intro acls ep

7/27/2019 Intro ACLS EP

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Advanced CardiacLife Support forExperienced Providers

Introduction1999 American Heart Association


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Why a new course on

Advanced Cardiac L ife Supportfor Exper ienced Providers

(ACLS-EP)?


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Many providers skip renewal courses


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Why ACLS forExperienced Providers?

ACLS Provider Course Current algorithms do not cover

everything Need more specific recommendations

for specific causes of arrest

Providers need more case-basedteaching of problems based on the premisesof ACLS-EP


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Two Premises Underlie theACLS-EP Course

Cause of arrest changes management If you know why a person goes into

cardiac arrest, that should influence howyou manage the arrest.

Arrests can be aborted if anticipated If you know why a person is on his or

her way to cardiac arrest, you can dosomething to prevent the arrest.


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What is the

Universal Clinical

Approach?


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Approach all patients with

this system

Universal Clinical Approach

A system


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The Five Quadrads Approach

Provides a system Includes Primary ABCD Survey

Includes Secondary ABCD Survey Includes periarrest patients Includes patients without an algorithm


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Case Example

You can judge the quality of an ACLS

instructor by how soon he or she starts an

interactive case discussion.

Goal: f irst case within 3 slides or 3 minutes!


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Cisco Quadramos

15-year-old with IDDM, ESRD Arrives in ED: weak, short of breath,

chest pain Depressed, taking TCAs Missed last 2 dialysis treatments

Triage nurse: He looks like hell Weak pulse, working hard to breathe

How would you manage this patient?


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Cisco Quadramos

You walk into the room The nurse suddenly shouts, No pulse,

unconscious! Cardiac arrest!

Now how would you manage this patient?


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Use the Five Quadrads

Cardiac arrest

1. Primary ABCD Survey

2. Secondary ABCD SurveyPeriarrest

3. OxygenIVmonitorfluids

4. TemperatureHRBPrespirations5. Tanktankpumprate


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The Five Quadrads Approach

Helps to remember 20 things for

Starting a code

Codes that are not going well Codes when you arrive late Everycardiopulmonary emergency


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The Five Quadrads: Details

1. Primary ABCD

A = Airway

B = BreathingC = Circulation (CPR)

D = Defibrillation (AED)


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2. Secondary ABCD

A = Intubate patient

B = Assess intubationC = IV access; rhythm/drugs

D = Differential Diagnosis (Think!)


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3. OxygenIVmonitorfluids

Consider as 1 word:

oxygenIVmonitorfluids Always right thing to do

Buys time to think


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4. TempHRBPRR

Drives major CPR decisions

Most neglected information in ACLS


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5. Tanktankpumprate*

How big is the tank

(perivascular resistance)? How much is in the tank (volume)?

Pump working?

Too fast? Too slow?

*Also called the cardiovascular triad in the ACLS textbook


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Ruby Lovelle

Common aphorism:

Sudden respiratory distress in a patient on a

ventilator with CPAP =pneumothorax until proved otherwise

Note: I f nothing works, repeat F ive Quadrads!


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Ruby Lovelle

Primary ABCD

A=Airway

B=Breathing

C

=

CirculationD=Defibrillation

Oxygen

IV

Monitor

Fluids

Temp

HR

BP

RR

Tank size

Tank contents

Pump

Rate

Secondary ABCD

A=Airway (intubation)

B=Breathing (tube check)

C

=

Cardiac rhythm/drugsD=Differential Diagnosis(Think!)


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Thomas Gill

34-year-old recreational soccer player Goes to ED for acute, severe ankle sprain

Given IM Toradol; sent to x-ray 15 minutes later, returns on a gurney;x-ray tech: Help him. He turned blue andpassed out!

Quick check: cyanotic, pulseless, breathless Initial rhythm assessment: coarse VF

How would you manage this patient?

Cardiac Arrest Associated


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What are the treatment differences?

Cardiac Arrest AssociatedWith Anaphylaxis and

Pseudoallergic Reactions

Cardiac Arrest Associated


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Cardiac Arrest AssociatedWith Anaphylaxis and

Pseudoallergic Reactions

Volume: massive infusions Epinephrine: much higher doses

Corticosteroids: early, large doses Inhaled adrenergics General anesthesia

Antihistamines: early, large doses


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What Are SpecialResuscitation Cases?

Definition: ACLS and PALS treatments thatvary from standard

Rhythm: PEA or asystole; rarely VF/VT

Treatment: Treat underlying cause, not rhythm


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Special Resuscitation CasesCauses: Hs and Ts

Hypoxia (CNS events) Hypokalemia/hyperkalemia (and other

electrolytes) Hypothermia/hyperthermia Hypoglycemia/hyperglycemia

Hydrogen ion Hypovolemia (tank/anaphylaxis, gravid)


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Special Resuscitation CasesCauses: Hs and Ts

Trauma Tamponade

Tension (pneumothorax, asthma) Thrombosis (pulmonary) Thrombosis (coronary)

Tablets (ODs, drugs, etc)


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Shannon Patterson

15-year-old withE. coli (HUS) renal failure Last 2 dialyses did not go well

On exam: weak, short of breath, lungssound wet Blood drawn for electrolytes; glucose:pending

What is the problem and what is your approach?


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Shannon Patterson

Patient looks uncomfortable Intercom: Critical labs on line 6

Suddenly patient goes into wide-complextachycardia

What is the problem and what is your approach?


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What is your first action?What medications are indicated?

08:23 AM: initial rhythm strip

08:23 AM

08:27 AMRx given. What was Rx??


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08:27 AM (continuous strip)

08:27 AM: now 4 minutes later


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08:31 AM

08:31 AM: final strip, 8 minutes from startWhat is the ful l regimen for this problem?


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Shift (contd): Then: insulin + glucose

Reg insulin: 10 U IV + 1 amp (50 g) glucose

Onset = 30 min

Remove: Lasix: 40 to 80 mg IV

Kayexalate: 15 to 50 g + sorbitol Dialysis (peritoneal or hemodialysis)

Treatment of Urgent Hyperkalemia


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Janelle Ratcliffe

17-year-old female college student rushedto ED by 2 young men

Appears unconscious, cyanotic; has aweak pulse

Her companions: She has been very depressed

Hold an empty bottle of a common TCA

What is going on?How would you manage this patient?


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Treatment of TCA Overdose

Not in full cardiac arrest: Hyperventilate to pH = 7.5

Benzodiazepines (1st) vs phenobarbital (2nd)for seizures

Full cardiac arrest: Bicarb: 1 to 5 mEq/kg over 1 to 2 min

Bicarb infusion: 1 to 5 mEq/kg per hour MgSO4: 50 to 100 mg/kg IV bolus if unstable

(up to 5 to 10 g)


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Full cardiac arrest (contd): Norepinephrine (or high-dose dopamine):

hypotension/shock Perform CPR for much longer intervals(>60 min in some patients)

Consider charcoal hemoperfusion,cardiopulmonary bypass

Treatment of TCA Overdose


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P

Q

R

S

T

U

PRinterval

STsegment

Flat P=

PR longer=

QT interval prolongs:

Tall, peaked=

Wider=

Flatter=

Depressed=Hyperkalemia

Shortened=Hypercalcium

BBBs=Hypercalcium

HypomagnesiumTricyclicsNeuroleptics

Wide-complex tachys, VT, VF=

Hyperkalemiab

HyperkalemiaHypomagnesium

HyperkalemiaHypocalcemiaTricyclics

NeurolepticsCa channel blockers

Hyperkalemia

-Blockers

Hypomagnesium

Hypercalcium

b-BlockersQRS

interval

QTinterval

HypercalcemiaTricyclics

NeurolepticsCa channel blockers

HyperkalemiaHypocalciumTricyclicsNeuroleptics

U waves=Hypokalemia


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b-Blocker Overdose Prearrest management

Saline bolus: 20 mL/kg


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b-Blocker Overdose Arrest management

Dopamine infusion: 2 to 20 g/kg per minute

Calcium chloride: 20 to 25 mg/kg slow IV Pacing: either TCP or TV

Consider adding dobutamine, norepinephrine,isoproterenol

Prolonged CPR prn

Cardiopulmonary bypass

Intra-aortic pump


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Henrietta Cipa

12-year-old autistic child with multiple medicalproblems

Brought to ED by alarmed parents:

We think she has taken her unclesnifedipine

Fifteen 20-mg tablets are missing from a bottle

First-degree HB; sinus bradycardia=50 bpm;BP=90/60 mm Hg; QRS widening

What is ini tial management?What if she goes into ful l cardiac arrest?

Course Topics for


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Course Topics forACLS for Experienced Providers

Arrest associated with drug toxicity TCAs, phenothiazines, calcium channelblockers, b-blockers, cocaine,benzodiazepines, narcotics

Arrest associated with electrolyteabnormalities

Potassium, sodium, magnesium, calcium,acid-base problems

Course Topics for


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Arrest associated with environmentalfactors

Hypothermia, near-drowning, trauma,pregnancy, lightning, electric shock

Cardiovascular-pulmonary mechanisms Anaphylaxis, asthma, pulmonary

embolus, AMI, cardiomyopathies,hypertrophies

Course Topics forACLS for Experienced Providers


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Summary

Provides option for renewal/refresher courses Enriches knowledge of experienced providers Focus: periarrest period (1 hour before and

1 hour after)

Focus: diagnosis and treatment of reversiblecauses of arrest

Focus:Thinkabout the patient

ACLS Course forExperienced Providers

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