Advanced Cardiac Life Support

Overview

• Advanced Cardiac Life Support (ACLS) Team
  • Leader: older physician, orders medications, administers defibrillation as necessary, delegates role
  • Intubator: a physician with experience in placing ET tube
  • Thinker: a physician who can identify the possible underlying cause
  • IV nurse: nurse or trained professional to administer IV meds
  • CPR givers: anyone trained in CPR, preferably at least two people (one for pumping, the other for masking)

Cardiac Arrest

Refers to sudden loss of pulse, drop in blood pressure, and loss of perfusion. Death results in 5 minutes without proper resuscitation (but brain damage results earlier than this). This is a medical emergency. Can be idiopathic. Basic appearance, BMP, and history should clue you in.

• Causes of cardiac arrest (6 H’s and 5 T’s)
  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hypo-/Hyperkalemia
  • Hyperthermia
  • Toxins
  • Tamponade, cardiac
  • Tension pneumothorax
  • Thrombosis (Myocardial infarction (MI) or pulmonary embolism (PE))
  • Trauma

Cardiopulmonary Resuscitation (CPR)

The first step is to initiate CPR

• CPR (30 and 2)
  • 30 strong chest pumps (”Stayin’ Alive” – 100-120 bpm, 2 inches deep)
  • 2 rescue breaths (look for symmetrical chest rise)
  • Ensure full chest recoil during pumps!
  • Someone qualified should meanwhile be attempting to place an airway (endotracheal tube)

Reading the EKG

While CPR is being administered, someone should be reading the EKG.

The first thing to do is to determine whether or not the rhythm is “shockable”. Shockable rhythms may convert to non-shockable rhythm or vice versa so keep watch of the EKG.

• Shockable rhythm
  • Ventricular Fibrillation (V-Fib)
  • Ventricular Tachycardia (V-Tach)
• Non-shockable rhythms
  • Pulseless electrical activity (PEA; any rhythm apart from V-fib, V-tach, and asystole occurring without a pulse)
  • Asystole

Cardioversion (V-fib or Pulseless V-Tach)

If you have a shockable rhythm, switch the defibrillator to non-synchronized then deliver a shock.

• Monomorphic V-Tach
  • Start with 100 J on the first attempt → 200 J → 300 J
• Polymorphic V-tach
  • 360 J if monophasic device
  • 200 J if biphasic device (or unsure)

First round

Warm resuscitator then deliver a shock. Assess for pulse, and rhythm, and resume CPR (30/2) immediately if necessary.

Second round

If there is still no pulse, administer IV epinephrine 1mg (q 3-5 minutes). Shock. Check for pulse, and rhythm, and resume CPR (30/2) if necessary

Third round

If there is still no pulse administer IV epinephrine 1mg (3-5 mins after the previous dose)

Consider IV amiodarone 300mg or IV magnesium 2 (over 1-2 minutes). Amiodarone > Lidocaine. Can repeat amiodarone in subsequent rounds at 150 mg.

Shock. Check for pulse, and rhythm, and resume CPR (30/2) if necessary, repeat.

Asystole or Pulseless Electrical Activity (PEA)

Non-shockable rhythm. During CPR, administer IV epinephrine 1mg and IV atropine 1mg (if asystole or bradycardic PEA).

Repeat epinephrine every 3-5 mins. Atropine may be given up to 3 mg. Every 3-5 mins, check pulse/rhythm.

Post-resuscitation

If resuscitation is successful transfer the patient to an ICU. House elementary and proper ventilation is mandatory. Intensely monitor the patient over the next 24-48 hours.

Do a full physical exam, and check ribs for trauma from CPR (imaging)

Labs to get: Serial CMP, CBC, Cardiac enzymes

CXR and other diagnostic tests as necessary based on the patient’s state.