Transcript ACLS Overview

ACLS Overview
Kevin Mikielski, DO
January 16, 2007
Initial Evaluation and
Management
Initial Evaluation and Management
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Immediately call for backup and crash cart
Keep your cool
Assess for responsiveness
Promptly feel for pulse
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Don’t waste time
Won’t harm patient by doing CPR if they have a pulse
DEFINITELY WILL NOT HELP PATIENT IF YOU
THINK YOU FEEL A PULSE BUT THEY ARE
ACTUALLY PULSELESS
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Happens 10-20% of the time to us
Initial Evaluation and Management
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Start CPR immediately if no pulse
Chest compressions are much more important than
ventilation, especially initially
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Critical to maintain cerebral and coronary perfusion
Increases the likelihood of successful debrillation of VF
Compress with base of hand over lower sternum
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1.5 to 2 inches of compression
Rate of 100/minute
Avoid interruption of compressions; if need to cease compressions,
be brief and resume promptly
Begin ventilations with Ambu bag at ratio of 30:2
Intubate but do not delay defibrillations in order to
intubate
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Once intubated, ventilate at 8-12 breaths per minute
Do not overventilate as this results in decreased cardiac output
and possibly pneumothorax
Initial Evaluation and Management
Quickly analyze rhythm on telemetry or
defibrillator
 Determine if rhythm is suitable for
defibrillation
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Need to have an underlying rhythm to
“shock”
Defibrillation vs
Cardioversion
Defibrillation vs Cardioversion
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Defibrillation is form of cardioversion
Also known as “unsynchronized”
cardioversion
 “Shocks” immediately without sensing
underlying rhythm
 Cardioversion is also referred to as
synchronized cardioversion because it
“senses” the underlying rhythm and delivers
shock at peak of R wave to avoid shocking at
time to result in R on T phenomenon and
subsequent VF
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How does
defibrillation/cardioversion work?
Does not “shock” heart back to normal
rhythm
 Induces asystole
 Allows heart’s normal intrinsic pacemakers
to discharge
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May take seconds to minutes
 May have period of PEA or asystole following
shocks
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Defibrillation vs Cardioversion
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Best positioning of pads in AP
Usually position pads or paddles over sternum
and apex
If attempting defibrillation, make sure that mode
is set to UNSYNCHRONIZED cardioversion
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If in Synch mode, nothing will happen
If attempting cardioversion, make sure mode is
set to SYNCHRONIZED cardioversion
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May need to hold/press button for a few seconds until
R waves are sensed
Defibrillation vs Cardioversion
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Energies utilized depend on type of device
Monophasic device
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At our institution
Defibrillation: 360 J
Cardioversion:
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A fib-100 J
PSVT, A flutter-50J
“Stable” VT-100 J
Biphasic device
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Lower Joules because device determines impedence
and adjusts energy delivered
Defibrillation vs Cardioversion
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Defibrillator rhythms
Pulseless VT
 Ventricular fibrillation
 Torsades de Pointes
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Cardioversion rhythms
Atrial fibrillation
 Atrial flutter
 PSVT
 “Stable” VT
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Defibrillation vs Cardioversion
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DO NOT SHOCK:
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BRADYCARDIA
ASYSTOLE
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Unless you think it may be fine ventricular fibrillation
SINUS TACHYCARDIA
PULSELESS ELECTRICAL ACTIVITY
Avoid cardioversion in patients with atrial
fibrillation who are on digoxin and are
hypokalemic
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May precipitate VF or asystole
Defibrillation vs Cardioversion
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Immediately resume CPR following
defibrillation
May have period of asystole or PEA following
defibrillation
 Constantly assess rhythm
 Check for pulse in 2-3 minutes
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Defibrillation vs Cardioversion
Be aggressive with pressors/fluids
 Remember to obtain stat labs/EKG/CXR
 Go with patient to ICU as many patients
“recode”
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Rhythms
VENTRICULAR TACHYCARDIA
VENTRICULAR TACHYCARDIA
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
VENTRICULAR FIBRILLATION
Torsades de Pointes
TORSADES DE POINTES
ASYSTOLE
Pulseless Electrical Activity
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Immediately need to think
of causes
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Hypovolemia
Hypoxia
Hypothermia
Hyper or hypokalemia
Severe acidosis
Massive PE
Massive MI
Tamponade
Tension pneumothorax
Drug overdose
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TCAs, antiarrhythmics, digoxin
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No indication for
pacing based on
current guidelines
Case Studies
Case 1
58 year old female
 Hx of CAD
 LVEF 15%
 Sitting in chair and feels “weak”
 Nursing student is there are sees patient
start to seize
 Monitor shows:
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Case 2
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42 year old AA male
Hx of end-stage renal disease on HD
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Presents to ED feeling “weak” and “sick”
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Has missed HD for past week
Vital signs: BP 80/40, P 130 (sinus), RR 22
“Funny sound” on cardiac auscultation
Several PVCs on monitor
Suddenly becomes unresponsive and pulseless
EKG shows:
Case 3
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42 year old AA male
Hx of end-stage renal disease on HD
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Presents to ED feeling “weak” and “sick”
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Has missed HD for past week
Vital signs: BP 80/40, P 130 (sinus), RR 22
Several PVCs on monitor
Suddenly becomes unresponsive and pulseless
EKG shows:
Case 4
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56 yo female
Admitted to ICU with midepigastric discomfort
and nausea with vomitus x 1
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Diagnosed with pancreatitis in ER
Amylase 250, lipase 200; liver enzymes ok
Hemodynamically stable but HR periodically in
50s with 1st degree AV block per ER doctor; no
acute ST segment changes
EKG reveals:
The next morning:
BP 60/30, P 40
Case 5
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70 yo white male
Hx CABG
Admitted with chest pain and dyspnea
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Troponin 14; EKG NS ST/T changes
Sx improved with asa, plavix, heparin, integrillin,
metoprolol, ntg gtt
Awaiting transfer for LHC/SCA
Suddenly becomes unresponsive in ICU and
telemetry shows:
Weak Pulse
No pulse
Pulse
Pulse
Case 6
32 year old white female
 Smoker
 POD 1 following TAH w BSO develops
mild dyspnea and “a funny feeling in my
chest”
 Vital signs stable; mild fever 100 F
 Symptoms improved with nebulizer and
O2
 Probably secondary to atelectasis
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Next day develops worsening dyspnea
with SaO2 of 88% on 4L
 BP 86/54 and Pulse 130; RR 22
 CXR: Probable RLL atelectasis vs infiltrate
 EKG reveals:
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Twenty minutes later, she collapses
and is pulseless . . .
No pulse
Pulse
Case 7
78 yo admitted with severe nausea,
abdominal pain, and diarrhea
 Baseline EKG reveals sinus rhythm with
1st degree AV block, RBBB and LAFB
 Occasional brief “pauses” on monitor
when abdominal pain increases
 Develops intractable nausea and
abdominal pain
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Vital signs BP 70/45, P 32
Pulse
Pulse
Case 8
25 yo white female
 On Behavioral Health floor
 On Risperdal, Haldol, Amitryptyline
 Develops palpitations
 Hemodynamically stable
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Weak Pulse
End of Lecture
Thank you for your attendance.