INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench,...
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Transcript of INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench,...
![Page 1: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/1.jpg)
INTRO TO ACLS
Department of Emergency Medicine
University of Manitoba
Zoe Oliver, Cheryl ffrench, Shai Harel,
Hareishun Shanmuganathan, Katie Sullivan
![Page 2: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/2.jpg)
OBJECTIVES
1. Approach to the first three minutes of a code
2. Primer on the rest….
![Page 3: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/3.jpg)
![Page 4: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/4.jpg)
![Page 5: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/5.jpg)
Part 1: He Looks Dead
Katie is a third year medical student on her Ortho rotation.
She is pre-rounding on her patients in the morning.
Pitfall:
Started CPR before checking responsiveness
![Page 6: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/6.jpg)
Checking Responsiveness
Voice (get close)
Pain (noxious central stimulus) Sternal Rub Upper Orbit Pressure Trapezius Pinch
![Page 7: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/7.jpg)
Part 2 – He Is Dead
Katie is a third year medical student on her Ortho rotation.
She is pre-rounding on her patients in the morning.
Pitfall:
Didn’t call for help
![Page 8: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/8.jpg)
Calling for help
Check which room you’re in
Go into hallway and look for nurse
Get someone to check the code status
No one there?
Go to phone and dial ‘55’ for an emergency line Code Blue vs. Medical 25 vs. Code 88
![Page 9: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/9.jpg)
Part 3 – How was your Weekend?
Katie and Shai are third year med students pre-rounding on their Ortho rotation.
They enter a four bed room together. Katie’s patient, “doesn’t look right”.
Pitfall:
Didn’t activate BLS
![Page 10: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/10.jpg)
Activating the BLS Primary Survey
![Page 11: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/11.jpg)
BLS Primary Survey
Simple interventions
![Page 12: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/12.jpg)
Part 4 – He’s Not Perking Up
Katie and Shai decide to activate BLS.
Pitfall:
Didn’t open airway
Gave inadequate breaths
Radial pulse check
![Page 13: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/13.jpg)
Primary
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Primary
•Give 2 breaths •NO response? 1 breath / 5 seconds and CPR
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No more than 5-10 seconds
NOT peripheral pulse
Start CPR
CPR board
Recheck pulse every 2 minutes
Ensure IV/IO access
Primary
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Part 5: The Team Will be Here Soon
Previous scenario continues
Ward resident Hareishun runs into the room…
Pitfall:
Too many CPR interruptions
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CPR
CPR board
100 compressions/minute
30:2 breaths
Hard and fast
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Parts 1-5: The Replay
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RECAP
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Who’s on the code team?
• Code team leader• More doctors if they happen to be around
• Nurses• Record keeper, someone to give meds
• RT
• Orderly• CPR
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How does the code team work?
• Code team leader:• Makes it clear who is in charge
• Call for quiet if there’s too much noise
• Stands at pt’s side, hand on pulse (femoral)
• If possible, delegate tasks to others
• Closed-loop communication
• Maintain sense of ‘big picture’
![Page 22: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/22.jpg)
What the team leader will ask you….
Patient name, age, reason for admission
Past medical history
CODE STATUS
Time of arrest, events leading up
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What next?
Repeat the BLS Primary Survey
Can now do ‘D’
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At casino: No pulse power-on AED and
follow voice prompts Apply pads Administer shock as
directed
In hospital: will not have AED immediately available
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Once you know the rhythm, you can follow the algorithm
Today: Non-Perfusing Rhythms
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Non-Perfusing Rhythms
![Page 27: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/27.jpg)
What are VF and VT?
• These two rhythms are treated in the same way (if pulseless)
• Both represent the ventricle trying to pump blood in a disorganized way
• Usually due to myocardial ischemia (for whatever cause)
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VF and VT
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Examples
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Examples
![Page 31: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/31.jpg)
Examples
![Page 32: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/32.jpg)
Examples
![Page 33: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/33.jpg)
Defibrillators 101
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Defibrillators 101
• Gel pads• Select energy (200J)• No Sync• Charge• Clear everyone• Shock
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Putting it together
• You’ve found an unresponsive patient
• Called a code
• Did as much of the BLS primary survey as you could
• Code team has arrived and repeated the primary survey, including defibrillation if needed
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First three minutes…
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OBJECTIVES
1. Approach to the first three minutes of a code
2. Primer on the rest….
![Page 38: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/38.jpg)
Incorporating ACLS
![Page 39: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/39.jpg)
Now: ACLS Secondary Survey
Advanced interventions
![Page 40: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/40.jpg)
Is the airway patent?
Is an advanced airway indicated?
Laryngeal Mask Airway (LMA) Endotracheal Tube (ETT)
![Page 41: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/41.jpg)
Is the airway in the right place?
Is the tube secure?
Are we monitoring O2 and CO2?
![Page 42: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/42.jpg)
What is/was the rhythm?
Is there IV access?
Is fluid needed?
Are drugs needed?
![Page 43: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/43.jpg)
Why did the patient arrest?
Is there a reversible cause for the arrest?
![Page 44: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/44.jpg)
Part 6:Dream Team Code
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PEA and Asystole
![Page 46: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/46.jpg)
PEA
Organized
No pulse
Fast or slow
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PEA
![Page 48: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/48.jpg)
PEA
![Page 49: INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan.](https://reader035.fdocuments.in/reader035/viewer/2022062716/56649dcf5503460f94ac3547/html5/thumbnails/49.jpg)
Asystole
Final rhythm
Depleted myocardium
Check two leads
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PEA and Asystole: Treatment
• Epinephrine
• Atropine for slow PEA/asystole
• CPR
• Fix the fixable• Hypovolemia: Bolus NS• Hypoxia: O2
• Hyperkalemia: ABG (for K+), Bicarbonate, Calcium Cl, • Acidosis, TCA OD: Bicarbonate• Pneumothorax/tamponade: Needle• MI/PE: Thrombolytics
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Part 7: An hour later…..
The Dream Team is still at it:
Switch to the other side of the flowchart
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Outcomes
Out-of-hospital In-hospital
Pulse never returns 70%
Death at one year 99%
Death or neurologic compromise
99.5%
Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine versus epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359:21-30Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785-792
Pulse never returns 50%
Death 80%
Death or neurologic compromise
85%
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Questions?