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

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

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

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

5. 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

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

7. 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

8. 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 mg
Elective Synchronized Cardioversion

9. 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 mg - 12 mg
Elective Synchronized Cardioversion

10. 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

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

12. 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

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

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

15. 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

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

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

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

19. 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

20. 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

21. 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.

22. 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

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

24. Effect of Ventilation on Venous Return

25. Effect of Ventilation on Venous Return

26. 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)

27. 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

28. 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

29. The UnConscious Patient

30. 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

31. 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

32. 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

33. 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

34. 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)

35. 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

36. 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)

37. 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

38. 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

39. 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

40. 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

41. 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

42. Thank You 