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Welcome/Introduction AHA ACLS Overview Video Instructor presentation of lethal rhythms & pretest AHA Video ACLS Primary/Secondary Survey Instructor presentation of 2011 BLS AHA ACLS Video Airway Management AHA BLS Video Practice BLS with manikins/BMV/Barrier/AED Instructor presentation of ACLS AHA video of Heart Attack and Stroke AHA video of Mega Code Instructor presentation of Mega Code Skills stations Written exam
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Welcome, Introduction, Pretest Lethal Rhythm Review & Practice Primary and Secondary Survey Video/Practice Airway Management BLS Practice Lunch VF/PEA/Asystole Bradycardias Tachycardias Acute Coronary Syndrome/Stroke Practice Skills Airway Management Defibrillation Cardioversion Scenario Discussions if time allows Mega Code instructor presentation
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Putting it all together Mega Code Review Mega Code and Written evaluation Remediation if appropriate
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Q = Infarction ST (depression = ischemia) (elevation = acuteness) T inversion = Ischemia Q waves with ST segment elevation may indicate an ST segment elevated myocardial infarction (STEMI) and rapid and early reperfusion is essential for optimal outcome.
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This is a First Degree Block because the PR interval is greater than 0.20 seconds. ♥ ♥ Each little box measures 0.04 seconds. There are 8 little boxes from the beginning of the P to the beginning of the Q. ♥ ♥ The PR interval in this strip is 8 x .04 = .32 seconds. bpm. If this patient is symptomatic and ♥ ♥ This heart rate is about 40 bpm. probably is, Atropine is the drug of choice at 0.5 mg.
This is a Mobitz I, Second Degree Block. It is also called the Wenckebach. ♥ ♥ The PR interval progressively lengthens until a QRS complex is dropped. ♥ ♥ The patient has a heart rate of about 60 bpm and may be asymptomatic and may require no intervention, but you won’t know until you check on this patient. If the patient is symptomatic you may consider Atropine at 0.5 mg.
This is a Mobitz II, Second Degree Block. The QRS complexes are dropped following some of the P waves. ♥ ♥ There is no progression of PR int ervals as in the Mobitz I. ♥ ♥ This is a serious situation!! ♥ ♥ This requires a Transcutaneous Pacemaker. Atropine 0.5 mg while awaiting the pacemaker. pacemaker. ♥ ♥ You may consider Atropine Atropine speeds up the SA 9 node and since t here are P waves that are “blocked” it is not a good drug for these high degree blocks. (AHA 2010
This a Third Degree/Complete Heart Block. The atrium is working. The ventricles are working. But they are not working together. The P waves are marching across. The QRS complexes are marching across. But they are not marching together. The P wave does not cause the QRS complex to occur. There is a complete block. This is serious. Your patient will require a Transcutaneous Pacemaker. Atropine speeds up the SA node and since there are P waves that are “blocked.” You need a transcutaneous pacemaker. You should consider Atropine while preparing for for the acemaker*. (A (AHA HA 201 2010 0 U dat datee
This is another sample of a Third Degree/Complete Heart Block Notice the PR intervals are not consistent. Try Atropine but don’t rely on atropine to do t he job Try Transcutanious Pacing Try Epinephrine and/or Dopamine for it’s vasoconstrictive properties. Epinephrine dose is 2-10 mcg/min whereas Dopamine dose is 2-10 mcg/kg/min Do you see the similarities Do you see the differences Keep in mind – check the pulse 10 If there is no pulse- administer Epinephrine 1 mg*
Atropine is no longer recommended. (AHA 2010 Update) Give priority to IV/IO access. Do not routinely insert an advanced airway unless bag/mask is ineffective
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This is a fibrillating heart and often referred referred to as a Ventricular Fibrillation – sometimes called a VF. To defibrillate a fibrillating heart – “shock it” to “stop it”. Like rebooting your computer!!!. This rhythm is appropriate to defibrillate There are two ways t o defibrillate – Monophasic or Biphasic Monophasic defibrillators direct the electrical energy into one Pad and out the other other - Use 360 joules Biphasic defibrillators direct the electrical energy into both pads at the same time. Biphasic is better because you only have to use use half half as as man man outles outles – 200 oules oules
This is an Asystole. It is also referred to as an agonal rhythm. You must not call this a Flat Line. A Flat Li ne occurs when the leads come off your patient. An Asystole occurs when the heart dies. To confirm the difference between asystole and flat line – turn up the gain or sensitivity on your monitor. An Asystole is the final rhythm of a patient initially in VF or VT Prolonged efforts are unnecessary and futile unless special si tuations exsist such as hypothermia and drug overdose. overdose. Keep up with your high-quality CPR Try some Epinephrine 1 mg every 3-5 minutes. Try some Vasopressin 40 units units for EITHER the first dose of
Epinephrine or the second dose. NOT in addition to Epi.. 11
This is a Torsades de Pointes. This is a rhythm that is “wide and ugly.” Wide and ugly is usually ventricular i n origin. Look closely at this rhythm – it appears in groups. That indicates it is “jumping its focus.” Ma nesium nesium is the the dru of choice. choice.
This is called a polymorphic tachycardia. This is another tachycardia that i s “wide and ugly!!” Wide and ugly is usually ventricular i n origin. The complexes are irregular. If a patient has polymorphic VT, the patient is likely to be unstable, and rescuers should treat the rhythm as V F. They should deliver highenergy defibrillations. (2005 Update)
This is called a monomorphic tachycardia. tachycardia. This is another tachycardia that i s “wide and ugly!!” This may or may not be ventricular 12i n origin. The complexes here are uniform.
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This is a Supraventricular Tachycardia. This rhythm is going very fast. It is going “super fast.” It is originating above the ventricles. ventricles. Therefore – supra-ventricular tachycardia. Check your patient. ♥ ♥ If this patient is stable – try Adenosine. The initial dose is 6 mg* If that doesn’t work you may try 12 mg and if that doesn’t work try again 12 mg. ♥ ♥ Push it fast and flush it fast. Anticipate a 6 second asystole. You could try the Vagal Maneuver. The AHA considers the vagal maneuver your first intervention.* Be careful, your hospital may not want you to do this. You may vagal your your patient down to a complete heart block.
This is another example of a Supraventricular Tachycardia.
This This is a Tach cardia cardia with with the the Va al Maneuv Maneuver. er.
This is a “wide-complex” tachycardia. Assume it is ventricular in origin until you prove prove otherwise. Therefore, this is a ventricular tachycardia.. If the patient is stable you should should consider Amiodarone for treatment. (AHA 2010 Update) ♥ ♥
Supraventricular Tachycardias: ♥ ♥ Usually go faster than 180 ♥ ♥ Have an abrupt start ♥ ♥ Have narrow complexes
If the patient is unstable you should check his pulse. If he is unstable with a pulse you would need to cardiovert. If there is no pulse this is a pulseless ventricular tachycardia and you need to defibrillate.
Note you may not see the abrupt start on the ECG strip (like on your test)!!! The test question states that the patient suddenly felt dizzy, indicating a SVT may have have occurred. If this patient is stable:* ♥ ♥ Try the vagal maneuver* ♥ ♥ If that doesn’t work, try adenosice 6-12-12 ♥ ♥ If that doesn’t work, try cardioversion
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Once the tube is inserted the placement needs to be confirmed: ♥ ♥ Mist in the tube may be first seen. ♥ ♥ Check for gastric sounds next. ♥ ♥ Check for lung sounds – left first then right. ♥ ♥ CO2 detector turning “gold.” capnography waveform is the most reli able method of ♥ ♥ Continuous capnography confirming and monitoring placement of the ET tube* ♥ ♥ Capnography is now recommended by the AHA to confirm and monitor the endotracheal tube as well as the adequacy for CPR* based on on end-tidal end-tidal CO2. Update 2010
Recall lab values values of CO2 level level of a blood Gas Gas should be 35-40. Therefore, the closer your capongrahy reading is to normal values, the more effective the resuscitation technique. Such as after ROSC the PETCO2 should be 35-40 mg/h A PETCO2 level of >10 would be a sign of effective CPR.* whereas, a PETCO2 level of 8 would indicate indicate ineffective CPR*
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S,.Q*( -4+// 4=( /(%#(*TT Continue CPRW Delegate your team to look for the Possible Causes P = Possible cause (?) E = Epinephrine 1 mg mg *. which is a vasopressor No vasopressor has been shown to increase survival from PEA. Because vasopressors (epinephrine (epinephrine and vasopressin) can improve aortic diastolic blood pressure and coronary artery perfusion pressure, vasopressors such as epinephrine continue to be recommended*. A = No longer is Atropine recommended for PEA.. The AHA recommends Vasopressin (2010 Update) The ability to achieve a good resuscitation outcome, with return of a perfusion rhythm and spontaneous respirations of a PEA depends on rapid assessment and identification of an i mmediately correctable cause. The two most common causes of PEA are hypovolemia and Hypoxia The American Heart refers to the causes as the H’s and T’s They are as follows: ♥ ♥ Hypovolemia Clues: Poor skin color (pallor). Rapid heart rate with narrow complex Flat neck vein Intervention: Open up the bag of NS ♥ ♥ Hypoxia Clues: Cyanosis Slow heart rate Intervention: Check the FIO2 Check airway placement
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Hypothermia Clues: Intervention: Caution: Hyperkalemia Clues: Intervention: Hypokalemia Clues: Intervention:
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Hydrogen ion excess Clues:
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Hypoglycemia – Clues: Intervention: Tension Pneumothorax Clues:
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Intervention: Tamponade – Clues: Intervention: Thrombosis Clues: Clues:
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Cold skin Low core temperature Use warmed NS “not dead till warm and dead.” Peaked T waves History of renal failure Infuse Na Bicarb Flat T waves Infuse K+ (not be confused with K+ bolus!) – metabolic acidosis Small amplitude QRS History of renal failure Altered LOC D5 w – check breath sounds Deviated trachea Neck vein distention Needle decompress the chest
Prognosis is poor ♥ ♥ Continue CPR ♥ ♥ IV access is a priority over advanced airway management unless bag/mask ventilation is ineffective. ♥ ♥ Do not routinely insert an advanced airway unless ventilations with a bag-mask are ineffective. ♥ done – Do not ♥ Start 2 IV sites in the anticubital if not already done interrupt CPR for IV access ♥ ♥ Try more Epi 1 mg or Vasopressin as an alternative for EITHER the first or se cond dose of epinephrine The standard epinephrine dose is 1 mg IV/IO every 3-5 minutes of 1:10,000 solution*. High-dose epinephrine is not routinely recommended. The AHA no longer recommends Atropine for the as ystole (2010 Update)
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Bulging neck veins Rapid heart rate Pericardiocentsis coronary and/or lung Coronary = ST segment elevation = STEMI Lung = Distended neck vein – Call the surgeon.
Toxins - (drug overdose) overdose) Clues: Bradycardia Intervention: Try some Narcan Trauma
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Remember – this is a nonshockable rhythm Be aware of some reasons to terminate resuscitative efforts, such as rigor mortis, indications of DNR and threat to safety.
This “delegating” is kinda nifty!! nifty!! You may like being the code code team leader!!
If the following rhythm appears on the monitor you must call this an asystole. Do not call this this rhythm a “flat line.”
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Capnography detects the return of ROSC. Post-cardiac arrest PETC02 with ROSC is 35 - 40 mm Hg During cardiac arrest, if you see PETCO2 shoot up, stop CPR and check for the pulse. There is an average sudden PETCO2 increase by 13.5mmHg with sudden ROSC before settling into a normal range. Capnography detects the loss of ROSC. If PETCO2 significantly drops, check for the pulse. If no pulse, start CPR. CAUTION: CAUTION: Hyperventilation in trauma victims decreases intracranial pressure (IPP) by decreasing the intracranial blood flow. The result is cerebral ischemia.
/*#,#0, 12#0,-)$0 1. The initial intervention for all bradycardia is __________ __________ (Atropine 0.5 mg) 2. A patient has sinus bradycardia with a rate of 36 per minute. Atropine has been administered administered to a total dose of 3 mg. mg. A transcutaneous pacemaker pacemaker has failed to capture. The patient is dizzy with SOB. Which drug would administer with with what dose? dose? _______________( _______________( Dopamine 2-10 mcg/kg/min) 3. A 52 year old female female presents to the ED with persistent epigastric pain. Her vitals are stable along with the O2 sat. What is you first interevention?_____________ interevention?______________________ _________________ _________ _ (Obtain a 12-lead ECG)) 4. High quality CPR includes 4 components. They are__________ are__________ (push hard),_____________(p hard),_____________(push ush fast)___________,(allow fast)___________,(allow the chest to recoil) and _____________(minimize _____________(minimize interruptions) 5. The best chance of successful defibrillation is_____________ is_____________ _________________________________________________ (perform high quality chest compressions prior to defibrillation) 6. What action would help to minimize i nterruptions during a code call that requires defibrillation? __________________ ______________________ ____ (Continuing Chest Compressions while the defibrillator is charging). 7. A defibrillator may be equipped with “hands free pads” are better than “paddles.” Why are hands free free pads better?________________________________________ They can provide a more rapid defibrillation) 8. Many hospitals have Rapid Response Teams. What is their main purpose?____________________________________( Prevents deterioration to overt a code call)
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28. An EMS crew can terminate resuscitation if _____________ (rigor mortis) sets in. 29. Three signs of an acute stroke stroke are facial drop, arm drift, and slurred speech. This is referred to as the________________ the________________ (Cincinnati Prehospital Stroke Scale assessment) 30. With a positive prehospital stroke scale you would obtain a set of vitals including blood glucose and order a ________________ ________________ ___________________ ___________________(noncontrast (noncontrast CT scan of the head) 31. If a patient is hypotensive who has achieved ROSC you should bolus with ___________________(1 ___________________(1-2 -2 L) NS or LR 32. The minimum systolic blood pressure you should accept for a hypotensive post cardiac arrest that has achieved ROSC i s ________________(90 mg Hg) 33. Your priority in the care a patient with ROSC is optimizing _________________and_______________(oxygenation and ventilations) 34. A patient suddenly collapsed and and is poorly responsive. The monitor reveals a third-degree block. There is an IV access and supplemental oxygen is being administered with a nonrebreather. What would you firs t do?_____________(Give do?_____________(Give atropine 0.5 mg and begin pacing as soon as the pacemaker is ready). 35. A patient becomes unresponsive and you are uncertain if a faint pulse is present. What would you you do?_________________ do?___________________(Begin __(Begin CPR wi th high-quality chest compressions) 36. A patient with a wide-complex tachycardia that is unstable you must_________________(card must_________________(cardiovert) iovert) You may not have time to medicate this patient if he is severely unstable.
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The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the Association.-ll
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