The Pass Code: the Pass Code to Access the Test Isacls15

Here is a link to watch 4 ACLS videos:

The pass code: The pass code to access the test isACLS15.

ACLS quick review:

PATIENT ASSESSMENT In ACLS, the specific treatment of a given dysrhythmia or condition depends on the patient’s hemodynamic status. In general, patients can be divided into four categories to determine treatment priorities: • Asymptomatic • Symptomatic – Stable • Symptomatic – Unstable • Pulseless

Asymptomatic patients do not receive treatment, but should be monitored for changes in condition. Any patient with symptoms (even apparently mild symptoms such as palpitations) should be assessed to determine if they are stable or unstable. Determination of a patient’s level of hemodynamic compromise can include several factors: • General Appearance: The first indication of hemodynamic status comes from a patient’s general appearance, including skin signs, level of activity, and work of breathing. If a patient shows signs of shock, such as pale, cool, or diaphoretic skin, chest pain, hypotension, or acute distress, they are unstable. • Level of Consciousness: Interaction with the patient allows the provider to evaluate the patient’s level of consciousness based on the patient’s activity, awareness of their surroundings, and ability to provide information. If a patient shows any level of mental deficit, family or friends should be consulted to determine if this state differs from the patient’s baseline. If the mental deficit is acute, the patient should be considered unstable.

• Vital signs: Vital signs provide a diagnostic evaluation of the patient. Blood pressure is the primary indicator. A systolic blood pressure above 90 mm usually indicates that the patient is stable (although the provider should be alert for changes in blood pressure that might indicate an unstable patient even if blood pressure is normal). Other vitalsigns may be useful; however, the provider should remember that various conditions (CO poisoning) can mask changes in blood oxygen levels, and that a high O2 saturation may be present in unstable patients (those in shock). Additionally, heart rate is of no use in determining if a patient is stable or unstable – a patient with a heart rate of 80 can be severely unstable, while a patient with a heart rate of 210 can be stable if they are still perfusing well.

If a patient’s General Appearance, Level of Consciousness, and Vital Signs are all normal, the patient is stable. If possible, treatment should be rendered starting with the least invasive that is appropriate for that patient’s hemodynamic status. In ACLS, the preferential treatment for symptomatic, but stable patients is generally medications. The preferential treatment for unstable patients is generally Electrical Therapy. Once treatment is rendered, the provider must reassess the patient. If the patient remains symptomatic, the appropriate treatment (medications or electricity) should be given again depending on the patient’s heart rhythm and current hemodynamic status. Thus, if a patient was stable before, but becomes unstable after administration of a drug, the patient should receive electrical therapy to continue treating the dysrhythmia rather than additional doses of a medication. If a patient’s General Appearance indicates they may be unconscious, you should check for responsiveness. If the patient is unresponsive, get help (send someone to call 911 and bring back an AED, call a code, etc.).

Assess for signs of life, such as moving, gasping, or breathing, then assess circulation by checking for a pulse. If the patient has a pulse, assess breathing next. If the patient is not breathing, or breathing inadequately, rescue breathing should be initiated. If the patient is pulseless, rescuers should begin CPR.

Once you determine that a patient is pulseless, an AED or EKG monitor should be attached as soon as possible. CPR should be continued with minimal interruptions. After each rhythm check, the patient should be defibrillated if appropriate (Ventricular Fibrillation or Pulseless Ventricular Tachycardia). Regardless of the heart rhythm, medications should be given as soon as possible after CPR is resumed. The specific medication should be determined by the patient’s exact status and heart rhythm.

Remember: Treat the patient not the monitor!!

Here is a long ACLS booklet and review from aha:

Here is a PowerPoint ACLS presentation from CPR Florida

Below is a 7 page acls short review:

ACLS REVIEW

CPR AND SPORTS MEDICINE SERVICES, LLC
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ACLS Course Agenda

ACLS Course Overview and Organization

ACLS Science Overview

BLS Primary Survey and ACLS Secondary Survey(DVD)

The Mega Code and Team Resuscitation Concept(DVD)

Technology Review

Management of Respiratory Arrest

CPR Practice and Competency Testing

Putting it all together

Course summary and testing details

Megacode test

Written test

Remediation

for Recertification of ACLS for Healthcare Providers

ACLS course Overview

BLS Primary Survey and ACLS Secondary Survey

Acute Coronary Syndrome

Stroke

Induced Hypothermia

Megacode and Resuscitation Team Concept

Review of pre-test

Learning Stations:

 Management of Respiratory Arrest/Adult CPR

 Pulseless Arrest Algorithm

 Bradycardia

 Tachycardias

Putting It all Together

Written Test

Mega Code Testing

Course Conclusion and Evaluation

______

ACLS Course Objectives

Upon completion of the ACLS provider and renewal course the learner will be able to:

Evaluate the ECG risk in determining an Acute Coronary Syndrome

Identify Therapies for ACS

Identify Contraindications for Fibrinolytics in ACS

Understanding of Ischemic Stroke

Time frame for stroke interventions

Airway management

Monophasic/Biphasic defibrillation

The learner will also be able to identify and select appropriate treatment for the following

rhythms:

Ventricular Fibrillation

PEA

Asystole

SVT

Atrial Fibrillation

Torsades de Pointes

Bradycardia

1st, 2nd, 3rd degree heart blocks

Pacing

Demonstrate Adult CPR and AED

______ Review

The Hearts Electrical Impulse

Electricity travels through the heart via the SA node to the AV node, as this happens it causes the atrium to contract or polarize and a P wave to occur on the ECG. As the electricity continues through the bundle branches to causes the ventricles to contract and creates a QRS complex on the ECG. The resting phase or repolarization causes a T wave to appear on the ECG. A normal sinus rhythm has a P wave that is smooth and rounded, a QRS that is tall and peaked and a T rounded T wave.

Q waves with ST segment elevation may indicate an ST segment elevation MI (STEMI). A non ST segment elevation MI (NSTEMI) is characterized by ST segment depression or T wave inversion with pain or discomfort.

STEMI is the most critical MI. Early reperfusion with fibrinolytics, balloon dilation or stent placement will reduce mortality and minimize myocardial infarction.

Bundle branch blocks are diagnosed by measuring the QRS complex. A normal QRS is .06-.10sec, and bundle branch block will have a QRS greater than .12. You can have a right or left BBB, normally a RBBB will look like “rabbit ears” and a LBBB will look have a “wave.

BLS Primary Survey/ACLS Secondary Survey

Check for Patient unresponsiveness, if patient is unresponsive, you must initiate the steps of CPR. Delegate someone to call 911 and get an AED. Remember CAB.

Check for a carotid pulse for at least 5 seconds but no longer than 10. If no pulse begin chest compressions until AED arrives. Remember to push hard and fast and allow for chest recoil

Every 30 compressions, open the airway with a head tilt/chin lift (if no trauma is suspected), and give 2 adequate breaths causing the chest to rise and fall. Each breath over 1 second. Rescue breaths may be performed by mouth-to-mouth, mouth-to-barrier or bag/mask ventilations - 1 breath every 5 seconds IF there is a pulse.

Defibrillation! Follow the steps on the AED. Power on, place pads without interrupting CPR; allow to analyze rhythm and shock if advised.

Best chance of survival is good quality CPR with early defibrillation.

ACLS Secondary Survey

Maintain airway patency, may use advanced airway placement if needed, but assess the necessity of an advanced airway. Provide supplemental oxygen. Ensure good rise and fall of the chest is achieved.

If an advanced airway is placed, confirm placement with physical examination, measurement of exhales CO2 and use of an esophageal detector device. Secure the device and continue monitoring. Confirm proper integration of CPR and Ventilations.ETCO2 of 10 mm Hg by

waveform capnography

Attach Quick Look Pads and ECG leads and monitor.

Obtain IV/IO access

Give appropriate drugs as needed.

Search for and treat reversible causes.

Defibrillation

Determine the type of monitor that you have.

Monophasic-One way current

Use one single shock at 360 joules for an adult.

Biphasic- Two way current

Use on single shock at 150-200

Joules.

Before the machine can deliver a shock, it needs to be charged, the new defibrillators charge rapidly, in less than 10 sec. Always keeps everyone safe!

I’m clear

You’re clear

Oxygen clear

We are all clear

Deliver the shock and immediately resume CPR. Continue the CPR for a full 2 minutes, and then you can recheck the rhythm, administer the medications as needed and deliver another shock if needed. Defibrillators that are available now can correct VF with the first shock, up to 85% of the time.

Drug Administration

Most people still choose Epinephrine for their first line medication. Epinephrine speeds up the heart and increases contractitility. Give 1mg IV or IO. This may be repeated every 3-5minutes.

If VF or VT persists you may look to giving an antiarrhythmic such as Lidocaine or Amiodarone. For asystole or PEA you will only use epinephrine.

The H’s and the T’s

Once you have done your BLS primary and ACLS secondary survey, you should immediately begin to assess your H’s and T’s to find a possible reason for your patient’s condition.

H’s

Hypovolemia: poor skin color, rapid heart rate, flat neck vein.

Intervention: fluid

Hypoxia: cyanosis, slow heart rate,

Intervention: oxygen, check airway placement, suction airway if needed

Hypothermia: cold skin, low temp

Intervention: Use warm NS, warm body temp slowly, patient is “not dead till warm and dead”

Hyperkalemia: Peaked T waves, history of renal disease

Intervention: Infusion of Sodium Bicarb

Hypokalemia: Flat T waves

Intervention: Give potassium infusion

Hydrogen ion excess: Metabolic acidosis- small amplitude QRS, may have renal history

Hypoglycemia: Altered LOC Intervention: check Blood sugar level, give D5W

T’s

Tension Pneumothorax: Deviated trachea, neck vein distention Interventions: Check breath sounds, needle decompression

Tamponade:enlarged neck veins, rapid heart rate Intervention: Pericardiocentesis

Thrombosis: ST segment elevation-STEMI

Toxins:drug overdose, bradycardia Intervention: Narcan

Trauma

Acute Coronary Syndrome

As an ACLS provider you must have a basic knowledge of ACS. You will need to use the Acute Coronary Syndrome as a guide for the clinical strategy for you patient. On your initial 12 lead ECG, you will be able to classify your patients into 3 categories- ST Segment elevation, ST segment depression and normal or nondiagnostic ECG.

The ACLS provider Course does emphasize the need to recognize ST segment elevation for early intervention. The ACLS provider course includes assessment, triage, and treatment for high risk unstable angina and non ST segment elevation MI patients.

Half of the patients who die of ACS do so prior to reaching the hospital, early recognition and intervention is critical.

Symptoms suggestive for ACS include:

Uncomfortable pressure, fullness, squeezing or pain in the center of the chest

Chest discomfort spreading to the shoulders, neck, arms, jaw, back or shoulder blades

Chest discomfort with dizziness, fainting, sweating or nausea

Unexplained shortness of breath, with or without chest discomfort

Treatment strategies continue to evolve, they focus on early dispatch and treatment, with priority on rapid reperfusion. EMS providers should obtain a 12 lead ECG if available and relay information to the arriving hospital ASAP. Treatment of ACS involves the use of drug therapy to relieve discomfort, dissolve clots and inhibit thrombin and platelets. These include:

Oxygen

Aspirin usually 160-325mg chewable

Nitro sublingually or spray every 3-5 minutes if BP is greater than 90mm and there is no recent use of phosphodiesterase

Morphine 2-4mg

Fibrinolytic therapy such as tPA or Reteplase

PCI (percutaneous coronary intervention)

Stroke

Each year in the US, 700,000 people suffer a new or a repeated stroke, and about 1 in 15 death in the US are the result of a stroke. The goal of stroke care is to minimize brain injury and maximize recovery.

The major types of strokes are

Ischemic stroke- these account for about 85% of all strokes and are usually caused by an occlusion of an artery in the brain

Hemorrhagic stroke- accounts for 15% of stroke cases and is a result of a blood vessel in the brain that has ruptured into the surrounding tissue.

The warning signs and symptoms may be subtle, patients and their families should be educated in these signs so that they can activate EMS. Currently one half of all stroke victims are driven to the

Hospital by their family or friends. Signs and symptoms include:

Sudden weakness or numbness to face, arm or leg, especially on one side of the body

Sudden confusion

Trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking

Dizziness or loss of balance or coordination

Sudden severe headache with no known cause

The Los Angeles Prehospital Stroke Screen (LAPSS) is more detail than the Cincinnati (CPSS), adding more criteria. A patient with positive findings in all 6 areas of the LAPSS is 97% likely to be having a stroke. Immediate assessment and treatment is critical, the goal of the stroke team is to have an assessment within 10 minutes of ED arrival.

Assess ABC’s and vital signs and give Oxygen

Start IV, obtain blood samples for CBC, coag studies, glucose and electrolytes

Complete stroke assessment, determine onset of symptoms

Check bedside glucose

Activate the stroke team

Order non-contrast CT, if the CT is positive there is a hemorrhage present and they are not a candidate for fibrinolytics

12 lead ECG

A good outcome is tPA for an ischemic stroke within 3 hours of onset of symptoms.

Induced Hypothermia

Clinical trials show moderate advantages and success rates as opposed to non use.

Induced hypothermia is initiated at ROSC. All comatose patients should have a target core temperature between 32°C and 36°C constantly maintained for at least 24 hours. (Initial studies of TTM examined cooling to temperatures between 32°C and 34°C compared with no well-defined TTM and found improvement in neurologic outcome for those in whom hypothermia was induced.)

Mild hypothermia is thought to suppressmany of the chemical reactions associated with reperfusion injury.

The routine prehospital cooling of patients with rapid infusion of cold IV fluids after ROSC is not with rapid infusion of cold IV fluids after ROSC is not recommended.

Although supporting data is limited,many critical care clinicians routinely sedate and ventilatethe lungs of comatose survivors of cardiac arrest for at least12 to 24 hours; thus, application of therapeutic hypothermiaover this period would be simple.

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