Pass ACLS Tip of the Day

The use of calcium channel blocker medications for tachycardias refractory to Adenosine and to lower the blood pressure of hypertensive stroke patients.

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

The primary use of calcium channel blockers in ACLS.

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

Contraindications of calcium channel blockers.

Nicardipine use during the treatment of ischemic strokes.

For more information on ACLS medications, tachycardia, or stroke check...

Review the ACLS treatment goals and targeted temperature management (TTM) for post-arrest patients that have return of spontaneous circulation (ROSC).

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

Identification of ROSC during CPR.

Initial patient management goals after identifying ROSC.

Indications for starting TTM.

Monitoring the patient’s core temperature.

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Review the indications, contraindications, and safe administration of nitroglycerine to Acute Coronary Syndrome (ACS) patients with ischemic chest pain.

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

Assessment of vital signs prior to administering nitro.

Indications for use of nitroglycerine.

Nitroglycerine's contraindications & considerations for use.

Effects of nitro on patients taking PDE inhibitors.

Administration of nitroglycerine to patients with ischemic chest pain.

Considerations for patients that took their home nitroglycerine.

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

Identification of Atrial Fibrillation (A-Fib) & Atrial Flutter on the ECG and the treatment of unstable and stable SVT patients with A-Fib/Flutter.

The ECG characteristics of A-Fib and A-Flutter.

Recognition and treatment of unstable patients in A-Fib/Flutter with rapid ventricular response (RVR).

Suggested energy settings for synchronized cardioversion of unstable patients with a narrow complex tachycardia.

Team safety when cardioverting an unstable patient in A-FIB/Flutter.

Adenosine’s role for stable SVT patients with underlying atrial rhythms.

Treatment of stable patients in A-Fib/Flutter with RVR.

Review of Tablets & Toxins as an ACLS H &T reversible causes of cardiac arrest with some specific, commonly encountered examples.

As an ACLS provider you do not need to be familiar with all of the different signs of various types of poisoning.  You should be able to obtain a history and know to order toxicology.

The majority of toxins don’t have a specific antidote.  There are a few toxins for which we have emergency interventions and ACLS providers should be familiar with.

Reviewing the patient's medical history for indicators that may lead us t...

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

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

Three key points to remember when using ACLS algorithms.

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

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Review of when we should consider beta blocker use in ACLS's Acute Coronary Syndrome (ACS) & Tachycardia algorithms and when they're contraindicated.

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

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

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

Beta blockers effects on the heart.

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

Cont...

A review of advanced airway use in ACLS’s Adult Cardiac Arrest algorithm including: advantages, types, insertion, and monitoring ETCO2.

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

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

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

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

Identification and management of...

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

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

Indications for use of an antiarrhythmic after ROSC.

Determining which antiarrhythmic to use post cardiac arrest.

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

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

Links to other medical podcasts that cover antiarrhythmics and other AC...

Hydrogen ions is on one of the Hs in ACLS's H&T reversible causes of cardiac arrest.  When considering hydrogen ions as a cause, what we’re looking at is the patient’s pH, or acid/base balance, and conditions that affect it.

The body's normal pH.

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

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

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

Correcting acidosis by changing the rate of ventilations.

The indications, dose...

BLS & ACLS's Adult Cardiac Arrest algorithm makes it easier to act as team leader during a code by following an If/Then methodology.

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

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

If the patient is in a shockable rhythm on the ECG such as V-Fib or V-Tach, we will...

Review of aspirin's mechanism of action, indications, contraindications, and administration for patients with acute coronary syndrome (ACS) or stroke.

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

Contraindications and considerations for aspirin’s use.

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

The use of aspirin in the ACLS Stroke algorithm.

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Review of lead II ECG characteristics, rules to identify first and third degree heart blocks, and treatment following the ACLS Bradycardia algorithm.

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

Review of normal ECG morphology in lead II.

Characteristics of first-degree heart block.

Characteristics of third-degree (complete) AV block.

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

Special considerations for use of Atropine...

Review of antiarrhythmic medications Amiodarone & Lidocaine for use in ACLS's Adult Cardiac Arrest, Post Arrest, and Tachycardia algorithms.

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

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

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

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

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

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Review the indications, contraindications, sizing, and insertion of the nasopharyngeal airway (NPA) to maintain the airway of patients with a gag reflex.

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

When the nasopharyngeal airway (NPA) should be used as an alternative to the oropharyngeal airway (OPA).

Examples of when a NPA should be considered.

Contraindications and considerations for nasal airway insertion.

Measuring a nasal airway for appropriate length and diameter.

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

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The causes, physiology, signs & symptoms, and treatment of cardiac tamponade as an ACLS H&T reversible cause of cardiac arrest.

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

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

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

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

Signs & symptoms of cardiac tamponade.

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The role of team leader, code team responsibilities, and the use of reference cards during your ACLS class megacode and written exam.

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

1.  The role of the team leader; and

2.  The ability to use your quick reference cards.

The team leader’s roles and responsibilities.

Using closed-loop communication and speaking up if there’s any doubt about an order or action.

Use of your course’s approved text book and quick re...

Early CPR and defibrillation improve cardiac arrest outcomes. Here's why CPR is important and five ACLS tips to reduce CPR interruptions.

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

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

The chance of defibrillation converting to a perfusing rhythm decreases every minute that passes.

How our chance of successfully defibrillating a patient into a perfusing rhythm significantly changes when good CPR is delivered vs...

Four uses for Quantitative waveform capnography in ACLS.

Waveform capnography use with, and without, an advanced airway in place.

Monitoring end tidal CO2 during rescue breathing.

Use of capnography to objectively measure good CPR.

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

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

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

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

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

Assessment & treatment of stable tachycardic patients.

Commonly used vagal techniques.

A less common technique to stimulate the vagus nerve.

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

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

Carotid sinus massage.

...

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

Defibrillators can be broken down into three basic categories:

1.  Automated External Defibrillator (AED);

2.  Biphasic defibrillators; and

3.  Monophasic defibrillators.

Use of an AED to rapidly deliver a shock.

Advantages & use of Biphasic defibrillators.

Energy for monophasic defibrillators to defibrillate V-Fib or pulseless V-Tach.

AEDs must not be used on patients with a pulse.

Cardioversion of patients in unstable SVT or V-Tach wit...

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

Signs & symptoms that indicate a bradycardic patient is unstable.

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

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

The indications and dosage of Atropine.

Precautions for Atropine use in patients with second or...

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

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

Identification of ROSC during CPR.

Initial patient management goals after identifying ROSC.

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

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

Monitoring the patient’s core temperature during TTM.

Patients can undergo EEG, C...

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

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

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

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

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

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

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

Medical conditions & medications that can cause potassium imbalance.

ECG changes seen in hypo and hyperkalemia.

Critical lab values that would indicate a need for treatment.

Emergent, ACLS interventions for hypokalemia and hyperkalemia.

Additional information on causes of hypo and hyperkalemia ca...

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

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

The first four steps in the Stroke Chain of Survival.

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

Stroke benchmarks for door to:

EMS interaction with stroke te...

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

Symptoms indicating a stable vs unstable patient.

Common causes of tachycardia.

Cardiac effects of Adenosine.

Indications for use in the ACLS Tachycardia algorithm.

Considerations and contraindications.

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

Dosing and administration.

Other podcasts that cover common ACLS antiarrhythmics in more detail and another covering Brugata Criteria used to differentiate V-Tach from SVT with an...

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

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

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

Identification of unstable bradycardia and its treatment with Atropine.

ECG...

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

The O in MONA is Oxygen.

When we should administer oxygen to ACS patients.

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

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

Review two common ACLS pre-arrest mega code scenarios.

Oxygen administration during CPR and post cardiac arrest.

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

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

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

Objective measures of high-quality CPR include:

The role of the CPR Coach on the code team.

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

The use of end tidal waveform...