1. ACLS Overview Kevin Mikielski, DO January 16, 2007

2. Initial Evaluation and Management

3. Immediately call for backup and crash cart Immediately call for backup and crash cart Keep your cool Keep your cool Assess for responsiveness Assess for responsiveness Promptly feel for pulse Promptly feel for pulse Don’t waste time Don’t waste time Won’t harm patient by doing CPR if they have a pulse Won’t harm patient by doing CPR if they have a pulse DEFINITELY WILL NOT HELP PATIENT IF YOU THINK YOU FEEL A PULSE BUT THEY ARE ACTUALLY PULSELESS DEFINITELY WILL NOT HELP PATIENT IF YOU THINK YOU FEEL A PULSE BUT THEY ARE ACTUALLY PULSELESS Happens 10-20% of the time to us Happens 10-20% of the time to us

4. Initial Evaluation and Management Start CPR immediately if no pulse Start CPR immediately if no pulse Chest compressions are much more important than ventilation, especially initially Chest compressions are much more important than ventilation, especially initially Critical to maintain cerebral and coronary perfusion Critical to maintain cerebral and coronary perfusion Increases the likelihood of successful debrillation of VF Increases the likelihood of successful debrillation of VF Compress with base of hand over lower sternum Compress with base of hand over lower sternum 1.5 to 2 inches of compression 1.5 to 2 inches of compression Rate of 100/minute Rate of 100/minute Avoid interruption of compressions; if need to cease compressions, be brief and resume promptly Avoid interruption of compressions; if need to cease compressions, be brief and resume promptly Begin ventilations with Ambu bag at ratio of 30:2 Begin ventilations with Ambu bag at ratio of 30:2 Intubate but do not delay defibrillations in order to intubate Intubate but do not delay defibrillations in order to intubate Once intubated, ventilate at 8-12 breaths per minute Once intubated, ventilate at 8-12 breaths per minute Do not overventilate as this results in decreased cardiac output and possibly pneumothorax Do not overventilate as this results in decreased cardiac output and possibly pneumothorax

5. Initial Evaluation and Management Quickly analyze rhythm on telemetry or defibrillator Quickly analyze rhythm on telemetry or defibrillator Determine if rhythm is suitable for defibrillation Determine if rhythm is suitable for defibrillation Need to have an underlying rhythm to “shock” Need to have an underlying rhythm to “shock”

6. Defibrillation vs Cardioversion

7. Defibrillation is form of cardioversion Defibrillation is form of cardioversion Also known as “unsynchronized” cardioversion Also known as “unsynchronized” cardioversion “Shocks” immediately without sensing underlying rhythm “Shocks” immediately without sensing underlying rhythm Cardioversion is also referred to as synchronized cardioversion because it “senses” the underlying rhythm and delivers shock at peak of R wave to avoid shocking at time to result in R on T phenomenon and subsequent VF Cardioversion is also referred to as synchronized cardioversion because it “senses” the underlying rhythm and delivers shock at peak of R wave to avoid shocking at time to result in R on T phenomenon and subsequent VF

8. How does defibrillation/cardioversion work? Does not “shock” heart back to normal rhythm Does not “shock” heart back to normal rhythm Induces asystole Induces asystole Allows heart’s normal intrinsic pacemakers to discharge Allows heart’s normal intrinsic pacemakers to discharge May take seconds to minutes May take seconds to minutes May have period of PEA or asystole following shocks May have period of PEA or asystole following shocks

9. Defibrillation vs Cardioversion Best positioning of pads in AP Best positioning of pads in AP Usually position pads or paddles over sternum and apex Usually position pads or paddles over sternum and apex If attempting defibrillation, make sure that mode is set to UNSYNCHRONIZED cardioversion If attempting defibrillation, make sure that mode is set to UNSYNCHRONIZED cardioversion If in Synch mode, nothing will happen If in Synch mode, nothing will happen If attempting cardioversion, make sure mode is set to SYNCHRONIZED cardioversion If attempting cardioversion, make sure mode is set to SYNCHRONIZED cardioversion May need to hold/press button for a few seconds until R waves are sensed May need to hold/press button for a few seconds until R waves are sensed

10. Defibrillation vs Cardioversion Energies utilized depend on type of device Energies utilized depend on type of device Monophasic device Monophasic device At our institution At our institution Defibrillation: 360 J Defibrillation: 360 J Cardioversion: Cardioversion: A fib-100 J A fib-100 J PSVT, A flutter-50J PSVT, A flutter-50J “Stable” VT-100 J “Stable” VT-100 J Biphasic device Biphasic device Lower Joules because device determines impedence and adjusts energy delivered Lower Joules because device determines impedence and adjusts energy delivered

11. Defibrillation vs Cardioversion Defibrillator rhythms Defibrillator rhythms Pulseless VT Pulseless VT Ventricular fibrillation Ventricular fibrillation Torsades de Pointes Torsades de Pointes Cardioversion rhythms Cardioversion rhythms Atrial fibrillation Atrial fibrillation Atrial flutter Atrial flutter PSVT PSVT “Stable” VT “Stable” VT

12. Defibrillation vs Cardioversion DO NOT SHOCK: DO NOT SHOCK: BRADYCARDIA BRADYCARDIA ASYSTOLE ASYSTOLE Unless you think it may be fine ventricular fibrillation Unless you think it may be fine ventricular fibrillation SINUS TACHYCARDIA SINUS TACHYCARDIA PULSELESS ELECTRICAL ACTIVITY PULSELESS ELECTRICAL ACTIVITY Avoid cardioversion in patients with atrial fibrillation who are on digoxin and are hypokalemic Avoid cardioversion in patients with atrial fibrillation who are on digoxin and are hypokalemic May precipitate VF or asystole May precipitate VF or asystole

13. Defibrillation vs Cardioversion Immediately resume CPR following defibrillation Immediately resume CPR following defibrillation May have period of asystole or PEA following defibrillation May have period of asystole or PEA following defibrillation Constantly assess rhythm Constantly assess rhythm Check for pulse in 2-3 minutes Check for pulse in 2-3 minutes

14. Defibrillation vs Cardioversion Be aggressive with pressors/fluids Be aggressive with pressors/fluids Remember to obtain stat labs/EKG/CXR Remember to obtain stat labs/EKG/CXR Go with patient to ICU as many patients “recode” Go with patient to ICU as many patients “recode”

15. Rhythms

16. VENTRICULAR TACHYCARDIA

17. VENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA

18. VENTRICULAR TACHYCARDIA

19. VENTRICULAR FIBRILLATION

21. Torsades de Pointes

22. TORSADES DE POINTES

23. ASYSTOLE

26. Pulseless Electrical Activity Immediately need to think of causes Immediately need to think of causes Hypovolemia Hypovolemia Hypoxia Hypoxia Hypothermia Hypothermia Hyper or hypokalemia Hyper or hypokalemia Severe acidosis Severe acidosis Massive PE Massive PE Massive MI Massive MI Tamponade Tamponade Tension pneumothorax Tension pneumothorax Drug overdose Drug overdose TCAs, antiarrhythmics, digoxin

28. No indication for pacing based on current guidelines No indication for pacing based on current guidelines

31. Case Studies

32. Case 1 58 year old female 58 year old female Hx of CAD Hx of CAD LVEF 15% LVEF 15% Sitting in chair and feels “weak” Sitting in chair and feels “weak” Nursing student is there are sees patient start to seize Nursing student is there are sees patient start to seize Monitor shows: Monitor shows:

34. Case 2 42 year old AA male 42 year old AA male Hx of end-stage renal disease on HD Hx of end-stage renal disease on HD Has missed HD for past week Has missed HD for past week Presents to ED feeling “weak” and “sick” Presents to ED feeling “weak” and “sick” Vital signs: BP 80/40, P 130 (sinus), RR 22 Vital signs: BP 80/40, P 130 (sinus), RR 22 “Funny sound” on cardiac auscultation “Funny sound” on cardiac auscultation Several PVCs on monitor Several PVCs on monitor Suddenly becomes unresponsive and pulseless Suddenly becomes unresponsive and pulseless EKG shows: EKG shows:

39. Case 3 42 year old AA male 42 year old AA male Hx of end-stage renal disease on HD Hx of end-stage renal disease on HD Has missed HD for past week Has missed HD for past week Presents to ED feeling “weak” and “sick” Presents to ED feeling “weak” and “sick” Vital signs: BP 80/40, P 130 (sinus), RR 22 Vital signs: BP 80/40, P 130 (sinus), RR 22 Several PVCs on monitor Several PVCs on monitor Suddenly becomes unresponsive and pulseless Suddenly becomes unresponsive and pulseless EKG shows: EKG shows:

43. Case 4 56 yo female 56 yo female Admitted to ICU with midepigastric discomfort and nausea with vomitus x 1 Admitted to ICU with midepigastric discomfort and nausea with vomitus x 1 Diagnosed with pancreatitis in ER Diagnosed with pancreatitis in ER Amylase 250, lipase 200; liver enzymes ok Amylase 250, lipase 200; liver enzymes ok Hemodynamically stable but HR periodically in 50s with 1 st degree AV block per ER doctor; no acute ST segment changes Hemodynamically stable but HR periodically in 50s with 1 st degree AV block per ER doctor; no acute ST segment changes EKG reveals: EKG reveals:

45. The next morning: BP 60/30, P 40

46. Case 5 70 yo white male 70 yo white male Hx CABG Hx CABG Admitted with chest pain and dyspnea Admitted with chest pain and dyspnea Troponin 14; EKG NS ST/T changes Troponin 14; EKG NS ST/T changes Sx improved with asa, plavix, heparin, integrillin, metoprolol, ntg gtt Sx improved with asa, plavix, heparin, integrillin, metoprolol, ntg gtt Awaiting transfer for LHC/SCA Awaiting transfer for LHC/SCA Suddenly becomes unresponsive in ICU and telemetry shows: Suddenly becomes unresponsive in ICU and telemetry shows:

48. Weak Pulse

50. No pulse

51. Pulse

52. Pulse

53. Case 6 32 year old white female 32 year old white female Smoker Smoker POD 1 following TAH w BSO develops mild dyspnea and “a funny feeling in my chest” POD 1 following TAH w BSO develops mild dyspnea and “a funny feeling in my chest” Vital signs stable; mild fever 100 F Vital signs stable; mild fever 100 F Symptoms improved with nebulizer and O2 Symptoms improved with nebulizer and O2 Probably secondary to atelectasis Probably secondary to atelectasis

54. Next day develops worsening dyspnea with SaO2 of 88% on 4L Next day develops worsening dyspnea with SaO2 of 88% on 4L BP 86/54 and Pulse 130; RR 22 BP 86/54 and Pulse 130; RR 22 CXR: Probable RLL atelectasis vs infiltrate CXR: Probable RLL atelectasis vs infiltrate EKG reveals: EKG reveals:

56. Twenty minutes later, she collapses and is pulseless...

57. No pulse

58. Pulse

59. Case 7 78 yo admitted with severe nausea, abdominal pain, and diarrhea 78 yo admitted with severe nausea, abdominal pain, and diarrhea Baseline EKG reveals sinus rhythm with 1 st degree AV block, RBBB and LAFB Baseline EKG reveals sinus rhythm with 1 st degree AV block, RBBB and LAFB Occasional brief “pauses” on monitor when abdominal pain increases Occasional brief “pauses” on monitor when abdominal pain increases Develops intractable nausea and abdominal pain Develops intractable nausea and abdominal pain Vital signs BP 70/45, P 32 Vital signs BP 70/45, P 32

60. Pulse

63. Pulse

64. Case 8 25 yo white female 25 yo white female On Behavioral Health floor On Behavioral Health floor On Risperdal, Haldol, Amitryptyline On Risperdal, Haldol, Amitryptyline Develops palpitations Develops palpitations Hemodynamically stable Hemodynamically stable

65. Weak Pulse

67. End of Lecture Thank you for your attendance.