Download - Acls prestudy packet

Critical Concepts

Advanced

Cardiovascular

Life

Support

Precourse Study Guide

Presented by:

Critical Concepts Corp. 3201 W. Griffin Rd.

Suite 205 Fort Lauderdale, FL 33312

Phone: 954-322-8883 Fax: 954-322-8817

Toll Free: 1-800-427-6355 Website: www.criticalconceptsusa.com

© Copyright 2006 S. Lunsford 1

HIPAA Training at your Location… Recently Released: June 9, 2005 more HIPAA Security Guidance from the US Government Agency (CMS) regarding Security Evaluation & Training. “13,000 Federal HIPAA Violation Complaints” as of June 9, 2005 (CMS 6.9.05) /“2,400 in May of 2003! (USA Today/Cover/10-16-2003). A Division under Health and Human Services (DCF), states "All employees and volunteers will be annually trained in HIPAA requirements. Not having your staff properly trained as per policy and procedures (<1 year) and current laws may result in fines, complaints and legal exposure.

Be Informed When Patients ask HIPAA Questions??? What is the Security Standard? How do I conduct Security Training and Evaluations. How do I write a Policy? Did a new requirement pass by? What did it require? Can you leave messages on voice mails? What kind? How long do you have to copy patients records? And if they are off-site? Can you charge? How Much? How often? What training is required?In what manner? Regarding what? What training records should I keep? Shred? What does HIPAA stand for? What is really the Law? Workmans Comp? s

Introducing your Professional Solution at- $325 HIPAA Renewal Training… We will provide all of the below ... We provide Training and Requirements to protect your facility. Included is The HIPAA Policy and Procedure Manual updated with recent Security Standards for 2005-2006. Sending a staff member to a “HIPAA Seminar” will leave them with incomplete documentation and days of work. We address Public Law 104-191, 45 CFR Parts 160, 162, 164 and more. Security Requirements with the Required Evaluation and Training Process, Privacy Requirements, Transaction Code Sets, National Provider Identifier. Large practices/certain locations slightly higher and multiple location discounts are available. See combo– program discount below. Annual Customer Support Included.

Combination Discount Below Will Save Money & Time!!!!! Call 1.800.427.6355 Press #4 Two programs done on the same day $50 off entire fee, All three programs completed the same day—$200 off the entire fee. Additional discounts may be available online.

T

CPR, ACLS or PALS at your Location… American Heart Courses How does a Stress-Free Private American Heart Association (AHA) Course Sound? One call takes care of it. Simply gather a group of 6, or close to it, and were there. We have even conducted 1 on 1 training to meet the needs of busy professionals. Weekday, Weekend & Evening Programs are available at your home, office or facility to meet your needs!

Reduced Renewal Fees: BLS (CPR) $30/person & ACLS or PALS $125/person based on 6 or more persons. Groups less than 6 persons welcome-fee slightly higher per person. Includes CE Credit and 2005 Study Guide. See combo-program discount below.

If you wish to take a Stress-Free Course at our facility, see the following page with schedule for: Ft. Lauderdale, Miami, Kissimmee, Orlando, Gainesville, Tampa, Jacksonville & 3 Georgia locations. All ECC texts available On-Line for purchase

Toll-Free 1.800.427.6355 9-6PM Mon-Fri. www.CriticalConceptsUsa.com Department of Health Provider FBON #2662

OSHA Training at your Location… Are you concerned about meeting Annual Mandatory OSHA, State and Local Compliance & Training Requirements for Your Healthcare Facility? In approximately 1 1/2 hours we will implement all programs and bring your facility into compliance. Having Documentation of Training & Manuals older than 365 calendar days is not current and falls out of compliance with the Following Excerpt from Federal Law: “Training must take place annually thereafter. 1910. 1030 (g)(2)(iii)” & from State Law FAC 64B-16.003. Expired or Incomplete compliance documentation will not mitigate Federal fines, sanctions and penalties for non-compliance. Let the Professionals at Critical Concepts be your total solution, call 1.800.427.6355, press # 4.

These Healthcare Laws Mandate Annual Training, Annual Program Updates, Annual Plan Reviews regarding Bloodborne Pathogens, Hazard Communication and Biomedical Waste Plan., Needle-Stick Injury Plans, and many more. Should your practice have one complaint, needle-stick, injury or occupational exposure and you can not show Recent (<365 days old) Compliance Documentation of specific training and that All the Below Requirements are complete— Serious Federal Fines, Sanctions, and Legal Exposure can occur.

Introducing your Solution, Affordably and Efficiently at $300—What we do is listed below ... We provide all of the below Services and an Updated OSHA Policy and Procedure Manual. Upon completion, you will receive a confidential compliance report, our corrective measures and an OSHA Compliance Certificate. We furnish all Required Training, Posting Mandatory Signs, Documentation, Annual Updated Plans, Labels, MSDS for Chemicals, Request Forms, Documentation Forms for HBV ,Biomedical Waste Program and more. All of the above training, materials, manuals, services and walk-through are included. Large practices and certain locations are slightly higher with Multiple Location discounts available, Please inquire. Please call 1.800.427.6355, press # 4. See combo-program discount below. Annual Customer Support Included.

NEED PRIVATE TRAINING AT YOUR OFFICE? SEE BELOW INFORMATION

We welcome you to Critical Concepts Corporation and the American Heart Association’s Advanced Cardiac Life Support Course. We provide a “Stress-Free” program to all individuals who participate in our hands-on training program. Please note if you are registered in the one-day re-certification course a current card is required and you will need to bring this to class. The re-certification course provides a brief update then into testing and hands-on skills. We recommend the renewal course for clinicians who utilize their ACLS skills frequently and can interpret rhythm strips. The two-day Initial ACLS Course is for a thorough review of ACLS with extensive practice and is enjoyed by all. Our organization has faculty consisting of MD’s, RN’s, Paramedics, Firefighters and Emergency Care Professionals. We teach need to know information in an enjoyable “Stress-Free” environment. For any questions or concerns feel free to contact us at [email protected] or call at 1-800-427-6355. If you are rusty on EKG’s no problem, simply purchase our Basic EKG Guide at www.CriticalConceptsUsa.com

Critical Concepts

ACLS Course Agenda

2 Day Course16 hours 1 Day Renewal 8 hours

IMPORTANT: PLEASE SEE START TIME LISTED AT YOUR FACILITY OR CHECK WITH THE DIRECTOR/MANAGER. START TIME VARIES BY LOCATION. AGENDA MAY VARY ACCORDING TO PARTICIPANTS NEEDS (i.e some individuals may need more help with one subject of the other)

Day 1

10 min Welcome/Introductions

10 min Lesson 1 – ACLS Course Overview 5 min Lesson 2 – Course Organization 20 min Lesson 3 – BLS Primary Survey and ACLS Secondary Survey

Divide class into 2 groups

Lesson 4 Management of Respiratory Arrest

Learning Station

Lesson 5 CPR Practice and Competency

Test 1 hour Group 1 Group 2 15 min Break Break 1 hour Group 2 Group 1

One large group 15 min Lesson 6 – Technology Review 1 hour Lunch 30 min Lesson 7 – The Megacode and Resuscitation Team Concept


Lesson 8 Pulseless Arrest VF/VT

Learning Station

Lesson 8 Pulseless Arrest VF/VT

Learning Station 1 hour 30 min Group 1 Group 2

One large group (or 2 small groups) 35 min Lesson 9 – ACS 15 min Break


Lesson 10 Bradycardia/Asystole/PEA

Learning Station

Lesson 11 Tachycardia, Stable and Unstable

Learning Station 1 hour Group 1 Group 2 1 hour Group 2 Group 1

One large group (or 2 small groups) 35 min Lesson 12 – Stroke End of Day 1


Critical Concepts

ACLS Course Agenda

Day 2


Lesson 13 Putting It All Together

Learning Station

Lesson 13 Putting It All Together

Learning Station 1 hour 30 min Group 1 Group 2

One large group 5 min Lesson 14 – Course Summary and Testing Details 15 min Break Divide class into 2 groups

Lesson 15 Megacode Test

Lesson 15 Megacode Test

1 hour 30 min Group 1 Group 2

One large group (as students finish Megacode test) 1 hour Lesson 16 – Written Test Class Ends/Remediation


Critical Concepts

ACLS Study Guide 2006

Read Prestudy Material. Guidelines have recently changed and certain American Heart Association Textbooks/Materials/Handbooks will be available at different intervals. Please check with your educator for library AHA books or order by calling Channing Bete at 1.800.611.6083 and keep them on you. Please also take the pre-test in the back of this book and use the checklists to prepare. By the end of this course you must be able to demonstrate during a simulated VF (Ventricular Fibrillation) arrest scenario:

assessing a victim by the Primary and Secondary ABCDs effective adult 1 and 2 rescuer CPR using an AED on an adult safe defibrillation with a manual defibrillator maintaining an open airway confirmation of effective ventilation addressing vascular access stating rhythm appropriate drugs, route and dose consideration of treatable causes

What happens if I do not do well in the course? The Course Director or Instructor will first “remediate” (tutor) you and allowed to continue in the course.

Any questions please contact this office.


Critical Concepts

What is ACLS?

ACLS is an “assess – then manage” approach for those at risk of or in cardiac arrest. This approach is outlined in algorithms within you materials. Instructor to assess learning needs of students.

Primary and Secondary ABCDs This is a methodical “assess-then-manage” approach used to treat adults in respiratory distress and failure, stable and unstable arrhythmias and pulseless arrest. Algorithms are “menus” that guide you through recommended treatment interventions. Know the following ABCDs approach because it begins all ACLS case scenarios. The information you gather during the assessment will determine which algorithm you choose for the patient’s treatment.

Primary ABCDs: these refer to CPR and the AED. • Assess: Tap and ask: Are you OK?

• Send someone to call 911 and bring an AED. • If alone call 911, get an AED and return to victim.

• Airway: Open with the head-tilt/chin lift. • Breathing: Assess for adequate breathing.

• If inadequate: give 2 breaths over 1 second each. • Each breath should cause a visible chest rise. • Use mouth-to-mask or barrier, bag-mask-ventilation (BMV) or mouth-to-

mouth. • Give oxygen (O2) as soon as it is available.

• Circulation: Check carotid pulse for no more than 10

seconds. • If not definitely felt, give 30 compressions in center of chest, between the

nipples. • Compress the chest wall 1

1/2 - 2 inches.

• One cycle of CPR is 30 compressions and 2 breaths • Give 5 cycles of CPR, (about 2 minutes). • Minimize interruptions to compressions.

• 2-rescuers: the compressor PAUSES while 2 breaths are given. • Change compressors after 5 cycles to avoid fatigue and ineffective

compressions.


Critical Concepts • Defibrillation: When an AED arrives, immediately

power it on! • Follow the voice prompts. • Use adult pads on adults.

Secondary ABCDs: • Airway: Use bag-mask connected to 100%O2.

• Give each breath over 1 second each. • Compressor pauses to allow the 2 breaths to go in. • Consider inserting an advanced airway (see Advanced Airway on next page).

• Breathing: Look for visible chest rise during each breath. • Confirm advanced airway tube placement (see Advanced Airway on next

page). • Secure the airway tube. • Compressor now gives 100 continuous compressions per minute. • Ventilator gives 8-10 breaths per minute (one every 6-8 seconds).

• Circulation: Obtain vascular access with an IV (intravascular) or IO (intraosseous) cannula. • Give drugs as recommended per algorithm.

• Diagnosis: Why is the patient in the rhythm? Look for any possible causes to treat:

6 Hs 5 Ts Hypoxia Hypovolemia Hypothermia Hypoglycemia Hypo / Hyperkalemia Hydrogen ion (acidosis)

T amponade T ension pneumothorax T oxins – poisons, drugs T hrombosis – coronary (AMI) – pulmonary (PE) T rauma

Spacing separations may help as a memory aid.


Critical Concepts


Airway Skills During the course you will be expected to participate in manikin practice and

demonstrate the below skills.

Basic Airway: • Oxygen: • Open the Airway: Use the head tilt-chin lift when assessing for adequate breathing.

Use a jaw thrust for unresponsive-unwitnessed, trauma or drowning victims.

• If unable to open the airway with a jaw thrust, use head-tilt chin lift.

• Maintain: Insert an oropharyngeal airway when unconscious with no cough or gag

reflex.

Insert a nasopharyngeal airway when a cough or gag reflex is present (better tolerated).

• Ventilate: Give each breath over 1 second using enough volume to see the chest rise.

• 2-rescuer CPR: give 2 breaths during the pause following 30 compressions.

• Rescue breathing: when a pulse is present, give 10-12 breaths/minute (one each 5-6 seconds).

Advanced Airway: Laryngeal Mask Airway (LMA): requires the least training for insertion.

• Inserts blindly into the hypopharynx. • Regurgitation and aspiration are reduced but not prevented. • Confirm placement: see chest rise and listen for breath sounds over

lung fields. • Contraindications: gastric reflux, full stomach, pregnancy or morbid

obesity.

Critical Concepts


Combitube: requires more training for insertion than the LMA. • Inserts blindly into esophagus (80% of the time) or the trachea. • Ventilation can occur whether the tube is the esophagus or the

trachea. • Confirm placement: clinical exam and a confirmation device (see

below). Advanced Airway (Con’t):

• Contraindications: gag reflex, esophageal disease, caustic ingestion,

under 16 yr. or 60 in. Endotracheal Tube (ETT): requires the most training, skill and frequent retraining for insertion.

• Inserts by direct visualization of vocal cords. • Isolates the trachea, greatly reduces risk of aspiration, and provides

reliable ventilation. • High risk of tube displacement or obstruction whenever patient is

moved. • Confirm placement: clinical exam and a confirmation device (see

below). Immediately confirm tube placement by clinical assessment and a device: ►Clinical assessment:

• Look for bilateral chest rise. • Listen for breath sounds over stomach and the 4 lung fields (left and

right anterior and midaxillary). • Look for water vapor in the tube (if seen this is helpful but not

definitive). ►Devices:

• End-Tidal CO2 Detector (ETD): if weight > 2 kg • Attaches between the ET and Ambu bag; give 6 breaths with the Ambu

bag: • - Litmus paper center should change color with each inhalation and

each exhalation.

• Original color on inhalation = Okay O2 is being inhaled: expected. • Color change on exhalation = CO2!! Tube is in trachea.

• Original color on exhalation = Oh-OH!! Litmus paper is wet: replace ETD.

Tube is not in trachea: remove ET. Cardiac output is low during CPR.

Critical Concepts • Esophageal Detector (EDD): if weight > 20 kg and in a perfusing rhythm

• Resembles a turkey baster: o Compress the bulb and attach to end of ET. o Bulb inflates quickly! Tube is in the trachea. o Bulb inflates poorly? Tube is in the esophagus.

• No recommendation for its use in cardiac arrest.


Critical Concepts

Arrhythmias During the course you will be expected to demonstrate your ability to identify the below

arrhythmias.

Pulseless Rhythms(Arrest Rhythms)

Shockable VF (Ventricular Fibrillation) VT (Ventricular Tach Pulseless) Torsades de Pointes

Non-Shockable PEA (Pulseless Electrical Activity) Asystole (Silent Heart)

Perfusing Rhythms(Non-Arrest Rhythms)

Tachycardias: Narrow QRS Regular Rhythms: Sinus Tachycardia Atrial Flutter Supraventricular Tachycardia Junctional Tachycardia Irregular Rhythms: Atrial Flutter Atrial Fibrillation Multifocal Atrial Tachycardia

Tachycardias: Wide QRS Regular Rhythm: Ventricular Tachycardia- monomorphicIrregular Rhythms: Ventricular Tachycardia-polymorphic Torsades de pointes

Bradycardia Sinus Bradycardia Junctional Rhythm Idioventricular Rhythm Artioventricular Block: 1st Degree 2nd Degree: Mobitz Type I

(Wenckebach) Mobitz Type II 3rd Degree (Complete Heart Block)


Critical Concepts

Electrical Therapy During the course you will practice and then demonstrate safe, effective technique

and know indications.

• Defibrillation: High energy single shocks with manual defibrillator:ECC handbook p.9 • Recommended shock dose: biphasic = 120- 200 J (per manufacturer) • Recommended shock dose: monophasic = 360 J

• Synchronized Cardioversion: Timed low energy shocks: ECC Handbook p.14 • Timed to QRS to reduce risk of “R-on-T”: a shock that hits the T wave may cause VF

• Transcutaneous Pacer: Noninvasive emergent bedside pacing: ECC Handbook p. 62.

• Apply pacer pads. • Verify pacer capture.

Vascular Access Be prepared to discuss

• Peripheral: Preferred in arrest due to easy access and no interruption in CPR

• Use a large bore IV catheter. • Attempt large veins: antecubital, external jugular, cephalic, femoral • Can take 1-2 minutes for IV drugs to reach the central circulation. • Follow IV drugs with a 20ml bolus of IV fluid, and elevate extremity for 10-20 seconds.

• Intraosseous (IO): Inserts into a large bone and accesses the venous plexus.

• May use if unable to obtain intravascular access. • Drug delivery is similar to that via a central line. • Safe access for fluids, drugs, blood samples and • Commercial kits are available for adult IO access. • Drug doses are the same as when given IV.

• Central Line: Not needed in most resuscitations.

• Insertion requires interruption of CPR. • If a central line is already in place and patent, it can be used.

• Endotracheal: Some drugs may be given via the ETT in the absence of a IV/IO.

• Drug delivery is unpredictable thus IV/IO delivery is preferred. • Drug blood concentration stays lower than when given IV. • Increase dose given to 2 - 2.5 times the recommended IV dose. • Drugs that absorb via the trachea: • N aloxone A tropine

V asopressin E pinephrine L idocaine


Critical Concepts

ACLS Drugs

Look up drug dosages in the ECC Handbook .You may be allowed to use it as a reference in class.

The Primary focus in cardiac arrest is effective CPR and early defibrillation. Drug administration is secondary and should NOT interrupt CPR. Know the timing of drug administration in CPR as shown: The Class of Recommendation number denotes potential benefit versus risk.

General Statements: • Pulseless arrest, all: Give a Vasopressor drug – Epinephrine or Vasopressin

Vasopressors cause peripheral vasoconstriction, which shunts increased blood flow to the heart and brain.

• Pulseless ventricular rhythms: Consider antiarrhythmics – Amiodarone, Lidocaine, or

Magnesium May make myocardium easier to defibrillate and/or more difficult for it to again fibrillate after

conversion. • Bradycardia: Give a “Speed Up” drug - Atropine

Atropine blocks vagal input and stimulates the SA node, which can increase heart rate.

Consider dopamine and epinephrine infusions if unresponsive to atropine and waiting on a pacer.

Dopamine and epinephrine may increase heart rate but also increase myocardial oxygen demand. • Tachycardia, Reentry SVT: Give a drug to interrupt the rhythm - Adenosine

Adenosine blocks the AV node for a few seconds, which may break the re-entry pattern.

• Tachycardia, AFib or AFlutter: to convert rhythm – Amiodarone.

to slow rate – Beta Blocker. Dilitazem: • Tachycardia, VT, stable: to convert rhythm – Amiodarone.

or Sync Cardiovert: • Acute Coronary Syndromes: First line treatment is “MONA”: ECC

Oxygen increases the oxygen available to the ischemic or injured heart muscle. Aspirin decreases platelet clumping, the first step in forming a new blood clot. *** Nitroglycerin dilates coronary arteries so more oxygenated blood can reach the muscle and decrease

pain; also dilates peripheral vessels decreasing the resistance the heart has to pump against. Morphine decreases pain not relieved by nitroglycerin; also dilates peripheral vessels decreasing

resistance against which the heart has to pump. *** If allergic to Aspirin (ASA): Give Clopidogrel (Plavix) – affects platelet clumping similar to ASA.


Critical Concepts

ACLS Core Cases 1-10 Study the algorithms and drugs well in the 2006 ECC Handbook. The following may help.

1. Respiratory Arrest Case

• The skills listed on p. 4-5 of the study guide will be practiced in most case scenarios. 2. VF Treated with CPR and AED Case You are walking down the hall and the person in front of you suddenly collapses

• Assess: - Tap, ask: Are you Okay? - No Movement or response, call 911 and get the AED!!!

or if a second person is present, send them to call and get the AED

• Primary ABCD Survey: - Airway: Open and hold (Head tilt – Chin lift or Jaw Thrust), Look, listen &

Feel - Breathing: Give 2 breaths (1 second each) that make the chest rise

• Avoid rapid or forceful breaths. - Circulation: Check carotid pulse – at least 5 but no longer than 10 seconds

• Begin CPR if a definite pulse is not felt. o 30 Compressions: 2 ventilations = 1 cycle o Push hard: 1 ½ -2 inches deep o Push fast: 100 compressions per minute o Allow the chest wall to completely recoil ( take weight off

hands) o Minimize interruptions

• Recheck pulse after 5 cycles of CPR (Approx. 2 minutes) • 2 – Rescuer CPR, basic airway: Pause compressions to ventilate

- Defibrillation: Automated External Defibrillator

1. Power On – Turn power on. (Some AEDs automatically turn on) 2. Attachment – Select Adult Pads, Attach pads to patient (upper right sternal border

and cardiac apex), Attach cables to AED, if needed. 3. Analysis – Announce, “Analyzing rhythm – stand clear!” Press Analyze, if needed. 4. Shock – If shock indicated, Announce, “Shock is indicated. Stand Clear! I’m going

to shock” Verify no one is touching the patient. Press shock button when signaled to do so.

• If no shock indicated, follow prompts from AED. Unacceptable actions:

• Did not provide effective CPR. • Did not follow AED’s commands. • Did not clear patient before shock (unsafe defibrillation)


Critical Concepts 3. Pulseless Arrest: VF / Pulseless VT Case. ECC Handbook p. 7 left side You respond to a patient monitor alarm, to find the patient is unresponsive. Call for help and begin CPR (primary ABC survey). A team member arrives with the crash cart, which has a manual defibrillator and advanced equipment. The patient is attached to the monitor and you identify and verify VF or PVT.

• Primary D: Defibrillation: Shock #1 o After verifying the rhythm, Resume CPR while the defibrillator is charging. o Once Charged, Clear!!! Ensure that no one is touching the patient or bed. o Give 1 shock: biphasic defibrillators = Mfg recommendation, if unknown 200J

Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles o After 5 cycles: check rhythm (shockable?), check pulse (5-10 seconds)

• Secondary ABCD Survey: conducted between 1st and 2nd shock and Ongoing

o Airway: o BVM with 100% O2 o Consider advanced airway placement: LMA, Combitube, or ETT

o Breathing: o Check for visible chest rise with BVM o Confirm advanced airway placement by exam and confirmation device o Secure advanced airway in place with tape or a commercial device o Give 8-10 breaths/min and continuous compressions at 100 per minute.

o Circulation: Establish Vascular access via IV or IO o Do not interrupt CPR for access.

o Differential Diagnosis – Use the H’s and T’s mnemonic Defibrillation: Shock #2

o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds) o Resume CPR while defibrillator is charging o Once charged, Clear!!! Ensure no one is touching the patient or bed. o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J

Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles

Medications: Administer either: Give during CPR • Epinephrine 1mg IV/IO (every 3 – 5 minutes) or • Vasopressin 40U IV/IO to replace first or second dose of epinephrine.

Defibrillation: Shock #3 o After 5 cycles of CPR: Check rhythm (shockable?), Check pulse (5-10 seconds) o Resume CPR while defibrillator is charging o Once charged, Clear!!! Ensure no one is touching the patient or bed. o Give 1 Shock: biphasic defibrillators = Mfg recommendation, if unknown 200J

Monophasic defibrillators = 360J o Immediately resume CPR for 5 cycles

Medications: Consider Antiarrhythmics: Give during CPR o Amiodarone 300mg IV/IO once, then consider additional 150mg IV/IO once. o Lidocaine 1-1.5mg/kg first dose then 0.5-0.75mg/kg IV/IO, max 3 doses or

3mg/kg o Magnesium 1-2g IV/IO loading dose for torsades de pointes

Unacceptable actions:

Did not provide effective CPR. Did not clear before shock Did not confirm advanced airway placement Did not give a vassopressor


Critical Concepts

4. Pulseless Arrest: Pulseless Electrical Activity (PEA) Case 5. Pulseless Arrest: Asystole Case

You find that a patient is unresponsive. Call for help and begin CPR (primary ABC survey). A team member arrives with the crash cart, which has a manual defibrillator and advanced equipment. The patient is attached to the monitor and you identify and verify Asystole or PEA.

• Primary D: Defibrillation: NO Shock indicated for Asystole or PEA

• Secondary ABCD Survey: Ongoing o Airway:

o BVM with 100% O2 o Consider advanced airway placement: LMA, Combitube, or ETT

o Breathing: o Check for visible chest rise with BVM o Confirm advanced airway placement by exam and confirmation device o Secure advanced airway in place with tape or a commercial device o Give 8-10 breaths/min and continuous compressions at 100 per minute.

o Circulation: Establish Vascular access via IV or IO o Do not interrupt CPR for access.

o Medication: Give a Vasopressor • Epinephrine 1mg IV/IO (repeat every 3-5 minutes) • Vasopressin 40 U IV/IO to replace first or second dose of epinephrine. • Consider Atropine 1mg for Asystole or PEA rate less than 60

o Check rhythm, check pulse after 2 minutes of CPR (5 cycles)

o Differential Diagnosis – Use the H’s and T’s mnemonic

6 H’s 5 T’s

Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypoglycemia Hypothermia

Toxins (Drug overdose) Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma

o Consider Family members: Unacceptable actions:

• Did not provide effective CPR. • Did not confirm advanced airway placement. • Did not give a vasopressor. • Did not look for reversible causes to treat. • Attempted defibrillation. • Attempted transcutaneous pacing for asystole


Critical Concepts 6. Acute Coronary Syndromes (ACS) Case Your neighbor complains of feeling weak and is sweaty, short of breath and slightly nauseated. You are worried this is an acute coronary problem and call 911. While waiting for their arrival, you ask if he can take aspirin. He says yes, and you have him chew 2-4 baby aspirin (81mg)

• EMS arrival: o Attach monitor, Start IV o Give MONA: o Obtain 12-lead ECG if available: o Notify hospital and transport o Begin fibrinolytic checklist:

• Arrival at ED: Assess 12 – Lead ECG

ST segment Elevation (STEMI)

ST segment Depression

(Non-STEMI or NSTEMI)

ST segment – T wave Normal

Injury Ischemia Non-diagnostic

Drug Therapy: • Beta blockers: ↓myocardial work • Clopidogrel: ↓ platelet clumping • Heparin: ↓ fibrin so new clot doesn’t form Goal is reperfusion by: Fibrinolytic: lyses fibrin in • If <12 hours from onset • If no contraindications • ED door to drug goal = 30 Or PCI (percutaneous intervention: Angioplasty and/or stents) • If < 12 hours from onset • ED door to balloon goal = 90 min After reperfusion give: • Resume above drugs • ACE-inhibitor: ↓ myocardial work • Statin: ↓ inflammation and arrhythmias

Drug Therapy: Nitroglycerin: ↓ work Beta blockers Clopidogrel Heparin IIb /IIIa inhibitor: ↓ platelet-fibrin bonding Goal is revascularization: • PCI or possible surgery After revascularization give: • Resume above drugs as needed • ACE-inhibitor • Statin

Consider admit to ED bed: Serial enzymes + Troponin: ECC Handbook p. 37 Repeat ECGs Monitor ST segment Consider stress test Admit to hospital bed if: • Troponin positive • ST segment deviates • Refractory chest pain • Ventricular Tachycardia • Becomes unstable Discharge if: • No ischemia/ injury evolves • Give follow-up directions


Critical Concepts Unacceptable actions:

• Did not give oxygen and aspirin to a suspected chest pain patient. • Did not attempt to control chest pain. • Did not obtain 12 – lead ECG.


Critical Concepts 7. Bradycardia Case A patient appears pale and complains of dizziness and fatigue. The pulse rate is 56, blood pressure is 86/60 and on the monitor you identify a bradycardia rhythm.

• Primary ABCD Survey: o Maintain patent airway; assist breathing as needed o Give oxygen o Monitor ECG (identify rhythm), blood pressure, oximetry o Establish IV access

• Assess rhythm and perfusion:

Is the heart rate <60 bpm

or Inadequate for clinical condition

Signs or symptoms of poor perfusion caused by the Bradycardia? (eg, acute altered mental status, ongoing chest pain, hypotension, or other signs of shock)

• Prepare for transcutaneous pacing;

use without delay for high-degree block (type II second-degree block or third-degree AV block)

• Consider Atropine 0.5mg IV while awaiting pacer. May repeat to a total dose of 3mg. If ineffective, begin pacing

• Consider epinephrine (2 to 10 ug/min)or

dopamine (2 to 10 ug/kg per min) infusion while awaiting pacer or if pacing ineffective

Adequate Perfusion Observe /

Monitor


Critical Concepts

• Prepare for transvenous pacing • Treat contributing causes • Consider expert consultation

• If pulseless arArrest Algorith

• Search for and

factors: -Hypovolemia -Hypoxia -Hydrogen Ion (aci-Hypo/hyperkalem-Hypoglycemia -Hypothermia

PoorPerfusion

Unacceptable Did not ide Did not ini Treated as

8. Unstab9. Stable T A patient appepressure is 10

• Primao o o o

• Is pat Un

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Reminders

rest develops, go to Pulseless m.

treat possible contributing

-Toxins -Tamponade, cardiac

dosis) -Tension pneumothorax ia -Thrombosis (coronary or

pulmonary) -Trauma (hypovolemia, Increased ICP)

actions: ntify a high-degree block

tiate TCP immediately for high-degree block ymptomatic patient as if had poor perfusion

le Tachycardia Case achycardia Case

ars pale and complains of dizziness and fatigue. The pulse rate is 170, blood 0/60 and on the monitor you identify a tachycardia rhythm.

ry ABCD Survey: Assess and support ABC’s as needed Give Oxygen Monitor ECG (identify rhythm), blood pressure, oximetry Identify and treat reversible causes

ient stable? stable signs include altered mental status, ongoing chest pain, hypotension, or other ns of shock. te: Rate-related symptoms uncommon if heart rate <150/min stable – Perform Immediate synchronized Cardioversion Establish IV access and give sedation if patient is conscious: do not delay Cardioversion Consider expert consultation If pulseless arrest develops, see Pulseless Arrest Algorithm

able – See chart below. Establish IV access Obtain 12-lead ECG (when available or rhythm strip) Is QRS narrow (<0.12sec)?

2006 S. Lunsford 19

Critical Concepts

Narrow QRS: Is Rhythm regular?

• Attempt vagal maneuvers • Give Adenosine 6mg rapid IV

push. If no conversion, give 12mg rapid IV push; may repeat 12mg dose once

Does rhythm convert?

Note: Consider expert

consultation

Regular Irregular Irregular Regular

Irregular Narrow-Complex Tachycardia Probable atrial fibrillation or possible atrial flutter or MAT (Multifocal atrial tachycardia) • Consider expert consultation • Control rate (eg, diltiazem,

B-blockers, use B-blockers with caution in COPD and CHF

Does Not Convert

If rhythm does NOT convert, possible atrial flutter, ectopic atrial tachycardia, or Junctional tachycardia:- Control rate - Treat underlying cause - Consider expert

consultation

Converts

If ventricular tachycardia or uncertain rhythm • Amiodarone

150mg IV over 10 min Repeat as needed to max dose of 2.2g/24hr

• Prepare for elective Synchronized Cardioversion

If SVT with aberrancy: • Give Adenosine

6mg rapid IV push. If no conversion, give 12mg rapid IV push, may repeat 12mg dose once

If atrial fibrillation with aberrancy • See Irregular Narrow

Complex tachycardia If pre-excited atrial fibrillation (AF+ WPW) • Expert consultation

advised • Avoid AV nodal

blocking agents (eg, adenosine, digoxin, diltiazem, verapamil)

• Consider antiarrhythmics (eg, amiodarone 150mg IV over 10 min)

If recurrent polymorphic VT, seek expert consultation If torsades de pointes, give magnesium (load with 1-2g over 5-60 min, then infusion)

If rhythm converts, probable reentry SVT: - Observe for recurrence - Treat recurrence with adenosine or longer-acting AV nodal blocking agent

Wide QRS: Is Rhythm regular? Expert consultation advised

10. Acute Stroke Case You find a normally alert, active adult in a chair staring blankly at the television and leaning to one side.

• Identify signs of possible stroke o Critical EMS assessments and actions

• Support ABC’s; give oxygen if needed • Perform prehospital stroke assessment:

- The Cincinnati Prehospital Stroke Scale o Facial Droop (have the patient show teeth or smile) o Arm Drift (patient closes eyes and extends both arms

straight out with palms up, for 10 seconds) o Abnormal Speech (have the patient say “you can’t teach

an old dog new tricks”) - Los Angeles Prehospital Stroke Screen ECC Handbook p. 18

• Establish time when patient last known normal (symptoms onset) • Transport; consider triage to a center with a stroke unit if appropriate;

consider bringing a witness, family member, or caregiver • Alert Hospital • Check glucose if possible


Critical Concepts o ED Arrival: Immediate general assessment and stabilization < 10min

• Assess ABCs, vital signs • Provide oxygen if hypoxemic • Obtain IV access and blood samples • Check glucose; treat if indicated • Perform neurologic screening assessment • Activate stroke team • Order emergent Non-contrast CT scan of brain • Obtain 12-lead ECG

o ED Arrival: immediate neurologic assessment by stroke team < 25min • Review patient history • Establish symptom onset • Perform neurologic examination (NIH Stroke Scale)

o Does CT scan show any hemorrhage? < 45min • Hemorrhage – Consult neurologist or neurosurgeon; consider transfer • No Hemorrhage

- Probable acute ischemic stroke; consider fibrinolytic therapy o Check for fibrinolytic exclusions ECC Handbook p.20 o Repeat neurologic exam: are deficits rapidly improving?

• Patient remains candidate for fibrinolytic therapy? - Not a candidate

o Administer aspirin - Candidate < 60min

o Review risks/benefits with patient and family: o If acceptable-

Give tPA No anticoagulants or antiplatelet treatment for

24 hours


PRINTED Name___________________________ ACLS Precourse Self-Assessment Answer Sheet Circle the correct answers

1. A B C D 2. A B C D 3. A B C D 4. A B C D 5. A B C D 6. A B C D 7. A B C D 8. A B C D 9. A B C D 10. A B C D 11. A B C D 12. A B C D 13. A B C D 14. A B C D 15. A B C D 16. A B C D 17. A B C D

18. A B C D 19. A B C D 20. A B C D 21. A B C D 22. A B C D 23. A B C D 24. A B C D 25. A B C D 26. A B C D 27. A B C D 28. A B C D 29. A B C D 30. A B C D

Please fill in the correct rhythm for questions 31-40 31._____________________________ 32._____________________________ 33._____________________________ 34._____________________________ 35._____________________________ 36._____________________________ 37._____________________________ 38._____________________________ 39._____________________________ 40._____________________________

ACLS Precourse Self-Assessment Answer Key Circle the correct answers

1. D 2. B 3. C 4. C 5. A 6. C 7. A 8. B 9. A 10. C 11. B 12. C 13. A 14. A 15. D 16. B 17. C

18. D 19. B 20. A 21. C 22. C 23. A 24. D 25. C 26. D 27. A 28. C 29. D 30. D

Please fill in the correct rhythm for questions 31-40 31. Normal Sinus Rhythm 32. Second Degree Atrioventricular Block 33. Sinus Bradycardia 34. Arial Flutter 35. Sinus Bradycardia 36. Third Degree Atrioventricular Block 37. Atrial Fibrillation 38. Monomorphic Ventricular Tachycardia 39. Polymorphic Ventricular Tachycardia 40. Ventricular Fibrillation

Critical Concepts

References: American Heart Association 2005 ECC Guidelines

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