ACLS Review Introduction • Purpose of ACLS • Audience • How to succeed • Purpose of this presentation Science of Resuscitation • CPR is king • Chest recoil • CCF • ETCO2>10 mmHg • DBP>20 mmHg • Feedback devices CPR Coach • Team leader vs. CPR coach • Monitor person BLS • BLS before ALS • Sequence • Rate, depth, recoil • Pauses <10 s • 30:2 vs. continuous • AED • Child & infant Airway Management • Respiratory distress vs. failure • Oxygen devices & goals • ETCO2 • Need for ventilation and airway management • Basic airways • Advanced airways • BVM (1 & 2 person) • Don’t over-ventilate (q 6 s) Basic Airway Management Systematic Approach • Airway • Breathing • Circulation • Disability • Exposure • Vitals • O2 • Monitor • IV • Treatment H’s & T’s • Hypovolemia H’s & T’s • IV fluids • Hypoxia • Manage airway & high-flow oxygen • Hydrogen ions • Treat metabolic acidosis • Missed dialysis, DKA, toxins • IV sodium bicarbonate • Hypoglycemia** • Consider if <50 mg/dL • IV D50 or D10 Most Common H’s & T’s (cont.) • Hypo-/Hyperkalemia • Missed dialysis, DKA, diuretics • IV calcium, bicarbonate • Hypothermia • Rewarming as capable • Tension Pneumothorax • Chest trauma • Needle decompression, then chest tube • Tamponade • Chest trauma • Pericardiocentesis, OR • Toxins H’s & T’s (cont.) • Pupils, pupils, pupils • Opiates, BBs, CCBs, TCAs • Specific antidotes, dialysis, etc. – consult toxicology • Thrombosis, Pulmonary • Massive PE can cause sudden arrest • Hx & TTE • Fibrinolytics potentially • Thrombosis, Cardiac • MC cause of VFib & VTach is cardiac ischemia • Coronary catheterization High-Performance Teams • Importance of teamwork • Pre-charging monitor • Closed-loop communication • Clear roles & responsibilities • Understand your limitations ACS • Unstable angina, NSTEMI, STEMI • S&S of ACS • Retrosternal CP • Arm, jaw, neck, back pain • SOB • N/V • Diaphoresis • Fatigue • Most important screening tool ACS (cont.) • Initial Treatment • Oxygen • Aspirin • Nitroglycerin • • • Hypotension, tachycardia, bradycardia PDE-5 inhibitors Inferior (right-sided) MI • Opiate narcotics sildenafil – Viagra – 24 hrs vardenafil – Levitra – 24 hrs tadalafil – Cialis – 48 hrs ACS (cont.) • EMS notification • PCI & fibrinolytics • FMC-to-balloon – 90 minutes • FMC-to-needle – 30 minutes Stroke • Types of Strokes • Ischemic (87%) • Hemorrhagic (13%) • When to suspect stroke Stroke (cont.) • PHSS • Face • Arms • Speech • Time • LVO • Stroke centers & early notification Stroke (cont.) • CBG, 12-lead, labs • Non-contrast head CT w/i 20 min • TPA & EVT • 3 vs. 4.5 hrs • Give vs. withhold • Absolute vs. relative contraindications Cardiac Arrest • Being realistic • OHCA survival – 10% • Good neuro outcome in <10% • IHCA survival – 25% • Good neuro outcome in 73% • Outcome much better if shockable rhythm • Don’t forget BLS before ALS Tools • Electricity • Terminates fatal rhythm • Defibrillate at max setting • Electrical safety • Epinephrine • Given in every cardiac arrest • 1, 1, 2 agonist – inc. cardiac PP • Controversial drug • 1 mg IVP every 3-5 min • No max dose • Defibrillation 1. Select energy** 2. Charge 3. Clear 4. Shock • Amiodarone Tools (cont.) • Class III – K+ channel blocker • Terminates ventricular dysrhythmias • Initially 300 mg IVP • Repeat at 150 mg IVP after 5 min • Lidocaine • Class IB – Na+ channel blocker • Terminates ventricular dysrhythmias • Initially 1-1.5 mg/kg IVP • Repeat at 0.5-0.75 mg/kg IVP after 5 min • Max 3 mg/kg Cardiac Arrest Management • Recognize arrest early • Immediately begin CPR • Place pads and analyze rhythm • If it’s shockable, shock it • Begin 2 min cycles • 1:45 – Precharge monitor & find pulse** • 2:00 – Hold compressions, ID rhythm, shock if poss. • Check rhythm q 2 min – be prepared for rhythm • Continue until ROSC or d/c resusc. Shockable Arrest • Shockable Rhythms • • VTach VFib • Why shock? • Management • • • • • CPR Defibrillation Epinephrine Amiodarone or Lidocaine Correctable Causes • Recognize Arrest • Algorithm Immediate CPR + pads • Immediate Shock #1 • CPR (2 min) + IV/IO • Shock #2 • CPR (2 min) + 1 mg Epi + Adv. Airway (ETCO2) • Shock #3 • CPR (2 min) + Antidysrhythmic • H’s & T’s • Continue shocks + 1 mg Epi 3-5 min Non-Shockable Arrest • Non-Shockable Rhythms • Asystole • PEA • Why not shock? • Management • CPR • Early Epinephrine • Correctable Causes Algorithm • Recognize arrest • Immediate CPR + pads • IV/IO • Early Epi • Adv. Airway (ETCO2) • H’s & T’s • Reassess rhythm q 2 min Case • 55 yo male • Sudden LOC • BLS & 1° assessment • Immediate CPR • Pads & rhythm • Immediate shock • Resume CPR • 1 mg Epinephrine IVP • 300 mg Amiodarone IVP • • • • • • • Unresponsive, apneic, pulseless HR 0 BP UTO RR 0 SpO2 UTO Temp 36.5 CBG 104 PCAC • ROSC • • • in rhythm Inc. in ETCO2 Waveform on arterial line • Management • • • • • Advanced Airway Breathing (92-98% SpO2) Circulation (90 mmHg) Disability (32-36°C at least 24 hrs) Early EKG • Transport to PCI-capable facility Case • 55 yo male • Sudden LOC, VFib arrest • ETCO2 changes from 20 to 65 • Advanced Airway • SpO2 93% • BP 74/50, HR 74 • Unresponsive • 12-lead shows AFib TTM • Called therapeutic hypothermia • Targeted temperature management more accurate • 32 to 36°C for 24 hrs • Start ASAP • Post-Resuscitation Syndrome • Follow institutional protocols • Invasive temperature monitoring • Don’t prognosticate too early Bradycardia • Conduction system review • Rhythms • Sinus bradycardia • First degree block • Second degree type I block • Second degree type II block • Third degree block • Magic number is <50 Heart Block Review Rhythm PR Interval (120-200 ms) PR Interval P:QRS Ratio Sinus Bradycardia Normal Consistent 1:1 First Degree HB Long Consistent 1:1 Second Degree Type I HB Normal then Longer Lengthening Dropped QRS complexes Second Degree Type II HB Normal Normal Dropped QRS complexes Third Degree HB Erratic Erratic No connection Heart Block Review (cont.) Second Degree Type II Third Degree Heart Block Review (cont.) First Degree Second Degree Type I “Wenckebach” Bradycardia (cont.) • Symptomatic vs. “asymptomatic” • Signs of Hemodynamic Instability • Chest pain • Hypotension (<90 mmHg) • Acute AMS • Pulmonary edema/HF • Signs of shock Bradycardia (cont.) • Management • • • • • Treat the underlying cause Atropine • • • Anticholinergic Foot off the brake Unlikely to affect second degree type II or complete HB Positive Chronotropes • • Epinephrine or dopamine infusion Foot on the gas Pacing • • Use manual defibrillator 60 and 60 Expert consultation • Pacing 1. 2. 3. 4. 5. 6. Turn on pacer Set rate Set mAmp Ensure electrical capture Ensure mechanical capture Consider sedation Pacing Video Symptomatic? No Monitor + Expert Yes • Symptomatic Tx Underlying Cause (O2, tox, etc.) IV/IO + 1 mg atropine No Work Work Repeat atropine 1 mg PRN Max 3 mg Pacing +/- Infusion Expert Consultation TVP • HR <50 • Chest Pain • Hypotension • Acute AMS • Pulm. Edema/HF • Signs of Shock Case • 78 yo female • S/p hip replacement • C/o dizziness • ABCDE, VOMIT • 12-lead EKG • Atropine 1 mg IVP • TCP • What HR & mAmp • Expert consultation • • • • • • • Awake & alert HR 38 BP 78/49 RR 14 SpO2 90% Temp 37.2 CBG 98 • • • • • Responsive to pain HR 40 BP 72/50 RR 10 SpO2 96% Tachycardia • Rhythms • Sinus tachycardia • SVT • Atrial fibrillation • Atrial flutter • Pre-excitation tachycardia • Monomorphic ventricular tachycardia • Polymorphic ventricular tachycardia • Magic number is >150 Tachycardia (cont.) • Rhythms can be divided functionally • Narrow vs. wide • Regular vs. irregular • VTach w/ pulse vs. VTach w/o a pulse • Stable vs. unstable • If it ain’t broke, don’t fix it • Causes of Narrow-Complex Tachycardia Tachycardia (cont.) • Signs of Hemodynamic Instability • Chest pain • Hypotension (<90 mmHg) • Acute AMS • Pulmonary edema/HF • Signs of shock Tachycardia (cont.) • Management • Expert consultation • Electricity • Vagal maneuvers • Adenosine • • WPW Adenosine in VTach • Beta blockers • Calcium channel blockers • Synchronized Cardioversion 1. Press sync 2. Adjust energy 3. Consider sedation 4. Charge 5. Clear 6. Zap Yes Stable No QRS Wide Narrow Antidysrhythmic Infusion + Expert Irregular CCBs or BBs • Unstable Regularity Regular Vagal Maneuvers Adenosine 6 mg IVP Adenosine 12 mg CCBs or BBs • HR >150 • Chest Pain • Hypotension • Acute AMS • Pulm. Edema/HF • Signs of Shock Case • 26 yo male • PA student • C/o palpitations • ABCDE, VOMIT • 12-lead EKG • Vagal maneuvers • Adenosine 6 mg IVP • Uh oh – he had WPW • Synchronized cardioversion • • • • • • • Awake & alert HR 166 BP 110/78 RR 22 SpO2 95% Temp 37.5 CBG 115 • • • • • Unresponsive HR 240 BP 83/54 RR 14 SpO2 96% Review • BLS • CPR is king • Airway Management • BLS before ALS • Don’t overventilate • Systematic Approach • Focus on life threats • High-Performance Teams • Use your resources • Stay calm and be a leader Review (cont.) • ACS • CP = 12-lead EKG • OANO • PCI • Stroke • PHSS • Non-contrast head CT • TPA & EVT Review (cont.) • Cardiac Arrest • Shockable • • • • CPR Defibrillation Epinephrine Amiodarone or lidocaine • Non-Shockable • • • CPR Early epinephrine Correctable causes Review (cont.) • PCAC • Adv. Airway • Breathing (92-98%) • Circulation (SBP90) • Disability (32-36°C for 24 hrs) • Early EKG Review (cont.) • Bradycardia • HR <50 • Tx underlying causes • Atropine 1 mg • Can repeat up to 3 mg • Pacing • 60 and 60 • Infusion • Epinephrine or dopamine Review (cont.) • Tachycardia • HR >150 • Stable vs. unstable • If unstable → sync. cardioversion • If stable, consider wide vs. narrow • If wide, consult & antidysrhythmic infusion • If narrow & regular • • • Vagal maneuvers Adenosine 6 mg, then 12 mg BBs or CCBs • If narrow & irregular • BBs or CCBs Megacodes • Will probably get 3 different rhythms • E.g. bradycardia, then VFib, then ROSC • Stay calm, think on your feet • Work as a team • Closed loop communication • Use your resources Megacodes (cont.) • Positions • Team Leader • Compressors x2 • Monitor/CPR Coach • Airway • Access & Drugs • Recorder & Timer** Megacode Scenario • 54 yo male • S/p MI & stents • Severe crushing CP • ABCDE, VOMIT • 12-lead EKG • STEMI Alert & OANO • Sudden LOC • Rhythm change • • • • • • • Awake & alert HR 64 BP 165/78 RR 14 SpO2 91% Temp 36.9 CBG 87 Megacode Scenario • 87 yo male • Hx of CAD, DM, dyslipidemia • C/o palpitations • ABCDE, VOMIT • 12-lead EKG • Eyes roll back • Rhythm change • • • • • • • Awake & alert HR 154 BP 107/68 RR 16 SpO2 94% Temp 37.2 CBG 113 • • • • • Unresponsive HR 168 BP 76/68 RR 10 SpO2 85% • • • • • Unresponsive HR 0 BP UTO RR 0 SpO2 54% Summary • Keep it simple – manage ABCs • Don’t hesitate to reach out – agcobb1027@email.campbell.edu • Remember I’m not Dr. Finn