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ACLS 2015

In the past, clinicians frequently interrupted CPR to check for

pulses, perform tracheal intubation, or obtain venous


access.
The 2010 ACLS Guidelines strongly recommend that every effort

be madeNOTto interrupt CPR; other less vital interventions


(eg, tracheal intubation or administration of medications to treat
arrhythmias) are made either while CPR is performed or
during the briefest possible interruption.
Interventions that cannot be performed while CPR is in progress

(eg, defibrillation) should be performed during brief


interruptions at two minute intervals (after the completion of
a full cycle of CPR).

Studies in both the in-hospital & prehospital settings

demonstrate that chest compressions are often


performed incorrectly, inconsistently, & with excessive
interruption.
Chest compressions must be of sufficient depth (at least 5

cm, or 2 inches) & rate (at least 100 per min), & allow for
complete recoil of the chest between compressions, to
be effective.
A single biphasic defibrillation remains the recommended

treatment for ventricular fibrillation (VF) or pulseless


ventricular tachycardia (VT).

CPR should be performed until the defibrillator is ready

for immediate discharge & resumed immediately after


the shock is given, without pausing to recheck a pulse at
that moment.
Interruptions in CPR (eg, for subsequent attempts at

defibrillation or pulse checks) should occur no more


frequently than every two minutes, & for the shortest
possible duration.
Patients are often over-ventilated during resuscitations,

which can compromise venous return resulting in


reduced cardiac output & inadequate cerebral &
cardiac perfusion.

A 30 to 2 compression to ventilation ratio (one cycle)

is recommended in patients without advanced airways.


According to the 2010 ACLS Guidelines, asynchronous

ventilations at 8 to 10 per minute are administered if an


endotracheal tube or extraglottic airway is in place, while
continuous chest compressions are performed
simultaneously.
We believe that 6 to 8 ventilations per minute are sufficient

in the low-flow state of cardiac resuscitation & help to


prevent over-ventilation.

Key principles in the performance of ACLS


Excellent CPR is crucial.
Excellent chest compressionsmustbe performed throughout the
resuscitation without interruption, using proper timing (100
compressions per minute) and force (5 cm depth), and allowing for
complete chest recoil.
Donotstop compressions until the defibrillator is fully charged.
Anything short of excellent CPR does not achieve adequate cerebral
and coronary perfusion.
Excellent chest compressions take priority over ventilation. If a second
rescuer is present, ventilations must be performed using proper timing
(6 to 8 breaths per minute in the intubated patient; ratio of 30
compressions to 2 ventilations if not intubated) and force (each breath
delivered over a full 1 to 2 seconds); avoid hyperventilation.
Defibrillate VF and pulseless VT as rapidly as possible.
Rapidlyidentify and treat causes of non-shockable arrest (PEA,
asystole).
Important causes include the 5 H's and 5 T's:
Hypoxia, Hypovolemia, Hydrogen ions (acidosis), Hyper/Hypo-kalemia,
Hypothermia;
Tension pneumothorax, Tamponade-cardiac, Toxins, Thrombosis-coronary
(MI), Thrombosis-pulmonary (PE).

Bradycardia
Bradycardia is defined conservatively as a heart rate below 60

beats per minute, but symptomatic bradycardia generally


entails rates below 50 beats per minute.
The 2010 ACLS Guidelines recommend that clinicians not

intervene unless the patient exhibits evidence of inadequate


tissue perfusion thought to result from the slow heart rate.
Signs & symptoms of inadequate perfusion include hypotension,

altered mental status, signs of shock, ongoing ischemic chest


pain, & evidence of acute pulmonary edema. Hypoxemia is a
common cause of bradycardia; look for signs of labored
breathing (eg, increased respiratory rate, retractions,
paradoxical abdominal breathing) & low oxygen saturation. Mild
symptoms may not warrant treatment.

Tachycardia
Tachycardia is defined as a heart rate above 100 beats per

minute, but symptomatic tachycardia generally involves rates


over 150 beats per minute, unless underlying ventricular
dysfunction exists.
Management of tachyarrhythmias is governed by the presence

of clinical symptoms & signs caused by the rapid heart rate.


The fundamental approach is as follows: First determine if the

patient is unstable (eg, manifests ongoing ischemic chest pain,


acute mental status changes, hypotension, signs of shock, or
evidence of acute pulmonary edema). Hypoxemia is a
common cause of tachycardia; look for signs of labored
breathing (eg, increased respiratory rate, retractions,
paradoxical abdominal breathing) & low oxygen saturation.

POST-RESUSCITATION CARE
The 2010 ACLS Guidelines recommend a combination

of goal-oriented interventions provided by an


experienced multidisciplinary team for all cardiac arrest
patients with return of spontaneous circulation.
Important objectives for such care include:

Optimizing cardiopulmonary function & perfusion of


vital organs
Managing acute coronary syndromes
Implementing strategies to prevent & manage organ
system dysfunction & injury