HeartCode ACLS. Learning Technology by Laerdal. Learning Technology by Laerdal. Heartcode_ACLS_IH_Booklet.indd 1

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1 The Official AHA Self-directed ACLS elearning Program HeartCode ACLS Student Guide Learning Technology by Laerdal Learning Technology by Laerdal Heartcode_ACLS_IH_Booklet.indd 1 06/03/

2 Preface The goal of the HeartCode ACLS program is to improve the quality of care provided to the adult victim of cardiac arrest or other cardiopulmonary emergencies. HeartCode ACLS, an official American Heart Association elearning program, offers an alternative to the traditional AHA ACLS class. In today s fast-paced environment, it is not always easy for healthcare providers to keep their certifications current. HeartCode ACLS offers a convenient method for obtaining an American Heart Association ACLS card, while practicing critical thinking skills and team dynamics to help improve the quality of patient care. Providers can complete the course at their own pace, on their own schedule, potentially saving time and money and improving the utilization of a limited pool of instructor resources. This specific program is designed to educate clinicians about treatments for cardiovascular emergencies and stroke. Target Audience Physicians, nurses, paramedics/emt-is, residents, nurse practitioners, physician assistants, clinical pharmacists and respiratory therapist are the target audience. Other healthcare workers who care directly for patients may also benefit. 2 Heartcode_ACLS_IH_Booklet.indd 2 06/03/

3 Content Content Introduction... 4 Core Cases (Patients)... 6 Patient: Brad Stephens... 7 Patient: Ervin Waters... 8 Patient: John Mitchell... 9 Patient: Stan Loftus Patient: Derrick Gentry Patient: Ian Denholm Patient: Lou Weston Patient: Walter Hampton Patient: David Miller Patient: Paul Smith Special Features Accreditation / Disclosure Statements Heartcode_ACLS_IH_Booklet.indd 3 06/03/

4 Introduction Introduction The HeartCode ACLS program includes all of the exams required for successful completion of the cognitive portion of the American Heart Association s ACLS course: Team Dynamics Lesson (team principles) 10 ACLS Cases (realistic patient-simulation cases) ACLS Written Test Also included in the program: Precourse self-assessment The objective of the HeartCode ACLS precourse self-assessment is to evaluate the student s ability to integrate both rhythm interpretation and the use of pharmacologic agents. There is no passing score in the self-assessment, but a score of 84% or higher will help the learner to participate effectively in the lessons and testing sections. Electronic versions of the entire AHA textbooks ACLS Provider Manual 2005 American Heart Association Guidelines for Cardiovascular Resuscitation and Emergency Cardiovascular Care Supplementary AHA material ACLS Science Overview Video ACLS Core Drugs ACLS Provider Manual Supplementary Material Nine additional BLS videos HeartCode ACLS includes microsimulation technology that improves both the educational content and user-friendliness of the program. Providers are presented with realistic patient cases and are required to interact with the program to assess the patient, formulate a treatment plan based on the ACLS algorithms and effect treatment. The advanced technology allows the simulated patient to react accordingly to the treatment provided (positively or negatively) in order to improve the learning experience. 4 Heartcode_ACLS_IH_Booklet.indd 4 06/03/

5 Introduction Upon completion of a given case, the provider is presented with a detailed debriefing screen. This debriefing is more than just a list of events ending with a score. Providers are presented with an account of their actions, pointing out both correct and incorrect interventions. Suggestions for improvement are offered, and all appropriate AHA reference material is hyperlinked to the debriefing, allowing immediate remediation at the conclusion of the case. To claim the HeartCode ACLS certificates, the learner needs to: Review the background material to the extent desired Successfully complete: -- Team Dynamics Lesson Patient Scenarios -- ACLS Written Test -- Claim the HeartCode ACLS Part 1 Certificate Perform a skills practice and test with an AHA ACLS Instructor or using the voice assisted manikin (VAM) system with the HeartCode program Claim the HeartCode ACLS skills practice and testing certificate Upon successful completion of the cognitive and skills test portions, the student receives an AHA ACLS Course Completion Card. 5 Heartcode_ACLS_IH_Booklet.indd 5 06/03/

6 ACLS Cases (Patients) Description and Learning Objectives The 10 ACLS cases in HeartCode provide learners with an opportunity to test their ability to manage a range of important cardiovascular emergencies and stroke in a realistic simulation setting while working toward ACLS certification. The intelligent debriefing provides optimal opportunity to learn from and improve performance. 6 Heartcode_ACLS_IH_Booklet.indd 6 06/03/

7 Descriptions and Learning Objectives Patient: Brad Stephens A 48-year-old man has collapsed after being brought into the outpatient clinic at which you are a first responder. He complained of some shortness of breath and chest pain before losing consciousness. Diagnosis: VF/Pulseless VT Difficulty: Beginner Learning Objectives: Executes a BLS Primary Survey to assess patient. Executes relevant cardiorespiratory support. Executes effective CPR when indicated. Identifies a clinical situation where advanced help is necessary and help must be called immediately. Implements the VF/VT pathway in the ACLS Pulseless Arrest algorithm. Executes proficient defibrillation with an AED. Recalls that CPR and defibrillation are critical steps in the treatment of VF and pulseless VT. Recalls that chest compressions should only be interrupted for ventilation (unless an advanced airway is in place), rhythm checks and shock delivery. 7 Heartcode_ACLS_IH_Booklet.indd 7 06/03/

8 Descriptions and Learning Objectives Patient: Ervin Waters A 42-year-old man with palpitations has been sent to the Emergency Department by his family doctor. Diagnosis: Atrial fibrillation Difficulty: Beginner Learning Objectives: Executes BLS Primary and ACLS Secondary Surveys to assess patient. Implements the ACLS Tachycardia algorithm. Distinguishes between stable and unstable tachycardia. Recalls characteristics of a stable tachycardia. Identifies narrow complex tachycardia on ECG. Distinguishes between regular and irregular narrow complex tachycardia on ECG. Recalls the importance of determining the duration of atrial fibrillation. Recalls that anticoagulation measures are mandatory before attempting cardioversion in stable patients with AF ~ >48 h. 8 Heartcode_ACLS_IH_Booklet.indd 8 06/03/

9 Descriptions and Learning Objectives Patient: John Mitchell A 56-year-old man is complaining of chest pain. He is a smoker who has not seen a doctor for several years. Diagnosis: Acute coronary syndromes Difficulty: Medium Learning Objectives: Executes BLS Primary and ACLS Secondary Surveys to assess patient. Executes relevant cardiorespiratory support. Recognizes symptoms of ACS. Implements the ACLS Acute Coronary Syndromes algorithm. Implements the AHA recommended ED plan for immediate assessment and general treatment of the patient with chest pain suggestive of ischemia. Executes attempts to control chest pain aggressively. Executes initial treatment for patients with ACS correctly. Recalls that 12-lead ECG is central to the initial risk and treatment stratification of ACS patients. Classifies ACS patients according to ST-elevation on ECG. Evaluates an ACS patient s eligibility for reperfusion therapy rapidly. Recalls indications for reperfusion therapy. Recalls to minimize door-to-drug interval. Recalls indications, contraindications, dosage and administration of drugs relevant to treatment of ACS. Understands that time is critical in the management of ACS. 9 Heartcode_ACLS_IH_Booklet.indd 9 06/03/

10 Descriptions and Learning Objectives Patient: Stan Loftus A man is brought into the ED from his home, where his wife found him unresponsive on the couch. Basic life support was not started until the ambulance arrived. Diagnosis: Asystole/PEA Difficulty: Medium Learning Objectives: Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient. Executes effective CPR when indicated. Recalls that chest compressions should only be interrupted for ventilation (unless an advanced airway is in place), rhythm checks and shock delivery. Implements the ACLS Pulseless Arrest algorithm. Analyzes ECG and clinical situation to correctly identify PEA. Recognizes asystole on ECG. Executes confirmation that a flatline on the ECG is indeed asystole. Recalls that asystole usually represents a confirmation of death rather than a rhythm to be treated. Recalls the AHA criteria for when to stop resuscitative efforts. Recalls when to look for and honor a valid Do Not Resuscitate Order (DNAR). Recalls that asystole and PEA are not shockable rhythms. Summarizes that PEA is often associated with reversible causes. Implements the mnemotechnic rule of the H s and T s to check for conditions that could have contributed to PEA and/or asystole. 10 Heartcode_ACLS_IH_Booklet.indd 10 06/03/

11 Descriptions and Learning Objectives Patient: Derrick Gentry A 72-year-old man is brought into the ED by ambulance complaining of loss of movement in his left arm. He has a history of hypertension and hypercholesterolemia. Diagnosis: Stroke Difficulty: Medium Learning Objectives: Recognizes major signs and symptoms of stroke. Implements the ACLS Suspected Stroke algorithm. Recalls that fibrinolytic therapy for eligible acute stroke patients within three hours of symptom onset is a class Ia recommendation. Executes a rapid neurological exam. Recalls that the clinical condition of patients with stroke may change rapidly. Recalls that an urgent non-contrast CT scan of head should be obtained in a patient with suspected stroke. Summarizes the importance of determining time of symptom onset. Recalls indications, contraindications and dosages for drugs relevant when managing a patient with stroke. Rapidly evaluates a patient s eligibility for fibrinolytic therapy. Implements guidelines for administration of fibrinolytics to a stroke patient. Recalls that blood glucose should be evaluated in a patient with suspected stroke. 11 Heartcode_ACLS_IH_Booklet.indd 11 06/03/

12 Descriptions and Learning Objectives Patient: Ian Denholm A 74-year-old man is complaining of fatigue on exertion. He has noticed that his heart rate is well over 100 beats per minute. Diagnosis: VT with pulse Difficulty: Medium Learning Objectives: Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient. Executes relevant cardiorespiratory support. Executes continuous assessment of the patient. Recognizes signs and symptoms of tachycardia. Distinguishes between wide and narrow-complex tachycardias on ECG. Implements the ACLS Tachycardia algorithm. Distinguishes between stable and unstable tachycardia. Identifies the tachycardic patient who is unstable from tachycardia. Recalls that first-line treatment for the hemodynamically unstable patient is urgent electrical cardioversion, regardless of tachycardic subtype. Executes electrical cardioversion correctly when appropriate. Recalls when to use synchronization during cardioversion. 12 Heartcode_ACLS_IH_Booklet.indd 12 06/03/

13 Descriptions and Learning Objectives Patient: Lou Weston A 72-year-old man has fallen twice in the last 24 hours. He is taking medication for hypertension, but is otherwise well. Diagnosis: Bradycardia Difficulty: Medium Learning Objectives: Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient. Executes relevant cardiorespiratory support. Recognizes signs and symptoms of symptomatic bradycardia. Understands that only symptomatic bradycardia should be treated. Implements the ACLS Bradycardia algorithm. Recalls that transvenous pacing is indicated when second-degree type II or third-degree AV block is identified. Recognizes bradycardia on ECG. Classifies the type of AV block on ECG. Recalls indications for transcutaneous pacing. Executes transcutaneous pacing when relevant. Recalls indications, contraindications, dosage and administration of drugs relevant to treatment of bradycardia. 13 Heartcode_ACLS_IH_Booklet.indd 13 06/03/

14 Descriptions and Learning Objectives Patient: Walter Hampton A 49-year-old man is found unresponsive and unconscious. Diagnosis: Respiratory arrest Difficulty: Beginner Learning Objectives: Executes BLS Primary and ACLS Secondary surveys to assess patient. Implements AHA guidelines when managing respiratory arrest. Executes relevant cardiorespiratory support. Recalls appropriate ventilation rates. Recalls indications for suctioning. Recalls indications for placement of advanced airways. Executes confirmation of placement of advanced airway correctly. 14 Heartcode_ACLS_IH_Booklet.indd 14 06/03/

15 Descriptions and Learning Objectives Patient: David Miller A 65-year-old man is complaining of palpitations. Diagnosis: Megacode case Tachycardia/Cardiac arrest Difficulty: Advanced Learning Objectives: Executes BLS Primary and ACLS Secondary Surveys to assess patient. Implements the ACLS Tachycardia algorithm. Implements the ACLS Pulseless Arrest algorithm. Distinguishes between stable and unstable tachycardia. Distinguishes between wide and narrow-complex tachycardias on ECG. Executes electrical cardioversion correctly when appropriate. Recalls when to use synchronization during cardioversion. Recalls indications, contraindications and dosages for drugs relevant when managing a patient in cardiac arrest. Recognizes signs and symptoms of tachycardia. Recalls indications, contraindications and dosages for drugs relevant when managing a patient with tachycardia. Analyzes ECG and clinical situation to correctly identify PEA. Continuously re-evaluates clinical situation to determine correct treatment plan. Recalls that chest compressions during cardiac arrest should be interrupted only for ventilations (unless advanced airway is in place), rhythm checks and shock delivery. Classifies arrest rhythms on ECG. 15 Heartcode_ACLS_IH_Booklet.indd 15 06/03/

16 Descriptions and Learning Objectives Patient: Paul Smith A 47-year-old man is complaining of indigestion. He is cold, clammy and diaphoretic. He tells you he is about to faint. Diagnosis: Megacode case Bradycardia/Cardiac arrest Difficulty: Advanced Learning Objectives: Executes BLS Primary and ACLS Secondary Surveys to assess patient. Implements the ACLS Bradycardia algorithm. Implements the ACLS Pulseless Arrest algorithm. Classifies type of bradycardia on ECG. Recalls indications for transcutaneous pacing. Executes transcutaneous pacing when relevant. Recalls indications, contraindications and dosages for drugs relevant when managing a patient in cardiac arrest. Recalls indications, contraindications and dosages for drugs relevant when managing a patient with bradycardia. Recognizes signs and symptoms of bradycardia. Continuously re-evaluates clinical situation to determine correct treatment plan. Recalls that chest compressions during cardiac arrest should be interrupted only for ventilations (unless advanced airway is in place), rhythm checks and shock delivery. Classifies arrest rhythms on ECG. Recalls that asystole and PEA are not shockable rhythms. Recalls the AHA criteria for when to stop resuscitative efforts. 16 Heartcode_ACLS_IH_Booklet.indd 16 06/03/

17 Special Features Special features in HeartCode ACLS 17 Heartcode_ACLS_IH_Booklet.indd 17 06/03/

18 Special Features in HeartCode ACLS Chest tube A chest tube can be inserted through an intercostal space directly into the pleural cavity. This is indicated when treating a suspected pneumothorax. Needle decompression A needle decompression relieves a suspected pneumothorax by allowing any air trapped inside the thorax to escape through the cannula. Carotid sinus massage (carotid sinus pressure) The carotid sinus contains baroreceptors that respond to pressure changes in the carotid artery. Carotid massage can be used in conjunction with the Valsalva maneuver to terminate spontaneous Reentry SVT. Valsalva maneuver The Valsalva maneuver produces an abrupt increase in intra-abdominal and intrathoracic pressure when the patient strains against a closed glottis while holding his breath. It is often used in conjunction with carotid sinus massage to terminate spontaneous Reentry SVT. 18 Heartcode_ACLS_IH_Booklet.indd 18 06/03/

19 Special Features in HeartCode ACLS Continuous temperature monitoring This tool allows you to continuously monitor the patient s core temperature. CT scanning A CT scan of the cerebrum is primarily used to identify intracerebral or subarachnoid hemorrhage in suspected stroke patients. A noncontrast CT scan is the single most important test when ruling out hemorrhagic stroke. Transfer patient to PCI Patients with acute chest pain should be evaluated as potential candidates for percutaneous coronary intervention (PCI) either angioplasty or intracoronary stenting. PCI is superior to fibrinolytic therapy when treating ACS and is reasonable in patients with cardiogenic shock or heart failure complicating MI. Transfer patient to transvenous pacing Transvenous pacing is an invasive procedure stimulating the heart to contract, thereby supporting cardiac output. In contrast to transcutaneous pacing, which can be started quickly and conveniently at the bedside, transvenous pacing requires involvement of an invasive cardiology team. 19 Heartcode_ACLS_IH_Booklet.indd 19 06/03/

20 Special features in HeartCode ACLS Pacing (transcutaneous) Transcutaneous cardiac pacing (TCP) supports cardiac output by stimulating the heart through large pacing electrodes placed on the patient s chest and back, thereby causing the heart to contract. TCP can be used in early treatment of asystole and symptomatic bradycardias. Troponin test Troponin is a serum cardiac marker that can be used to detect myocardial damage when ACS is suspected. The result is given as a positive or negative result, positive representing myocardial damage. Fibrinolytic drugs Fibrinolytic agents hydrolyze fibrin clots. Patients with acute chest pain or suspicion of acute ischemic stroke should be evaluated as potential candidates for fibrinolytic therapy. 20 Heartcode_ACLS_IH_Booklet.indd 20 06/03/

21 Accreditation / Disclosure Statements ACCREDITATION TERMS: ACCME/AMA (Physicians) - September 2008 September 2011 AACN (Nurses) - September 2008 September 2009 ACPE (Pharmacists) - September 2008 September 2011 CECBEMS (EMS Practitioners) - September 2008 September 2011 ACCREDITATION STATEMENTS: Continuing Medical Education Accreditation - Physicians The American Heart Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American Heart Association designates this educational activity for a maximum of AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. All faculty participating in CME/CE activities sponsored by The American Heart Association will disclose to the audience (1) significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and /or the manufacturer(s) of products or devices discussed in their presentation, and (2) unlabeled/unapproved uses of drugs or devices discussed in their presentation. Such disclosures will be made in writing in course presentation materials. Continuing Medical Education Accreditation Physician Assistants AAPA accepts Category 1 credit from AOACCME, Prescribed credit from AAFP, and AMA PRA Category 1 Credit from organizations accredited by ACCME. Continuing Education Accreditation - Nurses This program (08-NC-176) has been approved by the American Association of Critical Care Nurses (AACN) for Contact Hours, Category A, File number Continuing Education Accreditation Pharmacists The American Heart Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Credit: Contact Hours or CEUs. Universal Program Number: H01-P. Successful completion of this CME/CE activity includes completion of the following: Team dynamics lesson, 10 interactive medical cases, posttest and evaluation form. Once successful completion has been achieved, a CME/CE certificate can be claimed immediately by selecting your profile, selecting the Claim CME/CE Certificate button and printing your CME/CE certificate. 21 Heartcode_ACLS_IH_Booklet.indd 21 06/03/

22 Accreditation / Disclosure Statements Continuing Education Accreditation Emergency Medical Services This continuing education activity is approved by the American Heart Association, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for Advanced CEHs, activity number 08-AMHA-F I. Instructions for Independent Study Successful completion of this CE activity includes the following: (1) Complete the Team Dynamics lesson, the 10 cases with a debriefing grade of 70% or above and the written test. (2) Complete the appropriate CE request application and activity evaluation form. (3) Print Certificate/Statement of Credit. II. Cost The cost for the activity is 120 US dollars. There is no additional fee for CME/CE/CEH credits for this activity. Disclosure Statement As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Association of Critical-Care Nurses (AACN), the Council for Pharmacy Education (ACPE), and the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), the American Heart Association must ensure fair balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational activities. Accreditation / Disclosure Statements Therefore, all faculty and authors participating in continuing education activities sponsored by the American Heart Association must disclose to the audience: (1) any significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and/or the manufacturer(s) of products or devices discussed in the activity, and (2) unlabeled/unapproved uses of drugs or devices discussed in the activity. The intent of this disclosure is not to prevent an author with a significant financial or other relationship from contributing but rather to provide participants with information with which they can make their own judgments. It remains for the participants to determine whether the author s interests or relationships may influence the content. I. The following authors have declared financial interest(s) and / or affiliations: II. The following faculty have declared NO financial interest(s) and or affiliations: Name John Field, MD Erik Soderberg, MS 22 Heartcode_ACLS_IH_Booklet.indd 22 06/03/

23 Accreditation / Disclosure Statements Unlabeled/unapproved uses of drugs or devices are included in this activity This continuing education computer-based instruction contains recommendations from the American Heart Association Emergency Cardiovascular Care Committee, Subcommittee on Advanced Cardiovascular Life Support, as published in the American Heart Association ACLS Provider Manual. Most of these recommendations are based on guidelines developed in an evidence evaluation consensus process for the Guidelines 2005 Conference. The evidence evaluation consists of expert review, an analysis, and discussion of relevant scientific studies published in peerreviewed journals. The drug treatments recommended in this text are consistent with the indications, contraindications, and doses approved by the Food and Drug Administration (FDA) with the exceptions listed here. Alteplase, recombinant (rtpa) For patients with acute ischemic stroke who are ineligible to receive intravenous thrombolysis but who are evaluated within 6 hours of symptom onset, administration of intra-arterial thrombolysis in an experienced stroke center with immediate access to cerebral angiography and qualified interventionalists may be considered (Class I, Level of Evidence B). Facilities are encouraged to define criteria to credential individuals who can perform intra-arterial thrombolysis (Class I, Level of Evidence C). Intra-arterial thrombolysis is reasonable in patients who have contraindications to use of intravenous thrombolysis, such as recent surgery (Class IIa, Level of Evidence C). Pending publication of additional clinical trial data, intra-arterial administration of tpa has not yet been approved by the US Food and Drug administration (FDA). Amiodarone This drug is FDA approved for life-threatening ventricular arrhythmias, including recurrent VF and hemodynamically unstable VT. All other use constitutes an offlabel indication, including hemodynamically stable VT, wide-complex tachycardia of uncertain origin, AF, atrial flutter, pre-excited arrhythmias and arrhythmias in context of CHF. Similarly, the use of IV amiodarone for shock refractory VF/VT would not be an off-label use if given as a 150 mg dose, but giving it as a 300 mg bolus for this approved indication could be construed as off label. Vasopressin This drug is approved for diabetes insipidus, abdominal distention, and abdominal roentgenography. Vasopressin has not been shown to differ from Epinephrine (Class Indeterminate) in cardiac arrest. One dose of vasopressin may replace either the first or second dose of epinephrine. 23 Heartcode_ACLS_IH_Booklet.indd 23 06/03/

24 Accreditation / Disclosure Statements Note on Medication Doses Emergency cardiovascular care is a dynamic science. Advances in treatment and drug therapies occur rapidly. Readers are advised to check for changes in recommended dose, indications, and contraindications in the following sources: Currents in Emergency Cardiovascular Care, future editions of this handbook, and the AHA textbooks as well as the package insert product information sheet for each drug. Clinical condition and pharmacokinetics may require drug dose or interval dosing adjustments. Specific parameters may require monitoring, for example, creatinine clearance or QT interval. Some medications listed in this handbook were scientifically reviewed by the Guidelines evidence-based evaluation process. They may not be available in all countries and may not be specifically approved by the FDA for a particular treatment or application. 24 Heartcode_ACLS_IH_Booklet.indd 24 06/03/

25 25 Heartcode_ACLS_IH_Booklet.indd 25 06/03/

26 Notes 26 Heartcode_ACLS_IH_Booklet.indd 26 06/03/

27 Notes 27 Heartcode_ACLS_IH_Booklet.indd 27 06/03/

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