Acls

Ad v a c e d C a r d io v a s c la r Life S p p o r t P R O V I D E R

M A n u A L

Ed itors

ACLS Su b c om m itte e 2010-2011

Elizabeth Sinz, MD, Associate Science Editor Kenneth Navarro, Content Consultant

Clifton W. Callaway, MD, PhD, Chair Robert W. Neumar, MD, PhD, Immediate Past Chair, 2008-2010 Steven Brooks , MD Daniel P. Davis , MD Michael Donnino, MD Andrea Gabrielli, MD Romergryko Geocadin, MD Erik Hes s , MD, MSc Mark S. Link, MD Bryan McNally, MD, MPH Venu Menon, MD Graham Nichol, MD, MPH Brian O’Neil, MD J os eph P. Ornato, MD Charles W. Otto, MD Michael Shus ter, MD Scott M. Silvers , MD Mintu Turakhia, MD, MS Terry L. Vanden Hoek, MD J anice L. Zimmerman, MD

Se n ior Ma n a g in g Ed itor Erik S. Soderberg, MS

Sp e c ia l Con trib u tors Clifton W. Callaway, MD, PhD Diana M. Cave, RN, MSN Heba Cos tandy, MD, MS Mary Fran Hazins ki, RN, MSN Theres a Hoadley, RN, PhD, TNS Robert W. Neumar, MD, PhD Peter D. Panagos , MD Sallie Young, PharmD, BCPS

© 2011 American Heart As s ociation ISBN 978-1-61669-010-6 Printed in the United States of America Firs t American Heart As s ociation Printing May 2011 eBook edition © 2013 American Heart As s ociation. ISBN 978-1-61669-350-3

i

ACLS Subc om m itte e 2009-2010 Robert W. Neumar, MD, PhD, Chair Laurie J . Morris on, MD, MSc, Immediate Past Chair, 2006-2008 Steven Brooks , MD Cli ton W. Callaway, MD, PhD Daniel P. Davis , MD Andrea Gabrielli, MD Romergryko Geocadin, MD Richard Kerber, MD Mark S. Link, MD Bryan McNally, MD, MPH Graham Nichol, MD, MPH Brian O’Neil, MD J os eph P. Ornato, MD Charles Otto, MD, PhD Michael Shus ter, MD Scott M. Silvers , MD Terry L. Vanden Hoek, MD

Ac knowle dgm e nts Peter Olu Anders on, MD Ulrik Chris tens en, MD

To f nd out about any updates or corrections to this text, vis it www.he a rt.o rg /c p r, navigate to the page or this cours e, and click on “Updates .” To acces s the Student Webs ite or this cours e, go to www.he a rt.o rg /e c c s tud e nt and enter this code: algorithm ii

Conte nts P a rt 1 Co u r s e Ove r vie w

1 Cours e De s c ription a nd Goa l

1

Cours e Obje c tive s

1

Cours e De s ign

2

Cours e Pre re q uis ite s a nd P re p a ra tion

2

BLS Skills

2

ECG Rhythm Interpretation for Core ACLS Rhythms

3

Bas ic ACLS Drug and Pharmacology Knowledge

3

Practical Application of ACLS Rhythms and Drugs

3

Effective Res us citation Team Concepts

3

Cours e Ma te ria ls

3

ACLS Provider Manual

4

Student Webs ite

5

Pocket Reference Cards

6

Precours e Preparation Checklis t

6

Re quire m e nts for Suc c e s s fu l Cours e Com ple tion

7

ACLS Upda te Cours e

7

ACLS P rovide r Ma nua l Abb re via tions

7

P a rt 2 Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys

11

Introduction

11

Learning Objectives

11

The Sys te m a tic Ap p roa c h : The BLS a nd ACLS Su rve ys Overview of the Sys tematic Approach

The BLS Surve y Overview of the BLS Survey

The ACLS Surve y Overview of the ACLS Survey

11 11

12 12

14 14

iii

C o n t e n t s

P a rt 3 Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s

17

Introduction

17

Learning Objectives

17

Role s of th e Te a m Le a d e r a n d Te a m Me m b e rs

18

Role of the Team Leader

18

Role of the Team Member

18

Ele m e n ts of Effe c tive Re s u s c ita tion Te a m Dyn a m ic s

19

Clos ed-Loop Communications

19

Clear Mes s ages

19

Clear Roles and Res pons ibilities

20

Knowing One’s Limitations

21

Knowledge Sharing

22

Cons tructive Intervention

22

Reevaluation and Summarizing

23

Mutual Res pect

23

P a rt 4 S ys t e m s o f Ca re

25 Introduction

25

Learning Objectives

25

Ca rd iop u lm on a ry Re s u s c ita tion

25

Quality Improvement in Res us citation Sys tems , Proces s es , and Outcomes A Sys tems Approach

26

Meas urement

27

Benchmarking and Feedback

27

Change

27

Summary

27

Pos t–Ca rd ia c Arre s t Ca re

28

Therapeutic Hypothermia

28

Hemodynamic and Ventilation Optimization

28

Immediate Coronary Reperfus ion With PCI

28

Glycemic Control

28

Neurologic Care and Prognos tication

29

Ac ute Coron a ry Syndrom e s

iv

25

29

Starts “On the Phone” With Activation of EMS

29

EMS Components

29

Hos pital-Bas ed Components

29

Con te n ts

Ac ute Stroke

30

Regionalization of Stroke Care

30

Community and Profes s ional Education

30

EMS

30

Ed u c a tion , Im p le m e n ta tion , a n d Te a m s

30

The Need for Teams

30

Cardiac Arres t Teams (In-Hos pital)

31

Rapid Res pons e Sys tem

31

Medical Emergency Teams and Rapid Res pons e Teams

31

Regional Sys tems of Emergency Cardiovas cular Care

32

Publis hed Studies

32

Implementation of a Rapid Res pons e Sys tem

32

P a rt 5 Th e ACLS Ca s e s

33 Overview of the Cas es

Re s pira tory Arre s t Ca s e

33

34

The BLS Survey

34

The ACLS Survey

36

Management of Res piratory Arres t

38

Giving Supplementary Oxygen

38

Opening the Airway

38

Providing Bas ic Ventilation

40

Bas ic Airway Adjuncts : Oropharyngeal Airway

42

Bas ic Airway Adjuncts : Nas opharyngeal Airway

43

Suctioning

45

Providing Ventilation With an Advanced Airway

47

Precautions for Trauma Patients

49

VF Tre a te d With CP R a n d AED Ca s e

49

The BLS Survey

50

AED Us e in Special Situations

57

VF/P u ls e le s s VT Ca s e

59

Managing VF/Puls eles s VT: The Cardiac Arres t Algorithm

60

Application of the Cardiac Arres t Algorithm: VF/VT Pathway

62

Routes of Acces s for Drugs

69

Vas opres s ors

70

Antiarrhythmic Agents

71

Immediate Pos t–Cardiac Arres t Care

72

Application of the Immediate Pos t–Cardiac Arres t Care Algorithm

73

P u ls e le s s Ele c tric a l Ac tivity Ca s e Des cription of PEA

78 78 v

C o n t e n t s Managing PEA: The Cardiac Arres t Algorithm

79

Managing PEA: Diagnos ing and Treating Underlying Caus es

82

As ys tole Ca s e

86

Approach to As ys tole

86

Managing As ys tole

87

Application of the Cardiac Arres t Algorithm: As ys tole Pathway

88

Terminating Res us citative Efforts

89

Ac ute Coron a ry Syndrom e s Ca s e

91

Goals for ACS Patients

92

Managing ACS: The Acute Coronary Syndromes Algorithm

95

Identification of Ches t Dis comfort Sugges tive of Is chemia (Box 1)

96

EMS As s es s ment, Care, and Hos pital Preparation (Box 2)

96

Immediate ED As s es s ment and Treatment (Box 3)

99

STEMI (Boxes 5 Through 8)

100

Clas s ify Patients According to ST-Segment Deviation (Boxes 5, 9, and 13)

Bra d yc a rd ia Ca s e

104

Des cription of Bradycardia

107

Managing Bradycardia: The Bradycardia Algorithm

108

Application of the Bradycardia Algorithm

109

Trans cutaneous Pacing

112

Un s ta b le Ta c h yc a rd ia Ca s e

114

The Approach to Uns table Tachycardia

114

Managing Uns table Tachycardia: The Tachycardia Algorithm

116

Application of the Tachycardia Algorithm to the Uns table Patient

118

Cardiovers ion

120

Synchronized Cardiovers ion Technique

122

Sta b le Ta c h yc a rd ia Ca s e

124

Approach to Stable Tachycardia

125

Managing Stable Tachycardia: The Tachycardia Algorithm

126

Application of the Tachycardia Algorithm to the Stable Patient

127

Ac ute Stroke Ca s e

vi

101

130

Approach to Stroke Care

132

Identification of Signs of Pos s ible Stroke (Box 1)

135

Critical EMS As s es s ments and Actions (Box 2)

138

In-Hos pital, Immediate General As s es s ment and Stabilization (Box 3)

139

Immediate Neurologic As s es s ment by Stroke Team or Des ignee (Box 4)

140

CT Scan: Hemorrhage or No Hemorrhage (Box 5)

141

Fibrinolytic Therapy

143

General Stroke Care (Boxes 11 and 12)

146

Con te n ts

Ap p e n d ix

149 Te s tin g Ch e c klis ts a n d Le a rn in g Sta tion Ch e c klis ts

151

2010 AHA Guid e line s fo r CPR a nd ECC Su m m a ry Ta b le

163

ACLS Ph a rm a c ology Sum m a ry Ta ble

165

Glos s a ry

168

Founda tion Inde x

171

In d e x

173

No t e o n Me d ic a t io n Do s e s Emergency cardiovas cular care is a dynamic s cience. Advances in treatment and drug therapies occur rapidly. Readers s hould us e the following s ources to check for changes in recommended dos es , indications , and contraindications : the ECC Handbook, available as optional s upplementary material, and the package ins ert product information s heet for each drug and medical device. vii

C o n t e n t s

Part

1

Cours e Ove rvie w Co u r s e De s c r ip t io n a n d Go a l The Advanced Cardiovas cular Life Support (ACLS) Provider Cours e is des igned for healthcare providers who either direct or participate in the management of cardiopulmonary arres t or other cardiovas cular emergencies . Through didactic ins truction and active participation in s imulated cas es , s tudents will enhance their s kills in the diagnos is and treatment of cardiopulmonary arres t, acute arrhythmia, s troke, and acute coronary s yndromes (ACS). After s ucces s ful completion of this cours e, s tudents will be able to apply important concepts , including •  The Bas ic Life Support (BLS) Survey •  High-quality cardiopulmonary res us citation (CPR) •  The ACLS Survey •  The ACLS algorithms •  Effective res us citation team dynamics •  Immediate pos t–cardiac arres t care The goal of the ACLS Provider Cours e is to improve outcomes for adult patients with cardiac arres t or other cardiopulmonary emergencies through provider training.

Co u r s e Ob je c t ive s Upon s ucces s ful completion of this cours e s tudents s hould be able to •  Recognize and initiate early management of periarres t conditions that may res ult in cardiac arres t or complicate res us citation outcome •  Demons trate proficiency in providing BLS care, including prioritizing ches t compres s ions and integrating automated external defibrillator (AED) us e •  Recognize and manage res piratory arres t •  Recognize and manage cardiac arres t until termination of res us citation or trans fer of care, including immediate pos t–cardiac arres t care •  Recognize and initiate early management of ACS, including appropriate dis pos ition •  Recognize and initiate early management of s troke, including appropriate dis pos ition •  Demons trate effective communication as a member or leader of a res us citation team and recognize the impact of team dynamics on overall team performance

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P a r t

1

Co u r s e De s ig n To help you achieve thes e objectives , the ACLS Provider Cours e includes practice learning s tations and a Megacode evaluation s tation. The practice learning stations give you an opportunity to actively participate in a variety of learning activities , including •  Simulated clinical s cenarios •  Demons trations by ins tructors or video •  Dis cus s ion and role playing •  Practice in effective res us citation team behaviors In thes e learning s tations you will practice es s ential s kills both individually and as part of a team. This cours e emphas izes effective team s kills as a vital part of the res us citative effort. You will have the opportunity to practice as a team member and a team leader. At the end of the cours e, you will participate in a Megacode evaluation station to validate your achievement of the cours e objectives . A s imulated cardiac arres t s cenario will evaluate the following: •  Knowledge of core cas e material and s kills •  Knowledge of algorithms •  Unders tanding of arrhythmia interpretation •  Us e of appropriate bas ic ACLS drug therapy •  Performance as an effective team leader

Co u r s e P re re q u is it e s a n d P re p a r a t io n The American Heart As s ociation (AHA) limits enrollment in the ACLS Provider Cours e to healthcare providers who direct or participate in the res us citation of a patient either in or out of hos pital. Participants who enter the cours e mus t have the bas ic knowledge and s kills to participate actively with the ins tructor and other s tudents . Before the cours e, pleas e read the ACLS Provider Manual, complete the s elf-as s es s ment modules on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt), identify any gaps in your knowledge, and remediate thos e gaps by s tudying the applicable content in the ACLS Provider Manual or other s upplementary res ources . The following knowledge and s kills are required for s ucces s ful cours e completion: •  BLS s kills •  Electrocardiogram (ECG) rhythm interpretation for core ACLS rhythms •  Knowledge of airway management and adjuncts •  Bas ic ACLS drug and pharmacology knowledge •  Practical application of ACLS rhythms and drugs •  Effective res us citation team concepts

BLS S k ills

The foundation of advanced life s upport is s trong BLS s kills . You mus t pas s the 1-Res cuer CPR and AED Tes ting Station to s ucces s fully complete the ACLS cours e. Make sure that you are proficient in BLS skills before attending the course. Watch the CPR and AED Skills video found on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). Review the CPR and AED Tes ting Checklis t located in the Appendix.

2

Cou rs e Ove rvie w

ECG Rh yt h m In t e r p r e t a t io n fo r Co r e ACLS Rh yt h m s

The bas ic cardiac arres t and periarres t algorithms require s tudents to recognize thes e ECG rhythms : •  Sinus rhythm •  Atrial fibrillation and flutter •  Bradycardia •  Tachycardia •  Atrioventricular (AV) block •  As ys tole •  Puls eles s electrical activity (PEA) •  Ventricular tachycardia (VT) •  Ventricular fibrillation (VF) The AHA recommends that you complete the ECG rhythm identification s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of the as s es s ment you will receive your s core and feedback to help you identify areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering the cours e. During the cours e you mus t be able to identify and interpret rhythms during practice as well as during the final Megacode evaluation s tation.

Ba s ic ACLS Dr u g a n d P h a r m a c o lo g y Kn o w le d g e

You mus t know the drugs and dos es us ed in the ACLS algorithms . You will als o need to know when to us e which drug bas ed on the clinical s ituation.

P r a c t ic a l Ap p lic a t io n o f ACLS Rh yt h m s a n d Dr u g s

Take the ACLS practical application s elf-as s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) to evaluate your ability to integrate both rhythm interpretation and the us e of pharmacologic agents . This as s es s ment pres ents a clinical s cenario and an ECG rhythm. You will need to take an action, give a s pecific drug, or direct your team to intervene. Us e this s elf-as s es s ment to confirm that you have the knowledge you need to be an active participant in the cours e and pas s the final Megacode tes t.

Effe c t ive Re s u s c it a t io n Te a m Co n c e p t s

Ins tructors throughout the cours e will evaluate your effectivenes s as a team leader and a team member. A clear unders tanding of thes e concepts is integral to s ucces s ful performance in the learning activities and the Megacode tes t. Review Part 3 in the ACLS Provider Manual before the cours e. During the Megacode the ins tructor will evaluate your team leader s kills with a major emphas is on your ability to direct the integration of BLS and ACLS activities by your team members .

The AHA recommends that you complete the ACLS pharmacology review s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of the as s es s ment you will receive your s core and feedback to help you identify areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering the cours e.

Co u r s e Ma t e r ia ls Cours e materials cons is t of the ACLS Provider Manual, Student Webs ite (www.he a rt.o rg /e c c s tud e nt), 2 pocket reference cards , and Precours e Preparation Checklis t. The icon on the left directs you to additional s upplemental information on the Student Webs ite.

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P a r t

1

ACLS P r o vid e r Ma n u a l

The ACLS Provider Manual contains the bas ic information you need for effective participation in the cours e. This important material includes the s ys tematic approach to a cardiopulmonary emergency, effective res us citation team communication, and the ACLS cas es and algorithms . Please review this manual before attending the course. Bring it with you for use and reference during the course. The manual is organized into the following parts :

Co n t e n t s P a rt 1

Cours e Overview

P a rt 2

The Sys tematic Approach

P a rt 3

Effective Res us citation Team Dynamics

P a rt 4

Sys tems of Care

P a rt 5

The ACLS Cas es

Ap p e nd ix •  Te s ting Che c klis ts a nd Le a rning Sta tio n Che c klis ts •  2010 AHA Gu id e lin e s for CP R a n d ECC Sum m a ry Ta b le

Summary of the new 2010 AHA Guidelines for CPR and ECC

•  ACLS P ha rm a c o lo g y Sum m a ry Ta b le

Bas ic ACLS drugs , dos es , indications /contraindications , and s ide effects

•  Glo s s a ry

Alphabetical lis t of terms

•  Fo und a tio n Ind e x

Pages where key s ubjects can be found (eg, epinephrine, cardiovers ion, pacing)

Ind e x The AHA s trongly recommends that s tudents complete the Precours e Self-As s es s ment found on the Student Webs ite and print their s cores for s ubmis s ion to their ACLS Ins tructor. Supplemental topics located on the Student Webs ite are us eful but not es s ential for s ucces s ful completion of the cours e.

Ca ll-ou t Boxe s The ACLS Provider Manual contains important information pres ented in call-out boxes that require the reader’s attention. Pleas e pay particular attention to the call-out boxes , lis ted below: •  Critical Concepts •  Caution •  FYI 2010 Guidelines •  Foundational Facts

Cr it ic a l Co n c e p t s Im p o rta nt Info rm a tio n to Re vie w a nd Stud y

4

•  Pay particular attention to the Critic a l Co nc e p ts boxes that appear in the ACLS Provider Manual. Thes e boxes contain the mos t important information that you mus t know.

Cou rs e Ove rvie w

Ca u t io n

•  Ca utio n boxes  emphas ize s pecific ris ks  as s ociated with interventions .

FYI 2 0 1 0 Gu id e lin e s

•  FYI 2010 Guid e line s  boxes  contain the new 2010 AHA Guidelines for CPR and ECC  information.

Fo u n d a t io n a l Fa c t s

•  You will s ee Fo und a tio na l Fa c ts boxes  throughout the ACLS Provider Manual.  Thes e boxes  contain bas ic information that will help you unders tand the topics    c overed in the cours e.

S t u d e n t We b s it e

The ACLS Student Webs ite (www.he a rt.o rg /e c c s tud e nt) contains  the following  s elf-as s es s ment and s upplementary res ources :

Re s o u rc e

De s c r ip t io n

Ho w t o Us e

ACLS Rhythm Id e ntific a tio n

Web-bas ed s elf-as s es s ment: recognition of bas ic  ECG rhythms

ACLS P ha rm a c o lo g y

Web-bas ed s elf-as s es s ment: drugs  us ed in   algorithms

P ra c tic a l Ap p lic a tio n o f ACLS Alg o rithm s

Web-bas ed s elf-as s es s ment: evaluates  the   practical application of  rhythm recognition and  pharmacology in the ACLS  algorithms

ACLS Sup p le m e nta ry Info rm a tio n

•  Bas ic Airway  Management •  Advanced Airway  Management •  ACLS Core Rhythms •  Defibrillation •  Acces s  for Medications •  Acute Coronary  Syndromes •  Human, Ethical, and  Legal Dimens ions  of  ECC and ACLS

Additional information   to s upplement bas ic   concepts  pres ented in  ACLS cours e

Supplementary  res ources :  review current BLS  s equence and s kills

Review BLS s kills  to   p repare for the 1-Res cuer  CPR and AED Tes ting  Station

CP R a nd AED Skills vid e o

Complete before the  cours e to help evaluate  your proficiency and   determine the need for  additional review and   practice 

Some information is  s upplementary; other areas  are  for the   interes ted   s tudent  or advanced  p rovider

(continued)

5

P a r t

1 (continued)

Re s o u rc e

P o c k e t Re fe r e n c e Ca r d s

6

Ho w t o Us e

ACS vid e o

Supplementary res ources : ACS as s es s ment and treatment

Review for ACS Learning Station

Stro ke vid e o

Supplementary res ources : s troke as s es s ment and treatment

Review for Stroke Learning Station

ACLS Sc ie nc e Ove rvie w vid e o

Supplementary res ources : core emphas is of the ACLS cours e from a s cience pers pective

Update ACLS knowledge and learn about changes in application of ACLS s cience

IO a nim a tio n

Supplementary res ources : information and demons tration of intraos s eous (IO) ins ertion

Expanded information on IOs

The Pocket Reference Cards are 2 s tand-alone cards packaged with the ACLS Provider Manual. Thes e cards can be carried in your pocket for quick reference on the following topics :

To p ic

Pre c ours e P r e p a r a t io n Ch e c k lis t

De s c r ip t io n

Re fe re n c e Ca rd s

Ca rd ia c a rre s t, a rrhythm ia s , a nd tre a tm e nt

•  Cardiac Arres t Algorithms •  Gray box with drugs and dos age reminders •  Immediate Pos t–Cardiac Arres t Care Algorithm •  Bradycardia Algorithm •  Tachycardia Algorithm

ACS a nd s tro ke

•  ACS Algorithm •  Fibrinolytic Checklis t for STEMI •  Fibrinolytic Contraindications for STEMI •  Sus pected Stroke Algorithm •  Stroke As s es s ment–CPSS •  Us e of IV rtPA for Acute Is chemic Stroke •  Hypertens ion Management in Acute Is chemic Stroke

The Precours e Preparation Checklis t is packaged with the ACLS Provider Manual. Pleas e review and check the boxes after you have completed preparation for each s ection.

Cou rs e Ove rvie w

Re q u ire m e n t s fo r S u c c e s s fu l Co u r s e Co m p le t io n To s ucces s fully complete the ACLS Provider Cours e and obtain your cours e completion card, you mus t •  Pas s the 1-Res cuer Adult CPR and AED Tes t •  Pas s the Bag-Mas k Ventilation Tes t •  Demons trate competency in learning s tation s kills •  Pas s the Megacode Tes t •  Pas s the clos ed-book written exam with a minimum s core of 84%

ACLS Up d a t e Co u r s e The ACLS Update Cours e is for s tudents who have a current ACLS Provider card and need to update and refres h their ACLS s kills . This cours e is primarily focus ed on s kills competency tes ting. •  Maximum renewal period: 2 years •  Update requirements : Previous ACLS cours e completion card (not expired)

ACLS P r o vid e r Ma n u a l Ab b re via t io n s A ABCD

ACLS Survey: Airway, Breathing, Circulation, Differential Diagnos is

ACE

Angiotens in-converting enzyme

ACLS

Advanced cardiovas cular life s upport

ACS

Acute coronary s yndromes

AED

Automated external defibrillator

AHF

Acute heart failure

AIVR

Accelerated idioventricular rhythm

AMI

Acute myocardial infarction

a P TT

Activated partial thromboplas tin time

B BLS

Bas ic life s upport: Check res pons ivenes s , activate emergency res pons e s ys tem, check carotid puls e, provide defibrillation

C CARES

Cardiac Arres t Regis try to Enhance Survival

CP R

Cardiopulmonary res us citation

CP SS

Cincinnati Prehos pital Stroke Scale

CT

Computed tomography (continued) 7

P a r t

1 (continued)

D DNAR

Do not attempt res us citation

E ECG

Electrocardiogram

ED

Emergency department

EMS

Emergency medical s ervices

ET

Endotracheal

F FDA

Food and Drug Adminis tration

F io 2

Fraction of ins pired oxygen

G GI

Gas trointes tinal

I ICU

Intens ive care unit

INR

International normalized ratio

IO

Intraos s eous

IV

Intravenous

L LMWH

Low-molecular-weight heparin

LV

Left ventricle or left ventricular

M mA

Milliamperes

MACE

Major advers e cardiac events

MET

Medical emergency team

MI

Myocardial infarction

m m Hg

Millimeters of mercury

N NIH

National Ins titutes of Health

NIHSS

National Ins titutes of Health Stroke Scale

NINDS

National Ins titute of Neurological Dis orders and Stroke

NPA

Nas opharyngeal airway

NSAIDs

Nons teroidal anti-inflammatory drugs

NSTEMI

Non–ST-s egment elevation myocardial infarction (continued)

8

Cou rs e Ove rvie w

(continued)

O OPA

Oropharyngeal airway

P Paco2

Partial pres s ure of carbon dioxide in arterial blood

P CI

Percutaneous coronary intervention

PE

Pulmonary embolis m

P EA

Puls eles s electrical activity

PT

Prothrombin time

R ROSC

Return of s pontaneous circulation

RRT

Rapid res pons e team

rtPA

Recombinant tis s ue plas minogen activator

RV

Right ventricle or right ventricular

S SBP

Sys tolic blood pres s ure

STEMI

ST-s egment elevation myocardial infarction

SVT

Supraventricular tachycardia

T TCP

Trans cutaneous pacing

U UA

Uns table angina

UFH

Unfractionated heparin

V VF

Ventricular fibrillation

VT

Ventricular tachycardia

9

P a r t

1

Part

2

The Sys te m a tic Approa c h: The BLS a nd ACLS Surve ys In t r o d u c t io n

Healthcare providers us e a s ys tematic approach to as s es s and treat arres t and acutely ill or injured patients for optimum care. The goal of the res us citation team’s interventions for a patient in res piratory or cardiac arres t is to s upport and res tore effective oxygenation, ventilation, and circulation with return of intact neurologic function. An intermediate goal of res us citation is the return of s pontaneous circulation (ROSC). The actions us ed are guided by the following s ys tematic approaches : •  BLS Survey (s teps des ignated by the numbers 1, 2, 3, 4) •  ACLS Survey (s teps des ignated by the letters A, B, C, D)

Le a r n in g Ob je c t ive s

By the end of this part you s hould be able to 1. Des cribe the critical actions of the BLS Survey and ACLS Survey 2. Des cribe as s es s ment and management that occur with each s tep of the s ys tematic approach 3. Des cribe how the as s es s ment/management approach is applicable to mos t cardiopulmonary emergencies

Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys Ove r vie w o f t h e S ys t e m a t ic Ap p r o a c h

The s ys tematic approach firs t requires ACLS providers to determine the patient’s level of cons cious nes s . As you approach the patient: •  If the patient appears uncons cious – Us e the BLS Survey for the initial as s es s ment. – After completing all of the appropriate s teps of the BLS Survey, us e the ACLS Survey for more advanced as s es s ment and treatment. •  If the patient appears cons cious – Us e the ACLS Survey for your initial as s es s ment. The details of the BLS and ACLS Surveys are des cribed below.

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Th e BLS S u r ve y Ove r vie w o f t h e BLS S u r ve y

The BLS Survey is a s ys tematic approach to bas ic life s upport that any trained healthcare provider can perform. This approach s tres s es early CPR and early defibrillation. It does not include advanced interventions , s uch as advanced airway techniques or drug adminis tra tion. By us ing the BLS Survey, healthcare providers may achieve their goal of s upporting or res toring effective oxygenation, ventilation, and circulation until ROSC or initiation of ACLS interventions . Performing the actions in the BLS Survey s ubs tantially improves the patient’s chance of s urvival and a good neurologic outcome. Be fore c on d u c tin g th e BLS or ACLS Su rve y, look to m a ke s u re th e s c e n e is s a fe . •  The BLS Survey us es a s eries of 4 s equential as s es s ment s teps des ignated by the numbers 1, 2, 3, and 4. Simultaneous ly with each as s es s ment s tep, you s hould perform appropriate corrective action(s ) before proceeding to the next s tep. As s es s ment is a key component in this approach (eg, check the puls e before s tarting ches t compres s ions or attaching an AED). Re m e m b e r: As s e s s …th e n p e rform a p p rop ria te a c tion .

FYI 2 0 1 0 Gu id e lin e s

Pleas e note the 2 key changes from the 2005 AHA Guidelines for CPR and ECC:

Cha ng e s in the BLS Surve y

•  The 2010 AHA Guidelines for CPR and ECC alters the BLS s equence by eliminating “look, lis ten, and feel” followed by 2 res cue breaths . This change promotes earlier initiation of ches t compres s ions in cardiac arres t patients . •  The BLS Survey is no longer repres ented by the letters A, B, C, D but is repres ented by the numbers 1, 2, 3, 4 ins tead.

Fo u n d a t io n a l Fa c t s

•  Although no publis hed human or animal evidence demons trates that s tarting CPR with 30 compres s ions rather than 2 ventilations leads to improved outcomes , it is clear that blood flow depends on ches t compres s ions . Therefore, providers mus t minimize delays in and interruptions of ches t compres s ions throughout the entire res us citation. Pos itioning the head, achieving a s eal for mouth to mouth res cue breaths , or getting a bag mas k device for res cue breaths takes time. Beginning CPR with 30 compres s ions rather than 2 ventilations leads to a s horter delay to the firs t compres s ion. •  Once one provider begins ches t compres s ions , a s econd trained healthcare provider s hould deliver res cue breaths to provide oxygenation and ventilation as follows : – Deliver each res cue breath over 1 s econd – Give a s ufficient tidal volume to produce vis ible ches t ris e

Sta rting With Che s t Co m p re s s io ns vs 2 Bre a ths

Although the BLS Survey requires no advanced equipment, healthcare providers can us e any readily available univers al precaution s upplies or adjuncts , s uch as a bag mas k venti lation device. Whenever pos s ible, place the patient on a firm s urface in a s upine pos ition to maximize the effectivenes s of ches t compres s ions . Table 1 is an overview of the BLS Survey, and Figures 1 through 4 illus trate the s teps needed during the BLS Survey. Before approaching the patient, ens ure s cene s afety. For more details , review the VF Treated With CPR and AED Cas e in Part 5 of this manual and watch the CPR and AED Skills video on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt).

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Ta b le 1 . The BLS Surve y

As s e s s 1

Che c k re s p o ns ive ne s s

As s e s s m e n t Te c h n iq u e a n d Ac t io n •  Tap and s hout, “Are you a ll rig h t? ” •  Check for abs ent or abnormal breathing (no breathing or  only gas ping) by looking at or s c a nning the c he s t fo r m o ve m e nt (about 5 to 10 s econds )

Fig u re 1 . Check res pons ivenes s .

2

Ac tiva te the e m e rg e nc y re s p o ns e s ys te m /g e t AED

•  Activate the emergency res pons e s ys tem and get an AED  if one is  available or s end s omeone to activate the emergency res pons e s ys tem and get an AED or defibrillator

Fig u re 2 . Activate the emergency res pons e s ys tem.

3

Circ ula tio n

•  Che c k the c a ro tid p uls e  for 5 to 10 s econds   •  If no puls e within 10 s econds , s tart CPR (30:2) beginning  with ches t compres s ions – Compres s  the center of the ches t (lower half of the   s ternum) hard and fas t with at leas t 100 compres s ions   per minute at a depth of at leas t 2 inches – Allow complete ches t recoil after each compres s ion – Minimize interruptions  in compres s ions    (10 s econds  or les s ) – Switch providers  about every 2 minutes  to avoid fatigue – Avoid exces s ive ventilation •  If there is  a puls e, s tart res cue breathing at 1 breath every   5 to 6 s econds  (10 to 12 breaths  per minute). Check puls e  about every 2 minutes

4

De fib rilla tio n

Fig u re 3 . Check the carotid puls e.

•  If no puls e, check for a s hockable rhythm with an AED/ defibrillator as  s oon as  it arrives •  Provide s hocks  as  indicated •  Follow each s hock immediately with CPR, beginning with   compres s ions

Fig u re 4 . Defibrillation.

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Cr it ic a l Co n c e p t s Minim izing Inte rrup tio ns

ACLS p ro vid e rs m us t m a ke e ve ry e ffo rt to m inim ize a ny inte rrup tio ns in c he s t c o m p re s s io ns . Try to limit interruptions in ches t compres s ions (eg, defibrillation and advanced airway) to no longer than 10 s econds , except in extreme circums tances , s uch as removing the patient from a dangerous environment. When you s top ches t compres s ions , blood flow to the brain and heart s tops . Avo id : •  Prolonged rhythm analys is •  Frequent or inappropriate puls e checks •  Taking too long to give breaths to the patient •  Unneces s arily moving the patient

Fo u n d a t io n a l Fa c t s Lo ne He a lthc a re P ro vid e r Ma y Ta ilo r Re s p o ns e

Cr it ic a l Co n c e p t s Hig h-Qua lity CP R

•  Lone healthcare providers may tailor the s equence of res cue actions to the mos t likely caus e of arres t. For example, if a lone healthcare provider s ees an adoles cent s uddenly collaps e, it is reas onable to as s ume that the patient has s uffered a s udden cardiac arres t. •  The lone res cuer s hould call for help (activate the emergency res pons e s ys tem), get an AED (if nearby), return to the patient to attach the AED, and then provide CPR. •  On the other hand, if hypoxia is the pres umed caus e of the cardiac arres t (s uch as in a drowning patient), the healthcare provider may give about 5 cycles (approximately 2 minutes ) of CPR before activating the emergency res pons e s ys tem.

•  Compres s the ches t hard and fas t. •  Allow complete ches t recoil after each compres s ion. •  Minimize interruptions in compres s ions (10 s econds or les s ). •  Switch providers about every 2 minutes to avoid fatigue. •  Avoid exces s ive ventilation.

Th e ACLS S u r ve y Ove r vie w o f t h e ACLS S u r ve y

For uncons cious patients in arres t (cardiac or res piratory): •  Healthcare providers s hould conduct the ACLS Survey after completing the BLS s urvey. For cons cious patients who may need more advanced as s es s ment and management techniques : •  Healthcare providers s hould conduct the ACLS Survey firs t. An important component of this s urvey is the differential diagnos is , where identification and treatment of the underlying caus es may be critical to patient outcome. In the ACLS Survey you continue to as s es s and perform an action as appropriate until trans fer to the next level of care. Many times , team members perform as s es s ments and actions in ACLS s imultaneous ly. Re m e m b e r: As s e s s …th e n p e rform a p p rop ria te a c tion .

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Table 2 provides an overview of the ACLS Survey. The ACLS cas es provide details on thes e components . Ta b le 2 . The ACLS Surve y

As s e s s Airwa y – Is the airway patent? – Is an advanced airway indicated? – Is proper placement of airway device confirmed? – Is tube secured and placement reconfirmed frequently?

Ac t io n a s Ap p ro p r ia t e •  Ma inta in a irwa y p a te nc y in unc o ns c io us p a tie nts by us e of the head tilt–chin lift, oropharyngeal airway (OPA), or nas opharyngeal airway (NPA) •  Us e a d va nc e d a irwa y m a na g e m e nt if ne e d e d (eg, laryngeal mas k airway, laryngeal tube, es ophageal-tracheal tube, endotracheal tube [ET tube]) Healthcare providers must weigh the benefit of advanced airway placement against the adverse effects of interrupting chest compressions. If bagmask ventilation is adequate, healthcare providers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation or until spontaneous circulation returns. Advanced airway devices such as a laryngeal mask airway, laryngeal tube, or esophageal-tracheal tube can be placed while chest compressions continue. If us ing advanced airway devices : •  Co nfirm p ro p e r inte g ra tio n o f CP R a nd ve ntila tio n •  Co nfirm p ro p e r p la c e m e nt o f a d va nc e d a irwa y d e vic e s by – Phys ical examination – Quantitative waveform capnography ▪ Clas s I recommendation for ET tube ▪ Reas onable for s upraglottic airways •  Se c ure the d e vic e to p re ve nt d is lo d g m e nt •  Mo nito r a irwa y p la c e m e nt with c o ntinuo us q ua ntita tive wa ve fo rm c a p no g ra p hy

Bre a thing – Are ventilation and oxygenation adequate? – Are quantitative waveform capnography and oxyhemoglobin saturation monitored?

•  Give s up p le m e nta ry o xyg e n whe n ind ic a te d – For cardiac arres t patients , adminis ter 100% oxygen – For others , titrate oxygen adminis tration to achieve oxygen s aturation values of ≥94% by puls e oximetry •  Mo nito r the a d e q ua c y o f ve ntila tio n a nd o xyg e na tio n by – Clinical criteria (ches t ris e and cyanos is ) – Quantitative waveform capnography – Oxygen s aturation •  Avo id e xc e s s ive ve ntila tio n (continued)

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2 (continued)

As s e s s Circ ula tio n – Are chest compressions effective? – What is the cardiac rhythm? – Is defibrillation or cardioversion indicated? – Has IV/IO access been established? – Is ROSC present? – Is the patient with a pulse unstable? – Are medications needed for rhythm or blood pressure? – Does the patient need volume (fluid) for resuscitation? Diffe re ntia l d ia g no s is – Why did this patient develop symptoms or arrest? – Is there a reversible cause that can be treated?

Ac t io n a s Ap p ro p r ia t e •  Mo nito r CP R q ua lity – Quantitative waveform capnography (if P e t c o 2 is