Acls

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ISBN 978-1-61669-010-6

Printed in the United States of America

Firs t American Heart As s ociation Printing May 2011

Editors

Elizabeth Sinz, MD, Associate Science Editor Kenneth Navarro, Content Consultant

Se nior Ma na ging Editor

Erik S. Soderberg, MS

Spe cia l Contributors

Clifton W. Callaway, MD, PhD Diana M. Cave, RN, MSN Heba Cos tandy, MD, MS

Mary Fran Hazins ki, RN, MSN Theres a Hoadley, RN, PhD, TNS Robert W. Neumar, MD, PhD Peter D. Panagos , MD

Sallie Young, PharmD, BCPS

ACLS Subcom m itte e 2010-2011

Clifton W. Callaway, MD, PhD, Chair

Robert W. Neumar, MD, PhD, Immediate Past Chair, 2008-2010 Steven Brooks , MD Daniel P. Davis , MD Michael Donnino, MD Andrea Gabrielli, MD Romergryko Geocadin, MD Erik Hes s , MD, MSc Mark S. Link, MD Bryan McNally, MD, MPH Venu Menon, MD Graham Nichol, MD, MPH Brian O’Neil, MD J os eph P. Ornato, MD Charles W. Otto, MD Michael Shus ter, MD Scott M. Silvers , MD Mintu Turakhia, MD, MS Terry L. Vanden Hoek, MD J anice L. Zimmerman, MD

Ad va c e d C a rd io va s c la r

Life S p p o r t

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ACLS Subcom m itte e 2009-2010

Robert W. Neumar, MD, PhD, Chair

Laurie J . Morrison, MD, MSc, Immediate Past Chair, 2006-2008

Steven Brooks , MD

Cli ton W. Callaway, MD, PhD Daniel P. Davis , MD Andrea Gabrielli, MD Romergryko Geocadin, MD Richard Kerber, MD Mark S. Link, MD Bryan McNally, MD, MPH Graham Nichol, MD, MPH Brian O’Neil, MD J oseph P. Ornato, MD Charles Otto, MD, PhD Michael Shus ter, MD Scott M. Silvers , MD

Terry L. Vanden Hoek, MD

Acknowle dgm e nts

Peter Olu Anders on, MD Ulrik Chris tens en, MD

To f nd out about any updates or corrections to this text, vis it www.he a rt.org/c p r, navigate

to the page or this course, and click on “Updates.”

To access the Student Website or this course, go to www.he a rt.org/e c c s tude nt and enter

this code: algorithm

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C o n t e n t s

P a rt 1

Co u r s e Ove r vie w

1 Cours e De s cription a nd Goa l

1 Cours e Obje ctive s

1 Cours e De s ign

2 Cours e Pre re quis ite s a nd Pre pa ra tion

2 BLS Skills

2 ECG Rhythm Interpretation for Core ACLS Rhythms

3 Bas ic ACLS Drug and Pharmacology Knowledge

3 Practical Application of ACLS Rhythms and Drugs

3 Effective Res us citation Team Concepts

3 Cours e Ma te ria ls

3 ACLS Provider Manual

4 Student Webs ite

5 Pocket Reference Cards

6 Precours e Preparation Checklis t

6 Re quire m e nts for Succe s s ful Cours e Com ple tion

7 ACLS Upda te Cours e

7 ACLS Provide r Ma nua l Abbre via tions

7 P a rt 2

Th e Sys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys

1 1

Introduction

11 Learning Objectives

11 The Sys te m a tic Approa ch: The BLS a nd ACLS Surve ys

11 Overview of the Sys tematic Approach

11 The BLS Surve y

12 Overview of the BLS Survey

12 The ACLS Surve y

14 Overview of the ACLS Survey

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C o n t e n t s

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Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s

1 7

Introduction

17 Learning Objectives

17 Role s of the Te a m Le a de r a nd Te a m Me m be rs

18 Role of the Team Leader

18 Role of the Team Member

18 Ele m e nts of Effe ctive Re s us cita tion Te a m Dyna m ics

19 Clos ed-Loop Communications

19 Clear Mes s ages

19 Clear Roles and Res pons ibilities

20 Knowing One’s Limitations

21 Knowledge Sharing

22 Cons tructive Intervention

22 Reevaluation and Summarizing

23 Mutual Res pect

23 P a rt 4

Sys t e m s o f Ca re

2 5

Introduction

25 Learning Objectives

25 Ca rdiopulm ona ry Re s us cita tion

25 Quality Improvement in Res us citation Sys tems ,

Proces s es , and Outcomes

25 A Sys tems Approach

26 Meas urement

27 Benchmarking and Feedback

27 Change

27 Summary

27 Pos t–Ca rdia c Arre s t Ca re

28 Therapeutic Hypothermia

28 Hemodynamic and Ventilation Optimization

28 Immediate Coronary Reperfus ion With PCI

28 Glycemic Control

28 Neurologic Care and Prognos tication

29 Acute Corona ry Syndrom e s

29 Starts “On the Phone” With Activation of EMS

29 EMS Components

29 Hos pital-Bas ed Components

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Con te n ts

Acute Stroke

30 Regionalization of Stroke Care

30 Community and Profes s ional Education

30 EMS

30 Educa tion, Im ple m e nta tion, a nd Te a m s

30 The Need for Teams

30 Cardiac Arres t Teams (In-Hos pital)

31 Rapid Res pons e Sys tem

31 Medical Emergency Teams and Rapid Res pons e Teams

31 Regional Sys tems of Emergency Cardiovas cular Care

32 Publis hed Studies

32 Implementation of a Rapid Res pons e Sys tem

32 P a rt 5

Th e ACLS Ca s e s

3 3

Overview of the Cas es

33 Re s pira tory Arre s t Ca s e

34 The BLS Survey

34 The ACLS Survey

36 Management of Res piratory Arres t

38 Giving Supplementary Oxygen

38 Opening the Airway

38 Providing Bas ic Ventilation

40 Bas ic Airway Adjuncts : Oropharyngeal Airway

42 Bas ic Airway Adjuncts : Nas opharyngeal Airway

43 Suctioning

45 Providing Ventilation With an Advanced Airway

47 Precautions for Trauma Patients

49 VF Tre a te d With CPR a nd AED Ca s e

49 The BLS Survey

50 AED Us e in Special Situations

57 VF/Puls e le s s VT Ca s e

59 Managing VF/Puls eles s VT: The Cardiac Arres t Algorithm

60 Application of the Cardiac Arres t Algorithm: VF/VT Pathway

62 Routes of Acces s for Drugs

69 Vas opres s ors

70 Antiarrhythmic Agents

71 Immediate Pos t–Cardiac Arres t Care

72 Application of the Immediate Pos t–Cardiac Arres t Care Algorithm

73 Puls e le s s Ele ctrica l Activity Ca s e

78 Des cription of PEA

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C o n t e n t s

Managing PEA: The Cardiac Arres t Algorithm

79 Managing PEA: Diagnos ing and Treating Underlying Caus es

82 As ys tole Ca s e

86 Approach to As ys tole

86 Managing As ys tole

87 Application of the Cardiac Arres t Algorithm: As ys tole Pathway

88 Terminating Res us citative Efforts

89 Acute Corona ry Syndrom e s Ca s e

91 Goals for ACS Patients

92 Managing ACS: The Acute Coronary Syndromes Algorithm

95 Identification of Ches t Dis comfort Sugges tive of Is chemia (Box 1)

96 EMS As s es s ment, Care, and Hos pital Preparation (Box 2)

96 Immediate ED As s es s ment and Treatment (Box 3)

99 STEMI (Boxes 5 Through 8)

100 Clas s ify Patients According to ST-Segment Deviation

(Boxes 5, 9, and 13)

101 Bra dyca rdia Ca s e

104 Des cription of Bradycardia

107 Managing Bradycardia: The Bradycardia Algorithm

108 Application of the Bradycardia Algorithm

109 Trans cutaneous Pacing

112 Uns ta ble Ta chyca rdia Ca s e

114 The Approach to Uns table Tachycardia

114 Managing Uns table Tachycardia: The Tachycardia Algorithm

116 Application of the Tachycardia Algorithm to the Uns table Patient

118 Cardiovers ion

120 Synchronized Cardiovers ion Technique

122 Sta ble Ta chyca rdia Ca s e

124 Approach to Stable Tachycardia

125 Managing Stable Tachycardia: The Tachycardia Algorithm

126 Application of the Tachycardia Algorithm to the Stable Patient

127 Acute Stroke Ca s e

130 Approach to Stroke Care

132 Identification of Signs of Pos s ible Stroke (Box 1)

135 Critical EMS As s es s ments and Actions (Box 2)

138 In-Hos pital, Immediate General As s es s ment and Stabilization (Box 3)

139 Immediate Neurologic As s es s ment by Stroke Team or Des ignee (Box 4)

140 CT Scan: Hemorrhage or No Hemorrhage (Box 5)

141 Fibrinolytic Therapy

143 General Stroke Care (Boxes 11 and 12)

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Con te n ts

Ap p e n d ix

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Te s ting Che cklis ts a nd Le a rning Sta tion Che cklis ts

151 2010 AHA Guide line s for CPR a nd ECC Sum m a ry Ta ble

163 ACLS Pha rm a cology Sum m a ry Ta ble

165 Glos s a ry

168 Founda tion Inde x

171 In d e x

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No t e o n Me d ic a t io n Do s e s

Emergency cardiovas cular care is a dynamic s cience. Advances in treatment and drug therapies occur rapidly.

Readers s hould us e the following s ources to check for changes in recommended dos es , indications , and contraindi-cations : the ECC Handbook, available as optional s upplementary material, and the package ins ert product information sheet for each drug and medical device.

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C o n t e n t s

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Co u rs e De s c rip t io n a n d Go a l

The Advanced Cardiovas cular Life Support (ACLS) Provider Cours e is des igned for healthcare providers who either direct or participate in the management of cardiopul-monary arres t or other cardiovas cular emergencies . Through didactic ins truction and active participation in s imulated cas es , s tudents will enhance their s kills in the diagnos is and treatment of cardiopulmonary arres t, acute arrhythmia, s troke, and acute coronary s yndromes (ACS).

After s ucces s ful completion of this cours e, s tudents will be able to apply important concepts , including

• The Bas ic Life Support (BLS) Survey

• High-quality cardiopulmonary res us citation (CPR)

• The ACLS Survey

• The ACLS algorithms

• Effective res us citation team dynamics

• Immediate pos t–cardiac arres t care

The goal of the ACLS Provider Cours e is to improve outcomes for adult patients with cardiac arres t or other cardiopulmonary emergencies through provider training.

Co u rs e Ob je c t ive s

Upon s ucces s ful completion of this cours e s tudents s hould be able to

• Recognize and initiate early management of periarres t conditions that may res ult in cardiac arres t or complicate res us citation outcome

• Demons trate proficiency in providing BLS care, including prioritizing ches t compres -s ion-s and integrating automated external defibrillator (AED) u-s e

• Recognize and manage res piratory arres t

• Recognize and manage cardiac arres t until termination of res us citation or trans fer of care, including immediate pos t–cardiac arres t care

• Recognize and initiate early management of ACS, including appropriate dis pos ition

• Recognize and initiate early management of s troke, including appropriate dis pos ition

• Demons trate effective communication as a member or leader of a res us citation team and recognize the impact of team dynamics on overall team performance

Cours e Overview

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Co u rs e De s ig n

To help you achieve thes e objectives , the ACLS Provider Cours e includes practice learning s tations and a Megacode evaluation s tation.

The practice learning stations give you an opportunity to actively participate in a variety of learning activities , including

• Simulated clinical s cenarios

• Demons trations by ins tructors or video

• Dis cus s ion and role playing

• Practice in effective res us citation team behaviors

In thes e learning s tations you will practice es s ential s kills both individually and as part of a team. This cours e emphas izes effective team s kills as a vital part of the res us citative effort. You will have the opportunity to practice as a team member and a team leader.

At the end of the cours e, you will participate in a Megacode evaluation station to validate your achievement of the cours e objectives . A s imulated cardiac arres t s cenario will evalu-ate the following:

• Knowledge of core cas e material and s kills

• Knowledge of algorithms

• Unders tanding of arrhythmia interpretation

• Us e of appropriate bas ic ACLS drug therapy

• Performance as an effective team leader

Co u rs e P re re q u is it e s a n d P re p a ra t io n

The American Heart As s ociation (AHA) limits enrollment in the ACLS Provider Cours e to healthcare providers who direct or participate in the res us citation of a patient either in or out of hos pital. Participants who enter the cours e mus t have the bas ic knowledge and s kills to participate actively with the ins tructor and other s tudents .

Before the cours e, pleas e read the ACLS Provider Manual, complete the s elf-as s es s ment modules on the Student Website (www.he a rt.o rg /e c c s tud e nt), identify any gaps in your knowledge, and remediate thos e gaps by s tudying the applicable content in the ACLS Provider Manual or other s upplementary res ources .

The following knowledge and skills are required for succes sful cours e completion:

• BLS s kills

• Electrocardiogram (ECG) rhythm interpretation for core ACLS rhythms

• Knowledge of airway management and adjuncts

• Bas ic ACLS drug and pharmacology knowledge

• Practical application of ACLS rhythms and drugs

• Effective res us citation team concepts

BLS Sk ills

The foundation of advanced life s upport is s trong BLS s kills . You mus t pas s the 1-Res cuer CPR and AED Tes ting Station to s ucces s fully complete the ACLS cours e. Make sure that you are proficient in BLS skills before attending the course.

Watch the CPR and AED Skills video found on the Student Webs ite

(www.he a rt.o rg /e c c s tude nt). Review the CPR and AED Tes ting Checklis t located in the Appendix.

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ECG Rh yt h m

In t e rp re t a t io n

fo r Co r e ACLS

Rh yt h m s

The basic cardiac arres t and periarres t algorithms require s tudents to recognize thes e ECG rhythms :

• Sinus rhythm

• Atrial fibrillation and flutter

• Bradycardia

• Tachycardia

• Atrioventricular (AV) block

• As ys tole

• Puls eles s electrical activity (PEA)

• Ventricular tachycardia (VT)

• Ventricular fibrillation (VF)

The AHA recommends that you complete the ECG rhythm identification s

elf-as s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of the as s es s ment you will receive your s core and feedback to help you identify areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering the cours e. During the cours e you mus t be able to identify and interpret rhythms during practice as well as during the final Megacode evaluation s tation.

Ba s ic ACLS Dr u g

a n d P h a rm a c o lo g y

Kn o w le d g e

You mus t know the drugs and dos es us ed in the ACLS algorithms . You will als o need to know when to us e which drug bas ed on the clinical s ituation.

The AHA recommends that you complete the ACLS pharmacology review s elf-as s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tude nt). At the end of the as s es s ment you will receive your s core and feedback to help you identify areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering the cours e.

P r a c t ic a l

Ap p lic a t io n o f

ACLS Rh yt h m s

a n d Dru g s

Take the ACLS practical application s elf-as s es s ment on the Student Webs ite (www.he a rt.org/e c c s tude nt) to evaluate your ability to integrate both rhythm interpretation and the us e of pharmacologic agents . This as s es s ment pres ents a clinical scenario and an ECG rhythm. You will need to take an action, give a s pecific drug, or direct your team to intervene. Us e this s elf-as s es s ment to confirm that you have the knowledge you need to be an active participant in the cours e and pas s the final

Megacode tes t.

Effe c t ive

Re s u s c it a t io n

Te a m Co n c e p t s

Ins tructors throughout the cours e will evaluate your effectivenes s as a team leader and a team member. A clear unders tanding of thes e concepts is integral to s ucces s ful performance in the learning activities and the Megacode tes t. Review Part 3 in the ACLS Provider Manual before the cours e. During the Megacode the ins tructor will evaluate your team leader s kills with a major emphas is on your ability to direct the integration of BLS and ACLS activities by your team members .

Co u rs e Ma t e ria ls

Cours e materials cons is t of the ACLS Provider Manual, Student Website (www.he a rt.o rg /e c c s tude nt), 2 pocket reference cards , and Precours e

Preparation Checklis t. The icon on the left directs you to additional s upplemental information on the Student Webs ite.

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ACLS P ro vid e r

Ma n u a l

The ACLS Provider Manual contains the bas ic information you need for effective participa-tion in the cours e. This important material includes the s ys tematic approach to a cardio-pulmonary emergency, effective res us citation team communication, and the ACLS cas es and algorithms . Please review this manual before attending the course. Bring it with you for use and reference during the course.

The manual is organized into the following parts:

Co n t e n t s

Pa rt 1 Cours e Overview

Pa rt 2 The Sys tematic Approach

Pa rt 3 Effective Res us citation Team Dynamics

Pa rt 4 Sys tems of Care

Pa rt 5 The ACLS Cases

Appe ndix

• Te s ting Che c klis ts a nd Le a rning Sta tio n Che c klis ts

• 2010 AHA Guide line s for CP R a nd ECC Sum m a ry Ta ble

Summary of the new 2010 AHA Guidelines for CPR and ECC

• ACLS Pha rm a c ology Sum m a ry Ta ble

Bas ic ACLS drugs , dos es , indications /contraindications , and s ide effects

• Glo s s a ry Alphabetical lis t of terms

• Founda tion Inde x Pages where key s ubjects can be found (eg, epinephrine, cardiovers ion, pacing)

Inde x

The AHA s trongly recommends that s tudents complete the Precours e Self-As s es s ment found on the Student Webs ite and print their s cores for submission to their ACLS

Ins tructor. Supplemental topics located on the Student Webs ite are us eful but not es s en-tial for s ucces s ful completion of the cours e.

Ca ll-ou t Boxe s

The ACLS Provider Manual contains important information pres ented in call-out boxes that require the reader’s attention. Pleas e pay particular attention to the call-out boxes , lis ted below:

• Critical Concepts

• Caution

• FYI 2010 Guidelines • Foundational Facts

Cr it ic a l Co n c e p t s

Im p orta nt Info rm a tion to

Re vie w a nd Stud y

• Pay particular attention to the Critic a l Conc e pts boxes that appear in the ACLS Provider Manual. Thes e boxes contain the mos t important information that you must know.

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Ca u t io n

• Ca utio n boxes emphas ize s pecific ris ks as s ociated with interventions .

FYI 2 0 1 0 Gu id e lin e s

• FYI 2010 Guide line s boxes contain the new 2010 AHA Guidelines for CPR and ECC

information.

Fo u n d a t io n a l Fa c t s

• You will s ee Found a tio na l Fa c ts boxes throughout the ACLS Provider Manual.

Thes e boxes contain bas ic information that will help you unders tand the topics covered in the cours e.

St u d e n t We b s it e

The ACLS Student Webs ite (www.he a rt.o rg /e c c s tude nt) contains the following s elf-as s es s ment and s upplementary res ources :

Re s o u rc e

De s c r ip t io n

Ho w t o Us e

ACLS Rhythm

Ide ntific a tio n

Web-bas ed s elf-as s ess-ment: recognition of basic ECG rhythms Complete before the cours e to help evaluate your proficiency and determine the need for additional review and practice

ACLS Pha rm a c olo gy Webbas ed s elfas s es s -ment: drugs used in algorithms

P ra c tic a l Applic a tion of ACLS Algorithm s

Webbas ed s elfas s es s -ment: evaluates the practical application of rhythm recognition and pharmacology in the ACLS algorithms

ACLS Supple m e nta ry Inform a tion • Bas ic Airway Management • Advanced Airway Management • ACLS Core Rhythms • Defibrillation • Access for Medications • Acute Coronary Syndromes • Human, Ethical, and Legal Dimens ions of ECC and ACLS

Additional information to s upplement bas ic concepts pres ented in ACLS cours e Some information is s up-plementary; other areas are for the interested student or advanced provider CPR a nd AED Skills vide o Supplementary res ources : review current BLS s equence and s kills

Review BLS s kills to

prepare for the 1-Res cuer CPR and AED Tes ting

Station

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(continued)

Re s o u rc e

De s c r ip t io n

Ho w t o Us e

ACS vide o Supplementary res ources :

ACS assessment and treatment

Review for ACS Learning Station

Stroke vide o Supplementary res ources :

s troke as s es s ment and treatment

Review for Stroke Learning Station

ACLS Sc ie nc e Ove rvie w vid e o

Supplementary res ources : core emphas is of the

ACLS course from a s cience pers pective

Update ACLS knowledge and learn about changes in application of ACLS s ci-ence

IO a nim a tio n Supplementary res ources :

information and demon-s tration of intraodemon-s demon-s eoudemon-s (IO) ins ertion

Expanded information on IOs

P o c k e t Re fe r e n c e

Ca rd s

The Pocket Reference Cards are 2 stand-alone cards packaged with the ACLS Provider Manual. Thes e cards can be carried in your pocket for quick reference on the following topics :

To p ic

Re fe re n c e Ca rd s

Ca rdia c a rre s t, a rrhythm ia s , a nd tre a tm e nt

• Cardiac Arres t Algorithms

• Gray box with drugs and dos age reminders

• Immediate Pos t–Cardiac Arres t Care Algorithm

• Bradycardia Algorithm

• Tachycardia Algorithm

ACS a nd s troke • ACS Algorithm

• Fibrinolytic Checklis t for STEMI

• Fibrinolytic Contraindications for STEMI

• Suspected Stroke Algorithm

• Stroke As s es s ment–CPSS

• Us e of IV rtPA for Acute Is chemic Stroke

• Hypertens ion Management in Acute Is chemic Stroke

P r e c o u r s e

P r e p a r a t io n

Ch e c klis t

The Precours e Preparation Checklis t is packaged with the ACLS Provider Manual. Pleas e review and check the boxes after you have completed preparation for each s ection.

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Re q u ire m e n t s fo r S u c c e s s fu l Co u rs e Co m p le t io n

To s ucces s fully complete the ACLS Provider Cours e and obtain your cours e completion card, you mus t

• Pas s the 1-Res cuer Adult CPR and AED Tes t

• Pas s the Bag-Mas k Ventilation Tes t

• Demons trate competency in learning s tation s kills

• Pas s the Megacode Tes t

• Pas s the clos ed-book written exam with a minimum s core of 84%

ACLS Up d a t e Co u rs e

The ACLS Update Cours e is for s tudents who have a current ACLS Provider card and need to update and refres h their ACLS s kills . This cours e is primarily focus ed on s kills competency tes ting.

• Maximum renewal period: 2 years

• Update requirements : Previous ACLS cours e completion card (not expired)

ACLS P ro vid e r Ma n u a l Ab b re via t io n s

A

ABCD ACLS Survey: Airway, Breathing, Circulation, Differential

Diagnos is

ACE Angiotens in-converting enzyme

ACLS Advanced cardiovas cular life s upport

ACS Acute coronary s yndromes

AED Automated external defibrillator

AHF Acute heart failure

AIVR Accelerated idioventricular rhythm

AMI Acute myocardial infarction

a PTT Activated partial thromboplas tin time

B

BLS Bas ic life s upport: Check res pons ivenes s , activate emergency res pons e s ys tem, check carotid puls e, provide defibrillation

C

CARES Cardiac Arres t Regis try to Enhance Survival

CP R Cardiopulmonary res us citation

CP SS Cincinnati Prehos pital Stroke Scale

CT Computed tomography

(continued)

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(continued)

D

DNAR Do not attempt res us citation

E

ECG Electrocardiogram

ED Emergency department

EMS Emergency medical s ervices

ET Endotracheal

F

FDA Food and Drug Adminis tration

Fio 2 Fraction of ins pired oxygen

G

GI Gas trointes tinal

I

ICU Intens ive care unit

INR International normalized ratio

IO Intraos s eous

IV Intravenous

L

LMWH Low-molecular-weight heparin

LV Left ventricle or left ventricular

M

m A Milliamperes

MACE Major advers e cardiac events

MET Medical emergency team

MI Myocardial infarction

m m Hg Millimeters of mercury

N

NIH National Ins titutes of Health

NIHSS National Ins titutes of Health Stroke Scale

NINDS National Ins titute of Neurological Dis orders and Stroke

NPA Nas opharyngeal airway

NSAIDs Nons teroidal anti-inflammatory drugs

NSTEMI Non–ST-s egment elevation myocardial infarction

(continued)

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Cours e Ove rvie w

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O

OPA Oropharyngeal airway

P

Pa c o2 Partial pres s ure of carbon dioxide in arterial blood

PCI Percutaneous coronary intervention

PE Pulmonary embolis m

PEA Puls eles s electrical activity

PT Prothrombin time

R

ROSC Return of s pontaneous circulation

RRT Rapid res pons e team

rtPA Recombinant tis s ue plas minogen activator

RV Right ventricle or right ventricular

S

SBP Sys tolic blood pres s ure

STEMI ST-s egment elevation myocardial infarction

SVT Supraventricular tachycardia

T

TCP Trans cutaneous pacing

U

UA Uns table angina

UFH Unfractionated heparin

V

VF Ventricular fibrillation

VT Ventricular tachycardia

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The Sys tematic Approach:

The BLS and ACLS Surveys

In t ro d u c t io n

Healthcare providers us e a s ys tematic approach to as s es s and treat arres t and acutely ill or injured patients for optimum care. The goal of the res us citation team’s interventions for a patient in res piratory or cardiac arres t is to s upport and res tore effective oxygenation, ventilation, and circulation with return of intact neurologic function. An intermediate goal of res us citation is the return of s pontaneous circulation (ROSC). The actions us ed are guided by the following s ys tematic approaches :

• BLS Survey (s teps des ignated by the numbers 1, 2, 3, 4)

• ACLS Survey (s teps des ignated by the letters A, B, C, D)

Le a rn in g Ob je c t ive s

By the end of this part you s hould be able to

1. Des cribe the critical actions of the BLS Survey and ACLS Survey

2. Des cribe as s es s ment and management that occur with each s tep of the s ys tematic approach

3. Des cribe how the as s es s ment/management approach is applicable to mos t cardio-pulmonary emergencies

Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS Su r ve ys

Ove r vie w o f

t h e Sys t e m a t ic

Ap p ro a c h

The s ys tematic approach firs t requires ACLS providers to determine the patient’s level of cons cious nes s . As you approach the patient:

• If the patient appears uncons cious

– Us e the BLS Survey for the initial as s es s ment.

– After completing all of the appropriate s teps of the BLS Survey, us e the ACLS Survey for more advanced as s es s ment and treatment.

• If the patient appears cons cious

– Us e the ACLS Survey for your initial as s es s ment.

The details of the BLS and ACLS Surveys are des cribed below.

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Th e BLS S u r ve y

Ove r vie w o f t h e

BLS Su r ve y

The BLS Survey is a s ys tematic approach to bas ic life s upport that any trained healthcare provider can perform. This approach s tres s es early CPR and early defibrillation. It does not include advanced interventions , s uch as advanced airway techniques or drug adminis tra tion. By us ing the BLS Survey, healthcare providers may achieve their goal of s upporting or res toring effective oxygenation, ventilation, and circulation until ROSC or initiation of ACLS interventions . Performing the actions in the BLS Survey s ubs tantially improves the patient’s chance of s urvival and a good neurologic outcome.

Be fore c onduc ting the BLS or ACLS Surve y, look to m a ke s ure the s ce ne is s a fe .

• The BLS Survey us es a s eries of 4 s equential as s es s ment s teps des ignated by the numbers 1, 2, 3, and 4. Simultaneous ly with each as s es s ment s tep, you s hould perform appropriate corrective action(s ) before proceeding to the next s tep. As s es s ment is a key component in this approach (eg, check the puls e before s tarting ches t compres s ions or attaching an AED).

Re m e m be r: As s e s s …the n pe rform a pp ropria te a c tion.

FYI 2 0 1 0 Gu id e lin e s

Cha ng e s in the BLS

Surve y

Pleas e note the 2 key changes from the 2005 AHA Guidelines for CPR and ECC:

• The 2010 AHA Guidelines for CPR and ECC alters the BLS s equence by eliminating “look, lis ten, and feel” followed by 2 res cue breaths . This change promotes earlier initiation of ches t compres s ions in cardiac arres t patients .

• The BLS Survey is no longer repres ented by the letters A, B, C, D but is repres ented by the numbers 1, 2, 3, 4 ins tead.

Fo u n d a t io n a l Fa c t s

Sta rting With Che s t

Com pre s s io ns vs

2 Bre a ths

• Although no publis hed human or animal evidence demons trates that s tarting CPR with 30 compres s ions rather than 2 ventilations leads to improved outcomes , it is clear that blood flow depends on ches t compres s ions . Therefore, providers mus t minimize delays in and interruptions of ches t compres s ions throughout the entire res us citation. Pos itioning the head, achieving a s eal for mouth to mouth res cue

breaths , or getting a bag mas k device for res cue breaths takes time. Beginning CPR with 30 compres s ions rather than 2 ventilations leads to a s horter delay to the firs t compres s ion.

• Once one provider begins ches t compres s ions , a s econd trained healthcare provider s hould deliver res cue breaths to provide oxygenation and ventilation as follows :

– Deliver each res cue breath over 1 s econd

– Give a s ufficient tidal volume to produce vis ible ches t ris e

Although the BLS Survey requires no advanced equipment, healthcare providers can us e any readily available univers al precaution s upplies or adjuncts , s uch as a bag mas k venti lation device. Whenever pos s ible, place the patient on a firm s urface in a s upine pos ition to maximize the effectivenes s of ches t compres s ions . Table 1 is an overview of the BLS Survey, and Figures 1 through 4 illus trate the s teps needed during the BLS Survey. Before approaching the patient, ens ure s cene s afety.

For more details , review the VF Treated With CPR and AED Cas e in Part 5 of this manual and watch the CPR and AED Skills video on the Student Webs ite (www.he a rt.o rg /e c c s tude nt).

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Th e Sys te m a tic Ap proa ch

1 3 Ta b le 1 . The BLS Surve y

As s e s s

As s e s s m e n t Te c h n iq u e a n d Ac t io n

1 Che c k re s p o ns ive -ne s s

• Tap and s hout, “Are you a ll rig h t? ”

• Check for abs ent or abnormal breathing (no breathing or only gas ping) by looking at or s c a nning the c he s t fo r m o ve m e nt (about 5 to 10 s econds )

Fig u re 1 . Check res pons ivenes s .

2 Ac tiva te the e m e rg e nc y re s p o ns e s ys te m /g e t AED

• Activate the emergency res pons e s ys tem and get an AED if one is available or s end s omeone to activate the emer-gency res pons e s ys tem and get an AED or defibrillator

Fig u re 2 . Activate the emergency res pons e s ys tem.

3 Circ ula tio n • Che c k the c a rotid puls e for 5 to 10 s econds

• If no puls e within 10 s econds , s tart CPR (30:2) beginning with ches t compres s ions

– Compress the center of the chest (lower half of the sternum) hard and fas t with at leas t 100 compres s ions per minute at a depth of at leas t 2 inches – Allow complete chest recoil after each compression – Minimize interruptions in compressions (10 s econds or les s )

– Switch providers about every 2 minutes to avoid fatigue

– Avoid exces s ive ventilation

• If there is a puls e, s tart res cue breathing at 1 breath every 5 to 6 s econds (10 to 12 breaths per minute). Check puls e about every 2 minutes

Fig u re 3 . Check the carotid puls e.

4 De fib rilla tio n • If no puls e, check for a s hockable rhythm with an AED/ defibrillator as s oon as it arrives

• Provide s hocks as indicated

• Follow each s hock immediately with CPR, beginning with compres s ions

90-1014_ACLS_P rvdrMnl_P a rt_2.indd 13 3/22/11 8:00 AM

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Cr it ic a l Co n c e p t s

Minim izing Inte rrup tions

ACLS provide rs m us t m a ke e ve ry e ffort to m inim ize a ny inte rruptions in c he s t c om p re s s io ns . Try to limit interruptions in ches t compres s ions (eg, defibrillation and advanced airway) to no longer than 10 s econds , except in extreme circums tances , s uch as removing the patient from a dangerous environment. When you s top ches t compres s ions , blood flow to the brain and heart s tops .

Avoid:

• Prolonged rhythm analys is

• Frequent or inappropriate pulse checks

• Taking too long to give breaths to the patient • Unneces s arily moving the patient

Fo u n d a t io n a l Fa c t s

Lo ne He a lthc a re

P ro vide r Ma y Ta ilor

Re s p ons e

• Lone healthcare providers may tailor the s equence of res cue actions to the mos t likely caus e of arres t. For example, if a lone healthcare provider s ees an adoles cent s uddenly collaps e, it is reas onable to as s ume that the patient has s uffered a s udden cardiac arres t.

• The lone res cuer s hould call for help (activate the emergency res pons e s ys tem), get an AED (if nearby), return to the patient to attach the AED, and then provide CPR. • On the other hand, if hypoxia is the pres umed caus e of the cardiac arres t (s uch as

in a drowning patient), the healthcare provider may give about 5 cycles (approxi-mately 2 minutes ) of CPR before activating the emergency res pons e s ys tem.

Cr it ic a l Co n c e p t s

High-Qua lity CPR

• Compres s the ches t hard and fas t.

• Allow complete ches t recoil after each compres s ion.

• Minimize interruptions in compres s ions (10 s econds or les s ). • Switch providers about every 2 minutes to avoid fatigue. • Avoid exces s ive ventilation.

Th e ACLS S u r ve y

Ove r vie w o f t h e

ACLS S u r ve y

For uncons cious patients in arres t (cardiac or res piratory):

• Healthcare providers s hould conduct the ACLS Survey after completing the BLS s urvey.

For cons cious patients who may need more advanced as s es s ment and management techniques :

• Healthcare providers s hould conduct the ACLS Survey firs t.

An important component of this s urvey is the differential diagnos is , where identification and treatment of the underlying caus es may be critical to patient outcome.

In the ACLS Survey you continue to as s es s and perform an action as appropriate until trans fer to the next level of care. Many times , team members perform as s es s ments and actions in ACLS s imultaneous ly.

Re m e m be r: As s e s s …the n pe rform a pp ropria te a c tion.

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Th e Sys te m a tic Ap proa ch

1 5 Table 2 provides an overview of the ACLS Survey. The ACLS cas es provide details on

thes e components .

Ta b le 2 . The ACLS Surve y

As s e s s

Ac t io n a s Ap p ro p r ia t e

Airwa y

– Is the airway patent? – Is an advanced airway

indicated?

– Is proper placement of airway device confirmed? – Is tube secured and

placement reconfirmed frequently?

• Ma inta in a irwa y pa te nc y in unc ons c ious pa tie nts by us e of the head tilt–chin lift, oropharyngeal air-way (OPA), or nas opharyngeal airair-way (NPA)

• Us e a dva nc e d a irwa y m a na g e m e nt if ne e de d (eg, laryngeal mas k airway, laryngeal tube,

es ophageal-tracheal tube, endotracheal tube [ET tube])

Healthcare providers must weigh the benefit of advanced airway placement against the adverse effects of interrupting chest compressions. If bag-mask ventilation is adequate, healthcare providers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation or until spontaneous circulation returns. Advanced airway devices such as a laryngeal mask airway, laryn-geal tube, or esophalaryn-geal-tracheal tube can be placed while chest compressions continue.

If us ing advanced airway devices :

• Confirm prope r inte gra tion o f CPR a nd ve ntila tio n

• Confirm prope r pla c e m e nt of a dva nc e d a irwa y de vic e s by

– Phys ical examination

– Quantitative waveform capnography

▪

Clas s I recommendation for ET tube

▪

Reas onable for s upraglottic airways

• Se c ure the de vic e to pre ve nt dis lodg m e nt

• Monitor a irwa y pla c e m e nt with c ontinuous qua ntita tive wa ve form c a pnogra phy

Bre a thing

– Are ventilation and oxygen-ation adequate?

– Are quantitative waveform capnography and oxyhemo-globin saturation monitored?

• Give s up p le m e nta ry o xyg e n whe n ind ic a te d – For cardiac arres t patients , adminis ter 100%

oxygen

– For others , titrate oxygen adminis tration to achieve oxygen s aturation values of ≥94% by puls e oximetry

• Monitor the a de qua c y of ve ntila tion a nd oxyge n-a tio n by

– Clinical criteria (ches t ris e and cyanos is ) – Quantitative waveform capnography

– Oxygen s aturation

• Avoid e xc e s s ive ve ntila tion

(continued)

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(continued)

As s e s s

Ac t io n a s Ap p ro p r ia t e

Circ ula tion

– Are chest compressions effective?

– What is the cardiac rhythm? – Is defibrillation or

cardiover-sion indicated?

– Has IV/IO access been established?

– Is ROSC present?

– Is the patient with a pulse unstable?

– Are medications needed for rhythm or blood pressure? – Does the patient need

volume (fluid) for resuscita-tion?

• Monitor CP R qua lity

– Quantitative waveform capnography (if Pe t c o ₂ is

<10 mm Hg, attempt to improve CPR quality) – Intra-arterial pres s ure (if relaxation phas e

[dias tolic] pres s ure is <20 mm Hg, attempt to improve CPR quality)

• Atta c h m onitor/de fibrilla tor for a rrhythm ia s o r c a rd ia c a rre s t rhythm s (eg, VF, puls eles s VT, as ys tole, PEA)

• P rovide de fibrilla tion/c a rdiove rs ion

• Ob ta in IV/IO a c c e s s

• Give a p p ro p ria te d rug s to manage rhythm and blood pres s ure

• Give IV/IO fluid s if ne e d e d

Diffe re ntia l dia g nos is

– Why did this patient develop symptoms or arrest?

– Is there a reversible cause that can be treated?

• Se a rc h for, find , a nd tre a t re ve rs ible c a us e s (ie, definitive care)

Pe t c o ₂ is the partial pres s ure of CO₂ in exhaled air at the end of the exhalation phas e.

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1 7

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In t ro d u c t io n

Succes s ful res us citation attempts often require healthcare providers to s imultaneous ly perform a variety of interventions . Although a CPR-trained bys tander working alone can res us citate a patient within the firs t moments after collaps e, mos t attempts require the concerted efforts of multiple healthcare providers . Effective teamwork divides the tas ks while multiplying the chances of a s ucces s ful outcome.

Succes s ful teams not only have medical expertis e and mas tery of res us citation s kills , but they als o demons trate effective communication and team dynamics . Part 3 of this manual dis cus s es the importance of team roles , behaviors of effective team leaders and team

members , and elements of effective res us citation team dynamics .

During the cours e you will have an opportunity to practice performing different roles as a member and a leader of a simulated resuscitation team.

Le a rn in g Ob je c t ive s

1. Des cribe team leader’s and team members ’ roles

2. Explain the importance of the team leader and team members unders tanding their s pecific roles

3. Des cribe how s kills mas tery combined with team dynamics may lead to increas ed s ucces s in res us citation outcomes

4. Des cribe key elements of an effective res us citation

5. Coordinate team functions while ens uring continuous high-quality CPR, defibrillation, and rhythm as s es s ment

Fo u n d a t io n a l Fa c t s

Unde rs ta nd ing Te a m

Role s

Whether you are a team member or team leader during a res us citation attempt, you s hould unde rs ta nd not only your role but a ls o the role s of othe r te a m m e m be rs . This awarenes s will help you anticipate

• What actions will be performed next

• How to communicate and work as a member or leader of the team

Effective Res us citation Team Dynamics

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Ro le s o f t h e Te a m Le a d e r a n d Te a m Me m b e rs

Ro le o f t h e Te a m

Le a d e r

The role of the team leader is multifaceted. The team leader

• Organizes the group

• Monitors individual performance of team members

• Backs up team members

• Models excellent team behavior

• Trains and coaches

• Facilitates understanding

• Focus es on comprehens ive patient care

Every res us citation team needs a leader to organize the efforts of the group. The team leader is res pons ible for making s ure everything is done at the right time in the right way by monitoring and integrating individual performance of team members . The role of the team leader is s imilar to that of an orches tra conductor directing individual mus icians . Like a conductor, the team leader does not play the ins truments but ins tead knows how each member of the orches tra fits into the overall mus ic.

The role of the team leader als o includes modeling excellent team behavior and leaders hip skills for the team and other people involved or interes ted in the res us citation. The team leader s hould s erve as a teacher or guide to help train future team leaders and improve team effectivenes s . After res us citation the team leader can facilitate analys is , critique, and practice in preparation for the next res us citation attempt.

The team leader als o helps team members unders tand why they mus t perform certain tas ks in a s pecific way. The team leader s hould be able to explain why it is es s ential to

• Pus h hard and fas t

• Ens ure complete ches t recoil

• Minimize interruptions in ches t compres s ions

• Avoid exces s ive ventilations

Whereas team members s hould focus on their individual tas ks , the team leader mus t focus on comprehens ive patient care.

Review the ACLS Science Overview video on the Student Webs ite (www.he a rt.o rg /e c c s tude nt) to help prepare for this role.

Ro le o f t h e Te a m

Me m b e r

Team members mus t be proficient in performing the s kills authorized by their s cope of practice. It is es s ential to the s ucces s of the res us citation attempt that team members are

• Clear about role as s ignments

• Prepared to fulfill their role res pons ibilities

• Well practiced in res us citation s kills

• Knowledgeable about the algorithms

• Committed to s ucces s

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Effe ctive Re s u s cita tion Te a m Dyna m ics

1 9

Ele m e n t s o f Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s

Clo s e d -Lo o p

Co m m u n ic a t io n s

When communicating with res us citation team members , the team leader s hould us e clos ed-loop communication by taking thes e s teps :

1. The team leader gives a mes s age, order, or as s ignment to a team member.

2. By receiving a clear res pons e and eye contact, the team leader confirms that the team member heard and unders tood the mes s age.

3. The team leader lis tens for confirmation of task performance from the team member before assigning another tas k.

Do

Te a m le a d e r • As s ign another tas k after receiving oral confirmation that a tas k has been completed, s uch as , “Now that the IV is in, give 1 mg of epinephrine”

Te a m m e m b e rs • Clos e the loop: Inform the team leader when a tas k begins or ends, s uch as , “The IV is in”

Do n ’t

Te a m le a d e r • Give more tas ks to a team member without as king or receiving confirmation of a completed as s ignment

Te a m m e m b e rs • Give drugs without verbally confirming the order with the team leader

• Forget to inform the team leader after giving the drug or performing the procedure

Cle a r Me s s a g e s

Clear mes s ages cons is t of concis e communication s poken with dis tinctive s peech in a controlled tone of voice. All healthcare providers s hould deliver mes s ages and orders in a calm and direct manner without yelling or s houting. Unclear communication can lead to unneces s ary delays in treatment or to medication errors .

For example: “Did the patient get IV propofol s o I can proceed with the cardiovers ion? ” “No, I thought you s aid to give him propranolol.”

Yelling or s houting can impair effective team interaction. Only one pers on s hould talk at any time.

Do

Te a m le a d e r • Encourage team members to s peak clearly Te a m m e m b e rs • Repeat the medication order

• Ques tion an order if the s lightes t doubt exis ts

Do n ’t

Te a m le a d e r • Mumble or speak in incomplete s entences

• Give unclear mes s ages and drug/medication orders

• Yell, s cream, or s hout

Te a m m e m b e rs • Feel patronized by dis tinct and concis e mes s ages

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Cle a r Ro le s a n d

Re s p o n s ib ilit ie s

Every member of the team s hould know his or her role and res pons ibilities . J us t as different s haped pieces make up a jigs aw puzzle, each team member’s role is unique and critical to the effective performance of the team. Figure 5 identifies 6 team roles for res us citation. When <6 people are pres ent, all tas ks mus t be as s igned to the healthcare providers pres ent.

When roles are unclear, team performance s uffers . Signs of unclear roles include

• Performing the s ame tas k more than once

• Mis s ing es s ential tas ks

• Freelancing of team members

To avoid inefficiencies , the team leader mus t clearly delegate tas ks . Team members s hould communicate when and if they can handle additional res pons ibilities . The team leader s hould encourage team members to participate in leaders hip and not s imply follow directions blindly.

Do

Te a m le a d e r • Clearly define all team member roles in the clinical s etting

Te a m m e m b e rs • Seek out and perform clearly defined tas ks appropri-ate to your level of competence

• As k for a new tas k or role if you are unable to perform your as s igned tas k becaus e it is beyond your level of experience or competence

Do n ’t

Te a m le a d e r • Neglect to as s ign tas ks to all available team members

• Assign tasks to team members who are unsure of their res pons ibilities

• Dis tribute as s ignments unevenly, leaving s ome with too much to do and others with too little

Te a m m e m b e rs • Avoid taking as s ignments

• Take as s ignments beyond your level of competence or expertis e

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Effe ctive Re s u s cita tion Te a m Dyna m ics

2 1

Airwa y

IV/IO/Me d s

Mo nito r/

De b rilla to r

Co m p re s s o r

TEAM LEADER

Ob s e rve r/

Re c o rd e r

Fig u re 5 . Sugges ted locations of team leader and team members during cas e s imulations .

Kn o w in g On e ’s

Lim it a t io n s

Not only s hould everyone on the team know his or her own limitations and capabilities , but the team leader s hould als o be aware of them. This allows the team leader to evaluate team res ources and call for backup of team members when as s is tance is needed. Team members s hould anticipate s ituations in which they might require as s is tance and inform the team leader.

During the s tres s of an attempted res us citation, do not practice or explore a new s kill. If you need extra help, request it early. It is not a s ign of weaknes s or incompetence to as k for help; it is better to have more help than needed rather than not enough help, which might negatively affect patient outcome.

Do

Te a m le a d e r a nd te a m m e m be rs

• Call for as s is tance early rather than waiting until the patient deteriorates to the point that help is critical

• Seek advice from more experienced pers onnel when the patient’s condition wors ens des pite primary

treatment

Do n ’t

• Reject offers from others to carry out an as s igned tas k you are unable to complete, es pecially if tas k completion is es s ential to treatment

Te a m m e m b e rs • Us e or s tart an unfamiliar treatment or therapy with-out s eeking advice from more experienced pers onnel

• Take on too many as s ignments at a time when as s is -tance is readily available

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Kn o w le d g e Sh a rin g

Sharing information is a critical component of effective team performance. Team leaders may become trapped in a s pecific treatment or diagnos tic approach; this common human error is called a fixation error. Examples of 3 common types of fixation errors are

• “Everything is okay.”

• “This and only this is the correct path.”

• “Anything but this .”

When res us citative efforts are ineffective, go back to the bas ics and talk as a team. “Well, we’ve gotten the following on the ACLS Survey…. Have we mis s ed s omething? ”

Team members s hould inform the team leader of any changes in the patient’s condition to ens ure that decis ions are made with all available information.

Do

Te a m le a d e r • Encourage an environment of information s haring and as k for s ugges tions if uncertain of the next bes t inter-ventions

• Ask for good ideas for differential diagnoses

• As k if anything has been overlooked (eg, IV acces s s hould have been obtained or drugs s hould have been adminis tered)

Te a m m e m b e rs • Share information with other team members

Do n ’t

Te a m le a d e r • Ignore others ’ s ugges tions for treatment

• Overlook or fail to examine clinical s igns that are relevant to the treatment

Te a m m e m b e rs • Ignore important information to improve your role

Co n s t ru c t ive

In t e r ve n t io n

During a res us citation attempt the team leader or a team member may need to intervene if an action that is about to occur may be inappropriate at the time. Although cons tructive intervention is neces s ary, it s hould be tactful. Team leaders s hould avoid confrontation with team members . Ins tead, conduct a debriefing afterward if cons tructive criticis m is needed.

Do

Te a m le a d e r • As k that a different intervention be s tarted if it has a higher priority

Te a m m e m b e rs • Sugges t an alternative drug or dos e in a confident manner

• Ques tion a colleague who is about to make a mis take

Do n ’t

Te a m le a d e r • Fail to reas s ign a team member who is trying to func-tion beyond his or her level of s kill

Te a m m e m b e rs • Ignore a team member who is about to adminis ter a drug incorrectly

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Effe ctive Re s u s cita tion Te a m Dyna m ics

2 3

Re e va lu a t io n a n d

Su m m a rizin g

An es s ential role of the team leader is monitoring and reevaluating

• The patient’s status

• Interventions that have been performed

• As s es s ment findings

A good practice is for the team leader to s ummarize this information out loud in a periodic update to the team. Review the s tatus of the res us citation attempt and announce the plan for the next few s teps . Remember that the patient’s condition can change. Remain flexible to changing treatment plans and revis iting the initial differential diagnos is . As k for informa-tion and s ummaries from the code recorder as well.

Do

Te a m le a d e r • Draw continuous attention to decis ions about differ-ential diagnos es

• Review or maintain an ongoing record of drugs and treatments adminis tered and the patient’s res pons e Te a m le a d e r a nd te a m

m e m be rs

• Clearly draw attention to s ignificant changes in the patient’s clinical condition

• Increas e monitoring (eg, frequency of res pirations and blood pres s ure) when the patient’s condition deteriorates

Do n ’t

Te a m le a d e r • Fail to change a treatment s trategy when new infor-mation supports such a change

• Fail to inform arriving pers onnel of the current s tatus and plans for further action

Mu t u a l Re s p e c t

The best teams are composed of members who share a mutual res pect for each other and work together in a collegial, s upportive manner. To have a high-performing team, everyone mus t abandon ego and res pect each other during the res us citation attempt, regardles s of any additional training or experience that the team leader or s pecific team members may have.

Do

• Speak in a friendly, controlled tone of voice

• Avoid s houting or dis playing aggres s ion if you are not unders tood initially

Te a m le a d e r • Acknowledge correctly completed as s ignments by s aying, “Thanks —good job!”

Do n ’t

• Shout or yell at team members —when one pers on rais es his voice, others will res pond s imilarly

• Behave aggres s ively or confus e directive behavior with aggres s ion

• Be uninteres ted in others

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Sys tems of Care

In t ro d u c t io n

A s ys tem is a group of regularly interacting and interdependent components . The s ys tem provides the links for the chain and determines the s trength of each link and the chain as a whole. By definition, the s ys tem determines the ultimate outcome and s trength of the chain and provides collective s upport and organization. For patients with pos s ible ACS, the s ys tem rapidly triages patients , determines a pos s ible or provis ional diagnos is , and initiates a s trategy bas ed on initial clinical characteris tics .

Le a rn in g Ob je c t ive s

1. Des cribe how s ys tems of care are coordinated on the bas is of the individual’s health needs

2. Define s ys tems of care that provide early acces s to coronary angiography, pos tarres t therapeutic hypothermia, and admis s ion to units providing s pecialized care

3. Des cribe the components of a rapid res pons e s ys tem

4. Dis cus s how the us e of a rapid res pons e team (RRT) or medical emergency team (MET) may improve patient outcomes

Ca rd io p u lm o n a r y Re s u s c it a t io n

Qu a lit y Im p r o ve m e n t

in Re s u s c it a t io n

Sys t e m s , P r o c e s s e s ,

a n d Ou t c o m e s

Cardiopulmonary res us citation is a s eries of lifes aving actions that improve the chance of s urvival following cardiac arres t. Although the optimal approach to CPR may vary, depending on the res cuer, the patient, and the available res ources , the fundamental challenge remains how to achieve early and effective CPR.

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A S ys t e m s Ap p ro a c h

Succes s ful res us citation following cardiac arres t requires an integrated s et of coordinated actions repres ented by the links in the adult Chain of Survival (Figure 6). The links include the following:

• Immediate recognition of cardiac arres t and activation of the emergency res pons e s ys tem

• Early CPR with an emphas is on ches t compres s ions

• Rapid defibrillation

• Effective advanced life s upport

• Integrated pos t–cardiac arres t care

Effective res us citation requires an integrated res pons e known as a s ys tem of care.

Fundamental to a s ucces s ful res us citation s ys tem of care is the collective appreciation of the challenges and opportunities pres ented by the Chain of Survival. Thus , individuals and groups mus t work together, s haring ideas and information, to evaluate and improve their res us citation s ys tem. Leaders hip and accountability are important components of this team approach.

To improve care, leaders mus t as s es s the performance of each s ys tem component.

Only when performance is evaluated can participants in a s ys tem effectively intervene to improve care. This proces s of quality improvement cons is ts of an iterative and continuous cycle of

• Sys tematic evaluation of res us citation care and outcome

• Benchmarking with s takeholder feedback

• Strategic efforts to addres s identified deficiencies

Fig u re 6 . The adult Chain of Survival.

Fo u n d a t io n a l Fa c t s

Me dic a l Em e rg e nc y

Te a m s (METs ) a nd Ra pid

Re s p ons e Te a m s (RRTs )

• Many hos pitals have implemented the us e of METs or RRTs . The purpos e of thes e teams is to improve patient outcomes by identifying and treating early clinical dete-rioration (Figure 7). In-hos pital cardiac arres t is commonly preceded by phys iologic changes . In one s tudy nearly 80% of hos pitalized patients with cardiores piratory arres t had abnormal vital s igns documented for up to 8 hours before the actual arres t. Many of thes e changes can be recognized by monitoring routine vital s igns . Intervention before clinical deterioration or cardiac arres t may be pos s ible.

• Cons ider this ques tion: “Would you have done anything differently if you knew 15 minutes before the arres t that…?”

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Sys te m s of Ca re

2 7 Ra p id Re s p o n s e Te a m Co d e Te a m Cr it ic a l Ca re Te a m

n

U

U s t a

tt b le

ll P a

P

P t i

tt e

ii n t

Fig u re 7 . Management of life-threatening emergencies requires integration of multidis ciplinary teams that can involve rapid res pons e teams , cardiac arres t teams , and intens ive care s pecialties to achieve s urvival of the patient. Team leaders have an es s ential role in coordination of care with team members and other s pecialis ts .

Me a s u r e m e n t

Quality improvement relies on valid as s es s ment of res us citation performance and outcome.

The Uts tein Guidelines provide guidance for core performance meas ures , including – Rate of bys tander CPR

– Time to defibrillation

– Survival to hos pital dis charge

Importance of information s haring among all links in the s ys tem of care – Dis patch records

– Emergency medical s ervices (EMS) patient care report – Hos pital records

Be n c h m a rk in g

a n d Fe e d b a c k

Data s hould be s ys tematically reviewed and compared internally to prior performance and externally to s imilar s ys tems . Exis ting regis tries can facilitate this benchmarking effort.

Examples include the

Cardiac Arres t Regis try to Enhance Survival (CARES) for out-of-hos pital cardiac arres t

Get With The Guidelines®_{–Res us citation program for in-hos pital cardiac arres t}

Ch a n g e

Simply meas uring and benchmarking care can pos itively influence outcome. However,

ongoing review and interpretation are neces s ary to identify areas for improvement, s uch as

Increas ed bys tander CPR res pons e rates

Improved CPR performance

Shortened time to defibrillation

Citizen awarenes s

Citizen and healthcare profes s ional education and training

S u m m a r y

Over the pas t 50 years the modern-era bas ic life s upport fundamentals of early recogni-tion and activarecogni-tion, early CPR, and early defibrillarecogni-tion have s aved hundreds of thous ands of lives around the world. However, we s till have a long road to travel if we are to fulfill the potential offered by the Chain of Survival. Survival dis parities pres ent a generation ago appear to pers is t. Fortunately, we currently pos s es s the knowledge and tools — repres ented by the Chain of Survival—to addres s many of thes e care gaps , and future dis coveries will offer opportunities to improve rates of s urvival.

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P a r t

4

2 8

P o s t –Ca rd ia c Arre s t Ca re

The healthcare s ys tem s hould implement a comprehens ive, s tructured, multidis ciplinary s ys tem of care in a cons is tent manner for the treatment of pos t–cardiac arres t patients . Programs s hould addres s therapeutic hypothermia, hemodynamic and ventilation opti-mization, immediate coronary reperfus ion with percutaneous coronary intervention (PCI), glycemic control, neurologic care and prognos tication, and other s tructured interventions . Individual hos pitals with a high frequency of treating cardiac arres t patients s how an

increas ed likelihood of s urvival when thes e interventions are provided.

Th e ra p e u t ic

Hyp o t h e r m ia

The 2010 AHA Guidelines for CPR and ECC recommends cooling comatos e (ie, lack of meaningful res pons e to verbal commands ) adult patients with ROSC after out-of-hos pital VF cardiac arres t to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours . Healthcare provid-ers s hould als o cons ider induced hypothermia for comatos e adult patients with ROSC after in-hos pital cardiac arres t of any initial rhythm or after out-of-hos pital cardiac arres t with an initial rhythm of PEA or as ys tole.

He m o d yn a m ic

a n d Ve n t ila t io n

Op t im iza t io n

Although providers often us e 100% oxygen while performing the initial res us citation,

providers s hould titrate ins pired oxygen during the pos t–cardiac arres t phas e to the lowes t level required to achieve an arterial oxygen s aturation of ≥94% . This helps to avoid any potential complications as s ociated with oxygen toxicity.

Avoid exces s ive ventilation of the patient becaus e of potential advers e hemodynamic effects when intrathoracic pres s ures are increas ed and becaus e of potential decreas es in cerebral blood flow when Pac o₂ decreas es .

Healthcare providers may s tart ventilation rates at 10 to 12 breaths per minute and titrate to achieve a Pe t c o ₂ of 35 to 40 mm Hg or a Pac o ₂ of 40 to 45 mm Hg.

Healthcare providers s hould titrate fluid adminis tration and vas oactive or inotropic agents as needed to optimize blood pres s ure, cardiac output, and s ys temic perfus ion. The

optimal pos t–cardiac arres t blood pres s ure remains unknown; however, a mean arterial pres s ure ≥65 mm Hg is a reas onable goal.

Im m e d ia t e

Co ro n a r y

Re p e r fu s io n

Wit h P CI

Following ROSC, res cuers s hould trans port the patient to a facility capable of reliably

providing coronary reperfus ion (eg, PCI) and other goal-directed pos tarres t care therapies . The decis ion to perform PCI can be made irres pective of the pres ence of coma or the

decis ion to induce hypothermia, becaus e concurrent PCI and hypothermia are reported to be feas ible and s afe and have good outcomes .

Glyc e m ic Co n t r o l

Cons ider s trategies to target moderate glycemic control (144 to 180 mg/dL [8 to 10 mmol/L]) in adult patients with ROSC after cardiac arrest.

Healthcare providers s hould not attempt to alter glucos e concentration within a lower range (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) due to the increas ed ris k of hypoglycemia.