Transcript EASY TO UNDERSTAND ACLS ALGORITHMS 2nd Edition

JOE JONES, NREMT-PARAMEDIC
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This patient is one who you may have
resuscitated from cardiopulmonary arrest and
now has a pulse. Also consider the patient who
is in complete Respiratory failure. Both of these
patients must have the airway controlled or both
will suffer complete cardio-pulmonary arrest
EXAMPLES OF RESPIRATORY FAILURE
The patient who has C.O.P.D. or Pulmonary
Edema
With any of these cases the provider must be
able to maintain an airway using basic skills, or
using advanced airways in the proper way to
assure the best outcome for the patient.
OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
COMBITUBE
LMA
ENDOTRACHEAL TUBE
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Continuous waveform capnography is recommended
in addition to clinical assessment as the most reliable
method of confirming and monitoring correct
placement of an endotracheal tube:
The proper ventilatory rate for a patient who is not
intubated is 10 – 12 breaths/minute.
The proper ventilatory rate for a patient who is
intubated is 8 – 10 breaths/minute.
One needs to be cautious not to increase thoracic
pressure to the point where provider does not make
matters worse, i.e. Pneumothorax.
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Check Responsiveness
 A – B – C’s
 Begin CPR with Chest Compressions
 Call for AED or Defibrillator
 AED/Defibrillator Arrives Reveals Rhythm Above
 Defibrillate at 120 – 200 Biphasic/360 Monophasic
 Continue CPR
 Initiate IV
 Administer Epinephrine 1 mg/1-10,000 IVP
 May Substitute Vasopressin 40 units on 1st or 2nd dose of
Epinephrine
 Continue CPR for 2 minutes or 5 cycles
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Stop CPR then defibrillate
 120 – 200 Biphasic
 360 Monophasic.
 Continue CPR
 Administer Cordarone 300 mg. IVP repeat in 5 minutes.
 Administer Epinephrine 1 mg or 40 units of Vasopressin
 After 2 minutes CPR (Stop)
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Defibrillate
120 – 200 Biphasic
360 Monophasic
Continue CPR
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Continue CPR Defibrillating between each round
 Continue to Administer Epinephrine 1 mg q- 3 – 5 minutes.
 Repeat Cordarone 150 mg. IVP
 If Ventricular Tachycardia is Polymorphic then consider Torsades
 Administer Magnesium Sulfate 1 – 2 grams IVP
 Sodium Bicarbonate not routinely recommended unless known
acidosis.
HIGH QUALITY CPR IS A MUST. DO NOT DELAY THIS
TASK. COMPRESS AT LEAST 2 INCHES ALLOW
COMPLETE RECOIL AT LEAST 100 COMPRESSIONS PER
MINUTE. CONTINUE TO IDENIFY AND TREAT
CORRECTABLE CAUSES OF THE ARREST.
(5 H’S AND 5 T’S)
ROSC
◦ AFTER THE RETURN OF SPONTANEOUS CIRCULATION THEN
SUPPORT VITAL SIGNS, IF NEEDED USE VASOPRESSORS TO
MAINTAIN PERFUSION, CONTINUE OXYGENATION OF THE
PATIENT AND SEEK EXPERT CONSULTATION.
A-B-C’s
 PT. PULSELESS AND APNEIC
 BEGIN CPR WITH CHEST COMPRESSIONS
 CALL FOR MONITOR/AED
 MONITOR ARRIVES
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ASYSTOLE CONFIRMED IN TWO LEADS
THEN CONTINUE CPR FOR 2 MINUTES OR 5
CYCLES 30 COMPRESSIONS TO 2 VENTILATIONS.
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IV in place and infusing at W/O Rate
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Administer Epinephrine 1 mg of a 1-10,000 solution
repeat dose in 3 – 5 minutes.
May substitute Epinephrine on 1st or 2nd dose with
Vasopressin 40 units IVP
Prepare and place an Advanced Airway
Continue to provide good quality CPR
Atropine no longer recommended in Asystole
Routine use of Bicarbonate no longer recommended
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TREAT ALL CORRECTABLE CAUSES:
H's and T's
Hypovolemia
Toxins
Hypoxia
Tamponade (cardiac)
Hydrogen Ion (acidosis)
Tension pneumothorax
Hyper/hypokalemia
Thrombosis (pulmonary & coronary)
Hypoglycemia
Trauma
Hypothermia
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In some special resuscitation situations, such as preexisting metabolic
acidosis, hyperkalemia, or tricyclic antidepressant overdose, bicarbonate
can be beneficial (see Part 12: "Cardiac Arrest in Special Situations").
However, routine use of sodium bicarbonate is not recommended for
patients in cardiac arrest.
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AFTER ALL CAUSES HAVE BEEN EVALUATED AND TREATED THEN
CONSIDER TERMINATION OF EFFORTS.
A-B-C’s
 PT. PULSELESS AND APNEIC
 BEGIN CPR WITH CHEST COMPRESSIONS
 CALL FOR MONITOR/AED
 MONITOR ARRIVES
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PEA CONFIRMED THEN CONTINUE CPR FOR 2
MINUTES OR 5 CYCLES 30 COMPRESSIONS TO 2
VENTILATIONS.
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IV in place and infusing at W/O Rate
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Administer Epinephrine 1 mg of a 1-10,000 solution
repeat dose in 3 – 5 minutes.
May substitute Epinephrine on 1st or 2nd dose with
Vasopressin 40 units IVP
Prepare and place an Advanced Airway
Continue to provide good quality CPR
Atropine no longer recommended in PEA
Routine use of Bicarbonate no longer recommended
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There are four rhythms in the tachycardia algorithm
which can cause instability with the cardiovascular
system, they are identified as follows:
Supraventricular Tachycardia (SVT)
Ventricular Tachycardia (VT)
Uncontrolled Atrial Fibrillation (A-Fib)
Uncontrolled Atrial Flutter (A-Flutter)
Sinus Tachycardia does not fall in the algorithm, treat the
cause of the tachycardia.
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A – B – C’s
Oxygen
12 Lead if time permits
Consider causes
Regular monomorphic narrow complex
◦ Consider sedation then
◦ Synchronize cardiovert at 50 – 100 joules Biphasic increase as
needed up to 200 joules, 100 joules monophasic increase as
needed up to 360
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A – B- C’s Administer Oxygen
IV Sedate if time permits
◦ Synchronize Cardiovert at 100 joules Biphasic or Monophasic
◦ Increase biphasic up to 200 joules and monophasic up to 360
joules.
UNCONTROLLED ATRIAL FIBRILLATION
A – B- C’s Administer Oxygen
IV Sedate if time permits
Synchronize at 120 – 200 joules Biphasic or 200 joules
Monophasic. Increase Biphasic up to 200 and Monophasic
up to 360 joules
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A – B- C’s administer oxygen
Consider all causes
IV
Vagal Maneuvers
Adenosine 6 mg rapid IVP (flush with 15 ml saline)
Adenosine 12 mg rapid IVP (flush with 15 ml saline)
Adenosine 12 mg rapid IVP (flush with 15 ml saline)
◦ Consult expert consultation
 May consider beta blocker/ calcium channel blocker
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With this rhythm one must take in consideration what
is causing the problem. In most cases the problem is
arising from a rapid ventricular rate. If the patient is
stable however take in consideration of how long he or
she has been experiencing this arrhythmia.
With all this in mind consider anticoagulant prior to
converting the rhythm.
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Assess appropriateness for the situation
A – B – C’s Apply Oxygen
IV @ KVO RATE
12 LEAD ECG
MEDICATIONS TO CONSIDER
This will be left up to the physician in charge of the patient.
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Calcium Channel Blocker
Beta Blocker
Digitalis Products
Cordarone
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With this rhythm one must remember what is
causing the patient’s signs and symptoms.
Remember the patient must be having signs and
symptoms prior to beginning treatment
◦ Some rhythms which would fall under the algorithm
are:
 Sinus Brady
 Junctional
 Heart Blocks
 1st degree, Wenchebach, Mobitz type II and Complete Heart
Block or better known as a 3rd degree block
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Assess Appropriateness for the clinical situation
Consider expert consultation
A – B – C’s Apply Oxygen
IV @ KVO
Atropine .5 mg IVP may be repeated up to 3 mg.
maximum dose
Transcutaneous Pacing
Dopamine or Epinephrine Infusion
Dopamine Dose: 2 – 10 mcg/kg/min
Epinephrine Dose: 2 – 10 mcg/min.
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Prior to treating a high degree heart block always
keep in mind that if the block is at the AV node or
lower Atropine may not work.
In this case make sure to seek expert consultation
Consider the need for immediate TCP
Consider being aggressive with Chronotrope
Medications.
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Remember when dealing with a patient with an ACS
one must know the ultimate treatment is to get the
blocked Coronary open. With this in mind one must
seek expert consultation quickly.
Being aggressive with this patient is a must in order
to prevent any further damage to the myocardium.
There are two ways one may use in order to open
the blocked artery, they are:
◦ Cath. Lab
◦ Thrombolytics
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While preparing the patient for his/her
treatment one should consider:
◦ A – B – C’s Consider Oxygen
◦ Monitor for arrhythmia’s, if present treat according
to American Heart guidelines
◦ IV
◦ 12 lead EKG
◦ Aspirin
◦ Nitro repeat times 3 titrating to blood pressure and
pain
◦ Morphine
◦ Beta Blocker
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While treatment is being performed to attempt to
stabilize the patient make sure to seek expert
consultation.
REMEMBER
TIME IS
MUSCLE::::
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With the patient experiencing signs and symptoms
of an acute stroke one must act fast in order for the
patient to receive definitive treatment.
The time line is three hours from the time signs first
began.