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LIFESAVERS FOUNDATION
www.lifesaverspakistan.com
Dear BLS& ACLS provider course student, Welcome to the BLS&ACLS provider course
Registration
At the time of registration, you will be given a booklet and ACLS card for the preparation of
the course.
From the link elearning.heart.org/courses you can excess more material for preparation.
Course Requirements
1. Complete part 1 the pretest and then part 2 course work (Mandatory from the above link)
2. Review the ACLS rhythm and pharmacology required to successfully perform the
megapode test. (Review from booklet)
What to Wear
Please wear loose, comfortable clothing to class. You will be practicing skills that require you
to work on your hands and knees, and the course requires bending, standing, and lifting. If
you have any physical condition that might prevent you from engaging in these activities,
please tell your instructor. The instructor may be able to adjust the equipment if you have
back, knee, or hip problems. We look forward to welcoming you if you have any questions
about the course.
Please Call: 0344-5253656
Dr. Khurram Zubair
Executive Director
Lifesavers Foundation, Islamabad
Requirements for Course Completion
Given a patient situation, perform competently in the management of each of the following
situations:

 Respiratory Arrest
 Automated External Defibrillation (AED)
 Pulseless Ventricular Tachycardia/Ventricular Fibrillation
 Asystole
 Pulseless Electrical Activity
 Acute Coronary Syndromes
 Bradycardias and AV Blocks
 Unstable Tachycardia
 Stable Tachycardia
 Acute Ischemic Stroke

MEGACODE
 Given a patient situation, perform competently as a Team Leader for simulated cardiac
arrest, physically demonstrating the delivery of all electrical interventions.

WRITTEN EXAMINATION
 Obtain a minimum score of 80% in a closed book, multiple-choice written
examination

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CARDIAC ARREST

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 ASSESSMENT
Pulse
Vitals
OMI (oxygen/monitor/IV line)

*--If no response and no pulse start CPR in the sequence of CAB

(compression/airway/breathing) --*

1. START CPR
Give oxygen
Attach monitor/defibrillator

*---Decision Point Is Rhythm (Shockable/Non-Shockable) ---*

*VF/PVT/*
2. SHOCK 1
(200joules -biphasic and 360joules -monophasic)
One Shock (Defibrillate one time if needed for persistent
Ventricular Fibrillation (V. Fib.) or Ventricular Tachycardia
(V. Tach.), in succession, do not stop if rhythm still present.)

*--Remember it is your responsibility to make sure no one touches the patient or anything
touching the patient--*
Call out: "I'M CLEAR!
YOU’RE CLEAR!
EVERYONE CLEAR!"

3. RESUME CPR IMMEDIATELY

IV/IO access

4. REASSESS (after every 2 minutes or 5 cycles of CPR.)

Stop CPR
Check pulse
Check electrodes
Check rhythm
Switch tasks

*--If rhythm still shockable--*

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 5. SHOCK 2
(200joules -biphasic and 360joules -monophasic)

6. RESUME CPR
Resume CPR for 30 - 60 seconds to help circulate the
medication, remember the only heartbeat is the one you
manually give the patient.
EPINEPHRINE
(1 mg IV q3-5 min.) Flush with 20 mL NS or run IV fluids to
keep meds running into the vein and raise the arm.

*--Stop CPR and Reassess again and if the rhythm is still shock able--*

7. SHOCK 3
(200joules -biphasic and 360joules -monophasic)

8. RESUME CPR
v
AMIODARONE
(300mg IV push, repeat in 3-5 minutes with 150mg IV.)
OR LIDOCAINE
(1mg/kg - 1.5mg/kg IV push repeat in 3-5 minutes with half
the dose (0.5 - 0.75 mg/kg to a maximum of 3mg/kg.)

*-- Consider Buffers--*

Magnesium sulfates 1-2grams IV over 1-2minutes for hypo-magnesia state or Torsade‟s de pointes.

Bicarbonate (nahco3-Sodium Bicarbonate) 1meq/kg IV q 10 minutes - class 1 intervention for

hyperkalemia.

Used for

 Certain drug overdoses to alkalinize the urine and metabolic acidosis.

 Contraindicated in respiratory acidosis, not used prophylactically.

*--Search and treat reversible causes including 5 H’s and 5 T’s--*

1. Hypovolemia-give fluids and/or blood products (the #1 cause of PEA)

2. Hypoxia-give 100% ventilated oxygen.
3. Hypo/hyperkalemia- KCL boluses not more than 20mEq per hour for low K+ level. NaHCO3
1mEq/kg IV q 10 minutes for high K+ level.
4. Hypothermia/Hyperthermia-warm pt with blankets and warmed IVFs for hypothermia. Keep
the patient from getting too warm.
5. Hypoglycemia - treat with IV dextrose, but don't let blood sugar get too high keep about (80-
110).
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Thrombosis Pulmonary (PE) - thrombolytic or surgery to remove the blockage.
1. Thrombosis Cardiac (MI) - thrombolytic or surgery to remove the blockage.
2. Tension Pneumothorax-needle decompression.
3. Tamponade Cardiac- pericardial centesis,
4. Tablets (OD) - give nahco3 for certain antidepressants.
5. Trauma- treat the underlying problems such as the source of bleeding, surgical needs, respiratory
support, electrolyte imbalances, etc.
6. *PEA*
7.
1. RESUME CPR
8.
IV/IO
9.access

2. EPINEPHRINE
(1 mg IV q3-5 min.) Flush with 20 mL NS or run IVFs to
keep meds running into the vein and raise the arm.

3. REVERSIBLE CAUSES
Treat 5Hs and 5Ts

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TACHYCARDIA WITH PULSE

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 ASSESSMENT
Pulse
Vitals
OMI (oxygen/monitor/IV line)

*--Decision point is PATIENTS’ STABILITY--*

1. CHECK STABILITY
BP less than 90 systolic?
Chest pain?
Shortness of breath?
Decreased level of consciousness?

*--if yes--*
*Unstable tachycardia*
It doesn't matter whether it is wide or narrow complex
tachycardia, If the patient has unstable tachyarrhythmia and the
monitor shows the following rhythms Prepare for immediate
synchronized cardio version.

 Monomorphic regular ventricular tachycardia

 Supraventricular tachycardia
 Atrial fibrillation
 Atrial flutter

Make sure the IV line is patent.

Premedicate: Midazolam or Diazepam for sedation with
analgesia such as Morphine or Demerol.

Synchronized Cardioversion Procedure:

 Turn on defibrillator.
 Attach monitor leads to the patient.
 Hit the SYNC button on the defibrillator. (This will allow the defibrillator to synchronize with
the pt.‟s QRS complex)
 Look for markers on the R waves on the defibrillator's monitor indicating sync mode (increase
the gain if necessary so each R wave has a marker)
 Select energy level, start at 100J, then increase in above increments with each shock.
 Place pads on pt. as marked (Sternum-Apex) or paddles with gel
 Announce charging defibrillator- "Stand Clear!"
 Press the charge button on the defibrillator or on the apex paddle.

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 State:
o I'm clear! - make sure you are clear.
o You're clear! - make sure your helpers are clear.
o Everybody's clear! - make sure everyone is clear of the patient.
 If using paddles, apply at least 25lbs of pressure on the chest. Also, if using paddles, you need a
water-soluble lubricant placed on the paddles.
 Press the discharge button on the defibrillator or discharge buttons simultaneously on each
paddle.

Note: The difference between cardioversion and defibrillation is that the sync button
is on for cardioversion and off for defibrillation. The machine will still be called a
defibrillator, but defibrillation and cardioversion are different procedures as
described.

*--If no--*
*Stable tachycardia*
If patient bp is more than 90 systolic and symptoms are mild
then the patient is stable‟
Then Look for QRS width ≥ 0.12 second

Narrow Complex Tachycardia

Narrow complex tachycardia‟s:

 SVT
 Atrial flutter
 Atrial fibrillation

In stable NCT, our first task is to. Control the rate

VAGAL MANEUVERS
If regular
ADENOSINE
6mg is the drug of choice for SVT
The second dose of 12mg can be given if 6mg does not work
Always given very fast
„Contraindicated in asthma or COPD‟.

BETA-BLOCKERS
Atenolol 5mg
Metoprolol 5mg
CALCIUM CHANNEL BLOCKERS
Verapamil 2.5 to 5mg
Diltiazem 15 to 20mg
Beta-blockers and calcium channel blockers are drugs of choice
for atrial fibrillation and atrial flutter
Beta-blocker and calcium channel blockers are contraindicated
in wide complex tachycardia and they cannot be given
simultaneously.
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 Wide Complex Tachycardia’s
If the patient is stable, usually the ventricular rate is less than
150 BPM
ADENOSINE
6mg
Second dose of 12mg
Adenosine is always given very fast and it is contraindicated in
asthma or COPD.
AMIODARONE
150 mg over 10 minutes IV, then hang a drip at 1mg/min for 6
hours, then 0.5 mg/min to a max dose of 2.2 grams in 24 hours.
OR LIDOCAINE
1 to 1.5mg/kg

*--In sinus tachycardia with pulse treat the underlying cause--*

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BRADYCARDIA WITH PULSE

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 ASSESSMENT
Pulse
Vitals
OMI (oxygen/monitor/IV line)

*--Decision point is PATIENTS’ STABILITY--*

1. CHECK STABILITY
BP less than 90 systolic?
Chest pain?
Shortness of breath?
Decreased level of consciousness?

*--if yes--*
Go to immediate treatment.
ATROPINE
1 mg IV q 3-5 minutes to a maximum dose of 3 mg.
If atropine does not work then contact the cardiology
department for
PERMANENT PACING
While permanent pacing is getting ready use the following
agents to stabilize the patient
DOPAMINE
IV infusion at 5-20 mcg/kg/min
EPINEPHRINE
IV infusion at 2-10mcg/min

*--If no--*
Observe and Monitor the patient, closely.

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 ACUTE CORONARY SYNDROME
*--Pt is responsive at this time--*

Signs And Symptoms

chest pain.
Uncomfortable pressure
Fullness
Squeezing
pain in the center of the chest lasting greater than 15 minutes.
Pain spreading to shoulders, neck, arms, jaw, or pain between the Shoulder
blades.
Chest discomfort with light-headedness
Fainting door to drug
Sweating treatment < 30
Nausea minutes)
shortness of air.

Immediate Assessment
"O2, IV, Monitor"
Get vital signs
Obtain a 12-lead ECG
Draw blood for cardiac marker levels (CPK, CK-MB, Troponin I), Electrolytes,
CBC, & coagulation panel
Initial physical exam and history focus on eligibility for thrombolytic therapy.
Portable Chest X-Ray

Immediate General Treatment (MONA)

MORPHINE
2-4mg IV q 5 minutes not relieved by NTG,
OXYGEN
2-4 L/min. via nasal cannula,
NITRO-GLYCERINE (NTG)
0.4mg sublingual q 5 minutes x 3-will lower BP, monitor
ASPIRIN
160-325mg PO chewed

Remember your ABCDs when deciding what order to give these in.
Oxygen is the first priority.
NTG is next to dilate the arteries and stop the chest pain.
Aspirin is next to strip the platelets to prevent clotting.
Morphine IV is next to stop the pain and decrease oxygen demand.

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 Assessment of 12 Lead ECG-Centre of the Decision Pathway
Place into 1 of the 3 categories:
*--ST-segment elevation or new Bundle Branch Block--*
Strongly suspicious for injury
Leads:
II, III, AvF-inferior
V2,V3,V4-anterior
I, V5, V6-lateral
V1-septal
Treatment:
Beta blockers-class I < 12hrs
Nitro-glycerine (NTG) IV-class I < 24-48hrs
Heparin IV
ACE Inhibitors

*--ST-segment depression or dynamic T-wave inversion or high-risk

unstable angina or non-Q wave acute MI--*
Strongly suspicious for ischemia
Leads:
see above
Treatment:
Heparin IV (unfractionated heparin) or
LMWH (low molecular weight heparin)
NTG IV
Aspirin
Beta-blockers IV
Glycoprotein Receptor Inhibitors
If the patient is a high risk, then send them for a heart cath. (PTCA-
percutaneous transluminal coronary angioplasty) and/or open-heart surgery
(CABG-coronary artery bypass grafting)
If the patient is stable, then monitor ECG and serial cardiac markers.

*--Nondiagnostic ECG--*
Absence of changes in ST-segment or T waves
New-onset angina treatment same
Otherwise, admit to an ECG monitored bed and serial ECGs and cardiac
markers

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 General guidelines for all < 12-hour time frame from onset of symptoms
*--Consider a reperfusion strategy--*

THROMBOLYTICS
(Commonly known as clot busters)
Within 3 to 6 hrs is best, some studies suggest within 12 hours
Contraindicated in:
Active bleeding, bleeding disorders, GI bleeding,
Recent intracranial, intraspinal, or eye surgery,
Severe hypertension,
> 75 yrs. Old
There are several new thrombolytics on the market now, these are some of the
older ones.
TPA
short acting within 2-6 hrs, expensive: 15 mg IV bolus,
then 0.75mg/kg over next 30 minutes (not greater than 50mg),
then 0.50mg/kg over next 60 minutes (not greater than 35mg),
start your Heparin protocol with the TPA
Streptokinase
longer acting, less expensive, watch for pts
with strep throat or received this product in the past may be
contraindicated: 1.5 million IU over 1 hour, start Heparin
protocol after Streptokinase is finished
5. Reteplase: 10 units IV plus a 10-unit IV bolus over 2 minutes,
30 minutes apart.

B. PTCA (heart Cath) with CABG (open heart surgery) as back up

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 ACUTE ISCHEMIC STROKE

Stroke is the 3rd leading cause of death in the U. S. and the leading cause of brain injury in
adults. Each year approximately 500,000 Americans suffer a new or recurrent stroke and nearly 25%
die. Main change in treatment is the use of thrombolytic therapy for ischemic stroke

Identify The Type Of Stroke:

Ischemic-occlusion of an artery in the brain or
Hemorrhagic-arterial bleeds in the brain.

1. DETECTION
F.A.S.T.
Cincinnati Prehospital Scale

Facial droop
Show teeth or smile

Arm drift
Ask to hold their arms out in front of them and close their eyes.
Normal is both move or none move.
Abnormal is one stays and the other drifts away

Speech
Repeat, "You can't teach old dog new tricks."
Normal is correct words and no slurring
Abnormal is slurring of words and/or wrong words

Time
Time to call help

2. DISPATCH
Early activation and dispatch of EMS

3. DELIVERY
Rapid EMS identification, management, and transport

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 4. DOOR
Transport to stroke center
Assess
ABGS
O2, IV, Monitor
Immediate general
Blood glucose if not done already
assessment < 10
Assess neurological function minutes after arrival
to hospital
Alert stroke team
Review history and neuro exam:
Glasgow Coma Scale for level of consciousness (LOC)
CT scan < 25 minutes after arrival to hospital
CT read < 45 minutes after arrival to hospital

5. DATA
Rapid triage, evaluation, and management in ED
Does CT scan show intracerebral or subarachnoid hemorrhage?
If yes
Then consult neurosurgery.
If no
Then review CT exclusions.
Review thrombolytic exclusions:
If hemorrhage still suspected despite negative CT scan, then
Lumbar puncture may be ordered;
If no blood on l.p., then support pt.
If yes blood on l.p., then consult neurosurgery

6. DECISION
Stroke expertise and therapy selection

7. DRUG
Fibrin lytic therapy, intra-arterial strategies
Review risk and benefits with pt. And family

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 8. DISPOSITION
Rapid admission to the stroke unit or critical care unit

Thrombolytic TX goal is to treat < 60 minutes from arrival to

the hospital
Monitor neurological status
Emergency CT if deterioration occurs
Monitor BP
Admit to critical care
No anticoagulants or antiplatelet Tx x 24 hours

LABETALOL
Favored for controlling BP because it does not cause cerebral
Vasodilation
NITROPRUSSIDE
Causes cerebral vasodilation and can increase ICP (intracranial
pressure)
TPA
Currently the only FDA approved drug for ischemic stroke.
0.9mg/kg max 90mg (Give 10% as bolus and rest over 1 hour)
Give only if < 3 hrs of onset of symptoms
Make sure you establish 2 large bore IVs #18g or greater befor
starting, so no sticks are required after giving TPA and so blood
can be given if pt. bleeds

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 GLOSSARY
The following is a detailed explanation for Hs and Td of the differential diagnosis.

Hypovolemia can be evident from a trauma or from patient assessment. It is the #1 cause of
PEA. Give IVFs Normal Saline or Lactated Ringers and even blood products if needed. When the
IV is placed, usually IVFs are hung and thereby treating the low volume problem.
Hypoxia is being treated in the A=Airway when the patient was intubated and ventilated with 100%
oxygen. The airway is ALWAYS the first priority. It only takes a few minutes to cause an insult to
the brain for lack of oxygen, so be vigilant with this assessment as an ongoing concern.
Hypokalemia seen with increased heart rate or arrythmias can be treated with Potassium boluses
10-20mEq over 1 hour (see your policy for total amount to be given as giving too rapid
administration will stop a heart).
Hyperkalemia seen with decreased heart rate and various blocks and arrythmias can be treated with
Sodium Bicarbonate 1mEq/kg (class 1 intervention). It can be treated with D50W and IV Regular
Insulin to get the K+ back into the cells or even Calcium Chloride.
Hydrogen Ion (acidosis) is a little more complicated. 1st we would need a ABG (arterial blood
gas) to determine respiratory or metabolic acidosis, but mainly we want to look at the PH (7.35-7.45
is generally the norm, again look at your lab policy). If less than 7.2, then we need to rapidly
correct this by possibly hyperventilating the patient or considering NaHCO3 (Sodium Bicarbonate).
The problem with hyperventilating is that it can hurt certain types of patients such as head-injuries.
The problem with Sodium Bicarbonate is that correcting the patient and making him or her alkalotic
causes problems that are not as easily reversed. We don't want to hypo ventilate a patient to let
their CO2 level increase. So generally, we will treat this specific to the patient problem by looking at
the ABGs, telling us the source respiratory or renal (metabolic) cause.
Hypothermia/Hyperthermia is treated by warming the patient and possibly running warmed IVFs.
Drugs may need to be held until the temperature is up. The old saying is true: "There is no dead
patient, until he or she is warm and dead."
Hypoglycemia is treated by keeping the blood sugar tightly controlled about 80-110. Hypoglycemia
may be deadly, and needs to be treated with IV dextrose. Hyperglycemia can also increase risk of
infection and other complications.

Thrombosis, pulmonary can be seen by ventilating the patient well, good bilateral breath sounds;
yet, poor saturations and even mottled skin color. What is happening is that the perfusion side of
the V/Q (ventilation/perfusion) equation is being affected. The oxygen is being delivered through
ventilations, but the oxygen in the blood cannot carry it to the rest of the body because there is a
blockage in the vessels of the lungs. This can be corrected with either thrombolytics or through
surgery to remove the blockage.
Thrombosis, cardiac can be confirmed with a 12 lead ECG, seeing a Q wave with ST elevation and
T wave inversion; however, a patient can have a non-Q wave MI. ST elevation STEMI is what we
are looking for on the ECG or a non-STEMI where clinically the patient presents with symptoms but
does not show ST elevation on the 12 lead ECG. A patient with a cardiac history, or signs and
symptoms of a "heart attack" like chest pain, "heavy" feeling on the chest, neck or jaw discomfort,
nausea, diaphoresis, arm or shoulder discomfort before the code blue may give you an idea that an
MI has occurred. The fact that a patient is in V.fib or V.tach generally leads us to believe a "heart
attack" has occurred. The ways to correct this is by thrombolytics, heart catherization, or heart
surgery (CABG-coronary artery bypass graft).
Tension pneumothorax is heard in a loss of breath sounds; generally, on one lung field (both lungs
could be affected). While continually assessing the B=Breathing, this should be noticed if the patient

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suddenly has one sided chest rise or low oxygen saturations. Check this first by listening for breath
sounds and checking E.T. tube placement. To correct this, take a large bore needle such as 14g
needle and along the side where lung sounds are diminished find the 2nd-3rd anterior ribs at the
mid-clavicular line and place the needle to hit the 2nd rib and go just underneath it into the 2nd ICS,
and we should hear pop, then a release of air. A chest tube will need to be placed, but until then, if
available connect to a flutter valve. A flutter valve can be made with a torn finger of a glove with a
small hole poked in the finger tape the finger over the hub. The small hole will act as a flutter
valve. Also, IV tubing connected to the needle and placed in water will crudely act as a water seal
until more appropriate equipment can be applied.
Cardiac Tamponade is a life-threatening condition caused by fluid under pressure around the heart.
Fluid that collects in the pericardial sac (the tissue sac in which the heart lies) can develop enough
pressure to prevent the heart from relaxing completely between beats. Usually, this fluid has
accumulated rapidly, and the increase in pericardial pressure causes a sudden decrease in cardiac
output. Commonly seen symptoms require a live patient with the ability to complain of dyspnea,
chest pain or of a heart beat and circulation as heard with muffled heart sounds and seen with
Pulsus Paradoxus (inspiratory drop in blood pressure greater than 10mm Hg) and jugular venous
distention (JVD)-to perform this, the patient needs to be sitting up ideally 45 degrees, in a code most
patients will be flat and will have JVD, so trauma history, cardiac history, and events leading up
to the code blue become very important. To fix the problem, we need to withdraw the fluid with a
needle and syringe. Only experienced personnel should attempt this because of the risk of further
damaging the heart or its vessels. Procedure: A small puncture is made just below and to the left of
xiphoid process. A long needle is positioned at 45 degrees above the body and 45 degrees to the
right of midline. Through the skin puncture, the needle is advanced (the 60 mL syringe attached
should be aspirated the entire time) in the position towards head and towards the left scapula.
Withdraw the syringe and aspirate un-clotted blood from pericardial sac. Note: This blood will not
clot and is one way to tell if you‟re in the pericardial sac. From a 12 lead ECG machine, attaching
the lead V alligator clip to the needle as you insert. This will help determine position and
if any arrythmias occur.
Tablets (Drug Overdose) are another issue with multiple treatments depending upon the
problem. The treatment depends upon the drug taken. For tricyclic antidepressants and for
phenobarbitone overdoses, give Sodium Bicarbonate to alkalize the urine. If pt has an established
heart history looks for drugs such as Digoxin to be the culprit and treat accordingly. This is not an
attempt to cover all drug possibilities. This is too broad of an area to discuss all possible drug
overdoses. The clinician will use their assessment skills for the patient and the environment to pick
up on clues causing the problem. Dialysis can also be used as a treatment in a critical situation as in
Hyperkalemia to remove the unwanted substance quickly, but even then, some drugs cannot be
removed by dialysis. Many times, clinicians treat the symptoms of the overdose until the cause can
be determined or counteracted.
Trauma - is another issue with multiple treatments depending upon the problem. Trauma is a huge
problem that may fall into some of these other areas like hypovolemia due to blood loss or hypoxia
or hydrogen ion (acidosis), but unlike the other problems, managing this type of patient require
identifying the cause of the problem, like a head injury or a spleen rupture, or a required surgical
intervention. It means that rapid response and identification of the causing concerns is the priority

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 GUIDELINES ACLS SUMMARY
1. Ventilation during cardiac arrest must be done well. Each breath should last for approx. 1
second, and BVM respirations should be delivered at a rate of 10 -12 breaths per minute, or once
every 5-6 seconds.
2. When ventilating a patient who has ceased spontaneous respiration, the focus should be on
establishing good ventilation through use of good head position, a proper filling mask and
effective rate and volume of ventilation
3. When treating a bradycardic patient, remember that Atropine 1mg should be given to a patient
who is bradycardic and displaying signs of hypoperfusion. IF ATROPINE DOES NOT
WORK THEN PERMANENT PACEMAKER IS THE TREATMENT OF CHOICE.
4. New ACLS guidelines stress the importance of performing CPR without interruptions.
Following manual defibrillation, AED defibrillation, or after receiving a message from and AED
that says “no shock advised” the operator must begin CPR without delay and check for
spontaneous circulation 2 minutes later.
5. Avoiding mistakes by improving communication is an important part of the new ACLS.
ACLS suggest closed loop communications – which is when the team leader makes a
request, and the team member acknowledges when the request has been completed. This
allows the team leader to ensure all requested steps are performed.
6. PEA is a cardiac arrest presentation in which there is an EKG rhythm (EXCEPT VF/VT), but no
corresponding pulse is identified. Prognosis from true PEA is poor, however, recalling the
ACLS H‟s and T‟s is a method to quickly recall and rule out correctable causes of this
rhythm.
7. The TREATMENT STRATEGY for all ACLS medical arrest WITH ASYSTOLE/PEA
begins with CPR AND ADMINISTERING A VASOCONSTRICTOR WHICH provides
peripheral vasoconstriction, thus allowing for better perfusion of thoracic organs and the
brain. Presently Epinephrine 1.0 mg IV given every 3 – 5 minutes is recommended.
8. Epinephrine is packaged in several different concentrations for different conditions.
Epinephrine 1 mg in a 10 ml pre-filled syringe is most commonly used for cardiac arrest. The
concentration of Epinephrine in this packaging is 1:10,000. Epinephrine 1 mg in 1 ml ampule is
typically used for SC injection. This concentration is 1:1,000.
9. Fast heart rhythms are typically considered problematic at rates greater than 150. Sinus
tachycardia, usually seen between 100 and 150, is often a compensatory tachycardia, and the
underlying cause should be identified in order to resolve the condition.
10. Tachycardias with pulse are unusually subdivided into stable or unstable in nature. An
unstable tachycardia is one with BP LESS THAN 90 SYSTOLIC that produces chest pain,
shortness of breath, hypotension, alteration of consciousness, or any other serious systemic
condition.
11. IN SINUS TACHYCARDIA TREAT THE UNDERLYING CAUSE
12. IV thrombolytics are used to treat acute ST elevation MI and ischemic stroke, after careful
patient evaluation, evaluation of laboratory data an imaging, which can be guided by
thrombolytic checklist.
13. It is important for the team leader to monitor all team members during technical periods
during CPR and ACLS. If a team member is having difficulty completing a skill (IV, ETT etc.)
the team leader should offer assistance, or direct additional team members to assist in the
successful completion of the skill.

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14. To confirm ETT placement, today‟s team leader must RELY ON WAVEWFORM
CAPNOGRAPHY AND ENSURE THAT BREATH SOUNDS have been confirmed, and
ETCO2 detection has yielded positive indication.
15. For years ACLS procedures have changed. Drugs have come and gone, but the outcome from
unexpected cardiac arrest has not improved substantially. This version of ACLS stresses on
HIGH QUALITY CPR, WITHOUT INTERRUPTIONS as the most critical component of
cardiac resuscitation.
16. VF/PVT SHOULD IMMEDIATELY BE TREATED WITH CPR AND DEFIBRILLATION
(HIGH ENERGY UNSYNCRONISED SHOCK) IMMEDIATELY.
17. Remember that treating UNSTABLE TACHYCARDIA patients with CARDIOVERSION.
Stable patients are treated based on their rhythm presentation. In many cases exact
identification of the tachycardic rhythm may be difficult, obtain expert consultation” when
treating patients in challenging tachycardias. We encourage providers to utilize the help of
more knowledgeable resources, to ensure patient receive correct therapy.
18. When a patient presents with an acute MI, certain steps should be done quickly and with
attention to detail. The standard approach to STEMI includes early MONA, possible use of
beta-blockers, followed by heparin, Plavix and ultimately the decision to utilize
thrombolytics, or to move the patient to catheterization. Thrombolytics should be employed in no
more than 30 minutes from patient presentation, and catheterization should occur in no less than
90.
REMEMBER DOOR TO NEEDLE TIME IS 30 MINUTES AND DOOR TO
BALLOON TIME IS 90 MINUTES.
19. When treating a patient of stroke, the following tasks must be completed. EARY
DETECTION BY FAST, RAPID TRANPORT TO ED. The patient must be examined and
CT ordered in the first 20 minutes. The CT should be completed and the results provided to the
attending in 45 minutes. COSULTATION WITH THE NEUROLOGY DEPARTMENT The
consent process may then take place. The time limit for providing peripheral TPA is no
greater than 3 hours following symptom onset.
REMEMBER ASPIRIN OR ANY BLOOD THINNER IS CONTRAINDICATED IF
YOU ARE PLANNING TO GIVE TPA.
IF BP HIGER THAN 180/110 TPA IS CONTRAINDICATED
CT SCAN IS MUST TO RULE OUT BLEED.
20. IN NEW GUIDELINES ROSC ALGORYTHM IS COMPLETELY UPDATED AFTER
STABILIZING THE PATIENT, YOU HAVE TO DO THERAPEUTIC TEMPERATURE
MANAGEMENT (TTM) IF PATIENT IS NOT RESPONDING. GLYCAEMIC CONTROL OF
BLOOD GLUCOSE LEVELS AT 6-10 mmols/L. CT AND MRI IMAGING OF BRAIN.
EEG MONITORING.

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