CRNA ACLS, PALS, & BLS REFRESHER

Attn: Certified Nurse Anesthetists (CRNA) CPR Consultants, Inc. 7404 G Chapel Hill Road, Raleigh, NC, 27607 CRNA ACLS, PALS, & BLS REFRESHER CRNA American Heart Association Triple Certification (BLS, ACLS, and PALS) CPR Consultants offers American Heart Association certifications in BLS, ACLS, and PALS to be completed in one day of training. This is only available for CRNAs. CPR Consultants understands that CRNAs have advanced training in many of the topics covered in the American Heart Association courses. CPR Consultants uses this experience, knowledge base, and a unique blending of elearning and traditional critical thinking class work to deliver this training in a one day format. This unique format for American Heart Association training allows for CRNAs to have a time and economic value to their training experience. Classes are conducted in a small format to allow for maximum amount of hands on training and critical thinking learning. CPR Consultants has experts in the field of resuscitation to help deliver this approach. This is how it works: 1. Complete the BLS for Healthcare Provider online provided with your class fee, prior to the class date. This is sent to you in an email format. If not received please check your Spam/Junk email filter. If not received please contact our office by email info@cprconsultants.com or 919-850-9295/866-990- 2772 2. From 8 am 12 pm, ACLS Renewal is completed. a. Science Review b. CPR Teaching and Testing Adult and Infant Skills Check c. Review of Respiratory Emergencies d. BLS and ACLS Survey e. ACS and Stroke Review f. Team Approach g. Algorithm Review h. Putting It All Together i. Megacode and Written Testing 3. From 1 pm 5 pm, PALS is completed. a. Science Review b. Pediatric Assessment c. Review of Core Cases Respiratory Emergencies

Upper Airway Lower Airway Lung Tissue Disorder of Breathing Shock Emergencies Hypovolemic bstructive Distributive Cardiogenic Rhythm Recognition and Management Tachycardia Bradycardia Pulseless VF/VTach PEA/Asystole d. Putting It All Together e. Megacode and Written Testing Please be sure to complete the elearning BLS Certificate prior to coming to the class date. Instructions are attached. Please complete the Pre-Test for ACLS and PALS using the algorithms provided as a guide prior to the class. If any questions are not clear please be ready to address those questions at the start of class. To complete the ACLS Pretest www.heart.org/eccstudent password: compression To complete the PALS pretest www.heart.org/eccstudent password: palsprovider

AUTMATIC EXTERNAL DEFIBRILLATR (AED) 2010 ECC GUIDELINES An Automatic External Defibrillator (AED) is a computerized battery-operated machine that is used to 1) analyze the heart rhythms of an unresponsive person; 2) recognize the abnormal rhythms that requires an electrical shock; 3) advise the operator through voice prompts and lighted indicators when a shock is needed; and 4) deliver the electrical shock to the heart. The prompt use of an AED after a sudden cardiac arrest greatly increases the victim s chances of survival. During Cardiac Arrest, every minute that goes by without the use of an AED, the patient s chance of survival decreases by 10%. The goal is to have an AED by the victim and have the AED delivering a shock within 3 minutes if it is available. Steps for CPR and AED use with 2 rescuers 1. ne person checks victim for responsiveness and evaluates for breathing. The rescuer initiates C-A-B. 2 nd person activates emergency response team or calls 911 and gets AED if available and will initiate AED use if trained to do so. Use protected barrier equipment. 2. C = Check for definitive pulse. No pulse then begin chest compressions (30 chest compressions and 2 breaths, 5 sets every 2 minutes) until AED arrives onto the scene. Compression rate: at least 100 per minute. Compression depth: at least 2 inches for adult, full pressure release but keep hand placement and skin contact on upstroke 3. A = pen airway with a head tilt-chin lift (use a jaw thrust with any suspected head and neck trauma). 4. B = Give 2 breaths if victim not breathing (use barrier devices and supplemental oxygen whenever available). 5. D = Defibrillate by following voice prompts regarding cardiac arrthymias and shock deliverance. Actions for the AED user 1. PWER N. Turn on the AED first. (Note: some AEDs automatically "power on" when the lid is opened.) Listen and follow AED voice prompts. 2. ATTACH PADS.. Check pictures on pads to ensure correct placement and attach the AED adhesive electrode pads to the victim. Try to attach the pads while CPR is in progress. Make sure cables are securely connected to AED. 3. "CLEAR" T ANALYZE. Make sure everyone is not touching the victim before and during analysis, saying I m clear, you re clear, everybody s clear. Visually scan the victim from head to toe to make everyone is cleared away. 4. "CLEAR" T DELIVER SHCK. Check again that the victim is clear of human contact, saying I m clear, you re clear, everybody s clear" and look to check that no one is touching the victim before pushing shock button. 5. NUMBER F SHCKS DELIVERED The AED may shock up to two more times if AED signals shock indicated. Clear the victim before every analysis and again before each shock is delivered. With the new AHA Guidelines 2010, AHA is recommending AED s shock only once every 2 minutes. Follow the prompts of the AED. 6. SHCK INDICATED MESSAGE. Begin compressions immediately after shock or no shock advised Resume CPR for 2 minutes. Switch rescuers to perform compressions every 2 minutes if available. Reanalyze rhythm and follow the voice prompts regarding shock deliverance steps. If victim is breathing normally, carefully turn the victim onto his side (recovery position) if there is no suspected head/neck injury. therwise do not move the victim and maintain an open airway. 7. Do not remove the AED pads once they are in place! nce EMS arrives, they may replace pads if needed to use their own medical equipment. Special conditions to consider while using an AED It is currently recommended that adults, children, and infants in cardiac arrest have the AED applied. If using adult pads on children or infants, one pad may be placed on the chest and the other pad on the back (anterior posterior placement) If victim is wet, dry the chest off before attaching and using AED. If victim is in water, remove them from water and dry the chest before using AED. If victim has an implanted defibrillator or pacemaker (a hard lump under the skin) do not put AED directly over the device - place the pad at least one inch away from any implanted machines. If victim has medication patch on skin, remove the patch and wipe skin dry before attaching AED pads. If victim has a very hairy chest, you may have to dry shave the area so the AED pads can be attached. Handout updated 4/15/11: Source ECC 2010 Guidelines BLS Instructor Guidelines

PST-CARDIAC ARREST ptimize Ventilation and xygen Maintain Sa2 >94 99 % Consider advanced airway and ETC2 Avoid hyperventilation Based on AHA ECC 2010 Guidelines TACHYCARDIA HR typically > 150 BPM TREAT HYPTENSIN IV/I BLUS Vasopressor Infusion Treatable causes H s & T s 12 Lead EKG UNIVERSAL ASSESSMENT Reversible Causes? H s & T s Airway? BVM as necessary xygen if Hypoxic Pulse, and Blood Pressure Cardiac Monitor IV Access 12 Lead EKG. D T delay therapy Consider Induced Hypothermia FLLW CMMANDS? Persistent tachyarrhythmia with HYPPERFUSIN: Hypotension Altered Mental Status Shock Ischemic Chest Pain/ discomfort Acute heart failure SYNC Cardioversion Consider Sedation If regular narrow complex, consider adenosine PCI Reperfusion r Fibrinolytics STEMI r High Suspicion of AMI Wide QRS? >.12 second Consider Adenosine if regular and monomorphic Consider antiarrhythmic infusion EXPERT CNSULTATIN Advanced Critical Care Vagal Maneuvers Adenosine (SVT) 6mg IV Bolus 12mg IV Bolus β-blocker or Calcium Channel Blocker EXPERT CNSULTATIN Wide Complex Antiarrhythmic Infusion Procainamide - 20-50 mg/min Amiodarone - 150 mg over 10 min Sotalol - 100 mg (1.5 mg/kg) over 5 min

AT 2 MINUTE CYCLE RE-EVALUATE RHYTHM BRADYCARDIA WITH A PULSE Heart Rate typically < 50 BPM with complaint CARDIAC ARREST ALGRITHM HELP ACTIVATE EMERGENCY RESPNSE Monitor and bserve Expert Consultation UNIVERSAL ASSESSMENT Reversible Causes? H s & T s Airway? BVM as necessary xygen if Hypoxic Pulse, and Blood Pressure Cardiac Monitor IV Access Persistent bradyarrhythmia with HYPPERFUSIN: Hypotension Altered Mental Status Shock Ischemic Chest Pain/discomfort CNSIDER ATRPINE Atropine Dose: - First Dose: 0.5 mg IV Bolus - Repeat Dose: 0.5-1 mg IV Bolus Repeat every 3-5 minutes Max total dose: 3 mg If Atropine is not effective: - Transcutaneous Pacing R - Dopamine infusion - 2-10 mcg/kg/min R - Epinephrine infusion - 2-10 mcg min START CPR Give xygen Attach Monitor/Defibrillator CHECK RHYTHM VF/VT SHCK Drug Therapy IV/I Access Vasopressor 3-5 min Amiodarone VF/VT CNSIDER ADVANCED AIRWAY TREAT REVERSIBLE CAUSES H s & T s RSC C N T I N U U S C P R M N I T R C P R E T C 2 M A P Consider: Expert Consultation Transvenous Pacing PST CARDIAC ARREST CARE

PALS Assessment Peds Assessment Triangle Alert Skin Color Breathing Primary Assessment Airway Patent? Breath- Breathing Sa2? Rate? Work of Breathing? Supplemental 2? Circulation Skin Color/Temp Heart Rate-Heart Rhythm -B/P Pulses Cap Refill Disability AVPU Response GCS Pupillary Response Exposure Secondary Survey HISTRY Signs and Symptoms Allergies Medications Past Medical History Last Meal Events Detailed Physical Head to Toe Assessment Tertiary Assessment Bedside Glucose ABG PETC2 Monitoring Chest X-Ray Expiratory Peak Flow CAT Scan Respiratory Emergency Respiratory Distress vs Failure? Upper Airway - Croup - Anaphylaxsis - Foreign Body Sa2 94-99% Lower Airway Asthma/RAD Bronchiolitis Lung Tissue Disease - Infectious Pneumonia - Aspiration - Chemical Exposure - ARDS - Pulmonary Edema Disorder of Breathing - Drug overdose - Poisoning - Increased ICP - Neuromuscular Disease Evaluate Identify Intervene Circulatory Emergency Shock Hypovolemic - Nonhemorrhagic - Hemhorrhagic bstructive - Cardiac Tamponade - Tension Pneumo - Pulmonary Emboli - Congenital Lesions Distributive - Septic - Anaphylactic - Neurogenic Cardiogenic - pulmonary edema - venous congestion - cardiomegaly Fluids 5-10 ml/kg Evaluate B/P 0-1 y/o >60-70 systolic 1-10 y/o > (age x 2) + 70 > 10 y/o > 90 systolic 20cc/kg isotonic crystalloid Intravenous Intraosseous Rhythm Tachycardia 0-1y/o >220 BPM > 1 y/o >180 BPM Bradycardia HR < 60 BPM CPR Pulseless VF/VT r PEA/Asystole VF/VT Defibrillate 2-4 j/kg IV/I access Rhythm? Defibrillate 4j/kg Epi.01 mg/kg q 3-5 min Rhythm? Defibrillate 4j/kg Advanced Airway PETC2 Amiodarone 5mg/kg H & Ts PALS CARDIAC ARREST Call for Help/Activate Code Team START CPR (Hard and Fast) Give xygen Attach Monitor/Defibrillator Asystole/PEA IV/I access Rhythm? No Epi.01 mg/kg q 3-5 min Rhythm? No Advanced Airway PETC2 H & Ts H & Ts Hypovolemia Hypoxia Hydrogen Ion (H+) Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension Pneumo Thrombosis Pulmonary Coronary Trauma Based on 2010 Emergency Cardiovascular Guidelines for PALS Science

PALS Tachycardia (2010 Guidelines) Identify and Treat Cause Maintain Airway Monitor Pulse ximetry and B/P xygen, IV/I, Csrdisc Monitor, 12 Lead if available Bradycardia <60 BPM CARDIPULMNARY CMPRMISE?? Probable Sinus Tach Hx suggests known cause P wave present Regular R-R and PR interval Infants: <220 BPM Children: <180 BPM Evaluate QRS Width Evaluate Rhythm Probable SVT Vague, non-specific hx Abrupt Rate Changes in HR P waves absent/abnorm Regular R-R and PR interval Infants: >220 BPM Children: >180 BPM Probable V Tach QRS wide >.09 sec Cardiopulmonary Compromise? Hypotension Altered Mental Status Signs of Shock Identify and Treat Underlying Causes Airway and Breathing Sa2? xygen? Respiratory Failure? Circulation Cardiac Monitor Blood Pressure- - Skin Color Cap Refill IV/ I established 12 Lead EKG HR< 60 BPM START CPR Cardiopulmonary Compromise Altered Mental Status Signs of Shock Respiratory Failure Hypotension Treat Reversible Causes Hs & Ts Cardiopulmonary Compromise? Hypotension Altered Mental Status Signs of Shock Bradycardia Persists? Consider Adenosine if regular and monomorphic SYNC Cardioversion Epinephrine.01 mg/kg Consider Vagal Maneuvers Establish vascular access Consider adenosine 0.1 mg/kg IV/I (max 6 mg) Second dose adenosine 0.2 mg/kg IV/I (max 12mg) Consider Vagal Maneuvers DELAYS If IV/I present,give adenosine R IF IV/I Access is not available, or if adenosine is ineffective, SYNC Cardioversion Expert consultation advised CARDIVERSIN 0.5 to 1 J/kg (may increase if initial dose ineffective) Sedate before Cardioversion Airway Breathing Circulation bserve CNSIDER EXPERT CN- SULTATIN Bradycardia Persists? Repeat Epinephrine Consider Atropine Consider Pacing Treat Hs & Ts

Basic Life Support for Healthcare Providers 2010 Guidelines Recommendations Adult Child Infant Evaluation Unresponsive No Breathing or only gasping/agonal breathes No pulse palpated within 10 seconds CPR Sequence Compression Rate Compressions Airway Breathing > 100/minute Compression Depth > 2 inches > 1/3 Diameter of Chest Approx 2 inches > 1/3 Diameter of Chest Approx 1.5 inches Chest Wall Recoil Allow complete recoil between compressions Rotate Compressors every 2 minutes Compression Interruptions Minimize Interruptions Limit interruptions to less than 10 seconds Airway Compression:Ventilation Ratio With Basic Airway BVM or Mask Ventilations with Advanced Airway Defibrillation Head Tilt Chin Lift (suspected Trauma: Jaw Thrust) 30:2 1 or 2 rescuers 30:2 ne Rescuer 15:2 Two Rescuer 1 breath every 6 8 seconds (8-10 breaths/minute) Continuous compressions while ventilations are delivered Use AED as soon as available. Continue compressions while applying AED if second rescuer is available. MINIMIZE INTERRUPTINS Resume CPR Starting with Compressions