1. American Heart Association BLS/ACLS/PALS Update
Janet Smith

3. Forget everything you know

4. Instructor Goals
Incorporate the previous changes from 2001 & present 2005 revisions
Less number of algorithms
Review Acute Pulmonary Edema, Hypotension, & Shock combined algorithms, & Hypothermia algorithm
Stroke algorithm less busy & ACS not much change

5. February 24, 2006 - Rollout First session BLS changes
Second session ACLS & PALS update
Begin new test – revised 2005
Handbook of Emergency Cardiovascular Care – includes Guidelines CPR/ECC Nice addition cardiac markers, Treatment w/ Non-ST-segment Elevation MI

6. Instructor Objectives
Fit the course to your needs
Adult learners need positive reinforcement & deal well with scenarios
Understand the exam (new & improved)
What is your environment

7. Student Objectives Discuss new basic life support guidelines
Discuss patient assessment & survey
Discuss the use of ACLS drugs
Stations: Determine competency
Discuss the ethical considerations in resuscitation

8. What type of course do you need?
Recertification versus full course
Utilize your study guides or “cheat sheets”
Review pretest written exam
Provide scenarios

9. ACLS goals
Emphasis on trained & equipped Health Care Professional (HCP), but only in conjunction with trained lay rescuer & reduce time to CPR and shock delivery & obtain ultimate success
Effective ACLS begins with high-quality CPR

10. Drug changes 2005
Most drug doses are the same as those recommended in 2000 – except use Atropine 0.5 mg IV for Bradycardia. May repeat to a total of 3 mg. Epinephrine or dopamine may be administered while waiting for a pacemaker

11. Early intervention & effective CPR

12. 5 major changes 2005 guidelines
Emphasis on, & recommendations to improve, delivery of effective chest compressions
A single compression-to-ventilation ratio for all single rescuers for all victims (except newborns)

13. 5 major changes 2005 guidelines
Recommendation that each rescue breath be given over 1 second & should produce visible chest rise
A new recommendation that single shock, followed by immediate CPR, be used to attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every 2 minutes

14. 5 major changes 2005 guidelines
Endorsement of the 2003 ILCOR recommendations for use of AEDs in children 1 to 8 years old (and older); use a child dose-reduction system if available

15. 5 major changes continued: AED – teaching point
Some AED’s have shown to be very accurate in recognizing pediatric shockable rhythms & may be used with regular adult pads

16. Age Definition
“Child” CPR guidelines apply to victims 1 year to the onset of puberty (about 12 – 14 years old)
Chest compressions are recommended if the heart rate is less than 60 per minute with signs of poor perfusion

17. Effective chest compressions
“push hard & push fast” & chest compress the a rate of about 100 per minute (except newborns)
Use 1 or 2 hands with a child (Use technique that gives best results)
Allow the chest to recoil
Limit interruptions in chest compression

18. Effective chest compressions
Chest compressions create a small amount of blood flow to vital organs – the better the chest compressions (adequate rate, depth, & allowing for recoil) the more blood flow is produced

20. Arterial and central venous pressure waveforms during external closed chest compression
Idris, A. H. et al. Circulation 1996;94:
Copyright ©1996 American Heart Association

21. Universal Compression-to-Ventilation – all lone rescuers
One universal compression-to-ventilation ratio for all lone rescuers: Single compression to ventilation ration of 30:2 for single rescuers of victims of all ages
Teaching point: Simplify CPR & increase blood flow to the heart

22. 1-Second breaths during all CPR
All breaths should be given over 1 second w/ significant volume to achieve visible chest rise
Teaching point: During CPR, blood flow to the lungs is much less than normal, so the victim needs less ventilation than normal

24. Review of BLS guidelines
Determine if you require BLS proof prior to your course

25. Basic Life Support – Teaching concepts
Early bystander CPR can double or triple the victim’s survival from VF & Sudden cardiac arrest (SCA)
CPR plus defibrillator within 3 – 5 minutes of collapse can produce survival rates as high as 49% to 75%

26. Basic Life Support – Calling for help
Lone Healthcare provider: Sudden collapse – Phone 911 & get an AED available & then return to victim to begin CPR
Unresponsive victim w/ likely drowning – deliver about 5 cycles (about 2 minutes) of CPR prior to phoning 911 to get the AED & then return to CPR

27. Lone Healthcare Provider/CPR
Scenario: Patient unresponsive & non-breathing the Lone Healthcare provider will give 2 rescue breaths & then feel a pulse for no more than 10 seconds. If no pulse – begin compression
Adult: 30:2
Child: 15:2 (two rescuers)

28. HCP- Rescue breathing Deliver rescue breath over 1 second
Rescue breathing for a victim w/pulse
Adult: to 12 breaths/minute
Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than normal & not as effective as compressions

29. Chest compressions – components
Adult: Center chest nipple line & 1 ½ to 2 inches using heel of both hands & lower half of sternum
Child: 1/3 to ½ depth of chest & using heel of one hand
Rate: 100 on all patients

30. HCP Chest compressions
Compression during CPR & NO advanced airway is present:
Deliver cycles of compressions 30:2
Compression during CPR & advanced airway IS present: No longer use cycles or pausing for rescue breathing. Deliver 100 compressions/minute w/ 8-10 breaths/minute

31. Lay Rescuers CPR – may include information with your course
Lay rescuers should immediately begin cycles of chest compressions after delivering 2 rescue breaths in the unresponsive victim. Lay rescuers are not taught to assess for pulse or sings or circulation
Research notes that the lay public has a difficult time locating the correct place for palpation

32. Defibrillation
One shock followed by immediate CPR beginning w/ chest compressions & 5 cycles or 2 minutes
Monophasic: 360 J
Biphasic: 150 to 200 J

33. AED Review Use the model for teaching & state the proper order -
4-Universal steps: Power AED Attach to victim Analyze rhythm Deliver shock if indicated

34. Use of the AED Use adult pads on adults
Use AED after 5 cycles of CPR (out of hospital)
No recommendation for infants < 1 year of age
Children 1 to 8 Use an AED with pediatric dose-attenuator

35. Electrical Therapies
Defibrillation involves delivery of current through the chest & to the heart to depolarize myocardial cells & eliminate VF
Monophasic – Deliver current to one polarity & higher energy level
Biphasic – Lower energy & are more in current use

36. Management of Pulseless Arrest
5 cycles or 2 minutes or uninterrupted CPR & should resume immediately after deliver 1 shock
Pulse & rhythm are NOT checked after shock

37. Management of cardiac arrest
Drug administration is of 2nd importance
NO IV access: Lidocaine, epinephrine, atropine, narcan, & vasopression are absorbed via the trachea w/typical dose 2 to 2 ½ times the recommended IV dose & should dilute with water or NS
Administer drugs during CPR

38. HCP- Rescue breathing Deliver rescue breath over 1 second
Rescue breathing for a victim w/pulse
Adult: to 12 breaths/minute
Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than normal & not as effective as compressions

39. Airway management - review & observe student performance
Demonstrate the BVM
Intubation techniques
Secondary confirmation techniques
Securing the ETT
C-Spine precautions & trauma
5-point chest exam

40. Airway & C-spine management
Use head tilt-chin lift technique to open the airway of trauma victim unless cervical spine injury is suspected
Teaching point: Jaw thrust is a difficult maneuver & may not be an effective way to open the airway

41. Airway station – Use BVM
Anyone providing prehospital care for adult, children, or infants should be trained to deliver effective oxygenation & ventilation
The use of BVM should be considered to be the primary method of venilatory support, especially if transport times are short

42. Airway Management – Issues to discuss during the station:
BVM can be as effective as ETT
A study noted 25% intubations were found to have esophageal/pharyngeal tube placement
Secondary confirmation involves the use of end-tidal CO2 detectors
Review tube holder & LMA

43. Verify correct ETT placement
To reduce the risk of esophageal misplacement or displacement – Confirm the placement immediately after insertion, in the transport vehicle, & whenever the patient is moved

44. Acute Coronary Syndromes - goals
Reduce the amount of myocardial necrosis & preserve LV function
Prevent Major adverse cardiac events “MACE”
Review new ACS algorithm

45. Acute Coronary Syndromes
M – O – N – A = Same Rx
Each minute the patient is in VF has 10% decrease of chance of survival
EMS: Monitor, support ABCs, CPR, & defibrillation
Goal: Door-balloon 90 minutes & Door- needle 30 minutes

47. Stroke
Intravenous tPA who meet (NINDS) is administered by physicians w/ defined protocol, knowledgeable team, & institutional commitment
Stroke patients should be admitted to Stroke Units

48. Acute Ischemic Stroke Lower blood sugar (> 200mg/dL)
Orders urgent CT Scan < 25 minutes
Reads CT scan < 45 minutes
If scan shows ICH/SAH call Neurosurgery
If no hemorrhage, continues protocol
Symptom onset > 3 hours?

49. Algorithm Review

50. Treatment of Wide Complex Tachycardias
ACLS providers should make a reasonable attempt to distinguish hemodynamically stable VT from SVT with aberrancy. History of CAD suggest ventricular origin.
Obtain a 12-lead (when possible) & note the QRS yet accuracy requires experience

51. Tachycardia with Pulses
Treatment summarized in a single algorithm – Immediate synchronized cardioversion for unstable patient
Narrow versus Wide Complex – Control rate (Diltiazem review)
Treat contributing factors

52. Unstable Tachycardia/Cardioversion
Primary & Secondary ABCs
D = Determine Defibrillation
Determine Sedatives & Analgesics
Know rapid infusion of antiarrhythmic agents
Post cardioversion care
Change unsynchronized mode

54. Pulseless Arrest VF/VT
5 cycles of CPR prior to defibrillation & minimize interruptions
Deliver 1 shock (120 or 200j) & resume CPR immediately
Epinephrine 1mg or vasopressin 40 U IV/IO to replace 1st dose of Epinephrine
May shock either 200j (unknown biphasic device) or 360j

55. Asystole/PEA Attach monitor/defibrillator Shockable
Epinephrine & Vasopressin
Consider Atropine 1 mg IV/IO for asystole or slow PEA rate

56. Asystole Advanced airway control Establish IV – Epinephrine & Atropine
Consider TCP once)
Consider differential diagnosis
Look for specific causes – The H’s & T’s with new addition

57. Pulseless Electrical Activity
Primary & Secondary
Airway control
IV access – Epinephrine 1 mg IVP
Atropine 1 mg IVP (if rate is slow)
6 H’s & 5 T’s
Act upon differential diagnosis when reasonable

58. Correct contributing factors
Hypovolemia
Hypoxia
Hydrogen
Hypo/Hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade
Tension pneumo
Thrombosis (coronary or pulmonary)
Trauma

59. Bradycardia Prepare TCP without delay
Recognize 2nd & 3rd Degree Blocks
Atropine 0.5 mg IV while waiting TCP (total dose 3mg)
Epinephrine 2 to 10 mcg/min or Dopamine infusion 2 to 10 mcg
Search contributing factors

60. Medication Review

61. Anti-arrhythmic agents
Lidocaine – Alternative to Amiodarone
Adenosine – Slow AV nodal conduction
Procainamide – Supraventricular arrhythmias & VT 20 mg/min total 17mg/kg
Amiodarone – Is effective with SVT because it alters conduction through the accessory pathway

62. Dobutamine
Indication – Pump problems (CHF, Pulmonary congestion) SBP 70 to 100 mm Hg & no signs of shock
Precautions – May cause tachyarrhythmias, fluctuations in blood pressure, headache, & nausea
2 to 20 mcg/kg/minute

63. Dopamine Second-line drug for symptomatic bradycardia (after atropine)
Use for hypotension SBP , 70 to 100 mm Hg) with signs & symptoms of shock
Correct hypovolemia with volume replacement
2 to 20 mcg/kg/minute

64. Amiodarone Recurrent VF & recurrent hemodynamically unstable VT
Requires several time consuming steps for administration (Glass ampule, etc)
Cardiac arrest: 300 mg IV initial dose & ONE 150 mg IVP in 3-5 minutes
Recurrent Ventricular arrhythmias: 150 mg IV over 10 minutes

65. Magnesium Life-threatening digitalis toxicity 1-2 g over 5 -20 min
Use in cardiac arrest only if Torsades de Pointes is suspected or Hypomagnesaemia is present
Life-threatening digitalis toxicity
1-2 g over min

66. Diltiazem
Indications: To control ventricular rate in atrial fibrillation & atrial flutter
Rate control: 15 to 20 mg (0.25 mg/kg) IV over 2 minutes
Caution: Avoid in patient receiving or Beta blockers, B/P may drop due to peripheral vasodilation

67. Epinephrine Cardiac arrest: VF, Pulseless VT, Asystole, PEA
Symptomatic bradycardia: after atropine & an alternative infusion to dopamine
Dose: IV/IO 1 mg (10 mL of 1:10,000) every 3-5 minutes

68. Vasopressin
Indications: Alternative pressor to epinephrine in treatment of adult shock-refractory VF
Dose: 40 U IV/IO push may replace either first or second dose of epinephrine

69. Fibinolytic Agents (Activase, tPA)
Indications: For AMI in Adults –
ST elevation ( > 1 mm in 2 leads) or new LBB, in context of S & S of AMI, Time of onset of symptoms < 12 hours
Indications: For Acute Ischemic Stroke
Focal neurologic deficits, Absence of Intracerbral or SAH on CT, & non-improving symptoms < 3 hours onset

70. “Flat Line Protocol”
The sensitivity or “gain” displayed on the monitor is one of the important things to check or confirm true asystole.
Check the POWER (on/off)
Battery supply & lead select (if set to paddles)

71. Postresuscitation support
Vasoactive support
Induced hypothermia cooled to 32 to 34C for 12 to 24 hours after ROSC
Ace Inhibitors: Reduces mortality & CHF with AMI (Angiotensin or ACE is a chemical that causes the heart to contract such as Vasotec)

72. Ethical Considerations
Do not resuscitate
Family presence – Let the family view all of your care & include in decision making if possible
Family & staff grief counseling
CISD assistance

73. The written exam Review EID & hypopharyngeal intubation (esophageal)
Hypovolemia easy to treat
Prehospital asystole = drug overdose
Non-contrast CT
Review Retavase & Heparin
CVA v insulin-induced hypoglycemia

74. The written exam Cannot be open book or use of notes
Be prepared to deal with the student that challenges the exam or the answers
How do you deal with the student who fails the exam?

75. What can you expect in the course
Decreased lectures
More “hands on”
Role-play
Scenario review
Group involvement

76. Questions?