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CORE ACLS

CONCEPTS
08/23/18
Core ACLS Concepts
 “The chain of survival” has 4 links applied to
all CPR settings (hospital, ER (A&E), ICU,
CCU, or community)

Early Early Early Early

Access CPR Defibrillation Advanced


care
Advanced
Cardiovascular/Cardiac Life
Support

 Is a training program that generally


aims to develop the knowledge and
skills of health care providers as
they make effective use of
themselves when assisting in a
code situation.
Definition of Terms:

 ACLS – Iincludes the knowledge and


skills necessary to provide the
appropriate early treatment for
cardiopulmonary current which
reduces BLS and use of adjunctive
equipment and special technique to
establish and maintain ventilation and
circulation.
Terminologies

 Cardioversion - The discharge of electrical energy


synchronized on the R wave of the
electrocardiogram.
 Defibrillation - use of unsynchronized electrical
energy for revision of cardiac arrhythmias.
 Algorithm – sets of step-by-step procedure
guides to assist caregivers in making informed
decisions regarding the diagnosis and treatment
of disease.
 ECC – (Emergency Cardiac Care) includes all
responses necessary to deal with sudden and
often life threatening events affecting the
cardiovascular and pulmonary system.
 Megacode - situation wherein the algorithm will
be applied and an individual will be tested on his
ability to recite the exact sequences of an
algorithm.
 Resuscitation (Code Red)
 General Policy:
 The Cardiac Code team’s goals are to preserve
life, restore health, relieve suffering and limit
disability. These goals shall be carried out
promptly with patient safety foremost in the
mind.
A team is composed of :
1. Person for chest compression
2. Ventilator
3. Person to insert IV lined and will administer
medications.
4. Person to monitor the cardiac and will do the
defibrillation .
5. Recorder
 Role of the Nurses:
1.Prepares and set-up all equipments necessary for resuscitation.
2. Regular checking of E-cart (every shift before
receiving the endorsement)
3.Document Checklist
4,Location of E-cart
5.Administer assist BLS measure
6.Carries out Doctor’s order and record the chronological event
using the CPR Record Form
.7. Arranges all matters pertinent to the ad
mission and transfer of patient when
necessary
8.Arranges all matters pertinent to the
discharge of patient(expired patient)
9. Autopsy, DOA, HAMA
10. REPLENISHES AND CHARGES ALL ITEMS
USED
 GENERAL GUIDELINES FOR ALL TEAMS
 Maintain quiet, orderly and professional
environment
 Patient should be automatically hooked to
EKG, cardiac monitor,defibrillator and pulse
oximeter
 State vital signs every 5 minutes / PRN
 State each medication given
 Document
 GENERAL GUIDELINES FOR ALL TEAMS
 Maintain quiet, orderly and professional
environment
 Patient should be automatically hooked to
EKG, cardiac monitordefibrillator and pulse
oximeter
 State vital signs every 5 minutes of PRN
 State each medication given
 Document
 Request clarification of any order if not
clearly understood
 Limit traffic
 Comfort relatives and advise to stay
outside the room
 EQUIPMENT
 E-cart
 Pulse oximeter
 Cardiac monitor with defibrillator
 Ambu-bag
DOCUMENTATION
CPR Record Form
Nurse fills up the data and activities
Team leader documents the CPR outcome
 The algorithm Approach Emergency Cardiac
Care(ECC)

 The following clinical recomendations apply


to all treament algorithms
 First, treat the patient not the monitor.
 Algorithms for cardiac arrest presume that the
condition under discussion continually
persists, that the patient remains in cardiac
arrest, and that CPR is always perform.
 Apply different interventions whenever appropriate
indications exist.
 The flow diagrams present mostly
 Class I(acceptable, definitely
effective)recomendations.
 The footnotes present Class IIa(acceptable, probably
effective),
 band Class Iib (acceptable, possibly effective), and
 Class III (not indicated, may be harmful)
recomendations.
 Adequate oxygenation,airway, ventilation,.
Chest compressions, and defibrillation are more
important than administration of medications
and takes precedence over initiating an
intravenous line or ejecting pharmacologic
agents.
 Several medications (epinephrine. Lidocaine,
and atropine) can be administered via the
endotracheal tube but the dose must be 2 – 2.5
times the intravenous dose. (use a catheter or
suction tip which be passed beyond the tip of the
endoctracheal tube.)
 With a few exceptions, intravenous
medications should always be administered
rapidly, in bolus method.
 After each intravenous medication, give a 20-
30 ml bolus of intraveus fluid and
immediately elevate the extremity. This will
enhance the delivery of drugs to the central
circulation, which may take 1-2 minutes.
 Last, treat the patient, not the monitor.
Core ACLS Concepts

 The Most Important Goal : > Cerebral


resuscitation
 The Patients :
 For Many >> Their hearts should be too good to die.
 For Some >> The last heartbeat should be the last.

Treat the patient, not the monitor


Cardio-pulmonary-cerebral resuscitation
 Primary purpose : to return the
patient to his/her best possible
neurological outcome.
Arrythmia Recognition
 Important in any ACLS/ CPR sequence
 All algorithms start with identifying rhythm
 Cannot identify arrhytthmais- cannot mange
corrrectly
The Beating Heart –
Electrophysiology
Electrical Stimulation &
Contraction
BEFORE THE HEART CONTRACTS

IT MUST BE ELECTRICALLY STIMULATED

DEPOLARIZATION
 Pacemaker impulses are initiated in
the SA node, travelling through
atrial pathways, at frequencies
between 60-100bpm
 There is the presence of a P wave,
followed by a QRS complex at a
regular rate
Normal Sinus Rhythm

Look at the P waves ;


 rate is 60-100/min
 Cycle length do not vary by 10%
 PR interval is 0.12 – 0.20sec.
During ACLS/BLS:

• Patient is hooked to cardiac monitor/ defibrillator


•Patient’s heart rate is automatically detected
•Normal HR = 60 to 100 bpm
MANAGEMENT:
A. No specific drug treatment
B. Identification of cause
C. Treatment of underlying cause
D. Check hemodynamics
 Characterized by tachycardia with a narrow
QRS complex
 Sudden onset and termination
 150-250 beats/min (180-200 bpm in adults)
 Regular rhythm
 QRS complex is normal in contour and
duration
 No P waves
•P waves are generally buried in the QRS complex
•Often, P wave is seen just prior to or just after the end of the
QRS and cause a subtle alteration in the QRS complex that
results in pseudo- s or pseudo - r
A. Cardiovert the patient!
B. Defibrillate the
patient!
C. Give Verapamil!
D. Check hemodynamics
 Prematurely occurring complex
 Wide, bizarre looking QRS complex
 Usually no preceding P waves
 T wave opposite in deflection to the QRS
complex
 Complete compensatory pause following every
premature beat
 Before starting any resuscitative effort,
the minimum personal protective
equipment should include:
 Gloves
 Face mask
 Goggles
 Splash gown
• Adult (1 to 2L) bag and the provider should
deliver approximately 600 ml of tidal volume
sufficient to produce chest rise over 1 second
•Open the airway adequately with a head tilt-
chin lift, lifting the jaw against the mask and
holding the mask against the face, creating a
tight seal
•During CPR give 2 breaths (each 1 second)
during a brief ( about 3 to 4 seconds) pause
after every 30 chest compressions.
 Use of 100% inspired oxygen (FiO2 1.0) as
soon as it becomes available is reasonable
during resuscitation from cardiac arrest
(Class IIa, LOE C)

 Titrate oxygen administration to achieve


arterial oxyhemoglobin saturation > 94%
 To facilitate delivery of ventilations with a
bag-mask device, the nasopharyngeal
airway can be used in patients with a
compromised airway
 In the presence of known or suspected
basal skull fracture or severe coagulopathy,
an oral airway is preffered (Class II a, LOE C)
ADVANTAGES
 Keeps airway patent
 Permits suctioning of airway secretions
 Enables delivery of a high concentration oxygen
 Provides an alternative route for administration of some
drugs
 Facilitates delivery of a selected tidal volume
 With use of a cuff, may protect the airway from
aspiration
 Epinephrine
 Lidocaine
 Vasopressin
 Endotracheal intubation is frequently
associated with interruption of
compressions for many seconds
 Placement of a supraglottic airway is a
reasonable alternative to endotracheal
intubation and can be done successfully
without interrupting chest
compressionsa
 Rescuer should record the depth of the
tube as marked at the front of the teeth
and secure it.
 Providers should verify correct
placement of all advanced airways after
insertion and whenever the patient is
moved.
VENTILATION
 Chest x-ray
Rationale: Confirm secure
airway and detect causes or
complications of arrest:
pneumonitis, pneumonia,
pulmonary edema.
VENTILATION
 After ROSC, routine hyperventilation
leading to hypocapnia should be avoided to
prevent additional cerebral ischemia.
CONTROLLED OXYGENATION
 There is insufficient evidence to support or
refute the use of titrated inspired oxygen
content in the early care of cardiac arrest
patients following sustained ROSC
VENTILATION
 Mechanical Ventilation
o Rationale: Minimize acute lung injury,
potential oxygen toxicity
o Tidal volume – 6 – 9ml/kg
o Titrate minute ventilation to
- PETCO2 – 35- 40 mm Hg
- PaCO2 – 40- 45 mm Hg
o Reduce FiO2 as tolerated to keep SpO2 or
SaO2 > 94%
ELECTRICAL THERAPIES
DEFIBRILLATION & CARDIAC PACING

PHA Council on CPR


Electrical Therapies
 Defibrillation
 Cardioversion
 Cardiac Pacing
Key Challenges (2010
Guidelines)
 Improve time for Defibrillator
Availability
- Immediate AED availability
- Improve response time and
training
 Decrease interruptions in chest
compressions pre and post
shocks
DEFIBRILLATION
 Is the therapeutic use of electric current
delivered in large amounts over very brief
periods of time.
 Temporarily “stuns” an irregularly beating
heart and allows more coordinated
contractile activity to resume.
 Termination of VF for at least 5 seconds
follwing the shock.
AUTOMATED EXTERNAL
DEFIBRILLATORS
 Sophisticated, reliable computerized devices
that use voice and visual prompts to guide lay
rescuers and health care providers to safely
defibrillate VF SCA
 Recorded information about frequency and depth
of chest compressions during CPR.
BIPHASIC WAVE FORM
DEFIBRILLATORS
 Defibrillation with biphasic waveforms
uses relatively low energy ( < 200 J ) that is
safe and has equivalent or higher efficacy
for termination of VF than monophasic
waveform shocks (class llb)
SYNCHRONIZED CARDIOVERSION

 Synchronization avoids shock delivery


during the relative refractory portion of
the cardiac cycle, when a shock could
produce VF.
 The energy (shock dose) used for a
synchronized shock is lower than that
used for unsynchronized shocks
(defibrillation)
CARDIAC PACING
 Deliver an electric stimulus through
electrodes to the heart causing
electrical depolarizations and
subsequent cardiac contraction
INTRAVENOUS ACCESS
PERIPHERAL IV SITE
Administer drugs by Bolus

20cc of saline or distilled


water

Elevate the extremity for


10-20 seconds
Tracheal Drug
Administration
 NAVEL (Naloxone, Atropine,
Vasopressin, Epinephrine, Lidocaine)
 Administer 2 to 2.5 times the
recommended IV dose diluted in 10ml
NSS or distilled water
ACLS DRUGS

Agents used to Optimize Agents used to treat


Arrhythmias
Cardiac Output and blood pressure

Cardiac Arrest Shock Heart Failure/ Tachycardia Bradycardia


Pulmonary Edema, Misc;
buffers
MONOPHASIC WAVE FORM
DEFIBRILLATORS
 Deliver current of one polarity
 Monophasic damped sinusoidal waveforms
(MDS) returns to zero gradually, whereas the
Monophasic truncated exponential waveform
current is abruptly returned to baseline to zero
current flow.
 Initial shock is 360J and if VF persists, the
subsequent shocks should be 360J
Time Sequence &
Estimated Probability of Survival
Eisenberge,
Eisenberge,et
etalal1990
1990

Time(min) 2 4 6 8 10
CPR Team & Organization
BLS & ACLS
Training &
Retraining,
CPR Code
Organization,
Performance
Evaluation &
Peers Review
Core ACLS Concepts

Classification of Therapeutic Interventions


in CPR & ECC
 Class I : acceptable, definitely effective
 Class II : acceptable, uncertain efficacy
II a > probably effective
II b > possibly effective & not harmful
 Class III : inappropriate & may be
harmful
The Algorithm Approach
in ACLS & ECC
 Treat the patient, not the monitor

 Continue CPR (include defibrillation) is more


important than the
procedure and pharmacologic agents
 Flow diagrams: mostly class I,
footnotes: class IIa, IIb, or III
 Most ACLS medications(but few exceptions)
should be given as iv. bolus
 “2nd Syringe Technique” for 20-30 ml. iv. bolus
after each iv. medications
 Epinephrine, lidocaine, atropine, etc can be given
via ET tube at 2-2.5 times of iv. Route
Learn and practice the most difficult
resuscitation skills*:
 when not to start CPR
 when to stop CPR
 how to tell the family members
 how to talk with your colleagues
Even though it’s the most difficult, but
it’s more important & more challenging!