This uptodate.com article has ACLS Algorithms.
Contraindications for Nitroglycerin during ACS.
- Severe bradycardia.
- Tachycardia.
- Hypotension
- Phosphodiesterase inhibitors within the past 24 to 48 hours (often used for erectile dysfunction)
- Right ventricular infarction – often presents as inferior wall STEMIs. Get right-sided 12-lead ECG. If RV infarction is present, nitrates are contraindicated.
If NTG doesn’t relieve pain, may use oxygen for pain control.
For STEMI patients
- PCI in 120 minutes from first medical contact or 90 minutes from ED arrival.
High-Quality BLS
- Compress at a depth of least 2 inches
- Position body over the patient
- Rate 100 to 120 / min.
- Allow complete chest recoil b/c it allows maximum blood return to the heart.
- Minimize interruptions in compressions (including pauses to give breaths).
- Avoid excessive ventilation.
- *Don’t forget to lay the patient on the floor or use a bed board for compressions. Doing compressions on a bed is worthless and won’t count
- 30:2 in the un-intubated patient = Combine 30 compressions with 2 ventilations. Single-rescuer vs. two rescuer approaches.
- If intubated, give 6 to 8 breaths per minute or give ventilations every 6 seconds.
- If not intubated (bag-mask) give ventilations every 5-6 seconds.
- If a patient has spontaneous circulation but needs ventilation support, give ventilations every 5-6 seconds.
- Take 1 second to give each breath.
- Each breath should be about 500 to 600 ml.
- Switch compressors every 2 minutes to avoid fatigue.
- Use audio and visual feedback devices to improve CPR quality in real time.
- Apply AED pads to the pt’s bare chest while continuing excellent chest compressions. Stop compressions and assess rhythm. If shockable rhythm (VF or VT), Clear the patient and give the shock. Also, clear pt when the AED is analyzing heart rhythm or delivering the shock.
- Excellent chest compressions take priority over ventilation.
- Ventilate until you see the chest rise – minimizes the risk of air entering the pts stomach during bag-mask ventilation.
- Resume compressions immediately after giving a shock or using AED to analyze the rhythm.
- The maximum interval for pausing chest compressions = 10 seconds to give two breaths.
- Advanced airways include ET (intubation); Laryngeal mask airway; Laryngeal tube.
Stroke
- 87% of all strokes in the U.S. are ischemic. The rest are hemorrhagic.
- The 8 Ds of stroke care.
- Hold aspirin for at least 24 hours if rtPA is administered.
ACLS keys
- Shock /Defibrillate VF and VT
- Non-shockable rhythms = PEA and Asystole.
- Identity and treat treatable conditions: The Reversible Causes of Cardiac Arrest (5 H’s and 5 T’s).
- Torsade de point is an indication for the use of magnesium in cardiac arrest.
**If IV is unsuccessful, use IO.