acls ii sept 25 students copy 2003

8/2/2019 ACLS II Sept 25 Students Copy 2003

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CORE ACLS

CONCEPTS

ADVANCED

CARDIAC LIFE SUPPORT

3/2/2012



Core ACLS Concepts “The chain of survival” has 4 links applied to

all CPR settings (hospital, ER (A&E), ICU,

CCU, or community)

Early Early Early Early

Access CPR Defibrillation Advanced care



Advanced Cardiovascular/Cardiac Life Support

Is a training program that generally aims to

develop the knowledge and skills of health

care providers as they make effective use of

themselves when assisting in a code

situation.



Definition of Terms:

ACLS – Iincludes the knowledge and skills

necessary to provide the appropriate early

treatment for cardiopulmonary current which

reduces BLS and use of adjunctive

equipment and special technique to establish

and maintain ventilation and circulation.



Terminologies

Cardioversion - The discharge of electrical energy synchronized on

the R wave of the electrocardiogram.

Defibrillation - use of unsynchronized electrical energy for revision of

cardiac arrhythmias.

Algorithm – sets of step-by-step procedure guides to assist caregiversin making informed decisions regarding the diagnosis and treatment

of disease.



ECC – (Emergency Cardiac Care) includes all responses necessary to deal with

sudden and often life threatening events affecting the cardiovascular andpulmonary system.

Megacode - situation wherein the algorithm will be applied and an individual

will be tested on his ability to recite the exact sequences of an algorithm.



Resuscitation (Code Red)

General Policy:

The Cardiac Code team’s goals are to preserve life, restore health, relieve

suffering and limit disability. These goals shall be carried out promptly with

patient safety foremost in the mind.



A team is composed of :

1. Person for chest compression

2. Ventilator

3. Person to insert IV lined and will administer medications.

4. Person to monitor the cardiac and will do the defibrillation .

5. Recorder



Role of the Nurses:

1.Prepares and set-up all equipments necessary for resuscitation.

2. Regular checking of E-cart (every shift before

receiving the endorsement)

3.Document Checklist

4,Location of E-cart

5.Administer assist BLS measure

6.Carries out Doctor’s order and record the chronological event

using the CPR Record Form



.7. Arranges all matters pertinent to the ad

mission and transfer of patient whennecessary

8.Arranges all matters pertinent to the discharge

of patient(expired patient)

9. Autopsy, DOA, HAMA

10. REPLENISHES AND CHARGES ALL ITEMS

USED



GENERAL GUIDELINES FOR ALL TEAMS

Maintain quiet, orderly and professional

environment

Patient should be automatically hooked to EKG,

cardiac monitor,defibrillator and pulse oximeter

State vital signs every 5 minutes / PRN

State each medication given

Document



GENERAL GUIDELINES FOR ALL TEAMS

Maintain quiet, orderly and professional

environment

Patient should be automatically hooked to EKG,

cardiac monitordefibrillator and pulse oximeter

State vital signs every 5 minutes of PRN

State each medication given

Document



Request clarification of any order if not clearly

understood

Limit traffic

Comfort relatives and advise to stay outside the room



EQUIPMENT

E-cart

Pulse oximeter

Cardiac monitor with defibrillator

Ambu-bag



DOCUMENTATION

CPR Record Form

Nurse fills up the data and activities

Team leader documents the CPR outcome



The algorithm Approach Emergency Cardiac

Care(ECC)

The following clinical recomendations apply to all

treament algorithms

First, treat the patient not the monitor.

Algorithms for cardiac arrest presume that thecondition under discussion continually persists, that

the patient remains in cardiac arrest, and that CPR is

always perform.



Apply different interventions whenever appropriate indications

exist.

The flow diagrams present mostly

Class I(acceptable, definitely effective)recomendations.

The footnotes present Class IIa(acceptable, probably effective),

band Class Iib (acceptable, possibly effective), and

Class III (not indicated, may be harmful) recomendations.



Adequate oxygenation,airway, ventilation,. Chest

compressions, and defibrillation are more important

than administration of medications and takes

precedence over initiating an intravenous line or

ejecting pharmacologic agents.

Several medications (epinephrine. Lidocaine, and

atropine) can be administered via the endotracheal

tube but the dose must be 2 – 2.5 times the

intravenous dose. (use a catheter or suction tip which

be passed beyond the tip of the endoctracheal tube.)



With a few exceptions, intravenous medications

should always be administered rapidly, in bolus

method.

After each intravenous medication, give a 20-30

ml bolus of intraveus fluid and immediately

elevate the extremity. This will enhance the

delivery of drugs to the central circulation, whichmay take 1-2 minutes.

Last, treat the patient, not the monitor.



Core ACLS Concepts The Most Important Goal : > Cerebral resuscitation

The Patients :

u For Many >> Their hearts should be too good to die.

u For Some >> The last heartbeat should be the last.

Treat the patient, not the monitor



Cardio-pulmonary-cerebral resuscitation Primary purpose : to return the

patient to his/her best possible

neurological outcome.



Arrythmia Recognition

Important in any ACLS/ CPR sequence

All algorithms start with identifying rhythm

Cannot identify arrhytthmais- cannot mange

corrrectly



The Beating Heart – ElectrophysiologyElectrical Stimulation & Contraction

BEFORE THE HEART CONTRACTS

IT MUST BE ELECTRICALLY STIMULATED

DEPOLARIZATION



Pacemaker impulses are initiated in the SA node,

travelling through atrial pathways, at frequenciesbetween 60-100bpm

There is the presence of a P wave, followed by a

QRS complex at a regular rate



Normal Sinus Rhythm

Look at the P waves ;

rate is 60-100/min

Cycle length do not vary by 10%

PR interval is 0.12 – 0.20sec.



During ACLS/BLS:

• Patient is hooked to cardiac monitor/ defibrillator

•Patient’s heart rate is automatically detected

•Normal HR = 60 to 100 bpm



MANAGEMENT:

A. No specific drug treatment

B. Identification of cause

C. Treatment of underlying cause

D. Check hemodynamics



Characterized by tachycardia with a narrow QRS complex

Sudden onset and termination

150-250 beats/min (180-200 bpm in adults)

Regular rhythm

QRS complex is normal in contour and duration

No P waves

•P waves are generally buried in the QRS complex

•Often, P wave is seen just prior to or just after the end of the QRS and cause a subtle

alteration in the QRS complex that results in pseudo- s or pseudo - r



A. Cardiovert the patient!

B. Defibrillate the patient!

C. Give Verapamil!

D. Check hemodynamics



Prematurely occurring complex

Wide, bizarre looking QRS complex

Usually no preceding P waves

T wave opposite in deflection to the QRS complex

Complete compensatory pause following every premature beat



• Adult (1 to 2L) bag and the provider should deliver

approximately 600 ml of tidal volume sufficient to produce chest

rise over 1 second

•Open the airway adequately with a head tilt-chin lift, lifting the

jaw against the mask and holding the mask against the face,

creating a tight seal

•During CPR give 2 breaths (each 1 second) during a brief (

about 3 to 4 seconds) pause after every 30 chest compr essions.



Use of 100% inspired oxygen (FiO2 1.0) as soon as it becomes

available is reasonable during resuscitation from cardiac

arrest (Class IIa, LOE C)

Titrate oxygen administration to achieve arterial

oxyhemoglobin saturation > 94%



To facilitate delivery of ventilations with a bag-mask device,

the nasopharyngeal airway can be used in patients with a

compromised airway

In the presence of known or suspected basal skull fracture or

severe coagulopathy, an oral airway is preffered (Class II a,

LOE C)



ADVANTAGES

Keeps airway patent

Permits suctioning of airway secretions

Enables delivery of a high concentration oxygen

Provides an alternative route for administration of some

drugs

Facilitates delivery of a selected tidal volume

With use of a cuff, may protect the airway from

aspiration



Epinephrine

Lidocaine

Vasopressin



Endotracheal intubation is frequently associated with

interruption of compressions for many seconds

Placement of a supraglottic airway is a reasonable

alternative to endotracheal intubation and can be done

successfully without interrupting chest compressionsa



Rescuer should record the depth of the tube as marked

at the front of the teeth and secure it.

Providers should verify correct placement of all

advanced airways after insertion and whenever the

patient is moved.



VENTILATION

Chest x-ray

Rationale: Confirm secure airway and detect

causes or complications of arrest:

pneumonitis, pneumonia, pulmonary edema.



VENTILATION

After ROSC, routine hyperventilation leading to hypocapnia

should be avoided to prevent additional cerebral ischemia.

CONTROLLED OXYGENATION

There is insufficient evidence to support or refute the use of

titrated inspired oxygen content in the early care of cardiac

arrest patients following sustained ROSC



VENTILATION

Mechanical Ventilation

o Rationale: Minimize acute lung injury, potential oxygen

toxicity

o Tidal volume – 6 – 9ml/kg

o Titrate minute ventilation to

- PETCO2 – 35- 40 mm Hg

- PaCO2 – 40- 45 mm Hg

o Reduce FiO2 as tolerated to keep SpO2 or SaO2 > 94%



ELECTRICAL THERAPIES

DEFIBRILLATION & CARDIAC PACING

PHA Council on CPR



Electrical Therapies

Defibrillation

Cardioversion

Cardiac Pacing



Key Challenges (2010 Guidelines)

Improve time for Defibrillator Availability

- Immediate AED availability

- Improve response time and training

Decrease interruptions in chest

compressions pre and post shocks



DEFIBRILLATION

Is the therapeutic use of electric current delivered in large

amounts over very brief periods of time.

Temporarily “stuns” an irregularly beating heart and allows

more coordinated contractile activity to resume.

Termination of VF for at least 5 seconds follwing the shock.



AUTOMATED EXTERNAL DEFIBRILLATORS

Sophisticated, reliable computerized devices that use voice and

visual prompts to guide lay rescuers and health care providers to

safely defibrillate VF SCA

Recorded information about frequency and depth of chest

compressions during CPR.



BIPHASIC WAVE FORM DEFIBRILLATORS

Defibrillation with biphasic waveforms uses relatively low

energy ( < 200 J ) that is safe and has equivalent or higher

efficacy for termination of VF than monophasic waveform

shocks (class llb)



SYNCHRONIZED CARDIOVERSION

Synchronization avoids shock delivery during the

relative refractory portion of the cardiac cycle, when a

shock could produce VF.

The energy (shock dose) used for a synchronized shock

is lower than that used for unsynchronized shocks

(defibrillation)



CARDIAC PACING

Deliver an electric stimulus through electrodes to

the heart causing electrical depolarizations and

subsequent cardiac contraction



INTRAVENOUS ACCESS



PERIPHERAL IV SITE

Administer drugs by Bolus

20cc of saline or distilled water

Elevate the extremity for 10-20

seconds



Tracheal Drug Administration

NAVEL (Naloxone, Atropine, Vasopressin, Epinephrine,

Lidocaine)

Administer 2 to 2.5 times the recommended IV dose

diluted in 10ml NSS or distilled water



ACLS DRUGS

Agents used to Optimize Agents used to treat Arrhythmias

Cardiac Output and blood pressure

Cardiac Arrest Shock Heart Failure/ Tachycardia Bradycardia

Pulmonary Edema, Misc;

buffers



MONOPHASIC WAVE FORM DEFIBRILLATORS

Deliver current of one polarity

Monophasic damped sinusoidal waveforms (MDS) returns to zero

gradually, whereas the Monophasic truncated exponential

waveform current is abruptly returned to baseline to zero current

flow.

Initial shock is 360J and if VF persists, the subsequent shocks

should be 360J

Time Sequence &



Time Sequence &

Estimated Probability of Survival

Eisenberge, et al 1990

Time(min) 2 4 6 8 10

CPR T & O i i



CPR Team & Organization

BLS & ACLS

Training &

Retraining,

CPR Code

Organization,

Performance

Evaluation &

Peers R eview



Core ACLS Concepts Classification of Therapeutic Interventions

in CPR & ECC

Class I : acceptable, definitely effective

Class II : acceptable, uncertain efficacyII a > probably effective

II b > possibly effective & not harmful

Class III : inappropriate & may beharmful

The Algorithm Approach



in ACLS & ECC

Treat the patient, not the monitor

Continue CPR (include defibrillation) is moreimportant than the procedure and pharmacologicagents

Flow diagrams: mostly class I,footnotes: class IIa, IIb, or III

Most ACLS medications(but few exceptions) shouldbe given as iv. bolus

“2

nd

Syringe Technique” for 20-30 ml. iv. bolus aftereach iv. medications

Epinephrine, lidocaine, atropine, etc can be given viaET tube at 2-2.5 times of iv. Route

Summary :



Summary : Ten Commandments for ACLS

1. Do good CPR : do CPR whenindicated, not do when not indicated,and do well

2. Highest priority is the primary C A-B--D* survey & hunt for VF

3. The next highest priority is thesecondary CA-B--D** survey

4. Know the defibrillator! : familiarizeand daily maintenance check

5. Search for reversible or treatable causes.

Summary :




6. Know the ECC medications : “Why?”,“When?”, “How?”, and “Watch out?!?”

7. Be a good team : conductor ormember

8. Practice the phase responseresuscitation format :anticipation/entry/resuscitation/maintenance/ family notification/transfer/critique

9. Determined “code status” in advance

Summary :




10. Learn and practice the most difficultresuscitation skills*:

when not to start CPR

when to stop CPR

how to tell the family members

how to talk with your colleagues

Even though it’s the most difficult, but it’s

more important & more challenging!

acls ii sept 25 students copy 2003

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