all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal here with this channel is to try to give you guys the confidence to succeed in the icu by taking these complex critical care topics and making them really easy to understand if i'm able to do just that for you i hope that i'm able to earn a like from you at the end of this video as well as possibly a new subscriber if you do subscribe make sure you hit that bell icon and select all notifications that way you never miss out when i release a new lesson alright so in this lesson here today we are going to start working through the different various american heart association the aha acls algorithms and so these algorithms are specifically designed to simplify the approach that we should be taking to managing different cardiovascular emergencies or really specifically to try to prevent such now most of the emergencies that you're going to be dealing with are going to be related to some sort of arrhythmia as a result it's going to be essential that you're able to properly identify these rhythms on ecg so depending on which arrhythmia your patient is presenting with is really going to determine which algorithm you want to utilize typically within each algorithm decision points exist which direct the treatment really depending on the severity of the patient's condition of all of the algorithms the most commonly used one and really arguably the most important of these is going to be the cardiac arrest algorithm which we're going to talk about here now all right so the cardiac arrest algorithm this is going to be the one that you are probably going to use the most and you'll probably become if you're not already the most comfortable with this one this particular algorithm is going to be for the pulseless patient in cardiac arrest and it's going to be accompanied by one of four possible arrhythmias your patient could either be in ventricular tachycardia or vtec ventricular fibrillation or v-fib pulseless electrical activity or pea or in a systole now as i mentioned your ability to be able to assess and identify these rhythms on ecg is really going to be essential to the successful use of this algorithm so what i'm going to do is i'm going to link to an entire series that i've already done talking about ecg rhythm interpretation so i'm going to link to that up above if you guys need some helpful review on this information but given that a majority of patients who experience sudden cardiac arrest are going to be treated with this algorithm so your understanding and mastery of it is really going to be vital in achieving the best possible outcomes that you can for your patients all right so let's get in and talk about the actual cardiac arrest algorithm so first and foremost from our systematic approach which i discussed in full depth in the lesson previous to this one in this series which i'm going to link to up above the first thing that you want to do is call for help activate your emergency response alert or call a code and then immediately begin cpr now when this happens make sure that you guys are also providing oxygen and ventilatory support for your patient as many times we find that this is neglected at least initially and then make sure that we have our ecg monitor on and that we attach the defibrillator now as soon as you get that defibrillator attached from here we need to immediately assess the patient's rhythm for whether or not it's shockable and then depending on the answer to this assessment there are two branches to this algorithm and so first if our patient does have a shockable rhythm then we're going to move to the left branch over here and this is going to be for our v-fib and pulseless v-tac and so on this left branch first and most importantly is that we want to deliver a shock again remember here that early defibrillation is absolutely key but the whole goal of defibrillation is not actually to restart the heart what we do is we use this electricity to actually stun the heart and our whole goal here is to try and stop all electrical activity and thus hopefully terminating the lethal arrhythmia that they were in now as far as the energy the joules required for this shock i know it really depends on whether we're using monophasic or biphasic but i really think at this point that most places are no longer using monophasic devices so here initially our first shock should be anywhere from 120 to 200 joules now immediately after the shock is when you want to move into a round of high quality cpr so this is going to be five cycles or two minutes of chest compressions so it's at this point where if you don't already have it that you need to get iv io access now after the two minutes go by that this is when we're gonna do another rhythm check is this rhythm shockable and so then again at this point based on the assessment that we do here that we're going to have two potential paths that we can go if the rhythm is a shockable rhythm then we want to do just that and deliver a shock now it's at this point that we want to begin stepping up the joules on the defibrillator until we eventually reach the max joules now if the rhythm is not a shockable rhythm then we want to actually assess two different things the first is if we have any signs of return of spontaneous circulation or rosk if there's not then we're actually going to move into the right branch of this algorithm which i'm going to get to talking about here in just a minute but if we do have rosk this is actually one we're going to move into the post cardiac arrest algorithm which is going to be a future lesson so going back to the left branch here we did the second rhythm check we assessed that if it was a shockable rhythm and it was so we delivered a shock and then once again you want to immediately resume high quality cpr for another two minutes and keep in mind we're wanting to keep the time in which we're not delivering cpr to a minimum so as soon as you deliver that shock we immediately move into cpr again so we're now at this point in the algorithm where if we make the assumption that in the previous round of cpr that we were working on getting our iv io access then it's at this point here where we want to give our first dose of epinephrine the dose that we're going to be giving here is one milligrams iv push and we're going to want to make sure we followed it up with a good flush 10 to 20 mls so i am going to preface this with if you were on the first round of cpr and you already had good iv i o access then at that point you're going to want to also give the epinephrine there you don't have to wait until this point here and so as soon as we give this first dose then we're actually going to repeat the dose of epi every three to five minutes until either the code is called or we have rosk it's also at this point here where we now want to consider that advanced airway and then ensuring that we do have our waveform capnography the end tidal co2 at this point now after the two minutes are up again we're going to do another rhythm check and see if this is another shockable rhythm and so once again based on this assessment if the rhythm is not chalkable we're going to move back to assessing whether we have rosk in our patient but then again if the rhythm is shockable still we want to deliver another shock here and again make sure you guys are continuing to increase those joules until you reach the the max for the delivery of the shock and then once again like i talked about you want to immediately resume the high quality cpr for another two minutes so it's at this point if they've remained in this shockable rhythm that we want to give them some sort of antiarrhythmic so at this point here in the algorithm that we're actually going to want to give them a dose of amiodarone and this dose is going to be 300 milligrams again iv push and this is specifically for the first dose of amio a second dose of amio can be given later on and this time for the second dose we would give him 150 milligrams and so as a quick aside the question often comes up especially with amiodarone and even sometimes with our epi is how fast we want to give this and sort of the wry response to this is really the patient's not getting any deader you basically want to slam this medication in as quick as you can and so hopefully at this point the heart hasn't responded to just the electricity alone we're hoping that adding the additional antiarrhythmic will work to help to get them out of this lethal arrhythmia and so after the two minutes are up what we're going to do at this point is just loop back to checking whether or not our patient is in a shockable rhythm and then progressing through the algorithm until either we have rosk in our patient a non-shockable rhythm presents itself or the code is called and the patient is declared deceased so now at this point let's move over and talk about the right branch of this algorithm and this is going to be for when that rhythm is not shockable and so then what this means is that your patient is either in pea or asystole so in just the same way that we're treating both v-fib and pulseless v-tac the same way pea and asystole are also going to be treated the same via this right branch of the algorithm now we're often going to see progression from the left branch to the right branch and while it's less common it certainly can occur where we can also then progress from the right branch back to the left branch and i'll kind of get in and talk about that here in just a minute as we go through this algorithm so at this point we've assessed the rhythm it's not shockable and so as you can probably figure out that this is where you want to immediately begin your high quality cpr and a really important point for you guys to remember here is that we do not shock pea and asystole despite what they like to really love to show on tv this is going to be completely useless for a patient we are only shocking v fib and vtac now just as with the left side here that we want to ensure that we do have iv io access and if not then we want to make sure and get it again if we have the access or you get the axis then we want to give that dose of epinephrine and again the dose is the same here one milligram iv push every three to five minutes and then we also want to consider that advanced airway and our end tidal co2 monitoring so now as soon as the two minutes are up just as we've been doing on the left branch that we want to do a rhythm check and see whether or not they have a shockable rhythm if it's not a shockable rhythm again we want to assess whether or not we have rosk in our patient and if not immediately resume high quality cpr and so it's at this point here as well as i forgot to mention this at the last stop the last point at which we do cpr on the left branch it's at this point here where we want to assess and treat for any of our reversible causes of cardiac arrest and so again after these two minutes this is when we are going to loop back around do another check on whether or not the patient has a shockable rhythm and whether or not they have achieved risk now like i said at this point if they do have a shockable rhythm then at this point this is when we want to move back over to the left branch and so you can kind of see depending on what's going on with your patient that you can go back and forth between these branches and treat them appropriately and then again just like with the left side really for either of these sides we're going to continue in that loop until we either achieve risk or the code is called and the patient is declared deceased and so that is essentially our cardiac arrest algorithm we have two branches the left and right branch which is really dependent on that initial assessment after we've begun cpr on whether or not the patient has a shockable rhythm if they do they've got v fiber v-tach so we're going to move to the left branch over here we're going to immediately deliver that shock go into our cpr and begin working the algorithm on the left side if at any point we do a rhythm check and they do not have a shockable rhythm and they have not achieved rosk then we're going to move over to the right hand side this means that they're in either pea or asystole at this point we're going to immediately begin our high quality cpr and we're going to begin looping through here still doing rhythm checks to see whether or not rosk has has happened for our patients or whether or not we need to move back into the left branch and so again the whole point of this algorithm is to really try to simplify the approach and give us the steps that we need to go through in order to make sure that we're doing the best possible things that we can to try and achieve risk for our patients so what i actually want to do real quick at this point something that i really haven't done before is i want to go through a quick little scenario with you guys and so basically we're just going to go through and kind of talk through a situation that you could potentially come across and then help you to try and work through this algorithm and really kind of cement this knowledge and so here in our scenario you come in you find your patient unconscious in accordance with the systematic approach you're going to check their responsiveness and then immediately assess their circulation and their breathing it's at this point that you determine that they're not breathing and they don't have a pulse so you call for help and you immediately begin your bls assessment beginning with cpr now a code cart comes in quickly we get the pads on the patient and we assess the patient's rhythm and this is the rhythm that we see what is this rhythm this is going to be what do you want to do with this rhythm at this point you want to shock it and then as soon as you deliver that shock what is it that you want to do that's right immediately begin high quality cpr now at this point here while you're doing cpr what is it that you want to ensure that you have iv io access so now at this point we've gone through two minutes of cpr and then we see this on the monitor what rhythm is this that we see that's right this is v fib and what do you want to do with this rhythm deliver a shock and at this point anything else we want to do that's right immediately begin high quality cpr and then hopefully you remember to give one milligram of epinephrine iv push which we're going to repeat every three to five minutes and so now we've gone through another two minutes of cpr we do another rhythm check and we see this again what do we do now that's right hopefully recognize this as v fib again so we want to deliver another shock and is there anything else that we want to do at this point as soon as the shock is delivered immediately go into another round of high quality cpr and at this point is when we want to consider giving them the dose of amiodarone 300 milligrams iv push all right so let's continue on another two minutes of cpr passes we do another rhythm check and we see this rhythm here all right now what do you guys do well hopefully you think at this point that you want to do a pulse check and there's no pulse so what is this rhythm it's right it's not normal sinus rhythm because we don't have a pulse this is going to be our pulseless electrical activity or pea and so now what are you going to do well hopefully you have recognized that your patient does not have rosk and so we're actually going to move over into the right branch and immediately begin high quality cpr so again another two minutes goes by we do another rhythm check and we now see this rhythm here what rhythm is this this is a systole so what do you want to do at this point hopefully you recognize that we are not going to shock this so we're going to immediately go into another round of high quality cpr anything else you want to do at this point perhaps it's been three to five minutes perhaps we can give another dose of epinephrine as well as looking to treat the reversible causes of cardiac arrest all right so we're continuing through another two rounds of cpr has completed we do another rhythm check and once again we see this rhythm here what do you want to do at this point that's right do another pulse check aha at this point there's a pulse so what are we going to do now this is where we're going to move into the post cardiac arrest algorithm all right you guys i hope you guys enjoyed that algorithm i hope it helped to cement some of the information from the cardiac arrest algorithm here and hopefully we'll make it a little bit easier if you find yourself in a situation where you're having to use it use this more than likely working in the icu you're going to run into this algorithm a lot you're probably going to get comfortable with it but in the meantime make sure you are taking the time to go back and review the information from the aha after your certification so that you can always stay on top of this because again when this emergency situation happens time is going to be of the essence and the last thing you want to do is be fumbling through this trying to remember okay what's the next next step that i want to do here you really want to have this stuff cemented into your knowledge base all right so that's going to complete this lesson i really hope you guys enjoyed it if you did please leave me a like as well as a comment down below i love reading the comments and responding to you guys if you haven't subscribed already make sure you do so as well uh also a quick shout out to our awesome youtube and patreon members the support that you guys offer for this channel is truly appreciated and i really appreciate you guys for the rest of you guys if you'd be interested in showing support for this channel feel free to check out the youtube membership down below or head over to the patreon page and check out some of the extra perks that you get for doing just that you can also support this channel by sharing this video with other people that might find it useful as well as following some of the links down in the lesson description and checking out some of the merch down there as well make sure you guys stay tuned for the next lesson in this series otherwise in the meantime check out a couple awesome lessons i'm going to link to right here as always thank you guys so much for watching have a great day