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 Clifton W. Callaway, MD, PhD, Chair
Kenneth Navarro, Content Consultant Robert W. Neumar, MD, PhD, Immediate
Past Chair, 2008-2010
Se n ior Ma n a g in g Ed itor Steven Brooks , MD
Erik S. Soderberg, MS Daniel P. Davis , MD
Michael Donnino, MD
Sp e c ia l Con trib u tors Andrea Gabrielli, MD
Clifton W. Callaway, MD, PhD Romergryko Geocadin, MD
Diana M. Cave, RN, MSN Erik Hes s , MD, MSc
Heba Cos tandy, MD, MS Mark S. Link, MD
Mary Fran Hazins ki, RN, MSN Bryan McNally, MD, MPH
Theres a Hoadley, RN, PhD, TNS Venu Menon, MD
Robert W. Neumar, MD, PhD Graham Nichol, MD, MPH
Peter D. Panagos , MD Brian O’Neil, MD
Sallie Young, PharmD, BCPS 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

© 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
i
 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 O’Neil, 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 1

Cours e Obje c tive s 1

Cours e De s ign 2

Cours e Pre re q uis ite s a nd P re p a ra tion 2

BLS Skills 2
ECG Rhythm Interpretation for Core ACLS Rhythms 3
Bas ic ACLS Drug and Pharmacology Knowledge 3
Practical Application of ACLS Rhythms and Drugs 3
Effective Res us citation Team Concepts 3

Cours e Ma te ria ls 3
ACLS Provider Manual 4
Student Webs ite 5
Pocket Reference Cards 6
Precours e Preparation Checklis t 6

Re quire m e nts for Suc c e s s fu l Cours e Com ple tion 7

ACLS Upda te Cours e 7

ACLS P rovide r Ma nua l Abb re via tions 7

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 11

Overview of the Sys tematic Approach 11

The BLS Surve y 12

Overview of the BLS Survey 12

The ACLS Surve y 14

Overview of the ACLS Survey 14

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 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 One’s 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 25
A Sys tems Approach 26
Meas urement 27
Benchmarking and Feedback 27
Change 27
Summary 27

Pos t–Ca 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 29

Starts “On the Phone” With Activation of EMS 29
EMS Components 29
Hos pital-Bas ed Components 29

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 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 33

Re s pira tory Arre s t Ca s e 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 t–Cardiac Arres t Care 72
Application of the Immediate Pos t–Cardiac Arres t Care Algorithm 73

P u ls e le s s Ele c tric a l Ac tivity Ca s e 78

Des cription of PEA 78

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 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) 101

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 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

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 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 contraindi-
cations : 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 1
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 cardiopul-
monary 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 t–cardiac 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 t–cardiac 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

1
 P a r t 1

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 evalu-
ate 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.

2

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
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
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
Effe c t ive
Re s u s c it a t io n
Te a m Co n c e p t s
Co u r s e Ma t e r ia ls
Cou rs e Ove rvie w
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 elf-
as 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.
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.
The AHA recommends that you complete the ACLS pharmacology review 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). 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.
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.
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 .
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.
3
 P a r t 1

ACLS P r o vid e r The ACLS Provider Manual contains the bas ic information you need for effective participa-
Ma n u a l tion in the cours e. This important material includes the s ys tematic approach to a cardio-
pulmonary 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 Summary of the new 2010 AHA Guidelines for CPR
for CP R a n d ECC and ECC
Sum m a ry Ta b le

•  ACLS P ha rm a c o lo g y Bas ic ACLS drugs , dos es , indications /contraindications ,

Sum m a ry Ta b le 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 en-
tial 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 reader’s 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 •  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
Im p o rta nt Info rm a tio n to mus t know.
Re vie w a nd Stud y

4
 Cou rs e Ove rvie w

Ca u t io n •  Ca utio n boxes  emphas ize s pecific ris ks  as s ociated with interventions .

FYI 2 0 1 0 Gu id e lin e s •  FYI 2010 Guid e line s  boxes  contain the new 2010 AHA Guidelines for CPR and ECC 
information.

Fo u n d a t io n a l Fa c t s •  You will s ee Fo und a tio na l Fa c ts boxes  throughout the ACLS Provider Manual. 

Thes e boxes  contain bas ic information that will help you unders tand the topics  
 c overed in the cours e.

S t u d e n t We b s it e The ACLS Student Webs ite (www.he a rt.o rg /e c c s tud e nt) contains  the following 

s elf-as s es s ment and s upplementary res ources :

Re s o u rc e De s c r ip t io n Ho w t o Us e
ACLS Rhythm Web-bas ed s elf-as s es s - Complete before the 
Id e ntific a tio n ment: recognition of bas ic  cours e to help evaluate 
ECG rhythms your proficiency and  
determine the need for 
additional review and  
practice 

ACLS P ha rm a c o lo g y Web-bas ed s elf-as s es s -

ment: drugs  us ed in  
algorithms

P ra c tic a l Ap p lic a tio n o f Web-bas ed s elf-as s es s -

ACLS Alg o rithm s ment: evaluates  the  
practical application of 
rhythm recognition and 
pharmacology in the ACLS 
algorithms

ACLS Sup p le m e nta ry •  Bas ic Airway  Additional information  

Info rm a tio n Management to s upplement bas ic  
•  Advanced Airway  concepts  pres ented in 
Management ACLS cours e
•  ACLS Core Rhythms
Some information is  s up-
•  Defibrillation
plementary; other areas  are 
•  Acces s  for Medications
for the  
interes ted  
s tudent 
•  Acute Coronary 
or advanced  p rovider
Syndromes
•  Human, Ethical, and 
Legal Dimens ions  of 
ECC and ACLS

CP R a nd AED Skills Supplementary  res ources :  Review BLS s kills  to 

vid e o review current BLS   p repare for the 1-Res cuer 
s equence and s kills CPR and AED Tes ting 
Station
(continued)

5
 P a r t 1

(continued)

Re s o u rc e De s c r ip t io n Ho w t o Us e
ACS vid e o Supplementary res ources : Review for ACS Learning
ACS as s es s ment and Station
treatment

Stro ke vid e o Supplementary res ources : Review for Stroke Learning

s troke as s es s ment and Station
treatment

ACLS Sc ie nc e Ove rvie w Supplementary res ources : Update ACLS knowledge

vid e o core emphas is of the and learn about changes
ACLS cours e from a in application of ACLS s ci-
s cience pers pective ence

IO a nim a tio n Supplementary res ources : Expanded information on

information and demon- IOs
s tration of intraos s eous
(IO) ins ertion

P o c k e t Re fe r e n c e The Pocket Reference Cards are 2 s tand-alone cards packaged with the ACLS Provider
Ca r d s Manual. Thes e cards can be carried in your pocket for quick reference on the following
topics :

To p ic
Ca rd ia c a rre s t,
a rrhythm ia s , a nd
tre a tm e nt
ACS a nd s tro ke
Re fe re n c e Ca rd s
•  Cardiac Arres t Algorithms
•  Gray box with drugs and dos age reminders
•  Immediate Pos t–Cardiac Arres t Care Algorithm
•  Bradycardia Algorithm
•  Tachycardia Algorithm
•  ACS Algorithm
•  Fibrinolytic Checklis t for STEMI
•  Fibrinolytic Contraindications for STEMI
•  Sus pected Stroke Algorithm
•  Stroke As s es s ment–CPSS
•  Us e of IV rtPA for Acute Is chemic Stroke
•  Hypertens ion Management in Acute Is chemic Stroke

Pre c ours e The Precours e Preparation Checklis t is packaged with the ACLS Provider Manual. Pleas e
P r e p a r a t io n review and check the boxes after you have completed preparation for each s ection.
Ch e c k lis t

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 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 Non–ST-s egment elevation myocardial infarction

(continued)

8
 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

9
P a r t 1

In t r o d u c t io n
Le a r n in g Ob je c t ive s
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
Part 2
The Sys te m a tic Approa c h:
The BLS a nd ACLS Surve ys
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 team’s 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)
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 cardio-
pulmonary emergencies
The s ys tematic approach firs t requires ACLS providers to determine the patient’s 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 2
Th e BLS S u r ve y
Ove r vie w o f t h e
BLS S u r ve y
FYI 2 0 1 0 Gu id e lin e s
Cha ng e s in the BLS
Surve y
Fo u n d a t io n a l Fa c t s
Sta rting With Che s t
Co m p re s s io ns vs
2 Bre a ths
12
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
patient’s 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 .
Pleas e note the 2 key changes from the 2005 AHA Guidelines for CPR and ECC:
•  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.
•  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
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).
 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 As s e s s m e n t Te c h n iq u e a n d Ac t io n
1 Che c k •  Tap and s hout, “Are you a ll rig h t? ”
re s p o ns ive - •  Check for abs ent or abnormal breathing (no breathing or 
ne s s only gas ping) by looking at or s c a nning the c he s t fo r
m o ve m e nt (about 5 to 10 s econds )

Fig u re 1 . Check res pons ivenes s .

2 Ac tiva te the •  Activate the emergency res pons e s ys tem and get an AED 

e m e rg e nc y if one is  available or s end s omeone to activate the emer-
re s p o ns e gency res pons e s ys tem and get an AED or defibrillator
s ys te m /g e t
AED

Fig u re 2 . Activate the emergency res pons e s ys tem.

3 Circ ula tio n •  Che c k the c a ro tid p uls e  for 5 to 10 s econds  

•  If no puls e within 10 s econds , s tart CPR (30:2) beginning 
with ches t compres s ions
– Compres s  the center of the ches t (lower half of the 
 s ternum) hard and fas t with at leas t 100 compres s ions  
per minute at a depth of at leas t 2 inches
– 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
•  If there is  a puls e, s tart res cue breathing at 1 breath every   Fig u re 3 . Check the carotid puls e.
5 to 6 s econds  (10 to 12 breaths  per minute). Check puls e 
about every 2 minutes

4 De fib rilla tio n •  If no puls e, check for a s hockable rhythm with an AED/

defibrillator as  s oon as  it arrives
•  Provide s hocks  as  indicated
•  Follow each s hock immediately with CPR, beginning with  
compres s ions

Fig u re 4 . Defibrillation.

13
 P a r t 2
Cr it ic a l Co n c e p t s
Minim izing Inte rrup tio ns
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
Th e ACLS S u r ve y
Ove r vie w o f t h e
ACLS S u r ve y
14
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
•  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 (approxi-
mately 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.
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 .

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?
Bre a thing
– Are ventilation and oxygen-
ation adequate?
– Are quantitative waveform
capnography and oxyhemo-
globin saturation monitored?
Th e Sys te m a tic Ap p roa c h
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 tilt–chin lift, oropharyngeal air-
way (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 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. Advanced
airway devices such as a laryngeal mask airway, laryn-
geal 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
•  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 n-
a 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 cardiover-
sion 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 resuscita-
tion?
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

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
Le a r n in g Ob je c t ive s
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
Part 3
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.
By the end of this part you s hould be able to
1. Des cribe team leader’s 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
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 3

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

Le a d e r •  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 Team members mus t be proficient in performing the s kills authorized by their s cope of
Me m b e r 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 When communicating with res us citation team members , the team leader s hould us e
Co m m u n ic a t io n s 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
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

Cle a r Me s s a g e s 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 3

Cle a r Ro le s a n d Every member of the team s hould know his or her role and res pons ibilities . J us t as
Re s p o n s ib ilit ie s different s haped pieces make up a jigs aw puzzle, each team member’s 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 appropri-
ate 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
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

20
 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 Not only s hould everyone on the team know his or her own limitations and capabilities ,
Lim it a t io n s 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 •  Call for as s is tance early rather than waiting until the
m e m b e rs patient deteriorates to the point that help is critical
•  Seek advice from more experienced pers onnel when
the patient’s condition wors ens des pite primary
treatment

Do n ’t
Te a m le a d e r a nd te a m •  Reject offers from others to carry out an as s igned
m e m b e rs 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 with-
out 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 3

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,
we’ve 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 patient’s 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 inter-
ventions
•  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
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

Co n s t r u c t ive
In t e r ve n t io n
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
Te a m le a d e r •  Fail to reas s ign a team member who is trying to func-
tion 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

22
 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 An es s ential role of the team leader is monitoring and reevaluating

S u m m a r iz in g •  The patient’s 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 patient’s condition can change. Remain flexible
to changing treatment plans and revis iting the initial differential diagnos is . As k for informa-
tion and s ummaries from the code recorder as well.

Do
Te a m le a d e r
Te a m le a d e r a nd te a m
m e m b e rs
•  Draw continuous attention to decis ions about differ-
ential diagnos es
•  Review or maintain an ongoing record of drugs and
treatments adminis tered and the patient’s res pons e
•  Clearly draw attention to s ignificant changes in the
patient’s clinical condition
•  Increas e monitoring (eg, frequency of res pirations
and blood pres s ure) when the patient’s condition
deteriorates

Do n ’t
Te a m le a d e r •  Fail to change a treatment s trategy when new infor-
mation s upports s uch a change
•  Fail to inform arriving pers onnel of the current s tatus
and plans for further action

Mu t u a l Re s p e c t 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 •  Speak in a friendly, controlled tone of voice
m e m b e rs •  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 •  Shout or yell at team members —when one pers on
m e m b e rs 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 3
 Part 4
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 individual’s 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 Cardiopulmonary res us citation is a s eries of lifes aving actions that improve the chance
in Re s u s c it a t io n of s urvival following cardiac arres t. Although the optimal approach to CPR may vary,
S ys t e m s , P r o c e s s e s , depending on the res cuer, the patient, and the available res ources , the fundamental
a n d Ou t c o m e s challenge remains how to achieve early and effective CPR.

25
 P a r t 4
A S ys t e m s Ap p r o a c h
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
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 t–cardiac 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.
•  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 dete-
rioration (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
Cod e Cr it ic a l
Re s p o n s e
Te a m Ca re Te a m
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 Data s hould be s ys tematically reviewed and compared internally to prior performance and
a n d Fe e d b a c k 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 recogni-
tion 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 Survival—to 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 4

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 t–cardiac arres t patients .
Programs s hould addres s therapeutic hypothermia, hemodynamic and ventilation opti-
mization, 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 The 2010 AHA Guidelines for CPR and ECC recommends cooling comatos e (ie, lack of
Hyp o t h e r m ia meaningful res pons e to verbal commands ) adult patients with ROSC after out-of-hos pital
VF cardiac arres t to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours . Healthcare provid-
ers 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 Although providers often us e 100% oxygen while performing the initial res us citation,
a n d Ve n t ila t io n providers s hould titrate ins pired oxygen during the pos t–cardiac arres t phas e to the lowes t
Op t im iz a t io n 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 t–cardiac 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 Following ROSC, res cuers s hould trans port the patient to a facility capable of reliably
Co r o n a r y providing coronary reperfus ion (eg, PCI) and other goal-directed pos tarres t care therapies .
Re p e r fu s io n The decis ion to perform PCI can be made irres pective of the pres ence of coma or the
Wit h P CI 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

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
Ac u t e Co ro n a r y S yn d ro m e s
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
EMS Co m p o n e n t s
Ho s p it a l-Ba s e d
Co m p o n e n t s
Sys te m s of Ca re
The goal of pos t–cardiac 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 com-
ponent of pos t–cardiac 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 accu-
rate and reliable, with a fals e-pos itive rate approaching 0% .
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
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.
•  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
•  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 4
Ac u t e S t ro k e
Re g io n a liz a t io n o f
S t r o k e Ca r e
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
EMS
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
Th e Ne e d fo r Te a m s
30
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 .
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 .
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.
•  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 action—activate the emergency res pons e s ys tem.
The integration of EMS into regional s troke models is crucial for improvement of
patient outcomes :
•  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
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.
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 particu-
larly 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.

Ca r d ia c Ar r e s t
Te a m s (In -Ho s p it a l)
Ra p id Re s p o n s e
S ys t e m
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
Sys te m s of Ca re
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 patient’s 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 cata-
s 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.
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
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 patient’s 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 4
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
P u b lis h e d S t u d ie s
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
32
Hos pitals with larger patient volumes have a better s urvival-to–hos pital dis charge rate than
low-volume centers for patients treated for either in- or out-of-hos pital cardiac arres t.
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 .
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 atten-
tion 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.
 Part 5
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 5
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Ca s e Dr u g s
Th e BLS S u r ve y
BLS S u r ve y
As s e s s m e n t
As s e s s a n d
Re a s s e s s t h e
P a t ie n t
Ve n t ila t io n a n d
P u ls e Ch e c k
34
Re s p ir a t o r y Ar re s t Ca s e
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 car-
diac arres t.
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
This cas e involves the following drugs :
•  Oxygen
Sys tems or facilities us ing rapid s equence intubation may cons ider additional drugs .
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.
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.
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 As s e s s m e n t Te c h n iq u e a n d Ac t io n
1 Che c k •  Tap and s hout, “Are you a ll rig h t? ”
re s p o ns ive - •  Check for abs ent or abnormal breathing (no breathing or 
ne s s only gas ping) by looking at or s c a nning the c he s t fo r
m o ve m e nt (about 5 to 10 s econds )

Check res pons ivenes s .

2 Ac tiva te the •  Activate the emergency res pons e s ys tem and get an AED 

e m e rg e nc y if one is  available or s end s omeone to activate the emer-
re s p o ns e gency res pons e s ys tem and get an AED or defibrillator
s ys te m /g e t
AED

Activate the emergency res pons e s ys tem.

3 Circ ula tio n •  Che c k the c a ro tid p uls e  for 5 to 10 s econds  

•  If no puls e within 10 s econds , s tart CPR (30:2) beginning 
with ches t compres s ions
– Compres s  the center of the ches t (lower half of the 
 s ternum) hard and fas t with at leas t 100 compres s ions  
per minute at a depth of at leas t 2 inches
– 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
•  If there is  a puls e, s tart res cue breathing at 1 breath every   Check the carotid puls e.
5 to 6 s econds  (10 to 12 breaths  per minute). Check puls e 
about every 2 minutes

4 De fib rilla tio n •  If no puls e, check for a s hockable rhythm with an AED/

defibrillator as  s oon as  it arrives
•  Provide s hocks  as  indicated
•  Follow each s hock immediately with CPR, beginning with  
compres s ions

Defibrillation.

35
 P a r t 5

Ve n t ila t io n Ra t e s Ve n t ila t io n s Du r in g Ve n t ila t io n s Du r in g

Air w a y De vic e
Ba g -m a s k
Any a d va nc e d a irwa y
Ca rd ia c Ar re s t
2 ventilations after every
30 compres s ions
1 ve ntila tio n e ve ry 6 to 8
s e c o nd s
(8 to 10 breaths per
minute)
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 If bag-mas k ventilation is adequate, providers may defer ins ertion of an advanced airway.
in Re s p ir a t o r y Ar r e s t 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 tilt–chin 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 esophageal-
tracheal tube can be placed while chest compres-
sions 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 oxygen-
ation adequate?
– Are quantitative waveform
capnography and oxyhemo-
globin saturation monitored?
Circ ula tio n
– What is the cardiac rhythm?
– Is the patient with a pulse
unstable?
– Is defibrillation or cardiover-
sion 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 vol-
ume (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?
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.
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 n-
a 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)

Ve n t ila t io n s 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 ventila-
tion (too many breaths per minute or too large a volume per breath).

FYI 2 0 1 0 Gu id e lin e s •  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 place-
Co rre c t P la c e m e nt o f ment of an ET tube.
End o tra c he a l Tub e

37
 P a r t 5
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
Cr it ic a l Co n c e p t s
Avo id ing Exc e s s ive
Ve ntila tio n
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
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
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 r-
fu 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 ).
•  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 .
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.
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

Oral Nas op harynx

Cavity

Tongue

Vallecula
Orop harynx

Epiglottis

Vocal Fold
(Cords )

Thyroid Laryngopharynx
Cartilage
Cricoid
Cartilage

Trachea

Es ophagus

Fig u re 8 . Airway anatomy.

A B C

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
tilt–chin lift relieves obs truction in the unres pons ive patient. A, The tongue is obs tructing the airway. B, The head tilt–chin lift lifts the tongue, reliev-
ing 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 5

Ba s ic Air w a y Bas ic airway opening techniques will effectively relieve airway obs truction caus ed either
Op e n in g Te c h n iq u e s by the tongue or from relaxation of mus cles in the upper airway. The bas ic airway open-
ing technique is head tilt with anterior dis placement of the mandible, ie, head tilt–chin 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 tilt–chin 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 pon-
taneous 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 tilt–chin 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-to–barrier 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 patient’s s ide. Perform a head tilt–chin 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
patient’s 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 patient’s head tilts the patient’s head
and s eals the mas k agains t the patient’s 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 5

Ba g -Ma s k A bag-mas k ventilation device cons is ts of a ventilation bag attached to a face mas k.
Ve n t ila t io n 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 ventila-
tion 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 provid-
ers 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.

A B
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 Ste p Ac t io n
In s e r t io n
1 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.

2 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.

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

4 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 •  OPAs that are too large may obs truct the larynx or caus e trauma to the laryngeal
s tructures .
Be Awa re o f the •  OPAs that are too small or ins erted improperly may pus h the bas e of the tongue
Fo llo wing Whe n Us ing pos teriorly and obs truct the airway.
a n OPA •  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 manage-
ment 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 lead-
ing to upper airway obs truction.

43
 P a r t 5

A B

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 Ste p Ac t io n
In s e r t io n
1 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 patient’s 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 patient’s nos e to the earlobe.

2 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.

3 Ins e rt the a irwa y through the nos tril in a pos terior direction perpendicu-
lar to the plane of the face. Pas s it gently along the floor of the nas o-
pharynx (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 man-
dible 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 suc-
tioning 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 •  Take care to ins ert the airway gently to avoid complications . The airway can irritate 

the mucos a or lacerate adenoidal tis s ue and caus e bleeding, with pos s ible as pira-
Be Awa re o f the tion of clots  into the trachea. Suction may be neces s ary to remove blood or s ecre-
Fo llo wing Whe n tions .
Us ing a n NPA •  An improperly s ized NPA may enter the es ophagus . With active ventilation, s uch as  
bag-mas k ventilation, the NPA may caus e gas tric inflation and pos s ible hypoventila-
tion.
•  An NPA may caus e laryngos pas m and vomiting, even though it is  commonly toler-
ated by s emicons cious  patients .
•  Us e caution in patients  with facial trauma becaus e of the ris k of mis placement into 
the cranial cavity through a fractured cribriform plate.

Fo u n d a t io n a l Fa c t s Take the following precautions  when us ing an OPA or NPA:

P re c a utio ns fo r OPAs •  Always  check s pontaneous  res pirations  immediately after ins ertion of either an OPA 

a nd NPAs or an NPA.
•  If res pirations  are abs ent or inadequate, s tart pos itive-pres s ure ventilations  at once 
with an appropriate device.
•  If adjuncts  are unavailable, us e mouth-to-mas k barrier device ventilation.

S u c t io n in g

In t r o d u c t io n Suctioning is  an es s ential component of maintaining a patient’s  airway. Providers  

s hould s uction the airway immediately if there are copious  s ecretions , blood, or 
vomit.

Suction devices  cons is t of both portable and wall-mounted units .

•  Portable s uction devices  are eas y to trans port but may not provide adequate s uction 
power. A s uction force of −80 to −120 mm Hg is  generally neces s ary.
•  Wall-mounted s uction units  s hould be capable of providing an airflow of >40 L/min at 
the end of the delivery tube and a vacuum of more than −300 mm Hg when the tube 
is  clamped at full s uction.
•  Adjus t the amount of s uction force for us e in children and intubated patients .

S o ft vs Rig id Both s oft flexible and rigid s uctioning catheters  are available. 

Ca t h e t e r s Soft flexible catheters may be us ed in the mouth or nos e. Soft flexible catheters  are avail-
able in s terile wrappers  and can als o be us ed for ET tube deep s uctioning. 

Rigid catheters (eg, Yankauer) are us ed to s uction the oropharynx. Thes e are better for 

s uctioning thick s ecretions  and particulate matter.

Ca t h e t e r
Us e fo r
Typ e
So ft •  As piration of thin s ecretions  from the oropharynx and nas opharynx
•  Performing intratracheal s uctioning
•  Suctioning through an in-place airway (ie, NPA) to acces s  the back of 
the pharynx in a patient with clenched teeth

Rig id •  More effective s uctioning of the oropharynx, particularly if there is  

thick particulate matter

45
 P a r t 5

Or o p h a r yn g e a l Follow the s teps below to perform oropharyngeal s uctioning.

S u c t io n in g Ste p Ac t io n
P roc e d u re
1 •  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.

2 •  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 gen-
tly into the oral cavity. Advance by pus hing the tongue down to reach
the oropharynx if neces s ary.

En d o t r a c h e a l Patients with pulmonary s ecretions may require s uctioning even after endotracheal intuba-
Tu b e S u c t io n in g tion. Follow the s teps below to perform ET tube s uctioning:
P roc e d u re Ste p Ac t io n
1 •  Us e s terile technique to reduce the likelihood of airway contamination.

2 •  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 recom-
mended becaus e it may injure the endotracheal mucos a or s timulate
coughing or bronchos pas m.

3 •  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 hypox-
emia, 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 t’s 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 r-

a 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 train-
ing 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 integrat-
ing 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 Ve n t ila t io n s Du r in g

Air w a y De vic e
Ba g -m a s k
Any a d va nc e d a irwa y
Ca rd ia c Ar re s t Re s p ir a t o r y Ar re s t
2 ventilations after every 1 ve ntila tio n e ve ry 5 to 6
30 compres s ions s e c o nd s
(10 to 12 breaths per
1 ve ntila tio n e ve ry 6 to 8
minute)
s e c o nd s
(8 to 10 breaths per
minute)

La r yn g e a l Ma s k The laryngeal mas k airway is an advanced airway alternative to endotracheal intubation

Air w a y 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 5
Es o p h a g e a l-
Tr a c h e a l Tu b e
En d o t r a c h e a l Tu b e
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
48
The es ophageal-tracheal tube is an advanced airway alternative to endotracheal intuba-
tion. 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 manage-
ment in cardiac arres t. Fatal complications may occur with us e of this device. Only provid-
ers 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.
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.
•  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 air-
way 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 ynchro-
nize 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).

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
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
Le a r n in g Ob je c t ive s
Rh yt h m s fo r VF
Tr e a t e d Wit h CP R
a n d AED
Dr u g s fo r VF Tr e a t e d
Wit h CP R a n d AED
Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED
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 high-
s 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 tilt–chin 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.
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.
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
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? ”
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 5
Th e BLS S u r ve y
In t r o d u c t io n
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
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 manage-
ment of a patient in res piratory arres t with a puls e. In this cas e you will as s es s and man-
age a patient without a puls e and us e the AED.
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 As s e s s m e n t Te c h n iq u e a n d Ac t io n
1 Che c k •  Tap and s hout, “Are you a ll rig h t? ”
re s p o ns ive - •  Check for abs ent or abnormal breathing (no breathing or 
ne s s only gas ping) by looking at or s c a nning the c he s t fo r
m o ve m e nt (about 5 to 10 s econds )

Check res pons ivenes s .

2 Ac tiva te the •  Activate the emergency res pons e s ys tem and get an AED 

e m e rg e nc y if one is  available or s end s omeone to activate the emer-
re s p o ns e gency res pons e s ys tem and get an AED or defibrillator
s ys te m /g e t
AED

Activate the emergency res pons e s ys tem.

3 Circ ula tio n •  Che c k the c a ro tid p uls e  for 5 to 10 s econds  

•  If no puls e within 10 s econds , s tart CPR (30:2) beginning 
with ches t compres s ions
– Compres s  the center of the ches t (lower half of the 
 s ternum) hard and fas t with at leas t 100 compres s ions  
per minute at a depth of at leas t 2 inches
– 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
•  If there is  a puls e, s tart res cue breathing at 1 breath every   Check the carotid puls e.
5 to 6 s econds  (10 to 12 breaths  per minute). Check puls e 
about every 2 minutes

4 De fib rilla tio n •  If no puls e, check for a s hockable rhythm with an AED/

defibrillator as  s oon as  it arrives
•  Provide s hocks  as  indicated
•  Follow each s hock immediately with CPR, beginning with  
compres s ions

Defibrillation.

51
 P a r t 5

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

1
Unre s p o ns ive Hig h-Qua lity CP R
No b re a thing o r no no rm a l b re a thing
•   Rate at leas t 100/min
(ie, only gas ping)
•   C ompres s ion depth at 
leas t 2 inches (5 cm)
2
•   Allow complete ches t recoil 
Ac tiva te e m e rg e nc y re s p o ns e s ys te m after each compres s ion
Ge t AED/d e fib rilla to r
•   Minimize interruptions  in 
or s end s econd res cuer (if available) to do this
ches t compres s ions
•   
Avoid exces s ive ventilation
3 3A
De fin it e
Che c k p uls e : P u ls e •   G ive  1 b re a th e ve ry 
DEFINITE p uls e 5 to 6 s e c o nd s
within 10 s e c o nd s ? •   R e c he c k p uls e  e ve ry 
2 m inute s
No P u ls e
4

Begin cycles of 30 COMP RESSIONS and 2 BREATHS

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 No t S h o c k a b le
7 8

Give 1 s ho c k Re s um e CP R im m e d ia te ly
Re s um e CP R im m e d ia te ly for 2 minutes
for 2 minutes Check rhythm every
2 minutes ; continue until
ALS providers take over or
victim s tarts to move

Note: The boxes  bordered with das hed lines  are performed 

by healthcare providers and not by lay res cuers © 2010 American Heart As s ociation

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

52
 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 Ge t
e m e rg e nc y d e fib rilla to r
re s p o ns e

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
P
u

h
s

a
s

Ha F
rd • P u s h
© 2010 American Hea rt As s ociation

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

53
 P a r t 5

Pu rpos e of Defibrillation does not res tart the heart. Defibrillation s tuns the heart and briefly terminates
De fib r illa t io n 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 com-
pres s ions immediately after a s hock.

P r in c ip le o f Ea r ly The interval from collaps e to defibrillation is one of the mos t important determinants of
De fib r illa t io n 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 immedi-
ate CPR and defibrilliation within a few minutes of the initial arres t. Res toration of a per-
fus 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 defibrilla-
tion. 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
Sta rt o f CP R

Tim e to d e b rilla tio n

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 out-
of-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

AED Op e r a t io n
Cr it ic a l Co n c e p t s
Ag o na l Ga s p s
Kn o w Yo u r AED
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
Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED
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 demon-
s 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.
Ag o na l g a s p s a re no t a d e q ua te b re a thing .
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 n’t res pond.
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.
Once the AED arrives , place it at the patient’s 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 elec-
trode 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 Ac t io n
1 P o we r o n the AED (this activates voice prompts for guidance in all s ubs e-
quent 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).
2 Atta c h e le c tro d e p a d s to the patient’s bare ches t.
•  Choos e the correct s ize pads (adult vers us pediatric) for the patient’s
s ize/age. Peel the backing away from the electrode pads .
•  Quickly wipe the patient’s 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 patient’s 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 Ac t io n
3 Ana lyze rhythm .
•  Always  clear the patient during analys is . Be s ure no one is  touching the 
patient, not even the pers on in charge of giving breaths .
•  Some AEDs  will ins truct you to pus h a button to allow the AED to begin 
analyzing the heart rhythm; others  will do that automatically. The AED 
rhythm analys is  may take about 5 to 15 s econds .
•  The AED rhythm analys is  will determine if the patient needs  a s hock.

4 If the AED advis es  a s hock, it will tell you to BE SURE TO CLEAR THE

PATIENT (ie , d o no t to uc h the p a tie nt):
•  Clear the patient before delivering the s hock; be s ure no one is  touching 
the patient.
•  Loudly and quickly s tate a “clear the patient” mes s age, s uch as  “Clear, 
I am going to s hock on three,” “One, two, three, s hocking,” or s imply 
“Clear.”
•  Perform a vis ual check to ens ure that no one is  in contact with the 
patient.
•  Pres s  the SHOCK button.
•  The s hock will produce a s udden contraction of the patient’s  mus cles .

As  s oon as  the s hock is  delivered, res ume CPR, s tarting with ches t compres s ions , and 

give cycles  of 30 compres s ions  and 2 breaths . Do not perform a puls e or rhythm check. 
After 2 minutes  of CPR the AED will prompt you to repeat s teps  3 and 4.

Fig u re 1 8 . AED electrode pad placement on the patient.

56

Fo u n d a t io n a l Fa c t s
Alte rna tive AED
Ele c tro d e P a d
P la c e m e nt P o s itio ns
Tr o u b le s h o o t in g
t h e AED
S h o c k Fir s t vs
CP R Fir s t
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
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
Ha ir y Ch e s t
Th e ACLS Ca s e s : VF Tre a te d With CP R a n d AED
There are 4 acceptable AED electrode pad pos itions :
•  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 defibrilla-
tion. 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 charac-
teris tics .
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-main-
tained 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.
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.
•  The AHA s trongly recommends performing CPR while a defibrillator or AED is read-
ied for us e and while charging for all patients in cardiac arres t.
•  Res ponders us ing an AED s hould follow the machine’s voice prompts .
The following s pecial s ituations may require the operator to take extra care in placing the
electrode pads when us ing an AED.
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 patient’s 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 5

Ste p Ac t io n
1 If the pads s tick to the hair ins tead of the s kin, pres s down firmly on
each pad.

2 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.

3 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.

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

Wa t e r Do not us e an AED in the water.

If water is pres ent on the patient’s 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... Th e n ...
The patient is in the water Pull the patient out of the water
The patient’s 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 Us e the AED
s mall puddle

Im p la n t e d Patients known to be at high ris k for s udden cardiac arres t may have implanted defibril-
P a c e m a ke r lators /pacemakers that automatically deliver s hocks directly to the heart mus cle if a life-
threatening 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 rang-
es 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 contraindi-
cation 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 con-
flict. If the implanted defibrillator is delivering s hocks to the patient (the patient’s 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
Do not place AED electrodes directly on top of a medication patch (eg, a patch of nitro-
glycerin, 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.

58
 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), defibril-
lation 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 patient’s 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 5

Rh yt h m s fo r VF/ This cas e involves thes e ECG rhythms :

P u ls e le s s VT •  VF
•  VT
•  ECG artifact that looks like VF
•  New left bundle branch block

Dr u g s fo r VF/ This cas e involves thes e drugs :

P u ls e le s s VT •  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 e-
les 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 Becaus e many patients with s udden cardiac arres t demons trate VF at s ome point in their
(Le ft S id e ) 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 ynchro-
nized s hocks .

As ys t o le / P EA The right s ide of the algorithm outlines the s equence of actions to perform if the rhythm is
(Rig h t S id e ) 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 treat-
ment of VF/VT by following the s teps on the left s ide of the Cardiac Arres t Algorithm
(Boxes 1 through 8).

60
 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
1
Sta rt CP R

30:2 compres s ion-

Ye s Rhythm No capnography
2 s ho c ka b le ? ETCO2
9 attempt to improve
VF/VT As ys to le /P EA

3
Shoc k
Re turn o f Sp o nta ne o us
4 Circ ula tio n (ROSC)
CP R 2 m in -
creas e in P ETCO 2

Rhythm No
s ho c ka b le ? Sho c k Ene rg y

Ye s
5
Shoc k

-
6 10
CP R 2 m in CP R 2 m in
Ep ine p hrine every 3-5 min 360 J
Ep ine p hrine every 3-5 min
capnography Drug The ra p y
capnography

Va s o p re s s in
Rhythm No Rhythm Ye s
s ho c ka b le ? s ho c ka b le ?
epinephrine
Ye s
7
Shoc k No
Ad va nc e d Airwa y

8 11
CP R 2 m in CP R 2 m in
Am io d a ro ne

compres s ions
No Rhythm Ye s Re ve rs ib le Ca us e s
s ho c ka b le ? – H
– H
12 – H
– H
Go to 5 o r 7 – Hypothermia
– T
10 or 11 – T
– T
– T
– T
© 2010 American Heart As s ociation

Fig u re 1 9 .

61
 P a r t 5

FYI 2 0 1 0 Gu id e lin e s •  The 2010 Cardiac Arres t Algorithms  (Figures  19 and 21) are pres ented in the 

 t raditional box-and-line format and a new circular format (Figure 21). The 2 formats  
ACLS Ca rd ia c Arre s t facilitate learning and memorization of the treatment recommendations . Overall 
Alg o rithm s thes e algorithms  reflect an emphas is  on the importance of high-quality, minimally 
interrupted CPR. This  action is  fundamental to the management of all cardiac  
arres t rhythms .

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 This  cas e dis cus s es  the as s es s ment and treatment of a patient with refractory VF or 

(Bo xe s 1 Th r o u g h 4 ) puls eles s  VT. This  algorithm as s umes  that healthcare providers  have completed the BLS 
Survey, including activation of the emergency res pons e s ys tem, performing CPR, attach-
ing the manual defibrillator, and delivering the firs t s hock (Boxes  1 through 4).

The ACLS res us citation team now intervenes  and conducts  the ACLS Survey. In this  cas e 

the team as s es s es  the patient and takes  actions  as  needed. The team leader coordinates  
the efforts  of the res us citation team as  they perform the s teps  lis ted in the VF/VT pathway 
on the left s ide of the Cardiac Arres t Algorithm. 

Min im a l In t e r r u p t io n A team member s hould continue to perform high-quality CPR until the defibrillator 

o f Ch e s t arrives  and is  attached to the patient. The team leader as s igns  roles  and res pons ibili-
Co m p r e s s io n s ties  and organizes  interventions  to minimize interruptions  in ches t compres s ions . This  
 a ccomplis hes  the mos t critical interventions  for VF or puls eles s  VT: CPR with minimal 
interruptions  in ches t compres s ions  and defibrillation during the firs t minutes  of arres t.

The AHA does  not recommend continued us e of an AED (or the automatic mode) when 

a manual defibrillator is  available and the provider’s  s kills  are adequate for rhythm 
 interpretation. Rhythm analys is  and s hock adminis tration with an AED may res ult in 
 p rolonged interruptions  in ches t compres 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 hip of quality CPR to coronary perfus ion pres s ure (CPP) demons trating the need to minimize interruptions  in compres s ions . 

Coronary perfus ion pres s ure is  aortic relaxation (“dias tolic”) pres s ure minus  right atrial 

relaxation (“dias tolic”) pres s ure. During CPR, CPP correlates  with both myocardial blood 
flow and ROSC. In one human s tudy ROSC did not occur unles s  a CPP ≥15 mm Hg was  
achieved during CPR.

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 •  Shortening the interval between the las t compres s ion and the s hock by even a few 

s econds  can improve s hock s ucces s  (defibrillation and ROSC). Thus , it is  reas on-
Re s um e CP R While able for healthcare providers  to practice efficient coordination between CPR and 
Ma nua l De fib rilla to r Is  d efibrillation to minimize the hands -off interval between s topping compres s ions  and 
Cha rg ing adminis tering the s hock.
•  For example, after verifying a s hockable rhythm and initiating the charging s equence 
on the defibrillator, another res cuer s hould res ume ches t compres s ions  and continue 
until the defibrillator is  fully charged. The defibrillator operator s hould deliver the 
s hock as  s oon as  the compres s or removes  his  or her hands  from the patient’s  ches t 
and all providers  are “clear” of contact with the patient.
•  Us e of a multimodal defibrillator in manual mode may reduce the duration of ches t 
compres s ion interruption required for rhythm analys is  compared with automatic 
mode but could increas e the frequency of inappropriate s hock. Individuals  who are 
not comfortable interpreting cardiac rhythms  can continue to us e an AED.
•  For an AED, follow the device’s  prompts .

De live r 1 S h o c k Box 3 directs  you to deliver 1 s hock. The appropriate energy dos e is  determined by the 

(Bo x 3 ) identity of the defibrillator—monophas ic or biphas ic. See the column on the right of the 
algorithm.

If you are us ing a monophasic defibrillator, give a s ingle 360-J  s hock. Us e the s ame 

 e nergy dos e for s ubs equent s hocks .

Biphasic defibrillators  us e a variety of waveforms , each of which is  effective for terminat-

ing VF over a s pecific dos e range. When us ing biphas ic defibrillators , providers  s hould 
us e the manufacturer’s  recommended energy dos e (eg, initial dos e of 120 to 200 J ). Many 
biphas ic defibrillator manufacturers  dis play the effective energy dos e range on the face of 
the device. If you do not know the effective dos e range, deliver the maximal energy dos e 
for the firs t and all s ubs equent s hocks .

If the initial s hock terminates  VF but the arrhythmia recurs  later in the res us citation 

attempt, deliver s ubs equent s hocks  at the previous ly s ucces s ful energy level.

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 ) •  Immediately res ume CPR, beginning with ches t compres s ions .

•  Do not perform a rhythm or puls e check at this  point.
•  Es tablis h IV/IO acces s .

63
 P a r t 5
Fo u n d a t io n a l Fa c t s
Cle a ring fo r De fib rilla tio n
Rh yt h m Ch e c k
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
64
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 patient’s 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 coordina-
tion 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.
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 check—preferably during rhythm analysis—only if an
organized rhythm is present.
•  If the rhythm 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, give 1 s hock and res ume CPR imme-
diately for 2 minutes after the s hock (Box 6).
•  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 elf-
adhes 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 patient’s 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 .
 Th e ACLS Ca s e s : VF/ P u ls e le s s VT

Sh oc k a n d For pers is tent VF/puls eles s VT, give 1 s hock and res ume CPR immediately for 2 minutes
Va s o p r e s s o r s (about 5 cycles ) after the s hock.
(Bo x 6 ) 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/IO—repeat every 3 to 5 minutes
or
•  Va s o p re s s in 40 units IV/IO—may 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 α -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 random-

ized 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 Give 1 s hock and res ume CPR beginning with ches t compres s ions for 2 minutes (about 5
An t ia r r h yt h m ic s cycles ) immediately after the s hock.
(Bo x 8 ) 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 300 mg IV/IO bolus , then cons ider an additional 150 mg IV/IO once

If amiodarone is  not available, providers  may adminis ter lidocaine.
•  Lid o c a ine 1 to 1.5 mg/kg IV/IO firs t dos e, then 0.5 to 0.75 mg/kg IV/IO at 5- to 
10-minute intervals , to a maximum dos e of 3 mg/kg
Providers  s hould cons ider magnes ium s ulfate only for tors ades  de pointes  as s ociated with 
a long QT interval.
•  Ma g ne s ium s ulfa te for tors ades  de pointes , loading dos e 1 to 2 g IV/IO diluted in  
10 mL (eg, D5 W, normal s aline) given as  IV/IO bolus , typically over 5 to 20 minutes
Routine adminis tration of magnes ium s ulfate in cardiac arres t is  not recommended unles s  
tors ades  de pointes  is  pres ent.

Search for and treat any treatable underlying caus e of cardiac arres t. See column on the 

right of the algorithm.

Ca r d ia c Ar r e s t The Cardiac Arres t Circular Algorithm (Figure 21) s ummarizes  the recommended s equence 

Tr e a t m e n t of CPR, rhythm checks , s hocks , and delivery of drugs  bas ed on expert cons ens us . The 
Se q u e n c e s optimal number of cycles  of CPR and s hocks  required before s tarting pharmacologic 
therapy remains  unknown. Note that rhythm checks  and s hocks  are organized around 5 
cycles  of compres s ions  and ventilations , or 2 minutes  if a provider is  timing the arres t.

Ad ult Ca rd ia c Arre s t CP R Qua lity

•   P us h hard (≥2 inches  [5 cm]) and fas t (≥100/min) and allow complete 
ches t recoil
•   Minimize interruptions  in compres s ions
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e •   Avoid exces s ive ventilation
•   Rotate compres s or every 2 minutes
•   If no advanced airway, 30:2 compres s ion-ventilation ratio
•   Q uantitative waveform capnography
Sta rt CP R –  If P e t c o 2  <10 mm Hg, attempt to improve CPR quality
• Give oxygen
•   Intra-arterial pres s ure
• Attach monitor/de brillator
–  If relaxation phas e (dias tolic) pres s ure <20 mm Hg, attempt to 
Re turn o f Sp o nta ne o us improve CPR quality
2 m inute s Circ ula tio n (ROSC) Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)
•   P uls e and blood pres s ure
Che c k P o s t–Ca rd ia c •   Abrupt s us tained increas e in P e t c o 2  (typically ≥40 mm Hg)
Rhythm Arre s t Ca re •   S pontaneous  arterial pres s ure waves  with intra-arterial monitoring
If VF/VT
Sh o c k Sho c k Ene rg y
•   
Bip ha s ic : Manufacturer recommendation (eg, initial dos e of 120-200 J );
Drug The ra p y if unknown, us e maximum available. Second and s ubs equent dos es  
s hould be equivalent, and higher dos es  may be cons idered.
R

IV/IO acces s
•  Mo no p ha s ic : 360 J
o
P

Epinephrine every 3-5 minutes

n
C

Amiodarone for refractory VF/VT Drug The ra p y

ti
s

•   
E p ine p hrine  IV/IO Do s e : 1 mg every 3-5 minutes
u

•   
Va s o p re s s in IV/IO Do s e : 40 units  can replace firs t or s econd dos e 
o

Co ns id e r Ad va nc e d Airwa y of epinephrine
u

su

Quantitative waveform capnography

ni

•   Amioda rone  IV/IO Dos e : First dose: 300 mg bolus. Second dose: 150 mg.

tn

Ad va nc e d Airwa y
P
o

•   
S upraglottic advanced airway or endotracheal intubation
C

Tre a t Re ve rs ib le Ca us e s •   
Waveform capnography to confirm and monitor ET tube placement 
•   8 -10 breaths  per minute with continuous  ches t compres s ions
Mo lit y Re ve rs ib le Ca us e s
n it o r u a
CP R Q – Hypovolemia
– Hypoxia
–
–
Tens ion pneumothorax
Tamponade, cardiac
– Hydrogen ion (acidos is ) – Toxins
– Hypo-/hyperkalemia – Thrombos is , pulmonary
© 2010 American Heart As s ociation – Hypothermia – Thrombos is , coronary

Fig u re 2 1 . The Cardiac Arres t Circular Algorithm. Do not delay s hock. Continue CPR while preparing and adminis tering drugs  and charging 

the defibrillator. Interrupt ches t compres s ions  only for the minimum amount of time required for ventilation (until advanced airway placed), rhythm 
check, and actual s hock delivery.

66

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
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
• 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 high-
quality, 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 valu-
able information on both the patient’s condition and the res pons e to therapy. Mos t impor-
tant, 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 io-
logic 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 com-
pres 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 ur-
rogate for CPP during CPR is arterial relaxation (“dias tolic”) pres s ure, which can be mea-
s 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 o-
pres s or therapy.
67
 P a r t 5

A
60
g
40
H
m
m
20

0
Time

120
g
80
H
m
m
40

B
60
g
40
H
m
m
20
10
0

Time

120
g
80
H
m
m
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 com-
pres 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

Tr e a t m e n t o f VF/ VT
in Hyp o t h e r m ia
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
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
1-minute interval
50
g
37.5
H
m
25
m
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 con-
tinuous 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.
For a cardiac arres t patient in VF/VT who has s evere hypothermia and a body tempera-
ture of <30°C (<86°F), 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 hypother-
mic 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 tan-
dard 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 (30°C to 34°C [86°F to 93.2°F]),
s tart CPR, attempt defibrillation, give medications s paced at longer intervals , and, if in
hos pital, provide active core rewarming.
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 5
In t r a ve n o u s Ro u t e
In t r a o s s e o u s Ro u t e
En d o t r a c h e a l Ro u t e
Va s o p re s s o r s
In t r o d u c t io n
70
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, typi-
cally 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.
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).
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 2½ 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.
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.

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
Ep in e p h r in e
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
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
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
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 unpre-
dictable drug abs orption and blood levels .
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 rou-
tine 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 .
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.
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 5
Am io d a r o n e
Lid o c a in e
Ma g n e s iu m S u lfa t e
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
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
•  Cons ider amiodarone for treatment of VF or puls eles s  VT unres pons ive to s hock 
delivery, CPR, and a vas opres s or. 
•  Amiodarone is  a complex drug that affects  s odium, potas s ium, and calcium channels . 
It als o has  α -adrenergic and ß-adrenergic blocking properties .
•  During cardiac arres t, cons ider amiodarone 300 mg IV/IO pus h for the firs t dos e.  
If VF/puls eles s  VT pers is ts , cons ider giving a s econd dos e of 150 mg IV/IO in  
3 to 5 minutes .
•  Lidocaine is  an alternative antiarrhythmic of long-s tanding and wides pread familiarity. 
However, it has  no proven s hort-term or long-term efficacy in cardiac arres t. Providers  
may cons ider giving lidocaine when amiodarone is  not available.
•  The initial lidocaine dos e is  1 to 1.5 mg/kg IV/IO. Repeat if indicated at  
0.5 to 0.75 mg/kg IV/IO over 5- to 10-minute intervals  to a maximum of 3 mg/kg.
•  If no IV/IO acces s  is  available, the dos e for endotracheal adminis tration is   
2 to 4 mg/kg.
•  IV magnes ium may terminate or prevent recurrent tors ades  de pointes  in patients   
who have a prolonged QT interval during normal s inus  rhythm. When VF/puls eles s   
VT  c ardiac arres t is  as s ociated with tors ades  de pointes , give magnes ium s ulfate at  
a loading dos e of 1 to 2 g IV/IO diluted in 10 mL (eg, D5 W, normal s aline) over 5 to  
20 minutes . If a prearres t 12-lead ECG is  available for review, check the QT interval 
for prolongation.
•  Remember that puls eles s  VT is  treated with an immediate high-energy s hock, where-
as  magnes ium is  an adjunctive agent us ed to prevent recurrent or treat pers is tent VT 
as s ociated with tors ades  de pointes .
•  Magnes ium s ulfate is  als o indicated for patients  with known or s us pected low s erum 
magnes ium, s uch as  patients  with alcoholis m or other conditions  as s ociated with 
malnutrition or hypomagnes emic s tates . For patients  in refractory VF/puls eles s  VT, 
check the patient’s  his tory, if available, for one of thes e conditions  that s ugges ts  the 
pres ence of a revers ible electrolyte abnormality.
There is  increas ing recognition that s ys tematic pos t–cardiac arres t care after ROSC can 
improve the likelihood of patient s urvival with good quality of life. This  cas e focus es  on 
the management of and optimization of cardiopulmonary function and perfus ion of vital 
organs  after ROSC.
To ens ure the s ucces s  of pos t–cardiac arres t care, healthcare providers  mus t
•  Optimize the patient’s  hemodynamic and ventilation s tatus
•  Initiate therapeutic hypothermia
•  Provide immediate coronary reperfus ion with PCI
•  Ins titute glycemic control
•  Provide neurologic care and prognos tication and other s tructured interventions
In this  cas e you will have an opportunity to us e the 12-lead ECG while us ing the as s es s -
ment and action s kills  typically performed after ROSC. 
The Immediate Pos t–Cardiac Arres t Care Algorithm (Figure 24) outlines  all the s teps  for 
immediate as s es s ment and management of pos t–cardiac arres t patients  with ROSC. 
During this  cas e team members  will continue to maintain good ventilation and oxygenation 
with a bag-mas k device or advanced airway. Throughout the cas e dis cus s ion of the Pos t–
Cardiac Arres t Care Algorithm, we will refer to Boxes  1 through 8. Thes e are the numbers  
as s igned to the boxes  on the algorithm.
 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 t–Ca rd ia c Arre s t Ca re

1
Do s e s /De ta ils
Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)
Ve ntila tio n/Oxyg e na tio n
Avoid exces s ive ventilation. 
2 Start at 10-12 breaths /min 
and titrate to target P e t c o 2
Op tim ize ve ntila tio n a nd o xyg e na tio n of 35-40 mm Hg.
When feas ible, titrate Fio 2
•  Maintain oxygen s aturation ≥94%
to minimum neces s ary to 
•  Cons ider advanced airway and waveform capnography
achieve Sp o 2 ≥94% .
•  Do not hyperventilate
IV Bo lus
1-2 L normal s aline 
or lactated Ringer’s .
3
If inducing hypothermia, 
Tre a t hyp o te ns io n (SBP <90 m m Hg ) may us e 4°C fluid.

•  IV/IO bolus Ep ine p hrine IV Infus io n:

0.1-0.5 mcg/kg per minute 
•  Vas opres s or infus ion
(in 70-kg adult: 7-35 mcg per 
•  Cons ider treatable caus es minute)
•  12-Lead ECG
Do p a m ine IV Infus io n:
5-10 mcg/kg per minute
5 4 No re p ine p hrine
No Fo llo w IV Infus io n:
Co ns id e r ind uc e d hyp o the rm ia c o m m a nd s ? 0.1-0.5 mcg/kg per minute 
(in 70-kg adult: 7-35 mcg per 
minute)
Ye s Re ve rs ib le Ca us e s
6 – Hypovolemia
7
– Hypoxia
Ye s STEMI
Co ro na ry re p e rfus io n – Hydrogen ion (acidos is )
OR 
high s us picion of AMI – Hypo-/hyperkalemia
– Hypothermia
– Tens ion pneumothorax
No – Tamponade, cardiac
8 – Toxins
– Thrombos is , pulmonary
Ad va nc e d c ritic a l c a re
– Thrombos is , coronary

© 2010 American Heart As s ociation

Fig u re 2 4 . The Immediate Pos t–Cardiac Arres t Care Algorithm.

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 e dis cus s es  the as s es s ment and treatment of a patient who had cardiac arres t 

and was  res us citated with the us e of the BLS Survey and ACLS Survey. During rhythm 
check in the ACLS Survey, the patient’s  rhythm was  organized and a puls e was  detected 
(Box 12, Cardiac Arres t Algorithm [Figure 19]). The team leader will coordinate the efforts  
of the pos t–cardiac arres t care team as  they perform the s teps  of the Pos t–Cardiac Arres t 
Care Algorithm.

73
 P a r t 5

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 mechani-
cal 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 oxyhemoglo-
bin s aturation ≥94% . When titration of ins pired oxygen is not feas ible (eg, in an out-
of-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% , pro-
vided the patient can maintain oxyhemoglobin s aturation ≥94% .

60
g
40
H
m
m
20

Time
A
60
g
40
H
m
m
20

0
Time
B
60
g
40
H
m
m
20

0
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

60
g
40
H
m
m
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 •  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 ,
Wa ve fo rm Ca p no g ra p hy and detect ROSC during ches t compres s ions or when a rhythm check reveals an
organized rhythm.

Ca u t io n •  When s ecuring an advanced airway, avoid us ing ties that pas s circumferentially
around the patient’s neck, thereby obs tructing venous return from the brain.
Thing s to Avo id •  Exces s ive ventilation may potentially lead to advers e hemodynamic effects when
During Ve ntila tio n 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 5

Fo u n d a t io n a l Fa c t s •  End-tidal CO 2  is  the concentration of carbon dioxide in exhaled air at the end of 

expiration. It is  typically expres s ed as  a partial pres s ure in millimeters  of mercury 
Wa ve fo rm Ca p no g ra p hy (P e t c o 2 ). Becaus e CO 2  is  a trace gas  in atmos pheric air, CO2  detected by capnogra-
phy in exhaled air is  produced in the body and delivered to the lungs  by circulating 
blood.
•  Cardiac output is  the major determinant of CO2  delivery to the lungs . If ventilation is  
relatively cons tant, P e t c o 2  correlates  well with cardiac output during CPR.
•  Providers  s hould obs erve a pers is tent capnographic waveform with ventilation to 
confirm and monitor ET tube placement in the field, in the trans port vehicle, on arriv-
al at the hos pital, and after any patient trans fer to reduce the ris k of unrecognized 
tube mis placement or dis placement.
•  Although capnography to confirm and monitor correct placement of s upraglottic 
airways  (eg, laryngeal mas k airway, laryngeal tube, or es ophageal-tracheal tube) has  
not been s tudied, effective ventilation through a s upraglottic airway device s hould 
res ult in a capnography waveform during CPR and after ROSC.

FYI 2 0 1 0 Gu id e lin e s •  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 
Wa ve fo rm Ca p no g ra p hy of an ET tube.

Tr e a t Hyp o t e n s io n Box 3 directs  you to treat hypotens ion when SBP is  <90 mm Hg. Providers  s hould obtain 

(S BP <9 0 m m Hg ) IV acces s  if not already es tablis hed. Verify the patency of any IV lines . IV lines  s hould 
(Bo x 3 ) replace IO acces s  if IO is  us ed during res us citation. ECG monitoring s hould continue after 
ROSC, during trans port, and throughout ICU care until deemed clinically not neces s ary. At 
this  s tage, cons ider treating any revers ible caus es  that might have precipitated the cardiac 
arres t but pers is t after ROSC.

When IV is  es tablis hed, treat hypotens ion as  follows :

•  IV b o lus  1-2 L normal s aline or lactated Ringer’s . If therapeutic hypothermia is  
 indicated or will be performed, you may us e 4°C fluids .
•  Ep ine p hrine 0.1-0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute) IV 
 infus ion titrated to achieve a minimum SBP of >90 mm Hg or a mean arterial pres s ure 
of >65 mm Hg
•  Do p a m ine  5-10 mcg/kg per minute IV infus ion titrated to achieve a minimum SBP of 
>90 mm Hg or a mean arterial pres s ure of >65 mm Hg
•  No re p ine p hrine  0.1-0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute) IV 
infus ion titrated to achieve a minimum SBP of >90 mm Hg or a mean arterial pres s ure 
of >65 mm Hg

Ep ine p hrine  can be us ed in patients  who are not in cardiac arres t but who require inotro-

pic or vas opres s or s upport.

Do p a m ine  hydrochloride is  a catecholamine-like agent and a chemical precurs or of nor-

epinephrine that s timulates  the heart through both α - and ß-adrenergic receptors .

No re p ine p hrine  (levarterenol) is  a naturally occurring potent vas ocons trictor and inotro-

pic agent. It may be effective for management of patients  with s evere hypotens ion (eg, 
SBP <70 mm Hg) and a low total peripheral res is tance who fail to res pond to les s  potent 
adrenergic drugs  s uch as  dopamine, phenylephrine, or methoxamine.

Fo llo w in g Co m m a n d s Box 4 directs  you to examine the patient’s  ability to follow verbal commands . 

(Bo x 4 ) If the patient fails  to follow commands , the healthcare team s hould cons ider implementing 
therapeutic hypothermia (Box 5). If the patient is  able to follow verbal commands , move to 
Box 6.

76

Th e r a p e u t ic
Hyp o t h e r m ia (Bo x 5 )
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
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 )
Co r o n a r y Re p e r fu s io n
(Bo x 7 )
Ad va n c e d Cr it ic a l
Ca r e (Bo x 8 )
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
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
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 32°C to 34°C 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, non–glucos e-contain-
ing 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-of-
hos pital cardiac arres t with an initial rhythm of PEA or as ys tole.
•  In comatos e patients who s pontaneous ly develop a mild degree of hypothermia
(>32°C) 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 neuro-
logic 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 patient’s 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 con-
current PCI and hypothermia are reported to be feas ible and s afe.
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).
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 diag-
nos ed with STEMI to reduce reperfus ion delay.
Following coronary reperfus ion interventions or in cas es where the pos t–cardiac 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.
There is no evidence to s upport continued prophylactic adminis tration of antiarrhythmic
medications once the patient achieves ROSC.
77
 P a r t 5
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Rh yt h m s fo r P EA
Dr u g s fo r P EA
De s c r ip t io n o f P EA
In t r o d u c t io n
78
P u ls e le s s Ele c t r ic a l Ac t ivit y Ca s e
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 identi-
fied, 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 .
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
You will need to recognize the following rhythms :
•  Rate—too fas t or too s low
•  Width of QRS complexes —wide vers us narrow
This cas e involves thes e drugs :
•  Epinephrine
•  Vas opres s in
•  Other medications , depending on the caus e of the PEA arres t
PEA encompas s es a heterogeneous group of rhythms that are organized or s emiorga-
nized, 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.
 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 Previous ly res us citation teams us ed the term electromechanical dissociation (EMD) to
P e r s p e c t ive 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 contrac-
tile function is pres ent—detectable by invas ive monitoring or echocardiography—but
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 manage-
ment, 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 effec-
tive 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 5

CP R Qua lity
•   
P us h hard (≥2 inches
Ad ult Ca rd ia c Arre s t [5 cm]) and fast 
(≥100/min) and allow
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e complete ches t recoil
•   Minimize interruptions  in 
compres s ions
1 •   Avoid excessive ventilation
Sta rt CP R •   Rotate compres s or every 
•   G ive oxygen 2 minutes
•   Attach monitor/defibrillator •   If no advanced airway, 
30:2 compres s ion-
ventilation ratio
•   Q uantitative waveform 
Ye s Rhythm No capnography
2 s ho c ka b le ? – If P e t c o 2 <10 mm Hg,
9 attempt to improve
VF/VT As ys to le /P EA CPR quality
•   Intra-arterial pres s ure
–  If relaxation phas e 
3 (dias tolic) pres s ure 
Shoc k <20 mm Hg, attemp t 
to improve CPR quality
Re turn o f Sp o nta ne o us
4 Circ ula tio n (ROSC)
•   
P ulse and blood pressure
CP R 2 m in •   Ab rupt s us tained 
•  IV/IO acces s
increas e in P e t c o 2
(typically ≥40 mm Hg)
•   
S pontaneous  arterial 
pres s ure waves  with 
intra-arterial monitoring
Rhythm No
s ho c ka b le ? Sho c k Ene rg y
•   
Bipha s ic : Manufacturer 
Ye s recommendation 
(eg, initial dos e of 
5 120-200 J ); if unknown, 
Shoc k
us e maximum available.
Second and subsequent 
doses should be equiva-
6 10
CP R 2 m in CP R 2 m in lent, and higher doses  
•  IV/IO acces s may be considered.
•   E p in e p hrin e every 3-5 min
•   E p ine p hrin e every 3-5 min •  Mo no p ha s ic : 360 J
•   C ons ider advanced airway, 
capnography •   C ons ider advanced airway,  Drug The ra p y
capnography •   Epine phrine IV/IO Do s e :
1 mg every 3-5 minutes
•   Va s o p re s s in IV/IO Do s e :
No Ye s 40 units  can replace 
Rhythm Rhythm
s ho c ka b le ? s ho c ka b le ? firs t or second dose of 
epinephrine
Ye s •   Am io d a ro ne IV/IO Do s e :
First dose: 300 mg bolus. 
7
Shoc k No Second dos e: 150 mg.
Ad va nc e d Airwa y
•   S up raglottic ad vanced 
8 11 airway or endotracheal 
CP R 2 m in CP R 2 m in
intubation
•   Am io d a ro ne •   Waveform capnography 
•  Treat revers ib le caus es to confirm and monitor
•  Treat revers ible caus es
ET tube placement 
•   8 -10 breaths per minute 
with continuous  ches t 
compres s ions
No Ye s Re ve rs ib le Ca us e s
Rhythm
s ho c ka b le ? – Hypovolemia
– Hypoxia
12
– Hydrogen ion (acidos is )
– Hypo-/hyperkalemia
•   
If no s igns  of return of  Go to 5 o r 7 – Hypothermia
s pontaneous  circulation  – Tens ion pneumothorax
(ROSC), go to 10 or 11 – Tamponade, cardiac
•   If ROSC, go to  – Toxins
Pos t–Cardiac Arres t Care – Thrombos is , pulmonary
© 2010 American Heart As s ociation – Thrombos is , coronary

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

80

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
Rh yt h m Ch e c k :
De c is io n P o in t
Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )
FYI 2 0 1 0 Gu id e lin e s
No Atro p ine During
Ca rd ia c Arre s t
No n s h o c k a b le
Rh yt h m
(Bo x 1 2 )
De c is io n P o in t :
S h o c k a b le Rh yt h m
Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity
In this cas e the patient is in cardiac arrest. Team members initiate and perform high-
quality 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 path-
way 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 simul-
taneously conduct a search for an underlying and treatable cause of the PEA in addition to
performing their assigned roles.
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 .
•  Give a vas opres s or as s oon as IV/IO acces s becomes available.
– Epinephrine 1 mg IV/IO—repeat 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.
•  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.
•  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 ec-
onds 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, immedi-
ately 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 t–cardiac
arres t care.
•  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 5

As ys t o le a n d Figure 28 s ummarizes the recommended s equence of CPR, rhythm checks , and delivery
P EA Tr e a t m e n t of drugs for PEA and as ys tole bas ed on expert cons ens us .
Se q u e n c e s

Ad ult Ca rd ia c Arre s t CP R Qua lity

•   
P us h hard (≥2 inches  [5 cm]) and fas t (≥100/min) and allow complete 
ches t recoil
•   Minimize interruptions  in compres s ions
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e •   Avoid exces s ive ventilation
•   Rotate  compres s or every 2 minutes
•   If no advanced airway, 30:2 compres s ion-ventilation ratio
•   Q uantitative waveform capnography
Sta rt CP R –  If P e t c o 2  <10 mm Hg, attempt to improve CPR quality
• Give oxygen
•   Intra-arterial pres s ure
• Attach monitor/de brillator
–  If relaxation phas e (dias tolic) pres s ure <20 mm Hg, atte mpt to 
Re turn o f Sp o nta ne o us improve CPR quality
2 m inute s Circ ula tio n (ROSC) Re turn o f Spo nta ne o us Circ ula tio n (ROSC)
•   P uls e and blood pres s ure
Che c k P o s t–Ca rd ia c •   Abrupt s us tained increa s e in P e t c o 2  (typically ≥40 mm Hg)
Rhythm Arre s t Ca re •   
S pontaneous  arterial pres s ure waves  with intra-arterial monitoring
If VF/VT
Sh oc k Sho c k Ene rg y
•   Bipha s ic : Manufacturer recommendation (eg, initial dos e of 120-200 J );
Drug The ra p y if unknown, us e maximum available. Second and s ubs equent dos es  
s hould be equivalent, and higher dos es  may be cons idered.
R

IV/IO acces s
•  Mo no p ha s ic : 360 J
o
P

Epinephrine every 3-5 minutes

n
C

Amiodarone for refractory VF/VT Drug The ra p y

ti
s

•   E p ine p hrine  IV/IO Do s e : 1 mg every 3-5 minutes

u

•   Va s o p re s s in IV/IO Do s e : 40 units  can replace firs t or s econd dos e 

o

Co ns id e r Ad va nc e d Airwa y of epinephrine
u

su

Quantitative waveform capnography

ni

•   
Amioda rone  IV/IO Dos e : First dose: 300 mg bolus. Second dose: 150 mg.
tn

Ad va nc e d Airwa y
P
o

•   S upraglottic advanced airway or endotracheal intubation
C

Tre a t Re ve rs ib le Ca us e s •   Waveform capnography to confirm and monitor ET tube placement 
•   8 -10 breaths  per minute with continuous  ches t compres s ions
Mo lit y Re ve rs ib le Ca us e s
n it o r ua
CP R Q – Hypovolemia
– Hypoxia
–
–
Tens ion pneumothorax
Tamponade, cardiac
– Hydrogen ion (acidos is ) – Toxins
– Hypo-/hyperkalemia – Thrombos is , pulmonary
© 2010 American Heart As s ociation – Hypothermia – 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 cor-
rect 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 H’s and T’s
•  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

H’s a n d T’s 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 H’s and T’s in the table below:

H’s T’s
Hypovolemia Tens ion pneumothorax
Hypoxia Tamponade (cardiac)
Hydrogen ion (acidos is ) Toxins
Hyper-/hypokalemia Thrombos is (pulmonary)
Hypothermia Thrombos is (coronary)

Co n d it io n s a n d The factors in the patient’s his tory and phys ical exam that may help identify revers ible
Ma n a g e m e n t 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 (H’s a nd T’s )

Clu e s Fro m His t o r y

Clu e s Fro m ECG a n d P o t e n t ia l Effe c t ive
Co n d it io n a n d P h ys ic a l
Mo n it o r In t e r ve n t io n s
Exa m in a t io n
Hyp o vo le m ia Narrow complex His tory, flat neck veins Volume infus ion

Rapid rate
Hyp o xia Slow rate (hypoxia) Cyanos is , blood gas es , Oxygenation, ventilation,
airway problems advanced airway
Hyd ro g e n io n (a c id o s is ) Smaller-amplitude QRS His tory of diabetes , bicar- Ventilation, s odium
complexes bonate-res pons ive preexis t- bicarbonate
ing acidos is , renal failure
Hyp e rka le m ia “High- potassium” ECG: His tory of renal failure, dia- Hyperkalemia:
betes , recent dialys is , dialy-
•  T waves taller and •  Calcium chloride
peaked s is fis tulas , medications
•  Sodium bicarbonate
•  P waves get s maller •  Glucos e plus ins ulin
or
•  QRS widens •  Pos s ibly albuterol
•  Sine-wave PEA
Hyp o ka le m ia “Low-potassium” ECG: Abnormal los s of potas - Hypokalemia:
s ium, diuretic us e
•  T waves flatten •  Add magnes ium if car-
•  Prominent U waves diac arres t
•  QRS widens
•  QT prolongs
•  Wide-complex tachy-
cardia
Hyp o the rm ia J or Os borne waves His tory of expos ure to cold, Rewarm according to local
central body temperature protocol
(continued)

83
 P a r t 5
(continued)
Co n d it io n
Te ns io n p ne um o tho ra x
Ta m p o na d e , c a rd ia c
To xins (d rug o ve rd o s e ):
tric yc lic s , d ig o xin,
ß-b lo c ke rs , c a lc ium
c ha nne l b lo c ke rs
Thro m b o s is , lung s : m a s -
s ive p ulm o na ry e m b o lis m
Thro m b o s is , he a rt: a c ute ,
m a s s ive MI
An a lyz e ECG fo r
Clu e s t o Un d e r lyin g
Ca u s e
Hyp o vo le m ia
84
Clu e s Fro m His t o r y
Clu e s Fro m ECG a n d P o t e n t ia l Effe c t ive
a n d P h ys ic a l
Mo n it o r In t e r ve n t io n s
Exa m in a t io n
Narrow complex His tory, no puls e felt with Needle decompres s ion
CPR, neck vein dis tention,
Slow rate (hypoxia) Tube thoracos tomy
tracheal deviation, unequal
breath s ounds , difficult to
ventilate patient
Narrow complex His tory, no puls e felt with Pericardiocentes is
CPR, vein dis tention
Rapid rate
Various effects on ECG, Bradycardia, empty bottles Intubation, s pecific
predominately prolongation at the s cene, pupils , neuro- antidotes and agents per
of QT interval logic exam toxidrome
Narrow complex His tory, no puls e felt with Surgical embolectomy,
CPR, dis tended neck veins , fibrinolytics
Rapid rate
prior pos itive tes t for deep
vein thrombos is or pulmo-
nary embolis m
Abnormal 12-lead ECG: His tory, cardiac markers ,
good puls e with CPR
•  Q waves
•  ST-s egment changes
•  T waves , invers ions
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 wave–QRS–T 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 wide-
complex 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.
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.

Ca r d ia c a n d
P u lm o n a r y
Co n d it io n s
Dr u g Ove r d o s e s
o r To xic Exp o s u r e s
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
Th e ACLS Ca s e s : P u ls e le s s Ele c tric a l Ac tivity
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 car-
diogenic 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.
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 common—they 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 t–c a rd ia c a rre s t c a re s ho uld
b e initia te d .
•  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 5
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Rh yt h m s fo r As ys t o le
Dr u g s fo r As ys t o le
Ap p ro a c h t o As ys t o le
In t r o d u c t io n
86
As ys t o le Ca s e
In this cas e the patient is in cardiac arrest. Team members initiate and perform high-
quality 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 simul-
taneously conduct a search for an underlying and treatable cause of the asystole in addi-
tion 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.
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-attempt-
res 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 cor-
rectable 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
You will need to recognize the following rhythms :
•  As ys tole
•  Slow PEA terminating in bradyas ys tolic rhythm
This cas e involves thes e drugs :
•  Epinephrine
•  Vas opres s in
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

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
P a t ie n t s Wit h DNAR
Or d e r s
As ys t o le a s a n
En d P o in t
Ma n a g in g As ys t o le
Ove r vie w
Ca r d ia c Ar r e s t
Alg o r it h m
Th e ACLS Ca s e s : As ys tole
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 electri-
cal 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
During the BLS Survey and ACLS Survey, you s hould be aware of reas ons to s top or with-
hold 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 appli-
cable 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 pro-
cedures . Many hos pitals will record this in the medical record.
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.
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
As des cribed in the VF/Puls eles s VT and PEA Cas es , the Cardiac Arres t Algorithm con-
s 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 5
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
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
Co n fir m e d As ys t o le
Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )
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
No n s h o c k a b le
Rh yt h m
88
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 cita-
tive efforts to be potentially s ucces s ful. Us e the H’s and T’s 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 H’s and T’s , including clinical clues and s ugges ted treatments .
In this cas e you have a patient in cardiac arres t. High-quality CPR is performed through-
out 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 begin-
ning 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.
Give priority to IV/IO acces s . Do not routinely ins ert an advanced airway unles s ventila-
tions with a bag-mas k are ineffective. Do not interrupt CPR while es tablis hing IV or
IO acces s .
•  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/IO—repeat 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.
•  Although there is no evidence that atropine has detrimental effects during brady-
cardic 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 .
•  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 t–cardiac 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 The diagram in Figure 28 (in the previous cas e, PEA) s ummarizes the recommended
Tr e a t m e n t S e q u e n c e s 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 Several randomized controlled trials failed to s how benefit from attempted TCP for as ys -
Re c o m m e n d e d 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 There is no evidence that attempting to “defibrillate” as ys tole is beneficial. In one s tudy

Ad m in is t r a t io n No t the group that received s hocks had a trend toward wors e outcome. Given the importance
Re c o m m e n d e d 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 medi-
cal directors may cons ider implementing a protocol that allows EMS res ponders to pro-
vide 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 If res cuers cannot rapidly identify a revers ible caus e and the patient fails to res pond to
In -Ho s p it a l the BLS and ACLS Surveys and s ubs equent interventions , termination of all res us citative
Re s u s c it a t ive efforts s hould be cons idered.
Effo r t s 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 deter-
mine with a high degree of certainty that the patient will not res pond to further ACLS.

89
 P a r t 5

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 :
•  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

Du r a t io n o f Available s cientific s tudies demons trate that in the abs ence of mitigating factors , pro-
Re s u s c it a t ive Effo r t s longed 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.

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

An Ag o n a l Rh yt h m •  As a terminal rhythm in a res us citation attempt that s tarted with another rhythm
Co n fir m in g •  As the firs t rhythm identified in a patient with unwitnes s ed or prolonged arres t
De a t h
In either of thes e s cenarios , as ys tole mos t often repres ents an agonal rhythm confirm-
ing 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 ch-
emia 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).

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.

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

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
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s
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 continu-
ing CPR is jus tified if interventions available in the ED cannot be performed in the out-
of-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 t–cardiac 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 t–cardiac arres t patient to an appropriate critical care unit
capable of providing comprehens ive pos t–cardiac arres t care.
Ac u t e Co ro n a r y S yn d ro m e s Ca s e
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
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 tra-
tion 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 5
Rh yt h m s fo r ACS
Dr u g s fo r ACS
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
92
Sudden cardiac death due to VF and hypotens ive bradyarrythmias occurs with acute is ch-
emia. Providers will unders tand to anticipate thes e rhythms and be prepared for immedi-
ate attempts at defibrillation and adminis tration of drug or electrical therapy for s ymptom-
atic 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 umma-
rizes the identification and management of patients with STEMI.
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 complica-
tions . 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
•  ß-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)
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

FYI 2 0 1 0 Gu id e lin e s
Go a ls o f The ra p y
fo r ACS
P a t h o p h ys io lo g y
o f ACS
Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s
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 tinfarc-
tion 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 mechani-
cal 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.
Patients with coronary atheros cleros is may develop a s pectrum of clinical s yndromes rep-
res enting varying degrees of coronary artery occlus ion. Thes Ae Uns
s yndromes include
tab le plaq ue uns table
Ea rly(UA),
angina p la q NSTEMI,
ue fo rm aand
tio nSTEMI. Sudden cardiac death may occur with each of thes e
B Plaq ue rupture
s yndromes . Figure 29 illus trates the pathophys iology of ACS.
C Uns table angina
A AUnsUns
tabletab le plaq ue
plaque
Ea rly p la q ue fo rm a tio n D Microemboli
B Plaque rupture
CB Plaq
EUnsOccus ueive
rupture
table anginathrombus
Sig ni c a nt p la q ue fo rm a tio n D CMicroemboli
Uns table angina
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 B C
D
Uns ta b le
P la q ue rup ture /thro m b us B C a ng ina /
D
NSTEMI
Uns ta b le
a ng ina /
STEMI E NSTEMI
Re s o lutio n /s ta b le a ng ina
STEMI E
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 5

Ac ute  Co ro na ry Synd ro m e s

1
Sym p to m s  s ug g e s tive  o f is c he m ia  o r infa rc tio n

2
EMS a s s e s s m e nt a nd  c a re  a n d  h o s p ita l p re p a ra tio n :
•   
Monitor, s upport ABCs . Be  prepare d to provide CPR and defibrilla tion
•  Adminis ter a s pirin and cons id er oxyge n, nitroglyc erin, and  morphine  if nee ded
•   O btain 12-lea d ECG; if ST elevation:
–  Notify re ceiving hos p ital with trans mis s ion or interpretation; note time of 
ons et and firs t med ica l conta ct
•  Notified hos pital s hould mobilize hos pital res ources  to res pond to STEMI
•  If cons idering prehos pital fibrinolys is , us e fibrinolytic checklis t

3
Co nc urre nt ED a s s e s s m e nt (<10 m inute s ) Im m e d ia te  ED g e ne ra l tre a tm e nt
•   C heck vital s igns ; evaluate  oxygen s a turation •   If O 2  s a t <94% , s tart o xyg e n at 4 L/min, titrate
•   Es ta blis h IV acce s s •  As p irin 160 to 325 mg (if not give n b y EMS)
•   P erform brie f, targeted  his tory, phys ic al exa m •  Nitro g lyc e rin s ublingua l or s pray
•   Review/c omp lete  fibrinolytic chec klis t;  •   Mo rp hine  IV if dis c omfort not relieved by 
che ck contra indications nitroglycerin
•   O btain initial c ardia c marker levels , 
initial e lectrolyte and coagulation s tudie s
•   
O bta in portable ches t x-ra y (<30 minute s )

4
ECG inte rp re ta tio n

5 9 13
ST e le va tio n o r ne w o r   ST d e p re s s io n o r d yna m ic   No rm a l o r no nd ia g no s tic  c ha ng e s  
p re s um a b ly ne w LBBB; T-wa ve  inve rs io n; s tro ng ly  in ST s e g m e nt o r T wa ve
s tro ng ly s us p ic io us  fo r injury s us p ic io us  fo r is c he m ia Lo w-/inte rm e d ia te -ris k ACS
ST-e le va tio n MI (STEMI) Hig h-ris k uns ta b le  a ng ina /
n o n–ST-e le va tio n  MI (UA/NSTEMI)
14
6
10 Co ns id e r a d m is s io n  
•   S ta rt a d ju nc tive  the ra p ie s    to  ED c he s t p a in unit o r  
a s indica te d Tro p o n in  e le va te d  o r h ig h -ris k p a tie nt  to  a p p ro p ria te  b e d  a nd   
•  Do  no t d e la y re p e rfus io n Cons ider e arly inva s ive s trategy if:  fo llo w:
•  Re frac tory is c hemic  c hes t d is comfort  •   S e ria l cardiac markers
7 •  Re curre nt/pe rs is tent ST devia tion  (including trop onin)
>1 2
•  Ventricula r tachycard ia  •   Rep eat ECG/continuous  
Tim e  fro m  o ns e t of   hours
•  Hemod yna mic  ins tab ility  ST-s egment monitoring
s ym p tom s  ≤12 ho urs ? •  Signs  of heart failure •   
C ons ider noninvas ive 
diagnos tic te s t

11
≤1 2 h ou rs 15
Sta rt a d junc tive  tre a tm e nts  a s  ind ic a te d
•  Nitroglycerin  De ve lo p s  1 o r m o re :
•  Heparin (UFH or LMWH)  Ye s •  Clinic a l high-ris k fe a ture s
•  Cons ider: PO ß-blockers   •   
Dyna m ic  ECG c ha ng e s   
•  Cons ider: Clopidogrel  c o ns is te nt with is c he m ia
•  Cons ider: Glycoprotein IIb/IIIa inhibitor •  Tro po nin e le va te d

8 12 16 No

Re p e rfus io n  g o a ls : Ad m it to  m o nito re d  b e d   Ye s Abno rm a l d ia g nos tic   

Therap y de fined  b y p atient and  As s e s s  ris k s ta tus no ninva s ive  im a g ing  o r  
center c rite ria Co ntinue  ASA, he p a rin, a nd  o the r   p hys io lo g ic  te s ting ?
•   Do o r-to –b a llo o n infla tio n  (P CI)  the ra p ie s  a s  ind ic a te d
g o a l o f 90 m inute s •  ACE inhibitor/ARB
17 No
•   Do o r-to -n e e d le  (fib rin o lys is )  •   HMG CoA reduc ta s e inhibitor 
g o a l o f 30 m inute s (s tatin therap y)
If no  e vid e nc e  o f is c he m ia   
Not a t high ris k: ca rdiology to ris k s tratify
o r infa rc tio n b y te s ting , c a n 
d is c ha rg e  with fo llo w-up
© 2010 American Heart As s ociation

Fig u re 3 0 . The Acute Coronary Syndromes Algorithm.

94

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
Im p o r t a n t
Co n s id e r a t io n s
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
Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s
The Acute Coronary Syndromes Algorithm (Figure 30) outlines the as s es s ment and man-
agement 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 patient’s arrival at the hos pital, the ED provider s hould imple-
ment this component of care.
Subs equent treatment occurs on the patient’s 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 patient’s 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/non–ST-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.
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 .
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 5

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 All dis patchers and EMS providers mus t receive training in ACS s ymptom recognition
Dis p a t c h along with the potential complications . Dis patchers , when authorized by medical con-
trol 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 mor-
phine 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 Monitoring and s upport of ABCs includes

S u p p o r t ABCs •  Monitoring vital s igns and cardiac rhythm
•  Being prepared to provide CPR
•  Us ing a defibrillator if needed

Ad m in is t e r Oxyg e n Providers s hould be familiar with the actions , indications , cautions , and treatment of s ide
a n d Dr u g s effects .

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 atu-
ration 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 evi-
dence 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, particu-
larly 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 volume-
depleting 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 refrac-
tory 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.

97
 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 •  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
P a in Re lie f With etiologies as well as other caus es of ches t dis comfort can “res pond” to nitroglycerin
Nitro g lyc e rin adminis tration. Therefore, the res pons e to nitrate therapy is not diagnos tic of ACS.

Ca u t io n •  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
Us e o f No ns te ro id a l drugs s hould not be adminis tered during hos pitalization for STEMI becaus e of the
Anti-infla m m a to ry Drug s increas ed ris k of mortality, reinfarction, hypertens ion, heart failure, and myocardial
rupture as s ociated with their us e.

Ob t a in a EMS providers s hould obtain a 12-lead ECG. The 2010 AHA Guidelines for CPR and ECC
1 2 -Le a d ECG 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
12-Le a d ECG if a va ila b le
P re a rriva l ho s p ita l no tific a tio n fo r
STEMI
Fib rino lytic c he c klis t if a p p ro p ria te
Re c o m m e n d a t io n
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.
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 fibrino-
lytics or PCI or both, which may reduce
mortality and minimize myocardial injury.
If STEMI is identified on the 12-lead ECG,
complete a fibrinolytic checklis t if appro-
priate.

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.

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 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
patient’s 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
II
0.04 second

ST-segment
baseline

TP s egment ST-segment deviation

A (baseline) = 5.0 mm

V2 V5

J point
plus 0.04
s econd

ST-s egment
baseline

ST-segment
deviation
= 4.5 mm
TP s egment (baseline)
B
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 5
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 )
P a t ie n t Ge n e r a l
Tr e a t m e n t (Bo x 3 )
Cr it ic a l Co n c e p t s
Oxyg e n, As p irin,
Nitra te s , Mo rp hine
S TEMI (Bo xe s 5 Th ro u g h 8 )
In t r o d u c t io n
100
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 patient’s 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.
Unles s allergies or contraindications exis t, 4 agents are routinely recommended for con-
s 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 upple-
mental 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.”)
•  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.
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 catheter-
bas 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 .

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
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
Th e ACLS Ca s e s : Ac u te Coron a ry Syn d rom e s
•  Routine cons ultation with a cardiologis t or another phys ician s hould not delay diag-
nos is  and treatment except in equivocal or uncertain cas es . Cons ultation delays  
therapy and is  as s ociated with increas ed hos pital mortality rates .
•  Potential delay during the in-hos pital evaluation period may occur from d o o r to data 
(ECG), from d a ta  to decis ion, and from d e c is io n to d rug  (or PCI). Thes e 4 major 
points  of in-hos pital therapy are commonly referred to as  the “4 D’s .”
•  All providers  mus t focus  on minimizing delays  at each of thes e points . Out-of-
hos pital trans port time cons titutes  only 5%  of delay to treatment time; ED evaluation 
cons titutes  25%  to 33%  of this  delay.
Rapidly identify patients  with STEMI and quickly s creen them for indications  and contrain-
dications  to fibrinolytic therapy by us ing a fibrinolytic checklis t if appropriate.
The firs t qualified phys ician who encounters  a patient with STEMI s hould interpret or con-
firm the 12-lead ECG, determine the ris k/benefit of reperfus ion therapy, and direct admin-
is tration of fibrinolytic therapy or activation of the PCI team. Early activation of PCI may 
occur with es tablis hed protocols . The following time frames  are recommended:
•  If the patient meets  the criteria for fib rin olytic th e ra p y, an ED door-to-needle time 
(needle time is  the beginning of infus ion of a fibrinolytic agent) of 30 minutes  is  the 
medical s ys tem goal that is  cons idered the longes t time acceptable. Sys tems  s hould 
s trive to achieve the s hortes t time pos s ible.
•  For P CI, this  goal for ED door–to–balloon inflation time is  90 minutes .
•  Patients  who are ineligible for fibrinolytic therapy s hould be cons idered for trans fer to 
a PCI facility regardles s  of delay. The s ys tem s hould prepare for a door-to-departure 
time of 30 minutes  when a trans fer decis ion is  made.
Adjunctive treatments  may als o be indicated.
Review the initial 12-lead ECG (Box 4) and clas s ify patients  into 1 of the 3 following clini-
cal groups  (Boxes  5, 9, and 13):
Ge n e r a l Gro u p De s c r ip t io n
STEMI ST elevation 
Hig h-ris k UA/NSTEMI ST depres s ion or dynamic T-wave  
invers ion
Inte rm e d ia te /lo w-ris k UA Normal or nondiagnos tic ECG
•  STEMI is  characterized by ST-s egment elevation in 2 or more contiguous  leads  or 
new LBBB. Thres hold values  for ST-s egment elevation cons is tent with STEMI are 
J -point 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. 
*2.5 mm in men <40 years ; 1.5 mm in all women.
•  Hig h -ris k UA/ NSTEMI is  characterized by is chemic ST-s egment depres s ion ≥0.5 mm 
(0.05 mV) or dynamic T-wave invers ion with pain or dis comfort. Nonpers is tent or tran-
s ient ST elevation ≥0.5 mm for <20 minutes  is  als o included in this  category.
•  In te rm e d ia te or low-ris k UA is  characterized by normal or nondiagnos tic changes  in 
the ST s egment or T wave that are inconclus ive and require further ris k s tratification. 
This  clas s ification includes  patients  with normal ECGs  and thos e with ST-s egment 
deviation in either direction of <0.5 mm (0.05 mV) or T-wave invers ion ≤2 mm or 0.2 
mV. Serial cardiac s tudies  and functional tes ting are appropriate. Note that additional 
information (troponin) may place the patient into a higher ris k clas s ification after initial 
clas s ification.
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 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 per-
centage 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 A fibrinolytic agent or “clot bus ter” is adminis tered to patients with J -point ST-s egment
Th e r a p y 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 con-
s is tent with true pos terior MI. Experienced providers will recognize this as a con-
dition 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 contin-
ues with pers is tent ST-s egment elevation.
•  Do not give fibrinolytics to patients who pres ent >24 hours after the onset of symp-
toms 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 fibrino-
lytics in patients who may have pers is tent occlus ion of the infarct artery (failure to reper-
fus 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 pre-
s 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, percutane-
ous 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 arrival–to-balloon time at the PCI-
capable 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

•  For patients  admitted to a hos pital without PCI capabilities , there may be s ome 

benefit as s ociated with trans fer for PCI vers us  adminis tration of on-s ite fibrinolytics  
in terms  of reinfarction, s troke, and a trend to lower mortality when PCI can be per-
formed within 90 minutes  of ons et of STEMI.
•  PCI is  als o preferred in patients  with contraindications  to fibrinolytics  and is  indicated 
in patients  with cardiogenic s hock or heart failure complicating MI.
•  In patients  with STEMI who pres ent 3 hours or less from onset of symptoms, treat-
ment is  more time s ens itive, and PCI is  s uperior to fibrinolys is .

 
Ad ju n c t ive Other drugs  are us eful when indicated in addition to oxygen, s ublingual or s pray nitroglyc-
Tr e a t m e n t s erin, as pirin, morphine, and fibrinolytic therapy. Thes e include
•  IV nitroglycerin
•  Heparin
•  Clopidogrel
•  ß-Blockers
•  ACE inhibitors
•  HMG–CoA reductas e inhibitor therapy (s tatin)
IV nitroglycerin and heparin are commonly us ed early in the management of patients  with 
STEMI. Thes e agents  are briefly dis cus s ed below. We will not review the us e of ß-blockers , 
ACE inhibitors , and s tatin therapy in STEMI. Us e of thes e agents  requires  additional 
ris k s tratification s kills  and a detailed knowledge of the s pectrum of ACS and, in s ome 
ins tances , continuing knowledge of the res ults  of clinical trials .

IV Nitrog lyc e rin

Routine us e of IV nitroglycerin is  not indicated and has  not been s hown to s ignificantly 
reduce mortality in STEMI. IV nitroglycerin is  indicated and us ed widely in is chemic s yn-
dromes . It is  preferred over topical or long-acting forms  becaus e it can be titrated in a 
patient with potentially uns table hemodynamics  and clinical condition. Indications  for  
initiation of IV nitroglycerin in STEMI are
•  Recurrent or continuing ches t dis comfort unres pons ive to s ublingual or s pray nitro-
glycerin 
•  Pulmonary edema complicating STEMI
•  Hypertens ion complicating STEMI
Treatment goals  us ing IV nitroglycerin are as  follows :

Tre a t m e n t Go a l
Re lie f o f is c he m ic c he s t d is c o m fo rt
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
Ma n a g e m e n t
•  Titrate to effect
•  Keep SBP >90 mm Hg
•  Limit drop in SBP to 30 mm Hg below 
bas eline in hypertens ive patients
•  Titrate to effect
•  Limit drop in SBP to 10%  of bas eline in 
normotens ive patients
•  Limit drop in SBP to 30 mm Hg below 
bas eline in hypertens ive patients

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 P a r t 5

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 itua-
tions , s uch as LV mural thrombus , atrial fibrillation, and prophylaxis for pulmonary throm-
boembolis 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 t-
e 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 brady-
cardia (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 interpreta-
tion, 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 con-
dition

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

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 Th e ACLS Ca s e s : Bra d yc a rd ia

Rh yt h m s fo r This cas e involves thes e ECG rhythms :

Br a d yc a r d ia •  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 impor-
tant 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 immedi-
ate 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 5

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, Second-
degree 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 This cas e involves thes e drugs :

Br a d yc a r d ia •  Atropine
•  Dopamine (infus ion)
•  Epinephrine (infus ion)

106

De s c r ip t io n o f Br a d yc a rd ia
De fin it io n s
S ym p t o m a t ic
Br a d yc a r d ia
S ig n s a n d S ym p t o m s
Th e ACLS Ca s e s : Bra d yc a rd ia
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/min—eg, third-degree AV block—or
s inus bradycardia. When bradycardia is
the caus e of s ymptoms , the rate is gener-
ally <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.
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.
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 con-
s 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 prema-
ture ventricular complexes or VT.
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 P a r t 5

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 The Bradycardia Algorithm (Figure 34) outlines the s teps for as s es s ment and manage ment
Alg o r it h m 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 patient’s
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)
1

As s es s appropriatenes s for clinical condition.

Heart rate typically <50/min if bradyarrhythmia.

Id e ntify a nd tre a t und e rlying c a us e

•  Maintain patent airway; as s is t breathing as  neces s ary
•  Oxygen (if hypoxemic)
•  Cardiac monitor to identify rhythm; monitor blood pres s ure and oximetry
•  IV acces s
•  12-Lead ECG if available; don’t delay therapy

3
P e rs is te nt b ra d ya rrhythm ia
4 c a us ing :
No •  Hypotens ion?
Mo nito r a nd o b s e rve
•  Acutely altered mental s tatus ?
•  Signs of s hock?
•  Is chemic ches t dis comfort?
•  Acute heart failure?

5 Ye s
Do s e s /De ta ils
Atro p ine Atro p ine IV Do s e :
Firs t dos e: 0.5 mg bolus  
If atropine ineffective:
Repeat every 3-5 minutes  
 •  Trans cutaneous  pacing
Maximum: 3 mg
                 OR
•  Do p a m ine infus ion Do p a m ine IV Infus io n:
                 OR 2-10 mcg/kg per minute
•  Ep ine p hrine infus ion Ep ine p hrine IV Infus io n:
2-10 mcg per minute
6

Co ns id e r:
•  Expert cons ultation
•  Trans venous  pacing

© 2010 American Heart As s ociation

Fig u re 3 4 . The Bradycardia Algorithm.

FYI 2 0 1 0 Gu id e lin e s •  The Bradycardia Algorithm has  been modified to reflect the changes  in treatment 

pres ented in the 2010 AHA Guidelines for CPR and ECC.
The Bra d yc a rd ia •  The initial treatment of bradycardia is  atropine. If bradycardia is  unres pons ive to 
Alg o rithm atropine, IV infus ion of ß-adrenergic agonis ts  with rate-accelerating effects  (dopa-
mine, epinephrine) or TCP can be effective while the patient is  being prepared for 
emergent trans venous  temporary pacing if required.

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 In this  cas e you have a patient pres enting with s ymptoms  of bradycardia. You conduct 

appropriate as s es s ment and interventions  as  outlined in the Bradycardia Algorithm. At the 
s ame time you are s earching for and treating pos s ible contributing factors .

109
 P a r t 5
Id e n t ific a t io n o f
Br a d yc a r d ia (Bo x 1 )
BLS a n d ACLS
S u r ve ys (Bo x 2 )
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 )
Cr it ic a l Co n c e p t s
Bra d yc a rd ia
De c is io n P o in t :
Ad e q u a t e P e r fu s io n ?
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 )
110
Identify whether the bradycardia is
•  Pres ent by definition, ie, heart rate <50/min
•  Inadequate for the patient’s condition (functional or relative)
Next, perform the ACLS Survey, including the following:
A Maintain patent airway.
B As s is t breathing as needed; give oxygen in cas e of hypoxemia; monitor oxygen
s aturation.
C Monitor blood pres s ure and heart rate; obtain and review a 12-lead ECG; es tab-
lis h IV acces s .
D 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 o-
ciated with bradycardia may be due to myocardial dys function rather than the bradycar-
dia. Keep this in mind when you reas s es s the patient’s res pons e to treatment.
•  The key clinical ques tion is whether the bradycardia is caus ing the patient’s s ymp-
toms or s ome other illnes s is caus ing the bradycardia.
You mus t now decide if the patient has adequate or poor perfus ion.
•  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.
If the patient has poor perfus ion s econdary to bradycardia, the treatment s equence is as
follows :
Give atropine as firs t-line treatment Atropine 0.5 mg IV—may repeat to a total
dos e of 3 mg
If a t ro p in e is in e ffe c t ive
Trans cutaneous pacing •  Dopamine 2 to 10 mcg/kg per minute
or (chronotropic or heart rate dos e)
•  Epinephrine 2 to 10 mcg/min

Tr e a t m e n t S e q u e n c e :
At r o p in e
Tr e a t m e n t S e q u e n c e :
P a c in g
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
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 patient’s clinical pres entation.
For patients with s ymptomatic bradycardia, move quickly through this s equence. Thes e
patients may be “pre–cardiac arres t” and may need multiple interventions s imultaneous ly.
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 fur-
ther s lowing of the heart rate.
Us e atropine cautious ly in the pres ence of acute coronary is chemia or MI. An atropine-
mediated 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.
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 high-
degree heart block when IV acces s is not available. It is reas onable for healthcare provid-
ers 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 eda-
tives for pain control. Note that many of thes e drugs may further decreas e blood pres s ure
and affect the patient’s mental s tatus . Try to identify and correct the caus e of the brady-
cardia.
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 inef-
fective des pite capture.
If you chos e TCP as the s econd–line 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 ve-
nous pacing by obtaining expert cons ultation.
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 patient’s 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 5

Tr e a t m e n t S e q u e n c e : Although ß-adrenergic agonis ts with rate-accelerating effects are not firs t-line agents for
Ep in e p h r in e , treatment of s ymptomatic bradycardia, they are alternatives to TCP or in s pecial circum-
Do p a m in e s tances s uch as overdos e with a ß-blocker or calcium channel blocker.

Becaus e epinephrine and dopamine are vas ocons trictors , as well as chronotropes , health-
care providers mus t as s es s the patient’s intravas cular volume s tatus and avoid hypovole-
mia 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 inap-
propriate 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 After cons ideration of the treatment s equence in Box 5, you may need to
(Bo x 6 ) •  Prepare the patient for trans venous pacing
•  Treat the contributing caus es of the bradycardia
•  Cons ider expert cons ultation—but 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 elec-
trical 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

Te c h n iq u e
As s e s s Re s p o n s e t o
Tr e a t m e n t
Br a d yc a r d ia Wit h
Es c a p e Rh yt h m s
Th e ACLS Ca s e s : Bra d yc a rd ia
Perform TCP by following thes e s teps :
Ste p Ac t io n
1 Place pacing electrodes on the ches t according to package ins tructions .
2 Turn the pacer ON.
3 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 tab-
lis hed.
4 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 .
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 patient’s 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 myo-
cardial 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 chro-
notropic 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
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 5
S t a n d b y P a c in g
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Rh yt h m s fo r Un s t a b le
Ta c h yc a r d ia
Dr u g s fo r Un s t a b le
Ta c h yc a r d ia
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
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 myocar-
dial 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
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.
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
This cas e involves thes e ECG rhythms :
•  Atrial fibrillation
•  Atrial flutter
•  Reentry s upraventricular tachycardia (SVT)
•  Monomorphic VT
•  Polymorphic VT
•  Wide-complex tachycardia of uncertain type
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.
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 tachycar-
dia 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.

De fin it io n s
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
S ym p t o m s a n d S ig n s
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
S e ve r it y
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 .
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.
Uns table tachycardia exis ts when the heart rate is too fas t for the patient’s clinical condi-
tion 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
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)
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 t’s 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 tachy-
cardia 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 underly-
ing conditions .
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 5

In d ic a t io n s fo r Rapid identification of s ymptomatic tachycardia will help you determine whether you
Ca r d io ve r s io n 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, ane-
mia, 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 tachy-
cardia 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 tachycar-
dia), 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 (includ-
ing 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 pro-
vide treatment bas ed on the patient’s 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 anti-
arrhythmic 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 tachy-
cardia 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

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
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
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 pre-
s 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.
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 .
•  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 facil-
itate 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 5

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.

Id e ntify a nd tre a t und e rlying c a us e Do s e s /De ta ils

•  Maintain patent airway; as s is t breathing as  neces s ary Sync hro nize d Ca rd io ve rs io n

•  Oxygen (if hypoxemic) Initial recommended dos es :
•   C ardiac monitor to identify rhythm; monitor blood  •  Narrow regular: 50-100 J
pres s ure and oximetry •   Narrow irregular: 120-200 J  biphas ic 
or 200 J  monophas ic
•  Wide regular: 100 J
•   Wide irregular: defibrillation dos e
3 (NOT s ynchronized)

P e rs is te nt ta c hya rrhythm ia 4 Ad e no s ine IV Do s e :

c a us ing : Firs t dos e: 6 mg rapid IV pus h; follow 
Sync hro nize d c a rd io ve rs io n with NS flus h.
•  Hypotens ion? Ye s •  Cons ider s edation Second dos e: 12 mg if required.
•  Acutely altered mental s tatus ? •   If regular narrow complex, 
•  Signs  of s hock? cons ider adenos ine An tia rrh yth m ic In fu s ion s for
•  Is chemic ches t dis comfort? Sta b le Wid e -QRS Ta c h yc a rd ia
•  Acute heart failure?
6 P ro c a ina m id e IV Do s e :
20-50 mg/min until arrhythmia 
No •   IV acces s  and 12-lead ECG  s uppres s ed, hypotens ion ens ues , 
5
if available QRS duration increas es  >50% , or 
Wid e QRS? Ye s •   C ons ider adenos ine only if  maximum dos e 17 mg/kg given. 
≥0.12 s e c o nd regular and monomorphic Maintenance infus ion: 1-4 mg/min. 
•  Cons ider antiarrhythmic infus ion Avoid if prolonged QT or CHF.
•  Cons ider expert cons ultation
Am io d a ro ne IV Do s e :
No Firs t dos e: 150 mg over 10 minutes . 
7 Repeat as  needed if VT recurs . 
•  IV acces s  and 12-lead ECG if available Follow by maintenance infus ion of 
•  Vagal maneuvers 1 mg/min for firs t 6 hours .
•  Adenos ine (if regular) So ta lo l IV Do s e :
•  ß-Blocker or calcium channel blocker 100 mg (1.5 mg/kg) over 5 minutes . 
•  Cons ider expert cons ultation Avoid if prolonged QT.
© 2010 American Heart As s ociation

Fig u re 3 5 . The Tachycardia With a Puls e Algorithm. 

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

In t r o d u c t io n In this  cas e you have a patient with tachycardia and a puls e. You conduct the s teps  out-

lined in the Tachycardia Algorithm to evaluate and manage the patient.

As s e s s •  Tachycardia is  defined as  an arrhythmia with a rate >100/min.

Ap p r o p r ia t e n e s s •  The rate takes  on clinical s ignificance at its  greater extremes  and is  more likely attribut-
fo r Clin ic a l able to an arrhythmia rate of ≥150/min.
Co n d it io n (Bo x 1 ) •  It is  unlikely that s ymptoms  of ins tability are caus ed primarily by the tachycardia when 
the heart rate is  <150/min unles s  there is  impaired ventricular function.

118

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 )
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 )
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
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 deter-
mined 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.
•  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 patient’s 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 ymp-
toms 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 tachyar-
rhythmia, 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, deter-
mine 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 5
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
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 )
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 )
Ca rd io ve r s io n
In t r o d u c t io n
120
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 poly-
morphic 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 manu-
s cript for the 2010 AHA Guidelines for CPR and ECC was in preparation. Thus , this
recommendation repres ents expert opinion.
•  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 tachy-
cardia 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.
•  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.
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

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
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
Re c o m m e n d a t io n s
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
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
patient’s 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 pre-
cipitate VF. Synchronized cardiovers ion us es a lower energy level than attempted defibril-
lation. Low-energy s hocks s hould always be delivered as s ynchronized s hocks to avoid
precipitating VF.
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 ynchronize—uns ucces s fully in that the machine will
not dis charge—and 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).
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 SVT
•  Uns table atrial fibrillation
•  Uns table atrial flutter
•  Uns table 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 5

En e r g y Do s e s fo r Select the energy dos e for the s pecific type of rhythm.

Ca r d io ve r s io n 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 car-
diovers 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 pe-
cific device.

Ste p Ac t io n
1 Sedate all cons cious patients unles s uns table or deteriorating rapidly.

2 Turn on the defibrillator (monophas ic or biphas ic).

3 Attach monitor leads to the patient (“white to right, red to ribs , what’s left
over to the left s houlder”) and ens ure proper dis play of the patient’s rhythm.
Pos ition adhes ive electrode (conductor) pads on the patient.

4 Pres s the SYNC control button to engage the s ynchronization mode.

5 Look for markers on the R wave indicating s ync mode.

6 Adjus t monitor gain if neces s ary until s ync markers occur with each R wave.

7 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 Treat as VF with high-energy s hock
a nd ra te ) a nd uns ta b le (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 defibrillator—s tand clear!”

9 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 5
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Rh yt h m s fo r S t a b le
Ta c h yc a r d ia
124
S t a b le Ta c h yc a rd ia Ca s e
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 treat-
ment 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 maneu-
vers 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 immedi-
ate uns ynchronized s hock or s ynchronized cardiovers ion as dis cus s ed in the Uns table
Tachycardia Cas e.
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
Tachycardias can be clas s ified in s everal ways bas ed on the appearance of the QRS com-
plex, heart rate, and whether they are regular or irregular:
•  Narrow–QRS complex (SVT) tachycardias (QRS <0.12 s econd) in order of frequency
– Sinus tachycardia
– Atrial fibrillation
– Atrial flutter
– AV nodal reentry
•  Wide–QRS complex tachycardias (QRS ≥0.12 s econd)
– Monomorphic VT
– Polymorphic VT
•  Regular or irregular tachycardias
– Irregular narrow-complex tachycardias are probably atrial fibrillation

Dr u g s fo r S t a b le
Ta c h yc a r d ia
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
Qu e s t io n s t o
De t e r m in e
Cla s s ific a t io n
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
Th e ACLS Ca s e s : Sta b le Ta c h yc a rd 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 cardiover-
s ion. Thes e agents are not covered in the ACLS Provider Cours e.
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
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.
•  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 age-
related. 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 termi-
nation.
•  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.
•  ß-Blockers may caus e clinical deterioration if the cardiac output falls when a com-
pensatory 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, car-
diac output will fall and the patient’s 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 5

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.

Id e ntify a nd tre a t und e rlying c a us e Do s e s /De ta ils

•  Maintain patent airway; as s is t breathing as  neces s ary Sync hro nize d Ca rd io ve rs io n

•  Oxygen (if hypoxemic) Initial recommended dos es :
•   C ardiac monitor to identify rhythm; monitor blood  •  Narrow regular: 50-100 J
pres s ure and oximetry •   Narrow irregular: 120-200 J  biphas ic 
or 200 J  monophas ic
•  Wide regular: 100 J
•   Wide irregular: defibrillation dos e
3 (NOT s ynchronized)

P e rs is te nt ta c hya rrhythm ia 4 Ad e no s ine IV Do s e :

c a us ing : Firs t dos e: 6 mg rapid IV pus h; follow 
Sync hro nize d c a rd io ve rs io n with NS flus h.
•  Hypotens ion? Ye s •  Cons ider s edation Second dos e: 12 mg if required.
•  Acutely altered mental s tatus ? •   If regular narrow complex, 
•  Signs  of s hock? cons ider adenos ine An tia rrh yth m ic In fu s ion s for
•  Is chemic ches t dis comfort? Sta b le Wid e -QRS Ta c h yc a rd ia
•  Acute heart failure?
6 P ro c a ina m id e IV Do s e :
20-50 mg/min until arrhythmia 
No •   IV acces s  and 12-lead ECG  s uppres s ed, hypotens ion ens ues , 
5
if available QRS duration increas es  >50% , or 
Wid e QRS? Ye s •   C ons ider adenos ine only if  maximum dos e 17 mg/kg given. 
≥0.12 s e c o nd regular and monomorphic Maintenance infus ion: 1-4 mg/min. 
•  Cons ider antiarrhythmic infus ion Avoid if prolonged QT or CHF.
•  Cons ider expert cons ultation
Am io d a ro ne IV Do s e :
No Firs t dos e: 150 mg over 10 minutes . 
7 Repeat as  needed if VT recurs . 
•  IV acces s  and 12-lead ECG if available Follow by maintenance infus ion of 
•  Vagal maneuvers 1 mg/min for firs t 6 hours .
•  Adenos ine (if regular) So ta lo l IV Do s e :
•  ß-Blocker or calcium channel blocker 100 mg (1.5 mg/kg) over 5 minutes . 
•  Cons ider expert cons ultation Avoid if prolonged QT.
© 2010 American Heart As s ociation

Fig u re 3 6 . The Tachycardia With a Puls e Algorithm. 

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 In this  cas e a patient has stable tachycardia with a pulse. Conduct the s teps  outlined in 
the Tachycardia Algorithm to evaluate and manage the patient.

P a t ie n t As s e s s m e n t Box 1 directs  you to as s es s  the patient’s  condition. Typically, a heart rate >150/min at res t 

(Bo x 1 ) is due to tachyarrhythmias other than s inus tachycardia.

127
 P a r t 5
BLS a n d ACLS
S u r ve ys (Bo x 2 )
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 )
IV Ac c e s s a n d
1 2 -Le a d ECG
(Bo x 5 )
De c is io n P o in t :
Na r r o w o r Wid e
(Bo x 6 , Bo x 7 )
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 )
128
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.
Un s ta b le
If the patient is unstable with s igns or s ymptoms as a res ult of the tachycardia (eg, hypo-
tens 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.
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).
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 cardiover-
s ion.
•  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 wide-
complex (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 con-
s 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 con-
sultation.
The mos t common forms of life-threatening wide-complex tachycardias likely to deterio-
rate 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, pre-
excited 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.
 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 diag-
nos is . IV antiarrhythmic drugs may be effective. We recommend procainamide, amioda-
rone, or s otalol. See the right column on the algorithm (Figure 36, page 127) for recom-
mended 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 fibrilla-
tion to s inus rhythm (rhythm control), or both. Expert cons ultation is advis ed.

Ca u t io n •  Avoid AV nodal blocking agents s uch as adenos ine, calcium channel blockers ,
digoxin, and pos s ibly ß-blockers in patients with pre-excitation atrial fibrillation,
Drug s to Avo id in becaus e thes e drugs may caus e a paradoxical increas e in the ventricular res pons e.
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 , The therapy for narrow QRS with regular rhythm is :

Re g u la r Rh yt h m •  Attempt vagal maneuvers
(Bo x 7 ) •  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 ec-
ond. 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 arrhyth-
mias 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
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
In t r o d u c t io n
130
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 ß-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.
•  AV nodal blocking drugs s hould not be us ed for pre-excited atrial fibrillation or flut-
ter. 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 ß-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 con-
trol 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
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 evalu-
ation of s troke patients . Thes e targets or goals s hould be achieved for at leas t 80% of
patients with acute s troke.

Le a r n in g Ob je c t ive s
P o t e n t ia l Ar r h yt h m ia s
Wit h S t r o k e
Dr u g s fo r S t r o k e
Fo u n d a t io n a l Fa c t s
Ma jo r Typ e s o f Stro ke
Th e ACLS Ca s e s : Ac u te Stroke
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 type–s 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 D’s 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
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 .
This cas e involves thes e drugs :
•  Approved fibrinolytic agent (rtPA)
•  Glucos e (D50 )
•  Labetalol
•  Nicardipine
•  Enalaprilat
•  As pirin
•  Nitroprus s ide
Stroke is a general term. It refers to acute neurologic impairment that follows interrup-
tion 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 occlu-
s 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 5
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 per-
s 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 t-
ever 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
Fo u n d a t io n a l Fa c t s
Stro ke Cha in o f Surviva l
132
10%
87% Is c he m ic
3% Intra c e re b ra l
Sub a ra c hno id
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.
The goal of s troke care is to minimize brain injury and maximize the patient’s recov-
ery. 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 recognition and reaction to s troke warning s igns
•  Rapid EMS dis patch
•  Rapid EMS s ys tem trans port and prearrival notification to the receiving hos pital
•  Rapid diagnos is and treatment in the hos pital
Fig u re 3 8 . The Stroke Chain of Survival.
 Th e ACLS Ca s e s : Ac u te Stroke

FYI 2 0 1 0 Gu id e lin e s •  The background and icons  in the figure depicting the s troke Chain of Survival  

(Figure 38) differ s lightly from thos e in the figure publis hed in the 2006 edition of the 
Stro ke Cha in o f Surviva l ACLS Provider Manual. The figure was  revis ed to enhance memorization and avoid 
confus ion with the adult Chain of Survival (Figure 6, page 26), which is  new to the 
2011 edition of the Provider Manual.

Fo u n d a t io n a l Fa c t s The 8 D’s  of Stroke Care highlight the major s teps  in diagnos is  and treatment of s troke 

and key points  at which delays  can occur:
The 8 D’s o f Stro ke Ca re
•  De te c tio n: Rapid recognition of s troke s ymptoms  
•  Dis p a tc h: Early activation and dis patch of EMS by 911
•  De live ry: Rapid EMS identification, management, and trans port
•  Do o r: Appropriate triage to s troke center
•  Da ta : Rapid triage, evaluation, and management within the ED
•  De c is io n: Stroke expertis e and therapy s election
•  Drug : Fibrinolytic therapy, intra-arterial s trategies
•  Dis p o s itio n: Rapid admis s ion to the s troke unit or critical care unit
For more information on thes e critical elements , s ee the Sus pected Stroke Algorithm 
(Figure 39).

Go a ls o f S t r o k e Ca r e The Sus pected Stroke Algorithm (Figure 39) emphas izes  important elements  of out-of-

hos pital care for pos s ible s troke patients . Thes e actions  include a s troke s cale or s creen 
and rapid trans port to the hos pital. As  with ACS, prior notification of the receiving hos pital 
s peeds  the care of the s troke patient upon arrival.

The NINDS has  es tablis hed critical in-hos pital time goals  for as s es s ment and manage-

ment of patients  with s us pected s troke. This  algorithm reviews  the critical in-hos pital time 
periods  for patient as s es s ment and treatment:

1. Immediate general as s es s ment by the s troke team, emergency phys ician, or another 

expert within 10 minutes of arrival; order urgent noncontras t CT s can

2. Neurologic as s es s ment by the s troke team or des ignee and CT s can performed with-

in 25 minutes of hos pital arrival

3. Interpretation of the CT s can within 45 minutes of ED arrival

4. Initiation of fibrinolytic therapy in appropriate patients  (thos e without contraindica-

tions ) within 1 hour of hos pital arrival and 3 hours from s ymptom ons et

5. Door-to-admis s ion time of 3 hours

133
 ACLS_Suspected_StrokeAlgo_NoTables.pdf 1 12/16/10 6:14 PM

P a r t 5

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
NINDS • Perform prehos pital s troke as s es s ment
TIME • Es tablis h time of s ymptom ons et (las t normal)
GOALS • Triage to s troke center
• Alert hos pital
• Check glucos e if pos s ible

ED
Arriva l
3

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
10 • As s es s ABCs , vital s igns
m in
• 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
ED
Arriva l 4
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
25 Canadian Neurological Scale)
m in

ED
Arriva l 5

45 Doe s CT s ca n s how he m orrha ge ?

m in
No He m o r r h a g e He m o r r h a g e

6 7
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 Cons ult neurologis t
or neuros urgeon;
• Check for brinolytic exclus ions
cons ider trans fer if
• Repeat neurologic exam: are de cits rapidly improving to normal?
not a vailable
8 9
P a tie n t re m a ins c a nd id a te for No t a Ca n d id a t e
b rin olytic th e ra p y? Adminis te r a s p irin
ED
Arriva l
60 m in 10 Ca n d id a t e 11
Re vie w ris ks /b e ne ts with p a tie n t a n d fa m ily. • Begin s troke or
If a c c e p ta b le : he morrhage pa thway
• Give rtPA • Admit to s troke unit or
• No anticoagulants or antiplatelet treatment for intens ive ca re unit
24 hours
Stro ke
Ad m is s io n
3 ho urs 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

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
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
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
Th e ACLS Ca s e s : Ac u te Stroke
•  The NINDS is  a branch of the National Ins titutes  of Health (NIH). Its  mis s ion is  to 
reduce the burden of neurologic dis eas e by s upporting and conducting res earch. 
NINDS res earchers  have s tudied s troke and reviewed data leading to recommenda-
tions  for acute s troke care. The NINDS has  s et critical time goals  for as s es s ment 
and management of s troke patients  bas ed on experience obtained in large s tudies  
of s troke patients .
Patients  with acute is chemic s troke have a time-dependent benefit for fibrinolytic therapy 
s imilar to that of patients  with ST-s egment elevation MI, but this  time-dependent benefit is  
much s horter. 
The critical time period for adminis tration of IV fibrinolytic therapy begins  with the ons et of 
s ymptoms . Critical time periods  from hos pital arrival are s ummarized below:
Im m e d ia te g e ne ra l a s s e s s m e nt 10 minutes
Im m e d ia te ne uro lo g ic a s s e s s m e nt 25 minutes
Ac q uis itio n o f CT o f the he a d 25 minutes
Inte rp re ta tio n o f the CT s c a n 45 minutes
Ad m inis tra tio n o f fib rino lytic the ra p y, tim e d fro m ED a rriva l 60 minutes
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 3 hours , or 4.5 
s ym p to m s hours  in s elected 
patients
Ad m is s io n to a m o nito re d b e d 3 hours
We will now dis cus s  the s teps  in the algorithm, as  well as  other related topics :
•  Identification of s igns  and s ymptoms  of pos s ible s troke and activation of emergency 
res pons e (Box 1)
•  Critical EMS as s es s ments  and actions  (Box 2)
•  Immediate general as s es s ment and s tabilization (Box 3)
•  Immediate neurologic as s es s ment by the s troke team or des ignee (Box 4)
•  CT s can: hemorrhage or no hemorrhage (Box 5)
•  Fibrinolytic therapy ris k s tratification if candidate (Boxes  6, 8, and 10)
•  General s troke care (Boxes  11 and 12)
The s igns  and s ymptoms  of a s troke may be s ubtle. They include
•  Sudden weaknes s  or numbnes s  of the face, arm, or leg, es pecially on one s ide of the 
body
•  Sudden confus ion
•  Trouble s peaking or unders tanding
•  Sudden trouble s eeing in one or both eyes
•  Sudden trouble walking
•  Dizzines s  or los s  of balance or coordination
•  Sudden s evere headache with no known caus e
135
 P a r t 5

Ac t iva t e EMS S ys t e m Stroke patients and their families mus t be educated to activate EMS as s oon as they
Im m e d ia t e ly 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 pi-
tal. 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 patient’s 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 The 2010 AHA Guidelines for CPR and ECC recommends that all EMS pers onnel be
To o ls trained to recognize s troke us ing a validated, abbreviated out-of-hos pital neurologic evalu-
ation 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 can’t 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 •  No rm a l—both s ides of face move
s mile (Figure 40) equally
•  Ab no rm a l—one s ide of face does not
move as well as the other s ide
Arm d rift: Patient clos es eyes and •  No rm a l—both arms move the s ame
extends both arms s traight out, with or both arms do not move at all (other
palms up, for 10 s econds (Figure 41) findings , s uch as pronator drift, may be
helpful)
•  Ab no rm a l—one 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 •  No rm a l—patient us es correct words
can’t teach an old dog new tricks ” with no s lurring
•  Ab no rm a l—patient 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: repro-
ducibility 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 5

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 To provide the bes t outcome for the patient with potential s troke:
As s e s s m e n t s a n d
Ac t io n s (Bo x 2 ) 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 hypox-
emic (eg, oxygen s aturation <94% ) s troke patients or thos e
patients with unknown oxygen s aturation.
P e rfo rm s tro ke Perform a rapid out-of-hos pital s troke as s es s ment (CPSS,
a s s e s s m e nt 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 Trans port the patient rapidly and cons ider triage to a s troke
c e nte r 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

Fo u n d a t io n a l Fa c t s
Stro ke Ce nte rs a nd
Stro ke Units
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
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 combi-
nation 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.
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 commu-
nity. 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 dedi-
cated unit with a s pecialized team.
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 5

Im m e d ia t e Ge n e r a l ED providers s hould do the following:

As s e s s m e n t a n d
S t a b iliz a t io n 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 Es tablis h IV acces s and obtain blood s amples for bas eline blood
a c c e s s a nd count, coagulation s tudies , and blood glucos e. Do not let this
o b ta in b lo o d delay obtaining a CT s can of the brain.
s a m p le s

Che c k g luc o s e Promptly treat hypoglycemia.

P e rfo rm Perform a neurologic s creening as s es s ment. Us e the NIH Stroke

ne uro lo g ic Scale (NIHSS) or a s imilar tool.
a s s e s s m e nt

Ac tiva te the Activate the s troke team or arrange cons ultation with a s troke
s tro ke te a m expert bas ed on predetermined protocols .

Ord e r CT b ra in Order an emergent CT s can of the brain. Have it read promptly by

scan a qualified phys ician.

Ob ta in 12-le a d Obtain a 12-lead ECG, which may identify a recent or ongoing

ECG 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 tran-
s 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 life-
threatening arrhythmias .

Life-threatening arrhythmias can follow or accompany s troke, par-

ticularly intracerebral hemorrhage. If the patient is hemodynami-
cally s table, treatment of non–life-threatening arrhythmias (brady-
cardia, 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 patient’s his tory, performs a general phys ical examination, and es tab-
lis 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 nt’s a rriva l in

th e ED: “Tim e Is Bra in ” (Box 4).

140

Es t a b lis h S ym p t o m
On s e t
Ne u r o lo g ic
Exa m in a t io n
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
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
Th e ACLS Ca s e s : Ac u te Stroke
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.
As s es s the patient’s 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 mea-
s 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.
A critical decis ion point in the as s es s ment of the patient with acute s troke is the perfor-
mance and interpretation of a noncontras t CT s can to differentiate is chemic from hemor-
rhagic s troke. As s es s ment als o includes identifying other s tructural abnormalities that may
be res pons ible for the patient’s 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 hem-
orrhage.
The CT s ca n s hould be c om ple te d within 25 m inute s of the pa tie nt’s 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).
Additional imaging techniques s uch as CT perfus ion, CT angiography, or magnetic res o-
nance 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 hem-
orrhage 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 inter-
vention, 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 5

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 pen-
umbra 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

Fib r in o lyt ic Th e r a p y
In t r o d u c t io n
Eva lu a t e fo r
Fib r in o lyt ic Th e r a p y
(Bo x 6 )
Th e ACLS Ca s e s : Ac u te Stroke
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 ymp-
toms , 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 rig-
orous 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 likeli-
hood 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 titu-
tional 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.
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 patient’s 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 >¹⁄³ cerebral hemis phere)
(continued)
143
 P a r t 5
P o t e n t ia l Ad ve r s e
Effe c t s
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 )
Ext e n d e d IV
r t PA Win d o w
3 t o 4 .5 Ho u r s
144
(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 ider-
ation and weighing of ris k to benefit—patients may receive fibrinolytic therapy des pite 1
or more relative contraindications . Cons ider ris k to benefit of rtPA adminis tration care-
fully 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, pro-
thrombin 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.
As with all drugs , fibrinolytics have potential advers e effects . At this point weigh the
patient’s 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.
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 titution’s 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 .
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 .

In t r a -a r t e r ia l r t PA
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 rec-
ommended if rtPA is adminis tered by phys icians in the s etting of a clearly defined proto-
col, 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 FDA–approved 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 ini-
tiated 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.
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 5
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
Be g in S t r o k e
P a t h w a y (Bo xe s 1 1
and 12)
Mo n it o r Blo o d
Glu c o s e
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
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
146
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.
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 neu-
ros urgery as appropriate.
Additional s troke care includes s upport of the airway, oxygenation, ventilation, and nutri-
tion. Provide normal s aline to maintain intravas cular volume (eg, approximately 75 to
100 mL/h) if needed.
Hyperglycemia is as s ociated with wors e clinical outcome in patients with acute is ch-
emic 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 u-
lin to lower blood glucos e in patients with acute is chemic s troke when the s erum glucos e
level is >185 mg/dL.
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.
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 lim-
ited, mos t patients with s us tained hypertens ion above thes e levels will not be eligible for
IV rtPA.
 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 5
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
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 c o r re c t ly
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 ventilation—rate 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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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 if d o n e
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
Ste p
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)
2 Tells s omeone to activate the emergency res pons e s ys tem and get an AED
3 Checks carotid puls e (minimum 5 seconds; maximum 10 seconds)
4 Bares patient’s ches t and locates CPR hand pos ition
5 Delivers firs t cycle of compres s ions at correct rate (acceptable: 18 seconds or less
for 30 compressions)
6 Gives 2 breaths (1 s econd each)

AED Ar r ive s
AED Turns AED on, s elects proper pads , and places pads correctly
1
AED Clears patient to analyze (must be visible and verbal check)
2
AED Clears patient to s hock/pres s es s hock button (must be visible and verbal check;
3 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)
8 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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
Ins tructor Signature: ________________________________________________
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
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
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 drug–rhythm check/s hock–CPR
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 (H’s and T’s )
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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
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 drug–rhythm check/s hock–CPR
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 (H’s and T’s )
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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
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 drug–rhythm check/s hock–CPR
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 (H’s and T’s )
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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
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 drug–rhythm check/s hock–CPR
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 (H’s and T’s )
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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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
Cr it ic a l P e r fo r m a n c e S t e p s c o r re c t ly
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 drug–rhythm check/s hock–CPR
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 (H’s and T’s )
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: P NR

Ins tructor s ignature affirms that s kills tes ts
were done according to AHA Guidelines .
Save this sheet with course record.
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

1
Sta rt CP R

Ye s No
2 ETCO
9

3
Sh oc k

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

ETCO

No
Sho c k Ene rg y

Ye s
5
Sh oc k

6 10

Ep ine p hrine
Ep ine p hrine
Drug The ra p y

No Ye s

Ye s
7
Sh oc k No

8 11

No Ye s
H
12 H
H
H
Go to 5 o r 7
H
T
10 11 T
T
T
T

158
 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
1
Sta rt CP R

30:2 compres s ion-

Ye s Rhythm No capnography
2 s ho c ka b le ? ETCO2
9 attempt to improve
VF/VT As ys to le /P EA

3
Shoc k

Re turn o f Sp o nta ne o us
4 Circ ula tio n (ROSC)
CP R 2 m in
increas e in P ETCO 2

Rhythm No
s ho c ka b le ? Sho c k Ene rg y

Ye s
5
Shoc k

-
6 10
CP R 2 m in CP R 2 m in
Ep ine p hrine every 3-5 min 360 J
Ep ine p hrine every 3-5 min
capnography Drug The ra p y
capnography

Va s o p re s s in
Rhythm No Rhythm Ye s
s ho c ka b le ? s ho c ka b le ?
epinephrine
Ye s
7
Shoc k No
Ad va nc e d Airwa y

8 11
CP R 2 m in CP R 2 m in
Am io d a ro ne

compres s ions
No Rhythm Ye s Re ve rs ib le Ca us e s
s ho c ka b le ? – H
– H
12 – H
– H
Go to 5 o r 7 – Hypothermia
– T
10 or 11 – T
– T
– T
© 2010 American Heart As s ociation – 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 t–Ca rd ia c Arre s t Ca re

1
Do s e s /De ta ils
Re turn o f Sp o nta ne o us Circ ula tio n (ROSC)
Ve ntila tio n/Oxyg e na tio n
Avoid exces s ive ventilation. 
2 Start at 10-12 breaths /min 
and titrate to target P e t c o 2
Op tim ize ve ntila tio n a nd o xyg e na tio n of 35-40 mm Hg.
When feas ible, titrate Fio 2
•  Maintain oxygen s aturation ≥94%
to minimum neces s ary to 
•  Cons ider advanced airway and waveform capnography
achieve Sp o 2 ≥94% .
•  Do not hyperventilate
IV Bo lus
1-2 L normal s aline 
or lactated Ringer’s .
3
If inducing hypothermia, 
Tre a t hyp o te ns io n (SBP <90 m m Hg ) may us e 4°C fluid.

•  IV/IO bolus Ep ine p hrine IV Infus io n:

0.1-0.5 mcg/kg per minute 
•  Vas opres s or infus ion
(in 70-kg adult: 7-35 mcg 
•  Cons ider treatable caus es per minute)
•  12-Lead ECG
Do p a m ine IV Infus io n:
5-10 mcg/kg per minute
5 4 No re p ine p hrine
No Fo llo w IV Infus io n:
Co ns id e r ind uc e d hyp o the rm ia c o m m a nd s ? 0.1-0.5 mcg/kg per minute 
(in 70-kg adult: 7-35 mcg 
per minute)
Ye s Re ve rs ib le Ca us e s
6 – Hypovolemia
7
– Hypoxia
Ye s STEMI
Co ro na ry re p e rfus io n – Hydrogen ion (acidos is )
OR 
high s us picion of AMI – Hypo-/hyperkalemia
– Hypothermia
– Tens ion pneumothorax
No – Tamponade, cardiac
8 – Toxins
– Thrombos is , pulmonary
Ad va nc e d c ritic a l c a re
– Thrombos is , coronary

© 2010 American Heart As s ociation

160
 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)
1

As s es s appropriatenes s for clinical condition.

Heart rate typically <50/min if bradyarrhythmia.

Id e ntify a nd tre a t und e rlying c a us e

•  Maintain patent airway; as s is t breathing as  neces s ary
•  Oxygen (if hypoxemic)
•  Cardiac monitor to identify rhythm; monitor blood pres s ure and oximetry
•  IV acces s
•  12-Lead ECG if available; don’t delay therapy

3
P e rs is te nt b ra d ya rrhythm ia
4 c a us ing :
No •  Hypotens ion?
Mo nito r a nd o b s e rve
•  Acutely altered mental s tatus ?
•  Signs of s hock?
•  Is chemic ches t dis comfort?
•  Acute heart failure?

5 Ye s
Do s e s /De ta ils
Atro p ine Atro p ine IV Do s e :
Firs t dos e: 0.5 mg bolus  
If atropine ineffective:
Repeat every 3-5 minutes  
 •  Trans cutaneous  pacing
Maximum: 3 mg
                 OR
•  Do p a m ine infus ion Do p a m ine IV Infus io n:
                 OR 2-10 mcg/kg per minute
•  Ep ine p hrine infus ion Ep ine p hrine IV Infus io n:
2-10 mcg per minute
6

Co ns id e r:
•  Expert cons 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.

Id e ntify a nd tre a t und e rlying c a u s e Do s e s /De ta ils

•  Maintain patent airway; as s is t breathing as  neces s ary Sync hro nize d Ca rd io ve rs io n

•  Oxygen (if hypoxemic) Initial recommend ed dos es :
•   C ard iac monitor to identify rhythm; monitor b lood  •  Narrow regular: 50-100 J
pres s ure and oximetry •   Narrow irregular: 120-200 J  b iphas ic 
or 200 J  monophas ic
•  Wide regular: 100 J
•   Wide irregular: defibrillation dos e
3 (NOT s ynchronized)

P e rs is te nt ta c hya rrhythm ia 4 Ad e no s ine IV Do s e :

c a us ing : Firs t dos e: 6 mg rapid IV pus h; follow 
Sync hro nize d c a rd io ve rs io n with NS flus h.
•  Hypotens ion? Ye s •  Cons ider s edation Second dos e: 12 mg if required .
•  Acutely altered mental s tatus ? •   If regular narrow complex, 
•  Signs  of s hock? cons ider adenos ine An tia rrh yth m ic In fu s ion s for
•  Is chemic ches t dis comfort? Sta b le Wid e -QRS Ta c h yc a rd ia
•  Acute heart failure?
6 P ro c a ina m id e IV Do s e :
20-50 mg/min until arrhythmia 
No •   IV acces s  and 12-lead ECG  s up pres s ed, hypotens ion ens ues , 
5
if availab le QRS duration increas es  >50% , or 
Wid e QRS? Ye s •   C ons ider adenos ine only if  maximum d os e 17 mg/kg given. 
≥0.12 s e c o nd regular and monomorp hic Maintenance infus ion: 1-4 mg/min. 
•  Cons ider antiarrhythmic infus ion Avoid if prolonged QT or CHF.
•  Cons ider exp ert cons ultation
Am io d a ro ne IV Do s e :
No Firs t dos e: 150 mg over 10 minutes . 
7
Repeat as  needed if VT recurs . 
•  IV acces s  and 12-lead ECG if available Follow by maintenanc e infus ion of 
•  Vagal maneuvers 1 mg/min for firs t 6 hours .
•  Adenos ine (if regular) So ta lo l IV Do s e :
•  ß-Blocker or calcium channel blocker 100 mg (1.5 mg/kg) over 5 minutes . 
•  Cons id er expert cons ultation Avoid if prolonged QT.
© 2010 American Heart As s ociation

162
 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 2 0 0 5 Gu id e lin e s 2 0 1 0 Gu id e lin e s
Sys te m a tic •   A-B-C-D: Airway, Breathing,  •  1-2-3-4
Ap p ro a c h: Circulation, Defibrillation 1. Che c k re s p o ns ive ne s s .
BLS Surve y •   “Look, lis ten, and feel” for  2. Ac tiva te the e m e rg e nc y
breathing and give 2 res cue  re s p o ns e s ys te m a nd g e t a n
breaths AED.
3. Circ ula tio n: Check the carotid 
puls e. If you cannot detect a 
puls e within 10 s econds , s tart 
CPR, beginning with ches t 
compres s ions , immediately. 
4. De fib rilla tio n: If indicated, 
deliver a s hock with an AED or 
defibrillator.

To p ic 2 0 1 0 Gu id e lin e s
BLS: •  A rate of a t le a s t 100 ches t compres s ions  per minute
Hig h-Qua lity CP R •  A compres s ion depth of a t le a s t 2 inc he s  in adults
•  Allowing complete ches t recoil after each compres s ion
•  Minimizing interruptions  in compres s ions  (10 s econds  or les s )
•  Switching providers  about every 2 minutes  to avoid fatigue 
•  Avoiding exces s ive ventilation
ACLS: •   The 2010 AHA Guidelines for CPR and ECC s implifies  the Cardiac Arres t 
Ca rd ia c Arre s t Alogorithm and includes  a circular algorithm.
a nd Bra d yc a rd ia •   The priority is  the 2-minute continuous  period of high-quality CPR and 
Alg o rithm s defibrillation.
•   All advanced interventions —including IV acces s , drug delivery, and 
advanced airways —s hould not interrupt ches t compres s ions  and s hocks .  
Rather, they s hould be performed or adminis tered s trategically a fte r the 
brief paus e for defibrillation.
•   Thes e actions  continue until ROSC, when healthcare providers  initiate 
pos t–cardiac arres t care protocols .
•   During cardiac arres t, providers  s hould adminis ter a vas opres s or every 
3 to 5 minutes . Epinephrine is  commonly us ed, although vas opres s in 
can replace the firs t or s econd dos e of epinephrine. Regardles s  of the 
vas opres s or given, one s hould be adminis tered every 3 to 5 minutes . 
ACLS providers  s hould adminis ter amiodarone for refractory VF and VT.
•   The American Heart As s ociation no longer recommends  atropine for 
routine us e in managing PEA or as ys tole.
•   For treatment of undifferentiated wide-complex tachycardia with regular 
rhythm, ACLS providers  can cons ider adenos ine in the initial treatment.
•   Atropine remains  the firs t-line treatment for all s ymptomatic bradycardias , 
regardles s  of type.
•   For s ymptomatic bradycardia, the American Heart As s ociation now 
recommends  IV infus ion of chronotropic agents  as  an equally effective 
alternative to external trans cutaneous  pacing when atropine is  ineffective.
(continued)

163
 (continued)

To p ic 2 0 1 0 Gu id e lin e s
ACLS: • The 2010 AHA Guidelines for CPR and ECC s implifies the Tachycardia
Ta c hyc a rd ia – Algorithm.
Sync hro nize d • For cardiovers ion of uns table atrial fibrillation, the 2010 AHA Guidelines
Ca rd io ve rs io n 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: A new s ection focus ing on pos t–cardiac arres t care was introduced in
P o s t–Ca rd ia c the 2010 AHA Guidelines for CPR and ECC. Recommendations aimed at
Arre s t Ca re 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 t–cardiac 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 t–cardiac 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 t–c 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: • The 2010 AHA Guidelines for CPR and ECC recommends us ing waveform
Ma na g ing capnography to monitor the amount of carbon dioxide exhaled by the
the Airwa y 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 • Integrated s ys tems of care s hould include community members , EMS,
P a tie nt Ca re : phys icians , and hos pitals .
Sys te m s o f Ca re

164
 ACLS P h a r m a c o lo g y S u m m a r y Ta b le
P re c a u t io n s /
Dr u g In d ic a t io n s Ad u lt Do s a g e
Co n t r a in d ic a t io n s
Ad e no s ine •  Firs t drug for mos t forms  of  •  Contraindicated in pois on/ IV Ra p id P us h
s table narrow-complex SVT.  drug-induced tachycardia or  •  Place patient in mild revers e 
Effective in terminating thos e  s econd- or third-degree heart  Trendelenburg pos ition before 
due to reentry involving AV  block adminis tration of drug
node or s inus  node •  Trans ient s ide effects  include  •  Initial bolus  of 6 mg given rap-
•  May cons ider for uns table  flus hing, ches t pain or tight- idly over 1 to 3 s econds  fol-
narrow-complex  reentry  nes s , brief periods  of as ys tole  lowed by NS bolus  of 20 mL; 
tachycardia while preparations   or bradycardia, ventricular  then elevate the extremity
are made for cardiovers ion ectopy •  A s econd dos e (12 mg) can 
•  Regular and monomorphic  •  Les s  effective (larger dos es   be given in 1 to 2 minutes  if 
wide-complex tachycardia,  may be required) in patients   needed
thought to be or previous ly  taking theophylline or caffeine
Inje c tio n Te c hniq ue
defined to be reentry SVT •  Reduce initial dos e to 3 mg in  •  Record rhythm s trip during 
•  Does  not convert atrial fibrilla- patients  receiving dipyridam- adminis tration
tion, atrial flutter, or VT ole or carbamazepine, in heart 
•  Draw up adenos ine dos e and 
•  Diagnos tic maneuver: s table  trans plant patients , or if given 
flus h in 2 s eparate s yringes
narrow-complex SVT by central venous  acces s
•  Attach both s yringes  to the 
•  If adminis tered for irregular, 
IV injection port clos es t to 
polymorphic wide-complex 
patient
tachycardia/VT, may caus e 
deterioration (including  •  Clamp IV tubing above 
hypotens ion)  injection port
•  Trans ient periods  of s inus   •  Pus h IV adenos ine as quickly
bradycardia and ventricular  as possible (1 to 3 s econds )
ectopy are common after  •  While maintaining pres s ure on 
 t ermination of SVT adenos ine plunger, pus h NS 
•  Safe and effective in  flus h as rapidly as possible
pregnancy after adenos ine
•  Unclamp IV tubing
Am io d a ro ne Becaus e its  us e is  as s ociated  Ca u tion : Multip le c o m p le x VF/VT Ca rd ia c Arre s t
with toxicity, amiodarone is   d rug inte ra c tio ns Unre s p o ns ive to CP R, Sho c k,
indicated for us e in patients   a nd Va s o p re s s o r
•  Rapid infus ion may lead to 
with life-threatening arrhythmias   hypotens ion •  Firs t d o s e : 300 mg IV/IO 
when adminis tered with appro- •  With multiple dos ing, cumu- pus h
priate monitoring: lative dos es  >2.2 g over 24  •  Se c o nd d o s e (if ne e d e d ): 
hours  are as s ociated with s ig- 150 mg IV/IO pus h
•  VF/puls eles s  VT unres pons ive 
nificant hypotens ion in clinical 
to s hock delivery, CPR, and a  Life -Thre a te ning Arrhythm ia s
trials
vas opres s or
•  Do not adminis ter with other  Ma xim um c um ula tive d o s e :
•  Recurrent, hemodynamically 
drugs  that prolong QT interval  2.2 g IV over 24 hours . May be 
uns table VT
(eg, procainamide)
With expert consultation amiod- adminis tered as  follows :
•  Terminal elimination is  
arone may be us ed for treatment  extremely long (half-life las ts   •  Ra p id infus io n: 150 mg IV 
of s ome atrial and ventricular  up to 40 days ) over firs t 10 minutes  (15 mg 
arrhythmias per minute). May repeat rapid 
infus ion (150 mg IV) every 10 
minutes  as  needed
•  Slo w infus io n: 360 mg 
IV over 6 hours  (1 mg per 
minute)
•  Ma inte na nc e infus io n: 540 
mg IV over 18 hours  (0.5 mg 
per minute)
(continued)

165
 (continued)

P re c a u t io n s /
Dr u g In d ic a t io n s Ad u lt Do s a g e
Co n t r a in d ic a t io n s
Atro p ine •  Firs t drug for s ymptomatic  •  Us e with caution in pres ence  Bra d yc a rd ia (With o r
Sulfa te s inus  bradycardia of myocardial is chemia and  Witho ut ACS)
Can be given •  May be beneficial in pres ence  hypoxia. Increas es  myocardial  •  0.5 mg IV every 3 to 5 min-
of AV nodal block. No t like ly oxygen demand utes  as  needed, not to exceed 
via endotra-
to b e e ffe c tive fo r typ e II •  Avoid in hypothermic  total dos e of 0.04 mg/kg (total 
cheal tube
s e c o nd -d e g re e o r third - bradycardia 3 mg)
d e g re e AV b lo c k o r a b lo c k •  May not be effective for  •  Us e s horter dos ing interval (3 
in no n-no d a l tis s ue infranodal (type II) AV block  minutes ) and higher dos es  in 
•  Routine us e during PEA or  and new third-degree block  s evere clinical conditions
as ys tole is  unlikely to have a  with wide QRS complexes .  Org a no p ho s p ha te P o is o ning
therapeutic benefit (In thes e patients  may caus e 
Extremely large dos es  (2 to 4 
•  Organophos phate (eg, nerve  paradoxical s lowing. Be 
prepared to pace or give  mg or higher) may be needed
agent) pois oning: extremely 
large dos es  may be needed catecholamines )
•  Dos es  of atropine <0.5 mg 
may res ult in paradoxical 
s lowing of heart rate
Do p a m ine •  Second-line drug for s ymp- •  Correct hypovolemia with  IV Ad m inis tra tio n
IV infusion tomatic bradycardia (after  volume replacement before  •  Us ual infus ion rate is  2 to 20 
atropine) initiating dopamine mcg/kg per minute
•  Us e for hypotens ion (SBP ≤70  •  Us e with caution in cardio- •  Titrate to patient res pons e; 
to 100 mm Hg) with s igns  and  genic s hock with accompany- taper s lowly
s ymptoms  of s hock ing CHF
•  May caus e tachyarrhythmias , 
exces s ive vas ocons triction
•  Do not mix with s odium 
bicarbonate
Ep ine p hrine •  Ca rd ia c a rre s t: VF, puls eles s   •  Rais ing blood pres s ure and  Ca rd ia c Arre s t
Can be given VT, as ys tole, PEA increas ing heart rate may  •  IV/IO d o s e : 1 mg (10 mL of 
via endotra- •  Sym p to m a tic b ra d yc a rd ia :  caus e myocardial is chemia,  1:10 000 s olution) adminis -
Can be cons idered after atro- angina, and increas ed myo- tered every 3 to 5 minutes  
cheal tube
pine as  an alternative infus ion  cardial oxygen demand during res us citation. Follow 
Available to dopamine •  High dos es  do not improve  each dos e with 20 mL flus h, 
s urvival or neurologic out- elevate arm for 10 to 20 s ec-
in 1:10 000 •  Se ve re hyp o te ns io n: Can be 
come and may contribute to  onds  after dos e
and 1:1000 us ed when pacing and atro-
pine fail, when hypotens ion  pos tres us citation myocardial  •  Hig he r d o s e : Higher dos es  
concentrations dys function (up to 0.2 mg/kg) may be 
accompanies  bradycardia, 
or with phos phodies teras e  •  Higher dos es  may be required  us ed for s pecific indications  
enzyme inhibitor to treat pois on/drug-induced  (ß-blocker or calcium channel 
s hock blocker overdos e)
•  Ana p hyla xis , s e ve re a lle rg ic
re a c tio ns : Combine with large  •  Co ntinuo us infus io n: Initial 
fluid volume, corticos teroids ,  rate: 0.1 to 0.5 mcg/kg per 
antihis tamines minute (for 70-kg patient: 7 to 
35 mcg per minute); titrate to 
res pons e
•  End o tra c he a l ro ute : 2 to 2.5 
mg diluted in 10 mL NS
P ro fo und Bra d yc a rd ia o r
Hyp o te ns io n
2 to 10 mcg per minute infus ion; 
titrate to patient res pons e
(continued)

166
(continued)

P re c a u t io n s /
Dr u g In d ic a t io n s Ad u lt Do s a g e
Co n t r a in d ic a t io n s
Lid o c a ine •  Alternative to amiodarone in  •  Co ntra ind ic a tio n:  Ca rd ia c Arre s t Fro m VF/VT
Can be given cardiac arres t from VF/VT Prophylactic us e in AMI is   •  Initial dos e: 1 to 1.5 mg/kg  
via endotra- •  Stable monomorphic VT with  contraindicated IV/IO
cheal tube pres erved ventricular function •  Reduce maintenance dos e  •  For refractory VF may give 
•  Stable polymorphic VT with  (not loading dos e) in pres ence  additional 0.5 to 0.75 mg/kg IV 
normal bas eline QT interval  of impaired liver function or LV  pus h, repeat in 5 to 10 min-
and pres erved LV function  dys function utes ; maximum 3 dos es  or 
when is chemia is  treated  •  Dis continue infus ion imme- total of 3 mg/kg
and electrolyte balance is   diately if s igns  of toxicity  P e rfus ing Arrhythm ia
corrected develop For s table VT, wide-complex 
•  Can be us ed for s table poly- tachycardia of uncertain type, 
morphic VT with bas eline 
s ignificant ectopy:
QT-interval prolongation if tor-
s ades  s us pected •  Dos es  ranging from 0.5 to 
0.75 mg/kg and up to 1 to 1.5 
mg/kg may be us ed
•  Repeat 0.5 to 0.75 mg/kg 
every 5 to 10 minutes ; maxi-
mum total dos e: 3 mg/kg
Ma inte na nc e Infus io n
1 to 4 mg per minute (30 to 50 
mcg/kg per minute)
Ma g ne s ium •  Recommended for us e in car- •  Occas ional fall in blood pres - Ca rd ia c Arre s t
Sulfa te diac arres t only if tors ades  de  s ure with rapid adminis tration (Due to Hyp o m a g ne s e m ia o r
pointes  or s us pected hypo- •  Us e with caution if renal fail- To rs a d e s d e P o inte s )
magnes emia is  pres ent ure is  pres ent 1 to 2 g (2 to 4 mL of a 50%  
•  Life-threatening ventricular 
s olution diluted in 10 mL [eg, 
arrhythmias  due to digitalis  
toxicity D5 W, normal s aline] given IV/IO)
•  Routine adminis tration in hos - To rs a d e s d e P o inte s
pitalized patients  with AMI is   With a P uls e o r AMI With
no t recommended
Hyp o m a g ne s e m ia
•  Loading dose of 1 to 2 g mixed 
in 50 to 100 mL of diluent  
(eg, D5 W, normal s aline) over 
5 to 60 minutes  IV
•  Follow with 0.5 to 1 g per 
hour IV (titrate to control 
tors ades )
Va s o p re s s in •  May be us ed as  alternative  •  Potent peripheral vas ocon- IV Ad m inis tra tio n
Can be given pres s or to epinephrine in  s trictor. Increas ed peripheral  Ca rd ia c a rre s t: One dos e of 40 
via endotra- treatment of adult s hock- vas cular res is tance may pro- units  IV/IO pus h may replace 
refractory VF voke cardiac is chemia and 
cheal tube either firs t or s econd dos e of 
•  May be us eful alternative to  angina
epinephrine. Epinephrine can be 
epinephrine in as ys tole, PEA •  Not recommended for res pon-
s ive patients  with coronary  adminis tered every 3 to 5 min-
•  May be us eful for hemody-
artery dis eas e utes  during cardiac arres t
namic s upport in vas odilatory 
s hock (eg, s eptic s hock) Va s o d ila to ry s ho c k: 
Continuous  infus ion of 0.02 to 
0.04 units  per minute

167

Ac ute
Ac ute m yo c a rd ia l infa rc tio n
(AMI)
Ad va nc e d c a rd io va s c ula r life
s up p o rt (ACLS)
As ys to le
Atria l fib rilla tio n
Atria l flutte r
Atrio ve ntric ula r b lo c k
Auto m a te d e xte rna l
d e fib rilla to r (AED)
Ba s ic life s up p o rt (BLS)
Bra d yc a rd ia
Ca p no g ra p hy
Ca rd ia c a rre s t
Ca rd io p ulm o na ry
re s us c ita tio n (CP R)
Co ro na ry s ynd ro m e
Co ro na ry thro m b o s is
Ele c tro c a rd io g ra m (ECG)
Enc e p ha lo p a thy
End o tra c he a l intub a tio n
Es o p ha g e a l d e te c to r d e vic e
Es o p ha g e a l-tra c he a l tub e
168
Glo s s a r y
A
Having a s udden ons et and s hort cours e
The early critical s tage of necros is of heart mus cle tis s ue caus ed by blockage of a
coronary artery
Emergency medical procedures in which bas ic life s upport efforts of CPR are s upple-
mented with drug adminis tration, IV fluids , etc
Abs ence of electrical and mechanical activity in the heart
In atrial fibrillation the atria “quiver” chaotically and the ventricles beat irregularly
Rapid, irregular atrial contractions due to an abnormality of atrial excitation
A delay in the normal flow of electrical impuls es that caus e the heart to beat
A portable device us ed to res tart a heart that has s topped
B
Emergency treatment of a victim of cardiac or res piratory arres t through cardiopulmo-
nary res us citation and emergency cardiovas cular care
Slow heartbeat, whether phys iologically or pathologically
C
The meas urement and graphic dis play of CO 2 levels in the airways , which can be per-
formed by infrared s pectros copy
Temporary or permanent ces s ation of the heartbeat
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
A group of clinical s ymptoms compatible with acute myocardial is chemia (als o called
coronary heart disease)
The blocking of the coronary artery of the heart by a thrombus
E
A tes t that provides a typical record of normal heart action
Degeneration of brain function. Als o called cephalopathy, cerebropathy.
The pas s age of a tube through the nos e or mouth into the trachea for maintenance of
the airway
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
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 95°F
(35°C)
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 patient’s body temperature is between 90 and 95°F
Mo d e ra te hyp o the rm ia When the patient’s body temperature is between 86 and 90°F

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 Continued electrical rhythmicity of the heart in the abs ence of effective mechanical
(P EA) function

R
Re c o m b ina nt tis s ue A clot-dis s olving s ubs tance produced naturally by cells in the walls of blood ves s els
p la s m ino g e n a c tiva to r (rtPA)

S
Se ve re hyp o the rm ia When the patient’s body temperature is <86°F
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
Ta c hyc a rd ia
Ta m p o na d e (c a rd ia c )
Te ns io n p ne um o tho ra x
Thro m b us
Uns ync hro nize d s ho c k
Ve ntric ula r fib rilla tio n (VF)
Ve ntric ula r ta c hyc a rd ia (VT)
170
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
Increas ed heartbeat, us ually ≥100/min
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 heart’s ability to pump s uf-
ficient blood.
Pneumothorax res ulting from a wound in the ches t wall which acts as a valve that per-
mits air to enter the pleural cavity but prevents its es cape
A blood clot formed within a blood ves s el
U
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 car-
diac cycle.
V
Very rapid uncoordinated fluttering contractions of the ventricles
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 tilt–chin 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 45

172
 In d e x
Abbreviations us ed, 7-9 emergency department as s es s ment and treatment in, 29,
ABCD approach, 7, 163 94, 99-100
Accelerated idioventricular rhythm (AIVR), 7, 113 emergency medical s ervices in, 29, 92, 95, 96-98; algorithm
ACE inhibitors in acute coronary s yndromes , 94, 103 on, 94
Acetyls alicylic acid 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 primary, 92, 93, 102; res cue, 102; in ST-s egment
as ys tole/PEA in, 83 elevation, 100, 101, 102-103
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159 puls eles s electrical activity in, 85
Pos t–Cardiac Arres t Care Algorithm on, 73, 160 s igns and s ymptoms in, 96
ACLS. See Advanced cardiovas cular li e s upport time to treatment in, 94, 95, 99, 100, 101; in f brinolytic
ACLS cas es , 33-147 therapy, 102; in percutaneous coronary interventions ,
on acute coronary s yndromes , 91-104 102-103
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 algorithm on, 118, 127, 162
overview o , 33 ß-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 s urvey in (see ACLS Survey)
abbreviations us ed in, 7-9 s ys temic approach in, 11
ACLS Survey, 11, 14-16 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 t–cardiac 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 tachycardia with puls e, 119, 128; algorithm on, 118,
in prehos pital care, 97-98; in ST-s egment elevation, 127, 162
100, 101 in ventricular f brillation/puls eles s VT, 61, 66, 158

173
 I n d e x
AIVR (accelerated idioventricular rhythm), 7, 113
Algorithms
on acute coronary s yndromes , 94, 95-104
on as ys tole, 60, 61, 79, 86, 88-89, 159
on bas ic li e s upport, 52-53
on bradycardia, 108-112, 161
on pos t–cardiac arres t care, 72-77, 160
on puls eles s electrical activity, 60, 61, 78, 79-82, 159
on s troke, 133-147
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
Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159
in tachycardia with puls e, 129; algorithm on, 118, 127, 162
in ventricular brillation/puls eles s VT, 66, 72, 158, 165
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
in tachycardia with puls e, 129; algorithm on, 118, 127, 162
in ventricular brillation/puls eles s VT, 65-66, 71-72
Anti-inf ammatory drugs , nons teroidal, 8
contraindications in ACS, 98
Arm dri t in s troke, 136, 137
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
common caus es o , 86, 88
de nition o , 168
drug therapy in, 86, 88; algorithm on, 61, 80, 82, 159
duration o res us citation e orts in, 87, 90
ethical is s ues in, 90
Megacode evaluation o s kills in, 153
termination o res us citation e orts in, 86, 87, 89-90
trans port o patients in, 91
treatment s equence in, 82, 86, 89
Atheros cleros is , acute coronary s yndromes in, 93
Atrial brillation and f utter, 114, 124, 128
cardiovers ion in, 116, 121, 122, 123
de nitions o , 168
drug therapy in, 129
s troke in, 131, 140
Atrioventricular block
bradycardia in, 105, 106, 111, 112, 113
de nition o , 168
174
drug therapy in, 111
rs t-degree, 105, 106
s econd-degree, 105, 106, 111, 112, 114
third-degree, 105, 106, 111, 112, 114
trans cutawneous pacing in, 112, 113, 114
Atrioventricular nodal blocking drugs , precautions in us e
o , 129, 130
Atrioventricular nodal reentry tachycardia, 124
Atropine s ul ate, 166
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
ches t hair a ecting, 57-58
de nition o , 168
electrode pad placement, 55, 56, 57
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
univers al s teps in operation o , 55-56
in ventricular brillation/puls eles s VT: and CPR, 52, 53, 54,
57; and lone res cuer, 49-58; s teps in us e o , 55-57;
troubles hooting problems with, 57
water a ecting, 58
Bag-mas k ventilation, 36, 41, 42, 151
in cardiac arres t, 36, 47
E-C clamp technique, 41
in 2 res cuers , 41
Bas ic li e s upport, 7
de nition o , 168
prerequis ite s kills required, 2
s ummary o 2010 Guidelines on, 163
s urvey in (see BLS Survey)
s ys temic approach in, 11
Benchmarks on CPR per ormance and outcome, 27
ß-Blockers
in acute coronary s yndromes , 94, 103
in tachycardia, 125, 129, 130; algorithm on, 118, 127, 162
Biphas ic de brillators , 63, 66
Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159
Blood pres s ure, 9
in hypotens ion (see Hypotens ion)
in pos t–cardiac arres t care, 28, 73, 76, 160
in res piratory arres t, 37
in s troke, 146-147
BLS. See Bas ic li e s upport
BLS Survey, 11, 12-14
 In d e x

in as ys tole, 81, 88, 89 arterial partial pres s ure (Paco 2 ), 9; in pos t–cardiac arres t
in bradycardia, 108, 110 care, 28, 74
changes in 2010 Guidelines on, 12, 163 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 t–cardiac 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 Cardiac arres t, 28-29
in ventricular f brillation/puls eles s VT, 50-57, 62 in acute coronary s yndromes , 92
Bradycardia, 104-114 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 t–cardiac arres t care, 28-29, 72-77 (see also Pos t–
nitroglycerin precautions in, 97; and trans cutaneous cardiac arres t care)
pacing, 113; in treatment s equence, 110, 111, 112 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 Cardiac Arres t Algorithm, 163
trans cutaneous pacing in, 108, 110, 111, 112-114; in as ys tole, 60, 61, 79, 86, 88-89, 159
algorithm on, 109, 161 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 in ventricular f brillation/puls eles s VT, 60-69, 158
changes in 2010 Guidelines , 109, 163 Cardiac Arres t Regis try to Enhance Survival (CARES), 7, 27
Breathing as s es s ment, 15 Cardiac output, 76, 125
agonal gas ps in, 55 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 high-quality, 14, 52, 62, 163
algorithm on, 118, 127, 162 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 t–cardiac 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 airway, 48
Carbon dioxide in s troke, 136
175
 I n d e x
s ummary o 2010 Guidelines on, 163
s ys tems approach to, 26
team approach to, 3, 17-23
in ventricular f brillation/puls eles s VT: AED us e with, 52,
53, 54, 57; Cardiac Arres t Algorithm on, 61, 62-63, 66,
158; drug therapy with, 65-66; and lone res cuer, 49-58;
manual def brillator us e with, 59, 61, 62-63, 64, 65,
66; phys iologic monitoring during, 67-69; in treatment
s equence, 66
Cardiovers ion
in s table tachycardia, 116
s ynchronized: changes in 2010 Guidelines , 164; compared
to uns ynchronized, 121; def nition o , 169; potential
problems in, 121; Tachycardia With Puls e Algorithm on,
118, 127, 162; in uns table tachycardia, 118, 120, 121,
122-123
in uns table tachycardia, 114, 119, 120-123; algorithm on,
118; indications or, 116, 121; s ynchronized s hocks
in, 118, 120, 121, 122-123; uns ynchronized s hocks in,
120, 121
CARES (Cardiac Arres t Regis try to Enhance Survival), 7, 27
Carotid puls e, 13
in res piratory arres t, 35
in trans cutaneous pacing, 112
in ventricular f brillation/puls eles s VT, 51
Catheterization
or airway s uctioning, 45
intraos s eous (see Intraos s eous acces s )
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
coronary per us ion pres s ure in, 62
in high-quality CPR, 14, 163
minimizing interruptions in, 12, 13, 14, 81
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 ventricular f brillation/puls eles s VT, 50, 51, 158; and
AED us e, 52, 53, 56, 57; in cycles o CPR, 56, 64, 65;
and manual def brillator us e, 59, 62-63; minimizing
interruptions in, 62, 65; phys iologic monitoring during,
67-69
Ches t hair a ecting AED us e, 57-58
176
Ches t pain and dis com ort
in acute coronary s yndromes , 96; nitroglycerin in, 98
in bradycardia, 107, 110, 113, 161; algorithm on, 109, 161
in tachycardia, 115, 117, 119; algorithm on, 118, 127
Cincinnati Prehos pital Stroke Scale (CPSS), 7, 136-138
Circulation
in ACLS Survey, 16, 37
in BLS Survey, 13, 35
in bradycardia, 110
in res piratory arres t, 35, 37
return o s pontaneous circulation (see Return o
s pontaneous circulation)
Clarity o communication in res us citation team, 19
Clopidogrel in acute coronary s yndromes , 94, 103
Clos ed-loop communication in res us citation team, 19
Communication in res us citation team, 19
clarity o mes s ages in, 19
cons tructive interventions in, 22
delegation o roles and res pons ibilities in, 20-21
knowledge s haring in, 22
mutual res pect in, 23
on patient s tatus , 22, 23
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
Cons tructive interventions in res us citation team, 22
Cons ultation with expert
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 t–Cardiac Arres t Care Algorithm on, 73, 160
CPR, 7, 168. See also Cardiopulmonary res us citation
CPSS (Cincinnati Prehos pital Stroke Scale), 7, 136-138
Cricoid pres s ure, 48
Def brillation, 13
in as ys tole/puls eles s electrical activity, 80, 89, 159
with automated external def brillator (see Automated
external def brillator)
with implanted device, a ecting AED us e, 58
in res piratory arres t, 34, 35, 37
in ventricular f brillation/puls eles s VT: algorithm on, 61,
158; with automated external def brillator, 49-58; in

BLS Survey, 51; clearing warning in, 56, 64; and drug
therapy, 65-66; early, importance o , 54; and lone
res cuer, 49-58; with manual de brillator, 59, 61, 62-63,
64, 66, 158; purpos e o , 54; treatment s equence in, 57
Di erential diagnos is in ACLS Survey, 16
in bradycardia, 108
in res piratory arres t, 37
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 t–cardiac arres t care, 73, 76, 160
Drug overdos e, 84, 85, 90
Drug therapy, 165-167
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
in bradycardia (see Bradycardia, drug therapy in)
in pos t–cardiac arres t care, 73, 76, 160
prerequis ite knowledge required, 3
in puls eles s electrical activity, 78, 81; algorithm on, 61, 80,
82, 159
in s table tachycardia, 125, 129-130; algorithm on, 118, 127
in s troke (see Stroke, drug therapy in)
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)
ECASS (European Cooperative Acute Stroke Study), 144, 145
Edema, pulmonary, de nition o , 169
Education, community and pro es s ional, on s troke, 30, 132
Electrocardiography, 8, 168
in acute coronary s yndromes , 91, 92, 95; algorithm on, 94;
in emergency department, 99; in prehos pital care, 98;
ris k clas s i cation bas ed on, 101-102
in as ys tole, 86, 87
in bradycardia, 105, 106, 110; algorithm on, 109, 161
de nition o , 168
prerequis ite interpretation s kills required, 3
in puls eles s electrical activity, 83-84
in s table tachycardia, 128
in s troke, 131, 134, 140
technical problems in, 87
in uns table tachycardia, 114, 117, 118, 119; and
s ynchronized cardiovers ion, 121
in ventricular brillation/puls eles s VT, 60
In d e x
Electrode pad placement in AED us e, 55, 56, 57
Electromechanical dis s ociation, 79
Embolis m, pulmonary, 9, 84, 85. See also Pulmonary
thromboembolis m
Emergency department as s es s ment and treatment
in acute coronary s yndromes , 29, 94, 99-100
in s troke, 134, 139-140
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
Enalaprilat in s troke, 131
Encephalopathy, 168
End-tidal carbon dioxide. See Carbon dioxide, end-tidal partial
pres s ure
Endotracheal intubation
as s es s ment o tube placement in, 37, 48, 76
de nition o , 168
in pos t–cardiac arres t care, 74, 75
in res piratory arres t, 36, 47, 48; s uctioning procedure in, 46
in ventricular brillation/puls eles s VT, 69, 70
Epiglottis , airway obs truction rom, 39
Epinephrine, 166
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 t–cardiac arres t care, 73, 76, 160
in ventricular brillation/puls eles s VT, 61, 65, 66, 70, 71, 158
Es cape rhythms in bradycardia, 112, 113
Es ophageal detector device, 168
Es ophageal-tracheal tube, 168
in res piratory arres t, 36, 47, 48
Ethical is s ues in as ys tole, 90
European Cooperative Acute Stroke Study, 144, 145
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
Facial droop in s troke, 136, 137
Fibrillation
atrial (see Atrial brillation and f utter)
ventricular (see Ventricular brillation and tachycardia)
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 t–cardiac 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 Hypothermia, 169
Fixation errors in res us citation team, 22 bradycardia and trans cutaneous pacing contraindication in,
Fluid adminis tration 112
in pos t–cardiac 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 t–Cardiac 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 t–cardiac arres t care, 28 Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
in s troke, 134, 139, 140, 146 Pos t–Cardiac 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 tilt–chin li t maneuver, 36, 39, 40, 49 Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Heart ailure, acute, 7 Pos t–Cardiac Arres t Care Algorithm on, 73, 160
bradycardia algorithm on, 109, 161
in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162 Idioventricular rhythm, accelerated, 7, 113
Heparin, 8, 9 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 , Intens ive care unit, 8
94, 103 trans er to, pos t–cardiac arres t, 77
Hos pital s etting 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 t–cardiac arres t care, 73, 76, 160
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159 in res piratory arres t, 37
Pos t–Cardiac 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 t–Cardiac Arres t Care Algorithm on, 73, 160 Labetalol in s troke, 131, 147
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 Lay res cuer AED programs , 54
178
 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 National Ins titute o Neurological Dis orders and Stroke (NINDS),
Lone res cuer, 15 8, 30, 130, 133, 135, 143, 145
in res piratory arres t, 40 National Ins titutes o Health Stroke Scale (NIHSS), 8, 140, 141,
s kill checklis t on, 152 143
in ventricular f brillation/puls eles s VT, 49-58 Neurologic as s es s ment
in cardiac arres t, 29, 77
Magnes ium s ul ate, 167 in s troke, 134, 135, 136-138, 140-141, 143
in tors ades de pointes , 66, 72, 167 Nicardipine in s troke, 131, 147
Meas urements on CPR per ormance and outcomes , 27 NIHSS (National Ins titutes o Health Stroke Scale), 8, 140,
Medical emergency teams , 8, 26 141, 143
in cardiac arres t, 31, 32 NINDS (National Ins titute o Neurological Dis orders and
Megacode evaluation, 2, 153-157 Stroke), 8, 30, 130, 133, 135, 143, 145
Mental s tatus alteration 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 Non–ST-s egment elevation myocardial in arction (NSTEMI), 8,
Monophas ic def brillators , 63, 66 93, 95, 101
Cardiac Arres t Algorithm on, 61, 80, 82, 158, 159 Norepinephrine in pos t–cardiac arres t care, 73, 76, 160
Morphine in acute coronary s yndromes , 94, 97-98, 100 NSTEMI (non–ST-s egment elevation myocardial in arction), 8,
Mouth-to-mas k ventilation, 40 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 t–Cardiac 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 precautions in, 43, 45
in erior wall, 97 s ize s election, 43
non–ST-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 t–cardiac arres t care, 73, 74,
ST-s egment depres s ion in, 91, 94, 101, 102 160
ST-s egment elevation in (see ST-s egment elevation Oxygen therapy, 15
myocardial in arction) 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 t–cardiac 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 Pacing
ins ertion technique, 44 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
Patch or trans dermal medications , AED us e in, 58
PEA. See Puls eles s electrical activity
Percutaneous coronary interventions , 9
in acute coronary s yndromes , 93, 102-103; as primary
therapy, 92, 93, 102; as res cue therapy, 102; in ST-
s egment elevation, 100, 101, 102-103
in pos t–cardiac arres t care, 28
Per us ion, def nition o , 169
Pharmacology. See Drug therapy
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
as ys tole/PEA in, 83, 84, 85
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos t–Cardiac Arres t Care Algorithm on, 73, 160
Pocket Re erence Cards , 6
Pos t–cardiac arres t care, 28-29, 72-77
changes in 2010 Guidelines , 164
critical actions in, 164
learning s tation checklis t on, 160
Megacode evaluation o s kills in, 153-157
trans port o patients or, 91
Pos t–Cardiac Arres t Care Algorithm, 72-77, 160
Practice learning s tations , 2
Precours e Preparation Checklis t, 6
Prerequis ite knowledge and s kills required or Provider Cours e,
2-3
s el -as s es s ment o , 2-3, 5
Procainamide in tachycardia with puls e, 129
algorithm on, 118, 127, 162
Prophylaxis , def nition o , 169
Provider Cours e, 1-9
abbreviations us ed in, 7-9
ACLS cas es in, 33-147 (see also ACLS cas es )
completion requirements in, 7
components o , 2
critical concepts in, 4
des cription o , 1
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
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
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos t–Cardiac Arres t Care Algorithm on, 73, 160
Puls e checks , 13
in as ys tole, 86, 88
in puls eles s electrical activity, 81
in res piratory arres t, 34, 35
in s table tachycardia, 126
in uns table tachycardia, 114, 116, 117
in ventricular f brillation/tachycardia, 50, 51; BLS algorithms
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
drug therapy in, 78, 80, 81
his torical des cription o , 79
Megacode evaluation o s kills in, 154-157
rhythms included in, 78
treatment s equence in, 81, 82, 89
Puls eles s ventricular tachycardia, 49-77
lone res cuer CPR and AED us e in, 49-58
re ractory, 59-77
QRS complex, in tachycardia, 117, 118, 120, 124, 128-129
algorithm on, 118, 127, 162
and s ynchronized cardiovers ion, 121, 122
Quality improvement in CPR, 25, 27
Rapid res pons e teams , 9, 26-27
in cardiac arres t, 31, 32
Recombinant tis s ue plas minogen activator. See Tis s ue
plas minogen activator, recombinant
Re ractory VF/puls eles s VT, 59-77
Regional care s ys tems
in cardiac arres t, 32
in s troke, 30
Reper us ion therapy
in acute coronary s yndromes , 92, 93, 100-101; f brinolytics
in, 92, 93, 98, 100, 101, 102; percutaneous coronary
interventions in, 92, 93, 100, 101, 102-103
in acute s troke, 147; f brinolytics in, 130, 131, 134, 135,
141, 143-145, 146
in pos t–cardiac arres t care, 28, 73, 77, 160
Res cue breathing, 12, 13
in cardiac arres t, 36, 47

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
Res pect in res us citation team, 23
Res piratory arres t, 34-49
ACLS Survey in, 36-37, 151
airway as s es s ment and management in, 36, 38-49
BLS Survey in, 34-36, 151
critical concepts in, 38
lone res cuer in, 40
oxygen therapy in, 37, 38
in trauma, 39, 49
Res pons ivenes s as s es s ment, 13
in pos t–cardiac arres t care, 73, 76
in res piratory arres t, 35; and nas opharyngeal airway, 43;
and oropharyngeal airway, 42, 43
in ventricular f brillation/puls eles s VT, 51, 52, 53
Reteplas e in acute coronary s yndromes , 102
Return o s pontaneous circulation, 9
in as ys tole/puls eles s electrical activity, 61, 80, 82, 90, 159
in in-hos pital cardiac arres t, 30
Megacode evaluation o s kills in, 153-157
in out-o -hos pital cardiac arres t, 91
pos t–cardiac arres t care in, 28, 72-77, 160
in ventricular f brillation/puls eles s VT, 61, 63, 66, 67-69, 158
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
Sa ety concerns in BLS Survey, 12
Sedation
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
on cours e prerequis ite s kills , 2-3, 5
on res us citation team s kills , 21
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
In d e x
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
ST-s egment depres s ion myocardial in arction, 91, 94, 101, 102
ST-s egment elevation myocardial in arction, 9, 29, 91-104
adjunctive therapy in, 103-104
algorithm on, 94
electrocardiography and ris k clas s if cation in, 101
emergency department as s es s ment and treatment in,
99-100
emergency medical s ervices in, 96-98
goals o therapy in, 93
percutaneous coronary interventions in, 92
Pos t–Cardiac Arres t Care Algorithm on, 73, 77
reper us ion therapy in, 100-101, 102-103
Stable tachycardia, 124-130
algorithm on, 118, 127
Statin therapy in acute coronary s yndromes , 94, 103
STEMI. See ST-s egment elevation myocardial in arction
Streptokinas e in acute coronary s yndromes , 102
Stroke, 30, 130-147
algorithm on, 133-147
arrhythmias in, 131, 140
as s es s ment tools in, 136-138
Chain o Survival in, 132-133
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,
146-147; inclus ion criteria on, 143, 145; intra-arterial
adminis tration o , 145; time to treatment in, 135, 143,
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
goals o care in, 132, 133
hemorrhagic, 131, 132, 134, 140; computed tomography in,
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 s upraventricular (see Supraventricular tachycardia)
trans port o patients in, 136; to s troke centers and s troke uns table, 114-123; algorithm on, 116-120; cardiovers ion
units , 138, 139 in, 114, 116, 119, 120-123; di erentiated rom s table
Student Webs ite, 2, 3, 5-6 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 ventricular, 9, 170 (see also Ventricular f brillation and
on f brinolytic therapy, 98 tachycardia)
on heparin therapy, 104 wide-complex, 114, 118, 120, 124, 128-129, 130
on intraos s eous acces s , 70 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 Pos t–Cardiac Arres t Care Algorithm on, 73, 160
di erentiated rom VT, 120, 128 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 Tenecteplas e in acute coronary s yndromes , 102
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 pulmonary (see Pulmonary thromboembolis m)
s table, 124-130; advanced management in, 130; algorithm Tis s ue plas minogen activator, recombinant, 9
on, 118, 126-130; cardiovers ion in, 116; clas s if cation in acute coronary s yndromes , 102
182

def nition o , 169
in s troke, 30, 134, 141, 143-145; algorithm on, 134;
hypertens ion management in, 146-147; intra-arterial
adminis tration o , 145
Tongue, airway obs truction rom, 38, 39, 40, 42
Tors ades de pointes , 128
magnes ium s ul ate in, 66, 72, 167
Toxic conditions
as ys tole/PEA in, 83, 84, 85
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos t–Cardiac Arres t Care Algorithm on, 73, 160
Tracheal intubation. See Endotracheal intubation
Trans dermal medication patches , AED us e in, 58
Trans port o patients
in cardiac arres t, 91
s pinal immobilization in, 49
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
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
Vagal maneuvers in tachycardia, 129
algorithm on, 118, 127, 162
Vas opres s in, 167
in as ys tole, 88, 159
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
in as ys tole, 88
in puls eles s electrical activity, 81
in ventricular f brillation/puls eles s VT, 65, 70-71
Ventilation techniques
bag-mas k ventilation in (see Bag-mas k ventilation)
compres s ion-ventilation ratio in, 48, 61, 80, 82, 158, 159
coronary per us ion pres s ure in, 62
in pos t–cardiac 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
In d e x
manual def brillator us e, 59; rate o breaths in, 51
Ventricular f brillation and tachycardia, 49-77
abbreviations or, 9, 170
ACLS Survey in, 62
BLS Survey in, 50-57, 62
in bradycardia with es cape rhythms , 113
Cardiac Arres t Algorithm in, 60-69, 158
cycles o CPR in, 64, 65
def nitions o , 170
drug therapy in, 60, 65-66, 69-72; algorithm on, 61, 65-66,
158; antiarrhythmics in, 65-66, 71-72; hypothermia
a ecting, 69; routes o acces s or, 69-70; in treatment
s equence, 66, 69; vas opres s ors in, 65, 70-71
in hypothermia, 69
lone res cuer CPR and AED us e in, 49-58
manual def brillators in, 59, 61, 62-63; biphas ic, 61, 63,
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;
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
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
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
Wenckebach atrioventricular block, 105
Withdrawal o li e-s us taining care
in as ys tole, 87
pos t–cardiac arres t, 29
Yankauer catheters , 45, 46
183
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