Essential ACLS Rhythms and Cardiac Arrest Management, Exams of Advanced Education

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essential ACLS rhythms

normal sinus rhythm, bradycardia, tachycardia, atrial fibrillation, atrial flutter, atrioventricular (AV) block, asystole, pulseless electrical activity (PEA), ventricular tachycardia (VT), and ventricular fibrillation (VF) BLS survey

1. check responsiveness.
2. unresponsive, shout for help, activate EMS including mobile, get AED.
3. look for breathing while checking for pulse.
4. perform CPR if no pulse.
5. use an AED to defibrillate respiratory arrest step 1 ensure safety.

• The first step in any emergency is to assess the scene for safety. This includes safety for both the victim(s) and the rescuer(s). Move the victim(s) out of water or traffic. Use caution and personal protective equipment if blood or bodily fluids are present - becoming a victim yourself only adds to the difficulty of the situation. respiratory arrest step 2 assess victim.
• Determine if the victim is responsive. The simplest way to determine responsiveness is to tap and shout, "Are you OK?" Unresponsive persons will not move or make a verbal response. If unresponsive, shout for help and activate EMS via mobile device if appropriate. Get an AED and emergency equipment (or send someone else). adult BLS algorithm adult chain of survival in hospital cardiac arrest (IHCA)

adult chain of survival out of hospital cardiac arrest (OHCA) key BLS concepts

• Recognize unresponsiveness as soon as possible
• Utilize a cell phone to summon help and an AED, if available, as soon as possible
• Minimize interruptions in chest compressions
• Pulse checks should take no longer than ten (10) seconds
• Initiating CPR for presumed cardiac arrest is preferable to withholding chest compressions in non-arrest scenarios
• Avoid frequent pulse checks
• Perform five (5) cycles of CPR and utilize an AED
• Do not delay CPR if an AED is not nearby
• Oxygenation and airway management are critical in pregnant victims
• Lone providers can adjust responses based on the most likely cause of arrest
• Compressions are delivered at 100 - 120 per minute
• Compressions are given before breaths
• Allow complete chest wall recoil. Do not lean on the chest between compressions
• Do not over-ventilate
• Ventilation rate changed to ten (10) breaths per minute for all victims if an advanced airway is utilized
• In special situations, social media may aid in gathering willing bystanders to help in cases of out-of-hospital cardiac arrest (OHCA)
• Debriefing and support are beneficial to support the mental health of both lay and professional rescuers T/F: if the patient is conscious BLS is still required. FALSE. it is not typically required and assessment focuses on the ACLS survey. ACLS Survey ABCD A-airway B-breathing C-circulation D-differential diagnosis A-airway ACLS Survey.

1. Open airway utilizing head-tilt, chin-lift (or jaw thrust alone if trauma) maneuver

2. Consider airway adjuncts - oropharyngeal or nasopharyngeal airway
3. Place advanced airway if needed, but minimize interruptions of chest compressions
4. Confirm proper placement - pulse oximetry, clinical assessment, quantitative waveform capnography
5. Secure airway device B-breathing ACLS Survey.
6. Administer 100% oxygen to all cardiac arrest patients
7. Titrate to oxygen saturation of 92 - 98% in all others if pulse oximetry is available
8. Assess the adequacy of ventilation and oxygenation
9. Use appropriate monitoring devices - oxygen saturation and end-tidal CO (quantitative capnography). ETCO2 monitoring during ACLS may improve CPR quality
10. Do not excessively ventilate patient to decrease the risk of aspiration due to stomach inflation
11. Deliver one (1) breath every six (6) seconds [ten (10) breaths/minute]
12. If an advanced airway is in place, do not interrupt compressions to deliver breaths C-circulation ACLS Survey:
13. Monitor CPR to ensure high-quality compressions are delivered (compression depth 2 - 2.4 inches)
14. If PETCO2 < 10 mm Hg, CPR quality needs to be improved
15. Attach monitor with defibrillator capabilities for all arrest patients
16. Defibrillate or perform synchronized cardioversion when indicated
17. Obtain access for drug therapy and/or IV fluids (IV or IO). IV access is the preferred route. IO route is acceptable if IV is not available or cannot be quickly established
18. Administer appropriate drug therapy. Early administration of Epinephrine is reaffirmed in the 2020 guideline updates.
19. Give IV/IO fluids D-differential diagnosis ACLS Survey:
20. Determining the cause can allow for directed intervention
21. Find and treat all reversible causes steps for performing adult CPR

points of emphasis for CPR

• When the presence of a pulse is in doubt, perform CPR
• It can be challenging for lay rescuers to accurately detect a pulse. For victims with very low blood pressure, a pulse may be extremely difficult to palpate, and CPR should not be delayed while searching for a pulse
• Keeping the arms straight or locking the elbows will improve compression efficiency and help to minimize fatigue
• Perform the head-tilt, chin-lift maneuver by placing one (1) hand on the forehead and using two (2) fingers from the other hand to elevate the chin. Place these fingers on the bony prominence of the chin and avoid pressing the soft tissue under the jaw, as this can block the airway
• Chest compressions are always delivered at a rate of 100 - 120 per minute
• The compression-to-breath ratio is always 30:2 for adults
• If a neck injury is suspected, use a jaw thrust maneuver only high quality CPR
• Chest compression rate of 100 - 120 per minute
• Compression depth of approximately 2 - 2.4 inches (5 - 6 cm) in adults
• Compression depth of approximately 1.5 inches (4 cm) in infants less than one (1) year
• Compression depth of approximately 2 inches (5 cm) or at least 1/3 AP chest diameter in children one (1) year to puberty
• Minimize interruptions in compressions
• Do not over-ventilate the victim; one (1) breath every six (6) seconds [ten (10) / minute]
• Allow the chest to completely recoil after each compression
• Do not lean on the chest wall in between compressions
• Audiovisual feedback devices can help optimize real-time CPR performance post-arrest cardiac care
• targeted temperature management (TTM)
• optimization of hemodynamics.
• optimation of ventilation.
• immediate PCI.
• glycemic control.
• neurological care. targeted temperature management (TTM) All comatose (unresponsive to verbal commands) adults with ROSC after cardiac arrest should undergo therapeutic cooling utilizing TTM. The goal is a temperature between 32°C and 36°C. The temperature should be maintained for at least 24-hours. The precise temperature can be determined by the treating physician and clinical factors. Fever can occur in a post-arrest patient after the TTM period - active treatment of fever is reasonable.

Untreated fever may worsen neurologic outcomes. Routine out-of-hospital cooling of cardiac arrest patients is not recommended. optimization of hemodynamics IV fluids and vasopressor drugs may be required to support circulation and perfusion. The mean arterial pressure (MAP) should be maintained at or above 65 mm Hg. Studies note that a systolic blood pressure less than 90 mm Hg, or a mean arterial pressure of less than 65 mm Hg, is associated with higher mortality and diminished functional recovery. Steroids, combined with epinephrine for IHCA, may provide some benefit, and their co- administration is reasonable. optimization of ventilation Oxygen saturation is titrated to 92% - 98% in the post-arrest phase of care. 100% oxygen can cause a spectrum of lung injury, including mild tracheobronchitis to diffuse alveolar damage. (2,3) immediate PCI Emergency coronary angiography is recommended for all patients with ST-elevation (STEMI) or unstable (hemodynamically or electrically) non-STEMI patients for whom a cardiovascular lesion is suspected. Transport a post-arrest victim with ROSC to a facility capable of performing percutaneous coronary intervention (PCI) when feasible. Therapeutic hypothermia can be performed concurrently. Coma does not preclude the performance of PCI. glycemic control Maintain glucose control (144 to 180 mg/dl) in ROSC patients, but do not attempt to normalize blood glucose, due to the risk of hypoglycemia and neuronal damage. neurological care he earliest time to determine prognosis after TTM is 72 hours after cardiac arrest. This time may be longer if residual effects of sedation, or paralytic drugs, are suspected due to interference with clinical examination and decision-making acute coronary syndrome (ACS) In this syndrome, the blood supply to the heart is compromised. This can result in an acute myocardial infarction, heart failure, life-threatening cardiac dysrhythmias, and/or cardiogenic shock. In cardiogenic shock, the heart cannot effectively pump blood. acute coronary syndrome care

• Minimizing the damage to the heart muscle (myocardial ischemia and necrosis)
• Preserving left ventricular function / preventing heart failure
• Preventing death, nonfatal MI, or the need for emergency bypass surgery
• Treating all life-threatening complications acute stroke

Stroke, a sudden neurologic deficit of presumed vascular origin, is a clinical syndrome rather than a single disease. Rapid transport is critical, as the window for administering thrombolytic therapy is narrow. Current guidelines accept three (3) hours from the time of symptom onset, which can be extended to 4.5 hours for select patients. (6,7) goals of systematic approach for ACLS systems of care

• Early Recognition of Cardiac Arrest
• Early Activation of 911
• Early CPR and AED Use
• Rapid Defibrillation
• Effective ACLS
• Delivery to Definitive Care (Post-Cardiac Arrest Care)