This summary review is designed to hit the high yield aspects of the 2015 update to BLS, ACLS and PALS that is not included in the algorithmic portions of these courses. It is designed to supplement classroom didactics for both students and instructors.
Basic Life Support (BLS)
AED Pearls
- If patient is in body of water: remove patient from water prior to defibrillation (can use in rain and snow)
- If pacemaker is present: place pads front and back (keep 10 cm away from pacemaker)
- If AICD is shocking patient: wait 30 seconds after AICD to shock with AED
- If patient is pregnant: place pads front and back
- If patient is too hairy for pads to stick: just do good compressions until hair can be removed
- Adult pads CAN be used on pediatrics (do not cut pads)
- Pediatric pads CANNOT be used on adults
- Do not let pads cross (never cross the streams)
Airway Pearls
Bag Valve Mask
- BVM is a 2 person technique. Always use 2 people, if able
Adjunctive Airway
- Always use an adjunctive airway, unless there is a contraindication
- Oropharyngeal Airway (OPA): Measure corner of mouth to angle of mandible
- Nasopharyngeal Airway (NPA): Corner of nose to tip of the ear
Breathing Pearls
Rescue Breathing
Circulation Pearls
Compressions
- Rate of 100-120 for everyone
- Keep pulse check 5-10 seconds
- Minimize interruptions (once compressions are held; it takes a while to regain adequate Cerebral Perfusion Pressure (CPP)
Pediatric Advanced Life Support (PALS)
General Pearls
- Check Glucose on everyone
- Use your Broslow tape
CPR
- Start compressions if Heart Rate is < 60 bpm AND signs of poor perfusion
- Unwitnessed arrest of infant and child: do 1 round of CPR and then activate EMS/get AED
- Witnessed arrest: get help and then start CPR
General Pearls
- Check Glucose on everyone
- Use your Broslow tape
V. fib/pulseless V.tach Pearls
- 2 rounds of CPR and 2 shocks prior to first Epi in VF/pVT
- Defibrillation doses:
- 1st shock: 2 J/Kg
- 2nd shock: 4 J/Kg
- 3rd shock: > 4 J/kg (up to 10 J/Kg or adult dose reached)
- Mnemonic: “2, 4, 6, 8…thats the dose to defibrillate!”
Synchronized Cardioversion Pearls
- Don’t forget to hit the “Synch” button. This is a cardioversion, not a defibrillation.
- Get in the habit of hitting the “Synch” button immediately after you deliver a shock, and before you even re-assess the patient. It will automatically un-synch after shock is given. If a second shock is needed, you don’t want this to accidentally be unsynchronized.
- Cardioversion doses:
- 1st shock: 0.5-1 J/Kg
- 2nd shock: 2 J/Kg
- Dose is about half of the defibrillation dose
Formulas
- Normal Blood Pressure: Systolic Blood Pressure = 90 (2 x age)
- Uncuffed ETT size (age 2-10) = (age/4) + 4
- Cuffed ETT size (age 1-8) = (age/4) + 3.5
Dextrose Administration
- Glucagon:
- 0.3 mg/kg
- Don’t use in infants (need a mature liver to use)
- Dextrose:
- Option 1: Give age recommended dextrose concentrations (Rule of 50’s)
- D10 x 5 cc/Kg = 50 (will provide 0.5g/kg of dextrose) – use in neonates
- D25 x 2 cc/Kg = 50 (will provide 0.5g/kg of dextrose) – use in pediatrics
- D50 x 1 cc/Kg = 50 (will provide 0.5g/kg of dextrose) – use in adults
- Option 2: You can use D10 in everyone
- D10 has 1g of Dextrose in 10 cc’s
- You want to provide 0.5-1 g/kg Dextrose in hypoglycemia
- To make it simple, take the weight in kg and multiple it by 10. That is the volume of D10 to provide to achieve 1 g/kg of Dextrose
- This fluid does NOT count towards replacement fluids*
- Example:
- 10 Kg child
- 10 cc of D10 has 1 gm Dextrose
- Multiply weight by 10 to get the cc’s of D10 to provide
- (10 x 10 kg) = 100 cc of D10
- Option 1: Give age recommended dextrose concentrations (Rule of 50’s)
- Glucagon:
Advanced Cardiac Life Support (ACLS)
2015 Updates Summary
- Emphasis on chest compressions
- Untrained lay rescuers should provide hands-only CPR for adults until an AED arrives, unless trained to give rescue breaths
- Compression rate of 100-120 (old was at least 100)
- 2 rounds of shock prior to first Epi in VF/pVT
Patient Monitoring Pearls
pETCO2
- ETco2 = measurement of CO2 during Expiration (usually 2 to 5 mmHg < Paco2 due to the dilution of the end-tidal gases by physiologic dead space gas).
- VQ mismatch ratios including pulmonary embolism, cardiac arrest, hypovolemia, obstructive lung disease, and the lateral decubitus position can widen the Pa-ETco2 gradient
- The level of measurable CO2 is dependent on ventilation and perfusion. In a cardiac arrest patient with an advanced airway, ventilation is fixed by artificial respirations. Therefore, any changes to Cardiac Output are the direct result of changes in perfusion. So, during CPR…. ETco2 = CO
- What do these levels mean in CPR?
- < 10 mmHg: improve CPR (move hand position as you may be occluding the LV outflow, or change out compressor)
- If < 10 mmHg after 20 minutes of CPR: no evidence of survivability in literature, consider calling the code
- If > 20 mmHg after 20 minutes of CPR: literature suggests survivaability, keep going (google the name Howard Snitzer)
- What do these levels mean in CPR?
Arterial Line
- Diastolic BP measured by an arterial line can also be used to assess cardiac output during resuscitation.
- Diastolic BP < 20: improve quality of CPR or reposition hands (you may be obstructing LV outflow tract during compressions)
Intraosseous (IO) Pearls
Insertion Location
Contraindications
- Fracture of target bone
- Vascular injury of target extremity
- Infection at are of insertion
- Inability to identify landmarks
- IO or attempted IO access in target bone within the last 48 hours
- Prosthesis or orthopedic procedure near insertion site
- Osteogenesis imperfecta
Recommended anesthetic for patients responsive to pain:
- Observe cautions/contraindications to using 2% preservative and epinephrine free lidocaine (IV lidocaine)
- Confirm lidocaine dose per institutional protocol
- Prime extension set with lidocaine
- Slowly infuse lidocaine 40 mg in adults (o.5 mg/kg in pediatrics) IO over 120 seconds
- Allow lidocaine to dwell in IO space 60 seconds
- Flush with 5-10 mL of normal saline
- Slowly administer an additional 20 mg of lidocaine IO over 60 seconds AND repeat PRN
Needle Sizes
- Pink/Red: 15 mm (patient weight: 3-39 kg)
- Blue: 25 mm (patient weight: > 40 kg)
- Yellow: 45 mm (patient weight > 40 kg and obese)
IO General Pearls
- < 1% serious complication rate
- It is essential to perform a rapid normal saline (NS) syringe flush into the IO space before attempting to infuse fluids through the catheter. A rapid syringe flush of 5-10 mL normal saline in adults and 2-5 mL normal saline in infants and children helps clear the marrow and fibrin from the medullary space, allowing for effective infusion rates.
- Administer meds in same dose, rate and concentration as given via peripheral IV and follow with a flush
- Can use for up to 24 hours
- Needle is NOT MRI compatible
IO Flow Rates
Accuracy of IO labs
Medications down the Endotracheal Tube
- True drug equivalents unknown
- Give directly down the tube at 2-2.5 x IV/IO dose and dilute in 10 cc NS (adults) or 5 cc NS (peds). Normal saline is preferred over distilled water…
- Note: pediatric Epi needs 10 X the IV/IO dose (can give the higher anaphylactic Epi concentration [1:1000])
Stroke Core Measures
- Fibrinolysis: Door to needle time is 30 minutes
- PCI: Door to balloon time is 90 minutes
STEMI Core Measures
- 10 min – NIHSS must be completed
- 25 min – CT must be COMPLETED
- 45 min – all labs/x-ray/EKG must be completed
- 60 min – tPA goal
Targeted Temperature Management
- 32-36 degrees C for at least 24 hours
- Start within 3 hours for any benefit
Emergency Physician at Lake Michigan Emergency Specialists - Core faculty member at West Michigan EM Residency - Michigan State University COM Clinical Faculty - Founder of Banana Bag Blog
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