2005 ACLS OVERVIEW & STUDY GUIDE

Transcription

1 2005 ACLS OVERVIEW & STUDY GUIDE Vanderbilt Resuscitation Program ACLS is a course dedicated to sharing a core of advanced information regarding respiratory and cardiac emergencies. It is taught according to the most current guidelines approved by the American Heart Association as a uniform approach to the treatment of these emergencies. Because of the volume of materials to be covered in this course, the following skills are STRONGLY recommended as prerequisites to attending ACLS: (a) BLS - it is highly recommended that you have attended a BLS course within the last two years. You will be expected to perform BLS during the case studies and you must be able to perform BLS flawlessly during the Mega VF and BLS/AED evaluation stations. (b) Arrhythmia recognition - you MUST be able to easily recognize arrhythmias to successfully complete ACLS. If you do not work with arrhythmias on a regular basis, it is STRONGLY suggested that you consider attending Essentials of Resuscitation and a Basic Arrhythmia Course prior to attending ACLS. (c) Pharmacology - you MUST be comfortable with the drugs used in ACLS. If you do not work with these drugs on a regular basis, it is STRONGLY suggested that you spend time reviewing a pharmacology text. SUCCESSFUL ACLS COURSE COMPLETION One ACLS course requirement is completion of the enclosed multiple choice and ECG exams. Bring your completed exams with you they are your entrance tickets into class. The other course completion criteria are: 1. Active participation in ALL stations, including demonstrated knowledge of ACLS principles. Inability to demonstrate mastery of these "ACLS essentials" would require that you be remediated and re-evaluated: a. Assure that the patient s ABCs are intact, either spontaneously or with your assistance. i. Airway: open it, keep it open ii. Breathing: make sure it is adequate at ALL times---give oxygen as a first-line drug iii. Circulation: make sure it is adequate at ALL times---begin and continue CPR as needed b. Assess and reassess the patient's condition frequently and intervene as indicated c. Perform early, safe, and effective defibrillation for VF or pulseless VT. d. Know and use appropriate pharmacological agents---which drug, which route, which dose 2. Mega-VF evaluation. You will manage the first 10 minutes of resuscitation for a patient in ventricular fibrillation or pulseless ventricular tachycardia. You will be functioning as the team leader, and must direct all care provided for the "patient". 3. Automated External Defibrillation. You will properly attach and safely use an automated external defibrillator. This may be a separate station or could be incorporated into your Mega VF evaluation, depending on your experience with an AED. 4. ACLS Post-test. A post-test, very similar in content to the pre-test, will be given at the end of class. You will be expected to complete this exam with a score of 84% or greater. TEXTS The following texts are required for all ACLS Provider Courses and recommended but optional for all ACLS Renewal Courses: ACLS Provider Manual Handbook of Emergency Cardiovascular Care (ECC Handbook) 1

2 THE 10 ACLS CASES Respiratory Arrest w/ Pulse VF/Pulseless VT Bradycardia Stable Tachycardia Acute Coronary Syndromes Unstable Tachycardia Asystole Pulseless Electrical Activity (PEA) Acute Ischemic Stroke Automated External Defibrillation THE ACLS SKILLS 1. Airway/Breathing a. Provide oxygen i. Nasal cannula 2-6 liters/minute ii. 100% non-rebreather mask b. Open the airway/keep it open i. Head-tilt/chin-lift ii. Jaw thrust iii. Oral airway iv. Nasal airway v. Suction vi. Endotracheal Intubation vii. Alternative Devices/Techniques 1. LMA 2. Combitube 3. Needle Cricothyrotomy c. Ventilate i. Mouth-to-Mask ii. Bag-Mask 1. with oral airway 2. 2-person technique 2. Circulation 3. Dysrhythmia Recognition a. Non-perfusing (arrest) rhythms i. Shockable 1. VF 2. Pulseless VT ii. Non-shockable 1. PEA 2. Asystole b. Perfusing (peri-arrest) rhythms i. Symptomatic Bradycardia ii. Tachycardia, Stable and Unstable 4. Electrical Therapy a. Defibrillation b. Synchronized cardioversion c. Transcutaneous pacing 5. Peripheral IV access 6. Pharmacology 2

3 PHARMACOLOGY The following drugs are part of the ACLS algorithms and are the ones you are expected to know readily (drug, dose, route(s), indications, contraindications): ** DRUGS ACCEPTABLE VIA ETT ROUTE: Drugs given via endotracheal tube should be given at 2 to 2.5 times the IV dose and diluted in 10 ml. of saline. IV PUSH DRUGS: Epinephrine** 1 mg q. 3-5 min. Vasopressin 40 units, single dose, one time only (VF only) Atropine** mg q. 3-5 min, up to a total of 0.04 mg/kg Amiodarone (VF/VT) 300 mg, consider repeating 150 mg in 3-5 min. Lidocaine** mg/kg; repeat at mg/kg q min. up to 3 mg/kg max Procainamide mg/min, up to a total of 17 mg/kg INFUSIONS: Lidocaine 2-4 mg/min. Mix 1-2 gm/250 cc. of D 5 W Procainamide 1-4 mg/min. Mix 1-2 gm/250 cc of D 5 W Dopamine 5-10 mcg/kg/min. Mix 400 mg/250 cc of D 5 W Epinephrine 2-10 mcg/min. Mix 1-2 mg/250 cc of D 5 W Amiodarone Rapid infusion (non-vf): 150 mg over 10 min, may repeat every 10 mins prn. Maintenance infusion: 1 mg/min for 6 hrs decreasing to 0.5 mg/min for 18 hrs. Max cumulative dose 2.2 gm IV/24 hrs. Magnesium Sulfate 1-2 gm in 10 ml of D 5 W over 1-2 min. Sodium Bicarbonate 1 meq/kg; repeat at 0.5 meq/kg q. 10 mins. Adenosine 6 mg over 1-3 sec. followed by saline bolus to flush; repeat at 12 mg. after 1-2 min. twice (30 mg total) Further information on ACLS Pharmacology can be found in the ECC Handbook, pgs

4 UNIVERSAL PULSELESS RHYTHM MANAGEMENT V-FIB Shock Shock Shock ASYSTOLE PEA C O T E CPR Oxygen Tubes: ET, IV Epinephrine 1 mg Q 3-5 minutes Acceptable to use Vasopressin 40 U IV, single dose, 1 time only as alternative to epinephrine and may return to epinephrine 1 mg Q 3-5 mins if no response after mins. Shock Drug Shock Drug Atropine 1 mg q3min x 3 Etiology Atropine (if HR<60) The central concept is that the COTE mnemonic is the core treatment of all non-perfusing rhythms with the additions listed in line with each particular rhythm. Remember: 1) V-Fib rhymes with Defib and there should be a direct neurologic synapse between them. Next go to COTE then think Defib - Drug - Defib - Drug - etc. 2) Asystole goes straight to COTE then out to Atropine, which also begins with an A. 3) PEA goes straight to COTE then out to Etiology and then to Atropine if the rate is less than 60. 4

5 AUTOMATED EXTERNAL DEFIBRILLATION (pending the arrival of EMS) Unresponsive AED: Check if unresponsive Call 911 Get AED Identify and respond to special situations Unresponsive Start ABCDs: Airway: open airway, hold it open Breathing: look, listen and feel for breathing Breathing Not Breathing Breathing adequate? Place in recovery position Breathing inadequate? Start rescue breathing: 1 breath every 5 seconds Monitor signs of circulation every seconds: pulse, color, movement, return or remaining presence of normal breathing pattern, coughing Provide 2 slow breaths Circulation: check for carotid pulse No Circulation Circulation Start rescue breathing: 1 breath every 5 seconds Monitor signs of circulation every seconds: pulse, color, movement, return of normal breathing pattern, coughing Perform CPR until AED arrives and is ready to attach: Chest compressions 100/minute 15 compressions to 2 breaths (1 or 2 rescuers) Attempt Defibrillation (when AED arrives) POWER ON AED first ATTACH AED electrode pads (stop CPR) ANALYZE ( all clear! ) SHOCK ( all clear! ) up to 3 times if advised After 3 shocks or No shock indicated : Recheck ABCs No Pulse? Begin CPR Leave AED on and attached to victim for repeat analysis at automatically preset intervals 5

6 Respiratory Emergencies Is the patient breathing? YES NO Allow pt. to assume position of comfort Provide oxygen prn Suction prn Monitor respirations: Depth, bilateral chest rise, resp. rate Begin ventilations as indicated Attempt to ventilate patient: Does chest rise with ventilation? YES NO ACT QUICKLY! PATIENT WILL DIE IF NO AIRWAY IS ESTABLISHED Continue ventilations w/ 100% oxygen Squeeze bag slowly and gently, use 2 people Maintain head-tilt/chin-lift, consider oral airway Consider quickly reversible causes of apnea: narcotic OD, hypoglycemia, hypercarbia, hypoxia Consider intubation by most experienced person Continue bag-mask ventilation and call anesthesia if no experienced person present Reposition airway---head-tilt/chin-lift Consider oral airway, use 2 people Rapidly assess for airway obstruction Immediately intubate if no obstruction Prepare for alternative airway access: LMA, Combitube, needle cricothyrotomy, emergent bedside 6

7 SYMPTOMATIC BRADYCARDIA Assess ABCs Oxygen IV access monitor fluids Vital signs, pulse oximetry, monitor BP Type II second-degree AV block or Third-degree AV block Sinus Bradycardia Junctional Rhythm Type I second-degree AV block (Wenckebach) Atropine mg q 3-5 min (up to 0.04 mg/kg) Transcutaneous pacing if available Dopamine 5-20 µg/kg per minute Epinephrine 2-10 µg/min Isoproterenol 2-10 µg/min Transcutaneous pacer ---may try Atropine until transcutaneous pacer arrives. Reassess ABCs Blood pressure preferred circulatory assessment 7

8 STABLE TACHYCARDIAS Assess ABCs Oxygen IV Monitor Narrow-complex Consider vagal maneuvers Adenosine 6 mg rapid IV push + flush, may be repeated in 1 to 2 mins at 12 mg x 2. amiodarone 150 mg over 10 mins β blockers calcium channel blockers digoxin procainamide May go directly to cardioversion Wide-complex amiodarone 150 mg over 10 mins lidocaine mg/kg, may repeat at ½ original dose in 5 mins x 2 procainamide mg/min up to 17 mg/kg magnesium 1-2 gm over 1-2 mins Additional options if Torsades suspected: overdrive pacing isoproterenol drip phenytoin lidocaine Sedation with short-acting agent Synchronized cardioversion 100 J 200 J 300 J 360 J 8

9 UNSTABLE TACHYCARDIAS Assess ABCs Oxygen IV Monitor Sedate if possible DO NOT DELAY CARDIOVERSION! Have ready: Functional suction unit Bag-valve-mask Intubation equipment Synchronized cardioversion Ventricular Tachycardia Paroxysmal supraventricular 100 J tachycardia (PSVT) 200 J 300 J Atrial fibrillation 360 J Atrial flutter Considerations: Effective regimens have included a sedative (eg, diazepam, midazolam, barbiturates, etomidate, ketamine, methohexital) with or without an analgesic agent (eg, fentanyl, morphine, meperidine). Many experts recommend anesthesia if service is readily available. NOTE POSSIBLE NEED TO RESYNCHRONIZE AFTER EACH ENERGY DELIVERY. If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks. Treat polymorphic ventricular tachycardia (irregular form and rate) like ventricular fibrillation: see VF/pulseless VT algorithm. PSVT and Atrial flutter often respond to lower energy levels (50 J). 9

10 PULSELESS ELECTRICAL ACTIVITY CPR call for monitor-defibrillator Ventilate/oxygenate, IV access, fluids Intubate: hyperoxygenate, confirm tube placement, secure Rhythm on monitor without detectable pulse Rule out causes POTENTIALLY FAST or EASY TO DIAGNOSE/TREAT Hypoxia Tension PTX Cardiac Tamponade Hypovolemia Hyper/hypokalemia Acidosis Hypothermia Drug Overdose PROBABLY UNTREATABLE Massive MI Massive PE epinephrine 1 mg every 3 mins Atropine 1 mg every 3 mins x 3 for HR < 60 10

11 ASYSTOLE CPR call for defibrillator Confirm Asystole in two leads Rapid scene survey: any evidence personnel should not attempt resuscitation? If the use of electricity is considered, trancutaneous pacing should be performed immediately upon diagnosis of asystole. Insufficient data to support use of defibrillation to rule out ultra-fine VF. Ventilate, oxygenate, IV access Intubate: hyperoxygenate, confirm placement, secure tube Rule out potentially reversible causes: Hypoxia Hypovolemia Hypo-/hyperkalemia Acidosis Hypothermia Drug Overdose Cardiac Tamponade Tension Pneumothorax Massive Acute MI Massive PE epinephrine 1 mg every 3 mins atropine 1 mg every 3 mins x 3 If asystole persists: Cease resuscitation efforts? Consider quality of resuscitation/reassess ABCs/Recheck end-tidal CO2 detector Consider termination if no response after 10 mins Atypical clinical features present? Hypothermia Drug OD Near Drowning In the field: termination protocols in place? 11

12 SUSPECTED STROKE (Pre-hospital to ED arrival) Immediate general assessment: <10 mins from arrival Immediate neuro assessment: <25 mins from arrival Assess ABCs, vital signs Review patient history Oxygen IV--Monitor Establish onset (<3 hours required for fibrinolytics) LABS: CBC, Lytes, coag studies Physical examination Check blood sugar; treat if indicated Perform neurological examination: *check level of consciousness (Glasgow Coma Scale) *check level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale) 12-lead EKG; check for arrhythmias Urgent noncontrast CT Alert Stroke Team --door-to-ct performed goal: <25 minutes Read CT scan --door-to-ct read goal: <45 minutes Perform lateral cervical spine xray (pt.comatose/hx of trauma) CT indicates non-hemorrhagic stroke Consider fibrinolytics TPA only approved drug for stroke: door-to-treatment goal <60 mins Lytics contraindicated for rapidly improving symptoms Emergent CT if deterioration No anticoagulant or antiplatelet therapy for 24 hrs Treat hypertension CT indicates hemorrhagic stroke Consult Neurosurgery Reverse any anticoagulants Reverse any bleeding disorder Monitor neurological condition Treat hypertension in awake patients Cincinnati Prehospital Stroke Scale (72% probability with one positive marker) Facial Droop: Have patient smile or show teeth Arm Drift: Have patient hold both arms straight out for 10 seconds with eyes closed Abnormal Speech: Have patient repeat the phrase, You can t teach an old dog new tricks. 12

13 ISCHEMIC CHEST PAIN Immediate assessment (<10 minutes) Vital signs IV access 12-lead ECG (physician reviews) Brief, targeted H&P; focus on eligibility for fibrinolytics LABS: serum cardiac markers, electrolytes, coag studies CXR (<30 minutes) Immediate general assessment Oxygen Aspirin Nitroglycerin SL or spray Morphine IV (if pain not relieved w/ nitroglycerin) Remember: MONA greets all patients (Morphine, Oxygen, Nitroglycerin, Aspirin) Start treatment as indicated Aspirin β blockers IV Nitroglycerin IV Consider ACE inhibitors Heparin (unfractionated or low molecular weight) IV Glycoprotein IIb/IIIa inhibitors EMS personnel can perform immediate assessment/treatment ( MONA ), incl. initial 12-lead ECG and review for fibrinolytic therapy indications and contraindications. Select a reperfusion strategy based on resources: Lytics -many choices -rule out absolute contraindications -major surgery or trauma (incl. traumatic CPR) in last days -stroke of any kind in last 6 months -presence of head lesions -known active bleeding -bleeding disorder: plts <150,000 -uncontrolled HTN (>180/100) Interventional Cath Lab -experienced operators (>75/year) -high-volume center (>250/year) -cardiac surgical back up GOAL: door-to-balloon inflation mins. GOAL: door-to-drug <30 minutes 13

14 VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA CPR call for defibrillator Defibrillate ASAP 200 J 200 J (BIPHASIC) 200 J Check pulse/resume CPR Ventilate, oxygenate, IV access Intubate: hyperoxygenate, confirm tube placement, secure tube epinephrine 1 mg every 3 mins OR Vasopressin 40 units IV x 1 only (may resume epinephrine after 10 mins) Defibrillate 200 J (BIPHASIC) ANTIARRHYTHMIC CHOICES: amiodarone: 300 mg, consider repeating 150 mg in 5 mins lidocaine: 1 to 1.5 mg/kg, may repeat in 5 mins up to 3 mg/kg magnesium: 1 to 2 gm in 10 ml D 5 W over 1 to 2 mins, may repeat in 5 mins procainamide: 20 to 50 mg/minute, up to 17 mg/kg Defibrillate 200 J (BIPHASIC) 14