1. Advanced Cardiac Life Support (ACLS)
By: Diana Blum MSN
Metropolitan Community College
Nursing 2150

2. STABLE
 These patients generally have an EKG rhythm that is undesirable.
their vitals signs are stable
they have no complaints such as, shortness of breath, chest pain or confusion.
if rhythm untreated the patient may become ____________.

3. UNSTABLE These patients also have an EKG rhythm that is undesirable.
vital signs are not stable!
Other sign and symptoms: low blood pressure, shortness of breath, chest pain or confusion.
if the rhythm is not treated the patient may die..
BE AGGRESSIVE in approach in unstable patients.
You should always do CPR until code cart is available. Rhythms Too fast; like ventricular tachycardia, or ventricular fibrillation we defibrillate. Absent, as in asystole we pace with a Trans Cutaneous Pacing patches.

4. DEAD These patients also have an EKG rhythm that is undesirable.
vital signs are absent! They have no pulse!
Your first thought for intervention is SHOCK EM! Especially if witness going down.
Step 2 CPR. ---new protocol is compressions compressions compressions!
The last intervention in order is MEDICINE.
"all dead people get epinephrine, the deader they are, the more epinephrine they get!"
American Heart studies show that the sooner electrical intervention is introduced, the better the outcome for survival!
Your second intervention is CPR. Think of CPR as your bridge and time-buyer.
Good CPR keeps the vital organs per fused until your electrical and drugs can do their job.
Always make good CPR a priority.

5. Primary Survey
Airway: Open airway, look, listen, and feel for breathing
Breathing: If not breathing slowly give 2 rescue breaths. If breaths go in continue to next step.
Circulation: check pulse 5-10 seconds
Defibrillation: Search for a shockable rhythm like vtach/vfib

6. Adult ACLS Secondary Survey ABCDs (abbreviated)
Airway: Intubate if not breathing. Assess bilateral breath sounds for proper tube placement.
Breathing: Provide positive pressure ventilations with 100% O2.
Circulation: If no pulse continue CPR, obtain IV access, give proper medications.
Differential Diagnosis: Attempt to identify treatable causes for the problem.

8. Pulseless Electrical Activity, or PEA
This is a condition where you have some electrical activity but not mechanical activity.
AKA: no pulse is present.
You can have a normal sinus rhythm, but if there is no pulse, the condition is called PEA.
If you have a patient with the condition of PEA, and the rhythm is a slow wide ventricular rhythm, you may want to try TCP.

9. PEA
Problem search..Treat accordingly. (see differential diagnosis table)
Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi.
Atropine 1 mg IV/IO q3-5 min. (3mg max.)

10. condition
Assess
Intervention
Pulmonary Embolism
No pulse w/ CPR, JVD
Thrombolytics, surgery
Acidosis (preexisting)
Diabetic/renal patient, ABGs
Sodium bicarbonate, hyperventilation
Tension pneumothorax
No pulse w/ CPR, JVD, tracheal deviation
Needle thoracostomy
Cardiac Tamponade
No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest
Pericardiocentesis
Hyperkalemia (preexisting)
Renal patient, EKG, serum K level
Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate
Hypokalemia
EKG, serum K level
Treat with great prudence after careful assessment of the cause. K can kill.
Hypovolemia
Collapsed vasculature
Fluids
Hypoxia
Airway, cyanosis, ABGs
Oxygen, ventilation
Myocardial infarct
History, EKG
Acute Coronary Syndrome algorithm
Drugs
Medications, illicit drug use, toxins
Treat accordingly
Shivering
Core temperature
Hypothermia Algorithm

11. ELECTRICAL!
If the rhythm is too fast, the goal is to slow it down and convert it
use synchronized cardioversion.
If too slow the goal is to speed it up,
use external transcutaneous pacing or TCP.
“ how do I know when to pace, defibrillate, or use synchronized cardioversion?"
HINT: D=Deceased,
only defibrillate fast rhythms!
look at suspected asystole in more that one ekg lead, to confirm asystole.

12. Bradycardia
HR (<60bpm) or relative (slower rate than expected) bradycardia with circulatory compromise. Start the Secondary ABCDs
Pacing:Immediately prepare for transcutaneous pacing related to bradycardia (especially high-degree blocks) or if atropine failed to increase rate.
Always Atropine1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg)
Ends: Epinephrine µg/min2nd-line drugs to consider if atropine and/or TCP are ineffective..
Danger: Dopamine µg/kg/min
*pacing may not work every time with brady arrhythmias. If the above measures do not improve circulatory stability the bradycardia may be from other issues, think differential diagnosis! (Refer to slide 10)

13. Cardioversion Synchronized Electrical Cardioversion
the following mnemonic directs preparations for synchronized electrical cardioversion of unstable tachycardia with fast rate (do not delay shocking if seriously unstable)
Oh O2 Saturation monitor
Say Suctioning equipment
It IV line
Isn't Intubation equipment
So Sedation and possibly analgesics
**Synchronized Electrical Cardioversion *Energy Levels:The initial synchronized shock is 100J monophasic (50J for SVT/A-Flutter) with increasing energy, i.e., 200J, 300J, 360J, if successive shocks are needed.

14. Adult Cardiac Arrest

15. 1st Start CPR
Is the rhythm shockable? Yes or No
If shockable (VF/VT)? Yes or NO
If not shockable(Asystole)? Yes or NO
If VF/VT
Shock
CPR x 2 minutes
Get IV/IO access
Reanalyze (shockable??)
Yes
Shock then CPR x 2minutes and or epinephrine/capnography NO
CPRx 2 minutes, epinephrine/ Airway
Repeat steps as needed
Asystole
CPR x 2 minutes, , epinephrine/ Airway
Reanalyze
Shockable
Shock cpr epinephrine airway No
CPR x 2 minutes, treat causes

16. Mega code practice http://www.acls.net/quiz.htm