ACLS

• ARE NOT NORMAL BREATHING
• May be present in first minutes after sudden cardiac arrest
• Pt who gasps usually looks like he is drawing air very quickly. Gasps may appear weak of forceful
• Some time may pass between gasps as they usually happen at slow rate
• IS SIGN OF CARDIAC ARREST

• Compress chest at least 2 inches
• Rate btwn 100 to 120 per min
• Allow complete chest recoil after each compression
• Minimize interruptions to 10 sec
• Avoid excessive ventilation

• DOES NOT restart heart
• Rather, it stuns the heart and briefly terminates all electrical activity, including VF and pVT

• Airway 
• Breathing
• Circulation
• Disablility
• Exposure

• Maintain patency in unconscious pt's
• Use advanced airway if needed
• IF USING ADVANCED AIRWAY:
• Confirm proper integration of CPR & ventilation
• Confirm proper placement of advanced airway devices by physical examination or quantitative waveform capnography
• Secure device to prevent dislodgement
• Monitor airway placement with continuous quantitative waveform capnography

• Give suppl O2 when indicated: cardiac arrest pt get 100%; others titrate O2 to achieve 94% or greater by pulse ox
• Monitor adequacy of ventilation and oxygenation: chest rise and cyanosis, quantitative waveform capnography, O2 sat
• AVOID EXCESSIVE VENTILATION!

• Monitor CPR quality: Quantitative waveform capnography
• Attach monitor/defib for arrhythmia or cardiac arrest rhythms
• Provide defib/cardioversion
• Obtain IV/IO access
• Give approp drugs to manage rhythm & BP
• Check glucose & temp
• Check perfusion issues

If PETCO2 is less than 10 mmHg, attempt to improve CPR quality (PETCO2 is the partial pressure of CO2 in exhaled air at the end of the exhalation phase)

Intra-arterial pressure : if diastolic pressure is less than 20mmHg, attempt to improve CPR quality

• Check for neurologic function
• Quickly assess for responsiveness, levels of consciousness, and pupil dilation

AVPU: ALERT, VERBAL, PAIN, UNRESP

• Remove clothing to perform physical exam
• Look for obvious trauma, bleeding, burns, unusual markings, or med alert bracelets

involves differential dx, including med hx and H&T's

Use SAMPLE along with H's & T's

• Signs/Sx
• Allergies
• Medications (including last doses)
• Past med hx
• Last meal consumed
• Events leading up to

H's and T's

• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo/hyperkalemia
• Hypothermia

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary)
• Thrombosis (cardiac)

Hypovolemia and hypoxia, both potentially reversible

• clinical state characterized by abnormal respiratory rate or effort
• Includes:
• tachypnea
• Increased resp effort (nasal flaring, retraction)
• Hyperventilation/bradypnea
• Tachycardia
• Cyanosis
• Change in LOC/agitation
• Use of ab muscles in breathing

• Clinical state of inadequate oxygenation, ventilation, or both
• Is end stage of respiratory distress
• Includes:
• Marked tachypenea
• Bradypnea, apnea (late)
• Increas, decre, or no resp effort
• Tachycardia (early)
• Bradycardia (late)
• cyanosis
• stupor, coma (late)

• Absence of breathing
• Usually caused by event such as drowning or head injury

continuous waveform capnography in addition to clinical assessment

• Give O2
• Open airway
• Provide basic vent
• Use basic airway adjuncts
• suction as needed

• Place OPA at side of face
• When flange of OPA is a corner of mouth, and tip is at angle of mandible
• Too large may obstruct larynx or cause additional trauma
• Too small may push base of tongue posteriorly and obstruct airway

• Compare outer circumference with inner aperture of nares
• NAP should be same distance from tip of nose to earlobe

Any condition brought on by a sudden reduction or blockage of blood flow to the heart.

• *Acute coronary syndrome - tx involves initial use of drugs to relieve ischemic discomfort, dissolve clots and inhibit thrombin and platelets:
• MONA (Morphine, O2, Nitro, Aspirin)
• Fibrinolytic therapy
• Heparin

• Beta-blockers
• Adenosine diphosphate antagonists
• ACE inhibitors
• Statins (HMG-CoA inhibitors)
• Glycoprotein llb/llla inhibitors

• Giving MONA (Morphine, Oxygen, Nitro, Aspirin)
• Obtain initial 12 lead ECG
• If EMS if trained, can give fibrinolytic therapy. If not, call ahead to ED

• If O2 <90, start oxygen at 4 L/min, titrate
• Aspirin 160 to 325 mg
• Nitro (subL or spray) 1once every 5 min, 3x max
• Morphine by IV

• 1. Whats the HR
• 2. Is HR reg or irreg
• 3. Is P wave present
• 4. Is QRS present
• 5. Is there a relationship w P + QRS

• Normal sinus rhythm
• A flutter
• A-fib
• 1° block
• 2° block type I

• Sinus tach
• A flutter
• A-fib

• V-tach
• SVT/A-tach

• Sinus brady
• A flutter
• A-fib
• 1° block
• 2° block type I or II
• 3°

• V. Fib (no rate)
• Asystole
• 3° block

relating to or denoting the sinoatrial node of the heart or its function as a pacemaker.

• Asystole
• PEA

• a sinus rhythm with a rate that is lower than normal.
• Generally resting HR btwn 30 - 59 bpm
• Not necessarily life threatening, but could be a prob

• Premature ventricular contraction
• Extra, abnormal heartbeats that begin in one of the heart's two lower chambers.
• caused by an ectopic cardiac pacemaker located in the ventricle.
• PVCs are wide & ugly
• Characterized by premature and bizarrely shaped QRS complexes usually wider than 120 msec on with the width of the electrocardiogram (ECG)
• Can be caused by caffeine, stress or meds
• Something caused heart to be irritated & kicked off beat

• Fast heart rhythm that starts in the lower part of the heart (ventricles). If left untreated, may get worse and lead to v-fib, which can quickly become lethal
• Will go one way or another soon!

• Regular rhythm
• NO P WAVE
• NO P - QRS RELATIONSHIP
• May or may not have a pulse = PEA

The lower chambers quiver and the heart can't pump any blood, causing cardiac arrest.

• Has no rate, no P-QRS complex
• Irregular
• No P Wave
• Lethal!! Must be treated quickly
• Shockable!

Possible causes: hypothermic, electrical, electrolyte imbalance (hyperkalemia)

• Nothingness
• No rate, 
• NEVER SHOCKABLE!! If you try to shock, you'll never bring back your pt

• Premature arterial contraction
• Extra, abnormal heartbeat that starts in the upper chambers of the heart (atria).
• look like normal rhythm
• Can be caused by caffeine, stress, hot guy walks by...
• Not prob unless symptomatic
• Chronic PAC could need ablation

• Also called Atrial Tachycardia (A-Tach)
• *this is the one that looks like P is cheating on QRS with T, T is humping P
• Atria is no given time to completely fill up. 

• Reg HR
• P wave is present
• QRS is present
• Is a relationship w P-QRS, BUT unhealthy as it's moving too fast. Can't keep up for long

• Can be caused from caffine, congenital heart disease
• Will be SOB, increased HR, posturing due to oxygen deprivation

#1 tx: vagal manuvers. Can also put pt face in ice water

Pharm: ADENOSINE

• Problem with perfusing.
• If perfusing, then overfilling ventricle before has chance to contract. 

• Reg HR
• No P wave 
• QRS is present/ but not present
• No relationship with P-QRS

• Cardiovert if symptomatic
• Use drugs first, if that doesn't work shock

*Concern is whether a clot is building with blood swirling in heart

Atria not contracting, blood just flowing. Clots can be developing

• Reg rate
• No P wave
• QRS is present
• No relationship
• Narrow QRS
• *can be lethal
• People walk around in this rhythm all the type. They are put on coumadin used for prevention

• Tx: Pharm first
• Then shock

• Reg HR
• P Wave is present
• QRS is present
• There is a relationship, but it is distant. 
• They don't want to break up, but P & QRS is distant
• Could be potential problem

• Also called Winkie (Wenckebach)
• Reg HR
• Irregular P wave
• QRS is present
• No relationship!
• It's a bad relationship as ventricular overfills and then a mega-bolus of blood gets pushed out

• Reg HR, but weird
• P wave is present as is QRS
• Bad relationship = Together/apart/together

• Problem is volume is not being pumped out. 
• Causes hypotension, clammy, pale, dizzy

• Tx: fluids, meds to increase HR
• Well ultimately need pacemaker

• Complete heart block
• HR is too slow
• Regular rhythm
• P is present
• QRS is present
• No relationship btwn P-QRS. They are both individually reg, but not regularly together
• Lethal!! Will code soon!