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 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

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 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’

 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 VFib VTac Shockable PEA Asystole Non- Shockable

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

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… Checked response Voice Pain Called help BLS Primary Survey Airway Breathing Circulation (Defibrillation)

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) Continued CPR ACLS Secondary Survey Airway Breathing Circulation Differential

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 O 2 and CO 2 ?

 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 VFib VTac Shockable PEA Asystole Non- Shockable

PEA  Organized  No pulse  Fast or slow

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 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;359:21-30 Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299: Pulse never returns 50% Death 80% Death or neurologic compromise 85%

Questions?