ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

CHAIN OF SURVIVAL RECOGNITION:

1. Immediate recognition of Cardiac Arrest and Activation of the Emergency Response System. 1. Signs of Clinical Deterioration.
2. Early High Quality CPR with emphasis on Chest Compression. 2. Threatened airway.
3. Rapid Defibrillation. 3. Respiratory rate of <6 or >30 breaths per minute
4. Effective Advanced Life Support. 4. Heart rate of <40 or >140 beats per minute.
5. Integrated Post-Cardiac Arrest Care 5. Symptomatic Hypertension.
6. Unexpected decrease in Level of Consciousness (LOC)
CHEST COMPRESSION FRACTION (CCF) 7. Seizures
8. Significant Decrease in urine output.
Is the proportion of time during cardiac arrest resuscitation when chest compression are performed.
9. Subjective concern about the patient.
*Pre-charging the Defibrillator

SCIENCE OF RESUSCITATION

1. Minimize interruptions in compression.

2. No more than 10 seconds interruption and without compression.
3. Allow complete chest recoil.
4. Compression Depth of at least 2 inches in adult patients.
5. 100 - 120 chest compression per minute.
6. ROSC is unlikely if PETCO2 is less than 10mm/Hg

Be Prepared for an
Emergency. Be Trained.
Save a Life.
 Systemic Approach
Initial Impression - A quick visual assessment of the patient’s Appearance/ Level of Consciousness, Airway, Breathing and Circulation/Skin Color.
Unconcious Patient Conscious Patient
BLS Assessment Primary Assessment Secondary Assessment

1. Assess the scene for safety. Airway - Assess if airway is patent. SAMPLE History

Action: Breathing Signs and Symptoms, Allergies, Medication, Past

“Scene is safe, I have gloves and mask on”  Assess respiratory rate (12-20 bpm) and O2 Sat Medical History, Last Oral Intake, Events prior to illness
(≥94%). or injury.
2. Assess the patient for responsiveness.  Rescue Breathing if not breathing or has
inadequate breathing (1 breath/6 seconds) OPQRST
Action: w/supplemental O2.
Tap the patient’s shoulders and shout “Hey Onset, Provocation, Quality, Radiation/Region,
are you ok” (twice) Circulation Severity, Time
 Vital Signs (HR, BP, CRT, Glucose level).
3. Activate the Emergency Response System.  Intravenous Access (IV or IO)
 Monitor - Attached Cardiac Monitor, Assess for
Action: Cardiac Arrhythmia (Brady or Tachy) or ST
If alone: Shout for help or call 911 Segment Elevation.
Not Alone:  Appropriate management/intervention/
a. Out-of-Hospital: “Call 911 (emergency Response medication
System) and get the AED”.
b. In-Hospital: “Call a code and get a crash cart” or Disability
“Code Blue”  Assess patients Neurologic function.
 Check level of consciousness (use AVPU Scale) and
4. Check for breathing or Agonal Breathing and Pulse pupil reaction.
for 5-10 seconds.
Exposure
5. If not breathing or Agonal breathing and pulseless,  Perform physical examination. Check for any signs
start High Quality CPR. of injury or trauma (use DCAP- BTLS scale).
 Check for medical alert tags.

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Be Prepared for an
Emergency. Be Trained.
Save a Life.
ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Airway Management
Bag-valve-mask Ventilation Airway Adjuncts Advanced Airway
Oropharyngeal Airway (OPA) Nasopharyngeal Airway (NPA) ETT, LMA, LT airway
Rescue Breathing  Unconscious/No gag reflex patient.  Conscious, semi-conscious,  Difficult to ventilate (BVM).
 Measure from the corner of the unconscious patient  Airway compromise
1 breath/6 seconds  Need to isolate airway
mouth to the angle of the mandible.  Measure from the tip of the nose to
the ear lobe.
Excessive Ventilation Confirmation Device for ETT Placement
Recommended Tidal Volume:  Causes Gastric Insufflation. Waveform Capnography Other uses of Waveform Capnography:
 500 - 600ml  Aspiration of gastric contents.  Measures end tidal CO2
 Half a bag squeeze  Increases Intrathoracic pressure.  Cardiac Arrest Phase
 Decreases venous return. Pre-arrest phase PETCO2 of 20mm/Hg = HCPR
 Decreases cardiac output. PETCO2 35-45 mm/Hg  Post Cardiac Arrest Phase
 Lower survival rate. PETCO2 of 35-45 mm/Hg = ROSC

Leading Causes of Cardiac Arrest Among Adults

Acute Coronary Syndrome (ACS) Stroke
Common signs and symptoms Crushing chest pain or chest discomfort Unilateral weakness, Facial drooping, slurred speech
 12-lead ECG  F-A-S-T (72% ≥1 indicators)
 OPQRST and SAMPLE History  SAMPLE History
Assessment and diagnostic procedure  CT Scan
- Within 20 minutes upon arrival at hospital.
- Result within 45 minutes (Ischemic 87%, Hemorrhagic 13%)
 MONA  Ischemic Stroke
Morphine, O2, Nitroglycerine, Aspirin 162 -325 mg - Fibrinolytic Theraphy within 3 hours of onset and up to 4.5
Intervention and treatment  30 mins - Fibrinolytics hours for selected patients
 90 min - Percutaneous Coronary Intervention (PCI)  Hemorrhagic Stroke
- Seek expert consultation (surgery0

Be Prepared for an
Emergency. Be Trained.
Save a Life.
ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Assessment and Checking for Stability of Acute Coronary Syndromes (ACS)

Hypotension SBP ≥ 90 (Desired SBP)
Altered Mental Status Decrease LOC
Signs of Shock Pale, cool and diaphoretic skin, delayed CRT
Ischemic Chest Discomfort Chest pain/discomfort
Acute Heart Failure All Abnormal

Bradyarrhythmia (Heart Rate of <60 bpm)

Intervention
Heart Block Waves Description
Stable Unstable

1st Degree Heart Block Complete Consistent Prolonged PR interval  Atropine (1mg/dose, max. of 3mg),
Monitor  Transcutaneous Pacing (TCP) and,
2nd Degree Heart Block, Mobitz and observe  Dopamine (5-20 mcg/kg/min), or
Incomplete Prolonging PR interval with skip beats Epinephrine (2-10 mcg /min)
Type 1 Wenckebach 
nd
2 Degree Heart Block, Mobitz  Atropine (ineffective), seek expert advice
Incomplete Same PR interval with skip beats
Type 2 Monitor  Transcutaneous Pacing (TCP) and,
and observe  Dopamine (5-20 mcg/kg/min), or
3rd Degree Heart Block Complete Inconsistent PR interval, divorces QRS complex  Epinephrine (2-10 mcg /min)

If patient is in Shock Transcutaneous Pacing (TCP)/ Transvenous Pacing Goal is to pace the HR to a normal rate

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Be Prepared for an
Emergency. Be Trained.
Save a Life.
 Assessment and Checking for Stability of Acute Coronary Syndromes (ACS)
Hypotension SBP ≥ 90 (Desired SBP)
Altered Mental Status Decrease LOC
Signs of Shock Pale, cool and diaphoretic skin, delayed CRT
Ischemic Chest Discomfort Chest pain/discomfort
Acute Heart Failure All Abnormal

Tachyarrhytmia (Heart Rate of ≥ 150 bpm)

Intervention
Rhythm Rate QRS Complex
Stable (Medication) Unstable (Shock)
 Beta Blockers
Atrial Fibrillation Irregular Narrow
 Calcium Channel Blockers
Atrial Flutter Regular Narrow  Carotid Massage (Vagal Maneuver) 5 - 10 seconds
 Adenosine - 1st dose 6 mg., 2nd dose 12 mg Synchronized
Supraventricular Tachycardia (SVT) HR ≥ 170 Regular Narrow  Beta Blockers Cardioversion
 Calcium Channel Blockers
 Adenosine - 1st dose 6 mg., 2nd dose 12 mg
Monomorphic VTach Regular Wide
 Anti Arrhythmic Infusion
Polymorphic VTach Irregular Wide  Seek Expert Advice Defibrillation

Synchronized Cardioversion Patient with (+) Pulse only Goal is to convert the tachyarrythmia to a sinus rhythm.

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Be Prepared for an
Emergency. Be Trained.
Save a Life.
 Cardiac Arrest Phase Management
Rhythms Medication
Vasoconstrictor Anti-Arrhythmic
Shckable Rhythm Non-Shockable Rhythm
Epinephrine Amiodarone Lidocaine
 Ventricular Fibrillation  Asystole
 Pulseless Monomorphic  Pulseless Electrical Activity 1mg in 10 ml PNSS (1:10,000)
1st dose - 300mg 1st dose - 1 - 1.5 mg/kg
Vtach (PEA) or
2nd dose - 150mg nd
2 dose - 0.5 -0.75 mg/kg
 Pulseless Polymorphic 1mg in 1ml PNSS (1:1,000)
Vtach
Priority Priority
1. Defibrillation/Shock 1. Epinephrine 1mg  1st medication to be administered on  2nd medication to be administered for cardiac
2. Resume CPR after 2. Resume CPR after no shock cardiac arrest. arrest with shockable rhythms.
Defibrillation advice.  Only medication to be given for a non-  Not to be administered for non-shockable
3. 1 mg Epinephrine 3. Advanced Airway shockable rhythm. rhythms.
4. Advanced Airway 4. Rule out H’s and T’s  PRN (no max. dose)  Preferred for refracctory VF.
5. Amiodarone or Lidocaine  Once administered flush with 20cc NSS,  Maximum of 2 doses only.
6. Rule out H’s and T’s arms elevated 20° for 20 seconds (Rule  Once administered flush with 20cc NSS, arms
of 20). elevated 20° for 20 seconds (Rule of 20).
Don’t’s Don’ts
 No pulse checks after  No to Shock
Shock  No to Amiodarone or
Lidocaine

Reversible Causes (H’s & T’s)

Hypoxia Tension Pneumothorax
Hypovolemia Tamponade (Cardiac)
Hyperkalemia/Hypokalemia Thrombosis (Pulmonary)
Hydrogen Ion (Acidosis) either metabolic or respiratory Thrombosis (Cardiac)
Hypothermia Toxins
Also: Check and treat for Hypoglycemia

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) 2020

Be Prepared for an
Emergency. Be Trained.
Save a Life.
 Post-Cardiac Arrest Phase Management
Disability
Airway Breathing Circulation
Unconscious Conscious

Early Placement of ETT Tube  Rescue Breathing (1  Systolic BP of >90  TTM  Other critical care
breath/6 seconds)  MAP of >65  Obtain Brain CT management
 SPO2 of 92% - 98%  EEG Monitoring
 PaCO2 of 35 - 45 mm/Hg MAP = (DBP x 2) + SBP  Other critical care
3 management

Obtain 12-lead ECG Other Critical Care Management Targeted Temperature Management (TTM)

Consider for emergent cardiac  Continuous monitoring of core temperature (esophageal, If patient unable to follow command start TTM.
intervention if: rectal or bladder).
 Maintain normoxia, normocapnia, euglycemia.  4°C PNSS at 30cc/kg
 STEMI is present.  Provide continuous or intermittent EEG monitoring.  Maintain core body temperature at 32°C -36°C.
 Unstable Cardiogenic Shock  Provide lung protective ventilation  Monitor core temperature (esophageal, rectal or bladder).
 Mechanical Circulatory  TTM for at least 24 hours.
support required.
The ultimate goal is ROSC and Prevention of RE-ARREST

Be Prepared for an
Emergency. Be Trained.
Save a Life.