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ACLS Online Training MaterialUnit One: General ConceptsAdvanced Cardiovascular Life Support (ACLS) focuses on identification of, and early intervention in, acute arrhythmias, acute coronary syndromes (ACS), cardiopulmonary arrest and stroke in order to help adults survive cardiopulmonary emergencies. ACLS will teach the student: BLS and ACLS Surveys; High quality CPR; ACLS sequences of care; and Post cardiac arrest care

2010 Guidelines ChangesThe American Heart Association did a major revision of CPR and ACLS Guidelines in 2010. The major changes associated with the 2010 Guidelines include: Changing from the ABCs to a C-A-B sequence of steps. With the 2010 standards, the proper sequence for BLS activities is 1) Chest Compressions, 2) Airway, 3) Breathing. Experts believe that decreasing the delay in beginning compressions will increase survival rates. Removal of the "Look, listen and feel" for breathing. This assessment of the victim's breathing has been removed since untrained responders tended to mistake agonal breathing for effective breathing. This step has been replaced by the instruction to begin CPR if the victim is not responsive, has no pulse, and is not breathing or only gasping. Emphasis on high-quality CPR defined as: o Compression rate of AT LEAST 100 per minute; o Compression depth of AT LEAST 2 inches in adults; o Allowing complete chest recoil with each compression; o IV, drug delivery, advanced airways should not interrupt CPR but should be performed when getting ready for defibrillation; o Avoiding excessive ventilation; An emphasis on providing CPR as a team with providers performing actions simultaneously decreasing the time to definitive treatment (see Team Dynamics unit); Cricoid pressure is no longer recommended; De-emphasis on the pulse check since many responders are unable to reliably detect a pulse. The current recommendation is to feel for a pulse for 10 seconds; then, begin CPR if no pulse is felt OR if the responder is not sure that a pulse is present. When Return of Spontaneous Circulation (ROSC) occurs, begin post cardiac arrest measures (see the new Post Cardiac Arrest section); Administer a vasopressor every 3-5 minutes; endotracheal tube may be used for epinephrine until an IV is established; Atropine is not recommended for asystole or PEA but is the drug of choice for any symptomatic bradycardia; Tachycardia sequence has been simplified (see the tachycardia case); 2011 Pacific Medical Training. All rights reserved.

Quantitative Waveform capnography is recommended to verify ET tube placement and monitor ventilation; Finally, the 2010 guidelines include a recommendation that systems of care must be integrated (see the Systems of Care unit).

2011 Pacific Medical Training. All rights reserved.

Unit Two: BLS and ACLS SurveysThe goal of ACLS is to support the patient in cardiac arrest and provide for optimal outcomes. This is done systematically by conducting BLS and ACLS surveys. If the patient is not responsive, the process should begin with the BLS survey using the ACLS survey for advanced treatment. If the patient is conscious and responsive, the responder should start with the ACLS survey.

BLS SurveyBasic Life Support for adults consists of chest compressions, establishing an airway, rescue breathing, and defibrillation when available. In the past, BLS for healthcare providers has focused on one rescuer resuscitation. The current thinking is that it is very likely that more than one responder will be available to do several actions at the same time; therefore, the CPR course now focuses on CPR as a team. However, skill testing is still done on both one and two rescuer BLS.

Secure the Scene

Make sure you and the patient are safe from environmental hazards (traffic, wet floor, etc.) Shake the victim and shout asking him if he is OK Check breathing Call for help Activate the system yourself if alone Treatment for Ventricular fibrillation is electrical shockCheck Pulse Chest Compressions and Breathing Appropriate Defibrillation

Assess the Patient

Activate Emergency System

Get Defibrillator

CPR

Adult BLS/CPR1. Secure the SceneBefore beginning BLS and CPR on any victim, be sure that both you and the victim are safe from other hazards. For example, if the victim is in the middle of a busy road, attempt to move him out of traffic.

2. Assess the VictimCheck for responsiveness by shaking the victims shoulder and shouting at him. Check to see if the victim is breathing normally; if the victim is not breathing or is only gasping proceed with the next step.

2011 Pacific Medical Training. All rights reserved.

3. Activate the Emergency Response System and get AEDShout for help. If a second rescuer comes, instruct him to call for help and get an AED. If no one responds, call for help using a phone and go for an AED if you know where one is.

4. Perform CPR1. Check for the carotid pulse on the side of the neck between the trachea and the muscles of the neck. Feel for a pulse for at least 5 but NO MORE THAN 10 seconds. 2. If there is no pulse (or if you are unsure), begin cycles of 30 chest compressions followed by 2 breaths. a. With the victim face up on a hard surface, put the heel of one hand on the lower half of the sternum. b. Put the heel of the other hand on top of the first hand. c. Straighten your arms with your shoulders directly over your hands on the victims sternum. d. Press down HARD and FAST. Each compression should be AT LEAST two inches deep and at the rate of AT LEAST 100 per minute. e. Allow the chest to re-expand after each compression to allow the blood to flow back into the heart. f. After 30 compressions, perform a head tilt/chin lift to open the airway. i. Place a hand on the victims forehead and push back to tilt the head. ii. With the other hand, lift the jaw by placing your fingers on the bony part of the lower jaw and lifting up. iii. If a neck injury is suspected and two rescuers are available, open the airway by using the jaw thrust. To perform the jaw thrust, place one hand on each side of the victims head with your fingers under the angles of the jaw and push the lower jaw forward. g. Using a barrier device (if available), give a breath over one second watching the chest rise. Repeat giving a second breath. h. Begin compressions again. i. Switch providers every two minutes as needed to provide rest periods. j. Provide defibrillation when AED arrives; continue compressions.

ACLS SurveyOnce the BLS survey is complete, or if the patient is conscious and responsive, the responder should conduct the ACLS survey with a focus on the identification and treatment of underlying cause(s) of the patients problem. 1. Assess the Patients Airway a. If the patient is unconscious, maintain the airway using head/tilt maneuvers. b. Determine if an advanced airway is needed. Try to avoid interrupting CPR to place an advanced airway unless the patients condition is deteriorating. Use the least invasive airway possible (laryngeal mask, laryngeal tube, or esophageal tracheal tube). c. If an advanced airway is in place, secure the airway and confirm placement by exam and by waveform capnography if available. 2011 Pacific Medical Training. All rights reserved.

2. Assess the Patients Breathing a. If the patient is in cardiac arrest, give 100% oxygen; if the patient is NOT in cardiac arrest, titrate the oxygen to keep the patients oxygen saturation at 94%. b. If available, monitor oxygenation using waveform capnography; watch for signs of cyanosis while avoiding excessive ventilation. 3. Assess the Patients Circulation a. Monitor the quality of CPR using Quantitative waveform capnography, if available; if the partial pressure of CO2 (PETCO2) is < 10 mm Hg, direct faster and deeper CPR. b. Monitor the cardiac monitor for arrhythmias c. Give ACLS drugs per the appropriate sequence. d. Defibrillate or cardiovert as necessary. e. Support the patient with IV fluids. 4. Determine the cause of the symptoms and treat the causes.

2011 Pacific Medical Training. All rights reserved.

Unit Three: Team DynamicsEach member of a resuscitation team must understand his role and the role of all other members. Typically, there is one team leader who will ensure that everything gets done correctly. The role of the team leader includes: Organizing the group Monitoring performance of all team members Being able to perform all skills if required Modeling team behavior Coaching other team members Focusing on excellent patient care Providing analysis and critique of group performance after the resuscitation effort is over.

Team members should be used as dictated by their scope of practice. Team members must: Understand their particular role in the resuscitation Be willing and able to perform the role Be practiced in performing the skills of the role Understand the PALS sequences Be committed to the success of the team

The dynamics of the team will be effective when each member understands and performs within the team: Expectation Communication Team Leader Actions The team leader Gives succinct assignments and confirms that message has been received; confirms performance of task Speak clearly, distinctly, and in a normal tone of voice when giving orders;; request clarification of messages Must define all roles of each team member based on competencies of the members Ask for opinions and suggestions from team members as appropriate Intervene if a team member is preparing to perform an incorrect action or if a team member is unable to perform a task quickly Ask for opinions and suggestions from Team Member Actions Clearly informs leader of receipt assignment; confirms when assignment has been completed Speak clearly and in a normal tone of voice when repeating orders; question ambiguous orders Informs the team l