ACLS Notes
CPR Physiology:
CPR produces 10-20% of CO, up to BP of 100mmHg Systolic
Changes in thoracic AP diameter keep blood moving (not heart compression)
Compression/Decompression (toilet plunger theory) more effective
Myocardial Perfusion:
Aortic root pressure: coronary a.’s hi pressure is good (ie Adr)
RAP: coronary sinus empties into RA, low pressure is good)
Tone of coronary a.’s: dilated/constricted, fixed stenosis/dilatable
Ventric wall tension: coronary capillaries constrict during systole, ischaemia  ventric
wall tension
Brain Death due to  02
O2 Stores:
Lungs = 400ml
Hb = 8-900ml
Total = 12-1300ml
O2 Consumption 250ml/min (140ml/min/m2)
1200/250 = 4-5 mins
If you can CIRCULATE the O2 in body you’ll prolong survival
Neuronal damage:
Hypoxia – anaerobic metab – CO2 + H+ buildup – cerebral/lactic acidosis – neuronal
damage due to cell memb damage & influx of H20 – cell swelling -  ICP -  cerebral
perfusion
ONLY STOP CPR FOR:
Defibrillation
Intubation
Recovery Checks
To remove patient/self from danger
Cardiac Arrest
Definition of Cardiac Arrest:
Life threatening sudden loss of cardiac output
Causes of Cardiac Arrest:
* Ventricular Arrhythmias: VF, VT or Asystole
* In Children: BRADYCARDIA WITH OR WITHOUT PULSE
* EMD/PEA
Signs/Symptoms: UNCONSCIOUS + NO PULSE
Often assoc. with resp arrest (ie cardiac arrest 2o to resp arrest)
Sudden unconsciousness
Absent major pulse/BP/Heart sounds
Absence of breathing, or agonal breathing
Pallor or cyanosis (late sign)
Dilated pupils after 45secs
Management of Cardiac Arrest:




FIRST STEP:
Check for danger: water on floor, electrical, body fluids
NOTE TIME
CALL FOR HELP
PUT ON GLOVES
If Unconscious:
Left lat position: protects airway, stomach on left
PREGNANT: gets them off IVC
Clear Airway: suction/finger
Head tilt, jaw support
Turn face slightly down, mouth open
Check Breathing: if breathing – leave in left lat position, apply O2, observe ABC
Position: on firm flat surface (remember backboard)
Exposure: expose abdomen & chest
Conscious state: Shake, call name, tactile stimulus
Airway: visual inspection, leave well-fitting dentures in, otherwise remove, insert
Guedels’s airway, connect bag/mask to high flow O2
Respiration: look listen feel
Circulation: check major pulse (carotid/femoral) for at least 5 secs
Simultaneously
Think about establishing a precipitating cause
What happened to Pt just prior to arrest, ie drugs, in previous hour,…etc
What pre-existing illnesses do they have?
When were they last seen alive?
Then:
Connect O2 at highest flow (Bag/Mask initially)
Cease all IV infusions
Connect N.Saline or Dextrose line
Prepare drugs: Adr/Atropine/Lignocaine
Airway Management
Clear airway (as described)
Head tilt, jaw thrust, “sniffing” position
Guedels/Nasopharyngeal airways
Guedels:
unconscious patients
Size: corner of mouth to earlobe (size 2 in most adults)
Use tongue depressor to assist if difficult (esp children)
Nasopharyngeal:
alternative to oropharyngeal
Not in suspected fracture B.O.S.
Size: patients little finger (small-med=6-7, med/large=7-9)
Lubricate, right nostril, flange medially, rotate
Breathing Management
Give 5 breaths in 10 secs, (to restore FRC) then reassess breathing
Mouth to Mouth (infection, poisoning risks)
Mouth to Mask (can connect O2 to mask)
Bag/Mask (alone = 21% O2, + O2 supply at 10-12l/min = 50% O2, + reservoir bag +
O2 at 12-15l/min = 90-100% O2)
EAR:
Head tilt
Jaw support
Adult
Yes
Yes
Child
(1-8 yr)
Infant
(0-1yr)
Slight
Yes
No
Yes
Assessment of effectiveness:
Resistance felt
Chest rise/fall
Feel/hear air escape
Colour improvement
Complications:
Gastric distension/rupture
Regurgitation/aspiration
Hyperventilation – pneumothorax
No of
Breaths
1 every
4secs
1 every
3secs
1 every
3secs
Cycles
20/min
Breath
Strength
Full (chest
rise)
Gentle
20/min
Cheek puffs
15/min
C-spine trauma
Broken teeth
Ineffective
If patient vomits:
StopCPR/EAR turn on left side, clear airway
Recheck airway patency/position of hands on sternum
Insert NGT (head forward) to empty stomach
Circulation Management
ie No pulse after 5-10 secs palpation:
Infants: carotid not palable – use brachial
Pregnant: PUT PT FLAT WITH PELVIS IN LEFT LAT TILT
CPR
Hand Position: Lower half sternum
START GENTLY
CPR In Children
Indication = BRADYCARDIA + other Syx/Signs of arrest (ie unconscious,
apnoea, pallor, floppy, in extremis)
Infant (1month-1year) – PR < 80
Young Child (1-8 years) – PR < 60
OlderChild (9-14 years) – PR < 40
Site
Use
Depth
Compressions:
Breaths 1
operator
Compressions:
Breaths 2
operator
Effective pulse
rate
Adult
Lower ½ sternum
2 hands
4-5 cm
15:2 in 15 secs
4 cycles/min
Young Child
Lower ½ sternum
Heel of 1 hand
3cm
5:1 in 5 secs
12 cycles/min
Infant
Lower ½ sternum
2 finger
2cm
5:1 in 5 secs
12 cycles/min
5:1 in 5 secs
12 cycles/min
5:1 in 5 secs
12 cycles/min
5:1 in 5 secs
12 cycles/min
60-80
80-100
80-100
Effectiveness:
Pulse/ECG artefact coincides with compression
Colour improvement
Patient wakes up!
Complications:
Bruising
Fracture rib, xiphoid, sternum, flail segment
Lacerated liver, spleen, lung – pneumothorax
Ineffective
Assess for ROSC after 1 min then every 2 mins
If at any time Pt makes a purposeful movement – STOP! And assess Pt
Care of Patient Post Arrest
Reassure/explain
Find Cause
Full physical examination
Mx Other Syx: CP, SOB, N&V, UO
Monitor vitals, neuro obs,
IV infusion (espec of drugs that helped correct any arrhythmias)
Side effects of drugs, fluid overload
If intubated, only extubate when able to:
Lift head off pillow
Touch nose with finger
Maintain ABG’s
Ix: ECG, ABG, FBE, U&E, Glucose, CE’s, +/- CxR
? Transfer – ICU/other hospital
Notify next of kin
Documentation
Causes Of Unconsciousness Other Than Cardiac Arrest:
A
Anaesthetics, alcohol
V
O
M
I
T
Vascular – bleeding (incl intracranial), PE, arrhythmias
OD: intentional/accidental poisoning, envonomation
Metabolic: ARF, DKA,  or  Na+, hepatic encephalopathy,
Infection: septicaemia, (+/- shock), meningitis/encephalitis/brain abcess
Trauma: head injury, haemorrhage/hypovolaemia
S
H
E
E
T
Syncope: postural  BP
Hypoxia +/- hypercarbia
Epilepsy: post-ictal
Endocrine: thyrotoxic, myxoedema,  or  glucose, HONC
Tumor: cerebral
Airway Obstruction:
Partial
Breathing is:
Noisy
Laboured
Wheezy
Stridor
ie air movement present but limited
NB: quieter noise = narrower airway!
Mx:
Reassure patient – instruct them how to breathe
Allow Pt to adopt their own position
Complete
Breathing:
Visual breathing effort, intercostals recession, tracheal tug
BUT
No sound of breathing or air movement in or out of lungs
Mx:
Clear airway/make patent
Commence EAR if indicated
Indications for EAR:
Unconscious
No air movement
Pulse present/absent
If EAR not successful (ie no ventilation with first breath):
Children:
invert child – pick up by legs
Back blows
Lateral chest thrust
Adult:
Back blows
Lateral chest thrust
If unsuccessful – cricothyroidotomy / emergency tracheostomy