ACLS

Question 1

Advanced Cardiac Life Support

Answer 1

-ACLS is a series of evidence based responses simple enough to be committed to memory and recall under moments of stress. AMerican Heart Association (AHA) protocols are considered to be the GOLD standard ACLS protocols it gets reviewed every 5 years

Question 2

Importance of BLS in ACLS

Answer 2

-ACLS in built heavily upon the foundation of BLS

Question 3

AHA Adult Chain of Survival

Answer 3

1.)Immediate recognition of cardiac arrest and activation of emergency response system

2.)Early CPR with an emphasis on chest compressions

3.)Rapid defibrillation

4.)Effective advanced life support

5.)Integrated post-cardiac arrest care

Question 4

AHA PEDIATRIC Chain of Survival

Answer 4

Prevent Arrest -> Perform Early CPR -> Activate EMS -> Advanced Life Support -> Post Cardiac Arrest Care

Question 5

COMPONENT OF HIGH QUALITY CPR IN BLS

Answer 5

Scene safety:

Make sure the environment is safe for rescuers and victim

Recognition of cardiac arrest:

Check for responsiveness

No breathing or only gasping (ie no normal breathing)

No definite pulse felt within 10 secs ( Carotid or femoral pulse)

(Breathing and pulse check can be performed simultaneously within 10 secs)

• Activation of emergency response system:

-If alone with no mobile phone, leave the victim to activate the emergency response system and get the AED before beginning CPR

-Otherwise, send someone and begin CPR immediately ; use the AED as soon as it is available

Question 6

• WITNESSED

Answer 6

• IFALONE

• ACTIVATE EMS

• THEN CPR

• IF 2 RESCUERS

• START CPR

• SECOND ONE - ACTIVATE EMS

Question 7

• UNWITNESSED

Answer 7

• START CPR

• GIVE FOR 2 MINS

• ACTIVATE EMS

Question 8

Chest compression Adult

Answer 8

30:2

Question 9

Children or infant-

Answer 9

30:2 if one rescuer

15:2 if more than one rescuer

Question 10

Compression rate:

Answer 10

100-120/ min

Question 11

Compression depth:

Answer 11

Adult- at least 5 cm

Children or infant- at least 1/3rd AP diameter of chest

Question 12

Hand placement:

Answer 12

Adult - 2 hands on the lower half of the sternum

Children - 1 or 2 hands on the lower half of the sternum Infants - 2 fingers or 2 thumb defending of the number of rescuers Chest recoil:

allow full recoil of chest after each compression; do not lean on the chest after each compression.

Minimizing interruption: Limit interruptions in chest compressions to less than 10 secs.

Question 13

Ventricular Tachycardia

Answer 13

• R-R interval usually regular, not always

• QRS not preceded by p wave.

• Wide and bizzare QRS.

• Difficult to find seperation between QRS and T

wave

Rate=100-250bpm

Question 14

Torsades de Pointes

Answer 14

. Twisting of points, is a distinctive form of polymorphic ventricular tachycardia characterized by a gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line.

Rate cannot be determined

Question 15

Ventricular Fibrillation

Answer 15

A severely abnormal heart rhythm (arrhythmia) that can be life-threatening.

No identifiable P, QRS or T wave Emergency-requires Basic Life Support

Rate cannot be discerned, rhythm unorganized

Question 16

Asystole

Answer 16

a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow.

Rate, rhythm, p and QRS are absent

Question 17

Pulseless Electrical Activity

Answer 17

• Pulseless electrical activity (PEA)

• unresponsiveness and no palpable pulse

• some organized cardiac electrical activity.

• Previously referred to as electromechanical dissociation

Question 18

Asystole/PEA

Answer 18

Continuous CPR (intubate and establish IV Access)-> Identify and RX reversible causes-> Continue CPR is asystole/PEA

Question 19

Treatable Causes of Cardiac Arrest: The Hs and Ts

The Five Hs

Answer 19

-H’s

	-Hypoxia

	-Hypovolemia

	-Hydrogen ion (acidosis)

	-Hypo-/hyperkalemia

	-Hypothermia

Question 20

Treatable Causes of Cardiac Arrest: The Hs and Ts

Ts

Answer 20

T’s

	-Toxins

	-Tamponade (cardiac)

	-Tension Pneumothorax

	-Thrombosis, pulmonary

	-Thrombosis, Coronary

Question 21

Defibrillation

Answer 21

-Biphasic wave form: 120-200 J

-Monophasic wave form: 360 J

-AED- device specific


-Failure of a single adequate shock to restore a pulse should be followed by continued CPR and second shock delivered after five cycles of CPR

Question 22

How to use defibrillator

-Safety

Answer 22

-If PT not intubated remove o2 delivery devices

	-If intubated either leave bag valve resuscitator attached to Et or remove it

	-If available use self adhesive defibrillation pads

	-Do not place over pacemakers

	-Remove transdermal patches

Question 23

How to use defibrillator

Procedures

Answer 23

-Place sternal paddle over right of the sternum below clavicle

-Place apical paddle in mid axillary line in 5th IC space

-Switch on the defibrillator

-Charge the Defibrillator to 200J or 360J

-Warn all other rescuers to stand clear -” ARE YOU CLEAR”

-Visually check all are clear

-Ensure yourself you are not touching PT or bed “AM I CLEAR”

-Deliver shock restart cpr with out checking pulse

Question 24

Automatic External Defibrillator

Answer 24

• Switch on AED.

• Attach electrode pads.

• Place electrodes as that of manual one

• Follow voice commands

• Make sure no one in contact with patient

• Push shock button.

Question 25

1-Shock Protocol Versus 3- Shock Sequence

Answer 25

• Evidence from 2 well-conducted pre/post design studies suggested significant survival benefit with the single shock defibrillation protocol compared with 3-stacked-shock protocols • If 1 shock fails to eliminate VF, the incremental benefit of another shock is low, and resumption of CPR is likely to confer a greater value than another shock

Question 26

Airway and Ventilations

Answer 26

• Opening airway - Head tilt, chin lift or jaw thrust, in addition explore the airway for foreign bodies, dentures and remove them.

Question 27

Breathing devices

Answer 27

BASIC AIRWAYS • Oropharyngeal airway • Nasopharyngeal airway ADVANCED • Endotracheal tube • Laryngeal mask airway • Laryngeal tube • Esophageal tracheal tube

Question 28

Pharmacotherapy Routes of Administration

Answer 28

-Peripheral IV - must followed by 20 ml NS push  -Central IV - fast onset of action, but do not wait or waste time for CV line -Intraosseous - alternative IV route in peds, also in Adult -Intratracheally (down an ET tube) - not recommended now a days

Question 29

Amiodarone (Cordarone)

Answer 29

Indications: Vtach, Vfib • IV Dose: • 300 mg in 20-30 ml of N/S • Supplemental dose of 150 mg in 20-30 ml of N/S • Followed with continuous infusion of 1 mg/min for 6 hours then .5mg/min to a maximum daily dose of 2grams

Question 30

Lidocaine

Answer 30

• Indications: VT, VF Can be toxic so no longer given prophylactically • IV dose : 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min Can be given down ET tube • Signs of toxicity: slurred speech, seizures altered consciousness

Question 31

Magnesium

Answer 31

Used for refractory VF or VT caused by hypomagnesemia and Torsades de Pointes Dose: 1-2 grams IV or 10 over 2 minutes • Side Effects Hypotension Asystole

Question 32

Propranolol/ Esmolol

Answer 32

• Beta blocker that may be useful for VF and VT that has not responded to other therapies • Very useful for patients whose cardiac emergency was precipitated by hypertension

Question 33

Epinephrine

Answer 33

• Alpha, beta-1, and beta-2 stimulation • Increases heart rate, stroke volume and blood pressure • IV Dose: 1 mg every 3-5 minutes May increase ischemia because of increased Oxxgen demand by the heart

Question 34

Sodium Bicarbonate

Answer 34

• METABOLIC acidosis / hyperkalemia • Airway and ventilation have to be functional • IV Dose: Can be given bolus or infusion - 1 mEq/kg of idea body weight, followed by 0.5 mg/kg every 10 min. • Side effects: • Metabolic alkalosis • Increased CO2 production

Question 35

Adult bradycardia Algorithm With Issues

Answer 35

1.)Assess appropriateness for clinical conditions Heart rate typically <50/mon if bradyarrhythmia  2.) Identify and treat underlying cause -Maintain patent airway: assist breathing necessary -Oxygen (if hypoxemic) -Cardiac monitor to identify rhythm: monitor blood pressure and oximetry -IV access -12- lead ECG if available, don't delay therapy  -Consider possible hypoxic and toxicologic causes  3.) Persistent bradyarrhythmia causing: -Hypotension?  -Acutely altered mental status? -Signs of shock? -Ischemic chest discomfort? -Acute heart failure? -If yes 4.) Atropine  -If atropine ineffective  -Transcutaneous pacing and or  -Dopamine infusion  -Epinephrine infusion  5.) Consider -Expert consultation -Transvenous pacing

Question 36

Adult bradycardia Algorithm With No Issues

Answer 36

1.)Assess appropriateness for clinical conditions Heart rate typically <50/mon if bradyarrhythmia  2.) Identify and treat underlying cause -Maintain patent airway: assist breathing necessary -Oxygen (if hypoxemic) -Cardiac monitor to identify rhythm: monitor blood pressure and oximetry -IV access -12- lead ECG if available, don't delay therapy  -Consider possible hypoxic and toxicologic causes  3.) Persistent bradyarrhythmia causing: -Hypotension?  -Acutely altered mental status? -Signs of shock? -Ischemic chest discomfort? -Acute heart failure? -If no 4.) Monitor and observe

Question 37

Adult bradycardia Algorithm Doses/Details

Answer 37

-Atropine IV dose: -1st dose 1 mg bolus -Repeat every 3-5 minutes. -Maximum 3 mg  -Dopamine IV Infusion -Usual infusion rate is 5-20 mcg/kg per minute. Titrate to PT response, taper slowly  -Epinephrine IV infusion: -2-10 mcg per minute infusion. Titrate to PT response -Causes: -Myocardial ischemia / infarction -Drugs/ toxicologic  -Hypoxia -Electrolytes abnormality

Question 38

Adult Tachycardia With a Pulse Algorithm if Causing Issues

Answer 38

1.)Assess appropriateness for clinical condition. Heart rate typically ≥ 150/min if tachyarrhythmia. 2.)Identify and treat underlying cause - Maintain patent airway: assist breathing as necessary - Oxygen (if hypoxemic) - Cardiac monitor to identify rhythm: monitor blood pressure and oximetry - IV access - 12-lead ECG, If available 3.)Persistent tachyarrhythmia causing: - Hypotension? - Acutely altered mental status? - Signs of shock? - Ischemic chest discomfort? - Acute heart failure? -If yes 4.)Synchronized cardioversion - Consider sedation - If regular, narrow complex. consider adenosine 5.)If refractory. consider - Underlying cause - Need to increase energy level for next cardioversion - Addition of anti-arrhythmic drug - Expert consultation

Question 39

Adult Tachycardia With a Pulse Algorithm if Wide QRS?

Answer 39

1.)Assess appropriateness for clinical condition. Heart rate typically ≥ 150/min if tachyarrhythmia. 2.)Identify and treat underlying cause - Maintain patent airway: assist breathing as necessary - Oxygen (if hypoxemic) - Cardiac monitor to identify rhythm: monitor blood pressure and oximetry - IV access - 12-lead ECG, If available 3.)Persistent tachyarrhythmia causing: - Hypotension? - Acutely altered mental status? - Signs of shock? - Ischemic chest discomfort? - Acute heart failure? -If no 4.) Wide QRS? =.12 seconds  5.)Consider - Adenosine only if regular and monomorphic - Antiarrhythmic infusion - Expert consultation 6.)If refractory. consider - Underlying cause - Need to increase energy level for next cardioversion - Addition of anti-arrhythmic drug - Expert consultation

Question 40

Adult Tachycardia With a Pulse Algorithm if no major issues 

Answer 40

1.)Assess appropriateness for clinical condition. Heart rate typically ≥ 150/min if tachyarrhythmia. 2.)Identify and treat underlying cause - Maintain patent airway: assist breathing as necessary - Oxygen (if hypoxemic) - Cardiac monitor to identify rhythm: monitor blood pressure and oximetry - IV access - 12-lead ECG, If available 3.)Persistent tachyarrhythmia causing: - Hypotension? - Acutely altered mental status? - Signs of shock? - Ischemic chest discomfort? - Acute heart failure? -If no 4.) Wide QRS? =.12 seconds -of no 5.) - Vagal maneuvers (If regular)      - Adenosine (If regular)       - b-Blocker or calcium channel blocker                  - Consider expert consultation

Question 41

Adult Tachycardia With a Pulse Algorithm Doses/ Details

Answer 41

-Synchronized cardioversion: -Refer to your specific device's recommended energy level to maximize first shock success. -Adenosine IV dose: -First dose: 6 mg rapid IV push: follow with NS flush. -Second dose: 12 mg if required. -Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia - Procainamide IV dose: -20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. -Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF. -Amiodarone IV dose: -First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. -Follow by maintenance infusion of 1 mg/min for first 6 hours. -Sotalol IV dose: -100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

Question 42

Synchronised cardioversion

Answer 42

• Synchronised cardioversion - shock delivery that is timed (synchronized) with the QRS complex • Narrow regular : 50 - 100 J • Narrow irregular : Biphasic - 120 - 200 J and Monophasic - 200 J • Wide regular - 100 J • Wide irregular - defibrillation dose

Question 43

ADENOSINE

Answer 43

•Slows conduction time through the A-V node, can interrupt the reentry pathways through the A-V node • Pottasium channel opener and hyperpolarisation • IV Dose: -6 mg rapid iv push, follow with NS flush. Second dose 12 mg -Side effects:- Flushing of face, bronchospasm

Question 44

Maternal Cardiac Arrest First Responder

Answer 44

• Activate maternal cardiac arrest team • Document time of onset of maternal cardiac arrest • Place the patient supine • Start chest compressions as per BLS algorithm; place hands slightly higher on sternum than usual

Question 45

Maternal Cardiac Arrest Subsequent Responders ( Maternal Interventions)

Answer 45

Treat per BLS and ACLS Algorithms • Do not delay defibrillation • Give typical ACLS drugs and doses • Ventilate with 100% oxygen • Monitor waveform capnography and CPR quality • Provide post-cardiac arrest care as appropriate Maternal Modifications • Start IV above the diaphragm • Assess for hypovolemla and give fluid bolus when required • Anticipate difficult airway; experienced provider preferred for advanced airway placement • I patient receiving IV/IO magnesium pre arrest, stop magnesium and give IV/O calcium chloride 10 mL in 10% solution, or calcium gluconate 30 mL in 10% solution • Continue all maternal resuscitative interventions (CPR, positioning, defibrillation, drugs, and fluids) during and after cesarean section

Question 46

Maternal Cardiac Arrest Subsequent Responders ( Obstetric Interventions for PTs with an Obviously Gravid Uterus)

Answer 46

Obstetric Interventions for Patient With an Obviously Gravid Uterus* • Perform manual left uterine displacement (LUD)-displace uterus to the patient's left to relieve aortocaval compression • Remove both internal and external fetal monitors If present Obstetric and neonatal tears should immediately prepare for possible emergency cesarean section • It no ROSC by 4 minutes of resuscitative efforts, consider performing immediate emergency cesarean section • Aim for delivery within 5 minutes of onset of resuscitative efforts *An obviously gravid uterus is a uterus that is deemed clinically to be sufficiently large to cause aortocaval compression

Question 47

Causes

Answer 47

B - Bleeding/ DIC E - Embolism( pulmonary, coronary, amniotic ) A - Anesthetic complications U - Uterine atony C - Cardiac disease MI/Aortic D - dissection/Cardiomyopathy) H - Hypertension ( Pre eclampsia/ Eclampsia) 0 - Other reversible causes P- Placenta

Question 48

Recommendation for emergency caesarean section

Answer 48

Recommendation • When the gravid uterus is large enough to cause maternal hemodynamic changes due to aortocaval compression, • emergency caesarean section should be considered, regardless of fetal viability

Question 50

BLS Healthcare Provider Adult Cardiac Arrest Algorithm (Normal Breathing has Pulse) 

Answer 50

-Verify scene safety  -Victim is unresponsive. Shout for nearby help. Activate emergency response system via mobile device (if appropriate) Get AED and emergency equipment (or send someone to do so).  -Look for no breathing or only gasping and check pulse ( simultaneously) is pulse definitely felt within 10 seconds.  If they have a Pulse -Monitor until emergency responders arrive.

Question 51

BLS Healthcare Provider Adult Cardiac Arrest Algorithm ( No Normal breathing, has pulse)

Answer 51

-Verify scene safety  -Victim is unresponsive. Shout for nearby help. Activate emergency response system via mobile device (if appropriate) Get AED and emergency equipment (or send someone to do so).  -Look for no breathing or only gasping and check pulse ( simultaneously) is pulse definitely felt within 10 seconds? -No Normal breathing, has pulse -Provide rescue breathing: 1 breathing every 5-6 seconds, or about 10-12 breaths/min  -Activate emergency response system (if not already done) after 2 minutes. -Continue rescue breathing; check pulse about every 2 minutes. If no pulse , begin CPR (go to CPR box) -If possible opioid overdose, administer naloxone if available per protocol.

Question 52

BLS Healthcare Provider Adult Cardiac Arrest Algorithm ( No breathing or only gasping, no pulse) -If Yes, shockable

Answer 52

-Verify scene safety  -Victim is unresponsive. Shout for nearby help. Activate emergency response system via mobile device (if appropriate) Get AED and emergency equipment (or send someone to do so).  -Look for no breathing or only gasping and check pulse ( simultaneously) is pulse definitely felt within 10 seconds? -CPR begins cycles of 30 compressions and 2 breaths. Use AED as soon as it is available  -AED arrives -Check rhythm shockable rhythm? -If Yes, shockable  -Give 1 shock. Resume CPRnimmediately for about 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS provides take over or the victim starts to move.

Question 53

BLS Healthcare Provider Adult Cardiac Arrest Algorithm ( No breathing or only gasping, no pulse) -If Not, shockable 

Answer 53

-Verify scene safety  -Victim is unresponsive. Shout for nearby help. Activate emergency response system via mobile device (if appropriate) Get AED and emergency equipment (or send someone to do so).  -Look for no breathing or only gasping and check pulse ( simultaneously) is pulse definitely felt within 10 seconds? -CPR begins cycles of 30 compressions and 2 breaths. Use AED as soon as it is available  -AED arrives -Check rhythm shockable rhythm? -If Not, shockable  -Resume CPR immediately for about 2 minutes ( until prompted by AED to allow rhythm check) Continue until ALS providers take over or victim starts to move