ACLS Review Handout revised: Critical care, Deadly algorithms and corresponding medications PDF

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AHA ACLS ReviewBook: Advanced Cardiovascular Life Support Provider Manual (2016 AHA) Precourse Self-Assessment: heart/eccstudent Enter code: aclsThe Systematic Approach Unconscious patient: ● BLS survey 1. Check responsiveness (“Are you OK?”) ▪ Absent or gasping* – scan chest for movement 5-10 secon...

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AHA ACLS Review Book: Advanced Cardiovascular Life Support Provider Manual (2016 AHA) Precourse Self-Assessment: www.heart.org/eccstudent Enter code: acls15 The Systematic Approach Unconscious patient: ● BLS survey 1. Check responsiveness (“Are you OK?”) ▪ Absent or gasping* – scan chest for movement 5-10 seconds 2. Shout for help. Activate EMS; get AED if available (if you are a lone rescuer you get the AED…if not you send someone else…and certainly in the hospital someone will grab the code cart!) 3. Check breathing and carotid pulse (5-10 seconds); if no pulse, start CPR ▪ Ventilate with 2 breaths per 30 compressions. ▪ Agonal gasps* are not normal breathing! This is a sign of cardiac arrest. 4. Check for shockable rhythm with AED/defib as soon as it arrives; shock as indicated, follow each shock with CPR (begin with compressions) ● If patient has a pulse but no breathing, give 1 breath every 6 seconds (10 breaths/minute) Recheck the pulse every 2 minutes. Critical Concepts: ● Minimize interruptions to chest compressions – 10 seconds or less! ● Push hard and fast (100-120 per minute; at least 2 inches deep); allow complete chest recoil; switch providers every 2 minutes; continue CPR while defibrillator is charging; avoid excessive ventilation Primary Assessment Unconscious patient complete BLS survey first – then start primary assessment. Conscious patient begin with Primary Assessment. 1. Airway (unconscious patient use head tilt-chin lift, jaw thrust, oropharyngeal airway (OPA - measure from corner of mouth to angle of mandible), nasopharyngeal airway (NPA - measure from tip of nose to earlobe) ▪ Advanced airway if needed (includes endotracheal tube, laryngeal mask airway, laryngeal tube, esophageal-tracheal tube) – the LMA, laryngeal tube and esophageal-tracheal tube can all be placed while chest compressions continue….may need to interrupt compressions to place ET ▪ For advanced airway – confirm placement by physical exam and capnography device; secure device ● Monitor placement with continuous waveform capnography (the most reliable method of confirming and monitoring correct placement!) 2. Breathing – supplemental O2 (100% for cardiac arrest); for others titrate O2 to achieve sat of 92-98% ; avoid excessive ventilation! 3. Circulation – ▪ Monitor CPR quality

● Quantitative waveform capnography (PETCO2): if 65, fluids 1-2L (assess for wet lungs, edema), give vasopressors: epi, norepi 0.1-0.5 mcg/kg/min, dopamine 5-10mcg/kg/min. Disability: neuro as., TTM candidate if 0 (cool pt, 32-36* for 24 hours). Labs, EKG: if elevated ST, take to cath lab 32. What is the target PETCO2 after ROSC? 35-40

33. Hypotension following ROSC is treated if the BP is_______? What is the initial treatment? What treatment is initiated next if the patient fails to respond to the initial treatment? 34. What treatment is recommended if the patient remains unresponsive (unable to follow verbal commands) following ROSC? 35. The 12-lead EKG performed following ROSC reveals ST elevation. What treatment plan is now recommended? Bradycardia 36. The patient has a heart rate of 42 and is not symptomatic. What treatment is recommended? Monitor 37. The patient has a heart rate of 54 and is hypotensive and confused. What treatment is recommended? Atropine, 1 mg, q3, q 3-5mins. If unaffective, use TCP. 38. The patient with symptomatic bradycardia has not responded to atropine and a transcutaneous pacer is not available. What medication therapy is recommended? Dopamine (5-10) or Epi (220) monitor BP to titrate Electrical Therapy 39. At what point in the EKG is the shock delivered in synchronized cardioversion? Back of the R wave 40. What rhythms can be cardioverted? Unstable tachycardias How many joules with each rhythm? 41. The patient in unstable, wide, regular tachycardia is undergoing cardioversion. Following a shock of 100 J the patient is now in Vfib. What is the next step? Charge again and shock 42. What safety steps must be taken prior to pushing the “shock” button to defibrillate or cardiovert? ACS 43. What findings on the 12 lead EKG indicate STEMI? ST elevation 44. What is the goal for “door to balloon inflation time” in the STEMI patient? 90mins 45. What is the recommended dose of aspirin for ACS? 162-325 46. Name 3 situations where nitroglycerin should either be used cautiously or not at all? Hypotenions, if they’ve taken -phils, inf. Wall vent MI (nitro reduces preload) 47. What assessment tool is a priority in patients with chest pain (do within first 10 minutes of arrival)? EKG Stroke 48. What is the Cincinnati Pre-hospital Stroke Scale? FAST, face, arms, slurred speech, time 49. What is the most important action an EMS team will do to ensure the patient with suspected stroke will receive immediate care in a hospital stroke center? Call hospital, stroke alert and clear CT (20mins from door to CT), results in 45 mins. 50. Why is a head CT performed ASAP on patients with stroke symptoms? To know what type of stroke it is, 2 different treatments, TPA for clots. 51. The CT scan should be completed within _____ minutes of the patient’s arrival in the ED and read within _______ minutes from ED arrival. 52. When is thrombolytic therapy considered for a patient presenting with signs of stroke? *4.5 hours for TPA tx *you can only see the bleeding on CT Team Dynamics

53. Why should the team leader delegate tasks to team members at the start of a code? Organization, 54. What is the role of the CPR Coach during a code? Increasing CCF, and ensuring good compressions 55. What is the purpose of closed-loop communication? Verify communication is heard 56. What will a team member do if assigned an unfamiliar task during a code? Speak up 57. What will a team member do if another member is performing a task incorrectly during a code? Speak up

ACLS Review Questions (with Answers) BLS: 1. What is your priority of care for a pulseless patient? BLS survey – check responsiveness, call for help (active EMS/get AED if available), check for breathing and pulse 5-10 seconds for each check, if no pulse start CPR (30:2 – 30 compressions, 2 breaths). As soon as AED/defib available check rhythm and defibrillate shockable rhythm, follow each shock immediately with 2 minutes of CPR 30:2 (5 cycles) 2. How soon should compressions be started in the pulseless patient? How long should the breathing/pulse check take? Start compressions right after checking for breathing and pulse. Try to check for both simultaneously but you can spend 5-10 seconds checking for breathing; then 5-10 seconds checking for pulse. 3. What is the compression to ventilation ratio for the pulseless patient without an advanced airway? 30 to 2 4. What is the correct compression rate and depth? Rate of 100-120 per minute and depth of at least 2 inches. If compression depth can be measured should be 2-2.4 inches. 5. What is the maximum time allowed for interruptions in chest compressions? No longer than 10 seconds unless under extreme circumstances 6. How often should we switch CPR compressors? Every 2 minutes or 5 complete cycles; this helps to ensure good quality compressions 7. What is your priority if there is a problem with the defibrillator or AED? Resume high quality chest compressions and ventilations. Someone else can trouble-shoot the AED…never delay chest compressions to trouble-shoot an AED! 8. How often can you defibrillate a patient? Every 2 minutes if it is a shockable rhythm. What rhythms can be defibrillated? Vfib and pulseless Vtach 9. What can increase the chances that defibrillation will successfully convert VF? Immediate CPR and defibrillation within a few minutes of cardiac arrest. The quicker the better. Why? Probability of defibrillation being successful diminishes with time. 10. The patient has just been defibrillated. What will the team do next? Resume chest compressions Airway: 11. What is the ventilation rate for the adult patient with a pulse? Rate/min and frequency? 1 breath every 6 seconds (10 breaths/min) 12. What is the best way to confirm and monitor ET placement? AHA recommends continuous waveform capnography (PETCO2) as the best way to confirm placement and monitor for continued placement. Physical exam – listening for bilateral breath sounds, watching for bilateral rise and fall of the chest and confirmation device. 13. What is the best way to confirm adequacy of CPR? Quantitave waveform capnography (PETCO2) and/or intra-arterial pressure. What reading is goal during CPR? PETCO2 ≥10; Intra-arterial relaxation pressure ≥20 mm Hg 14. After ROSC, what is the target PETCO2 reading? Normal range, 35-40 mm Hg 15. What is the ventilation rate on the pulseless patient after advanced airway placement. 1 ventilation every 6 seconds (≈10 breaths/min) Should you pause compressions during ventilation with an advanced airway? No, continuous compressions Medications: 16. What is the preferred medication route for a pulseless patient? IV What is the 2nd choice? IO 17. Medications are administered during which part of the CPR cycle? During compressions; early as possible in the cycle so meds can circulate to the heart 18. What is the FIRST drug all pulseless patients get? Epinephrine Dose? 1 mg

19. What is the SECOND drug given for pulseless VT or VF? Dose? Frequency? Amiodarone 300 mg IV/IO push for 1st dose. If VF or pulseless VT persists a second dose of 150 mg IV/IO can be given in 3-5 minutes. Or may administer lidocaine 1-1.5 mg/kg IV/IO. Second dose 0.75 0.5 mg/kg IV/IO 20. What antiarrhythmic is recommended for polymorphic VT/torsades? Dose? Magnesium sulfate. If patient is pulseless dose is 1-2 grams IV/IO diluted in 10 mL D5W and given over 5 – 20 minutes. 21. What diagnostic tool should be used to first screen stable SVT? 12 lead EKG Following that, what is the recommended treatment for stable SVT? Vagel maneuvers; adenosine if that does not work. May try beta blockers or calcium channel blockers. For unstable SVT? Synchronized cardioversion 22. What is the recommended treatment for stable VT with a pulse? 12 lead EKG, consider adenosine if regular and monomorphic, consider antiarrhythmics…procainamide 20-50 mg/min until arrhythmia suppressed, hypotension, QRS increases >50% or max dose 17 mg/kg given. Amiodarone 150 mg over 10 minutes, can repeat if needed and follow with maintenance infusion of 1 mg/min for 1st 6 hours. Sotalol 100 mg IV/IO. For unstable VT with a pulse? Synchronized cardioversion 23. What is the first treatment option (medication) for unstable bradycardia? Atropine 24. What is the recommended dose of adenosine for SVT? Second dose? 1st dose 6 mg; 2nd dose 12 mg rapid IV push followed with 20 mg NS rapid push PEA/Asystole: 25. List the 5 H’s and 5 T’s: Hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombus pulmonary, thrombus coronary 26. Define PEA. An organized rhythm without a pulse 27. What are the 2 most common causes of PEA? Hypovolemia and hypoxia 28. How do you confirm a patient is really in asystole? Check in more than one lead, check for operator error, loose lead, no power. 29. The patient has persistent asystole after high quality continuous CPR for >20 minutes and PETCO2 is less than 10. What discussion might be appropriate at this point? Termination of efforts 30. What are reasons to stop resuscitative efforts during BLS/ACLS? Rigor mortis, indicators of DNR status, threat to safety of providers Post Cardiac Arrest – after ROSC: 31. What is the first treatment priority after ROSC? Ensure an adequate airway and support breathing. 32. What is the target PETCO2 after ROSC? 35-40 mm Hg 33. Hypotension following ROSC is treated if the BP is_SBP 90 or MAP >65 mm Hg: Epinephrine 0.1 – 0.5 mcg/kg/min (approx 7-35 mcg/min); Dopamine 5-10 mcg/kg/min; Norepinephrine 0.1 – 0.5 mcg/mg/min (7-35 mcg/min) 34. What treatment is recommended if the patient remains unresponsive (unable to follow verbal commands) following ROSC? Targeted temperature management; cool to target temp of 32-36° C for at least 24 hours. 35. The 12-lead EKG performed following ROSC reveals ST elevation. What treatment plan is now recommended? Coronary reperfusion (PCI) Bradycardia

36. The patient has a heart rate of 42 and is not symptomatic. What treatment is recommended? Monitor and observe. 37. The patient has a heart rate of 54 and is hypotensive and confused. What treatment is recommended? Atropine 1 mg IV/IO, repeat every 3-5 minutes, Max dose 3 mg 38. The patient with symptomatic bradycardia has not responded to atropine and a transcutaneous pacer is not available. What medication therapy is recommended? Dopamine infusion 2-20 mcg/kg/min or epinephrine IV 2-10 mcg/min Electrical Therapy 39. At what point in the EKG is the shock delivered in synchronized cardioversion? At the peak of the QRS…the “R” wave 40. What rhythms can be cardioverted? How many joules with each rhythm? Unstable SVT (50 100 J), unstable atrial fibrillation (120-200 J), unstable atrial flutter (50 - 100 J), unstable regular monomorphic tachycardia with pulse (100 J) 41. The patient in unstable, wide, regular tachycardia is undergoing cardioversion. Following a shock of 100 J the patient is now in Vfib. What is the next step? Initiate CPR and defibrillate as quickly as possible. 42. What safety steps must be taken prior to pushing the “shock” button to defibrillate or cardiovert? Always announce the shock – be sure and state loudly and in a forceful voice so everyone pays attention. Make a visual check to see that no one is touching the patient or anything leading to the patient. Make sure oxygen is not flowing across the patient’s chest. ACS 43. What findings on the 12 lead EKG indicate STEMI? ST elevation or new or presumably new LBBB 44. What is the goal for “first medical contact to balloon inflation time” for PCI in the STEMI patient? 90 minutes 45. What is the recommended dose of aspirin for ACS? 162-325 mg 46. Name 3 situations where nitroglycerin should either be used cautiously or not at all? Inferior wall MI with right ventricular infarction; hypotension, bradycardia or tachycardia; recent phosphodiesterase inhibitor use (sildenafil, vardenafil, tadafil) 47. What assessment tool is the priority in patients with chest pain (do within first 10 minutes of arrival)? 12 lead EKG Stroke 48. What is the Cincinnati Pre-hospital Stroke Scale? Used by EMS personnel for early recognition of stroke – 3 areas of physical assessment: facial droop, arm drift, abnormal speech 49. What is the most important action an EMS team will do to ensure the patient with suspected stroke will receive immediate care in a hospital stroke center? Alert the hospital ahead of time so they can activate the stroke team and clear CT. 50. Why is a head CT performed ASAP on patients with stroke symptoms? R/O hemorrhagic stroke. 51. The CT is critical to decision making in suspected stroke and should be completed within _20_ minutes of the patient’s arrival in the ED and read within __45__ minutes from ED arrival. 52. When is thrombolytic therapy considered for a patient presenting with signs of stroke? Time from symptom onset is 80% is goal) 55. What is the purpose of closed-loop communication? Ensure accuracy during the code; confirm that a team member understands verbal orders; reduces errors and facilitates accurate documentation. 56. What will a team member do if assigned an unfamiliar task during a code? Inform the team leader and ask for a new task or role. 57. What will a team member do if another member is performing a task incorrectly during a code? Speak up and let the team member/leader know....