ACLS Online Training Material

Unit One: General Concepts

Advanced Cardiovascular Life Support (ACLS) focuses on identification of, and early intervention in, acute arrhythmias, acute coronary syndromes (ACS), cardiopulmonary arrest and stroke in order to help adults survive cardiopulmonary emergencies. ACLS will teach the student: BLS and ACLS Surveys; High quality CPR; ACLS sequences of care; and Post cardiac arrest care

2010 Guidelines Changes

The American Heart Association did a major revision of CPR and ACLS Guidelines in 2010. The major changes associated with the 2010 Guidelines include: Changing from the ABCs to a C-A-B sequence of steps. With the 2010 standards, the proper sequence for BLS activities is 1) Chest Compressions, 2) Airway, 3) Breathing. Experts believe that decreasing the delay in beginning compressions will increase survival rates. Removal of the "Look, listen and feel" for breathing. This assessment of the victim's breathing has been removed since untrained responders tended to mistake agonal breathing for effective breathing. This step has been replaced by the instruction to begin CPR if the victim is not responsive, has no pulse, and is not breathing or only gasping. Emphasis on high-quality CPR defined as: o Compression rate of AT LEAST 100 per minute; o Compression depth of AT LEAST 2 inches in adults; o Allowing complete chest recoil with each compression; o IV, drug delivery, advanced airways should not interrupt CPR but should be performed when getting ready for defibrillation; o Avoiding excessive ventilation; An emphasis on providing CPR as a team with providers performing actions simultaneously decreasing the time to definitive treatment (see Team Dynamics unit); Cricoid pressure is no longer recommended; De-emphasis on the pulse check since many responders are unable to reliably detect a pulse. The current recommendation is to feel for a pulse for 10 seconds; then, begin CPR if no pulse is felt OR if the responder is not sure that a pulse is present. When Return of Spontaneous Circulation (ROSC) occurs, begin post cardiac arrest measures (see the new Post Cardiac Arrest section); Administer a vasopressor every 3-5 minutes; endotracheal tube may be used for epinephrine until an IV is established; Atropine is not recommended for asystole or PEA but is the drug of choice for any symptomatic bradycardia; Tachycardia sequence has been simplified (see the tachycardia case);
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Quantitative Waveform capnography is recommended to verify ET tube placement and monitor ventilation; Finally, the 2010 guidelines include a recommendation that systems of care must be integrated (see the Systems of Care unit).

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Unit Two: BLS and ACLS Surveys

The goal of ACLS is to support the patient in cardiac arrest and provide for optimal outcomes. This is done systematically by conducting BLS and ACLS surveys. If the patient is not responsive, the process should begin with the BLS survey using the ACLS survey for advanced treatment. If the patient is conscious and responsive, the responder should start with the ACLS survey.

BLS Survey
Basic Life Support for adults consists of chest compressions, establishing an airway, rescue breathing, and defibrillation when available. In the past, BLS for healthcare providers has focused on one rescuer resuscitation. The current thinking is that it is very likely that more than one responder will be available to do several actions at the same time; therefore, the CPR course now focuses on CPR as a team. However, skill testing is still done on both one and two rescuer BLS.

Secure the Scene

Make sure you and the patient are safe from environmental hazards (traffic, wet floor, etc.) Shake the victim and shout asking him if he is OK Check breathing Call for help Activate the system yourself if alone Treatment for Ventricular fibrillation is electrical shock
Check Pulse Chest Compressions and Breathing Appropriate Defibrillation

Assess the Patient

Activate Emergency System

Get Defibrillator

CPR

Adult BLS/CPR
1. Secure the Scene
Before beginning BLS and CPR on any victim, be sure that both you and the victim are safe from other hazards. For example, if the victim is in the middle of a busy road, attempt to move him out of traffic.

2. Assess the Victim

Check for responsiveness by shaking the victims shoulder and shouting at him. Check to see if the victim is breathing normally; if the victim is not breathing or is only gasping proceed with the next step.

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3. Activate the Emergency Response System and get AED

Shout for help. If a second rescuer comes, instruct him to call for help and get an AED. If no one responds, call for help using a phone and go for an AED if you know where one is.

4. Perform CPR
1. Check for the carotid pulse on the side of the neck between the trachea and the muscles of the neck. Feel for a pulse for at least 5 but NO MORE THAN 10 seconds. 2. If there is no pulse (or if you are unsure), begin cycles of 30 chest compressions followed by 2 breaths. a. With the victim face up on a hard surface, put the heel of one hand on the lower half of the sternum. b. Put the heel of the other hand on top of the first hand. c. Straighten your arms with your shoulders directly over your hands on the victims sternum. d. Press down HARD and FAST. Each compression should be AT LEAST two inches deep and at the rate of AT LEAST 100 per minute. e. Allow the chest to re-expand after each compression to allow the blood to flow back into the heart. f. After 30 compressions, perform a head tilt/chin lift to open the airway. i. Place a hand on the victims forehead and push back to tilt the head. ii. With the other hand, lift the jaw by placing your fingers on the bony part of the lower jaw and lifting up. iii. If a neck injury is suspected and two rescuers are available, open the airway by using the jaw thrust. To perform the jaw thrust, place one hand on each side of the victims head with your fingers under the angles of the jaw and push the lower jaw forward. g. Using a barrier device (if available), give a breath over one second watching the chest rise. Repeat giving a second breath. h. Begin compressions again. i. Switch providers every two minutes as needed to provide rest periods. j. Provide defibrillation when AED arrives; continue compressions.

ACLS Survey
Once the BLS survey is complete, or if the patient is conscious and responsive, the responder should conduct the ACLS survey with a focus on the identification and treatment of underlying cause(s) of the patients problem. 1. Assess the Patients Airway a. If the patient is unconscious, maintain the airway using head/tilt maneuvers. b. Determine if an advanced airway is needed. Try to avoid interrupting CPR to place an advanced airway unless the patients condition is deteriorating. Use the least invasive airway possible (laryngeal mask, laryngeal tube, or esophageal tracheal tube). c. If an advanced airway is in place, secure the airway and confirm placement by exam and by waveform capnography if available.
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2. Assess the Patients Breathing a. If the patient is in cardiac arrest, give 100% oxygen; if the patient is NOT in cardiac arrest, titrate the oxygen to keep the patients oxygen saturation at 94%. b. If available, monitor oxygenation using waveform capnography; watch for signs of cyanosis while avoiding excessive ventilation. 3. Assess the Patients Circulation a. Monitor the quality of CPR using Quantitative waveform capnography, if available; if the partial pressure of CO2 (PETCO2) is < 10 mm Hg, direct faster and deeper CPR. b. Monitor the cardiac monitor for arrhythmias c. Give ACLS drugs per the appropriate sequence. d. Defibrillate or cardiovert as necessary. e. Support the patient with IV fluids. 4. Determine the cause of the symptoms and treat the causes.

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Unit Three: Team Dynamics

Each member of a resuscitation team must understand his role and the role of all other members. Typically, there is one team leader who will ensure that everything gets done correctly. The role of the team leader includes: Organizing the group Monitoring performance of all team members Being able to perform all skills if required Modeling team behavior Coaching other team members Focusing on excellent patient care Providing analysis and critique of group performance after the resuscitation effort is over.

Team members should be used as dictated by their scope of practice. Team members must: Understand their particular role in the resuscitation Be willing and able to perform the role Be practiced in performing the skills of the role Understand the PALS sequences Be committed to the success of the team

The dynamics of the team will be effective when each member understands and performs within the team: Expectation Communication Team Leader Actions The team leader Gives succinct assignments and confirms that message has been received; confirms performance of task Speak clearly, distinctly, and in a normal tone of voice when giving orders;; request clarification of messages Must define all roles of each team member based on competencies of the members Ask for opinions and suggestions from team members as appropriate Intervene if a team member is preparing to perform an incorrect action or if a team member is unable to perform a task quickly Ask for opinions and suggestions from Team Member Actions Clearly informs leader of receipt assignment; confirms when assignment has been completed Speak clearly and in a normal tone of voice when repeating orders; question ambiguous orders Informs the team leader if assigned task is beyond the team member's experience or skills; ask for help if a task cannot be quickly performed Share information with team; try to identify factors limiting the resuscitation effort Ask the team leader to verify an action if you think an error is about to occur; suggest alternatives if an error is about to be made Draw attention to changes in the patient's

Messages

Roles

Knowledge Sharing Intervention

Evaluation and

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Summary

team members; review patient's responses; inform team members of current status and plans for additional actions; provide positive and corrective feedback

condition

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Unit Four: Systems of Care

The primary purpose of Basic and Advanced Life Support is to give providers the necessary steps to increase the chances of survival for a victim of cardiac arrest. The Chain of Survival is made up of individuals and systems and is a useful way of viewing what must happen to increase survival rates of Acute Coronary Syndromes (ACS) and stroke.

Activation of the emergency response system

Early cardiopulmonary resuscitation (CPR)

Rapid Defibrillation

Effective Advanced Life Support

Comprehensive post-cardiac arrest care

Figure 1: Adult Chain of Survival

Post Cardiac Arrest Care

Studies show that post cardiac arrest care is critical for optimal results following use of ACLS protocols. Recommended treatments following cardiac arrest include: Therapeutic Hypothermia is recommended for adults with return of spontaneous circulation who are non-responsive to verbal commands. The recommendation includes lowering the patient's core temperature to 32-34 degrees Centigrade for 12 to 24 hours after arrest. Hemodynamic/Ventilation Optimization should be controlled using Quantitative waveform capnography to keep the PETCO2 at 35-40 mm Hg. It has been determined that this monitoring is the most accurate way to prevent oxygen toxicity. If capnography is not available, the team should keep the oxygen saturation 94%. Fluids and vasoactive medications should be titrated to keep blood pressure and systemic perfusion at optimal levels. The patient should be transported to a facility capable of coronary reperfusion with Percutaneous Coronary Intervention (PCI). Glycemic Control should be targeted to a glucose level of 144-180 mg/dL; attempting to achieve a lower level has been shown to incur a risk of hypoglycemia. Neurologic testing must be very reliable particularly when withdrawing treatment is being considered.

Acute Coronary Syndromes (ACS)

For patients with ACS, systems must be in place to prevent cardiovascular complications and major cardiac events and to treat complications of ACS including arrhythmias, shock and pulmonary edema. Systems of care that should be in place to achieve these goals include: Education of the public to recognize ACS and education of all healthcare providers to evaluate and appropriately treat ACS as quickly as possible. Activate the Emergency Response system to ensure that the Emergency Medical System (EMS) is involved in acquiring ECGs before arrival to the Emergency Department (ED). Training of EMS should include recognition of acute myocardial infarction (AMI) in order to notify the hospital to have the appropriate systems standing by in the hospital.
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Systems in the hospital should be geared to shortening the time to definitive treatment of the ACS patient. ED personnel, particularly the ED physician, should be trained in emergency care for the ACS patient including selection of the best reperfusion strategy.

Acute Stroke Care

Care for patients with stroke has improved and outcomes have improved through implementation of systems of care for stroke including: Public education about the symptoms of stroke and the necessity for seeking treatment within the first hour. EMS must be integrated into the system of care for strokes in order to have professionals in the field trained to recognize stroke and get the patient to definitive care in the shortest possible time. Regional stroke centers have decreased the time to definitive treatment and have increased the knowledge of the healthcare providers who receive and care for stroke patients.

Education and Teams

Survival rates for patients suffering in-hospital cardiac arrest are as low as 21%. Patients at risk for cardiac arrest must be identified before cardiac arrest occurs. This involves education of healthcare providers to monitor each patient and recognize physiologic changes that may precede cardiopulmonary arrest. In-hospital systems of care for intervention include: Cardiac Arrest Teams have traditionally been the teams to respond at the time of a cardiac arrest. Because they responded late in the process (i.e., when a cardiac arrest had occurred), these teams did not lower the mortality rate from cardiac arrest. Hospitals are beginning to replace these teams with rapid response teams. Hospital Rapid Response Teams (RRTs) have been developed to intervene early BEFORE a cardiac arrest occurs. Anyone, including family members, who sense that the patient is deteriorating, can activate the RRT. Criteria for activating the RRT may include: o Very slow, rapid, or labored respirations o Very slow or rapid heart rate o Hypo or hypertension o Decreased level of consciousness o Any change in mentation o Seizure o Any subjective concern When the RRT is called early, intervention can occur immediately to reverse the deterioration of the patient's condition. The goals of the RRT, and the results of published studies, show that the use of RRTs can result in: o Drop in the rate of cardiac arrests and resulting mortality; o Drop in transfers to the ICU; o Drop in morbidity rates.

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Unit Five: ACLS Cases

BLS and ACLS Surveys
In all cases, the responding team should perform the BLS and ACLS surveys before proceeding with the sequence for the specific arrhythmia or problem. (See Unit Two for the procedure for the BLS and ACLS surveys)

Adult BLS/CPR
1. Secure the Scene Before beginning BLS and CPR on any victim, be sure that both you and the victim are safe from other hazards. For example, if the victim is in the middle of a busy road, attempt to move him out of traffic. 2. Assess the Victim Check for responsiveness by shaking the victims shoulder and shouting at him. Check to see if the victim is breathing normally; if the victim is not breathing or is only gasping proceed with the next step. 3. Activate the Emergency Response System and get AED Shout for help. If a second rescuer comes, instruct him to call for help and get an AED. If no one responds, call for help using a phone and go for an AED if you know where one is. 4. Perform CPR a. Check for the carotid pulse on the side of the neck between the trachea and the muscles of the neck. Feel for a pulse for at least 5 but NO MORE THAN 10 seconds. b. If there is no pulse (or if you are unsure), begin cycles of 30 chest compressions followed by 2 breaths. c. With the victim face up on a hard surface, put the heel of one hand on the lower half of the sternum. d. Put the heel of the other hand on top of the first hand. e. Straighten your arms with your shoulders directly over your hands on the victims sternum. f. Press down HARD and FAST. Each compression should be AT LEAST two inches deep and at the rate of AT LEAST 100 per minute. g. Allow the chest to re-expand after each compression to allow the blood to flow back into the heart. h. After 30 compressions, perform a head tilt/chin lift to open the airway. i. Place a hand on the victims forehead and push back to tilt the head. ii. With the other hand, lift the jaw by placing your fingers on the bony part of the lower jaw and lifting up. iii. If a neck injury is suspected and two rescuers are available, open the airway by using the jaw thrust. To perform the jaw thrust, place one hand on each side of the victims head with your fingers under the angles of the jaw and push the lower jaw forward.

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i.

Using a barrier device (if available), give a breath over one second watching the chest rise. Repeat giving a second breath. j. Begin compressions again. k. Switch providers every two minutes as needed to provide rest periods. l. Provide defibrillation when AED arrives; continue compressions.

ACLS Survey
Once the BLS survey is complete, or if the patient is conscious and responsive, the responder should conduct the ACLS survey with a focus on the identification and treatment of underlying cause(s) of the patients problem. 1. Assess the Patients Airway a. If the patient is unconscious, maintain the airway using head/tilt maneuvers. b. Determine if an advanced airway is needed. Try to avoid interrupting CPR to place an advanced airway unless the patients condition is deteriorating. Use the least invasive airway possible (laryngeal mask, laryngeal tube, or esophageal tracheal tube). c. If an advanced airway is in place, secure the airway and confirm placement by exam and by waveform capnography if available. 2. Assess the Patients Breathing a. If the patient is in cardiac arrest, give 100% oxygen; if the patient is NOT in cardiac arrest, titrate the oxygen to keep the patients oxygen saturation at 94%. b. If available, monitor oxygenation using waveform capnography; watch for signs of cyanosis while avoiding excessive ventilation. 3. Assess the Patients Circulation a. Monitor the quality of CPR using Quantitative waveform capnography, if available; if the partial pressure of CO2 (PETCO2) is < 10 mm Hg, direct faster and deeper CPR. b. Monitor the cardiac monitor for arrhythmias c. Give ACLS drugs per the appropriate sequence. d. Defibrillate or cardiovert as necessary. e. Support the patient with IV fluids. 4. Determine the cause of the symptoms and treat the causes.

Respiratory Arrest
The first line of treatment for a respiratory emergency is provision of a patent airway and delivery of oxygen to maintain saturation at >94%. For the patient in respiratory arrest with a pulse, ventilate the patient at the rate of one breath every 5-6 seconds watching to ensure that the chest rises with each breath. There are several basic airway skills that can be attempted to establish an airway for a compromised patient: First, position the patient to maintain an open airway using the head tilt/chin lift or jaw thrust maneuver (if neck injury is suspected). Positioning the patient in respiratory arrest may be all that is required to allow the patient to begin to breathe. Mouth to mouth ventilation can be used if no barriers are available. Mouth to nose ventilation can be used if there are injuries to the mouth. Mouth to barrier ventilation can be used if a pocket mask is available.
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Bag-mask ventilation is effective when performed properly. Select a mask that covers the patient's nose and mouth to the cleft of the chin. Ensure that oxygen is attached and flowing to the bag at all times during the resuscitation. Verify that the bag has no leaks and that the pop-off valve (if one is present on the bag) can be closed. This device can be used to deliver oxygen through other airways.

Avoid excessive ventilation; use only the amount of volume necessary to make the chest rise. Monitor O2 saturation, vital signs and the patient's condition to determine effectiveness. If establishing an airway becomes necessary, equipment should be readily available: Universal Precautions equipment -- gloves, mask, eye protection Monitoring devices -- cardiac monitor, BP monitor, pulse oximetry, carbon dioxide detector IV/IO equipment, suction equipment Airways of all sizes; oxygen supply and bag masks Various sizes of endotracheal tubes and laryngoscope Syringes to test ET tube balloon Adhesive tape to secure tube.

Basic Airway Management

Oropharyngeal Airway The oropharyngeal airway (OPA) is only used with an unconscious patient. Do not insert the oropharyngeal airway if the casualty is conscious or semiconscious. The airway could cause the person to gag and vomit. It is important to select the right airway size; if the airway is not the correct size, it could injure the patient's throat or obstruct his airway. The right size keeps the patient's tongue from falling down the back of his throat. To insert the OPA: 1. Position the patient on his back. 2. Place your thumb and index finger of one hand on the patient's upper and lower teeth near a corner of his mouth so the thumb and finger will cross when his mouth is opened. 3. Push your thumb and index finger against the patient's upper and lower teeth in a scissors-like motion until his teeth separate and his mouth opens. 4. If the teeth do not separate, wedge your index finger behind the his back molars and force the teeth apart. 5. Place the tip end of the airway into the victim's mouth. Make sure the tip is on top of the tongue. Point the tip of the airway up toward the roof of his mouth. 6. Slide the airway along the roof of the victim's mouth, following the natural curvature of the tongue. 7. When the tip of the airway reaches the back of the tongue past the soft palate, rotate the airway 180 degrees so the tip of the airway points toward the patient's throat. 8. Advance the airway until the flange rests against his lips. 9. The airway should now be positioned so the tongue is held in place and will not slide to the back of the patient's throat. 10. Remove the airway immediately if the patient regains consciousness.

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Nasopharyngeal Airway The nasopharyngeal airway (NPA) may be used in a conscious or unconscious victim. The NA can be used with a victim who has mouth trauma or who has an intact gag reflex since the NA does not cause the patient to gag. To insert the NA: 1. Select the proper size by comparing the size of the NPA with the size of the patient's largest nostril. Select the proper length by measuring from the ear lobe to the tip of the nose. 2. Use a water soluble lubricant to lubricate the airway. 3. Insert the NPA gently but firmly through the largest nostril. The nasal passage goes backwards at a right angle to the face; if resistance is encountered, rotate the airway slightly or attempt to use the other nostril. Suctioning the Airway Suctioning the airway is critical for maintaining a patent airway and improving oxygenation. Wall mounted suction devices should be used if available since they provide the power necessary to keep the airway clear. Rigid ( for example, Yankauer) catheters are only used for suctioning the mouth and upper pharynx. Soft catheters should be used for suctioning all other airways. To suction an endotracheal tube: 1. Wash hands and use sterile technique if possible to prevent risk of infection. 2. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. Recommend 80-120 mmHg; adjust lower for children and the elderly. Significant hypoxia and damage to tracheal mucosa can result from excessive negative pressure. 3. Pick up suction catheter, being careful to avoid touching nonsterile surfaces. With the non-dominant hand, pick up connecting tubing. Secure suction catheter to connecting tubing. 4. Without applying suction, gently but quickly insert catheter with dominant hand during inspiration until resistance is met; then pull back 1-2 cm. Catheter is now in tracheobronchial tree. 5. Apply intermittent suction by placing and releasing dominant thumb over the control vent of the catheter. Rotate the catheter between the dominant thumb and forefinger as you slowly withdraw the catheter. With in-line suction, apply continuous suction by depressing suction valve and pull catheter straight back. Time should not exceed 10-15 seconds. 6. Replace oxygen delivery device. Hyperoxygenate between passes of catheter and following suctioning procedure. 7. Monitor patients cardiopulmonary status during and between suction passes. Observe for signs of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety, bronchospasms, and changes in mental status.

Advanced Airway Management

In a team situation where there is at least one member trained and competent in insertion of an advanced airway, one of these airways can provide better ventilation and oxygenation. Placement of these airways is beyond the scope of ACLS, but each team member should know how to ventilate and maintain these airways. With one of these advanced airways, ventilations should be one every 6-8 seconds during cardiac arrest and one every 5-6 seconds in respiratory arrest. The Laryngeal Mask Airway is an alternative to an ET tube that provides comparable oxygenation.
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A Laryngeal Tube is a compact airway that can be used instead of bag-mask or ET tube ventilation. An Esophageal-Tracheal tube provides oxygenation similar to an ET tube. Great care should be taken with this tube. The Endotracheal Tube (ETT) is the airway that is typically thought of as an advanced airway and may be the airway of choice during a cardiac arrest. Team members should be aware of how the ETT is placed and maintained; however, only a trained and competent practitioner should insert the tube. Team members should be prepared to: o Prepare the equipment o Perform the ET intubation (only to be done by a trained practitioner) o Inflate the cuff after intubation o Attach the ventilation bag and give breaths at the appropriate rate. o Confirm placement by Quantitative waveform Capnography (if available) and by clinical assessment. o Secure the tube. o Monitor the tube.

Once the patient is intubated, chest compressions in CPR should not be interrupted to deliver breaths. Breaths should be delivered during the normal chest recoil during CPR. For a patient with suspected neck injury, manually stabilize the neck to avoid spine movement; an immobilization collar may interfere with maintaining an open airway.

Ventricular Fibrillation (VF) with CPR and AED

In the case of cardiac arrest, the team must perform effective CPR and use an AED.

Adult BLS/CPR
1. Secure the Scene Before beginning BLS and CPR on any victim, be sure that both you and the victim are safe from other hazards. For example, if the victim is in the middle of a busy road, attempt to move him out of traffic. 2. Assess the Victim Check for responsiveness by shaking the victims shoulder and shouting at him. Check to see if the victim is breathing normally; if the victim is not breathing or is only gasping proceed with the next step. 3. Activate the Emergency Response System and get AED Shout for help. If a second rescuer comes, instruct him to call for help and get an AED. If no one responds, call for help using a phone and go for an AED if you know where one is. 4. Perform CPR a. Check for the carotid pulse on the side of the neck between the trachea and the muscles of the neck. Feel for a pulse for at least 5 but NO MORE THAN 10 seconds. b. If there is no pulse (or if you are unsure), begin cycles of 30 chest compressions followed by 2 breaths.
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c. With the victim face up on a hard surface, put the heel of one hand on the lower half of the sternum. d. Put the heel of the other hand on top of the first hand. e. Straighten your arms with your shoulders directly over your hands on the victims sternum. f. Press down HARD and FAST. Each compression should be AT LEAST two inches deep and at the rate of AT LEAST 100 per minute. g. Allow the chest to re-expand after each compression to allow the blood to flow back into the heart. h. After 30 compressions, perform a head tilt/chin lift to open the airway. iv. Place a hand on the victims forehead and push back to tilt the head. v. With the other hand, lift the jaw by placing your fingers on the bony part of the lower jaw and lifting up. vi. If a neck injury is suspected and two rescuers are available, open the airway by using the jaw thrust. To perform the jaw thrust, place one hand on each side of the victims head with your fingers under the angles of the jaw and push the lower jaw forward. i. Using a barrier device (if available), give a breath over one second watching the chest rise. Repeat giving a second breath. j. Begin compressions again. k. Switch providers every two minutes as needed to provide rest periods.

Using the Automated External Defibrillator

One of the primary causes of sudden cardiac death is ventricular fibrillation. This dysrhythmia causes the heart to quiver rather than contract. The treatment for this rhythm is to provide an electric shock to the heart. The automated external defibrillator (AED) is a computerized device that identifies the victims heart rhythm and delivers an electric shock to appropriate rhythms. Because no knowledge of cardiac rhythms is required, the AED is safe for use by the general public or healthcare providers. If more than one rescuer is present, the team should coordinate the work so that one rescuer continues CPR while the second rescuer prepares the AED for use. Although there are many different brands of AEDs available, all of them operate in the same basic manner: 1. If the victim is in water, move the victim out of the water before using the AED. 2. Open the case and turn on the AED. At this point, the AED will guide you through the subsequent steps. 3. Stop CPR and perform the next steps as quickly as possible. The effectiveness of shock delivery decreases significantly for every 10 seconds that elapses between compressions and shock delivery, so it is critical to deliver a shock quickly. 4. Open or cut off the victims shirt to expose the bare chest; if the chest is wet, dry it with a towel or the victims own shirt. 5. Open the AED pads, peel the backing from the pads, and attach the pads to the upper right chest above the breast and the lower left chest with the top edge a few inches below the armpit. If you feel a hard lump below the skin in the victims upper chest or abdomen, it is likely the victim has an implanted pacemaker or defibrillator; avoid placing the pads over these devices. If you see a medication patch, either avoid placing the pad over the patch or quickly remove the patch and wipe away any medication.
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6. Follow the specific instructions provided by the AED for attaching wires to the AED box; many AEDs are now available with the pads preconnected to the box. 7. Have all rescuers and bystanders move away from the victim (clear the victim) and allow the AED to analyze the cardiac rhythm. No one should be touching the victim during this time. Any movement of the victim during this analysis will interfere with the machines ability to detect the rhythm. 8. If the AED advises you to check pads/check electrodes, it typically means the pads are not making full contact with the victims skin. Press down firmly on each pad and allow the AED to analyze again. If the victims skin is very hairy, quickly pull off the pads, shave the area if necessary, and reapply a new set of pads. 9. If the AED detects ventricular fibrillation, it will advise you to clear the victim and deliver a shock. Loudly state clear and verify that no one is touching the victim. Press the Shock button. 10. If the AED does NOT advise a shock, immediately resume CPR. 11. After approximately two minutes of CPR, the AED will prompt rescuers to repeat steps 5 and 6.

VF, Pulseless VT, PEA and Asystole

Cardiac arrest is associated with one of the arrest rhythms: Asystole -- Also called cardiac standstill, asystole is the absence of electrical activity on the ECG. Pulseless Electrical Activity (PEA) -- Used to describe any electrical activity on a monitor with no palpable pulses, PEA is typically seen as a slow rhythm on the monitor. PEA typically results in poor outcomes unless the underlying cause is identified and treated quickly. Ventricular Fibrillation -- VF is characterized by chaotic electrical activity on the cardiac monitor with no palpable pulses. Pulseless ventricular tachycardia -- Characterized by wide QRS complexes and no pulses, pulseless VT will quickly deteriorate into VF and should be treated the same as VF. Torsades de Pointes is a form of VT

Early intervention BEFORE cardiac arrest is the key to successful outcomes; once the patient has gone into cardiac arrest, the prognosis is poor. Highest survival rates occur when there is bradycardia and chest compressions are begun immediately. Cardiac arrest is the cessation of circulation due to absent or ineffective cardiac activity. The pulse cannot be felt, the patient is unresponsive, and respirations are absent or agonal. Return of spontaneous circulation (ROSC) is the goal of intervention in cardiac arrest. Advanced life support may include: Assessment of rhythm to determine whether the rhythm is shockable or not. Vascular access to provide a route for drug administration. If possible, the intravenous route is preferable but is often difficult in a patient. When IV access cannot be established, the intraosseous route (IO) can be used for safe delivery of medications. See Unit Seven for notes on IO access. Finally, the endotracheal route can be used for the LEAN drugs (lidocaine, epinephrine, atropine and naloxone) and vasopressin. The ET route is less desirable than IV or IO because drug absorption is not predictable and optimal doses may not be known. After instilling the drug into the ET tube, flush the tube with 5 mL of saline and provide 5 rapid ventilations after the saline. Defibrillation -- Providing a shock to the heart may end VF and allow the heart's pacemaker to resume a normal rhythm.
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Medication Therapy is aimed at increasing blood flow, stimulating more forceful myocardial contractility, increasing the heart rate, treating possible causes of arrest, and treating arrhythmias. Advanced Airway Management -- During CPR, an ET tube can be placed; however, good bagmask ventilations have been shown to be as effective as an ET tube for short-term resuscitation efforts.

Cardiac Arrest Sequence

This sequence is designed to continue high-quality CPR and provide efficient electrical and medication therapy when appropriate. The sequence is structured around 2 minute periods of CPR during which the rest of the team should be preparing for the next step in the process. This sequence assumes that a manual defibrillator is available and that the team can identify cardiac rhythms on the monitor. Success of resuscitation efforts for patients with cardiac arrest may be influenced by: Interval between collapse and CPR -- The shorter the time between collapse and initiation of CPR, the better the predicted outcome. Quality of CPR -- High-quality CPR (fast and hard) improves the likelihood of a good outcome. Duration of CPR -- In general, the longer CPR continues, the poorer the prognosis becomes. Underlying conditions -- If reversible causes of arrest can be determined and treated early, the prognosis improves.

The decision to stop resuscitation efforts will be influenced by the cause of the arrest and the presence of reversible conditions. Prolonged efforts should be considered in patients who: 1) have recurring VF or VT that responds to treatment, 2) have drug or poisoning toxicity that might be reversed, or 3) have hypothermic injuries. When a patient in cardiac arrest does not respond to BLS interventions, the resuscitation team should implement the Cardiac Arrest Sequence: 1. If it has not been done already, activate the Emergency response system. 2. Begin CPR with compressions at a rate of at least 100 per minute; establish an airway and provide oxygen if available; connect the patient to cardiac and blood pressure monitors when available. 3. If the patient is in asystole or PEA on the monitor, go to step 13. 4. If the patient is in Ventricular tachycardia (VT) or ventricular fibrillation (VF) on the monitor, immediately apply the pads and shock the patient with 120-200 Joules on a biphasic defibrillator or 360 Joules on a monophasic defibrillator. 5. Continue CPR for 2 minutes while establishing IV or IO access. 6. If the patient develops asystole or PEA on the monitor, go to step 13. 7. If the patient is still in VT or VF, shock again. 8. Continue CPR for 2 minutes while giving Epinephrine 1 mg every 3-5 minutes. 9. If the patient is still in VT or VF, shock again. 10. Continue CPR for 2 minutes while giving Amiodarone 300 mg bolus; may repeat with a 2nd dose of 150 mg bolus as needed. If amiodarone is not available, Lidocaine 1-1.5 mg/kg may be given followed by half doses ever 5-10 minutes to a maximum of 3 mg. 11. Continue shocking any shockable rhythms.

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12. If it is determined at any time that the patient is in asystole or PEA, continue CPR while giving Epinephrine 1 mg every 3-5 minutes. Reevaluate the rhythm every 2 minutes and shock if the patient develops VT or VF. 13. Continue to Evaluate, Identify and Intervene on underlying reversible causes. Use the H's and T's to identify the possible cause of arrest: a. Hypovolemia -- Will typically be seen as a rapid rate with narrow QRS -- Treatment includes infusion of saline or lactated Ringer's solution. b. Hypoxia -- Will typically be seen as a slow rate with cyanosis -- Treatment includes airway management and effective ventilation and oxygenation. c. Hydrogen Ion excess (Acidosis) -- Will typically be seen as small amplitude QRS complexes -- Treatment includes hyperventilation and bolus of sodium bicarbonate. d. Hypoglycemia --Can be tested with blood sample -- Treatment includes bolus of dextrose. e. Hypokalemia -- Will be seen as flattened T waves and the appearance of a U wave. QRS may widen resulting in a wide complex tachycardia -- Treatment should include infusion of magnesium. f. Hyperkalemia -- Will be seen as peaked T waves with widened QRS -- Treatment may include calcium chloride, sodium bicarbonate, and glucose with insulin. g. Hypothermia -- Will be preceded by exposure to cold -- Should be treated by rewarming. h. Tension Pneumothorax -- May be seen as a slow rate with narrow complexes -Treatment should include needle decompression or thoracostomy. i. Tamponade (Cardiac) -- Will be seen as a rapid rate with narrow complexes -- Treatment should be pericardiocentesis. j. Toxins -- Usually seen as a prolonged QT interval -- Treatment must be based on the overdose agent k. Thrombosis (pulmonary embolus) -- Will typically be seen as a rapid rate with narrow complexes -- Treatment will include fibrinolytics and/or surgical embolectomy. a. Thrombosis (acute MI) -- ECG will be abnormal 14. If able to identify the cause(s), treat the cause. 15. If Return of Spontaneous Circulation occurs at any point, go to the Post Cardiac Arrest case.

Manual Defibrillation for VF or Pulseless VT

At any point in the cardiac arrest rhythm when a shockable rhythm (VF or pulseless VT) is present, the team should prepare to deliver a shock while continuing high quality CPR. When a manual defibrillator is present, the following steps should be taken: 1. Turn on the defibrillator 2. Select the largest pads or paddles that can be used without touching each other on the patient's chest. 3. Apply conductive gel to paddles or apply adhesive pads to the chest. 4. If using paddles, apply firm pressure. 5. Select dose as in the sequence above. 6. Press charge button on defibrillator and announce "Charging". 7. When fully charged, announce "All clear". 8. Confirm that team members are clear of the patient and bed and press the shock button or discharge buttons. 9. Resume CPR for 2 minutes and recheck rhythm.

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Routes of Access for Drugs

For effective treatment, medications are often required. In order of preference, the route of administration of drugs should be: Intravenous (IV): If a central line is already in place, use the central line. If a central line is not in place, insert a peripheral IV. Medications given in a peripheral IV should be followed by a 20 cc bolus of IV fluids to insure more rapid infusion into the central circulation. Raising the extremity may also help move the medication into the circulation. Intraosseus (IO): If an IV cannot be established, IO administration of medications and fluids is more effective than by ET tubes. Any medication can be administered via the IO route. Intraosseus access (IO) is an effective way to establish vascular access when it is not possible to quickly establish an IV. An IO infusion can be started in the proximal tibia, distal tibia, distal femur, or anterior superior iliac spine. IO access should NOT be attempted when there are fractures or crush injuries near the site, infection is apparent in the tissues over the site, or previous attempts have been tried in the same bone.

While an IO site is simple to establish, it must be monitored to ensure that the needle is not displaced. The site should be replaced with IV access as soon as possible after resuscitation. To establish IO access: Use universal precautions. Position the extremity and identify the insertion site. Disinfect the skin at the site. Use an IO needle with stylet in the needle during insertion. 5. Insert the needle using a firm pressure and a twisting motion. 6. Continue the firm pressure until a sudden decrease in resistance is felt; once in the bone, the needle should stand without support. 7. Remove the stylet and attach a syringe. 8. Aspirate bone marrow and blood to confirm placement. 9. If blood is aspirated, it may be sent to the lab for tests. 10. Infuse saline watching for signs of swelling at the site or on the other side of the insertion site. 11. Support the needle with gauze pads and tape the needle flange. 12. Attach the IV tubing to the needle and tape the tubing to the skin. 13. All IV medications can also be given via the IO route. 14. Flush all medications with a saline flush after administration. Endotracheal (ET): The least preferred method for drug administration is via the ET tube. When using this route, the typical dose should be 2 to 2.5 times the IV dose. In addition, only Lidocaine, epinephrine, atropine, and naloxone should be administered via the ET route. 1. 2. 3. 4.

Monitoring During CPR

The 2010 guidelines recommend the use of Quantitative Waveform Capnography to monitor the quality of CPR and ventilations. If the PETCO2 decreases to < 10 mm Hg, the team leader should direct the team member doing compressions to increase the depth and/or rate of compressions. If the PETCO2 stays < 10 mm Hg despite adequate CPR, the prognosis for return of spontaneous circulation (ROSC) is
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poor. If the PETCO2 increases to 35-40 mm Hg, this should be considered a return of spontaneous circulation. If central monitoring is in place, increased coronary perfusion pressure can be an indication of ROSC. The team should not interrupt CPR to insert a central line. If a central venous catheter is in place, arterial oxygen saturation can be measured. The normal range for SCVO2 is 60-80%. If arterial oxygen saturation falls below 30%, the team leader should direct the team member doing chest compressions to increase the rate and depth of the compressions.

Medications During Cardiac Arrest

Vasopressors (Epinephrine and Vasopressin) may improve the patient's chances for ROSC. A vasopressor should be given every 3-5 minutes during cardiac arrest. Antiarrhythmics, particularly amiodarone, may increase short term survival. If amiodarone is not available, lidocaine may be used. It is also the antiarrhythmic that can be used through an ET tube. For the patient with a pulseless persistent torsades de pointes, magnesium sulfate may be given with a loading does of 1-2 gram over 5-20 minutes. Magnesium should also be given in a case of known or suspected hypomagnesemia. See Unit 6 for additional information about these medications.

Post Cardiac Arrest Care Sequence

If the patient in cardiac arrest experiences ROSC, the care received after return of circulation may influence the ultimate patient outcome. This sequence includes: 1. Determine that ROSC has occurred. 2. Assure oxygenation and ventilation by starting at a breath every 5-6 seconds. If waveform capnography is available, titrate the oxygen and ventilation to a PETCO2 of 35-40 mm Hg. If capnography is not available, titrate oxygenation to an oxygen saturation >94%. 3. Monitor the patient's blood pressure and treat a systolic blood pressure < 90 mm Hg. If an IV is not in place, establish one. a. Give 1 to 2 liters of IV fluids (saline or lactated Ringer's solution) quickly. b. Give Epinephrine infusion to keep the SBP > 90 mmHg. c. May give Dopamine IV infusion d. May give norepinephrine in cases of extremely low SBP. 4. Evaluate the H's and T's for treatable causes: a. b. c. d. e. Hypovolemia Hypoxia Hydrogen Ion excess (Acidosis) Hypoglycemia Hypo or hyperkalemia
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f. g. h. i. j. k.

Hypothermia Tension Pneumothorax Tamponade (Cardiac) Toxins Thrombosis (coronary or pulmonary) Trauma

5. Evaluate the patient's level of consciousness. 6. If the patient does not follow commands, consider inducing hypothermia. 7. If the patient does follow commands, or after inducing hypothermia, obtain a 12 lead ECG to determine if ST segment elevation myocardial infarction (STEMI) or acute myocardial infarction (AMI) has occurred. 8. If STEMI or AMI is suspected, the patient should receive Percutaneous Coronary Intervention (PCI) to perfuse the coronary arteries. 9. When AMI is not suspected, or after PCI, the patient should be transferred to an Intensive Care Unit for advanced critical care.

When to Terminate Resuscitation

If the victim fails to respond to ACLS interventions, the team leader must consider terminating treatment. Factors to consider when making this decision include: Amount of time that elapsed before CPR and defibrillation occurred Any other diseases or conditions the patient might have If the patient has a Do Not Resuscitate order that is presented to the team Amount of time the resuscitation efforts last; studies show that prolonged efforts result in poor outcomes Policies and protocols in the healthcare facility.

Acute Coronary Syndromes (ACS)

Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from those for STsegment elevation myocardial infarction (STEMI) to presentations found in nonST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. Goals of therapy for ACS must include: Identification of patients with ST Elevation MI (STEMI) in order to facilitate early reperfusion Relief of chest pain Treatment of life-threatening complications including VF, VT and unstable tachyarrhythmias. Prevention of major adverse cardiac events (MACE)

ACS Sequence
1. Recognition of symptoms that suggest myocardial infarction a. Chest pain or pressure b. Possible radiation of pain to the jaw, shoulder, or arms c. Lightheadedness, sweating, nausea and vomiting d. Sudden shortness of breath
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2. Activation of EMS system a. Be prepared to provide CPR while supporting the ABCs b. Administer aspirin if the patient is not allergic and does not have a recent history of GI bleeding. c. Administer oxygen if the oxygen saturation is <94% or if the patient is short of breath. d. Obtain and transmit a 12 lead ECG if possible; notify the hospital if there is any ST elevation. e. Give the patient a nitroglycerin tablet every 3 to 5 minutes for ongoing pain AND if permitted by protocol. f. If pain is not controlled by nitroglycerin, give morphine (by protocol or order). 3. Emergency Department (ED) Assessment and treatment a. If an ECG was not obtained by EMS, perform a 12 lead ECG. b. Establish an IV if not done by EMS c. Give aspirin, nitroglycerin and morphine if not already done; monitor for hypotension. d. Continually monitor vital signs and oxygen saturation; if oxygen saturation is <94%, start oxygen at 2-4 L/minute and titrate e. Perform a brief assessment and complete the fibrinolytic checklist f. Draw baseline lab work g. Obtain portable chest x-ray. 4. Interpret the ECG and classify the ECG in one of three categories and provide treatment based on the ECG interpretation a. ST elevation MI (STEMI) i. If the time from the onset of symptoms is more than 12 hours, follow the NSTEMI sequence ii. If the time from onset of symptoms is less than 12 hours, begin protocol for reperfusion therapy. If PCI is not available within 90 minutes, consider use of fibrinolytic therapy for reperfusion. If PCI can be done within 90 minutes, that is the treatment of choice and fibrinolytics should be held. Minimize delays to definitive reperfusion therapy. iii. Adjunctive therapies including heparin, beta blockers and ACE inhibitors may be started if these therapies do not delay reperfusion treatment. b. Non ST elevation MI (NSTEMI) i. If troponin is elevated and patient has persistent ST depression, VT, hemodynamic instability or congestive heart failure, consider invasive strategies. ii. Adjunctive therapies including heparin, beta blockers and ACE inhibitors may be started. iii. Admit to a monitored bed. iv. Consider statin therapy c. Normal or nondiagnostic ECG -- Low risk for ACS i. Consider admission for serial troponin evaluation ii. If the patient has ECG changes or if the troponin is elevated indicating ischemia, follow the NSTEMI sequence. iii. If there are no abnormal imaging or physiological tests, discharge the patient with instructions for follow up.

Bradycardia
Bradycardia is any rhythm with a heart rate < 50 beats per minute. Symptomatic Bradycardia may include any of the symptoms in the following chart:
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Clinical System Airway Patency Respiratory Rate and Effort Systolic BP Heart Rate ECG Characteristics Peripheral Pulses Capillary Refill Skin Color and Temperature Level of Consciousness Usually unaffected

Sign or Symptom

Respiratory distress or failure Decreased Slower than normal for age and activity P wave may/may not be visible; QRS complex narrow or wide; P wave and QRS complex may not be related (AV Dissociation) Diminished or absent Increased time to pink after blanching Cool, Pale Decreased level of consciousness; Fatigue; Syncope; Lightheadedness
Figure 2: Signs & Symptoms of Bradycardia

As treatment proceeds for bradycardia, the team should attempt to identify and treat the underlying cause of bradycardia. Hypoxia Supplemental oxygen Acidosis Ventilation; consider sodium bicarbonate for severe metabolic acidosis Hyperkalemia Restore normal potassium Hypothermia Rewarm but avoid hyperthermia Heart block Consider atropine, chronotropic drugs, and external pacemaker. Toxins/Overdoses Supportive care and antidote specific to the drug or toxin Trauma Oxygenation and ventilation; bradycardia in head trauma must be treated aggressively to avoid increased ICP

When a patient is bradycardic with poor perfusion, the following sequence should be followed: 1. Attempt to identify and treat the underlying cause of the bradycardia (consider toxins, hypothermia, and increased intracranial pressure) but do NOT delay treatment of the bradycardia. 2. Establish the airway and assist breathing if necessary; hook the patient up to cardiac and blood pressure monitors and pulse oximetry if available. 3. Establish an IV or IO access. 4. If the patient is not hypotensive or exhibiting signs of shock, continue to support oxygenation and monitor the patient; obtain consults. 5. If the patient is hypotensive or exhibiting signs of shock, give Atropine 0.5 mg bolus; Repeat every 3-5 minutes to a maximum dose of 3 mg. a. If atropine is not effective, consider trancutaneous pacing while continuing to treat the cause b. OR- begin a Dopamine infusion at 2-10 mcg/kg/minute c. OR- begin an Epinephrine infusion at 2-10 mcg/kg/minute

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Stable and Unstable Tachycardia

Tachycardia is a faster than normal heart rhythm that can be tolerated but may deteriorate to shock or cardiac arrest. Tachycardia is usually classified as narrow complex (QRS < 0.12 seconds on ECG) or wide complex (QRS > 0.12 seconds on ECG). Sinus Tachycardia (ST) is a narrow complex tachycardia that is not considered an arrhythmia. Supraventricular Tachycardia (SVT) may be wide or narrow complex and originates above the ventricles. Ventricular Tachycardia (VT) is a wide complex tachycardia that must be treated aggressively since it can deteriorate to ventricular fibrillation and cardiac arrest. Clinical System Onset Atrial fib/flutter Gradual usually related to fever, pain, hemorrhage, or dehydration Usually unaffected Tachypneic SVT Abrupt with sudden onset of palpitations VT Abrupt onset and uncommon in children in absence of underlying heart disease Usually unaffected Tachypneic

Airway Patency Respiratory Rate and Effort

Usually unaffected Tachypneic with increased work of breathing; May be Crackles, Wheezing Hypotension Rate > 150/minute Not affected by activity QRS complex may be > or < 0.12 sec; P waves absent or abnormal; R-R may be constant

Systolic BP Heart Rate

Variable Rate <150/min Rate increases with activity QRS complex < 0.12 sec; P waves present & normal; PR constant; RR variable

Variable Usually, at least 120/min and regular QRS complex > 0.12 sec; P waves may not be identifiable; QRS complexes may be uniform or variable in appearance Weak Increased time to pink after blanching Cool, pale Decreased level of consciousness; Fatigue; Syncope; Lightheadedness

ECG Characteristics

Peripheral Pulses Capillary Refill Skin Color and Temperature Level of Consciousness

Normal Normal Cool, Pale Fatigue; Syncope; Lightheadedness

Weak Increased time to pink after blanching Diaphoretic, cool, pale, mottled, gray or cyanotic Decreased level of consciousness; Fatigue; Syncope; Lightheadedness

Figure 3: Signs and Symptoms of Tachycardia

Interventions designed specifically for emergency management of tachycardia include:

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Vagal Maneuvers Vagal maneuvers may help slow the patients heart rate. If the victim can cooperate, instruct him to blow through a partially occluded straw; for an adult who cannot cooperate, apply an ice bag to the top half of the patients face for 15 to 20 seconds. Carotid massage can also be used. Synchronized cardioversion In order to perform synchronized cardioversion, the defibrillator must have a synchronized mode. o Apply the pads. o Switch the defibrillator to synchronized mode. o Select the appropriate dose. o Charge the defibrillator. o Clear the patient and bed o Press the shock buttons and hold the paddle in place until the shock is delivered. o If tachycardia does not resolve, increase the dose, check that the synchronized mode is still selected, and prepare to cardiovert again. Prepare to give medications (Refer to Unit Six for specifics about medications) o Adenosine o Amiodarone o Procainamide

Tachycardia Sequence
When the cardiac monitor indicates that the patient is in tachycardia follow the Tachycardia sequence: 1. Throughout these steps, attempt to identify and treat the underlying cause of the tachycardia. 2. Monitor the EKG and blood pressure; ensure adequate oxygenation. 3. Determine if the tachycardia is stable or unstable. Unstable tachycardia will cause hypotension, altered level of consciousness, symptoms of shock or chest pain. 4. If the patient has unstable tachycardia, perform synchronized cardioversion: a. If the QRS is narrow and regular, use 50-100 Joules. b. If the QRS is narrow and irregular, use 120-200 Joules. c. If the QRS is wide and regular, use 100 Joules. d. If the QRS is wide and irregular, turn off the synchronized mode and defibrillate. 5. If the patient is stable, measure the QRS interval on the EKG. 6. If the QRS interval is prolonged (>0.12 seconds), go to Step 11. 7. If the QRS interval is normal ( 0.12 seconds), consider performing vagal maneuvers (see previous section on vagal maneuvers). 8. Establish an IV or IO access for fluid and medication administration. 9. Consider giving Adenosine 6 mg bolus; may give a second dose of 12 mg if needed. 10. If Adenosine is not effective, consider giving Procainamide 20-50 mg to a maximum dose of 17 mg/kg with a maintenance infusion of 1-4 mg/minutes OR Amiodarone 150 mg over 10 minutes with second dose for recurrent VT followed by infusion of 1 mg/min. 11. If the QRS interval is prolonged (>0.12 seconds), consider adenosine if the QRS intervals are regular. 12. Consider an antiarrhythmic infusion.

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Acute Stroke
An acute stroke can have many causes; recent studies indicate that, although there may be arrhythmias with stroke, most of these do not require treatment as long as the patient is stable hemodynamically. Strokes can be categorized as ischemic or hemorrhagic. Ischemic stroke is caused by occlusion of an artery in the brain; hemorrhagic stroke occurs when there is bleeding into the brain from a ruptured blood vessel. Fibrinolytic therapy can be used for ischemic stroke IF the patient gets treatment within 3 hours of symptom onset. The goal of stroke care is to minimize brain injury. As with cardiac arrest, there is also a chain of survival for stroke.

Recognition of Stroke (Detection)

Activation of EMS (Dispatch)

Rapid transport to Care (Delivery, Door)

Rapid Diagnosis and Treatment (Data, Decision, Drug, Disposition)

Figure 4: Stroke Chain of Survival

This chain of survival can be amplified by the 8 D's of stroke care: Detection, Dispatch, Delivery, Door, Data, Decision, Drug, and Disposition). The National Institute of Neurological Disorders and Stroke (NINDS) have established a timeline for stroke care in the hospital. This timeline optimizes the Time is Brain" goal:

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Assessment by the Stroke Team within 10 minutes of arrival

Results of the CT scan within 45 minutes of arrival

Admitted within 3 hours of arrival

CT scan without contrast performed within 25 minutes of arrival

Fibrinolytic therapy started within 60 minutes of arrival

Figure 5: Timeline for ED Treatment of Stroke

Suspected Stroke Sequence

The stroke sequence is critical in providing rapid assessment and treatment to minimize disability: 1. Identify signs of stroke by the public a. Sudden weakness of the face or one side of the body b. Sudden confusion c. Garbled speech d. Sudden trouble seeing out of one or both eyes e. Trouble walking with loss of balance or decreased coordination f. Sudden severe headache 2. After identification of possible stroke, activate Emergency Response system. 3. EMS Assessment and Treatments a. EMS should do a rapid stroke assessment i. Facial droop -- When patient smiles, one side of face does not move ii. Arm drift -- When extending arms with palms up, one arm does not move or drifts down iii. Speech -- Speech slurred or incomprehensible or inappropriate words or mute. b. Support the ABCs to keep oxygen saturation > 94% c. Attempt to determine when the last time was that the patient appeared to be normal d. Alert the hospital that a possible stroke victim is on the way to the hospital. 4. Transport to Emergency Department. If possible the patient should be transported to a hospital with a stroke center. During transport, check the patient's glucose. 5. Assessment and stabilization in the ED a. Monitor the ABCs and assess vital signs. b. Administer oxygen to keep oxygen saturation > 94%. c. Start an IV and do baseline lab exams. d. Treat hypoglycemia with glucose. e. Conduct a neurological exam. f. Arrange consultation with the stroke team -- know the facility protocols for activation of the stroke team. g. Order a CT scan of the brain - do not delay the CT scan for other tests. h. Obtain an ECG and monitor cardiac rhythms for at least the first 24 hours.
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6. Neurological assessment by the stroke team - The stroke team will do a more in-depth neurological exam (such as the National Institutes of Health Stroke Scale). 7. Interpret CT scan - Do not give any anticoagulants until hemorrhagic stroke is ruled out. a. If the CT scan shows a hemorrhage, consult a neurosurgeon and admit to a stroke unit. b. If the CT scan shows an ischemic stroke, the stroke team will review the criteria for fibrinolytic therapy: i. Patient age > 18 years ii. Diagnosis = ischemic stroke with neurological deficit iii. Onset of symptoms < 3 hours in past iv. No exclusion criteria identified: 1. Previous stroke or head trauma in last 3 months 2. Subarachnoid hemorrhage 3. Blood glucose < 50 mg/dL 4. Acute bleeding disorders or diathesis 5. Active bleeding at time of examination 6. Hypertension with SBP>185 mm Hg or DBP > 110 mm Hg. v. Risk /Benefit ratio should be evaluated if patient has seizures, a major serious within the past 2 weeks, GI bleed within the last 3 weeks, or AMI within the last 3 months. c. If the patient is NOT a candidate for fibrinolytic therapy, give aspirin and admit to the stroke unit. d. If the patient IS a candidate for fibrinolytic therapy, the stroke team will discuss risks and benefits with the patient's family. 8. Administer fibrinolytic therapy according to facility protocol. 9. Provide general post rtPA stroke care. a. Admit patient to stroke unit b. Support ABCs c. Monitor vital signs d. Monitor blood glucose and give insulin to keep blood glucose < 185 mg/dL e. Monitor for complications of rtPA administration

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Unit Six: Pharmacology in Resuscitation

Since medications change rapidly, it is recommended that current drugs, doses and indications be verified and that a qualified medical professional be in charge of ordering all medications in a resuscitation effort. All team members should be familiar with indications and doses for the most commonly used medications.
Drug Adenosine Classification Antiarrhythmic Indications SVT Dose/Administration 1st dose = 6 mg rapid IV push followed by saline bolus 2nd dose = 12 mg rapid IV push in 1-2 minutes Possible Side effects Dizziness, headache, metallic taste, dyspnea, hypotension, bradycardia, palpitations, nausea, flushing, sweating; do not use in 2nd or 3rd degree heart block Headache; dizziness; tremors; ataxia; syncope; significant hypotension; bradycardia; CHF; torsades de pointes; nausea, vomiting, diarrhea; rash; skin discoloration; hair loss; flushing; coagulation abnormalities Headache; dizziness; confusion; anxiety; flushing; blurred vision; photophobia; pupil dilation; dry mouth; tachycardia; hypotension; hypertension; nausea; vomiting; constipation; urinary retention; painful urination; rash; dry skin Headache; dyspnea; palpitations; PVCs; SVT; VT; nausea/vomiting; acute renal failure Considerations Cardiac monitoring during administration; administer through central line if available; flush with saline following administration: must be given very rapidly

Amiodarone

Antiarrhythmic

Unstable VT with pulses; VF; VT without pulse and unresponsive to shock

300 mg rapid bolus with 2nd dose of 150 mg if necessary to a maximum of 2.2 grams over 24 hours

Monitor ECG and blood pressure Use with caution in patients with a perfusing rhythm, hepatic failure. Contraindicated for 2nd or 3rd degree heart block

Atropine

Anticholinergic

Symptomatic bradycardia; toxins and overdoses

Bradycardia: 0.5 mg IV every 3-5 minutes with 3 mg max dose; May be given by ETT Toxins/overdose: 2-4 mg may be needed until symptoms reverse

Monitor ECG, oxygen, and BP; Administer before intubation if bradycardia is present; Contraindicated in glaucoma and tachyarrhythmias; Do not give doses less than 0.5mg since this may result in slowing of heart rate

Dopamine

Catecholamine Vasopressor, Inotrope

May be given for bradycardia after Atropine; May be used for SBP < 100mm Hg with signs of shock

2 to 20 mcg/kg per minute infusion titrated to response

Monitor ECG and BP If hypovolemic, give fluid boluses first; Avoid high infusion rates; Do not mix in alkaline solutions or with sodium bicarbonate

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Epinephrine

Catecholamine Vasopressor, Inotrope

Cardiac arrest Anaphylaxis with fluids and antihistamines; Symptomatic bradycardia after atropine; Shock when pacing and atropine do not work;

Cardiac arrest: 1.0 mg (1:10000) IV or 22.5 mg (1:1000) per ETT every 3 to 5 minutes; follow with 0.1-0.5 mcg/kg/min infusion titrated to response Symptomatic bradycardia or shock: 2-10 mcg/minute infusion titrated to response

Tremors; anxiety; headaches; dizziness; confusion; hallucinations; dyspnea; SVT; VT; palpitations; chest pain; hypertension; nausea; vomiting; hyperglycemia; hypokalemia; vasoconstriction

Available in 1:1000 and 1:10000 concentrations so the team must be aware of which concentration is being used. Monitor BP, oxygen, and ECG Administer via central line if possible; tissue necrosis may occur if IV infiltrates Do not give in cocaine induced VT

Drug Lidocaine

Classification Antiarrhythmic

Indications Cardiac arrest from VF or VT Wide complex tachycardia

Dose/Administration Cardiac Arrest: 1-1.5 mg/kg IV bolus; may repeat twice at half dose in 5-10 minutes to total of 3mg/kg; followed with infusion of 1-4 mg per minute infusion Wide complex tachycardia with pulse: 0.5-1.5 mg/kg IV; may repeat twice at half dose in 5-10 minutes to total of 3mg/kg; followed with infusion of 1-4 mg per minute infusion

Possible Side effects Seizures; headache; dizziness; tremor; drowsiness; tinnitus; blurred vision; hypotension; heart block; bradycardia; dyspnea; respiratory depression; nausea, vomiting; rash

Considerations Monitor ECG and BP May cause seizures Contraindicated for wide complex bradycardia; Should not be used prophylactically in acute MI

Magnesium Sulfate

Electrolyte; bronchodilator

Torsades de pointes; Hypo magnesemia; Digitoxicity

Cardiac arrest due to hypomagnesemia or Torsades: 1-2 gram IV bolus Torsades with a pulse: 1-2 gram IV over 5-60 minutes followed by infusion at 0.5-1 gram per hour IV

Confusion; sedation; weakness; respiratory depression; hypotension; heart block; bradycardia; cardiac arrest; nausea vomiting; muscle cramps; flushing; sweating Fever; vertigo; arrhythmia; chest pain; hypertension; nausea, vomiting; abdominal cramps; urticaria

Monitor ECG, oxygen and BP Rapid bolus may cause hypotension and bradycardia Calcium chloride can be used if needed to reverse hypermagnesemia

Vasopressin

Antidiuretic hormone analogue

As alternative to epinephrine for VF/asystole/PEA Shock

Cardiac arrest: 40 units IV as replacement for 2nd or 3rd dose of epinephrine Shock: IV infusion of

Monitor BP and distal pulses; watch for signs of water intoxication; tissue necrosis may develop from IV extravasation

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0.02-0.04 units/minute Oxygen Elemental gas Hypoxia; Respiratory distress or failure; shock; trauma; cardiac arrest In resuscitation, administer at 100% via high flow system and titrate to response to maintain oxygen saturation > 94% Headache; dry nose, mouth; airway obstruction if secretions become dry Monitor oxygen saturation; Insufficient flow rates may cause carbon dioxide retention

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Rhythm Recognition
Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Rhythm with 1st Degree Heart Block

2nd Degree Heart Block

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3rd Degree Heart Block

Supraventricular Tachycardia (SVT)

Atrial Fibrillation

Atrial Flutter

Ventricular Tachycardia (VT)

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Ventricular Fibrillation (VF)

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