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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 Automated External Defibrillation. You will properly attach and safely use an automated external

fibrillation or pulseless ventricular tachycardia. You will be functioning as the team leader, and must direct all care provided for the "patient".

3.

4. ACLS Post-test.
TEXTS

defibrillator. This may be a separate station or could be incorporated into your Mega VF evaluation, depending on your experience with an AED. 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.

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)

Created by Kim Chunn 9/01 Revised 12/04

1

Needle Cricothyrotomy c. Dysrhythmia Recognition a. Defibrillation b. Synchronized cardioversion c. Electrical Therapy a. PEA 2. Oral airway iv. VF 2. Tachycardia. Stable and Unstable 4. Pulseless VT ii. Non-shockable 1. Combitube 3. Suction vi. Asystole b. Provide oxygen i. Transcutaneous pacing 5. Head-tilt/chin-lift ii. Perfusing (peri-arrest) rhythms i. Non-perfusing (arrest) rhythms i. Airway/Breathing a. Nasal airway v. Open the airway/keep it open i. Pharmacology VF/Pulseless VT Stable Tachycardia Unstable Tachycardia Pulseless Electrical Activity (PEA) Automated External Defibrillation Created by Kim Chunn 9/01 Revised 12/04 2 . 100% non-rebreather mask b. Peripheral IV access 6. Ventilate i. Shockable 1. LMA 2. Nasal cannula 2-6 liters/minute ii.THE 10 ACLS CASES Respiratory Arrest w/ Pulse Bradycardia Acute Coronary Syndromes Asystole Acute Ischemic Stroke THE ACLS SKILLS 1. 2-person technique 2. Circulation 3. Alternative Devices/Techniques 1. with oral airway 2. Jaw thrust iii. Mouth-to-Mask ii. Bag-Mask 1. Endotracheal Intubation vii. Symptomatic Bradycardia ii.

5-1 mg q.5-1. Mix 1-2 gm/250 cc of D5W Dopamine 5-10 mcg/kg/min. up to a total of 17 mg/kg Magnesium Sulfate 1-2 gm in 10 ml of D5W over 1-2 min. Adenosine 6 mg over 1-3 sec. Maintenance infusion: 1 mg/min for 6 hrs decreasing to 0.5 mg/min for 18 hrs.2 gm IV/24 hrs. one time only (VF only) Atropine** 0. Vasopressin 40 units. contraindications): ** DRUGS ACCEPTABLE VIA ETT ROUTE: Drugs given via endotracheal tube should be given at 2 to 2. Created by Kim Chunn 9/01 Revised 12/04 3 . 3-5 min. pgs. single dose. 10 mins. up to a total of 0. dose. 5-10 min. Lidocaine** 1-1. INFUSIONS: Lidocaine 2-4 mg/min. consider repeating 150 mg in 35 min. Max cumulative dose 2.5 times the IV dose and diluted in 10 ml. indications. 3-5 min. 54-72. Mix 400 mg/250 cc of D5W Epinephrine 2-10 mcg/min. repeat at 0. Sodium Bicarbonate 1 mEq/kg. repeat at 12 mg.04 mg/kg Amiodarone (VF/VT) 300 mg.PHARMACOLOGY The following drugs are part of the ACLS algorithms and are the ones you are expected to know readily (drug. Mix 1-2 gm/250 cc. may repeat every 10 mins prn. after 1-2 min. IV PUSH DRUGS: Epinephrine** 1 mg q. of saline. twice (30 mg total) Further information on ACLS Pharmacology can be found in the ECC Handbook. up to 3 mg/kg max Procainamide 20-50 mg/min. route(s). Mix 1-2 mg/250 cc of D5W Amiodarone Rapid infusion (non-VF): 150 mg over 10 min.5 mg/kg.5 mg/kg q. repeat at 0.5 mEq/kg q. of D5W Procainamide 1-4 mg/min. followed by saline bolus to flush.

Remember: 1) V-Fib rhymes with Defib and there should be a direct neurologic synapse between them. 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. Next go to COTE then think Defib . 2) Asystole goes straight to COTE then out to Atropine.etc.Drug . which also begins with an A. single dose.Defib . 1 time only as alternative to epinephrine and may return to epinephrine 1 mg Q 3-5 mins if no response after 10-20 mins. Created by Kim Chunn 9/01 Revised 12/04 4 .Drug .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. 3) PEA goes straight to COTE then out to Etiology and then to Atropine if the rate is less than 60.

movement. 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 30-60 seconds: pulse. return or remaining presence of normal breathing pattern.AUTOMATED EXTERNAL DEFIBRILLATION (pending the arrival of EMS) Unresponsive—911---AED: • Check if unresponsive • Call 911 • Get AED • Identify and respond to special situations Unresponsive Start ABCDs: • Airway: open airway. color. 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 30-60 seconds: pulse. 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 Created by Kim Chunn 9/01 Revised 12/04 5 . color. hold it open • Breathing: look. movement.

hypoxia Reposition airway---head-tilt/chin-lift Consider oral airway. needle cricothyrotomy. use 2 people Maintain head-tilt/chin-lift. hypercarbia. Consider intubation by most experienced person Continue bag-mask ventilation and call anesthesia if no experienced person present Created by Kim Chunn 9/01 Revised 12/04 6 . hypoglycemia.Respiratory Emergencies Is the patient breathing? YES NO Allow pt. Combitube. consider oral airway Consider quickly reversible causes of apnea: narcotic OD. to assume position of comfort Provide oxygen prn Suction prn Monitor respirations: Depth. resp. use 2 people Rapidly assess for airway obstruction Immediately intubate if no obstruction Prepare for alternative airway access: emergent tracheotomy @ bedside LMA. rate Attempt to ventilate patient: Does chest rise with ventilation? Begin ventilations as indicated YES NO ACT QUICKLY! PATIENT WILL DIE IF NO AIRWAY IS ESTABLISHED Continue ventilations w/ 100% oxygen Squeeze bag slowly and gently. bilateral chest rise.

1. Reassess ABCs—Blood pressure preferred circulatory assessment Created by Kim Chunn 9/01 Revised 12/04 7 .20 µg/kg per minute Epinephrine 2 . 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 0.10 µg/min Transcutaneous pacer ---may try Atropine until transcutaneous pacer arrives.04 mg/kg) Transcutaneous pacing if available Dopamine 5 .10 µg/min Isoproterenol 2 .SYMPTOMATIC BRADYCARDIA Assess ABCs Oxygen—IV access—monitor—fluids Vital signs.0 mg q 3-5 min (up to 0. pulse oximetry.5 .

May go directly to cardioversion Wide-complex amiodarone 150 mg over 10 mins β blockers calcium channel blockers digoxin procainamide amiodarone 150 mg over 10 mins lidocaine 1.0-1.5 mg/kg. may be repeated in 1 to 2 mins at 12 mg x 2.STABLE TACHYCARDIAS Assess ABCs Oxygen—IV—Monitor Narrow-complex Consider vagal maneuvers Adenosine 6 mg rapid IV push + flush. may repeat at ½ original dose in 5 mins x 2 procainamide 20-50 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 Created by Kim Chunn 9/01 Revised 12/04 8 .

NOTE POSSIBLE NEED TO RESYNCHRONIZE AFTER EACH ENERGY DELIVERY. Many experts recommend anesthesia if service is readily available. go immediately to unsynchronized shocks. barbiturates. meperidine). midazolam. fentanyl. PSVT and Atrial flutter often respond to lower energy levels (50 J). ketamine. morphine. Treat polymorphic ventricular tachycardia (irregular form and rate) like ventricular fibrillation: see VF/pulseless VT algorithm. If delays in synchronization occur and clinical condition is critical. methohexital) with or without an analgesic agent (eg. diazepam. Created by Kim Chunn 9/01 Revised 12/04 9 .UNSTABLE TACHYCARDIAS Assess ABCs Oxygen—IV—Monitor DO NOT DELAY CARDIOVERSION! Have ready: Functional suction unit Bag-valve-mask Intubation equipment Sedate if possible Synchronized cardioversion • • • • Ventricular Tachycardia Paroxysmal supraventricular tachycardia (PSVT) Atrial fibrillation Atrial flutter 100 J 200 J 300 J 360 J Considerations: Effective regimens have included a sedative (eg. etomidate.

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 Created by Kim Chunn 9/01 Revised 12/04 10 . confirm tube placement. fluids Intubate: hyperoxygenate. IV access.PULSELESS ELECTRICAL ACTIVITY CPR—call for monitor-defibrillator Ventilate/oxygenate.

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. Ventilate. oxygenate. IV access Intubate: hyperoxygenate. confirm placement. Insufficient data to support use of defibrillation to rule out “ultra-fine” VF. 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? Created by Kim Chunn 9/01 Revised 12/04 11 .

Lytes.” Created by Kim Chunn 9/01 Revised 12/04 12 . “You can’t teach an old dog new tricks. coag studies Check blood sugar. vital signs Oxygen—IV--Monitor LABS: CBC. treat if indicated Immediate neuro assessment: <25 mins from arrival Review patient history Establish onset (<3 hours required for fibrinolytics) Physical examination Perform neurological examination: *check level of consciousness (Glasgow Coma Scale) *check level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale) Urgent noncontrast CT --door-to-CT performed goal: <25 minutes Read CT scan --door-to-CT read goal: <45 minutes Perform lateral cervical spine xray (pt. check for arrhythmias Alert Stroke Team 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.comatose/hx of trauma) 12-lead EKG.SUSPECTED STROKE (Pre-hospital to ED arrival) Immediate general assessment: <10 mins from arrival Assess ABCs.

Oxygen. focus on eligibility for fibrinolytics • LABS: serum cardiac markers. Start treatment as indicated • Aspirin • β blockers IV • Nitroglycerin IV • Consider ACE inhibitors • Heparin (unfractionated or low molecular weight) IV • Glycoprotein IIb/IIIa inhibitors Select a reperfusion strategy based on resources: Lytics -many choices -rule out absolute contraindications -major surgery or trauma (incl. Aspirin) EMS personnel can perform immediate assessment/treatment (“MONA”). Nitroglycerin. 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. incl. traumatic CPR) in last 21-30 days -stroke of any kind in last 6 months -presence of head lesions -known active bleeding -bleeding disorder: plts <150. targeted H&P. electrolytes. Created by Kim Chunn 9/01 Revised 12/04 13 .ISCHEMIC CHEST PAIN Immediate assessment (<10 minutes) • Vital signs • IV access • 12-lead ECG (physician reviews) • Brief.000 -uncontrolled HTN (>180/100) GOAL: door-to-drug <30 minutes Interventional Cath Lab -experienced operators (>75/year) -high-volume center (>250/year) -cardiac surgical back up GOAL: door-to-balloon inflation 60-120 mins. initial 12-lead ECG and review for fibrinolytic therapy indications and contraindications.

up to 17 mg/kg Defibrillate 200 J (BIPHASIC) Created by Kim Chunn 9/01 Revised 12/04 14 . may repeat in 5 mins up to 3 mg/kg magnesium: 1 to 2 gm in 10 ml D5 W over 1 to 2 mins. confirm tube placement.VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA CPR—call for defibrillator Defibrillate ASAP 200 J 200 J (BIPHASIC) 200 J Check pulse/Resume CPR Ventilate. may repeat in 5 mins procainamide: 20 to 50 mg/minute. 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. IV access Intubate: hyperoxygenate.5 mg/kg. consider repeating 150 mg in 5 mins lidocaine: 1 to 1. oxygenate.

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