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The chain of survival for a cardiac emergency and stroke start the same:
1. preparedness & recognition of an emergency;
2. activation of EMS;
3. delivery of Advanced Life Support; and
4. transporting to the most appropriate facility.
ALS ambulances are staffed with paramedics who have training in ACLS skills.
Why EMS "Destination Protocols" for suspected stroke and STEMI make a difference.
ACLS’s timed benchmarks for:
point of first medical contact to PCI for ST elevation MI;door to tPA for ischemic stroke; andonset of symptoms to EVT for LVO strokes.Why EMS should bypass a close hospital to transport a STEMI or suspected stroke patient to a hospital capable of 24/7 PCI or a certified stroke center.
Check out the Pod Resource page at passacls.com for links to the "EMS On Air" podcast for links to episodes that look at EMS's role in stroke outcomes in the rural vs urban area.
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Performing good CPR and delivering a shock as soon as possible to a patient in Ventricular Fibrillation or pulseless V-Tach are the two most critical interventions that have been shown to increase survival from sudden cardiac arrest.
Studies have demonstrated significantly better out-of-hospital cardiac arrest survival outcomes in communities with robust public CPR training and public access/first responder AEDs.
The general use of AED including:
indications for use; attaching the AED pads; following verbal prompts; and safely administering a shock.Following the Adult Cardiac Arrest algorithm while using an AED.
Contraindications to AED use.
General safety considerations to remember.
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For apneic patients without a carotid pulse or patients with only gasping/agonal respirations, we will follow the Adult Cardiac Arrest algorithm.
For pulseless patients that the AED doesn't advise a shock, the patient's ECG shows asystole, or a non-perfusing organized rhythm (PEA), we will follow the right side of the Adult Cardiac Arrest algorithm.
Initial steps are aimed at delivery of high-quality CPR to keep the brain and vital organs alive.
Epinephrine administration.
Placement of an advanced airway.
Considering possible reversible H & T causes of cardiac arrest including three common causes of PEA and their emergent interventions.
When we should discontinue resuscitation efforts and call the code.
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Providing good, high-quality CPR with minimal interruptions and early defibrillation are two key interventions shown to improved cardiac arrest outcomes.
A training tool used in many CPR and ACLS classes is to use a song (or a song list) with a tempo of 100 to 120 beats per minute to help the person doing chest compressions maintain an adequate rate.
Characteristics of good songs that will help us.
Advantages & disadvantages of using a song during CPR.
Selected songs from various genres and time periods from AHA's "Don’t Drop The Beat" playlist on Spotify. https://open.spotify.com/playlist/2mU2FNAhSOtQwW0hBgQMaK
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A patient’s medical history will help us identify things that may be causing (or contributing) to their current condition as well as guide our decisions so we provide the safest evidence-based care possible.
Examples of information obtained in a medical history that will impact the treatment we provide.
There are several mnemonics and memory aids that people use to guide their history taking.
Review the SAMPLE-PQRST medical history format.
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Although magnesium can be used in the treatment of other medical conditions such as eclampsia, asthma, & digitalis toxicity; for ACLS, magnesium is primarily used to treat Torsades de Pointes.
Identification of Torsades on the ECG.
Administration of a magnesium infusion for stable patients vs slow IV push for patients in cardiac arrest.
Procainamide use for stable patients with a monomorphic wide-complex tachycardia.
Procainamide dosing and when to stop the infusion.
Tip for determining whether magnesium or Procainamide should be used when treating stable patients with V-Tach.
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Listen to Pass ACLS tips and other medical podcasts at ConveyMed.io
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When a patient loses excessive amounts of fluids, we say that they are in a state of hypovolemia.
The most obvious cause of hypovolemia is from bleeding.
Bleeding can be internal or external and caused by trauma, pathology, or iatrogenic.
Classic signs & symptoms of hypovolemic shock.
Volume replacement with crystalloids vs blood.
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MONA is the acronym sometimes used to help us remember the interventions to consider for patients with Acute Coronary Syndrome or ACS.
Morphine's use in the Acute Coronary Syndrome (ACS) algorithm.
Why Morphine is helpful for patients with ACS.
Contraindications and considerations for the safe administration of Morphine.
Morphine as an alternative to nitro for patients with chest pain that take PDE inhibitors.
Common dosing & administration of Morphine.
Monitoring of the patient's level of consciousness, pain, blood pressure, and respirations after administration.
Possible side effects of Morphine administration.
Narcan as an antidote to Morphine if needed.
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Even good CPR is far less efficient at circulating blood than a functioning heart.
The indicators of high-quality CPR that were identified at the 2012 AHA CPR Quality Summit in order of importance include:
Chest compression fraction (CCF);Chest compression rate;Chest compression depth;Allowing for full recoil; andAdequate ventilations.Using real-time feedback devices and ETCO2 to assess CPR quality.
Three tips to limit pauses in CPR compressions to 10 seconds or less.
Limiting interruptions to chest compressions to less than 10 seconds so we can maintain a CCF of 80% requires teamwork and communication.
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Epinephrine and Dopamine are adrenergic agonist used in several ACLS algorithms.
The use of epinephrine for severe anaphylaxis and unstable bradycardia.
Review epinephrine’s effects on blood vessels and bronchioles.
Why epinephrine is helpful for patients with anaphylaxis.
Using an epi drip for unstable bradycardia.
Epinephrine administration during cardiac arrest.
Starting and epinephrine or Dopamine drip for patients that have ROSC.
Review the effects of Dopamine based on mcg/kg/min dosing.
Monitoring the patient and titrating epi or Dopamine drips to prevent harm.
For more information on ACLS medications, check out the pod resource page at passacls.com.
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Providing rescue breathing to apneic patients with a palpable pulse.
Normal end tidal CO2 for patients with a pulse.
Identification of cardiac arrest and our immediate actions.
Providing artificial ventilations during CPR without an advanced airway vs with an advanced airway in place.
Using quantitative waveform capnography to confirm placement of an advanced airway, assess the quality of CPR, and identify ROSC.
The effects of hyperventilating patients in cardiac arrest.
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Good luck with your ACLS class!
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Hypothermic patients aren't dead until they are warm and dead.
When a patient’s core body temperature drops below 96.8 F (36 C), they are hypothermic. As the body’s temperature drops below 36 C, hypothermia may further be classified as moderate or severe:
Moderate if the patient’s body core temp is between 30-34 C; and Severe if it's below 30 C.Modifying the ACLS Adult Cardiac Arrest algorithm for patients with severe hypothermia.
Following the ACLS algorithm for patients with a body core temperature above 30 C.
Methods for rewarming patients with moderate vs severe hypothermia.
Continuation of CPR and ACLS efforts until the patient’s body core temp is above 36 C.
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Calcium is one of the ions that move across the cellular membrane during cardiac contraction and relaxation.
The primary use of calcium channel blockers in ACLS is for the treatment of stable, narrow complex tachycardias refractory to Adenosine and to lower the blood pressure of ischemic stroke patients with severe hypertension.
Use of calcium channel blockers for SVT refractory to Adenosine and A-Fib or A-Flutter with RVR.
Contraindications of calcium channel blockers.
Nicardipine use during the treatment of ischemic strokes.
For more information on ACLS medications, tachycardia, or stroke check out the pod resource page at passacls.com.
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The goal of CPR is to keep the brain and vital organs perfused until return of spontaneous circulation (ROSC) is achieved.
Post-arrest care and recovery are the final two links in the chain of survival.
Identification of ROSC during CPR.
Initial patient management goals after identifying ROSC.
The patient’s GCS/LOC should be evaluated to determine if targeted temperature management (TTM) is indicated.
Patients that cannot obey simple commands should receive TTM for at least 24 hours.
Monitoring the patient’s core temperature during TTM.
Why we should cool unresponsive post-arrest patients.
Patients can undergo EEG, CT, MRI, & PCI while receiving TTM.
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Nitroglycerine is vasodilator that affects peripheral blood vessels and coronary arteries.
Because of its widespread dilation effects on blood vessels, nitro can quickly lower a patient’s blood pressure, sometimes to the point of making a patient hypotensive.
Assessment of vital signs prior to administering nitro is necessary to ensure patient safety.
Indications for use of nitroglycerine.
Nitroglycerine's contraindications & considerations for use.
Effects of nitro on patients taking PDE inhibitors.
Administration of nitroglycerine to patients with ischemic chest pain.
Considerations for patients that took their home nitroglycerine.
Monitoring patient's pain and vital signs after nitro administration.
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The ACLS algorithms are designed to make it easier to remember the key interventions we should deliver, and the order in which they should be delivered, to provide the best evidence-based care possible.
Generally speaking, if there’s a change in a patient’s condition, we should ensure we’re using the correct algorithm.
Three key points to remember when using ACLS algorithms:
1. If a patient’s condition changes, we should do an assessment and use the algorithm that matches the patient’s current state.
2. If an action was already done, we don’t need to repeat it.
3. We only do actions that are clinically appropriate and within our scope of practice.
Walk through of an example mega code scenario with explanations of when and why we change to a different ACLS algorithm.
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Beta blocking medications attach to Beta receptors to inhibit or “block” the effects of epinephrine (adrenaline)and norepinephrine in the body.
The primary locations of Beta I, II, and III receptors.
Effects of epinephrine & norepinephrine’s stimulation of beta receptors on the heart.
Beta blockers effects on the heart.
When we should consider the use of beta blockers in the Acute Coronary Syndrome (ACS)and Tachycardia algorithms.
Contraindications to the use of beta blocker medications.
More detailed information about beta blocker’s mechanism of action and specific instances for their use can be found on the Pod Resource page at PassACLS.com.
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This episode we are reviewing the use of advanced airways in the adult cardiac arrest algorithm.
When we should consider insertion of an advanced airway for patients in a shockable vs non-shockable rhythm.
In addition to an endotracheal tube (ETT), other ACLS advanced airways include the Laryngeal Mask Airway (LMA) and the Laryngeal Tube airway.
The advantages of using an advanced airway over basic airway maneuvers.
Use of end tidal CO2 waveform capnography to confirm placement and assess the adequacy of CPR.
Identification and management of a misplaced ET tube.
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Our primary focus immediately following return of spontaneous circulation (ROSC) is aimed at ensuring adequate perfusion of the patient’s vital organs and decreasing cerebral damage.
Post-arrest goals for O2 saturation, ETCO2, and BP/MAP.
Indications for use of an antiarrhythmic after ROSC.
Determining which antiarrhythmic to use post cardiac arrest.
Administration of Amiodarone or Lidocaine to control ventricular ectopy after ROSC.
The use of Amiodarone post arrest if no antiarrhythmics were administered prior to obtaining ROSC.
Links to other medical podcasts that cover antiarrhythmics and other ACLS-related topics are on the Pod Resource page at PassACLS.com.
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Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.
Good luck with your ACLS class!
Discover medical podcasts with CE at https://conveymed.io
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Hydrogen ions is on one of the Hs in ACLS's H&T reversible causes of cardiac arrest.
When considering hydrogen ions as a cause, what we’re looking at is the patient’s pH, or acid/base balance, and conditions that affect it.
The body's normal pH.
Using patient history, ABGs, & labs to determine acidosis or alkalosis.
Common conditions/causes that may lead us to suspect acidosis.
Common conditions/causes that may lead us to suspect alkalosis.
Correcting acidosis by changing the rate of ventilations.
The indications, dose, and considerations for use of Sodium Bicarbonate.
Treatment of alkalosis depends on the type (metabolic or respiratory) and is aimed at correcting the underlying cause.
Other podcasts that cover acid/base balance and conditions that cause acidosis or alkalosis can be found on the Pod Resource Page at PassACLS.com.
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Good luck with your ACLS class!
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