ACS
Acute coronary syndrome
ALS
advanced life support
AMI
acute myocardial infarction
CCF
Chest compression fraction
CPSS
Cincinnati Prehospital Stroke Scale
CQI
continuous quality improvement
DNAR
do not attempt resuscitation
ECC
emergency cardiovascular care
IHCA
in hospital cardiac arrest
MACE
major adverse cardiac events
MET
medical emergency team
NIH
National institutes of health
what is the national survival rate for IHCA?
24%
More than half of IHCAs are due to __ failure or _____
Respiratory
hypovolemic shock
NINDA
National Institute of Neurological Disorders & Stroke
NSTE-ACS
Non-ST Elevation Acute Coronary Syndrome
NSTEMI
Non-ST Elevation MI
OHCA
Out of Hospital Cardiac Arrest
PCI
Percutaneous Coronary Intervention
ROSC
Return of Spontaneous Circulation
RRT
Rapid response team
rTPA
Recombinant Tissue Plasminogen Activator
STEMI
ST elevation MI
TCP
transcutaneous pacing
TTM
Targeted Temperature Management
UA
unstable angina
The most common cause of out of hospital cardiac arrest is ______
ischemia from coronary artery disease
______ may be the first indicators of cardiac arrest in the adult patient
brief seizures
ROSC occurs when an arrested patient comes out of arrest and displays what 3 things?
- pulse and adequate BP
- abrupt increase in EtCO2 >40 mmHg
- spontaneous arterial BP waves with IV monitoring
what is a prominent sign of ROSC?
sudden increase in EtCO2
After a patient has been resuscitated from cardiac arrest, most deaths that do occur will occur ____hours after the resuscitation
within 24 hours
What is described as gasping,” snorting, gurgling, moaning, grunting, and can be associated with myoclonus (“jerking” of muscle groups)?
agonal breathing
-occur in almost half of cardiac arrests
are agonal breaths considered adequate breathing?
NO;
they do not provide adequate oxygenation
-a brain reflex that occurs when the heart is not circulating oxygen rich blood
What should you do when a patient is showing signs of agonal breathing?
Start CPR immediately
Slow, complex rhythms that immediately precede asystole are often referred to as
agonal rhythms
_Agonal rhythms do not produce a life sustaining cardiac output, and therefore chest compressions should be initiated whenever agonal rhythms are encountered
What is a normal capillary refill time?
≤2 seconds
What is a prolonged capillary refill time?
What are 3 causes?
> 5 seconds
- dehydration
- shock
- hypothermia
the proportion of time spent performing chest compressions for patients in cardiac arrest
chest compression fraction (CCF)
What percentage should CCF occupy of the resuscitation attempt?
at least 60% and ideally greater than 80%
Neonate age
1st 28 days of life
infant age
1 month to ~ one year of age
child age
1 year to the onset of puberty
adult age
puberty and older
a person who does not have specialized or professional knowledge of a subject (refers to ordinary people in the community without training in healthcare)
Lay person, or lay provider
hypoventilation RR
RR less than 6
bradypnea RR
RR less than 12
normal RR
12-16
tachypnea RR
RR greater than 20
RR for infant < 1 year
30-53
RR for toddler 1-3 years
22-37
RR for preschooler 4-5 years
20-28
RR for school age 6-12 years
18-25
RR for adolescent 13-18 years
12-20
4 implications of Respiratory Distress
- increased RR and effort, but able to move air
- potential abnormal airway sounds and pallor
- tachycardia and anxiety
- patient improves with initial therapy
3 implications of Respiratory Failure
- Labored breathing that is accompanied by signs of shock (cyanosis, lethargy, bradycardia)
- Requires intervention/assistance (may even be totally apneic)
- They may not respond to initial breathing treatments & interventions (low SpO2 despite high flow supplemental oxygen administration)
6 Person High-Performance Teams
assigns roles to team members, makes decisions, provides feedback, and is responsible for roles not assigned
Team Leader
6 Person High-Performance Teams
Alternates with AED person every 5 cycles (or two minutes), or when fatigue sets in
Compressor (first priority)
6 Person High-Performance Teams
Obtains & operates the defibrillator, places the monitor so the team leader can see it, and rotates with the compressor
AED/Monitor/Defibrillator (second priority)
6 Person High-Performance Teams
Ventilates and intubates (if appropriate)
Airway (third priority)
6 Person High-Performance Teams
Establishes access and pushes the drugs
IV/IO/Medications
6 Person High-Performance Teams
Records the times of interventions & medications, announces when the next drug is due, and records the frequency and duration of interruptions in compressions
Timer/recorder
These teams unlikely PREVENT arrest because they only respond AFTER the arrest has occurred
Cardiac arrest teams (code blue teams)
The purpose of these teams is to identify and treat early clinical deterioration BEFORE the arrest (i.e., PREVENT the arrest)
“Rapid response teams” (RRTs), or “medical emergency teams” (METs)
-Almost 80% of IHCA patients have abnormal vitals documented for up to 8 hours before the arrest (which means that early intervention will probably save lives). This is teaching us that the best success is not allowing the arrest to happen in the first place!
what is the primary difference between OHCA and IHCA?
OHCA says how to treat a cardiac arrest that occurs outside the hosptital
IHCA focuses on the PREVENTION of cardiac arrest inside the hospital
ABCDEs of ACLS
Airway Breathing Circulation Disability Exposure
Airway wall suction should be capable of _____ to_____suction pressure and most wall suction units are capable of more than ____ suction force
- 80 to -120 mmHg
- 300mmHg
airway suction attempts should not last more than______, and total suction attempts should be limited to less than _____ at a time
10 seconds
10
What should the anesthetist precede and follow suction attempts with?
100% oxygen
Before suctioning thick material what should you do?
squirt 1-2 mL of NS
this suction catheter is used for tracheal suction, and are more appropriate for thin secretions
soft suction catheters
these suction catheters are better at suctioning thick secretions
rigid suction catheter (yankauer)
when managing/ assisting the airway in trauma patients, how should the airway be opened?
Jaw thrust
-However, if a jaw thrust does not open the airway, a chin lift may be considered (because ventilation takes priority over the potential cervical instability)
How should the anesthetist intervene with severe choking in a responsive adult?
Heimlich maneuver (place the hands ABOVE THE NAVEL and BELOW THE BREASTBONE and lift upward)
How should the anesthetist intervene with severe choking in a responsive child?
Heimlich maneuver or perform “abdominal thrusts” below the Xyphoid process
What 3 steps should the anesthetist perform with severe choking in a responsive infant?
- place the patient prone in one arm and deliver 5 back slaps
- flip the patient supine in the other arm and deliver 5 downward chest thrusts with 2 fingers
- continue the cycle until the obstruction is relieved or the patient loses consciousness
How should the anesthetist treat choking in an unresponsive patient?
What is the additional step?
immediately start CPR (even if there is a pulse)
-The thought process is that compressions may help dislodge the foreign body
each time you look in the airway to deliver breaths, look for the object in the mouth (do not perform blind finger sweeps)
In victims of drowning in icy water, survival is possible after submersion times of as long as _____ and prolonged duration of CPR _______. When drowning occurs in ice water, rewarming to a core temperature of at least ___°C is recommended before CPR efforts are abandoned
40 minutes
greater than 2 hours
30
______is the most rapid and effective technique for rewarming severely hypothermic cardiac arrest victims after submersion in icy water”
extracorporeal circulation
______is the single most important factor influencing survival in drowning.”
immediate CPR
7 Airway Management strategies for Foreign Body Airway Obstruction
- How should the patient remain?
- The patient should be (spontaneously/ manually) breathing
- What is the common approach for PROXIMAL foreign bodies?
- How should you reduce the hemodynamic and airway reactions to introduction of the bronchoscope?
- How should anesthesia be maintained?
- What should be used in situations where an advanced airway is not placed or if an oxygen mask with bronchoscope adapter is not available?
- what can be used to treat the inflammation and/or airway edema incurred by bronchoscopy?
- the patient should remain calm
- sedatives can be used so long as the respiratory drive is not suppressed - The patient should remain spontaneously breathing
- Positive pressure ventilation can convert a PROXIMAL partial obstruction to a complete obstruction - PROXIMAL foreign bodies should use mask induction or cautious IV induction with maintenance of spontaneous ventilation
- Anesthetizing the pharynx and vocal cords with local anesthetic
- propofol-remifentanil based TIVA with maintenance of spontaneous ventilation
- this technique prevents leakage of volatile agent around the bronchoscope - Use of jet ventilation and/or oxygen insufflation through the bronchoscope may help prevent hypoxia
- steroids (dexamethasone)
In a foreign body airway obstruction, what can be used if the patient is not intubated?
a bronchoscopy mask
in a foreign body airway obstruction, what can be used if the patient needs to be intubated?
an adapter for the ETT
(high/low) flow O2 should be administered during CPR resuscitation period
high flow O2
(high/low) flow O2 shows increased harm after ROSC
high flow
When CPR is NOT being administered, what should the SpO2 of oxygen be administered and titrated to?
- 94-99% for all non-ACS syndrome cases
2. ≥90% for ACS syndrome cases
When CPR IS being administered, what should the SpO2 of oxygen be?
100%
What is the patient’s FiO2 for mouth to mouth ventilation?
17% oxygen and 4% CO2
How should mouth to mouth ventilation be performed on an adult?
pinch the nose and perform a head tilt/chin lift
How should mouth to mouth ventilation be performed on a child?
place your mouth over their mouth and nose
______should only be performed with 2 rescuer ventilation
bag mask ventilation
-The “mask ventilator” is at the head of the victim, while the “compressor” is at the side of the victim
_____should be performed with single rescuer ventilation
mouth to mouth
- In this instance, a “pocket mask” is recommended
What technique provides a more effective ventilation and more accurate EtCO2 when a patient is in cardiac arrest?
intubation
When securing the ETT with circumferential ties (trach ties), what should we be cautious of?
potential danger of obstructing venous return from the brain
4 disadvantages to excessive ventilation
- creates gastric inflation
- decreases venous return and cardiac output
- from increased thoracic pressure - decreases cerebral blood flow
- lowers survival
What is the best way to avoid excessive ventilation?
give a breath and chest rise is observed
What is the goal tidal volume for adults during arrest?
500-600 mL
routine cricoid pressure (is/ is not) recommended during bag mask ventilation in ACLS
is not
what is the preferred method for confirming effective ventilation and correct endotracheal tube placement?
CONTINUOUS WAVEFORM capnography
is continuous waveform capnography quantitative or qualitative?
quantitative
-it can tell a provider the patient’s precise EtCO2
what type of capnography may be used if continuous waveform is not available?
Colorimetric (non-waveform)
Is colorimetric capnography qualitative or quantitative?
semi-qualitative
- It simply confirms that there is EtCO2, but does not tell you what the actual EtCO2 is
-Keep in mind that colorimetric capnography “may fail to detect the presence of exhaled CO2 during cardiac arrest despite correct placement of the ET tube”
When the colorimetric capnography is purple, what is the EtCO2?
≤ 2.28 mmHg
When the colorimetric capnography is beige, what is the EtCO2?
3.8-7.6 mmHg
When the colorimetric capnography is yellow, what is the EtCO2?
> 15.2 mmHg
Breathing rate in ACLS:
Intubated; If compressions are required (cardiac arrest)
the breathing rate is (higher/lower)?
What is the breathing rate?
lower
10 breaths/min, or 1 breath every 6 seconds
- This makes sense, because the higher the number of positive pressure breaths, the lower the venous return
- Venous return is more important in patients who require chest compressions
Breathing rate in ACLS:
Intubated; during respiratory arrest without compressions
The breathing rate is (higher/lower)?
What is the breathing rate?
lower
-the breaths are more effective
10 breaths/min
(once per 6 seconds)
Breathing rate in ACLS:
Mask-ventilatd; during cardiac arrest with compressions
what is the breathing rate?
30:2 compression : ventilation ratio
Breathing rate in ACLS:
Mask-ventilated; during respiratory arrest without compressions
The breathing rate is (higher/lower)?
What is the breathing rate?
higher
-A drop in venous return isn’t as crucial in a patient that doesn’t require compressions
10-12 breaths/min
(once per 5-6 seconds)
How should agonal breaths be treated during cardiac arrest?
the same as apnea
- indication to provide rescue breaths
- agonal breaths + unresponsive patient = cardiac arrest
4 steps of the breathing protocol
- R ( check Responsiveness)
- if patient is unresponsive, call for help - A (activate EMS, call for help)
- C (circulation; check pulse and breathing)
- no breathing but a pulse- give 10-12 rescue breaths/min
- (1 breath every 5-6 seconds; each breath over 1 second)
How long should breathing/pulse checks be and how often do we re-check?
10-15 seconds and 2 minutes
if there is no pulse or are unsure after checking for 10 seconds, what should you do?
begin compressions
3 places for vascular access in ACLS in order of priority
- IV access
- IO (intraosseus) access
- ETT
Because peripheral lines can take 1-2 minutes to reach the central circulation, what should the IV dose be followed with?
What is the bolus for peds?
What is the bolus for adults?
what should be done with the extremities?
a N/S bolus
5mL for peds
20mL for adults)
extremity should be elevated for 10-20 seconds
how long does it take IO access to be achieved?
What is the IO dosing?
What can be administered in an IO?
30-60 seconds
same as IV dosing
ALL fluids (including blood)
where is the best IO access?
anterior tibia
what is the best way to tell proper IO placement?
if fluids can flow freely without local soft tissue swelling
5 steps to administering drugs via ETT
- inject drug in ETT
- follow dose with 5-10 mL N/S
- Provide 5 rapid positive pressure ventilations after the drug is injected
- Compressions should be temporarily interrupted to prevent regurgitation of the drug from the endotracheal tube
what is the recommended ETT Epi dose in adults?
2-3 times the IV dose (ACLS)
what is the recommended ETT Epi dose in peds?
10 times the IV dose (PALS)
what is the recommended ETT Epi dose in neonates?
same as the IV dose (NALS)
What 2 things will low concentration of Epi through the ETT produce?
- beta-2 effects
2. hypotension and decrease chances of ROSC
What are the drugs that can be given via the ETT in adults?
NAVEL
Narcan Atropine Vasopressin Epi Lidocaine
What are the drugs that can be given via the ETT in peds?
LEAN
Lidocaine
Epinephrine
Atropine
Narcan
Where should the pulse be checked in patients > 1 year old?
carotid or femoral
Where should the pulse be checked in patients <1 year old?
brachial pulse
3 indications for chest compressions
- in adults?
- in children?
- in larger (older) children?
- when there is no pulse
- when the HR is less than 60 bpm
- when the HR is less than 40 bpm
what is the rate for chest compressions?
100-120 per minute
-It takes ≈20-25 compressions before good blood flow
5 steps of good compression technique
- where should compressions be initiated?
- Where on the patient should compressions be
performed? - What depth should the compressions be?
adults?
children?
infants? - should you allow complete recoil of the chest?
- when should you switch providers?
- hard, flat surface
- lower half of the breastbone
- 2 to 2.4 inches for adults & adolescents
2 inches for children
1/3 to ½ depth of chest (or 1.5 inches) for infants - yes, allow complete chest recoil
- every 2 minutes or 5 cycles
What is the High quality CPR pneumonic?
C
-chest recoil
P
-push hard, push fast
R
-rotate rescuers
what type of CPR technique is used for adults and adolescents?
2 hand
what type of CPR technique is used for children 1-8 years old?
one hand
what type of CPR technique is used for infants when only one responder is available?
2 finger
Where is the placement of the 2 finger CPR technique on infants?
we place two fingers just below the nipples and just above the xyphoid process
What CPR technique is used for infants when there are 2 responders available?
thumb encircling technique
During CPR in Mask Ventilated Patients:
- Compressions (are/ are not) interrupted when giving breaths
- CPR is performed in ____ cycles over a ___ period
- compressions ARE interrupted
2. five cycles over a 2 minute period
What is the CPR compression to breath ratio in mask ventilated adults?
30:2
What is the CPR compression to breath ratio in mask ventilated infants/children with ONE rescuer?
30:2
What is the CPR compression to breath ratio in mask ventilated infants/children with TWO rescuers?
15:2
What is the CPR compression to breath ratio in mask ventilated neonates for a respiratory cause of arrest?
3:1
What is the CPR compression to breath ratio in mask ventilated neonates for cardiac cause of arrest?
15:2
During CPR on intubated patients:
- Compressions (are/ are not) interrupted when giving breaths
- CPR is performed in _____ increments, not _____
- compressions are NOT interrupted
2. 2 minute increments, not cycles
What is the compression and breathing rate for intubated adults?
100-120 compressions per minute
10 breaths per minute
What is the compression and breathing rate for intubated kids?
100-120 compressions per minute
breathing rate may be faster depending on their age
Goals for chest compressions
- EtCO2?
- diastolic BP?
- coronary perfusion pressure?
- mixed venous SaO2?
- EtCO2 of at least 20 mmHg
- Chest compressions should be improved if the EtCO2 is < 10mmHg - Diastolic BP on an arterial line of at least 20 mmHg
- coronary perfusion pressure of at least 10 mmHg
- Mixed venous SaO2 of at least 30%
- Normal is 60-80%
*****the quality of chest compressions must be improved if any of these are not met
What are the 2 exceptions in which cardiac compressions do not take priority?
- calling for help
2. defibrillating vfib/vtach when the defibrillator pads are ready to go
in the EMS setting of continuous chest compressions:
- the provider provides ____ periods of _____ chest compressions
each round of ____ chest compressions lasts ____ minutes
- Advanced airway is _____
- ______ replaces positive pressure ventilation until ____ minutes has passed
- 3 periods of 200 chest compressions
200 chest compressions lasts 2 minutes
- compressions are still interrupted for rhythm analysis and defibrillation
2. deferred
3. passive oxygen insufflation 6 minutes ( 3 rounds of 200 chest compressions)
______ is defined as the proportion of time spent performing chest compressions for patients in cardiac arrest
chest compression fraction
what is the ideal chest compression fraction the AHA recommends in a resuscitation attempt?
at least 60% and ideally 80%
What are the 4 instances when CPR should be withheld?
- There is a “Do Not Resuscitate” (DNR) request
- There is a threat to the safety of rescuers
- Rigor mortis
- Lividity
- Defined as a black and blue discoloration of the skin of a cadaver, resulting from an accumulation of deoxygenated blood in subcutaneous vessels
What are the 5 steps in CPR with a defibrillator?
- check the pulse
- perform CPR until AED arrives
- defibrillate ASAP
- resume 2 minutes of CPR BEFORE reanalyzing the rhythm
- rhythms usually don’t create perfusion in the first few minutes post defibrillation - re-analyze the rhythm and check the pulse if an organized rhythm is present
- do not exceed 10 seconds
When should IV/IO meds be given in CPR with a defibrillator?
Immedeltely before or after shock delivery so drugs have time to circulate before next rhythm check
What can be used in certain setting with select cardiac arrest patients who have reversible causes of cardiac arrest but do not respond to CPR?
ECMO
What does “disability” refer to in ACLS?
a provider checking the neurologic status of a patient
What are the 4 ways neurologic function (disability) is assessed?
- Checking the patient’s blood sugar
- hypoglycemia can cause somnolence (drowsiness)
- think “D” in “disability” as “D” in “dextrose” - checking the patient’s pupil response to light
- AVPU pediatric response scale
- basic neurologic assessment that anyone can perform
- best test in the PRE-hospital setting - Glasgow Coma Scale (GCS)
- advanced neurologic assessment performed by trained professionals
in the disability check, if a patient is hypoglycemic, what is the treatment?
Dextrose
- think “D” in “disability” as “D” in “dextrose”
What 3 things should be assessed in checking disability by examining the pupils with light?
- pupil size (mm)
- equality size of pupils
- constriction of pupils in response to light
What is the acronym for normal pupil response to light
PERRL
Pupils Equal, Round, Reactive to Light
What should be suspected if the pupils do not constrict to light?
brainstem injury
what may cause unequal pupil size?
increased intracranial pressure
the steps of checking disability with the AVPU scale
A: alert
“this patient is alert”
V: responsive to Voice
“not as awake but can respond to commands”
P: responsive to Pain
“the patient only responds to painful stimuli”
U: Unresponsive
“patient is completely unresponsive to all stimuli”
Which disability scale works best in an “in hospital” setting?
Glasgow coma scale
What Glasgow score is intubation indicated
GCS is ≤ 8
What is the lowest possible score you can get on the Glasgow scale?
3
What is the highest possible score you can get on the Glasgow scale?
15
What is the “exposure” step of ACLS?
provider undresses the child to perform a quick physical exam and assesses for signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets
What are the 2 principle things and AED does?
- can sense and analyze Vfib/Vtach
2. can defibrillate
AED chooses the energy dose
What are the 3 limitations of the AED?
- does not produce an ECG rhythm strip
- does not sense other arrhythmias besides Vfib/Vtach - cannot pace
- cannot perform synchronized cardioversion
When the AED advises you to deliver a shock, you should deliver the shock within _____ seconds
10 seconds
What is the difference between a “semi-automated” AED and a “fully automated” AED?
“Semi automated” (most AEDs) mean that the AED only ADVISES a shock if indicated
The provider must push the shock button
“Fully automated” (some newer AEDs) means that the AED shocks for you if indicated
What are the 5 steps to using the AED
- Power on the AED
- Attach the electrode pads
- clear the victim
- analyze the shock
- charge and shock if advised
What are the 3 “extra” abilities the manual defibrillator has in addition to the AED abilities
- an show an ECG rhythm strip
- can perform synchronized cardioversion
- can perform transcutaneous pacing
most defibrillators are (monophonic/ biphasic)
biphasic
-they allow the maximum efficiency delivered with the smallest possible amount of energy
In synchronized cardioversion, when is the shock delivered?
during the R wave
What could shock delivery on the t wave potentially produce?
could precipitate Vtach or Vfib
What are 2 indications for synchronized cardioversion?
- unstable supraventricular rhythms
- SVT
- Afib
- atrial flutter - unstable monomorphic Vtach with a pulse
in synchronized cardioversion where should the pads be placed?
in a posterior, left fashion
in synchronized cardioversion of an atrial rhythm, where should the anterior pad be placed?
on the right chest
in synchronized cardioversion of a ventricular rhythm, where should the anterior pad be placed?
on the left chest
What is another name for defibrillation?
unsynchronized cardioversion
What rhythms is defibrillation indicated for?
is sedation necessary?
ALL rhythms that are pulseless and/or irregular
- Vfib
- pulseless Vtach
- Torsades de pointes
NO, sedation is not necessary
what are 3 rhythms that defibrillation is NOT used for?
- supra ventricular rhythms
- asystole
- PEA
How are the pads placed in defibrillation?
in an “anterior-posterior” or “anterior-anterior” fashion
adult biphasic defibrillator energy dose
120-200 J
adult monophonic defibrillator energy dose
360 J
Pediatric defibrillator energy dose
(1st dose: 2J/kg)
(2nd dose: 4J/kg)
(Up to 10J/kg)
synchronized cardioversion biphasic energy dose for irregular SVT (Afib)
120-200 J
synchronized cardioversion monophasic energy dose for irregular SVT (Afib)
200 J
synchronized cardioversion biphasic energy dose for SVT
50-100 J
synchronized cardioversion biphasic energy dose for monomorphic Vtach
100 J
transcutaneous pacing biphasic energy dose
40-80 mA
When is transcutaneous pacing indicated?
any case of severe bradycardia that is unresponsive to drug therapy (atropine/epinephrine)
in transcutaneous pacing, how are the pad placed on the patient?
posterior, left anterior
in transcutaneous pacing, where should the maintenance threshold be held?
10% above the pacing threshold (capture)
4 disadvantages of transcutaneous pacing
- only shows ventricular ECG waveform
- cannot pace the atria and ventricles independently - doesn’t produce as effective capture as trans venous capture
- causes muscle jerking, which may mimic a carotid pulse
- its painful
- patient should be sedated prior to pacing if hemodynamically stable
what is the pacing threshold?
at what amperage does it usually occur?
the current at which “capture” (when the heart starts beating) is observed
usually occurs between 40 and 80mA with the transcutaneous approach
what is the maintenance threshold?
Where should it be set according to the pacing threshold?
the current at which the pacemaker should be maintained
should be set at 10% above the stimulation threshold
for anterior-anterior pad placement, where are the pads placed?
- upper right chest above the nipple
2. apex/ lateral pad is placed at the left anterior or mid axillary line of the 5th intercostal space
for posterior, left anterior pad placement, where are the pads placed?
- posterior pad is placed under the left scapula
2. anterior pad is placed to the left of the sternum under the left breast
for posterior, right anterior pad placement, where are the pads placed?
- posterior pad is placed under the left scapula
2. the anterior pad is placed to the right of the sternum above the right breast
what is the most common pad placement for AED?
anterior-anterior
what is the second option for pad placement for AED?
posterior- left anterior
what is the recommended (preferred) pad placement for transcutaneous pacing?
posterior- left anterior
what is the second option for pad placement for transcutaneous pacing?
anterior-anterior
what are the 2 pad placement options for defibrillation and cardioversion of ventricular tachycardia?
which one is more recommended?
- posterior, left anterior
- anterior-anterior
posterior, left anterior is more recommended
What is the recommended pad placement for cardioversion of atrial rhythms?
posterior, right anterior pad placement
what is the second option for pad placement for cardioversion of atrial rhythms?
anterior-anterior pad placement
what is the most common and recommended Paddle placement in adults for defibrillation?
anterior-anterior
-Posterior, left anterior can be used, but will most likely take longer and be harder to “clear” the patient
what is the most common and recommended Paddle placement in infants (less than 1 year old) for defibrillation?
anterior- anterior
what is the most common and recommended Paddle placement in small children > 1 year for defibrillation?
anterior-anterior placement
OR
anterior- posterior sandwich
at what age are pediatric manual defibrillators used?
children ≤ 1 years old,
-manual defibrillator is capable of using lower energy doses than an AED
at what age are pediatric AED pads used?
on children 1-8 years old
at what age are adult AED pads used?
kids >8 years old
can you use adult AED pads on an infant?
yes, if pediatric pads are not available
what does “priming the pump” refer to?
EMS providers performing a period of CPR before defibrillating a patient
What should a LONE rescuer do if they encounter a HYPOXIC arrest?
provide 2 minutes of CPR BEFORE activating EMS
What should a LONE rescuer do if they WITNESS a sudden collapse?
- Call for help (activate EMS)/ or leave the patient to get an AED
BEFORE
initiating chest compressions
Higher chance the patient is in Vfib
(unless it was a hypoxic event that caused the collapse)
what should a LONE rescuer do if they DO NOT witness the collapse?
perform 2 minutes of CPR BEFORE calling for help/ activating EMS
if a patient is unconscious/unresponsive what are the initial ABC steps?
- Checking for a pulse (C) and breath sounds (AB)
- Calling for help, starting CPR, and getting a defibrillator if there is no pulse (C)
- Providing rescue breaths (AB) and placing monitors (C)if there is a pulse but the patient isn’t breathing (AB)
if a patient is conscious/responsive, what are the initial ABC steps?
- Placing monitors on the patient (C)
- Starting an IV (C)
- Placing oxygen on the patient if needed (AB)
What is the first thing an ACLS provider should do when approaching a patient?
check a patient’s responsiveness to see if they are conscious or not
In ACLS, the initial steps we take when approaching unconscious and/or unresponsive patients (calling for help, checking a pulse and breathing) are referred to as the _____
BLS assessment
What is the pneumonic for the steps of the BLS assessment?
RACD
Responsiveness
Activate EMS and get an AED
Check Circulation: pulse and breathing simultaneously
Defibrillation
If a patient has no pulse or you are unsure if a patient has a pulse, what is the first thing you should do?
start compressions
if a patient is not breathing but does have a pulse, what is the first thing you should do?
give 2 rescue breaths
If the patient conscious/responsive, what steps do we start?
ABCDE’s of ACLS (Start with CAB first)
- monitors (circulation)
- IV access (circulation)
- oxygen (airway/breathing)
whenever you encounter a conscious/responsive patient in ACLS, just START OUT by saying that you want _______
IV, monitors, oxygen (CAB)
After the initial interventions with the primary assessment of the ABCDE’s, what are the 2 steps of the secondary assessment?
SAMPLE
H’s and Ts
What is SAMPLE?
Signs and Symptoms Allergies Medications Past medical hx Last meal eaten Events
Which secondary assessment should be verbalized in a scenario where a patient is conscious?
SAMPLE
Which secondary assessment should be verbalized in a scenario where a patient is unconscious?
the H’s and T’s
The 7 H’s of Pulseless Arrest
- Hypovolemia
- Hypoxia
- Hypokalemia
- Hypothermia
- Hypoglycemia
- Hyperkalemia
- H+ (acidosis)
The 5 T’s of Pulseless Arrest
- Tamponade (cardiac tamponade)
- fluid around the pericardial sac compresses the heart
- decreased stroke volume and cardiac output - Thrombosis (coronary and pulmonary)
- Tension pneumothorax
- Trauma
- hypotension and exsanguination - Toxins (drug overdose)
- can lead to prolonged QT interval on ECG
How is cardiac tamponade diagnosed and treated?
bedside ultrasound and pericardiocentesis
How is thrombosis diagnosed and treated?
PE can be diagnosed with bedside ultrasound
In patients with cardiac arrest due to known PE, we can administer fibrinolytics
5 identifications of Tension Pneumothorax
- unilateral absent breath sounds
- deviated trachea
- hypotension
- chest x-ray (CXR)
- bedside ultrasound
2 treatments for Tension Pneumothorax
- Needle decompression first
- 2nd intercostal space
- mid clavicular line - Chest tube second
- 6th intercostal space
- mid axillary line
What are 3 ways Toxins (drug overdose) treated?
- Monitoring blood sugar
- beta blocker or alcohol overdose can lead to hypoglycemia - Gastric lavage
- washing out the stomach using water flow - charcoal tablets
What are the 4 Goals of Post Cardiac Arrest Care?
after achieving ROSC
- Optimize ventilation and hemodynamic status (blood pressure)
- Initiate Targeted Temperature Management (TTM)
- only intervention to improve neurologic recovery - Provide immediate coronary reperfusion with PCI
- for patients in which coronary occlusion was suspected - Provide neurologic care and prognostication and other structured interventions
- brain injury and cardiovascular instability are major factors that determine survival after cardiac arrest
What is the FIRST priority in someone who achieves ROSC?
oxygenation and ventilation
What type of ventilation do unconscious patients usually need after ROSC?
an advanced airway
in unconscious patients who achieve ROSC, what should the head of the bed be elevated to and what does this help do?
30 degrees
decreases the risk of cerebral edema, aspiration, and ventilatory associated pneumonia
When should TTM be administered?
To any patient who is comatose and unresponsive to verbal commands after ROSC
What is the goal TTM temperature of a comatose patient?
32-36⁰C for at least 24 hours
- medical hx should be considered
1. patients with bleeding risk may not tolerate hypothermia
2. patients with seizures or cerebral edema have worse outcomes with higher temperatures
Which sites are most appropriate of core temperature for TTM?
bladder
esophageal
For patients not treated with TTM, the earliest time for neurologic assessment is _______
72 hours after cardiac arrest
For patients treated with TTM, wait ______ before assessing neurologic status
72 hours after return to normothermia
3 methods of initiating TTM
- Rapid infusion of ice cold, isotonic, non-glucose-containing fluid (30mL/kg)
- good for initiating hypothermia, not for target temp.
- Pre-hospital (EMS) cooling is not recommended - surface cooling devices
- ice bags
What should the SpO2 be titrated to post resuscitation?
Titrate the FiO2 to the lowest level required to keep the SpO2 ≥94%
What should the minute ventilation be started at for post resuscitation?
10 breaths per minute
What should the EtCO2 and PaCO2 be post resuscitation?
EtCO2 of 35-40 mmHg
PaCO2- 40-45 mmHg
What type of ECG should be ordered post resuscitation and what are 3 things to look for after patient achieves ROSC?
12 lead ECG
arrhythmias, ST elevation, left bundle branch block
-consider coronary reperfusion therapy if STEMI or AMI is detected
What should the MAP and the systolic BP be post resuscitation?
mean arterial pressure ≥ 65mmHg
systolic pressure ≥ 90mmHg
What should the temperature be post resuscitation?
Consider hypothermia (32-36°C for 24 hrs) -indicated for comatose patients who have achieved ROSC after having an in hospital or out of hospital arrest
When is hypothermia TTM not considered after ROSC?
in conscious patients
What are 2 prophylactic antiarrythmic therapies that can be administered after achieving ROSC following an arrest due to Vfib/Vtach?
- oral or IV beta blockers
2. lidocaine
3 criteria for TERMINATING resuscitation efforts
- . Providers are unable to get EtCO2 >10mmHg after 20 minutes of CPR in intubated patients
- Valid DNAR is present
- resuscitation is taking place in a hazardous environment
2 criteria for PROLONGING resuscitation efforts
- cause of cardiac arrest is reversible (hypothermia, drug overdose, etc)
- If return of spontaneous circulation (ROSC) occurred at any time throughout the resuscitation attempt
Resuscitation in Hypothermic patient:
Severe hypothermia (<30⁰C)
- Provider should perform _____
- Subsequent defibrillation attempts AND drug therapy should be delayed until the temperature is_____
- single defibrillation attempt
2. > 30⁰C
What are 2 considerations for Resuscitation in Hypothermic patients?
- drug levels may accumulate to toxic levels
- therapy should be aimed at re-warming
Hypothermic hearts may be unresponsive to drugs, defibrillation, and pacing
Resuscitation in Hypothermic Patient:
Moderate hypothermia (<34⁰C)
- the provider can defibrillate ______, but should _______ between drug doses
defibrillate normally, wait longer intervals
In victims drowning in icy water, survival is possible after submersion times of ______
40 minutes
When drowning occurs in ice water, rewarming to a core temp of at least___ is recommended before starting CPR
30°C
how should medications be given in hypothermic patients?
longer paced intervals
what is the most rapid and effective technique for re-warming severely hypothermic patients?
extracorporeal circulation
What are the 7 things you should say you should do in ACLS once a patient achieves ROSC?
- order a 12 lead ECG
- consider hypothermia (32-36)
- maintain normal blood pressure
(1-2 L of crystalloid bolus) - get frequent lab work
- Maintain SpO2 of 94-99%
- consider intubation and EtCO2 of 35-40mmHg
- consider lidocaine or beta blockers
What are the 3 drugs used for bradycardia? (and doses)
- Atropine
- 0.5 mg every 3-5 minutes
- max dose of 3 mg - Epinephrine
- 2-10 mcg/min - Dopamine
- 2-20 mcg/kg/min
What are 3 types of drugs used for SVT? (and doses)
- Adenosine (short acting 5-10 seconds and uncomfortable)
- initial 6 mg bolus
- up to 2 additional doses of 12 mg - Sotalol (beta blocker)
- 100mg or 1.5mg/kg - Calcium channel blockers (cardizem)
How do adenosine, Sotalol, and calcium channel blockers work?
slows conduction through the AV node
What is the treatment for unstable atrial fib/ flutter?
synchronized cardioversion
In which patients should Sotalol be avoided?
patients with prolonged QT syndrome
What is the treatment for stable atrial fib/ flutter?
get a consult
What is adenosine used for in Atial fib/ flutter?
Afib/flutter does not originate from the AV node, so Adenosine will NOT terminate these arrythmias
Adenosine is only used to SLOW the HR enough to diagnose the rhythm
What drug is given in pulseless rhythms? (Vtach/ Vfib/ PEA, Systole)
What is the dose?
Epinephrine (increases myocardial blood flow)
- 1 mg every 3-5 minutes
Which rhythm should amiodarone be administered?
monomorphic Vtach (with/without a pulse) Vfib
In which patients is amiodarone avoided?
patients with prolonged QT interval
including Torsades de Pointes
Amiodarone is an “antiarrhythmic agent primarily used to treat _______
atrial or ventricular tachyarrhythmias
_______ continues to be recommended as the first-line antiarrhythmic agent for shockable rhythms refractory to CPR, defibrillation and vasopressor therapy
amiodarone
Amiodarone dosing:
If the patient has monomorphic Vtach, but is awake or still has a pulse, the dose is _____
150 mg over 10 minutes
Amiodarone dosing:
If the patient is in Vfib/pulseless Vtach, the dose is ______
300mg bolus for the 1st dose
150mg bolus for the 2nd dose
Amiodarone dosing:
The post-resuscitation infusion dose is _____
1mg/min for the 1st 6hrs, and 0.5mg/min for the next 18hrs
A loading dose of 150mg Amiodarone is given if it was not given during the arrest
What rhythms is procainamide used?
What is the dose?
Vfib or monomorphic Vtach
-20-50 mg/min
When is procainamide stopped?
- When the arrhythmia is gone
- hypotension continues
- QRS duration increases 50%
What is the maintenance infusion of procainamide?
1-4 mg/min
What is the max dose of procainamide?
27 mg/kg
In what patients is procainamide avoided?
patients with prolonged QT syndrome and or CHF
What arrhythmia is magnesium administered?
what is the dose?
polymorphic Vtach (Torsades de Pointes) -1-2 g
