American heart association acls book 2012 pdf

When using handheld paddles and gel or pads, you must ensure that the paddle is in full contact with the skin. Even smaller pads have been found to be effective in VF of brief duration. Use of the smallest pediatric pads, however, can result in unacceptably high transthoracic impedance in larger children. Early defibrillation is critical to survival from sudden cardiac arrest SCA.

A common initial rhythm in out-of-hospital witnessed SCA is VF, the treatment for which is defibrillation. The probability of successful defibrillation diminishes rapidly over time, and VF tends to deteriorate to asystole within 10 to 15 minutes. Therefore, whether the adhesive electrode pads or paddles are being used, you should be very careful not to delay the shock during CPR to minimize the time between last compression and shock delivery.

Intervals between pausing chest compressions and shock delivery have been shown to last approximately 20 to 30 seconds, which is no longer acceptable.

If CPR is in progress, chest compressions should continue until the defibrillator electrode adhesive pads are attached to the chest and the manual defibrillator is ready to analyze the rhythm. When any rescuer witnesses an out-of-hospital arrest and an automated external defibrillator AED is immediately available onsite, the rescuer should start CPR and use the AED as soon as possible. If VF persists after the first shock, second and subsequent shocks of J should be given.

After delivering a single shock, immediately resume CPR, pushing hard and fast at a rate of at least compressions per minute. Minimize interruption of CPR and allow full chest recoil after each compression.

You should state the warning quickly to minimize the time from last compression to shock delivery. One, two, three, shocking. You do not need to use those exact words. But it is imperative that you warn others that you are about to deliver a shock and that everyone stand clear. Make sure all personnel step away from the patient, remove their hands from the patient, and end contact with any device or object touching the patient.

Any personnel in indirect contact with the patient, such as the team member holding a ventilation bag attached to an ET tube, must also end contact with the patient. Take the time to learn to operate the defibrillator used in your workplace and its energy settings.

This principle holds true regardless of the type of defibrillator or waveform. However, new science and consensus opinion have prioritized both access routes and drug administration. Remember, no drug g iven during cardiac arrest has been shown to improve survival to hospital discharge or improve neurologic function after cardiac arrest.

Drug administration is of secondary importance. Drugs can be administered while other interventions are underway and should not interrupt chest compressions. Unless bag-mask ventilation is ineffective, insertion of an advanced airway whether for drug administration or ventilation is of secondary importance.

Some advanced airway devices can be placed while chest compressions continue. If insertion of an advanced airway requires interruption of chest compression for many seconds, the provider should weigh the need for compression against the need for an advanced airway.

Absorption of drugs given by the endotracheal route is unpredictable, and optimal dosing is unknown. For this reason, the IO route is preferred when IV access is not available.

A peripheral IV is preferred for drug and fluid administration, unless a central line is already in place. Central line access is not needed during most resuscitation attempts. Attempts to insert a central line may interrupt CPR. In addition, CPR can cause complications during central line insertion, such as vascular laceration, hematomas, and bleeding.

Insertion of a central line in a noncompressible area of a vein is a relative contraindication to fibrinolytic therapy eg, for the patient with an ST-segment elevation myocardial infarction [STEMI] and sudden cardiac arrest. Establishing a peripheral line should not require interruption of CPR. Drugs typically require 1 to 2 minutes to reach the central circulation when given by the peripheral IV route.

Keep this in mind during CPR. The drug you give based on a rhythm check will not take effect until it is flushed into the patient and has been circulated by the blood flow generated during CPR. Briefly elevating the extremity during and after drug administration theoretically may also recruit the benefit of g ravity to facilitate delivery to the central circulation, but has not been systematically studied.

IO access is safe and effective for fluid resuscitation, drug delivery, and blood sampling for laboratory evaluation. IO access can be established in all age groups. Any drug or fluid that can be given by the IV route can also be given by the IO route.

The IO route is preferred over the ET tube route. IO cannulation provides access to a noncollapsible venous plexus in the bone marrow. This vascular network provides a rapid, safe, and reliable route for administration of drugs, crystalloids, colloids, and blood during resuscitation. It is often possible to achieve IO access in 30 to 60 seconds. The technique uses a rigid needle, preferably a specially designed IO or bone marrow needle. Use of an IO needle with stylet may be preferred to use of a needle without stylet because the stylet prevents obstruction of the needle with cortical bone during insertion.

Butterfly needles and standard hypodermic need les can also be used. Commercially available kits can facilitate IO access in adults. Endotracheal Route The IV and IO routes of administration are preferred over the endotracheal route of administration during CPR because drug absorption and drug effect are much less predictable when drugs are administered by this route.

To give drugs via the endotracheal route, dilute the dose in 5 to 10 mL of sterile water or normal saline and inject the drug directly into the ET tube. Follow with several positivepressure breaths.

You can give the following drugs by the endotracheal route during cardiac arrest: vasopressin, epinephrine, and lidocaine. Favored sites are the dorsum of the hands, the wrists, and the antecubital fossae. Ideally, only the antecubital veins should be used for drug administration during CPR. Anatomy: Upper Extr emi ti es Figure 31 Starting at the radial side of the wrist, a thick vein, the superficial radial vein, runs laterally up to the antecubital fossa and joins the median cephalic vein to form the cephalic vein.

Superficial veins on the ulnar aspect of the forearm run to the elbow and join the median basilic vein to form the basilic vein. The cephalic vein of the forearm bifurcates into a Y in the antecubital fossa, becoming the median cephalic laterally and the median basilic medially. Technique: Antecubital Venipuncture The largest surface veins of the arm are in the antecubital fossa.

Select these veins first for access if the patient is in circulatory collapse or cardiac arrest Figur e Select a point between the junctions of 2 antecubital veins.

The vein is more stable here, and venipuncture is more often successful. If peripheral access is impossible, consider central access via the femoral veins since chest compressions and other resuscitation interventions should not be interrupted, and potential vascular injuries can be better controlled at this site.

If upper extremity access is impossible and a central line is not an option, consider a peripheral leg vein. Antecubital venipuncture.

A, Scene perspective from a distance. B, Close-up view of antecubital area: anatomy of veins of upper extremity. Figur e 31A. Strict aseptic technique is compromised in most emergency venipunctures, where speed is essential. This compromise is particularly likely when emergency vascular access is established outside the hospital, because personnel and equipment are limited.

IV solutions are usually packaged in nonbreakable plastic bottles or bags. Squeeze plastic bags before use to detect punctures that may lead to contamination of the contents. Avoid adding drugs that may be adsorbed by the plastic bag or tubing eg, IV nitroglycerin. If you must administer these drugs without specialty infusion systems, allow for drug adsorption when you titrate the drug administration rate.

Saline lock catheter systems are particularly useful for patients who have spontaneous circulation and require drug injections but not IV volume infusion. Most contemporary systems use needleless injection sites. These systems permit drug and flush infusions without the use of needles and the associated risk of needle sticks. Avoid letting the arm with the IV access hang off the bed. Place the arm at the level of the heart, or slightly above the heart, to facilitate delivery of fluids and medications to the central circulation.

During cardiac arrest follow all peripherally administered drugs with a bolus of at least 20 mL of IV flush solution. Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

Be aware of complications common to all IV techniques. Local complications include hematomas, cellulitis, thrombosis, infiltration, and phlebitis. Systemic complications include sepsis, pulmonary thromboembolism, air embolism, and catheter fragment embolism.

Needles The technique uses a rigid needle, preferably a specially designed IO or Jamshidi-type bone marrow needle. In the past the higher bone density in older children and adults made it difficult for smaller IO needles to penetrate the bone without bending. With the development of IO cannula systems for adults, IO access is now easier to obtain in older children and adults.

Indications and Administration Resuscitation drugs, fluids, and blood products can be administered safely by the IO route. Continuous catecholamine infusions can also be provided by this route. The onset of action and drug levels after IO infusion during CPR are comparable to those for vascular routes of administration, including central venous access.

Administer viscous drugs and solutions and fluid for rapid volume resuscitation under pressure using an infusion pump, pressure bag, or forceful manual pressure to overcome the resistance of the emissary veins. Some have expressed concern that high-pressure infusion of blood might induce hemolysis, but animal studies have failed to document this problem.

Careful technique helps to prevent complications. Action Always use universal precautions when attempting vascular access. Disinfect the overlying skin and surrounding a rea with an appropriate agent. Identify the tibial tuberosity just below the knee joint.

The insertion site is the flat part of the tibia, 1 or 2 finger widths below and medial to this bony prominence. Figur e 32 shows some of the sites for IO access. The stylet should remain in place during insertion to prevent the needle from becoming clogged with bone or tissue.

Stabilize the leg to facilitate needle insertion. Do not place your hand behind the leg. When placing an IO needle in other locations, aim slightly away from the nearest joint space to reduce the risk of injury to the epiphysis or joint but keep the needle as perpendicular to the bone as possible to avoid bending.

Use a twisting motion with gentle but firm pressure. Some IO needles have threads. These threads must be turned clockwise and screwed into the bone. This release occurs as the needle enters the marrow space. If the needle is placed correctly, it will stand easily without support.

Figur e 32A. A, Locations for IO insertion in the distal femur, proximal tibia and medial malleolus. B, Location for IO insertion in the anterior-superior iliac spine. Aspiration of bone marrow contents and blood in the hub of the needle confirms appropriate placement. You may send this blood to the lab for study. Note: Blood or bone marrow may not be aspirated in every case.

Infuse a small volume of saline and observe for swelling at the insertion site. Also check the extremity behind the insertion site in case the needle has penetrated into and through the posterior cortical bone. Fluid should easily infuse with saline injection from the syringe with no evidence of swelling at the site.

If the cortex of the bone is penetrated, placing another needle in the same extremity will permit fluids and drugs to escape from the original hole and infiltrate the soft tissues, potentially causing injury. There are a number of methods to stabilize the needle. Place tape over the flange of the needle to provide support. Position gauze padding on both sides of the needle for additional support.

When connecting IV tubing, tape it to the skin to avoid displacing the needle by placing tension on the tubing. Volume resuscitation can be delivered via a stopcock attached to extension tubing or by infusion of fluid under pressure. When using a pressurized fluid bag, take care to avoid air embolism.

Follow-up is important after you establish IO access. Check the site often for needle displacement. Delivery of fluids or drugs through a displaced needle may cause severe complications eg, tissue necrosis or compartment syndrome. Replace the IO access with vascular access as soon as reasonable. Replacement with long -term vascular access is usually done in the intensive care unit. Inappropriate parasympathetic discharge can cause symptomatic bradycardia and hypotension. If hypotension is present, it is usually due to a combination of hypovolemia decreased left ventricular [LV] f illing pressure and bradycardia.

Repeat fluid administration typically up to 1 to 2 L if there is improvement and no symptoms or signs of heart failure or volume overload.

Reassess the patient before each fluid administration. For patients with RV infarct and hypotension, volume administration may be lifesaving. When hypotension is present, a slow heart rate is inappropriate. The heart rate should be faster in the presence of low blood pressure. The fluid bolus increases RV f illing pressures, which cause an increase in the strength of RV contractions Starling mechanism , blood flow through the lungs, and ultimately LV filling pressure and cardiac output.

However, if the patient remains asymptomatic and hemodynamically stable, transcutaneous pacing TCP and a transvenous pacemaker are not indicated. Monitor the patient and prepare for transcutaneous pacing if high-degree block develops and the patient becomes symptomatic or unstable before expert cardiology evaluation. The patient may be sta ble if junctional pacemaker cells can function and maintain an adequate ventricular rate.

This rhythm usually has a narrowcomplex QRS and a ventricular rate of 40 to 60 beats per minute. Unless a large amount of myocardium is nonfunctional or comorbid conditions exist, the patient is often stable. If the bradycardia is symptomatic, follow the Bradycardia Algorithm.

Prepare for TCP. Use atropine to increase heart rate and blood pressure if the patient becomes symptomatic. The initial recommended atropine dose is 0. Repeat every 3 to 4 minutes, not exceeding the maximum dose of 3 mg. Use only the dose necessary to stabilize the patient. Excess atropine may increase ischemia by excessively increasing heart rate and contractility—major determinants of myocardial oxygen consumption.

If the patient does not respond to drugs or TCP, start transvenous pacing. Obtain immediate expert consultation for evaluation and recommendation eg, transvenous temporary pacemaker. Cardiac arrest occurs both in and out of the hospital. Cardiac arrest continues to be an all-too-common cause of premature death, and small incremental improvements in survival can translate into thousands of lives saved every year.

Many public health experts consider CPR training to be the most successful public health initiative of modern times. Millions of people have prepared themselves to take action to save the life of a fellow human being. But despite our best efforts, in most locations half or more of out-of-hospital resuscitation attempts do not succeed.

Tragically even when ROSC occurs, few of VF cardiac arrest patients admitted to the emergency department and hospital survive and go home. We must consider and plan for the emotional reactions from rescuers and witnesses to any resuscitation attempt. The individual links are interdependent, and the success of each link is dependent on the effectiveness of those that precede it. Adult Chain of Survival. Now you can be confident that you will be better prepared to do the right thing when your professional skills are needed.

Of course these emergencies can have negative outcomes. You and the other emergency personnel who arrive to help in the resuscitation may not succeed in restoring life. Some people have a cardiac arrest simply because they have reached the end of their life.

Your success will not be measured by whether a cardiac arrest patient lives or dies, but rather by the fact that you tried and worked well together as a team. Simply by taking action, making an effort, and trying to help, you will be judged a success. Stress A cardiac arrest is a dramatic and emotional event, especially if the patient is a friend or loved one. The emergency may involve Reactions disagreeable physical details, such as bleeding, vomiting, or After Resuscitation poor hygiene.

The emergency can produce strong emotional Attem pt s reactions in physicians, nurses, bystanders, lay rescuers, and EMS professionals. Failed attempts at resuscitation can impose even more stress on rescuers. This stress can result in a variety of emotional reactions and physical symptoms that may last long after the original emergency.

Usually such stress reactions occur immediately or within the first few hour s after the event. Sometimes the emotional response occurs later.

These reactions are frequent and normal. There is nothing wrong with you or with someone who has such reactions after an event. Psychologists working with professional emergency personnel have learned that rescuers may e xperience grief, anxiety, anger, and guilt. Many people say they are unable to stop thinking about the event.

Remember that these reactions are common and normal. With the understanding and support of friends and loved ones, the stress reactions usually pass. Techniques to Reduce Stress in Rescuers and Witnesses Psychologists tell us that one of the most successful ways to reduce stress after a rescue effort is simple: talk about it. Sit down with other people who witnessed the event and talk it over.

EMS personnel who respond to calls from lay rescuer defibrillation sites are encouraged to offer emotional support to lay rescuers and bystanders. More formal discussions, called critical event debriefings, should include not only the lay rescuers but also the professional responders.

In these discussions, you will be encouraged to describe what happened. It is natural and healthy to talk about the event. Describe what went through your mind during the rescue effort. Describe how it made you feel at the time. Describe how you feel now. Be patient with yourself. Understand that many reactions will diminish within a few days. Sharing your thoughts and feelings with your companions at work, fellow rescuers, EMS personnel, or friends will help reduce stress reactions and help you recover.

Other sources of psychological and emotional support are local clergy, police chaplains, fire service chaplains, and hospital and emergency department social workers. Your course instructor may be able to tell you what plans are established for critical event debriefings in your professional setting. ACLS providers have expressed some common concerns about responding to sudden cardiac emergencies: Will I be able to take action?

Will I remember how to perform the skills of CPR, defibrillation, and intubation and the details of drug doses and the steps in the algorithms? Will I really have what it takes to respond to a true emergency? Any emergency involving a patient you have grown close to, a friend or a family member, will produce a strong emotional reaction.

Will you really be able to perform mouth-to-mouth rescue breathing on a stranger? What if the patient is bleeding from facial injuries? Would this not pose a risk of disease for a rescuer without a CPR barrier device? You cannot attach defibrillation electrodes unless the pads are placed directly on the skin.

Common courtesy and modesty may cause some people to hesitate before removing the clothing of strangers, especially in front of many other people in a public location. Everyone is familiar with the concept of defibrillation shocks as shown in television shows and movies.

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