ACLS training most important points to remember

- 5 cycles of 30/2 = 2 minutes switch with other person after 2

minutes!
- Most important person during resuscitation response is the
RESCUER make sure the scene is safe for the rescuer
- Compressions from 100-120/minute
- Interruption of CPR must be limited to no more than 10
seconds!!!!
o Continue to do CPR when the AED is charging
- No cricoid pressure anymore for routine CPR!
o If you intubate = celic maneuver which is not used to stop
things from going into and out of the esophagus (like
cricoid pressure which stops air from going to the stomach)
- CPR gets 30% of circulation of blood flow
- Defib is the most impt BLS intervention for V fib
o The earlier you can shock V fib, the better the chance to
get them out of cardiac arrest
- 1 ventilation/6 seconds = 10 ventilations/minute with advanced
airway placement with CPR
- Peripheral veins are the first choice for IV access (external
jugular, NOT internal jugular).
o Interosseous route is the second choice for IV access
- Vasopressin is NO LONGER USED !
- Capnography or Pet CO2 should be maintained at 10mmHG or
higher! Btw 10-20 mmHg
- Crew can contact medical control and request terminate
resuscitation efforts after 25 minutes or more minutes and the
person isnt cold/hypothermic and the pt is still asystole
o Paramedics, EMTs and first responders and all rescue crew
are able to communicate with medical control
- Consider therapeutic hypothermia (target temp 32-36 degrees
celcius WITHIN 20 minutes!!!!) with fluid at 4 degrees celcius for
12-24 hours!
o This is to try and save pts nervous system
- Give 1-2 L of normal saline or lactated ringers to get pt out of
hypoTN after cardiac arrest
o 250-500 ml boluses should be followed by reassessment of
BP before proceeding to additional boluses
o If not corrected, give VASOPRESSOR infusions
- With unstable tachy pt, next action is to get him an EKG
o For unstable definition pt needs to have HR between 50-
150, high RR, pulse ox less than 94%
Need to act QUICK, cant use drugs cardiovert
- If pt BP is 160/100 with HR >150 with pulse ox of 96% but is
dizzy, pt is still STABLE
o Have time to give drugs since pt is stable
o But next step is still to get an EKG
o With stable tacky, narrow QRS:
IV access and 12 lead EKG
Vagal maneuvers
6 mg Adenosine/IVB 12mg adenosine
Consider B block or Calcium blocker
Expert consult
o With WIDE QRS
IV access and 12 lead EKG
Adenosine if regular and monomorphic
Consider antiarrhthmics
Expert consult
o Unstable tacky >150 bpm
Consider sedation for cardioversion if pt is
CONSCIOUS and coherent (benzos)
Consider adenosine if rhythm is NARROW and regular
- Purpose of MET and RRT is to Identify and treat pts during the
early stages of deterioration early intervention of these teams
has shown to improve pt outcomes; this is NOT a code team.
o inside the hospital emergency team
- Closed loop communications
o Team leader of resuscitation request a second team
member to perform an action
o Team leader makes eye contact with the second member
and listens for clear responses that the request has been
understood
o Team leader listens for the second team member to inform
him/her when the task begins and when it is complete
- CT scan and CVA
o Stroke centers must have a functioning CAT scan. If it goes
down, it is no longer considered a stroke center until it is
repaired and the pt has to be diverted to the nearest stroke
center
- Right ventricular infarctions decrease the preload of left ventricle
and CO. Standard tx with preload reducing agents and morphine
will aggravate the condition and cause shock
o The standard tx for RIGHT ventricular infarctions is to give
fluid infusion to increase the preload
- Defibrillation points to remember
o Defib of a pt with water on the chest can cause arcing of
current across the surface of the chest
 o Avoid o2 blowing across the chest which may ignite a spark
into a flame
o Defib is not affected by the pt laying on the snow
- Pre hospital stroke scale
o Facial droop
o Arm drift (keep arms straight)
o Abnormal speech (you cant treat an old dog new tricks)
o If pt has one or more of these72% change pt is having a
stroke
- Hyperventilation with ROSC
o Decreases BF to the brain
o Causes alkalosis and hypoxia
o Increases thoracic pressure decreasing venous return and
preload
- Signs for not initiating resuscitation
o Dependent lividity
o Decapitation
o Rigor mortis
o Decomposition
- Ventilation rates
o Resp rate = 1 breath every 5/6 seconds for cardiac arrest
30 compressions / 2 ventilations
o Cardiac arrest with advanced airway
1 breath every 6 seconds, no ratio
o ROSC = respiratory arrest
1 breath every 5/6 seconds
- AHA EKGs
o Count 30 boxes to determine a 6 second strip which allows
you to determine whats going on !

Saftey of the rescuer (MD, PA, Nurse, Paramedic, fireman, layperson) is

the most important component of CPR.

If location of pt is dangerous or hazardous dont approach patient until

scene is safe

If scene becomes hazardous while doing cpr and the pt cant be safetly
removed, stop CPR and move to place of safety

Interruption of CPR must be limited to 10 secondscan be helped by

continuing CPR compressions while its charging.
NO CRICOID PRESSURE in CPR

You only get 15 30 % of the normal blood flow when u do CPR

Defrib is #1 for Vfib

Not an advanced airway -> oro or nasopharyngeal airway

Ater you do advanced airway -> do 100-120 compression rate,

ventilation every 6 seconds (10 breaths per minutes)

#1 peripheral IV, #2 is IO
Atropine is no longer used in cardiac arrest
- We use it for symptomatic bradycardias <50 bpm

Vasopressin is no longer used in cardiac arrest

Capnography should be maintained at 10 or greater

- Capnography confirms:
o High quality CPR
o Proper endotracheal tube placement
o Return of spontaneous circulation (ROSC)
o Insures adequate ventilation post arrest

Paramdeics are in contact with Telemetry control doctor, if paramedic

after 25 min-30 min did everything terminate the resuscitation

Post cardiac arrest care management

- Simultaneous all of this
- Ventilate and oxygenate
- 94 or better pulse ox
- treat hypotension with fluids 1-2 liters bolus, if not, pressors NE,
Epi, or DA.
- Assess pts reponse to command
- Consider targeted tep management (target temp in less than 20
min) fluid is 4 degress celcius we want the pt at 32-36 degrees
celcius to slow down cell death.
- Get 12 lead for STEMI.if had an MI send to cath lab
- Then to ICU

ROSC
- Came back but they may not be breathing

Get an ekg!
MET and RRT teams identify and treat patients during early stages of
deterioration. Early intervention of these teams improves pt outcomes.
THEY ARE NOT CODE TEAMS

Closed loop communications team leader requests something from a

2nd team member, leader makes eye contact and listens for clear
response that it was understood, then the team member informs him
when the task starts and ends

If cat scan stops working in stoke center, you cannot receive stroke
patients.

Right ventricular infarctions give fluid infusion to increase preload.

Its the only MI thats treated with fluids. Nitrates can cause rv
inafrction to turn into arrestdont use nitrates or morphine!

Water on chest, causes arching of current across the surface of chest

Avoid bowing o2 on chest while shoking

Snow is fine

Facial droop, arm drift, slurred speech - Cincinnati stroke smptms

Sings for not initiatin rescuciitation

1. Dependent lividity pooling of blood out into tissues wherever pt
is laying
2. Decapitations
3. Rigor mortis
4. Decomposition

V fib pressor AA pressor AA pressor pressor pressor pressor

PEA and astystole non shockable