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Ad v a c e d C a r d io v a s c la r

Life S p p o r t
P R O V I D E R

M A n u A L

Ed itors

ACLS Su b c om m itte e 2010-2011

Elizabeth Sinz, MD, Associate Science Editor


Kenneth Navarro, Content Consultant

Clifton W. Callaway, MD, PhD, Chair


Robert W. Neumar, MD, PhD, Immediate
Past Chair, 2008-2010
Steven Brooks , MD
Daniel P. Davis , MD
Michael Donnino, MD
Andrea Gabrielli, MD
Romergryko Geocadin, MD
Erik Hes s , MD, MSc
Mark S. Link, MD
Bryan McNally, MD, MPH
Venu Menon, MD
Graham Nichol, MD, MPH
Brian ONeil, MD
J os eph P. Ornato, MD
Charles W. Otto, MD
Michael Shus ter, MD
Scott M. Silvers , MD
Mintu Turakhia, MD, MS
Terry L. Vanden Hoek, MD
J anice L. Zimmerman, MD

Se n ior Ma n a g in g Ed itor
Erik S. Soderberg, MS

Sp e c ia l Con trib u tors


Clifton W. Callaway, MD, PhD
Diana M. Cave, RN, MSN
Heba Cos tandy, MD, MS
Mary Fran Hazins ki, RN, MSN
Theres a Hoadley, RN, PhD, TNS
Robert W. Neumar, MD, PhD
Peter D. Panagos , MD
Sallie Young, PharmD, BCPS

2011 American Heart As s ociation


ISBN 978-1-61669-010-6
Printed in the United States of America
Firs t American Heart As s ociation Printing May 2011
eBook edition 2013 American Heart As s ociation. ISBN 978-1-61669-350-3

ACLS Subc om m itte e 2009-2010


Robert W. Neumar, MD, PhD, Chair
Laurie J . Morris on, MD, MSc, Immediate
Past Chair, 2006-2008
Steven Brooks , MD
Cli ton W. Callaway, MD, PhD
Daniel P. Davis , MD
Andrea Gabrielli, MD
Romergryko Geocadin, MD
Richard Kerber, MD
Mark S. Link, MD
Bryan McNally, MD, MPH
Graham Nichol, MD, MPH
Brian ONeil, MD
J os eph P. Ornato, MD
Charles Otto, MD, PhD
Michael Shus ter, MD
Scott M. Silvers , MD
Terry L. Vanden Hoek, MD

Ac knowle dgm e nts


Peter Olu Anders on, MD
Ulrik Chris tens en, MD

To f nd out about any updates or corrections to this text, vis it www.he a rt.o rg /c p r, navigate
to the page or this cours e, and click on Updates .
To acces s the Student Webs ite or this cours e, go to www.he a rt.o rg /e c c s tud e nt and enter
this code: algorithm
ii

Conte nts
P a rt 1
Co u r s e Ove r vie w

1
Cours e De s c ription a nd Goa l

Cours e Obje c tive s

Cours e De s ign

Cours e Pre re q uis ite s a nd P re p a ra tion

BLS Skills

ECG Rhythm Interpretation for Core ACLS Rhythms

Bas ic ACLS Drug and Pharmacology Knowledge

Practical Application of ACLS Rhythms and Drugs

Effective Res us citation Team Concepts

Cours e Ma te ria ls

ACLS Provider Manual

Student Webs ite

Pocket Reference Cards

Precours e Preparation Checklis t

Re quire m e nts for Suc c e s s fu l Cours e Com ple tion

ACLS Upda te Cours e

ACLS P rovide r Ma nua l Abb re via tions

P a rt 2
Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys

11

Introduction

11

Learning Objectives

11

The Sys te m a tic Ap p roa c h : The BLS a nd ACLS Su rve ys


Overview of the Sys tematic Approach

The BLS Surve y


Overview of the BLS Survey

The ACLS Surve y


Overview of the ACLS Survey

11
11

12
12

14
14

iii

C o n t e n t s

P a rt 3
Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s

17

Introduction

17

Learning Objectives

17

Role s of th e Te a m Le a d e r a n d Te a m Me m b e rs

18

Role of the Team Leader

18

Role of the Team Member

18

Ele m e n ts of Effe c tive Re s u s c ita tion Te a m Dyn a m ic s

19

Clos ed-Loop Communications

19

Clear Mes s ages

19

Clear Roles and Res pons ibilities

20

Knowing Ones Limitations

21

Knowledge Sharing

22

Cons tructive Intervention

22

Reevaluation and Summarizing

23

Mutual Res pect

23

P a rt 4
S ys t e m s o f Ca re

25
Introduction

25

Learning Objectives

25

Ca rd iop u lm on a ry Re s u s c ita tion

25

Quality Improvement in Res us citation Sys tems ,


Proces s es , and Outcomes
A Sys tems Approach

26

Meas urement

27

Benchmarking and Feedback

27

Change

27

Summary

27

Pos tCa rd ia c Arre s t Ca re

28

Therapeutic Hypothermia

28

Hemodynamic and Ventilation Optimization

28

Immediate Coronary Reperfus ion With PCI

28

Glycemic Control

28

Neurologic Care and Prognos tication

29

Ac ute Coron a ry Syndrom e s

iv

25

29

Starts On the Phone With Activation of EMS

29

EMS Components

29

Hos pital-Bas ed Components

29

Con te n ts

Ac ute Stroke

30

Regionalization of Stroke Care

30

Community and Profes s ional Education

30

EMS

30

Ed u c a tion , Im p le m e n ta tion , a n d Te a m s

30

The Need for Teams

30

Cardiac Arres t Teams (In-Hos pital)

31

Rapid Res pons e Sys tem

31

Medical Emergency Teams and Rapid Res pons e Teams

31

Regional Sys tems of Emergency Cardiovas cular Care

32

Publis hed Studies

32

Implementation of a Rapid Res pons e Sys tem

32

P a rt 5
Th e ACLS Ca s e s

33
Overview of the Cas es

Re s pira tory Arre s t Ca s e

33

34

The BLS Survey

34

The ACLS Survey

36

Management of Res piratory Arres t

38

Giving Supplementary Oxygen

38

Opening the Airway

38

Providing Bas ic Ventilation

40

Bas ic Airway Adjuncts : Oropharyngeal Airway

42

Bas ic Airway Adjuncts : Nas opharyngeal Airway

43

Suctioning

45

Providing Ventilation With an Advanced Airway

47

Precautions for Trauma Patients

49

VF Tre a te d With CP R a n d AED Ca s e

49

The BLS Survey

50

AED Us e in Special Situations

57

VF/P u ls e le s s VT Ca s e

59

Managing VF/Puls eles s VT: The Cardiac Arres t Algorithm

60

Application of the Cardiac Arres t Algorithm: VF/VT Pathway

62

Routes of Acces s for Drugs

69

Vas opres s ors

70

Antiarrhythmic Agents

71

Immediate Pos tCardiac Arres t Care

72

Application of the Immediate Pos tCardiac Arres t Care Algorithm

73

P u ls e le s s Ele c tric a l Ac tivity Ca s e


Des cription of PEA

78
78
v

C o n t e n t s
Managing PEA: The Cardiac Arres t Algorithm

79

Managing PEA: Diagnos ing and Treating Underlying Caus es

82

As ys tole Ca s e

86

Approach to As ys tole

86

Managing As ys tole

87

Application of the Cardiac Arres t Algorithm: As ys tole Pathway

88

Terminating Res us citative Efforts

89

Ac ute Coron a ry Syndrom e s Ca s e

91

Goals for ACS Patients

92

Managing ACS: The Acute Coronary Syndromes Algorithm

95

Identification of Ches t Dis comfort Sugges tive of Is chemia (Box 1)

96

EMS As s es s ment, Care, and Hos pital Preparation (Box 2)

96

Immediate ED As s es s ment and Treatment (Box 3)

99

STEMI (Boxes 5 Through 8)

100

Clas s ify Patients According to ST-Segment Deviation


(Boxes 5, 9, and 13)

Bra d yc a rd ia Ca s e

104

Des cription of Bradycardia

107

Managing Bradycardia: The Bradycardia Algorithm

108

Application of the Bradycardia Algorithm

109

Trans cutaneous Pacing

112

Un s ta b le Ta c h yc a rd ia Ca s e

114

The Approach to Uns table Tachycardia

114

Managing Uns table Tachycardia: The Tachycardia Algorithm

116

Application of the Tachycardia Algorithm to the Uns table Patient

118

Cardiovers ion

120

Synchronized Cardiovers ion Technique

122

Sta b le Ta c h yc a rd ia Ca s e

124

Approach to Stable Tachycardia

125

Managing Stable Tachycardia: The Tachycardia Algorithm

126

Application of the Tachycardia Algorithm to the Stable Patient

127

Ac ute Stroke Ca s e

vi

101

130

Approach to Stroke Care

132

Identification of Signs of Pos s ible Stroke (Box 1)

135

Critical EMS As s es s ments and Actions (Box 2)

138

In-Hos pital, Immediate General As s es s ment and Stabilization (Box 3)

139

Immediate Neurologic As s es s ment by Stroke Team or Des ignee (Box 4)

140

CT Scan: Hemorrhage or No Hemorrhage (Box 5)

141

Fibrinolytic Therapy

143

General Stroke Care (Boxes 11 and 12)

146

Con te n ts

Ap p e n d ix

149
Te s tin g Ch e c klis ts a n d Le a rn in g Sta tion Ch e c klis ts

151

2010 AHA Guid e line s fo r CPR a nd ECC Su m m a ry Ta b le

163

ACLS Ph a rm a c ology Sum m a ry Ta ble

165

Glos s a ry

168

Founda tion Inde x

171

In d e x

173

No t e o n Me d ic a t io n Do s e s
Emergency cardiovas cular care is a dynamic s cience. Advances in treatment and drug therapies occur rapidly.
Readers s hould us e the following s ources to check for changes in recommended dos es , indications , and contraindications : the ECC Handbook, available as optional s upplementary material, and the package ins ert product information
s heet for each drug and medical device.
vii

C o n t e n t s

Part

Cours e Ove rvie w


Co u r s e De s c r ip t io n a n d Go a l
The Advanced Cardiovas cular Life Support (ACLS) Provider Cours e is des igned for
healthcare providers who either direct or participate in the management of cardiopulmonary arres t or other cardiovas cular emergencies . Through didactic ins truction and
active participation in s imulated cas es , s tudents will enhance their s kills in the diagnos is
and treatment of cardiopulmonary arres t, acute arrhythmia, s troke, and acute coronary
s yndromes (ACS).
After s ucces s ful completion of this cours e, s tudents will be able to apply important
concepts , including
The Bas ic Life Support (BLS) Survey
High-quality cardiopulmonary res us citation (CPR)
The ACLS Survey
The ACLS algorithms
Effective res us citation team dynamics
Immediate pos tcardiac arres t care
The goal of the ACLS Provider Cours e is to improve outcomes for adult patients with
cardiac arres t or other cardiopulmonary emergencies through provider training.

Co u r s e Ob je c t ive s
Upon s ucces s ful completion of this cours e s tudents s hould be able to
Recognize and initiate early management of periarres t conditions that may res ult in
cardiac arres t or complicate res us citation outcome
Demons trate proficiency in providing BLS care, including prioritizing ches t compres s ions and integrating automated external defibrillator (AED) us e
Recognize and manage res piratory arres t
Recognize and manage cardiac arres t until termination of res us citation or trans fer of
care, including immediate pos tcardiac arres t care
Recognize and initiate early management of ACS, including appropriate dis pos ition
Recognize and initiate early management of s troke, including appropriate dis pos ition
Demons trate effective communication as a member or leader of a res us citation team
and recognize the impact of team dynamics on overall team performance

P a r t

Co u r s e De s ig n
To help you achieve thes e objectives , the ACLS Provider Cours e includes practice learning
s tations and a Megacode evaluation s tation.
The practice learning stations give you an opportunity to actively participate in a variety of
learning activities , including
Simulated clinical s cenarios
Demons trations by ins tructors or video
Dis cus s ion and role playing
Practice in effective res us citation team behaviors
In thes e learning s tations you will practice es s ential s kills both individually and as part of
a team. This cours e emphas izes effective team s kills as a vital part of the res us citative
effort. You will have the opportunity to practice as a team member and a team leader.
At the end of the cours e, you will participate in a Megacode evaluation station to validate
your achievement of the cours e objectives . A s imulated cardiac arres t s cenario will evaluate the following:
Knowledge of core cas e material and s kills
Knowledge of algorithms
Unders tanding of arrhythmia interpretation
Us e of appropriate bas ic ACLS drug therapy
Performance as an effective team leader

Co u r s e P re re q u is it e s a n d P re p a r a t io n
The American Heart As s ociation (AHA) limits enrollment in the ACLS Provider Cours e to
healthcare providers who direct or participate in the res us citation of a patient either in or
out of hos pital. Participants who enter the cours e mus t have the bas ic knowledge and
s kills to participate actively with the ins tructor and other s tudents .
Before the cours e, pleas e read the ACLS Provider Manual, complete the s elf-as s es s ment
modules on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt), identify any gaps in your
knowledge, and remediate thos e gaps by s tudying the applicable content in the ACLS
Provider Manual or other s upplementary res ources .
The following knowledge and s kills are required for s ucces s ful cours e completion:
BLS s kills
Electrocardiogram (ECG) rhythm interpretation for core ACLS rhythms
Knowledge of airway management and adjuncts
Bas ic ACLS drug and pharmacology knowledge
Practical application of ACLS rhythms and drugs
Effective res us citation team concepts

BLS S k ills

The foundation of advanced life s upport is s trong BLS s kills . You mus t pas s the 1-Res cuer
CPR and AED Tes ting Station to s ucces s fully complete the ACLS cours e. Make sure that
you are proficient in BLS skills before attending the course.
Watch the CPR and AED Skills video found on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt). Review the CPR and AED Tes ting Checklis t
located in the Appendix.

Cou rs e Ove rvie w

ECG Rh yt h m
In t e r p r e t a t io n
fo r Co r e ACLS
Rh yt h m s

The bas ic cardiac arres t and periarres t algorithms require s tudents to recognize thes e
ECG rhythms :
Sinus rhythm
Atrial fibrillation and flutter
Bradycardia
Tachycardia
Atrioventricular (AV) block
As ys tole
Puls eles s electrical activity (PEA)
Ventricular tachycardia (VT)
Ventricular fibrillation (VF)
The AHA recommends that you complete the ECG rhythm identification s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of
the as s es s ment you will receive your s core and feedback to help you identify
areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering
the cours e. During the cours e you mus t be able to identify and interpret rhythms during
practice as well as during the final Megacode evaluation s tation.

Ba s ic ACLS Dr u g
a n d P h a r m a c o lo g y
Kn o w le d g e

You mus t know the drugs and dos es us ed in the ACLS algorithms . You will als o need to
know when to us e which drug bas ed on the clinical s ituation.

P r a c t ic a l
Ap p lic a t io n o f
ACLS Rh yt h m s
a n d Dr u g s

Take the ACLS practical application s elf-as s es s ment on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) to evaluate your ability to integrate both rhythm
interpretation and the us e of pharmacologic agents . This as s es s ment pres ents a
clinical s cenario and an ECG rhythm. You will need to take an action, give a s pecific drug,
or direct your team to intervene. Us e this s elf-as s es s ment to confirm that you have the
knowledge you need to be an active participant in the cours e and pas s the final
Megacode tes t.

Effe c t ive
Re s u s c it a t io n
Te a m Co n c e p t s

Ins tructors throughout the cours e will evaluate your effectivenes s as a team leader
and a team member. A clear unders tanding of thes e concepts is integral to s ucces s ful
performance in the learning activities and the Megacode tes t. Review Part 3 in the ACLS
Provider Manual before the cours e. During the Megacode the ins tructor will evaluate your
team leader s kills with a major emphas is on your ability to direct the integration of BLS
and ACLS activities by your team members .

The AHA recommends that you complete the ACLS pharmacology review s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of
the as s es s ment you will receive your s core and feedback to help you identify
areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering
the cours e.

Co u r s e Ma t e r ia ls
Cours e materials cons is t of the ACLS Provider Manual, Student Webs ite
(www.he a rt.o rg /e c c s tud e nt), 2 pocket reference cards , and Precours e
Preparation Checklis t. The icon on the left directs you to additional s upplemental
information on the Student Webs ite.

P a r t

ACLS P r o vid e r
Ma n u a l

The ACLS Provider Manual contains the bas ic information you need for effective participation in the cours e. This important material includes the s ys tematic approach to a cardiopulmonary emergency, effective res us citation team communication, and the ACLS cas es
and algorithms . Please review this manual before attending the course. Bring it with you
for use and reference during the course.
The manual is organized into the following parts :

Co n t e n t s
P a rt 1

Cours e Overview

P a rt 2

The Sys tematic Approach

P a rt 3

Effective Res us citation Team Dynamics

P a rt 4

Sys tems of Care

P a rt 5

The ACLS Cas es

Ap p e nd ix
Te s ting Che c klis ts
a nd Le a rning Sta tio n
Che c klis ts
2010 AHA Gu id e lin e s
for CP R a n d ECC
Sum m a ry Ta b le

Summary of the new 2010 AHA Guidelines for CPR


and ECC

ACLS P ha rm a c o lo g y
Sum m a ry Ta b le

Bas ic ACLS drugs , dos es , indications /contraindications ,


and s ide effects

Glo s s a ry

Alphabetical lis t of terms

Fo und a tio n Ind e x

Pages where key s ubjects can be found (eg, epinephrine,


cardiovers ion, pacing)

Ind e x
The AHA s trongly recommends that s tudents complete the Precours e Self-As s es s ment
found on the Student Webs ite and print their s cores for s ubmis s ion to their ACLS
Ins tructor. Supplemental topics located on the Student Webs ite are us eful but not es s ential for s ucces s ful completion of the cours e.

Ca ll-ou t Boxe s
The ACLS Provider Manual contains important information pres ented in call-out boxes
that require the readers attention. Pleas e pay particular attention to the call-out boxes ,
lis ted below:
Critical Concepts
Caution
FYI 2010 Guidelines
Foundational Facts

Cr it ic a l Co n c e p t s
Im p o rta nt Info rm a tio n to
Re vie w a nd Stud y

Pay particular attention to the Critic a l Co nc e p ts boxes that appear in the ACLS
Provider Manual. Thes e boxes contain the mos t important information that you
mus t know.

Cou rs e Ove rvie w

Ca u t io n

Ca utio nboxes emphas izes pecificris ks as s ociatedwithinterventions .

FYI 2 0 1 0 Gu id e lin e s

FYI 2010 Guid e line s boxes containthenew2010 AHA Guidelines for CPR and ECC
information.

Fo u n d a t io n a l Fa c t s

Youwills eeFo und a tio na l Fa c ts boxes throughouttheACLS Provider Manual.


Thes eboxes containbas icinformationthatwillhelpyouunders tandthetopics
c overedinthecours e.

S t u d e n t We b s it e

TheACLSStudentWebs ite(www.he a rt.o rg /e c c s tud e nt)contains thefollowing


s elf-as s es s mentands upplementaryres ources :

Re s o u rc e

De s c r ip t io n

Ho w t o Us e

ACLS Rhythm
Id e ntific a tio n

Web-bas eds elf-as s es s ment:recognitionofbas ic


ECGrhythms

ACLS P ha rm a c o lo g y

Web-bas eds elf-as s es s ment:drugs us edin


algorithms

P ra c tic a l Ap p lic a tio n o f


ACLS Alg o rithm s

Web-bas eds elf-as s es s ment:evaluates the


practicalapplicationof
rhythmrecognitionand
pharmacologyintheACLS
algorithms

ACLS Sup p le m e nta ry


Info rm a tio n

Bas icAirway
Management
AdvancedAirway
Management
ACLSCoreRhythms
Defibrillation
Acces s forMedications
AcuteCoronary
Syndromes
Human,Ethical,and
LegalDimens ions of
ECCandACLS

Additionalinformation
tos upplementbas ic
concepts pres entedin
ACLScours e

Supplementaryres ources :
reviewcurrentBLS
s equenceands kills

ReviewBLSs kills to
p repareforthe1-Res cuer
CPRandAEDTes ting
Station

CP R a nd AED Skills
vid e o

Completebeforethe
cours etohelpevaluate
yourproficiencyand
determinetheneedfor
additionalreviewand
practice

Someinformationis s upplementary;otherareas are


forthe
interes ted
s tudent
oradvancedp rovider

(continued)

P a r t

1
(continued)

Re s o u rc e

P o c k e t Re fe r e n c e
Ca r d s

Ho w t o Us e

ACS vid e o

Supplementary res ources :


ACS as s es s ment and
treatment

Review for ACS Learning


Station

Stro ke vid e o

Supplementary res ources :


s troke as s es s ment and
treatment

Review for Stroke Learning


Station

ACLS Sc ie nc e Ove rvie w


vid e o

Supplementary res ources :


core emphas is of the
ACLS cours e from a
s cience pers pective

Update ACLS knowledge


and learn about changes
in application of ACLS s cience

IO a nim a tio n

Supplementary res ources :


information and demons tration of intraos s eous
(IO) ins ertion

Expanded information on
IOs

The Pocket Reference Cards are 2 s tand-alone cards packaged with the ACLS Provider
Manual. Thes e cards can be carried in your pocket for quick reference on the following
topics :

To p ic

Pre c ours e
P r e p a r a t io n
Ch e c k lis t

De s c r ip t io n

Re fe re n c e Ca rd s

Ca rd ia c a rre s t,
a rrhythm ia s , a nd
tre a tm e nt

Cardiac Arres t Algorithms


Gray box with drugs and dos age reminders
Immediate Pos tCardiac Arres t Care Algorithm
Bradycardia Algorithm
Tachycardia Algorithm

ACS a nd s tro ke

ACS Algorithm
Fibrinolytic Checklis t for STEMI
Fibrinolytic Contraindications for STEMI
Sus pected Stroke Algorithm
Stroke As s es s mentCPSS
Us e of IV rtPA for Acute Is chemic Stroke
Hypertens ion Management in Acute Is chemic Stroke

The Precours e Preparation Checklis t is packaged with the ACLS Provider Manual. Pleas e
review and check the boxes after you have completed preparation for each s ection.

Cou rs e Ove rvie w

Re q u ire m e n t s fo r S u c c e s s fu l Co u r s e Co m p le t io n
To s ucces s fully complete the ACLS Provider Cours e and obtain your cours e completion
card, you mus t
Pas s the 1-Res cuer Adult CPR and AED Tes t
Pas s the Bag-Mas k Ventilation Tes t
Demons trate competency in learning s tation s kills
Pas s the Megacode Tes t
Pas s the clos ed-book written exam with a minimum s core of 84%

ACLS Up d a t e Co u r s e
The ACLS Update Cours e is for s tudents who have a current ACLS Provider card and
need to update and refres h their ACLS s kills . This cours e is primarily focus ed on s kills
competency tes ting.
Maximum renewal period: 2 years
Update requirements : Previous ACLS cours e completion card (not expired)

ACLS P r o vid e r Ma n u a l Ab b re via t io n s


A
ABCD

ACLS Survey: Airway, Breathing, Circulation, Differential


Diagnos is

ACE

Angiotens in-converting enzyme

ACLS

Advanced cardiovas cular life s upport

ACS

Acute coronary s yndromes

AED

Automated external defibrillator

AHF

Acute heart failure

AIVR

Accelerated idioventricular rhythm

AMI

Acute myocardial infarction

a P TT

Activated partial thromboplas tin time

B
BLS

Bas ic life s upport: Check res pons ivenes s , activate emergency


res pons e s ys tem, check carotid puls e, provide defibrillation

C
CARES

Cardiac Arres t Regis try to Enhance Survival

CP R

Cardiopulmonary res us citation

CP SS

Cincinnati Prehos pital Stroke Scale

CT

Computed tomography
(continued)
7

P a r t

1
(continued)

D
DNAR

Do not attempt res us citation

E
ECG

Electrocardiogram

ED

Emergency department

EMS

Emergency medical s ervices

ET

Endotracheal

F
FDA

Food and Drug Adminis tration

F io 2

Fraction of ins pired oxygen

G
GI

Gas trointes tinal

I
ICU

Intens ive care unit

INR

International normalized ratio

IO

Intraos s eous

IV

Intravenous

L
LMWH

Low-molecular-weight heparin

LV

Left ventricle or left ventricular

M
mA

Milliamperes

MACE

Major advers e cardiac events

MET

Medical emergency team

MI

Myocardial infarction

m m Hg

Millimeters of mercury

N
NIH

National Ins titutes of Health

NIHSS

National Ins titutes of Health Stroke Scale

NINDS

National Ins titute of Neurological Dis orders and Stroke

NPA

Nas opharyngeal airway

NSAIDs

Nons teroidal anti-inflammatory drugs

NSTEMI

NonST-s egment elevation myocardial infarction


(continued)

Cou rs e Ove rvie w

(continued)

O
OPA

Oropharyngeal airway

P
Paco2

Partial pres s ure of carbon dioxide in arterial blood

P CI

Percutaneous coronary intervention

PE

Pulmonary embolis m

P EA

Puls eles s electrical activity

PT

Prothrombin time

R
ROSC

Return of s pontaneous circulation

RRT

Rapid res pons e team

rtPA

Recombinant tis s ue plas minogen activator

RV

Right ventricle or right ventricular

S
SBP

Sys tolic blood pres s ure

STEMI

ST-s egment elevation myocardial infarction

SVT

Supraventricular tachycardia

T
TCP

Trans cutaneous pacing

U
UA

Uns table angina

UFH

Unfractionated heparin

V
VF

Ventricular fibrillation

VT

Ventricular tachycardia

P a r t

Part

The Sys te m a tic Approa c h:


The BLS a nd ACLS Surve ys
In t r o d u c t io n

Healthcare providers us e a s ys tematic approach to as s es s and treat arres t and acutely ill
or injured patients for optimum care. The goal of the res us citation teams interventions for
a patient in res piratory or cardiac arres t is to s upport and res tore effective oxygenation,
ventilation, and circulation with return of intact neurologic function. An intermediate goal of
res us citation is the return of s pontaneous circulation (ROSC). The actions us ed are guided
by the following s ys tematic approaches :
BLS Survey (s teps des ignated by the numbers 1, 2, 3, 4)
ACLS Survey (s teps des ignated by the letters A, B, C, D)

Le a r n in g Ob je c t ive s

By the end of this part you s hould be able to


1. Des cribe the critical actions of the BLS Survey and ACLS Survey
2. Des cribe as s es s ment and management that occur with each s tep of the s ys tematic
approach
3. Des cribe how the as s es s ment/management approach is applicable to mos t cardiopulmonary emergencies

Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys
Ove r vie w o f
t h e S ys t e m a t ic
Ap p r o a c h

The s ys tematic approach firs t requires ACLS providers to determine the patients level of
cons cious nes s . As you approach the patient:
If the patient appears uncons cious
Us e the BLS Survey for the initial as s es s ment.
After completing all of the appropriate s teps of the BLS Survey, us e the ACLS
Survey for more advanced as s es s ment and treatment.
If the patient appears cons cious
Us e the ACLS Survey for your initial as s es s ment.
The details of the BLS and ACLS Surveys are des cribed below.

11

P a r t

Th e BLS S u r ve y
Ove r vie w o f t h e
BLS S u r ve y

The BLS Survey is a s ys tematic approach to bas ic life s upport that any trained healthcare
provider can perform. This approach s tres s es early CPR and early defibrillation. It does not
include advanced interventions , s uch as advanced airway techniques or drug adminis tra
tion. By us ing the BLS Survey, healthcare providers may achieve their goal of s upporting
or res toring effective oxygenation, ventilation, and circulation until ROSC or initiation of
ACLS interventions . Performing the actions in the BLS Survey s ubs tantially improves the
patients chance of s urvival and a good neurologic outcome.
Be fore c on d u c tin g th e BLS or ACLS Su rve y, look to m a ke s u re th e s c e n e is s a fe .
The BLS Survey us es a s eries of 4 s equential as s es s ment s teps des ignated by the
numbers 1, 2, 3, and 4. Simultaneous ly with each as s es s ment s tep, you s hould
perform appropriate corrective action(s ) before proceeding to the next s tep. As s es s
ment is a key component in this approach (eg, check the puls e before s tarting ches t
compres s ions or attaching an AED).
Re m e m b e r: As s e s s th e n p e rform a p p rop ria te a c tion .

FYI 2 0 1 0 Gu id e lin e s

Pleas e note the 2 key changes from the 2005 AHA Guidelines for CPR and ECC:

Cha ng e s in the BLS


Surve y

The 2010 AHA Guidelines for CPR and ECC alters the BLS s equence by eliminating
look, lis ten, and feel followed by 2 res cue breaths . This change promotes earlier
initiation of ches t compres s ions in cardiac arres t patients .
The BLS Survey is no longer repres ented by the letters A, B, C, D but is repres ented
by the numbers 1, 2, 3, 4 ins tead.

Fo u n d a t io n a l Fa c t s

Although no publis hed human or animal evidence demons trates that s tarting CPR
with 30 compres s ions rather than 2 ventilations leads to improved outcomes , it is
clear that blood flow depends on ches t compres s ions . Therefore, providers mus t
minimize delays in and interruptions of ches t compres s ions throughout the entire
res us citation. Pos itioning the head, achieving a s eal for mouth to mouth res cue
breaths , or getting a bag mas k device for res cue breaths takes time. Beginning CPR
with 30 compres s ions rather than 2 ventilations leads to a s horter delay to the firs t
compres s ion.
Once one provider begins ches t compres s ions , a s econd trained healthcare provider
s hould deliver res cue breaths to provide oxygenation and ventilation as follows :
Deliver each res cue breath over 1 s econd
Give a s ufficient tidal volume to produce vis ible ches t ris e

Sta rting With Che s t


Co m p re s s io ns vs
2 Bre a ths

Although the BLS Survey requires no advanced equipment, healthcare providers can us e
any readily available univers al precaution s upplies or adjuncts , s uch as a bag mas k venti
lation device. Whenever pos s ible, place the patient on a firm s urface in a s upine pos ition
to maximize the effectivenes s of ches t compres s ions . Table 1 is an overview of the BLS
Survey, and Figures 1 through 4 illus trate the s teps needed during the BLS Survey. Before
approaching the patient, ens ure s cene s afety.
For more details , review the VF Treated With CPR and AED Cas e in Part 5 of
this manual and watch the CPR and AED Skills video on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt).

12

Th e Sys te m a tic Ap p roa c h

Ta b le 1 . The BLS Surve y

As s e s s
1

Che c k
re s p o ns ive ne s s

As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )

Fig u re 1 . Checkres pons ivenes s .

Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED

Activatetheemergencyres pons es ys temandgetanAED


ifoneis availableors ends omeonetoactivatetheemergencyres pons es ys temandgetanAEDordefibrillator

Fig u re 2 . Activatetheemergencyres pons es ys tem.

Circ ula tio n

Che c k the c a ro tid p uls e for5to10s econds


Ifnopuls ewithin10s econds ,s tartCPR(30:2)beginning
withches tcompres s ions
Compres s thecenteroftheches t(lowerhalfofthe
s ternum)hardandfas twithatleas t100compres s ions
perminuteatadepthofatleas t2inches
Allowcompleteches trecoilaftereachcompres s ion
Minimizeinterruptions incompres s ions
(10s econds orles s )
Switchproviders aboutevery2minutes toavoidfatigue
Avoidexces s iveventilation
Ifthereis apuls e,s tartres cuebreathingat1breathevery
5to6s econds (10to12breaths perminute).Checkpuls e
aboutevery2minutes

De fib rilla tio n

Fig u re 3 . Checkthecarotidpuls e.

Ifnopuls e,checkforas hockablerhythmwithanAED/


defibrillatoras s oonas itarrives
Provides hocks as indicated
Followeachs hockimmediatelywithCPR,beginningwith
compres s ions

Fig u re 4 . Defibrillation.

13

P a r t

Cr it ic a l Co n c e p t s
Minim izing Inte rrup tio ns

ACLS p ro vid e rs m us t m a ke e ve ry e ffo rt to m inim ize a ny inte rrup tio ns in c he s t


c o m p re s s io ns . Try to limit interruptions in ches t compres s ions (eg, defibrillation and
advanced airway) to no longer than 10 s econds , except in extreme circums tances ,
s uch as removing the patient from a dangerous environment. When you s top ches t
compres s ions , blood flow to the brain and heart s tops .
Avo id :
Prolonged rhythm analys is
Frequent or inappropriate puls e checks
Taking too long to give breaths to the patient
Unneces s arily moving the patient

Fo u n d a t io n a l Fa c t s
Lo ne He a lthc a re
P ro vid e r Ma y Ta ilo r
Re s p o ns e

Cr it ic a l Co n c e p t s
Hig h-Qua lity CP R

Lone healthcare providers may tailor the s equence of res cue actions to the mos t
likely caus e of arres t. For example, if a lone healthcare provider s ees an adoles cent
s uddenly collaps e, it is reas onable to as s ume that the patient has s uffered a s udden
cardiac arres t.
The lone res cuer s hould call for help (activate the emergency res pons e s ys tem), get
an AED (if nearby), return to the patient to attach the AED, and then provide CPR.
On the other hand, if hypoxia is the pres umed caus e of the cardiac arres t (s uch as
in a drowning patient), the healthcare provider may give about 5 cycles (approximately 2 minutes ) of CPR before activating the emergency res pons e s ys tem.

Compres s the ches t hard and fas t.


Allow complete ches t recoil after each compres s ion.
Minimize interruptions in compres s ions (10 s econds or les s ).
Switch providers about every 2 minutes to avoid fatigue.
Avoid exces s ive ventilation.

Th e ACLS S u r ve y
Ove r vie w o f t h e
ACLS S u r ve y

For uncons cious patients in arres t (cardiac or res piratory):


Healthcare providers s hould conduct the ACLS Survey after completing the
BLS s urvey.
For cons cious patients who may need more advanced as s es s ment and management
techniques :
Healthcare providers s hould conduct the ACLS Survey firs t.
An important component of this s urvey is the differential diagnos is , where identification
and treatment of the underlying caus es may be critical to patient outcome.
In the ACLS Survey you continue to as s es s and perform an action as appropriate until
trans fer to the next level of care. Many times , team members perform as s es s ments and
actions in ACLS s imultaneous ly.
Re m e m b e r: As s e s s th e n p e rform a p p rop ria te a c tion .

14

Th e Sys te m a tic Ap p roa c h

Table 2 provides an overview of the ACLS Survey. The ACLS cas es provide details on
thes e components .
Ta b le 2 . The ACLS Surve y

As s e s s
Airwa y
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of
airway device confirmed?
Is tube secured and
placement reconfirmed
frequently?

Ac t io n a s Ap p ro p r ia t e
Ma inta in a irwa y p a te nc y in unc o ns c io us p a tie nts
by us e of the head tiltchin lift, oropharyngeal airway (OPA), or nas opharyngeal airway (NPA)
Us e a d va nc e d a irwa y m a na g e m e nt if ne e d e d
(eg, laryngeal mas k airway, laryngeal tube,
es ophageal-tracheal tube, endotracheal tube
[ET tube])
Healthcare providers must weigh the benefit of
advanced airway placement against the adverse
effects of interrupting chest compressions. If bagmask ventilation is adequate, healthcare providers
may defer insertion of an advanced airway until the
patient fails to respond to initial CPR and defibrillation
or until spontaneous circulation returns. Advanced
airway devices such as a laryngeal mask airway, laryngeal tube, or esophageal-tracheal tube can be placed
while chest compressions continue.
If us ing advanced airway devices :
Co nfirm p ro p e r inte g ra tio n o f CP R a nd
ve ntila tio n
Co nfirm p ro p e r p la c e m e nt o f a d va nc e d a irwa y
d e vic e s by
Phys ical examination
Quantitative waveform capnography
Clas s I recommendation for ET tube
Reas onable for s upraglottic airways
Se c ure the d e vic e to p re ve nt d is lo d g m e nt
Mo nito r a irwa y p la c e m e nt with c o ntinuo us
q ua ntita tive wa ve fo rm c a p no g ra p hy

Bre a thing
Are ventilation and oxygenation adequate?
Are quantitative waveform
capnography and oxyhemoglobin saturation monitored?

Give s up p le m e nta ry o xyg e n whe n ind ic a te d


For cardiac arres t patients , adminis ter 100%
oxygen
For others , titrate oxygen adminis tration to
achieve oxygen s aturation values of 94% by
puls e oximetry
Mo nito r the a d e q ua c y o f ve ntila tio n a nd o xyg e na tio n by
Clinical criteria (ches t ris e and cyanos is )
Quantitative waveform capnography
Oxygen s aturation
Avo id e xc e s s ive ve ntila tio n
(continued)

15

P a r t

2
(continued)

As s e s s
Circ ula tio n
Are chest compressions
effective?
What is the cardiac rhythm?
Is defibrillation or cardioversion indicated?
Has IV/IO access been
established?
Is ROSC present?
Is the patient with a pulse
unstable?
Are medications needed for
rhythm or blood pressure?
Does the patient need
volume (fluid) for resuscitation?
Diffe re ntia l d ia g no s is
Why did this patient develop
symptoms or arrest?
Is there a reversible cause
that can be treated?

Ac t io n a s Ap p ro p r ia t e
Mo nito r CP R q ua lity
Quantitative waveform capnography (if P e t c o 2 is
<10 mm Hg, attempt to improve CPR quality)
Intra-arterial pres s ure (if relaxation phas e
[dias tolic] pres s ure is <20 mm Hg, attempt to
improve CPR quality)
Atta c h m o nito r/d e fib rilla to r fo r a rrhythm ia s
o r c a rd ia c a rre s t rhythm s (eg, VF, puls eles s VT,
as ys tole, PEA)
P ro vid e d e fib rilla tio n/c a rd io ve rs io n
Ob ta in IV/IO a c c e s s
Give a p p ro p ria te d rug s to manage rhythm and
blood pres s ure
Give IV/IO fluid s if ne e d e d

Se a rc h fo r, find , a nd tre a t re ve rs ib le c a us e s (ie,


definitive care)

P e t c o 2 is the partial pres s ure of CO 2 in exhaled air at the end of the exhalation phas e.

16

Part

Effe c tive Re s us c ita tion Te a m Dyna m ic s

In t r o d u c t io n

Succes s ful res us citation attempts often require healthcare providers to s imultaneous ly
perform a variety of interventions . Although a CPR-trained bys tander working alone can
res us citate a patient within the firs t moments after collaps e, mos t attempts require the
concerted efforts of multiple healthcare providers . Effective teamwork divides the tas ks
while multiplying the chances of a s ucces s ful outcome.
Succes s ful teams not only have medical expertis e and mas tery of res us citation s kills , but
they als o demons trate effective communication and team dynamics . Part 3 of this manual
dis cus s es the importance of team roles , behaviors of effective team leaders and team
members , and elements of effective res us citation team dynamics .
During the cours e you will have an opportunity to practice performing different roles as a
member and a leader of a s imulated res us citation team.

Le a r n in g Ob je c t ive s

By the end of this part you s hould be able to


1. Des cribe team leaders and team members roles
2. Explain the importance of the team leader and team members unders tanding their
s pecific roles
3. Des cribe how s kills mas tery combined with team dynamics may lead to increas ed
s ucces s in res us citation outcomes
4. Des cribe key elements of an effective res us citation
5. Coordinate team functions while ens uring continuous high-quality CPR, defibrillation,
and rhythm as s es s ment

Fo u n d a t io n a l Fa c t s
Und e rs ta nd ing Te a m
Ro le s

Whether you are a team member or team leader during a res us citation attempt, you
s hould u n d e rs ta n d n ot on ly you r role b u t a ls o th e role s of oth e r te a m m e m b e rs .
This awarenes s will help you anticipate
What actions will be performed next
How to communicate and work as a member or leader of the team

17

P a r t

Ro le s o f t h e Te a m Le a d e r a n d Te a m Me m b e r s
Ro le o f t h e Te a m
Le a d e r

The role of the team leader is multifaceted. The team leader


Organizes the group
Monitors individual performance of team members
Backs up team members
Models excellent team behavior
Trains and coaches
Facilitates unders tanding
Focus es on comprehens ive patient care
Every res us citation team needs a leader to organize the efforts of the group. The team
leader is res pons ible for making s ure everything is done at the right time in the right way
by monitoring and integrating individual performance of team members . The role of the
team leader is s imilar to that of an orches tra conductor directing individual mus icians . Like
a conductor, the team leader does not play the ins truments but ins tead knows how each
member of the orches tra fits into the overall mus ic.
The role of the team leader als o includes modeling excellent team behavior and leaders hip
s kills for the team and other people involved or interes ted in the res us citation. The team
leader s hould s erve as a teacher or guide to help train future team leaders and improve
team effectivenes s . After res us citation the team leader can facilitate analys is , critique, and
practice in preparation for the next res us citation attempt.
The team leader als o helps team members unders tand why they mus t perform certain
tas ks in a s pecific way. The team leader s hould be able to explain why it is es s ential to
Pus h hard and fas t
Ens ure complete ches t recoil
Minimize interruptions in ches t compres s ions
Avoid exces s ive ventilations
Whereas team members s hould focus on their individual tas ks , the team leader mus t
focus on comprehens ive patient care.
Review the ACLS Science Overview video on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) to help prepare for this role.

Ro le o f t h e Te a m
Me m b e r

Team members mus t be proficient in performing the s kills authorized by their s cope of
practice. It is es s ential to the s ucces s of the res us citation attempt that team members are
Clear about role as s ignments
Prepared to fulfill their role res pons ibilities
Well practiced in res us citation s kills
Knowledgeable about the algorithms
Committed to s ucces s

18

Effe c tive Re s u s c ita tion Te a m Dyn a m ic s

Ele m e n t s o f Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s


Clo s e d -Lo o p
Co m m u n ic a t io n s

When communicating with res us citation team members , the team leader s hould us e
clos ed-loop communication by taking thes e s teps :
1. The team leader gives a mes s age, order, or as s ignment to a team member.
2. By receiving a clear res pons e and eye contact, the team leader confirms that the
team member heard and unders tood the mes s age.
3. The team leader lis tens for confirmation of tas k performance from the team member
before as s igning another tas k.

Do
Te a m le a d e r

As s ign another tas k after receiving oral confirmation


that a tas k has been completed, s uch as , Now that
the IV is in, give 1 mg of epinephrine

Te a m m e m b e rs

Clos e the loop: Inform the team leader when a tas k


begins or ends , s uch as , The IV is in

Do n t

Cle a r Me s s a g e s

Te a m le a d e r

Give more tas ks to a team member without as king or


receiving confirmation of a completed as s ignment

Te a m m e m b e rs

Give drugs without verbally confirming the order with


the team leader
Forget to inform the team leader after giving the drug
or performing the procedure

Clear mes s ages cons is t of concis e communication s poken with dis tinctive s peech in a
controlled tone of voice. All healthcare providers s hould deliver mes s ages and orders in
a calm and direct manner without yelling or s houting. Unclear communication can lead to
unneces s ary delays in treatment or to medication errors .
For example: Did the patient get IV propofol s o I can proceed with the cardiovers ion?
No, I thought you s aid to give him propranolol.
Yelling or s houting can impair effective team interaction. Only one pers on s hould talk at
any time.

Do
Te a m le a d e r

Encourage team members to s peak clearly

Te a m m e m b e rs

Repeat the medication order


Ques tion an order if the s lightes t doubt exis ts

Do n t
Te a m le a d e r

Mumble or s peak in incomplete s entences


Give unclear mes s ages and drug/medication orders
Yell, s cream, or s hout

Te a m m e m b e rs

Feel patronized by dis tinct and concis e mes s ages

19

P a r t

Cle a r Ro le s a n d
Re s p o n s ib ilit ie s

Every member of the team s hould know his or her role and res pons ibilities . J us t as
different s haped pieces make up a jigs aw puzzle, each team members role is unique
and critical to the effective performance of the team. Figure 5 identifies 6 team roles for
res us citation. When <6 people are pres ent, all tas ks mus t be as s igned to the healthcare
providers pres ent.
When roles are unclear, team performance s uffers . Signs of unclear roles include
Performing the s ame tas k more than once
Mis s ing es s ential tas ks
Freelancing of team members
To avoid inefficiencies , the team leader mus t clearly delegate tas ks . Team members
s hould communicate when and if they can handle additional res pons ibilities . The team
leader s hould encourage team members to participate in leaders hip and not s imply follow
directions blindly.

Do
Te a m le a d e r

Clearly define all team member roles in the clinical


s etting

Te a m m e m b e rs

Seek out and perform clearly defined tas ks appropriate to your level of competence
As k for a new tas k or role if you are unable to perform
your as s igned tas k becaus e it is beyond your level of
experience or competence

Do n t

20

Te a m le a d e r

Neglect to as s ign tas ks to all available team members


As s ign tas ks to team members who are uns ure of
their res pons ibilities
Dis tribute as s ignments unevenly, leaving s ome with
too much to do and others with too little

Te a m m e m b e rs

Avoid taking as s ignments


Take as s ignments beyond your level of competence
or expertis e

Effe c tive Re s u s c ita tion Te a m Dyn a m ic s

Airwa y

Co m p re s s o r

IV/IO/Me d s

Mo nito r/
De b rilla to r
Ob s e rve r/
Re c o rd e r

TEAM LEADER
Fig u re 5 . Sugges ted locations of team leader and team members during cas e s imulations .

Kn o w in g On e s
Lim it a t io n s

Not only s hould everyone on the team know his or her own limitations and capabilities ,
but the team leader s hould als o be aware of them. This allows the team leader to evaluate
team res ources and call for backup of team members when as s is tance is needed. Team
members s hould anticipate s ituations in which they might require as s is tance and inform
the team leader.
During the s tres s of an attempted res us citation, do not practice or explore a new s kill. If
you need extra help, reques t it early. It is not a s ign of weaknes s or incompetence to as k
for help; it is better to have more help than needed rather than not enough help, which
might negatively affect patient outcome.

Do
Te a m le a d e r a nd te a m
m e m b e rs

Call for as s is tance early rather than waiting until the


patient deteriorates to the point that help is critical
Seek advice from more experienced pers onnel when
the patients condition wors ens des pite primary
treatment

Do n t
Te a m le a d e r a nd te a m
m e m b e rs

Reject offers from others to carry out an as s igned


tas k you are unable to complete, es pecially if tas k
completion is es s ential to treatment

Te a m m e m b e rs

Us e or s tart an unfamiliar treatment or therapy without s eeking advice from more experienced pers onnel
Take on too many as s ignments at a time when as s is tance is readily available

21

P a r t

Kn o w le d g e S h a r in g

Sharing information is a critical component of effective team performance. Team leaders


may become trapped in a s pecific treatment or diagnos tic approach; this common human
error is called a fixation error. Examples of 3 common types of fixation errors are
Everything is okay.
This and only this is the correct path.
Anything but this .
When res us citative efforts are ineffective, go back to the bas ics and talk as a team. Well,
weve gotten the following on the ACLS Survey. Have we mis s ed s omething?
Team members s hould inform the team leader of any changes in the patients condition to
ens ure that decis ions are made with all available information.

Do
Te a m le a d e r

Encourage an environment of information s haring and


as k for s ugges tions if uncertain of the next bes t interventions
As k for good ideas for differential diagnos es
As k if anything has been overlooked (eg, IV acces s
s hould have been obtained or drugs s hould have
been adminis tered)

Te a m m e m b e rs

Share information with other team members

Do n t

Co n s t r u c t ive
In t e r ve n t io n

Te a m le a d e r

Ignore others s ugges tions for treatment


Overlook or fail to examine clinical s igns that are
relevant to the treatment

Te a m m e m b e rs

Ignore important information to improve your role

During a res us citation attempt the team leader or a team member may need to intervene
if an action that is about to occur may be inappropriate at the time. Although cons tructive
intervention is neces s ary, it s hould be tactful. Team leaders s hould avoid confrontation
with team members . Ins tead, conduct a debriefing afterward if cons tructive criticis m
is needed.

Do
Te a m le a d e r

As k that a different intervention be s tarted if it has a


higher priority

Te a m m e m b e rs

Sugges t an alternative drug or dos e in a confident


manner
Ques tion a colleague who is about to make a mis take

Do n t

22

Te a m le a d e r

Fail to reas s ign a team member who is trying to function beyond his or her level of s kill

Te a m m e m b e rs

Ignore a team member who is about to adminis ter a


drug incorrectly

Effe c tive Re s u s c ita tion Te a m Dyn a m ic s

Re e va lu a t io n a n d
S u m m a r iz in g

An es s ential role of the team leader is monitoring and reevaluating


The patients s tatus
Interventions that have been performed
As s es s ment findings
A good practice is for the team leader to s ummarize this information out loud in a periodic
update to the team. Review the s tatus of the res us citation attempt and announce the plan
for the next few s teps . Remember that the patients condition can change. Remain flexible
to changing treatment plans and revis iting the initial differential diagnos is . As k for information and s ummaries from the code recorder as well.

Do
Te a m le a d e r

Draw continuous attention to decis ions about differential diagnos es


Review or maintain an ongoing record of drugs and
treatments adminis tered and the patients res pons e

Te a m le a d e r a nd te a m
m e m b e rs

Clearly draw attention to s ignificant changes in the


patients clinical condition
Increas e monitoring (eg, frequency of res pirations
and blood pres s ure) when the patients condition
deteriorates

Do n t
Te a m le a d e r

Mu t u a l Re s p e c t

Fail to change a treatment s trategy when new information s upports s uch a change
Fail to inform arriving pers onnel of the current s tatus
and plans for further action

The bes t teams are compos ed of members who s hare a mutual res pect for each other
and work together in a collegial, s upportive manner. To have a high-performing team,
everyone mus t abandon ego and res pect each other during the res us citation attempt,
regardles s of any additional training or experience that the team leader or s pecific team
members may have.

Do
Te a m le a d e r a nd te a m
m e m b e rs

Speak in a friendly, controlled tone of voice


Avoid s houting or dis playing aggres s ion if you are not
unders tood initially

Te a m le a d e r

Acknowledge correctly completed as s ignments by


s aying, Thanks good job!

Do n t
Te a m le a d e r a nd te a m
m e m b e rs

Shout or yell at team members when one pers on


rais es his voice, others will res pond s imilarly
Behave aggres s ively or confus e directive behavior
with aggres s ion
Be uninteres ted in others

23

P a r t

Part

Sys te m s of Ca re

In t r o d u c t io n

A s ys tem is a group of regularly interacting and interdependent components . The s ys tem


provides the links for the chain and determines the s trength of each link and the chain as
a whole. By definition, the s ys tem determines the ultimate outcome and s trength of the
chain and provides collective s upport and organization. For patients with pos s ible ACS,
the s ys tem rapidly triages patients , determines a pos s ible or provis ional diagnos is , and
initiates a s trategy bas ed on initial clinical characteris tics .

Le a r n in g Ob je c t ive s

By the end of this part you s hould be able to


1. Des cribe how s ys tems of care are coordinated on the bas is of the individuals health
needs
2. Define s ys tems of care that provide early acces s to coronary angiography, pos tarres t
therapeutic hypothermia, and admis s ion to units providing s pecialized care
3. Des cribe the components of a rapid res pons e s ys tem
4. Dis cus s how the us e of a rapid res pons e team (RRT) or medical emergency team
(MET) may improve patient outcomes

Ca rd io p u lm o n a r y Re s u s c it a t io n
Qu a lit y Im p r o ve m e n t
in Re s u s c it a t io n
S ys t e m s , P r o c e s s e s ,
a n d Ou t c o m e s

Cardiopulmonary res us citation is a s eries of lifes aving actions that improve the chance
of s urvival following cardiac arres t. Although the optimal approach to CPR may vary,
depending on the res cuer, the patient, and the available res ources , the fundamental
challenge remains how to achieve early and effective CPR.

25

P a r t

A S ys t e m s Ap p r o a c h

Succes s ful res us citation following cardiac arres t requires an integrated s et of coordinated
actions repres ented by the links in the adult Chain of Survival (Figure 6). The links include
the following:
Immediate recognition of cardiac arres t and activation of the emergency res pons e
s ys tem
Early CPR with an emphas is on ches t compres s ions
Rapid defibrillation
Effective advanced life s upport
Integrated pos tcardiac arres t care
Effective res us citation requires an integrated res pons e known as a s ys tem of care.
Fundamental to a s ucces s ful res us citation s ys tem of care is the collective appreciation
of the challenges and opportunities pres ented by the Chain of Survival. Thus , individuals
and groups mus t work together, s haring ideas and information, to evaluate and improve
their res us citation s ys tem. Leaders hip and accountability are important components of
this team approach.
To improve care, leaders mus t as s es s the performance of each s ys tem component.
Only when performance is evaluated can participants in a s ys tem effectively intervene to
improve care. This proces s of quality improvement cons is ts of an iterative and continuous
cycle of
Sys tematic evaluation of res us citation care and outcome
Benchmarking with s takeholder feedback
Strategic efforts to addres s identified deficiencies

Fig u re 6 . The adult Chain of Survival.

Fo u n d a t io n a l Fa c t s
Me d ic a l Em e rg e nc y
Te a m s (METs ) a nd Ra p id
Re s p o ns e Te a m s (RRTs )

26

Many hos pitals have implemented the us e of METs or RRTs . The purpos e of thes e
teams is to improve patient outcomes by identifying and treating early clinical deterioration (Figure 7). In-hos pital cardiac arres t is commonly preceded by phys iologic
changes . In one s tudy nearly 80% of hos pitalized patients with cardiores piratory
arres t had abnormal vital s igns documented for up to 8 hours before the actual
arres t. Many of thes e changes can be recognized by monitoring routine vital s igns .
Intervention before clinical deterioration or cardiac arres t may be pos s ible.
Cons ider this ques tion: Would you have done anything differently if you knew 15
minutes before the arres t that?

Sys te m s of Ca re

U n s t a b le
l P a t ie n t
Ra p id
Re s p o n s e
Te a m

Cod e
Te a m

Cr it ic a l
Ca re Te a m

Fig u re 7 . Management of life-threatening emergencies requires integration of multidis ciplinary teams


that can involve rapid res pons e teams , cardiac arres t teams , and intens ive care s pecialties to achieve
s urvival of the patient. Team leaders have an es s ential role in coordination of care with team members
and other s pecialis ts .

Me a s u r e m e n t

Quality improvement relies on valid as s es s ment of res us citation performance and


outcome.
The Uts tein Guidelines provide guidance for core performance meas ures , including
Rate of bys tander CPR
Time to defibrillation
Survival to hos pital dis charge
Importance of information s haring among all links in the s ys tem of care
Dis patch records
Emergency medical s ervices (EMS) patient care report
Hos pital records

Be n c h m a r k in g
a n d Fe e d b a c k

Data s hould be s ys tematically reviewed and compared internally to prior performance and
externally to s imilar s ys tems . Exis ting regis tries can facilitate this benchmarking effort.
Examples include the
Cardiac Arres t Regis try to Enhance Survival (CARES) for out-of-hos pital cardiac arres t
Get With The Guidelines Res us citation program for in-hos pital cardiac arres t

Ch a n g e

Simply meas uring and benchmarking care can pos itively influence outcome. However,
ongoing review and interpretation are neces s ary to identify areas for improvement,
s uch as
Increas ed bys tander CPR res pons e rates
Improved CPR performance
Shortened time to defibrillation
Citizen awarenes s
Citizen and healthcare profes s ional education and training

Su m m a r y

Over the pas t 50 years the modern-era bas ic life s upport fundamentals of early recognition and activation, early CPR, and early defibrillation have s aved hundreds of thous ands
of lives around the world. However, we s till have a long road to travel if we are to fulfill
the potential offered by the Chain of Survival. Survival dis parities pres ent a generation
ago appear to pers is t. Fortunately, we currently pos s es s the knowledge and tools
repres ented by the Chain of Survivalto addres s many of thes e care gaps , and future
dis coveries will offer opportunities to improve rates of s urvival.

27

P a r t

P o s t Ca rd ia c Ar re s t Ca re
The healthcare s ys tem s hould implement a comprehens ive, s tructured, multidis ciplinary
s ys tem of care in a cons is tent manner for the treatment of pos tcardiac arres t patients .
Programs s hould addres s therapeutic hypothermia, hemodynamic and ventilation optimization, immediate coronary reperfus ion with percutaneous coronary intervention (PCI),
glycemic control, neurologic care and prognos tication, and other s tructured interventions .
Individual hos pitals with a high frequency of treating cardiac arres t patients s how an
increas ed likelihood of s urvival when thes e interventions are provided.

Th e r a p e u t ic
Hyp o t h e r m ia

The 2010 AHA Guidelines for CPR and ECC recommends cooling comatos e (ie, lack of
meaningful res pons e to verbal commands ) adult patients with ROSC after out-of-hos pital
VF cardiac arres t to 32C to 34C (89.6F to 93.2F) for 12 to 24 hours . Healthcare providers s hould als o cons ider induced hypothermia for comatos e adult patients with ROSC
after in-hos pital cardiac arres t of any initial rhythm or after out-of-hos pital cardiac arres t
with an initial rhythm of PEA or as ys tole.

He m o d yn a m ic
a n d Ve n t ila t io n
Op t im iz a t io n

Although providers often us e 100% oxygen while performing the initial res us citation,
providers s hould titrate ins pired oxygen during the pos tcardiac arres t phas e to the lowes t
level required to achieve an arterial oxygen s aturation of 94% . This helps to avoid any
potential complications as s ociated with oxygen toxicity.
Avoid exces s ive ventilation of the patient becaus e of potential advers e hemodynamic
effects when intrathoracic pres s ures are increas ed and becaus e of potential decreas es in
cerebral blood flow when Pa c o 2 decreas es .
Healthcare providers may s tart ventilation rates at 10 to 12 breaths per minute and titrate
to achieve a P e t c o 2 of 35 to 40 mm Hg or a Pa c o 2 of 40 to 45 mm Hg.
Healthcare providers s hould titrate fluid adminis tration and vas oactive or inotropic agents
as needed to optimize blood pres s ure, cardiac output, and s ys temic perfus ion. The
optimal pos tcardiac arres t blood pres s ure remains unknown; however, a mean arterial
pres s ure 65 mm Hg is a reas onable goal.

Im m e d ia t e
Co r o n a r y
Re p e r fu s io n
Wit h P CI

Following ROSC, res cuers s hould trans port the patient to a facility capable of reliably
providing coronary reperfus ion (eg, PCI) and other goal-directed pos tarres t care therapies .
The decis ion to perform PCI can be made irres pective of the pres ence of coma or the
decis ion to induce hypothermia, becaus e concurrent PCI and hypothermia are reported to
be feas ible and s afe and have good outcomes .

Glyc e m ic Co n t r o l

Cons ider s trategies to target moderate glycemic control (144 to 180 mg/dL [8 to 10
mmol/L]) in adult patients with ROSC after cardiac arres t.
Healthcare providers s hould not attempt to alter glucos e concentration within a lower
range (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) due to the increas ed ris k of hypoglycemia.

28

Sys te m s of Ca re

Ne u r o lo g ic Ca r e
a n d P r o g n o s t ic a t io n

The goal of pos tcardiac arres t management is to return patients to their prearres t
functional level. Reliable early prognos tication of neurologic outcome is an es s ential component of pos tcardiac arres t care. Mos t importantly, when cons idering decis ions to limit
or withdraw life-s us taining care, tools us ed to prognos ticate poor outcome mus t be accurate and reliable, with a fals e-pos itive rate approaching 0% .

Ac u t e Co ro n a r y S yn d ro m e s
The primary goals of therapy for patients with ACS are to
1. Reduce the amount of myocardial necros is that occurs in patients with acute
myocardial infarction (AMI), thus pres erving left ventricular (LV) function, preventing
heart failure, and limiting other cardiovas cular complications
2. Prevent major advers e cardiac events (MACE): death, nonfatal MI, and the need for
urgent revas cularization
3. Treat acute, life-threatening complications of ACS, s uch as VF, puls eles s VT, uns table
tachycardias , s ymptomatic bradycardias , pulmonary edema, cardiogenic s hock, and
mechanical complications of AMI

S t a r t s On t h e
P h o n e Wit h
Ac t iva t io n o f EMS

Prompt diagnos is and treatment offers the greates t potential benefit for myocardial
s alvage. Thus , it is imperative that healthcare providers recognize patients with potential
ACS in order to initiate evaluation, appropriate triage, and management as expeditious ly
as pos s ible.

EMS Co m p o n e n t s

Prehos pital ECGs


Notification of the receiving facility of a patient with pos s ible ST-s egment elevation
myocardial infarction (STEMI alert)
Activation of the cardiac catheterization team to s horten reperfus ion time
Continuous review and quality improvement

Ho s p it a l-Ba s e d
Co m p o n e n t s

Em e rg e nc y d e p a rtm e nt (ED) p ro to c o ls
Activation of the cardiac catheterization laboratory
Admis s ion to the coronary intens ive care unit (ICU)
Quality as s urance, real-time feedback, and healthcare provider education
Em e rg e nc y p hys ic ia n
Empowered to s elect the mos t appropriate reperfus ion s trategy
Empowered to activate the cardiac catheterization team as indicated
Ho s p ita l le a d e rs hip
Mus t be involved in the proces s and committed to s upport rapid acces s to STEMI
reperfus ion therapy

29

P a r t

Ac u t e S t ro k e
The healthcare s ys tem has achieved s ignificant improvements in s troke care through
integration of public education, emergency dis patch, prehos pital detection and triage,
hos pital s troke s ys tem development, and s troke unit management. Not only have the rates
of appropriate fibrinolytic therapy increas ed over the pas t 5 years , but overall s troke care
has als o improved, in part through the creation of s troke centers .

Re g io n a liz a t io n o f
S t r o k e Ca r e

With the National Ins titute of Neurological Dis orders and Stroke (NINDS) recombinant
tis s ue plas minogen activator (rtPA) trial, the crucial need for local partners hips between
academic medical centers and community hos pitals became clear. The time-s ens itive
nature of s troke requires s uch an approach, even in dens ely populated metropolitan
centers .

Co m m u n it y a n d
P r o fe s s io n a l
Ed u c a t io n

Community and profes s ional education is es s ential and has s ucces s fully increas ed the
proportion of s troke patients treated with fibrinolytic therapy.

EMS

The integration of EMS into regional s troke models is crucial for improvement of
patient outcomes :

Patient education efforts are mos t effective when the mes s age is clear and s uccinct.
Educational efforts need to couple the knowledge of the s igns and s ymptoms of
s troke with actionactivate the emergency res pons e s ys tem.

EMS res pons e pers onnel trained in s troke recognition


Stroke-prepared hos pitals primary s troke centers
Acces s to s troke expertis e via telemedicine from the neares t s troke center

Ed u c a t io n , Im p le m e n t a t io n , a n d Te a m s
The Chain of Survival is a metaphor us ed to organize and des cribe the integrated s et of
time-s ens itive coordinated actions neces s ary to maximize s urvival from cardiac arres t.
The us e of evidence-bas ed education and implementation s trategies can optimize the
links in the chain.

Th e Ne e d fo r Te a m s

Mortality from in-hos pital cardiac arres t remains high. The average s urvival rate is
approximately 21% des pite s ignificant advances in treatments . Survival rates are particularly poor for arres t as s ociated with rhythms other than VF/VT. Non-VF/VT rhythms are
pres ent in >75% of arres ts in the hos pital.
Many in-hos pital arres ts are preceded by eas ily recognizable phys iologic changes , many
of which are evident with routine monitoring of vital s igns . In recent s tudies nearly 80% of
hos pitalized patients with cardiores piratory arres t had abnormal vital s igns documented
for up to 8 hours before the actual arres t. This finding s ugges ts that there is a period of
increas ing ins tability before the arres t.
Of the s mall percentage of in-hos pital cardiac arres t patients who experience ROSC and
are admitted to the ICU, 80% ultimately die before dis charge. In comparis on, only 44% of
nonarres t patients admitted to intens ive care urgently from the floor (ie, before an arres t
occurs ) die before dis charge.

30

Sys te m s of Ca re

Ca r d ia c Ar r e s t
Te a m s (In -Ho s p it a l)

Cardiac arres t teams are unlikely to prevent arres ts becaus e their focus has traditionally
been to res pond only after the arres t has occurred. Unfortunately, the mortality rate is
about 80% once the arres t occurs .
Over the pas t few years , hos pitals have s hifted the focus away from cardiac arres t teams
to patient s afety and prevention of arres t. The bes t way to improve a patients chance of
s urvival from a cardiores piratory arres t is to prevent it from happening.
The majority of cardiores piratory arres ts in the hos pital s hould be clas s ified as a failure to
res cue rather than as an is olated, unexpected, random occurrence. Doing s o requires a
s ignificant cultural s hift within ins titutions . Actions and interventions need to be proactive
with the goal of improving rates of morbidity and mortality rather than reacting to a catas trophic event.
Rapid as s es s ment and intervention for many abnormal phys iologic variables can decreas e
the number of arres ts occurring in the hos pital.

Ra p id Re s p o n s e
S ys t e m

Over the pas t decade, hos pitals in s everal countries have des igned s ys tems to identify
and treat early clinical deterioration in patients . The purpos e of thes e rapid res pons e
s ys tems is to improve patient outcomes by bringing critical care expertis e to patients .
The rapid res pons e s ys tem has s everal components :
Event detection and res pons e triggering arm
A planned res pons e arm, s uch as the RRT
Quality monitoring
Adminis trative s upport
Many rapid res pons e s ys tems allow activation by a nurs e, phys ician, or family member
who is concerned that the patient is deteriorating. Some rapid res pons e s ys tems us e
s pecific phys iologic criteria to determine when to call the team. The following lis t gives
examples of s uch criteria for adult patients :
Threatened airway
Res piratory rate <6 or >30 breaths per minute
Heart rate <40/min or >140/min
Sys tolic blood pres s ure (SBP) <90 mm Hg
Symptomatic hypertens ion
Unexpected decreas e in level of cons cious nes s
Unexplained agitation
Seizure
Significant fall in urine output
Subjective concern about the patient

Me d ic a l Em e r g e n c y
Te a m s a n d Ra p id
Re s p o n s e Te a m s

There are s everal names for rapid res pons e s ys tems , including medical emergency team,
rapid response team, and rapid assessment team.
The rapid res pons e s ys tem is critically dependent on early identification and activation to
immediately s ummon the team to the patients beds ide. Thes e teams typically cons is t of
healthcare providers with both the critical care or emergency care experience and s kills to
s upport immediate intervention for life-threatening s ituations . Thes e teams are res pons ible
for performing a rapid patient as s es s ment and initiating appropriate treatment to revers e
phys iologic deterioration and prevent a poor outcome.

31

P a r t

Re g io n a l S ys t e m s
o f Em e r g e n c y
Ca r d io va s c u la r Ca r e

Hos pitals with larger patient volumes have a better s urvival-tohos pital dis charge rate than
low-volume centers for patients treated for either in- or out-of-hos pital cardiac arres t.

P u b lis h e d S t u d ie s

The majority of publis hed before and after s tudies of METs or rapid res pons e s ys tems
have reported a 17% to 65% drop in the rate of cardiac arres ts after the intervention.
Other documented benefits of thes e s ys tems include
A decreas e in unplanned emergency trans fers to the ICU
Decreas ed ICU and total hos pital length of s tay
Reductions in pos toperative morbidity and mortality rates
Improved rates of s urvival from cardiac arres t
The recently publis hed MERIT trial is the only randomized controlled trial comparing
hos pitals with a MET and thos e without one. The s tudy did not s how a difference in the
compos ite primary outcome (cardiac arres t, unexpected death, unplanned ICU admis s ion) between the 12 hos pitals in which a MET s ys tem was introduced and 11 hos pitals
that had no MET s ys tem in place. Further res earch is needed about the critical details of
implementation and the potential effectivenes s of METs in preventing cardiac arres t or
improving other important patient outcomes .

Im p le m e n t a t io n o f
a Ra p id Re s p o n s e
S ys t e m

Implementing any type of rapid res pons e s ys tem will require a s ignificant cultural change
in mos t hos pitals . Thos e who des ign and manage the s ys tem mus t pay particular attention to is s ues that may prevent the s ys tem from being us ed effectively. Examples of s uch
is s ues are ins ufficient res ources , poor education, fear of calling the team, fear of los ing
control over patient care, and res is tance from team members .
Implementation of a rapid res pons e s ys tem requires ongoing education, impeccable data
collection and review, and feedback. Development and maintenance of thes e programs
requires a long-term cultural and financial commitment from the hos pital adminis tration,
which mus t unders tand that the potential benefits from the s ys tem (decreas ed res ource
us e and improved s urvival rates ) may have independent pos itive financial ramifications .
Hos pital adminis trators and healthcare profes s ionals need to reorient their approach to
emergency medical events and develop a culture of patient s afety with a primary goal of
decreas ing morbidity and mortality.

32

Part

The ACLS Ca s e s
Ove r vie w o f t h e Ca s e s
The ACLS s imulated cas es are des igned to review the knowledge and s kills you need to
s ucces s fully participate in cours e events and pas s the Megacode s kills tes t. Each cas e
contains the following topics :
Introduction
Learning objectives
Rhythms and drugs
Des criptions or definitions of key concepts
Overview of algorithm
Algorithm figure
Application of the algorithm to the cas e
Other related topics
This part contains the following cas es :

Ca s e

Page

Res piratory Arres t

34

VF Treated With CPR and AED

49

VF/Puls eles s VT

59

Puls eles s Electrical Activity

78

As ys tole

86

Acute Coronary Syndromes

91

Bradycardia

104

Uns table Tachycardia

114

Stable Tachycardia

124

Acute Stroke

130

33

P a r t

Re s p ir a t o r y Ar re s t Ca s e
In t r o d u c t io n

This cas e reviews appropriate as s es s ment, intervention, and management options for an
unconscious, unresponsive adult patient in respiratory arrest. Respirations are completely
absent or clearly inadequate to maintain effective oxygenation and ventilation. A pulse is
present. (Do not confus e agonal gas ps with adequate res pirations .) The BLS Survey and
the ACLS Survey are us ed even though the patient is in res piratory arres t and not in cardiac arres t.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Des cribe the us e of the BLS and ACLS Surveys for a patient with res piratory arres t
with a puls e
2. Des cribe when airway adjuncts s hould be us ed to manage an airway
3. Demons trate us e of an OPA to manage an airway
4. Demons trate us e of an NPA to manage an airway
5. Demons trate us e of bag-mas k ventilation to manage an airway

Ca s e Dr u g s

This cas e involves the following drugs :


Oxygen
Sys tems or facilities us ing rapid s equence intubation may cons ider additional drugs .

Th e BLS S u r ve y
BLS S u r ve y
As s e s s m e n t

Proceed with the BLS Survey As s es s ment as des cribed on the next page.
Note th a t th e BLS Su rve y foc u s e s on e a rly CP R a n d e a rly d e fib rilla tion .
IV/IO acces s is not dis cus s ed here even though medications may provide a clinical benefit
to s ome patients . Advanced as s es s ments and interventions are part of the ACLS Survey.

As s e s s a n d
Re a s s e s s t h e
P a t ie n t

The s ys tematic approach of the BLS Survey is assessment, then action, for each s tep in
the s equence.
Re m e m b e r: As s e s s th e n p e rform a p p rop ria te a c tion .
In this cas e you as s es s and find that the patient has a puls e, s o you do not us e the AED
or begin ches t compres s ions . During the cours e your ins tructor will emphas ize the need
to reas s es s the patient and be ready to do CPR, attach the AED, and s hock the patient if
indicated.

Ve n t ila t io n a n d
P u ls e Ch e c k

34

In the cas e of a patient in res piratory arres t with a puls e, give 1 breath every 5 to 6
s econds (10 to 12 breaths per minute) with a bag-mas k or any advanced airway device.
Recheck the puls e about every 2 minutes . Take at leas t 5 s econds but no more than 10
s econds for a puls e check.

Th e ACLS Ca s e s : Re s p ira tory Arre s t

As s e s s
1

Che c k
re s p o ns ive ne s s

As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )

Checkres pons ivenes s .

Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED

Activatetheemergencyres pons es ys temandgetanAED


ifoneis availableors ends omeonetoactivatetheemergencyres pons es ys temandgetanAEDordefibrillator

Activatetheemergencyres pons es ys tem.

Circ ula tio n

Che c k the c a ro tid p uls e for5to10s econds


Ifnopuls ewithin10s econds ,s tartCPR(30:2)beginning
withches tcompres s ions
Compres s thecenteroftheches t(lowerhalfofthe
s ternum)hardandfas twithatleas t100compres s ions
perminuteatadepthofatleas t2inches
Allowcompleteches trecoilaftereachcompres s ion
Minimizeinterruptions incompres s ions
(10s econds orles s )
Switchproviders aboutevery2minutes toavoidfatigue
Avoidexces s iveventilation
Ifthereis apuls e,s tartres cuebreathingat1breathevery
5to6s econds (10to12breaths perminute).Checkpuls e
aboutevery2minutes

De fib rilla tio n

Checkthecarotidpuls e.

Ifnopuls e,checkforas hockablerhythmwithanAED/


defibrillatoras s oonas itarrives
Provides hocks as indicated
Followeachs hockimmediatelywithCPR,beginningwith
compres s ions

Defibrillation.

35

P a r t

Ve n t ila t io n Ra t e s
Air w a y De vic e

Ve n t ila t io n s Du r in g
Ca rd ia c Ar re s t

Ba g -m a s k

2 ventilations after every


30 compres s ions

Any a d va nc e d a irwa y

1 ve ntila tio n e ve ry 6 to 8
s e c o nd s
(8 to 10 breaths per
minute)

Ve n t ila t io n s Du r in g
Re s p ir a t o r y Ar re s t
1 ve ntila tio n e ve ry 5 to 6
s e c o nd s
(10 to 12 breaths per
minute)

Th e ACLS S u r ve y
Air w a y Ma n a g e m e n t
in Re s p ir a t o r y Ar r e s t

If bag-mas k ventilation is adequate, providers may defer ins ertion of an advanced airway.
Healthcare providers s hould make the decis ion to place an advanced airway during the
ACLS Survey.
Advanced airway equipment includes the laryngeal mas k airway, the laryngeal tube, the
es ophageal-tracheal tube, and the ET tube. If it is within your s cope of practice, you may
us e advanced airway equipment in the cours e when appropriate and available.
The following is a s ummary of the ACLS Survey:

As s e s s
Airwa y
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of
airway device confirmed?
Is tube secured and
placement reconfirmed
frequently?

Ac t io n a s Ap p ro p r ia t e
Ma inta in a irwa y p a te nc y in unc o ns c io us p a tie nts
by us e of head tiltchin lift, OPA, or NPA
Us e a d va nc e d a irwa y m a na g e m e nt if ne e d e d
(eg, laryngeal mas k airway, laryngeal tube,
es ophageal-tracheal tube, ET tube)
The benefit of advanced airway placement is weighed
against the adverse effects of interrupting chest
compressions. If bag-mask ventilation is adequate,
healthcare providers may defer insertion of an
advanced airway until the patient fails to respond
to initial CPR and defibrillation or until spontaneous
circulation returns. An advanced airway such as a
laryngeal mask airway, laryngeal tube, or esophagealtracheal tube can be placed while chest compressions continue.
If using advanced airway devices:
Co nfirm p ro p e r inte g ra tio n o f CP R a nd
ve ntila tio n
Co nfirm p ro p e r p la c e m e nt o f a d va nc e d a irwa y
d e vic e s by
Phys ical examination
Quantitative waveform capnography
Clas s I recommendation for ET tube
Reas onable for s upraglottic airways
Se c ure the d e vic e to p re ve nt d is lo d g m e nt
Mo nito r a irwa y p la c e m e nt with c o ntinuo us
q ua ntita tive wa ve fo rm c a p no g ra p hy
(continued)

36

Th e ACLS Ca s e s : Re s p ira tory Arre s t

(continued)

As s e s s
Bre a thing
Are ventilation and oxygenation adequate?
Are quantitative waveform
capnography and oxyhemoglobin saturation monitored?

Circ ula tio n


What is the cardiac rhythm?
Is the patient with a pulse
unstable?
Is defibrillation or cardioversion indicated?
Are chest compressions
effective?
Is ROSC present?
Has IV/IO access been
established?
Are medications needed for
rhythm or blood pressure?
Does the patient need volume (fluid) for resuscitation?
Diffe re ntia l d ia g no s is
Why did this patient develop
symptoms or arrest?
Is there a reversible cause
that can be treated?

Ac t io n a s Ap p ro p r ia t e
Give s up p le m e nta ry o xyg e n whe n ind ic a te d
For cardiac arres t patients , adminis ter 100%
oxygen
For others , titrate oxygen adminis tration to
achieve oxygen s aturation values of 94% by
puls e oximetry
Mo nito r the a d e q ua c y o f ve ntila tio n a nd o xyg e na tio n b y
Clinical criteria (ches t ris e and cyanos is )
Quantitative waveform capnography
Oxygen s aturation
Avo id e xc e s s ive ve ntila tio n
Mo nito r CP R q ua lity
Quantitative waveform capnography (if P e t c o 2
is <10 mm Hg, attempt to improve CPR quality)
Intra-arterial pres s ure (if relaxation phas e
[dias tolic] pres s ure is <20 mm Hg, attempt to
improve CPR quality)
Atta c h m o nito r/d e fib rilla to r fo r a rrhythm ia s
o r c a rd ia c a rre s t rhythm s (eg, VF, puls eles s VT,
as ys tole, PEA)
De fib rilla tio n/c a rd io ve rs io n
Ob ta in IV/IO a c c e s s
Give a p p ro p ria te d rug s to m a na g e rhythm a nd
b lo o d p re s s ure
Give IV/IO fluid s if ne e d e d

Se a rc h fo r, find , a nd tre a t re ve rs ib le c a us e s
(ie, definitive care)

P e t c o 2 is the partial pres s ure of end-tidal CO 2 , a meas ure of the amount of carbon
dioxide pres ent in the exhaled air.

Ve n t ila t io n s

FYI 2 0 1 0 Gu id e lin e s
Co rre c t P la c e m e nt o f
End o tra c he a l Tub e

In this cas e the patient is in res piratory arres t but continues to have a puls e. You s hould
ventilate the patient o nc e e ve ry 5 to 6 s e c o nd s (10 to 12 times per minute). Each breath
s hould take 1 s econd and achieve vis ible ches t ris e. Be careful to avoid exces s ive ventilation (too many breaths per minute or too large a volume per breath).

The AHA recommends continuous waveform capnography in addition to clinical


as s es s ment as the mos t reliable method of confirming and monitoring correct placement of an ET tube.

37

P a r t

Ma n a g e m e n t o f Re s p ir a t o r y Ar re s t
Ove r vie w

Management of res piratory arres t includes both BLS and ACLS interventions . Thes e
interventions may include
Giving s upplementary oxygen
Opening the airway
Providing bas ic ventilation
Us ing bas ic airway adjuncts (OPA and NPA)
Suctioning
Ac c ord in g to th e 2010 AHA Guid e line s fo r CP R a nd ECC, for p a tie n ts with a p e rfu s in g rh yth m , d e live r 1 b re a th e ve ry 5 to 6 s e c o nd s (10 to 12 b re a th s p e r m in u te ).

Cr it ic a l Co n c e p t s
Avo id ing Exc e s s ive
Ve ntila tio n

When us ing any form of as s is ted ventilation, you mus t avoid delivering exces s ive ventilation (too many breaths per minute or too large a volume per breath).
Exces s ive ventilation can be harmful becaus e it increas es intrathoracic pres s ure,
decreas es venous return to the heart, and diminis hes cardiac output. It may als o
caus e gas tric inflation and predis pos e the patient to vomiting and as piration of gas tric contents .

Givin g S u p p le m e n t a r y Oxyg e n
Ma in t a in Oxyg e n
S a t u r a t io n

Give oxygen to patients with acute cardiac s ymptoms or res piratory dis tres s . Monitor
oxygen s aturation and titrate s upplementary oxygen to maintain a s aturation of 94% .
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for details on us e of
oxygen in patients not in res piratory or cardiac arres t.

Op e n in g t h e Air w a y
Co m m o n Ca u s e o f
Air w a y Ob s t r u c t io n

38

Figure 8 demons trates the anatomy of the airway. The mos t common caus e of upper
airway obs truction in the uncons cious /unres pons ive patient is los s of tone in the throat
mus cles . In this cas e the tongue falls back and occludes the airway at the level of the
pharynx (Figure 9A).

Th e ACLS Ca s e s : Re s p ira tory Arre s t

Nas al
Cavity
Nas op harynx

Oral
Cavity
Tongue
Vallecula

Orop harynx

Epiglottis
Vocal Fold
(Cords )
Laryngopharynx

Thyroid
Cartilage
Cricoid
Cartilage
Trachea
Es ophagus

Fig u re 8 . Airway anatomy.

Fig u re 9 . Obs truction of the airway by the tongue and epiglottis . When a patient is unres pons ive, the tongue can obs truct the airway. The head
tiltchin lift relieves obs truction in the unres pons ive patient. A, The tongue is obs tructing the airway. B, The head tiltchin lift lifts the tongue, relieving the obs truction. C, If cervical s pine trauma is s us pected, healthcare providers s hould us e the jaw thrus t without head extens ion.

39

P a r t

Ba s ic Air w a y
Op e n in g Te c h n iq u e s

Bas ic airway opening techniques will effectively relieve airway obs truction caus ed either
by the tongue or from relaxation of mus cles in the upper airway. The bas ic airway opening technique is head tilt with anterior dis placement of the mandible, ie, head tiltchin lift
(Figure 9B).
In the trauma patient with s us pected neck injury, us e a jaw thrus t without head extens ion
(Figure 9C). Becaus e maintaining an open airway and providing ventilation is a priority, us e
a head tiltchin lift maneuver if the jaw thrus t does not open the airway. ACLS providers
s hould be aware that current BLS training cours es teach the jaw thrus t technique to
healthcare providers but not to lay res cuers .

Air w a y Ma n a g e m e n t

Proper airway pos itioning may be all that is required for patients who can breathe s pontaneous ly. In patients who are uncons cious with no cough or gag reflex, ins ert an OPA or
NPA to maintain airway patency.
If you find an uncons cious /unres pons ive patient who was known to be choking and is
now unres pons ive and in res piratory arres t, open the mouth wide and look for a foreign
object. If you s ee one, remove it with your fingers . If you do not s ee a foreign object,
begin CPR. Each time you open the airway to give breaths , open the mouth wide and look
for a foreign object. Remove it with your fingers if pres ent. If there is no foreign object,
res ume CPR.

P ro vid in g Ba s ic Ve n t ila t io n
Ba s ic Air w a y S k ills

Bas ic airway s kills us ed to ventilate a patient are


Head tiltchin lift
J aw thrus t without head extens ion (s us pected cervical s pine trauma)
Mouth-to-mouth ventilation
Mouth-to-nos e ventilation
Mouth-tobarrier device (us ing a pocket mas k) ventilation (Figure 10)
Bag-mas k ventilation (Figures 11 and 12)

Fig u re 1 0 . Mouth-to-mas k ventilation, 1 res cuer. The res cuer performs 1-res cuer CPR from a pos ition
at the patients s ide. Perform a head tiltchin lift to open the airway while holding the mas k tightly agains t
the face.

40

Th e ACLS Ca s e s : Re s p ira tory Arre s t

Fig u re 1 1 . E-C clamp technique for holding the mas k while lifting the jaw. Pos ition yours elf at the
patients head. Circle the thumb and firs t finger around the top of the mas k (forming a C) while us ing the
third, fourth, and fifth fingers (forming an E) to lift the jaw.

Fig u re 1 2 . Two-res cuer us e of the bag-mas k. The res cuer at the patients head tilts the patients head
and s eals the mas k agains t the patients face with the thumb and firs t finger of each hand creating a C to
provide a complete s eal around the edges of the mas k. The res cuer us es the remaining 3 fingers (the E)
to lift the jaw (this holds the airway open). The s econd res cuer s lowly s queezes the bag (over 1 s econd)
until the ches t ris es . Both providers s hould obs erve ches t ris e.

41

P a r t

Ba g -Ma s k
Ve n t ila t io n

5
A bag-mas k ventilation device cons is ts of a ventilation bag attached to a face mas k.
Thes e devices have been a mains tay of emergency ventilation for decades . Bag-mas k
devices are the mos t common method of providing pos itive-pres s ure ventilation. When
us ing a bag-mas k device, deliver approximately 600 mL tidal volume s ufficient to produce
ches t ris e over 1 s econd.
The univers al connections pres ent on all airway devices allow you to connect any ventilation bag to numerous adjuncts . Valves and ports may include
One-way valves to prevent the patient from rebreathing exhaled air
Oxygen ports for adminis tering s upplementary oxygen
Medication ports for adminis tering aeros olized and other medications
Suction ports for clearing the airway
Ports for quantitative s ampling of end-tidal CO 2
You can attach other adjuncts to the patient end of the valve, including a pocket face
mas k, laryngeal mas k airway, laryngeal tube, es ophageal-tracheal tube, and ET tube.
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for more information on
bag-mas k ventilation.

Ba s ic Air w a y Ad ju n c t s : Oro p h a r yn g e a l Air w a y


In t r o d u c t io n

The OPA is us ed in patients who are at ris k for developing airway obs truction from the
tongue or from relaxed upper airway mus cles . This J -s haped device (Figure 13A) fits over
the tongue to hold it and the s oft hypopharyngeal s tructures away from the pos terior wall
of the pharynx.
The OPA is us ed in unconscious patients if procedures to open the airway (eg, head tilt
chin lift or jaw thrus t) fail to provide and maintain a clear, unobs tructed airway. An OPA
should not be used in a conscious or semiconscious patient becaus e it may s timulate
gagging and vomiting. The key as s es s ment is to check whether the patient has an intact
cough and gag reflex. If s o, do not us e an OPA.
The OPA may be us ed to keep the airway open during bag-mas k ventilation when providers might unknowingly pus h down on the chin, blocking the airway. The OPA is als o us ed
during s uctioning of the mouth and throat and in intubated patients to prevent them from
biting and occluding the ET tube.

Fig u re 1 3 . Oropharyngeal airways . A, Oropharyngeal airway devices . B, Oropharyngeal airway device ins erted.

42

Th e ACLS Ca s e s : Re s p ira tory Arre s t

Te c h n iq u e o f OPA
In s e r t io n

Ste p

Ac t io n

Cle a r the m o uth a nd p ha rynx of s ecretions , blood, or vomit us ing a


rigid pharyngeal s uction tip if pos s ible.

Se le c t the p ro p e r s ize OPA. Place the OPA agains t the s ide of the
face. When the tip of the OPA is at the corner of the mouth, the flange is
at the angle of the mandible. A properly s ized and ins erted OPA res ults
in proper alignment with the glottic opening.

Ins e rt the OPA s o that it curves upward toward the hard palate as it
enters the mouth.

As the OPA pas s es through the oral cavity and approaches the pos terior
wall of the pharynx, ro ta te it 180 into the proper pos ition (Figure 13B).
The OPA can als o be ins erted at a 90 angle to the mouth and then
turned down toward the pos terior pharynx as it is advanced. In both
methods , the goal is to curve the device around the tongue s o that the
tongue is not inadvertently pus hed back into the pharynx rather than
being pulled forward by the OPA.
An a lte rna tive m e tho d is to ins ert the OPA s traight in while us ing a
tongue depres s or or s imilar device to hold the tongue forward as the
OPA is advanced.

After ins ertion of an OPA, monitor the patient. Keep the head and jaw pos itioned properly
to maintain a patent airway. Suction the airway as needed.

Ca u t io n
Be Awa re o f the
Fo llo wing Whe n Us ing
a n OPA

OPAs that are too large may obs truct the larynx or caus e trauma to the laryngeal
s tructures .
OPAs that are too small or ins erted improperly may pus h the bas e of the tongue
pos teriorly and obs truct the airway.
Ins ert the OPA carefully to avoid s oft tis s ue trauma to the lips and tongue.
Remember to us e the OPA only in the unres pons ive patient with no cough or gag
reflex. If the patient has a cough or gag reflex, the OPA may s timulate vomiting and
laryngos pas m.

Ba s ic Air w a y Ad ju n c t s : Na s o p h a r yn g e a l Air w a y
In t r o d u c t io n

The NPA is us ed as an alternative to an OPA in patients who need a bas ic airway management adjunct. The NPA is a s oft rubber or plas tic uncuffed tube (Figure 14A) that provides
a conduit for airflow between the nares and the pharynx.
Unlike oral airways , NPAs may be used in conscious or semiconscious patients (patients
with an intact cough and gag reflex). The NPA is indicated when ins ertion of an OPA is
technically difficult or dangerous . Examples include patients with a gag reflex, tris mus ,
mas s ive trauma around the mouth, or wiring of the jaws . The NPA may als o be us ed in
patients who are neurologically impaired with poor pharyngeal tone or coordination leading to upper airway obs truction.

43

P a r t

Fig u re 1 4 . Nas opharyngeal airways . A, Nas opharyngeal airway devices . B, Nas opharyngeal airway device ins erted.

Te c h n iq u e o f NPA
In s e r t io n

Ste p
1

Ac t io n
Se le c t the p ro p e r s ize NPA.
Compare the outer circumference of the NPA with the inner aperture
of the nares . The NPA s hould not be s o large that it caus es s us tained blanching of the nos trils . Some providers us e the diameter of
the patients s malles t finger as a guide to s electing the proper s ize.
The length of the NPA s hould be the s ame as the dis tance from the
tip of the patients nos e to the earlobe.

Lub ric a te the a irwa y with a wa te r-s o lub le lub ric a nt o r a ne s the tic
je lly.

Ins e rt the a irwa y through the nos tril in a pos terior direction perpendicular to the plane of the face. Pas s it gently along the floor of the nas opharynx (Figure 14B).
If you encounter res is tance:
Slightly rotate the tube to facilitate ins ertion at the angle of the nas al
pas s age and nas opharynx.
Attempt placement through the other nos tril becaus e patients have
different-s ized nas al pas s ages .

Reevaluate frequently. Maintain head tilt by providing anterior dis placement of the mandible us ing a chin lift or jaw thrus t. Mucus , blood, vomit, or the s oft tis s ues of the pharynx
can obs truct the NPA, which has a s mall internal diameter. Frequent evaluation and suctioning of the airway may be necessary to ensure patency.

44

Th e ACLS Ca s e s : Re s p ira tory Arre s t

Ca u t io n
Be Awa re o f the
Fo llo wing Whe n
Us ing a n NPA

Takecaretoins erttheairwaygentlytoavoidcomplications .Theairwaycanirritate


themucos aorlacerateadenoidaltis s ueandcaus ebleeding,withpos s ibleas pirationofclots intothetrachea.Suctionmaybeneces s arytoremovebloodors ecretions .
Animproperlys izedNPAmayenterthees ophagus .Withactiveventilation,s uchas
bag-mas kventilation,theNPAmaycaus egas tricinflationandpos s iblehypoventilation.
AnNPAmaycaus elaryngos pas mandvomiting,eventhoughitis commonlytoleratedbys emicons cious patients .
Us ecautioninpatients withfacialtraumabecaus eoftheris kofmis placementinto
thecranialcavitythroughafracturedcribriformplate.

Fo u n d a t io n a l Fa c t s

Takethefollowingprecautions whenus inganOPAorNPA:

P re c a utio ns fo r OPAs
a nd NPAs

Always checks pontaneous res pirations immediatelyafterins ertionofeitheranOPA


oranNPA.
Ifres pirations areabs entorinadequate,s tartpos itive-pres s ureventilations atonce
withanappropriatedevice.
Ifadjuncts areunavailable,us emouth-to-mas kbarrierdeviceventilation.

S u c t io n in g
In t r o d u c t io n

Suctioningis anes s entialcomponentofmaintainingapatients airway.Providers


s houlds uctiontheairwayimmediatelyiftherearecopious s ecretions ,blood,or
vomit.
Suctiondevices cons is tofbothportableandwall-mountedunits .
Portables uctiondevices areeas ytotrans portbutmaynotprovideadequates uction
power.As uctionforceof80to120mmHgis generallyneces s ary.
Wall-mounteds uctionunits s houldbecapableofprovidinganairflowof>40L/minat
theendofthedeliverytubeandavacuumofmorethan300mmHgwhenthetube
is clampedatfulls uction.
Adjus ttheamountofs uctionforceforus einchildrenandintubatedpatients .

S o ft vs Rig id
Ca t h e t e r s

Boths oftflexibleandrigids uctioningcatheters areavailable.


Soft flexible catheters maybeus edinthemouthornos e.Softflexiblecatheters areavailableins terilewrappers andcanals obeus edforETtubedeeps uctioning.
Rigid catheters (eg,Yankauer)areus edtos uctiontheoropharynx.Thes earebetterfor
s uctioningthicks ecretions andparticulatematter.

Ca t h e t e r
Typ e

Us e fo r

So ft

As pirationofthins ecretions fromtheoropharynxandnas opharynx


Performingintratracheals uctioning
Suctioningthroughanin-placeairway(ie,NPA)toacces s thebackof
thepharynxinapatientwithclenchedteeth

Rig id

Moreeffectives uctioningoftheoropharynx,particularlyifthereis
thickparticulatematter

45

P a r t

Or o p h a r yn g e a l
S u c t io n in g
P roc e d u re

En d o t r a c h e a l
Tu b e S u c t io n in g
P roc e d u re

Follow the s teps below to perform oropharyngeal s uctioning.

Ste p

Ac t io n

Meas ure the catheter before s uctioning and do not ins ert it any further
than the dis tance from the tip of the nos e to the earlobe.
Gently ins ert the s uction catheter or device into the oropharynx
beyond the tongue.

Apply s uction by occluding the s ide opening of the catheter while


withdrawing with a rotating or twis ting motion.
If us ing a rigid s uction device (eg, Yankauer s uction) place the tip gently into the oral cavity. Advance by pus hing the tongue down to reach
the oropharynx if neces s ary.

Patients with pulmonary s ecretions may require s uctioning even after endotracheal intubation. Follow the s teps below to perform ET tube s uctioning:

Ste p

Ac t io n

Us e s terile technique to reduce the likelihood of airway contamination.

Gently ins ert the catheter into the ET tube. Be s ure the s ide opening is
not occluded during ins ertion.
Ins ertion of the catheter beyond the tip of the ET tube is not recommended becaus e it may injure the endotracheal mucos a or s timulate
coughing or bronchos pas m.

Apply s uction by occluding the s ide opening only while withdrawing


the catheter with a rotating or twis ting motion.
Su c tion a tte m p ts s h ou ld n ot e xc e e d 10 s e c on d s . To avoid hypoxemia, precede and follow s uctioning attempts with a s hort period of
adminis tration of 100% oxygen.

Mon itor th e p a tie n ts h e a rt ra te , p u ls e , oxyg e n s a tu ra tion , a n d c lin ic a l a p p e a ra n c e d u rin g s u c tion in g . If b ra d yc a rd ia d e ve lop s , oxyg e n s a tu ra tion d rop s , or c lin ic a l a p p e a ra n c e d e te riora te s , in te rru p t s u c tion in g a t on c e . Ad m in is te r h ig h -flow
oxyg e n u n til th e h e a rt ra te re tu rn s to n orm a l a n d th e c lin ic a l c on d ition im p rove s .
As s is t ve n tila tion a s n e e d e d .

46

Th e ACLS Ca s e s : Re s p ira tory Arre s t

P ro vid in g Ve n t ila t io n Wit h a n Ad va n c e d Air w a y


In t r o d u c t io n

Selection of an advanced airway device depends on the training, s cope of practice, and
equipment of the providers on the res us citation team. Advanced airways include
Laryngeal mas k airway
Laryngeal tube
Es ophageal-tracheal tube
Endotracheal tube
Becaus e a s mall proportion of patients cannot be ventilated with a laryngeal mas k airway,
providers who us e this device s hould have an alternative airway management s trategy. A
bag-mas k can be this alternate s trategy.
This cours e will familiarize you with types of advanced airways . Ins truction in the s killed
placement of thes e airways is beyond the s cope of the bas ic ACLS Provider Cours e. To
be proficient in the us e of advanced airway devices , you mus t have adequate initial training and ongoing experience. Providers who ins ert advanced airways mus t participate in a
proces s of continuous quality improvement to document and minimize complications .
In this cours e you will practice ventilating with an advanced airway in place and integrating ventilation with ches t compres s ions .

Ve n t ila t io n Ra t e s

Ve n t ila t io n s Du r in g
Ca rd ia c Ar re s t

Ve n t ila t io n s Du r in g
Re s p ir a t o r y Ar re s t

Ba g -m a s k

2 ventilations after every


30 compres s ions

Any a d va nc e d a irwa y

1 ve ntila tio n e ve ry 6 to 8
s e c o nd s
(8 to 10 breaths per
minute)

1 ve ntila tio n e ve ry 5 to 6
s e c o nd s
(10 to 12 breaths per
minute)

Air w a y De vic e

La r yn g e a l Ma s k
Air w a y

The laryngeal mas k airway is an advanced airway alternative to endotracheal intubation


and provides comparable ventilation. It is acceptable to us e the laryngeal mas k airway as
an alternative to an ET tube for airway management in cardiac arres t. Only experienced
providers s hould perform laryngeal mas k airway ins ertion.
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for more information on
the laryngeal mas k airway.

La r yn g e a l Tu b e

The advantages of the laryngeal tube are s imilar to thos e of the es ophageal-tracheal tube;
however, the laryngeal tube is more compact and les s complicated to ins ert.
Healthcare profes s ionals trained in the us e of the laryngeal tube may cons ider it as an
alternative to bag-mas k ventilation or endotracheal intubation for airway management in
cardiac arres t. Only experienced providers s hould perform laryngeal tube ins ertion.
See the Laryngeal Intubation s ection on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) for more information on this procedure.

47

P a r t

Es o p h a g e a lTr a c h e a l Tu b e

The es ophageal-tracheal tube is an advanced airway alternative to endotracheal intubation. This device provides adequate ventilation comparable to an ET tube. It is acceptable
to us e the es ophageal-tracheal tube as an alternative to an ET tube for airway management in cardiac arres t. Fatal complications may occur with us e of this device. Only providers experienced with its us e s hould perform es ophageal-tracheal tube ins ertion.
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for more information on
the es ophageal-tracheal tube.

En d o t r a c h e a l Tu b e

A brief s ummary of the bas ic s teps for performing endotracheal intubation is given here to
familiarize the ACLS provider who may as s is t with the procedure.
Prepare for intubation by as s embling the neces s ary equipment.
Perform endotracheal intubation (s ee the Student Webs ite).
Inflate cuff or cuffs on the tube.
Attach the ventilation bag.
Confirm correct placement by phys ical examination and a confirmation device.
Continuous waveform capnography is recommended (in addition to clinical as s es s ment) as the mos t reliable method of confirming and monitoring correct placement
of an ET tube. Healthcare providers may us e colorimetric and nonwaveform carbon
dioxide detectors when waveform capnography is not available.
Secure the tube in place.
Monitor for dis placement.
Only experienced providers s hould perform endotracheal intubation.
See the Endotracheal Intubation s ection on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) for more information on this procedure.

Ca u t io n
Us e o f Cric o id P re s s ure

FYI 2 0 1 0 Gu id e lin e s
Cric o id P re s s ure

Fo u n d a t io n a l Fa c t s
Re s c ue Bre a ths fo r
CP R With a n Ad va nc e d
Airwa y in P la c e

Cricoid pres s ure in nonarres t patients may offer s ome meas ure of protection to the
airway from as piration and gas tric ins ufflation during bag-mas k ventilation. However,
it als o may impede ventilation and interfere with placement of a s upraglottic airway
or intubation.

The role of cricoid pres s ure during out-of-hos pital and in-hos pital cardiac arres t has
not been s tudied. If cricoid pres s ure is us ed in a few s pecial circums tances during
cardiac arres t, the pres s ure s hould be adjus ted, relaxed, or releas ed if it impedes
ventilation or advanced airway placement. The routine us e of cricoid pres s ure in
cardiac arres t is not recommended.

During CPR the compres s ion-to-ventilation ratio is 30:2. But once an advanced airway is in place (ie, laryngeal mas k airway, laryngeal tube, es ophageal-tracheal tube,
or ET tube), ches t compres s ions are no longer interrupted for ventilations .
When ventilating through a properly placed advanced airway, give 1 breath every 6
to 8 s econds (approximately 8 to 10 breaths per minute) without trying to s ynchronize breaths to compres s ions . Ideally deliver the breath during ches t recoil between
compres s ions . Continuous ly reevaluate compres s ions and ventilations . Be prepared
to make modifications if either is ineffective.
In this cas e the patient has a puls e, and compres s ions are not indicated. Give 1 breath
every 5 to 6 s econds (10 to 12 breaths per minute).

48

Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED

P re c a u t io n s fo r Tr a u m a P a t ie n t s
Su m m a r y

When providing as s is ted ventilation for patients with known or s us pected cervical s pine
trauma, avoid unneces s ary s pine movement. Exces s ive head and neck movement in
patients with an uns table cervical s pinal column can caus e irrevers ible injury to the s pinal
cord or wors en a minor s pinal cord injury. Approximately 2% of patients with blunt trauma
s erious enough to require s pinal imaging in the ED have a s pinal injury. This ris k is tripled
if the patient has a head or facial injury. As s ume that any patient with multiple trauma,
head injury, or facial trauma has a s pine injury. Be particularly cautious if a patient has
s us pected cervical s pine injury. Examples are patients who have been involved in a highs peed motor vehicle collis ion, have fallen from a height, or were injured while diving.
Follow thes e precautions if you s us pect cervical s pine trauma:
Open the airway by us ing a jaw thrus t without head extension. Becaus e maintaining a
patent airway and providing adequate ventilation are priorities , us e a head tiltchin lift
maneuver if the jaw thrus t is not effective.
Have another team member s tabilize the head in a neutral pos ition during airway
manipulation. Us e m a n u a l s p in a l m otion re s tric tion ra th e r th a n im m ob iliza tion
d e vic e s . Manual s pinal immobilization is s afer. Cervical collars may complicate airway
management and may even interfere with airway patency.
Spinal immobilization devices are helpful during trans port.

VF Tre a t e d Wit h CP R a n d AED Ca s e


In t r o d u c t io n

This cas e will provide the knowledge you need to pas s the CPR and AED Tes ting Station.
This cas e dis cus s es how to res pond as a lone res cuer to an out-of-hos pital emergency,
equipped with only CPR s kills and an AED. The cas e s cenario pres ents a patient who
collapses from either VF or pulseless VT. The only equipment available is an AED s tocked
with a pocket face mas k. Becaus e other providers are not pres ent, you mus t care for the
patient without help.
ACLS interventions , including advanced airway control and IV medications , are not
options in this s cenario.
Note that during the cours e you will be required to demons trate both your knowledge of
this cas e and competency in bas ic s kill performance.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Demons trate the s kills and s equence outlined in the BLS Healthcare Providers
Algorithm (Figures 15 and 16), including high-quality CPR and AED us e
2. Implement the BLS Healthcare Provider Algorithm by performing 1-res cuer CPR
3. Implement the BLS Healthcare Provider Algorithm by operating an AED

Rh yt h m s fo r VF
Tr e a t e d Wit h CP R
a n d AED

With an AED, there are no rhythms to learn. The AED will ans wer the ques tion Is the
rhythm s hockable, ie, VF or puls eles s VT?

Dr u g s fo r VF Tr e a t e d
Wit h CP R a n d AED

There are no new drugs to learn in this cas e. You will us e only your CPR s kills and
an AED.

49

P a r t

Th e BLS S u r ve y
In t r o d u c t io n

The BLS Survey is us ed in all cas es of cardiac arres t.


In the Res piratory Arres t Cas e you learned the bas ics of airway as s es s ment and management of a patient in res piratory arres t with a puls e. In this cas e you will as s es s and manage a patient without a puls e and us e the AED.

As s e s s m e n t
Fo u n d a t io n a l Fa c t s
Sta rting CP R Whe n Yo u
Are No t Sure Ab o ut a
P uls e

50

Perform the BLS Survey s teps on the next page.

If you are uns ure about the pres ence of a puls e, begin cycles of compres s ions and
ventilations . Unneces s ary compres s ions are les s harmful than failing to provide
compres s ions when needed. Delaying or failing to s tart CPR in a patient without a
puls e reduces the chance of s urvival.

Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED

As s e s s
1

Che c k
re s p o ns ive ne s s

As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )

Checkres pons ivenes s .

Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED

Activatetheemergencyres pons es ys temandgetanAED


ifoneis availableors ends omeonetoactivatetheemergencyres pons es ys temandgetanAEDordefibrillator

Activatetheemergencyres pons es ys tem.

Circ ula tio n

Che c k the c a ro tid p uls e for5to10s econds


Ifnopuls ewithin10s econds ,s tartCPR(30:2)beginning
withches tcompres s ions
Compres s thecenteroftheches t(lowerhalfofthe
s ternum)hardandfas twithatleas t100compres s ions
perminuteatadepthofatleas t2inches
Allowcompleteches trecoilaftereachcompres s ion
Minimizeinterruptions incompres s ions
(10s econds orles s )
Switchproviders aboutevery2minutes toavoidfatigue
Avoidexces s iveventilation
Ifthereis apuls e,s tartres cuebreathingat1breathevery
5to6s econds (10to12breaths perminute).Checkpuls e
aboutevery2minutes

De fib rilla tio n

Checkthecarotidpuls e.

Ifnopuls e,checkforas hockablerhythmwithanAED/


defibrillatoras s oonas itarrives
Provides hocks as indicated
Followeachs hockimmediatelywithCPR,beginningwith
compres s ions

Defibrillation.

51

P a r t

Ad ult BLS He a lthc a re P ro vid e rs


1

Unre s p o ns ive
No b re a thing o r no no rm a l b re a thing
(ie, only gas ping)

Hig h-Qua lity CP R


Rateatleas t100/min
C ompres s iondepthat
leas t 2 inches (5 cm)

Allowcompleteches trecoil
after each compres s ion

Ac tiva te e m e rg e nc y re s p o ns e s ys te m
Ge t AED/d e fib rilla to r
or s end s econd res cuer (if available) to do this

Minimizeinterruptions in
ches t compres s ions

Avoid exces s ive ventilation

De fin it e
P u ls e

Che c k p uls e :
DEFINITE p uls e
within 10 s e c o nd s ?

3A
G ive 1b re a the ve ry
5 to 6 s e c o nd s
R e c he c kp uls e e ve ry
2 m inute s

No P u ls e

Begin cycles of 30 COMP RESSIONS and 2 BREATHS

5
AED/d e fib rilla to r ARRIVES

Che c k rhythm
Sho c ka b le rhythm ?
S h o c k a b le
7

No t S h o c k a b le
8

Give 1 s ho c k
Re s um e CP R im m e d ia te ly
for 2 minutes

Re s um e CP R im m e d ia te ly
for 2 minutes
Check rhythm every
2 minutes ; continue until
ALS providers take over or
victim s tarts to move

Note:Theboxes borderedwithdas hedlines areperformed


by healthcare providers and not by lay res cuers

Fig u re 1 5 . The BLS Healthcare Provider Algorithm.

52

2010 American Heart As s ociation

Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED

Sim p lifie d Ad ult BLS HCP

Unre s p o ns ive
No b re a thing o r
no no rm a l b re a thing
(o nly g a s p ing )

Ac tiva te
e m e rg e nc y
re s p o ns e

Ge t
d e fib rilla to r

Che c k p uls e

Sta rt CP R

Che c k rhythm /
s ho c k if
ind ic a te d
Re p e a t e ve ry 2 m inute s

Ha

rd P u s h

a
F

2010 American Hea rt As s ociation

Fig u re 1 6 . The Simplified Adult BLS Algorithm.

53

P a r t

Pu rpos e of
De fib r illa t io n

Defibrillation does not res tart the heart. Defibrillation s tuns the heart and briefly terminates
all electrical activity, including VF and VT. If the heart is s till viable, its normal pacemakers
may eventually res ume electrical activity (return of s pontaneous rhythm) that ultimately
res ults in a perfus ing rhythm (ROSC).
In the firs t minutes after s ucces s ful defibrillation, however, any s pontaneous rhythm is
typically s low and does not create puls es or adequate perfus ion. The patient needs CPR
(beginning with ches t compres s ions ) for s everal minutes until adequate heart function
res umes . This is the rationale for res uming high-quality CPR, beginning with ches t compres s ions immediately after a s hock.

P r in c ip le o f Ea r ly
De fib r illa t io n

The interval from collaps e to defibrillation is one of the mos t important determinants of
s urvival from cardiac arres t. Early defibrillation is critical for patients with s udden cardiac
arres t for the following reas ons :
A common initial rhythm in out-of-hos pital witnes s ed s udden cardiac arres t is VF.
Puls eles s VT rapidly deteriorates to VF. When VF is pres ent, the heart quivers and
does not pump blood.
Electrical defibrillation is the mos t effective way to treat VF (delivery of a s hock to
s top the VF).
The probability of s ucces s ful defibrillation decreas es quickly over time.
VF deteriorates to as ys tole if not treated.
The earlier defibrillation occurs , the higher the s urvival rate. When VF is pres ent, CPR can
provide a s mall amount of blood flow to the heart and brain but cannot directly res tore an
organized rhythm. The likelihood of res toring a perfus ing rhythm is optimized with immediate CPR and defibrilliation within a few minutes of the initial arres t. Res toration of a perfus ing rhythm requires immediate CPR and defibrillation within a few minutes of the initial
arres t (Figure 17).
For every minute that pas s es between collaps e and defibrillation, the chance of s urvival
from a witnes s ed VF s udden cardiac arres t declines by 7% to 10% per minute if no
bys tander CPR is provided. When bys tanders perform CPR, the decline is more gradual
and averages 3% to 4% per minute. CPR performed early can double or triple s urvival
from witnes s ed s udden cardiac arres t at mos t defibrillation intervals .
Lay res cuer AED programs increas e the likelihood of early CPR and attempted defibrillation. This helps s horten the time between collaps e and defibrillation for a greater number
of patients with s udden cardiac arres t.
Co lla p s e
EMS no ti c a tio n
Dis p a tc h o f EMS units
Tim e to CP R

Tim e to d e b rilla tio n

Sta rt o f CP R
Sta rt o f d e b rilla tio n
Re turn o f p e rfus ing rhythm

Tim e to d e nitive c a re

Arriva l o f full ACLS s up p o rt

Fig u re 1 7 . Sequence of events and key intervals that occur with cardiac arres t.
Modified from Eis enberg MS, Cummins RO, Damon S, Lars en MP, Hearne TR. Survival rates from outof-hos pital cardiac arres t: recommendations for uniform definitions and data to report. Ann Emerg Med.
1990;19:1249-1259. With permis s ion from Els evier.

54

Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED

AED Op e r a t io n

Us e AEDs only when patients have the following 3 clinical findings :


No res pons e
Abs ent or abnormal breathing (ie, no breathing or only gas ping)
No puls e
In the firs t few minutes after the ons et of s udden cardiac arres t, the patient may demons trate agonal gas ps , which are not adequate breathing. A nonres pons ive patient with
agonal gas ping who has no puls e is in cardiac arres t.

Cr it ic a l Co n c e p t s

Ag o na l g a s p s a re no t a d e q ua te b re a thing .

Ag o na l Ga s p s

A patient who gas ps us ually looks like he is drawing air in very quickly. The patient
may open his mouth and move his jaw, head, or neck. Gas ps may appear forceful
or weak, and s ome time may pas s between gas ps becaus e they us ually happen at a
s low rate. The gas p may s ound like a s nort, s nore, or groan. Gas ping is not regular or
normal breathing. It is a s ign of cardiac arres t in s omeone who does nt res pond.

Kn o w Yo u r AED

You mus t be familiar with the AED us ed in your clinical s etting and be ready to us e it at
any time. Review the troubles hooting checklis t s upplied by the AED manufacturer. Learn
to perform daily maintenance checks . Not only are thes e checks an effective review of the
s teps of operation, but they are als o a means of verifying that the AED is ready for us e.

Th e Un ive r s a l AED:
Co m m o n S t e p s t o
Op e r a t e All AEDs

Once the AED arrives , place it at the patients s ide, next to the res cuer who will operate
it. This pos ition provides ready acces s to the AED controls and eas y placement of electrode pads . It als o allows a s econd res cuer to perform CPR from the oppos ite s ide of the
patient without interfering with AED operation.
AEDs are available in different models . Although there are s mall differences from model to
model, all AEDs operate in bas ically the s ame way. The following table lis ts the 4 univers al
s teps for operating an AED:

Ste p
1

Ac t io n
P o we r o n the AED (this activates voice prompts for guidance in all s ubs equent s teps ).
Open the carrying cas e or the top of the AED.
Turn the power on (s ome devices will power on automatically when you
open the lid or cas e).

Atta c h e le c tro d e p a d s to the patients bare ches t.


Choos e the correct s ize pads (adult vers us pediatric) for the patients
s ize/age. Peel the backing away from the electrode pads .
Quickly wipe the patients ches t if it is covered with water or s weat (but
do not delay attaching the pads or s hock delivery).
Attach the adhes ive electrode pads to the patients bare ches t.
Place one electrode pad on the upper-right s ide of the bare ches t to
the right of the s ternum directly below the clavicle.
Place the other pad to the left of the nipple, with the top margin of the
pad a few inches below the left armpit (Figure 18).
Attach the AED connecting cables to the AED box (s ome are
preconnected).
(continued)
55

P a r t

5
(continued)

Ste p
3

Ac t io n
Ana lyze rhythm .
Always clearthepatientduringanalys is .Bes urenooneis touchingthe
patient,noteventhepers oninchargeofgivingbreaths .
SomeAEDs willins tructyoutopus habuttontoallowtheAEDtobegin
analyzingtheheartrhythm;others willdothatautomatically.TheAED
rhythmanalys is maytakeabout5to15s econds .
TheAEDrhythmanalys is willdetermineifthepatientneeds as hock.

IftheAEDadvis es as hock,itwilltellyoutoBE SURE TO CLEAR THE


PATIENT (ie , d o no t to uc h the p a tie nt):
Clearthepatientbeforedeliveringthes hock;bes urenooneis touching
thepatient.
Loudlyandquicklys tateaclearthepatientmes s age,s uchas Clear,
Iamgoingtos hockonthree,One,two,three,s hocking,ors imply
Clear.
Performavis ualchecktoens urethatnooneis incontactwiththe
patient.
Pres s theSHOCKbutton.
Thes hockwillproduceas uddencontractionofthepatients mus cles .

As s oonas thes hockis delivered,res umeCPR,s tartingwithches tcompres s ions ,and


givecycles of30compres s ions and2breaths .Donotperformapuls eorrhythmcheck.
After2minutes ofCPRtheAEDwillpromptyoutorepeats teps 3and4.

Fig u re 1 8 . AEDelectrodepadplacementonthepatient.

56

Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED

Fo u n d a t io n a l Fa c t s

There are 4 acceptable AED electrode pad pos itions :

Alte rna tive AED


Ele c tro d e P a d
P la c e m e nt P o s itio ns

Anterolateral
Anteropos terior
Anterior-left infras capular
Anterior-right infras capular
All 4 pos itions are equally effective in s hock s ucces s and are reas onable for defibrillation. For eas e of placement, anterolateral is a reas onable default electrode placement.
Providers may cons ider alternative pad pos itions bas ed on individual patient characteris tics .

Tr o u b le s h o o t in g
t h e AED

Studies of AED failures have s hown that mos t problems are caus ed by operator error
rather than by AED defects . Operator error is les s likely if the operator is experienced in
us ing the AED, has had recent training or practice with the AED, and is us ing a well-maintained AED.
If the AED does not promptly analyze the rhythm, do the following:
Res ume high-quality ches t compres s ions and ventilations .
Check all connections between the AED and the patient to make s ure that they are
intact.
Ne ve r d e la y c h e s t c om p re s s ion s to trou b le s h oot th e AED.

S h o c k Fir s t vs
CP R Fir s t

When you care for an adult patient in cardiac arres t, s hould you attempt to s hock firs t with
an AED or provide CPR firs t?
Healthcare providers who treat cardiac arres t in hos pitals and other facilities s hould
provide immediate CPR until the AED/defibrillator is ready for us e. Us e the AED as
s oon as it is available.
At this time the benefit of delaying defibrillation to perform CPR before defibrillation
is unclear. EMS s ys tem medical directors may cons ider implementing a protocol that
allows EMS res ponders to provide CPR while preparing for defibrillation of patients
found by EMS pers onnel to be in VF.

FYI 2 0 1 0 Gu id e lin e s
Co o rd ina ting Sho c k
De live ry a nd CP R

The AHA s trongly recommends performing CPR while a defibrillator or AED is readied for us e and while charging for all patients in cardiac arres t.
Res ponders us ing an AED s hould follow the machines voice prompts .

AED Us e in S p e c ia l S it u a t io n s
In t r o d u c t io n

The following s pecial s ituations may require the operator to take extra care in placing the
electrode pads when us ing an AED.

Ha ir y Ch e s t

If the patient has a hairy ches t, the AED pads may s tick to the hair and not to the s kin on
the ches t. If this occurs , the AED will not properly analyze the patients heart rhythm. The
AED will give a check electrodes or check electrode pads mes s age. If this happens ,
complete the following s teps and actions while minimizing interruptions in ches t compres s ions .

57

P a r t

Ste p

Wa t e r

Ac t io n

If the pads s tick to the hair ins tead of the s kin, pres s down firmly on
each pad.

If the AED continues to prompt you to check pads or check electrodes ,


quickly pull off the pads . This will remove much of the hair.

If too much hair remains where you will put the pads , s have the area with the
razor in the AED carrying cas e, if available.

Put on a new s et of pads . Follow the AED voice prompts .

Do not us e an AED in the water.


If water is pres ent on the patients ches t, it may conduct the s hock electricity acros s the
s kin of the ches t. This will prevent the delivery of an adequate s hock dos e to the heart.

If...

Im p la n t e d
P a c e m a ke r

Th e n ...

The patient is in the water

Pull the patient out of the water

The patients ches t is covered with water

Wipe the ches t quickly before attaching


the electrodes

The patient is lying on s now or ice or in a


s mall puddle

Us e the AED

Patients known to be at high ris k for s udden cardiac arres t may have implanted defibrillators /pacemakers that automatically deliver s hocks directly to the heart mus cle if a lifethreatening arrhythmia is detected. You can immediately identify thes e devices becaus e
they create a hard lump beneath the s kin of the upper ches t or abdomen. The lump ranges in s ize from the s ize of a s ilver dollar to half the s ize of a deck of cards , with a s mall
overlying s car. The pres ence of an implanted defibrillator or pacemaker is not a contraindication to attaching and us ing an AED. Avoid placing the AED electrode pads directly over
the device becaus e the devices may interfere with each other.
If you identify an implanted defibrillator/pacemaker:
If pos s ible, place the AED electrode pad to either s ide and not directly on top of the
implanted device.
Follow the normal s teps for operating an AED.
Occas ionally the analys is and s hock cycles of implanted defibrillators and AEDs will conflict. If the implanted defibrillator is delivering s hocks to the patient (the patients mus cles
contract in a manner like that obs erved after an AED s hock), allow 30 to 60 s econds for
the implanted defibrillator to complete the treatment cycle before delivering a s hock from
the AED.

Tr a n s d e r m a l
Me d ic a t io n P a t c h e s

58

Do not place AED electrodes directly on top of a medication patch (eg, a patch of nitroglycerin, nicotine, pain medication, hormone replacement therapy, or antihypertens ive
medication). The medication patch may block the trans fer of energy from the electrode
pad to the heart or caus e s mall burns to the s kin. To prevent thes e complications , remove
the patch and wipe the area clean before attaching the AED electrode pad. Try to minimize
interruptions in ches t compres s ions and do not delay s hock delivery.

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

VF/ P u ls e le s s VT Ca s e
In t r o d u c t io n

This cas e focus es on the as s es s ment and actions us ed for a witnes s ed cardiac arres t due
to VF or puls eles s VT that is refractory (unres pons ive) to the firs t s hock. You will us e a
manual defibrillator in this cas e.
In this cas e and during the cours e you will have an opportunity to demons trate effective
res us citation team behaviors while performing the as s es s ment and action s kills . During
the BLS Survey, team members will perform continuous high-quality CPR with effective
ches t compres s ions and ventilation with a bag-mas k device. The team leader will conduct
the ACLS Survey, including rhythm recognition (s hockable vers us nons hockable), defibrillation us ing a manual defibrillator, res us citation drugs , a dis cus s ion of IV/IO acces s , and
advanced airways .
The success of any resuscitation attempt is built on a strong base of high-quality CPR and
defibrillation when required by the patients ECG rhythm.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Des cribe s igns that the patient is experiencing VF/puls eles s VT
2. Recognize VF and VT on the ECG
3. Manage VF/puls eles s VT according to the Cardiac Arres t Algorithm
4. Recall indications for drugs recommended for refractory VF/puls eles s VT
5. Recall contraindications for drugs recommended for refractory VF/puls eles s VT
6. Recall dos es for drugs recommended for refractory VF/puls eles s VT
7. Recall routes of adminis tration for drugs recommended for refractory
VF/puls eles s VT
8. State appropriate electrical dos es us ed for VF/puls eles s VT arres t
9. Perform defibrillation with minimal (10 s econds or les s ) interruption of ches t
compres s ions
10. ROSC: Support blood pres s ure with fluids
11. ROSC: Support blood pres s ure with pres s ors
12. ROSC: Ens ure ventilation by us ing quantitative waveform capnography
13. ROSC: Titrate Fio 2 by us ing puls e oximetry
14. ROSC: As s es s for STEMI: 12-lead and intervention
15. ROSC: As s es s level of cons cious nes s
16. ROSC: Cons ider hypothermia for comatos e patients
17. ROSC: Treat revers ible caus es
18. ROSC: Place patient into appropriate s ys tem of care

59

P a r t

Rh yt h m s fo r VF/
P u ls e le s s VT

This cas e involves thes e ECG rhythms :

Dr u g s fo r VF/
P u ls e le s s VT

This cas e involves thes e drugs :

VF
VT
ECG artifact that looks like VF
New left bundle branch block

Epinephrine
Norepinephrine
Vas opres s in
Amiodarone
Lidocaine
Magnes ium s ulfate
Dopamine
Oxygen

Ma n a g in g VF/ P u ls e le s s VT: Th e Ca rd ia c Ar re s t Alg o r it h m


Ove r vie w

The Cardiac Arres t Algorithm (Figure 19) is the mos t important algorithm to know for adult
res us citation. This algorithm outlines all as s es s ment and management s teps for the puls eles s patient who does not initially res pond to BLS interventions , including a firs t s hock
from an AED. The AHA s implified and redes igned the 2005 algorithm to emphas ize the
importance of minimally interrupted high-quality CPR. The algorithm cons is ts of the 2
pathways for a cardiac arres t:
A s hockable rhythm (VF/puls eles s VT) dis played on the left s ide of the algorithm
A nons hockable rhythm (as ys tole/PEA) dis played on the right s ide of the algorithm
Throughout the cas e dis cus s ion of the Cardiac Arres t Algorithm, we will refer to Boxes 1
through 12. Thes e are the numbers as s igned to the boxes on the algorithm.

VF/ VT
(Le ft S id e )

Becaus e many patients with s udden cardiac arres t demons trate VF at s ome point in their
arres t, it is likely that ACLS providers will frequently follow the left s ide of the Cardiac
Arres t Algorithm (Figure 19). Rapid treatment of VF according to this s equence is the bes t
s cientific approach to res toring s pontaneous circulation.
Puls eles s VT is included in the algorithm becaus e it is treated as VF. VF and puls eles s VT
require CPR until a defibrillator is available. Both are treated with high-energy uns ynchronized s hocks .

60

As ys t o le / P EA
(Rig h t S id e )

The right s ide of the algorithm outlines the s equence of actions to perform if the rhythm is
nons hockable. You will have an opportunity to practice this s equence in the as ys tole and
PEA cas es .

Su m m a r y

The VF/Puls eles s VT Cas e gives you the opportunity to practice performing rapid treatment of VF/VT by following the s teps on the left s ide of the Cardiac Arres t Algorithm
(Boxes 1 through 8).

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

CP R Qua lity

Ad ult Ca rd ia c Arre s t
Sho ut fo r He lp /Ac tiva te Em e rg e nc y Re s p o ns e
compres s ions

Sta rt CP R
30:2 compres s ionYe s

No

Rhythm
s ho c ka b le ?

capnography
ETCO2

VF/VT

attempt to improve

As ys to le /P EA

3
Shoc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

CP R 2 m in

creas e in P ETCO 2

Rhythm
s ho c ka b le ?

No

Sho c k Ene rg y

Ye s

Shoc k
-

10

CP R 2 m in

CP R 2 m in

Ep ine p hrine every 3-5 min

Ep ine p hrine every 3-5 min

capnography

360 J
Drug The ra p y

capnography
Va s o p re s s in

Rhythm
s ho c ka b le ?

No

Rhythm
s ho c ka b le ?

Ye s
epinephrine

Ye s

Shoc k

No

Ad va nc e d Airwa y

11

CP R 2 m in

CP R 2 m in

Am io d a ro ne

compres s ions
No

Rhythm
s ho c ka b le ?

Ye s

12
Go to 5 o r 7
10 or 11

2010 American Heart As s ociation

Re ve rs ib le Ca us e s
H
H
H
H
Hypothermia
T
T
T
T
T

Fig u re 1 9 .
61

P a r t

FYI 2 0 1 0 Gu id e lin e s
ACLS Ca rd ia c Arre s t
Alg o rithm s

The2010CardiacArres tAlgorithms (Figures 19and21)arepres entedinthe


t raditionalbox-and-lineformatandanewcircularformat(Figure21).The2formats
facilitatelearningandmemorizationofthetreatmentrecommendations .Overall
thes ealgorithms reflectanemphas is ontheimportanceofhigh-quality,minimally
interruptedCPR.This actionis fundamentaltothemanagementofallcardiac
arres trhythms .

Ap p lic a t io n o f t h e Ca rd ia c Ar re s t Alg o r it h m : VF/ VT P a t h w a y


In t r o d u c t io n
(Bo xe s 1 Th r o u g h 4 )

This cas edis cus s es theas s es s mentandtreatmentofapatientwithrefractoryVFor


puls eles s VT.This algorithmas s umes thathealthcareproviders havecompletedtheBLS
Survey,includingactivationoftheemergencyres pons es ys tem,performingCPR,attachingthemanualdefibrillator,anddeliveringthefirs ts hock(Boxes 1through4).
TheACLSres us citationteamnowintervenes andconducts theACLSSurvey.Inthis cas e
theteamas s es s es thepatientandtakes actions as needed.Theteamleadercoordinates
theefforts oftheres us citationteamas theyperformthes teps lis tedintheVF/VTpathway
onthelefts ideoftheCardiacArres tAlgorithm.

Min im a l In t e r r u p t io n
o f Ch e s t
Co m p r e s s io n s

Ateammembers houldcontinuetoperformhigh-qualityCPRuntilthedefibrillator
arrives andis attachedtothepatient.Theteamleaderas s igns roles andres pons ibilities andorganizes interventions tominimizeinterruptions inches tcompres s ions .This
a ccomplis hes themos tcriticalinterventions forVForpuls eles s VT:CPRwithminimal
interruptions inches tcompres s ions anddefibrillationduringthefirs tminutes ofarres t.
TheAHAdoes notrecommendcontinuedus eofanAED(ortheautomaticmode)when
amanualdefibrillatoris availableandtheproviders s kills areadequateforrhythm
interpretation.Rhythmanalys is ands hockadminis trationwithanAEDmayres ultin
p rolongedinterruptions inches tcompres s ions .
Ch e s t c om p re s s ion s s h ou ld id e a lly b e in te rru p te d on ly for ve n tila tion (u n le s s a n
a d va n c e d a irwa y is p la c e d ), rh yth m c h e c ks , a n d a c tu a l s h oc k d e live ry. P e rform a
p u ls e c h e c k on ly if a n org a n ize d rh yth m is ob s e rve d .

Fig u re 2 0 . Relations hipofqualityCPRtocoronaryperfus ionpres s ure(CPP)demons tratingtheneedtominimizeinterruptions incompres s ions .


Coronaryperfus ionpres s ureis aorticrelaxation(dias tolic)pres s ureminus rightatrial
relaxation(dias tolic)pres s ure.DuringCPR,CPPcorrelates withbothmyocardialblood
flowandROSC.Inonehumans tudyROSCdidnotoccurunles s aCPP15mmHgwas
achievedduringCPR.

62

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Fo u n d a t io n a l Fa c t s
Re s um e CP R While
Ma nua l De fib rilla to r Is
Cha rg ing

De live r 1 S h o c k
(Bo x 3 )

Shorteningtheintervalbetweenthelas tcompres s ionandthes hockbyevenafew


s econds canimproves hocks ucces s (defibrillationandROSC).Thus ,itis reas onableforhealthcareproviders topracticeefficientcoordinationbetweenCPRand
d efibrillationtominimizethehands -offintervalbetweens toppingcompres s ions and
adminis teringthes hock.
Forexample,afterverifyingas hockablerhythmandinitiatingthechargings equence
onthedefibrillator,anotherres cuers houldres umeches tcompres s ions andcontinue
untilthedefibrillatoris fullycharged.Thedefibrillatoroperators houlddeliverthe
s hockas s oonas thecompres s orremoves his orherhands fromthepatients ches t
andallproviders areclearofcontactwiththepatient.
Us eofamultimodaldefibrillatorinmanualmodemayreducethedurationofches t
compres s ioninterruptionrequiredforrhythmanalys is comparedwithautomatic
modebutcouldincreas ethefrequencyofinappropriates hock.Individuals whoare
notcomfortableinterpretingcardiacrhythms cancontinuetous eanAED.
ForanAED,followthedevices prompts .

Box3directs youtodeliver1s hock.Theappropriateenergydos eis determinedbythe


identityofthedefibrillatormonophas icorbiphas ic.Seethecolumnontherightofthe
algorithm.
Ifyouareus ingamonophasic defibrillator,giveas ingle360-J s hock.Us ethes ame
e nergydos efors ubs equents hocks .
Biphasic defibrillators us eavarietyofwaveforms ,eachofwhichis effectiveforterminatingVFoveras pecificdos erange.Whenus ingbiphas icdefibrillators ,providers s hould
us ethemanufacturers recommendedenergydos e(eg,initialdos eof120to200J ).Many
biphas icdefibrillatormanufacturers dis playtheeffectiveenergydos erangeonthefaceof
thedevice.Ifyoudonotknowtheeffectivedos erange,deliverthemaximalenergydos e
forthefirs tandalls ubs equents hocks .
Iftheinitials hockterminates VFbutthearrhythmiarecurs laterintheres us citation
attempt,delivers ubs equents hocks attheprevious lys ucces s fulenergylevel.
Im m e d ia te ly a fte r th e s h oc k, re s u m e CP R, b e g in n in g with c h e s t c om p re s s ion s .
Give 2 m in u te s (a b ou t 5 c yc le s ) of CP R. A c yc le c on s is ts of 30 c om p re s s ion s
followe d b y 2 ve n tila tion s in th e p a tie n t with ou t a n a d va n c e d a irwa y.

Re s u m e CP R (Bo x 4 )

Immediatelyres umeCPR,beginningwithches tcompres s ions .


Donotperformarhythmorpuls echeckatthis point.
Es tablis hIV/IOacces s .

63

P a r t

Fo u n d a t io n a l Fa c t s
Cle a ring fo r De fib rilla tio n

To ens ure s afety during defibrillation, always announce the s hock warning. State
the warning firmly and in a forceful voice before delivering each s hock (this entire
s equence s hould take <5 s econds ):
Cle a r. I a m g o ing to s ho c k o n thre e .
Check to make s ure you are clear of contact with the patient, the s tretcher, or
other equipment.
Make a vis ual check to ens ure that no one is touching the patient or s tretcher.
Be s ure oxygen is not flowing acros s the patients ches t.
One , two , thre e . Sho c king . When pres s ing the SHOCK button, the defibrillator
operator s hould face the patient, not the machine. This helps to ens ure coordination with the ches t compres s or and to verify that no one res umed contact with the
patient.
You need not us e thes e exact words , but you mus t warn others that you are about to
deliver s hocks and that everyone mus t s tand clear of the patient.

Rh yt h m Ch e c k

Conduct a rhythm check after 2 minutes (about 5 cycles ) of CPR. Be careful to minimize
interruptions in ches t compres s ions .
Th e p a u s e in c h e s t c om p re s s ion s to c h e c k th e rh yth m s h ou ld n ot e xc e e d
10 s e c on d s .
If a nons hockable rhythm is pres ent and the rhythm is organized, a team member
s hould try to palpate a puls e. If there is any doubt about the pres ence of a puls e,
immediately res ume CPR.
Re m e m b e r: Perform a pulse checkpreferably during rhythm analysisonly if an
organized rhythm is present.
If the rhythm is organized and there is a palpable puls e, proceed to pos tcardiac
arres t care.
If the rhythm check reveals a nons hockable rhythm and there is no puls e, proceed
along the as ys tole/PEA pathway on the right s ide of the Cardiac Arres t Algorithm
(Boxes 9 through 11).
If the rhythm check reveals a s hockable rhythm, give 1 s hock and res ume CPR immediately for 2 minutes after the s hock (Box 6).

Fo u n d a t io n a l Fa c t s
P a d d le s vs P a d s

Us ing conductive materials during the defibrillation attempt reduces trans thoracic
impedance, or the res is tance that ches t s tructures have on electrical current.
Conductive materials include paddles with electrode pas te, gel pads , or s elfadhes ive pads .
No exis ting data s ugges t that one is better than the others . Self-adhes ive pads ,
however, reduce the ris k of arcing, allow monitoring of the patients underlying
rhythm, and permit the rapid delivery of a s hock if neces s ary.
For thes e reas ons , the AHA recommends routine us e of s elf-adhes ive pads ins tead of
paddles .

64

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Sh oc k a n d
Va s o p r e s s o r s
(Bo x 6 )

For pers is tent VF/puls eles s VT, give 1 s hock and res ume CPR immediately for 2 minutes
(about 5 cycles ) after the s hock.
Im m e d ia te ly a fte r th e s h oc k, re s u m e CP R, b e g in n in g with c h e s t c om p re s s ion s .
Give 2 m in u te s (a b ou t 5 c yc le s ) of CP R.
When IV/IO acces s is available, give a vas opres s or during CPR (either before or after the
s hock) as follows :
Ep ine p hrine 1 mg IV/IOrepeat every 3 to 5 minutes
or
Va s o p re s s in 40 units IV/IOmay s ubs titute for the firs t or s econd dos e of
epinephrine
Note: If additional team members are available, they s hould anticipate the need for drugs
and prepare them in advance.
Ep ine p hrine hydrochloride is us ed during res us citation primarily for its -adrenergic
effects , ie, vas ocons triction. Vas ocons triction increas es cerebral and coronary blood flow
during CPR by increas ing mean arterial pres s ure and aortic dias tolic pres s ure. In previous
s tudies , es calating and high-dos e epinephrine adminis tration did not improve s urvival to
dis charge or neurologic outcome after res us citation from cardiac arres t.
Va s o p re s s in is a nonadrenergic peripheral vas ocons trictor. A meta-analys is of 5 randomized trials found no difference between vas opres s in and epinephrine for ROSC, 24-hour
s urvival, or s urvival to hos pital dis charge.

Rh yt h m Ch e c k

Conduct a rhythm check after 2 minutes (about 5 cycles ) of CPR. Be careful to minimize
interruptions in ches t compres s ions .
In te rru p tion in CP R to c on d u c t a rh yth m a n a lys is s h ou ld n ot e xc e e d 10 s e c on d s .
If a nons hockable rhythm is pres ent and the rhythm is organized, a team member
s hould try to palpate a puls e. If there is any doubt about the pres ence of a puls e,
immediately res ume CPR.
If the rhythm check is organized and there is a palpable puls e, proceed to pos t
cardiac arres t care.
If the rhythm check reveals a nons hockable rhythm and there is no puls e, proceed
along the as ys tole/PEA pathway on the right s ide of the Cardiac Arres t Algorithm
(Boxes 9 through 11).
If the rhythm check reveals a s hockable rhythm, res ume ches t compres s ions if
indicated while the defibrillator is charging (Box 8). The team leader is res pons ible for
team s afety while compres s ions are being performed and the defibrillator is charging.

Sh oc k a n d
An t ia r r h yt h m ic s
(Bo x 8 )

Give 1 s hock and res ume CPR beginning with ches t compres s ions for 2 minutes (about 5
cycles ) immediately after the s hock.
Healthcare providers may cons ider giving antiarrhythmic drugs , either before or after the
s hock; however, there is no evidence that any antiarrhythmic drug given during cardiac
arres t increas es s urvival to hos pital dis charge. If adminis tered, amiodarone is the firs t-line
antiarrhythmic agent given in cardiac arres t becaus e it has been clinically demons trated
that it improves the rate of ROSC and hos pital admis s ion in adults with refractory VF/
puls eles s VT.

65

P a r t

5
Am io d a ro ne 300mgIV/IObolus ,thencons ideranadditional150mgIV/IOonce
Ifamiodaroneis notavailable,providers mayadminis terlidocaine.
Lid o c a ine 1to1.5mg/kgIV/IOfirs tdos e,then0.5to0.75mg/kgIV/IOat5-to
10-minuteintervals ,toamaximumdos eof3mg/kg
Providers s houldcons idermagnes iums ulfateonlyfortors ades depointes as s ociatedwith
alongQTinterval.
Ma g ne s ium s ulfa te fortors ades depointes ,loadingdos e1to2gIV/IOdilutedin
10mL(eg,D5 W,normals aline)givenas IV/IObolus ,typicallyover5to20minutes
Routineadminis trationofmagnes iums ulfateincardiacarres tis notrecommendedunles s
tors ades depointes is pres ent.
Searchforandtreatanytreatableunderlyingcaus eofcardiacarres t.Seecolumnonthe
rightofthealgorithm.

Ca r d ia c Ar r e s t
Tr e a t m e n t
Se q u e n c e s

TheCardiacArres tCircularAlgorithm(Figure21)s ummarizes therecommendeds equence


ofCPR,rhythmchecks ,s hocks ,anddeliveryofdrugs bas edonexpertcons ens us .The
optimalnumberofcycles ofCPRands hocks requiredbefores tartingpharmacologic
therapyremains unknown.Notethatrhythmchecks ands hocks areorganizedaround5
cycles ofcompres s ions andventilations ,or2minutes ifaprovideris timingthearres t.

Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
Sta rt CP R
Give oxygen
Attach monitor/de brillator
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

2 m inute s

If VF/VT
Sh o c k

n
o

ti

Drug The ra p y
IV/IO acces s
Epinephrine every 3-5 minutes
Amiodarone for refractory VF/VT

ni

su

Co ns id e r Ad va nc e d Airwa y
Quantitative waveform capnography
o

tn

C
Tre a t Re ve rs ib le Ca us e s

Mo

n it o r

CP R Q

Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)



P uls eandbloodpres s ure

Abrupts us tainedincreas einP e t c o 2 (typically40mmHg)
S pontaneous arterialpres s urewaves withintra-arterialmonitoring
Sho c k Ene rg y

Bip ha s ic :Manufacturerrecommendation(eg,initialdos eof120-200J );
ifunknown,us emaximumavailable.Secondands ubs equentdos es
s houldbeequivalent,andhigherdos es maybecons idered.
Mo no p ha s ic :360J

P o s tCa rd ia c
Arre s t Ca re

Che c k
Rhythm

CP R Qua lity
P us hhard(2inches [5cm])andfas t(100/min)andallowcomplete
ches trecoil

Minimizeinterruptions incompres s ions

Avoidexces s iveventilation

Rotatecompres s orevery2minutes
Ifnoadvancedairway,30:2compres s ion-ventilationratio
Q uantitativewaveformcapnography

IfP e t c o 2 <10mmHg,attempttoimproveCPRquality
Intra-arterialpres s ure
Ifrelaxationphas e(dias tolic)pres s ure<20mmHg,attemptto
improveCPRquality

it y
l
a
u

2010 American Heart As s ociation

Drug The ra p y

E p ine p hrine IV/IODo s e :1mgevery3-5minutes

Va s o p re s s in IV/IODo s e :40units canreplacefirs tors econddos e
ofepinephrine
Amioda rone IV/IODos e :Firstdose:300mgbolus.Seconddose:150mg.
Ad va nc e d Airwa y

S upraglotticadvancedairwayorendotrachealintubation

WaveformcapnographytoconfirmandmonitorETtubeplacement
8 -10breaths perminutewithcontinuous ches tcompres s ions
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia

Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary

Fig u re 2 1 . TheCardiacArres tCircularAlgorithm.Donotdelays hock.ContinueCPRwhilepreparingandadminis teringdrugs andcharging


thedefibrillator.Interruptches tcompres s ions onlyfortheminimumamountoftimerequiredforventilation(untiladvancedairwayplaced),rhythm
check,andactuals hockdelivery.

66

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

FYI 2 0 1 0 Gu id e lin e s
Ca rd ia c Arre s t Circ ula r
Alg o rithm

P h ys io lo g ic
Mo n it o r in g Du r in g
CP R

The 2010 AHA Guidelines for CPR and ECC introduced a new circular format for the
Cardiac Arres t Algorithm (Figure 21) to facilitate learning and memorization of the
treatment recommendations . This new algorithm emphas izes the importance of highquality, minimally interrupted CPR, which is fundamental to the management of all
cardiac arres t rhythms .

The 2010 AHA Guidelines for CPR and ECC recommend us ing quantitative waveform
capnography in intubated patients to monitor CPR quality (Figure 22A), optimize ches t
compres s ions , and detect ROSC during ches t compres s ions (Figure 23) or when rhythm
check reveals an organized rhythm. Although placement of invas ive monitors during CPR
is not generally warranted, phys iologic parameters s uch as intra-arterial relaxation pres s ures (Figure 22A) and central venous oxygen s aturation (Scvo 2 ), when available, may als o
be helpful for optimizing CPR and detecting ROSC.
Animal and human s tudies indicate that P e t c o 2 , CPP, and Scvo 2 monitoring provides valuable information on both the patients condition and the res pons e to therapy. Mos t important, P e t c o 2 , CPP, and Scvo 2 correlate with cardiac output and myocardial blood flow
during CPR. When ches t compres s ions fail to achieve identified thres hold values , ROSC is
rarely achieved. Furthermore, an abrupt increas e in any of thes e parameters is a s ens itive
indicator of ROSC that can be monitored without interrupting ches t compres s ions .
Although no clinical s tudy has examined whether titrating res us citative efforts to phys iologic parameters improves outcome, it is reas onable to us e thes e parameters , if available,
to optimize compres s ions and guide vas opres s or therapy during cardiac arres t.

En d -Tid a l CO 2
The main determinant of P e t c o 2 during CPR is blood delivery to the lungs . Pers is tently
low P e t c o 2 values <10 mm Hg during CPR in intubated patients (Figure 22B) s ugges t that
ROSC is unlikely. If P e t c o 2 abruptly increas es to a normal value of 35 to 40 mm Hg, it is
reas onable to cons ider this an indicator of ROSC.
If the P e t c o 2 is <10 mm Hg during CPR, it is reas onable to try to improve ches t compres s ions and vas opres s or therapy.

Coron a ry P e rfu s ion P re s s u re or Arte ria l Re la xa tion P re s s u re


Increas ed CPP correlates with both myocardial blood flow and ROSC. A reas onable s urrogate for CPP during CPR is arterial relaxation (dias tolic) pres s ure, which can be meas ured by us ing an intra-arterial catheter.
If the arterial relaxation pres s ure is <20 mm Hg (Figure 22B), it is reas onable to try to
improve ches t compres s ions and vas opres s or therapy.

Ce n tra l Ve n ou s Oxyg e n Sa tu ra tion


If oxygen cons umption, arterial oxygen s aturation, and hemoglobin are cons tant, changes
in Scvo 2 reflect changes in oxygen delivery due to changes in cardiac output. Scvo 2 can
be meas ured continuous ly by us ing oximetric tipped central venous catheters placed in
the s uperior vena cava or pulmonary artery. Normal range is 60% to 80% .
If the Scvo 2 is <30% , it is reas onable to try to improve ches t compres s ions and vas opres s or therapy.

67

P a r t

A
g

60

40

20

Time

80

120

40

B
40

60

20
10
0

Time

80

120

40
20
0

Fig u re 2 2 . Phys iologic monitoring during CPR. A, High-quality compres s ions are s hown through waveform capnography and intra-arterial
relaxation pres s ure. P e t c o 2 values <10 mm Hg in intubated patients or intra-arterial relaxation pres s ures <20 mm Hg indicate that cardiac output
is inadequate to achieve ROSC. In either of thos e cas es it is reas onable to cons ider trying to improve quality of CPR by optimizing ches t compres s ion parameters or giving a vas opres s or or both. B, Ineffective CPR compres s ions s hown through waveform capnography and intra-arterial
relaxation pres s ure.

68

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

1-minute interval
50
37.5
25
12.5
0
CPR

ROSC

Fig u re 2 3 . Waveform capnography during CPR with ROSC. This capnography tracing dis plays P e t c o 2
in millimeters of mercury on the vertical axis over time. This patient is intubated and receiving CPR. Note
that the ventilation rate is approximately 8 to 10 breaths per minute. Ches t compres s ions are given continuous ly at a rate s lightly fas ter than 100/min but are not vis ible with this tracing. The initial P e t c o 2 is
<12.5 mm Hg during the firs t minute, indicating very low blood flow. P e t c o 2 increas es to between 12.5 and
25 mm Hg during the s econd and third minutes , cons is tent with the increas e in blood flow with ongoing
res us citation. ROSC occurs during the fourth minute. ROSC is recognized by the abrupt increas e in P e t c o 2
(vis ible jus t after the fourth vertical line) to >50 mm Hg, which is cons is tent with a s ubs tantial improvement
in blood flow.

Tr e a t m e n t o f VF/ VT
in Hyp o t h e r m ia

For a cardiac arres t patient in VF/VT who has s evere hypothermia and a body temperature of <30C (<86F), a s ingle defibrillation attempt is appropriate. If the patient fails to
res pond to the initial s hock, it is reas onable to perform additional defibrillation attempts
according to the us ual BLS guidelines while engaging in active rewarming. The hypothermic patient may have a reduced rate of drug metabolis m, rais ing concern that drug levels
may accumulate to toxic levels with s tandard dos ing regimens . Although the evidence
does not s upport the us e of antiarrhythmic drug therapy in hypothermic patients in cardiac
arres t, it is reas onable to cons ider adminis tration of a vas opres s or according to the s tandard ACLS algorithm concurrent with rewarming s trategies .
ACLS treatment of the patient with s evere hypothermia in cardiac arres t in the hos pital
s hould be aimed at rapid core rewarming.
For patients in cardiac arres t with moderate hypothermia (30C to 34C [86F to 93.2F]),
s tart CPR, attempt defibrillation, give medications s paced at longer intervals , and, if in
hos pital, provide active core rewarming.

Ro u t e s o f Ac c e s s fo r Dr u g s
P r io r it ie s

Priorities during cardiac arres t are high-quality CPR and early defibrillation. Ins ertion of
an advanced airway and drug adminis tration are of s econdary importance. No drug given
during cardiac arres t has been s hown to improve s urvival to hos pital dis charge or improve
neurologic function after cardiac arres t.
His torically in ACLS, providers have adminis tered drugs via either the IV or endotracheal
route. Endotracheal abs orption of drugs is poor and optimal drug dos ing is not known. For
this reas on, the IO route is preferred when IV acces s is not available. Priorities for vas cular
acces s are
IV route
IO route
Endotracheal route

69

P a r t

In t r a ve n o u s Ro u t e

A peripheral IV is preferred for drug and fluid adminis tration unles s central line acces s is
already available.
Central line acces s is not neces s ary during mos t res us citation attempts . Central line acces s
may caus e interruptions in CPR and complications during ins ertion, including vas cular
laceration, hematomas , and bleeding. Ins ertion of a central line in a noncompres s ible ves s el
is a relative (not abs olute) contraindication to fibrinolytic therapy in patients with ACS.
Es tablis hing a peripheral line does not require interruption of CPR. Drugs , however, typically require 1 to 2 minutes to reach the central circulation when given by the peripheral IV
route. Keep in mind that drugs adminis tered during the CPR s equence will likely not take
effect until completion of s everal cycles of CPR.
If a drug is given by the peripheral venous route, adminis ter it as follows :
Give the drug by bolus injection unles s otherwis e s pecified.
Follow with a 20-mL bolus of IV fluid.
Elevate the extremity for about 10 to 20 s econds to facilitate delivery of the drug to
the central circulation.

In t r a o s s e o u s Ro u t e

Drugs and fluids during res us citation can be delivered s afely and effectively via the IO
route if IV acces s is not available. Important points about IO acces s are
IO acces s can be es tablis hed in all age groups .
IO acces s often can be achieved in 30 to 60 s econds .
The IO route of adminis tration is preferred over the endotracheal route.
Any ACLS drug or fluid that is adminis tered IV can be given IO.
IO cannulation provides acces s to a noncollaps ible marrow venous plexus , which s erves
as a rapid, s afe, and reliable route for adminis tration of drugs , crys talloids , colloids , and
blood during res us citation. The technique us es a rigid needle, preferably a s pecially
des igned IO or bone marrow needle from an IO acces s kit.
For more information on IO acces s , s ee the Acces s for Medications s ection on
the Student Webs ite (www.he a rt.o rg /e c c s tud e nt).

En d o t r a c h e a l Ro u t e

IV and IO adminis tration routes are preferred over the endotracheal adminis tration route.
When cons idering adminis tration of drugs via the endotracheal route during CPR, keep
thes e concepts in mind:
The optimal dos e of mos t drugs given by the endotracheal route is unknown.
The typical dos e of drugs adminis tered via the endotracheal route is 2 to 2 times
the IV route.
Studies demons trate that epinephrine, vas opres s in, and lidocaine are abs orbed into the
circulatory s ys tem after adminis tration via the endotracheal route. When giving drugs via
the endotracheal route, dilute the dos e in 5 to 10 mL of s terile water or normal s aline.
Inject the drug directly into the trachea.

Va s o p re s s o r s
In t r o d u c t io n

70

There is no evidence to date that routine us e of any vas opres s or at any s tage during
management of cardiac arres t increas es rates of s urvival to hos pital dis charge. But there
is evidence that the us e of vas opres s ors favors initial res us citation with ROSC.

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Va s o p r e s s o r s Us e d
Du r in g Ca r d ia c
Ar r e s t

Vas opres s ors optimize cardiac output and blood pres s ure. The vas opres s ors us ed during
cardiac arres t are
Epinephrine: 1 mg IV/IO (repeat every 3 to 5 minutes )
Vas opres s in: 1 dos e of 40 units IV/IO may replace either the firs t or s econd dos e of
epinephrine
If IV/IO acces s cannot be es tablis hed or is delayed, give epinephrine 2 to 2.5 mg diluted
in 5 to 10 mL of s terile water or normal s aline and injected directly into the ET tube.
Remember, the endotracheal route of drug adminis tration res ults in variable and unpredictable drug abs orption and blood levels .

Ep in e p h r in e

Although healthcare providers have us ed epinephrine for years in res us citation, there are
few data to s how that it improves outcome in humans . Epinephrine adminis tration does
appear to improve ROSC. No s tudies demons trate improved rates of s urvival to hos pital
dis charge or neurologic outcome when comparing s tandard epinephrine dos es with initial
high-dos e or es calating dos e epinephrine. Therefore, the AHA cannot recommend the routine us e of high-dos e or es calating dos es of epinephrine.
Epinephrine is thought to s timulate adrenergic receptors , producing vas ocons triction,
increas ing blood pres s ure and heart rate, and improving perfus ion pres s ure to the brain
and heart.
Repeat epinephrine 1 mg IV/IO every 3 to 5 minutes during cardiac arres t.
Re m e m b e r, follow e a c h d os e g ive n b y p e rip h e ra l in je c tion with a 20-m L flu s h
of IV flu id a n d e le va te th e e xtre m ity a b ove th e le ve l of th e h e a rt for 10 to
20 s e c on d s .

Va s o p r e s s in

Fo u n d a t io n a l Fa c t s
Va s o p re s s o rs

Vas opres s in is a nonadrenergic peripheral vas ocons trictor that increas es arterial blood
pres s ure. Becaus e the efficacy of vas opres s in is no different from that of epinephrine in
cardiac arres t, a s ingle dos e of vas opres s in (40 units IV/IO) may replace either the firs t or
s econd dos e of epinephrine.

Becaus e the effects of vas opres s in have not been s hown to differ from thos e of
epinephrine in cardiac arres t, either vas opres s in or epinephrine can be us ed as the
initial vas opres s or during cardiac arres t.
A vas opres s or is given every 3 to 5 minutes during cardiac arres t.
One dos e of vas opres s in 40 units IV/IO may replace either the firs t or s econd dos e
of epinephrine in the treatment of cardiac arres t.
Epinephrine is adminis tered 3 to 5 minutes after the dos e of vas opres s in if there is a
continuing need for a vas opres s or.

An t ia r r h yt h m ic Ag e n t s
In t r o d u c t io n

There is no evidence that any antiarrhythmic drug given routinely during human cardiac
arres t increas es s urvival to hos pital dis charge. Amiodarone, however, has been s hown
to increas e s hort-term s urvival to hos pital admis s ion when compared with placebo or
lidocaine.

71

P a r t

Am io d a r o n e

Cons ideramiodaronefortreatmentofVForpuls eles s VTunres pons ivetos hock


delivery,CPR,andavas opres s or.
Amiodaroneis acomplexdrugthataffects s odium,potas s ium,andcalciumchannels .
Itals ohas -adrenergicand-adrenergicblockingproperties .
Duringcardiacarres t,cons ideramiodarone300mgIV/IOpus hforthefirs tdos e.
IfVF/puls eles s VTpers is ts ,cons idergivingas econddos eof150mgIV/IOin
3to5minutes .

Lid o c a in e

Lidocaineis analternativeantiarrhythmicoflong-s tandingandwides preadfamiliarity.


However,ithas noprovens hort-termorlong-termefficacyincardiacarres t.Providers
maycons idergivinglidocainewhenamiodaroneis notavailable.
Theinitiallidocainedos eis 1to1.5mg/kgIV/IO.Repeatifindicatedat
0.5to0.75mg/kgIV/IOover5-to10-minuteintervals toamaximumof3mg/kg.
IfnoIV/IOacces s is available,thedos eforendotrachealadminis trationis
2to4mg/kg.

Ma g n e s iu m S u lfa t e

IVmagnes iummayterminateorpreventrecurrenttors ades depointes inpatients


whohaveaprolongedQTintervalduringnormals inus rhythm.WhenVF/puls eles s
VTc ardiacarres tis as s ociatedwithtors ades depointes ,givemagnes iums ulfateat
aloadingdos eof1to2gIV/IOdilutedin10mL(eg,D5 W,normals aline)over5to
20minutes .Ifaprearres t12-leadECGis availableforreview,checktheQTinterval
forprolongation.
Rememberthatpuls eles s VTis treatedwithanimmediatehigh-energys hock,whereas magnes iumis anadjunctiveagentus edtoprevent recurrentortreatpers is tentVT
as s ociatedwithtors ades depointes .
Magnes iums ulfateis als oindicatedforpatients withknownors us pectedlows erum
magnes ium,s uchas patients withalcoholis morotherconditions as s ociatedwith
malnutritionorhypomagnes emics tates .Forpatients inrefractoryVF/puls eles s VT,
checkthepatients his tory,ifavailable,foroneofthes econditions thats ugges ts the
pres enceofarevers ibleelectrolyteabnormality.

Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re
In t r o d u c t io n

Thereis increas ingrecognitionthats ys tematicpos tcardiacarres tcareafterROSCcan


improvethelikelihoodofpatients urvivalwithgoodqualityoflife.This cas efocus es on
themanagementofandoptimizationofcardiopulmonaryfunctionandperfus ionofvital
organs afterROSC.
Toens urethes ucces s ofpos tcardiacarres tcare,healthcareproviders mus t
Optimizethepatients hemodynamicandventilations tatus
Initiatetherapeutichypothermia
Provideimmediatecoronaryreperfus ionwithPCI
Ins tituteglycemiccontrol
Provideneurologiccareandprognos ticationandothers tructuredinterventions
Inthis cas eyouwillhaveanopportunitytous ethe12-leadECGwhileus ingtheas s es s mentandactions kills typicallyperformedafterROSC.

Ma n a g in g P o s t
Ca r d ia c Ar r e s t Ca r e :
Th e P o s t Ca r d ia c
Ar r e s t Ca r e
Alg o r it h m
72

TheImmediatePos tCardiacArres tCareAlgorithm(Figure24)outlines allthes teps for


immediateas s es s mentandmanagementofpos tcardiacarres tpatients withROSC.
Duringthis cas eteammembers willcontinuetomaintaingoodventilationandoxygenation
withabag-mas kdeviceoradvancedairway.Throughoutthecas edis cus s ionofthePos t
CardiacArres tCareAlgorithm,wewillrefertoBoxes 1through8.Thes earethenumbers
as s ignedtotheboxes onthealgorithm.

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Ad ult Im m e d ia te P o s tCa rd ia c Arre s t Ca re


1
Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)

2
Op tim ize ve ntila tio n a nd o xyg e na tio n
Maintainoxygens aturation94%
Cons ideradvancedairwayandwaveformcapnography
Donothyperventilate

3
Tre a t hyp o te ns io n (SBP <90 m m Hg )
IV/IObolus
Vas opres s orinfus ion
Cons idertreatablecaus es
12-LeadECG

5
No

Co ns id e r ind uc e d hyp o the rm ia

Fo llo w
c o m m a nd s ?

Ye s

7
Ye s

Co ro na ry re p e rfus io n

STEMI
OR
highs us picionofAMI
No

Ad va nc e d c ritic a l c a re

Do s e s /De ta ils
Ve ntila tio n/Oxyg e na tio n
Avoidexces s iveventilation.
Startat10-12breaths /min
andtitratetotargetP e t c o 2
of35-40mmHg.
Whenfeas ible,titrateFio 2
tominimumneces s aryto
achieveSp o 2 94% .
IV Bo lus
1-2Lnormals aline
orlactatedRingers .
Ifinducinghypothermia,
mayus e4Cfluid.
Ep ine p hrine IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcgper
minute)
Do p a m ine IV Infus io n:
5-10mcg/kgperminute
No re p ine p hrine
IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcgper
minute)
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary

2010 American Heart As s ociation

Fig u re 2 4 . TheImmediatePos tCardiacArres tCareAlgorithm.

Ap p lic a t io n o f t h e Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re Alg o r it h m
In t r o d u c t io n (Bo x 1 )

This cas edis cus s es theas s es s mentandtreatmentofapatientwhohadcardiacarres t


andwas res us citatedwiththeus eoftheBLSSurveyandACLSSurvey.Duringrhythm
checkintheACLSSurvey,thepatients rhythmwas organizedandapuls ewas detected
(Box12,CardiacArres tAlgorithm[Figure19]).Theteamleaderwillcoordinatetheefforts
ofthepos tcardiacarres tcareteamas theyperformthes teps ofthePos tCardiacArres t
CareAlgorithm.

73

P a r t

Op t im iz e Ve n t ila t io n
a n d Oxyg e n a t io n
(Bo x 2 )

Box 2 directs you to ens ure an adequate airway and s upport breathing immediately after
ROSC. An uncons cious /unres pons ive patient will require an advanced airway for mechanical s upport of breathing.
Us e continuous waveform capnography to confirm and monitor correct placement of
the ET tube (Figures 25 and 26).
Us e the lowes t ins pired oxygen concentration that will maintain arterial oxyhemoglobin s aturation 94% . When titration of ins pired oxygen is not feas ible (eg, in an outof-hos pital s etting), it is reas onable to empirically us e 100% oxygen until the patient
arrives at the ED.
Avoid exces s ive ventilation of the patient (do not ventilate too fas t or too much).
Providers may begin ventilations at 10 to 12 breaths per minute and titrate to achieve
a P e t c o 2 of 35 to 40 mm Hg or a Pa c o 2 of 40 to 45 mm Hg.
If appropriate equipment is available, adjus t the Fio 2 after achieving ROSC to the minimum
concentration needed to achieve arterial oxyhemoglobin s aturation 94% . The goal is to
avoid hyperoxia while ens uring adequate oxygen delivery.
Becaus e an oxygen s aturation of 100% may corres pond to a Pa o 2 between approximately
80 and 500 mm Hg, in general it is appropriate to wean Fio 2 for a s aturation of 100% , provided the patient can maintain oxyhemoglobin s aturation 94% .

40

60

20

Time

40

60

20

Time

40

60

20

Time

C
Fig u re 2 5 . Waveform capnography. A, Normal range of 35 to 45 mm Hg. B, 20 mm Hg. C, 0 mm Hg.

74

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

40

60

20

Time

Fig u re 2 6 . Waveform capnography with an ET tube, s howing normal (adequate) ventilation pattern:
P e t c o 2 35 to 40 mm Hg

Cr it ic a l Co n c e p t s
Wa ve fo rm Ca p no g ra p hy

Ca u t io n
Thing s to Avo id
During Ve ntila tio n

In addition to monitoring ET tube pos ition, quantitative waveform capnography


allows healthcare pers onnel to monitor CPR quality, optimize ches t compres s ions ,
and detect ROSC during ches t compres s ions or when a rhythm check reveals an
organized rhythm.

When s ecuring an advanced airway, avoid us ing ties that pas s circumferentially
around the patients neck, thereby obs tructing venous return from the brain.
Exces s ive ventilation may potentially lead to advers e hemodynamic effects when
intrathoracic pres s ures are increas ed and becaus e of potential decreas es in cerebral
blood flow when Pa c o 2 decreas es .

75

P a r t

Fo u n d a t io n a l Fa c t s
Wa ve fo rm Ca p no g ra p hy

FYI 2 0 1 0 Gu id e lin e s
Wa ve fo rm Ca p no g ra p hy

Tr e a t Hyp o t e n s io n
(S BP <9 0 m m Hg )
(Bo x 3 )

End-tidalCO 2 is theconcentrationofcarbondioxideinexhaledairattheendof
expiration.Itis typicallyexpres s edas apartialpres s ureinmillimeters ofmercury
(P e t c o 2 ).Becaus eCO 2 is atracegas inatmos phericair,CO2 detectedbycapnographyinexhaledairis producedinthebodyanddeliveredtothelungs bycirculating
blood.
Cardiacoutputis themajordeterminantofCO2 deliverytothelungs .Ifventilationis
relativelycons tant,P e t c o 2 correlates wellwithcardiacoutputduringCPR.
Providers s houldobs erveapers is tentcapnographicwaveformwithventilationto
confirmandmonitorETtubeplacementinthefield,inthetrans portvehicle,onarrivalatthehos pital,andafteranypatienttrans fertoreducetheris kofunrecognized
tubemis placementordis placement.
Althoughcapnographytoconfirmandmonitorcorrectplacementofs upraglottic
airways (eg,laryngealmas kairway,laryngealtube,ores ophageal-trachealtube)has
notbeens tudied,effectiveventilationthroughas upraglotticairwaydevices hould
res ultinacapnographywaveformduringCPRandafterROSC.

Continuous waveformcapnographyis recommended,inadditiontoclinicalas s es s ment,as themos treliablemethodofconfirmingandmonitoringcorrectplacement


ofanETtube.

Box3directs youtotreathypotens ionwhenSBPis <90mmHg.Providers s houldobtain


IVacces s ifnotalreadyes tablis hed.VerifythepatencyofanyIVlines .IVlines s hould
replaceIOacces s ifIOis us edduringres us citation.ECGmonitorings houldcontinueafter
ROSC,duringtrans port,andthroughoutICUcareuntildeemedclinicallynotneces s ary.At
this s tage,cons idertreatinganyrevers iblecaus es thatmighthaveprecipitatedthecardiac
arres tbutpers is tafterROSC.
WhenIVis es tablis hed,treathypotens ionas follows :
IV b o lus 1-2Lnormals alineorlactatedRingers .Iftherapeutichypothermiais
indicatedorwillbeperformed,youmayus e4Cfluids .
Ep ine p hrine 0.1-0.5mcg/kgperminute(in70-kgadult:7-35mcgperminute)IV
infus iontitratedtoachieveaminimumSBPof>90mmHgorameanarterialpres s ure
of>65mmHg
Do p a m ine 5-10mcg/kgperminuteIVinfus iontitratedtoachieveaminimumSBPof
>90mmHgorameanarterialpres s ureof>65mmHg
No re p ine p hrine 0.1-0.5mcg/kgperminute(in70-kgadult:7-35mcgperminute)IV
infus iontitratedtoachieveaminimumSBPof>90mmHgorameanarterialpres s ure
of>65mmHg
Ep ine p hrine canbeus edinpatients whoarenotincardiacarres tbutwhorequireinotropicorvas opres s ors upport.
Do p a m ine hydrochlorideis acatecholamine-likeagentandachemicalprecurs orofnorepinephrinethats timulates theheartthroughboth -and-adrenergicreceptors .
No re p ine p hrine (levarterenol)is anaturallyoccurringpotentvas ocons trictorandinotropicagent.Itmaybeeffectiveformanagementofpatients withs everehypotens ion(eg,
SBP<70mmHg)andalowtotalperipheralres is tancewhofailtores pondtoles s potent
adrenergicdrugs s uchas dopamine,phenylephrine,ormethoxamine.

Fo llo w in g Co m m a n d s
(Bo x 4 )

76

Box4directs youtoexaminethepatients abilitytofollowverbalcommands .


Ifthepatientfails tofollowcommands ,thehealthcareteams houldcons iderimplementing
therapeutichypothermia(Box5).Ifthepatientis abletofollowverbalcommands ,moveto
Box6.

Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Th e r a p e u t ic
Hyp o t h e r m ia (Bo x 5 )

To protect the brain and other organs , the res us citation team s hould induce therapeutic
hypothermia in adult patients who remain comatos e (lack of meaningful res pons e to verbal
commands ) with ROSC after out-of-hos pital VF cardiac arres t. When ROSC occurs in the
out-of-hos pital s etting, EMS pers onnel may initiate the cooling proces s and s hould trans port the patient to a facility that reliably provides this therapy.
Healthcare providers s hould cool patients to a target temperature of 32C to 34C for a
period of 12 to 24 hours . Although the optimal method of achieving the target temperature
is unknown, any combination of rapid infus ion of ice-cold, is otonic, nonglucos e-containing fluid (30 mL/kg), endovas cular catheters , s urface cooling devices , or s imple s urface
interventions (eg, ice bags ) appears s afe and effective.
Healthcare providers s hould als o cons ider induced hypothermia for comatos e adult
patients with ROSC after in-hos pital cardiac arres t of any initial rhythm or after out-ofhos pital cardiac arres t with an initial rhythm of PEA or as ys tole.

Ca u t io n
Avo id Ac tive Re wa rm ing
Afte r ROSC

Fo u n d a t io n a l Fa c t s
Ind uc e d Hyp o the rm ia

In comatos e patients who s pontaneous ly develop a mild degree of hypothermia


(>32C) after res us citation from cardiac arres t, avoid active rewarming during the
firs t 12 to 24 hours after ROSC.

Therapeutic hypothermia is the only intervention demons trated to improve neurologic recovery after cardiac arres t.
The optimal duration of induced hypothermia is at leas t 12 hours and may be >24
hours . The effect of a longer duration of cooling on outcome has not been s tudied in
adults , but hypothermia for up to 72 hours was us ed s afely in newborns .
Healthcare providers s hould monitor the patients core temperature during induced
hypothermia by us ing an es ophageal thermometer, a bladder catheter in nonanuric
patients , or a pulmonary artery catheter if one is placed for other indications .
Axillary and oral temperatures are inadequate for meas urement of core temperature
changes .
Induced hypothermia s hould not affect the decis ion to perform PCI, becaus e concurrent PCI and hypothermia are reported to be feas ible and s afe.

S TEMI Is P r e s e n t o r
Hig h S u s p ic io n o f
AMI (Bo x 6 )

Both in- and out-of-hos pital medical pers onnel s hould obtain a 12-lead ECG as s oon as
pos s ible after ROSC in order to identify thos e patients with STEMI or a high s us picion of
AMI. Once identified, hos pital pers onnel s hould attempt coronary reperfus ion (Box 7).
EMS pers onnel s hould trans port thes e patients to a facility that reliably provides this
therapy (Box 7).

Co r o n a r y Re p e r fu s io n
(Bo x 7 )

Aggres s ive treatment of STEMI or AMI s hould begin if detected after ROSC, regardles s
of coma or induced hypothermia, including coronary reperfus ion with PCI. In the cas e of
out-of-hos pital STEMI, provide advance notification to receiving facilities for patients diagnos ed with STEMI to reduce reperfus ion delay.

Ad va n c e d Cr it ic a l
Ca r e (Bo x 8 )

Following coronary reperfus ion interventions or in cas es where the pos tcardiac arres t
patient has no ECG evidence or s us picion of MI, the healthcare team s hould trans fer the
patient to an intens ive care unit.

P o s t Ca r d ia c
Ar r e s t Ma in t e n a n c e
Th e r a p y

There is no evidence to s upport continued prophylactic adminis tration of antiarrhythmic


medications once the patient achieves ROSC.

77

P a r t

P u ls e le s s Ele c t r ic a l Ac t ivit y Ca s e
In t r o d u c t io n

This cas e focus es on as s es s ment and management of a cardiac arrest patient with PEA.
During the BLS Survey, team members will demons trate high-quality CPR with effective
ches t compres s ions and ventilation with a bag-mas k. In the ACLS Survey the team leader
will recognize PEA and implement the appropriate interventions outlined in the Cardiac
Arres t Algorithm. Becaus e correction of an underlying caus e of PEA, if pres ent and identified, is critical to patient outcome, the team leader will verbalize the differential diagnos is
while leading the res us citation team in the s earch for and treatment of revers ible caus es .

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Des cribe s igns and s ymptoms of PEA
2. Demons trate treatment priorities of individuals experiencing PEA as s pecified by the
Cardiac Arres t Algorithm
3. State the correct dos age of epinephrine in PEA
4. Recall the correct method of adminis tering epinephrine in PEA
5. State the correct dos age of vas opres s in in PEA
6. Des cribe the target of PEA (treatment of the caus e, not the rhythm)
7. Des cribe the mos t likely caus es of PEA
8. As s ign team functions , monitor CPR, monitor treatments , and monitor drug
adminis tration

Rh yt h m s fo r P EA

You will need to recognize the following rhythms :


Ratetoo fas t or too s low
Width of QRS complexes wide vers us narrow

Dr u g s fo r P EA

This cas e involves thes e drugs :


Epinephrine
Vas opres s in
Other medications , depending on the caus e of the PEA arres t

De s c r ip t io n o f P EA
In t r o d u c t io n

PEA encompas s es a heterogeneous group of rhythms that are organized or s emiorganized, but lack a palpable puls e. PEA includes
Idioventricular rhythms
Ventricular es cape rhythms
Pos tdefibrillation idioventricular rhythms
Sinus rhythm
Any organized rhythm without a puls e is defined as PEA. Even s inus rhythm without a
detectable puls e is called PEA. Puls eles s rhythms that are excluded by definition include
VF, VT, and as ys tole.

78

Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity

His t o r ic a l
P e r s p e c t ive

Previous ly res us citation teams us ed the term electromechanical dissociation (EMD) to


des cribe patients who dis played electrical activity on the cardiac monitor but lacked
apparent contractile function becaus e of an undetectable puls e. That is , weak contractile function is pres entdetectable by invas ive monitoring or echocardiographybut
the cardiac function is too weak to produce a puls e or effective cardiac output. This is
the mos t common initial condition pres ent following s ucces s ful defibrillation. PEA als o
includes other conditions where the heart is empty becaus e of inadequate preload. In this
cas e, the contractile function of the heart is adequate, but there is inadequate volume for
the ventricle to eject. This may occur as a res ult of s evere hypovolemia, or as a res ult of
decreas ed venous return from pulmonary embolis m or pneumothorax.

Ma n a g in g P EA: Th e Ca rd ia c Ar re s t Alg o r it h m
Ove r vie w

As des cribed earlier, the Cardiac Arres t Algorithm cons is ts of 2 cardiac arres t pathways
(Figures 19 and 27). The left s ide of the algorithm outlines treatment for a s hockable
rhythm (VF/VT). The right s ide of the algorithm (Boxes 9 through 11) outlines treatment for
a nons hockable rhythm (as ys tole/PEA). Becaus e of the s imilarity in caus es and management, the Cardiac Arres t Algorithm combines the as ys tole and PEA pathways , although
we will review thes e rhythms in s eparate cas es . In both pathways , therapies are organized
around periods (2 minutes or 5 cycles ) of uninterrupted, high-quality CPR.
The ability to achieve a good res us citation outcome with return of a perfus ing rhythm and
s pontaneous res pirations depends on the ability of the res us citation team to provide effective CPR and to identify and correct a caus e of PEA if pres ent.
Everyone on the res us citation team mus t carry out the s teps outlined in the algorithm and
at the s ame time focus on the identification and treatment of revers ible caus es of
the arres t.

79

P a r t

CP R Qua lity

P us hhard(2 inches
[5cm])andfast
(100/min)andallow
completeches trecoil
Minimizeinterruptions in
compres s ions
Avoidexcessiveventilation
Rotatecompres s orevery
2minutes

Ifnoadvancedairway,
30:2 compres s ionventilationratio

Q uantitativewaveform
capnography
IfP e t c o 2<10mmHg,
attempt to improve
CPRquality

Intra-arterialpres s ure
Ifrelaxationphas e
(dias tolic)pres s ure
<20mmHg,attemp t
toimproveCPRquality

Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
1

Sta rt CP R

G iveoxygen
Attachmonitor/defibrillator

Ye s

No

Rhythm
s ho c ka b le ?

VF/VT

As ys to le /P EA

3
Shoc k

Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

P ulseandbloodpressure
Ab rupts us tained
increas e in P e t c o 2
(typically40mmHg)

S pontaneous arterial
pres s urewaves with
intra-arterialmonitoring

CP R 2 m in
IV/IOacces s

No

Rhythm
s ho c ka b le ?
Ye s

Shoc k

10

CP R 2 m in

IV/IOacces s
E p ine p hrin e every 3-5 min
C ons ideradvancedairway,
capnography

E p in e p hrin e every 3-5 min


C ons ideradvancedairway,
capnography

Rhythm
s ho c ka b le ?

CP R 2 m in

No

Ye s

Rhythm
s ho c ka b le ?

Shoc k

No

Ad va nc e d Airwa y
S up raglotticad vanced
airwayorendotracheal
intubation
Waveformcapnography
toconfirmandmonitor
ETtubeplacement
8 -10breathsperminute
withcontinuous ches t
compres s ions

11

CP R 2 m in

CP R 2 m in

Am io d a ro ne
Treatrevers iblecaus es

Treatrevers ib lecaus es

No

Rhythm
s ho c ka b le ?

Ye s

12

Ifnos igns ofreturnof
s pontaneous circulation
(ROSC),goto10 or 11
IfROSC,goto
Pos tCardiacArres tCare
2010 American Heart As s ociation

Fig u re 2 7 . The Cardiac Arres t Algorithm.


80

Drug The ra p y
Epine phrine IV/IO Do s e :
1mgevery3-5minutes
Va s o p re s s in IV/IO Do s e :
40units canreplace
firs torseconddoseof
epinephrine
Am io d a ro ne IV/IO Do s e :
Firstdose:300mgbolus.
Seconddos e:150mg.

Ye s

Sho c k Ene rg y

Bipha s ic :Manufacturer
recommendation
(eg,initialdos eof
120-200J );ifunknown,
us emaximumavailable.
Secondandsubsequent
dosesshouldbeequivalent,andhigherdoses
maybeconsidered.
Mo no p ha s ic : 360 J

Go to 5 o r 7

Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary

Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity

Th e P EA P a t h w a y o f
t h e Ca r d ia c Ar r e s t
Alg o r it h m

In this cas e the patient is in cardiac arrest. Team members initiate and perform highquality CPR throughout the BLS Survey and the ACLS Survey. The team interrupts CPR
for 10 s econds or les s for rhythm and puls e checks . This patient has an organized rhythm
on the monitor but no pulse. The condition is PEA (Box 9). Ches t compres s ions res ume
immediately. The team leader now directs the team in the s teps outlined in the PEA pathway of the Cardiac Arres t Algorithm (Figure 27), beginning with Box 10.
IV/IO access is a priority over advanced airway management unless bag-mask ventilation is
ineffective or the arrest is caused by hypoxia. All resuscitation team members must simultaneously conduct a search for an underlying and treatable cause of the PEA in addition to
performing their assigned roles.

Rh yt h m Ch e c k :
De c is io n P o in t

Conduct a rhythm check and give 2 minutes (about 5 cycles ) of CPR after adminis tration
of the drugs . Be careful to minimize interruptions in ches t compres s ions .
Th e p a u s e in CP R to c on d u c t a rh yth m c h e c k s h ou ld n ot e xc e e d 10 s e c on d s .

Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )

Give a vas opres s or as s oon as IV/IO acces s becomes available.


Epinephrine 1 mg IV/IOrepeat every 3 to 5 minutes
or
Vas opres s in 40 units IV/IO to replace firs t or s econd dos e of epinephrine
Ad m in is te r d ru g s d u rin g CP R. Do n ot s top CP R to a d m in is te r d ru g s .
No known vas opres s or (epinephrine and vas opres s in) increas es s urvival from PEA.
Becaus e thes e medications can improve aortic dias tolic blood pres s ure, coronary artery
perfus ion pres s ure, and the rate of ROSC, the AHA continues to recommend their us e.
Cons ider advanced airway and capnography.

FYI 2 0 1 0 Gu id e lin e s
No Atro p ine During
Ca rd ia c Arre s t

There is no evidence that atropine has detrimental effects during bradycardic or


as ys tolic cardiac arres t. On the other hand, available evidence s ugges ts that routine
us e of atropine during PEA or as ys tole is unlikely to have a therapeutic benefit. For
this reas on, the AHA has removed atropine from the Cardiac Arres t Algorithm.

No n s h o c k a b le
Rh yt h m
(Bo x 1 2 )

If no electrical activity is present (as ys tole), go back to Box 10.


If organized electrical activity is pres ent, try to palpate a puls e. Take at leas t 5 s econds but do not take more than 10 s econds to check for a puls e.
If no pulse is present, or if there is any doubt about the pres ence of a puls e, immediately res ume CPR for 2 minutes , s tarting with ches t compres s ions . Go back to Box
10 and repeat the s equence.
If a palpable puls e is pres ent and the rhythm is organized, begin pos tcardiac
arres t care.

De c is io n P o in t :
S h o c k a b le Rh yt h m

If the rhythm check reveals a s hockable rhythm, res ume CPR with ches t compres s ions while the defibrillator is charging if pos s ible.
Switch to the left s ide of the algorithm and perform s teps according to the VF/VT
s equence s tarting with Box 5 or 7.

81

P a r t

As ys t o le a n d
P EA Tr e a t m e n t
Se q u e n c e s

Figure 28 s ummarizes the recommended s equence of CPR, rhythm checks , and delivery
of drugs for PEA and as ys tole bas ed on expert cons ens us .

Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
Sta rt CP R
Give oxygen
Attach monitor/de brillator
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

2 m inute s

If VF/VT
Sh oc k

Drug The ra p y
IV/IO acces s
Epinephrine every 3-5 minutes
Amiodarone for refractory VF/VT

n
o

ti

ni

su

Co ns id e r Ad va nc e d Airwa y
Quantitative waveform capnography

Mo

n it o r

CP R Q

tn

Tre a t Re ve rs ib le Ca us e s

Re turn o f Spo nta ne o us Circ ula tio n (ROSC)


P uls eandbloodpres s ure
Abrupts us tainedincrea s einP e t c o 2 (typically40mmHg)

S pontaneous arterialpres s urewaves withintra-arterialmonitoring
Sho c k Ene rg y
Bipha s ic :Manufacturerrecommendation(eg,initialdos eof120-200J );
ifunknown,us emaximumavailable.Secondands ubs equentdos es
s houldbeequivalent,andhigherdos es maybecons idered.
Mo no p ha s ic :360J

P o s tCa rd ia c
Arre s t Ca re

Che c k
Rhythm

CP R Qua lity

P us hhard(2inches [5cm])andfas t(100/min)andallowcomplete
ches trecoil
Minimizeinterruptions incompres s ions
Avoidexces s iveventilation
Rotate compres s orevery2minutes
Ifnoadvancedairway,30:2compres s ion-ventilationratio

Q uantitativewaveformcapnography
IfP e t c o 2 <10mmHg,attempttoimproveCPRquality

Intra-arterialpres s ure
Ifrelaxationphas e(dias tolic)pres s ure<20mmHg,atte mptto
improveCPRquality

y
t
i
l
ua

2010 American Heart As s ociation

Drug The ra p y
E p ine p hrine IV/IODo s e :1mgevery3-5minutes
Va s o p re s s in IV/IODo s e :40units canreplacefirs tors econddos e
ofepinephrine

Amioda rone IV/IODos e :Firstdose:300mgbolus.Seconddose:150mg.
Ad va nc e d Airwa y
S upraglotticadvancedairwayorendotrachealintubation
WaveformcapnographytoconfirmandmonitorETtubeplacement

8 -10breaths perminutewithcontinuous ches tcompres s ions
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia

Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary

Fig u re 2 8 . The Cardiac Arres t Circular Algorithm.

Ma n a g in g P EA: Dia g n o s in g a n d Tre a t in g Un d e r lyin g Ca u s e s


In t r o d u c t io n

Patients with PEA have poor outcomes . Rapid as s es s ment and aggres s ive management
offer the bes t chance of s ucces s . PEA may be caus ed by a revers ible problem. If you can
quickly identify a s pecific condition that has caus ed or is contributing to PEA and correct it, you may achieve ROSC. The identification of the underlying caus e is of paramount
importance in cas es of PEA and as ys tole.
In the s earch for the underlying caus e, do the following:
Cons ider frequent caus es of PEA by recalling the Hs and Ts
Analyze the ECG for clues to the underlying caus e
Recognize hypovolemia
Recognize drug overdos e/pois onings

82

Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity

Hs a n d Ts

PEA is as s ociated with many conditions . Healthcare providers s hould memorize the lis t
of common caus es to keep from overlooking an obvious caus e of PEA that might be
revers ed by appropriate treatment.
The mos t common caus es of PEA are pres ented as Hs and Ts in the table below:

Hs

Co n d it io n s a n d
Ma n a g e m e n t

Ts

Hypovolemia

Tens ion pneumothorax

Hypoxia

Tamponade (cardiac)

Hydrogen ion (acidos is )

Toxins

Hyper-/hypokalemia

Thrombos is (pulmonary)

Hypothermia

Thrombos is (coronary)

The factors in the patients his tory and phys ical exam that may help identify revers ible
caus es of PEA have been combined with potentially effective interventions in Table 3.

Ta b le 3 . P o te ntia lly Re ve rs ib le Ca us e s o f P EA a nd As ys to le (Hs a nd Ts )

Co n d it io n
Hyp o vo le m ia

Clu e s Fro m ECG a n d


Mo n it o r
Narrow complex

Clu e s Fro m His t o r y


a n d P h ys ic a l
Exa m in a t io n

P o t e n t ia l Effe c t ive
In t e r ve n t io n s

His tory, flat neck veins

Volume infus ion

Rapid rate
Hyp o xia

Slow rate (hypoxia)

Cyanos is , blood gas es ,


airway problems

Oxygenation, ventilation,
advanced airway

Hyd ro g e n io n (a c id o s is )

Smaller-amplitude QRS
complexes

His tory of diabetes , bicarbonate-res pons ive preexis ting acidos is , renal failure

Ventilation, s odium
bicarbonate

Hyp e rka le m ia

High- potassium ECG:

His tory of renal failure, diabetes , recent dialys is , dialys is fis tulas , medications

Hyperkalemia:

Abnormal los s of potas s ium, diuretic us e

Hypokalemia:

His tory of expos ure to cold,


central body temperature

Rewarm according to local


protocol

or

Hyp o ka le m ia

T waves taller and


peaked
P waves get s maller
QRS widens
Sine-wave PEA
Low-potassium ECG:
T waves flatten
Prominent U waves
QRS widens
QT prolongs
Wide-complex tachycardia

Hyp o the rm ia

J or Os borne waves

Calcium chloride
Sodium bicarbonate
Glucos e plus ins ulin
Pos s ibly albuterol

Add magnes ium if cardiac arres t

(continued)

83

P a r t

(continued)

Co n d it io n
Te ns io n p ne um o tho ra x

Clu e s Fro m ECG a n d


Mo n it o r
Narrow complex
Slow rate (hypoxia)

Ta m p o na d e , c a rd ia c

Narrow complex
Rapid rate

Clu e s Fro m His t o r y


a n d P h ys ic a l
Exa m in a t io n

P o t e n t ia l Effe c t ive
In t e r ve n t io n s

His tory, no puls e felt with


CPR, neck vein dis tention,
tracheal deviation, unequal
breath s ounds , difficult to
ventilate patient

Needle decompres s ion

His tory, no puls e felt with


CPR, vein dis tention

Pericardiocentes is

Tube thoracos tomy

To xins (d rug o ve rd o s e ):
tric yc lic s , d ig o xin,
-b lo c ke rs , c a lc ium
c ha nne l b lo c ke rs

Various effects on ECG,


predominately prolongation
of QT interval

Bradycardia, empty bottles


at the s cene, pupils , neurologic exam

Intubation, s pecific
antidotes and agents per
toxidrome

Thro m b o s is , lung s : m a s s ive p ulm o na ry e m b o lis m

Narrow complex

His tory, no puls e felt with


CPR, dis tended neck veins ,
prior pos itive tes t for deep
vein thrombos is or pulmonary embolis m

Surgical embolectomy,
fibrinolytics

Thro m b o s is , he a rt: a c ute ,


m a s s ive MI

Abnormal 12-lead ECG:

An a lyz e ECG fo r
Clu e s t o Un d e r lyin g
Ca u s e

Rapid rate

Q waves
ST-s egment changes
T waves , invers ions

His tory, cardiac markers ,


good puls e with CPR

The ECG may provide valuable clues to the pos s ible caus es of PEA. Many providers think
that the term PEA refers to the broad, s lurred, s low, and dis organized electrical activity
that bears no s imilarity to a normal P waveQRST wave complex. The ECG, however,
may dis play normal intervals or complexes or both. For example, s inus rhythm due to
hypovolemia or s eps is may pres ent as PEA. Other ECG findings in PEA may include widecomplex QRS.
Reas s es s the monitored rhythm and note the rate and width of the QRS complexes . PEA
with narrow complexes is more likely to have a noncardiac caus e.

Hyp o vo le m ia

Hypovolemia, a common caus e of PEA, initially produces the clas s ic phys iologic res pons e
of a rapid, narrow-complex tachycardia (sinus tachycardia) and typically produces
increas ed dias tolic and decreas ed s ys tolic pres s ures . As los s of blood volume continues ,
blood pres s ure drops , eventually becoming undetectable, but the narrow QRS complexes
and rapid rate continue (ie, PEA).
You s hould cons ider hypovolemia as a caus e of hypotens ion, which can deteriorate to
PEA. Providing prompt treatment can revers e the puls eles s s tate by rapidly correcting
the hypovolemia. Common nontraumatic caus es of hypovolemia include occult internal
hemorrhage and s evere dehydration. Cons ider volume infus ion for PEA as s ociated with a
narrow-complex tachycardia.

84

Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity

Ca r d ia c a n d
P u lm o n a r y
Co n d it io n s

ACS involving a large amount of heart mus cle can pres ent as PEA. That is , occlus ion of
the left main or proximal left anterior des cending coronary artery can pres ent with cardiogenic s hock rapidly progres s ing to cardiac arres t and PEA. However, in patients with
cardiac arres t and without known pulmonary embolis m (PE), routine fibrinolytic treatment
given during CPR s hows no benefit and is not recommended.
Mas s ive or s addle PE obs tructs flow to the pulmonary vas culature and caus es acute right
heart failure. In patients with cardiac arres t due to pres umed or known PE, it is reas onable
to adminis ter fibrinolytics .
Cardiac tamponade may be a revers ible condition. Volume infus ion in this condition may
als o help while definitive therapy is initiated. Tens ion pneumothorax can be effectively
treated once recognized.
Note that cardiac tamponade, tens ion pneumothorax, and mas s ive PE cannot be treated
unles s recognized. Beds ide ultras ound, when performed by a s killed provider, may aid in
rapid identification of tamponade and PE. There is growing evidence that pneumothorax
can be identified us ing beds ide ultras ound as well. Treatment for cardiac tamponade may
require pericardiocentes is . Tens ion pneumothorax requires needle as piration and ches t
tube placement. Thes e procedures are beyond the s cope of the ACLS Provider Cours e.

Dr u g Ove r d o s e s
o r To xic Exp o s u r e s

Certain drug overdos es and toxic expos ures may lead to peripheral vas cular dilatation
and/or myocardial dys function with res ultant hypotens ion. Thes e are another caus e of
PEA. The approach to pois oned patients s hould be aggres s ive becaus e the toxic effects
may progres s rapidly and may be of limited duration. In thes e s ituations myocardial dys function and arrhythmias may be revers ible. Numerous cas e reports confirm the s ucces s
of many s pecific limited interventions with one thing in commonthey buy time.
Treatments that can provide this level of s upport include
Prolonged bas ic CPR in s pecial res us citation s ituations
Cardiopulmonary bypas s
Intra-aortic balloon pumping
Renal dialys is
Specific drug antidotes (digoxin immune Fab, glucagon, bicarbonate)
Trans cutaneous pacing (TCP)
Correction of s evere electrolyte dis turbances (potas s ium, magnes ium, calcium,
acidos is )
Specific adjunctive agents (eg, naloxone)
Re m e m b e r, if the p a tie nt s ho ws s ig ns o f ROSC, p o s tc a rd ia c a rre s t c a re s ho uld
b e initia te d .

Cr it ic a l Co n c e p t s
Co m m o n Re ve rs ib le
Ca us e s o f P EA

Hypovolemia and hypoxia are the 2 mos t common and eas ily revers ible caus es of
PEA. Be s ure to look for evidence of thes e problems as you as s es s the patient.

85

P a r t

As ys t o le Ca s e
In t r o d u c t io n

In this cas e the patient is in cardiac arrest. Team members initiate and perform highquality CPR throughout the BLS Survey and the ACLS Survey. The team interrupts CPR
for 10 s econds or les s for a rhythm check. This patient has no pulse and the rhythm on the
monitor is asystole. Ches t compres s ions res ume immediately. The team leader now directs
the team in the s teps outlined in the as ys tole pathway of the Cardiac Arres t Algorithm
(Figure 27, page 80), beginning with Box 10.
IV/IO access is a priority over advanced airway management unless bag-mask ventilation is
ineffective or the arrest is caused by hypoxia. All resuscitation team members must simultaneously conduct a search for an underlying and treatable cause of the asystole in addition to performing their assigned roles.
At the end of this cas e the team will dis cus s the criteria for terminating res us citative
efforts ; in s ome cas es we mus t recognize that the patient is dead and that it would be
more appropriate to direct efforts to s upporting the family.

Le a r n in g Ob je c t ive s

By the end of the cas e you s hould be able to


1. Dis cus s when res us citation s hould not be initiated, including do-not-attemptres us citation (DNAR) orders
2. Recall why s urvival from as ys tole is poor
3. Differentiate as ys tole and PEA: caus es , treatments , and early, diligent s earch for correctable caus es
4. Recall revers ible caus es of as ys tole
5. Outline treatments for caus es of as ys tole
6. Des cribe the Cardiac Arres t Algorithm for as ys tole
7. Des cribe correct dos ages and adminis tration of epinephrine and vas opres s in during
cardiac arres t
8. As s ign team member roles : monitor performance

Rh yt h m s fo r As ys t o le

You will need to recognize the following rhythms :


As ys tole
Slow PEA terminating in bradyas ys tolic rhythm

Dr u g s fo r As ys t o le

This cas e involves thes e drugs :


Epinephrine
Vas opres s in

Ap p ro a c h t o As ys t o le
In t r o d u c t io n

As ys tole is a cardiac arres t rhythm as s ociated with no dis cernible electrical activity on the
ECG (als o referred to as flat line). You s hould confirm that the flat line on the monitor is
indeed true as ys tole by validating that the flat line is
Not another rhythm (eg, fine VF) mas querading as a flat line
Not the res ult of an operator error

86

Th e ACLS Ca s e s : As ys tole

Fo u n d a t io n a l Fa c t s
As ys to le a nd Te c hnic a l
P ro b le m s

As ys tole is a s pecific diagnos is , but flat line is not. The term flat line is nons pecific
and can res ult from s everal pos s ible conditions , including abs ence of cardiac electrical activity, lead or other equipment failure, and operator error. Some defibrillators and
monitors s ignal the operator when a lead or other equipment failure occurs . Some of
thes e problems are not applicable to all defibrillators .
For a patient with cardiac arres t and as ys tole, quickly rule out any other caus es of an
is oelectric ECG, s uch as
Loos e leads or leads not connected to the patient or defibrillator/monitor
No power
Signal gain (amplitude/s ignal s trength) too low

P a t ie n t s Wit h DNAR
Or d e r s

During the BLS Survey and ACLS Survey, you s hould be aware of reas ons to s top or withhold res us citative efforts . Some of thes e are
Rigor mortis
Indicators of DNAR s tatus (eg, bracelet, anklet, written documentation)
Threat to s afety of providers
Out-of-hos pital providers need to be aware of EMS-s pecific policies and protocols applicable to thes e s ituations . In-hos pital providers and res us citation teams s hould be aware
of advance directives or s pecific limits to res us citation attempts that are in place. That is ,
s ome patients may cons ent to CPR and defibrillation but not to intubation or invas ive procedures . Many hos pitals will record this in the medical record.

As ys t o le a s a n
En d P o in t

The prognos is for cardiac arres t with as ys tole is very poor. A large percentage of as ys tolic
patients do not s urvive. Often as ys tole repres ents the final rhythm. Cardiac function has
diminis hed until electrical and functional cardiac activity finally s top and the patient dies .
As ys tole is als o the final rhythm of a patient initially in VF or VT.
Prolonged efforts are unneces s ary and futile unles s s pecial res us citation s ituations exis t,
s uch as hypothermia and drug overdos e.

Ma n a g in g As ys t o le
Ove r vie w

The management of as ys tole cons is ts of the following components :


Implementing the s teps in the Cardiac Arres t Algorithm
Identifying and correcting underlying caus es
Terminating efforts as appropriate

Ca r d ia c Ar r e s t
Alg o r it h m

As des cribed in the VF/Puls eles s VT and PEA Cas es , the Cardiac Arres t Algorithm cons is ts of 2 pathways (Figure 27). The left s ide of the algorithm outlines treatment for a
s hockable rhythm (VF/puls eles s VT). The right s ide of the algorithm (Boxes 9 through 11)
outlines treatment for a nons hockable rhythm (as ys tole/PEA). In both pathways therapies
are des igned around periods (2 minutes or 5 cycles ) of uninterrupted, high-quality CPR. In
this cas e we will focus on the as ys tole component of the as ys tole/PEA pathway.

87

P a r t

Id e n t ific a t io n
a n d Co r r e c t io n o f
Un d e r lyin g Ca u s e

Treatment of as ys tole is not limited to the interventions outlined in the algorithm.


Healthcare providers s hould attempt to identify and correct an underlying caus e if pres ent.
Res cuers mus t s top, think, and as k Why did this pers on have this cardiac arres t at this
time? It is es s ential to s earch for and treat revers ible caus es of as ys tole for res us citative efforts to be potentially s ucces s ful. Us e the Hs and Ts to recall conditions that could
have contributed to as ys tole. See column on the right of the algorithm and the PEA cas e
for more information on the Hs and Ts , including clinical clues and s ugges ted treatments .

Ap p lic a t io n o f t h e Ca rd ia c Ar re s t Alg o r it h m : As ys t o le P a t h w a y
In t r o d u c t io n

In this cas e you have a patient in cardiac arres t. High-quality CPR is performed throughout the BLS Survey and the ACLS Survey. Interrupt CPR for 10 s econds or les s while you
perform a rhythm check. You interpret the rhythm on the monitor as as ys tole. CPR beginning with ches t compres s ions for 2 minutes res umes immediately. You now conduct the
s teps outlined in the as ys tole pathway of the Cardiac Arres t Algorithm beginning with
Box 9. At the s ame time you are s earching for a pos s ible underlying caus e of the as ys tole.

Co n fir m e d As ys t o le

Give priority to IV/IO acces s . Do not routinely ins ert an advanced airway unles s ventilations with a bag-mas k are ineffective. Do not interrupt CPR while es tablis hing IV or
IO acces s .

Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )

Continue high-quality CPR, and as s oon as IV/IO acces s is available, give a vas opres s or as follows :
Ep ine p hrine 1 mg IV/IOrepeat every 3 to 5 minutes
or
Va s o p re s s in 40 units IV/IO to replace firs t or s econd dos e of epinephrine
Ad m in is te r d ru g s d u rin g CP R. Do n ot s top CP R to a d m in is te r d ru g s .
You can s ubs titute vas opres s in for either the firs t or s econd dos e of epinephrine.
Cons ider advanced airway and capnography.

FYI 2 0 1 0 Gu id e lin e s
No Atro p ine During
As ys to le

De c is io n P o in t :
Rh yt h m Ch e c k

Although there is no evidence that atropine has detrimental effects during bradycardic or as ys tolic cardiac arres t, routine us e of atropine during PEA or as ys tole is
unlikely to have a therapeutic benefit. The AHA removed atropine from the Cardiac
Arres t Algorithm.

Check the rhythm after 2 minutes (about 5 cycles ) of CPR.


In te rru p tion of c h e s t c om p re s s ion s to c on d u c t a rh yth m c h e c k s h ou ld n ot
e xc e e d 10 s e c on d s .

No n s h o c k a b le
Rh yt h m

88

If no electrical activity is present (as ys tole), go back to Box 10 or 11.


If electrical activity is pres ent, try to palpate a puls e.
If no pulse is present or if there is any doubt about the pres ence of a puls e, continue
CPR, s tarting with ches t compres s ions for 2 minutes . Go back to Box 10 and repeat
the s equence.
If a good pulse is present and the rhythm is organized, begin pos tcardiac arres t care.

Th e ACLS Ca s e s : As ys tole

S h o c k a b le Rh yt h m

If the rhythm check reveals a s hockable rhythm, prepare to deliver a s hock (res uming
ches t compres s ions during charging if appropriate). Refer to the left s ide of the algorithm
and perform s teps according to the VF/VT s equence, s tarting with Box 5 or 7.

As ys t o le a n d P EA
Tr e a t m e n t S e q u e n c e s

The diagram in Figure 28 (in the previous cas e, PEA) s ummarizes the recommended
s equence of CPR, rhythm checks , and delivery of drugs for PEA and as ys tole bas ed on
expert cons ens us .

TCP No t
Re c o m m e n d e d

Several randomized controlled trials failed to s how benefit from attempted TCP for as ys tole. At this time the AHA does not recommend the us e of TCP for patients with as ys tolic
cardiac arres t.

Ro u t in e S h o c k
Ad m in is t r a t io n No t
Re c o m m e n d e d

There is no evidence that attempting to defibrillate as ys tole is beneficial. In one s tudy


the group that received s hocks had a trend toward wors e outcome. Given the importance
of minimizing interruption of ches t compres s ions , there is no jus tification for interrupting
ches t compres s ions to deliver a s hock to patients with as ys tole.

Wh e n in Do u b t

If it is unclear whether the rhythm is fine VF or as ys tole, an initial attempt at defibrillation


may be warranted. Fine VF may be the res ult of a prolonged arres t. At this time the benefit
of delaying defibrillation to perform CPR before defibrillation is unclear. EMS s ys tem medical directors may cons ider implementing a protocol that allows EMS res ponders to provide CPR while preparing for defibrillation of patients found by EMS pers onnel to be in VF.

Te r m in a t in g Re s u s c it a t ive Effo r t s
Te r m in a t in g
In -Ho s p it a l
Re s u s c it a t ive
Effo r t s

If res cuers cannot rapidly identify a revers ible caus e and the patient fails to res pond to
the BLS and ACLS Surveys and s ubs equent interventions , termination of all res us citative
efforts s hould be cons idered.
The decis ion to terminate res us citative efforts res ts with the treating phys ician in the
hos pital and is bas ed on cons ideration of many factors , including
Time from collaps e to CPR
Time from collaps e to firs t defibrillation attempt
Comorbid dis eas e
Prearres t s tate
Initial arres t rhythm
Res pons e to res us citative meas ures
None of thes e factors alone or in combination is clearly predictive of outcome. However,
the duration of res us citative efforts is an important factor as s ociated with poor outcome.
The chance that the patient will s urvive to hos pital dis charge and be neurologically intact
diminis hes as res us citation time increas es . Stop the res us citation attempt when you determine with a high degree of certainty that the patient will not res pond to further ACLS.

89

P a r t

Te r m in a t in g
Ou t -o f-Ho s p it a l
Re s u s c it a t ive
Effo r t s

Continue out-of-hos pital res us citative efforts until one of the following occurs :

Du r a t io n o f
Re s u s c it a t ive Effo r t s

Available s cientific s tudies demons trate that in the abs ence of mitigating factors , prolonged res us citative efforts are unlikely to be s ucces s ful. The final decis ion to s top res us citative efforts can never be as s imple as an is olated time interval. If ROSC of any duration
occurs , it may be appropriate to cons ider extending the res us citative effort.

Res toration of effective, s pontaneous circulation and ventilation


Trans fer of care to a s enior emergency medical profes s ional
The pres ence of reliable criteria indicating irrevers ible death
The healthcare provider is unable to continue becaus e of exhaus tion or dangerous
environmental hazards or becaus e continued res us citation places the lives of others
in jeopardy
A valid DNAR order is pres ented
Online authorization from the medical control phys ician or by prior medical protocol
for termination of res us citation

Experts have developed clinical rules to as s is t in decis ions to terminate res us citative
efforts for in-hos pital and out-of-hos pital arres ts . You s hould familiarize yours elf with the
es tablis hed policy or protocols for your hos pital or EMS s ys tem.
It may als o be appropriate to cons ider other is s ues , s uch as drug overdos e and s evere
prearres t hypothermia (eg, s ubmers ion in icy water) when deciding whether to extend
res us citative efforts . Special res us citation interventions and prolonged res us citative efforts
may be indicated for patients with hypothermia, drug overdos e, or other potentially revers ible caus es of arres t.

As ys t o le :
An Ag o n a l Rh yt h m
Co n fir m in g
De a t h

You will s ee as ys tole mos t frequently in 2 s ituations :

Et h ic a l
Co n s id e r a t io n s

The res us citation team mus t make a cons cientious and competent effort to give patients
a trial of CPR and ACLS, provided the patient had not expres s ed a decis ion to forego
res us citative efforts and the victim is not obvious ly dead (eg, rigor mortis , decompos ition,
hemis ection, decapitation) (s ee the DNAR dis cus s ion on the Student Webs ite). The final
decis ion to s top res us citative efforts can never be as s imple as an is olated time interval.

As a terminal rhythm in a res us citation attempt that s tarted with another rhythm
As the firs t rhythm identified in a patient with unwitnes s ed or prolonged arres t
In either of thes e s cenarios , as ys tole mos t often repres ents an agonal rhythm confirming death rather than a rhythm to be treated or a patient who can be res us citated if the
attempt pers is ts long enough. Pers is tent as ys tole repres ents extens ive myocardial is chemia and damage from prolonged periods of inadequate coronary perfus ion. Prognos is
is very poor unles s a s pecial res us citation circums tance or immediately revers ible caus e
is pres ent. Survival from as ys tole is better for in-hos pital than for out-of-hos pital arres ts
according to data from Get With The Guidelines Res us citation, formerly the National
Regis try of CPR (www.he a rt.o rg /re s us c ita tio n).

See Human, Ethical, and Legal Dimens ions of CPR on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt).

90

Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Tr a n s p o r t o f P a t ie n t s
in Ca r d ia c Ar r e s t

Emergency medical res pons e s ys tems s hould not require field pers onnel to trans port
every patient in cardiac arres t back to a hos pital or to an ED. Trans portation with continuing CPR is jus tified if interventions available in the ED cannot be performed in the outof-hos pital s etting and they are indicated for s pecial circums tances (ie, cardiopulmonary
bypas s or extracorporeal circulation for patients with s evere hypothermia).
After out-of-hos pital cardiac arres t with ROSC, trans port the patient to an appropriate
hos pital with a comprehens ive pos tcardiac arres t treatment s ys tem of care that includes
acute coronary interventions , neurologic care, goal-directed critical care, and hypothermia.
Trans port the in-hos pital pos tcardiac arres t patient to an appropriate critical care unit
capable of providing comprehens ive pos tcardiac arres t care.

Ac u t e Co ro n a r y S yn d ro m e s Ca s e
In t r o d u c t io n

The ACLS provider mus t have the bas ic knowledge to as s es s and s tabilize patients with
ACS. Patients in this case have signs and symptoms of ACS, including possible AMI. You
will us e the ACS Algorithm as the guide to clinical s trategy.
The initial 12-lead ECG is us ed in all ACS cas es to clas s ify patients into 1 of 3 ECG
categories , each with different s trategies of care and management needs . Thes e 3 ECG
categories are ST-s egment elevation s ugges ting current injury, ST-s egment depres s ion
s ugges ting is chemia, and nondiagnos tic or normal ECG. Thes e are outlined in the ACS
Algorithm, but STEMI with time-s ens itive reperfus ion s trategies is the focus of this cours e
(Figure 30).
Key components of this cas e are
Identification, as s es s ment, and triage of acute is chemic ches t dis comfort
Initial treatment of pos s ible ACS
Emphas is on early reperfus ion of the patient with ACS/STEMI

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Dis cus s the differential diagnos is of life-threatening ches t dis comfort
2. Apply the ACS Algorithm for initial us e of drugs
3. Apply the ACS Algorithm for initial drug dos es
4. Apply the ACS Algorithm for initial res us citation s trategies and triage patients with
s udden cardiac death to PCI facilities
5. Explain early identification of patients with ACS
6. Explain ris k s tratification of patients with ACS
7. Explain initial treatment of patients with ACS
8. Explain actions , indications , precautions , contraindications , dos age, and adminis tration for oxygen, as pirin, nitroglycerin, morphine, and heparin (low-molecular-weight
heparin [LMWH] or unfractionated heparin [UFH])
9. Des cribe guidelines for reperfus ion s trategies

91

P a r t

Rh yt h m s fo r ACS

Sudden cardiac death due to VF and hypotens ive bradyarrythmias occurs with acute is chemia. Providers will unders tand to anticipate thes e rhythms and be prepared for immediate attempts at defibrillation and adminis tration of drug or electrical therapy for s ymptomatic bradyarrhythmias .
Although 12-lead ECG interpretation is beyond the s cope of the ACLS Provider Cours e,
s ome ACLS providers will have 12-lead ECG reading s kills . For them, this cas e s ummarizes the identification and management of patients with STEMI.

Dr u g s fo r ACS

Drug therapy and treatment s trategies continue to evolve rapidly in the field of ACS. ACLS
providers and ins tructors will need to monitor important changes . The ACLS Provider
Cours e pres ents only bas ic knowledge focus ing on early treatment and the priority of
rapid reperfus ion, relief of is chemic pain, and treatment of early life-threatening complications . Reperfus ion may involve the us e of fibrinolytic therapy or coronary angiography with
PCI (ie, balloon angioplas ty/s tenting). When us ed as the initial reperfus ion s trategy for
STEMI, PCI is called primary percutaneous coronary intervention or PPCI.
Treatment of ACS involves the initial us e of drugs to relieve is chemic dis comfort, dis s olve
clots , and inhibit thrombin and platelets . Thes e drugs are
Oxygen
As pirin
Nitroglycerin
Morphine
Fibrinolytic therapy (overview)
Heparin (UFH, LWMH)
Additional agents that are adjunctive to initial therapy and will not be dis cus s ed in the
ACLS Provider Cours e are
-Blockers
Adenos ine diphos phate (ADP) antagonis ts (clopidogrel, pras ugrel)
Angiotens in-converting enzyme (ACE) inhibitors
HMG-CoA reductas e inhibitor (s tatin therapy)

Go a ls fo r ACS P a t ie n t s
Fo u n d a t io n a l Fa c t s
Out-o f-Ho s p ita l Ca rd ia c
Arre s t Re s p o ns e

Half of the patients who die of ACS do s o before reaching the hos pital. VF or puls eles s
VT is the precipitating rhythm in mos t of thes e deaths . VF is mos t likely to develop
during the firs t 4 hours after ons et of s ymptoms .
Communities s hould develop programs to res pond to out-of-hos pital cardiac arres t.
Such programs s hould focus on
Recognizing s ymptoms of ACS
Activating the EMS s ys tem, with EMS advance notification of the receiving hos pital
Providing early CPR
Providing early defibrillation with AEDs available through public acces s defibrillation
programs and firs t res ponders
Providing a coordinated s ys tem of care among the EMS s ys tem, the ED, and
Cardiology

92

Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

FYI 2 0 1 0 Gu id e lin e s
Go a ls o f The ra p y
fo r ACS

The 2010 AHA Gu id e lin e s for CP R a n d ECC c o m b ine d the p rim a ry a nd s e c o nd a ry


g o a ls a nd c o ns id e re d a ll g o a ls p rim a ry g o a ls .
The primary goals are
Identification of patients with STEMI and triage for early reperfus ion therapy
Relief of is chemic ches t dis comfort
Prevention of MACE, s uch as death, nonfatal MI, and the need for urgent pos tinfarction revas cularization
Treatment of acute, life-threatening complications of ACS, s uch as VF/puls eles s VT,
s ymptomatic bradycardias , and uns table tachycardias
Reperfus ion therapy opens an occluded coronary artery with either drugs or mechanical means . Clot bus ter drugs are called fibrinolytics, a more accurate term than
thrombolytics. PCI, performed in the heart catheterization s uite following coronary
angiography, allows balloon dilation and/or s tent placement for an occluded coronary
artery. PCI performed as the initial reperfus ion method is called primary PCI.

P a t h o p h ys io lo g y
o f ACS

Patients with coronary atheros cleros is may develop a s pectrum of clinical s yndromes repres enting varying degrees of coronary artery occlus ion. Thes
s yndromes
include
Ae Uns
tab le plaq
ue uns table
Ea rly(UA),
p la q NSTEMI,
ue fo rm aand
tio nSTEMI. Sudden cardiac death may occur with each of thes e
angina
B Plaq ue rupture
s yndromes . Figure 29 illus trates the pathophys iology of ACS.
C Uns table angina
A AUnsUns
tabletab
plaque
le plaq ue
D
Microemboli
Ea rly p la q ue fo rm a tio n
B Plaque rupture
Plaq
ueive
rupture
EUnsOccus
thrombus
CB
table angina
D CMicroemboli
Uns table angina
Sig ni c a nt p la q ue fo rm a tio n
E Occlus ive thrombus
A D Microemboli
E Occus ive thrombus

Sig ni c a nt p la q ue fo rm a tio n
A

P la q ue rup ture /thro m b us

C
D

P la q ue rup ture /thro m b us

STEMI

STEMI

Uns ta b le
a ng ina /
D
NSTEMI

Uns ta b le
a ng ina /
NSTEMI
Re s o lutio n /s ta b le a ng ina

Re s o lutio n /s ta b le a ng ina
Fig u re 2 9 . Pathophys iology of ACS.

93

P a r t

Ac ute Co ro na rySynd ro m e s
1
Sym p to m s s ug g e s tive o fis c he m ia o rinfa rc tio n
2
EMSa s s e s s m e nta nd c a re a n d h o s p ita lp re p a ra tio n :

Monitor,s upportABCs .Be prepare dtoprovideCPRanddefibrilla tion
Adminis tera s pirinandcons id eroxyge n,nitroglyc erin,and morphine ifnee ded
O btain12-lea dECG;ifSTelevation:
Notifyre ceivinghos p italwithtrans mis s ionorinterpretation;notetimeof
ons etandfirs tmed ica lconta ct
Notifiedhos pitals houldmobilizehos pitalres ources tores pondtoSTEMI
Ifcons ideringprehos pitalfibrinolys is ,us efibrinolyticchecklis t

3
Co nc urre ntEDa s s e s s m e nt(<10m inute s )
C heckvitals igns ;evaluate oxygens a turation
Es ta blis hIVacce s s
P erformbrie f,targeted his tory,phys ic alexa m
Review/c omp lete fibrinolyticchec klis t;
che ckcontra indications
O btaininitialc ardia cmarkerlevels ,
initiale lectrolyteandcoagulations tudie s

O bta inportableches tx-ra y(<30minute s )

Im m e d ia te EDg e ne ra ltre a tm e nt
IfO 2 s a t<94% ,s tarto xyg e nat4L/min,titrate
As p irin160to325mg(ifnotgive nb yEMS)
Nitro g lyc e rins ublingua lors pray
Mo rp hine IVifdis c omfortnotrelievedby
nitroglycerin

4
ECGinte rp re ta tio n

13

STd e p re s s io no rd yna m ic
T-wa ve inve rs io n;s tro ng ly
s us p ic io us fo ris c he m ia
Hig h-ris kuns ta b le a ng ina /
n o nST-e le va tio n MI(UA/NSTEMI)

No rm a lo rno nd ia g no s tic c ha ng e s
inSTs e g m e nto rTwa ve
Lo w-/inte rm e d ia te -ris kACS

STe le va tio no rne wo r


p re s um a b lyne wLBBB;
s tro ng lys us p ic io us fo rinjury
ST-e le va tio nMI(STEMI)

14

7
Tim e fro m o ns e tof
s ym p tom s 12ho urs ?

Co ns id e ra d m is s io n
to EDc he s tp a inunito r
to a p p ro p ria te b e d a nd
fo llo w:
S e ria lcardiacmarkers
(includingtrop onin)
Rep eatECG/continuous
ST-s egmentmonitoring

C ons idernoninvas ive
diagnos ticte s t

10

S ta rta d ju nc tive the ra p ie s


a s indica te d
Do no td e la yre p e rfus io n
>1 2
hours

Tro p o n in e le va te d o rh ig h -ris kp a tie nt


Cons idere arlyinva s ives trategyif:
Re frac toryis c hemic c hes td is comfort
Re curre nt/pe rs is tentSTdevia tion
Ventricula rtachycard ia
Hemod yna mic ins tab ility
Signs ofheartfailure

11
1 2 h ou rs

8
Re p e rfus io n g o a ls :
Therap yde fined b yp atientand
centerc rite ria
Do o r-to b a llo o ninfla tio n (P CI)
g o a lo f90m inute s
Do o r-to -n e e d le (fib rin o lys is )
g o a lo f30m inute s

Sta rta d junc tive tre a tm e nts a s ind ic a te d


Nitroglycerin
Heparin(UFHorLMWH)
Cons ider:PO-blockers
Cons ider:Clopidogrel
Cons ider:GlycoproteinIIb/IIIainhibitor

Ye s

12

De ve lo p s 1o rm o re :
Clinic a lhigh-ris kfe a ture s

Dyna m ic ECGc ha ng e s
c o ns is te ntwithis c he m ia
Tro po nine le va te d

16

Ad m itto m o nito re d b e d
As s e s s ris ks ta tus
Co ntinue ASA,he p a rin,a nd o the r
the ra p ie s a s ind ic a te d
ACEinhibitor/ARB
HMGCoAreduc ta s einhibitor
(s tatintherap y)
Nota thighris k:ca rdiologytoris ks tratify

2010AmericanHeartAs s ociation

Fig u re 3 0 . The Acute Coronary Syndromes Algorithm.

94

15

No
Abno rm a ld ia g nos tic
no ninva s ive im a g ing o r
p hys io lo g ic te s ting ?

Ye s

17

No

Ifno e vid e nc e o fis c he m ia


o rinfa rc tio nb yte s ting ,c a n
d is c ha rg e withfo llo w-up

Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Ma n a g in g ACS : Th e Ac u t e Co ro n a r y S yn d ro m e s Alg o r it h m
Ove r vie w
o f t h e Alg o r it h m

The Acute Coronary Syndromes Algorithm (Figure 30) outlines the as s es s ment and management s teps for a patient pres enting with s ymptoms s ugges tive of ACS. The EMS
res ponder in the out-of-hos pital environment can begin immediate as s es s ments and
actions . Thes e include giving oxygen, as pirin, nitroglycerin, and morphine if needed, and
obtaining an initial 12-lead ECG (Box 2). Bas ed on the ECG findings , the EMS provider
may complete a fibrinolytic therapy checklis t and notify the receiving ED of a potential
AMI-STEMI when appropriate (Box 3). If out-of-hos pital providers are unable to complete
thes e initial s teps before the patients arrival at the hos pital, the ED provider s hould implement this component of care.
Subs equent treatment occurs on the patients arrival at the hos pital. ED pers onnel s hould
review the out-of-hos pital 12-lead ECG if available. If not performed, acquis ition of the
12-lead ECG s hould be a priority. The goal is to analyze the 12-lead ECG within 10
minutes of the patients arrival in the ED (Box 4). Hos pital pers onnel s hould categorize
patients into 1 of 3 groups according to analys is of the ST s egment or the pres ence of left
bundle branch block (LBBB) on the 12-lead ECG. Treatment recommendations are s pecific
to each group.
STEMI
High-ris k UA/nonST-elevation MI (NSTEMI)
Intermediate/low-ris k UA
The ACS Cas e will focus on the early reperfus ion of the STEMI patient, emphas izing initial
care and rapid triage for reperfus ion therapy.

Im p o r t a n t
Co n s id e r a t io n s

The ACS Algorithm (Figure 30) provides general guidelines that apply to the initial triage
of patients bas ed on s ymptoms and the 12-lead ECG. Healthcare pers onnel often obtain
s erial cardiac markers (CK-MB, cardiac troponins ) in mos t patients that allow additional
ris k s tratification and treatment recommendations . Two important points for STEMI need
emphas is :
The ECG is central to the initial ris k and treatment s tratification proces s .
Healthcare pers onnel do not need evidence of elevated cardiac markers to make a
decis ion to adminis ter fibrinolytic therapy or perform diagnos tic coronary angiography
with coronary intervention (angioplas ty/s tenting) in STEMI patients .

Ap p lic a t io n o f t h e
ACS Alg o r it h m

FYI 2 0 1 0 Gu id e lin e s
ACS Alg o rithm

The boxes in the algorithm guide as s es s ment and treatment:


Identification of ches t dis comfort s ugges tive of is chemia (Box 1)
EMS as s es s ment, care, trans port, and hos pital prearrival notification (Box 2)
Immediate ED as s es s ment and treatment (Box 3)
Clas s ification of patients according to ST-s egment analys is (Boxes 5, 9, and 13)
STEMI (Boxes 5 through 8)

The AHA introduced changes to the ACS Algorithm to ens ure prompt diagnos is and
treatment. This offers the greates t potential benefit for myocardial s alvage in the firs t
hours of STEMI, and provides early and focus ed management of UA and NSTEMI.
Thes e changes s hould reduce advers e events and improve outcome.

95

P a r t

Id e n t if c a t io n o Ch e s t Dis c o m o r t S u g g e s t ive o Is c h e m ia (Bo x 1 )


S ig n s a n d Co n d it io n s

You s hould know how to identify ches t dis comfort s ugges tive of is chemia. Conduct a
prompt and targeted evaluation of every patient whos e initial complaints s ugges t
pos s ible ACS.
The mos t common s ymptom of myocardial is chemia and infarction is retros ternal ches t
dis comfort. The patient may perceive this dis comfort more as pres s ure or tightnes s than
actual pain.
Symptoms s ugges tive of ACS may als o include
Uncomfortable pres s ure, fullnes s , s queezing, or pain in the center of the ches t las ting
s everal minutes (us ually more than a few minutes )
Ches t dis comfort s preading to the s houlders , neck, one or both arms , or jaw
Ches t dis comfort s preading into the back or between the s houlder blades
Ches t dis comfort with light-headednes s , dizzines s , fainting, s weating, naus ea, or
vomiting
Unexplained, s udden s hortnes s of breath, which may occur with or without ches t
dis comfort
Cons ider the likelihood that the pres enting condition is ACS or one of its potentially lethal
mimics . Other life-threatening conditions that may caus e acute ches t dis comfort are aortic
dis s ection, acute PE, acute pericardial effus ion with tamponade, and tens ion pneumothorax.

Fig u re 3 1 . The STEMI Chain of Survival.

S t a r t in g Wit h
Dis p a t c h

All dis patchers and EMS providers mus t receive training in ACS s ymptom recognition
along with the potential complications . Dis patchers , when authorized by medical control or protocol, s hould tell patients with no his tory of as pirin allergy or s igns of active or
recent gas trointes tinal (GI) bleeding to chew an as pirin (160 to 325 mg) while waiting for
EMS providers to arrive.

EMS As s e s s m e n t , Ca re , a n d Ho s p it a l P re p a r a t io n (Bo x 2 )
In t r o d u c t io n

EMS as s es s ment, care, and hos pital preparation are outlined in Box 2. EMS res ponders
may perform the following as s es s ments and actions during the s tabilization, triage, and
trans port of the patient to an appropriate facility:
Monitor and s upport ABCs
Adminis ter as pirin and cons ider oxygen if O 2 s aturation <94% , nitroglycerin, and morphine if dis comfort unres pons ive to nitrates
Obtain a 12-lead ECG; interpret or trans mit for interpretation
Complete a fibrinolytic checklis t if indicated
Provide prearrival notification to the receiving facility if ST elevation

96

Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Mo n it o r a n d
S u p p o r t ABCs

Monitoring and s upport of ABCs includes

Ad m in is t e r Oxyg e n
a n d Dr u g s

Providers s hould be familiar with the actions , indications , cautions , and treatment of s ide
effects .

Monitoring vital s igns and cardiac rhythm


Being prepared to provide CPR
Us ing a defibrillator if needed

Oxyg e n
EMS providers s hould adminis ter oxyg e n if the patient is dys pneic, is hypoxemic, has
obvious s igns of heart failure, has an arterial oxygen s aturation <94% or the oxygen s aturation is unknown. Providers s hould titrate oxygen therapy to a noninvas ively monitored
oxyhemoglobin s aturation 94% . There is ins ufficient evidence to s upport the routine us e
of oxygen in uncomplicated ACS without s igns of hypoxemia or heart failure or both.

As p irin (Ac e tyls a lic ylic Ac id )


If the patient has not taken a s p irin and has no his tory of true as pirin allergy and no evidence of recent GI bleeding, give the patient as pirin (160 to 325 mg) to chew. In the initial
hours of an ACS, as pirin is abs orbed better when chewed than when s wallowed, particularly if morphine has been given. Us e rectal as pirin s uppos itories (300 mg) for patients
with naus ea, vomiting, active peptic ulcer dis eas e, or other dis orders of the upper GI tract.

Nitrog lyc e rin (Glyc e ryl Trin itra te )


Give the patient 1 s ublingual n itrog lyc e rin tablet (or s pray dos e) every 3 to 5 minutes
for ongoing s ymptoms if it is permitted by medical control and no contraindications exis t.
Healthcare providers may repeat the dos e twice (total of 3 dos es ). Adminis ter nitroglycerin
only if the patient remains hemodynamically s table: SBP is >90 mm Hg or no lower than
30 mm Hg below bas eline (if known) and the heart rate is 50 to 100/min.
Nitroglycerin is a venodilator and needs to be us ed cautious ly or not at all in patients with
inadequate ventricular preload. Thes e s ituations include
Infe rio r wa ll MI a nd rig ht ve ntric ula r (RV) infa rc tio n. RV infarction may complicate
an inferior wall MI. Patients with acute RV infarction are very dependent on RV filling
pres s ures to maintain cardiac output and blood pres s ure. If RV infarction cannot be
confirmed providers mus t us e caution in adminis tering nitrates to patients with inferior
STEMI. If RV infarction is confirmed by right-s ided precordial leads or clinical findings
by an experienced provider, nitroglycerin and other vas odilators (morphine) or volumedepleting drugs (diuretics ) are contraindicated as well.
Hyp o te ns io n, b ra d yc a rd ia , o r ta c hyc a rd ia . Avoid us e of nitroglycerin in patients
with hypotens ion (SBP <90 mm Hg), marked bradycardia (<50/min), or tachycardia.
Re c e nt p ho s p ho d ie s te ra s e inhib ito r us e . Avoid the us e of nitroglycerin if it is s us pected or known that the patient has taken s ildenafil or vardenafil within the previous
24 hours or tadalafil within 48 hours . Nitrates may caus e s evere hypotens ion refractory to vas opres s or agents .

Morp h in e
Give m orp h in e for ches t dis comfort unres pons ive to s ublingual or s pray nitroglycerin if
authorized by protocol or medical control. Morphine is indicated in STEMI when ches t
dis comfort is unres pons ive to nitrates . Us e morphine with caution in UA/NSTEMI becaus e
of an as s ociation with increas ed mortality.

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P a r t

5
Morphine is an important treatment for ACS becaus e it
Produces central nervous s ys tem analges ia, which reduces the advers e effects of
neurohumoral activation, catecholamine releas e, and heightened myocardial oxygen
demand
Produces venodilation, which reduces left ventricular (LV) preload and oxygen
requirements
Decreas es s ys temic vas cular res is tance, thereby reducing LV afterload
Helps redis tribute blood volume in patients with acute pulmonary edema
Remember, morphine is a venodilator. Like nitroglycerin, us e morphine with caution in
patients who may be preload dependent. If hypotens ion develops , adminis ter fluids as a
firs t line of therapy.

Cr it ic a l Co n c e p t s
P a in Re lie f With
Nitro g lyc e rin

Ca u t io n
Us e o f No ns te ro id a l
Anti-infla m m a to ry Drug s

Ob t a in a
1 2 -Le a d ECG

Relief of pain with nitroglycerin is neither s pecific nor a us eful diagnos tic tool to
determine the etiology of s ymptoms in ED patients with ches t pain or dis comfort. GI
etiologies as well as other caus es of ches t dis comfort can res pond to nitroglycerin
adminis tration. Therefore, the res pons e to nitrate therapy is not diagnos tic of ACS.

Us e of nons teroidal anti-inflammatory drugs (NSAIDs ) is contraindicated (except for


as pirin) and s hould be dis continued. Both nons elective as well as COX-2 s elective
drugs s hould not be adminis tered during hos pitalization for STEMI becaus e of the
increas ed ris k of mortality, reinfarction, hypertens ion, heart failure, and myocardial
rupture as s ociated with their us e.

EMS providers s hould obtain a 12-lead ECG. The 2010 AHA Guidelines for CPR and ECC
recommends out-of-hos pital 12-lead ECG diagnos tic programs in urban and s uburban
EMS s ys tems .

EMS Ac t io n

Re c o m m e n d a t io n

12-Le a d ECG if a va ila b le

The AHA recommends routine us e of


12-lead out-of-hos pital ECGs for patients
with s igns and s ymptoms of pos s ible
ACS.

P re a rriva l ho s p ita l no tific a tio n fo r


STEMI

Prearrival notification of the ED s hortens


the time to treatment (10 to 60 minutes
has been achieved in clinical s tudies ) and
s peeds reperfus ion therapy with fibrinolytics or PCI or both, which may reduce
mortality and minimize myocardial injury.

Fib rino lytic c he c klis t if a p p ro p ria te

If STEMI is identified on the 12-lead ECG,


complete a fibrinolytic checklis t if appropriate.

See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for a s ample fibrinolytic
checklis t.

98

Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Im m e d ia t e ED As s e s s m e n t a n d Tre a t m e n t (Bo x 3 )
In t r o d u c t io n

The healthcare team s hould quickly evaluate the patient with potential ACS on the
patients arrival in the ED. Within the firs t 10 minutes , obtain a 12-lead ECG (if not already
performed before arrival) and as s es s the patient.
Th e 12-le a d ECG is a t th e c e n te r of th e d e c is ion p a th wa y in th e m a n a g e m e n t of
is c h e m ic c h e s t d is c om fort a n d is th e on ly m e a n s of id e n tifyin g STEMI.
A targeted evaluation s hould be performed and focus on ches t dis comfort, s igns and
s ymptoms of heart failure, cardiac his tory, ris k factors for ACS, and his torical features that
may preclude the us e of fibrinolytics . For the patient with STEMI, the goals of reperfus ion
are to give fibrinolytics within 30 minutes of arrival or perform PCI within 90 minutes of
arrival.
Figure 32 s hows how to meas ure ST-s egment deviation.
J point plus
0.04 second

II

ST-segment
baseline

ST-segment deviation
= 5.0 mm

TP s egment
(baseline)

V2

V5

J point
plus 0.04
s econd

ST-s egment
baseline

ST-segment
deviation
= 4.5 mm

TP s egment (baseline)

Fig u re 3 2 . How to meas ure ST-s egment deviation. A, Inferior MI. The ST s egment has no low point (it
is covered or concave). B, Anterior MI.

99

P a r t

P a t ie n t As s e s s m e n t
In <1 0 Min u t e s
(Bo x 3 )

As s es s ment of the patient in the firs t 10 minutes s hould include the following:
Check vital s igns and evaluate oxygen s aturation.
Es tablis h IV acces s .
Take a brief focus ed his tory and perform a phys ical examination.
Complete the fibrinolytic checklis t and check for contraindications , if indicated.
Obtain a blood s ample to evaluate initial cardiac marker levels , electrolytes , and
coagulation.
Obtain and review portable ches t x-ray (<30 minutes after the patients arrival in the
ED). This s hould not delay fibrinolytic therapy for STEMI or activation of the PCI team
for STEMI.
Note: The res ults of cardiac markers , ches t x-ray, and laboratory s tudies s hould not
delay reperfus ion therapy unles s clinically neces s ary, eg, s us pected aortic dis s ection or
coagulopathy.

P a t ie n t Ge n e r a l
Tr e a t m e n t (Bo x 3 )

Unles s allergies or contraindications exis t, 4 agents are routinely recommended for cons ideration in patients with is chemic-type ches t dis comfort:
Oxygen if hypoxemic (O 2 % <94% ) or s igns of heart failure
As pirin
Nitroglycerin
Morphine (if ongoing dis comfort or no res pons e to nitrates )
Becaus e thes e agents may have been given out of hos pital, adminis ter initial or s upplemental dos es as indicated. (See the dis cus s ion of thes e drugs in the previous s ection,
EMS As s es s ment, Care, and Hos pital Preparation.)

Cr it ic a l Co n c e p t s
Oxyg e n, As p irin,
Nitra te s , Mo rp hine

Unles s contraindicated, initial therapy with oxygen if needed, as pirin, nitrates , and, if
indicated, morphine is recommended for all patients s us pected of having is chemic
ches t dis comfort.
The major contraindication to nitroglycerin and morphine is hypotens ion, including
hypotens ion from an RV infarction. The major contraindications to as pirin are true
as pirin allergy and active or recent GI bleeding.

S TEMI (Bo xe s 5 Th ro u g h 8 )
In t r o d u c t io n

Patients with STEMI us ually have complete occlus ion of an epicardial coronary artery.
Th e m a in s ta y of tre a tm e n t for STEMI is e a rly re p e rfu s ion th e ra p y a c h ie ve d with
fib rin olytic s or p rim a ry P CI.
Reperfus ion therapy for STEMI is perhaps the mos t important advancement in treatment
of cardiovas cular dis eas e in recent years . Early fibrinolytic therapy or direct catheterbas ed reperfus ion has been es tablis hed as a s tandard of care for patients with STEMI
who pres ent within 12 hours of ons et of s ymptoms with no contraindications . Reperfus ion
therapy reduces mortality and s aves heart mus cle; the s horter the time to reperfus ion, the
greater the benefit. A 47% reduction in mortality was noted when fibrinolytic therapy was
provided in the firs t hour after ons et of s ymptoms .

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Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Cr it ic a l Co n c e p t s
De la y o f The ra p y

Ea r ly Re p e r fu s io n
Th e r a p y

Routinecons ultationwithacardiologis toranotherphys icians houldnotdelaydiagnos is andtreatmentexceptinequivocaloruncertaincas es .Cons ultationdelays


therapyandis as s ociatedwithincreas edhos pitalmortalityrates .
Potentialdelayduringthein-hos pitalevaluationperiodmayoccurfromd o o rtodata
(ECG),fromd a ta todecis ion,andfromd e c is io ntod rug (orPCI).Thes e4major
points ofin-hos pitaltherapyarecommonlyreferredtoas the4Ds .
Allproviders mus tfocus onminimizingdelays ateachofthes epoints .Out-ofhos pitaltrans porttimecons titutes only5% ofdelaytotreatmenttime;EDevaluation
cons titutes 25% to33% ofthis delay.

Rapidlyidentifypatients withSTEMIandquicklys creenthemforindications andcontraindications tofibrinolytictherapybyus ingafibrinolyticchecklis tifappropriate.


Thefirs tqualifiedphys icianwhoencounters apatientwithSTEMIs houldinterpretorconfirmthe12-leadECG,determinetheris k/benefitofreperfus iontherapy,anddirectadminis trationoffibrinolytictherapyoractivationofthePCIteam.EarlyactivationofPCImay
occurwithes tablis hedprotocols .Thefollowingtimeframes arerecommended:
Ifthepatientmeets thecriteriaforfib rin olytic th e ra p y,anEDdoor-to-needletime
(needletimeis thebeginningofinfus ionofafibrinolyticagent)of30minutes is the
medicals ys temgoalthatis cons ideredthelonges ttimeacceptable.Sys tems s hould
s trivetoachievethes hortes ttimepos s ible.
ForP CI,this goalforEDdoortoballooninflationtimeis 90minutes .
Patients whoareineligibleforfibrinolytic therapys houldbecons ideredfortrans ferto
aPCIfacilityregardles s ofdelay.Thes ys tems houldprepareforadoor-to-departure
timeof30minutes whenatrans ferdecis ionis made.
Adjunctivetreatments mayals obeindicated.

Cla s s ify P a t ie n t s Ac c o rd in g t o ST-S e g m e n t De via t io n (Bo xe s 5 , 9 , a n d 1 3 )


Cla s s ify In t o 3
Gr o u p s Ba s e d o n
S T-S e g m e n t
De via t io n

Reviewtheinitial12-leadECG(Box4)andclas s ifypatients into1ofthe3followingclinicalgroups (Boxes 5,9,and13):

Ge n e r a l Gro u p

De s c r ip t io n

STEMI

STelevation

Hig h-ris k UA/NSTEMI

STdepres s ionordynamicT-wave
invers ion

Inte rm e d ia te /lo w-ris k UA

Normalornondiagnos ticECG

STEMIis characterizedbyST-s egmentelevationin2ormorecontiguous leads or


newLBBB.Thres holdvalues forST-s egmentelevationcons is tentwithSTEMIare
J -pointelevationgreaterthan2mm(0.2mV)inleads V2andV3*and1mmormore
inallotherleads orbyneworpres umednewLBBB.
*2.5mminmen<40years ;1.5mminallwomen.
Hig h -ris k UA/ NSTEMIis characterizedbyis chemicST-s egmentdepres s ion0.5mm
(0.05mV)ordynamicT-waveinvers ionwithpainordis comfort.Nonpers is tentortrans ientSTelevation0.5mmfor<20minutes is als oincludedinthis category.
In te rm e d ia te or low-ris k UAis characterizedbynormalornondiagnos ticchanges in
theSTs egmentorTwavethatareinconclus iveandrequirefurtherris ks tratification.
This clas s ificationincludes patients withnormalECGs andthos ewithST-s egment
deviationineitherdirectionof<0.5mm(0.05mV)orT-waveinvers ion2mmor0.2
mV.Serialcardiacs tudies andfunctionaltes tingareappropriate.Notethatadditional
information(troponin)mayplacethepatientintoahigherris kclas s ificationafterinitial
clas s ification.
101

P a r t

5
The ECG clas s ification of is chemic s yndromes is not meant to be exclus ive. A s mall percentage of patients with normal ECGs may be found to have MI, for example. If the initial
ECG is nondiagnos tic and clinical circums tances indicate (eg, ongoing ches t dis comfort),
repeat the ECG.

Us e o f Fib r in o lyt ic
Th e r a p y

A fibrinolytic agent or clot bus ter is adminis tered to patients with J -point ST-s egment
elevation greater than 2 mm (0.2 mV) in leads V2 and V3 and 1 mm or more in all other
leads or by new or pres umed new LBBB (eg, leads III, aVF; leads V3 , V4 ; leads I and aVL)
without contraindications . Fibrin-s pecific agents are effective in achieving normal flow
in about 50% of patients given thes e drugs . Examples of fibrin-s pecific drugs are rtPA,
reteplas e, and tenecteplas e. Streptokinas e was the firs t fibrinolytic us ed widely, but it
is not fibrin s pecific. It is s till the mos t common agent us ed worldwide for acute STEMI
reperfus ion therapy.
Cons iderations for the us e of fibrinolytic therapy are as follows :
In the abs ence of contraindications and in the pres ence of a favorable ris k-benefit
ratio, fibrinolytic therapy is one option for reperfus ion in patients with STEMI and
onset of symptoms within 12 hours of presentation with qualifying ECG findings and if
PCI is not available within 90 minutes of firs t medical contact.
In the abs ence of contraindications , it is als o reas onable to give fibrinolytics to
patients with onset of symptoms within the prior 12 hours and ECG findings cons is tent with true pos terior MI. Experienced providers will recognize this as a condition where ST-s egment depres s ion in the early precordial leads is equivalent to
ST-s egment elevation in others . When thes e changes are as s ociated with other ECG
findings , it is s ugges tive of a STEMI on the pos terior wall of the heart.
Fibrinolytics are generally not recommended for patients pres enting >12 hours after
onset of symptoms. But they may be cons idered if is chemic ches t dis comfort continues with pers is tent ST-s egment elevation.
Do not give fibrinolytics to patients who pres ent >24 hours after the onset of symptoms or patients with ST-s egment depres s ion unles s a true pos terior MI is s us pected.

Us e o f P CI

The mos t commonly us ed form of PCI is coronary intervention with s tent placement.
Primary PCI is us ed as an alternative to fibrinolytics . Rescue PCI is us ed early after fibrinolytics in patients who may have pers is tent occlus ion of the infarct artery (failure to reperfus e with fibrinolytics ), although this term has been recently replaced and included by the
term pharmacoinvasive strategy. PCI has been s hown to be s uperior to fibrinolys is in the
combined end points of death, s troke, and reinfarction in many s tudies for patients pres enting between 3 and 12 hours after ons et. However, thes e res ults have been achieved
in experienced medical s ettings with s killed providers (performing >75 PCIs per year) at a
s killed PCI facility (performing >200 PCIs for STEMI with cardiac s urgery capabilities ).
Cons iderations for the us e of PCI include the following:
At the time of publication of the 2010 AHA Guidelines for CPR and ECC, percutaneous coronary intervention is the treatment of choice for the management of STEMI
when it can be performed effectively with a door-to-balloon time of <90 minutes from
firs t medical contact by a s killed provider at a s killed PCI facility.
Primary PCI may als o be offered to patients pres enting to non-PCI centers if PCI can
be initiated promptly within 90 minutes from EMS arrivalto-balloon time at the PCIcapable hos pital. The TRANSFER AMI (Trial of Routine Angioplas ty and Stenting After
Fibrinolys is to Enhance Reperfus ion in Acute Myocardial Infarction) trial s upports the
trans fer of high-ris k patients who receive fibrinolys is in a non-PCI center witihin 12
hours of s ymptom ons et to a PCI center within 6 hours of fibrinolytic adminis tration to
receive routine early PCI.

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Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s

Forpatients admittedtoahos pitalwithoutPCIcapabilities ,theremaybes ome


benefitas s ociatedwithtrans ferforPCIvers us adminis trationofon-s itefibrinolytics
interms ofreinfarction,s troke,andatrendtolowermortalitywhenPCIcanbeperformedwithin90minutes ofons etofSTEMI.
PCIis als opreferredinpatients withcontraindications tofibrinolytics andis indicated
inpatients withcardiogenics hockorheartfailurecomplicatingMI.
Inpatients withSTEMIwhopres ent3 hours or less from onset of symptoms,treatmentis moretimes ens itive,andPCIis s uperiortofibrinolys is .

Ad ju n c t ive
Tr e a t m e n t s

Otherdrugs areus efulwhenindicatedinadditiontooxygen,s ublingualors praynitroglycerin,as pirin,morphine,andfibrinolytictherapy.Thes einclude


IVnitroglycerin
Heparin
Clopidogrel
-Blockers
ACEinhibitors
HMGCoAreductas einhibitortherapy(s tatin)
IVnitroglycerinandheparinarecommonlyus edearlyinthemanagementofpatients with
STEMI.Thes eagents arebrieflydis cus s edbelow.Wewillnotreviewtheus eof-blockers ,
ACEinhibitors ,ands tatintherapyinSTEMI.Us eofthes eagents requires additional
ris ks tratifications kills andadetailedknowledgeofthes pectrumofACSand,ins ome
ins tances ,continuingknowledgeoftheres ults ofclinicaltrials .

IV Nitrog lyc e rin


Routineus eofIVnitroglycerinis notindicatedandhas notbeens howntos ignificantly
reducemortalityinSTEMI.IVnitroglycerinis indicatedandus edwidelyinis chemics yndromes .Itis preferredovertopicalorlong-actingforms becaus eitcanbetitratedina
patientwithpotentiallyuns tablehemodynamics andclinicalcondition.Indications for
initiationofIVnitroglycerininSTEMIare
Recurrentorcontinuingches tdis comfortunres pons ivetos ublingualors praynitroglycerin
PulmonaryedemacomplicatingSTEMI
Hypertens ioncomplicatingSTEMI
Treatmentgoals us ingIVnitroglycerinareas follows :

Tre a t m e n t Go a l

Ma n a g e m e n t

Re lie f o f is c he m ic c he s t d is c o m fo rt

Titratetoeffect
KeepSBP>90mmHg
LimitdropinSBPto30mmHgbelow
bas elineinhypertens ivepatients

Im p ro ve m e nt in p ulm o na ry e d e m a a nd
hyp e rte ns io n

Titratetoeffect
LimitdropinSBPto10% ofbas elinein
normotens ivepatients
LimitdropinSBPto30mmHgbelow
bas elineinhypertens ivepatients

103

P a r t

He p a rin
Heparin is routinely given as an adjunct for PCI and fibrinolytic therapy with fibrin-s pecific
agents (rtPA, reteplas e, tenecteplas e). It is als o indicated in other s pecific high-ris k s ituations , s uch as LV mural thrombus , atrial fibrillation, and prophylaxis for pulmonary thromboembolis m in patients with prolonged bed res t and heart failure complicating MI. If you
us e thes e drugs you mus t be familiar with dos ing s chedules for s pecific clinical s trategies .
Th e in a p p rop ria te d os in g a n d m on itorin g of h e p a rin th e ra p y h a s c a u s e d e xc e s s
in tra c e re b ra l b le e d in g a n d m a jor h e m orrh a g e in STEMI p a tie n ts . P rovid e rs u s in g
h e p a rin n e e d to kn ow th e in d ic a tion s , d os in g , a n d u s e in th e s p e c ific ACS c a te g orie s .
Th e d os in g , u s e , a n d d u ra tion h a ve b e e n d e rive d from u s e in c lin ic a l tria ls .
Sp e c ific p a tie n ts m a y re q u ire d os e m od ific a tion . Se e th e ECC Ha n d b ook for
we ig h t-b a s e d d os in g g u id e lin e s , in te rva ls of a d m in is tra tion , a n d a d ju s tm e n t (if
n e e d e d ) in re n a l fu n c tion . Se e th e ACC/ AHA Gu id e lin e s for d e ta ile d d is c u s s ion in
s p e c ific c a te g orie s .

Br a d yc a rd ia Ca s e
In t r o d u c t io n

This cas e dis cus s es as s es s ment and management of a patient with symptomatic bradycardia (heart rate <50/min).
The corners tones of managing bradycardia are to
Differentiate between s igns and s ymptoms that are caus ed by the s low rate vers us
thos e that are unrelated
Correctly diagnos e the pres ence and type of AV block
Us e atropine as the drug intervention of firs t choice
Decide when to s tart TCP
Decide when to s tart epinephrine or dopamine to maintain heart rate and blood pres s ure
Know when to call for expert cons ultation regarding complicated rhythm interpretation, drugs , or management decis ions
In addition, you mus t know the techniques and cautions for us ing TCP.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Recognize s igns and s ymptoms of s ymptomatic bradycardia
2. Recognize caus es of s ymptomatic bradycardia
3. State treatments for s ymptomatic bradycardia
4. Determine whether s igns and s ymptoms are caus ed by bradycardia or another condition
5. Identify s econd- and third-degree AV blocks
6. Des cribe indications for TCP and dos es of drugs us ed to treat bradycardia: atropine,
dopamine, and epinephrine

104

Th e ACLS Ca s e s : Bra d yc a rd ia

Rh yt h m s fo r
Br a d yc a r d ia

This cas e involves thes e ECG rhythms :


Sinus bradycardia
Firs t-degree AV block
Second-degree AV block
Type I (Wenckebach/Mobitz I)
Type II (Mobitz II)
Third-degree AV block
You s hould know the major AV blocks becaus e important treatment decis ions are bas ed
on the type of block pres ent (Figure 33). Complete AV block is generally the mos t important and clinically s ignificant degree of block. Als o, complete or third-degree AV block
is the degree of block mos t likely to caus e cardiovas cular collaps e and require immediate pacing. Recognition of a symptomatic bradycardia due to AV block is a primary goal.
Recognition of the type of AV block is a s econdary goal.

105

P a r t

E
Fig u re 3 3 . Examples of AV block. A, Sinus bradycardia with borderline firs t-degree AV block. B, Second-degree AV block type I. C, Seconddegree AV block type II. D, Complete AV block with a ventricular es cape pacemaker (wide QRS: 0.12 to 0.14 s econd). E, Third-degree AV block
with a junctional es cape pacemaker (narrow QRS: <0.12 s econd).

Dr u g s fo r
Br a d yc a r d ia

106

This cas e involves thes e drugs :


Atropine
Dopamine (infus ion)
Epinephrine (infus ion)

Th e ACLS Ca s e s : Bra d yc a rd ia

De s c r ip t io n o f Br a d yc a rd ia
De fin it io n s

Definitions us ed in this cas e are as follows :

Te r m

De fin it io n

Bra d ya rrhythm ia o r b ra d yc a rd ia *

Any rhythm dis order with a heart rate


<60/mineg, third-degree AV blockor
s inus bradycardia. When bradycardia is
the caus e of s ymptoms , the rate is generally <50/min.

Sym p to m a tic b ra d ya rrhythm ia

Signs and s ymptoms due to the s low


heart rate

*For the purpos es of this cas e we will us e the term bradycardia interchangeably with
bradyarrhythmia unles s s pecifically defined.

S ym p t o m a t ic
Br a d yc a r d ia

Sinus bradycardia may have multiple caus es . Some are phys iologic and require no
as s es s ment or therapy. For example, a well-trained athlete may have a heart rate in the
range of 40 to 50/min or occas ionally lower.
In contras t, s ome patients have heart rates in the normal s inus range, but thes e heart
rates are inappropriate or ins ufficient for them. This is called a functional or relative
bradycardia. For example, a heart rate of 70/min is too s low for a patient in cardiogenic
or s eptic s hock.
This cas e will focus on the patient with a bradycardia and heart rate <50/min. Key to the
cas e management is the determination of s ymptoms or s igns due to the decreas ed heart
rate. A s ymptomatic bradycardia exis ts clinically when 3 criteria are pres ent:
1. The heart rate is s low.
2. The patient has s ymptoms .
3. The s ymptoms are due to the s low heart rate.

S ig n s a n d S ym p t o m s

You mus t perform a focus ed his tory and phys ical examination to identify the s igns and
s ymptoms of a bradycardia.
Symptoms include ches t dis comfort or pain, s hortnes s of breath, decreas ed level of cons cious nes s , weaknes s , fatigue, light-headednes s , dizzines s , and pres yncope or s yncope.
Signs include hypotens ion, drop in blood pres s ure on s tanding (orthos tatic hypotens ion),
diaphores is , pulmonary conges tion on phys ical examination or ches t x-ray, frank conges tive heart failure or pulmonary edema, and bradycardia-related (es cape) frequent premature ventricular complexes or VT.

107

P a r t

Ma n a g in g Br a d yc a rd ia : Th e Br a d yc a rd ia Alg o r it h m
Ove r vie w o f t h e
Alg o r it h m

The Bradycardia Algorithm (Figure 34) outlines the s teps for as s es s ment and manage ment
of a patient pres enting with s ymptomatic bradycardia with puls e. Implementation of this
algorithm begins with the identification of bradycardia (Box 1); the heart rate is
<50/min. Firs t s teps include the components of the BLS Survey and the ACLS Survey,
s uch as s upporting circulation and airway management, giving oxygen, monitoring the
rhythm and vital s igns , es tablis hing IV acces s , and obtaining a 12-lead ECG if available
(Box 2). In the differential diagnos is you determine if the patient has s igns or s ymptoms of
poor perfus ion and if thes e are caus ed by the bradycardia (Box 3).
The primary decis ion point in the algorithm is the determination of adequate perfus ion. If
the patient has adequate perfus ion, you obs erve and monitor (Box 4). If the patient has
poor perfus ion, you adminis ter atropine (Box 5). If atropine is ineffective, prepare for TCP
or cons ider dopamine or epinephrine infus ion (Box 5). If indicated, you prepare for trans venous pacing, s earch for and treat contributing caus es , and s eek expert cons ultation
(Box 6).
The treatment s equence in the algorithm is determined by the s everity of the patients
condition. You may need to implement multiple interventions s imultaneous ly. If cardiac
arres t develops , go to the Cardiac Arres t Algorithm.

108

Th e ACLS Ca s e s : Bra d yc a rd ia

Ad ult Bra d yc a rd ia
(With Puls e)

As s es s appropriatenes s for clinical condition.


Heart rate typically <50/min if bradyarrhythmia.

2
Id e ntify a nd tre a t und e rlying c a us e
Maintainpatentairway;as s is tbreathingas neces s ary
Oxygen(ifhypoxemic)
Cardiacmonitortoidentifyrhythm;monitorbloodpres s ureandoximetry
IVacces s
12-LeadECGifavailable;dontdelaytherapy

3
P e rs is te nt b ra d ya rrhythm ia
c a us ing :

4
Mo nito r a nd o b s e rve

No

Hypotens ion?
Acutely altered mental s tatus ?
Signs of s hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s

Atro p ine
Ifatropineineffective:
Trans cutaneous pacing
OR
Do p a m ine infus ion
OR
Ep ine p hrine infus ion

Do s e s /De ta ils
Atro p ine IV Do s e :
Firs tdos e:0.5mgbolus
Repeatevery3-5minutes
Maximum:3mg
Do p a m ine IV Infus io n:
2-10mcg/kgperminute
Ep ine p hrine IV Infus io n:
2-10mcgperminute

6
Co ns id e r:
Expertcons ultation
Trans venous pacing
2010 American Heart As s ociation

Fig u re 3 4 . TheBradycardiaAlgorithm.

FYI 2 0 1 0 Gu id e lin e s
The Bra d yc a rd ia
Alg o rithm

TheBradycardiaAlgorithmhas beenmodifiedtoreflectthechanges intreatment


pres ented in the 2010 AHA Guidelines for CPR and ECC.
Theinitialtreatmentofbradycardiais atropine.Ifbradycardiais unres pons iveto
atropine,IVinfus ionof-adrenergicagonis ts withrate-acceleratingeffects (dopamine,epinephrine)orTCPcanbeeffectivewhilethepatientis beingpreparedfor
emergenttrans venous temporarypacingifrequired.

Ap p lic a t io n o f t h e Br a d yc a rd ia Alg o r it h m
In t r o d u c t io n

Inthis cas eyouhaveapatientpres entingwiths ymptoms ofbradycardia.Youconduct


appropriateas s es s mentandinterventions as outlinedintheBradycardiaAlgorithm.Atthe
s ame time you are s earching for and treating pos s ible contributing factors .
109

P a r t

Id e n t ific a t io n o f
Br a d yc a r d ia (Bo x 1 )

Identify whether the bradycardia is

BLS a n d ACLS
S u r ve ys (Bo x 2 )

Next, perform the ACLS Survey, including the following:

Ar e S ig n s o r
S ym p t o m s Ca u s e d
b y Br a d yc a r d ia ?
(Bo x 3 )

Pres ent by definition, ie, heart rate <50/min


Inadequate for the patients condition (functional or relative)

Maintain patent airway.

As s is t breathing as needed; give oxygen in cas e of hypoxemia; monitor oxygen


s aturation.

Monitor blood pres s ure and heart rate; obtain and review a 12-lead ECG; es tablis h IV acces s .

Conduct a problem-focus ed his tory and phys ical examination; s earch for and
treat pos s ible contributing factors .

Box 3 prompts you to cons ider if the s igns or s ymptoms of poor perfus ion are caus ed by
the bradycardia.
The key clinical ques tions are
Are there s erious s igns or s ymptoms ?
Are the s igns and s ymptoms related to the s low heart rate?
Look for advers e s igns and s ymptoms of the bradycardia:
Symptoms (eg, ches t dis comfort, s hortnes s of breath, decreas ed level of cons cious nes s , weaknes s , fatigue, light-headednes s , dizzines s , pres yncope or s yncope)
Signs (eg, hypotens ion, conges tive heart failure, ventricular arrhythmias related to the
bradycardia)
Sometimes the s ymptom is not due to the bradycardia. For example, hypotens ion as s ociated with bradycardia may be due to myocardial dys function rather than the bradycardia. Keep this in mind when you reas s es s the patients res pons e to treatment.

Cr it ic a l Co n c e p t s
Bra d yc a rd ia

The key clinical ques tion is whether the bradycardia is caus ing the patients s ymptoms or s ome other illnes s is caus ing the bradycardia.

De c is io n P o in t :
Ad e q u a t e P e r fu s io n ?

You mus t now decide if the patient has adequate or poor perfus ion.

Tr e a t m e n t S e q u e n c e
S u m m a r y (Bo x 5 )

If the patient has poor perfus ion s econdary to bradycardia, the treatment s equence is as
follows :

If the patient has a d e q u a te p e rfu s ion , obs erve and monitor (Box 4).
If the patient has p oor p e rfu s ion , proceed to Box 5.

Atropine 0.5 mg IVmay repeat to a total


dos e of 3 mg

Give atropine as firs t-line treatment

If a t ro p in e is in e ffe c t ive
Trans cutaneous pacing
or

110

Dopamine 2 to 10 mcg/kg per minute


(chronotropic or heart rate dos e)
Epinephrine 2 to 10 mcg/min

Th e ACLS Ca s e s : Bra d yc a rd ia

The treatment s equence is determined by the s everity of the patients clinical pres entation.
For patients with s ymptomatic bradycardia, move quickly through this s equence. Thes e
patients may be precardiac arres t and may need multiple interventions s imultaneous ly.

Tr e a t m e n t S e q u e n c e :
At r o p in e

In the abs ence of immediately revers ible caus es , atropine remains the firs t-line drug for
acute s ymptomatic bradycardia. Atropine adminis tration s hould not delay implementation
of external pacing for patients with poor perfus ion. Dopamine and epinephrine may be
s ucces s ful as an alternative to TCP.
For bradycardia, give atropine 0.5 mg IV every 3 to 5 minutes to a total dos e of 0.04 mg/kg
(maximum total dos e of 3 mg). Atropine dos es of <0.5 mg may paradoxically res ult in further s lowing of the heart rate.
Us e atropine cautious ly in the pres ence of acute coronary is chemia or MI. An atropinemediated increas e in heart rate may wors en is chemia or increas e infarct s ize.
Do not rely on atropine in Mobitz type II s econd- or third-degree AV block or in patients
with third-degree AV block with a new wide QRS complex.

Tr e a t m e n t S e q u e n c e :
P a c in g

TCP may be us eful for treatment of s ymptomatic bradycardia. TCP is noninvas ive and can
be performed by ACLS providers .
Healthcare providers s hould cons ider immediate pacing in uns table patients with highdegree heart block when IV acces s is not available. It is reas onable for healthcare providers to initiate TCP in uns table patients who do not res pond to atropine.
Following initiation of pacing, confirm electrical and mechanical capture. Reas s es s the
patient for s ymptom improvement and hemodynamic s tability. Give analges ics and s edatives for pain control. Note that many of thes e drugs may further decreas e blood pres s ure
and affect the patients mental s tatus . Try to identify and correct the caus e of the bradycardia.
Some limitations apply. TCP can be painful and may fail to produce effective electrical and
mechanical capture. If s ymptoms are not caus ed by the bradycardia, pacing may be ineffective des pite capture.
If you chos e TCP as the s econdline treatment and it is als o ineffective (eg, incons is tent
capture), begin an infus ion of dopamine or epinephrine and prepare for pos s ible trans venous pacing by obtaining expert cons ultation.

Fo u n d a t io n a l Fa c t s
Se d a tio n a nd P a c ing

Mos t cons cious patients s hould be given s edation before pacing. If the patient is in
cardiovas cular collaps e or rapidly deteriorating, it may be neces s ary to s tart pacing
without prior s edation, particularly if drugs for s edation are not immediately available.
The clinician mus t evaluate the need for s edation in light of the patients condition and
need for immediate pacing. A review of the drugs us ed is beyond the s cope of the
ACLS Provider Cours e. The general approach could include the following:
Give parenteral benzodiazepine for anxiety and mus cle contractions .
Give a parenteral narcotic for analges ia.
Us e a chronotropic infus ion once available.
Obtain expert cons ultation for trans venous pacing.

111

P a r t

Tr e a t m e n t S e q u e n c e :
Ep in e p h r in e ,
Do p a m in e

Although -adrenergic agonis ts with rate-accelerating effects are not firs t-line agents for
treatment of s ymptomatic bradycardia, they are alternatives to TCP or in s pecial circums tances s uch as overdos e with a -blocker or calcium channel blocker.
Becaus e epinephrine and dopamine are vas ocons trictors , as well as chronotropes , healthcare providers mus t as s es s the patients intravas cular volume s tatus and avoid hypovolemia when us ing thes e drugs .
Both epinephrine and dopamine infus ions may be us ed for patients with s ymptomatic
bradycardia, particularly if as s ociated with hypotens ion, for whom atropine may be inappropriate or after atropine fails .
Begin epinephrine infus ion at a dos e of 2 to 10 mcg/min and titrate to patient res pons e.
Begin dopamine infus ion at 2 to 10 mcg/kg per minute and titrate to patient res pons e. At
lower dos es dopamine has a more s elective effect on inotropy and heart rate; at higher
dos es (>10 mcg/kg per minute) it als o has vas ocons trictive effects .

Ne xt Ac t io n s
(Bo x 6 )

After cons ideration of the treatment s equence in Box 5, you may need to
Prepare the patient for trans venous pacing
Treat the contributing caus es of the bradycardia
Cons ider expert cons ultationbut do not delay treatment if the patient is uns table or
potentially uns table

Tr a n s c u t a n e o u s P a c in g
In t r o d u c t io n

A variety of devices can pace the heart by delivering an electrical s timulus , caus ing electrical depolarization and s ubs equent cardiac contraction. TCP delivers pacing impuls es
to the heart through the s kin by us e of cutaneous electrodes . Mos t manufacturers have
added a pacing mode to manual defibrillators .
The ability to perform TCP is now often as clos e as the neares t defibrillator. Providers
need to know the indications , techniques , and hazards for us ing TCP.

In d ic a t io n s

Indications for TCP are as follows :


Hemodynamically uns table bradycardia (eg, hypotens ion, acutely altered mental
s tatus , s igns of s hock, is chemic ches t dis comfort, acute heart failure hypotens ion)
Uns table clinical condition likely due to the bradycardia
For pacing readines s in the s etting of AMI as follows :
Symptomatic s inus bradycardia
Mobitz type II s econd-degree AV block
Third-degree AV block
New left, right, or alternating bundle branch block or bifas cicular block
Bradycardia with s ymptomatic ventricular es cape rhythms

P r e c a u t io n s

Precautions for TCP are as follows :


TCP is contraindicated in s evere hypothermia and is not recommended for as ys tole.
Cons cious patients require analges ia for dis comfort unles s delay for s edation will
caus e/contribute to deterioration.
Do not as s es s the carotid puls e to confirm mechanical capture; electrical s timulation
caus es mus cular jerking that may mimic the carotid puls e.

112

Th e ACLS Ca s e s : Bra d yc a rd ia

Te c h n iq u e

Perform TCP by following thes e s teps :

Ste p

Ac t io n

Place pacing electrodes on the ches t according to package ins tructions .

Turn the pacer ON.

Set the demand rate to approximately 60/min. This rate can be adjus ted
up or down (bas ed on patient clinical res pons e) once pacing is es tablis hed.

Set the current milliamperes output 2 mA above the dos e at which cons is tent capture is obs erved (s afety margin).

External pacemakers have either fixed rates (as ynchronous mode) or demand rates .

As s e s s Re s p o n s e t o
Tr e a t m e n t

Rather than target a precis e heart rate, the goal of therapy is to ens ure improvement in
clinical s tatus (ie, s igns and s ymptoms related to the bradycardia). Signs of hemodynamic
impairment include hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic
ches t dis comfort, acute heart failure, or other s igns of s hock related to the bradycardia.
Start pacing at a rate of about 60/min. Once pacing is initiated, adjus t the rate bas ed on
the patients clinical res pons e. Mos t patients will improve with a rate of 60 to 70/min if the
s ymptoms are primarily due to the bradycardia.
Cons ider giving atropine before pacing in mildly s ymptomatic patients . Do not delay
pacing for uns table patients , particularly thos e with high-degree AV block. Atropine may
increas e heart rate, improve hemodynamics , and eliminate the need for pacing. If atropine
is ineffective or likely to be ineffective or if es tablis hment of IV acces s or atropine adminis tration is delayed, begin pacing as s oon as it is available.
Patients with ACS s hould be paced at the lowes t heart rate that allows clinical s tability.
Higher heart rates can wors en is chemia becaus e heart rate is a major determinate of myocardial oxygen demand. Is chemia, in turn, can precipitate arrhythmias .
An alternative to pacing if s ymptomatic bradycardia is unres pons ive to atropine is a chronotropic drug infus ion to s timulate heart rate:
Epinephrine: Initiate at 2 to 10 mcg/min and titrate to patient res pons e
Dopamine: Initiate at 2 to 10 mcg/kg per minute and titrate to patient res pons e

Br a d yc a r d ia Wit h
Es c a p e Rh yt h m s

A bradycardia may lead to bradycardia-dependent ventricular rhythms . When the heart


rate falls , an electrically uns table ventricular area may es cape s uppres s ion by higher
and fas ter pacemakers (eg, s inus node), es pecially in the s etting of acute is chemia.
Thes e ventricular rhythms often fail to res pond to drugs . With s evere bradycardia s ome
patients will develop wide-complex ventricular beats that can precipitate VT or VF. Pacing
may increas e the heart rate and eliminate bradycardia-dependent ventricular rhythms .
However, an accelerated idioventricular rhythm (s ometimes called AIVR) may occur in the
s etting of inferior wall MI. This rhythm is us ually s table and does not require pacing.
Patients with ventricular es cape rhythms may have normal myocardium with dis turbed
conduction. After correction of electrolyte abnormalities or acidos is , rapid pacing can
s timulate effective myocardial contractions until the conduction s ys tem recovers .

113

P a r t

S t a n d b y P a c in g

Several bradycardic rhythms in ACS are caus ed by acute is chemia of conduction tis s ue
and pacing centers . Patients who are clinically s table may decompens ate s uddenly or
become uns table over minutes to hours from wors ening conduction abnormalities . Thes e
bradycardias may deteriorate to complete AV block and cardiovas cular collaps e.
Place TCP electrodes in anticipation of clinical deterioration in patients with acute myocardial is chemia or infarction as s ociated with the following rhythms :
Symptomatic s inus node dys function with s evere and s ymptomatic s inus bradycardia
As ymptomatic Mobitz type II s econd-degree AV block
As ymptomatic third-degree AV block
Newly acquired left, right, or alternating bundle branch block or bifas cicular block in
the s etting of AMI

Un s t a b le Ta c h yc a rd ia Ca s e
In t r o d u c t io n

If you are the team leader in this cas e, you will conduct the as s es s ment and management
of a patient with a rapid, unstable heart rate. You mus t be able to clas s ify the tachycardia
and implement appropriate interventions as outlined in the Tachycardia Algorithm. You will
be evaluated on your knowledge of the factors involved in s afe and effective s ynchronized
cardiovers ion as well as your performance of the procedure.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Differentiate characteris tics of s table and uns table tachycardias
2. Des cribe the ACLS priorities of care in the Tachycardia Algorithm
3. Identify uns table patients and follow this arm of the Tachycardia Algorithm
4. Des cribe energy levels required for electrical cardiovers ion of tachycardia varieties
5. Demons trate s afety procedures when performing cardiovers ion

Rh yt h m s fo r Un s t a b le
Ta c h yc a r d ia

This cas e involves thes e ECG rhythms :

Dr u g s fo r Un s t a b le
Ta c h yc a r d ia

Drugs are generally not us ed to manage patients with uns table tachycardia. Immediate
cardiovers ion is recommended. Cons ider adminis tering s edative drugs in the cons cious
patient. But do not delay immediate cardiovers ion in the uns table patient.

Atrial fibrillation
Atrial flutter
Reentry s upraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type

Th e Ap p ro a c h t o Un s t a b le Ta c h yc a rd ia
In t r o d u c t io n

114

A tachyarrhythmia (rhythm with heart rate >100/min) has many potential caus es and may
be s ymptomatic or as ymptomatic. The key to management of a patient with any tachycardia is to determine whether puls es are pres ent. If puls es are pres ent, determine whether
the patient is s table or uns table and then provide treatment bas ed on patient condition
and rhythm.

Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia

If the tachyarrhythmia is s inus tachycardia, conduct a diligent s earch for the caus e of the
tachycardia. Treatment and correction of this caus e will improve the s igns and s ymptoms .

De fin it io n s

Definitions us ed in this cas e are as follows :

Te r m

De fin it io n

Ta c hya rrhythm ia , ta c hyc a rd ia *

Heart rate >100/min

Sym p to m a tic ta c hya rrhythm ia

Signs and s ymptoms due to the rapid


heart rate

*For the purpos es of this cas e we will us e the term tachycardia interchangeably with
tachyarrhythmia. Sinus tachycardia will be s pecifically indicated.

P a t h o p h ys io lo g y
o f Un s t a b le
Ta c h yc a r d ia

Uns table tachycardia exis ts when the heart rate is too fas t for the patients clinical condition and the exces s ive heart rate caus es s ymptoms or an uns table condition becaus e the
heart is
Beating so fast that cardiac output is reduced; this can caus e pulmonary edema,
coronary is chemia, and reduced blood flow to vital organs (eg, brain, kidneys )
Beating ineffectively s o that coordination between the atrium and ventricles or the
ventricles thems elves reduces cardiac output

S ym p t o m s a n d S ig n s

Uns table tachycardia leads to s erious s igns and s ymptoms that include
Hypotens ion
Acutely altered mental s tatus
Signs of s hock
Is chemic ches t dis comfort
Acute heart failure (AHF)

Ra p id Re c o g n it io n
Is t h e Ke y t o
Ma n a g e m e n t

The 2 keys to management of patients with uns table tachycardia are


1. Rapid recognition that the patient is significantly symptomatic or even unstable
2. Rapid recognition that the signs and symptoms are caused by the tachycardia
You m u s t q u ic kly d e te rm in e wh e th e r th e p a tie n ts ta c h yc a rd ia is p rod u c in g h e m od yn a m ic in s ta b ility a n d s e riou s s ig n s a n d s ym p tom s or wh e th e r th e
s ig n s a n d s ym p tom s (e g , th e p a in a n d d is tre s s of a n AMI) a re p rod u c in g th e
ta c h yc a rd ia .
This determination can be difficult. Many experts s ugges t that when a heart rate is
<150/min, it is unlikely that s ymptoms of ins tability are caus ed primarily by the tachycardia unles s there is impaired ventricular function. A heart rate >150/min is an
inappropriate res pons e to phys iologic s tres s (eg, fever, dehydration) or other underlying conditions .

S e ve r it y

As s es s for the pres ence or abs ence of s igns and s ymptoms and for their s everity.
Frequent patient as s es s ment is indicated.

115

P a r t

In d ic a t io n s fo r
Ca r d io ve r s io n

Rapid identification of s ymptomatic tachycardia will help you determine whether you
s hould prepare for immediate cardiovers ion. For example:
Sinus tachycardia is a phys iologic res pons e to extrins ic factors , s uch as fever, anemia, or hypotens ion/s hock, which create the need for increas ed cardiac output. There
is us ually a high degree of s ympathetic tone and neurohormonal factors . Sinus tachycardia will not res pond to cardiovers ion. In fact, if a s hock is delivered, the heart rate
often increas es .
If the patient with tachycardia is s table (ie, no s erious s igns related to the tachycardia), patients may await expert cons ultation becaus e treatment has the potential for
harm.
Atrial flutter typically produces a heart rate of approximately 150/min (lower rates may
be pres ent in patients who have received antiarrhythmic therapy). Atrial flutter at this
rate is often s table in the patient without heart or s erious s ys temic dis eas e.
At rates >150/min, s ymptoms are often pres ent and cardiovers ion is often required if
the patient is uns table.
If the patient is s erious ly ill or has underlying cardiovas cular dis eas e, s ymptoms may
be pres ent at lower rates .
You mus t know when cardiovers ion is indicated, how to prepare the patient for it (including appropriate medication), and how to s witch the defibrillator/monitor to operate as a
cardioverter.

Ma n a g in g Un s t a b le Ta c h yc a rd ia :
Th e Ta c h yc a rd ia Alg o r it h m
In t r o d u c t io n

The Tachycardia Algorithm s implifies initial management of tachycardia. The pres ence or
abs ence of puls es is cons idered key to management of a patient with any tachycardia.
If puls es are pres ent, determine whether the patient is s table or uns table and then provide treatment bas ed on the patients condition and rhythm. If a puls eles s tachycardia is
pres ent, then manage the patient according to the Cardiac Arres t Algorithm (Figure 19,
page 61).
The ACLS provider s hould either be an expert or be able to obtain expert cons ultation.
Actions in the boxes require advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy and are intended to be accomplis hed in the in-hos pital s etting with
expert cons ultation available.

Ove r vie w

The Tachycardia Algorithm (Figure 35) outlines the s teps for as s es s ment and management
of a patient pres enting with s ymptomatic tachycardia with puls es . Implementation of this
algorithm begins with the identification of tachycardia with puls es (Box 1). If a tachycardia
and a puls e are pres ent, perform as s es s ment and management s teps guided by the BLS
Survey and the ACLS Survey (Box 2). The key in this as s es s ment is to decide if the tachycardia is s table or uns table.
If s igns and s ymptoms pers is t des pite provis ion of s upplementary oxygen and s upport of
airway and circulation and if s ignificant s igns or s ymptoms are due to the tachycardia (Box
3), then the tachycardia is uns table and immediate s ynchronized cardiovers ion is indicated
(Box 4).

116

Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia

If the patient is s table, you will evaluate the ECG, and determine if the QRS complex is
wide or narrow and regular or irregular (Box 5). The treatment of s table tachycardia is pres ented in the next cas e (Box 6).
A precis e diagnos is of the rhythm (eg, reentry SVT, atrial flutter) may not be pos s ible at
this time.

Fo u n d a t io n a l Fa c t s
Se rio us o r Sig nific a nt
Sym p to m s
Uns ta b le Co nd itio n

Intervention is determined by the pres ence of s ignificant s ymptoms or by an uns table


condition res ulting from the tachycardia.*
Serious s ymptoms and s igns include
Hypotens ion
Acutely altered mental s tatus
Signs of s hock
Is chemic ches t dis comfort
Acute heart failure (AHF)
Ventricular rates <150/min us ually do not caus e s erious s igns or s ymptoms .

FYI 2 0 1 0 Gu id e lin e s
Ta c hyc a rd ia With a P uls e
Alg o rithm

Su m m a r y

The 2010 Tachycardia With a Puls e Algorithm (Figure 35) is pres ented in the traditional
box-and-line format. Overall, the algorithm has been s implified and redes igned to facilitate learning and memorization of the treatment recommendations and to emphas ize
the importance of identifying whether the tachycardia is a caus e or a s ymptom of an
underlying condition, which is fundamental to the management of all tachyarrhythmias .

Your as s es s ment and management of this patient will be guided by the following key
ques tions pres ented in the Tachycardia Algorithm:
Are s ymptoms pres ent or abs ent?
Is the patient s table or uns table?
Is the QRS narrow or wide?
Is the rhythm regular or irregular?
Is the QRS monomorphic or polymorphic?
Your ans wers to thes e ques tions will determine the next appropriate s teps .

117

P a r t

Ad ult Ta c hyc a rd ia
(With Puls e)

1
As s es s appropriatenes s for clinical condition.
Heart rate typically 150/min if tachyarrhythmia.

2
Id e ntify a nd tre a t und e rlying c a us e

Do s e s /De ta ils

Maintainpatentairway;as s is tbreathingas neces s ary


Oxygen(ifhypoxemic)
C ardiacmonitortoidentifyrhythm;monitorblood
pres s ureandoximetry

Sync hro nize d Ca rd io ve rs io n


Initialrecommendeddos es :
Narrowregular:50-100J
Narrowirregular:120-200J biphas ic
or200J monophas ic
Wideregular:100J
Wideirregular:defibrillationdos e
(NOTs ynchronized)

3
4

P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?

Ye s

No

Wid e QRS?
0.12 s e c o nd

Sync hro nize d c a rd io ve rs io n


Cons iders edation
Ifregularnarrowcomplex,
cons ider adenos ine

Ye s

IVacces s and12-leadECG
ifavailable
C ons ideradenos ineonlyif
regularandmonomorphic
Cons iderantiarrhythmicinfus ion
Cons iderexpertcons ultation

No

IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons iderexpertcons ultation

Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired.
An tia rrh yth m ic In fu s ion s for
Sta b le Wid e -QRS Ta c h yc a rd ia
P ro c a ina m id e IV Do s e :
20-50mg/minuntilarrhythmia
s uppres s ed,hypotens ionens ues ,
QRSdurationincreas es >50% ,or
maximumdos e17mg/kggiven.
Maintenanceinfus ion:1-4mg/min.
AvoidifprolongedQTorCHF.
Am io d a ro ne IV Do s e :
Firs tdos e:150mgover10minutes .
Repeatas neededifVTrecurs .
Followbymaintenanceinfus ionof
1mg/minforfirs t6hours .
So ta lo l IV Do s e :
100mg(1.5mg/kg)over5minutes .
AvoidifprolongedQT.

2010 American Heart As s ociation

Fig u re 3 5 . TheTachycardiaWithaPuls eAlgorithm.

Ap p lic a t io n o f t h e Ta c h yc a rd ia Alg o r it h m t o t h e Un s t a b le P a t ie n t

118

In t r o d u c t io n

Inthis cas eyouhaveapatientwithtachycardiaandapuls e.Youconductthes teps outlinedintheTachycardiaAlgorithmtoevaluateandmanagethepatient.

As s e s s
Ap p r o p r ia t e n e s s
fo r Clin ic a l
Co n d it io n (Bo x 1 )

Tachycardiais definedas anarrhythmiawitharate>100/min.


Theratetakes onclinicals ignificanceatits greaterextremes andis morelikelyattributabletoanarrhythmiarateof150/min.
Itis unlikelythats ymptoms ofins tabilityarecaus edprimarilybythetachycardiawhen
theheartrateis <150/minunles s thereis impairedventricularfunction.

Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia

Id e n t ify a n d Tr e a t
t h e Un d e r lyin g
Ca u s e : BLS a n d
ACLS S u r ve ys
(Bo x 2 )

Us e the BLS Survey and the ACLS Survey to guide your approach.
Look for s igns of increas ed work of breathing (tachypnea, intercos tal retractions ,
s upras ternal retractions , paradoxical abdominal breathing) and hypoxemia as determined by puls e oximetry.
Give oxygen, if indicated and monitor oxygen s aturation.
Obtain an ECG to identify the rhythm.
Evaluate blood pres s ure.
Es tablis h IV acces s .
Identify and treat revers ible caus es .
If s ymptoms pers is t des pite s upport of adequate oxygenation and ventilation, proceed to
Box 3.

Cr it ic a l Co n c e p t s
Uns ta b le P a tie nts

De c is io n P o in t :
Is t h e P e r s is t e n t
Ta c h ya r r h yt h m ia
Ca u s in g S ig n ific a n t
S ig n s o r S ym p t o m s ?
(Bo x 3 )

Healthcare providers s hould obtain a 12-lead ECG early in the as s es s ment to better
define the rhythm.
However, uns table patients require immediate cardiovers ion.
Do not delay immediate cardiovers ion for acquis ition of the 12-lead ECG if the
patient is uns table.

As s es s the patients degree of ins tability and determine if the ins tability is related to the
tachycardia.

Un s ta b le
If the patient demons trates rate-related cardiovas cular compromis e with s igns and s ymptoms s uch as hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic ches t
dis comfort, acute heart failure, or other s igns of s hock s us pected to be due to a tachyarrhythmia, proceed to immediate s ynchronized cardiovers ion (Box 4).
Serious s igns and s ymptoms are unlikely if the ventricular rate is <150/min in patients with
a healthy heart. However, if the patient is s erious ly ill or has s ignificant underlying heart
dis eas e or other conditions , s ymptoms may be pres ent at a lower heart rate.

Sta b le
If the patient does not have rate-related cardiovas cular compromis e, proceed to Box 5.
The healthcare provider has time to obtain a 12-lead ECG, evaluate the rhythm, determine if the width of the QRS, and determine treatment options . Stable patients may await
expert cons ultation becaus e treatment has the potential for harm.

119

P a r t

Fo u n d a t io n a l Fa c t s
Tre a tm e nt Ba s e d o n
Typ e o f Ta c hyc a rd ia

You may not always be able to dis tinguis h between s upraventricular and ventricular
rhythms . Mos t wide-complex (broad-complex) tachycardias are ventricular in origin
(es pecially if the patient has underlying heart dis eas e or is older). If the patient is
puls eles s , treat the rhythm as VF and follow the Cardiac Arres t Algorithm.
If the patient has a wide-complex tachycardia and is uns table, as s ume it is VT until
proven otherwis e. The amount of energy required for cardiovers ion of VT is determined
by the morphologic characteris tics .
If the patient is uns table but has a puls e with regular uniform wide-complex VT
(monomorphic VT).
Treat with s ynchronized cardiovers ion and an initial s hock of 100 J (monophas ic
waveform).
If there is no res pons e to the firs t s hock, increas ing the dos e in a s tepwis e fas hion
is reas onable.*
Arrhythmias with a polymorphic QRS appearance (polymorphic VT), s uch as
tors ades de pointes will us ually not permit s ynchronization. If the patient has
polymorphic VT:
Treat as VF with high-energy uns ynchronized s hocks (eg, defibrillation dos es ).
If there is any doubt about whether an uns table patient has monomorphic or polymorphic VT, do not delay treatment for further rhythm analys is . Provide high-energy,
uns ynchronized s hocks .
*No s tudies that addres s ed this is s ue had been identified at the time that the manus cript for the 2010 AHA Guidelines for CPR and ECC was in preparation. Thus , this
recommendation repres ents expert opinion.

P e r fo r m Im m e d ia t e
S yn c h r o n iz e d
Ca r d io ve r s io n
(Bo x 4 )

If pos s ible es tablis h IV acces s before cardiovers ion and adminis ter s edation if the
patient is cons cious .
Do not delay cardiovers ion if the patient is extremely uns table.
Further information about cardiovers ion appears below.
If the patient with a regular narrow-complex SVT or a monomorphic wide-complex tachycardia is not hypotens ive, healthcare providers may adminis ter adenos ine while preparing
for s ynchronized cardiovers ion.
If cardiac arres t develops , s ee the Cardiac Arres t Algorithm.

De t e r m in e t h e Wid t h
o f t h e QRS Co m p le x
(Bo x 5 )

If the width of the QRS complex is 0.12 s econd, go to Box 6.


If the width of the QRS complex is <0.12 s econd, go to Box 7.

Ca rd io ve r s io n
In t r o d u c t io n

You mus t know when cardiovers ion is indicated and what type of s hock to adminis ter.
Before cardiovers ion, es tablis h IV acces s and s edate the res pons ive patient if pos s ible,
but do not delay cardiovers ion in the uns table or deteriorating patient.
This s ection dis cus s es the following important concepts about cardiovers ion:
The difference between uns ynchronized and s ynchronized s hocks
Potential challenges to delivery of s ynchronized s hocks
Energy dos es for s pecific rhythms

120

Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia

Un s yn c h r o n iz e d vs
S yn c h r o n iz e d S h o c k s

Modern defibrillator/cardioverters are capable of delivering 2 types of s hocks :


Uns ynchronized s hocks
Synchronized s hocks
An unsynchronized s hock s imply means that the electrical s hock will be delivered as s oon
as the operator pus hes the SHOCK button to dis charge the device. Thus , the s hock may
fall randomly anywhere within the cardiac cycle. These shocks should use higher energy
levels than synchronized cardioversion.
Synchronized cardioversion us es a s ens or to deliver a s hock that is s ynchronized with
a peak of the QRS complex (eg, the highes t point of the R wave). When this option
(the s ync option) is engaged, the operator pres s es the SHOCK button to deliver a
s hock. There will likely be a delay before the defibrillator/cardioverter delivers a s hock
becaus e the device will s ynchronize s hock delivery with the peak of the R wave in the
patients QRS complex. This s ynchronization may require analys is of s everal complexes .
Synchronization avoids the delivery of a s hock during cardiac repolarization (repres ented
on the s urface ECG as the T wave), a period of vulnerability in which a s hock can precipitate VF. Synchronized cardiovers ion us es a lower energy level than attempted defibrillation. Low-energy s hocks s hould always be delivered as s ynchronized s hocks to avoid
precipitating VF.

P o t e n t ia l P r o b le m s
Wit h S yn c h r o n iz a t io n

In theory, s ynchronization is s imple. The operator pus hes the SYNC control on the face
of the defibrillator/cardioverter. In practice, however, there are potential problems . For
example:
If the R-wave peaks of a tachycardia are undifferentiated or of low amplitude, the
monitor s ens ors may be unable to identify an R-wave peak and therefore will not
deliver the s hock.
Many cardioverters will not s ynchronize through the handheld quick-look paddles . An
unwary practitioner may try to s ynchronizeuns ucces s fully in that the machine will
not dis chargeand may not recognize the problem.
Synchronization can take extra time (eg, if it is neces s ary to attach electrodes or if the
operator is unfamiliar with the equipment).

Re c o m m e n d a t io n s

Wh e n to Us e Syn c h ron ize d Sh oc ks


Synchronized s hocks are recommended for patients with
Uns table
Uns table
Uns table
Uns table

SVT
atrial fibrillation
atrial flutter
regular monomorphic tachycardia with puls es

Wh e n to Us e Un s yn c h ron ize d Sh oc ks
Uns ynchronized high-energy s hocks are recommended
For a patient who is puls eles s
For a patient demons trating clinical deterioration (in prearres t), s uch as thos e with
s evere s hock or polymorphic VT, when you think a delay in converting the rhythm will
res ult in cardiac arres t
When you are uns ure whether monomorphic or polymorphic VT is pres ent in the
uns table patient
Should the uns ynchronized s hock caus e VF (occurring in only a very s mall minority of
patients des pite the theoretical ris k), immediately attempt defibrillation.

121

P a r t

En e r g y Do s e s fo r
Ca r d io ve r s io n

Select the energy dos e for the s pecific type of rhythm.


For uns table atrial fibrillation:
Monophas ic cardiovers ion: Deliver an initial 200-J s ynchronized s hock.
Biphas ic cardiovers ion: Deliver an initial 120- to 200-J s ynchronized s hock.
In either cas e, increas e the energy dos e in a s tepwis e fas hion for any s ubs equent cardiovers ion attempts .
A dos e of 120 J to 200 J is reas onable with a biphas ic waveform. Es calate the s econd
and s ubs equent s hock dos e as needed.
Cardiovers ion of atrial flutter and SVT generally require les s energy. An initial energy dos e
of 50 J to 100 J with a monophas ic or biphas ic waveform is often s ufficient. If the initial
50-J dos e fails , increas e the dos e in a s tepwis e fas hion.
Monomorphic VT (regular form and rate) with a puls e res ponds well to monophas ic or
biphas ic waveform cardiovers ion (s ynchronized) s hocks at an initial dos e of 100 J . If there
is no res pons e to the firs t s hock, increas e the dos e in a s tepwis e fas hion. No s tudies were
identified that addres s ed this is s ue. Thus , this recommendation repres ents expert opinion.

S yn c h ro n iz e d Ca rd io ve r s io n Te c h n iq u e
In t r o d u c t io n

Synchronized cardiovers ion is the treatment of choice when a patient has a s ymptomatic
(uns table) reentry SVT or VT with puls es . It is als o recommended to treat uns table atrial
fibrillation and uns table atrial flutter.
Cardiovers ion is unlikely to be effective for treatment of junctional tachycardia or ectopic
or multifocal atrial tachycardia becaus e thes e rhythms have an automatic focus aris ing
from cells that are s pontaneous ly depolarizing at a rapid rate. Delivery of a s hock generally
cannot s top thes e rhythms and may actually increas e the rate of the tachyarrhythmia.
In s ynchronized cardiovers ion, s hocks are adminis tered through adhes ive electrodes or
handheld paddles . You will need to place the defibrillator/monitor in synchronized (sync)
mode. The s ync mode is des igned to deliver energy jus t after the R wave of the QRS
complex.

122

Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia

Te c h n iq u e

Follow thes e s teps to perform s ynchronized cardiovers ion. Modify the s teps for your s pecific device.

Ste p

Ac t io n

Sedate all cons cious patients unles s uns table or deteriorating rapidly.

Turn on the defibrillator (monophas ic or biphas ic).

Attach monitor leads to the patient (white to right, red to ribs , whats left
over to the left s houlder) and ens ure proper dis play of the patients rhythm.
Pos ition adhes ive electrode (conductor) pads on the patient.

Pres s the SYNC control button to engage the s ynchronization mode.

Look for markers on the R wave indicating s ync mode.

Adjus t monitor gain if neces s ary until s ync markers occur with each R wave.

Select the appropriate energy level.


Deliver monophas ic s ynchronized s hocks in the following s equence:

If

In it ia l Do s e *

Uns ta b le a tria l fib rilla tio n

200 J

Uns ta b le m o no m o rp hic VT

100 J

Othe r uns ta b le SVT/Atria l flutte r

50 to 100 J

P o lym o rp hic VT (irre g ula r fo rm


a nd ra te ) a nd uns ta b le

Treat as VF with high-energy s hock


(defibrillation dos es )

*Biphas ic waveforms us ing lower energy are acceptable if documented to


be clinically equivalent or s uperior to reports of monophas ic s hock s ucces s .
Extrapolation from elective cardiovers ion of atrial fibrillation s upports an initial
biphas ic dos e of 120 J to 200 J with es calation as needed.
Cons ult the device manufacturer for s pecific recommendations .
8

Announce to team members : Charging defibrillators tand clear!

Pres s the CHARGE button.

10

Clear the patient when the defibrillator is charged. (See Foundational Facts :
Clearing for Defibrillation in the VF/Puls eles s VT Cas e.)

11

Pres s the SHOCK button(s ).

12

Check the monitor. If tachycardia pers is ts , increas e the energy level (joules )
according to the Electrical Cardiovers ion Algorithm.

13

Activate the s ync mode after delivery of each s ynchronized s hock. Most
defibrillators default back to the unsynchronized mode after delivery of a
synchronized shock. This default allows an immediate s hock if cardiovers ion
produces VF.

123

P a r t

S t a b le Ta c h yc a rd ia Ca s e
In t r o d u c t io n

This cas e reviews as s es s ment and management of a stable patient (ie, no serious signs
related to the tachycardia) with a rapid heart rate. Patients with heart rates >100/min
have a tachyarrhythmia or tachycardia. In this cas e we will us e the terms tachycardia and
tachyarrhythmia interchangeably. Note that s inus tachycardia is excluded from the treatment algorithm. Sinus tachycardia is almos t always phys iologic, developing in res pons e to
a compromis e in s troke volume or a condition that requires an increas e in cardiac output
(eg, fever, hypovolemia). Treatment involves identification and correction of that underlying
problem.
You mus t be able to clas s ify the type of tachycardia (wide or narrow; regular or irregular)
and implement appropriate interventions as outlined in the Tachycardia Algorithm. During
this cas e you will
Perform initial as s es s ment and management
Treat regular narrow-complex rhythms (except s inus tachycardia) with vagal maneuvers and adenos ine
If the rhythm does not convert, you will monitor the patient and trans port or obtain expert
cons ultation. If the patient becomes clinically uns table, you will prepare for immediate uns ynchronized s hock or s ynchronized cardiovers ion as dis cus s ed in the Uns table
Tachycardia Cas e.

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Perform an initial patient as s es s ment to identify s ymptoms of a s table tachycardia
2. Identify s inus tachycardia
3. State that treatment of s inus tachycardia involves identification of an underlying
caus e
4. Differentiate between tachycardias with narrow or wide QRS complexes
5. Treat s table tachycardias by us ing the Tachycardia Algorithm
6. Verbalize when to cons ider expert cons ultation

Rh yt h m s fo r S t a b le
Ta c h yc a r d ia

Tachycardias can be clas s ified in s everal ways bas ed on the appearance of the QRS complex, heart rate, and whether they are regular or irregular:
NarrowQRS complex (SVT) tachycardias (QRS <0.12 s econd) in order of frequency
Sinus tachycardia
Atrial fibrillation
Atrial flutter
AV nodal reentry
WideQRS complex tachycardias (QRS 0.12 s econd)
Monomorphic VT
Polymorphic VT
Regular or irregular tachycardias
Irregular narrow-complex tachycardias are probably atrial fibrillation

124

Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia

Dr u g s fo r S t a b le
Ta c h yc a r d ia

This cas e involves the following drug:


Adenos ine
Several agents are als o us ed to provide analges ia and s edation during electrical cardiovers ion. Thes e agents are not covered in the ACLS Provider Cours e.

Ap p ro a c h t o S t a b le Ta c h yc a rd ia
In t r o d u c t io n

In this cas e a s table tachycardia refers to a condition in which the patient has
A heart rate >100/min
No s ignificant s igns or s ymptoms caus ed by the increas ed rate
An underlying cardiac electrical abnormality that generates the rhythm

Qu e s t io n s t o
De t e r m in e
Cla s s ific a t io n

Clas s ification of the tachycardia depends on the careful clinical evaluation of thes e ques tions :
Are s ymptoms pres ent or abs ent?
Are s ymptoms due to the tachycardia?
Is the patient s table or uns table?
Is the QRS complex narrow or wide?
Is the rhythm regular or irregular?
Is the QRS monomorphic or polymorphic?
Is the rhythm s inus tachycardia?
The ans wers guide s ubs equent diagnos is and treatment.

Fo u n d a t io n a l Fa c t s
Und e rs ta nd ing Sinus
Ta c hyc a rd ia

Sinus tachycardia is a heart rate that is >100/min and is generated by s inus node
dis charge. The heart rate in s inus tachycardia does not exceed 220/min and is agerelated. Sinus tachycardia us ually does not exceed 120 to 130/min, and it has a
gradual ons et and gradual termination. Reentry SVT has an abrupt ons et and termination.
Sinus tachycardia is caus ed by external influences on the heart, s uch as fever,
anemia, hypotens ion, blood los s , or exercis e. Thes e are s ys temic conditions , not
cardiac conditions . Sinus tachycardia is a regular rhythm, although the rate may be
s lowed by vagal maneuvers . Cardiovers ion is contraindicated.
-Blockers may caus e clinical deterioration if the cardiac output falls when a compensatory tachycardia is blocked. This is becaus e cardiac output is determined by
the volume of blood ejected by the ventricles with each contraction (s troke volume)
and the heart rate.
Cardiac output (CO) = Stroke volume (SV) Heart rate
If a condition s uch as a large AMI limits ventricular function (s evere heart failure
or cardiogenic s hock), the heart compens ates by increas ing the heart rate. If you
attempt to reduce the heart rate in patients with a compens atory tachycardia, cardiac output will fall and the patients condition will likely deteriorate.
In s in u s ta c h yc a rd ia th e g oa l is to id e n tify a n d tre a t th e u n d e rlyin g s ys te m ic
cause.

125

P a r t

Ma n a g in g S t a b le Ta c h yc a rd ia : Th e Ta c h yc a rd ia Alg o r it h m
In t r o d u c t io n

As noted in the Uns table Tachycardia Cas e, the key to management of a patient with
any tachycardia is to determine whether puls es are pres ent, and if puls es are pres ent, to
determine whether the patient is s table or uns table and then to provide treatment bas ed
on patient condition and rhythm. If the patient is puls eles s , manage the patient according
to the Cardiac Arres t Algorithm (Figure 19, page 61). If the patient has puls es , manage the
patient according to the Tachycardia Algorithm (Figure 36, page 127).

Ove r vie w

If a tachycardia and a puls e are pres ent, perform as s es s ment and management s teps
guided by the BLS Survey and the ACLS Survey. Determine if s ignificant s ymptoms
or s igns are pres ent and if thes e s ymptoms and s igns are due to the tachycardia. This
will direct you to either the stable (Boxes 5 through 7) or unstable (Box 4) s ection of the
algorithm.
If s ignificant s igns or s ymptoms are due to the tachycardia, then the tachycardia is
unstable and immediate cardiovers ion is indicated (s ee the Uns table Tachycardia
Cas e).
If the patient develops pulseless VT, deliver uns ynchronized high-energy s hocks
(defibrillation energy) and follow the Cardiac Arres t Algorithm.
If the patient has polymorphic VT, treat the rhythm as VF and deliver high-energy
uns ynchronized s hocks (ie, defibrillation energy).
In this cas e the patient is s table, and you will manage according to the s table s ection of
the Tachycardia Algorithm (Figure 36). A precis e identification of the rhythm (eg, reentry
SVT, atrial flutter) may not be pos s ible at this time.

126

Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia

Ad ult Ta c hyc a rd ia
(With Puls e)

1
As s es s appropriatenes s for clinical condition.
Heart rate typically 150/min if tachyarrhythmia.

2
Id e ntify a nd tre a t und e rlying c a us e

Do s e s /De ta ils

Maintainpatentairway;as s is tbreathingas neces s ary


Oxygen(ifhypoxemic)
C ardiacmonitortoidentifyrhythm;monitorblood
pres s ureandoximetry

Sync hro nize d Ca rd io ve rs io n


Initialrecommendeddos es :
Narrowregular:50-100J
Narrowirregular:120-200J biphas ic
or200J monophas ic
Wideregular:100J
Wideirregular:defibrillationdos e
(NOTs ynchronized)

3
4

P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?

Ye s

No
Wid e QRS?
0.12 s e c o nd

Sync hro nize d c a rd io ve rs io n


Cons iders edation
Ifregularnarrowcomplex,
cons ider adenos ine

Ye s

IVacces s and12-leadECG
ifavailable
C ons ideradenos ineonlyif
regularandmonomorphic
Cons iderantiarrhythmicinfus ion
Cons iderexpertcons ultation

No

IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons iderexpertcons ultation

Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired.
An tia rrh yth m ic In fu s ion s for
Sta b le Wid e -QRS Ta c h yc a rd ia
P ro c a ina m id e IV Do s e :
20-50mg/minuntilarrhythmia
s uppres s ed,hypotens ionens ues ,
QRSdurationincreas es >50% ,or
maximumdos e17mg/kggiven.
Maintenanceinfus ion:1-4mg/min.
AvoidifprolongedQTorCHF.
Am io d a ro ne IV Do s e :
Firs tdos e:150mgover10minutes .
Repeatas neededifVTrecurs .
Followbymaintenanceinfus ionof
1mg/minforfirs t6hours .
So ta lo l IV Do s e :
100mg(1.5mg/kg)over5minutes .
AvoidifprolongedQT.

2010 American Heart As s ociation

Fig u re 3 6 . TheTachycardiaWithaPuls eAlgorithm.

Ap p lic a t io n o f t h e Ta c h yc a rd ia Alg o r it h m t o t h e S t a b le P a t ie n t
In t r o d u c t io n

Inthis cas eapatient has stable tachycardia with a pulse. Conductthes teps outlinedin
theTachycardiaAlgorithmtoevaluateandmanagethepatient.

P a t ie n t As s e s s m e n t
(Bo x 1 )

Box1directs youtoas s es s thepatients condition.Typically,aheartrate>150/minatres t


is due to tachyarrhythmias other than s inus tachycardia.

127

P a r t

BLS a n d ACLS
S u r ve ys (Bo x 2 )

Us ing the BLS Survey and the ACLS Survey to guide your approach, evaluate the patient
and do the following as neces s ary:
Look for s igns of increas ed work of breathing and hypoxia as determined by puls e
oximetry.
Give oxygen; monitor oxygen s aturation.
Support the airway, breathing, and circulation.
Obtain an ECG to identify the rhythm; check blood pres s ure.
Identify and treat revers ible caus es .
If s ymptoms pers is t, proceed to Box 3.

De c is io n P o in t :
S t a b le o r Un s t a b le
(Bo x 3 )

Un s ta b le
If the patient is unstable with s igns or s ymptoms as a res ult of the tachycardia (eg, hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic ches t dis comfort, or
AHF), go to Box 4 (perform immediate s ynchronized cardiovers ion). See the Uns table
Tachycardia Cas e.

Sta b le
If the patient is s table, go to Box 5.

IV Ac c e s s a n d
1 2 -Le a d ECG
(Bo x 5 )

If the patient with tachycardia is stable (ie, no s erious s igns or s ymptoms related to the
tachycardia), you have time to evaluate the rhythm and decide on treatment options .
Es tablis h IV acces s if not already obtained. Obtain a 12-lead ECG (when available) or
rhythm s trip to determine if the QRS is narrow (<0.12 s econd) or wide (0.12 s econd).

De c is io n P o in t :
Na r r o w o r Wid e
(Bo x 6 , Bo x 7 )

The path of treatment is now determined by whether the QRS is wide (Box 6) or narrow
(Box 7), and whether the rhythm is regular or irregular. If a monomorphic wide-complex
rhythm is pres ent and the patient is s table, expert cons ultation is advis ed. Polymorphic
wide-complex tachycardia s hould be treated with immediate uns ynchronized cardiovers ion.

Fo u n d a t io n a l Fa c t s
Tre a ting Ta c hyc a rd ia

Wid e (Br o a d )Co m p le x


Ta c h yc a r d ia s
(Bo x 6 )

You may not always be able to dis tinguis h between s upraventricular (aberrant) and
ventricular wide-complex rhythms . If you are uns ure, be aware that mos t widecomplex (broad-complex) tachycardias are ventricular in origin.
If a patient is pulseless, follow the Cardiac Arres t Algorithm.
If a patient becomes unstable, do not delay treatment for further rhythm analys is .
For stable patients with wide-complex tachycardias , trans port and monitor or cons ult an expert, becaus e treatment has the potential for harm.

Wide-complex tachycardias are defined as a QRS of 0.12 s econd. Consider expert consultation.
The mos t common forms of life-threatening wide-complex tachycardias likely to deteriorate to VF are:
Monomorphic VT
Polymorphic VT
Determine if the rhythm is regular or irregular.
A regular wide-complex tachycardia is pres umed to be VT or SVT with aberrancy.
An irregular wide-complex tachycardia may be atrial fibrillation with aberrancy, preexcited atrial fibrillation (atrial fibrillation us ing an acces s ory pathway for antegrade
conduction), or polymorphic VT/tors ades de pointes . Thes e are advanced rhythms
requiring additional expertis e or expert cons ultation.

128

Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia

If the rhythm is likely VT or SVT in a s table patient, treat bas ed on the algorithm for that
rhythm.
If the rhythm etiology cannot be determined and is regular in its rate and monomorphic,
recent evidence s ugges ts that IV adenos ine is relatively s afe for both treatment and diagnos is . IV antiarrhythmic drugs may be effective. We recommend procainamide, amiodarone, or s otalol. See the right column on the algorithm (Figure 36, page 127) for recommended dos es .
In the cas e of irregular wide-complex tachycardia, management focus es on control of the
rapid ventricular rate (rate control), convers ion of hemodynamically uns table atrial fibrillation to s inus rhythm (rhythm control), or both. Expert cons ultation is advis ed.

Ca u t io n
Drug s to Avo id in
P a tie nts With Irre g ula r
Wid e -Co m p le x
Ta c hyc a rd ia

Na r r o w QRS ,
Re g u la r Rh yt h m
(Bo x 7 )

Avoid AV nodal blocking agents s uch as adenos ine, calcium channel blockers ,
digoxin, and pos s ibly -blockers in patients with pre-excitation atrial fibrillation,
becaus e thes e drugs may caus e a paradoxical increas e in the ventricular res pons e.

The therapy for narrow QRS with regular rhythm is :


Attempt vagal maneuvers
Give adenos ine
Vagal maneuvers and adenos ine are the preferred initial interventions for terminating
narrow-complex tachycardias that are s ymptomatic and s upraventricular in origin (SVT).
Vagal maneuvers alone (Vals alva maneuver or carotid s inus mas s age) will terminate about
25% of SVTs . Adenos ine is required for the remainder.
If SVT does not res pond to vagal maneuvers :
Give a d e no s ine 6 mg as a rapid IV pus h in a large (eg, antecubital) vein over 1 s econd. Follow with a 20 mL s aline flus h and elevate the arm immediately.
If SVT does not convert within 1 to 2 minutes , give a s econd dos e of adenos ine
12 mg rapid IV pus h following the s ame procedure above.
Adenos ine increas es AV block and will terminate approximately 90% of reentry arrhythmias within 2 minutes . Adenos ine will not terminate atrial flutter or atrial fibrillation but will
s low AV conduction, allowing for identification of flutter or fibrillation waves .
Adenos ine is s afe and effective in pregnancy. Adenos ine does , however, have s everal
important drug interactions . Larger dos es may be required for patients with s ignificant
blood levels of theophylline, caffeine, or theobromine. The initial dos e s hould be reduced
to 3 mg in patients taking dipyridamole or carbamazepine. There have been recent cas e
reports of prolonged as ys tole following adenos ine adminis tration to patients with trans planted hearts or following central venous adminis tration, s o lower dos es s uch as 3 mg
may be cons idered in thes e s ituations .
Adenos ine may caus e bronchos pas m; therefore, adenos ine s hould not be given to
patients with as thma.

129

P a r t

5
If the rhythm converts with adenos ine, it is probable reentry SVT. Obs erve for recurrence.
Treat recurrence with adenos ine or longer-acting AV nodal blocking agents s uch as the
non-dihydropyridine calcium channel blockers (verapamil and diltiazem) or -blockers .
Typically you s hould obtain expert cons ultation if the tachycardia recurs .
If the rhythm does not convert with adenos ine, it is pos s ible atrial flutter, ectopic atrial
tachycardia, or junctional tachycardia. Obtain expert cons ultation about diagnos is and
treatment.

Ca u t io n :
Wha t to Avo id With AV
No d a l Blo c king Ag e nts

Ta c h yc a r d ia
Alg o r it h m : Ad va n c e d
Ma n a g e m e n t S t e p s

AV nodal blocking drugs s hould not be us ed for pre-excited atrial fibrillation or flutter. Treatment with an AV nodal blocking agent is unlikely to s low the ventricular rate
and in s ome ins tances may accelerate the ventricular res pons e. Caution is advis ed
when combining AV nodal blocking agents that have a longer duration of action,
s uch as calcium channel blockers or -blockers , becaus e their actions may overlap
if given s erially, which can provoke profound bradycardia.

Some ACLS providers may be familiar with the differential diagnos is and therapy of
s table tachycardias that do not res pond to initial treatment. The bas ic ACLS provider is
expected to recognize a s table narrow-complex or wide-complex tachycardia and clas s ify
the rhythm as regular or irregular. Regular narrow-complex tachycardias may be treated
initially with vagal maneuvers and adenos ine. If thes e are uns ucces s ful, the ACLS provider
s hould trans port or seek expert consultation.
If ACLS providers have experience with the differential diagnos is and therapy of s table
tachycardias beyond initial management, the Tachycardia Algorithm lis ts additional s teps
and pharmacologic agents us ed in the treatment of thes e arrhythmias , both for rate control and for termination of the arrhythmia.
If a t a n y p oin t you b e c om e u n c e rta in or u n c om forta b le d u rin g th e tre a tm e n t of
a s ta b le p a tie n t, s e e k e xp e rt c on s u lta tion . Th e tre a tm e n t of s ta b le p a tie n ts m a y
a wa it e xp e rt c on s u lta tion b e c a u s e tre a tm e n t h a s th e p ote n tia l for h a rm .

Ac u t e S t ro k e Ca s e
In t r o d u c t io n

The identification and initial management of patients with acute s troke is within the s cope
of an ACLS provider. This cas e covers principles of out-of-hospital care and fundamental
aspects of initial in-hospital acute stroke care.
Out-of-hos pital acute s troke care focus es on
Rapid identification and as s es s ment of patients with s troke
Rapid trans port (with prearrival notification) to a facility capable of providing acute
s troke care
In-hos pital acute s troke care includes the
Ability to rapidly determine patient eligibility for fibrinolytic therapy
Adminis tration of fibrinolytic therapy to appropriate candidates , with availability of
neurologic medical s upervis ion within target times
Initiation of the s troke pathway and patient admis s ion to a s troke unit if available
The target times and goals are recommended by the National Ins titute of Neurological
Dis orders and Stroke (NINDS), which has recommended meas urable goals for the evaluation of s troke patients . Thes e targets or goals s hould be achieved for at leas t 80% of
patients with acute s troke.

130

Th e ACLS Ca s e s : Ac u te Stroke

Le a r n in g Ob je c t ive s

By the end of this cas e you s hould be able to


1. Des cribe the major s igns and s ymptoms of s troke
2. Clas s ify s trokes to explain s troke types pecific treatments
3. Demons trate the us e of one of the out-of-hos pital s troke s cales (s creening tools ) to
identify patients with s us pected s troke
4. Apply the 8 Ds of Stroke Care
5. Explain why timely action is crucial when s omeone experiences a s troke
6. Follow the Sus pected Stroke Algorithm: NINDS time goals
7. Des cribe why rapid trans port to a healthcare facility capable of providing acute
s troke care is recommended
8. Recall general eligibility criteria for fibrinolytic therapy
9. Activate the s troke team

P o t e n t ia l Ar r h yt h m ia s
Wit h S t r o k e

The ECG does not take priority over obtaining a computed tomography (CT) s can. No
arrhythmias are s pecific for s troke, but the ECG may identify evidence of a recent AMI or
arrhythmias s uch as atrial fibrillation as a caus e of an embolic s troke. Many patients with
s troke may demons trate arrhythmias , but if the patient is hemodynamically s table, mos t
arrhythmias will not require treatment. There is general agreement to recommend cardiac
monitoring during the firs t 24 hours of evaluation in patients with acute is chemic s troke to
detect atrial fibrillation and potentially life-threatening arrhythmias .

Dr u g s fo r S t r o k e

This cas e involves thes e drugs :


Approved fibrinolytic agent (rtPA)
Glucos e (D50 )
Labetalol
Nicardipine
Enalaprilat
As pirin
Nitroprus s ide

Fo u n d a t io n a l Fa c t s
Ma jo r Typ e s o f Stro ke

Stroke is a general term. It refers to acute neurologic impairment that follows interruption in blood s upply to a s pecific area of the brain. Although expeditious s troke care is
important for all patients , this cas e emphas izes reperfus ion therapy for acute is chemic
s troke.
The major types of s troke are
Is chemic s troke: accounts for 87% of all s trokes and is us ually caus ed by an occlus ion of an artery to a region of the brain (Figure 37).
Hemorrhagic s troke: accounts for 13% of all s trokes and occurs when a blood
ves s el in the brain s uddenly ruptures into the s urrounding tis s ue. Fibrinolytic therapy
is contraindicated in this type of s troke. Avoid anticoagulants .

131

P a r t

10%
87%

Is c he m ic

3%

Intra c e re b ra l
Sub a ra c hno id

Fig u re 3 7 . Types of s troke. Eighty-s even percent of s trokes are is chemic and potentially eligible for fibrinolytic therapy if patients otherwis e
qualify. Thirteen percent of s trokes are hemorrhagic, and the majority of thes e are intracerebral. The male-to-female incidence ratio is 1.25 in pers ons 55 to 64 years of age, 1.50 in thos e 65 to 74, 1.07 in thos e 75 to 84, and 0.76 in thos e 85 and older. Blacks have almos t twice the ris k of firs tever s troke compared with whites .

Ap p ro a c h t o S t ro k e Ca re
In t r o d u c t io n

Each year in the United States about 795 000 people s uffer a new or recurrent s troke.
Stroke remains a leading caus e of death in the United States .
Early recognition of acute is chemic s troke is important becaus e IV fibrinolytic treatment
s hould be provided as early as pos s ible, generally within 3 hours of ons et of s ymptoms ,
or within 4.5 hours of ons et of s ymptoms for s elected patients . Mos t s trokes occur at
home, and only half of acute s troke patients us e EMS for trans port to the hos pital. Stroke
patients often deny or try to rationalize their s ymptoms . Even high-ris k patients , s uch
as thos e with atrial fibrillation or hypertens ion, fail to recognize the s igns of s troke. This
delays activation of EMS and treatment, res ulting in increas ed morbidity and mortality.
Community and profes s ional education is es s ential, and it has been s ucces s ful in increas ing the proportion of eligible s troke patients treated with fibrinolytic therapy. Healthcare
providers , hos pitals , and communities mus t continue to develop s ys tems to improve the
efficiency and effectivenes s of s troke care.

Fo u n d a t io n a l Fa c t s
Stro ke Cha in o f Surviva l

The goal of s troke care is to minimize brain injury and maximize the patients recovery. The Stroke Chain of Survival (Figure 38) des cribed by the AHA and the American
Stroke As s ociation is s imilar to the Chain of Survival for s udden cardiac arres t. It links
actions to be taken by patients , family members , and healthcare providers to maximize
s troke recovery. Thes e links are
Rapid
Rapid
Rapid
Rapid

recognition and reaction to s troke warning s igns


EMS dis patch
EMS s ys tem trans port and prearrival notification to the receiving hos pital
diagnos is and treatment in the hos pital

Fig u re 3 8 . The Stroke Chain of Survival.


132

Th e ACLS Ca s e s : Ac u te Stroke

FYI 2 0 1 0 Gu id e lin e s
Stro ke Cha in o f Surviva l

Fo u n d a t io n a l Fa c t s
The 8 Ds o f Stro ke Ca re

Thebackgroundandicons inthefiguredepictingthes trokeChainofSurvival


(Figure38)differs lightlyfromthos einthefigurepublis hedinthe2006editionofthe
ACLS Provider Manual. Thefigurewas revis edtoenhancememorizationandavoid
confus ionwiththeadultChainofSurvival(Figure6,page26),whichis newtothe
2011editionoftheProviderManual.

The8Ds ofStrokeCarehighlightthemajors teps indiagnos is andtreatmentofs troke


andkeypoints atwhichdelays canoccur:
De te c tio n: Rapidrecognitionofs trokes ymptoms
Dis p a tc h: Earlyactivationanddis patchofEMSby911
De live ry:RapidEMSidentification,management,andtrans port
Do o r: Appropriatetriagetos trokecenter
Da ta :Rapidtriage,evaluation,andmanagementwithintheED
De c is io n: Strokeexpertis eandtherapys election
Drug : Fibrinolytictherapy,intra-arterials trategies
Dis p o s itio n:Rapidadmis s iontothes trokeunitorcriticalcareunit
Formoreinformationonthes ecriticalelements ,s eetheSus pectedStrokeAlgorithm
(Figure39).

Go a ls o f S t r o k e Ca r e

TheSus pectedStrokeAlgorithm(Figure39)emphas izes importantelements ofout-ofhos pitalcareforpos s ibles trokepatients .Thes eactions includeas trokes caleors creen
andrapidtrans porttothehos pital.As withACS,priornotificationofthereceivinghos pital
s peeds thecareofthes trokepatientuponarrival.
TheNINDShas es tablis hedcriticalin-hos pitaltimegoals foras s es s mentandmanagementofpatients withs us pecteds troke.This algorithmreviews thecriticalin-hos pitaltime
periods forpatientas s es s mentandtreatment:
1. Immediategeneralas s es s mentbythes troketeam,emergencyphys ician,oranother
expertwithin10 minutes ofarrival;orderurgentnoncontras tCTs can
2. Neurologicas s es s mentbythes troketeamordes igneeandCTs canperformedwithin25 minutes ofhos pitalarrival
3. InterpretationoftheCTs canwithin45 minutes ofEDarrival
4. Initiationoffibrinolytictherapyinappropriatepatients (thos ewithoutcontraindications )within1 hourofhos pitalarrivaland3 hoursfroms ymptomons et
5. Door-to-admis s iontimeof3 hours

133

ACLS_Suspected_StrokeAlgo_NoTables.pdf 1 12/16/10 6:14 PM

P a r t

Ad ult Sus p e c te d Stro ke


1

Id e ntify s ig ns a nd s ym p to m s o f p o s s ib le s tro ke
Ac tiva te Em e rg e nc y Re s p o ns e
2

Critic a l EMS a s s e s s m e nts a nd a c tio ns


Support ABCs ; give o xyg e n if needed
Perform prehos pital s troke as s es s ment
Es tablis h time of s ymptom ons et (las t normal)
Triage to s troke center
Alert hos pital
Check glucos e if pos s ible

NINDS
TIME
GOALS

ED
Arriva l

Im m e d ia te g e ne ra l a s s e s s m e nt a nd s ta b iliza tio n
As s es s ABCs , vital s igns
Provide o xyg e n if hypoxemic
Obtain IV acces s and perform lab oratory as s es s ments
Check glucos e; treat if indicated
Perform neurologic s creening as s es s ment
Activate s troke team
Order emergent CT s can or MRI of brain
Obtain 12-lead ECG

10
m in

ED
Arriva l

Im m e d ia te ne uro lo g ic a s s e s s m e nt b y s tro ke te a m o r d e s ig ne e
Review patient his tory
Es tablis h time of s ymptom ons et or las t known normal
Perform neurologic examination (NIH Stroke Scale or
Canadian Neurological Scale)

25
m in
ED
Arriva l

Doe s CT s ca n s how he m orrha ge ?

45
m in

No He m o r r h a g e

He m o r r h a g e

Cons ult neurologis t


or neuros urgeon;
cons ider trans fer if
not a vailable

P ro b a b le a c ute is c he m ic s tro ke ; c o ns id e r b rino lytic the ra p y


Check for brinolytic exclus ions
Repeat neurologic exam: are de cits rapidly improving to normal?
8
ED
Arriva l
60 m in

P a tie n t re m a ins c a nd id a te for


b rin olytic th e ra p y?
10

No t a Ca n d id a t e

Ca n d id a t e

Re vie w ris ks /b e ne ts with p a tie n t a n d fa m ily.


If a c c e p ta b le :
Give rtPA
No anticoagulants or antiplatelet treatment for
24 hours
Stro ke
Ad m is s io n
3 ho urs

Adminis te r a s p irin
11

Begin s troke or
he morrhage pa thway
Admit to s troke unit or
intens ive ca re unit

12

Begin pos t-rtPA s troke pathway


Aggres s ively monitor:
BP per protocol
For neurologic d eterioration
Emergent admis s ion to s troke unit or
intens ive care unit
2010 America n Heart As s ociation

Fig u re 3 9 . The Sus pected Stroke Algorithm.


134

Th e ACLS Ca s e s : Ac u te Stroke

Fo u n d a t io n a l Fa c t s :
The Na tio na l Ins titute o f
Ne uro lo g ic a l Dis o rd e rs
a nd Stro ke

Cr it ic a l Tim e P e r io d s

TheNINDSis abranchoftheNationalIns titutes ofHealth(NIH).Its mis s ionis to


reducetheburdenofneurologicdis eas ebys upportingandconductingres earch.
NINDSres earchers haves tudieds trokeandrevieweddataleadingtorecommendations foracutes trokecare.TheNINDShas s etcriticaltimegoals foras s es s ment
andmanagementofs trokepatients bas edonexperienceobtainedinlarges tudies
ofs trokepatients .

Patients withacuteis chemics trokehaveatime-dependentbenefitforfibrinolytictherapy


s imilartothatofpatients withST-s egmentelevationMI,butthis time-dependentbenefitis
muchs horter.
Thecriticaltimeperiodforadminis trationofIV fibrinolytictherapybegins withtheons etof
s ymptoms .Criticaltimeperiods fromhos pitalarrivalares ummarizedbelow:

Ap p lic a t io n o f t h e
Su s p e c te d Stroke
Alg o r it h m

Im m e d ia te g e ne ra l a s s e s s m e nt

10minutes

Im m e d ia te ne uro lo g ic a s s e s s m e nt

25minutes

Ac q uis itio n o f CT o f the he a d

25minutes

Inte rp re ta tio n o f the CT s c a n

45minutes

Ad m inis tra tio n o f fib rino lytic the ra p y, tim e d fro m ED a rriva l

60minutes

Ad m inis tra tio n o f fib rino lytic the ra p y, tim e d fro m o ns e t o f


s ym p to m s

3hours ,or4.5
hours ins elected
patients

Ad m is s io n to a m o nito re d b e d

3hours

Wewillnowdis cus s thes teps inthealgorithm,as wellas otherrelatedtopics :


Identificationofs igns ands ymptoms ofpos s ibles trokeandactivationofemergency
res pons e(Box1)
CriticalEMSas s es s ments andactions (Box2)
Immediategeneralas s es s mentands tabilization(Box3)
Immediateneurologicas s es s mentbythes troketeamordes ignee(Box4)
CTs can:hemorrhageornohemorrhage(Box5)
Fibrinolytictherapyris ks tratificationifcandidate(Boxes 6,8,and10)
Generals trokecare(Boxes 11and12)

Id e n t if c a t io n o S ig n s o P o s s ib le S t ro k e (Bo x 1 )
Wa r n in g S ig n s a n d
S ym p t o m s

Thes igns ands ymptoms ofas trokemaybes ubtle.Theyinclude


Suddenweaknes s ornumbnes s oftheface,arm,orleg,es peciallyonones ideofthe
body
Suddenconfus ion
Troubles peakingorunders tanding
Suddentroubles eeinginoneorbotheyes
Suddentroublewalking
Dizzines s orlos s ofbalanceorcoordination
Suddens evereheadachewithnoknowncaus e
135

P a r t

Ac t iva t e EMS S ys t e m
Im m e d ia t e ly

Stroke patients and their families mus t be educated to activate EMS as s oon as they
detect potential s igns or s ymptoms of s troke. Currently half of all s troke patients are driven
to the ED by family or friends .
EMS provides the s afes t and mos t efficient method of emergency trans port to the hos pital. The advantages of EMS trans port include the following:
EMS pers onnel can identify and trans port a s troke patient to a hos pital capable of
providing acute s troke care and notify the hos pital of the patients impending arrival.
Prearrival notification allows the hos pital to prepare to evaluate and manage the
patient efficiently.
Emergency medical dis patchers als o play a critical role in timely treatment of potential
s troke by
Identifying pos s ible s troke patients
Providing high-priority dis patch
Ins tructing bys tanders in lifes aving CPR s kills or other s upportive care if needed while
EMS providers are on the way

S t r o k e As s e s s m e n t
To o ls

The 2010 AHA Guidelines for CPR and ECC recommends that all EMS pers onnel be
trained to recognize s troke us ing a validated, abbreviated out-of-hos pital neurologic evaluation tool s uch as the Cincinnati Prehos pital Stroke Scale (CPSS) (Table 4).

Cin c in n a ti P re h os p ita l Stroke Sc a le


The CPSS identifies s troke on the bas is of 3 phys ical findings :
Facial droop (have the patient s mile or try to s how teeth)
Arm drift (have the patient clos e eyes and hold both arms out, with palms up)
Abnormal s peech (have the patient s ay You cant teach an old dog new tricks
By us ing the CPSS, medical pers onnel can evaluate the patient in <1 minute. The pres ence of 1 finding on the CPSS has a s ens itivity of 59% and a s pecificity of 89% when
s cored by prehos pital providers .
With s tandard training in s troke recognition, paramedics demons trated a s ens itivity of
61% to 66% for identifying patients with s troke. After receiving training in us e of a s troke
as s es s ment tool, paramedic s ens itivity for identifying patients with s troke increas ed to
86% to 97% .

136

Th e ACLS Ca s e s : Ac u te Stroke

Ta b le 4 . The Cinc inna ti P re ho s p ita l Stro ke Sc a le

Te s t

Fin d in g s

Fa c ia l d ro o p : Have patient s how teeth or


s mile (Figure 40)

No rm a lboth s ides of face move


equally
Ab no rm a lone s ide of face does not
move as well as the other s ide

Arm d rift: Patient clos es eyes and


extends both arms s traight out, with
palms up, for 10 s econds (Figure 41)

No rm a lboth arms move the s ame


or both arms do not move at all (other
findings , s uch as pronator drift, may be
helpful)
Ab no rm a lone arm does not move or
one arm drifts down compared with the
other

Ab no rm a l s p e e c h: Have patient s ay you


cant teach an old dog new tricks

No rm a lpatient us es correct words


with no s lurring
Ab no rm a lpatient s lurs words , us es
the wrong words , or is unable to s peak

Interpretation: If any 1 of thes e 3 s igns is abnormal, the probability of a s troke is 72% .


The pres ence of all 3 findings indicates that the probability of s troke is >85% .
Modified from Kothari RU, Pancioli A, Liu T, Brott T, Broderick J . Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emergency Med. 1999;33:373-378. With permis sion from Elsevier.

Fig u re 4 0 . Facial droop.

137

P a r t

Fig u re 4 1 . One-s ided motor weaknes s (right arm).

Cr it ic a l EMS As s e s s m e n t s a n d Ac t io n s (Bo x 2 )
In t r o d u c t io n

Prehos pital EMS providers mus t minimize the interval between the ons et of s ymptoms and
patient arrival in the ED. Specific s troke therapy can be provided only in the appropriate
receiving hos pital ED, s o time in the field only delays (and may prevent) definitive therapy.
More extens ive as s es s ments and initiation of s upportive therapies can continue en route
to the hos pital or in the ED.

Cr it ic a l EMS
As s e s s m e n t s a n d
Ac t io n s (Bo x 2 )

To provide the bes t outcome for the patient with potential s troke:

Id e n t ify S ig n s

De fin e a n d Re c o g n iz e t h e S ig n s o f S t ro k e (Bo x 1 )

Sup p o rt ABCs

Support the ABCs and provide s upplemental oxygen to hypoxemic (eg, oxygen s aturation <94% ) s troke patients or thos e
patients with unknown oxygen s aturation.

P e rfo rm s tro ke
a s s e s s m e nt

Perform a rapid out-of-hos pital s troke as s es s ment (CPSS,


Table 4).

Es ta b lis h tim e

Determine when the patient was las t known to be normal or


at neurologic bas eline. This repres ents time zero. If the patient
wakes from s leep with s ymptoms of s troke, time zero is the las t
time the patient was s een to be normal.

Tria g e to s tro ke
c e nte r

Trans port the patient rapidly and cons ider triage to a s troke
center. Support cardiopulmonary function during trans port. If
pos s ible, bring a witnes s , family member, or caregiver with the
patient to confirm time of ons et of s troke s ymptoms .
(continued)

138

Th e ACLS Ca s e s : Ac u te Stroke

(continued)

Id e n t ify S ig n s

De fin e a n d Re c o g n iz e t h e S ig n s o f S t ro k e (Bo x 1 )

Ale rt ho s p ita l

Provide prearrival notification to the receiving hos pital.

Che c k g luc o s e

During trans port, check blood glucos e if protocols or medical


control allows .

The patient with acute s troke is at ris k for res piratory compromis e from as piration, upper
airway obs truction, hypoventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfus ion and hypoxemia will exacerbate and extend is chemic brain injury,
and it has been as s ociated with wors e outcome from s troke.
Both out-of-hos pital and in-hos pital medical pers onnel s hould provide s upplementary
oxygen to hypoxemic (ie, oxygen s aturation <94% ) s troke patients or patients for whom
oxygen s aturation is unknown.

Fo u n d a t io n a l Fa c t s
Stro ke Ce nte rs a nd
Stro ke Units

Initial evidence indicates a favorable benefit from triage of s troke patients directly to
des ignated s troke centers , but the concept of routine out-of-hos pital triage of s troke
patients requires continued evaluation.
Each receiving hos pital s hould define its capability for treating patients with acute
s troke and s hould communicate this information to the EMS s ys tem and the community. Although not every hos pital has the res ources to s afely adminis ter fibrinolytics ,
every hos pital with an ED s hould have a written plan that des cribes how patients with
acute s troke will be managed in that ins titution. The plan s hould
Detail the roles of healthcare providers in the care of patients with acute s troke,
including identifying s ources of neurologic expertis e
Define which patients to treat with fibrinolytics at that facility
Des cribe when patient trans fer to another hos pital with a dedicated s troke unit is
appropriate
Patients with stroke who require hospitalization should be admitted to a stroke unit
when a stroke unit with a multidisciplinary team experienced in managing stroke is
available within a reasonable transport interval.
Studies have documented improvement in 1-year s urvival rate, functional outcomes ,
and quality of life when patients hos pitalized for acute s troke receive care in a dedicated unit with a s pecialized team.

In -Ho s p it a l, Im m e d ia t e Ge n e r a l As s e s s m e n t a n d S t a b iliz a t io n (Bo x 3 )


In t r o d u c t io n

Once the patient arrives in the ED, a number of as s es s ments and management activities
mus t occur quickly. Protocols s hould be us ed to minimize delay in definitive diagnos is and
therapy.
Th e g oa l of th e s troke te a m , e m e rg e n c y p h ys ic ia n , or oth e r e xp e rts s h ou ld b e to
a s s e s s th e p a tie n t with s u s p e c te d s troke with in 10 m inute s o f a rriva l in th e ED:
Tim e Is Bra in (Box 3).

139

P a r t

Im m e d ia t e Ge n e r a l
As s e s s m e n t a n d
S t a b iliz a t io n

ED providers s hould do the following:

Ste p

Ac t io n s

As s e s s ABCs

As s es s the ABCs and evaluate bas eline vital s igns .

P ro vid e o xyg e n

Provide s upplemental oxygen to hypoxemic (eg, oxyhemoglobin


s aturation <94% ) s troke patients or thos e patients with unknown
oxygen s aturation.

Es ta b lis h IV
a c c e s s a nd
o b ta in b lo o d
s a m p le s

Es tablis h IV acces s and obtain blood s amples for bas eline blood
count, coagulation s tudies , and blood glucos e. Do not let this
delay obtaining a CT s can of the brain.

Che c k g luc o s e

Promptly treat hypoglycemia.

P e rfo rm
ne uro lo g ic
a s s e s s m e nt

Perform a neurologic s creening as s es s ment. Us e the NIH Stroke


Scale (NIHSS) or a s imilar tool.

Ac tiva te the
s tro ke te a m

Activate the s troke team or arrange cons ultation with a s troke


expert bas ed on predetermined protocols .

Ord e r CT b ra in
scan

Order an emergent CT s can of the brain. Have it read promptly by


a qualified phys ician.

Ob ta in 12-le a d
ECG

Obtain a 12-lead ECG, which may identify a recent or ongoing


AMI or arrhythmias (eg, atrial fibrillation) as a caus e of embolic
s troke. A s mall percentage of patients with acute s troke or trans ient is chemic attack have coexis ting myocardial is chemia or other
abnormalities . There is general agreement to recommend cardiac
monitoring during the firs t 24 hours of evaluation in patients with
acute is chemic s troke to detect atrial fibrillation and potentially lifethreatening arrhythmias .
Life-threatening arrhythmias can follow or accompany s troke, particularly intracerebral hemorrhage. If the patient is hemodynamically s table, treatment of nonlife-threatening arrhythmias (bradycardia, VT, and AV conduction blocks ) may not be neces s ary.
Do n ot d e la y th e CT s c a n to ob ta in th e ECG.

Im m e d ia t e Ne u ro lo g ic As s e s s m e n t b y S t ro k e Te a m o r De s ig n e e (Bo x 4 )
Ove r vie w

The s troke team, neurovas cular cons ultant, or emergency phys ician does the following:
Reviews the patients his tory, performs a general phys ical examination, and es tablis hes time of s ymptom ons et
Performs a neurologic examination (eg, NIHSS)
Th e g oa l for n e u rolog ic a s s e s s m e n t is with in 25 m inute s o f the p a tie nts a rriva l in
th e ED: Tim e Is Bra in (Box 4).

140

Th e ACLS Ca s e s : Ac u te Stroke

Es t a b lis h S ym p t o m
On s e t

Es tablis hing the time of s ymptom ons et may require interviewing out-of-hos pital providers ,
witnes s es , and family members to determine the time the patient was las t known to be
normal.

Ne u r o lo g ic
Exa m in a t io n

As s es s the patients neurologic s tatus us ing one of the more advanced s troke s cales .
Following is an example:
Na tio na l Ins titute s o f He a lth Stro ke Sc a le
The NIHSS us es 15 items to as s es s the res pons ive s troke patient. This is a validated meas ure of s troke s everity bas ed on a detailed neurologic examination. A detailed dis cus s ion
is beyond the s cope of the ACLS Provider Cours e.

CT S c a n : He m o r r h a g e o r No He m o r r h a g e (Bo x 5 )
In t r o d u c t io n

A critical decis ion point in the as s es s ment of the patient with acute s troke is the performance and interpretation of a noncontras t CT s can to differentiate is chemic from hemorrhagic s troke. As s es s ment als o includes identifying other s tructural abnormalities that may
be res pons ible for the patients s ymptoms or that repres ent contraindication to fibrinolytic
therapy. The initial noncontras t CT s can is the mos t important tes t for a patient with acute
s troke.
If a CT s can is not readily available, s tabilize and promptly trans fer the patient to a
facility with this capability.
Do not give as pirin, heparin, or rtPA until the CT s can has ruled out intracranial hemorrhage.
The CT s ca n s hould be c om ple te d within 25 m inute s of the pa tie nts a rriva l in the
ED a nd s hould be re a d within 45 m inute s from ED a rriva l: Tim e Is Bra in (Box 5).

De c is io n P o in t :
He m o r r h a g e o r No
He m o r r h a g e

Additional imaging techniques s uch as CT perfus ion, CT angiography, or magnetic res onance imaging s cans of patients with s us pected s troke s hould be promptly interpreted
by a phys ician s killed in neuroimaging interpretation. Obtaining thes e s tudies s hould not
delay initiation of IV rtPA in eligible patients . The pres ence of hemorrhage vers us no hemorrhage determines the next s teps in treatment (Figures 42A and B).

Ye s , He m orrh a g e Is P re s e n t
If hemorrhage is noted on the CT s can, the patient is not a candidate for fibrinolytics .
Cons ult a neurologis t or neuros urgeon. Cons ider trans fer for appropriate care (Box 7).

No, He m orrh a g e Is Not P re s e n t


If the CT s can s hows no evidence of hemorrhage and no s ign of other abnormality
(eg, tumor, recent s troke), the patient may be a candidate for fibrinolytic therapy (Boxes 6
and 8).
If hemorrhage is not pres ent on the initial CT s can and the patient is not a candidate for
fibrinolytics for other reas ons , cons ider giving as pirin (Box 9) either rectally or orally after
performing a s wallowing s creen (s ee below). Although as pirin is not a time-critical intervention, it is appropriate to adminis ter as pirin in the ED if the patient is not a candidate
for fibrinolys is . The patient mus t be able to s afely s wallow before as pirin is given orally.
Otherwis e us e the s uppos itory form.

141

P a r t

Is chemic Penumbra

Infarcted Brain Tis s ue

Fig u re 4 2 . Occlus ion in a cerebral artery by a thrombus . A, Area of infarction s urrounding immediate s ite and dis tal portion of brain tis s ue after
occlus ion. B, Area of is chemic penumbra (is chemic, but not yet infarcted [dead] brain tis s ue) s urrounding areas of infarction. This is chemic penumbra is alive but dys functional becaus e of altered membrane potentials . The dys function is potentially revers ible. Current s troke treatment tries to
keep the area of permanent brain infarction as s mall as pos s ible by preventing the areas of revers ible brain is chemia in the penumbra from trans forming into larger areas of irrevers ible brain infarction.

142

Th e ACLS Ca s e s : Ac u te Stroke

Fib r in o lyt ic Th e r a p y
In t r o d u c t io n

Several s tudies have s hown a higher likelihood of good to excellent functional outcome
when rtPA is given to adults with acute is chemic s troke within 3 hours of ons et of s ymptoms , or within 4.5 hours of ons et of s ymptoms for s elected patients . But thes e res ults
are obtained when rtPA is given by phys icians in hos pitals with a s troke protocol that rigorous ly adheres to the eligibility criteria and therapeutic regimen of the NINDS protocol.
Evidence from pros pective randomized s tudies in adults als o documents a greater likelihood of benefit the earlier treatment begins .
The AHA and s troke guidelines recommend giving IV rtPA to patients with acute is chemic
s troke who meet the NINDS eligibility criteria if it is given by
Phys icians us ing a clearly defined ins titutional protocol
A knowledgeable interdis ciplinary team familiar with s troke care
An ins titution with a commitment to comprehens ive s troke care and rehabilitation
The s uperior outcomes reported in both community and tertiary care hos pitals in the
NINDS trials can be difficult to replicate in hos pitals with les s experience in, and ins titutional commitment to, acute s troke care. There is s trong evidence to avoid all delays and
treat patients as s oon as pos s ible. Failure to adhere to protocol is as s ociated with an
increas ed rate of complications , particularly ris k of intracranial hemorrhage.

Eva lu a t e fo r
Fib r in o lyt ic Th e r a p y
(Bo x 6 )

If the CT s can is negative for hemorrhage, the patient may be a candidate for fibrinolytic
therapy. Immediately perform further eligibility and ris k s tratification:
If the CT s can s hows no hemorrhage, the probability of acute is chemic s troke
remains . Review inclusion and exclusion criteria for IV fibrinolytic therapy (Table 5) and
repeat the neurologic exam (NIHSS or Canadian Neurological Scale).
If the patients neurologic function is rapidly improving toward normal, fibrinolytics
may be unneces s ary.
Ta b le 5 . Inc lus io n a nd Exc lus io n Cha ra c te ris tic s o f P a tie nts With Is c he m ic Stro ke Who Co uld Be
Tre a te d With rtPA Within 3 Hou rs Fro m Sym p to m Ons e t*

In c lu s io n Cr it e r ia
Diagnos is of is chemic s troke caus ing meas urable neurologic deficit
Ons et of s ymptoms <3 hours before beginning treatment
Age 18 years

Exc lu s io n Cr it e r ia
Head trauma or prior s troke in previous 3 months
Symptoms s ugges t s ubarachnoid hemorrhage
Arterial puncture at noncompres s ible s ite in previous 7 days
His tory of previous intracranial hemorrhage
Elevated blood pres s ure (s ys tolic >185 mm Hg or dias tolic >110 mm Hg)
Evidence of active bleeding on examination
Acute bleeding diathes is , including but not limited to
Platelet count <100 000/mm 3
Heparin received within 48 hours , res ulting in an aPTT greater than the upper
limit of normal
Current us e of anticoagulant with INR >1.7 or PT >15 s econds
Blood glucos e concentration <50 mg/dL (2.7 mmol/L)
CT demons trates multilobar infarction (hypodens ity > cerebral hemis phere)
(continued)
143

P a r t

5
(continued)

Re la t ive Exc lu s io n Cr it e r ia
Recent experience s ugges ts that under s ome circums tances with careful cons ideration and weighing of ris k to benefitpatients may receive fibrinolytic therapy des pite 1
or more relative contraindications . Cons ider ris k to benefit of rtPA adminis tration carefully if any one of thes e relative contraindications is pres ent:
Only minor or rapidly improving s troke s ymptoms (clearing s pontaneous ly)
Seizure at ons et with pos tictal res idual neurologic impairments
Major s urgery or s erious trauma within previous 14 days
Recent gas trointes tinal or urinary tract hemorrhage (within previous 21 days )
Recent acute myocardial infarction (within previous 3 months )
Abbreviations : aPTT, activated partial thromboplas tin time; INR, international normalized ratio; PT, prothrombin time; rtPA, recombinant tis s ue plas minogen activator.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Ros enwas ser RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart Ass ociation/
American Stroke Ass ociation Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vascular Disease and Quality of Care Outcomes in
Research Interdisciplinary Working Groups . Stroke. 2007;38:1655-1711.

P o t e n t ia l Ad ve r s e
Effe c t s

As with all drugs , fibrinolytics have potential advers e effects . At this point weigh the
patients ris k for advers e events agains t the potential benefit and dis cus s with the patient
and family.
Confirm that no exclus ion criteria are pres ent (Table 5).
Cons ider ris ks and benefits .
Be prepared to monitor and treat any potential complications .
The major complication of IV rtPA for s troke is intracranial hemorrhage. Other bleeding
complications may occur and may range from minor to major. Angioedema and trans ient
hypotens ion may occur.

P a t ie n t Is a
Ca n d id a t e fo r
Fib r in o lyt ic Th e r a p y
(Bo xe s 8 a n d 1 0 )

If the patient remains a candidate for fibrinolytic therapy (Box 8), dis cus s the ris ks and
potential benefits with the patient or family if available (Box 10). After this dis cus s ion, if
the patient or family members decide to proceed with fibrinolytic therapy, give the patient
rtPA. Begin your ins titutions s troke rtPA protocol, often called a pathway of care.
Do n ot a d m in is te r a n tic oa g u la n ts or a n tip la te le t tre a tm e n t for 24 h ou rs a fte r
a d m in is tra tion of rtPA, typ ic a lly u n til a follow-u p CT s c a n a t 24 h ou rs s h ows n o
in tra c ra n ia l h e m orrh a g e .

Ext e n d e d IV
r t PA Win d o w
3 t o 4 .5 Ho u r s

144

Treatment of carefully s elected patients with acute is chemic s troke with IV rtPA between 3
and 4.5 hours after ons et of s ymptoms has als o been s hown to improve clinical outcome,
although the degree of clinical benefit is s maller than that achieved with treatment within 3
hours . Data s upporting treatment in this time window come from a large, randomized trial
(ECASS-3 [European Cooperative Acute Stroke Study]) that s pecifically enrolled patients
between 3 and 4.5 hours after s ymptom ons et, as well as a meta-analys is of prior trials .

Th e ACLS Ca s e s : Ac u te Stroke

At pres ent, us e of IV rtPA within the 3- to 4.5-hour window has not yet been approved
by the US Food and Drug Adminis tration (FDA), although it is recommended by an AHA/
American Stroke As s ociation s cience advis ory. Adminis tration of IV rtPA to patients with
acute is chemic s troke who meet the NINDS or ECASS-3 eligibility criteria (Table 6) is recommended if rtPA is adminis tered by phys icians in the s etting of a clearly defined protocol, a knowledgeable team, and ins titutional commitment.
Ta b le 6 . Inc lus io n a nd Exc lus io n Cha ra c te ris tic s o f P a tie nts With Is c he m ic Stro ke Who Co uld Be
Tre a te d With rtPA Fro m 3 to 4.5 Ho urs Fro m Sym p to m Ons e t*

In c lu s io n Cr it e r ia
Diagnos is of is chemic s troke caus ing meas urable neurologic deficit
Ons et of s ymptoms 3 to 4.5 hours before beginning treatment

Exc lu s io n Cr it e r ia
Age >80 years
Severe s troke (NIHSS >25)
Taking an oral anticoagulant regardles s of INR
His tory of both diabetes and prior is chemic s troke
No te s
The checklis t includes s ome US FDAapproved indications and contraindications
for adminis tration of rtPA for acute is chemic s troke. Recent AHA/ASA guideline
revis ions may differ s lightly from FDA criteria. A phys ician with expertis e in acute
s troke care may modify this lis t.
Ons et time is either witnes s ed or las t known normal.
In patients without recent us e of oral anticoagulants or heparin, treatment with rtPA
can be initiated before availability of coagulation s tudy res ults but s hould be dis continued if INR is >1.7 or PT is elevated by local laboratory s tandards .
In patients without a his tory of thrombocytopenia, treatment with rtPA can be initiated before availability of platelet count but s hould be dis continued if platelet
count is <100 000/mm 3 .
Abbreviations : FDA, Food and Drug Adminis tration; INR, international normalized ratio; NIHSS, National
Ins titutes of Health Stroke Scale; PT, prothrombin time; rtPA, recombinant tis s ue plas minogen activator.

*del Zoppo

GJ , Saver J L, J auch EC, Adams HP J r; on behalf of the American Heart As s ociation Stroke
Council. Expans ion of the time window for treatment of acute is chemic s troke with intravenous tis s ue plas minogen activator: a s cience advis ory from the American Heart As s ociation/American Stroke
As s ociation. Stroke. 2009;40:2945-2948.

In t r a -a r t e r ia l r t PA

Improved outcome from us e of cerebral intra-arterial rtPA has been documented. For
patients with acute is chemic s troke who are not candidates for s tandard IV fibrinolys is ,
cons ider intra-arterial fibrinolys is in centers with the res ources and expertis e to provide it
within the firs t 6 hours after ons et of s ymptoms . Intra-arterial adminis tration of rtPA is not
yet approved by the FDA.

145

P a r t

Ge n e r a l S t ro k e Ca re (Bo xe s 1 1 a n d 1 2 )
In t r o d u c t io n

The general care of all patients with s troke includes the following:
Begin s troke pathway.
Support airway, breathing, and circulation.
Monitor blood glucos e.
Monitor blood pres s ure.
Monitor temperature.
Perform dys phagia s creening.
Monitor for complications of s troke and fibrinolytic therapy.
Trans fer to general intens ive care if indicated.

Be g in S t r o k e
P a t h w a y (Bo xe s 1 1
and 12)

Admit patients to a s troke unit (if available) for careful obs ervation (Box 11), including
monitoring of blood pres s ure and neurologic s tatus . If neurologic s tatus wors ens , order an
emergent CT s can. Determine if cerebral edema or hemorrhage is the caus e; cons ult neuros urgery as appropriate.
Additional s troke care includes s upport of the airway, oxygenation, ventilation, and nutrition. Provide normal s aline to maintain intravas cular volume (eg, approximately 75 to
100 mL/h) if needed.

Mo n it o r Blo o d
Glu c o s e

Hyperglycemia is as s ociated with wors e clinical outcome in patients with acute is chemic s troke. But there is no direct evidence that active glucos e control improves clinical
outcome. There is evidence that ins ulin treatment of hyperglycemia in other critically ill
patients improves s urvival rates . For this reas on, cons ider giving IV or s ubcutaneous ins ulin to lower blood glucos e in patients with acute is chemic s troke when the s erum glucos e
level is >185 mg/dL.

Mo n it o r fo r
Co m p lic a t io n s
of Stroke a n d
Fib r in o lyt ic Th e r a p y

Prophylaxis for s eizures is not recommended. But treatment of acute s eizures followed by
adminis tration of anticonvuls ants to prevent further s eizures is recommended. Monitor the
patient for s igns of increas ed intracranial pres s ure. Continue to control blood pres s ure to
reduce the potential ris k of bleeding.

Hyp e r t e n s io n
Ma n a g e m e n t in r t PA
Ca n d id a t e s

Although management of hypertens ion in the s troke patient is controvers ial, patients who
are candidates for fibrinolytic therapy s hould have their blood pres s ure controlled to lower
the ris k of intracerebral hemorrhage following adminis tration of rtPA. General guidelines for
the management of hypertens ion are outlined in Tables 7 and 8.
If patient is eligible for fibrinolytic therapy, blood pres s ure mus t be 185 mm Hg s ys tolic and 110 mm Hg dias tolic to limit the ris k of bleeding complications . Becaus e the
maximum interval from ons et of s troke until effective treatment of s troke with rtPA is limited, mos t patients with s us tained hypertens ion above thes e levels will not be eligible for
IV rtPA.

146

Th e ACLS Ca s e s : Ac u te Stroke

Ta b le 7 . P o te ntia l Ap p ro a c he s to Arte ria l Hyp e rte ns io n in P a tie nts With Ac ute Is c he m ic Stro ke
Who Are P ote ntia l Ca nd id a te s fo r Ac ute Re p e rfus io n The ra p y*

Patient otherwis e eligible for acute reperfus ion therapy except that blood pres s ure is
>185/110 mm Hg:
Labetalol 10-20 mg IV over 1-2 minutes , may repeat 1, or
Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes ,
maximum 15 mg per hour; when des ired blood pres s ure is reached, lower to 3 mg
per hour, or
Other agents (hydralazine, enalaprilat, etc) may be cons idered when appropriate
If blood pres s ure is not maintained at or below 185/110 mm Hg, do not adminis ter rtPA.
Management of blood pres s ure during and after rtPA or other acute reperfus ion therapy:
Monitor blood pres s ure every 15 minutes for 2 hours from the s tart of rtPA therapy,
then every 30 minutes for 6 hours , and then every hour for 16 hours .
If s ys tolic blood pres s ure 180-230 mm Hg or dias tolic blood pres s ure 105-120 mm Hg:
Labetalol 10 mg IV followed by continuous IV infus ion 2-8 mg per minute, or
Nicardipine IV 5 mg per hour, titrate up to des ired effect by 2.5 mg per hour every
5-15 minutes , maximum 15 mg per hour
If blood pres s ure not controlled or dias tolic blood pres s ure >140 mm Hg, cons ider
s odium nitroprus s ide.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgens tern LB, Qures hi AI, Ros enwas s er RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart As s ociation/
American Stroke As s ociation Stroke Council, Clinical Cardiology Council, Cardiovas cular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vas cular Dis eas e and Quality of Care Outcomes in
Res earch Interdis ciplinary Working Groups . Stroke. 2007;38:1655-1711.

Ta b le 8 . Ap p ro a c h to Arte ria l Hyp e rte ns io n in P a tie nts With Ac ute Is c he m ic Stro ke Who Are Not
P o te ntia l Ca nd id a te s fo r Ac ute Re p e rfus io n The ra p y*

Cons ider lowering blood pres s ure in patients with acute is chemic s troke if s ys tolic
blood pres s ure >220 mm Hg or dias tolic blood pres s ure >120 mm Hg.
Cons ider blood pres s ure reduction as indicated for other concomitant organ s ys tem
injury:
Acute myocardial infarction
Conges tive heart failure
Acute aortic dis s ection
A reas onable target is to lower blood pres s ure by 15% to 25% within the firs t day.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgens tern LB, Qures hi AI, Ros enwas s er RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart As s ociation/
American Stroke As s ociation Stroke Council, Clinical Cardiology Council, Cardiovas cular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vas cular Dis eas e and Quality of Care Outcomes in
Res earch Interdis ciplinary Working Groups . Stroke. 2007;38:1655-1711.

147

P a r t

Ap p e n d ix

149

Ma n a g e m e n t o f Re s p ir a t o r y Ar re s t
Ba g -Ma s k Ve n t ila t io n Te s t in g Ch e c k lis t
Student Name: ______________________________________________________________ Tes t Date: _______________________
if d o n e
c o r re c t ly

P e r fo r m a n c e Gu id e lin e s a n d Cr it ic a l Ac t io n s
BLS S u r ve y a n d In t e r ve n t io n s
Checks for res pons ivenes s
Taps and s houts , Are you all right?
and
Scans ches t for movement (5-10 s econds )
Activates the emergency res pons e s ys tem
Activates the emergency res pons e s ys tem and gets the AED
or
Directs s econd res cuer to activate the emergency res pons e s ys tem and get the AED
Checks carotid puls e (5-10 s econds ). Notes that puls e is pres ent
Does not initiate ches t compres s ions or attach AED
Performs ventilations at the correct rate of 1 breath every 5-6 s econds
(10-12 breaths per minute)

ACLS S u r ve y Ca s e S k ills
Ins erts oropharyngeal or nas opharyngeal airway
Adminis ters oxygen
Performs correct bag-mas k ventilation for 1 minute

Cr it ic a l Ac t io n s
Effectively ventilates with a bag-mas k device for 1 minute
Gives proper ventilationrate and volume
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________

151

CP R a n d AED S k ills Te s t
1 -Re s c u e r Ad u lt CP R a n d AED Ch e c k lis t
Student Name: ______________________________________________________________ Tes t Date: _______________________

S k ill
Ste p

if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s

BLS S u r ve y a n d In t e r ve n t io n s
1

Checks for res pons ivenes s : Taps and shouts, Are you all right? and
scans the chest for movement (5-10 seconds)

Tells s omeone to activate the emergency res pons e s ys tem and get an AED

Checks carotid puls e (minimum 5 seconds; maximum 10 seconds)

Bares patients ches t and locates CPR hand pos ition

Delivers firs t cycle of compres s ions at correct rate (acceptable: 18 seconds or less
for 30 compressions)

Gives 2 breaths (1 s econd each)

AED Ar r ive s
AED
1

Turns AED on, s elects proper pads , and places pads correctly

AED
2

Clears patient to analyze (must be visible and verbal check)

AED
3

Clears patient to s hock/pres s es s hock button (must be visible and verbal check;
maximum time from AED arrival less than 45 seconds)

S t u d e n t Co n t in u e s CP R
7

Delivers s econd cycle of compres s ions at correct hand pos ition (acceptable: greater
than 23 of 30 compressions)

Gives 2 breaths (1 s econd each) with vis ible ches t ris e

The next step is performed only if the manikin is equipped with a feedback device, such as a clicker or light. If there is
no feedback device, STOP THE TEST.
9

Delivers third cycle of compres s ions of adequate depth with complete ches t recoil
(acceptable: greater than 23 compressions)
STOP TEST

Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
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Print Ins tructor Name: _____________________________________________
Date: ________________

152

Me g a c o d e Te s t in g Ch e c k lis t 1 / 2
Br a d yc a rd ia
VF/ P u ls e le s s VT

As ys t o le

ROS C

Student Name: ______________________________________________________________ Tes t Date: _______________________


if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well

Br a d yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes s ymptomatic bradycardia
Adminis ters correct dos e of atropine
Prepares for s econd-line treatment

VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es

As ys t o le Ma n a g e m e n t
Recognizes as ys tole
Verbalizes potential revers ible caus es of as ys tole/PEA (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm checks

P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________

153

Me g a c o d e Te s t in g Ch e c k lis t 3
Ta c h yc a rd ia
VF/ P u ls e le s s VT

P EA

ROS C

Student Name: ______________________________________________________________ Tes t Date: _______________________


if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well

Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes uns table tachycardia
Recognizes s ymptoms due to tachycardia
Performs immediate s ynchronized cardiovers ion

VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es

P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks

P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________

154

Me g a c o d e Te s t in g Ch e c k lis t 4
Ta c h yc a rd ia
VF/ P u ls e le s s VT

P EA

ROS C

Student Name: ______________________________________________________________ Tes t Date: _______________________


if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well

Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes tachycardia (s pecific diagnos is )
Recognizes no s ymptoms due to tachycardia
Attempts vagal maneuvers
Gives appropriate initial drug therapy

VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es

P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks

P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________
155

Me g a c o d e Te s t in g Ch e c k lis t 5
Ta c h yc a rd ia
VF/ P u ls e le s s VT

P EA

ROS C

Student Name: ______________________________________________________________ Tes t Date: _______________________


if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well

Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes uns table tachycardia
Recognizes s ymptoms due to tachycardia
Performs immediate s ynchronized cardiovers ion

VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es

P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks

P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________

156

Me g a c o d e Te s t in g Ch e c k lis t 6
Ta c h yc a rd ia
VF/ P u ls e le s s VT

P EA

ROS C

Student Name: ______________________________________________________________ Tes t Date: _______________________


if d o n e
c o r re c t ly

Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well

Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes tachycardia (s pecific diagnos is )
Recognizes no s ymptoms due to tachycardia
Gives appropriate initial drug therapy

VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es

P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks

P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults

Circ le P o r NR to Ind ic a te P a s s o r Ne e d s Re m e d ia tio n:

Ins tructor s ignature affirms that s kills tes ts


were done according to AHA Guidelines .
Save this sheet with course record.

NR

Ins tructor Signature: ________________________________________________


Print Ins tructor Name: _____________________________________________
Date: ________________

157

Ca rd ia c Ar re s t VF/ P u ls e le s s VT Le a r n in g S t a t io n Ch e c k lis t
CP R Qua lity

Sta rt CP R

No

Ye s

ETCO

3
Sh oc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

ETCO

No

Sho c k Ene rg y

Ye s

Sh oc k

10

6
Ep ine p hrine

Ep ine p hrine
Drug The ra p y

No

Ye s

Ye s

Sh oc k

No

11

No

Ye s

12
Go to 5 o r 7
10

158

11

H
H
H
H
H
T
T
T
T
T

Ca rd ia c Ar re s t P EA/ As ys t o le Le a r n in g S t a t io n Ch e c k lis t
CP R Qua lity

Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s po ns e
compres s ions

Sta rt CP R
30:2 compres s ionYe s

No

Rhythm
s ho c ka b le ?

ETCO2

VF/VT

capnography
attempt to improve

As ys to le /P EA

3
Shoc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)

CP R 2 m in
increas e in P ETCO 2

Rhythm
s ho c ka b le ?

No

Sho c k Ene rg y

Ye s

Shoc k

10

CP R 2 m in

Ep ine p hrine every 3-5 min

CP R 2 m in

capnography

Drug The ra p y

capnography

Rhythm
s ho c ka b le ?

360 J

Ep ine p hrine every 3-5 min

Va s o p re s s in

No

Rhythm
s ho c ka b le ?

Ye s
epinephrine

Ye s

Shoc k

No
Ad va nc e d Airwa y

11

CP R 2 m in

CP R 2 m in

Am io d a ro ne

compres s ions
No

Rhythm
s ho c ka b le ?

Ye s

12
Go to 5 o r 7
10 or 11

2010 American Heart As s ociation

Re ve rs ib le Ca us e s
H
H
H
H
Hypothermia
T
T
T
T
T

159

Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re Le a r n in g S t a t io n Ch e c k lis t

Ad ult Im m e d ia te P o s tCa rd ia c Arre s t Ca re


1
Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)

2
Op tim ize ve ntila tio n a nd o xyg e na tio n
Maintainoxygens aturation94%
Cons ideradvancedairwayandwaveformcapnography
Donothyperventilate

3
Tre a t hyp o te ns io n (SBP <90 m m Hg )
IV/IObolus
Vas opres s orinfus ion
Cons idertreatablecaus es
12-LeadECG

5
No

Co ns id e r ind uc e d hyp o the rm ia

Fo llo w
c o m m a nd s ?

7
Ye s

Co ro na ry re p e rfus io n

Ye s
STEMI
OR
highs us picionofAMI
No
Ad va nc e d c ritic a l c a re

2010 American Heart As s ociation

160

Do s e s /De ta ils
Ve ntila tio n/Oxyg e na tio n
Avoidexces s iveventilation.
Startat10-12breaths /min
andtitratetotargetP e t c o 2
of35-40mmHg.
Whenfeas ible,titrateFio 2
tominimumneces s aryto
achieveSp o 2 94% .
IV Bo lus
1-2Lnormals aline
orlactatedRingers .
Ifinducinghypothermia,
mayus e4Cfluid.
Ep ine p hrine IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcg
perminute)
Do p a m ine IV Infus io n:
5-10mcg/kgperminute
No re p ine p hrine
IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcg
perminute)
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary

Br a d yc a rd ia Le a r n in g S t a t io n Ch e c k lis t

Ad ult Bra d yc a rd ia
(With Puls e)

As s es s appropriatenes s for clinical condition.


Heart rate typically <50/min if bradyarrhythmia.

2
Id e ntify a nd tre a t und e rlying c a us e
Maintainpatentairway;as s is tbreathingas neces s ary
Oxygen(ifhypoxemic)
Cardiacmonitortoidentifyrhythm;monitorbloodpres s ureandoximetry
IVacces s
12-LeadECGifavailable;dontdelaytherapy

3
P e rs is te nt b ra d ya rrhythm ia
c a us ing :

4
Mo nito r a nd o b s e rve

No

Hypotens ion?
Acutely altered mental s tatus ?
Signs of s hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s

Atro p ine
Ifatropineineffective:
Trans cutaneous pacing
OR
Do p a m ine infus ion
OR
Ep ine p hrine infus ion

Do s e s /De ta ils
Atro p ine IV Do s e :
Firs tdos e:0.5mgbolus
Repeatevery3-5minutes
Maximum:3mg
Do p a m ine IV Infus io n:
2-10mcg/kgperminute
Ep ine p hrine IV Infus io n:
2-10mcgperminute

6
Co ns id e r:
Expertcons ultation
Trans venous pacing
2010 American Heart As s ociation

161

Ta c h yc a rd ia Le a r n in g S t a t io n Ch e c k lis t

Ad ult Ta c hyc a rd ia
(With Puls e)

1
As s es s appropriatenes s for clinical cond ition.
Heart rate typically 150/min if tachyarrhythmia.

2
Id e ntify a nd tre a t und e rlying c a u s e

Do s e s /De ta ils

Maintainpatentairway;as s is tbreathingas neces s ary


Oxygen(ifhypoxemic)
C ard iacmonitortoidentifyrhythm;monitorb lood
pres s ureandoximetry

Sync hro nize d Ca rd io ve rs io n


Initialrecommend eddos es :
Narrowregular:50-100J
Narrowirregular:120-200J b iphas ic
or200J monophas ic
Wideregular:100J
Wideirregular:defibrillationdos e
(NOTs ynchronized)

3
4

P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?

Ye s

No
Wid e QRS?
0.12 s e c o nd

Sync hro nize d c a rd io ve rs io n


Cons iders edation
Ifregularnarrowcomplex,
cons ider adenos ine

Ye s

IVacces s and12-leadECG
ifavailab le
C ons ideradenos ineonlyif
regularandmonomorp hic
Cons iderantiarrhythmicinfus ion
Cons iderexp ertcons ultation

No
IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons id erexpertcons ultation

An tia rrh yth m ic In fu s ion s for


Sta b le Wid e -QRS Ta c h yc a rd ia
P ro c a ina m id e IV Do s e :
20-50mg/minuntilarrhythmia
s up pres s ed,hypotens ionens ues ,
QRSdurationincreas es >50% ,or
maximumd os e17mg/kggiven.
Maintenanceinfus ion:1-4mg/min.
AvoidifprolongedQTorCHF.
Am io d a ro ne IV Do s e :
Firs tdos e:150mgover10minutes .
Repeatas neededifVTrecurs .
Followbymaintenanc einfus ionof
1mg/minforfirs t6hours .
So ta lo l IV Do s e :
100mg(1.5mg/kg)over5minutes .
AvoidifprolongedQT.

2010 American Heart As s ociation

162

Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired .

2 0 1 0 AHA Gu id e lin e s fo r CP R a n d ECC S u m m a r y Ta b le


To p ic
Sys te m a tic
Ap p ro a c h:
BLS Surve y

2 0 0 5 Gu id e lin e s

2 0 1 0 Gu id e lin e s

A-B-C-D:Airway,Breathing,
Circulation,Defibrillation
Look,lis ten,andfeelfor
breathingandgive2res cue
breaths

1-2-3-4
1. Che c k re s p o ns ive ne s s .
2. Ac tiva te the e m e rg e nc y
re s p o ns e s ys te m a nd g e t a n
AED.
3. Circ ula tio n: Checkthecarotid
puls e.Ifyoucannotdetecta
puls ewithin10s econds ,s tart
CPR,beginningwithches t
compres s ions ,immediately.
4. De fib rilla tio n:Ifindicated,
deliveras hockwithanAEDor
defibrillator.

To p ic
BLS:
Hig h-Qua lity CP R

2 0 1 0 Gu id e lin e s
Arateofa t le a s t 100ches tcompres s ions perminute
Acompres s iondepthofa t le a s t 2 inc he s inadults
Allowingcompleteches trecoilaftereachcompres s ion
Minimizinginterruptions incompres s ions (10s econds orles s )
Switchingproviders aboutevery2minutes toavoidfatigue
Avoidingexces s iveventilation

ACLS:
Ca rd ia c Arre s t
a nd Bra d yc a rd ia
Alg o rithm s

The2010 AHA Guidelines for CPR and ECCs implifies theCardiacArres t


Alogorithmandincludes acircularalgorithm.
Thepriorityis the2-minutecontinuous periodofhigh-qualityCPRand
defibrillation.
Alladvancedinterventions includingIVacces s ,drugdelivery,and
advancedairways s houldnotinterruptches tcompres s ions ands hocks .
Rather,theys houldbeperformedoradminis tereds trategicallya fte rthe
briefpaus efordefibrillation.
Thes eactions continueuntilROSC,whenhealthcareproviders initiate
pos tcardiacarres tcareprotocols .
Duringcardiacarres t,providers s houldadminis teravas opres s orevery
3to5minutes .Epinephrineis commonlyus ed,althoughvas opres s in
canreplacethefirs tors econddos eofepinephrine.Regardles s ofthe
vas opres s orgiven,ones houldbeadminis teredevery3to5minutes .
ACLSproviders s houldadminis teramiodaroneforrefractoryVFandVT.
TheAmericanHeartAs s ociationnolongerrecommends atropinefor
routineus einmanagingPEAoras ys tole.
Fortreatmentofundifferentiatedwide-complextachycardiawithregular
rhythm,ACLSproviders cancons ideradenos ineintheinitialtreatment.
Atropineremains thefirs t-linetreatmentforalls ymptomaticbradycardias ,
regardles s oftype.
Fors ymptomaticbradycardia,theAmericanHeartAs s ociationnow
recommends IVinfus ionofchronotropicagents as anequallyeffective
alternativetoexternaltrans cutaneous pacingwhenatropineis ineffective.
(continued)

163

(continued)

To p ic
ACLS:
Ta c hyc a rd ia
Sync hro nize d
Ca rd io ve rs io n

2 0 1 0 Gu id e lin e s
The 2010 AHA Guidelines for CPR and ECC s implifies the Tachycardia
Algorithm.
For cardiovers ion of uns table atrial fibrillation, the 2010 AHA Guidelines
for CPR and ECC recommends that the initial biphas ic energy dos e be
between 120 and 200 J . Cardiovers ion with monophas ic waveforms
s hould begin at 200 J and increas e in a s tepwis e fas hion if not s ucces s ful.
For cardiovers ion of uns table SVT or uns table atrial flutter, the 2010 AHA
Guidelines for CPR and ECC recommends that the initial monophas ic or
biphas ic energy dos e be between 50 to 100 J .
The 2010 AHA Guidelines for CPR and ECC als o recommends
cardiovers ion for uns table monomorphic VT, with an initial energy dos e of
100 J .
If the initial s hock fails , providers s hould increas e the dos e in a s tepwis e
fas hion.

ACLS:
P o s tCa rd ia c
Arre s t Ca re

A new s ection focus ing on pos tcardiac arres t care was introduced in
the 2010 AHA Guidelines for CPR and ECC. Recommendations aimed at
improving s urvival after ROSC include
Optimizing cardiopulmonary function and vital organ perfus ion, es pecially
to the brain and heart
Trans porting out-of-hos pital cardiac arres t patients to an appropriate
facility with pos tcardiac arres t care that includes acute coronary
interventions , neurologic care, goal-directed critical care, and hypothermia
Trans porting in-hos pital cardiac arres t patients to a critical care unit
capable of providing comprehens ive pos tcardiac arres t care
Identifying and treating the caus es of the arres t and preventing recurrence
Cons idering therapeutic hypothermia to optimize s urvival and neurologic
recovery in comatos e patients
Identifying and treating acute coronary s yndromes
Optimizing mechanical ventilation to minimize lung injury
Gathering data for prognos is
As s is ting patients and families with rehabilitation s ervices if needed
Critic a l a c tio ns fo r p o s tc a rd ia c a rre s t c a re :
Hemodynamic optimization, including a focus on treating hypotens ion
Acquis ition of a 12-lead ECG
Induction of therapeutic hypothermia
Monitoring advanced airway placement and ventilation s tatus with
quantitative waveform capnography in intubated patients
Optimizing arterial oxygen s aturation

ACLS:
Ma na g ing
the Airwa y

The 2010 AHA Guidelines for CPR and ECC recommends us ing waveform
capnography to monitor the amount of carbon dioxide exhaled by the
patient and to verify placement of an endotracheal tube.
Cricoid pres s ure s hould not be us ed routinely during cardiac arres t. This
technique is difficult to mas ter and may not be effective for preventing
as piration. It may als o delay or prevent placement of an advanced airway.
Agonal gas ps are not effective breaths and s hould not be confus ed with
normal breathing.

Hig h-Qua lity


P a tie nt Ca re :
Sys te m s o f Ca re
164

Integrated s ys tems of care s hould include community members , EMS,


phys icians , and hos pitals .

ACLS P h a r m a c o lo g y S u m m a r y Ta b le
Dr u g
Ad e no s ine

Am io d a ro ne

In d ic a t io n s

P re c a u t io n s /
Co n t r a in d ic a t io n s

Ad u lt Do s a g e

Firs tdrugformos tforms of


s tablenarrow-complexSVT.
Effectiveinterminatingthos e
duetoreentryinvolvingAV
nodeors inus node
Maycons iderforuns table
narrow-complexreentry
tachycardiawhilepreparations
aremadeforcardiovers ion
Regularandmonomorphic
wide-complextachycardia,
thoughttobeorprevious ly
definedtobereentrySVT
Does notconvertatrialfibrillation,atrialflutter,orVT
Diagnos ticmaneuver:s table
narrow-complexSVT

Contraindicatedinpois on/
drug-inducedtachycardiaor
s econd-orthird-degreeheart
block
Trans ients ideeffects include
flus hing,ches tpainortightnes s ,briefperiods ofas ys tole
orbradycardia,ventricular
ectopy
Les s effective(largerdos es
mayberequired)inpatients
takingtheophyllineorcaffeine
Reduceinitialdos eto3mgin
patients receivingdipyridamoleorcarbamazepine,inheart
trans plantpatients ,orifgiven
bycentralvenous acces s
Ifadminis teredforirregular,
polymorphicwide-complex
tachycardia/VT,maycaus e
deterioration(including
hypotens ion)
Trans ientperiods ofs inus
bradycardiaandventricular
ectopyarecommonafter
t erminationofSVT
Safeandeffectivein
pregnancy

IV Ra p id P us h
Placepatientinmildrevers e
Trendelenburgpos itionbefore
adminis trationofdrug
Initialbolus of6mggivenrapidlyover1to3s econds followedbyNSbolus of20mL;
thenelevatetheextremity
As econddos e(12mg)can
begivenin1to2minutes if
needed

Becaus eits us eis as s ociated


withtoxicity,amiodaroneis
indicatedforus einpatients
withlife-threateningarrhythmias
whenadminis teredwithappropriatemonitoring:

Ca u tion : Multip le c o m p le x
d rug inte ra c tio ns

VF/VT Ca rd ia c Arre s t
Unre s p o ns ive to CP R, Sho c k,
a nd Va s o p re s s o r

Rapidinfus ionmayleadto
hypotens ion
Withmultipledos ing,cumulativedos es >2.2gover24
hours areas s ociatedwiths ig VF/puls eles s VTunres pons ive
nificanthypotens ioninclinical
tos hockdelivery,CPR,anda
trials
vas opres s or
Donotadminis terwithother
Recurrent,hemodynamically
drugs thatprolongQTinterval
uns tableVT
(eg,procainamide)
With expert consultationamiod Terminaleliminationis
aronemaybeus edfortreatment
extremelylong(half-lifelas ts
ofs omeatrialandventricular
upto40days )
arrhythmias

Inje c tio n Te c hniq ue


Recordrhythms tripduring
adminis tration
Drawupadenos inedos eand
flus hin2s eparates yringes
Attachboths yringes tothe
IVinjectionportclos es tto
patient
ClampIVtubingabove
injectionport
Pus hIVadenos ineas quickly
as possible(1to3s econds )
Whilemaintainingpres s ureon
adenos ineplunger,pus hNS
flus has rapidly as possible
afteradenos ine
UnclampIVtubing

Firs t d o s e :300mgIV/IO
pus h
Se c o nd d o s e (if ne e d e d ):
150mgIV/IOpus h
Life -Thre a te ning Arrhythm ia s
Ma xim um c um ula tive d o s e :
2.2gIVover24hours .Maybe
adminis teredas follows :
Ra p id infus io n:150mgIV
overfirs t10minutes (15mg
perminute).Mayrepeatrapid
infus ion(150mgIV)every10
minutes as needed
Slo w infus io n:360mg
IVover6hours (1mgper
minute)
Ma inte na nc e infus io n:540
mgIVover18hours (0.5mg
perminute)
(continued)

165

(continued)

Dr u g
Atro p ine
Sulfa te
Can be given
via endotracheal tube

In d ic a t io n s
Firs tdrugfors ymptomatic
s inus bradycardia
Maybebeneficialinpres ence
ofAVnodalblock.No t like ly
to b e e ffe c tive fo r typ e II
s e c o nd -d e g re e o r third d e g re e AV b lo c k o r a b lo c k
in no n-no d a l tis s ue
Routineus eduringPEAor
as ys toleis unlikelytohavea
therapeuticbenefit
Organophos phate(eg,nerve
agent)pois oning:extremely
largedos es maybeneeded

P re c a u t io n s /
Co n t r a in d ic a t io n s
Us ewithcautioninpres ence
ofmyocardialis chemiaand
hypoxia.Increas es myocardial
oxygendemand
Avoidinhypothermic
bradycardia
Maynotbeeffectivefor
infranodal(typeII)AVblock
andnewthird-degreeblock
withwideQRScomplexes .
(Inthes epatients maycaus e
paradoxicals lowing.Be
preparedtopaceorgive
catecholamines )
Dos es ofatropine<0.5mg
mayres ultinparadoxical
s lowingofheartrate

Ad u lt Do s a g e
Bra d yc a rd ia (With o r
Witho ut ACS)
0.5mgIVevery3to5minutes as needed,nottoexceed
totaldos eof0.04mg/kg(total
3mg)
Us es horterdos inginterval(3
minutes )andhigherdos es in
s evereclinicalconditions
Org a no p ho s p ha te P o is o ning
Extremelylargedos es (2to4
mgorhigher)maybeneeded

Do p a m ine
IV infusion

Second-linedrugfors ymp Correcthypovolemiawith


tomaticbradycardia(after
volumereplacementbefore
atropine)
initiatingdopamine
Us eforhypotens ion(SBP70 Us ewithcautionincardioto100mmHg)withs igns and
genics hockwithaccompanys ymptoms ofs hock
ingCHF
Maycaus etachyarrhythmias ,
exces s ivevas ocons triction
Donotmixwiths odium
bicarbonate

Ep ine p hrine
Can be given
via endotracheal tube

Ca rd ia c a rre s t:VF,puls eles s Rais ingbloodpres s ureand


Ca rd ia c Arre s t
VT,as ys tole,PEA
increas ingheartratemay
IV/IO d o s e :1mg(10mLof
caus emyocardialis chemia,
1:10000s olution)adminis Sym p to m a tic b ra d yc a rd ia :
angina,andincreas edmyoteredevery3to5minutes
Canbecons ideredafteratrocardialoxygendemand
duringres us citation.Follow
pineas analternativeinfus ion
eachdos ewith20mLflus h,
todopamine
Highdos es donotimprove
elevatearmfor10to20s ecs urvivalorneurologicout Se ve re hyp o te ns io n:Canbe
onds afterdos e
comeandmaycontributeto
us edwhenpacingandatropos tres us citationmyocardial
Hig he r d o s e : Higherdos es
pinefail,whenhypotens ion
dys function
(upto0.2mg/kg)maybe
accompanies bradycardia,
us edfors pecificindications
orwithphos phodies teras e
Higherdos es mayberequired
(-blockerorcalciumchannel
enzymeinhibitor
totreatpois on/drug-induced
blockeroverdos e)
s hock
Ana p hyla xis , s e ve re a lle rg ic
Co ntinuo us infus io n:Initial
re a c tio ns :Combinewithlarge
rate:0.1to0.5mcg/kgper
fluidvolume,corticos teroids ,
minute(for70-kgpatient:7to
antihis tamines
35mcgperminute);titrateto
res pons e
End o tra c he a l ro ute :2to2.5
mgdilutedin10mLNS

Available
in 1:10 000
and 1:1000
concentrations

IV Ad m inis tra tio n


Us ualinfus ionrateis 2to20
mcg/kgperminute
Titratetopatientres pons e;
tapers lowly

P ro fo und Bra d yc a rd ia o r
Hyp o te ns io n
2to10mcgperminuteinfus ion;
titratetopatientres pons e
(continued)

166

(continued)

Dr u g
Lid o c a ine
Can be given
via endotracheal tube

In d ic a t io n s
Alternativetoamiodaronein
cardiacarres tfromVF/VT
StablemonomorphicVTwith
pres ervedventricularfunction
StablepolymorphicVTwith
normalbas elineQTinterval
andpres ervedLVfunction
whenis chemiais treated
andelectrolytebalanceis
corrected
Canbeus edfors tablepolymorphicVTwithbas eline
QT-intervalprolongationiftors ades s us pected

P re c a u t io n s /
Co n t r a in d ic a t io n s
Co ntra ind ic a tio n:
Prophylacticus einAMIis
contraindicated
Reducemaintenancedos e
(notloadingdos e)inpres ence
ofimpairedliverfunctionorLV
dys function
Dis continueinfus ionimmediatelyifs igns oftoxicity
develop

Ad u lt Do s a g e
Ca rd ia c Arre s t Fro m VF/VT
Initialdos e:1to1.5mg/kg
IV/IO
ForrefractoryVFmaygive
additional0.5to0.75mg/kgIV
pus h,repeatin5to10minutes ;maximum3dos es or
totalof3mg/kg
P e rfus ing Arrhythm ia
Fors tableVT,wide-complex
tachycardiaofuncertaintype,
s ignificantectopy:
Dos es rangingfrom0.5to
0.75mg/kgandupto1to1.5
mg/kgmaybeus ed
Repeat0.5to0.75mg/kg
every5to10minutes ;maximumtotaldos e:3mg/kg
Ma inte na nc e Infus io n
1to4mgperminute(30to50
mcg/kgperminute)

Ma g ne s ium
Sulfa te

Va s o p re s s in
Can be given
via endotracheal tube

Recommendedforus eincardiacarres tonlyiftors ades de


pointes ors us pectedhypomagnes emiais pres ent
Life-threateningventricular
arrhythmias duetodigitalis
toxicity
Routineadminis trationinhos pitalizedpatients withAMIis
no trecommended

Occas ionalfallinbloodpres s urewithrapidadminis tration


Us ewithcautionifrenalfailureis pres ent

Maybeus edas alternative


pres s ortoepinephrinein
treatmentofadults hockrefractoryVF
Maybeus efulalternativeto
epinephrineinas ys tole,PEA
Maybeus efulforhemodynamics upportinvas odilatory
s hock(eg,s eptics hock)

Potentperipheralvas ocons trictor.Increas edperipheral


vas cularres is tancemayprovokecardiacis chemiaand
angina
Notrecommendedforres pons ivepatients withcoronary
arterydis eas e

Ca rd ia c Arre s t
(Due to Hyp o m a g ne s e m ia o r
To rs a d e s d e P o inte s )
1to2g(2to4mLofa50%
s olutiondilutedin10mL[eg,
D5 W,normals aline]givenIV/IO)
To rs a d e s d e P o inte s
With a P uls e o r AMI With
Hyp o m a g ne s e m ia
Loadingdoseof1to2gmixed
in50to100mLofdiluent
(eg,D5 W,normals aline)over
5to60minutes IV
Followwith0.5to1gper
hourIV(titratetocontrol
tors ades )
IV Ad m inis tra tio n
Ca rd ia c a rre s t:Onedos eof40
units IV/IOpus hmayreplace
eitherfirs tors econddos eof
epinephrine.Epinephrinecanbe
adminis teredevery3to5minutes duringcardiacarres t
Va s o d ila to ry s ho c k:
Continuous infus ionof0.02to
0.04units perminute

167

Glo s s a r y
A
Ac ute

Having a s udden ons et and s hort cours e

Ac ute m yo c a rd ia l infa rc tio n


(AMI)

The early critical s tage of necros is of heart mus cle tis s ue caus ed by blockage of a
coronary artery

Ad va nc e d c a rd io va s c ula r life
s up p o rt (ACLS)

Emergency medical procedures in which bas ic life s upport efforts of CPR are s upplemented with drug adminis tration, IV fluids , etc

As ys to le

Abs ence of electrical and mechanical activity in the heart

Atria l fib rilla tio n

In atrial fibrillation the atria quiver chaotically and the ventricles beat irregularly

Atria l flutte r

Rapid, irregular atrial contractions due to an abnormality of atrial excitation

Atrio ve ntric ula r b lo c k

A delay in the normal flow of electrical impuls es that caus e the heart to beat

Auto m a te d e xte rna l


d e fib rilla to r (AED)

A portable device us ed to res tart a heart that has s topped

B
Ba s ic life s up p o rt (BLS)

Emergency treatment of a victim of cardiac or res piratory arres t through cardiopulmonary res us citation and emergency cardiovas cular care

Bra d yc a rd ia

Slow heartbeat, whether phys iologically or pathologically

C
Ca p no g ra p hy

The meas urement and graphic dis play of CO 2 levels in the airways , which can be performed by infrared s pectros copy

Ca rd ia c a rre s t

Temporary or permanent ces s ation of the heartbeat

Ca rd io p ulm o na ry
re s us c ita tio n (CP R)

A bas ic emergency procedure for life s upport, cons is ting of mainly manual external
cardiac mas s age and s ome artificial res piration

Co ro na ry s ynd ro m e

A group of clinical s ymptoms compatible with acute myocardial is chemia (als o called
coronary heart disease)

Co ro na ry thro m b o s is

The blocking of the coronary artery of the heart by a thrombus

168

Ele c tro c a rd io g ra m (ECG)

A tes t that provides a typical record of normal heart action

Enc e p ha lo p a thy

Degeneration of brain function. Als o called cephalopathy, cerebropathy.

End o tra c he a l intub a tio n

The pas s age of a tube through the nos e or mouth into the trachea for maintenance of
the airway

Es o p ha g e a l d e te c to r d e vic e

A dis pos able tool us ed to verify proper endotracheal tube placement by us ing the
anatomical differences between the trachea and es ophagus

Es o p ha g e a l-tra c he a l tub e

A double-lumen tube with inflatable balloon cuffs that s eal off the hypopharynx from
the oropharynx and es ophagus ; us ed for airway management

H
Hyd ro g e n io n (a c id o s is )

The accumulation of acid and hydrogen ions or depletion of the alkaline res erve
(bicarbonate content) in the blood and body tis s ues , decreas ing the pH

Hyp e rka le m ia

An abnormally high concentration of potas s ium ions in the blood. Als o called
hyperpotassemia.

Hyp o g lyc e m ia

An abnormally low concentration of glucos e in the blood

Hyp o ka le m ia

An abnormally low concentration of potas s ium ions in the blood. Als o called
hypopotassemia.

Hyp o the rm ia

A potentially fatal condition that occurs when body temperature falls below 95F
(35C)

Hyp o vo le m ia

A decreas e in the volume of circulating blood

Hyp o xia

A deficiency of oxygen reaching the tis s ues of the body

I
Intra o s s e o us (IO)

Within a bone

Intra ve no us (IV)

Within a vein

M
Mild hyp o the rm ia

When the patients body temperature is between 90 and 95F

Mo d e ra te hyp o the rm ia

When the patients body temperature is between 86 and 90F

N
Na s o p ha ryng e a l

Pertaining to the nos e and pharynx

O
Oro p ha ryng e a l a irwa y

A tube us ed to provide free pas s age of air between the mouth and pharynx

P
P e rfus io n

The pas s age of fluid (s uch as blood) through a s pecific organ or area of the body
(s uch as the heart)

P ro p hyla xis

Prevention of or protection agains t dis eas e

P ulm o na ry e d e m a

A condition in which fluid accumulates in the lungs

P uls e le s s e le c tric a l a c tivity


(P EA)

Continued electrical rhythmicity of the heart in the abs ence of effective mechanical
function

R
Re c o m b ina nt tis s ue
p la s m ino g e n a c tiva to r (rtPA)

A clot-dis s olving s ubs tance produced naturally by cells in the walls of blood ves s els

S
Se ve re hyp o the rm ia

When the patients body temperature is <86F

Sinus rhythm

The rhythm of the heart produced by impuls es from the s inoatrial node

Sup ra g lo ttic

Situated or occurring above the glottis

Sync hro nize d c a rd io ve rs io n

Us es a s ens or to deliver a s hock that is s ynchronized with a peak in the QRS complex
169

Sync o p e

A los s of cons cious nes s over a s hort period of time, caus ed by a temporary lack of
oxygen in the brain

T
Ta c hyc a rd ia

Increas ed heartbeat, us ually 100/min

Ta m p o na d e (c a rd ia c )

A condition caus ed by accumulation of fluid between the heart and the pericardium,
res ulting in exces s pres s ure on the heart. This impairs the hearts ability to pump s ufficient blood.

Te ns io n p ne um o tho ra x

Pneumothorax res ulting from a wound in the ches t wall which acts as a valve that permits air to enter the pleural cavity but prevents its es cape

Thro m b us

A blood clot formed within a blood ves s el

U
Uns ync hro nize d s ho c k

An electrical s hock that will be delivered as s oon as the operator pus hes the SHOCK
button to dis charge the defibrillator. Thus , the s hock can fall anywhere within the cardiac cycle.

170

Ve ntric ula r fib rilla tio n (VF)

Very rapid uncoordinated fluttering contractions of the ventricles

Ve ntric ula r ta c hyc a rd ia (VT)

A rapid heartbeat that originates in one of the lower chambers (ventricles ) of the heart

Fo u n d a t io n In d e x
A
Acute coronary s yndromes

91

Amiodarone

72

Antiarrhythmic drugs

71

As pirin

97

As ys tole

86

Atrioventricular (AV) block

105

Atropine

110

B
Bag-mas k

42

Bradycardia

104

D
Defibrillation

54

Dopamine

76, 112

E
Endotracheal tube s uctioning procedure

46

Epinephrine

65

Es ophageal-tracheal tube

48

F
Fibrinolytic therapy

102

Firs t-degree AV block

105

H
Head tiltchin lift

40

Heparin

104

I
IV/IO acces s

69

L
Laryngeal mas k airway

47

Lidocaine

72

Lone healthcare provider

14

M
Magnes ium s ulfate

72

Morphine

97

N
Nitroglycerin

97

O
Oropharyngeal s uctioning procedure

46

Oxygen

38
171

P
Paddles vers us pads

64

Puls eles s electrical activity (PEA)

78

Puls eles s VT

59

R
Recombinant tis s ue plas minogen activator (rtPA)

144

Refractory VF

59

Reteplas e

102

S
Second-degree AV block

105

Streptokinas e

102

ST-s egment elevation myocardial infarction (STEMI)

101

T
Tachycardia

114

Tenecteplas e

102

Third-degree AV block

105

Trans cutaneous pacing (TCP)

111

V
Vas opres s in

65

Vas opres s or agents

65

Ventricular fibrillation (VF)

59

Ventricular tachycardia (VT)

128

Y
Yankauer

172

45

In d e x
Abbreviations us ed, 7-9
ABCD approach, 7, 163
Accelerated idioventricular rhythm (AIVR), 7, 113
ACE inhibitors in acute coronary s yndromes , 94, 103
Acetyls alicylic acid

emergency department as s es s ment and treatment in, 29,


94, 99-100
emergency medical s ervices in, 29, 92, 95, 96-98; algorithm
on, 94
goals o therapy in, 29, 92-93

in acute coronary s yndromes , 96, 100

pathophys iology o , 93

in s troke, 131, 134, 141

percutaneous coronary interventions in, 93, 102-103;

Acidos is , 169
as ys tole/PEA in, 83

primary, 92, 93, 102; res cue, 102; in ST-s egment


elevation, 100, 101, 102-103

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

puls eles s electrical activity in, 85

Pos tCardiac Arres t Care Algorithm on, 73, 160

s igns and s ymptoms in, 96

ACLS. See Advanced cardiovas cular li e s upport


ACLS cas es , 33-147
on acute coronary s yndromes , 91-104

time to treatment in, 94, 95, 99, 100, 101; in f brinolytic


therapy, 102; in percutaneous coronary interventions ,
102-103

on acute s troke, 130-147

Acute Coronary Syndromes Algorithm, 94, 95-104

on as ys tole, 86-91

Acute s troke, 30, 130-147. See also Stroke

on bradycardia, 104-114

Adenos ine in tachycardia, 125, 129-130, 165

on lone res cuer CPR and AED us e in VF/puls eles s VT, 49-58
overview o , 33

algorithm on, 118, 127, 162


-Adrenergic blockers

on puls eles s electrical activity, 78-85

in acute coronary s yndromes , 94, 103

on re ractory VF/puls eles s VT, 59-77

in tachycardia, 125, 129, 130; algorithm on, 118, 127, 162

on res piratory arres t, 34-49

Advanced cardiovas cular li e s upport, 7

on s table tachycardia, 124-130

def nition o , 168

on uns table tachycardia, 114-123

provider cours e on (see Provider Cours e)

ACLS Provider Manual, 4-5, 6


abbreviations us ed in, 7-9
ACLS Survey, 11, 14-16

s urvey in (see ACLS Survey)


s ys temic approach in, 11
AED. See Automated external def brillator

in as ys tole, 81, 88, 89

Agonal gas ps , 55

in bradycardia, 108, 110

Airway as s es s ment and management, 15

in puls eles s electrical activity, 78, 81

in as ys tole, 82, 86, 88, 159

in res piratory arres t, 36-37, 151

in bradycardia, 109, 110, 161

in s table tachycardia, 126, 128

Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159

in uns table tachycardia, 116, 119

in cervical s pine trauma, 39, 40, 49

in ventricular f brillation/puls eles s VT, 62

changes in 2010 Guidelines , 164

Acute coronary s yndromes , 7, 29, 91-104

in pos tcardiac arres t care, 73, 74, 75, 160

algorithm on, 94, 95-104

in puls eles s electrical activity, 81, 82, 159

bradycardia in, 113, 114

in res piratory arres t, 36, 38-49

drug therapy in, 92, 93, 96, 102; adjunctive, 103-104;

in s troke, 146

algorithm on, 94; in emergency department, 100;


in prehos pital care, 97-98; in ST-s egment elevation,
100, 101

in tachycardia with puls e, 119, 128; algorithm on, 118,


127, 162
in ventricular f brillation/puls eles s VT, 61, 66, 158
173

I n d e x
AIVR (accelerated idioventricular rhythm), 7, 113
Algorithms

drug therapy in, 111


rs t-degree, 105, 106

on acute coronary s yndromes , 94, 95-104

s econd-degree, 105, 106, 111, 112, 114

on as ys tole, 60, 61, 79, 86, 88-89, 159

third-degree, 105, 106, 111, 112, 114

on bas ic li e s upport, 52-53

trans cutawneous pacing in, 112, 113, 114

on bradycardia, 108-112, 161


on pos tcardiac arres t care, 72-77, 160

Atrioventricular nodal blocking drugs , precautions in us e


o , 129, 130

on puls eles s electrical activity, 60, 61, 78, 79-82, 159

Atrioventricular nodal reentry tachycardia, 124

on s troke, 133-147

Atropine s ul ate, 166

on tachycardia with puls e, 118, 127, 162; s table, 126-130;


uns table, 116-120
on ventricular brillation/puls eles s VT, 60-69, 158
Amiodarone, 165

in as ys tole/puls eles s electrical activity, 81, 88


in bradycardia, 106, 108, 166; algorithm on, 109, 161; in
treatment s equence, 110, 111, 113
Automated external de brillator, 7, 13

Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159

ches t hair a ecting, 57-58

in tachycardia with puls e, 129; algorithm on, 118, 127, 162

de nition o , 168

in ventricular brillation/puls eles s VT, 66, 72, 158, 165

electrode pad placement, 55, 56, 57

Angina, uns table, 9, 93, 95


electrocardiography and ris k clas s i cation in, 101
Angiotens in-converting enzyme inhibitors , in acute coronary
s yndromes , 94, 103
Antiarrhythmic drugs

implanted pacemaker a ecting, 58


lay res cuer us ing, 54
in lone res cuer, 49-58, 152
in res piratory arres t, 34, 35
trans dermal medication patches a ecting, 58

in tachycardia with puls e, 129; algorithm on, 118, 127, 162

univers al s teps in operation o , 55-56

in ventricular brillation/puls eles s VT, 65-66, 71-72

in ventricular brillation/puls eles s VT: and CPR, 52, 53, 54,

Anti-inf ammatory drugs , nons teroidal, 8


contraindications in ACS, 98
Arm dri t in s troke, 136, 137

57; and lone res cuer, 49-58; s teps in us e o , 55-57;


troubles hooting problems with, 57
water a ecting, 58

As pirin
in acute coronary s yndromes , 96, 100
in s troke, 131, 134, 141
As ys tole, 86-91
as agonal rhythm con rming death, 90
Cardiac Arres t Algorithm on, 60, 61, 79, 86, 88-89, 159

in cardiac arres t, 36, 47


E-C clamp technique, 41
in 2 res cuers , 41
Bas ic li e s upport, 7

common caus es o , 86, 88

de nition o , 168

de nition o , 168

prerequis ite s kills required, 2

drug therapy in, 86, 88; algorithm on, 61, 80, 82, 159

s ummary o 2010 Guidelines on, 163

duration o res us citation e orts in, 87, 90

s urvey in (see BLS Survey)

ethical is s ues in, 90

s ys temic approach in, 11

Megacode evaluation o s kills in, 153

Benchmarks on CPR per ormance and outcome, 27

termination o res us citation e orts in, 86, 87, 89-90

-Blockers

trans port o patients in, 91

in acute coronary s yndromes , 94, 103

treatment s equence in, 82, 86, 89

in tachycardia, 125, 129, 130; algorithm on, 118, 127, 162

Atheros cleros is , acute coronary s yndromes in, 93


Atrial brillation and f utter, 114, 124, 128
cardiovers ion in, 116, 121, 122, 123

Biphas ic de brillators , 63, 66


Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159
Blood pres s ure, 9

de nitions o , 168

in hypotens ion (see Hypotens ion)

drug therapy in, 129

in pos tcardiac arres t care, 28, 73, 76, 160

s troke in, 131, 140

in res piratory arres t, 37

Atrioventricular block

174

Bag-mas k ventilation, 36, 41, 42, 151

in s troke, 146-147

bradycardia in, 105, 106, 111, 112, 113

BLS. See Bas ic li e s upport

de nition o , 168

BLS Survey, 11, 12-14

In d e x

in as ys tole, 81, 88, 89


in bradycardia, 108, 110
changes in 2010 Guidelines on, 12, 163

arterial partial pres s ure (Paco 2 ), 9; in pos tcardiac arres t


care, 28, 74
end-tidal partial pres s ure (P e t c o 2 ), 16, 76; Cardiac Arres t

in puls eles s electrical activity, 78, 81

Algorithm on, 61, 80, 82, 158, 159; during CPR, 67-69;

in res piratory arres t, 34-36, 151

in pos tcardiac arres t care, 28, 73, 74, 75, 160; in

in s table tachycardia, 126, 128

res piratory arres t, 37

in uns table tachycardia, 116, 119


in ventricular f brillation/puls eles s VT, 50-57, 62
Bradycardia, 104-114

Cardiac arres t, 28-29


in acute coronary s yndromes , 92
as ys tole in, 86-91

in airway s uctioning procedure, 46

cricoid pres s ure in, 48

algorithm on, 108-112, 161; changes in 2010 Guidelines ,

def nition o , 168

109, 163

hypothermia induced in, 28, 73, 77, 160

contributing actors in, 110

in-hos pital, 30-32

def nition o , 107, 168

lone res cuer in, 14, 49-58

drug therapy in, 106, 108; algorithm on, 109, 161;

and pos tcardiac arres t care, 28-29, 72-77 (see also Pos t

nitroglycerin precautions in, 97; and trans cutaneous


pacing, 113; in treatment s equence, 110, 111, 112

cardiac arres t care)


with puls eles s electrical activity, 78-85

es cape rhythms in, 112, 113

in re ractory VF/VT, 59-77

unctional or relative, 107

revers ible caus es o , 61, 66, 73, 80, 82; learning s tation

learning s tation checklis t on, 161

checklis ts on, 158-160

Megacode evaluation o s kills in, 153

team approach to, 26-27, 30-32, 73

per us ion as s es s ment in, 110

trans port o patients in, 91

rhythms included in, 105, 106

treatment s equence in, 57, 66

s igns and s ymptoms in, 107, 110

ventilation rate in, 36, 47

s inus , 105, 106, 107


trans cutaneous pacing in, 108, 110, 111, 112-114;
algorithm on, 109, 161

Cardiac Arres t Algorithm, 163


in as ys tole, 60, 61, 79, 86, 88-89, 159
circular ormat, 66, 67, 82

trans venous pacing in, 108, 109, 112, 161

learning s tation checklis ts on, 158-159

treatment s equence in, 108, 110-111

in puls eles s electrical activity, 60, 61, 78, 79-82, 159

Bradycardia Algorithm, 108-112, 161


changes in 2010 Guidelines , 109, 163
Breathing as s es s ment, 15
agonal gas ps in, 55

in ventricular f brillation/puls eles s VT, 60-69, 158


Cardiac Arres t Regis try to Enhance Survival (CARES), 7, 27
Cardiac output, 76, 125
Cardiopulmonary res us citation, 25-27

in res piratory arres t, 35, 37

in ACLS Survey, 15, 16, 36, 37

in ventricular f brillation/puls eles s VT, 51, 52, 53, 55

in acute coronary s yndromes , 92

Bundle branch block

in as ys tole, 86, 88, 89-90; algorithm on, 61, 80, 82, 159

acute coronary s yndromes in, 95

in BLS Survey, 12, 13, 34, 35

trans cutaneous pacing in, 112, 114

ches t compres s ions in (see Ches t compres s ions )

ventricular f brillation/puls eles s VT in, 60

coronary per us ion pres s ure in, 62, 67


def nition o , 168

Calcium channel blockers in tachycardia, 129, 130


algorithm on, 118, 127, 162

high-quality, 14, 52, 62, 163


in lone res cuer, 15, 49-58, 152

Canadian Neurological Scale, 134, 143

meas urements on per ormance and outcome o , 27

Capnography

in puls eles s electrical activity, 79, 81; algorithm on, 61, 80,

def nition o , 168

82, 159

in endotracheal tube as s es s ment, 37, 48, 76

quality improvement in, 25, 27

in pos tcardiac arres t care, 73, 74, 75, 76

res cue breathing in (see Res cue breathing)

in res piratory arres t, 36, 37

in res piratory arres t, 34, 35, 36, 37, 40; and advanced

in ventricular f brillation/puls eles s VT and CPR, 67-69


Carbon dioxide

airway, 48
in s troke, 136
175

I n d e x
s ummary o 2010 Guidelines on, 163

Ches t pain and dis com ort

s ys tems approach to, 26

in acute coronary s yndromes , 96; nitroglycerin in, 98

team approach to, 3, 17-23

in bradycardia, 107, 110, 113, 161; algorithm on, 109, 161

in ventricular f brillation/puls eles s VT: AED us e with, 52,

in tachycardia, 115, 117, 119; algorithm on, 118, 127

53, 54, 57; Cardiac Arres t Algorithm on, 61, 62-63, 66,

Cincinnati Prehos pital Stroke Scale (CPSS), 7, 136-138

158; drug therapy with, 65-66; and lone res cuer, 49-58;

Circulation

manual def brillator us e with, 59, 61, 62-63, 64, 65,

in ACLS Survey, 16, 37

66; phys iologic monitoring during, 67-69; in treatment

in BLS Survey, 13, 35

s equence, 66

in bradycardia, 110

Cardiovers ion
in s table tachycardia, 116
s ynchronized: changes in 2010 Guidelines , 164; compared

in res piratory arres t, 35, 37


return o s pontaneous circulation (see Return o
s pontaneous circulation)

to uns ynchronized, 121; def nition o , 169; potential

Clarity o communication in res us citation team, 19

problems in, 121; Tachycardia With Puls e Algorithm on,

Clopidogrel in acute coronary s yndromes , 94, 103

118, 127, 162; in uns table tachycardia, 118, 120, 121,

Clos ed-loop communication in res us citation team, 19

122-123

Communication in res us citation team, 19

in uns table tachycardia, 114, 119, 120-123; algorithm on,

clarity o mes s ages in, 19

118; indications or, 116, 121; s ynchronized s hocks

cons tructive interventions in, 22

in, 118, 120, 121, 122-123; uns ynchronized s hocks in,

delegation o roles and res pons ibilities in, 20-21

120, 121

knowledge s haring in, 22

CARES (Cardiac Arres t Regis try to Enhance Survival), 7, 27

mutual res pect in, 23

Carotid puls e, 13

on patient s tatus , 22, 23

in res piratory arres t, 35


in trans cutaneous pacing, 112
in ventricular f brillation/puls eles s VT, 51
Catheterization

reques ts or as s is tance in, 21


Computed tomography, 7
in s troke, 131, 134, 135, 140; criteria or f brinolytic therapy
in, 143; hemorrhagic, 134, 141; time to, 135, 141

or airway s uctioning, 45

Cons tructive interventions in res us citation team, 22

intraos s eous (see Intraos s eous acces s )

Cons ultation with expert

intravenous (see Intravenous acces s )


Cerebral artery thrombos is , is chemic s troke in, 142
Cervical s pine trauma
airway as s es s ment and management in, 39, 40, 49
immobilization in, 49
Chain o Survival, 26, 27, 30
in acute coronary s yndromes , 96
in acute s troke, 132-133
Ches t compres s ions , 12, 13, 36, 47
in as ys tole, 86, 88, 89, 159

in bradycardia, algorithm on, 109, 161


in tachycardia, 128, 129, 130; algorithm on, 118, 127, 162
Coronary per us ion pres s ure in CPR, 62, 67
Coronary s yndromes
acute, 91-104 (see also Acute coronary s yndromes )
def nition o , 168
Coronary thrombos is , 168
as ys tole/PEA in, 83, 84
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos tCardiac Arres t Care Algorithm on, 73, 160

coronary per us ion pres s ure in, 62

CPR, 7, 168. See also Cardiopulmonary res us citation

in high-quality CPR, 14, 163

CPSS (Cincinnati Prehos pital Stroke Scale), 7, 136-138

minimizing interruptions in, 12, 13, 14, 81

Cricoid pres s ure, 48

in puls eles s electrical activity, 81, 159


ratio to ventilation, 48, 61, 80, 82, 158, 159
in res piratory arres t, 35, 36, 37, 48

in as ys tole/puls eles s electrical activity, 80, 89, 159

in ventricular f brillation/puls eles s VT, 50, 51, 158; and

with automated external def brillator (see Automated

AED us e, 52, 53, 56, 57; in cycles o CPR, 56, 64, 65;

external def brillator)

and manual def brillator us e, 59, 62-63; minimizing

with implanted device, a ecting AED us e, 58

interruptions in, 62, 65; phys iologic monitoring during,

in res piratory arres t, 34, 35, 37

67-69

in ventricular f brillation/puls eles s VT: algorithm on, 61,

Ches t hair a ecting AED us e, 57-58


176

Def brillation, 13

158; with automated external def brillator, 49-58; in

In d e x

BLS Survey, 51; clearing warning in, 56, 64; and drug

Electrode pad placement in AED us e, 55, 56, 57

therapy, 65-66; early, importance o , 54; and lone

Electromechanical dis s ociation, 79

res cuer, 49-58; with manual de brillator, 59, 61, 62-63,

Embolis m, pulmonary, 9, 84, 85. See also Pulmonary

64, 66, 158; purpos e o , 54; treatment s equence in, 57


Di erential diagnos is in ACLS Survey, 16

thromboembolis m
Emergency department as s es s ment and treatment

in bradycardia, 108

in acute coronary s yndromes , 29, 94, 99-100

in res piratory arres t, 37

in s troke, 134, 139-140

Digoxin in tachycardia, 129


Do not attempt res us citation (DNAR), 8
in as ys tole, 87, 90
Dopamine, 166
in bradycardia, 106, 108, 113, 166; algorithm on, 109, 161;
in treatment s equence, 110, 112
in pos tcardiac arres t care, 73, 76, 160

Emergency medical s ervices , 8, 13, 29


in acute coronary s yndromes , 29, 92, 95, 96-98; algorithm
on, 94
in res piratory arres t, 35
in s troke, 30, 130, 132, 134, 135; activation o , 136; critical
actions in, 138-139
in ventricular brillation/puls eles s VT, 51, 52, 53

Drug overdos e, 84, 85, 90

Enalaprilat in s troke, 131

Drug therapy, 165-167

Encephalopathy, 168

in acute coronary s yndromes (see Acute coronary


s yndromes , drug therapy in)
in as ys tole, 86, 88; algorithm on, 61, 80, 82, 159

End-tidal carbon dioxide. See Carbon dioxide, end-tidal partial


pres s ure
Endotracheal intubation

in bradycardia (see Bradycardia, drug therapy in)

as s es s ment o tube placement in, 37, 48, 76

in pos tcardiac arres t care, 73, 76, 160

de nition o , 168

prerequis ite knowledge required, 3

in pos tcardiac arres t care, 74, 75

in puls eles s electrical activity, 78, 81; algorithm on, 61, 80,

in res piratory arres t, 36, 47, 48; s uctioning procedure in, 46

82, 159

in ventricular brillation/puls eles s VT, 69, 70

in s table tachycardia, 125, 129-130; algorithm on, 118, 127

Epiglottis , airway obs truction rom, 39

in s troke (see Stroke, drug therapy in)

Epinephrine, 166

s ummary table on, 165-167


with trans dermal medication patches , AED us e in, 58
in uns table tachycardia, 114, 118
in ventricular brillation and tachycardia (see Ventricular
brillation and tachycardia, drug therapy in)

in as ys tole/puls eles s electrical activity, 80, 81, 82, 88, 159,


166
in bradycardia, 106, 108, 113, 166; algorithm on, 109, 161;
in treatment s equence, 110, 112
Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159
in pos tcardiac arres t care, 73, 76, 160

ECASS (European Cooperative Acute Stroke Study), 144, 145

in ventricular brillation/puls eles s VT, 61, 65, 66, 70, 71, 158

Edema, pulmonary, de nition o , 169

Es cape rhythms in bradycardia, 112, 113

Education, community and pro es s ional, on s troke, 30, 132

Es ophageal detector device, 168

Electrocardiography, 8, 168

Es ophageal-tracheal tube, 168

in acute coronary s yndromes , 91, 92, 95; algorithm on, 94;

in res piratory arres t, 36, 47, 48

in emergency department, 99; in prehos pital care, 98;

Ethical is s ues in as ys tole, 90

ris k clas s i cation bas ed on, 101-102

European Cooperative Acute Stroke Study, 144, 145

in as ys tole, 86, 87
in bradycardia, 105, 106, 110; algorithm on, 109, 161
de nition o , 168

Exhaled air, carbon dioxide concentration in, 76. See also


Carbon dioxide, end-tidal partial pres s ure
Expert cons ultation. See Cons ultation with expert

prerequis ite interpretation s kills required, 3


in puls eles s electrical activity, 83-84

Facial droop in s troke, 136, 137

in s table tachycardia, 128

Fibrillation

in s troke, 131, 134, 140

atrial (see Atrial brillation and f utter)

technical problems in, 87

ventricular (see Ventricular brillation and tachycardia)

in uns table tachycardia, 114, 117, 118, 119; and


s ynchronized cardiovers ion, 121
in ventricular brillation/puls eles s VT, 60

Fibrinolytic therapy
in acute coronary s yndromes , 92, 93, 102; in prehos pital
care, 98; in ST-s egment elevation, 100, 101, 102
177

I n d e x
in acute s troke, 130, 131, 141, 143-145; advers e e ects

in hypovolemia, 84

o , 144; algorithm on, 134; complications o , 146;

nitroglycerin precautions in, 97

exclus ion criteria on, 141, 143-144, 145; inclus ion

pos tcardiac arres t, 73, 76, 160

criteria on, 143, 145; intra-arterial adminis tration o ,

in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162

145; time to treatment in, 135, 143, 144-145


Fixation errors in res us citation team, 22
Fluid adminis tration

Hypothermia, 169
bradycardia and trans cutaneous pacing contraindication in,
112

in pos tcardiac arres t care, 28, 73, 76, 160

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

in res piratory arres t, 37

de brillation in, 69

routes o , 70

drug metabolis m in, 69

in s troke, 146

duration o res us citation e orts in, 90

Flutter, atrial. See Atrial brillation and f utter

electrocardiography in, 83

Foreign body airway obs truction, 40

his tory and phys ical examination in, 83


Pos tCardiac Arres t Care Algorithm on, 73, 160

Gas ps , agonal, 55

rewarming in, 69, 77

Get With The Guidelines Res us citation, 27, 90

therapeutic, in cardiac arres t, 28, 73, 77, 160

Glucos e blood levels

Hypovolemia, 169

in hypoglycemia, 28, 169

as ys tole/PEA in, 83, 84, 85

in pos tcardiac arres t care, 28

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

in s troke, 134, 139, 140, 146

Pos tCardiac Arres t Care Algorithm on, 73, 160


Hypoxia, 169

Hairy ches t a ecting AED us e, 57-58

as ys tole/PEA in, 83, 85

Head tiltchin li t maneuver, 36, 39, 40, 49

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

Heart ailure, acute, 7

Pos tCardiac Arres t Care Algorithm on, 73, 160

bradycardia algorithm on, 109, 161


in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162
Heparin, 8, 9

Idioventricular rhythm, accelerated, 7, 113


Immobilization in cervical s pine trauma, 49

in acute coronary s yndromes , 94, 103, 104

Implanted de brillator/pacemaker, AED us e in, 58

in s troke, 141

In ormation s haring in res us citation team, 22

HMG-CoA reductas e inhibitors in acute coronary s yndromes ,


94, 103
Hos pital s etting

Intens ive care unit, 8


trans er to, pos tcardiac arres t, 77
Intraos s eous acces s , 8, 169

acute coronary s yndrome therapy in, 29

in as ys tole, 81, 88, 159

cardiac arres t in, 30-32

in res piratory arres t, 37

s troke care in, 130, 139-140

in ventricular brillation/puls eles s VT, 69, 70, 158

Hydrogen ion accumulation in acidos is , 169. See also Acidos is

Intravenous acces s , 8, 169

Hyperglycemia in s troke, 146

in as ys tole, 81, 88, 159

Hyperkalemia, 169

in bradycardia, 109, 161

as ys tole/PEA in, 83

in pos tcardiac arres t care, 73, 76, 160

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

in res piratory arres t, 37

Pos tCardiac Arres t Care Algorithm on, 73, 160

in s troke, 140

Hypertens ion, s troke and brinolytic therapy in, 146-147

in tachycardia with puls e, 118, 127, 162

Hypoglycemia, 28, 169

in ventricular brillation/puls eles s VT, 69, 70, 158

Hypokalemia, 169
as ys tole/PEA in, 83

J aw thrus t maneuver, in trauma and res piratory arres t, 40, 49

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos tCardiac Arres t Care Algorithm on, 73, 160
Hypomagnes emia, 72, 167

Laryngeal mas k airway, 36, 47, 48

Hypotens ion

Laryngeal tube, 36, 47, 48

in bradycardia, 107, 110, 113; algorithm on, 109, 161


178

Labetalol in s troke, 131, 147

Lay res cuer AED programs , 54

In d e x

Leaders hip s kills in res us citation team, 3, 17-23

precautions in, 45

Lidocaine, 167

s ize s election, 44

in ventricular f brillation/puls eles s VT, 66, 72, 167


Lone res cuer, 15
in res piratory arres t, 40
s kill checklis t on, 152
in ventricular f brillation/puls eles s VT, 49-58

National Ins titute o Neurological Dis orders and Stroke (NINDS),


8, 30, 130, 133, 135, 143, 145
National Ins titutes o Health Stroke Scale (NIHSS), 8, 140, 141,
143
Neurologic as s es s ment
in cardiac arres t, 29, 77

Magnes ium s ul ate, 167


in tors ades de pointes , 66, 72, 167
Meas urements on CPR per ormance and outcomes , 27

in s troke, 134, 135, 136-138, 140-141, 143


Nicardipine in s troke, 131, 147
NIHSS (National Ins titutes o Health Stroke Scale), 8, 140,

Medical emergency teams , 8, 26


in cardiac arres t, 31, 32

141, 143
NINDS (National Ins titute o Neurological Dis orders and

Megacode evaluation, 2, 153-157


Mental s tatus alteration

Stroke), 8, 30, 130, 133, 135, 143, 145


Nitroglycerin in acute coronary s yndromes , 98, 103

bradycardia algorithm on, 109, 161

algorithm on, 94

in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162

in emergency department, 100

MERIT trial, 32

precautions in, 97

Mobitz types o atrioventricular block, 105

in prehos pital care, 97

drug therapy in, 111

Nitroprus s ide in s troke, 131, 147

trans cutaneous pacing in, 112, 114

NonST-s egment elevation myocardial in arction (NSTEMI), 8,

Monophas ic def brillators , 63, 66


Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159
Morphine in acute coronary s yndromes , 94, 97-98, 100
Mouth-to-mas k ventilation, 40

93, 95, 101


Norepinephrine in pos tcardiac arres t care, 73, 76, 160
NSTEMI (nonST-s egment elevation myocardial in arction), 8,
93, 95, 101

Myocardial is chemia and in arction, 8, 91-104


accelerated idioventricular rhythm in, 113

Organophos phate pois oning, atropine s ul ate in, 166

acute, 7, 29, 168; Pos tCardiac Arres t Care Algorithm on,

Oropharyngeal airway, 9, 36, 40, 42-43

73, 77

def nition o , 169

drug therapy in, 92

indications or, 42

electrocardiography in, 91, 92; ris k clas s if cation bas ed on,

ins ertion technique, 43

101-102
in erior wall, 97

precautions in, 43, 45


s ize s election, 43

nonST-s egment elevation, 8, 93, 95, 101

Oropharyngeal s uctioning procedure, 46

pathophys iology in, 93

Oxygen

right ventricular, 97

central venous s aturation in CPR, 67

s igns and s ymptoms in, 96

raction o ins pired, 8; in pos tcardiac arres t care, 73, 74,

ST-s egment depres s ion in, 91, 94, 101, 102


ST-s egment elevation in (see ST-s egment elevation
myocardial in arction)

160
Oxygen therapy, 15
in acute coronary s yndromes , 94, 96, 97, 100

tachycardia in, 125

in bradycardia, 109, 161

time to treatment in, 94, 95, 99, 100, 101; and f brinolytic

in pos tcardiac arres t care, 28, 73, 74, 160

therapy, 102; and percutaneous coronary interventions ,

in res piratory arres t, 37, 38

102-103

in s troke, 134, 139, 140

trans cutaneous pacing in, 112, 114

in tachycardia with puls e, 119, 128; algorithm on, 118, 127,

uns table tachycardia in, 115

162
toxicity o , 28

Nas opharyngeal airway, 8, 36, 40


indications or, 43
ins ertion technique, 44

Pacing
with implanted pacemaker, AED us e in, 58
179

I n d e x
trans cutaneous , 9; in as ys tole, 89; in bradycardia, 108, 109,
110, 111, 112-114, 161
trans venous , in bradycardia, 108, 109, 112, 161
Paddles and pads o def brillators , 64
o automated external def brillators , 55, 56, 57

Webs ite)
or updating and re res hing s kills , 7
Pulmonary edema, def nition o , 169
Pulmonary thromboembolis m, 9
as ys tole/PEA in, 83, 84, 85

Patch or trans dermal medications , AED us e in, 58

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

PEA. See Puls eles s electrical activity

Pos tCardiac Arres t Care Algorithm on, 73, 160

Percutaneous coronary interventions , 9


in acute coronary s yndromes , 93, 102-103; as primary

Puls e checks , 13
in as ys tole, 86, 88

therapy, 92, 93, 102; as res cue therapy, 102; in ST-

in puls eles s electrical activity, 81

s egment elevation, 100, 101, 102-103

in res piratory arres t, 34, 35

in pos tcardiac arres t care, 28

in s table tachycardia, 126

Per us ion, def nition o , 169

in uns table tachycardia, 114, 116, 117

Pharmacology. See Drug therapy

in ventricular f brillation/tachycardia, 50, 51; BLS algorithms

Phos phodies teras e inhibitor us e, nitroglycerin precautions in, 97


Plaque in atheros cleros is , ormation and rupture o , 93
Plas minogen activator, recombinant tis s ue. See Tis s ue
plas minogen activator, recombinant
Pneumothorax, tens ion, 170

on, 52, 53; ches t compres s ion interruption or, 62, 64, 65
Puls eles s electrical activity, 9, 78-85
Cardiac Arres t Algorithm on, 60, 61, 78, 79-82
common caus es o , 82-85
def nition o , 169

as ys tole/PEA in, 83, 84, 85

drug therapy in, 78, 80, 81

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

his torical des cription o , 79

Pos tCardiac Arres t Care Algorithm on, 73, 160

Megacode evaluation o s kills in, 154-157

Pocket Re erence Cards , 6

rhythms included in, 78

Pos tcardiac arres t care, 28-29, 72-77

treatment s equence in, 81, 82, 89

changes in 2010 Guidelines , 164

Puls eles s ventricular tachycardia, 49-77

critical actions in, 164

lone res cuer CPR and AED us e in, 49-58

learning s tation checklis t on, 160

re ractory, 59-77

Megacode evaluation o s kills in, 153-157


trans port o patients or, 91

QRS complex, in tachycardia, 117, 118, 120, 124, 128-129

Pos tCardiac Arres t Care Algorithm, 72-77, 160

algorithm on, 118, 127, 162

Practice learning s tations , 2

and s ynchronized cardiovers ion, 121, 122

Precours e Preparation Checklis t, 6

Quality improvement in CPR, 25, 27

Prerequis ite knowledge and s kills required or Provider Cours e,


2-3

Rapid res pons e teams , 9, 26-27

s el -as s es s ment o , 2-3, 5


Procainamide in tachycardia with puls e, 129
algorithm on, 118, 127, 162

Recombinant tis s ue plas minogen activator. See Tis s ue


plas minogen activator, recombinant

Prophylaxis , def nition o , 169

Re ractory VF/puls eles s VT, 59-77

Provider Cours e, 1-9

Regional care s ys tems

abbreviations us ed in, 7-9

in cardiac arres t, 32

ACLS cas es in, 33-147 (see also ACLS cas es )

in s troke, 30

completion requirements in, 7


components o , 2

Reper us ion therapy


in acute coronary s yndromes , 92, 93, 100-101; f brinolytics

critical concepts in, 4

in, 92, 93, 98, 100, 101, 102; percutaneous coronary

des cription o , 1

interventions in, 92, 93, 100, 101, 102-103

materials us ed in, 3-6


objectives o , 1
prerequis ite knowledge and s kills required or, 2-3; s el as s es s ment o , 2-3, 5
Student Webs ite res ources or, 2, 3, 5-6 (see also Student
180

in cardiac arres t, 31, 32

in acute s troke, 147; f brinolytics in, 130, 131, 134, 135,


141, 143-145, 146
in pos tcardiac arres t care, 28, 73, 77, 160
Res cue breathing, 12, 13
in cardiac arres t, 36, 47

In d e x

in res piratory arres t, 34, 35, 36; and advanced airway, 36,
47, 48; exces s ive ventilation in, 38; rate o , 35, 36, 37,
38, 47, 48; ratio to ches t compres s ions , 48; without
ches t compres s ions , 48
in ventricular f brillation/puls eles s VT: and AED us e, 56; rate
o , 51
Res cuer, lone. See Lone res cuer

in hypovolemia, 84
Sotalol in tachycardia with puls e, 129
algorithm on, 118, 127, 162
Speech dis orders in s troke, 136, 137
Spinal injuries , cervical
airway as s es s ment and management in, 39, 40, 49
immobilization in, 49

Res pect in res us citation team, 23

ST-s egment depres s ion myocardial in arction, 91, 94, 101, 102

Res piratory arres t, 34-49

ST-s egment elevation myocardial in arction, 9, 29, 91-104

ACLS Survey in, 36-37, 151

adjunctive therapy in, 103-104

airway as s es s ment and management in, 36, 38-49

algorithm on, 94

BLS Survey in, 34-36, 151

electrocardiography and ris k clas s if cation in, 101

critical concepts in, 38

emergency department as s es s ment and treatment in,

lone res cuer in, 40

99-100

oxygen therapy in, 37, 38

emergency medical s ervices in, 96-98

in trauma, 39, 49

goals o therapy in, 93

Res pons ivenes s as s es s ment, 13

percutaneous coronary interventions in, 92

in pos tcardiac arres t care, 73, 76

Pos tCardiac Arres t Care Algorithm on, 73, 77

in res piratory arres t, 35; and nas opharyngeal airway, 43;

reper us ion therapy in, 100-101, 102-103

and oropharyngeal airway, 42, 43


in ventricular f brillation/puls eles s VT, 51, 52, 53

Stable tachycardia, 124-130


algorithm on, 118, 127

Reteplas e in acute coronary s yndromes , 102

Statin therapy in acute coronary s yndromes , 94, 103

Return o s pontaneous circulation, 9

STEMI. See ST-s egment elevation myocardial in arction

in as ys tole/puls eles s electrical activity, 61, 80, 82, 90, 159

Streptokinas e in acute coronary s yndromes , 102

in in-hos pital cardiac arres t, 30

Stroke, 30, 130-147

Megacode evaluation o s kills in, 153-157

algorithm on, 133-147

in out-o -hos pital cardiac arres t, 91

arrhythmias in, 131, 140

pos tcardiac arres t care in, 28, 72-77, 160

as s es s ment tools in, 136-138

in ventricular f brillation/puls eles s VT, 61, 63, 66, 67-69, 158

Chain o Survival in, 132-133

Rewarming techniques in hypothermia, 69


precautions a ter ROSC, 77
Roles and res pons ibilities in res us citation team, 17, 18, 20-21
ROSC. See Return o s pontaneous circulation

community and pro es s ional education on, 30, 132


critical elements in, 133
drug therapy in, 30, 130, 131, 132, 135, 143-145; algorithm
on, 134; complications o , 146; exclus ion criteria on,
141, 143-144, 145; hypertens ion management in,

Sa ety concerns in BLS Survey, 12

146-147; inclus ion criteria on, 143, 145; intra-arterial

Sedation

adminis tration o , 145; time to treatment in, 135, 143,

in bradycardia and trans cutaneous pacing, 111


in tachycardia and cardiovers ion, 118, 120, 125, 127
Seizures in s troke, 146
Sel -as s es s ment

144-145
emergency medical s ervices in, 30, 130, 132, 134, 135;
activation o , 136; critical actions in, 138-139
general care in, 134, 146-147

on cours e prerequis ite s kills , 2-3, 5

goals o care in, 132, 133

on res us citation team s kills , 21

hemorrhagic, 131, 132, 134, 140; computed tomography in,

Shock
in bradycardia, 113, 161
in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162
Sinus bradycardia, 105, 106, 107
Sinus rhythm, def nition o , 169
Sinus tachycardia, 115, 124
cardiovers ion in, 116
caus es o , 125

134, 141; drug therapy contraindications in, 141, 143,


144
in-hos pital care in, 130, 139-140
is chemic, 131, 132, 134, 140, 142; f brinolytic therapy in,
143-145
neurologic as s es s ment in, 134, 136-138, 140-141, 143; time
to, 135, 140
NINDS res earch on, 30, 130, 133, 135, 143, 145
181

I n d e x
regionalization o care in, 30

o , 124, 125; di erentiated rom uns table tachycardia,

s igns and s ymptoms in, 132, 135

116, 119, 126, 128; drug therapy in, 118, 125,

team approach in, 134, 139, 140

127, 129-130; rhythms in, 124, 128-130; s igns and

time to treatment in, 132, 133, 134, 135, 138, 139, 143,

s ymptoms in, 126; vagal maneuvers in, 118, 127, 129

144-145
trans port o patients in, 136; to s troke centers and s troke
units , 138, 139
Student Webs ite, 2, 3, 5-6

s upraventricular (see Supraventricular tachycardia)


uns table, 114-123; algorithm on, 116-120; cardiovers ion
in, 114, 116, 119, 120-123; di erentiated rom s table
tachycardia, 116, 119, 126, 128; drug therapy in, 114,

on bag-mas k ventilation, 42

118; pathophys iology o , 115; rapid recognition o , 115;

on BLS Survey, 12

rhythms in, 114, 117; s everity o , 115, 117; s igns and

on endotracheal intubation, 48

s ymptoms in, 115, 117, 118, 119; underlying caus e o ,

on es ophageal-tracheal tube, 48

118, 119

on ethical is s ues in CPR, 90


on f brinolytic therapy, 98
on heparin therapy, 104
on intraos s eous acces s , 70

ventricular, 9, 170 (see also Ventricular f brillation and


tachycardia)
wide-complex, 114, 118, 120, 124, 128-129, 130
Tachycardia With Puls e Algorithm, 118, 127, 164

on laryngeal intubation, 47

learning s tation checklis t on, 162

on laryngeal mas k airway, 47

in s table patient, 126-130

on oxygen therapy, 38

in uns table patient, 116-120

on team approach, 18

Tamponade, cardiac, 170

Suctioning o airways in res piratory arres t, 45-46

as ys tole/PEA in, 83, 84, 85

Supraventricular tachycardia, 9, 128, 129

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

cardiovers ion in, 120, 121, 122, 123


di erentiated rom VT, 120, 128

Pos tCardiac Arres t Care Algorithm on, 73, 160


Team approach, 3, 17-23

drug therapy in, 129-130

in as ys tole, 86

reentry, 114, 122, 125

in cardiac arres t, 26-27, 73; in-hos pital, 30-32

vagal maneuvers in, 129

communication in, 19, 20-21, 22, 23

Sus pected Stroke Algorithm, 133-147

cons tructive interventions in, 22

Synchronized cardiovers ion. See Cardiovers ion, s ynchronized

knowledge s haring in, 22

Syncope, def nition o , 170

medical emergency teams in, 8, 26, 31, 32

Sys tems o care, 25-32, 164

Megacode evaluation o s kills in, 3, 153-157

in acute coronary s yndromes , 29

monitoring, reevaluating, and s ummarizing in, 23

in cardiac arres t, 28-29

mutual res pect in, 23

cardiopulmonary res us citation in, 25-27

in puls eles s electrical activity, 79, 81

Chain o Survival in, 26

rapid res pons e teams in, 9, 26-27, 31, 32

publis hed s tudies on, 32

reques ts or as s is tance in, 21

rapid res pons e in, 32

roles and res pons ibilities in, 17, 18, 20-21

regional, 32

s el -awarenes s o abilities and limitations in, 21

in s troke, 30

in s troke, 134, 139, 140

team approach in, 30-31

in uns table tachycardia, 114


in ventricular f brillation/puls eles s VT, 59

Tachycardia, 114-130
def nition o , 115, 118, 170

Tens ion pneumothorax. See Pneumothorax, tens ion

Megacode evaluation o s kills in, 154-157

Thrombos is

narrow-complex, 124, 128, 129-130

cerebral, is chemic s troke in, 142

nitroglycerin precautions in, 97

coronary (see Coronary thrombos is )

s inus , 115, 124; cardiovers ion in, 116; caus es o , 125; in

def nition o , 170

hypovolemia, 84
s table, 124-130; advanced management in, 130; algorithm
on, 118, 126-130; cardiovers ion in, 116; clas s if cation
182

Tenecteplas e in acute coronary s yndromes , 102

pulmonary (see Pulmonary thromboembolis m)


Tis s ue plas minogen activator, recombinant, 9
in acute coronary s yndromes , 102

In d e x

def nition o , 169


in s troke, 30, 134, 141, 143-145; algorithm on, 134;

manual def brillator us e, 59; rate o breaths in, 51


Ventricular f brillation and tachycardia, 49-77

hypertens ion management in, 146-147; intra-arterial

abbreviations or, 9, 170

adminis tration o , 145

ACLS Survey in, 62

Tongue, airway obs truction rom, 38, 39, 40, 42

BLS Survey in, 50-57, 62

Tors ades de pointes , 128

in bradycardia with es cape rhythms , 113

magnes ium s ul ate in, 66, 72, 167


Toxic conditions

Cardiac Arres t Algorithm in, 60-69, 158


cycles o CPR in, 64, 65

as ys tole/PEA in, 83, 84, 85

def nitions o , 170

Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159

drug therapy in, 60, 65-66, 69-72; algorithm on, 61, 65-66,

Pos tCardiac Arres t Care Algorithm on, 73, 160

158; antiarrhythmics in, 65-66, 71-72; hypothermia

Tracheal intubation. See Endotracheal intubation

a ecting, 69; routes o acces s or, 69-70; in treatment

Trans dermal medication patches , AED us e in, 58

s equence, 66, 69; vas opres s ors in, 65, 70-71

Trans port o patients

in hypothermia, 69

in cardiac arres t, 91

lone res cuer CPR and AED us e in, 49-58

s pinal immobilization in, 49

manual def brillators in, 59, 61, 62-63; biphas ic, 61, 63,

in s troke, 136; to s troke centers and s troke units , 138, 139


Trauma, res piratory arres t and airway management in, 39, 40, 49

66; Cardiac Arres t Algorithm on, 61, 62-63, 66, 158;


clearing warning in, 64; and drug therapy, 65-66;
monophas ic, 61, 63, 66; paddles and pads o , 64;

Uns table angina, 9, 93, 95


electrocardiography and ris k clas s if cation in, 101
Uns table tachycardia, 114-123
Uns ynchronized s hocks , 170
in uns table tachycardia, 120, 121
Uts tein Guidelines , 27

s hock delivery in, 61, 63


Megacode evaluation o s kills in, 153-157
monomorphic VT, 114, 120, 124, 128, 129; cardiovers ion in,
121, 122, 123
phys iologic monitoring in, 67-69
polymorphic VT, 114, 120, 124, 126, 128; cardiovers ion in,
121, 123

Vagal maneuvers in tachycardia, 129


algorithm on, 118, 127, 162
Vas opres s in, 167
in as ys tole, 88, 159

re ractory, 59-77
team res pons e to, 59
time to def brillation and CPR in, 54
treatment s equence in, 57, 66, 69

Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159


in puls eles s electrical activity, 81, 82, 159
in ventricular f brillation/puls eles s VT, 65, 66, 71, 158; routes
o adminis tration, 70, 71
Vas opres s or drugs

Warming techniques in hypothermia, 69


precautions a ter ROSC, 77
Water a ecting AED us e, 58
Webs ite res ources or Provider Cours e. See Student Webs ite

in as ys tole, 88

Wenckebach atrioventricular block, 105

in puls eles s electrical activity, 81

Withdrawal o li e-s us taining care

in ventricular f brillation/puls eles s VT, 65, 70-71


Ventilation techniques

in as ys tole, 87
pos tcardiac arres t, 29

bag-mas k ventilation in (see Bag-mas k ventilation)


compres s ion-ventilation ratio in, 48, 61, 80, 82, 158, 159

Yankauer catheters , 45, 46

coronary per us ion pres s ure in, 62


in pos tcardiac arres t care, 28, 73, 74, 160; exces s ive
ventilation in, 28, 73, 74, 75
in res piratory arres t, 34, 35, 36; and advanced airway,
36, 47, 48; bag-mas k ventilation in, 36, 41, 42, 151;
compres s ion-to-ventilation ratio in, 48; exces s ive
ventilation in, 38; rate o breaths in, 35, 36, 37, 38, 47,
48
in ventricular f brillation/puls eles s VT: and AED us e, 56; and
183

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