Explorez tous les épisodes du podcast Pass ACLS Tip of the Day

Two factors to cardiac arrest survivability that have been clearly shown to make the biggest difference is continuous, high-quality CPR and early defibrillation.

The most common dysrhythmia present during the first few minutes of cardiac arrest is ventricular fibrillation.

The chance of successful defibrillation decreases every minute that passes. 

How our chance of successfully defibrillating a patient into a perfusing rhythm significantly changes when good CPR is delivered vs when it isn't.

Why bystander CPR is important for out-of-hospital cardiac arrest (OHCA) outcomes. 

The role of the CPR coach.

Five tips to aid us in limiting CPR interruptions to less than 10 seconds so we can maintain a chest compression fraction (CCF) of 80% or more.

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Quantitative waveform capnography is used in ACLS as a way to confirm good CPR and placement of an endotracheal tube; identify return of spontaneous circulation; and during post-cardiac arrest care.

We can use waveform capnography with, and without, an advanced airway in place.

Monitoring end tidal CO2 during rescue breathing.

Use of capnography to objectively measure good CPR.

Capnography is a preferred method of confirming endotracheal tube (ETT) placement over x-ray during a code.

During CPR, a sudden increase in ETCO2 may indicate ROSC.

Quantitative waveform capnography use in the post-cardiac arrest algorithm.

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To pass the written ACLS exam and mega code, students need to be able to identify basic ECG dysrhythmias, including the two types of second-degree heart block.

One method of ECG rhythm identification is to ask a series of questions such as:

What's the rate (<60, 60-100, 101-149, or >150);

Is the rhythm regular or irregular;

What's the shape, width, and frequency of P waves and QRS complexes; and

What's the P-R interval and is it constant?

ECG characteristics of a second-degree Mobitz type I (Wenckebach).

Identification of unstable bradycardia and its treatment with Atropine.

ECG characteristics of a second-degree Mobitz type II.

Possible effect of using Atropine on patients with a second-degree type II AV block.

Treatment of unstable bradycardic patients refractory to Atropine using TCP, Dopamine, or Epinephrine drip.

Starting dose and titration of Dopamine and Epinephrine drips.

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The Curious Clinicians: History of Doctor Wenckebach & Mobitz

https://curiousclinicians.com/2022/07/06/episode-52-way-back-wenckebach/

Practice ECGs with rationale at Dialed Medics:

https://dialedmedics.com/

When treating patients with Acute Coronary Syndrome (ACS), MONA is an acronym sometimes used to help us remember the initial interventions.

The O in MONA is Oxygen.

When we should administer oxygen to ACS patients.

When O2 administration is unnecessary based on an accurate pulse ox.

Monitoring patient's oxygen saturation (SaO2) using a pulse oximeter.

Review two common ACLS pre-arrest mega code scenarios.

Oxygen administration during CPR and post cardiac arrest.

You can find additional medical podcasts that cover ACLS-related topics, on the Pod Resources page at PassACLS.com

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Check out ConveyMed.io for more free online medical education (FOAMed) opportunities.

Along with early defibrillation, high quality CPR with minimal interruptions is one of the two factors that has been shown to improve cardiac arrest outcomes.

How do we know if high quality, effective CPR is being performed?

Objective measures of high-quality CPR include:

• Compression rate;
• Compression depth & recoil;
• ETCO2; and
• Chest Compression Fraction (CCF).

The role of the CPR Coach on the code team.

The advantages and use of real-time feedback devices to monitor the rate, depth, and chest recoil of CPR compressions.

The use of end tidal waveform capnography. (ETCO2)

A no-tech way to monitor effective CPR if no compression feedback device or ETCO2 capnography isn’t available.

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When we should use the bradycardia algorithm.

The signs & symptoms of unstable bradycardia.

Atropine's bradycardic dose and maximum.

The use of atropine when a patient is in a second degree type II or third degree heart block.

ECG changes that indicate subsequent doses of atropine are likely to be ineffective.

The starting dose of Dopamine.

The use of Dopamine for bradycardia as an interim until TCP vs hypotension.

The use of Atropine and Dopamine in patients with myocardial ischemia.

Podcasts with additional (advanced-provider level) information about bradycardia, Atropine, & Dopamine can be found on the Pass ACLS Pod Resources page.

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The tongue is the most common airway obstruction in an unconscious patient.

Insertion an oropharyngeal airway helps keep the patient’s tongue from falling to the back of the pharynx, causing an airway obstruction.

The oropharyngeal airway is sometimes called an OPA or simply an oral airway.

Indications for using an oral airway.

Contraindication for an oral airway and an alternative airway that can be used for patients with an intact gag reflex.

Measuring an OPA and possible complications from inserting one that's too small or too large.

Two techniques to properly insert an OPA.

The use of an oral airway during CPR.

The use of an OPA as a bite block after a patient has an advanced airway placed.

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Patients with a narrow complex tachycardia with a rate over 150 BPM are in SVT.

Unstable patients in SVT, or V-Tach with a pulse, should be cardioverted with a synchronized shock.

Assessment & treatment of stable tachycardic patients.

Commonly used vagal techniques.

A less common technique to stimulate the vagus nerve is the dive reflex.

Indications and use of Adenosine for stable patients in SVT refractory to vagal maneuvers.

Possible treatments for patients found to be in A-Fib or A-Flutter with RVR after administration of Adenosine.

Carotid sinus massage.

Additional medical podcasts that have episodes on tachycardia can be found on the pod resources page at passacls.com.

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Remembering all the different energy setting needed for synchronized cardioversion and defibrillation used to be confusing for a lot of people.

Defibrillators can be broken down into three basic categories:

1.  Automated External Defibrillator (AED);

2.  Biphasic defibrillators; and

3.  Monophasic defibrillators.

Use of an AED to rapidly deliver a shock.

Advantages & use of Biphasic defibrillators.

For monophasic defibrillators, use 360J to defibrillate V-Fib or pulseless V-Tach.

AEDs must not be used on patients with a pulse.

Cardioversion of patients in unstable SVT or V-Tach with a pulse using biphasic vs monophasic monitor/defibrillators.

Team safety when performing synchronized cardioversion.

Energy needed to cardiovert unstable patients with a narrow vs wide complex tachycardia.

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Patients with a heart rate less than 60 are bradycardic. Some people can have a resting heart rate in the 40s without any compromise.  For others, a heart rate of 50 or less could signify the need for immediate intervention and warrants additional assessment.

Signs & symptoms that indicate a bradycardic patient is unstable.

Monitoring oxygen saturation with pulse oximetry and indications for administration of oxygen.

Calcium channel blockers and beta blocker medication as treatable causes of bradycardia.

The indications and dosage of Atropine.

Precautions for Atropine use in patients with second or third degree AV blocks.

The use of transcutaneous pacing (TCP) for unstable bradycardic patients refractory to Atropine.

The use and dosing of Dopamine and Epinephrine drips.

For additional information about causes and treatment of bradycardia, check out the pod resources page at PassACLS.com.

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The goal of CPR is to keep the brain and vital organs perfused until return of spontaneous circulation (ROSC) is achieved.

Post-arrest care and recovery are the final two links in the chain of survival.

Identification of ROSC during CPR.

Initial patient management goals after identifying ROSC.

The patient’s GCS/LOC should be evaluated to determine if targeted temperature management (TTM) is indicated.

Patients that cannot obey simple commands should receive TTM for at least 24 hours.

Recently published studies on TTM and ACLS’s current standard.

Monitoring the patient’s core temperature during TTM.

Patients can undergo EEG, CT, MRI, & PCI while receiving TTM.

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The chain of survival for ACLS is the same as was learned in your BLS class.

The beginning steps of the Cardiac Emergency and Stroke chain of survival.

ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke.

Characteristics of areas that have significantly better stroke and out-of-hospital cardiac arrest outcomes.

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Heart muscle contraction and repolarization is dependent on Sodium, Calcium, Magnesium, and Potassium ions crossing cellular membranes.

When a patient’s potassium levels get too low or too high, hypokalemia or hyperkalemia results respectively.

Two things that may lead us to suspect hypo or hyperkalemia.

Medical conditions & medications that can cause potassium imbalance.

ECG changes seen in hypo and hyperkalemia.

Critical lab values that would indicate a need for treatment.

Emergent, ACLS interventions for hypokalemia and hyperkalemia.

Additional information on causes of hypo and hyperkalemia can be found on Ninja Nerd podcast.  Check out the pod resources page at passacls.com.

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When treating patients having an MI or stroke, more minutes equals more dead cells. 

Because the majority of strokes are the ischemic type, the treatment for stroke is similar to an MI – to reestablish perfusion to the ischemic tissues. 

The first four steps in the Stroke Chain of Survival.

Time criteria for the administration of tPA (or a similar fibrinolytic medication) or EVT of LVO strokes.

Stroke benchmarks for door to:

• assessment;
• completing a non-contrast CT; and
• administration of fibrinolytic medication such as tPA (door-to-needle).

EMS interaction with stroke teams and destination protocols to reduce time to definitive care.

The difference for timed goals for the identification & treatment of AMI vs Stroke.

Additional information about timed goals for stroke and how EMS affects outcomes, can be found on the PassACLS.com pod resources page.

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Adenosine is the first IV medication given to stable patients with sustained supraventricular tachycardia (SVT) refractory to vagal maneuvers.

Symptoms indicating a stable vs unstable patient.

Common causes of tachycardia.

Cardiac effects of Adenosine.

Indications for use in the ACLS Tachycardia algorithm.

Considerations and contraindications.

Adenosine as a diagnostic for patients in A-Fib or A-Flutter with RVR.

Dosing and administration.

Other podcasts that cover common ACLS antiarrhythmics in more detail and another covering Brugata Criteria used to differentiate V-Tach from SVT with an aberrancy, can be found on the Pod Resources page at passacls.com.

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Two things have changed in recent years to aid students that don't use ACLS in their daily practice.

1.  The role of the team leader; and

2.  The ability to use your quick reference cards.

The team leader is responsible for assigning tasks and overall direction of the team but can & should ask team members for help.

Using closed-loop communication to ensure the clarity of orders and speaking up if there’s any doubt about an order or action.

Use of your course’s approved text book and quick reference cards during the megacode and written exam.

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Being the team leader during a cardiac arrest is challenging.  Using an algorithm helps by standardizing & prioritizing our interventions using an If/Then methodology.

Review of BLS steps for determining if rescue breathing or CPR is needed and use of an AED for patients in cardiac arrest.

If the patient is in a non-shockable rhythm on the ECG such as PEA or asystole, we will go down the right side of the Adult Cardiac Arrest Algorithm.

If the patient is in a shockable rhythm on the ECG such as V-Fib or V-Tach, we will go down the left side of the Adult Cardiac Arrest Algorithm.

An example of a code's flow for shockable rhythms when an antiarrhythmic such as Amiodarone or Lidocaine is administered.

We will follow the algorithm until the patient has ROSC or we call the code.

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Other Pass ACLS episodes mentioned:

Objective Measures of Good CPR at https://passacls.com/bls/objective-measures-of-good-cpr

For patients exhibiting symptoms consistent with myocardial ischemia, Aspirin is the first medications we should consider along with morphine, oxygen, and nitroglycerine; if indicated & safe.

Aspirin's mechanism of action & benefits for Acute Coronary Syndrome (ACS) patients.

Contraindications and considerations for aspirin’s use.

The dose and route of administration of aspirin for ACS patients.

The use of aspirin in the ACLS Stroke algorithm.

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To pass ACLS, you will need to be able to identify common rhythms on a monitor during your mega code and ECG strips on your written exam.

If you don't normally monitor patients as part of your job, I suggest two things:

1. Find a system for ECG interpretation that works well for you; and
2. Practice reading ECGs every day for a few weeks before your class.

Review of normal ECG morphology of P wave, QRS complex, and T wave in lead II.

Characteristics of first degree heart block.

Characteristics of third degree (complete) AV block.

Treatment of unstable patients in third degree block following the ACLS Bradycardia algorithm.

Special considerations for use of Atropine when patients are in a third degree heart block.

The use of TCP, Dopamine, & Epinephrine drip for unstable bradycardic patients refractory to Atropine.

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Practice ECGs at Dialed Medics: https://dialedmedics.com/

In the Adult Cardiac Arrest algorithm, we should administer an antiarrhythmic medication to patients in V-Fib or pulseless ventricular tachycardia approximately two minutes after the first dose of epinephrine.

The two first-line ACLS antiarrhythmics that are generally used are Amiodarone and Lidocaine.

Review of Lidocaine dosing and administration to patients in persistent V-Fib or pulseless V-Tach.

Review of Amiodarone dosing and administration to patients in persistent V-Fib or pulseless V-Tach.

Use of antiarrhythmic infusions post-cardiac arrest to suppress ventricular ectopy. 

Amiodarone use & dosing for stable patients in V-Tach with a pulse.

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The tongue is the most common airway obstruction in an unconscious patient.

For patients with a decreased level of consciousness that can't control their airway, yet have an intact gag reflex, the nasopharyngeal airway (NPA) should be used as an alternative to the oropharyngeal airway (OPA).

Examples of when a NPA should be considered.

Contraindications and considerations for nasal airway insertion.

Measuring a nasal airway for appropriate length and diameter.

Insertion of a nasopharyngeal airway into the right vs left nostril.

Patients with a NPA in place can receive supplemental O2, be ventilated with a BVM, have ETCO2 monitored, and have their upper airway suctioned as needed.

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When blood, or other fluids, accumulate in the sac around the heart it’s called a cardiac tamponade or pericardial tamponade.

The effects of tamponade on the electrical system and chambers of the heart.

Cardiac tamponade can be acute or chronic and caused by traumatic, iatrogenic, or pathological etiologies.

Common traumatic events, medical procedures, and diseases that can result in a pericardial tamponade.

Signs & symptoms of cardiac tamponade.

Treatment of cardiac tamponade with pericardiocentesis.

For additional information on cardiac tamponade, check out the Pod Resources page at PassACLS.com. 

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The ACLS algorithms are designed to make it easier to remember the key interventions we should deliver, and the order in which they should be delivered, to provide the best evidence-based care possible.

Generally speaking, if there’s a change in a patient’s condition, we should ensure we’re using the correct algorithm.

Three key points to remember when using ACLS algorithms:

1.  If a patient’s condition changes, we should do an assessment and use the algorithm that matches the patient’s current state.

2.  If an action was already done, we don’t need to repeat it.

3.  We only do actions that are clinically appropriate and within our scope of practice.

Walk through of an example mega code scenario with explanations of when and why we change to a different ACLS algorithm. 

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Beta blocking medications attach to Beta receptors to inhibit or “block” the effects of epinephrine (adrenaline)and norepinephrine in the body.

The primary locations of Beta I, II, and III receptors.

Effects of epinephrine & norepinephrine’s stimulation of beta receptors on the heart.

Beta blockers effects on the heart.

When we should consider the use of beta blockers in the Acute Coronary Syndrome (ACS)and Tachycardia algorithms.

Contraindications to the use of beta blocker medications.

More detailed information about beta blocker’s mechanism of action and specific instances for their use can be found on the Pod Resource page at PassACLS.com.

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This episode we are reviewing the use of advanced airways in the adult cardiac arrest algorithm.

When we should consider insertion of an advanced airway for patients in a shockable vs non-shockable rhythm.

In addition to an endotracheal tube (ETT), other ACLS advanced airways include the Laryngeal Mask Airway (LMA) and the Laryngeal Tube airway.

The advantages of using an advanced airway over basic airway maneuvers.

Use of end tidal CO2 waveform capnography to confirm placement and assess the adequacy of CPR.

Identification and management of a misplaced ET tube.

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Our primary focus immediately following return of spontaneous circulation (ROSC) is aimed at ensuring adequate perfusion of the patient’s vital organs and decreasing cerebral damage.

Post-arrest goals for O2 saturation, ETCO2, and BP/MAP.

Indications for use of an antiarrhythmic after ROSC.

Determining which antiarrhythmic to use post cardiac arrest.

Administration of Amiodarone or Lidocaine to control ventricular ectopy after ROSC.

The use of Amiodarone post arrest if no antiarrhythmics were administered prior to obtaining ROSC.

Links to other medical podcasts that cover antiarrhythmics and other ACLS-related topics are on the Pod Resource page at PassACLS.com.

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Discover medical podcasts with CE at https://conveymed.io

Hydrogen ions is on one of the Hs in ACLS's H&T reversible causes of cardiac arrest. 

When considering hydrogen ions as a cause, what we’re looking at is the patient’s pH, or acid/base balance, and conditions that affect it.

The body's normal pH.

Using patient history, ABGs, & labs to determine acidosis or alkalosis.

Common conditions/causes that may lead us to suspect acidosis.

Common conditions/causes that may lead us to suspect alkalosis.

Correcting acidosis by changing the rate of ventilations.

The indications, dose, and considerations for use of Sodium Bicarbonate.

Treatment of alkalosis depends on the type (metabolic or respiratory) and is aimed at correcting the underlying cause.

Other podcasts that cover acid/base balance and conditions that cause acidosis or alkalosis can be found on the Pod Resource Page at PassACLS.com.

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Calcium is one of the ions that move across the cellular membrane during cardiac contraction and relaxation.

The primary use of calcium channel blockers in ACLS is for the treatment of stable, narrow complex tachycardias refractory to Adenosine and to lower the blood pressure of ischemic stroke patients with severe hypertension.

Use of calcium channel blockers for SVT refractory to Adenosine and A-Fib or A-Flutter with RVR.

Contraindications of calcium channel blockers.

Nicardipine use during the treatment of ischemic strokes.

For more information on ACLS medications, tachycardia, or stroke check out the pod resource page at passacls.com.

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The goal of CPR is to keep the brain and vital organs perfused until return of spontaneous circulation (ROSC) is achieved.

Post-arrest care and recovery are the final two links in the chain of survival.

Identification of ROSC during CPR.

Initial patient management goals after identifying ROSC.

The patient’s GCS/LOC should be evaluated to determine if targeted temperature management (TTM) is indicated.

Patients that cannot obey simple commands should receive TTM for at least 24 hours.

Monitoring the patient’s core temperature during TTM.

Why we should cool unresponsive post-arrest patients.

Patients can undergo EEG, CT, MRI, & PCI while receiving TTM.

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Nitroglycerine is vasodilator that affects peripheral blood vessels and coronary arteries.

Because of its widespread dilation effects on blood vessels, nitro can quickly lower a patient’s blood pressure, sometimes to the point of making a patient hypotensive.

Assessment of vital signs prior to administering nitro is necessary to ensure patient safety.

Indications for use of nitroglycerine.

Nitroglycerine's contraindications & considerations for use.

Effects of nitro on patients taking PDE inhibitors.

Administration of nitroglycerine to patients with ischemic chest pain.

Considerations for patients that took their home nitroglycerine.

Monitoring patient's pain and vital signs after nitro administration.

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