Advanced Cardiac Life Support (ACLS)

By: Diana Blum MSN Metropolitan Community College Nursing 2150

STABLE
These patients generally have an EKG

rhythm that is undesirable. their vitals signs are stable they have no complaints such as, shortness of breath, chest pain or confusion. if rhythm untreated the patient may become ____________.

UNSTABLE
These patients also have an EKG rhythm that is undesirable. vital signs are not stable! Other sign and symptoms: low blood pressure, shortness of

breath, chest pain or confusion. if the rhythm is not treated the patient may die.. BE AGGRESSIVE in approach in unstable patients. You should always do CPR until code cart is available. Rhythms Too fast; like ventricular tachycardia, or ventricular fibrillation we defibrillate. Absent, as in asystole we pace with a Trans Cutaneous Pacing patches.

DEAD
These patients also have an EKG rhythm that is undesirable. vital signs are absent! They have no pulse! Your first thought for intervention is SHOCK EM! Especially if witness

going down. Step 2 CPR. ---new protocol is compressions compressions compressions! The last intervention in order is MEDICINE.

"all dead people get epinephrine, the deader they are, the more epinephrine they get!"

American Heart studies show that the sooner electrical intervention is

introduced, the better the outcome for survival! Your second intervention is CPR. Think of CPR as your bridge and time-buyer. Good CPR keeps the vital organs per fused until your electrical and drugs can do their job. Always make good CPR a priority.

Primary Survey
Airway: Open airway, look, listen, and feel for

breathing Breathing: If not breathing slowly give 2 rescue breaths. If breaths go in continue to next step. Circulation: check pulse 5-10 seconds Defibrillation: Search for a shockable rhythm like vtach/vfib

Adult ACLS Secondary Survey ABCDs (abbreviated)

Airway: Intubate if not breathing. Assess

bilateral breath sounds for proper tube placement. Breathing: Provide positive pressure ventilations with 100% O2. Circulation: If no pulse continue CPR, obtain IV access, give proper medications. Differential Diagnosis: Attempt to identify treatable causes for the problem.

http://www.youtube.com/watch?v=tVHJq9o p5cw&feature=relmfu

Pulseless Electrical Activity, or PEA

This is a condition where you have some

electrical activity but not mechanical activity.

AKA: no pulse is present. You can have a normal sinus rhythm, but if there is

no pulse, the condition is called PEA. If you have a patient with the condition of PEA, and the rhythm is a slow wide ventricular rhythm, you may want to try TCP.

PEA
Problem search..Treat accordingly. (see

differential diagnosis table) Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi.
Atropine 1 mg IV/IO q3-5 min. (3mg max.)

condition Pulmonary Embolism Acidosis (preexisting)

Assess No pulse w/ CPR, JVD Diabetic/renal patient, ABGs

Intervention Thrombolytics, surgery Sodium bicarbonate, hyperventilation

Tension pneumothorax

No pulse w/ CPR, JVD, tracheal deviation

Needle thoracostomy

Cardiac Tamponade

No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest

Pericardiocentesis

Hyperkalemia (preexisting)

Renal patient, EKG, serum K level

Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate Treat with great prudence after careful assessment of the cause. K can kill. Fluids Oxygen, ventilation Acute Coronary Syndrome algorithm

Hypokalemia Hypovolemia Hypoxia Myocardial infarct Drugs

EKG, serum K level Collapsed vasculature Airway, cyanosis, ABGs History, EKG

Medications, illicit drug use, toxins

Treat accordingly

Shivering

Core temperature Hypothermia Algorithm

ELECTRICAL!
If the rhythm is too fast, the goal is to slow it down

and convert it use synchronized cardioversion. If too slow the goal is to speed it up, use external transcutaneous pacing or TCP.
how do I know when to pace, defibrillate, or use

synchronized cardioversion?" HINT: D=Deceased, only defibrillate fast rhythms! look at suspected asystole in more that one ekg lead, to confirm asystole.

Bradycardia
HR (<60bpm) or relative (slower rate than expected) bradycardia with

circulatory compromise. Start the Secondary ABCDs Pacing:Immediately prepare for transcutaneous pacing related to bradycardia (especially high-degree blocks) or if atropine failed to increase rate. Always Atropine1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg) Ends: Epinephrine 2-10 g/min2nd-line drugs to consider if atropine and/or TCP are ineffective.. Danger: Dopamine 2-10 g/kg/min
*pacing may not work every time with brady arrhythmias. If the above

measures do not improve circulatory stability the bradycardia may be from other issues, think differential diagnosis! (Refer to slide 10)

Cardioversion
Synchronized Electrical Cardioversion the following mnemonic directs preparations for synchronized electrical

cardioversion of unstable tachycardia with fast rate (do not delay shocking if seriously unstable) Oh O2 Saturation monitor Say Suctioning equipment It IV line Isn't Intubation equipment So Sedation and possibly analgesics **Synchronized Electrical Cardioversion *Energy Levels:The initial synchronized shock is 100J monophasic (50J for SVT/A-Flutter) with increasing energy, i.e., 200J, 300J, 360J, if successive shocks are needed.

Adult Cardiac Arrest

1st Start CPR Is the rhythm shockable? Yes or No If shockable (VF/VT)? Yes or NO If not shockable(Asystole)? Yes or NO If VF/VT Shock CPR x 2 minutes Get IV/IO access Reanalyze (shockable??) Yes Shock then CPR x 2minutes and or epinephrine/capnography NO CPRx 2 minutes, epinephrine/ Airway Repeat steps as needed Asystole CPR x 2 minutes, , epinephrine/ Airway Reanalyze Shockable Yes Shock cpr epinephrine airway No CPR x 2 minutes, treat causes

Mega code practice

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