ACLS Provider Update/Initial

BLS

Stuff to do before class gets there: Start computer and projector, get out book and DVD from cabinet, get out 4-5 adult and infant mannikans, get out adult and infant BVM’s with facemask, get out personal blue mouth breathers, get out AED and rhythm simulator, get evaluation sheets and give one to each student (have them put name on it and it gets turned in after BLS session) – Jim puts test out on table at 1000 or a little after

Video
Set to renewal and ratio for update or initial is 2:1
They will watch sections of the video and stop to practice when given time, make sure they are counting out loud and they can move the mannikan to the floor if they need to do compressions
Emphasize change to CAB, just enough bagging to get visible chest rise, minimize interruptions, allow complete recoil of chest, rotate and change out compressors every 2 minutes (when tired you are 30% less effective at compressions), no more look, listen and feel (just take less than 10 seconds to determine a pulse and breathing) 1. First practice compressions only (switch) 2. Second practice mask breathing only (switch) 3. BWM practice only (switch) 4. Put it all together ( ADULT ONLY)

Watch both AED section then demonstrate AED (TURN IT ON) – in infants under 1 y/o manual defib preferred if don’t have use dose attenuator if don’t have that use normal AED, 1-8 y/o a dose attenuator preferred – if you don’t have either can use regular AED – can use AED in small puddle and snow, accelerometer in puck, razor and towel only 1 set so don’t rip them off
Child = 1 y/o until puberty (boys look for chest and underarm hair, girls look for breast development

Only practice choking infant not child, demonstrate on adult manikin kneeling and doing Heimlich for child

CPR Rates
Adult 1 or 2 person 30:2 (at least 100 compressions/minute) – compressions should be at least 2 inches, check for carotid pulse, switch compressors after 5 sets which should be about 2 minutes, place hands on the lower half of the breastbone
Child Single rescuer 30:2 / Child 2 rescuers 15:2 – compressions should be 1/3 depth of chest about 2 inches, check for carotid pulse
Infant (same as child), except when 2 rescuer you should place hands around chest and use thumbs and discontinue two fingers, also depth is at least 1/3 depth of chest which should be about 1½ inches, check for brachial pulse, switch compressors every 10 cycles *Once advanced airway (ET tube) is placed do compressions at least 100 minute and ventilate 1 breath every 6-8 sec which should be about 8-10 breaths/min, waveform capnography best to monitor *Continue CPR until patient gets a pulse or EMS arrives

Rescue Breathing,Pad Placement with implanted device, and why CPR after shock, infant choking
Rescue breathing adult- 1 breath every 5-6 seconds (count one-one thousand, etc, breath goes in on five one thousand, if trauma jaw thrust, if not head tilt chin-lift
Rescue breathing child/infant – 1 breath every 3-5 seconds (do not need to put child or infant head back as far as adult) if trauma suspected jaw thrust, if not head tilt chin-lift
AED -After shock we immediately restart CPR starting with chest compressions, as the heart is stunned and probably hypoxic because of the nature of a code the heart is lacking oxygen and energy, lay people and medical personnel not effective at feeling a pulse, if the myocardium has no oxygen and energy the likelihood that a shock with both eliminate VF and you get ROSC in unlikely, remember to CLEAR and always be on the side of the patient
If you have to place the pads over a pacemaker or implanted defibrillator place it as least 1 inch away from the device, anterior posterior and anterior-lateral are both acceptable placement options for the pads
Choking infant – in a responsive infant use 5 back blows and 5 chest thrusts, no blind finger sweeps only do this if foreign object is seen, if child becomes unresponsive begin CPR beginning with compressions, make sure to support childs head (lay them on leg while kneeling)
CPR test out and Final Test
Test out in pairs, use simulator have them do a couple of sets for time purposes, do times with stop watch in cabinet, give back sheet to be turned in, remind them to meet back upstairs after lunch and what time, they can miss 5 and still pass, they can use the the flip open on test

Technology/Team Concept - ALS
Watch video on team concept (approx. 20 minutes) – overview of megacode and team concept (don’t need binder)
Watch video and discuss IO Tibial placement
Humeral head placement Needle differences Cleanse site, black line, pressure bag, lidocaine (40 mg another 20mg can be given if needed, max dose is 300mg over 1 hour) – give over about 2 minutes then follow with a rapid bolus of 10ml of NS, pressure bag start at 100mmHg, increase until infusing can go as high as 300mmHg, don’t apply pressure let drill do work only go until a “pop” is felt Humerus thought to be less painful due to it taking less pressure to infuse, medullary space must be opened up and this is most painful part, pressure bag almost always needed to the pressure inside the medullary space Can pull out by twisting, very little blood, cover with a dressing and instruct patient to watch site for sign of infection.
Monitor – Are they familiar with It?
Demonstrate all major functions – 120J 150J 200J automatically increases (hospital Zoll not EMS) Defibrillation – VF, Pulseless V-tach Pace- complete heart block, 2nd degree blocks in unable patients (will need to put on leads) , increase 10% when you get capture (70 mA = an increase of 7 mA), chronotropes can be used as an alternative to pacing = dopamine and epi infusion Cardiovert – v-tach with a pulse, SVT, a-fib, a-flutter (remember to synchronize before each shock)
Remind that Joules are listed on top of all monitors
Purple diamond
Hitting analyze with start you a 2 minute timer
Triangle Pad has leads built in

Respiratory
Lots of video, get out a manikin for each student, also a BVM, and NPA’s and OPA’s, little Dixie cup with water to simulate lubricant
Best way to to get confirmation of ET tube placement and CPR quality is through waveform capnography, also used to determine ROSC (ROSC is determined by an abrupt increase in the Petco2 typically greater than or equal to 40mmHg)
4 scenarios of patient found unresponsive but has a pulse OPA in and bag (x2) OPA but doesn’t work patient gags go to NPA (x2)
Rescue breathe until become responsive or lose pulse
Sequence for Respiratory Video 1. Yes 2. Yes 3. No 4. No 5. No 6. yes

Putting it all together & Pulseless Arrest (update/initial)
List on board the team roles * team lead, airway, IV-IO/meds, monitor, compressions, recorder
List on board H’s & T’s (PEA & asystole) =reversible causes * hypovolemia * hypoxia * hydrogen ion (acidosis) * hypo-/hyperkalemia * tension pneumothorax * tamponade, cardiac * toxins * thrombosis, pulmonary (PE) * thrombosis, coronary (MI)
Choose team lead have them assign roles, have them actually do CPR and ventilations for a few cycles
O2, monitor, IV
PEA/Asystole=H’s&T’s, epi
Post cardiac arrest care
ROSC=BP, 12 lead, SpO2, advanced airway (intubate and capnography), labs, therapeutic hypothermia
Treat hypotension SBP less than 90mmHg = IV/IO bolus vasopressor infusion Epi infusion = 0.1-0.5 mcg/kg/min Dopamine infusion=5-10 mcg/kg/min Norepi =0.1-0.5 mcg/kg/min

Debrief after code= what went well and what could be changed for next time?

8 keys =code situation 1. closed loop communication 2. clear message 3. know limitations 4. clear roles/responsibility 5. knowledge sharing 6. constructive intervention 7. summarize/re-evaluate 8. mutual respect
Cases are available in binder, when getting ready to test fill out a green sheet for each student, if you have max 8 students two scenarios get repeated

Scenarios
1. 62 y/o female lightheaded
Pale,cool,clammy – BP 70/56, P=40, R=18, SpO2 91% RA
Sinus Brady------Pulseless VT-------PEA---------ROSC
2. 70 y/o male chest discomfort
BP=80/58, P=45, R=16, Spo2=93% RA
2nd degree type II block------VF-------Asystole--------ROSC

3. 65 y/o male palpitations and chest discomfort
BP 90/P, P=180, R=18, Spo2=91% RA
VT with a pulse------VF---------PEA------ROSC

4. 48 y/o male palpitations and dizzy
BP=92/68, P=168, R=18, Spo2=90% RA
SVT------VT no pulse-------asystole--------ROSC

5. 70 y/o female lightheaded, syncopal
BP= 79/50, P=35, R=15, SpO2=90% RA
3rd degree block--------VT no pulse------PEA-----ROSC
If update class they can miss 10 on the test before they have to come back to re-take. If day 1 initial you do not give the ACLS test that day.

Drugs/Dosages/Usage
Epinephrine 1mg (1:10,000) every 3-5 min IV or IO

Amiodarone – 300mg first dose, 150mg second dose (cardiac arrest)

Amiodarone – 150mg first dose for ventricular dysrhythmias * if hemodynamically unstable VT w/pulse do cardioversion NOT amiodarone * if hemodynamically stable VT use amiodarone – must be monomorphic VT as amiodarone is contraindicated for polymorphic VT because it can be associated with prolonged QT interval which can be made worse with anti-arrythmics – the dose if it is stable monomorphic VT is 150mg IV over 10 min

Vasopressin= 40 Units one time dose in cardiac arrest, has to either be first or second dose that replaces Epi

Atropine – 1st dose .5mg every 3-5min to a max of 3mg – for symptomatic/unstable bradycardia * no longer indicated for PEA & Asystole

Adenosine - 1st dose 6 mg with rapid flush, 2nd dose 12 mg rapid flush, SVT tachycardia, it should not be used for irregular wide complex tachycardias as it can lead them into VF
Epi / Dopamine IV infusion Dopamine – 2-10mcg/kg/min Epinephrine (1:1000) ??????????? 2-10mcg/kg/min