EASY TO UNDERSTAND ACLS ALGORITHMS 2 nd Edition

1. EASY TO UNDERSTAND ACLSALGORITHMS 2nd Edition JOE JONES, NREMT-PARAMEDIC

2. Respiratory Arrest with a Pulse • This patient is one who you may have resuscitated from cardiopulmonary arrest and now has a pulse. Also consider the patient who is in complete Respiratory failure. Both of these patients must have the airway controlled or both will suffer complete cardio-pulmonary arrest • EXAMPLES OF RESPIRATORY FAILURE • The patient who has C.O.P.D. or Pulmonary Edema • With any of these cases the provider must be able to maintain an airway using basic skills, or using advanced airways in the proper way to assure the best outcome for the patient.

3. AIRWAYS USED IN RESPIRATORY ARREST/FAILURE Oropharyngeal Airway Nasopharyngeal Airway Combitube LMA Endotracheal tube

4. Respiratory Arrest with a Pulse • Continuous waveform capnography is recommended in addition toclinical assessment as the most reliable method of confirmingand monitoring correct placement of an endotracheal tube: • The proper ventilatory rate for a patient who is not intubated is 10 – 12 breaths/minute. • The proper ventilatory rate for a patient who is intubated is 8 – 10 breaths/minute. • One needs to be cautious not to increase thoracic pressure to the point where provider does not make matters worse, i.e. Pneumothorax.

5. VENTRICULAR FIBRILLATIONPULSELESS VENTRICULAR TACHYCARDIA • Check Responsiveness • A – B – C’s • Begin CPR with Chest Compressions • Call for AED or Defibrillator • AED/Defibrillator Arrives Reveals Rhythm Above • Defibrillate at 120 – 200 Biphasic/360 Monophasic • Continue CPR • Initiate IV • Administer Epinephrine 1 mg/1-10,000 IVP • May Substitute Vasopressin 40 units on 1st or 2nd dose of Epinephrine • Continue CPR for 2 minutes or 5 cycles

6. V-FIB/PULSELESS V-TACH • Stop CPR then defibrillate • 120 – 200 Biphasic • 360 Monophasic. • Continue CPR • Administer Cordarone 300 mg. IVP repeat in 5 minutes. • Administer Epinephrine 1 mg or 40 units of Vasopressin • After 2 minutes CPR (Stop) • Defibrillate • 120 – 200 Biphasic • 360 Monophasic • Continue CPR

7. V-FIB/PULSELESS V-TACH • Continue CPR Defibrillating between each round • Continue to Administer Epinephrine 1 mg q- 3 – 5 minutes. • Repeat Cordarone 150 mg. IVP • If Ventricular Tachycardia is Polymorphic then consider Torsades • Administer Magnesium Sulfate 1 – 2 grams IVP • Sodium Bicarbonate not routinely recommended unless known acidosis.

8. V-FIB/PULSELESS V-TACH HIGH QUALITY CPR IS A MUST. DO NOT DELAY THIS TASK. COMPRESS AT LEAST 2 INCHES ALLOW COMPLETE RECOIL AT LEAST 100 COMPRESSIONS PER MINUTE. CONTINUE TO IDENIFY AND TREAT CORRECTABLE CAUSES OF THE ARREST. (5 H’S AND 5 T’S) ROSC • AFTER THE RETURN OF SPONTANEOUS CIRCULATION THEN SUPPORT VITAL SIGNS, IF NEEDED USE VASOPRESSORS TO MAINTAIN PERFUSION, CONTINUE OXYGENATION OF THE PATIENT AND SEEK EXPERT CONSULTATION.

9. ASYSTOLE • A-B-C’s • PT. PULSELESS AND APNEIC • BEGIN CPR WITH CHEST COMPRESSIONS • CALL FOR MONITOR/AED • MONITOR ARRIVES • ASYSTOLE CONFIRMED IN TWO LEADS THEN CONTINUE CPR FOR 2 MINUTES OR 5 CYCLES 30 COMPRESSIONS TO 2 VENTILATIONS.

10. ASYSTOLE IV in place and infusing at W/O Rate • Administer Epinephrine 1 mg of a 1-10,000solution repeat dose in 3 – 5 minutes. • May substitute Epinephrine on 1st or 2nd dose with Vasopressin 40 units IVP • Prepare and place an Advanced Airway • Continue to provide good quality CPR • Atropine no longer recommended in Asystole • Routine use of Bicarbonate no longer recommended

11. ASYSTOLE • TREAT ALL CORRECTABLE CAUSES: •  H's and T's •  Hypovolemia • Toxins •  Hypoxia • Tamponade (cardiac) • Hydrogen Ion (acidosis) •  Tension pneumothorax •  Hyper/hypokalemia •  Thrombosis (pulmonary & coronary) •  Hypoglycemia •  Trauma • Hypothermia

12. ASYSTOLE • In some special resuscitation situations, such as preexistingmetabolic acidosis, hyperkalemia, or tricyclic antidepressantoverdose, bicarbonate can be beneficial (see Part 12: "CardiacArrest in Special Situations"). However, routine use of sodiumbicarbonate is not recommended for patients in cardiac arrest. • AFTER ALL CAUSES HAVE BEEN EVALUATED AND TREATED THEN CONSIDER TERMINATION OF EFFORTS.

13. Pulseless Electrical Activity • A-B-C’s • PT. PULSELESS AND APNEIC • BEGIN CPR WITH CHEST COMPRESSIONS • CALL FOR MONITOR/AED • MONITOR ARRIVES • PEA CONFIRMED THEN CONTINUE CPR FOR 2 MINUTES OR 5 CYCLES 30 COMPRESSIONS TO 2 VENTILATIONS.

14. PULSELESS ELECTRICAL ACTIVITY IV in place and infusing at W/O Rate • Administer Epinephrine 1 mg of a 1-10,000solution repeat dose in 3 – 5 minutes. • May substitute Epinephrine on 1st or 2nd dose with Vasopressin 40 units IVP • Prepare and place an Advanced Airway • Continue to provide good quality CPR • Atropine no longer recommended in PEA • Routine use of Bicarbonate no longer recommended

15. UNSTABLE TACHYCARDIA • There are four rhythms in the tachycardia algorithm which can cause instability with the cardiovascular system, they are identified as follows: • Supraventricular Tachycardia (SVT) • Ventricular Tachycardia (VT) • Uncontrolled Atrial Fibrillation (A-Fib) • Uncontrolled Atrial Flutter (A-Flutter) • Sinus Tachycardia does not fall in the algorithm, treat the cause of the tachycardia.

16. UNSTABLE TACHYCARDIA • A – B – C’s • Oxygen • 12 Lead if time permits • Consider causes • Regular monomorphic narrow complex • Consider sedation then • Synchronize cardiovert at 50 – 100 joules Biphasic increase as needed up to 200 joules, 100 joules monophasic increase as needed up to 360

17. WIDE COMPLEX TACHYCARDIA • A – B- C’s Administer Oxygen • IV Sedate if time permits • Synchronize Cardiovert at 100 joules Biphasic or Monophasic • Increase biphasic up to 200 joules and monophasic up to 360 joules. UNCONTROLLED ATRIAL FIBRILLATION • A – B- C’s Administer Oxygen • IV Sedate if time permits • Synchronize at 120 – 200 joules Biphasic or 200 joules Monophasic. Increase Biphasic up to 200 and Monophasic up to 360 joules

18. NARROW COMPLEX TACHYCARDIA STABLE • A – B- C’s administer oxygen • Consider all causes • IV • Vagal Maneuvers • Adenosine 6 mg rapid IVP (flush with 15 ml saline) • Adenosine 12 mg rapid IVP (flush with 15 ml saline) • Adenosine 12 mg rapid IVP (flush with 15 ml saline) • Consult expert consultation • May consider beta blocker/ calcium channel blocker

19. ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE • With this rhythm one must take in consideration what is causing the problem. In most cases the problem is arising from a rapid ventricular rate. If the patient is stable however take in consideration of how long he or she has been experiencing this arrhythmia. • With all this in mind consider anticoagulant prior to converting the rhythm.

20. STABLE ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE • Assess appropriateness for the situation • A – B – C’s Apply Oxygen • IV @ KVO RATE • 12 LEAD ECG MEDICATIONS TO CONSIDER This will be left up to the physician in charge of the patient. • Calcium Channel Blocker • Beta Blocker • Digitalis Products • Cordarone

21. BRADYCARIA • With this rhythm one must remember what is causing the patient’s signs and symptoms. • Remember the patient must be having signs and symptoms prior to beginning treatment • Some rhythms which would fall under the algorithm are: • Sinus Brady • Junctional • Heart Blocks • 1st degree, Wenchebach, Mobitz type II and Complete Heart Block or better known as a 3rd degree block

22. BRADY CARDIA • Assess Appropriateness for the clinical situation • Consider expert consultation • A – B – C’s Apply Oxygen • IV @ KVO • Atropine .5 mg IVP may be repeated up to 3 mg. maximum dose • Transcutaneous Pacing • Dopamine or Epinephrine Infusion • Dopamine Dose: 2 – 10 mcg/kg/min • Epinephrine Dose: 2 – 10 mcg/min.

23. BRADYCARDIA • Prior to treating a high degree heart block always keep in mind that if the block is at the AV node or lower Atropine may not work. • In this case make sure to seek expert consultation • Consider the need for immediate TCP • Consider being aggressive with Chronotrope Medications.

24. ACUTE CORONARY SYNDROME • Remember when dealing with a patient with an ACS one must know the ultimate treatment is to get the blocked Coronary open. With this in mind one must seek expert consultation quickly. • Being aggressive with this patient is a must in order to prevent any further damage to the myocardium. • There are two ways one may use in order to open the blocked artery, they are: • Cath. Lab • Thrombolytics

25. ACUTE CORONARY SYNDROME • While preparing the patient for his/her treatment one should consider: • A – B – C’s Consider Oxygen • Monitor for arrhythmia’s, if present treat according to American Heart guidelines • IV • 12 lead EKG • Aspirin • Nitro repeat times 3 titrating to blood pressure and pain • Morphine • Beta Blocker

26. ACUTE CORONARY SYNDROMES • While treatment is being performed to attempt to stabilize the patient make sure to seek expert consultation. • REMEMBER TIME IS MUSCLE::::

27. THE ACUTE ISCHEMIC STROKE • With the patient experiencing signs and symptoms of an acute stroke one must act fast in order for the patient to receive definitive treatment. • The time line is three hours from the time signs first began.