T h e O f f i c i a l AHA Self- direc ted ACLS eLearning Program
HeartCode ™ ACLS Student Guide
Learning Technolog Technolog y by Laerdal Learning Technology Technology by Laerdal Heartcode ACLS IH Booklet.indd 1
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Preace The goal o the HeartCode ACLS program is to improve the quality o care provided to the adult victim o cardiac arrest or o ther cardiopulmonary emergencies.
HeartCode ACLS, an ocial American Heart Association eLearning program, oers an alternative to the traditional AHA ACLS class. In today’s ast-paced environment, it is not always easy or healthcare providers to keep their certications current. HeartCode ACLS oers a convenient method or obtaining an American Heart Association ACLS card, while practicing critical thinking skills and team dynamics to help improve the quality o patient care. Providers can complete the course at their own pace, on their own schedule, potentially saving time and money and improving the utilization o a limited pool o instructor resources. This specic program is designed to educate clinicians about treatments or cardiovascular emergencies and stroke. Target Audience Physicians, nurses, paramedics/EMT paramedics/EMT-Is, -Is, residents, nurse practitioners, physician assistants, clinical pharmacists and respiratory therapist are the target audience. Other healthcare workers who care directly or patients may also benet.
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Content
Content Introduction ................................................................................................. 4 Core Cases (Patients) .................................................................................. 6 Patient: Brad Stephens ............................................................................... 7 Patient: Ervin Waters ................................................................................... 8 Patient: John Mitchell .................................................................................. 9 Patient: Stan Lotus ................................................................................... 10 Patient: Derrick Gentry .............................................................................. 11 Patient: Ian Denholm ................................................................................. 12 Patient: Lou Weston .................................................................................. 13 Patient: Walter Hampton ........................................................................... 14 Patient: David Miller .................................................................................. 15 Patient: Paul Smith .................................................................................... 16 Special Features ........................................................................................ 17 Accreditation / Disclosure Statements ...................................................... 21
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Introduction
Introduction The HeartCode ACLS program includes all o the exams required or successul completion o the cognitive portion o the American Heart Association’s ACLS course: • Team Dynamics Lesson (team principles) •
10 ACLS Cases (realistic patient-simulation cases)
ACLS Written Test
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Also included in the program: Precourse sel-assessment The objective o the HeartCode ACLS precourse sel-assessment is to evaluate the student’s ability to integrate both rhythm interpretation and the use o pharmacologic agents. There is no passing score in the sel-assessment, but a score o 84% or higher will help the learner to participate eectively in the lessons and testing sections. Electronic versions o the entire AHA textbooks
ACLS Provider Manual
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2005 American Heart Association Guidelines or Cardiovascular Resuscitation and Emergency Cardiovascular Care
Supplementary AHA material
ACLS Science Overview Video
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ACLS Core Drugs
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ACLS Provider Manual Supplementary Material
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Nine additional BLS videos
HeartCode ACLS includes microsimulation technology that improves both the educational content and user-riendliness o the program. Providers are presented with realistic patient cases and are required to interact with the program to assess the patient, ormulate a treatment plan based on the ACLS algorithms and eect treatment. The advanced technology allows the simulated patient to react accordingly to the treatment provided (positively or negatively) in order to improve the learning experience.
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Introduction
Upon completion o a given case, the provider is presented with a detailed debrieng screen. This debrieng is more than just a list o events ending with a score. Providers are presented with an account o their actions, pointing out both correct and incorrect interventions. Suggestions or improvement are oered, and all appropriate AHA reerence material is hyperlinked to the debrieng, allowing immediate remediation at the conclusion o the case. To claim the HeartCode ACLS certifcates, the learner needs to: •
Review the background material to the extent desired
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Successully complete: - Team Dynamics Lesson - 10 Patient Scenarios - ACLS Written Test - Claim the HeartCode ACLS Part 1 Certicate
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Perorm a skills practice and test with an AHA ACLS Instructor or using the voice assisted manikin (VAM) system with the HeartCode program
Claim the HeartCode ACLS skills practice and testing certicate Upon successul completion o the cognitive and skills test portions, the student receives an AHA ACLS Course Completion Card. •
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ACLS Cases (Patients) Description and Learning Objectives The 10 ACLS cases in HeartCode provide learners with an opportunity to test their ability to manage a range o important cardiovascular emergencies and stroke in a realistic simulation setting while working toward ACLS certication. The intelligent debrieng provides optimal opportunity to learn rom and improve perormance.
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Descriptions and Learning Objectives
Patient: Brad Stephens A 48-year-old man has collapsed ater being brought into the outpatient clinic at which you are a rst responder. He complained o some shortness o breath and chest pain beore losing consciousness. Diagnosis: VF/Pulseless VT Difculty: Beginner Learning Objectives: •
Executes a BLS Primary Survey to assess patient.
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Executes relevant cardiorespiratory support.
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Executes eective CPR when indicated.
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Identies a clinical situation where advanced help is necessary and help must be called immediately.
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Implements the VF/VT pathway in the ACLS Pulseless Arrest algorithm.
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Executes procient debrillation with an AED.
Recalls that CPR and debrillation are critical steps in the treatment o VF and pulseless VT.
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Recalls that chest compressions should only be interrupted or ventilation (unless an advanced airway is in place), rhythm checks and shock delivery.
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Descriptions and Learning Objectives
Patient: Ervin Waters A 42-year-old man with palpitations has been sent to the Emergency Department by his amily doctor. Diagnosis: Atrial fbrillation Difculty: Beginner Learning Objectives: •
Executes BLS Primary and ACLS Secondary Surveys to assess patient.
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Implements the ACLS Tachycardia algorithm.
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Distinguishes between stable and unstable tachycardia.
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Recalls characteristics o a stable tachycardia.
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Identies narrow complex tachycardia on ECG.
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Distinguishes between regular and irregular narrow complex tachycardia on ECG.
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Recalls the importance o determining the duration o atrial brillation.
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Recalls that anticoagulation measures are mandatory beore attempting cardioversion in stable patients with AF ~ >48 h.
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Descriptions and Learning Objectives
Patient: John Mitchell A 56-year-old man is complaining o chest pain. He is a smoker who has not seen a doctor or several years. Diagnosis: Acute coronary syndromes Difculty: Medium Learning Objectives: •
Executes BLS Primary and ACLS Secondary Surveys to assess patient.
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Executes relevant cardiorespiratory support.
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Recognizes symptoms o ACS.
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Implements the ACLS Acute Coronary Syndromes algorithm.
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Implements the AHA recommended ED plan or immediate assessment and general treatment o the patient with chest pain suggestive o ischemia.
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Executes attempts to control chest pain aggressively.
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Executes initial treatment or patients with ACS correctly.
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Recalls that 12-lead ECG is central to the initial risk and treatment stratication o ACS patients.
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Classies ACS patients according to ST-elevation on ECG.
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Evaluates an ACS patient’s eligibility or reperusion therapy rapidly.
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Recalls indications or reperusion therapy.
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Recalls to minimize door-to-drug interval.
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Recalls indications, contraindications, dosage and administration o drugs relevant to treatment o ACS.
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Understands that time is critical in the management o ACS.
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Descriptions and Learning Objectives
Patient: Stan Lotus A man is brought into the ED rom his home, where his wie ound him unresponsive on the couch. Basic lie support was not started until the ambulance arrived. Diagnosis: Asystole/PEA Difculty: Medium Learning Objectives: •
Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient.
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Executes eective CPR when indicated.
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Recalls that chest compressions should only be interrupted or ventilation (unless an advanced airway is in place), rhythm checks and shock delivery.
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Implements the ACLS Pulseless Arrest algorithm.
Analyzes ECG and clinical situation to correctly identiy PEA.
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Recognizes asystole on ECG.
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Executes conrmation that a fatline on the ECG is indeed asystole.
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Recalls that asystole usually represents a conrmation o death rather than a rhythm to be treated.
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Recalls the AHA criteria or when to stop resuscitative eorts.
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Recalls when to look or and honor a valid Do Not Resuscitate Order (DNAR).
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Recalls that asystole and PEA are not shockable rhythms.
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Summarizes that PEA is oten associated with reversible causes.
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Implements the mnemotechnic rule o the H´s and T´s to check or conditions that could have contributed to PEA and/or asystole.
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Descriptions and Learning Objectives
Patient: Derrick Gentry A 72-year-old man is brought into the ED by ambulance complaining o loss o movement in his let arm. He has a history o hypertension and hypercholesterolemia. Diagnosis: Stroke Difculty: Medium Learning Objectives: •
Recognizes major signs and symptoms o stroke.
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Implements the ACLS Suspected Stroke algorithm.
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Recalls that brinolytic therapy or eligible acute stroke patients within three hours o symptom onset is a class Ia recommendation.
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Executes a rapid neurological exam.
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Recalls that the clinical condition o patients with stroke may change rapidly.
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Recalls that an urgent non-contrast CT scan o head should be obtained in a patient with suspected stroke.
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Summarizes the importance o determining time o symptom onset.
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Recalls indications, contraindications and dosages or drugs relevant when managing a patient with stroke.
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Rapidly evaluates a patient’s eligibility or brinolytic therapy.
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Implements guidelines or administration o brinolytics to a stroke patient.
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Recalls that blood glucose should be evaluated in a patient with suspected stroke.
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Descriptions and Learning Objectives
Patient: Ian Denholm A 74-year-old man is complaining o atigue on exertion. He has noticed that his heart rate is well over 100 beats per minute. Diagnosis: VT with pulse Difculty: Medium Learning Objectives: •
Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient.
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Executes relevant cardiorespiratory support.
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Executes continuous assessment o the patient.
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Recognizes signs and symptoms o tachycardia.
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Distinguishes between wide and narrow-complex tachycardias on ECG.
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Implements the ACLS Tachycardia algorithm.
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Distinguishes between stable and unstable tachycardia.
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Identies the tachycardic patient who is unstable rom tachycardia.
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Recalls that rst-line treatment or the hemodynamically un stable patient is urgent electrical cardioversion, regardless o tachycardic subtype.
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Executes electrical cardioversion correctly when appropriate.
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Recalls when to use synchronization during cardioversion.
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Descriptions and Learning Objectives
Patient: Lou Weston A 72-year-old man has allen twice in the last 24 hours. He is taking medication or hypertension, but is otherwise well. Diagnosis: Bradycardia Difculty: Medium Learning Objectives: •
Executes BLS Primary and ACLS Secondary ABCD Surveys to assess patient.
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Executes relevant cardiorespiratory support.
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Recognizes signs and symptoms o symptomatic bradycardia.
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Understands that only symptomatic bradycardia should be treated.
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Implements the ACLS Bradycardia algorithm.
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Recalls that transvenous pacing is indicated when second-degree type II or third-degree AV block is identied.
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Recognizes bradycardia on ECG.
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Classies the type o AV block on ECG.
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Recalls indications or transcutaneous pacing.
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Executes transcutaneous pacing when relevant.
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Recalls indications, contraindications, dosage and administration o drugs relevant to treatment o bradycardia.
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Descriptions and Learning Objectives
Patient: Walter Hampton A 49-year-old man is ound unresponsive and unconscious. Diagnosis: Respiratory arrest Difculty: Beginner Learning Objectives: •
Executes BLS Primary and ACLS Secondary surveys to assess patient.
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Implements AHA guidelines when managing respiratory arrest.
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Executes relevant cardiorespiratory support.
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Recalls appropriate ventilation rates.
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Recalls indications or suctioning.
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Recalls indications or placement o advanced airways.
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Executes conrmation o placement o advanced airway correctly.
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Descriptions and Learning Objectives
Patient: David Miller A 65-year-old man is complaining o palpitations. Diagnosis: Megacode case – Tachycardia/Cardiac arrest Difculty: Advanced Learning Objectives: •
Executes BLS Primary and ACLS Secondary Surveys to assess patient.
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Implements the ACLS Tachycardia algorithm.
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Implements the ACLS Pulseless Arrest algorithm.
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Distinguishes between stable and unstable tachycardia.
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Distinguishes between wide and narrow-complex tachycardias on ECG.
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Executes electrical cardioversion correctly when appropriate.
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Recalls when to use synchronization during cardioversion.
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Recalls indications, contraindications and dosages or drugs relevant when managing a patient in cardiac arrest.
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Recognizes signs and symptoms o tachycardia.
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Recalls indications, contraindications and dosages or drugs relevant when managing a patient with tachycardia.
Analyzes ECG and clinical situation to correctly identiy PEA.
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Continuously re-evaluates clinical situation to determine correct treatment plan.
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Recalls that chest compressions during cardiac arrest should be interrupted only or ventilations (unless advanced airway is in place), rhythm checks and shock delivery.
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Classies arrest rhythms on ECG.
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Descriptions and Learning Objectives
Patient: Paul Smith A 47-year-old man is complaining o indigestion. He is cold, clammy and diaphoretic. He tells you he is about to aint. Diagnosis: Megacode case – Bradycardia/Cardiac arrest Difculty: Advanced Learning Objectives: •
Executes BLS Primary and ACLS Secondary Surveys to assess patient.
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Implements the ACLS Bradycardia algorithm.
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Implements the ACLS Pulseless Arrest algorithm.
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Classies type o bradycardia on ECG.
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Recalls indications or transcutaneous pacing.
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Executes transcutaneous pacing when relevant.
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Recalls indications, contraindications and dosages or drugs relevant when managing a patient in cardiac arrest.
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Recalls indications, contraindications and dosages or drugs relevant when managing a patient with bradycardia.
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Recognizes signs and symptoms o bradycardia.
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Continuously re-evaluates clinical situation to determine correct treatment plan.
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Recalls that chest compressions during cardiac arrest should be interrupted only or ventilations (unless advanced airway is in place), rhythm checks and shock delivery.
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Classies arrest rhythms on ECG.
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Recalls that asystole and PEA are not shockable rhythms.
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Recalls the AHA criteria or when to stop resuscitative eorts.
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Special Features Special features in HeartCode ACLS
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Special Features in HeartCode ACLS
Chest tube
A chest tube can be inserted through an intercostal space directly into the pleural cavity. This is indicated when treating a suspected pneumothorax.
Needle decompression
A needle decompression relieves a suspected pneumothorax by allowing any air trapped inside the thorax to escape through the cannula.
Carotid sinus massage (carotid sinus pressure)
The carotid sinus contains baroreceptors that respond to pressure changes in the carotid artery. Carotid massage can be used in conjunction with the Valsalva maneuver to terminate spontaneous Reentry SVT.
Valsalva maneuver
The Valsalva maneuver produces an abrupt increase in intra-abdominal and intrathoracic pressure when the patient strains against a closed glottis while holding his breath. It is oten used in conjunction with carotid sinus massage to terminate spontaneous Reentry SVT. 18
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Special Features in HeartCode ACLS
Continuous temperature monitoring
This tool allows you to continuously monitor the patient’s core temperature.
CT scanning
A CT scan o the cerebrum is primarily used to identiy intracerebral or subarachnoid hemorrhage in suspected stroke patients. A noncontrast CT scan is the single most important test when ruling out hemorrhagic stroke.
Transer patient to PCI
Patients with acute chest pain should be evaluated as potential candidates or percutaneous coronary intervention (PCI) either angioplasty or intracoronary stenting. PCI is superior to brinolytic therapy when treating ACS and is reasonable in patients with cardiogenic shock or heart ailure complicating MI.
Transer patient to transvenous pacing
Transvenous pacing is an invasive procedure stimulating the heart to contract, thereby supporting cardiac output. In contrast to transcutaneous pacing, which can be started quickly and conveniently at the bedside, transvenous pacing requires involvement o an invasive cardiology team. 19
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Special eatures in HeartCode ACLS
Pacing (transcutaneous)
Transcutaneous cardiac pacing (TCP) supports cardiac output by stimulating the heart through large pacing electrodes placed on the patient’s chest and back, thereby causing the heart to contract. TCP can be used in early treatment o asystole and symptomatic bradycardias.
Troponin test
Troponin is a serum cardiac marker that can be used to detect myocardial damage when ACS is suspected. The result is given as a positive or negative result, positive representing myocardial damage.
Fibrinolytic drugs
Fibrinolytic agents hydrolyze brin clots. Patients with acute chest pain or suspicion o acute ischemic stroke should be evaluated as potential candidates or brinolytic therapy.
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Accreditation / Disclosure Statements
ACCREDITATION TERMS: • ACCME/AMA (Physicians) - September 2008 – September 2011 • AACN (Nurses) - September 2008 – September 2009 • ACPE (Pharmacists) - September 2008 – September 2011 • CECBEMS (EMS Practitioners) - September 2008 – September 2011 ACCREDITATION STATEMENTS: Continuing Medical Education Accreditation - Physicians The American Heart Association is accredited by the Accreditation Council or Continuing Medical Education to provide continuing medical education or physicians. The American Heart Association designates this educational activity or a maximum o 12.00 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent o their participation in the activity.
All aculty participating in CME/CE activities sponsored by The American Heart Association will disclose to the audience (1) signicant nancial relationships with the manuacturer(s) o products rom the commercial supporter(s) and /or the manuacturer(s) o products or devices discussed in their presentation, and (2) unlabeled/unapproved uses o drugs or devices discussed in their presentation. Such disclosures will be made in writing in course presentation materials. Continuing Medical Education Accreditation – Physician Assistants AAPA accepts Category 1 credit rom AOACCME, Prescribed credit rom AAFP, and AMA PRA Category 1 Credit™ rom organizations accredited by ACCME. Continuing Education Accreditation - Nurses This program (08-NC-176) has been approved by the American Association o Critical Care Nurses (AACN) or 12.00 Contact Hours, Category A, File number 00014666. Continuing Education Accreditation – Pharmacists The American Heart Association is accredited by the Accreditation Council or Pharmacy Education as a provider o continuing pharmacy education. ACPE Credit: 12.00 Contact Hours or 1.200 CEUs. Universal Program Number: 256-000-08-569-H01-P.
Successul completion o this CME/CE activity includes completion o the ollowing: Team dynamics lesson, 10 interactive medical cases, posttest and evaluation orm. Once successul completion has been achieved, a CME/CE certicate can be claimed immediately by selecting your prole, selecting the “Claim CME/CE Certicate” button and printing your CME/CE certicate.
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Accreditation / Disclosure Statements
Continuing Education Accreditation – Emergency Medical Services This continuing education activity is approved by the American Heart Association, an organization accredited by the Continuing Education Coordinating Board or Emergency Medical Services (CECBEMS), or 12.00 Advanced CEHs, activity number 08-AMHA-F3-0053. I. Instructions or Independent Study Successul completion o this CE activity includes the ollowing: (1) Complete the Team Dynamics lesson, the 10 cases with a debrieng grade o 70% or above and the written test. (2) Complete the appropriate CE request application and activity evaluation orm. (3) Print Certicate/Statement o Credit. II. Cost The cost or the activity is 120 US dollars. There is no additional ee or CME/CE/CEH credits or this activity. Disclosure Statement As a sponsor accredited by the Accreditation Council or Continuing Medical Education (ACCME), the American Association o Critical-Care Nurses (AACN), the Council or Pharmacy Education (ACPE), and the Continuing Education Coordinating Board or Emergency Medical Services (CECBEMS), the American Heart Association must ensure air balance, independence, objectivity, and scientic rigor in all o its individually sponsored or jointly sponsored educational activities. Accreditation / Disclosure Statements Thereore, all aculty and authors participating in continuing education activities sponsored by the American Heart Association must disclose to the audience: (1) any signicant nancial relationships with the manuacturer(s) o products rom the commercial supporter(s) and/or the manuacturer(s) o products or devices discussed in the activity, and (2) unlabeled/unapproved uses o drugs or devices discussed in the activity. The intent o this disclosure is not to prevent an author with a signicant nancial or other relationship rom contributing but rather to provide participants with inormation with which they can make their own judgments. It remains or the participants to determine whether the author’s interests or relationships may infuence the content.
I. The ollowing authors have declared nancial interest(s) and / or aliations: II. The ollowing aculty have declared NO nancial interest(s) and or aliations: Name John Field, MD Erik Soderberg, MS
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Accreditation / Disclosure Statements
Unlabeled/unapproved uses o drugs or devices are included in this activity This continuing education computer-based instruction contains recommendations rom the American Heart Association Emergency Cardiovascular Care Committee, Subcommittee on Advanced Cardiovascular Lie Support, as published in the American Heart Association ACLS Provider Manual. Most o these recommendations are based on guidelines developed in an evidence evaluation consensus process or the Guidelines 2005 Conerence. The evidence evaluation consists o expert review, an analysis, and discussion o relevant scientic studies published in peerreviewed journals. The drug treatments recommended in this text are consistent with the indications, contraindications, and doses approved by the Food and Drug Administration (FDA) with the exceptions listed here. Alteplase, recombinant (rtPA) For patients with acute ischemic stroke who are ineligible to receive intravenous thrombolysis but who are evaluated within 6 hours o symptom onset, administration o intra-arterial thrombolysis in an experienced stroke center with immediate access to cerebral angiography and qualied interventionalists may be considered (Class I, Level o Evidence B). Facilities are encouraged to dene criteria to credential individuals who can perorm intra-arterial thrombolysis (Class I, Level o Evidence C). Intra-arterial thrombolysis is reasonable in patients who have contraindications to use o intravenous thrombolysis, such as recent surgery (Class IIa, Level o Evidence C). Pending publication o additional clinical trial data, intra-arterial administration o tPA has not yet been approved by the US Food and Drug administration (FDA). Amiodarone This drug is FDA approved or lie-threatening ventricular arrhythmias, including recurrent VF and hemodynamically unsta ble VT. All other use constitutes an “olabel” indication, including hemodynamically stable VT, wide-complex tachycardia o uncertain origin, AF, atrial futter, pre-excited arrhythmias and arrhythmias in context o CHF. Similarly, the use o IV amiodarone or “shock reractory VF/VT” would not be an o-label use i given as a 150 mg dose, but giving it as a 300 mg bolus or this approved indication could be construed as “o label.” Vasopressin This drug is approved or diabetes insipidus, abdominal distention, and abdominal roentgenography.
Vasopressin has not been shown to dier rom Epinephrine (Class Indeterminate) in cardiac arrest. One dose o vasopressin may replace either the rst or second dose o epinephrine.
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Accreditation / Disclosure Statements
Note on Medication Doses Emergency cardiovascular care is a dynamic science. Advances in treatment and drug therapies occur rapidly. Readers are advised to check or changes in recommended dose, indications, and contraindications in the ollowing sources: Currents in Emergency Cardiovascular Care, uture editions o this handbook, and the AHA textbooks as well as the package insert product inormation sheet or each drug.
Clinical condition and pharmacokinetics may require drug dose or interval dosing adjustments. Specic parameters may require monitoring, or example, creatinine clearance or QT interval. Some medications listed in this handbook were scientically reviewed by the Guidelines’ evidence-based evaluation process. They may not be available in all countries and may not be specically approved by the FDA or a particular treatment or application.
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Notes
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Notes
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A v e r 9 7 2 4 P S
7272 G reenville Avenue Dallas, Texas 75231-45 96 americanheart.org ©2009 Laerdal Medical Corporation. All Rights Reserved. Produced in Denmark. 03/09
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