ACLS Review: ACLS Review 2005 Guidelines


ABCD: ABCD Witnessed or unwitnessed collapse- Verify unresponsiveness Call 911 Get AED Start CPR Asphyxial Victim Verify unresponsiveness Provide 5 cycles of 911 Get AED


AIRWAY: AIRWAY head tilt-chin lift - try 1-2 times to open airway jaw thrust without head extension- if trauma suspected


Breathing: Breathing Verify not breathing: Give 2 breaths that make the chest rise at 1 sec/breath Abdominal thrusts for foreign body Rescue breathing only 10-12 breaths/min Recheck pulse every 2 minutes


Breathing: Breathing Rescue breathing with CPR Use 30:2 ration compressions to ventilations Push hard and fast at 100/min Release completely Minimize interruptions in compressions


Breathing: Breathing Rescue breathing; CPR: Advanced airway Push hard and fast at 100/min without pauses for ventilation 8-10 breaths /min


Circulation: Circulation Check pulse Check carotid pulse up to 10 sec Check upt to 30-45 sec if hypothermic Minimize CPR interruptions


Circulation: Circulation 1 or 2 Rescuer CPR Use 30:2 ratio at 100/min. Push hard and fast at 1.5-2 inches Allow complete recoil Heels of both hands between nipples If two rescuers rotate compressor role every 2 minutes


Defibrillation with AED: Defibrillation with AED Settings Monophasic-360 Joules Biphasic Manual: 150-200 second dose same or higher Use adult pads


Defibrillation: Defibrillation Sequence Begin/resume CPR immediately after shock delivered: Check rhythm every 5 cycles or 2 minutes Continue until ALS providers arrive or victim starts to move


Asytole/PEA: Asytole/PEA Rapid Scene survey Check for DNR order, signs of death Determine if resuscitation efforts are appropriate before initiating CPR Initiate PRIMARY ABCDs-


Asytole/PEA: Asytole/PEA Primary ABCDs Check responsiveness Activate EMS and call for Defibrillator


Secondary ABCDs: Secondary ABCDs Airway, breathing, circulation, differential diagnosis Place airway device Confirm using two methods and secure device Establish IV Attach cardiac monitor CPR now continuous with 8-10 breaths /min


Secondary ABCDs: Secondary ABCDs Treat reversible causes 6Hs Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia hypothermia


Secondary ABCDS: Secondary ABCDS Treat reversible causes 5 T’s Toxins Tamponade Tension Pneumothorax Thrombosis trauma


Asystole/PEA: Asystole/PEA Resume CPR for 2 minutes Give 5 cycles or 2 minutes CPR before next rhythm check Give meds during CPR


Asystole/PEA: Asystole/PEA EPINEPHRINE 1 mg IV push q 2-5 minutes Alternate-2-2.5 mg ETT q 3-5 min prm 1 mg= 10 ml 1:10,000 solution


Asystole/PEA: Asystole/PEA VASOPRESSIN (40 units IV or IO once) May be used to replace 1st or second dose of epinephrine


Asystole/PEA: Asystole/PEA ATROPINE- 1m IV/IO push q 3-5 min Max- 3 doses or 0.04 mg/kg total Used for asystole or slow PEA rate


Asytole/PEA: Asytole/PEA Resume CPR for 2 minutes give 5 cycles or 2 minutes of CPR before next rhythm check Give meds during CPR


Asystole/PEA: Asystole/PEA Cease Resuscitation Reevaluate after a trial of CPR and ACLS Decision of whether to cease resuscitation efforts should be made


Bradycardia: Bradycardia Determine Rate Absolute or relative bradycardia Rate less than 60/minute or slower than expected for underlying condition or cause


Bradycardia: Bradycardia Evaluate Patient Primary and Secondary ABCDS Secure airway Oxygen IV Access Pulse oximeter Cardiac monitor Blood pressure cuff 12 lead EKG Portable chest Xray


Bradycardia: Bradycardia Evaluate Patient (Continued) Primary and Secondary ABCDS assess vital signs Focused history and exam Consider acute MI


Bardycardia: Bardycardia Treat Reversible causes: 6Hs 5Ts


Bradycardia: Bradycardia Adequate perfusion Observe and monitor Poor perfusion Prepare for transcutaneous pacing Do not delay with IV access or Atropine Use without delay for type II second degree or third degree block Consider Atropine- Dose: ).5 mg q 3-5 minutes prn- Total max is 3 mg


Bradycardia: Bradycardia Atropine (continued) If patient has had a heart transplant go directly to pacing and/or dopamine or epinephrine Consider Epinephrine- Dose 2-10 mcg/min IV Use if unresponsive to atropine or for refractory and profoundly symptomatic bradycardia


Bradycardia: Bradycardia Consider Dopamine- Dose: 2-10 mcg/kg/minute if unresponsive to atropine May be administered with epinephrine or alone


VF/Pulseless VT: VF/Pulseless VT Primary ABCDs Defibillate Unsynchronized one time Use monophasic 360 J or Biphasic 120-200 Joules Resume CPR immediately Resume CPR 5 cycle of CPR before next rhythm check


VF/Pulseless VT: VF/Pulseless VT Secondary ABCDs Resume CPR- Give 5 cycles or 2 minutes CPR before next rhythm check Give meds during CPR


VF/Pulseless VTach: VF/Pulseless VTach Epinephrine- Dose: 1mg/IV/IO q 3-5 min If no IV site may give 2-2.5 mg per ETT q 3-5 minutes prn 1 mg =10 ml o 1:10,000 solution Consider Vasopressin- dose: 40 units IV X1 May be used to replace 1st or second dose of epinephrine


VF/Pulseless VT: VF/Pulseless VT Defibrillate Unsynchronized one time Monophasic 360 Joules or Biphasic 150-200 J Resume CPR Immediately after shock Give 5 cycles or 2 min CPR before next rhythm check Give meds during CPR


VF/ Pulseless VT (meds): VF/ Pulseless VT (meds) Consider Other Drugs: Amiodarone-dose: 300 IV push one time May give 150 mg in 3-5 minutes in VF/Pulseless VT recurs Max: 2.2 grams in 24 hours If patient stable infuse 1 mg/min for 6 hours and 0.5 mg/min fir 18 hours Lidocaine- Dose: 1-1.5 mg/kg Iv first dose Second dose 0.5 to 0.75 mg/kg IV Max is 3 doses or 3 mg/kg If no IV may be given 2-4 mg/kg per ETT


VF/Pulseless VTach (Meds2): VF/Pulseless VTach (Meds2) Consider Magnesium sulfate Dose: 1-2 Grams IV over 1-2 minutes if it is Torsades de Pointes


TachycardiaStable Narrow Complex: Tachycardia Stable Narrow Complex Evaluate patient- verify pulses present Oxygen 12 lead EKG BP Pulse oximetry Measure EF or assess clinical signs Identify and treat reversible causes


TachycardiaStable narrow complex: Tachycardia Stable narrow complex Verify Rhythm- 12 lead EKG and or rhythm strip with <0.12 sec and regular Treat Reversible causes 6Hs 5Ts


TachycardiaStable narrow complex: Tachycardia Stable narrow complex Regular rhythm Vagal maneuvers (Stimulation) Carotid massage, valsalva: terminates 25 % of SVT 75% will need Adenosine Adenosine- Dose: 6 mg rapid IV push 1-3 seconds followed by 20 cc saline flush May give 2 additional doses of 12 mg at 1-2 min, intervals Reduce initial dose 50% if central line, heart transplant, carbamezepine or dipyridamole use


TachycardiaStable Narrow Complex: Tachycardia Stable Narrow Complex Rhythm converts to NSR Probable reentry SVT’ Treat recurrence with adenosine, diltiazem 15-20 mg IV over 2 minutes, verapamil 2.5- 5 mg IV over 2-3 minutes or beta blockers such as atenolol or Metoprolol 5 mg IV over 5 minutes Use beta blockers with caution in Pulm disease or CHF Consider expert consultation


TachycardiaStable Narrow Complex: Tachycardia Stable Narrow Complex Rhythm does not convert Possible atrial flutter, ectopic atrial tach, or junctional atrial tach Control rate with diltiazem 15-20 mg IV over 2 minutes: Verapamil 2.5- 5mg IV over 2-3 minutes or Beta blockers such as atenolol IV or Metoprolol 5mg IV over 5 Minutes-Using caution in CHF and Pulmonary disease Consider the 6Hs and 5 Ts and treat causes Consider expert consultation


TachycardiaStable Narrow Complex: Tachycardia Stable Narrow Complex Irregular Rhythm- Afib. Aflutter, Multifocal atrial tach Consider expert consultation Control rate with Diltiazem, verapamil, or beta blockers as with regular rapid rhythm Caution using beta blockers with pulmonary disease or CHF


Tachycardia Wide Complex: Tachycardia Wide Complex Evaluate patient- Verify Rhythm 12 lead EKG and/or Rhythm strip with QRS>0.12 sec and regular Expert consultation is advised Regular rhythm- VT or uncertain rhythm Amiodarone 150 mg IV over 10 minutes repeat prn up to 2.2 g/24h Prepare for elective cardioversion


Tachycardia Wide Complex: Tachycardia Wide Complex Regular Rhythm SVT with abberancy Adenosine 6 mg IV push over 1-3 sec followed by 20 ml saline flush May give 12 mg time two more doses every 1-2 minutes, reducing initial dose with central line, heart transplant, carbemazepine or dipyridamole use


Tachycardia Wide Complex: Tachycardia Wide Complex Irregular Rhythm Afib with abberancy Consider expert consultation Control rate with Diltiazem, verapamil, or beta blockers Afib with Wolf Parkinson White Expert consultation advised Avoid adenosine, digoxin, diltiazem, verapamil Consider amiodarone 150 mg IV over 10 min


Tachycardia Wide Complex: Tachycardia Wide Complex Irregular Rhythm Recurrent Polymorphic VT Seek expert consultation Torsades de Pointes Stop meds that prolong QT Stop Toxic drugs Check electrolytes Give magnesium sulfate 1-2 grams in 50-100 ml D5w over 5-60 min May follow with 0.5-1 g/h IV


TachycardiaUnstable: Tachycardia Unstable Evaluate Patient-serious signs and symptoms Chest pain Dyspnea Decreased level of consciousness Hypotension Shock Pulmonary congestion CHF Acute MI VERIFY PRESENCE OF PULSE


TachycardiaUnstable: Tachycardia Unstable Evaluate Rate- Regular rate>150 /min Prepare for immediate cardioversion May give brief trial of meds for specific arrhythmias Defibrillate polymorphic VT Regular rate <150/min Rate–related symptoms uncommon: immediate cardioversion generally not needed Observe for changes


TachycardiaUnstable: Tachycardia Unstable Premedicate if possible-sedative plus analgesic if cardioversion necessary Place oximetry IV access present Intubation equipment at bedside Suction equipment set up


TachycardiaUnstable: Tachycardia Unstable Synchronized cardioversion- increase energy stepwise Consider expert consultation Use monophasic 100, 200, 300, 360 J Use biphasic equivalent: Start at 50 J for atrila flutter, 200 J for monomophic VT


Rapid Sequence Intubation: Rapid Sequence Intubation Pre event Preparation Assess pt history Assess Primary ABCDs Prepare: Personnel Equipment Medications


Rapid Sequence Intubation: Rapid Sequence Intubation Preoxygenate 100% oxygen 10-15 l/min Use tight – fitting face mask if breathing spontaneously Other wise ventilate gently Apply cricoid pressure if unconscious


Rapid Sequence Intubation: Rapid Sequence Intubation Pretreat/ Premedicate use in conscious patients if indications listed are present Step 1: Lidocaine 1.5 mg/kg IV if increased ICP or reactive airway disease present Step 2: Fentanyl 3 mcg/kg IV if not contraindicated Step 3: Atropine 0.02mg/kg IV if bradycardic, age <12 mo., age 1-5 years if getting only one dose of succinylcholine, and all ages if getting more than one dose of succinylcholine


Rapid Sequence Intubation: Rapid Sequence Intubation Step 4: defasciculating agent IV at 10% paralyzing dose Paralyze after sedation- wait three minutes after premedications Step 1: Induce with one of the following: Etomidate ).2-0.6 mg/kg IV Fentanyl 2-10mcg/kg IV Ketamine 2 mg/kg IV Midazolam 0,07-0,3 mg/kg IV


Rapid Sequence Intubation: Rapid Sequence Intubation Paralyze continued Step 2 : Paralyze with succinylcholine 1-2 mg/kg IV push Assess pt for intubation readiness Protection/Positioning- wait 30 sec after suc before placement Apply cricoid pressure just as airway protective reflexes lost, maintain until tube placed.


Rapid Sequence Intubation: Rapid Sequence Intubation Placement/ Confirmation Intubate Monitor HR, Pulse oximetry, appearance of patient: if deterioration occurs interrupt to ventilate with 100% Oxygen via bag- mask: Inflate balloon cuff when tube in place


Rapid Sequence Intubation: Rapid Sequence Intubation Placement/ Confirmation ( Continued) Primary Placement verification- Direct visualization of tube passing through vocal cords Chest rise/fall bilaterally with each ventilation 5 point chest ausculation


Rapid Sequence Intubation: Rapid Sequence Intubation Placement/ Confirmation ( Continued) Secondary Placement verification- Esophageal detector device if pt in cardiac arrest End tidal detector device if perfusing rhythm present Monitor pulse oximeter Monitor end tidal CO2 levels


Rapid Sequence Intubation: Rapid Sequence Intubation Postintubation Management- oxygenate and ventilate Secure tube with commercial holder (preferred) or tape Consider C- spine if in field Obtain Xray confirmation of tube placement