Acls 2020-2025
Acls 2020-2025
Acls 2020-2025
-2025
Guidelines and
Standards
ACLS
Advanced Cardiac
Life Support
Provider Handbook
By Dr. Karl Disque
All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, no part of this publication
can be reproduced, distributed, or transmitted in any form or by any means, or stored in a database
or retrieval system, without the prior consent of the publisher.
Version 2021.01
8 ACLS Essentials . . . . . . . 71
9 Additional Tools . . . . . . . 72
MediCode – 72
CertAlert+ – 72
10 ACLS Review Questions . . . . . . . 73
INTRODUCTION
TO ACLS
The goal of Advanced Cardiovascular Life Support (ACLS) is to achieve the best possible outcome
for individuals who are experiencing a life-threatening event. ACLS is a series of evidence-based
responses simple enough to be committed to memory and recalled under moments of stress. These
ACLS protocols have been developed through research, patient case studies, clinical studies, and
opinions of experts in the field. The gold standard in the United States and other countries is the
course curriculum published by the International Liaison Committee on Resuscitation (ILCOR).
Previously, the ILCOR published periodic updates to their Cardiopulmonary Resuscitation (CPR)
and Emergency Cardiovascular Care (ECC) guidelines on a five-year cycle, with the most recent
update published in 2020. Moving forward, the ILCOR will no longer wait five years between updates;
instead, it will maintain the most up-to-date recommendations online at ECCguidelines.heart.org.
Health care providers are recommended to supplement the materials presented in this handbook
with the guidelines published by the ILCOR and refer to the most current interventions and
rationales throughout their study of ACLS.
While ACLS providers should always be mindful of
Refer to the Basic Life Support (BLS) timeliness, it is important to provide the intervention that
Provider Handbook, also Presented by most appropriately fits the needs of the individual. Proper
utilization of ACLS requires rapid and accurate assessment
the Save a Life Initiative, for a more of the individual’s condition. This not only applies to the
comprehensive review of the BLS provider’s initial assessment of an individual in distress,
Survey. This handbook specifically but also to the reassessment throughout the course of
covers ACLS algorithms and only treatment with ACLS.
briefly describes BLS. All ACLS ACLS protocols assume that the provider may not have all
of the information needed from the individual or all of the
providers are presumed capable of
resources needed to properly use ACLS in all cases. For
performing BLS correctly. While this example, if a provider is utilizing ACLS on the side of the
handbook covers BLS basics, it road, they will not have access to sophisticated devices to
is essential that ACLS providers be measure breathing or arterial blood pressure. Nevertheless,
in such situations, ACLS providers have the framework to
proficient in BLS first.
provide the best possible care in the given circumstances.
ACLS algorithms are based on past performances and
results in similar life-threatening cases and are intended to achieve the best possible outcome for the
individual during emergencies. The foundation of all algorithms involves the systematic approach of
the BLS Survey and the ACLS Survey (using steps ABCD) that you will find later in this handbook.
THE INITIAL
ASSESSMENT
Determining whether an individual is conscious or unconscious can be done very quickly. If you
notice someone in distress, lying down in a public place, or possibly injured, call out to them.
• Make sure the scene is safe before If the individual is unconscious, then start with the BLS
approaching the individual and Survey (Figure 20) and move on to the ACLS Survey (Figure 9).
conducting the BLS or ACLS Survey.
• When encountering an individual If they are conscious and responsive, obtain consent to
who is “down,” the first assessment to provide care and continue assessment and questioning to
determine next steps.
make is whether they are conscious or
unconscious.
BASIC LIFE
SUPPORT
The ILCOR has updated the Basic Life Support (BLS) course over the years as new research in cardiac
care has become available. Cardiac arrest continues to be a leading cause of death in the United
States. BLS guidelines have changed dramatically, and the elements of BLS continue to be some of
the most important steps in initial treatment. General concepts of BLS include:
POST
ACTIVATION DEFIBRILLATE ADVANCED
PERFORM CARDIAC
OF EMERGENCY WITH LIFE RECOVERY
EARLY CPR ARREST
RESPONSE AED SUPPORT
CARE
Figure 1
ADVANCED POST-CARDIAC
PREVENT ACTIVATE PERFORM
LIFE ARREST RECOVERY
ARREST EMS EARLY CPR
SUPPORT CARE
Figure 2
UNRESPONSIVE: NO
BREATHING OR ONLY
GASPING
ACTIVATE
GET AED AND
EMERGENCY
START CPR RESPONSE
- MONITOR RHYTHM
- SHOCK IF NEEDED
- REPEAT AFTER 2 MIN
Figure 3
Be Safe
• If inside, watch for dangers such as construction debris, unsecured weapons, violent individuals,
electrical hazards.
• If outside, watch out for downed electrical wires, leaking fuel from car accidents, building
collapse, or natural disaster/dangerous weather conditions. (Drowning persons should be
removed from the water and dried off; they should also be removed from standing water, such as
puddles, pools, gutters, etc.).
•Be sure you do not become injured yourself.
Call EMS
• Send someone for help and to get an AED.
• If alone, call for help while assessing for breathing and pulse. (The ILCOR emphasizes that cell
phones are available everywhere now and most have a built-in speakerphone. Call for help
without leaving the person.)
CPR
• Check pulse simultaneously with checking for breathing. Do not pause more than 10 seconds to
check for breathing and pulse.
• Begin chest compressions and delivering breaths.
Defibrillate
• Attach the AED when available.
• Listen and perform the steps as directed.
A B C
D E F
Figure 4
A B C
Figure 5
A B C
Figure 6
1. Deliver 30 high-quality chest compressions while counting out loud (Figure 6a).
2. T
he second rescuer holds the bag-mask with one hand using the thumb and index finger
in the shape of a “C” on one side of the mask to form a seal between the mask and the face,
while the other fingers open the airway by lifting the person’s lower jaw (Figure 6b).
3. The second rescuer gives two breaths over one second each as you watch the person’s chest
rise (Figure 6c).
4. Practice using the bag valve mask; it is essential to forming a tight seal and delivering
effective breaths.
Start cycles of 30
compressions
and two breaths
AED/DEFIBRILLATOR
ARRIVES
ASSESS FOR
SHOCKABLE
RHYTHM
BLS for children and infants also focuses on doing several tasks simultaneously. In many situations,
more than one person is available to do CPR.
This simultaneous and choreographed method includes performing chest compressions, managing
the airway, delivering rescue breaths, and using the AED, all as a team. By coordinating efforts, a
team of rescuers can save valuable seconds when time lost equals damage to the heart and brain.
Be Safe
• Move the child out of traffic or any unsafe situation.
• Move the child out of water and dry the child. (Drowning children should be removed from
the water and dried off; they should also be removed from standing water, such as puddles,
pools, gutters, etc.)
• Be sure you do not become injured yourself.
Call EMS
• Send someone for help and to get an AED.
• If alone, shout for help while assessing for breathing and pulse. (The ILCOR emphasizes that
cell phones are available everywhere now and most have a built-in speakerphone. Call for
help without leaving the child.)
• If no one answers and you do not have a cell phone available, perform 2 minutes of CPR
before taking a moment to find help.
CPR
• Begin CPR with chest compressions and delivering breaths in a ratio of 15:2.
Defibrillate
• Attach the AED when it becomes available. Use pediatric pads for children under the age of 8
and less than 55 pounds (25 kg).
• Listen to the AED and perform the steps as directed.
1. Use the heel of one hand on the lower half of the sternum in the middle of the chest.
3. Straighten your arms and press straight down. Compressions should be about two
inches (5 cm) into the child’s chest and at a rate of 100 to 120 compressions per minute.
4. Be sure that between each compression you completely stop pressing on the chest and
allow the chest wall to return to its natural position. Leaning or resting on the chest between
compressions can keep the heart from refilling in between each compression and make CPR
less effective.
5. After 15 compressions, stop compressions and open the airway by tilting the head and lifting
the chin.
a. Put your hand on the child’s forehead and tilt the head back. Lift the child’s jaw by
placing your index and middle fingers on the lower jaw; lift up.
b. Do not perform the head-tilt/chin-lift maneuver if you suspect the child may have
a neck injury. In that case, the jaw-thrust is used. Lift the child’s jaw by placing
your index and middle fingers on the lower jaw; lift straight up. If their lips are
closed, open the lower lip using your thumb.
6. Give a breath while watching the chest rise. Repeat while giving a second breath. Breaths
should be delivered over one second.
7. Resume chest compressions. Switch quickly between compressions and rescue breaths to
minimize interruptions in chest compressions.
Be Safe
• Move the infant out of traffic or any unsafe situation.
• Move the infant out of water and dry the infant. (Drowning infants should be removed
from the water and dried off; they should also be removed from standing water, such as
puddles, pools, gutters, etc.)
• Be sure you do not become injured yourself.
Call EMS
• Send someone for help and to get an AED.
• If alone, shout for help while assessing for breathing and pulse. (The ILCOR emphasizes that
cell phones are available everywhere now and most have a built-in speakerphone. Call for
help without leaving the infant.)
• If no one answers and you do not have a cell phone available, perform 2 minutes of CPR
before taking a moment to find help.
CPR
• Begin CPR with chest compressions and delivering breaths in a ratio of 15:2.
Defibrillate
• Attach the AED when it becomes available. Use pediatric pads for infants and place the pads
in an anterior-posterior position if they would overlap on the front of the chest.
• Listen to the AED and perform the steps as directed.
2. P
ress straight down. Compressions should be 1.5 inches
(4 cm) into the infant’s chest (or about 1/3 the diameter
of the chest) and at a rate of 100 to 120 compressions per
minute.
a. Put your hand on the infant’s forehead and tilt the head back. Lift the infant’s jaw
by placing your index and middle fingers on the lower jaw; lift up. Aim for a
neutral neck position and do not overextend the neck.
b. Do not perform the head-tilt/chin-lift maneuver if you suspect the infant may
have a neck injury. In that case, the jaw-thrust is used. Lift the infant’s jaw by
placing your index and middle fingers on the lower jaw; lift straight up. If their lips
are closed, open the lower lip using your thumb.
5. Give a breath while watching the chest rise. Repeat while giving a second breath. Breaths
should be delivered over one second.
6. Resume chest compressions. Switch quickly between compressions and rescue breaths to
minimize interruptions in chest compressions.
2. Seal the mask against the child’s face by placing four fingers of one
hand across the top of the mask and the thumb of the other hand
along the bottom edge of the mask (Figure 48). Figure 48
3. U
sing the fingers of your hand on the bottom of the mask, open
the airway using the head-tilt/chin-lift maneuver. (Don’t do this if you suspect the child may
have a neck injury).
4. P
ress firmly around the edges of the mask and ventilate by delivering a breath over one
second as you watch the child’s chest rise.
5. Practice using the pocket mask; it is essential to form a tight seal in delivering effective
breaths.
2. The second rescuer holds the BVM with one hand using the thumb
and index finger in the shape of a “C” on one side of the mask to
form a seal between the mask and the face (Figure 49), while the
other fingers open the airway by lifting the child’s lower jaw.
Figure 49
3. T
he first rescuer squeezes the bag giving two breaths over one
second each. Watch for chest rise.
4. Practice using the BVM; it is essential to form a tight seal in delivering effective breaths.
4. CPR is initiated on an Adult and the person’s pulse returns, but he is not breathing. What
ventilation rate should be used for this person?
a. 6-8 breaths per minute
b. 10-12 breaths per minute
c. 18-20 breaths per minute
d. Depends on his color
6. A
fter activating EMS and sending someone for an AED, which of the following is correct for
one-rescuer BLS of an unresponsive individual with no pulse?
a. Start rescue breathing.
b. Apply AED pads.
c. Run to get help.
d. Begin chest compressions.
2. C
When responding to an individual who is “down,” first determine if they are conscious or
not.
3. A
Always assess the safety of the scene in any emergency situation. Do not become injured
yourself.
4. B
Most experts recommend a ventilation rate of 10-12 breaths per minute for adults.
5. C
The focus is on early CPR and defibrillation.
6. D
An unresponsive adult without a pulse must receive CPR, and chest compressions should be
initiated immediately followed by ventilation.
ADVANCED
CARDIAC LIFE
SUPPORT
NORMAL HEART ANATOMY AND PHYSIOLOGY
Understanding normal cardiac anatomy and QRS
physiology is an important component of Complex
This atrial contraction registers on an electrocardiogram (ECG) strip as the P wave. This impulse
then travels to the AV node, which in turn conducts the electrical impulse through the Bundle of
His, bundle branches, and Purkinje fibers of the ventricles causing ventricular contraction. The
time between the start of atrial contraction and the start of ventricular contraction registers on
an ECG strip as the PR interval. The ventricular contraction registers on the ECG strip as the QRS
complex. Following ventricular contraction, the ventricles rest and repolarize, which is registered
on the ECG strip as the T wave. The atria also repolarize, but this coincides with the QRS complex,
and therefore, cannot be observed on the ECG strip. Together a P wave, QRS complex, and T wave at
proper intervals are indicative of normal sinus rhythm (NSR) (Figure 8). Abnormalities that are in the
conduction system can cause delays in the transmission of the electrical impulse and are detected on
the ECG. These deviations from normal conduction can result in dysrhythmias such as heart blocks,
pauses, tachycardias and bradycardias, blocks, and dropped beats. These rhythm disturbances will
be covered in more detail further in the handbook.
B
• Give 100% oxygen
advanced airway, continue giving CPR without
pausing. However, if you are in a hospital or near • Assess effective ventilation with
quantitative waveform capnography
trained professionals who can efficiently insert and
• Do NOT over-ventilate
use the airway, consider pausing CPR.
BREATHING
In cardiac arrest, administer 100% oxygen. Keep blood • Evaluate rhythm and pulse
C
O2 saturation (sats) greater than or equal to 94 percent • Defibrillation/cardioversion
as measured by a pulse oximeter. Use quantitative • Obtain IV/IO access
waveform capnography when possible. Normal partial • Give rhythm-specific medications
pressure of CO2 is between 35 to 40 mmHg. • Give IV/IO fluids if needed
High-quality CPR should produce a ETCO2 between
10 to 20 mmHg. If the ETCO2 reading is less than
10 mmHg after 20 minutes of CPR for an intubated
D
individual, then you may consider stopping • Identify and treat reversible causes
DIFFERENTIAL DIAGNOSIS
Start with the most likely cause of the arrest and then assess for less likely causes. Treat reversible
causes and continue CPR as you create a differential diagnosis. Stop only briefly to confirm a
diagnosis or to treat reversible causes. Minimizing interruptions in perfusion is key.
Figure 10
AIRWAY MANAGEMENT
If bag-mask ventilation is adequate, providers may defer insertion of an advanced airway. Health care
providers should make the decision as to the appropriateness of placing an advanced airway during
the ACLS Survey. The value of securing the airway must be balanced against the need to minimize
the interruption in perfusion that results in halting compressions during airway placement.
Basic airway equipment includes the oropharyngeal airway (OPA) and the nasopharyngeal airway
(NPA). The primary difference between an OPA (Figure 10a) and a NPA (Figure 10b) is that an OPA
is placed in the mouth (Figure 10c and 10d) while an NPA is inserted through the nose. Both airway
equipment terminate in the pharynx. The main advantage of an NPA over an OPA is that it can be
used in either conscious or unconscious individuals because the device does not stimulate the
gag reflex.
Advanced airway equipment includes the laryngeal mask airway, laryngeal tube, esophageal-tracheal
tube, and endotracheal tube. Different styles of these supraglottic airways are available. If it is within
your scope of practice, you may use advanced airway equipment when appropriate and available.
INSERTING AN OPA
STEP 1: Clear the mouth of blood and secretions with suction if possible.
STEP 2: Select an airway device that is the correct size for the person.
• Too large of an airway device can damage the throat.
• Too small of an airway device can press the tongue into the airway.
STEP 3: Place the device at the side of the person’s face. Choose the device that extends from the
corner of the mouth to the earlobe.
STEP 4: Insert the device into the mouth so the point is toward the roof of the mouth or parallel to
the teeth.
• Do not press the tongue back into the throat.
STEP 5: Once the device is almost fully inserted, turn it until the tongue is cupped by the interior
curve of the device.
INSERTING AN NPA
STEP 1: Select an airway device that is the correct size for the person.
STEP 2: Place the device at the side of the person’s face. Choose the device that extends from the tip
of the nose to the earlobe. Use the largest diameter device that will fit.
STEP 3: Lubricate the airway with a water-soluble lubricant or anesthetic jelly.
STEP 4: Insert the device slowly, moving straight into the face (not toward the brain).
STEP 5: It should feel snug; do not force the device into the nostril. If it feels stuck, remove it and try
the other nostril.
TIPS ON SUCTIONING
• OPAs too large or too small may • When suctioning the oropharynx, do not insert the
obstruct the airway. catheter too deeply. Extend the catheter to the maxi-
• NPAs sized incorrectly may enter mum safe depth and suction as you withdraw.
• When suctioning an endotracheal (ET) tube, keep in
the esophagus.
mind the tube is within the trachea and that you may
• Always check for spontaneous be suctioning near the bronchi or lung. Therefore,
respirations after insertion sterile technique should be used.
of either device. • Each suction attempt should be for no longer than 10
seconds. Remember the person will not get oxygen
during suctioning.
• Monitor vital signs during suctioning and stop suc-
tioning immediately if the person
experiences hypoxemia (oxygen sats less than 94%),
has a new arrhythmia or becomes cyanotic.
ENDOTRACHEAL TUBE
The endotracheal (ET) tube is an advanced airway alternative. It is a specific type of tracheal tube that
is inserted through the mouth or nose. It is the most technically difficult airway to place; however, it
is the most secure airway available. Only experienced providers should perform ET intubation. This
technique requires the use of a laryngoscope. Fiber optic portable laryngoscopes have a video screen,
improve success, and are gaining popularity for field use.
LARYNGEAL TUBE
The advantages of the laryngeal tube are similar to those of the esophageal-tracheal tube; however,
the laryngeal tube is more compact and less complicated to insert. This tube has only one larger
balloon to inflate and can be inserted blindly.
ESOPHAGEAL-TRACHEAL TUBE
• During CPR, the chest compression The esophageal-tracheal tube (sometimes referred to
to ventilation rate for adults is 30:2. as a combitube) is an advanced airway alternative to ET
intubation. This device provides adequate ventilation
• If advanced airway is placed, do comparable to an ET tube. The combitube has two separate
not interrupt chest compressions balloons that must be inflated and two separate ports.
for breaths. Give one breath every The provider must correctly determine which port to
6 seconds with continuous chest ventilate through to provide adequate oxygenation.
compressions.
INTRAVENOUS ROUTE
A peripheral IV is preferred for drug and fluid administration unless central line access is already
available. Central line access is not necessary during most resuscitation attempts, as it may cause
interruptions in CPR and complications during insertion. Placing a peripheral line does not require
CPR interruption.
If a drug is given via peripheral route of administration, do the following:
PHARMACOLOGICAL TOOLS
Use of any of the ALCS medication in Table 1 should be done within your scope of practice and after
thorough study of the actions and side effects. This table only provides a brief reminder for those who
are already knowledgeable in the use of these medications. Moreover, Table 1 contains only adult
doses, indications, and routes of administration for the most common ACLS drugs.
• Shock/CHF
• 2 to 20 mcg/kg/min • Fluid resuscitation first
Dopamine • Symptomatic
• Titrate to desired blood pressure • Cardiac and BP monitoring
bradycardia
• Tachyarrhythmia
Table 1 Sotalol • Monomorphic VT • 100 mg (1.5 mg/kg) IV over 5 min • Do not use in prolonged QT
• 3rd line anti-arrhythmic
1. A
n individual presents with symptomatic bradycardia. Her heart rate is 32. Which of the
following are acceptable therapeutic options?
a. Atropine
b. Epinephrine
c. Dopamine
d. All of the above
2. A
person with alcoholism collapses and is found to be in Torsades de Pointes. What
intervention is most likely to correct the underlying problem?
a. Rewarm the individual to correct hypothermia.
b. Administer magnesium sulfate 1 to 2 gm IV diluted in 10 mL D5W to correct
low magnesium.
c. Administer glucose to correct hypoglycemia.
d. Administer naloxone to correct narcotic overdose.
3. Y
ou have just administered a drug for an individual in supraventricular tachycardia (SVT).
She complains of flushing and chest heaviness. Which drug is the most likely cause?
a. Aspirin
b. Adenosine
c. Amiodarone
d. Amitriptyline
ANSWERS
1. D
Atropine is the initial treatment for symptomatic bradycardia. If unresponsive, IV dopamine
or epinephrine is the next step. Pacing may be effective if other measures fail to improve the
rate.
2. B
Hypomagnesemia or low Mg++ is commonly caused by alcoholism and malnutrition.
Administration of IV magnesium may prevent or terminate Torsades de Pointes.
3. B
Adenosine is the correct choice for SVT treatment and commonly results in reactions such as
flushing, dyspnea, chest pressure, and lightheadedness.
PRINCIPLES
OF EARLY
DEFIBRILLATION
The earlier the defibrillation occurs, the higher the survival rate. When a fatal arrhythmia is present,
CPR can provide a small amount of blood flow to the heart and the brain, but it cannot directly
restore an organized rhythm. The likelihood of restoring a perfusing rhythm is optimized with
immediate CPR and defibrillation. The purpose of defibrillation is to disrupt a chaotic rhythm and
allow the heart’s normal pacemakers to resume effective electrical activity.
The appropriate energy dose is determined by the design of the defibrillator—monophasic or
biphasic. If you are using a monophasic defibrillator, give a single 360 J shock. Use the same energy
dose on subsequent shocks. Biphasic defibrillators use a variety of waveforms and have been
shown to be more effective for terminating a fatal arrhythmia. When using biphasic defibrillators,
providers should use the manufacturer’s recommended energy dose. Many biphasic defibrillator
manufacturers display the effective energy dose range on the face of the device. If the first shock does
not terminate the arrhythmia, it may be reasonable to escalate the energy delivered if the defibrillator
allows it.
To minimize interruptions in chest compressions during CPR, continue CPR while the defibrillator is
charging. Be sure to clear the individual by ensuring that oxygen is removed, and no one is touching
the individual prior to delivering the shock. Immediately after the shock, resume CPR, beginning
with chest compressions. Give CPR for two minutes (approximately five cycles). A cycle consists of 30
compressions followed by two breaths for an adult without an advanced airway. Those individuals
with an advanced airway device in place can be ventilated at a rate of one breath every 5 to 6 seconds
(or 10 to 12 breaths per minute).
3. A
ttach the pads to bare chest (not over medication patches) and make sure cables
are connected. (Dry the chest if necessary.)
4. P
lace one pad on upper right side and the other on the chest a few inches below the
left arm.
5. Clear the area to allow AED to read rhythm, which may take up to 15 seconds.
7. I f the AED indicates a shock is needed, clear the individual, making sure no one is
touching them and that the oxygen has been removed. Ensure visually that the
individual is clear and shout “CLEAR!”
10. After two minutes of CPR, analyze the rhythm with the AED.
SYSTEMS
OF CARE
The ILCOR guidelines describe Systems of Care as Unstable Patient
a separate and important part of ACLS provider
training. These Systems of Care describe the
organization of professionals necessary to achieve
the best possible result for a given individual’s
circumstances. They include an overview of the
ways life-saving interventions should be organized Rapid
to ensure they are delivered efficiently and Response
effectively. Hospitals, EMS staff, and communities Team (RRT)
that follow comprehensive Systems of Care
demonstrate better outcomes for their patients
than those who do not.
FPO
Code
Team
Critical Care
Team
Figure 13
CARDIOPULMONARY RESUSCITATION
Successful cardiopulmonary resuscitation (CPR) requires the use of it as part of a system of care
called the Chain of Survival (Figure 14). As with any chain, it is only as strong as its weakest link. Thus,
everyone must strive to make sure each link is strong. For instance, community leaders can work to
increase awareness of the signs and symptoms of cardiac arrest and make AEDs available in public
places. EMS crews must stay abreast of updates and innovations in resuscitation and hone the skills
required to deliver CPR quickly and effectively. Hospitals should be ready to receive patients in
cardiac arrest and provide excellent care. Critical care and reperfusion centers should be staffed by
experts and equipped with the latest technology. Because recovery from cardiac arrest continues
long after the initial hospitalization, patients should have formal assessment and support for their
physical, cognitive, and psychosocial needs.
POST
ACTIVATION DEFIBRILLATE ADVANCED
PERFORM CARDIAC
OF EMERGENCY WITH LIFE RECOVERY
EARLY CPR ARREST
RESPONSE AED SUPPORT
CARE
Figure 14
THERAPEUTIC HYPOTHERMIA
• Recommended for comatose individuals with return of spontaneous circulation after a cardiac
arrest event.
• Individuals should be cooled to 89.6 to 93.2 degrees F (32 to 36 degrees C) for at least 24 hours.
NEUROLOGICAL CARE
• Neurologic assessment is key, especially when withdrawing care (i.e., brain death) to decrease
false-positive rates. Specialty consultation should be obtained to monitor neurologic signs and
symptoms throughout the post-resuscitation period.
Figure 15
TRANPORT
RECOGNIZE TO & NOTIFY GUIDELINE QUALITY
TIMELY EMS
SYMPTOMS & STROKE BASED STROKE POST-STROKE
ACTIVATE EMS RESPONSE CARE CARE
CENTER
Figure 17
Table 2 DISPOSITION Rapid admission to the stroke unit or critical care unit
THREATENED AIRWAY OR
ALTERED MENTAL STATUS
LABORED BREATHING
3. What is the role of the second rescuer during a cardiac arrest scenario?
a. Summon help.
b. Retrieve AED.
c. Perform ventilations.
d. All of the above
ANSWERS
1. B
Pulse checks are limited to no more than 10 seconds. If you are unsure whether a pulse is
present, begin CPR.
2. D
Chest compression 100 to 120 per minute; 2 to 2.4 inches deep (5-6cm).
3. D
Take advantage of any bystander and enlist their help based on their skill level.
ACLS
CASES
RESPIRATORY ARREST
Individuals with ineffective breathing patterns are considered to be in respiratory arrest and require
immediate attention. There are many causes of respiratory arrest, including but not limited to
cardiac arrest and cardiogenic shock. Resuscitate individuals in apparent respiratory arrest following
BLS or ACLS protocols.
1 CHECK RESPONSIVENESS
• Shake and shout, “Are you okay?”
2 CALL EMS & GET AED
• Send someone to call for emergency
medical services (EMS)
• Check for breathing and carotid pulse
for at least 5 seconds but no more than • Send someone to get an automated
10 seconds external defibrillator (AED)
• If NOT breathing or insufficiently breathing, • If you are the ONLY provider, activate EMS
continue survey and get AED
3 DEFIBRILLATION
• If NO pulse, check for shockable rhythm
with AED
• If shockable rhythm, stand clear when
delivering shocks
• Provide CPR between shocks, starting with
chest compressions
PULSE NO PULSE
A
• Maintain airway in unconscious patient
• Consider advanced airway
• Monitor advanced airway if placed with
quantitative waveform capnography
B
• Give 100% oxygen
• Assess effective ventilation with
quantitative waveform capnography
• Do NOT over ventilate
C
• Defibrillation/cardioversion
• Obtain IV/IO access
• Give rhythm-specific medications
• Give IV/IO fluids if needed
D
• Identify and treat reversible causes
• Cardiac rhythm and patient history are
the keys to differential diagnosis
• Assess when to shock versus medicate
Figure 21
TYPES OF AIRWAYS
ADVANCED BASIC
ET BAG-MASK VENTILATION
LMA NPA
Table 4
Figure 23
Do not over ventilate (i.e., give too many breaths per minute or too large
volume per breath). Both can increase intrathoracic pressure, decrease venous
return to heart, diminish cardiac output, as well as predispose individuals to
vomit and aspirate gastrointestinal contents.
The rate appears rapid, but the disorganized electrical activity prevents
RATE
the heart from pumping.
RULES FOR
VENTRICULAR TACHYCARDIA
(REGULAR/RAPID WIDE
COMPLEX TACHYCARDIA)
Figure 25
QRS complex measures more than 0.12 seconds. The QRS will usually be
QRS COMPLEX wide and bizarre. It is usually difficult to see a separation between the
Table 6 QRS complex and the T wave.
RULES FOR
TORSADES DE POINTES
(IRREGULAR WIDE
COMPLEX TACHYCARDIA) Figure 26
VF and pulseless VT are both shockable rhythms. The AED cannot tell
if the individual has a pulse or not.
RULES FOR
ASYSTOLE AND PEA
A “flat line” is reserved for Asystole
definition but PEA includes flat line as
well as any other wave (except VF, VT,
and SVT). Figure 27
REVERSIBLE CAUSES
Figure 28
Hypoxia Tamponade
H+ (acidosis) Toxins
1
START CPR
• Give oxygen
• Attach monitor/defibrillator
2 9
VF/PVT ASYSTOLE/PEA
3
ADMINISTER SHOCK
EPINEPHRINE ASAP
4
CPR FOR TWO MINUTES
• IV/IO access
SHOCKABLE RHYTHM? NO
5 YES
ADMINISTER SHOCK
10
CPR FOR TWO MINUTES
6 • IV/IO Access
CPR FOR TWO MINUTES • Epinephrine every 3 to 5 min
• Epinephrine every 3 to 5 min • Consider advanced airway
• Consider advanced airway and capnography
and capnography
7 YES NO
11
ADMINISTER SHOCK CPR TWO MINUTES
• Treat reversible causes
8
CPR FOR TWO MINUTES
• Amiodarone or Lidocaine SHOCKABLE RHYTHM?
• Treat reversible causes
NO YES
GO TO STEP 5 OR 7
• If no signs of ROSC,
go to step 10 or 11
• If signs of ROSC, go to
Figure 29 Post-Cardiac Arrest Care
• Consider appropriateness
of continued resuscitation
CPR Quality
• Push hard (2-2.4” (5-6 cm)) and fast (100-120 bpm) and allow chest recoil
• Minimize interruptions
•Do not over ventilate
• If no advanced airway, 30:2 compression to ventilation ratio
• Quantitative waveform capnography
- If ETCO2 <10 mmHg, attempt to improve CPR quality
Shock Energy
• Biphasic: Biphasic delivery of energy during defibrillation has been shown to be more effective
than older monophasic waveforms. Follow manufacturer recommendation (e.g., initial dose
of 120 to 200 J); if unknown, use the maximum dose available. Second and subsequent doses
should be equivalent and higher doses should be considered.
• Monophasic: 360 J
Advanced Airway
• Supraglottic advanced airway or ET intubation
• Waveform capnography to confirm and monitor ET tube placement
• 10 breaths per minute with continuous chest compressions
Drug Therapy
• Epinephrine IV/IO Dose: 1 mg, administer as soon as possible then every 3 to 5 minutes after
• Amiodarone IV/IO Dose: first dose is 300 mg bolus, second dose is 150 mg
• Lidocaine: 1st dose: 1-1.5 mg/kg, second dose: 0.5-0.75 mg/kg
Reversible Causes
• Hypovolemia • Tamponade, cardiac
• Hypoxia • Toxins
• H+(acidosis) • Tension pneumothorax
• Hypothermia • Thrombosis, pulmonary or coronary
• Hypo-/hyperkalemia • Trauma
• Hypoglycemia
HYPOTHERMIA
Hypothermia is the only documented intervention that improves/enhances brain recovery after
cardiac arrest. Induced hypothermia can be performed in unresponsive individuals and should
be continued for at least 24 hours. The goal of induced hypothermia is to maintain a core body
temperature between 89.6 to 96.8 degrees F (32 to 36 degrees C) for at least 24 hours by using a
cooling device with a feedback loop. Device manufacturers have developed several innovative
technologies that improve the ability to affect and manage hypothermia in the post-arrest
individual. Hypothermia should be induced and monitored by trained professionals. Induced
hypothermia should not affect the decision to perform percutaneous coronary intervention (PCI),
because concurrent PCI and hypothermia are reported to be feasible and safe.
Figure 31 Figure 32
R-R intervals are regular, overall R-R intervals are regular, overall
REGULARITY REGULARITY
rhythm is regular. rhythm is regular.
The rate is less than 60 bpm, but The rate depends on the
RATE RATE
usually more than 40 bpm. underlying rhythm.
There is one P wave in front There is one P wave in front
P WAVE of every QRS. The P waves P WAVE of every QRS. The P waves
appear uniform. appear uniform.
Measures between 0.12 and Measures more than 0.20 seconds
PR INTERVAL 0.20 seconds in duration. PR PR INTERVAL in duration. PR interval is
interval is consistent. consistent.
QRS COMPLEX Measures less than 0.12 seconds. QRS COMPLEX Measures less than 0.12 seconds.
Table 10 & 11
RULES FOR 2ND DEGREE TYPE I AV RULES FOR 2ND DEGREE TYPE II AV
BLOCK (WENCKEBACH/MOBITZ I) BLOCK (MOBITZ II)
Figure 33 Figure 34
QRS COMPLEX Measures less than 0.12 seconds. QRS COMPLEX Measures less than 0.12 seconds.
Table 12 & 13
SYMPTOMATIC BRADYCARDIA
Bradycardia is defined as a heart rate of less than 60 beats per minute. While any heart rate less
than 60 beats per minute is considered bradycardia, not every individual with bradycardia is
symptomatic or having a pathological event. Individuals in excellent physical shape often have
sinus bradycardia. Symptomatic bradycardia may cause a number of signs and symptoms
including low blood pressure, pulmonary edema, and congestion, abnormal rhythm, chest
discomfort, shortness of breath, lightheadedness, and/or confusion. Symptomatic bradycardia
should be treated with the ACLS Survey. If bradycardia is asymptomatic but occurs with an
arrhythmia listed below, obtain a consultation from a cardiologist experienced in treating
rhythm disorders.
SYMPTOMS OF BRADYCARDIA
• Shortness of breath
• Altered mental status
• Hypotension
• Pulmonary edema/congestion
• Weakness/dizziness/lightheadedness
Assess signs/symptoms
Heart rate typically <50 beats per VENTILATION/OXYGENATION:
minute if bradyarrhythmia Avoid excessive ventilation. Start at 10
to 12 breaths/min and titrate to target
PETCO2 of 35 to 40 mmHg
PERSISTENT BRADYARRHYHMIA
CAUSING:
• Hypotension? NO
• Acutely altered mental status? MONITOR AND OBSERVE
• Signs of shock?
• Chest pain?
• Acute heart failure?
CONSIDER:
• Specialist consultation
• Transvenous pacing
Figure 36
SYMPTOMS OF TACHYCARDIA
• Hypotension • Chest pain/discomfort
• Sweating • Shortness of breath
•Pulmonary edema/congestion • Weakness/dizziness/lightheadedness
• Jugular venous distension • Altered mental state
Figure 37
RATE The rate is over 100 bpm but usually less than 150 bpm.
P WAVE There is one P wave in front of every QRS. The P waves appear uniform.
Figure 38 Figure 39
• Vagal maneuvers
• Adenosine (if regular)
•β -Blocker or calcium
channel blocker
• Consider expert consultation
EMS
OXYGEN • Use four liters per minute nasal cannula; titrate as needed
ASPIRIN • If no allergy, give 160 to 325 mg ASA to chew. Avoid coated ASA
SYMPTOMS OF STROKE
• Weakness in the arm and leg or face
• Vision problems
• Confusion
• Nausea or vomiting
• Trouble speaking or forming the correct words
•Problems walking or moving
• Severe headache (hemorrhagic)
EMS
Clinical signs of stroke depend on the region of the brain affected by decreased or blocked blood
flow. Signs and symptoms can include: weakness or numbness of the face, arm, or leg, difficulty
walking, difficulty with balance, vision loss, slurred or absent speech, facial droop, headache,
vomiting, and change in level of consciousness. Not all of these symptoms are present, and the exam
findings depend on the cerebral artery affected.
The Cincinnati Prehospital Stroke Scale (CPSS) is used to diagnose the presence of stroke in an
individual if any of the following physical findings are seen: facial droop, arm drift, or abnormal
speech. Individuals with one of these three findings as a new event have a 72% probability of an
ischemic stroke. If all three findings are present, the probability of an acute stroke is more than
85%. Becoming familiar and proficient with the tool FAST utilized by the rescuers’ EMS system is
recommended. Mock scenarios and practice will facilitate the use of these valuable screening tools.
FAST: Face Drooping, Arm Weakness, Speech, and Time Symptoms Started
Individuals with ischemic stroke who are not candidates for fibrinolytic therapy should receive
aspirin unless contraindicated by true allergy to aspirin. All individuals with confirmed stroke should
be admitted to Neurologic Intensive Care Unit if available. Stroke treatment includes blood pressure
monitoring and regulation per protocol, seizure precautions, frequent neurological checks, airway
support as needed, physical/occupational/speech therapy evaluation, body temperature checks, and
blood glucose monitoring. Individuals who received fibrinolytic therapy should be followed for signs
of bleeding or hemorrhage. Certain individuals (age 18 to 79 years with mild to moderate stroke) may
be able to receive tPA (tissue plasminogen activator) up to 4.5 hours after symptom onset. Under
certain circumstances, intra-arterial tPA is possible up to six hours after symptom onset. When
the time of symptom onset is unknown, it is considered an automatic exclusion for tPA. If time of
symptom onset is known, the National Institute of Neurological Disorders and Stroke (NINDS) has
established the time goals below.
Figure 44
• Before giving anything (medication or food) by mouth, you must perform a bedside swallow
screening. All acute stroke individuals are considered NPO on admission.
• The goal of the stroke team, emergency physician, or other experts should be to assess the
individual with suspected stroke within 10 minutes of arrival in the emergency department (ED).
• The CT scan should be completed within 25 minutes of the individual’s arrival in the ED and
should be read within 45 minutes.
ISCHEMIC HEMORRHAGIC
Figure 45
NO FIBRINOLYTIC NO FIBRINOLYTIC FIBRINOLYTIC
GENERAL ASSESSMENT/STABILIZATION
• Evaluate vital signs/airway
• Attain IV access/perform lab assessments
ED ARRIVAL • Attain 12-lead ECG
WITHIN 10 • Give O2 if hypoxemic
MINUTES OR LESS • Check glucose; treat if needed
• Complete neurologic screening assessment
• Order MRI of brain/emergency CT scan
• Activate stroke team
ED ARRIVAL
WITHIN 45 CT scan displays hemorrhage?
MINUTES OR LESS YES NO
NON-CANDIDATE
Give aspirin Fibrinolytic therapy
still possible?
CANDIDATE
GO OVER RISKS/BENEFITS
• Admit to stroke or intensive care unit ED ARRIVAL WITH PATIENT/FAMILY
• Start stroke or hemorrhage pathway WITHIN 60 If satisfactory:
Figure 46 MINUTES • No antiplatelet/anticoagulant
treatment <24 hours
OR LESS
• Administer tPA
1. Which of the following is the correct next step in management after delivery of a shock?
a. Check pulse.
b. Ventilate only.
c. Do chest compressions.
d. Shock again.
2. Where does the electrical impulse for normal cardiac activity originate?
a. Unknown
b. SA node
c. AV node
d. Purkinje fibers
3. Choose the correct sequence of electrical activity in the heart for normal sinus rhythm?
a. SA node, Purkinje, AV node, Bundle of His
b. Purkinje, Bundle of His, AV node, SA node
c. SA node, AV node, Bundle of His, Purkinje fibers
d. AV node, SA node, Bundle of Hers, Purkinje fibers
6. Y
ou are transporting an individual who goes into cardiac arrest during transport. IV access is
unsuccessful. What is the next step?
a. Terminate resuscitation.
b. Obtain intraosseous access.
c. Place a central line.
d. Administer all medications through ET tube.
7. A
n individual has been ill, and the monitor reveals sinus tachycardia with a heart rate of 135.
What is the primary goal in treating this individual?
a. Determine the underlying cause.
b. Prepare for synchronized cardioversion.
c. Transfuse packed red blood cells.
d. Administer Adenosine.
9. Y
ou are treating an individual who presented in ventricular fibrillation. After CPR and one
attempt at defibrillation, his new rhythm is third-degree AV block. What is the next step in
management?
a. Repeat defibrillation
b. Vasopressin
c. Transcutaneous pacing
d. High dose epinephrine
10. A 55-year-old male has stroke symptoms, and the CT scan shows multilobar infarction (more
than one-third of the cerebral hemisphere). What therapy is contraindicated?
a. Oxygen
b. Monitoring glucose
c. Thrombolytic therapy
d. Blood pressure monitoring
12. True or False: The goal of stroke care is to complete the ED initial evaluation within 10
minutes, the neurologic evaluation within 25 minutes of arrival, and have the head CT read
within 45 minutes of arrival.
ACLS
ESSENTIALS
• Prompt recognition and intervention with high-quality CPR is
critical in any arrest situation.
• Mentally prepare for resuscitation as you approach the scene and the individual.
• Scene safety is critical; do not get injured yourself.
• BLS focus is early CPR and early defibrillation.
• Do not attempt to place an oropharyngeal airway in an awake individual.
• Pull the jaw up into the mask; do not push the mask onto the face as it may
close the airway.
• IV or IO is the preferred routes for drug delivery; ET tube absorption is unpredictable.
• The dose of amiodarone is different for VF and VT with a pulse.
• Resume chest compressions immediately after delivering a shock.
• Therapeutic hypothermia is utilized after return of spontaneous circulation.
• Learn specific cardiac rhythms: sinus tachycardia, SVT, atrial fibrillation/flutter,
VF, VT, torsades de pointes, and asystole.
• Confirm asystole in two separate leads.
• VF and pulseless VT are treated the same: deliver a shock.
• Remember the causes of PEA: the H’s and the T’s.
• Capnography is a valuable tool in resuscitation. If PETCO2 is greater than 10, attempt to
improve CPR quality.
• Use nitroglycerin with caution in individuals with inferior myocardial infarction; avoid if
systolic blood pressure (SBP) is less than 90 mmHg, or if taking erectile dysfunction
medications (phosphodiesterase inhibitors) within 24 hours.
• Confusion may be a presenting sign of a stroke.
ADDITIONAL
TOOLS
MEDICODE
With MediCode, you no longer will have to carry a set of expandable cards
with you at all times while at work. You will never have to waste valuable
time in an emergency situation searching through multiple algorithms
until you find the right one. All of the algorithms are now accessible from
the palm of your hand, and you will be selecting your desired algorithm
by memory in no time. Choose between multiple viewing options and
easily share algorithms with co-workers and friends through email and
social media.
To improve functionality and speed in obtaining your desired algorithm
as quickly as possible in an emergency, they have been divided between
BLS, ACLS, PALS, and CPR. All are accessible from the home screen.
The individual algorithms included in this app are:
• Basic Life Support (BLS)
• Advanced Cardiac Life Support (ACLS)
• Pediatric Advanced Life Support (PALS)
• Cardiopulmonary Resuscitation (CPR) AED, and First Aid
CERTALERT+
CertAlert+ is the perfect app to minimize a potential area of stress and
distraction in your life. With CertAlert+, you will have all your licenses and
certifications in one place anytime you need them. We will keep track and
remind you when your expiration date approaches, and we will help you
with your registration whenever possible.
With CertAlert+, you can:
• Compile all required licenses and certifications in one location.
• Take photos (front and back) of certification cards and licenses for
simple reference.
• Record all expiration dates and store with ease.
• Choose when you want to be reminded of your approaching
expiration dates.
• Send all license or certification information directly to your email
after exporting from the app.
• Quick access to easily register for online certification
and recertification courses.
ACLS REVIEW
QUESTIONS
1. The following are included in the ACLS Survey:
a. Airway, Breathing, Circulation, Differential Diagnosis
b. Airway, Breathing, Circulation, Defibrillation
c. Assessment, Breathing, Circulation, Defibrillation
d. Airway, Breathing, CPR, Differential Diagnosis
9. _____ joules (J) are delivered per shock when using a monophasic defibrillator.
a. 380
b. 320
c. 340
d. 360
10. The following medication(s) can be used to treat hypotension during the post-cardiac arrest
phase:
a. Dopamine
b. Milrinone
c. Amiodarone
d. Both A and B
11. The following antiarrhythmic drug(s) can be used for persistent ventricular fibrillation or
pulseless ventricular tachycardia, except:
a. Amiodarone
b. Lidocaine
c. Atropine
d. Epinephrine
16. _____ access is preferred in arrest due to easy access and no interruption in CPR.
a. Central
b. Peripheral
c. Intraosseous
d. Endotracheal
19. Which of the following is not found within the 8 D’s of stroke care?
a. Detection
b. Dispatch
c. Delivery
d. Defibrillate
2. D
Both A and B
3. A
Oropharyngeal airway
4. C
Both A and B
5. C
Sinoatrial node
6. B
100 to 120 compressions per minute at a depth of 2 to 2.4 inches (5 to 6 cm)
7. B
30:2
8. A
Resume CPR
9. D
360
10. A
Dopamine
11. C
Atropine
12. C
Hyperventilation
13. D
All of the above
14. A
Fibrinolytic therapy
15. A
Atrial fibrillation
16. B
Peripheral
17. D
All of the above
18. D.
Seizure
19. D
Defibrillate