Advanced Cardiovascular Life Support (ACLS)

Dysrhythmias

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Outline

Overview

Advanced cardiovascular life support (ACLS)
1. Clinical interventions
  1. Medical emergencies
  2. Builds upon basic life support (BLS)
2. Who needs ACLS certification?
  1. Medical professionals
    1. Emergency units
    2. Critical care units
    3. Surgery
    4. Probable cardiac related emergencies
3. Components of ACLS
  1. Basic life support (BLS)
  2. Treatment for
    1. Cardiac arrest
    2. Respiratory arrest
    3. Return of spontaneous circulation (ROSC)
    4. Acute coronary syndrome (ACS)
    5. Acute stroke
  3. Resuscitation/life support medications
  4. Arrhythmias

Nursing Points

General

Basic life support (BLS) review
1. Responsive?
  1. Check for breathing
2. Activate EMS/call code
3. Circulation
  1. No pulse – Begin CPR
4. Defibrillation
  1. Shockable rhythm
Cardiac arrest
1. Shockable rhythm?
  1. Yes – Vfib/pulseless vtach algorithm
    1. Provide unsynchronized shock
    2. Resume CPR
    3. Epinephrine every 3-5 minutes
    4. Amiodarone or lidocaine
    5. Rhythm not shockable
      1. Move to PEA/asystole algorithm
    6. Patient regains consciousness
      1. Move to ROSC rhythm (see below)
  2. No – PEA/asystole algorithm
    1. Chest compressions/CPR – 2 minutes
    2. Epinephrine IV/IO
      1. Continue compressions
    3. Rhythm checks every 2 minutes
    4. Epinephrine every 3-5 minutes
      1. After two, 2 minute cycles CPR
    5. Shockable rhythm
      1. Move to Vfib/pulseless vtach algorithm

Respiratory arrest
1. Responsive breathing – Yes
  1. Myocardial infarction?
  2. Stroke/neuro issue?
  3. Cardiac/lung issue?
2. Responsive breathing – No
  1. Activate EMS/Code blue
  2. If circulation present
    1. Respiratory arrest ACLS algorithm
      1. Airway – Maintain airway/advanced airway
      2. Breathing – Titrate oxygen
      3. Circulation – Check for pulse
      4. Differential diagnosis – Treat reversible causes
  3. If no circulation – Cardiac arrest ACLS algorithm
ROSC – Return of Spontaneous Circulation
1. Ventilation/oxygenation
  1. Keep oxygen greater than 93%
2. Blood pressure
  1. Keep systolic greater than 90 mmHg
  2. Consider pressors
3. Focused neurological exam
4. Myocardial infarction?
  1. STEMI by ECG?
5. Intensive care unit
Acute coronary syndrome (ACS)
1. ECG interpretation
  1. ST segment elevation MI
  2. Non-ST segment elevation MI
  3. Low risk acute coronary syndrome
2. Possible treatments
  1. Medications
    1. Heparin
    2. Beta blocker
    3. Statin
    4. Antiplatelets
    5. Fibrinolytics
  2. Cardiac stress testing
  3. Percutaneous intervention
Acute stroke
1. Symptoms of stroke
  1. Facial droop
  2. Slurred speech
2. Patient assessment
  1. Vitals
  2. IV access
  3. Labs
  4. ECG
3. Stroke assessment
  1. Determine symptom onset
  2. Perform neuro exam
    1. Stroke scale
    2. MRI/CT scan
    3. Fibrinolytic checklist
  3. Brain bleed?
    1. Yes – Neurosurgery
    2. No – Administer fibrinolytics
4. Admit to ICU/Stroke unit

Assessment

Resuscitation/life support medications
1. Adenosine
  1. Supraventricular tachycardia
2. Amiodarone
  1. Pulseless ventricular tachycardia
  2. Ventricular fibrillation
3. Atropine
  1. Symptomatic bradycardia
4. Dopamine
  1. Symptomatic bradycardia
    1. If atropine fails
  2. Pressor for shock
5. Epinephrine
  1. Cardiac arrest
  2. Anaphylaxis
6. Lidocaine
  1. Cardiac arrest
  2. Ventricular fibrillation
  3. Ventricular tachycardia
7. Magnesium sulfate
  1. Torsades de pointes
8. Vasopressin
  1. Ventricular fibrillation

Therapeutic Management

Team responsibilities
1. Team leader
  1. Competent in all ACLS duties
  2. Directs team members
  3. Assigns roles
  4. Asks for suggestions
  5. Documents resuscitation
2. Team member
  1. Competent in specific role
  2. Responds to team leader
  3. Informs team leader when task is complete
  4. Shares suggestions
  5. Provides information for documentation

Nursing Concepts

Clinical judgement
EKG rhythms
Oxygenation
Teamwork and collaboration

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Transcript

Hey guys! So today I just want to do a quick review with you all regarding ACLS or Advanced Cardiac Life Support! If you do not already have this certification there is a very good chance that before your nursing career is over you will be required to have this! Keep in mind though this is just a brief review and in your actual ACLS class, you will go more in depth and even participate in practice codes! So ACLS are clinical interventions that are used during medical emergencies which build upon your BLS training or Basic Life Support!

So who exactly needs ACLS certification? Well, this is going to be for medical professionals (not just nurses) where there could be medical emergencies particularly in the ER, critical care units, surgery, or anywhere there could be probable cardiac related emergencies.

Listed here are some of the common components of ACLS which builds on BLS and also focuses on treating cardiac and respiratory arrest, acute coronary syndrome, return of spontaneous circulation or ROSC, acute stroke, life support medications and the treatment of arrhythmias. I’m going to dig a bit deeper into these components in the upcoming slides.

So lets quickly review BLS is the patient responsive? Check for breathing, activate ems or call a code, if there is no pulse begin CPR and if there is a shockable rhythm defibrillation should take place.

So lets look cardiac arrest situations when the patient has a shockable rhythm. In this instance you will follow the Vfib/pulseless vtach algorithm which is listed here. An unsynchronized shock is provided, CPR is resumed, there’s a really good chance Epinephrine will be administered and also amiodarone or lidocaine. If the rhythm becomes unshockable you will move to the PEA/asystole algorithm. Guys if the patient regains consciousness you will move to the ROSC algorithm which we will look at in a later slide.

In the event that the patient does not have a shockable rhythm the PEA/asystole algorithm would be followed which would include chest compressions/CPR for 2 minutes, epinephrine will be administered. Compressions will be continued with rhythm checks every 2 minutes. After two 2 minute cycles epinephrine will be administered again. Guys if the rhythm becomes shockable you would move to the vfib/vtach algorithm.

What about respiratory arrest? Ok so if responsive breathing is present the underlying issue must be identified so was there an MI, stroke, cardiac issue? But if there is no responsive breathing we will follow the respiratory arrest algorithm which consists of maintaining the airway or placing an advanced airway, breathing or titrating oxygen, checking for a pulse or circulation, and also finding reversible causes of the respiratory arrest and treating those issues.

Here we have the ROSC algorithm which stands for return of spontaneous circulation and I mentioned this a few slides ago if our patient is in cardiac arrest but then regains consciousness this is the algorithm according to the ACLS standards that we would move to. So first we will make sure our patient is being ventilated and oxygenated with a goal of sats greater than 93%, watch the blood pressure maybe consider pressors, there should be a focused neuro exam or even consideration of an MI, and finally the patient should be transferred to the ICU.

So guys acute coronary syndrome which is basically symptoms that occur due to decreased blood flow to the coronaries. So ACLS definitely teaches about this and what to do in this situation. Typically the ECG is interpreted looking for STEMI, non STEMI, etc. Possible treatments for acute coronary syndrome include medications like heparin, antiplatelets, or fibrinolytic. Cardiac stress testing may be order or even percutaneous intervention like a cardiac cath.

ACLS training also has guidelines in the event of a stroke. As we all know time matters when we are talking about a stroke so its important to determine the onset of stroke symptoms. A neuro exam should be performed along with a stroke scale, MRI/CT scan, and determining if the patient even qualifies to receive fibrinolytic because guys not everyone can! If the patient has a brain bleed surgery will typically be the next step but if the patient does not have a bleed the next step would be to administer fibrinolytics to dissolve the clot. The patient should definitely be admitted to the ICU or stroke unit.

Lets take a look at some of the most important life support medications which you would definitely go over in ACLS. Adenosine for supraventricular tachycardia, amiodarone for pulseless vtach or vfib, atropine for symptomatic bradycardia, dopamine for symptomatic bradycardia if atropine fails, and epinephrine for cardiac arrest or anaphylaxis.

A few more ACLS meds include lidocaine for cardiac arrest, vfib, and vtach, magnesium sulfate in the event of torsades de pointes which is a form of vtach, and vasopressin for vfib.

Lets do a quick review! ACLS is required for medical professionals who work anywhere where a cardiac arrest might take place and also for those who work in the ICU, ER, and even surgery. The components that are included in the ACLS certification which builds BLS are cardiac/respiratory arrest, acute coronary syndrome, and acute stroke. Medications are a big part of ACLS which include amiodarone, adenosine, dopamine, epinephrine, atropine, lidocaine, and vasopressin.

A few nursing concepts that can definitely be applied to ACLS are clinical judgment, ekg rhythms, and oxygenation as these are all components very important to the ACLS certification.

We love you guys! Go out and be your best self today! And as always, Happy Nursing!