Episode Two: ACLS – Part I


Objective One: Keep up to date with ACLS recommendations
  • Know your algorithms!
  • Know the cardiac arrest pathway, either going left down the Vf/pulselessVt or the right side with PEA
    • don’t check the rhythm after a shock, ensure straight back to compressions
  • Know the Bradycardia with a pulse pathway
    • atropine or transcutaneous pacing if unstable
  • Know the Tachycardia with a pulse pathway
    • pulseless? go to your cardiac arrest pathway
    • clarify sinus vs arrhythmia
    • if unstable, cardioversion

adenosine together with saline in a single syringe is non-inferior to traditional method of pushing adenosine then chasing with separate saline push

McDowell M, Mokszycki R, Greenberg A, Hormese M, Lomotan N, Lyons N. Single-syringe Administration of Diluted Adenosine. Acad Emerg Med. 2020 Jan;27(1):61-63. doi: 10.1111/acem.13879. Epub 2019 Nov 25. PMID: 31665806.
  • For each of these start a MOVIE
    • Get monitors on, Oxygen supplementation if hypoxemia, Vitals, IV/IO access, ECG to clarify rhythm
Objective Two: Promptly defibrillate a patient with Ventricular Fibrillation or Pulseless or Symptomatic Ventricular Tachycardia
  • Ventricular Fibrillation
    • irregular, various amplitudes, no P-waves, no T-waves, no QRS complexes
    • the MOST important shockable rhythm as it will not support life
    • Requires defibrillation
Ventricular Fibrillation https://litfl.com/ventricular-fibrillation-vf-ecg-library
  • Ventricular Tachycardia
    • wide complex as it is from the ventricles
    • need to uncover if pulseless or not
      • if no pulse you need to defibrillate
      • symptomatic but with a pulse, needs synchronized electrical cardioversion
Ventricular Tachycardia

  • Know your steps to defibrillating
    • ensure good contact with skin, shave hair if necessary and wipe dry
    • no sync needed
    • set energy level to max
    • press charge and ensure compressions are continued during this
    • announce clear and ensure everyone is clear
    • back on chest immediately after shock, do NOT check rhythm after shocking
Objective Three: Diagnose serious arrhythmias and treat according to ACLS protocols
  • Ventricular Tachycardia
    • wide complex regular
    • use Brugada criteria to differentiate from other wide-complex tachycardias
    • but if in doubt, treat it as Ventricular Tachycardia
    • Treat:
      • symptomatic with a pulse = synchronized electrical cardioversion
      • without a pulse = defibrillation per cardiac arrest ACLS pathway
Ventricular Tachycardia
  • Ventricular Fibrillation
    • can progress to finer Vfib, arrest and Torsades de Pointe
    • needs defibrillation
  • Supraventricular Tachycardia
    • narrow complex,
    • regular, retrograde p-waves, if you can see them
    • can be wide complex if aberancy present
    • can trial modified valsalva maneuver or other vagal maneuvers
    • adenosine
    • CCB or B-Blockers
    • If recurs, may need ablation to break the offending conduction pathway
Supraventricular Tachycardia
Modified Valsalva – The Red Shift
  • Atrial Fibrillation
    • Irregularly irregular (measure between R peaks)
    • Narrow complex, unless secondary pathology
    • Rate control first if RVR with BB/CCB
    • Anticoagulation to protect against stroke
    • if symptomatic, use synchronized cardioversion to attain sinus rhythm
Atrial Fibrillation
  • Second Degree Heart Block
    • Mobitz 1: “Wenckebach”
      • PR progressively prolonged, then drops QRS
      • generally benign
Mobitz – Type 1
  • Mobitz 2
      • Consistent PR interval, with dropped QRS complexes
      • more likely structural damage to conduction and more likely to progress to 3rd degree heart block
      • admit, cardiology, monitor and be ready to pace
Mobitz – Type 2
  • Third Degree Heart Block
    • Looks for separate atrial and ventricular heart rates
    • admit, cardiology, monitor and ready to pace
3rd Degree Heart Block

Start a MOGIE?

The GenerEhlist – CCFP 105 Topics Podcast, Episode Two: ACLS Part I is now available for your listening pleasure 🙂

#canadian #familymedicine #primarycare #FOAMed

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