Next week I’ll be re-certifying in Basic Life Support and in Advanced Cardiac Life Support. The post today consists of excerpts from Part 4 of the 2016 ACLS Provider Manual, The Systematic Approach:
Healthcare providers use a systematic approach to assess and treat arrest and acutely ill or injured patients for optimal care. . . . The actions used are guided by the following systematic approaches:
- BLS Assessment
- Primary Assessment (A, B, C, D, and E)
- Secondary Assessment (SAMPLE, H’s and T’s)
Overview of the Systematic Approach
After determination of scene safety, the systematic approach first requires that ACLS providers to determine the patient’s level of consciousness. As you approach the patient,
- If the patient appears unconscious
- Use the BLS Assessment for the initial evulation
- After completing all of the appropriate steps of the BLS Assessment, use the Primary and Secondary Assessments for more advanced evaluation and treatment
- If the patient appears conscious
- Use the Primary Assessment for your initial evaluation
The BLS Assessment
- Check responsiveness
- Tap and shout, “Are you OK?”
- Shout for nearby help/activate the emergency response system and get the AED/defibrillator
- Shout for nearby help
- Activate the emergency response system
- Get an AED if one is available, or send someone to activate the emergency response system and get an AED or defibrillator
- Check breathing and pulse
- Defibrillation
For conscious patients, healthcare providers should conduct the Primary Assessment first.
The Primary Assessment
- Airway
- Is the airway patent?
- Is an advanced airway indicated?
- Is proper placement of airway device confirmed?
- Is tube secured and placement reconfirmed frequently?
- Breathing
- Are ventilation and oxygenation adequate?
- Are quantitative waveform capnography and oxyhemoglobin saturation monitored?
- Circulation
- Are chest compressions effective?
- What is the cardiac rhythm?
- Is defibrillation or cardioversion indicated?
- Has IV/IO access been established?
- Is ROSC present?
- Is the patient with a pulse unstable?
- Are medications needed for rhythm or blood pressure?
- Does the patient need volume (fluid) for resuscitation?
- Disability
- Check for neurologic function
- Quickly assess for responsivness, level of consciousness, and pupil dilatation
- AVPU: Alert, Voice, Painful, Unresponsive
- Exposure
- Remove clothing to perform a physical examination, looking for obvious signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets
The Secondary Assessment
Overview
SAMPLE
- Signs and symptoms
- Allergies
- Medications (including the last dose taken)
- Past medical history (especially relating the to the current illness
- Last meal consumed
- Events
The Most Common Causes of Cardiac Arrest As Well As Emergency Cardiopulmonary Conditions (H’s And T’s).
H’s
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypothermia
T’s
- Tension pneumothorax
- Tamponade (cardiac)
- Toxins
- Thrombosis (pulmonary)
- Thrombosis (coronary)
Common Underlying Causes of Pulseless Electric Activity (PEA)
- Hypovolemia and hypoxia are the 2 most common underlying and potentially reversible causes of PEA.
- Be sure to look for evidence of these problems as you to assess the patient.
Hypovolemia
Hypovolemia, a common cause of PEA, initially produces the classic physiologic response of a rapid, narrow complex tachycardia and typically produces increased diastolic and decreased systolic pressures. As loss of blood volume continues, blood pressure drops, eventually becoming undetectable, but the narrow QRS complexes and rapid rate continue (ie, PEA).
You should consider hypovolemia as a cause of hypotension, which can deteriorate to PEA. Providing prompt treatment can reverse the pulseless state by rapidly correcting the hypovolemia. Common nontraumatic causes of hypovolemia include occult internal hemorrhage and severe dehydration. Consider volume infusion for PEA with a narrow-complex tachycardia.
Cardiac And Pulmonary Conditions
Drug Overdoses or Toxic Exposure
Certain drug overdoses and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction with resultant hypotension. The approach to poisoned patients should be aggressive because the toxic effects may progress rapidly and may be of limited duration. In these situations, myocardial dysfunction may be reversible. Numerous case reports confirm the success of many specific limited interventions with one thing in common: they buy time.
Treatments that can provide this level of support include
- Prolonged basic CPR in special reuscitation situations
- Extracorporeal CPR
- Intra-aortic balloon pumping
- Intravenous lipid emulsion
- Renal dialysis
- Intravenous lipid eulsion
- Specific drug antidotes (digoxin immune Fab, glucagon, bicarbonate)
- Transcutaneous pacing
- Correction of severe electrolyte disturbances (potassium, magnesium, calcium, acidosis)
- Specific adjunctive agents
