Workshop: ACLS Challenge Course

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1 Workshop: ACLS Challenge Course Brian V. McCambley, MPAS, PA-C (Moderator); Jennifer Krueger, PA-C 3/21/2010 8:00 AM - 11:00 AM

2 ACLS RECERTIFICATION SEMPA TUCSON MARCH

3 ACLS FAST TRACKED PRESENTED BY: BRIAN McCAMBLEY, MPAS, PA C DANBURY HOSPITAL BLS/ACLS/PALS/ACLS EP FACULTY EMERGENCY MEDICINE/HOSPITALIST SERVICE DANBURY, CT SEMPA PRESIDENT ELECT AND EVERY GREAT MAGICIAN NEEDS AN ASSISTANT... JENNIFER KRUEGER, MBA, PA C SEMPA CME/CONFERENCE CHAIR SEMPA PRESIDENT EMERGENCY MEDICINE MISSOULA, MT 2

4 OBJECTIVES IDENTIFY CHANGES TO AHA 2005 ACLS GUIDELINES IDEN TIFY/UTILIZE PROPER ACLS MEDICATIONS WITH UPDATED DOSING RHYTHM RECOGNITION AND EMPLOYING PROPER ALGORITHMIC PATHWAY UTILIZE SYSTEMATIC APPROACH TO ADULT CARDIORESPIRATORY EMERGENCIES RECERT COURSE FORMAT BRIEF OVERVIEW OF AHA BLS/ACLS CHANGES MEDICATION REVIEW ALGORITHMIC REVIEW PRACTICAL/HANDS ON AND TESTING 3

5 AMERICAN HEART THE CHANGES... IN 2005, AHA MADE SEVERAL CHANGES TO THE CURRENT ACLS PROTOCOLS MANY OF THEM SURRENDER THE IDEAS OF ADVANCED TECHNIQUES, AND GO BACK TO BASICS BLS BEFORE ACLS.COMING FULL CIRCLE 4

6 WHAT HASN T CHANGED A B C s.first AIRWAY BREATHING CIRCULATION THE KEYS TO SUCCESS THE CHANGES.. BLS FIRST... 5

7 PRESS HARD PRESS FAST CPR..CPR CPR BLS...WHAT S NEW BLS SKILLS HAVE BECOME MAJOR FOCUS ; GOOD CPR COMPRESSION RATE TO BREATHS NOW 30:2 FOR ADULTS AND ALL, ACROSS THE BOARD (15:2 CHILD, INFANT WITH 2 RESC.) CPR IN 2 MINUTE CYCLES; 5 TOTAL CYCLES OF CPR 6

8 TIME ADVANCE SKILLS; (IE: MEDS, DEFIB, ETC.) AT 2 MINUTE MARK, OR 5 TOTAL CPR CYCLES PULSE CHECK SHOULD NOT TAKE MORE THAN 5 10 SEC; IF NO PULSE PALPABLE, ASSUME NO PULSE AND BEGIN CPR!! MINIMAL INTERRUPTIONS FOR CPR 7

9 LONE HEALTHCARE PROVIDERS SHOULD TAILOR INTIAL THERAPY TO LIKELY CAUSE OF ARREST; CARDIAC vs. PULMONARY IF SUDDEN WITNESSED COLLAPSE, 2 MINUTES OF CPR FIRST, (5 CYCLES), THAN CALL FOR HELP AVOID EXCESSIVE VENTILATION; MAY BE HARMFUL CHEST COMPRESSIONS FOR INFANT/CHILD WITH HEART RATE LESS THAN 60, AND SIGNS OF POOR PERFUSION COMPRESSIONS WITH ADEQUATE RATE AND DEPTH, AND ALLOW CHEST RECOIL WITH MINIMAL INTERRUPTIONS IN CHEST COMPRESSIONS AS THE KEY 8

10 USE 1 OR 2 HANDS FOR CHILD CPR; INFANT SHOULD USE THUMB ENCIRCLING CHEST METHOD INFANT/CHILDREN COMPRESSION TO VENT RATE, 15:2 ACROSS ALL AGES WITH 2 RESC; O/W SAME 30:2 ONCE ADVANCE AIRWAY IN PLACE, NO LONGER CYCLES OF COMPRESSIONS WITH PAUSE FOR VENTILATION; 8 10 BREATHS/MIN. 9

11 ACLS..THE UPDATES WHAT S NEW IN 2005 AND BEYOND. 10

12 ACLS ADVANCE SKILLS EMPHASIS ON HIGH QUALITY CPR ET INTUBATION/ADVANCE AIRWAYS LIMITED TO PROVIDERS WITH ADEQUATE TRAINING; LMA, COMBITUBE USE CONFIRM ET INTUBATION WITH CLINICAL ASSESSMENT AND NOW ALSO PRIMARY CONFIRMATION ESOPH BULB, CO2 DETECTION; NOW PRIMARY, NOT SECONDARY THE SPECIFIC ALGORITHMIC CHANGES FROM SINUS TO TACHY AND ALL IN BETWEEN. 11

13 PULSELESS ARREST NOW CHANGED TO INCLUDE V FIB, PULSELESS V TACH, ASYSTOLE, AND PEA PRIORITY IS GOOD BLS SKILLS; CHEST COMPRESSIONS, VENTILATIONS ADVANCED AIRWAY NOT A HIGH PRIORITY ORGANIZE CARE TO PROVIDE MINIMAL INTERRUPTIONS IN CHEST COMPRESSIONS FOR RHYTHM CHECK, SHOCK DELIVERY, VASCULAR ACCESS, AND ADVANCE AIRWAY INSERTION IV/IO ACCESS IS PREFERRED ROUTE FOR MED ADMINISTRATION (OVER ET) 12

14 V FIB/PULSELESS V TACH WOW THIS PERSON S REALLY SICK. 13

15 1 SHOCK DELIVERED FOR DEFIB; AT HIGHEST ENERY; 360 J MONOPHASIC, J BIPHASIC; NO LONGER 3 STACKED SHOCKS COMPRESSIONS ONLY INTERRUPTED FOR RHYTHM CHECKS AND DEFIB; COMP CONT D WHILE DEFIB CHARGING NO PULSE CHECK AFTER DEFIB NO RHYTHM CHECK AFTER DEFIB; CPR RIGHT AWAY, 2 MINUTES OR 5 CYCLES, THAN CHECK DRUGS DELIVERED DURING CPR ASAP AFTER RHYTHM CHECKS 14

16 VF/VT PERSISTENT, (AFTER INITIAL DEFIB), VASOPRESSOR OR ANTIARRHYTHMIC DELIVERED ASAP AFTER RHYTHM CHECK VASOPRESSORS ARE ADMINISTERED WHEN AN IV/IO LINE IS IN PLACE; AFTER VF/VT PERSISTENT AFTER 1 ST OR 2 ND SHOCK; USE OF EPI OR VASOPRESSIN EPI EVERY 3 5 MINUTES CONT D; SINGLE DOSE OF VASOPRESSIN MAY BE GIVEN TO REPLACE 1 ST OR 2 ND EPI DOSE ANTIARRYTHMICS MAY BE CONSIDERED AFTER 1 ST DOSE OF VASOPRESSORS AMIODARONE PREFERRED TO LIDOCAINE, BUT EITHER IS ACCEPTABLE 15

17 ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY...WHERE FLAT IS NO GOOD 16

18 ASYSTOLE/PEA EPI ADMINISTERED EVERY 3 5 MINUTES; AGAIN VASOPRESSIN CAN BE SUBSTITUTED TREATMENT OF SYMPTOMATIC BRADY; ATROPINE DOSING NOW 0.5 MG IV/IO, TO TOTAL DOSE OF 3MG, OR 0.04 MG/KG MEDICATION/RHYTHM.. ASYSTOLE/PEA EPINEPHRINE VASOPRESSIN +/ ATROPINE BRADYCARDIA KEY SX S OR NOT ATROPINE TCP PACINGPACING 17

19 MEDS/RHYTHM, CONT D V TACH, STABLE AMIODARONE LIDOCAINE MAGNESIUM SULFATE, TORSADES VT, UNSTABLE CARDIOVERSION SAME MEDS AS STABLE MEDS/RHYTHM, CONT D STABLE TACHY ADENOSINE CA BLOCKERS B BLOCKERS AMIODARONE LIDOCAINE +/ CARDIOVERSION COMMON. 02 MONITORING VS IV THERAPY.. IDENTIFY BEFORE..BETTER FOR PT. 18

20 TAKE HOME POINTS... CPR, CPR, CPR.BLS BEFORE ACLS SKILLS BVM S ARE JUST AS EFFECTIVE AS ET TUBES IN THE RIGHT HANDS PRACTICE MAKES PERFECT.OR NEAR PERFECT AVOID HYPERTHERMIA FOR ALL PTS AFTER RESUSCITATION; INDUCED HYPOTHERMIA MAY BE OPTION IN SOME CLINICAL SITUATIONS PEA..GOAL TO REVERS, SEARCH FOR CAUSE, THE 5 H S AND 5 T S DON T CODE JULY 1 ST ESPECIALLY IN TEACHING HOSPITALS.. 19

21 AHA STROKE DEVELOPMENT OF STROKE CENTERS; EXCELLENCE IN STROKE CARE TPA IF MEET CRITERIA, AND WITHIN 3 HOUR WINDOW; PRE HOSPT CREWS TRAINED IN RECOGNITION OF STROKE SX S PTS WHO MEET STROKE CRITERIA 20

22 QUESTIONS, COMMENTS, CONCERNS, OBJECTIONS????? 21

23 Workshop: PALS Challenge Course Brian V. McCambley, MPAS, PA-C (Moderator); Jennifer Krueger, PA-C 3/21/ :30 AM - 2:30 PM

24 PALS.FAST TRACKED NEW AND IMPROVED 22

25 PALS...THE RECERT PRESENTED BY: BRIAN McCAMBLEY, MPAS, PA C DANBURY HOSPITAL BLS/ACLS/PALS/ACLS EP FACULTY EMERGENCY MEDICINE/HOSPITALIST SERVICE DANBURY, CT SEMPA SECRETARY TREASURER 23

26 ASSISTED BY... JENNIFER KRUEGER, MBA, PA C SEMPA CME/CONFERENCE CHAIR SEMPA PRESIDENT ELECT EMERGENCY MEDICINE COMMUNITY HOSPITAL OF ANACONDA MISSOULA, MT OBJECTIVES IDENTIFY NEW CHANGES TO AHA PEDIATRIC GUIDELINES IDENTIFY NEW MEDICATIONS UTILIZED IN PEDS ALGORITHM PROPER RHYTHM RECOGNITION AND ALGORITHMIC PATHWAY UTILIZE PEDIATRIC ALGORITHMS PROPERLY IN CARDIORESPIRATORY EMERGENCIES 24

27 RECERT COURSE FORMAT BRIEF OVERVIEW TO AHA, BLS/PALS UPDATES PALS MEDICATION REVIEW PALS ALGORITHMIC REVIEW HANDS ON PRACTICAL AND TESTING 25

28 PALS BLS UPDATES 2 RESCURER INFANT AND CHILD CPR, 15:2; COMPRESSION AND VENT RATIO, O/W 1 RESC. SAME, 30:2 CHEST COMPRESSIONS ARE RECOMMENDED IN CHILD/INFANT WITH SIGNS POOR PERFUSION AND HR LESS THAN 60 1 OR 2 HANDS FOR CHILD, MID STERNUM; INFANT, HAND AROUND TORSO AND NIPPLE LINE 5 CYCYLES OF CPR, 2 MINUTES NOW GOLD STANDARD, THAN QUICK REASSESSMENT; ALL INTERVENTIONS NOW TIMES AROUND 2 MIN CYCLE; NOT WASTING TIME; INTERVENTIONS ALL IN SUCCESSION AT 2 MIN MARK 26

29 PALS...THE UPDATES CAUTION WITH USE ET TUBES; LMA NOW ACCEPTABLE CUFFED ET TUBE MAY BE NOW BE USED IN INFANTS; KEEP CUFF PRESSURE < 20 CM H20 CONFIRM ET TUBE WITH CLINICAL ASSESSMENT AND ASSESSMENT OF EXHALED CO2 WITH ADVANCED AIRWAY IN PLACE, PROVIDERS NO LONGER PROVIDE CYCLES OF CPR; CHEST COMPRESSIONS AT RATE OF 100/MIN, AND 8 10 BREATHS PER MIN; 1 BREATH APPROX EVERY 6 8 SEC IV/IO ROUTES OVER ET ROUTE FOR MEDS NO HIGH DOSE EPI 27

30 LIDOCAINE NOT USED; RATHER AMIODARONE IF HAVE ; OK LIDOCAINE IF AMIO NOT AVAILABLE INDUCED HYPOTHERMIA CONSIDERED (32 34 DEGREES C) FOR HOURS IF CHILD REMAINS COMATOSE AFTER RESUSCITATION SHOCK DOSES REMAIN SAME IN PEDS; 2 ND DOSE WAS 2 4 J/KG, NOW IS 4 J/KG 28

31 MEDICATIONS SIMILAR TO ADULT, ACLS SPECIFIC PEDS DOSING.. BROSELOW TAPE.UTILIZE AT ALL TIMES DURING PEDS RESUSCITATION CAN LAY TAPE ALONGSIDE PT ON STRETCHER, DOSES CORRESPOND TO COLOR CODE BASED ON CHILD S BODY LENGTH FLUID RESUSCITATION..NSS, 20 MG/KG BOLUS, UP TO TIMES 3 29

32 CHECK GLUCOSE; IF LOW, REPLACE MANY METHODS EASIEST FOR ME, LEAST AMOUNT OF MATH; D5NS, 1 2 BOLUSES OF 20 MG/KG AS LEAD BOLUS(ES) MEDS/RHYTHMS, CONT D BRADYCARDIA EPINEPHRINE ATROPINE CPR, HR<60, POOR PERFUSION TACHY, PULSE SVT ADENOSINE, VAGAL MANEUV. CARDIOVERSION J/KG, THAN 2J AMIODARONE +/ LIDO 30

33 MEDS/RHYTHM, CONT D PULSELESS VF/VT SHOCK, 2J/KG TIMES 1 OR AED, CHILD; 2 ND, 4 J/KG EPI ANTIARRHY; LIDO, AMIODO SEPTIC SHOCK RECOG CAUSE, VS, GLUCOSE, LABS, ABX S, ETC. ISOTONIC FLUID RESUSCITATION SHOCK, NOT RESONDING FLUIDS, PRESSORS MEDS/RHYTHM, CONT D POST RESUSC MILRINONE, CARDIAC HX, ISSUES DOPAMINE EPI/EPI GGTT DOBUTAMINE DOSING COMPLICATED MG/ KG, J/KG.USE BROSELOW TAPE, POCKET CARDS.. PERIPHERAL BRAIN 31

34 32

35 QUESTIONS, COMMENTS, CONCERNS, OBJECTIONS???? 33

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