The primary assessment of checking the ABCDEs in ACLS is for unconscious patients in full
arrest that are cardiac or respiratory in nature.
ACLS healthcare providers should conduct the primary assessment after completing the basic
life support assessment.
And remember, this is comprised of checking for responsiveness with a tap and a shout,
if they’re unresponsive we’re gonna call 911 or call a code depending on the area in
which you work.
Check for breathing and a pulse and then attach the defibrillator and possibly defibrillate
if there is no pulse.
For conscious patients who may need more advanced assessments and management techniques: the
healthcare professional will conduct the primary assessment first.
In the primary assessment, you continue to assess and perform an action as appropriate
until the patient is transferred to the next level of care.
Many times, members of a high-performance team will perform assessments and actions
in ACLS simultaneously.
Now it’s important to remember, per the latest guidelines, that we want to assess
the patient and then perform the appropriate action.
Please keep in mind that when you get to the scenario based testing with ProACLS, it’s
formatted in a linear fashion in order to simplify and clarify the vital skills needed
to pass the test successfully.
Now that being said, I want to reiterate that real ACLS codes will have many working parts
and many of the will happen dynamically and simultaneously in order to expedite important
assessments, treatments and therapies in order to successfully save the patient’s life.
Now the following is a breakdown of the ACLS primary assessment following the ABCDE method.
First, airway.
It’s vital that we maintain an open airway in the unconscious patient.
Ways that we can accomplish this is by head tilt-chin lift, or a basic airway adjunct
like an oropharyngeal or nasopharyngeal airway.
The advanced practitioner can use an advanced airway if a basic airway is not sufficient
or if capnography is vital to the success of the resuscitation.
Different forms of advanced airways include but are not limited to: endotracheal tubes,
esophageal tracheal tubes, laryngeal tube or laryngeal mask.
Keep in mind that the healthcare professional must weigh the cost vs benefits of advanced
airway placement compared to interrupting chest compressions.
If bag mask ventilation is adequate, the healthcare provider may wait to insert an advanced airway
until the patient does not respond to the initial resuscitation attempts with CPR and
defibrillation or until ROSC occurs.
The advanced airway devices such as an LMA, laryngeal tube or an SOA can be placed while
chest compressions continue.
It’s important to confirm the proper placement of any advanced airway once it is placed.
This can be done with a physical exam or quantitative waveform capnography readings.
CPR should be properly integrated with ventilations after intubation is done in order to optimize
pulse pressures and oxygenation of vital organs and cells.
Because both movement with CPR and transportation can alter and dislodge the actual advanced
airway, it’s really important that we used a securing device so that we can hold that
tube in place.
Make note of your organization's protocols and operating procedures in order to use the
proper and prescribed devices for tube immobilization.
And lastly, be sure to monitor the airway placement with continuous quantitative waveform
capnography.
When assessing breathing, are the ventilations and oxygenation adequate?
For arrest patients, we administer 100% oxygen but for others, we will want to titrate oxygen
administration to achieve oxygen sats of 94% or greater by pulse ox.
Secondly, are quantitative waveform capnography and oxyhemoglobin saturation monitored?
We will of course rely on appropriate chest rise and fall to confirm breath compliance
but quantitative waveform capnography will help us understand how well our CPR and rescue
breaths are oxygenating the patient and how well the patient is processing that oxygen
from a biological perspective.
It’s vital that we assess and reassess the quality of CPR.
Monitor the quantitative waveform capnography and if PetCO2 is less than 10 mm of Mercury,
it may be a sign that we should work at improving CPR quality.
Now if we are able to monitor intra-arterial pressures and the relaxation phase or diastolic
pressure is less than 20 mm of Mercury, we should probably attempt to improve CPR quality
by assessing depth and rate of compressions as well as hand placement.
Attach monitor and defibrillator for arrhythmias or cardiac arrest rhythms like ventricular
fibrillation, pulseless ventricular tachycardia, asystole, or pulseless electrical activity.
And lastly, we want to be sure and provide defibrillation/cardioversion as needed, obtain
an IV or lO access to deliver adequate fluid replacement and medications, and give appropriate
drugs to manage rhythm and blood pressure, Then give IV or IO fluids if needed.
Later we’re gonna check glucose and then temperature, and check and correct, if possible,
the perfusion.
Next, we’re gonna talk about disability.
When it comes to disability, we want to evaluate the following: Check the patient for neurologic
function and quickly assess for responsiveness, levels of consciousness, and check for pupil
dilation which may indicate brain death or viability but not in every case.
And lastly we’re going to use AVPU, which is an acronym, to assess if the patient is
a, alert, responds to, v, voice or, p, painful stimulus or is completely, u, unresponsive.
Exposure.
Exposure reminds the healthcare professional to remove patient's clothing and perform a
good physical examination, looking for obvious and not so obvious signs of trauma, bleeding,
burns, unusual markings, or medical alert bracelets.