notes

TOPIC

PAGE

BLS SURVEY ...... 2

ACLS SURVEY ...... 3
CARDIAC ARREST ALGORITHM .... 4
POST CARDIAC ARREST ALGORITHM ... 5
BRADYCARDIA ALGORITHM ... 6
TACHYCARDIA ALGORITHM ... 7
ACUTE CORONARY SYNDROMW . 8
ACUTE STROKE .... 9
AIRWAY MANGEMENT .. 10
ELECTRICAL THERAPY ... 11
CODE TEAM .. 12
PUTTING IT ALL TOGETHER ... 13

3340 Riverside Dr, Suite H

Chino, CA 91710
(909) 464-2299
These notes are provided as a learning tool and are
intended to be used in conjunction with the
2011 AHA ACLS Provider Manual only.

To register for classes, visit

www.FlexEd.com.
SPECIAL THANKS TO: AUGUSTO TEODORO, JR., MD, DPBECP
REFERENCES:
AHA Advanced Cardiovascular Life Support Provider Manual, 2011
2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science

2012 Flex Ed, Inc

BLS and ACLS SURVEYS

IF patient is conscious ACLS SURVEY
IF patient is unconscious BLS SURVEY ACLS SURVEY

I. BLS SURVEY

RResponsiveness.
Scan chest for movement

Tap and shout Are you alright?

Look for absent or abnormal breathing.
NO MORE look , listen and feel. NO MORE 2 initial breaths

A Activate EMS and get

an AED

CCirculation

Check carotid pulse for NO MORE than 10 seconds.

IF (-) pulsestart CPR (30 compressions followed by 2 ventilations).
IF (+) pulsedo rescue breathing (1 breath every 5-6 sec or 10-12 bpm)
IF unsure if pulse is presentStart CPR

DDefibrillate

Power ON, Attach pads, Connect plug, Shock if indicated

While AED is ANALYZING hands OFF the chest.
While AED is CHARGING hands ON the chest

CRITICAL CONCEPTS:

WHEN TO WITHOLD CPR

HIGH QUALITY CPR

C- Chest Recoil

Allow full chest recoil

P- Push hard
Push fast

Depth of at least 2 inches

Rate of at least 100 per minute

R- Rotate

Rescuers switch roles every 2 mins.

Do Not Resuscitate request

Threat to safety of rescuers

Decapitation

Lividity

Rigor Mortis

MINIMIZE INTERRUPTIONS IN CHEST COMPRESSIONS

1. Response/breathing check
2. Pulse check
3. Defibrillation
4. Intubation during arrest

NO MORE THAN
10 SECONDS

AVOID EXCESSIVE VENTILATION

1. creates gastric inflation
2. increases intrathoracic pressure
3. decreases venous return
4. lowers survival
5. decreases cerebral blood flow

HIGH QUALITY CPR provides small amount of

oxygenated blood flowing to the different parts of the
body most importantly to the heart and the brain.
2012 Flex Ed, Inc

II. ACLS SURVEY

Airway

Maintain patent airway.

Consider inserting an advanced airway.
Ensure proper placement of advanced airway Quantitative waveform capnography
Suction as needed

Breathing

DURING CARDIAC ARREST: 2 ventilations after 30 compressions. IF advanced airway

is in place 1 breath every 6-8 sec or 8-10 breaths per minute
DURING RESPIRATORY ARREST: 1 breath every 5-6 sec or 10-12 breaths per minute

A
B
C
D

Circulation
Differential
Diagnosis

Attach ECG leads.

Obtain IV/IO access.
Give appropriate drugs to manage rhythms

Search for and treat reversible causes or symptoms by reviewing Hs and Ts

Vital signs

LOC, BP, HR, RR, T, Pain scale,

O2 saturation

Oxygen

Maintain O2 saturation > 94%

Monitor

Cardiac monitor
Access Circulation
Cardiac Drugs

Look for HYPOTENSION and Altered LOC -> UNSTABLE

Look for weak and thready central pulse or NO peripheral pulse

12-lead ECG, cardiac monitor,

defibrillator, laboratory tests

chest pain, epigastric pain, chest discomfort 12-leadECG look

for STEMI
ALIVE PATIENT check rhythm look for signs of poor perfusion
ARRESTED PATIENT check rhythm look for shockable rhythm

Preferred IV fluid: Plain LR or NS

Most common Hs hypovolemia and hypoxia

Most common Ts tension pneumothorax and tamponade

IV/IO Access

Preferred site: Peripheral

antecubital vein
IF IV inaccessible IO

Treatment/
Transport

Search for reversible/

correctible causes

Successful resuscitation following cardiac arrest requires an

integrated set of coordinated actions which are represented by the
links in the ADULT CHAIN OF SURVIVAL

1-2-3-4 of BLS Survey stresses:

Activation of EMS
Early CPR
Rapid defibrillation
A-B-C-D of ACLS Survey integrates advanced
techniques such as:

Immediate
RECOGNITION of
cardiac arrest and
ACTIVATION of EMS

EARLY
CPR

RAPID
Effective
DEFIBRILLATION ADVANCED
LIFE
SUPPORT

Integrated
immediate
POST
CARDIAC
ARREST CARE

Advanced airway
Quantitative waveform capnography
IV/IO access and drug delivery
Diagnosis and treatment of reversible causes
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CARDIAC ARREST ALGORITHM

Patient is UNCONSCIOUS:
BLS SURVEY (1-2-3-4) ACLS SURVEY (A-B-C-D)

4 POSSIBLE CARDIAC ARREST RHYTHMS:

1. VENTRICULAR FIBRILLATION chaotic, disorganized, no identifiable PQRST

2. VENTRICULAR TACHYCARDIA regular, no P, wide QRS, T wave opposite polarity

3. ASYSTOLE flat line, no PQRST

4. PEA any organized, or semi-organized electrical activity but without pulse

RHYTHM

DEFIB
(biphasic)

VASOPRESSORS* given every 3-5 minutes

ANTIARRHYTHMIC*

REMARKS

VF

200J

Epinephrine 1mg

Vasopressin 40IU one time

only (sub to 1st/2nd Epi)

Amiodarone 300mg then

150mg (3-5 minutes apart)

VT

200J

Epinephrine 1mg

Vasopressin 40IU one time

only (sub to 1st/2nd Epi)

Amiodarone 300mg then

150mg (3-5 minutes apart)

Asystole

No shock

Epinephrine 1mg

Vasopressin 40IU one time

only (sub to 1st/2nd Epi)

No more atropine

PEA

No shock

Epinephrine 1mg

Vasopressin 40IU one time

only (sub to 1st/2nd Epi)

No more atropine

*IV/IO drugs administration should be 1. given during CPR, 2. given as rapid bolus, 3. followed by 20mL flush then elevate arm for 10-20 seconds.

VF/pVT

>

U/C
0BP
0PR
0RR

Start CPR
Attach monitor
IV/IO access
Prepare Epi 1

>

>

>
>
Start CPR

Attach monitor
IV/IO access
Prepare Epi 1

>

Give Epi 1
Get Amio 300
Check CPR
Correct Hs/Ts

>

>

>
Give SKIP
Get Epi 1
Check CPR
Correct Hs/Ts

>

>
Give Epi 1
Get SKIP
Check CPR
Correct Hs/Ts

>
Give
Get
Check
Correct

>

>
Give Amio 150
Get Epi 1
Check CPR
Correct Hs/Ts

>

>

Give Epi 1
Get Amio 150
Check CPR
Correct Hs/Ts

>
Give Epi 1
Get SKIP
Check CPR
Correct Hs/Ts

Give Amio 300

Get Epi 1
Check CPR
Correct Hs/Ts

Asystole/
R
PEA
U/C
0BP
0PR
0RR

>

>
Give SKIP
Get Epi 1
Check CPR
Correct Hs/Ts

>

2012 Flex Ed, Inc

Give
Get
Check
Correct

POST CARDIAC ARREST CARE ALGORITHM

Patient has: (+) PULSE
(+)/(-) consciousness
(+)/(-) breathing

1. OPTIMIZE VENTILATION and

OXYGENATION
TARGET

IF TOO MUCH

OXYGENATION SpO2 >94%

O2 toxicity

VENTILATION

Decreased
cerebral blood
flow

Start at 10-12
breaths/minute
(1 breath q 5-6s)

IF abnormal or (-) breathing RESCUE BREATHING

Target PETCO2 35-40 mmHg
Avoid ties that pass circumferentially
around the neck OBSTRUCTS
VENOUS RETURN FROM THE BRAIN

USES OF CONTINUOUS WAVEFORM

CAPNOGRAPHY

2. TREAT HYPOTENSION when

SBP <90 mmHg
DOSE

During CARDIAC ARREST: monitors effectiveness of

chest compression (PETCO2 >10mmHg)

During CARDIAC ARREST: IF PETCO2 < 10mmHg

= ineffective CPR

During cardiac arrest: PETCO2 shoots up to 35-40mmHg

indicates ROSC

FLUIDS

Plain NS/LR

1-2 liters
4OC if inducing hypothermia

VASOPRESSORS

During ROSC: maintain PETCO2 at 35-40mmHg

Epinephrine

0.1-0.5 mcg/kg/min

Dopamine
Norepinephrine

5-10 mcg/kg/min
0.1-0.5 mcg/kg/min

3. INDUCE HYPOTHERMIA
-the only intervention shown to improve neurologic recovery
Requirement

UNRESPONSIVE patient

Optimal Duration

12-24 hours

Target temperature

32-34 OC

4. CORONARY REPERFUSION
MOST RELIABLE indicator of ET tube position

- get 12-lead ECG

- identify patients with STEMI or suspicion of AMI
- coronary reperfusion with PCI
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BRADYCARDIA ALGORITHM
Patient has: (+) PULSE

BOX NO. 2:

V. O. M. I. T.

BOX NO. 3:

Look for H. A. S. I. A.

DECISION POINT: Is the patient SYMPTOMATIC?

CRITERIA FOR SYMPTOMATIC BRADYCARDIA:
The heart is slow
The patient has symptoms
The symptoms are due to slow heart rate
BOX NO. 5:

TREATMENT

Search and treat reversible causes

First Line: ATROPINE 0.5 mg IVP q 3-5min (Max 3mg)
- regardless of the type of bradycardia
- Atropine should NOT delay the implementation of
TCP for patients with poor perfusion
-DO NOT RELY on Atropine for infranodal AVB
IF INEFFECTIVE:

SINUS BRADYCARDIA

Dopamine 2-10 mcg/kg/min OR

Epinephrine 2-10 mcg/min
1st DEGREE AV BLOCK

IF NO H. A. S. I. A.:

F V
F V

Monitor and Observe

2nd DEGREE AV BLOCK TYPE 1

RECOGNIZING AV BLOCKS
PR INTERVAL?

Q1

FIXED/CONSTANT

2nd DEGREE AV BLOCK TYPE 2

3rd DEGREE AV BLOCK

2 O AVB Type
2
3 O AV
B

O VB
1 A
e1
O
2 AVB Typ

Transcutaneous Pacing (TCP) OR

Q2

VARIABLE

1O AVB

2O AVB
Type II

2O AVB
Type I

3O AVB

NO

YES

IRREG

REG

DROPS QRS?

VENTRICULAR RHYTHM?
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TACHYCARDIA ALGORITHM
Adult Tachycardia
(With Pulse)

Patient has: (+) PULSE

BOX NO. 2:

V. O. M. I. T.

BOX NO. 3:

Look for H. A. S. I. A.

DECISION POINT: Is the patient UNSTABLE?

CRITERIA FOR UNSTABLE TACHYCARDIA:
The heart is fast
The patient has symptoms
The symptoms are due to fast heart rate
BOX NO. 4,6,7:

TREATMENT

IF (+) H.A.S.I.A. UNSTABLESYNCHRONIZED CARDIOVERSION

Narrow
Wide
Regular
Irregular

SINUS TACHYCARDIA (rate usually does not exceed 120-130)

Narrow
Wide
Regular
Irregular

SUPRAVENTRICULAR TACHYCARDIA (rate >150)

Narrow
Wide
Regular
Irregular

IF
Narrow-Regular

MONO

Unstable SVT, Aflutter 200J

BIPHASIC
50-100J

Narrow-Irregular Unstable Atrial fib

200J

120-200J

Wide-Regular

Unstable mono VT

100J

100J

Wide-irregular

Unstable poly VT

Treat as VF

Treat as VF

IF(-) H.A.S.I.A. STABLEQRS COMPLEX WIDE or NARROW

IF

TREATMENT

ATRIAL FIBRILLATION

ATRIAL FLUTTER

Narrow
Wide
Regular
Irregular
Both
Narrow
Wide
Regular
Irregular

Narrow-Regular

Identify and treat underlying cause

Attempt VAGAL maneuvers
ADENOSINE 6 mg then 12 mg RIVP
(1-2 minutes apart)

Narrow-Irregular

-blocker, Calcium channel blocker

Wide-Regular

Antiarrhythmic infusion
AMIODARONE 150mg SIVP over 10 minutes,
may repeat

Wide-irregular

Expert consult

VENTRICULAR TACHYCARDIA, MONOMORPHIC

Narrow
Wide
Regular
Irregular

VENTRICULAR TACHYCARDIA, POLYMORPHIC

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ACUTE CORONARY SYNDROME

SIGNS AND SYMPTOMS SUGGESTIVE OF
ISCHEMIA
uncomfortable pressure, fullness, squeezing or pain in
the center of the chest lasting several minutes
chest discomfort spreading to the shoulders, neck, one
or both arms or jaw

ACS CHAIN OF SURVIVAL

1.
2.
3.
4.

Identify warning signs of ischemia

Assessment, care and hospital preparation
Transport to ER/hospital capable of reperfusion
Treatment

chest discomfort spreading to the back of between the

shoulder blades
chest discomfort with light-headedness, dizziness, fainting, sweating, nausea or vomiting
unexplained sudden shortness of breath, which may
occur with or without chest discomfort
atypical signs and symptoms among women and
patients with IDDM

OBTAIN 12 LEAD ECG

within the FIRST 10 MINUTES upon arrival in the ED

INITIAL MANAGEMENT
DOSE

REMARKS

Oxygen

>94%

Administer O2 if dyspneic

ASA

160-325 mg
non-enteric
coated

No true allergy to ASA

No recent GI bleeding

NTG

SL (0.3mg) or
spray (0.4mg)

Monitor BP between each

dose

q 3-5min up to
3 doses

CI: bradycardia
tachycardia
hypotension
RV infarct
phosphodiesterase
inhibitor for E.D. within
the last 24-48 hrs

2-4mg

Given for chest discomfort

unresponsive to NTG

Morphine

2mg increment

IF hypotension develops
FLUIDS is the first line of
treatment

12 lead ECG is at the center of the decision pathway in

the management of ischemic chest discomfort and is
the ONLY means of identifying STEMI

ST-segment Elevation

1mm above the baseline (limb leads)

2mm above baseline (chest leads)
0.04sec to the right of J point
What to look for: ST segment elevation in 2 or more
anatomically contiguous leads

CARDIAC MARKERS
Myoglobin, CPK-MB, Troponin

TARGET UPON ARRIVAL IN THE ED:

Fibrinolytics within 30 minutes
PCI within 90 minutes

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ACUTE STROKE
TIME IS BRAIN
ISCHEMIC STROKE (87%) - a clot blocks a
blood vessel
HEMORRHAGIC STROKE (13%) - a blood
vessel ruptures

ACUTE STROKE CHAIN OF SURVIVAL

1. ACTIVATE EMERGENCY RESPONSE SYSTEM (ERS)
D Detection of symptoms
sudden weakness or numbness of face, arm, leg
sudden confusion
trouble speaking or understanding
sudden trouble seeing in one or both eyes
dizziness or loss of balance or coordination
sudden severe headache with no known cause
2. RAPID EMS DISPATCH
D Dispatch of EMS
early activation and dispatch of EMS
Stroke Assessment using the

Immediate general assessment and stabilization

Assess ABC, vital signs
Provide oxygen if hypoxemic
Obtain IV access
D Data collection
Draw blood for labs (glucose, e-, CBC, coagulation
studies) assessment
Check glucose and treat as needed
Perform neurologic screening assessment
Activate stroke team
Order emergent non-contrast head CT scan or MRI of
the brain
Obtain 12-lead ECG
4. RAPID DIAGNOSIS and TREATMENT
D Decision
Use fibrinolytic check list to see eligibility
Repeat neurologic exam
Make sure the time from symptom onset is <3hours
D Drug administration
Fibrinolytic therapy, intra-arterial strategies
rTPA is the only approved fibrinolytic for acute ischemic
stroke
D Disposition
Rapid admission to stroke unit or critical care unit

CINCINNATI PREHOSPITAL S.T.R.OKE SCALE

Smile

Facial droop

Talk

Abnormal speech

Raise arms

Arm drift

3. RAPID EMS TRANSPORT OF PATIENT

D Delivery
rapid EMS identification, management and transport
appropriate triage to stroke center
D Door
Effective triage of the patient

CRITICAL TIME PERIODS FROM ED ARRIVAL

Immediate general assessment

10 minutes

Immediate neurologic assessment

25 minutes

Acquisition of head CT

25 minutes

Interpretation of head CT

45 minutes

Administration of fibrinolytic therapy upon

arrival in the ED

60 minutes

Administration of fibrinolytic therapy from

onset of symptoms

3-4.5 hours

Admission to monitored bed

3 hours

INITIAL MANAGEMENT:
1. Oxygen
2. IV access/labs
3. Check glucose
4. Perform neurologic screening (NIH) assessment
5. EMERGENT NON-CONTRAST HEAD CT SCAN or MRI of
the brain
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10
BAG-MASK VENTILATIONE-C Technique

AIRWAY MANAGEMENT
OPENING THE AIRWAY
Head-tilt chin-lift
IF suspected head and neck injury
Jaw thrust without head-tilt BUT IF
ineffective head-tilt-chin-lift

One-rescuer

Routine use of CRICOID

PRESSURE is NO longer
recommended

Maintaining an open airway is a priority

CLEARING THE AIRWAY

Suctioninguse large-bore, non-kinking
suction tube. Hyperoxygenate then
suction during withdrawal for no more
than 10 seconds

Two-rescuer

VENTILATING A PATIENT IN CARDIAC ARREST

Tidal volume 500-600 mL
Enough to see visible chest rise
Half a bag squeeze when using a bag-mask device
1-second per breath

MAINTAINING THE AIRWAY

Oropharyngeal airway (OPA)

USING AN OPA
holds the tongue away from the posterior pharyngeal wall
patient should be unconscious and without gag reflex

Nasopharyngeal airway (NPA)

SIZING: flange at the corner of the

mouth while the tip at the angle of the
mandible

ADVANCED AIRWAY

IF TOO SMALL: may push the tongue

against the posterior wall causing
obstruction
IF TOO BIG: may push the epiglottis
against the entrance of the larynx
resulting in complete airway obstruction
METHOD OF INSERTION:
A. Insert OPA with tip pointing to the
hard palate
B. Rotate 180O until the tip touches the
posterior wall of the pharynx passed
the uvula

Confirm ET Tube placement:

visible chest rise
5-point auscultation
direct visualization
Chest x-ray
(qualitative) colorimetric method
--(quantitative) continuous waveform
capnographyMOST RELIABLE

SCENARIO
AIRWAY DEVICE

CARDIAC ARREST
unresponsive, (-) breathing, (-) pulse

RESPIRATORY ARREST*
(-) breathing, (+) pulse

ROSC: post arrest

(-) breathing, (+) pulse

Bag-mask
30 compressions then pause for 2 ventilations
(SYNCHRONOUS)
Advanced
Airway

1 breath every 6-8 seconds or

8-10 breaths per minute
Continuous chest compressions without pauses
(ASYNCHRONOUS)

Perform RESCUE BREATHING

1 breath every 5-6 seconds
(10-12 breaths per minute)
Check pulse every 2 minutes *

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11

ELECTRICAL THERAPY
DEFIBRILLATION (UNSYCHRONIZED CARDIOVERSION) for
SHOCKABLE CARDIAC ARREST (VF/pVT)

Whenever possible, choose pads

over paddles BECAUSE it is faster to
deliver shocks with pads.

Whether you are using AED or

manual defibrillator, first step is to
POWER ON.

If its taking TOO LONG for the AED

to ANALYZE the patients rhythm,
RESUME CHEST COMPRESSION.

SYNCHRONIZED CARDIOVERSIONUNSTABLE TACHYCARDIA

TRANSCUTANEOUS PACINGSYMPTOMATIC BRADYCARDIA
The treatment of choice
for
UNSTABLE TACHYCARDIA
is
SYNCHRONIZED
CARDIOVERSION.
For acute SYMPTOMATIC BRADYCARDIA, the first line of
treatment is ATROPINE.
However, atropine should not
delay implementation of TCP
for patients with
POOR PERFUSION.

UNSTABLE POLYMORPHIC VT is
treated like VF
DEFIBRILLATION

A patient lying on the SNOW is

NOT A CONTRAINDICATION
to delivery of shock using an AED.

OXYGEN CLEAR. When delivering a

shock, make sure that NO oxygen is
blowing directly to the patients head
and chest.

While the AED or manual defibrillator is CHARGING,

HANDS ON the chest.

During cardiac arrest, after 2 minutes of CPR:

1. Check the rhythm
2. Palpate for pulse if (+) organized
rhythm or (+) VT
3. Decide if the rhythm is shockable

There are only 2 SHOCKABLE cardiac

arrest rhythms : VF and pulseless VT

To MINIMIZE INTERRUPTIONS in chest compression,

AFTER delivery of shock, dont waste time checking for a
pulse, RESUME COMPRESSION immediately.

2012 Flex Ed, Inc

12

CODE TEAM
RAPID RESPONSE TEAM
Identifies and treats early clinical
deterioration

CODE TEAM
Manages patient in respiratory or
cardiac arrest

CRITICAL CARE TEAM

Manages patient with ROSC

AIRWAY MANAGER
DEFIBRILLATOR PERSON
CHEST COMPRESSOR

RECORDER/OBSERVER

IV/IO ACCESS/
MEDICATIONS
TEAM LEADER

CODE TEAM
TEAM LEADER
TEAM MEMBERS:
Chest compressor
Airway manager
Defibrillation person
IV/IO access/meds
Recorder/observer
REMEMBER: CLOSE-LOOP COMMUNICATIONS The team leader makes sure that the team member heard and
understood the order and in turn acknowledges when the order has been completed.
2012 Flex Ed, Inc

13

PUTTING IT ALL TOGETHER

MEGACODE PHASES
I

II

III

IV

PRE/PERI-ARREST

SHOCKABLE
CARDIAC ARREST

NON-SHOCKABLE
CARDIAC ARREST

RETURN OF SPONTANEOUS
CIRCULATION (ROSC)

ACLS SURVEY (A-B-C-D)

BLS (1-2-3-4) then

ACLS (A-B-C-D) SURVEY

BLS (1-2-3-4) then

ACLS (A-B-C-D) SURVEY

Optimize ventilation and

oxygenation

VF and pVT

Asystole and PEA

Treat hypotension

High quality CPR

High quality CPR

Induce hypothermia

Shock

NO Shock

Coronary reperfusion

Epinephrine/Vasopressin

Epinephrine/Vasopressin

Amiodarone

NO Amiodarone

V.O.M.I.T.
H.A.S.I.A.
Bradycadia:
Symptomatic vs.
Asymptomatic
Tachycardia:
Stable vs. Unstable

H
A
S
I
A

MEGACODE TIMELINE

PRE-ARREST
symptomatic/asymptomatic
stable/unstable
bradycardia/tachycardia

ORGANIZED RHYTHM WITH PULSE

POST-ARREST
V
O
M
I
T

RHYTHM
PULSE

immediate care of patient with

ROSC
ORGANIZED RHYTHM WITHOUT PULSE (PEA)
ASYSTOLE
VENTRICULAR FIBRILLATION
PULSELSS VENTRICULAR TACHYCARDIA

START CPR
X 2minutes
DEFIB

1. Give appropriate drug

2. Get next drug ready and hold
Two minutes up
Hold CPR

3. Check compression and airway

quality
2012 Flex Ed, Inc