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Advanced Cardiac Life Support for Experienced Providers Introduction

1999 American Heart Association


Why a new course on Advanced Cardiac Life Support for Experienced Providers (ACLS-EP)?

Why ACLS for Experienced Providers?

Many providers skip renewal courses
<50% of physicians attend renewal courses every 2 years Alternative renewal course needed Current ACLS Provider Course Too many topics Some topics skipped, incomplete

Why ACLS for Experienced Providers?

ACLS Provider Course
Current algorithms do not cover everything Need more specific recommendations for specific causes of arrest Providers need more case-based teaching of problems based on the premises of ACLS-EP

Two Premises Underlie the ACLS-EP Course

Cause of arrest changes management
If you know why a person goes into cardiac arrest, that should influence how you manage the arrest. Arrests can be aborted if anticipated If you know why a person is on his or her way to cardiac arrest, you can do something to prevent the arrest.

What is the

Universal Clinical Approach?


Universal Clinical Approach A system Approach all patients with this system

The Five Quadrads Approach

Provides a system Includes Primary ABCD Survey Includes Secondary ABCD Survey Includes periarrest patients Includes patients without an algorithm

Case Example
You can judge the quality of an ACLS instructor by how soon he or she starts an interactive case discussion.

Goal: first case within 3 slides or 3 minutes!

Cisco Quadramos
15-year-old with IDDM, ESRD Arrives in ED: weak, short of breath,
chest pain Depressed, taking TCAs Missed last 2 dialysis treatments Triage nurse: He looks like hell Weak pulse, working hard to breathe How would you manage this patient?

Cisco Quadramos
You walk into the room The nurse suddenly shouts, No pulse,
unconscious! Cardiac arrest! Now how would you manage this patient?


Use the Five Quadrads

Cardiac arrest 1. Primary ABCD Survey 2. Secondary ABCD Survey Periarrest 3. OxygenIVmonitorfluids 4. TemperatureHRBPrespirations 5. Tanktankpumprate

The Five Quadrads Approach

Helps to remember 20 things for Starting a code Codes that are not going well Codes when you arrive late Every cardiopulmonary emergency


The Five Quadrads: Details

1. Primary ABCD A = Airway B = Breathing C = Circulation (CPR) D = Defibrillation (AED)


The Five Quadrads: Details

2. Secondary ABCD A = Intubate patient B = Assess intubation C = IV access; rhythm/drugs D = Differential Diagnosis (Think!)


The Five Quadrads: Details

3. OxygenIVmonitorfluids Consider as 1 word: oxygenIVmonitorfluids Always right thing to do Buys time to think


The Five Quadrads: Details

4. TempHRBPRR Drives major CPR decisions Most neglected information in ACLS


The Five Quadrads: Details

5. Tanktankpumprate* How big is the tank (perivascular resistance)? How much is in the tank (volume)? Pump working? Too fast? Too slow?
*Also called the cardiovascular triad in the ACLS textbook


Ruby Lovelle
You are on duty in the ICU Ruby: 20-year-old woman on ventilator set
for CPAP Nasotracheally intubated, lightly sedated Developed ARDS after MVA: multiple fractures After a brief coughing episode: acutely agitated, fighting restraints How would you manage this patient?

Ruby Lovelle
Common aphorism: Sudden respiratory distress in a patient on a ventilator with CPAP = pneumothorax until proved otherwise

Note: If nothing works, repeat Five Quadrads!


Ruby Lovelle
Primary ABCD A = Airway B = Breathing C = Circulation D = Defibrillation

Secondary ABCD A = Airway (intubation) B = Breathing (tube check) C = Cardiac rhythm/drugs D = Differential Diagnosis (Think!)
Temp HR BP RR Tank size Tank contents Pump Rate

Oxygen IV Monitor Fluids

Thomas Gill
34-year-old recreational soccer player Goes to ED for acute, severe ankle sprain Given IM Toradol; sent to x-ray 15 minutes later, returns on a gurney;

x-ray tech: Help him. He turned blue and passed out! Quick check: cyanotic, pulseless, breathless Initial rhythm assessment: coarse VF How would you manage this patient?

Cardiac Arrest Associated With Anaphylaxis and Pseudoallergic Reactions

What are the treatment differences?


Cardiac Arrest Associated With Anaphylaxis and Pseudoallergic Reactions

Volume: massive infusions Epinephrine: much higher doses Corticosteroids: early, large doses Inhaled adrenergics General anesthesia Antihistamines: early, large doses


What Are Special Resuscitation Cases?

Definition: ACLS and PALS treatments that
vary from standard

Rhythm: PEA or asystole; rarely VF/VT

Treatment: Treat underlying cause, not rhythm


Special Resuscitation Cases

Causes: Hs and Ts Hypoxia (CNS events) Hypokalemia/hyperkalemia (and other
electrolytes) Hypothermia/hyperthermia Hypoglycemia/hyperglycemia Hydrogen ion Hypovolemia (tank/anaphylaxis, gravid)


Special Resuscitation Cases

Causes: Hs and Ts Trauma Tamponade Tension (pneumothorax, asthma) Thrombosis (pulmonary) Thrombosis (coronary) Tablets (ODs, drugs, etc)


Shannon Patterson
15-year-old with E. coli (HUS) renal failure Last 2 dialyses did not go well On exam: weak, short of breath, lungs
sound wet Blood drawn for electrolytes; glucose: pending What is the problem and what is your approach?

Shannon Patterson
Patient looks uncomfortable Intercom: Critical labs on line 6 Suddenly patient goes into wide-complex

What is the problem and what is your approach?


What is your first action? What medications are indicated? 08:23 AM: initial rhythm strip
08:23 AM

Rx given. What was Rx??

08:27 AM


08:27 AM: now 4 minutes later

08:27 AM

(continuous strip)


08:31 AM: final strip, 8 minutes from start What is the full regimen for this problem?

08:31 AM


Treatment of Urgent Hyperkalemia

Immediate: CaCl, 5 to 10 mL IV of 10% solution (500 to 1000 mg) Onset = 1 to 3 min 0.5 to 1.0 h Shift: Next: sodium bicarb, 1 mEq/kg IV bolus Onset = 5 to 10 min 1 to 2 h


Treatment of Urgent Hyperkalemia

Shift (contd):
Then: insulin + glucose Reg insulin: 10 U IV + 1 amp (50 g) glucose Onset = 30 min Remove: Lasix: 40 to 80 mg IV Kayexalate: 15 to 50 g + sorbitol Dialysis (peritoneal or hemodialysis)


Janelle Ratcliffe
17-year-old female college student rushed
to ED by 2 young men Appears unconscious, cyanotic; has a weak pulse Her companions: She has been very depressed Hold an empty bottle of a common TCA What is going on? How would you manage this patient?

Follow the Five Quadrads

1. 2. 3. 4. 5. Primary ABCD Secondary ABCD OxygenIVmonitorfluids TempHRBPrespirations Tanktankpumprate


Treatment of TCA Overdose

Not in full cardiac arrest:
Hyperventilate to pH = 7.5 Benzodiazepines (1st) vs phenobarbital (2nd) for seizures Full cardiac arrest: Bicarb: 1 to 5 mEq/kg over 1 to 2 min Bicarb infusion: 1 to 5 mEq/kg per hour MgSO4: 50 to 100 mg/kg IV bolus if unstable (up to 5 to 10 g)

Treatment of TCA Overdose

Full cardiac arrest (contd):
Norepinephrine (or high-dose dopamine): hypotension/shock Perform CPR for much longer intervals (>60 min in some patients) Consider charcoal hemoperfusion, cardiopulmonary bypass


BBBs= Hypercalcium Hypomagnesium Tricyclics Neuroleptics Flat P= Hyperkalemia PR longer= Hyperkalemia Hypomagnesium

QT interval prolongs: Hyperkalemia R Hypocalcemia Tricyclics Neuroleptics Ca channel blockers Tall, peaked= Hyperkalemia b-Blockers Flatter= Hypomagnesium Wider= Hypercalcium

ST seg me nt PR interval

U waves= Hypokalemia

QRS interval

Hypercalcemia Tricyclics Neuroleptics Ca channel blockers

Depressed= Hyperkalemia Shortened= Hypercalcium b-Blockers

QT interval

Wide-complex tachys, VT, VF= Hyperkalemia Hypocalcium Tricyclics Neuroleptics


Kristen Hendricksen
24-year-old Norwegian exchange student Acutely despondent over fathers suicide Took 20 capsules of 40-mg propranolol over
15 minutes Confused; weak, thready pulse HR = 35 bpm; first-degree HB = 0.3 sec; BP = 75/50 mm Hg How would you manage this patient at this point? What would you do if she has cardiac arrest?

b-Blocker Overdose
Prearrest management
Saline bolus: 20 mL/kg <20 min; repeat prn Glucagon: 1 to 5 mg IV (over 2 to 5 min) Atropine: 0.02 mg/kg IV (max 1 to 2 mg total) If bradycardic Epinephrine: 0.01 mg/kg, then 0.1 to 1.0 g/kg per minute if hypotensive

b-Blocker Overdose
Arrest management
Dopamine infusion: 2 to 20 g/kg per minute Calcium chloride: 20 to 25 mg/kg slow IV Pacing: either TCP or TV Consider adding dobutamine, norepinephrine, isoproterenol Prolonged CPR prn Cardiopulmonary bypass Intra-aortic pump

Henrietta Cipa
12-year-old autistic child with multiple medical
problems Brought to ED by alarmed parents: We think she has taken her uncles nifedipine Fifteen 20-mg tablets are missing from a bottle First-degree HB; sinus bradycardia = 50 bpm; BP = 90/60 mm Hg; QRS widening

What is initial management? What if she goes into full cardiac arrest?

Course Topics for

ACLS for Experienced Providers Arrest associated with drug toxicity
TCAs, phenothiazines, calcium channel blockers, b-blockers, cocaine, benzodiazepines, narcotics Arrest associated with electrolyte abnormalities Potassium, sodium, magnesium, calcium, acid-base problems

Course Topics for

ACLS for Experienced Providers Arrest associated with environmental
factors Hypothermia, near-drowning, trauma, pregnancy, lightning, electric shock Cardiovascular-pulmonary mechanisms Anaphylaxis, asthma, pulmonary embolus, AMI, cardiomyopathies, hypertrophies

ACLS Course for Experienced Providers

Provides option for renewal/refresher courses Enriches knowledge of experienced providers Focus: periarrest period (1 hour before and
1 hour after) Focus: diagnosis and treatment of reversible causes of arrest Focus: Think about the patient