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….

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 pre-rounding 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

BLS Primary Survey

Simple interventions

Part 4 – He’s Not Perking Up

Katie and Shai decide to activate BLS.

Pitfall:

Didn’t open airway

Gave inadequate breaths

Radial pulse check

Primary

Primary

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

No more than 5-10 seconds

NOT peripheral pulse

Start CPR

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

CPR board

100 compressions/minute

30:2 breaths

Hard and fast

Parts 1-5: The Replay

RECAP

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’

At casino: No pulse power-on AED and

follow voice prompts Apply pads Administer shock as

directed

In hospital: will not have AED immediately available

Once you know the rhythm, you can follow the algorithm

Today: Non-Perfusing Rhythms

Non-Perfusing Rhythms

What are VF and VT?

• These two rhythms are treated in the same way (if pulseless)

• Both represent the ventricle trying to pump blood in a disorganized way

• Usually due to myocardial ischemia (for whatever cause)

VF and VT

Examples

Examples

Examples

Examples

Defibrillators 101

Defibrillators 101

• Gel pads• Select energy (200J)• 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…

OBJECTIVES

1. Approach to the first three minutes of a code

2. Primer on the rest….

Incorporating ACLS

Now: ACLS Secondary Survey

Advanced interventions

Is the airway patent?

Is an advanced airway indicated?

Laryngeal Mask Airway (LMA) Endotracheal Tube (ETT)

Is the airway in the right place?

Is the tube secure?

Are we monitoring O2 and CO2?

What is/was the rhythm?

Is there IV access?

Is fluid needed?

Are drugs needed?

Why did the patient arrest?

Is there a reversible cause for the arrest?

Part 6:Dream Team Code

PEA and 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: O2

• 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

Out-of-hospital In-hospital

Pulse never returns 70%

Death at one year 99%

Death or neurologic compromise

99.5%

Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine versus epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359:21-30Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785-792

Pulse never returns 50%

Death 80%

Death or neurologic compromise

85%

Questions?