By: Diana Blum MSN Metropolitan Community College

Nursing 2150

Advanced Cardiac Life Support (ACLS)

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 SurveyAirway: Open airway, look, listen, and

feel for breathingBreathing: 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=tVHJq9op5cw&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.

PEAProblem 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 Assess Intervention

Pulmonary Embolism No pulse w/ CPR, JVD Thrombolytics, surgery

Acidosis(preexisting)

Diabetic/renal patient, ABGs Sodium bicarbonate,hyperventilation

Tension pneumothorax No pulse w/ CPR, JVD, tracheal deviation Needle thoracostomy

CardiacTamponade

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

Hypokalemia EKG, serum K level Treat with great prudence after careful assessment of the cause. K can kill.

Hypovolemia Collapsed vasculature Fluids

Hypoxia Airway, cyanosis, ABGs Oxygen, ventilation

Myocardialinfarct

History, EKG Acute Coronary Syndrome algorithm

Drugs 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 ituse 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 ABCDsPacing: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: Epinephrine2-10 µg/min2nd-line drugs to consider if atropine and/or TCP are ineffective..

Danger: Dopamine2-10 µg/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 practicehttp://www.acls.net/quiz.htm

http://www.mdchoice.com/cyberpt/acls/acls.asp