ACLS Algorithm

Question 1

How many breaths do you give with a bag/mask AND with an artificial airway?

Answer 1

Bag/mask = 30:2 (however at SPHs, it’s whenever you can get a breath in, so 1 breath every 6 seconds on the upstroke of compression.
Artificial airway: 1 breath every 6 seconds (10 breaths per minute) on the upstroke of compression.
Bagging with 100% O2.

Question 2

How many compressions per minute?

Answer 2

100-120 compressions per minute

Question 3

which two ECG rhythms are shockable?

Answer 3

Pulseless Ventricular Tachycardia
Ventricular fibrillation.
These are non-perfusing rhythms so we need CPR as well.

Question 4

which two ECG rhythms are non-shockable

Answer 4

Pulseless electrical activity (PEA)
Asystole
These are non-perfusing rhythms so we need CPR as well.

Question 5

what is PEA?

Answer 5

Pulseless electrical activity.

An organized rhythm without enough contraction to produce a palpable pulse/BP. You cannot defibrillator this

Question 6

what is asystole?

Answer 6

Complete absence of cardiac activity, there is not pulse, no CO. You cannot defibrillator this

Question 7

Where do the defibrillator pads go?

Answer 7

Right upper chest and Left midaxillary

Question 8

What are the differences between monophonic and biphasic shock?

Answer 8

Monophasic - 360 Joules. Shock is given in ONE direction, requires more energy.
Biphasic - 120-200 Joules. Shock delivered in two vectors. Uses less energy, less damage to heart.
*All defibrillators are biphasic now.

Question 9

What does it mean if the ETCO2 drops <10 mmHg?

Answer 9

Compressor fatigue - time to switch compressions

Question 10

What does an abrupt rise in ETCO2 >40 mmHg mean?

Answer 10

ROSC = return of spontaneous circulation

Question 11

What are some ways you know you got ROSC?

Answer 11

• ETCO2 abruptly increases >40 mmHg.
• Pt starts gagging on airway (you at HOB will be looking for this).
• Pulse or BP
• Spontaneous arterial pressure waves intra-arterial monitoring

Question 12

T/F: You should only use end tidal once the artificial airway is in place

Answer 12

FALSE!

Also use it with your bagger! You can get ROSC before you intubate

Question 13

Pt is in pulseless Vtach or VFib, how many shocks are given before the first dose of Epi?

Answer 13

2

Question 14

How long does CPR go for until the rhythm is reassessed?

Answer 14

2 minutes

Question 15

What is the dosing for Epi?

Answer 15

1 mg every 3-5 mins

Question 16

The pt was in Vtach and now they are in asystole - what do you do?

Answer 16

NO MORE DEFIBRILLATION
Continue providing breaths (30:2 bag/mask or 1 breath every 6 seconds with airway) and continue CPR.
Epi every 3-5 mins.
1 mg Epi –> CPR 2 mins –> check rhythm, repeat if needed.

Question 17

What is the dosage for Amiodarone?

Answer 17

First bolus = 300 mg

2nd bolus = 150 mg

Question 18

What is the dosage for lidocaine?

Answer 18

1st dose = 1-1.5 mg/kg
2nd dose = 0.5-0.75 mg/kg
*Ryan said Lidocaine is no longer used in ACLS.

Question 19

what are the 5 H’s for reversible causes? How would you treat them?

Answer 19

1. Hypovolemia (i.e. was the pt bleeding? vomiting? Melena?) - Treat with normal saline and find the source of bleeding
2. Hypothermia (<35 degrees) - warm pt with warm fluids and heated blankets.
3. Hypoxia (i.e. not breathing for a period of time, drowning) - establish an airway and 100% O2
4. Hydrogen Ion (acidosis) caused by long period of hypoxemia - Give Bicarb
5. Hypokalemia/Hyperkalemia (due to vomiting/diarrhea) - for hypokalemia Tx with K+. For hyperkalemia Tx with insulin, glucose and Ca2+ (shifts K+ into cells, out of blood).

Question 20

what are the 5 T’s for reversible causes? How would you treat them?

Answer 20

1. Tension pneumothorax (i.e. due you see tracheal deviation, decrease A/E, asymmetrical chest rise?) - Tx with thoracentesis, and then chest tube. Use US to find.
2. Tamponade, cardiac (usually occurs with crush injuries) - Dx with US - Tx with pericardiocentesis
3. Toxins - Dx with toxin screen, Hx - Tx with reversal agent (Narcan for opioid, Flumazenil for Benzos).
4. Thrombosis, pulmonary - Dx with CT/PEA, D-dimer
5. Thrombosis, cardiac - go to Cath lab
   * *note: thombolytics are not usually used for thrombosis in ACLS bc brain bleeds during an arrest are likely.

Question 21

Where does thoracentesis occur?

Answer 21

2nd intercostal space, midclavicular

Question 22

Where does a chest tube go?

Answer 22

4rth intercostal space, midaxillary

Question 23

Factors that determine termination of the algorithm

Answer 23

• duration of arrest >30 mins without a perfusing rhythm
• asystole t/o the entire arrest
• prolonged time b/w estimated time of arrest and initiation of resuscitation
• pt age and comorbidities (cancer, very old)
• absence of brain reflexes
• ETCO2 < 10 mmHg for 20 mins
• no ROSC after 3 doses of Epi

Question 24

What to do when you get ROSC

Answer 24

1. Manage a/w - early placement of ETT
2. Manage resp parameters - Start 10 bpm, SpO2 92-98%, PaCo2 35-35 mmHg
3. Manage hemodynamic parameters - SBP > 90 mmHg, MAP > 65 mmHg

Then obtain a 12 lad ECG
Initiate temp management (if we think the pt has brain hypoxia) with TTM (targeted temp management)

Question 25

What is TTM?

Answer 25

Targeted temp management.
It’s induced hypothermia (32-36 degrees for 24 hrs after ROSC).
It reduces the brains O2 demand and decreased cerebral metabolism.
use cooling blankets, ice packs and cooled solutions through central catheters