Advanced Cardiac Life Support (ACLS

By: Diana Blum MSN Metropolitan Community College Nursing 2150

chest pain or confusion..if we leave the rhythm untreated the patient may become unstable! ..  The major problem here is. shortness of breath.  their vitals signs are stable  they have no complaints such as.STABLE  These patients generally have an EKG rhythm that is undesirable.

 their vital signs are unstable!  They may have a low blood pressure or complain of shortness of breath.UNSTABLE  These patients also have an EKG rhythm that is undesirable. Absent. chest pain or become confused. or ventricular fibrillation we defibrillate. as in asystole we pace with a TCP.  The major problem here is..if we leave the rhythm untreated the patient may become dead. like ventricular tachycardia.  generally use a more aggressive approach in unstable patients first  the code cart may not be readily available to your patient. .  You should always do CPR until electrical is available in dead patients. Too fast..

 Good CPR keeps the vital organs perfused until your electrical and drugs can do their job. Think of CPR as your bridge and time-buyer. or not available to your patient.  Their vital signs are absent! They have no pulse!  Your first thought for intervention is ELECTRICAL!  Step 2 CPR. . don't waste time. use electrical first! American Heart studies show that the sooner electrical intervention is introduced into your dead patient's treatment regime. Remember here. is electrical.DEAD  These patients also have an EKG rhythm that is undesirable. always check pulses with CPR. If electrical intervention is at your hands length. Always make good CPR a priority.  The last intervention in order is MEDICINE. the more epinephrine they get!"  your best intervention for saving this patient's life if they are dead. the better the outcome for survival! The longer electrical is withheld. "all dead people get epinephrine. the less likely the outcome will be favorable. the deader they are. always assess ventilation! What type of electrical do we use in dead patients? Well of course that depends on the rhythms. Your second intervention is CPR.

 Circulation: Check the carotid artery (Adult) for a pulse. listen. and feel for breathing  Breathing: If not breathing slowly give 2 rescue breaths. If breaths go in continue to next step. If no pulse begin CPR. look.  Defibrillation: Search for and Shock VFib/Pulseless V-Tach .Primary Survey  Airway: Open airway.

obtain IV access.Adult ACLS Secondary Survey ABCDs (abbreviated)  Airway: Intubate if not breathing. give proper medications.  Breathing: Provide positive pressure ventilations with 100% O2. Assess bilateral breath sounds for proper tube placement. .  Differential Diagnosis: Attempt to identify treatable causes for the problem.  Circulation: If no pulse continue CPR. Y9JW8&feature=related .youtube.

and the rhythm is a slow wide ventricular rhythm.  Remember. or PEA  This is a condition where you have some electrical activity but not mechanical activity.Pulseless Electrical Activity. do it right away! . but a condition. the heart is not contracting.  If you have a patient with the condition of PEA. giving you a pulse. the condition is PEA.  PEA is really not a rhythm. don't wait if your going to try it.  In other words.  You can have a normal sinus rhythm. you may want to try TCP. but if there is no pulse. try it early on.

in place of the 1st or 2nd dose of epi..  Atropine 1 mg IV/IO q3-5 min.  Epinephrine 1 mg IV/IO q3-5 min.PEA  Problem search. Or vasopressin 40 U IV/IO. (see differential diagnosis table) **Continue this algorithm if indicated. once. (3mg max.Treat accordingly.) .

tracheal deviation Needle thoracostomy Cardiac Tamponade No pulse w/ CPR. toxins Treat accordingly Shivering Core temperature Hypothermia Algorithm . JVD Diabetic/renal patient. illicit drug use. Fluids Hypokalemia Hypovolemia EKG. dialysis. diuresis. serum K level Collapsed vasculature Hypoxia Myocardial infarct Airway. serum K level Sodium bicarbonate. insulin/glucose. narrow pulse pressure prior to arrest Pericardiocentesis Hyperkalemia (preexisting) Renal patient. ABGs History. cyanosis. K can kill. JVD. ABGs Intervention Thrombolytics. JVD. calcium chloride. albuterol nebulizer. surgery Sodium bicarbonate. EKG Oxygen. EKG. ventilation Acute Coronary Syndrome algorithm Drugs Medications. Kayexalate Treat with great prudence after careful assessment of the cause.condition Pulmonary Embolism Acidosis (preexisting) Assess No pulse w/ CPR. hyperventilation Tension pneumothorax No pulse w/ CPR.

Electrical is the method of treatment first in unstable!  “ how do I know when to pace. to confirm asystole. use TCP. our second treatment option is medicine in unstable patients.ELECTRICAL!    The goal.  If our patient has a second or third degree heart block with a slow rhythm and were unstable. and set it up. Think electrical first in unstable. FINE VENTRICULAR FIBRILLATION can look like asystole. defibrillate. that's why we look at suspected asystole in more that one ekg lead. unstable patients still have a pulse. then medications next. It most instances you can try medication. D=DEAD. dead patients have no pulse! We only defibrillate fast rhythms! Yes.  "Well then. . you can tell that it's TOO SLOW!  After we try electrical first. "Does this mean that if the code cart is down the hall. we would do a synchronized cardioversion to slow it down. or do we want to speed it up?“ If the rhythm is too fast. what electrical intervention do we use on asystole?“  Without jumping too far ahead. we would use external transcutaneous pacing or TCP. we would use synchronized cardioversion.  Examples: If our patient had an EKG rhythm of Atrial Tachycardia and they were unstable. I should wait to give electrical first if I have medication closer?" NO! It means your very first thought is electrical.  "how do I know when to cardiovert?" Cardioversion is reserved for unstable patients. having someone get it. they are not dead or pulseless! We cardiovert fast rhythms. we would use TCP. AS LONG AS IT DOES NOT INTERFERE WITH YOUR FIRST ACTION WHICH IS ELECTRICAL!  What's the rational? Remember your patient is unstable. or use synchronized cardioversion?" Here is a rule to remember. our goal is to slow it down and convert it. we Defibrillate Dead patients. "do you want to slow down and convert this rhythm. If our rhythm is too slow our goal is to speed it up. they have a high likelihood to become DEAD.  You may say wait a minute! "I don't know what a second or third degree heart block is!" Well. that's okay. and early on into the arrest.

 Danger Dopamine 2-10 µg/kg/min  *Pacing does not "always end danger" in brady arrhythmias. (max. Use with extreme caution.Consider medications while pacing is readied.Bradycardia  The following mnemonic directs AHA accepted actions after absolute (<60bpm) or relative (slower rate than expected) bradycardia with circulatory compromise due to the slow rate is discovered. 0. 3mg)  Ends Epinephrine 2-10 µg/min2nd-line drugs to consider if atropine and/or TCP are ineffective.5 mg IV/IO q3-5 min. managed by an expert.  . think Differential Diagnosis! **Prepare for transvenous pacing (TVP). Start the Secondary ABCDs and remember: *Pacing Always Ends Danger  Mnemonic Intervention Note  Pacing**TCP Immediately prepare for transcutaneous pacing (TCP) with serious circulatory compromise due to bradycardia (especially high-degree blocks) or if atropine failed to increase rate. If the above measures do not improve circulatory stability the bradycardia may merely be an indication of a pathological process.  Always Atropine1st-line drug. if .

 Synchronized Electrical Cardioversion  As part of the Secondary ABCDs the following mnemonic directs preparations for synchronized electrical cardioversion of unstable tachycardia with circulatory compromise due to the fast rate (do not delay shocking if seriously unstable)  :Oh Say It Isn't So Mnemonic Preparation  Oh  Say  It  Isn't  So O2 Saturation monitor Suctioning equipment IV line Intubation equipment Sedation and possibly analgesics **Synchronized Electrical Cardioversion *Energy Levels:The initial synchronized shock is 100J monophasic (50J for SVT/A-Flutter) with increasing energy. Only experts should manage synchronized electrical cardioversion of a stable patient.  Unsynchronized Electrical Cardioversion  Give unsynchronized shocks at VF/PVT *energy levels without delay for unstable tachycardia with critical circulatory compromise due to the fast rate. Also give unsynchronized shocks if you cannot synchronize.Cardioversion  It is essential that ACLS Providers know the indications for electrical cardioversion and receive proper training using their equipment before attempting to perform this risky procedure. if successive shocks are needed. 300J. 360J. If VF/PVT develops. 200J.. or if polymorphic VT is present. i. immediately defibrillate at *360J per the VF/PVT Algorithm. *Or biphasic equivalent .e.

Tachycardia .

and consider the following questions: 1. Multifocal Atrial Tachycardia. at 12mg) Or Cardizem (diltiazem) managed by an expert if stable. q1-2min. next question No. Junctional or Ectopic Atrial Tachycardia Rate Control: diltiazem or beta blocker -------------------------------------------------------------------------------Stable Wide Irregular Tachycardia (Avoid calcium channel blockers and digoxin due to possible AF+WPW) Consider amiodarone. VS. for torsades -------------------------------------------------------------------------------Stable Wide Regular Tachycardia If VT. Regular? Yes. Magnesium 2g IV over 5min. amiodarone 150mg IV over 10min. irregular = Consult an expert** -------------------------------------------------------------------------------Consult an Expert Most stable tachycardia rhythms require management by an expert due to the challenge of accurately determining and safely treating tachyarrhythmias. regular tachyarrhythmia continues Perform immediate electrical cardioversion if a patient becomes unstable at any time.12 sec) 3. unstable = Immediate electrical cardioversion 2. repeat prn (max 2.2g IV/24hr). elective synchronized cardioversion                     . possibly Atrial Flutter Rate Control: diltiazem or beta blocker -------------------------------------------------------------------------------Stable Narrow Regular Tachycardia Recurrent SVT. Adenosine 6mg rapid IV push (may repeat x2. if this fails. -------------------------------------------------------------------------------Stable Narrow Irregular Tachycardia Atrial Fibrillation. next question No. Vagal maneuvers.             The following directs AHA accepted actions after tachycardia with symptoms due to the fast rate is discovered: Start the Secondary ABCDs with emphasis on oxygenation. narrow.. For sinus tachycardia consider possible causes and treat accordingly. and EKG. No. IV. wide = Consult an expert (QRS ≥0. A sampling of rhythms and possible expert interventions are listed below. Narrow? Yes. Atrial Flutter. Stable? Yes.

(Do not check rhythm or pulse) RhythmRhythm check after 2 minutes of CPR (and after every 2 minutes of CPR thereafter) and shock again if indicated.VF/ PVT The following acronym directs AHA accepted actions after the Primary ABCDs have been enacted and an AED or Manual Defibrillator arrives and a shockable rhythm (VF or PVT) is present: SCREAM  LetterIntervention Note   Shock360J* monophasic. Give drugs during CPR before or after shocking. once. if VF/PVT persists or Lidocaine (if amiodarone unavailable) 1.      (Shock every 2 minutes if indicated) CPRAfter shock. Consider Differential Diagnosis. push) for torsades de pointes or suspected/ known hypomagnesemia. Antiarrhythmic Medications Consider antiarrhythmics. may repeat X 2. may repeat once at 150mg in 3-5 min. q5-10 min.75 mg/kg. use 200J for 1st shock and the same or higher energy level for subsequent shocks. (3mg/kg max.or Magnesium Sulfate1-2 g IV/IO diluted in 10mL D5W (5-20 min. Check pulse only if an organized or non-shockable rhythm is present. follow the manufacturer's recommendation. 1st and subsequent shocks. Or vasopressin 40 U IV/IO. If recommendation is unknown. in place of the 1st or 2nd dose of epi. (Any Legitimate Medication) Amiodarone 300mg IV/IO.5-0.0-1. Epinephrine1 mg IV/IO q3-5 min. at 0. Minimize interruptions in chest compressions to <10 seconds. . Continue this algorithm if indicated. immediately begin chest compressions followed by respirations (30:2 ratio) for 2 minutes.5 mg/kg IV/IO. * Biphasic energy level is device dependent. loading dose) if VF/PVT persists.Implement the Secondary ABCD Survey.

net/quiz.htm  http://www.Mega code practice  http://www.asp

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