminating CPR Scene Safety Obvious death Evidence of rigor mortis Prolonged or deteriorated arrest following a lengthy arrest attempt

Patients in Shockable Rhythm VF/Pulseless VT – (Torsade-de-pointes) Defibrillation (Unsynchronized cardioversion) 120 j – 150 j – 200 j (at appropriate intervals) Access – IV/IO Medication Administration During CPR (allows circulation before defibrillation) Epinephrine – 1mg 1:10,000 IV/IO Push – Flush – CPR - Defib Amiodarone – 300 mg IV/IO Push – Flush – CPR – Defib Other Considerations based on identified cause (H’s & T’s)

Patients in Non-Shockable Rhythm PEA (Pulseless Electrical Activity) & Asystole CPR – Compression rate – “at least” 100/minute Out of hospital personnel should contact medical control for orders to terminate resuscitation efforts in extended CPR events Rotate Compressors Ratio – 30:2 until advanced airway inserted

Patients in Non-Shockable Rhythm Access – IV/IO Medication Administration Give during CPR Epinephrine – 1mg 1:10,000 IV/IO – Push - CPR Other Considerations based on identified cause (H’s & T’s)

Post Arrest Care Maximize Oxygenation & Ventilation Fluid for Hypotension 1 – 2 L/IV Fluid Bolus if hypotensive (Systolic BP < 90 mmHg) Maintain Systolic BP at 90/mmHg or greater Pressors for Hypotension IV Epinephrine – 0.1 – 0.5 mcg/kg/minute IV Dopamine – 5 – 10 mcg/kg/minute

Post Arrest Care PCI considerations (In-hospital/Out-of-Hospital) Out of hospital personnel should transport patients with ROSC to a hospital capable of performing PCI Prevent Oxygen toxicity – Maintain SaO2 at 94% – 99% Target PETCO2 to 35 – 40 mmHg Do not hyperventilate the patient

Post Arrest Care Hypothermia Protocol Follow Up Patient Remains Unresponsive to Verbal Commands Maintain core temperature at 32 – 34 degrees Celsius for 12 to 24 hours Follow Up

Additional Information The Medical Emergency Team (MET) or Rapid Response Team (RRT) can help improve patient outcomes by identifying and treating early deterioration of the patient ! Pulse checks – NO!! Following defibrillation of VF/Pulseless VT - chest compressions ! Organized rhythm on monitor following 2 minutes of CPR – Ok NOTE: Zoll Defibrillators have “See-through” CPR (bottom rhythm is patient’s rhythm) Keep O2 away from the patient and bedding during defibrillation to avoid fire risk

AED’s Use the AED when it arrives Early defibrillation is essential in BLS survey if indicatead Malfunctioning AED – begin chest compressions Special Considerations Snow – use AED Puddles of Water – move victim

Thank You 