Scene Safety First always first, your safety is above everything else, hands only CPR (use pocket

BLS BASICS: Scene Safety First always first, your safety is above everything else, hands only CPR (use pocket facemask or AMBU bag) Adults call it in, start CPR, get AED Child CPR First, Phone call second Head Tilt Chin Lift method to open airway (moves tongue away from back of throat) CAB Compression, Airway, Breathing CPR for unresponsive, no normal breathing, no pulse: place hands lower half of breastbone above xiphoid process, switch after every two minutes, compressions at 100 120 compressions/minute Check for breathing and/or pulse for NO MORE than 10 seconds (5 to 10 seconds) High Quality CPR means no interruptions for more than 10 seconds, early rapid defibrillation as quickly as possible (survival decreased 10% every minute they are down) Single Rescuer Recommended not use AMBU bag (Bag mask device) Give breath just until you see visible chest rise not stomach (to minimize risk of air entering the stomach), let patient exhale, one breath every 5 6 seconds (10 12 breaths per minute) Child give one breath every 3 5 seconds Compression depth (Compressions are important to create blood flow during compressions) ADULT: atleast 2 inches (5cm) CHILD/INFANT: 1/3 depth of chest 1.5 inches (4 cm) Compression rate is universal for all ages is AT LEAST 100 compressions/minute (100 to 120 compressions/minute) CHOKING: If responsive and unable to talk, Heimlich maneuver, if unresponsive activate 911 and start CPR and compressions Effective Rescue breathing able to see visible chest rise (not stomach), resistance readjust, resistance again resume CPR Infant CPR: 2 thumbs encircling technique Infant choking: begin 5 cycles back slaps, then 5 chest thrust

ACLS ESSENTIALS: Compression Ventilation ratio 1 Rescuer Adult CPR 30:2 2 Rescuer Adult CPR with Advanced Airway at least 100/min, 1 breath every 6 8 seconds 2 Rescuer Child/Infant 15:2 (provide more breaths) Child: Pulse greater than 60/min and not breathing GIVE rescue breaths one breath every 3 5 seconds (pulse will follow) Child: Pulse less than 60/min start CPR (not perfusing properly) after two minutes call for help if alone Children run on glucose, once depleted 7% survival (children are respiratory dependent, adults are cardiac) Adult pads/dose may be used for pediatric pads unavailable Two person CPR: One person gives compressions change after two minutes, second person maintains open airway, give rescue breathing/breaths AED: call it in, put it in play *Turn it on, Put it on (apply pads) AED: only recognizes vfib (Shock advised hit the button, Shock not advised Go back to CPR) after SHOCK, immediately restart CPR and compressions, do not delay, do not check pulse ROSC: Return of Spontaneous Circulation EMS: Purpose of EMS is to improve patient outcomes by identifying and treating early clinical detection VFib, Pulseless V Tach must defibrillate (high energy unsynchronized shock) CPR switch after every two minutes, compressions at 100 120 compressions/minute AHA (American Heart Association) recommends qualitative waveform capnography (confirmation of ETT) greater than 10 mmhg (Less than 10 mmhg is inadequate) Agonal gasps most accurate indication of cardiac arrest Squeeze bag every 5 6 seconds (excessive ventilation actually decreases cardiac output by increasing thoracic pressure, decreasing venous return and decreasing cardiac output) CPR switch after every two minutes, compressions at 100 120 compressions/minute

CVA: Alert hospital (MOST IMPORTANT SO THEY ARE READY) Start fibrinolytic therapy one hour from arrival, three hours from onset of symptoms STEMI: fibrinolysis 30 min from arrival, 90 min until PCTI After Cardiac Arrest maintain temperature 32-36 degreesc for at least 24 hours Target Blood Pressure: SBP >90mmHg, MAP >65mmHg Minimum Systolic BP with fluid and vasoactive agents in Post Cardiac Arrest Patient with ROSC Goal: >90mmHG AV Block First-degree atrioventricular block - PR Interval greater than 0.20sec. Second-degree atrioventricular block - Type 1 (Mobitz 1, Wenckebach): Progressive prolongation of PR interval with dropped beats (the PR interval gets longer and longer; finally one beat drops) Type 2 (Mobitz 2, Hay): PR interval remains unchanged prior to the P wave which suddenly fails to conduct to the ventricles. Third-degree atrioventricular block - No association between P waves and QRS complexes. All modern defibrillators are biphasic Closed Loop Communication: Give 1mg Atropine IV Response: I'll draw up 1mg Atropine Clearly Delegate Tasks, Address Team member immediately if about to make a mistake, if unable to perform the team member should ask for a new task PEA: After 2 min CPR, start IV, give Epi 1mg IV Most appropriate EMS destination for Sudden Cardiac Arrest with ROSC to a Coronary Reperfusion Capable Medical Center Always Alert Hospital of Arrival Correct Placement ETT (Endotracheal Tube) with Continuous Waveform Capnography If Patient Unresponsive on floor, Check breathing and pulse then is needed Open Patients Airway PEtCO2 of 8 (<10mmHg) chest compressions may not be effective, monitor and assess CPR quality

Suspected Stroke - Get Non-contrast Head CT Scan within 25min of arrival in ER For example, symptoms 2 hours ago, neg Head CT, no hemorrhage, no contraindication to fibrinolytic Rx: START FIBRINOLYTICS Minimize interruptions in chest compressions during CPR, continue CPR while Defib recharges ACS (Acute Coronary Syndrome) give ASA 160-325 mg PO If patient is symptomatic, skip vagal maneuvers and go to Synchronized Cardioversion Pulse check for no more than 5-10 seconds Patient with chest discomfort, stable check 12 LEAD EKG FIRST STEMI maximum goal time from ER to PCI (percutaneous coronary intervention/balloon inflation) in 90 minutes Excessive ventilation decreases cardiac output Stable Narrow Complex Tachyarrhythmia: Adenosine 6mg, 12mg, 12mg Amiodarone 300mg for refractory VFib OPA (oral pharyngeal airway) measure from corner of mouth to angle of mandible

Useful Tips: High quality CPR and early defibrillator is the core of ACLS care in the cardiac arrest patient. High quality CPR can be measured by Partial End Tidal Carbon Dioxide (PETCO). -A reading greater than 10 and less than 23 indicates high quality CPR. The normal PETCO is 35-45 mm HG. Any reading less than 10 indicates ine!ectiveness CPR during resuscitation. A sudden rise of PETCO towards normal is the first sign of return spontaneous circulation (ROSC). If an AED does not analyze it is defective, do not attempt to troubleshoot. Atropine is no longer recommended for the treatment of Asystole or PEA. Pulseless Electrical Activity is finding of a rhythm that would normally profuse, but is not. All symptomatic bradycardiac patients should receive Atropine 0.5 mg IVB Q 3-5 minutes up to 3 mg., those patients who do not respond may be treated with Dopamine or Epinephrine infusions or Transcutaneous pacing. Any regular tachycardia that is unstable and the treatment of choice should be synchronized defibrillator, with or without sedation. In the ROSC algorithms the first priority is to maintain airway, overall focus is maintenance of homeostasis. PCI and induction of therapeutic hypothermia can be safely combined. Target values after ROSC, PAO2 / FIO2 94-98, PETCO 35-45, BP 90 mm HG systolic. ROSC patients can receive 1-2L of 4 degree Celsius Saline or Ringers. In Bradycardia and Tachycardia always consider underlying causes as first line treatment.