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ACLS Study Guide

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BLS And ACLS Surveys

ACLS draws heavily on Basic Life Support (BLS). In fact, it is assumed that all people who are pursuing ACLS will be competent in the techniques of BLS—so
much so that it is considered a prerequisite to ACLS

The first step in any resuscitation is to make sure the rescuers (you!) and the victim are safe. Therefore, if
your victim is in the middle of the highway or in a burning building, the first step is to move the victim to
safety.

Assuming you and the victim are in a safe location, the next step is to assess whether the patient is
responsiv

If patient is not responsive, move to BLS survey

If patient is responsive, move to ACLS survey

The BLS Survey

The BLS Survey

1. Responsive? Shake and Shout! Don’t be afraid to make noise.

Check for effective breathing for 5 to 10 seconds.

2. Activate EMS/Call Code In the hospital, you can call a “code” and send someone to get a defibrillator. In the community, call 911 and send for an AED

3. Circulation Check the carotid pulse for no more than 10 seconds. If no pulse, begin high quality CPR.

4. Defibrillation If there is a shockable rhythm, pulseless ventricular tachycardia or ventricular fibrillation, provide a shock

Adult BLS is slightly different if there is one provider (solo) or more than one provider (team) present. The difference between solo provider BLS and team BLS is
that responsibilities are shared when more than one person is present. These will be detailed in Solo and Team Adult BLS.

For healthcare providers, the difference between a witnessed cardiac arrest and a victim who is found down is the order of the initial steps.

If you are alone and witness a victim suddenly collapse: Assume cardiac arrest with a shockable rhythm. If you can get an AED quickly, you
may activate EMS, leave the victim to get an AED, provide CPR for 2 minutes, and use the AED.
If you are alone and find an unresponsive adult: Tailor response to the prospective cause of injury.
If you suspect cardiac arrest: Activate EMS, get AED, 2 min of CPR, use AED
If you suspect asphyxia: 2 min of CPR, Activate EMS, get AED, use AED

Solo Provider Adult BLS

Always make sure that you are safe and the victim is safe before you start BLS.
Check to see if the victim is responsive. Shake and shout! Is the victim breathing effectively? Does the victim have a pulse in the
carotid artery?
If you witnessed the victim suddenly collapse, assume cardiac arrest with a shockable rhythm. If you can get an AED quickly, you
may activate EMS, leave the victim to get an AED, CPR for 2 minutes, and use AED
If you find an unresponsive adult, tailor response to the presumed cause of injury.
If you suspect cardiac arrest: Activate EMS, get AED, 2 min of CPR, use AED
If you suspect asphyxia: 2 min of CPR, Activate EMS, get AED, use AED
High Quality CPR includes
Fast and deep compressions, 100 compressions per minute
 Two inches deep, complete rebound
If you can provide respiration, 2 breaths for 30 comps
If you cannot provide respiration, just give chest comps
Check for a pulse and cardiac rhythm every two minutes. Follow directions on the AED. After providing a shock, immediately
resume CPR. Keep going until EMS arrives or the victim regains circulation.

Team Adult BLS

Always make sure that your team is safe and the victim is safe before you start BLS.
Check to see if the victim is responsive. Shake and shout! Is the victim breathing effectively? Does the victim have a pulse in the
carotid artery?
One provider activates EMS and retrieves an AED. The other provider(s) stays with the victim.
Provide High Quality CPR includes
Fast and deep compressions, 100 compressions per minute
Two inches deep, complete rebound
If you can provide breaths, 2 breaths for 30 comps
If you cannot provide breaths, just give chest comps
The provider who retrieved the AED applies the AED and follows directions given by the device. The provider that stayed with the
victim provides CPR until the AED is ready.
Check for a pulse and cardiac rhythm every two minutes. Follow directions on the AED. If a shock is indicated, clear everyone and
administer a shock. After providing a shock, immediately resume Team CPR.
 In Team CPR, the provider giving chest compressions changes every 2 minutes
Keep going until EMS arrives or the victim regains spontaneous circulation.

Cardiac Arrest
Cardiac arrest is the sudden sensation cessation of blood flow to the tissues in brain the results from a heart that is not pumping effectively. Four rhythms may
occur during cardiac arrest: ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity, and asystole. The primary intervention for
ventricular fibrillation and pulseless ventricular tachycardia is unsynchronized cardioversion, more commonly known as a “shock.” The primary intervention for
pulseless electrical activity and asystole is pharmacological, beginning with the administration of epinephrine.

While ACLS provides algorithms for each of these cardiac arrest rhythms, in the real world a patient may move between these rhythms during a single instance of
cardiac arrest. Therefore, the provider must be able to accurately assess and adapt to changing circumstances. After every 2 minutes of CPR, check for a pulse
and check the cardiac rhythm. If the rhythm has switched from shockable or to shockable, then switch algorithms.

Ventricular Fibrillation And Pulseless Ventricular Tachycardia

In ventricular fibrillation or pulseless ventricular tachycardia, the heart’s conduction system exhibits a disordered rhythm that can sometimes be corrected by
applying energy to it. This energy may come in the form of an automated external defibrillator (AED) defibrillator paddles, or defibrillator pads. VFib and VTach are
treated with unsynchronized cardioversion, since there is no way for the defibrillator to decipher the disordered waveform. In fact, it is important not to provide
synchronized shock for these rhythms.

Ventricular fibrillation is recognized by a disordered waveform, appearing as rapid peaks and valleys as shown in this ECG rhythm strip:
Ventricular tachycardia may provide waveform similar to any other tachycardia; however, the biggest difference in cardiac arrest is that the patient will not have a
pulse and, consequently, will be unconscious and unresponsive. Two examples of ventricular tachycardia are shown in this ECG rhythm strips. The first is narrow
complex tachycardia and the second is wide complex tachycardia:

Ventricular Fibrillation And Pulseless Ventricular Tachycardia Algorithm

Once you have determined that a patient has a shockable rhythm, immediately
provide an unsynchronized shock.
If you are using biphasic energy, use recommended settings on the device. If you
do not know what that setting is, use the highest available setting, (120 to 200
J).
If you are using a monophasic energy source, administer 360 J.
Resume CPR immediately after a shock. Minimize interruptions of chest
compressions.Provide 2 rescue breaths for each 30 compressions.
Epinephrine (1 mg IV/IO) is given every 3 to 5 minutes (two 2 minute cycles of
CPR)
Vasopressin (40 units IV/IO) can be used instead of the first or second dose of
epinephrine
Amiodarone (IV/IO)
First dose 300 mg
Second dose 150 mg
Lidocaine may replace amiodarone when amiodarone is not available.
First dose: 1-1.5 mg/kg IV
Second dose: 0.5-0.75 mg/kg IV every 5 to 10 min
If the arrest rhythm is no longer shockable, move to PEA/Asystole algorithm
If the patient regains consciousness, move to ROSC algorithm for him and him

Pulseless Electrical Activity And Asystole

Pulseless electrical activity or PEA is a cardiac rhythm that does not create a palpable pulse is even though it should. A PEA rhythm can be almost any rhythm
except ventricular fibrillation (incl. torsade de pointes) or pulseless ventricular tachycardia.
Asystole is the “flatline” on the ECG monitor. It represents a lack of electrical activity in the heart. It is critically important not to confuse true asystole with
disconnected leads or an inappropriate gain setting on an in-hospital defibrillator. Asystole may also masquerade as a very fine ventricular fibrillation. If the ECG
device is optimized and is functioning properly, a flatline rhythm is diagnosed as asystole. Note that asystole is also the rhythm one would expect from a person
who has died. Consider halting ACLS efforts in people who have had prolonged asystole.

It is inappropriate to provide a shock to pulseless electrical activity or asystole. Cardiac function can only be recovered in PEA or asystole through the
administration of medications.

PEA And Asystole Algorithm

As long as the patient is in PEA or asystole, the rhythm is not shockable.
Chest compressions/high-quality CPR should be interrupted as little as
possible during resuscitation.
After 2 min. of high-quality CPR, give 1 mg of epinephrine IV/IO.
Remember, chest compressions are a means of artificial circulation, which
should deliver the epinephrine to the heart. Without chest compressions,
epinephrine is not likely to be effective.
Chest compressions should be continued while epinephrine is administered.
Rhythm checks every 2 min.
Epinephrine (1 mg IV/IO) is given every 3 to 5 minutes (after two, 2 minute
cycles of CPR)
Vasopressin (40 units IV/IO) can be used instead of the first or second dose of
epinephrine
If the arrest rhythm becomes shockable, move to VFib/Pulseless VTach
algorithm
If the patient regains circulation, move to ROSC algorithm

Respiratory Arrest
While cardiac arrest is more common in adults than respiratory arrest, there are times when patients will have a pulse but are not breathing or not breathing
effectively (e.g., agonal breathing). A person who has a pulse but is not breathing effectively is in respiratory arrest.

When you encounter a patient in need, you will not know he or she is in respiratory arrest, so perform a BLS survey:
Airway Management
In ACLS, the term airway is used to refer both to the pathway between the lungs and the outside world and victim in the devices that help keep that airway open.
The simplest way to “manage an airway” is the head tilt-chin lift, which creates the straightest passageway for air to flow into the lungs. As if the victim may have
experienced head or neck trauma, airway management should include a jaw thrust, which leaves the head and neck unmoved, but which opens up the airway.

If one is to use a pocket mask or a bag mask to perform ventilations, it is important to make a tight seal with a mask on the victim’s face. Proper use of these
masks may require the rescuer to use one or even two hands to secure the mask to the victim’s face.

A nasopharyngeal airway, which extends from the nose to the pharynx, can be used in both conscious and unconscious patients. An oropharyngeal airway can
only be used in unconscious patients because it may stimulate the gag reflex.

Advanced airways such as endotracheal tubes (ET tubes) and laryngeal mask airways (LMAs) usually require specialized training, but are useful in-hospital
resuscitations (especially LMAs).
“Basic” Airways: Tips And Tricks
While nasopharyngeal and oropharyngeal airways are basic airways, they do require a bit of preparation and skill to use correctly.

Inserting an

Oropharyngeal Airway
Select an airway that is the correct size for the patient
Too big and it will damage the throat
Too small and it will press the tongue into the airway
Place the device at the side of the patient’s face. Choose the device that extends from the corner of the mouth to the earlobe

Clear the mouth or blood or secretions with suction, if possible.

Insert the device so that the point is toward the roof of the mouth or parallel to the teeth
Do not press the tongue back into the throat

Once the device is almost fully inserted, turn it so that the tongue is cupped by the interior curve of the device.

Inserting an

Nasopharyngeal Airway
Select an airway that is the correct size for the patient
Place the device at the side of the patient’s face. Choose the device that extends from the tip of the nose to the earlobe. Use the
largest diameter device that will fit.

Lubricate the airway with a water-soluble lubricant

Insert the device slowly, straight into the face (not toward the brain!)

It should feel snug; do not force the device. If it feels stuck, remove it and try the other nostril.
 Tips on

Suctioning
Adequate suctioning usually requires negative pressures of – 80 to -120 mmHg. Wallmounted suction can deliver this, but
portable devices may not.

When suctioning the oropharynx, do not insert the catheter too deeply. Extend the catheter to the maximum safe depth and
suction as you withdraw.
When suctioning an endotracheal tube, remember that the tube is within the trachea and you may be suctioning near the
bronchi/lung. Therefore sterile technique should be used.

Each suction attempt should be for no longer than 10 seconds. Prior to suctioning, give a brief period of 100% oxygen—
remember that the patient will get no oxygen during suctioning.
Monitor vital signs during suctioning and stop suctioning immediately if the patient experiences hypoxemia (O2 sats 94 has a
new arrhythmia, or becomes cyanotic.

Return Of Spontaneous Circulation (ROSC) And Post Arrest Care

The patient who has been successfully resuscitated will regain spontaneous circulation.
You can detect spontaneous circulation by feeling a palpable pulse at the carotid artery.
Even after Return of Spontaneous Circulation (ROSC), the patient still needs close attention and
support. The patient is at risk for reentering cardiac arrest at any time. Therefore, the patient should
be moved to an intensive care unit.
Titrate the patient’s blood oxygen levels to ≥94%
Does the person need an advanced airway? If so, it should be placed.
Add quantitative waveform capnography
Titrate the patient’s systolic blood pressure to at least 90 mmHg. this may require the addition of
fluids and/or vasopressors o Epinephrine IV 0.1-0.5 mcg/kg/min o Dopamine IV 5-10 mcg/kg/min o
Norepinephrine IV 0.1-0.5 mcg/kg/min o 1-2 liters of fluid resuscitation
Does the person follow verbal commands? If not, there may be neurological compromise. Consider
inducing therapeutic hypothermia with 4°C fluids during fluid resuscitation.
Does the person have signs of myocardial infarction by ECG? Move to ACS algorithm.

Rapid Differential Diagnosis Of Cardiac Arrest

Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate
or treat the most typical causes of cardiac arrest. To facilitate remembering the main, reversible causes of cardiac arrest, they can be organized as the Hs and the
Ts.

The Hs Symptoms/Signs/Tests Intervention

Hypovolemia Rapid heart rate, narrow QRS complex, Fluid resuscitation
Hypoxia Decreased heart rate Airway management, oxygen
Hydrogen Ion
Decreased heart rate Airway management, oxygen
(Acidosis)
Hypoglycemia Fingerstick glucose testing IV Dextrose
Hypokalemia Flat T waves, pathological U wave IV Magnesium
Hyperkalemia Peaked T waves, wide QRS complex Calcium chloride, sodium bicarb,

insulin/glucose, hemodialysis
Hypothermia History of cold exposure Rewarming blankets/fluids

The Ts Symptoms/Signs/Tests Intervention

Tension Pneumothorax Slow heart rate, narrow QRS complex, acute dyspnea, history Thoracotomy, needle

of chest trauma decompression

Tamponade (Cardiac) Rapid heart rate and narrow QRS complex Pericardiocentesis
Toxins Variable, prolonged QT interval, neuro deficits Antidote/antivenom (toxin-specific)
Thrombosis (pulmonary) Rapid heart rate, narrow QRS complex Fibrinolytics, embolectomy
Thrombosis (coronary) ST segment elevation/depression, abnormal T waves Fibrinolytics, Percutaneous intervention

Bradycardia
Bradycardia Algorithm

Bradycardia is any heart rate less than 60 bpm. In practice, however,

bradycardia is only a concern if it is unusual or abnormal for the patient or
causing symptoms.
New cases of bradycardia should be evaluated, but most will not require
specific treatment.
Evaluation of bradycardia includes cardiac and blood oxygen monitoring and a
12 lead ECG if available.
Bradycardia may be treated by providing supplemental oxygen and supporting
the patient’s airway if needed.
Unstable bradycardia (i.e., an abnormally slow heart rate that causes altered
mental status, hypotension, symptoms of shock, cardiac chest pain, or new
signs and symptoms of heart failure) should be treated immediately.
Unstable bradycardia is first treated with intravenous atropine at a dose of 0.5
mg. Additional doses can be given every 3 to 5 min. up to a maximum of 3 mg.
Pulseless bradycardia is considered PEA.
If atropine is unsuccessful in treating symptomatic, unstable bradycardia,
consider transcutaneous pacing, dopamine or norepinephrine infusion, or
transvenous pacing. An intensive or cardiologist may need to be consulted for
these interventions and the patient may need to be moved to the intensive care
unit

Tachycardia
Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern. Some leads may
show P waves while most leads do not. Atrial contraction rates may exceed 300 bpm. The ventricular rate often range is between 100 to 180 bpm. The pulse may
be “irregularly irregular.”
Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about 300 bpm. This often translates to a regular ventricular
rate of 150 bpm, but may be far less if there is a 3:1 or 4:1 conduction. By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes
called F waves. These waves are most notable in leads II, III, and aVF

Narrow QRS complex tachycardias include several different tachyarrhythmias. A narrow QRS complex tachycardia is distinguished by a QRS complex of less than
120 ms. One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below.

Wide complex tachycardias are difficult to distinguish from ventricular tachycardia. Ventricular tachycardia leading to cardiac arrest should be treated using the
ventricular tachycardia algorithm. A wide complex tachycardia in a conscious person should be treated using the tachycardia algorithm.

Tachycardia Algorithm
Tachycardia is any heart rate greater than 100 bpm. In practice, however,
tachycardia is usually only a concern if it is
New cases of tachycardia should be evaluated with cardiac and blood oxygen
monitoring and a 12 lead ECG if available.
Tachycardia may be treated by providing supplemental oxygen, supporting the
patient’s airway if needed, vagal maneuvers, and IV adenosine.
Adenosine IV rapid push
First dose: 6 mg
Second dose: 12 mg
Unstable tachycardia (i.e., an abnormally slow heart rate that causes altered
mental status, hypotension, symptoms of shock, cardiac chest pain, or new
signs and symptoms of heart failure) should be treated with synchronized
cardioversion or adenosine. Consider beta-blocker or calcium channel blocker.
Wide QRS tachycardia may require antiarrhythmic drugs.
Procainamide Amiodarone Sotalol
150 mg IV over 10 minutes with 100 mg (1.5 mg/kg)

20-50 mg IV,
second dose for recurrent VT. over 5 min.
stop if
Maintenance at 1 mg/min for 6 h
hypotensive or
max dose of 17
mg/kg.
Maintenance
infusion at 1-4
mg/min.

Atrioventricular (Heart) Block

Atrioventricular block or heart block is a failure of the heart’s electrical system to properly coordinate conduction. There are four main types of atrioventricular
block: first degree, second degree type I, second degree type II, and third degree heart block. The types of second degree heart block are referred to as Mobitz
type I and Mobitz type II. Second degree heart block Mobitz type I is also known as the Wenckebach phenomenon.

Atrioventricular blocks may be acute or chronic. Chronic heart block may be treated with pacemaker devices. From the perspective of ACLS assessment and
intervention, heart block is important because it can cause hemodynamic instability and can evolve into cardiac arrest. In ACLS, heart block is often treated as a
bradyarrhythmia.

 
 The PR interval is a consistent size, but longer or larger than it should be in first degree heart block.

The PR interval increases in size until a QRS complexes dropped, resulting in missed “beat.”

A QRS wave will occasionally drop, though the PR interval is the same size.

Complete dissociation between P waves and the QRS complex. No atrial impulses reach the ventricle.

Acute Coronary Syndrome

Acute coronary syndrome or ACS is a spectrum of signs and symptoms ranging from angina to myocardial infarction. ACS
includes ST segment elevation myocardial infarction (STEMI) non- ST segment elevation myocardial infarction (NSTEMI), and
unstable angina.
Cardiac chest pain ( any new chest discomfort) should be evaluated promptly. This includes high degree of suspicion by
individuals in the community, prompt rapid action by EMS personnel, assessment in the emergency department, and definitive
treatment.
People with symptoms of cardiac ischemia should be given oxygen, aspirin ( if not allergic), nitroglycerin, and possibly morphine.
Obtain a 12 lead ECG ASAP.
The patient should be assessed in the ED within 10 min. of arrival. Draw and send labs ( e.g., cardiac enzymes, coags), Obtain IV
access. Give statin (if not contraindicated). Obtain chest Xray.
The results of the ECG will be the primary guidance for how the patient with possible cardiac chest pain is managed. The ECG diagnosis of acute coronary
syndrome can be complex. STEMI is recognized by ST segment elevation with/without pathological Q waves.

NSTEMI can be a more challenging electrocardiographic diagnosis. It may result in ST segment depression, “flipped” T waves (T wave
flattening or inversion), peaked T waves, U wave inversion, and bundle branch block. The electrocardiographic of diagnosis of an NSTEMI
is beyond the scope of ACLS.
Unstable angina is new onset cardiac chest pain without ECG changes, angina that occurs at rest and lasts for more than 20 min., and/or
angina that has become rapidly and progressively worse.
STEMI and NSTEMI patients will have elevated cardiac markers in the blood (e.g. troponins) several hours after the acute event. People
with unstable angina will not have elevated cardiac markers.

Acute Coronary Syndrome Algorithm

 STEMI patients should be treated per hospital protocol. His may include anti-platelet drug(s), anticoagulation, a beta-blocker, an ACE
inhibitor, a statin, and either PCI or a fibrinolytic.
NSTEMI is treated with medical therapy as above without a PCI or fibrinolytic, unless they do not improve with medical therapy.
Patients with unstable angina are admitted and monitored for evidence of MI. Patients who do not “rule in” (develop MI) can undergo
cardiac stress testing the next day or as an outpatient.

Acute Stroke

The EMS team should take patients with suspected stroke to a stroke center. While
in transit, the EMS team should try to determine the time at which the patient was
last normal, which is considered the onset of symptoms. EMS administer oxygen via
nasal cannula or face mask, obtain a fingerstick glucose measurement, and alert the
stroke center.
Within 10 min. of the patient’s arrival at the hospital, personnel should assess the
patient. They should obtain vital signs and IV access, draw and send labs (e.g.
coags), obtain a 12-lead ECG, order CT, and perform a general assessment.
Within 25 min. of the patient’s arrival at the hospital, the stroke team should
determine symptom onset, perform and narrow exam including the NIH stroke scale
or equivalent, perform the fibrinolytic checklist, have the results of the CT scan of the
brain.
Within 45 min. of the patient’s arrival at the hospital, the CT scan of the brain should
be read for the presence of ischemic or hemorrhagic stroke.
Within 60 min. of the patient’s arrival at the hospital, fibrinolytic therapy should be
administered in cases of ischemic stroke if the patient is a candidate. If the patient
with an ischemic stroke is not a candidate for fibrinolytic, administer aspirin if the
patient is not allergic. If the patient is having a hemorrhagic stroke, neurosurgery
should be consulted.
Within three hours of the patient’s arrival at the hospital, the patient should be moved
to the neurology/neurosurgery intensive care unit, stroke unit, or med/surg intensive
care unit.

Resuscitation And Life Support Medications

Drug Use(s) Dosage/Route Contraindications/Warnings

Adenosine Supraventricular First dose: 6 mg IV push Second dose: 12 mg IV Second or third degree heart block;
Tachycardia tachycardia due to poisoning

Amiodarone Pulseless ventricular First dose: 300 mg bolus Second dose: 150 mg Max: 2.2 Second or third degree heart block;
tachycardia Ventricular grams/day hypotension may result with rapid infusion
fibrillation or multiple doses

Atropine Symptomatic bradycardia 0.5 mg IV every 3-5 min Max: 3 mg max dose Higher doses may be Doses < 0.5 mg may worsen bradycardia
(No longer recommended required for organophosphate poisoning
for PEA or asystole)

Toxins, poisons, and Up to 2 to 4 mg until symptoms resolve

overdoses

Dopamine Symptomatic bradycardia 2 to 20 mcg/kg IV per min Titrate to blood pressure response Do not mix with sodium bicarbonate or
(if atropine fails) Pressor alkalis/bases Correct hypovolemia before
for shock/hypotension administration

Epinephrine Cardiac arrest Anaphylaxis 1 mg (1:10000) IV OR 2-2.5 mg (1:1000) ETT q3 to 5 min Then Cocaine-induced ventricular tachycardia
Symptomatic bradycardia infuse 0.1-0.5 mcg/kg/min titrated to blood pressure response May increase oxygen demand
instead of dopamine
 Drug Use(s) Dosage/Route Contraindications/Warnings

Symptomatic bradycardia 2-10 mcg/minute infusion titrated to blood pressure response

(if atropine fails) Pressor
for hypotension

Lidocaine Cardiac arrest VFib/VTach First dose: 1-1.5 mg/kg IV

Wide complex bradycardia Should not be
Second dose: 0.5-0.75 mg/kg IV every 5 to 10 min Max: 3 mg/kg used in cases of acute myocardial
Infuse 1-4 mg IV per min infarction Observe for signs of toxicity

Wide complex tachycardia Wide complex tachycardia with pulse: 0.5-1.5 mg/kg IV; may Wide complex bradycardia
repeat twice at half dose in 5-10 minutes to total of 3mg/kg;
followed with infusion of 1-4 mg per minute infusion

Magnesium Torsades de pointes Pulseless Torsades: 1-2 gram IV bolus Torsades with a pulse: 1-2 Rapid bolus may cause hypotension and
Sulfate gram IV over 5-60 minutes followed by infusion at 0.5-1 gram per bradycardia; Can also be used to reverse
hour IV digitalis poisoning

Hypomagnesemia with 1-2 gram IV bolus

cardiac arrest

Vasopressin Ventricular fibrillation 40 units IV instead of epinephrine Deliver through central line Peripheral IV
Pulseless ventricular administration can cause tissue necrosis
tachycardia Asystole PEA

Shock Infuse 0.02-0.04 units/min IV

Time Is Brain! Stroke Time Goals For Evaluation And Therapy

In people who are candidates for fibrinolytics, the goal is to ad mister the agent within 3 hours of the onset of symptoms.

Fibrinolytic Checklist

Inclusion Criteria Exclusion Criteria

Ischemic stroke with neurological deficit Stroke/ head trauma in last 3 months
Onset of symptoms 3 hours History of brain
Age 18 years old Brain tumor, arteriovenous malformation, or aneurysm
Brain or spine surgery in last
Arterial line or blood draw in last week
Possible subarachnoid hemorrhage
Systolic ≥ 185 mmHg or diastolic ≥ 110 mmHg consistently
Serum glucose
Currently bleeding internally or bleeding diathesis
Platelet <100,000/mm (if known)
INR >1.7 or PT >15 seconds (if known)
Elevated aPTT (if known)
Currently taking anticoagulants
Hemorrhage on CT
Stroke includes > 1/3 of entire cerebrum
Relative Exclusion Criteria
Minor neurologic deficits
Rapidly improving neurologic deficits
Major surgery/serious trauma in last 2 weeks
Gastrointestinal/urinary tract bleeding in last 3 weeks
Heart attack in last 3 months
Seizure with stroke with postictal period
Pregnant

In select individuals, the window for fibrinolytics can be extended to 4.5 hours.

Fibrinolytic Checklist for 3 to 4.5 Hours from Symptom Onset

Meets all criteria for fibrinolytic use at 3 hours plus these criteria:
Inclusion Criteria Exclusion Criteria
Ischemic stroke with neurological deficit <3 hours Currently taking anticoagulants
Onset of symptoms 3 to 4.5 hours Severe stroke; NIH Stroke Scale score >25
Age 18 to 79 years old Previous ischemic stroke and diabetes
Team Dynamics
The 2015 edition of the AHA ACLS guidelines highlights the importance of effective team dynamics during resuscitation. ACLS in the hospital will be performed
by several providers. These individuals must provide coordinated, organized care. Providers must organize themselves rapidly and efficiently. The AHA
recommends establishing a Team Leader and several Team Members. The Team Leader is usually a physician, ideally the provider with the most experience in
leading ACLS codes. Resuscitation demands mutual respect, knowledge sharing, and constructive criticism, after the code.

Team Leader Responsibilities Team Member Responsibilities

Usually stands at the foot of the bed Stands in a position dictated by role
Competent in all ACLS duties Competent in specific role (at least)
Directs Team Members in a professional, calm voice Responds with eye contact and voice affirmation
Assigns roles Clearly states when he/she cannot perform a role
Listens for confirmation from Team Member Informs Team Leader when task is complete
Ask for ideas from Team Members when needed Openly share suggestions if it does not disrupt flow
Listens for confirmation from Team Member Provides constructive feedback after code
Documents resuscitation in patient chart Provides information for documentation as needed

When performing a resuscitation, the Team Leader and Team Members should assort themselves around the patient so they can be maximally effective and have
sufficient room to perform their role.

Table Of Contents
Overview of Advanced Cardiovascular Life Support………………………………………………….2

Updates to ACLS in 2015………………………………………………….3

Chain of Survival………………………………………………….4

Adult BLS Chain of Survival………………………………………………….4

BLS and ACLS Surveys………………………………………………….5

The BLS Survey………………………………………………….5

Solo Provider Adult BLS………………………………………………….6

Team Adult BLS………………………………………………….7

Cardiac Arrest……………………………8

Ventricular Fibrillation and Pulseless Ventricular Tachycardia………………………………………………….9

Ventricular Fibrillation and Pulseless Ventricular Tachycardia Algorithm………………………………………………….10

Pulseless Electrical Activity and Asystole………………………………………………….11

PEA and Asystole Algorithm………………………………………………….12

Respiratory Arrest………………………………………………….13

Airway Management………………………………………………….14

Return of Spontaneous Circulation (ROSC) and Post Arrest Care……………………………16

Rapid Differential Diagnosis of Cardiac Arrest………………………………………………….17

Bradycardia………………………………………………….18

Bradycardia Algorithm………………………………………………….18
Tachycardia………………………………………………….19

Tachycardia Algorithm………………………………………………….20

Atrioventricular (Heart) Block……………………………21

Acute Coronary Syndrome………………………………………………….22

Acute Coronary Syndrome Algorithm………………………………………………….23

Acute Stroke………………………………………………….24

Time is Brain! Stroke Time Goals for Evaluation and Therapy………………………………………………….25

Team Dynamics………………………………………………….26

Resuscitation and Life Support Medications……………………………27

Overview Of Advanced Cardiovascular Life Support

Advanced Cardiac Life Support, or ACLS, is a system of algorithms and best practice recommendations intended to provide the best outcome for patients in
cardiopulmonary crisis. ACLS protocols are based on basic and clinical research, patient case studies, clinical studies, and reflect the consensus opinion of
experts in the field. While the term Advanced Cardiovascular Life Support was coined by the American Heart Association, the content contained in this manual is
based on the most recent guidelines published by the American Heart Association, the American College of Cardiology, the American Red Cross, and The
European Society of Cardiology.

Prior to taking ACLS, it is assumed that you are proficient and currently certified in Basic Life Support (BLS). Once you become certified in ACLS, the certification
is valid for two years. However, we encourage you to regularly login back in to your account to check for updates on resuscitation science advances.

This Advanced Life Support provider manual includes:

Updates to ACLS in 2015

Solo and Team BLS
The ACLS Survey
Cardiac and Respiratory Arrest
Return of Spontaneous Circulation (ROSC) and Post Arrest Care
Bradycardia and Tachycardia Management
ECG Rhythm Recognition
Atrioventricular Blocks
Acute Coronary Syndrome and Acute Stroke Management
Resuscitation Medications
Team Dynamics and Systems of Care

Updates To ACLS In 2015

As we learn more about resuscitation science and medicine, physicians and researchers realize what works best and what works fastest in a critical, life-saving
situation. Therefore, it is necessary to periodically update life-support techniques and algorithms. If you have previously certified in advanced cardiovascular life
support, then you will probably be most interested in what has changed since the latest update in 2010. The table below also includes changes proposed since
the last AHA manual was published. These changes will likely appear in future editions of the provider manual.

2015 Science Summary Changes Table

Topic 2010 2015
Systematic Approach BLS Assessment (Name Change) 1-2-3-4
Check for response by tap and Check for response by tap and
shout and watching the chest for shout
movement Call for help and Activate the area
Activate the area emergency emergency response system
response system Obtain an AED
Obtain an AED Check breathing and pulse at same
Check the pulse for 10 seconds or time
less If no pulse, begin chest
If no pulse, begin chest compressions
compressions Defibrillate
Defibrillate
Systematic Approach Primary Assessment (name Airway Airway
change) Breathing Breathing
Circulation Circulation
Evaluate H’s and T’s Disability
Exposure
Systematic Approach Secondary Assessment (new) NA SAMPLE acronym
H’s and T’s
 2015 Science Summary Changes Table
High Quality CPR Compression rate at least 100 per Compression rate of 100 to 120 per
minute minute
Compression depth of at least 2 Compression depth of at least 2
inches in adults inches in adults. If a feedback
Allow complete chest recoil after device is in place, depth can be
compressions adjusted to maximum of 2.4 inches
Compressions should not be in adults or adolescents
interrupted for more than 10 Allow complete chest recoil after
seconds compressions
Excessive ventilation should be Compressions should not be
avoided interrupted for more than 10
Switch providers of compressions seconds
every 2 minutes Excessive ventilation should be
avoided
Chest compression fraction (% of
time spent doing chest
compressions during CPR) should
be at least 60% but ideally 80%
Switch providers of compressions
every 2 minutes
ACLS Post Cardiac Arrest Care Consider hypothermia treatment Consider hypothermia treatment
for 12 to 24 hours in comatose for at least 24 hours in comatose
patients patients
Not recommended to cool patients
in out of hospital setting with cold
IV fluids
ACLS Airway Management If an advanced airway is in place, If an advanced airway is in place,
ventilate every 6 to 8 seconds ventilate every 6 seconds
ACLS Bradycardia Dopamine dose = 2 to 10 mcg per Consider hypothermia treatment
kg per minute for at least 24 hours in comatose
patients

ACLS Airway Management NTEMI NSTE-ACS

Titrate oxygen to create oxygen Titrate oxygen to create oxygen
saturation > 94% saturation > 90%

Chain Of Survival
Advanced Cardiovascular Life Support continues to emphasize the Chain of Survival. The Chain of Survival is a sequence of steps or links that, when followed to
its completion, increases the likelihood that a victim of a life-threatening event will survive. The adult and pediatricchains of survival are slightly different. The
person who is providing BLS is only responsible for the early links, that is, making sure the person is cared for by emergency personnel. The emphasis on early
care is to reinforce that time is a critical factor in life supportcare.  The 2022 standards include the concept of out of hospital care versus in-hospital care.

Adult BLS Chain of Survival

The links of the Adult ACLS Chain of Survival are:

EMS – Early activation of EMS

CPR – Early administration of High-quality CPR
AED – Early use of an AED
ACLS – Early Advanced Cardiovascular Life Support
Post-Arrest Care – Transport victim to the hospital

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