C – Circulation (VIMA)

ACLS AHA 2020 Guidelines

V - Vital Signs (Heart Rate, BP, Glucose level, Temp)
Form an Initial Impression I – Intravenous (IV) or Intraosseous ( IO) access
 2 failed attempts of IV, consider IO
(consciousness, breathing, color)
 Give 1L PNSS@ KVO rate at the antecubital vein
M – Monitor (Cardiac) / 12-Lead ECG if available
Conscious Unconscious Basic Lead Placement:
Primary Assessment BLS Survey - White on right, smoke over fire
- Traffic Light
Secondary Assessment
A – Appropriate Management/Drugs
Primary Assessment Bradycardia Narrow Complex Tachy Wide Complex Tachy
A – Airway Atropine SO4 STABLE ( > 90 sys bp) STABLE ( >90 sys bp)
 Assess for patency Ini.dose - 1 mg
o Suction as needed, insert adjuncts, consider advance airway
 Vagal Manuever  Amiodarone
Max dose - 3 mg  Adenosine 150 mg for 10 mins
BASIC ADJUNCTS ADVANCE AIRWAY Interval – 3-5 mins st Max: 2.2 g in 24 HRS
1 dose 6 mg
Transcutaneous ∞ (Procainamide, Sotalol)
A.Oropharyngeal Airway (OPA) A.Supraglottic 2nd dose 12 mg
Pacing (TCP) - Refer to expert consult
(rapid iv push+20ml NSS
-Unconscious with no gag reflex -Laryngeal Mask Airway, Laryngeal Tube Dopamine Infusion UNSTABLE
Dose:5-20 mcg/kg/min flush)
B. Infraglottic 1.Sedate + Analgesic
B.Nasopharyngeal Airway (NPA)
Epinephrine Infusion UNSTABLE(<90 sys bp)
-Endotracheal Tube Dose:2-10 mcg/min 2.Sync Cardioversion
-Conscious, semi –conscious , 1.Sedate + Analgesic
unconscious with or w/o gag reflex -Ensure proper placement by: Mono Biphasic
Note:
a. 5 point auscultation Atropine is not effective
2.Sync Cardioversion VT 100 J 100 J
Contraindication:
b. colorimetric CO2 detector/EDD for Mobitz II and 3o AV Mono Biphasic
Epistaxis, brain injury, facial c. waveform capnography – 35-45 mmhg Block, Infranodal blocks. SVT 200J 50-100J
trauma, ICP
Cardiac Arrest – not < 10 mmHg Afib 200J 120-200J
ROSC –jump to higher value >40 mmhg
Acute Coronary Syndrome (ACS)
B – Breathing - If O2 sat falls below 90%, Give Oxygen.
 Check Respiratory rate and Attach Pulse Oximeter - Aspirin 162-325 mg, non enteric coated, chew and swallow.
If O2 Saturation is < 94%, apply O2. - Nitroglycerin and Morphine (contraindications: RVI, sildenafil, vardanafil)
o Nasal Cannula – 1 – 6 Lpm - Fibrinolytic therapy and PCI
o Simple Face Mask – 6 - 10 Lpm D - Disability
o Non Rebreathing Mask – 10 - 15 Lpm  Check pupil dilation and level of consciousness (AVPU), Alert orientation
o BVM – 1 breath every 6 secs (Adult) –10 breaths/min E – Exposure
- 1 breath every 2-3 secs (Infant / Child) – 20-30 breaths/min  Expose skin to check signs of trauma (bruises, burns, deformities)
 Check for Medical Alert Tags
o Advance Airway – 1 breath every 6 secs (for all ages)
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 Secondary Assessment BLS SURVEY
Differential Diagnosis  Check Responsiveness
 Signs and Symptoms o “Hey2, are you okay? Hey2, are you alright?”
 Allergies
 Shout for nearby help ( if alone)
 Medication o “Help, I need some help!”
 Past/present medical history  Check for pulse and breathing simultaneously
 Last meal taken o Check for no less than 5 secs and not more than 10
 Events prior to illness/injury secs.
o If no pulse and not breathing or only gasping
Diagnosing and Treating Underlying Causes: H’s and T’s
 Activate EMS and get an AED
H ypoxia (Code blue at the ___ and get the
 Check good and equal chest rise and fall, O2 sat, ABG defibrillator/crash cart)
H ydrogen Ion Acidosis  Start High Quality CPR
 Check good and equal chest rise and fall, Obtain ABG  30:2:5
T ension pneumothorax  Push Hard and Fast
 Assess unequal chest expansion, tracheal deviation
 At least 2 inches (5cm) deep
T amponade, Cardiac
 At a rate of 100-120/min
 Beck’s triad: JVD, muffled heart & low BP; xray, 2D echo
 Minimize interruption to no more than 10
T hrombosis (pulmonary and cardiac)
 Request for ECG, MRI, echocardiography, ultrasound secs.
 Diminished or absence of carotid pulses even with HQCPR  Do a complete chest recoil
H ypothermia o If has pulse but not breathing
 Core Temp that drops below 35oC, assess abdomen  Activate EMS and get an AED
H ypovolemia (Code blue at the ___ and get the
 Ensure and check patency of IV line, check active bleeding defibrillator/crash cart)
H ypo/Hyperkalemia  Start Rescue Breathing
1

 Request serum electrolytes, check T waves of ECG

 Give 1 breath every 6 secs for adult
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T oxins
patients (10 breaths/min)
 Request for blood test
 Give 1 breath every 2-3 secs for child and
Troponins
infant (20-30 breaths/min)
 Request lab test
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 Cardiac Arrest Return of Spontaneous Circulation (ROSC)
(Example Case of a Shockable Rhythm) (+) Heart rate
10:26 am – (-) pulse, (-) breathing, Ventricular Fibrillation (VF)-shockable
Class I - HQCPR
A & B – Airway and Breathing
Class IIa- Defib @ _____
 Assess airway patency
Class IIb- No drugs
____________Stop…Switch…Analyze______________ Less than 10 secs  Check for spontaneous breathing and O2 Saturation
o Maintain SPO2 of > 92-98%
10:28 am – Refractory/persistent VF o Do rescue breathing if necessary
Class I - HQCPR o Insert advance airway when needed
Class IIa- Defib @ _____ o Target PETCO2: 35 – 40 mmHg, PaCO2: 35-45mmHg
Class IIb- Epinephrine 1mg ( 10 mL1:10,000)+20 ml NSS flush ↑arm
(If possible, initiate insertion of an advance airway) C- Circulation
____________Stop…Switch…Analyze______________ Less than 10 secs If SBP < 90mmHg Initial
 Give IV/IO bolus of 1-2L of PNSS/PLR, if not congested. stabilization
10:30 am – Refractory VF
 Dopamine Infusion : 5– 20mcg/kg/min phase
Class I - HQCPR
Class IIa- Defib @ _____ o Vasopressor dose: 5-10 mcg/kg/min
Class IIb- Amio 300 mg(/Lido 1-1.5 mg/kg/min) +20 ml NSS flush ↑arm  Epinephrine continuous infusion
____________Stop…Switch…Analyze______________ Less than 10 secs o 0.1- 0.5mcg/kg/min
10:32 am – Refractory VF o Titrate to patient response
Class I - HQCPR  Norepinephrine Infusion
Class IIa- Defib @ _____ o 0.1– 0.5mcg/kg/min
Class IIb- Epinephrine 1mg (1:10,000)+20 ml NSS flush ↑arm
____________Stop…Switch…Analyze______________ Less than 10 secs Obtain 12 lead ECG
10:34 am – Refractory VF Consider Emergent Cardiac Intervention if
Class I - HQCPR - STEMI, Unstable cardiogenic shock, Mechanical
Class IIa- Defib @ _____ circulatory support required
Class IIb- Amiodarone 150 mg +20 ml NSS flush ↑arm D – Disability
Shockable Rhythms – Ventricular Fibrillation, Pulseless Vtach  GCS 3 (comatose patient)
o Start Targeted Temperature Management (TTM) Continued
Manual Defibrillator – Follow specific guidelines of your unit o
 4 C PNSS at 30 ml/kg for 24 hours Management
Monophasic Energy Level - 360 J o
 Maintain core body temp: 32 – 36 C for 24 hrs
Biphasic Energy Level - 120 - 200 J  Use cooling device with feedback loop
Non Shockable Rhythms – Asystole and PEA o Obtain Brain CT, EEG monitoring, other CCM
- No Defibrillation/shock o Evaluate and Treat H’s and T’s

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