ACLS Flashcards
How to do CPR
CPR 2” compression depth, 100-120bpm x2 mins, pulse check no longer than 10s. Use visual and audio feedback devices.
When to stop CPR
Stop CPR after 20 mins if no ROSC or no viable rhythm evident, and no reversible factors, pre-existing chronic illness that would prevent recovery, acute illness that would prevent recovery, 20 mins in agonal or asystole
What are the exceptions to stopping CPR?
Exceptions:
Hypothermia (need to be warmed before pronounced dead)
Asthma (reversible factors = hyperinflation)
Young person with persistent VF until reversible factors managed
Toxicology arrest
Thrombolytics given during CPR - must continue for 2 hrs
Pregnant woman until C/S taken place
Any reversible factors that can be corrected
management of bradycardia
MOVIE - monitors, oxygen if <94%, vitals, IV access, ECG
Asymptomatic - monitor
Symptomatic (hypotension, altered mental status, angina, acute HF) - atropine 0.5mg, repeat every 3-5 mins up to 6 doses
Not responding - pads on - transcutaneous pacing - sedation, change machine to pacer mode, set desired HR, increase milliampss until pacer spike followed by QRS complex
Consider dobutaminr 2-20mcg/kg/min titrate up
Epi 2-10mcg/kg/min titrate up
Management of tachycardia
Pulse or pulseless
MOVIE - monitors, oxygen if <94%, vitals, IV access, ECG
SVT - narrow (<120), regular, retrograde p waves, originates from above Bundle of His. Can be wide if there is abherrancy or WPW
Stable - valsalva, then adenosine 6mg then 12mg, then BB or CCB
Unstable - synchronised cardioversion - sedation, sync, energy level 50-100J, increase as needed
If wide complex tachy (regular, monomorphic) = adenosine. If irregular, get consult - may need amiodarone
AFib - irregularly irregular, no p waves
Symptomatic - sedation, sync, energy level 200J, increase as needed
VF - wide, rapid, irregular rhythm, various amplitudes, no PQRST waves
Defibrillation
VT - wide complex, regular, faster than 150 bpm.
Pulseless = go to cardiac arrest algorithm
Symptomatic w wide complex regular = synchronised cardioversion at 100J
Symptomatic w/ wide complex irregular = defibrillation dose
Can use Brugada criteria to determine if VT
2nd degree Mobitz 1 (Wenkebach)
Reversible conduction block at AV node. PR interval lengthens with each cycle, then drops. Usually benign. Responds to atropine if needed
2nd degree Mobitz 2
consistent PR interval with spontaneous drop of QRS complex. D/t failure of conduction at His/ Purkinje level. D/t structural damage. Associated with bradycardia and instability, may need transcutaneous pacing + definitive pacer
3rd degree
- complete loss of conduction between atria and ventricles. Complete independence of P waves and QRS complex. Separate rates for each. Need admission, transcutaneous pacing, needs permanent pacer
ventilation in ACLS
Adequate ventilation: Adult = 1 breath with enough vol to see chest rise every 5-6s, should go in quickly (1s). Child = 1 breath with enough vol to see chest rise every 3-4s
Avoid barotrauma
Positional changes - head tilt, chin lift or jaw thrust if concern for C spine
Use OPA or NPA if unconscious
OPA - corner of mouth to angle of mandible
Advanced airway - try LMA if needed for transfer. ROSC but not return of GCS = definitive airway
Reversible causes of cardiac arrest
Hypovolemia
Hypothermia
H+ excess (acidosis)
Hypoglycemia
Hypo/ hyperkalemia
Thrombosis of coronary artery (MI)
Thrombosis of pulmonary artery (PE)
Toxins
Tamponade
Tension pneumothorax
Management of hyperkalemia
Management:
Hold meds that increase K+ - NSAIDs, ACEi
If <6.5 - stop meds
If ECG changes, symptomatic or >7:
IV calcium gluconate 1.5-3g over 2-5 mins (1-2 amps IV)
Insulin 10 units + 1 amp D50W IV (contains 25g glucose) - measure glucose Q1H
Bicarb 1-3 amps diluted in 1L D5W
Salbutamol nebs 10mg inhaled or 0.5mg IV
Furosemide 40mg IV - may need to maintain fluid volume with IVF
Lactulose or kexalate to remove K+ via GI tract
Last resort: dialysis
Digoxin toxicity - chronic vs acute, Sx, management
Chronic toxicity occurs in elderly cardiac pts taking digoxin long term
Acute toxicity occurs with accidental or intentional OD
10mg in adults
4mg in kids
Sx: N/V, abdo pain, arrhythmias (most commonly PVCs), fatigue, weakness, confusion, hyperkalemia
Don’t wait for serum digoxin level before treatment
Management: supportive, charcoal if recent ingestion, Digibind (Digoxin antibody fragment) if unstable or hyperkalemia - need ICU for 6-12 hrs, extended obs w/ serum digoxin levels
What to include in convo about code status
Discuss with patients with end-stage disease or multiple medical issues, including advanced directives
I - introduce idea of advanced care planning
D - discuss understanding, goals, functions they wouldn’t want to live without, fears, medical interventions they would/ wouldn’t want
D - decide on SDM
D - document, identify SDM
how to manage families during cardiac arrest
1) assess pts wishes via prior communications or advanced directives
2) communicate with family during resus
3) Offer for family to be present during resus if feasible
4) assess likely outcomes
5) in conjunction with family + PCP, weigh risks and benefits of resus
6) consider teaching procedures with consent of surrogate
7) use MDT approach to family communications - use SW
8) provide spiritual, psychosocial and education support to family throughout + after resus
What resources to use in peds resus
Pedistat
Lexicomp for peds dosing
Pedmed.org
Breslow tape - red end of tape at head, use colour at feet to determine ideal weight
