Download ANESTHESIA ACLS ! for WRHA Anesthesiology staff

ANESTHESIA ACLS
for WRHA Anesthesiology staff
!
OUTLINE
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TRADITIONAL ACLS - Review
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Anesthesia-Specific ACLS
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Quiz
ACLS
• Systematic approach to assessment and management of
cardiopulmonary emergencies
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• Continuation of Basic Life Support - ACLS builds on good
BLS (C - A - B). Emphasis on compressions and
maintenance of circulation
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• Resuscitation efforts aimed at restoring spontaneous
circulation and retaining intact neurologic function
ACLS
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As Anesthesia lifelong learners, we are up to date
with literature. However, current ACLS certification
courses focus to paramedic and primary care
scenarios.
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In the OR setting, ACLS is a real entity; however,
the ddx and specific management is unique and
not part of current ACLS courses
Review of Traditional ACLS
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very simple algorithms for a number of cardiac
situations
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communication and the Team Approach is very
important
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someone acts as Team Leader, but all members
can contribute
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the debrief at the end is a useful tool to strengthen
and improve the response for the next code
Drug Administration
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Peripheral IV – easiest to insert during CPR
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Central IV – fast onset of action
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Endo-trachealy (down an ET tube) (NAVEL)
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Narcan, Atropine, Ventolin, Epinepherine, Lidocaine
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Need 2-2.5x the IV dose, unpredictable response
Intraosseous – with no IV access - Useful in paediatrics
Algorithms
CPR
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The cornerstone of good ACLS
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Push hard, Push fast (100 compressions per
minute)
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Goal is to minimize interruptions in compressions
ACS
STROKE
Fibrinolytic Checklist
Bradycardia
PACING
• Always appropriate
• Doesn’t always work (trans-thoracic)
• Technique
–Attach pacer pads
–Set a rate to 80 bpm
–Turn up the juice (amps) until you get capture
• Painful – may need sedation / analgesia
• Disposition becomes important
Tachycardia
V-fib/V-tach/Asystole/PEA
DDX - the traditional approach
The Basic H’s and T’s do not always include what we think
about
ROSC - Return of
Spontaneous Circulation
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extremely important time
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disposition important
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cause may still need to be treated (stenting, sx)
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if non responsive, cooling may be appropriate
Anesthesia Specific ACLS
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Most often witnessed pre-arrest and arrest events
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Almost pre-emptive or immediate interventions
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The ddx is widened as certain events specific to
peri-operative period
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Often the arrest is short lived, and we choose to
use lower doses of drugs that traditional ACLS
would otherwise suggest.
Anesthesia ACLS
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More often than not, the sequence of events is
different than following the basic ACLS approach
ex. cardiac arrest during thoracotomy
ex. managing hypotension/bradycardia in a
patient with a new vascular graft.
Common Arrest-Anesthesia
Situations
Intubation during CPR
Algorithm
DDX - H’s and T’s
As we can see, the Ddx is more inclusive
Hypotension - common Pre
arrest
Tachycardia
Know when to stop
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return of spontaneous circulation (but work’s not
done)
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no ROSC after prolonged efforts (situation
dependant)
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DNR orders presented
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Obvious signs of irreversible death
Post event
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Be sure to debrief with the team
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Anesthesia, Surgery, Nursing, Aids
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All play important roles and it i very important to
acknowledge what went well and review what
could be done better
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Debriefing also helps cope with the stress of the
situation
Quiz
Read the following questions and pick the best answer. The
answer key is at the end.
1. You find an unresponsive patient, not
breathing. After calling EMS, you determine
there is no pulse. What is your next action?
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A. Open the airway with a head tilt, chin lift
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B. Administer Epinepherine at a dose of 1mg/kg
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C. Deliver 2 rescue breaths each over 1 second
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D. Start chest compressions at a rate of at least
100/min
2. You are assessing a 58 yr old with chest
pain. BP is 92/50, HR 92, RR 14, non laboured.
pulse ox 97%. Which assessment is best?
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A. PET C02
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B. CXR
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C. Lab testing
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D. 12 lead EKG
3. What is a common but sometimes fatal
mistake in cardiac arrest management?
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A. failure to obtain vascular access
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B. prolonged periods of no ventilations
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C. failure to perform endotracheal intubation
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D. prolonged interruptions in chest compressions
4. Which action increases the chance
of successful conversion of v-fib?
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A. pausing chest compressions immediately after a
defibrillation attempt.
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B. administering 4 quick ventilations immediately
before a defibrillation attempt
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C. using manual defibrillation pads pressed lightly
on the chest
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D. providing quality compressions immediately
before a defibrillation attempt.
5. 3 minutes after a witnessed cardiac arrest, a team
member intubates during compressions. Waveform
capnography reads 8 mmHg. What is significance of this
finding?
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A. chest compressions may not be effective
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B. The ET tube is no longer in the tracy
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C. The patient meets criteria to discontinue efforts
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D. The team is hyperventilating the patient
6. Which is a safe and effective practice
within the defibrillation sequence?
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A. stop chest compressions during defibrillator
charge
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B. be sure oxygen is not blowing over patient’s
chest during shock
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C. Assess for the presence of a pule immediately
after the shock
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D. commandingly announce “clear” after you
deliver the shock
7. Which drug and dose is recommended
for the management of a patient in
refractory v-fib?
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A. Atropine 2mg
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B. Amiodarone 300 mg
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C. Vasopressin 1mg/kg
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D. Dopamine 2 mg/kg/min
8. Which of the following is a
sign of effective CPR?
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A. PET C02 greater than 10 mmHg
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B. measured urine output of 1 ml/kg/hr
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C. patient temp greater than 32 degrees Celsius
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D. diastolic intra-arterial pressure less than 20
mmHg
9. A patient presents the the ER with dizziness
and fatigue. HR 35, BP 70/50, RR 22, Sats 95%.
What is best first medication to administer?
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A. Atropine 0.5 mg
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B. Oxygen 12-15 lpm
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C. Epinepherine 0.5 mg
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D. Aspirin 160 mg chewed
10. A patient presents to the ER with dizziness and SOB
with a HR of 40. Initial atropine dose was ineffective.
Monitor does not have pacing capability. What’s the
appropriate dose of dopamine?
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A. 2-10 mg/min
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B. 2-10 mcg/kg/min
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C. 10-15 mg/min
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D. 10-15 mcg/kg/min
11. EMS is transporting a patient with a positive
prehospital stroke assessment. In the ER, BP 138/78, HR
80, RR 12, Sats 95%, EKG sinus, glucose N. What should
you do next?
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A. Head CT
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B. transfer to stroke unit
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C. immediate rTPA administration
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D. administer 100% 02
12. What is the initial priority for an
unconscious patient with any tachycardia
on the monitor?
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A. review the patient’s home meds
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B. evaluate the breath sounds
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C. determine wether pulses are present
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D. administer selective drugs
13. Which rhythm requires
synchronized cardioverison?
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A. unstable supraventricular tachycardia
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B. Atrial Fibrillation
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C. Sinus Tachycardia
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D. NSR on monitor, but no pulse
14. Which condition is a contraindication to
therapeutic hypothermia during the post-cardiac
arrest period for patients who achieve ROSC?
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A. initial rhythm of asystole
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B. responding to verbal commands
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C. patient age greater than 60
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D. desire to provide coronary repercussion (ex.
PCI)
15. What is the minimum SBP one should attempt to
achieve with fluid, inotropic, or vasopressor administration
in a hypotensive post cardiac arrest patient who achieves
ROSC (return of spontaneous circulation)?
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A. 90 mmHg
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B. 85 mmHg
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C. 80 mmHg
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D. 75 mmHg
ANSWER KEY
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1-D
2-D
3-D
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4-D
5-A
6-B
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7-B
8-A
9-A
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10 - B
11 - A
12 - C
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13 - A
14 - B
15 - A
Congrats.
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Print off the next slide as proof you completed the
didactic portion of the program.
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Department of Anesthesia
2nd Floor, Harry Medovy House
671 William Avenue
Winnipeg, Manitoba
R3E 0Z2
Phone: (204) 787-2261 Fax #: (204) 787-4291
This is to certify that
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!_________________________________________________________________________
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Has successfully completed the
didactic portion of the Anesthesia
ACLS course (approx 2 hours).
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Having completed the didactic portion,
the person mentioned above can now
participate in the hands-on session in
the Sim Lab.
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