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CORE ACLS
CONCEPTS
ADVANCED
CARDIAC LIFE SUPPORT
3/2/2012
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Core ACLS Concepts “The chain of survival” has 4 links applied to
all CPR settings (hospital, ER (A&E), ICU,
CCU, or community)
Early Early Early Early
Access CPR Defibrillation Advanced care
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Advanced Cardiovascular/Cardiac Life Support
Is a training program that generally aims to
develop the knowledge and skills of health
care providers as they make effective use of
themselves when assisting in a code
situation.
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Definition of Terms:
ACLS – Iincludes the knowledge and skills
necessary to provide the appropriate early
treatment for cardiopulmonary current which
reduces BLS and use of adjunctive
equipment and special technique to establish
and maintain ventilation and circulation.
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Terminologies
Cardioversion - The discharge of electrical energy synchronized on
the R wave of the electrocardiogram.
Defibrillation - use of unsynchronized electrical energy for revision of
cardiac arrhythmias.
Algorithm – sets of step-by-step procedure guides to assist caregiversin making informed decisions regarding the diagnosis and treatment
of disease.
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ECC – (Emergency Cardiac Care) includes all responses necessary to deal with
sudden and often life threatening events affecting the cardiovascular andpulmonary system.
Megacode - situation wherein the algorithm will be applied and an individual
will be tested on his ability to recite the exact sequences of an algorithm.
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Resuscitation (Code Red)
General Policy:
The Cardiac Code team’s goals are to preserve life, restore health, relieve
suffering and limit disability. These goals shall be carried out promptly with
patient safety foremost in the mind.
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A team is composed of :
1. Person for chest compression
2. Ventilator
3. Person to insert IV lined and will administer medications.
4. Person to monitor the cardiac and will do the defibrillation .
5. Recorder
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Role of the Nurses:
1.Prepares and set-up all equipments necessary for resuscitation.
2. Regular checking of E-cart (every shift before
receiving the endorsement)
3.Document Checklist
4,Location of E-cart
5.Administer assist BLS measure
6.Carries out Doctor’s order and record the chronological event
using the CPR Record Form
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.7. Arranges all matters pertinent to the ad
mission and transfer of patient whennecessary
8.Arranges all matters pertinent to the discharge
of patient(expired patient)
9. Autopsy, DOA, HAMA
10. REPLENISHES AND CHARGES ALL ITEMS
USED
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GENERAL GUIDELINES FOR ALL TEAMS
Maintain quiet, orderly and professional
environment
Patient should be automatically hooked to EKG,
cardiac monitor,defibrillator and pulse oximeter
State vital signs every 5 minutes / PRN
State each medication given
Document
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GENERAL GUIDELINES FOR ALL TEAMS
Maintain quiet, orderly and professional
environment
Patient should be automatically hooked to EKG,
cardiac monitordefibrillator and pulse oximeter
State vital signs every 5 minutes of PRN
State each medication given
Document
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Request clarification of any order if not clearly
understood
Limit traffic
Comfort relatives and advise to stay outside the room
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EQUIPMENT
E-cart
Pulse oximeter
Cardiac monitor with defibrillator
Ambu-bag
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DOCUMENTATION
CPR Record Form
Nurse fills up the data and activities
Team leader documents the CPR outcome
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The algorithm Approach Emergency Cardiac
Care(ECC)
The following clinical recomendations apply to all
treament algorithms
First, treat the patient not the monitor.
Algorithms for cardiac arrest presume that thecondition under discussion continually persists, that
the patient remains in cardiac arrest, and that CPR is
always perform.
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Apply different interventions whenever appropriate indications
exist.
The flow diagrams present mostly
Class I(acceptable, definitely effective)recomendations.
The footnotes present Class IIa(acceptable, probably effective),
band Class Iib (acceptable, possibly effective), and
Class III (not indicated, may be harmful) recomendations.
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Adequate oxygenation,airway, ventilation,. Chest
compressions, and defibrillation are more important
than administration of medications and takes
precedence over initiating an intravenous line or
ejecting pharmacologic agents.
Several medications (epinephrine. Lidocaine, and
atropine) can be administered via the endotracheal
tube but the dose must be 2 – 2.5 times the
intravenous dose. (use a catheter or suction tip which
be passed beyond the tip of the endoctracheal tube.)
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With a few exceptions, intravenous medications
should always be administered rapidly, in bolus
method.
After each intravenous medication, give a 20-30
ml bolus of intraveus fluid and immediately
elevate the extremity. This will enhance the
delivery of drugs to the central circulation, whichmay take 1-2 minutes.
Last, treat the patient, not the monitor.
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Core ACLS Concepts The Most Important Goal : > Cerebral resuscitation
The Patients :
u For Many >> Their hearts should be too good to die.
u For Some >> The last heartbeat should be the last.
Treat the patient, not the monitor
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Cardio-pulmonary-cerebral resuscitation Primary purpose : to return the
patient to his/her best possible
neurological outcome.
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Arrythmia Recognition
Important in any ACLS/ CPR sequence
All algorithms start with identifying rhythm
Cannot identify arrhytthmais- cannot mange
corrrectly
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The Beating Heart – ElectrophysiologyElectrical Stimulation & Contraction
BEFORE THE HEART CONTRACTS
IT MUST BE ELECTRICALLY STIMULATED
DEPOLARIZATION
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Pacemaker impulses are initiated in the SA node,
travelling through atrial pathways, at frequenciesbetween 60-100bpm
There is the presence of a P wave, followed by a
QRS complex at a regular rate
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Normal Sinus Rhythm
Look at the P waves ;
rate is 60-100/min
Cycle length do not vary by 10%
PR interval is 0.12 – 0.20sec.
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During ACLS/BLS:
• Patient is hooked to cardiac monitor/ defibrillator
•Patient’s heart rate is automatically detected
•Normal HR = 60 to 100 bpm
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MANAGEMENT:
A. No specific drug treatment
B. Identification of cause
C. Treatment of underlying cause
D. Check hemodynamics
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Characterized by tachycardia with a narrow QRS complex
Sudden onset and termination
150-250 beats/min (180-200 bpm in adults)
Regular rhythm
QRS complex is normal in contour and duration
No P waves
•P waves are generally buried in the QRS complex
•Often, P wave is seen just prior to or just after the end of the QRS and cause a subtle
alteration in the QRS complex that results in pseudo- s or pseudo - r
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A. Cardiovert the patient!
B. Defibrillate the patient!
C. Give Verapamil!
D. Check hemodynamics
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Prematurely occurring complex
Wide, bizarre looking QRS complex
Usually no preceding P waves
T wave opposite in deflection to the QRS complex
Complete compensatory pause following every premature beat
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• Adult (1 to 2L) bag and the provider should deliver
approximately 600 ml of tidal volume sufficient to produce chest
rise over 1 second
•Open the airway adequately with a head tilt-chin lift, lifting the
jaw against the mask and holding the mask against the face,
creating a tight seal
•During CPR give 2 breaths (each 1 second) during a brief (
about 3 to 4 seconds) pause after every 30 chest compr essions.
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Use of 100% inspired oxygen (FiO2 1.0) as soon as it becomes
available is reasonable during resuscitation from cardiac
arrest (Class IIa, LOE C)
Titrate oxygen administration to achieve arterial
oxyhemoglobin saturation > 94%
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To facilitate delivery of ventilations with a bag-mask device,
the nasopharyngeal airway can be used in patients with a
compromised airway
In the presence of known or suspected basal skull fracture or
severe coagulopathy, an oral airway is preffered (Class II a,
LOE C)
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ADVANTAGES
Keeps airway patent
Permits suctioning of airway secretions
Enables delivery of a high concentration oxygen
Provides an alternative route for administration of some
drugs
Facilitates delivery of a selected tidal volume
With use of a cuff, may protect the airway from
aspiration
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Epinephrine
Lidocaine
Vasopressin
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Endotracheal intubation is frequently associated with
interruption of compressions for many seconds
Placement of a supraglottic airway is a reasonable
alternative to endotracheal intubation and can be done
successfully without interrupting chest compressionsa
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Rescuer should record the depth of the tube as marked
at the front of the teeth and secure it.
Providers should verify correct placement of all
advanced airways after insertion and whenever the
patient is moved.
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VENTILATION
Chest x-ray
Rationale: Confirm secure airway and detect
causes or complications of arrest:
pneumonitis, pneumonia, pulmonary edema.
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VENTILATION
After ROSC, routine hyperventilation leading to hypocapnia
should be avoided to prevent additional cerebral ischemia.
CONTROLLED OXYGENATION
There is insufficient evidence to support or refute the use of
titrated inspired oxygen content in the early care of cardiac
arrest patients following sustained ROSC
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VENTILATION
Mechanical Ventilation
o Rationale: Minimize acute lung injury, potential oxygen
toxicity
o Tidal volume – 6 – 9ml/kg
o Titrate minute ventilation to
- PETCO2 – 35- 40 mm Hg
- PaCO2 – 40- 45 mm Hg
o Reduce FiO2 as tolerated to keep SpO2 or SaO2 > 94%
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ELECTRICAL THERAPIES
DEFIBRILLATION & CARDIAC PACING
PHA Council on CPR
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Electrical Therapies
Defibrillation
Cardioversion
Cardiac Pacing
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Key Challenges (2010 Guidelines)
Improve time for Defibrillator Availability
- Immediate AED availability
- Improve response time and training
Decrease interruptions in chest
compressions pre and post shocks
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DEFIBRILLATION
Is the therapeutic use of electric current delivered in large
amounts over very brief periods of time.
Temporarily “stuns” an irregularly beating heart and allows
more coordinated contractile activity to resume.
Termination of VF for at least 5 seconds follwing the shock.
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AUTOMATED EXTERNAL DEFIBRILLATORS
Sophisticated, reliable computerized devices that use voice and
visual prompts to guide lay rescuers and health care providers to
safely defibrillate VF SCA
Recorded information about frequency and depth of chest
compressions during CPR.
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BIPHASIC WAVE FORM DEFIBRILLATORS
Defibrillation with biphasic waveforms uses relatively low
energy ( < 200 J ) that is safe and has equivalent or higher
efficacy for termination of VF than monophasic waveform
shocks (class llb)
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SYNCHRONIZED CARDIOVERSION
Synchronization avoids shock delivery during the
relative refractory portion of the cardiac cycle, when a
shock could produce VF.
The energy (shock dose) used for a synchronized shock
is lower than that used for unsynchronized shocks
(defibrillation)
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CARDIAC PACING
Deliver an electric stimulus through electrodes to
the heart causing electrical depolarizations and
subsequent cardiac contraction
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INTRAVENOUS ACCESS
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PERIPHERAL IV SITE
Administer drugs by Bolus
20cc of saline or distilled water
Elevate the extremity for 10-20
seconds
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Tracheal Drug Administration
NAVEL (Naloxone, Atropine, Vasopressin, Epinephrine,
Lidocaine)
Administer 2 to 2.5 times the recommended IV dose
diluted in 10ml NSS or distilled water
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ACLS DRUGS
Agents used to Optimize Agents used to treat Arrhythmias
Cardiac Output and blood pressure
Cardiac Arrest Shock Heart Failure/ Tachycardia Bradycardia
Pulmonary Edema, Misc;
buffers
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MONOPHASIC WAVE FORM DEFIBRILLATORS
Deliver current of one polarity
Monophasic damped sinusoidal waveforms (MDS) returns to zero
gradually, whereas the Monophasic truncated exponential
waveform current is abruptly returned to baseline to zero current
flow.
Initial shock is 360J and if VF persists, the subsequent shocks
should be 360J
Time Sequence &
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Time Sequence &
Estimated Probability of Survival
Eisenberge, et al 1990
Time(min) 2 4 6 8 10
CPR T & O i i
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CPR Team & Organization
BLS & ACLS
Training &
Retraining,
CPR Code
Organization,
Performance
Evaluation &
Peers R eview
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Core ACLS Concepts Classification of Therapeutic Interventions
in CPR & ECC
Class I : acceptable, definitely effective
Class II : acceptable, uncertain efficacyII a > probably effective
II b > possibly effective & not harmful
Class III : inappropriate & may beharmful
The Algorithm Approach
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in ACLS & ECC
Treat the patient, not the monitor
Continue CPR (include defibrillation) is moreimportant than the procedure and pharmacologicagents
Flow diagrams: mostly class I,footnotes: class IIa, IIb, or III
Most ACLS medications(but few exceptions) shouldbe given as iv. bolus
“2
nd
Syringe Technique” for 20-30 ml. iv. bolus aftereach iv. medications
Epinephrine, lidocaine, atropine, etc can be given viaET tube at 2-2.5 times of iv. Route
Summary :
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Summary : Ten Commandments for ACLS
1. Do good CPR : do CPR whenindicated, not do when not indicated,and do well
2. Highest priority is the primary C A-B--D* survey & hunt for VF
3. The next highest priority is thesecondary CA-B--D** survey
4. Know the defibrillator! : familiarizeand daily maintenance check
5. Search for reversible or treatable causes.
Summary :
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Summary : Ten Commandments for ACLS
6. Know the ECC medications : “Why?”,“When?”, “How?”, and “Watch out?!?”
7. Be a good team : conductor ormember
8. Practice the phase responseresuscitation format :anticipation/entry/resuscitation/maintenance/ family notification/transfer/critique
9. Determined “code status” in advance
Summary :
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Summary : Ten Commandments for ACLS
10. Learn and practice the most difficultresuscitation skills*:
when not to start CPR
when to stop CPR
how to tell the family members
how to talk with your colleagues
Even though it’s the most difficult, but it’s
more important & more challenging!
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