ACLS

Pulmonary edema, hypotension, or shock algorithm

Definition
Shock
Condition of severe impairment of
tissue perfusion leading to cellular
injury and dysfunction. Cell
membrane dysfunction is a common
end stage for various forms of shock.
Rapid recognition and treatment are
essential to prevent irreversible
organ damage.

Clinical manifestation

Hypotension (systolic bp < 90, mean

bp < 60), tachycardia, tachypnea,
pallor,
restlessness, and altered sensorium.
Signs of intense peripheral
vasoconstriction, with weak pulses and
cold clammy extremities.
Oliguria (<20 mL/h) and metabolic
acidosis common.

 Acute Pulmonary edema

Life-threatening, acute development of
alveolar lung edema often due to:
1. Elevation of hydrostatic pressure in
the pulmonary capillaries (left heart
failure, mitral stenosis)

2. Specific precipitants resulting in

cardiogenic pulmonary edema in pts
with previously compensated CHF or
without previous cardiac history
(AMI, Acute mitral regurgitation)
3. Increased permeability of pulmonary
alveolar-capillary membrane
(noncardiogenic pulmonary edema).

...Nitrate

ACLS
Suspected Stroke
Algorithm

 For patients presenting with an ischemic

stroke, the goal of care is rapid cerebral
reperfusion to prevent permanent
neurological deficits.
For patients presenting with a hemorrhagic
stroke, the focus is on stabilizing the patient
to control bleeding and on considering
advanced interventions. The importance of
transporting patients to specialized stroke
centers cannot be overemphasized.

Clinical Presentation
Facial droop, arm or leg
weakness/numbness, especially
unilateral
Difficulty speaking or understanding,
confusion
Sudden severe headache, visual
disturbances, dizziness, loss of
balance or coordination.

CINCINNATI PREHOSPITAL STROKE

SCALE
Facial Droop: Have patient show teeth or smile:
NormalBoth sides of face move equally well.
AbnormalOne side of face does not move as well as the other
side.
Arm Drift: Have patient close eyes and hold both arms straight out with
palms up for 10 sec:
NormalBoth arms move the same or do not move at all.
AbnormalOne arm does not move or drifts down lower than the
other.
Speech: Have patient say You cant teach an old dog new tricks:
NormalPatient uses correct words with no slurring.
AbnormalPatient slurs words, uses inappropriate words, or is
unable
to speak.

I. Emergency Medical Service

Response
Support ABC
Administer O2 if needed

Prehospital Assessment: Use CPSS

Establish Time, onset
Arrange rapid triage and transport to a
center capable of providing acute stroke care
if available.
Alert hospital.
Be sure hospital CT scan is functional.

Check patients glucose level.

Time is brain

he following should be performed

n 60 min after patient has arrive
the emergency department!

Within first 10 minutes....

Assess airway, breathing, circulation, and
vital signs.
Administer oxygen if patient is
hypoxemic.
Obtain IV access and blood samples.
Check glucose level.
Treat if indicated.
Perform initial neurological screening.
Activate stroke team.

...keep counting
Order emergent non-contrast CT
scan (or MRI) of brain.
This is the most important test for a
patient with a suspected stroke.

Obtain 12-lead ECG.

Within 25 minutes of arrival

Review patients history and perform general
physical examination.
Establish time of symptom onset or last time
patient was known to be normal.
Perform a neurological examination.
Use a stroke or neurological scale, such as
the National Institutes of Health Stroke Scale
(NIHSS) or the Canadian Neurological Scale.
Interpret CT scan within 45 min of arrival.
Does CT scan show hemorrhage?

If CT does not shows hemorhage. In

45 minutes of arrival...
Review fibrinolytic inclusion,
exclusion, and relative exclusion
criteria.

 Repeat neurological examination to determine whether

patients
symptoms are improving/resolving.
If patient is a candidate for fi brinolytic therapy:
Review risks and benefits of fibrinolytic therapy with
patient/family.
If patient/family agree, give rtPA within 60 min of arrival.
Do not give anticoagulants or antiplatelet treatment for 24 hr.
Begin post-rtPA stroke pathway.
Admit to stroke unit or intensive care unit.
Initiate supportive therapy.
Treat comorbidities.

 If patient is not a candidate for fi

brinolytic therapy:
Administer aspirin (orally if the patient
can swallow, or rectally if the patient has
difficulty swallowing).
Begin stroke pathway.
Admit to stroke unit or intensive care unit.
Initiate supportive therapy.
Treat comorbidities.

Another scenario in 45 minutes if CT

shows hemorrhage
No aspirin, anticoagulation, or fi brinolytic
therapy.
Consult neurologist or neurosurgeon.
Consider transfer if such expertise is not
available.
Initiate supportive therapy.
Begin stroke pathway within 60 min of arrival.
Admit to stroke unit or intensive care unit
within 3 hr of arrival.
Treat comorbidities.

 Begin stroke pathway.

Continue to support airway, breathing, circulation.
Maintain oxygen saturation 94%99%.
Maintain cardiac monitoring for fi rst 24 hr or longer if indicated.
Avoid intravenous D5W or excessive fluid loading.
Monitor BP.
Manage hypertension if systolic BP is >220 mm Hg or diastolic BP is
>120 mm Hg.
Monitor blood glucose.
Treat hyperglycemia.
Monitor temperature.
Treat fever with acetaminophen.
Perform dysphagia screening/swallow evaluation.
Monitor for complications of stroke and fibrinolytic therapy (if
administered).