ACLS – NurseCheung.com https://nursecheung.com From "You're Not Good Enough" To "Look At Me Now!" Wed, 06 Dec 2023 15:11:19 +0000 en-US hourly 1 https://wordpress.org/?v=6.5.5 https://2hya11.p3cdn1.secureserver.net/wp-content/uploads/2023/01/nurse-cheung-logo-Logo-1000-×-1000-px-2-150x150.png ACLS – NurseCheung.com https://nursecheung.com 32 32 Advanced Cardiac Life Support (ACLS) Overview: What You Need to Know https://nursecheung.com/acls/ Sat, 07 Jan 2023 17:14:47 +0000 https://nursecheung.com/advanced-cardiac-life-support-acls-overview-what-you-need-to-know/

If you work in the medical field, then you have probably heard of ACLS. But what exactly is it?

Advanced Cardiac Life Support (ACLS) is a set of guidelines that healthcare providers use to treat cardiac arrest and other life-threatening cardiovascular emergencies.

In this blog post, we will provide an overview of what you need to know about ACLS. We will discuss the history of ACLS, the goals of the program, and the basic steps involved in providing treatment.

Disclaimer: The information covered in this post is in line with the 2020 American Heart Association ACLS guidelines.

ACLS History and Goals

ACLS was created in the 1970s in response to the growing number of cardiac arrests that were occurring outside of the hospital setting.

The goal of ACLS is to improve patient outcomes by providing high-quality care in a timely manner.

One of the key ways that ACLS achieves this goal is by standardizing the care that is provided.

The ACLS guidelines are based on the latest evidence and best practices.

They are regularly updated to ensure that healthcare providers are using the most effective treatments.

Basic Life Support Guidelines

To learn more about Basic Life Support (BLS)? ^^^ Click the Title above ^^^

Adult BLS Assessment

The basic steps of BLS are:

  • Verify scene safety
  • Check for responsiveness
  • Call for help (Activate the Emergency Response System)
  • Check for breathing and pulse
  • Begin chest compressions
  • Provide rescue breaths
  • Continue chest compressions and rescue breaths until help arrives or the patient begins to breathe on their own
 

Verify scene safety

Many times you may find that the scene may be unsafe with locations such as in the water, in the middle of the road, etc. If it is not safe, make the scene safe and move the person prior to starting interventions.

Check for Responsiveness

Tap the shoulders and shout “Are you okay?”

If the patient does not respond, then they are unresponsive.

Activating the Emergency Response System

The first step in any emergency is to call for help.

You have two options

  • If you have someone near you, have them get help and obtain an AED/Defibrillator
  • If you are by yourself, perform a round of CPR then call for help and obtain an AED/Defibillator
 

Checking for Breathing and a Pulse

To check for breathing, look for the rise and fall of the chest.

To check for a pulse, place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse.

These actions should be performed a maximum of no more than 10 seconds.

If no breathing and pulse are present, immediately begin cardiopulmonary resuscitation (CPR).

Compressions, Airway, Breathing (CAB)

Chest Compressions Ratios and Placement

For adults, the compression-to-ventilation ratio is 30:2 (30 compressions followed by two breaths).

Begin by placing the palm of your hand over the patient’s sternum just above the xiphoid process. Previous indicator was to place the palm of your hands on the mid-nipple line; however, due to the increase in obesity the nipple line may no longer be the best indicator.

Disclaimer regarding rescue breaths: According to guidelines posted by the American Heart Association on January 24, 2022, appropriate percautions should be worn when providing BLS, ACLS, and PALS standards with potential and confirmed COVID-19 positive patients. All providers should wear a respirator (i.e. N95), gown, gloves, and eye protection for suspected or confirmed COVID-19 infections, when performing aerosol-generating procedures (AGP)s. Out of hospitla cardiac arrest is dependent on early initiation of CPR including chest compression. It is not recommend for mouth to mouth resuscitation at this time but all patients should receive the best resuscitative efforts.

Depth of Chest Compressions

For adults, the depth of chest compressions should be at least two inches (five centimeters).

Chest Compression Rate

The compression rate should be 100-120 compressions per minute.

You can keep track of the rate by counting out loud or using a metronome.

Allow for full chest recoil between compression and minimize interruptions to less than 10 seconds.

Be sure to switch compression team members every 2 minutes.

Airway and Breathing (CAB)

Utilize the head tilt-chin lift or jaw thrust (trauma to the cervical spine).

Rescue breaths are one breath every 5 to 6 seconds. You will want to see visible chest rise and fall within each rescue breath.

It is important to avoid excess ventilation because it can decrease coronary perfusion pressure and a reduction of cerebral blood flow causing PaCO2 to decrease.

How to use an AED/Defibrillator

When the AED arrives, review the instructions with the bystander.

If you are alone, perform one minute of CPR before using the AED.

Step One: Turn on the AED and follow the prompts.

Step Two: After removing the person’s shirt, apply the electrode pads to the patient’s bare chest in accordance with the instructions and plug in the connector. It is important to remove any wet barriers or medication patches before applying the pads.

Step Three: Stop chest compressions and confirm everyone is clear by saying “Stand Clear.”

Step Four: Push the analyze button and the AED will analyze the patient’s heart rhythm and, if needed, deliver a shock.

Step Five: if a shock is recommended, make sure no one is touching the person and repeat “Stand Clear.” Once clear, press the shock button.

Step Six: Immediately begin CPR following the shock or if no shock is advised. Perform another two minutes of CPR and follow the AED prompts again.

Bradycardic Rhythms in ACLS

Some bradycardic rhythms you may encounter in ALCS include sinus bradycardia, first-degree heart block, second-degree heart block type I, second-degree heart block type II, and third-degree heart block.

Sinus Bradycardia is defined as a heart rate of less than 60 bpm and the QRS complex is normal. The patient may or may not have symptoms.

First-degree heart block is defined as a PR interval greater than 0.20 seconds but less than 0.30 seconds with a normal QRS complex. The patient usually has no symptoms.

Second-degree heart block type I is defined as a PR interval greater than 0.20 seconds with some occasional dropped QRS complexes.

Second-degree heart block type II is defined as a constant PR interval greater than 0.20 seconds with consistently dropped QRS complexes.

Third-degree heart block is defined as a complete absence of electrical conduction from the atria to the ventricles. The atrial rhythm is regular and the QRS complex is regular with a rate of less than 60 bpm. The conduction in the atria is not communicating with the conduction system in the ventricles.

Bradycardic Rhythm Interventions

Atropine

If symptomatic, the ACLS guideline’s first drug of choice recommends atropine for bradycardia interventions. The initial dose is 1 mg (maximum of 3 mg) and may be given every three to five minutes.

Second-degree type II and third-degree heart blocks do not typically respond to atropine.

If the patient is unresponsive to atropine or has a high-degree heart block, you will need to place transcutaneous pacing pads.

Transcutaneous Pacing

Transcutaneous pacing is an external form of pacing that uses electrical current to stimulate the heart through the skin. This is considered a temporizing measure and is not a definitive treatment.

The pads are placed in the anterolateral position on the patient’s chest and plugin the pacing unit.

The unit will automatically deliver a pacing stimulus/demand rate at 60-100 bpm.

Pacer current (mA) output is also important as it determines the strength of the electrical impulse being delivered to the heart. The higher the number, the greater current being delivered which can cause burns if used for too long.

The recommended settings for an adult are:

-Pacing mode: demand

-Pacing rate: 60-100 bpm (can be set lower if the patient has a pre-existing tachycardia)

-Pacer output: 50-80 mA

Transcutaneous pacing should be continued until the patient’s condition improves, a transvenous pacemaker can be placed, or for no more than 45 minutes to avoid skin burns and patient discomfort.

Transcutaneous Precautions

Conscious paced patients may require additional analgesics for pacing discomfort. Also, you will want to avoid palpating the carotid pulses to confirm capture as the electric impulses cause muscle jerking that may mimic a pulse.

Dopamine

Dopamine is the second drug of choice for symptomatic bradycardia. The starting dose is low at 5 to 20 mcg/kg/min and should be titrated slowly based on the patient’s blood pressure/hemodynamics.

It is important to correct any hypovolemia with adequate fluid replacement prior to starting any dopamine drip. Use this medication cautiously with cardiogenic shock with congestive heart failure.

For additional precautions, please reference an up-to-date drug guide.

Epinephrine

Epinephrine is an alternative drug choice for symptomatic bradycardia in place of dopamine when not appropriate. This alternative is usually used when pacing and atropine fail as well as in cases of severe hypotension.

The recommended dose is 2 to 10 mcg/min infusion and should be titrated slowly based on the patient’s blood pressure/hemodynamics.

Use epinephrine cautiously as raising blood pressures with an increase in heart rate can cause angina, myocardial ischemia, and increase oxygen demand.

For additional precautions, please reference an up-to-date drug guide.

Tachycardic Rhythms in ACLS

One of the most common tachycardic rhythms you may encounter in ALCS includes supraventricular tachycardia.

Supraventricular Tachycardia is defined as tachycardia that originates from above the ventricles in the atria or AV node.

Tachycardic Rhythm Interventions

Oxygenation and Ventilation

The first and most important intervention for any patient in tachycardia is to ensure they are adequately oxygenated and ventilated.

As the oxygen demand on the heart increases with tachycardia, it is important to ensure they are receiving as much oxygen as possible.

Be sure to monitor the patient’s oxygen saturation for any changes in condition or fluctuation that may require supplemental oxygen.

Vagal Maneuvers

Vagal maneuvers are a physical intervention used to decrease the heart rate by stimulating the vagus nerve.

The most common maneuver is the Valsalva maneuver which is performed by having the patient:

  • Take a deep breath in
  • Attempt to exhale by bearing down or blowing through an occluded 10mL syringe for 15 to 20 seconds
 

This should result in a decrease in heart rate by decreasing the conduction of electrical impulses through the AV node.

Additional vagal techniques include coughing, a cold stimulus to the face, carotid massage, and gagging.

Adenosine

If unsuccessful vagal maneuvers are unsuccessful, the next step is to administer adenosine.

Adenosine is a medication that works by decreasing the conduction of electrical impulses through the AV node.

The recommended initial dose is 6 mg given as a rapid IV push followed by a 20 mL saline flush. It also helps to elevate the extremity after administration.

The recommended second dose is 12 mg given as a rapid IV push followed by a 20 mL saline flush. Typically, you will wait for 1 to 2 minutes between doses as needed.

Synchronized Cardioversion

If the patient remains unstable or unresponsive to previous interventions, synchronized cardioversion may be necessary.

Cardioversion is a procedure that uses electrical shocks to reset the heart’s electrical impulses and rhythm.

It is important to note that this should only be done when the patient is unstable or unresponsive as it can be a painful and traumatic experience for the patient.

The recommended dose of electricity is 50-100 J for monophasic defibrillators and 100- J for biphasic defibrillators. However, always follow your facility’s guidelines for the most accurate doses.

Initial recommended voltage doses

  • Narrow regular (SVT): 50 – 100 joules (SVT or Atrial Flutter)
  • Narrow irregular: 120 – 200 joules biphasic or 200 joules monophasic (atrial fibrillation)
  • Wide regular: 100 -360 joules (monomorphic ventricular tachycardia)
  • Wide irregular: defibrillation dose (not synchronized cardioversion)
 

Synchronized Cardioversion Procedure

  1. Obtain a 12-Lead ECG if the patient is stable
  2. Prepare proper sedation since cardioversion is painful and have emergency equipment ready in case of complications
  3. Place defibrillator pads on the patient and set the monitor to synchronized (sync) mode. Engage the synch mode before each attempt.
  4. Look for sync markers above each R wave.
  5. Set your dose of electricity/voltage
  6. Clear all personnel from the patient prior to the shock
  7. Press the “charge” button, “clear” the patient, and press the “shock” button
  8. Reassess the patient after each shock

ACLS Shockable Rhythms

There are two shockable rhythms in the AHA ACLS guidelines that you may encounter in ACLS: pulseless ventricular tachycardia and ventricular fibrillation.

Pulseless Ventricular Tachycardia is defined as a wide complex tachycardia with a heart rate of >100 bpm in the absence of a pulse.

Ventricular Fibrillation is defined as a rapid, erratic, and chaotic electrical activity in the ventricles that results in the loss of coordinated contractions.

ACLS Shockable Rhythm Interventions

Cardiopulmonary Resuscitation

Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.

Review the Basic Life Support Guidelines for CPR detail

Defibrillation

Defibrillation is the use of electrical shocks to reset the heart’s electrical impulses and rhythm without syncing to the patient’s intrinsic rhythm.

The recommended dose of electricity is 120-200 J for biphasic machines and up to 360 J for monophasic.

Defibrillation Procedure

  1. Turn on the defibrillator and set the joules based on the machine used
  2. Place adhesive pads on patient: one on the right anterior chest wall and one on the left axillary position
  3. Announce to the team “Charging defibrillator” and press the charge button
  4. When the defibrillator is fully charged, verify all team members are clear by announcing the shock. Once the team announces all clear and you have verified the team is not touching the patient or bed, call “All Clear!”
  5. Press the shock button on the defibrillator
  6. Immediately after shock is delivered, resume CPR for 5 cycles (2 minutes) then reassess rhythm

Epinephrine

Epinephrine is a medication that is used to stimulate the heart and increase blood pressure.

The recommended dose is 1 mg administered every 3 to 5 minutes during resuscitation. Follow each dose with a 20 mL flush and elevate the arm for 10 to 20 seconds.

Amiodarone

Amiodarone is a medication that is used to slow the heart rate and improve cardiac output.

The recommended initial dose is 300 mg IV or IO push.

The second dose is 150 mg IV or IO push.

The maximum dosage for amiodarone is 450 mg IV over 24 hours.

Lidocaine

Lidocaine is a medication that is used to treat ventricular arrhythmias and is considered immediately after the return of spontaneous circulation (ROSC).

The recommended initial dose during active CPR is 1 to 1.5 mg/kg IV or IO.

Refractory Ventricular Fibrillation doses can be provided. This dose is 0.5 to 0.75 mg/kg IV push every 5 to 10 minutes (maximum 3 doses or total of 3 mg/kg).

Lidocaine can also be used for maintenance post-cardiac arrest is 1 to 4 mg/min (30 to 50 mcg/kg/min).

ACLS Non-Shockable Rhythms

There are two non-shockable rhythms in the AHA ACLS guidelines that you may encounter in ACLS: asystole and pulseless electrical activity.

Asystole is defined as a heart rhythm that is not amenable to defibrillation also known as a flat line.

Pulseless Electrical Activity (PEA) is defined as electrical activity on the monitor but no mechanical activity.

ACLS Non-Shockable Rhythm Interventions

Cardiopulmonary Resuscitation

Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.

Review the Basic Life Support Guidelines for CPR detail.

Epinephrine

Epinephrine is a medication that is used to stimulate the heart and increase blood pressure.

The recommended dose is 1 mg administered every 3 to 5 minutes during resuscitation. Follow each dose with a 20 mL flush and elevate the arm for 10 to 20 seconds.

Consider your H and T causes

It is important to consider your H’s and T’s for these rhythms and treat accordingly.

H’s and T’s are mnemonics for the major causes of arrest:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ions (acidosis)
  • Hyperkalemia or hypokalemia
  • Hypothermia
  • Tamponade (cardiac, tension)
  • Toxins
  • Tension pneumothorax
  • Thrombosis (coronary, pulmonary)

ACLS Post Cardiac Arrest / Return of Spontaneous Circulation (ROSC)

Once the patient has been successfully resuscitated, it is important to focus on post-arrest care.

This includes:

Brain Management

  • Targeted Temperature Management is the current standard of care for comatose post-cardiac arrest patients.
  • The AHA recommends a target temperature of 33 degrees Celsius for 24 hours be used in comatose patients.
 

Heart Management

  • Coronary intervention should be considered in all patients who remain unstable after resuscitation.
  • This can be done via angioplasty or thrombectomy.
  • Treat hypotension with systolic blood pressure less than 90 mmHg.
  • Obtain a 12-Lead ECG
 

Intensive Care Management

  • Respiratory Failure – Maintaining the patient’s airway, mechanical ventilation
  • Liver Failure – Monitor for signs and symptoms, maintain adequate nutrition
  • Renal Failure – Monitor for signs and symptoms, maintain hydration, dialysis if needed

AHA ACLS Acute Coronary Syndrome (ACS)

The AHA released updated guidelines for the management of ACS in 2020.

Acute Coronary Syndrome (ACS) is defined as a sudden onset of coronary artery disease that can lead to myocardial infarction (heart attack).

The mainstay of therapy for ACS is:

  • Obtain a 12-Lead ECG
  • Provide oxygen if oxygen is less than 94%
  • Aspirin 160-325 mg if no contraindications
  • Pain Control (morphine)
  • Nitroglycrin sublingual or spray

Obtain a 12-Lead ECG

The AHA recommends that all patients with ACS receive a 12-Lead ECG to assess for ST-segment elevation.

If the patient has ST-segment elevation, they should be treated with early reperfusion therapy.

Oxygenation

The first and most important intervention for any patient in tachycardia is to ensure they are adequately oxygenated and ventilated.

As the oxygen demand on the heart increases, it is important to ensure they are receiving as much oxygen as possible.

Aspirin

The AHA recommends that all patients with ACS be treated with aspirin 162 to 325 mg as soon as possible.

There are very few contraindications to aspirin and it has been shown to decrease mortality in ACS.

Morphine Pain Control

Morphine is the preferred pain control agent in ACS.

It has been shown to decrease mortality and myocardial oxygen demand.

Nitroglycerin

Nitroglycerin is a medication that is used to decrease the workload on the heart and coronary dilation.

It can be given sublingually or as a spray. The AHA recommends that all patients with ACS be treated with nitroglycerin.

Contraindications for nitroglycerin inclde right ventircular acute myocardial infarction and sexual enhancement medication use such as Cialis and Viagra.

STEMI (ST Elevation MI) Interventions

The AHA recommends early reperfusion for all patients with ST-segment elevation myocardial infarction.

Reperfusion can be done via thrombolytics or primary percutaneous coronary intervention.

  • Door to ballon inflation (PCI) goal is 90 minutes
  • Door to needle (fibrinloysis) goal is 30 minutes

ACLS Dynamic Teams

ACLS is a team-based approach to resuscitation.

The most important part of ACLS is the development of a well-functioning team that can work together to provide the best care for the patient.

The AHA recommends that all ACLS teams have a designated team leader.

The team leader is responsible for coordinating the efforts of the team and ensuring that all members are aware of their roles.

The AHA also recommends that all ACLS teams have a designated medical director.

The medical director is responsible for the overall medical care of the patient and for the development of ACLS protocols.

If a person is given an assignment outside of their scope of practice or are not knowledge, it is the person’s responsibility to ask for another role.

Lastly, closed loop communication is vitally important during resuscitation efforts. The person performing an action should repeat back what the person has called and advised for clarification or when an action is being performed.

ACLS Stroke Guidelines

The AHA released updated guidelines for the management of stroke in 2020.

The mainstay of therapy for stroke is:

  • Rapid identification and assessment
  • Determining the time of last known well (LKW)
  • Immediate blood pressure control if systolic blood pressure is greater than 185 mmHg or diastolic blood pressure is greater than 110 mmHg
  • CT scan with no contrast to be performed immediately upon arrival
  • Provide fibrinolytic therapy immediately as long as no contraindications are noted
  • Rapid transfer to a comprehensive stroke center if one is available
  • The AHA also recommends the use of telemedicine for the evaluation of stroke patients when a comprehensive stroke center is not available.

ACLS Mega Code Survey

The ACLS mega code survey is a tool that can be used to assess the knowledge of ACLS providers.

The ACLS Megacode survey consist of a primary survey and secondary survey.

ACLS Primary Survey (ABCDE)

The ACLS Primary Survey is ABCDE (Airway, Breathing, Circulation, Disability, and Exposure).

Airway

The airway should be assessed for patency and the presence of foreign bodies.

  • Maintain airway patency in unconscious patients​
  • Use advanced airway if needed​
  • Confirm CPR/Ventilation/Secure Device​
  • Monitor Airway Placement with continuous quantitative waveform capnography

Breathing

The breathing should be assessed for the quality of breathing

  • Give supplementary oxygen as needed​
  • 100% oxygen for cardiac arrest patients​
  • Titrate oxygen for stable patients​
  • Avoid excessive ventilations​
  • IMPORTANT: AGONAL GASPS ARE NOT NORMAL (FIRST SIGNS OF IMPENDING CARDIAC ARREST). START CPR IMMEDIATELY.

Circulation

The circulation should be assessed for blood pressure, heart rate, and pulse quality.

Monitor CPR quality

  • Minimize interruptions and checking pulse no more than 10 seconds
  • If person performing CPR starts to provide ineffective chest compressions: Give constructive feedback
 

Attach Monitor/Defibrillator/AED

  • First Step to using AED is turning on the device. Then follow the prompts. 
 

Obtain IV/IO Access

  • Give Appropriate medications
  • Administer IV/IO fluids
 

Check glucose levels/temperature/ capillary refill

IMPORTANT: BLOOD PRESSURE MINIMUM IS 90 mmHg

Disability

The disability should be assessed for the level of consciousness and the presence of seizures.

  • Check for neurological function
  • Quickly assess for responsiveness (LOC, Pupil Dilation)
 

AVPU

  • Alert
  • Verbal stimulation
  • Painful stimulation
  • Unresponsive

Exposure

The exposure should be assessed for the presence of signs and symptoms of injuries.

Remove clothing: Assess for obvious signs of trauma, bleeding, burns, markings, medical alert bracelet.

ACLS Secondary Survey (SAMPLE)

The ACLS Secondary Survey is SAMPLE (signs and symptoms; allergies; medications, past medical history; last meal, liquid consumed; and events).

Signs and Symptoms

The signs and symptoms should be assessed for the presence of any changes.

  • Objective information from what we see
  • Subjective information from family or the ambulance

Allergies

The allergies should be assessed for any food, medication, or environmental causes.

Medications

The medications should be assessed any medication causes.

  • Over the counter medications​
  • Vitamins​
  • Supplements​
  • Prescribed Medications​
  • Any medications not prescribed that may have been ingested or used

Past Medical History

The past medical history should be assessed pre-existing conditions.

  • Medical conditions​
  • Surgical history​
  • Previous hospitalizations
  • Clinical procedures​

Last Meal, Liquid Consumed

The last meal, liquid consumed should be assessed for the time of the last meal or drink.

  • Time of last meal​
  • Type of food or drink consumed

Events

The events should be assessed for any changes that lead up to the current presentation.

  • Headache​
  • Dizziness​
  • Nausea/vomiting​
  • Visual changes​
  • Sudden onset of symptoms (e.g., slurred speech)

Conclusion

ACLS algorithms are standardized protocols that guide the management of a variety of cardiac and non-cardiac emergencies. These ACLS algorithms provide a framework for the delivery of care, but they do not replace the need for clinical judgment. The ACLS provider must be able to assess the patient, identify the problem, and select the appropriate ACLS intervention.

The ACLS provider must also be familiar with the basic concepts of advanced airway management, defibrillation, and intravenous access. These ACLS interventions are the cornerstone of care for cardiac and non-cardiac emergencies.

]]> Out-Of-Hospital ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ooh-airwaymanagement/ Sat, 07 Jan 2023 17:14:33 +0000 https://nursecheung.com/out-of-hospital-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

Table of Contents

Adult Out-Of-Hospital Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult respiratory arrest Megacode:

You are a paramedic and arrive on the scene for a woman having an asthma attack at home.

Demonstrate what you would do next

Initial Impression

The woman is conscious and reports difficulty breathing during her evening meal. The woman begins to have respiratory distress and a decrease in mental status.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is starting to swell. The flow through the trachea is impaired.

Breathing: Oxygenation is showing less than 50% on room air. Agonal gasps are noted.

Circulation: Blood pressure is 60/38, heart rate is 120/min, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to verbal stimulation.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the woman becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. No breathing present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. The decision between oropharyngeal or nasopharyngeal airway can be difficult, but there are a few things to consider when making the decision.
  3. Oropharyngeal airways are inserted into the mouth, and nasopharyngeal airways are inserted into the nose. Oropharyngeal airways are more likely to be successful the first time, but nasopharyngeal airways are less likely to cause vomiting.
  4. Administer oxygen. Oxygen saturation is less than 50%. 
  5. Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag).
 

The woman is stable and oxygen saturation is rising. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, swelling is still present.

Allergies: The woman’s friend states she has an allergy to peanuts.

Medications: Albuterol inhaler and an epinephrine pen

Past Medical History: Asthma

Last Meal, Liquid Consumed: Last meal and liquid consumed during the asthma attack. This ordered Chinese takeout Pai Thai.

Events: No events lead up to the asthma attack.

What are your text interventions?

  • Epinephrine
  • Diphenhydramine
  • Albuterol
  • Vital signs monitoring
  • Monitor for any changes
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ed-airwaymanagement/ Sat, 07 Jan 2023 17:14:31 +0000 https://nursecheung.com/emergency-department-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

The Airway Management section of the AHA Emergency Department (ED) ACLS algorithm is one of the most important, and it can be difficult to know what to do when someone is choking or has another airway emergency.

We will provide you with a step-by-step guide on how to manage an airway emergency, as well as some tips for avoiding common mistakes.

In this blog post, we will discuss the best strategies for saving lives in the Emergency Department setting.

Adult ED Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the ED adult respiratory arrest Megacode:

You are working the day shift in an emergency department. You are asked to see a new patient in your bay. A bystander called 911 after finding a man unconscious in a ditch.

Demonstrate what you would do next

Initial Impression

The man is unconscious with mildly cyanotic lips. The paramedics placed a nasopharyngeal airway and have been trying to ventilate but have had difficulty. The paramedics also noted that there were drug paraphernalia on the scene and an empty syringe.

Primary Assessment Survey (A, B, C, D, E)

Airway: There is a nasopharyngeal airway present. It is being ventilated by paramedics on arrival and taken over by respiratory. The flow through the trachea is impaired by the tongue.

Breathing: Oxygenation is showing 75% with bag valve mask ventilation. The man has no spontaneous breaths.

Circulation: Blood pressure is 100/60, heart rate is 140/min, the rhythm is narrow-complex rapid tachycardia, and the pulse is present but weak.

Disability: Unresponsive to any stimuli. Pupils are dilated bilaterally at 7 mm (commonly misused drugs that dilate pupils are amphetamines, bath salts, benzodiazepines, cocaine, crystal meth, ecstasy, LSD)

Exposure: Numerous track marks are located on the man’s arms.

Change in Condition

After assessment of the initial impression and primary assessment, the man’s oxygen continues to decline and his heart rate increases.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” Found unresponsive during the primary survey, move on to the next step.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. No spontaneous breathing was present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. The nasopharyngeal airway is not working effectively. It may be time to switch to endotracheal intubation.
  3. Administer oxygen. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
  4. Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag) until the ventilator arrives.
 

The man is stable and oxygen saturation is normal. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving, heart rate has decreased to 90 bpm normal sinus rhythm; however, no spontaneous breathing is noted.

Allergies: Unknown if there are any allergies.

Medications: Unknown if there are any medications.

Past Medical History: Unknown if there is any past medical history.

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed.

Events: No events were noted outside of what was discussed with the paramedic team.

What are your text interventions?

  • Drug urinalysis
  • Labs
  • Fluids
  • Naloxone trial with escalating doses
  • Transfer to a higher level of care – Intensive Care Unit
 
 

You will begin the transfer to the unit. Your scenario has concluded.

]]> Inpatient ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ip-airwaymanagement/ Sat, 07 Jan 2023 17:14:29 +0000 https://nursecheung.com/inpatient-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

The Airway Management section of the AHA Inpatient ACLS algorithm is one of the most important, and it can be difficult to know what to do when someone is choking or has another airway emergency.

We will provide you with a step-by-step guide on how to manage an airway emergency, as well as some tips for avoiding common mistakes.

In this blog post, we will discuss the best strategies for saving lives in the inpatient setting.

Adult Inpatient Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the inpatient adult respiratory arrest Megacode:

You are the healthcare provider taking care of a female patient with a history of diabetes in the intermediate care unit. The patient is noncompliant with medications for her asthma and heart failure and is well known by the cardiologist and pulmonologist. She has been intubated and sedated prior to coming to you.

Demonstrate what you would do next

Initial Impression

The woman is currently on CPAP at 10 as part of her heart failure treatment. She is becoming restless, short of breath, and trying to take the mask off.

Primary Assessment Survey (A, B, C, D, E)

Airway: There is a CPAP mask present. It is hard to determine if the woman’s airway is patent due to her restlessness and combativeness.

Breathing: Oxygen saturation is showing 80% with CPAP 100% oxygen. Respiratory rate is 28/min. The patient states “I can’t keep this up much longer.” Breath sounds are diminished bilaterally. Wheezing and crackles are noted upon auscultation.

Circulation: Blood pressure is 128/90, heart rate is 82/min, and the pulse is present but weak. Capillary refill is 3 seconds.

Disability: The woman is alert, oriented, and restless. She is attempting to remove the CPAP mask and eventually takes it off.

Exposure: Skin is cool to the touch.

Change in Condition

After assessment of the initial impression and primary assessment, the woman becomes unresponsive while attempting to place the mask back on and waiting for respiratory therapy/rapid response.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman is unresponsive and doesn’t answer any stimuli.
  2. Activate the emergency response system. Shout for backup and announce what room you are in. It is perfectly acceptable to hit the code button for faster backup.
  3. Check for breathing: Look for visible chest rising and falling. No spontaneous breathing was present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. Start providing oxygenation via bag valve mask with oxygen while waiting for help to arrive. Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag) until the ventilator arrives.
  3. Consider endotracheal re-intubation due to condition deterioration. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
 

The woman is stable, restless, and oxygen saturation is within normal but falling slowly due to her biting on the tube. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, no spontaneous breathing is noted.

Allergies: Allergic to morphine and acetaminophen

Medications: Albuterol, Metformin, and digoxin

Past Medical History: Diabetes, asthma, and congestive heart failure

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed as she was transferred to your unit without a full report.

Events: No events were noted outside of what was discussed.

What are your text interventions?

  • Albuterol
  • Sedation for restlessness
  • Arterial Blood Gases
  • Maybe Fluid – Depends on the Heart Failure
  • Waveform Capnography
  • Critical Care Consult
  • Transfer back to a higher level of care – Intensive Care Unit
 
 

You will begin the transfer to the unit. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/alcsmegacode-ooh-unstablebradycardia/ Sat, 07 Jan 2023 17:14:28 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an out-of-hospital ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Out-Of-Hospital Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable bradycardia Megacode:

You are a paramedic responding to a call of a person with altered mental status.

Demonstrate what you would do next upon arrival

Initial Impression

The 60-year-old male person is sitting upright on a couch. He is disoriented, pale, and diaphoretic.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 86% on room air. You provide oxygen 4LNC.

Circulation: Blood pressure is 80/68, heart rate is 40/min, a rhythm check shows third-degree heart block, and the pulse is present but weak.

Disability: Decrease in mental status. Responsive to painful stimulation.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the man becomes unresponsive.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is no response.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but weak.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

  1. Pulse and breathing is present so we will not begin CPR starting with compressions.
 

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – person is on 4LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 80/68, 98% on 4LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – YES
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – Wife states the man experienced chest pain prior to becoming unresponsive – YES
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – relatively contraindicated in high-degree blocks

If atropine is not effective or contraindicated:

  • Transcutaneous pacing – YES
  • Dopamine
  • Epinephrine
 
 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/aclsmegacode-ed-unstablebradycardia/ Sat, 07 Jan 2023 17:14:26 +0000 https://nursecheung.com/emergency-department-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an emergency department ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Emergency Department Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the ED adult unstable bradycardia Megacode:

You are a healthcare provider working in the emergency department. You are assessing a woman with a history of syncopal episodes. She is present in the ED as she feels she is going to have another syncopal episode.

Demonstrate what you would do next

Initial Impression

The 75-year-old female is sitting upright on a stretcher. She is feeling dizzy, light-headed, weak, and faint. There are no complaints of chest pain, dyspnea, or palpitations. Overall she has been healthy with no recent changes to her medications.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on room air.

Circulation: Blood pressure is 76/50, heart rate is 30/min, a rhythm check shows second-degree heart block Type II, and the pulse is present but weak.

Disability: The patient is oriented but drowsy. Overall alert, but responsive to verbal stimuli at times.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s mental status starts to deteriorate and the monitor shows a third-degree AV block.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” There is a slight response.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but weak.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and does not require oxygen.
  3. Cardiac monitor, blood pressure, oximetry – Third Degree Heart Block, BP 76/50, 98% on room air
  4. IV Access – 20 gauge in the left and right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – YES
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – Unknown at this time but declined on previous assessment
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – relatively contraindicated in high-degree blocks

If atropine is not effective or contraindicated:

  • Transcutaneous pacing – YES
  • Dopamine
  • Epinephrine
  • Labs – electrolytes and cardiac biomarkers
  • Urinalysis
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Inpatient ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/aclsmegacode-ip-unstablebradycardia/ Sat, 07 Jan 2023 17:14:24 +0000 https://nursecheung.com/inpatient-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an inpatient ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Inpatient Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the inpatient adult unstable bradycardia Megacode:

You are a healthcare provider working in the cardiac telemetry observation unit. You are performing your morning patient assessment when you note that the monitor is showing bradycardia.

Demonstrate what you would do next

Initial Impression

The 45-year-old male is sitting upright on the hospital bed. He is feeling cold and clammy. There are no complaints of chest pain, dyspnea, or palpitations. Overall he has been healthy with no recent changes to his medications.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on 2LNC.

Circulation: Blood pressure is 90/50, heart rate is 30/min, a rhythm check shows sinus bradycardia, and the pulse is present but weak.

Disability: The patient is alert and oriented.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient states he is having some chest discomfort and his extremities feel cool to the touch.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” This step is not necessary as the patient is awake, alert, and oriented.
  2. Activate the emergency response system. Call your charge nurse, call rapid response, and place a page out to the doctor.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but slightly weak.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and already has 2LNC on.
  3. Cardiac monitor, blood pressure, oximetry – Sinus Bradycardia, BP 90/50 (confirmed this is low for the patient), 98% on 2LNC
  4. IV Access – 20 gauge in the left and right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – No
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – Atropine was successful

If atropine was not effective or contraindicated:

  • Transcutaneous pacing
  • Dopamine
  • Epinephrine
  • Labs – electrolytes and cardiac biomarkers
  • Urinalysis
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care – Cardiac or Medical PCU
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Out-Of-Hospital ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ooh-unstabletachycardia/ Sat, 07 Jan 2023 17:14:22 +0000 https://nursecheung.com/out-of-hospital-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult Out-Of-Hospital Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the out-of-hospital adult unstable tachycardia megacode:

You are working on an advanced life support ambulance and are dispatched to a person who doesn’t feel right.

Demonstrate what you would do next upon arrival

Initial Impression

The person is a 58-year-old female lying down in the front doorway of her home. She is anxious, pale, and dizzy.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent but is experiencing mild respiratory distress. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 92% on room air. You provide oxygen 2LNC.

Circulation: Blood pressure is 92/60, heart rate is not being captured on the monitor, the rhythm check shows monomorphic wide complex ventricular tachycardia and the pulse is present.

Disability: The woman is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet. The woman’s son states he helped her to the doorway to get some cold air. He denies any falls or injuries.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is weak.
  2. Activate the emergency response system. You direct the second rescuer to activate the emergency response system and get an AED.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The woman is on 2LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – monomorphic wide complex ventricular tachycardia, BP 92/60, 96% on 2LNC
  4. IV Access – 20 gauge in the right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, woman states chest discomfort
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Synchornized Cardioversion – Consider sedation
 

If synchronized cardioversion is not effective or contraindicated:

  • Amiodarone IV Drip: 1-4 mg/min
  • Procainamide 20-50 mg/min until the arrhythmia is suppressed, hypotension ensues, QRS duration increases. There is a maintenance infusion dose.
  • Sotalol 100 mg (1.5 mg/kg) over 5 minutes. Avoid if QT is prolonged.
 

Outcomes

Two attempts at synchronized cardioversion were performed unsuccessfully. No change in rhythm was noted.

Amiodarone infusion started. After 5 minutes, another attempt at synchronized cardioversion was attempted and successful.

Rhythm is now normal sinus rhythm at 80 bpm.

 

You will begin the transfer to the nearest hospital. Your scenario has concluded.

]]> Emergency Department ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ed-unstabletachycardia/ Sat, 07 Jan 2023 17:14:20 +0000 https://nursecheung.com/emergency-department-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult Emergency Department Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are working in the emergency department and are assessing a woman who has had multiple reports of syncopal episodes and palpitations.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 32-year-old female lying down on the stretcher. She is anxious, pale, weak, and dizzy. She states these episodes have happened over the last few years but have become more frequent recently.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The woman is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and she is short of breath.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman responds but is becoming increasingly weak.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The woman is on 4LNC upon Primary Assessment
  3. Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
  4. IV Access – 20 gauge in the right and left antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Synchronized Cardioversion – Consider sedation
 

If synchronized cardioversion is not effective or contraindicated:

  • Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required
 

Outcomes

Two attempts at synchronized cardioversion were performed successfully.

Rhythm is now normal sinus rhythm at 80 bpm.

Next steps for this patient:

  • Labs – electrolytes and cardiac biomarkers
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Inpatient ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ip-unstabletachycardia/ Sat, 07 Jan 2023 17:14:18 +0000 https://nursecheung.com/inpatient-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult inpatient Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are a healthcare provider working in the cardiovascular intermediate care unit. You are caring for a post-motor vehicle trauma patient with a chest tube. The patient’s wife runs into the nurse’s station yelling that her husband needs help.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 30-year-old male lying down in a hospital bed. He is anxious, pale, weak, and dizzy. He states his chest feels funny.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The patient is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and he is short of breath.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The man responds but is becoming increasingly weak.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is on 4LNC after a change in condition
  3. Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
  4. IV Access – 20 gauge in the right and left antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions are available for you to perform next?

  • Synchronized Cardioversion – Consider sedation
  • Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required
 

What are we Missing?

The chest tube is a vital piece of equipment during our assessment that may be a contributing factor. Previously during our initial assessment, there was minimal drainage. Now the drainage is over 1,500 mL.

Outcomes

The patient was taken to the Operating Room and found to have a hemothorax.

Next steps for this patient:

  • Post-operative care
  • Chest tube management
  • Physical therapy and walking schedule
  • Labs – electrolytes and cardiac biomarkers
  • Fluids including blood products
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]>