ACLS Review

Jack Hornick
7/28/15
 Announced overhead
DR Heart
First floor
Atrium

DR Heart
First floor
Atrium
 Who goes to the code
Interns, senior residents, AIs, and 3rd
year medical students on Long Call
on wards and in MICU
DACR/VACR/NACR
Anesthesia team
Respiratory Therapists
Critical care nurses (from MICU/CICU)
Critical care pharmacist (sometimes)
 Who runs the code?
First resident on the scene, or
DACR/VACR/NACR
The leader of the code assigns roles
and responsibilities to the other
residents and interns available
 Roles during the code
Stabilizing/managing airway
Line for chest compressions
Recording timing of events
Managing code cart/ Medication
administration
Checking labs and past medical history,
telemetry
Obtaining emergency access
Thinking through Hs and Ts
Calling the patients family
 Code Blue
You are the Naff intern on call, working
on notes in the Naff team room. Code
Blue is called for a patient on
Lakeside 20. Your senior is MIA. You
run down the hall and are the first on
the scene. What do you do?
 Scenario 1
You feel a thready femoral pulse, the
patient feels tachycardic
Automatic blood pressure cuff is not
reading
Patient is agonal breathing, not
responding to verbal or painful stimuli
The nurses look to you and say
Doctor, what do we do?
 On arrival, you do a quick initial
assessment while assessing his
responsiveness and vital signs and
immediately instruct someone to begin
compressions.
While compressions are occurring you ask
the nurse to apply pads and electrodes to
the patient to analyze the rhythm.
In addition, you ask that oxygen be applied
to the patient
You ask about any complaints the patient
may have had and find that minutes ago
he was complaining of chest pain,
palpitations, and dizziness.
Being a very keen intern, you recognize
this may be Acute Coronary Syndrome
causing arrest.
Cardiac Arrest, 4 rhythms
 As you pause during compressions you analyze the
rhythm the patient is in Ventricular Fibrillation
The DACR runs into the room, you notify him/her of
the patients rhythm and
ANALYZE.. CLEARSHOCK DELIVERED
Resume CPR! Wait to reanalyze the rhythm after
the next round of CPR
The patient receives a dose of Epinephrine in
addition to another shock and has conversion to
sinus rhythm. He has ROSC. His vitals begin to
improve and he is rushed to the Cardiac
Catherization Lab.
Nice Work!
 High quality CPR is key
Rate approx 100/min
Compression depth
>2 inches (5cm) in
adults
Allow complete chest
recoil after each
compression
Minimize interruptions
Rotate every 2
minutes
 Scenario 2
One of your many pagers on Intern
Nightfloat goes off.
Theres a Code White on your patient
in Lakeside 55 her heart rate is a little
low and shes feeling dizzy
You ask the nurse to get a full set of
vitals as you head towards the patients
room.
As youre headed over you hear the
overhead announcement CODE BLUE,
CODE BLUE, CODE BLUE..LAKESIDE 55
 You arrive at the patients room and the
nurse informs you that the patients HR was
60-70s during the day but suddenly
decreased from 48 to 35bpm.
Current vitals: HR 35bpm, SBP 70/DBP is
undetectable RR 16/min, and O2 saturation
93%.
The patient was initially complaining of
lightheadedness but now is more lethargic.
You take a look at the EKG that was obtained.
 You request oxygen be applied to the
patient and the pads for transcutaneous
pacing be applied.
Just as you are doing so, additional help
arrives and your Nightfloat senior assists
you.
Atropine is obtained from the crashcart and
the patient is bolused 0.5mg.
The patients HR slightly improves to 49bpm
but he remains somewhat confused and
lethargic.
Transcutaneous pacing is started with a
target HR of 60bpm. She begins to wake up
and her BP improves to 110/57.
EP is consulted and the patient receives a
transvenous and ultimately an implanted
pacemaker.
 Last Scenario
You are on Hellerstein waiting to sign
out at 630 pm on a Sunday when
youre paged about a patient with
past hx of SVT here for CP now has a
HR of 160.
BP 125/80, narrow complex
tachycardia as below
 After attempting vagal maneuvers
(unsuccessful) you give adenosine
6mg IV push, and then 12 mg IV push
Now the patient develops severe
chest pain, He 220, BP not
obtainable, pulse weak. The patient
begins losing consciousness. What do
you do next?
 Synchronized cardioversion is
unsuccessful. Patient now is pulseless
and unconscious.

What next? Time to shock!

(unsynchronized 120-200 J)
 Synchronized vs
unsynchronized cardioversion
Synchronized Unsynchronized
Low energy shock High energy shock
delivers shock w/ delivers as soon as
peak of QRS shock button is
Indications: unstable pushed
A fib, A flutter, SVT
Indications:
pulseless VT/VF
If shock occurs on t-
wave, high likelihood
of VF
 After 5 cycles of CPR, the rhythm check
suggests a second shock. Now with 200 J.
Which medications should you be giving?

Epinephrine 1mg IV q3min and/or

vasopressin 40 U IV to replace first or
second epi dose
Amiodarone after 3rd shock in pulseless VT
(300 mg IV x1, then consider 150 mg IV x1
 SROC! The patient was intubated by
anesthesia at the scene, and is not
responding to verbal commands.
Patient transported to CICU. What
post cardiac arrest intervention
would this patient benefit from?
 What Is ACLS?
ACLS guidelines first published 1974 by
AHA, most recent update 2010
A series of interventions for urgent
treatment of cardiac arrest, stroke, and life
threatening medical emergencies
Several algorithms for VF/Pulseless VT,
Bradycardia, Suspected Stroke
An essential part of using the algorithm
correctly is to search for and correct
potentially reversible causes of arrest
Performing high quality CPR, identifying
arrhythmias and understanding the
pharmacology behind key drugs are central
to ACLS.
 Hs and Ts
Treatable causes of cardiac
arrest
Hypoxia Thrombosis
Hypovolemia (pulmonary)
Hydrogen ion Thrombosis
(acidosis) (coronary)
Hypokalemia Tamponade
Hyperkalemia Tension
Hypothermia pneumothorax
Toxins
 Things to discuss with
patients
All patients admitted to the hospital
should be asked about their code status
Its important to discuss the morbidity
associated with ACLS
Statistics regarding survival after arrest
Adverse outcomes of CPR and
Advanced Airway Support
Dont forget to pick up your ACLS cards
from the chiefs office!

Remember to check your own pulse

first.