ACLS Review

1
ACLS Review

• Jack Hornick
• 8/04/16

2
Announced overhead

• CODE BLUE
• Lakeside 20
• CODE BLUE
• Lakeside 20

3
Who goes to the code

• Interns, senior residents, AIs, and 3rd year
  medical students on Long Call on wards and in
  MICU
• DACR/VACR/NACR
• Anesthesia team
• Respiratory Therapists
• Critical care nurses (from MICU/CICU)
• Critical care pharmacist (Business hours M-F)

4
Who runs the code?

• First resident on the scene, or DACR/VACR/NACR
• The leader of the code assigns roles and
  responsibilities to the other residents and
  interns available

5
Roles during the code

• Stabilizing/managing airway
• Managing code cart
• Medication administration
• Recording timing of events
• Line for chest compressions (preferably 4 deep)
• Checking labs and past medical history, telemetry
• Pulse checker
• Thinking through Hs and Ts
• Calling the patients family
• Crowd control
• Obtaining emergency access

6
Roles during the code

• Stabilizing/managing airway RT, Anesthesia
• Managing code cart CICU RN
• Medication administration SICU RN
• Recording timing of events MICU RN
• Line for chest compressions (preferably 4 deep)
  Everyone
• Checking labs and past medical history, telemetry
  Intern
• Pulse checker Intern/Senior
• Thinking through Hs and Ts Code leader,
  intern/senior
• Calling the patients family Intern/senior
• Crowd control Senior
• Obtaining emergency access Code White RN can
  attempt IO, resident femoral CVC

7
Code Blue

• You are the Naff intern on call, working on notes
  in the Naff team room. Code Blue is called for a
  patient on Lakeside 20. Your senior is MIA. You
  run down the hall and are the first on the scene.
  What do you do?

8
Scenario 1

• You feel a thready femoral pulse, the patient
  feels tachycardic
• Automatic blood pressure cuff is not reading
• Patient is agonal breathing, not responding to
  verbal or painful stimuli
• The nurses look to you and say Doctor, what do
  we do?

9
(No Transcript)
10

• On arrival, you do a quick initial assessment
  while assessing his responsiveness and vital
  signs and immediately instruct someone to begin
  compressions.
• While compressions are occurring you ask the
  nurse to apply pads and electrodes to the patient
  to analyze the rhythm.
• In addition, you ask that oxygen be applied to
  the patient
• You ask about any complaints the patient may have
  had and find that minutes ago he was complaining
  of chest pain, palpitations, and dizziness.
• Being a very keen intern, you recognize this may
  be Acute Coronary Syndrome causing arrest.

11
Cardiac Arrest, 4 rhythms
12
(No Transcript)
13

• As you pause during compressions you analyze the
  rhythm the patient is in Ventricular
  Fibrillation
• The DACR runs into the room, you notify him/her
  of the patients rhythm and
• ANALYZE.. CLEARSHOCK DELIVERED
• Resume CPR! Wait to reanalyze the rhythm after
  the next round of CPR
• The patient receives a dose of Epinephrine in
  addition to another shock and has conversion to
  sinus rhythm. He has ROSC. His vitals begin to
  improve and he is rushed to the Cardiac
  Catherization Lab.
• Nice Work!

14
High quality CPR is key

• Rate approx 100/min
• Compression depth gt2 inches (5cm) in adults
• Allow complete chest recoil after each
  compression
• Minimize interruptions
• Rotate every 2 minutes

15
Scenario 2

• One of your many pagers on Intern Nightfloat goes
  off.
• Theres a Code White on your patient in Lakeside
  55 her heart rate is a little low and shes
  feeling dizzy
• You ask the nurse to get a full set of vitals as
  you head towards the patients room.
• As youre headed over you hear the overhead
  announcement CODE BLUE, CODE BLUE, CODE
  BLUE..LAKESIDE 55

16

• You arrive at the patients room and the nurse
  informs you that the patients HR was 60-70s
  during the day but suddenly decreased from 48 to
  35bpm.
• Current vitals HR 35bpm, SBP 70/DBP is
  undetectable RR 16/min, and O2 saturation 93.
• The patient was initially complaining of
  lightheadedness but now is more lethargic.
• You take a look at the EKG that was obtained.

17
(No Transcript)
18

• You request oxygen be applied to the patient and
  the pads for transcutaneous pacing be applied.
• Just as you are doing so, additional help arrives
  and your Nightfloat senior assists you.
• Atropine is obtained from the crashcart and the
  patient is bolused 0.5mg.
• The patients HR slightly improves to 49bpm but
  he remains somewhat confused and lethargic.
• Transcutaneous pacing is started with a target HR
  of 60bpm. She begins to wake up and her BP
  improves to 110/57.
• EP is consulted and the patient receives a
  transvenous and ultimately an implanted
  pacemaker.

19
Last Scenario

• You are on Hellerstein waiting to sign out at 630
  pm on a Sunday when youre paged about a patient
  with past hx of SVT here for CP now has a HR of
  160.
• BP 125/80, narrow complex tachycardia as below

20
(No Transcript)
21
What do you try first?

• After attempting vagal maneuvers (unsuccessful)
  you give adenosine 6mg IV push, and then 12 mg IV
  push
• Now the patient develops severe chest pain, Hr
  220, BP not obtainable, pulse weak. The patient
  begins losing consciousness. What do you do next?

22

• Synchronized cardioversion is unsuccessful.
• Patient now is pulseless and unconscious.
• What next?
• Time to shock! (unsynchronized 120-200 J)

23
Synchronized vs unsynchronized cardioversion

• Synchronized
• Low energy shock
• delivers shock w/ peak of QRS
• Indications unstable A fib, A flutter, SVT
• If shock occurs on t-wave, high likelihood of VF

• Unsynchronized
• High energy shock
• delivers as soon as shock button is pushed
• Indications pulseless VT/VF

24

• After 5 cycles of CPR, the rhythm check suggests
  a second shock. Now with 200 J. Which medications
  should you be giving?
• Epinephrine 1mg IV q3min and/or vasopressin 40 U
  IV to replace first or second epi dose
• Amiodarone after 3rd shock in pulseless VT (300
  mg IV x1, then consider 150 mg IV x1

25

• ROSC! The patient was intubated by anesthesia at
  the scene, and is not responding to verbal
  commands. Patient transported to CICU. What post
  cardiac arrest intervention would this patient
  benefit from?

26
(No Transcript)
27
What Is ACLS?

• ACLS guidelines first published 1974 by AHA, most
  recent update 2015
• A series of interventions for urgent treatment of
  cardiac arrest, stroke, and life threatening
  medical emergencies
• Several algorithms for VF/Pulseless VT,
  Bradycardia, Suspected Stroke
• An essential part of using the algorithm
  correctly is to search for and correct
  potentially reversible causes of arrest
• Performing high quality CPR, identifying
  arrhythmias and understanding the pharmacology
  behind key drugs are central to ACLS.

28
Hs and TsTreatable causes of cardiac arrest

• Hypoxia
• Hypovolemia
• Hydrogen ion (acidosis)
• Hypokalemia
• Hyperkalemia
• Hypothermia

• Thrombosis (pulmonary)
• Thrombosis (coronary)
• Tamponade
• Tension pneumothorax
• Toxins

29
Things to discuss with patients

• All patients admitted to the hospital should be
  asked about their code status
• Its important to discuss the morbidity
  associated with ACLS
• Statistics regarding survival after arrest
• Adverse outcomes of CPR and Advanced Airway
  Support

30

• Dont forget to pick up your ACLS cards from the
  chiefs office!
• Remember to check your own pulse first.