https://www.proacls.com/training/video/introduction-to-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2442.mp4 Introduction to ACLS Welcome to the ProACLS course. This ACLS (Advanced Cardiovascular Life Support) course was designed specifically for you, the busy healthcare professional. In this lesson, we'll get into the benefits of choosing ProTrainings for your ACLS education. We'll get into the WHY regarding your chosen field and career path. And at the end of the course, we'll provide you with some advanced cardiovascular life support survival rates. We designed ProACLS with three core components in mind: Ease of use Learning efficiency Paced at your own speed ProACLS is available 24/7, whether you're watching a video for the first time, the third time, or coming back after several months for a quick refresher. We're here whenever you need us to be, regardless of your schedule. We'll get into specific course objectives in a subsequent lesson, but in this course, you can expect to gain all the guidelines and knowledge about current ACLS regulations. Which will ultimately lead to meeting and exceeding the most important course objective: Providing you with enough real-world knowledge so that when you're a team leader or team member during a cardiac emergency, you can feel as confident as possible to contribute to a positive outcome in that patient's life. Becoming that kind of confident takes action to achieve – as in, gaining a deeper knowledge than you already possess. Along with honing and refining the necessary skills that many of you already have. Which leads to an important point: Participants in the ProACLS course are required to have basic knowledge and skills pertaining to basic life support and basic cardiac life support. Which brings up another great point: Warning: Some things in this course may be familiar to you already, and if they are, that's not always a good thing. We tend to passively listen, read, and learn when things sound familiar. And when this happens, you're much more likely to miss a point or two that one day you may need. Fight this human tendency and you'll get much more from this course. If you're wondering, what can I expect from the ProACLS course, that's a great question. Here is a list of the knowledge and skills you'll be required to learn in order to successfully complete your course. Appropriate basic life support competency Electrocardiogram rhythm interpretation for all core ACLS rhythms Knowledge of airway management including all appropriate adjuncts ACLS drug and pharmacological knowledge Practical applications of ACLS rhythms and drugs Effective high-performance team skills Learning these important and valuable skills takes commitment and dedication, and it may require that you watch the videos more than once. It may mean practicing case scenarios several times until they become automatic. However, what you'll get from that confidence isn't nearly as important as what you can do with that confidence – making a difference when it matters most and possibly saving someone's life. Throughout the course you can also expect a few Warnings from time to time, like the above warning, and even more Pro Tips, when the information warrants highlighting. And when there's a need for supplemental information, you'll find a section at the end of these written course lessons that go beyond the video components. One other thing before we begin, keep in mind WHY you've chosen this field. Life is a precious thing. It's something that should be appreciated, savored, and celebrated. As a healthcare provider, you have enormous power to help people in need. To give back to them the one resource that is truly extinguishable – time. Time for everything that matters to them. Keep the WHY in your mind as you work your way through this course. A Word About Advanced Cardiovascular Life Support Survival Rates ACLS providers face an important challenge — functioning as a team to implement and integrate both basic and advanced life support to help save a life. The 2020 American Heart Association guidelines update for CPR and ECC reviewed evidence that has shown that in both out-of-hospital and in-hospital settings, many cardiac arrest patients do not receive high-quality CPR, and the majority do not survive. One study of in-hospital cardiac arrest showed that the quality of CPR was inconsistent and did not always meet the AHA guidelines and recommendations. However, over the years, patient outcomes post-cardiac arrest have still improved. Cardiac Arrest Survival Data Out-of-Hospital Year Bystander CPR % Survival % 2012 41.0 11.4 2013 40.1 9.5 2014 40.8 10.4 2015 45.9 10.6 In-Hospital Year Survival % 2012 23.1 2013 23.9 2014 22.7 2015 25.5 To analyze these findings, a back-to-basics evidence review refocused on the essentials of CPR, the links in the Chain of Survival, and the integration of BLS with ACLS. Minimizing the interval between stopping chest compressions and delivering a shock improves the chances of shock success and patient survival. Experts believe that high survival rates from both out-of-hospital and in-hospital sudden cardiac death are possible when utilizing strong systems of care. High survival rates have been associated with several key elements: Training of knowledgeable healthcare providers Planned and practiced response Rapid recognition of sudden cardiac arrest Prompt delivery of CPR Defibrillation as soon as possible and within 3 to 5 minutes of collapse Organized post-cardiac arrest care When you can implement these elements early, ACLS has the best chance of producing a successful outcome. https://d3imrogdy81qei.cloudfront.net/video_images/4349/introduction-to-acls.jpg Yes 71 https://www.proacls.com/training/video/acls-course-overview https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2443.mp4 ACLS Course Overview This ProTrainings ProACLS course has been designed for the busy healthcare professional who participates in, or directs the management of, cardiovascular emergencies and cardiac arrest situations. In this course overview lesson, we'll be covering your course goals or objectives and basically outline everything that will be in the course from A to Z. And at the end of the lesson, we'll provide you with a Word about medical emergency teams and rapid response teams. The aim of this course is to help you enhance your skills, including being better able to recognize and treat cardiopulmonary arrest, post-cardiac arrest, acute arrhythmias, stroke, and acute coronary syndrome, or ACS for short. Throughout this ProACLS program, you'll be actively participating, by combining cognitive and interactive simulation, and while covering scenarios based on actual medical emergencies. And by the end of your training program, you should be much more equipped at improving the outcomes of adult patients who are suffering from cardiac arrest and other cardiopulmonary emergencies. Your training should also help you become more effective at recognizing and intervening with the proper care in any cardiac-related emergency. It doesn't matter if you're a healthcare provider who works in a pre-hospital setting or you're part of a larger in-hospital team. ProACLS will help you enhance your skills regardless of where you work and when you work. ProACLS Course Objectives Your ProACLS certification course includes the following 10 objectives: Evaluating and treating adult patients with basic life support skills, including the provision of early chest compressions and the proper utilization and timing of an automated external defibrillator. Recognizing and managing respiratory arrest in adult patients. Recognizing and managing acute coronary syndrome, including the appropriate characteristics. Recognizing and managing the signs and symptoms of stroke, including the appropriate characteristics. Recognizing and treating both bradyarrhythmias and tachyarrhythmias that could result in cardiac arrest or complicate the resuscitation process and outcome. Recognizing and treating cardiac arrest, including immediate post-cardiac arrest care. Evaluating your resuscitation efforts during cardiac arrest scenarios through continuous assessment of cardiopulmonary resuscitation, including monitoring patients' physiological responses and delivering real-time feedback in a team setting. Demonstrating effective communication as either team leader or as a team member in a high-performing team, while also recognizing the impact of team dynamics on overall team performance. Learning about and utilizing the rapid response of a medical emergency team that will help contribute to the improvement of patient outcomes and defining the guidelines for the systems of care. Becoming more proficient with the proper administration of ACLS medications. Now let's go over the ProTraining ProACLS course design. To help you achieve these important objectives, we've included practice sessions and megacode evaluations. These practice learning stations will give you the opportunity to actively engage and learn from the following: The simulation of clinical cardiac emergency scenarios The video demonstrations of these scenarios Scenario-based role playing Practicing effective high-performing team behaviors During the testing phase of your ProACLS course, you'll be required to pass a megacode evaluation station in order to properly validate the achievement of your course objectives. Also, a simulated cardiac arrest scenario will help evaluate you in the following areas: Your competency of all core case materials and skills Your competency of ACLS algorithms Your adequate understanding of arrythmia interpretation Your proper use of appropriate basic ACLS drugs and therapies Your ability to perform effective leadership skills within a high-performing team environment A Word About Medical Emergency Teams and Rapid Response Teams Many hospitals have incorporated the use of medical emergency teams (MET) or rapid response teams (RRT). The purpose of these teams is to improve patient outcomes by properly identifying and treating early clinical deterioration. In-hospital cardiac arrest is often preceded by physiologic changes in the patient. In fact, recent studies have shown that nearly 80 percent of hospitalized patients with cardiorespiratory arrest first had abnormal documented vital signs for up to eight hours before the actual arrest occurred. The vast majority of these changes can and should be recognized by monitoring routine vital signs. Proper intervention before this clinical deterioration or cardiac arrest should be possible. The Route of Care for the Unstable Patient: Rapid Response Team → Code Team → Critical Care Team The management of life-threatening cardiac emergencies requires the integration of multidisciplinary teams that can involve rapid response teams, cardiac arrest teams, and intensive care specialists to achieve the ultimate goal – the survival of the patient. Team leaders, in particular, have an essential role in this coordinated effort of care with other team members and other specialists. https://d3imrogdy81qei.cloudfront.net/video_images/4351/acls-course-overview.jpg Yes 228 https://www.proacls.com/training/video/fibrinolytic-agents https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2455.mp4 Fibrinolytic Agents In this lesson, we'll go over the use of fibrinolytic medications and all of their effects, including indications, precautions and contraindications, and adult dosages. Fibrinolytic medications are not usually found in advanced cardiac life support pharmacological drug cards specifically. However, their use is vitally important to reperfusion therapies. Fibrinolytic drugs – also called thrombolytic drugs – are any medication that is capable of stimulating the dissolution of blood clots, or as they're sometimes referred to as – thrombus. These types of drugs work by activating something referred to as fibrinolytic pathways. Pro Tip #1: This is important because it differentiates fibrinolytic medications from anticoagulant drugs, routinely referred to as heparin and Coumadin – Two common anticoagulants that work by preventing normal clotting factors from functioning correctly, thereby inhibiting the blood from clotting. Fibrinolytic medications, which prevent the formation of blood clots by suppressing the function of multiple clotting factors that are normal and present in the blood, are different from anticoagulants. Pro Tip #2: There are numerous fibrinolytic agents on the market, each of which may produce varying mechanisms of action. And while there are similarities between these are anticoagulants, fibrinolytic drugs produce the therapeutic effect of breaking down the fibrin and fibrinogen matrix of a thrombosis (fibrinolysis), thus fragmenting the clot that is obstructing an artery and reestablishing distal blood flow. Fibrinolytic Indications Now let's take a look at some indications for fibrinolytic medications. The most common indication for the use of fibrinolytic medications include the following two: Acute myocardial infarction, also known as AMI. Acute ischemic stroke, also known as AIS. In patients with acute myocardial infarction, fibrinolytic drugs would be indicated if the ST-segment elevation is consistent with a myocardial infarction of greater than or equal to 1mm in two or more contiguous leads. Contiguous leads are next to one another anatomically speaking. They view the same general area of the heart (specifically the left ventricle). Fibrinolytic drugs can also be indicated if the signs and symptoms of a myocardial infarction last longer than 15 minutes and less than 12 hours and if PCI (percutaneous coronary intervention) is not available within 90 minutes of medical contact. If the indication is related to ischemic stroke, patients may qualify if they suffer from sudden onset of a focal neurological deficit such as: Slurred speech Facial droop Weakness on one side of their body Paralysis on one side of their body Patients may also qualify for fibrinolytic medications if the stroke symptoms do not seem to be self-resolving, which is what you usually see when it's a transient ischemic attack (or TIA) and the signs and symptoms are present for up to three hours but not greater than 4.5 hours. Fibrinolytic Precautions and Contraindications There are a few precautions and contraindications when it comes to administering fibrinolytic medications that you should be aware of. When using fibrinolytic drugs, there are several patient factors that would exclude their use, which include (but are not limited to): Hypertension with systolic blood pressure greater than 180 to 200mm HG Right arm vs. left arm blood pressure differences greater than 15mm HG Significant head or facial trauma within the past 3 months Prior intracranial hemorrhage A bleeding disorder or internal bleeding within the prior 2 to 4 weeks The use of a current anticoagulant treatment Pregnancy A serious systemic disease which would include advanced cancer or kidney disease Ischemic stroke greater than 3 hours or less than 3 months Pro Tip #3: However, that last contraindication would not include the current condition being considered for the current fibrinolytic treatment. Adult Dosage of Fibrinolytic Medications The adult dosage for fibrinolytic treatments can be a little complex because the dose of the treatment would depend on the exact fibrinolytic medication being used. Having said that, there are three major classes of fibrinolytic drugs: tissue plasminogen activator (tPA), streptokinase (SK), and urokinase (UK). While drugs in these three classes all have the ability to effectively dissolve blood clots, they differ in their detailed mechanisms in ways that alter their selectivity for fibrin clots. https://d3imrogdy81qei.cloudfront.net/video_images/4375/fibrinolytic-agents.jpg Yes 208 https://www.proacls.com/training/video/nitroglycerin https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2459.mp4 Nitroglycerin In this lesson, we'll go over the medication nitroglycerin and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we'll continue our look at respiratory problems, specifically respiratory failure. Nitroglycerin is a nitrate that causes smooth muscle relaxation, which produces systemic venous pooling of blood through the action of vasodilation. This, in effect, decreases venous blood flow return to the heart and also reduces preload as well as venous after load. Pro Tip #1: The administration of nitroglycerin should be monitored closely so as to not cause detrimental hypotension. Nitroglycerin Indications Now let's take a look at nitroglycerin indications. Nitroglycerin is indicated to relieve chest discomfort that is suspected to be the result of acute myocardial infarction, otherwise known as AMI. Nitroglycerin can also be effective in relieving cardiogenic pulmonary edema that is related to left side heart failure. Nitroglycerin Precautions and Contraindications Now let's go over the precautions and contraindications for nitroglycerin. There are multiple situations when the use of nitroglycerin may not be indicated or may even be contraindicated and harmful to the outcome of the patient. Here are some examples of those contraindicated situations: The patient is suffering from low systolic blood pressure of less than 90mm HG The patient has a right-sided ventricular infarction The patient is using medications like tadalafil, better known as Cialis or Adcirca The patient has severe bradycardia of fewer than 50 beats per minute The patient has a tachycardia greater than 100 beats per minute in the absence of heart failure Different from tadalafil, but in the same class of complications with nitroglycerin, when a patient may be taking a phosphodiesterase type 5 (a class of medication that includes Sildenafil) within the past 24 hours, this could cause severe hypotensive side effects if the patient is using that medication and also taking nitroglycerin. Pro Tip #2: It's vitally important to gather a thorough medications list from the patient, a reliable family member, or the patient's caregiver to avoid any serious contraindications that could occur when mixing these types of medications. Adult Dosage of Nitroglycerin Now let's look at the adult dosage of nitroglycerin. There are three methods of administering nitroglycerin: Nitroglycerin can be administered sublingually (under the tongue) in a dose of 0.4 mg, which is typically one tablet. This dose can be repeated in 5-minute intervals to a maximum dose of 3 tablets. Nitroglycerin can also be administered via a sublingual spray in metered doses. One spray of nitroglycerin will usually be the equivalent of a 0.4 mg tablet. This, too, can be repeated in 5-minute intervals to a maximum dose of 3 sprays. And finally, nitroglycerin can also be administered via IV and may be increased to 10 mcg per minute every 3 to 5 minutes until you've reached the desired effect. Warning: And as mentioned in the Pro Tip at the top of this lesson, it's important to closely monitor the patient's serial blood pressure and treat hypotension accordingly. A Word About Respiratory Failure In the last lesson on morphine sulfate, we took a look at respiratory distress. In this Word, we'll look at respiratory failure. Respiratory failure is a clinical state of inadequate oxygenation, ventilation, or both. Respiratory failure is often the end stage of respiratory distress. If there is abnormal central nervous system control of breathing or muscle weakness, the patient may show little or no respiratory effort despite being in respiratory failure. In these types of situations, you will have to identify the patient's respiratory failure based on clinical findings. It's important to confirm the diagnosis with objective measurements, such as pulse oximetry or blood gas analysis. You should suspect the probability of respiratory failure if you notice some or all of the following signs: Marked tachypnea Bradypnea, apnea (late) Increased, decreased, or no respiratory effort Poor to absent distal air movement Tachycardia (early) Bradycardia (late) Cyanosis Stupor or coma (late) Respiratory failure can result from upper or lower airway obstruction, lung tissue disease, and disordered control of breathing, such as apnea or shallow, slow respiration. When respiratory effort is not adequate, respiratory failure can occur without the usual signs of respiratory distress. Respiratory failure is a clinical state that requires intervention to prevent its deterioration into cardiac arrest. Respiratory failure can occur with a rise in arterial carbon dioxide levels (hypercapnia), a drop in blood oxygenation (hypoxemia), or both. https://d3imrogdy81qei.cloudfront.net/video_images/4383/nitroglycerin.jpg Yes 177 https://www.proacls.com/training/video/magnesium-sulfate https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2457.mp4 Magnesium Sulfate In this lesson, we'll go over the medication magnesium sulfate, sometimes referred to as simply mag sulfate, and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we conclude our look at STEMI. Magnesium sulfate affects the SA node by slowing down its impulse rate, and it also reduces the automaticity in partially depolarized cells. Magnesium sulfate causes vasodilation, and when administered rapidly, can also create hypotension. Magnesium Sulfate Indications Now let's take a look at magnesium sulfate indications. Magnesium sulfate is effective as an anticonvulsant and antiarrhythmic and is used to treat polymorphic ventricular tachycardia with a pulse Magnesium sulfate is recommended for use in cardiac arrest only in cases of torsade's de pointes or suspected cases of hypomagnesemia. Whenever you see these conditions present, this is when you would use magnesium sulfate. Magnesium sulfate is also indicated for life threatening ventricular arrythmias due to digitalis toxicity. Pro Tip: Digitalis toxicity (DT) occurs when you take too much digitalis (also known as digoxin or digitoxin), a medication used to treat heart conditions. Signs of toxicity include nausea, vomiting, and an irregular heartbeat. Magnesium Sulfate Precautions and Contraindications Magnesium sulfate is contraindicated for patients with central nervous system depression or hypermagnesemia. And caution must be taken when used on patients with renal impairment as well. Routine administration of magnesium sulfate in hospitalized patients with acute myocardial infarction is also not recommended. Adult Dosage of Magnesium Sulfate Now let's look at the adult dosage of magnesium sulfate. The administration of magnesium sulfate in pulseless cardiac arrest is 1 to 2 grams (or 2 to 4ml) of a 50 percent solution diluted in 10ml of D5W or normal saline via slow IV or IO push over 5 to 20 minutes. When dealing with adult patients with torsade's with a pulse or acute myocardial infarction with hypomagnesemia, a loading dose will be required of 1 to 2 grams mixed in 50 to 100ml of D5W or normal saline via IV over a 5 to 60-minute period. This should then be followed with a .5 to 1 gram per hour IV titrated to control torsade's de pointes. A Word About STEMI We provided an introduction into ST-Elevation Myocardial Infarction (STEMI) in the last Word section of the Lidocaine lesson. In this Word, we'll dig a little deeper into STEMI. Early Reperfusion Therapy Healthcare providers should rapidly identify patients with STEMI and quickly screen them for indications and contraindications to fibrinolytic therapy by using a fibrinolytic checklist if appropriate. The first qualified physician who encounters a patient with STEMI should interpret or confirm the 12-lead ECG, determine the risk vs. benefit of reperfusion therapy, and direct administration of fibrinolytic therapy or activation of the PCI (percutaneous coronary intervention) team. Early activation of PCI can occur with established protocols. The following time frames are recommended by the American Heart Association: For PCI, the goal for ED door-to-balloon inflation time is 90 minutes. In patients presenting to a non-PCI-capable hospital, the time from first medical contact to device should be less than 120 minutes when primary percutaneous coronary intervention is considered. If fibrinolysis is the intended reperfusion, an ED door-to-needle time (needle time relates to the beginning of infusion of a fibrinolytic agent) of 30 minutes is the goal that's considered the longest acceptable time. It goes without saying that systems should strive to achieve the shortest time possible. Patients who are ineligible for fibrinolytic treatment should be considered for transfer to a PCI facility regardless of the delay. The system should strive for a door-to-departure time of 30 minutes after a transfer decision has been made. Adjunctive treatments can also be indicated. Use of PCI The most frequently used form of percutaneous coronary intervention is coronary intervention with stent placement. Optimally performed primary PCI is the preferred reperfusion strategy over fibrinolytic administration. Rescue PCI should be used early after fibrinolytics in patients who may have persistent occlusion of the infarct artery, although this term has been recently replaced by the term pharmacoinvasive strategy. PCI has been shown to be superior to fibrinolysis in the combined end points of death, stroke, and reinfarction in many studies for patients presenting between 3 and 12 hours after onset. However, these results have been achieved in experienced medical settings involving skilled healthcare providers at skilled PCI facilities – those performing more than 200 PCl's for STEMI with cardiac surgery capabilities. Considerations for the use of PCI include the following: PCI is the treatment of choice for the management of STEMI when it can be performed effectively with a door-to-balloon time of less than 90 minutes from first medical contact by a skilled provider at a skilled PCI facility. Primary PCI can also be offered to patients presenting to non-PCI-capable healthcare centers if PCI can be initiated promptly within 120 minutes from first medical contact. The TRANSFER AMI (Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction) trial supports the transfer of high-risk patients who receive fibrinolysis in a non-PCI center within 12 hours of symptom onset to a PCI center within 6 hours of fibrinolytic administration to receive routine early coronary angiography and PCI if indicated. For patients admitted to a hospital without PCI capabilities, there may be some benefit associated with transfer for PCI versus administration of on-site fibrinolytics in terms of reinfarction, stroke, and a trend to lower mortality when PCI can be performed within 120 minutes of first medical contact. PCI is also preferred in patients with contraindications to fibrinolytics and is indicated in patients with cardiogenic shock or heart failure complicating myocardial infarctions. https://d3imrogdy81qei.cloudfront.net/video_images/4379/magnesium-sulfate.jpg Yes 137 https://www.proacls.com/training/video/adenosine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2448.mp4 Adenosine In this lesson, we'll go over the medication adenosine and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we'll provide you with a Word about defibrillation. Adenosine is effective at terminating narrow complex SVT due to a reentry involving the AV or sinus node. It's used for unstable narrow complex reentry tachycardia and should be given to the patient while also preparing to cardiovert. Pro Tip #1: It's important to note that adenosine does not convert atrial fibrillation, atrial flutter, or ventricular tachycardia. Adenosine Indications Indications for adenosine include: Narrow complex SVT Unstable narrow complex reentry tachycardia Regular and monomorphic wide complex tachycardia As a diagnostic maneuver for stable narrow complex SVT Adenosine Precautions and Contraindications There are some adenosine precautions and contraindications to be aware of, including: Poison induced tachycardia Drug induced tachycardia 2nd degree heart blocks 3rd degree heart blocks Adenosine is safe to administer to pregnant patients. Pro Tip #2: Adenosine is less effective in patients who are taking theophylline or caffeine. And if administered for irregular polymorphic wide complex tachycardia or V-tach, it could cause a deterioration including hypotension. Adenosine side effects include: Transient periods of flushing Chest pain Chest tightness Brief periods of asystole Brief periods of bradycardia Ventricular ectopy Pro Tip #3: Reduce the initial dose of adenosine to 3mg in patients who are also receiving dipyridamole or carbamazepine, in heart transplant patients, or if adenosine is given by central venous access. Remember, transient periods of sinus bradycardia and ventricular ectopy are common after termination of SVT. Adult Dosage of Adenosine Adenosine should be delivered via rapid IV push and follow the steps below when administering the drug. 1. First, place the patient in a moderate reverse Trendelenburg position before administering the drug. It is highly recommended that whatever extremity in which adenosine is administered is elevated.2. Rapidly administer the initial bolus of 6 mg over 1 to 3 seconds.3. Follow the adenosine with a normal saline bolus of 20 ml. A 2nd dose of 12 mg of adenosine can be given after 1 to 2 minutes if needed.4. While administering the medication, make sure to record the rhythm strip. Pro Tip #4: Draw up the adenosine dose and saline flush in two separate syringes. Attach both syringes to the IV injection port that's closest to the patient. Clamp the IV tubing above the injection port. Push the IV adenosine as quickly as possible. While maintaining pressure on the adenosine plunger, push the normal saline flush as quickly as possible after the adenosine. 5. Unclamp the IV tubing.6. Monitor the outcome. A Word (or Two) About Defibrillation The Purpose of Defibrillation Defibrillation does not restart the heart. Defibrillation only stuns the heart and briefly terminates all electrical activity, including V-Fib and pulseless V-tach. If the heart is still viable, its normal pacemakers can eventually resume electrical activity, such as a return of spontaneous rhythm, that ultimately results in a perfusing rhythm. In the first minutes after successful defibrillation, however, any spontaneous rhythm is typically slow and may not create pulses or adequate perfusion. The patient needs CPR, beginning with chest compressions, for several minutes until sufficient heart function resumes. Also, not all shocks will lead to successful defibrillation. Which is why it's important to resume high-quality CPR immediately after a shock, beginning with chest compressions. Clearing for Defibrillation To ensure safety during defibrillation, always announce the shock warning. State the warning firmly and in a forceful voice before delivering each shock. This entire shock warning sequence should take less than 5 seconds: Announce the shock – clear! Check to make sure you're clear of contact with the patient, the stretcher, or other equipment. Make a visual check to make sure that no other member of the team is touching the patient, stretcher, or other equipment. Make sure oxygen isn't flowing across the patient's chest. Deliver the shock to the patient. When pressing the shock button, the operator of the defibrillator should be facing the patient, not the machine. This helps to ensure coordination with the chest compressor and to verify that no one accidentally resumed contact with the patient. You don't necessarily need to say, clear (as you could choose another word), but you must warn other members of the team that you are about to deliver a shock and that everyone must stand clear of the patient. Though, uniformity isn't a bad thing, and if all are expecting to hear, clear, that might still be the best option. https://d3imrogdy81qei.cloudfront.net/video_images/4361/adenosine.jpg Yes 182 https://www.proacls.com/training/video/morphine-sulfate https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2458.mp4 Morphine Sulfate In this lesson, we'll go over the medication morphine sulfate and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we take a look at respiratory distress. Morphine sulfate is a mu-opioid receptor agonist used to relieve pain. It produces analgesic effects by binding to mu-opioid receptors in the central nervous system. Morphine Sulfate Indications Now let's take a look at morphine sulfate indications. Morphine sulfate is indicated for chest pain that is refractory to the use of nitroglycerin. Morphine Sulfate Precautions and Contraindications Now let's go over the precautions and contraindications for morphine sulfate. Opioids, like morphine sulfate, are known to depress the respiratory system and may also lower blood pressure. For this reason, consider using a reduced dosage in older patients or those patients with an altered level of consciousness. Adult Dosage of Morphine Sulfate Now let's look at the adult dosage of morphine sulfate. Morphine sulfate may be given to patients in 2 to 4 mg increments via slow IV push. Additional morphine can be given in doses of 2 to 8 mg 5 to 15 minutes after the first dose. Pro Tip: Be sure to titrate the dose of morphine to the patient's response and effects. If you notice signs of hypotension, hypoventilation, bradycardia, or any other serious central nervous system depression symptoms appear, naloxone may be given at 0.4 to 2 mg via IV to reverse the opioid side effects. Also, be aware that gastrointestinal upset may occur in higher doses as well. A Word About Respiratory Distress As respiratory depression can occur with the use of morphine sulfate, we're going to dive a little deeper into the three types of respiratory issues – respiratory distress, respiratory failure, and respiratory arrest. In this Word, we'll first look at respiratory distress. Normal and Abnormal Breathing The average respiratory rate for an adult is about 12 to 16 respirations per minute. Normal tidal volume of 8 to 10 ml per kg will maintain normal oxygenation and the elimination of CO2. Tachypnea occurs when the patient's respiratory rate is above 20 respirations per minute, while bradypnea occurs when their respiratory rate falls below 12 respirations per minute. A respiratory rate below 6 respirations per minute (known as hypoventilation) will require assisted ventilation with a bag-mask device or an advanced airway with 100 percent oxygen. Respiratory Distress Respiratory distress is a clinical state that is characterized by an abnormal respiratory rate (such as tachypnea) or effort. The respiratory effort may be increased (such as nasal flaring, retractions, and the use of accessory muscles) or it may be inadequate (like hypoventilation or bradypnea). Respiratory distress can range from mild to severe. For instance, a patient with mild tachypnea and a mild increase in respiratory effort with changes in airway sounds would be considered in mild respiratory distress. A patient with marked tachypnea, a significantly increased respiratory effort, a deterioration in skin color, and changes in their mental status would be considered in severe respiratory distress. Severe respiratory distress can be an indication of respiratory failure. Clinical signs and symptoms of respiratory distress will typically include a few, or all, of the following signs: Tachypnea Increased respiratory effort, such as nasal flaring and retractions Inadequate respiratory effort, such as hypoventilation or bradypnea Abnormal airway sounds, such as stridor, wheezing, and grunting Tachycardia Pale, cool skin; however, it's important to note that some causes of respiratory distress, such as sepsis, may cause the skin to get warm, red, and diaphoretic Changes in the patient's level of consciousness and/or agitation The use of abdominal muscles to assist the patient with breathing It's also important to note that these indicators may vary in severity. Respiratory distress should be apparent when a patient tries to maintain adequate gas exchange despite airway obstruction, reduced lung compliance, or lung tissue disease. As the patient begins to tire or as respiratory function or effort (or both) deteriorate, adequate gas exchange cannot be maintained. When this happens, clinical signs of respiratory failure will develop. https://d3imrogdy81qei.cloudfront.net/video_images/4381/morphine-sulfate.jpg Yes 90 https://www.proacls.com/training/video/pharmacology https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2447.mp4 Pharmacology In this section of your ACLS course, we're going to look at the current ACLS pharmacological treatments, including some important things to keep in mind as you progress through this section of your course. At the end of the lesson, we'll look at the finer points of resuming CPR while a defibrillator is charging. It's important to remember that no medication will work the way you expect it to or want it to unless the patient's biological status, at the cellular level, works the way you want it to or expect it to. What do we mean by this? We know that there has been a lot of research done that better helps us understand that when a patient is in cardiac arrest, at the cellular level they have a very specific amount of time before clinical death transitions into biological or cellular death. In other words, permanent death. As cellular hypoxia progresses into cellular death, the body's ability to react to treatments, including the medications we'll be covering in this section, become much more difficult and much more unlikely. For this reason, it's vitally important that, as a healthcare professional, you are able to provide highly effective basic life support skills. These are foundational skills and extremely important for any and all successful ACLS outcomes. ACLS Medications The variety of medications that we'll cover in this section of the course are only one part of any successful resuscitation (and one part of the chain of survival) and will include: Adenosine Amiodarone Aspirin Atropine Dopamine Epinephrine Fibrinolytic Agents Lidocaine Magnesium sulfate Morphine sulfate Nitroglycerin Oxygen Procainamide The ACLS Chain of Survival Essentially, basic life support helps the patient by buying them time. Time it takes the body to transition from clinical death to biological, cellular, and permanent death. The ACLS medications listed above that we'll be digging into in subsequent lessons are just one small part of any successful resuscitation. ACLS is the next level in the chain of survival that includes four main components: The administration of medications EKG and ECG monitoring Advanced airways Other treatment options Your goal is to help keep the patient in a state of survivability until, ultimately, you're able to get them appropriate and definitive treatment that will hopefully and ideally reverse their life-threatening condition. The Administration of Medications As you begin to learn about, or refresh your knowledge of, these current ACLS medications, we'll be breaking down each into four distinct categories: The drug and its effects The drug's indications The drug's precautions and contraindications The drug's appropriate dosage A Word About Resuming CPR While the Defibrillator is Charging It's important to continue to perform high-quality CPR until a defibrillator arrives and is attached to the patient. The team should assign team member roles and responsibilities as well as organize the appropriate interventions to minimize interruptions in chest compressions. Doing so accomplishes the most critical interventions for VFib or pulseless V-tach – CPR with minimal interruptions in chest compressions and defibrillation during the first minutes of arrest. The American Heart Association does not recommend continued use of an AED (or the automatic mode) when a manual defibrillator is available and when the healthcare provider's skills are sufficient for rhythm interpretation. The reasons is simple – rhythm analysis and shock administration with an AED may result in prolonged interruptions in chest compressions. Shortening the interval between the last chest compression and the ensuing shock by even a few seconds can help improve shock success. Thus, it is reasonable for healthcare providers to practice efficient coordination between CPR and defibrillation to minimize the hands-off interval between stopping compressions and administering the shock. For example, after verifying that the patient has a shockable rhythm and initiating the charging sequence on the defibrillator, another provider should resume chest compressions and continue performing them until the defibrillator is fully charged. The operator of the defibrillator should deliver the shock as soon as the compressor removes his or her hands from the patient's chest and after all providers are clear of contact with the patient. Use of a multimodal defibrillator in manual mode can help reduce the duration of chest compression interruptions that are required for rhythm analysis when compared to automatic mode. However, this could increase the frequency of inappropriate shocks. Individuals who are not comfortable interpreting cardiac rhythms can and should continue to use an AED. When using an AED, follow the device's prompts or know your device-specific manufacturer's recommendations. It's important that all healthcare providers be knowledgeable of how their defibrillator works, and whenever possible, limit interruptions in chest compressions for rhythm analysis and shock delivery. https://d3imrogdy81qei.cloudfront.net/video_images/4359/pharmacology.jpg Yes 111 https://www.proacls.com/training/video/dopamine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2453.mp4 Dopamine In this lesson, we'll go over the medication dopamine and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we conclude our look at the various access routes for medication delivery. Dopamine is a naturally occurring catecholamine – any of a class of aromatic amines that includes a number of neurotransmitters – that has direct alpha- and beta-adrenergic effects depending on the dose administered. When medium doses are administered, like between 5 and 10 mcg/kg per minute in adult patients, dopamine will act directly on the beta 1 receptors, which causes an increase in both myocardial contractility and heart rate. Pro Tip #1: Contractility is the inherent strength and vigor of the heart's contraction during systole. According to Starling's Law, the heart will eject a greater stroke volume at greater filling pressures. For any filling pressure, the stroke volume will be greater if the contractility of the heart is greater. When dopamine is administered in doses greater than 10 mcg/kg per minute, the alpha receptors are typically stimulated. This causes an increase in systemic vascular resistance, also known as vasoconstriction. Dopamine Indications Now let's take a look at dopamine indications. Dopamine can be quite effective in treating hypotension when there are signs and symptoms that the patient is in shock and is usually used as a second-line drug for symptomatic bradycardia after atropine. Dopamine Precautions and Contraindications Dopamine has a couple precautions and contraindications to be aware of. Pro Tip #2: Dopamine can cause tachyarrhythmias and, as already mentioned, excessive vasoconstriction, which means that it should be used with caution in any patients who are suffering from cardiogenic shock with associated symptoms of congestive heart failure. Warning: It's vitally important to correct hypovolemia with volume replacement before initiating dopamine therapy. Adult Dosage of Dopamine Now let's look at the adult dosage of dopamine. The adult dosage of dopamine should be administered via IV and the most common infusion rate is between 5 and 20 mcg/kg per minute. You want to be sure to titrate the dosage and drip rate to the patient's response slowly and carefully. A Word About the Routes of Access for Drugs In the last Word, we looked at the priorities of access routes along with some specifics concerning the intravenous route. In this Word section, we'll finish up by looking at both the intraosseous route and the endotracheal route, along with a little information on fluid administration. Intraosseous (IO) Route Medications and fluids administered during resuscitation can be safely and effectively delivered via the IO route if IV access is not available. Important points to remember about IO access are: IO access can be established in all age groups IO access can often be achieved in 30 to 60 seconds The IO route of drug administration is preferred over the endotracheal (ET) route and may also be easier to establish in cardiac arrest patients Any ACLS medication or fluid that is given via IV can also be administered via IO IO cannulation provides access to a non-collapsible marrow venous plexus, which serves as a rapid, safe, and reliable route for the administration of medications, crystalloids, colloids, and blood during resuscitation. This technique uses a rigid needle, preferably a specially designed IO or bone marrow needle from an IO access kit. Endotracheal (ET) Route Both IV and IO routes of medication administration are preferred over the endotracheal route of administration. When considering the administration of medications via the endotracheal route during CPR, it's important to keep these concepts in mind: The optimal dosage of most medications delivered via the endotracheal route is not known The normal dosage of medications administered via the endotracheal route is roughly 2 to 2.5 times the intravenous route CPR will need to be interrupted so the medications don't regurgitate up the endotracheal tube Studies have demonstrated that epinephrine, vasopressin, and lidocaine are absorbed into the circulatory system after administration via the endotracheal route. When administering medications via the endotracheal route, dilute the dose in 5 to 10 ml of normal saline or sterile water, then inject the medications directly into the endotracheal tube. Fluid Administration It's important that healthcare providers titrate fluid administration and vasoactive or inotropic agents as needed to properly optimize blood pressure, cardiac output, and systemic perfusion. The optimal post-cardiac arrest blood pressure isn't known. However, a mean arterial pressure of 65 mm Hg or greater is a reasonable goal. In hypovolemic patients, the ECF volume is typically restored with normal saline or lactated Ringer's solution. Avoid D5W because it will reduce serum sodium too quickly. Serum electrolytes should be appropriately monitored. D5W refers to 5 percent Dextrose in Water (also known as D5). It's an isotonic carbohydrate solution that contains glucose as the solute. When it's used, the glucose is quickly absorbed by the cells and utilized for energy, leaving only water behind, which is then a hypotonic solution. https://d3imrogdy81qei.cloudfront.net/video_images/4371/dopamine.jpg Yes 109 https://www.proacls.com/training/video/atrial-fibrillation-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2465.mp4 Atrial Fibrillation Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure, and other heart-related complications. In this lesson, we'll look at the three types of atrial fibrillation and then look at a typical ECG readout for an adult patient in AFib and provide a cardiac interpretation. And at the end of the lesson, we'll look at some common causes and side effects of AFib in adult patients. The Three Types of Atrial Fibrillation 1. Paroxysmal Paroxysmal, or transient atrial fibrillation, is defined by the following: Episodes that stop on their own Episodes that last anywhere from seconds to minutes, hours, or even up to one week 2. Persistent Persistent atrial fibrillation is defined by the following: Episodes that last longer than one week Episodes that last less than one week but are only stopped using either pharmacological intervention or electrical cardioversion 3. Long-Standing Persistent Long-standing persistent atrial fibrillation, formerly known as chronic or permanent atrial fibrillation, is defined as episodes that last longer than a year. Atrial fibrillation occurs when multiple electrical impulses are being generated in the atria and at the same time, which causes chaotic myocardia responses. AFib can diminish the preload and effectiveness of the cardiac contractions. This action could then cause the development of microemboli due to stagnant blood flow from the atria. In certain instances, this will even lead to a rapid ventricular response that's secondary to a reentry problem. Pro Tip: The electrical pattern on an ECG will have no discernible P-waves, but instead, will show fibrillatory waves between each QRS complex. And because there's a lack of coordinated electrical impulses generated from the atria traveling through the AV node into the ventricles, the result is usually an irregular ventricular response, which also occurs irregularly. Now let's take a look at an ECG for an adult patient in atrial fibrillation. *Atrial Fibrillation ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is irregular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's 80 beats per minute, which is within normal range, but it's also variable because of its irregularity. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No! Do they occur regularly? The answer is obviously no again. Is there one P-wave for each QRS complex? No. Are the P-waves smooth, rounded, and upright? No, only fibrillatory waves are present. Do all the P-waves have a similar shape? Again, that answer is no, because they aren't present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, it is within the normal range. Is the QRS complex wide or narrow? In this case, it's narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in atrial fibrillation. We have an irregular rhythm. We have a rate that is 80 beats per minute but also variable/irregular. The P-waves are missing. There is no PR interval. The QRS is less than .12 seconds and thus normal. Common Causes and Side Effects of AFib in Adult Patients The causes of AFib are numerous, but some common underlying reasons for it are: Congestive heart failure Previous history of damage to the SA node Conductive system dysfunction, from either current or past myocardial infarction A traumatic injury An underlying disease Past or present use of harmful drugs A metabolic disorder Common side effects of AFib include but aren't limited to: A higher risk for coronary, cerebral, or pulmonary embolism and as a result of the increased potential for microemboli to develop, secondary to the lack of circulation of blood from the atria. Rapid ventricular response which can accelerate the ventricular rate to above 100 beats per minute. AFib combined with higher ventricular rates may decrease the amount of blood ejected from the heart due to the lack of, what is sometimes referred to as, the preloading atrial kick. https://d3imrogdy81qei.cloudfront.net/video_images/4393/atrial-fibrillation-acls.jpg Yes 281 https://www.proacls.com/training/video/atrial-flutter https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2466.mp4 Atrial Flutter Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate. In this lesson, we'll look at why/how atrial flutter occurs, and then look at a typical ECG readout for an adult patient in atrial flutter and provide a cardiac interpretation at the end. On an ECG, atrial flutter typically includes sawtooth-like F-waves, which are either the result of an ectopic atrial pacemaker or because of rapid reentry pathways somewhere within the atria, but outside of the SA node. The origin of this ectopic pacemaker is usually somewhere in the lower atrium and closer to the AV node, thereby resulting in that distinct sawtooth wave pattern. Pro Tip #1: Due to this erratic electrical activity, the normal function of the SA node is usually suppressed and noneffective. Which is why, instead of a P-wave, atrial flutter will produce flutter, or F-waves. And as a result of the depolarization of the atria in an abnormal manner, the classic F-waves of atrial flutter resemble a sawtooth, hence the name. Now let's take a look at an ECG for an adult patient in atrial flutter. *Atrial Flutter ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is variable and dependent on the ratio of F-waves to the QRS complexes. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's variable due to its irregularity. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present, and do they resemble normal P-waves or just those sawtooth type of F-waves? Since the answer is, they resemble sawtooth style F-waves, all of the other P-wave questions you normally ask yourself do not apply, once you notice the F-wave flutter. There are no real SA node P-waves present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because it's variable and there are no P-waves. Is the PR interval constant? Again, this is non-applicable because of the above answer. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, it is within the normal range. Is the QRS complex wide or narrow? In this case, it's narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in atrial flutter. We have a variable rhythm that is dependent on the ratio of F-waves to the QRS complexes. We have a variable heart rate due to its irregularity. The P-waves are not normal and resemble sawtooth style F-waves. The PR interval is variable and there are no normal P-waves. The QRS is less than .12 seconds and thus normal. From the ECG alone, it would indicate that the patient is in atrial flutter Pro Tip #2: Structural heart disease is the usual cause of atrial flutter. In the same way that atrial fibrillation complicates adequate ventricular preload filling, atrial flutter complicates circulation and especially when it is accompanied by a syndrome called rapid ventricular rate or response. What is rapid ventricular rate or response? In some cases of AFib, the fibrillation of the atria causes the ventricles, or lower chambers of the heart, to beat too fast. When this happens, it's called a rapid ventricular rate or response, or RVR for short. Pro Tip #3: The faster the ventricular response, the more likely it is that the patient's circulation will be compromised. When the ventricles beat too rapidly, they aren't able to fill completely with blood from the atria. As a result, they can't efficiently pump blood out to meet the needs of the body. This can ultimately lead to heart failure. https://d3imrogdy81qei.cloudfront.net/video_images/4395/atrial-flutter.jpg Yes 178 https://www.proacls.com/training/video/asystole https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2467.mp4 Asystole The term asystole simply refers to an absence of ventricular activity, which means the patient will exhibit no discernible electrical activity on an ECG readout. In most cases, asystole is a lethal arrhythmia and survival is extremely rare. In this lesson, we'll look at an ECG readout for a patient in asystole, tackle those H's and T's and provide some corresponding information about their diagnostic use, and at the end of the lesson, provide some information on asystole and technical problems. Asystole is a cardiac standstill where there is no discernable electrical activity. It Is represented by a straight flat, or almost flat, line on an ECG. Warning: However, do not rely on an ECG alone for your diagnosis of a patient in cardiac arrest. It's a good idea to always confirm it clinically, because what appears to be a flat line on the ECG can also be caused by a loose ECG lead. Now let's take a look at an ECG for a patient in asystole. *Asystole ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, there is no heart rhythm. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, there is no rate and no pulse. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No, making any other questions about QRS non-applicable. However, in some cases, a small P-wave can be seen but it isn't followed by any other waveforms. Pro Tip #1: If you notice these small P-waves on the ECG that aren't followed by any other waveforms, this can mean that, in rare cases, the atrial pacemaker may be trying to send an impulse but has no ventricular reaction. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? No. In fact, there is no evidence of a QRS complex, making any other questions about QRS non-applicable. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in asystole. Because there is no myocardial, electrical, or mechanical activity, there is no pulse and no circulation of blood and oxygen. Pro Tip #2: Asystole is most commonly seen following a period of unconverted ventricular fibrillations or ventricular tachycardia. And while asystole is most commonly seen after extended, untreated, and sudden cardiac arrest, it can also be caused by reversible conditions outlined below. The most common reversible causes of asystole can best be remembered by keeping in mind the H's and T's. H's and T's The following H's and T's are designed to help you identify (and easily remember) potentially reversible causes of cardiac arrest or factors that may be complicating your resuscitative efforts. The H's The T's Hypothermia Toxins Hyper or hypodalemia Tamponade Hypoxia Tension pneumothorax Hydrogen ion (acidosis) Thrombosis (pulmonary) Hypovolemia Thrombosis (coronary) A Word About Asystole and Technical Problems Asystole is a specific diagnosis. However, a flat line is not. The term flat line is nonspecific and can be the result of several possible conditions, including the absence of cardiac electrical activity, lead or other equipment failure, and/or operator error. Some defibrillators and monitors will signal the operator when a lead or other equipment failure occurs. However, some of these problems do not apply to all defibrillators. For a patient with cardiac arrest and asystole, you should quickly rule out any other causes of an isoelectric ECG, such as: Loose leads or those that are not connected to the patient or defibrillator/monitor No power source to the defibrillator/monitor Signal gain (amplitude/signal strength) that is too low https://d3imrogdy81qei.cloudfront.net/video_images/4397/asystole.jpg Yes 106 https://www.proacls.com/training/video/normal-sinus-rhythm https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2464.mp4 Normal Sinus Rhythm When talking about treating a patient for something that we consider abnormal, it's always helpful to define and understand what normal looks like, in this case, for a normal sinus rhythm. In this lesson, we'll look more closely at an example of a normal sinus rhythm on an ECG (aka EKG) for an adult patient and see what findings and measurements are considered normal, and what to be on the lookout for that would be considered abnormal. And at the end of the lesson, we'll provide a Word about acute coronary syndrome. *Normal Sinus Rhythm ECG/EKG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the above graphic, it's regular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? Remember, to determine the patient's heart rate you'll want to observe the following areas on the ECG paper printout and perform the following calculations. The horizontal axis of ECG paper grids is where time is measured. Each small square is 1mm in length and represents .04 seconds. Each larger square is 5mm in length and represents .2 seconds. Therefore a 6 second interval would be 30 large squares. To determine the heart rate, count the number of QRS complexes over this 6 second interval and multiply by 10. In the ECG above, the rate is 80 beats per minute, and this is normal. For an adult patient, the normal heart rate range is 60 to 100 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? Do they occur regularly? Is there one P-wave for each QRS complex? Are the P-waves smooth, rounded, and upright? Do all the P-waves have a similar shape? The answer to each of those questions is, yes, meaning the P-waves are normal. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal for an adult patient, meaning between .12 and .20 seconds, or is it contained within one large square on the readout? Is the PR interval constant? The answer to both questions is, yes. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Pro Tip: As long as the QRS fits within two small squares on the ECG printout and is not greater than three small squares, it's within the normal range. Is the QRS complex wide or narrow? If it's narrow, such as on the ECG printout above, then that's considered normal. Are the QRS complexes similar in appearance or are there noticeable differences? For the above ECG readout, the answer is, they're similar in appearance and thus normal. So, what is your cardiac interpretation? (This is something we'll be asking ourselves each time we look at a new ECG rhythm.) Based on these questions and on the findings from the ECG readout above, it's safe to say that the patient has a normal sinus rhythm. We have a regular rhythm. We have a normal heart rate. The P-waves look normal, with each being followed by a QRS complex. The PR interval is between .12 and .20 seconds. The QRS is less than .12 seconds. Unless the patient has no pulse or other serious signs or symptoms, it's safe to assume that there is nothing of significance, in a negative sense, from this patient's cardiac rhythm. A Word About Acute Coronary Syndrome As an ACLS provider, you should have the basic knowledge to assess and stabilize patients with acute coronary syndrome (ACS). In these cases, you will use the ACS algorithm as your guide to clinical strategy. The initial 12-lead ECG is used in all ACS cases to classify patients into one of three ECG categories. Each of these categories has different strategies of care and management needs. The three ECG categories are ST-segment elevation suggesting ongoing acute injury, ST-segment depression suggesting ischemia, and nondiagnostic or normal ECG. All three are outlined in the ACS Algorithm. Key components of these cases are: Identification, assessment, and triage of acute ischemic chest discomfort Initial treatment of possible ACS Emphasis on early reperfusion of the patient with ACS/STEMI (ST-Elevation Myocardial Infarction) Rhythms for ACS Sudden cardiac death and hypotensive bradyarrhythmias may occur with acute ischemia. You should learn to anticipate these rhythms and be prepared for immediate attempts at defibrillation and administration of medication or electrical therapy for symptomatic bradyarrhythmias. https://d3imrogdy81qei.cloudfront.net/video_images/4391/normal-sinus-rhythm.jpg Yes 183 https://www.proacls.com/training/video/the-cardiac-conduction-system https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2444.mp4 The Cardiac Conduction System In this section of the PALS course, we're going to cover the cardiac conduction system and all of its components, and we'll start with a deep dive into the biomechanical and electromechanical actions of the heart. In this lesson, we'll take a closer look at the heart and how it functions as a circulatory muscle, including the mechanisms that allow it to function. The myocardium is a muscle unlike any other muscle that we have in our bodies. What makes it so unique is its ability to generate its own electrical impulses, known as automaticity. Pro Tip #1: Automaticity is the body's ability to do things without occupying the mind and with low-level details required, allowing it to become an automatic response pattern or habit. One particularly special part of the heart muscle is located in the superior aspect of the right atrium, called the sinoatrial node, or SA node for short. It works like an internal/biological pacemaker. This SA node, when the heart is functioning as it was designed to function, generates an electrical impulse that travels through the myocardium in a very organized and deliberate way. The SA node generates electrical impulses at a rate between 60 and 100 times per minute. If we were to follow the pathway of that electrical impulse from the SA node to the place where it terminates, that place would be at the end of the Purkinje fibers. Pro Tip #2: The Purkinje fibers are specialized conducting fibers composed of electrically excitable cells that are larger than cardiomyocytes with fewer myofibrils and many mitochondria and which cells conduct cardiac action potentials more quickly and efficiently than any other cells in the heart. After the SA node initiates that electrical impulse, it then travels via pathways, known as internodal pathways, throughout the right and left atria. It then depolarizes the myocardia cells which causes the heart muscle in the atrium to contract. From the atria, that electrical impulse travels along the pathway to the atrial ventricular node, or the AV node, where it's strategically delayed before moving through the bundle of His, or AV bundle, and ultimately to the Purkinje fibers. The Purkinje fibers travel down through and around the ventricles, thereby completing the electromechanical cycle of one complete heartbeat. The delay in the AV node, which is located in the left lower wall of the right atrium, is a very necessary process. This delay allows the ventricles to beat independently of one another, which allows them to operate as a double pump action. If for whatever reason, the SA node doesn't operate properly as the primary impulse generator, or our biological pacemaker, the AV node can then begin sending its own electrical impulse instead; providing the heart with a failsafe mechanism or backup electrical generator. While the AV node can generate its own electrical impulses, it does so at a much slower rate, which ranges between 40 and 60 impulses per minute. When the AV node is called upon to generate this electrical impulse, it travels from the AV node through the bundle of His and eventually reaches the Purkinje fibers, which wrap around the ventricles we mentioned earlier, and once again completing the electromechanical cycle of one complete heartbeat. This ventricle contraction then circulates the majority of oxygenated blood throughout the rest of the body. Pro Tip #3: The bundle of His is the bundle of cardiac muscle fibers that conducts the electrical impulses that regulate the heartbeat, from the AV node in the right atrium to the septum between the ventricles, and then to the left and right ventricles. Upon reaching the bundle of His, that electrical impulse then travels down the length of the intraventricular septum, which leads to the left and right bundle branches. The left bundle branch has two fascicles (or bundle of fibers) due to its size, since the left ventricle is larger than the right ventricle, which has only one fascicle. These bundle branches ultimately terminate, or lead into, the Purkinje fibers, which then depolarize the ventricular cells and cause the ventricular muscles to contract. In situations where both the SA and AV nodes aren't able to generate electrical impulses properly, the Purkinje fibers located within the ventricles then become the primary pacemaker source. The problem with this scenario is that the Purkinje fibers only generate electrical impulses in the range of around 15 to 40 beats per minute. This rate is usually too slow to produce adequate systolic blood pressure or oxygenate the cells in the body. https://d3imrogdy81qei.cloudfront.net/video_images/4353/the-cardiac-conduction-system.jpg Yes 235 https://www.proacls.com/training/video/atropine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2451.mp4 Atropine In this lesson, we'll go over the medication atropine and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of this lesson, we provide a Word about the various routes of access for drug administration. Atropine sulfate is an anticholinergic or antiparasympathetic, sometimes referred to as a parasympatholytic drug. A parasympatholytic agent is any substance or activity that has the effect of reducing the activity of the parasympathetic nervous system. Pro Tip #1: An anticholinergic agent is a substance that blocks the action of the neurotransmitter acetylcholine at synapses in the central and the peripheral nervous system. These agents inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The parasympathetic nervous system is often described as the rest and digest part of the autonomic nervous system. Atropine works by blocking this action. The autonomic nervous system is a control system that acts mostly unconsciously as it regulates bodily functions, such as the heart rate, respiratory rate, pupillary response, digestion, urination, and sexual arousal. Atropine Indications Now let's take a look at some indications for atropine. Atropine is one of the few ACLS medications that can be delivered via an endotracheal tube. However, vascular access is still the preferred route and, in most cases, would be the preference. Pro Tip #2: Atropine should be your first choice of treatment of symptomatic sinus bradycardia, as it may be the most beneficial in the presence of atrioventricular nodal blocks. Atropine Precautions and Contraindications There are a couple of precautions and contraindications when it comes to administering atropine. It is well known that atropine use during pulseless electrical activity (PEA) and asystole usually has no therapeutic benefit. Also important to remember, is that atropine most likely will not affect type 2, 2nd degree or 3rd degree AV blocks or blocks in non-modal tissue. Adult Dosage of Atropine Let's take a closer look at the adult dose of atropine. For bradycardia with or without acute coronary syndrome (ACS), administer 1 mg of atropine every 3 to 5 minutes or as needed. And make sure not to exceed a total dose of 0.04mg/kg or a total of 3 mg. Pro Tip #3: It's recommended to use a shorter dosing interval, such as every 3 minutes, and higher doses in severe clinical conditions. For organophosphate poisoning, you may need to use 2 – 4mg of atropine or higher to reverse the life-threatening symptoms of such a poisoning. The good news, as it relates to administering atropine, is that giving the drug via the intraosseous (IO) route has been found to be just as effective as intravenous (IV) infusion for rapid delivery of the drug. Pro Tip #4: Because large amounts of atropine may be required in patients with organophosphate poisoning, reconstitution of powdered atropine may be a viable option, especially when there is a mass casualty setting. Warning: It's also important to remember to utilize your personal protective equipment when treating patients with organophosphate toxicity to reduce and prevent the risk of cross-contamination with other rescuers. A Word About the Routes of Access for Drugs In this Word, we'll look at the priorities of access routes along with some specifics concerning the intravenous route. In the following Word section in the dopamine lesson, we'll finish up by looking at both the intraosseous route and the endotracheal route, along with a little information on fluid administration. Prioritizing Drug Access Routes The obvious priorities during cardiac arrest are high-quality CPR and early defibrillation. While the insertion of an advanced airway and drug administration are of secondary importance. It's important to understand that no drug given during cardiac arrest has been shown to improve survival rates to hospital discharge or improved neurologic function after cardiac arrest. Historically in ACLS, healthcare providers have administered medications via either the IV or endotracheal route. However, endotracheal absorption of medications is poor and unpredictable which makes optimal drug dosing problematic. Because of this, the IV or IO route will always be preferred. Intravenous (IV) Route A peripheral IV will be preferred for medication and fluid administration unless central line access is already available. However, central line access isn't necessary during most resuscitation attempts. Central line access could cause interruptions in CPR and complications during insertion, including vascular laceration, hematomas, and bleeding. Also, insertion of a central line in a non-compressible vessel is a relative, but not absolute, contraindication to fibrinolytic therapy in patients with acute coronary syndrome. Establishing a peripheral line, by contrast, does not require an interruption of CPR. Drugs, however, typically require 1 to 2 minutes to reach the central circulation when administered via the peripheral IV route. If a medication is administered via the peripheral venous route, administer it as follows: Administer the medication by bolus injection unless otherwise specified Follow the drug with a 20 ml bolus of IV fluid Elevate the extremity for about 10 to 20 seconds to facilitate the delivery of the medication into the central circulation https://d3imrogdy81qei.cloudfront.net/video_images/4367/atropine.jpg Yes 162 https://www.proacls.com/training/video/procainamide https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2461.mp4 Procainamide In this lesson, we'll go over the medication procainamide and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we provide you with a Word about wide complex tachycardias. Procainamide is effective at slowing the conduction in the atria, ventricles, and the His-Purkinje system by prolonging the P-R and Q-T intervals and the refractory period of the AV node. Procainamide also slows the refractory period within the atria and ventricles and slows the conduction velocity. Procainamide Indications Now let's take a look at procainamide indications. Procainamide is effective for the treatment of supraventricular tachycardia that returns after vagal maneuvers and adenosine are ineffective. Procainamide is also effective at treating the following: Stable wide complex tachycardia of uncertain origin Stable monomorphic ventricular tachycardia with normal QT intervals Atrial fibrillation with a rapid ventricular rate of response in patients with Wolff Parkinson White syndrome Recurrent ventricular fibrillation Pulseless ventricular tachycardia Procainamide Precautions and Contraindications Warning: it's important that you're aware of any known patient sensitivity to procainamide or similar medications before administering it. Also important to note is that digitalis toxicity may complicate an already existing AV conduction depression. Other procainamide contraindications would include: 3rd degree heart block Preexisting prolongation of the QRS complexes Preexisting prolongation of the QT intervals Pro Tip #1: The use of procainamide should be avoided in patients with prolonged QT intervals and associated congestive heart failure (CHF). Adult Dosage of Procainamide Now let's look at the adult dosage for procainamide. Pro Tip #2: The use of procainamide is limited in ACLS for cardiac arrest due to its requirements of slow infusion, as well as its occasional unknown effectiveness. If you're administering procainamide for recurrent ventricular fibrillation and pulseless V-tach, you should give 20mg per minute via IV infusion up to total max dose of 17mg per kg. For supraventricular tachycardia, atrial fibrillation, and wide complex tachycardia of uncertain origin, administer procainamide at 20mg per minute via IV infusion up to a total maximum dose of 17mg per kg. For maintenance doses of procainamide, administer the drug at 1 to 4mg per minute titrated to the desired effect and the patient response. It's important to note that the use of procainamide should be stopped if any of the following occurs: Arrhythmia suppression The onset of hypotension The QRS complex widens by more than 50 percent of its pretreatment width The maximum dose of 17mg per kg is reached A Word About Wide Complex Tachycardias Since wide complex tachycardias are one instance in which you may administer procainamide, let's take a broader look at it. Wide-complex tachycardias are defined as a QRS of 0.12 seconds or more. The most common types of life threatening wide complex tachycardias that are likely to deteriorate to ventricular fibrillation are: Monomorphic ventricular tachycardia Polymorphic ventricular tachycardia You should determine if the rhythm is regular or irregular: A regular wide complex tachycardia is presumed to be ventricular tachycardia or supraventricular tachycardia with aberrancy. An irregular wide complex tachycardia can be the following:a. Atrial fibrillation with aberrancyb. Pre-excited atrial fibrillation, such as atrial fibrillation using an accessory pathway for antegrade conductionc. Polymorphic ventricular tachycardia/torsade's de pointes These are all advanced rhythms requiring expert consultation. If the rhythm is likely ventricular tachycardia or supraventricular tachycardia in a stable patient, treat the condition based on the algorithm for that rhythm. If the rhythm etiology cannot be determined and is regular in its rate and monomorphic, recent research and evidence suggests that adenosine administered via IV is relatively safe for both treatment and diagnosis. IV antiarrhythmic drugs may be effective. The American Heart Association recommends procainamide, amiodarone, or sotalol. In the case of irregular wide-complex tachycardia, management of the condition should be focused on controlling the rapid ventricular rate, the conversion of hemodynamically unstable atrial fibrillation to sinus rhythm, or both. Again, expert consultation is advised. https://d3imrogdy81qei.cloudfront.net/video_images/4387/procainamide.jpg Yes 181 https://www.proacls.com/training/video/ventricular-fibrillation https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2468.mp4 Ventricular Fibrillation Ventricular fibrillation (also called VFib or VF) is caused by multiple ectopic electrical impulses which depolarize the myocardium in a chaotic fashion. This results in a quivering (or fibrillatory) heart that cannot produce a pulse or adequate cardiac output. In this lesson, we'll dig a little deeper into ventricular fibrillation and then look at a typical ECG readout for a patient in VFib and provide a cardiac interpretation. And at the end of the lesson, we'll provide a preview of the medications we'll be looking at in the following section of your ProACLS course. Now let's take a look at an ECG for a patient in ventricular fibrillation. *Ventricular Fibrillation ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is irregular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's somewhere between 200 and 250 beats per minute and thus, extremely fast. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No. Do they occur regularly? No. Is there one P-wave for each QRS complex? No. Are the P-waves smooth, rounded, and upright? No, only fibrillatory waves are present. Do all the P-waves have a similar shape? Again, that answer is no, because normal P-waves aren't present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? No. In fact, there is no evidence of a QRS complex. Is the QRS complex wide or narrow? Not applicable. Are the QRS complexes similar in appearance or are there noticeable differences? Not applicable, since not present. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in ventricular fibrillation. We have an irregular rhythm. We have no heart rate and no pulse. The P-waves are missing; there are only fibrillatory waves present. There is no PR interval. The QRS is nonexistent. When a patient is in ventricular fibrillation, the heart has no organized rhythm as well as no coordinated contractions. The electrical activity is very chaotic. The heart quivers and it does not pump blood. Therefore, pulses are not palpable. Ventricular fibrillation may be preceded by a brief period of ventricular tachycardia with or without a pulse. Pro Tip: VFib is a non-perfusing and lethal dysrhythmia that is most commonly seen during the first few minutes of cardiac arrest. Because of this, it's important that high-quality CPR be administered as soon as possible, including defibrillation, to increase that patient's chance of a successful resuscitation. A Word About Pharmacology (A Preview) It's important that you know basic information about medications and other interventions used in the ACLS algorithms. A basic understanding of pharmacology information includes the indications, contraindications, and methods of administration for each. You'll also need to know when to use which drug based on each clinical situation. Medications and interventions that we'll be looking at in detail in the upcoming ProACLS course section are: Adenosine Adenosine is a prescription drug used for conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PVST), including that associated with accessory bypass tracts (Wolff-Parkinson-White Syndrome). Adenosine is available under the following different brand names: Adenocard, and Adenoscan. Amiodarone Amiodarone is used to treat certain types of serious (possibly fatal) irregular heartbeat (such as persistent ventricular fibrillation/tachycardia). It is used to restore normal heart rhythm and maintain a regular, steady heartbeat. Amiodarone is known as an anti-arrhythmic drug. It works by blocking certain electrical signals in the heart that can cause an irregular heartbeat. Aspirin Aspirin, also known as acetylsalicylic acid (or ASA), is a medication used to treat pain, fever, or inflammation. Specific inflammatory conditions which aspirin is used to treat include Kawasaki disease, pericarditis, and rheumatic fever. Aspirin can also be given shortly after a heart attack to decrease the risk of death. And it can be used long-term to help prevent future heart attacks, ischemic strokes, and blood clots in people with a higher than normal risk. Atropine Atropine is a medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Dopamine Dopamine is indicated for the correction of hemodynamic imbalances present in the shock syndrome due to myocardial infarction, trauma, endotoxic septicemia, open-heart surgery, renal failure, and chronic cardiac decompensation as in congestive failure. Epinephrine Adrenaline, also known as epinephrine, is a hormone and medication. Adrenaline is normally produced by both the adrenal glands and a small number of neurons in the medulla oblongata where it acts as a neurotransmitter involved in regulating visceral functions. It's used in emergencies to treat very serious allergic reactions to insect stings/bites, foods, drugs, or other substances. Epinephrine acts quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat. Fibrinolytic Agents Thrombolytic drugs, or fibrinolytic agents, are used to help dissolve blood clots. Blood clots can occur in any vascular bed. However, when they occur in coronary, cerebral, or pulmonary vessels, they can be immediately life-threatening. Coronary thrombi are the cause of myocardial infarctions. Cerebrovascular thrombi produce strokes. And pulmonary thromboemboli can lead to respiratory and cardiac failure. Lidocaine Lidocaine is used to relieve nerve pain after shingles (infection with the herpes zoster virus). This type of pain is called post-herpetic neuralgia. Lidocaine helps to reduce sharp/burning/aching pain as well as discomfort caused by skin areas that are overly sensitive to touch. Lidocaine belongs to a class of drugs known as local anesthetics. It works by causing a temporary loss of feeling in the area where you apply the patch. Lidocaine is available under the following different brand names: Lidocaine CV, and Lidopen. Magnesium Sulfate Magnesium sulfate is a naturally occurring mineral used to control low blood levels of magnesium. Magnesium sulfate injection is also used for pediatric acute nephritis and to prevent seizures in severe pre-eclampsia, eclampsia, or toxemia of pregnancy. Magnesium sulfate is available under the following different brand names: MgSO4. Morphine Morphine is a pain medication of the opiate family which is found naturally in a number of plants and animals. It acts directly on the central nervous system to decrease feelings of pain. Morphine can be taken for both acute pain and chronic pain. It's frequently given for pain stemming from myocardial infarction and also during labor. And it can be administered a number of different ways, including by mouth, by injection, intravenously, and rectally. Nitroglycerin Nitroglycerin belongs to the group of medicines called nitrates. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload. Nitroglycerin is often used to prevent angina that's caused by coronary artery disease. And it can be used to relieve an angina attack that's already occurring. Oxygen Oxygen is the odorless gas that is present in the air and necessary to maintain life. Oxygen may be given in a medical setting, either to reduce the volume of other gases in the blood or as a vehicle for delivering anesthetics in gas form. It can be delivered via nasal tubes, an oxygen mask, or an oxygen tent. Patients with lung disease or damage may need to use portable oxygen devices on a temporary or permanent basis. Procainamide Pronestyl (procainamide hydrochloride) is a cardiac antiarrhythmic drug used to help keep the heart beating normally in people with certain heart rhythm disorders of the ventricles (the lower chambers of the heart that allow blood to flow out of the heart). The brand name Pronestyl is discontinued in the U.S. Generic versions may be available. https://d3imrogdy81qei.cloudfront.net/video_images/4399/ventricular-fibrillation.jpg Yes 100 https://www.proacls.com/training/video/amiodarone https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2449.mp4 Amiodarone In this lesson, we'll go over the medication amiodarone and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we give you a Word on rhythm checks after defibrillation. Amiodarone is an effective treatment for a wide variety of atrial and ventricular tachyarrhythmias in pediatric patients. It can prolong AV conduction and ultimately slow the heart rate by elongating the AV refractory period, QRS, and the Q to T intervals. Because amiodarone is an alpha and beta-blocker (while also blocking sodium, potassium, and calcium channels), it is a well-known drug for its multi-channel blocking capabilities. Amiodarone Indications Some indications for the drug amiodarone, as an antiarrhythmic drug, is that it will be used specifically for its broad range of electrophysiological effects. Pro Tip #1: Amiodarone is primarily chosen for ACLS as a first-line antiarrhythmic agent for cardiac arrest because it has shown to be clinically effective and reliable for improving the rate of return of spontaneous circulation (also known as ROSC) and improved ROSC to hospital admission in adults with refractory VFib or pulseless V-tach. Amiodarone may also be considered when VFib and V-tach are unresponsive to: CPR Defibrillation Epinephrine Amiodarone Precautions and Contraindications Now let's look at some amiodarone precautions and contraindications. Warning: With amiodarone, there are multiple complex drug interactions, so care must be taken when using this medication. And do not administer amiodarone with other drugs that prolong the QT interval, such as procainamide. A rapid infusion of amiodarone could lead to hypotension. However, during cardiac arrest, there isn't any blood pressure and therefore the American Heart Association recommendation is still to use an amiodarone rapid IV push for the treatment of antiarrhythmias. It's important to remember that when using multiple doses of amiodarone, which can be cumulative doses of greater than 2.2 grams over a 24-hour period, significant hypotension has been noted in clinical trials. Because the terminal elimination and half-life of amiodarone is so long – having a half-life sometimes lasting as long as 40 days – amiodarone can be a complicated medication to work with and around when treating a patient who has experienced a return of spontaneous circulation. Which means that using amiodarone may eliminate the option of using other medications until it has been effectively eliminated from the body. Adult Dosage of Amiodarone When using amiodarone to treat V-Fib or pulseless V-tach cardiac arrest which is unresponsive to CPR, shock, and vasopressors, a first dose is given at 300 mg via IV or IO push. And a second dose is delivered at half that, or 150 mg, also via IV or IO push. For life-threatening arrhythmias, a maximum accumulated dose is 2.2 grams via IV over a 24-hour period. For patients with a pulse but also suffering from a life-threatening arrhythmia, administer amiodarone via rapid infusion and delivered at 150 mg IV over the first 10 minutes, which equals 15 mg per minute. This dose can be repeated also via rapid infusion every 10 minutes as needed, up to the maximum dose of 2.2 grams in a 24-hour period. When administering amiodarone via slow infusion, deliver the medication at 360 mg IV over a 6-hour period, or 1  mg per minute. A maintenance infusion can be given at 540mg IV over 18 hours, or 0.5 mg per minute. Pro Tip #2: Remember, these infusions should not exceed 2.2 grams over a 24-hour period. And when delivered at this maximum dosage, the effects can last up to 40 days. A Word About the Resumption of CPR and Rhythm Checks Post-Defibrillation Resume CPR After defibrillating an adult patient, you should: Immediately resume CPR, starting with chest compressions Not perform a rhythm check or pulse check at this time unless the patient is beginning to show signs of life or advanced monitoring indicates ROSC Establish IV or IO access The American Heart Association guidelines recommend that healthcare providers tailor the sequence of their rescue actions based on the presumed etiology of the arrest. Also, ACLS providers that are functioning within a high-performance resuscitation team may choose the optimal approach for minimizing interruptions in chest compressions. Examples of optimizing CCF and high-quality CPR are the use of different protocols such as: 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts Compression-only CPR in the first few minutes after the arrest Continuous chest compressions with asynchronous ventilation once every 6 seconds with the use of a bag-mask device A default compression-to-ventilation ratio of 30:2 should be used by healthcare providers with less training or experience or if the 30:2 ratio is your established protocol. Rhythm Checks Conduct a rhythm check after 2 minutes of CPR and be careful to minimize interruptions in chest compressions. Remember, the pause in chest compressions when checking the patient's rhythm should not exceed 10 seconds. If a non-shockable rhythm is present and the rhythm is organized, one of the team members should try to palpate a pulse. And if there is any doubt about the presence of a pulse, immediately resume CPR. Remember to perform a pulse check, ideally during rhythm analysis, only if an organized rhythm is present. If the rhythm is organized and you detect a palpable pulse, proceed to post-cardiac arrest care. If your rhythm check reveals a shockable rhythm, resume chest compressions if indicated while the defibrillator is charging. https://d3imrogdy81qei.cloudfront.net/video_images/4363/amiodarone.jpg Yes 225 https://www.proacls.com/training/video/overview-and-team-roles-and-responsibilities https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2445.mp4 Overview and Team Roles and Responsibilities The complexity of advanced resuscitation requires a systematic and highly organized set of assessments and treatments that: Take place simultaneously and Are performed efficiently and effectively in as little time as possible. In this lesson, you'll learn about how these high-functioning teams operate, including a breakdown of the individual roles and responsibilities for each. As successful resuscitation rates increase, so do the chances that the patient receives the best chance for a positive, long-term outcome. And for a resuscitation attempt to be successful, all parts must be performed correctly by a high-performing team of highly trained, organized, and communicative healthcare professionals. Successful high-performance teams take a lot of work and don't just happen by chance. Each individual in a team must have the expertise to perform his or her job and a high-level mastery of their resuscitation skills. And they have to function as one cohesive unit, which requires a focus on communication within the team dynamic. It doesn't matter if you're a team leader or a supportive team member. All members of a resuscitation team are equal, and each plays a vital role in any team resuscitation scenario. Pro Tip #1: What does matter is your ability to not only understand your role, but also the roles of others on your team. When you know the roles and responsibilities of each team member, you can anticipate what's coming next, which will increase the ability of the team to communicate, improve the efficiency and performance of the resuscitation, and the chances for the patient to have a positive outcome. Now that you understand the importance of understanding the roles and responsibilities of each team member, let's look at some common duties and requirements for each. High-Performing Resuscitation Team Roles The roles of each team member must be carried out in a proficient manner based on the skills of each team member and their scope of expertise and practice. It's vitally important that each member of a resuscitation team: Understands and are clear about their role assignments Are prepared to fulfill their role and responsibilities Have working knowledge regarding algorithms Have had sufficient practice in resuscitation skills Are committed to the success of the ACLS resuscitation There are a total of six team member roles and each are critical to the success of the entire team. Team leader Compressor Airway manager AED/Monitor/Defibrillator IV/IO medications provider Time recorder Now let's look at the roles and responsibilities of each. Team Leader The team leader is required to have a big picture mindset. This includes the following duties: Keep the resuscitation team organized and on track Monitor the team's overall performance and accuracy Back up any other team member when appropriate Train and coach other team members when needed and provide feedback Facilitate all actions and understanding during the code Focus on the comprehensive care of the patient Assign remaining roles to the other team members Make appropriate treatment decisions based on proper diagnosis Every symphony needs a conductor, just as every successful resuscitation team needs a team leader for the group to operate effectively and efficiently. The team leader has a responsibility to ensure that all team members are playing their individual role to the best of their abilities, and this includes doing things the right way at the right times. But perhaps the biggest responsibility of the team leader centers on his or her ability to communicate clearly and effectively and explain to team members the specifics of resuscitation care, such as: Pushing hard and fast in the center of the patient's chest Ensuring the complete chest recoil Minimizing interruptions in chest compressions Avoiding excessive ventilations The team leader assigns the remaining roles to the other team members and makes appropriate treatment decisions based on proper diagnosis and interpretation of the patient's signs and symptoms. The team leader also provides feedback to the team and assumes any team roles that other team members cannot perform or if some team members are not available. Compressor The team member in charge of compressions should know and follow all the latest recommendations and resuscitation guidelines to maximize their role in basic life support. Chest compressions are vital when performing CPR. So vital, in fact, that this team member often rotates with another team member (usually the AED/monitor/defibrillator) to combat fatigue. The best time to switch positions is after five cycles of CPR, or roughly two minutes. However, if you're feeling fatigued, it's better to not wait if the quality of chest compressions has diminished. Airway Manager The airway manager is in charge of all aspects concerning the patient's airway. This includes opening the airway and maintaining it. And using equipment like a bag valve mask or more advanced airway adjuncts as needed. AED/Monitor/Defibrillator As you might have guessed, this team member is in charge of bringing an AED to the scene (unless one is already present) and operating the AED. This team member is also the most likely candidate to share chest compression duties with the compressor. Pro Tip #2: It's important to understand how important high-quality CPR is to the overall resuscitation effort. The compressions must be performed at the right depth and rate. ACLS begins with basic life support, and that begins with high-quality CPR. If BLS isn't effective, the whole resuscitation process will be ineffective as well. IV/IO/Medications Provider This team member is in charge of all vascular duties, including: Initiating vascular access using whatever technique is appropriate Administering medications with accuracy and timeliness as directed by the team leader Providing feedback or advice when appropriate Time Recorder The time recorder is responsible for keeping a rolling record of time for: All specific resuscitation interventions All medications or treatments administered The frequency and duration of any CPR interruptions The time recorder also announces to the team when/if a next treatment or more medication is due. If no one person is available to fill the role of time recorder, the team leader will assign these duties to another team member or handle them herself/himself. https://d3imrogdy81qei.cloudfront.net/video_images/4355/overview-and-team-roles-and-responsibilities.jpg Yes 424 https://www.proacls.com/training/video/epinephrine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2454.mp4 Epinephrine In this lesson, we'll go over the medication epinephrine and all of its effects, including indications, precautions and contraindications, and adult dosages. Epinephrine, also commonly referred to as epi, is a chemical that narrows the blood vessels and opens the airways in the lungs. And it's also commonly known as adrenaline. Adrenaline is a hormone that is secreted mainly by the medulla of the adrenal glands and functions primarily to increase cardiac output and to raise blood glucose levels. Epinephrine is typically released during periods of acute stress and its effects are a built-in defense mechanism and what prepares an individual for either a fight or flight response. For this reason, it's also a primary medication for non-perfusing cardiac arrest in pediatric patients. One common effect of epinephrine is reversing low blood pressure. Epinephrine is a sympathomimetic drug. Sympathomimetic drugs mimic the effects of the sympathetic nervous system and are thus used to increase the heart rate and blood pressure. Drugs in this category are usually the synthetically produced equivalent to what is endogenous (naturally occurring) in the human body. Epinephrine is also a naturally occurring catecholamine. It possesses positive alpha- and beta-adrenergic effects. Its alpha effects result in vasoconstriction, thus increasing the blood pressure. Its selective beta1 effects result in increased heart rate (positive chronotropy) and increased myocardial contractility (positive inotropy). While its selective beta2 effects cause a relaxation of bronchial smooth muscle (bronchodilation). Epinephrine Indications Now let's take a look at epinephrine indications. Epinephrine is used in cardiac arrest arrhythmias such as V-Fib, pulseless V-tach, asystole, and pulseless electrical activity (PEA). Epinephrine can also be used in symptomatic bradycardia and for the treatment of severe hypotension. Epinephrine can be administered after atropine as an alternative to infusing dopamine. It has also been established that epinephrine can be administered when external pacing and atropine fail and when bradycardia causes hypotension. It's safe to administer epinephrine with phosphodiesterase enzyme inhibitors, and it's also an effective treatment for anaphylaxis. Pro Tip #1: It's recommended that epinephrine be combined with large volumes of fluids, corticosteroids, and antihistamines. Epinephrine Precautions and Contraindications Epinephrine has a few precautions and contraindications that we should note. Care should especially be taken when administering epinephrine in cases where raising the patient's blood pressure and increasing their heart rate might cause myocardial ischemia, angina, and increase the demand for myocardial oxygen. Pro Tip #2: It should be noted that high doses of epinephrine do not improve neurological outcomes or survival rates and may actually contribute to post-resuscitation complications like myocardial dysfunction. In healthcare settings, we commonly see high doses of epinephrine treatment with poisoning and drug-induced shock. Adult Dosage of Epinephrine Now let's look at the adult dosage of epinephrine. Warning: Epinephrine is available in two concentrations and it's important to know when to use each, and to pay extra attention to which concentration you're actually using when administering epinephrine to patients. The two available concentrations are 1:1000 and 1:10,000. And for cardiac arrest in adult patients, you should deliver via IV or IO at 1 mg or 10 ml of 1:10,000 every 3 to 5 minutes during resuscitation. Follow each dose of epinephrine with 20 ml of normal saline as a flush. And elevate the patient's arm in which the medication was delivered for 10 to 20 seconds after the dose has been administered. If you encounter a situation where there is no IV or IO access, epinephrine may be delivered via the endotracheal route at 2 to 2.5 mg diluted in 10 ml of normal saline. Pro Tip #3: Higher doses of epinephrine – up to 0.2 mg per kg of body weight may be used for specific indications like beta-blocker or calcium channel blocker overdose. If you're administering epinephrine as a continuous infusion, the initial rate is 0.1 to 0.5 mcg per kg per minute. An example of this would be if you're giving epinephrine to a patient weighing 90 kg, you'd give the patient between 9 and 45 mcg per minute and titrated to a positive patient response. In cases of profound bradycardia or hypotension, deliver 2 to 10mcg per minute of epinephrine titrated to a patient response delivering a drip via an IV infusion. And add 1mg of epinephrine (or 1ml of 1:1000 solution) to a 250ml or 500ml of normal saline. For treatment of anaphylactic shock, an epinephrine concentration of 1:1000 should be given at .01mg per kg of body weight via intermuscular delivery. https://d3imrogdy81qei.cloudfront.net/video_images/4373/epinephrine.jpg Yes 245 https://www.proacls.com/training/video/atrioventricular-blocks https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2586.mp4 Atrioventricular Blocks In this lesson, we're going to look at the four types of atrioventricular blocks, usually called AV heart blocks or AV blocks for short. The four types are: 1st degree heart block 2nd degree heart block 2nd degree type 2 heart block 3rd degree heart block We'll include an example ECG for each, so you can see the differences, while also reading about those differences. 1st Degree AV Heart Block First-degree heart blocks are usually caused by a delayed, inconsistent, and sometimes absent electrical conduction pathway traveling through the AV node and can exhibit the following signs on an ECG readout. *1st Degree AV Heart Block ECG for Patient 1. Rhythm regular 2. Rate normal or slow 3. P-waves present and upright 4. PR interval prolonged, beyond .20 seconds 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio 1:1 There is usually little to no clinical significance with this type of heart block. 2nd Degree AV Heart Block (Mobitz Type 1) Second-degree heart blocks, also known as Mobitz type 1 AV blocks, is commonly caused by: Heart disease affecting the AV node Vagal stimulation that's often associated with difficult bowel movements Coughing fits Certain medications An ECG for a patient with Mobitz type 1 will exhibit the following signs. *2nd Degree (Mobitz type 1) AV Heart Block ECG for Patient 1. Rhythm regularly irregular 2. Rate normal or slow 3. P-waves present and upright 4. PR interval progressively widening 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio 1:1, until the P-wave is blocked Pro Tip #1: The QRS complex will become progressively delayed at the AV node until it completely disappears. When this happens, the ECG will only show a P-wave but no QRS following it. 2nd Degree AV Heart Block (Mobitz Type 2) The third type of heart block is regularly known as a Mobitz type 2 block. It usually occurs when the heart block is below the AV node. A Mobitz type 2 block is usually caused by more advanced heart disease and can also originate from damage below the bundle of His. Because of this, Mobitz type 2 can deteriorate more quickly into a symptomatic dysrhythmia and could eventually become a 3rd-degree heart block. An ECG for a patient with Mobitz type 2 will appear to have intermittent blocks where some P-waves do not have a QRS complex following, and there's typically no elongation of the PR interval. *2nd Degree (Mobitz type 2) AV Heart Block ECG for Patient 1. Rhythm variable, depending on the P:QRS ratio 2. Rate variable, but usually slow 3. P-waves present and upright 4. PR interval between .12 and .20 seconds 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio variable – 2:1, 3:1, 4:1 and greater 3rd Degree AV Heart Block The fourth and last type of heart block is called a 3rd degree complete AV heart block and is the most serious of the four. A 3rd-degree heart block occurs when the electrical conduction is completely blocked between the atria and the ventricles. The exact location of the block can vary, however it's usually around the AV node or lower but will disassociate the SA pacemaker from the AV or bundle of His pacemakers. Pro Tip #2: When this happens, a 3rd degree AV heart block will create an ECG readout that shows regular P-waves, regular QRS waves, but they'll be at different rates that are completely disassociated altogether. An ECG for a patient with a 3rd-degree heart block will exhibit the following signs. *3rd Degree AV Heart Block ECG for Patient 1. Rhythm regular 2. Rate bradycardic and between 20 and 40 beats per minute 3. P-waves present and upright 4. PR interval variable with no set pattern 5. QRS complex greater than .11 seconds 6. P:QRS ratio variable The clinical significance of this type of dysrhythmia is serious. The patient will usually be symptomatic and unstable due to their very slow bradycardic heart rhythm and rate. Pro Tip #3: This type of heart block is preventing any pace that originates from the SA node. Therefore, the ventricular pacemaker will stimulate a pulse rate closer to 20 to 40 beats per minute, which is usually not enough to maintain a stable blood pressure. This is why the ECG readout will usually display wide QRS complexes. Studies have shown that 3rd degree AV heart blocks may be transient or permanent, depending on underlying causes. https://d3imrogdy81qei.cloudfront.net/video_images/4545/atrioventricular-blocks.jpg Yes 287 https://www.proacls.com/training/video/bradycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2583.mp4 Bradycardia There can be many forms of bradycardia. Commonly seen blocks include sinus bradycardia, and for multiple blockages, complete and 3rd-degree heart block. In this lesson, we’ll look more closely at an example of what bradycardia looks like on an ECG for an adult patient and see what findings and measurements lead us to that conclusion. It’s vital to remember that if there are signs of bradycardia, regardless of whatever underlying reasons that are causing the patient to display symptoms related to bradycardia, we must first treat for the bradycardia, as it takes precedent over those underlying causes. *Bradycardia ECG for Adult Patient 1. The Heart Rhythm The first thing you’ll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the above graphic, it’s regular. 2. The Heart Rate Next, you’ll want to look at the heart rate of the patient. What is the patient’s heart rate? Is it normal? Or is it too slow or too fast? In this case, it’s too slow, as the rate is less than 60 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient’s P-waves look normal by asking yourself the following few questions. Are the patient’s P-waves present? In this case, the answer is, yes. Do they occur regularly? The answer is yes again. Is there one P-wave for each QRS complex? Yes, there is. Are the P-waves smooth, rounded, and upright? The answer is again, yes. Do all the P-waves have a similar shape? Yes, they all have a similar shape. 4. PR Interval Next, look at the PR interval on the patient’s ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is yes, it’s between .12 and .20 seconds, consistent, and contained within one large square. Is the PR interval constant? Yes, it is. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, the QRS interval is between .06 and .11 seconds. Remember, as long as the QRS fits within two small squares on the ECG printout and is not greater than three small squares, it’s within the normal range. Is the QRS complex wide or narrow? In this case, it’s narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it’s safe to say that this patient is in sinus bradycardia. We have a regular rhythm. We have a slower than normal heart rate, at less than 60 beats per minute. The P-waves look normal, with each being followed by a QRS complex. The PR interval is between .12 and .20 seconds. The QRS is between .06 and .11 seconds. And the P:QRS ratio is 1:1. Bradycardia in adults can result from many things – from benign causes like aerobic exercise to pathological causes, such as: Structural heart disease Damage to the electrical conduction system (usually related to a past heart attack) Hypoxia Metabolic dysfunction Certain medications Pro Tip: To properly treat an adult patient in bradycardia, it’s important to get a thorough patient history, including a list of medications that the patient is taking, along with any other past medical problems that may have contributed to their bradycardia. Having said that, if the patient is showing symptoms related to their bradycardia, you should begin treating them for it while also asking yourself the following questions: What is the underlying cause of the bradycardia? Is that underlying cause reversible? Additional Bradycardia Information Bradycardia is defined as a slower than normal heart rate. The heart rates of adults at rest is usually between 60 and 100 beats per minute. For adults with bradycardia, their hearts beat fewer than 60 times a minute. Symptomatic Bradycardia Symptomatic bradycardia is defined as a heart rate less than 60 beats per minute that elicits signs and symptoms. However, the heart rate is typically less than 50 beats per minute. Symptomatic bradycardia exists when the following three criteria are present: The heart rate is slow. The patient has symptoms. The symptoms are due to the slow heart rate. https://d3imrogdy81qei.cloudfront.net/video_images/4539/bradycardia.jpg Yes 103 https://www.proacls.com/training/video/pulseless-electrical-activity https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2587.mp4 Pulseless Electrical Activity Pulseless electrical activity, most commonly known as PEA, is a condition where the electrical activity of the heart is not accompanied by a palpable or effective pulse. It's important to find out the potential cause, correct it, and hopefully get a pulse back for that patient. In this lesson, we'll look closer at PEA, outline several possible causes, including an important caveat or warning. And at the end of the lesson, we'll provide an additional Word on pulseless electrical activity. Treatable Causes for PEA It's always important to treat the patient's symptoms, rather than rely on the ECG readout alone. Underlying and treatable causes for PEA include: Pulmonary thrombosis Coronary thrombosis Tension pneumothorax Cardiac tamponade Hypovolemia Hyperkalemia Hypoxia Hydrogen ion (acidosis) Pro Tip: It's important to rule out any and all of the treatable H's and T's as underlying causes for pulseless electrical activity in order to correct the mechanical disassociation that could be causing the cardiac arrest. Warning: The ECG interpretation for a patient exhibiting signs of PEA could be the same as normal sinus rhythm. Which is why treating the patient's symptoms, particularly when it comes to pulseless electrical activity, is so important. Rather than merely reacting to and relying on the rhythms that are being displayed on the ECG monitor. An Additional Word on Pulseless Electrical Activity Pulseless electrical activity (PEA) is not a specific rhythm. Instead it's a term used to describe any organized electrical activity – but not VFib or asystole — on an ECG or cardiac monitor that is associated with no palpable pulses. Pulsations can be detected by an arterial waveform or Doppler study. However, pulses are not palpable. The rate of electrical activity may be slow (which is most common), normal, or fast. Very slow PEA can also be referred to as agonal. When a patient is in PEA, the ECG can display normal or wide QRS complexes, as well as other abnormalities, which include: Low or high-amplitude T-waves Prolonged PR and QT intervals Atrioventricular disassociation Complete heart block Ventricular complexes without P-waves It's important to remember to assess the patient's monitored rhythm and note the rate and width of the QRS complexes. And as mentioned above, PEA can be caused by reversible conditions easily remembered as the H's and T's. Warning: One important takeaway is this: Unless you can quickly identify and treat the cause of PEA, the rhythm will likely deteriorate to asystole. The adult cardiac arrest algorithm is the most important algorithm to know for adult resuscitation. This algorithm outlines all of the assessment and management steps you'll need to know for all pulseless patients who do not initially respond to basic life support interventions, including the first shock from an AED. The algorithm consists of the two pathways for a cardiac arrest: A shockable rhythm, such as VFib or pulseless V-tach A non-shockable rhythm, such as asystole or PEA Common medications used to treat VFib or pulseless V-tach include: Epinephrine Norepinephrine Lidocaine Magnesium sulfate Dopamine Oxygen Other medications, depending on the cause of the V-tach or pulseless V-tach arrest Common medications used to treat asystole and PEA include: Epinephrine Other medications, depending on the cause of the asystole or PEA arrest https://d3imrogdy81qei.cloudfront.net/video_images/4547/pulseless-electrical-activity.jpg Yes 82 https://www.proacls.com/training/video/wide-complex-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2588.mp4 Wide Complex Tachycardia Many wide complex tachycardias originate in the ventricles, but not all. The ones that don't include a bundle branch block, and a ventricular reentry problem, where the ventricles contract too early after a partial repolarization – like a pre-excited tachycardia or Wolff-Parkinson-White (WPW) syndrome. In this lesson, we'll look at monomorphic ventricular tachycardia (including an ECG), polymorphic ventricular tachycardia, or (thankfully) PVT for short (also including an ECG), and pulseless ventricular tachycardia. And at the end of the lesson, we'll provide a Word about treatments based on the type of tachycardia. Monomorphic Ventricular Tachycardia One very common V-tach is called monomorphic ventricular tachycardia, which means that all of the complexes are the same size, direction, and shape. It's usually caused by an ectopic pacemaker located somewhere in the ventricles. An ECG for a patient with monomorphic V-tach will exhibit the following signs. *Monomorphic V-tach ECG for Pediatric Patient 1. Rhythm regular, but could also be slightly irregular 2. Rate between 100 and 200 beats per minute 3. P-waves rarely discernible 4. PR interval not discernible 5. QRS complex greater than .11 seconds, wide and strange-looking 6. P:QRS ratio does not exist The main problem with this type of fast and wide complex tachycardias is that the hemodynamics are unstable. The heart rate is so fast that it inhibits the atrium from prefilling and preloading the ventricles before the next contraction. In these cases, it's important to know whether or not the patient is stable or unstable. Pro Tip #1: If the patient is stable, try to learn more about why the patient could be experiencing this type of arrhythmia. And remember, wide complex V-tach can sometimes be caused by heart disease, electrolyte imbalance (especially potassium) and a Q to T interval prolongation. If the patient is stable, check to see if their rhythm is supraventricular or ventricular in origin. Warning: If the patient is unstable, immediate treatment is vital. Polymorphic Ventricular Tachycardia Poly simply means multiple and describes the origin of electrical foci in the ventricles. In fact, polymorphic V-tach is caused by multiple ventricular foci with the resulting QRS complexes varying in axis, amplitude, and duration. Polymorphic V-tach can also be described as bi-directional V-tach, which is another type of polymorphic V-tach that is commonly associated with digoxin toxicity, commonly known as torsades de pointes. Along with digoxin toxicity, we often see polymorphic V-tach with hypokalemia or hypomagnesemia. An ECG for a patient with polymorphic V-tach will exhibit the following signs. * Polymorphic Ventricular Tachycardia ECG for Pediatric Patient 1. Rhythm irregular 2. Rate between 200 and 250 beats per minute 3. P-waves not discernible 4. PR interval missing 5. QRS complex variable, but greater than .11 seconds, wide and strange 6. P:QRS ratio missing In torsades, it can sometimes appear that the apex of the V-wave changes from top to bottom and back again. And actually, torsades (French in origin) literally translates as a twisting of points. The most important thing to remember with this type, along with monomorphic wide-complex V-tach, is that both can become pulseless V-tach or VFib pretty quickly. Pulseless Ventricular Tachycardia Pro Tip #2: One important thing to remember is that wide complex V-tach can present with or without a pulse and you may even see pulseless V-tach in a cardiac arrest patient. However, in most cases, pulseless V-tach will quickly deteriorate into VFib. Also keep in mind that pulseless V-tach is treated the same as VFib and that recognition of the condition and treatment for it will be vital for a potential positive outcome. Pro Tip #3: An ECG interpretation for pulseless V-tach can be the same for pulsed V-tach. The difference is that the patient is unresponsive, not breathing normally, and has no pulse. A Word About Treatments Based on Type of Tachycardia Distinguish between supraventricular and ventricular rhythms can be difficult. Most wide complex tachycardias are ventricular in origin, particularly if the patient is older or has underlying heart disease. If the patient is pulseless, you should treat the rhythm as VFib and follow the cardiac arrest algorithm. If the patient has a wide complex tachycardia and is also unstable, you should assume it's V-tach until proven wrong. The amount of energy required for cardioversion of V-tach is determined by the following morphologic characteristics. 1. If the patient is unstable but has a pulse with regular, uniform wide complex V-tach, or monomorphic V-tach: Treat with synchronized cardioversion and an initial shock of 100 joules If there is no response to the first shock, it's reasonable to increase the dose in a stepwise fashion 2. Arrhythmias with a polymorphic QRS appearance, or polymorphic V-tach, such as torsades de pointes, will usually not permit synchronization. If the patient has polymorphic V-tach: Treat as VFib with high-energy, unsynchronized shocks, such as defibrillation doses If there is any doubt about whether an unstable patient has monomorphic or polymorphic V-tach, don't delay treatment for further rhythm analysis. Instead, go right into providing high-energy, unsynchronized shocks. https://d3imrogdy81qei.cloudfront.net/video_images/4549/wide-complex-tachycardia.jpg Yes 254 https://www.proacls.com/training/video/lidocaine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2456.mp4 Lidocaine In this lesson, we'll go over the medication lidocaine and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, you'll find a Word about STEMI. Lidocaine works by bringing about negative inotropic (meaning, modifying the force or speed of the contraction of muscles) effects and antiarrhythmic actions in the heart which weaken the force of muscular contractions and can calm erratic and uncoordinated electro myocardial activity. In other words, lidocaine decreases automaticity and suppresses ventricular arrhythmias. Lidocaine Indications Now let's take a look at lidocaine indications. Due to lidocaine's antiarrhythmic properties, the primary use of lidocaine is for cardiac arrest from ventricular fibrillation (VFib) and pulseless ventricular tachycardia. Lidocaine is also an effective medication for treating the following conditions: Stable monomorphic ventricular tachycardia (V-tach) with preserved ventricular function Stable polymorphic V-tach with normal baseline A QT interval and preserved lower ventricular function when ischemia is treated, and electrolyte balance is corrected Stable polymorphic V-tach with baseline and QT interval prolongation when torsade's is suspected Lidocaine Precautions and Contraindications Now let's go over the precautions and contraindications for lidocaine. Lidocaine should not be used a prophylactic treatment in patients with acute myocardial infarction. It has also been suggested that you should reduce the maintenance dose in the presence of impaired liver function or lower ventricular dysfunction. And you should discontinue the infusion immediately if signs of toxicity develop. Lidocaine would be contraindicated if the patient has a known hypersensitivity to lidocaine or its derivatives, such as xylocaine, Novocain (also known as procaine), and similar drugs. And also in patients with sinus bradycardia and atrioventricular blocks. Adult Dosage of Lidocaine Now let's look at the adult dosage of lidocaine. For adult dosages when treating for cardiac arrest from VFib or pulseless V-tach, the initial dose is 1 to 1.5 mg per kg via IV or IO. And remember, lidocaine is one of those drugs that can also be administered via an endotracheal tube. For refractory VFib, an additional 0.5 to 0.75 mg per kg may be given via IV push. This can be repeated after 5 to 10 minutes. And the maximum number of lidocaine doses should not exceed 3 and the total amount should not exceed 3 mg per kg. For perfusing arrhythmias like stable V-tach, wide complex tachycardia, or uncertain type or significant ectopy, doses range from 0.5 to 0.75 mg per kg, up to 1 to 1.5 mg per kg. This can also be repeated at 0.5 to 0.75mg per kg every 5 to 10 minutes, up to that maximum dose of 3 mg per kg. For a maintenance infusion, give 1 to 4 mg per minute equal to 30 to 50 mcg per kg per minute. And remember, a micro drip infusion set is needed in order to deliver the appropriate dose. Pro Tip: A common and simple calculation for mixing a lidocaine drip is this: IV bag amount (usually in ml) × the dose ordered (usually mg per minute) × the drip set (drops per minute) ÷ the drug on hand (usually in mg). This should equal the correct drops per minute you'll need. A Word About STEMI ST-Elevation Myocardial Infarction (STEMI) is a very serious type of heart attack during which one of the heart's major arteries is blocked. Patients with STEMI usually have complete occlusion of an epicardial coronary artery. The mainstay of treatment for STEMI is early reperfusion therapy achieved with primary PCI or fibrinolytics. Reperfusion therapy for STEMI is probably the most important advancement in the treatment of cardiovascular disease in recent years. Early fibrinolytic therapy has been established as the standard of care for patients with STEMI who present within 12 hours after the onset of symptoms with no contraindications. Reperfusion therapy reduces mortality and saves heart muscle – the shorter the time to reperfusion, the greater the benefit. A 47 percent reduction in mortality has been noted when fibrinolytic therapy is provided in the first hour after the onset of symptoms. Delay of Therapy can be Critical It's important that routine consultation with a cardiologist or another physician does not delay the diagnosis and treatment except in equivocal or uncertain cases. Consultation can delay therapy and is associated with an increase in hospital mortality rates. Potential delays during the pivotal in-hospital evaluation period can occur in several key areas: from door to data (ECG), from data to decision, and from decision to drug (or PCI). These four major points of in-hospital therapy – Door, Data, Decision, and Drug – are commonly referred to as the 4 D's. All healthcare providers should focus on minimizing these delays at each of these points. Out-of-hospital transport time accounts for only 5 percent of delays to treatment time, while ED evaluation accounts for between 25 and 33 percent of these delays. In the next lesson – Magnesium Sulfate – we'll continue our Word on STEMI, specifically – early reperfusion therapy. https://d3imrogdy81qei.cloudfront.net/video_images/4377/lidocaine.jpg Yes 210 https://www.proacls.com/training/video/aspirin https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2450.mp4 Aspirin In this lesson, we'll go over the medication aspirin, or ASA, and all of its effects, including indications, precautions and contraindications, and pediatric dosages. At the end of the lesson, you'll find a Word about vasopressors. Aspirin blocks the formation of Thromboxane A2, thus inhibiting the sticking together of platelets and thus also reducing clot formation. The use of aspirin for myocardial infarctions helps reduce the chances of death and also the probability of reinfarction in stroke victims. Aspirin Indications The use of aspirin is indicated in the presence of signs and symptoms of acute coronary syndromes (ACS) such as those patients suffering from: Chest pain Chest pressure Discomfort, like pain radiating into the neck, jaw or down either arm Another reason for administering aspirin is when there are ECG changes that are consistent with acute coronary syndromes. A few examples of this would include, but are not limited to, ST elevation, depression, or T-wave inversion. Aspirin Precautions and Contraindications Now let's look at some aspirin precautions and contraindications. Before administering aspirin, be sure to ask the patient if he or she has any known hypersensitivities like Samter's Triad. This is a serious condition that can lead to a serious reaction when those patients are given aspirin. Pro Tip #1: Samter's Triad is a chronic condition defined by asthma, sinus inflammation with recurring nasal polyps, and aspirin sensitivity. It's also called aspirin-exacerbated respiratory disease (AERD), or ASA triad. You will also need to know, before giving a patient aspirin, if they have any bleeding disorders, like hemophilia, active ulcer disease, or recent gastrointestinal bleeding. Also, take heed of the Pro Tip above and ask the patient if he or she has a severe allergy like anaphylaxis or asthma-related to aspirin, as compared to more moderate sensitivities like sneezing or stuffiness. Adult Dosage of Aspirin A proper adult aspirin dose is 2 to 4 chewable aspirins or 162 to 324 mg of non-enteric coated aspirin as soon as possible following the onset of symptoms. Aspirin suppositories – usually in a 300 mg dosage – are also a safe alternative if the patient has any severe nausea, vomiting, or gastrointestinal disorders. Pro Tip #2: It's important to note, that in order to achieve a rapid therapeutic blood level of aspirin, you should instruct the patient to chew the oral aspirin before swallowing. A Word About Vasopressors While there is evidence that the use of vasopressors favors initial resuscitation with ROSC, research is still lacking on the effect of the routine use of vasopressors at any stage during the management of cardiac arrest on the rates of survival to hospital discharge. Vasopressors Used During Cardiac Arrest Vasopressors optimize cardiac output and blood pressure. The vasopressor used during cardiac arrest is: Epinephrine – 1 mg delivered IV or IO and repeated every 3 to 5 minutes. If IV or IO access cannot be established or for some reason is delayed, instead give epinephrine 2 to 2.5 mg diluted in 5 to 10 ml of sterile water or normal saline and injected directly into the patient's endotracheal tube. It's important to remember that the endotracheal route of drug administration results in variable and unpredictable drug absorption and blood levels. Epinephrine Although healthcare providers have used epinephrine for years during resuscitation, there haven't been many studies conducted to address the question of whether it improves outcomes in human patients. Epinephrine administration improves the return of spontaneous circulation as well as hospital admission rates. However, large studies have not been conducted to evaluate whether survival is actually improved. Because there haven't been any large studies to confirm long-term patient outcomes, we must rely on the positive short-term effects of increased return of spontaneous circulation and the increased hospital admission to support the use of epinephrine in cardiac arrest cases. No studies demonstrate improved rates of survival to hospital discharge or neurologic outcome when comparing standard epinephrine doses with initial high-dose or escalating-dose epinephrine. Therefore, the American Heart Association does not recommend the routine use of high-dose or escalating doses of epinephrine. Epinephrine is believed to: Stimulate adrenergic receptors Produce vasoconstriction Increase blood pressure and heart rate Improve perfusion pressure to the brain and heart Repeat epinephrine doses of 1 mg via IV or IO every 3 to 5 minutes during cardiac arrest. Remember, follow each dose given by peripheral injection with a 20 ml flush of IV fluid and elevate the extremity above the level of the heart for 10 to 20 seconds. https://d3imrogdy81qei.cloudfront.net/video_images/4365/aspirin.jpg Yes 143 https://www.proacls.com/training/video/asystole-case-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2787.mp4 Asystole Case Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – asystole. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 30-year-old female patient who was found unconscious in her office by coworkers. Witnesses tell you that she was emotionally distraught and may have had a chronic illness, as well as using different pain pills. By the time you find her, she appears cyanotic and seems to be unresponsive. You direct a member of your team or an assistant to check her responsiveness using taps and shouts and you get no response. You call in a code or ask for additional help depending on your situation and area of practice. Your initial assessment recap: 30-year-old female Found unconscious Appears cyanotic Is unresponsive Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a member of your team to check for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if she's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. CPR is initiated. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign a compressor and a monitor/defibrillator and remind the team that high quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths. You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute. Remember, now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient. In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations. During CPR, the monitor/defibrillator team member is preparing the patient for defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in asystole. You decide to double-check that everything is working by asking yourself and the team the following questions: Are all the leads on correctly? Are all the leads attached to the patient with good contact? Does the ECG have a sufficient power supply? Is the amplitude set correctly to determine asystole vs. fine VFib? All answers point to the patient being in asystole and you instruct your team to continue providing high-quality CPR. While CPR resumes, you prepare the team for medications delivery. Pro Tip #1: Since asystole is not a shockable rhythm, you move immediately to gaining IV (or IO) access via an 18 gauge in the antecubital and call for 1mg of epinephrine 1:10,000 concentration via IV push flushed with 20cc of normal saline – to ensure the medication gets into the patient's central circulatory system. And perhaps most importantly, you instruct your team to continue CPR while the medication is being administered. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. You take a quick look at the monitor to see if there any changes in the patient's rhythm – no longer than 10 seconds – before deciding if you need to deliver a shock or continue with CPR. You tell the team that the patient is still in asystole and to continue with high quality CPR. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the vocal cords and lung sounds are oscillated for ET tube placement accuracy. Pro Tip #2: Both upper lobes and over the stomach are checked to ensure proper placement of the tube – in the trachea and not the esophagus. If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. And it is. You tell your team, CPR quality looks good. Let's make sure to monitor capnography. The recorder calls out, It's been 4 minutes since the first dose of epi. You call for a second dose of epinephrine at 1mg 1:10,000 concentration via IV push followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct. You keep an eye on chest compressions and remember to change compressors every 2 minutes or if you notice fatigue setting in to ensure adequate compressions throughout the code. You tell your team that CPR is looking good or you make suggestions for improvements. At this time, you encourage suggestions from your team as to why this patient may be in asystole. You consider the H's and T's: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia Hyperkalemia Tension pneumothorax Cardiac tamponade Toxins Cardiac thrombosis Coronary thrombosis Pro Tip #3: As a healthcare professional, you never know when a patient will survive against all odds and scientific reasoning. For this reason, you instruct your team to work with enthusiasm and high expectations throughout the resuscitation. However, it's also important to understand that studies have shown that asystole represents what's termed, the final rhythm. In other words, cardiac function and electrical activity have diminished over time until there is no perceivable electrical or mechanical activity in the patient. At which point, the patient, is biologically or permanently dead. Unless there are special circumstances, as provided in the last lesson's Word section, such as hypothermia or drug overdose, a prolonged resuscitation effort beyond 20 minutes is usually futile. As the team leader, you may have to consider stopping resuscitation, especially if the EtCO2 is less than 10 after high quality CPR and all other treatment options have been exhausted. https://d3imrogdy81qei.cloudfront.net/video_images/5035/asystole-case-teaching.jpg Yes 416 https://www.proacls.com/training/video/post-cardiac-arrest-care https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2794.mp4 Post Cardiac Arrest Care There has been substantial research and success in post-resuscitation care and recovery. Because of this, it has become an extremely important part of an aggressive ACLS resuscitation program. In this section of your ProACLS course, we'll be discussing the most current guidelines for achieving the most effective and successful recovery post-resuscitation and return of spontaneous circulation available today. This section will follow the latest recommendations provided by the American Heart Association and has been taken from the latest ECC published protocols. Now let's look at the return of spontaneous circulation (ROSC) and post-cardiac arrest care. Post Cardiac Arrest Programs Every healthcare system should implement a comprehensive and multidisciplinary system of care in a universal and consistent manner for the treatment of post-cardiac arrest patients to assure the very best of outcomes. All post-cardiac arrest programs should address the following: Targeted temperature management (TTM) Hemodynamic and ventilation optimization Immediate coronary reperfusion Percutaneous coronary intervention (PCI) for eligible patients Neurological care and prognostication Cognitive impairments Other structured interventions Post Cardiac Arrest Syndrome Pro Tip #1: It's important to understand that patients who have experienced a return of spontaneous circulation after cardiac arrest, regardless of the setting, have a complex combination of pathophysiological processes that are described as post-cardiac arrest syndrome. Post cardiac arrest syndrome includes the following: Post arrest brain injury Post arrest myocardial dysfunction Systemic ischemia Reperfusion response Persistent, acute, and chronic pathologies that may have participated in the cardiac arrest itself Post-cardiac arrest syndromes play a significant role in patient mortality and should be taken very seriously. Support for Caregivers Post Cardiac Arrest In addition to patient support, caregivers are also vulnerable. They should receive comprehensive discharge planning that includes: Medical and rehabilitative recommendations Return to normal activity expectations Return to work expectations This caregiver support should begin immediately during the patient's initial hospitalization and continue for as long as it's needed. Return to Normal Life Post Cardiac Arrest Returning to normal life after a traumatic event is never an easy thing. And it can be a challenge for both the patient and their primary caregiver. For this reason, a structured assessment should be part of any post-cardiac arrest care plan to assess for: Anxiety Depression Post-traumatic stress Fatigue And again, this assessment should be done for both the cardiac arrest survivor and any of their caregivers. Post Cardiac Arrest Care for Healthcare Providers It's not just the cardiac arrest survivors and their caregivers who need support after a traumatic cardiac arrest event. Both in-hospital and out-of-hospital healthcare providers may also experience emotional or psychological effects after providing care for patients in cardiac arrest. Pro Tip #2: The work of healthcare providers is never easy, and good outcomes are never guaranteed. When a patient dies following a cardiac arrest event, healthcare providers are at their most vulnerable. This is when emotional support is most needed. Following a cardiac arrest event, debriefing and referrals should be offered for follow-up care for emotional support. This should be provided for everyone involved, including lay rescuers, EMS providers, and hospital-based healthcare workers. A team debriefing can also be beneficial to allow for a review of the team's performance and quality improvement. A Word About Post Cardiac Arrest Treatment Providers should ensure an adequate airway and support breathing immediately after ROSC. Unconscious patients usually require an advanced airway for mechanical support of breathing. Providers should also elevate the head of the bed 30 degrees if tolerated by the patient to reduce the incidence of cerebral edema, aspiration, and ventilatory-associated pneumonia. Proper placement of an advanced airway, particularly during patient transport, should be monitored by waveform capnography. The oxygenation of the patient should be monitored continuously with pulse oximetry. While 100 percent oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial oxygen saturation of 92 to 98 percent to avoid potential oxygen toxicity. Hyperventilation is common after cardiac arrest and should be avoided because of the potential for adverse hemodynamic effects. Hyperventilation increases intrathoracic pressure, which decreases preload and lowers cardiac output. The decrease in PaCO2 seen with hyperventilation can also decrease cerebral blood flow directly. Ventilation should be started at 10 per minute and titrated to achieve a PetCO2 of 35 to 40 mmHg or a PaCO2 of 40 to 45 mmHg. Healthcare providers should frequently reassess vital signs and monitor for recurrent cardiac arrhythmias by using continuous ECG monitoring. If the patient is hypotensive, fluid boluses can be administered. If TTM is indicated, cold fluids may be helpful for the initial induction of hypothermia. If the patient's volume status is adequate, infusions of vasoactive agents may be initiated and titrated to achieve a minimum SBP of 90 mmHg or greater or a mean arterial pressure of 65 mmHg or more. Some advocate higher mean arterial pressures to promote cerebral blood flow. Brain injury and cardiovascular instability are the major factors that determine survival after cardiac arrest. Because TTM is currently the only intervention demonstrated to improve neurologic recovery, it should be considered for any patient who is comatose and unresponsive to verbal commands after ROSC. The patient should be transported to a location that reliably provides this therapy in addition to coronary reperfusion and other goal-directed post-arrest care therapies. Clinicians should treat the precipitating cause of cardiac arrest after ROSC and initiate or request studies that will further aid in evaluating the patient. It is essential to identify and treat any cardiac, electrolyte, toxicologic, pulmonary, and neurologic precipitants of the arrest. Overall, the most common cause of cardiac arrest is cardiovascular disease and associated coronary ischemia. Therefore, a 12-lead ECG should be obtained as quickly as possible to detect ST elevation or LBBB. Coronary angiography should be performed emergently for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG. When there is a high suspicion of AMI, local protocols for the treatment of AMI and coronary reperfusion should be activated. Coronary angiography, if indicated, can be beneficial in post-cardiac arrest patients regardless of whether they are awake or comatose. Even in the absence of ST elevation, emergent coronary angiography is reasonable for patients who are comatose after OHCA of suspected cardiac origin. Concurrent PCI and TTM are safe, with good outcomes reported for some comatose patients who have undergone PCI. Critical care facilities that treat patients after cardiac arrest should use a comprehensive care plan that includes acute cardiovascular interventions, use of TTM, standardized medical goal-directed therapies, and advanced neurologic monitoring and care. Neurologic prognosis may be difficult to determine during the first 72 hours after resuscitation. This should be the earliest time to prognosticate a poor neurologic outcome in patients not treated with TTM. For those treated with TTM, providers should wait 72 hours after the patient returns to normothermia before prognosticating by using clinical examination where sedation or paralysis can be a confounder. Many initially comatose survivors of cardiac arrest have the potential for a full recovery. For this reason, it's important to place patients in a hospital critical care unit where expert care and neurologic evaluation can be performed and where appropriate testing to aid prognosis can also be performed promptly. https://d3imrogdy81qei.cloudfront.net/video_images/4997/post-cardiac-arrest-care.jpg Yes 182 https://www.proacls.com/training/video/optimization-of-cardiopulmonary-function https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2795.mp4 Optimization of Cardiopulmonary Function In this lesson, we're going to cover post cardiac arrest interventions, such as targeted temperature management, hemodynamic and ventilation optimization, immediate coronary reperfusion with PCI, glycemic control, and neurologic care and prognostication. Targeted Temperature Management According to the latest national guidelines update for CPR and ECC, it is recommended that targeted temperature management interventions, also known as TTM, be administered to comatose adult patients with ROSC after cardiac arrest by selecting and maintaining a constant temperature somewhere between 32 and 36 degrees Celsius, or 89.6 to 95.2 degrees Fahrenheit, for at least 24 hours. Comatose is technically defined as lacking meaningful response to verbal commands. Hemodynamic and Ventilation Optimization Hemodynamic and ventilation optimization is the next intervention in post arrest care. Pro Tip #1: Although ACLS providers often use 100 percent oxygen while performing their initial resuscitation, you should titrate inspired oxygen during post cardiac arrest care to the lowest level required to achieve arterial oxygen saturation of 92 to 98 percent whenever possible. Doing so may help prevent any potential complications associated with oxygen therapy. Warning: Remember, excessive ventilations with high oxygen levels can have adverse hemodynamic effects, especially when intrathoracic pressures increase and because of a potential decrease in cerebral blood flow when partial pressure of carbon dioxide (PaCO2) in arterial blood decreases. It's important that healthcare providers start ventilation rates at 10 per minute. The goal is to achieve normocarbia – a partial pressure of end-tidal carbon dioxide (PetCO2) of 30 to 40 mmHg or a PaCO2 of 35 to 45 mmHg. This is a reasonable goal unless patient factors prompt more individualized treatments. Other PaCO2 targets may be tolerated for specific patients. An example of this would be when a higher PaCO2 may be more appropriate in a patient with an acute lung injury or high airway pressures. Likewise, mild hypercapnia might be a beneficial treatment as a temporary measure when treating cerebral edema. But hyperventilation could cause cerebra vasoconstriction. Pro Tip #2: Health care providers should note that when a patient's temperature is below normal, laboratory values reported for PaCO2 might be higher than actual values. In addition, healthcare professionals should titrate fluid administration in vasoactive or inotropic agents as needed to optimize blood pressure, cardiac output, and systemic perfusion. While optimal post cardiac arrest blood pressure remains unknown, a mean arterial pressure of 65 mmHg or greater is a reasonable goal per scientific studies and current guidelines. Immediate Coronary Reperfusion with PCI When treating for a return of spontaneous circulation in patients where coronary artery occlusion is suspected, rescuers should transport patients to a capable and reliable facility known for providing coronary reperfusion and other goal-directed post cardiac arrest care therapies. The decision to perform percutaneous coronary intervention (PCI) can be made irrespective of coma or a decision to induce hypothermia, because concurrent PCI and hypothermia are feasible and safe and have reported good outcomes. Glycemic Control Altering glucose concentration within a lower range of 80 to 110 mg/dL should not be attempted because of the increased risk of hypoglycemia. The latest guidelines update for CPR and ECC does not have a recommended specific target range of glucose management in adult patients with a return of spontaneous circulation after cardiac arrest. Neurologic Care and Prognostication The American Heart Association guidelines have established the following: the goal of post cardiac arrest management is to return the patient to their prearrest function levels. Reliable early prognostication on neurological outcome is an essential component of post cardiac arrest care. However, optimal timing is important to consider. In patients treated with TTM, prognostication using clinical examinations should be delayed for at least 72 hours after the return of normothermia. For those patients not treated with TTM, the earliest time is 72 hours after cardiac arrest and potentially longer if the residual effects of sedation or paralysis confounds the clinical examination. https://d3imrogdy81qei.cloudfront.net/video_images/5001/optimization-of-cardiopulmonary-function.jpg Yes 298 https://www.proacls.com/training/video/acls-secondary-survey-overview https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2774.mp4 ACLS Secondary Survey Overview In this lesson, we'll get into some details on performing a secondary assessment for ACLS healthcare providers. And at the end of the lesson, we'll discuss some common questions, with answers, you may encounter during the assessment phase. Performing a secondary assessment overview in ACLS is different than performing a primary assessment in ACLS. And it's significantly different than performing a primary assessment in basic life support situations. In a nutshell, a secondary assessment ACLS overview is the process of differentiating between two or more conditions that share similar signs and symptoms. This includes a focused medical history, as well as thoroughly searching through the H's and T's for any intriguing underlying causes that may have contributed to the patient's condition. Pro Tip: Gathering a focused medical, and non-medical, history of the patient is highly recommended during the secondary survey. Ask yourself specific questions that are related to that history as well as the patient's presentation. To this end, use the following acronym and memory aide during your evaluations – SAMPLE. S - What are the patient's Signs and Symptoms?A - Does the patients have any Allergies?M - Is the patient taking any Medications, including the last dose?P - Is there anything in the patient's Past medical history that could be related?L - What was the Last meal that the patient consumed?E - What Events may have led to the patient's current condition? The answers to the above questions during your secondary assessment may help lead you to a correct and informed diagnosis and an appropriate course of treatment to help reverse the patient's condition and restore their health. Of particular importance are the H's and T's. To help you discover and treat any underlying causes that may have led to this event, consider the H's and T's to ensure you aren't overlooking any likely or dangerous possibilities. The H's and T's can help create a road map for you as you attempt to find possible diagnoses and the ensuing interventions and treatment options for your patient. The H's and T's are a tried and true reminder that can help you rule out some possibilities and also confirm other possibilities, and it's the focus of the next lesson. Some Helpful Q&A that May Help You During Your Secondary Assessment and Beyond In this section, we'll go over some common questions you may encounter in ACLS and specifically during the assessment phases. What are the most common causes of cardiac arrest? This is where the H's and T's can help you in identifying potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions. The most common causes of cardiac arrest are: H's T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypo/hyperkalemia Thrombosis (pulmonary) Hypothermia Thrombosis (coronary) Should I start CPR if I'm not sure if the patient has a pulse? If you aren't sure about the presence of a pulse, you should still begin cycles of compressions and ventilations. Unnecessary compressions are less harmful than failing to provide compressions if the patient needs them, as delaying or failing to start CPR in a patient without a pulse reduces the chance of their survival. How can I differentiate agonal gasps from normal breathing? As you know, agonal gasps are not considered normal breathing. And they may be present in the first minutes after sudden cardiac arrest. A patient with agonal gasps usually appears to be drawing air in very quickly. The mouth may be open, and the jaw, head, and/or neck will sometimes move with the gasps. Gasps can appear forceful or weak. Some time may pass between each gasp because they usually happen at a slow rate. The sound of the gasp can resemble a snort, snore, or groan. The important thing to remember is that gasping is not normal breathing and, instead, is a sign of cardiac arrest. What are some things to be aware of when trying to minimize CPR interruptions? As an ACLS provider, you must make every effort to minimize any interruptions in chest compressions. When you do have to interrupt compressions, try to limit those interruptions to no longer than 10 seconds, except in extreme circumstances, such as removing the patient from a dangerous environment. When you interrupt chest compressions, blood flow to the brain and heart stops. To this end, try and avoid the following: Prolonged rhythm analysis Frequent or inappropriate pulse checks Taking too long to give breaths to the patient Unnecessarily moving the patient How should I handle patients with DNAR orders? During basic life support, primary assessments, and secondary assessments, you should be aware of the reasons to stop or withhold resuscitative efforts, such as: Rigor mortis has set in Indicators of do-not-attempt-resuscitation (DNAR) status, like discovering a bracelet, anklet, or written documentation There is a threat to the safety of providers Out-of-hospital providers need to be aware of EMS-specific policies and protocols applicable to these situations. In-hospital providers and high-performance teams should be aware of any directives or specific limits to resuscitation attempts that are in place. For instance, some patients may consent to CPR and defibrillation but not to intubation or invasive procedures. Many hospitals will record this in the medical record. https://d3imrogdy81qei.cloudfront.net/video_images/5007/acls-secondary-survey-overview.jpg Yes 105 https://www.proacls.com/training/video/what-is-pulseless-arrest-v-fib https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2782.mp4 What is Pulseless Arrest V-fib? In this lesson, we're going to cover pulseless arrest and ventricular fibrillation. And at the end of the lesson, we'll provide you with a Word about cardiac arrest rhythms in general. Ventricular fibrillation, also known as VFib, and pulseless ventricular tachycardia, also known as V-tach, are lethal dysrhythmias that do not produce a pulse. VFib is the most common initial dysrhythmia in cardiac arrest patients and will regress to asystole if it isn't treated in a short amount of time. That treatment includes rapid defibrillation. Warning: Rapid defibrillation is vital. How vital? For every single minute that defibrillation is delayed, the chance of the patient surviving is reduced by a full 10 percent. The key steps to treating VFib are as follows: Rapid assessment to confirm the patient's cardiac arrest Starting CPR Applying the defibrillator Delivering the first shock Performing high quality CPR Performing high-quality CPR is equally vital, as is performing it with as few interruptions as possible. High-quality CPR is performed by giving cycles of compressions at a depth of 2 to 2.4 inches and at a rate of 100 to 120 compressions per minute, followed by 2 full rescue breaths that cause the chest to rise and fall. Pro Tip #1: Equally important is changing the CPR compressor, if available, every 2 minutes to avoid fatigue. Compressor fatigue leads to a shallower compression depth and a slower than optimal rate, both of which significantly and detrimentally affect the quality of CPR being performed. After the initial defibrillator shock has been delivered, it's important to then establish IV or IO access in order to deliver medications and fluids. The first medication that should be administered is epinephrine (or epi for short) at 1mg of the 1:10,000 concentration via rapid IV or IO push every 3 to 5 minutes. After that initial dose of epi is delivered, a second shock is then given. At this point you should also consider placing an advanced airway with capnography. Pro Tip #2: Remember that once an advanced airway is in place, your CPR compressions then become continuous. The compressions are still 100 to 120 per minute, along with the same depth, but you'll now deliver 1 breath every 6 seconds. If the patient remains in persistent VFib following the initial defibrillator shock and the first dose of epi, the next medication to be given is amiodarone at 300mg via rapid IV or IO push. A second dose of amiodarone can be given at 150mg. This dose can only be repeated one time after 3 to 5 minutes. Successful treatment of VFib continues by: Providing high-quality CPR Reassessing the patient's cardiac rhythm every 2 minutes Delivering a defibrillator shock if the VFib remains present And giving medications as indicated. A Word About Cardiac Arrest Rhythms This Word section covers the dysrhythmias that do not produce a palpable pulse, which leads to cardiac arrest. It is crucial to recognize and treat these rhythms as quickly as possible to improve the patient's chances of survival. Ventricular Fibrillation and Pulseless Ventricular Tachycardia The origin of ventricular fibrillation is due to multiple ectopic ventricular pacemakers, which depolarize in a random and chaotic fashion and spread throughout the myocardium. This results in uncontrolled myocardial quivering, or fibrillating, and does not produce cardiac output or a pulse. Ventricular fibrillation is clinically significant because it is a lethal dysrhythmia and, as mentioned already above, is the most common initial rhythm in sudden cardiac arrest for adult patients, and often occurring in public places or non-hospital settings. As you've already learned, immediate defibrillation is vital when it comes to managing ventricular fibrillation. Ventricular fibrillation of relatively large amplitude is often initially seen but becomes less coarse and less responsive to defibrillation as minutes pass. Myocardial ischemia or infarction and sudden cardiac rhythm disturbances are the most common causes of ventricular fibrillation in adults. Ventricular tachycardia (V-tach), can present with or without a pulse. Pulseless V-tach can occur in patients with cardiac arrest. While not as often as ventricular fibrillation, ventricular tachycardia can be witnessed as the first rhythm in cardiac arrest before it deteriorates further into ventricular fibrillation. Pulseless V-tach treatment is the same as ventricular fibrillation, as both require immediate defibrillation. Asystole The term asystole in cardiac arrest refers to ventricular asystole. Often, if you were to look at the monitor closely, you'll notice that there are still P-waves and atrial depolarization but no conduction to the ventricles. This results in a total absence of mechanical activity in the myocardium. For obvious reasons, ventricular asystole does not produce a pulse because the ventricles are not beating. It is usually the result of untreated ventricular fibrillation that will eventually degenerate into fine VFib and ventricular standstill or asystole. Other causes of asystole include severe hypoxia, acidosis, or electrolyte abnormalities. Pulseless Electrical Activity (PEA) PEA is not a particular cardiac rhythm. Rather, it's a condition in which an organized cardiac rhythm is not accompanied by a palpable pulse. PEA can be caused by anything that impedes myocardial mechanical activity or causes profound shock. Treatable causes of PEA include the H's and T's: hypoxia, hydrogen ion (acidosis), hypovolemia, hyperkalemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, pulmonary thrombosis, and coronary thrombosis. https://d3imrogdy81qei.cloudfront.net/video_images/5025/what-is-pulseless-arrest-v-fib.jpg Yes 147 https://www.proacls.com/training/video/acls-adult-cpr https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2814.mp4 Adult CPR Teaching In this lesson, we're going to cover adult CPR, including exactly how to provide care. A patient who is unconscious, not breathing normally, and has no pulse is in cardiac arrest and needs CPR. At the end of the lesson, we'll provide you with a Word on high-quality CPR. CPR is a combination of chest compressions and ventilations that circulates blood and oxygen to the brain and other vital organs for a person whose heart and breathing have stopped. Remember the five links in the Adult Cardiac Chain of Survival: Recognize the cardiac emergency and call 911 Early CPR Early defibrillation Advanced life support Integrated, post-cardiac arrest care How to Provide Care As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive. Are you OK? Can you hear me? If you don't get an initial response, place your hand on the victim's forehead and tap on his or her collarbone. If you still do not get a response, proceed with the following steps. Call 911 and activate EMS or call in a code if you're in a healthcare setting. If there is a bystander nearby, you can ask for their help – calling 911, locating an AED, etc. In the event that you do not know how to proceed, call 911 on your cell phone, put it on speaker, and follow their instructions. Continue to assess the victim's responsiveness and vital signs – signs of breathing normally, signs of a pulse, etc. Check for the carotid pulse, located between the trachea and sternocleidomastoid muscle, in the valley between these two structures. Use the flat parts of your index and middle fingers and press with moderate force in that valley. Spend no more than 10 seconds looking for a pulse. If you've determined at this point that the victim is unresponsive, not breathing normally (as you now know, agonal respiration is not breathing normally and should be considered the same as NO respirations), and has no pulse, continue immediately with CPR. CPR Technique for Adults 1. Locate the area over the heart to begin chest compressions – between the breasts and on the lower third of the sternum.2. Stand or kneel directly over the patient's chest. Lock your elbows and use only your upper body weight to supply the force for the chest compressions, and count as you perform them. Pro Tip #1: Make sure you're directly over the victim's chest to maximize cardiac output, and not off to one side. If you're not directly over the chest, you may not adequately compress the heart. 3. Conduct compressions that go 2-2.4 inches deep (or 1/3 the depth of the victim's chest) and at a rate of between 100 and 120 compressions per minute, which amounts to two compressions per second.4. Perform 30 chest compressions. Pro Tip #2: To maintain a steady rhythm, count out loud while performing chest compressions – one, as you press down, and, as you allow the chest to recoil. When you reach 13, drop the and to maintain a two-syllable cadence on the compressions and not disrupt the rhythm. 5. Grab the rescue mask and seal it over the victim's face and nose.6. Lift the victim's chin and tilt his or her head back slightly.7. Breathe into the rescue mask and wait for the chest to rise and fall before administering the next breath.8. Continue to perform 30 chest compressions to two rescue breaths until help arrives, an AED arrives, or the victim is responding positively and breathing normally. Warning: Once you perform a chest compression, make sure you allow for full recoil of the chest cavity. You want to allow the chest to come all the way back to the neutral position before performing another compression. A Word About High-Quality CPR It's important to understand what constitutes high-quality CPR, as performing CPR correctly will give the victim the best chance of survival. High-Quality CPR Performing chest compressions at a rate of 100-120 per minute Compressing to a depth of at least 2 inches but not exceeding 2.4 Allowing for full recoil after each compression Minimizing pauses in compressions Ventilating adequately – two breaths after 30 compressions, with each breath delivered over one second, and each causing the patient's chest to rise Low-Quality CPR Compressing at a rate slower than 100 per minute or faster than 120 per minute Compressing to a depth of less than two inches or greater than 2.4 inches Leaning on the chest between compressions or performing compressions while not directly over the victim's heart Interrupting compressions for greater than 10 seconds Providing excessive ventilation – too many breaths or breaths with excessive force Warning: Once you begin CPR, it's important not to stop. If you must stop, do so for no more than 10 seconds. Reasons to discontinue CPR include more advanced medical personnel taking over for you, seeing obvious signs of life and the patient breathing normally again, an AED being available and ready to use, or being too exhausted to continue. https://d3imrogdy81qei.cloudfront.net/video_images/4979/acls-adult-cpr.jpg Yes 246 https://www.proacls.com/training/video/overview-of-primary-assessment https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2773.mp4 Overview of Primary Assessment In this lesson, we'll cover the primary patient assessment by thoroughly checking the ABCDE's in ACLS for unconscious patients who are in full arrest that are either cardiac or respiratory in nature. However, all ACLS healthcare providers should conduct a primary assessment after first completing a basic life support assessment. This BLS assessment includes checking for responsiveness with taps and shouts, and if the patient is found to be unresponsive, calling 911 or calling in a code. Also check the patient for breathing and a pulse and defibrillate if necessary. However, for unconscious patients who need a more advanced level of assessment and management, you should conduct a primary assessment first. During your primary assessment, continue to assess and perform all actions appropriately until the patient is transferred to the next level of care. Pro Tip #1: Oftentimes, members of a high-performance team will perform the assessment and actions in ACLS simultaneously. However, if this isn't the case, it's important to remember, per the latest guidelines, to assess the patient first then perform the appropriate actions. Keep in mind, when you get into the scenario-based testing part of this course, it's formatted in a linear fashion to simplify and clarify the vital skills needed to successfully pass the test. However, real-life ACLS codes have many working parts, many of which will happen dynamically and simultaneously to expediate important assessments, treatments, and therapies in order to help save the patient's life. The following is a breakdown of the primary ACLS primary assessment by using the ABCDE method. Airway It's vital to maintain an open airway in an unconscious patient. The ways in which you'll accomplish this include: Head tilt, chin lift Basic airway adjuncts like:• Oropharyngeal Airway (OPA)• Nasopharyngeal Airway (NPA) Advanced healthcare providers can use advanced airways if basic airways are not sufficient or if capnography is vital to a successful resuscitation. The different types of advanced airways include, but are not limited to: Endotracheal tubes Esophageal tracheal tubes Laryngeal tubes Laryngeal masks Pro Tip #2: It's important to weigh the costs vs. the benefits of advanced airway placements if they'll interrupt chest compressions. If a bag valve mask ventilation is adequate, you might want to wait before inserting a more advanced airway until the patient doesn't respond to initial resuscitation attempts with CPR and defibrillation or until ROSC occurs. Also keep in mind that some advanced airway devices, such as laryngeal masks and laryngeal tubes, can be placed while chest compressions continue. It's important to confirm the proper placement of all advanced airways. This can be done by a physical examination of the airway or a quantitative waveform from capnography readings. And CPR should be properly integrated with ventilations after intubating the patient to optimize pulse pressures and oxygenation of vital organs and cells. Pro Tip #3: Because movements from CPR and transportation can alter or dislodge an advanced airway, it's important to use a securing device to hold the advanced airway in place. And remember to monitor airway placement with continuous quantitative waveform capnography. Also, make note of your organization's protocols and operating procedures when using prescribed devices for tube immobilization. Breathing When assessing a patient's breathing, it's important to ask yourself, are ventilations and oxygenation adequate? For arrest patients, administer 100 percent oxygen, once ROSC is achieved, then 92%-98%, but for all other patients, titrate oxygen administration to achieve oxygen saturation of 94 percent or greater by pulse oximetry. And monitor quantitative waveform capnography and oxyhemoglobin saturation. Of course, you should rely on the visual of the patient's chest rising and falling to confirm breath compliance. But quantitative waveform capnography will better help you understand how well CPR and rescue breathing are working to oxygenate the patient and how well that patient is processing that oxygen from a biological perspective. Circulation It's important to assess and reassess the quality of CPR by monitoring the quantitative waveform capnography. And if PETCO2 is less than 10ml of mercury, this may be a sign that you should work to improve CPR quality. Pro Tip #4: If you're able to monitor intra-arterial pressures, and the relaxation phase or diastolic pressure is less than 20 ml of mercury, attempt to improve CPR quality by assessing compression depth, rate, and hand placement. Attach a monitor and defibrillator to check for arrhythmias or cardiac arrest rhythms like: Ventricular fibrillation Pulseless ventricular tachycardia Asystole Pulseless electrical activity Lastly, be sure to provide defibrillation cardioversion as needed. Obtain IV or IO access to deliver adequate fluid replacement, medications, and give appropriate drugs to manage rhythm and blood pressure. And later, check glucose levels, temperature, and incorrect perfusion. Disability When it comes to disability, check the patient for neurologic function and quickly assess for responsiveness, levels of consciousness, and pupil dilation, which may indicate brain death or viability, but not in every case. Assess disability using the acronym AVPU: A - Is the patient Alert?V - Does the patient respond to your Voice?P - Does the patient respond to Painful stimulus?U - Is the patient Unresponsive? Exposure Exposure is a reminder for healthcare providers to remove the patient's clothing and perform a good physical examination. While doing so, look for signs of trauma, such as: Bleeding Burns Unusual markings Medical alert bracelets https://d3imrogdy81qei.cloudfront.net/video_images/5005/overview-of-primary-assessment.jpg Yes 409 https://www.proacls.com/training/video/conclusion-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2796.mp4 Conclusion Congratulations on completing your Advanced Life Support course. We hope it was everything you thought it would be … and more. The good news is that you're now ready to take your exam. Remember that muscles that don't get used begin to atrophy. Even those mental muscles. The same goes for the newly acquired skills you've just gained, as they can easily be forgotten if not used or refreshed on a regular basis. Don't let all that important knowledge get flabby. To that end, we have a free weekly video training series delivered via email that you can easily sign up for that will deliver important training right to your inbox in small doses. If you'd like to sign up for this training, you can do so here: Sign Up. Now that you've acquired these all-important life-saving skills, don't let the fear of infectious disease stand in the way of you becoming someone's potential hero. To combat this fear, you can get a keyring CPR shield through ProTrainings that will protect you from disease no matter the situation. And as long as you have your keys with you, you'll be protected. You may be in a situation where you're not required to perform a mannequin skills test and practice. However, if you find out later that your employer does require this, or if you simply think this would be great practice for you (Spoiler Alert: It is!), ProTrainings has you covered with a mannequin solution for your skills practice and training. If you're interested in this mannequin training solution, contact ProTrainings at 616-855-2500 and we'll have one delivered to you at a time that's convenient. Also, for anyone who has taken one of our 100 percent online courses and still requires an evaluation, now or in the future, you can do that with a simple phone call to ProTrainings at any time. Thanks again for choosing ProTrainings as your training resource. But before we sign off, we'd just like you to consider WHY you've chosen this field. Life is a precious thing. It's something that should be appreciated, savored, and celebrated. As a healthcare provider, you have enormous power to help people in need. To give back to them the one resource that is truly extinguishable – time. Time for everything that matters to them. Keep the WHY in you mind as you work every day to help those who need it most. Now, go forth and rescue! https://d3imrogdy81qei.cloudfront.net/video_images/4999/conclusion-acls.jpg Yes 87 https://www.proacls.com/training/video/what-is-pulseless-electrical-activity https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2784.mp4 What is Pulseless Electrical Activity? In this lesson, we're going to cover a type of cardiac arrest known as pulseless electrical activity or PEA for short. At the end of the lesson, we'll provide you with an in-depth Word about the underlying causes of cardiac arrest (and PEA), otherwise known as the H's and T's. PEA is an organized rhythm without a pulse where the electrical activity of the heart may appear normal, but the heart muscle is not responding. What is super unique about PEA is that the heart muscle is completely disassociated from the electrical activity. Pro Tip #1: Any rhythm can deteriorate into PEA. So, it's really important to closely monitor the patient's pulse, blood pressure, and any underlying conditions he or she might have. Remember, performing high-quality CPR is the initial treatment for PEA. In addition to CPR, identifying the underlying causes early, such as the H's and T's, and providing treatment quickly, is the key to reversing most pulseless electrical activity. As mentioned above, some of the more common reversible causes of PEA can be more easily remembered by the H's and T's. The H's and T's PEA is associated with many conditions. As healthcare providers, you should memorize the list of common causes to keep from overlooking an obvious cause of PEA that might be reversed by appropriate treatment. The most common causes of cardiac arrest are presented as H's and T's as indicated below. The H's The T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypokalemia Thrombosis (pulmonary) Hyperkalemia Thrombosis (coronary) Hypothermia     Of the H's and T's, hypovolemia and hypoxia are the two most common underlying and potentially reversible causes of PEA. Which is why it's important to look for evidence of these problems as you assess the patient. In these two cases – hypovolemia and hypoxia – it's vital to recognize the condition early and treat for it quickly with volume replacement and oxygen therapy. Pro Tip #2: Remember, pulseless electrical activity is not a shockable rhythm. Treatment involves high-quality CPR, proper airway management, IV or IO therapy, and the appropriate medication therapy. The primary medication to treat PEA is 1mg of epinephrine 1:10,000 concentration every 3 to 5 minutes via rapid IV or IO push. However, in order to correct PEA, the ultimate goal will always be to identify and treat the underlying cause of the cardiac arrest. A Word About the Underlying Causes of Cardiac Arrest In this Word section, we're going to take a closer look at the H's and T's, since they are so vitally important in treating PEA and other types of cardiac arrest. Hypovolemia Look for: a history of trauma or severe dehydration, flat jugular veins, and ECG is rapid with narrow ORS complexes. Treat with: give a 500ml bolus of normal saline and then reassess. Hypoxia Look for: profound cyanosis, suggestive blood gas readings, and airway problems. Treat with: effective oxygenation and ventilation. Hydrogen ion (acidosis) Look for: a history of diabetes, such as hyperglycemic ketoacidosis, suggestive blood gas readings, bicarbonate-responsive preexisting acidosis, and renal failure. Treat with: effective oxygenation and ventilation first, then consider sodium bicarbonate. Hyperkalemia/hypokalemia Look for: a history of renal failure, recent dialysis, diuretic use, and abnormal ECG findings. Treat with: calcium chloride and sodium bicarbonate for hyperkalemia, and cautious infusion of potassium and magnesium for hypokalemia. Hypothermia (spontaneous or environmental) Look for: a history of recent exposure to cold environment and low core body temperature. Treat with: remove from the cold environment, perform active internal rewarming, and limit defibrillations to one attempt and withhold cardiac medications until the core body temperature is raised above 86°F (30°C). Toxins (intentional/accidental overdose) Look for: a history of ingestion, empty bottles at the scene, abnormal neurologic exam, bradycardia, tachycardia, and a prolonged Q-T interval. Treat with: intubation, activated charcoal, antidotes specific to ingestion (naloxone for narcotics and sodium bicarbonate for tricyclic antidepressants), and hemodialysis for certain agents. Tamponade (cardiac) Look for: a history of thoracic trauma or invasive cancer, pulses not palpable during CPR, and jugular venous distention. Treat with: pericardiocentesis. Tension pneumothorax Look for: a history of thoracic trauma, pulses not palpable during CPR, jugular venous distention, absent breath sounds on the affected side, decreased compliance when ventilating, and contralateral tracheal shift (late) Treat with: needle decompression (thoracentesis) Thrombosis (coronary, ACS) Look for: a history suggestive of acute myocardial infarction (AMI) and ST-segment and T-wave changes Treat with: PCI or fibrinolytics Thrombosis (pulmonary) Look for: a sudden onset of dyspnea and pleuritic chest pain shortly before the arrest, cyanosis that persists despite supplemental oxygen, pulses not palpable during CPR, and jugular venous distention. Treat with: anticoagulation or fibrinolytic therapy. https://d3imrogdy81qei.cloudfront.net/video_images/5029/what-is-pulseless-electrical-activity.jpg Yes 126 https://www.proacls.com/training/video/acls-adult-aed https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2815.mp4 Adult AED Teaching In this lesson, we're going to cover using an AED on an adult patient, including the exact technique and steps you'll use when faced with a cardiac emergency that requires the use of an AED. An AED (Automated External Defibrillator) is a portable electronic device that analyzes the rhythm of the heart and delivers an electrical shock, known as defibrillation, which helps the heart re-establish an effective rhythm. Warning: When using an AED, there are a couple of important things to keep in mind as it relates to your surroundings. Are there combustible gases or liquids at the scene? Are there any liquids that could connect the victim with yourself, the responder, or someone else, that could result in electrocution? Pro Tip #1: If the scene isn't safe enough to use an AED, drag or move the patient to a safer area where you won't have to worry about explosives or electrocution from water and then use the AED. These are two important considerations before using an AED, but there are a few other things to note when defibrillating an adult patient. If the victim is female and wearing an underwire bra, it shouldn't present any complications. However, if it is a concern, you can disconnect it and remove it from the pathway to the heart. Necklaces should be moved to the side Any patches – nicotine, analgesic, nitro gel, etc. – should be removed if they are in the way of the pads Piercings shouldn't cause any problems It's OK if the victim or the victim's clothing is wet, as long as the chest area is dry and you or the victim aren't submerged in water or connected by it There are no special considerations for pregnant women Pro Tip #2: It's OK to be just as aggressive with a pregnant woman as you would any other patient. The primary focus should be on the mother, as saving her will also help save the baby. The care you provide to the mother won't put the baby in any more jeopardy. How to Provide Care As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive. Are you OK? Can you hear me? If you don't get an initial response, place your hand on the victim's forehead and tap on his or her collarbone. If you still do not get a response, proceed with the following steps. Call 911 and activate EMS or call in a code if you're in a healthcare setting. If there is a bystander nearby, you can ask for their help – calling 911, locating an AED, etc. In the event that you do not know how to proceed, call 911 on your cell phone, put it on speaker, and follow their instructions. Continue to assess the victim's responsiveness and vital signs – signs of breathing normally, signs of a pulse, etc. Check for the carotid pulse, located between the trachea and sternocleidomastoid muscle, in the valley between these two structures. Use the flat parts of your index and middle fingers and press with moderate force in that valley. Spend no more than 10 seconds looking for a pulse. If you've determined at this point that the victim is unresponsive, not breathing normally, and has no pulse, continue immediately with your AED. AED Technique for Adults Turn on the AED. Remove the patient's clothing to reveal a bare chest and dry the chest off if it's wet. Attach the AED pads to the patient's chest. The pads should have a diagram on placement if you need a reminder. The first pad goes on the top right side of the chest. The second pad goes on the bottom left side mid axillary, under the left breast. Make sure they adhere well. Plug the cable into the AED and be sure no one is touching the patient, including yourself. The AED should now be charging and analyzing the rhythm of the patient's heart. If the scene is clear and no one is touching the patient, push the flashing shock button. Then go right into CPR. It's OK to perform CPR over the pads, so don't worry about moving them. Stand or kneel directly over the patient's chest. Lock your elbows and use only your upper body weight to supply the force for the chest compressions, and count as you perform them. Conduct compressions that go 2-2.4 inches deep (or 1/3 the depth of the victim's chest) and at a rate of between 100 and 120 compressions per minute, which amounts to two compressions per second. Perform 30 chest compressions. Grab the rescue mask and seal it over the victim's face and nose. Lift the victim's chin and tilt his or her head back. Breathe into the rescue mask and wait for the chest to rise and fall before administering the next breath. After one round of CPR, let the AED analyze the patient again. If the AED advises you to perform another shock, make sure no one is touching the patient and press the shock button. Go right back into CPR. Continue this cycle of CPR, re-analyzation, charging, shock, back into CPR until help arrives, the patient is responsive and breathing normally, or the next level of care takes over. https://d3imrogdy81qei.cloudfront.net/video_images/4981/acls-adult-aed.jpg Yes 356 https://www.proacls.com/training/video/respiratory-arrest-case-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2777.mp4 Respiratory Arrest Case Teaching In this lesson, we're going to take a look at a respiratory case that you could be confronted with at some point in your career. And at the end of the lesson, we'll take a brief look at alternative airway devices. For the purpose of this lesson, we're making you the team leader throughout this entire scenario, a move that will be repeated throughout this section of your ProACLS course. Here's what you know about the scene and situation. You have just come upon a 25-year-old male who appears to be unresponsive. Witnesses tell you that the man was wheezing and having a difficult time breathing. He then collapsed, which is how you find him. Your initial assessment recap: 25-year-old male Appears to be unresponsive Was having a difficult time breathing The patient then collapsed Let's also assume that the scene is safe and all personal protective equipment is available or in use. Pro Tip #1: While we've probably pointed this out before, it's important to remember that before engaging in any advanced life support actions, that you first practice basic life support. Proper Steps for Treating a Patient in Respiratory Arrest 1. The first thing you need to do is verify that the patient is indeed unresponsive. To this end, you (the team leader) direct a team member to use the tap and shout sequence to determine responsiveness. You find the patient to be unresponsive and call in a code team. 2. You direct a team member to check the patient for a pulse and signs of normal breathing. Your team finds that the male patient has a pulse but is not breathing normally. 3. You then direct the team member in charge of airway management to place a basic airway adjunct and begin rescue breathing with a bag valve mask at 15 liters per minute with oxygen. 4. You direct the airway management team member to give 1 breath every 6 seconds. Pro Tip #2: Make sure to look for visible signs of good chest rise and fall to ensure the rescue breaths are effective. 5. You then direct the team member in charge of the defibrillator and monitor to get a set of vitals and attach the ECG monitor to the patient. The vitals the team member gives you are as follows: a. Blood pressure: 100/70b. Pulse rate: 120 and weakc. O2 saturation: 94 percentd. ECG: normal sinus rhythm How do You Proceed with this Information? Since the ECG is showing a normal sinus rhythm, oxygenation is good, and the patient's blood pressure is normal, you continue providing rescue breathing and consider possible causes for the patient's respiratory arrest. In preparation for further treatment, you also decide to place an advanced airway and establish an IV. A Word About Alternative Airway Devices If you find yourself in a situation where endotracheal intubation is unsuccessful, and basic airway management techniques do not provide adequate ventilation, alternative airway devices that allow you to secure a patent airway should be considered. The laryngeal mask airway (LMA) is inserted blindly into the airway while it is guided in place using your middle finger. The mask, when properly seated, will cover the esophagus and facilitate airflow into the lungs. Dual-lumen airway devices, such as the esophageal Combitube, are also acceptable alternatives to intubation. Dual-lumen devices are also blindly advanced into the airway and will come to rest in the esophagus in most situations. Proper verification of its placement is accomplished by ventilating into the tube that produces clear and equal breath sounds and no epigastric sounds. This can also be confirmed with waveform capnography. Other alternative advanced airway devices, such as the King LT, and supraglottic airway devices, such as the LMA and iGel, may also be considered as alternatives to endotracheal intubation. https://d3imrogdy81qei.cloudfront.net/video_images/5015/respiratory-arrest-case-teaching.jpg Yes 115 https://www.proacls.com/training/video/what-is-bradycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2788.mp4 What is Bradycardia? In this lesson, we're going to cover bradycardia, including some things to be aware of when dealing with bradycardic patients, types of bradycardia, and some information on the best courses of treatment to resolve that patient's bradycardia. And at the end of the lesson, we'll dig a little deeper into the types of bradycardia. Absolute bradycardia is defined as a pulse rate less than 60 beats per minute. During your patient assessment, it's important to determine whether any life-threatening signs and symptoms are present that have been caused by that bradycardia. Bradycardia can present itself in several different cardiac rhythms, which include sinus bradycardia and varying degrees of AV heart blocks. Pro Tip #1: Regardless of the patient's rhythm, if their heart rate is too slow and the patient has symptoms from that slow heart rate, bradycardia should be treated to increase the heart rate and improve perfusion. For patients who are asymptomatic, you should continue to provide care with close monitoring and choose which appropriate treatment and care should be given. The primary treatment for symptomatic bradycardia includes the following: 1. Administration of supplemental oxygen if pulse oximetry is below 94 percent and establish IV access.2. Monitor the patient's ECG rhythm.3. Obtain a 12 lead as soon as possible, but don't delay therapy to get it.4. Administration of atropine at 1 mg via rapid IV push to increase the patient's heart rate.5. If atropine is proving to be ineffective, consider transcutaneous pacing. Pro Tip #2: If there are serious signs and symptoms that the patient is unresponsive, the first line of treatment should be transcutaneous pacing rather than atropine. 6. Consider the administration of other medications such as:a. An epinephrine infusion at between 2 to 10 mcg per minuteb. A dopamine infusion at between 5 and 10 mcg per kg per minute Warning: If you are dealing with a conscious patient who needs transcutaneous pacing, you may want to consider sedation first to help alleviate their discomfort. Some patients may present with relative bradycardia when their heart rate is over 60 beats per minute, but they present with a low blood pressure or decreased level of consciousness. In these cases, the same interventions would be required as a patient with absolute bradycardia. An Additional Word About Bradycardia As already mentioned above, bradycardia is defined by a heart rate of less than 60 beats per minute. This can result in a decrease in cardiac output, which may lead to a patient becoming clinically unstable if the patient's heart cannot compensate for the decreased rate by increasing its ability to pump more blood with each heartbeat. Also mentioned above, absolute bradycardia is defined as any heart rate less than 60 beats per minute. While relative bradycardia is a term used to describe a heart rate that is greater than 60 beats per minute but too slow given the patient's condition. For example, the patient may have a heart rate of 70 beats per minute, while also experiencing altered mental status, hypotension, or other signs of hemodynamic compromise. This would be considered a clinically significant bradycardia because the heart rate is not adequate for their clinical condition. Hypoxemia is a common cause of bradycardia. Other causes of bradycardia include medications, structural damage, and metabolic dysfunction, such as electrolyte abnormalities and thyroid disease. The ACLS algorithm is a guideline for the treatment of clinically significant bradycardia. Sinus Bradycardia Sinus bradycardia can result from excess vagal stimulation, which slows SA node discharge. This may result from hypoxia, structural heart disease, damage to the cardiac electrical conduction system, medications, such as beta-blockers and calcium channel blockers, and metabolic dysfunction. The clinical significance of sinus bradycardia is that it can result in decreased cardiac output. ln those patients who routinely engage in aerobic exercise, sinus bradycardia could be a normal finding. Idioventricular Rhythm Idioventricular rhythms occur when a ventricular focus acts as the primary pacemaker for the heart. This is identified by a slow ventricular rate of 20 to 40 beats per minute and a wide and bizarre appearance of the QRS complexes. Because atrial activity is absent, there are no P waves preceding each QRS complex. The clinical significance of idioventricular rhythm is that it can result in decreased cardiac output and poor perfusion. In the absence of atrial contraction, a reduced volume of blood is ejected into the ventricles. In addition, the ventricular rate is slow, which may result in a reduced cardiac output. Heart Blocks As mentioned in the opening of this lesson, bradycardia can present itself in several different cardiac rhythms, which include varying degrees of atrioventricular (AV) heart blocks. AV heart blocks are caused by delayed, inconsistent, or absent electrical conduction through the AV node. These are classified as first degree, second degree (Mobitz type l and II), and third-degree. https://d3imrogdy81qei.cloudfront.net/video_images/5037/what-is-bradycardia.jpg Yes 133 https://www.proacls.com/training/video/what-is-acute-coronary-syndrome https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2778.mp4 What is Acute Coronary Syndrome? In order for you to be a functional ACLS healthcare provider, you must have the basic knowledge and skills to recognize and treat patients with acute coronary syndrome, or ACS for short. In this lesson, along with the next lesson, you'll be learning how to assess and treat the ACS patient following the latest recommendations and guidelines. And at the end of the lesson, we'll provide you with a brief Word on the goals of therapy for patients with acute coronary syndromes, along with EMS and hospital-based components. An initial 12 lead ECG is used as part of the identification process for all ACS cases. The three ECG categories for ACS include the following: ST-segment elevation, which suggests an acute myocardial infarction (or AMI). ST-segment depression, which suggests ischemia Nondiagnostic or normal ECG STEMI (ST-Elevation Myocardial Infarction) will be the focus of this section as it is the most time-sensitive for reperfusion therapies and can also limit the amount and extent of the myocardial damage. Although 12 lead ECG interpretation is beyond the scope of this ACLS provider course, some practitioners who are already ACLS certified will have already been trained in the interpretation and reading of 12 lead ECGs. For those particular healthcare providers, this ACS case summarizes identification and treatment of STEMI patients. Pro Tip: Remember, the main goal of a STEMI acute coronary syndrome is to reperfuse myocardial tissue that is being damaged by the blockage. Reperfusion may involve the use of coronary angiography with a balloon, angioplasty, and angioplasty with a stent, also known as PCI –percutaneous coronary intervention. When PCI is used as the initial reperfusion treatment for STEMI, it's referred to as a primary PCI. Treatments other than primary PCI include, but are not limited to: Oxygen Aspirin or ASA Nitroglycerin sublingual tablet or spray Fibrinolytic therapies Heparin – UHF (Unfractionated Heparin) Heparin – LWMH (Low Molecular Weight Heparin) A Word About the Primary Goals of Therapy for Patients with Acute Coronary Syndromes The primary goals of therapy for patients with acute coronary syndromes (ACS) are to: Reduce the amount of myocardial necrosis that can occur in patients with acute myocardial infarction (AMI), thus preserving left ventricular function, preventing heart failure, and limiting other cardiovascular complications. Prevent major adverse cardiac events, such as death, nonfatal myocardial infarction, and the need for urgent revascularization. Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VFib), pulseless ventricular tachycardia (pVT), unstable tachycardias, symptomatic bradycardias, pulmonary edema, cardiogenic shock, and mechanical complications of acute myocardial infarction. Prompt diagnosis and treatment offers the greatest potential benefit for myocardial salvage. Therefore, it is imperative that all healthcare providers are able to recognize patients with potential acute coronary syndromes in order to initiate evaluation, appropriate treatment, and management as quickly and effectively as possible. EMS Components EMS components include: Prehospital ECGs The notification of the receiving facility of a patient with possible ST-segment elevation myocardial infarction (also known as a “STEMI alert") The activation of the cardiac catheterization team to shorten the reperfusion time Continuous review and quality improvement Hospital-Based Components Hospital-based components include: ED Protocols• Activation of the cardiac catheterization laboratory• Admission to the coronary ICU• Quality assurance, real time feedback, and healthcare provider education Emergency Physician• Empowered to select the most appropriate reperfusion strategy• Empowered to activate the cardiac catheterization team as indicated Hospital Leadership• Must be involved in the process and committed to support rapid access to STEMI reperfusion therapy https://d3imrogdy81qei.cloudfront.net/video_images/5017/what-is-acute-coronary-syndrome.jpg Yes 129 https://www.proacls.com/training/video/what-is-asystole https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2786.mp4 What is Asystole? Asystole, sometimes referred to as a flat line on the monitor, represents an absence of both electrical and mechanical activity in the heart. In this lesson, we'll dig a little deeper into what it is and how it can be treated. And at the end of the lesson, you'll find a Word about the duration of resuscitative efforts. Pro Tip #1: It's important to understand that if a patient has no pulse and this is confirmed in one lead, there are a few things you can double-check to confirm this, such as: Are all the leads on correctly? Are all the leads attached to the patient with good contact? Does the ECG have a sufficient power supply? Is the amplitude set correctly to determine asystole vs. fine VFib? Like pulseless electrical activity (PEA), it's also important to determine what may have caused the patient's asystole, or in other words, examine the H's and T's. If you can figure out why the patient went into cardiac arrest, looking at the H's and T's will help you determine the possibility of treating any reversible causes of the asystole. Those H's and T's are: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia Hyperkalemia Tension pneumothorax Cardiac tamponade Toxins Cardiac thrombosis Coronary thrombosis Pro Tip #2: Asystole is not a shockable rhythm. So, treatment will involve high-quality CPR, airway management, IV or IO therapy, and medication therapy – specifically 1mg of epinephrine 1:10,000 concentration every 3 to 5 minutes via rapid IV or IO push. Having said that, it's rare for asystole to be reversed, especially if the patient has been in asystole for a long duration of time. Stopping resuscitation efforts is never an easy choice to make, and this is a gross understatement. However, if the patient is not responding to all of your basic and advanced cardiac life support treatment attempts, the decision to terminate resuscitation will need to be made. If you have a high degree of certainty that the patient will not respond to further ACLS interventions, then it would be appropriate to stop. When to Terminate Resuscitative Efforts As stated above, this will never be an easy decision. And the decision to do so must be based on your specific protocols and consideration of the following criteria: The time from the patient's collapse to CPR The time from the patient's collapse to your first defibrillation attempt The underlying causes if you've found any The patient's response to your resuscitation measures When the patient's EtCO2 is less than 10 after 20 minutes of CPR All of the above should be considered before deciding to terminate your resuscitation attempts in all patients in asystole. A Word About the Duration of Resuscitative Efforts While we already provided you with a list of criteria above that you can use to make this very difficult decision, let's dig a little deeper into the duration of resuscitative efforts. Deciding to terminate resuscitative efforts can never be as simple as an isolated time interval. If the return of spontaneous circulation of any duration occurs, it may be appropriate to consider extending your resuscitative efforts. Experts have developed clinical rules to assist in decisions to terminate resuscitative efforts for in-hospital and out-of-hospital arrests. However, you should also familiarize yourself with the established policy or protocols for your hospital or EMS system. For Out-of-Hospital Arrest You should consider the continuation of out-of-hospital resuscitative efforts until one of the following occurs: Restoration of effective, spontaneous circulation and ventilation Transfer of care to a senior emergency medical professional The presence of reliable criteria indicating irreversible death You, the rescuer, are unable to continue because of exhaustion or dangerous environmental hazards or because continued resuscitation will place the lives of others in jeopardy A valid DNAR order is presented Online authorization from the medical control physician or by prior medical protocol for the termination of resuscitation It might also be appropriate to consider other issues, such as drug overdose and severe prearrest hypothermia, due to submersion in icy water, for instance, when deciding whether to extend resuscitative efforts. Special resuscitation interventions and prolonged resuscitative efforts might be indicated for patients with hypothermia, drug overdose, or other potentially reversible causes of the arrest. https://d3imrogdy81qei.cloudfront.net/video_images/5033/what-is-asystole.jpg Yes 112 https://www.proacls.com/training/video/what-is-stroke https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2780.mp4 What is Stroke? In this lesson, we're going to look at the major types of stroke of which you should be familiar. But first, the word stroke is a general term that refers to an acute neurological impairment following an interruption in blood supply to a specific area of tissue within the brain. Although immediate stroke care is vital for every patient, the point of this particular lesson is about reperfusion therapy for acute ischemic stroke. There are two major types of stroke: Ischemic stroke – this type of stroke accounts for almost 87 percent of all strokes. It's usually caused by an embolism which occludes an artery and affects the subsequent tissue of the brain that that particular artery affected. Hemorrhagic stroke – this type of stroke accounts for around 13 percent of all strokes. It occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue which causes damage. Warning: In cases of suspected or confirmed hemorrhagic stroke, fibrinolytic therapy is contraindicated, and the use of anticoagulants is to be avoided. Around 795,000 people have a new or recurrent stroke each year in the U.S., which is why stroke remains a leading cause of death in the U.S. Pro Tip #1: It's important to realize that early recognition and treatment of acute ischemic stroke is vital because IV fibrinolytic treatment should be provided as quickly as possible. Over the years, there have been significant improvements in stroke care because of the combined efforts between public education, 911 dispatch, early detection by EMS and triage, systematic hospital stroke protocol, and better overall management of stroke units. There has also been an increase in appropriate fibrinolytic therapies and overall stoke care has definitely improved. In many cases, ACLS providers are well within the scope of being qualified to identify and manage the initial care of patients who are displaying acute stroke symptoms. In stroke cases, it's important to recognize that while an ECG is helpful, it should not take priority over obtaining a computed tomography, known commonly as a CT scan. Pro Tip #2: It's also important to remember that no one arrhythmia is specific for or related to stroke. However, an ECG may help identify some evidence of a recent acute myocardial infarction or an arrhythmia such as atrial fibrillation, which could have caused that embolic stroke. Many stroke patients demonstrate arrhythmias, but if the patient is hemodynamically stable, treatment of such arrhythmias are not usually indicated. It is generally accepted and recommended to initiate and maintain cardiac monitoring during the first 24 hours of observation in patients who have experienced an acute ischemic stroke in order to detect atrial fibrillation and other potentially life-threatening arrhythmias. This is important because the goal of stroke care is to minimize brain injury and maximize recovery. Stroke Chain of Survival The American Heart Association and the American Stroke Association have developed a stroke chain of survival that is similar to the chain of survival for sudden cardiac arrest. The stroke chain of survival correlates actions to be taken by patients, family members, and healthcare providers in order to maximize stroke recovery. The established links in the stroke chain of survival are as follows: Rapid recognition and reaction to the stroke warning signs. Rapid EMS dispatch by calling 911. Rapid EMS system transport and pre-arrival notification to the receiving hospital by the EMTs. Rapid diagnosis and treatment upon arrival to the appropriate hospital. Patients with acute ischemic stroke have what is referred to as time-dependent benefit for fibrinolytic therapies, which is similar to patients with a myocardial infarction that demonstrates ST-segment elevation. However, in stroke cases, this time-dependent benefit is much shorter. Pro Tip #3: It's important to remember that the critical time period for the administration of IV fibrinolytic therapies begins with the onset of symptoms. The critical time periods from hospital arrival are as follows: The immediate general assessment should be within 10 minutes The immediate neurological assessment should be performed within 25 minutes The acquisition of a CT scan (or CAT scan) of the patient's head should be done within 25 minutes The interpretation of the scan should be completed within 45 minutes The administration of fibrinolytic therapies should be within 60 minutes from the time of emergency department arrival The administration of fibrinolytic therapies may be delivered in as much as 3 to 4.5 hours in some select patients timed from the onset of symptoms The administration of endovascular therapy should be within 6 hours in select patients timed from the onset of symptoms The admission to a monitored hospital bed should be within 3 hours https://d3imrogdy81qei.cloudfront.net/video_images/5021/what-is-stroke.jpg Yes 314 https://www.proacls.com/training/video/acls-philosophy https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2772.mp4 ACLS Philosophy Before we get into the depth of the ProACLS course, it's important to go over the philosophies of ACLS, which is the subject of this important lesson. And at the end of the lesson, we'll provide you with a Word about the optimization of ACLS. If you look back 10 or 20 years, ACLS training and certification has changed significantly. Two decades ago, it was more about the technical aspects of acquiring the skills necessary for certification and training. A couple examples of this: If you were learning about intubating a patient, you'd be expected to show or prove that you could actually perform this skill on a dummy or mannequin. You'd have to demonstrate the proper use of the techniques involved. And you'd have to show that you could properly use the appropriate tools to get the job done successfully. If you were learning about starting an IV, you would have been expected to demonstrate that you could actually start an IV on a mannequin. However, these days, it's important to point out that advanced cardiovascular life support training and certification is NOT about the technical aspect of the job or the skills acquisition part of the job. Today, ACLS training is more about learning and understanding all the signs and symptoms of emergent cardiovascular problems that require advanced cardiovascular life support care, in order to help stabilize the patient and possibly save a person's life. Pro Tip #1: So, in a sentence, ACLS training and certification has gone from techniques to greater understanding. Knowing that upfront will serve you well as you progress through your ACLS course. Having said that, though, it's probably fair to assume that not all of you are as polished when it comes to your advanced cardiovascular life support skills as you need to be, or as you want to be. And yet, the situation may exist for some of you where you could be called upon to assume the team leader role in a cardiovascular emergency one day. For this reason, we have built this ACLS certification course, or re-certification for some, so that each of you can pretend at some point to assume those all-important team leader responsibilities and that role in general. In fact, to pass your ProACLS course, you must fulfill the obligations and demonstrate the responsibilities of a team leader. You will be expected to show that you can sufficiently orchestrate and execute a code and perform it as well as can be expected. However, we also understand that in your particular role and organization, you may never be put into that type of position. But since none of us can predict the future, and since these skills can potentially be vital at some point, we encourage you to receive this education and training in the most serious way. Our hope and expectation is that you will practice the different scenarios in a way, regardless of the chances of you being put into one of these positions, in which you can say to yourself – if for some reason I'm ever called upon to be a team leader, I'll have the confidence and understanding of not only the cognitive skills, but also the tactile skills. And ultimately be able to make a difference in a patient's life in a positive way. Which is why we have this challenge for you: If there are any skills that you do not feel comfortable with but maybe one day you'll be called upon to use, take the onus upon yourself. Be the best healthcare professional you can be and seek out the additional education and practice that you need. And sharpen any skills you feel deficient in. Take advantage of this self-paced ACLS training program. And become the best ACLS provider that you can be. After all, you never know when you'll be called upon to execute those life-saving skills. A Word About the Optimization of ACLS CPR is defined as a series of lifesaving actions that can improve the chances of survival after cardiac arrest. And while the optimal approach to CPR can vary, depending on the rescuer, the patient, and whatever resources are available, the fundamental challenge remains how to achieve early and effective CPR. One way to maximize the effectiveness of CPR, and thus improve patient survival rates, is by limiting chest compression interruptions. ACLS is best optimized when a team leader can effectively integrate high-quality CPR with minimal interruptions of high-quality compressions with advanced life support strategies, such as defibrillation, medication therapy, and advanced airways. The importance of minimizing these interruptions in chest compressions cannot be overstated. For instance, studies have shown that reducing the interval between pausing chest compressions and shock delivery can increase the predicted shock success. Which is why interruptions in compressions should only be limited to those critical interventions, such as interruptions for rhythm analysis, shock delivery, intubation, and so forth. And even then, those interruptions should always be minimized to 10 seconds or less. https://d3imrogdy81qei.cloudfront.net/video_images/5003/acls-philosophy.jpg Yes 202 https://www.proacls.com/training/video/acute-coronary-syndrome-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2779.mp4 Acute Coronary Syndrome Teaching In this lesson, we're going to let you play the role of team leader during an acute coronary syndrome emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 55-year-old male who is conscious and alert. As you interview the patient and ask him how he's feeling, you learn that he is responsive, has an open airway, and is suffering from shortness of breath. You also learn that he was watching TV when the symptoms began, which was about 3 hours ago. And he's now complaining of chest pain, pressure in the chest, and is sweating. Your initial assessment recap: 55-year-old male Conscious and alert Shortness of breath Chest pain and pressure Sweating Symptoms began 3 hours previous You know the patient has a pulse and is breathing, so the next step is to check for more in-depth vital signs. As the team leader, you ask another available member of your team to attach a blood pressure cuff and place the patient on an O2 saturation monitor. A more detailed pulse check is taken, and his respiratory rate and temperature check are also assessed. However, even before vital signs are recorded, a first drug may be given to the patient if you suspect a heart attack, and that first drug would be aspirin. If this is the case, first ask the patient if he's allergic to aspirin or has problems with gastrointestinal bleeding. Pro Tip #1: Keep in mind, there's a difference between aspirin sensitivity and having an anaphylactic reaction to aspirin. Also, stomach upset doesn't qualify as gastrointestinal bleeding. If the patient answers yes to either of those two questions above, aspirin may be contraindicated. However, in our fictional scenario, the patient has no aspirin allergy, nor does he have any gastrointestinal bleeding issues. In this case, the correct dose would be somewhere between 160 and 324 mg of chewable aspirin, and in this particular scenario, you administer 324 mg. The team member now has the patient's vital signs and tells you the following: Pulse: 124 beats per minute and regular Respiratory rate: 22 Blood pressure: 140/90 Skin: cool and pale O2 saturation: 92 percent Based on this information, you decide that the patient is stable at the moment. One thing to keep in mind, however, is that the goal for oxygen therapy is to titrate the amount given to achieve at least 94 percent saturation. Pro Tip #2: It's not necessary and even potentially harmful to use high-flow oxygen to bring the O2 saturation higher, as high-flow oxygen therapy can reduce cardiac output and stroke volume, which can cause vasoconstriction at a time when you especially need vasodilation. Also, remember that oxygen is not recommended for an O2 saturation of 94 percent or greater. But since your patient has an O2 saturation of 92 percent, it would be appropriate to begin a low-flow amount of oxygen via nasal cannula between 2 and 4 liters per minute. Now that the patient's basic vital signs are known and oxygen has been established, it's important to get a 12-lead ECG on the patient. This will help you in assessing his need for fibrinolytic therapy. Pro Tip #3: Within the first 10 minutes of contact with a healthcare provider, a 12-lead ECG, a targeted patient history, and a physical exam all need to be done to assess whether or not fibrinolytic therapy is appropriate. When assessing a 12-lead ECG, an ST elevation or depression would create a strong suspicion of injury or ischemia. In this scenario, however, it looks like a normal sinus rhythm. And at this time, it's important to gain IV access to draw blood to send to the lab. A good choice for that would be an 18-gauge IV with normal saline at a TKO rate – a rate that flows just enough to keep the vein open. And since the patient is still complaining of chest pain and his blood pressure is above 90 systolic, nitroglycerin should be administered. Before giving the patient nitroglycerin, it's important to ask him if he's taken any erectile dysfunction drugs or any other medications that would behave in a vasodilatory fashion within the last 24 to 48 hours. If the patient has, nitroglycerin would be contraindicated. If the patient can have nitroglycerin, it would be given in a 0.4mg tablet or spray sublingually, and this can be repeated every 5 minutes for pain as long as his blood pressure remains above 90 systolic. Tell your patient that you're going to give him a tablet of nitroglycerin to be dissolved under his tongue, and that this should help with his pain. Pro Tip #4: Talk to your patient and tell him what to expect. In this situation, you could also mention that the nitroglycerin may cause a little bit of a headache or a tingling sensation under the tongue as normal side effects. It's important to monitor the patient closely and look for changes in his status, such as his level of chest pain and blood pressure, which should be assessed at least every 5 minutes (or serial vitals) in order to consider additional doses of nitroglycerin. In this scenario, the patient's level of pain is still at an 8 out of 10 and his blood pressure is 120/88. This would indicate the recommendation for a second dose of nitroglycerin, again at 0.4mg sublingually. It would also be appropriate to run another 12-lead ECG to see if any changes have occurred. The most important interventions early on for an ACS patient are: Provide adequate oxygenation Administer pharmacological interventions to reduce pain and anxiety Perform timely assessments:• 12-lead ECG• History• Blood labs The patient should be evaluated early for the possibility of fibrinolytic therapy, catheter lab consideration for percutaneous coronary intervention (PCI), or to be transferred for continued care at a cardiac unit. https://d3imrogdy81qei.cloudfront.net/video_images/5019/acute-coronary-syndrome-teaching.jpg Yes 343 https://www.proacls.com/training/video/pulseless-electrical-activity-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2785.mp4 Pulseless Electrical Activity Teaching In this lesson, we're going to let you play the role of team leader during another cardiac emergency – pulseless electrical activity (PEA). From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 42-year-old male patient who fell out of a tree stand while hunting. He fell about 12 feet and may have landed on a tree stump. He walked back to his house and shortly after began to develop breathing difficulty and chest discomfort. While interviewing the patient, he tells you that his breathing is getting more labored and he's feeling lightheaded. Your initial assessment recap: 42-year-old male Fell about 12 feet Difficulty breathing Chest discomfort You place the patient on O2 via nasal cannula at 4 liters and his vital signs are taken: Blood pressure: 98/68 Pulse: 112 and tachy Respirations: 20 and shallow The patient begins to become less coherent and stops responding to your questions. Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive. Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. CPR has been initiated – 30 compressions at a depth of 2 to 2.4 inches deep at a rate between 100 and 120 compressions per minute and followed by 2 rescue breaths. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign an airway person and directions to begin with a basic airway providing breaths using a bag valve mask at 15 liters of oxygen at cycles of 30 compressions to 2 rescue breaths. While compressions are being given, you direct the monitor/defibrillator team member to attach the defibrillator pads to get the patient's initial rhythm and shock him if needed. As soon as the pads are on, you give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, Stand clear while the rhythm is analyzed. It shows what looks like a slow normal sinus rhythm. You call for the airway manager to check again for a pulse, or the compressor if the airway manager is busy. No pulse can be found, and you determine that the patient is in PEA. You direct the team to continue performing high-quality CPR and call for an IV to be established with an 18-gauge needle, start him on normal saline, and prepare to give medications. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. You take a quick look at the monitor – no longer than 10 seconds – to see if a shock needs to be given or CPR resumed. In this scenario, you still see what looks like a slow normal sinus rhythm and ask again for a pulse check. There is still no pulse; the patient is still in PEA. You direct the compressor to continue performing CPR and call for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct. Pro Tip #1: Remember, flushing the line ensures that the medication gets into the central circulatory system more effectively. Also important to remember, CPR does not stop for the delivery of medications. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds. Remember, if you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. The chest is also showing signs of good chest rise and fall, which also indicates the tube placement was accurate. When the ET tube is in place and capnography is attached, you look to see if compressions and rescue breaths are effective, and CPR quality looks great. The recorder calls out, We're at 4 minutes. The compressor and monitor/defibrillator team member switch again after the second dose of epi is given and flushed with 20cc of normal saline. Pro Tip #2: As team leader, part of your duties is to either encourage the CPR compressor when compressions are good or make suggestions to improve quality if they are not. You decide that now is a good time to ask the team for feedback to help determine why the patient is in PEA. You do this by considering the reversible H's and T's: The H's The T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypokalemia Thrombosis (pulmonary) Hyperkalemia Thrombosis (coronary) Hypothermia     Since you're not sure if the trauma/fall is to blame for the PEA, or if something else is, you're open to suggestions from the team. The team considers the effects of the head and/or chest trauma from the fall and someone suggests tension pneumothorax could be the cause. You think about this but eventually dismiss it – the patient has good equal lung sounds and has great compliance when giving ventilations, which indicates it's probably not tension pneumothorax. Another member of the team suggests that chest trauma may be causing the PEA due to cardiac tamponade: Blunt trauma to the chest Low blood pressure Fast heart rate Fast breathing This sounds like a good suggestion and all measures for correcting it are expedited. However, what if all reversible causes have been eliminated and the patient remains in cardiac arrest? As team leader, you may reach a point when a decision to stop resuscitation may have to be made, especially if EtCO2 is less than 10 after 20 minutes of high-quality CPR and all treatment options have been exhausted. In many cases, PEA will deteriorate into asystole over time. It's never easy to call it quits. Everyone has invested a lot of effort and time and everyone on the team wants to see the patient survive. However, if nothing is working and the patient's condition isn't improving or is deteriorating further, you may have to make the hard decision to conclude the resuscitation attempt. https://d3imrogdy81qei.cloudfront.net/video_images/5031/pulseless-electrical-activity-teaching.jpg Yes 431 https://www.proacls.com/training/video/what-is-respiratory-arrest https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2776.mp4 What is Respiratory Arrest? Respiratory arrest cases occur when a patient has a pulse but is not breathing normally. It's important to remember that agonal aspirations is not considered normal breathing. In this lesson, we'll cover signs of respiratory distress and respiratory arrest, normal respiratory rates for adults, and some tools you may use when helping to properly oxygenate a patient in either respiratory distress or arrest. At the end of the lesson, we'll take a more in-depth look at airway management. Pro Tip #1: One sure-fire reliable sign of inadequate breathing is when the patient's breathing attempts do not produce visible signs of chest rise and fall. If you're unsure whether breathing is normal or not, look for this tell-tale sign. Respirations are only considered effective if there's enough volume of air inspired to circulate oxygen to the patient's brain and other vital organs, along with enough volume of air expelled to remove the proper amount of CO2. Pro Tip #2: The key element for helping a patient with respiratory problems is to recognize respiratory distress quickly and treat it appropriately before it transitions into respiratory arrest, which is much more serious and more difficult to treat. Signs of respiratory distress include: Pale, cool skin Changes in the patient's level of consciousness Changes in the patient's level of agitation The use of abdominal muscles to assist in breathing Wheezing Tachypnea (fast breathing) Bradypnea (slow breathing) The normal breathing rate for an adult is between 12 and 20 breaths per minute. Respiratory rates that are less than 8 breaths per minute require the healthcare provider to assist the patient with ventilations using a bag valve mask, a basic airway, or an advanced airway with 100 percent oxygen, or titrate to ensure SpO2 is greater than or equal to 94%. Pro Tip #3: As mentioned above, agonal gasps are not normal breathing. A patient who gasps will often look like he or she is drawing air in very quickly. The mouth can be open, and the jaw, head, or neck can move with the gasps. Gasps can appear forceful or weak. Some time can pass between gasps because they usually happen at a slow rate. The gasp can sound like a snort, snore, or groan. Again, this type of gasping is not normal breathing. Instead it is a sign of cardiac arrest. Tools such as capnography and oxygen saturation monitors can help to determine if enough oxygen is being delivered to the patient. Warning: Although oxygen is vitally important for a patient in respiratory distress or respiratory arrest, keep in mind that more oxygen isn't always better. Excessive ventilation can actually be harmful to the patient by reducing venous return and decreasing cardiac output. A Word About Airway Management Management Initial management for a patient in respiratory arrest involves maintaining a patent airway using a combination of manual head positioning and the insertion of a basic airway adjunct, such as an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA). Positive-pressure ventilations are then provided using a bag-valve mask or a pocket mask device at a rate of 10 breaths per minute, or around 1 breath every 6 seconds. You should ensure that supplemental oxygen is attached to the ventilatory device you are using to deliver high concentrations of oxygen. Foreign Body Airway Obstruction (FBAO) A foreign body, such as a piece of food, can obstruct the airway and prevent the patient from moving air. FBAO is suspected when there is airway resistance and/or a lack of chest rise and fall when the airway is open, and attempts are made to ventilate. This is clearly a serious emergency that should be immediately corrected. Further management of the patient would obviously be futile if the airway is not patent. If the chest does not rise visibly and/or there is resistance during your initial attempts to ventilate the patient, reposition their head, and then reattempt to ventilate the patient. If subsequent breaths do not produce visible chest rise, you should perform 30 chest compressions to attempt to dislodge the obstruction. If your chest compressions fail to dislodge the airway obstruction, visualize the vocal cords with a laryngoscope, and remove the obstruction using Magill forceps. Advanced Airway Management While there are numerous advanced airway devices that you can use to secure a patient's airway, endotracheal intubation provides the best protection against aspiration if the patient regurgitates. Patients in both respiratory and cardiac arrest usually require prolonged ventilatory support and are at an increased risk for regurgitation and aspiration of stomach contents. Therefore, you should secure the patient's airway with an endotracheal tube or another advanced airway device. https://d3imrogdy81qei.cloudfront.net/video_images/5013/what-is-respiratory-arrest.jpg Yes 105 https://www.proacls.com/training/video/stroke-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2781.mp4 Stroke Teaching In this lesson, we're going to let you play the role of team leader during a stroke emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 70-year-old female patient. A friend of hers told you that she was watching TV when she started to feel weak and suddenly had difficulty speaking. Her left side also became very weak. When her friend tried to help her stand up, as told to you by the friend, your patient was unable to walk on her own. She is conscious and breathing normally but appears agitated. As you ask the patient a few questions, you notice that she's having difficulty speaking and also giving appropriate answers. Her friend said that she noticed the difficulty of speaking about 30 minutes ago. Your initial assessment recap: 70-year-old female Difficulty speaking Left side weakness Conscious and breathing normally Because the initial signs indicate a possible stroke, you should perform a stroke assessment. If you're a pre-hospital provider, you might want to perform an abbreviated assessment, known as the Cincinnati Prehospital Stroke Scale (CPSS). This abbreviated stroke assessment consists of four elements: Facial droop Arm drift Speech Time If you're an in-hospital provider, you might want to perform a more detailed full NIH stroke score to more completely document the patient's neurological status. During your patient's assessment, you found her to be conscious and alert. However, the patient does have facial droop, left arm drift, and has trouble speaking. This is enough information to call for a stroke team to respond and also order an emergency CAT/CT scan. The next step is to obtain a full set of vitals for this patient. So, you direct one of your team members to place a blood pressure cuff on the woman and also an O2 saturation monitor. The team member now has the patient's vital signs and tells you the following: Pulse: 78 beats per minute Respiratory rate: 18 Blood pressure: 124/100 Skin: warm and dry O2 saturation: 96 percent Based on your patient's vital signs, you determine that she does not need oxygen. At this time, you attach the monitor and get a 12-lead ECG. And as you look at the 12-lead printout, you see a normal sinus rhythm. You then direct the team member to continue checking the woman's blood pressure every 5 minutes and keep a close eye on any changes in her breathing. Pro Tip #1: An important diagnostic tool for potential stroke is blood glucose. Hypoglycemia or low blood glucose can mimic stroke symptoms, such as confusion and slurred speech, so it's important to rule this out. You direct a team member to check the patient's glucose level and find that it's normal at around 90. In order to consider fibrinolytic therapy, you need to determine the time since the onset of symptoms. And since the woman arrived at the emergency room, it's been another 15 minutes. Remember, symptoms began 30 minutes before the woman arrived into your care. Since the patient's blood pressure, O2 saturation, and blood glucose levels are all within normal limits, and since symptoms started less than 3 hours ago, you decide that this patient may be a good candidate for rtPA. Pro Tip #2: rtPA, also known as recombinant tissue plasminogen activator, includes specific medications like alteplase, reteplase, and tenecteplase. These are often used in clinical medicine to treat embolic or thrombotic stroke. Indications for rtPA include: Symptom onset less than 3 hours No history of strokes Normal blood glucose levels No blood thinners No contraindicated medications No other contraindications A clear CT scan If the patient has no history or previous strokes, isn't on blood thinners or contraindicated medications, or has other contraindications, then the CT scan will be the determining factor. If the CT scan shows no hemorrhage, you'll be able to go with rtPA. To get ready for this potential drug therapy, this would be the time to start an IV. You direct a team member to start an IV – 18 gauge antecubital with normal saline. And you'll keep this at a TKO rate. Remember, the goal is to recognize the patient's potential stroke signs early and get her the appropriate fibrinolytic therapy, or the most appropriate reperfusion strategy, in a timely remember. https://d3imrogdy81qei.cloudfront.net/video_images/5023/stroke-teaching.jpg Yes 212 https://www.proacls.com/training/video/bradycardia-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2789.mp4 Bradycardia Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – bradycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 78-year-old female patient who is pale and diaphoretic. She tells you that she is feeling dizzy and weak and also that she began feeling this way about 3 hours ago. She also tells you that her condition seems to be getting worse. She is conscious and alert, which means that at the moment she's stable. And since she doesn't seem to have any life-threatening conditions, you determine that the first step should be to get a good set of vitals, which you have instructed an assistant to get. Your initial assessment recap: 78-year-old female Pale and diaphoretic Feels dizzy and weak Conscious and alert Your assistant tells you that the patient's vital signs are: Respiratory rate: 20 Pulse rate: 48 and irregular Blood pressure: 78/40 SPO2: 94 percent Based on these vital signs, you don't need to start oxygen immediately. However, the patient is obviously bradycardic and hypotensive. And in order to know if the patient's hypotension and bradycardia are related to her heart arrythmia or another cause, you decide to get an ECG reading. The assistant attached the ECG monitor to the patient and takes a quick look at her rhythm. As you look at the monitor, you see narrow QRS complexes along with regular P-waves, until the entire QRS is dropped. You recognize that this rhythm indicates 2nd degree, Mobitz type II heart block. And because this type of heart block is below the bundle of His, it could turn into complete heart block rather quickly. Pro Tip #1: Since hypotension and bradycardia are a concern, you direct the assistant to start an IV in order to consider administering atropine to the patient. But if the patient was unstable, as in unconscious and pulseless, you would then begin with transcutaneous pacing instead. However, since the patient is still responsive, you choose atropine as the first treatment option. You direct the assistant to give 1 mg of atropine via rapid IV push and wait for the assistant to repeat the order back to you, which she does. She follows the order and administers the atropine. After a minute has passed, you recheck the patient's vital signs and find the following: Respiratory rate is still around 20 Heart rate is still around 46, irregular, and weak Blood pressure has not improved and is 76/40 The pulse oximeter is still reading 94 percent Based on these new set of vitals, it appears that the atropine has been ineffective. As you come to this conclusion, the assistant tells you that the patient's heart rate and blood pressure just both went down, and now suddenly the patient just went unconscious. You now have a situation where the patient has an unstable bradycardia, which means you need to begin transcutaneous pacing as quickly as you can. You direct the assistant to apply the pacing pads and turn the pacer on. Pro Tip #2: Individual protocols will dictate specifics and vary from place to place. However, the American Heart Association guidelines recommend starting at 60 beats per minute and as the pacer is running, turn up the milliamps until the heart muscle is captured. In our scenario, you achieve consistent capture at 70 milliamps. Once you have that consistent capture, you should then turn the machine's interval up 2 to 5 milliamps – just enough to keep the capture. In this scenario, you decide to turn it up to 75. Pro Tip #3: Once you have consistent capture at 60 beats per minute, you turn up the rate until symptoms improve, which is typically between 60 and 70 beats per minute. In our scenario, you turn the rate up to 68 beats per minute. You then begin to see the patient becoming responsive again. Upon checking her vitals once more, you have: Respiratory rate of 16 Heart rate of 68 under capture with a transcutaneous pacemaker Blood pressure of 96/60 Pulse oximeter up to 96 percent Once the patient's perfusion improves, you need to continue to monitor the patient closely and work on improving perfusion further by trying to determine her cause of the bradycardia, and then treat it accordingly. Warning: Keep in mind that transcutaneous pacing can be really uncomfortable for a conscious patient. You may want to consider some sort of pain management while also considering whether or not to move the patient to the next level of care for further cardiac treatment. https://d3imrogdy81qei.cloudfront.net/video_images/5039/bradycardia-teaching.jpg Yes 258 https://www.proacls.com/training/video/pulseless-arrest-v-fib-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2783.mp4 Pulseless Arrest V-fib Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – pulseless arrest VFib. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 56-year-old male patient who arrived at the ER complaining of moderate to severe chest pains and discomfort. He also has some weakness and shortness of breath. And symptoms have been ongoing for about 4 hours. Over the last 2 hours, his pain has intensified and is now radiating up into his neck, jaw, and down his left arm. When you ask him to assess his level of pain from 1 to 10, he says it's currently a 9. He also mentions that he's beginning to feel nauseous and may even vomit. As you continue to ask him more questions, he suddenly stops responding and now appears unconscious. Your initial assessment recap: 56-year-old male Severe chest pain Radiating into jaw, neck, left arm Pain currently at 9/10 Now appears unconscious Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive. At this point, you call in a code or ask for additional help depending on you and your team's experience and level of expertise. Help is on the way. Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign a compressor and a monitor/defibrillator and remind the team that high-quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths. Pro Tip #1: It's important for everyone on your team to remember that high-quality CPR has risen to the top of importance even in ACLS, so you communicate this to everyone on your team. You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute. Pro Tip #2: Now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient. In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations. During CPR, the monitor/defibrillator team member is preparing the patient for rapid defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in VFib. CPR is continued while the automated defibrillator charges (or if the defibrillator is manual, shocks will be delivered at 360 joules.) Once the defibrillator is fully charged, the monitor/defibrillator team member calls out, everyone stand clear; shocking on 3; 1-2-3. The monitor/defibrillator person then pushes the shock button. CPR resumes and you prepare the team for medications delivery. Pro Tip #3: While both IV and IO are acceptable, try IV first and only move to IO if you're unable to obtain patient IV access for effective medication and fluid delivery. Your team is able to get patent IV access via an 18 gauge in the left antecubital and start the patient on normal saline. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. As the compressor calls out the last few compressions – 28, 29, 30 – that's when the switch occurs. After 2 ventilations are delivered, the monitor/defibrillator switches positions with the compressor and readies his or her hands in the appropriate chest position, then begins effective chest compressions immediately after the last ventilation. Now is the time for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct. CPR resumes for 2 more minutes. At the end of that cycle, you call out, Stop compressions, and allow the ECG to check the patient's rhythm. You find that the patient is still in VFib, so you call out for another shock to be delivered. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #6 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds. Pro Tip #4: If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. The recorder calls out, We're at 4 minutes. You instruct the rest of the team to stand clear of the patient while his rhythm is checked and then announce another switch for the compressor and monitor/defibrillator team members. The patient is still in VFib, so you prepare the team for a third shock. You instruct everyone to continue CPR and also direct the medication team member to prepare the next round of medication – amiodarone at 300mg followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct. A second dose of amiodarone may be given for persistent VFib, which is half the initial dose, or 150mg, and administered after 2 more minutes of CPR and another shock if the rhythm has not converted. Alternatively, epi can be given every 3 to 5 minutes instead and staggered between shocks and CPR. This scenario continues until all treatment options have been exhausted and all possible causes have been ruled out. https://d3imrogdy81qei.cloudfront.net/video_images/5027/pulseless-arrest-v-fib-teaching.jpg Yes 504 https://www.proacls.com/training/video/effective-communication https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2446.mp4 Effective Communication In order for a resuscitation team to be successful, they must practice effective communication. In this lesson, we'll be getting into some specific techniques or tips to help you achieve this vital element for positive patient outcomes. It's important that each member of a resuscitation team knows their individual roles and how to function as part of their team. And how to communicate those roles and duties effectively to other team members. Warning: Communication is a vital component in all walks of life. But when that communication is often a matter of life and death, it becomes even more vital. Don't discount just how important effective communication is for a resuscitation team. Techniques to Improve Communication Good communication doesn't happen by accident; it takes work. It's important to remember, when it comes to communication or any other aspect of your job, that the patient must always come first. It's vital that all resuscitation team members know their individual roles, how to function within those roles, and how to communicate effectively in a team environment to fulfill the goals and objectives and to increase patient survival rates during a cardiac arrest event. Now let's look at the eight essential elements of effective communication for a resuscitation team. 1. How to Establish Clear Roles and Responsibilities It's important that every team member knows and understands each of his or her duties on the team. However, it's also important that you understand the roles and responsibilities of the other team members. Understanding everyone's role and properly communicating specifics of each role will be crucial for helping the patient. Having a basic understanding of each role will allow you to fill in for other team members in situations where there aren't enough members to fill all required roles. The team leader will decide who fills in, in these situations, or will take on the role herself/himself. It's important that the team leader not get too myopic and instead always concentrate on the bigger picture. It's also important for all team members to assist the team leader in accomplishing this. Even in situations where there are enough team members, unclear roles and responsibilities will often lead to poor overall team performance. Which is why it's important for the team leader to effectively communicate to each member what their role is. All team members will have different levels of skills based on their individual training and experience, which is why it's important for the team leader to be aware of these proficiencies and properly assign responsibilities to those who can handle them. 2. Know Your Limitations Every team member must know their own ACLS capabilities and limitations. This will help the team leader to properly evaluate all available resources, assign duties to those who can handle them, and call for assistance if needed. Pro Tip #1: Asking for help should never be considered a sign of weakness or incompetence. It's better to be honest about your skills and experience and get the appropriate help when needed, than to do something that will negatively impact the team and ultimately the patient. 3. How to Perform Constructive Intervention There will be times when the team leader will have to intervene. For instance, if a team member isn't handling a specific action correctly, it may be necessary for the team leader to take over that duty or reassign it to another member of the team. However, it's equally important that the team leader handle the situation professionally and tactfully. Pro Tip #2: Team leaders should always avoid a confrontation with a member of the team. These will only serve to produce negative consequences for the patient. This includes avoiding any statements that may appear derisive or hostile. And watch your tone. Remember, often it's not what you say, but how you say it. 4. How to Communicate Knowledge Sharing American Heart Association research shows that knowledge sharing is a critical component of effective resuscitation team performance. It's important for team leaders to avoid becoming fixated on a specific treatment or diagnosis, or that myopic mindset we mentioned above. This is called fixation error. There are three common types of fixation errors that a team leader may communicate by saying things like: Everything is OK Only this is the correct way Do anything but this When resuscitation efforts are ineffective, it's important to go back to the basics and talk as a team. For instance, the team leader can do this by recapping out-loud what has been done that hasn't worked and encourage feedback from members of the team. Maybe there's something that was missed. Or something else that may produce a better outcome. Sharing knowledge is crucial, especially in those moments when things aren't working. Pro Tip #3: All team members should communicate any changes in the patient's condition. This will help the team leader to make calculated, informed decisions correctly. 5. How to Summarize and Reevaluate The team leader should always be asking herself or himself questions pertaining to the patient's condition. Monitoring their condition and reevaluating the situation is essential. These questions can include: What is the current status? What treatments have been performed? What changes in the patient have those treatments produced? What are the latest assessment findings that will help me proceed with providing the best care possible? Pro Tip #4: Team leaders should summarize and reevaluate the patient's condition out loud through regular updates to the team. Verbalizing everything to the team is important for effective communication, efficient team leading, and ultimately providing better care to the patient. Reviewing the resuscitation efforts and mapping out the next steps is vitally important, not only for better communication, but also for better patient care. And don't forget to get input or information from the time recorder. 6. How to Perform Closed-Loop Communication When a team leader gives an assignment or an order, closed-loop communication is how we make certain that the message was understood and is being executed. It serves as confirmation and must be done before the team leader assigns another task. So, what does closed-loop communication look like? Once the team leader assigns a task or provides direction, the exact message must be repeated by the team member that the message was directed towards. That's it! Simply repeat the message and then began to execute the order. 7. How to Use Clear Messages Giving concise, clear orders is essential for any successful resuscitation team. This includes good enunciation and a tone of voice that's calm and clear. The message should be direct and absent of emotion. Shouting or flustered speech in a frantic manner isn't going to help the situation. It'll only serve to waste time, as the team member may feel rushed or confused and may even impair that team member's ability to think clearly about the task they're performing. It's also important that team members aren't talking over one another. Only one person on the team should be talking at a time. 8. How to Practice Mutual Respect Mutual respect is vital for effective and efficient communication. It's obviously the professional way to communicate with peers. But also, members of a resuscitation team who work together in a respectful and supportive manner will have more success achieving favorable outcomes. Pro Tip #5: All members of a resuscitation team work diligently toward the same goal. No one is better than anyone else, regardless of their training, experience, or expertise. Every team member, including the team leader, should recognize the value the other team members provide and leave the ego at home. Practicing these communication techniques will help you establish an efficient and successful ACLS resuscitation team. A team that will better serve the community, produce more positive outcomes, and increase survival rates for those they serve. https://d3imrogdy81qei.cloudfront.net/video_images/4357/effective-communication.jpg Yes 412 https://www.proacls.com/training/video/acls-secondary-survey-hs-and-ts https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2775.mp4 ACLS Secondary Survey H's and T's In this lesson, we'll be going over the most common causes of cardiac arrest, which we touched on briefly at the end of the last lesson, as presented as what's commonly referred to as the H's and T's. This lesson will include a little information on common treatments for specific H's and T's, and at the end of the lesson, we'll provide you with a Word about diagnosing and treating underlying causes. Common Causes of Cardiac Arrest – the H's Hypovolemia – can often be corrected with fluid replacement. Hypoxia – can be corrected with appropriate oxygenation and tissue perfusion. Hydrogen ion or acidosis (respiratory or metabolic) – if respiratory, you can correct it with oxygen and respirations, and if metabolic, you might need sodium bicarbonate to correct it. Hypokalemia – when dealing with hypokalemia, you may need to administer potassium. Hyperkalemia – when dealing with hyperkalemia, you need to administer calcium chloride. Hypothermia Pro Tip #1: It's important to remember that with hypokalemia, you may see flat T-waves on the ECG, as well as something called U-waves. If you do see these, administer potassium magnesium per the protocols. Common Causes of Cardiac Arrest – the T's Tension pneumothorax – can often be relieved with needle decompression and later with a chest tube. Cardiac tamponade – this would require surgical intervention to correct. Toxins Pulmonary thrombosis – this would require a corrective procedure or thrombolytic therapy. Coronary thrombosis – the same as above is applicable, but additionally, treatment may also include percutaneous coronary intervention, commonly known as PCI. Pro Tip #2: Percutaneous Coronary Intervention, or PCI, (formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis. Warning: It's important to note that the most common causes of pulseless electrical activity (PEA) are hypoxia and hypovolemia, and both are potentially reversible. Which is why it's vital to look for evidence of these problems when assessing your patients. A Word About Diagnosing and Treating Underlying Causes Patients in cardiac arrest, such as VFib, pulseless V-tach, asystole, and PEA, require rapid assessment and management, as their cardiac arrest may be caused by an underlying and potentially reversible issue or condition. If you can quickly identify a specific condition that has caused or contributed to PEA and correct it, you may achieve ROSC. The identification of the underlying cause is extremely important in cases of PEA and asystole. When you're searching for the underlying cause, consider the following: Consider frequent causes of PEA by recalling the H's and T's Analyze the ECG for clues to the underlying cause Recognize hypovolemia Recognize drug overdose and/or poisoning Hypovolemia Hypovolemia is a common cause of PEA and initially produces the classic physiologic response of a rapid, narrow-complex tachycardia. And it typically produces increased diastolic and decreased systolic pressures. As the loss of blood volume continues, blood pressure will drop and will eventually become undetectable. However, the narrow QRS complexes and rapid rate will continue. You should consider hypovolemia as a cause of hypotension, which can deteriorate to PEA. Providing quick treatment can often reverse this pulseless state by rapidly correcting the hypovolemia. Common nontraumatic causes of hypovolemia can include occult internal hemorrhage and severe dehydration. Cardiac and Pulmonary Conditions Acute coronary syndromes involving a large amount of heart muscle can present as PEA. That is, occlusion of the left main or proximal left anterior descending coronary artery can present with cardiogenic shock rapidly progressing to cardiac arrest and PEA. However, in patients with cardiac arrest and without known pulmonary embolism, routine fibrinolytic treatment provided during CPR shows no benefit and is therefore not recommended. Massive or saddle pulmonary embolism obstructs flow to the pulmonary vasculature and causes acute right heart failure. In patients with cardiac arrest due to presumed or known pulmonary embolism, you should consider administering fibrinolytics. Pericardial tamponade may be a reversible condition. In the peri-arrest period, volume infusion in this condition may help while definitive therapy is initiated. Tension pneumothorax can often be effectively treated once recognized. Drug Overdoses or Toxic Exposures Certain drug overdoses and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction with resultant hypotension. Your approach to poisoned patients should be aggressive, as the toxic effects can progress rapidly and may be of limited duration. In these situations, myocardial dysfunction and arrhythmias may be reversible. Numerous case reports confirm the success of many specific limited interventions with one thing in common: they buy time. Treatments that can provide this level of support include: Prolonged basic CPR in special resuscitation situations Extracorporeal CPR Intra-aortic balloon pumping Renal dialysis Intravenous lipid emulsion Specific drug antidotes, such as digoxin immune Fab, glucagon, and bicarbonate Transcutaneous pacing Correction of severe electrolyte disturbances, such as potassium, magnesium, calcium, and acidosis Specific adjunctive agents It's important to note that if the patient shows signs of ROSC, post-cardiac arrest care should be initiated. https://d3imrogdy81qei.cloudfront.net/video_images/5009/acls-secondary-survey-hs-and-ts.jpg Yes 103 https://www.proacls.com/training/video/oxygen https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2460.mp4 Oxygen In this lesson, we'll go over oxygen therapy and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of this lesson, we'll provide you with a Word about respiratory arrest. Oxygen is an atmospheric gas that increases the saturation of hemoglobin oxygen and when used at therapeutic concentrations, it can aid the oxygenation of certain tissues as long as the patient isn't in shock or has some other complication, like carbon monoxide poisoning. This could affect the distribution or reception of oxygen molecules within the body and its cells. Oxygen Indications Now let's take a look at oxygen indications. The primary indication for the use of oxygen in ACLS is the presence of hypoxemia, which would be representative of an SpO2 of less than 94 percent, severe respiratory distress, as in asthma, and respiratory depression, as in opioid overdose. When you administer oxygen therapy after the return of spontaneous circulation, otherwise known as ROSC, it's important to deliver sufficient oxygenation to maintain an SpO2 that's greater than, or equal to, 92 percent but less than 98 percent. Oxygen Precautions and Contraindications There are few, if any, known precautions and contraindications for oxygen therapy use in the true hypoxic patient. Precautions should be based on new and ongoing research that reveals the vasoconstrictive properties that hyperoxia may produce. Pro Tip #1: If you begin to hyper oxygenate a normoxic cardiac patient, studies and research indicate that you might cause lower oxygen absorption and distribution to the patient's vital organs that need oxygenation during a coronary crisis. Adult Dosage of Oxygen Now let's look at the adult dosage of oxygen. The appropriate dose of oxygen will be dependent on the patient's needs and unique oxygen requirements. Oxygen therapy can be delivered via several different methods, and the percent of oxygenation will be regulated by the flow of oxygen per minute as well as the delivery adjunct you use. When delivering oxygen via nasal cannula is indicated, you should deliver it at a rate between 2 and 6 liters per minute. If a nonrebreather mask is used, that flow rate should be increased to between 12 and 15 liters per minute. If the patient's respiratory system is distressed or depressed, or for those patients who are completely apneic (not breathing), the delivery of oxygenated ventilations would be via a positive pressure device like a bag valve mask. In this case, the oxygen flow should be set at 15 liters per minute. Pro Tip #2: It's important, according to current guidelines, to titrate the oxygen therapy to maintain an SpO2 of at least 94 percent but less than 100 percent. Equally important, is to remember that a restricted airway will affect the therapeutic response of oxygenation treatment. The use of basic or advanced airway adjuncts may be needed to open or maintain a patent airway in order to treat the patient effectively. Pro Tip #3: It's important to always monitor the signs and symptoms of the patient, along with electronic and technical monitoring systems, so as to properly treat the patient. Rather than simply relying on electronic and technical monitoring systems alone. In other words, if the SpO2 reads 92 percent but the patient's skin appears normal, they could have an underlying blood disorder like anemia, which can impede the cyanosis due to a lack of hemoglobin and give the inaccurate appearance of adequate oxygenation. A Word About Respiratory Arrest In the last two lessons, we took a look at respiratory distress and respiratory failure. In this Word, we'll look at respiratory arrest. Respiratory arrest is defined as the absence of breathing and is usually caused by an event such as drowning or head injury. For an adult in respiratory arrest, providing a tidal volume of approximately 500 to 600 ml (or 6 to 7ml per kg) should be sufficient. This would be consistent with a tidal volume that produces a visible chest rise in the patient. Patients with an airway obstruction or poor lung compliance may require high pressures to be properly ventilated (in other words, to make the chest visibly rise). A pressure relief valve on a resuscitation bag-mask device may prevent the delivery of a sufficient tidal volume in these patients. Which is why it's important to make sure that the bag-mask device allows you to bypass the pressure relief valve and use high pressures, if necessary, to achieve visible chest expansion. Excessive ventilation is unnecessary and can cause gastric inflation and the resulting complications, like regurgitation and aspiration. More importantly, excessive ventilation can be harmful as it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival. As a healthcare provider, you should work to avoid excessive ventilation, as in too many breaths and/or too large a volume of breaths, during respiratory arrest and cardiac arrest. https://d3imrogdy81qei.cloudfront.net/video_images/4385/oxygen.jpg Yes 223 https://www.proacls.com/training/video/basic-airways https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2890.mp4 Basic Airways In this lesson, we'll cover the exact procedure for inserting a basic airway. And at the end of the lesson, we'll provide you with a Word about bag-mask ventilation. Basic airways are adjuncts that help direct air and oxygen around natural obstacles in the mouth, like the tongue. There are two types of basic airways: Oropharyngeal Airway (OPA) – OPAs are primarily used for patients who are usually unconscious and have no gag reflex. Nasopharyngeal Airway (NPA) – NPAs are basic airways that are inserted in patients who have a gag reflex and might be semi-conscious. Pro Tip #1: The correct size of both OPAs and NPAs are very important in order to not cause further harm to the patient, or in some cases, even block the airway entirely. To measure for an OPA, connect or place the tip of the flange to the side of patient's mouth and the base of the curved plastic to the earlobe area. As mentioned briefly above, it's important to check the patient for a gag reflex if you're not sure about their level of consciousness and responsiveness. A trick of the trade for checking for a gag reflex is to rub the patient's eyelid and see if they have a blinking reflex. If you notice that they do, you should opt for an NPA as the patient will be better able to tolerate it while/if they are still somewhat conscious. To measure for an NPA, hold the airway next to the patient's face and gauge the length from the edge of the nostril to the earlobe. However, if you're certain that the patient is unresponsive and there isn't a gag reflex, prepare a properly sized OPA as indicated in the Pro Tip above. Pro Tip #2: Make sure you have either a portable suction device or a battery-operated or regular concurrent suction catheter. Once you begin to insert the OPA, if the patient does have a gag reflex, they could vomit, and you'll need to clean that out of their airway. Alternatively, you may notice some blood, mucous, or something else in the airway that you'll need to suction. It's important to note that when suctioning the patient's airway, you should never take longer than 10 seconds at a time before oxygenating the patient again. Procedure for Inserting an OPA You may want to consider re-watching the corresponding video lesson for the exact procedure as watching will always be superior to reading. Make sure you perform a head tilt chin lift on the patient. Invert the OPA tube, so the end or tip follows the roof of the mouth and continue to insert downward until it gets closer to the back of the oral pharynx. Twist the OPA tube a full 180 degrees as you continue to insert it further and until it's in place. Pro Tip #3: If you're wondering why you begin by inserting the OPA tube backward, essentially, it's done this way to help move the patient's tongue out of the way and bring it forward. This will better allow you to put air behind the tongue and into the lungs. A Word About Bag-Mask Ventilation A bag-mask ventilation device consists of a ventilation bag attached to a face mask. Bag mask ventilation devices have been a mainstay of emergency ventilation for decades and are the most common method of providing positive-pressure ventilation. When using a bag-mask ventilation device, you should deliver approximately 600ml of tidal volume sufficient to produce the patient's chest to rise over one full second. It's important to note that bag-mask ventilation is not the recommended method of ventilation for a single healthcare provider while they are also administering CPR. Instead, a single healthcare provider should use a pocket mask to provide ventilations, if one is available. It's much easier for two trained rescuers to provide bag-mask ventilation, as one rescuer can open the airway and seal the mask to the patient's face while the other squeezes the bag. And when there are two rescuers, both should be watching for visible chest rise. The universal connections that are present on all airway devices will allow you to connect any ventilation bag to numerous adjuncts. Valves and ports can include: One-way valves to prevent the patient from rebreathing exhaled air Oxygen ports for administering supplemental oxygen Medication ports for administering medications Suction ports for clearing the patient's airway Ports for quantitative sampling of end-tidal CO2 You can also attach other adjuncts to the patient end of the valve, including a pocket face mask, laryngeal mask airway, laryngeal tube, esophageal tracheal tube, and an endotracheal tube. https://d3imrogdy81qei.cloudfront.net/video_images/5011/basic-airways.jpg Yes 127 https://www.proacls.com/training/video/ecg-interpretation https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2463.mp4 ECG Interpretation To successfully manage a patient who is in cardiac arrest, the caregiver must carefully, immediately, and systematically identify the cardiac rhythm and choose the most appropriate treatment algorithm. In the following lessons, we'll look at different cardiac dysrhythmias that can lead to cardiac arrest, their characteristics, and the appropriate therapies used to treat and correct the particular dysrhythmia whenever possible. However, in this lesson, we'll first look at interpreting the information on ECGs. Pro Tip #1: It's important to remember that knowing the patient's medical history, including all the events that have led up to the medical emergency, will greatly aid you in determining if there's any chance of reversing underlying causes for the cardiac arrest. An example of the above would be assessing the patient using the five H's and five T's. (Which will be discussed in detail in the secondary survey section of this program.) The Five Hs Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo or hyperkalemia Hypothermia The Five Ts Tension pneumothorax Tamponade Toxins Thrombosis (coronary) Thrombosis (pulmonary) Pro Tip #2: It's also important to remember that until an underlying cause has been identified and corrected, pharmacological and electrical therapies might offer little or no help when trying to resuscitate a cardiac arrest victim. When assessing the electrical activity of a patient's heart, it's vital to recognize the underlying dysrhythmia and know how to treat it appropriately to restore a perfusing cardiac rhythm. A sinus rhythm is defined as any cardiac rhythm where depolarization of the cardiac muscle begins at the sinus node, which is characterized by the presence of correctly oriented P-waves on the electrocardiogram. An ECG waveform represents each electrical event in the cardiac conduction system during a cardiac cycle. However, this doesn't mean that the heart muscle is reacting properly or in correlation with the electrical patterns. It simply shows that the electrical events that may stimulate myocardial function are happening. (This will be discussed in more detail when we look at each individual rhythm.) Waveforms Explained For the following explanations, we'll be assuming that the waveform is normal, and that normal mechanical function is occurring. The P-Wave The P-wave is the first waveform in the complete waveform complex, and it's normally found upright in healthy patients. It represents the depolarization of both the right and left atria, which occurs at the same time. The PR Segment The segment between the P-wave and the R-wave represents the delay of the electrical circuit in the AV node. This segment shows the time it takes from the end of the P-wave to the beginning of the ventricular response, represented by the QRS complex. The QRS Complex The QRS complex is the combination of three of the graphical deflections seen on a typical electrocardiogram (EKG or ECG). It is usually the central and most visually obvious part of the tracing; in other words, it's the main spike seen on an ECG line. The Q-Wave The Q-wave represents the first activity of the ventricular depolarization and is usually the first negative deflection after the P-wave in the complete complex. (We'll discuss the significance of Q-wave formations specifically as it relates to certain dysrhythmias in each of the rhythm evaluations.) The R-Wave The R-wave is the first positive deflection after the P-wave. The S-Wave The S-wave is the first negative deflection after the R-wave. The ST Segment The ST segment represents the timeframe between ventricular polarization and repolarization. It's the baseline of the cardiac cycle and, therefore, electrically neutral; there should be no inflection or deflection as it's isoelectric. Pro Tip #3: An ST elevation or depression of more than 1mm can be clinically significant and may indicate an underlying cardiac issue, either acutely or chronically. The T-Wave The T-wave represents repolarization of the ventricles and should be seen moving in the same general direction as the QRS segment. If the T-wave is inverted, this could also indicate a potential cardiac problem. It's quite helpful for healthcare providers to have a repeatable and easy method for interpreting ECG rhythms, which is why we'll be following a serial pattern for reading and interpreting all ECGs. Interpreting ECG Rhythms The pattern of interpretation most commonly used is to look at the following: Is the rhythm regular or irregular? Is the heart rate normal, fast, or slow? To determine the patient's heart rate The horizontal axis of ECG paper grids is where time is measured. Each small square is 1mm in length and represents .04 seconds. Each larger square is 5mm in length and represents .20 seconds. Therefore a 6 second interval would be 30 large squares. To determine the heart rate, count the number of QRS complexes over this 6 second interval and multiply by 10. Are the P-waves present? Do they occur regularly? Is there one P-wave for each QRS complex? Are they smooth, rounded, and upright? Do they all have a similar shape? Does the PR interval fall within the norm of .12 to .20 seconds? Is it constant? On the QRS complex, is the QRS interval less than .12 seconds? Is it wide or narrow? Are they similar in appearance? When using a systematic approach for interpreting ECG rhythms, you'll help yourself and your teammates to efficiently and effectively diagnose underlying cardiac conditions. Which, goes without saying, will also help the cardiac patient. https://d3imrogdy81qei.cloudfront.net/video_images/4389/ecg-interpretation.jpg Yes 351 https://www.proacls.com/training/video/supraventricular-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2584.mp4 Supraventricular Tachycardia Narrow complex tachycardia, also called supraventricular tachycardia or SVT for short, is caused by some sort of stimulus originating above the patient's ventricles, as opposed to the normal stimulus that's generated by the SA node. In this lesson, we'll take a deeper dive into supraventricular tachycardia for the adult patient, including looking more closely at an example of what it looks like on an ECG and see what findings and measurements lead us to our conclusion. Understanding Tachycardia Tachycardia simply describes an abnormally fast heart rate. And there are a couple of different definitions, or types, of tachycardias – narrow complex (like SVT) and wide complex. To be more specific, if the QRS interval is less than .12 seconds in length, that signifies a narrow complex tachycardia, or SVT. If the QRS interval is greater than .12 seconds, that signifies a wide complex tachycardia, and we'll get more into wide complex tachycardias in a subsequent lesson. However, just know that this is significant because it's measurable and can tell us if the cause is atrial-based or ventricular-based. If the patient's heart rate is too fast for their condition or the condition of their heart, the result is usually a decrease in cardiac output, poor perfusion of oxygenated blood, and a decrease in blood pressure. Supraventricular Tachycardia (SVT) With SVT, that stimulus comes from a rogue myocardial cell that stimulates an erratic atrial contraction, or a series of erratic atrial contractions, like those found in patient's with atrial fibrillation and atrial flutter. Remember, Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure, and other heart-related complications. And as you know, Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate. Pro Tip #1: While these appear to be the same, the difference is in the beat. Atrial flutter and atrial fibrillation are both abnormal heart rhythms. However, in atrial fibrillation, the atria beat irregularly, while in atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles, so you may have four atrial beats to every one ventricular beat. The important thing to note with SVT is that it can persist until there is medical intervention, or it can be intermittent and self-limiting and can come and go without warning. By looking at an ECG readout alone, SVT can be difficult to differentiate from sinus tachycardia, AFib, or AFL. However, there are things that you can look at to help you determine which rhythm is being displayed. Now let's take a look at an ECG for a patient with supraventricular, or narrow complex, tachycardia. *Narrow Complex Supraventricular Tachycardia ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is regular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's too fast and greater than 100 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? Yes, the P-waves are present and upright. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal for an adult patient, meaning between .12 and .20 seconds, or is it contained within one large square on the readout? Yes, it is. Is the PR interval constant? Yes. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, the QRS interval is between .06 and .11 seconds. Is the QRS complex wide or narrow? In this case, it's narrow. Pro Tip #2: It's unusual for SVT to present with a wide complex QRS. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in supraventricular tachycardia. We have a regular rhythm. We have a faster than normal heart rate at greater than 100 beats per minute. The P-waves are present and upright. The PR interval is between .12 and .20 seconds. The QRS is between .06 and .11. The P:QRS ratio is 1:1. From the ECG alone, it would indicate that the patient is in SVT. However, patient signs and symptoms must be taken into account to properly identify the rhythm correctly and to determine whether or not treatment is necessary. The leading causes of most tachycardias are: Heart disease Electrolyte imbalance Medications Hypoxemia Other causes of hemodynamic instability Regardless of the cause, if the patient is unstable, rapid treatment must be given immediately to correct the cause of the tachycardia. Pro Tip #3: Keep in mind, a narrow complex tachycardia is less likely to cause hemodynamic instability and, in some cases, can be a normal response to the body requiring better circulation due to fear, exercise, or due to moderate bleeding resulting in blood volume issues. https://d3imrogdy81qei.cloudfront.net/video_images/4541/supraventricular-tachycardia.jpg Yes 132 https://www.proacls.com/training/video/what-is-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2790.mp4 What is Tachycardia? In this lesson, we're going to cover tachycardia, including some things to be aware of when dealing with tachycardic patients, types of tachycardia, underlying causes, and some information on the best courses of treatment to resolve that patient's tachycardia. Tachycardias can be both stable and unstable. In adults, tachycardia is technically defined as heart rates greater than 100 beats per minute. Types of Tachycardia Common types of tachycardia include: Atrial fibrillation Atrial flutter Sinus tachycardia Supraventricular tachycardia (SVT) Ventricular tachycardia Ventricular fibrillation Causes of Tachycardia Many things can cause tachycardia, including semi-benign causes such as fever or stress. More serious causes of tachycardia include: Shock Medications Metabolic dysfunction Hypoxemia Damage to the heart muscle Perfusion problems may develop when the patient's heart beats too fast and the ventricles are not able to fill properly with blood, which is technically called ejection fraction compromise. This occurs due to a lack of preload before the heart fully contracts and can cause a decrease in cardiac output and poor perfusion, which can lead to hemodynamic instability. Pro Tip #1: It's important to quickly assess a tachycardic patient and determine if their signs and symptoms are the result of the tachycardia. It's equally important to find underlying causes of the tachycardia and treat those causes. Patients with heart rates between 100 and 150 beats per minute will rarely have symptoms related to the tachycardia. Rather, symptoms in this range are normally the result of other medical issues. However, the higher the heart rate, the more likely that the tachycardia is the culprit of the patient's symptoms. For this reason, a thorough primary and secondary survey will help you properly assess the patient's condition. Identifying and Treating Tachycardia When you have a patient with tachycardia, the first step is to identify whether or not the patient is stable. A stable patient has no serious signs or symptoms as a result of the increased heart rate, such as: Altered mental status Chest pain Hypotension Other signs of shock For stable patients, you should do the following: Check their vital signs Monitor their oxygen saturation Give oxygen as needed Get an ECG or 12 lead Identify their heart rhythm Start an IV Pro Tip #2: If you determine a patient to be unstable, as in one that has some of those more serious symptoms listed in the list above, synchronized cardioversion is the treatment of choice and should be done immediately. Remember, electrical therapy can cause some discomfort. If time permits and the patient is conscious, consider sedation. But if time does not permit, you may need to defibrillate regardless of sedation. If you have a patient with no pulse, treat this rhythm as if it was ventricular fibrillation (VFib) and follow the pulseless arrest algorithm. Pro Tip #3: The first step to identifying tachycardic heart rhythms is to determine if the QRS complexes are wide or narrow. Wide QRS complexes are .12 seconds or greater, while narrow QRS complexes are less than .12 seconds. Narrow complex tachycardias typically originate above the ventricles. While wide complex tachycardias typically originate in the ventricles and pose a higher risk of deteriorating into cardiac arrest. For patients with regular narrow complex stable tachycardia: It's appropriate to first attempt vagal maneuvers. If that doesn't work, give adenosine at 6mg via rapid IV push. If the patient does not convert and remains stable, give a second dose of adenosine at 12mg via rapid IV push. Pro Tip #4: While you understand the side effects of adenosine, your patient probably does not. So, after administering the medication, tell them they may get a feeling of breathlessness, a flushed feeling, or the feeling that their heart is skipping a beat. And let them know these side effects will pass quickly. For stable patients with irregular narrow complex QRS tachycardia, it's probably atrial fibrillation (AFib), atrial flutter (AF), or a multi-focal atrial tachycardia and would require expert consultation to treat. For stable patients with regular or irregular wide complex QRS tachycardia, this would usually be treated with antiarrhythmics like procainamide or amiodarone and will also require expert consultation. It's also important to remember that management and treatment of wide complex stable tachycardia requires advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy. https://d3imrogdy81qei.cloudfront.net/video_images/5041/what-is-tachycardia.jpg Yes 248 https://www.proacls.com/training/video/tachycardia-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2791.mp4 Tachycardia Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – stable and unstable tachycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 35-year-old male patient who is conscious and alert. You begin by asking him how he feels. During your primary assessment, you find him to be responsive, his airway open, and his breathing is rapid. He tells you that symptoms began while he was at work. It was a very stressful day and symptoms began about an hour before you saw him. His chief complaints are that his heart feels like it's racing, he's experiencing some dizziness, and also some weakness. Your initial assessment recap: 35-year-old male Conscious and alert Symptoms began about one hour ago Heart is racing Feels dizzy Feels weak Since the patient doesn't appear to have any life-threatening conditions, you direct a team member to get a good set of vitals. A member of your team a few minutes later tells you that the patient's vital signs are: Respiratory rate: 24 Pulse rate: 188 Blood pressure: 110/70 Skin: cool and pale SPO2: 92 percent Based on his O2 saturation, you decide to start oxygen immediately and you do so at 4 liters via nasal cannula. Your goal is to titrate oxygen to keep his O2 saturation level at 94 percent or higher. After oxygen has been started, you then decide that you need to get an ECG reading. You ask a team member to do this and after an ECG has been attached and you look at the readout, you see a narrow complex supraventricular tachycardia (SVT). Since the patient is stable, you direct a team member to first try vagal maneuvers. However, that didn't work, so you now opt for drug therapy and direct a team member to start an antecubital IV 18 gauge with normal saline at a TKO rate. Now that you have the IV established, you decide to try administering adenosine at 6mg via rapid IV push. You remind the team member in charge of medications to flush the line with 20ml of saline after giving the adenosine, so the medication gets completely into the central circulatory system. You begin to consider a second dose of adenosine at 12mg in 1 to 2 minutes if this first dose doesn't work and if the patient is still stable. After that first dose of adenosine, you take a look at the monitor and see that the patient is still in SVT. You direct a team member to get a new set of vitals. The team member comes back with the following information: Respiratory rate: 18 and shallow Pulse rate: 174 and weak Blood pressure: 94/70 Skin: cool and pale SPO2: 94 percent As you begin to consider getting a 12 lead ECG attached to the patient, he suddenly goes unconscious. Now that you have an unstable patient, that possible second dose of adenosine is off the table, so you direct the defibrillator team to perform synchronized cardioversion. The defibrillator pads are applied, and the defibrillator is set for a synchronized shock of 50 joules. A defibrillator team member announces, Clear, charging, shocking at 50 joules on 3 – 1,2,3, and delivers a shock to the patient. You again look at the monitor to see if there are any changes in the patient's rhythm, and this time, you see a normal sinus rhythm at 80 beats per minute. The patient's rhythm has been successfully converted. The patient begins to regain consciousness after a few seconds. As he is becoming more responsive, you direct a team member to get a new set of vitals, as you continue to monitor the patient for changes. https://d3imrogdy81qei.cloudfront.net/video_images/5043/tachycardia-teaching.jpg Yes 202 https://www.proacls.com/training/video/what-is-the-megacode https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2792.mp4 What is the Megacode? In this lesson, we'll provide you with a brief overview of the megacode. And at the end of the lesson, we'll provide you with an additional Word on the approach to unstable tachycardias, that you learned about in the last two lessons. Back in the day, megacodes were known to cause mega stress, and were widely considered one of the most fearful things that healthcare providers could imagine doing as it relates to their ACLS certification course. Why, you might ask? Because megacodes are so dynamic, much like a difficult word problem or riddle that you've been tasked with solving. And since not everyone loves word problems or riddles, think of megacodes like you would a puzzle, if that helps. Unlike an IRS audit or a colonoscopy, we're going to try to make megacodes as enjoyable as possible, and as simple as possible. And by the time you've completed and mastered your ACLS training at ProACLS, you'll feel confident that you'll be able to make a difference in your community, as in saving lives. Megacode testing scenarios combine knowledge and protocols of multiple ACLS algorithms. These can include any of the following: Acute coronary syndrome Acute stroke Cardiac arrest Pulseless VFib or V-tach Asystole Pulseless electrical activity (PEA) Bradycardia Tachycardia, whether stable or unstable To be a successful ACLS provider, you need to know about: Appropriate therapies Appropriate drugs Drug doses used in each ACLS algorithm When to use which drug based on the situation and patient And you need to know how to identify and interpret basic arrest and pre-arrest cardiac rhythms so you can know their proper treatments as well, related to the ECG. Pro Tip: It's important to remember that providing good ACLS always begins with providing high-quality basic life support. Make sure that you take full advantage of all the training provided by ProACLS so that you can have a rock-solid knowledge base and become as proficient with your skills as possible, in order to be ready to handle any life-threatening emergency. By gaining and building upon this knowledge base, you'll be able to increase the rate of survival for those people you help, which may mean returning loved ones back to family and friends once again. A Word About the Approach to Unstable Tachycardia A tachyarrhythmia, as in a rhythm with a heart rate greater than 100 beats per minute, has many potential causes and can be either symptomatic or asymptomatic. The key to managing a patient with any tachycardia is to determine whether pulses are present. If pulses are present, you should first determine whether the patient is stable or unstable and then provide treatment based on the patient's condition and their rhythm. If the tachyarrhythmia is sinus tachycardia, you should conduct a diligent search for the cause of the tachycardia. Treatment and correction of this cause will usually improve the signs and symptoms. Unstable tachycardia exists when the heart rate is too fast for the patient's clinical condition and the excessive heart rate causes symptoms or an unstable condition because the heart is: Beating so fast that cardiac output is reduced; this can cause pulmonary edema, coronary ischemia, and hypotension with reduced blood flow to vital organs, such as the brain or the kidneys. Beating ineffectively so that coordination between the atrium and ventricles, or the ventricles themselves, reduces cardiac output. Signs and Symptoms Unstable tachycardia leads to serious signs and symptoms that include the following: Hypotension Acutely altered mental status Signs of shock Ischemic chest discomfort AHF Rapid Recognition The two keys to managing patients with unstable tachycardia are: Rapid recognition that the patient is significantly symptomatic or even unstable. Rapid recognition that the signs and symptoms are caused by the tachycardia. The first step is to quickly determine whether the patient's tachycardia is producing hemodynamic instability and serious signs and symptoms or whether the signs and symptoms are producing the tachycardia. Making this determination can be difficult. Many experts suggest that when a heart rate is less than 150 beats per minute, it's unlikely that the symptoms of instability are caused primarily by the tachycardia unless there is impaired ventricular function. While a heart rate greater than 150 beats per minute is usually an inappropriate response to physiologic stress, such as fever and dehydration, or other underlying conditions. Indications for Cardioversion Rapid identification of symptomatic tachycardia will help you determine whether you should prepare for immediate cardioversion. For example: Sinus tachycardia is a physiologic response to extrinsic factors, such as fever, anemia, or hypotension/shock, which create the need for a compensatory and physiological increase in heart rate. There is usually a high degree of sympathetic tone and neurohormonal factors in these settings. Sinus tachycardia will not respond to cardioversion. In fact, if a shock is delivered, the heart rate often increases. If the patient with tachycardia is stable, patients may await expert consultation because treatment has the potential for harm. Atrial flutter typically produces a heart rate of approximately 150 beats per minute. Atrial flutter at this rate is often stable in the patient without heart or serious systemic disease. At rates greater than 150 beats per minute, symptoms are often present, and cardioversion is often required if the patient is unstable. If the patient is seriously ill or has underlying cardiovascular disease, symptoms may be present at lower rates. It's important to know when cardioversion is indicated, how to prepare the patient for it, and how to switch the defibrillator/monitor to operate as a cardioverter. https://d3imrogdy81qei.cloudfront.net/video_images/5045/what-is-the-megacode.jpg Yes 106 https://www.proacls.com/training/video/megacode-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2793.mp4 Megacode Teaching In this lesson, we're going to let you play the role of team leader during a megacode emergency, also known as the granddaddy of all cardiac emergencies. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. A megacode scenario will require a combined knowledge of procedures and treatments from many or all ACLS algorithms. In this scenario, you've been presented with a 45-year-old male patient who now appears unresponsive. Witnesses state that the victim was choking, and the object was removed. He was brought to advanced medical care because afterward he had difficulty breathing. While you're talking with the patient, he goes unresponsive. It's important to remember to use basic life support skills before any advanced life support skills. Your initial assessment recap: 45-year-old male Appears unresponsive Was choking but object removed Brought to medical care for difficulty breathing You or a member of your team check for responsiveness using taps and shouts. His unresponsiveness is confirmed so you call in a code and check for a pulse and signs of normal breathing. You find that the patient is in respiratory arrest. You call for an advanced airway, either an NPA or OPA, to be inserted, then start rescue breaths with a bag valve mask at 15 liters of oxygen delivered at 1 breath every 6 seconds. You call for his vitals to be taken and an ECG monitor to be attached. According to the ECG, the patient has a normal sinus rhythm with pre ventricular contractions (PVC) at 78 beats per minute but they are irregular. Knowing that a rhythm with multiple and frequent PVCs could quickly deteriorate, you start an IV to administer saline and other medications. And a short time later, the monitor is indicating that no pulse is being detected. It now looks like the patient is in ventricular fibrillation (VFib). You check the patient for a pulse to confirm and do not find one. You now call for CPR at 30 compressions to 2 rescue breaths, while defibrillator pads are applied. When the pads are in place, you instruct everyone to stand clear while the rhythm is analyzed. VFib is still present on the ECG. Using a monophasic defibrillator, you ask that it be charged to 360 joules to shock the patient. CPR resumes immediately after delivery of the first shock. Since the patient is in VFib, a first shock has been delivered, and an IV has been established, it's now time to administer the first medication – epinephrine at 1 mg 1:10,000 concentration. Pro Tip #1: You remind your team that CPR must continue during drug administration, because doing so will help circulate the medication throughout the body and especially into the heart. After the recorder lets you know that it's been 2 minutes since CPR began, you call for the compressor and monitor/defibrillator team members to switch. it's important that you always have a fresh compressor that can deliver high quality compressions between 100 and 120 compressions per minute and at the appropriate depth. However, during the switch and before resuming CPR, you take a quick look at the monitor. It reveals persistent VFib. You then call for another shock with the monophasic defibrillator at 360 joules. This time, when you check the monitor, you notice that the patient now has a normal sinus rhythm. You check for a pulse to confirm a perfusing rhythm. You find a pulse, but the patient still isn't breathing You call for rescue breaths to continue at 1 breath every 6 seconds. And you call for a set of vitals to determine the next course of treatment. You find a blood pressure of 88 systolic after achieving ROSC (return of spontaneous circulation). Pro Tip #2: A systolic blood pressure below 90 requires a 1 to 2-liter bolus of normal saline in order to raise the patient's blood pressure. Since the patient is still in respiratory arrest, you call for an ET tube to be put in place and begin to monitor capnography. With capnography in place, you can verify proper tube placement when a persistent waveform is present at 35 to 40 mmHg. Capnography measures the concentration of carbon dioxide in the patient's exhaled air at the end of expiration. The CO2 detected by capnography in this exhaled air is produced in the body and delivered to the lungs by circulating blood. Pro Tip #3: This is why it's so helpful to know when compressions are being done correctly, by producing circulation though the body that gets that CO2 out to the lungs to be exhaled. This helps you know that CPR is effective or when the body is returning biologically, and you can see that exchange of gases – oxygen and CO2. Your megacode scenario ends with you calling for a 12 lead ECG and another set of vitals as you and your team begin to consider the underlying causes that went into this patient's cardiac arrest. And by finding those causes, you can begin correcting them and save the patient's life. https://d3imrogdy81qei.cloudfront.net/video_images/5047/megacode-teaching.jpg Yes 315 https://www.proacls.com/training//video/acls-secondary-survey-overview https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2774.mp4 ACLS Secondary Survey Overview In this lesson, we'll get into some details on performing a secondary assessment for ACLS healthcare providers. And at the end of the lesson, we'll discuss some common questions, with answers, you may encounter during the assessment phase. Performing a secondary assessment overview in ACLS is different than performing a primary assessment in ACLS. And it's significantly different than performing a primary assessment in basic life support situations. In a nutshell, a secondary assessment ACLS overview is the process of differentiating between two or more conditions that share similar signs and symptoms. This includes a focused medical history, as well as thoroughly searching through the H's and T's for any intriguing underlying causes that may have contributed to the patient's condition. Pro Tip: Gathering a focused medical, and non-medical, history of the patient is highly recommended during the secondary survey. Ask yourself specific questions that are related to that history as well as the patient's presentation. To this end, use the following acronym and memory aide during your evaluations – SAMPLE. S - What are the patient's Signs and Symptoms?A - Does the patients have any Allergies?M - Is the patient taking any Medications, including the last dose?P - Is there anything in the patient's Past medical history that could be related?L - What was the Last meal that the patient consumed?E - What Events may have led to the patient's current condition? The answers to the above questions during your secondary assessment may help lead you to a correct and informed diagnosis and an appropriate course of treatment to help reverse the patient's condition and restore their health. Of particular importance are the H's and T's. To help you discover and treat any underlying causes that may have led to this event, consider the H's and T's to ensure you aren't overlooking any likely or dangerous possibilities. The H's and T's can help create a road map for you as you attempt to find possible diagnoses and the ensuing interventions and treatment options for your patient. The H's and T's are a tried and true reminder that can help you rule out some possibilities and also confirm other possibilities, and it's the focus of the next lesson. Some Helpful Q&A that May Help You During Your Secondary Assessment and Beyond In this section, we'll go over some common questions you may encounter in ACLS and specifically during the assessment phases. What are the most common causes of cardiac arrest? This is where the H's and T's can help you in identifying potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions. The most common causes of cardiac arrest are: H's T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypo/hyperkalemia Thrombosis (pulmonary) Hypothermia Thrombosis (coronary) Should I start CPR if I'm not sure if the patient has a pulse? If you aren't sure about the presence of a pulse, you should still begin cycles of compressions and ventilations. Unnecessary compressions are less harmful than failing to provide compressions if the patient needs them, as delaying or failing to start CPR in a patient without a pulse reduces the chance of their survival. How can I differentiate agonal gasps from normal breathing? As you know, agonal gasps are not considered normal breathing. And they may be present in the first minutes after sudden cardiac arrest. A patient with agonal gasps usually appears to be drawing air in very quickly. The mouth may be open, and the jaw, head, and/or neck will sometimes move with the gasps. Gasps can appear forceful or weak. Some time may pass between each gasp because they usually happen at a slow rate. The sound of the gasp can resemble a snort, snore, or groan. The important thing to remember is that gasping is not normal breathing and, instead, is a sign of cardiac arrest. What are some things to be aware of when trying to minimize CPR interruptions? As an ACLS provider, you must make every effort to minimize any interruptions in chest compressions. When you do have to interrupt compressions, try to limit those interruptions to no longer than 10 seconds, except in extreme circumstances, such as removing the patient from a dangerous environment. When you interrupt chest compressions, blood flow to the brain and heart stops. To this end, try and avoid the following: Prolonged rhythm analysis Frequent or inappropriate pulse checks Taking too long to give breaths to the patient Unnecessarily moving the patient How should I handle patients with DNAR orders? During basic life support, primary assessments, and secondary assessments, you should be aware of the reasons to stop or withhold resuscitative efforts, such as: Rigor mortis has set in Indicators of do-not-attempt-resuscitation (DNAR) status, like discovering a bracelet, anklet, or written documentation There is a threat to the safety of providers Out-of-hospital providers need to be aware of EMS-specific policies and protocols applicable to these situations. In-hospital providers and high-performance teams should be aware of any directives or specific limits to resuscitation attempts that are in place. For instance, some patients may consent to CPR and defibrillation but not to intubation or invasive procedures. Many hospitals will record this in the medical record. https://d3imrogdy81qei.cloudfront.net/video_images/5007/acls-secondary-survey-overview.jpg Yes 105 https://www.proacls.com/training//video/asystole-case-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2787.mp4 Asystole Case Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – asystole. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 30-year-old female patient who was found unconscious in her office by coworkers. Witnesses tell you that she was emotionally distraught and may have had a chronic illness, as well as using different pain pills. By the time you find her, she appears cyanotic and seems to be unresponsive. You direct a member of your team or an assistant to check her responsiveness using taps and shouts and you get no response. You call in a code or ask for additional help depending on your situation and area of practice. Your initial assessment recap: 30-year-old female Found unconscious Appears cyanotic Is unresponsive Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a member of your team to check for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if she's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. CPR is initiated. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign a compressor and a monitor/defibrillator and remind the team that high quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths. You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute. Remember, now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient. In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations. During CPR, the monitor/defibrillator team member is preparing the patient for defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in asystole. You decide to double-check that everything is working by asking yourself and the team the following questions: Are all the leads on correctly? Are all the leads attached to the patient with good contact? Does the ECG have a sufficient power supply? Is the amplitude set correctly to determine asystole vs. fine VFib? All answers point to the patient being in asystole and you instruct your team to continue providing high-quality CPR. While CPR resumes, you prepare the team for medications delivery. Pro Tip #1: Since asystole is not a shockable rhythm, you move immediately to gaining IV (or IO) access via an 18 gauge in the antecubital and call for 1mg of epinephrine 1:10,000 concentration via IV push flushed with 20cc of normal saline – to ensure the medication gets into the patient's central circulatory system. And perhaps most importantly, you instruct your team to continue CPR while the medication is being administered. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. You take a quick look at the monitor to see if there any changes in the patient's rhythm – no longer than 10 seconds – before deciding if you need to deliver a shock or continue with CPR. You tell the team that the patient is still in asystole and to continue with high quality CPR. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the vocal cords and lung sounds are oscillated for ET tube placement accuracy. Pro Tip #2: Both upper lobes and over the stomach are checked to ensure proper placement of the tube – in the trachea and not the esophagus. If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. And it is. You tell your team, CPR quality looks good. Let's make sure to monitor capnography. The recorder calls out, It's been 4 minutes since the first dose of epi. You call for a second dose of epinephrine at 1mg 1:10,000 concentration via IV push followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct. You keep an eye on chest compressions and remember to change compressors every 2 minutes or if you notice fatigue setting in to ensure adequate compressions throughout the code. You tell your team that CPR is looking good or you make suggestions for improvements. At this time, you encourage suggestions from your team as to why this patient may be in asystole. You consider the H's and T's: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia Hyperkalemia Tension pneumothorax Cardiac tamponade Toxins Cardiac thrombosis Coronary thrombosis Pro Tip #3: As a healthcare professional, you never know when a patient will survive against all odds and scientific reasoning. For this reason, you instruct your team to work with enthusiasm and high expectations throughout the resuscitation. However, it's also important to understand that studies have shown that asystole represents what's termed, the final rhythm. In other words, cardiac function and electrical activity have diminished over time until there is no perceivable electrical or mechanical activity in the patient. At which point, the patient, is biologically or permanently dead. Unless there are special circumstances, as provided in the last lesson's Word section, such as hypothermia or drug overdose, a prolonged resuscitation effort beyond 20 minutes is usually futile. As the team leader, you may have to consider stopping resuscitation, especially if the EtCO2 is less than 10 after high quality CPR and all other treatment options have been exhausted. https://d3imrogdy81qei.cloudfront.net/video_images/5035/asystole-case-teaching.jpg Yes 416 https://www.proacls.com/training//video/aspirin https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2450.mp4 Aspirin In this lesson, we'll go over the medication aspirin, or ASA, and all of its effects, including indications, precautions and contraindications, and pediatric dosages. At the end of the lesson, you'll find a Word about vasopressors. Aspirin blocks the formation of Thromboxane A2, thus inhibiting the sticking together of platelets and thus also reducing clot formation. The use of aspirin for myocardial infarctions helps reduce the chances of death and also the probability of reinfarction in stroke victims. Aspirin Indications The use of aspirin is indicated in the presence of signs and symptoms of acute coronary syndromes (ACS) such as those patients suffering from: Chest pain Chest pressure Discomfort, like pain radiating into the neck, jaw or down either arm Another reason for administering aspirin is when there are ECG changes that are consistent with acute coronary syndromes. A few examples of this would include, but are not limited to, ST elevation, depression, or T-wave inversion. Aspirin Precautions and Contraindications Now let's look at some aspirin precautions and contraindications. Before administering aspirin, be sure to ask the patient if he or she has any known hypersensitivities like Samter's Triad. This is a serious condition that can lead to a serious reaction when those patients are given aspirin. Pro Tip #1: Samter's Triad is a chronic condition defined by asthma, sinus inflammation with recurring nasal polyps, and aspirin sensitivity. It's also called aspirin-exacerbated respiratory disease (AERD), or ASA triad. You will also need to know, before giving a patient aspirin, if they have any bleeding disorders, like hemophilia, active ulcer disease, or recent gastrointestinal bleeding. Also, take heed of the Pro Tip above and ask the patient if he or she has a severe allergy like anaphylaxis or asthma-related to aspirin, as compared to more moderate sensitivities like sneezing or stuffiness. Adult Dosage of Aspirin A proper adult aspirin dose is 2 to 4 chewable aspirins or 162 to 324 mg of non-enteric coated aspirin as soon as possible following the onset of symptoms. Aspirin suppositories – usually in a 300 mg dosage – are also a safe alternative if the patient has any severe nausea, vomiting, or gastrointestinal disorders. Pro Tip #2: It's important to note, that in order to achieve a rapid therapeutic blood level of aspirin, you should instruct the patient to chew the oral aspirin before swallowing. A Word About Vasopressors While there is evidence that the use of vasopressors favors initial resuscitation with ROSC, research is still lacking on the effect of the routine use of vasopressors at any stage during the management of cardiac arrest on the rates of survival to hospital discharge. Vasopressors Used During Cardiac Arrest Vasopressors optimize cardiac output and blood pressure. The vasopressor used during cardiac arrest is: Epinephrine – 1 mg delivered IV or IO and repeated every 3 to 5 minutes. If IV or IO access cannot be established or for some reason is delayed, instead give epinephrine 2 to 2.5 mg diluted in 5 to 10 ml of sterile water or normal saline and injected directly into the patient's endotracheal tube. It's important to remember that the endotracheal route of drug administration results in variable and unpredictable drug absorption and blood levels. Epinephrine Although healthcare providers have used epinephrine for years during resuscitation, there haven't been many studies conducted to address the question of whether it improves outcomes in human patients. Epinephrine administration improves the return of spontaneous circulation as well as hospital admission rates. However, large studies have not been conducted to evaluate whether survival is actually improved. Because there haven't been any large studies to confirm long-term patient outcomes, we must rely on the positive short-term effects of increased return of spontaneous circulation and the increased hospital admission to support the use of epinephrine in cardiac arrest cases. No studies demonstrate improved rates of survival to hospital discharge or neurologic outcome when comparing standard epinephrine doses with initial high-dose or escalating-dose epinephrine. Therefore, the American Heart Association does not recommend the routine use of high-dose or escalating doses of epinephrine. Epinephrine is believed to: Stimulate adrenergic receptors Produce vasoconstriction Increase blood pressure and heart rate Improve perfusion pressure to the brain and heart Repeat epinephrine doses of 1 mg via IV or IO every 3 to 5 minutes during cardiac arrest. Remember, follow each dose given by peripheral injection with a 20 ml flush of IV fluid and elevate the extremity above the level of the heart for 10 to 20 seconds. https://d3imrogdy81qei.cloudfront.net/video_images/4365/aspirin.jpg Yes 143 https://www.proacls.com/training//video/the-cardiac-conduction-system https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2444.mp4 The Cardiac Conduction System In this section of the PALS course, we're going to cover the cardiac conduction system and all of its components, and we'll start with a deep dive into the biomechanical and electromechanical actions of the heart. In this lesson, we'll take a closer look at the heart and how it functions as a circulatory muscle, including the mechanisms that allow it to function. The myocardium is a muscle unlike any other muscle that we have in our bodies. What makes it so unique is its ability to generate its own electrical impulses, known as automaticity. Pro Tip #1: Automaticity is the body's ability to do things without occupying the mind and with low-level details required, allowing it to become an automatic response pattern or habit. One particularly special part of the heart muscle is located in the superior aspect of the right atrium, called the sinoatrial node, or SA node for short. It works like an internal/biological pacemaker. This SA node, when the heart is functioning as it was designed to function, generates an electrical impulse that travels through the myocardium in a very organized and deliberate way. The SA node generates electrical impulses at a rate between 60 and 100 times per minute. If we were to follow the pathway of that electrical impulse from the SA node to the place where it terminates, that place would be at the end of the Purkinje fibers. Pro Tip #2: The Purkinje fibers are specialized conducting fibers composed of electrically excitable cells that are larger than cardiomyocytes with fewer myofibrils and many mitochondria and which cells conduct cardiac action potentials more quickly and efficiently than any other cells in the heart. After the SA node initiates that electrical impulse, it then travels via pathways, known as internodal pathways, throughout the right and left atria. It then depolarizes the myocardia cells which causes the heart muscle in the atrium to contract. From the atria, that electrical impulse travels along the pathway to the atrial ventricular node, or the AV node, where it's strategically delayed before moving through the bundle of His, or AV bundle, and ultimately to the Purkinje fibers. The Purkinje fibers travel down through and around the ventricles, thereby completing the electromechanical cycle of one complete heartbeat. The delay in the AV node, which is located in the left lower wall of the right atrium, is a very necessary process. This delay allows the ventricles to beat independently of one another, which allows them to operate as a double pump action. If for whatever reason, the SA node doesn't operate properly as the primary impulse generator, or our biological pacemaker, the AV node can then begin sending its own electrical impulse instead; providing the heart with a failsafe mechanism or backup electrical generator. While the AV node can generate its own electrical impulses, it does so at a much slower rate, which ranges between 40 and 60 impulses per minute. When the AV node is called upon to generate this electrical impulse, it travels from the AV node through the bundle of His and eventually reaches the Purkinje fibers, which wrap around the ventricles we mentioned earlier, and once again completing the electromechanical cycle of one complete heartbeat. This ventricle contraction then circulates the majority of oxygenated blood throughout the rest of the body. Pro Tip #3: The bundle of His is the bundle of cardiac muscle fibers that conducts the electrical impulses that regulate the heartbeat, from the AV node in the right atrium to the septum between the ventricles, and then to the left and right ventricles. Upon reaching the bundle of His, that electrical impulse then travels down the length of the intraventricular septum, which leads to the left and right bundle branches. The left bundle branch has two fascicles (or bundle of fibers) due to its size, since the left ventricle is larger than the right ventricle, which has only one fascicle. These bundle branches ultimately terminate, or lead into, the Purkinje fibers, which then depolarize the ventricular cells and cause the ventricular muscles to contract. In situations where both the SA and AV nodes aren't able to generate electrical impulses properly, the Purkinje fibers located within the ventricles then become the primary pacemaker source. The problem with this scenario is that the Purkinje fibers only generate electrical impulses in the range of around 15 to 40 beats per minute. This rate is usually too slow to produce adequate systolic blood pressure or oxygenate the cells in the body. https://d3imrogdy81qei.cloudfront.net/video_images/4353/the-cardiac-conduction-system.jpg Yes 235 https://www.proacls.com/training//video/what-is-respiratory-arrest https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2776.mp4 What is Respiratory Arrest? Respiratory arrest cases occur when a patient has a pulse but is not breathing normally. It's important to remember that agonal aspirations is not considered normal breathing. In this lesson, we'll cover signs of respiratory distress and respiratory arrest, normal respiratory rates for adults, and some tools you may use when helping to properly oxygenate a patient in either respiratory distress or arrest. At the end of the lesson, we'll take a more in-depth look at airway management. Pro Tip #1: One sure-fire reliable sign of inadequate breathing is when the patient's breathing attempts do not produce visible signs of chest rise and fall. If you're unsure whether breathing is normal or not, look for this tell-tale sign. Respirations are only considered effective if there's enough volume of air inspired to circulate oxygen to the patient's brain and other vital organs, along with enough volume of air expelled to remove the proper amount of CO2. Pro Tip #2: The key element for helping a patient with respiratory problems is to recognize respiratory distress quickly and treat it appropriately before it transitions into respiratory arrest, which is much more serious and more difficult to treat. Signs of respiratory distress include: Pale, cool skin Changes in the patient's level of consciousness Changes in the patient's level of agitation The use of abdominal muscles to assist in breathing Wheezing Tachypnea (fast breathing) Bradypnea (slow breathing) The normal breathing rate for an adult is between 12 and 20 breaths per minute. Respiratory rates that are less than 8 breaths per minute require the healthcare provider to assist the patient with ventilations using a bag valve mask, a basic airway, or an advanced airway with 100 percent oxygen, or titrate to ensure SpO2 is greater than or equal to 94%. Pro Tip #3: As mentioned above, agonal gasps are not normal breathing. A patient who gasps will often look like he or she is drawing air in very quickly. The mouth can be open, and the jaw, head, or neck can move with the gasps. Gasps can appear forceful or weak. Some time can pass between gasps because they usually happen at a slow rate. The gasp can sound like a snort, snore, or groan. Again, this type of gasping is not normal breathing. Instead it is a sign of cardiac arrest. Tools such as capnography and oxygen saturation monitors can help to determine if enough oxygen is being delivered to the patient. Warning: Although oxygen is vitally important for a patient in respiratory distress or respiratory arrest, keep in mind that more oxygen isn't always better. Excessive ventilation can actually be harmful to the patient by reducing venous return and decreasing cardiac output. A Word About Airway Management Management Initial management for a patient in respiratory arrest involves maintaining a patent airway using a combination of manual head positioning and the insertion of a basic airway adjunct, such as an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA). Positive-pressure ventilations are then provided using a bag-valve mask or a pocket mask device at a rate of 10 breaths per minute, or around 1 breath every 6 seconds. You should ensure that supplemental oxygen is attached to the ventilatory device you are using to deliver high concentrations of oxygen. Foreign Body Airway Obstruction (FBAO) A foreign body, such as a piece of food, can obstruct the airway and prevent the patient from moving air. FBAO is suspected when there is airway resistance and/or a lack of chest rise and fall when the airway is open, and attempts are made to ventilate. This is clearly a serious emergency that should be immediately corrected. Further management of the patient would obviously be futile if the airway is not patent. If the chest does not rise visibly and/or there is resistance during your initial attempts to ventilate the patient, reposition their head, and then reattempt to ventilate the patient. If subsequent breaths do not produce visible chest rise, you should perform 30 chest compressions to attempt to dislodge the obstruction. If your chest compressions fail to dislodge the airway obstruction, visualize the vocal cords with a laryngoscope, and remove the obstruction using Magill forceps. Advanced Airway Management While there are numerous advanced airway devices that you can use to secure a patient's airway, endotracheal intubation provides the best protection against aspiration if the patient regurgitates. Patients in both respiratory and cardiac arrest usually require prolonged ventilatory support and are at an increased risk for regurgitation and aspiration of stomach contents. Therefore, you should secure the patient's airway with an endotracheal tube or another advanced airway device. https://d3imrogdy81qei.cloudfront.net/video_images/5013/what-is-respiratory-arrest.jpg Yes 105 https://www.proacls.com/training//video/introduction-to-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2442.mp4 Introduction to ACLS Welcome to the ProACLS course. This ACLS (Advanced Cardiovascular Life Support) course was designed specifically for you, the busy healthcare professional. In this lesson, we'll get into the benefits of choosing ProTrainings for your ACLS education. We'll get into the WHY regarding your chosen field and career path. And at the end of the course, we'll provide you with some advanced cardiovascular life support survival rates. We designed ProACLS with three core components in mind: Ease of use Learning efficiency Paced at your own speed ProACLS is available 24/7, whether you're watching a video for the first time, the third time, or coming back after several months for a quick refresher. We're here whenever you need us to be, regardless of your schedule. We'll get into specific course objectives in a subsequent lesson, but in this course, you can expect to gain all the guidelines and knowledge about current ACLS regulations. Which will ultimately lead to meeting and exceeding the most important course objective: Providing you with enough real-world knowledge so that when you're a team leader or team member during a cardiac emergency, you can feel as confident as possible to contribute to a positive outcome in that patient's life. Becoming that kind of confident takes action to achieve – as in, gaining a deeper knowledge than you already possess. Along with honing and refining the necessary skills that many of you already have. Which leads to an important point: Participants in the ProACLS course are required to have basic knowledge and skills pertaining to basic life support and basic cardiac life support. Which brings up another great point: Warning: Some things in this course may be familiar to you already, and if they are, that's not always a good thing. We tend to passively listen, read, and learn when things sound familiar. And when this happens, you're much more likely to miss a point or two that one day you may need. Fight this human tendency and you'll get much more from this course. If you're wondering, what can I expect from the ProACLS course, that's a great question. Here is a list of the knowledge and skills you'll be required to learn in order to successfully complete your course. Appropriate basic life support competency Electrocardiogram rhythm interpretation for all core ACLS rhythms Knowledge of airway management including all appropriate adjuncts ACLS drug and pharmacological knowledge Practical applications of ACLS rhythms and drugs Effective high-performance team skills Learning these important and valuable skills takes commitment and dedication, and it may require that you watch the videos more than once. It may mean practicing case scenarios several times until they become automatic. However, what you'll get from that confidence isn't nearly as important as what you can do with that confidence – making a difference when it matters most and possibly saving someone's life. Throughout the course you can also expect a few Warnings from time to time, like the above warning, and even more Pro Tips, when the information warrants highlighting. And when there's a need for supplemental information, you'll find a section at the end of these written course lessons that go beyond the video components. One other thing before we begin, keep in mind WHY you've chosen this field. Life is a precious thing. It's something that should be appreciated, savored, and celebrated. As a healthcare provider, you have enormous power to help people in need. To give back to them the one resource that is truly extinguishable – time. Time for everything that matters to them. Keep the WHY in your mind as you work your way through this course. A Word About Advanced Cardiovascular Life Support Survival Rates ACLS providers face an important challenge — functioning as a team to implement and integrate both basic and advanced life support to help save a life. The 2020 American Heart Association guidelines update for CPR and ECC reviewed evidence that has shown that in both out-of-hospital and in-hospital settings, many cardiac arrest patients do not receive high-quality CPR, and the majority do not survive. One study of in-hospital cardiac arrest showed that the quality of CPR was inconsistent and did not always meet the AHA guidelines and recommendations. However, over the years, patient outcomes post-cardiac arrest have still improved. Cardiac Arrest Survival Data Out-of-Hospital Year Bystander CPR % Survival % 2012 41.0 11.4 2013 40.1 9.5 2014 40.8 10.4 2015 45.9 10.6 In-Hospital Year Survival % 2012 23.1 2013 23.9 2014 22.7 2015 25.5 To analyze these findings, a back-to-basics evidence review refocused on the essentials of CPR, the links in the Chain of Survival, and the integration of BLS with ACLS. Minimizing the interval between stopping chest compressions and delivering a shock improves the chances of shock success and patient survival. Experts believe that high survival rates from both out-of-hospital and in-hospital sudden cardiac death are possible when utilizing strong systems of care. High survival rates have been associated with several key elements: Training of knowledgeable healthcare providers Planned and practiced response Rapid recognition of sudden cardiac arrest Prompt delivery of CPR Defibrillation as soon as possible and within 3 to 5 minutes of collapse Organized post-cardiac arrest care When you can implement these elements early, ACLS has the best chance of producing a successful outcome. https://d3imrogdy81qei.cloudfront.net/video_images/4349/introduction-to-acls.jpg Yes 71 https://www.proacls.com/training//video/acls-course-overview https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2443.mp4 ACLS Course Overview This ProTrainings ProACLS course has been designed for the busy healthcare professional who participates in, or directs the management of, cardiovascular emergencies and cardiac arrest situations. In this course overview lesson, we'll be covering your course goals or objectives and basically outline everything that will be in the course from A to Z. And at the end of the lesson, we'll provide you with a Word about medical emergency teams and rapid response teams. The aim of this course is to help you enhance your skills, including being better able to recognize and treat cardiopulmonary arrest, post-cardiac arrest, acute arrhythmias, stroke, and acute coronary syndrome, or ACS for short. Throughout this ProACLS program, you'll be actively participating, by combining cognitive and interactive simulation, and while covering scenarios based on actual medical emergencies. And by the end of your training program, you should be much more equipped at improving the outcomes of adult patients who are suffering from cardiac arrest and other cardiopulmonary emergencies. Your training should also help you become more effective at recognizing and intervening with the proper care in any cardiac-related emergency. It doesn't matter if you're a healthcare provider who works in a pre-hospital setting or you're part of a larger in-hospital team. ProACLS will help you enhance your skills regardless of where you work and when you work. ProACLS Course Objectives Your ProACLS certification course includes the following 10 objectives: Evaluating and treating adult patients with basic life support skills, including the provision of early chest compressions and the proper utilization and timing of an automated external defibrillator. Recognizing and managing respiratory arrest in adult patients. Recognizing and managing acute coronary syndrome, including the appropriate characteristics. Recognizing and managing the signs and symptoms of stroke, including the appropriate characteristics. Recognizing and treating both bradyarrhythmias and tachyarrhythmias that could result in cardiac arrest or complicate the resuscitation process and outcome. Recognizing and treating cardiac arrest, including immediate post-cardiac arrest care. Evaluating your resuscitation efforts during cardiac arrest scenarios through continuous assessment of cardiopulmonary resuscitation, including monitoring patients' physiological responses and delivering real-time feedback in a team setting. Demonstrating effective communication as either team leader or as a team member in a high-performing team, while also recognizing the impact of team dynamics on overall team performance. Learning about and utilizing the rapid response of a medical emergency team that will help contribute to the improvement of patient outcomes and defining the guidelines for the systems of care. Becoming more proficient with the proper administration of ACLS medications. Now let's go over the ProTraining ProACLS course design. To help you achieve these important objectives, we've included practice sessions and megacode evaluations. These practice learning stations will give you the opportunity to actively engage and learn from the following: The simulation of clinical cardiac emergency scenarios The video demonstrations of these scenarios Scenario-based role playing Practicing effective high-performing team behaviors During the testing phase of your ProACLS course, you'll be required to pass a megacode evaluation station in order to properly validate the achievement of your course objectives. Also, a simulated cardiac arrest scenario will help evaluate you in the following areas: Your competency of all core case materials and skills Your competency of ACLS algorithms Your adequate understanding of arrythmia interpretation Your proper use of appropriate basic ACLS drugs and therapies Your ability to perform effective leadership skills within a high-performing team environment A Word About Medical Emergency Teams and Rapid Response Teams Many hospitals have incorporated the use of medical emergency teams (MET) or rapid response teams (RRT). The purpose of these teams is to improve patient outcomes by properly identifying and treating early clinical deterioration. In-hospital cardiac arrest is often preceded by physiologic changes in the patient. In fact, recent studies have shown that nearly 80 percent of hospitalized patients with cardiorespiratory arrest first had abnormal documented vital signs for up to eight hours before the actual arrest occurred. The vast majority of these changes can and should be recognized by monitoring routine vital signs. Proper intervention before this clinical deterioration or cardiac arrest should be possible. The Route of Care for the Unstable Patient: Rapid Response Team → Code Team → Critical Care Team The management of life-threatening cardiac emergencies requires the integration of multidisciplinary teams that can involve rapid response teams, cardiac arrest teams, and intensive care specialists to achieve the ultimate goal – the survival of the patient. Team leaders, in particular, have an essential role in this coordinated effort of care with other team members and other specialists. https://d3imrogdy81qei.cloudfront.net/video_images/4351/acls-course-overview.jpg Yes 228 https://www.proacls.com/training//video/supraventricular-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2584.mp4 Supraventricular Tachycardia Narrow complex tachycardia, also called supraventricular tachycardia or SVT for short, is caused by some sort of stimulus originating above the patient's ventricles, as opposed to the normal stimulus that's generated by the SA node. In this lesson, we'll take a deeper dive into supraventricular tachycardia for the adult patient, including looking more closely at an example of what it looks like on an ECG and see what findings and measurements lead us to our conclusion. Understanding Tachycardia Tachycardia simply describes an abnormally fast heart rate. And there are a couple of different definitions, or types, of tachycardias – narrow complex (like SVT) and wide complex. To be more specific, if the QRS interval is less than .12 seconds in length, that signifies a narrow complex tachycardia, or SVT. If the QRS interval is greater than .12 seconds, that signifies a wide complex tachycardia, and we'll get more into wide complex tachycardias in a subsequent lesson. However, just know that this is significant because it's measurable and can tell us if the cause is atrial-based or ventricular-based. If the patient's heart rate is too fast for their condition or the condition of their heart, the result is usually a decrease in cardiac output, poor perfusion of oxygenated blood, and a decrease in blood pressure. Supraventricular Tachycardia (SVT) With SVT, that stimulus comes from a rogue myocardial cell that stimulates an erratic atrial contraction, or a series of erratic atrial contractions, like those found in patient's with atrial fibrillation and atrial flutter. Remember, Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure, and other heart-related complications. And as you know, Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate. Pro Tip #1: While these appear to be the same, the difference is in the beat. Atrial flutter and atrial fibrillation are both abnormal heart rhythms. However, in atrial fibrillation, the atria beat irregularly, while in atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles, so you may have four atrial beats to every one ventricular beat. The important thing to note with SVT is that it can persist until there is medical intervention, or it can be intermittent and self-limiting and can come and go without warning. By looking at an ECG readout alone, SVT can be difficult to differentiate from sinus tachycardia, AFib, or AFL. However, there are things that you can look at to help you determine which rhythm is being displayed. Now let's take a look at an ECG for a patient with supraventricular, or narrow complex, tachycardia. *Narrow Complex Supraventricular Tachycardia ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is regular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's too fast and greater than 100 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? Yes, the P-waves are present and upright. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal for an adult patient, meaning between .12 and .20 seconds, or is it contained within one large square on the readout? Yes, it is. Is the PR interval constant? Yes. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, the QRS interval is between .06 and .11 seconds. Is the QRS complex wide or narrow? In this case, it's narrow. Pro Tip #2: It's unusual for SVT to present with a wide complex QRS. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in supraventricular tachycardia. We have a regular rhythm. We have a faster than normal heart rate at greater than 100 beats per minute. The P-waves are present and upright. The PR interval is between .12 and .20 seconds. The QRS is between .06 and .11. The P:QRS ratio is 1:1. From the ECG alone, it would indicate that the patient is in SVT. However, patient signs and symptoms must be taken into account to properly identify the rhythm correctly and to determine whether or not treatment is necessary. The leading causes of most tachycardias are: Heart disease Electrolyte imbalance Medications Hypoxemia Other causes of hemodynamic instability Regardless of the cause, if the patient is unstable, rapid treatment must be given immediately to correct the cause of the tachycardia. Pro Tip #3: Keep in mind, a narrow complex tachycardia is less likely to cause hemodynamic instability and, in some cases, can be a normal response to the body requiring better circulation due to fear, exercise, or due to moderate bleeding resulting in blood volume issues. https://d3imrogdy81qei.cloudfront.net/video_images/4541/supraventricular-tachycardia.jpg Yes 132 https://www.proacls.com/training//video/magnesium-sulfate https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2457.mp4 Magnesium Sulfate In this lesson, we'll go over the medication magnesium sulfate, sometimes referred to as simply mag sulfate, and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we conclude our look at STEMI. Magnesium sulfate affects the SA node by slowing down its impulse rate, and it also reduces the automaticity in partially depolarized cells. Magnesium sulfate causes vasodilation, and when administered rapidly, can also create hypotension. Magnesium Sulfate Indications Now let's take a look at magnesium sulfate indications. Magnesium sulfate is effective as an anticonvulsant and antiarrhythmic and is used to treat polymorphic ventricular tachycardia with a pulse Magnesium sulfate is recommended for use in cardiac arrest only in cases of torsade's de pointes or suspected cases of hypomagnesemia. Whenever you see these conditions present, this is when you would use magnesium sulfate. Magnesium sulfate is also indicated for life threatening ventricular arrythmias due to digitalis toxicity. Pro Tip: Digitalis toxicity (DT) occurs when you take too much digitalis (also known as digoxin or digitoxin), a medication used to treat heart conditions. Signs of toxicity include nausea, vomiting, and an irregular heartbeat. Magnesium Sulfate Precautions and Contraindications Magnesium sulfate is contraindicated for patients with central nervous system depression or hypermagnesemia. And caution must be taken when used on patients with renal impairment as well. Routine administration of magnesium sulfate in hospitalized patients with acute myocardial infarction is also not recommended. Adult Dosage of Magnesium Sulfate Now let's look at the adult dosage of magnesium sulfate. The administration of magnesium sulfate in pulseless cardiac arrest is 1 to 2 grams (or 2 to 4ml) of a 50 percent solution diluted in 10ml of D5W or normal saline via slow IV or IO push over 5 to 20 minutes. When dealing with adult patients with torsade's with a pulse or acute myocardial infarction with hypomagnesemia, a loading dose will be required of 1 to 2 grams mixed in 50 to 100ml of D5W or normal saline via IV over a 5 to 60-minute period. This should then be followed with a .5 to 1 gram per hour IV titrated to control torsade's de pointes. A Word About STEMI We provided an introduction into ST-Elevation Myocardial Infarction (STEMI) in the last Word section of the Lidocaine lesson. In this Word, we'll dig a little deeper into STEMI. Early Reperfusion Therapy Healthcare providers should rapidly identify patients with STEMI and quickly screen them for indications and contraindications to fibrinolytic therapy by using a fibrinolytic checklist if appropriate. The first qualified physician who encounters a patient with STEMI should interpret or confirm the 12-lead ECG, determine the risk vs. benefit of reperfusion therapy, and direct administration of fibrinolytic therapy or activation of the PCI (percutaneous coronary intervention) team. Early activation of PCI can occur with established protocols. The following time frames are recommended by the American Heart Association: For PCI, the goal for ED door-to-balloon inflation time is 90 minutes. In patients presenting to a non-PCI-capable hospital, the time from first medical contact to device should be less than 120 minutes when primary percutaneous coronary intervention is considered. If fibrinolysis is the intended reperfusion, an ED door-to-needle time (needle time relates to the beginning of infusion of a fibrinolytic agent) of 30 minutes is the goal that's considered the longest acceptable time. It goes without saying that systems should strive to achieve the shortest time possible. Patients who are ineligible for fibrinolytic treatment should be considered for transfer to a PCI facility regardless of the delay. The system should strive for a door-to-departure time of 30 minutes after a transfer decision has been made. Adjunctive treatments can also be indicated. Use of PCI The most frequently used form of percutaneous coronary intervention is coronary intervention with stent placement. Optimally performed primary PCI is the preferred reperfusion strategy over fibrinolytic administration. Rescue PCI should be used early after fibrinolytics in patients who may have persistent occlusion of the infarct artery, although this term has been recently replaced by the term pharmacoinvasive strategy. PCI has been shown to be superior to fibrinolysis in the combined end points of death, stroke, and reinfarction in many studies for patients presenting between 3 and 12 hours after onset. However, these results have been achieved in experienced medical settings involving skilled healthcare providers at skilled PCI facilities – those performing more than 200 PCl's for STEMI with cardiac surgery capabilities. Considerations for the use of PCI include the following: PCI is the treatment of choice for the management of STEMI when it can be performed effectively with a door-to-balloon time of less than 90 minutes from first medical contact by a skilled provider at a skilled PCI facility. Primary PCI can also be offered to patients presenting to non-PCI-capable healthcare centers if PCI can be initiated promptly within 120 minutes from first medical contact. The TRANSFER AMI (Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction) trial supports the transfer of high-risk patients who receive fibrinolysis in a non-PCI center within 12 hours of symptom onset to a PCI center within 6 hours of fibrinolytic administration to receive routine early coronary angiography and PCI if indicated. For patients admitted to a hospital without PCI capabilities, there may be some benefit associated with transfer for PCI versus administration of on-site fibrinolytics in terms of reinfarction, stroke, and a trend to lower mortality when PCI can be performed within 120 minutes of first medical contact. PCI is also preferred in patients with contraindications to fibrinolytics and is indicated in patients with cardiogenic shock or heart failure complicating myocardial infarctions. https://d3imrogdy81qei.cloudfront.net/video_images/4379/magnesium-sulfate.jpg Yes 137 https://www.proacls.com/training//video/adenosine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2448.mp4 Adenosine In this lesson, we'll go over the medication adenosine and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we'll provide you with a Word about defibrillation. Adenosine is effective at terminating narrow complex SVT due to a reentry involving the AV or sinus node. It's used for unstable narrow complex reentry tachycardia and should be given to the patient while also preparing to cardiovert. Pro Tip #1: It's important to note that adenosine does not convert atrial fibrillation, atrial flutter, or ventricular tachycardia. Adenosine Indications Indications for adenosine include: Narrow complex SVT Unstable narrow complex reentry tachycardia Regular and monomorphic wide complex tachycardia As a diagnostic maneuver for stable narrow complex SVT Adenosine Precautions and Contraindications There are some adenosine precautions and contraindications to be aware of, including: Poison induced tachycardia Drug induced tachycardia 2nd degree heart blocks 3rd degree heart blocks Adenosine is safe to administer to pregnant patients. Pro Tip #2: Adenosine is less effective in patients who are taking theophylline or caffeine. And if administered for irregular polymorphic wide complex tachycardia or V-tach, it could cause a deterioration including hypotension. Adenosine side effects include: Transient periods of flushing Chest pain Chest tightness Brief periods of asystole Brief periods of bradycardia Ventricular ectopy Pro Tip #3: Reduce the initial dose of adenosine to 3mg in patients who are also receiving dipyridamole or carbamazepine, in heart transplant patients, or if adenosine is given by central venous access. Remember, transient periods of sinus bradycardia and ventricular ectopy are common after termination of SVT. Adult Dosage of Adenosine Adenosine should be delivered via rapid IV push and follow the steps below when administering the drug. 1. First, place the patient in a moderate reverse Trendelenburg position before administering the drug. It is highly recommended that whatever extremity in which adenosine is administered is elevated.2. Rapidly administer the initial bolus of 6 mg over 1 to 3 seconds.3. Follow the adenosine with a normal saline bolus of 20 ml. A 2nd dose of 12 mg of adenosine can be given after 1 to 2 minutes if needed.4. While administering the medication, make sure to record the rhythm strip. Pro Tip #4: Draw up the adenosine dose and saline flush in two separate syringes. Attach both syringes to the IV injection port that's closest to the patient. Clamp the IV tubing above the injection port. Push the IV adenosine as quickly as possible. While maintaining pressure on the adenosine plunger, push the normal saline flush as quickly as possible after the adenosine. 5. Unclamp the IV tubing.6. Monitor the outcome. A Word (or Two) About Defibrillation The Purpose of Defibrillation Defibrillation does not restart the heart. Defibrillation only stuns the heart and briefly terminates all electrical activity, including V-Fib and pulseless V-tach. If the heart is still viable, its normal pacemakers can eventually resume electrical activity, such as a return of spontaneous rhythm, that ultimately results in a perfusing rhythm. In the first minutes after successful defibrillation, however, any spontaneous rhythm is typically slow and may not create pulses or adequate perfusion. The patient needs CPR, beginning with chest compressions, for several minutes until sufficient heart function resumes. Also, not all shocks will lead to successful defibrillation. Which is why it's important to resume high-quality CPR immediately after a shock, beginning with chest compressions. Clearing for Defibrillation To ensure safety during defibrillation, always announce the shock warning. State the warning firmly and in a forceful voice before delivering each shock. This entire shock warning sequence should take less than 5 seconds: Announce the shock – clear! Check to make sure you're clear of contact with the patient, the stretcher, or other equipment. Make a visual check to make sure that no other member of the team is touching the patient, stretcher, or other equipment. Make sure oxygen isn't flowing across the patient's chest. Deliver the shock to the patient. When pressing the shock button, the operator of the defibrillator should be facing the patient, not the machine. This helps to ensure coordination with the chest compressor and to verify that no one accidentally resumed contact with the patient. You don't necessarily need to say, clear (as you could choose another word), but you must warn other members of the team that you are about to deliver a shock and that everyone must stand clear of the patient. Though, uniformity isn't a bad thing, and if all are expecting to hear, clear, that might still be the best option. https://d3imrogdy81qei.cloudfront.net/video_images/4361/adenosine.jpg Yes 182 https://www.proacls.com/training//video/conclusion-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2796.mp4 Conclusion Congratulations on completing your Advanced Life Support course. We hope it was everything you thought it would be … and more. The good news is that you're now ready to take your exam. Remember that muscles that don't get used begin to atrophy. Even those mental muscles. The same goes for the newly acquired skills you've just gained, as they can easily be forgotten if not used or refreshed on a regular basis. Don't let all that important knowledge get flabby. To that end, we have a free weekly video training series delivered via email that you can easily sign up for that will deliver important training right to your inbox in small doses. If you'd like to sign up for this training, you can do so here: Sign Up. Now that you've acquired these all-important life-saving skills, don't let the fear of infectious disease stand in the way of you becoming someone's potential hero. To combat this fear, you can get a keyring CPR shield through ProTrainings that will protect you from disease no matter the situation. And as long as you have your keys with you, you'll be protected. You may be in a situation where you're not required to perform a mannequin skills test and practice. However, if you find out later that your employer does require this, or if you simply think this would be great practice for you (Spoiler Alert: It is!), ProTrainings has you covered with a mannequin solution for your skills practice and training. If you're interested in this mannequin training solution, contact ProTrainings at 616-855-2500 and we'll have one delivered to you at a time that's convenient. Also, for anyone who has taken one of our 100 percent online courses and still requires an evaluation, now or in the future, you can do that with a simple phone call to ProTrainings at any time. Thanks again for choosing ProTrainings as your training resource. But before we sign off, we'd just like you to consider WHY you've chosen this field. Life is a precious thing. It's something that should be appreciated, savored, and celebrated. As a healthcare provider, you have enormous power to help people in need. To give back to them the one resource that is truly extinguishable – time. Time for everything that matters to them. Keep the WHY in you mind as you work every day to help those who need it most. Now, go forth and rescue! https://d3imrogdy81qei.cloudfront.net/video_images/4999/conclusion-acls.jpg Yes 87 https://www.proacls.com/training//video/what-is-pulseless-electrical-activity https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2784.mp4 What is Pulseless Electrical Activity? In this lesson, we're going to cover a type of cardiac arrest known as pulseless electrical activity or PEA for short. At the end of the lesson, we'll provide you with an in-depth Word about the underlying causes of cardiac arrest (and PEA), otherwise known as the H's and T's. PEA is an organized rhythm without a pulse where the electrical activity of the heart may appear normal, but the heart muscle is not responding. What is super unique about PEA is that the heart muscle is completely disassociated from the electrical activity. Pro Tip #1: Any rhythm can deteriorate into PEA. So, it's really important to closely monitor the patient's pulse, blood pressure, and any underlying conditions he or she might have. Remember, performing high-quality CPR is the initial treatment for PEA. In addition to CPR, identifying the underlying causes early, such as the H's and T's, and providing treatment quickly, is the key to reversing most pulseless electrical activity. As mentioned above, some of the more common reversible causes of PEA can be more easily remembered by the H's and T's. The H's and T's PEA is associated with many conditions. As healthcare providers, you should memorize the list of common causes to keep from overlooking an obvious cause of PEA that might be reversed by appropriate treatment. The most common causes of cardiac arrest are presented as H's and T's as indicated below. The H's The T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypokalemia Thrombosis (pulmonary) Hyperkalemia Thrombosis (coronary) Hypothermia     Of the H's and T's, hypovolemia and hypoxia are the two most common underlying and potentially reversible causes of PEA. Which is why it's important to look for evidence of these problems as you assess the patient. In these two cases – hypovolemia and hypoxia – it's vital to recognize the condition early and treat for it quickly with volume replacement and oxygen therapy. Pro Tip #2: Remember, pulseless electrical activity is not a shockable rhythm. Treatment involves high-quality CPR, proper airway management, IV or IO therapy, and the appropriate medication therapy. The primary medication to treat PEA is 1mg of epinephrine 1:10,000 concentration every 3 to 5 minutes via rapid IV or IO push. However, in order to correct PEA, the ultimate goal will always be to identify and treat the underlying cause of the cardiac arrest. A Word About the Underlying Causes of Cardiac Arrest In this Word section, we're going to take a closer look at the H's and T's, since they are so vitally important in treating PEA and other types of cardiac arrest. Hypovolemia Look for: a history of trauma or severe dehydration, flat jugular veins, and ECG is rapid with narrow ORS complexes. Treat with: give a 500ml bolus of normal saline and then reassess. Hypoxia Look for: profound cyanosis, suggestive blood gas readings, and airway problems. Treat with: effective oxygenation and ventilation. Hydrogen ion (acidosis) Look for: a history of diabetes, such as hyperglycemic ketoacidosis, suggestive blood gas readings, bicarbonate-responsive preexisting acidosis, and renal failure. Treat with: effective oxygenation and ventilation first, then consider sodium bicarbonate. Hyperkalemia/hypokalemia Look for: a history of renal failure, recent dialysis, diuretic use, and abnormal ECG findings. Treat with: calcium chloride and sodium bicarbonate for hyperkalemia, and cautious infusion of potassium and magnesium for hypokalemia. Hypothermia (spontaneous or environmental) Look for: a history of recent exposure to cold environment and low core body temperature. Treat with: remove from the cold environment, perform active internal rewarming, and limit defibrillations to one attempt and withhold cardiac medications until the core body temperature is raised above 86°F (30°C). Toxins (intentional/accidental overdose) Look for: a history of ingestion, empty bottles at the scene, abnormal neurologic exam, bradycardia, tachycardia, and a prolonged Q-T interval. Treat with: intubation, activated charcoal, antidotes specific to ingestion (naloxone for narcotics and sodium bicarbonate for tricyclic antidepressants), and hemodialysis for certain agents. Tamponade (cardiac) Look for: a history of thoracic trauma or invasive cancer, pulses not palpable during CPR, and jugular venous distention. Treat with: pericardiocentesis. Tension pneumothorax Look for: a history of thoracic trauma, pulses not palpable during CPR, jugular venous distention, absent breath sounds on the affected side, decreased compliance when ventilating, and contralateral tracheal shift (late) Treat with: needle decompression (thoracentesis) Thrombosis (coronary, ACS) Look for: a history suggestive of acute myocardial infarction (AMI) and ST-segment and T-wave changes Treat with: PCI or fibrinolytics Thrombosis (pulmonary) Look for: a sudden onset of dyspnea and pleuritic chest pain shortly before the arrest, cyanosis that persists despite supplemental oxygen, pulses not palpable during CPR, and jugular venous distention. Treat with: anticoagulation or fibrinolytic therapy. https://d3imrogdy81qei.cloudfront.net/video_images/5029/what-is-pulseless-electrical-activity.jpg Yes 126 https://www.proacls.com/training//video/basic-airways https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2890.mp4 Basic Airways In this lesson, we'll cover the exact procedure for inserting a basic airway. And at the end of the lesson, we'll provide you with a Word about bag-mask ventilation. Basic airways are adjuncts that help direct air and oxygen around natural obstacles in the mouth, like the tongue. There are two types of basic airways: Oropharyngeal Airway (OPA) – OPAs are primarily used for patients who are usually unconscious and have no gag reflex. Nasopharyngeal Airway (NPA) – NPAs are basic airways that are inserted in patients who have a gag reflex and might be semi-conscious. Pro Tip #1: The correct size of both OPAs and NPAs are very important in order to not cause further harm to the patient, or in some cases, even block the airway entirely. To measure for an OPA, connect or place the tip of the flange to the side of patient's mouth and the base of the curved plastic to the earlobe area. As mentioned briefly above, it's important to check the patient for a gag reflex if you're not sure about their level of consciousness and responsiveness. A trick of the trade for checking for a gag reflex is to rub the patient's eyelid and see if they have a blinking reflex. If you notice that they do, you should opt for an NPA as the patient will be better able to tolerate it while/if they are still somewhat conscious. To measure for an NPA, hold the airway next to the patient's face and gauge the length from the edge of the nostril to the earlobe. However, if you're certain that the patient is unresponsive and there isn't a gag reflex, prepare a properly sized OPA as indicated in the Pro Tip above. Pro Tip #2: Make sure you have either a portable suction device or a battery-operated or regular concurrent suction catheter. Once you begin to insert the OPA, if the patient does have a gag reflex, they could vomit, and you'll need to clean that out of their airway. Alternatively, you may notice some blood, mucous, or something else in the airway that you'll need to suction. It's important to note that when suctioning the patient's airway, you should never take longer than 10 seconds at a time before oxygenating the patient again. Procedure for Inserting an OPA You may want to consider re-watching the corresponding video lesson for the exact procedure as watching will always be superior to reading. Make sure you perform a head tilt chin lift on the patient. Invert the OPA tube, so the end or tip follows the roof of the mouth and continue to insert downward until it gets closer to the back of the oral pharynx. Twist the OPA tube a full 180 degrees as you continue to insert it further and until it's in place. Pro Tip #3: If you're wondering why you begin by inserting the OPA tube backward, essentially, it's done this way to help move the patient's tongue out of the way and bring it forward. This will better allow you to put air behind the tongue and into the lungs. A Word About Bag-Mask Ventilation A bag-mask ventilation device consists of a ventilation bag attached to a face mask. Bag mask ventilation devices have been a mainstay of emergency ventilation for decades and are the most common method of providing positive-pressure ventilation. When using a bag-mask ventilation device, you should deliver approximately 600ml of tidal volume sufficient to produce the patient's chest to rise over one full second. It's important to note that bag-mask ventilation is not the recommended method of ventilation for a single healthcare provider while they are also administering CPR. Instead, a single healthcare provider should use a pocket mask to provide ventilations, if one is available. It's much easier for two trained rescuers to provide bag-mask ventilation, as one rescuer can open the airway and seal the mask to the patient's face while the other squeezes the bag. And when there are two rescuers, both should be watching for visible chest rise. The universal connections that are present on all airway devices will allow you to connect any ventilation bag to numerous adjuncts. Valves and ports can include: One-way valves to prevent the patient from rebreathing exhaled air Oxygen ports for administering supplemental oxygen Medication ports for administering medications Suction ports for clearing the patient's airway Ports for quantitative sampling of end-tidal CO2 You can also attach other adjuncts to the patient end of the valve, including a pocket face mask, laryngeal mask airway, laryngeal tube, esophageal tracheal tube, and an endotracheal tube. https://d3imrogdy81qei.cloudfront.net/video_images/5011/basic-airways.jpg Yes 127 https://www.proacls.com/training//video/acls-secondary-survey-hs-and-ts https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2775.mp4 ACLS Secondary Survey H's and T's In this lesson, we'll be going over the most common causes of cardiac arrest, which we touched on briefly at the end of the last lesson, as presented as what's commonly referred to as the H's and T's. This lesson will include a little information on common treatments for specific H's and T's, and at the end of the lesson, we'll provide you with a Word about diagnosing and treating underlying causes. Common Causes of Cardiac Arrest – the H's Hypovolemia – can often be corrected with fluid replacement. Hypoxia – can be corrected with appropriate oxygenation and tissue perfusion. Hydrogen ion or acidosis (respiratory or metabolic) – if respiratory, you can correct it with oxygen and respirations, and if metabolic, you might need sodium bicarbonate to correct it. Hypokalemia – when dealing with hypokalemia, you may need to administer potassium. Hyperkalemia – when dealing with hyperkalemia, you need to administer calcium chloride. Hypothermia Pro Tip #1: It's important to remember that with hypokalemia, you may see flat T-waves on the ECG, as well as something called U-waves. If you do see these, administer potassium magnesium per the protocols. Common Causes of Cardiac Arrest – the T's Tension pneumothorax – can often be relieved with needle decompression and later with a chest tube. Cardiac tamponade – this would require surgical intervention to correct. Toxins Pulmonary thrombosis – this would require a corrective procedure or thrombolytic therapy. Coronary thrombosis – the same as above is applicable, but additionally, treatment may also include percutaneous coronary intervention, commonly known as PCI. Pro Tip #2: Percutaneous Coronary Intervention, or PCI, (formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis. Warning: It's important to note that the most common causes of pulseless electrical activity (PEA) are hypoxia and hypovolemia, and both are potentially reversible. Which is why it's vital to look for evidence of these problems when assessing your patients. A Word About Diagnosing and Treating Underlying Causes Patients in cardiac arrest, such as VFib, pulseless V-tach, asystole, and PEA, require rapid assessment and management, as their cardiac arrest may be caused by an underlying and potentially reversible issue or condition. If you can quickly identify a specific condition that has caused or contributed to PEA and correct it, you may achieve ROSC. The identification of the underlying cause is extremely important in cases of PEA and asystole. When you're searching for the underlying cause, consider the following: Consider frequent causes of PEA by recalling the H's and T's Analyze the ECG for clues to the underlying cause Recognize hypovolemia Recognize drug overdose and/or poisoning Hypovolemia Hypovolemia is a common cause of PEA and initially produces the classic physiologic response of a rapid, narrow-complex tachycardia. And it typically produces increased diastolic and decreased systolic pressures. As the loss of blood volume continues, blood pressure will drop and will eventually become undetectable. However, the narrow QRS complexes and rapid rate will continue. You should consider hypovolemia as a cause of hypotension, which can deteriorate to PEA. Providing quick treatment can often reverse this pulseless state by rapidly correcting the hypovolemia. Common nontraumatic causes of hypovolemia can include occult internal hemorrhage and severe dehydration. Cardiac and Pulmonary Conditions Acute coronary syndromes involving a large amount of heart muscle can present as PEA. That is, occlusion of the left main or proximal left anterior descending coronary artery can present with cardiogenic shock rapidly progressing to cardiac arrest and PEA. However, in patients with cardiac arrest and without known pulmonary embolism, routine fibrinolytic treatment provided during CPR shows no benefit and is therefore not recommended. Massive or saddle pulmonary embolism obstructs flow to the pulmonary vasculature and causes acute right heart failure. In patients with cardiac arrest due to presumed or known pulmonary embolism, you should consider administering fibrinolytics. Pericardial tamponade may be a reversible condition. In the peri-arrest period, volume infusion in this condition may help while definitive therapy is initiated. Tension pneumothorax can often be effectively treated once recognized. Drug Overdoses or Toxic Exposures Certain drug overdoses and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction with resultant hypotension. Your approach to poisoned patients should be aggressive, as the toxic effects can progress rapidly and may be of limited duration. In these situations, myocardial dysfunction and arrhythmias may be reversible. Numerous case reports confirm the success of many specific limited interventions with one thing in common: they buy time. Treatments that can provide this level of support include: Prolonged basic CPR in special resuscitation situations Extracorporeal CPR Intra-aortic balloon pumping Renal dialysis Intravenous lipid emulsion Specific drug antidotes, such as digoxin immune Fab, glucagon, and bicarbonate Transcutaneous pacing Correction of severe electrolyte disturbances, such as potassium, magnesium, calcium, and acidosis Specific adjunctive agents It's important to note that if the patient shows signs of ROSC, post-cardiac arrest care should be initiated. https://d3imrogdy81qei.cloudfront.net/video_images/5009/acls-secondary-survey-hs-and-ts.jpg Yes 103 https://www.proacls.com/training//video/epinephrine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2454.mp4 Epinephrine In this lesson, we'll go over the medication epinephrine and all of its effects, including indications, precautions and contraindications, and adult dosages. Epinephrine, also commonly referred to as epi, is a chemical that narrows the blood vessels and opens the airways in the lungs. And it's also commonly known as adrenaline. Adrenaline is a hormone that is secreted mainly by the medulla of the adrenal glands and functions primarily to increase cardiac output and to raise blood glucose levels. Epinephrine is typically released during periods of acute stress and its effects are a built-in defense mechanism and what prepares an individual for either a fight or flight response. For this reason, it's also a primary medication for non-perfusing cardiac arrest in pediatric patients. One common effect of epinephrine is reversing low blood pressure. Epinephrine is a sympathomimetic drug. Sympathomimetic drugs mimic the effects of the sympathetic nervous system and are thus used to increase the heart rate and blood pressure. Drugs in this category are usually the synthetically produced equivalent to what is endogenous (naturally occurring) in the human body. Epinephrine is also a naturally occurring catecholamine. It possesses positive alpha- and beta-adrenergic effects. Its alpha effects result in vasoconstriction, thus increasing the blood pressure. Its selective beta1 effects result in increased heart rate (positive chronotropy) and increased myocardial contractility (positive inotropy). While its selective beta2 effects cause a relaxation of bronchial smooth muscle (bronchodilation). Epinephrine Indications Now let's take a look at epinephrine indications. Epinephrine is used in cardiac arrest arrhythmias such as V-Fib, pulseless V-tach, asystole, and pulseless electrical activity (PEA). Epinephrine can also be used in symptomatic bradycardia and for the treatment of severe hypotension. Epinephrine can be administered after atropine as an alternative to infusing dopamine. It has also been established that epinephrine can be administered when external pacing and atropine fail and when bradycardia causes hypotension. It's safe to administer epinephrine with phosphodiesterase enzyme inhibitors, and it's also an effective treatment for anaphylaxis. Pro Tip #1: It's recommended that epinephrine be combined with large volumes of fluids, corticosteroids, and antihistamines. Epinephrine Precautions and Contraindications Epinephrine has a few precautions and contraindications that we should note. Care should especially be taken when administering epinephrine in cases where raising the patient's blood pressure and increasing their heart rate might cause myocardial ischemia, angina, and increase the demand for myocardial oxygen. Pro Tip #2: It should be noted that high doses of epinephrine do not improve neurological outcomes or survival rates and may actually contribute to post-resuscitation complications like myocardial dysfunction. In healthcare settings, we commonly see high doses of epinephrine treatment with poisoning and drug-induced shock. Adult Dosage of Epinephrine Now let's look at the adult dosage of epinephrine. Warning: Epinephrine is available in two concentrations and it's important to know when to use each, and to pay extra attention to which concentration you're actually using when administering epinephrine to patients. The two available concentrations are 1:1000 and 1:10,000. And for cardiac arrest in adult patients, you should deliver via IV or IO at 1 mg or 10 ml of 1:10,000 every 3 to 5 minutes during resuscitation. Follow each dose of epinephrine with 20 ml of normal saline as a flush. And elevate the patient's arm in which the medication was delivered for 10 to 20 seconds after the dose has been administered. If you encounter a situation where there is no IV or IO access, epinephrine may be delivered via the endotracheal route at 2 to 2.5 mg diluted in 10 ml of normal saline. Pro Tip #3: Higher doses of epinephrine – up to 0.2 mg per kg of body weight may be used for specific indications like beta-blocker or calcium channel blocker overdose. If you're administering epinephrine as a continuous infusion, the initial rate is 0.1 to 0.5 mcg per kg per minute. An example of this would be if you're giving epinephrine to a patient weighing 90 kg, you'd give the patient between 9 and 45 mcg per minute and titrated to a positive patient response. In cases of profound bradycardia or hypotension, deliver 2 to 10mcg per minute of epinephrine titrated to a patient response delivering a drip via an IV infusion. And add 1mg of epinephrine (or 1ml of 1:1000 solution) to a 250ml or 500ml of normal saline. For treatment of anaphylactic shock, an epinephrine concentration of 1:1000 should be given at .01mg per kg of body weight via intermuscular delivery. https://d3imrogdy81qei.cloudfront.net/video_images/4373/epinephrine.jpg Yes 245 https://www.proacls.com/training//video/pharmacology https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2447.mp4 Pharmacology In this section of your ACLS course, we're going to look at the current ACLS pharmacological treatments, including some important things to keep in mind as you progress through this section of your course. At the end of the lesson, we'll look at the finer points of resuming CPR while a defibrillator is charging. It's important to remember that no medication will work the way you expect it to or want it to unless the patient's biological status, at the cellular level, works the way you want it to or expect it to. What do we mean by this? We know that there has been a lot of research done that better helps us understand that when a patient is in cardiac arrest, at the cellular level they have a very specific amount of time before clinical death transitions into biological or cellular death. In other words, permanent death. As cellular hypoxia progresses into cellular death, the body's ability to react to treatments, including the medications we'll be covering in this section, become much more difficult and much more unlikely. For this reason, it's vitally important that, as a healthcare professional, you are able to provide highly effective basic life support skills. These are foundational skills and extremely important for any and all successful ACLS outcomes. ACLS Medications The variety of medications that we'll cover in this section of the course are only one part of any successful resuscitation (and one part of the chain of survival) and will include: Adenosine Amiodarone Aspirin Atropine Dopamine Epinephrine Fibrinolytic Agents Lidocaine Magnesium sulfate Morphine sulfate Nitroglycerin Oxygen Procainamide The ACLS Chain of Survival Essentially, basic life support helps the patient by buying them time. Time it takes the body to transition from clinical death to biological, cellular, and permanent death. The ACLS medications listed above that we'll be digging into in subsequent lessons are just one small part of any successful resuscitation. ACLS is the next level in the chain of survival that includes four main components: The administration of medications EKG and ECG monitoring Advanced airways Other treatment options Your goal is to help keep the patient in a state of survivability until, ultimately, you're able to get them appropriate and definitive treatment that will hopefully and ideally reverse their life-threatening condition. The Administration of Medications As you begin to learn about, or refresh your knowledge of, these current ACLS medications, we'll be breaking down each into four distinct categories: The drug and its effects The drug's indications The drug's precautions and contraindications The drug's appropriate dosage A Word About Resuming CPR While the Defibrillator is Charging It's important to continue to perform high-quality CPR until a defibrillator arrives and is attached to the patient. The team should assign team member roles and responsibilities as well as organize the appropriate interventions to minimize interruptions in chest compressions. Doing so accomplishes the most critical interventions for VFib or pulseless V-tach – CPR with minimal interruptions in chest compressions and defibrillation during the first minutes of arrest. The American Heart Association does not recommend continued use of an AED (or the automatic mode) when a manual defibrillator is available and when the healthcare provider's skills are sufficient for rhythm interpretation. The reasons is simple – rhythm analysis and shock administration with an AED may result in prolonged interruptions in chest compressions. Shortening the interval between the last chest compression and the ensuing shock by even a few seconds can help improve shock success. Thus, it is reasonable for healthcare providers to practice efficient coordination between CPR and defibrillation to minimize the hands-off interval between stopping compressions and administering the shock. For example, after verifying that the patient has a shockable rhythm and initiating the charging sequence on the defibrillator, another provider should resume chest compressions and continue performing them until the defibrillator is fully charged. The operator of the defibrillator should deliver the shock as soon as the compressor removes his or her hands from the patient's chest and after all providers are clear of contact with the patient. Use of a multimodal defibrillator in manual mode can help reduce the duration of chest compression interruptions that are required for rhythm analysis when compared to automatic mode. However, this could increase the frequency of inappropriate shocks. Individuals who are not comfortable interpreting cardiac rhythms can and should continue to use an AED. When using an AED, follow the device's prompts or know your device-specific manufacturer's recommendations. It's important that all healthcare providers be knowledgeable of how their defibrillator works, and whenever possible, limit interruptions in chest compressions for rhythm analysis and shock delivery. https://d3imrogdy81qei.cloudfront.net/video_images/4359/pharmacology.jpg Yes 111 https://www.proacls.com/training//video/acls-philosophy https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2772.mp4 ACLS Philosophy Before we get into the depth of the ProACLS course, it's important to go over the philosophies of ACLS, which is the subject of this important lesson. And at the end of the lesson, we'll provide you with a Word about the optimization of ACLS. If you look back 10 or 20 years, ACLS training and certification has changed significantly. Two decades ago, it was more about the technical aspects of acquiring the skills necessary for certification and training. A couple examples of this: If you were learning about intubating a patient, you'd be expected to show or prove that you could actually perform this skill on a dummy or mannequin. You'd have to demonstrate the proper use of the techniques involved. And you'd have to show that you could properly use the appropriate tools to get the job done successfully. If you were learning about starting an IV, you would have been expected to demonstrate that you could actually start an IV on a mannequin. However, these days, it's important to point out that advanced cardiovascular life support training and certification is NOT about the technical aspect of the job or the skills acquisition part of the job. Today, ACLS training is more about learning and understanding all the signs and symptoms of emergent cardiovascular problems that require advanced cardiovascular life support care, in order to help stabilize the patient and possibly save a person's life. Pro Tip #1: So, in a sentence, ACLS training and certification has gone from techniques to greater understanding. Knowing that upfront will serve you well as you progress through your ACLS course. Having said that, though, it's probably fair to assume that not all of you are as polished when it comes to your advanced cardiovascular life support skills as you need to be, or as you want to be. And yet, the situation may exist for some of you where you could be called upon to assume the team leader role in a cardiovascular emergency one day. For this reason, we have built this ACLS certification course, or re-certification for some, so that each of you can pretend at some point to assume those all-important team leader responsibilities and that role in general. In fact, to pass your ProACLS course, you must fulfill the obligations and demonstrate the responsibilities of a team leader. You will be expected to show that you can sufficiently orchestrate and execute a code and perform it as well as can be expected. However, we also understand that in your particular role and organization, you may never be put into that type of position. But since none of us can predict the future, and since these skills can potentially be vital at some point, we encourage you to receive this education and training in the most serious way. Our hope and expectation is that you will practice the different scenarios in a way, regardless of the chances of you being put into one of these positions, in which you can say to yourself – if for some reason I'm ever called upon to be a team leader, I'll have the confidence and understanding of not only the cognitive skills, but also the tactile skills. And ultimately be able to make a difference in a patient's life in a positive way. Which is why we have this challenge for you: If there are any skills that you do not feel comfortable with but maybe one day you'll be called upon to use, take the onus upon yourself. Be the best healthcare professional you can be and seek out the additional education and practice that you need. And sharpen any skills you feel deficient in. Take advantage of this self-paced ACLS training program. And become the best ACLS provider that you can be. After all, you never know when you'll be called upon to execute those life-saving skills. A Word About the Optimization of ACLS CPR is defined as a series of lifesaving actions that can improve the chances of survival after cardiac arrest. And while the optimal approach to CPR can vary, depending on the rescuer, the patient, and whatever resources are available, the fundamental challenge remains how to achieve early and effective CPR. One way to maximize the effectiveness of CPR, and thus improve patient survival rates, is by limiting chest compression interruptions. ACLS is best optimized when a team leader can effectively integrate high-quality CPR with minimal interruptions of high-quality compressions with advanced life support strategies, such as defibrillation, medication therapy, and advanced airways. The importance of minimizing these interruptions in chest compressions cannot be overstated. For instance, studies have shown that reducing the interval between pausing chest compressions and shock delivery can increase the predicted shock success. Which is why interruptions in compressions should only be limited to those critical interventions, such as interruptions for rhythm analysis, shock delivery, intubation, and so forth. And even then, those interruptions should always be minimized to 10 seconds or less. https://d3imrogdy81qei.cloudfront.net/video_images/5003/acls-philosophy.jpg Yes 202 https://www.proacls.com/training//video/bradycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2583.mp4 Bradycardia There can be many forms of bradycardia. Commonly seen blocks include sinus bradycardia, and for multiple blockages, complete and 3rd-degree heart block. In this lesson, we’ll look more closely at an example of what bradycardia looks like on an ECG for an adult patient and see what findings and measurements lead us to that conclusion. It’s vital to remember that if there are signs of bradycardia, regardless of whatever underlying reasons that are causing the patient to display symptoms related to bradycardia, we must first treat for the bradycardia, as it takes precedent over those underlying causes. *Bradycardia ECG for Adult Patient 1. The Heart Rhythm The first thing you’ll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the above graphic, it’s regular. 2. The Heart Rate Next, you’ll want to look at the heart rate of the patient. What is the patient’s heart rate? Is it normal? Or is it too slow or too fast? In this case, it’s too slow, as the rate is less than 60 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient’s P-waves look normal by asking yourself the following few questions. Are the patient’s P-waves present? In this case, the answer is, yes. Do they occur regularly? The answer is yes again. Is there one P-wave for each QRS complex? Yes, there is. Are the P-waves smooth, rounded, and upright? The answer is again, yes. Do all the P-waves have a similar shape? Yes, they all have a similar shape. 4. PR Interval Next, look at the PR interval on the patient’s ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is yes, it’s between .12 and .20 seconds, consistent, and contained within one large square. Is the PR interval constant? Yes, it is. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, the QRS interval is between .06 and .11 seconds. Remember, as long as the QRS fits within two small squares on the ECG printout and is not greater than three small squares, it’s within the normal range. Is the QRS complex wide or narrow? In this case, it’s narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it’s safe to say that this patient is in sinus bradycardia. We have a regular rhythm. We have a slower than normal heart rate, at less than 60 beats per minute. The P-waves look normal, with each being followed by a QRS complex. The PR interval is between .12 and .20 seconds. The QRS is between .06 and .11 seconds. And the P:QRS ratio is 1:1. Bradycardia in adults can result from many things – from benign causes like aerobic exercise to pathological causes, such as: Structural heart disease Damage to the electrical conduction system (usually related to a past heart attack) Hypoxia Metabolic dysfunction Certain medications Pro Tip: To properly treat an adult patient in bradycardia, it’s important to get a thorough patient history, including a list of medications that the patient is taking, along with any other past medical problems that may have contributed to their bradycardia. Having said that, if the patient is showing symptoms related to their bradycardia, you should begin treating them for it while also asking yourself the following questions: What is the underlying cause of the bradycardia? Is that underlying cause reversible? Additional Bradycardia Information Bradycardia is defined as a slower than normal heart rate. The heart rates of adults at rest is usually between 60 and 100 beats per minute. For adults with bradycardia, their hearts beat fewer than 60 times a minute. Symptomatic Bradycardia Symptomatic bradycardia is defined as a heart rate less than 60 beats per minute that elicits signs and symptoms. However, the heart rate is typically less than 50 beats per minute. Symptomatic bradycardia exists when the following three criteria are present: The heart rate is slow. The patient has symptoms. The symptoms are due to the slow heart rate. https://d3imrogdy81qei.cloudfront.net/video_images/4539/bradycardia.jpg Yes 103 https://www.proacls.com/training//video/atropine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2451.mp4 Atropine In this lesson, we'll go over the medication atropine and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of this lesson, we provide a Word about the various routes of access for drug administration. Atropine sulfate is an anticholinergic or antiparasympathetic, sometimes referred to as a parasympatholytic drug. A parasympatholytic agent is any substance or activity that has the effect of reducing the activity of the parasympathetic nervous system. Pro Tip #1: An anticholinergic agent is a substance that blocks the action of the neurotransmitter acetylcholine at synapses in the central and the peripheral nervous system. These agents inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The parasympathetic nervous system is often described as the rest and digest part of the autonomic nervous system. Atropine works by blocking this action. The autonomic nervous system is a control system that acts mostly unconsciously as it regulates bodily functions, such as the heart rate, respiratory rate, pupillary response, digestion, urination, and sexual arousal. Atropine Indications Now let's take a look at some indications for atropine. Atropine is one of the few ACLS medications that can be delivered via an endotracheal tube. However, vascular access is still the preferred route and, in most cases, would be the preference. Pro Tip #2: Atropine should be your first choice of treatment of symptomatic sinus bradycardia, as it may be the most beneficial in the presence of atrioventricular nodal blocks. Atropine Precautions and Contraindications There are a couple of precautions and contraindications when it comes to administering atropine. It is well known that atropine use during pulseless electrical activity (PEA) and asystole usually has no therapeutic benefit. Also important to remember, is that atropine most likely will not affect type 2, 2nd degree or 3rd degree AV blocks or blocks in non-modal tissue. Adult Dosage of Atropine Let's take a closer look at the adult dose of atropine. For bradycardia with or without acute coronary syndrome (ACS), administer 1 mg of atropine every 3 to 5 minutes or as needed. And make sure not to exceed a total dose of 0.04mg/kg or a total of 3 mg. Pro Tip #3: It's recommended to use a shorter dosing interval, such as every 3 minutes, and higher doses in severe clinical conditions. For organophosphate poisoning, you may need to use 2 – 4mg of atropine or higher to reverse the life-threatening symptoms of such a poisoning. The good news, as it relates to administering atropine, is that giving the drug via the intraosseous (IO) route has been found to be just as effective as intravenous (IV) infusion for rapid delivery of the drug. Pro Tip #4: Because large amounts of atropine may be required in patients with organophosphate poisoning, reconstitution of powdered atropine may be a viable option, especially when there is a mass casualty setting. Warning: It's also important to remember to utilize your personal protective equipment when treating patients with organophosphate toxicity to reduce and prevent the risk of cross-contamination with other rescuers. A Word About the Routes of Access for Drugs In this Word, we'll look at the priorities of access routes along with some specifics concerning the intravenous route. In the following Word section in the dopamine lesson, we'll finish up by looking at both the intraosseous route and the endotracheal route, along with a little information on fluid administration. Prioritizing Drug Access Routes The obvious priorities during cardiac arrest are high-quality CPR and early defibrillation. While the insertion of an advanced airway and drug administration are of secondary importance. It's important to understand that no drug given during cardiac arrest has been shown to improve survival rates to hospital discharge or improved neurologic function after cardiac arrest. Historically in ACLS, healthcare providers have administered medications via either the IV or endotracheal route. However, endotracheal absorption of medications is poor and unpredictable which makes optimal drug dosing problematic. Because of this, the IV or IO route will always be preferred. Intravenous (IV) Route A peripheral IV will be preferred for medication and fluid administration unless central line access is already available. However, central line access isn't necessary during most resuscitation attempts. Central line access could cause interruptions in CPR and complications during insertion, including vascular laceration, hematomas, and bleeding. Also, insertion of a central line in a non-compressible vessel is a relative, but not absolute, contraindication to fibrinolytic therapy in patients with acute coronary syndrome. Establishing a peripheral line, by contrast, does not require an interruption of CPR. Drugs, however, typically require 1 to 2 minutes to reach the central circulation when administered via the peripheral IV route. If a medication is administered via the peripheral venous route, administer it as follows: Administer the medication by bolus injection unless otherwise specified Follow the drug with a 20 ml bolus of IV fluid Elevate the extremity for about 10 to 20 seconds to facilitate the delivery of the medication into the central circulation https://d3imrogdy81qei.cloudfront.net/video_images/4367/atropine.jpg Yes 162 https://www.proacls.com/training//video/post-cardiac-arrest-care https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2794.mp4 Post Cardiac Arrest Care There has been substantial research and success in post-resuscitation care and recovery. Because of this, it has become an extremely important part of an aggressive ACLS resuscitation program. In this section of your ProACLS course, we'll be discussing the most current guidelines for achieving the most effective and successful recovery post-resuscitation and return of spontaneous circulation available today. This section will follow the latest recommendations provided by the American Heart Association and has been taken from the latest ECC published protocols. Now let's look at the return of spontaneous circulation (ROSC) and post-cardiac arrest care. Post Cardiac Arrest Programs Every healthcare system should implement a comprehensive and multidisciplinary system of care in a universal and consistent manner for the treatment of post-cardiac arrest patients to assure the very best of outcomes. All post-cardiac arrest programs should address the following: Targeted temperature management (TTM) Hemodynamic and ventilation optimization Immediate coronary reperfusion Percutaneous coronary intervention (PCI) for eligible patients Neurological care and prognostication Cognitive impairments Other structured interventions Post Cardiac Arrest Syndrome Pro Tip #1: It's important to understand that patients who have experienced a return of spontaneous circulation after cardiac arrest, regardless of the setting, have a complex combination of pathophysiological processes that are described as post-cardiac arrest syndrome. Post cardiac arrest syndrome includes the following: Post arrest brain injury Post arrest myocardial dysfunction Systemic ischemia Reperfusion response Persistent, acute, and chronic pathologies that may have participated in the cardiac arrest itself Post-cardiac arrest syndromes play a significant role in patient mortality and should be taken very seriously. Support for Caregivers Post Cardiac Arrest In addition to patient support, caregivers are also vulnerable. They should receive comprehensive discharge planning that includes: Medical and rehabilitative recommendations Return to normal activity expectations Return to work expectations This caregiver support should begin immediately during the patient's initial hospitalization and continue for as long as it's needed. Return to Normal Life Post Cardiac Arrest Returning to normal life after a traumatic event is never an easy thing. And it can be a challenge for both the patient and their primary caregiver. For this reason, a structured assessment should be part of any post-cardiac arrest care plan to assess for: Anxiety Depression Post-traumatic stress Fatigue And again, this assessment should be done for both the cardiac arrest survivor and any of their caregivers. Post Cardiac Arrest Care for Healthcare Providers It's not just the cardiac arrest survivors and their caregivers who need support after a traumatic cardiac arrest event. Both in-hospital and out-of-hospital healthcare providers may also experience emotional or psychological effects after providing care for patients in cardiac arrest. Pro Tip #2: The work of healthcare providers is never easy, and good outcomes are never guaranteed. When a patient dies following a cardiac arrest event, healthcare providers are at their most vulnerable. This is when emotional support is most needed. Following a cardiac arrest event, debriefing and referrals should be offered for follow-up care for emotional support. This should be provided for everyone involved, including lay rescuers, EMS providers, and hospital-based healthcare workers. A team debriefing can also be beneficial to allow for a review of the team's performance and quality improvement. A Word About Post Cardiac Arrest Treatment Providers should ensure an adequate airway and support breathing immediately after ROSC. Unconscious patients usually require an advanced airway for mechanical support of breathing. Providers should also elevate the head of the bed 30 degrees if tolerated by the patient to reduce the incidence of cerebral edema, aspiration, and ventilatory-associated pneumonia. Proper placement of an advanced airway, particularly during patient transport, should be monitored by waveform capnography. The oxygenation of the patient should be monitored continuously with pulse oximetry. While 100 percent oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial oxygen saturation of 92 to 98 percent to avoid potential oxygen toxicity. Hyperventilation is common after cardiac arrest and should be avoided because of the potential for adverse hemodynamic effects. Hyperventilation increases intrathoracic pressure, which decreases preload and lowers cardiac output. The decrease in PaCO2 seen with hyperventilation can also decrease cerebral blood flow directly. Ventilation should be started at 10 per minute and titrated to achieve a PetCO2 of 35 to 40 mmHg or a PaCO2 of 40 to 45 mmHg. Healthcare providers should frequently reassess vital signs and monitor for recurrent cardiac arrhythmias by using continuous ECG monitoring. If the patient is hypotensive, fluid boluses can be administered. If TTM is indicated, cold fluids may be helpful for the initial induction of hypothermia. If the patient's volume status is adequate, infusions of vasoactive agents may be initiated and titrated to achieve a minimum SBP of 90 mmHg or greater or a mean arterial pressure of 65 mmHg or more. Some advocate higher mean arterial pressures to promote cerebral blood flow. Brain injury and cardiovascular instability are the major factors that determine survival after cardiac arrest. Because TTM is currently the only intervention demonstrated to improve neurologic recovery, it should be considered for any patient who is comatose and unresponsive to verbal commands after ROSC. The patient should be transported to a location that reliably provides this therapy in addition to coronary reperfusion and other goal-directed post-arrest care therapies. Clinicians should treat the precipitating cause of cardiac arrest after ROSC and initiate or request studies that will further aid in evaluating the patient. It is essential to identify and treat any cardiac, electrolyte, toxicologic, pulmonary, and neurologic precipitants of the arrest. Overall, the most common cause of cardiac arrest is cardiovascular disease and associated coronary ischemia. Therefore, a 12-lead ECG should be obtained as quickly as possible to detect ST elevation or LBBB. Coronary angiography should be performed emergently for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG. When there is a high suspicion of AMI, local protocols for the treatment of AMI and coronary reperfusion should be activated. Coronary angiography, if indicated, can be beneficial in post-cardiac arrest patients regardless of whether they are awake or comatose. Even in the absence of ST elevation, emergent coronary angiography is reasonable for patients who are comatose after OHCA of suspected cardiac origin. Concurrent PCI and TTM are safe, with good outcomes reported for some comatose patients who have undergone PCI. Critical care facilities that treat patients after cardiac arrest should use a comprehensive care plan that includes acute cardiovascular interventions, use of TTM, standardized medical goal-directed therapies, and advanced neurologic monitoring and care. Neurologic prognosis may be difficult to determine during the first 72 hours after resuscitation. This should be the earliest time to prognosticate a poor neurologic outcome in patients not treated with TTM. For those treated with TTM, providers should wait 72 hours after the patient returns to normothermia before prognosticating by using clinical examination where sedation or paralysis can be a confounder. Many initially comatose survivors of cardiac arrest have the potential for a full recovery. For this reason, it's important to place patients in a hospital critical care unit where expert care and neurologic evaluation can be performed and where appropriate testing to aid prognosis can also be performed promptly. https://d3imrogdy81qei.cloudfront.net/video_images/4997/post-cardiac-arrest-care.jpg Yes 182 https://www.proacls.com/training//video/optimization-of-cardiopulmonary-function https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2795.mp4 Optimization of Cardiopulmonary Function In this lesson, we're going to cover post cardiac arrest interventions, such as targeted temperature management, hemodynamic and ventilation optimization, immediate coronary reperfusion with PCI, glycemic control, and neurologic care and prognostication. Targeted Temperature Management According to the latest national guidelines update for CPR and ECC, it is recommended that targeted temperature management interventions, also known as TTM, be administered to comatose adult patients with ROSC after cardiac arrest by selecting and maintaining a constant temperature somewhere between 32 and 36 degrees Celsius, or 89.6 to 95.2 degrees Fahrenheit, for at least 24 hours. Comatose is technically defined as lacking meaningful response to verbal commands. Hemodynamic and Ventilation Optimization Hemodynamic and ventilation optimization is the next intervention in post arrest care. Pro Tip #1: Although ACLS providers often use 100 percent oxygen while performing their initial resuscitation, you should titrate inspired oxygen during post cardiac arrest care to the lowest level required to achieve arterial oxygen saturation of 92 to 98 percent whenever possible. Doing so may help prevent any potential complications associated with oxygen therapy. Warning: Remember, excessive ventilations with high oxygen levels can have adverse hemodynamic effects, especially when intrathoracic pressures increase and because of a potential decrease in cerebral blood flow when partial pressure of carbon dioxide (PaCO2) in arterial blood decreases. It's important that healthcare providers start ventilation rates at 10 per minute. The goal is to achieve normocarbia – a partial pressure of end-tidal carbon dioxide (PetCO2) of 30 to 40 mmHg or a PaCO2 of 35 to 45 mmHg. This is a reasonable goal unless patient factors prompt more individualized treatments. Other PaCO2 targets may be tolerated for specific patients. An example of this would be when a higher PaCO2 may be more appropriate in a patient with an acute lung injury or high airway pressures. Likewise, mild hypercapnia might be a beneficial treatment as a temporary measure when treating cerebral edema. But hyperventilation could cause cerebra vasoconstriction. Pro Tip #2: Health care providers should note that when a patient's temperature is below normal, laboratory values reported for PaCO2 might be higher than actual values. In addition, healthcare professionals should titrate fluid administration in vasoactive or inotropic agents as needed to optimize blood pressure, cardiac output, and systemic perfusion. While optimal post cardiac arrest blood pressure remains unknown, a mean arterial pressure of 65 mmHg or greater is a reasonable goal per scientific studies and current guidelines. Immediate Coronary Reperfusion with PCI When treating for a return of spontaneous circulation in patients where coronary artery occlusion is suspected, rescuers should transport patients to a capable and reliable facility known for providing coronary reperfusion and other goal-directed post cardiac arrest care therapies. The decision to perform percutaneous coronary intervention (PCI) can be made irrespective of coma or a decision to induce hypothermia, because concurrent PCI and hypothermia are feasible and safe and have reported good outcomes. Glycemic Control Altering glucose concentration within a lower range of 80 to 110 mg/dL should not be attempted because of the increased risk of hypoglycemia. The latest guidelines update for CPR and ECC does not have a recommended specific target range of glucose management in adult patients with a return of spontaneous circulation after cardiac arrest. Neurologic Care and Prognostication The American Heart Association guidelines have established the following: the goal of post cardiac arrest management is to return the patient to their prearrest function levels. Reliable early prognostication on neurological outcome is an essential component of post cardiac arrest care. However, optimal timing is important to consider. In patients treated with TTM, prognostication using clinical examinations should be delayed for at least 72 hours after the return of normothermia. For those patients not treated with TTM, the earliest time is 72 hours after cardiac arrest and potentially longer if the residual effects of sedation or paralysis confounds the clinical examination. https://d3imrogdy81qei.cloudfront.net/video_images/5001/optimization-of-cardiopulmonary-function.jpg Yes 298 https://www.proacls.com/training//video/acls-adult-cpr https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2814.mp4 Adult CPR Teaching In this lesson, we're going to cover adult CPR, including exactly how to provide care. A patient who is unconscious, not breathing normally, and has no pulse is in cardiac arrest and needs CPR. At the end of the lesson, we'll provide you with a Word on high-quality CPR. CPR is a combination of chest compressions and ventilations that circulates blood and oxygen to the brain and other vital organs for a person whose heart and breathing have stopped. Remember the five links in the Adult Cardiac Chain of Survival: Recognize the cardiac emergency and call 911 Early CPR Early defibrillation Advanced life support Integrated, post-cardiac arrest care How to Provide Care As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive. Are you OK? Can you hear me? If you don't get an initial response, place your hand on the victim's forehead and tap on his or her collarbone. If you still do not get a response, proceed with the following steps. Call 911 and activate EMS or call in a code if you're in a healthcare setting. If there is a bystander nearby, you can ask for their help – calling 911, locating an AED, etc. In the event that you do not know how to proceed, call 911 on your cell phone, put it on speaker, and follow their instructions. Continue to assess the victim's responsiveness and vital signs – signs of breathing normally, signs of a pulse, etc. Check for the carotid pulse, located between the trachea and sternocleidomastoid muscle, in the valley between these two structures. Use the flat parts of your index and middle fingers and press with moderate force in that valley. Spend no more than 10 seconds looking for a pulse. If you've determined at this point that the victim is unresponsive, not breathing normally (as you now know, agonal respiration is not breathing normally and should be considered the same as NO respirations), and has no pulse, continue immediately with CPR. CPR Technique for Adults 1. Locate the area over the heart to begin chest compressions – between the breasts and on the lower third of the sternum.2. Stand or kneel directly over the patient's chest. Lock your elbows and use only your upper body weight to supply the force for the chest compressions, and count as you perform them. Pro Tip #1: Make sure you're directly over the victim's chest to maximize cardiac output, and not off to one side. If you're not directly over the chest, you may not adequately compress the heart. 3. Conduct compressions that go 2-2.4 inches deep (or 1/3 the depth of the victim's chest) and at a rate of between 100 and 120 compressions per minute, which amounts to two compressions per second.4. Perform 30 chest compressions. Pro Tip #2: To maintain a steady rhythm, count out loud while performing chest compressions – one, as you press down, and, as you allow the chest to recoil. When you reach 13, drop the and to maintain a two-syllable cadence on the compressions and not disrupt the rhythm. 5. Grab the rescue mask and seal it over the victim's face and nose.6. Lift the victim's chin and tilt his or her head back slightly.7. Breathe into the rescue mask and wait for the chest to rise and fall before administering the next breath.8. Continue to perform 30 chest compressions to two rescue breaths until help arrives, an AED arrives, or the victim is responding positively and breathing normally. Warning: Once you perform a chest compression, make sure you allow for full recoil of the chest cavity. You want to allow the chest to come all the way back to the neutral position before performing another compression. A Word About High-Quality CPR It's important to understand what constitutes high-quality CPR, as performing CPR correctly will give the victim the best chance of survival. High-Quality CPR Performing chest compressions at a rate of 100-120 per minute Compressing to a depth of at least 2 inches but not exceeding 2.4 Allowing for full recoil after each compression Minimizing pauses in compressions Ventilating adequately – two breaths after 30 compressions, with each breath delivered over one second, and each causing the patient's chest to rise Low-Quality CPR Compressing at a rate slower than 100 per minute or faster than 120 per minute Compressing to a depth of less than two inches or greater than 2.4 inches Leaning on the chest between compressions or performing compressions while not directly over the victim's heart Interrupting compressions for greater than 10 seconds Providing excessive ventilation – too many breaths or breaths with excessive force Warning: Once you begin CPR, it's important not to stop. If you must stop, do so for no more than 10 seconds. Reasons to discontinue CPR include more advanced medical personnel taking over for you, seeing obvious signs of life and the patient breathing normally again, an AED being available and ready to use, or being too exhausted to continue. https://d3imrogdy81qei.cloudfront.net/video_images/4979/acls-adult-cpr.jpg Yes 246 https://www.proacls.com/training//video/dopamine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2453.mp4 Dopamine In this lesson, we'll go over the medication dopamine and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we conclude our look at the various access routes for medication delivery. Dopamine is a naturally occurring catecholamine – any of a class of aromatic amines that includes a number of neurotransmitters – that has direct alpha- and beta-adrenergic effects depending on the dose administered. When medium doses are administered, like between 5 and 10 mcg/kg per minute in adult patients, dopamine will act directly on the beta 1 receptors, which causes an increase in both myocardial contractility and heart rate. Pro Tip #1: Contractility is the inherent strength and vigor of the heart's contraction during systole. According to Starling's Law, the heart will eject a greater stroke volume at greater filling pressures. For any filling pressure, the stroke volume will be greater if the contractility of the heart is greater. When dopamine is administered in doses greater than 10 mcg/kg per minute, the alpha receptors are typically stimulated. This causes an increase in systemic vascular resistance, also known as vasoconstriction. Dopamine Indications Now let's take a look at dopamine indications. Dopamine can be quite effective in treating hypotension when there are signs and symptoms that the patient is in shock and is usually used as a second-line drug for symptomatic bradycardia after atropine. Dopamine Precautions and Contraindications Dopamine has a couple precautions and contraindications to be aware of. Pro Tip #2: Dopamine can cause tachyarrhythmias and, as already mentioned, excessive vasoconstriction, which means that it should be used with caution in any patients who are suffering from cardiogenic shock with associated symptoms of congestive heart failure. Warning: It's vitally important to correct hypovolemia with volume replacement before initiating dopamine therapy. Adult Dosage of Dopamine Now let's look at the adult dosage of dopamine. The adult dosage of dopamine should be administered via IV and the most common infusion rate is between 5 and 20 mcg/kg per minute. You want to be sure to titrate the dosage and drip rate to the patient's response slowly and carefully. A Word About the Routes of Access for Drugs In the last Word, we looked at the priorities of access routes along with some specifics concerning the intravenous route. In this Word section, we'll finish up by looking at both the intraosseous route and the endotracheal route, along with a little information on fluid administration. Intraosseous (IO) Route Medications and fluids administered during resuscitation can be safely and effectively delivered via the IO route if IV access is not available. Important points to remember about IO access are: IO access can be established in all age groups IO access can often be achieved in 30 to 60 seconds The IO route of drug administration is preferred over the endotracheal (ET) route and may also be easier to establish in cardiac arrest patients Any ACLS medication or fluid that is given via IV can also be administered via IO IO cannulation provides access to a non-collapsible marrow venous plexus, which serves as a rapid, safe, and reliable route for the administration of medications, crystalloids, colloids, and blood during resuscitation. This technique uses a rigid needle, preferably a specially designed IO or bone marrow needle from an IO access kit. Endotracheal (ET) Route Both IV and IO routes of medication administration are preferred over the endotracheal route of administration. When considering the administration of medications via the endotracheal route during CPR, it's important to keep these concepts in mind: The optimal dosage of most medications delivered via the endotracheal route is not known The normal dosage of medications administered via the endotracheal route is roughly 2 to 2.5 times the intravenous route CPR will need to be interrupted so the medications don't regurgitate up the endotracheal tube Studies have demonstrated that epinephrine, vasopressin, and lidocaine are absorbed into the circulatory system after administration via the endotracheal route. When administering medications via the endotracheal route, dilute the dose in 5 to 10 ml of normal saline or sterile water, then inject the medications directly into the endotracheal tube. Fluid Administration It's important that healthcare providers titrate fluid administration and vasoactive or inotropic agents as needed to properly optimize blood pressure, cardiac output, and systemic perfusion. The optimal post-cardiac arrest blood pressure isn't known. However, a mean arterial pressure of 65 mm Hg or greater is a reasonable goal. In hypovolemic patients, the ECF volume is typically restored with normal saline or lactated Ringer's solution. Avoid D5W because it will reduce serum sodium too quickly. Serum electrolytes should be appropriately monitored. D5W refers to 5 percent Dextrose in Water (also known as D5). It's an isotonic carbohydrate solution that contains glucose as the solute. When it's used, the glucose is quickly absorbed by the cells and utilized for energy, leaving only water behind, which is then a hypotonic solution. https://d3imrogdy81qei.cloudfront.net/video_images/4371/dopamine.jpg Yes 109 https://www.proacls.com/training//video/morphine-sulfate https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2458.mp4 Morphine Sulfate In this lesson, we'll go over the medication morphine sulfate and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we take a look at respiratory distress. Morphine sulfate is a mu-opioid receptor agonist used to relieve pain. It produces analgesic effects by binding to mu-opioid receptors in the central nervous system. Morphine Sulfate Indications Now let's take a look at morphine sulfate indications. Morphine sulfate is indicated for chest pain that is refractory to the use of nitroglycerin. Morphine Sulfate Precautions and Contraindications Now let's go over the precautions and contraindications for morphine sulfate. Opioids, like morphine sulfate, are known to depress the respiratory system and may also lower blood pressure. For this reason, consider using a reduced dosage in older patients or those patients with an altered level of consciousness. Adult Dosage of Morphine Sulfate Now let's look at the adult dosage of morphine sulfate. Morphine sulfate may be given to patients in 2 to 4 mg increments via slow IV push. Additional morphine can be given in doses of 2 to 8 mg 5 to 15 minutes after the first dose. Pro Tip: Be sure to titrate the dose of morphine to the patient's response and effects. If you notice signs of hypotension, hypoventilation, bradycardia, or any other serious central nervous system depression symptoms appear, naloxone may be given at 0.4 to 2 mg via IV to reverse the opioid side effects. Also, be aware that gastrointestinal upset may occur in higher doses as well. A Word About Respiratory Distress As respiratory depression can occur with the use of morphine sulfate, we're going to dive a little deeper into the three types of respiratory issues – respiratory distress, respiratory failure, and respiratory arrest. In this Word, we'll first look at respiratory distress. Normal and Abnormal Breathing The average respiratory rate for an adult is about 12 to 16 respirations per minute. Normal tidal volume of 8 to 10 ml per kg will maintain normal oxygenation and the elimination of CO2. Tachypnea occurs when the patient's respiratory rate is above 20 respirations per minute, while bradypnea occurs when their respiratory rate falls below 12 respirations per minute. A respiratory rate below 6 respirations per minute (known as hypoventilation) will require assisted ventilation with a bag-mask device or an advanced airway with 100 percent oxygen. Respiratory Distress Respiratory distress is a clinical state that is characterized by an abnormal respiratory rate (such as tachypnea) or effort. The respiratory effort may be increased (such as nasal flaring, retractions, and the use of accessory muscles) or it may be inadequate (like hypoventilation or bradypnea). Respiratory distress can range from mild to severe. For instance, a patient with mild tachypnea and a mild increase in respiratory effort with changes in airway sounds would be considered in mild respiratory distress. A patient with marked tachypnea, a significantly increased respiratory effort, a deterioration in skin color, and changes in their mental status would be considered in severe respiratory distress. Severe respiratory distress can be an indication of respiratory failure. Clinical signs and symptoms of respiratory distress will typically include a few, or all, of the following signs: Tachypnea Increased respiratory effort, such as nasal flaring and retractions Inadequate respiratory effort, such as hypoventilation or bradypnea Abnormal airway sounds, such as stridor, wheezing, and grunting Tachycardia Pale, cool skin; however, it's important to note that some causes of respiratory distress, such as sepsis, may cause the skin to get warm, red, and diaphoretic Changes in the patient's level of consciousness and/or agitation The use of abdominal muscles to assist the patient with breathing It's also important to note that these indicators may vary in severity. Respiratory distress should be apparent when a patient tries to maintain adequate gas exchange despite airway obstruction, reduced lung compliance, or lung tissue disease. As the patient begins to tire or as respiratory function or effort (or both) deteriorate, adequate gas exchange cannot be maintained. When this happens, clinical signs of respiratory failure will develop. https://d3imrogdy81qei.cloudfront.net/video_images/4381/morphine-sulfate.jpg Yes 90 https://www.proacls.com/training//video/what-is-bradycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2788.mp4 What is Bradycardia? In this lesson, we're going to cover bradycardia, including some things to be aware of when dealing with bradycardic patients, types of bradycardia, and some information on the best courses of treatment to resolve that patient's bradycardia. And at the end of the lesson, we'll dig a little deeper into the types of bradycardia. Absolute bradycardia is defined as a pulse rate less than 60 beats per minute. During your patient assessment, it's important to determine whether any life-threatening signs and symptoms are present that have been caused by that bradycardia. Bradycardia can present itself in several different cardiac rhythms, which include sinus bradycardia and varying degrees of AV heart blocks. Pro Tip #1: Regardless of the patient's rhythm, if their heart rate is too slow and the patient has symptoms from that slow heart rate, bradycardia should be treated to increase the heart rate and improve perfusion. For patients who are asymptomatic, you should continue to provide care with close monitoring and choose which appropriate treatment and care should be given. The primary treatment for symptomatic bradycardia includes the following: 1. Administration of supplemental oxygen if pulse oximetry is below 94 percent and establish IV access.2. Monitor the patient's ECG rhythm.3. Obtain a 12 lead as soon as possible, but don't delay therapy to get it.4. Administration of atropine at 1 mg via rapid IV push to increase the patient's heart rate.5. If atropine is proving to be ineffective, consider transcutaneous pacing. Pro Tip #2: If there are serious signs and symptoms that the patient is unresponsive, the first line of treatment should be transcutaneous pacing rather than atropine. 6. Consider the administration of other medications such as:a. An epinephrine infusion at between 2 to 10 mcg per minuteb. A dopamine infusion at between 5 and 10 mcg per kg per minute Warning: If you are dealing with a conscious patient who needs transcutaneous pacing, you may want to consider sedation first to help alleviate their discomfort. Some patients may present with relative bradycardia when their heart rate is over 60 beats per minute, but they present with a low blood pressure or decreased level of consciousness. In these cases, the same interventions would be required as a patient with absolute bradycardia. An Additional Word About Bradycardia As already mentioned above, bradycardia is defined by a heart rate of less than 60 beats per minute. This can result in a decrease in cardiac output, which may lead to a patient becoming clinically unstable if the patient's heart cannot compensate for the decreased rate by increasing its ability to pump more blood with each heartbeat. Also mentioned above, absolute bradycardia is defined as any heart rate less than 60 beats per minute. While relative bradycardia is a term used to describe a heart rate that is greater than 60 beats per minute but too slow given the patient's condition. For example, the patient may have a heart rate of 70 beats per minute, while also experiencing altered mental status, hypotension, or other signs of hemodynamic compromise. This would be considered a clinically significant bradycardia because the heart rate is not adequate for their clinical condition. Hypoxemia is a common cause of bradycardia. Other causes of bradycardia include medications, structural damage, and metabolic dysfunction, such as electrolyte abnormalities and thyroid disease. The ACLS algorithm is a guideline for the treatment of clinically significant bradycardia. Sinus Bradycardia Sinus bradycardia can result from excess vagal stimulation, which slows SA node discharge. This may result from hypoxia, structural heart disease, damage to the cardiac electrical conduction system, medications, such as beta-blockers and calcium channel blockers, and metabolic dysfunction. The clinical significance of sinus bradycardia is that it can result in decreased cardiac output. ln those patients who routinely engage in aerobic exercise, sinus bradycardia could be a normal finding. Idioventricular Rhythm Idioventricular rhythms occur when a ventricular focus acts as the primary pacemaker for the heart. This is identified by a slow ventricular rate of 20 to 40 beats per minute and a wide and bizarre appearance of the QRS complexes. Because atrial activity is absent, there are no P waves preceding each QRS complex. The clinical significance of idioventricular rhythm is that it can result in decreased cardiac output and poor perfusion. In the absence of atrial contraction, a reduced volume of blood is ejected into the ventricles. In addition, the ventricular rate is slow, which may result in a reduced cardiac output. Heart Blocks As mentioned in the opening of this lesson, bradycardia can present itself in several different cardiac rhythms, which include varying degrees of atrioventricular (AV) heart blocks. AV heart blocks are caused by delayed, inconsistent, or absent electrical conduction through the AV node. These are classified as first degree, second degree (Mobitz type l and II), and third-degree. https://d3imrogdy81qei.cloudfront.net/video_images/5037/what-is-bradycardia.jpg Yes 133 https://www.proacls.com/training//video/atrial-fibrillation-acls https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2465.mp4 Atrial Fibrillation Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure, and other heart-related complications. In this lesson, we'll look at the three types of atrial fibrillation and then look at a typical ECG readout for an adult patient in AFib and provide a cardiac interpretation. And at the end of the lesson, we'll look at some common causes and side effects of AFib in adult patients. The Three Types of Atrial Fibrillation 1. Paroxysmal Paroxysmal, or transient atrial fibrillation, is defined by the following: Episodes that stop on their own Episodes that last anywhere from seconds to minutes, hours, or even up to one week 2. Persistent Persistent atrial fibrillation is defined by the following: Episodes that last longer than one week Episodes that last less than one week but are only stopped using either pharmacological intervention or electrical cardioversion 3. Long-Standing Persistent Long-standing persistent atrial fibrillation, formerly known as chronic or permanent atrial fibrillation, is defined as episodes that last longer than a year. Atrial fibrillation occurs when multiple electrical impulses are being generated in the atria and at the same time, which causes chaotic myocardia responses. AFib can diminish the preload and effectiveness of the cardiac contractions. This action could then cause the development of microemboli due to stagnant blood flow from the atria. In certain instances, this will even lead to a rapid ventricular response that's secondary to a reentry problem. Pro Tip: The electrical pattern on an ECG will have no discernible P-waves, but instead, will show fibrillatory waves between each QRS complex. And because there's a lack of coordinated electrical impulses generated from the atria traveling through the AV node into the ventricles, the result is usually an irregular ventricular response, which also occurs irregularly. Now let's take a look at an ECG for an adult patient in atrial fibrillation. *Atrial Fibrillation ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is irregular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's 80 beats per minute, which is within normal range, but it's also variable because of its irregularity. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No! Do they occur regularly? The answer is obviously no again. Is there one P-wave for each QRS complex? No. Are the P-waves smooth, rounded, and upright? No, only fibrillatory waves are present. Do all the P-waves have a similar shape? Again, that answer is no, because they aren't present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, it is within the normal range. Is the QRS complex wide or narrow? In this case, it's narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in atrial fibrillation. We have an irregular rhythm. We have a rate that is 80 beats per minute but also variable/irregular. The P-waves are missing. There is no PR interval. The QRS is less than .12 seconds and thus normal. Common Causes and Side Effects of AFib in Adult Patients The causes of AFib are numerous, but some common underlying reasons for it are: Congestive heart failure Previous history of damage to the SA node Conductive system dysfunction, from either current or past myocardial infarction A traumatic injury An underlying disease Past or present use of harmful drugs A metabolic disorder Common side effects of AFib include but aren't limited to: A higher risk for coronary, cerebral, or pulmonary embolism and as a result of the increased potential for microemboli to develop, secondary to the lack of circulation of blood from the atria. Rapid ventricular response which can accelerate the ventricular rate to above 100 beats per minute. AFib combined with higher ventricular rates may decrease the amount of blood ejected from the heart due to the lack of, what is sometimes referred to as, the preloading atrial kick. https://d3imrogdy81qei.cloudfront.net/video_images/4393/atrial-fibrillation-acls.jpg Yes 281 https://www.proacls.com/training//video/what-is-stroke https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2780.mp4 What is Stroke? In this lesson, we're going to look at the major types of stroke of which you should be familiar. But first, the word stroke is a general term that refers to an acute neurological impairment following an interruption in blood supply to a specific area of tissue within the brain. Although immediate stroke care is vital for every patient, the point of this particular lesson is about reperfusion therapy for acute ischemic stroke. There are two major types of stroke: Ischemic stroke – this type of stroke accounts for almost 87 percent of all strokes. It's usually caused by an embolism which occludes an artery and affects the subsequent tissue of the brain that that particular artery affected. Hemorrhagic stroke – this type of stroke accounts for around 13 percent of all strokes. It occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue which causes damage. Warning: In cases of suspected or confirmed hemorrhagic stroke, fibrinolytic therapy is contraindicated, and the use of anticoagulants is to be avoided. Around 795,000 people have a new or recurrent stroke each year in the U.S., which is why stroke remains a leading cause of death in the U.S. Pro Tip #1: It's important to realize that early recognition and treatment of acute ischemic stroke is vital because IV fibrinolytic treatment should be provided as quickly as possible. Over the years, there have been significant improvements in stroke care because of the combined efforts between public education, 911 dispatch, early detection by EMS and triage, systematic hospital stroke protocol, and better overall management of stroke units. There has also been an increase in appropriate fibrinolytic therapies and overall stoke care has definitely improved. In many cases, ACLS providers are well within the scope of being qualified to identify and manage the initial care of patients who are displaying acute stroke symptoms. In stroke cases, it's important to recognize that while an ECG is helpful, it should not take priority over obtaining a computed tomography, known commonly as a CT scan. Pro Tip #2: It's also important to remember that no one arrhythmia is specific for or related to stroke. However, an ECG may help identify some evidence of a recent acute myocardial infarction or an arrhythmia such as atrial fibrillation, which could have caused that embolic stroke. Many stroke patients demonstrate arrhythmias, but if the patient is hemodynamically stable, treatment of such arrhythmias are not usually indicated. It is generally accepted and recommended to initiate and maintain cardiac monitoring during the first 24 hours of observation in patients who have experienced an acute ischemic stroke in order to detect atrial fibrillation and other potentially life-threatening arrhythmias. This is important because the goal of stroke care is to minimize brain injury and maximize recovery. Stroke Chain of Survival The American Heart Association and the American Stroke Association have developed a stroke chain of survival that is similar to the chain of survival for sudden cardiac arrest. The stroke chain of survival correlates actions to be taken by patients, family members, and healthcare providers in order to maximize stroke recovery. The established links in the stroke chain of survival are as follows: Rapid recognition and reaction to the stroke warning signs. Rapid EMS dispatch by calling 911. Rapid EMS system transport and pre-arrival notification to the receiving hospital by the EMTs. Rapid diagnosis and treatment upon arrival to the appropriate hospital. Patients with acute ischemic stroke have what is referred to as time-dependent benefit for fibrinolytic therapies, which is similar to patients with a myocardial infarction that demonstrates ST-segment elevation. However, in stroke cases, this time-dependent benefit is much shorter. Pro Tip #3: It's important to remember that the critical time period for the administration of IV fibrinolytic therapies begins with the onset of symptoms. The critical time periods from hospital arrival are as follows: The immediate general assessment should be within 10 minutes The immediate neurological assessment should be performed within 25 minutes The acquisition of a CT scan (or CAT scan) of the patient's head should be done within 25 minutes The interpretation of the scan should be completed within 45 minutes The administration of fibrinolytic therapies should be within 60 minutes from the time of emergency department arrival The administration of fibrinolytic therapies may be delivered in as much as 3 to 4.5 hours in some select patients timed from the onset of symptoms The administration of endovascular therapy should be within 6 hours in select patients timed from the onset of symptoms The admission to a monitored hospital bed should be within 3 hours https://d3imrogdy81qei.cloudfront.net/video_images/5021/what-is-stroke.jpg Yes 314 https://www.proacls.com/training//video/tachycardia-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2791.mp4 Tachycardia Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – stable and unstable tachycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 35-year-old male patient who is conscious and alert. You begin by asking him how he feels. During your primary assessment, you find him to be responsive, his airway open, and his breathing is rapid. He tells you that symptoms began while he was at work. It was a very stressful day and symptoms began about an hour before you saw him. His chief complaints are that his heart feels like it's racing, he's experiencing some dizziness, and also some weakness. Your initial assessment recap: 35-year-old male Conscious and alert Symptoms began about one hour ago Heart is racing Feels dizzy Feels weak Since the patient doesn't appear to have any life-threatening conditions, you direct a team member to get a good set of vitals. A member of your team a few minutes later tells you that the patient's vital signs are: Respiratory rate: 24 Pulse rate: 188 Blood pressure: 110/70 Skin: cool and pale SPO2: 92 percent Based on his O2 saturation, you decide to start oxygen immediately and you do so at 4 liters via nasal cannula. Your goal is to titrate oxygen to keep his O2 saturation level at 94 percent or higher. After oxygen has been started, you then decide that you need to get an ECG reading. You ask a team member to do this and after an ECG has been attached and you look at the readout, you see a narrow complex supraventricular tachycardia (SVT). Since the patient is stable, you direct a team member to first try vagal maneuvers. However, that didn't work, so you now opt for drug therapy and direct a team member to start an antecubital IV 18 gauge with normal saline at a TKO rate. Now that you have the IV established, you decide to try administering adenosine at 6mg via rapid IV push. You remind the team member in charge of medications to flush the line with 20ml of saline after giving the adenosine, so the medication gets completely into the central circulatory system. You begin to consider a second dose of adenosine at 12mg in 1 to 2 minutes if this first dose doesn't work and if the patient is still stable. After that first dose of adenosine, you take a look at the monitor and see that the patient is still in SVT. You direct a team member to get a new set of vitals. The team member comes back with the following information: Respiratory rate: 18 and shallow Pulse rate: 174 and weak Blood pressure: 94/70 Skin: cool and pale SPO2: 94 percent As you begin to consider getting a 12 lead ECG attached to the patient, he suddenly goes unconscious. Now that you have an unstable patient, that possible second dose of adenosine is off the table, so you direct the defibrillator team to perform synchronized cardioversion. The defibrillator pads are applied, and the defibrillator is set for a synchronized shock of 50 joules. A defibrillator team member announces, Clear, charging, shocking at 50 joules on 3 – 1,2,3, and delivers a shock to the patient. You again look at the monitor to see if there are any changes in the patient's rhythm, and this time, you see a normal sinus rhythm at 80 beats per minute. The patient's rhythm has been successfully converted. The patient begins to regain consciousness after a few seconds. As he is becoming more responsive, you direct a team member to get a new set of vitals, as you continue to monitor the patient for changes. https://d3imrogdy81qei.cloudfront.net/video_images/5043/tachycardia-teaching.jpg Yes 202 https://www.proacls.com/training//video/acls-adult-aed https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2815.mp4 Adult AED Teaching In this lesson, we're going to cover using an AED on an adult patient, including the exact technique and steps you'll use when faced with a cardiac emergency that requires the use of an AED. An AED (Automated External Defibrillator) is a portable electronic device that analyzes the rhythm of the heart and delivers an electrical shock, known as defibrillation, which helps the heart re-establish an effective rhythm. Warning: When using an AED, there are a couple of important things to keep in mind as it relates to your surroundings. Are there combustible gases or liquids at the scene? Are there any liquids that could connect the victim with yourself, the responder, or someone else, that could result in electrocution? Pro Tip #1: If the scene isn't safe enough to use an AED, drag or move the patient to a safer area where you won't have to worry about explosives or electrocution from water and then use the AED. These are two important considerations before using an AED, but there are a few other things to note when defibrillating an adult patient. If the victim is female and wearing an underwire bra, it shouldn't present any complications. However, if it is a concern, you can disconnect it and remove it from the pathway to the heart. Necklaces should be moved to the side Any patches – nicotine, analgesic, nitro gel, etc. – should be removed if they are in the way of the pads Piercings shouldn't cause any problems It's OK if the victim or the victim's clothing is wet, as long as the chest area is dry and you or the victim aren't submerged in water or connected by it There are no special considerations for pregnant women Pro Tip #2: It's OK to be just as aggressive with a pregnant woman as you would any other patient. The primary focus should be on the mother, as saving her will also help save the baby. The care you provide to the mother won't put the baby in any more jeopardy. How to Provide Care As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive. Are you OK? Can you hear me? If you don't get an initial response, place your hand on the victim's forehead and tap on his or her collarbone. If you still do not get a response, proceed with the following steps. Call 911 and activate EMS or call in a code if you're in a healthcare setting. If there is a bystander nearby, you can ask for their help – calling 911, locating an AED, etc. In the event that you do not know how to proceed, call 911 on your cell phone, put it on speaker, and follow their instructions. Continue to assess the victim's responsiveness and vital signs – signs of breathing normally, signs of a pulse, etc. Check for the carotid pulse, located between the trachea and sternocleidomastoid muscle, in the valley between these two structures. Use the flat parts of your index and middle fingers and press with moderate force in that valley. Spend no more than 10 seconds looking for a pulse. If you've determined at this point that the victim is unresponsive, not breathing normally, and has no pulse, continue immediately with your AED. AED Technique for Adults Turn on the AED. Remove the patient's clothing to reveal a bare chest and dry the chest off if it's wet. Attach the AED pads to the patient's chest. The pads should have a diagram on placement if you need a reminder. The first pad goes on the top right side of the chest. The second pad goes on the bottom left side mid axillary, under the left breast. Make sure they adhere well. Plug the cable into the AED and be sure no one is touching the patient, including yourself. The AED should now be charging and analyzing the rhythm of the patient's heart. If the scene is clear and no one is touching the patient, push the flashing shock button. Then go right into CPR. It's OK to perform CPR over the pads, so don't worry about moving them. Stand or kneel directly over the patient's chest. Lock your elbows and use only your upper body weight to supply the force for the chest compressions, and count as you perform them. Conduct compressions that go 2-2.4 inches deep (or 1/3 the depth of the victim's chest) and at a rate of between 100 and 120 compressions per minute, which amounts to two compressions per second. Perform 30 chest compressions. Grab the rescue mask and seal it over the victim's face and nose. Lift the victim's chin and tilt his or her head back. Breathe into the rescue mask and wait for the chest to rise and fall before administering the next breath. After one round of CPR, let the AED analyze the patient again. If the AED advises you to perform another shock, make sure no one is touching the patient and press the shock button. Go right back into CPR. Continue this cycle of CPR, re-analyzation, charging, shock, back into CPR until help arrives, the patient is responsive and breathing normally, or the next level of care takes over. https://d3imrogdy81qei.cloudfront.net/video_images/4981/acls-adult-aed.jpg Yes 356 https://www.proacls.com/training//video/fibrinolytic-agents https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2455.mp4 Fibrinolytic Agents In this lesson, we'll go over the use of fibrinolytic medications and all of their effects, including indications, precautions and contraindications, and adult dosages. Fibrinolytic medications are not usually found in advanced cardiac life support pharmacological drug cards specifically. However, their use is vitally important to reperfusion therapies. Fibrinolytic drugs – also called thrombolytic drugs – are any medication that is capable of stimulating the dissolution of blood clots, or as they're sometimes referred to as – thrombus. These types of drugs work by activating something referred to as fibrinolytic pathways. Pro Tip #1: This is important because it differentiates fibrinolytic medications from anticoagulant drugs, routinely referred to as heparin and Coumadin – Two common anticoagulants that work by preventing normal clotting factors from functioning correctly, thereby inhibiting the blood from clotting. Fibrinolytic medications, which prevent the formation of blood clots by suppressing the function of multiple clotting factors that are normal and present in the blood, are different from anticoagulants. Pro Tip #2: There are numerous fibrinolytic agents on the market, each of which may produce varying mechanisms of action. And while there are similarities between these are anticoagulants, fibrinolytic drugs produce the therapeutic effect of breaking down the fibrin and fibrinogen matrix of a thrombosis (fibrinolysis), thus fragmenting the clot that is obstructing an artery and reestablishing distal blood flow. Fibrinolytic Indications Now let's take a look at some indications for fibrinolytic medications. The most common indication for the use of fibrinolytic medications include the following two: Acute myocardial infarction, also known as AMI. Acute ischemic stroke, also known as AIS. In patients with acute myocardial infarction, fibrinolytic drugs would be indicated if the ST-segment elevation is consistent with a myocardial infarction of greater than or equal to 1mm in two or more contiguous leads. Contiguous leads are next to one another anatomically speaking. They view the same general area of the heart (specifically the left ventricle). Fibrinolytic drugs can also be indicated if the signs and symptoms of a myocardial infarction last longer than 15 minutes and less than 12 hours and if PCI (percutaneous coronary intervention) is not available within 90 minutes of medical contact. If the indication is related to ischemic stroke, patients may qualify if they suffer from sudden onset of a focal neurological deficit such as: Slurred speech Facial droop Weakness on one side of their body Paralysis on one side of their body Patients may also qualify for fibrinolytic medications if the stroke symptoms do not seem to be self-resolving, which is what you usually see when it's a transient ischemic attack (or TIA) and the signs and symptoms are present for up to three hours but not greater than 4.5 hours. Fibrinolytic Precautions and Contraindications There are a few precautions and contraindications when it comes to administering fibrinolytic medications that you should be aware of. When using fibrinolytic drugs, there are several patient factors that would exclude their use, which include (but are not limited to): Hypertension with systolic blood pressure greater than 180 to 200mm HG Right arm vs. left arm blood pressure differences greater than 15mm HG Significant head or facial trauma within the past 3 months Prior intracranial hemorrhage A bleeding disorder or internal bleeding within the prior 2 to 4 weeks The use of a current anticoagulant treatment Pregnancy A serious systemic disease which would include advanced cancer or kidney disease Ischemic stroke greater than 3 hours or less than 3 months Pro Tip #3: However, that last contraindication would not include the current condition being considered for the current fibrinolytic treatment. Adult Dosage of Fibrinolytic Medications The adult dosage for fibrinolytic treatments can be a little complex because the dose of the treatment would depend on the exact fibrinolytic medication being used. Having said that, there are three major classes of fibrinolytic drugs: tissue plasminogen activator (tPA), streptokinase (SK), and urokinase (UK). While drugs in these three classes all have the ability to effectively dissolve blood clots, they differ in their detailed mechanisms in ways that alter their selectivity for fibrin clots. https://d3imrogdy81qei.cloudfront.net/video_images/4375/fibrinolytic-agents.jpg Yes 208 https://www.proacls.com/training//video/respiratory-arrest-case-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2777.mp4 Respiratory Arrest Case Teaching In this lesson, we're going to take a look at a respiratory case that you could be confronted with at some point in your career. And at the end of the lesson, we'll take a brief look at alternative airway devices. For the purpose of this lesson, we're making you the team leader throughout this entire scenario, a move that will be repeated throughout this section of your ProACLS course. Here's what you know about the scene and situation. You have just come upon a 25-year-old male who appears to be unresponsive. Witnesses tell you that the man was wheezing and having a difficult time breathing. He then collapsed, which is how you find him. Your initial assessment recap: 25-year-old male Appears to be unresponsive Was having a difficult time breathing The patient then collapsed Let's also assume that the scene is safe and all personal protective equipment is available or in use. Pro Tip #1: While we've probably pointed this out before, it's important to remember that before engaging in any advanced life support actions, that you first practice basic life support. Proper Steps for Treating a Patient in Respiratory Arrest 1. The first thing you need to do is verify that the patient is indeed unresponsive. To this end, you (the team leader) direct a team member to use the tap and shout sequence to determine responsiveness. You find the patient to be unresponsive and call in a code team. 2. You direct a team member to check the patient for a pulse and signs of normal breathing. Your team finds that the male patient has a pulse but is not breathing normally. 3. You then direct the team member in charge of airway management to place a basic airway adjunct and begin rescue breathing with a bag valve mask at 15 liters per minute with oxygen. 4. You direct the airway management team member to give 1 breath every 6 seconds. Pro Tip #2: Make sure to look for visible signs of good chest rise and fall to ensure the rescue breaths are effective. 5. You then direct the team member in charge of the defibrillator and monitor to get a set of vitals and attach the ECG monitor to the patient. The vitals the team member gives you are as follows: a. Blood pressure: 100/70b. Pulse rate: 120 and weakc. O2 saturation: 94 percentd. ECG: normal sinus rhythm How do You Proceed with this Information? Since the ECG is showing a normal sinus rhythm, oxygenation is good, and the patient's blood pressure is normal, you continue providing rescue breathing and consider possible causes for the patient's respiratory arrest. In preparation for further treatment, you also decide to place an advanced airway and establish an IV. A Word About Alternative Airway Devices If you find yourself in a situation where endotracheal intubation is unsuccessful, and basic airway management techniques do not provide adequate ventilation, alternative airway devices that allow you to secure a patent airway should be considered. The laryngeal mask airway (LMA) is inserted blindly into the airway while it is guided in place using your middle finger. The mask, when properly seated, will cover the esophagus and facilitate airflow into the lungs. Dual-lumen airway devices, such as the esophageal Combitube, are also acceptable alternatives to intubation. Dual-lumen devices are also blindly advanced into the airway and will come to rest in the esophagus in most situations. Proper verification of its placement is accomplished by ventilating into the tube that produces clear and equal breath sounds and no epigastric sounds. This can also be confirmed with waveform capnography. Other alternative advanced airway devices, such as the King LT, and supraglottic airway devices, such as the LMA and iGel, may also be considered as alternatives to endotracheal intubation. https://d3imrogdy81qei.cloudfront.net/video_images/5015/respiratory-arrest-case-teaching.jpg Yes 115 https://www.proacls.com/training//video/ecg-interpretation https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2463.mp4 ECG Interpretation To successfully manage a patient who is in cardiac arrest, the caregiver must carefully, immediately, and systematically identify the cardiac rhythm and choose the most appropriate treatment algorithm. In the following lessons, we'll look at different cardiac dysrhythmias that can lead to cardiac arrest, their characteristics, and the appropriate therapies used to treat and correct the particular dysrhythmia whenever possible. However, in this lesson, we'll first look at interpreting the information on ECGs. Pro Tip #1: It's important to remember that knowing the patient's medical history, including all the events that have led up to the medical emergency, will greatly aid you in determining if there's any chance of reversing underlying causes for the cardiac arrest. An example of the above would be assessing the patient using the five H's and five T's. (Which will be discussed in detail in the secondary survey section of this program.) The Five Hs Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo or hyperkalemia Hypothermia The Five Ts Tension pneumothorax Tamponade Toxins Thrombosis (coronary) Thrombosis (pulmonary) Pro Tip #2: It's also important to remember that until an underlying cause has been identified and corrected, pharmacological and electrical therapies might offer little or no help when trying to resuscitate a cardiac arrest victim. When assessing the electrical activity of a patient's heart, it's vital to recognize the underlying dysrhythmia and know how to treat it appropriately to restore a perfusing cardiac rhythm. A sinus rhythm is defined as any cardiac rhythm where depolarization of the cardiac muscle begins at the sinus node, which is characterized by the presence of correctly oriented P-waves on the electrocardiogram. An ECG waveform represents each electrical event in the cardiac conduction system during a cardiac cycle. However, this doesn't mean that the heart muscle is reacting properly or in correlation with the electrical patterns. It simply shows that the electrical events that may stimulate myocardial function are happening. (This will be discussed in more detail when we look at each individual rhythm.) Waveforms Explained For the following explanations, we'll be assuming that the waveform is normal, and that normal mechanical function is occurring. The P-Wave The P-wave is the first waveform in the complete waveform complex, and it's normally found upright in healthy patients. It represents the depolarization of both the right and left atria, which occurs at the same time. The PR Segment The segment between the P-wave and the R-wave represents the delay of the electrical circuit in the AV node. This segment shows the time it takes from the end of the P-wave to the beginning of the ventricular response, represented by the QRS complex. The QRS Complex The QRS complex is the combination of three of the graphical deflections seen on a typical electrocardiogram (EKG or ECG). It is usually the central and most visually obvious part of the tracing; in other words, it's the main spike seen on an ECG line. The Q-Wave The Q-wave represents the first activity of the ventricular depolarization and is usually the first negative deflection after the P-wave in the complete complex. (We'll discuss the significance of Q-wave formations specifically as it relates to certain dysrhythmias in each of the rhythm evaluations.) The R-Wave The R-wave is the first positive deflection after the P-wave. The S-Wave The S-wave is the first negative deflection after the R-wave. The ST Segment The ST segment represents the timeframe between ventricular polarization and repolarization. It's the baseline of the cardiac cycle and, therefore, electrically neutral; there should be no inflection or deflection as it's isoelectric. Pro Tip #3: An ST elevation or depression of more than 1mm can be clinically significant and may indicate an underlying cardiac issue, either acutely or chronically. The T-Wave The T-wave represents repolarization of the ventricles and should be seen moving in the same general direction as the QRS segment. If the T-wave is inverted, this could also indicate a potential cardiac problem. It's quite helpful for healthcare providers to have a repeatable and easy method for interpreting ECG rhythms, which is why we'll be following a serial pattern for reading and interpreting all ECGs. Interpreting ECG Rhythms The pattern of interpretation most commonly used is to look at the following: Is the rhythm regular or irregular? Is the heart rate normal, fast, or slow? To determine the patient's heart rate The horizontal axis of ECG paper grids is where time is measured. Each small square is 1mm in length and represents .04 seconds. Each larger square is 5mm in length and represents .20 seconds. Therefore a 6 second interval would be 30 large squares. To determine the heart rate, count the number of QRS complexes over this 6 second interval and multiply by 10. Are the P-waves present? Do they occur regularly? Is there one P-wave for each QRS complex? Are they smooth, rounded, and upright? Do they all have a similar shape? Does the PR interval fall within the norm of .12 to .20 seconds? Is it constant? On the QRS complex, is the QRS interval less than .12 seconds? Is it wide or narrow? Are they similar in appearance? When using a systematic approach for interpreting ECG rhythms, you'll help yourself and your teammates to efficiently and effectively diagnose underlying cardiac conditions. Which, goes without saying, will also help the cardiac patient. https://d3imrogdy81qei.cloudfront.net/video_images/4389/ecg-interpretation.jpg Yes 351 https://www.proacls.com/training//video/what-is-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2790.mp4 What is Tachycardia? In this lesson, we're going to cover tachycardia, including some things to be aware of when dealing with tachycardic patients, types of tachycardia, underlying causes, and some information on the best courses of treatment to resolve that patient's tachycardia. Tachycardias can be both stable and unstable. In adults, tachycardia is technically defined as heart rates greater than 100 beats per minute. Types of Tachycardia Common types of tachycardia include: Atrial fibrillation Atrial flutter Sinus tachycardia Supraventricular tachycardia (SVT) Ventricular tachycardia Ventricular fibrillation Causes of Tachycardia Many things can cause tachycardia, including semi-benign causes such as fever or stress. More serious causes of tachycardia include: Shock Medications Metabolic dysfunction Hypoxemia Damage to the heart muscle Perfusion problems may develop when the patient's heart beats too fast and the ventricles are not able to fill properly with blood, which is technically called ejection fraction compromise. This occurs due to a lack of preload before the heart fully contracts and can cause a decrease in cardiac output and poor perfusion, which can lead to hemodynamic instability. Pro Tip #1: It's important to quickly assess a tachycardic patient and determine if their signs and symptoms are the result of the tachycardia. It's equally important to find underlying causes of the tachycardia and treat those causes. Patients with heart rates between 100 and 150 beats per minute will rarely have symptoms related to the tachycardia. Rather, symptoms in this range are normally the result of other medical issues. However, the higher the heart rate, the more likely that the tachycardia is the culprit of the patient's symptoms. For this reason, a thorough primary and secondary survey will help you properly assess the patient's condition. Identifying and Treating Tachycardia When you have a patient with tachycardia, the first step is to identify whether or not the patient is stable. A stable patient has no serious signs or symptoms as a result of the increased heart rate, such as: Altered mental status Chest pain Hypotension Other signs of shock For stable patients, you should do the following: Check their vital signs Monitor their oxygen saturation Give oxygen as needed Get an ECG or 12 lead Identify their heart rhythm Start an IV Pro Tip #2: If you determine a patient to be unstable, as in one that has some of those more serious symptoms listed in the list above, synchronized cardioversion is the treatment of choice and should be done immediately. Remember, electrical therapy can cause some discomfort. If time permits and the patient is conscious, consider sedation. But if time does not permit, you may need to defibrillate regardless of sedation. If you have a patient with no pulse, treat this rhythm as if it was ventricular fibrillation (VFib) and follow the pulseless arrest algorithm. Pro Tip #3: The first step to identifying tachycardic heart rhythms is to determine if the QRS complexes are wide or narrow. Wide QRS complexes are .12 seconds or greater, while narrow QRS complexes are less than .12 seconds. Narrow complex tachycardias typically originate above the ventricles. While wide complex tachycardias typically originate in the ventricles and pose a higher risk of deteriorating into cardiac arrest. For patients with regular narrow complex stable tachycardia: It's appropriate to first attempt vagal maneuvers. If that doesn't work, give adenosine at 6mg via rapid IV push. If the patient does not convert and remains stable, give a second dose of adenosine at 12mg via rapid IV push. Pro Tip #4: While you understand the side effects of adenosine, your patient probably does not. So, after administering the medication, tell them they may get a feeling of breathlessness, a flushed feeling, or the feeling that their heart is skipping a beat. And let them know these side effects will pass quickly. For stable patients with irregular narrow complex QRS tachycardia, it's probably atrial fibrillation (AFib), atrial flutter (AF), or a multi-focal atrial tachycardia and would require expert consultation to treat. For stable patients with regular or irregular wide complex QRS tachycardia, this would usually be treated with antiarrhythmics like procainamide or amiodarone and will also require expert consultation. It's also important to remember that management and treatment of wide complex stable tachycardia requires advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy. https://d3imrogdy81qei.cloudfront.net/video_images/5041/what-is-tachycardia.jpg Yes 248 https://www.proacls.com/training//video/stroke-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2781.mp4 Stroke Teaching In this lesson, we're going to let you play the role of team leader during a stroke emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 70-year-old female patient. A friend of hers told you that she was watching TV when she started to feel weak and suddenly had difficulty speaking. Her left side also became very weak. When her friend tried to help her stand up, as told to you by the friend, your patient was unable to walk on her own. She is conscious and breathing normally but appears agitated. As you ask the patient a few questions, you notice that she's having difficulty speaking and also giving appropriate answers. Her friend said that she noticed the difficulty of speaking about 30 minutes ago. Your initial assessment recap: 70-year-old female Difficulty speaking Left side weakness Conscious and breathing normally Because the initial signs indicate a possible stroke, you should perform a stroke assessment. If you're a pre-hospital provider, you might want to perform an abbreviated assessment, known as the Cincinnati Prehospital Stroke Scale (CPSS). This abbreviated stroke assessment consists of four elements: Facial droop Arm drift Speech Time If you're an in-hospital provider, you might want to perform a more detailed full NIH stroke score to more completely document the patient's neurological status. During your patient's assessment, you found her to be conscious and alert. However, the patient does have facial droop, left arm drift, and has trouble speaking. This is enough information to call for a stroke team to respond and also order an emergency CAT/CT scan. The next step is to obtain a full set of vitals for this patient. So, you direct one of your team members to place a blood pressure cuff on the woman and also an O2 saturation monitor. The team member now has the patient's vital signs and tells you the following: Pulse: 78 beats per minute Respiratory rate: 18 Blood pressure: 124/100 Skin: warm and dry O2 saturation: 96 percent Based on your patient's vital signs, you determine that she does not need oxygen. At this time, you attach the monitor and get a 12-lead ECG. And as you look at the 12-lead printout, you see a normal sinus rhythm. You then direct the team member to continue checking the woman's blood pressure every 5 minutes and keep a close eye on any changes in her breathing. Pro Tip #1: An important diagnostic tool for potential stroke is blood glucose. Hypoglycemia or low blood glucose can mimic stroke symptoms, such as confusion and slurred speech, so it's important to rule this out. You direct a team member to check the patient's glucose level and find that it's normal at around 90. In order to consider fibrinolytic therapy, you need to determine the time since the onset of symptoms. And since the woman arrived at the emergency room, it's been another 15 minutes. Remember, symptoms began 30 minutes before the woman arrived into your care. Since the patient's blood pressure, O2 saturation, and blood glucose levels are all within normal limits, and since symptoms started less than 3 hours ago, you decide that this patient may be a good candidate for rtPA. Pro Tip #2: rtPA, also known as recombinant tissue plasminogen activator, includes specific medications like alteplase, reteplase, and tenecteplase. These are often used in clinical medicine to treat embolic or thrombotic stroke. Indications for rtPA include: Symptom onset less than 3 hours No history of strokes Normal blood glucose levels No blood thinners No contraindicated medications No other contraindications A clear CT scan If the patient has no history or previous strokes, isn't on blood thinners or contraindicated medications, or has other contraindications, then the CT scan will be the determining factor. If the CT scan shows no hemorrhage, you'll be able to go with rtPA. To get ready for this potential drug therapy, this would be the time to start an IV. You direct a team member to start an IV – 18 gauge antecubital with normal saline. And you'll keep this at a TKO rate. Remember, the goal is to recognize the patient's potential stroke signs early and get her the appropriate fibrinolytic therapy, or the most appropriate reperfusion strategy, in a timely remember. https://d3imrogdy81qei.cloudfront.net/video_images/5023/stroke-teaching.jpg Yes 212 https://www.proacls.com/training//video/megacode-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2793.mp4 Megacode Teaching In this lesson, we're going to let you play the role of team leader during a megacode emergency, also known as the granddaddy of all cardiac emergencies. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. A megacode scenario will require a combined knowledge of procedures and treatments from many or all ACLS algorithms. In this scenario, you've been presented with a 45-year-old male patient who now appears unresponsive. Witnesses state that the victim was choking, and the object was removed. He was brought to advanced medical care because afterward he had difficulty breathing. While you're talking with the patient, he goes unresponsive. It's important to remember to use basic life support skills before any advanced life support skills. Your initial assessment recap: 45-year-old male Appears unresponsive Was choking but object removed Brought to medical care for difficulty breathing You or a member of your team check for responsiveness using taps and shouts. His unresponsiveness is confirmed so you call in a code and check for a pulse and signs of normal breathing. You find that the patient is in respiratory arrest. You call for an advanced airway, either an NPA or OPA, to be inserted, then start rescue breaths with a bag valve mask at 15 liters of oxygen delivered at 1 breath every 6 seconds. You call for his vitals to be taken and an ECG monitor to be attached. According to the ECG, the patient has a normal sinus rhythm with pre ventricular contractions (PVC) at 78 beats per minute but they are irregular. Knowing that a rhythm with multiple and frequent PVCs could quickly deteriorate, you start an IV to administer saline and other medications. And a short time later, the monitor is indicating that no pulse is being detected. It now looks like the patient is in ventricular fibrillation (VFib). You check the patient for a pulse to confirm and do not find one. You now call for CPR at 30 compressions to 2 rescue breaths, while defibrillator pads are applied. When the pads are in place, you instruct everyone to stand clear while the rhythm is analyzed. VFib is still present on the ECG. Using a monophasic defibrillator, you ask that it be charged to 360 joules to shock the patient. CPR resumes immediately after delivery of the first shock. Since the patient is in VFib, a first shock has been delivered, and an IV has been established, it's now time to administer the first medication – epinephrine at 1 mg 1:10,000 concentration. Pro Tip #1: You remind your team that CPR must continue during drug administration, because doing so will help circulate the medication throughout the body and especially into the heart. After the recorder lets you know that it's been 2 minutes since CPR began, you call for the compressor and monitor/defibrillator team members to switch. it's important that you always have a fresh compressor that can deliver high quality compressions between 100 and 120 compressions per minute and at the appropriate depth. However, during the switch and before resuming CPR, you take a quick look at the monitor. It reveals persistent VFib. You then call for another shock with the monophasic defibrillator at 360 joules. This time, when you check the monitor, you notice that the patient now has a normal sinus rhythm. You check for a pulse to confirm a perfusing rhythm. You find a pulse, but the patient still isn't breathing You call for rescue breaths to continue at 1 breath every 6 seconds. And you call for a set of vitals to determine the next course of treatment. You find a blood pressure of 88 systolic after achieving ROSC (return of spontaneous circulation). Pro Tip #2: A systolic blood pressure below 90 requires a 1 to 2-liter bolus of normal saline in order to raise the patient's blood pressure. Since the patient is still in respiratory arrest, you call for an ET tube to be put in place and begin to monitor capnography. With capnography in place, you can verify proper tube placement when a persistent waveform is present at 35 to 40 mmHg. Capnography measures the concentration of carbon dioxide in the patient's exhaled air at the end of expiration. The CO2 detected by capnography in this exhaled air is produced in the body and delivered to the lungs by circulating blood. Pro Tip #3: This is why it's so helpful to know when compressions are being done correctly, by producing circulation though the body that gets that CO2 out to the lungs to be exhaled. This helps you know that CPR is effective or when the body is returning biologically, and you can see that exchange of gases – oxygen and CO2. Your megacode scenario ends with you calling for a 12 lead ECG and another set of vitals as you and your team begin to consider the underlying causes that went into this patient's cardiac arrest. And by finding those causes, you can begin correcting them and save the patient's life. https://d3imrogdy81qei.cloudfront.net/video_images/5047/megacode-teaching.jpg Yes 315 https://www.proacls.com/training//video/overview-of-primary-assessment https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2773.mp4 Overview of Primary Assessment In this lesson, we'll cover the primary patient assessment by thoroughly checking the ABCDE's in ACLS for unconscious patients who are in full arrest that are either cardiac or respiratory in nature. However, all ACLS healthcare providers should conduct a primary assessment after first completing a basic life support assessment. This BLS assessment includes checking for responsiveness with taps and shouts, and if the patient is found to be unresponsive, calling 911 or calling in a code. Also check the patient for breathing and a pulse and defibrillate if necessary. However, for unconscious patients who need a more advanced level of assessment and management, you should conduct a primary assessment first. During your primary assessment, continue to assess and perform all actions appropriately until the patient is transferred to the next level of care. Pro Tip #1: Oftentimes, members of a high-performance team will perform the assessment and actions in ACLS simultaneously. However, if this isn't the case, it's important to remember, per the latest guidelines, to assess the patient first then perform the appropriate actions. Keep in mind, when you get into the scenario-based testing part of this course, it's formatted in a linear fashion to simplify and clarify the vital skills needed to successfully pass the test. However, real-life ACLS codes have many working parts, many of which will happen dynamically and simultaneously to expediate important assessments, treatments, and therapies in order to help save the patient's life. The following is a breakdown of the primary ACLS primary assessment by using the ABCDE method. Airway It's vital to maintain an open airway in an unconscious patient. The ways in which you'll accomplish this include: Head tilt, chin lift Basic airway adjuncts like:• Oropharyngeal Airway (OPA)• Nasopharyngeal Airway (NPA) Advanced healthcare providers can use advanced airways if basic airways are not sufficient or if capnography is vital to a successful resuscitation. The different types of advanced airways include, but are not limited to: Endotracheal tubes Esophageal tracheal tubes Laryngeal tubes Laryngeal masks Pro Tip #2: It's important to weigh the costs vs. the benefits of advanced airway placements if they'll interrupt chest compressions. If a bag valve mask ventilation is adequate, you might want to wait before inserting a more advanced airway until the patient doesn't respond to initial resuscitation attempts with CPR and defibrillation or until ROSC occurs. Also keep in mind that some advanced airway devices, such as laryngeal masks and laryngeal tubes, can be placed while chest compressions continue. It's important to confirm the proper placement of all advanced airways. This can be done by a physical examination of the airway or a quantitative waveform from capnography readings. And CPR should be properly integrated with ventilations after intubating the patient to optimize pulse pressures and oxygenation of vital organs and cells. Pro Tip #3: Because movements from CPR and transportation can alter or dislodge an advanced airway, it's important to use a securing device to hold the advanced airway in place. And remember to monitor airway placement with continuous quantitative waveform capnography. Also, make note of your organization's protocols and operating procedures when using prescribed devices for tube immobilization. Breathing When assessing a patient's breathing, it's important to ask yourself, are ventilations and oxygenation adequate? For arrest patients, administer 100 percent oxygen, once ROSC is achieved, then 92%-98%, but for all other patients, titrate oxygen administration to achieve oxygen saturation of 94 percent or greater by pulse oximetry. And monitor quantitative waveform capnography and oxyhemoglobin saturation. Of course, you should rely on the visual of the patient's chest rising and falling to confirm breath compliance. But quantitative waveform capnography will better help you understand how well CPR and rescue breathing are working to oxygenate the patient and how well that patient is processing that oxygen from a biological perspective. Circulation It's important to assess and reassess the quality of CPR by monitoring the quantitative waveform capnography. And if PETCO2 is less than 10ml of mercury, this may be a sign that you should work to improve CPR quality. Pro Tip #4: If you're able to monitor intra-arterial pressures, and the relaxation phase or diastolic pressure is less than 20 ml of mercury, attempt to improve CPR quality by assessing compression depth, rate, and hand placement. Attach a monitor and defibrillator to check for arrhythmias or cardiac arrest rhythms like: Ventricular fibrillation Pulseless ventricular tachycardia Asystole Pulseless electrical activity Lastly, be sure to provide defibrillation cardioversion as needed. Obtain IV or IO access to deliver adequate fluid replacement, medications, and give appropriate drugs to manage rhythm and blood pressure. And later, check glucose levels, temperature, and incorrect perfusion. Disability When it comes to disability, check the patient for neurologic function and quickly assess for responsiveness, levels of consciousness, and pupil dilation, which may indicate brain death or viability, but not in every case. Assess disability using the acronym AVPU: A - Is the patient Alert?V - Does the patient respond to your Voice?P - Does the patient respond to Painful stimulus?U - Is the patient Unresponsive? Exposure Exposure is a reminder for healthcare providers to remove the patient's clothing and perform a good physical examination. While doing so, look for signs of trauma, such as: Bleeding Burns Unusual markings Medical alert bracelets https://d3imrogdy81qei.cloudfront.net/video_images/5005/overview-of-primary-assessment.jpg Yes 409 https://www.proacls.com/training//video/what-is-pulseless-arrest-v-fib https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2782.mp4 What is Pulseless Arrest V-fib? In this lesson, we're going to cover pulseless arrest and ventricular fibrillation. And at the end of the lesson, we'll provide you with a Word about cardiac arrest rhythms in general. Ventricular fibrillation, also known as VFib, and pulseless ventricular tachycardia, also known as V-tach, are lethal dysrhythmias that do not produce a pulse. VFib is the most common initial dysrhythmia in cardiac arrest patients and will regress to asystole if it isn't treated in a short amount of time. That treatment includes rapid defibrillation. Warning: Rapid defibrillation is vital. How vital? For every single minute that defibrillation is delayed, the chance of the patient surviving is reduced by a full 10 percent. The key steps to treating VFib are as follows: Rapid assessment to confirm the patient's cardiac arrest Starting CPR Applying the defibrillator Delivering the first shock Performing high quality CPR Performing high-quality CPR is equally vital, as is performing it with as few interruptions as possible. High-quality CPR is performed by giving cycles of compressions at a depth of 2 to 2.4 inches and at a rate of 100 to 120 compressions per minute, followed by 2 full rescue breaths that cause the chest to rise and fall. Pro Tip #1: Equally important is changing the CPR compressor, if available, every 2 minutes to avoid fatigue. Compressor fatigue leads to a shallower compression depth and a slower than optimal rate, both of which significantly and detrimentally affect the quality of CPR being performed. After the initial defibrillator shock has been delivered, it's important to then establish IV or IO access in order to deliver medications and fluids. The first medication that should be administered is epinephrine (or epi for short) at 1mg of the 1:10,000 concentration via rapid IV or IO push every 3 to 5 minutes. After that initial dose of epi is delivered, a second shock is then given. At this point you should also consider placing an advanced airway with capnography. Pro Tip #2: Remember that once an advanced airway is in place, your CPR compressions then become continuous. The compressions are still 100 to 120 per minute, along with the same depth, but you'll now deliver 1 breath every 6 seconds. If the patient remains in persistent VFib following the initial defibrillator shock and the first dose of epi, the next medication to be given is amiodarone at 300mg via rapid IV or IO push. A second dose of amiodarone can be given at 150mg. This dose can only be repeated one time after 3 to 5 minutes. Successful treatment of VFib continues by: Providing high-quality CPR Reassessing the patient's cardiac rhythm every 2 minutes Delivering a defibrillator shock if the VFib remains present And giving medications as indicated. A Word About Cardiac Arrest Rhythms This Word section covers the dysrhythmias that do not produce a palpable pulse, which leads to cardiac arrest. It is crucial to recognize and treat these rhythms as quickly as possible to improve the patient's chances of survival. Ventricular Fibrillation and Pulseless Ventricular Tachycardia The origin of ventricular fibrillation is due to multiple ectopic ventricular pacemakers, which depolarize in a random and chaotic fashion and spread throughout the myocardium. This results in uncontrolled myocardial quivering, or fibrillating, and does not produce cardiac output or a pulse. Ventricular fibrillation is clinically significant because it is a lethal dysrhythmia and, as mentioned already above, is the most common initial rhythm in sudden cardiac arrest for adult patients, and often occurring in public places or non-hospital settings. As you've already learned, immediate defibrillation is vital when it comes to managing ventricular fibrillation. Ventricular fibrillation of relatively large amplitude is often initially seen but becomes less coarse and less responsive to defibrillation as minutes pass. Myocardial ischemia or infarction and sudden cardiac rhythm disturbances are the most common causes of ventricular fibrillation in adults. Ventricular tachycardia (V-tach), can present with or without a pulse. Pulseless V-tach can occur in patients with cardiac arrest. While not as often as ventricular fibrillation, ventricular tachycardia can be witnessed as the first rhythm in cardiac arrest before it deteriorates further into ventricular fibrillation. Pulseless V-tach treatment is the same as ventricular fibrillation, as both require immediate defibrillation. Asystole The term asystole in cardiac arrest refers to ventricular asystole. Often, if you were to look at the monitor closely, you'll notice that there are still P-waves and atrial depolarization but no conduction to the ventricles. This results in a total absence of mechanical activity in the myocardium. For obvious reasons, ventricular asystole does not produce a pulse because the ventricles are not beating. It is usually the result of untreated ventricular fibrillation that will eventually degenerate into fine VFib and ventricular standstill or asystole. Other causes of asystole include severe hypoxia, acidosis, or electrolyte abnormalities. Pulseless Electrical Activity (PEA) PEA is not a particular cardiac rhythm. Rather, it's a condition in which an organized cardiac rhythm is not accompanied by a palpable pulse. PEA can be caused by anything that impedes myocardial mechanical activity or causes profound shock. Treatable causes of PEA include the H's and T's: hypoxia, hydrogen ion (acidosis), hypovolemia, hyperkalemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, pulmonary thrombosis, and coronary thrombosis. https://d3imrogdy81qei.cloudfront.net/video_images/5025/what-is-pulseless-arrest-v-fib.jpg Yes 147 https://www.proacls.com/training//video/pulseless-arrest-v-fib-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2783.mp4 Pulseless Arrest V-fib Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – pulseless arrest VFib. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 56-year-old male patient who arrived at the ER complaining of moderate to severe chest pains and discomfort. He also has some weakness and shortness of breath. And symptoms have been ongoing for about 4 hours. Over the last 2 hours, his pain has intensified and is now radiating up into his neck, jaw, and down his left arm. When you ask him to assess his level of pain from 1 to 10, he says it's currently a 9. He also mentions that he's beginning to feel nauseous and may even vomit. As you continue to ask him more questions, he suddenly stops responding and now appears unconscious. Your initial assessment recap: 56-year-old male Severe chest pain Radiating into jaw, neck, left arm Pain currently at 9/10 Now appears unconscious Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive. At this point, you call in a code or ask for additional help depending on you and your team's experience and level of expertise. Help is on the way. Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign a compressor and a monitor/defibrillator and remind the team that high-quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths. Pro Tip #1: It's important for everyone on your team to remember that high-quality CPR has risen to the top of importance even in ACLS, so you communicate this to everyone on your team. You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute. Pro Tip #2: Now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient. In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations. During CPR, the monitor/defibrillator team member is preparing the patient for rapid defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in VFib. CPR is continued while the automated defibrillator charges (or if the defibrillator is manual, shocks will be delivered at 360 joules.) Once the defibrillator is fully charged, the monitor/defibrillator team member calls out, everyone stand clear; shocking on 3; 1-2-3. The monitor/defibrillator person then pushes the shock button. CPR resumes and you prepare the team for medications delivery. Pro Tip #3: While both IV and IO are acceptable, try IV first and only move to IO if you're unable to obtain patient IV access for effective medication and fluid delivery. Your team is able to get patent IV access via an 18 gauge in the left antecubital and start the patient on normal saline. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. As the compressor calls out the last few compressions – 28, 29, 30 – that's when the switch occurs. After 2 ventilations are delivered, the monitor/defibrillator switches positions with the compressor and readies his or her hands in the appropriate chest position, then begins effective chest compressions immediately after the last ventilation. Now is the time for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct. CPR resumes for 2 more minutes. At the end of that cycle, you call out, Stop compressions, and allow the ECG to check the patient's rhythm. You find that the patient is still in VFib, so you call out for another shock to be delivered. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #6 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds. Pro Tip #4: If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. The recorder calls out, We're at 4 minutes. You instruct the rest of the team to stand clear of the patient while his rhythm is checked and then announce another switch for the compressor and monitor/defibrillator team members. The patient is still in VFib, so you prepare the team for a third shock. You instruct everyone to continue CPR and also direct the medication team member to prepare the next round of medication – amiodarone at 300mg followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct. A second dose of amiodarone may be given for persistent VFib, which is half the initial dose, or 150mg, and administered after 2 more minutes of CPR and another shock if the rhythm has not converted. Alternatively, epi can be given every 3 to 5 minutes instead and staggered between shocks and CPR. This scenario continues until all treatment options have been exhausted and all possible causes have been ruled out. https://d3imrogdy81qei.cloudfront.net/video_images/5027/pulseless-arrest-v-fib-teaching.jpg Yes 504 https://www.proacls.com/training//video/bradycardia-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2789.mp4 Bradycardia Teaching In this lesson, we're going to let you play the role of team leader during a cardiac emergency – bradycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 78-year-old female patient who is pale and diaphoretic. She tells you that she is feeling dizzy and weak and also that she began feeling this way about 3 hours ago. She also tells you that her condition seems to be getting worse. She is conscious and alert, which means that at the moment she's stable. And since she doesn't seem to have any life-threatening conditions, you determine that the first step should be to get a good set of vitals, which you have instructed an assistant to get. Your initial assessment recap: 78-year-old female Pale and diaphoretic Feels dizzy and weak Conscious and alert Your assistant tells you that the patient's vital signs are: Respiratory rate: 20 Pulse rate: 48 and irregular Blood pressure: 78/40 SPO2: 94 percent Based on these vital signs, you don't need to start oxygen immediately. However, the patient is obviously bradycardic and hypotensive. And in order to know if the patient's hypotension and bradycardia are related to her heart arrythmia or another cause, you decide to get an ECG reading. The assistant attached the ECG monitor to the patient and takes a quick look at her rhythm. As you look at the monitor, you see narrow QRS complexes along with regular P-waves, until the entire QRS is dropped. You recognize that this rhythm indicates 2nd degree, Mobitz type II heart block. And because this type of heart block is below the bundle of His, it could turn into complete heart block rather quickly. Pro Tip #1: Since hypotension and bradycardia are a concern, you direct the assistant to start an IV in order to consider administering atropine to the patient. But if the patient was unstable, as in unconscious and pulseless, you would then begin with transcutaneous pacing instead. However, since the patient is still responsive, you choose atropine as the first treatment option. You direct the assistant to give 1 mg of atropine via rapid IV push and wait for the assistant to repeat the order back to you, which she does. She follows the order and administers the atropine. After a minute has passed, you recheck the patient's vital signs and find the following: Respiratory rate is still around 20 Heart rate is still around 46, irregular, and weak Blood pressure has not improved and is 76/40 The pulse oximeter is still reading 94 percent Based on these new set of vitals, it appears that the atropine has been ineffective. As you come to this conclusion, the assistant tells you that the patient's heart rate and blood pressure just both went down, and now suddenly the patient just went unconscious. You now have a situation where the patient has an unstable bradycardia, which means you need to begin transcutaneous pacing as quickly as you can. You direct the assistant to apply the pacing pads and turn the pacer on. Pro Tip #2: Individual protocols will dictate specifics and vary from place to place. However, the American Heart Association guidelines recommend starting at 60 beats per minute and as the pacer is running, turn up the milliamps until the heart muscle is captured. In our scenario, you achieve consistent capture at 70 milliamps. Once you have that consistent capture, you should then turn the machine's interval up 2 to 5 milliamps – just enough to keep the capture. In this scenario, you decide to turn it up to 75. Pro Tip #3: Once you have consistent capture at 60 beats per minute, you turn up the rate until symptoms improve, which is typically between 60 and 70 beats per minute. In our scenario, you turn the rate up to 68 beats per minute. You then begin to see the patient becoming responsive again. Upon checking her vitals once more, you have: Respiratory rate of 16 Heart rate of 68 under capture with a transcutaneous pacemaker Blood pressure of 96/60 Pulse oximeter up to 96 percent Once the patient's perfusion improves, you need to continue to monitor the patient closely and work on improving perfusion further by trying to determine her cause of the bradycardia, and then treat it accordingly. Warning: Keep in mind that transcutaneous pacing can be really uncomfortable for a conscious patient. You may want to consider some sort of pain management while also considering whether or not to move the patient to the next level of care for further cardiac treatment. https://d3imrogdy81qei.cloudfront.net/video_images/5039/bradycardia-teaching.jpg Yes 258 https://www.proacls.com/training//video/atrial-flutter https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2466.mp4 Atrial Flutter Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate. In this lesson, we'll look at why/how atrial flutter occurs, and then look at a typical ECG readout for an adult patient in atrial flutter and provide a cardiac interpretation at the end. On an ECG, atrial flutter typically includes sawtooth-like F-waves, which are either the result of an ectopic atrial pacemaker or because of rapid reentry pathways somewhere within the atria, but outside of the SA node. The origin of this ectopic pacemaker is usually somewhere in the lower atrium and closer to the AV node, thereby resulting in that distinct sawtooth wave pattern. Pro Tip #1: Due to this erratic electrical activity, the normal function of the SA node is usually suppressed and noneffective. Which is why, instead of a P-wave, atrial flutter will produce flutter, or F-waves. And as a result of the depolarization of the atria in an abnormal manner, the classic F-waves of atrial flutter resemble a sawtooth, hence the name. Now let's take a look at an ECG for an adult patient in atrial flutter. *Atrial Flutter ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is variable and dependent on the ratio of F-waves to the QRS complexes. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's variable due to its irregularity. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present, and do they resemble normal P-waves or just those sawtooth type of F-waves? Since the answer is, they resemble sawtooth style F-waves, all of the other P-wave questions you normally ask yourself do not apply, once you notice the F-wave flutter. There are no real SA node P-waves present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because it's variable and there are no P-waves. Is the PR interval constant? Again, this is non-applicable because of the above answer. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Yes, it is within the normal range. Is the QRS complex wide or narrow? In this case, it's narrow. Are the QRS complexes similar in appearance or are there noticeable differences? In this case, we can see that each looks similar. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in atrial flutter. We have a variable rhythm that is dependent on the ratio of F-waves to the QRS complexes. We have a variable heart rate due to its irregularity. The P-waves are not normal and resemble sawtooth style F-waves. The PR interval is variable and there are no normal P-waves. The QRS is less than .12 seconds and thus normal. From the ECG alone, it would indicate that the patient is in atrial flutter Pro Tip #2: Structural heart disease is the usual cause of atrial flutter. In the same way that atrial fibrillation complicates adequate ventricular preload filling, atrial flutter complicates circulation and especially when it is accompanied by a syndrome called rapid ventricular rate or response. What is rapid ventricular rate or response? In some cases of AFib, the fibrillation of the atria causes the ventricles, or lower chambers of the heart, to beat too fast. When this happens, it's called a rapid ventricular rate or response, or RVR for short. Pro Tip #3: The faster the ventricular response, the more likely it is that the patient's circulation will be compromised. When the ventricles beat too rapidly, they aren't able to fill completely with blood from the atria. As a result, they can't efficiently pump blood out to meet the needs of the body. This can ultimately lead to heart failure. https://d3imrogdy81qei.cloudfront.net/video_images/4395/atrial-flutter.jpg Yes 178 https://www.proacls.com/training//video/atrioventricular-blocks https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2586.mp4 Atrioventricular Blocks In this lesson, we're going to look at the four types of atrioventricular blocks, usually called AV heart blocks or AV blocks for short. The four types are: 1st degree heart block 2nd degree heart block 2nd degree type 2 heart block 3rd degree heart block We'll include an example ECG for each, so you can see the differences, while also reading about those differences. 1st Degree AV Heart Block First-degree heart blocks are usually caused by a delayed, inconsistent, and sometimes absent electrical conduction pathway traveling through the AV node and can exhibit the following signs on an ECG readout. *1st Degree AV Heart Block ECG for Patient 1. Rhythm regular 2. Rate normal or slow 3. P-waves present and upright 4. PR interval prolonged, beyond .20 seconds 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio 1:1 There is usually little to no clinical significance with this type of heart block. 2nd Degree AV Heart Block (Mobitz Type 1) Second-degree heart blocks, also known as Mobitz type 1 AV blocks, is commonly caused by: Heart disease affecting the AV node Vagal stimulation that's often associated with difficult bowel movements Coughing fits Certain medications An ECG for a patient with Mobitz type 1 will exhibit the following signs. *2nd Degree (Mobitz type 1) AV Heart Block ECG for Patient 1. Rhythm regularly irregular 2. Rate normal or slow 3. P-waves present and upright 4. PR interval progressively widening 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio 1:1, until the P-wave is blocked Pro Tip #1: The QRS complex will become progressively delayed at the AV node until it completely disappears. When this happens, the ECG will only show a P-wave but no QRS following it. 2nd Degree AV Heart Block (Mobitz Type 2) The third type of heart block is regularly known as a Mobitz type 2 block. It usually occurs when the heart block is below the AV node. A Mobitz type 2 block is usually caused by more advanced heart disease and can also originate from damage below the bundle of His. Because of this, Mobitz type 2 can deteriorate more quickly into a symptomatic dysrhythmia and could eventually become a 3rd-degree heart block. An ECG for a patient with Mobitz type 2 will appear to have intermittent blocks where some P-waves do not have a QRS complex following, and there's typically no elongation of the PR interval. *2nd Degree (Mobitz type 2) AV Heart Block ECG for Patient 1. Rhythm variable, depending on the P:QRS ratio 2. Rate variable, but usually slow 3. P-waves present and upright 4. PR interval between .12 and .20 seconds 5. QRS complex between .06 and .11 seconds 6. P:QRS ratio variable – 2:1, 3:1, 4:1 and greater 3rd Degree AV Heart Block The fourth and last type of heart block is called a 3rd degree complete AV heart block and is the most serious of the four. A 3rd-degree heart block occurs when the electrical conduction is completely blocked between the atria and the ventricles. The exact location of the block can vary, however it's usually around the AV node or lower but will disassociate the SA pacemaker from the AV or bundle of His pacemakers. Pro Tip #2: When this happens, a 3rd degree AV heart block will create an ECG readout that shows regular P-waves, regular QRS waves, but they'll be at different rates that are completely disassociated altogether. An ECG for a patient with a 3rd-degree heart block will exhibit the following signs. *3rd Degree AV Heart Block ECG for Patient 1. Rhythm regular 2. Rate bradycardic and between 20 and 40 beats per minute 3. P-waves present and upright 4. PR interval variable with no set pattern 5. QRS complex greater than .11 seconds 6. P:QRS ratio variable The clinical significance of this type of dysrhythmia is serious. The patient will usually be symptomatic and unstable due to their very slow bradycardic heart rhythm and rate. Pro Tip #3: This type of heart block is preventing any pace that originates from the SA node. Therefore, the ventricular pacemaker will stimulate a pulse rate closer to 20 to 40 beats per minute, which is usually not enough to maintain a stable blood pressure. This is why the ECG readout will usually display wide QRS complexes. Studies have shown that 3rd degree AV heart blocks may be transient or permanent, depending on underlying causes. https://d3imrogdy81qei.cloudfront.net/video_images/4545/atrioventricular-blocks.jpg Yes 287 https://www.proacls.com/training//video/what-is-the-megacode https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2792.mp4 What is the Megacode? In this lesson, we'll provide you with a brief overview of the megacode. And at the end of the lesson, we'll provide you with an additional Word on the approach to unstable tachycardias, that you learned about in the last two lessons. Back in the day, megacodes were known to cause mega stress, and were widely considered one of the most fearful things that healthcare providers could imagine doing as it relates to their ACLS certification course. Why, you might ask? Because megacodes are so dynamic, much like a difficult word problem or riddle that you've been tasked with solving. And since not everyone loves word problems or riddles, think of megacodes like you would a puzzle, if that helps. Unlike an IRS audit or a colonoscopy, we're going to try to make megacodes as enjoyable as possible, and as simple as possible. And by the time you've completed and mastered your ACLS training at ProACLS, you'll feel confident that you'll be able to make a difference in your community, as in saving lives. Megacode testing scenarios combine knowledge and protocols of multiple ACLS algorithms. These can include any of the following: Acute coronary syndrome Acute stroke Cardiac arrest Pulseless VFib or V-tach Asystole Pulseless electrical activity (PEA) Bradycardia Tachycardia, whether stable or unstable To be a successful ACLS provider, you need to know about: Appropriate therapies Appropriate drugs Drug doses used in each ACLS algorithm When to use which drug based on the situation and patient And you need to know how to identify and interpret basic arrest and pre-arrest cardiac rhythms so you can know their proper treatments as well, related to the ECG. Pro Tip: It's important to remember that providing good ACLS always begins with providing high-quality basic life support. Make sure that you take full advantage of all the training provided by ProACLS so that you can have a rock-solid knowledge base and become as proficient with your skills as possible, in order to be ready to handle any life-threatening emergency. By gaining and building upon this knowledge base, you'll be able to increase the rate of survival for those people you help, which may mean returning loved ones back to family and friends once again. A Word About the Approach to Unstable Tachycardia A tachyarrhythmia, as in a rhythm with a heart rate greater than 100 beats per minute, has many potential causes and can be either symptomatic or asymptomatic. The key to managing a patient with any tachycardia is to determine whether pulses are present. If pulses are present, you should first determine whether the patient is stable or unstable and then provide treatment based on the patient's condition and their rhythm. If the tachyarrhythmia is sinus tachycardia, you should conduct a diligent search for the cause of the tachycardia. Treatment and correction of this cause will usually improve the signs and symptoms. Unstable tachycardia exists when the heart rate is too fast for the patient's clinical condition and the excessive heart rate causes symptoms or an unstable condition because the heart is: Beating so fast that cardiac output is reduced; this can cause pulmonary edema, coronary ischemia, and hypotension with reduced blood flow to vital organs, such as the brain or the kidneys. Beating ineffectively so that coordination between the atrium and ventricles, or the ventricles themselves, reduces cardiac output. Signs and Symptoms Unstable tachycardia leads to serious signs and symptoms that include the following: Hypotension Acutely altered mental status Signs of shock Ischemic chest discomfort AHF Rapid Recognition The two keys to managing patients with unstable tachycardia are: Rapid recognition that the patient is significantly symptomatic or even unstable. Rapid recognition that the signs and symptoms are caused by the tachycardia. The first step is to quickly determine whether the patient's tachycardia is producing hemodynamic instability and serious signs and symptoms or whether the signs and symptoms are producing the tachycardia. Making this determination can be difficult. Many experts suggest that when a heart rate is less than 150 beats per minute, it's unlikely that the symptoms of instability are caused primarily by the tachycardia unless there is impaired ventricular function. While a heart rate greater than 150 beats per minute is usually an inappropriate response to physiologic stress, such as fever and dehydration, or other underlying conditions. Indications for Cardioversion Rapid identification of symptomatic tachycardia will help you determine whether you should prepare for immediate cardioversion. For example: Sinus tachycardia is a physiologic response to extrinsic factors, such as fever, anemia, or hypotension/shock, which create the need for a compensatory and physiological increase in heart rate. There is usually a high degree of sympathetic tone and neurohormonal factors in these settings. Sinus tachycardia will not respond to cardioversion. In fact, if a shock is delivered, the heart rate often increases. If the patient with tachycardia is stable, patients may await expert consultation because treatment has the potential for harm. Atrial flutter typically produces a heart rate of approximately 150 beats per minute. Atrial flutter at this rate is often stable in the patient without heart or serious systemic disease. At rates greater than 150 beats per minute, symptoms are often present, and cardioversion is often required if the patient is unstable. If the patient is seriously ill or has underlying cardiovascular disease, symptoms may be present at lower rates. It's important to know when cardioversion is indicated, how to prepare the patient for it, and how to switch the defibrillator/monitor to operate as a cardioverter. https://d3imrogdy81qei.cloudfront.net/video_images/5045/what-is-the-megacode.jpg Yes 106 https://www.proacls.com/training//video/pulseless-electrical-activity-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2785.mp4 Pulseless Electrical Activity Teaching In this lesson, we're going to let you play the role of team leader during another cardiac emergency – pulseless electrical activity (PEA). From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 42-year-old male patient who fell out of a tree stand while hunting. He fell about 12 feet and may have landed on a tree stump. He walked back to his house and shortly after began to develop breathing difficulty and chest discomfort. While interviewing the patient, he tells you that his breathing is getting more labored and he's feeling lightheaded. Your initial assessment recap: 42-year-old male Fell about 12 feet Difficulty breathing Chest discomfort You place the patient on O2 via nasal cannula at 4 liters and his vital signs are taken: Blood pressure: 98/68 Pulse: 112 and tachy Respirations: 20 and shallow The patient begins to become less coherent and stops responding to your questions. Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a team member to perform a tap and shout sequence to confirm the patient's unresponsiveness. And he remains unconscious and unresponsive. Your team checks for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment. Your team finds no pulse and no signs of breathing. Someone in the team either places a CPR board under the patient or if he's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. CPR has been initiated – 30 compressions at a depth of 2 to 2.4 inches deep at a rate between 100 and 120 compressions per minute and followed by 2 rescue breaths. Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol. You assign an airway person and directions to begin with a basic airway providing breaths using a bag valve mask at 15 liters of oxygen at cycles of 30 compressions to 2 rescue breaths. While compressions are being given, you direct the monitor/defibrillator team member to attach the defibrillator pads to get the patient's initial rhythm and shock him if needed. As soon as the pads are on, you give directions to your team to pause CPR to check the patient's underlying rhythm. You tell everyone, Stand clear while the rhythm is analyzed. It shows what looks like a slow normal sinus rhythm. You call for the airway manager to check again for a pulse, or the compressor if the airway manager is busy. No pulse can be found, and you determine that the patient is in PEA. You direct the team to continue performing high-quality CPR and call for an IV to be established with an 18-gauge needle, start him on normal saline, and prepare to give medications. The recorder team member states, It's been 2 minutes. You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue. You take a quick look at the monitor – no longer than 10 seconds – to see if a shock needs to be given or CPR resumed. In this scenario, you still see what looks like a slow normal sinus rhythm and ask again for a pulse check. There is still no pulse; the patient is still in PEA. You direct the compressor to continue performing CPR and call for the first medication delivery. You call out the drug order for 1mg of 1:10,000 concentration of epi via IV push flushed with 20cc of normal saline and wait for the IV/medication team member to repeat the order back to you, which they do. You verify the repeated order by saying, That's correct. Pro Tip #1: Remember, flushing the line ensures that the medication gets into the central circulatory system more effectively. Also important to remember, CPR does not stop for the delivery of medications. At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography. As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the left and right lobes. You also check the patient's stomach for any air sounds. Remember, if you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. The chest is also showing signs of good chest rise and fall, which also indicates the tube placement was accurate. When the ET tube is in place and capnography is attached, you look to see if compressions and rescue breaths are effective, and CPR quality looks great. The recorder calls out, We're at 4 minutes. The compressor and monitor/defibrillator team member switch again after the second dose of epi is given and flushed with 20cc of normal saline. Pro Tip #2: As team leader, part of your duties is to either encourage the CPR compressor when compressions are good or make suggestions to improve quality if they are not. You decide that now is a good time to ask the team for feedback to help determine why the patient is in PEA. You do this by considering the reversible H's and T's: The H's The T's Hypovolemia Tension pneumothorax Hypoxia Tamponade (cardiac) Hydrogen ion (acidosis) Toxins Hypokalemia Thrombosis (pulmonary) Hyperkalemia Thrombosis (coronary) Hypothermia     Since you're not sure if the trauma/fall is to blame for the PEA, or if something else is, you're open to suggestions from the team. The team considers the effects of the head and/or chest trauma from the fall and someone suggests tension pneumothorax could be the cause. You think about this but eventually dismiss it – the patient has good equal lung sounds and has great compliance when giving ventilations, which indicates it's probably not tension pneumothorax. Another member of the team suggests that chest trauma may be causing the PEA due to cardiac tamponade: Blunt trauma to the chest Low blood pressure Fast heart rate Fast breathing This sounds like a good suggestion and all measures for correcting it are expedited. However, what if all reversible causes have been eliminated and the patient remains in cardiac arrest? As team leader, you may reach a point when a decision to stop resuscitation may have to be made, especially if EtCO2 is less than 10 after 20 minutes of high-quality CPR and all treatment options have been exhausted. In many cases, PEA will deteriorate into asystole over time. It's never easy to call it quits. Everyone has invested a lot of effort and time and everyone on the team wants to see the patient survive. However, if nothing is working and the patient's condition isn't improving or is deteriorating further, you may have to make the hard decision to conclude the resuscitation attempt. https://d3imrogdy81qei.cloudfront.net/video_images/5031/pulseless-electrical-activity-teaching.jpg Yes 431 https://www.proacls.com/training//video/what-is-acute-coronary-syndrome https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2778.mp4 What is Acute Coronary Syndrome? In order for you to be a functional ACLS healthcare provider, you must have the basic knowledge and skills to recognize and treat patients with acute coronary syndrome, or ACS for short. In this lesson, along with the next lesson, you'll be learning how to assess and treat the ACS patient following the latest recommendations and guidelines. And at the end of the lesson, we'll provide you with a brief Word on the goals of therapy for patients with acute coronary syndromes, along with EMS and hospital-based components. An initial 12 lead ECG is used as part of the identification process for all ACS cases. The three ECG categories for ACS include the following: ST-segment elevation, which suggests an acute myocardial infarction (or AMI). ST-segment depression, which suggests ischemia Nondiagnostic or normal ECG STEMI (ST-Elevation Myocardial Infarction) will be the focus of this section as it is the most time-sensitive for reperfusion therapies and can also limit the amount and extent of the myocardial damage. Although 12 lead ECG interpretation is beyond the scope of this ACLS provider course, some practitioners who are already ACLS certified will have already been trained in the interpretation and reading of 12 lead ECGs. For those particular healthcare providers, this ACS case summarizes identification and treatment of STEMI patients. Pro Tip: Remember, the main goal of a STEMI acute coronary syndrome is to reperfuse myocardial tissue that is being damaged by the blockage. Reperfusion may involve the use of coronary angiography with a balloon, angioplasty, and angioplasty with a stent, also known as PCI –percutaneous coronary intervention. When PCI is used as the initial reperfusion treatment for STEMI, it's referred to as a primary PCI. Treatments other than primary PCI include, but are not limited to: Oxygen Aspirin or ASA Nitroglycerin sublingual tablet or spray Fibrinolytic therapies Heparin – UHF (Unfractionated Heparin) Heparin – LWMH (Low Molecular Weight Heparin) A Word About the Primary Goals of Therapy for Patients with Acute Coronary Syndromes The primary goals of therapy for patients with acute coronary syndromes (ACS) are to: Reduce the amount of myocardial necrosis that can occur in patients with acute myocardial infarction (AMI), thus preserving left ventricular function, preventing heart failure, and limiting other cardiovascular complications. Prevent major adverse cardiac events, such as death, nonfatal myocardial infarction, and the need for urgent revascularization. Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VFib), pulseless ventricular tachycardia (pVT), unstable tachycardias, symptomatic bradycardias, pulmonary edema, cardiogenic shock, and mechanical complications of acute myocardial infarction. Prompt diagnosis and treatment offers the greatest potential benefit for myocardial salvage. Therefore, it is imperative that all healthcare providers are able to recognize patients with potential acute coronary syndromes in order to initiate evaluation, appropriate treatment, and management as quickly and effectively as possible. EMS Components EMS components include: Prehospital ECGs The notification of the receiving facility of a patient with possible ST-segment elevation myocardial infarction (also known as a “STEMI alert") The activation of the cardiac catheterization team to shorten the reperfusion time Continuous review and quality improvement Hospital-Based Components Hospital-based components include: ED Protocols• Activation of the cardiac catheterization laboratory• Admission to the coronary ICU• Quality assurance, real time feedback, and healthcare provider education Emergency Physician• Empowered to select the most appropriate reperfusion strategy• Empowered to activate the cardiac catheterization team as indicated Hospital Leadership• Must be involved in the process and committed to support rapid access to STEMI reperfusion therapy https://d3imrogdy81qei.cloudfront.net/video_images/5017/what-is-acute-coronary-syndrome.jpg Yes 129 https://www.proacls.com/training//video/asystole https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2467.mp4 Asystole The term asystole simply refers to an absence of ventricular activity, which means the patient will exhibit no discernible electrical activity on an ECG readout. In most cases, asystole is a lethal arrhythmia and survival is extremely rare. In this lesson, we'll look at an ECG readout for a patient in asystole, tackle those H's and T's and provide some corresponding information about their diagnostic use, and at the end of the lesson, provide some information on asystole and technical problems. Asystole is a cardiac standstill where there is no discernable electrical activity. It Is represented by a straight flat, or almost flat, line on an ECG. Warning: However, do not rely on an ECG alone for your diagnosis of a patient in cardiac arrest. It's a good idea to always confirm it clinically, because what appears to be a flat line on the ECG can also be caused by a loose ECG lead. Now let's take a look at an ECG for a patient in asystole. *Asystole ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, there is no heart rhythm. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, there is no rate and no pulse. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No, making any other questions about QRS non-applicable. However, in some cases, a small P-wave can be seen but it isn't followed by any other waveforms. Pro Tip #1: If you notice these small P-waves on the ECG that aren't followed by any other waveforms, this can mean that, in rare cases, the atrial pacemaker may be trying to send an impulse but has no ventricular reaction. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? No. In fact, there is no evidence of a QRS complex, making any other questions about QRS non-applicable. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in asystole. Because there is no myocardial, electrical, or mechanical activity, there is no pulse and no circulation of blood and oxygen. Pro Tip #2: Asystole is most commonly seen following a period of unconverted ventricular fibrillations or ventricular tachycardia. And while asystole is most commonly seen after extended, untreated, and sudden cardiac arrest, it can also be caused by reversible conditions outlined below. The most common reversible causes of asystole can best be remembered by keeping in mind the H's and T's. H's and T's The following H's and T's are designed to help you identify (and easily remember) potentially reversible causes of cardiac arrest or factors that may be complicating your resuscitative efforts. The H's The T's Hypothermia Toxins Hyper or hypodalemia Tamponade Hypoxia Tension pneumothorax Hydrogen ion (acidosis) Thrombosis (pulmonary) Hypovolemia Thrombosis (coronary) A Word About Asystole and Technical Problems Asystole is a specific diagnosis. However, a flat line is not. The term flat line is nonspecific and can be the result of several possible conditions, including the absence of cardiac electrical activity, lead or other equipment failure, and/or operator error. Some defibrillators and monitors will signal the operator when a lead or other equipment failure occurs. However, some of these problems do not apply to all defibrillators. For a patient with cardiac arrest and asystole, you should quickly rule out any other causes of an isoelectric ECG, such as: Loose leads or those that are not connected to the patient or defibrillator/monitor No power source to the defibrillator/monitor Signal gain (amplitude/signal strength) that is too low https://d3imrogdy81qei.cloudfront.net/video_images/4397/asystole.jpg Yes 106 https://www.proacls.com/training//video/what-is-asystole https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2786.mp4 What is Asystole? Asystole, sometimes referred to as a flat line on the monitor, represents an absence of both electrical and mechanical activity in the heart. In this lesson, we'll dig a little deeper into what it is and how it can be treated. And at the end of the lesson, you'll find a Word about the duration of resuscitative efforts. Pro Tip #1: It's important to understand that if a patient has no pulse and this is confirmed in one lead, there are a few things you can double-check to confirm this, such as: Are all the leads on correctly? Are all the leads attached to the patient with good contact? Does the ECG have a sufficient power supply? Is the amplitude set correctly to determine asystole vs. fine VFib? Like pulseless electrical activity (PEA), it's also important to determine what may have caused the patient's asystole, or in other words, examine the H's and T's. If you can figure out why the patient went into cardiac arrest, looking at the H's and T's will help you determine the possibility of treating any reversible causes of the asystole. Those H's and T's are: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia Hyperkalemia Tension pneumothorax Cardiac tamponade Toxins Cardiac thrombosis Coronary thrombosis Pro Tip #2: Asystole is not a shockable rhythm. So, treatment will involve high-quality CPR, airway management, IV or IO therapy, and medication therapy – specifically 1mg of epinephrine 1:10,000 concentration every 3 to 5 minutes via rapid IV or IO push. Having said that, it's rare for asystole to be reversed, especially if the patient has been in asystole for a long duration of time. Stopping resuscitation efforts is never an easy choice to make, and this is a gross understatement. However, if the patient is not responding to all of your basic and advanced cardiac life support treatment attempts, the decision to terminate resuscitation will need to be made. If you have a high degree of certainty that the patient will not respond to further ACLS interventions, then it would be appropriate to stop. When to Terminate Resuscitative Efforts As stated above, this will never be an easy decision. And the decision to do so must be based on your specific protocols and consideration of the following criteria: The time from the patient's collapse to CPR The time from the patient's collapse to your first defibrillation attempt The underlying causes if you've found any The patient's response to your resuscitation measures When the patient's EtCO2 is less than 10 after 20 minutes of CPR All of the above should be considered before deciding to terminate your resuscitation attempts in all patients in asystole. A Word About the Duration of Resuscitative Efforts While we already provided you with a list of criteria above that you can use to make this very difficult decision, let's dig a little deeper into the duration of resuscitative efforts. Deciding to terminate resuscitative efforts can never be as simple as an isolated time interval. If the return of spontaneous circulation of any duration occurs, it may be appropriate to consider extending your resuscitative efforts. Experts have developed clinical rules to assist in decisions to terminate resuscitative efforts for in-hospital and out-of-hospital arrests. However, you should also familiarize yourself with the established policy or protocols for your hospital or EMS system. For Out-of-Hospital Arrest You should consider the continuation of out-of-hospital resuscitative efforts until one of the following occurs: Restoration of effective, spontaneous circulation and ventilation Transfer of care to a senior emergency medical professional The presence of reliable criteria indicating irreversible death You, the rescuer, are unable to continue because of exhaustion or dangerous environmental hazards or because continued resuscitation will place the lives of others in jeopardy A valid DNAR order is presented Online authorization from the medical control physician or by prior medical protocol for the termination of resuscitation It might also be appropriate to consider other issues, such as drug overdose and severe prearrest hypothermia, due to submersion in icy water, for instance, when deciding whether to extend resuscitative efforts. Special resuscitation interventions and prolonged resuscitative efforts might be indicated for patients with hypothermia, drug overdose, or other potentially reversible causes of the arrest. https://d3imrogdy81qei.cloudfront.net/video_images/5033/what-is-asystole.jpg Yes 112 https://www.proacls.com/training//video/acute-coronary-syndrome-teaching https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2779.mp4 Acute Coronary Syndrome Teaching In this lesson, we're going to let you play the role of team leader during an acute coronary syndrome emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations. In this scenario, you've been presented with a 55-year-old male who is conscious and alert. As you interview the patient and ask him how he's feeling, you learn that he is responsive, has an open airway, and is suffering from shortness of breath. You also learn that he was watching TV when the symptoms began, which was about 3 hours ago. And he's now complaining of chest pain, pressure in the chest, and is sweating. Your initial assessment recap: 55-year-old male Conscious and alert Shortness of breath Chest pain and pressure Sweating Symptoms began 3 hours previous You know the patient has a pulse and is breathing, so the next step is to check for more in-depth vital signs. As the team leader, you ask another available member of your team to attach a blood pressure cuff and place the patient on an O2 saturation monitor. A more detailed pulse check is taken, and his respiratory rate and temperature check are also assessed. However, even before vital signs are recorded, a first drug may be given to the patient if you suspect a heart attack, and that first drug would be aspirin. If this is the case, first ask the patient if he's allergic to aspirin or has problems with gastrointestinal bleeding. Pro Tip #1: Keep in mind, there's a difference between aspirin sensitivity and having an anaphylactic reaction to aspirin. Also, stomach upset doesn't qualify as gastrointestinal bleeding. If the patient answers yes to either of those two questions above, aspirin may be contraindicated. However, in our fictional scenario, the patient has no aspirin allergy, nor does he have any gastrointestinal bleeding issues. In this case, the correct dose would be somewhere between 160 and 324 mg of chewable aspirin, and in this particular scenario, you administer 324 mg. The team member now has the patient's vital signs and tells you the following: Pulse: 124 beats per minute and regular Respiratory rate: 22 Blood pressure: 140/90 Skin: cool and pale O2 saturation: 92 percent Based on this information, you decide that the patient is stable at the moment. One thing to keep in mind, however, is that the goal for oxygen therapy is to titrate the amount given to achieve at least 94 percent saturation. Pro Tip #2: It's not necessary and even potentially harmful to use high-flow oxygen to bring the O2 saturation higher, as high-flow oxygen therapy can reduce cardiac output and stroke volume, which can cause vasoconstriction at a time when you especially need vasodilation. Also, remember that oxygen is not recommended for an O2 saturation of 94 percent or greater. But since your patient has an O2 saturation of 92 percent, it would be appropriate to begin a low-flow amount of oxygen via nasal cannula between 2 and 4 liters per minute. Now that the patient's basic vital signs are known and oxygen has been established, it's important to get a 12-lead ECG on the patient. This will help you in assessing his need for fibrinolytic therapy. Pro Tip #3: Within the first 10 minutes of contact with a healthcare provider, a 12-lead ECG, a targeted patient history, and a physical exam all need to be done to assess whether or not fibrinolytic therapy is appropriate. When assessing a 12-lead ECG, an ST elevation or depression would create a strong suspicion of injury or ischemia. In this scenario, however, it looks like a normal sinus rhythm. And at this time, it's important to gain IV access to draw blood to send to the lab. A good choice for that would be an 18-gauge IV with normal saline at a TKO rate – a rate that flows just enough to keep the vein open. And since the patient is still complaining of chest pain and his blood pressure is above 90 systolic, nitroglycerin should be administered. Before giving the patient nitroglycerin, it's important to ask him if he's taken any erectile dysfunction drugs or any other medications that would behave in a vasodilatory fashion within the last 24 to 48 hours. If the patient has, nitroglycerin would be contraindicated. If the patient can have nitroglycerin, it would be given in a 0.4mg tablet or spray sublingually, and this can be repeated every 5 minutes for pain as long as his blood pressure remains above 90 systolic. Tell your patient that you're going to give him a tablet of nitroglycerin to be dissolved under his tongue, and that this should help with his pain. Pro Tip #4: Talk to your patient and tell him what to expect. In this situation, you could also mention that the nitroglycerin may cause a little bit of a headache or a tingling sensation under the tongue as normal side effects. It's important to monitor the patient closely and look for changes in his status, such as his level of chest pain and blood pressure, which should be assessed at least every 5 minutes (or serial vitals) in order to consider additional doses of nitroglycerin. In this scenario, the patient's level of pain is still at an 8 out of 10 and his blood pressure is 120/88. This would indicate the recommendation for a second dose of nitroglycerin, again at 0.4mg sublingually. It would also be appropriate to run another 12-lead ECG to see if any changes have occurred. The most important interventions early on for an ACS patient are: Provide adequate oxygenation Administer pharmacological interventions to reduce pain and anxiety Perform timely assessments:• 12-lead ECG• History• Blood labs The patient should be evaluated early for the possibility of fibrinolytic therapy, catheter lab consideration for percutaneous coronary intervention (PCI), or to be transferred for continued care at a cardiac unit. https://d3imrogdy81qei.cloudfront.net/video_images/5019/acute-coronary-syndrome-teaching.jpg Yes 343 https://www.proacls.com/training//video/effective-communication https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2446.mp4 Effective Communication In order for a resuscitation team to be successful, they must practice effective communication. In this lesson, we'll be getting into some specific techniques or tips to help you achieve this vital element for positive patient outcomes. It's important that each member of a resuscitation team knows their individual roles and how to function as part of their team. And how to communicate those roles and duties effectively to other team members. Warning: Communication is a vital component in all walks of life. But when that communication is often a matter of life and death, it becomes even more vital. Don't discount just how important effective communication is for a resuscitation team. Techniques to Improve Communication Good communication doesn't happen by accident; it takes work. It's important to remember, when it comes to communication or any other aspect of your job, that the patient must always come first. It's vital that all resuscitation team members know their individual roles, how to function within those roles, and how to communicate effectively in a team environment to fulfill the goals and objectives and to increase patient survival rates during a cardiac arrest event. Now let's look at the eight essential elements of effective communication for a resuscitation team. 1. How to Establish Clear Roles and Responsibilities It's important that every team member knows and understands each of his or her duties on the team. However, it's also important that you understand the roles and responsibilities of the other team members. Understanding everyone's role and properly communicating specifics of each role will be crucial for helping the patient. Having a basic understanding of each role will allow you to fill in for other team members in situations where there aren't enough members to fill all required roles. The team leader will decide who fills in, in these situations, or will take on the role herself/himself. It's important that the team leader not get too myopic and instead always concentrate on the bigger picture. It's also important for all team members to assist the team leader in accomplishing this. Even in situations where there are enough team members, unclear roles and responsibilities will often lead to poor overall team performance. Which is why it's important for the team leader to effectively communicate to each member what their role is. All team members will have different levels of skills based on their individual training and experience, which is why it's important for the team leader to be aware of these proficiencies and properly assign responsibilities to those who can handle them. 2. Know Your Limitations Every team member must know their own ACLS capabilities and limitations. This will help the team leader to properly evaluate all available resources, assign duties to those who can handle them, and call for assistance if needed. Pro Tip #1: Asking for help should never be considered a sign of weakness or incompetence. It's better to be honest about your skills and experience and get the appropriate help when needed, than to do something that will negatively impact the team and ultimately the patient. 3. How to Perform Constructive Intervention There will be times when the team leader will have to intervene. For instance, if a team member isn't handling a specific action correctly, it may be necessary for the team leader to take over that duty or reassign it to another member of the team. However, it's equally important that the team leader handle the situation professionally and tactfully. Pro Tip #2: Team leaders should always avoid a confrontation with a member of the team. These will only serve to produce negative consequences for the patient. This includes avoiding any statements that may appear derisive or hostile. And watch your tone. Remember, often it's not what you say, but how you say it. 4. How to Communicate Knowledge Sharing American Heart Association research shows that knowledge sharing is a critical component of effective resuscitation team performance. It's important for team leaders to avoid becoming fixated on a specific treatment or diagnosis, or that myopic mindset we mentioned above. This is called fixation error. There are three common types of fixation errors that a team leader may communicate by saying things like: Everything is OK Only this is the correct way Do anything but this When resuscitation efforts are ineffective, it's important to go back to the basics and talk as a team. For instance, the team leader can do this by recapping out-loud what has been done that hasn't worked and encourage feedback from members of the team. Maybe there's something that was missed. Or something else that may produce a better outcome. Sharing knowledge is crucial, especially in those moments when things aren't working. Pro Tip #3: All team members should communicate any changes in the patient's condition. This will help the team leader to make calculated, informed decisions correctly. 5. How to Summarize and Reevaluate The team leader should always be asking herself or himself questions pertaining to the patient's condition. Monitoring their condition and reevaluating the situation is essential. These questions can include: What is the current status? What treatments have been performed? What changes in the patient have those treatments produced? What are the latest assessment findings that will help me proceed with providing the best care possible? Pro Tip #4: Team leaders should summarize and reevaluate the patient's condition out loud through regular updates to the team. Verbalizing everything to the team is important for effective communication, efficient team leading, and ultimately providing better care to the patient. Reviewing the resuscitation efforts and mapping out the next steps is vitally important, not only for better communication, but also for better patient care. And don't forget to get input or information from the time recorder. 6. How to Perform Closed-Loop Communication When a team leader gives an assignment or an order, closed-loop communication is how we make certain that the message was understood and is being executed. It serves as confirmation and must be done before the team leader assigns another task. So, what does closed-loop communication look like? Once the team leader assigns a task or provides direction, the exact message must be repeated by the team member that the message was directed towards. That's it! Simply repeat the message and then began to execute the order. 7. How to Use Clear Messages Giving concise, clear orders is essential for any successful resuscitation team. This includes good enunciation and a tone of voice that's calm and clear. The message should be direct and absent of emotion. Shouting or flustered speech in a frantic manner isn't going to help the situation. It'll only serve to waste time, as the team member may feel rushed or confused and may even impair that team member's ability to think clearly about the task they're performing. It's also important that team members aren't talking over one another. Only one person on the team should be talking at a time. 8. How to Practice Mutual Respect Mutual respect is vital for effective and efficient communication. It's obviously the professional way to communicate with peers. But also, members of a resuscitation team who work together in a respectful and supportive manner will have more success achieving favorable outcomes. Pro Tip #5: All members of a resuscitation team work diligently toward the same goal. No one is better than anyone else, regardless of their training, experience, or expertise. Every team member, including the team leader, should recognize the value the other team members provide and leave the ego at home. Practicing these communication techniques will help you establish an efficient and successful ACLS resuscitation team. A team that will better serve the community, produce more positive outcomes, and increase survival rates for those they serve. https://d3imrogdy81qei.cloudfront.net/video_images/4357/effective-communication.jpg Yes 412 https://www.proacls.com/training//video/wide-complex-tachycardia https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2588.mp4 Wide Complex Tachycardia Many wide complex tachycardias originate in the ventricles, but not all. The ones that don't include a bundle branch block, and a ventricular reentry problem, where the ventricles contract too early after a partial repolarization – like a pre-excited tachycardia or Wolff-Parkinson-White (WPW) syndrome. In this lesson, we'll look at monomorphic ventricular tachycardia (including an ECG), polymorphic ventricular tachycardia, or (thankfully) PVT for short (also including an ECG), and pulseless ventricular tachycardia. And at the end of the lesson, we'll provide a Word about treatments based on the type of tachycardia. Monomorphic Ventricular Tachycardia One very common V-tach is called monomorphic ventricular tachycardia, which means that all of the complexes are the same size, direction, and shape. It's usually caused by an ectopic pacemaker located somewhere in the ventricles. An ECG for a patient with monomorphic V-tach will exhibit the following signs. *Monomorphic V-tach ECG for Pediatric Patient 1. Rhythm regular, but could also be slightly irregular 2. Rate between 100 and 200 beats per minute 3. P-waves rarely discernible 4. PR interval not discernible 5. QRS complex greater than .11 seconds, wide and strange-looking 6. P:QRS ratio does not exist The main problem with this type of fast and wide complex tachycardias is that the hemodynamics are unstable. The heart rate is so fast that it inhibits the atrium from prefilling and preloading the ventricles before the next contraction. In these cases, it's important to know whether or not the patient is stable or unstable. Pro Tip #1: If the patient is stable, try to learn more about why the patient could be experiencing this type of arrhythmia. And remember, wide complex V-tach can sometimes be caused by heart disease, electrolyte imbalance (especially potassium) and a Q to T interval prolongation. If the patient is stable, check to see if their rhythm is supraventricular or ventricular in origin. Warning: If the patient is unstable, immediate treatment is vital. Polymorphic Ventricular Tachycardia Poly simply means multiple and describes the origin of electrical foci in the ventricles. In fact, polymorphic V-tach is caused by multiple ventricular foci with the resulting QRS complexes varying in axis, amplitude, and duration. Polymorphic V-tach can also be described as bi-directional V-tach, which is another type of polymorphic V-tach that is commonly associated with digoxin toxicity, commonly known as torsades de pointes. Along with digoxin toxicity, we often see polymorphic V-tach with hypokalemia or hypomagnesemia. An ECG for a patient with polymorphic V-tach will exhibit the following signs. * Polymorphic Ventricular Tachycardia ECG for Pediatric Patient 1. Rhythm irregular 2. Rate between 200 and 250 beats per minute 3. P-waves not discernible 4. PR interval missing 5. QRS complex variable, but greater than .11 seconds, wide and strange 6. P:QRS ratio missing In torsades, it can sometimes appear that the apex of the V-wave changes from top to bottom and back again. And actually, torsades (French in origin) literally translates as a twisting of points. The most important thing to remember with this type, along with monomorphic wide-complex V-tach, is that both can become pulseless V-tach or VFib pretty quickly. Pulseless Ventricular Tachycardia Pro Tip #2: One important thing to remember is that wide complex V-tach can present with or without a pulse and you may even see pulseless V-tach in a cardiac arrest patient. However, in most cases, pulseless V-tach will quickly deteriorate into VFib. Also keep in mind that pulseless V-tach is treated the same as VFib and that recognition of the condition and treatment for it will be vital for a potential positive outcome. Pro Tip #3: An ECG interpretation for pulseless V-tach can be the same for pulsed V-tach. The difference is that the patient is unresponsive, not breathing normally, and has no pulse. A Word About Treatments Based on Type of Tachycardia Distinguish between supraventricular and ventricular rhythms can be difficult. Most wide complex tachycardias are ventricular in origin, particularly if the patient is older or has underlying heart disease. If the patient is pulseless, you should treat the rhythm as VFib and follow the cardiac arrest algorithm. If the patient has a wide complex tachycardia and is also unstable, you should assume it's V-tach until proven wrong. The amount of energy required for cardioversion of V-tach is determined by the following morphologic characteristics. 1. If the patient is unstable but has a pulse with regular, uniform wide complex V-tach, or monomorphic V-tach: Treat with synchronized cardioversion and an initial shock of 100 joules If there is no response to the first shock, it's reasonable to increase the dose in a stepwise fashion 2. Arrhythmias with a polymorphic QRS appearance, or polymorphic V-tach, such as torsades de pointes, will usually not permit synchronization. If the patient has polymorphic V-tach: Treat as VFib with high-energy, unsynchronized shocks, such as defibrillation doses If there is any doubt about whether an unstable patient has monomorphic or polymorphic V-tach, don't delay treatment for further rhythm analysis. Instead, go right into providing high-energy, unsynchronized shocks. https://d3imrogdy81qei.cloudfront.net/video_images/4549/wide-complex-tachycardia.jpg Yes 254 https://www.proacls.com/training//video/pulseless-electrical-activity https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2587.mp4 Pulseless Electrical Activity Pulseless electrical activity, most commonly known as PEA, is a condition where the electrical activity of the heart is not accompanied by a palpable or effective pulse. It's important to find out the potential cause, correct it, and hopefully get a pulse back for that patient. In this lesson, we'll look closer at PEA, outline several possible causes, including an important caveat or warning. And at the end of the lesson, we'll provide an additional Word on pulseless electrical activity. Treatable Causes for PEA It's always important to treat the patient's symptoms, rather than rely on the ECG readout alone. Underlying and treatable causes for PEA include: Pulmonary thrombosis Coronary thrombosis Tension pneumothorax Cardiac tamponade Hypovolemia Hyperkalemia Hypoxia Hydrogen ion (acidosis) Pro Tip: It's important to rule out any and all of the treatable H's and T's as underlying causes for pulseless electrical activity in order to correct the mechanical disassociation that could be causing the cardiac arrest. Warning: The ECG interpretation for a patient exhibiting signs of PEA could be the same as normal sinus rhythm. Which is why treating the patient's symptoms, particularly when it comes to pulseless electrical activity, is so important. Rather than merely reacting to and relying on the rhythms that are being displayed on the ECG monitor. An Additional Word on Pulseless Electrical Activity Pulseless electrical activity (PEA) is not a specific rhythm. Instead it's a term used to describe any organized electrical activity – but not VFib or asystole — on an ECG or cardiac monitor that is associated with no palpable pulses. Pulsations can be detected by an arterial waveform or Doppler study. However, pulses are not palpable. The rate of electrical activity may be slow (which is most common), normal, or fast. Very slow PEA can also be referred to as agonal. When a patient is in PEA, the ECG can display normal or wide QRS complexes, as well as other abnormalities, which include: Low or high-amplitude T-waves Prolonged PR and QT intervals Atrioventricular disassociation Complete heart block Ventricular complexes without P-waves It's important to remember to assess the patient's monitored rhythm and note the rate and width of the QRS complexes. And as mentioned above, PEA can be caused by reversible conditions easily remembered as the H's and T's. Warning: One important takeaway is this: Unless you can quickly identify and treat the cause of PEA, the rhythm will likely deteriorate to asystole. The adult cardiac arrest algorithm is the most important algorithm to know for adult resuscitation. This algorithm outlines all of the assessment and management steps you'll need to know for all pulseless patients who do not initially respond to basic life support interventions, including the first shock from an AED. The algorithm consists of the two pathways for a cardiac arrest: A shockable rhythm, such as VFib or pulseless V-tach A non-shockable rhythm, such as asystole or PEA Common medications used to treat VFib or pulseless V-tach include: Epinephrine Norepinephrine Lidocaine Magnesium sulfate Dopamine Oxygen Other medications, depending on the cause of the V-tach or pulseless V-tach arrest Common medications used to treat asystole and PEA include: Epinephrine Other medications, depending on the cause of the asystole or PEA arrest https://d3imrogdy81qei.cloudfront.net/video_images/4547/pulseless-electrical-activity.jpg Yes 82 https://www.proacls.com/training//video/lidocaine https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2456.mp4 Lidocaine In this lesson, we'll go over the medication lidocaine and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, you'll find a Word about STEMI. Lidocaine works by bringing about negative inotropic (meaning, modifying the force or speed of the contraction of muscles) effects and antiarrhythmic actions in the heart which weaken the force of muscular contractions and can calm erratic and uncoordinated electro myocardial activity. In other words, lidocaine decreases automaticity and suppresses ventricular arrhythmias. Lidocaine Indications Now let's take a look at lidocaine indications. Due to lidocaine's antiarrhythmic properties, the primary use of lidocaine is for cardiac arrest from ventricular fibrillation (VFib) and pulseless ventricular tachycardia. Lidocaine is also an effective medication for treating the following conditions: Stable monomorphic ventricular tachycardia (V-tach) with preserved ventricular function Stable polymorphic V-tach with normal baseline A QT interval and preserved lower ventricular function when ischemia is treated, and electrolyte balance is corrected Stable polymorphic V-tach with baseline and QT interval prolongation when torsade's is suspected Lidocaine Precautions and Contraindications Now let's go over the precautions and contraindications for lidocaine. Lidocaine should not be used a prophylactic treatment in patients with acute myocardial infarction. It has also been suggested that you should reduce the maintenance dose in the presence of impaired liver function or lower ventricular dysfunction. And you should discontinue the infusion immediately if signs of toxicity develop. Lidocaine would be contraindicated if the patient has a known hypersensitivity to lidocaine or its derivatives, such as xylocaine, Novocain (also known as procaine), and similar drugs. And also in patients with sinus bradycardia and atrioventricular blocks. Adult Dosage of Lidocaine Now let's look at the adult dosage of lidocaine. For adult dosages when treating for cardiac arrest from VFib or pulseless V-tach, the initial dose is 1 to 1.5 mg per kg via IV or IO. And remember, lidocaine is one of those drugs that can also be administered via an endotracheal tube. For refractory VFib, an additional 0.5 to 0.75 mg per kg may be given via IV push. This can be repeated after 5 to 10 minutes. And the maximum number of lidocaine doses should not exceed 3 and the total amount should not exceed 3 mg per kg. For perfusing arrhythmias like stable V-tach, wide complex tachycardia, or uncertain type or significant ectopy, doses range from 0.5 to 0.75 mg per kg, up to 1 to 1.5 mg per kg. This can also be repeated at 0.5 to 0.75mg per kg every 5 to 10 minutes, up to that maximum dose of 3 mg per kg. For a maintenance infusion, give 1 to 4 mg per minute equal to 30 to 50 mcg per kg per minute. And remember, a micro drip infusion set is needed in order to deliver the appropriate dose. Pro Tip: A common and simple calculation for mixing a lidocaine drip is this: IV bag amount (usually in ml) × the dose ordered (usually mg per minute) × the drip set (drops per minute) ÷ the drug on hand (usually in mg). This should equal the correct drops per minute you'll need. A Word About STEMI ST-Elevation Myocardial Infarction (STEMI) is a very serious type of heart attack during which one of the heart's major arteries is blocked. Patients with STEMI usually have complete occlusion of an epicardial coronary artery. The mainstay of treatment for STEMI is early reperfusion therapy achieved with primary PCI or fibrinolytics. Reperfusion therapy for STEMI is probably the most important advancement in the treatment of cardiovascular disease in recent years. Early fibrinolytic therapy has been established as the standard of care for patients with STEMI who present within 12 hours after the onset of symptoms with no contraindications. Reperfusion therapy reduces mortality and saves heart muscle – the shorter the time to reperfusion, the greater the benefit. A 47 percent reduction in mortality has been noted when fibrinolytic therapy is provided in the first hour after the onset of symptoms. Delay of Therapy can be Critical It's important that routine consultation with a cardiologist or another physician does not delay the diagnosis and treatment except in equivocal or uncertain cases. Consultation can delay therapy and is associated with an increase in hospital mortality rates. Potential delays during the pivotal in-hospital evaluation period can occur in several key areas: from door to data (ECG), from data to decision, and from decision to drug (or PCI). These four major points of in-hospital therapy – Door, Data, Decision, and Drug – are commonly referred to as the 4 D's. All healthcare providers should focus on minimizing these delays at each of these points. Out-of-hospital transport time accounts for only 5 percent of delays to treatment time, while ED evaluation accounts for between 25 and 33 percent of these delays. In the next lesson – Magnesium Sulfate – we'll continue our Word on STEMI, specifically – early reperfusion therapy. https://d3imrogdy81qei.cloudfront.net/video_images/4377/lidocaine.jpg Yes 210 https://www.proacls.com/training//video/nitroglycerin https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2459.mp4 Nitroglycerin In this lesson, we'll go over the medication nitroglycerin and all of its effects, including indications, precautions and contraindications, and adult dosages. At the end of the lesson, we'll continue our look at respiratory problems, specifically respiratory failure. Nitroglycerin is a nitrate that causes smooth muscle relaxation, which produces systemic venous pooling of blood through the action of vasodilation. This, in effect, decreases venous blood flow return to the heart and also reduces preload as well as venous after load. Pro Tip #1: The administration of nitroglycerin should be monitored closely so as to not cause detrimental hypotension. Nitroglycerin Indications Now let's take a look at nitroglycerin indications. Nitroglycerin is indicated to relieve chest discomfort that is suspected to be the result of acute myocardial infarction, otherwise known as AMI. Nitroglycerin can also be effective in relieving cardiogenic pulmonary edema that is related to left side heart failure. Nitroglycerin Precautions and Contraindications Now let's go over the precautions and contraindications for nitroglycerin. There are multiple situations when the use of nitroglycerin may not be indicated or may even be contraindicated and harmful to the outcome of the patient. Here are some examples of those contraindicated situations: The patient is suffering from low systolic blood pressure of less than 90mm HG The patient has a right-sided ventricular infarction The patient is using medications like tadalafil, better known as Cialis or Adcirca The patient has severe bradycardia of fewer than 50 beats per minute The patient has a tachycardia greater than 100 beats per minute in the absence of heart failure Different from tadalafil, but in the same class of complications with nitroglycerin, when a patient may be taking a phosphodiesterase type 5 (a class of medication that includes Sildenafil) within the past 24 hours, this could cause severe hypotensive side effects if the patient is using that medication and also taking nitroglycerin. Pro Tip #2: It's vitally important to gather a thorough medications list from the patient, a reliable family member, or the patient's caregiver to avoid any serious contraindications that could occur when mixing these types of medications. Adult Dosage of Nitroglycerin Now let's look at the adult dosage of nitroglycerin. There are three methods of administering nitroglycerin: Nitroglycerin can be administered sublingually (under the tongue) in a dose of 0.4 mg, which is typically one tablet. This dose can be repeated in 5-minute intervals to a maximum dose of 3 tablets. Nitroglycerin can also be administered via a sublingual spray in metered doses. One spray of nitroglycerin will usually be the equivalent of a 0.4 mg tablet. This, too, can be repeated in 5-minute intervals to a maximum dose of 3 sprays. And finally, nitroglycerin can also be administered via IV and may be increased to 10 mcg per minute every 3 to 5 minutes until you've reached the desired effect. Warning: And as mentioned in the Pro Tip at the top of this lesson, it's important to closely monitor the patient's serial blood pressure and treat hypotension accordingly. A Word About Respiratory Failure In the last lesson on morphine sulfate, we took a look at respiratory distress. In this Word, we'll look at respiratory failure. Respiratory failure is a clinical state of inadequate oxygenation, ventilation, or both. Respiratory failure is often the end stage of respiratory distress. If there is abnormal central nervous system control of breathing or muscle weakness, the patient may show little or no respiratory effort despite being in respiratory failure. In these types of situations, you will have to identify the patient's respiratory failure based on clinical findings. It's important to confirm the diagnosis with objective measurements, such as pulse oximetry or blood gas analysis. You should suspect the probability of respiratory failure if you notice some or all of the following signs: Marked tachypnea Bradypnea, apnea (late) Increased, decreased, or no respiratory effort Poor to absent distal air movement Tachycardia (early) Bradycardia (late) Cyanosis Stupor or coma (late) Respiratory failure can result from upper or lower airway obstruction, lung tissue disease, and disordered control of breathing, such as apnea or shallow, slow respiration. When respiratory effort is not adequate, respiratory failure can occur without the usual signs of respiratory distress. Respiratory failure is a clinical state that requires intervention to prevent its deterioration into cardiac arrest. Respiratory failure can occur with a rise in arterial carbon dioxide levels (hypercapnia), a drop in blood oxygenation (hypoxemia), or both. https://d3imrogdy81qei.cloudfront.net/video_images/4383/nitroglycerin.jpg Yes 177 https://www.proacls.com/training//video/oxygen https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2460.mp4 Oxygen In this lesson, we'll go over oxygen therapy and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of this lesson, we'll provide you with a Word about respiratory arrest. Oxygen is an atmospheric gas that increases the saturation of hemoglobin oxygen and when used at therapeutic concentrations, it can aid the oxygenation of certain tissues as long as the patient isn't in shock or has some other complication, like carbon monoxide poisoning. This could affect the distribution or reception of oxygen molecules within the body and its cells. Oxygen Indications Now let's take a look at oxygen indications. The primary indication for the use of oxygen in ACLS is the presence of hypoxemia, which would be representative of an SpO2 of less than 94 percent, severe respiratory distress, as in asthma, and respiratory depression, as in opioid overdose. When you administer oxygen therapy after the return of spontaneous circulation, otherwise known as ROSC, it's important to deliver sufficient oxygenation to maintain an SpO2 that's greater than, or equal to, 92 percent but less than 98 percent. Oxygen Precautions and Contraindications There are few, if any, known precautions and contraindications for oxygen therapy use in the true hypoxic patient. Precautions should be based on new and ongoing research that reveals the vasoconstrictive properties that hyperoxia may produce. Pro Tip #1: If you begin to hyper oxygenate a normoxic cardiac patient, studies and research indicate that you might cause lower oxygen absorption and distribution to the patient's vital organs that need oxygenation during a coronary crisis. Adult Dosage of Oxygen Now let's look at the adult dosage of oxygen. The appropriate dose of oxygen will be dependent on the patient's needs and unique oxygen requirements. Oxygen therapy can be delivered via several different methods, and the percent of oxygenation will be regulated by the flow of oxygen per minute as well as the delivery adjunct you use. When delivering oxygen via nasal cannula is indicated, you should deliver it at a rate between 2 and 6 liters per minute. If a nonrebreather mask is used, that flow rate should be increased to between 12 and 15 liters per minute. If the patient's respiratory system is distressed or depressed, or for those patients who are completely apneic (not breathing), the delivery of oxygenated ventilations would be via a positive pressure device like a bag valve mask. In this case, the oxygen flow should be set at 15 liters per minute. Pro Tip #2: It's important, according to current guidelines, to titrate the oxygen therapy to maintain an SpO2 of at least 94 percent but less than 100 percent. Equally important, is to remember that a restricted airway will affect the therapeutic response of oxygenation treatment. The use of basic or advanced airway adjuncts may be needed to open or maintain a patent airway in order to treat the patient effectively. Pro Tip #3: It's important to always monitor the signs and symptoms of the patient, along with electronic and technical monitoring systems, so as to properly treat the patient. Rather than simply relying on electronic and technical monitoring systems alone. In other words, if the SpO2 reads 92 percent but the patient's skin appears normal, they could have an underlying blood disorder like anemia, which can impede the cyanosis due to a lack of hemoglobin and give the inaccurate appearance of adequate oxygenation. A Word About Respiratory Arrest In the last two lessons, we took a look at respiratory distress and respiratory failure. In this Word, we'll look at respiratory arrest. Respiratory arrest is defined as the absence of breathing and is usually caused by an event such as drowning or head injury. For an adult in respiratory arrest, providing a tidal volume of approximately 500 to 600 ml (or 6 to 7ml per kg) should be sufficient. This would be consistent with a tidal volume that produces a visible chest rise in the patient. Patients with an airway obstruction or poor lung compliance may require high pressures to be properly ventilated (in other words, to make the chest visibly rise). A pressure relief valve on a resuscitation bag-mask device may prevent the delivery of a sufficient tidal volume in these patients. Which is why it's important to make sure that the bag-mask device allows you to bypass the pressure relief valve and use high pressures, if necessary, to achieve visible chest expansion. Excessive ventilation is unnecessary and can cause gastric inflation and the resulting complications, like regurgitation and aspiration. More importantly, excessive ventilation can be harmful as it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival. As a healthcare provider, you should work to avoid excessive ventilation, as in too many breaths and/or too large a volume of breaths, during respiratory arrest and cardiac arrest. https://d3imrogdy81qei.cloudfront.net/video_images/4385/oxygen.jpg Yes 223 https://www.proacls.com/training//video/procainamide https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2461.mp4 Procainamide In this lesson, we'll go over the medication procainamide and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we provide you with a Word about wide complex tachycardias. Procainamide is effective at slowing the conduction in the atria, ventricles, and the His-Purkinje system by prolonging the P-R and Q-T intervals and the refractory period of the AV node. Procainamide also slows the refractory period within the atria and ventricles and slows the conduction velocity. Procainamide Indications Now let's take a look at procainamide indications. Procainamide is effective for the treatment of supraventricular tachycardia that returns after vagal maneuvers and adenosine are ineffective. Procainamide is also effective at treating the following: Stable wide complex tachycardia of uncertain origin Stable monomorphic ventricular tachycardia with normal QT intervals Atrial fibrillation with a rapid ventricular rate of response in patients with Wolff Parkinson White syndrome Recurrent ventricular fibrillation Pulseless ventricular tachycardia Procainamide Precautions and Contraindications Warning: it's important that you're aware of any known patient sensitivity to procainamide or similar medications before administering it. Also important to note is that digitalis toxicity may complicate an already existing AV conduction depression. Other procainamide contraindications would include: 3rd degree heart block Preexisting prolongation of the QRS complexes Preexisting prolongation of the QT intervals Pro Tip #1: The use of procainamide should be avoided in patients with prolonged QT intervals and associated congestive heart failure (CHF). Adult Dosage of Procainamide Now let's look at the adult dosage for procainamide. Pro Tip #2: The use of procainamide is limited in ACLS for cardiac arrest due to its requirements of slow infusion, as well as its occasional unknown effectiveness. If you're administering procainamide for recurrent ventricular fibrillation and pulseless V-tach, you should give 20mg per minute via IV infusion up to total max dose of 17mg per kg. For supraventricular tachycardia, atrial fibrillation, and wide complex tachycardia of uncertain origin, administer procainamide at 20mg per minute via IV infusion up to a total maximum dose of 17mg per kg. For maintenance doses of procainamide, administer the drug at 1 to 4mg per minute titrated to the desired effect and the patient response. It's important to note that the use of procainamide should be stopped if any of the following occurs: Arrhythmia suppression The onset of hypotension The QRS complex widens by more than 50 percent of its pretreatment width The maximum dose of 17mg per kg is reached A Word About Wide Complex Tachycardias Since wide complex tachycardias are one instance in which you may administer procainamide, let's take a broader look at it. Wide-complex tachycardias are defined as a QRS of 0.12 seconds or more. The most common types of life threatening wide complex tachycardias that are likely to deteriorate to ventricular fibrillation are: Monomorphic ventricular tachycardia Polymorphic ventricular tachycardia You should determine if the rhythm is regular or irregular: A regular wide complex tachycardia is presumed to be ventricular tachycardia or supraventricular tachycardia with aberrancy. An irregular wide complex tachycardia can be the following:a. Atrial fibrillation with aberrancyb. Pre-excited atrial fibrillation, such as atrial fibrillation using an accessory pathway for antegrade conductionc. Polymorphic ventricular tachycardia/torsade's de pointes These are all advanced rhythms requiring expert consultation. If the rhythm is likely ventricular tachycardia or supraventricular tachycardia in a stable patient, treat the condition based on the algorithm for that rhythm. If the rhythm etiology cannot be determined and is regular in its rate and monomorphic, recent research and evidence suggests that adenosine administered via IV is relatively safe for both treatment and diagnosis. IV antiarrhythmic drugs may be effective. The American Heart Association recommends procainamide, amiodarone, or sotalol. In the case of irregular wide-complex tachycardia, management of the condition should be focused on controlling the rapid ventricular rate, the conversion of hemodynamically unstable atrial fibrillation to sinus rhythm, or both. Again, expert consultation is advised. https://d3imrogdy81qei.cloudfront.net/video_images/4387/procainamide.jpg Yes 181 https://www.proacls.com/training//video/overview-and-team-roles-and-responsibilities https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2445.mp4 Overview and Team Roles and Responsibilities The complexity of advanced resuscitation requires a systematic and highly organized set of assessments and treatments that: Take place simultaneously and Are performed efficiently and effectively in as little time as possible. In this lesson, you'll learn about how these high-functioning teams operate, including a breakdown of the individual roles and responsibilities for each. As successful resuscitation rates increase, so do the chances that the patient receives the best chance for a positive, long-term outcome. And for a resuscitation attempt to be successful, all parts must be performed correctly by a high-performing team of highly trained, organized, and communicative healthcare professionals. Successful high-performance teams take a lot of work and don't just happen by chance. Each individual in a team must have the expertise to perform his or her job and a high-level mastery of their resuscitation skills. And they have to function as one cohesive unit, which requires a focus on communication within the team dynamic. It doesn't matter if you're a team leader or a supportive team member. All members of a resuscitation team are equal, and each plays a vital role in any team resuscitation scenario. Pro Tip #1: What does matter is your ability to not only understand your role, but also the roles of others on your team. When you know the roles and responsibilities of each team member, you can anticipate what's coming next, which will increase the ability of the team to communicate, improve the efficiency and performance of the resuscitation, and the chances for the patient to have a positive outcome. Now that you understand the importance of understanding the roles and responsibilities of each team member, let's look at some common duties and requirements for each. High-Performing Resuscitation Team Roles The roles of each team member must be carried out in a proficient manner based on the skills of each team member and their scope of expertise and practice. It's vitally important that each member of a resuscitation team: Understands and are clear about their role assignments Are prepared to fulfill their role and responsibilities Have working knowledge regarding algorithms Have had sufficient practice in resuscitation skills Are committed to the success of the ACLS resuscitation There are a total of six team member roles and each are critical to the success of the entire team. Team leader Compressor Airway manager AED/Monitor/Defibrillator IV/IO medications provider Time recorder Now let's look at the roles and responsibilities of each. Team Leader The team leader is required to have a big picture mindset. This includes the following duties: Keep the resuscitation team organized and on track Monitor the team's overall performance and accuracy Back up any other team member when appropriate Train and coach other team members when needed and provide feedback Facilitate all actions and understanding during the code Focus on the comprehensive care of the patient Assign remaining roles to the other team members Make appropriate treatment decisions based on proper diagnosis Every symphony needs a conductor, just as every successful resuscitation team needs a team leader for the group to operate effectively and efficiently. The team leader has a responsibility to ensure that all team members are playing their individual role to the best of their abilities, and this includes doing things the right way at the right times. But perhaps the biggest responsibility of the team leader centers on his or her ability to communicate clearly and effectively and explain to team members the specifics of resuscitation care, such as: Pushing hard and fast in the center of the patient's chest Ensuring the complete chest recoil Minimizing interruptions in chest compressions Avoiding excessive ventilations The team leader assigns the remaining roles to the other team members and makes appropriate treatment decisions based on proper diagnosis and interpretation of the patient's signs and symptoms. The team leader also provides feedback to the team and assumes any team roles that other team members cannot perform or if some team members are not available. Compressor The team member in charge of compressions should know and follow all the latest recommendations and resuscitation guidelines to maximize their role in basic life support. Chest compressions are vital when performing CPR. So vital, in fact, that this team member often rotates with another team member (usually the AED/monitor/defibrillator) to combat fatigue. The best time to switch positions is after five cycles of CPR, or roughly two minutes. However, if you're feeling fatigued, it's better to not wait if the quality of chest compressions has diminished. Airway Manager The airway manager is in charge of all aspects concerning the patient's airway. This includes opening the airway and maintaining it. And using equipment like a bag valve mask or more advanced airway adjuncts as needed. AED/Monitor/Defibrillator As you might have guessed, this team member is in charge of bringing an AED to the scene (unless one is already present) and operating the AED. This team member is also the most likely candidate to share chest compression duties with the compressor. Pro Tip #2: It's important to understand how important high-quality CPR is to the overall resuscitation effort. The compressions must be performed at the right depth and rate. ACLS begins with basic life support, and that begins with high-quality CPR. If BLS isn't effective, the whole resuscitation process will be ineffective as well. IV/IO/Medications Provider This team member is in charge of all vascular duties, including: Initiating vascular access using whatever technique is appropriate Administering medications with accuracy and timeliness as directed by the team leader Providing feedback or advice when appropriate Time Recorder The time recorder is responsible for keeping a rolling record of time for: All specific resuscitation interventions All medications or treatments administered The frequency and duration of any CPR interruptions The time recorder also announces to the team when/if a next treatment or more medication is due. If no one person is available to fill the role of time recorder, the team leader will assign these duties to another team member or handle them herself/himself. https://d3imrogdy81qei.cloudfront.net/video_images/4355/overview-and-team-roles-and-responsibilities.jpg Yes 424 https://www.proacls.com/training//video/amiodarone https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2449.mp4 Amiodarone In this lesson, we'll go over the medication amiodarone and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we give you a Word on rhythm checks after defibrillation. Amiodarone is an effective treatment for a wide variety of atrial and ventricular tachyarrhythmias in pediatric patients. It can prolong AV conduction and ultimately slow the heart rate by elongating the AV refractory period, QRS, and the Q to T intervals. Because amiodarone is an alpha and beta-blocker (while also blocking sodium, potassium, and calcium channels), it is a well-known drug for its multi-channel blocking capabilities. Amiodarone Indications Some indications for the drug amiodarone, as an antiarrhythmic drug, is that it will be used specifically for its broad range of electrophysiological effects. Pro Tip #1: Amiodarone is primarily chosen for ACLS as a first-line antiarrhythmic agent for cardiac arrest because it has shown to be clinically effective and reliable for improving the rate of return of spontaneous circulation (also known as ROSC) and improved ROSC to hospital admission in adults with refractory VFib or pulseless V-tach. Amiodarone may also be considered when VFib and V-tach are unresponsive to: CPR Defibrillation Epinephrine Amiodarone Precautions and Contraindications Now let's look at some amiodarone precautions and contraindications. Warning: With amiodarone, there are multiple complex drug interactions, so care must be taken when using this medication. And do not administer amiodarone with other drugs that prolong the QT interval, such as procainamide. A rapid infusion of amiodarone could lead to hypotension. However, during cardiac arrest, there isn't any blood pressure and therefore the American Heart Association recommendation is still to use an amiodarone rapid IV push for the treatment of antiarrhythmias. It's important to remember that when using multiple doses of amiodarone, which can be cumulative doses of greater than 2.2 grams over a 24-hour period, significant hypotension has been noted in clinical trials. Because the terminal elimination and half-life of amiodarone is so long – having a half-life sometimes lasting as long as 40 days – amiodarone can be a complicated medication to work with and around when treating a patient who has experienced a return of spontaneous circulation. Which means that using amiodarone may eliminate the option of using other medications until it has been effectively eliminated from the body. Adult Dosage of Amiodarone When using amiodarone to treat V-Fib or pulseless V-tach cardiac arrest which is unresponsive to CPR, shock, and vasopressors, a first dose is given at 300 mg via IV or IO push. And a second dose is delivered at half that, or 150 mg, also via IV or IO push. For life-threatening arrhythmias, a maximum accumulated dose is 2.2 grams via IV over a 24-hour period. For patients with a pulse but also suffering from a life-threatening arrhythmia, administer amiodarone via rapid infusion and delivered at 150 mg IV over the first 10 minutes, which equals 15 mg per minute. This dose can be repeated also via rapid infusion every 10 minutes as needed, up to the maximum dose of 2.2 grams in a 24-hour period. When administering amiodarone via slow infusion, deliver the medication at 360 mg IV over a 6-hour period, or 1  mg per minute. A maintenance infusion can be given at 540mg IV over 18 hours, or 0.5 mg per minute. Pro Tip #2: Remember, these infusions should not exceed 2.2 grams over a 24-hour period. And when delivered at this maximum dosage, the effects can last up to 40 days. A Word About the Resumption of CPR and Rhythm Checks Post-Defibrillation Resume CPR After defibrillating an adult patient, you should: Immediately resume CPR, starting with chest compressions Not perform a rhythm check or pulse check at this time unless the patient is beginning to show signs of life or advanced monitoring indicates ROSC Establish IV or IO access The American Heart Association guidelines recommend that healthcare providers tailor the sequence of their rescue actions based on the presumed etiology of the arrest. Also, ACLS providers that are functioning within a high-performance resuscitation team may choose the optimal approach for minimizing interruptions in chest compressions. Examples of optimizing CCF and high-quality CPR are the use of different protocols such as: 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts Compression-only CPR in the first few minutes after the arrest Continuous chest compressions with asynchronous ventilation once every 6 seconds with the use of a bag-mask device A default compression-to-ventilation ratio of 30:2 should be used by healthcare providers with less training or experience or if the 30:2 ratio is your established protocol. Rhythm Checks Conduct a rhythm check after 2 minutes of CPR and be careful to minimize interruptions in chest compressions. Remember, the pause in chest compressions when checking the patient's rhythm should not exceed 10 seconds. If a non-shockable rhythm is present and the rhythm is organized, one of the team members should try to palpate a pulse. And if there is any doubt about the presence of a pulse, immediately resume CPR. Remember to perform a pulse check, ideally during rhythm analysis, only if an organized rhythm is present. If the rhythm is organized and you detect a palpable pulse, proceed to post-cardiac arrest care. If your rhythm check reveals a shockable rhythm, resume chest compressions if indicated while the defibrillator is charging. https://d3imrogdy81qei.cloudfront.net/video_images/4363/amiodarone.jpg Yes 225 https://www.proacls.com/training//video/normal-sinus-rhythm https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2464.mp4 Normal Sinus Rhythm When talking about treating a patient for something that we consider abnormal, it's always helpful to define and understand what normal looks like, in this case, for a normal sinus rhythm. In this lesson, we'll look more closely at an example of a normal sinus rhythm on an ECG (aka EKG) for an adult patient and see what findings and measurements are considered normal, and what to be on the lookout for that would be considered abnormal. And at the end of the lesson, we'll provide a Word about acute coronary syndrome. *Normal Sinus Rhythm ECG/EKG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the above graphic, it's regular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? Remember, to determine the patient's heart rate you'll want to observe the following areas on the ECG paper printout and perform the following calculations. The horizontal axis of ECG paper grids is where time is measured. Each small square is 1mm in length and represents .04 seconds. Each larger square is 5mm in length and represents .2 seconds. Therefore a 6 second interval would be 30 large squares. To determine the heart rate, count the number of QRS complexes over this 6 second interval and multiply by 10. In the ECG above, the rate is 80 beats per minute, and this is normal. For an adult patient, the normal heart rate range is 60 to 100 beats per minute. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? Do they occur regularly? Is there one P-wave for each QRS complex? Are the P-waves smooth, rounded, and upright? Do all the P-waves have a similar shape? The answer to each of those questions is, yes, meaning the P-waves are normal. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal for an adult patient, meaning between .12 and .20 seconds, or is it contained within one large square on the readout? Is the PR interval constant? The answer to both questions is, yes. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? Pro Tip: As long as the QRS fits within two small squares on the ECG printout and is not greater than three small squares, it's within the normal range. Is the QRS complex wide or narrow? If it's narrow, such as on the ECG printout above, then that's considered normal. Are the QRS complexes similar in appearance or are there noticeable differences? For the above ECG readout, the answer is, they're similar in appearance and thus normal. So, what is your cardiac interpretation? (This is something we'll be asking ourselves each time we look at a new ECG rhythm.) Based on these questions and on the findings from the ECG readout above, it's safe to say that the patient has a normal sinus rhythm. We have a regular rhythm. We have a normal heart rate. The P-waves look normal, with each being followed by a QRS complex. The PR interval is between .12 and .20 seconds. The QRS is less than .12 seconds. Unless the patient has no pulse or other serious signs or symptoms, it's safe to assume that there is nothing of significance, in a negative sense, from this patient's cardiac rhythm. A Word About Acute Coronary Syndrome As an ACLS provider, you should have the basic knowledge to assess and stabilize patients with acute coronary syndrome (ACS). In these cases, you will use the ACS algorithm as your guide to clinical strategy. The initial 12-lead ECG is used in all ACS cases to classify patients into one of three ECG categories. Each of these categories has different strategies of care and management needs. The three ECG categories are ST-segment elevation suggesting ongoing acute injury, ST-segment depression suggesting ischemia, and nondiagnostic or normal ECG. All three are outlined in the ACS Algorithm. Key components of these cases are: Identification, assessment, and triage of acute ischemic chest discomfort Initial treatment of possible ACS Emphasis on early reperfusion of the patient with ACS/STEMI (ST-Elevation Myocardial Infarction) Rhythms for ACS Sudden cardiac death and hypotensive bradyarrhythmias may occur with acute ischemia. You should learn to anticipate these rhythms and be prepared for immediate attempts at defibrillation and administration of medication or electrical therapy for symptomatic bradyarrhythmias. https://d3imrogdy81qei.cloudfront.net/video_images/4391/normal-sinus-rhythm.jpg Yes 183 https://www.proacls.com/training//video/ventricular-fibrillation https://d3imrogdy81qei.cloudfront.net/videos/course_videos/en/2468.mp4 Ventricular Fibrillation Ventricular fibrillation (also called VFib or VF) is caused by multiple ectopic electrical impulses which depolarize the myocardium in a chaotic fashion. This results in a quivering (or fibrillatory) heart that cannot produce a pulse or adequate cardiac output. In this lesson, we'll dig a little deeper into ventricular fibrillation and then look at a typical ECG readout for a patient in VFib and provide a cardiac interpretation. And at the end of the lesson, we'll provide a preview of the medications we'll be looking at in the following section of your ProACLS course. Now let's take a look at an ECG for a patient in ventricular fibrillation. *Ventricular Fibrillation ECG for Adult Patient 1. The Heart Rhythm The first thing you'll want to look at is the heart rhythm. Does the heart rhythm look regular? Or does it look irregular? In the ECG above, the rhythm is irregular. 2. The Heart Rate Next, you'll want to look at the heart rate of the patient. What is the patient's heart rate? Is it normal? Or is it too slow or too fast? In this case, it's somewhere between 200 and 250 beats per minute and thus, extremely fast. 3. P-Wave After looking at the heart rate, check to see if the patient's P-waves look normal by asking yourself the following few questions. Are the patient's P-waves present? No. Do they occur regularly? No. Is there one P-wave for each QRS complex? No. Are the P-waves smooth, rounded, and upright? No, only fibrillatory waves are present. Do all the P-waves have a similar shape? Again, that answer is no, because normal P-waves aren't present. 4. PR Interval Next, look at the PR interval on the patient's ECG readout and ask yourself the following questions: Is the PR interval normal, meaning between .12 and .20 seconds or is it contained within one large square on the readout? The answer is no, because there isn't a PR interval. Is the PR interval constant? Again, this in non-applicable since there isn't a P-wave. 5. QRS Complex The last thing you should look at to determine if the sinus rhythm is normal or not is the QRS complex and ask yourself these questions while you do: Is the QRS interval less than .12 seconds? No. In fact, there is no evidence of a QRS complex. Is the QRS complex wide or narrow? Not applicable. Are the QRS complexes similar in appearance or are there noticeable differences? Not applicable, since not present. So, what is your cardiac interpretation? Based on these questions and on the findings from the ECG readout above, it would appear that this patient is in ventricular fibrillation. We have an irregular rhythm. We have no heart rate and no pulse. The P-waves are missing; there are only fibrillatory waves present. There is no PR interval. The QRS is nonexistent. When a patient is in ventricular fibrillation, the heart has no organized rhythm as well as no coordinated contractions. The electrical activity is very chaotic. The heart quivers and it does not pump blood. Therefore, pulses are not palpable. Ventricular fibrillation may be preceded by a brief period of ventricular tachycardia with or without a pulse. Pro Tip: VFib is a non-perfusing and lethal dysrhythmia that is most commonly seen during the first few minutes of cardiac arrest. Because of this, it's important that high-quality CPR be administered as soon as possible, including defibrillation, to increase that patient's chance of a successful resuscitation. A Word About Pharmacology (A Preview) It's important that you know basic information about medications and other interventions used in the ACLS algorithms. A basic understanding of pharmacology information includes the indications, contraindications, and methods of administration for each. You'll also need to know when to use which drug based on each clinical situation. Medications and interventions that we'll be looking at in detail in the upcoming ProACLS course section are: Adenosine Adenosine is a prescription drug used for conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PVST), including that associated with accessory bypass tracts (Wolff-Parkinson-White Syndrome). Adenosine is available under the following different brand names: Adenocard, and Adenoscan. Amiodarone Amiodarone is used to treat certain types of serious (possibly fatal) irregular heartbeat (such as persistent ventricular fibrillation/tachycardia). It is used to restore normal heart rhythm and maintain a regular, steady heartbeat. Amiodarone is known as an anti-arrhythmic drug. It works by blocking certain electrical signals in the heart that can cause an irregular heartbeat. Aspirin Aspirin, also known as acetylsalicylic acid (or ASA), is a medication used to treat pain, fever, or inflammation. Specific inflammatory conditions which aspirin is used to treat include Kawasaki disease, pericarditis, and rheumatic fever. Aspirin can also be given shortly after a heart attack to decrease the risk of death. And it can be used long-term to help prevent future heart attacks, ischemic strokes, and blood clots in people with a higher than normal risk. Atropine Atropine is a medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Dopamine Dopamine is indicated for the correction of hemodynamic imbalances present in the shock syndrome due to myocardial infarction, trauma, endotoxic septicemia, open-heart surgery, renal failure, and chronic cardiac decompensation as in congestive failure. Epinephrine Adrenaline, also known as epinephrine, is a hormone and medication. Adrenaline is normally produced by both the adrenal glands and a small number of neurons in the medulla oblongata where it acts as a neurotransmitter involved in regulating visceral functions. It's used in emergencies to treat very serious allergic reactions to insect stings/bites, foods, drugs, or other substances. Epinephrine acts quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat. Fibrinolytic Agents Thrombolytic drugs, or fibrinolytic agents, are used to help dissolve blood clots. Blood clots can occur in any vascular bed. However, when they occur in coronary, cerebral, or pulmonary vessels, they can be immediately life-threatening. Coronary thrombi are the cause of myocardial infarctions. Cerebrovascular thrombi produce strokes. And pulmonary thromboemboli can lead to respiratory and cardiac failure. Lidocaine Lidocaine is used to relieve nerve pain after shingles (infection with the herpes zoster virus). This type of pain is called post-herpetic neuralgia. Lidocaine helps to reduce sharp/burning/aching pain as well as discomfort caused by skin areas that are overly sensitive to touch. Lidocaine belongs to a class of drugs known as local anesthetics. It works by causing a temporary loss of feeling in the area where you apply the patch. Lidocaine is available under the following different brand names: Lidocaine CV, and Lidopen. Magnesium Sulfate Magnesium sulfate is a naturally occurring mineral used to control low blood levels of magnesium. Magnesium sulfate injection is also used for pediatric acute nephritis and to prevent seizures in severe pre-eclampsia, eclampsia, or toxemia of pregnancy. Magnesium sulfate is available under the following different brand names: MgSO4. Morphine Morphine is a pain medication of the opiate family which is found naturally in a number of plants and animals. It acts directly on the central nervous system to decrease feelings of pain. Morphine can be taken for both acute pain and chronic pain. It's frequently given for pain stemming from myocardial infarction and also during labor. And it can be administered a number of different ways, including by mouth, by injection, intravenously, and rectally. Nitroglycerin Nitroglycerin belongs to the group of medicines called nitrates. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload. Nitroglycerin is often used to prevent angina that's caused by coronary artery disease. And it can be used to relieve an angina attack that's already occurring. Oxygen Oxygen is the odorless gas that is present in the air and necessary to maintain life. Oxygen may be given in a medical setting, either to reduce the volume of other gases in the blood or as a vehicle for delivering anesthetics in gas form. It can be delivered via nasal tubes, an oxygen mask, or an oxygen tent. Patients with lung disease or damage may need to use portable oxygen devices on a temporary or permanent basis. Procainamide Pronestyl (procainamide hydrochloride) is a cardiac antiarrhythmic drug used to help keep the heart beating normally in people with certain heart rhythm disorders of the ventricles (the lower chambers of the heart that allow blood to flow out of the heart). The brand name Pronestyl is discontinued in the U.S. Generic versions may be available. https://d3imrogdy81qei.cloudfront.net/video_images/4399/ventricular-fibrillation.jpg Yes 100