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ACLS
STUDY GUIDE
This page intentionally left blank
ACLS
STUDY GUIDE
Barbara Aehlert, MSEd, BSPA, RN
FIFTH EDITION
3251 Riverport Lane
St. Louis, Missouri 63043
ACLS STUDY GUIDE, FIFTH EDITION ISBN: 978-0-323-40114-2
Copyright © 2017, Elsevier Inc. All rights reserved.

Previous editions copyrighted 2012, 2007, 2002.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about
the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Content Strategist: Sandra Clark

Content Development Specialist: Melissa Kinsey/Melissa Rawe
Content Development Manager: Jean Sims Fornango
Publishing Services Manager: Hemamalini Rajendrababu
Senior Project Manager: Umarani Natarajan
Design Direction: Amy Buxton
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
PREFACE TO THE FIFTH EDITION
As Stiggins has observed, “Many of us grew up in classrooms in which our teachers believed that the way
you maximize learning is by maximizing anxiety. Assessment was always the intimidator. Many of our
teachers believed that if a little intimidation doesn’t work, turn up the heat—try a lot of intimidation.
This is why most adults today feel that being evaluated is a distinctly dangerous enterprise. It always left
us feeling vulnerable” (Stiggins, 2005, p. 18*).
I took my first Advanced Cardiac Life Support (ACLS) class many years ago. I felt terrified and lost
throughout the entire course. Although I had spent weeks studying before the course began, material now
seemed to be written in a foreign language. I could find no resources to “translate” the information into
something that was useful to me. The course consisted of very long lectures by instructors who read slides
and offered little useful insight. The most memorable part of the course was the “Patient Management”
station, in which each course participant was evaluated one-on-one by an instructor. (Those of you who
have been around a while are probably having flashbacks of those days.) I will never forget that experience.
Despite my preparation, as soon as the door closed behind me I was a mental wreck. The instructor
proceeded to methodically strip away any self-confidence I might have had in treating patients with car-
diac emergencies. I was able to answer the questions asked of me until I was presented with a patient who
had symptomatic bradycardia. Atropine had not worked (transcutaneous pacing was not readily available
back then), and the next drug recommended at that time was isoproterenol. I knew that. What I could
not recall was whether isoproterenol was given in mcg/min (correct) or mg/min. I took a “50/50” guess
and said mg/min. Because that was the wrong decision, I was told I had failed and would need to attend
another 2-day course.
Before driving home, I sat outside for a few minutes contemplating what had happened and what I
might have done to change the outcome. Then and there, promised myself I would become an ACLS
instructor someday and find a way to teach this information in a more user-friendly way. I vowed to teach
courses that were useful to practicing health care professionals and delivered in an environment in which
the participants looked forward to the class—instead of dreading it.
As the years passed, I did become an ACLS instructor and I loved it. At the conclusion of each course,
participants often wrote on their evaluation forms that a study guide would have been helpful in preparing
for class. Those suggestions resulted in my writing a few pages of information that ultimately became a
book—this book.
The ACLS Study Guide is a course preparation tool designed for paramedic, nursing, and medical
students, ECG monitor technicians, nurses, and other allied health personnel working in emergency
departments, critical care units, postanesthesia care units, operating rooms, and telemetry units. The fifth
edition of this book is based on the following scientific principles, treatment recommendations, and
guidelines:
• 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
• 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science with Treatment Recommendations
• Other evidence-based treatment recommendations or sources cited in the references section of rele-
vant chapters.
*
Stiggins, R. J. (2005). An introduction to student-involved assessment for learning (5th ed.). Upper Saddle River, NJ: Pearson Prentice
Hall. v
vi Preface to the Fifth Edition
This book is designed for use with the American Safety and Health Institute (ASHI) ACLS Course.
It can also be used as supplementary material by those participating in ACLS courses offered by other
organizations.
I have made every attempt to provide information consistent with the current literature, including the
latest resuscitation guidelines; however, medicine is a dynamic field. Resuscitation guidelines change,
new medications and technology are being developed, and medical research is ongoing. As a result,
be sure to learn and follow local protocols as defined by your medical advisors. The author and publisher
assume no responsibility or liability for loss or damage resulting from the use of information contained
within.
I genuinely hope the content of this book is helpful to you, and I wish you success in your ACLS
course and clinical practice.
Sincerely,
Barbara Aehlert
ACKNOWLEDGMENTS
My sincerest thanks to Melissa Kinsey for her guidance throughout the development of this text. A spe-
cial thanks to the manuscript reviewers who provided insightful comments and suggestions.
A special thanks to these instructors, who share my ACLS teaching philosophy: Robert Aiken, CEP;
Andrew Baird, CEP; Eileen Blackstone, CEP; Lynn Browne-Wagner, RN; Randy Budd, CEP; Joanna
Burgan, CEP; Thomas Cole, CEP; Mike Connor, CEP; Paul Honeywell, CEP; James Johnson, CEP;
Stephen Knox, CEP; Bill Loughran, RN; Terence Mason, RN; Kevin McColm, CEP; Sean Newton,
CEP; Anthony Pino, RN; Jan Post, RN; Gary Smith, MD; Ed Tirone, CEP; and Maryalice
Witzel, RN.
vii
REVIEWERS FOR THE FIFTH EDITION
N.K. Alexander, EMT-P J.A. Nelson, DO, MS, FACOEP, FACEP

Instructor/Chief Operating Officer State EMS Medical Director
Wilton Emergency Squad, Inc Florida Department of Health
Saratoga Springs, New York Tallahassee, Florida
B. Cetanyan, RN S.L. Pinski, MD

Eastern Iowa Community College Head, Section of Cardiac Pacing and
Davenport, Iowa Electrophysiology
Robert and Suzanne Tomsich Department of
Cardiology
F.O. Garcia, EMT-P
Cleveland Clinic Florida
President
Weston, Florida
Professional EMS Education, LLC
Grand Junction, Colorado
B.R. Shade, EMT-P, EMS-I, AAS
AHA Program Instructor, Adjunct Faculty,
C. Horsfield, BA Firefighter
Paramedic Teaching Fellow Paramedic, retired Assistant Safety Director
School of Health Sciences Cleveland Clinic, Cuyahoga Community College,
University of Surrey Willoughby Fire Department, City of
Guildford, Surrey, UK Cleveland
Cleveland, Ohio
ix
ABOUT THE AUTHOR
Barbara Aehlert, MSEd, BSPA, RN, has been a registered nurse for more than 40 years, with clinical
experience in medical/surgical nursing, critical care nursing, prehospital education, and nursing educa-
tion. Barbara is an active CPR and ACLS instructor with a special interest in teaching basic dysrhythmia
recognition and ACLS to nurses and paramedics.
xi
CONTENTS
1 Emergency Cardiovascular Care 1

Introduction 1
Sudden Cardiac Death 2
Out-of-Hospital Cardiac Arrest 4
In-Hospital Cardiac Arrest 5
Chain of Survival 5
Out-of-Hospital Chain of Survival 5
In-Hospital Chain of Survival 8
Cardiopulmonary Resuscitation 10
Physiology of Chest Compressions 10
Barriers to Effective Cardiopulmonary Resuscitation 10
Feedback during Cardiopulmonary Resuscitation 11
Mechanical Chest Compression Devices 12
Patient Assessment 14
Primary Survey 15
Secondary Survey 17
Putting It All Together 18
Chapter Quiz 18
Chapter Quiz Answers 19
References 20
2 Airway Management 23
Introduction 23
Anatomy Review 25
Upper Airway 25
Lower Airway 27
The Patient with Respiratory Compromise 28
Patient Assessment 29
Oxygen Delivery Devices 32
Nasal Cannula 33
Simple Face Mask 34
Partial Rebreather Mask 35
Nonrebreather Mask 36
Manual Airway Maneuvers 37
Head Tilt–Chin Lift 37
Jaw Thrust 38
Suctioning 39
Airway Adjuncts 40
Oral Airway 40
Nasal Airway 42
xiii
xiv Contents
Positive Pressure Ventilation 44

Noninvasive Positive Pressure Ventilation 44
Mouth-to-Mask Ventilation 45
Bag-Mask Ventilation 47
Advanced Airways 49
Confirming Endotracheal Tube Placement 51
Chapter Quiz 53
References 60
3 Cardiac Anatomy and Electrophysiology 63

Introduction 63
Coronary Arteries 65
Cardiac Cells 66
Cardiac Action Potential 66
Depolarization 67
Repolarization 67
Phases of the Cardiac Action Potential 67
Refractory Periods 68
Conduction System 69
Sinoatrial Node 69
Atrioventricular Node and Bundle 70
Right and Left Bundle Branches 70
Purkinje Fibers 70
The Electrocardiogram 71
Electrodes 72
Leads 72
Electrocardiography Paper 76
Waveforms and Complexes 76
Segments and Intervals 77
Acute Coronary Syndromes 78
Chapter Quiz 79
References 81
4 Cardiac Arrest Rhythms 83

Introduction 83
Cardiac Arrest Rhythms 84
Ventricular Tachycardia 85
Ventricular Fibrillation 85
Asystole 88
Pulseless Electrical Activity 90
Defibrillation 91
Monophasic versus Biphasic Defibrillation 93
Transthoracic Impedance 94
Defibrillation Procedure 97
Automated External Defibrillation 99
Automated External Cardioverter-Defibrillators 100
Possible Complications 100
The Resuscitation Team 100
Team Leader Responsibilities 101
Team Member Responsibilities 102
Resuscitation Efforts 104
Helping the Caregivers 112
Contents xv

Chapter Quiz 113
References 125
5 Tachycardias 129
Introduction 129
Narrow-QRS Tachycardias 131
Sinus Tachycardia 131
Supraventricular Tachycardia 132
Wide-QRS Tachycardias 140
Ventricular Tachycardia 142
Irregular Tachycardias 143
Multifocal Atrial Tachycardia 143
Atrial Flutter 144
Atrial Fibrillation 145
Polymorphic Ventricular Tachycardia 148
Synchronized Cardioversion 150
Procedure 150
Chapter Quiz 153
References 165
6 Bradycardias 167
Introduction 167
Sinus Bradycardia 169
Junctional Escape Rhythm 169
Ventricular Escape Rhythm 171
Atrioventricular Blocks 172
First-Degree Atrioventricular Block 172
Second-Degree Atrioventricular Blocks 173
Third-Degree Atrioventricular Block 176
Transcutaneous Pacing 176
Indications 177
Procedure 178
Limitations 179
Possible Complications 180
Chapter Quiz 181
References 191
7 Acute Coronary Syndromes 193

Introduction 193
Pathophysiology of Acute Coronary Syndromes 194
Myocardial Ischemia, Injury, and Infarction 196
Myocardial Ischemia 196
Myocardial Injury 199
Myocardial Infarction 200
xvi Contents
Patient Evaluation 201

Patient History 201
Atypical Presentation 202
Physical Examination 203
Electrocardiogram Findings 204
Cardiac Biomarkers 214
Imaging Studies 215
Initial Management of Acute Coronary Syndromes 215
Prehospital Management 215
Emergency Department Management 216
Pharmacologic Therapies 217
Reperfusion Therapies 224
Chapter Quiz 227
References 235
8 Acute Ischemic Stroke 237

Introduction 237
Definition of Stroke 239
Anatomy Review 239
Stroke Types 240
Subarachnoid Hemorrhage 240
Intracerebral Hemorrhage 241
Ischemic Stroke 242
Transient Ischemic Attack 243
Stroke Systems of Care 243
Public Education 244
Emergency Medical Services 244
Stroke Centers 246
Chapter Quiz 251
References 256
9 Post Test 259

Post test Answers 269
References 276
Glossary 277
Index 281
CHAPTER 1
Emergency
Cardiovascular Care
INTRODUCTION
Heart disease is a broad term that refers to conditions that affect the heart, and it is a leading cause of
death for both men and women in the United States. Because someone in the United States experiences a
coronary event every 25 seconds, the likelihood of encountering a patient who requires basic life support
(BLS) or advanced cardiac life support (ACLS) care is high (Roger, et al., 2012).
Just as BLS is a systematic way of providing care to a choking victim or to someone who needs car-
diopulmonary resuscitation (CPR), ACLS is an orderly approach to providing advanced emergency care
to a patient who is experiencing a cardiac-related problem. This chapter discusses risk factors for coronary
artery disease (CAD), sudden cardiac death (SCD), the Chain of Survival, and a systematic approach to
patient assessment.
D E S I R E D RE S U L T S
G O A L Given a patient situation, and working in a team setting, direct or perform an initial patient
assessment, identify common barriers to effective CPR, and identify actions that can be taken to
overcome them.
LEARNING OBJECTIVES
After completing this chapter, you should be able to:
1. Define cardiovascular collapse, cardiac arrest, sudden cardiac death, and sudden cardiac
arrest.
2. Discuss the phases of a cardiac arrest.
3. Discuss the prearrest factors that influence survival in out-of-hospital cardiac
arrest (OHCA).
4. Identify the initial cardiac rhythms that are typically recorded in OHCA.
5. Discuss the prearrest factors that influence survival in in-hospital cardiac arrest (IHCA).
6. Identify the initial cardiac rhythms that are typically recorded in IHCA.
7. Describe the links in the Chain of Survival.
8. Discuss the requirements for performing high-quality CPR.
9. Discuss common barriers to effective CPR and possible actions that can be taken to
overcome them.
10. Explore the use of feedback devices during CPR. 1
2 CHAPTER 1 Emergency Cardiovascular Care
11. Discuss the use of continuous end-tidal carbon dioxide (EtCO2) monitoring during
resuscitation efforts.
12. Discuss the use of mechanical chest compression devices during resuscitation efforts.
13. State three areas to assess when forming a general impression of a patient.
14. Differentiate between the purposes and components of the primary and secondary
surveys.
15. Discuss a systematic approach to the initial emergency care of an unresponsive patient.
LEARNING PLAN
• Whether you are preparing for your first ACLS course or your tenth, schedule time to study
and review before the course. Studying in half-hour intervals with 10-minute breaks allows
a reasonable period for both learning and relaxation.
• Read this chapter before class. Take the time to highlight important concepts as you read.
• Develop and use flashcards, flowcharts, and mnemonics to help enhance your retention of
the information presented.
• Complete the chapter quiz and review the quiz answers provided.
KEY TERMS
Automated external defibrillator (AED) A machine with a sophisticated computer system
that analyzes a patient’s heart rhythm using an algorithm to distinguish shockable rhythms
from nonshockable rhythms and provides visual and auditory instructions to the rescuer to
deliver an electrical shock if a shock is indicated.
Cardiopulmonary (cardiac) arrest The absence of cardiac mechanical activity, which is
confirmed by the absence of a detectable pulse, unresponsiveness, and apnea or agonal,
gasping breathing.
Cardiovascular collapse A sudden loss of effective blood flow that is caused by cardiac and/
or peripheral vascular factors that may reverse spontaneously (eg, syncope) or only with
interventions (eg, cardiac arrest).
Cardiovascular disease (CVD) A collection of conditions that involve the circulatory system,
which contains the heart (cardio) and blood vessels (vascular), including congenital
cardiovascular diseases.
Chain of Survival The essential elements of a system of care that are necessary to link the
victim of sudden cardiac arrest with survival.
Coronary artery disease (CAD) Disease affecting the arteries that supply the heart muscle
with blood.
Coronary heart disease (CHD) Disease of the coronary arteries and resulting complications,
such as angina pectoris and acute myocardial infarction.
Heart disease A broad term that refers to conditions affecting the heart.
Risk factors Traits and lifestyle habits that may increase a person’s chance of developing a
disease.
Sudden cardiac death (SCD) A natural death of cardiac cause that is preceded by an abrupt
loss of consciousness within 1 hour of the onset of an acute change in cardiovascular
status; sudden cardiac arrest is a term commonly applied to such an event when the patient
survives.
SUDDEN CARDIAC DEATH

[Objectives 1, 2]
Cardiovascular disease (CVD) is a collection of conditions that involve the circulatory system, which
contains the heart (cardio) and blood vessels (vascular), including congenital CVD. More than one in
three American adults has one or more types of cardiovascular disease (Roger, et al., 2012). The preven-
tion of CVD requires the management of risk factors. Risk factors are traits and lifestyle habits that may
increase a person’s chance of developing a disease. Some risk factors can be modified by specific,
CHAPTER 1 Emergency Cardiovascular Care 3
preventable measures. Risk factors that cannot be modified are called nonmodifiable or fixed risk factors.
Contributing risk factors are thought to lead to an increased risk of heart disease, but their exact role has
not been defined (Table 1.1).
Coronary heart disease (CHD) refers to disease of the coronary arteries and resulting complications,
such as angina pectoris and acute myocardial infarction. Approximately one of every six deaths in the
United States was caused by CHD in 2008 (Roger, et al., 2012). Coronary artery disease (CAD) affects
the arteries that supply the heart muscle with blood. More than 90% of CAD events occur in individuals
who have at least one risk factor (Mack & Gopal, 2014). The relationships among CAD and its major
sequelae are shown in Fig. 1.1.
Cardiovascular collapse is a sudden loss of effective blood flow caused by cardiac factors, peripheral
vascular factors, or both, that may reverse spontaneously (eg, syncope) or only with interventions
(eg, cardiac arrest) (Myerburg & Castellanos, 2012). Cardiopulmonary (cardiac) arrest is the absence
of cardiac mechanical activity, which is confirmed by the absence of a detectable pulse, unresponsiveness,
and apnea or agonal, gasping breathing. Gasping is abnormal breathing, is common during the first few
minutes of primary cardiac arrest, and is a sign of adequate blood flow to the brainstem (Ewy, 2012).
Respiratory efforts can persist for 1 minute or longer after the onset of a cardiac arrest (Myerburg &
Castellanos, 2012).
TABLE 1.1 Cardiovascular Disease Risk Factors

Nonmodifiable (Fixed) Factors Modifiable Factors Contributing Factors
• Age • Diabetes mellitus • Alcohol intake
• Family history of cardiovascular • Elevated serum cholesterol levels • Inflammatory markers
disease • Hypertension • Psychosocial factors
• Gender • Metabolic syndrome • Sleep apnea
• Race • Obesity • Stress
• Physical inactivity
• Tobacco exposure
• Unhealthy dietary habits
CORONARY ARTERY DISEASE
Acute plaque Myocardial ischemia

Myocardial
change; coronary of increased severity
ischemia
artery thrombosis and duration
MYOCARDIAL INFARCTION
with muscle loss
and arrhythmias
Infarct Ventricular Hypertrophy,

healing remodeling dilation of
viable muscle
Chronic ischemic heart disease
Congestive heart failure
SUDDEN CARDIAC DEATH
Fig. 1.1 The relationships among coronary artery disease and its major sequelae. (From Kumar V, Abbas AK, Aster JC: Rob-
bins basic pathology, ed 9, Philadelphia, 2013, Saunders.)
TABLE 1.2 Phases of Cardiac Arrest

Phase Interval Focus of Care
Prearrest Period before the arrest Identify, anticipate, and manage factors that may result in
cardiac arrest (eg, use of rapid response teams to
recognize and treat patients at risk of deterioration)
No flow Untreated cardiac arrest Prompt initiation of basic life support upon recognition of the
arrest by a bystander or health care professional
Low flow Onset of cardiopulmonary Delivery of high-quality chest compressions to optimize
resuscitation myocardial and cerebral perfusion
Postresuscitation Return of spontaneous Identify and treat the cause of the arrest, preserve
circulation neurologic function, and support end organ perfusion and
function
Sudden cardiac death (SCD) is a natural death of cardiac cause that is preceded by an abrupt loss of
consciousness within 1 hour of the onset of an acute change in cardiovascular status (Myerburg &
Castellanos, 2012). SCD is often the patient’s first and only symptom of heart disease (O’Connor,
et al., 2010). For others, warning signs may be present up to 1 hour before the actual arrest. Sudden cardiac
arrest is a term commonly applied to such an event when the patient survives (Taniguchi, et al., 2012).
Four phases of cardiac arrest have been described, each with unique physiology and treatment strategies
(Topjian, et al., 2013) (Table 1.2).
Heart rhythms that may be observed in a cardiac arrest include the following:
1. Pulseless ventricular tachycardia (pVT), in which the electrocardiogram (ECG) displays a wide, reg-
ular QRS complex at a rate faster than 120 beats per minute (beats/min).
2. Ventricular fibrillation (VF), in which irregular chaotic deflections that vary in shape and height are
observed on the ECG but there is no coordinated ventricular contraction.
3. Asystole, in which no cardiac electrical activity is present.
4. Pulseless electrical activity (PEA), in which electrical activity is visible on the ECG but central pulses
are absent.
pVT and VF are shockable rhythms. This means that delivering a shock to the heart by means of a
defibrillator may result in termination of the rhythm. Asystole and PEA are nonshockable rhythms.
Out-of-Hospital Cardiac Arrest

[Objectives 3, 4]
Most nontraumatic OHCAs in the United States are the result of a primary cardiac arrest, rather than
secondary to respiratory arrest (Ewy & Bobrow, 2016). A primary cardiac arrest is an unexpected wit-
nessed (ie, seen or heard) collapse in an individual who is not responsive (Ewy, 2012). Seventy percent
of nontraumatic OHCAs occur in the home (Centers for Disease Control and Prevention, 2014). Of
these arrests, 50.3% are unwitnessed, 37.7% are witnessed by a bystander, and 12.1% are witnessed
by a 9-1-1 responder (Centers for Disease Control and Prevention, 2014).
Prearrest factors that influence survival in OHCA include the following (Boyd & Perina, 2012;
Martinez, 2012):
• Performance of bystander CPR
• Mode of arrest (ie, respiratory versus cardiac)
• Witnessed arrest
• Age (older age associated with worsened survival)
• Initial presenting rhythm of VF
• Short response times to defibrillation
• Location of the arrest (survival is 3 to 4 times more likely if an arrest occurs in a public place; survival is
6 times more likely if the arrest occurs in the workplace)
• Time of day (peak incidence occurs between 8 am and 10 am; survival to hospital discharge lowest for
arrests between midnight and 6 am)
When an OHCA occurs, the initial rhythm recorded by emergency personnel is generally considered
the electrical mechanism of the arrest (Myerburg & Castellanos, 2012). This information is important
because it affects patient outcome. Patients who are in sustained VT at the time of initial contact have the
best outcome, whereas those who present with a bradyarrhythmia or asystole at initial contact have the
worst prognosis (Myerburg & Castellanos, 2012). When the initial rhythm recorded is VF, the patient’s
outcome is intermediate between the outcomes associated with sustained VT and those of bradyarrhyth-
mia and asystole (Myerburg & Castellanos, 2012). Data from nontraumatic OHCAs in 2014 indicate
that asystole was the most common initial cardiac arrest rhythm (45.6%), followed by an idioventricular
rhythm/PEA (21.4%), VF/pVT/unknown shockable rhythm (20.4%), and an unknown nonshockable
rhythm (12.5%) (Centers for Disease Control and Prevention, 2014). Overall survival from nontraumatic
OHCA to hospital admission was 28.3%, and overall survival to hospital discharge was 10.8% (Centers
for Disease Control and Prevention, 2014).
In-Hospital Cardiac Arrest

[Objectives 5, 6]
The most common causes of IHCA include cardiac arrhythmia, acute respiratory insufficiency, and
hypotension (Morrison, et al., 2013) with predictable deterioration before the event (eg, tachypnea,
tachycardia) (Kronick, et al., 2015). Prearrest factors that influence survival in IHCA include the follow-
ing (Martinez, 2012):
• Initial presenting rhythm of VF
• Time to CPR and defibrillation (survival is 33% when CPR is started within 1 minute of arrest versus
14% if the time interval is greater than 1 minute; survival is 38% in pVT/VF arrests when defibrillation
is performed within 3 minutes versus 21% if the time interval is greater than 3 minutes)
• Location (survival is highest if an arrest occurs in an intensive care unit [ICU; witnessed and mon-
itored arrest, advanced life support {ALS} immediately available], better survival rates for wards that
have more than 5 cardiac arrests per year)
• Time of day (arrests that occur at night on general hospital wards have one-half the likelihood of
survival)
• AED use
With regard to adult IHCA, asystole and PEA are more common than VF or pVT as the initial
rhythm (Morrison, et al., 2013). In a large study of adult IHCA patients, only 23% presented with shock-
able rhythms (Wallace, et al., 2013). An analysis of multicenter IHCAs published in 2010 observed that
the onset of the IHCA was witnessed in 79.2% of instances and approximately 32% of IHCAs occurred
within 24 hours of admission, 34% occurred within 1 week of admission, and 23% occurred more than
1 week after admission (Larkin, et al., 2010). Generally, IHCA has a better outcome than OHCA with
22.3% to 25.5% of adult patients surviving to discharge (Kleinman, et al., 2015).
The terms code and code blue are often used in hospitals when a patient experiences a respiratory arrest,
a cardiac arrest, or a cardiac dysrhythmia that is associated with unresponsiveness. When a code blue is
called, usually by means of an overhead paging system, a predesignated team of health care professionals
is deployed to the patient’s bedside to provide lifesaving interventions. The configuration of the resus-
citation team and the responsibilities of each team member are discussed in Chapter 4.
CHAIN OF SURVIVAL
[Objective 7]
The Chain of Survival represents the essential elements of a system of care that are necessary to link the
victim of sudden cardiac arrest with survival. Although links of the Chain have been used for almost
25 years to depict the interrelated steps necessary with regard to an adult cardiac arrest both outside
and inside the hospital setting, the 2015 resuscitation guidelines depict two separate chains because there
are differences in these systems of care. Time is critical when dealing with a victim of sudden cardiac
arrest; a weak or missing link in either Chain of Survival can reduce the likelihood of a positive outcome.
Out-of-Hospital Chain of Survival

[Objective 7]
The links in the out-of-hospital Chain of Survival for adults include early recognition and activation,
early CPR, rapid defibrillation, effective ALS, and integrated post–cardiac arrest care.
Early Recognition and Activation

The first link in the out-of-hospital Chain of Survival is early recognition and activation of the emergency
medical services system (EMSS). When a cardiac emergency occurs, the patient (or a family member or
bystander) must identify his or her signs and symptoms, recognize that they are related to a heart con-
dition, and seek medical assistance in the hope of preventing cardiac arrest. Delays in seeking assistance
and delays in the arrival of assistance ultimately affect patient outcome.
Emergency dispatchers, who are located at public service access points, are the link between the
call for help and the arrival of medical assistance (Kronick, et al., 2015). Dispatchers are trained to
recognize the caller’s description of a potential heart attack or cardiac arrest and to provide real-time
CPR instructions over the phone if necessary while quickly sending appropriately trained and equipped
emergency medical services (EMS) personnel to the scene. Some emergency medical dispatch
protocols include telephone instructions for guiding an untrained rescuer in performing
compression-only CPR. In some areas, emergency dispatchers have used social media to summon
volunteer rescuers to the scene to provide bystander CPR until the arrival of EMS professionals
(Kronick, et al., 2015).
Early Cardiopulmonary Resuscitation

After recognizing that an emergency exists, the scene must be assessed to ensure that it is safe to enter. If
the scene is safe, the patient must be quickly assessed for life-threatening conditions and the nature of the
emergency determined.
CPR is a part of BLS. BLS includes the recognition of signs of cardiac arrest, heart attack, stroke, and
foreign body airway obstruction (FBAO); the relief of FBAO; CPR; and defibrillation with an AED.
BLS must be provided until advanced medical help arrives and assumes responsibility for the patient’s
care. Necessary care may include the following:
• Patient positioning
• CPR for victims of cardiac arrest
• Defibrillation with an AED
• Rescue breathing for victims of respiratory arrest
• Recognition and relief of FBAO
If CPR is necessary, compressions on adult victims of cardiac arrest should be performed at a rate of
100 to 120 compressions/minute with a compression depth of at least 2 inches (5 cm) but no more than
2.4 inches (6 cm) (Kleinman, et al., 2015).
Rapid Defibrillation
When an individual experiences a cardiac arrest, the likelihood of successful resuscitation is affected
by the speed with which CPR and defibrillation are performed. The goal for providing the first
shock for sudden cardiac arrest resulting from VF or pVT is within 3 minutes of collapse (Link,
et al., 2010).
The American Heart Association has promoted the development of AED programs to improve sur-
vival from sudden cardiac arrest since 1995. An automated external defibrillator (AED) is a machine
with a sophisticated computer system that analyzes the patient’s heart rhythm (Figs. 1.2 to 1.4). The AED
uses an algorithm to distinguish shockable rhythms from nonshockable rhythms. If the AED detects a
shockable rhythm, it provides visual and auditory instructions to the rescuer to deliver an electrical shock.
Defibrillation performed by citizens (such as flight attendants, casino security officers, athletic or golf club
employees, and ushers at sporting events) at the scene is called public access defibrillation.
Some AEDs:
• Have CPR pads available that are equipped with a sensor that detects the rate and depth of chest
compressions. If the rate or depth of compressions is inadequate, the machine provides voice prompts
to the rescuer.
• Provide voice instructions in adult and infant/child CPR at the user’s option. A metronome function
encourages rescuers to perform chest compressions at the recommended rate per minute.
• Are programmed to detect spontaneous movement by the patient or others.
• Have adapters available for many popular manual defibrillators, enabling the AED pads to remain on
the patient when patient care is transferred.
• Can be configured to allow ALS personnel to switch to a manual mode, allowing more decision-
making control.
• Are equipped with a small screen that allows the rescuer to view the patient’s cardiac rhythm, assisting
in identification of shockable versus nonshockable rhythms.
Fig. 1.2 The Philips HeartStart FR3 AED. (Courtesy of Philips Healthcare. All rights reserved.)
Fig. 1.3 The Cardiac Science Powerheart G3 Plus automated external defibrillator. (Courtesy Cardiac Science Corporation,
Waukesha, WI)
Fig. 1.4 The LIFEPAK® 1000 Defibrillator. (Courtesy Physio-Control, Inc., Redmond, WA)
• Can detect the patient’s transthoracic resistance through the adhesive pads applied to the patient’s
chest. The AED automatically adjusts the voltage and length of the shock, thus customizing how
the energy is delivered to that patient.
• Are equipped with a pediatric attenuator (ie, a pad-cable system or key). When the attenuator is
attached to the AED, the machine recognizes the pediatric cable connection and automatically adjusts
its defibrillation energy accordingly.
Defibrillation is discussed in more detail in Chapter 4.
Effective Advanced Life Support

Outside the hospital, early advanced care is provided by paramedics (and/or nurses) arriving on the scene.
Prehospital professionals work quickly to stabilize the patient by providing ventilation support, vascular
access, and giving emergency medications, among other interventions.
Integration of Post–Cardiac Arrest Care

Prehospital professionals transport and then transfer the patient to the closest most appropriate emergency
department (ED) or directly to a specialized cardiac arrest center where definitive care can be provided.
In-Hospital Chain of Survival

[Objective 7]
The links in the in-hospital Chain of Survival for adults include surveillance and prevention of cardiac
arrest, prompt notification and response when a cardiac arrest occurs, the performance of high-quality
CPR, prompt defibrillation, and intra-arrest and post–cardiac arrest care (Kronick, et al., 2015).
Surveillance and Prevention

A cardiac arrest experienced by a hospitalized adult is often preceded by warning signs and symptoms
that suggest physiologic deterioration such as tachypnea, tachycardia, and hypotension (Tibballs & van
der Jagt, 2008). Recognizing that early detection and treatment of the patient who demonstrates signs of
clinical deterioration may prevent cardiac arrest and improve patient outcome, the concept of a Rapid
Response System (RRS) emerged. The RRS is mobilized by other hospital staff based on predetermined
criteria for activation of the team. The Joint Commission National Patient Safety Goals require hospitals
to implement systems that enable health care workers to directly request additional assistance from spe-
cially trained individuals when the patient’s condition appears to be worsening (Joint Commission on
Accreditation of Healthcare Organizations, 2007).
Several types of responding teams exist, and large hospitals may require more than one response team.
It has been suggested that the term medical emergency team (MET) be used for teams that are generally led
by physicians and have the ability to: (1) prescribe therapy; (2) place central vascular lines; (3) initiate
ICU-level care at the bedside; and (4) perform advanced airway management (Devita, et al., 2006;
McCurdy & Wood, 2012). It is recommended that the term rapid response team (RRT) be used to
describe a team without all four of those abilities that performs a preliminary evaluation of a patient
and summons additional help or facilitates patient transfer to a higher level of care if warranted
(McCurdy & Wood, 2012). RRTs typically consist of multidisciplinary members such as a physician
(eg, critical care or hospitalist), a critical care nurse, and a respiratory therapist who respond to emergen-
cies, proactively identify and evaluate patients at risk for decompensation, educate and act as a liaison to
ward staff, and follow up on patients who have been discharged from the ICU. In addition to their role in
identifying prearrest conditions, studies have shown that MET and RRT services have also contributed
to the detection and management of medical errors, surgical postoperative morbidity, and clarification of
do not resuscitate status (Tibballs & van der Jagt, 2008).
Several scoring systems for detecting warning signs of patient deterioration exist, and they are used
as tools to assist in determining when the RRT should be activated. For example, with one type of scoring
system, the RRT is activated when a single vital sign or clinical abnormality is outside a predetermined
range (Box 1.1). With the Modified Early Warning Score (MEWS) points are assigned based on the
degree of derangement of ventilatory rate, heart rate, systolic blood pressure (BP), mental status, temper-
ature, and hourly urine output. Regardless of the type of scoring system used, the decision to activate the
RRT based on a score is ultimately the responsibility of the bedside clinician (McCurdy & Wood, 2012).
Adoption of an RRT necessitates teaching and staff empowerment because it usually “involves
substituting a traditional response reserved for cardiac or respiratory arrest (eg, Code Blue) with a system
that responds to the early onset of signs and symptoms that may lead to these conditions” (Tibballs & van
BOX 1.1 Rapid Response System Calling Criteria

• Abnormal or worsening respiratory symptoms • Progressive lethargy
• Acute change in mental status • Staff concern about the patient’s condition
• Chest pain or discomfort unrelieved by • Systolic blood pressure greater than 180 mm
nitroglycerin Hg or less than 90 mm Hg
• Heart rate greater than 140 beats/minute or • Threatened airway
less than 40 beats/minute • Urine output less than 50 mL over 4 hours
• Oxygen saturation less than 90% despite • Ventilatory rate greater than 28 breaths/
supplemental oxygen minute or less than 8 breaths/minute
der Jagt, 2008). Barriers to activation of the RRT by nurses have been identified and include the follow-
ing (McCurdy & Wood, 2012):
• The nurse may not know whom to contact when a patient’s condition deteriorates.
• The nurse may fear blame if activation of the RRS is later deemed unnecessary.
• Nurses often observe patients who briefly exhibit abnormal vital signs that spontaneously normalize.
Even when a dedicated response team exists within an institution, such teams are usually not imme-
diately available and most medical emergencies must be managed by ad-hoc teams (Monteleone & Lin,
2012). After-hours cardiac arrests (ie, evening and weekend) are associated with twice the mortality of
office-hour arrests, which is thought to be a result of both the availability and the experience of staff
(Herlitz, et al., 2002; Monteleone & Lin, 2012).
Studies show considerable variation in patient outcome data with regard to the use of RRTs. In adults,
some studies demonstrate reductions in both IHCA and mortality, others demonstrate reductions in
IHCA without a significant change in mortality, and still others show no significant differences in either
IHCA or mortality (McCurdy & Wood, 2012). The 2015 resuscitation guidelines note that for adult
patients, RRTs or MET systems can be effective in reducing the incidence of cardiac arrest, particularly
in general care wards; pediatric MET/RRT systems may be considered in facilities where children with
high-risk illnesses are cared for on general in-patient units; and the use of early warning sign systems may
be considered for adults and children (Kronick, et al., 2015).
Notification and Response

Every member of the hospital staff should know how to recognize a cardiac arrest and know how to sum-
mon assistance when such an event occurs. Prompt notification and activation of the code team may
include pressing a “code button” at the patient’s bedside, calling a specific phone extension, or use of a
“quick dial button” located on telephones within the facility. When the operator is reached, the type
of emergency and its location are stated. Once the operator is notified of the emergency, members of
the code team typically are activated by means of cell phones and/or a hospital-wide public address system.
Cardiopulmonary Resuscitation
Although cardiac arrests and the performance of CPR are relatively uncommon in in-hospital environ-
ments (Kronick, et al., 2015), it is essential that hospital staff be able to perform high-quality CPR.
Because training may not be adequate to ensure optimal performance, strategies such as timely access
to equipment, visual reminders, regular testing, and point-of-care feedback have been suggested as
methods to improve the translation of resuscitation guidelines into practice during cardiac arrest
(Morrison, et al., 2013).
Prompt Defibrillation
It has been estimated that about half of all IHCAs occur outside the ICU (Morrison, et al., 2013).
Because it can take several minutes for code team members to arrive with a defibrillator, the strategic
deployment of AEDs throughout the facility can aid in achieving prompt defibrillation, with the goal
being the delivery of the first shock within 3 minutes of collapse (Link, et al., 2010).
Intra-Arrest and Post–Cardiac Arrest Care

During the arrest, and under the direction of a team leader, the code team works to stabilize the patient by
continuing high-quality CPR, performing defibrillation for pVT/VF, obtaining vascular access and giv-
ing medications, performing advanced airway management procedures when warranted, and providing
ventilation support, among other interventions. If a return of spontaneous circulation (ROSC) is

achieved, post–cardiac arrest care, including advanced monitoring and targeted temperature manage-
ment, is provided by a multidisciplinary team in an ICU. Post–cardiac arrest care is discussed in more
detail in Chapter 4. After the resuscitation, a debriefing of the resuscitation team is recommended to
discuss areas such as psychomotor skill issues, cognitive issues, team issues, family emotional issues,
and professional staff emotional issues (Kronick, et al., 2015).
CARDIOPULMONARY RESUSCITATION
[Objective 8]
When an adult develops VF and suddenly collapses, his or her lungs, pulmonary veins, left heart, aorta,
and arteries contain oxygenated blood (Ewy, 2005; Meursing, et al., 2005). After recognizing that CPR
is indicated, chest compressions should be the initial action performed (instead of opening the airway or
giving ventilations) when starting CPR in victims of sudden cardiac arrest. Performing chest compres-
sions before ventilations enables better delivery of the oxygen that is already present in the lungs and
arterial circulation to the heart and brain (Kern & Mostafizi, 2009).
Physiology of Chest Compressions

[Objective 8]
During CPR, myocardial blood flow is dependent on coronary perfusion pressure, which is generated
when performing chest compressions. Coronary perfusion pressure is a key determinant of the success
of resuscitation, and adequate cerebral and coronary perfusion pressures are critical to neurologically nor-
mal survival (Ewy, 2005). During the low-flow phase of cardiac arrest, the only source of coronary and
cerebral perfusion pressures comes from the BP generated by high-quality chest compressions (Berg,
et al., 2010). High-quality chest compressions require compressing the chest at an adequate rate and
depth, allowing full chest recoil after each compression (enabling the heart to refill with blood), mini-
mizing interruptions in chest compressions, and avoiding excessive ventilation (Kleinman, et al., 2015).
Cardiac output is the product of stroke volume and heart rate. During CPR, the force of compressions
is a major determinant of stroke volume and the rate of compressions is the determinant of heart rate
(Berg, et al., 2010). Current resuscitation guidelines recommend a compression rate for adults of 100
to 120 per minute (Kleinman, et al., 2015). Because stroke volume also depends on preload, an adequate
blood volume is necessary for adequate perfusion. An adequate perfusion pressure cannot be obtained if
the patient’s blood volume is low, such as that caused by blood loss or significant venous dilation (eg,
hypovolemic shock, septic shock). These patients may require additional intravascular fluid volume to
generate an adequate stroke volume with chest compressions (Berg, et al., 2010).
During the compression (systolic) phase of chest compression, it is essential that the compressions
delivered be of sufficient depth to deliver adequate stroke volume and cerebral perfusion pressure
(Benner, et al., 2011). Current resuscitation guidelines recommend a compression depth for adults of
at least 2 inches (5 cm), not to exceed 2.4 inches (6 cm) (Kleinman, et al., 2015). During the release
(diastolic) phase of chest compression, intrathoracic pressure is low. This helps increase the return of
venous blood into the chest. If intrathoracic pressure is too high, venous return is inhibited.
ACLS Pearl
Hyperventilation is a common cause of excessive intrathoracic pressure during CPR. It is important
to ventilate a patient in cardiac arrest at an age-appropriate rate and with just enough volume to see
the patient’s chest rise gently. Ventilating a cardiac arrest patient too fast or with too much volume
results in excessive intrathoracic pressure, which results in decreased venous return into the chest,
decreased coronary and cerebral perfusion pressures, diminished cardiac output, and decreased
rates of survival.
Barriers to Effective Cardiopulmonary Resuscitation

[Objective 9]
Numerous studies have shown that the quality of CPR during actual resuscitation often falls short of
established resuscitation guidelines in both out-of-hospital and in-hospital settings. Possible factors
influencing these deficiencies include infrequent training, lack of awareness of the quality of CPR during
resuscitation, and inadequate team leadership during resuscitation efforts (Abella, et al., 2014).
Rescuer fatigue has been identified as an important potential contributor to poor CPR quality
(Brooks, et al., 2014). Rescuer fatigue contributes to an inadequate depth of compressions, compromises
coronary perfusion pressure, and also leads to inadequate chest recoil (Reynolds, et al., 2012). Research
has shown that the depth of compressions is compromised after just 1 minute of performing CPR
(Hightower, et al., 1995; Zhang, et al., 2013) and rescuers tend not to recognize their own fatigue until
after approximately 5 minutes of CPR (Reynolds, et al., 2012). To minimize fatigue, rescuers delivering
chest compressions should rotate every 2 minutes. Ideally, the switch should be accomplished in less than
5 seconds and should be done while another intervention is being performed (eg, defibrillation).
The brain and heart are sensitive to ischemic injury. Because it takes time to build up cerebral and
coronary perfusion pressures, even short pauses (4 to 5 seconds) in chest compressions have resulted
in a dramatic drop-off in cerebral and coronary perfusion pressures, thereby reducing blood flow to
the brain and heart (Ewy, 2005; Wik, et al., 2005). When chest compressions are stopped during cardiac
arrest, no blood flow is generated. Even after compressions are resumed, several chest compressions are
needed to restore coronary perfusion pressure.
ACLS Pearl
When caring for a patient in cardiac arrest it is essential that interruptions in chest compressions for
cardiac rhythm analysis, vascular access, airway management, and other interventions be kept to a
minimum. For example, charging the defibrillator before the end of a compression cycle in anticipa-
tion of delivering a shock is one technique that is often used to minimize compression interruptions.
It is important to allow the chest wall to rebound to its normal position after each compression. Incom-
plete chest wall recoil is common when performing CPR, particularly when rescuers are fatigued, and can
occur when a rescuer leans over the patient’s chest (Meaney, et al., 2013). Incomplete recoil results in
higher intrathoracic pressure, decreased coronary perfusion pressure, decreased myocardial blood flow,
decreased cerebral perfusion, and decreased cardiac output (Rajab, et al., 2011; Reynolds, et al., 2012).
Feedback during Cardiopulmonary Resuscitation

[Objectives 10, 11]
Feedback devices provide voice or visual cues about the quality of CPR that are measured and reported
by a defibrillator, a handheld device, or alternative technology (Morrison, et al., 2013). For example, a
metronome can be used to guide the rate and rhythm of chest compressions using auditory or visual
prompting at regular intervals. Timing lights may be used to prompt or time ventilations.
Some feedback devices enable information about CPR quality (eg, chest compression rate, depth, chest
wall recoil) to be fed back to the rescuer using a sternal force detector or accelerometer (or both) through an
external device placed between the rescuer’s hands and the patient’s sternum (Sutton, et al., 2012). With
some feedback-enabled defibrillators, audible voice prompts and visual messages on the monitor screen are
triggered when measured chest compressions or ventilations are interrupted or when they deviate from
preprogrammed resuscitation guideline parameters (Fig. 1.5). It is important that the chest compressor
have an unobstructed view of the monitor screen throughout a resuscitation effort to enhance the effec-
tiveness of audiovisual feedback (Bobrow, et al., 2013). Some defibrillators also possess technology that
filters CPR artifact, allowing the rescuer to analyze a patient’s cardiac rhythm without interrupting CPR
(Fig. 1.6). Although studies to date have not demonstrated a significant improvement in favorable
neurologic outcome or survival to hospital discharge with the use of CPR feedback devices during actual
cardiac arrest events, current resuscitation guidelines reflect that it may be reasonable to use audiovisual
feedback devices during CPR for real-time optimization of CPR performance (Kleinman, et al., 2015).
For intubated patients, continuous EtCO2 monitoring should be used to monitor the quality of com-
pressions during resuscitation efforts. When ventilation is constant, EtCO2 reflects lung perfusion and
therefore cardiac output (McGlinch & White, 2009). EtCO2 falls sharply with the onset of cardiac
arrest, increases when effective CPR is delivered (generally 10 to 20 millimeters of mercury [mm
Hg]), and returns to physiologic levels (35 to 40 mm Hg) with the ROSC (Abella, et al., 2014).
Low EtCO2 values (ie, less than 10 mm Hg) during resuscitation efforts indicate the need to explore
factors that are hindering effective CPR (eg, rescuer fatigue, cardiac tamponade, pneumothorax, bron-
chospasm, mucus plugging of the endotracheal tube (ETT), kinking of the ETT, alveolar fluid in the
Fig. 1.5 Several defibrillators, such as the MRx-QCPR shown here, are equipped with a chest compression pad that enables
monitoring of the quality of chest compressions and provides corrective feedback to rescuers. (Courtesy of Philips Healthcare.
All rights reserved.)
Fig. 1.6 This Zoll R Series Monitor defibrillator filters cardiopulmonary resuscitation artifact, enabling the rescuer to analyze a
patient’s cardiac rhythm without interrupting chest compressions. (Courtesy Zoll Medical Corporation, Chelmsford, MA)
ETT, an airway with an air leak, hyperventilation) (Kodali & Urman, 2014; Link, et al., 2015). As the
rescuer performing chest compressions tires, a gradual decrease in waveform height can be observed on
the monitor screen, indicating the need to change rescuer positions. A sudden sustained increase in
EtCO2 during CPR is an indicator of ROSC. In addition to improving the quality of CPR delivered,
EtCO2 monitoring allows clinicians to perform chest compressions without pausing for pulse checks
unless a sudden increase in EtCO2 is observed, at which time ROSC can be verified (Cunningham,
et al., 2012). When feasible, additional physiologic parameters that may be used to monitor and optimize
CPR quality, guide vasopressor therapy, and detect ROSC include arterial relaxation diastolic pressure,
arterial pressure monitoring, and central venous oxygen saturation (Link, et al., 2015).
Mechanical Chest Compression Devices

[Objectives 12]
The use of mechanical chest compression devices has been proposed as an alternative to manual
compressions to improve compression depth, rate, and consistency. When mechanical devices are used,
training should be provided to reduce the time needed for device deployment (Brooks, et al., 2014).
Training should also stress the importance of minimizing interruptions in chest compressions while
the device is in use (Morrison, et al., 2013).
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And would you be a harlot
Again, for him?
GENEVIVA.
Hush, never!
MARCOMIR.
No, we two
Should understand each other, for we dare not
Become what we have been. For my own sake
I will not leave the world.
GENEVIVA.
He watches us ...
O agony! And he is turned away,
And casts me off for ever. Go to him—
I cannot; for he sees me as I am,
The glory dropt away.
[Marcomir makes a forward movement]
You shall not go!
What do I say? I should not have the strength,
Not all alone. Stay with me! It is plain
What I must do to win him, and so hard—
It smiles so in the stream. Oh, hush! Look there!
That is worse dying. How they pass before him,
There, standing in his chains.
And Pepin looks
And hurries on, but all his gaze is fixed
On Chilperic’s shorn head.
See, how they pass!
Now Zacharias—
And he curses him:
The earth is trembling.
CARLOMAN.
[making a movement as if to curse Zacharias]
But I have no God

To curse you with. I cannot do you harm.
I have no God, no friend, no glowing hate:
You all will pass before me in procession
Day after day as shadows.
ZACHARIAS.
To his cell!
ACT V
Scene: The Prison at Vienne.
[Carloman lying on a plank bed.]
CARLOMAN.
Though Time has played me false—it is not that:

It is the fading colours in my soul,
And all the brilliant darkness through that chink;
It is—
[The door opens and a Warder enters.]
O Warder, put the food away;

But come and chat with me.
WARDER.
I have instructions
I must not speak a word.
CARLOMAN.
Is that the sentence?

Sit down.
WARDER.
But I must see you drink this wine.

The Pope, King Pepin too—they all are anxious
Your life should be preserved.
CARLOMAN.
Sit down and drink.

Now you will chat with me!
WARDER.
[drinking, and speaking always in an undertone]
How do you feel?

Here’s to your health.
CARLOMAN.
Why, that is like a prayer—

Warmed by your voice. They who would shut men up,
And bar them from their fellows’ kindly voices,
God cripple every motion of their soul!
So I am here for ever.
Take that bread:
I like to see you eat. Now talk again.
WARDER.
But you will eat some too?
CARLOMAN.
No, my good jailer,

You shall not forge that chain. You know I’m dying;
Bring me my food and eat it here and talk,
Then you will stay a little longer. Tell me,
How is it with the sky to-day, the winds
And the flowers crying after them? O God!
[He buries his face in his hand.]

WARDER.
Sir, it’s a south wind.
CARLOMAN.
Do the birds fly high?

I watched them in great circles as I travelled—
WARDER.
I have not noticed them.
CARLOMAN.
In wheeling flocks
They mounted ...
Have you nothing more to say?
It must be early morning in the world
Where all is changing.
WARDER.
Ah, you’d know the time;

Most prisoners get confused.
CARLOMAN.
No night nor day;

God promised them forever—morn and eve,
The gathering of the shadows, the decline,
The darkness with no footfall: then the day
And all things reappearing. That’s for all—
Most for the prisoners, if you’d have them gentle.
Throw down this shutter!
WARDER.
[shaking his head] That is just the point—

In prison you get thwarted every way;
You won’t ask that to-morrow.
[He rises, shakes the crumbs from his lap, sets the half-empty wine-bottle on
a ledge within Carloman’s reach and goes out.]
CARLOMAN.
Is he gone?
[Carloman drags himself up and props himself by the wall with his ear
against it.]
I hear the river rushing past the walls,

Rushing and rushing, and through all my dreams
I labour to keep pace with it: awake,
I give myself to rest. It comforts me,
To hear the bounding current pass along,
To think of the far travel of the drops,
Crisping the tiny waves. Away, away!
It is great peace to follow: to pursue
Is misery.
And if I kneel down here,
I can just catch the glitter of the sun
A-tumble down the stream....
[He crouches and looks through the chinks.]

[Enter Zacharias and two Monks.]
ZACHARIAS.
Where is he?
MONK.
There,
Peering between the loosened stones.
CARLOMAN.
[turning] The Pope!

Leave me in peace. You promised me seclusion.
I told you I would be alone with God.
Leave me!
ZACHARIAS.
But you are shut up with the devil!

Deep as you lie, you dare not make pretence
That you have found your God.
CARLOMAN.
[laughing nervously] The seeker lost

More than the thing to find. Leave me alone—
You break the thread, you break it!
O the stream,
It flows and flows, and there are waterfalls
Somewhere, great, heaving torrents ...
ZACHARIAS.
[bending over him] To Vienne

Pilate, they say, was banished—here to die.
CARLOMAN.
What, Pilate!
ZACHARIAS.
Do you tremble at the name?
CARLOMAN.
O God, he saw the light and knew it not,

He had worse memories than Iscariot had
Misusing his great office. He had power,
Power to avert even Calvary ... and yet
We owe salvation to him.
[lifting himself up from the ground] Can it be
My blunder, my effacement shall prevail?
[to Zacharias] So he was banished and came here to die—
As you have banished me; it is enough;
In chains and soon to die. There, hear them rattle;
Now you have done your part.
ZACHARIAS.
Not till you yield,

Not till I see you suffer. [aside] Are hell’s rings
Of fire prepared in vain for him?—Repent!
CARLOMAN.
Leave me!
ZACHARIAS.
No sinner has withstood me yet.

You shall repent.
CARLOMAN.
But I am strong as you:
I will not.
ZACHARIAS.
Oh, you must, for God’s own sake,

His Majesty—He cannot strive and fail;
His heart is set on you and He must have you,
If but to bind in hell. Repent the past,
Repent, repent!
CARLOMAN.
Not anything—the whole

Strange journey and its perils that have brought me
Here to the brink of Death: and all will come
And touch that wonder, all will enter in,
And rest and be revived. Why should one trouble?
Death comes to all, you cannot banish him,
And Death has all we seek for!
ZACHARIAS.
These are words

For men the Church has blessed: but if you die
Without the holy Sacraments, unshriven,
And unabsolved, you will be flung away
To yonder stream, shroudless and like a dog.
Thus heretics are judged.
CARLOMAN.
[excitedly] Be borne along,
Borne with the current. Is that possible?
Borne dead—well, each man takes his full desert—
Mine ... is it possible? And further on
Past towns and cities ... then at last the sea.
ZACHARIAS.
Vain hope! You are God’s prisoner. No escape,

No waves to hide you and no help of man;
For prayer itself like hope is quenched before
The everlasting Prison-house. Farewell!
[Exit with the Monks.]

CARLOMAN.
Ha! ha! He shuts the door—so blank a sound!

And now the river comes about my brain,
And now the music foams incessantly,
The music of my funeral. Enough
For me that I shall lie against the heart
Of that on-pouring volume ...
I am left
By every creature I have breathed beside—
They do not want me. God—He least of all!
He has a King to crown.
All’s well, all are provided for.... My brother
Is in my place; my friend will take my wife.
How Geneviva shuddered at my chains
And clung to her old paramour! So easy
The world’s wounds are to heal. A little time,
Ten years, a year—and all is found defeat
In any life, all turned to ridicule.
[Enter Marcomir in lay dress.]

MARCOMIR.
I have great news for you.
CARLOMAN.
But I am dying!
And now if all the doors were open wide
I should not move to pass through any one.
You cannot bring great news; I know it all,
All that must come now: I can alter nothing.
Rome will be succoured.
MARCOMIR.
Yes, the siege is raised,

And Astolph in retreat. I am not come
To talk of politics.
CARLOMAN.
Of private matters?
My Astolph, Lombardy ...
MARCOMIR.
To say farewell,
To bless you. I am here as from the King;
I showed the monks a parchment with the seal
You used when you were ruler: it was found
Among her jewels ...
CARLOMAN.
Ah, I see, a gift.
So you too play the King. My signet yours,
Ay, and all else that ever bore my name.
Keep it.
MARCOMIR.
But Carloman—
CARLOMAN.
I cannot wait
To hear; I have so very little time
To speak in and such hatred; hate that burns
My heart through to the core. You, all of you,
So glad that I am sunk here; Geneviva
Moving no step to me; and that great Pope,
I gave my soul to in a wondering love,
Vexed that he cannot tame me, not desiring
My help, my pardon. You must hear it all—
I am not in despair: I have a treasure,
A burthen at my heart—where it belongs
I do not know. I have tried many names,
Tried God’s ... You see me dying, that may be;
But not till I have cast my burthen down
Can I be certain of my journey’s end.
How very still your face is! Are you dreaming,
You look so happy? And that scarlet cloak—
Where is your habit?
MARCOMIR.
I have cast it off
Forever; all my oaths are pushed aside,
With all my penitence, by something holy,
And the world seems new-born about me now;
I live as in a kind of bliss,—such joy,
Such fresh, warm sorrow.
CARLOMAN.
Geneviva—yes
I know she loves you. Wait till I am dead.
MARCOMIR.
O Carloman, I dare not break my news,

Not yet, you are not worthy. Do you hear
How the Rhone sings outside?
CARLOMAN.
Beyond these shutters—

The light, the lightning music!
MARCOMIR.
So life sweeps
Down through my blood; at last I have its secret.
CARLOMAN.
Go, dash yourself into the Rhone and die!

There is no secret hid in life—illusion,
That is the great discovery.
MARCOMIR.
O listen!
I am left poor and lonely in the world,
So poor, so lonely, not a soul that needs,
That ever can have need of me! Unloved
And undesired, with just the sun to hail,
The spring to welcome till I die, no more.
And yet—
If they should thrust me in a prison-cell
I should sing on in rapture.
CARLOMAN.
Undesired!
She desires no one ... but you dote on her,
And that will set you singing.
MARCOMIR.
On my lips
Already there is savour of rich song.
That is the joy I spoke of. Oh, to spread
The fame of my dead lady through the lands,
To sing of Geneviva!
CARLOMAN.
She is dead?
Come closer. Chafe my hands—
MARCOMIR.
They mocked at her:
“If the Monk-King should ask now for his wife,
And we presented him the prostitute,
Would he not feel the ribaldry!” She stood
Quite silent, and the ashen lines turned black
On cheek and forehead; and they mocked her more:
“The harlot and the monk!” Then suddenly
A young, wild, girlish glory crossed her face,
She grasped me by the hand—but how we went
Through the hot streets I know not.
On the bridge
She turned to me—“Tell Carloman his wife
Is dead”—and looking down, I saw her stretched
Across the buoyant waters: from my sight
Sucked under by the current ’neath the bridge,
She did not rise.
CARLOMAN.
[triumphantly] And Marcomir, they promise

To cast my body to the river there,
And let it sweep along.
MARCOMIR.
But I shall sing

Of life and youth, virginity and love.
You leave me in the world; O Carloman,
You leave me here delivered.
CARLOMAN.
We shall meet;
And yet such life wells up in me I fear
Lest I should not be dying. Geneviva!
[turning to Marcomir]
And you will sing to me?
[He lies back, wrapt in ecstasy.]
MARCOMIR.
To you, to all.
A tax is laid upon my very heart
To sing the sweeping music of the Rhone,
That rushes through my ears, that chants of her,
Of all you have delivered. In its depths
You will be buried, but the very burthen
You die to utter, far away in France
Will be caught up; Love will be free, and life
Free to make change as childhood.
Someone comes—
Hush, very softly, do not be afraid.
[Boniface enters and steals up to Carloman.]

BONIFACE.
Beloved—
CARLOMAN.
[putting his hand on the lips of Boniface]

No more! Dear voice, end with that word:
Beloved is not a prelude, it is all
A dying man can bear.
BONIFACE.
[blessing him] All that I go
To publish to the folk in heathen lands.
Tho’ very often it means martyrdom
To listen to my story, I am blest
Proclaiming it.
CARLOMAN.
[opening his eyes wide and raising himself]
O Boniface, before
I saw you as an angel.
Is that wine
Still on the stony ledge?
[Marcomir brings the wine-bottle]
Now let us drink,

Drink all of us.
[to Boniface] Go to your heathen lands
With that great lay of love.
This is a poet,
And he too has a burthen, but more sad—
Men love so fitfully. I for myself
Drink deep to life here in my prison-cell.
I had a song ... O Marcomir, the words—
Why do you stumble? Once again the cup!
Fellowship, pleasure
These are the treasure—
So I believe, so in the name of Time ...
[He sinks back and dies.]

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Copyright © 2017, Elsevier Inc. All rights reserved.

Content Strategist: Sandra Clark

N.K. Alexander, EMT-P J.A. Nelson, DO, MS, FACOEP, FACEP

B. Cetanyan, RN S.L. Pinski, MD

1 Emergency Cardiovascular Care 1

Positive Pressure Ventilation 44

3 Cardiac Anatomy and Electrophysiology 63

4 Cardiac Arrest Rhythms 83

Putting It All Together 113

7 Acute Coronary Syndromes 193

Patient Evaluation 201

8 Acute Ischemic Stroke 237

9 Post Test 259

SUDDEN CARDIAC DEATH

TABLE 1.1 Cardiovascular Disease Risk Factors

CORONARY ARTERY DISEASE

Acute plaque Myocardial ischemia

Infarct Ventricular Hypertrophy,

Chronic ischemic heart disease

Congestive heart failure

SUDDEN CARDIAC DEATH

TABLE 1.2 Phases of Cardiac Arrest

Out-of-Hospital Cardiac Arrest

In-Hospital Cardiac Arrest

Out-of-Hospital Chain of Survival

Early Recognition and Activation

Early Cardiopulmonary Resuscitation

Effective Advanced Life Support

Integration of Post–Cardiac Arrest Care

In-Hospital Chain of Survival

Surveillance and Prevention

BOX 1.1 Rapid Response System Calling Criteria

Notification and Response

Intra-Arrest and Post–Cardiac Arrest Care

ventilation support, among other interventions. If a return of spontaneous circulation (ROSC) is

Physiology of Chest Compressions

Barriers to Effective Cardiopulmonary Resuscitation

Feedback during Cardiopulmonary Resuscitation

Mechanical Chest Compression Devices

[making a movement as if to curse Zacharias]

But I have no God

Though Time has played me false—it is not that:

[The door opens and a Warder enters.]

O Warder, put the food away;

Is that the sentence?

But I must see you drink this wine.

Sit down and drink.

[drinking, and speaking always in an undertone]

How do you feel?

Why, that is like a prayer—

But you will eat some too?

No, my good jailer,

[He buries his face in his hand.]