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BLS Adult

Signs of cardiac arrest include: pulselessness, apnea or agonal breathing, and decreased level of consciousness.  CAB over ABC unless infant/pediatric cardio-respiratory arrest where initially, airway and breathing should take priority.  Compressions should be delivered in a ratio of 30 compressions to 2 breaths (30:2) regardless of single or double rescuer.  Rescue breathing is 1 breath every 5-6 seconds in the context of apnea with a pulse or for a protected airway.  Compression depth is 2-2.4cm or 5cm and location is lower sternum.  Characteristics of high-quality CPR include: compressing at an adequate rate and depth; minimizing interruptions in compressions (less than 10s); assessing breathing and pulse simultaneously (less than 10s); allowing for chest recoil; early defibrillation; and avoid excessive ventilations.  Pulse checks and changing compressors are done every 2-minutes.  In the context where a rescuer comes across a victim experiencing a cardiac arrest, the rescuer should perform 2-minutes of CPR before activating the emergency response system.  In the context where the rescuer witnesses someone having a cardiac arrest in real time, the rescuer should activate the emergency response system before initiating CPR.   

Adult and Infant Choking

Treatment would depend on the severity of the choking event regardless of whether it's an adult or infant/pediatric choking event.  In the context of choking in a conscious patient with mild distress, keep calm and encourage the patient to cough the object out.  In the context of choking the conscious patient with severe obstruction (i.e, barely breathing, making an inspiratory effort but not chest rise/air entry), activate the emergency response system and proceed to making efforts to expectorate the item.  For the adult patient that is responsive but in distress, the rescuer should perform abdominal thrusts (i.e., the Heimlich maneuver) until either the object is expelled, or the patient goes unconscious where at that time, CPR is initiated.  For the infant/pediatric patient that is responsive but in distress, the rescuer should perform back slaps and chest compressions in a ratio of 5 backslaps followed by 5 chest compressions with the patient in the head down position.  Back slaps and compressions should continue until the item is expelled or the patient becomes conscious.  If the patient becomes unconscious, then CPR should be initiated.  For the unconscious choking victim, CPR should always be promptly initiated.

Special circumstances:

What changes when delivering CPR to a pregnant woman? 

When delivering CPR to a pregnant woman, the patient should be placed in the left uterine displacement position (i.e, R. side elevated) in order to prevent the uterus from compressing the inferior and superior vena cava, thus minimizing venous return and subsequent cardiac output.

What to do when using an AED on a pregnant woman?

No alterations are required for using an AED on a pregnant woman.  The maternal and uterine environments are considered independent environments and the use of an AED on the mother will not affect the fetus. 

What to do when using an AED on water, ice, and snow?

No change for using an AED on ice or snow.  When using an AED around water, remove the individual from the water source and dry off the chest before using an AED.  Water is a conductor of electricity and can potentially injure rescuers in contact with the wet patient.  

How to use an AED if a patient has a medication patch.

If the medication patch is placed in the region where the AED defibrillator pad would be placed, then remove the patch and wipe the area dry before defibrillator pad application.  Make sure to wear a set of gloves prior to removing the medication as some medications (i.e, nitroglycerin) can cross from the pad and into the rescuer, causing potentially life-threatening affects.  

Treating a patient with an implantable pacemaker or defibrillator.

When placing AED pads on a patient with an implantable pacemaker and/or defibrillator, the AED pads should be placed at least 1-2 inches away from the anti-arrhythmic device.

ACLS Course Preparation

NEW- 2020 American Heart Association Guidelines updates

A 6th link, recovery, has been added to each link of the chain of survival (in-hospital cardiac arrest and out-hospital cardiac arrest) to maximize the chance of survival from a cardiac arrest.  

The hallmark of cardiac arrest management continues to be high-quality CPR including: compressing at a rate between 100-120Bpm; compressing at a depth of 2 inches or 5centimeters while avoiding excessive chest compression depths (i.e., 2.4 inches or 6 centimeters).

Double-sequential defibrillation (i.e., shock delivery by 2 sequential defibrillator simultaneously) for shock-refractory arrhythmias has not been established.

There is new evidence suggesting some uncertainty with the efficacy of the IO route compared with the IV route.  Therefore, it is reasonable for providers to first attempt establishing IV access for medication administration during cardiac arrest before IO attempt.  

Early epinephrine administration reaffirmed.  For a cardiac arrest with a non-shockable rhythm, epinephrine should be administered as soon as possible.  For a cardiac arrest with a shockable rhythm, epinephrine should be delivered after initial defibrillation attempts have have failed.

Point of care ultrasound should not be used in making decisions on futility and termination of resuscitation efforts.  This recommendation does not preclude the use of ultrasound to identify potentially reversible causes or cardiac arrest or detect ROSC.

In patients who remain comatose after cardiac arrest, neuroprognostication should be made at a minimum of 72hrs after the return of normothermia.

ACLS algorithms

Cardiac arrest in Pregnancy in-hospital ACLS algorithm

Considerations include: using the most experienced provider during intubation as the risk for a difficult intubation is greater in the obstetric patient versus the non-obstetric patient; the patient should be placed in the left lateral displacement position and fetal monitors removed as they can interfere with CPR application; if no ROSC in 5 minutes, prepare for perimortem caesarean delivery.

Opioid-associated emergency for healthcare providers

In the context where the patient has a pulse and there is suspected opioid overdose, open the airway and reposition; provide bag-mask ventilation, give naloxone.  In pulseless opioid overdose, use and AED, consider naloxone, and BLS/cardiac arrest algorithm.

Adult cardiac arrest algorithm

Identify the presence of cardiac arrest (i.e., apnea or agonal breathing, pulselessness, decreased LOC), initiate CPR and place the patient on a monitor/defibrillator.  If the rhythm is shockable, shock with 120-200J and continue CPR for 2 minutes.  Subsequent doses should be equivalent or higher.  At 2 minutes, assess pulse and identify if shockable rhythm.  If shockable, defibrillate, continue CPR for 2 minutes, and give 1mg Epinephrine.  At 2 minutes, if pulseless and a shockable arrhythmia, defibrillate, initiate CPR, and give Amiodarone/Lidocaine.  Amiodarone 300mg first bolus and if second dose required 150mg.  If using Lidocaine, first dose 1-1.5mg/kg and second dose .5-.75mg/kg.  In the presence of cardiac arrest with a non-shockable rhythm, initiate 2 minutes of CPR and early epinephrine 1mg administration.  Epinephrine can be repeated every 3-5 minutes.

Adult post-cardiac arrest care

Resuscitation is ongoing during the post-ROSC phase, and many of these activities can occur concurrently.  However, if prioritization is necessary, follow these steps:

  • airway management: waveform capnography or capnometry to confirm and monitor endotracheal tube placement

  • manage respiratory parameters: titrate Fio2 for spo2 92-98%; start at 10bpm; titrate to PaCO2 35-45mmhg

  • manage hemodynamic parameters: administer crystalloid and/or vasopressor or inotrope for goal SBP>90mmhg or MAP>65mmhg

  • emergent cardiac intervention: early evaluation of 12-lead ECG; consider hemodynamics for decision on cardiac intervention

  • consider emergent cardiac intervention if: STEMI present; unstable cardiogenic shock; mechanical circulatory support required

  • TTM: if patient is not following commands, start TTM as soon as possible; begin at 32-36 degrees Celsius for 24hrs by using a cooling device with a feedback loop

  • other interventions including CT head and EEG should be considered if pt. not following commands

Bradycardia with a pulse algorithm

The decision to intervene in the context of bradycardia with a pulse is dependent on patient stability.  In the context of the bradyarrhythmia causing patient instability (i.e., hypotension; altered LOC; signs of shock; ischemic chest discomfort; acute heart failure), a decision should be made to give atropine 1mg.  Atropine 1mg can be given every 3-5 minutes for up to 3mg.  If atropine is ineffective, the clinician can consider transcutaneous pacing and/or inotropic/vasopressor infusion.  Dopamine can be given at 5-20mcg/kg/min or epinephrine at 2-10mcg/min

  • remember that atropine is relatively ineffective for 1st-degree type 2 blocks and third-degree blocks

Tachycardia with a pulse algorithm

The decision to intervene in the context of tachycardia with a pulse is dependent on patient stability.  In the situation of tachycardia with a pulse causing patient instability (i.e., hypotension; altered LOC; signs of shock; ischemic chest discomfort; acute heart failure), the patient should be cardioverted with a level of energy corresponding to the type of tachycardia.  Initial recommended dosages include:

  • narrow regular: 50-100J

  • narrow irregular: 120-200J

  • wide regular: 100J

  • wide irregular: defibrillation 200J

In the context of stable tachycardia, the next assessment includes QRS complex duration.  For the QRS complex less than .12s, treatment options include adenosine 6mg rapid IV push first dose and 12mg rapid IV push second dose; vagal maneuvers; b-blocker or calcium channel blocker.  For stable tachycardia with a QRS complex greater than .12s, consider adenosine if regular and monomorphic; Amiodarone 150mg over 10minutes followed by a maintenance infusion of 1mg/min for 6hrs; Procainamide; Sotalol

Acute coronary syndrome

The 12-lead ECG is at the centre of the decision pathway in the management of ischemic chest discomfort and the gold standard for diagnosing a STEMI.

 

Category 1: STEMI- ST segment elevation in 2 or more contiguous leads or new LBBB.  Classic definition is ST segment elevation of greater than 2.5mm in men under 40 or 2mm in men over 40 or 1.5mm in woman and ST segment elevation of 1mm or more in all other leads or a new LBBB.

Category 2: non-STEMI ACS is ST segment depression of .5mm or greater or dynamic T-wave inversion  with pain or discomfort

Category 3: low/intermediate risk ACS- normal or nondiagnostic changes in ST segment or T-wave inversion.

-blood work should assess CBC + cardiac markers, electrolytes, and coagulation.

 

Treatment options: oxygen should be given if the patient spo2<90% on R/A, dyspneic; if there are obvious signs of HF; Aspirin 160-325mg non-enterric coated for irreversibly inhibiting the enzyme cyclooxygenase that decreases thromboxane production and platelet aggregation. Nitroglycerin- a peripheral arterial and veno-dilator that decreases RV and LV preload, decreasing myocardial oxygen consumption.  Give the patient 1 sublingual nitroglycerin tablet or spray every 3-5 minutes if symptomatic.  This dose can only be repeated twice.  NG should only be administered in hemodynamically stable patients (SBP>90 or no lower than 30 below baseline and HR between 50-100).  It should not be administered if the patient has taken a recent phosphodiester inhibitor. Nitroglycerin (400mcg/ml) dose is 10-100mcg/min/bolus is 50-100mcg Opiates (morphine): given for refractory chest discomfort.  Benefits include: venodilation, decreas LV preload, decrease SVR

Treatment for acute coronary syndromes include:

1. PCI should be considered when door-to-balloon time is within 90 minutes or 120 if being transferred to a facility with PCI

2.  Fibrinolytics indications: 

  1. In the absence of contraindications, and can be initiated within 12hrs of symptom onset if PCI is not available within 90 minutes of medical contact

  2. In the absence of contraindications and can be initiated within 12hrs of symptom onset and ECG findings consistent with a true posterior MI

  3. Fibrinolytics not recommended for pt.’s presenting greater than 12hrs post-symptom onset but can be considered if ischemic chest discomfort continues with persistent ST-segment elevation

  4. Do not give fibrinolytics in patients that present greater than 24hrs after symptom onset or pt.’s with st segment depression unless a true posterior MI is suspected

 

IV heparin is used in combination with PCI and fibrinolytics

IV nitro is used widely in ischemic syndromes but not routinely for STEMI.

Indications

  1. Recurrent chest discomfort unresponsive to sublingual or spray nitro

  2. Pulmonary edema complicated stemi

ACLS suspected stroke algorithm

The ACLS suspected stroke algorithm begins by including time-sensitive goals set by the National Institute of Neurological Disorders (NINDS) for in-hospital assessment and management.  These goals include: 

  • immediate general assessment by a stroke team, emergency physician, or other expert within 10 minutes of arrival, including the order for an urgent CT scan

  • neurological assessment by stroke team and CT scan performed within 25 minutes of arrival

  • interpretation of CT scan within 45 minutes of ED arrival

  • initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from symptom onset.  rTpa can be administered in "well screened" patients who are at low risk for bleeding for up to 4.5hrs

  • door-to-admission time of 3 hours for all patients

5-step stroke algorithm

1. Identify the signs of a possible stroke and the time when the symptoms began.

  • Facial droop (have patient show teeth or smile)

  • arm drift (patient closes eyes and extends both arms straight out, with aplms up for 10 seconds)

  • speech is abnormal

  • time of symptom onset (last known well time)

*if any 1 of these 3 symptoms are abnormal, the probability of a stroke is 72%

2. Call 911 immediately.  Best practice is for EMS transport vs. being transported by a family member as EMS can transport the patient directly to a facility that can perform angiography

3. Complete the following assessments and actions:

a) define and recognize the signs of stroke.  Support the ABCs as needed

b) assess the patient according to CPSS or LAPSS.  Assess the orientation of the patient.  Ask the patient to state their name, DOB, orientation.  LAPSS assessment includes patient age, medical history, blood sugar, duration of symptoms, current hospitalization status, and motor asymmetry.

c) establish last well know time

d) transport the patient quickly to a stroke center if possible

e) assess neurological status while the patient is being transported

4. Within 10 minutes of the patient's arrival in the ED, take the following actions: support ABCs and evaluate vital signs; give oxygen if the pt. is hypoxic (spo2<94%); draw blood work for CBC, coagulation, and blood glucose; assess the patient using a neurological screening assessment (NIHSS); order a CT head and have it read quickly; obtain a 12-lead ECG and assess for arrhythmias

5. Within 25 minutes of the patient's arrival, the following should be completed: review the patient's history; review physical exam; establish last well-known time; perform a neurological exam using the NIHSS to assess the patient's status.  The CT scan should be completed within 25 minutes from the patient's arrival in the ED and should be read within 45 minutes

6. Within 45 minutes of the patient's arrival, the specialist must decide, based on the CT scan or MRI, if a hemorrhage is present.  If a hemorrhage is present, the patient is not a candidate for fibrinolytics and a consultation with neurology should be made.  If a hemorrhagic stroke is ruled out, the clinician must decide if the patient is a candidate for fibrinolytics by reviewing the fibrinolytic checklist

Treatment should commence within 60 minutes from arrival.  The risks and benefits of therapy should be reviewed with the patient and family (the main complication of IV tPA is intracranial hemorrhage) and give tissue plasminogen activator (tPA).  If the patient is not a candidate for tPA, give aspirin.

Managing hypertension in patients with an acute ischemic stroke 

For patients not eligible for fibrinolytic therapy, and with a pressure less than 220 or diastolic 120, just monitor and treat the patient's other symptoms of stroke (i.e, headache, pain, nausea).  In the context of systolic pressure greater than 220mmHg or diastolic between 121-150, labetalol 10-20mg IV every 1-2 minutes- may repeat or double every 10 minutes for a max dose of 300mg

For patient eligible for fibrinolytic therapy, and with a pressure between 180-230 systolic and 105-120 diastolic, labetalol 10mg over 1-2 minutes and may repeat or double the dose every 10 minutes for a maximum 300mg total

PALS Course Preparation 

BLS Infant and Child

Compression RR: 100-120 Bpm; Compression depth: 1/3 the AP distance of the chest or 1.5 inches or 4 cm (infant)//1/3 the AP distance of the chest or 2 inches or 5 cm (child).  Limiting interruptions in compressions to under 10s.  Allowing for complete chest recoil.  Assessing pulse and breathing at the same time (10s).  Breathing RR: rescue breathing is 1 breath every 2-3s.  During respiratory arrest with a pulse, 1 breath every 2-3s.  Breath to be given over 1s.  Compression Ratio: 30:2 unless 2 rescuers where it"s 15:2.  Compression technique: 1 person infant is 2-fingers lower sternum just underneath nipple line/  2 person infant is thumb-encircling technique with thumbs at lower sternum just below nipple line. Compression technique: 1 person child is heal of hand over heal of other hand.  This is the same for child.  For a witnessed arrest, go and active your ERS and ask for an AED before initiating compressions.  For unwitnessed arrest, give 2-min of compressions and then go and active your ERS and ask for an AED. 

Systematic Approach to Pediatric Assessment

Lets start with the PAT(Pediatric Assessment Tool) Appearance, Breathing, Color.   This is your initial impression and intended to identify a life-threatening situation that needs immediate intervention.  Then you go through ABCDE, secondary assessment SAMPLE, diagnostic tests. Airway refers to the patency of the airway and its either patent, maintainable, or non-patent.  breathing looks at RR, spo2, WOB, BS, chest expansion.  Circulation includes BP, HR, Pulse strength, color, cap refill (<2s is normal).  Disability is neurological status (AVPU) and blood sugar.  Exposure looks at temperature, skin condition. 

Respiratory

Respiratory Emergencies include: upper airway, lower airway, parenchymal, and respiratory drive.  Upper airway emergencies include croup, upper airway obstruction, etc.  They can be treated by repositioning the upper airway using a head-tilt, chin-lift position or just chin-lift in certain cases.  Inserting an oral or nasopharyngeal airway is also an option.  Nebulized Epinephrine for stridor is recommended.  Lower airway emergencies include Asthma and other reactive airway processes.  They are usually treated with Bronchodilators (Ventolin) and Corticosteroids. Parychymal emergencies include Pneumonia and Bronchiolitis.  Treatment could be anything from providing forms of respiratory support to oxygen therapy.  Respiratory drive problems arise from seizures, excessive sedation.  The clinician may need to provide PPV or even consider intubation.

Shock

 Uncompensated vs. compensated shock is defined by the systolic blood pressure.  For infants (30d-1yr) <70mmhg.  For ages 1-10yrs, 70+ (age*2)  Types of shock include Hypovolemic, Cardiogenic, Distributive, and Obstructive.  Fluid therapy is the mainstay treatment for shock.  Recommended dosage is 20cc's/kg over 5-20 minutes depending on the patient's condition.  Can give up to 3 dosages until you consider pressors.  Be careful giving fluids during Cardiogenic shock.  Use smaller amounts and infuse over a longer period of time.  Sepsis is a form of Distributive Shock and is treated with fluids, antibiotics, and potentially inotropes.

Cardioversion/Defibrillation

Cardioverting arrythmias include SVT and wide-complex arrythmias with a pulse however pt. is unstable.Initial energy level is .5-1J/kg.  Usually start at 1J/kg and then go up to 2J/kg and then up to 4J/kg if refractory,  If still refractory, re-evaluate differential of sinus tachycardia vs. SVT.  Defibrillating arrythmias include vfib and PVT.  Energy dose is 2-4J/Kg.  Start with 2J/kg and then go up to 4J/kg.  If the pt. needs a 3rd shock, you can use anywhere between 4-10J/kg. 

Arrest Algorithms

Bradycardia with a pulse.  Can be the result of impending respiratory failure or respiratory failure.  If HR between 60-100Bpm and there are signs of respiratory failure i.e RR 6bpm, provide PPV.  If HR less than 60Bpm and there are signs of circulatory failure i.e absent peripheral pulse, pallor, increased cap refill, then provide effective PPV/oxygenation.  Provide CPR with bradycardia with a pulse if HR less than 60Bpm and signs of poor end-organ perfusion and you have provided effective oxygenation/ventilation.  Consider epinephrine .01mg/kg of 1:10000 or .1ml/kg.  Consider atropine if you believe its due to increased parasympathetic tone .02mg/kg.  May be repeated once.

PEA/Asystole- CPR and Epinephrine q3-5minutes

SVT with a pulse(stable)- usually treated with vagal manuevers and/or adenosine .1mg/kg for a max dose of 6mg.  Can be repeated at.2mg/kg for max dose of 12mg.  Needs to be infused rapidly and with a NS bolus of 5cc's.  Pt. may need Cardioversion.

Vfib/PVT- CPR-defibrillation-CPR-defibrillation-CPR-epinephrine-defibrillation-CPR-Amiodorone.  No difference in effectiveness between Amiodarone and Epinephrine.  Amiodarone dose is 5mg/kg infused over 20-60min.  Repeat dose of 5mg/kg up to a mx of 15mg/kg/day.

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