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 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
- 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 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
- 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
- Second Degree Heart Block
- Mobitz 1: “Wenckebach”
- PR progressively prolonged, then drops QRS
- generally benign
- Mobitz 1: “Wenckebach”
- 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
- Third Degree Heart Block
- Looks for separate atrial and ventricular heart rates
- admit, cardiology, monitor and ready to pace
Start a MOGIE?
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The GenerEhlist – CCFP 105 Topics Podcast, Episode Two: ACLS Part I is now available for your listening pleasure 🙂
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