INTRO TO ACLS Department of Emergency Medicine University

INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench, Shai Harel, Hareishun Shanmuganathan, Katie Sullivan

OBJECTIVES 1. Approach to the first three minutes of a code 2. Primer on the rest….

ACLS Clinical Rotation Resus Day Intro Lecture

Part 1: He Looks Dead Katie is a third year medical student on her Ortho rotation. She is pre-rounding on her patients in the morning. Pitfall: Started CPR before checking responsiveness

Checking Responsiveness Voice (get close) Pain (noxious central stimulus) Sternal Rub Upper Orbit Pressure Trapezius Pinch

Part 2 – He Is Dead Katie is a third year medical student on her Ortho rotation. She is pre-rounding on her patients in the morning. Pitfall: Didn’t call for help

Calling for help Check which room you’re in Go into hallway and look for nurse Get someone to check the code status No one there? Go to phone and dial ‘ 55’ for an emergency line Code Blue vs. Medical 25 vs. Code 88

Part 3 – How was your Weekend? Katie and Shai are third year med students prerounding on their Ortho rotation. They enter a four bed room together. Katie’s patient, “doesn’t look right”. Pitfall: Didn’t activate BLS

Activating the BLS Primary Survey A B C (D)

BLS Primary Survey • • Airway Breathing Circulation Defibrillation Simple interventions

Part 4 – He’s Not Perking Up Pitfall: Katie and Shai decide to activate BLS. Didn’t open airway Gave inadequate breaths Radial pulse check

Airway Primary

Breathing • Give 2 breaths • NO response? 1 breath / 5 seconds and CPR Primary

Circulation No more than 5 -10 seconds NOT peripheral pulse Start CPR board Recheck pulse every 2 minutes Ensure IV/IO access Primary

Part 5: The Team Will be Here Soon Previous scenario continues Ward resident Hareishun runs into the room… Pitfall: Too many CPR interruptions

CPR board 100 compressions/minute 30: 2 breaths Hard and fast

Parts 1 -5: The Replay

RECAP Checked response • Voice • Pain Called help BLS Primary Survey • • Airway Breathing Circulation (Defibrillation) Continued CPR

Who’s on the code team? • Code team leader • More doctors if they happen to be around • Nurses • Record keeper, someone to give meds • RT • Orderly • CPR

How does the code team work? • Code team leader: • • • Makes it clear who is in charge Call for quiet if there’s too much noise Stands at pt’s side, hand on pulse (femoral) If possible, delegate tasks to others Closed-loop communication Maintain sense of ‘big picture’

What the team leader will ask you…. Patient name, age, reason for admission Past medical history CODE STATUS Time of arrest, events leading up

What next? Repeat the BLS Primary Survey Can now do ‘D’ A B C D

Defibrillation In hospital: will not have AED immediately available At casino: No pulse power-on AED and follow voice prompts Apply pads Administer shock as directed

D: Rhythm Recognition Once you know the rhythm, you can follow the algorithm Today: Non-Perfusing Rhythms

Non-Perfusing Rhythms Non. Shockable VFib PEA VTac Asystole

What are VF and VT? • These two rhythms are treated in the same way pulseless) • Both represent the ventricle trying to pump blood in a disorganized way • Usually due to myocardial ischemia (for whatever cause) (if

VF and VT

Examples

Examples

Examples

Examples

Defibrillators 101

Defibrillators 101 • Gel pads • Select energy (200 J) • No Sync • Charge • Clear everyone • Shock

Putting it together • You’ve found an unresponsive patient • Called a code • Did as much of the BLS primary survey as you could • Code team has arrived and repeated the primary survey, including defibrillation if needed

First three minutes… Checked response • Voice • Pain Called help BLS Primary Survey • • Airway Breathing Circulation (Defibrillation) Simple interventions

OBJECTIVES 1. Approach to the first three minutes of a code 2. Primer on the rest….

Incorporating ACLS Checked response • Voice • Pain Called help BLS Primary Survey • • Airway Breathing Circulation (Defibrillation) Simple interventions Continued CPR ACLS Secondary Survey • • Airway Breathing Circulation Differential Advanced interventions

Now: ACLS Secondary Survey • • Airway Breathing Circulation Differential Advanced interventions

ACLS Secondary Survey: Airway Is the airway patent? Is an advanced airway indicated? Laryngeal Mask Airway (LMA) Endotracheal Tube (ETT)

ACLS Secondary Survey: Breathing Is the airway in the right place? Is the tube secure? Are we monitoring O 2 and CO 2?

ACLS Secondary Survey: Circulation What is/was the rhythm? Is there IV access? Is fluid needed? Are drugs needed?

ACLS Secondary Survey: Differential Why did the patient arrest? Is there a reversible cause for the arrest?

Part 6: Dream Team Code

PEA and Asystole Non. Shockable VFib PEA VTac Asystole

PEA Organized No pulse Fast or slow

PEA

PEA

Asystole Final rhythm Depleted myocardium Check two leads

PEA and Asystole: Treatment • Epinephrine • Atropine for slow PEA/asystole • CPR • Fix the fixable • • • Hypovolemia: Bolus NS Hypoxia: O 2 Hyperkalemia: ABG (for K+), Bicarbonate, Calcium Cl, Acidosis, TCA OD: Bicarbonate Pneumothorax/tamponade: Needle MI/PE: Thrombolytics

Part 7: An hour later…. . The Dream Team is still at it: Switch to the other side of the flowchart

Outcomes In-hospital Out-of-hospital Pulse never returns 70% Pulse never returns 50% Death at one year 99% Death 80% Death or neurologic compromise 99. 5% Death or neurologic compromise 85% Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine versus epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008; 359: 21 -30 Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008; 299: 785 -792

Questions?