Contents

Units:
1. Unit 01: Advanced Cardiac Life Support…………………………………………………..2
2. Unit 02: ACLS Overview……………………………………………………………………………...4
3. Unit 03: BLS and ACLS Surveys………………………………………………………………….9
4. Unit 04: Team Dynamics…………………………………………………………..................13
5. Unit 05: Chain of Survival………………………………………………………….................15
6. Unit 06: ACLS Cases……………………………………………………….……..………………..…19
7. Unit 07: ACLS Resuscitation Medications…………………………………………….…53
8. Unit 08: Rhythm Recognition…………………………………………………………………..…61
9. Unit 09: References……………………………………………………...…………...................67
Tables:
1. Table 1: Curriculum…………………………………………………………………………………….6-7
2. Table 2: Team dynamics……………………………………………………………................14
3. Table 3: ACS categorization……………………………………………………………………….27
4. Table 4: Signs and symptoms of tachycardia……………………………..………….30
5. Table 5: H’s and T’s as causes of PEA……………………………………………………..32
6. Table 6: Routes for medication administration…………………………..…………..43
7. Table 7: ACLS medications for resuscitation ………………………………………….45
8. Table 8: ACLS medications for resuscitation………………………………….….54-60
Figures:
1. Figure 1: Tasks for BLS survey…………………………………………………………………….…..10
2. Figure 2: Tasks for ACLS survey………………………………………………………………….……12
3. Figure 3: In-hospital chain of survival for cardiac arrest………………………….…...16
4. Figure 4: Outside-of-hospital chain of survival for cardiac arrest…………….….17
5. Figure 5: Chain of survival for a stroke…………………………………………………………….23
6. Figure 6: Timeline for stroke treatment……………………………………………………………23
7. Figure 7: ACLS acute coronary syndrome algorithm……………………………………..28
8. Figure 8: ACLS bradycardia algorithm……………………………………………………………..34
9. Figure 9: ACLS tachycardia algorithm……………………………………………………………..36
10. Figure 10: BLS AED algorithm…………………………………………………………………….……..40
11. Figure 11: ACLS cardiac arrest pea and asystole algorithm…………………….…..44
12. Figure 12: ACLS cardiac arrest Vtach and Vfib algorithm………………………..……45
13. Figure 13: ACLS post cardiac arrest care algorithm………………………………….…..50
14. Figure 14: BLS suspected opioid overdose algorithm……………………………………52

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 Unit 01: Advanced Cardiac Life
Support
Author:

Takeesha Roland-Jenkins, MD

Credits Available:

Physicians: 4.25 AMA Category 1 PRA CME Nurses: 4.25 CE

Course Availability:

4/29/2021 thru 4/28/2024

Target Audience and Goal Statement:

This activity is intended for physicians and other healthcare professionals who may need
to recognize and treat adult patients suffering from cardiac arrest and other
cardiopulmonary emergencies. The activity is intended to provide instructional material
to physicians and other healthcare professionals to guide them in performing Advanced
Cardiac Life Support. Upon completing this activity, participants will be able to analyze
cardiopulmonary emergencies to reduce fatal outcomes. After completing this activity,
the participant should be able to:

• Improve survival rates for adults who experience cardiac and neurologic
emergencies.
• Recognize and initiate early management of cardiac conditions that may result in
cardiac arrest.
• Demonstrate proficiency in providing Basic Life Saving skills
• Manage cardiac arrest until return of spontaneous circulation

Accreditation Statement:

• TeamHealth Institute is accredited by the Accreditation Council for Continuing

Medical Education (ACCME) to provide continuing medical education for
physicians (#0001513)
• TeamHealth Institute designates this live activity for a maximum of 4.25 AMA PRA
Category 1 credits™.
• Physicians should only claim credit commensurate with the extent of their
participation in the activity.

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 • Save your certificate and the course objectives in case you are audited for your
state licensure or national certification.

Medical Reviewers and Disclosures:

Name of Planners/Reviewers Reported Financial Relationship

• Andrew Prolux, MD - Author Nothing to disclose

• Susanne J. Danis, APRN-C, CDE - Reviewer Nothing to disclose
• Raghavendra Kulkarni, MD - Reviewer Nothing to disclose
• Cyrus Yau, MD - Editor Nothing to disclose
• Paige Fillio, PA - Contributor Nothing to disclose

Instructions for Participation and Credit:

To successfully earn credit, participants must read the course content outlined within the
modules and achieve a minimum score of 80% on the post-test.

Follow these steps to earn CME/CE credit:

1. Review the target audience, learning objectives, and author disclosures.

2. Study the educational content online
3. Choose the best answer to each question in the post-test. To receive credit, you
must obtain a passing score as described at the start of the test.

Once completed, you can now view or download the certificate. Alteration of the
certificate in any way is not permitted. Your completed certificates will automatically save
in Certificate Tracker.

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 Unit 02: ACLS Overview
Advanced cardiac life support (ACLS)

Also known as cardiovascular life support, is a set of clinical guidelines for the
identification and intervention of cardiac dysrhythmias such as:

• Stroke
• Acute Coronary Syndrome (ACS)
• Cardiopulmonary Arrest

Focus

This training focuses on improving survival rates for adults who experience cardiac and
neurologic emergencies. The ACLS course entails teaching students the following skill
sets:

• Basic life support (BLS) survey

• ACLS survey
• ACLS cases for specific disorders
• High-quality cardiopulmonary resuscitation (CPR)
• Post-cardiac arrest care

Course Prerequisites

It is recommended that students have a basic knowledge of the following subjects before
taking this course:

• BLS skills
• Electrocardiogram (ECG) rhythm recognition and management
• Utilization of airway equipment and management procedures
• An understanding of adult pharmacology, including common emergency drugs
and dosages used for resuscitation.

Course Structure

Students who take this course will review course modules through which proficiency and
competency in respiratory arrest, CPR, and Automated External Defibrillator (AED) use
will be required in response to the following types of incidents:

• Bradycardia
• Tachycardia

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 • Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (VT)
• Pulseless Electrical Activity (PEA)/asystole
• Post-cardiac arrest care
• Opiate Associated Emergency (for health care providers)
• Cardiac arrest in pregnancy

Training in BLS (for one or two rescuers) will not be covered in this course.

"Though students will not be directly tested on megacode, they are strongly encouraged
to participate in these training sessions at their local institutions.”

To complete the ACLS course, students will be required to pass a final exam that
encompasses the curriculum's cognitive components.

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Key Points

1) According to research, starting chest compressions early on during the resuscitation

process helps improve survival rates.
2) The evaluation of a victim’s breathing has been omitted as first responders often
misinterpret gasping for air as efficient breathing.
3) High-quality CPR for adults is defined by medical experts as:
a) A chest compression rate of 100-120 compressions per minute.
b) A compression depth of at least 2 inches [5 cm].
c) Allowing complete chest recoil after each compression.
d) Avoiding excessive ventilation during CPR.
e) Minimizing interruptions in compressions for treatments such as:
i) Administration of medications
ii) Placement of advanced airways
iii) Insertion of intravenous catheters. It is recommended to wait until the
defibrillator is prepared and perform any necessary treatments during that
phase of the CPR.
4) Checking for a pulse is no longer critical as many providers are unable to detect a
pulse during an emergency reliably.
5) As soon as the Return of Spontaneous Circulation (ROSC) arises, post-cardiac arrest
care should formally start.
6) A vasopressor (e.g., epinephrine) should be administered every 3 to 5 minutes along
with the use of an Endotracheal Tube (ET) if available until IV access has been
established.
7) Care and Support During Recovery
a) All cardiac arrest survivors should receive:
i) Multimodal rehabilitation assessment and treatment
ii) Comprehensive, multidisciplinary discharge planning for both patients and
caregivers.
iii) Assessment for anxiety, depression, PTSD, and fatigue
8) Cardiac Arrest in Pregnancy
a) Oxygenation and airway should be prioritized due to the increased risk of hypoxia.
b) Fetal monitoring should not be obtained during cardiac arrest.
c) Targeted temperature management if a pregnant patient remains comatose.
i) During this treatment, monitoring for fetal bradycardia is recommended.
d) Prepare for perimortem caesarian delivery if necessary to save the infant and
improve resuscitative changes for the mother.
9) Post-resuscitation debriefing
a) After resuscitation, debriefing of lay rescuers and healthcare workers may be
beneficial to their mental health and wellbeing.
10) Opiate Associated Emergency
a) Algorithms for both lay responders and health care providers

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 Unit 03: BLS and ACLS Surveys
Primary Goal

Prepare students to competently and quickly assist victims who are in cardiac arrest. The
aim is to:

• improve survival rates

• ensure positive, high-quality outcomes.

Students will learn systematic strategies that allow them to provide immediate care using
BLS and ACLS surveys.

“Accordingly, if a patient is unresponsive, the BLS survey should be utilized first.”

After the completion of the BLS survey or when the victim is responsive and awake, the
ACLS survey is the next step that entails providing advanced treatment approaches.

The BLS Survey

Research pertaining to conducting BLS for adults indicates that the probability of only
one responder being available during an incident that requires BLS is rare.

“Therefore, emphasis is placed on performing several actions simultaneously during the

resuscitation process as two responders are often available.”

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However, each student must be able to demonstrate both one-and two-responder
resuscitation skills. The specific tasks that are required are presented below in Figure 1:

. FIGURE 1: TASKS FOR BLS SURVEY

Adult BLS/CPR

The last part of the BLS survey involves starting CPR. BLS training manuals offer a more
comprehensive description of CPR. During the class as well as at testing, students will be
required to demonstrate competency in performing CPR effectively.

Step by Step CPR Review

1. Try to locate the carotid pulse behind the trachea on the side of the neck. A pulse
may be hard to detect. Therefore, an attempt to feel the pulse should only be
performed for about 5-10 seconds.
2. If the victim is not lying on the back, place the victim’s back on a surface that will
not compress as CPR is being performed.

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 3. If a pulse cannot be distinctly detected, assume that there is no pulse. Start
alternating 30 chest compressions and 2 breaths.
4. Open the victim’s airway by slightly lifting the chin.
5. Place the heel of the right hand on the bottom of the victim’s breastbone and then
place the heel of left hand on top of the right hand.
6. Make sure the arms and shoulders are straight and begin the chest compressions
hard and fast. Effective chest compressions will be at least 2 inches deep for
adults.
7. Furthermore, the frequency of chest compressions should be 100 to 120 per
minute. The chest needs to fully expand between each compression to allow blood
to flow into the victim’s heart. Do not lean on the chest at any time during CPR.
8. After performing 30 hard and fast chest compressions, tilt the head and chin to
make sure the victim’s airway is still open. If the victim appears to have a neck
injury, perform a jaw thrust to open the airway by gently moving the jaw forward.
9. If a barrier device is available, place it on the victim’s mouth and nose.
10. Deliver one slow deep breath for 1 second and watch the victim’s chest expand.
Deliver a-second-deep breath.
11. Perform another round of 30 chest compressions followed by 2 breaths that are 1
second each.
12. If two or more responders are available, switch out every 2 minutes.
13. As soon as a responder arrives with a defibrillator and cardiac rhythm is assessed,
defibrillation should be performed quickly and as directed.
14. Ensure that CPR interruptions are minimal.

ACLS Survey

After completing the BLS survey, or if the victim is responsive, conscious, or awake, the
responder should begin the ACLS survey. Focus needs to be placed on identifying and
treating the underlying cause of the victim’s problem.

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 FIGURE 2: TASKS FOR ACLS SURVEY

1) Regarding assessing the victim’s airway:

• Try to use the least advanced airway as possible to maintain an open airway and
efficient oxygenation (e.g., laryngeal tube, laryngeal mask, or esophageal tracheal
tube).
2) Regarding assessing the victim’s breathing:
• Carefully monitor the placement of the tube as well as oxygenation by using
waveform capnography if it is available and try to avoid excessive ventilation.
3) Regarding assessing the victim’s circulation:
• Perform CPR, administer medications and fluids, and perform defibrillation when
needed and according to the ACLS survey indications.
4) Try to determine the cause of the cardiac arrest, arrhythmia, or other symptoms and
treat the causes.

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 Unit 04: Team Dynamics
Guidelines

In 2015 the guidelines began to place emphasis on the dynamics of working as a team
during the resuscitation process. However, to improve patient outcomes, each member
of the team must be able to perform specific tasks and must understand how the
designated role is interrelated with other team members’ roles.

Team Leader

A resuscitation team typically has one leader who is responsible for ensuring that
resuscitation efforts flow smoothly and that each task is properly executed. A physician
usually takes on this role, but it can be performed by anyone and it entails:

• Organizing and mentoring the team.

• Monitoring the members’ abilities to execute each role.
• Performing any skills that may be necessary.
• Modeling appropriate behaviors.
• Offering feedback as well as individual performance evaluations when the
resuscitation effort is over.
• Coaching team members when necessary.
• Focusing on providing exceptional care.

“Accordingly, team members should be assigned specific roles based on their expertise,
the scope of their practice, and their training in relation to the required tasks.”

Furthermore, a team member needs to be able to:

• Understand the assigned role in the resuscitation process.

• Perform the assigned tasks efficiently.
• Understand the ACLS guidelines, protocols, and algorithms.
• Contribute to and promote the success of the team.

The efficiency of the team dynamic depends on whether each member can effectively
meet the expectations of the assigned role in the team.

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 Unit 05: Chain of Survival
Teaching BLS and ACLS within a community increases the survival rates for victims of
cardiac arrest or stroke.

The Chain of Survival for adults is composed of several systems that must function
optimally to improve the survival rates of stroke victims and those with acute coronary
syndromes (ACS).

Acute Coronary Syndrome

For ACS victims, the chain of survival aims at preventing complications and additional
cardiac events. The intervention process must include:

• Education pertaining to the ability to recognize ACS symptoms.

• Continuing education that prepares medical professionals for rapid recognition
and the appropriate treatment of ACS
• The early activation of the EMS to allow an assessment and treatment to begin on-
site before emergency services arrives.
• EMS training that includes the recognition of Acute Myocardial Infarction (AMI) on-
site to provide early notification to hospital personnel and to decrease the time to
treat in the ED.
• Once the victim is in the hospital, the system of care must shorten the amount of
time it takes to initiate definitive treatment.
• Emergency medical personnel need to be trained to provide optimal emergency
care, especially regarding selecting reperfusion strategies.

Acute Stroke Care

For victims of stroke, the system of care needs to include: Education pertaining to the
ability to recognize stroke symptoms.

• Continuing education that pertains to the importance of seeking medical

treatment during the first hour of the symptom onset
• The early activation of the EMS to allow an assessment and treatment to begin on-
site before emergency services arrives.
• EMS training that includes the recognition of a stroke on-site to provide early
notification to hospital personnel and to decrease the time to treat in the ED.
• Whenever it is possible, the establishment of regional stroke centers with efficient
systems of care in place.

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 FIGURE 3: IN-HOSPITAL CHAIN OF SURVIVAL FOR CARDIAC ARREST

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 FIGURE 4: OUTSIDE-OF-HOSPITAL CHAIN OF SURVIVAL FOR CARDIAC ARREST

Post-Cardiac Arrest Care

Research indicates that increased survival rates and positive victim outcomes of ACLS
are directly influenced by the quality of post-cardiac care that a victim receives. Vital post-
resuscitation efforts include:

• Early placement of the endotracheal tube (ETT).

• The use of quantitative waveform capnography to keep the partial pressure of end-
tidal carbon dioxide (PETCO2) between 35 to 45 mm Hg. This form of monitoring
is the most effective means of optimizing hemodynamics and ventilation.
• Set initial RR 10 breaths/min, goal SPO2 92-98%.
• Administer inotropes, crystalloid, or vasopressors to maintain BPs > 90/65 mmHg
• The application of therapeutic hypothermia if the victim achieves ROSC but does
not respond to verbal stimulation. This entails lowering the victim’s core
temperature to 32°C- 36°C for at least 24 hours post-resuscitation.
• Obtain EKG and evaluate for STEMI / cardiogenic shock.
• Transport the victim to a facility capable of performing coronary reperfusion using
percutaneous coronary intervention (PCI).

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 • Maintaining glucose levels between 144 mg/dL and 180 mg/dL without
attempting to achieve a lower blood glucose level as the risk of causing
hypoglycemia outweighs the benefits.
• Post resuscitative neuroprognostication should be obtained within 72 hours of
normothermia (CT, MRI, EEG, N20 SSEP, serum NSE).

Education Within Team Settings

Even when the system of care is ideal, the survival rate for victims who go into cardiac
arrest is around 21%. In addition, the survival rate decreases as the time between the
cardiac event and the onset of definitive treatment increases.

“Several hospitals have teams that are available to respond to a cardiac arrest, but the
teams have not been able to dramatically improve survival rates in hospitals due to the
relatively late response time following a cardiac event.”

Therefore, it is vital that all medical professionals receive continuing education regarding
the recognition of victims who are at risk of experiencing cardiac arrest. Accordingly,
many hospitals have started to incorporate systems of care for early intervention services
that include:

• Cardiac arrest teams that are prepared to respond to this incident as soon as it
occurs.
• The implementation of rapid response teams (RRTs) at some hospitals instead of
cardiac arrest teams
• The activation of RRTs when a victim appears to be deteriorating, with the intent
of providing intervention before cardiac arrest occurs.
• Hospitals typically establish their own criteria for the activation of RRTs, but the
criteria generally encompass:
o A dramatic change in heart rate.
o An extreme change in respiratory status.
o An increase or decrease in blood pressure.
o The deterioration of the level of consciousness or mentation.
o The onset of seizure activity.
o Any other subjective concerns
• RRTs focus on intervening immediately to stop the victim from deteriorating and
to accomplish three main goals:
o Lower the rate of cardiac arrests that lead to mortality.
o Decrease the need to transfer victims to the ICU.
o Decrease morbidity rates.

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 Unit 06: ACLS Cases
BLS and ACLS Surveys

An individual or members of a team must always conduct BLS and ACLS surveys before
proceeding with an algorithm for a specific arrhythmia or problem (See Unit Two for the
appropriate procedure for these surveys).

Basic Airway Management

To prevent airway obstruction in a patient and hence secure an open pathway between
their lungs and the external surrounding, certain medical procedures must be performed.

Oropharyngeal Airway

An Oropharyngeal Airway (OPA) should only be used for victims who are unconscious. If
it is inserted in a partially or fully conschious victim, the OPA may cause a gag reflex and
the victim may vomit. In addition, it is important to choose the right airway size to avoid
a throat injury or an airway obstruction. The OPA insertion process is as follows:

1. Place the victim flat on the back.

2. Insert the index finger and thumb into the victim's mouth against the upper and
lower teeth.
3. Use a scissor-like motion to separate the victim's teeth until the mouth opens.
4. Insert the tip of the OPA into the victim's mouth and place it on top of the tongue.
5. Point the tip upward toward the roof of the victim's mouth.
6. Slide the OPA carefully back by following the curve of the tongue.
7. When the tip of the OPA reaches the back of the tongue past the soft palate, rotate
it to point the tip toward the victim's throat.
8. Continue inserting the OPA until the flared flange is pressed against the victim's
lips.
9. If the OPA is inserted properly and is the right size, the victim's tongue should not
slide to the back of the throat.
10. Remove the OPA if the victim regains consciousness.

Nasopharyngeal Airway

A Nasopharyngeal Airway (NPA) can be used for conscious or unconscious victims. It is

inserted through the nose and thusly, can be used on a victim with a mouth injury or one
that is experiencing a strong gag reflex. The insertion of a NPA is as follows:

1. Make sure to measure the NPA by comparing the size of the victim's nostril to the
diameter of the NPA.
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 2. The proper length of the NPA can be estimated by holding it next to a victim's face.
An appropriate NPA length will extend across the ear lobe to the tip of the nose.
3. Use a water-soluble lubricant to moisten the NPA before attempting the insertion.
4. The NPA should be gently inserted through the victim's largest nostril. If resistance
is encountered as the NPA is inserted, slightly rotate it or attempt to use the other
nostril.

Advanced Airway Management

When a rescuer is trained and competent in use of an advanced airway, these airways
can provide better oxygenation. Although learning to insert an advanced airway is beyond
the scope of ACLS, every team member should know how to maintain them. When an
advanced airway is in place, administer 1 ventilation every 6 seconds (10 breaths every
minute).

• Use a laryngeal mask airway as an alternative to an ET tube since this airway

provides comparable oxygenation.
• A laryngeal tube is another advanced airway that can be used instead of bag-mask
or ET tube ventilation.
• An esophageal-tracheal tube is another advanced airway that provides
oxygenation comparable to an ET tube. Caution should be used when selecting
this tube.
• If a team member has been trained, the ET tube may be the best airway to insert
during a cardiac arrest. All team members should be trained to:
o Assemble the equipment necessary for intubation.
o Inflate the cuff after intubation.
o Attach the Ambu bag and give breaths at the appropriate rate.
o Confirm placement by quantitative waveform capnography (if
available) and by clinical assessment (appropriate chest rise, equal breath
sounds bilaterally).
o Secure the tube.
o Monitor ET tube placement
• Only a trained practitioner should perform the ET intubation.

“Interrupt CPR only long enough to intubate the victim. Once intubated, CPR should NOT
be interrupted to deliver breaths. Instead, deliver breaths as the chest recoils between
compressions. In any victim with a possible neck injury, a team member should manually
stabilize the neck as a cervical collar may interfere with the airway.”

Suctioning the Airway

Maintain an open airway by properly suctioning it. Use a wall-mounted device, if available
since this will provide enough power to suction the airway. A rigid Yankauer catheter

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should only be used to suction the victim's mouth. Use a soft catheter to suction any
airway. To suction an ET tube:

1. If possible, use sterile techniques to prevent the possibility of infection.

2. Turn on the suction machine and set vacuum regulator to 80-120 mm Hg if
available. Use only enough pressure to effectively suction since hypoxia and
damage to respiratory mucosa can occur if suction pressure is too high.
3. Using sterile gloves, pick up the soft suction catheter, and avoid touching it to any
non-sterile surfaces. With your opposite hand, pick up the connecting tubing and
attach the catheter to it.
4. Without suction, gently insert the catheter into the ET tube until you feel resistance.
Pull the catheter back 1-2 centimeters.
5. Apply suction by occluding and opening the control vent on the catheter. Slowly
pull the catheter out of the tube as you rotate the catheter between your
fingers. Suctioning time should NEVER exceed 10-15 seconds.
6. After suctioning, hyper-oxygenate by delivering several deep breaths.
7. Monitor the victim's condition during suctioning, observing for cyanosis, airway
spasms, cardiac dysrhythmias, and changes in level of consciousness.

Respiratory Arrest

During a respiratory emergency, make sure to open the victim’s airway and deliver oxygen
to maintain an oxygen saturation that is higher than 94%. If the victim has a pulse, but
there is no respiratory effort, provide 1 breath every 5-6 seconds (about 10 to 12 breaths
per minute).

“If an advanced airway is used, provide one breath every 6 seconds (about 10 breaths per
minute)”

If respiratory arrest has occurred, try one of the following approaches to establish an
airway:

• Use the head tilt and chin lift or the jaw thrust maneuver to place the victim in a
position that maintains an open airway. Oftentimes, repositioning the victim is all
that is required to improve or restore respiration.
• Perform mouth-to-mouth resuscitation if no mouth/nose barriers are available.
• Perform mouth-to-nose ventilation if the mouth or teeth are injured.
• If a pocket mask or some other form of barrier is available, use the barrier during
the resuscitation effort.
• If a mask and Ambu bag are available, choose the mask that covers the victim's
nose, mouth, and chin. If the Ambu bag is being used, make sure that oxygen is
flowing into the bag and that there are no leaks in the bag. An Ambu bag can be
used with both basic and advanced airways.

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When using an Ambu bag, excessive ventilation should be avoided by delivering only
enough oxygen to make the chest rise.

“The victim's general condition and oxygen saturation should also be monitored to
determine the effectiveness of the respiratory efforts.”

If a basic or advanced airway must be inserted, ensure that the proper equipment is
available which includes:

• Standard equipment such as gloves, a mask, and eye protection.

• Monitoring devices such as a pulse oximetry unit, a cardiac monitor, a carbon
dioxide detector, and a blood pressure monitor.
• Suctioning equipment.
• IV/IO equipment.
• Laryngoscope.
• Adhesive tape.
• Different types of airways in all sizes.
• Ambu bags and oxygen.
• All available sizes of ET tubes for advanced airway placement.
• Syringes to test ET tube balloon.

Acute Stroke

An acute stroke is classified as either a hemorrhagic or an ischemic stroke. A ruptured

blood vessel in the brain typically causes a hemorrhagic stroke, while an arterial occlusion
in the brain usually results in an ischemic stroke. The reason an acute stroke is covered
in the ACLS course is because like cardiac events, treatment time following a stroke is
critical toward improving the prognosis and outcomes.
“More specifically, treatment should be initiated within three hours of the symptom onset
and fibrinolytic therapy is an effective form of treatment for an ischemic stroke, while this
approach is not appropriate for a hemorrhagic stroke.”

Timely treatment is critical as a brain injury that occurs due to a stroke can be minimized
through early stroke care. Therefore, the chain of survival for a stroke is just as essential
as cardiac care.

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 FIGURE 5: CHAIN OF SURVIVAL FOR A STROKE

FIGURE 6: TIMELINE FOR STROKE TREATMENT

Algorithm for a Suspected Stroke

The stroke algorithm emphasizes the importance of a rapid assessment, identification,

and medical intervention to minimize the effects of a stroke.

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 1. Provide education to the community regarding the signs and symptoms of a
stroke:
a. Sudden weakness of one side of the body or face.
b. Sudden onset of confusion.
c. Distorted speech.
d. Sudden onset of sight problems in one or both eyes.
e. Difficulty walking, maintaining balance, or coordination problems.
f. Sudden, severe headache
2. After identifying a potential stroke, activate the emergency medical services
(EMS).
3. EMS assessment and treatments:
4.
a. Rapid stroke assessment
1. Facial droop on one side
2. Inability to keep one arm from drifting when extended in front of
patient.
3. Garbled or inappropriate speech
b. Maintain an open airway and O2saturation that is greater than 94%
c. Determine how long the victim has been symptomatic.
d. Alert the hospital to allow a stroke team time to prepare in the emergency
department (ED)
5. Transport the victim to the ED of a hospital with a stroke center if available.
6. Upon arrival at the ED:
7.
a. Continuously monitor the victim’s respiratory status and vital signs.
b. Make sure oxygen saturation is maintained at >94%
c. Establish an IV site and send blood for lab testing if is have not been done
already.
d. Test blood sugar levels and treat hypoglycemia with an IV glucose bolus.
e. Assess the victim’s neurological status.
f. If a stroke is suspected, consult with a neurologist or a stroke team if one
is available)
g. Perform a CT scan of the brain.
h. Monitor the victim’s cardiac rhythm and run an ECG if this has not already
been done by the EMS.
8. When the neurologist or stroke team arrives, complete a comprehensive
neurological exam with an instrument such as the NIH Stroke Scale.
9. The neurologist or stroke team will consult with a radiologist for an accurate
interpretation of the CT scan which should demonstrate:
10. Whether the CT scan reveals a hemorrhagic stroke. If yes, admit the victim to the
stroke or neurological unit and speak with a neurosurgeon regarding the definitive
treatment. Do NOT treat the victim with fibrinolytics.
11. Whether the CT scan results meet the following criteria for an ischemic stroke and
fibrinolytic treatment:

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 a. The diagnosis is an ischemic stroke.
b. The victim must be 18 years of age or older.
c. The onset of the symptoms occurred less than 3 hours before the victim
arrived at the ED.
d. The neurologist or stroke team will verify that the victim is a candidate for
fibrinolytic therapy. Exclusion criteria include:
1. A history of stroke or head trauma during the past 3 months.
2. A history of subarachnoid hemorrhage at any time in the past.
3. Uncontrolled blood glucose of less than 50 mg/dL.
4. An active bleeding disorder.
5. Active bleeding during the assessment
6. Systolic blood pressure higher than 185 mm Hg or diastolic blood
pressure higher than 110 mm Hg
12.
a.
1. Relative contraindications exist for any victim who has a history of
seizures, an acute myocardial infarction in the last 3 months, major
surgery during the past 2 weeks, or a gastrointestinal bleeding
incident within the past 3 weeks. If any of these conditions are
present, the neurologist or stroke team should decide with the
patient and family members if the benefits of fibrinolytic therapy
outweigh the risks.
b. If the team determines that the victim should NOT receive fibrinolytic
therapy, treatment with aspirin should begin and the victim needs to be
admitted to the neurological or stroke unit for monitoring.
c. If the team determines that the victim is a candidate for fibrinolytic therapy,
the team will discuss benefits and risks with the victim and family.
13. Administer fibrinolytic therapy and provide associated care:
a. Admit the victim to the neurological or stroke unit.
b. Maintain an open airway.
c. Monitor the vital signs and level of consciousness.
d. Maintain blood glucose levels between 55 and 185 mg/dL by administering
glucose or insulin.
e. Monitor the victim for potential complications of fibrinolytic treatment.

Acute Coronary Syndrome (ACS)

Acute coronary syndrome (ACS) is a range of cardiac diagnoses including ST-segment

elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction
(NSTEMI) or unstable angina. Therapy goals in treatment of ACS include:

• Identification of type of cardiac event to facilitate early reperfusion when

appropriate.
• Relief of chest pain

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 • Prevention or treatment of complications (ventricular tachycardia and fibrillation
and unstable tachycardia)
• Prevention of major adverse cardiac events (MACE).

ACS Algorithm

1. Recognize myocardial infarction signs and symptoms early in the process:

a. Chest pain or discomfort radiating to the arm, shoulder, or jaw.
b. Nausea, vomiting and diaphoresis.
c. Sudden shortness of breath.
2. In the field, activate the emergency management system (EMS):
a. Support the airway, breathing and circulation and be prepared to provide
CPR.
b. Administer aspirin.
c. Administer oxygen to maintain the oxygen saturation at or above 94%.
Routine oxygen is not needed for people with normal oxygen levels (≥94%)
d. Obtain a 12-lead ECG in the field and transmit to the receiving hospital if
possible.
e. Administer a nitroglycerin tablet every 3-5 minutes for ongoing pain.
f. Administer morphine for pain not controlled by nitroglycerin.
3. In the emergency department (ED):
a. Perform a 12-lead ECG if not done.
b. Insert an IV if not done.
c. Administer aspirin, nitroglycerin and morphine and monitor for hypotension.
d. Monitor oxygen saturation and titrate oxygen to keep saturation between
94% and 99%
e. Do a quick assessment and history.
f. Complete the fibrinolytic checklist.
g. Obtain lab work and chest x-ray.
h. Based on the ECG, classify the cardiac disease into one of three categories
and treat according to the category
4. Interventional team:
a. Coronary angiography should be performed emergently for STEMI. PCI is
preferred to fibrinolysis for STEMI. EMS should deliver patient to PCI-
equipped facility when practical.
b. Emergent coronary angiography is reasonable for unstable, comatose
patients with cardiac arrest of a suspected cardiac source, regardless of ST
segment elevation or if they are conscious or comatose.
c. The earliest time to offer a prognosis about poor neurological outcome in
patients not treated with targeted temperature management (TTM) is 72
hours—even longer in TTM.

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 TABLE 3: ACS CATEGORIZATION

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 The ACLS Acute Coronary Syndrome Algorithm is shown in Figure 3.

FIGURE 7: ACLS ACUTE CORONARY SYNDROME ALGORITHM

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Stable and Unstable Tachycardia

Tachycardia is a faster than normal heart rhythm (greater than 100 beats per minute for
an adult) that can quickly deteriorate to cardiac arrest if left untreated.

“When looking at the ECG, tachycardia can be classified as narrow complex with a QRS less
than 0.12 seconds or wide complex when the QRS exceeds 0.12 seconds.”

A narrow complex rhythm, sinus tachycardia (ST), is not considered an arrhythmia.

Originating above the ventricles of the heart, supraventricular tachycardia (SVT) may have
a wide or narrow QRS complex. A wide complex rhythm, VT, can deteriorate to VF and
cardiac arrest, and therefore, must be treated immediately.

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 TABLE 4: SIGNS AND SYMPTOMS OF TACHYCARDIA

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Tachycardia Algorithm

For the tachycardic patient:

1. Identify and treat the cause of the dysrhythmia.

2. Monitor cardiac rhythm, blood pressure and oxygenation.
3. Determine if the patient is stable or unstable. Unstable tachycardia =
hypotension, chest pain, symptoms of shock and possible decreased mentation.
4. For unstable tachycardia, perform immediate synchronized cardioversion:
1.
1. If the QRS is narrow and regular, cardiovert with 50-100 Joules.
2. If the QRS is narrow and irregular, cardiovert with 120-200 Joules.
3. If the QRS is wide and regular, cardiovert with 100 Joules.
4. If the QRS is wide and irregular, turn off the synchronization and
defibrillate immediately.
5. For stable tachycardia and a prolonged/wide QRS complex (>0.12 seconds), go to
Step 7.
6. For stable tachycardia with a normal/narrow QRS complex (≤0.12 seconds),
consider performing vagal maneuvers.
7. Establish an IV or IO to administer medications.
8. Consider giving adenosine 6 mg IV bolus; give a second double dose (12 mg) if
needed. Adenosine must be given rapidly. Consider using stop-cock technique
with 10 cc flush on one attachment and adenosine syringe on second attachment.
9. If adenosine does not terminate the tachycardia, consider procainamide 20-50
mg/minute IV (maximum dose = 17 mg/kg IV). Start a maintenance infusion of
procainamide at 1-4 mg/minutes. Instead of procainamide, you may consider
giving amiodarone 150 mg IV over 10 minutes with second dose for any recurrent
VT. Start a maintenance infusion of amiodarone at 1 mg/min IV.

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Bradycardia

In an adult, bradycardia is a rhythm with a rate <50 per minute. Bradycardia is defined as
symptomatic when any or all of these symptoms occur:

TABLE 5: SIGNS & SYMPTOMS OF BRADYCARDIA

“Treatment for bradycardia should be based on controlling the symptoms and identifying
the cause using the H's and T's (See Figure 4 & Table 8: H's and T's).”
For Bradycardia:

1. Do not delay treatment but look for underlying causes of the bradycardia using the
H's and T's (see Figure 4 & Table 8).
2. Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen
saturation.
3. Insert an IV or IO for medications.
4. If the patient is stable, call for consults.
5. If the patient is symptomatic, administer atropine 0.5 mg IV or IO bolus and repeat
the atropine every 3-5 minutes to a total dose of 3 mg:
1. If atropine does not relieve the bradycardia, continue evaluating the patient
to determine the underlying cause and consider transcutaneous pacing.

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 2. Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute.
3. Consider an IV/IO epinephrine infusion at 2-10 mcg/minute.

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 FIGURE 8: ACLS BRADYCARDIA ALGORITHM
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Perform Synchronized Cardioversion

If the defibrillator has a synchronization mode, attempt to cardiovert the unstable patient
with a tachycardiac rhythm:

• Apply the pads.

• Switch to synchronized mode.
• Dial in the appropriate dose.
• Charge the machine.
• Ensure that no one is touching the patient or bed.
• Press the buttons; the shock will be synchronized with the ECG. Therefore, the
shock may not be delivered immediately. Keep clear of the bed and patient until
the shock is delivered.
• For continued tachycardia, ensure that the machine is still in synchronized mode,
increase the dose, and repeat synchronized cardioversion.

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 FIGURE 9: ACLS TACHYCARDIA ALGORITHM
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VENTRICULAR FIBRILLATION, PULSELESS VENTRICULAR
TACHYCARDIA, PEA AND ASYSTOLE

Cardiac arrest is associated with one of the following rhythms:

• Pulseless ventricular tachycardia (VT): Is usually seen as very wide QRS

complexes on the ECG. The victim will be pulseless with this rhythm. Without
treatment, VT can quickly deteriorate into VF; consequently, the treatment is the
same as for VF.
• Ventricular fibrillation (VF): Characterized by chaotic electrical activity on the
monitor, a victim with VF will have no palpable pulses.
• Pulseless electrical activity (PEA): When there are visible complexes on the cardiac
monitor, but no pulses can be felt, the rhythm is PEA. The goal of treatment for
PEA is to identify and treat the underlying cause of the rhythm using the H's and
T's. PEA will not respond to shocks.
• Asystole: Often called cardiac standstill or flat line and is the absence of all
evidence of electrical activity on the ECG. There are no complexes visible on the
monitor. Asystole will not respond to shocks.

Once cardiac arrest occurs, the goal of advanced life support is the return of spontaneous
circulation (ROSC). In cardiac arrest, the victim has no pulse and is unresponsive and not
breathing. Once a victim is in cardiac arrest, prognosis for survival is very poor. Therefore,
it is critical to intervene BEFORE cardiac arrest occurs. Advanced life support includes:

• Defibrillation
• Medication therapy
• Determination of whether the cardiac rhythm is shockable.
• Provision of vascular access for drug administration (see Routes of Access for
Medication Administration)
• Advanced airway management (although an ET tube is preferred, efficient bag-
mask ventilations can be just as effective for short resuscitation effort

CARDIAC ARREST: VENTRICULAR FIBRILLATION (VF) WITH CPR AND AED

ADULT BLS/CPR

Conduct the BLS survey first by performing the following steps:

1. Secure the scene.

2. Assess the victim.
3. Activate EMS
4. Use an AED, if available
5. Perform CPR

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“See Unit Two for a complete review of the CPR steps. Remember, chest compressions
should be hard, at a depth of at least 2 inches and fast, with 100-120 compressions per
minute.”

High-quality CPR can be exhausting. If more than one rescuer is available, be sure to
provide relief by alternating rescuer positions every two minutes.

Using the Automated External Defibrillator

Sudden cardiac death is often caused by VF that causes the cardiac muscle to fibrillate
rather than contract in a normal heartbeat. The effective treatment for this arrhythmia is
an electric shock by a defibrillator. With the ready availability of the automated external
defibrillator (AED), the public now has a ready way to:

• identify the heart rhythm of a victim.

• appropriately administer a shock if the victim is in VF.

The AED is safe because knowledge of cardiac rhythms is NOT required, and a rescuer
does not even need experience with the machine. However, previous familiarity with the
AED can minimize anxiety when its use is required. All AEDs are similar. To operate an
AED, refer to the BLS AED Algorithm (see Figure 5).

1. Secure the scene and verify the victim is NOT in water.

2. Open and turn the AED on
3. Continue CPR until the AED pads are on, the wires are connected (if not connected)
and the device is powered. CPR should be stopped only when the device is ready
to analyze the rhythm.
4. Stop CPR. The effectiveness of shock delivery decreases significantly for every 10
seconds that elapses between compressions and shock delivery; it is therefore
critical to deliver a shock quickly.
5. Expose the victim's chest and dry the skin if necessary.
6. Open the AED pads and attach the pads to the victim's chest. A hard lump on the
victim's chest may indicate an implanted pacemaker. Do not place an AED pad
over the lump. Remove any medication patch that is on the chest.
7. Instruct all bystanders to move away while the AED analyzes the victim's rhythm.
DO NOT TOUCH the victim during this analysis. If you get a message to check the
pads, press on each pad to ensure the pads are making full contact. Occasionally,
you may have to apply a new set of pads.
8. If the AED detects a shockable rhythm, it will verbally tell you to not touch the
victim. The AED will advise you to deliver a shock. After announcing “Clear,” ensure
that no one is in contact with the victim. Press the “Shock” button
9. If the AED does NOT detect a shockable rhythm, it will tell you to resume CP.

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“After performing CPR for 2 minutes, the AED will advise you to stop CPR to analyze the
rhythm. Repeat this process as needed until the victim regains consciousness or EMS
arrives.”

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 FIGURE 10: BLS AED ALGORITHM

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Cardiac Arrest

The cardiac arrest algorithms are designed to provide high-quality CPR, electrical
intervention when appropriate, and medication therapy. These algorithms assume that
CPR is being done and a well-trained team is in place with all required equipment.
Immediate intervention in cardiac arrest is critical since it is well documented that
success of resuscitation will depend on:

• Length of time between a victim's arrest and beginning of CPR: Outcomes are
better with shorter lengths of time.
• Provision of high-quality CPR.
• Duration of CPR: Prognosis becomes worse as duration of CPR increases.
• Early determination and treatment of causes of the arrest.

When BLS interventions are unsuccessful in a cardiac arrest victim, the team will
implement the appropriate algorithm based on whether the rhythm is shockable (VT or
VF) or not shockable (PEA or asystole). Figures 6 and 7 (below) represent the separate
halves of the Cardiac Arrest Algorithm:

1. Do high-quality CPR, establish an airway and provide oxygen to keep oxygen

saturation above 94%, and monitor the victim's heart rhythm and blood pressure.
2. If the patient is in asystole or PEA, go to step 11 and follow the PEA and Asystole
Algorithm (Figure 6).
3. If the monitor and assessment indicate pulseless VT or VF, apply defibrillator pads
and shock the patient with 120-200 Joules on a biphasic defibrillator or 360 Joules
using a monophasic defibrillator (refer to Figure 7: VT and VF Algorithm).
4. Continue CPR and attempt to establish IV or IO access.
5. If the monitor and assessment indicate asystole or PEA, go to step 11 (refer to
Figure 6: PEA and Asystole Algorithm).
6. After 2 minutes of CPR, defibrillate again if the victim is still in VT or VF.
7. Give epinephrine 1 mg ASAP and every 3-5 minutes.
8. If the monitor and assessment continue to show VT or VF, shock again.
9. Continue CPR for 2 minutes and give a 300 mg IV bolus of amiodarone. Repeat
amiodarone at a dose of 150 mg bolus if needed. If amiodarone is unavailable,
substitute lidocaine at 1-1.5 mg/kg IV. If the first dose is not effective, give half
doses of lidocaine every 5-10 minutes to a maximum of 3 mg/kg IV.
10. Alternate 2 minutes of CPR with defibrillation for VT or VF.
11. If the monitor and physical assessment indicate the victim is in asystole or PEA,
continue CPR and administer epinephrine 1 mg IV as soon as possible and again
every 3-5 minutes as needed. Every two minutes stop CPR in order to evaluate the
cardiac rhythm. If PEA or asystole develops into VT or VF (shockable rhythms),
defibrillate the victim and (refer to Figure 7: VTach and VFib Algorithm).
12. H's and T's – Here are several known causes of PEA that can be treated. These
causes are known as the H's and T's. As treatment continues, the team leader

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 should continuously evaluate and intervene if any of these underlying causes are
identified. Continue to Evaluate, Identify, and Intervene on underlying reversible
causes (see Table 5).
13. Once identified, treat the cause of the PEA or asystole.
14. If ROSC occurs at any point in the algorithm, proceed to the post-cardiac arrest
case.
15. Extracorporeal CPR may be considered in some victims (e. g., reversible cause,
awaiting heart transplant) who did not respond to traditional CPR.

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 TABLE 6: H'S AND T'S AS CAUSES OF PEA

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 FIGURE 11: ACLS CARDIAC ARREST PEA AND ASYSTOLE ALGORITHM

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 FIGURE 12: ACLS CARDIAC ARREST VTACH AND VFIB ALGORITHM

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Manual Defibrillation for VF or Pulseless VT

During the Cardiac Arrest Algorithm, any time the monitor shows a shockable rhythm (VF
or pulseless VT), prepare to defibrillate while continuing high-quality CPR. To operate a
manual defibrillator:

1. Turn on the machine.

2. Apply conductive gel to paddles or apply adhesive pads to the chest (select the
largest pads or paddles available that do not touch each other).
3. If using paddles, press down firmly on the patient's chest.
4. Select dose as in the VTach and VFib Algorithm (see Figure 7, above).
5. Press the charge button on the defibrillator.
6. When the defibrillator is charged, announce "Clear" and verify that all team
members are clear of the bed and victim.
7. Press the shock or discharge buttons.
8. Immediately, continue CPR for 2 minutes and recheck rhythm. If the rhythm is
shockable, administer another defibrillation

Routes of Access for Medication Administration

During resuscitation, medication administration will often be needed. The preferred route
of administration of medications is:

TABLE 7: ROUTES FOR MEDICATION ADMINISTRATION

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Insertion of an IO Catheter

An IO catheter can be inserted into an adult or child for quick access during resuscitation.
The IO catheter should be replaced by an IV as soon as possible. To insert an IO catheter:

1. Use standard precautions.

2. Position and immobilize the extremity.
3. Disinfect the skin at the insertion site.
4. If available, use an IO needle with stylet for insertion.
5. Insert the IO needle using continuing firm pressure and a twisting motion until you
feel a sudden decrease in resistance.
6. Remove the stylet and attach a large syringe.
7. Aspirate a combination of blood and bone marrow to confirm IO placement.
8. Blood aspirated from the IO site can be used for lab tests.
9. Start an infusion of normal saline; observe the site for signs of a dislodged
catheter.
10. Support the IO needle with gauze and tape the needle flange to the skin.
11. Attach the IV tubing to the needle.
12. After giving any medication via the IO port, flush with sterile saline IV solution.

Monitoring During CPR

Quantitative waveform capnography is the most accurate measure of the quality of CPR
and airway management during resuscitation. If the PETCO2 measured by capnography
goes below 10 mm Hg during CPR, the team member doing compressions should be
directed to increase the depth and rate of compressions.
“In addition, the placement of the ET tube should be verified. After making those
adjustments, a PETCO2 <10 mm Hg indicates that the prognosis for ROSC is poor. Return
of the PETCO 2 to 35-40 mm Hg indicates ROSC.”
Another indication of ROSC is increased coronary perfusion pressure. Arterial oxygen
saturation should be maintained above 30%. If the O2 saturation falls below this level, the
CPR compression rate and depth should be increased.

Medications Used During Cardiac Arrest

Administration of epinephrine may improve the victim's chances for ROSC. Give a
vasopressor every 3-5 minutes during cardiac arrest.
“Antiarrhythmics such as amiodarone and lidocaine may increase short-term survival
rates (See Unit 6: Commonly Used Medications in Resuscitation for additional information
about medications used during ACLS).”

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Lidocaine provides no long-term benefit or harm. Likewise, beta-blockers are not to be
routinely used after cardiac arrest. Lidocaine and/or beta-blockers may be considered
after ROSC in victims who had a cardiac arrest due to pulseless VT or VF.

When to Terminate Resuscitation Efforts

If the victim fails to respond to ACLS interventions, the team leader must consider
terminating treatment. Factors to consider when making the decision to terminate
resuscitation efforts include:

• Failure to respond to ACLS interventions.

• Amount of time after collapse before CPR and defibrillation began.
• Any other comorbid disease or conditions.
• Discovery of a “Do Not Resuscitate” order for the victim.
• Length of the resuscitation effort; increased time generally results in poor
outcomes.
• Policies of the healthcare facility.
• Low end-tidal carbon dioxide (ETCO2) after 20 minutes of CPR in intubated victims
(e.g., <10 mm Hg by quantitative waveform capnography) along with other items
listed above.

Post-Cardiac Arrest Care

Treatment for a victim of cardiac arrest must continue post resuscitation in order to
optimize the outcomes. The Post-Cardiac Arrest Care Algorithm (see Figure 8) includes
the following steps:

1. Verify ROSC.
2. Manage the airway and provide a breath every 5-6 seconds. If an advanced airway
is in place, provide a breath every 6 seconds. Using quantitative waveform
capnography, titrate the oxygen to maintain a PETCO2of 35-40 mm Hg. If you do
not have access to a waveform capnography machine, titrate oxygen to keep the
victim's oxygen saturation between 94% and 99%.
3. Insert and maintain an IV for medication administration. Maintain the blood
pressure above 90 mm Hg and/or a mean arterial pressure of 65 mmHg. Avoid
hypotension. For a low blood pressure, consider one or more of these treatments:
1. Give 1-2 liters of saline or Ringer's lactate IV fluid.
2. Start an epinephrine IV infusion to keep the systolic pressure >90 mm Hg.
3. Start a dopamine IV infusion.
4. Consider norepinephrine for extremely low systolic blood pressure.
4. Evaluate the H's and T's for treatable causes (see Figure 4: H's and T's).
5. Track the victim's mental status. For decreased level of consciousness after
resuscitation, consider inducing hypothermia.

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 6. Targeted temperature management (TTM) should be performed in all comatose
adult victims who have ROSC after cardiac arrest. The target temperature is
between 32°C and 36°C for at least 24 hours. Fever should be actively prevented
after patients in TTM return to normothermia (normal temperature). Victims of
outside-of-hospital cardiac arrest should not be routinely cooled before they reach
the ED.
7. Obtain a 12-lead ECG to determine if the victim has suffered an ST segment
elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial
infarction (NSTEMI).
8. If STEMI or AMI is suspected, consider percutaneous coronary intervention (PCI)
to open the coronary arteries.
9. When myocardial infarction is not suspected or after PCI, transfer the victim to a
coronary care unit.

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 FIGURE 13: ACLS POST CARDIAC ARREST CARE ALGORITHM

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Opioid Overdose Algorithm

Unresponsive victims who have a known or suspected opioid overdose should be given
intranasal or intramuscular naloxone. Opioids are drugs such as heroin, methadone, and
morphine. Naloxone is an opioid receptor antagonist (blocker) that can reverse the
effects of excessive opioids.
“Intranasal (2 mg) or intramuscular (0.4 mg) naloxone should be administered to anyone
in respiratory distress/arrest that is likely or definitely because of opioids. Do not delay
EMS activation to administer naloxone, but also do not delay naloxone administration to
activate EMS.”
Naloxone has a short half-life (does not last very long in the body). A repeat dose of
naloxone can be given after 4 minutes if the victim starts to lose consciousness again or
again experiences respiratory distress/arrest. The BLS Suspected Opioid Overdose
Algorithm is shown in Figure 10 (below).

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 FIGURE 14: BLS SUSPECTED OPIOID OVERDOSE ALGORITHM

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 Unit 07: ACLS Resuscitation
Medications
The administration of resuscitation medications and observations regarding their effects
and side effects often lead to different guidelines for the types, doses, and uses of
medication.

For instance, vasopressin was removed from the ACLS algorithm in 2015. Therefore, it is
vital that emergency medical responders remain up to date on the procedures for treating
victims with medication during resuscitation.

Furthermore, each member of the resuscitation team needs to be familiar with the drugs
that are most used for emergencies, which are listed in Table 8. The uses and doses are
in accordance with the AHA recommendations.

“These medications should only be administered by licensed and experienced medical

professionals.”

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 TABLE 8: ACLS MEDICATIONS FOR RESUSCITATION

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 Unit 08: Rhythm Recognition
Sinus Rhythm

A normal sinus rhythm demonstrates regular P, Q-R-S, T deflections and intervals with a
rate = 60-100 at rest.

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Sinus Bradycardia

Sinus bradycardia in an adult is a cardiac rhythm that demonstrates a rate less than 60
per minute.

Sinus Tachycardia

Sinus tachycardia in an adult is a cardiac rhythm that demonstrates a rate greater than
100 per minute and the p waves are still present.

Sinus Rhythm With 1st Degree Heart Block

A 1st degree heart block is a cardiac rhythm which demonstrates a prolonged PR interval
of more than 0.20 seconds due to a delay in the transmission of an action potential from
the atria to the ventricles.

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2nd Degree AV Heart Block

A 2nd degree AV block is generally classified as either Mobitz Type I (Wenckebach) or

Mobitz Type II. The Mobitz Type I heart block is characterized by the progressive
lengthening of the PR interval until there is a block of the QRS complex in which the heart
skips a beat.

The Mobitz Type II heart block is characterized by consistent PR intervals before a block
of the QRS complex occurs. In victims with this type of heart block, some of the action
potentials are not transmitted to the ventricles and the pattern is irregular. This may
cause a slower than normal heartbeat and it is a serious condition.

3rd Degree Heart Block

A 3rd degree heart block is also known as a complete heart block. This is a cardiac rhythm
in which there is no activity between the P and QRS waves. That is, the electrical signals
are not transmitted from the atria to the ventricles and the heart tries to compensate by
producing electrical signals from a specialized pacemaker-like region in the ventricles
(escape QRS complexes). These abnormal signals cause the heart to contract and pump
blood, but at a much slower rate than normal.

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Supraventricular Tachycardia (SVT)

Supraventricular tachycardia (SVT) is an extremely fast atrial rhythm with typically narrow
QRS complexes (although can be wide complex when conducting aberrantly). When this
occurs, the impulses originate above the bundle branches, which is above the ventricles.

Atrial Fibrillation (AF)

Atrial fibrillation (AF) is a very common arrhythmia. This cardiac rhythm is characterized
by the absence of waves before the QRS complex occurs and it produces an irregularly
irregular heart rate.

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Atrial Flutter

An atrial flutter is a supraventricular arrhythmia that produces a “saw-toothed” pattern on

an ECG, which reflects multiple P waves before each QRS complex.

Asystole

Asystole is most referred to as a "flat line" where no electrical activity is observed on a

cardiac monitor and the victim is no longer responsive to electrical defibrillation.

Pulseless Electrical Activity

Pulseless electrical activity (PEA) refers to any ECG rhythm in a victim who is
unresponsive and does not have a palpable pulse. Therefore, it is difficult for a responder
to learn how to recognize a PEA rhythm. However, it should not be confused with specific
pulseless scenarios that were previously described.

Ventricular Tachycardia (VT)

Ventricular tachycardia (VT) is characterized by abnormally widened QRS complexes, the

absence of P waves, and a heart rate that typically exceeds 100 beats per minute. In
addition, VT may quickly deteriorate to ventricular fibrillation and death. However, a victim
who is experiencing VT may still be responsive to electrical defibrillation.

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Ventricular Fibrillation (VF)

Ventricular fibrillation (VF) is characterized by an erratic wave pattern without a pulse.

However, a victim experiencing VF may still be responsive to electrical defibrillation.

Torsades de pointes (TDP)

Torsades de pointes is a specific type of polymorphic ventricular tachycardia that

demonstrates a long QT interval. It is characterized by rapid and irregular QRS complexes
that appear to be twisting on an ECG.

This arrhythmia may degenerate into ventricular fibrillation or spontaneously stop. It may
also cause significant hemodynamic compromise and often leads to death.

Treatment is with IV magnesium sulfate and approaches that shorten the QT interval as
well as direct-current defibrillation if ventricular fibrillation arises.

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 Unit 09: References
References:

1. ACLS Medical Training. (2020, September 16). Commonly Used Medications in

ACLS. https://www.aclsmedicaltraining.com/commonly-used-medications-in-
acls/
2. ECC Guidelines. (2018, October). Highlights of the 2018 Guidelines Focused
Updates Highlights of the 2019 Guidelines. https://eccguidelines.heart.org/wp-
content/uploads/2018/10/2018-Focused-Updates_Highlights.pdf
3. Katherine M. Berg, Jasmeet Soar, Lars W. Andersen, Bernd W. Böttiger, Sofia
Cacciola, Clifton W. Callaway, Keith Couper. (2020). Adult Advanced Life Support:
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment
Recommendations. Circulation, 142(suppl 1): S92–
S139. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000893
4. Soar J, Donnino MW, Maconochie I, et al. (2018). International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
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