Transcription
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.
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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 patient's breathing and their circulation.
Now, for your patient's 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 "Stayin' Alive."
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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 of the chest between each compression. The whole point of this is this is going to allow for the filling 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 in cardiac arrest is really key, and we really want to see this happen within the first three or four minutes from the time of arrest. 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 arrest 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 bag valve mask, 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 end-tidal 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 patient's 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 100% 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 end-tidal 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. 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 ROSC. 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-tidal 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 AVPU: A, V, P, U. 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, 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.
At this point here, we want to try and focus on the reversible causes of cardiac arrest, something that we refer to as our Hs and Ts. And the Hs and Ts 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 Hs and Ts 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 ROSC, 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 arrest 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 future lessons in this series that I am going to be covering in detail. So, make sure you guys stay tuned for those.
I really hope that you guys enjoyed this lesson here. If you did, please leave it a like. Leave me a comment down below, let me know what you thought. I love reading your comments. Make sure and share this video with other people that you might think would find this useful as well. And then, if you haven't already, subscribe to the channel to get more critical care content just like this video here. A special shout out to the awesome YouTube and Patreon members out there. The support that you guys show for this channel is really appreciated. It's going to allow me to continue to do bigger and better things with the channel moving forward in the future here. So, for the rest of you guys, if you'd be interested in showing support for this channel, then you can join the YouTube membership down below or head over to the Patreon page and check out some of the additional perks that you guys get for doing just that. You can also support this channel through the awesome merch down below, as well as following some of the links down in the description there as well. Like I said, make sure and stay tuned for the next lesson in the series. Otherwise, in the meantime, check out a couple of the awesome lessons I'm going to link to right here. As always, thank you guys so much for watching. You have a great day.