The Systematic Approach to Emergency Situations - ACLS Review

Summary

In this video lesson from ICU Advantage, Eddie Watson introduces a new series on Advanced Cardiac Life Support (ACLS). The series aims to simplify critical care concepts and is designed to supplement ACLS and BLS certifications. The lesson covers the systematic approach to ACLS, starting with initial assessments and moving through primary and secondary evaluations. Watson emphasizes the importance of quick, effective actions to improve patient outcomes in life-threatening situations. The video includes practical tips on CPR, defibrillation, and maintaining patient airway and circulation. Viewers are encouraged to like, comment, and subscribe for more critical care content.

Takeaways

• 😀 Eddie Watson introduces a series on Advanced Cardiac Life Support (ACLS) aimed at simplifying complex critical care subjects for ICU practitioners.
• 📚 The series will not replace ACLS and Basic Life Support (BLS) certification but aims to supplement learning and understanding of guidelines and best practices.
• 🚑 The primary goal of ACLS training is to improve patient outcomes in life-threatening situations by supporting oxygenation, ventilation, and circulation to preserve neurological function.
• 🔍 Initial assessment of a patient's condition is crucial, determining whether the patient is conscious and requires immediate intervention or not.
• 🆘 In cases of unconscious patients, immediate help should be called for, activating emergency response protocols and initiating BLS assessment.
• 💡 BLS forms the foundation of any ACLS algorithm and involves assessing a patient's breathing and circulation, with a focus on minimizing the delay in detecting cardiac arrest.
• 🚀 The importance of early defibrillation within the first few minutes of cardiac arrest is emphasized for better patient outcomes.
• 🎼 Songs like 'Stayin' Alive' or 'Baby Shark' can help maintain the correct compression rate during CPR.
• 🩺 The systematic approach to ACLS involves an initial impression, BLS assessment, primary assessment using the ABCDE model (Airway, Breathing, Circulation, Disability, Exposure), and a secondary assessment.
• 🧬 The secondary assessment focuses on identifying and treating the underlying cause of the emergency, often using the 'H's and T's' mnemonic to remember common causes of cardiac arrest.
• 🔗 Eddie Watson provides additional resources and encourages hands-on practice for familiarity with equipment and procedures.

Q & A

What is the primary goal of Advanced Cardiac Life Support (ACLS) training?

The primary goal of ACLS training is to improve patient outcomes in life-threatening situations by providing a systematic approach to handling patients, with a focus on supporting their oxygenation, ventilation, and circulation to preserve neurological function.

Why is it important to assess if a patient is conscious or unconscious during the initial assessment in the ICU?

Assessing if a patient is conscious or unconscious is crucial as it determines the point of entry into the systematic approach for handling the patient's condition. It helps in deciding whether to immediately call for help or proceed with basic life support (BLS) assessment.

What is the significance of checking for agonal breathing during the BLS assessment?

Agonal breathing is significant as it is a reflexive response characterized by labored gasps and strange vocalizations, which can be present in the first few moments following a cardiac arrest. Recognizing agonal breathing helps in quickly identifying the need for CPR.

How should one check for a patient's pulse during the BLS assessment, and why is the carotid pulse preferred?

One should check for a patient's pulse by feeling for the carotid pulse in the neck, as it is the easiest to access and less prone to error compared to other pulses like the femoral. It is important to check the pulse to determine if the patient requires CPR.

What is the recommended rate and depth for chest compressions during CPR, and why is full recoil important?

The recommended rate for chest compressions is 100 to 120 compressions per minute, with a depth of at least 2 inches. Full recoil is important to allow the heart to fully fill between compressions, which is crucial for maintaining effective blood flow.

Why is minimizing interruptions during chest compressions critical, and what is the impact of stopping compressions?

Minimizing interruptions during chest compressions is critical because stopping compressions immediately stops perfusion to the heart and brain. It takes about five compressions to restore effective perfusion pressure, so keeping interruptions short and ideally under 10 seconds is essential.

What is the role of an AED (Automated External Defibrillator) in the ACLS systematic approach, and why is early defibrillation important?

An AED plays a crucial role in the ACLS systematic approach by providing early defibrillation, which is key in treating shockable rhythms during cardiac arrest. Early defibrillation within the first few minutes of arrest can significantly improve the chances of survival.

What does the ABCDE model represent in the primary assessment of a patient, and why is it used?

The ABCDE model stands for Airway, Breathing, Circulation, Disability, and Exposure. It is used in the primary assessment to systematically evaluate and address the patient's condition, ensuring that all critical aspects are covered to prevent further deterioration.

How can end-tidal CO2 monitoring be used to assess a patient's circulation during CPR?

End-tidal CO2 monitoring can be used to assess a patient's circulation during CPR by providing an indication of the effectiveness of chest compressions. A value of at least 10 to 20 mmHg, and more likely greater than 20, suggests adequate compressions that are promoting blood flow.

What are the 'H's and T's' in the context of cardiac arrest, and how do they aid in identifying reversible causes?

The 'H's and T's' refer to a list of common reversible causes of cardiac arrest, including Hypoxia, Hypovolemia, Hydrogen ion (Acidosis), Hypo-/Hyperkalemia, Hypothermia, and Toxins (including drugs and poisons). They aid in identifying and treating potential causes that could be reversed to improve patient outcomes.

Outlines

00:00

📚 Introduction to ACLS Training

Eddie Watson introduces the video lesson from ICU Advantage, focusing on simplifying complex critical care subjects for ICU success. He emphasizes the importance of Advanced Cardiac Life Support (ACLS) guidelines and best practices, which are a collaborative effort from global practitioners and the American Heart Association. The video is intended to supplement ACLS and BLS certification, highlighting the necessity for quick thinking and action in critical patient situations to improve outcomes.

05:00

🚑 Basic Life Support (BLS) Foundation

This section outlines the foundational role of Basic Life Support in ACLS protocols. It details the initial steps in an emergency, including assessing the patient's consciousness, breathing, and circulation. The importance of checking for a carotid pulse and treating the absence of a pulse as a cardiac arrest is stressed. The summary also covers the correct approach to chest compressions, including rate, depth, and full recoil, as well as the significance of minimizing interruptions during CPR and the use of AED/defibrillator for early defibrillation.

10:02

🛑 Systematic Approach to ACLS

The paragraph explains the systematic approach to ACLS using the ABCDE model (Airway, Breathing, Circulation, Disability, Exposure). It discusses maintaining the airway, supporting breathing with a bag valve mask, ensuring proper circulation through compressions and monitoring, and checking for disability in neurological functioning. The summary highlights the need for IV/IO access, ECG monitoring, and the administration of appropriate drugs and fluids. It also underscores the importance of a thorough patient exposure to visually inspect for any signs of issues and the performance of these assessments often simultaneously in experienced teams.

15:03

🔍 Secondary Assessment and Reversibility of Cardiac Arrest

The final paragraph delves into the secondary assessment process, which includes a focused medical history using the SAMPLE acronym. The goal is to diagnose and treat the underlying cause of the emergency, with a particular focus on the reversible causes of cardiac arrest, referred to as the 'H's and T's. The summary stresses the importance of identifying and reversing these causes to aid in the recovery of spontaneous circulation and prevention of future arrests. It concludes with an invitation to stay tuned for future lessons and a call to action for viewers to subscribe and support the channel.

Keywords

💡ICU

ICU stands for Intensive Care Unit, which is a specialized department of a hospital that provides intensive care medicine to patients who require life support systems and close monitoring. In the video, the ICU is the primary setting where the content is applied, emphasizing the importance of understanding critical care subjects for healthcare professionals working in this high-stakes environment.

💡Advanced Cardiac Life Support (ACLS)

ACLS refers to a set of clinical interventions for the urgent treatment of cardiac emergencies, including cardiac arrest. The video is focused on teaching and reviewing ACLS protocols, which are crucial for improving patient outcomes in life-threatening situations, as outlined by the American Heart Association and other experts in critical care.

💡Basic Life Support (BLS)

BLS is the foundation of emergency care, including the initial steps to take during a medical emergency before advanced medical personnel arrive. It includes techniques like chest compressions and rescue breaths. The script mentions BLS as the starting point for any ACLS algorithm, emphasizing its importance as the first step in dealing with emergencies.

💡Cardiac Arrest

Cardiac arrest is a sudden loss of effective blood circulation due to the cessation of the heart's normal rhythmic contractions. The video discusses the recognition and response to agonal breathing, a sign of cardiac arrest, and the importance of immediate action in such situations to improve patient outcomes.

💡CPR

CPR, or cardiopulmonary resuscitation, is an emergency procedure that combines chest compressions and rescue breaths to maintain oxygen flow in the body when the heart has stopped. The script highlights the urgency of starting CPR within the first few minutes of cardiac arrest to maximize the chances of survival.

💡Defibrillation

Defibrillation is the use of an electric shock to restore the normal rhythm of the heart in the case of certain abnormal heart rhythms. The video emphasizes the importance of early defibrillation within the first few minutes of cardiac arrest, which is key to improving survival rates.

💡ABCDE

The ABCDE model is a systematic approach to the primary assessment of a patient's condition, standing for Airway, Breathing, Circulation, Disability, and Exposure. The script uses this model to guide healthcare professionals through a structured assessment process to quickly identify and address the most critical issues in a patient's condition.

💡Agonal Breathing

Agonal breathing is a type of abnormal breathing characterized by gasps or labored breaths that can occur immediately following a cardiac arrest. The video script describes agonal breathing as a reflexive response and emphasizes that it is not normal breathing, indicating the need for immediate medical intervention.

💡Intubation

Intubation is the insertion of a tube into the trachea to facilitate mechanical ventilation. The script mentions intubation as a potential step in managing a patient's airway during the primary assessment, especially when the bag valve mask is not sufficient to maintain adequate ventilation.

💡ECG

ECG stands for electrocardiogram, a diagnostic tool that measures the electrical activity of the heart. The video discusses the importance of ECG monitoring to detect arrhythmias and guide appropriate interventions during cardiac emergencies.

💡ROSC

ROSC stands for Return of Spontaneous Circulation, which is the resumption of effective blood circulation after a period of cardiac arrest. The script describes ROSC as a critical outcome to assess during the management of a cardiac emergency, indicating that interventions have been successful in restoring the patient's heartbeat.

Highlights

Introduction to a new series on Advanced Cardiac Life Support (ACLS) by Eddie Watson, aiming to simplify complex critical care subjects.

Importance of ACLS and Basic Life Support (BLS) certification for improving patient outcomes in life-threatening situations.

The systematic approach of ACLS, focusing on supporting patients' oxygenation, ventilation, and circulation to preserve neurological function.

Initial assessment of a patient's condition, emphasizing the difference between conscious and unconscious patients in the ICU.

The necessity of calling for help and initiating an emergency response when a patient appears unconscious.

Foundation of BLS as the first step in any emergency, including assessing a patient's breathing and circulation.

Differentiating between normal and agonal breathing, with the latter being a reflexive response post-cardiac arrest.

Technique for checking a patient's carotid pulse and the importance of not delaying CPR if uncertain about the presence of a pulse.

The procedure for providing rescue breaths with a bag valve mask and avoiding over-ventilation.

Initiating chest compressions when a patient has no pulse, with guidelines on rate, depth, and full recoil.

Use of songs like 'Stayin' Alive' or 'Baby Shark' to maintain the correct compression rate during CPR.

Importance of minimizing interruptions in chest compressions and keeping them under 10 seconds to maintain perfusion.

Utilization of an AED or defibrillator upon arrival, with emphasis on early defibrillation for improved outcomes.

The ABCDE model for primary assessment, covering Airway, Breathing, Circulation, Disability, and Exposure.

Techniques for maintaining a patient's airway, including head tilt chin lift and use of airway devices.

Assessment of a patient's breathing using bag valve mask and titrating oxygen levels with pulse oximetry.

Ensuring proper IV/IO access, ECG monitoring, and management of arrhythmias with appropriate drugs and fluids.

Assessing for return of spontaneous circulation (ROSC) through pulse check, ECG, and end-tidal CO2 levels.

The secondary assessment focusing on potential causes of the emergency and a focused medical history using the SAMPLE acronym.

Identification and treatment of reversible causes of cardiac arrest, referred to as the H's and T's.

Conclusion emphasizing the systematic approach as a framework for additional algorithms and guidelines in ACLS.

Transcripts

all right you guys welcome back to

another video lesson from icu advantage

and my name is eddie watson and my goal

is to give you guys the confidence to

succeed in the icu by taking these

complex critical care subjects and

making them easy to understand

if i'm able to do just that for you guys

then make sure you guys leave a like at

the end of this video as well as feel

free to subscribe to the channel to get

more content just like this here now in

this lesson here this is going to be the

first lesson

in a new series that i'm doing reviewing

a very

important concept in the world of

critical care our advanced cardiac life

support or

acls now years of expertise of many

practitioners

around the world along with the american

heart association

have come together with guidelines

algorithms and really

best practices for us with the end goal

of being improving patient outcomes in

these life-threatening situations

now over the course of this series i'm

going to be reviewing over some of the

major components of these guidelines and

really best practices

but remember that this series is

absolutely no substitute for

acls and bls certification my hope

though is that these videos are going to

be

available to kind of help supplement

your learning needs either before you go

to class

or during that two-year period between

your certification

and so working in the icu and really

caring for critically ill patients

it's going to be imperative that you

understand these guidelines and really

know them like the back of your hand

when you find your patient deteriorating

or even

coding time is of the essence and being

able to think and act quick

is really going to have a direct effect

on the outcome of your patient

so i hope to be able to help to cement

this knowledge for you guys

and we're going to start off this series

talking about the systematic approach

of acls

[Music]

all right as i mentioned the the whole

goal with our training of acls is

to be better practitioners of

peer-reviewed guidelines and best

practices

with the hopes of decreasing mortality

in our patients

the american heart association the aha

has worked to provide

a systematic approach to how we should

really handle patients

in these life-threatening situations our

primary goal

when our patients are in these

situations are to really support

their oxygenation ventilation and

circulation

all with the end goal of preserving

neurological

functioning for our patient when it's

all said and done

the whole process of a systematic

approach

really all begins with our initial

impression

and assessment of the situation so it's

here where we're going to first take in

the information about what's going

on where is the patient how do they look

what do we see on the monitor the most

important part of this initial

assessment

is going to be the assessment of if our

patient is either

unconscious or not now in the icu

oftentimes you're going to be caring for

ventilated and sedated patients

and the assessment is really not going

to give us any useful information

and so we're going to have to take in

more information at that point to make a

determination about what is going on

now whether our patient is conscious or

unconscious

is really going to determine at what

point in the systematic approach that we

enter in order to really do this

assessment you need to make sure and

tap your patient and shout at them are

you all right now

if they appear unconscious then first

and foremost

call for help so it's at this point here

where you're either

going to activate your emergency

response alert or your code

and really start off with our basic life

support assessment which i'm going to

talk about

now now our basic life support or our

bls is really going to be the

foundation of any acls algorithm that

we're working with

this is always going to be the first

step in dealing with any emergency

situation

now in some cases we're able to bypass

past this assessment because it's just

not required but this is

always going to be a part of the first

assessment that we evaluate whether we

need to intervene

at this point and so with our bls the

very

first thing that you want to do is to

assess two different things together

our patients breathing and their

circulation now for your patients

breathing

this is where you want to assess either

are they even breathing at all

or do they have any kind of abnormal

breathing now remember though that

agonal breathing is not normal breathing

and can really be present in the first

few moments following cardiac arrest in

your patient

and our agonal breathing is really a

reflexive response characterized in our

patients by

labored gasps that they're taking and

really strange vocalizations

it's pretty obvious when you see it and

you hear it and it screams

not normal now for a patient's

circulation it's really important that

you check a carotid pulse

it's the easiest to access and it's less

prone to error

when compared to checking like a femoral

pulse if you're

ever in doubt about whether your patient

has a pulse then treat it as if they

don't

now what's really important here is that

we actually want to be checking

both of these the breathing and the

circulation together

and the whole point of this is to

minimize the delay in detecting cardiac

arrest in your patient

and starting cpr this initial step

should take

no more than 5 to 10 seconds now if your

patient has a pulse

then we need to immediately move in to

support their breathing

so at this point you want to grab your

bag valve mask your ambu bag

and you want to begin giving them rescue

breaths remember this is going to be

one breath every five to six seconds

make sure that you're maintaining

a good seal and that you're seeing that

rise and fall of the patient's chest

also don't over ventilate the patient so

either going too fast or

too much with each breath and while

you're doing this you want to make sure

that we're continuing to check for a

pulse at least every two minutes

now if things at this point have

deteriorated or when you do that initial

assessment

that your patient has no pulse then

immediately begin chest compressions

now here make sure that you guys are

maintaining the adequate rate

the depth of the compressions and full

recoil of the compressions

for the right here we're talking 100 to

120 compressions per minute a couple

songs that fall within this range which

sometimes can kind of help to keep you

in line

would be something like staying alive

[Music]

or even baby shark if you want to have

that song stuck in your head

now when it comes to compressing the

chest that you want to make sure that

you're going at least

two inches now more often than not chest

compressions are going to be

too shallow than they are too deep but

studies do also show us that going too

deep on compressions can impact our

patients mortality as well so it's

really important that we're

we're sort of hitting that sweet spot

now when it comes to our recoil we want

to allow the full recoil the chest

between each compression

the whole point of this is this is going

to allow for the fulfilling of the heart

between the next compression

this is really important and so to

really kind of aid

in ensuring that we're having adequate

compressions if you guys

have a compression feedback device

make sure you guys use it it's very easy

especially as the code goes on

and exhaustion sets in that we can start

to see

decreased effectiveness of compressions

now it's also important though that you

remember as soon as you stop chest

compressions

that perfusion to both the heart and the

head are going to

immediately stop and then it takes about

five compressions

to really get that perfusion pressure

back high enough to be effective for our

patient

so what this means is that you want to

minimize any interruptions

and then really keep them as short as

possible when you do and ideally keeping

this less than 10 seconds

now as soon as the aed or probably in

the case of the hospital setting the

defibrillator arrives

you want to get the pads on your patient

and then assess for a shockable rhythm

immediately

and so the reason for this is that early

defibrillation and cardiac arrest is

really

key and we really want to see this

happen within the first three or four

minutes

from the time of a rest and so in order

to help achieve that it's going to be

really important that you guys are

comfortable with this equipment and

you're able to quickly apply the pads

assess the rhythm and deliver the shock

as quickly as you possibly can

now to kind of help talk through some of

this i'm actually going to link to a

lesson that i previously covered talking

specifically about the defibrillator

but this is really no substitute for

hands-on practice and familiarity with

your

own equipment as that's going to be key

to your success

and so back to our earlier point here

that you want to try to minimize

any disruption in chest compressions in

order to apply the pads

but as soon as you're able you want to

assess the rhythm and deliver a shock

immediately

you don't want to wait for two minutes

of chest compressions to end

now this may require stopping

compressions in order to analyze the

rhythm

and then obviously when we deliver the

shock but in some situations

and with some defibrillators that they

do have algorithms that

will allow you to continue to do

compressions

while actually being able to assess the

underlying rhythm

and then charge it up and get everything

ready to go and then from here you're

just going to continue to follow your

bls

training and guidelines but if your

initial assessment finds your patient

either conscious or you've already

performed your bls assessment

then what we next want to move to is the

primary assessment

to our systematically assess our

situation

and our conscious patients that they may

still require some

advanced assessment and actions without

the use of the bls

the hope in these situations is to try

and prevent the further

deterioration and then eventual rest of

your patient

now the systematic approach for the

primary assessment involves

a series of assessments and then actions

using

the abcde model all right so

here a stands for our airway b

is for our breathing c is for our

circulation

d is for our disability and then e is

for our exposure

so to begin we want to maintain the

airway of our patient

and this is going to be using something

like the head tilt chin lift

as well as using a device like a

nasopharyngeal

or oropharyngeal airway to help keep

that airway open

now here you guys remember please don't

use an oropharyngeal airway if your

patients are awake

in addition to this we do want to

utilize an advanced airway if it's

needed so

in almost all inpatient settings this is

going to mean intubation

now if our back valve mass though is

sufficiently working

then we're often going to be delaying

intubation until the patient

hasn't responded to our initial efforts

with cpr

now once we do have them intubated

though it's going to be really important

that you are confirming

placement of the airway both by

verifying that you have

equal chest rise and that you are

auscultating bilateral lung sounds

in addition to that you want to be using

entitled co2

also referred to as our waveform

capnography and this is going to be used

both

to verify placement and for continued

assessment moving forward

and then finally make sure you have the

endotracheal tube secured to your

patient

so when it comes to our patients

breathing that we want to be utilizing

the

bag valve mask to ensure that we're

providing them supplemental oxygen

supporting their ventilation while not

excessively ventilating the patient

now if you're in a code situation use a

hundred percent fio2 through the bvm

otherwise you want to be adjusting the

fio2 to maintain at least that's a 94

and so if you guys don't have it already

this is where we want to be using our

entitled co2 and our pulse oximetry or

spo2

in order to really be able to assess our

patient's breathing

now moving on to our patient's

circulation this is where you're really

going to want to ensure that you have

the proper

depth and rate of compressions and this

is both through

observed as well as watching our end

tidal co2

where we want to have at least 10 to 20

millimeters of mercury but more likely

closer or greater than 20. now first and

foremost at this point is you want to

assess whether you have iv io access

and if it's not present or it's not

functional then immediately get access

trust me the last thing you want is to

not have functional access

when one of these situations happens now

again if it's not already done then we

want to have our ecg monitoring going on

and we want to be keeping an eye out for

any arrhythmias and then obviously

defibrillate those as needed now we're

going to give them

any appropriate drugs and fluids that

are needed as well as this is also the

point where you want to

check a glucose and a temperature and

then really we want to

be watching for if we have achieved rosk

so this is the return of our spontaneous

circulation

and how do we know well check a pulse do

you feel a pulse with an

organized rhythm on the ecg also if you

have your end title co2

you're going to see an abrupt rise in

the co2 generally greater than

40 or more so now that you've done all

that at this point we want to

be checking for disability in our

patients and this means checking

their neurological functioning so this

is going to include our basic assessment

of responsiveness

level of consciousness and the patient's

pupillary reflex

and so when it comes to assessing their

level of consciousness

it helps to remember appvu apvu

this is our alert voice painful and

unresponsive

and then finally the last part of this

primary assessment is going to be

our patient's exposure and this really

means that we want to

uncover the patient from head to toe and

visually inspect for if there's any

obvious signs

of any potential issues and this can be

for things like

trauma bleeding burns any unusual

marks or even looking for any alert

bracelets now

the key thing to remember with all of

this that i just talked about in this

primary assessment

is that oftentimes especially as you

have more experience and you have more

experienced

teams that many of these assessments and

their actions

are going to be performed simultaneously

and not necessarily

in a step-by-step fashion now once this

primary assessment is done

then this is where we are going to move

on to our secondary assessment

now for a secondary assessment that this

is going to consist of the

evaluations of the potential causes of

the emergency

and then if possible an evaluation of a

focused medical history for the patient

for this focused medical history it

really helps to remember the acronym

sample and this is going to be the signs

and symptoms

any allergies any medications including

the last dose

past medical history last meal consumed

and events being any events in the past

or recently that led up to this

now the goal here with this secondary

assessment is going to be to diagnose

and then treat the

underlying cause now at this point here

we want to try and focus

on the reversible causes of cardiac

arrest

something that we refer to as our h's

and ts

and the h's and t's is really a list and

it can be

really useful in memorizing the most

common causes of cardiac arrest

and it can be useful in assessing and

evaluating what has led to the current

situation

now i am going to link to a video up

above where i did cover

these h t's quite in depth so make sure

you guys watch that if you want to learn

more about those

but here if we're able to rapidly

identify and then

reverse the cause or the potential cause

then we could potentially aid in the

recovery

of spontaneous circulation achieving

risk as well as the prevention

of future arrest following that all

right so the

systematic approach that we have laid

out here from the

initial impression that we get moving

right into our bls assessment

into our primary assessment for acls and

then on to the secondary assessment

that this approach is going to allow us

to quickly evaluate the situation with

our patient

and then to act quickly and

appropriately

with the best possible actions to try

and either

prevent a rest or to work to reverse the

issue and see a return of spontaneous

circulation

this approach here is merely the

framework on which

all of the additional algorithms and

guidelines sit on top of

which in the future lessons in this

series that i am going to be covering in

detail so make sure you guys stay tuned

for those

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