ACLS

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• ACLS

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ACLS General Objectives

• Suppress Arrhythmias
• Correct Hypoxemia
• Spontaneous Circulation

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Primary A-B-C-Ds

• A - Open Airway (Head tilt/chin lift)
• B - Provide Manual Ventilations (BVM)
• C - Chest Compressions (Pulses?)
• 302
• D - Defibrillate (As soon as Defib Avail)

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SECONDARY A-B-C-Ds

• A - Advanced Airway Control
• ET Tube-LMA-CombiTube
• B - Ventilation Adequacy
• Remember to use and End-Tidal CO2 or EDD
• C - Circulation Access
• D - Differential Diagnosis

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Identify the rhythm ?
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Defibrillate (Know your device)
What do you do first?

• Single Shock
• 360 Joules (mono phasic)
• Resume CPR (302)
• CHECK PULSE after 2 minutes of CPR
• Advanced Airway (ET,LMA)
• IV

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V-Fib / Pulseless V-Tach
Two Choices for 1st medication

• VASOPRESSIN..
• 40 Units
• IVP ONCE

• EPINEPHRINE..
• 1mg IVP q 3-5 min
• (Via ET 2 2.5 x the dose)

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Vasopressin

• Alternative vasopressor to Epinephrine in the
  Adult V-Fib Algorithm
• Can be given as either the first or second choice
  vasopressor
• Given as a single dose (40 Units) IV
• Epinephrine would still be used after 10-20
  minutes, if no response _at_ 1mg q 3-5 min.
  

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VF Cont.

• Defibrillation attempt(s) approx every 2 minutes
  or after each drug
• Focus is on proper CPR, O2 Defib.
• Still VF/Pulseless VT?
• Consider Anti-Arrythmics

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VF / VT Anti-Arrythmics

• AMIODARONE (preferred)
• 300 mg IV Push
• Repeat Once at 150 mg in 3-5 min
• LIDOCAINE
• 1- 1.5 mg/kg IVP
• Repeat at 0.50.75 mg/kg
• Total Dose 3 mg/kg

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Still VF/VT no Pulse?

• For Severe Refractory VF or Hypomagnesemia
• MAGNESIUM SULFATE
• 1-2 gm IVP (in 10cc D5W)
• For recurrent VF
• PROCAINAMIDE
• up to 50 mg/min - 17 mg/kg total dose

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Post Arrest

• Check Pulse
• Begin Anti-arrhythmic Drip
• Assess Hemodynamic status
• Hypotensive?

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Dopamine Dosage

• Recommended Range
• 2-20 microgram/kg/min

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Common IV Drips

• Lidocaine .. 1-4 mg/min
• Amiodarone..1.0 mg/min (6 hrs)
• 0.5 mg/min
• Procainamide1-4 mg/min
• Dopamine .2-20 microgm/kg/min

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Identify the rhythm ?
Pulseless
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IF ASYSTOLE

• Confirm by
• Check pulse
• Cable Connections
• Set on leads?
• Gain appropriate?
• Confirm second lead

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ASYSTOLE / PEA

• CPR - IV Advanced Airway
• Causes ?

• Toxins
• Tamponade
• Tension Pneumo
• Thrombosis
• Trauma

• Hypovolemia
• Hypoxia
• Hydrogen Ion (Acidosis)
• Hypo/hyperkalemia
• Hypoglycemia
• Hypothermia

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Meds
Two Choices for 1st medication

• VASOPRESSIN..
• 40 Units
• IVP ONCE

• EPINEPHRINE..
• 1mg IVP q 3-5 min
• (Via ET 2 2.5 x the dose)

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Meds

• Epinephrine/Vasopressin
• Atropine (if PEAlt HRlt60)
• 1.0 mg IVP q 3-5 Min
• Up to 3 doses (3mg)

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Identify the rhythm ?
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Bradycardia

• Defined as HR lt 60 or HR lt 65 with Symptoms
• O2 ? IV ? Vital Sign Monitoring
• Any Serious Signs Symptoms?
• (Low BP, Dyspnea, CP, etc)

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Signs Symptoms ?

• YES Treat
• ATROPINE 0.5mg IVP
• q 3-5 min
• Total dose 3 mg
• TCP

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Bradycardia Cont..

• Prepare for one of the following if TCP is
  ineffective or waiting for one to arrive
• Dopamine Drip... 2-20 ug/kg/min
• Epinephrine Drip 2-10 ug/min

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Tachycardias Is the patient Stable?
YES
NO

• Cardiovert
• Begin _at_ 100 J
• 50 J for SVT, A. Flutter

• Identify the Rhythm
• Administer appropriate
• Treatment

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Remember.

• Oxygen Start IV
• Obtain a 12 lead as early as possible

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Narrow SVT

• Diagnostics
• VAGAL MANEUVERS
• ADENOSINE
• 6 mg ? 12mg ? 12mg

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SVT Stable

• Diltiazem 0.25 mg/kg (15-20 mg) over 2 min
• Can repeat _at_ .35 mg/kg (20-25 mg)
• Amiodarone (150mg over 10 minutes)
• Beta Blockers
• Metoprolol Tartrate (5mg IV, total 15mg)
• Atenolol (5 mg IV, repeat in 10 minutes)
• Propanolol ( 0.1 mg/kg, 3 does max)
• Esmolol (0.5 mg/kg over 1 min)
• Labetalol (10mg IV over 1-2 min)

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Atrial Fibrillation

• If the AF is greater than 48 hours duration, the
  use of any agents to cease the rhythm should be
  preceded by anti-coagulation therapy prior to
  treatment.
• If stable with gt 48hrs, give anti-coag x 3
  weeks, perform DC Cardioversion, then 4
  additional weeks of anti-coagulation tx.

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Identify the rhythm?
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Stable Ventricular Tachycardia

• PROCAINAMIDE
• 20 mg/min
• OR
• AMIODARONE
• 150 mg over 10 minutes
• OR
• LIDOCAINE
• 1 -1.5 mg/kg IVP

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ProcainamideAdministration

• Arrhythmia Terminates
• Increase in Hypotension
• QRS Widens gt 50
• Total Dose 17 mg/kg

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• RHYTHM ANALYSIS TIPS
• FAST? SLOW?
• WIDE? NARROW?
• REGULAR? IRREGULAR?

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Some MI Tips
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Items of Immediate Assessment (lt10 min)

• Check vital signs with automatic or standard BP
  cuff
• Determine oxygen saturation
• Obtain IV access
• Obtain 12-lead ECG
• Obtain a brief, targeted history and perform a
  physical examination use checklist (yes-no)
  focus on eligibility for fibrinolytic therapy
• Obtain blood sample for initial cardiac marker
  levels
• Initiate electrolyte and coagulation studies

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Immediate General Treatment
MONA

• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain not relieved with
  nitroglycerin)

Review the Why? (actions), When? (indications),
How? (dose), and Watch Out! (precautions) of
these medications to consider in patients with
ischemic chest pain.
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Assess Initial 12-Lead ECG Findings

• ST depression or dynamicT-wave inversion
• strongly suspicious for ischemia
• High-risk unstable angina/nonST-elevation AMI

• Nondiagnostic ECG
• absence of changes in ST segment or T waves
• Intermediate/low-riskunstable angina

• ST elevation or new or presumably new LBBB
• strongly suspicious for injury
• ST-elevation AMI

fibrinolytic
percutaneous coronary intervention PCI)
PCI) (CABG)

• Classify patients with acute ischemic chest pain
  into
• 1 of the 3 groups above within 10 minutes of
  arrival.

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Acute Stroke Review
Triage/transfer to the most appropriate setting
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Different Causes of Collapse and Focal
Neurologic Deficits

• Hemorrhagic stroke
• Ischemic stroke
• Craniocerebral/cervical trauma
• Hypertensive encephalopathy

• Intracranial mass
• Meningitis/encephalitis
• Seizure
• Migraine
• Metabolic conditions (including hypoglycemia or
  hyperglycemia, drug overdose)

What further information would be helpful?
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Acute Stroke Algorithm

• Detection
• Dispatch
• Delivery
• Door

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Acute Stroke Algorithm

• Detection
• Dispatch
• Delivery
• Door

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Acute Stroke Algorithm

• Detection
• Dispatch
• Delivery
• Door

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Fibrinolytic Therapy Yes/No Checklist

• Inclusion Criteria
• (all Yes boxes must be checked before
• fibrinolytics are given)
• Yes
• ? Age 18 years or older
• ? Clinical diagnosis of ischemic stroke causing
  a measurable neurologic deficit
• ? Time of symptom onset well established to be
  lt180 minutes before treatment would begin

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The Stroke Chain of Survival Detection
Dispatch Delivery Door Data Decision
Drug

• The era of reperfusion, starring new
  fibrinolytic treatments, has revolutionized the
  treatment of ACS patients. This has not yet
  happened for acute stroke patients.
• The Stroke Chain of Survival, if aggressively
  applied in every community, has great potential
  to diminish the devastation of cerebrovascular
  disease.

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Identify the rhythm ?
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Identify the rhythm ?
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Identify the rhythm ?
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Identify the rhythm?
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Identify the rhythm ?
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