Advanced Cardiac Life Support (ACLS)

By: Diana Blum MSN Metropolitan Community College Nursing 2150

STABLE
These patients generally have an EKG

rhythm that is undesirable. their vitals signs are stable they have no complaints such as, shortness of breath, chest pain or confusion. The major problem here is...if we leave the rhythm untreated the patient may become unstable!

UNSTABLE
These patients also have an EKG rhythm that is undesirable. their vital signs are unstable! They may have a low blood pressure or complain of shortness of

breath, chest pain or become confused. The major problem here is...if we leave the rhythm untreated the patient may become dead. generally use a more aggressive approach in unstable patients first
the code cart may not be readily available to your patient.

You should always do CPR until electrical is available in dead

patients. Too fast, like ventricular tachycardia, or ventricular fibrillation we defibrillate. Absent, as in asystole we pace with a TCP.

DEAD
These patients also have an EKG rhythm that is undesirable. Their vital signs are absent! They have no pulse! Your first thought for intervention is ELECTRICAL! Step 2 CPR.

The last intervention in order is MEDICINE. Remember here, "all dead people get epinephrine, the deader they are, the more epinephrine they get!" your best intervention for saving this patient's life if they are dead, is electrical. If electrical intervention is at your hands length, don't waste time, use electrical first! American Heart studies show that the sooner electrical intervention is introduced into your dead patient's treatment regime, the better the outcome for survival! The longer electrical is withheld, or not available to your patient, the less likely the outcome will be favorable. Your second intervention is CPR. Think of CPR as your bridge and time-buyer. Good CPR keeps the vital organs perfused until your electrical and drugs can do their job. Always make good CPR a priority, always check pulses with CPR, always assess ventilation! What type of electrical do we use in dead patients? Well of course that depends on the rhythms.

Primary Survey
Airway: Open airway, look, listen, and feel for

breathing Breathing: If not breathing slowly give 2 rescue breaths. If breaths go in continue to next step. Circulation: Check the carotid artery (Adult) for a pulse. If no pulse begin CPR. Defibrillation: Search for and Shock VFib/Pulseless V-Tach

Adult ACLS Secondary Survey ABCDs (abbreviated)

Airway: Intubate if not breathing. Assess

bilateral breath sounds for proper tube placement. Breathing: Provide positive pressure ventilations with 100% O2. Circulation: If no pulse continue CPR, obtain IV access, give proper medications. Differential Diagnosis: Attempt to identify treatable causes for the problem.

http://www.youtube.com/watch?v=Teu62H Y9JW8&feature=related

Pulseless Electrical Activity, or PEA

This is a condition where you have some

electrical activity but not mechanical activity.

In other words, the heart is not contracting, giving

you a pulse.
PEA is really not a rhythm, but a condition. You can have a normal sinus rhythm, but if there is no pulse, the condition is PEA. If you have a patient with the condition of PEA, and the rhythm is a slow wide ventricular rhythm, you may want to try TCP.
Remember, try it early on, don't wait if your going to try it, do

it right away!

PEA
Problem search..Treat accordingly. (see

differential diagnosis table) **Continue this algorithm if indicated. Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi. Atropine 1 mg IV/IO q3-5 min. (3mg max.)

condition Pulmonary Embolism Acidosis (preexisting)

Assess No pulse w/ CPR, JVD Diabetic/renal patient, ABGs

Intervention Thrombolytics, surgery Sodium bicarbonate, hyperventilation

Tension pneumothorax

No pulse w/ CPR, JVD, tracheal deviation

Needle thoracostomy

Cardiac Tamponade

No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest

Pericardiocentesis

Hyperkalemia (preexisting)

Renal patient, EKG, serum K level

Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate Treat with great prudence after careful assessment of the cause. K can kill. Fluids

Hypokalemia Hypovolemia

EKG, serum K level Collapsed vasculature

Hypoxia
Myocardial infarct

Airway, cyanosis, ABGs

History, EKG

Oxygen, ventilation
Acute Coronary Syndrome algorithm

Drugs

Medications, illicit drug use, toxins

Treat accordingly

Shivering

Core temperature Hypothermia Algorithm

ELECTRICAL!

The goal, "do you want to slow down and convert this rhythm, or do we want to speed it up? If the rhythm is too fast, our goal is to slow it down and convert it, we would use synchronized cardioversion. If our rhythm is too slow our goal is to speed it up, we would use external transcutaneous pacing or TCP. Examples: If our patient had an EKG rhythm of Atrial Tachycardia and they were unstable, we would do a synchronized cardioversion to slow it down. If our patient has a second or third degree heart block with a slow rhythm and were unstable, we would use TCP. You may say wait a minute! "I don't know what a second or third degree heart block is!" Well, that's okay, you can tell that it's TOO SLOW! After we try electrical first, our second treatment option is medicine in unstable patients. Think electrical first in unstable, then medications next. "Does this mean that if the code cart is down the hall, I should wait to give electrical first if I have medication closer?" NO! It means your very first thought is electrical, having someone get it, and set it up. It most instances you can try medication, AS LONG AS IT DOES NOT INTERFERE WITH YOUR FIRST ACTION WHICH IS ELECTRICAL! What's the rational? Remember your patient is unstable, they have a high likelihood to become DEAD. Electrical is the method of treatment first in unstable! how do I know when to pace, defibrillate, or use synchronized cardioversion?" Here is a rule to remember, D=DEAD, we Defibrillate Dead patients, dead patients have no pulse! We only defibrillate fast rhythms! Yes, FINE VENTRICULAR FIBRILLATION can look like asystole, that's why we look at suspected asystole in more that one ekg lead, to confirm asystole. "Well then, what electrical intervention do we use on asystole? Without jumping too far ahead, use TCP, and early on into the arrest. "how do I know when to cardiovert?" Cardioversion is reserved for unstable patients, unstable patients still have a pulse, they are not dead or pulseless! We cardiovert fast rhythms.

Bradycardia
The following mnemonic directs AHA accepted actions after absolute

(<60bpm) or relative (slower rate than expected) bradycardia with circulatory compromise due to the slow rate is discovered. Start the Secondary ABCDs and remember: *Pacing Always Ends Danger Mnemonic Intervention Note Pacing**TCP Immediately prepare for transcutaneous pacing (TCP) with serious circulatory compromise due to bradycardia (especially high-degree blocks) or if atropine failed to increase rate. .Consider medications while pacing is readied. Always Atropine1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg) Ends Epinephrine 2-10 g/min2nd-line drugs to consider if atropine and/or TCP are ineffective. Use with extreme caution. Danger Dopamine 2-10 g/kg/min
*Pacing does not "always end danger" in brady arrhythmias. If the

above measures do not improve circulatory stability the bradycardia may merely be an indication of a pathological process, think Differential Diagnosis! **Prepare for transvenous pacing (TVP), managed by an expert, if

Cardioversion
It is essential that ACLS Providers know the indications for electrical

cardioversion and receive proper training using their equipment before attempting to perform this risky procedure. Only experts should manage synchronized electrical cardioversion of a stable patient. Synchronized Electrical Cardioversion
As part of the Secondary ABCDs the following mnemonic directs preparations for

synchronized electrical cardioversion of unstable tachycardia with circulatory compromise due to the fast rate (do not delay shocking if seriously unstable) :Oh Say It Isn't So Mnemonic Preparation
Oh Say It Isn't So

O2 Saturation monitor Suctioning equipment IV line Intubation equipment Sedation and possibly analgesics

**Synchronized Electrical Cardioversion *Energy Levels:The initial synchronized shock is 100J monophasic (50J for SVT/A-Flutter) with increasing energy, i.e., 200J, 300J, 360J, if successive shocks are needed. Unsynchronized Electrical Cardioversion Give unsynchronized shocks at VF/PVT *energy levels without delay for unstable tachycardia with critical circulatory compromise due to the fast rate. Also give unsynchronized shocks if you cannot synchronize, or if polymorphic VT is present. If VF/PVT develops, immediately defibrillate at *360J per the VF/PVT Algorithm. *Or biphasic equivalent

Tachycardia

The following directs AHA accepted actions after tachycardia with symptoms due to the fast rate is discovered: Start the Secondary ABCDs with emphasis on oxygenation, IV, VS, and EKG, and consider the following questions: 1. Stable? Yes, next question No, unstable = Immediate electrical cardioversion 2. Narrow? Yes, next question No, wide = Consult an expert (QRS 0.12 sec) 3. Regular? Yes, Vagal maneuvers, if this fails.. Adenosine 6mg rapid IV push (may repeat x2, q1-2min. at 12mg) Or Cardizem (diltiazem) managed by an expert if stable, narrow, regular tachyarrhythmia continues Perform immediate electrical cardioversion if a patient becomes unstable at any time. For sinus tachycardia consider possible causes and treat accordingly. No, irregular = Consult an expert** -------------------------------------------------------------------------------Consult an Expert Most stable tachycardia rhythms require management by an expert due to the challenge of accurately determining and safely treating tachyarrhythmias. A sampling of rhythms and possible expert interventions are listed below. -------------------------------------------------------------------------------Stable Narrow Irregular Tachycardia Atrial Fibrillation, Multifocal Atrial Tachycardia, possibly Atrial Flutter Rate Control: diltiazem or beta blocker -------------------------------------------------------------------------------Stable Narrow Regular Tachycardia Recurrent SVT, Atrial Flutter, Junctional or Ectopic Atrial Tachycardia Rate Control: diltiazem or beta blocker -------------------------------------------------------------------------------Stable Wide Irregular Tachycardia (Avoid calcium channel blockers and digoxin due to possible AF+WPW) Consider amiodarone. Magnesium 2g IV over 5min. for torsades -------------------------------------------------------------------------------Stable Wide Regular Tachycardia If VT, amiodarone 150mg IV over 10min. repeat prn (max 2.2g IV/24hr), elective synchronized cardioversion

VF/ PVT
The following acronym directs AHA accepted actions after the Primary ABCDs have been enacted and an AED or Manual Defibrillator arrives and a shockable rhythm (VF or PVT) is present: SCREAM LetterIntervention Note

Shock360J* monophasic, 1st and subsequent shocks.

(Shock every 2 minutes if indicated) CPRAfter shock, immediately begin chest compressions followed by respirations (30:2 ratio) for 2 minutes. (Do not check rhythm or pulse) RhythmRhythm check after 2 minutes of CPR (and after every 2 minutes of CPR thereafter) and shock again if indicated. Check pulse only if an organized or non-shockable rhythm is present.Implement the Secondary ABCD Survey. Continue this algorithm if indicated. Give drugs during CPR before or after shocking. Minimize interruptions in chest compressions to <10 seconds. Consider Differential Diagnosis. Epinephrine1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi. Antiarrhythmic Medications Consider antiarrhythmics. (Any Legitimate Medication) Amiodarone 300mg IV/IO, may repeat once at 150mg in 3-5 min. if VF/PVT persists or Lidocaine (if amiodarone unavailable) 1.0-1.5 mg/kg IV/IO, may repeat X 2, q5-10 min. at 0.5-0.75 mg/kg, (3mg/kg max. loading dose) if VF/PVT persists,or Magnesium Sulfate1-2 g IV/IO diluted in 10mL D5W (5-20 min. push) for torsades de pointes or suspected/ known hypomagnesemia. * Biphasic energy level is device dependent, follow the manufacturer's recommendation. If recommendation is unknown, use 200J for 1st shock and the same or higher energy level for subsequent shocks.

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