PROVIDED BY LIFE SUPPORT EDUCATIONAUGUST 2013

ACLSHELPFUL HINTS

Patient Assessment - Conscious Patient

Initial Assessment ABC’s12 Lead EKGExpert ConsultConsider Oxygen with O2 sat < 94%SAMPLE History

SAMPLE

Signs & SymptomsAllergiesMedicationsPast Pertinent Medical HistoryLast Oral IntakeEvents 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)

HypoxiaHypovolemiaHydrogen Ions

(Acidosis)Hypo/HyperkalemiaHypothermia

Hypoglycemia - not included

Tension PneumothoraxTamponade – CardiacThrombosis – CardiacThrombosis –

PulmonaryToxins

Trauma – Separate Considerations

H’s & T’s

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’s12 Lead EKGExpert ConsultConsider 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 Chest compressions – Look in Mouth – Attempt Ventilations

BVM Use

OPA (oropharyngeal airway) or NPA (nasopharyngeal airway)

Proper Placement of Advanced Airway

Airway Management

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

What it tells us:

ET Tube placement

PETCO2 < 10-ROSC unlikely (need to improve CPR technique)

Abrupt sustained increase in waveform - ROSC

Capnography

Capnography

Useful for 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 is used for verification of advance airway and for indication of return of spontaneous circulation (ROSC) during CPR.

7055402510 0m

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[1 Minute Interval]

45

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Capnography for ROSC

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 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 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