1What are the different ACLS treatment algorithms?
- Cardiac arrest
- Post-arrest Care
- Perfusion arrhythmias
- Opioid associated emergency
2BLS
What are the components of BLS in the setting of cardiac arrest?
- Early recognition of cardiac arrest
- High quality cardiopulmonary resuscitation (CPR) = Chest compressions + Rescue breaths
- Early defibrillation with AED
- Goal to provide high-quality CPR until ACLS providers arrive or patient is responsive
3BLS
T/F: BLS ensures the most important interventions happen immediately in cardiac arrest!
True!
4ACLS
Every resuscitation team must have a defined _____________.
Leader
5ACLS - Airway / Breathing
What is the preferred form of ventilation if no advanced airway has been placed?
Bag mask ventilation
- 30:2 compression - ventilation ratio applies
6ACLS - Airway / Breathing
Pauses in _______ should be minimized when placing an advanced airway. What is the exception to this?
- CPR
- Exception in COVID-19 patients: Prioritize intubation > compressions
7ACLS - Airway / Breathing
What are the advanced airway options? Which is preferred?
- Endotracheal (ET) tube (preferred)
- Laryngeal mask airway (LMA) / Laryngeal tube (King airway): May be used when an ET cannot be placed
8ACLS - Airway / Breathing
Once the advanced airway is in place, give ___ breath every ___ seconds or ___ breaths per minute continuously.
- 1 breath every 6 seconds
- 10 breaths every mins
9ACLS - Airway / Breathing
What does attaching a waveform capnography help us with?
- Measures concentration of carbon dioxide in exhaled air at the end of expiration
- Verifies correct ET tube placement in trachea
- Assess adequacy of resuscitation efforts
10Cardiac Arrest
What is it?
Cessation of heart activity with sudden and sustained loss of consciousness, pulselessness, and apnea or agonal breathing
11Cardiac Arrest
What is the immediate goal of resuscitation?
Return of spontaneous circulation (ROSC) with effective perfusion and ventilation as quickly as possible to minimize hypoxic damage to vital organs
12Cardiac Arrest
What is the long-term goal of resuscitation?
Survive to hospital discharge with good neurologic function
13Cardiac Arrest
What are the primary causes?
- Coronary heart disease = Main cause
- Structural heart disease
- Abnormal heart rhythm or conduction
14Cardiac Arrest
What is the first thing we should do after BLS in cardiac arrest?
Determine if there is a shockable rhythm or not
15Cardiac Arrest
What are the two rhythms in cardiac arrest?
Which one do shock?
Which one is associate with poor survival?
Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT)
- Shock these patients!
Asystole and Pulseless Electrical Activity (PEA)
- Do NOT shock these patients
- Poor survival
16Cardiac Arrest
What is C-A-B?
Circulation
- High-quality chest compressions with interruptions minimized
- Defibrillation aimed at restoring circulation
- Medications aimed at restoring circulation
Airway and Breathing
- No advanced airway: Rescue breaths with a compression-ventilation ratio of 30:2
- Advanced airway: Continuous breathing with breaths every 6 seconds and quantitative waveform capnography
17Cardiac Arrest
What is the most important component of CPR?
High Quality Chest Compressions
18Cardiac Arrest
Chest compressions must be of sufficient ____________ and ______________.
- Depth (2 to 2.5 inches)
- Rate (between 100 and 120 per minute)
19Cardiac Arrest
Who should get defibrillation?
Shockable rhythms
- VF
- Pulseless VT
20Cardiac Arrest
T/F: Electrical defibrillation provides the single most important therapy for the treatment of patients with pulseless VF and VT.
TRUE = When we know it is a shockable rhythm, shock them immediately. Do not wait until the next cycle of compressions.
21Cardiac Arrest
What are the three access points to give medications?
- Peripheral IV access (sometimes already have this)
- Central IV access
- Intraosseous (IO) IV access (bone)
- ET = LAST resort
22Cardiac Arrest
T/F: Anything that can be given IV can be given IO.
TRUE
23Cardiac Arrest
What is the pharmacists role during a cardiac arrest code?
- Optimizing medication choice and doses
- Prevention of medication errors (especially in light of drug shortages)
- Assist with timing of medications and documentation
- Medication preparation and acquisition
- Know the code cart contents!!
- Provision of drug information
24Cardiac Arrest
T/F: Medications have been shown to improve overall survival and we should administer them ASAP.
FALSE -- There is no medication to improve neurologic outcomes. Meds are secondary to CPR and defibrillation.
25Cardiac Arrest Medications - Epinephrine
Who gets it?
Asystole/PEA and VF/pulseless VT
- The one medication that everyone can get
- Only medication that asystole/PEA gets
26Cardiac Arrest Medications - Epinephrine
What does it do in cardiac arrest?
- Used primarily for it's alpha-adrenergic effects producing vasoconstriction to increase coronary and cerebral blood flow
- Stimulation of beta 1 and 2 receptors which can increase myocardial contractility, but also increase myocardial oxygen demand (may not be good)
27Cardiac Arrest Medications - Epinephrine
When is it indicated for asystole/PEA?
As soon as access is obtained
28Cardiac Arrest Medications - Epinephrine
When is it indicated for VF/VT?
During CPR after the 2nd defibrillation
29Cardiac Arrest Medications - Epinephrine
What is the dose?
What must we always look at when dosing this?
- Dose = 1 mg every 3-5 mins
- Have to look at the dilution to see how many mL you need
30Cardiac Arrest Medications - Epinephrine
What other ROA than IV can it be given?
ET at 2-2.5 mg
31Cardiac Arrest Medications
What two drugs are used in patients with refractory VF and pulseless VT?
Lidocaine or amiodarone
32Cardiac Arrest Medications - Lidocaine
When is it indicated?
Dose?
After the 3rd shock in VF/VT if ROSC not achieved
- Lidocaine 1-1.5 mg/kg IV push
33Cardiac Arrest Medications - Lidocaine
Additional ROA?
ET
34Cardiac Arrest Medications - Lidocaine
Monitoring?
Cardiac monitor, HR, BP, neurologic effects (seizures)
35Cardiac Arrest Medications - Amiodarone
What is it indicated?
What dose?
- After the 3rd shock in VF/VT
- 300mg IV push, followed by 150mg if the dose is repeated
**this is the only time amio will dosed this high**
36Cardiac Arrest Medications - Magnesium
When is it indicated and at what dose?
Pulseless torsades de pointes only
- 1-2 gm IV with a 10 mL flush (over 5-10 mins per guidelines, but really over 1 minute)
**only time you will give magnesium as an IV push**
37Cardiac Arrest
What are the reversible causes that we should be continuously looking for during the code?
H's
- Hypoxia
- Hypovolemia
- Hydrogen ion (acidosis)
- Hypo/hyper- kalemia
- Hypoglycemia
- Hypothermia
T's
- Toxins
- Tamponade (cardiac)
- Tension pneumothorax
- Thrombosis (coronary or pulmonary)
38Cardiac Arrest - H's & T's
When is calcium chloride 1 gm IV push utilized? (3)
- Hyperkalemia
- Severe hypocalcemia
- Beta-blocker or CCB overdose
39Cardiac Arrest - H's & T's
When is insulin 10 units IV push utilized?
Hyperkalemia
- Always given with dextrose in order to prevent hypoglycemia from insulin
40Cardiac Arrest - H's & T's
What is used for hypovolemia?
IV crystalloid fluids to restore blood pressure and improve perfusion
- LR
- NaCl
41Cardiac Arrest - H's & T's
What would be utilized for confirmed or suspected massive pulmonary embolism leading to cardiovascular collapse in the absence of active bleeding?
Alteplase (tPA)
42Cardiac Arrest - H's & T's
When would sodium bicarbonate be utilized?
- Severe metabolic acidosis
- As a part of hyperkalemia tx
- TCA overdose
43Cardiac Arrest - Post-Resuscitation Care
What are signs of ROSC?
- Palpable pulse and blood pressure
- Abrupt sustained increase in the ETCO2
- Spontaneous arterial pressure waves if intra-arterial monitoring
- The patient starts becoming responsive or starts breathing spontaneously
44Cardiac Arrest - Post-Resuscitation Care
Pharmacists role? (2)
- Anticipate the need for fluid bolus to restore blood pressure
- Vasopressor infusions in the immediate post-ROSC period
45Cardiac Arrest - Post-Resuscitation Care
What is the only therapy documented to improve neurologic recovery following cardiac arrest?
Targeted Temperature Management (TTM) with hypothermia
46Cardiac Arrest - Post-Resuscitation Care
T/F: Hyperthermia thought to protect from cerebral injury from ischemic damage
FALSE -- Hypothermia
47Cardiac Arrest - Post-Resuscitation Care
What is the strategy of Targeted Temperature Management (TTM)?
Controlled cooling of body to 32-36 degrees C for ≥ 24 hours
48Cardiac Arrest - Post-Resuscitation Care
T/F: TTM is best utilized when the patient is conscious and awake.
FALSE -- Patient should NOT be awake
49Bradycardia
What is clinically significant bradycardia?
Typically occurs with heart rate < 50 BPM + symptoms
50Bradycardia
Goals of management?
Find underlying cause, restore perfusion, and prevent deterioration to cardiac arrest
51Bradycardia
When would treatment be indicated?
Must be SYMPTOMATIC to require treatment:
- Hypotension
- Acute change in mental status
- Chest Pain
- Acute Heart Failure
- Signs of Shock
52Bradycardia
First line treatment?
Atropine
53Bradycardia Tx - Atropine
Who gets it?
Only patients with symptomatic bradycardia in the setting of ACLS
54Bradycardia Tx - Atropine
What is another ROA?
ET
55Tachycardia With A Pulse
What is the definition?
Clinically significant arrhythmia at HR ≥ 150 BPM
56Tachycardia With A Pulse
What are the two types and how do we classify them?
- Ventricular tachycardia with a pulse = Wide QRS complex
- Supraventricular tachycardia (SVT) = Narrow QRS complex
57Tachycardia With A Pulse - Tx
What do we do is the patient is unstable?
Synchronized cardioversion
58Tachycardia With A Pulse - Tx
What do we do is the patient is stable with a narrow QRS complex?
Vagal maneuvers first!
- Adenosine if regular
- Beta-blocker, NDHP CCB if irregular
59Tachycardia With A Pulse - Tx
What do we do is the patient is stable with a wide QRS complex?
Most likely ventricular = Antiarrhythmic therapy*
60Tachycardia With A Pulse - Adenosine
When is it indicated and at what dose?
After vagal maneuvers in regular narrow complex tachycardia
- 6 mg IV rapid push with flush to follow (half life is 10 sec)
- If first dose ineffective, may repeat with a 12 mg dose
61Tachycardia With A Pulse - Adenosine
Monitoring?
- Chest pressure with sinus pause (warn patient)
- Asystole