- ACLS Agenda - Agenda for Recertification - ACLS Objectives -  ACLS Prestudy -

American Cardiac Education Specialists

 ACLS Provider Course Agenda

Day One

• Registration

• ACLS Course Overview

• BLS primary and ACLS secondary survey (DVD)

• Mega code Resuscitation Team concept (DVD)

• Learning Stations

Technology Review and Rhythm Recognition

Management of Respiratory Arrest

Adult CPR: practice and competency

• Acute Coronary Syndrome (DVD)

• Learning Stations

Pulseless V-Tach and V-Fib

Brady Cardia/PEA/ Asystole

Tachycardias

• Course review and expectations for Day Two

Day Two

• Registration

• Stroke (DVD)

• Review of Pre-test and rhythms

• Learning Station

• Putting it all together

• Written Test

• Mega Code Test

• Course conclusion

Rest breaks and meal breaks will be integrated into schedule

American Cardiac Education Specialists

 ACLS Renewal 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

• FINISH!!

Rest breaks and meal breaks will be integrated into the schedule.

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American Cardiac Education Specialists

Agenda for Recertification of ACLS for Healthcare Providers

Registration

ACLS course Overview

BLS Primary Survey and ACLS Secondary Survey

Acute Coronary Syndrome

Stroke

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

 

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American Cardiac Education Specialists

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

1^st, 2nd, 3rd degree heart blocks

Pacing

Demonstrate Adult CPR and AED

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American Cardiac Education Specialists

Pre-Study 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 your ABCD’s.

• Open the airway with head tilt/chin lift (if no trauma is suspected), look, listen and feel for adequate breathing. Adequate breathing causes the chest to rise and fall. If no breathing give 2 breaths, each over 1 second. Each breath should allow for rise and fall of the chest. Rescue breaths may be performed by mouth-to-mouth, mouth-to-barrier or bag/mask ventilations.

• 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.

• 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.

• Obtain IV/IO access

• Attach ECG leads and monitor.

• 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

• Your 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.

Vasopressin may be substituted for the 1^st or 2^nd doe of Epinephrine. Vasopressin may be given only once at 40 units.

 

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

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 patients 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 one(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 they are not a candidate for fibrinolytics

·         12 lead ECG

·      A good outcome is tPA for an ischemic stoke within 3 hours of onset of symptoms.

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