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PROVIDED BY LIFE SUPPORT EDUCATIONAUGUST 2013
ACLSHELPFUL HINTS
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Patient Assessment - Conscious Patient
Initial Assessment ABC’s12 Lead EKGExpert ConsultConsider Oxygen with O2 sat < 94%SAMPLE History
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SAMPLE
Signs & SymptomsAllergiesMedicationsPast Pertinent Medical HistoryLast Oral IntakeEvents Leading Up to Event
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Patient Assessment - Stable
Considerations for patients with perfusing rhythms who are Stable
ABC’s V/S Oxygen if Hypoxic Monitor Peripheral IV Access
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Patient Assessment - Stable
Bradycardic Patients – HR <50 usually for treatment
Monitor patient for change in mental status
Any Bradycardia that is symptomatic needs treatment with Atropine 0.5 mg (maximum dose – 3 mg)
Pressors – Epinephrine 2 – 10 mcg/min Dopamine 2 – 10 mcg/kg/min
Pacing
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Patient Assessment - Stable
Tachycardic Patients – Sinus Tach 100-150 bpm
ABC’s
12 Lead EKG
Treatable Causes (H’s & T’s)
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HypoxiaHypovolemiaHydrogen Ions
(Acidosis)Hypo/HyperkalemiaHypothermia
Hypoglycemia - not included
Tension PneumothoraxTamponade – CardiacThrombosis – CardiacThrombosis –
PulmonaryToxins
Trauma – Separate Considerations
H’s & T’s
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Patient Assessment - Stable
Narrow complex tachycardia – (SVT) – Supraventricular Tachycardia
Rate >150 – 220 bpm
ABC’s 12 Lead EKG Expert Consult Vagal Maneuvers Adenosine 6 mg - 12 mg Elective Synchronized Cardioversion
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Patient Assessment - Stable
Wide complex tachycardia – Ventricular Tachycardia
ABC’s 12 Lead EKG Expert Consult Amiodarone 150 mg/100cc D5W or NS
Administer over 10 minutes Adenosine 6 mg - 12 mg - 12 mg Elective Synchronized Cardioversion
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Acute Coronary Syndrome
Substernal Chest Pain – Radiation – SOB Patient History ASA 160 mg – 325 mg for ACS 12 Lead EKG SL NTG -
Hold if right ventricular infarct suspected Hold if taken phosphodiesterase inhibitors within 48
hours Hold for severe bradycardia or tachycardia Hold if systolic BP 90 mmHg or less
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Acute Coronary Syndromes
Peripheral IV Access for medication administration
Morphine if chest pain continues
Preparation for PCI
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Suspected Stroke
Weakness – facial droop – pronator drift ABC’s Oxygen if needed IV Access Glucose testing – fingerstick – lab Neurologic screening
include time of symptom onset Activate Stroke Team/Transport to Stroke Center
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Suspected Stroke
Patient History
Patient Stable - Head CT Scan – (R/O - Ischemic vs. Hemorrhagic) 12-Lead EKG rtPA Candidate (Yes/No)
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Patient Assessment - Conscious Patient
Initial Assessment ABC’s12 Lead EKGExpert ConsultConsider Oxygen with O2 sat < 94%SAMPLE History
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Patient Assessment – Unstable
Patients with perfusing rhythms who are Unstable
Atropine 0.5 mg if V/S indicate bradycardia/hypotension
Airway management if not breathing and heart rate decreasing
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Patient Assessment – Unstable
Synchronized Cardioversion indicated for
SVT and/or VT with hypotension
Sedation if time
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Synchronized Cardioversion
Narrow Complex Tachy or Atrial Flutter – 50 – 100 joules
Atrial Fibrillation – 120 – 200 joules
Wide Complex Tachy – 100 joules
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Patients in Respiratory Arrest
Patent Airway – (Yes/No)
Agonal Respirations
Ventilations – 1 every 5 – 6 seconds (10 – 12/min)
Advanced Airway Indicated – (Yes/No)
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Airway Management
Relief of FBAO in Unresponsive Victim Chest compressions – Look in Mouth – Attempt Ventilations
BVM Use
OPA (oropharyngeal airway) or NPA (nasopharyngeal airway)
Proper Placement of Advanced Airway
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Airway Management
ETT/King/LMA – Continuous compressions without pauses for ventilations Ventilations: 1 every 6 – 8 seconds (8-10 BPM) Suction if needed on withdrawal and for 10 seconds or less
Advanced airway verified – Listen Colormetric CO2 Device Waveform Capnography
Cricoid Pressure Do not use if it impedes ventilation or advanced airway
placement Not recommended in cardiac arrest airway management
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Oxygenation vs. Ventilation
Oxygenation- Amount of Oxygen in the blood Prolonged high concentrations may cause oxygen toxicity SaO2 of 100% may equal PO2 of 800 Maintain SaO2 at 94-99%
Ventilation-Rate at which we ventilate Hyperventilation decreases venous return which decreases
blood flow to the heart and lungs. Hyperventilation causes cerebral vasoconstriction which
decreases cerebral blood flow.
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Why not hyperventilate?
When we breath normally…. It is negative-pressure ventilation Helps venous return to the heart
When we stop breathing…… Lose benefit of negative pressure and venous return
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Why not hyperventilate?
When Delivering Positive Pressure Ventilations…
Prevents venous return
Every ventilation increases intrathoracic pressure for 2 seconds
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Effect of Ventilation on Venous Return
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Effect of Ventilation on Venous Return
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What it tells us:
ET Tube placement
PETCO2 < 10-ROSC unlikely (need to improve CPR technique)
Abrupt sustained increase in waveform - ROSC
Capnography
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Capnography
Useful for Compression effectiveness (if PETCO2 less than 10
need to improve compressions) Airway- ET Tube placement verification Pulse- ROSC (sudden increase in waveform)
Intubation- not a must if able to ventilate But…..
Better CPR Use of Capnography
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Capnography is used for verification of advance airway and for indication of return of spontaneous circulation (ROSC) during CPR.
7055402510 0m
m H
g
[1 Minute Interval]
45
0
Capnography for ROSC
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The UnConscious Patient
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Patient Assessment - Unconscious
Check Responsiveness
Observe chest for breathing
Call for help & ask for AED if available
Check Pulse (5 – 10 seconds)
Begin Chest Compressions if Needed
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Patients in Cardiac Arrest
CPR Produces blood flow through coronary arteries to the heart Never interrupt for more than 10 seconds Prolonged interruptions in compressions can be fatal for victim
Shockable Rhythm vs. Non-Shockable Rhythm Shockable- VF & Pulseless VT (Torsade-de-pointes) Non-Shockable – PEA & Asystole
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CPR Interventions
Compression rate – “at least” 100/minute
Depth of Compressions – 2 inches (at least)
Allow for complete chest recoil after each compression
Rotate Compressors every 2 minutes
Continue compressions while defibrillator charges
Ratio – 30:2 until advanced airway inserted
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CPR Interventions
Paddles vs. Pads Pads – more rapid defibrillation Paddles – circumstances where pads cannot be used
Burns/surgeries/other considerations
Withholding or Terminating CPR Scene Safety Obvious death Evidence of rigor mortis Prolonged or deteriorated arrest following a lengthy
arrest attempt
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Patients in Shockable Rhythm
VF/Pulseless VT – (Torsade-de-pointes) Defibrillation (Unsynchronized cardioversion)
120 j – 150 j – 200 j (at appropriate intervals)
Access – IV/IO
Medication Administration During CPR (allows circulation before defibrillation) Epinephrine – 1mg 1:10,000 IV/IO Push – Flush – CPR -
Defib Amiodarone – 300 mg IV/IO Push – Flush – CPR – Defib Other Considerations based on identified cause (H’s & T’s)
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Patients in Non-Shockable Rhythm
PEA (Pulseless Electrical Activity) & Asystole
CPR – Compression rate – “at least” 100/minute Out of hospital personnel should contact medical
control for orders to terminate resuscitation efforts in extended CPR events
Rotate Compressors
Ratio – 30:2 until advanced airway inserted
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Patients in Non-Shockable Rhythm
Access – IV/IO
Medication Administration Give during CPR Epinephrine – 1mg 1:10,000 IV/IO – Push - CPR
Other Considerations based on identified cause (H’s & T’s)
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Post Arrest Care
Maximize Oxygenation & Ventilation
Fluid for Hypotension 1 – 2 L/IV Fluid Bolus if hypotensive (Systolic BP < 90
mmHg) Maintain Systolic BP at 90/mmHg or greater
Pressors for Hypotension IV Epinephrine – 0.1 – 0.5 mcg/kg/minute IV Dopamine – 5 – 10 mcg/kg/minute
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Post Arrest Care
PCI considerations (In-hospital/Out-of-Hospital) Out of hospital personnel should transport patients with
ROSC to a hospital capable of performing PCI
Prevent Oxygen toxicity –
Maintain SaO2 at 94% – 99%
Target PETCO2 to 35 – 40 mmHg
Do not hyperventilate the patient
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Post Arrest Care
Hypothermia Protocol Patient Remains Unresponsive to Verbal Commands Maintain core temperature at 32 – 34 degrees Celsius
for 12 to 24 hours
Follow Up
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Additional Information
The Medical Emergency Team (MET) or Rapid Response Team (RRT) can help improve patient outcomes by identifying and treating early deterioration of the patient !
Pulse checks – NO!! Following defibrillation of VF/Pulseless VT - chest compressions ! Organized rhythm on monitor following 2 minutes of CPR – Ok NOTE: Zoll Defibrillators have “See-through” CPR
(bottom rhythm is patient’s rhythm)
Keep O2 away from the patient and bedding during defibrillation to avoid fire risk
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AED’s
Use the AED when it arrives Early defibrillation is essential in BLS survey if
indicatead
Malfunctioning AED – begin chest compressions
Special Considerations Snow – use AED Puddles of Water – move victim
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Thank You