ACLS FullMaps

ACLS
PRE
30 to 60 Days Before Course
Your Role
Determine course specifics
Target audience
Number of students
Special needs or equipment
Reserve equipment
Schedule room
Schedule additional instructors if needed
Reference
ACLS Instructor Manual/CD
2011 American Heart Association
90_1011_ACLS_LM.indd 1
ACLS1
12/21/10 2:18 PM
ACLS
PRE
ACLS Precourse Preparation Program

(Optional)
P
T
Instructors or Training Centers may consider offering an ACLS preparation program

days or weeks before the ACLS course to ensure that students understand
ECGs
Pharmacology
ACLS algorithms
Airway management
N
A
L
ACLS2
12/21/10 2:18 PM
ACLS
PRE
At Least 3 Weeks Before Course
Your Role
Ensure that students are sent precourse letters with student
materials
Ensure that students understand that precourse preparation is
necessary for successful participation in the ACLS course
Ensure that students are aware of Precourse Self-Assessment
Confirm additional instructors
Reference
ACLS3
1/22/11 12:53 PM
ACLS
PRE
Day Before Course
Your Role
Confirm room reservations and setups
Coordinate plan with additional instructors if needed for
class size
Make sure that all equipment is available and working
Ensure that all course paperwork is in order
Reference
ACLS4
12/21/10 2:18 PM
ACLS
PRE
Day of Course
Your Role
Greet students as they arrive to help make them feel at ease
Pass out supplies
Have student fill out course roster
(www.ahainstructornetwork.org)
Strongly recommended: Collect students Precourse SelfAssessment score and Precourse Preparation Checklist
Reference
ACLS5
1/22/11 12:53 PM
ACLS
START
0:00
Welcome, Introductions, and

Course Administration
Resources
5:00
Large group, all students
Course roster
Course agenda
Your Role
Student Role
Introduce themselves
Listen to you
Introduce instructors
Invite students to introduce themselves
Explain housekeeping issues, including paperwork and facilities
Explain that parts of the course are somewhat strenuous
Ask that anyone with a medical concern, such as knee or back
problems, speak with one of the instructors
Tell the students, We are scheduled to end at ____
Student Objectives
Get acquainted with you and
with other students
Reference
None
ACLS6
12/21/10 2:18 PM
ACLS
1A
0:00
ACLS Course Overview

and Organization
Resources
Course agenda
Listing of student groups
Student Role
Listen to you
Ask questions
Student Objectives
Understand the course design
Understand how the course is
organized
Understand the purpose and
function of the group rotations
Understand the course completion requirements
5:00

Your Role
Present course overview
Additional details about the course overview can be found
in the next Lesson Map
Explain the learning stations and rotations through stations
Assign students to small groups for learning stations
Tell students that they will be using their ACLS Provider
Manuals throughout the course
Clarify course completion requirements
Reference
ACLS Provider Manual Part 1
ACLS7
12/21/10 2:18 PM
ACLS
1B
ACLS Course Overview

and Organization
Details
Present Course Overview

Discuss course agenda, design, and completion requirements
Be certain that students understand major course concepts
Importance of high-quality CPR to patient survival
Integration of effective BLS with ACLS interventions
Importance of effective team interaction and communication during
resuscitation attempt
Answer students questions
ACLS8
1/22/11 12:53 PM
ACLS
2A
0:00
BLS and ACLS Surveys
Resources
BLS and ACLS Surveys video
AV equipment
Student Role
Watch the video
Participate in discussion
Student Objectives
Describe the BLS and ACLS
Surveys and critical interventions
Describe specific assessment
and management of each
step of the systematic ACLS
approach
Describe how this approach
can be applied to almost all
cardiopulmonary emergencies
20:00

Your Role
Introduce video on BLS and ACLS Surveys
Show video
Answer questions (use table on the next Lesson Map)
Have students follow along in their ACLS Provider Manuals
Reference
ACLS9
12/21/10 2:18 PM
ACLS
BLS and ACLS Surveys
2B
Review
Answer students questions. Use the table below to guide your answers.
Review the new steps of the BLS Survey.
BLS Survey
ACLS Survey
Check for responsiveness

Tap and shout, Are you all right?
Scan the chest for movement
Airway
Maintain airway patency by using OPA or NPA or an advanced
airway (supraglottic airway or endotracheal tube)
If inserting an advanced airway such as an endotracheal tube, verify
correct placement with waveform capnography
Activate the emergency response system/get the AED
Breathing
Give O2, use bag-mask with or without an advanced airway to
provide adequate ventilation
Avoid excessive ventilation
Circulation
Check carotid pulse (5-10 seconds)
If no pulse, start chest compressions immediately
Push hard, push fast
Allow complete chest recoil between compressions
Minimize interruptions in compressions (10 seconds or less)
Switch providers about every 2 minutes
Avoid excessive ventilation
Circulation
Attach leads and monitor
Obtain IV/IO access
Give appropriate drugs
Monitor CPR quality with waveform capnography and intra-arterial
relaxation pressure
Defibrillation
Attach AED/defibrillator, analyze, and defibrillate if needed
Differential diagnosis
Search for and treat reversible causes
ACLS10
1/22/11 12:53 PM
ACLS
3A
Learning/Testing
Station:
Mgmt. of
Respiratory
Arrest
Resources
AV equipment
Airway Management video
Airway manikins
OPAs, NPAs, bag-masks
Case Scenarios (in Appendix A
of ACLS Instructor Manual or on
Instructor CD)
Management of Respiratory Arrest
Bag-Mask Ventilation Testing Checklist
Student Role
Watch the video

Demonstrate the use of NPA or
OPA, oxygen, and adult bag-mask
ventilation
Student Objectives
Demonstrate insertion of NPA or OPA

Demonstrate oxygen delivery and
effective bag-mask ventilation
Demonstrate effective management of a
simulated respiratory arrest case, including a bag-mask ventilation skills test
0:00
4
45:00
6 students, 1 instructor
Your Role
Tell students to open ACLS Provider Manual to appropriate pages
Optional: Show Airway Management video: basic airway adjuncts
video segment (Practice Session Part 1)
Show Airway Management video: introduction and bag-mask
ventilation (PWW)
Present cases
Each student manages a complete airway case
(Testing Session Part 2)
Show Airway Management video: confirmation of advanced
airway devices
Optional: Show advanced airway video segment
(Practice Session Part 3)
Reference
ACLS11
12/22/10 6:28 PM
ACLS
3B
Learning/Testing Station:
Management of
Respiratory Arrest
Student Practice Details
Practice Session Part 1

Show Airway Management video: basic airway adjuncts segment
Pause video segment while each student practices insertion of NPA and OPA,
practices suctioning and administering oxygen on an airway manikin
Continue Airway Management video
N
A
L
ACLS12
12/21/10 2:18 PM
ACLS
Management of
Respiratory Arrest
3C
Practice-While-Watching (PWW) Session

Show Airway Management video: introduction and bag-mask ventilation
Pause video segment
Arrange students: 3:1 student-to-manikin ratio (or 2:1, 1:1)
Each student practices bag-mask ventilation while watching (PWW) for 1 minute
with the video
Pairs practice 2-person bag-mask ventilation (1 sealing mask, 1 squeezing bag)
for 1 minute with video (PWW), then switch roles
Use the following student rotation for the 2-person bag-mask practice for a
3:1 student-to-manikin ratio:
Person squeezing the bag
1
2
3
Person holding the mask

2
3
1
ACLS13
1/28/11 9:55 AM
ACLS
3D

Student Testing Details
Testing Session Part 2

Present airway case
Each student practices through the airway case (respiratory arrest with a pulse).
Student must
Perform full assessment, activate the emergency response system, and do a
pulse check
Begin ventilations without delay
Insert NPA or OPA
Connect bag-mask to oxygen and adjust flow rate to appropriate level
Give bag-mask ventilations for 1 minute (skills test)
Critique by using the Skills Station Checklist from ACLS Provider Manual or
Instructor Manual/CD
Check off students Skills Station Checklist as each student demonstrates
adequate management of the airway case (Case Scenarios can be found in
Appendix A of ACLS Instructor Manual or on Instructor CD)
ACLS14
12/21/10 2:18 PM
ACLS
3E

Video
Show Airway Management Video

Show video: Confirmation of advanced airway devices
ACLS15
12/21/10 2:19 PM
ACLS
3F
Management of
Respiratory Arrest
Practice Session Part 3

Show the Airway Management video: advanced airway segment
fter the video, students practice performing ventilations with a simulated

A
advanced airway in place (on the basis of manikin limitations, instructors may use
a standard manikin with a bag-mask rather than a bag connected to a simulated
airway tube)
Students perform 2-rescuer CPR, one student doing continuous compressions

and the other student ventilating
Students perform 1 minute of CPR, switch roles, do 1 minute of CPR,

and then stop
Rotate through all students performing ventilations
L
ACLS16
12/21/10 2:19 PM
ACLS
4A
CPR and
AED
Practice
and Testing
Resources
Adult manikins (at least 2)

Pocket masks (1 per manikin)
One-way valves (1 per student)
AED trainers (2)
AV equipment
CPR and AED Skills video
CPR and AED Testing Checklist
Stopwatch
Step stools
Student Role
Practice CPR with the video

Rotate through the testing station for
1-rescuer adult CPR and AED skills
Student Objectives
Do chest compressions and ventilation

practice (PWW)
Demonstrate competency in 1-rescuer
adult CPR and AED skills
0:00
4
45:00
Your Role
Facilitate CPR practice (PWW)
Show video and give feedback during the practice part of the
station
Additional details about CPR practice are included in
Lesson Map 4B
Conduct CPR and AED testing
Additional details about CPR and AED competency testing
are included in Lesson Map 4C
Reference
ECC Handbook, pocket reference cards, or crash cart cards
ACLS17
12/21/10 2:19 PM
ACLS
4B
Testing Station:
CPR and AED Practice

and Testing
Practice Details
CPR Practice
Arrange students in groups with manikins
3 or fewer students per manikin
Show CPR and AED Skills video
Give feedback during PWW
Be sure that students continue correct chest compressions throughout the
practice session
Video shows a 1-rescuer CPR and AED scenario and gives an introduction to the
CPR and AED test
ACLS18
12/21/10 2:19 PM
ACLS
4C
Testing Station:
CPR and AED Practice

and Testing
Testing Details
Test students one at a time

Students not testing should practice on another manikin
Test each student in a reasonably private environment
Each student must demonstrate entire sequence of 1-rescuer CPR and AED (with pocket mask)
without instructor prompting
Fill out the CPR and AED Testing Checklist for each student
Carefully observe the student being tested
If a student is unsuccessful, refer him or her for immediate remediation
Each student may retest 1 additional time during this station
If a student remains unsuccessful, refer for remediation at the end of the course
Summarize the importance of high-quality CPR to patient survival
Describe the following testing scenario:
This is a test of the 1-rescuer adult CPR and AED skills. The scene is safe and you are wearing protective
gloves. A man has collapsed in front of you, and there is no risk of a head or spinal cord injury. You are the
only healthcare provider on the scene. The emergency plan at the site is to activate the emergency response
system. You have a pocket mask, and an AED is available. No one else knows how to use the AED.
ACLS19
1/22/11 12:53 PM
ACLS
5A
0:00
The Megacode and Resuscitation

Team Concept
Resources
AV equipment
Megacode video
25:00
Large group, all students, 1 instructor (or may

be done in 2 smaller groups, 2 instructors)
Your Role
Student Role
Watch the video
Ask questions
Student Objectives
Identify the roles of the
resuscitation team leader and
team members
List elements of team dynamics
Ask students to open the ACLS Provider Manual to

appropriate pages
Show video
Answer questions (use points on the next Lesson Map to
guide your answers)
Remind students that they will be functioning as team
leader and different team members in the learning and
testing stations
Reference
ACLS20
12/21/10 2:19 PM
ACLS
5B
The Megacode and Resuscitation

Team Concept
Review
Elements of Effective Team Dynamics

Closed-loop communication
Clear messages
Clear roles and responsibilities
Knowing ones limitations
Knowledge sharing
Constructive intervention
Reevaluation and summarizing
Mutual respect
ACLS21
12/21/10 2:19 PM
0:00
ACLS
6A
Learning Station:
Cardiac Arrest (VF/Pulseless VT)
Resources
Code cart or code kit

Algorithms
Monitor/manual defibrillator and
simulator
Manikins for CPR and intubation/
ventilation
Stopwatch and countdown timer
Case Scenarios (in Appendix A of ACLS
Instructor Manual or on Instructor CD)
Step stools
Student Role
Practice in the role as team leader in a

VF/pulseless VT case
Practice all team roles if possible
Apply Immediate PostCardiac Arrest
Care Algorithm after ROSC
Student Objectives
Implement the Cardiac Arrest Algorithm

(VF/Pulseless VT) for a shockable rhythm
Show proper management of a simulated VF/pulseless VT case as team leader
Rotate through all team roles
90:00
Your Role
Monitor/defibrillator technology review
Review algorithms
Cardiac Arrest Algorithm (VF/Pulseless VT)
Immediate PostCardiac Arrest Care Algorithm
Review team roles, responsibilities, and assignments for each
case (see Lesson Maps 6B and 6C)
Students may use ECC Handbook, pocket reference cards, or
crash cart cards
Present cases for each student to demonstrate appropriate
management
Perform debriefing
Reference
ACLS22
12/21/10 2:19 PM
ACLS
6B
Learning Station:

Review Algorithms and Roles
Review algorithms (5 minutes)

Student Rotations in Learning Station Cases According
to Resuscitation Team Roles
The team leader will direct the actions of the other team members. (For example,
the team leader will coach the airway management team member if performance of
bag-mask ventilation is not making the chest rise.)
Team members will perform interventions as directed by the team leader. This is an
opportunity for students to practice skills and receive feedback from the team leader.
Students will demonstrate effective team behaviors (eg, closed-loop communication,
clear messages).
The timer/recorder will use a stopwatch to time 2-minute intervals for case management, announce each 2-minute interval for CPR switching, and record critical
action times on the ACLS Code Timer/Recorder Sheet (in Appendix B of ACLS
Instructor Manual or on Instructor CD) or a whiteboard.
ACLS23
1/22/11 12:53 PM
ACLS
6C
14 minutes per case
Learning Station:

Rotations
Team Role
Case
1
Case
2
Case
3
Case
4
Case
5
Case
6
Team leader
S1
S2
S3
S4
S5
S6
Airway
S2
S3
S4
S5
S6
S1
IV/meds
S3
S4
S5
S6
S1
S2
Defibrillator/airway #2
S4
S5
S6
S1
S2
S3
Compressions
S5
S6
S1
S2
S3
S4
Timer/recorder
S6
S1
S2
S3
S4
S5
It is important that every student have a role in each case. Student role assignments may vary
depending on the number of students at the station. However, every student must function as
the team leader for 1 case. Cases may be run in a different order, but ensure that no single
student always goes first in subsequent learning stations. Any additional students may be given
roles as additional recorders.
ACLS24
12/21/10 2:19 PM
ACLS
6D
Learning Station:

Details for Case Rotations
Directions for Case Rotations (6 rotations, 14 minutes each)

(Instructors must conduct the scenario in real time)
Start Case Scenario
(10 minutes)
Review assigned team roles from the rotation chart for this case
Ensure that students understand expectations of assigned roles (eg, Your role
is to use the bag-mask to give ventilations that cause the chest to rise)
Introduce the case by reading the Case Scenario
Set the timer to 10 minutes
Ask the team leader to begin managing the case
Observe and coach
Effective team performance
Appropriate case management
High-quality skill performance, including high-quality CPR throughout the scenario
Guide the team leader through management of the case
Stop the case after 10 minutes
Case 1 Debriefing
(4 minutes)

Conduct a team debriefing at the end of the case
Total time for case:

14 minutes
Repeat for each of the remaining 5 cases
ACLS25
1/22/11 12:53 PM
ACLS
7A
Learning Station:
Acute Coronary
Syndromes
Resources
0:00
45:00
AV equipment
ACS video
Your Role
Student Role
Watch the video
Participate in a discussion
about ACS and ACS
management
Student Objectives
Explain and apply the
ACS Algorithm
Discuss ACS management
Show ACS video

Pause video for discussion points
Lead the discussion with the group
Reference
ACLS26
12/21/10 2:19 PM
ACLS
7B
Learning Station:
Acute Coronary Syndromes

Video Discussion 1
Pause 1
1. What is the difference between stable angina, unstable angina, and myocardial
infarction?
Angina is a tightness or discomfort (not a sharp pain) in the center of the chest and/or the
surrounding area. The onset of discomfort associated with stable angina is often predictable; in
many cases, it begins during exertion or with strong emotions. It is a symptom, not a diagnosis
of coronary artery disease or acute ischemic symptoms. While often associated with myocardial
ischemia, angina may have other causes. In the presence of coronary disease, the most
common cause of angina is an obstructing or disrupted coronary plaque.
Angina may be stable and predictably produced by exertion or emotion. At rest, a fixed
coronary plaque generally allows enough blood supplybut blood flow is insufficient
during stress. When a plaque becomes unstable, ACS occurs. With minimal exertion or at rest,
blood flow is insufficient, causing unstable angina and prolonged discomfort.
Death of the heart muscle eventually occurs, which often correlates with angina episodes
of 15 minutes or longer.
ACLS27
1/22/11 12:53 PM
ACLS
7C
Learning Station:

Video Discussion 1
2. This patient is having chest discomfort. What are the possible causes of chest discomfort that may be life-threatening?
Although most life-threatening chest discomfort is due to ACS, the initial emergency
diagnosis may include several other disorders. When a diagnosis of ACS is uncertain, the
following possible diagnoses should be considered in the initial evaluation as well as
continuing assessment:
Aortic dissection
Pulmonary embolism
Acute pericarditis with effusion and tamponade
Spontaneous pneumothorax
Esophageal rupture
ACLS28
12/21/10 2:19 PM
ACLS
7D
Learning Station:

Video Discussion 1
3. What are the classic symptoms of acute ischemic chest discomfort?

The predominant symptom in most patients with ischemic syndromes is chest discomfort. This
discomfort is often not described as a pain. Brief episodes of chest discomfort may be due to
ischemia and may or may not progress to infarction. However, when symptoms are constant
(ie, last for more than 15 to 20 minutes), myocardial infarction may be present. Symptoms
suggestive of ACS include
Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting
several minutes (infarction: usually more than 15 minutes)
Pain spreading to the shoulders, neck, arms, or jaw, or pain in the back or between the
shoulder blades
Chest discomfort with lightheadedness, fainting, sweating, or nausea
Shortness of breath with or without chest discomfort
ACLS29
12/21/10 2:19 PM
ACLS
7E
Learning Station:

Video Discussion 2
Pause 2
1. Half of ACS patients do not arrive at the hospital by EMS. Why is early EMS dispatch
important for patients with ACS? What are the most important components of a
community ACS recognition program?
Patients arriving with ST-segment elevation MI (STEMI) have a complete occlusion of a
coronary artery. Early opening of the artery reduces mortality and the size of infarction.
Patients arriving by EMS receive earlier reperfusion.
ACS is the most common cause of cardiac arrest in adults. Every community should
develop a program to respond to cardiac arrest and identify patients with possible ACS.
Components of this program include
Recognizing symptoms of ACS
Activating the EMS system
Providing early CPR
Providing defibrillation with AEDs available through lay rescuer CPR and
defibrillation programs
ACLS30
1/22/11 12:53 PM
ACLS
7F
Learning Station:

Video Discussion 2
2. What are the goals of therapy for patients with ACS?

Improving systems of care enables early initiation of therapy for patients with possible ACS and
increases the likelihood of target goal achievement. These goals (discussed in detail in the ACS
video) are
Relief of ischemic chest discomfort

Prevention of major adverse cardiac events (MACE), such as death, nonfatal MI,
and the need for postinfarction urgent revascularization
Treatment of acute, life-threatening complications of ACS, such as VF/pulseless
VT, symptomatic bradycardias, and unstable tachycardias
Reperfusion therapy opens an occluded coronary artery with either drugs or mechanical means.
Clot buster drugs are called fibrinolyticsa more accurate term than thrombolytics. PCI,
performed in the heart catheterization suite following coronary angiography, allows balloon
dilation and/or stent placement for an occluded coronary artery. PCI performed as the initial
reperfusion method is called primary PCI.
ACLS31
12/21/10 2:19 PM
ACLS
7G
Learning Station:

Video Discussion 2
3. What role does aspirin play in ACS? What are the indications and contraindications?
The most common cause of ACS is the rupture of a lipid-laden plaque with a thin cap. After rupture, a monolayer of platelets covers the surface of the ruptured plaque (platelet adhesion). Additional platelets are recruited (platelet aggregation) and activated. Aspirin irreversibly binds to
platelets and partially inhibits platelet function.
Studies have shown that aspirin reduces mortality during MI. The recommended dose is 160 to
325 mg. Aspirin is indicated in all patients with possible ACS.
Contraindications include true aspirin allergy and recent or active GI bleeding.
ACLS32
12/21/10 2:19 PM
ACLS
7H
Learning Station:

Video Discussion 3
Pause 3
1. L
ets review. What is the initial drug therapy for ACS? We have already discussed aspirin.
Other initial agents are oxygen (to keep the saturation greater than or equal to 94%), nitroglycerin,
and morphine.
What are the doses and indications/contraindications/cautions for nitroglycerin?
Nitroglycerin is administered by sublingual or spray dosing. Three doses may be administered
after repeating assessments of blood pressure and heart rate. Conditions complicating
nitroglycerin administration in patients with ACS include
Inferior MI and RV infarction: Use nitroglycerin with caution in patients with known inferior wall
STEMI. For these patients, perform a right-sided ECG to assess the degree of RV involvement. If RV
infarction is confirmed by right sided precordial leads or clinical findings by an experienced provider, nitroglycerin and other vasodilators (morphine) or volume depleting drugs (diuretics) are contraindicated. Patients with acute RV infarction are very dependent on RV filling pressures to maintain
cardiac output and blood pressure.
Hypotension, bradycardia, or tachycardia: Avoid use of nitroglycerin in patients with hypotension
(systolic BP <90 mm Hg), extreme bradycardia (<50/min), or tachycardia.
Recent use of phosphodiesterase inhibitor for erectile dysfunction: If the patient has recently
taken a phosphodiesterase inhibitor (eg, sildenafil or vardenafil within 24 hours; tadalafil within
48 hours), nitrates may cause severe hypotension refractory to vasopressor agents.
ACLS33
1/22/11 12:53 PM
ACLS
7I
Learning Station:

Video Discussion 3
2.What are the possible ECG groups that help triage initial ACS? What are they called,
and why is it recommended that EMS send advance notification of the ECG to the
receiving facility?
Analysis of the ECG ST segment allows triage of ACS patients into 1 of 3 diagnostic and
treatment groups: STEMI; ST-segment depression (high-risk unstable angina/nonST-segment
elevation MI); and normal or nondiagnostic ECG. (Refer to boxes 5, 9, and 13 in the ACS
Algorithm.)
Time is a critical factor in producing a positive outcome for an ACS patient, especially for
STEMI patients. The American Heart Association recommends that EMS systems implement
12-lead ECG programs to assist in the early recognition of those patients who could benefit
most from treatment at a specialty cardiac center. EMS providers who lack training in
advanced ECG interpretation can still acquire and transmit the 12-lead ECG to the emergency
department for interpretation there. With an ECG diagnostic for STEMI, EMS providers should
activate the local STEMI response plan.
Early ECG interpretation and notification of the receiving hospital speeds the time to
reperfusion therapy, saves heart muscle, and may reduce mortality.
ACLS34
12/21/10 2:19 PM
ACLS
7J
Learning Station:

Video Discussion 3
3. Why is STEMI special and the focus of this case?

Reperfusion therapy for STEMI is perhaps the most important advance in the treatment of
cardiovascular disease in recent cardiovascular therapy. Early fibrinolytic therapy or direct
catheter-based reperfusion has been established as a standard of care for patients with AMI
who present within 12 hours of onset of symptoms with no contraindications.
Reperfusion therapy reduces mortality and saves heart muscle. The shorter the time to
reperfusion, the greater the benefit. For example, a 47% reduction in mortality was noted when
fibrinolytic therapy was provided in the first hour after onset of symptoms.
Guidelines have set goals for door-to-drug (fibrinolytic) administration time of 30 minutes and
PCI door-to-balloon time of 90 minutes. STEMI systems of care (EMS systems and emergency
department initial triage) have a major impact on these goals.
ACLS35
12/21/10 2:19 PM
ACLS
8A
0:00
Learning Station:
Resources
Stroke
45:00
AV equipment
Stroke video
Your Role
Student Role
Watch the video
Participate in a discussion
about stroke and stroke
management
Show Stroke video

Pause video for discussion points
Lead the discussion with the group
Student Objectives
Explain and apply the
Suspected Stroke Algorithm
Discuss the 8 Ds of Stroke
Care and explain why timely
action is crucial
Reference
ACLS36
12/21/10 2:19 PM
ACLS
8B
Learning Station:
Stroke Discussion
Video Discussion 1
Pause 1
1. What signs and symptoms is this patient having? How are they typical of stroke?
Students should recognize that the patient is having difficulty speaking and moving. These are
some of the warning signs of stroke. Ask students what some other warning signs or symptoms
of stroke are.
The signs and symptoms of a stroke may be subtle. They can include
Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
Sudden confusion
Trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking
Dizziness or loss of balance or coordination
Sudden severe headache with no known cause
ACLS37
1/22/11 12:53 PM
ACLS
8C
Learning Station:
Stroke Discussion
Video Discussion 1
2. What are the major types of stroke? Is there any treatment that can reduce disability?
Stroke is a general term. It refers to acute neurologic impairment that follows interruption in
blood supply to a specific area of the brain. Although expeditious care for stroke is important
for all patients, this case emphasizes reperfusion therapy for acute ischemic stroke because
rapid therapy with a fibrinolytic agent can reduce the disability from stroke. The major types of
stroke are
Ischemic stroke: Accounts for 87% of all strokes and is usually caused by an
occlusion of an artery to a region of the brain.
Hemorrhagic stroke: Accounts for 13% of all strokes and occurs when a blood vessel in the
brain suddenly ruptures into the surrounding tissue. Fibrinolytics are
contraindicated in this type of stroke.
A transient ischemic attack refers to any focal neurologic deficit that resolves spontaneously
and completely within 1 hour.
ACLS38
12/21/10 2:19 PM
ACLS
8D
Learning Station:
Stroke Discussion
Video Discussion 1
3. If this patient is having a stroke, what are some goals for stroke care?
The goal of stroke care is to minimize brain injury and maximize the patients recovery. The Stroke
Chain of Survival described by the AHA and the American Stroke Association is similar to the
Chain of Survival for sudden cardiac arrest. It links actions to be taken by patients,
family members, and healthcare providers to maximize stroke recovery. These links are
Rapid recognition and reaction to stroke warning signs
Rapid activation of the EMS system
Rapid EMS-system transport and prearrival notification to the receiving hospital
Rapid diagnosis and treatment in the hospital
ACLS39
12/21/10 2:19 PM
ACLS
8E
Learning Station:
Stroke Discussion
Video Discussion 2
Pause 2
1. What are the critical EMS assessments and actions to provide the best outcome for
this patient with a potential stroke?
Identify signs: Define and recognize the signs of TIA and stroke.
Support ABCs: Administer oxygen if the oxygen saturation is <94% or the oxygen saturation
is unknown.
Do stroke assessment: Perform a rapid out-of-hospital stroke assessment.
Establish time: Determine when the patient was last known to be at neurologic baseline.
This represents time zero. If the patient wakes from sleep and is found with symptoms of
stroke, time zero is the last time the patient was seen to be normal.
Transport: Transport the patient and consider triage to a stroke center. Consider bringing a
witness, family member, or caregiver with the patient to confirm time of onset of stroke
symptoms.
Alert hospital: Provide prearrival notification to the receiving hospital.
Check glucose: During transport, support cardiopulmonary function, monitor neurologic
status, and if authorized by medical control, check blood glucose.
ACLS40
1/22/11 12:53 PM
ACLS
8F
Learning Station:
Stroke Discussion
Video Discussion 2
2. What type of hospital is appropriate for this patient? Why is advance notification
so important?
A stroke center has the capability to rapidly triage and treat patients by using a multidisciplinary
approach.
Evidence indicates a favorable benefit when stroke patients are triaged directly to designated
stroke prepared centers (primary/comprehensive centers) (Class I).
Advance notification allows activation of the facility stroke plan and team, minimizing delay in
evaluation and treatment.
ACLS41
12/21/10 2:19 PM
ACLS
8G
Learning Station:
Stroke Discussion
Video Discussion 2
3. What stroke screen was used in the video? What are the 3 important physical findings?
Cincinnati Prehospital Stroke Scale (CPSS)
The CPSS identifies stroke on the basis of 3 physical findings:
Facial droop (have the patient smile or try to show teeth)
Arm drift (have the patient close eyes and hold both arms out)
Abnormal speech (have the patient say, You cant teach an old dog new tricks)
Using the CPSS, medical personnel can evaluate the patient in less than 1 minute.
The presence of 1 finding on the CPSS indicates a 72% probability of stroke.
The presence of all 3 findings indicates that the probability of stroke is greater than 85%.
ACLS42
1/22/11 12:53 PM
ACLS
8H
Learning Station:
Stroke Discussion
Video Discussion 3
Pause 3
1. Lets review. What is the initial emergency department assessment and stabilization?
Assess ABCDs: Assess the ABCDs and evaluate baseline vital signs.
Provide oxygen: Provide supplemental oxygen if the patient is hypoxemic, ie, oxygen saturation
<94% (Class I) or in patients with an unknown oxygen saturation value.
Establish IV access and obtain blood samples: Establish IV access and obtain blood samples
for baseline blood count, coagulation studies, and blood glucose, but do not let this delay obtaining
a CT scan of the brain.
Check glucose: Promptly treat hypoglycemia.
Perform neurologic screening: NIH Stroke Scale or Canadian Neurological Scale.
Activate stroke team: Activate the stroke team or arrange consultation with a stroke expert.
Order CT brain scan: Order an emergent CT scan of the brain and have it read promptly by
a radiologist.
Obtain 12-lead ECG: Obtain a 12-lead ECG, which may identify a recent AMI or arrhythmias
(eg, atrial fibrillation) as a cause of embolic stroke. Life-threatening arrhythmias can follow or
accompany stroke, particularly intracerebral hemorrhage. If the patient is hemodynamically stable,
treatment of nonlife-threatening arrhythmias (bradycardia, VT, and atrioventricular conduction
blocks) may not be necessary. This should not delay getting the CT scan of the brain.
ACLS43
1/22/11 12:53 PM
ACLS
8I
Learning Station:
Stroke Discussion
Video Discussion 3
2. What are the possible outcomes of the CT scan? Which test result makes the patient a
candidate for fibrinolytic therapy?
Emergent CT or MRI scans of patients with suspected stroke should be promptly interpreted
by an expert. The presence of hemorrhage versus no hemorrhage determines the next steps in
treatment and whether the patient is a candidate for fibrinolytic therapy.
No, hemorrhage is not present.
If the CT scan shows no evidence of hemorrhage, the patient may be a candidate for fibrinolytic
therapy.
Yes, hemorrhage is present.
If hemorrhage is noted on the CT scan, the patient is NOT a candidate for fibrinolytics. Consult
a neurologist or neurosurgeon and consider transfer for appropriate care.
ACLS44
1/22/11 12:53 PM
ACLS
8J
Learning Station:
Stroke Discussion
Video Discussion 3
3. What does fibrinolytic therapy do for patients with ischemic stroke?

Several studies have demonstrated a higher likelihood of good to excellent functional outcome
when rtPA was given to adults with acute ischemic stroke within 3 hours of symptom onset.
These results occurred only when rtPA was given by physicians in hospitals with a stroke
protocol that rigorously adhered to the eligibility criteria and therapeutic regimen of the NINDS
protocol. Evidence from prospective randomized studies in adults also documents a greater
likelihood of benefit when treatment begins earlier.
Studies have also shown improved clinical outcome in carefully selected patients when
fibrinolytic administration occurred between 3 and 4.5 hours after symptom onset, although the
degree of benefit was smaller than seen in the group receiving treatment at 3 hours.
ACLS45
12/21/10 2:19 PM
ACLS
8K
Learning Station:
Stroke Discussion
Review of 8 Ds
Detection: Rapid recognition of stroke symptoms

Dispatch: Early activation and dispatch of EMS by calling 911
Delivery: Rapid EMS identification, management, and transport
Door: Appropriate triage to stroke center
Data: Rapid triage, evaluation, and management within the emergency department
Decision: Stroke expertise and therapy selection
Drug: Fibrinolytic therapy, intra-arterial strategies
Disposition: Rapid admission to stroke unit, critical care unit
ACLS46
12/21/10 2:19 PM
0:00
ACLS
9A
Learning Station:
Bradycardia/PEA/Asystole
Resources
Algorithms
simulator
ventilation
Case Scenarios (in Appendix A of
ACLS Instructor Manual or on
Instructor CD)
Step stools
10
45:00
Your Role
Discuss algorithm
Demonstrate appropriate patient
management

Review algorithms
Bradycardia Algorithm
Cardiac Arrest Algorithm (PEA/Asystole)
Discuss bradycardias
Discuss Hs and Ts
case (see Lesson Maps 9D and 9E)
Present cases for each student team to manage
Additional details about the student cases are presented in
Lesson Map 9C
Perform debriefing
Student Objectives
Reference
Show proper management of a simulated bradycardia/PEA/asystole case

Rotate through team roles

Student Role
ACLS47
12/21/10 2:19 PM
ACLS
9B
Learning Station:
Algorithm, Bradycardia, and Hs and Ts Review
Review algorithms (5 minutes)

Discuss bradycardias: sinus, first-, second-, and third-degree AV blocks
(5 minutes)
Discuss Hs and Ts (5 minutes)
ACLS48
12/21/10 2:19 PM
ACLS
9C
Learning Station:
Roles
Student Rotations in Learning Station Cases According to Resuscitation

Team Roles
clear messages).
For Bradycardia: The timer/recorder will check off critical action boxes on the
Bradycardia Learning Station Checklist.
For PEA/Asystole case management: The timer/recorder will use a stopwatch to
time 2-minute intervals for case management, announce each 2-minute interval for
CPR switching, and record critical action times on the ACLS Code Timer/Recorder
Sheet (in Appendix B of ACLS Instructor Manual or on Instructor CD) or a whiteboard.
ACLS49
1/22/11 12:53 PM
ACLS
Learning Station:
9D
Rotations
10 minutes per case

Team Role
Case
1
Case
2
Case
3
Team leader
S6
S1
S2
Airway
S1
S2
S3
IV/meds
S2
S3
S4
Defibrillator
S3
S4
S5
Compressions (if needed)
S4
S5
S6
Timer/recorder
S5
S6
S1
This station is designed to allow 3 of the 6 students to be a team leader in this station and
3 to be a team leader in Lesson 10 (Tachycardia). Other assigned student roles may vary
depending on the number of students at the station. Any additional students may be given
roles as additional recorders. Cases may be run in a different order, but assigned student roles
should not be changed.
ACLS50
12/21/10 2:19 PM
ACLS
9E
Learning Station:

Start Case Scenario
(6 minutes)
Observe and coach
High-quality skill performance, including high-quality CPR throughout the scenario
Case debriefing
(4 minutes)

Conduct a debriefing at the end of the case
Ask the team leader to summarize the case, roles of team members, and areas
for improvement
Ask the timer/recorder to critique the case
Give a summary of key concepts of the case

10 minutes
Repeat for each of the remaining cases (Bradycardia/PEA/Asystole)

ACLS51
1/22/11 12:53 PM
ACLS
10A
Tachycardia,
Stable and Unstable
Resources

Algorithms
simulator
ventilation
Case Scenarios (in Appendix A
of ACLS Instructor Manual or on
Instructor CD)
Student Role
Participate in the case

Learn to assess and manage
tachycardia
Student Objectives
Explain and apply the Tachycardia

Algorithm
Understand wide and narrow QRS
complex
Demonstrate safe and effective
cardioversion
Practice team roles
0:00
Learning Station:
10
45:00
Your Role
Review Tachycardia Algorithm
Discuss tachycardias
case (see Lesson Maps 10D and 10E)
Present cases for each student to manage
Additional details about student cases can be found on
Lesson Map 10C
Perform debriefing
Reference
ACLS52
12/21/10 2:19 PM
ACLS
10B
Learning Station:
Tachycardia, Stable and Unstable

Algorithm and Tachycardia Review
Review the Tachycardia Algorithm (5 minutes)

Review tachycardias (10 minutes)
Sinus
Atrial fibrillation
Atrial flutter
Reentry supraventricular tachycardia
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type
ACLS53
12/21/10 2:19 PM
ACLS
10C
Learning Station:

Roles
Student Rotations in Learning Station Cases According to Resuscitation

Team Roles
clear messages).
The timer/recorder will check off critical action boxes on the Tachycardia Learning
Station Checklist.
ACLS54
1/22/11 12:53 PM
ACLS
Learning Station:
10D

Rotations
10 minutes per case

Team Role
Case
1
Case
2
Case
3
Team leader
S3
S4
S5
Airway
S4
S5
S6
IV/meds
S5
S6
S1
Defibrillator
S6
S1
S2
Compressions (if needed)
S1
S2
S3
Timer/recorder
S2
S3
S4
This station is designed to allow 3 of the 6 students to be a team leader in this station and
3 to be a team leader in Lesson 9 (Bradycardia). Other assigned student roles may vary
depending on the number of students at the station. Any additional students may be given
roles as additional recorders. Cases may be run in a different order, but assigned student roles
should not be changed.
ACLS55
12/21/10 2:19 PM
ACLS
10E
Learning Station:


Start Case Scenario
(6 minutes)
Observe and coach
High-quality skill performance
Case debriefing
(4 minutes)

Conduct a debriefing at the end of the case
Ask the team leader to summarize the case, roles of team members, and areas
for improvement
Ask the timer/recorder to critique the case
Give a summary of key concepts of the case

10 minutes
Repeat for each of the remaining cases (Stable and Unstable Tachycardia)
ACLS56
1/24/11 12:34 PM
ACLS
11A
0:00
Putting It All Together
Resources
AV equipment
Megacode video
Algorithms
simulator
ventilation
Megacode Case Scenarios (in
Appendix A of ACLS Instructor
Manual or on Instructor CD)
Step stools
Student Role
95:00
2 stations of 6 students each,

1 instructor per station
Your Role
Show Putting It All Together video (first part of Megacode video)
Highlight effective patient management through several
algorithms
Present a Megacode practice case for each student to manage
(see Lesson Map 11C)
Students may use ECC Handbook, pocket reference cards, or
crash cart cards
Perform structured debriefing
Practice as team leader for a

complete Megacode case
Student Objectives
Demonstrate team leader role for a

complete Megacode case
Clarify team roles and responsibilities
Reference
ACLS Provider Manual Parts 1-5
ACLS57
2/5/11 11:57 AM
ACLS
11B

Video
1. Show Putting It All Together video (first part of Megacode video)

Highlight effective patient management through several algorithms
ACLS58
2/5/11 11:57 AM
ACLS
11C

Practice Cases
3. Present Megacode practice case for each student (each case will be one of the following):
Bradycardia VF Asystole ROSC (Immediate PostCardiac Arrest Care)
Tachycardia VF PEA ROSC (Immediate PostCardiac Arrest Care)
Present 6 Megacode practice cases, one at a time, 14 minutes each (10-minute case,
4-minute debriefing):
Determine team leader for first case (see rotations on next Lesson Map)
Team leader organizes other students into team roles
Present case
Students may use the ECC Handbook, pocket reference cards, or emergency crash cart cards
Team leader practices through entire Megacode case
Give feedback, answer questions
Rotate through all students practicing as team leader for remaining 5 cases
Timer/recorder announces 2-minute intervals and checks off critical actions on Megacode
Testing Checklist
Make sure students understand their roles and responsibilities in managing a Megacode case.
ACLS59
2/5/11 11:57 AM
ACLS
11D

Rotations
Team Role
Case
1
Case
2
Case
3
Case
4
Case
5
Case
6
Team leader
S2
S3
S4
S5
S6
S1
Airway
IV/meds
Defibrillator
Team leader assigns other

students to each team role.
Compressions
Timer/recorder
Cases may be run in a different order, but assigned team leader roles should not be changed.
Each student must have the opportunity to run a complete Megacode case as a team leader.
ACLS60
2/5/11 11:57 AM
ACLS
T1
Resources
Testing Details
Course groups list

ACLS Provider Manual
Your Role
Student Role
Prepare for competency testing
Explain the testing rotation for the Megacode and written tests
Remind students that the passing grade for the written test
is 84%
Organize students into 2 groups of 6 for the Megacode testing
stations
Student Objectives
Learn the competency
testing for the Megacode and
written tests
Reference
ACLS61
2/5/11 11:57 AM
ACLS
T2
Testing Station Setups
Recommended testing station setup:

2 Megacode stations, 2 instructors, 6 students each
Other testing setups are permissible as long as
All students are given the opportunity to be tested as a team leader
1 time in Megacode
The written test is proctored and secure
The written test is not interrupted to move a student to the Megacode test
ACLS62
2/5/11 11:57 AM
ACLS
T3
0:00
Megacode Test
60:00
Resources
Your Role

ECG simulator and manikins
Case Scenario (in Appendix A
of ACLS Instructor Manual or
on Instructor CD)
Megacode Testing Checklist
Step stools
Provide Megacode Case Scenario

Additional details on Megacode test can be found in
Lesson Maps T4 and T5
Student Role
As team leader, direct a team in
the simulated Case Scenario
Student Objectives
Successfully demonstrate
competency as a team leader
managing a simulated patient
Reference
ACLS63
2/5/11 11:57 AM
ACLS
T4
Megacode Test
Details
Present Megacode Case Scenario:

Bradycardia VF/Pulseless VT Asystole ROSC (Immediate PostCardiac Arrest Care)
or
Tachycardia VF/Pulseless VT PEA ROSC (Immediate PostCardiac Arrest Care)
Using the Megacode Testing Checklist, test each student one at a time as he or she functions as
team leader
You must conduct the scenario in real time
Students not being evaluated may function as team members
Students may use the ECC Handbook, pocket reference cards, or emergency crash cart cards with
restrictions (see ACLS Instructor Manual)
Timer/recorder announces 2-minute intervals
Take no longer than 10 minutes to test and give students feedback on their performance (pass/fail)
Do not give hints or coaching during the test
Deliver test results in a reasonably private environment for each student after completion of the
Megacode test
Rotate among all students
Refer students who need remediation to remediation lesson
ACLS64
2/5/11 11:57 AM
ACLS
Megacode Test
T5
Rotations
Team Role
Case
1
Case
2
Case
3
Case
4
Case
5
Case
6
Team leader
S5
S6
S1
S2
S3
S4
Airway
IV/meds
Defibrillator
Team leader assigns other

students to each team role.
Compressions
Timer/recorder
Students may be tested in any order, but each student must have the opportunity to run a
complete case as a team leader.
ACLS65
2/5/11 11:57 AM
ACLS
T6
0:00
Written Test
45:00
Resources
Your Role
Written tests
Answer sheets
Answer key
Annotated answer key
Distribute the written test

Proctor the test
Collect and score each test
Review the answers with the students
Additional information about the written examination can be
found in the next Lesson Map
Student Role
Take the written test
Student Objectives
Successfully complete the
written test with a score of
84% or higher
Reference
ACLS66
2/5/11 11:57 AM
ACLS
T7
Written Test
Details
The written test is a closed-book test

Students may not cooperate or talk to each other during the test
When the student completes the test, grade the test
Refer to the annotated answer key to discuss questions answered incorrectly
Answer any questions
Students who scored <84% need immediate remediation
Make sure the student understands the errors and corrects the answers
Give a second test or have the student verbally go over each item that he or she
got incorrect, showing understanding of incorrect items
Do not interrupt the test to have a student go to the Megacode testing station
ACLS67
2/5/11 11:57 AM
ACLS
REM
Remediation
Resources
Your Role
Written tests
Answer sheets
Answer key
Megacode Testing Checklist
Review course material for each student who needs

remediation
Retest students as necessary
Give feedback
Evaluate competency
For Megacode retesting, instructor may play multiple team
member roles, or other available students may be
team members
Student Role
Undergo remediation as needed
Retake tests as needed
Student Objectives
written test with a score of 84%
or higher after remediation
Megacode testing after
remediation
Reference
ACLS68
2/5/11 11:57 AM

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ACLS

30 to 60 Days Before Course

2011 American Heart Association

ACLS Precourse Preparation Program

Instructors or Training Centers may consider offering an ACLS preparation program

At Least 3 Weeks Before Course

2011 American Heart Association

Day Before Course

2011 American Heart Association

2011 American Heart Association

Welcome, Introductions, and

Large group, all students

ACLS Course Overview

Large group, all students

ACLS Course Overview

Present Course Overview

2011 American Heart Association

BLS and ACLS Surveys

Large group, all students

BLS and ACLS Surveys

Check for responsiveness

Activate the emergency response system/get the AED

2011 American Heart Association

Watch the video

Demonstrate insertion of NPA or OPA

Student Practice Details

Practice Session Part 1

Continue Airway Management video

Student Practice Details

Practice-While-Watching (PWW) Session

2011 American Heart Association

Person holding the mask

Management of Respiratory Arrest

Testing Session Part 2

Management of Respiratory Arrest

Show Airway Management Video

2011 American Heart Association

Student Practice Details

Practice Session Part 3

 fter the video, students practice performing ventilations with a simulated

Students perform 2-rescuer CPR, one student doing continuous compressions

Students perform 1 minute of CPR, switch roles, do 1 minute of CPR,

Rotate through all students performing ventilations

Adult manikins (at least 2)

Practice CPR with the video

Do chest compressions and ventilation

CPR and AED Practice

2011 American Heart Association

CPR and AED Practice

Test students one at a time

2011 American Heart Association

The Megacode and Resuscitation

Large group, all students, 1 instructor (or may

Ask students to open the ACLS Provider Manual to

The Megacode and Resuscitation

Elements of Effective Team Dynamics

2011 American Heart Association

Cardiac Arrest (VF/Pulseless VT)

Code cart or code kit

Practice in the role as team leader in a

Implement the Cardiac Arrest Algorithm

Cardiac Arrest (VF/Pulseless VT)

Review algorithms (5 minutes)

Cardiac Arrest (VF/Pulseless VT)

Continue Airway Management video

fter the video, students practice performing ventilations with a simulated

Students perform 2-rescuer CPR, one student doing continuous compressions

Students perform 1 minute of CPR, switch roles, do 1 minute of CPR,

Rotate through all students performing ventilations

Do chest compressions and ventilation

Ask students to open the ACLS Provider Manual to

Practice in the role as team leader in a

Implement the Cardiac Arrest Algorithm

3. What are the classic symptoms of acute ischemic chest discomfort?

2. What are the goals of therapy for patients with ACS?

3. Why is STEMI special and the focus of this case?

3. What does fibrinolytic therapy do for patients with ischemic stroke?

Show proper management of a simulated bradycardia/PEA/asystole case

Explain and apply the Tachycardia