ACLS Provider 2015

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The sequence for BLS for an Adult or Child who is unresponsive and pulseless.

C-A-B (Chest compressions, Airway, Breathing)

A pulse check during the BLS survey should be performed for this length of time.

5 to 10 seconds

A likely indicator of a cardiac arrest in the unresponsive patient.

Agonal gasps

After discovering an unresponsive patient, what is the next step in the assessment and management of this patient?

Check the patient’s breathing and pulse

Compressions rate in an arrest.

100/min to 120/min

The ratio of compressions to breaths for the Adult, Child and 1 rescuer infant arrest.

30 compressions to 2 breaths

The ratio of compressions to breaths for Infant 2-rescuer arrest.

15 compressions to 1 breath

What you should do if the patient is unconscious and apneic and you are uncertain rather or not a patient has a pulse

Begin compressions

To properly ventilate a patient with a perfusing rhythm, what is the rate to squeeze the bag (BVM)

Once every 5 to 6 seconds

The potential complication of excessive ventilations.

Decreased cardiac output

Where to measure to appropriately size an oropharyngeal airway.

Measure from the corner of the mouth to the angle of the mandible

When an advanced airway is in place, how should compressions be delivered?

Continuous chest compressions without pauses

In the intubated patient, the technique to assess the quality of CPR.

Monitor the patient’s PETCO2

Your next action if after 2 minutes of CPR an organized, nonshockable rhythm is identified.

Check a carotid pulse

The recommendation for chest compression depth for an Adult and CHILD.

At least 2 inches (5 cm) but not more than 2.4 inches

Components of High-Quality CPR

• Compress the chest hard and fast • Allow complete recoil after each compression • Chest compressions should be interrupted 10 seconds or less • Switching providers every 2 minutes or every 5 compression (if unable to determine exact time) cycles improves the quality of chest compressions • Continue CPR while the defibrillator charges

The AHA position on routine use of cricoid pressure in cardiac arrest.

The guidelines do not recommend routine use of cricoid pressure in cardiac arrest.

The definitive treatment for ventricular fibrillation

Prompt defibrillation

The recommended next step after a defibrillation attempt

Resume CPR, starting with chest compressions

One measure to minimize interruptions in chest compressions

Continue CPR while charging the defibrillator

Action to take if during the use of an AED you are not directed to check the rhythm

Continue CPR (starting with chest compressions) then check the equipment.

Measures to provide electrical safety during cardioversion or defibrillation.

• Being sure oxygen is not blowing over the patient’s chest during the shock • Verbally and visually "clear" the field • Charge defibrillator when paddles are in place on the chest • Consider hands free pads

An advantage of hands-free pads verses defibrillator paddles

Hands-free pads allows for more rapid defibrillation

Physiology of how CPR is a survival advantage

Supplying a small amount of blood flow to the heart and reducing ischemia

Problem and management of using of an AED with a hairy chest

If skin contact is not made AED pads the machine will not be able to analyze; remove the hair.

Problem and management of using of an AED when the patient is partially submerged in water

Remove the patient from the water and dry off

Problem and management of using of an AED when patient is lying on snow or ice

Use the AED

If a patient has an implantable device such as a pacemaker/AICD that is not functioning the location you should place the universal pads

Place the AED pads on either side not directly on top of an implantable device

Special consideration where to locate AED pads if a patient has a medication patch who requires defibrillation

Do not place AED directly over a medication patch

The recommended initial biphasic energy dose for cardioversion of atrial fibrillation

120 to 200 Joules

The recommended initial monophasic energy dose for cardioversion of atrial fibrillation

200 Joules

Initial energy recommendation for an adult in unstable monomorphic ventricular tachycardia or SVT

Synchronized cardioversion initial energy of 100 Joules (or biphasic equivalent)

If rhythm is unresponsive to the initial cardioversion attempt, the energy recommendation for next attempt for an adult in unstable monomorphic ventricular tachycardia or SVT

Increase the dose in a stepwise fashion for monophasic 200 joules, 300 joules, then 360 joules (or biphasic equivalent)

Management for a patient who is rapidly deteriorating in SVT or monomorphic V-Tach with a pulse (even if profoundly hypotensive)

Immediately synchronized cardioversion starting at 100 joules (or biphasic equivalent)

If equipment is available, the management of a witnessed arrest of V-Fib or pulseless V-Tach

Immediately defibrillation at 360 joules or biphasic equivalent

In addition to the clinical assessment, ________________ is the most reliable method of confirming and monitoring correct placement of an endotracheal tube.

Continuous Waveform Capnography

High quality chest compressions are achieved when the PETCO2 value reaches

At least, 10-20 mmHg

The indication of a PETCO2 level < 10 mmHg

Potential poor perfusion from ineffective CPR

PETCO2 target range for the patient with return of spontaneous circulation

35-40 mmHg

Algorithm indicated for the tachycardic patient with a pulse

ACLS Tachycardia Algorithm

If a patient has respiratory failure but is perfusing and gradually becomes bradycardic, the management and treatment focus

Treat the respiratory cause of the bradycardia by airway maneuvers and assisting ventilation

The rationale for defibrillation of pulseless ventricular tachycardia

Pulseless ventricular tachycardia is treated like ventricular fibrillation because both are non-perfusing shockable rhythms

The initial priority for an unconscious patient with a tachycardia

Determine rather or not a pulse is present

Signs and symptoms of decreased perfusion

• Hypotension • Chest pain • Change in Level of Consciousness • New or worsening heart failure

Management of a patient is in a bradycardic rhythm (even 3rd degree AV Block) who is asymptomatic with stable vital signs

• Conduct a problem-focused history and physical exam • Consider having a transcutaneous pacemaker on stand-by

The first medications to be given in any cardiac arrest

Oxygen and epinephrine

The next recommended medication after epinephrine is administered for refractory ventricular fibrillation or pulseless ventricular tachycardia

Amiodarone 300 mg

Medication that is NO longer used in the management of pulseless electrical activity (PEA) or asystole


Indications for Adenosine

Initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide complex tachycardia (ventricular tachycardia) and SVT

Dosing of Adenosine

Adenosine is 6 mg IVP rapidly followed by 12 mg IVP rapidly

Dosing range for Dopamine

2 to 20 mcg/Kg/min

The treatment priority for patients who achieve return to spontaneous circulation

Optimize ventilation and oxygenation

SBP goal is to achieve by using fluid administration or vasoactive agents.

At least 90 mmHg,

Initial management of hypotension with return to spontaneous circulation

1 to 2 liters of NS or LR

The recommended dose of an Epinephrine infusion, for management of hypotension with return to spontaneous circulation

0.1 to 0.5 mcg/Kg/min

An important intervention to manage an out-of-hospital resuscitation that achieves return to spontaneous circulation

Transport to a facility capable of coronary reperfusion (performing a PCI)

Danger if you routinely administer high concentration of oxygen in the post arrest management of patients

Oxygen toxicity

The cardiopulmonary and neurologic support during the post arrest

Therapeutic hypothermia and percutaneous coronary interventions (PCIs),

Therapeutic hypothermia should be considered in these populations of adult patients who achieves return to spontaneous circulation

Patients who remain comatose after the arrest defined as the lack ability to follow commands without contraindications to inducing hypothermia

Contraindications to inducing hypothermia

• Patients responding to verbal commands • Patients with potential to bleed or recent bleeding • Hemorrhagic stroke • Arrest due to trauma

Target temperature goal and duration when inducing therapeutic hypothermia who achieves return to spontaneous circulation after an arrest

32 Degrees C to 36 Degrees C for a recommended duration of at least 24 hours.

Once the patient with chest discomfort is assessed as being stable, the most important assessment or next step

Obtain a 12-Lead ECG

The recommended goal from door-to-balloon inflation time for percutaneous coronary intervention (PCI)

90 minutes.

Management of a patient who is hemodynamically stable without chest pain in a tachycardic rhythm

12-lead done before another procedure to different the cause of the tachycardia (AMI).

The recommended dose of aspirin for a patient with chest pain

160 to 325 mg.

Target goal for oxyhemoglobin saturations in patients with acute coronary syndromes and/or stroke

Greater than or equal to 94%

The next step once the primary survey is performed on a potential stroke victim

Perform the Cincinnati Prehospital Stroke Scale assessment

According to the Adult Suspected Stroke Algorithm a critical action that should be performed by the EMS team to expedite the patient’s care on arrival and reduce time to treatment

Alert the hospital

Recommended time for a noncontrast CT scan of the head should be performed once a potential stroke victim arrives at the hospital

Within 25 minutes

Meaning of F.A.S.T. Acronym in a potential stroke victim

• Facial Droop • Arm Drift • Speech ineffective • Time of onset of symptoms

Action if a radio report is received in the pre-hospital setting that the CT scanner is inoperable and you are transporting a potential stroke patient

Diverted to a hospital that has CT capabilities

One of the first intervention in the ED, once a CT scan is obtained, for a stroke victim

Start fibrinolytic therapy as soon as possible as long as • CT is normal without signs of hemorrhage • The patient has arrived within the 3 to 4 ½ hours from the onset of symptoms • No assessed contraindications are present

Target range for Blood pressure prior to administering thrombolytics in a stroke victim

SBP less than 185 mmHg DBP less than 110 mmHg

Right ventricular infarcts are most often associated with __________ myocardial infarctions

Inferior MI (Leads II, III, AVF)

Considerations if right ventricular infarct suspected

• Obtain right-sided ECG • Nitrates and morphine may be contraindicated • Patient may require IV fluids for hypotension

Caveat to obtain vascular access, drug delivery, or advanced airway placement

Should NOT interrupt CPR

The location and leads used by Bob Page’s mnemonic "I See All Leads" to describe location of infarcts

• I = Inferior ( Leads II, III, AVF) • See = Septal (V1 and V2) • All = Anterior left ventricle (V3 and V4) • Leads = High lateral (I and AVL) Low lateral left ventricle (V5 and V6)

ECG changes associated with an acute MI (Injury)

ST segment elevation

ST segment elevation in lead I and III considered


The preferred access for medications in the arrest is a large peripheral vein such as the antecubital. If unable to obtain a peripheral access, the next most preferred route

Intraosseous (IO)

What the team leader should do to avoid inefficiencies during resuscitation

Clearly delegate tasks

Team leader instructs a team member to give 0.5 mg of Atropine, to which the team member responds with "I’ll draw up 0.5 mg of Atropine." This type of communication is called

Closed-loop communication

Action the team leader or other team members should do if a team member is about to make a mistake during resuscitation attempt

Address the team member immediately

The action that a Team Member is responsible to perform they feel they are unable to perform an assigned task because it is beyond the team member’s scope of practice

Ask for a new task or role

Action required by the Team Member Team member if they are uncertain if the correct amount of amiodarone was order by team leader, so the team member because of noise or other distractions

Should repeat the order and ask for verification

Medical Emergency Teams (MET) or rapid response teams (RRT) have demonstrated the reduction of cardiac arrest in the inpatient environment. The primary purpose of a MET or RRT

Improving patient outcomes by identifying and treating early clinical deterioration

Conditions where resuscitation efforts should be withheld

• There is a perceived safety threat to the provider • Signs of irreversible death (e.g., decapitation, rigor mortis, or decomposition) are present • If the patient has a medical directive excluding advanced cardiac life support techniques.

ST elevation in V1 through V4

Anterior MI (anteroseptal)

ST depression in V1 through V4

Potential Posterior MI

Considerations with return of spontaneous circulation

• Ventilation and Vital Signs • Oxygenation • Medications • IV access, IV fluid administration • Therapeutic interventions (Induction of hypothermia, 12-Lead ECG, Chest x-ray

Ventricular Fibrillation

Complete Heart Block

2nd Degree AV Block Type II


Monomorphic V-Tach

Torsades de Pointes

Antidote Tricyclic Overdose

Sodium Bicarb

Dose of Sodium Bicarb in an arrest

1 meq/Kg

Management hyperkalemia in the emergency

• Sodium Bicarb • Insulin and D50% • Calcium Chloride

ECG changes associated with hyperkalemia

• Tall peaked T waves • Wide QRS

ECG changes associated with hypokalemia

• Flat T waves • U wave

Antidote for opioid overdose

• Narcan

Antidote for benzodiazepines

• Flumazenil

Antidote for digoxin toxicity

• Digibind

Antidote for organophosphate poisoning

• Atropine • Pralidoxime (2 PAM)


Sinus Brady


Atrial Fibrillation

Atrial Flutter

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