INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench,...
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Transcript of INTRO TO ACLS Department of Emergency Medicine University of Manitoba Zoe Oliver, Cheryl ffrench,...
INTRO TO ACLS
Department of Emergency Medicine
University of Manitoba
Zoe Oliver, Cheryl ffrench, Shai Harel,
Hareishun Shanmuganathan, Katie Sullivan
OBJECTIVES
1. Approach to the first three minutes of a code
2. Primer on the rest….
Part 1: He Looks Dead
Katie is a third year medical student on her Ortho rotation.
She is pre-rounding on her patients in the morning.
Pitfall:
Started CPR before checking responsiveness
Checking Responsiveness
Voice (get close)
Pain (noxious central stimulus) Sternal Rub Upper Orbit Pressure Trapezius Pinch
Part 2 – He Is Dead
Katie is a third year medical student on her Ortho rotation.
She is pre-rounding on her patients in the morning.
Pitfall:
Didn’t call for help
Calling for help
Check which room you’re in
Go into hallway and look for nurse
Get someone to check the code status
No one there?
Go to phone and dial ‘55’ for an emergency line Code Blue vs. Medical 25 vs. Code 88
Part 3 – How was your Weekend?
Katie and Shai are third year med students pre-rounding on their Ortho rotation.
They enter a four bed room together. Katie’s patient, “doesn’t look right”.
Pitfall:
Didn’t activate BLS
Activating the BLS Primary Survey
BLS Primary Survey
Simple interventions
Part 4 – He’s Not Perking Up
Katie and Shai decide to activate BLS.
Pitfall:
Didn’t open airway
Gave inadequate breaths
Radial pulse check
Primary
Primary
•Give 2 breaths •NO response? 1 breath / 5 seconds and CPR
No more than 5-10 seconds
NOT peripheral pulse
Start CPR
CPR board
Recheck pulse every 2 minutes
Ensure IV/IO access
Primary
Part 5: The Team Will be Here Soon
Previous scenario continues
Ward resident Hareishun runs into the room…
Pitfall:
Too many CPR interruptions
CPR
CPR board
100 compressions/minute
30:2 breaths
Hard and fast
Parts 1-5: The Replay
RECAP
Who’s on the code team?
• Code team leader• More doctors if they happen to be around
• Nurses• Record keeper, someone to give meds
• RT
• Orderly• CPR
How does the code team work?
• Code team leader:• Makes it clear who is in charge
• Call for quiet if there’s too much noise
• Stands at pt’s side, hand on pulse (femoral)
• If possible, delegate tasks to others
• Closed-loop communication
• Maintain sense of ‘big picture’
What the team leader will ask you….
Patient name, age, reason for admission
Past medical history
CODE STATUS
Time of arrest, events leading up
What next?
Repeat the BLS Primary Survey
Can now do ‘D’
At casino: No pulse power-on AED and
follow voice prompts Apply pads Administer shock as
directed
In hospital: will not have AED immediately available
Once you know the rhythm, you can follow the algorithm
Today: Non-Perfusing Rhythms
Non-Perfusing Rhythms
What are VF and VT?
• These two rhythms are treated in the same way (if pulseless)
• Both represent the ventricle trying to pump blood in a disorganized way
• Usually due to myocardial ischemia (for whatever cause)
VF and VT
Examples
Examples
Examples
Examples
Defibrillators 101
Defibrillators 101
• Gel pads• Select energy (200J)• No Sync• Charge• Clear everyone• Shock
Putting it together
• You’ve found an unresponsive patient
• Called a code
• Did as much of the BLS primary survey as you could
• Code team has arrived and repeated the primary survey, including defibrillation if needed
First three minutes…
OBJECTIVES
1. Approach to the first three minutes of a code
2. Primer on the rest….
Incorporating ACLS
Now: ACLS Secondary Survey
Advanced interventions
Is the airway patent?
Is an advanced airway indicated?
Laryngeal Mask Airway (LMA) Endotracheal Tube (ETT)
Is the airway in the right place?
Is the tube secure?
Are we monitoring O2 and CO2?
What is/was the rhythm?
Is there IV access?
Is fluid needed?
Are drugs needed?
Why did the patient arrest?
Is there a reversible cause for the arrest?
Part 6:Dream Team Code
PEA and Asystole
PEA
Organized
No pulse
Fast or slow
PEA
PEA
Asystole
Final rhythm
Depleted myocardium
Check two leads
PEA and Asystole: Treatment
• Epinephrine
• Atropine for slow PEA/asystole
• CPR
• Fix the fixable• Hypovolemia: Bolus NS• Hypoxia: O2
• Hyperkalemia: ABG (for K+), Bicarbonate, Calcium Cl, • Acidosis, TCA OD: Bicarbonate• Pneumothorax/tamponade: Needle• MI/PE: Thrombolytics
Part 7: An hour later…..
The Dream Team is still at it:
Switch to the other side of the flowchart
Outcomes
Out-of-hospital In-hospital
Pulse never returns 70%
Death at one year 99%
Death or neurologic compromise
99.5%
Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine versus epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359:21-30Peberdy M, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785-792
Pulse never returns 50%
Death 80%
Death or neurologic compromise
85%
Questions?