Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
In this lesson, we'll cover the primary patient assessment by thoroughly checking the ABCDE's in ACLS for unconscious patients who are in full arrest that are either cardiac or respiratory in nature.
However, all ACLS healthcare providers should conduct a primary assessment after first completing a basic life support assessment.
This BLS assessment includes checking for responsiveness with taps and shouts, and if the patient is found to be unresponsive, calling 911 or calling in a code. Also check the patient for breathing and a pulse and defibrillate if necessary.
However, for unconscious patients who need a more advanced level of assessment and management, you should conduct a primary assessment first. During your primary assessment, continue to assess and perform all actions appropriately until the patient is transferred to the next level of care.
Pro Tip #1: Oftentimes, members of a high-performance team will perform the assessment and actions in ACLS simultaneously. However, if this isn't the case, it's important to remember, per the latest guidelines, to assess the patient first then perform the appropriate actions.
Keep in mind, when you get into the scenario-based testing part of this course, it's formatted in a linear fashion to simplify and clarify the vital skills needed to successfully pass the test. However, real-life ACLS codes have many working parts, many of which will happen dynamically and simultaneously to expediate important assessments, treatments, and therapies in order to help save the patient's life.
The following is a breakdown of the primary ACLS primary assessment by using the ABCDE method.
Airway
It's vital to maintain an open airway in an unconscious patient. The ways in which you'll accomplish this include:
- Head tilt, chin lift
- Basic airway adjuncts like:
• Oropharyngeal Airway (OPA)
• Nasopharyngeal Airway (NPA)
Advanced healthcare providers can use advanced airways if basic airways are not sufficient or if capnography is vital to a successful resuscitation.
The different types of advanced airways include, but are not limited to:
- Endotracheal tubes
- Esophageal tracheal tubes
- Laryngeal tubes
- Laryngeal masks
Pro Tip #2: It's important to weigh the costs vs. the benefits of advanced airway placements if they'll interrupt chest compressions. If a bag valve mask ventilation is adequate, you might want to wait before inserting a more advanced airway until the patient doesn't respond to initial resuscitation attempts with CPR and defibrillation or until ROSC occurs.
Also keep in mind that some advanced airway devices, such as laryngeal masks and laryngeal tubes, can be placed while chest compressions continue.
It's important to confirm the proper placement of all advanced airways. This can be done by a physical examination of the airway or a quantitative waveform from capnography readings. And CPR should be properly integrated with ventilations after intubating the patient to optimize pulse pressures and oxygenation of vital organs and cells.
Pro Tip #3: Because movements from CPR and transportation can alter or dislodge an advanced airway, it's important to use a securing device to hold the advanced airway in place. And remember to monitor airway placement with continuous quantitative waveform capnography.
Also, make note of your organization's protocols and operating procedures when using prescribed devices for tube immobilization.
Breathing
When assessing a patient's breathing, it's important to ask yourself, are ventilations and oxygenation adequate?
For arrest patients, administer 100 percent oxygen, once ROSC is achieved, then 92%-98%, but for all other patients, titrate oxygen administration to achieve oxygen saturation of 94 percent or greater by pulse oximetry. And monitor quantitative waveform capnography and oxyhemoglobin saturation.
Of course, you should rely on the visual of the patient's chest rising and falling to confirm breath compliance. But quantitative waveform capnography will better help you understand how well CPR and rescue breathing are working to oxygenate the patient and how well that patient is processing that oxygen from a biological perspective.
Circulation
It's important to assess and reassess the quality of CPR by monitoring the quantitative waveform capnography. And if PETCO2 is less than 10ml of mercury, this may be a sign that you should work to improve CPR quality.
Pro Tip #4: If you're able to monitor intra-arterial pressures, and the relaxation phase or diastolic pressure is less than 20 ml of mercury, attempt to improve CPR quality by assessing compression depth, rate, and hand placement.
Attach a monitor and defibrillator to check for arrhythmias or cardiac arrest rhythms like:
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Asystole
- Pulseless electrical activity
Lastly, be sure to provide defibrillation cardioversion as needed. Obtain IV or IO access to deliver adequate fluid replacement, medications, and give appropriate drugs to manage rhythm and blood pressure. And later, check glucose levels, temperature, and incorrect perfusion.
Disability
When it comes to disability, check the patient for neurologic function and quickly assess for responsiveness, levels of consciousness, and pupil dilation, which may indicate brain death or viability, but not in every case.
Assess disability using the acronym AVPU:
A - Is the patient Alert?
V - Does the patient respond to your Voice?
P - Does the patient respond to Painful stimulus?
U - Is the patient Unresponsive?
Exposure
Exposure is a reminder for healthcare providers to remove the patient's clothing and perform a good physical examination. While doing so, look for signs of trauma, such as:
- Bleeding
- Burns
- Unusual markings
- Medical alert bracelets
