IM2.{17,21-22,24} | ACS Resuscitation and Rehabilitation — Summary & Reflection

KEY TAKEAWAYS

BLS (Basic Life Support) — adult sequence:
- Safety → responsiveness check → shout for help + call emergency services → check breathing + pulse (≤10 sec) → start chest compressions
- Compressions: heel of hand on lower sternum; depth 5–6 cm; rate 100–120/min; full recoil; minimise interruptions; rotate compressors every 2 min
- Ventilation: 30:2 ratio (30 compressions: 2 breaths, 1 sec each); compression-only CPR acceptable if unable to ventilate
- Use AED as soon as available: apply pads, follow prompts, resume CPR immediately after each shock

ACLS algorithm — shockable (VF/pulseless VT):
- Shock 1 → 2 min CPR → check rhythm → Shock 2 → 2 min CPR → adrenaline 1 mg IV (after 2nd shock, then every 3–5 min) → check → Shock 3 → amiodarone 300 mg IV (after 3rd shock; 150 mg after 5th) → continue cycles
- Treat reversible causes throughout: 4Hs (Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia, Hypothermia) + 4Ts (Tension pneumothorax, Tamponade, Toxins, Thrombosis)
- Non-shockable (PEA/asystole): CPR + adrenaline every 3–5 min; treat reversible causes

Cardiac rehabilitation:
- Class I recommendation (Level A) for all post-ACS patients
- Phase I (inpatient, days 1–7): early mobilisation + education; Phase II (outpatient, weeks 2–12): supervised exercise + risk factor management; Phase III (maintenance): long-term self-managed
- Evidence: 26% CVD mortality reduction, 18% hospitalisation reduction (Cochrane 2016)
- Smoking cessation: most impactful intervention; offer varenicline (doubles quit rate)
- Return to work: desk job 2–4 weeks; physical labour 6–8 weeks post-exercise test clearance
- DAPT: aspirin + ticagrelor minimum 12 months — never stop without cardiologist advice

Patient counselling principles:
- Empathic opening before clinical recommendations
- Address common questions: return to work, sexual activity (safe at 4–6 weeks), medication adherence, dietary guidance
- Motivational interviewing: open questions, reflective listening, affirm, explore discrepancy
- Include family members in counselling session

REFLECT

Think about the two patients from the opening hook — the collapsed patient in the corridor (cardiac arrest) and Suresh going home after his anterior STEMI. For the arrest scenario: if you had only had 3 months of clinical training instead of 5 years, could you still have delivered effective CPR? The answer should be yes — because BLS is a skill defined by a small number of learnable physical parameters (depth, rate, recoil, ratio). The barrier is not knowledge but practice. When did you last practise CPR on a mannequin, and how confident are you that your compression depth was 5–6 cm? For Suresh: which single piece of information from your counselling session is most likely to change his 5-year trajectory — stopping smoking, taking ticagrelor for 12 months, attending cardiac rehabilitation, or attending follow-up in 4 weeks? The evidence suggests smoking cessation and DAPT adherence are the highest-impact individual behaviours. How would you prioritise and frame those two messages in a 10-minute discharge consultation with a frightened post-MI patient who is also worried about his income?