The document provides information about Advanced Cardiac Life Support (ACLS) certification training. It outlines the treatment protocols taught for cardiopulmonary emergencies including airway management, cardiac rhythms, cardiac arrest, and myocardial infarction. The document describes the algorithms for assessing airway patency and providing rescue breathing or advanced airways. It also reviews endotracheal intubation, combitube placement, and use of laryngeal mask airways.
The document provides information about Advanced Cardiac Life Support (ACLS) certification training. It outlines the treatment protocols taught for cardiopulmonary emergencies including airway management, cardiac rhythms, cardiac arrest, and myocardial infarction. The document describes the algorithms for assessing airway patency and providing rescue breathing or advanced airways. It also reviews endotracheal intubation, combitube placement, and use of laryngeal mask airways.
The document provides information about Advanced Cardiac Life Support (ACLS) certification training. It outlines the treatment protocols taught for cardiopulmonary emergencies including airway management, cardiac rhythms, cardiac arrest, and myocardial infarction. The document describes the algorithms for assessing airway patency and providing rescue breathing or advanced airways. It also reviews endotracheal intubation, combitube placement, and use of laryngeal mask airways.
The document provides information about Advanced Cardiac Life Support (ACLS) certification training. It outlines the treatment protocols taught for cardiopulmonary emergencies including airway management, cardiac rhythms, cardiac arrest, and myocardial infarction. The document describes the algorithms for assessing airway patency and providing rescue breathing or advanced airways. It also reviews endotracheal intubation, combitube placement, and use of laryngeal mask airways.
Cardiac Life support. The ACLS certi9cation course teaches healthcare professionals advanced interventional protocols and algorithms for the treatment of cardiopulmonary emergencies. These include primary survey, secondary survey, advanced airways, myocardial infarction, cardiac arrest, tachycardias, bradycardias, and stroke. The treatment protocols have been established through collaborative clinical research and later published by the International Liaison Committee on Resuscitation (ILCOR).
CPR for Adults (CABD)
CPR for Children (CABD)
CPR for Infants (CABD)
Choking Intervention for Adults & Children
Choking Intervention for Infants
Secondary ABCD (Adults)
Airway and Breathing
Advanced Airways
Cardiac/Electrical Therapy
Cardiac Rhythms
Acute Myocardial Infarction
Tachycardias
Bradycardias
Asystole
Pulseless Electrical Therapy (PEA)
Acute Stroke
ACLS Case Scenarios
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Secondary ABCD (Airway, Breathing,
Circulation, Differential Diagnosis) Airway (two provider) Initially provide rescue breaths using an ambu bag and a mask at full Eow oxygen. Perform continued assessment of airway patency while giving breaths. Have the person doing chest compressions pause during the 2 rescue breaths.
If the patient is not ventilating well or if there is a
presumed risk of aspiration, insert an advanced airway device when prudent: Endotreacheal Intubation is the preferred method. (View the advanced airway section)
Breathing Con$rm correct placement of the advanced airway device:
Look for condensation during exhalation.
Look for equal bilateral chest rise. Con9rming equal bilateral breath sounds with auscultation. Auscultate stomach to assure esophageal intubation didn’t occur. End-tidal CO2 should be veri9ed during exhalation using monitor or ETD Use portable chest x-ray.
If incorrect placement:
Remove the airway device, ventilate the patient
using the ambu bag for a short period of time, and then reattempt placement.
If correct placement:
Secure placement of the airway device.
Continue to monitor:
oxygenation saturation with pulse oximeter
end-tidal CO2
Rescue breathing during CPR with an advanced
airway:
8-10 breaths per minute (1 breath every 6-8
seconds) Chest compressions should be given continuously at a rate of 100 to 120 per minute.
Circulation Obtain IV or IO access. Monitors (ECG, BP cuff, pulse oximeter, et CO2 monitor)
Identify:
heart rhythm Obtain a 12 lead ECG if possible. Initiate therapy of ACLS algorithm corresponding with the identi9ed heart rhythm. (Drug therapy, Electrical therapy, Pacing, etc.)
Differential Diagnosis (needed for successful treatment of some patients) Consider reversible causes of rhythm/arrhythmia.
Differential Diagnosis Chart:
Airway & Breathing
There are two important principles when evaluating the airway and breathing. First, is the airway patent or obstructed. Second, is there possible injury or trauma that would change the providers method of treating an obstructed airway or ine\cient breathing.
Patent/obstructed If the airway is patent there should be noticeable chest rise/expansion with either spontaneous respirations or with rescue breaths. The provider may also be able to hear or feel the movement of air from the patient. A completely obstructed airway will be silent. An awake patient will lose their ability to speak, while both a conscious or unconscious patient will not have breath sounds on evaluation. If the patient is attempting spontaneous breaths without success, there may be noticeable effort of intercostal muscles, diaphram, or other accessory muscles without signi9cant chest rise/expansion. The provider will also not feel or hear the movement of air. If the airway is partially obstructed snoring or stridor may be heard.
Cervical Spine Injury?
If the provider evaluates the patient to have an obstructed airway, intervention should take place. If the adverse event of the patient was witnessed and there is no reason to suspect a cercival spine injury, the provider should use the head tilt-chin lift maneuver to open the airway. If there is a reason to suspect a cervical spine injury, if the patient’s adverse event went unwitnessed, if trauma occured, or the patient suffered drowning the jaw-thrust maneuver should be used to open the airway. If the jaw- thrust proves unsuccessful in opening the patient’s airway attempt an oropharangeal or nasopharangeal airway. If neither technique works, attempt an advanced airway using inline stabilization.
Brain Injury? The breathing center that controls respirations is found within the pons and medulla of the brain stem. If trauma, hypoxia, stroke, or any other form of injury affects this area, changes in respiratory function may occur. Some possible changes are apnea (cessation of breathing), irregular breathing patterns, or poor inspiratory volumes. If the breathing pattern or inspiratory volumes are inadequate to sustain life, rescue breathing will be required, and an advanced airway should be placed.
Oral Airway:
Assure the arti9cial airway is the appropriate
size for the patient. The airway should be easily inserted with a tongue blade. Avoid use in patients with an active gag reEex.
Nasal Trumpet Airway:
Best practice is to lube before insertion.
Careful not to cause trauma to nasal mucosa (results in bleeding). This is reasonably tolerated by patients with an active gag reEex.
Advanced Airways Indications:
When you are unable to open airway using
head tilt-chin lift or jaw thrust maneuvers. If you have di\culty forming a seal with the face mask. If the patient requiring continued ventilatory support. When the patient has a high risk for aspiration (provide an ETT or Combitube).
Remember, a patient should be unconscious or
sedated without an active gag reEex before instrumentation of the airway occurs with an ETT, Combitube, or LMA.
Endotracheal Tube (ETT)
Requires additional instrument for insertion
(laryngoscope, glidescope, 9beroptic). Laryngoscope blades (average adult size): MAC 3 or 4, Miller 2 or 3. ETTs require mastery of technique for consistent appropriate placement. Average size of ETT for orotracheal intubation for adults is 7.5mm. The ETT is placed into the trachea, having direct visualization of the vocal cords.
Average depth of intubation:
adult male is 23cm
adult female is 21cm Tracheal cuff of the ETT is then inEated. Allows for positive pressure ventilation. Reduces risk of aspiration. Helps maintain placement of ETT. Con9rm placement of ETT. Secure in place of ETT.
Esophageal-Tracheal Combitube
Gently advance the combitube into the mouth
midline along the base of the tongue. Assure tube rotation of the combitube is following the curvature of the pharynx. Cease advancement of the tube once the heavy black rings reach the patient’s teeth. The Combitube is blindly placed into the esophagus 80% of the time and into the trachea 20% of the time. The combitube provides ventilatory access irregardless of tracheal or esophageal intubation. InEate the pharangeal cuff with 100ml of air. Prevents leak through the nose and mouth. Helps secure placement. InEate the tracheal cuff with 15ml of air. Prevents ventilation of stomach. Reduces risk of aspiration of stomach content. Secure in place of ETT.
First attempt con9rmation of esophageal
intubation by ventilating through the esophageal tube. (See “Secondary ABCD” section regarding placement con9rmation)
If placement not con$rmed through esophageal
tube:
Attempt con9rmation of tracheal intubation by
ventilating through the tracheal tube. (See “Secondary ABCD” section regarding placement con9rmation)
Once placement has been con$rmed:
Mark which tube should be used for
ventilation. Secure tube in place. Both cuffs must be inEated to appropriately ventilate a patient in the case of esophageal intubation.
Laryngeal Mask Airway (LMA)
Visualization of the vocal cords is not required for
insertion.
When inserting the LMA have the laryngeal
cuff deEated. Guide in the LMA cuff without folding back the tip, pressing it against the hard palate. Advance the LMA till the cuff lies in the pharynx. After placement, inEate the laryngeal cuff and check for an adequate seal by using positive pressure ventilation.
Positive pressure ventilation is generally kept
under 20 CmH2O to prevent inEation of the stomach. LMA’s are contraindicated for the morbidly obese patient.
The patient is still at high risk of aspiration, even
with an appropriately placed LMA. LMA’s are contraindicated in patients with GERD, full stomachs, and pregnant women.
Cardiac/Electrical Therapy Transcutaneous Pacemaker (External Pacemaker): Used to treat unstable bradycardias not responding to drug therapy. Provides temporary pacing through the skin in emergency situations.
Place pads and electrodes in correct position
to assure an appropriate ECG reading. Set the pacer 10-20 beats per min above the patient’s intrinsic heart rate or 60 beats per min if there is no intrinsic heart rate. Start at O mA and work energy level up until you have capture (heart pulsation). Assure the patient is sedated and comfortable during pacer delivery.
Cardioversion:
Used if drug therapy and vagal maneuvers fail.
Used when patient has a pulse. Used to treat Atrial Fibrillation, Atrial Flutter, Atrial Tach, and Symptomatic VT. Shock performed at peak of R wave. Requires proper lead/pad placement to monitor ECG.
Shock energy level:
Monophasic: 100-200J Biphasic: factory recommendations (generally 100J) Assure the patient is sedated and comfortable during shock delivery.
De$brilation:
Used to treat VF and pulseless VT.
Delivery within 9rst 5 mins of cardiac arrest has best results. CPR before and after each shock improves outcomes.
