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2005 ACLS OVERVIEW & STUDY GUIDE

Vanderbilt Resuscitation Program

ACLS is a course dedicated to sharing a core of advanced information regarding respiratory and cardiac
emergencies. It is taught according to the most current guidelines approved by the American Heart Association as
a uniform approach to the treatment of these emergencies.

Because of the volume of materials to be covered in this course, the following skills are STRONGLY recommended
as prerequisites to attending ACLS:
(a) BLS - it is highly recommended that you have attended a BLS course within the last two years. You will be
expected to perform BLS during the case studies and you must be able to perform BLS flawlessly during
the Mega VF and BLS/AED evaluation stations.
(b) Arrhythmia recognition - you MUST be able to easily recognize arrhythmias to successfully complete
ACLS. If you do not work with arrhythmias on a regular basis, it is STRONGLY suggested that you
consider attending Essentials of Resuscitation and a Basic Arrhythmia Course prior to attending ACLS.
(c) Pharmacology - you MUST be comfortable with the drugs used in ACLS. If you do not work with these
drugs on a regular basis, it is STRONGLY suggested that you spend time reviewing a pharmacology text.

SUCCESSFUL ACLS COURSE COMPLETION


One ACLS course requirement is completion of the enclosed multiple choice and ECG exams.

Bring your completed exams with you—they are your “entrance tickets” into class.

The other course completion criteria are:


1. Active participation in ALL stations, including demonstrated knowledge of ACLS principles. Inability
to demonstrate mastery of these "ACLS essentials" would require that you be remediated and re-evaluated:
a. Assure that the patient’s ABCs are intact, either spontaneously or with your assistance.
i. Airway: open it, keep it open
ii. Breathing: make sure it is adequate at ALL times---give oxygen as a first-line drug
iii. Circulation: make sure it is adequate at ALL times---begin and continue CPR as needed
b. Assess and reassess the patient's condition frequently and intervene as indicated
c. Perform early, safe, and effective defibrillation for VF or pulseless VT.
d. Know and use appropriate pharmacological agents---which drug, which route, which dose
2. Mega-VF evaluation. You will manage the first 10 minutes of resuscitation for a patient in ventricular
fibrillation or pulseless ventricular tachycardia. You will be functioning as the team leader, and must direct all care
provided for the "patient".
3. Automated External Defibrillation. You will properly attach and safely use an automated external
defibrillator. This may be a separate station or could be incorporated into your Mega VF evaluation, depending on
your experience with an AED.
4. ACLS Post-test. A post-test, very similar in content to the pre-test, will be given at the end of class. You will
be expected to complete this exam with a score of 84% or greater.

TEXTS
The following texts are required for all ACLS Provider Courses and recommended but optional for all ACLS
Renewal Courses:
‰ ACLS Provider Manual
‰ Handbook of Emergency Cardiovascular Care (ECC Handbook)

Created by Kim Chunn 9/01


Revised 12/04
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THE 10 ACLS CASES
‰ Respiratory Arrest w/ Pulse ‰ VF/Pulseless VT
‰ Bradycardia ‰ Stable Tachycardia
‰ Acute Coronary Syndromes ‰ Unstable Tachycardia
‰ Asystole ‰ Pulseless Electrical Activity (PEA)
‰ Acute Ischemic Stroke ‰ Automated External Defibrillation

THE ACLS SKILLS


1. Airway/Breathing
a. Provide oxygen
i. Nasal cannula 2-6 liters/minute
ii. 100% non-rebreather mask
b. Open the airway/keep it open
i. Head-tilt/chin-lift
ii. Jaw thrust
iii. Oral airway
iv. Nasal airway
v. Suction
vi. Endotracheal Intubation
vii. Alternative Devices/Techniques
1. LMA
2. Combitube
3. Needle Cricothyrotomy
c. Ventilate
i. Mouth-to-Mask
ii. Bag-Mask
1. with oral airway
2. 2-person technique
2. Circulation
3. Dysrhythmia Recognition
a. Non-perfusing (arrest) rhythms
i. Shockable
1. VF
2. Pulseless VT
ii. Non-shockable
1. PEA
2. Asystole
b. Perfusing (peri-arrest) rhythms
i. Symptomatic Bradycardia
ii. Tachycardia, Stable and Unstable
4. Electrical Therapy
a. Defibrillation
b. Synchronized cardioversion
c. Transcutaneous pacing
5. Peripheral IV access
6. Pharmacology

Created by Kim Chunn 9/01


Revised 12/04
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PHARMACOLOGY
The following drugs are part of the ACLS algorithms and are the ones you are expected to know readily
(drug, dose, route(s), indications, contraindications):

** DRUGS ACCEPTABLE VIA ETT ROUTE: Drugs given via endotracheal tube should be given at 2 to 2.5
times the IV dose and diluted in 10 ml. of saline.

IV PUSH DRUGS: INFUSIONS:

Epinephrine** Lidocaine
1 mg q. 3-5 min. 2-4 mg/min. Mix 1-2 gm/250 cc. of D5W

Vasopressin Procainamide
40 units, single dose, one time only (VF only) 1-4 mg/min. Mix 1-2 gm/250 cc of D5W

Atropine** Dopamine
0.5-1 mg q. 3-5 min, up to a total of 0.04 mg/kg 5-10 mcg/kg/min. Mix 400 mg/250 cc of D5W

Amiodarone Epinephrine
(VF/VT) 300 mg, consider repeating 150 mg in 3- 2-10 mcg/min. Mix 1-2 mg/250 cc of D5W
5 min.
Amiodarone
Lidocaine** Rapid infusion (non-VF): 150 mg over 10 min, may
1-1.5 mg/kg; repeat at 0.5-1.5 mg/kg q. 5-10 min. repeat every 10 mins prn.
up to 3 mg/kg max Maintenance infusion: 1 mg/min for 6 hrs
decreasing to 0.5 mg/min for 18 hrs.
Procainamide Max cumulative dose 2.2 gm IV/24 hrs.
20-50 mg/min, up to a total of 17 mg/kg

Magnesium Sulfate
1-2 gm in 10 ml of D5W over 1-2 min.

Sodium Bicarbonate
1 mEq/kg; repeat at 0.5 mEq/kg q. 10 mins.

Adenosine
6 mg over 1-3 sec. followed by saline bolus to
flush; repeat at 12 mg. after 1-2 min. twice (30
mg total)

Further information on ACLS Pharmacology can be found in the ECC Handbook, pgs. 54-72.

Created by Kim Chunn 9/01


Revised 12/04
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UNIVERSAL PULSELESS RHYTHM MANAGEMENT

V-FIB ASYSTOLE PEA


Shock
Shock
Shock

C CPR

O Oxygen

T Tubes: ET, IV

E Epinephrine 1 mg Q 3-5 minutes

Acceptable to use Vasopressin


40 U IV, single dose, 1 time only as
alternative to epinephrine and may
return to epinephrine 1 mg Q 3-5
mins if no response after 10-20
mins.
Shock Atropine Etiology
Drug 1 mg q3min x 3 Atropine (if HR<60)
Shock
Drug

The central concept is that the COTE mnemonic is the core treatment of all non-perfusing rhythms with the
additions listed in line with each particular rhythm. Remember:
1) V-Fib rhymes with Defib and there should be a direct neurologic synapse between them. Next go to COTE
then think Defib - Drug - Defib - Drug - etc.
2) Asystole goes straight to COTE then out to Atropine, which also begins with an A.
3) PEA goes straight to COTE then out to Etiology and then to Atropine if the rate is less than 60.

Created by Kim Chunn 9/01


Revised 12/04
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AUTOMATED EXTERNAL DEFIBRILLATION
(pending the arrival of EMS)

Unresponsive—911---AED:
• Check if unresponsive
• Call 911
• Get AED
• Identify and respond to special situations

Unresponsive

Start ABCDs:
• Airway: open airway, hold it open
• Breathing: look, listen and feel for breathing

Breathing Not Breathing

• Provide 2 slow breaths


• Breathing adequate? Place in recovery position • Circulation: check for carotid pulse
• Breathing inadequate? Start rescue breathing:
1 breath every 5 seconds
• Monitor signs of circulation every 30-60 seconds: pulse, color,
movement, return or remaining presence of normal breathing
No Circulation
pattern, coughing

Circulation

Perform CPR until AED arrives and is


• Start rescue breathing: 1 breath every 5 seconds ready to attach:
• Monitor signs of circulation every 30-60 seconds: pulse, color, • Chest compressions 100/minute
movement, return of normal breathing pattern, coughing • 15 compressions to 2 breaths (1 or 2
rescuers)

Attempt Defibrillation (when AED arrives)


• POWER ON AED first
• ATTACH AED electrode pads (stop CPR)
• ANALYZE (“all clear!”)
• SHOCK (“all clear!”) up to 3 times if advised

After 3 shocks or “No shock indicated”:


• Recheck ABCs
• No Pulse? Begin CPR
• Leave AED on and attached to victim for
repeat analysis at automatically preset
intervals
Created by Kim Chunn 9/01
Revised 12/04
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Respiratory Emergencies

Is the patient breathing?

YES NO

Allow pt. to assume position of comfort


Provide oxygen prn Attempt to ventilate patient:
Suction prn Does chest rise with ventilation?
Monitor respirations:
Depth, bilateral chest rise, resp. rate
Begin ventilations as indicated
YES NO

ACT QUICKLY!
PATIENT WILL DIE
IF NO AIRWAY
IS ESTABLISHED

Reposition airway---head-tilt/chin-lift
Continue ventilations w/ 100% oxygen Consider oral airway, use 2 people
Squeeze bag slowly and gently, use 2 people Rapidly assess for airway obstruction
Maintain head-tilt/chin-lift, consider oral airway Immediately intubate if no obstruction
Consider quickly reversible causes of apnea: Prepare for alternative airway access:
narcotic OD, hypoglycemia, hypercarbia, hypoxia LMA, Combitube, needle cricothyrotomy,
Consider intubation by most experienced person emergent tracheotomy @ bedside
Continue bag-mask ventilation and call anesthesia
if no experienced person present

Created by Kim Chunn 9/01


Revised 12/04
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SYMPTOMATIC BRADYCARDIA

Assess ABCs
Oxygen—IV access—monitor—fluids
Vital signs, pulse oximetry, monitor
BP

Type II second-degree AV Sinus Bradycardia


block Junctional Rhythm
or Type I second-degree AV
Third-degree AV block block (Wenckebach)

Atropine 0.5 - 1.0 mg q 3-5 min (up to 0.04 mg/kg)


Transcutaneous pacing if available
Dopamine 5 - 20 µg/kg per minute
Epinephrine 2 - 10 µg/min
Isoproterenol 2 - 10 µg/min

Transcutaneous pacer ---may try


Atropine until transcutaneous pacer
arrives. Reassess ABCs—Blood pressure
preferred circulatory assessment

Created by Kim Chunn 9/01


Revised 12/04
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STABLE TACHYCARDIAS
Assess ABCs
Oxygen—IV—Monitor

Narrow-complex Wide-complex

May go directly
Consider vagal maneuvers to cardioversion
Adenosine 6 mg rapid IV push + flush, may
amiodarone 150 mg over 10 mins
be repeated in 1 to 2 mins at 12 mg x 2.
lidocaine 1.0-1.5 mg/kg, may repeat at ½
original dose in 5 mins x 2
procainamide 20-50 mg/min up to 17 mg/kg
amiodarone 150 mg over 10 mins magnesium 1-2 gm over 1-2 mins
β blockers
calcium channel blockers Additional options if Torsades suspected:
digoxin overdrive pacing
procainamide isoproterenol drip
phenytoin
lidocaine

Sedation with short-acting agent

Synchronized cardioversion
100 J
200 J
300 J
360 J

Created by Kim Chunn 9/01


Revised 12/04
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UNSTABLE TACHYCARDIAS

Assess ABCs
Oxygen—IV—Monitor

Sedate if possible
DO NOT DELAY CARDIOVERSION!

Have ready:
Functional suction unit
Bag-valve-mask
Intubation equipment

Synchronized cardioversion

• Ventricular Tachycardia

• Paroxysmal supraventricular 100 J


tachycardia (PSVT) 200 J
300 J
• Atrial fibrillation 360 J

• Atrial flutter

Considerations:

Effective regimens have included a sedative (eg, diazepam, midazolam, barbiturates, etomidate,
ketamine, methohexital) with or without an analgesic agent (eg, fentanyl, morphine, meperidine). Many
experts recommend anesthesia if service is readily available.

NOTE POSSIBLE NEED TO RESYNCHRONIZE AFTER EACH ENERGY DELIVERY.

If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized


shocks.

Treat polymorphic ventricular tachycardia (irregular form and rate) like ventricular fibrillation: see
VF/pulseless VT algorithm.

PSVT and Atrial flutter often respond to lower energy levels (50 J).

Created by Kim Chunn 9/01


Revised 12/04
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PULSELESS ELECTRICAL ACTIVITY

CPR—call for monitor-defibrillator


Ventilate/oxygenate, IV access, fluids
Intubate: hyperoxygenate, confirm tube placement, secure

Rhythm on monitor without detectable pulse

Rule out causes

• POTENTIALLY FAST or EASY • PROBABLY UNTREATABLE


TO DIAGNOSE/TREAT • Massive MI
• Hypoxia • Massive PE
• Tension PTX
• Cardiac Tamponade
• Hypovolemia
• Hyper/hypokalemia
• Acidosis
• Hypothermia
• Drug Overdose

epinephrine 1 mg every 3 mins

Atropine 1 mg every 3 mins x 3 for HR < 60

Created by Kim Chunn 9/01


Revised 12/04
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ASYSTOLE

CPR—call for defibrillator


Confirm Asystole in two leads
Rapid scene survey: any evidence personnel should not attempt resuscitation?

If the use of electricity is considered, trancutaneous pacing should be performed immediately upon
diagnosis of asystole. Insufficient data to support use of defibrillation to rule out “ultra-fine” VF.

Ventilate, oxygenate, IV access


Intubate: hyperoxygenate, confirm placement, secure tube

Rule out potentially reversible causes:


Hypoxia Hypovolemia Hypo-/hyperkalemia Acidosis
Hypothermia Drug Overdose Cardiac Tamponade
Tension Pneumothorax Massive Acute MI Massive PE

epinephrine 1 mg every 3 mins

atropine 1 mg every 3 mins x 3

If asystole persists:
Cease resuscitation efforts?
• Consider quality of resuscitation/Reassess
ABCs/Recheck end-tidal CO2 detector
• Consider termination if no response after 10 mins
• Atypical clinical features present?
• Hypothermia
• Drug OD
• Near Drowning
• In the field: termination protocols in place?

Created by Kim Chunn 9/01


Revised 12/04
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SUSPECTED STROKE
(Pre-hospital to ED arrival)

Immediate general assessment: <10 mins from arrival Immediate neuro assessment: <25 mins from arrival
Assess ABCs, vital signs Review patient history
Oxygen—IV--Monitor Establish onset (<3 hours required for fibrinolytics)
LABS: CBC, Lytes, coag studies Physical examination
Check blood sugar; treat if indicated Perform neurological examination:
*check level of consciousness (Glasgow Coma Scale)
*check level of stroke severity (NIH Stroke Scale or
Hunt and Hess Scale)
12-lead EKG; check for arrhythmias Urgent noncontrast CT
Alert Stroke Team --door-to-CT performed goal: <25 minutes
Read CT scan
--door-to-CT read goal: <45 minutes
Perform lateral cervical spine xray (pt.comatose/hx of trauma)

CT indicates non-hemorrhagic stroke CT indicates hemorrhagic stroke

• Consider fibrinolytics—TPA only approved • Consult Neurosurgery


drug for stroke: door-to-treatment goal <60 • Reverse any anticoagulants
mins • Reverse any bleeding disorder
• Lytics contraindicated for rapidly improving • Monitor neurological condition
symptoms • Treat hypertension in awake patients
• Emergent CT if deterioration
• No anticoagulant or antiplatelet therapy for 24 hrs
• Treat hypertension

Cincinnati Prehospital Stroke Scale (72% probability with one positive marker)
‰ Facial Droop: Have patient smile or show teeth
‰ Arm Drift: Have patient hold both arms straight out for 10 seconds with eyes closed
‰ Abnormal Speech: Have patient repeat the phrase, “You can’t teach an old dog new tricks.”

Created by Kim Chunn 9/01


Revised 12/04
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ISCHEMIC CHEST PAIN
Immediate assessment (<10 minutes) Immediate general assessment
• Vital signs • Oxygen
• IV access • Aspirin
• 12-lead ECG (physician reviews) • Nitroglycerin SL or spray
• Brief, targeted H&P; focus on eligibility for • Morphine IV (if pain not relieved w/
fibrinolytics nitroglycerin)
• LABS: serum cardiac markers, electrolytes, coag
studies Remember: “MONA” greets all patients
• CXR (<30 minutes) (Morphine, Oxygen, Nitroglycerin,
Aspirin)

EMS personnel can perform


immediate assessment/treatment
(“MONA”), incl. initial 12-lead ECG
and review for fibrinolytic therapy
indications and contraindications.
Start treatment as indicated
• Aspirin
• β blockers IV
• Nitroglycerin IV
• Consider ACE inhibitors
• Heparin (unfractionated or low
molecular weight) IV
• Glycoprotein IIb/IIIa inhibitors

Select a reperfusion strategy based on resources:

Lytics Interventional Cath Lab


-many choices -experienced operators (>75/year)
-rule out absolute contraindications -high-volume center (>250/year)
-major surgery or trauma (incl. -cardiac surgical back up
traumatic CPR) in last 21-30 days
-stroke of any kind in last 6 months GOAL: door-to-balloon inflation 60-120 mins.
-presence of head lesions
-known active bleeding
-bleeding disorder: plts <150,000
-uncontrolled HTN (>180/100)

GOAL: door-to-drug <30 minutes

Created by Kim Chunn 9/01


Revised 12/04
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VENTRICULAR FIBRILLATION/
PULSELESS VENTRICULAR TACHYCARDIA

CPR—call for defibrillator

Defibrillate ASAP
200 J
200 J (BIPHASIC)
200 J

Check pulse/Resume CPR

Ventilate, oxygenate, IV access


Intubate: hyperoxygenate, confirm tube placement, secure tube

epinephrine 1 mg every 3 mins


OR
Vasopressin 40 units IV x 1 only (may resume epinephrine after 10 mins)

Defibrillate 200 J (BIPHASIC)

ANTIARRHYTHMIC CHOICES:

amiodarone: 300 mg, consider repeating 150 mg in 5 mins

lidocaine: 1 to 1.5 mg/kg, may repeat in 5 mins up to 3 mg/kg

magnesium: 1 to 2 gm in 10 ml D5 W over 1 to 2 mins, may repeat in 5 mins

procainamide: 20 to 50 mg/minute, up to 17 mg/kg

Defibrillate 200 J (BIPHASIC)

Created by Kim Chunn 9/01


Revised 12/04
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