Figure 19.

Monomorphic VT at a rate of 150 per minute: wide QRS

complexes (arrow A) with opposite polarity T waves (arrow B).

Pathophysiology • Impulse conduction is slowed around multiple areas of ventricular

Polymorphic VT (Figure 20)

• These areas also serve as the source of ectopic impulses (irritable

injury, infarct, or ischemia

foci); irritable foci occur in multiple areas of the ventricles and thus

• These areas of injury can cause impulses to take a circular course,

are “polymorphic”

leading to the reentry phenomenon and rapid repetitive

depolarizations

Defining Criteria • Rate: ventricular rate >100 per minute; typically 120 to 250 per

• Rhythm: only regular ventricular

per ECG minute

Key: Marked • PR: nonexistent

variation and • P waves: seldom seen but present; VT is a form of AV dissociation
inconsistency • QRS complexes: marked variation and inconsistency seen in QRS
seen in QRS complexes
complexes
• Typically will rapidly deteriorate to pulseless VT or VF
• Symptoms of decreased cardiac output (orthostasis, hypotension,
Clinical
Manifestations

• Seldom sustained VT
poor perfusion, syncope, etc) present before pulseless arrest

Common • Acute ischemic event (see Pathophysiology) with areas of “ventricular

• PVCs that occur during relative refractory period of cardiac cycle (“R-
Etiologies irritability”

• Drug-induced prolonged QT interval (tricyclic antidepressants,

on-T phenomenon”)

procainamide, sotalol, amiodarone, ibutilide, dofetilide, some

• Hereditary long QT interval syndromes

antipsychotics, digoxin, some long-acting antihistamines)

© 2006 American Heart Association 41

 Figure 20. Polymorphic VT: QRS complexes display multiple
morphologies.

Torsades de Pointes (a Unique Subtype of Polymorphic VT) (Figure 21)

• QT interval is abnormally long (baseline ECG) (see the Maximum

Pathophysiology Specific pathophysiology of classic torsades:

• Leads to increase in relative refractory period (“vulnerable period”)

QT Interval table in the ECC Handbook)

of cardiac cycle. This increases probability that an irritable focus

(PVC) will occur on T wave (vulnerable period or R-on-T

• R-on-T phenomenon often induces VT

phenomenon)

Defining Criteria • Atrial rate: cannot determine

per ECG • Ventricular rate: 150 to 250 complexes/min
• Rhythm: only irregular ventricular rhythm
Key: QRS • PR: nonexistent
complexes • P waves: nonexistent
display a • QRS complexes: display classic spindle-node pattern (see “Key” at
“spindle-node” left)
pattern, in which
VT amplitude
increases and
then decreases in
a regular pattern
(creating the
“spindle”). The
initial deflection at
the start of one
spindle (eg,
negative) will be
followed by
complexes of
opposite (eg,
positive) polarity
or deflection at
the start of next
spindle (creating
the “node”).

© 2006 American Heart Association 42

 • Tends toward sudden deterioration to pulseless VT or VF
• Symptoms of decreased cardiac output are typical (orthostasis,
Clinical
Manifestations

• “Stable” torsades, sustained torsades is uncommon

hypotension, syncope, signs of poor perfusion, etc)

• Treated with unsynchronized high-energy (defibrillation) shocks

Common Most commonly occurs in patients with prolonged QT interval, due to

• Drug-induced: tricyclic antidepressants, procainamide, sotalol,

Etiologies many causes:

amiodarone, ibutilide, dofetilide, some antipsychotics, digoxin, some

• Electrolyte and metabolic alterations (hypomagnesemia is the

long-acting antihistamines

• Inherited forms of long QT syndrome

prototype)

• Acute ischemic events (see Pathophysiology)

Figure 21. Torsades de pointes: a unique type of polymorphic VT. A,

Start of a “spindle.” Note negative initial deflection and increasing QRS
amplitude. B, End of a spindle and start of a “node.” C, End of a node
and start of the next spindle. Note the positive initial deflection and
“spindling” in QRS amplitude.

© 2006 American Heart Association 43

Recognition of Sinus Bradycardia

Pathophysiology • Impulses originate at SA node at a slow rate

Sinus Bradycardia (Figure 22)

• May be physiologic
• Can be a physical sign, as in sinus tachycardia

•
•
Defining Criteria Rate: <60 per minute
per ECG
•
Rhythm: regular sinus

•
PR: regular, <0.20 second
Key: Regular P P waves: size and shape normal; every P wave is followed by a
waves followed
• QRS complex: narrow; ≤0.10 second in absence of
QRS complex, every QRS complex is preceded by a P wave
by regular QRS
complexes at rate intraventricular conduction defect
<60 per minute

Note: Often a
physical sign
rather than an
abnormal rhythm

• Usually asymptomatic at rest

• With increased activity and sinus node dysfunction, a persistent
Clinical
Manifestations
slow rate can lead to symptoms of easy fatigue, shortness of

• Can be normal for well-conditioned people

breath, dizziness or lightheadedness, syncope, hypotension

• Vasovagal event, such as vomiting, Valsalva maneuver, rectal

Common
Etiologies
stimuli, inadvertent pressure on carotid sinus (“shaver’s

• Acute coronary syndromes that affect circulation to SA node

syncope”)

• Adverse drug effects, eg, β-blockers or calcium channel blockers,

(right coronary artery); most often inferior AMIs

digoxin, quinidine

Figure 22. Sinus bradycardia.

© 2006 American Heart Association 44

Recognition of Atrioventricular (AV) Block

Pathophysiology • Impulse conduction is slowed (partial block) at AV node for a fixed

First-Degree AV Block (Figure 23)

• May be a sign of another problem or a primary conduction

interval

Defining Criteria • Rate: first-degree heart block can be seen with rhythms with both
abnormality

per ECG sinus bradycardia and sinus tachycardia as well as a normal sinus

• Rhythm: sinus, regular, both atria and ventricles

mechanism
Key: PR interval
greater than 0.20 • PR: prolonged, >0.20 second but does not vary (fixed)
second • P waves: size and shape normal; every P wave is followed by a

• QRS complex: narrow, ≤0.10 second in absence of

QRS complex, every QRS complex is preceded by P wave

intraventricular conduction defect

Clinical • Usually asymptomatic

Manifestations

Common • Many first-degree AV blocks are due to drugs, usually the AV

Etiologies nodal blockers: β-blockers, non-dihydropyridine calcium channel

• Any condition that stimulates the parasympathetic nervous

blockers, and digoxin

• AMIs that affect circulation to the AV node (right coronary artery);

system (eg, vasovagal reflex)

most often inferior AMIs

Figure 23. First-degree AV block.

© 2006 American Heart Association 45

 Pathophysiology • Site of pathology: AV node
Second-Degree Block Type I (Mobitz I–Wenckebach) (Figure 24)

• AV node blood supply comes from branches of right coronary

• Impulse conduction is progressively slowed at AV node (causing

artery (right dominant circulation)

increasing PR interval) until one sinus impulse is completely

blocked and QRS complex fails to follow

Defining Criteria • Rate: atrial rate just slightly faster than ventricular (because of

• Rhythm: atrial complexes are regular and ventricular complexes

per ECG dropped conduction); usually within normal range

Key: There is are irregular in timing (because of dropped beats); can see
progressive
• PR: progressive lengthening of PR interval occurs from cycle to
regular P waves marching through irregular QRS
lengthening of PR
interval until one cycle; then one P wave is not followed by QRS complex
P wave is not
• P waves: size and shape remain normal; occasional P wave not
(“dropped beat”)
followed by QRS
complex (dropped
• QRS complex: ≤0.10 second most often, but a QRS “drops out”
followed by QRS complex (“dropped beat”)
beat).
periodically

• Most often asymptomatic

Clinical Due to bradycardia:

• Symptoms: chest pain, shortness of breath, decreased level of

Manifestations—
Rate-Related

• Signs: hypotension, shock, pulmonary congestion, congestive

consciousness

heart failure (CHF), angina

Common • AV nodal blocking agents: β-blockers, non-dihydropyridine

• Conditions that stimulate the parasympathetic nervous system

Etiologies calcium channel blockers, digoxin

• Acute coronary syndrome that involves right coronary artery

Figure 24. Second-degree AV block Type I. Note the progressive

lengthening of the PR interval until one P wave (arrow) is not followed
by a QRS.

© 2006 American Heart Association 46

 Pathophysiology • The site of the block is most often below the AV node (infranodal)
Second-Degree AV Block Type II (Infranodal) (Mobitz II) (Figures 25)

• Impulse conduction is normal through node, thus no first-degree

at the bundle of His (infrequent) or at bundle branches

block and no prior PR prolongation

• Atrial rate: usually 60 to 100 per minute

• Ventricular rate: by definition (because of blocked impulses)
Defining Criteria
per ECG

• Rhythm: atrial = regular, ventricular = irregular (because of

slower than atrial rate

• PR: constant and set; no progressive prolongation as with Mobitz

blocked impulses)

• P waves: typical in size and shape; by definition some P waves

Type I second-degree block—a distinguishing characteristic

• QRS complex: narrow (≤0.10 second) implies high block relative

will not be followed by a QRS complex

to AV node; wide (>0.12 second) implies low block relative to AV

node

• Symptoms: chest pain, shortness of breath, decreased level of

Clinical Due to bradycardia:
Manifestations—

• Signs: hypotension, shock, pulmonary congestion, CHF, AMI

Rate-Related consciousness

Common • Acute coronary syndrome that involves branches of left coronary

Etiologies artery

© 2006 American Heart Association 47

 A

B
Figure 25. A, Type II (high block): regular PR-QRS intervals until 2
dropped beats occur; borderline normal QRS complexes indicate high
nodal or nodal block. B, Type II (low block): regular PR-QRS intervals
until dropped beats; wide QRS complexes indicate infranodal block.

• Injury or damage to cardiac conduction system so that no

Third-Degree AV Block and AV Dissociation (Figure 26)
Pathophysiology
Pearl: AV impulses (complete block) pass between atria and ventricles

• This complete block can occur at several different anatomic

dissociation is the (neither antegrade nor retrograde)
defining class;
third-degree or areas:
complete AV block — AV node (“high,” “supra-,” or “junctional” nodal block)
is one type of AV — Bundle of His
dissociation. By — Bundle branches (“low-nodal” or “infranodal” block)
convention
(outdated), if
ventricular escape
depolarization is
faster than atrial
rate, AV
dissociation is
present; if
ventricular rate is
slower than atrial
rate, third-degree
AV block is
present.

Defining Criteria • Atrial rate: usually 60 to 100 per minute; impulses completely

• Ventricular rate: depends on rate of ventricular escape beats

per ECG independent (“dissociated”) from the slower ventricular rate

Key: Third-degree that arise:

© 2006 American Heart Association 48
 block (see — Ventricular escape rate slower than atrial rate = third-
Pathophysiology) degree AV block (rate = 20 to 40 per minute)
causes atria and — Ventricular escape rate faster than atrial rate = AV

• Rhythm: both atrial rhythm and ventricular rhythm are regular

ventricles to dissociation (rate = 40 to 55 per minute)
depolarize

• PR: by definition there is no relationship between P wave and R

independently, with but independent (“dissociated”)
no relationship
between the two
• P waves: typical in size and shape
wave
(AV dissociation).
• QRS complex: narrow (≤0.10 second) implies high block
relative to AV node; wide (>0.12 second) implies low block
relative to AV node

• Symptoms: chest pain, shortness of breath, decreased level of

Clinical Due to bradycardia:
Manifestations—

• Signs: hypotension, shock, pulmonary congestion, CHF, AMI

Rate-Related consciousness

Common • Acute coronary syndrome that involves branches of left coronary

Etiologies artery
In particular, involves left anterior descending (LAD) artery and
branches to interventricular septum (supply bundle branches)

Figure 26. Third-degree AV block: regular P waves at 50 to 55 per

minute; regular ventricular “escape beats” at 35 to 40 per minute; no
relationship between P waves and escape beats.

© 2006 American Heart Association 49

 Defibrillation

© 2006 American Heart Association 50

 Part 1—Defibrillation and Safety

Manual Defibrillation
Using a When using a manual defibrillator/monitor, perform a rhythm check as
Manual indicated by the Pulseless Arrest Algorithm. This can be performed by
Defibrillator/ attaching the adhesive defibrillator electrode pads or placing the defibrillator
Monitor paddles on the chest (with appropriate conduction surface or gel) and using
the paddle “quick look” feature.

Because adhesive monitor/defibrillator electrode pads are as effective as gel

pads or paste and paddles, and the pads can be placed before cardiac arrest
to allow for monitoring and rapid administration of a shock when necessary,
adhesive pads should be used routinely instead of standard paddles.
Whether using the adhesive electrode pads or paddles, the ACLS provider
should be very careful not to delay the shock and during CPR to minimize the
time between last compression and shock delivery. Delays in delivery of the
first shock have been shown to last approximately 20 to 30 seconds, which is
no longer acceptable. If CPR is in progress, chest compressions should
continue until the defibrillator electrode adhesive pads are attached to the
chest and the manual defibrillator is ready to analyze the rhythm.

When you identify VF/pulseless VT, immediately deliver 1 shock. Use the
following energy levels:

• Manual biphasic: device-specific (typically a selected energy of 120 J with a

rectilinear biphasic waveform and a selected energy of 150 J to 200 J with
a biphasic truncated exponential waveform); if you do not know the device-

• Monophasic: 360 J
specific dose shown to be effective for elimination of VF, use 200 J

After delivering the shock, immediately resume CPR, pushing hard and fast
(compression rate 100 per minute). Allow full chest recoil after each
compression, and minimize interruptions in compressions.

Attaching the Most monitors use three leads: white, red, and black.
3 Monitor
Leads “WHITE to RIGHT”
“RED to RIBS”
“The LEAD LEFT OVER goes to LEFT SHOULDER”

The following table explains these directions in more detail.

© 2006 American Heart Association 51

 Attach… Where…
WHITE lead to RIGHT Right side of the chest, just beneath
the right clavicle
RED lead to RIBS Left midaxillary line, below the
expected point of maximum impulse
of the heart
The LEAD [that is] LEFT OVER goes Left side of the torso, just beneath
to LEFT SHOULDER the distal end of the left clavicle

Safety and Clearing the Patient

Clearing You To ensure the safety of defibrillation, whether manual or automated, the
and Your defibrillator operator must always announce that a shock is about to be
Team delivered and perform a visual check to make sure no one is in contact with
the patient. The operator is responsible for “clearing” the patient and
rescuers before each shock is delivered. Whenever you use a defibrillator,
firmly state a “defibrillation clearing or warning” before each shock. The
purpose of this warning is to ensure that no one has any contact with the
patient and that no oxygen is flowing across the patient’s chest or openly
flowing across the electrode pads. You should state the warning quickly to
minimize the time from last compression to shock delivery. For example:

• “I am going to shock on three. One, I am clear.” (Check to make sure you

• “Two, you are clear.” (Check to make sure no one is touching the patient.
have no contact with the patient, the stretcher, or other equipment.)

“No one” includes providers performing chest compressions, starting IVs,

inserting catheters, or performing ventilation and airway maintenance.)

Make sure all personnel step away from the patient, remove their hands
from the patient, and end contact with any device or object touching the
patient. Any personnel in indirect contact with the patient, such as the
team member holding a ventilation bag attached to an endotracheal tube,
must also end contact with the patient. The person responsible for airway
support and ventilation should ensure that oxygen is not openly flowing
around the electrode pads (or paddles) or across the patient’s chest.

• “Three, everybody is clear.” (Perform a visual check to make sure no one

has contact with the patient or stretcher.)

You do not need to use these exact words. But it is imperative that you warn
others that you are about to deliver a shock and that everyone stand clear.

© 2006 American Heart Association 52

A Final Note Most modern AEDs and manual defibrillators use biphasic
About waveforms. Take the time to learn to operate the defibrillator used in
Defibrillators your workplace and its energy settings. Remember, early defibrillation
increases the patient’s chance of survival. This principle holds true
regardless of the type of defibrillator or waveform.

© 2006 American Heart Association 53

 Part 2—AED Checklist

AED Readiness-for-Use Checklist

Daily/Weekly Checklist
Date __________ Covering Period ______________ to _______________

Organization Name/Identifier ___________________________________________

Manufacturer/Model No. _________________________
Serial/ID No. _________________
At the beginning of each shift or at the scheduled time, inspect the device using this checklist. Note any
inconsistencies, problems, and corrective actions taken. If the device is not ready for use or is out of
service, write OOS on the “day of month” line and note problems in the corrective action log.
1. Defibrillator unit Corrective Action Log Day of Month/Signature/Unit No.
a. Clean, no spills, unobstructed _________________ 1. __________________________
b. Casing intact _________________ 2. __________________________
2. Defibrillation cables and connectors _________________ 3. __________________________
a. Inspect for cracks, broken wires, or damage _________________ 4. __________________________
b. Connectors engage securely _________________ 5. __________________________
3. Supplies available _________________ 6. __________________________
a. Two sets of unexpired hands-free defibrillator _________________ 7. __________________________
pads in sealed packages _________________ 8. __________________________
b. Personal protection equipment—gloves, barrier _________________ 9. __________________________
device (or equivalent) _________________ 10. _________________________
c. Razor and scissors _________________ 11. _________________________
d. Hand towel _________________ 12. _________________________
e. Spare event documentation device* _________________ 13. _________________________
f. ECG paper* _________________ 14. _________________________
g. ECG monitoring electrodes* _________________ 15. _________________________
h. ALS module/key (or equivalent)* _________________ 16. _________________________
4. Power supply _________________ 17. _________________________
a. Verify fully charged battery(ies) in place _________________ 18. _________________________
b. Spare charged battery available* _________________ 19. _________________________
c. Rotate batteries per manufacturer’s _________________ 20. _________________________
specifications* _________________ 21. _________________________
d. AC power plugged into live outlet* _________________ 22. _________________________
5. Indicators and screen display _________________ 23. _________________________
a. POWER ON display and self-test OK* _________________ 24. _________________________
b. ECG monitor display functional* _________________ 25. _________________________
c. No error or service required indicator/message* _________________ 26. _________________________
d. Correct time displayed/set; synchronized with _________________ 27. _________________________
dispatch center _________________ 28. _________________________
6. ECG paper and event documentation device _________________ 29. _________________________
a. Event documentation device in place and _________________ 30. _________________________
functional* _________________ 31. _________________________
b. Adequate ECG paper* _________________
c. ECG recorder functional* Example entry: 5. John Jones
7. Charge/display cycle for defibrillation (signature)/Aid 2 checked Aid 2’s
a. Test per manufacturer’s recommended test device on the 5th day of this month
procedure and found it ready for use.
b. Identifies shockable rhythm*
c. Charges to appropriate energy level*
d. Acceptable discharge detected*
8. AED returned to patient-ready status
*Applicable only if the device has this capability or feature or if
required by medical authority.

© 2006 American Heart Association 54

 Access for Medications

© 2006 American Heart Association 55

 Part 1—Introduction

Correct Historically in ACLS, drugs were administered by the intravenous (IV)

Priorities or endotracheal (ET) route. But new science and consensus opinion
have prioritized both access routes and drug administration.
Remember, no drug given during cardiac arrest has been shown to
improve survival to hospital discharge or improve neurologic function
after cardiac arrest.

• High-quality CPR and early defibrillation are the top priorities during

• Drug administration is of secondary importance.

cardiac arrest.

• Insertion of an advanced airway whether for drug administration or

ventilation, unless bag-mask ventilation is ineffective, is of
secondary importance. Absorption of drugs given by the ET route
is unpredictable, and optimal dosing is unknown. For this reason the
IO route is preferred when IV access is not available.

Intravenous A peripheral IV is preferred for drug and fluid administration. Central

Route line access is not needed during most resuscitation attempts.
Attempts to insert a central line may interrupt CPR. In addition, CPR
can cause complications during central line insertion, such as
vascular laceration, hematomas, and bleeding. Insertion of a central
line in a noncompressible area of a vein is a relative contraindication
to fibrinolytic therapy (eg, for the patient with an STEMI and sudden
cardiac arrest).

Establishing a peripheral line should not require interruption of CPR.

And drugs typically require 1 to 2 minutes to reach the central
circulation when given by the peripheral IV route. Keep this in mind
during CPR. The drug you give based on a rhythm check will not take
effect until it is flushed into the patient and has been circulated by the
blood flow generated during CPR.

If you choose the peripheral venous route, give the drug by bolus
injection and follow with a 20-mL bolus of IV fluid. Elevate the
extremity for 10 to 20 seconds to facilitate delivery of the drug to the
central circulation.

Intraosseous Use the IO route to deliver drugs and fluids during resuscitation if IV
Route access is unavailable. IO access is safe and effective for fluid
resuscitation, drug delivery, and blood sampling for laboratory
evaluation. IO access can be established in all age groups.

© 2006 American Heart Association 56

 Any drug or fluid that can be given by the IV route can also be given
by the IO route. The IO route is preferred over the ET route.

IO cannulation provides access to a noncollapsible venous plexus in

bone marrow. This vascular network provides a rapid, safe, and
reliable route for administration of drugs, crystalloids, colloids, and
blood during resuscitation. It is often possible to achieve IO access in
30 to 60 seconds. The technique uses a rigid needle, preferably a
specially designed IO or bone marrow needle. Use of an IO needle
with stylet may be preferred to use of a needle without stylet because
the stylet prevents obstruction of the needle with cortical bone during
insertion. Butterfly needles and standard hypodermic needles also
can be used.

Endotracheal The IV and IO routes of administration are preferred over the ET

Route route of administration during CPR. When considering use of the ET
route during CPR, keep these concepts in mind:

• The optimal dose of most drugs given by the ET route is unknown.

• The typical dose of drugs administered by the ET route is 2 to 2½

• To give drugs via the ET route, dilute the dose in 5 to 10 mL of

times the dose given by the IV route.

water or normal saline and inject the drug directly into the

• You can give the following drugs by the ET route during cardiac
endotracheal tube. Follow with several positive-pressure breaths.

arrest: atropine, vasopressin, epinephrine, and lidocaine. The

memory aid NAVEL is often used to recall drugs that can be given
by the ET route. Arrest drugs that can be given are: atropine (A),
epinephrine (E), vasopressin (V) and lidocaine (L). “N” stands for
naloxone, which is often used for respiratory depressions due to
opioids. Note that the drug absorption and drug effect are much less
predictable when drugs are administered by the ET rather than by
the IV/IO route.

© 2006 American Heart Association 57

 Part 2—Intravenous Access

Using The most common sites for IV access are in the hands and arms.
Peripheral Favored sites are the dorsum of the hands, the wrists, and the
Veins for IV antecubital fossae. Ideally only the antecubital veins should be used
Access for drug administration during CPR.

Anatomy: Upper Extremities (Figure 27)

Starting at the radial side of the wrist, a thick vein, the superficial
radial vein, runs laterally up to the antecubital fossa and joins the
median cephalic vein to form the cephalic vein. Superficial veins on
the ulnar aspect of the forearm run to the elbow and join the median
basilic vein to form the basilic vein. The cephalic vein of the forearm
bifurcates into a Y in the antecubital fossa, becoming the median
cephalic (laterally) and the median basilic (medially).

The basilic vein passes up the inner side of the arm, where it joins the
brachial vein to become the axillary vein. The cephalic vein continues
laterally up the arm, crosses anteriorly, and courses deep between
the pectoralis major and deltoid muscles. After a sharp angulation it
joins the axillary vein at a 90° angle. This sharp angulation makes the
cephalic vein unsuitable for insertion of central venous pulmonary
artery catheters.

Technique: Antecubital Venipuncture

The largest surface veins of the arm are in the antecubital fossa.
Select these veins first for access if the patient is in circulatory
collapse or cardiac arrest (Figure 27). Select a point between the
junctions of 2 antecubital veins. The vein is more stable here, and
venipuncture is more often successful.

Self-contained kits allow easy central venous access, so today

providers rarely use peripheral leg veins for vascular access.

© 2006 American Heart Association 58

 A

B
Figure 27. Antecubital venipuncture. A, Scene perspective from a distance.
B, Close-up view of antecubital area: anatomy of veins of upper extremity.

© 2006 American Heart Association 59

General IV Once you gain vascular access, follow these important principles for
Principles administering IV therapy:

• After a cardiac arrest patient becomes stable, remove the cannula

inserted emergently and replace it with a new one under sterile
conditions. Strict aseptic technique is compromised in most
emergency venipunctures, where speed is essential. This
compromise is particularly likely when emergency vascular access
is established outside the hospital, because personnel and

• IV solutions are usually packaged in nonbreakable plastic bottles or

equipment are limited.

bags. Squeeze plastic bags before use to detect punctures that may

• Avoid adding drugs that may be adsorbed by the plastic bag or

lead to contamination of the contents.

tubing (eg, IV nitroglycerin). If you must administer these drugs

without specialty infusion systems, allow for drug adsorption when

• Ideally set the rate of infusion to at least 10 mL/h to keep the IV line
you titrate the drug administration rate.

• Saline lock catheter systems are particularly useful for patients who
open.

have spontaneous circulation and require drug injections but not IV

• Most contemporary systems use needleless injection sites. These

volume infusion.

systems permit drug and flush infusions without the use of needles

• Avoid letting the arm with the IV access hang off the bed. Place the
and the associated risk of needle sticks.

arm at the level of heart or slightly above the heart, to facilitate

• During cardiac arrest follow all peripherally administered drugs with

delivery of fluids and medications to the central circulation.

a bolus of at least 20 mL of IV flush solution. This flush will facilitate

delivery to the central circulation. Elevate the extremity for 10 to 20

• Be aware of complications common to all IV techniques. Local

seconds to facilitate drug delivery to the central circulation.

complications include hematomas, cellulitis, thrombosis, and

phlebitis. Systemic complications include sepsis, pulmonary
thromboembolism, air embolism, and catheter fragment embolism.

© 2006 American Heart Association 60

 Part 3—Intraosseous Access

Introduction When venous access cannot be rapidly achieved, intraosseous (IO)

access can serve as a rapid, safe, and reliable route for
administration of drugs, crystalloids, colloids, and blood. IO
cannulation provides access to a noncollapsible venous plexus in
bone marrow and can often be achieved in 30 to 60 seconds. This
vascular access technique is suitable for all age groups, from preterm
neonates through adulthood.

Needles The technique uses a rigid needle, preferably a specially designed IO

or Jamshidi-type bone marrow needle. An IO needle with stylet is
preferred to one without a stylet because the stylet can prevent
obstruction of the needle by cortical bone during insertion.
Commercial kits with specially designed needles are available.

In the past the higher bone density in older children and adults made
it difficult for smaller IO needles to penetrate the bone without
bending. With the development of IO cannula systems for adults, IO
access is now easier to obtain in older children and adults.

Sites Many sites are appropriate for IO infusion. For young children, the proximal
tibia, just below the growth plate, is the most common site used. In older
children and adults, successful IO insertion sites include the sternum, the
distal tibia just above the medial malleolus, the lateral or medial malleolus,
the distal radius and distal ulna, the distal femur, and the anterior-superior
iliac spine.

Indications Resuscitation drugs, fluids, and blood products can be administered

and safely by the IO route. Continuous catecholamine infusions can also
Administration be provided by this route.

The onset of action and drug levels following IO infusion during CPR
are comparable to those for vascular routes of administration,
including central venous access. When providing drugs and fluids by
the IO route, remember the following:

• Flush all IO medications with 5 to 10 mL of normal saline to facilitate

• Administer viscous drugs and solutions and fluid for rapid volume
delivery into the central circulation.

resuscitation under pressure using an infusion pump, pressure bag,

or forceful manual pressure to overcome the resistance of the
emissary veins.

© 2006 American Heart Association 61

 Some have expressed concern that high-pressure infusion of blood
might induce hemolysis. But animal studies have failed to document
this problem.

Complications Complications of IO infusion include tibial fracture, lower extremity

compartment syndrome or severe extravasation of drugs, and osteomyelitis.
But <1% of patients have complications after IO infusion. Careful technique
helps to prevent complications.

Contraindications Absolute contraindications to IO access are as follows:

• Fractures and crush injuries near the access site

• Conditions in which the bone is fragile, such as osteogenesis imperfecta
• Previous attempts to establish access in the same bone

Avoid IO cannulation if infection is present in overlying tissues.

Equipment The following equipment is needed to establish IO access:

•
Needed

•
Gloves

•
Skin disinfectant

•
IO needle (16 or 18 gauge) or bone marrow needle

•
Tape

•
Syringe
Isotonic crystalloid fluid and intravenous tubing

Procedure The steps to establish IO using the tibial tuberosity as an access site
example are as follows:

• Always use universal precautions when attempting vascular access. Disinfect the
Step Action
1

• Identify the tibial tuberosity just below the knee joint. The insertion site is the flat
overlying skin and surrounding area with an appropriate agent.

part of the tibia, 1 or 2 finger widths below and medial to this bony prominence.

• The stylet should remain in place during insertion to prevent the needle from
Figure 28 shows sites for IO access.
2

• Stabilize the leg to facilitate needle insertion. Do not place your hand behind the
becoming clogged with bone or tissue.

leg.

© 2006 American Heart Association 62

 3 • Insert the needle so that it is perpendicular to the tibia. (When placing an IO
needle in other locations, aim slightly away from the nearest joint space to reduce
the risk of injury to the epiphysis or joint but keep the needle as perpendicular to
the bone as possible to avoid bending.)

TWIST, DON'T PUSH, THE NEEDLE.

• Use a twisting motion with gentle but firm pressure. Some IO needles have
threads. These threads must be turned clockwise and screwed into the bone.
4 Continue inserting the needle through the cortical bone until there is a sudden
release of resistance. (This release occurs as the needle enters the marrow space.)
If the needle is placed correctly, it will stand easily without support.
A

B C

Figure 28. A, Locations for IO insertion in the distal tibia and the femur. B,
Location for IO insertion in the iliac crest. C, Location for IO insertion in
the distal tibia.

© 2006 American Heart Association 63

 • Remove the stylet and attach a syringe.
• Aspiration of bone marrow contents and blood in the hub of the needle confirms
5

appropriate placement. You may send this blood to the lab for study. (Note: Blood

• Infuse a small volume of saline and observe for swelling at the insertion site. Also
or bone marrow may not be aspirated in every case.)

check the extremity behind the insertion site in case the needle has penetrated
into and through the posterior cortical bone. Fluid should easily infuse with saline

• If the test injection is unsuccessful (ie, you observe infiltration/swelling at or near

injection from the syringe with no evidence of swelling at the site.

the insertion site), remove the needle and attempt the procedure on another
bone. If the cortex of the bone is penetrated, placing another needle in the same
extremity will permit fluids and drugs to escape from the original hole and infiltrate
the soft tissues, potentially causing injury.
6 There are a number of methods to stabilize the needle. Place tape over the flange
of the needle to provide support. Position gauze padding on both sides of the
needle for additional support.
7 When connecting IV tubing, tape it to the skin to avoid displacing the needle by
placing tension on the tubing.
8 Volume resuscitation can be delivered via a stopcock attached to extension tubing
or by infusion of fluid under pressure. When using a pressurized fluid bag, take
care to avoid air embolism.

• Use a syringe bolus via a medication port in the IV tubing (3-way stopcock not
Other methods include the following:

• Attach a saline lock to the IO cannula and then provide syringe boluses through
needed).

the lock.
9 Any medication that can be administered by the IV route can be given by the IO
route, including vasoactive drug infusions (eg, epinephrine drip).

All medications should be followed with a saline flush.

Follow-up Follow-up is important after you establish IO access. Use these guidelines:

•
•
Check the site frequently for signs of swelling.
Check the site often for needle displacement. Delivery of fluids or drugs
through a displaced needle may cause severe complications (eg, tissue

•
necrosis or compartment syndrome).
Replace the IO access with vascular access as soon as reasonable. IO
needles are intended for short-term use, generally <24 hours.
Replacement with long-term vascular access is usually done in the
intensive care unit.

© 2006 American Heart Association 64

 Acute Coronary Syndromes

© 2006 American Heart Association 65

 Part 1—STEMI Infarct Location and Heart Block

Right Patients with inferior or right ventricular (RV) infarction often present with
Ventricular excess parasympathetic tone. Inappropriate parasympathetic discharge will
Infarction can cause symptomatic bradycardia and hypotension. If hypotension is
present, it is usually due to a combination of hypovolemia (decreased left
ventricular [LV] filling pressure) and bradycardia.

• Give a careful fluid challenge with normal saline (250 to 500 mL based on
clinical assessment). Repeat fluid administration (typically up to 1 to 2 L) if
there is improvement and no symptoms or signs of heart failure or volume
overload. Reassess the patient before each fluid administration. For
patients with RV infarct and hypotension, volume administration may be
lifesaving.

When hypotension is present, a slow heart rate is inappropriate. The heart

rate should be faster in the presence of low blood pressure. The fluid bolus
increases RV filling pressures, which causes an increase in the strength of
RV contractions (Starling mechanism), blood flow through the lungs, and
ultimately LV filling pressure and cardiac output.

AV Block With Acute inferior wall myocardial infarction (usually a right coronary artery event)
Inferior MI may result in symptomatic second-degree or third-degree heart AV with a
junctional, narrow-complex escape rhythm. However, if the patient remains
asymptomatic and hemodynamically stable, transcutaneous pacing (TCP)
and a transvenous pacemaker is not indicated. Monitor the patient and
prepare for transcutaneous pacing if high-degree block develops and the
patient becomes symptomatic or unstable prior to cardiology expert
evaluation.

• Heart block frequently develops from excess vagal tone and atrioventricular
nodal ischemia. The patient may be stable if junctional pacemaker cells can
function and maintain an adequate ventricular rate. This rhythm usually has
a narrow-complex QRS and a ventricular rate of 40 to 60 per minute.
Unless a large amount of myocardium is nonfunctional or comorbid

• If the bradycardia is symptomatic, follow the Bradycardia Algorithm.

conditions exist, the patient is often stable.

• Prepare for TCP.

• Use atropine to increase heart rate and blood pressure if the patient
becomes symptomatic. The initial recommended atropine dose is 0.5 mg
IV. Avoid excessive use of atropine. Use only the dose necessary to
stabilize the patient. Excess atropine may increase ischemia by increasing
heart rate and contractility – major determinants of myocardial oxygen

• If there is no response to atropine and TCP, follow the Bradycardia

consumption.

Algorithm and consider epinephrine (2 to 10 µg/min) or dopamine

© 2006 American Heart Association 66

 • The conduction defect is often transient. But you should keep TCP on
(2 to 10 µg/kg per minute) infusion.

• Evaluation of AV block with AMI can be difficult. Obtain immediate expert

standby for these patients.

consultation for evaluation and recommendation (eg, transvenous

temporary pacemaker).

© 2006 American Heart Association 67

 Part 2—Fibrinolytic Checklist

Figure 29. Fibrinolytic checklist.

© 2006 American Heart Association 68

 Stroke

© 2006 American Heart Association 69

 Stroke Fibrinolytic Checklist
Table 3. Fibrinolytic Checklist for Patients With Acute Ischemic Stroke

© 2006 American Heart Association 70

 Medical Emergency (or Rapid
Response) Teams to Prevent
In-Hospital Cardiac Arrest

© 2006 American Heart Association 71

Introduction Mortality from in-hospital cardiac arrest remains high. The average
survival rate is approximately 17% despite significant advances in
treatments. Survival rates are particularly poor for arrest
associated with rhythms other than ventricular fibrillation
(VF)/ventricular tachycardia (VT) rhythms. Non-VF/VT rhythms are
present in more than 75% of arrests in the hospital.

Many in-hospital arrests are preceded by easily recognizable

physiologic changes, many of which are evident with routine
monitoring of vital signs. In recent studies nearly 80% of
hospitalized patients with cardiorespiratory arrest had abnormal
vital signs documented for up to 8 hours before the actual arrest.
This finding suggests that there is a period of increasing instability
before the arrest.

Of the small percentage of in-hospital cardiac arrest patients who

experience return of spontaneous circulation and are admitted to
the intensive care unit, 80% ultimately die before discharge. In
comparison, only 44% of nonarrest patients admitted to intensive
care urgently from the floor (ie, before an arrest occurs) die before
discharge.

Cardiac Cardiac arrest teams are unlikely to prevent arrests because their
Arrest Teams focus has traditionally been to respond only after the arrest has
(In Hospital) occurred. Once the arrest occurs, the mortality rate is greater than
80%.

There has been a major shift in focus for in-hospital cardiac arrest
over the past few years, with patient safety and prevention of
arrest now the focus. The best way to improve a patient’s chance
of survival from a cardiorespiratory arrest is to prevent it from
happening. For this reason recognizing clinical deterioration and
intervening at once to prevent arrest are now being stressed.
Rapid assessment and intervention for a number of abnormal
physiologic variables can decrease the number of arrests
occurring in the hospital. The majority of cardiorespiratory arrests
in the hospital should be classified as a “failure to rescue” rather
than an isolated, unexpected, random occurrence. This new
thinking requires a significant cultural shift within institutions.
Actions and interventions need to be proactive with the goal of
improving rates of morbidity and mortality rather than reacting to a
catastrophic event.

© 2006 American Heart Association 72

Rapid Over the past decade hospitals in several countries have
Response designed systems to identify and treat early clinical deterioration in
Systems patients. The purpose of these rapid response systems is to

♦ Rapid
improve patient outcomes by bringing critical care expertise to
ward patients. There are several names for these systems, such
Response as medical emergency team (MET), rapid response team (RRT),
Team and rapid assessment team.
(RRT)

♦ Medical
There are common basic components to all rapid response
systems. Success depends on many factors. Initially success
Emergency depends on activation of the MET by the floor or ward nurse or
Team
physician, who uses specific physiologic criteria to decide when to
(MET)
call the team. The following list gives examples of such “calling
criteria” for adult patients:

•
•
Threatened airway

•
Respiratory rate <6 or >30 breaths per minute

•
Heart rate <40 per minute or >140 per minute

•
Systolic blood pressure <90 mm Hg

•
Symptomatic hypertension

•
Sudden decrease in level of consciousness

•
Unexplained agitation

•
Seizure

•
Significant fall in urine output

•
Nurse or provider concerned about patient
Subjective criteria also may be used

The system is critically dependent on the primary nurse’s

identifying and acting on the specified criteria to immediately
summon the MET to the patient’s bedside. The MET typically
consists of healthcare providers with critical care or emergency
care experience and skills that support immediate intervention for
critical care situations. The MET is responsible for performing a
rapid patient assessment and beginning appropriate treatment to
reverse physiologic deterioration and prevent a poor outcome.

Published The majority of published “before and after” studies of METs or

Studies rapid response systems have reported a 17% to 65% drop in the
rate of cardiac arrests after the intervention. Other documented
benefits of these systems are a decrease in unplanned
emergency transfers to the intensive care unit (ICU), decreased
ICU and total hospital length of stay, reductions in postoperative
morbidity and mortality rates, and improved rates of survival from
cardiac arrest.

The recently published MERIT trial is the only randomized

controlled trial comparing hospitals with a MET and those without
one. The study did not show a difference in the composite primary
outcome (cardiac arrest, unexpected death, unplanned ICU
admission) between the 12 hospitals in which a MET system was
© 2006 American Heart Association 73
 introduced and 11 hospitals that had no MET system in place.
Further research is needed about the critical details of
implementation and the potential effectiveness of METs in
preventing cardiac arrest or improving other important patient
outcomes.

Implementation Implementing any type of rapid response system will require a

of a Rapid significant cultural change in most hospitals. Those who design
Response and manage the system must pay particular attention to issues
System that may prevent the system from being used effectively.
Examples of such issues are insufficient resources, poor
education, fear of calling the team, fear of losing control over
patient care, and resistance from team members.

Implementation of a rapid response system or MET requires

ongoing education, impeccable data collection and review, and
feedback. Development and maintenance of these programs
requires a long-term cultural and financial commitment from the
hospital administration, which must understand that the potential
benefits from the system (decreased resource use and improved
survival rates) may have independent positive financial
ramifications. Hospital administrators and healthcare professionals
need to reorient their approach to emergency medical events and
develop a culture of patient safety with a primary goal of
decreasing morbidity and mortality.

© 2006 American Heart Association 74

 Human, Ethical, and Legal
Dimensions of ECC and ACLS

© 2006 American Heart Association 75

 Part 1—Rescuer and Witness Issues

How Often Many public health experts consider CPR training to be the most successful
Will CPR, public health initiative of modern times. Millions of people have prepared
Defibrillation, themselves to take action to save the life of a fellow human being. But
and ACLS despite our best efforts, in most locations half or more of out-of-hospital
Succeed? resuscitation attempts do not succeed. CPR at home or in public results in
return of spontaneous circulation (ROSC)—ie, even temporary return of a
perfusing rhythm—only about 50% of the time.

Tragically even when ROSC occurs, only about half of VF cardiac arrest
patients admitted to the emergency department and hospital survive and go
home. This means that 3 of 4 prehospital CPR attempts will be
“unsuccessful” in terms of neurologically intact survival to hospital discharge.
Also, there is a > 80% mortality for in-hospital arrest. We must consider and
plan for the emotional reactions from rescuers and witnesses to any
resuscitation attempt. This is particularly true when their efforts appear to
have “failed.”

Take Pride in You should be proud that you are learning to become an ACLS provider.
Your Skills as Now you can be confident that you will be better prepared to do the right
an ACLS thing when your professional skills are needed. Of course these emergencies
Provider can have negative outcomes. You and the other emergency personnel who
arrive to help in the resuscitation may not succeed in restoring life. Some
people have a cardiac arrest simply because they have reached the end of
their life. Your success will not be measured by whether a cardiac arrest
patient lives or dies but rather by the fact that you tried and worked well
together as a team. Simply by taking action, making an effort, and trying to
help, you will be judged a success.

Stress A cardiac arrest is a dramatic and emotional event, especially if the patient is
Reactions a friend or loved one. The emergency may involve disagreeable physical
After details, such as bleeding, vomiting, or poor hygiene. The emergency can
Resuscitation produce strong emotional reactions in physicians, nurses, bystanders, lay
Attempts rescuers, and EMS professionals. Failed attempts at resuscitation can
impose even more stress on rescuers. This stress can result in a variety of
emotional reactions and physical symptoms that may last long after the
original emergency.

It is common for a person to experience emotional “aftershocks” following an

unpleasant event. Usually such stress reactions occur immediately or within
the first few hours after the event. Sometimes the emotional response occurs
later. These reactions are frequent and normal. There is nothing wrong with
you or with someone who has such reactions following an event.

© 2006 American Heart Association 76

 Psychologists working with professional emergency personnel have learned
that rescuers may experience grief, anxiety, anger, and guilt. Typical physical
reactions include difficulty sleeping, fatigue, irritability, changes in eating
habits, and confusion. Many people say they are unable to stop thinking
about the event. Remember that these reactions are common and normal.
They do not mean that you are “disturbed” or “weak.” Strong reactions simply
indicate that this particular event had a powerful impact on you. With the
understanding and support of friends and loved ones, the stress reactions
usually pass.

Techniques to Psychologists tell us that one of the most successful ways to reduce stress
Reduce after a rescue effort is simple: talk about it. Sit down with other people who
Stress in witnessed the event and talk it over. EMS personnel who respond to calls
Rescuers and from lay rescuer defibrillation sites are encouraged to offer emotional support
Witnesses to lay rescuers and bystanders. More formal discussions, called “critical
event debriefings,” should include not only the lay rescuers but also the
professional responders.

In these discussions you will be encouraged to describe what happened. Do

not be afraid of “reliving” the event. It is natural and healthy to talk about the
event. Describe what went through your mind during the rescue effort.
Describe how it made you feel at the time. Describe how you feel now. Be
patient with yourself. Understand that many reactions will diminish within a
few days. Sharing your thoughts and feelings with your companions at work,
fellow rescuers, EMS personnel, or friends will help reduce stress reactions
and help you recover.

Other sources of psychological and emotional support are local clergy, police
chaplains, fire service chaplains, and hospital and emergency department
social workers. Your course instructor may be able to tell you what plans are
established for critical event debriefings in your professional setting.

Psychological Performance Anxiety

Barriers to
Action The ACLS Provider Course helps prepare you to respond appropriately to a
future emergency. ACLS providers have expressed some common concerns
about responding to sudden cardiac emergencies: Will I be able to take
action? Will I remember the steps of the ACLS approach? Will I remember
how to perform the skills of CPR, defibrillation, and intubation and the details
of drug doses and the steps in the algorithms? Will I really have what it takes
to respond to a true emergency? Any emergency involving a patient you
have grown close to, a friend or a family member will produce a strong
emotional reaction.

Disagreeable Aspects of CPR

What about the unpleasant and disagreeable aspects of performing CPR in

either the in-hospital or out-of-hospital setting? Will you really be able to

© 2006 American Heart Association 77

 perform mouth-to-mouth rescue breathing on a stranger? What if the patient
is bleeding from facial injuries? Would this not pose a risk of disease for a
rescuer without a CPR barrier device? CPR and defibrillation require that the
rescuer remove clothing from the patient’s chest. You cannot attach
defibrillation electrodes unless the pads are placed directly on the skin. The
rescuer must open the patient’s shirt or blouse and remove the
undergarments. Common courtesy and modesty may cause some people to
hesitate before removing the clothing of strangers, especially in front of many
other people in a public location.

Everyone is familiar with the concept of defibrillation shocks as shown in

television shows and movies. Everyone knows to expect the “jump” and
muscle contractions whenever a character yells “clear” and delivers a shock.
These shocks appear painful. Can you overcome your natural tendency not
to hurt others, even in an emergency when your actions could be lifesaving?
Often friends and relatives will be at the scene of an emergency. If you
respond and take action, these people will look to you to perform quickly,
effectively, and confidently.

These psychological barriers can hinder a quick emergency response,

especially in settings where such events are rare. There are no easy
solutions to help overcome these psychological barriers. Your instructor will
encourage you to anticipate many of the scenes described above. The case
scenarios will include role-playing and rehearsals. Think through how you
would respond when confronted with such a circumstance. Mental practice,
even without hands-on practice, may help improve your future performance.
The best preparation, however, is frequent practice with manikins in realistic
scenarios and situations.

Leaders of all courses that follow the AHA guidelines are aware of the mental
and emotional challenge of rescue efforts. You will have support if you ever
participate in a resuscitation attempt. You may not know for several days
whether the patient lives or dies. If the person you try to resuscitate does not
live, take comfort from knowing that in taking action you did your best.

© 2006 American Heart Association 78

 Part 2—Legal and Ethical Issues

The Right The AHA has supported community CPR training for more than 3 decades.
Thing to Do Citizen CPR responders have helped save thousands of lives. The AHA
believes that training in the use of CPR and AEDs will dramatically increase
the number of survivors of cardiac arrest.

Anyone can perform emergency CPR without fear of legal action.

Chest compressions and rescue breathing require direct physical contact

between rescuer and patient. Often these 2 people are strangers. Too often
the arrest patient dies. In the United States people may take legal action
when they think that one person has harmed another, even unintentionally.
Despite this legal environment, CPR remains widely used and remarkably
free of legal issues and lawsuits. Although attorneys have included rescuers
who performed CPR in lawsuits, no “Good Samaritan” has ever been found
guilty of doing harm while performing CPR.

All 50 states have Good Samaritan laws that grant immunity to any volunteer
or lay rescuer who attempts CPR in an honest, “good faith” effort to save a
life. A person is considered a Good Samaritan if

• The person is genuinely trying to help

• The help is reasonable (you cannot engage in gross misconduct, ie, actions

• The rescue effort is voluntary and not part of the person’s job requirements
that a reasonable person with your training would never do)

Most Good Samaritan laws protect laypersons who perform CPR even if they
have had no formal training. The purpose of this protection is to encourage
broad awareness of resuscitative techniques and to remove a barrier to
involving more people. Unless you are expected to perform CPR as part of
your job responsibilities, you are under no legal obligation to attempt CPR for
a patient of cardiac arrest. Failure to attempt CPR when there is no danger to
the rescuer and the rescuer has the ability is not a legal violation, but it might
be considered an ethical violation by some.

Principle of If the purpose of medical treatment cannot be achieved, it is considered

Futility futile. The key determinants of medical futility are length and quality of life. An
intervention that cannot establish any increase in length or quality of life is
futile.

Patients or families may ask physicians to provide care that is inappropriate.

But physicians have no obligation to provide such care when there is
scientific and social consensus that the treatment is ineffective. An example
is CPR for patients with signs of irreversible death. Other healthcare
providers also have no obligation to provide CPR or ACLS if no benefit can
be expected (ie, CPR would not restore effective circulation). Beyond these
clinical circumstances, and in the absence of advance directives (including
© 2006 American Heart Association 79
 DNAR) or living wills with statements to the contrary, healthcare providers
should attempt resuscitation.

A careful balance of the patient’s prognosis for both length and quality of life
will determine whether CPR is appropriate. CPR is inappropriate when
survival is not expected.

When the likelihood of survival is borderline, or when the likelihood of

morbidity and burden to the patient are relatively high, rescuers should
support the patient’s desires. If the patient’s desires are unknown, healthcare
providers may follow the preferences of the legally authorized surrogate
decision maker. Noninitiation of resuscitation and discontinuation of life-
sustaining treatment during or after resuscitation are ethically equivalent.
When the patient’s prognosis is uncertain, consider a trial of treatment while
gathering more information to determine the likelihood of survival and the
expected clinical course.

Terminating The decision to stop resuscitative efforts rests with the treating physician in
Resuscitative the hospital. The physician bases this decision on many factors, including
Efforts time to CPR, time to defibrillation, comorbid disease, prearrest state, and
initial arrest rhythm. None of these factors alone or in combination is clearly
predictive of outcome. The most important factor associated with poor
outcome in adults with normothermic cardiac arrest is the duration of
resuscitative efforts. The chance of discharge from the hospital alive and
neurologically intact diminishes as resuscitation time increases. The
responsible clinician should stop the resuscitation when he or she
determines with a high degree of certainty that the patient will not respond to
further ACLS efforts.

In the absence of mitigating factors (eg, drug toxicity, hypothermia),

prolonged resuscitative efforts are unlikely to be successful. If ROSC of any
duration occurs, it may be appropriate to extend resuscitative efforts. It is
important to consider the circumstances of the cardiac arrest (eg, drug
overdose or submersion in icy water) when deciding whether to continue
resuscitative efforts.

For the newly born infant, discontinuation of resuscitation can be justified

after 10 minutes with no signs of life despite continuous and adequate
resuscitative efforts. The prognosis for survival or survival without disability
has been shown to be extremely poor when there is lack of response to
intensive resuscitative efforts for >10 minutes.

When Not to Few criteria can accurately predict the futility of CPR. In light of this
Start CPR uncertainty, all patients in cardiac arrest should receive resuscitation unless

• The patient has a valid Do Not Attempt Resuscitation (DNAR) order

• The patient has signs of irreversible death (eg, rigor mortis, decapitation,

• No physiologic benefit can be expected because vital functions have

decomposition, or dependent lividity)

© 2006 American Heart Association 80

 deteriorated despite maximal therapy (eg, progressive septic or cardiogenic
shock)

Withholding CPR for newly born infants in the delivery room may be
appropriate under circumstances such as the following:

•
•
Confirmed gestation <23 weeks

•
Birth weight <400 g

•
Confirmed anencephaly

•
Confirmed trisomy 13
Other congenital anomalies that are incompatible with life

Withholding BLS training urges the first lay responder at a cardiac arrest to begin CPR.
vs Healthcare providers are expected to provide BLS and ACLS as part of their
Withdrawing duty to respond. There are a few exceptions to this rule:

• A person lies dead with obvious clinical signs of irreversible death (eg, rigor
CPR

• Attempts to perform CPR would place the rescuer at risk of physical injury.
mortis, dependent lividity, decapitation, or decomposition).

• The patient or surrogate has indicated that resuscitation is not desired with

• No physiologic benefit can be expected because vital functions have

an advance directive (DNAR order).

deteriorated despite maximal therapy (eg, progressive sepsis or

cardiogenic shock).

No rescuer should make a judgment about the present or future quality of life
of a patient of cardiac arrest on the basis of current (ie, during the attempted
resuscitation) or anticipated neurologic status. Such “snap” judgments are
often inaccurate. Conditions such as irreversible brain damage or brain death
cannot be reliably assessed or predicted during an emergency.

Out-of-hospital DNAR protocols must be clear to all involved (eg, physicians,

patients, family members, loved ones, and out-of-hospital healthcare
providers). Advance directives can take many forms (eg, written bedside
orders from physicians, wallet identification cards, and identification
bracelets).

The ideal EMS DNAR form is portable in case the patient is transferred. In
addition to including out-of-hospital DNAR orders, the form should provide
direction to EMS about initiating or continuing life-sustaining interventions for
the patient who is not pulseless and apneic.

Withdrawal of Withdrawal of life support is an emotionally complex decision for family and
Life Support staff. Withholding and withdrawing life support are ethically similar. The
decision to withdraw life support is justifiable when it is determined that the
patient is dead, if the physician and patient or surrogate agree that treatment
goals cannot be met, or the burden to the patient of continued treatment
would exceed any benefits.
© 2006 American Heart Association 81
 Some patients do not regain consciousness after cardiac arrest and (ROSC).
In most cases the prognosis for adults who remain deeply comatose
(Glasgow Coma Scale score <5) after cardiac arrest can be predicted with
accuracy within 2 to 3 days of resuscitation. Specific physical findings or
laboratory tests may be helpful to assist with this process. The following 3
factors are associated with poor outcome:

• Absence of pupillary response to light on the third day

• Absence of motor response to pain on the third day
• Bilateral absence of cortical response to median somatosensory evoked
potentials when used in normothermic patients who are comatose for at
least 72 hours after the cardiac arrest and resuscitation.

Withdrawal of life support is ethically permissible under these circumstances.

Patients in the end stage of an incurable disease, whether responsive or

unresponsive, should receive care that ensures their comfort and dignity. The
goal of such care is to minimize the suffering associated with pain, dyspnea,
delirium, convulsions, and other terminal complications. It is ethically
acceptable to gradually increase the dose of narcotics and sedatives to
relieve pain and other symptoms, even to levels that might shorten the
patient’s life.

Advance An advance directive is any expression of a person’s thoughts, wishes, or

Directives, preferences for his or her end-of-life care. Advance directives can be based
Living Wills, on conversations, written directives, living wills, or durable powers of attorney
and Patient for health care. The legal validity of various forms of advance directives
Self- varies from jurisdiction to jurisdiction. Courts consider written advance
Determination directives to be more trustworthy than recollections of conversations.

A living will provides written direction to physicians about medical care the
patient would approve if he or she becomes terminally ill and unable to make
decisions. A living will constitutes clear evidence of the patient’s wishes and
can be legally enforced in most areas.

Patients should periodically reevaluate their living wills and advance

directives. Desires and medical conditions may change over time. The
Patient Self-Determination Act of 1991 requires healthcare institutions and
managed-care organizations to ask if patients have advance directives.
Healthcare institutions are required to facilitate the completion of advance
directives if patients request them.

Out-of- Many patients for whom 911 is called because of cardiac arrest are
Hospital chronically ill, have a terminal illness, or have a written advance directive
DNAR Orders (DNAR order). States and other jurisdictions have different laws for out-of-
hospital DNAR orders and advance directives. Even if a patient has a DNAR
order, it may be difficult to determine whether to start resuscitation. It is
© 2006 American Heart Association 82
 especially difficult if family members have differing opinions. You should
initiate CPR and ACLS if you have reason to believe that

• There is reasonable doubt about the validity of a DNAR order or advance

• The patient may have changed his or her mind

directive

• The best interests of the patient are in question

Sometimes within a few minutes of resuscitation’s being initiated, relatives or

other medical personnel arrive and confirm that the patient had clearly
expressed a wish that resuscitation not be attempted. CPR or other life
support measures may be discontinued, with approval of medical direction,
when further information becomes available.

When you cannot obtain clear information about the patient’s wishes,
you should initiate resuscitative measures.

EMS No-CPR A number of states have adopted “no-CPR” programs. These programs allow
Programs patients and family members to call 911 for emergency care, support, and
treatment for end-of-life distress (ie, shortness of breath, bleeding, or
uncontrolled pain). Patients do not have to fear unwanted resuscitative
efforts.

In a no-CPR program the patient, who usually has a terminal illness, signs a
document requesting “no heroics” if there is a loss of pulse or if breathing
stops. In some states the patient must wear a no-CPR identification bracelet.
In an emergency the bracelet or other documentation signals rescuers that
CPR efforts, including use of an AED, are not recommended.

If an ACLS provider arrives at the side of a person in apparent cardiac arrest

(unresponsive, no pulse, no breathing) and sees that the person is wearing a
no-CPR bracelet (or has some other indication of no-CPR status), the
provider should respect the person’s wishes. Report the problem as a
“collapsed, unresponsive person wearing a no-CPR bracelet.” State that you
think CPR should not be performed.

Check with your state or ask your instructor to see what the law is in your
jurisdiction regarding “no-CPR orders” in the out-of-hospital setting.

Transport If an EMS system does not allow nonphysicians to pronounce death and stop
all resuscitative efforts, personnel may be forced to transport a deceased
patient of cardiac arrest to the hospital. Such an action is unethical. If
carefully executed BLS and ACLS treatment protocols fail in the out-of-
hospital setting, then how could the same treatment succeed in the
emergency department? A number of studies have consistently shown that
<1% of patients transported with continuing CPR survive to hospital
discharge.
© 2006 American Heart Association 83
 Delayed or token efforts to provide CPR and ACLS—or so-called “slow
codes” (knowingly providing ineffective resuscitation)—are inappropriate.
These practices compromise the ethical integrity of healthcare providers and
undermine the provider-patient relationship.

Many EMS systems authorize the termination of a resuscitation attempt in

the out-of-hospital setting. EMS systems should establish protocols for
pronouncement of death and appropriate transport of the body. EMS systems
should also train personnel to deal sensitively with family and friends.

Legal Aspects Defibrillators, including many AEDs, are restricted medical devices. Most
of AED Use states have legislation that requires a physician to authorize the use of
restricted medical devices. Lay rescuer CPR and defibrillation programs that
make AEDs available to lay rescuers (and in some cases EMS providers)
may be required to have a medical authority or a healthcare provider who
oversees the purchase of AEDs, treatment protocols, training, and contact
with EMS providers. In a sense the medical authority prescribes the AED for
use by the lay responder and therefore complies with medical regulations.

In the United States malpractice accusations and product liability lawsuits

increase every year. In the past, fear of malpractice suits hindered innovative
programs to bring early CPR and early defibrillation into every community,
but such fears have proven unfounded.

To solve this problem of fear of litigation, all states have changed existing
laws and regulations to provide limited immunity for lay rescuers who use
AEDs in the course of attempting resuscitation. Many states have amended
Good Samaritan laws to include the use of AEDs by lay rescuers. This
means that the legal system will consider lay rescuers to be Good
Samaritans when they attempt CPR and defibrillation for someone in cardiac
arrest. As a Good Samaritan you cannot be successfully sued for any harm
or damage that occurs during the rescue effort (except in cases of gross
negligence). By the year 2000 plaintiffs and attorneys had started filing
lawsuits against some facilities for failing to train and equip their employees
to perform CPR and use an AED, but as of 2005 no lawsuits were identified
involving a lawsuit for an attempted resuscitation in which a lay rescuer used
an AED.

Some states grant limited immunity for lay rescuer use of AEDs only when
specific recommendations are fulfilled. These recommendations may require
that the rescuer must

• Have formal training in CPR and use of an AED (eg, the AHA Heartsaver

• Use treatment protocols approved by a recognized medical authority

AED Course or equivalent)

• Perform routine checks and maintenance of the AED as specified by the

• Notify local EMS authorities of the placement of the AED so that EMS
manufacturer

personnel, particularly the dispatchers, will know when emergency calls are

© 2006 American Heart Association 84

 made from a setting with an AED

The AHA recently published a statement detailing recommended legislation

to promote lay rescuer CPR and AED programs and to assist legislators and
policymakers in removing impediments to these programs:
(http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.172289v1)

Lay rescuer CPR and AED programs should implement processes of

• Performance of the emergency response plan, including accurate time

continuous quality improvement, including evaluation of the following:

intervals for key interventions (such as collapse to shock or no shock

• Responder performance
advisory to initiation of CPR) and patient outcome

• AED function
• Battery status and function
• Electrode pad function and readiness, including expiration date

© 2006 American Heart Association 85

 Part 3—Providing Emotional Support for the Family

Notifying Despite our best efforts, most resuscitation attempts fail. Notifying the family
Survivors of of the death of a loved one is an important aspect of resuscitation. It should
the Death of a be done compassionately, with sensitivity to the cultural and religious beliefs
Loved One and practices of the family.

Family members have often been excluded from the resuscitation of a loved
one. Surveys suggest that healthcare providers hold a range of opinions
concerning the presence of family members during a resuscitation attempt.
Several commentaries have expressed concern that family members may
interfere with procedures or faint. Exposure of the institution and providers to
legal liability is another concern.

But several surveys conducted before resuscitative efforts were observed

showed that most family members wished to be present during a
resuscitation attempt. Family members have reported that being at a loved
one’s side and saying goodbye during their final moments of life was
comforting. In addition, being present during the resuscitation attempt helped
them adjust to the death of their loved one, and most indicated they would
attend again. Several retrospective reports note positive reactions from
family members, many of whom said that they felt a sense of having helped
their loved one and of easing their own grieving process. Most parents
wanted to be given the option to decide whether to be present at the
resuscitation of a child.

Given the absence of data suggesting that family presence is harmful, and in
light of data suggesting that it may be helpful, it seems reasonable to offer
selected relatives the option to be present during a resuscitation attempt.
This recommendation assumes that the patient, if an adult, has not
previously raised an objection. Parents seldom ask if they can be present
unless encouraged to do so by healthcare providers.

Resuscitation team members should be sensitive to the presence of family

members. It is helpful to have one team member available to answer
questions from the family, clarify information, and otherwise offer comfort.

© 2006 American Heart Association 86