ACLS Manual2021

FOREWORD
An Ongoing Evolution
S
ince the establishment of the Council of all health care providers. All modules can be
Cardiopulmonary Resuscitation of the PHA in accessed through online registration through our
1982, its main flagship purpose is the PHA website and are presented in self- paced
continuous education and training of healthcare didactic instructional videos that the participants
professionals in the field of Resuscitation Science must complete before undergoing subsequent
specifically Basic and Advanced Cardiac Life scheduled face to face workshops and megacode
Support. The formal training program simulation examinations by our excellent trainers.
methodologies gradually evolved to more
comprehensive but practical hands-on skills All participants completing the didactic and
training. The basic traditional facilitator-driven scheduled face to face examinations will be given
training program has been strengthened by year formal certifications as proficient BLS and ACLS
2000 through its Training the Trainers program. providers by the Philippine Heart Association valid
Currently, this PHA training course has been the for two years.
primary training program for BLS and ACLS by all
cardiology Training institutions, Department of This newly redesigned training manual speaks for
Health agencies and hospitals, member institutions the evolution and continuous improvement of BLS
of the Expanded Council on CPR and majority of all and ACLS training standards in the Philippines. All
allied health care professionals in the Philippines. content and concepts of resuscitation standards
based from consensus guidelines of the
With the increasing demand on innovative International Liaison Council on Resuscitation
approaches on training, especially with the current (ILCOR) were collated and masterfully laid out in this
pandemic crisis hampering large group training, the manual in a more simple and practical way for better
Council is bringing everyone its first ever BLS-ACLS comprehension and application.
Online Training Program.
Be Trained. Be certified by PHA.
This Online Training program will be composed of Save A Life. Learn CPR.
basic modules on Basic Life Support and Advanced
Life Support that will meet the basic competency
requirements on knowledge ands skills needed by
Francis Lavapie, MD, FPCP, FPCC

CPR Council Chair 2014 - 2021
EDITORIAL STAFF
EDITOR’s NOTE ACLS MANUAL
3rd EDITION
Don Robespierre C. Reyes,

Borne of the Pandemic MD, FPCP, FPCC
Chief Editor
I f there was one good thing that the Of course, no training is complete Alexander D. Reyes, MD,
COVID19 Pandemic brought the without a manual. The story behind this FPCP, FPCC
Content Editor
Council of Cardiopulmonary manual parallels the saga of producing
Resuscitation of the Philippine Heart the online modules and restructuring Marc Denver A. Tiongson,
Association, that would be the swift the workshops. It was not easy, but not MD, FPCP, FPCC
creation of online modules and a new as difficult as churning out the new Format Editor
training program on Basic Life Support modules. We were more challenged by Manuel Vidal, Jr,
and Advanced Cardiac Life Support. the evolving recommendations on RCh, MD
resuscitation by the International Layout Artist
Paralyzed by national and local strict Liaison Committee on Resuscitation
quarantine restrictions, the Council and (where we derive most of the contents PHA
BOARD OF DIRECTORS
the PHA in general was not immediately of our modules) and by the American
ready to respond to a continuing and Heart Association. Thus, we deem it Gilbert C. Vilela,
pressing need to train and recertify practical to have this manual in digital MD, FPCP, FPCC
providers and trainers. Though the idea formats until we feel that no new President
of leveling the training up to something recommendations on the science of
close to online teaching and learning resuscitation is in the offing. Then we go Jude Erric L. Cinco,
MD, FPCP, FPCC
came about a couple of years ago, the for the print version by then. Vice President
3R (Revisit, Review and Revise) strategy
of coming up with updated and As most of us are already considered Romeo B. Cruz
modernized modules crawled on for children of digital space while some are VP for Finance
some time with not-so-frequent still transitioning into this new norm, we Atty Darlene Marie B. Berberabe
meetings (un)officially squeezed in have tried our best to consider your VP for External Affairs
between official events of the PHA. concerns when it comes to using
various gadgets to view (or a better Ronald E. Cuyco,
But when the pandemic came, the term is to read and comprehend) the MD, FPCP, FPCC
Secretary
dedicated, committed and selfless core contents of this manual with ease. We
group of the training arm of the Council tried to be more straightforward and Rodney M. Jimenez,
met virtually at least three times a week practical in presenting the necessary MD, FPCP, FPCC
from 8PM till midnight for about three information needed by a BLS or ACLS Treasurer
months. Like they were race horses provider. Walid A. Amil,
whipped relentlessly and mercilessly MD, FPCP, FPCC
just to reach the finish line the soonest. This work may not be as perfect as one Director I
With an urgency to resume training, the idealist might have wished for, but
team was fueled with passion and was modesty aside, this entire new training Aurora Muriel S. Gamponia,
MD, FPPS, FPCC
indefatigable in coming up with a new program together with all the modules, Director II
set of modules and a new pedagogy manual and methods is one for the
that is appropriate for the fast changing books for the PHA in general. Like Richard Henry P. Tiongco II,
and challenging times. A blessing in Pandora’s Box, there is always hope MD, FPCP, FPCC, FPSE
Director III
disguise, this PHA training on BLS and trapped in the box. And the CPR Council
ACLS has made a big leap in terms of has just unleashed and released Elpis Orlando R. Bugarin,
standardization of teaching and and now, we now see our own version MD, FPCP, FPCC
learning. of a silver lining amidst a cloud of Immediate Past President
uncertainty.
Read on. Learn and continue saving

lives!
Don Robespierre C. Reyes, MD, FPCP, FPCC

This manual is
Chief Editor produced and owned by the
Philippine Heart Association
Council on Cardiopulmonary
Council. Its contents are recent as
of July 2021.
ADVANCED CARDIAC LIFE SUPPORT MANUAL
3rd EDITION
Francis N. Lavapie, MD, FPCP, FPCC
Past Chair 2014-2021, Council on Cardiopulmonary Resuscitation
Don Robespierre C. Reyes, MD, FPCP, FPCC

Module Development Director
Current Chair, Council on Cardiopulmonary Resuscitation
Paul John L. Ablaza, Raymond D. Bayaua, Raymond A. Dela Cruz, MD, Karen Gail A. Floren,
MD, FPCP, FPCC MD, FPCP, FPCC FPCP, FPCC MD, FPCP, FPCC
Editor, Written Examination Recognition of Adult Cardiac Arrest Electrical Therapies
ACLS Rhythms
Ramayana D. Garcia, Regente I. Lapak, MD, FPPS, Jeannica K.G. Lerios-dela Peña, Eric John A. Marayag, MD,
MD, FPCP, FPCC FPCC, FPSE MD, FPCP, FPCC, FPSE FPCP
FBAO and Life-threatening Pediatric Basic Life Support Adult Basic Life Support for Drug Therapies
Conditions and First Aid for Healthcare Professionals Healthcare Professionals
Response
Alexander D. Reyes, MD, Neil Wayne C. Salces, MD, Ma. Luz Joanna B. Soria, MD, John Vincent T. Salvanera,
FPCP, FPCC FPCP, FPCC FPCP, FPCC MD, FPCP, FPCC
Airway Management and Post-cardiac Arrest Care Ethics in CPR Tachycardia Algorithm
Assisted Ventilation
Video editor
Jason S. Santos, Marc Denver A. Tiongson, Ma. Vanessa I. Yu,

MD, FPCP, FPCC MD, FPCP, FPCC MD, FPCP, FPCC
Bradycardia Algorithm Acute Coronary Syndrome Recognition of ACLS Rhythms
Video editor
Module Creators
Orlando R. Bugarin, MD, FPCP, FPCC

Alex T. Junia, MD, FPCP, FPCC
Consultants
TABLE OF CONTENTS
SECTION PAGE
CHAPTER 1
Adult Basic Life Support for Healthcare Professionals…………………… 1
CHAPTER 2
Pediatric Basic Life Support for Healthcare Professionals…………….. 8
CHAPTER 3
Foreign Body Airway Obstruction…………………….………………………………. 12
CHAPTER 4
Life-threatening Conditions and First Aid Response…………………….. 16
CHAPTER 5
Adult Cardiac Arrest …………………..…………………………..…………………………… 21
CHAPTER 6
Bradycardia……………………………………………………………………………………………. 25
CHAPTER 7
Tachycardia……………………………………………………………………………………………. 30
CHAPTER 8
Airway Management and Assisted Ventilation……………………………….. 36
CHAPTER 9
Post-cardiac Arrest Care……………………………………………………………………... 39
CHAPTER 10
Acute Coronary Syndrome…………………………………………………………………. 44
CHAPTER 11
Recognition of ACLS Rhythms……………………………………………………………. 49
CHAPTER 12
Cardiac Drugs…………………………………………………………………………….………….. 59
CHAPTER 13
Electrical Therapies………………………………………………………………………………. 63
Advanced Cardiac Life Support
Module 1: Adult Basic Life Support for Healthcare Professionals
Adult Basic Life Support

CHAPTER 1
for Healthcare Professionals

Jeannica K. G. Lerios-dela Peña, MD, FPCP, FPCC, FPSE
PRETEST 4. What is the correct way of performing chest

Select the letter of the correct answer. compressions?
1. What is the proper sequence of BLS a. Compress more than 120 per minute
during a pandemic? b. The rescuer's arms should be parallel to the
victim's body
a. Ensure scene safety → put on PPE → c. Compress for 5 cycles at 30 compressions
cover victim’s mouth → check for pulse each cycle
and breathing d. Depth of compression should be 4 inches
b. Put on PPE → ensure scene safety →
cover victim’s mouth → check for pulse 5. Which of the following is true of airway
and breathing management during BLS in a pandemic?
c. Ensure scene safety → put on PPE →
cover victim’s mouth → start CPR a. May give rescue breaths if the rescuer is
d. Put on PPE → ensure scene safety → fully vaccinated
cover victim’s mouth → start CPR b. Place a clear aerosol box over the patient's
head prior to starting CPR in out-of-
2. What is the proper sequence of the 5 Cs hospital lay-rescuer CPR
for out-of-hospital cardiac arrest during c. Consider early advanced airway via
a pandemic? intubation if possible
d. May use bag-valve-mask without filter for
a. Call → Cover → Check → Connect → airway management
Compress
b. Call → Cover→ Check → Compress →
Connect
c. Check → Call → Cover → Compress →
I. LEARNING OBJECTIVES
Connect • At the end of this module, the learner is
d. Check → Call→ Cover → Connect → expected to:
Compress o understand the need for cardiopulmonary
resuscitation (CPR);
3. What is the sixth link in the chain of o recognize an unconscious victim with
survival for adult out-of-hospital cardiac possible cardiopulmonary arrest; and
arrest?
o learn how to perform adult basic life
a. Activation of EMS support (BLS) for healthcare providers and
b. Recovery application of an automated external
c. Post-cardiac arrest care defibrillator (AED).
d. Advanced resuscitation
Council on Cardiopulmonary Resuscitation

1 Philippine Heart Association
II. ADULT BASIC LIFE SUPPORT o airway management and rescue breathing –
RATIONALE these inflate the lungs, facilitate oxygen
delivery, and open up pulmonary
• Cardiac arrest is the sudden stop in effective vasculature
blood circulation due to failure of the heart to • CPR prolongs the time that the victim is in
pump blood, leading to compromised blood ventricular fibrillation to buy time for a shock
flow and oxygen delivery to the entire body to be delivered, via an automated external
leading to loss of function within minutes. defibrillator (AED).
• Cardiac arrest can happen anytime, anywhere o AEDs use voice and visual prompts to guide
and to anyone. rescuers to safely deliver shocks to cardiac
• Approximately half of cardiac deaths occur as arrest victims.
sudden cardiac arrest. Pre-existing heart o The AED analyzes the victim’s rhythm and
disease is a common cause, but it may also will recommend shock delivery only if the
strike people without any history of cardiac victim’s heart rhythm is one that a shock can
problems. treat.
• The most common arrhythmia in adult out-of- • A shock delivered by the AED can temporarily
hospital cardiac arrest victims is ventricular stun the heart’s disorganized activity, to allow
fibrillation. restoration to sinus rhythm and return of
• “CPR” stands for “cardiopulmonary cardiac function thereby promoting adequate
resuscitation,” and involves 2 main circulation of oxygenated blood throughout
components: the body.
o chest compressions – these manually force
blood to circulate to the brain and heart
CHAIN OF SURVIVAL
Figure 1. 2020 American Heart Association Adult Chain of Survival for In-Hospital Cardiac Arrest
Figure 2. 2020 American Heart Association Adult Chain of Survival for Out-of-Hospital Cardiac Arrest

• The key person in the early access is the • Lay rescuers and healthcare professionals
trained healthcare provider or even a well- should use the combination of
informed lay person who is able to recognize unresponsiveness and absent/abnormal
the signs of a heart attack and respiratory breathing to identify cardiac arrest.
failure. o Agonal gasps, which are defined by short,
o The symptoms of a heart attack include labored, and irregular breathing, are
prolonged, compressing pain, or unusual common during cardiac arrest. Consider
discomfort in the center of the chest. This agonal gasps as NO BREATHING.
may radiate to the shoulder, arm, neck, or • CPR before emergency medical service (EMS)
jaw, usually on the left side, and may be arrival has been shown to:
accompanied by sweating, nausea, o prevent ventricular fibrillation or pulseless
vomiting and shortness of breath. ventricular tachycardia from deteriorating
o Respiratory failure, on the other hand, to asystole;
should be suspected when a person is o increase the chance of defibrillation;
unable to speak, breathe, or cough. The o contribute to preservation of heart and
universal distress signal involves the victim brain function; and,
clutching his/her neck and may be o improve overall survival.
accompanied by cyanosis or a bluish
discoloration of skin and lips due to lack of
a patent airway leading to lack of oxygen.
ADULT BASIC LIFE SUPPORT

Single-rescuer Adult Basic Life Support
a. Head-tilt chin-lift maneuver (if with NO SUSPECTED cervical spine injury)

b. Jaw thrust without head extension (if WITH SUSPECTED cervical spine injury)
https://nhcps.com/lesson/bls-adult-mouth-mask-bag-mask-ventilation/

Perform high-quality CPR:

• Kneel facing the victim’s chest.
• Place the heel of the hand on the sternum at
the center of the chest between the nipples.
• Put your other hand on top of the first with
fingers interlaced.
• Your shoulders should be over your hands,
arms perpendicular to the victim’s body, and
elbows locked.
• Perform high quality CPR at 100 to 120
compressions per minute at 5 to 6 cm (2.0 to
2.4 in) deep while keeping your hand in contact
with the chest at all times, and allowing for full
chest recoil.
• Perform 1 cycle of 30 chest compressions
while counting out loud, “1, 2, 3,… 27, 28, 29,
and ONE.” (Instead of saying “30,” say “1” to “5”
to indicate how many cycles of 30 chest
compressions you have already completed.)
• After 30 chest compressions, open the airway
using the head-tilt chin-lift maneuver, and
provide 2 full one-second breaths. Check for
chest rise in between breaths.
Hook the patient to an automated external

defibrillator (AED) once available:
• Activate the AED by turning the power on.
Attach the electrode pads:
o Peel the backing away from the electrode
pads.
o Wipe the victim’s chest dry.
o Attach one electrode pad to the right of
the breast bone directly below the
collarbone. Attach the other pad to the
left of the left nipple, a few inches below
the left armpit.
o Attach the AED cables to the AED box if
these are not pre-connected.
• Evaluate the rhythm.
• Deliver shock if advised by the voice
prompt.
• Start or resume CPR.
Two-rescuer Adult Basic Life Support

• The first rescuer will perform the chest compressions, while the second rescuer will deliver the
rescue breaths.
• The second rescuer will be the one to operate the AED.

III. ADULT BASIC LIFE SUPPORT IN THE COVID-19 PANDEMIC

In-hospital Cardiac Arrest for Suspected, Probable, or Confirmed Cases of COVID-19
Figure 3. Adult basic life support for in-hospital cardiac arrest victims during the COVID-19 pandemic

Out-of-hospital Cardiac Arrest
Figure 4. Adult basic life support for out-of-hospital cardiac arrest victims during the COVID-19 pandemic
3. What is the sixth link in the chain of survival
for adult out-of-hospital cardiac arrest?
POST-TEST
Select the letter of the correct answer. a. Activation of EMS
b. Recovery
1. What is the proper sequence of BLS c. Post-cardiac arrest care
during a pandemic? d. Advanced resuscitation
a. Ensure scene safety → put on PPE → 4. What is the correct way of performing chest
cover victim’s mouth → check for pulse compressions?
and breathing
b. Put on PPE → ensure scene safety →
cover victim’s mouth → check for pulse
a. Compress more than 120 per minute
and breathing b. The rescuer's arms should be parallel to the
c. Ensure scene safety → put on PPE → victim's body
cover victim’s mouth → start CPR c. Compress for 5 cycles at 30 compressions
d. Put on PPE → ensure scene safety → each cycle
cover victim’s mouth → start CPR d. Depth of compression should be 4 inches
2. What is the proper sequence of the 5 Cs 5. Which of the following is true of airway
for out-of-hospital cardiac arrest during management during BLS in a pandemic?
a pandemic?
a. May give rescue breaths if the rescuer is
a. Call → Cover → Check → Connect → fully vaccinated
Compress b. Place a clear aerosol box over the patient's
b. Call → Cover→ Check → Compress → head prior to starting CPR in out-of-
Connect
hospital lay-rescuer CPR
c. Check → Call → Cover → Compress → c. Consider early advanced airway via
Connect
d. Check → Call→ Cover → Connect →
intubation if possible
Compress d. May use bag-valve-mask without filter for
airway management
REFERENCES
Panchal A, Bartos J, Cabañas J, et al. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2020;142:S366–S468
Philippine Heart Association. Interim Consensus Guidelines for Basic and Advanced Resuscitation in Cardiac Arrest Patients
during COVID-19 Outbreak. March 2020.

Module 2: Pediatric Basic Life Support for Healthcare Professionals
Pediatric Basic Life Support

CHAPTER 2
for Healthcare Professionals

Regente I. Lapak, MD, FPPS, FPCC, FPSE
• At the end of this module, the learner is
PRETEST expected to:
True or false: o recognize common conditions causing
cardiac arrest in children; and
1. The first link in the pediatric chain of o gain knowledge and skills in performing
survival is early and effective CPR. pediatric basic life support and using an
2. The cause of pediatric cardiopulmonary automated external defibrillator.
arrest is similar to that of adults.
3. The landmark for chest compressions in II. INTRODUCTION
infants is 1 finger below the
intermammary line.
AGE CLASSIFICATION
4. The landmark for chest compressions in • For victims <28 days old, use BLS guidelines for
children is the lower half of the sternum. NEONATES.
5. It is allowable to stop CPR when the • For victims 28 days to <1 year old, use BLS
scene becomes unsafe.
guidelines for INFANTS.
• For victims 1 year to <8 years old, use BLS
guidelines for CHILDREN.
• For victims 8 years old and up, use BLS
guidelines for ADULTS.
PEDIATRIC CHAIN OF SURVIVAL
Figure 1. 2020 American Heart Association Pediatric Chain of Survival for In-Hospital Cardiac Arrest
Figure 2. 2020 American Heart Association Pediatric Chain of Survival for Out-of-Hospital Cardiac Arrest
CAUSES OF PEDIATRIC CARDIAC ARREST

Table 1. Causes of Pediatric Cardiac Arrest
More Common: Hypoxic-asphyxial Causes Less Common: Primary Arrhythmic Causes
• Hypertrophic cardiomyopathy
• Sudden infant death syndrome • Anomalous coronary artery
• Airway and breathing problems • Channelopathies
• Traumatic injury or accident • Myocarditis
• Drowning • Commotio cordis
• Electrocution • Intentional/accidental ingestion of
drugs/substances
III. PEDIATRIC BASIC LIFE SUPPORT

Table 2. Summary of High-quality CPR Components in Pediatric Victims
1 year to <8 years old 8 years old and above (children
Component 28 days to <1 year old (infants)
(children) and adolescents)
Scene safety Make sure the environment is safe for the rescuer/s and the victim.
• Check for responsiveness.

Recognition of • Check for pulse and breathing.
cardiac arrest • If with no breathing (or only gasping), and with no definite pulse felt within 10 seconds,
proceed to the next component.
• For WITNESSED COLLAPSE (more commonly VF in • If with only 1 RESCUER:

etiology, and among victims 8 years old and above): o Leave the victim to
• Use the PHONE FIRST strategy: activate the EMS and get
o Follow the same steps as for victims 8 years old and the AED before beginning
above. CPR.
o Use the AED as soon as it
Activation of • For UNWITNESSED COLLAPSE (more commonly is available.
emergency asphyxia in etiology, and among victims <8 years old):
response system • Use the PHONE FAST strategy: • If with >1 RESCUER:
o Give 2 minutes of CPR. o Send another rescuer to
o Leave the victim to activate the EMS and get the activate the EMS and get
AED. the AED, while you begin
o Return to the child or infant and resume CPR. CPR immediately.
o Use the AED as soon as it is available. o Use the AED as soon as it
is available.
If with only 1 RESCUER:
Compression-
30:2
ventilation ratio
30:2
without
If with >1 RESCUER:
advanced airway
15:2
Compression rate 100 to 120 compressions per minute
At least 1/3 of the AP
At least 1/3 of the AP diameter of
Compression diameter of the chest
the chest 2 to 2.4 inches or 5 to 6 cm
depth (about
(about 1.5 inches or 4 cm)
2 inches or 5 cm)

1 year to <8 years old 8 years old and above (children

Component 28 days to <1 year old (infants)
(children) and adolescents)
2 hands or 1 hand
• 2 fingers or 2 thumb-encircling (optional for very
hands at the center of the 2 hands on the lower half of the
Hand placement small child) on the
chest, just below the nipple breastbone (sternum)
lower half of the
line breastbone (sternum)
• Allow full chest recoil after each compression.

Chest recoil
• Do not lean on the chest after each compression.
Minimizing
interruptions • Limit interruptions in chest compressions to <10 seconds.
*AED = automated external defibrillator, AP = antero-posterior, CPR = cardiopulmonary resuscitation, EMS = emergency medical system
NOTES Victim with No Pulse and No Breathing

• Allow a child with respiratory distress (eg, a • Perform CPR.
child who is bent forward, in the tripod o Start chest compressions.
position, drooling, or appears toxic) to remain § For Infants:
in a position that is most comfortable for ¨ landmark: 1 finger below the inter-
him/her. mammary or nipple line
• Where to check for pulse: ¨ hand position: two-thumb
o infants – brachial pulse technique (preferred) or two-finger
o children – carotid or femoral pulses technique
§ For children:
Victim with Pulse and No Breathing ¨ landmark: lower half of the sternum
• Perform rescue breathing: ¨ hand position: two-hand technique
o Open the airway using the head-tilt chin-lift or one-hand technique
or jaw thrust without head extension. o Open the airway.
o Select the appropriate route (eg, mouth-to- o Perform rescue breathing.
mouth, mouth-to-nose-and-mouth, § compression-ventilation ratio if with
mouth-to-barrier, or bag-valve-mask). only 1 RESCUER: 30:2
o Provide 20-30 rescue breaths per minute § compression-ventilation ratio if with
(or 1 rescue breath every 2 to 3 seconds) for >1 RESCUER: 15:2
2 minutes. § Check for chest rise after giving each
• Reminders when performing rescue breathing: rescue breath
o Use a barrier device. • Use the AED as soon as it is available.
o Deliver each breath over 1 second. o Use of an AED with a pediatric attenuator is
o Give sufficient tidal volume to produce preferable over an AED without a pediatric
visible chest rise. attenuator.
o Avoid rapid or forceful breaths.

Table 3. AED for Pediatric Victims

<8 years old, or ≥8 years old, or
<55 lbs (26 kg) ≥55 lbs (26 kg) POST-TEST
True or false:
1. The first link in the pediatric chain of

Choice of survival is early and effective CPR.
AED pads 2. The cause of pediatric cardiopulmonary
arrest is similar to that of adults.
3. The landmark for chest compressions in
infants is 1 finger below the
intermammary line.
4. The landmark for chest compressions in
Placement children is the lower half of the sternum.
of AED 5. It is allowable to stop CPR when the
pads scene becomes unsafe.
REFERENCES
Maconochie, I. K., Aickin, R., Hazinski, M. F., Atkins, D. L.,
Victim with Pulse and Breathing Bingham, R., Couto, T. B., Guerguerian, A. M., Nadkarni,
• Put the victim in the recovery position V. M., Ng, K. C., Nuthall, G. A., Ong, G. Y. K., Reis, A. G.,
Schexnayder, S. M., Scholefield, B. R., Tijssen, J. A.,
Nolan, J. P., Morley, P. T., van de Voorde, P., Zaritsky, A.
L., & de Caen, A. R. (2020). Pediatric Life Support: 2020
International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Science With Treatment Recommendations. In
Circulation (Vol. 142, Issue 16 1).
https://doi.org/10.1161/CIR.0000000000000894
Topjian, A. A., Raymond, T. T., Atkins, D., Chan, M., Duff, J.
P., Joyner, B. L., Lasa, J. J., Lavonas, E. J., Levy, A.,
Mahgoub, M., Meckler, G. D., Roberts, K. E., Sutton, R.
M., & Schexnayder, S. M. (2020). Part 4: Pediatric Basic
and Advanced Life Support: 2020 American Heart
Figure 3. Recovery position in pediatric victims Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. In
Circulation (Vol. 142, Issue 16 2).
https://doi.org/10.1161/CIR.0000000000000901

Module 3: Foreign Body Airway Obstruction
CHAPTER 3
Foreign Body Airway Obstruction

Ramayana D. Garcia, MD, FPCP, FPCC
• Eighty percent of FBAO cases occur in children

below 3 years old and occur more frequently
PRETEST in those 1 to 2 years of age.
True or false: • The high incidence of FBAO among mobile
babies and toddlers are primarily due to
1. The most common cause of upper curdled milk and small round objects.
airway obstruction is obstruction by the
tongue.
• Among adults, common factors associated
2. FBAO is a common and preventable with choking include attempts to swallow
cause of cardiac arrest among adults. large, poorly chewed pieces of food; elevated
3. Café coronary is a condition associated blood alcohol levels; and dentures.
with choking emergencies that have been • Elderly patients with dysphagia are also at risk
mistaken for a heart attack. for FBAO and should take care while drinking
4. High incidence of FBAO among mobile and eating.
babies and toddlers is primarily due to • In restaurants, choking emergencies have
curdled milk and small round objects. been mistaken for a heart attack, giving rise to
5. In partial airway obstruction, the first aid
the term “café coronary.”
responder should immediately attempt to
expel the foreign body before it progress
to total airway obstruction. III. APPROACH TO FOREIGN BODY AIRWAY
OBSTRUCTION
AIRWAY OBSTRUCTION
• May occur when normal airway protective
• At the end of this module, the learner is mechanisms that prevent foreign bodies from
expected to: entering the upper airway (eg, glottal closure,
o recognize a patient with foreign body expiration reflex, cough reflex) become
airway obstruction and assess its severity; insufficient to prevent airway obstruction
and • Possible causes:
o know the immediate steps to relieve the o The most common cause of upper airway
obstruction. obstruction is obstruction by the tongue
during loss of consciousness, or
II. EPIDEMIOLOGY OF FOREIGN BODY AIRWAY cardiopulmonary arrest.
OBSTRUCTION o The tongue may fall backward into the
• Foreign body airway obstruction (FBAO) is a pharynx obstructing the upper airway.
relatively uncommon but preventable cause of o The epiglottis can block the entrance of the
cardiac arrest. airway in unconscious victims.
• Death from this cause is much less common o Blood from head and facial injuries, or
(1.2 deaths per 100,000 population) than regurgitated stomach contents may also
death from other emergencies: obstruct the upper airway.
o 1.7 deaths per 100,000 population from • Inhalation of a foreign body, usually while
drowning; eating, can lodge along the upper airway.
o 16.5 deaths per 100,000 population from
motor vehicle crashes; and
o 198 deaths per 100,000 from coronary
heart disease.
RECOGNITION OF FOREIGN BODY AIRWAY • Step 4: If still not relieved, turn over the infant
OBSTRUCTION and position your middle and ring finger in the
Partial Airway Obstruction middle of the infant’s sternum, just below the
imaginary line in between the infant’s nipples
• The victim may still be capable of “good air and deliver 5 chest thrusts. Repeat steps 2 to 4
exchange.” until effective or until infant becomes
• The victim is responsive, able to cough, with unconscious.
possible wheezing in between.
• The rescuer should not interfere with the
victim’s own attempts to expel the foreign
body, but should stay with the victim and
monitor these attempts. If partial airway
obstruction persists, activate the emergency
medical service (EMS) system.
Complete Airway Obstruction

• The victim is unable to speak, breathe, or Figure 2. Chest thrust on an infant
cough and may clutch the neck with the thumb • Step 5: If the infant becomes unresponsive,
and fingers. begin CPR. After 30 chest compressions,
• Movement of air is absent. check the oral cavity for any foreign body. Do
• If not relieved, the victim’s blood oxygen not perform a blind finger sweep. Continue
saturation will fall rapidly because the with the steps of pediatric BLS until help
obstructed airway prevents air entry into the arrives or the infant is revived.
lungs. The victim will become unresponsive,
and death will follow rapidly. Children 1 to 8 Years Old
• Complete airway obstruction is an emergency • Step 1: Determine if the child has a mild or
that will result in death within minutes if not severe airway obstruction.
treated. o If obstruction is mild, the child can still cough
or make some sounds. Hence, do not
RELIEF OF FOREIGN BODY AIRWAY interfere and allow the victim to clear the
OBSTRUCTION airway by coughing. Closely observe the
Infants Up to 1 Year Old child for progression to severe obstruction.
o If obstruction is severe, the child may be
• Step 1: With a conscious infant, verify if he/she
seen clutching his/her chest or neck, and
has a complete airway obstruction with note
unable to speak, breathe, or cough.
of breathing difficulties, ineffective cough, or
absence of strong cry. • Step 2: If obstruction is severe, immediately
position yourself behind the child. Give 5 back
• Step 2: Immediately position the infant face
blows by hitting the victim firmly on the back
down over one of your forearms, with the
between the shoulder blades. If back blows do not
head lower than the body. Support the infant’s
dislodge the foreign body, move to the next step.
head by holding the jaw with your hand.
• Step 3: Perform 5 upright abdominal thrusts
• Step 3: Deliver 5 back blows using the heel of
(also known as Heimlich maneuver) by holding
your hand between the infant’s shoulder blades.
the child around the waist and pulling upwards
above their belly button.
o Upright abdominal thrusts elevate the
diaphragm, forcing air out from the lungs. This
may be sufficient to create an artificial cough
and expel a foreign body from the airway.
• Repeat steps 2 and 3 until the foreign body is
Figure 1. Back blow on an infant expelled, or until the child becomes
unconscious.
maneuver, with the back slaps delivered

between the shoulder blades with the heel of
the rescuer’s hand.
• Step 3: If back slaps fail, perform 5 abdominal
thrusts. Stand behind the victim and allow the
victim to lean forward. Put both arms around
the upper abdomen and clench one fist, grasp
it with the other hand and pull sharply inward
and upward.
A B
Figure 3. Abdominal thrust in the upright (A) and
supine (B) position on a child
• If the child becomes unresponsive,
immediately perform CPR. After each 30
chest compressions, check the oral cavity for
the foreign body.
• If the foreign body can be seen, remove it. Do
not perform a blind finger sweep. Give 2
rescue breaths and continue with pediatric Figure 5. Upright abdominal thrust (or Heimlich
BLS. maneuver) on an adult
• Repeat the cycle until the airway is cleared or
o Repeat steps 2 and 3 until the foreign body
until help arrives.
is expelled, or until the victim becomes
unconscious.
Children >8 Years Old and Adults
• Step 4: If the victim becomes unconscious,
• Step 1: For a conscious victim, first identify the position the victim supine on a hard surface
universal distress signal which is seen as a and call for help. If a second rescuer is
victim clutching his/her neck. available, send the second rescuer to activate
the EMS system while you begin CPR.
• Step 5: Perform CPR, and in addition, inspect
the oral cavity for the foreign body each time
the airway is opened. If the foreign body is not
visible, proceed with CPR as previously
instructed. If the foreign body is visible,
perform the tongue-jaw lift as follows, but
only if you are a healthcare provider.
Figure 4. Universal distress signal

o Introduce yourself as a BLS provider who
knows how to perform the Heimlich
maneuver.
o If the victim is able to cough or speak, do
not interfere and allow the victim to clear
his/her airway by coughing, while
continuing to observe for signs of
progression to severe obstruction. Figure 6. Tongue-jaw lift
• Step 2: If the obstruction becomes severe (eg, o Insert the thumb of one hand into the mouth
the victim is unable to cough or speak), and press on the tongue. The other fingers of
provide up to 5 back blows/slaps as the initial the same hand grasp on the lower jaw.
o The maneuvering hand lifts the mandible.

Insert the index finger of your other hand
down along the inside of the cheek and POST-TEST
deeply into the victim’s throat to the base of True or false:
the tongue to sweep. Then use a hooking
action to dislodge the foreign body and 1. The most common cause of upper
maneuver it out of the mouth so that it can airway obstruction is obstruction by the
be removed. Be careful to avoid forcing the tongue.
object deeper into the airway. 2. FBAO is a common and preventable
cause of cardiac arrest among adults.
Special Situations 3. Café coronary is a condition associated
Victims who are obese or in the late stages of with choking emergencies that have been
pregnancy mistaken for a heart attack.
4. High incidence of FBAO among mobile
• Chest thrusts may be an alternative to
babies and toddlers is primarily due to
abdominal thrusts. curdled milk and small round objects.
• Stand behind the victim. Raise the victim’s 5. In partial airway obstruction, the first aid
arms, then make a fist with your hand and responder should immediately attempt to
position it on the victim’s sternum. expel the foreign body before it progress
• Grasp the fist with your other hand, then pull to total airway obstruction.
sharply inward with a quick motion.
• Repeat 5 times until the foreign body is expelled, REFERENCES
or until the victim becomes unconscious. Panchal A, Bartos J, Cabañas J, et al. 2020 American Heart
Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation. 2020;142:S366–S468
Emergency Cardiac Care Committee and Subcommittees,
American Heart Association. Guidelines for
cardiopulmonary resuscitation and emergency cardiac
care, VI: Pediatric advanced life support. JAMA.1992;
268:2262–2275.
Figure 7. Chest thrust

Victim is YOU
• If you should find yourself with a foreign body
airway obstruction, immediately thrust your
upper abdomen against any firm surface, such
as the back of a chair, side of a table, or porch
railing (self-administered Heimlich maneuver).
Repeat until the foreign body is expelled.
Figure 8. Self-administered Heimlich maneuver

Module 4: Life-threatening Conditions and First Aid Response
Life-threatening Conditions
CHAPTER 4
and First Aid Response

Ramayana D. Garcia, MD, FPCP, FPCC
FIRST AID PROVIDER

• Someone with formal training in first aid,
PRETEST emergency care or medicine who provides
True or false:
first aid
1. First aid is defined as helping behaviors • The goals of a first aid provider are the
provided for chronic illness or injury. following 3 Ps:
2. The goals of a first aid provider are to o preserve life;
preserve life, prevent further o prevent further illness or injury; and
illness/injury and promote recovery. o promote recovery.
3. Administration of oxygen is not
considered a standard first aid skill. FIRST AID COMPETENCIES
4. Administration of activated charcoal by
first aid rescuers for poison victim is not • Recognizing, assessing, and prioritizing the
recommended. need for first aid
5. Diabetics who display symptoms of • Providing care by using appropriate
confusion, altered behavior, diaphoresis knowledge, skills and behaviors
or sweating profusely should be assumed • Recognizing limitations and seeking additional
by the first aid provider to have care when needed
hypoglycemia.
BASIC PRINCIPLES IN FIRST AID
I. LEARNING OBJECTIVES • In the medical field, the most basic rule that
applies to first aid providers as well would be
primum non nocere, or “First, do no harm.”
expected to:
o understand the basic principles of first aid; • Before any immediate first aid response can be
and the done, the first aid responders should
o recognize life-threatening situations that always protect himself/herself by using proper
may lead to cardiac arrest and know the personal protective equipment. This is part of
immediate initial responses to these. the standard precautions that all healthcare
providers must take.
II. FIRST AID • Calling for help. The goal of first aid
intervention is to:
• Defined as helping behaviors and initial care o recognize when help is needed and how to
provided for an acute illness or injury get it;
• The assessment and interventions that can be o know how and when to access the EMS;
performed by a bystander with minimal or no o know how to activate the onsite emergency
medical equipment response plan;
o know how to contact the local poison
control center; and
o be familiar with the local emergency
hotlines.
• Patient positioning. Generally, an ill or injured
person should not be moved.

o This is especially important if you suspect Chest Discomfort or Chest Pain

that the person may have a pelvic or spine
• Chest pain is a common health problem with a
injury.
myriad of causes, ranging from minor chest
o There are times however when the patient
wall strains to pneumonia, angina, or
should be moved, particularly:
myocardial infarction.
§ if the area is unsafe for the first aid
provider or the person; and • Common signs and symptoms associated with
chest pain or discomfort of cardiac origin
§ if a person is unresponsive and breathing
include shortness of breath, nausea, sweating,
normally, it may be reasonable to place
or pain in the arm or back.
him/her in a lateral side-lying recovery
position. • First aid responders should assume that chest
o If a person has been injured and the nature of discomfort is cardiac in origin until proven
the injury suggests a neck, back, hip or pelvic otherwise.
injury, the person should not be rolled onto • Call the EMS immediately for anyone with
his/her side and instead should be left in the chest discomfort.
position in which they were found. • Encourage the victim to chew 1 adult aspirin
§ He or she must be turned face up to tablet (325 mg/tab) or 2 to 4 low dose baby
further evaluate the victim. aspirin tablets (80 mg/tab) after checking that
• Oxygen use in first aid the victim has no allergy or any other
o Administration of oxygen is not considered contraindications to aspirin.
a standard first aid skill.
o However, oxygen may be available in some Stroke
first aid environments and requires specific • Early stroke recognition through the use of
training in its use. stroke assessment systems decrease the
• In any life-threatening situation, a first aid interval between time of stroke and arrival at
provider must always: the hospital and definitive treatment.
o Do scene size up and primary survey of the • The use of a stroke assessment system, such
victim in terms of the victim’s circulation, as the BEFAST, by first aid providers is
breathing, and airway; and recommended.
o Determine the mechanism of injury for o B stands for loss of balance, headache or
trauma victims, or the nature of illness of dizziness
victims with a medical condition. o E stands for eyes, checking for blurring of
vision
LIFE-THREATENING CONDITIONS o F stands for face, assessing for any one-
AND FIRST AID RESPONSE sided facial weakness or drooping
Breathing Difficulties o A stands for arms, checking for any
unilateral weakness
• May occur among patients with chronic
o S stands for speech, checking for any
pulmonary conditions such as bronchial
speech difficulties
asthma, chronic bronchitis, or emphysema
o T stands for time to call for ambulance and
• May present as sudden shortness of breath or EMS
wheezing
• As first aid responders, call EMS and note the
• First aid providers can assist with the time the victim was seen. Perform CPR if
administration of the victim’s prescribed necessary. Do not let the victim go to sleep or
bronchodilators. talk you out of calling EMS. Do not give any
• Reasonable for first aid providers to be familiar medications.
with the available inhaled bronchodilator
devices
• If the victim becomes unresponsive, call for
help and proceed with CPR if needed.

Electrocution or Electric Shock Poison

• Factors that determine the nature and severity • Any substance that can damage body
of injury include the magnitude of voltage structures or impair body function by its
delivered, resistance to current flow, type of chemical action
current and duration of contact. • Can be ingested by mouth, inhaled by
• The severity of electrical injuries can vary from breathing, injected via syringes or absorbed
an unpleasant tingling sensation to thermal through skin by direct contact
burns, cardiopulmonary arrest, and death. • Rescuers must protect themselves before
• Thermal burns may result from burning administering first aid.
clothing or from electric current traversing a o Do not enter any area where victims are
portion of the body internally along its unconscious without knowledge of the
pathway. agents to which the victims have been
• Cardiopulmonary arrest is the primary cause exposed and without the required
of immediate death in persons who sustained protective equipment.
an electrical injury. o For chemical burns, remove all
• Cardiac arrhythmias, including ventricular contaminated clothing.
fibrillation, asystole, ventricular tachycardia o For toxic eye injuries, rinse eyes with water
that progresses to ventricular fibrillation may for at least 15 to 20 minutes, and encourage
occur as a result of exposure to low- or high- blinking.
voltage currents. o Do not administer anything by mouth
• As a first aid responder: unless advised by a poison control center.
o Do not place yourself in danger by touching o Administration of activated charcoal by first
the victim while the electricity is on. aid rescuers is not recommended.
o Turn the power off at its source. In case of o If the victim’s skin has been exposed,
high-voltage electrocution, such as a fallen thoroughly flush it with running water until
power line, immediately notify the EMS personnel arrive.
appropriate authorities. o If the poison is a gas or vapor, remove the
o Everything will conduct electricity if the victim from the contaminated area as soon
voltage is high enough, so do not enter the as possible.
area around the victim or attempt to o Evaluate victims of poisoning for adequacy
remove wires using other materials such as of airway, breathing and circulation and
wood until the power has been turned off. provide basic life support as required.
o Once off, assess the victim, who may need
CPR, defibrillation, and treatment for shock Drug Toxicity
and thermal burns. • Specific drugs can damage certain organs,
o If the victim does not have pulse and depending on the case, but they all share
breathing, proceed with CPR. If with pulse similar symptoms, varying only slightly.
and breathing, place the victim in the • Patients can present with shortness of breath,
recovery position and monitor until help heaving, wheezing, abdominal pain, vomiting,
arrives. nausea, diarrhea, blood in bowels, and
compromised vital signs.
• The first aid responders should stay calm and
call for help. Do not make the person vomit,
and do not give them anything to eat or drink.
Bring the pill contents, container or what’s left
of the medications to the hospital.

Seizure o Epinephrine is injected intramuscularly at a

dose of 0.3 mg for adults and children
• Approximately 10% of all people will have a
>30 kg, and 0.15 mg for children weighing
seizure during their lifetime, and 1-2% will have
15 to 30 kg.
recurrent seizures.
o Have the victim lie still on his/her back.
• Although seizures are rarely fatal, injuries o Loosen tight clothing and cover the victim
related to seizure such as fractures, with a blanket.
dislocations, burns, concussion, subdural o Don't give the person anything to drink.
hematoma, and intracerebral hemorrhage o If the victim becomes unresponsive,
may occur. proceed with CPR until help arrives.
• The general principles of the first aid
management of seizures are prevention of Animal Bites
injury, assurance of an open airway, and
reassurance of an open airway after the • Dog bites – wash the wound with soap and
seizure has ended. warm water. Gently press a clean cloth over
o The person having a seizure must be the wound to stop the flow of blood. Apply an
protected from injuring himself/herself. antibacterial ointment and cover with a sterile
o Try to keep the victim from falling. bandage. Seek help if you suspect infection or
o Protect the head with a pillow or something possible exposure to rabies.
soft. • Snake bites – do not suck the blood out. Apply
o Do not restrain the patient. a pressure immobilization bandage around the
o Note for any hanging objects. Loosen ties or entire length of the bitten extremity.
anything around the neck that may make it • Jellyfish stings – the goal is to prevent further
hard to breathe. discharge, and pain relief. To inactivate venom
o Time the seizure and call for help. load, wash the affected area with vinegar for
at least 30 seconds. For the pain, treat with hot
Hypoglycemia water immersion. Pressure immobilization
bandages are not recommended.
• Can manifest as a variety of symptoms,
including confusion, altered behavior,
Heat Emergencies
diaphoresis, or sweating profusely
• Diabetics who display these symptoms should Heat cramps
be assumed by the first aid provider to have • These are painful, involuntary muscle spasms
hypoglycemia. during heavy exercise in hot environments.
• Allow the patient to take glucose tablets. Fluid and electrolyte loss often contribute to
Candies can be used as an alternative. heat cramps. Muscles often affected include
• For more severe presentations such as loss of the calves, arms, abdominal wall, and back
consciousness, immediately call for help. muscles.
• First aid response is to advise the victim to rest,
Anaphylaxis cool down, replace fluids and not to resume
strenuous activity until cramps go away.
• Not all allergic reactions will progress into
anaphylaxis. Heat exhaustion
• An anaphylaxis is a progressive series of • Caused by exercise induced heat and fluid and
symptoms such as swelling, breathing electrolyte loss
difficulty, itching rash, and eventual shock. If • Symptoms include nausea, dizziness, muscle
left untreated, it may lead to death. cramps, feeling faint, headache, fatigue, and
• It is reasonable for a first aid responder to be heavy sweating.
made aware of the proper dosing of • First aid responders should have the victim lie
epinephrine injection. down in a cool place, take clothes off, spray
with cool water, and drink cool fluids.

Heat stroke
• Encompasses all symptoms of heat
exhaustion, plus central nervous system
involvement (dizziness, syncope, confusion, or
seizures)
• First aid responders should provide the victim
with immediate cooling by immersing the
victim in cold water and intravenous fluids.
• Do not try to force the victim to drink liquids.
POST-TEST
True or false:
1. First aid is defined as helping behaviors

provided for chronic illness or injury.
2. The goals of a first aid provider are to
preserve life, prevent further
illness/injury and promote recovery.
3. Administration of oxygen is not
considered a standard first aid skill.
4. Administration of activated charcoal by
first aid rescuers for poison victim is not
recommended.
5. Diabetics who display symptoms of
confusion, altered behavior, diaphoresis
or sweating profusely should be assumed
by the first aid provider to have
hypoglycemia.
REFERENCES
Panchal A, Bartos J, Cabañas J, et al. 2020 American Heart
Circulation. 2020;142:S366–S468

Module 5: Adult Cardiac Arrest
CHAPTER 5
Adult Cardiac Arrest

Raymond A. Dela Cruz, MD, FPCP, FPCC
PRETEST • At the end of this module, the learner is

Select the letter of the correct answer. expected to:
o recognize cardiac arrest rhythms; and
1. Which of the following is involved in the o manage cardiac arrest rhythms.
treatment of PEA?
II. INTRODUCTION
A. Assessment for and treating the underlying • Sudden cardiac arrest is an abrupt cessation of
causes cardiac mechanical function which may be
B. Immediate defibrillation
reversible by prompt intervention, but will
C. Administration of atropine
D. Precordial thump lead to death in its absence.
• It can happen anytime, anywhere and to
2. Which of the following below requires anyone, even if they appear healthy.
defibrillation?
III. CARDIAC ARREST RHYTHMS
A. Normal sinus rhythm but no pulse
B. Stable atrial fibrillation VENTRICULAR FIBRILLATION
C. Sinus tachycardia • An arrhythmia that occurs when the ventricles
D. Pulseless ventricular tachycardia
beat with rapid and erratic electrical impulses
3. Initial dose of amiodarone given in cardiac • Causes the ventricles to quiver instead of
arrest: pump blood
A. 300 mg
B. 150 mg
C. 6 mg
D. 12 mg
4. Initial treatment for a patient in asystole: Figure 1. Ventricular Fibrillation

A. CPR
PULSELESS VENTRICULAR TACHYCARDIA
B. Epinephrine
C. Defibrillation • Very rapid but ineffective ventricular
D. Amiodarone contractions leading to insufficient organ
perfusion and heart failure
5. Initial treatment for a patient in pulseless
ventricular tachycardia:
A. Shock
B. CPR
C. IV access Figure 2. Ventricular Tachycardia
D. Epinephrine

ASYSTOLE Medication nurse

• Absence of electrical and mechanical activity • Provides vascular access
in the heart • Prepares and gives medications ordered by
the captain
• Communicates data and completed
interventions to scribe and captain
Figure 3. Asystole Electrical therapist
• Operates/monitors the defibrillator
PULSELESS ELECTRICAL ACTIVITY
• An organized slow rhythm that does not Airway manager
produce a pulse • Manages the airway as directed by the captain
• Prepares the intubation materials
• Confirms ET tube placement
• Secures the ET tube
• Performs bag-valve mask ventilation
Figure 4. Idioventricular rhythm. If this rhythm does • Accompanies the patient to any scan or test to
not produce a pulse, then the victim is said to have manage the airway
“pulseless electrical activity.”
Chest compressor
IV. PRINCIPLES OF MANAGEMENT • Performs chest compressions of adequate
HIGH-QUALITY CPR depth and rate
• Minimize interruptions in chest compressions.
Scribe
• Provide chest compressions of adequate rate
and depth. • Communicates with the captain throughout
the code
• Avoid excessive ventilation.
• Maintains an accurate written record of the
RHYTHM INTERPRETATION timing of all interventions, including
medications and shocks
• ECGs must be interpreted correctly to arrive • Must have a working knowledge of standard
at the appropriate management. ACLS algorithms
• Finishes code sheet for submission
TEAM MANAGEMENT
Captain
• Clearly identifies self as the captain
• Directly assigns specific tasks
• Directs the overall resuscitative effort
• Ensures optimal airway management
• Issues all medical and resuscitative orders
Figure 5. Recommended position of team members during resuscitation

V. MANAGEMENT OF ADULT CARDIAC ARREST
Figure 6. 2020 American Heart Association Adult Cardiac Arrest Algorithm

NON-SHOCKABLE ARREST RHYTHMS • A very low EtCO2 (<10 mmHg) following

(ASYSTOLE AND PULSELESS ELECTRICAL ACTIVITY) prolonged resuscitation (>20 minutes) is a
• Asystole is a condition wherein there is absent sign of absent circulation and a strong
electrical, and therefore mechanical, cardiac activity. predictor of acute mortality.
• Pulseless electrical activity (PEA) is a
heterogeneous group of organized POST-TEST
electrocardiographic rhythms without Select the letter of the correct answer.
sufficient mechanical contraction of the heart
1. Which of the following is involved in the
to produce a palpable pulse. treatment of PEA?
• Asystole and PEA are non-perfusing rhythms
requiring the immediate initiation of high-quality CPR. A. Assessment for and treating the underlying
causes
• Asystole and PEA are addressed together B. Immediate defibrillation
because successful management for both C. Administration of atropine
depends on high-quality CPR and rapid D. Precordial thump
reversal of underlying causes, such as hypoxia, 2. Which of the following below requires
hyperkalemia, poisoning, and hemorrhage. defibrillation?
• Epinephrine is administered as soon as
A. Normal sinus rhythm but no pulse
feasible after CPR is begun. B. Stable atrial fibrillation
C. Sinus tachycardia
SHOCKABLE ARREST RHYTHMS D. Pulseless ventricular tachycardia
(VENTRICULAR FIBRILLATION AND PULSELESS 3. Initial dose of amiodarone given in cardiac
VENTRICULAR TACHYCARDIA) arrest:
• Ventricular fibrillation (VF) and pulseless A. 300 mg
ventricular tachycardia (pVT) are non- B. 150 mg
perfusing rhythms from the ventricles. C. 6 mg
D. 12 mg
• Management of patients in VF or pVT include
defibrillation, high-quality CPR, epinephrine, 4. Initial treatment for a patient in asystole:
and amiodarone or lidocaine.
A. CPR
• Magnesium sulfate (2 g IV/IO bolus, followed B. Epinephrine
by a maintenance infusion) may be used to C. Defibrillation
treat polymorphic ventricular tachycardia D. Amiodarone
consistent with torsade de pointes, but is not 5. Initial treatment for a patient in pulseless
recommended for routine use in adult cardiac ventricular tachycardia:
arrest patients.
A. Shock
VI. TERMINATION OF RESUSCITATIVE EFFORTS B. CPR
C. IV access
• Choosing whether to discontinue resuscitation D. Epinephrine
attempts in cardiac arrest patients is
challenging, and there is little high-quality REFERENCES
information to aid decision-making. Panchal A, Bartos J, Cabañas J, et al. 2020 American Heart
• According to physician survey data and Association Guidelines for Cardiopulmonary
professional practice recommendations, Resuscitation and Emergency Cardiovascular Care.
variables affecting the decision to discontinue Circulation. 2020;142:S366–S468
Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide
resuscitative measures include the following: and outcome of out-of-hospital cardiac arrest. N Engl
o duration of resuscitative effort >30 minutes J Med 1997; 337:301.
without a sustained perfusing rhythm Grmec S, Klemen P. Does the end-tidal carbon dioxide
o initial electrocardiographic rhythm of asystole (EtCO2) concentration have prognostic value during
o prolonged interval between estimated time out-of-hospital cardiac arrest? Eur J Emerg Med 2001;
8:263.
of arrest and initiation of resuscitation Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon
o patient age and severity of co-morbid disease dioxide measurements as a prognostic indicator of
o absent brainstem reflexes outcome in cardiac arrest. Am J Crit Care 2001; 10:391.

Module 6: Bradycardia
CHAPTER 6
Bradycardia
Jason S. Santos, MD, FPCP, FPCC
True or false: expected to:
o recognize unstable bradycardia;
1. In general, bradycardia causes symptoms o manage patients with unstable
when the rate is <60 beats per minute. bradycardia; and
2. The maximum dose of atropine for o acquire basic knowledge in pacing.
symptomatic and unstable bradycardia is
3 mg. II. INTRODUCTION
3. The infusion rate of dopamine for • Bradycardia is defined as a heart rate of <60
symptomatic and unstable bradycardia is beats per minute and is usually asymptomatic.
5-20 mcg/kg per minute.
• When bradycardia is the cause of
4. Epinephrine IV bolus may be given if
hemodynamic instability, the rate is generally
atropine is ineffective.
5. Transcutaneous pacing should be
<50 beats per minute.
considered in patients with severe
symptoms or hemodynamic III. UNSTABLE BRADYCARDIA
compromise, while preparing the patient • Immediate management is necessary.
for transvenous pacing.
• Bradycardia that produces signs and
symptoms of hemodynamic instability, such
as:
o hypotension;
o acutely altered mental status;
o signs of shock;
o ischemic chest discomfort; and
o acute heart failure.
IV. COMMON BRADYARRHYTHMIAS

SINUS BRADYCARDIA
• Normal upright P waves in lead II followed by a QRS complex at a rate of <60 beats per minute
• Frequently asymptomatic

SINUS PAUSE
• SA node does not fire
• P waves transiently lost
• QRS complexes absent
• Duration of the pause is not a multiple of the normal P-P interval
JUNCTIONAL RHYTHM
• Impulses originate from the AV node
• P waves inverted or buried within the QRS complexes, or follow the QRS complexes
• QRS complexes are narrow
• Rate is slow
IDIOVENTRICULAR RHYTHM
• Impulse originates from the ventricle
• P waves absent
• QRS complexes are wide (>0.12 sec)
• T waves are opposite the direction of the QRS complexes
• Rate <40 beats per minute

ATRIOVENTRICULAR (AV) BLOCKS

Second Degree AV Block
Mobitz Type 1
• PR interval progressively lengthens, with intermittent dropped beats
Mobitz Type 2
• PR interval fixed, with intermittent dropped beats
Third Degree AV Block or Complete Heart Block

• No atrial impulses get transmitted to the ventricles.
• Ventricles generate an escape impulse, which is independent of the atrial beat causing
atrioventricular dissociation.
• There are regularly occurring P waves (often at 60-100 beats per minute) and regularly occurring
QRS complexes (often at 30-45 beats per minute). P waves are asynchronous with the QRS
complexes.

V. ADULT BRADYCARDIA ALGORITHM
Figure 1. 2020 American Heart Association Adult Bradycardia Algorithm
APPROACH TO THE BRADYCARDIA o IV access

ALGORITHM o 12-lead ECG if available; don't delay therapy
o consider possible hypoxic and toxicologic
• Identify the rhythm correctly.
causes
• Check for pulse in under 10 seconds.
• Identify signs of poor perfusion (e.g.,
• If with pulse at <50 beats/min, identify and hypotension, acutely altered mental status,
treat the underlying cause. signs of shock, ischemic chest discomfort, and
o maintain patent airway; assist breathing as acute heart failure).
necessary
o oxygen (if hypoxemic)
o cardiac monitor to identify rhythm; monitor
blood pressure and oximetry
• If with no signs of poor perfusion and the REFERENCES

patient is stable, just monitor and observe. American Heart Association. 2020. Adult Bradycardia
Algorithm. https://cpr.heart.org/-/media/cpr-files/cpr-
• If with signs of poor perfusion and the patient guidelines-files/algorithms/
is unstable, initiate drug management and algorithmacls_bradycardia_200612.pdf
prepare the patient for pacing. Ashish R. Panchal, Jason A. Bartos, José G. Cabañas, et al.
Part 3: Adult Basic and Advanced Life Support: 2020
CARDIAC PACING American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
• Transvenous pacing (TVP) - for Cardiovascular Care. Circulation. 21 Oct
hemodynamically unstable bradyarrhythmias 2020;142:S366–S468
that are refractory to medical therapy Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR,
Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton
• Transcutaneous pacing (TCP) - for bridging to RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken
TVP in hemodynamically unstable KR, Patton KK, Pellegrini C, Selzman KA, Thompson A,
bradyarrhythmias that are refractory to Varosy PD. 2018 ACC/AHA/HRS guideline on the
medical therapy evaluation and management of patients with
bradycardia and cardiac conduction delay: a report of
the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines
and the Heart Rhythm Society. Circulation.
POST-TEST 2019;140:e382–e482. DOI: 10.1161/CIR.000000000000062
True or false:
1. In general, bradycardia causes symptoms

when the rate is <60 beats per minute.
2. The maximum dose of atropine for
3 mg.
3. The infusion rate of dopamine for
5-20 mcg/kg per minute.
4. Epinephrine IV bolus may be given if
atropine is ineffective.
5. Transcutaneous pacing should be
considered in patients with severe
symptoms or hemodynamic
compromise, while preparing the patient
for transvenous pacing.

Module 7: Tachycardia
CHAPTER 7
Tachycardia
John Vincent T. Salvanera, MD, FPCP, FPCC
o know the appropriate management of

different tachyarrhythmias.
PRETEST II. APPROACH TO TACHYARRHYTHMIAS
True or false:
• Tachycardia refers to a heart rate of >100 beats
1. Significant tachycardias are determined per minute in adults.
to be related to heart rates >100 beats • Clinically significant tachycardias (eg,
per minute. tachycardias with a higher risk of causing
2. The main assessment in adult patients hemodynamic instability) are often associated
with tachycardia is to determine whether with heart rates >/=150 beats per minute.
the patient is stable or not.
3. Signs of cardiovascular instability are • Physicians must not only consider treating the
hypotension, signs of shock or acute underlying cause of the tachycardia, but also
heart failure (flash pulmonary edema, consider immediate interventions directed at
jugular venous distention), altered mental the arrhythmia itself.
status, or ischemic chest pain. • The physician must be keen on the possible
4. In patients with unstable clinical conditions such as hypoxemia, anemia,
tachyarrhythmia, the next step is to do heart failure, COPD, and the like.
vagal maneuver.
5. In general, if a patient develops a stable III. NARROW- VS. WIDE-QRS TACHYCARDIA
tachyarrhythmia, we give drug therapy.
• Tachycardias can be classified in several ways,
I. LEARNING OBJECTIVES for example, basing on the appearance of the
QRS complexes and regularity.
• At the end of this module, the learner is • ACLS providers should be able to recognize
expected to: and differentiate between narrow- and wide-
o recognize narrow and wide complex QRS-complex tachycardias.
tachyarrhythmias;
o identify stable and unstable • Most wide-complex tachycardias are
tachyarrhythmias; and ventricular in origin.
SINUS TACHYCARDIA
• Upright, normal-looking P waves followed by narrow QRS complexes
• Heart rate >100 beats per minute
• Regular rhythm

SUPRAVENTRICULAR TACHYCARDIA
• Sudden-onset and termination
• No discernible P waves (e.g., P waves “buried” in the QRS complex)
• Narrow QRS complexes
• Ventricular rate typically 150-250 beats per minute
• Regular rhythm
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE

• No discernible P waves
• Irregularly irregular rhythm
ATRIAL FLUTTER
• "Flutter waves" with saw-tooth appearance
• Atrial rate typically 250-350 beats per minute
• May have regular or irregular rhythm

MULTIFOCAL ATRIAL TACHYCARDIA

• >/=3 different P wave morphologies
• Irregular rhythm
MONOMORPHIC VENTRICULAR TACHYCARDIA

• Most common type of ventricular tachycardia
• No P waves
• Wide QRS complexes
• Regular rhythm
POLYMORPHIC VENTRICULAR TACHYCARDIA

• Another type of ventricular tachycardia
• Multiple ventricular foci with the QRS complexes varying in amplitude, axis and duration

Torsades de pointes
• Specific form of polymorphic ventricular tachycardia
• Associated with QT prolongation
• “Twisting of points” along the isoelectric line
STABLE VS. UNSTABLE TACHYCARDIA

• The initial goal in adult patients with tachycardia is to determine whether the patient is stable or not.
• An unstable tachycardia exists when the cardiac output is reduced that may cause serious signs and
symptoms.
• Signs and symptoms of hemodynamic instability:
o hypotension
o acutely altered mental status
o signs of shock
o ischemic chest discomfort
o acute heart failure
IV. TACHYCARDIA ALGORITHM

Figure 1. 2020 American Heart Association Adult Tachycardia Algorithm
V. DRUGS FOR TACHYCARDIAS • Verapamil

NARROW QRS TACHYCARDIA o dose: 2.5-5.0 mg slow IV push over
2 minutes, every 15-30 minutes, up to a
Adenosine
maximum cumulative dose of 20 mg
• AV nodal blocking agent • Diltiazem
• Drug of choice for stable SVT o initial dose: 0.25 mg/kg (approximately
• Short half-life of <5 seconds 10-20 mg) slow IV push over 2 minutes
• Ideally administered rapidly through an IV o 2nd dose: 0.35 mg/kg (approximately
access placed in the antecubital area, followed 20-25 mg) slow IV push over 2 minutes,
by 20 mL of saline and arm elevation often followed by 5-10 mg/hr infusion
• Initial dose: 6 mg rapid IV push
Beta-blockers
• 2nd and 3rd doses: 12 mg rapid IV push
• Competitive inhibitors of beta-adrenergic
Calcium Channel Blockers receptors
(Non-dihydropyridine) • Widely used for supraventricular and
• Alternative to adenosine for stable SVT ventricular arrhythmias
• May be used as rate controller in stable atrial • Contraindications:
fibrillation/flutter o hypotension
o history of active bronchospasm (e.g.,
• Contraindications: asthma, COPD)
o hypotension o heart blocks
o heart failure with reduced ejection fraction
• Esmolol
o dose: 0.5 mg/kg slow IV push over
1 minute, followed by 0.05-0.20
mg/kg/min maintenance infusion
• Labetalol
o dose: 10 mg slow IV push over 1-2 minutes,
and may be repeated every 10 minutes up
to a maximum cumulative dose of 150 mg

WIDE QRS TACHYCARDIA

Amiodarone
POST-TEST
• Prolongs the action potential duration True or false:
• Decreases AV node conduction
• Widely used for supraventricular and 1. Significant tachycardias are determined
ventricular arrhythmias to be related to heart rates >100 beats
• Contraindication: per minute.
o hypotension 2. The main assessment in adult patients
with tachycardia is to determine whether
• Dose: 150 mg slow IV push over 10 minutes,
the patient is stable or not.
may be followed by 1 mg/min IV infusion for 3. Signs of cardiovascular instability are
6 hours, then 0.5 mg/min IV infusion for the hypotension, signs of shock or acute
next 18 hours heart failure (flash pulmonary edema,
jugular venous distention), altered mental
Lidocaine status, or ischemic chest pain.
• Sodium channel blocker 4. In patients with unstable
tachyarrhythmia, the next step is to do
• May be used as an alternative to amiodarone vagal maneuver.
if the latter is not available 5. In general, if a patient develops a stable
• Initial dose: 1.0-1.5 mg/kg rapid IV push tachyarrhythmia, we give drug therapy.
• 2nd dose: 0.50-0.75 mg/kg rapid IV push
Magnesium sulfate REFERENCES

Ashish R. Panchal, Jason A. Bartos, José G. Cabañas, et al.
• Used for termination of torsades de pointes Part 3: Adult Basic and Advanced Life Support: 2020
• Dose: 1-2 g in 100 mL D5W to be infused American Heart Association Guidelines for
over 1-2 minutes Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2020 | Volume 142,
Issue 16_suppl_2: S366–S468
VI. SYNCHRONIZED CARDIOVERSION Mark S. Link, Lauren C. Berkow, Peter J. Kudenchuk, et al.
• Unstable patients with tachycardia should be Part 7: Adult Advanced Cardiovascular Life Support
treated with synchronized cardioversion as 2015 American Heart Association Guidelines Update for
soon as possible. Cardiovascular Care. Circulation. 2015 | Volume 132,
• Refer to the specific device’s recommended Issue 18_suppl_2: S444–S464
energy level to maximize first shock success. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS
Guideline for the Management of Adult Patients With
Supraventricular Tachycardia: A Report of the
Table 1. Doses for Synchronized Cardioversion of ACC/AHA Task Force on Clinical Practice Guidelines and
Unstable Tachyarrhythmias the Heart Rhythm Society. J Am Coll Cardiol. 2016;
Rhythm Energy Level 67:e27–e115.
Robert W. Neumar, Charles W. Otto, et al. Part 8: Adult
Narrow regular 50-100 Joules Advanced Cardiovascular Life Support. 2010 American
Heart Association Guidelines for Cardiopulmonary
120-200 Joules (biphasic) Resuscitation and Emergency Cardiovascular Care.
Narrow irregular
200 Joules (monophasic) Circulation. 2010 | Volume 122, Issue 18_suppl_3: S729–
S767
Wide regular 100 Joules Ashish R. Panchal, Jason A. Bartos, José G. Cabañas, et al.
Wide irregular Defibrillation American Heart Association Guidelines for

Module 8: Airway Management and Assisted Ventilation
Airway Management
CHAPTER 8
and Assisted Ventilation

Alexander D. Reyes, MD, FPCP, FPCC
NOTE
PRETEST • Cricoid pressure

True or false:
o pressing over the cricoid cartilage to
compress the esophagus
1. Cricoid pressure is recommended to o prevents gastric inflation and reduces
prevent aspiration in adult cardiac arrest regurgitation and aspiration, but impedes
victims. ventilation
2. A chest x-ray can distinguish between o not recommended to be routinely used on
endotracheal and esophageal intubation. adult cardiac arrest victims
3. The ventilation rate for an adult cardiac
arrest patient using a bag-valve-mask AIRWAY DEVICES
device is 1 breath every 6 seconds.
4. Chest compressions can be interrupted Table 2. Airway devices used to deliver assisted
to a maximum of 30 seconds during ventilation during CPR
endotracheal intubation. Basic Airway Advanced Airway Devices
5. Oxygen supplementation on an adult Devices
cardiac arrest victim should be titrated to
maintain an oxygen saturation of ≥94%. 1. Bag-valve-mask 1. Endotracheal tube
device
expected to know how to:
o manage the airway; and
o deliver assisted ventilation during CPR. 2. Supraglottic airways
a. Laryngeal mask
airway
II. AIRWAY MANAGEMENT
AIRWAY ADJUNCTS
Table 1. Airway adjuncts used to maintain airway
patency during CPR
Airway Adjuncts Comments
b. Laryngeal tube
Oropharyngeal • Prevents the tongue from
airway occluding the airway
• Used on unconscious
victims with no cough or
gag reflex
• Can push the tongue into c. Esophageal-tracheal
the hypopharynx tube
Nasopharyngeal • Used if an oropharyngeal
airway airway cannot be placed
• Used with caution if with
basal skull fractures and
severe coagulopathy

ENDOTRACHEAL INTUBATION o If without an advanced airway in place: 2

breaths after every 30 chest compressions
• Advanced airway insertion during CPR:
(Deliver 2 breaths in <10 seconds.)
o allowable duration of interruption in chest
compressions during endotracheal • Avoid excessive ventilation.
intubation: <10 seconds
o Insertion of a supraglottic airway should not OXYGENATION
entail interruption in chest compressions. • Use the maximal feasible inspired oxygen
concentration during CPR.
Table 3. Clinical and device-based parameters to • Routine use of passive ventilation techniques
confirm correct endotracheal tube placement
during conventional CPR for adults is not
Clinical Parameters recommended.
• Visualization of the tube between the vocal
cords
• Symmetric chest wall expansion POST-TEST
True or false:
• Absent epigastric sounds
• Bilateral breath sounds
1. Cricoid pressure is recommended to
Device-Based Parameters prevent aspiration in adult cardiac arrest
victims.
• Continuous waveform capnography 2. A chest x-ray can distinguish between
o end-tidal carbon dioxide concentration endotracheal and esophageal intubation.
(ETCO2) >30 mmHg, on top of clinical 3. The ventilation rate for an adult cardiac
findings supportive of correct endotracheal arrest patient using a bag-valve-mask
tube placement device is 1 breath every 6 seconds.
• Chest x-ray 4. Chest compressions can be interrupted
o tip of the endotracheal tube >2 cm above to a maximum of 30 seconds during
the carina endotracheal intubation.
o Note: Chest x-ray can verify correct vertical 5. Oxygen supplementation on an adult
positioning of the endotracheal tube, but cardiac arrest victim should be titrated to
cannot distinguish between endotracheal maintain an oxygen saturation of ≥94%.
and esophageal intubation.
REFERENCES
NOTE: Berg, R. A., Hemphill, R., Abella, B. S., Aufderheide, T. P.,
Cave, D. M., Hazinski, M. F., Lerner, E. B., Rea, T. D.,
• Other devices for confirmation of correct Sayre, M. R., & Swor, R. A. (2010). Part 5: Adult basic
endotracheal tube placement: life support: 2010 American Heart Association
o non-waveform carbon dioxide detector Guidelines for Cardiopulmonary Resuscitation and
o esophageal detector device Emergency Cardiovascular Care. Circulation, 122(suppl
3), S685–S705.
o ultrasound Callaway, C. W., Soar, J., Aibiki, M., Böttiger, B. W., Brooks,
S. C., Deakin, C. D., Donnino, M. W., Drajer, S., Kloeck,
III. ASSISTED VENTILATION W., Morley, P. T., Morrison, L. J., Neumar, R. W.,
Nicholson, T. C., Nolan, J. P., Okada, K., O’Neil, B. J.,
VENTILATION TECHNIQUE Paiva, E. F., Parr, M. J., Wang, T. L., … Zimmerman, J.
• Use an adult (1 to 2 L) self-inflating bag. (2015). Part 4: Advanced life support: 2015 International
consensus on cardiopulmonary resuscitation and
• Deliver adequate tidal volume sufficient to emergency cardiovascular care science with treatment
produce chest rise. recommendations. Circulation, 132(suppl 1), S84–S145.
• Deliver tidal volume over 1 second. Kleinman, M. E., Brennan, E. E., Goldberger, Z. D., Swor, R.
A., Terry, M., Bobrow, B. J., Gazmuri, R. J., Travers, A. H.,
• Ventilation rate: & Rea, T. (2015). Part 5: Adult basic life support and
o If with an advanced airway in place: 1 breath cardiopulmonary resuscitation quality: 2015 American
every 6 seconds with continuous chest Heart Association guidelines update for
compressions cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 132(suppl 2), S414–
S435.

Link, M. S., Berkow, L. C., Kudenchuk, P. J., Halperin, H. R.,

Hess, E. P., Moitra, V. K., Neumar, R. W., O’Neil, B. J.,
Paxton, J. H., Silvers, S. M., White, R. D., Yannopoulos,
D., & Donnino, M. W. (2015). Part 7: Adult advanced
cardiovascular life support: 2015 American Heart
Association guidelines update for cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation, 132(suppl 2), S444–S464.
Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L.,
Shuster, M., Callaway, C. W., Kudenchuk, P. J., Ornato,
J. P., McNally, B., Silvers, S. M., Passman, R. S., White,
R. D., Hess, E. P., Tang, W., Davis, D., Sinz, E., &
Morrison, L. J. (2010). Part 8: Adult advanced
cardiovascular life support: 2010 American Heart
Circulation, 122(suppl 3), S729–S767.
Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W.,
Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M.
C., Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M.
A., Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., &
Berg, K. M. (2020). Part 3: Adult Basic and Advanced
Life Support: 2020 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation, 142(suppl
2), S366–S468.
Soar, J., MacOnochie, I., Wyckoff, M. H., Olasveengen, T.
M., Singletary, E. M., Greif, R., Aickin, R., Bhanji, F.,
Donnino, M. W., Mancini, M. E., Wyllie, J. P., Zideman,
D., Andersen, L. W., Atkins, D. L., Aziz, K., Bendall, J.,
Berg, K. M., Berry, D. C., Bigham, B. L., … Fran Hazinski,
M. (2019). 2019 International Consensus on
Cardiovascular Care Science with Treatment
Recommendations: Summary from the Basic Life
Support; Advanced Life Support; Pediatric Life
Support; Neonatal Life Support; Education, I.
Circulation, 140, e826–e880.
Soar, J., Nolan, J. P., Böttiger, B. W., Perkins, G. D., Lott, C.,
Carli, P., Pellis, T., Sandroni, C., Skrifvars, M. B., Smith,
G. B., Sunde, K., Deakin, C. D., Koster, R. W., Monsieurs,
K. G., & Nikolaou, N. I. (2015). European Resuscitation
Council Guidelines for Resuscitation 2015. Section 3.
Adult advanced life support. Resuscitation, 95, 100–
147.
Travers, A. H., Perkins, G. D., Berg, R. A., Castren, M.,
Considine, J., Escalante, R., Gazmuri, R. J., Koster, R. W.,
Lim, S. H., Nation, K. J., Olasveengen, T. M., Sakamoto,
T., Sayre, M. R., Sierra, A., Smyth, M. A., Stanton, D.,
Vaillancourt, C., Bierens, J. J. L. M., Bourdon, E., … Yeung,
J. (2015). Part 3: Adult basic life support and automated
external defibrillation: 2015 international consensus on
cardiopulmonary resuscitation and emergency
cardiovascular care science with treatment
recommendations. Circulation, 132(suppl 1), S51–S83.
Wang, H. E., & Carlson, J. N. (2020). Tracheal Intubation. In
J. E. Tintinalli, O. J. Ma, D. M. Yealy, G. D. Meckler, J. S.
Stapczynski, D. M. Cline, & S. H. Thomas (Eds.),
Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide (9th ed., pp. 179–190). McGraw-Hill
Education.

Module 9: Post-cardiac Arrest Care
CHAPTER 9
Post-cardiac Arrest Care

Neil Wayne C. Salces, MD, FPCP, FPCC
• Effective post-cardiac arrest care consists of

identification and treatment of the
PRETEST precipitating cause of cardiac arrest combined
True or false: with the assessment and mitigation of
ischemia-reperfusion injury to multiple organ
1. It is recommended to perform urgent systems.
coronary angiography with prompt
recanalization of any infarct-related
artery in select post–cardiac arrest
patients in whom ST-segment elevation
was identified.
2. Published protocols recommend a target
SBP of >90 mmHg, or MAP of >65 mmHg.
3. Targeted temperature management
refers to induced hypothermia as well as
active control of temperature at any
target.
4. In doing targeted temperature
management, we use the surface
temperature instead of the core Figure 1. Post-cardiac Arrest Care
temperature.
5. Immediate prognostication post-cardiac
MULTIDISCIPLINARY SYSTEM OF CARE
arrest is recommended.
• Care after cardiac arrest must be tailored to
the particular disease and dysfunction that
I. LEARNING OBJECTIVES affect each patient. Therefore, individual
patients may require few, many or all of the
• At the end of this module, the learner is specific interventions.
expected to:
• The best hospital care for patients with return
o know the basics of multidisciplinary system
of spontaneous circulation or ROSC after
of care for the treatment of post-cardiac
cardiac arrest is not completely known, but
arrest care patients: cardiovascular,
there is increasing interest in identifying and
neurologic, respiratory, and metabolic care;
optimizing practices that are likely to improve
and
outcomes.
o know related issues on prognostication and
organ donation. Cardiovascular care
II. POST-CARDIAC ARREST CARE • Acute coronary syndromes are a common
PRINCIPLES OF POST-CARDIAC ARREST CARE etiology for out-of-hospital cardiac arrest in
adults with no obvious extra-cardiac cause of
• Cardiac arrest can result from many different arrest, and also can precipitate some in-
diseases. hospital cardiac arrest.
• Regardless of cause, the hypoxemia, ischemia, • In the acute setting, you need to obtain a 12-
and reperfusion that occur during cardiac lead ECG as soon as possible after return of
arrest and resuscitation may cause damage to spontaneous circulation to check for acute ST
multiple organ systems. elevation.

Table 1. Common Vasoactive Drugs

Drug Dose
Dopamine 5-10 mcg/kg/min
Dobutamine 5-10 mcg/kg/min
Norepinephrine 0.5-2.0 mcg/kg/min
Epinephrine 0.1-0.5 mcg/kg/min
Figure 2. Inferior wall STE-ACS
Phenylephrine 0.1-0.5 mcg/kg/min
• Perform urgent coronary angiography with
Load 50 mcg/kg over 10 minutes
prompt recanalization of any infarct-related Milrinone
then infuse at 0.375 mcg/kg/min
artery in select post-cardiac arrest patients in
whom ST-segment elevation was identified. • Drugs may be selected to improve heart rate
(chronotropic effects), myocardial contractility
(inotropic effects), or arterial pressure
(vasoconstrictive effects), or to reduce
afterload (vasodilator effects).
Neurologic care
Targeted temperature management
• Refers to induced hypothermia as well as
Figure 3. Angiography of the right coronary artery active control of temperature at any target.
before and after percutaneous coronary intervention (PCI) Induced hypothermia consists of controlled
reduction of the patient’s core temperature
• Post–cardiac arrest patients are often with pre-defined therapeutic goals.
hemodynamically unstable, which can occur • Studies have found that targeted temperature
for multiple reasons that include the management significantly improves rates of
underlying etiology of the arrest as well as the long-term neurologically intact survival and it
ischemia-reperfusion injury from the arrest. has been considered as one of the most
Management of these patients can be important clinical advancements in the
challenging, and optimal hemodynamic goals science of resuscitation.
remain undefined. • In doing targeted temperature management,
• A specific mean arterial pressure or systolic use the core temperature instead of the
blood pressure that should be targeted as part surface temperature via:
of the bundle of post-resuscitation o continuous rectal temperature monitoring;
interventions could not be identified, although o esophageal;
published protocols recommend a target SBP o bladder; or
of >90 mmHg, or MAP of >65 mmHg. o central body temperature (eg, pulmonary
• Targets for other hemodynamic or perfusion artery catheter)
measures (such as cardiac output, • It is encouraged to develop a team of local
mixed/central venous oxygen saturation, and experts that physicians can refer patients to for
urine output) remain undefined in post– targeted temperature management.
cardiac arrest patients.
• To address the hemodynamic instability,
vasoactive drugs may be administered after
ROSC to support cardiac output to sustain
adequate blood flow to the heart and brain.

Table 2. Recommendations for Targeted o absence of the N20 somatosensory evoked

Temperature Management potential cortical wave 24 to 72 hours after
COR LOE Recommendations cardiac arrest or after rewarming
o presence of a marked reduction of the gray-
B-R for VF/pVT white ratio on brain CT obtained within
comatose (eg, lack of
OHCA 2 hours after cardiac arrest
meaningful response to
I verbal commands) adult o extensive restriction of diffusion on brain
C-EO for
patients with ROSC after MRI at 2 to 6 days after cardiac arrest
non-VF/pVT
cardiac arrest receive TTM o persistent absence of EEG reactivity to
and IHCA
external stimuli at 72 hours after cardiac
selecting and maintaining a arrest
constant temperature o Persistent burst suppression or intractable
I B-R
between 32ºC and 36ºC status epilepticus on EEG after rewarming
during TTM
§ *Note: Shock, temperature, metabolic
TTM be maintained for at derangement, prior sedatives or
least 24 hours after neuromuscular blockers, and other
IIa C-EO
achieving target clinical factors should be considered
temperature carefully because they may affect results
actively prevent fever in
or interpretation of some tests.
IIb C-LD comatose patients after • Absent motor movements, extensor
TTM posturing, or myoclonus should not be used
alone for predicting outcome.
routine prehospital cooling
of patients after ROSC with
Respiratory care
III A rapid infusion of cold
intravenous fluids is not • Present guidelines emphasize the identification
recommended of pulmonary dysfunction after cardiac arrest.
• Hypoxemia
Seizure management o an arterial oxygen saturation (SaO2) of less
• The prevalence of seizures, and other than 94%
epileptiform activity among patients who are o episodes of hypoxia that can add to organ
comatose after cardiac arrest is estimated to injury should also be prevented
be 12% to 22%. Available evidence does not • Mechanical ventilation
support prophylactic administration of o used to assist or replace spontaneous
anticonvulsant drugs. breathing in order to decrease the work of
• An electroencephalogram (EEG) should be breathing, thus avoiding respiratory muscle
promptly performed to determine the fatigue; and,
presence of epileptiform discharges, and then o to reverse life-threatening hypoxemia and
should be monitored frequently or progressive respiratory acidosis.
continuously in comatose patients after ROSC. o for protective ventilation
§ Initial back up rate of 10-12 breaths per
Clinical examination findings that predict minute
outcome § Tidal volume of 6-8 mL/kg
• Useful clinical findings that are associated with • Normocarbia, with an end-tidal CO2 30–40
poor neurologic outcome* mmHg or PaCO2 35–45 mmHg, is a reasonable
o absence of pupillary reflex to light at 72 goal unless patient factors prompt more
hours or more after cardiac arrest individualized treatment.
o presence of status myoclonus (different • Shortly after ROSC, patients may have
from isolated myoclonic jerks) during the peripheral vasoconstriction that makes
first 72 hours after cardiac arrest measurement of oxyhemoglobin saturation by
pulse oximetry difficult or unreliable.

Preventing hypoxic episodes is considered PROGNOSTICATION OF OUTCOME

more important than avoiding any potential • Immediate prognostication post-cardiac
risk of hyperoxia. arrest is not recommended.
• What to do to avoid hypoxia: • The earliest time to prognosticate a poor
o use the highest available oxygen neurologic outcome using clinical examination
concentration (100% FiO2) until arterial in patients not treated with TTM is 72 hours
oxyhemoglobin saturation or the partial after cardiac arrest, but this time can be even
pressure of arterial oxygen can be longer after cardiac arrest if the residual effect
measured of sedation or paralysis is suspected to
o when resources are available to titrate the confound the clinical examination.
FiO2 and to monitor oxyhemoglobin
• In patients treated with TTM, where sedation
saturation, decrease the FiO2 when
or paralysis could confound clinical
oxyhemoglobin saturation is 100%.
examination, it is reasonable to wait until 72
o oxyhemoglobin saturation can be
hours after return to normothermia before
maintained at 92 to 98% of greater.
predicting outcome.
Metabolic care
ORGAN DONATION
• In recent guidelines, management of • Organ donation is a noble and altruistic act of
metabolic derangements focuses only on saving a life through committing one’s organs
blood glucose.
or tissues upon one’s death.
• For hyperglycemic critically ill patients, a • Adult patients who progress to brain death
blood glucose target of 140 to 180 mg/dl is after resuscitation from cardiac arrest should
recommended, rather than a more stringent
be considered for organ donation.
(80-110 mg/dl) or a more liberal target (180-
200 mg/dl). • Donation after cardiac death is a second
pathway to organ donation (the first is
• However, the benefit of any specific target following the determination of brain death)
range of glucose management in adults with which can occur when a patient dies from
ROSC after cardiac arrest is still uncertain. cardiac arrest in the hospital.
III. ADULT POST-CARDIAC ARREST ALGORITHM

Figure 5. 2020 American Heart Association Adult Post-cardiac Arrest Care Algorithm
REFERENCES
Callaway, C. W., Donnino, M. W., Fink, E. L., Geocadin, R.
POST-TEST G., Golan, E., Kern, K. B., Leary, M., Meurer, W. J.,
True or false: Peberdy, M. A., Thompson, T. M., & Zimmerman, J. L.
(2015). Part 8: Post-cardiac arrest care: 2015 American
Heart Association guidelines update for
1. It is recommended to perform urgent cardiopulmonary resuscitation and emergency
coronary angiography with prompt cardiovascular care. Circulation, 132(18), S465–S482.
recanalization of any infarct-related https://doi.org/10.1161/CIR.0000000000000262
artery in select post–cardiac arrest Longstreth Jr, W. T., Fahrenbruch, C. E., Olsufka, M., Walsh,
patients in whom ST-segment elevation T. R., Copass, M. K., & Cobb, L. A. (2002). Randomized
was identified. clinical trial of magnesium, diazepam, or both after out-
2. Published protocols recommend a target of-hospital cardiac arrest. Neurology, 59(4), 506–514.
SBP of >90 mmHg, or MAP of >65 mmHg. https://doi.org/10.1212/wnl.59.4.506
3. Targeted temperature management Rittenberger, J. C., Popescu, A., Brenner, R. P., Guyette, F. X.,
& Callaway, C. W. (2012). Frequency and timing of
refers to induced hypothermia as well as
nonconvulsive status epilepticus in comatose post-
active control of temperature at any cardiac arrest subjects treated with hypothermia.
target. Neurocritical Care, 16(1), 114–122.
4. In doing targeted temperature https://doi.org/10.1007/s12028-011-9565-0
management, we use the surface Stapleton, R., & Heyland, D. (2019). Glycemic control and
temperature instead of the core intensive insulin therpay in critical illness. UpToDate.
temperature. Walker, A. C., & Johnson, N. J. (2019). Targeted Temperature
5. Immediate prognostication post-cardiac Management and Postcardiac arrest Care. Emergency
arrest is recommended. Medical Clinics of North America, 37(3), 381–393.
https://doi.org/10.1016/j.emc.2019.03.002.

Module 10: Acute Coronary Syndrome
CHAPTER 10
Acute Coronary Syndrome

Marc Denver A. Tiongson, MD, FPCP, FPCC
PATHOPHYSIOLOGY
• ACS can present with ST-elevation or non-ST-
PRETEST elevation changes on the ECG
True or false:
Table 1. Pathophysiologic mechanisms of acute
1. STE-ACS is a condition that results from coronary syndrome
partial occlusion of blood flow in the Illustration ECG changes
coronary artery.
2. The chest pain of ACS is sudden,
increasing in intensity and lasts more
than 30 minutes.
3. The coronary artery involved in inferior
wall STE-ACS is the left anterior
descending coronary artery.
4. Part of the initial care among patients • Total occlusion of the involved
suffering from ACS is oxygen therapy coronary artery as a result of
regardless of oxygen saturation. plaque rupture
5. Patients suffering from NSTE-ACS with • Presents with ST-elevation on
intractable chest pain should be referred ECG
for coronary angiogram and angioplasty.
expected to:
o recognize patients presenting with acute
coronary syndrome (ACS); and,
o know the initial management of patients
presenting with ACS.
II. ACUTE CORONARY SYNDROME • Partial occlusion of the involved

coronary artery as a significant
• A condition that results from decreased blood coronary artery narrowing
flow in the coronary arteries • Presents with ST-depression or
• As a consequence, the affected myocardium T wave inversion on ECG
dies and there is a decrease in cardiac function
• Most common proximate cause of sudden GOALS OF ACS MANAGEMENT
cardiac arrest (SCA) • Reduce myocardial necrosis
• Clinically presents with chest pain with or • Treat acute life-threatening complications
without associated ECG changes and/or • Prevent major adverse cardiac events (MACE)
elevated cardiac markers such as CK-MB and
troponin

CLINICAL MANIFESTATION RISK FACTORS

Table 2. Description of ischemic chest pain • Hypertension • Obesity
Parameter Description • Type 2 diabetes or • Dyslipidemia
Onset Sudden onset, increasing intensity metabolic • Kidney disease
Provoking Provoked by an activity (eg, syndrome • Smoking
and exercise, extreme emotion) • Family history of
palliating May or may not respond to
cardiovascular
factors sublingual nitroglycerin
Squeezing, tightness, heaviness, disease
Quality • Poor fitness or
crushing, fullness
Upper abdomen, shoulders, arms, sedentary lifestyle
Radiation wrist, fingers, neck and throat, lower
jaw and teeth (but not upper jaw),
Diffuse chest discomfort (no single
Site
spot)
Timing More than 30 minutes
ECG CHANGES IN ACS

ECG WAVEFORMS
Table 3. ECG parts and description
ECG
Description
component
P wave • Corresponds to atrial depolarization
QRS complex • Corresponds to ventricular depolarization
• Point of interest in the assessment of ACS
• Normally isoelectric
• May deviate between -0.5 to +1.0 mm from baseline
• Elevation in V2 and V3 ≥2 mm in men ≥40 years, ≥2.5 mm in
ST segment men <40 years, or ≥1.5 mm in women; or ST segment elevation in
all other leads ≥1 mm in at least 2 contiguous leads are suggestive
of STE-ACS.
• Depression ≥0.5 mm in at least 2 contiguous leads is suggestive of
Figure 1. The ischemia
electrocardiogram waves, • Corresponds to ventricular repolarization
complexes, and segment T wave • Usually upright
• T wave inversion >1 mm in at least 2 contiguous leads is suggestive
of ischemia
ECG LEAD AND CORONARY ARTERY CORRELATION
Table 4. ECG leads with myocardial
involvement and coronary artery
involvement correlation
ECG leads and Usual coronary artery
involvement involved
V1, V2 Left anterior descending
(Septal wall) coronary artery
V3, V4 Left anterior descending
(Anterior wall) coronary artery
V5, V6 Left circumflex
(Lateral wall) coronary artery
I, aVL
Left circumflex
(High lateral
coronary artery
wall)
Figure 2. 12L ECG tracing with myocardial involvement correlation II, III, aVF
Right coronary artery
(Inferior wall)

ECG EXAMPLES
Figure 3. 12L ECG tracing showing anteroseptal and high lateral wall STE-ACS. Note the ST-segment
elevation in leads I, aVL, and V1-V3 (red boxes).
Figure 4. 12L ECG tracing showing inferolateral wall ischemia. Note the ST-segment depression in
leads I, aVL, II, aVF, and V4-V6 (red arrows).
Figure 5. 12L ECG tracing showing inferior and anterolateral wall ischemia. Note the significant T wave
inversion in leads II, aVF, and V2-V6.

III. MANAGEMENT • Establish IV access and obtain blood tests,

GENERAL APPROACH TO ACS MANAGEMENT troponin
Initial assessment and care • Oxygen support if oxygen saturation <90%
• ABCs, vital signs, focused history and physical • Hook to cardiac monitor
examination • Obtain 12L ECG
• Aspirin 162 to 325 mg (chewed and
swallowed) ECG interpretation
• SL nitroglycerin 0.4 mg every 5 minutes unless • Assess ECG for changes
contraindicated (IV morphine if needed) • Identify if the patient has STE-ACS or
NSTE-ACS
DEFINITIVE MANAGEMENT
Figure 6. General algorithm for ACS management

Timing of reperfusion in STE-ACS ADJUNCTIVE THERAPIES
Table 5. Preferred reperfusion strategy with • Anti-platelet options as addition to aspirin for
respect to onset of chest pain dual antiplatelet therapy (DAPT)
Timing Strategy o Ticagrelor 90 mg (180 mg if for PCI)
2 hours Fibrinolysis > PCI o Prasugrel 5-10 mg (60 mg if for PCI)
2 to 3 hours Fibrinolysis = PCI o Clopidogrel 300 mg (600 mg if for PCI)
3 to 24 hours Fibrinolysis < PCI • Renin-angiotensin inhibitor
o Captopril 25 mg ¼ tab every 8 hours
• Anticoagulant
o Heparin (UFH or LMWH) or fondaparinux
• High-intensity statin
o Rosuvastatin 20-40 mg once a day
o Atorvastatin 40-80 mg once a day
• Beta-blocker
o Metoprolol 50 mg ½ tab every 6-12 hours
o Carvedilol 6.25 mg ½ tab every 12 hours
IV. STEMI CONSULT APP REFERENCES

Amsterdam EA, Wenger NK, Brindis RG, et al. 2014
• Local AHA/ACC guideline for the management of patients
application that with non-ST-elevation acute coronary syndromes:
helps patients executive summary: a report of the American College
and physicians of Cardiology/American Heart Association Task Force
in ACS on Practice Guidelines. Circulation 2014
Bossaert L, O’Connor RE, Arntz HR, Brooks SC, Diercks D,
management Feitosa- Filho G, Nolan JP, Hoek TL, Walters DL, Wong
• Provides A, Welsford M, Woolfrey K; Acute Coronary Syndrome
information on Chapter Collaborators. Part 9: acute coronary
heart attack syndromes: 2010 International Consensus on
• Enables users to Cardiovascular Care Science With Treatment
see centers Recommendations. Resuscitation. 2010;81 suppl
where they can 1:e175–e212. doi: 10.1016/j.resuscitation.2010.09.001.
get treatment Davis M, Lewell M, McLeod S, Dukelow A. A prospective
all over the evaluation of the utility of the prehospital 12-lead
electrocardiogram to change patient management in
country the emergency department. Prehosp Emerg Care.
• Provides 2014;18:9–14.
algorithmic Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O.
management Bonow ; founding editor and online editor Eugene
Braunwald. Braunwald's Heart Disease : a Textbook of
for ACS Cardiovascular Medicine. Philadelphia, PA
:Elsevier/Saunders, 2015.
Jameson, JL, A Fauci, D Kasper, et al. Harrison's Principles of
Internal Medicine. 20th edition. New York: McGraw Hill
Education, 2018.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA
guideline for the management of ST-elevation
myocardial infarction: a report of the American College
of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. Circulation 2013
O'Connor RE, William Brady, Steven C. Brooks, et al. Part
Scan QR code to download the app. 10: Acute Coronary Syndromes: 2010 American Heart
Circulation 2010;122;S787-S817
POST-TEST O’Connor RE, Al Ali AS, Brady WJ, Ghaemmaghami CA,
True or false: Menon V, Welsford M, Shuster M. Part 9: acute
coronary syndromes: 2015 American Heart
Association Guidelines Update for Cardiopulmonary
1. STE-ACS is a condition that results from Resuscitation and Emergency Cardiovascular Care.
partial occlusion of blood flow in the Circulation. 2015;132(suppl 2):S483–S500.
coronary artery.
2. The chest pain of ACS is sudden,
increasing in intensity and lasts more
than 30 minutes.
3. The coronary artery involved in inferior
wall STE-ACS is the left anterior
descending coronary artery.
4. Part of the initial care among patients
suffering from ACS is oxygen therapy
regardless of oxygen saturation.
5. Patients suffering from NSTE-ACS with
intractable chest pain should be referred
for coronary angiogram and angioplasty.

Module 11: Recognition of ACLS Rhythms
CHAPTER 11
Recognition of ACLS Rhythms

Raymond D. Bayaua, MD, FPCP, FPCC
5.
PRETEST
Choose the best corresponding rhythm
for each of the ECG strips provided.
1. A.Sinus arrest
B. High-grade AV block
C.Second degree AV block type II
D.Complete heart block
A. Asystole
B. Pulseless electrical activity
C. Complete heart block I. LEARNING OBJECTIVES
D. Idioventricular rhythm • At the end of this module, the learner is
expected to:
2.
o correctly identify a normal ECG tracing;
and
o correctly identify arrhythmias in the
emergency setting.
A.Sinus exit block II. ARRHYTHMIA RECOGNITION

B. Sinus arrest ANATOMY AND PHYSIOLOGY
C.Type I second degree AV block
D. Complete heart block
3.
A.Non-sustained ventricular tachycardia

B. Atrial premature complex
C.Accelerated idioventricular rhythm
4. Figure 1. Anatomy and physiology of cardiac

conduction
• The impulses from the SA node travel through

A.Atrial fibrillation the internodal connections to the
B. Atrial flutter atrioventricular node (or AV node). From the
C.Wandering atrial pacemaker AV node, impulses travel through the Bundle
D.Sinus rhythm of His and down the bundle branches. Both the
bundle branches terminate as Purkinje fibers,
spreading throughout the myocardium.

BASIC ECG INTERVALS AND MEASUREMENTS
Figure 2. Basic ECG intervals and measurements

Heart rate QTc = QTa⁄√RR
• 60 to 100 beats per minute: normal • QTc is prolonged if >450 ms in men or
• <60 beats per minute: bradycardia >460 ms in women.
• >100 beats per minute: tachycardia • QTc >500 ms is associated with an increased
risk for torsades de pointes.
Normal PR interval • QTc is abnormally short if <350 ms.
0.12 to 0.20 seconds (3 to 5 mm)
STEPS IN ECG INTERPRETATION
QRS duration Table 1. Steps in ECG interpretation
<0.12 seconds (<3 mm) 1. Check the regularity.
2. Check the rate.
3. Check if the rhythm is sinus.
QT interval 4. Check for P-QRS relationship.
• Compute for the corrected QT (QTc) by 5. Check the PR interval, QRS duration, and QT interval.
dividing the QT interval by the square root of 6. Check for other rhythm abnormalities.
the preceding R-to-R interval:
Regularity
Figure 3. Regularity. The beat-to-beat intervals (P-to-P or R-to-R) are the same.
Rate
Figure 4. Heart rate determination using the small squares, large squares, and 10-second strip
Figure 5. Heart rate determination for irregular rhythms using a 6-second strip. Count the number of complete
QRS complexes in a 6-second strip, then multiply it by 10, to get the heart rate. In this example, there are 6
complete QRS complexes in a 6-second strip, with a computed heart rate of 60 beats per minute (6 complete
QRS complexes in a 6-second strip, multiplied by 10).
Rhythm
• Native pacemaker impulses are initiated in the
SA node at a rate of 60 to 100 beats per
minute.
• The rhythm is “sinus” if the P waves have a
smooth contour and are upright in leads I, II,
aVF and in the left precordial leads.
• Normal sinus rhythm should have a P wave
always followed by a QRS complex at regular
intervals, at a rate of 60 to 100 beats per
Figure 6. Sinus rhythm.
minute.

THE ACLS RHYTHMS

Table 2. ACLS Rhythms
ARREST RHYTHMS SLOW RHYTHMS FAST RHYTHMS
• Ventricular fibrillation • Sinus bradycardia • Sinus tachycardia
• Pulseless ventricular • AV blocks • Supraventricular tachycardia
tachycardia • Escape rhythms • Atrial flutter
• Asystole o Junctional rhythm • Atrial fibrillation
• Pulseless electrical activity o Idioventricular rhythm • Multifocal atrial tachycardia
• Sinus pause • Ventricular tachycardia
Arrest Rhythms
VENTRICULAR FIBRILLATION
• Most serious cardiac rhythm disturbance
• Causes ventricles to fibrillate
• Chaotic oscillations of the baseline; no P-QRS complexes
• Indeterminate rate
Figure 7. Coarse (A), and fine (B) ventricular fibrillation
PULSELESS VENTRICULAR TACHYCARDIA

• Wide QRS complex, fast rhythm which clinically does not produce a pulse
o Although there is electrical activity on the monitor, this is clinically associated with no effective
contraction.
• Patients with this rhythm are considered in cardiac arrest
Figure 8. Ventricular tachycardia

ASYSTOLE
• Absence of electrical activity
• Appears as a near-straight line on the cardiac monitor
Figure 9. Asystole
PULSELESS ELECTRICAL ACTIVITY

• State of cardiac arrest wherein there is electrical activity on the monitor, but the heart does not
contract effectively, hence no palpable pulse
Figure 10. Idioventricular rhythm. If this rhythm does not produce a pulse, then the victim is said to have
“pulseless electrical activity.”
Slow Rhythms
Figure 11. Guide to the identification of slow ACLS rhythms

SINUS BRADYCARDIA
• Slow rhythm with regularly occurring P-QRS complexes at <60 beats per minute
Figure 12. Sinus bradycardia
1ST DEGREE AV BLOCK

• Prolonged PR interval of >0.20 seconds (or >5 small boxes)
• Rhythm is still regular, with a constant P-QRS relationship.
Figure 13. First-degree AV block
2ND DEGREE AV BLOCK, MOBITZ TYPE 1 (WENCKEBACH)

• Irregular rhythm with group beating
• Progressive prolongation of the PR interval with intermittent dropped beats
Figure 14. Second degree AV block, Mobitz type 1
2ND DEGREE AV BLOCK, MOBITZ TYPE 2

• Irregular rhythm with group beating
• Fixed PR interval with intermittent dropped beats
Figure 15. Second degree AV block, Mobitz type 2

3RD DEGREE AV BLOCK (OR COMPLETE HEART BLOCK)

• Regularly occurring P waves, and regularly occurring QRS complexes, but with no P-QRS relationship
• No evidence of AV conduction
Figure 16. Complete heart block
2:1 AV BLOCK
• Regularly occurring P waves, with 2 P waves preceding each QRS complex
Figure 17. 2:1 AV block

HIGH-GRADE AV BLOCK
• Regularly occurring P waves, with more than 2 P waves preceding each QRS complex
Figure 18. High-grade AV block

ESCAPE RHYTHMS PACEMAKER RHYTHMS

Junctional rhythm • Encountered among patients with artificial
• Slow and regular rhythm with a rate typically pacemakers
from 40 to 60 beats per minute • Pacemaker “spike” or “blip” preceding the QRS
• P waves are absent or retrogradely complex represents the microvolt stimulation of
conducted, with narrow QRS complexes the device to generate cardiac contraction.
• Origin of the impulse is in the area of the • Pacemaker systems may be dual- or single-chamber,
atrioventricular junction and the paced QRS complex is usually wide.
Figure 19. Junctional rhythm with retrogradely Figure 21. Pacemaker rhythm
conducted P wave
SINUS PAUSE (OR SINUS ARREST)
Idioventricular rhythm • Long pause interspersed among regularly
• Slow and regular rhythm with a rate typically occurring P-QRS complexes
from 20 to 40 beats per minute • Distinguished from 2nd degree AV block by
• Absent P waves with wide QRS complexes the absence of P waves with no subsequent
• Typically encountered as an arrest rhythm or dropped QRS complexes
Figure 20. Idioventricular rhythm Figure 22. Sinus pause
Fast Rhythms
Figure 23. Guide to the identification of fast ACLS rhythms

SINUS TACHYCARDIA VENTRICULAR TACHYCARDIA

• Regularly occurring P-QRS complexes at >100 • Regular, wide complex tachycardia
beats per minute • Occasionally with visible P waves, but are
• Most often results from physiologic stress dissociated from the QRS complexes
Figure 24. Sinus tachycardia Figure 28. Ventricular tachycardia
SUPRAVENTRICULAR TACHYCARDIA TORSADES DE POINTES

• Regular, narrow complex tachycardia • Fast, irregular, wide QRS complexes, with
• P waves usually indiscernible (e.g., buried in typical twisted appearance
the T wave, or retrograde) • Seen on the background of a prolonged QT interval
Figure 25. Supraventricular tachycardia Figure 29. Torsades de pointes
ATRIAL FLUTTER
• Narrow complex tachycardia, with
characteristic saw-tooth or flutter P waves
POST-TEST
Choose the best corresponding rhythm
• May present with variable degrees of AV for each of the ECG strips provided.
block, hence may be regular or irregular
1.
A. Asystole
B. Pulseless electrical activity
C. Complete heart block
Figure 26. Atrial flutter
D. Idioventricular rhythm
ATRIAL FIBRILLATION 2.
• Irregularly irregular rhythm with no
discernible P waves
A.Sinus exit block

B. Sinus arrest
C.Type I second degree AV block
Figure 27. Atrial fibrillation D. Complete heart block

REFERENCES
3. Ashish R. Panchal, Jason A. Bartos, José G. Cabañas, et al.
American Heart Association Guidelines for
A.Non-sustained ventricular tachycardia Mark S. Link, Lauren C. Berkow, Peter J. Kudenchuk, et al.
B. Atrial premature complex Part 7: Adult Advanced Cardiovascular Life Support
C.Accelerated idioventricular rhythm 2015 American Heart Association Guidelines Update for
4. Issue 18_suppl_2: S444–S464
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS
Guideline for the Management of Adult Patients With
Supraventricular Tachycardia: A Report of the
ACC/AHA Task Force on Clinical Practice Guidelines and
A.Atrial fibrillation the Heart Rhythm Society. J Am Coll Cardiol. 2016;
B. Atrial flutter 67:e27–e115.
Robert W. Neumar, Charles W. Otto, et al. Part 8: Adult
C.Wandering atrial pacemaker Advanced Cardiovascular Life Support. 2010 American
D.Sinus rhythm Heart Association Guidelines for Cardiopulmonary
Circulation. 2010 | Volume 122, Issue 18_suppl_3: S729–
5. S767
Ashish R. Panchal, Jason A. Bartos, José G. Cabañas, et al.
American Heart Association Guidelines for
A.Sinus arrest Issue 16_suppl_2: S366–S468
B. High-grade AV block
C.Second degree AV block type II
D.Complete heart block

Module 12: Cardiac Drugs
CHAPTER 12
Cardiac Drugs
Eric John A. Marayag, MD, FPCP, DPCC

Choose the best answer. expected to know the ACLS drugs’:
o basic mechanism of action;
1. A 42-year-old female presented at the o indications and contraindications;
emergency room due to dizziness. Patient is a o dosages; and
known case of Graves’ disease compliant to o route of administration.
medications. Patient is awake, responsive
with BP 140/90 HR 180 and presents with II. DRUGS FOR CARDIAC ARREST
supraventricular tachycardia on
electrocardiogram. She was given adenosine DRUG REMARKS
6 mg/ fast IV bolus followed by another 2
doses of adenosine 12 mg/IV. However on ! Catecholamine; agonist of beta-
rechecking of vital signs, BP 130/80 HR 160 and alpha-adrenergic system
still with supraventricular tachycardia on ! Increases systemic vascular
monitor. What would be the next best EPINEPHRINE resistance and heart rate thereby
therapeutic intervention? increases blood pressure
a. Epinephrine 1 mg/IV fast IV bolus ! Dose: 1 mg/IV bolus or 2.0 -2.5
b. Synchronized cardioversion at 100 Joules mg/ ET every 3-5 minutes
c. Defibrillation at 200 Joules
d. Verapamil 2.5 mg/IV ! Class III anti-arrhythmic agent that
prolongs after depolarization
2. In which of the following cases is ! Indicated in ventricular fibrillation
administering esmolol absolutely and pulseless ventricular
contraindicated? AMIODARONE tachycardia
a. A 50-year-old asthmatic female on ! 1st dose: 300 mg/IV after the 3rd
defibrillation
formoterol/budesonide with last asthma
attack one year ago ! 2nd dose: 150 mg/IV after the 4th
b. A 65-year-old male who was admitted for defibrillation
acute coronary syndrome
c. A 47-year-old male at the ER with syncope ! Class IB antiarrhythmic agent that
and 2nd degree Mobitz II heart block depresses normal and abnormal
d. A 57-year-old male with history of cardiac automaticity
peripheral artery disease LIDOCAINE ! Indicated in VF and pulseless VT
unresponsive to CPR and
True or False: amiodarone
1. Amiodarone 300 mg slow IV push is the ! 1st dose: 1.0-1.5 mg/kg/IV bolus
after the 3rd defibrillation
primary drug given for patients with torsades
de pointes.
2. If intravenous access is not available,
epinephrine must be given at 2.0-2.5 mg via
endotracheal tube during cardiac arrest.
3. For patients presenting with severe pneumonia
and shock unresponsive to fluid resuscitation,
norepinephrine must be started.

III. DRUGS FOR NARROW QRS TACHYCARDIA

! Slows SA node discharge and
DRUG REMARKS shortens atrial refractoriness
! Indicated in the treatment of
! Increases potassium conductance supraventricular arrhythmias (atrial
and hyperpolarizes the SA and AV fibrillation/atrial flutter)
node conductance hence blocks ! Alternative to calcium channel
downstream electrical impulse blockers or beta blockers for heart
! Drug of choice for stable SVT; has a DIGOXIN rate control
very short half-life (<5 secs) ! Dose: loading dose 0.5 to 1 mg
ADENOSINE
! 1st dose: 6 mg/IV bolus followed by IV/oral
10-20 cc saline o then 0.004 to 0.006 mg/kg
! 2nd dose: 12 mg/IV bolus followed initially over 5 minutes
by 10-20 cc saline o then 0.002 to 0.003 mg/kg at
4-8 hr interval
! 3rd dose: 12 mg/IV bolus followed
by 10-20 cc saline ! Total of 0.008 to 0.012 mg/kg
divided to 8 to 16 hours
! Blocks the slow calcium channel
receptors reducing height of
cardiac action potential IV. DRUGS FOR WIDE QRS TACHYCARDIA
! An alternative to adenosine in
stable SVT; rate controller for DRUG REMARKS
CALCIUM
stable atrial fibrillation and atrial
CHANNEL
flutter ! Class III antiarrhthymic agent that
BLOCKER
(CCB) - ! Contraindicated in patients with prolongs the action potential
Verapamil impaired ventricular function, thereby decreasing AV node
acute decompensated heart failure conduction
and hypotension AMIODARONE ! Indicated for stable ventricular
! Dose: 2.5-5 mg/IV over 2 minutes, tachycardia
repeated every 15-30 minutes to a ! Dose: 150 mg SIVP over 10 minutes
maximum dose of 20 mg followed by 1 mg/min for 6 hours
then 0.5 mg/min for 18 hours
! Blocks the beta-adrenergic cardiac
receptors thereby depresses
responsiveness of cardiac fibers ! Class IB antiarrhythmic agent
! Widely used to treat ! Alternative to amiodarone
supraventricular and ventricular ! 1st dose: 1.0-1.5 mg/kg/IV bolus
arrhythmias LIDOCAINE
! 2nd dose: 0.50-0.75 mg/kg/IV
BETA ! Contraindicated in patients with bolus
BLOCKERS- hypotension, bronchospasm and
Esmolol and ! Maybe followed by infusion at
heart block 1-4 mg/kg/min
Labetalol
! Doses
o Esmolol: 0.5 mg/kg loading
! Drug of choice for termination of
dose over 2 minutes then
torsades de pointes
0.05-0.20 mg/kg/min infusion MAGNESIUM
o Labetalol: 10 mg/IV push over ! Dose: 1-2 g in 100 ml D5W SIVP
1-2 mins every 10 minutes to a over 1-2 minutes
maximum dose of 150 mg

V. DRUGS FOR BRADYCARDIA

! Stronger beta than alpha
DRUG REMARKS effects hence better inotropic
than dopamine
! Cathecholamines, alpha and beta- ! May have systemic vasodilation
DOBUTAMINE
adrenergic receptor agonists ! Higher doses results in better
DOPAMINE/ ! Dose: cardiac stimulation and renal
EPINEPHRINE o Dopamine 5-20 mcg/kg/min IV vessel dilation
infusion ! Dose: 2-20 mcg/kg/min
o Epinephrine 2-10 mcg/min IV
infusion ! Stimulates alpha- and beta-
adrenergic receptors
! Parasympatholytic agent that
EPINEPHRINE ! Used when hypotension is
accelerates sinus node discharge
refractory to norepinephrine,
and improves AV node conduction
dopamine and/or dobutamine
! Indicated in unstable bradycardia
! Dose: 0.5-2.0 mcg/kg/min
and bradycardia with symptoms
(dizziness, loss of consciousness,
altered mentation) that are ! Promotes water reabsorption in
attributed to slow heart rate the kidneys (antidiuretic
ATROPINE
! Dose: 1 mg/IV bolus and may be VASOPRESSIN hormone effect) in addition to
repeated to a maximum dose of being a vasopressor
3 mg ! Dose: 0.01-0.04 units/min IV
! Remember to flush with 20 ml NSS
and elevate the extremity
immediately after administration POST-TEST
for rapid delivery and subsequent Choose the best answer.
absorption
1. A 42-year-old female presented at the
VI. DRUGS FOR SHOCK emergency room due to dizziness. Patient is a
known case of Graves’ disease compliant to
DRUG REMARKS medications. Patient is awake, responsive
with BP 140/90 HR 180 and presents with
supraventricular tachycardia on
! Potent vasoconstrictor and electrocardiogram. She was given adenosine
inotropic stimulant 6 mg/ fast IV bolus followed by another 2
! Stimulates the alpha-1 and doses of adenosine 12 mg/IV. However on
beta-1 adrenergic receptors rechecking of vital signs, BP 130/80 HR 160
NOREPINEPHRINE ! Drug of choice for septic and still with supraventricular tachycardia on
cardiogenic shock monitor. What would be the next best
therapeutic intervention?
! Used in all kinds of protracted
hypotension a. Epinephrine 1 mg/IV fast IV bolus
b. Synchronized cardioversion at 100 Joules
! Dose: 0.1-3.0 mcg/kg/min c. Defibrillation at 200 Joules
d. Verapamil 2.5 mg/IV
! Stimulates both beta 2. In which of the following cases is

adrenergic and dopaminergic administering esmolol absolutely
receptors contraindicated?
! Second line vasopressor for a. A 50-year-old asthmatic female on
shock formoterol/budesonide with last asthma
! Dilates renal vessels at low attack one year ago
DOPAMINE b. A 65-year-old male who was admitted for
doses (<2 mcg/kg/min)
acute coronary syndrome
! Positive chronotropic and c. A 47-year-old male at the ER with syncope
inotropic effects at moderate and 2nd degree Mobitz II heart block
doses (2-10 mcg/kg/min) d. A 57-year-old male with history of
! Vasoconstrictor at high doses peripheral artery disease
(10-20 mcg/kg/min)

REFERENCES
Berg, K. M., Soar, J., Andersen, L. W., Böttiger, B. W.,
True or False: Cacciola, S., Callaway, C. W., Couper, K., Cronberg, T.,
1. Amiodarone 300 mg slow IV push is the D’Arrigo, S., Deakin, C. D., Donnino, M. W., Drennan, I.
R., Granfeldt, A., Hoedemaekers, C. W. E., Holmberg,
primary drug given for patients with torsades
M. J., Hsu, C. H., Kamps, M., Musiol, S., Nation, K. J., …
de pointes. Nolan, J. P. (2020). Adult Advanced Life Support: 2020
2. If intravenous access is not available, International Consensus on Cardiopulmonary
epinephrine must be given at 2.0-2.5 mg via Resuscitation and Emergency Cardiovascular Care
endotracheal tube during cardiac arrest. Science With Treatment Recommendations. In
3. For patients presenting with severe pneumonia Circulation (Vol. 142, Issue 16 1).
and shock unresponsive to fluid resuscitation, https://doi.org/10.1161/CIR.0000000000000893
norepinephrine must be started. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W.,
Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M. C.,
Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M. A.,
Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., & Berg,
K. M. (2020). Part 3: Adult Basic and Advanced Life
Support: 2020 American Heart Association Guidelines for
Cardiovascular Care. Circulation, 142(suppl 2), S366–
S468. https://doi.org/10.1161/CIR.000000000000091

Module 13: Electrical Therapies
CHAPTER 13
Electrical Therapies
Karen Gail A. Floren, MD, FPCP, FPCC
sinus node dysfunction, 2nd and 3rd degree

AV blocks, and slow and unstable rhythms
PRETEST that are refractory to medical therapy.
True or false: o Transcutaneous pacing is recommended as
a bridge to transvenous pacing in patients
1. Cardiac pacing is recommended in with severe symptoms and hemodynamic
severe hypothermia and asystolic cardiac compromise.
arrest. o Pacing is not recommended in patients with
2. Synchronized cardioversion involves the stable bradycardia, with minimal
delivery of a high-energy shock that is symptoms, without hemodynamic
timed at a specific point in the QRS compromise, and in asystolic cardiac arrest.
complex.
3. Synchronized cardioversion is Transcutaneous Pacing (TCP)
administered in ventricular tachycardia
with no pulse. • The heart is stimulated with externally applied
4. Chest hair can increase transthoracic cutaneous electrodes that deliver electrical
impedance that adversely affects success impulses.
of defibrillation. • Most preferred, least invasive
5. Defibrillation is the therapeutic use of
• Serves as a bridge to transvenous cardiac
large electric currents delivered over
pacing
brief periods of time.
• Placement of electrodes: anterior/posterior or
anterior/lateral (see Figure 1)
I. LEARNING OBJECTIVES • Relative contraindication: In patients with
severe hypothermia, bradycardia may be a
• At the end of this module, the learner is physiologic phenomenon resulting from
expected to: decreased metabolic rate. As body
o acquire basic knowledge in pacing, temperature drops, the ventricles become
defibrillation and synchronized more prone to fibrillation and more resistant to
cardioversion; defibrillation.
o learn how to apply transcutaneous pacer;
and
o learn how to do defibrillation and
synchronized cardioversion.
II. ELECTRICAL THERAPIES

CARDIAC PACING
• Temporary cardiac pacing is an intervention in
which an electrical stimulus is delivered
through electrodes to the heart causing
electrical depolarizations and subsequent Figure 1. Placement of transcutaneous pacing
cardiac contraction. electrodes at the (A) anterior/posterior, and (B)
• Recommendations anterior/lateral positions. These electrodes are
o Transvenous pacing is recommended in connected to a defibrillator machine
patients with unstable bradycardia such as

Steps in TCP placement DEFIBRILLATION

• Apply the pacing pads. Consider sedation. • Definition
• Turn the monitor on and set it to pacing mode. o It is the therapeutic use of large electric
• Set the pacing rate at 80 beats per minute. currents delivered over very brief periods of
• Set the output at the lowest level, then time.
increase gradually until capture is achieved. o It temporarily stuns an irregularly beating
o Electrical capture occurs when a pacing heart and allows more coordinated
stimulus leads to depolarization of the contractile activity to resume.
ventricles. It is confirmed by ECG changes • Importance of defibrillation
typical of pacing, such as pacemaker spikes, o Defibrillation is the treatment for ventricular
widening of the QRS complexes, and tall, fibrillation, which is the most frequent initial
broad T waves opposite in direction to the rhythm in sudden cardiac arrest. It is critical
QRS. and should be administered as early as
• Confirm mechanical capture by palpating for possible to improve the chances of survival.
the femoral pulse. o The probability of successful defibrillation
o Confirmation by palpating for the carotid diminishes rapidly over time as ventricular
pulse is not recommended because TCP fibrillation tends to deteriorate to asystole
can create muscular movements that might within a few minutes.
be mistaken for carotid pulsation. • Importance of cardiopulmonary resuscitation
o CPR is performed prior to defibrillation and
Transvenous Pacing (TVP) is resumed after giving the shock.
• A procedure done by either an interventional o It delays the deterioration of ventricular
fibrillation to asystole, and extends the
cardiologist, electrophysiologist or intensivist.
window of time during which defibrillation
• This is a more invasive procedure, that can still be effective
involves endocardial stimulation of the right
atrium or ventricle or both via an electrode Manual Defibrillator
that is inserted through a central vein: internal
jugular, subclavian, or femoral veins. This is • Monophasic: delivers the current in one
connected to a generator box (see Figure 2). direction
• Biphasic: delivers a current that flows in a
positive direction over a specified duration. The
current reverses and flows in a negative
direction for the remaining milliseconds of the
electrical discharge.
Figure 3. Manual monophasic (left), and

Figure 2. (Left) Placement of catheter and biphasic (right) defibrillators
electrodes. (Right) Generator box.
Procedure for manual defibrillation
• Ensure scene safety for the rescuer and the
victim.
• Remove any transdermal medications and
shave the chest, if possible, to ensure
adequate skin contact with paddles.

o Chest hair can increase transthoracic • Double sequential defibrillation

impedance that adversely affects success o The use of 2 defibrillators to deliver 2
of defibrillation. This could be reduced by overlapping shocks or 2 rapid sequential
up to 35% with shaving. shocks – as a possible means of increasing
• Apply gel on the paddles. ventricular fibrillation termination rates
• Turn the machine on. o Routine use is not recommended.
• Select the energy level.
o monophasic: 360 J Automated Defibrillator
o biphasic: 200 J • Semi-automated: prompts the rescuers to
• Press the “charge” button. (A prompt will press the shock button if a shock is needed
appear on the defibrillator screen once the • Fully automated: designed to give a shock
paddles/electrodes are fully charged.) automatically, if needed, without the rescuer
• Ensure proper placement of the having to press a button to deliver the shock
paddles/electrodes (commonly in the
anterior/lateral position). Use
paddles/electrode pads more than 8 cm
across for adult victims.
o In patients with cardiac implantable
electronic devices (e.g., permanent
pacemaker, or implantable cardioverter-
defibrillator), place the paddle/electrode
pads more than 8 cm away from the
device, or use an alternative
paddle/electrode pad placement.
• Ensure that no one is in direct contact with the Figure 4. Automated external defibrillators
victim before delivering the shock.
• Press the “discharge” or “shock” button on the SYNCHRONIZED CARDIOVERSION
paddles or machine. (A prompt will appear on • Definition
the defibrillator screen once the shock has o It involves the delivery of a low-energy
been delivered.) shock, which is timed or synchronized with
the QRS complex on the ECG (see Figure 5).
Notes on manual defibrillation By timing the shock, electrical stimulation is
• Interruptions in chest compressions avoided during the vulnerable period,
o Limit interruptions in chest compressions which reduces the risk of inducing
to less than 5 seconds during defibrillation. ventricular fibrillation.
• Charging the defibrillator o The energy level used is lower than that
o Charging the defibrillator is conventionally used in defibrillation.
done AFTER rhythm check, accompanied
by a brief period of chest compressions
while waiting for the defibrillator to fully
charge.
o Charging the defibrillator can also be done
BEFORE rhythm check, near the end of a
compression cycle (known as Figure 5. Atrial fibrillation converting to sinus rhythm
“anticipatory defibrillator charging”). This after synchronized cardioversion (red dots indicate
has the advantage of having the shock the QRS complexes recognized by the device)
readily available to be discharged as soon
as indicated.
o Either approach may reduce no-flow time.

• Indications
o It is administered to victims with unstable
and refractory tachyarrhythmias, such as POST-TEST
unstable supraventricular tachycardia True or false:
(SVT), atrial fibrillation (AF), atrial flutter, or
monomorphic ventricular tachycardia (VT). 1. Cardiac pacing is recommended in
severe hypothermia and asystolic cardiac
Energy Level for Cardioversion arrest.
2. Synchronized cardioversion involves the
Table 1. Initial Doses for Synchronized Cardioversion
delivery of a high-energy shock that is
Rhythm Energy level timed at a specific point in the QRS
complex.
Narrow regular 50-100 J 3. Synchronized cardioversion is
120-200 J biphasic, or 200 J administered in ventricular tachycardia
Narrow irregular with no pulse.
monophasic
4. Chest hair can increase transthoracic
Wide regular 100 J impedance that adversely affects success
of defibrillation.
Defibrillation (not 5. Defibrillation is the therapeutic use of
Wide irregular
synchronized cardioversion) large electric currents delivered over
brief periods of time.
Procedure for Synchronized Cardioversion
• Sedate the patient.
REFERENCES
• Remove any transdermal medications and Berg, K. M., Soar, J., Andersen, L. W., Böttiger, B. W.,
shave the chest if possible to ensure adequate Cacciola, S., Callaway, C. W., Couper, K., Cronberg, T.,
skin contact with paddles. D’Arrigo, S., Deakin, C. D., Donnino, M. W., Drennan, I.
o Chest hair can increase transthoracic R., Granfeldt, A., Hoedemaekers, C. W. E., Holmberg,
impedance that adversely affects success M. J., Hsu, C. H., Kamps, M., Musiol, S., Nation, K. J., …
Nolan, J. P. (2020). Adult Advanced Life Support: 2020
of defibrillation. This could be reduced by International Consensus on Cardiopulmonary
up to 35% with shaving. Resuscitation and Emergency Cardiovascular Care
• Apply gel on the paddles. Science With Treatment Recommendations. In
• Turn the machine on. Circulation (Vol. 142, Issue 16 1).
https://doi.org/10.1161/CIR.0000000000000893
• Press the "sync" button. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W.,
• Select the energy level. Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M. C.,
Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M. A.,
• Press the "charge" button. (A prompt will Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., & Berg,
appear on the defibrillator screen once the K. M. (2020). Part 3: Adult Basic and Advanced Life
paddles/electrodes are fully charged.) Support: 2020 American Heart Association Guidelines for
• Ensure proper placement of the Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation, 142(suppl 2), S366–
paddles/electrodes (commonly in the S468. https://doi.org/10.1161/CIR.0000000000000916
anterior/lateral position).
• Ensure that no one is in direct contact with the
victim before delivering the shock.
• Press the “discharge” or “shock” button on the
paddles or machine and keep paddles in place
until the shock has been delivered. (A prompt
will appear on the defibrillator screen once the
shock has been delivered.)


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FOREWORD

Francis Lavapie, MD, FPCP, FPCC

Don Robespierre C. Reyes,

Read on. Learn and continue saving

Don Robespierre C. Reyes, MD, FPCP, FPCC

Don Robespierre C. Reyes, MD, FPCP, FPCC

Jason S. Santos, Marc Denver A. Tiongson, Ma. Vanessa I. Yu,

Orlando R. Bugarin, MD, FPCP, FPCC

Adult Basic Life Support

for Healthcare Professionals

PRETEST 4. What is the correct way of performing chest

Council on Cardiopulmonary Resuscitation

Council on Cardiopulmonary Resuscitation

ADULT BASIC LIFE SUPPORT

a. Head-tilt chin-lift maneuver (if with NO SUSPECTED cervical spine injury)

Council on Cardiopulmonary Resuscitation

Council on Cardiopulmonary Resuscitation

Perform high-quality CPR:

Hook the patient to an automated external

Two-rescuer Adult Basic Life Support

Council on Cardiopulmonary Resuscitation

III. ADULT BASIC LIFE SUPPORT IN THE COVID-19 PANDEMIC

Council on Cardiopulmonary Resuscitation

Out-of-hospital Cardiac Arrest

Council on Cardiopulmonary Resuscitation

Pediatric Basic Life Support

for Healthcare Professionals

PEDIATRIC CHAIN OF SURVIVAL

CAUSES OF PEDIATRIC CARDIAC ARREST

III. PEDIATRIC BASIC LIFE SUPPORT

• Check for responsiveness.

• For WITNESSED COLLAPSE (more commonly VF in • If with only 1 RESCUER:

Council on Cardiopulmonary Resuscitation

1 year to <8 years old 8 years old and above (children

• Allow full chest recoil after each compression.

NOTES Victim with No Pulse and No Breathing

Council on Cardiopulmonary Resuscitation

Table 3. AED for Pediatric Victims

1. The first link in the pediatric chain of

Council on Cardiopulmonary Resuscitation

Foreign Body Airway Obstruction

• Eighty percent of FBAO cases occur in children

Complete Airway Obstruction

maneuver, with the back slaps delivered

Figure 4. Universal distress signal

o The maneuvering hand lifts the mandible.

Figure 7. Chest thrust

Figure 8. Self-administered Heimlich maneuver

Council on Cardiopulmonary Resuscitation

and First Aid Response

FIRST AID PROVIDER

Council on Cardiopulmonary Resuscitation

o This is especially important if you suspect Chest Discomfort or Chest Pain

Council on Cardiopulmonary Resuscitation

Electrocution or Electric Shock Poison

Council on Cardiopulmonary Resuscitation

Seizure o Epinephrine is injected intramuscularly at a

Council on Cardiopulmonary Resuscitation

1. First aid is defined as helping behaviors

Council on Cardiopulmonary Resuscitation

Adult Cardiac Arrest

PRETEST • At the end of this module, the learner is

4. Initial treatment for a patient in asystole: Figure 1. Ventricular Fibrillation