Advanced Life Support

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Advanced Life Support

• Ben Constance, EMT, MSI

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Disclaimer!!!

• I am not an expert
• This information is to orient only this is not
  a course
• Medicine is a rapidly changing practice, so stay
  current
• Listen to your attendings and current literature,
  they are definitive sources

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Case scenario

• A 60 year old man collapses at the Timber Wolf
  while playing pool with his friends. Upon
  arrival they tell you that he was complaining of
  chest pain and they think he has heart problems.
  You had just received a DOT report that I90 will
  be closed for at least 30 minutes for avalanche
  control and snow removal. It is snowing heavily
  and you know from experience that Airlift
  Northwest cannot fly in this weather. A
  volunteer ski patrol physician is on the hill
  today and also responds to the call. What do you
  do?

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Objectives
At the end of this course, you should be able
to...

• Understand the chain of survival
• Understand the ABCDs of ALS
• Assist in ALS specific procedures, including
  intubation and IV therapy
• Recognize and prepare ALS specific equipment
• Document using a SOAP note and ALS flow chart

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The Chain of Survival (ALS)
Report of Incident
Ski Patrol Response
Snoq. Fire Dept./AMR
Patrol MD
OR
ALS transportation
Emergency Department
Definitive ALS care
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Primary ABCD Survey
Think Assess and Manage...

• Airway open the airway
• Breathing provide positive-pressure ventilation
  if needed
• Circulation give chest compressions if no pulse
• Defibrillate shock VF/pulseless VT

Source AHA ACLS Provider Manual
7
Secondary ABCD Survey
Think Assess and Manage...

• Airway provide advanced airway (ET tube)
• Breathing check for adequate oxygenation and
  ventilation - including physical exam,
  oxygenation monitoring, securing of adjunct
• Circulation obtain IV access, determine rhythm,
  give appropriate agents
• Differential Diagnosis search for, find, and
  treat reversible causes.

Source AHA ACLS Provider Manual
8
Patient Monitoring

• Heart rate and quality
• Respiratory rate and quality
• Blood pressure
• Oxygen saturation
• Cardiac rhythms using AED
• Skin color/temperature/texture
• Core body temperature

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Advanced Airways

• Gold standard for secure airway is endotracheal
  intubation (ET tube)
• Indications for ET tube
• Pulmonary or cardiac arrest
• Trauma patients in need of airway control or sup.
  Oxygen
• Respiratory distress
• Respiratory failure due to overdose
• Pulmonary edema (fluid in the lungs)
• Severe asthma
• Asphyxia
• Severe allergic reaction

Source Emergency Care 9th Ed.
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Endotracheal Intubation

• Steps in endotracheal intubation
• Hyperventilate patient prior to intubation
• Prepare and test all equipment
• Laryngoscope assembly
• Endotracheal tube with stylet and 10cc inflation
  syringe
• Position the patients head
• Make sure airway is aligned
• Prepare to insert laryngoscope blade
• Lift the tongue out of the way with the
  laryngoscope
• Bring the glottic opening into view
• Second rescuer perform Sellicks maneuver
  (cricoid pressure) during intubation to suppress
  vomiting and aid in visualization

Source Emergency Care 9th Ed.
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Endotracheal Intubation cont.

• Visualize the glottic opening
• Insert the endotracheal tube with a stylet
• Remove the laryngoscope and stylet. Inflate the
  cuff with 5-10cc air
• Attach a bag/valve unit to the the ET tube
  universal adapter
• Auscultate the lungs and epigastrium areas to
  confirm placement
• If placement confirmed, secure the tube in place

Source Emergency Care 9th Ed.
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Endotracheal tubes
Inflation catheter
Murphy Eye
Tracheal cuff inflation valve
Pilot Balloon
Tracheal cuff
Universal 15mm adapter
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Endotracheal tubes
ET tube size
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Laryngoscope
Handle
Light
Blade
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Laryngoscope Blades
1 Infant 2 Child 3 Adult 4 Large Adult
Miller
Macintosh
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Difficult Airways

• Anatomical variations
• Airway obstructions
• Anaphylaxis and airway swelling
• Penetrating injuries to head/neck
• Blunt trauma
• Excessive pharyngeal bleeding
• Cervical spine immobilization

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Alternatives!

• Oropharyngeal airways
• Nasopharyngeal airways
• Laryngeal mask airways (LMA)
• Combi-tubes
• ET tube introducers (Bougie)
• Surgical airways

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Oropharyngeal Airways
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Nasopharyngeal Airways
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Laryngeal Mask Airway (LMA)
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LMA cont.
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Combitubes
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Combitube cont.
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Introducer / Bougie

• Used to find trachea by feeling ridges of
  cartilage rings
• ET tube placed over the top of introducer
• ET tube secured in trachea

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Surgical Airway
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What to use?
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Confirming airway

• Confirm tube placement by
• End tidal CO2 detector (right)
• Auscultation
• Capnography
• Pulse-OX
• Chest XR

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Intravenous Therapy (IV)

• An intravenous line is inserted into a vein in
  order to
• Administer fluid volume
• Administer medications
• Administer blood (done in hospital)
• Indications (not all inclusive)
• Cardiac event
• Loss of consciousness
• Hypovolemia
• Severe hypothermia
• Shock
• Diabetic emergency
• Trauma

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IV Setup


IV solution
IV solution Drip Set
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IV Step by Step Setup

• Take out and inspect all equipment
• Select proper administration set
• Make sure the flow regulator is closed
• Remove all protective coverings, keeping
  everything sterile, and insert the spiked tip of
  the tubing into the fluid bag entirely with a
  quick twist
• Hold the fluid bag higher than the drip chamber,
  fill the chamber to the line by squeezing it
• Open the flow regulator and allow the fluid to
  flush the tubing
• Turn off the flow

Source Emergency Care 9th Ed.
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Maintaining an IV

• An IV must flow continually to stay open (TKO)
• Things that can interrupt flow
• Closed flow regulator
• Closed clamp
• Tubing kink
• Tubing caught under patient or backboard
• Tourniquet left in place
• Tubing pulled out of catheter
• Look out for
• Infiltrations
• Runaway flow rate (too fast may overload patient)
• Low level in fluid bag

Source Emergency Care 9th Ed.
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Angiocaths (IV needles)
Angiocath Size (gage / length)
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Electrocardiograms

• Graph of heart voltage vs. time
• 6 precordial leads leads
• 4 limb leads

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(No Transcript)
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Evaluation of EKGs

• First, determine rate
• Each small box is 40 msec
• Each larger box is 200 msec
• To estimate can use pneumonic
• "300-150-100-75-60-50"
• Count lines back from any QRS complex!

students.med.nyu.edu/erclub/ekgs
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Evaluation of EKGs

• Second, determine rhythm source and regularity
• Third, determine the axis

students.med.nyu.edu/erclub/ekgs
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EKGs

• Read Rapid Interpretation of EKGs
• Read the ACLS Provider Manual
• Search for online practice simulators
• Pursue EKG interpretation on clinical rotations

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Medication Kit
Needles
Large Vials
Small Vials
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Medications

• Name
• brand and chemical
• Concentration
• amount drug/volume
• Route
• where it goes

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Back to the Case Scenario
A 60 year old man collapses at the Timber Wolf
while playing pool with his friends. Upon
arrival they tell you that he was complaining of
chest pain and they think he has heart problems.
You had just received a DOT report that I90 will
be closed for at least 30 minutes for avalanche
control and snow removal. It is snowing heavily
and you know from experience that Airlift
Northwest cannot fly in this weather. A
volunteer ski patrol physician is on the hill
today and also responds to the call. What do you
do?
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Primary ABCDs

• Check for responsiveness
• Call aid room
• Establish code 99
• Ask for ALS response and ALS equipment
• Airway
• Open the airway patient not breathing
• Breathing
• Provide positive pressure ventilations still no
  breathing
• Circulation
• Check for pulse there is none
• Give chest compressions
• Defibrillate
• Assess for and shock VF/pulseless VT, up to 3
  times
• (200J, 300J, 360J) still no spontaneous
  circulation

Source AHA ACLS Provider Manual
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Secondary ABCDs

• Airway
• Place airway device as soon as possible (ET tube)
• Breathing
• Confirm airway device placement and secure
• Confirm oxygenation and ventilation
• Circulation
• Establish IV access
• Identify rhythm monitor
• Administer drugs appropriate for rhythm and
  condition
• Differential Diagnosis
• Search for and treat identified reversible causes
  

Source AHA ACLS Provider Manual
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Continued Management

• After the initial 3 shocks, the patient was
  intubated, an IV established with lactated
  ringers (LR), and an AED was attached showing the
  rhythm below. What do you want to do now?
• Epinephrine 1mg IV push, repeat every 3-5 minutes
• Resume attempts to defibrillate
• 1 X 360J still no spontaneous sinus rhythm

Source AHA ACLS Provider Manual
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Continued Management

• Consider antiarrhythmics, (one of the following
  examples)
• Amiodarone
• Lidocaine
• Magnesium
• Procainamide
• Resume attempts to defibrillate
• 1 X 360J Congratulations! the rhythm is shown
  below.

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Special Considerations

• Transportation should never be delayed to
  initiate ALS care on behalf of Ski Patrol
• Patrol ALS providers may travel with BLS
  transportation until the patient is transferred
  to Medics / Airlift
• ALS care should be coordinated with online
  medical control or responding medics / flight
  nurses
• Once ALS care is initiated, the provider must
  stay with the patient until transferred to
  equivalent care
• Special documentation must occur to provide
  quality continuation of care
• Ski Patrol does not! have a duty to provide ALS

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Documentation

• Full time job assign it early!
• If you are not qualified to assist in ALS this
  may be you!
• Incident form
• As usual
• SOAP form
• Subjective what the patient tells you
• Objective what you observe
• Assessment what you think is going on
• Plan what you plan to do about it
• Flow chart
• Time
• All vital signs
• Medications, how much, and when

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What you need to remember

• Stay calm
• Get the ball rolling early
• Follow the direction of the provider in charge
• Try to stay one step ahead of the game
• Stick to the basics most of this stuff makes
  sense
• Help with what you can
• Stay familiar with the equipment and procedures
  in your area
• Tail light of an ambulance are a good thing!

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Question?