Student- Advanced Responder Oct

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Advanced Responder

ACLS Prestudy With the 2011 AHA Updates

Recertification & Certification

N urses E ducational O pportunities

www.nursesed.net

Toll Free 866.266.2229Copyright 2011

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Advanced Cardiovascular Life Support Prestudy

Agenda for Recertification

8:00 Welcome/Introduction8: 15 AHA ACLS Overview Video

8:30 Instructor presentation of lethal rhythms & pretest

8:45 AHA Video ACLS Primary/Secondary Survey

Instructor presentation of 2011 BLS

9:00 AHA ACLS Video Airway Management

9:30 AHA BLS Video

9:45 Practice BLS with manikins/BMV/Barrier/AED

10:00 Instructor presentation of ACLS

11:00 AHA video of Heart Attack and Stroke12:00 AHA video of Mega Code

12:15 Instructor presentation of Mega Code

Skills stations

Written exam

Agenda for CertificationDay One 8:00 Welcome, Introduction, Pretest 8:30 Lethal Rhythm Review & Practice

9:30 Primary and Secondary Survey Video/Practice10:00 Airway Management

11:00 BLS Practice

12:00 Lunch

1:00 VF/PEA/Asystole

2:00 Bradycardias

Tachycardias

Acute Coronary Syndrome/Stroke

Practice Skills

Airway Management

Defibrillation

Cardioversion

3:00 Scenario Discussions if time allows

4:00 Mega Code instructor presentation

Day Two 8:00 Putting it all together

9:00 Mega Code Review

10:00 Mega Code and Written evaluation

11:00 Remediation if appropriate



5

`

P WaveOriginates in the SA

Node

P-R Interval 0.12 - 0.20

Beginning of the P to thebeginning of the R

QRS Complex Beginning of the Q to the end of the S

ST segment End of the S

To the beginning of the T Note: Depression or Elevation

T Wave

QT interval

Beginning of the Q To the end of the T

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12-Lead EKG

Q = InfarctionST (depression = ischemia)

(elevation = acuteness)

T inversion = Ischemia

Q waves with ST segment elevation may indicate an ST segmentelevated myocardial infarction (STEMI) and rapid and early reperfusion

is essential for optimal outcome.



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This is a First Degree Block because the PR interval is greater than 0.20

seconds.

♥♥♥♥♥♥♥♥ Each little box measures 0.04 seconds. There are 8 little boxes from

the beginning of the P to the beginning of the Q.

♥♥♥♥♥♥♥♥ The PR interval in this strip is 8 x .04 = .32 seconds.

♥♥♥♥♥♥♥♥ This heart rate is about 40 bpm. If this patient is symptomatic and

probably is, Atropine is the drug of choice at 0.5 mg.

This is a Mobitz I, Second Degree Block.

It is also called the Wenckebach.♥♥♥♥♥♥♥♥ The PR interval progressively lengthens until a QRS complex is

dropped.

♥♥♥♥♥♥♥♥ The patient has a heart rate of about 60 bpm and may be

asymptomatic and may require no intervention, but you won’t

know until you check on this patient. If the patient is symptomatic

you may consider Atropine at 0.5 mg.

This is a Mobitz II, Second Degree Block. The QRS complexes are dropped following some of the P waves.

♥♥♥♥♥♥♥♥ There is no progression of PR intervals as in the Mobitz I.

♥♥♥♥♥♥♥♥ This is a serious situation!!

♥♥♥♥♥♥♥♥ This requires a Transcutaneous Pacemaker.

♥♥♥♥♥♥♥♥ You may consider Atropine 0.5 mg while awaiting the pacemaker.

Atropine speeds up the SA node and since there are P waves that are

“blocked” it is not a good drug for these high degree blocks. (AHA 2010

Update)

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This is another sample of a Third Degree/Complete Heart Block

Notice the PR intervals are not consistent.

Try Atropine but don’t rely on atropine to do the job

Try Transcutanious Pacing

Try Epinephrine and/or Dopamine for it’s vasoconstrictive properties.

Epinephrine dose is 2-10 mcg/min

whereas

Dopamine dose is 2-10 mcg/kg/min

Do you see the similarities

Do you see the differences

Keep in mind – check the pulse

If there is no pulse- administer Epinephrine 1 mg*

This a Third Degree/Complete Heart Block. The atrium is working. The ventricles are working. But they are notworking together.

The P waves are marching across. The QRS complexes are marching

across. But they are not marching together.

The P wave does not cause the QRS complex to occur. There is a

complete block. This is serious. Your patient will require a

Transcutaneous Pacemaker. Atropine speeds up the SA node and sincethere are P waves that are “blocked.” You need a transcutaneous

pacemaker. You should consider Atropine while preparing for the

acemaker*. AHA 2010 U date



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This is an Asystole. It is also referred to as an agonal rhythm.You must not call this a Flat Line.

A Flat Line occurs when the leads come off your patient.An Asystole occurs when the heart dies.

To confirm the difference between asystole and flat line – turn up the

gain or sensitivity on your monitor.An Asystole is the final rhythm of a patient initially in VF or VT

Prolonged efforts are unnecessary and futile unless special situations

exsist such as hypothermia and drug overdose.

Keep up with your high-quality CPR

Try some Epinephrine 1 mg every 3-5 minutes.

Try some Vasopressin 40 units for EITHER the first dose of Epinephrine or the second dose. NOT in addition to Epi..

This is a fibrillating heart and often referred to as a

Ventricular Fibrillation – sometimes called a VF.

To defibrillate a fibrillating heart – “shock it” to “stop it”.

Like rebooting your computer!!!.

This rhythm is appropriate to defibrillate

There are two ways to defibrillate – Monophasic or BiphasicMonophasic defibrillators direct the electrical energy into one

Pad and out the other - Use 360 joules

Biphasic defibrillators direct the electrical energy into both pads

at the same time. Biphasic is better because you only

have to use half as man outles – 200 oules

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Atropine is no longer recommended. (AHA 2010 Update)

Give priority to IV/IO access.

Do not routinely insert an advanced airway unless bag/mask is

ineffective

This is a Torsades de Pointes.

This is a rhythm that is “wide and ugly.”

Wide and ugly is usually ventricular in origin.

Look closely at this rhythm – it appears in groups.That indicates it is “jumping its focus.”

Ma nesium is the dru of choice.

This is called a polymorphic tachycardia.This is another tachycardia that is “wide and ugly!!”

Wide and ugly is usually ventricular in origin.

The complexes are irregular.

If a patient has polymorphic VT, the patient is likely to be unstable, and

rescuers should treat the rhythm as VF. They should deliver high-energy defibrillations. (2005 Update)

This is called a monomorphic tachycardia.

This is another tachycardia that is “wide and ugly!!”

This may or may not be ventricular in origin.

The complexes here are uniform.

There are two rules about wide complex tachycardias.

Rule #1 – Always assume they are ventricular in origin



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This is another example of a Supraventricular Tachycardia.

Supraventricular Tachycardias:

♥♥♥♥♥♥♥♥ Usually go faster than 180 ♥♥♥♥♥♥♥♥ Have an abrupt start ♥♥♥♥♥♥♥♥ Have narrow complexes

Note you may not see the abrupt start on the ECG strip (like on yourtest)!!! The test question states that the patient suddenly felt dizzy,

indicating a SVT may have occurred. If this patient is stable:*

♥♥♥♥♥♥♥♥ Try the vagal maneuver* ♥♥♥♥♥♥♥♥ If that doesn’t work, try adenosice 6-12-12 ♥♥♥♥♥♥♥♥ If that doesn’t work, try cardioversion

This is a Supraventricular Tachycardia. This rhythm is going very

fast. It is going “super fast.” It is originating above the ventricles.

Therefore – supra-ventricular tachycardia. Check your patient.

♥♥♥♥♥♥♥♥ If this patient is stable – try Adenosine. The initial dose is 6

mg* If that doesn’t work you may try 12 mg and if that doesn’t

work try again 12 mg.

♥♥♥♥♥♥♥♥ Push it fast and flush it fast. Anticipate a 6 second asystole.

You could try the Vagal Maneuver. The AHA considers the vagalmaneuver your first intervention.* Be careful, your hospital may not

want you to do this. You may vagal your patient down to a complete

heart block.

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♥♥♥♥♥♥♥♥

This is a “wide-complex” tachycardia. Assume it is ventricular in

origin until you prove otherwise. Therefore, this is a ventricular

tachycardia..If the patient is stable you should consider Amiodarone for treatment. (AHA 2010 Update)

♥♥♥♥♥♥♥♥ If the patient is unstable you should check his pulse.

If he is unstable with a pulse you would need to

cardiovert.

If there is no pulse this is a pulseless ventricular tachycardia

and you need to defibrillate.

This is a Tach cardia with the Va al Maneuver.



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Once the tube is inserted the placement needs to be confirmed:

♥♥♥♥♥♥♥♥ Mist in the tube may be first seen.

♥♥♥♥♥♥♥♥ Check for gastric sounds next.

♥♥♥♥♥♥♥♥ Check for lung sounds – left first then right.

♥♥♥♥♥♥♥♥ CO2 detector turning “gold.”♥♥♥♥♥♥♥♥ Continuous capnography waveform is the most reliable method of

confirming and monitoring placement of the ET tube*

♥♥♥♥♥♥♥♥ Capnography is now recommended by the AHA to confirm and

monitor the endotracheal tube as well as the adequacy for CPR*

based on end-tidal CO2. Update 2010

Recall lab values of CO2 level of a blood Gas should be

35-40. Therefore, the closer your capongrahy reading is to

normal values, the more effective the resuscitationtechnique.

Such as after ROSC the PETCO2 should be 35-40 mg/hA PETCO2 level of >10 would be a sign of effective CPR.*

whereas, a PETCO2 level of 8 would indicate ineffective CPR*

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If you get a rhythm – check the pulseAny organized rhythm without a pulse is a PEA *

You’re still the leader!! Continue CPR* Delegate your team to look for the Possible Causes

P = Possible cause (?)

E = Epinephrine 1 mg *. which is a vasopressorNo vasopressor has been shown to increase survival

from PEA. Because vasopressors (epinephrine and

vasopressin) can improve aortic diastolic blood pressure

and coronary artery perfusion pressure, vasopressorssuch as epinephrine continue to be recommended*.

A = No longer is Atropine recommended for PEA.. The AHA

recommends Vasopressin (2010 Update)

The ability to achieve a good resuscitation outcome, with return of aperfusion rhythm and spontaneous respirations of a PEA depends on

rapid assessment and identification of an immediately correctable cause.

The two most common causes of PEA are hypovolemia and Hypoxia

The American Heart refers to the causes as the H’s and T’s They are as

follows:

♥♥♥♥♥♥♥♥ Hypovolemia

Clues: Poor skin color (pallor).Rapid heart rate with narrow complex

Flat neck vein

Intervention: Open up the bag of NS

♥♥♥♥♥♥♥♥ Hypoxia

Clues: Cyanosis

Slow heart rate

Intervention: Check the FIO2

Check airway placement



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♥♥♥♥♥♥♥♥ Hypothermia

Clues: Cold skin

Low core temperature

Intervention: Use warmed NS

Caution: “not dead till warm and dead.”

♥♥♥♥♥♥♥♥ HyperkalemiaClues: Peaked T waves

History of renal failure

Intervention: Infuse Na Bicarb

♥♥♥♥♥♥♥♥ Hypokalemia

Clues: Flat T waves

Intervention: Infuse K+ (not be confused with K+

bolus!)

♥♥♥♥♥♥♥♥

Hydrogen ion excess – metabolic acidosisClues: Small amplitude QRSHistory of renal failure

♥♥♥♥♥♥♥♥ Hypoglycemia –

Clues: Altered LOC

Intervention: D5w

♥♥♥♥♥♥♥♥ Tension Pneumothorax – check breath sounds

Clues: Deviated trachea

Neck vein distention

Intervention: Needle decompress the chest

♥♥♥♥♥♥♥♥ Tamponade –Clues: Bulging neck veins

Rapid heart rate

Intervention: Pericardiocentsis

♥♥♥♥♥♥♥♥ Thrombosis coronary and/or lung

Clues: Coronary = ST segment elevation =

STEMI

Clues: Lung = Distended neck vein – Call thesurgeon.

♥♥♥♥♥♥♥♥ Toxins - (drug overdose)

Clues: Bradycardia

Intervention: Try some Narcan

♥♥♥♥♥♥♥♥ Trauma

If the following rhythm appears on the monitor you must call this anasystole. Do not call this rhythm a “flat line.”

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Asystole

Prognosis is poor

♥♥♥♥♥♥♥♥ Continue CPR

♥♥♥♥♥♥♥♥ IV access is a priority over advanced airway management unless

bag/mask ventilation is ineffective.

♥♥♥♥♥♥♥♥ Do not routinely insert an advanced airway unless ventilations with

a bag-mask are ineffective.♥♥♥♥♥♥♥♥ Start 2 IV sites in the anticubital if not already done – Do not

interrupt CPR for IV access

♥♥♥♥♥♥♥♥ Try more Epi 1 mg or Vasopressin as an alternative for EITHERthe first or second dose of epinephrine

The standard epinephrine dose is 1 mg IV/IO every 3-5 minutes

of 1:10,000 solution*. High-dose epinephrine is not routinely

recommended.

The AHA no longer recommends Atropine for the asystole (2010

Update)

♥♥♥♥♥♥♥♥ Remember – this is a nonshockable rhythm

♥♥♥♥♥♥♥♥ Be aware of some reasons to terminate resuscitative efforts, suchas rigor mortis, indications of DNR and threat to safety.

This “delegating” is kinda nifty!! You may like being the code team

leader!!



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Capnography detects the return of ROSC.Post-cardiac arrest PETC02 with ROSC is 35 - 40 mm Hg

During cardiac arrest, if you see PETCO2 shoot up, stop

CPR and check for the pulse.There is an average sudden PETCO2 increase by

13.5mmHg with sudden ROSC before settling into anormal range.

Capnography detects the loss of ROSC.

If PETCO2 significantly drops, check for the pulse. If nopulse, start CPR.

CAUTION: Hyperventilation in trauma victims decreases

intracranial pressure (IPP) by decreasing the intracranial bloodflow. The result is cerebral ischemia.

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Pretest Questions

1. The initial intervention for all bradycardia is__________

(Atropine 0.5 mg)

2. A patient has sinus bradycardia with a rate of 36 per minute.

Atropine has been administered to a total dose of 3 mg. A

transcutaneous pacemaker has failed to capture. The patient is

dizzy with SOB. Which drug would administer with what dose?

_______________( Dopamine 2-10 mcg/kg/min)

3. A 52 year old female presents to the ED with persistent

epigastric pain. Her vitals are stable along with the O2 sat. What

is you first interevention?_______________________________

(Obtain a 12-lead ECG))

4. High quality CPR includes 4 components. They are__________(push hard),_____________(push fast)___________,(allow the

chest to recoil) and _____________(minimize interruptions)

5. The best chance of successful defibrillation is_____________

_________________________________________________(perform high quality chest compressions prior to defibrillation)

6. What action would help to minimize interruptions during a code

call that requires defibrillation? ______________________

(Continuing Chest Compressions while the defibrillator ischarging).

7. A defibrillator may be equipped with “hands free pads” are

better than “paddles.” Why are hands free padsbetter?________________________________________

They can provide a more rapid defibrillation)

8. Many hospitals have Rapid Response Teams. What is their main

purpose?____________________________________( Prevents

deterioration to overt a code call)



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28. An EMS crew can terminate resuscitation if _____________

(rigor mortis) sets in.

29. Three signs of an acute stroke are facial drop, arm drift, and

slurred speech. This is referred to as the________________

(Cincinnati Prehospital Stroke Scale assessment)

30. With a positive prehospital stroke scale you would obtain a set of

vitals including blood glucose and order a ________________

___________________(noncontrast CT scan of the head)

31. If a patient is hypotensive who has achieved ROSC you should

bolus with ___________________(1-2 L) NS or LR

32. The minimum systolic blood pressure you should accept for ahypotensive post cardiac arrest that has achieved ROSC is

________________(90 mg Hg)

33. Your priority in the care a patient with ROSC is optimizing

_________________and_______________(oxygenation and

ventilations)

34. A patient suddenly collapsed and is poorly responsive. The

monitor reveals a third-degree block. There is an IV access and

supplemental oxygen is being administered with a nonrebreather.What would you first do?_____________(Give atropine 0.5 mg

and begin pacing as soon as the pacemaker is ready).

35. A patient becomes unresponsive and you are uncertain if a faint

pulse is present. What would youdo?___________________(Begin CPR with high-quality chest

compressions)

36. A patient with a wide-complex tachycardia that is unstable you

must_________________(cardiovert) You may not have time tomedicate this patient if he is severely unstable.

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The American Heart Association strongly promotes knowledge and proficiencyin BLS, ACLS, and PALS and has developed instructional materials for this

purpose. Use of these materials in an educational course does not represent

course sponsorship by the American Heart Association. Any fees charged for

such a course, except for a portion of fees needed for AHA course material, do

not represent income to the Association.-ll

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