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Title: ACLS%20Review


1
ACLS Review
  • Jack Hornick
  • 7/28/15

2
Announced overhead
  • DR Heart
  • First floor
  • Atrium
  • DR Heart
  • First floor
  • Atrium

3
Who goes to the code
  • Interns, senior residents, AIs, and 3rd year
    medical students on Long Call on wards and in
    MICU
  • DACR/VACR/NACR
  • Anesthesia team
  • Respiratory Therapists
  • Critical care nurses (from MICU/CICU)
  • Critical care pharmacist (sometimes)

4
Who runs the code?
  • First resident on the scene, or DACR/VACR/NACR
  • The leader of the code assigns roles and
    responsibilities to the other residents and
    interns available

5
Roles during the code
  • Stabilizing/managing airway
  • Line for chest compressions
  • Recording timing of events
  • Managing code cart/ Medication administration
  • Checking labs and past medical history, telemetry
  • Obtaining emergency access
  • Thinking through Hs and Ts
  • Calling the patients family

6
Code Blue
  • You are the Naff intern on call, working on notes
    in the Naff team room. Code Blue is called for a
    patient on Lakeside 20. Your senior is MIA. You
    run down the hall and are the first on the scene.
    What do you do?

7
Scenario 1
  • You feel a thready femoral pulse, the patient
    feels tachycardic
  • Automatic blood pressure cuff is not reading
  • Patient is agonal breathing, not responding to
    verbal or painful stimuli
  • The nurses look to you and say Doctor, what do
    we do?

8
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9
  • On arrival, you do a quick initial assessment
    while assessing his responsiveness and vital
    signs and immediately instruct someone to begin
    compressions.
  • While compressions are occurring you ask the
    nurse to apply pads and electrodes to the patient
    to analyze the rhythm.
  • In addition, you ask that oxygen be applied to
    the patient
  • You ask about any complaints the patient may have
    had and find that minutes ago he was complaining
    of chest pain, palpitations, and dizziness.
  • Being a very keen intern, you recognize this may
    be Acute Coronary Syndrome causing arrest.

10
Cardiac Arrest, 4 rhythms
11
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12
  • As you pause during compressions you analyze the
    rhythm the patient is in Ventricular
    Fibrillation
  • The DACR runs into the room, you notify him/her
    of the patients rhythm and
  • ANALYZE.. CLEARSHOCK DELIVERED
  • Resume CPR! Wait to reanalyze the rhythm after
    the next round of CPR
  • The patient receives a dose of Epinephrine in
    addition to another shock and has conversion to
    sinus rhythm. He has ROSC. His vitals begin to
    improve and he is rushed to the Cardiac
    Catherization Lab.
  • Nice Work!

13
High quality CPR is key
  • Rate approx 100/min
  • Compression depth gt2 inches (5cm) in adults
  • Allow complete chest recoil after each
    compression
  • Minimize interruptions
  • Rotate every 2 minutes

14
Scenario 2
  • One of your many pagers on Intern Nightfloat goes
    off.
  • Theres a Code White on your patient in Lakeside
    55 her heart rate is a little low and shes
    feeling dizzy
  • You ask the nurse to get a full set of vitals as
    you head towards the patients room.
  • As youre headed over you hear the overhead
    announcement CODE BLUE, CODE BLUE, CODE
    BLUE..LAKESIDE 55

15
  • You arrive at the patients room and the nurse
    informs you that the patients HR was 60-70s
    during the day but suddenly decreased from 48 to
    35bpm.
  • Current vitals HR 35bpm, SBP 70/DBP is
    undetectable RR 16/min, and O2 saturation 93.
  • The patient was initially complaining of
    lightheadedness but now is more lethargic.
  • You take a look at the EKG that was obtained.

16
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17
  • You request oxygen be applied to the patient and
    the pads for transcutaneous pacing be applied.
  • Just as you are doing so, additional help arrives
    and your Nightfloat senior assists you.
  • Atropine is obtained from the crashcart and the
    patient is bolused 0.5mg.
  • The patients HR slightly improves to 49bpm but
    he remains somewhat confused and lethargic.
  • Transcutaneous pacing is started with a target HR
    of 60bpm. She begins to wake up and her BP
    improves to 110/57.
  • EP is consulted and the patient receives a
    transvenous and ultimately an implanted
    pacemaker.

18
Last Scenario
  • You are on Hellerstein waiting to sign out at 630
    pm on a Sunday when youre paged about a patient
    with past hx of SVT here for CP now has a HR of
    160.
  • BP 125/80, narrow complex tachycardia as below

19
  • After attempting vagal maneuvers (unsuccessful)
    you give adenosine 6mg IV push, and then 12 mg IV
    push
  • Now the patient develops severe chest pain, He
    220, BP not obtainable, pulse weak. The patient
    begins losing consciousness. What do you do next?

20
  • Synchronized cardioversion is unsuccessful.
    Patient now is pulseless and unconscious.
  • What next? Time to shock! (unsynchronized 120-200
    J)

21
Synchronized vs unsynchronized cardioversion
  • Synchronized
  • Low energy shock
  • delivers shock w/ peak of QRS
  • Indications unstable A fib, A flutter, SVT
  • If shock occurs on t-wave, high likelihood of VF
  • Unsynchronized
  • High energy shock
  • delivers as soon as shock button is pushed
  • Indications pulseless VT/VF

22
  • After 5 cycles of CPR, the rhythm check suggests
    a second shock. Now with 200 J. Which medications
    should you be giving?
  • Epinephrine 1mg IV q3min and/or vasopressin 40 U
    IV to replace first or second epi dose
  • Amiodarone after 3rd shock in pulseless VT (300
    mg IV x1, then consider 150 mg IV x1

23
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24
  • SROC! The patient was intubated by anesthesia at
    the scene, and is not responding to verbal
    commands. Patient transported to CICU. What post
    cardiac arrest intervention would this patient
    benefit from?

25
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26
What Is ACLS?
  • ACLS guidelines first published 1974 by AHA, most
    recent update 2010
  • A series of interventions for urgent treatment of
    cardiac arrest, stroke, and life threatening
    medical emergencies
  • Several algorithms for VF/Pulseless VT,
    Bradycardia, Suspected Stroke
  • An essential part of using the algorithm
    correctly is to search for and correct
    potentially reversible causes of arrest
  • Performing high quality CPR, identifying
    arrhythmias and understanding the pharmacology
    behind key drugs are central to ACLS.

27
Hs and TsTreatable causes of cardiac arrest
  • Hypoxia
  • Hypovolemia
  • Hydrogen ion (acidosis)
  • Hypokalemia
  • Hyperkalemia
  • Hypothermia
  • Thrombosis (pulmonary)
  • Thrombosis (coronary)
  • Tamponade
  • Tension pneumothorax
  • Toxins

28
Things to discuss with patients
  • All patients admitted to the hospital should be
    asked about their code status
  • Its important to discuss the morbidity
    associated with ACLS
  • Statistics regarding survival after arrest
  • Adverse outcomes of CPR and Advanced Airway
    Support

29
  • Dont forget to pick up your ACLS cards from the
    chiefs office!
  • Remember to check your own pulse first.
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