ACLS Review

By: Garv Bhasin

Sequence of Performing Assessments

1. Rapid Assessment
a. Perform a quick visual survey to assess for safety and determine what
resources are needed to treat/stabilize the patient. Formulate initial
impression of the patient.
b. Check Responsiveness- Shout, “Are you OK” and tap the patient’s
shoulder (Shout- Tap-Shout sequence). If the patient is unresponsive,
activate EMS and call for an AED
2. Primary Assessment
a. ABCDE Evaluation Tool- Airway, Breathing, Circulation, Disability, and
Exposure
3. Secondary Assessment- main purpose is to search for the
underlying cause of the emergency
a. Focused Medical History
b. Physical Exam
c. Search for Underlying causes
d. Diagnostic Test (x-rays, labs etc. )
“Normal” Values for Reference

❏ Blood Pressure : 120/80, Systolic = 120 and Diastolic = 80

❏ Heart Rate (pulse) = 60-100 Beats per minute (BPM)
❏ Slow pulse is called Bradycardia
❏ Fast pulse is called Tachycardia
❏ Normal Breaths / minute is considered to be 12-20
❏ Normal EtCo2/ PaCo2 values are 35-45 mmHg
❏ Normal values indicate adequate ventilations are being received
❏ Normal SpO2 levels are considered to be 94% or above
❏ Mean arterial pressure is 70-100 mmHg
❏ Normal rate of chest compressions is 100-120 compressions per minute
❏ Normal rate of ventilation is 1 ventilation every 6 seconds
❏ 2 seconds for capillary refill
❏ Pulse checks should not last longer than 10 seconds
EKG/ECG Rhythms:
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s/ecg-simulator/
Asystole

Description:

❏ No electrical activity (flatline), no heart contraction

❏ NOT A SHOCKABLE RHYTHM
❏ Perform CPR immediately

Drugs

❏ Administer Epinephrine 1 mg
Ventricular Fibrillation (Vfib)

Description:

❏ Pulseless vfib is a shockable rhythm

❏ Get the AED and follow instructions
❏ Erratic, rapid, completely ineffective depolarization of
ventricles

Drugs

❏ After 2 shocks administer epinephrine

❏ If rhythm is still shockable after 3 shocks-
❏ Administer an antiarrhythmic medication like Amiodarone or
Lidocaine
❏ If rhythm becomes non-shockable after 2 shocks-
❏
Ventricular Tachycardia

Description:

❏ If pulseless- bring the AED and give shocks

❏ If with a pulse- NOT a shockable rhythm; only pulseless Ventricular
Tachycardia is shockable
❏ Tendency to devolve to vfib

Drugs

❏ After 2 shocks administer epinephrine

❏ If rhythm is still shockable after 3 shocks-
❏ Administer an antiarrhythmic medication like Amiodarone or Lidocaine
❏ If rhythm becomes non-shockable after 2 shocks-
❏ Continue to administer epinephrine every 3-5 minutes
❏ Follow up with saline flush so that medications can reach the desired location
(the heart)
Atrial Fibrillation

Description:

❏ Chaotic Rhythm
❏ Unrecognizable QRS complexes
❏ Absence of p waves
❏ Heart’s upper chambers (atria) beat irregularly and out of sync with the
lower chambers (ventricles)
❏ Increased risk of stroke

Drugs:

❏ Administer Amiodarone 300mg with a 150 mg 2nd dose

❏ Other antiarrhythmic agents
Atrial Flutter

Description:

❏ Easily identified by its Sawtooth pattern

❏ A little bit of a more regular rhythm compared with atrial fibrillation
❏ Patients often feel rapid heartbeats or palpitations.

Drugs:

❏ Amiodarone 300mg followed up with a 150 mg 2nd dose

❏ Other antiarrhythmic agents
Sinus Bradycardia

Description:

❏ Especially common in athletes and the elderly

❏ Common in athletes due to more efficient cardiac output
❏ Rates greater than 50 beats/minute may be tolerated by healthy adults
❏ Narrow QRS complexes with upright P waves

Drugs:

❏ Atropine 1 mg
❏ AED- Atropine, Epinephrine, Dopamine
Sinus Tachycardia

Description:

❏ Often results from increased sympathetic stimulation possibly due to pain,

fever, increased oxygen demand etc.
❏ Other reasons could be anxiety, exercise, or hypovolemia
❏ Narrow QRS complexes
❏ Rate is usually below 150 beats/minutes

Drugs:

❏ Beta Adrenergic Blockers are the preferred treatment

Supraventricular Tachycardia (SVT)

Description:

❏ Beats of around 170-230 beats/minutes

❏ Narrow QRS Complexes

Drugs:

❏ Adenosine
1st Degree AV Block

Description:

❏ Consistently prolonged PR Intervals

❏ Caused by prolonged transmission of the electrical impulse through the AV
junction (AV node and Bundle of His)

Drugs:

❏ Usually doesn’t require treatment

2nd Degree AV Block Type I

Description:

❏ Cyclical Lengthening of the PR interval followed by a dropped QRS- a P

wave not partnered with a QRS complex.
❏ May be caused by enhanced vagal tone, myocardial ischemia, or the effect of
drugs such as calcium-channel blockers.

Drugs:

❏ No pharmacological treatment for asymptomatic patients

❏ Identification and correction of any reversible causes
❏ Atropine
2nd Degree AV Block Type II

Description:

❏ One or more QRS complexes are dropped with fixed PR intervals

❏ Occurs when the conduction of electrical impulses through the AV
node is temporarily blocked

Drugs:

❏ Management requires addressing the underlying causes of the

condition
❏ Pacemaker may be necessary to maintain an adequate heart rate
3rd Degree AV Block

Description:

❏ Lonely P waves- P waves without an accompanied QRS complex

❏ Chaotic PR interval

Drugs:

❏ Atropine, Epinephrine, or Dopamine

❏ Doctor may try transcutaneous pacing
Medications
❏ Adenosine : For supraventricular tachycardia (SVT). Think AdenoSine —>
Supraventricular Tachycardia
❏ Dose : 6 mg rapid IV push; if ineffective, 12 mg may be given twice.
❏ Amiodarone : For life-threatening arrhythmias.
❏ Dose : For cardiac arrest, 300 mg IV push; may repeat with 150 mg if necessary.
❏ Atropine : bradycardia and certain types of heart block. Think AtroPine, Pacing —>
Bradycardia
❏ Dose : 1 mg IV every 3-5 minutes as needed (maximum 3 mg)
❏ Epinephrine : Used in cardiac arrest, anaphylaxis, and severe asthma attacks.
❏ Dose : 1 mg IV/IO every 3-5 minutes; for anaphylaxis, .3-.5 mg
❏ Lidocaine : Utilized as an antiarrhythmic for ventricular arrhythmias and as a local
anesthetic.
❏ Dose : For ventricular arrhythmias, 1-1.5 mg/kg IV; may repeat with 0.5-0.75
mg/kg every 5-10 minutes.
❏ Nitroglycerin : Used for chest pain associated with angina and acute coronary
syndrome (ACS).
❏ Dose : 0.4 mg sublingual tablet or spray every 5 minutes up to 3 doses.
Dose : 2-4 mg IV, may repeat every 5-15 minutes as needed.
Medications (Continued)
❏ Naloxone (Narcan) : Used to reverse opioid overdose.
❏ Dose : 0.4-2 mg IV/IM/SC; may repeat every 2-3 minutes up to 10 mg if
needed
❏ Dopamine : Used to treat significant hypotension in the absence of
hypovolemia.
❏ Dose : 5-20 mcg/kg/min IV infusion, titrate to effect
❏ Norepinephrine (Levophed) : Used for severe hypotension and
shock.
❏ Dose : 0.1-0.5 mcg/kg/min IV infusion, titrate to effect
❏ Aspirin : Given in cases of suspected myocardial infarction (MI).
❏ Dose : 160-325 mg chewable tablet.
❏ Morphine : Used for pain relief and to reduce the workload on the
heart in cases of acute MI.
❏ Dose : 2-4 mg IV, may repeat every 5-15 minutes as needed.
❏ Sodium Bicarbonate : Used to treat metabolic acidosis in certain
situations such as prolonged cardiac arrest.
 Cardiac Arrest in Pregnancy

❏ When the fundus is at or above the umbilicus, LUD (Left Uterine

Displacement) must be provided continuously throughout the resuscitation
effort and until the infant is delivered, even if ROSC is achieved.
❏ LUD relieves pressure placed on the inferior vena cava by the gravid uterus,
increasing venous return to the heart to maximize cardiac output.
❏ Usually, two hands are needed to achieve the necessary displacement. To
provide LUD:
❏ From the patient’s left side, reach across the patient, place both hands
on the right side of the uterus, and pull the uterus to the left and up.
❏ Alternatively, from the patient’s right side, place two hands on the
right side of the uterus and push the uterus to the left and up.
Hs and Ts- Reversible Cause
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Hs and Ts Reversible Causes
Hs and Ts Reversible Causes
Respiration
 Respiratory Progression

❏ Respiratory Distress
❏ Patient is using compensatory mechanism to
maintain adequate oxygenation and ventilation
❏ Work of breathing is increased but oxygenation
and ventilation are adequate to meet metabolic
demands
❏ Respiratory Failure
❏ Respiratory system can no longer meet metabolic
demands
❏ Respiratory Arrest
❏ No breathing but presence of pulse
❏ Cardiac arrest
❏ No breathing and no pulse
Capnography
What is Capnography?

❏ Measurement of ETCo2 expressed as a value and a waveform

❏ Measures CO2 in expanded air
❏ Helps determine
❏ Severity of patient’s clinical condition
❏ Provides more context for the diagnoses
❏ Normal value 35-45 mmHg
❏ > 45 mmHg suggests hypercapnia (respiratory failure)
❏ <35 mmHg suggests hypocapnia (hyperventilation, hyperperfusion)
❏ Remember :
❏ Hypo - less of something
❏ Hyper - more of something
Capnography

❏ Phase I (A-B): Respiratory Baseline

❏ Represents beginning of exhalation
❏ Air is exhaled from the body
❏ Phase II (B-C) Respiratory Upstroke
❏ Represents air from the alveoli containing CO2 being exhaled from the body
❏ Should be nearly vertical
❏ Phase III ( C-D) Expiratory Plateau
❏ Represents last of the CO2 laden air from the alveoli being exhaled from the body
❏ EtCo2 peak value measured at the end
❏ Phase IV (D-E): Inspiratory Downslope
❏ Represents inhalation
❏ Rapid purging of Co2 from airways and alveoli
Capnography in Emergencies

❏ Respiratory baseline should be flat and consistent from breath to breath

❏ A baseline that slopes upwards and increases with each breath suggests that
the patient is rebreathing Co2.

Upward Sloping Baseline

Capnography in Emergencies

❏ Respiratory upstroke should be vertical

❏ A sloping, prolonged upstroke represents uneven alveolar emptying as a
result of bronchospasm
Prolonged, upward slope
Good Luck!