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