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Acls prestudy packet

  1. 1. Critical ConceptsAdvanced Cardiovascular Life Support Precourse Study Guide Presented by: Critical Concepts Corp. 3201 W. Griffin Rd. Suite 205 Fort Lauderdale, FL 33312 Phone: 954-322-8883 Fax: 954-322-8817 Toll Free: 1-800-427-6355 Website:© Copyright 2006 S. Lunsford 1
  2. 2. NEED PRIVATE TRAINING AT YOUR OFFICE? SEE BELOW INFORMATION Toll-Free 1.800.427.6355 9-6PM Mon-Fri. Department of Health Provider FBON #2662CPR, ACLS or PALS at your Location… American Heart CoursesHow does a Stress-Free Private American Heart Association (AHA) Course Sound? One call takes care of it.Simply gather a group of 6, or close to it, and were there. We have even conducted 1 on 1 training to meet the needs of busyprofessionals. Weekday, Weekend & Evening Programs are available at your home, office or facility to meet your needs!Reduced Renewal Fees: BLS (CPR) $30/person & ACLS or PALS $125/person based on 6 or more persons. Groups less than6 persons welcome-fee slightly higher per person. Includes CE Credit and 2005 Study Guide. See combo-program discount below.If you wish to take a Stress-Free Course at our facility, see the following page with schedule for: Ft. Lauderdale, Miami,Kissimmee, Orlando, Gainesville, Tampa, Jacksonville & 3 Georgia locations. All ECC texts available On-Line for purchaseOSHA Training at your Location…Are you concerned about meeting Annual Mandatory OSHA, State and Local Compliance &Training Requirements for Your Healthcare Facility?In approximately 1 1/2 hours we will implement all programs and bring your facility into compliance.Having Documentation of Training & Manuals older than 365 calendar days is not current and falls out of compliance with theFollowing Excerpt from Federal Law: “Training must take place annually thereafter. 1910. 1030 (g)(2)(iii)” & from StateLaw FAC 64B-16.003. Expired or Incomplete compliance documentation will not mitigate Federal fines, sanctionsand penalties for non-compliance. Let the Professionals at Critical Concepts be your total solution, call 1.800.427.6355, press # 4.These Healthcare Laws Mandate Annual Training, Annual Program Updates, Annual Plan Reviews regarding Bloodborne Pathogens,Hazard Communication and Biomedical Waste Plan., Needle-Stick Injury Plans, and many more. Should your practice have onecomplaint, needle-stick, injury or occupational exposure and you can not show Recent (<365 days old) Compliance Documentation ofspecific training and that All the Below Requirements are complete— Serious Federal Fines, Sanctions, and Legal Exposure can occur.Introducing your Solution, Affordably and Efficiently at $300—What we do is listed below ...We provide all of the below Services and an Updated OSHA Policy and Procedure Manual. Upon completion, you will receive a confidentialcompliance report, our corrective measures and an OSHA Compliance Certificate. We furnish all Required Training, Posting MandatorySigns, Documentation, Annual Updated Plans, Labels, MSDS for Chemicals, Request Forms, Documentation Forms for HBV ,BiomedicalWaste Program and more. All of the above training, materials, manuals, services and walk-through are included. Large practicesand certain locations are slightly higher with Multiple Location discounts available, Please inquire. Please call 1.800.427.6355, press # 4.See combo-program discount below. Annual Customer Support Included.HIPAA Training at your Location…Recently Released: June 9, 2005 more HIPAA Security Guidance from the USGovernment Agency (CMS) regarding Security Evaluation & Training.“13,000 Federal HIPAA Violation Complaints” as of June 9, 2005 (CMS 6.9.05) /“2,400 in May of 2003! (USA Today/Cover/10-16-2003). A Division under Health and Human Services (DCF), states "All employees and volunteers will be annually trained in HIPAA requirements.Not having your staff properly trained as per policy and procedures (<1 year) and current laws may result in fines, complaints and legal exposure.Be Informed When Patients ask HIPAA Questions??? What is the Security Standard? How do I conduct Security Training andEvaluations. How do I write a Policy? Did a new requirement pass by? What did it require? Can you leave messages on voice mails? What kind? Howlong do you have to copy patients records? And if they are off-site? Can you charge? How Much? How often? What training is required?In what manner?Regarding what? What training records should I keep? Shred? What does HIPAA stand for? What is really the Law? Workmans Comp?sIntroducing your Professional Solution at- $325 HIPAA Renewal Training… We will provide all of the below ...We provide Training and Requirements to protect your facility. Included is The HIPAA Policy and Procedure Manual updated with recentSecurity Standards for 2005-2006. Sending a staff member to a “HIPAA Seminar” will leave them with incomplete documentation and daysof work. We address Public Law 104-191, 45 CFR Parts 160, 162, 164 and more. Security Requirements with the Required Evaluation andTraining Process, Privacy Requirements, Transaction Code Sets, National Provider Identifier. Large practices/certain locations slightly higherand multiple location discounts are available. See combo– program discount below. Annual Customer Support Included.Combination Discount Below Will Save Money & Time!!!!! Call 1.800.427.6355 Press #4Two programs done on the same day $50 off entire fee, All three programs completed the same day—$200 off the entire fee.Additional discounts may be available online.
  3. 3. We welcome you to Critical Concepts Corporation and theAmerican Heart Association’s Advanced Cardiac Life SupportCourse. We provide a “Stress-Free” program to all individuals whoparticipate in our hands-on training program.Please note if you are registered in the one-day re-certificationcourse a current card is required and you will need to bring this toclass. The re-certification course provides a brief update then intotesting and hands-on skills. We recommend the renewal course forclinicians who utilize their ACLS skills frequently and can interpretrhythm strips. The two-day Initial ACLS Course is for a thoroughreview of ACLS with extensive practice and is enjoyed by all.Our organization has faculty consisting of MD’s, RN’s, Paramedics,Firefighters and Emergency Care Professionals. We teach need toknow information in an enjoyable “Stress-Free” environment.For any questions or concerns feel free to contact us or call at 1-800-427-6355.If you are rusty on EKG’s no problem, simply purchase ourBasic EKG Guide at
  4. 4. Critical Concepts ACLS Course Agenda 2 Day Course16 hours 1 Day Renewal 8 hoursIMPORTANT: PLEASE SEE START TIME LISTED AT YOUR FACILITY ORCHECK WITH THE DIRECTOR/MANAGER. START TIME VARIES BYLOCATION. AGENDA MAY VARY ACCORDING TO PARTICIPANTS NEEDS(i.e some individuals may need more help with one subject of the other) Day 110 min Welcome/Introductions10 min Lesson 1 – ACLS Course Overview5 min Lesson 2 – Course Organization20 min Lesson 3 – BLS Primary Survey and ACLS Secondary Survey Lesson 4 Lesson 5 Divide class into 2 Management of Respiratory Arrest CPR Practice and Competency groups Learning Station Test 1 hour Group 1 Group 2 15 min Break Break 1 hour Group 2 Group 1One large group15 min Lesson 6 – Technology Review1 hour Lunch30 min Lesson 7 – The Megacode and Resuscitation Team Concept Lesson 8 Lesson 8 Divide class into 2 Pulseless Arrest VF/VT Pulseless Arrest VF/VT groups Learning Station Learning Station 1 hour 30 min Group 1 Group 2One large group (or 2 small groups)35 min Lesson 9 – ACS15 min Break Lesson 10 Lesson 11 Divide class into 2 Bradycardia/Asystole/PEA Tachycardia, Stable and Unstable groups Learning Station Learning Station 1 hour Group 1 Group 2 1 hour Group 2 Group 1One large group (or 2 small groups)35 min Lesson 12 – Stroke End of Day 1© Copyright 2006 S. Lunsford 2
  5. 5. Critical Concepts ACLS Course Agenda Day 2 Lesson 13 Lesson 13 Divide class into 2 Putting It All Together Putting It All Together groups Learning Station Learning Station 1 hour 30 min Group 1 Group 2One large group5 min Lesson 14 – Course Summary and Testing Details15 min Break Divide class into 2 Lesson 15 Lesson 15 groups Megacode Test Megacode Test 1 hour 30 min Group 1 Group 2One large group (as students finish Megacode test)1 hour Lesson 16 – Written Test Class Ends/Remediation© Copyright 2006 S. Lunsford 3
  6. 6. Critical Concepts ACLS Study Guide 2006Read Prestudy Material. Guidelines have recently changed and certain American HeartAssociation Textbooks/Materials/Handbooks will be available at different intervals.Please check with your educator for library AHA books or order by calling Channing Beteat 1.800.611.6083 and keep them on you.Please also take the pre-test in the back of this book and use the checklists to prepare.By the end of this course you must be able to demonstrate during a simulated VF (VentricularFibrillation) arrest scenario: assessing a victim by the Primary and Secondary ABCDs effective adult 1 and 2 rescuer CPR using an AED on an adult safe defibrillation with a manual defibrillator maintaining an open airway confirmation of effective ventilation addressing vascular access stating rhythm appropriate drugs, route and dose consideration of treatable causesWhat happens if I do not do well in the course?The Course Director or Instructor will first “remediate” (tutor) you and allowed to continue in thecourse.Any questions please contact this office.© Copyright 2006 S. Lunsford 4
  7. 7. Critical Concepts What is ACLS?ACLS is an “assess – then manage” approach for those at risk of or in cardiac arrest. Thisapproach is outlined in algorithms within you materials.Instructor to assess learning needs of students.Primary and Secondary ABCDsThis is a methodical “assess-then-manage” approach used totreat adults in respiratory distress and failure, stable and unstable arrhythmiasand pulseless arrest. Algorithms are “menus” that guide you throughrecommended treatment interventions.Know the following ABCDs approach because it begins all ACLScase scenarios. The information you gather during the assessment will determinewhich algorithm you choose for the patient’s treatment.Primary ABCDs: these refer to CPR and the AED.• Assess: Tap and ask: Are you OK? • Send someone to call 911 and bring an AED. • If alone call 911, get an AED and return to victim.• Airway: Open with the head-tilt/chin lift.• Breathing: Assess for adequate breathing. • If inadequate: give 2 breaths over 1 second each. • Each breath should cause a visible chest rise. • Use mouth-to-mask or barrier, bag-mask-ventilation (BMV) or mouth-to- mouth. • Give oxygen (O2) as soon as it is available.• Circulation: Check carotid pulse for no more than 10 seconds. • If not definitely felt, give 30 compressions in center of chest, between the nipples. 1 • Compress the chest wall 1 /2 - 2 inches. • One cycle of CPR is 30 compressions and 2 breaths • Give 5 cycles of CPR, (about 2 minutes). • Minimize interruptions to compressions. • 2-rescuers: the compressor PAUSES while 2 breaths are given. • Change compressors after 5 cycles to avoid fatigue and ineffective compressions.© Copyright 2006 S. Lunsford 5
  8. 8. Critical Concepts• Defibrillation: When an AED arrives, immediately power it on! • Follow the voice prompts. • Use adult pads on adults.Secondary ABCDs:• Airway: Use bag-mask connected to 100%O2. • Give each breath over 1 second each. • Compressor pauses to allow the 2 breaths to go in. • Consider inserting an advanced airway (see Advanced Airway on next page).• Breathing: Look for visible chest rise during each breath. • Confirm advanced airway tube placement (see Advanced Airway on next page). • Secure the airway tube. • Compressor now gives 100 continuous compressions per minute. • Ventilator gives 8-10 breaths per minute (one every 6-8 seconds).• Circulation: Obtain vascular access with an IV (intravascular) or IO (intraosseous) cannula. • Give drugs as recommended per algorithm.• Diagnosis: Why is the patient in the rhythm? Look for any possible causes to treat: 6 Hs 5 Ts Hypoxia T amponade Hypovolemia T ension pneumothorax Hypothermia T oxins – poisons, drugs Hypoglycemia T hrombosis – coronary (AMI) – pulmonary Hypo / Hyperkalemia (PE) Hydrogen ion (acidosis) T rauma Spacing separations may help as a memory aid.© Copyright 2006 S. Lunsford 6
  9. 9. Critical Concepts Airway Skills During the course you will be expected to participate in manikin practice and demonstrate the below skills. Basic Airway: • Oxygen: • Open the Airway: Use the head tilt-chin lift when assessing for adequate breathing. Use a jaw thrust for unresponsive-unwitnessed, trauma or drowning victims. • If unable to open the airway with a jaw thrust, use head-tilt chin lift. • Maintain: Insert an oropharyngeal airway when unconscious with no cough or gag reflex. Insert a nasopharyngeal airway when a cough or gag reflex is present (better tolerated). • Ventilate: Give each breath over 1 second using enough volume to see the chest rise. • 2-rescuer CPR: give 2 breaths during the pause following 30 compressions. • Rescue breathing: when a pulse is present, give 10-12 breaths/minute (one each 5-6 seconds).Advanced Airway:Laryngeal Mask Airway (LMA): requires the least training for insertion. • Inserts blindly into the hypopharynx. • Regurgitation and aspiration are reduced but not prevented. • Confirm placement: see chest rise and listen for breath sounds over lung fields. • Contraindications: gastric reflux, full stomach, pregnancy or morbid obesity. © Copyright 2006 S. Lunsford 7
  10. 10. Critical ConceptsCombitube: requires more training for insertion than the LMA. • Inserts blindly into esophagus (80% of the time) or the trachea. • Ventilation can occur whether the tube is the esophagus or the trachea. • Confirm placement: clinical exam and a confirmation device (see below).Advanced Airway (Con’t): • Contraindications: gag reflex, esophageal disease, caustic ingestion, under 16 yr. or 60 in.Endotracheal Tube (ETT): requires the most training, skill and frequentretraining for insertion. • Inserts by direct visualization of vocal cords. • Isolates the trachea, greatly reduces risk of aspiration, and provides reliable ventilation. • High risk of tube displacement or obstruction whenever patient is moved. • Confirm placement: clinical exam and a confirmation device (see below).Immediately confirm tube placement by clinical assessment and a device:►Clinical assessment: • Look for bilateral chest rise. • Listen for breath sounds over stomach and the 4 lung fields (left and right anterior and midaxillary). • Look for water vapor in the tube (if seen this is helpful but not definitive).►Devices: • End-Tidal CO2 Detector (ETD): if weight > 2 kg • Attaches between the ET and Ambu bag; give 6 breaths with the Ambu bag: • - Litmus paper center should change color with each inhalation and each exhalation. • Original color on inhalation = Okay O2 is being inhaled: expected. • Color change on exhalation = CO2!! Tube is in trachea. • Original color on exhalation = Oh-OH!! Litmus paper is wet: replace ETD. Tube is not in trachea: remove ET. Cardiac output is low during CPR.© Copyright 2006 S. Lunsford 8
  11. 11. Critical Concepts • Esophageal Detector (EDD): if weight > 20 kg and in a perfusing rhythm • Resembles a turkey baster: o Compress the bulb and attach to end of ET. o Bulb inflates quickly! Tube is in the trachea. o Bulb inflates poorly? Tube is in the esophagus. • No recommendation for its use in cardiac arrest.© Copyright 2006 S. Lunsford 9
  12. 12. Critical Concepts Arrhythmias During the course you will be expected to demonstrate your ability to identify the below arrhythmias. Pulseless Rhythms (Arrest Rhythms) Shockable Non-Shockable VF (Ventricular Fibrillation) PEA (Pulseless Electrical Activity) VT (Ventricular Tach Pulseless) Torsades de Pointes Asystole (Silent Heart) Perfusing Rhythms (Non-Arrest Rhythms) Bradycardia Tachycardias: Narrow QRS Sinus Bradycardia Regular Rhythms: Junctional Rhythm Sinus Tachycardia Idioventricular Rhythm Atrial Flutter Supraventricular Tachycardia Artioventricular Block: Junctional Tachycardia 1st Degree 2nd Degree: Mobitz Type I Irregular Rhythms: (Wenckebach) Atrial Flutter Mobitz Type II Atrial Fibrillation 3rd Degree Multifocal Atrial Tachycardia (Complete Heart Block) Tachycardias: Wide QRS Regular Rhythm: Ventricular Tachycardia- monomorphic Irregular Rhythms: Ventricular Tachycardia-polymorphic Torsades de pointes© Copyright 2006 S. Lunsford 10
  13. 13. Critical Concepts Electrical TherapyDuring the course you will practice and then demonstrate safe, effective technique and know indications.• Defibrillation: High energy single shocks with manual defibrillator:ECC handbook p.9 • Recommended shock dose: biphasic = 120- 200 J (per manufacturer) • Recommended shock dose: monophasic = 360 J• Synchronized Cardioversion: Timed low energy shocks: ECC Handbook p.14 • Timed to QRS to reduce risk of “R-on-T”: a shock that hits the T wave may cause VF• Transcutaneous Pacer: Noninvasive emergent bedside pacing: ECC Handbook p. 62. • Apply pacer pads. • Verify pacer capture. Vascular Access Be prepared to discuss• Peripheral: Preferred in arrest due to easy access and no interruption in CPR • Use a large bore IV catheter. • Attempt large veins: antecubital, external jugular, cephalic, femoral • Can take 1-2 minutes for IV drugs to reach the central circulation. • Follow IV drugs with a 20ml bolus of IV fluid, and elevate extremity for 10-20 seconds.• Intraosseous (IO): Inserts into a large bone and accesses the venous plexus. • May use if unable to obtain intravascular access. • Drug delivery is similar to that via a central line. • Safe access for fluids, drugs, blood samples and • Commercial kits are available for adult IO access. • Drug doses are the same as when given IV.• Central Line: Not needed in most resuscitations. • Insertion requires interruption of CPR. • If a central line is already in place and patent, it can be used.• Endotracheal: Some drugs may be given via the ETT in the absence of a IV/IO. • Drug delivery is unpredictable thus IV/IO delivery is preferred. • Drug blood concentration stays lower than when given IV. • Increase dose given to 2 - 2.5 times the recommended IV dose. • Drugs that absorb via the trachea: • N aloxone A tropine V asopressin E pinephrine L idocaine© Copyright 2006 S. Lunsford 11
  14. 14. Critical Concepts ACLS DrugsLook up drug dosages in the ECC Handbook .You may be allowed to use it as a reference in class. The Primary focus in cardiac arrest is effective CPR and early defibrillation. Drug administration is secondary and should NOT interrupt CPR. Know the timing of drug administration in CPR as shown: The Class of Recommendation number denotes potential benefit versus risk.General Statements:• Pulseless arrest, all: Give a Vasopressor drug – Epinephrine or Vasopressin Vasopressors cause peripheral vasoconstriction, which shunts increased blood flow to the heart and brain.• Pulseless ventricular rhythms: Consider antiarrhythmics – Amiodarone, Lidocaine, or Magnesium May make myocardium easier to defibrillate and/or more difficult for it to again fibrillate after conversion.• Bradycardia: Give a “Speed Up” drug - Atropine Atropine blocks vagal input and stimulates the SA node, which can increase heart rate. Consider dopamine and epinephrine infusions if unresponsive to atropine and waiting on a pacer. Dopamine and epinephrine may increase heart rate but also increase myocardial oxygen demand.• Tachycardia, Reentry SVT: Give a drug to interrupt the rhythm - Adenosine Adenosine blocks the AV node for a few seconds, which may break the re-entry pattern.• Tachycardia, AFib or AFlutter: to convert rhythm – Amiodarone. to slow rate – Beta Blocker. Dilitazem:• Tachycardia, VT, stable: to convert rhythm – Amiodarone. or Sync Cardiovert:• Acute Coronary Syndromes: First line treatment is “MONA”: ECC Oxygen increases the oxygen available to the ischemic or injured heart muscle. Aspirin decreases platelet clumping, the first step in forming a new blood clot. *** Nitroglycerin dilates coronary arteries so more oxygenated blood can reach the muscle and decrease pain; also dilates peripheral vessels decreasing the resistance the heart has to pump against. Morphine decreases pain not relieved by nitroglycerin; also dilates peripheral vessels decreasing resistance against which the heart has to pump. *** If allergic to Aspirin (ASA): Give Clopidogrel (Plavix) – affects platelet clumping similar to ASA.© Copyright 2006 S. Lunsford 12
  15. 15. Critical Concepts ACLS Core Cases 1-10 Study the algorithms and drugs well in the 2006 ECC Handbook. The following may help.1. Respiratory Arrest Case • The skills listed on p. 4-5 of the study guide will be practiced in most case scenarios.2. VF Treated with CPR and AED CaseYou are walking down the hall and the person in front of you suddenly collapses • Assess: - Tap, ask: Are you Okay? - No Movement or response, call 911 and get the AED!!! or if a second person is present, send them to call and get the AED • Primary ABCD Survey: - Airway: Open and hold (Head tilt – Chin lift or Jaw Thrust), Look, listen & Feel - Breathing: Give 2 breaths (1 second each) that make the chest rise • Avoid rapid or forceful breaths. - Circulation: Check carotid pulse – at least 5 but no longer than 10 seconds • Begin CPR if a definite pulse is not felt. o 30 Compressions: 2 ventilations = 1 cycle o Push hard: 1 ½ -2 inches deep o Push fast: 100 compressions per minute o Allow the chest wall to completely recoil ( take weight off hands) o Minimize interruptions • Recheck pulse after 5 cycles of CPR (Approx. 2 minutes) • 2 – Rescuer CPR, basic airway: Pause compressions to ventilate - Defibrillation: Automated External Defibrillator 1. Power On – Turn power on. (Some AEDs automatically turn on) 2. Attachment – Select Adult Pads, Attach pads to patient (upper right sternal border and cardiac apex), Attach cables to AED, if needed. 3. Analysis – Announce, “Analyzing rhythm – stand clear!” Press Analyze, if needed. 4. Shock – If shock indicated, Announce, “Shock is indicated. Stand Clear! I’m going to shock” Verify no one is touching the patient. Press shock button when signaled to do so. • If no shock indicated, follow prompts from AED.Unacceptable actions: • Did not provide effective CPR. • Did not follow AED’s commands. • Did not clear patient before shock (unsafe defibrillation)© Copyright 2006 S. Lunsford 13
  16. 16. Critical Concepts3. Pulseless Arrest: VF / Pulseless VT Case. ECC Handbook p. 7 left sideYou respond to a patient monitor alarm, to find the patient is unresponsive. Call for help and beginCPR (primary ABC survey). A team member arrives with the crash cart, which has a manualdefibrillator and advanced equipment. The patient is attached to the monitor and you identify andverify VF or PVT. • Primary D: Defibrillation: Shock #1 o After verifying the rhythm, Resume CPR while the defibrillator is charging. o Once Charged, Clear!!! Ensure that no one is touching the patient or bed. o Give 1 shock: biphasic defibrillators = Mfg recommendation, if unknown 200J Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles o After 5 cycles: check rhythm (shockable?), check pulse (5-10 seconds) • Secondary ABCD Survey: conducted between 1st and 2nd shock and Ongoing o Airway: o BVM with 100% O2 o Consider advanced airway placement: LMA, Combitube, or ETT o Breathing: o Check for visible chest rise with BVM o Confirm advanced airway placement by exam and confirmation device o Secure advanced airway in place with tape or a commercial device o Give 8-10 breaths/min and continuous compressions at 100 per minute. o Circulation: Establish Vascular access via IV or IO o Do not interrupt CPR for access. o Differential Diagnosis – Use the H’s and T’s mnemonic Defibrillation: Shock #2 o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds) o Resume CPR while defibrillator is charging o Once charged, Clear!!! Ensure no one is touching the patient or bed. o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles Medications: Administer either: Give during CPR • Epinephrine 1mg IV/IO (every 3 – 5 minutes) or • Vasopressin 40U IV/IO to replace first or second dose of epinephrine. Defibrillation: Shock #3 o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds) o Resume CPR while defibrillator is charging o Once charged, Clear!!! Ensure no one is touching the patient or bed. o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles Medications: Consider Antiarrhythmics: Give during CPR o Amiodarone 300mg IV/IO once, then consider additional 150mg IV/IO once. o Lidocaine 1-1.5mg/kg first dose then 0.5-0.75mg/kg IV/IO, max 3 doses or 3mg/kg o Magnesium 1-2g IV/IO loading dose for torsades de pointesUnacceptable actions: Did not provide effective CPR. Did not clear before shock Did not confirm advanced airway placement Did not give a vassopressor© Copyright 2006 S. Lunsford 14
  17. 17. Critical Concepts4. Pulseless Arrest: Pulseless Electrical Activity (PEA) Case5. Pulseless Arrest: Asystole CaseYou find that a patient is unresponsive. Call for help and begin CPR (primary ABC survey). A teammember arrives with the crash cart, which has a manual defibrillator and advanced equipment. Thepatient is attached to the monitor and you identify and verify Asystole or PEA. • Primary D: Defibrillation: NO Shock indicated for Asystole or PEA • Secondary ABCD Survey: Ongoing o Airway: o BVM with 100% O2 o Consider advanced airway placement: LMA, Combitube, or ETT o Breathing: o Check for visible chest rise with BVM o Confirm advanced airway placement by exam and confirmation device o Secure advanced airway in place with tape or a commercial device o Give 8-10 breaths/min and continuous compressions at 100 per minute. o Circulation: Establish Vascular access via IV or IO o Do not interrupt CPR for access. o Medication: Give a Vasopressor • Epinephrine 1mg IV/IO (repeat every 3-5 minutes) • Vasopressin 40 U IV/IO to replace first or second dose of epinephrine. • Consider Atropine 1mg for Asystole or PEA rate less than 60 o Check rhythm, check pulse after 2 minutes of CPR (5 cycles) o Differential Diagnosis – Use the H’s and T’s mnemonic 6 H’s 5 T’s Hypovolemia Toxins (Drug overdose) Hypoxia Tamponade, cardiac Hydrogen ion (acidosis) Tension pneumothorax Hypo-/hyperkalemia Thrombosis (coronary or pulmonary) Hypoglycemia Trauma Hypothermia o Consider Family members:Unacceptable actions: • Did not provide effective CPR. • Did not confirm advanced airway placement. • Did not give a vasopressor. • Did not look for reversible causes to treat. • Attempted defibrillation. • Attempted transcutaneous pacing for asystole© Copyright 2006 S. Lunsford 15
  18. 18. Critical Concepts6. Acute Coronary Syndromes (ACS) CaseYour neighbor complains of feeling weak and is sweaty, short of breath and slightly nauseated.You are worried this is an acute coronary problem and call 911. While waiting for their arrival, youask if he can take aspirin. He says yes, and you have him chew 2-4 baby aspirin (81mg) • EMS arrival: o Attach monitor, Start IV o Give MONA: o Obtain 12-lead ECG if available: o Notify hospital and transport o Begin fibrinolytic checklist: • Arrival at ED: Assess 12 – Lead ECG ST segment ST segment ST segment – T wave Elevation Depression Normal (STEMI) (Non-STEMI or NSTEMI) Injury Ischemia Non- diagnosticDrug Therapy: Drug Therapy: Consider admit to ED bed:• Beta blockers: ↓myocardial work Nitroglycerin: ↓ work Serial enzymes + Troponin:• Clopidogrel: ↓ platelet clumping Beta blockers ECC Handbook p. 37• Heparin: ↓ fibrin so new clot doesn’t form Clopidogrel Repeat ECGs Heparin Monitor ST segmentGoal is reperfusion by: IIb /IIIa inhibitor: ↓ platelet- Consider stress test fibrin bondingFibrinolytic: lyses fibrin in Admit to hospital bed if: Goal is revascularization: • Troponin positive• If <12 hours from onset • PCI or possible surgery • ST segment deviates• If no contraindications• ED door to drug goal = 30 • Refractory chest pain • Ventricular Tachycardia After revascularization • Becomes unstableOr PCI (percutaneous intervention: give: Angioplasty and/or stents) • Resume above drugs as Discharge if:• If < 12 hours from onset needed • No ischemia/ injury evolves• ED door to balloon goal = 90 min • ACE-inhibitor • Give follow-up directions • StatinAfter reperfusion give:• Resume above drugs• ACE-inhibitor: ↓ myocardial work• Statin: ↓ inflammation and arrhythmias© Copyright 2006 S. Lunsford 16
  19. 19. Critical ConceptsUnacceptable actions: • Did not give oxygen and aspirin to a suspected chest pain patient. • Did not attempt to control chest pain. • Did not obtain 12 – lead ECG.© Copyright 2006 S. Lunsford 17
  20. 20. Critical Concepts7. Bradycardia CaseA patient appears pale and complains of dizziness and fatigue. The pulse rate is 56, bloodpressure is 86/60 and on the monitor you identify a bradycardia rhythm. • Primary ABCD Survey: o Maintain patent airway; assist breathing as needed o Give oxygen o Monitor ECG (identify rhythm), blood pressure, oximetry o Establish IV access • Assess rhythm and perfusion: Is the heart rate <60 bpm or Inadequate for clinical condition Signs or symptoms of poor perfusion caused by the Bradycardia? (eg, acute altered mental status, ongoing chest pain, hypotension, or other signs of shock) Observe / Adequate • Prepare for transcutaneous pacing; Perfusion use without delay for high-degree block Monitor (type II second-degree block or third-degree AV block) • Consider Atropine 0.5mg IV while awaiting pacer. May repeat to a total dose of 3mg. If ineffective, begin pacing • Consider epinephrine (2 to 10 ug/min)or dopamine (2 to 10 ug/kg per min) infusion while awaiting pacer or if pacing ineffective© Copyright 2006 S. Lunsford 18
  21. 21. Critical Concepts Poor Perfusion Reminders • If pulseless arrest develops, go to Pulseless Arrest Algorithm. • Search for and treat possible contributing factors: -Hypovolemia -Toxins -Hypoxia -Tamponade, cardiac -Hydrogen Ion (acidosis) -Tension pneumothorax -Hypo/hyperkalemia -Thrombosis (coronary or -Hypoglycemia pulmonary) • Prepare for transvenous pacing -Hypothermia -Trauma (hypovolemia, • Treat contributing causes Increased ICP) • Consider expert consultationUnacceptable actions: Did not identify a high-degree block Did not initiate TCP immediately for high-degree block Treated asymptomatic patient as if had poor perfusion 8. Unstable Tachycardia Case 9. Stable Tachycardia Case A patient appears pale and complains of dizziness and fatigue. The pulse rate is 170, blood pressure is 100/60 and on the monitor you identify a tachycardia rhythm. • Primary ABCD Survey: o Assess and support ABC’s as needed o Give Oxygen o Monitor ECG (identify rhythm), blood pressure, oximetry o Identify and treat reversible causes • Is patient stable? Unstable signs include altered mental status, ongoing chest pain, hypotension, or other signs of shock. Note: Rate-related symptoms uncommon if heart rate <150/min Unstable – Perform Immediate synchronized Cardioversion o Establish IV access and give sedation if patient is conscious: do not delay Cardioversion o Consider expert consultation o If pulseless arrest develops, see Pulseless Arrest Algorithm • Stable – See chart below. o Establish IV access o Obtain 12-lead ECG (when available or rhythm strip) o Is QRS narrow (<0.12sec)? © Copyright 2006 S. Lunsford 19
  22. 22. Critical Concepts Narrow QRS: Wide QRS: Is Rhythm regular? Is Rhythm regular? Expert consultation advised Regular Irregular Regular Irregular • Attempt vagal maneuvers If ventricular If atrial fibrillation with • Give Adenosine 6mg rapid IV tachycardia or aberrancy push. If no conversion, give uncertain rhythm • See Irregular Narrow Complex tachycardia 12mg rapid IV push; may repeat • Amiodarone 12mg dose once 150mg IV over If pre-excited atrial 10 min Repeat as fibrillation (AF+ WPW) needed to max • Expert consultation Irregular Narrow-Complex dose of 2.2g/24hr advised Does rhythm Tachycardia • Prepare for • Avoid AV nodal convert? Probable atrial fibrillation or elective blocking agents (eg, Note: Consider possible atrial flutter or MAT Synchronized adenosine, digoxin, expert (Multifocal atrial tachycardia) Cardioversion diltiazem, verapamil) consultation • Consider expert consultation • Consider • Control rate (eg, diltiazem, If SVT with antiarrhythmics (eg, B-blockers, use B-blockers aberrancy: amiodarone 150mg IV with caution in COPD and CHF • Give Adenosine over 10 min) Converts Does Not Convert 6mg rapid IV push. If no If recurrent If rhythm converts, If rhythm does NOT convert, conversion, give polymorphic VT, seek probable reentry possible atrial flutter, 12mg rapid IV expert consultation SVT: ectopic atrial tachycardia, push, may repeat - Observe for or Junctional tachycardia: 12mg dose once If torsades de pointes, recurrence - Control rate give magnesium - Treat recurrence - Treat underlying cause (load with 1-2g over with adenosine or - Consider expert 5-60 min, then infusion) longer-acting AV consultation nodal blocking agent10. Acute Stroke CaseYou find a normally alert, active adult in a chair staring blankly at the television and leaning to oneside. • Identify signs of possible stroke o Critical EMS assessments and actions • Support ABC’s; give oxygen if needed • Perform prehospital stroke assessment: - The Cincinnati Prehospital Stroke Scale o Facial Droop (have the patient show teeth or smile) o Arm Drift (patient closes eyes and extends both arms straight out with palms up, for 10 seconds) o Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”) - Los Angeles Prehospital Stroke Screen ECC Handbook p. 18 • Establish time when patient last known normal (symptoms onset) • Transport; consider triage to a center with a stroke unit if appropriate; consider bringing a witness, family member, or caregiver • Alert Hospital • Check glucose if possible© Copyright 2006 S. Lunsford 20
  23. 23. Critical Concepts o ED Arrival: Immediate general assessment and stabilization < 10min • Assess ABCs, vital signs • Provide oxygen if hypoxemic • Obtain IV access and blood samples • Check glucose; treat if indicated • Perform neurologic screening assessment • Activate stroke team • Order emergent Non-contrast CT scan of brain • Obtain 12-lead ECG o ED Arrival: immediate neurologic assessment by stroke team < 25min • Review patient history • Establish symptom onset • Perform neurologic examination (NIH Stroke Scale) o Does CT scan show any hemorrhage? < 45min • Hemorrhage – Consult neurologist or neurosurgeon; consider transfer • No Hemorrhage - Probable acute ischemic stroke; consider fibrinolytic therapy o Check for fibrinolytic exclusions ECC Handbook p.20 o Repeat neurologic exam: are deficits rapidly improving? • Patient remains candidate for fibrinolytic therapy? - Not a candidate o Administer aspirin - Candidate < 60min o Review risks/benefits with patient and family: o If acceptable- Give tPA No anticoagulants or antiplatelet treatment for 24 hours© Copyright 2006 S. Lunsford 21
  24. 24. PRINTED Name___________________________ACLS Precourse Self-AssessmentAnswer SheetCircle the correct answers Please fill in the correct rhythm for 1. A B C D questions 31-40 2. A B C D 3. A B C D 31._____________________________ 4. A B C D 5. A B C D 32._____________________________ 6. A B C D 7. A B C D 33._____________________________ 8. A B C D 9. A B C D 34._____________________________ 10. A B C D 11. A B C D 35._____________________________ 12. A B C D 13. A B C D 36._____________________________ 14. A B C D 15. A B C D 37._____________________________ 16. A B C D 17. A B C D 38._____________________________ 18. A B C D 19. A B C D 39._____________________________ 20. A B C D 21. A B C D 40._____________________________ 22. A B C D 23. A B C D 24. A B C D 25. A B C D 26. A B C D 27. A B C D 28. A B C D 29. A B C D 30. A B C D
  25. 25. ACLS Precourse Self-AssessmentAnswer KeyCircle the correct answers Please fill in the correct rhythm for 1. D questions 31-40 2. B 3. C 31. Normal Sinus Rhythm 4. C 5. A 32. Second Degree Atrioventricular 6. C Block 7. A 8. B 33. Sinus Bradycardia 9. A 10. C 34. Arial Flutter 11. B 12. C 35. Sinus Bradycardia 13. A 14. A 36. Third Degree Atrioventricular 15. D Block 16. B 17. C 37. Atrial Fibrillation 18. D 19. B 38. Monomorphic Ventricular 20. A Tachycardia 21. C 22. C 39. Polymorphic Ventricular 23. A Tachycardia 24. D 25. C 40. Ventricular Fibrillation 26. D 27. A 28. C 29. D 30. D
  26. 26. Critical Concepts References: American Heart Association 2005 ECC Guidelines We look forward to providing an enjoyable, informative learning experience.Please call us directly for any questions or concerns at 1.800.427.6355 x 201 andspeak with Jesus Pacheco, Administrator Or Shawn Nies, RN,EMT-P Director of Education© Copyright 2006 S. Lunsford 22