Transcript for:
ACLS Guidelines Overview

[Music] all right you guys welcome back to another video Lesson from ICU Advantage my name is Eddie Watson and my goal is to give you guys the confidence to succeed in the ICU by making these complex Critical Care subjects easy to understand all right you guys this lesson is the complete ACLS review series allinone video all six lessons from this series are here with the addition of the reversible causes of cardiac arrest that's added as well and don't forget that you can earn C credits for this series by becoming an ICU Advantage Academy member as well as you will also have access to the new notes that are available for this series too go to ICU advantage.com Academy to join and also if you don't want C credits but do want access to the original notes then you can always become a YouTube or patreon member and you'll have access to all the notes from this channel I hope you guys enjoy this complete ACLS review series now in this lesson here this is going to be the first lesson in a new series that I'm doing reviewing a very important Concept in the world of critical care our Advanced cardiac life support or ACLS now years of expertise of many practitioners around the world along with the American Heart Association have come together with guidelines algorithms and really best practices for us with the end goal of being improving patient outcomes in these life-threatening situations now over the course of this series I'm going to be reviewing over some of the major components of these guidelines and really best practices but remember that this series is absolutely no substitute for ACLS and BLS certification My Hope though is that these videos are going to be available to kind of help supplement your learning needs either before you go to class or during that 2-year period between your certification and so working in the ICU and really caring for critically ill patients it's going to be imperative that you understand these guidelines and really know them like the back of your hand when you find your patient deteriorating or even coding time is of the essence and being able to think and act quick is really going to have a direct effect on the outcome of your patient so I hope to be able to help to cement this knowledge for you guys and we're going to start off this series talking about the systematic approach of ACLS the whole goal with our training of ACLS is to be better practitioners of peer-reviewed guidelines and best practices with the hopes of decreasing mortality in our patients the American Heart Association the AHA has worked to provide a systematic approach to how we should really handle patients in these life-threatening situations our primary goal when our patients are in these situations are to really support their oxygenation ventilation and circulation all with the end goal of preserving neurological functioning for our patient when it's all said and done the whole process of a systematic approach really all begins with our initial impression and assessment of the situation so it's here where we're going to first take in the information about what's going on where is the patient how do they look what do we see on the monitor the most important part of this initial assessment is going to be the assessment of if our patient is either unconscious or not now in the ICU often times you're going to be caring for ventilated and sedated patients and the assessment is really not going to give us any useful information and so we're going to have to take in more information at that point to make a determination about what is going on now whether our patient is conscious or unconscious is really going to determine at what point in the systematic approach that we enter in order to really do this assessment you need to make sure and tap your patient and Shout at them are you all right now if they appear unconscious then first and foremost call for help so it's at this point here where you're either going to activate your emergency response alert or your code and really start off with our basic life support assessment which I'm going to talk about now now our basic life support or our BLS is really going to be the foundation of any ACLS algorithm that we're working with this this is always going to be the first step in dealing with any emergency situation now in some cases we're able to bypass P this assessment because it's just not required but this is always going to be a part of the first assessment that we evaluate whether we need to intervene at this point and so with our BLS the very first thing that you want to do is to assess two different things together our patients breathing and their circulation now for your patients breathing this is where you want to assess either are they even breathing at all or do they have any kind of abnormal breathing now remember though that agonal breathing is not normal breathing and can really be present in the first few moments following cardiac arrest in your patient and our agonal breathing is really a reflexive response characterized in our patients by labored gasps that they're taking and really strange vocalizations it's pretty obvious when you see it and you hear it and it screams not normal now for a patient's circulation it's really important that you check a cored pulse it's the easiest to access and it's less prone to error when compared to checking like a femoral pulse if you're ever in doubt about whether your patient has a pulse then treat it as if they don't now what's really important here is that we actually want to be checking both of these the breathing and the circulation together and the whole point of this is to minimize the delay in detecting cardiac arrest in your patient and starting CPR this initial step should take no more than 5 to 10 seconds now if your patient has a pulse then we need to immediately move into support their breathing so at this point you want to grab your bag valve mask your amboo bag and you want to begin giving them rescue breaths remember this is going to be one breath every 5 to 6 seconds make sure that you're maintaining a good seal and that you're seeing that rise in Fall of the patient's chest also don't over ventilate the patient so either going too fast or too much with each breath and while you're doing this you want to make sure that we're continuing to check for a pulse at least every 2 minutes now if things at this point have deteriorated or when you do that initial assessment that your patient has no pulse then immediately begin chest compressions now here make sure that you guys are maintaining the adequate rate the depth of the compressions and full recoil of the compressions for the right here we're talking 100 to 120 compressions per minute a couple songs that fall within this range which sometimes can kind of help to keep you in line would be something like staying [Music] alive or even baby shark if you want to have that song stuck in your head babyk now when it comes to compressing the chest that you want to make sure that you're going at least 2 in now more often than not chest compressions are going to be too shallow than they are too deep but studies do also show us that going too deep on compressions can impact our patients mortality as well so it's really important that we're we're sort of hitting that sweet spot now when it comes to our recoil we want to allow the full recoil of the chest between each compression the whole point of this is this is going to allow for the full filling of the heart between the next compression this is really important and so to really kind of Aid in ensuring that we're having adequate compressions if you guys have a compression feedback device make sure you guys use it it's very easy especially as the code goes on and exhaustion sets in that we can start to see decreased effectiveness of compressions now it's also important though that you remember as soon as you stop chest compressions that perfusion to both the heart and the head are going to immediately stop and then it takes about five compressions to really get that perfusion pressure back high enough to be effective for our patient so what this means is that you want to minimize any interruptions and then really keep them as short as possible possible when you do and ideally keeping this less than 10 seconds now as soon as the AED or probably in the case of the hospital setting the defibrillator arrives you want to get the pads on your patient and then assess for a shockable rhythm immediately and so the reason for this is that early defibrillation and cardiac arrest is really key and we really want to see this happen within the first 3 or 4 minutes from the time of arrest and so in order to help achieve that it's going to be really important that you guys are comfortable with with this equipment and you're able to quickly apply the pads assess the Rhythm and deliver the shock as quickly as you possibly can and so back to our earlier Point here that you want to try to minimize any disruption in chest compressions in order to apply the pads but as soon as you're able you want to assess the Rhythm and deliver a shock immediately you don't want to wait for 2 minutes of chest compressions to end now this may require stopping compressions in order to analyze the Rhythm and then obviously when we deliver the shock but in some situations and with some defibrillators that they do have algorithms that will allow you to continue to do compressions while actually being able to assess the underlying Rhythm and then charge it up and get everything ready to go and then from here you're just going to continue to follow your BLS training and guidelines but if your initial assessment finds your patient either conscious or you've already performed your BLS assessment then what we next want to move to is the primary assessment to our systematically assess our situation and are conscious patients that they may still require some Advanced assessment and actions without the use of the BLS The Hope in these situations is to try and prevent the further deterioration and then eventual arrest of your patient now the systematic approach for the primary assessment involves a series of Assessments and then actions us using the ABCDE e model all right so here a stands for our Airway B is for our breathing C is for our circulation D is for our disability and then e is for our exposure so to begin we want to maintain the airway of our patient and this is going to be using something like the head tilt chin lift uh as well as using a device like a naso farang or Oro faral Airway to help keep that air Way open now here you guys remember please don't use an Oro faral Airway if your patients are awake in addition to this we do want to utilize an advanced Airway if it's needed so in almost all inpatient settings this is going to mean intubation now if our bag valve Mass though is sufficiently working then we're often going to be delaying intubation until the patient hasn't responded to our initial efforts with CPR now once we do have them in though it's going to be really important that you are confirming placement of the airway both by verifying that you have equal chest rise and that you're are osculating bilateral lung sounds in addition to that you want to be using entitle CO2 also referred to as our waveform capnography and this is going to be used both to verify placement and for continued assessment moving forward and then finally make sure you have the endot trial tube secure to your patient so when it comes to our patient's breathing that we want to be utilizing the bag valve mask to ensure that we're providing them supplemental oxygen supporting their ventilation while not excessively ventilating the patient now if you're in a code situation use 100% F2 through the BVM otherwise you want to be adjusting the F2 to maintain at least SATs a 94% and so if you guys don't have it already this is where we want to be using our entitled CO2 and our pulse oxymetry or spo2 in order to really be able to assess our patient breathing now moving on to our patient circulation this is where you're really going to want to ensure that you have the proper depth and rate of compressions and this is both through observed as well as watching our entitle CO2 where we want to have at least 10 to 20 mm of mercury but more likely closer or greater than 20 now first and foremost at this point is you want to assess whether you have ivio access and if it's not present or it's not fun functional then immediately get access trust me the last thing you want is to not have functional access when one of these situations happens now again if it's not already done then we want to have our ECG monitoring going on and we want to be keeping an eye out for any arrhythmias and then obviously defibrillate those as needed now we're going to give them any appropriate drugs and fluids that are needed as well as this is also the point where you want to check a glucose and a temperature and then really we want to be watching for if we have achieved Ros so this is the return of our spontaneous circulation and how do we know well check a pulse do you feel a pulse with the organized Rhythm on the ECG also if you have your entitle CO2 you're going to see an Abrupt rise in the CO2 generally greater than 40 or more so now that you've done all that at this point we want to be checking for disability in our patients and this means checking their neurological functioning so this is is going to include our basic assessment of responsiveness level of Consciousness and the patient's pupilary reflex and so when it comes to assessing their level of Consciousness uh it helps to remember appu Apu this is our alert voice painful and unresponsive and then finally the last part of this primary assessment is going to be our patient exposure and this really means that we want to uncover the patient from head to toe and visually inspect for if there's any obvious signs of any potential issues and this can be for things like trauma bleeding Burns any unusual marks or even looking for any alert bracelets now the key thing to remember with all of this that I just talked about in this primary assessment is that often times especially as you have more experience and you have more experienced teams that many of these assessments and their actions are going to be performed s simultaneously and not necessarily in a step step-by-step fashion now once this primary assessment is done then this is where we are going to move on to our secondary assessment now for a secondary assessment that this is going to consist of the evaluations of the potential causes of the emergency and then if possible an evaluation of a focused medical history for the patient for this focused medical history it really helps to remember the acronym sample and this is going to be the signs and symptoms any allergy G's any medications including the last dose uh past medical history last meal consumed and events being any events in the past or recently that led up to this now the goal here with this secondary assessment is going to be to diagnose and then treat the underlying cause now at this point here we want to try and focus on the reversible causes of cardiac arrest something that we refer to as our H's and T's and the H's and T's is really a list and it can be really useful in memorizing the most common causes of cardiac arrest and it can be useful in assessing and evaluating what has led to the current situation here if we're able to rapidly identify and then reverse the cause or the potential cause then we could potentially Aid in the recovery of spontaneous circulation achieving rasque as well as the prevention of future arrest following that all right so the systematic approach that we have laid out here from the initial impression that we get moving right into our BLS assessment into our primary assessment for ACS and then onto the secondary assessment that this approach is going to allow us to quickly evaluate the situation with our patient and then to act quickly and appropriately with the best possible actions to try and either prevent rest or to work to reverse the issue and see a return of spontaneous circulation this approach here is merely the framework on which all of the additional algorithms and guidelines sit on top of which in the future lessons in this series that I am going to be covering in detail so make sure you guys stay tuned for those are reversible causes of cardiac arrest what we commonly refer to as the H's and T's so looking at and evaluating these when your patient is coding is going to be something that's going to be absolutely vital to the success and outcome of the code and I can remember being new and trying to think through what these H's and T's were which of course in that high stress situation is really not going to go too well so hopefully with this lesson here that you guys will have a better understanding of these and be able to recall them quickly when you find yourself in one of these situations all right so to start off let's imagine that we are at work we're taking care of a pretty sick patient and the unthinkable happens so your patient is coding now you've called a code you've started compressions everybody's showed up to your room and you've been following the ACs algorithm but still you've got nothing back on this patient so it's at this point that we want to start thinking about what are possible causes could be now some causes just are not reversible and this unfortunately is not going to turn out well for your patient more than likely but some causes are reversible though and often times if we fix the under in problem then we can get our patient back and really prevent this from happening again and so because of this fact we need to make sure that we search for and treat any possible contributing factors and so that really leads us into talking about these reversible causes and so we have 11 main reversible causes that you're really going to want to dedicate the time and energy into memorizing these anytime your patient codes you should be going through this list of these possible contributing factors and really seeing if any of them exist in your patient and whether or not they can and should be treated really in order to try to get your patient back again so to Aid you in Remembering these they've been divided up into two groups what we call the H's and the t's and so the H's are going to be a group of six causes that all began with the letter H and those six causes are hypovolemia hyp oxia hydrogen ions hypo or hyper calmia hypoglycemia and hypothermia and now for the t's these are going to be things like toxins tanod tension pumo thorax thrombus and Trauma so like I said it's going to be really important that you guys memorize these here when you're in that high stress code situation you really want to have these burned into your memory so these are the 11 reversible causes listed out here what I'm going to do is I'm going to go through these one by one and talk about each one a little bit more in depth in terms of what we're looking for and how we're possibly going to treat these so the first one here that we're going to talk about is our hypovolemia and so hypovolemia this is where our patients have decreased volume in their vasculature which essentially means we have decreased tissue perfusion and so some of the causes that we want to consider when looking at hypovolemia are going to be things like poor intake or loss and this is going to be from things like vomiting diarrhea dehydration and even Burns we could also be looking at a relative hypovolemia with something like sepsis or even something as simple as blood loss now some of the things that we could see in our patient perhaps maybe not in the moment of the code but perhaps just prior that can help us really determine that this might be one of the causes that we're looking at would be things like if they had a rapid heart rate and hypotension just prior do they have have any obvious blood loss or do they have an elevated temperature all of things can be Clues to give us an indication of what was going on now when it comes to treating these patients first and foremost we want to quickly establish either IV or IO access and so from there we either need to give this patient fluid or if this is a blood loss that's going on then we need to replace it with blood products all right so next let's go ahead and talk about hypoxia and I think hypoxia is pretty self-explanatory and really the the top cause for this is some sort of respiratory failure although less commonly we can see things like Airway obstruction now obviously when we're talking about respiratory failure this can cover a lot of different things so you really got to kind of think about what's going on with your patient and whether this is some sort of failure within their ability to either ventilate or oxygenate themselves for these patients obviously we're going to be looking at what our spo2 is we're going to get an ABG and use that to evaluate our what our patients gases are uh you're also going to see cyanosis in these patients and finally to treat these patients we need to give them oxygen we need to ventilate them and then possibly intubate we essentially need to take over the patient's respiratory effort to ensure that they're getting the oxygen that they need make sure though after intubation that we're checking for equal chest rise uh as well as getting that entitle CO2 and really at this point here if the intubation and full vent support is not enough and we've determined that this is some sort of reversible issue that's going on with this patient then we could also look at some other modality like VV EO all right the next on our list here is going to be our hydrogen ions and really if we think about this if we have an accumulation of hydrogen ions this means we have acidosis so kind of a tricky play on our H's and T's but it makes it fit in nicely here now when we're talking about acidos in our patients and we're looking at these causes there's really two main camps that we're looking at the first one is going to be our respiratory failure and this is essentially where we're going to see that accumulation of CO2 in these patients or we could be looking at some sort of metabolic acidosis and this can be from a variety of different things such as sepsis some sort of ingestion or tox or diabetic ketoacidosis or alcoholic ketoacidosis and our primary assessment for these patients is going to be to get an ABG and assess whether this is a respiratory or metabolic problem now if this is a respiratory problem we're going to need to ventilate these patients in order to blow that CO2 off if this is a metabolic problem then obviously we want to address whatever the cause of the metabolic acidosis is but in these patients we want to consider giving them bicarb in order to correct that acidosis all right continuing on let's talk about our hypo or hyperia IA now when we're talking about hypokalemia typically we're talking about anything less than 3.5 although we really start to see EKG changes when we're less than 2.7 and for hyperemia here we're talking about patients who have a potassium that's greater than 5.5 now if we're dealing with a hypokalemia some of the causes that we want to look at are going to be things like vomiting diarrhea or excessive use of diuretics but in the case of hyperemia we want to consider things like renal failure look and see do they have a fistula or an HD line this can be a really good indication and you probably want to consider hyperemia here is this patient in dka the acidosis that they're experiencing in the keto acidosis is going to shift that potassium out of the cells and into the vasculature as well as we're going to have the hypoglycemia that's going to be pulling water out as well which is also going to cause that solvent drag both of these contributing and adding to an elevation in our patient's potassium we can also see things like trauma Burns uh if there's some sort of homolysis that's going on or even rabdomiolisis now some of the things that we want to assess for as possible indications of this in the case of our hypokalemia we could see things like either flat or inverted t- waves and then also possibly the presence of U waves in the case of hyperemia we're going to be looking for those Peak t- waves or wide qrs's and then obviously in order to really know what's going on with the patient with their potassium we really have to get those stat labs and this is where it's really good to have some sort of point of Care lab testing like an ice stat that way you can get your results immediately and know what's going on now in order to treat these patients to treat the patient with hypokalemia obviously we want to make sure and give them potassium replacement we want to do this pretty quickly but remember not too quickly in the case of hyperemia there's a couple different things that we're going to do first is we're going to give them calcium with the goal of protecting the cardiac muscle then we're going to give them the combination of insulin and D50 with the goal of driving that potassium back into the cells and we can also follow things up with either albuterol treatment or Lasix and Kate we also want to give them sodium bicarb here because if we bring that ph up we're also going to cause a shift of potassium into cells and then finally this patient may need dialysis all right next here let's go and quickly talk about hypoglycemia this one's pretty obvious this is where a patient has an extremely low blood sugar so one of the things that we should be doing all the time pretty quickly is getting that point of care glucose test and then from there to treat these patients we want to give them D50 quickly all right so finally let's talk about the last H that we have and this is going to be our hypothermia so here we really consider hypothermia with a temperature less than 35 but once their temperature drops below 30 then we're really going to see an impact on their cardiac output typically hypothermia is going to be the result of some sort of exposure event and so because of this this really isn't often going to be a cause that we're going to see in the ICU treatment for these patients is going to be either some sort of passive or active rewarming and this is going to be things like blankets Bear Hugger or Poss posibly warm fluids all right so that finishes up our H's so let's start talking about our T's and the first one of these is going to be our toxins now obviously there can be many different toxins that we could list out here um but just so you know some of the most common causes of toxins that can lead to Cardiac Arrest are going to be things like our calcium channel blockers our beta blockers dexin uh our tcas and cocaine our assessment for these patients is going to involve looking for EKG changes such as QT prolongation uh looking at their pupils and really looking at the history to try to figure out what's going on and our treatment for these patients is going to really involve supportive care and then if there's any sort of antidote available to give them that all right next is going to be our cardiac tamponade and in cardiac tanod here we have fluid usually blood has built up around the heart in the paracardial sac that's preventing filling and and ultimately decreasing our patients cardiac output some of the causes that we want to consider for this are going to be patients who are either postcardiac surgery or post cathlab aortic dissections uh some sort of trauma with penetrating wound and we can also see malignancies and pericarditis but this is really not common things to assess for these patients are going to be things like our beex Triad which is going to be jvd muffled heart tones hypotension and ultimately some sort of bedside ultrasound or Echo is going to really be diagnostic for this treatment when we find our patients in this situation is very simple we need to get the blood out and we can do this through either a paric cardio centesis or thorocotomy through a new opening or re-exploring a sternotomy they may already have all right the next tea that we're going to talk about is something called tension pneumothorax and in attention numo here we have air that has accumulated in the patient's plural space which if it builds up to the point of tension that this can place pressure on the heart and the large vessels which is ultimately going to decrease preload and ultimately lead to a decrease in cardiac output for our patient causes for this can again be something like trauma it can be some sort of iatrogenic cause so think about did we just place a central line in this patient uh is as well as it can be related to Patient being on the vent and then some sort of barrot trauma that leads to air getting in there now when assessing these patients were going to be looking for things like jvd was there difficulty ventilating this patient do they have tracheal deviation uh uneven breath sounds and if you can or looking at a past x-ray may be beneficial as well once you discover this in your patient the treatment is pretty simple needle decompression and then place a chest tube all right the next tea that we're going to talk about is going to be our thrombus and this one we actually break up into two parts here one is going to be looking at our coronary thrombus or what we refer to as an MI and the other is going to be our pulmonary thrombus or what we call PE so in the case of our coronary thrombus here we have some sort of block profusion of cardiac muscle and that's ultimately going to lead to hypoxic injury and cell death here the patient might have been exhibiting substernal chest pain or those other classic Ami symptoms uh as well as we might also see St changes on the EKG so treatment for these patients is going to be get them to the cath lab ASAP if you have that available in order to revascularize them if not then we want to consider possible thrombolytics and finally a cabbage if necessary now looking at our pulmonary thrombus if they end up with a large PE like a saddle PE that that this can really restrict the output of the right ventricle these patients before could have been short of breath uh hypoxic and tartic just prior to this there's a few different treatment options that are available for these Patients First is going to be the possibility of an embolectomy we also might consider using fiber analytics and ultimately if you have the capability you might also be considering something like VA ECMO all right and then finally the last of these h& T's the last T that we're going to talk about here real quickly is going to be trauma and this there's really not much to say because in the ICU this typically isn't going to be the primary cause of our patients's Cardiac Arrest uh anything that could be a cause here is something that's going to be pretty obvious from primary and secondary surveys typically down in the Ed or trauma Bay so again not something that we really going to be considering in the ICU all right so that was all 11 of the h& t's hopefully those make sense for you guys in terms of what they are uh what we're looking for what some of those causes can be uh and how we're possibly going to treat this for our patient to reverse that cause of this Cardiac Arrest like I said dedicate that time and energy into memorizing these so that you can just spit them out off the top of your head in the middle of a stressful situation but one last way I have to kind of help you guys to remember these is if we really think about this in groups what we're looking at and what sort of information we're looking to get so just real quickly here if you think if you take a look at the monitor what is it that you're looking at in the monitor that can be an indication for you here we want to be looking at our blood pressure is this hypovolemia we want to be looking at our oxygen saturation as this hypoxia and make sure you're taking a look at your temperature to see if this is hypothermia next think about Labs that we want to check again we want to be checking an ABG to see if there's acidosis going on with these patients we want to be checking for pottassium see if they're hypo or hyper and then also we want to be checking a glucose to see if they're hypoglycemic next if we think about our two main organ systems our heart and our lungs for our heart we want to be considering things like are they having an MI with that thrombus or is there some sort of tanod when looking at the lungs this is where we're considering things like hypoxia or possibly tension pneumothorax and then finally if we just take a look at the whole body here we're considering things like trauma and toxins so hopefully that helps you guys out and gives you a different way of looking at this uh to give you another way to be able to make sure that you guys remember what are those reversible causes because again in that high pressure high stress situation of your patient coding the last thing you want to be thinking about is putting forth mental energy trying to remember and recall these all right 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 arhythmia as a result it's going to be essential that you're able to properly identify these Rhythms on ECG so depending on which arhythmia 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 tacac cardia or vac ventricular fibrillation or viib pulseless electrical activity or Pea or in ay 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 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 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 viib and pulseless vtac 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 arhythmia that they were in now as far as the energy the jewels required for this shock um I know it really depends on whether we're using monophasic or basic but I 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 jewles 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 2 minutes of chest compressions so it's at this point where if you don't already have it that you need to get IV iio access now after the 2 minutes go by that this is when we're going to 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 jewels on the defibrillator until we eventually reach the max Jewels now 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 Ros 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 Ros then this is actually when we're going to move into the postcardiac arrest algorithm which is going to be a future lesson so going back to the left Branch here uh we did the second r 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 2 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 iio 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 1 mg IV push and we're going to want to make sure we follow 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 ivio 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 3 to 5 minutes until either the code is called or we have Ros 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 that entitles CO2 at this point now after the 2 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 shockable we're going to move back to assessing whether we have Ros in our patient but then again if the rhythm is shockable still we want to deliver shock here and again make sure you guys are continuing to increase those Jewels 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 highquality CPR for another 2 minutes so it's at this point if they've remained in this shockable Rhythm that we want to give them some sort of anti-ar rhythmic 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 Amo a second dose of Amo can be given later on and this time for the second dose we would give them 150 milligrams and so as a quick aside the the question often comes up especially with am odone and even sometimes with our Epi is how fast we want to give this and sort of the Ry response to this is really the patient's not getting any dead 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 anti-ar rhythmic will work to help to get them out of this lethal arhythmia and so after the 2 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 Ros 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 asy so in just the same way that we're treating both viib and pulseless vtac the same way pea and asy 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 highquality CPR and a really important point for you guys to remember here is that we do not Shock pea and asy 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 viib and 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 access then we want to give that dose of epinephrine and again the dose is the same here 1 MGR IV push every 3 to 5 minutes and then we also want to consider that advanced Airway and our entitle CO2 monitoring so now as soon as the 2 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 Ros in our patient and if not immediately resume highquality CPR and so it's at this point here uh as well as I forgot to mention this at the last stop the last point in which we do CPR in 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 Ros 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 we're going to continue in that Loop until we either achieve Ros 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 vtac 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 work 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 are in either Pea or asy at this point we're going to immediately begin our highquality CPR and we're going to begin looping through here still doing Rhythm checks to see whether or not rasque 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 rasque 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 algorith 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 vac 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 highquality CPR now at this point here while you're doing CPR what is it that you want to ensure that you have IV iio access so now at this point we've gone through 2 minutes of CPR and then we see this on the monitor what rhythm is this that we see that's right this is VI 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 highquality CPR and then hopefully you remember to give 1 mgram of epinephrine IV push which we're going to repeat every 3 to 5 minutes and so now we've gone through another 2 minutes of CPR we do do another rhythm check and we see this again what do we do now that's right hopefully you recognize this is 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 highquality CPR and at this point is when we want to consider giving them the dose of am odone 300 mg IV push all right so let's continue on another 2 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 rasque and so we're actually going to move over into the right branch and immediately begin highquality CPR so again another 2 minutes goes by we do another rhythm check and we now see this Rhythm here what rhythm is this this is a syy 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 highquality CPR anything else you want to do at this point perhaps it's been 3 to 5 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 postcardiac 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 will make it a little bit easier if you find yourself in a situation where you're having to you 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 this next step that I want to do here you really want to have this stuff cemented into your knowledge base so in this lesson here we are going to continue our review of the American Heart Association ACLS algorithms and this time we are specifically going to be talking about the bra a cardia algorithm very important distin iction here is that this is going to be braid a cardia with a pulse if it's a Brady Rhythm and you have no pulse then you're going to follow the cardiac rest algorithm which we just discussed in the last lesson now while bra cardia basically is going to be any heart rhythm with a rate that's less than 60 beats per minute what we're most concerned with with this algorithm are going to be our symptomatic braic cartic patients and these patients are typically going to have a heart rate that's less than 50 beats per minute and they're going to elicit specific symptoms in our patient so we're looking specifically for a slow rhythm with specific symptoms that we would associate with that slow Rhythm so once again if we have this present in our patient we have a systematic approach to handling this situation which is what we're going to talk about in this lesson here all right so when we're talking about symptomatic braic cardia what we're really talking about is a Brady rhythm in our patient that is not providing adequate perfusion thus this is producing the symptoms that's associated with it now if our patient has adequate profusion then we want to just monitor them for any signs of change and then the development of any of these symptoms which would then lead us into this algorithm now the very first thing we need to do is to really assess the necessity and the appropriateness of using this algorithm and so essentially what this means here is we're assessing whether or not our patient is bradaric so typically less than 50 beats per minute and do they have Associated symptoms with it now some of the typical rhythms that we're going to see associated with symptomatic braidic cardia are going to be things like sinus bradicardia first degree AV block second degree AV block this includes both our mobitz type 1 or winky block and our moits type two our third degree AV block also known as our complete heart block and our junctional and ventricular rhythms so again it's imperative that you guys are able to assess these and pick these up on a monitor for your patient now once we've established that it's appropriate to be using this algorithm then we want to progress in but keep in mind that it's always going to be our priority that we are looking to identify and treat the underlying causes of the braic cardia now keeping that priority in mind there are a few things that this point we need to make sure that we're doing for our patient so you got to make sure that their Airway is painton and you want to be assessing breathing you're going to want to provide oxygen if they're hypoxic make sure you're monitoring ECG blood pressure and your oxygen saturation really important here make sure you have good IV access and then if you have the time and you're able to you want to get a 12 lead ECG but again don't delay therapy in order to obtain this now from here moving along in the algorithm we want to actually assess our patient's persistent braidic cardia and then what if if any impact that this is having on our patients perfusion now this is often going to be what is referred to as whether or not they are quote unquote unstable and so signs of this are really going to be braic cardia that's causing the following hypotension so is your map less than 60 or your systolic blood pressure less than 90 and altered level of Consciousness and this is really that decreasing mentation that's really resulting from decreased perfusion to the Head signs of shock so these are cool clammy skin pale skin cyanosis uh rapid breathing weakness and fatigue nausea vomiting is a patient having any medication called atropine and our dose here is going to be 1 mg IV push now the dose used to be 0.5 Mig but this was actually updated in 2020 by the aha so the new recommendation is 1 mgram this dose can be repeated every 3 to 5 minutes for a maximum dose of 3 Mig which in this case is going to be three doses now now it is important to know though that the way atropine works is by increasing activation of both the sa and the AV nodes now if your patient is in a thir Dee heart block that this medication is going to be useless it's also going to be less effective with some of our second degree blocks as well now atropine can also have negative effects if the braic cardia is the result of an acute MI and the reason for this is that atropine is going to increase the heart rate which is going to increase the workload on the heart and thus increasing myocardial oxygen consumption not a good thing with your patients having an MI now all that said if atropine is either ineffective or it's not indicated in your patient then we need to move on and either electrically or chemically Pace them at this point now here when I'm talking about electrically pacing what I'm talking about is our transcutaneous pacing and here we're going to deliver electrical energy via pads on the patient's chest with the goal of stimulating the heart to contract now the transcutaneous pacent is actually going to be the preferred treatment for patients with the acute MI as well as potentially for patients who are very unstable that said in the time it takes to get the defibrillator ready and to pce a patient a dose of atropine can often be given in that same time now please do remember though that this is often painful for the patient and so you're going to want to have analgesic and sedation available if the patient is going to be able to tolerate it but often times they may not be able to initially so you may need to actually start the pacing then administer those now our other option to electrically pacing a patient is to chemically Pace them and this is going to be use of either of the following medications really to help increase our patients heart rate while also supporting their blood pressure and from the AHA this is considered an equally effective alternative to transcutaneously pacing now we have two medication options to choose from the first one is going to be dopamine and then the other one is going to be epinephrine now the dopamine is going to be our first line of choice if the atropine is ineffective now also updated in 2020 is going to be the dose of dopamine is now recommended to be 5 to 20 microgr per kilogram per minute and then we want to titrate it to our patient's response and then taper the medication slowly now important to remember these new changes because the old recommendation used to be 2 to 20 microgr per kilog per minute but this is the new recommendation updated in 20120 again by the American Heart Association now the other medication here that can be used as an alternative to the dopamine is going to be our epinephrine here our dose is going to be 2 to 10 microgram per minute and again titrating to the patient's response and tapering slowly and then finally from here we want to consider the expert consultation from a cardiologist and if our patient is really persistent in this Bic cardia and requiring additional doses of atropine or continuous pacing or continuous medication for their heart rate then at this point we might want to consider something like a transv minus Pacer instead and possibly preparing for a trip to cathlab so as you can see the algorithm here for bra cardia is actually pretty simple and the biggest thing is whether or not the braic cardia is causing decreased profusion for our patients and if so then we need to act with either medication starting with atropine uh as well as progressing to dopamine and epinephrine if needed or using electricity and transcutaneously pacing them now important aside here many many people are really not comfortable with pacing via the defibrilator so I highly suggest that you take the time and learn how to quickly get into the mode of pacing and to make adjustments to the settings so that you're not fumbling around with this when the time comes and you actually have to do this on your unstable patient otherwise though that was our review here for the braic cardia algorithm I really hope that you guys like it I I really hope that this lesson help to uh solidify the information and cement the knowledge of this algorithm again it's really important that you guys are able to quickly act on this and quickly move through the algorithm especially when your patient is unstable all right so in this lesson we move on to tackle the next American Heart Association ACLS algorithm that we're going to talk about the tacac cardia algorithm now just as with our bra cardia arrhythmias our tacki arhythmia can also lead our patients into a state in which they have decreased perfusion which if left unchecked can continue to deteriorate into cardiac AR rest once again thanks to the the work and the recommendations of the AHA we have a simplified approach to managing patients in this emergency situation this can help to allow us to ensure timely and proper treatment for our patients and so we'll discuss this Tac cardia algorithm now all right so Tac cardia is a rapid heart rate which is greater than 100 beats per minute from there the faster that a patient's heart rate gets the less time that they're going to have for fill between each beat which can decrease our patients preload and then ultimately reduce their cardiac output this reduction in cardiac output can lead to decreased profusion and can lead to unstable tacac cardia now just like with the other algorithms it's going to be important for you to be able to identify the potential rhythms associated with unstable tacac cardia and those rhythms are sinus tacac cardia atrial fibrillation or aphid atrial flutter or a flutter re-entry super ventricular tacac cardia or SVT monomorphic vtac polymorphic vtac and wide complex tacac cardia but when beginning this algorithm the very first thing we need to ask is if our patient symptoms are being caused by the tacac cardia and if so then we need to treat the TAC cardia and so we need to assess the necessity and the appropriateness for treating their tacac cardia now typically we're going to see this when our patient's heart rate is greater than 150 now from here our priority should be to assess for and really treat any underlying causes while we're also maintaining the patients Airway and assisting their breathing if necessary providing oxygen to them if they are hypoxic and then monitoring their ECG blood pressure and P oximetry from there if the patient's tachicardia is persisting then we need to ask if it's causing symptoms of decreased profusion if it is then we need to act those signs and symptoms are going to include things like chest pain signs of shock difficulty breathing altered level of Consciousness weakness fatigue Syncopy and acute heart failure and so if we are seeing any of these signs and symptoms in our patient then the primary response to unstable tacac cardia should be synchronized cardiov version so this is going to be very similar to defibrillation except depending on the Rhythm that they have that this may use lower energy and then more importantly we're going to be synchronizing to the patient's Qs complex the purpose of this is to not land the shock on the patient's t-wave which can lead to lethal arrhythmias but also remember too that we do want to consider sedation if our patient are able to tolerate it unfortunately often times at least initially that if they're unstable that they're not going to have an adequate blood pressure to really support adding a sedative so please do keep this in mind that this is quite painful for the patient that said if the patient does have a narrow and regular QRS complex think SVT here then we can consider giving a medication called adenosine our dose for this is going to be 6 mg WRA IV push and we can give two subsequent doses of 12 mg so it's really important that you guys get this medication in very quickly so often times we'll set up a three-way stopcock where we can give the medication and immediately follow it up with a 10 mL flush so now if we've done that assessment and our patient is not unstable then we actually want to assess whether they have a wide or narrow QRS determined by if the QRS comp FX is greater than12 seconds now if they do have a wide QRS then there's a couple things that we want to do first we want to ensure that we have IV access and then we want to get a 12 lead ECG now in this situation we can consider using a Denine again if it's regular and monomorphic we also want to consider the use of some sort of anti-ar rythmic medication this is going to be things like amiodarone propanamide sodol and then if our patient is in polymorphic vtac then we also want to consider the use of 1 to 2 G of magnesium at this point we do want to consider that expert consultation with a cardiologist now if their QRS is narrow then we do want to consider uh again ensuring that we have IV access and getting that 12 Le dcg in these cases we can consider having the patient try vagel Maneuvers these are going to be things like asking them to Bear down like they're having to have a movement uh you can try having them blow real hard through a small straw uh as well as if you are properly trained you can also do the external cored massage now like I said if they have a regular rhythm and it's narrow then we can consider the use of adenosine but do also keep in mind though that sinus tacac cardia is often a normal physiological response so think our compensation mechanism for something else that's going on with the patient and these can be things like fever hypovolemia shock Etc now again for the narrow Qs things like beta blockers and calcium channel blockers may also be helpful and then again we want to consider that expert consultation of a cardiologist so remember here that our assessment and management of our patient with Tac cardia is really going to revolve around a few key questions are symptoms present or not are they stable or unstable is the cure narrow or wide is the Rhythm regular or irregular is the QRS monomorphic or polymorphic and then really based on the answers to these questions that this can guide us to the next appropriate steps in helping our patients all right and that completes our review of the recommendations from the AHA when it comes to tacac cardia and the ACLS algorithm for that now in this particular lesson here we're going to be taking a look at what is now the fifth Link in the American Heart association's chain of survival now while the actions and algorithms really proceeding this here certainly have greater impact the significance should not be downplayed of really having a systematic approach to handling the care of our patient after the cardiac arrest so in this lesson we're going to take a look at just that with a discussion around the aha's recommendations for postcardiac arrest care all right so while most most of our ACLS algorithms up to this point are focused on saving a person's life or preventing deterioration to really needing to do just that these guidelines are focused on continued Improvement in morbidity and mortality and even more importantly quality of life for our patient and the studies give us numbers in fact most deaths occur up to 24 hours post cardiac arrest and thus the impact of having this systematic approach can really truly be profound and we really do this by focusing on care that's centered around optimizing tissue perfusion of vital and organs so the approach to improving mortality and quality of life for a patients truly involves a multi-disciplinary approach and in reality will continue on through some time with their care but this is going to be something focused on the interventions and actions that are recommended immediately following Ros from Cardiac Arrest now this algorithm is designed to outline the steps that we should immediately be assessing and managing and to start off there are two big areas of focus now those areas are optimizing the ventilation and oxygenation for our patients and then treating their hypotension so first and foremost we need to ensure that our patient has a good Airway and that we are supporting their breathing now most of the time these patients are going to be either unconscious or unresponsive and if it hasn't already been done at this point then we're most likely going to need to use an advanced Airway to allow for mechanical support we do also want to be using waveform capnography again if that's not already in place because monitoring our patients entitle CO2 plays an important role in ensuring not only adequate CPR is taking place determining when Ros has occurred as well as also monitoring for proper et2 placement as well as in the aid of our management of this patient now during the actual rest we're typically using 100% F2 but once that's over we do want to titrate the oxygen requirements to maintain a SAT of 94% or higher if they are maintaining good SATs it is okay to decrease the oxygen that we are providing to them now in addition to oxygenation we also need to be thinking about ventilation and the key here is to avoid overv ventilating or hyperventilation in our patient so our Focus here is on not ventilating them too much or too fast our goal here is to achieve an entitle CO2 of about 35 to 40 now we do also run the risk of increasing inter thoracic pressure if we ventilate them too much which then can have negative effects on our patients hemodynamics also another thing to consider is that CO2 is a potent vasod dilator and so if we're hyperventilating them we're going to be blowing off tooo much that CO2 and thus the reduced levels can potentially decrease cerebral blood flow which is going to be something really important for a patient's postcardiac arrest now do remember and keep in mind though that individual situations with individual patients could warrant either permissive hyper or permissive hypocapnea so in addition to what we just talked about we do want to be treating our patients hypotension when their systolic blood pressure is less than 90 or their map is less than 65 now hopefully you already have it but if not make sure that you get IV iio access immediately and even if you do have it it's going to be really important to make sure that they're actually patent and functional now once you have good IV iio access then we're going to want to treat our patients hypotension first with fluids and then with the use of vasopressors so we're going to start off with one to two lers of either normal saline or LR now from there if pressors are needed then we want to consider one of the following three as a continuous infusion and that would either be our norepinephrine our epinephrine or dopamine now we do want to be titrating these medications to achieve a systolic blood pressure greater than 90 or a map greater than 65 and there's no need to overdo it here so if their systolic blood pressure is 91 or their map is 65 that that may be fine again kind of dependent on what your patient's individual situation is now it is important to note that immediately following Ros that we want to ensure that we're identifying and treating the underlying causes of the arrest if they are still present for the patient so here again remember your H's and T's from the systematic approach that we talked about in an earlier lesson now as soon as possible we want to get a 12 lead ECG and the purpose here is that we want to assess our patient for a stemi or those highly suspected of acute MI now if this is the case then we're going to want to have rapid activation of cath lab for coronary reperfusion now immediately following that or if our ECG is not suspicious for an MI then the next is a simple step and it's really the assessment of our patient ability to follow verbal commands at this point if they're not following commands then we want to consider initiating the targeted temperature management or hypothermia protocol this is actually a complex subject and one that's highly requested here on this channel and so soon I will be doing a detailed lesson looking at just this but it is important to know that targeted temperature management is really the only therapy that's been shown to improve the neurological functioning in patients postcardiac arrest now finally from here if they're not already there truly the the best place for Continued Care immediately following the cardiac arrest is going to be in the ICU the patient should be transferred there for ongoing management and closer observation by the teams of people that specialize in just that and that was our review of the postcardiac arrest algorithm now in this lesson here I am going to do a quick flyby on two different additional algorithms that the American Heart Association has recommendations for knowing these along with all the other aha recommendations and algorithms will really help to round out your systematic approaches to common medical emergencies that you're going to encounter working in the ICU so let's begin by talking about ACS and stroke algorithms so this will be a pretty quick review of these two algorithms while certainly important in their own right a lot of the algorithm is based around prehospital initiation now much of this information is applicable to the inpatient setting and certainly is applied within the hospital environment now the first one that we're going to talk about is our acute coronary syndrome or our ACS algorithm so the first step in this algorithm is the recognition of someone exhibiting signs and symptoms that might suggest that they are having an MI now these signs and symptoms are going to include things like chest pressure fullness squeezing or pain that really last for several minutes chest discomfort that spreads to the shoulders neck arm or jaw discomfort that spreads to the back or between their shoulder blades if they have discomfort with either dizziness light-headedness nausea vomit sweating or fainting or sudden shortness of breath with or without chest discomfort now on the ACs algorithm The Next Step that they move into is really related to EMS and prehospital setting so please refer to the ha guidelines which I am going to link down in the lesson description uh but everything in there is actually included in the next step that I'm going to talk about here now next are the steps for Ed assessment and management or in the case of inpatient what we would be doing for our patient so to start off there are three things that need to be done immediately we need to get a 12 lead ECG we need to obtain a set of vitals and really be prepared for CPR and defibrillation if needed and so this means get your code cart have it ready uh probably also isn't going to hurt to throw some pads on your patient now based on our vitals if our O2 sats are less than 90 then we do want to start oxygen at 4 L and then titrate that as necessary and then the third thing is that we want to give them the following medications aspirin 160 to 325 mg nitroglycerin sublingual and morphine IV if their chest pain is not relieved by the Nitro now next are the things that you want to be doing concurrently so they can come after the first three but we really should have these done within the first 10 minutes and these are going to be things like ensuring that you have a good working IV access you want to attempt to perform a quick history and assess we do also want to review over the checklist for giving fibr anotic and checking for any contraindications that the patient might have then we want to get blood for lab samples and these are going to be checking our cardiac markers electrolytes and coags and then finally we want to get a stat chest x-ray now this most likely is not going to happen within those 10 minutes so they do recommend that this is completed within 30 now from here the algorithm branches and gets a little complicated based on the read of the ECG and what is happening at various points but the first branch that I'm going to talk about is going to be when our patient has St elevation or a new left bundle branch block and this is going to be our stemi now in this case here you're going to want to immediately start a junctive therapy such as Hein nitroglycerin and beta blockers and then from here we need reperfusion therapy stat and so this is probably going to mean cath lab in most facilities but could be fibrinolytic therapy as well now we ask the question if they've had symptoms less than 12 hours this is most likely going to be the case for our patients in the hospital uh if so then for our reperfusion therapy we have a couple of goals if they're going to Cath Lab we expect to have the time to a balloon in cath lab within 90 minutes or if we're giving them the fibbr anotic therapy then our goal is to give that within 30 minutes now if it has been more than 12 hours then we actually are going to move into the first step of the ST depression branch which I'm going to talk about now this ST depression Branch this is going to be our non-stemi now in this Branch if our patients troponin are elevated or we do consider them to be highrisk and they have any of the following conditions uh these would be things like continued chest discomfort uh either continued or recurrent ST depression unstable hemodynamics or signs of heart heart failure if so we do want to consider early invasive strategies then from here we do want to start the adjunctive therapy and these are going to be things like nitroglycerin Hein Etc so now let's move on and talk about the third branch which is going to be if they have a normal ST segment now the AHA algorithm addresses the emergency department presentation and at this point they would consider possible admission now given that our patients already admitted we do want to continue to monitor them and really be prepared for further intervention if needed now if either St elevation or ST depression were to develop at this point then we do want to move into those respective branches and that is essentially our ACS so now let's move on and talk about our acute stroke algorithm now once again just like with the ACs the first step here is going to be in the identification of the signs and symptoms that somebody is possibly having a strok now these signs may be subtle so remember our acronym fast f is for face and this is going to be facial droop weakness or numbness A is for arm and again we're talking weakness or numbness s is for speech and this is going to be sudden confusion slurred or difficult speech or if they're having difficulty understanding and then the t is our time to act so if your facility has a stroke alert now is the the time to call it now other signs of a possible acute stroke could be things like trouble seeeing in either one or both of their eyes trouble walking dizziness or loss of balance and coordination or sudden severe headache with no known cause now again the next step is important EMS and prehospital interventions which for the purpose of this algorithm uh in the hospital will be included in our next step here and so for us the next step is going going to involve our assessment and stabilization of the patient and all of this really should occur within 10 minutes we're going to want to assess and support their ABCs and vitals if they're hypoxic give them oxygen again ensure that you have good working IV access and you do want to draw Labs here we're looking for our CBC coags and checking glucose and do treat that glucose if needed we also want to do a quick neurological assessment order an emergency te scan and get a 12 lead ECG now from here we want to have an immediate neurological assessment by the stroke team and we want to have this done within 25 minutes at this point we're going to be reviewing the patient's history uh establishing a time of onset of symptoms or really the last known time of them being normal this is really going to be key as we get a little bit further along in the algorithm and then we also want to perform the NIH Stroke Scale this is also going to be something that I am going to cover in a a future video so now it's off to CT and we want to have the results of this CT read no later than 45 minutes from the start of all of this now here we're primarily looking to see if there is hemorrhage as this is going to determine what our next step is if the patient does have a hemorrhagic stroke uh a neurologist or a neurosurgeon will be consulted uh and we do want to consider transferring them to a different facility if that's not available now at this point here you'll be begin the stroke or hemorrhagic pathway and then admit them to either a stroke unit or the ICU if they're not already there and all of this should happen within the first 60 minutes now if there is no Hemorrhage then we want to consider the use of a fibrinolytic therapy at this point so we want to evaluate for any contraindications and at this point really assess the patient's neuro status and see if their symptoms are rapidly improving from there we want to ask if they are a candidate for TPA if not then we're going to want to give them aspirin and then move to the final step of the hemorrhagic Branch if yes then we're going to want to rapidly review the risk and benefits with either the patient Andor the family and if they accept then we're going to give them the TPA within 60 minutes from the start of everything now during this time we're not going to give them any anti-coagulants or antiplatelets for at least 24 hours and then from here we're going to begin the TPA stroke pathway and it's going to be really important that we're aggressively monitoring their blood pressure as well as for any signs of neurological deterioration and then from here we want to emergently admit them to a stroke unit or ICU if they are not already there all right so that sums up our stroke algorithm uh as well as our overall review of the ACs and stroke algorithms