Advanced Cardiac Life Support (ACLS)

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.

7. http://www.youtube.com/watch?v=tVHJq9op5cw&feature=relmfu

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.)

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: Epinephrine2-10 µg/min2nd-line drugs to consider if atropine and/or TCP are ineffective.. • Danger: Dopamine2-10 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 • Yes • Shock cpr epinephrine airway • No • CPR x 2 minutes, treat causes

16. Mega code practice • http://www.acls.net/quiz.htm • http://www.mdchoice.com/cyberpt/acls/acls.asp