Professional Documents
Culture Documents
Life S p p o r t
P R O V I D E R
M A n u A L
Ed itors
Se n ior Ma n a g in g Ed itor
Erik S. Soderberg, MS
To f nd out about any updates or corrections to this text, vis it www.he a rt.o rg /c p r, navigate
to the page or this cours e, and click on Updates .
To acces s the Student Webs ite or this cours e, go to www.he a rt.o rg /e c c s tud e nt and enter
this code: algorithm
ii
Conte nts
P a rt 1
Co u r s e Ove r vie w
1
Cours e De s c ription a nd Goa l
Cours e De s ign
BLS Skills
Cours e Ma te ria ls
P a rt 2
Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys
11
Introduction
11
Learning Objectives
11
11
11
12
12
14
14
iii
C o n t e n t s
P a rt 3
Effe c t ive Re s u s c it a t io n Te a m Dyn a m ic s
17
Introduction
17
Learning Objectives
17
Role s of th e Te a m Le a d e r a n d Te a m Me m b e rs
18
18
18
19
19
19
20
21
Knowledge Sharing
22
22
23
23
P a rt 4
S ys t e m s o f Ca re
25
Introduction
25
Learning Objectives
25
25
26
Meas urement
27
27
Change
27
Summary
27
28
Therapeutic Hypothermia
28
28
28
Glycemic Control
28
29
iv
25
29
29
EMS Components
29
29
Con te n ts
Ac ute Stroke
30
30
30
EMS
30
Ed u c a tion , Im p le m e n ta tion , a n d Te a m s
30
30
31
31
31
32
32
32
P a rt 5
Th e ACLS Ca s e s
33
Overview of the Cas es
33
34
34
36
38
38
38
40
42
43
Suctioning
45
47
49
49
50
57
VF/P u ls e le s s VT Ca s e
59
60
62
69
70
Antiarrhythmic Agents
71
72
73
78
78
v
C o n t e n t s
Managing PEA: The Cardiac Arres t Algorithm
79
82
As ys tole Ca s e
86
Approach to As ys tole
86
Managing As ys tole
87
88
89
91
92
95
96
96
99
100
Bra d yc a rd ia Ca s e
104
107
108
109
112
Un s ta b le Ta c h yc a rd ia Ca s e
114
114
116
118
Cardiovers ion
120
122
Sta b le Ta c h yc a rd ia Ca s e
124
125
126
127
Ac ute Stroke Ca s e
vi
101
130
132
135
138
139
140
141
Fibrinolytic Therapy
143
146
Con te n ts
Ap p e n d ix
149
Te s tin g Ch e c klis ts a n d Le a rn in g Sta tion Ch e c klis ts
151
163
165
Glos s a ry
168
171
In d e x
173
No t e o n Me d ic a t io n Do s e s
Emergency cardiovas cular care is a dynamic s cience. Advances in treatment and drug therapies occur rapidly.
Readers s hould us e the following s ources to check for changes in recommended dos es , indications , and contraindications : the ECC Handbook, available as optional s upplementary material, and the package ins ert product information
s heet for each drug and medical device.
vii
C o n t e n t s
Part
Co u r s e Ob je c t ive s
Upon s ucces s ful completion of this cours e s tudents s hould be able to
Recognize and initiate early management of periarres t conditions that may res ult in
cardiac arres t or complicate res us citation outcome
Demons trate proficiency in providing BLS care, including prioritizing ches t compres s ions and integrating automated external defibrillator (AED) us e
Recognize and manage res piratory arres t
Recognize and manage cardiac arres t until termination of res us citation or trans fer of
care, including immediate pos tcardiac arres t care
Recognize and initiate early management of ACS, including appropriate dis pos ition
Recognize and initiate early management of s troke, including appropriate dis pos ition
Demons trate effective communication as a member or leader of a res us citation team
and recognize the impact of team dynamics on overall team performance
P a r t
Co u r s e De s ig n
To help you achieve thes e objectives , the ACLS Provider Cours e includes practice learning
s tations and a Megacode evaluation s tation.
The practice learning stations give you an opportunity to actively participate in a variety of
learning activities , including
Simulated clinical s cenarios
Demons trations by ins tructors or video
Dis cus s ion and role playing
Practice in effective res us citation team behaviors
In thes e learning s tations you will practice es s ential s kills both individually and as part of
a team. This cours e emphas izes effective team s kills as a vital part of the res us citative
effort. You will have the opportunity to practice as a team member and a team leader.
At the end of the cours e, you will participate in a Megacode evaluation station to validate
your achievement of the cours e objectives . A s imulated cardiac arres t s cenario will evaluate the following:
Knowledge of core cas e material and s kills
Knowledge of algorithms
Unders tanding of arrhythmia interpretation
Us e of appropriate bas ic ACLS drug therapy
Performance as an effective team leader
Co u r s e P re re q u is it e s a n d P re p a r a t io n
The American Heart As s ociation (AHA) limits enrollment in the ACLS Provider Cours e to
healthcare providers who direct or participate in the res us citation of a patient either in or
out of hos pital. Participants who enter the cours e mus t have the bas ic knowledge and
s kills to participate actively with the ins tructor and other s tudents .
Before the cours e, pleas e read the ACLS Provider Manual, complete the s elf-as s es s ment
modules on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt), identify any gaps in your
knowledge, and remediate thos e gaps by s tudying the applicable content in the ACLS
Provider Manual or other s upplementary res ources .
The following knowledge and s kills are required for s ucces s ful cours e completion:
BLS s kills
Electrocardiogram (ECG) rhythm interpretation for core ACLS rhythms
Knowledge of airway management and adjuncts
Bas ic ACLS drug and pharmacology knowledge
Practical application of ACLS rhythms and drugs
Effective res us citation team concepts
BLS S k ills
The foundation of advanced life s upport is s trong BLS s kills . You mus t pas s the 1-Res cuer
CPR and AED Tes ting Station to s ucces s fully complete the ACLS cours e. Make sure that
you are proficient in BLS skills before attending the course.
Watch the CPR and AED Skills video found on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt). Review the CPR and AED Tes ting Checklis t
located in the Appendix.
ECG Rh yt h m
In t e r p r e t a t io n
fo r Co r e ACLS
Rh yt h m s
The bas ic cardiac arres t and periarres t algorithms require s tudents to recognize thes e
ECG rhythms :
Sinus rhythm
Atrial fibrillation and flutter
Bradycardia
Tachycardia
Atrioventricular (AV) block
As ys tole
Puls eles s electrical activity (PEA)
Ventricular tachycardia (VT)
Ventricular fibrillation (VF)
The AHA recommends that you complete the ECG rhythm identification s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of
the as s es s ment you will receive your s core and feedback to help you identify
areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering
the cours e. During the cours e you mus t be able to identify and interpret rhythms during
practice as well as during the final Megacode evaluation s tation.
Ba s ic ACLS Dr u g
a n d P h a r m a c o lo g y
Kn o w le d g e
You mus t know the drugs and dos es us ed in the ACLS algorithms . You will als o need to
know when to us e which drug bas ed on the clinical s ituation.
P r a c t ic a l
Ap p lic a t io n o f
ACLS Rh yt h m s
a n d Dr u g s
Take the ACLS practical application s elf-as s es s ment on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) to evaluate your ability to integrate both rhythm
interpretation and the us e of pharmacologic agents . This as s es s ment pres ents a
clinical s cenario and an ECG rhythm. You will need to take an action, give a s pecific drug,
or direct your team to intervene. Us e this s elf-as s es s ment to confirm that you have the
knowledge you need to be an active participant in the cours e and pas s the final
Megacode tes t.
Effe c t ive
Re s u s c it a t io n
Te a m Co n c e p t s
Ins tructors throughout the cours e will evaluate your effectivenes s as a team leader
and a team member. A clear unders tanding of thes e concepts is integral to s ucces s ful
performance in the learning activities and the Megacode tes t. Review Part 3 in the ACLS
Provider Manual before the cours e. During the Megacode the ins tructor will evaluate your
team leader s kills with a major emphas is on your ability to direct the integration of BLS
and ACLS activities by your team members .
The AHA recommends that you complete the ACLS pharmacology review s elfas s es s ment on the Student Webs ite (www.he a rt.o rg /e c c s tud e nt). At the end of
the as s es s ment you will receive your s core and feedback to help you identify
areas of s trength and weaknes s . Remediate any gaps in your knowledge before entering
the cours e.
Co u r s e Ma t e r ia ls
Cours e materials cons is t of the ACLS Provider Manual, Student Webs ite
(www.he a rt.o rg /e c c s tud e nt), 2 pocket reference cards , and Precours e
Preparation Checklis t. The icon on the left directs you to additional s upplemental
information on the Student Webs ite.
P a r t
ACLS P r o vid e r
Ma n u a l
The ACLS Provider Manual contains the bas ic information you need for effective participation in the cours e. This important material includes the s ys tematic approach to a cardiopulmonary emergency, effective res us citation team communication, and the ACLS cas es
and algorithms . Please review this manual before attending the course. Bring it with you
for use and reference during the course.
The manual is organized into the following parts :
Co n t e n t s
P a rt 1
Cours e Overview
P a rt 2
P a rt 3
P a rt 4
P a rt 5
Ap p e nd ix
Te s ting Che c klis ts
a nd Le a rning Sta tio n
Che c klis ts
2010 AHA Gu id e lin e s
for CP R a n d ECC
Sum m a ry Ta b le
ACLS P ha rm a c o lo g y
Sum m a ry Ta b le
Glo s s a ry
Ind e x
The AHA s trongly recommends that s tudents complete the Precours e Self-As s es s ment
found on the Student Webs ite and print their s cores for s ubmis s ion to their ACLS
Ins tructor. Supplemental topics located on the Student Webs ite are us eful but not es s ential for s ucces s ful completion of the cours e.
Ca ll-ou t Boxe s
The ACLS Provider Manual contains important information pres ented in call-out boxes
that require the readers attention. Pleas e pay particular attention to the call-out boxes ,
lis ted below:
Critical Concepts
Caution
FYI 2010 Guidelines
Foundational Facts
Cr it ic a l Co n c e p t s
Im p o rta nt Info rm a tio n to
Re vie w a nd Stud y
Pay particular attention to the Critic a l Co nc e p ts boxes that appear in the ACLS
Provider Manual. Thes e boxes contain the mos t important information that you
mus t know.
Ca u t io n
FYI 2 0 1 0 Gu id e lin e s
FYI 2010 Guid e line s boxes containthenew2010 AHA Guidelines for CPR and ECC
information.
Fo u n d a t io n a l Fa c t s
S t u d e n t We b s it e
Re s o u rc e
De s c r ip t io n
Ho w t o Us e
ACLS Rhythm
Id e ntific a tio n
ACLS P ha rm a c o lo g y
Bas icAirway
Management
AdvancedAirway
Management
ACLSCoreRhythms
Defibrillation
Acces s forMedications
AcuteCoronary
Syndromes
Human,Ethical,and
LegalDimens ions of
ECCandACLS
Additionalinformation
tos upplementbas ic
concepts pres entedin
ACLScours e
Supplementaryres ources :
reviewcurrentBLS
s equenceands kills
ReviewBLSs kills to
p repareforthe1-Res cuer
CPRandAEDTes ting
Station
CP R a nd AED Skills
vid e o
Completebeforethe
cours etohelpevaluate
yourproficiencyand
determinetheneedfor
additionalreviewand
practice
(continued)
P a r t
1
(continued)
Re s o u rc e
P o c k e t Re fe r e n c e
Ca r d s
Ho w t o Us e
ACS vid e o
Stro ke vid e o
IO a nim a tio n
Expanded information on
IOs
The Pocket Reference Cards are 2 s tand-alone cards packaged with the ACLS Provider
Manual. Thes e cards can be carried in your pocket for quick reference on the following
topics :
To p ic
Pre c ours e
P r e p a r a t io n
Ch e c k lis t
De s c r ip t io n
Re fe re n c e Ca rd s
Ca rd ia c a rre s t,
a rrhythm ia s , a nd
tre a tm e nt
ACS a nd s tro ke
ACS Algorithm
Fibrinolytic Checklis t for STEMI
Fibrinolytic Contraindications for STEMI
Sus pected Stroke Algorithm
Stroke As s es s mentCPSS
Us e of IV rtPA for Acute Is chemic Stroke
Hypertens ion Management in Acute Is chemic Stroke
The Precours e Preparation Checklis t is packaged with the ACLS Provider Manual. Pleas e
review and check the boxes after you have completed preparation for each s ection.
Re q u ire m e n t s fo r S u c c e s s fu l Co u r s e Co m p le t io n
To s ucces s fully complete the ACLS Provider Cours e and obtain your cours e completion
card, you mus t
Pas s the 1-Res cuer Adult CPR and AED Tes t
Pas s the Bag-Mas k Ventilation Tes t
Demons trate competency in learning s tation s kills
Pas s the Megacode Tes t
Pas s the clos ed-book written exam with a minimum s core of 84%
ACLS Up d a t e Co u r s e
The ACLS Update Cours e is for s tudents who have a current ACLS Provider card and
need to update and refres h their ACLS s kills . This cours e is primarily focus ed on s kills
competency tes ting.
Maximum renewal period: 2 years
Update requirements : Previous ACLS cours e completion card (not expired)
ACE
ACLS
ACS
AED
AHF
AIVR
AMI
a P TT
B
BLS
C
CARES
CP R
CP SS
CT
Computed tomography
(continued)
7
P a r t
1
(continued)
D
DNAR
E
ECG
Electrocardiogram
ED
Emergency department
EMS
ET
Endotracheal
F
FDA
F io 2
G
GI
I
ICU
INR
IO
Intraos s eous
IV
Intravenous
L
LMWH
Low-molecular-weight heparin
LV
M
mA
Milliamperes
MACE
MET
MI
Myocardial infarction
m m Hg
Millimeters of mercury
N
NIH
NIHSS
NINDS
NPA
NSAIDs
NSTEMI
(continued)
O
OPA
Oropharyngeal airway
P
Paco2
P CI
PE
Pulmonary embolis m
P EA
PT
Prothrombin time
R
ROSC
RRT
rtPA
RV
S
SBP
STEMI
SVT
Supraventricular tachycardia
T
TCP
U
UA
UFH
Unfractionated heparin
V
VF
Ventricular fibrillation
VT
Ventricular tachycardia
P a r t
Part
Healthcare providers us e a s ys tematic approach to as s es s and treat arres t and acutely ill
or injured patients for optimum care. The goal of the res us citation teams interventions for
a patient in res piratory or cardiac arres t is to s upport and res tore effective oxygenation,
ventilation, and circulation with return of intact neurologic function. An intermediate goal of
res us citation is the return of s pontaneous circulation (ROSC). The actions us ed are guided
by the following s ys tematic approaches :
BLS Survey (s teps des ignated by the numbers 1, 2, 3, 4)
ACLS Survey (s teps des ignated by the letters A, B, C, D)
Le a r n in g Ob je c t ive s
Th e S ys t e m a t ic Ap p ro a c h : Th e BLS a n d ACLS S u r ve ys
Ove r vie w o f
t h e S ys t e m a t ic
Ap p r o a c h
The s ys tematic approach firs t requires ACLS providers to determine the patients level of
cons cious nes s . As you approach the patient:
If the patient appears uncons cious
Us e the BLS Survey for the initial as s es s ment.
After completing all of the appropriate s teps of the BLS Survey, us e the ACLS
Survey for more advanced as s es s ment and treatment.
If the patient appears cons cious
Us e the ACLS Survey for your initial as s es s ment.
The details of the BLS and ACLS Surveys are des cribed below.
11
P a r t
Th e BLS S u r ve y
Ove r vie w o f t h e
BLS S u r ve y
The BLS Survey is a s ys tematic approach to bas ic life s upport that any trained healthcare
provider can perform. This approach s tres s es early CPR and early defibrillation. It does not
include advanced interventions , s uch as advanced airway techniques or drug adminis tra
tion. By us ing the BLS Survey, healthcare providers may achieve their goal of s upporting
or res toring effective oxygenation, ventilation, and circulation until ROSC or initiation of
ACLS interventions . Performing the actions in the BLS Survey s ubs tantially improves the
patients chance of s urvival and a good neurologic outcome.
Be fore c on d u c tin g th e BLS or ACLS Su rve y, look to m a ke s u re th e s c e n e is s a fe .
The BLS Survey us es a s eries of 4 s equential as s es s ment s teps des ignated by the
numbers 1, 2, 3, and 4. Simultaneous ly with each as s es s ment s tep, you s hould
perform appropriate corrective action(s ) before proceeding to the next s tep. As s es s
ment is a key component in this approach (eg, check the puls e before s tarting ches t
compres s ions or attaching an AED).
Re m e m b e r: As s e s s th e n p e rform a p p rop ria te a c tion .
FYI 2 0 1 0 Gu id e lin e s
Pleas e note the 2 key changes from the 2005 AHA Guidelines for CPR and ECC:
The 2010 AHA Guidelines for CPR and ECC alters the BLS s equence by eliminating
look, lis ten, and feel followed by 2 res cue breaths . This change promotes earlier
initiation of ches t compres s ions in cardiac arres t patients .
The BLS Survey is no longer repres ented by the letters A, B, C, D but is repres ented
by the numbers 1, 2, 3, 4 ins tead.
Fo u n d a t io n a l Fa c t s
Although no publis hed human or animal evidence demons trates that s tarting CPR
with 30 compres s ions rather than 2 ventilations leads to improved outcomes , it is
clear that blood flow depends on ches t compres s ions . Therefore, providers mus t
minimize delays in and interruptions of ches t compres s ions throughout the entire
res us citation. Pos itioning the head, achieving a s eal for mouth to mouth res cue
breaths , or getting a bag mas k device for res cue breaths takes time. Beginning CPR
with 30 compres s ions rather than 2 ventilations leads to a s horter delay to the firs t
compres s ion.
Once one provider begins ches t compres s ions , a s econd trained healthcare provider
s hould deliver res cue breaths to provide oxygenation and ventilation as follows :
Deliver each res cue breath over 1 s econd
Give a s ufficient tidal volume to produce vis ible ches t ris e
Although the BLS Survey requires no advanced equipment, healthcare providers can us e
any readily available univers al precaution s upplies or adjuncts , s uch as a bag mas k venti
lation device. Whenever pos s ible, place the patient on a firm s urface in a s upine pos ition
to maximize the effectivenes s of ches t compres s ions . Table 1 is an overview of the BLS
Survey, and Figures 1 through 4 illus trate the s teps needed during the BLS Survey. Before
approaching the patient, ens ure s cene s afety.
For more details , review the VF Treated With CPR and AED Cas e in Part 5 of
this manual and watch the CPR and AED Skills video on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt).
12
As s e s s
1
Che c k
re s p o ns ive ne s s
As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )
Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED
Fig u re 3 . Checkthecarotidpuls e.
Fig u re 4 . Defibrillation.
13
P a r t
Cr it ic a l Co n c e p t s
Minim izing Inte rrup tio ns
Fo u n d a t io n a l Fa c t s
Lo ne He a lthc a re
P ro vid e r Ma y Ta ilo r
Re s p o ns e
Cr it ic a l Co n c e p t s
Hig h-Qua lity CP R
Lone healthcare providers may tailor the s equence of res cue actions to the mos t
likely caus e of arres t. For example, if a lone healthcare provider s ees an adoles cent
s uddenly collaps e, it is reas onable to as s ume that the patient has s uffered a s udden
cardiac arres t.
The lone res cuer s hould call for help (activate the emergency res pons e s ys tem), get
an AED (if nearby), return to the patient to attach the AED, and then provide CPR.
On the other hand, if hypoxia is the pres umed caus e of the cardiac arres t (s uch as
in a drowning patient), the healthcare provider may give about 5 cycles (approximately 2 minutes ) of CPR before activating the emergency res pons e s ys tem.
Th e ACLS S u r ve y
Ove r vie w o f t h e
ACLS S u r ve y
14
Table 2 provides an overview of the ACLS Survey. The ACLS cas es provide details on
thes e components .
Ta b le 2 . The ACLS Surve y
As s e s s
Airwa y
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of
airway device confirmed?
Is tube secured and
placement reconfirmed
frequently?
Ac t io n a s Ap p ro p r ia t e
Ma inta in a irwa y p a te nc y in unc o ns c io us p a tie nts
by us e of the head tiltchin lift, oropharyngeal airway (OPA), or nas opharyngeal airway (NPA)
Us e a d va nc e d a irwa y m a na g e m e nt if ne e d e d
(eg, laryngeal mas k airway, laryngeal tube,
es ophageal-tracheal tube, endotracheal tube
[ET tube])
Healthcare providers must weigh the benefit of
advanced airway placement against the adverse
effects of interrupting chest compressions. If bagmask ventilation is adequate, healthcare providers
may defer insertion of an advanced airway until the
patient fails to respond to initial CPR and defibrillation
or until spontaneous circulation returns. Advanced
airway devices such as a laryngeal mask airway, laryngeal tube, or esophageal-tracheal tube can be placed
while chest compressions continue.
If us ing advanced airway devices :
Co nfirm p ro p e r inte g ra tio n o f CP R a nd
ve ntila tio n
Co nfirm p ro p e r p la c e m e nt o f a d va nc e d a irwa y
d e vic e s by
Phys ical examination
Quantitative waveform capnography
Clas s I recommendation for ET tube
Reas onable for s upraglottic airways
Se c ure the d e vic e to p re ve nt d is lo d g m e nt
Mo nito r a irwa y p la c e m e nt with c o ntinuo us
q ua ntita tive wa ve fo rm c a p no g ra p hy
Bre a thing
Are ventilation and oxygenation adequate?
Are quantitative waveform
capnography and oxyhemoglobin saturation monitored?
15
P a r t
2
(continued)
As s e s s
Circ ula tio n
Are chest compressions
effective?
What is the cardiac rhythm?
Is defibrillation or cardioversion indicated?
Has IV/IO access been
established?
Is ROSC present?
Is the patient with a pulse
unstable?
Are medications needed for
rhythm or blood pressure?
Does the patient need
volume (fluid) for resuscitation?
Diffe re ntia l d ia g no s is
Why did this patient develop
symptoms or arrest?
Is there a reversible cause
that can be treated?
Ac t io n a s Ap p ro p r ia t e
Mo nito r CP R q ua lity
Quantitative waveform capnography (if P e t c o 2 is
<10 mm Hg, attempt to improve CPR quality)
Intra-arterial pres s ure (if relaxation phas e
[dias tolic] pres s ure is <20 mm Hg, attempt to
improve CPR quality)
Atta c h m o nito r/d e fib rilla to r fo r a rrhythm ia s
o r c a rd ia c a rre s t rhythm s (eg, VF, puls eles s VT,
as ys tole, PEA)
P ro vid e d e fib rilla tio n/c a rd io ve rs io n
Ob ta in IV/IO a c c e s s
Give a p p ro p ria te d rug s to manage rhythm and
blood pres s ure
Give IV/IO fluid s if ne e d e d
P e t c o 2 is the partial pres s ure of CO 2 in exhaled air at the end of the exhalation phas e.
16
Part
In t r o d u c t io n
Succes s ful res us citation attempts often require healthcare providers to s imultaneous ly
perform a variety of interventions . Although a CPR-trained bys tander working alone can
res us citate a patient within the firs t moments after collaps e, mos t attempts require the
concerted efforts of multiple healthcare providers . Effective teamwork divides the tas ks
while multiplying the chances of a s ucces s ful outcome.
Succes s ful teams not only have medical expertis e and mas tery of res us citation s kills , but
they als o demons trate effective communication and team dynamics . Part 3 of this manual
dis cus s es the importance of team roles , behaviors of effective team leaders and team
members , and elements of effective res us citation team dynamics .
During the cours e you will have an opportunity to practice performing different roles as a
member and a leader of a s imulated res us citation team.
Le a r n in g Ob je c t ive s
Fo u n d a t io n a l Fa c t s
Und e rs ta nd ing Te a m
Ro le s
Whether you are a team member or team leader during a res us citation attempt, you
s hould u n d e rs ta n d n ot on ly you r role b u t a ls o th e role s of oth e r te a m m e m b e rs .
This awarenes s will help you anticipate
What actions will be performed next
How to communicate and work as a member or leader of the team
17
P a r t
Ro le s o f t h e Te a m Le a d e r a n d Te a m Me m b e r s
Ro le o f t h e Te a m
Le a d e r
Ro le o f t h e Te a m
Me m b e r
Team members mus t be proficient in performing the s kills authorized by their s cope of
practice. It is es s ential to the s ucces s of the res us citation attempt that team members are
Clear about role as s ignments
Prepared to fulfill their role res pons ibilities
Well practiced in res us citation s kills
Knowledgeable about the algorithms
Committed to s ucces s
18
When communicating with res us citation team members , the team leader s hould us e
clos ed-loop communication by taking thes e s teps :
1. The team leader gives a mes s age, order, or as s ignment to a team member.
2. By receiving a clear res pons e and eye contact, the team leader confirms that the
team member heard and unders tood the mes s age.
3. The team leader lis tens for confirmation of tas k performance from the team member
before as s igning another tas k.
Do
Te a m le a d e r
Te a m m e m b e rs
Do n t
Cle a r Me s s a g e s
Te a m le a d e r
Te a m m e m b e rs
Clear mes s ages cons is t of concis e communication s poken with dis tinctive s peech in a
controlled tone of voice. All healthcare providers s hould deliver mes s ages and orders in
a calm and direct manner without yelling or s houting. Unclear communication can lead to
unneces s ary delays in treatment or to medication errors .
For example: Did the patient get IV propofol s o I can proceed with the cardiovers ion?
No, I thought you s aid to give him propranolol.
Yelling or s houting can impair effective team interaction. Only one pers on s hould talk at
any time.
Do
Te a m le a d e r
Te a m m e m b e rs
Do n t
Te a m le a d e r
Te a m m e m b e rs
19
P a r t
Cle a r Ro le s a n d
Re s p o n s ib ilit ie s
Every member of the team s hould know his or her role and res pons ibilities . J us t as
different s haped pieces make up a jigs aw puzzle, each team members role is unique
and critical to the effective performance of the team. Figure 5 identifies 6 team roles for
res us citation. When <6 people are pres ent, all tas ks mus t be as s igned to the healthcare
providers pres ent.
When roles are unclear, team performance s uffers . Signs of unclear roles include
Performing the s ame tas k more than once
Mis s ing es s ential tas ks
Freelancing of team members
To avoid inefficiencies , the team leader mus t clearly delegate tas ks . Team members
s hould communicate when and if they can handle additional res pons ibilities . The team
leader s hould encourage team members to participate in leaders hip and not s imply follow
directions blindly.
Do
Te a m le a d e r
Te a m m e m b e rs
Seek out and perform clearly defined tas ks appropriate to your level of competence
As k for a new tas k or role if you are unable to perform
your as s igned tas k becaus e it is beyond your level of
experience or competence
Do n t
20
Te a m le a d e r
Te a m m e m b e rs
Airwa y
Co m p re s s o r
IV/IO/Me d s
Mo nito r/
De b rilla to r
Ob s e rve r/
Re c o rd e r
TEAM LEADER
Fig u re 5 . Sugges ted locations of team leader and team members during cas e s imulations .
Kn o w in g On e s
Lim it a t io n s
Not only s hould everyone on the team know his or her own limitations and capabilities ,
but the team leader s hould als o be aware of them. This allows the team leader to evaluate
team res ources and call for backup of team members when as s is tance is needed. Team
members s hould anticipate s ituations in which they might require as s is tance and inform
the team leader.
During the s tres s of an attempted res us citation, do not practice or explore a new s kill. If
you need extra help, reques t it early. It is not a s ign of weaknes s or incompetence to as k
for help; it is better to have more help than needed rather than not enough help, which
might negatively affect patient outcome.
Do
Te a m le a d e r a nd te a m
m e m b e rs
Do n t
Te a m le a d e r a nd te a m
m e m b e rs
Te a m m e m b e rs
Us e or s tart an unfamiliar treatment or therapy without s eeking advice from more experienced pers onnel
Take on too many as s ignments at a time when as s is tance is readily available
21
P a r t
Kn o w le d g e S h a r in g
Do
Te a m le a d e r
Te a m m e m b e rs
Do n t
Co n s t r u c t ive
In t e r ve n t io n
Te a m le a d e r
Te a m m e m b e rs
During a res us citation attempt the team leader or a team member may need to intervene
if an action that is about to occur may be inappropriate at the time. Although cons tructive
intervention is neces s ary, it s hould be tactful. Team leaders s hould avoid confrontation
with team members . Ins tead, conduct a debriefing afterward if cons tructive criticis m
is needed.
Do
Te a m le a d e r
Te a m m e m b e rs
Do n t
22
Te a m le a d e r
Fail to reas s ign a team member who is trying to function beyond his or her level of s kill
Te a m m e m b e rs
Re e va lu a t io n a n d
S u m m a r iz in g
Do
Te a m le a d e r
Te a m le a d e r a nd te a m
m e m b e rs
Do n t
Te a m le a d e r
Mu t u a l Re s p e c t
Fail to change a treatment s trategy when new information s upports s uch a change
Fail to inform arriving pers onnel of the current s tatus
and plans for further action
The bes t teams are compos ed of members who s hare a mutual res pect for each other
and work together in a collegial, s upportive manner. To have a high-performing team,
everyone mus t abandon ego and res pect each other during the res us citation attempt,
regardles s of any additional training or experience that the team leader or s pecific team
members may have.
Do
Te a m le a d e r a nd te a m
m e m b e rs
Te a m le a d e r
Do n t
Te a m le a d e r a nd te a m
m e m b e rs
23
P a r t
Part
Sys te m s of Ca re
In t r o d u c t io n
Le a r n in g Ob je c t ive s
Ca rd io p u lm o n a r y Re s u s c it a t io n
Qu a lit y Im p r o ve m e n t
in Re s u s c it a t io n
S ys t e m s , P r o c e s s e s ,
a n d Ou t c o m e s
Cardiopulmonary res us citation is a s eries of lifes aving actions that improve the chance
of s urvival following cardiac arres t. Although the optimal approach to CPR may vary,
depending on the res cuer, the patient, and the available res ources , the fundamental
challenge remains how to achieve early and effective CPR.
25
P a r t
A S ys t e m s Ap p r o a c h
Succes s ful res us citation following cardiac arres t requires an integrated s et of coordinated
actions repres ented by the links in the adult Chain of Survival (Figure 6). The links include
the following:
Immediate recognition of cardiac arres t and activation of the emergency res pons e
s ys tem
Early CPR with an emphas is on ches t compres s ions
Rapid defibrillation
Effective advanced life s upport
Integrated pos tcardiac arres t care
Effective res us citation requires an integrated res pons e known as a s ys tem of care.
Fundamental to a s ucces s ful res us citation s ys tem of care is the collective appreciation
of the challenges and opportunities pres ented by the Chain of Survival. Thus , individuals
and groups mus t work together, s haring ideas and information, to evaluate and improve
their res us citation s ys tem. Leaders hip and accountability are important components of
this team approach.
To improve care, leaders mus t as s es s the performance of each s ys tem component.
Only when performance is evaluated can participants in a s ys tem effectively intervene to
improve care. This proces s of quality improvement cons is ts of an iterative and continuous
cycle of
Sys tematic evaluation of res us citation care and outcome
Benchmarking with s takeholder feedback
Strategic efforts to addres s identified deficiencies
Fo u n d a t io n a l Fa c t s
Me d ic a l Em e rg e nc y
Te a m s (METs ) a nd Ra p id
Re s p o ns e Te a m s (RRTs )
26
Many hos pitals have implemented the us e of METs or RRTs . The purpos e of thes e
teams is to improve patient outcomes by identifying and treating early clinical deterioration (Figure 7). In-hos pital cardiac arres t is commonly preceded by phys iologic
changes . In one s tudy nearly 80% of hos pitalized patients with cardiores piratory
arres t had abnormal vital s igns documented for up to 8 hours before the actual
arres t. Many of thes e changes can be recognized by monitoring routine vital s igns .
Intervention before clinical deterioration or cardiac arres t may be pos s ible.
Cons ider this ques tion: Would you have done anything differently if you knew 15
minutes before the arres t that?
Sys te m s of Ca re
U n s t a b le
l P a t ie n t
Ra p id
Re s p o n s e
Te a m
Cod e
Te a m
Cr it ic a l
Ca re Te a m
Me a s u r e m e n t
Be n c h m a r k in g
a n d Fe e d b a c k
Data s hould be s ys tematically reviewed and compared internally to prior performance and
externally to s imilar s ys tems . Exis ting regis tries can facilitate this benchmarking effort.
Examples include the
Cardiac Arres t Regis try to Enhance Survival (CARES) for out-of-hos pital cardiac arres t
Get With The Guidelines Res us citation program for in-hos pital cardiac arres t
Ch a n g e
Simply meas uring and benchmarking care can pos itively influence outcome. However,
ongoing review and interpretation are neces s ary to identify areas for improvement,
s uch as
Increas ed bys tander CPR res pons e rates
Improved CPR performance
Shortened time to defibrillation
Citizen awarenes s
Citizen and healthcare profes s ional education and training
Su m m a r y
Over the pas t 50 years the modern-era bas ic life s upport fundamentals of early recognition and activation, early CPR, and early defibrillation have s aved hundreds of thous ands
of lives around the world. However, we s till have a long road to travel if we are to fulfill
the potential offered by the Chain of Survival. Survival dis parities pres ent a generation
ago appear to pers is t. Fortunately, we currently pos s es s the knowledge and tools
repres ented by the Chain of Survivalto addres s many of thes e care gaps , and future
dis coveries will offer opportunities to improve rates of s urvival.
27
P a r t
P o s t Ca rd ia c Ar re s t Ca re
The healthcare s ys tem s hould implement a comprehens ive, s tructured, multidis ciplinary
s ys tem of care in a cons is tent manner for the treatment of pos tcardiac arres t patients .
Programs s hould addres s therapeutic hypothermia, hemodynamic and ventilation optimization, immediate coronary reperfus ion with percutaneous coronary intervention (PCI),
glycemic control, neurologic care and prognos tication, and other s tructured interventions .
Individual hos pitals with a high frequency of treating cardiac arres t patients s how an
increas ed likelihood of s urvival when thes e interventions are provided.
Th e r a p e u t ic
Hyp o t h e r m ia
The 2010 AHA Guidelines for CPR and ECC recommends cooling comatos e (ie, lack of
meaningful res pons e to verbal commands ) adult patients with ROSC after out-of-hos pital
VF cardiac arres t to 32C to 34C (89.6F to 93.2F) for 12 to 24 hours . Healthcare providers s hould als o cons ider induced hypothermia for comatos e adult patients with ROSC
after in-hos pital cardiac arres t of any initial rhythm or after out-of-hos pital cardiac arres t
with an initial rhythm of PEA or as ys tole.
He m o d yn a m ic
a n d Ve n t ila t io n
Op t im iz a t io n
Although providers often us e 100% oxygen while performing the initial res us citation,
providers s hould titrate ins pired oxygen during the pos tcardiac arres t phas e to the lowes t
level required to achieve an arterial oxygen s aturation of 94% . This helps to avoid any
potential complications as s ociated with oxygen toxicity.
Avoid exces s ive ventilation of the patient becaus e of potential advers e hemodynamic
effects when intrathoracic pres s ures are increas ed and becaus e of potential decreas es in
cerebral blood flow when Pa c o 2 decreas es .
Healthcare providers may s tart ventilation rates at 10 to 12 breaths per minute and titrate
to achieve a P e t c o 2 of 35 to 40 mm Hg or a Pa c o 2 of 40 to 45 mm Hg.
Healthcare providers s hould titrate fluid adminis tration and vas oactive or inotropic agents
as needed to optimize blood pres s ure, cardiac output, and s ys temic perfus ion. The
optimal pos tcardiac arres t blood pres s ure remains unknown; however, a mean arterial
pres s ure 65 mm Hg is a reas onable goal.
Im m e d ia t e
Co r o n a r y
Re p e r fu s io n
Wit h P CI
Following ROSC, res cuers s hould trans port the patient to a facility capable of reliably
providing coronary reperfus ion (eg, PCI) and other goal-directed pos tarres t care therapies .
The decis ion to perform PCI can be made irres pective of the pres ence of coma or the
decis ion to induce hypothermia, becaus e concurrent PCI and hypothermia are reported to
be feas ible and s afe and have good outcomes .
Glyc e m ic Co n t r o l
Cons ider s trategies to target moderate glycemic control (144 to 180 mg/dL [8 to 10
mmol/L]) in adult patients with ROSC after cardiac arres t.
Healthcare providers s hould not attempt to alter glucos e concentration within a lower
range (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) due to the increas ed ris k of hypoglycemia.
28
Sys te m s of Ca re
Ne u r o lo g ic Ca r e
a n d P r o g n o s t ic a t io n
The goal of pos tcardiac arres t management is to return patients to their prearres t
functional level. Reliable early prognos tication of neurologic outcome is an es s ential component of pos tcardiac arres t care. Mos t importantly, when cons idering decis ions to limit
or withdraw life-s us taining care, tools us ed to prognos ticate poor outcome mus t be accurate and reliable, with a fals e-pos itive rate approaching 0% .
Ac u t e Co ro n a r y S yn d ro m e s
The primary goals of therapy for patients with ACS are to
1. Reduce the amount of myocardial necros is that occurs in patients with acute
myocardial infarction (AMI), thus pres erving left ventricular (LV) function, preventing
heart failure, and limiting other cardiovas cular complications
2. Prevent major advers e cardiac events (MACE): death, nonfatal MI, and the need for
urgent revas cularization
3. Treat acute, life-threatening complications of ACS, s uch as VF, puls eles s VT, uns table
tachycardias , s ymptomatic bradycardias , pulmonary edema, cardiogenic s hock, and
mechanical complications of AMI
S t a r t s On t h e
P h o n e Wit h
Ac t iva t io n o f EMS
Prompt diagnos is and treatment offers the greates t potential benefit for myocardial
s alvage. Thus , it is imperative that healthcare providers recognize patients with potential
ACS in order to initiate evaluation, appropriate triage, and management as expeditious ly
as pos s ible.
EMS Co m p o n e n t s
Ho s p it a l-Ba s e d
Co m p o n e n t s
Em e rg e nc y d e p a rtm e nt (ED) p ro to c o ls
Activation of the cardiac catheterization laboratory
Admis s ion to the coronary intens ive care unit (ICU)
Quality as s urance, real-time feedback, and healthcare provider education
Em e rg e nc y p hys ic ia n
Empowered to s elect the mos t appropriate reperfus ion s trategy
Empowered to activate the cardiac catheterization team as indicated
Ho s p ita l le a d e rs hip
Mus t be involved in the proces s and committed to s upport rapid acces s to STEMI
reperfus ion therapy
29
P a r t
Ac u t e S t ro k e
The healthcare s ys tem has achieved s ignificant improvements in s troke care through
integration of public education, emergency dis patch, prehos pital detection and triage,
hos pital s troke s ys tem development, and s troke unit management. Not only have the rates
of appropriate fibrinolytic therapy increas ed over the pas t 5 years , but overall s troke care
has als o improved, in part through the creation of s troke centers .
Re g io n a liz a t io n o f
S t r o k e Ca r e
With the National Ins titute of Neurological Dis orders and Stroke (NINDS) recombinant
tis s ue plas minogen activator (rtPA) trial, the crucial need for local partners hips between
academic medical centers and community hos pitals became clear. The time-s ens itive
nature of s troke requires s uch an approach, even in dens ely populated metropolitan
centers .
Co m m u n it y a n d
P r o fe s s io n a l
Ed u c a t io n
Community and profes s ional education is es s ential and has s ucces s fully increas ed the
proportion of s troke patients treated with fibrinolytic therapy.
EMS
The integration of EMS into regional s troke models is crucial for improvement of
patient outcomes :
Patient education efforts are mos t effective when the mes s age is clear and s uccinct.
Educational efforts need to couple the knowledge of the s igns and s ymptoms of
s troke with actionactivate the emergency res pons e s ys tem.
Ed u c a t io n , Im p le m e n t a t io n , a n d Te a m s
The Chain of Survival is a metaphor us ed to organize and des cribe the integrated s et of
time-s ens itive coordinated actions neces s ary to maximize s urvival from cardiac arres t.
The us e of evidence-bas ed education and implementation s trategies can optimize the
links in the chain.
Th e Ne e d fo r Te a m s
Mortality from in-hos pital cardiac arres t remains high. The average s urvival rate is
approximately 21% des pite s ignificant advances in treatments . Survival rates are particularly poor for arres t as s ociated with rhythms other than VF/VT. Non-VF/VT rhythms are
pres ent in >75% of arres ts in the hos pital.
Many in-hos pital arres ts are preceded by eas ily recognizable phys iologic changes , many
of which are evident with routine monitoring of vital s igns . In recent s tudies nearly 80% of
hos pitalized patients with cardiores piratory arres t had abnormal vital s igns documented
for up to 8 hours before the actual arres t. This finding s ugges ts that there is a period of
increas ing ins tability before the arres t.
Of the s mall percentage of in-hos pital cardiac arres t patients who experience ROSC and
are admitted to the ICU, 80% ultimately die before dis charge. In comparis on, only 44% of
nonarres t patients admitted to intens ive care urgently from the floor (ie, before an arres t
occurs ) die before dis charge.
30
Sys te m s of Ca re
Ca r d ia c Ar r e s t
Te a m s (In -Ho s p it a l)
Cardiac arres t teams are unlikely to prevent arres ts becaus e their focus has traditionally
been to res pond only after the arres t has occurred. Unfortunately, the mortality rate is
about 80% once the arres t occurs .
Over the pas t few years , hos pitals have s hifted the focus away from cardiac arres t teams
to patient s afety and prevention of arres t. The bes t way to improve a patients chance of
s urvival from a cardiores piratory arres t is to prevent it from happening.
The majority of cardiores piratory arres ts in the hos pital s hould be clas s ified as a failure to
res cue rather than as an is olated, unexpected, random occurrence. Doing s o requires a
s ignificant cultural s hift within ins titutions . Actions and interventions need to be proactive
with the goal of improving rates of morbidity and mortality rather than reacting to a catas trophic event.
Rapid as s es s ment and intervention for many abnormal phys iologic variables can decreas e
the number of arres ts occurring in the hos pital.
Ra p id Re s p o n s e
S ys t e m
Over the pas t decade, hos pitals in s everal countries have des igned s ys tems to identify
and treat early clinical deterioration in patients . The purpos e of thes e rapid res pons e
s ys tems is to improve patient outcomes by bringing critical care expertis e to patients .
The rapid res pons e s ys tem has s everal components :
Event detection and res pons e triggering arm
A planned res pons e arm, s uch as the RRT
Quality monitoring
Adminis trative s upport
Many rapid res pons e s ys tems allow activation by a nurs e, phys ician, or family member
who is concerned that the patient is deteriorating. Some rapid res pons e s ys tems us e
s pecific phys iologic criteria to determine when to call the team. The following lis t gives
examples of s uch criteria for adult patients :
Threatened airway
Res piratory rate <6 or >30 breaths per minute
Heart rate <40/min or >140/min
Sys tolic blood pres s ure (SBP) <90 mm Hg
Symptomatic hypertens ion
Unexpected decreas e in level of cons cious nes s
Unexplained agitation
Seizure
Significant fall in urine output
Subjective concern about the patient
Me d ic a l Em e r g e n c y
Te a m s a n d Ra p id
Re s p o n s e Te a m s
There are s everal names for rapid res pons e s ys tems , including medical emergency team,
rapid response team, and rapid assessment team.
The rapid res pons e s ys tem is critically dependent on early identification and activation to
immediately s ummon the team to the patients beds ide. Thes e teams typically cons is t of
healthcare providers with both the critical care or emergency care experience and s kills to
s upport immediate intervention for life-threatening s ituations . Thes e teams are res pons ible
for performing a rapid patient as s es s ment and initiating appropriate treatment to revers e
phys iologic deterioration and prevent a poor outcome.
31
P a r t
Re g io n a l S ys t e m s
o f Em e r g e n c y
Ca r d io va s c u la r Ca r e
Hos pitals with larger patient volumes have a better s urvival-tohos pital dis charge rate than
low-volume centers for patients treated for either in- or out-of-hos pital cardiac arres t.
P u b lis h e d S t u d ie s
The majority of publis hed before and after s tudies of METs or rapid res pons e s ys tems
have reported a 17% to 65% drop in the rate of cardiac arres ts after the intervention.
Other documented benefits of thes e s ys tems include
A decreas e in unplanned emergency trans fers to the ICU
Decreas ed ICU and total hos pital length of s tay
Reductions in pos toperative morbidity and mortality rates
Improved rates of s urvival from cardiac arres t
The recently publis hed MERIT trial is the only randomized controlled trial comparing
hos pitals with a MET and thos e without one. The s tudy did not s how a difference in the
compos ite primary outcome (cardiac arres t, unexpected death, unplanned ICU admis s ion) between the 12 hos pitals in which a MET s ys tem was introduced and 11 hos pitals
that had no MET s ys tem in place. Further res earch is needed about the critical details of
implementation and the potential effectivenes s of METs in preventing cardiac arres t or
improving other important patient outcomes .
Im p le m e n t a t io n o f
a Ra p id Re s p o n s e
S ys t e m
Implementing any type of rapid res pons e s ys tem will require a s ignificant cultural change
in mos t hos pitals . Thos e who des ign and manage the s ys tem mus t pay particular attention to is s ues that may prevent the s ys tem from being us ed effectively. Examples of s uch
is s ues are ins ufficient res ources , poor education, fear of calling the team, fear of los ing
control over patient care, and res is tance from team members .
Implementation of a rapid res pons e s ys tem requires ongoing education, impeccable data
collection and review, and feedback. Development and maintenance of thes e programs
requires a long-term cultural and financial commitment from the hos pital adminis tration,
which mus t unders tand that the potential benefits from the s ys tem (decreas ed res ource
us e and improved s urvival rates ) may have independent pos itive financial ramifications .
Hos pital adminis trators and healthcare profes s ionals need to reorient their approach to
emergency medical events and develop a culture of patient s afety with a primary goal of
decreas ing morbidity and mortality.
32
Part
The ACLS Ca s e s
Ove r vie w o f t h e Ca s e s
The ACLS s imulated cas es are des igned to review the knowledge and s kills you need to
s ucces s fully participate in cours e events and pas s the Megacode s kills tes t. Each cas e
contains the following topics :
Introduction
Learning objectives
Rhythms and drugs
Des criptions or definitions of key concepts
Overview of algorithm
Algorithm figure
Application of the algorithm to the cas e
Other related topics
This part contains the following cas es :
Ca s e
Page
34
49
VF/Puls eles s VT
59
78
As ys tole
86
91
Bradycardia
104
114
Stable Tachycardia
124
Acute Stroke
130
33
P a r t
Re s p ir a t o r y Ar re s t Ca s e
In t r o d u c t io n
This cas e reviews appropriate as s es s ment, intervention, and management options for an
unconscious, unresponsive adult patient in respiratory arrest. Respirations are completely
absent or clearly inadequate to maintain effective oxygenation and ventilation. A pulse is
present. (Do not confus e agonal gas ps with adequate res pirations .) The BLS Survey and
the ACLS Survey are us ed even though the patient is in res piratory arres t and not in cardiac arres t.
Le a r n in g Ob je c t ive s
Ca s e Dr u g s
Th e BLS S u r ve y
BLS S u r ve y
As s e s s m e n t
Proceed with the BLS Survey As s es s ment as des cribed on the next page.
Note th a t th e BLS Su rve y foc u s e s on e a rly CP R a n d e a rly d e fib rilla tion .
IV/IO acces s is not dis cus s ed here even though medications may provide a clinical benefit
to s ome patients . Advanced as s es s ments and interventions are part of the ACLS Survey.
As s e s s a n d
Re a s s e s s t h e
P a t ie n t
The s ys tematic approach of the BLS Survey is assessment, then action, for each s tep in
the s equence.
Re m e m b e r: As s e s s th e n p e rform a p p rop ria te a c tion .
In this cas e you as s es s and find that the patient has a puls e, s o you do not us e the AED
or begin ches t compres s ions . During the cours e your ins tructor will emphas ize the need
to reas s es s the patient and be ready to do CPR, attach the AED, and s hock the patient if
indicated.
Ve n t ila t io n a n d
P u ls e Ch e c k
34
In the cas e of a patient in res piratory arres t with a puls e, give 1 breath every 5 to 6
s econds (10 to 12 breaths per minute) with a bag-mas k or any advanced airway device.
Recheck the puls e about every 2 minutes . Take at leas t 5 s econds but no more than 10
s econds for a puls e check.
As s e s s
1
Che c k
re s p o ns ive ne s s
As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )
Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED
Checkthecarotidpuls e.
Defibrillation.
35
P a r t
Ve n t ila t io n Ra t e s
Air w a y De vic e
Ve n t ila t io n s Du r in g
Ca rd ia c Ar re s t
Ba g -m a s k
Any a d va nc e d a irwa y
1 ve ntila tio n e ve ry 6 to 8
s e c o nd s
(8 to 10 breaths per
minute)
Ve n t ila t io n s Du r in g
Re s p ir a t o r y Ar re s t
1 ve ntila tio n e ve ry 5 to 6
s e c o nd s
(10 to 12 breaths per
minute)
Th e ACLS S u r ve y
Air w a y Ma n a g e m e n t
in Re s p ir a t o r y Ar r e s t
If bag-mas k ventilation is adequate, providers may defer ins ertion of an advanced airway.
Healthcare providers s hould make the decis ion to place an advanced airway during the
ACLS Survey.
Advanced airway equipment includes the laryngeal mas k airway, the laryngeal tube, the
es ophageal-tracheal tube, and the ET tube. If it is within your s cope of practice, you may
us e advanced airway equipment in the cours e when appropriate and available.
The following is a s ummary of the ACLS Survey:
As s e s s
Airwa y
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of
airway device confirmed?
Is tube secured and
placement reconfirmed
frequently?
Ac t io n a s Ap p ro p r ia t e
Ma inta in a irwa y p a te nc y in unc o ns c io us p a tie nts
by us e of head tiltchin lift, OPA, or NPA
Us e a d va nc e d a irwa y m a na g e m e nt if ne e d e d
(eg, laryngeal mas k airway, laryngeal tube,
es ophageal-tracheal tube, ET tube)
The benefit of advanced airway placement is weighed
against the adverse effects of interrupting chest
compressions. If bag-mask ventilation is adequate,
healthcare providers may defer insertion of an
advanced airway until the patient fails to respond
to initial CPR and defibrillation or until spontaneous
circulation returns. An advanced airway such as a
laryngeal mask airway, laryngeal tube, or esophagealtracheal tube can be placed while chest compressions continue.
If using advanced airway devices:
Co nfirm p ro p e r inte g ra tio n o f CP R a nd
ve ntila tio n
Co nfirm p ro p e r p la c e m e nt o f a d va nc e d a irwa y
d e vic e s by
Phys ical examination
Quantitative waveform capnography
Clas s I recommendation for ET tube
Reas onable for s upraglottic airways
Se c ure the d e vic e to p re ve nt d is lo d g m e nt
Mo nito r a irwa y p la c e m e nt with c o ntinuo us
q ua ntita tive wa ve fo rm c a p no g ra p hy
(continued)
36
(continued)
As s e s s
Bre a thing
Are ventilation and oxygenation adequate?
Are quantitative waveform
capnography and oxyhemoglobin saturation monitored?
Ac t io n a s Ap p ro p r ia t e
Give s up p le m e nta ry o xyg e n whe n ind ic a te d
For cardiac arres t patients , adminis ter 100%
oxygen
For others , titrate oxygen adminis tration to
achieve oxygen s aturation values of 94% by
puls e oximetry
Mo nito r the a d e q ua c y o f ve ntila tio n a nd o xyg e na tio n b y
Clinical criteria (ches t ris e and cyanos is )
Quantitative waveform capnography
Oxygen s aturation
Avo id e xc e s s ive ve ntila tio n
Mo nito r CP R q ua lity
Quantitative waveform capnography (if P e t c o 2
is <10 mm Hg, attempt to improve CPR quality)
Intra-arterial pres s ure (if relaxation phas e
[dias tolic] pres s ure is <20 mm Hg, attempt to
improve CPR quality)
Atta c h m o nito r/d e fib rilla to r fo r a rrhythm ia s
o r c a rd ia c a rre s t rhythm s (eg, VF, puls eles s VT,
as ys tole, PEA)
De fib rilla tio n/c a rd io ve rs io n
Ob ta in IV/IO a c c e s s
Give a p p ro p ria te d rug s to m a na g e rhythm a nd
b lo o d p re s s ure
Give IV/IO fluid s if ne e d e d
Se a rc h fo r, find , a nd tre a t re ve rs ib le c a us e s
(ie, definitive care)
P e t c o 2 is the partial pres s ure of end-tidal CO 2 , a meas ure of the amount of carbon
dioxide pres ent in the exhaled air.
Ve n t ila t io n s
FYI 2 0 1 0 Gu id e lin e s
Co rre c t P la c e m e nt o f
End o tra c he a l Tub e
In this cas e the patient is in res piratory arres t but continues to have a puls e. You s hould
ventilate the patient o nc e e ve ry 5 to 6 s e c o nd s (10 to 12 times per minute). Each breath
s hould take 1 s econd and achieve vis ible ches t ris e. Be careful to avoid exces s ive ventilation (too many breaths per minute or too large a volume per breath).
37
P a r t
Ma n a g e m e n t o f Re s p ir a t o r y Ar re s t
Ove r vie w
Management of res piratory arres t includes both BLS and ACLS interventions . Thes e
interventions may include
Giving s upplementary oxygen
Opening the airway
Providing bas ic ventilation
Us ing bas ic airway adjuncts (OPA and NPA)
Suctioning
Ac c ord in g to th e 2010 AHA Guid e line s fo r CP R a nd ECC, for p a tie n ts with a p e rfu s in g rh yth m , d e live r 1 b re a th e ve ry 5 to 6 s e c o nd s (10 to 12 b re a th s p e r m in u te ).
Cr it ic a l Co n c e p t s
Avo id ing Exc e s s ive
Ve ntila tio n
When us ing any form of as s is ted ventilation, you mus t avoid delivering exces s ive ventilation (too many breaths per minute or too large a volume per breath).
Exces s ive ventilation can be harmful becaus e it increas es intrathoracic pres s ure,
decreas es venous return to the heart, and diminis hes cardiac output. It may als o
caus e gas tric inflation and predis pos e the patient to vomiting and as piration of gas tric contents .
Givin g S u p p le m e n t a r y Oxyg e n
Ma in t a in Oxyg e n
S a t u r a t io n
Give oxygen to patients with acute cardiac s ymptoms or res piratory dis tres s . Monitor
oxygen s aturation and titrate s upplementary oxygen to maintain a s aturation of 94% .
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for details on us e of
oxygen in patients not in res piratory or cardiac arres t.
Op e n in g t h e Air w a y
Co m m o n Ca u s e o f
Air w a y Ob s t r u c t io n
38
Figure 8 demons trates the anatomy of the airway. The mos t common caus e of upper
airway obs truction in the uncons cious /unres pons ive patient is los s of tone in the throat
mus cles . In this cas e the tongue falls back and occludes the airway at the level of the
pharynx (Figure 9A).
Nas al
Cavity
Nas op harynx
Oral
Cavity
Tongue
Vallecula
Orop harynx
Epiglottis
Vocal Fold
(Cords )
Laryngopharynx
Thyroid
Cartilage
Cricoid
Cartilage
Trachea
Es ophagus
Fig u re 9 . Obs truction of the airway by the tongue and epiglottis . When a patient is unres pons ive, the tongue can obs truct the airway. The head
tiltchin lift relieves obs truction in the unres pons ive patient. A, The tongue is obs tructing the airway. B, The head tiltchin lift lifts the tongue, relieving the obs truction. C, If cervical s pine trauma is s us pected, healthcare providers s hould us e the jaw thrus t without head extens ion.
39
P a r t
Ba s ic Air w a y
Op e n in g Te c h n iq u e s
Bas ic airway opening techniques will effectively relieve airway obs truction caus ed either
by the tongue or from relaxation of mus cles in the upper airway. The bas ic airway opening technique is head tilt with anterior dis placement of the mandible, ie, head tiltchin lift
(Figure 9B).
In the trauma patient with s us pected neck injury, us e a jaw thrus t without head extens ion
(Figure 9C). Becaus e maintaining an open airway and providing ventilation is a priority, us e
a head tiltchin lift maneuver if the jaw thrus t does not open the airway. ACLS providers
s hould be aware that current BLS training cours es teach the jaw thrus t technique to
healthcare providers but not to lay res cuers .
Air w a y Ma n a g e m e n t
Proper airway pos itioning may be all that is required for patients who can breathe s pontaneous ly. In patients who are uncons cious with no cough or gag reflex, ins ert an OPA or
NPA to maintain airway patency.
If you find an uncons cious /unres pons ive patient who was known to be choking and is
now unres pons ive and in res piratory arres t, open the mouth wide and look for a foreign
object. If you s ee one, remove it with your fingers . If you do not s ee a foreign object,
begin CPR. Each time you open the airway to give breaths , open the mouth wide and look
for a foreign object. Remove it with your fingers if pres ent. If there is no foreign object,
res ume CPR.
P ro vid in g Ba s ic Ve n t ila t io n
Ba s ic Air w a y S k ills
Fig u re 1 0 . Mouth-to-mas k ventilation, 1 res cuer. The res cuer performs 1-res cuer CPR from a pos ition
at the patients s ide. Perform a head tiltchin lift to open the airway while holding the mas k tightly agains t
the face.
40
Fig u re 1 1 . E-C clamp technique for holding the mas k while lifting the jaw. Pos ition yours elf at the
patients head. Circle the thumb and firs t finger around the top of the mas k (forming a C) while us ing the
third, fourth, and fifth fingers (forming an E) to lift the jaw.
Fig u re 1 2 . Two-res cuer us e of the bag-mas k. The res cuer at the patients head tilts the patients head
and s eals the mas k agains t the patients face with the thumb and firs t finger of each hand creating a C to
provide a complete s eal around the edges of the mas k. The res cuer us es the remaining 3 fingers (the E)
to lift the jaw (this holds the airway open). The s econd res cuer s lowly s queezes the bag (over 1 s econd)
until the ches t ris es . Both providers s hould obs erve ches t ris e.
41
P a r t
Ba g -Ma s k
Ve n t ila t io n
5
A bag-mas k ventilation device cons is ts of a ventilation bag attached to a face mas k.
Thes e devices have been a mains tay of emergency ventilation for decades . Bag-mas k
devices are the mos t common method of providing pos itive-pres s ure ventilation. When
us ing a bag-mas k device, deliver approximately 600 mL tidal volume s ufficient to produce
ches t ris e over 1 s econd.
The univers al connections pres ent on all airway devices allow you to connect any ventilation bag to numerous adjuncts . Valves and ports may include
One-way valves to prevent the patient from rebreathing exhaled air
Oxygen ports for adminis tering s upplementary oxygen
Medication ports for adminis tering aeros olized and other medications
Suction ports for clearing the airway
Ports for quantitative s ampling of end-tidal CO 2
You can attach other adjuncts to the patient end of the valve, including a pocket face
mas k, laryngeal mas k airway, laryngeal tube, es ophageal-tracheal tube, and ET tube.
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for more information on
bag-mas k ventilation.
The OPA is us ed in patients who are at ris k for developing airway obs truction from the
tongue or from relaxed upper airway mus cles . This J -s haped device (Figure 13A) fits over
the tongue to hold it and the s oft hypopharyngeal s tructures away from the pos terior wall
of the pharynx.
The OPA is us ed in unconscious patients if procedures to open the airway (eg, head tilt
chin lift or jaw thrus t) fail to provide and maintain a clear, unobs tructed airway. An OPA
should not be used in a conscious or semiconscious patient becaus e it may s timulate
gagging and vomiting. The key as s es s ment is to check whether the patient has an intact
cough and gag reflex. If s o, do not us e an OPA.
The OPA may be us ed to keep the airway open during bag-mas k ventilation when providers might unknowingly pus h down on the chin, blocking the airway. The OPA is als o us ed
during s uctioning of the mouth and throat and in intubated patients to prevent them from
biting and occluding the ET tube.
Fig u re 1 3 . Oropharyngeal airways . A, Oropharyngeal airway devices . B, Oropharyngeal airway device ins erted.
42
Te c h n iq u e o f OPA
In s e r t io n
Ste p
Ac t io n
Se le c t the p ro p e r s ize OPA. Place the OPA agains t the s ide of the
face. When the tip of the OPA is at the corner of the mouth, the flange is
at the angle of the mandible. A properly s ized and ins erted OPA res ults
in proper alignment with the glottic opening.
Ins e rt the OPA s o that it curves upward toward the hard palate as it
enters the mouth.
As the OPA pas s es through the oral cavity and approaches the pos terior
wall of the pharynx, ro ta te it 180 into the proper pos ition (Figure 13B).
The OPA can als o be ins erted at a 90 angle to the mouth and then
turned down toward the pos terior pharynx as it is advanced. In both
methods , the goal is to curve the device around the tongue s o that the
tongue is not inadvertently pus hed back into the pharynx rather than
being pulled forward by the OPA.
An a lte rna tive m e tho d is to ins ert the OPA s traight in while us ing a
tongue depres s or or s imilar device to hold the tongue forward as the
OPA is advanced.
After ins ertion of an OPA, monitor the patient. Keep the head and jaw pos itioned properly
to maintain a patent airway. Suction the airway as needed.
Ca u t io n
Be Awa re o f the
Fo llo wing Whe n Us ing
a n OPA
OPAs that are too large may obs truct the larynx or caus e trauma to the laryngeal
s tructures .
OPAs that are too small or ins erted improperly may pus h the bas e of the tongue
pos teriorly and obs truct the airway.
Ins ert the OPA carefully to avoid s oft tis s ue trauma to the lips and tongue.
Remember to us e the OPA only in the unres pons ive patient with no cough or gag
reflex. If the patient has a cough or gag reflex, the OPA may s timulate vomiting and
laryngos pas m.
Ba s ic Air w a y Ad ju n c t s : Na s o p h a r yn g e a l Air w a y
In t r o d u c t io n
The NPA is us ed as an alternative to an OPA in patients who need a bas ic airway management adjunct. The NPA is a s oft rubber or plas tic uncuffed tube (Figure 14A) that provides
a conduit for airflow between the nares and the pharynx.
Unlike oral airways , NPAs may be used in conscious or semiconscious patients (patients
with an intact cough and gag reflex). The NPA is indicated when ins ertion of an OPA is
technically difficult or dangerous . Examples include patients with a gag reflex, tris mus ,
mas s ive trauma around the mouth, or wiring of the jaws . The NPA may als o be us ed in
patients who are neurologically impaired with poor pharyngeal tone or coordination leading to upper airway obs truction.
43
P a r t
Fig u re 1 4 . Nas opharyngeal airways . A, Nas opharyngeal airway devices . B, Nas opharyngeal airway device ins erted.
Te c h n iq u e o f NPA
In s e r t io n
Ste p
1
Ac t io n
Se le c t the p ro p e r s ize NPA.
Compare the outer circumference of the NPA with the inner aperture
of the nares . The NPA s hould not be s o large that it caus es s us tained blanching of the nos trils . Some providers us e the diameter of
the patients s malles t finger as a guide to s electing the proper s ize.
The length of the NPA s hould be the s ame as the dis tance from the
tip of the patients nos e to the earlobe.
Lub ric a te the a irwa y with a wa te r-s o lub le lub ric a nt o r a ne s the tic
je lly.
Ins e rt the a irwa y through the nos tril in a pos terior direction perpendicular to the plane of the face. Pas s it gently along the floor of the nas opharynx (Figure 14B).
If you encounter res is tance:
Slightly rotate the tube to facilitate ins ertion at the angle of the nas al
pas s age and nas opharynx.
Attempt placement through the other nos tril becaus e patients have
different-s ized nas al pas s ages .
Reevaluate frequently. Maintain head tilt by providing anterior dis placement of the mandible us ing a chin lift or jaw thrus t. Mucus , blood, vomit, or the s oft tis s ues of the pharynx
can obs truct the NPA, which has a s mall internal diameter. Frequent evaluation and suctioning of the airway may be necessary to ensure patency.
44
Ca u t io n
Be Awa re o f the
Fo llo wing Whe n
Us ing a n NPA
Fo u n d a t io n a l Fa c t s
P re c a utio ns fo r OPAs
a nd NPAs
S u c t io n in g
In t r o d u c t io n
S o ft vs Rig id
Ca t h e t e r s
Ca t h e t e r
Typ e
Us e fo r
So ft
Rig id
Moreeffectives uctioningoftheoropharynx,particularlyifthereis
thickparticulatematter
45
P a r t
Or o p h a r yn g e a l
S u c t io n in g
P roc e d u re
En d o t r a c h e a l
Tu b e S u c t io n in g
P roc e d u re
Ste p
Ac t io n
Meas ure the catheter before s uctioning and do not ins ert it any further
than the dis tance from the tip of the nos e to the earlobe.
Gently ins ert the s uction catheter or device into the oropharynx
beyond the tongue.
Patients with pulmonary s ecretions may require s uctioning even after endotracheal intubation. Follow the s teps below to perform ET tube s uctioning:
Ste p
Ac t io n
Gently ins ert the catheter into the ET tube. Be s ure the s ide opening is
not occluded during ins ertion.
Ins ertion of the catheter beyond the tip of the ET tube is not recommended becaus e it may injure the endotracheal mucos a or s timulate
coughing or bronchos pas m.
Mon itor th e p a tie n ts h e a rt ra te , p u ls e , oxyg e n s a tu ra tion , a n d c lin ic a l a p p e a ra n c e d u rin g s u c tion in g . If b ra d yc a rd ia d e ve lop s , oxyg e n s a tu ra tion d rop s , or c lin ic a l a p p e a ra n c e d e te riora te s , in te rru p t s u c tion in g a t on c e . Ad m in is te r h ig h -flow
oxyg e n u n til th e h e a rt ra te re tu rn s to n orm a l a n d th e c lin ic a l c on d ition im p rove s .
As s is t ve n tila tion a s n e e d e d .
46
Selection of an advanced airway device depends on the training, s cope of practice, and
equipment of the providers on the res us citation team. Advanced airways include
Laryngeal mas k airway
Laryngeal tube
Es ophageal-tracheal tube
Endotracheal tube
Becaus e a s mall proportion of patients cannot be ventilated with a laryngeal mas k airway,
providers who us e this device s hould have an alternative airway management s trategy. A
bag-mas k can be this alternate s trategy.
This cours e will familiarize you with types of advanced airways . Ins truction in the s killed
placement of thes e airways is beyond the s cope of the bas ic ACLS Provider Cours e. To
be proficient in the us e of advanced airway devices , you mus t have adequate initial training and ongoing experience. Providers who ins ert advanced airways mus t participate in a
proces s of continuous quality improvement to document and minimize complications .
In this cours e you will practice ventilating with an advanced airway in place and integrating ventilation with ches t compres s ions .
Ve n t ila t io n Ra t e s
Ve n t ila t io n s Du r in g
Ca rd ia c Ar re s t
Ve n t ila t io n s Du r in g
Re s p ir a t o r y Ar re s t
Ba g -m a s k
Any a d va nc e d a irwa y
1 ve ntila tio n e ve ry 6 to 8
s e c o nd s
(8 to 10 breaths per
minute)
1 ve ntila tio n e ve ry 5 to 6
s e c o nd s
(10 to 12 breaths per
minute)
Air w a y De vic e
La r yn g e a l Ma s k
Air w a y
La r yn g e a l Tu b e
The advantages of the laryngeal tube are s imilar to thos e of the es ophageal-tracheal tube;
however, the laryngeal tube is more compact and les s complicated to ins ert.
Healthcare profes s ionals trained in the us e of the laryngeal tube may cons ider it as an
alternative to bag-mas k ventilation or endotracheal intubation for airway management in
cardiac arres t. Only experienced providers s hould perform laryngeal tube ins ertion.
See the Laryngeal Intubation s ection on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) for more information on this procedure.
47
P a r t
Es o p h a g e a lTr a c h e a l Tu b e
The es ophageal-tracheal tube is an advanced airway alternative to endotracheal intubation. This device provides adequate ventilation comparable to an ET tube. It is acceptable
to us e the es ophageal-tracheal tube as an alternative to an ET tube for airway management in cardiac arres t. Fatal complications may occur with us e of this device. Only providers experienced with its us e s hould perform es ophageal-tracheal tube ins ertion.
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for more information on
the es ophageal-tracheal tube.
En d o t r a c h e a l Tu b e
A brief s ummary of the bas ic s teps for performing endotracheal intubation is given here to
familiarize the ACLS provider who may as s is t with the procedure.
Prepare for intubation by as s embling the neces s ary equipment.
Perform endotracheal intubation (s ee the Student Webs ite).
Inflate cuff or cuffs on the tube.
Attach the ventilation bag.
Confirm correct placement by phys ical examination and a confirmation device.
Continuous waveform capnography is recommended (in addition to clinical as s es s ment) as the mos t reliable method of confirming and monitoring correct placement
of an ET tube. Healthcare providers may us e colorimetric and nonwaveform carbon
dioxide detectors when waveform capnography is not available.
Secure the tube in place.
Monitor for dis placement.
Only experienced providers s hould perform endotracheal intubation.
See the Endotracheal Intubation s ection on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt) for more information on this procedure.
Ca u t io n
Us e o f Cric o id P re s s ure
FYI 2 0 1 0 Gu id e lin e s
Cric o id P re s s ure
Fo u n d a t io n a l Fa c t s
Re s c ue Bre a ths fo r
CP R With a n Ad va nc e d
Airwa y in P la c e
Cricoid pres s ure in nonarres t patients may offer s ome meas ure of protection to the
airway from as piration and gas tric ins ufflation during bag-mas k ventilation. However,
it als o may impede ventilation and interfere with placement of a s upraglottic airway
or intubation.
The role of cricoid pres s ure during out-of-hos pital and in-hos pital cardiac arres t has
not been s tudied. If cricoid pres s ure is us ed in a few s pecial circums tances during
cardiac arres t, the pres s ure s hould be adjus ted, relaxed, or releas ed if it impedes
ventilation or advanced airway placement. The routine us e of cricoid pres s ure in
cardiac arres t is not recommended.
During CPR the compres s ion-to-ventilation ratio is 30:2. But once an advanced airway is in place (ie, laryngeal mas k airway, laryngeal tube, es ophageal-tracheal tube,
or ET tube), ches t compres s ions are no longer interrupted for ventilations .
When ventilating through a properly placed advanced airway, give 1 breath every 6
to 8 s econds (approximately 8 to 10 breaths per minute) without trying to s ynchronize breaths to compres s ions . Ideally deliver the breath during ches t recoil between
compres s ions . Continuous ly reevaluate compres s ions and ventilations . Be prepared
to make modifications if either is ineffective.
In this cas e the patient has a puls e, and compres s ions are not indicated. Give 1 breath
every 5 to 6 s econds (10 to 12 breaths per minute).
48
P re c a u t io n s fo r Tr a u m a P a t ie n t s
Su m m a r y
When providing as s is ted ventilation for patients with known or s us pected cervical s pine
trauma, avoid unneces s ary s pine movement. Exces s ive head and neck movement in
patients with an uns table cervical s pinal column can caus e irrevers ible injury to the s pinal
cord or wors en a minor s pinal cord injury. Approximately 2% of patients with blunt trauma
s erious enough to require s pinal imaging in the ED have a s pinal injury. This ris k is tripled
if the patient has a head or facial injury. As s ume that any patient with multiple trauma,
head injury, or facial trauma has a s pine injury. Be particularly cautious if a patient has
s us pected cervical s pine injury. Examples are patients who have been involved in a highs peed motor vehicle collis ion, have fallen from a height, or were injured while diving.
Follow thes e precautions if you s us pect cervical s pine trauma:
Open the airway by us ing a jaw thrus t without head extension. Becaus e maintaining a
patent airway and providing adequate ventilation are priorities , us e a head tiltchin lift
maneuver if the jaw thrus t is not effective.
Have another team member s tabilize the head in a neutral pos ition during airway
manipulation. Us e m a n u a l s p in a l m otion re s tric tion ra th e r th a n im m ob iliza tion
d e vic e s . Manual s pinal immobilization is s afer. Cervical collars may complicate airway
management and may even interfere with airway patency.
Spinal immobilization devices are helpful during trans port.
This cas e will provide the knowledge you need to pas s the CPR and AED Tes ting Station.
This cas e dis cus s es how to res pond as a lone res cuer to an out-of-hos pital emergency,
equipped with only CPR s kills and an AED. The cas e s cenario pres ents a patient who
collapses from either VF or pulseless VT. The only equipment available is an AED s tocked
with a pocket face mas k. Becaus e other providers are not pres ent, you mus t care for the
patient without help.
ACLS interventions , including advanced airway control and IV medications , are not
options in this s cenario.
Note that during the cours e you will be required to demons trate both your knowledge of
this cas e and competency in bas ic s kill performance.
Le a r n in g Ob je c t ive s
Rh yt h m s fo r VF
Tr e a t e d Wit h CP R
a n d AED
With an AED, there are no rhythms to learn. The AED will ans wer the ques tion Is the
rhythm s hockable, ie, VF or puls eles s VT?
Dr u g s fo r VF Tr e a t e d
Wit h CP R a n d AED
There are no new drugs to learn in this cas e. You will us e only your CPR s kills and
an AED.
49
P a r t
Th e BLS S u r ve y
In t r o d u c t io n
As s e s s m e n t
Fo u n d a t io n a l Fa c t s
Sta rting CP R Whe n Yo u
Are No t Sure Ab o ut a
P uls e
50
If you are uns ure about the pres ence of a puls e, begin cycles of compres s ions and
ventilations . Unneces s ary compres s ions are les s harmful than failing to provide
compres s ions when needed. Delaying or failing to s tart CPR in a patient without a
puls e reduces the chance of s urvival.
As s e s s
1
Che c k
re s p o ns ive ne s s
As s e s s m e n t Te c h n iq u e a n d Ac t io n
Tapands hout, Are you a ll rig h t?
Checkforabs entorabnormalbreathing(nobreathingor
onlygas ping)bylookingators c a nning the c he s t fo r
m o ve m e nt(about5to10s econds )
Ac tiva te the
e m e rg e nc y
re s p o ns e
s ys te m /g e t
AED
Checkthecarotidpuls e.
Defibrillation.
51
P a r t
Unre s p o ns ive
No b re a thing o r no no rm a l b re a thing
(ie, only gas ping)
Allowcompleteches trecoil
after each compres s ion
Ac tiva te e m e rg e nc y re s p o ns e s ys te m
Ge t AED/d e fib rilla to r
or s end s econd res cuer (if available) to do this
Minimizeinterruptions in
ches t compres s ions
Avoid exces s ive ventilation
De fin it e
P u ls e
Che c k p uls e :
DEFINITE p uls e
within 10 s e c o nd s ?
3A
G ive 1b re a the ve ry
5 to 6 s e c o nd s
R e c he c kp uls e e ve ry
2 m inute s
No P u ls e
5
AED/d e fib rilla to r ARRIVES
Che c k rhythm
Sho c ka b le rhythm ?
S h o c k a b le
7
No t S h o c k a b le
8
Give 1 s ho c k
Re s um e CP R im m e d ia te ly
for 2 minutes
Re s um e CP R im m e d ia te ly
for 2 minutes
Check rhythm every
2 minutes ; continue until
ALS providers take over or
victim s tarts to move
52
Unre s p o ns ive
No b re a thing o r
no no rm a l b re a thing
(o nly g a s p ing )
Ac tiva te
e m e rg e nc y
re s p o ns e
Ge t
d e fib rilla to r
Che c k p uls e
Sta rt CP R
Che c k rhythm /
s ho c k if
ind ic a te d
Re p e a t e ve ry 2 m inute s
Ha
rd P u s h
a
F
53
P a r t
Pu rpos e of
De fib r illa t io n
Defibrillation does not res tart the heart. Defibrillation s tuns the heart and briefly terminates
all electrical activity, including VF and VT. If the heart is s till viable, its normal pacemakers
may eventually res ume electrical activity (return of s pontaneous rhythm) that ultimately
res ults in a perfus ing rhythm (ROSC).
In the firs t minutes after s ucces s ful defibrillation, however, any s pontaneous rhythm is
typically s low and does not create puls es or adequate perfus ion. The patient needs CPR
(beginning with ches t compres s ions ) for s everal minutes until adequate heart function
res umes . This is the rationale for res uming high-quality CPR, beginning with ches t compres s ions immediately after a s hock.
P r in c ip le o f Ea r ly
De fib r illa t io n
The interval from collaps e to defibrillation is one of the mos t important determinants of
s urvival from cardiac arres t. Early defibrillation is critical for patients with s udden cardiac
arres t for the following reas ons :
A common initial rhythm in out-of-hos pital witnes s ed s udden cardiac arres t is VF.
Puls eles s VT rapidly deteriorates to VF. When VF is pres ent, the heart quivers and
does not pump blood.
Electrical defibrillation is the mos t effective way to treat VF (delivery of a s hock to
s top the VF).
The probability of s ucces s ful defibrillation decreas es quickly over time.
VF deteriorates to as ys tole if not treated.
The earlier defibrillation occurs , the higher the s urvival rate. When VF is pres ent, CPR can
provide a s mall amount of blood flow to the heart and brain but cannot directly res tore an
organized rhythm. The likelihood of res toring a perfus ing rhythm is optimized with immediate CPR and defibrilliation within a few minutes of the initial arres t. Res toration of a perfus ing rhythm requires immediate CPR and defibrillation within a few minutes of the initial
arres t (Figure 17).
For every minute that pas s es between collaps e and defibrillation, the chance of s urvival
from a witnes s ed VF s udden cardiac arres t declines by 7% to 10% per minute if no
bys tander CPR is provided. When bys tanders perform CPR, the decline is more gradual
and averages 3% to 4% per minute. CPR performed early can double or triple s urvival
from witnes s ed s udden cardiac arres t at mos t defibrillation intervals .
Lay res cuer AED programs increas e the likelihood of early CPR and attempted defibrillation. This helps s horten the time between collaps e and defibrillation for a greater number
of patients with s udden cardiac arres t.
Co lla p s e
EMS no ti c a tio n
Dis p a tc h o f EMS units
Tim e to CP R
Sta rt o f CP R
Sta rt o f d e b rilla tio n
Re turn o f p e rfus ing rhythm
Tim e to d e nitive c a re
Fig u re 1 7 . Sequence of events and key intervals that occur with cardiac arres t.
Modified from Eis enberg MS, Cummins RO, Damon S, Lars en MP, Hearne TR. Survival rates from outof-hos pital cardiac arres t: recommendations for uniform definitions and data to report. Ann Emerg Med.
1990;19:1249-1259. With permis s ion from Els evier.
54
AED Op e r a t io n
Cr it ic a l Co n c e p t s
Ag o na l g a s p s a re no t a d e q ua te b re a thing .
Ag o na l Ga s p s
A patient who gas ps us ually looks like he is drawing air in very quickly. The patient
may open his mouth and move his jaw, head, or neck. Gas ps may appear forceful
or weak, and s ome time may pas s between gas ps becaus e they us ually happen at a
s low rate. The gas p may s ound like a s nort, s nore, or groan. Gas ping is not regular or
normal breathing. It is a s ign of cardiac arres t in s omeone who does nt res pond.
Kn o w Yo u r AED
You mus t be familiar with the AED us ed in your clinical s etting and be ready to us e it at
any time. Review the troubles hooting checklis t s upplied by the AED manufacturer. Learn
to perform daily maintenance checks . Not only are thes e checks an effective review of the
s teps of operation, but they are als o a means of verifying that the AED is ready for us e.
Th e Un ive r s a l AED:
Co m m o n S t e p s t o
Op e r a t e All AEDs
Once the AED arrives , place it at the patients s ide, next to the res cuer who will operate
it. This pos ition provides ready acces s to the AED controls and eas y placement of electrode pads . It als o allows a s econd res cuer to perform CPR from the oppos ite s ide of the
patient without interfering with AED operation.
AEDs are available in different models . Although there are s mall differences from model to
model, all AEDs operate in bas ically the s ame way. The following table lis ts the 4 univers al
s teps for operating an AED:
Ste p
1
Ac t io n
P o we r o n the AED (this activates voice prompts for guidance in all s ubs equent s teps ).
Open the carrying cas e or the top of the AED.
Turn the power on (s ome devices will power on automatically when you
open the lid or cas e).
P a r t
5
(continued)
Ste p
3
Ac t io n
Ana lyze rhythm .
Always clearthepatientduringanalys is .Bes urenooneis touchingthe
patient,noteventhepers oninchargeofgivingbreaths .
SomeAEDs willins tructyoutopus habuttontoallowtheAEDtobegin
analyzingtheheartrhythm;others willdothatautomatically.TheAED
rhythmanalys is maytakeabout5to15s econds .
TheAEDrhythmanalys is willdetermineifthepatientneeds as hock.
Fig u re 1 8 . AEDelectrodepadplacementonthepatient.
56
Fo u n d a t io n a l Fa c t s
Anterolateral
Anteropos terior
Anterior-left infras capular
Anterior-right infras capular
All 4 pos itions are equally effective in s hock s ucces s and are reas onable for defibrillation. For eas e of placement, anterolateral is a reas onable default electrode placement.
Providers may cons ider alternative pad pos itions bas ed on individual patient characteris tics .
Tr o u b le s h o o t in g
t h e AED
Studies of AED failures have s hown that mos t problems are caus ed by operator error
rather than by AED defects . Operator error is les s likely if the operator is experienced in
us ing the AED, has had recent training or practice with the AED, and is us ing a well-maintained AED.
If the AED does not promptly analyze the rhythm, do the following:
Res ume high-quality ches t compres s ions and ventilations .
Check all connections between the AED and the patient to make s ure that they are
intact.
Ne ve r d e la y c h e s t c om p re s s ion s to trou b le s h oot th e AED.
S h o c k Fir s t vs
CP R Fir s t
When you care for an adult patient in cardiac arres t, s hould you attempt to s hock firs t with
an AED or provide CPR firs t?
Healthcare providers who treat cardiac arres t in hos pitals and other facilities s hould
provide immediate CPR until the AED/defibrillator is ready for us e. Us e the AED as
s oon as it is available.
At this time the benefit of delaying defibrillation to perform CPR before defibrillation
is unclear. EMS s ys tem medical directors may cons ider implementing a protocol that
allows EMS res ponders to provide CPR while preparing for defibrillation of patients
found by EMS pers onnel to be in VF.
FYI 2 0 1 0 Gu id e lin e s
Co o rd ina ting Sho c k
De live ry a nd CP R
The AHA s trongly recommends performing CPR while a defibrillator or AED is readied for us e and while charging for all patients in cardiac arres t.
Res ponders us ing an AED s hould follow the machines voice prompts .
AED Us e in S p e c ia l S it u a t io n s
In t r o d u c t io n
The following s pecial s ituations may require the operator to take extra care in placing the
electrode pads when us ing an AED.
Ha ir y Ch e s t
If the patient has a hairy ches t, the AED pads may s tick to the hair and not to the s kin on
the ches t. If this occurs , the AED will not properly analyze the patients heart rhythm. The
AED will give a check electrodes or check electrode pads mes s age. If this happens ,
complete the following s teps and actions while minimizing interruptions in ches t compres s ions .
57
P a r t
Ste p
Wa t e r
Ac t io n
If the pads s tick to the hair ins tead of the s kin, pres s down firmly on
each pad.
If too much hair remains where you will put the pads , s have the area with the
razor in the AED carrying cas e, if available.
If...
Im p la n t e d
P a c e m a ke r
Th e n ...
Us e the AED
Patients known to be at high ris k for s udden cardiac arres t may have implanted defibrillators /pacemakers that automatically deliver s hocks directly to the heart mus cle if a lifethreatening arrhythmia is detected. You can immediately identify thes e devices becaus e
they create a hard lump beneath the s kin of the upper ches t or abdomen. The lump ranges in s ize from the s ize of a s ilver dollar to half the s ize of a deck of cards , with a s mall
overlying s car. The pres ence of an implanted defibrillator or pacemaker is not a contraindication to attaching and us ing an AED. Avoid placing the AED electrode pads directly over
the device becaus e the devices may interfere with each other.
If you identify an implanted defibrillator/pacemaker:
If pos s ible, place the AED electrode pad to either s ide and not directly on top of the
implanted device.
Follow the normal s teps for operating an AED.
Occas ionally the analys is and s hock cycles of implanted defibrillators and AEDs will conflict. If the implanted defibrillator is delivering s hocks to the patient (the patients mus cles
contract in a manner like that obs erved after an AED s hock), allow 30 to 60 s econds for
the implanted defibrillator to complete the treatment cycle before delivering a s hock from
the AED.
Tr a n s d e r m a l
Me d ic a t io n P a t c h e s
58
Do not place AED electrodes directly on top of a medication patch (eg, a patch of nitroglycerin, nicotine, pain medication, hormone replacement therapy, or antihypertens ive
medication). The medication patch may block the trans fer of energy from the electrode
pad to the heart or caus e s mall burns to the s kin. To prevent thes e complications , remove
the patch and wipe the area clean before attaching the AED electrode pad. Try to minimize
interruptions in ches t compres s ions and do not delay s hock delivery.
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
VF/ P u ls e le s s VT Ca s e
In t r o d u c t io n
This cas e focus es on the as s es s ment and actions us ed for a witnes s ed cardiac arres t due
to VF or puls eles s VT that is refractory (unres pons ive) to the firs t s hock. You will us e a
manual defibrillator in this cas e.
In this cas e and during the cours e you will have an opportunity to demons trate effective
res us citation team behaviors while performing the as s es s ment and action s kills . During
the BLS Survey, team members will perform continuous high-quality CPR with effective
ches t compres s ions and ventilation with a bag-mas k device. The team leader will conduct
the ACLS Survey, including rhythm recognition (s hockable vers us nons hockable), defibrillation us ing a manual defibrillator, res us citation drugs , a dis cus s ion of IV/IO acces s , and
advanced airways .
The success of any resuscitation attempt is built on a strong base of high-quality CPR and
defibrillation when required by the patients ECG rhythm.
Le a r n in g Ob je c t ive s
59
P a r t
Rh yt h m s fo r VF/
P u ls e le s s VT
Dr u g s fo r VF/
P u ls e le s s VT
VF
VT
ECG artifact that looks like VF
New left bundle branch block
Epinephrine
Norepinephrine
Vas opres s in
Amiodarone
Lidocaine
Magnes ium s ulfate
Dopamine
Oxygen
The Cardiac Arres t Algorithm (Figure 19) is the mos t important algorithm to know for adult
res us citation. This algorithm outlines all as s es s ment and management s teps for the puls eles s patient who does not initially res pond to BLS interventions , including a firs t s hock
from an AED. The AHA s implified and redes igned the 2005 algorithm to emphas ize the
importance of minimally interrupted high-quality CPR. The algorithm cons is ts of the 2
pathways for a cardiac arres t:
A s hockable rhythm (VF/puls eles s VT) dis played on the left s ide of the algorithm
A nons hockable rhythm (as ys tole/PEA) dis played on the right s ide of the algorithm
Throughout the cas e dis cus s ion of the Cardiac Arres t Algorithm, we will refer to Boxes 1
through 12. Thes e are the numbers as s igned to the boxes on the algorithm.
VF/ VT
(Le ft S id e )
Becaus e many patients with s udden cardiac arres t demons trate VF at s ome point in their
arres t, it is likely that ACLS providers will frequently follow the left s ide of the Cardiac
Arres t Algorithm (Figure 19). Rapid treatment of VF according to this s equence is the bes t
s cientific approach to res toring s pontaneous circulation.
Puls eles s VT is included in the algorithm becaus e it is treated as VF. VF and puls eles s VT
require CPR until a defibrillator is available. Both are treated with high-energy uns ynchronized s hocks .
60
As ys t o le / P EA
(Rig h t S id e )
The right s ide of the algorithm outlines the s equence of actions to perform if the rhythm is
nons hockable. You will have an opportunity to practice this s equence in the as ys tole and
PEA cas es .
Su m m a r y
The VF/Puls eles s VT Cas e gives you the opportunity to practice performing rapid treatment of VF/VT by following the s teps on the left s ide of the Cardiac Arres t Algorithm
(Boxes 1 through 8).
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
CP R Qua lity
Ad ult Ca rd ia c Arre s t
Sho ut fo r He lp /Ac tiva te Em e rg e nc y Re s p o ns e
compres s ions
Sta rt CP R
30:2 compres s ionYe s
No
Rhythm
s ho c ka b le ?
capnography
ETCO2
VF/VT
attempt to improve
As ys to le /P EA
3
Shoc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
CP R 2 m in
creas e in P ETCO 2
Rhythm
s ho c ka b le ?
No
Sho c k Ene rg y
Ye s
Shoc k
-
10
CP R 2 m in
CP R 2 m in
capnography
360 J
Drug The ra p y
capnography
Va s o p re s s in
Rhythm
s ho c ka b le ?
No
Rhythm
s ho c ka b le ?
Ye s
epinephrine
Ye s
Shoc k
No
Ad va nc e d Airwa y
11
CP R 2 m in
CP R 2 m in
Am io d a ro ne
compres s ions
No
Rhythm
s ho c ka b le ?
Ye s
12
Go to 5 o r 7
10 or 11
Re ve rs ib le Ca us e s
H
H
H
H
Hypothermia
T
T
T
T
T
Fig u re 1 9 .
61
P a r t
FYI 2 0 1 0 Gu id e lin e s
ACLS Ca rd ia c Arre s t
Alg o rithm s
Min im a l In t e r r u p t io n
o f Ch e s t
Co m p r e s s io n s
Ateammembers houldcontinuetoperformhigh-qualityCPRuntilthedefibrillator
arrives andis attachedtothepatient.Theteamleaderas s igns roles andres pons ibilities andorganizes interventions tominimizeinterruptions inches tcompres s ions .This
a ccomplis hes themos tcriticalinterventions forVForpuls eles s VT:CPRwithminimal
interruptions inches tcompres s ions anddefibrillationduringthefirs tminutes ofarres t.
TheAHAdoes notrecommendcontinuedus eofanAED(ortheautomaticmode)when
amanualdefibrillatoris availableandtheproviders s kills areadequateforrhythm
interpretation.Rhythmanalys is ands hockadminis trationwithanAEDmayres ultin
p rolongedinterruptions inches tcompres s ions .
Ch e s t c om p re s s ion s s h ou ld id e a lly b e in te rru p te d on ly for ve n tila tion (u n le s s a n
a d va n c e d a irwa y is p la c e d ), rh yth m c h e c ks , a n d a c tu a l s h oc k d e live ry. P e rform a
p u ls e c h e c k on ly if a n org a n ize d rh yth m is ob s e rve d .
62
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
Fo u n d a t io n a l Fa c t s
Re s um e CP R While
Ma nua l De fib rilla to r Is
Cha rg ing
De live r 1 S h o c k
(Bo x 3 )
Re s u m e CP R (Bo x 4 )
63
P a r t
Fo u n d a t io n a l Fa c t s
Cle a ring fo r De fib rilla tio n
To ens ure s afety during defibrillation, always announce the s hock warning. State
the warning firmly and in a forceful voice before delivering each s hock (this entire
s equence s hould take <5 s econds ):
Cle a r. I a m g o ing to s ho c k o n thre e .
Check to make s ure you are clear of contact with the patient, the s tretcher, or
other equipment.
Make a vis ual check to ens ure that no one is touching the patient or s tretcher.
Be s ure oxygen is not flowing acros s the patients ches t.
One , two , thre e . Sho c king . When pres s ing the SHOCK button, the defibrillator
operator s hould face the patient, not the machine. This helps to ens ure coordination with the ches t compres s or and to verify that no one res umed contact with the
patient.
You need not us e thes e exact words , but you mus t warn others that you are about to
deliver s hocks and that everyone mus t s tand clear of the patient.
Rh yt h m Ch e c k
Conduct a rhythm check after 2 minutes (about 5 cycles ) of CPR. Be careful to minimize
interruptions in ches t compres s ions .
Th e p a u s e in c h e s t c om p re s s ion s to c h e c k th e rh yth m s h ou ld n ot e xc e e d
10 s e c on d s .
If a nons hockable rhythm is pres ent and the rhythm is organized, a team member
s hould try to palpate a puls e. If there is any doubt about the pres ence of a puls e,
immediately res ume CPR.
Re m e m b e r: Perform a pulse checkpreferably during rhythm analysisonly if an
organized rhythm is present.
If the rhythm is organized and there is a palpable puls e, proceed to pos tcardiac
arres t care.
If the rhythm check reveals a nons hockable rhythm and there is no puls e, proceed
along the as ys tole/PEA pathway on the right s ide of the Cardiac Arres t Algorithm
(Boxes 9 through 11).
If the rhythm check reveals a s hockable rhythm, give 1 s hock and res ume CPR immediately for 2 minutes after the s hock (Box 6).
Fo u n d a t io n a l Fa c t s
P a d d le s vs P a d s
Us ing conductive materials during the defibrillation attempt reduces trans thoracic
impedance, or the res is tance that ches t s tructures have on electrical current.
Conductive materials include paddles with electrode pas te, gel pads , or s elfadhes ive pads .
No exis ting data s ugges t that one is better than the others . Self-adhes ive pads ,
however, reduce the ris k of arcing, allow monitoring of the patients underlying
rhythm, and permit the rapid delivery of a s hock if neces s ary.
For thes e reas ons , the AHA recommends routine us e of s elf-adhes ive pads ins tead of
paddles .
64
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
Sh oc k a n d
Va s o p r e s s o r s
(Bo x 6 )
For pers is tent VF/puls eles s VT, give 1 s hock and res ume CPR immediately for 2 minutes
(about 5 cycles ) after the s hock.
Im m e d ia te ly a fte r th e s h oc k, re s u m e CP R, b e g in n in g with c h e s t c om p re s s ion s .
Give 2 m in u te s (a b ou t 5 c yc le s ) of CP R.
When IV/IO acces s is available, give a vas opres s or during CPR (either before or after the
s hock) as follows :
Ep ine p hrine 1 mg IV/IOrepeat every 3 to 5 minutes
or
Va s o p re s s in 40 units IV/IOmay s ubs titute for the firs t or s econd dos e of
epinephrine
Note: If additional team members are available, they s hould anticipate the need for drugs
and prepare them in advance.
Ep ine p hrine hydrochloride is us ed during res us citation primarily for its -adrenergic
effects , ie, vas ocons triction. Vas ocons triction increas es cerebral and coronary blood flow
during CPR by increas ing mean arterial pres s ure and aortic dias tolic pres s ure. In previous
s tudies , es calating and high-dos e epinephrine adminis tration did not improve s urvival to
dis charge or neurologic outcome after res us citation from cardiac arres t.
Va s o p re s s in is a nonadrenergic peripheral vas ocons trictor. A meta-analys is of 5 randomized trials found no difference between vas opres s in and epinephrine for ROSC, 24-hour
s urvival, or s urvival to hos pital dis charge.
Rh yt h m Ch e c k
Conduct a rhythm check after 2 minutes (about 5 cycles ) of CPR. Be careful to minimize
interruptions in ches t compres s ions .
In te rru p tion in CP R to c on d u c t a rh yth m a n a lys is s h ou ld n ot e xc e e d 10 s e c on d s .
If a nons hockable rhythm is pres ent and the rhythm is organized, a team member
s hould try to palpate a puls e. If there is any doubt about the pres ence of a puls e,
immediately res ume CPR.
If the rhythm check is organized and there is a palpable puls e, proceed to pos t
cardiac arres t care.
If the rhythm check reveals a nons hockable rhythm and there is no puls e, proceed
along the as ys tole/PEA pathway on the right s ide of the Cardiac Arres t Algorithm
(Boxes 9 through 11).
If the rhythm check reveals a s hockable rhythm, res ume ches t compres s ions if
indicated while the defibrillator is charging (Box 8). The team leader is res pons ible for
team s afety while compres s ions are being performed and the defibrillator is charging.
Sh oc k a n d
An t ia r r h yt h m ic s
(Bo x 8 )
Give 1 s hock and res ume CPR beginning with ches t compres s ions for 2 minutes (about 5
cycles ) immediately after the s hock.
Healthcare providers may cons ider giving antiarrhythmic drugs , either before or after the
s hock; however, there is no evidence that any antiarrhythmic drug given during cardiac
arres t increas es s urvival to hos pital dis charge. If adminis tered, amiodarone is the firs t-line
antiarrhythmic agent given in cardiac arres t becaus e it has been clinically demons trated
that it improves the rate of ROSC and hos pital admis s ion in adults with refractory VF/
puls eles s VT.
65
P a r t
5
Am io d a ro ne 300mgIV/IObolus ,thencons ideranadditional150mgIV/IOonce
Ifamiodaroneis notavailable,providers mayadminis terlidocaine.
Lid o c a ine 1to1.5mg/kgIV/IOfirs tdos e,then0.5to0.75mg/kgIV/IOat5-to
10-minuteintervals ,toamaximumdos eof3mg/kg
Providers s houldcons idermagnes iums ulfateonlyfortors ades depointes as s ociatedwith
alongQTinterval.
Ma g ne s ium s ulfa te fortors ades depointes ,loadingdos e1to2gIV/IOdilutedin
10mL(eg,D5 W,normals aline)givenas IV/IObolus ,typicallyover5to20minutes
Routineadminis trationofmagnes iums ulfateincardiacarres tis notrecommendedunles s
tors ades depointes is pres ent.
Searchforandtreatanytreatableunderlyingcaus eofcardiacarres t.Seecolumnonthe
rightofthealgorithm.
Ca r d ia c Ar r e s t
Tr e a t m e n t
Se q u e n c e s
Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
Sta rt CP R
Give oxygen
Attach monitor/de brillator
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
2 m inute s
If VF/VT
Sh o c k
n
o
ti
Drug The ra p y
IV/IO acces s
Epinephrine every 3-5 minutes
Amiodarone for refractory VF/VT
ni
su
Co ns id e r Ad va nc e d Airwa y
Quantitative waveform capnography
o
tn
C
Tre a t Re ve rs ib le Ca us e s
Mo
n it o r
CP R Q
P o s tCa rd ia c
Arre s t Ca re
Che c k
Rhythm
CP R Qua lity
P us hhard(2inches [5cm])andfas t(100/min)andallowcomplete
ches trecoil
Minimizeinterruptions incompres s ions
Avoidexces s iveventilation
Rotatecompres s orevery2minutes
Ifnoadvancedairway,30:2compres s ion-ventilationratio
Q uantitativewaveformcapnography
IfP e t c o 2 <10mmHg,attempttoimproveCPRquality
Intra-arterialpres s ure
Ifrelaxationphas e(dias tolic)pres s ure<20mmHg,attemptto
improveCPRquality
it y
l
a
u
Drug The ra p y
E p ine p hrine IV/IODo s e :1mgevery3-5minutes
Va s o p re s s in IV/IODo s e :40units canreplacefirs tors econddos e
ofepinephrine
Amioda rone IV/IODos e :Firstdose:300mgbolus.Seconddose:150mg.
Ad va nc e d Airwa y
S upraglotticadvancedairwayorendotrachealintubation
WaveformcapnographytoconfirmandmonitorETtubeplacement
8 -10breaths perminutewithcontinuous ches tcompres s ions
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary
66
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
FYI 2 0 1 0 Gu id e lin e s
Ca rd ia c Arre s t Circ ula r
Alg o rithm
P h ys io lo g ic
Mo n it o r in g Du r in g
CP R
The 2010 AHA Guidelines for CPR and ECC introduced a new circular format for the
Cardiac Arres t Algorithm (Figure 21) to facilitate learning and memorization of the
treatment recommendations . This new algorithm emphas izes the importance of highquality, minimally interrupted CPR, which is fundamental to the management of all
cardiac arres t rhythms .
The 2010 AHA Guidelines for CPR and ECC recommend us ing quantitative waveform
capnography in intubated patients to monitor CPR quality (Figure 22A), optimize ches t
compres s ions , and detect ROSC during ches t compres s ions (Figure 23) or when rhythm
check reveals an organized rhythm. Although placement of invas ive monitors during CPR
is not generally warranted, phys iologic parameters s uch as intra-arterial relaxation pres s ures (Figure 22A) and central venous oxygen s aturation (Scvo 2 ), when available, may als o
be helpful for optimizing CPR and detecting ROSC.
Animal and human s tudies indicate that P e t c o 2 , CPP, and Scvo 2 monitoring provides valuable information on both the patients condition and the res pons e to therapy. Mos t important, P e t c o 2 , CPP, and Scvo 2 correlate with cardiac output and myocardial blood flow
during CPR. When ches t compres s ions fail to achieve identified thres hold values , ROSC is
rarely achieved. Furthermore, an abrupt increas e in any of thes e parameters is a s ens itive
indicator of ROSC that can be monitored without interrupting ches t compres s ions .
Although no clinical s tudy has examined whether titrating res us citative efforts to phys iologic parameters improves outcome, it is reas onable to us e thes e parameters , if available,
to optimize compres s ions and guide vas opres s or therapy during cardiac arres t.
En d -Tid a l CO 2
The main determinant of P e t c o 2 during CPR is blood delivery to the lungs . Pers is tently
low P e t c o 2 values <10 mm Hg during CPR in intubated patients (Figure 22B) s ugges t that
ROSC is unlikely. If P e t c o 2 abruptly increas es to a normal value of 35 to 40 mm Hg, it is
reas onable to cons ider this an indicator of ROSC.
If the P e t c o 2 is <10 mm Hg during CPR, it is reas onable to try to improve ches t compres s ions and vas opres s or therapy.
67
P a r t
A
g
60
40
20
Time
80
120
40
B
40
60
20
10
0
Time
80
120
40
20
0
Fig u re 2 2 . Phys iologic monitoring during CPR. A, High-quality compres s ions are s hown through waveform capnography and intra-arterial
relaxation pres s ure. P e t c o 2 values <10 mm Hg in intubated patients or intra-arterial relaxation pres s ures <20 mm Hg indicate that cardiac output
is inadequate to achieve ROSC. In either of thos e cas es it is reas onable to cons ider trying to improve quality of CPR by optimizing ches t compres s ion parameters or giving a vas opres s or or both. B, Ineffective CPR compres s ions s hown through waveform capnography and intra-arterial
relaxation pres s ure.
68
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
1-minute interval
50
37.5
25
12.5
0
CPR
ROSC
Fig u re 2 3 . Waveform capnography during CPR with ROSC. This capnography tracing dis plays P e t c o 2
in millimeters of mercury on the vertical axis over time. This patient is intubated and receiving CPR. Note
that the ventilation rate is approximately 8 to 10 breaths per minute. Ches t compres s ions are given continuous ly at a rate s lightly fas ter than 100/min but are not vis ible with this tracing. The initial P e t c o 2 is
<12.5 mm Hg during the firs t minute, indicating very low blood flow. P e t c o 2 increas es to between 12.5 and
25 mm Hg during the s econd and third minutes , cons is tent with the increas e in blood flow with ongoing
res us citation. ROSC occurs during the fourth minute. ROSC is recognized by the abrupt increas e in P e t c o 2
(vis ible jus t after the fourth vertical line) to >50 mm Hg, which is cons is tent with a s ubs tantial improvement
in blood flow.
Tr e a t m e n t o f VF/ VT
in Hyp o t h e r m ia
For a cardiac arres t patient in VF/VT who has s evere hypothermia and a body temperature of <30C (<86F), a s ingle defibrillation attempt is appropriate. If the patient fails to
res pond to the initial s hock, it is reas onable to perform additional defibrillation attempts
according to the us ual BLS guidelines while engaging in active rewarming. The hypothermic patient may have a reduced rate of drug metabolis m, rais ing concern that drug levels
may accumulate to toxic levels with s tandard dos ing regimens . Although the evidence
does not s upport the us e of antiarrhythmic drug therapy in hypothermic patients in cardiac
arres t, it is reas onable to cons ider adminis tration of a vas opres s or according to the s tandard ACLS algorithm concurrent with rewarming s trategies .
ACLS treatment of the patient with s evere hypothermia in cardiac arres t in the hos pital
s hould be aimed at rapid core rewarming.
For patients in cardiac arres t with moderate hypothermia (30C to 34C [86F to 93.2F]),
s tart CPR, attempt defibrillation, give medications s paced at longer intervals , and, if in
hos pital, provide active core rewarming.
Ro u t e s o f Ac c e s s fo r Dr u g s
P r io r it ie s
Priorities during cardiac arres t are high-quality CPR and early defibrillation. Ins ertion of
an advanced airway and drug adminis tration are of s econdary importance. No drug given
during cardiac arres t has been s hown to improve s urvival to hos pital dis charge or improve
neurologic function after cardiac arres t.
His torically in ACLS, providers have adminis tered drugs via either the IV or endotracheal
route. Endotracheal abs orption of drugs is poor and optimal drug dos ing is not known. For
this reas on, the IO route is preferred when IV acces s is not available. Priorities for vas cular
acces s are
IV route
IO route
Endotracheal route
69
P a r t
In t r a ve n o u s Ro u t e
A peripheral IV is preferred for drug and fluid adminis tration unles s central line acces s is
already available.
Central line acces s is not neces s ary during mos t res us citation attempts . Central line acces s
may caus e interruptions in CPR and complications during ins ertion, including vas cular
laceration, hematomas , and bleeding. Ins ertion of a central line in a noncompres s ible ves s el
is a relative (not abs olute) contraindication to fibrinolytic therapy in patients with ACS.
Es tablis hing a peripheral line does not require interruption of CPR. Drugs , however, typically require 1 to 2 minutes to reach the central circulation when given by the peripheral IV
route. Keep in mind that drugs adminis tered during the CPR s equence will likely not take
effect until completion of s everal cycles of CPR.
If a drug is given by the peripheral venous route, adminis ter it as follows :
Give the drug by bolus injection unles s otherwis e s pecified.
Follow with a 20-mL bolus of IV fluid.
Elevate the extremity for about 10 to 20 s econds to facilitate delivery of the drug to
the central circulation.
In t r a o s s e o u s Ro u t e
Drugs and fluids during res us citation can be delivered s afely and effectively via the IO
route if IV acces s is not available. Important points about IO acces s are
IO acces s can be es tablis hed in all age groups .
IO acces s often can be achieved in 30 to 60 s econds .
The IO route of adminis tration is preferred over the endotracheal route.
Any ACLS drug or fluid that is adminis tered IV can be given IO.
IO cannulation provides acces s to a noncollaps ible marrow venous plexus , which s erves
as a rapid, s afe, and reliable route for adminis tration of drugs , crys talloids , colloids , and
blood during res us citation. The technique us es a rigid needle, preferably a s pecially
des igned IO or bone marrow needle from an IO acces s kit.
For more information on IO acces s , s ee the Acces s for Medications s ection on
the Student Webs ite (www.he a rt.o rg /e c c s tud e nt).
En d o t r a c h e a l Ro u t e
IV and IO adminis tration routes are preferred over the endotracheal adminis tration route.
When cons idering adminis tration of drugs via the endotracheal route during CPR, keep
thes e concepts in mind:
The optimal dos e of mos t drugs given by the endotracheal route is unknown.
The typical dos e of drugs adminis tered via the endotracheal route is 2 to 2 times
the IV route.
Studies demons trate that epinephrine, vas opres s in, and lidocaine are abs orbed into the
circulatory s ys tem after adminis tration via the endotracheal route. When giving drugs via
the endotracheal route, dilute the dos e in 5 to 10 mL of s terile water or normal s aline.
Inject the drug directly into the trachea.
Va s o p re s s o r s
In t r o d u c t io n
70
There is no evidence to date that routine us e of any vas opres s or at any s tage during
management of cardiac arres t increas es rates of s urvival to hos pital dis charge. But there
is evidence that the us e of vas opres s ors favors initial res us citation with ROSC.
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
Va s o p r e s s o r s Us e d
Du r in g Ca r d ia c
Ar r e s t
Vas opres s ors optimize cardiac output and blood pres s ure. The vas opres s ors us ed during
cardiac arres t are
Epinephrine: 1 mg IV/IO (repeat every 3 to 5 minutes )
Vas opres s in: 1 dos e of 40 units IV/IO may replace either the firs t or s econd dos e of
epinephrine
If IV/IO acces s cannot be es tablis hed or is delayed, give epinephrine 2 to 2.5 mg diluted
in 5 to 10 mL of s terile water or normal s aline and injected directly into the ET tube.
Remember, the endotracheal route of drug adminis tration res ults in variable and unpredictable drug abs orption and blood levels .
Ep in e p h r in e
Although healthcare providers have us ed epinephrine for years in res us citation, there are
few data to s how that it improves outcome in humans . Epinephrine adminis tration does
appear to improve ROSC. No s tudies demons trate improved rates of s urvival to hos pital
dis charge or neurologic outcome when comparing s tandard epinephrine dos es with initial
high-dos e or es calating dos e epinephrine. Therefore, the AHA cannot recommend the routine us e of high-dos e or es calating dos es of epinephrine.
Epinephrine is thought to s timulate adrenergic receptors , producing vas ocons triction,
increas ing blood pres s ure and heart rate, and improving perfus ion pres s ure to the brain
and heart.
Repeat epinephrine 1 mg IV/IO every 3 to 5 minutes during cardiac arres t.
Re m e m b e r, follow e a c h d os e g ive n b y p e rip h e ra l in je c tion with a 20-m L flu s h
of IV flu id a n d e le va te th e e xtre m ity a b ove th e le ve l of th e h e a rt for 10 to
20 s e c on d s .
Va s o p r e s s in
Fo u n d a t io n a l Fa c t s
Va s o p re s s o rs
Vas opres s in is a nonadrenergic peripheral vas ocons trictor that increas es arterial blood
pres s ure. Becaus e the efficacy of vas opres s in is no different from that of epinephrine in
cardiac arres t, a s ingle dos e of vas opres s in (40 units IV/IO) may replace either the firs t or
s econd dos e of epinephrine.
Becaus e the effects of vas opres s in have not been s hown to differ from thos e of
epinephrine in cardiac arres t, either vas opres s in or epinephrine can be us ed as the
initial vas opres s or during cardiac arres t.
A vas opres s or is given every 3 to 5 minutes during cardiac arres t.
One dos e of vas opres s in 40 units IV/IO may replace either the firs t or s econd dos e
of epinephrine in the treatment of cardiac arres t.
Epinephrine is adminis tered 3 to 5 minutes after the dos e of vas opres s in if there is a
continuing need for a vas opres s or.
An t ia r r h yt h m ic Ag e n t s
In t r o d u c t io n
There is no evidence that any antiarrhythmic drug given routinely during human cardiac
arres t increas es s urvival to hos pital dis charge. Amiodarone, however, has been s hown
to increas e s hort-term s urvival to hos pital admis s ion when compared with placebo or
lidocaine.
71
P a r t
Am io d a r o n e
Lid o c a in e
Ma g n e s iu m S u lfa t e
Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re
In t r o d u c t io n
Ma n a g in g P o s t
Ca r d ia c Ar r e s t Ca r e :
Th e P o s t Ca r d ia c
Ar r e s t Ca r e
Alg o r it h m
72
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
2
Op tim ize ve ntila tio n a nd o xyg e na tio n
Maintainoxygens aturation94%
Cons ideradvancedairwayandwaveformcapnography
Donothyperventilate
3
Tre a t hyp o te ns io n (SBP <90 m m Hg )
IV/IObolus
Vas opres s orinfus ion
Cons idertreatablecaus es
12-LeadECG
5
No
Fo llo w
c o m m a nd s ?
Ye s
7
Ye s
Co ro na ry re p e rfus io n
STEMI
OR
highs us picionofAMI
No
Ad va nc e d c ritic a l c a re
Do s e s /De ta ils
Ve ntila tio n/Oxyg e na tio n
Avoidexces s iveventilation.
Startat10-12breaths /min
andtitratetotargetP e t c o 2
of35-40mmHg.
Whenfeas ible,titrateFio 2
tominimumneces s aryto
achieveSp o 2 94% .
IV Bo lus
1-2Lnormals aline
orlactatedRingers .
Ifinducinghypothermia,
mayus e4Cfluid.
Ep ine p hrine IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcgper
minute)
Do p a m ine IV Infus io n:
5-10mcg/kgperminute
No re p ine p hrine
IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcgper
minute)
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary
Ap p lic a t io n o f t h e Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re Alg o r it h m
In t r o d u c t io n (Bo x 1 )
73
P a r t
Op t im iz e Ve n t ila t io n
a n d Oxyg e n a t io n
(Bo x 2 )
Box 2 directs you to ens ure an adequate airway and s upport breathing immediately after
ROSC. An uncons cious /unres pons ive patient will require an advanced airway for mechanical s upport of breathing.
Us e continuous waveform capnography to confirm and monitor correct placement of
the ET tube (Figures 25 and 26).
Us e the lowes t ins pired oxygen concentration that will maintain arterial oxyhemoglobin s aturation 94% . When titration of ins pired oxygen is not feas ible (eg, in an outof-hos pital s etting), it is reas onable to empirically us e 100% oxygen until the patient
arrives at the ED.
Avoid exces s ive ventilation of the patient (do not ventilate too fas t or too much).
Providers may begin ventilations at 10 to 12 breaths per minute and titrate to achieve
a P e t c o 2 of 35 to 40 mm Hg or a Pa c o 2 of 40 to 45 mm Hg.
If appropriate equipment is available, adjus t the Fio 2 after achieving ROSC to the minimum
concentration needed to achieve arterial oxyhemoglobin s aturation 94% . The goal is to
avoid hyperoxia while ens uring adequate oxygen delivery.
Becaus e an oxygen s aturation of 100% may corres pond to a Pa o 2 between approximately
80 and 500 mm Hg, in general it is appropriate to wean Fio 2 for a s aturation of 100% , provided the patient can maintain oxyhemoglobin s aturation 94% .
40
60
20
Time
40
60
20
Time
40
60
20
Time
C
Fig u re 2 5 . Waveform capnography. A, Normal range of 35 to 45 mm Hg. B, 20 mm Hg. C, 0 mm Hg.
74
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
40
60
20
Time
Fig u re 2 6 . Waveform capnography with an ET tube, s howing normal (adequate) ventilation pattern:
P e t c o 2 35 to 40 mm Hg
Cr it ic a l Co n c e p t s
Wa ve fo rm Ca p no g ra p hy
Ca u t io n
Thing s to Avo id
During Ve ntila tio n
When s ecuring an advanced airway, avoid us ing ties that pas s circumferentially
around the patients neck, thereby obs tructing venous return from the brain.
Exces s ive ventilation may potentially lead to advers e hemodynamic effects when
intrathoracic pres s ures are increas ed and becaus e of potential decreas es in cerebral
blood flow when Pa c o 2 decreas es .
75
P a r t
Fo u n d a t io n a l Fa c t s
Wa ve fo rm Ca p no g ra p hy
FYI 2 0 1 0 Gu id e lin e s
Wa ve fo rm Ca p no g ra p hy
Tr e a t Hyp o t e n s io n
(S BP <9 0 m m Hg )
(Bo x 3 )
End-tidalCO 2 is theconcentrationofcarbondioxideinexhaledairattheendof
expiration.Itis typicallyexpres s edas apartialpres s ureinmillimeters ofmercury
(P e t c o 2 ).Becaus eCO 2 is atracegas inatmos phericair,CO2 detectedbycapnographyinexhaledairis producedinthebodyanddeliveredtothelungs bycirculating
blood.
Cardiacoutputis themajordeterminantofCO2 deliverytothelungs .Ifventilationis
relativelycons tant,P e t c o 2 correlates wellwithcardiacoutputduringCPR.
Providers s houldobs erveapers is tentcapnographicwaveformwithventilationto
confirmandmonitorETtubeplacementinthefield,inthetrans portvehicle,onarrivalatthehos pital,andafteranypatienttrans fertoreducetheris kofunrecognized
tubemis placementordis placement.
Althoughcapnographytoconfirmandmonitorcorrectplacementofs upraglottic
airways (eg,laryngealmas kairway,laryngealtube,ores ophageal-trachealtube)has
notbeens tudied,effectiveventilationthroughas upraglotticairwaydevices hould
res ultinacapnographywaveformduringCPRandafterROSC.
Fo llo w in g Co m m a n d s
(Bo x 4 )
76
Th e ACLS Ca s e s : VF/ P u ls e le s s VT
Th e r a p e u t ic
Hyp o t h e r m ia (Bo x 5 )
To protect the brain and other organs , the res us citation team s hould induce therapeutic
hypothermia in adult patients who remain comatos e (lack of meaningful res pons e to verbal
commands ) with ROSC after out-of-hos pital VF cardiac arres t. When ROSC occurs in the
out-of-hos pital s etting, EMS pers onnel may initiate the cooling proces s and s hould trans port the patient to a facility that reliably provides this therapy.
Healthcare providers s hould cool patients to a target temperature of 32C to 34C for a
period of 12 to 24 hours . Although the optimal method of achieving the target temperature
is unknown, any combination of rapid infus ion of ice-cold, is otonic, nonglucos e-containing fluid (30 mL/kg), endovas cular catheters , s urface cooling devices , or s imple s urface
interventions (eg, ice bags ) appears s afe and effective.
Healthcare providers s hould als o cons ider induced hypothermia for comatos e adult
patients with ROSC after in-hos pital cardiac arres t of any initial rhythm or after out-ofhos pital cardiac arres t with an initial rhythm of PEA or as ys tole.
Ca u t io n
Avo id Ac tive Re wa rm ing
Afte r ROSC
Fo u n d a t io n a l Fa c t s
Ind uc e d Hyp o the rm ia
Therapeutic hypothermia is the only intervention demons trated to improve neurologic recovery after cardiac arres t.
The optimal duration of induced hypothermia is at leas t 12 hours and may be >24
hours . The effect of a longer duration of cooling on outcome has not been s tudied in
adults , but hypothermia for up to 72 hours was us ed s afely in newborns .
Healthcare providers s hould monitor the patients core temperature during induced
hypothermia by us ing an es ophageal thermometer, a bladder catheter in nonanuric
patients , or a pulmonary artery catheter if one is placed for other indications .
Axillary and oral temperatures are inadequate for meas urement of core temperature
changes .
Induced hypothermia s hould not affect the decis ion to perform PCI, becaus e concurrent PCI and hypothermia are reported to be feas ible and s afe.
S TEMI Is P r e s e n t o r
Hig h S u s p ic io n o f
AMI (Bo x 6 )
Both in- and out-of-hos pital medical pers onnel s hould obtain a 12-lead ECG as s oon as
pos s ible after ROSC in order to identify thos e patients with STEMI or a high s us picion of
AMI. Once identified, hos pital pers onnel s hould attempt coronary reperfus ion (Box 7).
EMS pers onnel s hould trans port thes e patients to a facility that reliably provides this
therapy (Box 7).
Co r o n a r y Re p e r fu s io n
(Bo x 7 )
Aggres s ive treatment of STEMI or AMI s hould begin if detected after ROSC, regardles s
of coma or induced hypothermia, including coronary reperfus ion with PCI. In the cas e of
out-of-hos pital STEMI, provide advance notification to receiving facilities for patients diagnos ed with STEMI to reduce reperfus ion delay.
Ad va n c e d Cr it ic a l
Ca r e (Bo x 8 )
Following coronary reperfus ion interventions or in cas es where the pos tcardiac arres t
patient has no ECG evidence or s us picion of MI, the healthcare team s hould trans fer the
patient to an intens ive care unit.
P o s t Ca r d ia c
Ar r e s t Ma in t e n a n c e
Th e r a p y
77
P a r t
P u ls e le s s Ele c t r ic a l Ac t ivit y Ca s e
In t r o d u c t io n
This cas e focus es on as s es s ment and management of a cardiac arrest patient with PEA.
During the BLS Survey, team members will demons trate high-quality CPR with effective
ches t compres s ions and ventilation with a bag-mas k. In the ACLS Survey the team leader
will recognize PEA and implement the appropriate interventions outlined in the Cardiac
Arres t Algorithm. Becaus e correction of an underlying caus e of PEA, if pres ent and identified, is critical to patient outcome, the team leader will verbalize the differential diagnos is
while leading the res us citation team in the s earch for and treatment of revers ible caus es .
Le a r n in g Ob je c t ive s
Rh yt h m s fo r P EA
Dr u g s fo r P EA
De s c r ip t io n o f P EA
In t r o d u c t io n
PEA encompas s es a heterogeneous group of rhythms that are organized or s emiorganized, but lack a palpable puls e. PEA includes
Idioventricular rhythms
Ventricular es cape rhythms
Pos tdefibrillation idioventricular rhythms
Sinus rhythm
Any organized rhythm without a puls e is defined as PEA. Even s inus rhythm without a
detectable puls e is called PEA. Puls eles s rhythms that are excluded by definition include
VF, VT, and as ys tole.
78
His t o r ic a l
P e r s p e c t ive
Ma n a g in g P EA: Th e Ca rd ia c Ar re s t Alg o r it h m
Ove r vie w
As des cribed earlier, the Cardiac Arres t Algorithm cons is ts of 2 cardiac arres t pathways
(Figures 19 and 27). The left s ide of the algorithm outlines treatment for a s hockable
rhythm (VF/VT). The right s ide of the algorithm (Boxes 9 through 11) outlines treatment for
a nons hockable rhythm (as ys tole/PEA). Becaus e of the s imilarity in caus es and management, the Cardiac Arres t Algorithm combines the as ys tole and PEA pathways , although
we will review thes e rhythms in s eparate cas es . In both pathways , therapies are organized
around periods (2 minutes or 5 cycles ) of uninterrupted, high-quality CPR.
The ability to achieve a good res us citation outcome with return of a perfus ing rhythm and
s pontaneous res pirations depends on the ability of the res us citation team to provide effective CPR and to identify and correct a caus e of PEA if pres ent.
Everyone on the res us citation team mus t carry out the s teps outlined in the algorithm and
at the s ame time focus on the identification and treatment of revers ible caus es of
the arres t.
79
P a r t
CP R Qua lity
P us hhard(2 inches
[5cm])andfast
(100/min)andallow
completeches trecoil
Minimizeinterruptions in
compres s ions
Avoidexcessiveventilation
Rotatecompres s orevery
2minutes
Ifnoadvancedairway,
30:2 compres s ionventilationratio
Q uantitativewaveform
capnography
IfP e t c o 2<10mmHg,
attempt to improve
CPRquality
Intra-arterialpres s ure
Ifrelaxationphas e
(dias tolic)pres s ure
<20mmHg,attemp t
toimproveCPRquality
Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
1
Sta rt CP R
G iveoxygen
Attachmonitor/defibrillator
Ye s
No
Rhythm
s ho c ka b le ?
VF/VT
As ys to le /P EA
3
Shoc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
P ulseandbloodpressure
Ab rupts us tained
increas e in P e t c o 2
(typically40mmHg)
S pontaneous arterial
pres s urewaves with
intra-arterialmonitoring
CP R 2 m in
IV/IOacces s
No
Rhythm
s ho c ka b le ?
Ye s
Shoc k
10
CP R 2 m in
IV/IOacces s
E p ine p hrin e every 3-5 min
C ons ideradvancedairway,
capnography
Rhythm
s ho c ka b le ?
CP R 2 m in
No
Ye s
Rhythm
s ho c ka b le ?
Shoc k
No
Ad va nc e d Airwa y
S up raglotticad vanced
airwayorendotracheal
intubation
Waveformcapnography
toconfirmandmonitor
ETtubeplacement
8 -10breathsperminute
withcontinuous ches t
compres s ions
11
CP R 2 m in
CP R 2 m in
Am io d a ro ne
Treatrevers iblecaus es
Treatrevers ib lecaus es
No
Rhythm
s ho c ka b le ?
Ye s
12
Ifnos igns ofreturnof
s pontaneous circulation
(ROSC),goto10 or 11
IfROSC,goto
Pos tCardiacArres tCare
2010 American Heart As s ociation
Drug The ra p y
Epine phrine IV/IO Do s e :
1mgevery3-5minutes
Va s o p re s s in IV/IO Do s e :
40units canreplace
firs torseconddoseof
epinephrine
Am io d a ro ne IV/IO Do s e :
Firstdose:300mgbolus.
Seconddos e:150mg.
Ye s
Sho c k Ene rg y
Bipha s ic :Manufacturer
recommendation
(eg,initialdos eof
120-200J );ifunknown,
us emaximumavailable.
Secondandsubsequent
dosesshouldbeequivalent,andhigherdoses
maybeconsidered.
Mo no p ha s ic : 360 J
Go to 5 o r 7
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary
Th e P EA P a t h w a y o f
t h e Ca r d ia c Ar r e s t
Alg o r it h m
In this cas e the patient is in cardiac arrest. Team members initiate and perform highquality CPR throughout the BLS Survey and the ACLS Survey. The team interrupts CPR
for 10 s econds or les s for rhythm and puls e checks . This patient has an organized rhythm
on the monitor but no pulse. The condition is PEA (Box 9). Ches t compres s ions res ume
immediately. The team leader now directs the team in the s teps outlined in the PEA pathway of the Cardiac Arres t Algorithm (Figure 27), beginning with Box 10.
IV/IO access is a priority over advanced airway management unless bag-mask ventilation is
ineffective or the arrest is caused by hypoxia. All resuscitation team members must simultaneously conduct a search for an underlying and treatable cause of the PEA in addition to
performing their assigned roles.
Rh yt h m Ch e c k :
De c is io n P o in t
Conduct a rhythm check and give 2 minutes (about 5 cycles ) of CPR after adminis tration
of the drugs . Be careful to minimize interruptions in ches t compres s ions .
Th e p a u s e in CP R to c on d u c t a rh yth m c h e c k s h ou ld n ot e xc e e d 10 s e c on d s .
Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )
FYI 2 0 1 0 Gu id e lin e s
No Atro p ine During
Ca rd ia c Arre s t
No n s h o c k a b le
Rh yt h m
(Bo x 1 2 )
De c is io n P o in t :
S h o c k a b le Rh yt h m
If the rhythm check reveals a s hockable rhythm, res ume CPR with ches t compres s ions while the defibrillator is charging if pos s ible.
Switch to the left s ide of the algorithm and perform s teps according to the VF/VT
s equence s tarting with Box 5 or 7.
81
P a r t
As ys t o le a n d
P EA Tr e a t m e n t
Se q u e n c e s
Figure 28 s ummarizes the recommended s equence of CPR, rhythm checks , and delivery
of drugs for PEA and as ys tole bas ed on expert cons ens us .
Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s pons e
Sta rt CP R
Give oxygen
Attach monitor/de brillator
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
2 m inute s
If VF/VT
Sh oc k
Drug The ra p y
IV/IO acces s
Epinephrine every 3-5 minutes
Amiodarone for refractory VF/VT
n
o
ti
ni
su
Co ns id e r Ad va nc e d Airwa y
Quantitative waveform capnography
Mo
n it o r
CP R Q
tn
Tre a t Re ve rs ib le Ca us e s
P o s tCa rd ia c
Arre s t Ca re
Che c k
Rhythm
CP R Qua lity
P us hhard(2inches [5cm])andfas t(100/min)andallowcomplete
ches trecoil
Minimizeinterruptions incompres s ions
Avoidexces s iveventilation
Rotate compres s orevery2minutes
Ifnoadvancedairway,30:2compres s ion-ventilationratio
Q uantitativewaveformcapnography
IfP e t c o 2 <10mmHg,attempttoimproveCPRquality
Intra-arterialpres s ure
Ifrelaxationphas e(dias tolic)pres s ure<20mmHg,atte mptto
improveCPRquality
y
t
i
l
ua
Drug The ra p y
E p ine p hrine IV/IODo s e :1mgevery3-5minutes
Va s o p re s s in IV/IODo s e :40units canreplacefirs tors econddos e
ofepinephrine
Amioda rone IV/IODos e :Firstdose:300mgbolus.Seconddose:150mg.
Ad va nc e d Airwa y
S upraglotticadvancedairwayorendotrachealintubation
WaveformcapnographytoconfirmandmonitorETtubeplacement
8 -10breaths perminutewithcontinuous ches tcompres s ions
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary
Patients with PEA have poor outcomes . Rapid as s es s ment and aggres s ive management
offer the bes t chance of s ucces s . PEA may be caus ed by a revers ible problem. If you can
quickly identify a s pecific condition that has caus ed or is contributing to PEA and correct it, you may achieve ROSC. The identification of the underlying caus e is of paramount
importance in cas es of PEA and as ys tole.
In the s earch for the underlying caus e, do the following:
Cons ider frequent caus es of PEA by recalling the Hs and Ts
Analyze the ECG for clues to the underlying caus e
Recognize hypovolemia
Recognize drug overdos e/pois onings
82
Hs a n d Ts
PEA is as s ociated with many conditions . Healthcare providers s hould memorize the lis t
of common caus es to keep from overlooking an obvious caus e of PEA that might be
revers ed by appropriate treatment.
The mos t common caus es of PEA are pres ented as Hs and Ts in the table below:
Hs
Co n d it io n s a n d
Ma n a g e m e n t
Ts
Hypovolemia
Hypoxia
Tamponade (cardiac)
Toxins
Hyper-/hypokalemia
Thrombos is (pulmonary)
Hypothermia
Thrombos is (coronary)
The factors in the patients his tory and phys ical exam that may help identify revers ible
caus es of PEA have been combined with potentially effective interventions in Table 3.
Co n d it io n
Hyp o vo le m ia
P o t e n t ia l Effe c t ive
In t e r ve n t io n s
Rapid rate
Hyp o xia
Oxygenation, ventilation,
advanced airway
Hyd ro g e n io n (a c id o s is )
Smaller-amplitude QRS
complexes
His tory of diabetes , bicarbonate-res pons ive preexis ting acidos is , renal failure
Ventilation, s odium
bicarbonate
Hyp e rka le m ia
His tory of renal failure, diabetes , recent dialys is , dialys is fis tulas , medications
Hyperkalemia:
Hypokalemia:
or
Hyp o ka le m ia
Hyp o the rm ia
J or Os borne waves
Calcium chloride
Sodium bicarbonate
Glucos e plus ins ulin
Pos s ibly albuterol
(continued)
83
P a r t
(continued)
Co n d it io n
Te ns io n p ne um o tho ra x
Ta m p o na d e , c a rd ia c
Narrow complex
Rapid rate
P o t e n t ia l Effe c t ive
In t e r ve n t io n s
Pericardiocentes is
To xins (d rug o ve rd o s e ):
tric yc lic s , d ig o xin,
-b lo c ke rs , c a lc ium
c ha nne l b lo c ke rs
Intubation, s pecific
antidotes and agents per
toxidrome
Narrow complex
Surgical embolectomy,
fibrinolytics
An a lyz e ECG fo r
Clu e s t o Un d e r lyin g
Ca u s e
Rapid rate
Q waves
ST-s egment changes
T waves , invers ions
The ECG may provide valuable clues to the pos s ible caus es of PEA. Many providers think
that the term PEA refers to the broad, s lurred, s low, and dis organized electrical activity
that bears no s imilarity to a normal P waveQRST wave complex. The ECG, however,
may dis play normal intervals or complexes or both. For example, s inus rhythm due to
hypovolemia or s eps is may pres ent as PEA. Other ECG findings in PEA may include widecomplex QRS.
Reas s es s the monitored rhythm and note the rate and width of the QRS complexes . PEA
with narrow complexes is more likely to have a noncardiac caus e.
Hyp o vo le m ia
Hypovolemia, a common caus e of PEA, initially produces the clas s ic phys iologic res pons e
of a rapid, narrow-complex tachycardia (sinus tachycardia) and typically produces
increas ed dias tolic and decreas ed s ys tolic pres s ures . As los s of blood volume continues ,
blood pres s ure drops , eventually becoming undetectable, but the narrow QRS complexes
and rapid rate continue (ie, PEA).
You s hould cons ider hypovolemia as a caus e of hypotens ion, which can deteriorate to
PEA. Providing prompt treatment can revers e the puls eles s s tate by rapidly correcting
the hypovolemia. Common nontraumatic caus es of hypovolemia include occult internal
hemorrhage and s evere dehydration. Cons ider volume infus ion for PEA as s ociated with a
narrow-complex tachycardia.
84
Ca r d ia c a n d
P u lm o n a r y
Co n d it io n s
ACS involving a large amount of heart mus cle can pres ent as PEA. That is , occlus ion of
the left main or proximal left anterior des cending coronary artery can pres ent with cardiogenic s hock rapidly progres s ing to cardiac arres t and PEA. However, in patients with
cardiac arres t and without known pulmonary embolis m (PE), routine fibrinolytic treatment
given during CPR s hows no benefit and is not recommended.
Mas s ive or s addle PE obs tructs flow to the pulmonary vas culature and caus es acute right
heart failure. In patients with cardiac arres t due to pres umed or known PE, it is reas onable
to adminis ter fibrinolytics .
Cardiac tamponade may be a revers ible condition. Volume infus ion in this condition may
als o help while definitive therapy is initiated. Tens ion pneumothorax can be effectively
treated once recognized.
Note that cardiac tamponade, tens ion pneumothorax, and mas s ive PE cannot be treated
unles s recognized. Beds ide ultras ound, when performed by a s killed provider, may aid in
rapid identification of tamponade and PE. There is growing evidence that pneumothorax
can be identified us ing beds ide ultras ound as well. Treatment for cardiac tamponade may
require pericardiocentes is . Tens ion pneumothorax requires needle as piration and ches t
tube placement. Thes e procedures are beyond the s cope of the ACLS Provider Cours e.
Dr u g Ove r d o s e s
o r To xic Exp o s u r e s
Certain drug overdos es and toxic expos ures may lead to peripheral vas cular dilatation
and/or myocardial dys function with res ultant hypotens ion. Thes e are another caus e of
PEA. The approach to pois oned patients s hould be aggres s ive becaus e the toxic effects
may progres s rapidly and may be of limited duration. In thes e s ituations myocardial dys function and arrhythmias may be revers ible. Numerous cas e reports confirm the s ucces s
of many s pecific limited interventions with one thing in commonthey buy time.
Treatments that can provide this level of s upport include
Prolonged bas ic CPR in s pecial res us citation s ituations
Cardiopulmonary bypas s
Intra-aortic balloon pumping
Renal dialys is
Specific drug antidotes (digoxin immune Fab, glucagon, bicarbonate)
Trans cutaneous pacing (TCP)
Correction of s evere electrolyte dis turbances (potas s ium, magnes ium, calcium,
acidos is )
Specific adjunctive agents (eg, naloxone)
Re m e m b e r, if the p a tie nt s ho ws s ig ns o f ROSC, p o s tc a rd ia c a rre s t c a re s ho uld
b e initia te d .
Cr it ic a l Co n c e p t s
Co m m o n Re ve rs ib le
Ca us e s o f P EA
Hypovolemia and hypoxia are the 2 mos t common and eas ily revers ible caus es of
PEA. Be s ure to look for evidence of thes e problems as you as s es s the patient.
85
P a r t
As ys t o le Ca s e
In t r o d u c t io n
In this cas e the patient is in cardiac arrest. Team members initiate and perform highquality CPR throughout the BLS Survey and the ACLS Survey. The team interrupts CPR
for 10 s econds or les s for a rhythm check. This patient has no pulse and the rhythm on the
monitor is asystole. Ches t compres s ions res ume immediately. The team leader now directs
the team in the s teps outlined in the as ys tole pathway of the Cardiac Arres t Algorithm
(Figure 27, page 80), beginning with Box 10.
IV/IO access is a priority over advanced airway management unless bag-mask ventilation is
ineffective or the arrest is caused by hypoxia. All resuscitation team members must simultaneously conduct a search for an underlying and treatable cause of the asystole in addition to performing their assigned roles.
At the end of this cas e the team will dis cus s the criteria for terminating res us citative
efforts ; in s ome cas es we mus t recognize that the patient is dead and that it would be
more appropriate to direct efforts to s upporting the family.
Le a r n in g Ob je c t ive s
Rh yt h m s fo r As ys t o le
Dr u g s fo r As ys t o le
Ap p ro a c h t o As ys t o le
In t r o d u c t io n
As ys tole is a cardiac arres t rhythm as s ociated with no dis cernible electrical activity on the
ECG (als o referred to as flat line). You s hould confirm that the flat line on the monitor is
indeed true as ys tole by validating that the flat line is
Not another rhythm (eg, fine VF) mas querading as a flat line
Not the res ult of an operator error
86
Th e ACLS Ca s e s : As ys tole
Fo u n d a t io n a l Fa c t s
As ys to le a nd Te c hnic a l
P ro b le m s
As ys tole is a s pecific diagnos is , but flat line is not. The term flat line is nons pecific
and can res ult from s everal pos s ible conditions , including abs ence of cardiac electrical activity, lead or other equipment failure, and operator error. Some defibrillators and
monitors s ignal the operator when a lead or other equipment failure occurs . Some of
thes e problems are not applicable to all defibrillators .
For a patient with cardiac arres t and as ys tole, quickly rule out any other caus es of an
is oelectric ECG, s uch as
Loos e leads or leads not connected to the patient or defibrillator/monitor
No power
Signal gain (amplitude/s ignal s trength) too low
P a t ie n t s Wit h DNAR
Or d e r s
During the BLS Survey and ACLS Survey, you s hould be aware of reas ons to s top or withhold res us citative efforts . Some of thes e are
Rigor mortis
Indicators of DNAR s tatus (eg, bracelet, anklet, written documentation)
Threat to s afety of providers
Out-of-hos pital providers need to be aware of EMS-s pecific policies and protocols applicable to thes e s ituations . In-hos pital providers and res us citation teams s hould be aware
of advance directives or s pecific limits to res us citation attempts that are in place. That is ,
s ome patients may cons ent to CPR and defibrillation but not to intubation or invas ive procedures . Many hos pitals will record this in the medical record.
As ys t o le a s a n
En d P o in t
The prognos is for cardiac arres t with as ys tole is very poor. A large percentage of as ys tolic
patients do not s urvive. Often as ys tole repres ents the final rhythm. Cardiac function has
diminis hed until electrical and functional cardiac activity finally s top and the patient dies .
As ys tole is als o the final rhythm of a patient initially in VF or VT.
Prolonged efforts are unneces s ary and futile unles s s pecial res us citation s ituations exis t,
s uch as hypothermia and drug overdos e.
Ma n a g in g As ys t o le
Ove r vie w
Ca r d ia c Ar r e s t
Alg o r it h m
As des cribed in the VF/Puls eles s VT and PEA Cas es , the Cardiac Arres t Algorithm cons is ts of 2 pathways (Figure 27). The left s ide of the algorithm outlines treatment for a
s hockable rhythm (VF/puls eles s VT). The right s ide of the algorithm (Boxes 9 through 11)
outlines treatment for a nons hockable rhythm (as ys tole/PEA). In both pathways therapies
are des igned around periods (2 minutes or 5 cycles ) of uninterrupted, high-quality CPR. In
this cas e we will focus on the as ys tole component of the as ys tole/PEA pathway.
87
P a r t
Id e n t ific a t io n
a n d Co r r e c t io n o f
Un d e r lyin g Ca u s e
Ap p lic a t io n o f t h e Ca rd ia c Ar re s t Alg o r it h m : As ys t o le P a t h w a y
In t r o d u c t io n
In this cas e you have a patient in cardiac arres t. High-quality CPR is performed throughout the BLS Survey and the ACLS Survey. Interrupt CPR for 10 s econds or les s while you
perform a rhythm check. You interpret the rhythm on the monitor as as ys tole. CPR beginning with ches t compres s ions for 2 minutes res umes immediately. You now conduct the
s teps outlined in the as ys tole pathway of the Cardiac Arres t Algorithm beginning with
Box 9. At the s ame time you are s earching for a pos s ible underlying caus e of the as ys tole.
Co n fir m e d As ys t o le
Give priority to IV/IO acces s . Do not routinely ins ert an advanced airway unles s ventilations with a bag-mas k are ineffective. Do not interrupt CPR while es tablis hing IV or
IO acces s .
Ad m in is t e r
Va s o p r e s s o r s
(Bo x 1 0 )
Continue high-quality CPR, and as s oon as IV/IO acces s is available, give a vas opres s or as follows :
Ep ine p hrine 1 mg IV/IOrepeat every 3 to 5 minutes
or
Va s o p re s s in 40 units IV/IO to replace firs t or s econd dos e of epinephrine
Ad m in is te r d ru g s d u rin g CP R. Do n ot s top CP R to a d m in is te r d ru g s .
You can s ubs titute vas opres s in for either the firs t or s econd dos e of epinephrine.
Cons ider advanced airway and capnography.
FYI 2 0 1 0 Gu id e lin e s
No Atro p ine During
As ys to le
De c is io n P o in t :
Rh yt h m Ch e c k
Although there is no evidence that atropine has detrimental effects during bradycardic or as ys tolic cardiac arres t, routine us e of atropine during PEA or as ys tole is
unlikely to have a therapeutic benefit. The AHA removed atropine from the Cardiac
Arres t Algorithm.
No n s h o c k a b le
Rh yt h m
88
Th e ACLS Ca s e s : As ys tole
S h o c k a b le Rh yt h m
If the rhythm check reveals a s hockable rhythm, prepare to deliver a s hock (res uming
ches t compres s ions during charging if appropriate). Refer to the left s ide of the algorithm
and perform s teps according to the VF/VT s equence, s tarting with Box 5 or 7.
As ys t o le a n d P EA
Tr e a t m e n t S e q u e n c e s
The diagram in Figure 28 (in the previous cas e, PEA) s ummarizes the recommended
s equence of CPR, rhythm checks , and delivery of drugs for PEA and as ys tole bas ed on
expert cons ens us .
TCP No t
Re c o m m e n d e d
Several randomized controlled trials failed to s how benefit from attempted TCP for as ys tole. At this time the AHA does not recommend the us e of TCP for patients with as ys tolic
cardiac arres t.
Ro u t in e S h o c k
Ad m in is t r a t io n No t
Re c o m m e n d e d
Wh e n in Do u b t
Te r m in a t in g Re s u s c it a t ive Effo r t s
Te r m in a t in g
In -Ho s p it a l
Re s u s c it a t ive
Effo r t s
If res cuers cannot rapidly identify a revers ible caus e and the patient fails to res pond to
the BLS and ACLS Surveys and s ubs equent interventions , termination of all res us citative
efforts s hould be cons idered.
The decis ion to terminate res us citative efforts res ts with the treating phys ician in the
hos pital and is bas ed on cons ideration of many factors , including
Time from collaps e to CPR
Time from collaps e to firs t defibrillation attempt
Comorbid dis eas e
Prearres t s tate
Initial arres t rhythm
Res pons e to res us citative meas ures
None of thes e factors alone or in combination is clearly predictive of outcome. However,
the duration of res us citative efforts is an important factor as s ociated with poor outcome.
The chance that the patient will s urvive to hos pital dis charge and be neurologically intact
diminis hes as res us citation time increas es . Stop the res us citation attempt when you determine with a high degree of certainty that the patient will not res pond to further ACLS.
89
P a r t
Te r m in a t in g
Ou t -o f-Ho s p it a l
Re s u s c it a t ive
Effo r t s
Continue out-of-hos pital res us citative efforts until one of the following occurs :
Du r a t io n o f
Re s u s c it a t ive Effo r t s
Available s cientific s tudies demons trate that in the abs ence of mitigating factors , prolonged res us citative efforts are unlikely to be s ucces s ful. The final decis ion to s top res us citative efforts can never be as s imple as an is olated time interval. If ROSC of any duration
occurs , it may be appropriate to cons ider extending the res us citative effort.
Experts have developed clinical rules to as s is t in decis ions to terminate res us citative
efforts for in-hos pital and out-of-hos pital arres ts . You s hould familiarize yours elf with the
es tablis hed policy or protocols for your hos pital or EMS s ys tem.
It may als o be appropriate to cons ider other is s ues , s uch as drug overdos e and s evere
prearres t hypothermia (eg, s ubmers ion in icy water) when deciding whether to extend
res us citative efforts . Special res us citation interventions and prolonged res us citative efforts
may be indicated for patients with hypothermia, drug overdos e, or other potentially revers ible caus es of arres t.
As ys t o le :
An Ag o n a l Rh yt h m
Co n fir m in g
De a t h
Et h ic a l
Co n s id e r a t io n s
The res us citation team mus t make a cons cientious and competent effort to give patients
a trial of CPR and ACLS, provided the patient had not expres s ed a decis ion to forego
res us citative efforts and the victim is not obvious ly dead (eg, rigor mortis , decompos ition,
hemis ection, decapitation) (s ee the DNAR dis cus s ion on the Student Webs ite). The final
decis ion to s top res us citative efforts can never be as s imple as an is olated time interval.
As a terminal rhythm in a res us citation attempt that s tarted with another rhythm
As the firs t rhythm identified in a patient with unwitnes s ed or prolonged arres t
In either of thes e s cenarios , as ys tole mos t often repres ents an agonal rhythm confirming death rather than a rhythm to be treated or a patient who can be res us citated if the
attempt pers is ts long enough. Pers is tent as ys tole repres ents extens ive myocardial is chemia and damage from prolonged periods of inadequate coronary perfus ion. Prognos is
is very poor unles s a s pecial res us citation circums tance or immediately revers ible caus e
is pres ent. Survival from as ys tole is better for in-hos pital than for out-of-hos pital arres ts
according to data from Get With The Guidelines Res us citation, formerly the National
Regis try of CPR (www.he a rt.o rg /re s us c ita tio n).
See Human, Ethical, and Legal Dimens ions of CPR on the Student Webs ite
(www.he a rt.o rg /e c c s tud e nt).
90
Tr a n s p o r t o f P a t ie n t s
in Ca r d ia c Ar r e s t
Emergency medical res pons e s ys tems s hould not require field pers onnel to trans port
every patient in cardiac arres t back to a hos pital or to an ED. Trans portation with continuing CPR is jus tified if interventions available in the ED cannot be performed in the outof-hos pital s etting and they are indicated for s pecial circums tances (ie, cardiopulmonary
bypas s or extracorporeal circulation for patients with s evere hypothermia).
After out-of-hos pital cardiac arres t with ROSC, trans port the patient to an appropriate
hos pital with a comprehens ive pos tcardiac arres t treatment s ys tem of care that includes
acute coronary interventions , neurologic care, goal-directed critical care, and hypothermia.
Trans port the in-hos pital pos tcardiac arres t patient to an appropriate critical care unit
capable of providing comprehens ive pos tcardiac arres t care.
Ac u t e Co ro n a r y S yn d ro m e s Ca s e
In t r o d u c t io n
The ACLS provider mus t have the bas ic knowledge to as s es s and s tabilize patients with
ACS. Patients in this case have signs and symptoms of ACS, including possible AMI. You
will us e the ACS Algorithm as the guide to clinical s trategy.
The initial 12-lead ECG is us ed in all ACS cas es to clas s ify patients into 1 of 3 ECG
categories , each with different s trategies of care and management needs . Thes e 3 ECG
categories are ST-s egment elevation s ugges ting current injury, ST-s egment depres s ion
s ugges ting is chemia, and nondiagnos tic or normal ECG. Thes e are outlined in the ACS
Algorithm, but STEMI with time-s ens itive reperfus ion s trategies is the focus of this cours e
(Figure 30).
Key components of this cas e are
Identification, as s es s ment, and triage of acute is chemic ches t dis comfort
Initial treatment of pos s ible ACS
Emphas is on early reperfus ion of the patient with ACS/STEMI
Le a r n in g Ob je c t ive s
91
P a r t
Rh yt h m s fo r ACS
Sudden cardiac death due to VF and hypotens ive bradyarrythmias occurs with acute is chemia. Providers will unders tand to anticipate thes e rhythms and be prepared for immediate attempts at defibrillation and adminis tration of drug or electrical therapy for s ymptomatic bradyarrhythmias .
Although 12-lead ECG interpretation is beyond the s cope of the ACLS Provider Cours e,
s ome ACLS providers will have 12-lead ECG reading s kills . For them, this cas e s ummarizes the identification and management of patients with STEMI.
Dr u g s fo r ACS
Drug therapy and treatment s trategies continue to evolve rapidly in the field of ACS. ACLS
providers and ins tructors will need to monitor important changes . The ACLS Provider
Cours e pres ents only bas ic knowledge focus ing on early treatment and the priority of
rapid reperfus ion, relief of is chemic pain, and treatment of early life-threatening complications . Reperfus ion may involve the us e of fibrinolytic therapy or coronary angiography with
PCI (ie, balloon angioplas ty/s tenting). When us ed as the initial reperfus ion s trategy for
STEMI, PCI is called primary percutaneous coronary intervention or PPCI.
Treatment of ACS involves the initial us e of drugs to relieve is chemic dis comfort, dis s olve
clots , and inhibit thrombin and platelets . Thes e drugs are
Oxygen
As pirin
Nitroglycerin
Morphine
Fibrinolytic therapy (overview)
Heparin (UFH, LWMH)
Additional agents that are adjunctive to initial therapy and will not be dis cus s ed in the
ACLS Provider Cours e are
-Blockers
Adenos ine diphos phate (ADP) antagonis ts (clopidogrel, pras ugrel)
Angiotens in-converting enzyme (ACE) inhibitors
HMG-CoA reductas e inhibitor (s tatin therapy)
Go a ls fo r ACS P a t ie n t s
Fo u n d a t io n a l Fa c t s
Out-o f-Ho s p ita l Ca rd ia c
Arre s t Re s p o ns e
Half of the patients who die of ACS do s o before reaching the hos pital. VF or puls eles s
VT is the precipitating rhythm in mos t of thes e deaths . VF is mos t likely to develop
during the firs t 4 hours after ons et of s ymptoms .
Communities s hould develop programs to res pond to out-of-hos pital cardiac arres t.
Such programs s hould focus on
Recognizing s ymptoms of ACS
Activating the EMS s ys tem, with EMS advance notification of the receiving hos pital
Providing early CPR
Providing early defibrillation with AEDs available through public acces s defibrillation
programs and firs t res ponders
Providing a coordinated s ys tem of care among the EMS s ys tem, the ED, and
Cardiology
92
FYI 2 0 1 0 Gu id e lin e s
Go a ls o f The ra p y
fo r ACS
P a t h o p h ys io lo g y
o f ACS
Patients with coronary atheros cleros is may develop a s pectrum of clinical s yndromes repres enting varying degrees of coronary artery occlus ion. Thes
s yndromes
include
Ae Uns
tab le plaq
ue uns table
Ea rly(UA),
p la q NSTEMI,
ue fo rm aand
tio nSTEMI. Sudden cardiac death may occur with each of thes e
angina
B Plaq ue rupture
s yndromes . Figure 29 illus trates the pathophys iology of ACS.
C Uns table angina
A AUnsUns
tabletab
plaque
le plaq ue
D
Microemboli
Ea rly p la q ue fo rm a tio n
B Plaque rupture
Plaq
ueive
rupture
EUnsOccus
thrombus
CB
table angina
D CMicroemboli
Uns table angina
Sig ni c a nt p la q ue fo rm a tio n
E Occlus ive thrombus
A D Microemboli
E Occus ive thrombus
Sig ni c a nt p la q ue fo rm a tio n
A
C
D
STEMI
STEMI
Uns ta b le
a ng ina /
D
NSTEMI
Uns ta b le
a ng ina /
NSTEMI
Re s o lutio n /s ta b le a ng ina
Re s o lutio n /s ta b le a ng ina
Fig u re 2 9 . Pathophys iology of ACS.
93
P a r t
Ac ute Co ro na rySynd ro m e s
1
Sym p to m s s ug g e s tive o fis c he m ia o rinfa rc tio n
2
EMSa s s e s s m e nta nd c a re a n d h o s p ita lp re p a ra tio n :
Monitor,s upportABCs .Be prepare dtoprovideCPRanddefibrilla tion
Adminis tera s pirinandcons id eroxyge n,nitroglyc erin,and morphine ifnee ded
O btain12-lea dECG;ifSTelevation:
Notifyre ceivinghos p italwithtrans mis s ionorinterpretation;notetimeof
ons etandfirs tmed ica lconta ct
Notifiedhos pitals houldmobilizehos pitalres ources tores pondtoSTEMI
Ifcons ideringprehos pitalfibrinolys is ,us efibrinolyticchecklis t
3
Co nc urre ntEDa s s e s s m e nt(<10m inute s )
C heckvitals igns ;evaluate oxygens a turation
Es ta blis hIVacce s s
P erformbrie f,targeted his tory,phys ic alexa m
Review/c omp lete fibrinolyticchec klis t;
che ckcontra indications
O btaininitialc ardia cmarkerlevels ,
initiale lectrolyteandcoagulations tudie s
O bta inportableches tx-ra y(<30minute s )
Im m e d ia te EDg e ne ra ltre a tm e nt
IfO 2 s a t<94% ,s tarto xyg e nat4L/min,titrate
As p irin160to325mg(ifnotgive nb yEMS)
Nitro g lyc e rins ublingua lors pray
Mo rp hine IVifdis c omfortnotrelievedby
nitroglycerin
4
ECGinte rp re ta tio n
13
STd e p re s s io no rd yna m ic
T-wa ve inve rs io n;s tro ng ly
s us p ic io us fo ris c he m ia
Hig h-ris kuns ta b le a ng ina /
n o nST-e le va tio n MI(UA/NSTEMI)
No rm a lo rno nd ia g no s tic c ha ng e s
inSTs e g m e nto rTwa ve
Lo w-/inte rm e d ia te -ris kACS
14
7
Tim e fro m o ns e tof
s ym p tom s 12ho urs ?
Co ns id e ra d m is s io n
to EDc he s tp a inunito r
to a p p ro p ria te b e d a nd
fo llo w:
S e ria lcardiacmarkers
(includingtrop onin)
Rep eatECG/continuous
ST-s egmentmonitoring
C ons idernoninvas ive
diagnos ticte s t
10
11
1 2 h ou rs
8
Re p e rfus io n g o a ls :
Therap yde fined b yp atientand
centerc rite ria
Do o r-to b a llo o ninfla tio n (P CI)
g o a lo f90m inute s
Do o r-to -n e e d le (fib rin o lys is )
g o a lo f30m inute s
Ye s
12
De ve lo p s 1o rm o re :
Clinic a lhigh-ris kfe a ture s
Dyna m ic ECGc ha ng e s
c o ns is te ntwithis c he m ia
Tro po nine le va te d
16
Ad m itto m o nito re d b e d
As s e s s ris ks ta tus
Co ntinue ASA,he p a rin,a nd o the r
the ra p ie s a s ind ic a te d
ACEinhibitor/ARB
HMGCoAreduc ta s einhibitor
(s tatintherap y)
Nota thighris k:ca rdiologytoris ks tratify
2010AmericanHeartAs s ociation
94
15
No
Abno rm a ld ia g nos tic
no ninva s ive im a g ing o r
p hys io lo g ic te s ting ?
Ye s
17
No
Ma n a g in g ACS : Th e Ac u t e Co ro n a r y S yn d ro m e s Alg o r it h m
Ove r vie w
o f t h e Alg o r it h m
The Acute Coronary Syndromes Algorithm (Figure 30) outlines the as s es s ment and management s teps for a patient pres enting with s ymptoms s ugges tive of ACS. The EMS
res ponder in the out-of-hos pital environment can begin immediate as s es s ments and
actions . Thes e include giving oxygen, as pirin, nitroglycerin, and morphine if needed, and
obtaining an initial 12-lead ECG (Box 2). Bas ed on the ECG findings , the EMS provider
may complete a fibrinolytic therapy checklis t and notify the receiving ED of a potential
AMI-STEMI when appropriate (Box 3). If out-of-hos pital providers are unable to complete
thes e initial s teps before the patients arrival at the hos pital, the ED provider s hould implement this component of care.
Subs equent treatment occurs on the patients arrival at the hos pital. ED pers onnel s hould
review the out-of-hos pital 12-lead ECG if available. If not performed, acquis ition of the
12-lead ECG s hould be a priority. The goal is to analyze the 12-lead ECG within 10
minutes of the patients arrival in the ED (Box 4). Hos pital pers onnel s hould categorize
patients into 1 of 3 groups according to analys is of the ST s egment or the pres ence of left
bundle branch block (LBBB) on the 12-lead ECG. Treatment recommendations are s pecific
to each group.
STEMI
High-ris k UA/nonST-elevation MI (NSTEMI)
Intermediate/low-ris k UA
The ACS Cas e will focus on the early reperfus ion of the STEMI patient, emphas izing initial
care and rapid triage for reperfus ion therapy.
Im p o r t a n t
Co n s id e r a t io n s
The ACS Algorithm (Figure 30) provides general guidelines that apply to the initial triage
of patients bas ed on s ymptoms and the 12-lead ECG. Healthcare pers onnel often obtain
s erial cardiac markers (CK-MB, cardiac troponins ) in mos t patients that allow additional
ris k s tratification and treatment recommendations . Two important points for STEMI need
emphas is :
The ECG is central to the initial ris k and treatment s tratification proces s .
Healthcare pers onnel do not need evidence of elevated cardiac markers to make a
decis ion to adminis ter fibrinolytic therapy or perform diagnos tic coronary angiography
with coronary intervention (angioplas ty/s tenting) in STEMI patients .
Ap p lic a t io n o f t h e
ACS Alg o r it h m
FYI 2 0 1 0 Gu id e lin e s
ACS Alg o rithm
The AHA introduced changes to the ACS Algorithm to ens ure prompt diagnos is and
treatment. This offers the greates t potential benefit for myocardial s alvage in the firs t
hours of STEMI, and provides early and focus ed management of UA and NSTEMI.
Thes e changes s hould reduce advers e events and improve outcome.
95
P a r t
You s hould know how to identify ches t dis comfort s ugges tive of is chemia. Conduct a
prompt and targeted evaluation of every patient whos e initial complaints s ugges t
pos s ible ACS.
The mos t common s ymptom of myocardial is chemia and infarction is retros ternal ches t
dis comfort. The patient may perceive this dis comfort more as pres s ure or tightnes s than
actual pain.
Symptoms s ugges tive of ACS may als o include
Uncomfortable pres s ure, fullnes s , s queezing, or pain in the center of the ches t las ting
s everal minutes (us ually more than a few minutes )
Ches t dis comfort s preading to the s houlders , neck, one or both arms , or jaw
Ches t dis comfort s preading into the back or between the s houlder blades
Ches t dis comfort with light-headednes s , dizzines s , fainting, s weating, naus ea, or
vomiting
Unexplained, s udden s hortnes s of breath, which may occur with or without ches t
dis comfort
Cons ider the likelihood that the pres enting condition is ACS or one of its potentially lethal
mimics . Other life-threatening conditions that may caus e acute ches t dis comfort are aortic
dis s ection, acute PE, acute pericardial effus ion with tamponade, and tens ion pneumothorax.
S t a r t in g Wit h
Dis p a t c h
All dis patchers and EMS providers mus t receive training in ACS s ymptom recognition
along with the potential complications . Dis patchers , when authorized by medical control or protocol, s hould tell patients with no his tory of as pirin allergy or s igns of active or
recent gas trointes tinal (GI) bleeding to chew an as pirin (160 to 325 mg) while waiting for
EMS providers to arrive.
EMS As s e s s m e n t , Ca re , a n d Ho s p it a l P re p a r a t io n (Bo x 2 )
In t r o d u c t io n
EMS as s es s ment, care, and hos pital preparation are outlined in Box 2. EMS res ponders
may perform the following as s es s ments and actions during the s tabilization, triage, and
trans port of the patient to an appropriate facility:
Monitor and s upport ABCs
Adminis ter as pirin and cons ider oxygen if O 2 s aturation <94% , nitroglycerin, and morphine if dis comfort unres pons ive to nitrates
Obtain a 12-lead ECG; interpret or trans mit for interpretation
Complete a fibrinolytic checklis t if indicated
Provide prearrival notification to the receiving facility if ST elevation
96
Mo n it o r a n d
S u p p o r t ABCs
Ad m in is t e r Oxyg e n
a n d Dr u g s
Providers s hould be familiar with the actions , indications , cautions , and treatment of s ide
effects .
Oxyg e n
EMS providers s hould adminis ter oxyg e n if the patient is dys pneic, is hypoxemic, has
obvious s igns of heart failure, has an arterial oxygen s aturation <94% or the oxygen s aturation is unknown. Providers s hould titrate oxygen therapy to a noninvas ively monitored
oxyhemoglobin s aturation 94% . There is ins ufficient evidence to s upport the routine us e
of oxygen in uncomplicated ACS without s igns of hypoxemia or heart failure or both.
Morp h in e
Give m orp h in e for ches t dis comfort unres pons ive to s ublingual or s pray nitroglycerin if
authorized by protocol or medical control. Morphine is indicated in STEMI when ches t
dis comfort is unres pons ive to nitrates . Us e morphine with caution in UA/NSTEMI becaus e
of an as s ociation with increas ed mortality.
97
P a r t
5
Morphine is an important treatment for ACS becaus e it
Produces central nervous s ys tem analges ia, which reduces the advers e effects of
neurohumoral activation, catecholamine releas e, and heightened myocardial oxygen
demand
Produces venodilation, which reduces left ventricular (LV) preload and oxygen
requirements
Decreas es s ys temic vas cular res is tance, thereby reducing LV afterload
Helps redis tribute blood volume in patients with acute pulmonary edema
Remember, morphine is a venodilator. Like nitroglycerin, us e morphine with caution in
patients who may be preload dependent. If hypotens ion develops , adminis ter fluids as a
firs t line of therapy.
Cr it ic a l Co n c e p t s
P a in Re lie f With
Nitro g lyc e rin
Ca u t io n
Us e o f No ns te ro id a l
Anti-infla m m a to ry Drug s
Ob t a in a
1 2 -Le a d ECG
Relief of pain with nitroglycerin is neither s pecific nor a us eful diagnos tic tool to
determine the etiology of s ymptoms in ED patients with ches t pain or dis comfort. GI
etiologies as well as other caus es of ches t dis comfort can res pond to nitroglycerin
adminis tration. Therefore, the res pons e to nitrate therapy is not diagnos tic of ACS.
EMS providers s hould obtain a 12-lead ECG. The 2010 AHA Guidelines for CPR and ECC
recommends out-of-hos pital 12-lead ECG diagnos tic programs in urban and s uburban
EMS s ys tems .
EMS Ac t io n
Re c o m m e n d a t io n
See the Student Webs ite (www.he a rt.o rg /e c c s tud e nt) for a s ample fibrinolytic
checklis t.
98
Im m e d ia t e ED As s e s s m e n t a n d Tre a t m e n t (Bo x 3 )
In t r o d u c t io n
The healthcare team s hould quickly evaluate the patient with potential ACS on the
patients arrival in the ED. Within the firs t 10 minutes , obtain a 12-lead ECG (if not already
performed before arrival) and as s es s the patient.
Th e 12-le a d ECG is a t th e c e n te r of th e d e c is ion p a th wa y in th e m a n a g e m e n t of
is c h e m ic c h e s t d is c om fort a n d is th e on ly m e a n s of id e n tifyin g STEMI.
A targeted evaluation s hould be performed and focus on ches t dis comfort, s igns and
s ymptoms of heart failure, cardiac his tory, ris k factors for ACS, and his torical features that
may preclude the us e of fibrinolytics . For the patient with STEMI, the goals of reperfus ion
are to give fibrinolytics within 30 minutes of arrival or perform PCI within 90 minutes of
arrival.
Figure 32 s hows how to meas ure ST-s egment deviation.
J point plus
0.04 second
II
ST-segment
baseline
ST-segment deviation
= 5.0 mm
TP s egment
(baseline)
V2
V5
J point
plus 0.04
s econd
ST-s egment
baseline
ST-segment
deviation
= 4.5 mm
TP s egment (baseline)
Fig u re 3 2 . How to meas ure ST-s egment deviation. A, Inferior MI. The ST s egment has no low point (it
is covered or concave). B, Anterior MI.
99
P a r t
P a t ie n t As s e s s m e n t
In <1 0 Min u t e s
(Bo x 3 )
As s es s ment of the patient in the firs t 10 minutes s hould include the following:
Check vital s igns and evaluate oxygen s aturation.
Es tablis h IV acces s .
Take a brief focus ed his tory and perform a phys ical examination.
Complete the fibrinolytic checklis t and check for contraindications , if indicated.
Obtain a blood s ample to evaluate initial cardiac marker levels , electrolytes , and
coagulation.
Obtain and review portable ches t x-ray (<30 minutes after the patients arrival in the
ED). This s hould not delay fibrinolytic therapy for STEMI or activation of the PCI team
for STEMI.
Note: The res ults of cardiac markers , ches t x-ray, and laboratory s tudies s hould not
delay reperfus ion therapy unles s clinically neces s ary, eg, s us pected aortic dis s ection or
coagulopathy.
P a t ie n t Ge n e r a l
Tr e a t m e n t (Bo x 3 )
Unles s allergies or contraindications exis t, 4 agents are routinely recommended for cons ideration in patients with is chemic-type ches t dis comfort:
Oxygen if hypoxemic (O 2 % <94% ) or s igns of heart failure
As pirin
Nitroglycerin
Morphine (if ongoing dis comfort or no res pons e to nitrates )
Becaus e thes e agents may have been given out of hos pital, adminis ter initial or s upplemental dos es as indicated. (See the dis cus s ion of thes e drugs in the previous s ection,
EMS As s es s ment, Care, and Hos pital Preparation.)
Cr it ic a l Co n c e p t s
Oxyg e n, As p irin,
Nitra te s , Mo rp hine
Unles s contraindicated, initial therapy with oxygen if needed, as pirin, nitrates , and, if
indicated, morphine is recommended for all patients s us pected of having is chemic
ches t dis comfort.
The major contraindication to nitroglycerin and morphine is hypotens ion, including
hypotens ion from an RV infarction. The major contraindications to as pirin are true
as pirin allergy and active or recent GI bleeding.
S TEMI (Bo xe s 5 Th ro u g h 8 )
In t r o d u c t io n
Patients with STEMI us ually have complete occlus ion of an epicardial coronary artery.
Th e m a in s ta y of tre a tm e n t for STEMI is e a rly re p e rfu s ion th e ra p y a c h ie ve d with
fib rin olytic s or p rim a ry P CI.
Reperfus ion therapy for STEMI is perhaps the mos t important advancement in treatment
of cardiovas cular dis eas e in recent years . Early fibrinolytic therapy or direct catheterbas ed reperfus ion has been es tablis hed as a s tandard of care for patients with STEMI
who pres ent within 12 hours of ons et of s ymptoms with no contraindications . Reperfus ion
therapy reduces mortality and s aves heart mus cle; the s horter the time to reperfus ion, the
greater the benefit. A 47% reduction in mortality was noted when fibrinolytic therapy was
provided in the firs t hour after ons et of s ymptoms .
100
Cr it ic a l Co n c e p t s
De la y o f The ra p y
Ea r ly Re p e r fu s io n
Th e r a p y
Ge n e r a l Gro u p
De s c r ip t io n
STEMI
STelevation
STdepres s ionordynamicT-wave
invers ion
Normalornondiagnos ticECG
P a r t
5
The ECG clas s ification of is chemic s yndromes is not meant to be exclus ive. A s mall percentage of patients with normal ECGs may be found to have MI, for example. If the initial
ECG is nondiagnos tic and clinical circums tances indicate (eg, ongoing ches t dis comfort),
repeat the ECG.
Us e o f Fib r in o lyt ic
Th e r a p y
A fibrinolytic agent or clot bus ter is adminis tered to patients with J -point ST-s egment
elevation greater than 2 mm (0.2 mV) in leads V2 and V3 and 1 mm or more in all other
leads or by new or pres umed new LBBB (eg, leads III, aVF; leads V3 , V4 ; leads I and aVL)
without contraindications . Fibrin-s pecific agents are effective in achieving normal flow
in about 50% of patients given thes e drugs . Examples of fibrin-s pecific drugs are rtPA,
reteplas e, and tenecteplas e. Streptokinas e was the firs t fibrinolytic us ed widely, but it
is not fibrin s pecific. It is s till the mos t common agent us ed worldwide for acute STEMI
reperfus ion therapy.
Cons iderations for the us e of fibrinolytic therapy are as follows :
In the abs ence of contraindications and in the pres ence of a favorable ris k-benefit
ratio, fibrinolytic therapy is one option for reperfus ion in patients with STEMI and
onset of symptoms within 12 hours of presentation with qualifying ECG findings and if
PCI is not available within 90 minutes of firs t medical contact.
In the abs ence of contraindications , it is als o reas onable to give fibrinolytics to
patients with onset of symptoms within the prior 12 hours and ECG findings cons is tent with true pos terior MI. Experienced providers will recognize this as a condition where ST-s egment depres s ion in the early precordial leads is equivalent to
ST-s egment elevation in others . When thes e changes are as s ociated with other ECG
findings , it is s ugges tive of a STEMI on the pos terior wall of the heart.
Fibrinolytics are generally not recommended for patients pres enting >12 hours after
onset of symptoms. But they may be cons idered if is chemic ches t dis comfort continues with pers is tent ST-s egment elevation.
Do not give fibrinolytics to patients who pres ent >24 hours after the onset of symptoms or patients with ST-s egment depres s ion unles s a true pos terior MI is s us pected.
Us e o f P CI
The mos t commonly us ed form of PCI is coronary intervention with s tent placement.
Primary PCI is us ed as an alternative to fibrinolytics . Rescue PCI is us ed early after fibrinolytics in patients who may have pers is tent occlus ion of the infarct artery (failure to reperfus e with fibrinolytics ), although this term has been recently replaced and included by the
term pharmacoinvasive strategy. PCI has been s hown to be s uperior to fibrinolys is in the
combined end points of death, s troke, and reinfarction in many s tudies for patients pres enting between 3 and 12 hours after ons et. However, thes e res ults have been achieved
in experienced medical s ettings with s killed providers (performing >75 PCIs per year) at a
s killed PCI facility (performing >200 PCIs for STEMI with cardiac s urgery capabilities ).
Cons iderations for the us e of PCI include the following:
At the time of publication of the 2010 AHA Guidelines for CPR and ECC, percutaneous coronary intervention is the treatment of choice for the management of STEMI
when it can be performed effectively with a door-to-balloon time of <90 minutes from
firs t medical contact by a s killed provider at a s killed PCI facility.
Primary PCI may als o be offered to patients pres enting to non-PCI centers if PCI can
be initiated promptly within 90 minutes from EMS arrivalto-balloon time at the PCIcapable hos pital. The TRANSFER AMI (Trial of Routine Angioplas ty and Stenting After
Fibrinolys is to Enhance Reperfus ion in Acute Myocardial Infarction) trial s upports the
trans fer of high-ris k patients who receive fibrinolys is in a non-PCI center witihin 12
hours of s ymptom ons et to a PCI center within 6 hours of fibrinolytic adminis tration to
receive routine early PCI.
102
Ad ju n c t ive
Tr e a t m e n t s
Tre a t m e n t Go a l
Ma n a g e m e n t
Re lie f o f is c he m ic c he s t d is c o m fo rt
Titratetoeffect
KeepSBP>90mmHg
LimitdropinSBPto30mmHgbelow
bas elineinhypertens ivepatients
Im p ro ve m e nt in p ulm o na ry e d e m a a nd
hyp e rte ns io n
Titratetoeffect
LimitdropinSBPto10% ofbas elinein
normotens ivepatients
LimitdropinSBPto30mmHgbelow
bas elineinhypertens ivepatients
103
P a r t
He p a rin
Heparin is routinely given as an adjunct for PCI and fibrinolytic therapy with fibrin-s pecific
agents (rtPA, reteplas e, tenecteplas e). It is als o indicated in other s pecific high-ris k s ituations , s uch as LV mural thrombus , atrial fibrillation, and prophylaxis for pulmonary thromboembolis m in patients with prolonged bed res t and heart failure complicating MI. If you
us e thes e drugs you mus t be familiar with dos ing s chedules for s pecific clinical s trategies .
Th e in a p p rop ria te d os in g a n d m on itorin g of h e p a rin th e ra p y h a s c a u s e d e xc e s s
in tra c e re b ra l b le e d in g a n d m a jor h e m orrh a g e in STEMI p a tie n ts . P rovid e rs u s in g
h e p a rin n e e d to kn ow th e in d ic a tion s , d os in g , a n d u s e in th e s p e c ific ACS c a te g orie s .
Th e d os in g , u s e , a n d d u ra tion h a ve b e e n d e rive d from u s e in c lin ic a l tria ls .
Sp e c ific p a tie n ts m a y re q u ire d os e m od ific a tion . Se e th e ECC Ha n d b ook for
we ig h t-b a s e d d os in g g u id e lin e s , in te rva ls of a d m in is tra tion , a n d a d ju s tm e n t (if
n e e d e d ) in re n a l fu n c tion . Se e th e ACC/ AHA Gu id e lin e s for d e ta ile d d is c u s s ion in
s p e c ific c a te g orie s .
Br a d yc a rd ia Ca s e
In t r o d u c t io n
This cas e dis cus s es as s es s ment and management of a patient with symptomatic bradycardia (heart rate <50/min).
The corners tones of managing bradycardia are to
Differentiate between s igns and s ymptoms that are caus ed by the s low rate vers us
thos e that are unrelated
Correctly diagnos e the pres ence and type of AV block
Us e atropine as the drug intervention of firs t choice
Decide when to s tart TCP
Decide when to s tart epinephrine or dopamine to maintain heart rate and blood pres s ure
Know when to call for expert cons ultation regarding complicated rhythm interpretation, drugs , or management decis ions
In addition, you mus t know the techniques and cautions for us ing TCP.
Le a r n in g Ob je c t ive s
104
Th e ACLS Ca s e s : Bra d yc a rd ia
Rh yt h m s fo r
Br a d yc a r d ia
105
P a r t
E
Fig u re 3 3 . Examples of AV block. A, Sinus bradycardia with borderline firs t-degree AV block. B, Second-degree AV block type I. C, Seconddegree AV block type II. D, Complete AV block with a ventricular es cape pacemaker (wide QRS: 0.12 to 0.14 s econd). E, Third-degree AV block
with a junctional es cape pacemaker (narrow QRS: <0.12 s econd).
Dr u g s fo r
Br a d yc a r d ia
106
Th e ACLS Ca s e s : Bra d yc a rd ia
De s c r ip t io n o f Br a d yc a rd ia
De fin it io n s
Te r m
De fin it io n
Bra d ya rrhythm ia o r b ra d yc a rd ia *
*For the purpos es of this cas e we will us e the term bradycardia interchangeably with
bradyarrhythmia unles s s pecifically defined.
S ym p t o m a t ic
Br a d yc a r d ia
Sinus bradycardia may have multiple caus es . Some are phys iologic and require no
as s es s ment or therapy. For example, a well-trained athlete may have a heart rate in the
range of 40 to 50/min or occas ionally lower.
In contras t, s ome patients have heart rates in the normal s inus range, but thes e heart
rates are inappropriate or ins ufficient for them. This is called a functional or relative
bradycardia. For example, a heart rate of 70/min is too s low for a patient in cardiogenic
or s eptic s hock.
This cas e will focus on the patient with a bradycardia and heart rate <50/min. Key to the
cas e management is the determination of s ymptoms or s igns due to the decreas ed heart
rate. A s ymptomatic bradycardia exis ts clinically when 3 criteria are pres ent:
1. The heart rate is s low.
2. The patient has s ymptoms .
3. The s ymptoms are due to the s low heart rate.
S ig n s a n d S ym p t o m s
You mus t perform a focus ed his tory and phys ical examination to identify the s igns and
s ymptoms of a bradycardia.
Symptoms include ches t dis comfort or pain, s hortnes s of breath, decreas ed level of cons cious nes s , weaknes s , fatigue, light-headednes s , dizzines s , and pres yncope or s yncope.
Signs include hypotens ion, drop in blood pres s ure on s tanding (orthos tatic hypotens ion),
diaphores is , pulmonary conges tion on phys ical examination or ches t x-ray, frank conges tive heart failure or pulmonary edema, and bradycardia-related (es cape) frequent premature ventricular complexes or VT.
107
P a r t
Ma n a g in g Br a d yc a rd ia : Th e Br a d yc a rd ia Alg o r it h m
Ove r vie w o f t h e
Alg o r it h m
The Bradycardia Algorithm (Figure 34) outlines the s teps for as s es s ment and manage ment
of a patient pres enting with s ymptomatic bradycardia with puls e. Implementation of this
algorithm begins with the identification of bradycardia (Box 1); the heart rate is
<50/min. Firs t s teps include the components of the BLS Survey and the ACLS Survey,
s uch as s upporting circulation and airway management, giving oxygen, monitoring the
rhythm and vital s igns , es tablis hing IV acces s , and obtaining a 12-lead ECG if available
(Box 2). In the differential diagnos is you determine if the patient has s igns or s ymptoms of
poor perfus ion and if thes e are caus ed by the bradycardia (Box 3).
The primary decis ion point in the algorithm is the determination of adequate perfus ion. If
the patient has adequate perfus ion, you obs erve and monitor (Box 4). If the patient has
poor perfus ion, you adminis ter atropine (Box 5). If atropine is ineffective, prepare for TCP
or cons ider dopamine or epinephrine infus ion (Box 5). If indicated, you prepare for trans venous pacing, s earch for and treat contributing caus es , and s eek expert cons ultation
(Box 6).
The treatment s equence in the algorithm is determined by the s everity of the patients
condition. You may need to implement multiple interventions s imultaneous ly. If cardiac
arres t develops , go to the Cardiac Arres t Algorithm.
108
Th e ACLS Ca s e s : Bra d yc a rd ia
Ad ult Bra d yc a rd ia
(With Puls e)
2
Id e ntify a nd tre a t und e rlying c a us e
Maintainpatentairway;as s is tbreathingas neces s ary
Oxygen(ifhypoxemic)
Cardiacmonitortoidentifyrhythm;monitorbloodpres s ureandoximetry
IVacces s
12-LeadECGifavailable;dontdelaytherapy
3
P e rs is te nt b ra d ya rrhythm ia
c a us ing :
4
Mo nito r a nd o b s e rve
No
Hypotens ion?
Acutely altered mental s tatus ?
Signs of s hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s
Atro p ine
Ifatropineineffective:
Trans cutaneous pacing
OR
Do p a m ine infus ion
OR
Ep ine p hrine infus ion
Do s e s /De ta ils
Atro p ine IV Do s e :
Firs tdos e:0.5mgbolus
Repeatevery3-5minutes
Maximum:3mg
Do p a m ine IV Infus io n:
2-10mcg/kgperminute
Ep ine p hrine IV Infus io n:
2-10mcgperminute
6
Co ns id e r:
Expertcons ultation
Trans venous pacing
2010 American Heart As s ociation
Fig u re 3 4 . TheBradycardiaAlgorithm.
FYI 2 0 1 0 Gu id e lin e s
The Bra d yc a rd ia
Alg o rithm
Ap p lic a t io n o f t h e Br a d yc a rd ia Alg o r it h m
In t r o d u c t io n
P a r t
Id e n t ific a t io n o f
Br a d yc a r d ia (Bo x 1 )
BLS a n d ACLS
S u r ve ys (Bo x 2 )
Ar e S ig n s o r
S ym p t o m s Ca u s e d
b y Br a d yc a r d ia ?
(Bo x 3 )
Monitor blood pres s ure and heart rate; obtain and review a 12-lead ECG; es tablis h IV acces s .
Conduct a problem-focus ed his tory and phys ical examination; s earch for and
treat pos s ible contributing factors .
Box 3 prompts you to cons ider if the s igns or s ymptoms of poor perfus ion are caus ed by
the bradycardia.
The key clinical ques tions are
Are there s erious s igns or s ymptoms ?
Are the s igns and s ymptoms related to the s low heart rate?
Look for advers e s igns and s ymptoms of the bradycardia:
Symptoms (eg, ches t dis comfort, s hortnes s of breath, decreas ed level of cons cious nes s , weaknes s , fatigue, light-headednes s , dizzines s , pres yncope or s yncope)
Signs (eg, hypotens ion, conges tive heart failure, ventricular arrhythmias related to the
bradycardia)
Sometimes the s ymptom is not due to the bradycardia. For example, hypotens ion as s ociated with bradycardia may be due to myocardial dys function rather than the bradycardia. Keep this in mind when you reas s es s the patients res pons e to treatment.
Cr it ic a l Co n c e p t s
Bra d yc a rd ia
The key clinical ques tion is whether the bradycardia is caus ing the patients s ymptoms or s ome other illnes s is caus ing the bradycardia.
De c is io n P o in t :
Ad e q u a t e P e r fu s io n ?
You mus t now decide if the patient has adequate or poor perfus ion.
Tr e a t m e n t S e q u e n c e
S u m m a r y (Bo x 5 )
If the patient has poor perfus ion s econdary to bradycardia, the treatment s equence is as
follows :
If the patient has a d e q u a te p e rfu s ion , obs erve and monitor (Box 4).
If the patient has p oor p e rfu s ion , proceed to Box 5.
If a t ro p in e is in e ffe c t ive
Trans cutaneous pacing
or
110
Th e ACLS Ca s e s : Bra d yc a rd ia
The treatment s equence is determined by the s everity of the patients clinical pres entation.
For patients with s ymptomatic bradycardia, move quickly through this s equence. Thes e
patients may be precardiac arres t and may need multiple interventions s imultaneous ly.
Tr e a t m e n t S e q u e n c e :
At r o p in e
In the abs ence of immediately revers ible caus es , atropine remains the firs t-line drug for
acute s ymptomatic bradycardia. Atropine adminis tration s hould not delay implementation
of external pacing for patients with poor perfus ion. Dopamine and epinephrine may be
s ucces s ful as an alternative to TCP.
For bradycardia, give atropine 0.5 mg IV every 3 to 5 minutes to a total dos e of 0.04 mg/kg
(maximum total dos e of 3 mg). Atropine dos es of <0.5 mg may paradoxically res ult in further s lowing of the heart rate.
Us e atropine cautious ly in the pres ence of acute coronary is chemia or MI. An atropinemediated increas e in heart rate may wors en is chemia or increas e infarct s ize.
Do not rely on atropine in Mobitz type II s econd- or third-degree AV block or in patients
with third-degree AV block with a new wide QRS complex.
Tr e a t m e n t S e q u e n c e :
P a c in g
TCP may be us eful for treatment of s ymptomatic bradycardia. TCP is noninvas ive and can
be performed by ACLS providers .
Healthcare providers s hould cons ider immediate pacing in uns table patients with highdegree heart block when IV acces s is not available. It is reas onable for healthcare providers to initiate TCP in uns table patients who do not res pond to atropine.
Following initiation of pacing, confirm electrical and mechanical capture. Reas s es s the
patient for s ymptom improvement and hemodynamic s tability. Give analges ics and s edatives for pain control. Note that many of thes e drugs may further decreas e blood pres s ure
and affect the patients mental s tatus . Try to identify and correct the caus e of the bradycardia.
Some limitations apply. TCP can be painful and may fail to produce effective electrical and
mechanical capture. If s ymptoms are not caus ed by the bradycardia, pacing may be ineffective des pite capture.
If you chos e TCP as the s econdline treatment and it is als o ineffective (eg, incons is tent
capture), begin an infus ion of dopamine or epinephrine and prepare for pos s ible trans venous pacing by obtaining expert cons ultation.
Fo u n d a t io n a l Fa c t s
Se d a tio n a nd P a c ing
Mos t cons cious patients s hould be given s edation before pacing. If the patient is in
cardiovas cular collaps e or rapidly deteriorating, it may be neces s ary to s tart pacing
without prior s edation, particularly if drugs for s edation are not immediately available.
The clinician mus t evaluate the need for s edation in light of the patients condition and
need for immediate pacing. A review of the drugs us ed is beyond the s cope of the
ACLS Provider Cours e. The general approach could include the following:
Give parenteral benzodiazepine for anxiety and mus cle contractions .
Give a parenteral narcotic for analges ia.
Us e a chronotropic infus ion once available.
Obtain expert cons ultation for trans venous pacing.
111
P a r t
Tr e a t m e n t S e q u e n c e :
Ep in e p h r in e ,
Do p a m in e
Although -adrenergic agonis ts with rate-accelerating effects are not firs t-line agents for
treatment of s ymptomatic bradycardia, they are alternatives to TCP or in s pecial circums tances s uch as overdos e with a -blocker or calcium channel blocker.
Becaus e epinephrine and dopamine are vas ocons trictors , as well as chronotropes , healthcare providers mus t as s es s the patients intravas cular volume s tatus and avoid hypovolemia when us ing thes e drugs .
Both epinephrine and dopamine infus ions may be us ed for patients with s ymptomatic
bradycardia, particularly if as s ociated with hypotens ion, for whom atropine may be inappropriate or after atropine fails .
Begin epinephrine infus ion at a dos e of 2 to 10 mcg/min and titrate to patient res pons e.
Begin dopamine infus ion at 2 to 10 mcg/kg per minute and titrate to patient res pons e. At
lower dos es dopamine has a more s elective effect on inotropy and heart rate; at higher
dos es (>10 mcg/kg per minute) it als o has vas ocons trictive effects .
Ne xt Ac t io n s
(Bo x 6 )
After cons ideration of the treatment s equence in Box 5, you may need to
Prepare the patient for trans venous pacing
Treat the contributing caus es of the bradycardia
Cons ider expert cons ultationbut do not delay treatment if the patient is uns table or
potentially uns table
Tr a n s c u t a n e o u s P a c in g
In t r o d u c t io n
A variety of devices can pace the heart by delivering an electrical s timulus , caus ing electrical depolarization and s ubs equent cardiac contraction. TCP delivers pacing impuls es
to the heart through the s kin by us e of cutaneous electrodes . Mos t manufacturers have
added a pacing mode to manual defibrillators .
The ability to perform TCP is now often as clos e as the neares t defibrillator. Providers
need to know the indications , techniques , and hazards for us ing TCP.
In d ic a t io n s
P r e c a u t io n s
112
Th e ACLS Ca s e s : Bra d yc a rd ia
Te c h n iq u e
Ste p
Ac t io n
Set the demand rate to approximately 60/min. This rate can be adjus ted
up or down (bas ed on patient clinical res pons e) once pacing is es tablis hed.
Set the current milliamperes output 2 mA above the dos e at which cons is tent capture is obs erved (s afety margin).
External pacemakers have either fixed rates (as ynchronous mode) or demand rates .
As s e s s Re s p o n s e t o
Tr e a t m e n t
Rather than target a precis e heart rate, the goal of therapy is to ens ure improvement in
clinical s tatus (ie, s igns and s ymptoms related to the bradycardia). Signs of hemodynamic
impairment include hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic
ches t dis comfort, acute heart failure, or other s igns of s hock related to the bradycardia.
Start pacing at a rate of about 60/min. Once pacing is initiated, adjus t the rate bas ed on
the patients clinical res pons e. Mos t patients will improve with a rate of 60 to 70/min if the
s ymptoms are primarily due to the bradycardia.
Cons ider giving atropine before pacing in mildly s ymptomatic patients . Do not delay
pacing for uns table patients , particularly thos e with high-degree AV block. Atropine may
increas e heart rate, improve hemodynamics , and eliminate the need for pacing. If atropine
is ineffective or likely to be ineffective or if es tablis hment of IV acces s or atropine adminis tration is delayed, begin pacing as s oon as it is available.
Patients with ACS s hould be paced at the lowes t heart rate that allows clinical s tability.
Higher heart rates can wors en is chemia becaus e heart rate is a major determinate of myocardial oxygen demand. Is chemia, in turn, can precipitate arrhythmias .
An alternative to pacing if s ymptomatic bradycardia is unres pons ive to atropine is a chronotropic drug infus ion to s timulate heart rate:
Epinephrine: Initiate at 2 to 10 mcg/min and titrate to patient res pons e
Dopamine: Initiate at 2 to 10 mcg/kg per minute and titrate to patient res pons e
Br a d yc a r d ia Wit h
Es c a p e Rh yt h m s
113
P a r t
S t a n d b y P a c in g
Several bradycardic rhythms in ACS are caus ed by acute is chemia of conduction tis s ue
and pacing centers . Patients who are clinically s table may decompens ate s uddenly or
become uns table over minutes to hours from wors ening conduction abnormalities . Thes e
bradycardias may deteriorate to complete AV block and cardiovas cular collaps e.
Place TCP electrodes in anticipation of clinical deterioration in patients with acute myocardial is chemia or infarction as s ociated with the following rhythms :
Symptomatic s inus node dys function with s evere and s ymptomatic s inus bradycardia
As ymptomatic Mobitz type II s econd-degree AV block
As ymptomatic third-degree AV block
Newly acquired left, right, or alternating bundle branch block or bifas cicular block in
the s etting of AMI
Un s t a b le Ta c h yc a rd ia Ca s e
In t r o d u c t io n
If you are the team leader in this cas e, you will conduct the as s es s ment and management
of a patient with a rapid, unstable heart rate. You mus t be able to clas s ify the tachycardia
and implement appropriate interventions as outlined in the Tachycardia Algorithm. You will
be evaluated on your knowledge of the factors involved in s afe and effective s ynchronized
cardiovers ion as well as your performance of the procedure.
Le a r n in g Ob je c t ive s
Rh yt h m s fo r Un s t a b le
Ta c h yc a r d ia
Dr u g s fo r Un s t a b le
Ta c h yc a r d ia
Drugs are generally not us ed to manage patients with uns table tachycardia. Immediate
cardiovers ion is recommended. Cons ider adminis tering s edative drugs in the cons cious
patient. But do not delay immediate cardiovers ion in the uns table patient.
Atrial fibrillation
Atrial flutter
Reentry s upraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type
Th e Ap p ro a c h t o Un s t a b le Ta c h yc a rd ia
In t r o d u c t io n
114
A tachyarrhythmia (rhythm with heart rate >100/min) has many potential caus es and may
be s ymptomatic or as ymptomatic. The key to management of a patient with any tachycardia is to determine whether puls es are pres ent. If puls es are pres ent, determine whether
the patient is s table or uns table and then provide treatment bas ed on patient condition
and rhythm.
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
If the tachyarrhythmia is s inus tachycardia, conduct a diligent s earch for the caus e of the
tachycardia. Treatment and correction of this caus e will improve the s igns and s ymptoms .
De fin it io n s
Te r m
De fin it io n
*For the purpos es of this cas e we will us e the term tachycardia interchangeably with
tachyarrhythmia. Sinus tachycardia will be s pecifically indicated.
P a t h o p h ys io lo g y
o f Un s t a b le
Ta c h yc a r d ia
Uns table tachycardia exis ts when the heart rate is too fas t for the patients clinical condition and the exces s ive heart rate caus es s ymptoms or an uns table condition becaus e the
heart is
Beating so fast that cardiac output is reduced; this can caus e pulmonary edema,
coronary is chemia, and reduced blood flow to vital organs (eg, brain, kidneys )
Beating ineffectively s o that coordination between the atrium and ventricles or the
ventricles thems elves reduces cardiac output
S ym p t o m s a n d S ig n s
Uns table tachycardia leads to s erious s igns and s ymptoms that include
Hypotens ion
Acutely altered mental s tatus
Signs of s hock
Is chemic ches t dis comfort
Acute heart failure (AHF)
Ra p id Re c o g n it io n
Is t h e Ke y t o
Ma n a g e m e n t
S e ve r it y
As s es s for the pres ence or abs ence of s igns and s ymptoms and for their s everity.
Frequent patient as s es s ment is indicated.
115
P a r t
In d ic a t io n s fo r
Ca r d io ve r s io n
Rapid identification of s ymptomatic tachycardia will help you determine whether you
s hould prepare for immediate cardiovers ion. For example:
Sinus tachycardia is a phys iologic res pons e to extrins ic factors , s uch as fever, anemia, or hypotens ion/s hock, which create the need for increas ed cardiac output. There
is us ually a high degree of s ympathetic tone and neurohormonal factors . Sinus tachycardia will not res pond to cardiovers ion. In fact, if a s hock is delivered, the heart rate
often increas es .
If the patient with tachycardia is s table (ie, no s erious s igns related to the tachycardia), patients may await expert cons ultation becaus e treatment has the potential for
harm.
Atrial flutter typically produces a heart rate of approximately 150/min (lower rates may
be pres ent in patients who have received antiarrhythmic therapy). Atrial flutter at this
rate is often s table in the patient without heart or s erious s ys temic dis eas e.
At rates >150/min, s ymptoms are often pres ent and cardiovers ion is often required if
the patient is uns table.
If the patient is s erious ly ill or has underlying cardiovas cular dis eas e, s ymptoms may
be pres ent at lower rates .
You mus t know when cardiovers ion is indicated, how to prepare the patient for it (including appropriate medication), and how to s witch the defibrillator/monitor to operate as a
cardioverter.
Ma n a g in g Un s t a b le Ta c h yc a rd ia :
Th e Ta c h yc a rd ia Alg o r it h m
In t r o d u c t io n
The Tachycardia Algorithm s implifies initial management of tachycardia. The pres ence or
abs ence of puls es is cons idered key to management of a patient with any tachycardia.
If puls es are pres ent, determine whether the patient is s table or uns table and then provide treatment bas ed on the patients condition and rhythm. If a puls eles s tachycardia is
pres ent, then manage the patient according to the Cardiac Arres t Algorithm (Figure 19,
page 61).
The ACLS provider s hould either be an expert or be able to obtain expert cons ultation.
Actions in the boxes require advanced knowledge of ECG rhythm interpretation and antiarrhythmic therapy and are intended to be accomplis hed in the in-hos pital s etting with
expert cons ultation available.
Ove r vie w
The Tachycardia Algorithm (Figure 35) outlines the s teps for as s es s ment and management
of a patient pres enting with s ymptomatic tachycardia with puls es . Implementation of this
algorithm begins with the identification of tachycardia with puls es (Box 1). If a tachycardia
and a puls e are pres ent, perform as s es s ment and management s teps guided by the BLS
Survey and the ACLS Survey (Box 2). The key in this as s es s ment is to decide if the tachycardia is s table or uns table.
If s igns and s ymptoms pers is t des pite provis ion of s upplementary oxygen and s upport of
airway and circulation and if s ignificant s igns or s ymptoms are due to the tachycardia (Box
3), then the tachycardia is uns table and immediate s ynchronized cardiovers ion is indicated
(Box 4).
116
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
If the patient is s table, you will evaluate the ECG, and determine if the QRS complex is
wide or narrow and regular or irregular (Box 5). The treatment of s table tachycardia is pres ented in the next cas e (Box 6).
A precis e diagnos is of the rhythm (eg, reentry SVT, atrial flutter) may not be pos s ible at
this time.
Fo u n d a t io n a l Fa c t s
Se rio us o r Sig nific a nt
Sym p to m s
Uns ta b le Co nd itio n
FYI 2 0 1 0 Gu id e lin e s
Ta c hyc a rd ia With a P uls e
Alg o rithm
Su m m a r y
The 2010 Tachycardia With a Puls e Algorithm (Figure 35) is pres ented in the traditional
box-and-line format. Overall, the algorithm has been s implified and redes igned to facilitate learning and memorization of the treatment recommendations and to emphas ize
the importance of identifying whether the tachycardia is a caus e or a s ymptom of an
underlying condition, which is fundamental to the management of all tachyarrhythmias .
Your as s es s ment and management of this patient will be guided by the following key
ques tions pres ented in the Tachycardia Algorithm:
Are s ymptoms pres ent or abs ent?
Is the patient s table or uns table?
Is the QRS narrow or wide?
Is the rhythm regular or irregular?
Is the QRS monomorphic or polymorphic?
Your ans wers to thes e ques tions will determine the next appropriate s teps .
117
P a r t
Ad ult Ta c hyc a rd ia
(With Puls e)
1
As s es s appropriatenes s for clinical condition.
Heart rate typically 150/min if tachyarrhythmia.
2
Id e ntify a nd tre a t und e rlying c a us e
Do s e s /De ta ils
3
4
P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s
No
Wid e QRS?
0.12 s e c o nd
Ye s
IVacces s and12-leadECG
ifavailable
C ons ideradenos ineonlyif
regularandmonomorphic
Cons iderantiarrhythmicinfus ion
Cons iderexpertcons ultation
No
IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons iderexpertcons ultation
Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired.
An tia rrh yth m ic In fu s ion s for
Sta b le Wid e -QRS Ta c h yc a rd ia
P ro c a ina m id e IV Do s e :
20-50mg/minuntilarrhythmia
s uppres s ed,hypotens ionens ues ,
QRSdurationincreas es >50% ,or
maximumdos e17mg/kggiven.
Maintenanceinfus ion:1-4mg/min.
AvoidifprolongedQTorCHF.
Am io d a ro ne IV Do s e :
Firs tdos e:150mgover10minutes .
Repeatas neededifVTrecurs .
Followbymaintenanceinfus ionof
1mg/minforfirs t6hours .
So ta lo l IV Do s e :
100mg(1.5mg/kg)over5minutes .
AvoidifprolongedQT.
Ap p lic a t io n o f t h e Ta c h yc a rd ia Alg o r it h m t o t h e Un s t a b le P a t ie n t
118
In t r o d u c t io n
As s e s s
Ap p r o p r ia t e n e s s
fo r Clin ic a l
Co n d it io n (Bo x 1 )
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
Id e n t ify a n d Tr e a t
t h e Un d e r lyin g
Ca u s e : BLS a n d
ACLS S u r ve ys
(Bo x 2 )
Us e the BLS Survey and the ACLS Survey to guide your approach.
Look for s igns of increas ed work of breathing (tachypnea, intercos tal retractions ,
s upras ternal retractions , paradoxical abdominal breathing) and hypoxemia as determined by puls e oximetry.
Give oxygen, if indicated and monitor oxygen s aturation.
Obtain an ECG to identify the rhythm.
Evaluate blood pres s ure.
Es tablis h IV acces s .
Identify and treat revers ible caus es .
If s ymptoms pers is t des pite s upport of adequate oxygenation and ventilation, proceed to
Box 3.
Cr it ic a l Co n c e p t s
Uns ta b le P a tie nts
De c is io n P o in t :
Is t h e P e r s is t e n t
Ta c h ya r r h yt h m ia
Ca u s in g S ig n ific a n t
S ig n s o r S ym p t o m s ?
(Bo x 3 )
Healthcare providers s hould obtain a 12-lead ECG early in the as s es s ment to better
define the rhythm.
However, uns table patients require immediate cardiovers ion.
Do not delay immediate cardiovers ion for acquis ition of the 12-lead ECG if the
patient is uns table.
As s es s the patients degree of ins tability and determine if the ins tability is related to the
tachycardia.
Un s ta b le
If the patient demons trates rate-related cardiovas cular compromis e with s igns and s ymptoms s uch as hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic ches t
dis comfort, acute heart failure, or other s igns of s hock s us pected to be due to a tachyarrhythmia, proceed to immediate s ynchronized cardiovers ion (Box 4).
Serious s igns and s ymptoms are unlikely if the ventricular rate is <150/min in patients with
a healthy heart. However, if the patient is s erious ly ill or has s ignificant underlying heart
dis eas e or other conditions , s ymptoms may be pres ent at a lower heart rate.
Sta b le
If the patient does not have rate-related cardiovas cular compromis e, proceed to Box 5.
The healthcare provider has time to obtain a 12-lead ECG, evaluate the rhythm, determine if the width of the QRS, and determine treatment options . Stable patients may await
expert cons ultation becaus e treatment has the potential for harm.
119
P a r t
Fo u n d a t io n a l Fa c t s
Tre a tm e nt Ba s e d o n
Typ e o f Ta c hyc a rd ia
You may not always be able to dis tinguis h between s upraventricular and ventricular
rhythms . Mos t wide-complex (broad-complex) tachycardias are ventricular in origin
(es pecially if the patient has underlying heart dis eas e or is older). If the patient is
puls eles s , treat the rhythm as VF and follow the Cardiac Arres t Algorithm.
If the patient has a wide-complex tachycardia and is uns table, as s ume it is VT until
proven otherwis e. The amount of energy required for cardiovers ion of VT is determined
by the morphologic characteris tics .
If the patient is uns table but has a puls e with regular uniform wide-complex VT
(monomorphic VT).
Treat with s ynchronized cardiovers ion and an initial s hock of 100 J (monophas ic
waveform).
If there is no res pons e to the firs t s hock, increas ing the dos e in a s tepwis e fas hion
is reas onable.*
Arrhythmias with a polymorphic QRS appearance (polymorphic VT), s uch as
tors ades de pointes will us ually not permit s ynchronization. If the patient has
polymorphic VT:
Treat as VF with high-energy uns ynchronized s hocks (eg, defibrillation dos es ).
If there is any doubt about whether an uns table patient has monomorphic or polymorphic VT, do not delay treatment for further rhythm analys is . Provide high-energy,
uns ynchronized s hocks .
*No s tudies that addres s ed this is s ue had been identified at the time that the manus cript for the 2010 AHA Guidelines for CPR and ECC was in preparation. Thus , this
recommendation repres ents expert opinion.
P e r fo r m Im m e d ia t e
S yn c h r o n iz e d
Ca r d io ve r s io n
(Bo x 4 )
If pos s ible es tablis h IV acces s before cardiovers ion and adminis ter s edation if the
patient is cons cious .
Do not delay cardiovers ion if the patient is extremely uns table.
Further information about cardiovers ion appears below.
If the patient with a regular narrow-complex SVT or a monomorphic wide-complex tachycardia is not hypotens ive, healthcare providers may adminis ter adenos ine while preparing
for s ynchronized cardiovers ion.
If cardiac arres t develops , s ee the Cardiac Arres t Algorithm.
De t e r m in e t h e Wid t h
o f t h e QRS Co m p le x
(Bo x 5 )
Ca rd io ve r s io n
In t r o d u c t io n
You mus t know when cardiovers ion is indicated and what type of s hock to adminis ter.
Before cardiovers ion, es tablis h IV acces s and s edate the res pons ive patient if pos s ible,
but do not delay cardiovers ion in the uns table or deteriorating patient.
This s ection dis cus s es the following important concepts about cardiovers ion:
The difference between uns ynchronized and s ynchronized s hocks
Potential challenges to delivery of s ynchronized s hocks
Energy dos es for s pecific rhythms
120
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
Un s yn c h r o n iz e d vs
S yn c h r o n iz e d S h o c k s
P o t e n t ia l P r o b le m s
Wit h S yn c h r o n iz a t io n
In theory, s ynchronization is s imple. The operator pus hes the SYNC control on the face
of the defibrillator/cardioverter. In practice, however, there are potential problems . For
example:
If the R-wave peaks of a tachycardia are undifferentiated or of low amplitude, the
monitor s ens ors may be unable to identify an R-wave peak and therefore will not
deliver the s hock.
Many cardioverters will not s ynchronize through the handheld quick-look paddles . An
unwary practitioner may try to s ynchronizeuns ucces s fully in that the machine will
not dis chargeand may not recognize the problem.
Synchronization can take extra time (eg, if it is neces s ary to attach electrodes or if the
operator is unfamiliar with the equipment).
Re c o m m e n d a t io n s
SVT
atrial fibrillation
atrial flutter
regular monomorphic tachycardia with puls es
Wh e n to Us e Un s yn c h ron ize d Sh oc ks
Uns ynchronized high-energy s hocks are recommended
For a patient who is puls eles s
For a patient demons trating clinical deterioration (in prearres t), s uch as thos e with
s evere s hock or polymorphic VT, when you think a delay in converting the rhythm will
res ult in cardiac arres t
When you are uns ure whether monomorphic or polymorphic VT is pres ent in the
uns table patient
Should the uns ynchronized s hock caus e VF (occurring in only a very s mall minority of
patients des pite the theoretical ris k), immediately attempt defibrillation.
121
P a r t
En e r g y Do s e s fo r
Ca r d io ve r s io n
S yn c h ro n iz e d Ca rd io ve r s io n Te c h n iq u e
In t r o d u c t io n
Synchronized cardiovers ion is the treatment of choice when a patient has a s ymptomatic
(uns table) reentry SVT or VT with puls es . It is als o recommended to treat uns table atrial
fibrillation and uns table atrial flutter.
Cardiovers ion is unlikely to be effective for treatment of junctional tachycardia or ectopic
or multifocal atrial tachycardia becaus e thes e rhythms have an automatic focus aris ing
from cells that are s pontaneous ly depolarizing at a rapid rate. Delivery of a s hock generally
cannot s top thes e rhythms and may actually increas e the rate of the tachyarrhythmia.
In s ynchronized cardiovers ion, s hocks are adminis tered through adhes ive electrodes or
handheld paddles . You will need to place the defibrillator/monitor in synchronized (sync)
mode. The s ync mode is des igned to deliver energy jus t after the R wave of the QRS
complex.
122
Th e ACLS Ca s e s : Un s ta b le Ta c h yc a rd ia
Te c h n iq u e
Follow thes e s teps to perform s ynchronized cardiovers ion. Modify the s teps for your s pecific device.
Ste p
Ac t io n
Sedate all cons cious patients unles s uns table or deteriorating rapidly.
Attach monitor leads to the patient (white to right, red to ribs , whats left
over to the left s houlder) and ens ure proper dis play of the patients rhythm.
Pos ition adhes ive electrode (conductor) pads on the patient.
Adjus t monitor gain if neces s ary until s ync markers occur with each R wave.
If
In it ia l Do s e *
200 J
Uns ta b le m o no m o rp hic VT
100 J
50 to 100 J
10
Clear the patient when the defibrillator is charged. (See Foundational Facts :
Clearing for Defibrillation in the VF/Puls eles s VT Cas e.)
11
12
Check the monitor. If tachycardia pers is ts , increas e the energy level (joules )
according to the Electrical Cardiovers ion Algorithm.
13
Activate the s ync mode after delivery of each s ynchronized s hock. Most
defibrillators default back to the unsynchronized mode after delivery of a
synchronized shock. This default allows an immediate s hock if cardiovers ion
produces VF.
123
P a r t
S t a b le Ta c h yc a rd ia Ca s e
In t r o d u c t io n
This cas e reviews as s es s ment and management of a stable patient (ie, no serious signs
related to the tachycardia) with a rapid heart rate. Patients with heart rates >100/min
have a tachyarrhythmia or tachycardia. In this cas e we will us e the terms tachycardia and
tachyarrhythmia interchangeably. Note that s inus tachycardia is excluded from the treatment algorithm. Sinus tachycardia is almos t always phys iologic, developing in res pons e to
a compromis e in s troke volume or a condition that requires an increas e in cardiac output
(eg, fever, hypovolemia). Treatment involves identification and correction of that underlying
problem.
You mus t be able to clas s ify the type of tachycardia (wide or narrow; regular or irregular)
and implement appropriate interventions as outlined in the Tachycardia Algorithm. During
this cas e you will
Perform initial as s es s ment and management
Treat regular narrow-complex rhythms (except s inus tachycardia) with vagal maneuvers and adenos ine
If the rhythm does not convert, you will monitor the patient and trans port or obtain expert
cons ultation. If the patient becomes clinically uns table, you will prepare for immediate uns ynchronized s hock or s ynchronized cardiovers ion as dis cus s ed in the Uns table
Tachycardia Cas e.
Le a r n in g Ob je c t ive s
Rh yt h m s fo r S t a b le
Ta c h yc a r d ia
Tachycardias can be clas s ified in s everal ways bas ed on the appearance of the QRS complex, heart rate, and whether they are regular or irregular:
NarrowQRS complex (SVT) tachycardias (QRS <0.12 s econd) in order of frequency
Sinus tachycardia
Atrial fibrillation
Atrial flutter
AV nodal reentry
WideQRS complex tachycardias (QRS 0.12 s econd)
Monomorphic VT
Polymorphic VT
Regular or irregular tachycardias
Irregular narrow-complex tachycardias are probably atrial fibrillation
124
Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia
Dr u g s fo r S t a b le
Ta c h yc a r d ia
Ap p ro a c h t o S t a b le Ta c h yc a rd ia
In t r o d u c t io n
In this cas e a s table tachycardia refers to a condition in which the patient has
A heart rate >100/min
No s ignificant s igns or s ymptoms caus ed by the increas ed rate
An underlying cardiac electrical abnormality that generates the rhythm
Qu e s t io n s t o
De t e r m in e
Cla s s ific a t io n
Clas s ification of the tachycardia depends on the careful clinical evaluation of thes e ques tions :
Are s ymptoms pres ent or abs ent?
Are s ymptoms due to the tachycardia?
Is the patient s table or uns table?
Is the QRS complex narrow or wide?
Is the rhythm regular or irregular?
Is the QRS monomorphic or polymorphic?
Is the rhythm s inus tachycardia?
The ans wers guide s ubs equent diagnos is and treatment.
Fo u n d a t io n a l Fa c t s
Und e rs ta nd ing Sinus
Ta c hyc a rd ia
Sinus tachycardia is a heart rate that is >100/min and is generated by s inus node
dis charge. The heart rate in s inus tachycardia does not exceed 220/min and is agerelated. Sinus tachycardia us ually does not exceed 120 to 130/min, and it has a
gradual ons et and gradual termination. Reentry SVT has an abrupt ons et and termination.
Sinus tachycardia is caus ed by external influences on the heart, s uch as fever,
anemia, hypotens ion, blood los s , or exercis e. Thes e are s ys temic conditions , not
cardiac conditions . Sinus tachycardia is a regular rhythm, although the rate may be
s lowed by vagal maneuvers . Cardiovers ion is contraindicated.
-Blockers may caus e clinical deterioration if the cardiac output falls when a compensatory tachycardia is blocked. This is becaus e cardiac output is determined by
the volume of blood ejected by the ventricles with each contraction (s troke volume)
and the heart rate.
Cardiac output (CO) = Stroke volume (SV) Heart rate
If a condition s uch as a large AMI limits ventricular function (s evere heart failure
or cardiogenic s hock), the heart compens ates by increas ing the heart rate. If you
attempt to reduce the heart rate in patients with a compens atory tachycardia, cardiac output will fall and the patients condition will likely deteriorate.
In s in u s ta c h yc a rd ia th e g oa l is to id e n tify a n d tre a t th e u n d e rlyin g s ys te m ic
cause.
125
P a r t
Ma n a g in g S t a b le Ta c h yc a rd ia : Th e Ta c h yc a rd ia Alg o r it h m
In t r o d u c t io n
As noted in the Uns table Tachycardia Cas e, the key to management of a patient with
any tachycardia is to determine whether puls es are pres ent, and if puls es are pres ent, to
determine whether the patient is s table or uns table and then to provide treatment bas ed
on patient condition and rhythm. If the patient is puls eles s , manage the patient according
to the Cardiac Arres t Algorithm (Figure 19, page 61). If the patient has puls es , manage the
patient according to the Tachycardia Algorithm (Figure 36, page 127).
Ove r vie w
If a tachycardia and a puls e are pres ent, perform as s es s ment and management s teps
guided by the BLS Survey and the ACLS Survey. Determine if s ignificant s ymptoms
or s igns are pres ent and if thes e s ymptoms and s igns are due to the tachycardia. This
will direct you to either the stable (Boxes 5 through 7) or unstable (Box 4) s ection of the
algorithm.
If s ignificant s igns or s ymptoms are due to the tachycardia, then the tachycardia is
unstable and immediate cardiovers ion is indicated (s ee the Uns table Tachycardia
Cas e).
If the patient develops pulseless VT, deliver uns ynchronized high-energy s hocks
(defibrillation energy) and follow the Cardiac Arres t Algorithm.
If the patient has polymorphic VT, treat the rhythm as VF and deliver high-energy
uns ynchronized s hocks (ie, defibrillation energy).
In this cas e the patient is s table, and you will manage according to the s table s ection of
the Tachycardia Algorithm (Figure 36). A precis e identification of the rhythm (eg, reentry
SVT, atrial flutter) may not be pos s ible at this time.
126
Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia
Ad ult Ta c hyc a rd ia
(With Puls e)
1
As s es s appropriatenes s for clinical condition.
Heart rate typically 150/min if tachyarrhythmia.
2
Id e ntify a nd tre a t und e rlying c a us e
Do s e s /De ta ils
3
4
P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s
No
Wid e QRS?
0.12 s e c o nd
Ye s
IVacces s and12-leadECG
ifavailable
C ons ideradenos ineonlyif
regularandmonomorphic
Cons iderantiarrhythmicinfus ion
Cons iderexpertcons ultation
No
IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons iderexpertcons ultation
Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired.
An tia rrh yth m ic In fu s ion s for
Sta b le Wid e -QRS Ta c h yc a rd ia
P ro c a ina m id e IV Do s e :
20-50mg/minuntilarrhythmia
s uppres s ed,hypotens ionens ues ,
QRSdurationincreas es >50% ,or
maximumdos e17mg/kggiven.
Maintenanceinfus ion:1-4mg/min.
AvoidifprolongedQTorCHF.
Am io d a ro ne IV Do s e :
Firs tdos e:150mgover10minutes .
Repeatas neededifVTrecurs .
Followbymaintenanceinfus ionof
1mg/minforfirs t6hours .
So ta lo l IV Do s e :
100mg(1.5mg/kg)over5minutes .
AvoidifprolongedQT.
Ap p lic a t io n o f t h e Ta c h yc a rd ia Alg o r it h m t o t h e S t a b le P a t ie n t
In t r o d u c t io n
Inthis cas eapatient has stable tachycardia with a pulse. Conductthes teps outlinedin
theTachycardiaAlgorithmtoevaluateandmanagethepatient.
P a t ie n t As s e s s m e n t
(Bo x 1 )
127
P a r t
BLS a n d ACLS
S u r ve ys (Bo x 2 )
Us ing the BLS Survey and the ACLS Survey to guide your approach, evaluate the patient
and do the following as neces s ary:
Look for s igns of increas ed work of breathing and hypoxia as determined by puls e
oximetry.
Give oxygen; monitor oxygen s aturation.
Support the airway, breathing, and circulation.
Obtain an ECG to identify the rhythm; check blood pres s ure.
Identify and treat revers ible caus es .
If s ymptoms pers is t, proceed to Box 3.
De c is io n P o in t :
S t a b le o r Un s t a b le
(Bo x 3 )
Un s ta b le
If the patient is unstable with s igns or s ymptoms as a res ult of the tachycardia (eg, hypotens ion, acutely altered mental s tatus , s igns of s hock, is chemic ches t dis comfort, or
AHF), go to Box 4 (perform immediate s ynchronized cardiovers ion). See the Uns table
Tachycardia Cas e.
Sta b le
If the patient is s table, go to Box 5.
IV Ac c e s s a n d
1 2 -Le a d ECG
(Bo x 5 )
If the patient with tachycardia is stable (ie, no s erious s igns or s ymptoms related to the
tachycardia), you have time to evaluate the rhythm and decide on treatment options .
Es tablis h IV acces s if not already obtained. Obtain a 12-lead ECG (when available) or
rhythm s trip to determine if the QRS is narrow (<0.12 s econd) or wide (0.12 s econd).
De c is io n P o in t :
Na r r o w o r Wid e
(Bo x 6 , Bo x 7 )
The path of treatment is now determined by whether the QRS is wide (Box 6) or narrow
(Box 7), and whether the rhythm is regular or irregular. If a monomorphic wide-complex
rhythm is pres ent and the patient is s table, expert cons ultation is advis ed. Polymorphic
wide-complex tachycardia s hould be treated with immediate uns ynchronized cardiovers ion.
Fo u n d a t io n a l Fa c t s
Tre a ting Ta c hyc a rd ia
You may not always be able to dis tinguis h between s upraventricular (aberrant) and
ventricular wide-complex rhythms . If you are uns ure, be aware that mos t widecomplex (broad-complex) tachycardias are ventricular in origin.
If a patient is pulseless, follow the Cardiac Arres t Algorithm.
If a patient becomes unstable, do not delay treatment for further rhythm analys is .
For stable patients with wide-complex tachycardias , trans port and monitor or cons ult an expert, becaus e treatment has the potential for harm.
Wide-complex tachycardias are defined as a QRS of 0.12 s econd. Consider expert consultation.
The mos t common forms of life-threatening wide-complex tachycardias likely to deteriorate to VF are:
Monomorphic VT
Polymorphic VT
Determine if the rhythm is regular or irregular.
A regular wide-complex tachycardia is pres umed to be VT or SVT with aberrancy.
An irregular wide-complex tachycardia may be atrial fibrillation with aberrancy, preexcited atrial fibrillation (atrial fibrillation us ing an acces s ory pathway for antegrade
conduction), or polymorphic VT/tors ades de pointes . Thes e are advanced rhythms
requiring additional expertis e or expert cons ultation.
128
Th e ACLS Ca s e s : Sta b le Ta c h yc a rd ia
If the rhythm is likely VT or SVT in a s table patient, treat bas ed on the algorithm for that
rhythm.
If the rhythm etiology cannot be determined and is regular in its rate and monomorphic,
recent evidence s ugges ts that IV adenos ine is relatively s afe for both treatment and diagnos is . IV antiarrhythmic drugs may be effective. We recommend procainamide, amiodarone, or s otalol. See the right column on the algorithm (Figure 36, page 127) for recommended dos es .
In the cas e of irregular wide-complex tachycardia, management focus es on control of the
rapid ventricular rate (rate control), convers ion of hemodynamically uns table atrial fibrillation to s inus rhythm (rhythm control), or both. Expert cons ultation is advis ed.
Ca u t io n
Drug s to Avo id in
P a tie nts With Irre g ula r
Wid e -Co m p le x
Ta c hyc a rd ia
Na r r o w QRS ,
Re g u la r Rh yt h m
(Bo x 7 )
Avoid AV nodal blocking agents s uch as adenos ine, calcium channel blockers ,
digoxin, and pos s ibly -blockers in patients with pre-excitation atrial fibrillation,
becaus e thes e drugs may caus e a paradoxical increas e in the ventricular res pons e.
129
P a r t
5
If the rhythm converts with adenos ine, it is probable reentry SVT. Obs erve for recurrence.
Treat recurrence with adenos ine or longer-acting AV nodal blocking agents s uch as the
non-dihydropyridine calcium channel blockers (verapamil and diltiazem) or -blockers .
Typically you s hould obtain expert cons ultation if the tachycardia recurs .
If the rhythm does not convert with adenos ine, it is pos s ible atrial flutter, ectopic atrial
tachycardia, or junctional tachycardia. Obtain expert cons ultation about diagnos is and
treatment.
Ca u t io n :
Wha t to Avo id With AV
No d a l Blo c king Ag e nts
Ta c h yc a r d ia
Alg o r it h m : Ad va n c e d
Ma n a g e m e n t S t e p s
AV nodal blocking drugs s hould not be us ed for pre-excited atrial fibrillation or flutter. Treatment with an AV nodal blocking agent is unlikely to s low the ventricular rate
and in s ome ins tances may accelerate the ventricular res pons e. Caution is advis ed
when combining AV nodal blocking agents that have a longer duration of action,
s uch as calcium channel blockers or -blockers , becaus e their actions may overlap
if given s erially, which can provoke profound bradycardia.
Some ACLS providers may be familiar with the differential diagnos is and therapy of
s table tachycardias that do not res pond to initial treatment. The bas ic ACLS provider is
expected to recognize a s table narrow-complex or wide-complex tachycardia and clas s ify
the rhythm as regular or irregular. Regular narrow-complex tachycardias may be treated
initially with vagal maneuvers and adenos ine. If thes e are uns ucces s ful, the ACLS provider
s hould trans port or seek expert consultation.
If ACLS providers have experience with the differential diagnos is and therapy of s table
tachycardias beyond initial management, the Tachycardia Algorithm lis ts additional s teps
and pharmacologic agents us ed in the treatment of thes e arrhythmias , both for rate control and for termination of the arrhythmia.
If a t a n y p oin t you b e c om e u n c e rta in or u n c om forta b le d u rin g th e tre a tm e n t of
a s ta b le p a tie n t, s e e k e xp e rt c on s u lta tion . Th e tre a tm e n t of s ta b le p a tie n ts m a y
a wa it e xp e rt c on s u lta tion b e c a u s e tre a tm e n t h a s th e p ote n tia l for h a rm .
Ac u t e S t ro k e Ca s e
In t r o d u c t io n
The identification and initial management of patients with acute s troke is within the s cope
of an ACLS provider. This cas e covers principles of out-of-hospital care and fundamental
aspects of initial in-hospital acute stroke care.
Out-of-hos pital acute s troke care focus es on
Rapid identification and as s es s ment of patients with s troke
Rapid trans port (with prearrival notification) to a facility capable of providing acute
s troke care
In-hos pital acute s troke care includes the
Ability to rapidly determine patient eligibility for fibrinolytic therapy
Adminis tration of fibrinolytic therapy to appropriate candidates , with availability of
neurologic medical s upervis ion within target times
Initiation of the s troke pathway and patient admis s ion to a s troke unit if available
The target times and goals are recommended by the National Ins titute of Neurological
Dis orders and Stroke (NINDS), which has recommended meas urable goals for the evaluation of s troke patients . Thes e targets or goals s hould be achieved for at leas t 80% of
patients with acute s troke.
130
Th e ACLS Ca s e s : Ac u te Stroke
Le a r n in g Ob je c t ive s
P o t e n t ia l Ar r h yt h m ia s
Wit h S t r o k e
The ECG does not take priority over obtaining a computed tomography (CT) s can. No
arrhythmias are s pecific for s troke, but the ECG may identify evidence of a recent AMI or
arrhythmias s uch as atrial fibrillation as a caus e of an embolic s troke. Many patients with
s troke may demons trate arrhythmias , but if the patient is hemodynamically s table, mos t
arrhythmias will not require treatment. There is general agreement to recommend cardiac
monitoring during the firs t 24 hours of evaluation in patients with acute is chemic s troke to
detect atrial fibrillation and potentially life-threatening arrhythmias .
Dr u g s fo r S t r o k e
Fo u n d a t io n a l Fa c t s
Ma jo r Typ e s o f Stro ke
Stroke is a general term. It refers to acute neurologic impairment that follows interruption in blood s upply to a s pecific area of the brain. Although expeditious s troke care is
important for all patients , this cas e emphas izes reperfus ion therapy for acute is chemic
s troke.
The major types of s troke are
Is chemic s troke: accounts for 87% of all s trokes and is us ually caus ed by an occlus ion of an artery to a region of the brain (Figure 37).
Hemorrhagic s troke: accounts for 13% of all s trokes and occurs when a blood
ves s el in the brain s uddenly ruptures into the s urrounding tis s ue. Fibrinolytic therapy
is contraindicated in this type of s troke. Avoid anticoagulants .
131
P a r t
10%
87%
Is c he m ic
3%
Intra c e re b ra l
Sub a ra c hno id
Fig u re 3 7 . Types of s troke. Eighty-s even percent of s trokes are is chemic and potentially eligible for fibrinolytic therapy if patients otherwis e
qualify. Thirteen percent of s trokes are hemorrhagic, and the majority of thes e are intracerebral. The male-to-female incidence ratio is 1.25 in pers ons 55 to 64 years of age, 1.50 in thos e 65 to 74, 1.07 in thos e 75 to 84, and 0.76 in thos e 85 and older. Blacks have almos t twice the ris k of firs tever s troke compared with whites .
Ap p ro a c h t o S t ro k e Ca re
In t r o d u c t io n
Each year in the United States about 795 000 people s uffer a new or recurrent s troke.
Stroke remains a leading caus e of death in the United States .
Early recognition of acute is chemic s troke is important becaus e IV fibrinolytic treatment
s hould be provided as early as pos s ible, generally within 3 hours of ons et of s ymptoms ,
or within 4.5 hours of ons et of s ymptoms for s elected patients . Mos t s trokes occur at
home, and only half of acute s troke patients us e EMS for trans port to the hos pital. Stroke
patients often deny or try to rationalize their s ymptoms . Even high-ris k patients , s uch
as thos e with atrial fibrillation or hypertens ion, fail to recognize the s igns of s troke. This
delays activation of EMS and treatment, res ulting in increas ed morbidity and mortality.
Community and profes s ional education is es s ential, and it has been s ucces s ful in increas ing the proportion of eligible s troke patients treated with fibrinolytic therapy. Healthcare
providers , hos pitals , and communities mus t continue to develop s ys tems to improve the
efficiency and effectivenes s of s troke care.
Fo u n d a t io n a l Fa c t s
Stro ke Cha in o f Surviva l
The goal of s troke care is to minimize brain injury and maximize the patients recovery. The Stroke Chain of Survival (Figure 38) des cribed by the AHA and the American
Stroke As s ociation is s imilar to the Chain of Survival for s udden cardiac arres t. It links
actions to be taken by patients , family members , and healthcare providers to maximize
s troke recovery. Thes e links are
Rapid
Rapid
Rapid
Rapid
Th e ACLS Ca s e s : Ac u te Stroke
FYI 2 0 1 0 Gu id e lin e s
Stro ke Cha in o f Surviva l
Fo u n d a t io n a l Fa c t s
The 8 Ds o f Stro ke Ca re
Go a ls o f S t r o k e Ca r e
TheSus pectedStrokeAlgorithm(Figure39)emphas izes importantelements ofout-ofhos pitalcareforpos s ibles trokepatients .Thes eactions includeas trokes caleors creen
andrapidtrans porttothehos pital.As withACS,priornotificationofthereceivinghos pital
s peeds thecareofthes trokepatientuponarrival.
TheNINDShas es tablis hedcriticalin-hos pitaltimegoals foras s es s mentandmanagementofpatients withs us pecteds troke.This algorithmreviews thecriticalin-hos pitaltime
periods forpatientas s es s mentandtreatment:
1. Immediategeneralas s es s mentbythes troketeam,emergencyphys ician,oranother
expertwithin10 minutes ofarrival;orderurgentnoncontras tCTs can
2. Neurologicas s es s mentbythes troketeamordes igneeandCTs canperformedwithin25 minutes ofhos pitalarrival
3. InterpretationoftheCTs canwithin45 minutes ofEDarrival
4. Initiationoffibrinolytictherapyinappropriatepatients (thos ewithoutcontraindications )within1 hourofhos pitalarrivaland3 hoursfroms ymptomons et
5. Door-to-admis s iontimeof3 hours
133
P a r t
Id e ntify s ig ns a nd s ym p to m s o f p o s s ib le s tro ke
Ac tiva te Em e rg e nc y Re s p o ns e
2
NINDS
TIME
GOALS
ED
Arriva l
Im m e d ia te g e ne ra l a s s e s s m e nt a nd s ta b iliza tio n
As s es s ABCs , vital s igns
Provide o xyg e n if hypoxemic
Obtain IV acces s and perform lab oratory as s es s ments
Check glucos e; treat if indicated
Perform neurologic s creening as s es s ment
Activate s troke team
Order emergent CT s can or MRI of brain
Obtain 12-lead ECG
10
m in
ED
Arriva l
Im m e d ia te ne uro lo g ic a s s e s s m e nt b y s tro ke te a m o r d e s ig ne e
Review patient his tory
Es tablis h time of s ymptom ons et or las t known normal
Perform neurologic examination (NIH Stroke Scale or
Canadian Neurological Scale)
25
m in
ED
Arriva l
45
m in
No He m o r r h a g e
He m o r r h a g e
No t a Ca n d id a t e
Ca n d id a t e
Adminis te r a s p irin
11
Begin s troke or
he morrhage pa thway
Admit to s troke unit or
intens ive ca re unit
12
Th e ACLS Ca s e s : Ac u te Stroke
Fo u n d a t io n a l Fa c t s :
The Na tio na l Ins titute o f
Ne uro lo g ic a l Dis o rd e rs
a nd Stro ke
Cr it ic a l Tim e P e r io d s
Ap p lic a t io n o f t h e
Su s p e c te d Stroke
Alg o r it h m
Im m e d ia te g e ne ra l a s s e s s m e nt
10minutes
Im m e d ia te ne uro lo g ic a s s e s s m e nt
25minutes
25minutes
45minutes
Ad m inis tra tio n o f fib rino lytic the ra p y, tim e d fro m ED a rriva l
60minutes
3hours ,or4.5
hours ins elected
patients
Ad m is s io n to a m o nito re d b e d
3hours
Id e n t if c a t io n o S ig n s o P o s s ib le S t ro k e (Bo x 1 )
Wa r n in g S ig n s a n d
S ym p t o m s
P a r t
Ac t iva t e EMS S ys t e m
Im m e d ia t e ly
Stroke patients and their families mus t be educated to activate EMS as s oon as they
detect potential s igns or s ymptoms of s troke. Currently half of all s troke patients are driven
to the ED by family or friends .
EMS provides the s afes t and mos t efficient method of emergency trans port to the hos pital. The advantages of EMS trans port include the following:
EMS pers onnel can identify and trans port a s troke patient to a hos pital capable of
providing acute s troke care and notify the hos pital of the patients impending arrival.
Prearrival notification allows the hos pital to prepare to evaluate and manage the
patient efficiently.
Emergency medical dis patchers als o play a critical role in timely treatment of potential
s troke by
Identifying pos s ible s troke patients
Providing high-priority dis patch
Ins tructing bys tanders in lifes aving CPR s kills or other s upportive care if needed while
EMS providers are on the way
S t r o k e As s e s s m e n t
To o ls
The 2010 AHA Guidelines for CPR and ECC recommends that all EMS pers onnel be
trained to recognize s troke us ing a validated, abbreviated out-of-hos pital neurologic evaluation tool s uch as the Cincinnati Prehos pital Stroke Scale (CPSS) (Table 4).
136
Th e ACLS Ca s e s : Ac u te Stroke
Te s t
Fin d in g s
137
P a r t
Cr it ic a l EMS As s e s s m e n t s a n d Ac t io n s (Bo x 2 )
In t r o d u c t io n
Prehos pital EMS providers mus t minimize the interval between the ons et of s ymptoms and
patient arrival in the ED. Specific s troke therapy can be provided only in the appropriate
receiving hos pital ED, s o time in the field only delays (and may prevent) definitive therapy.
More extens ive as s es s ments and initiation of s upportive therapies can continue en route
to the hos pital or in the ED.
Cr it ic a l EMS
As s e s s m e n t s a n d
Ac t io n s (Bo x 2 )
To provide the bes t outcome for the patient with potential s troke:
Id e n t ify S ig n s
De fin e a n d Re c o g n iz e t h e S ig n s o f S t ro k e (Bo x 1 )
Sup p o rt ABCs
Support the ABCs and provide s upplemental oxygen to hypoxemic (eg, oxygen s aturation <94% ) s troke patients or thos e
patients with unknown oxygen s aturation.
P e rfo rm s tro ke
a s s e s s m e nt
Es ta b lis h tim e
Tria g e to s tro ke
c e nte r
Trans port the patient rapidly and cons ider triage to a s troke
center. Support cardiopulmonary function during trans port. If
pos s ible, bring a witnes s , family member, or caregiver with the
patient to confirm time of ons et of s troke s ymptoms .
(continued)
138
Th e ACLS Ca s e s : Ac u te Stroke
(continued)
Id e n t ify S ig n s
De fin e a n d Re c o g n iz e t h e S ig n s o f S t ro k e (Bo x 1 )
Ale rt ho s p ita l
Che c k g luc o s e
The patient with acute s troke is at ris k for res piratory compromis e from as piration, upper
airway obs truction, hypoventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfus ion and hypoxemia will exacerbate and extend is chemic brain injury,
and it has been as s ociated with wors e outcome from s troke.
Both out-of-hos pital and in-hos pital medical pers onnel s hould provide s upplementary
oxygen to hypoxemic (ie, oxygen s aturation <94% ) s troke patients or patients for whom
oxygen s aturation is unknown.
Fo u n d a t io n a l Fa c t s
Stro ke Ce nte rs a nd
Stro ke Units
Initial evidence indicates a favorable benefit from triage of s troke patients directly to
des ignated s troke centers , but the concept of routine out-of-hos pital triage of s troke
patients requires continued evaluation.
Each receiving hos pital s hould define its capability for treating patients with acute
s troke and s hould communicate this information to the EMS s ys tem and the community. Although not every hos pital has the res ources to s afely adminis ter fibrinolytics ,
every hos pital with an ED s hould have a written plan that des cribes how patients with
acute s troke will be managed in that ins titution. The plan s hould
Detail the roles of healthcare providers in the care of patients with acute s troke,
including identifying s ources of neurologic expertis e
Define which patients to treat with fibrinolytics at that facility
Des cribe when patient trans fer to another hos pital with a dedicated s troke unit is
appropriate
Patients with stroke who require hospitalization should be admitted to a stroke unit
when a stroke unit with a multidisciplinary team experienced in managing stroke is
available within a reasonable transport interval.
Studies have documented improvement in 1-year s urvival rate, functional outcomes ,
and quality of life when patients hos pitalized for acute s troke receive care in a dedicated unit with a s pecialized team.
Once the patient arrives in the ED, a number of as s es s ments and management activities
mus t occur quickly. Protocols s hould be us ed to minimize delay in definitive diagnos is and
therapy.
Th e g oa l of th e s troke te a m , e m e rg e n c y p h ys ic ia n , or oth e r e xp e rts s h ou ld b e to
a s s e s s th e p a tie n t with s u s p e c te d s troke with in 10 m inute s o f a rriva l in th e ED:
Tim e Is Bra in (Box 3).
139
P a r t
Im m e d ia t e Ge n e r a l
As s e s s m e n t a n d
S t a b iliz a t io n
Ste p
Ac t io n s
As s e s s ABCs
P ro vid e o xyg e n
Es ta b lis h IV
a c c e s s a nd
o b ta in b lo o d
s a m p le s
Es tablis h IV acces s and obtain blood s amples for bas eline blood
count, coagulation s tudies , and blood glucos e. Do not let this
delay obtaining a CT s can of the brain.
Che c k g luc o s e
P e rfo rm
ne uro lo g ic
a s s e s s m e nt
Ac tiva te the
s tro ke te a m
Ord e r CT b ra in
scan
Ob ta in 12-le a d
ECG
Im m e d ia t e Ne u ro lo g ic As s e s s m e n t b y S t ro k e Te a m o r De s ig n e e (Bo x 4 )
Ove r vie w
The s troke team, neurovas cular cons ultant, or emergency phys ician does the following:
Reviews the patients his tory, performs a general phys ical examination, and es tablis hes time of s ymptom ons et
Performs a neurologic examination (eg, NIHSS)
Th e g oa l for n e u rolog ic a s s e s s m e n t is with in 25 m inute s o f the p a tie nts a rriva l in
th e ED: Tim e Is Bra in (Box 4).
140
Th e ACLS Ca s e s : Ac u te Stroke
Es t a b lis h S ym p t o m
On s e t
Es tablis hing the time of s ymptom ons et may require interviewing out-of-hos pital providers ,
witnes s es , and family members to determine the time the patient was las t known to be
normal.
Ne u r o lo g ic
Exa m in a t io n
As s es s the patients neurologic s tatus us ing one of the more advanced s troke s cales .
Following is an example:
Na tio na l Ins titute s o f He a lth Stro ke Sc a le
The NIHSS us es 15 items to as s es s the res pons ive s troke patient. This is a validated meas ure of s troke s everity bas ed on a detailed neurologic examination. A detailed dis cus s ion
is beyond the s cope of the ACLS Provider Cours e.
CT S c a n : He m o r r h a g e o r No He m o r r h a g e (Bo x 5 )
In t r o d u c t io n
A critical decis ion point in the as s es s ment of the patient with acute s troke is the performance and interpretation of a noncontras t CT s can to differentiate is chemic from hemorrhagic s troke. As s es s ment als o includes identifying other s tructural abnormalities that may
be res pons ible for the patients s ymptoms or that repres ent contraindication to fibrinolytic
therapy. The initial noncontras t CT s can is the mos t important tes t for a patient with acute
s troke.
If a CT s can is not readily available, s tabilize and promptly trans fer the patient to a
facility with this capability.
Do not give as pirin, heparin, or rtPA until the CT s can has ruled out intracranial hemorrhage.
The CT s ca n s hould be c om ple te d within 25 m inute s of the pa tie nts a rriva l in the
ED a nd s hould be re a d within 45 m inute s from ED a rriva l: Tim e Is Bra in (Box 5).
De c is io n P o in t :
He m o r r h a g e o r No
He m o r r h a g e
Additional imaging techniques s uch as CT perfus ion, CT angiography, or magnetic res onance imaging s cans of patients with s us pected s troke s hould be promptly interpreted
by a phys ician s killed in neuroimaging interpretation. Obtaining thes e s tudies s hould not
delay initiation of IV rtPA in eligible patients . The pres ence of hemorrhage vers us no hemorrhage determines the next s teps in treatment (Figures 42A and B).
Ye s , He m orrh a g e Is P re s e n t
If hemorrhage is noted on the CT s can, the patient is not a candidate for fibrinolytics .
Cons ult a neurologis t or neuros urgeon. Cons ider trans fer for appropriate care (Box 7).
141
P a r t
Is chemic Penumbra
Fig u re 4 2 . Occlus ion in a cerebral artery by a thrombus . A, Area of infarction s urrounding immediate s ite and dis tal portion of brain tis s ue after
occlus ion. B, Area of is chemic penumbra (is chemic, but not yet infarcted [dead] brain tis s ue) s urrounding areas of infarction. This is chemic penumbra is alive but dys functional becaus e of altered membrane potentials . The dys function is potentially revers ible. Current s troke treatment tries to
keep the area of permanent brain infarction as s mall as pos s ible by preventing the areas of revers ible brain is chemia in the penumbra from trans forming into larger areas of irrevers ible brain infarction.
142
Th e ACLS Ca s e s : Ac u te Stroke
Fib r in o lyt ic Th e r a p y
In t r o d u c t io n
Several s tudies have s hown a higher likelihood of good to excellent functional outcome
when rtPA is given to adults with acute is chemic s troke within 3 hours of ons et of s ymptoms , or within 4.5 hours of ons et of s ymptoms for s elected patients . But thes e res ults
are obtained when rtPA is given by phys icians in hos pitals with a s troke protocol that rigorous ly adheres to the eligibility criteria and therapeutic regimen of the NINDS protocol.
Evidence from pros pective randomized s tudies in adults als o documents a greater likelihood of benefit the earlier treatment begins .
The AHA and s troke guidelines recommend giving IV rtPA to patients with acute is chemic
s troke who meet the NINDS eligibility criteria if it is given by
Phys icians us ing a clearly defined ins titutional protocol
A knowledgeable interdis ciplinary team familiar with s troke care
An ins titution with a commitment to comprehens ive s troke care and rehabilitation
The s uperior outcomes reported in both community and tertiary care hos pitals in the
NINDS trials can be difficult to replicate in hos pitals with les s experience in, and ins titutional commitment to, acute s troke care. There is s trong evidence to avoid all delays and
treat patients as s oon as pos s ible. Failure to adhere to protocol is as s ociated with an
increas ed rate of complications , particularly ris k of intracranial hemorrhage.
Eva lu a t e fo r
Fib r in o lyt ic Th e r a p y
(Bo x 6 )
If the CT s can is negative for hemorrhage, the patient may be a candidate for fibrinolytic
therapy. Immediately perform further eligibility and ris k s tratification:
If the CT s can s hows no hemorrhage, the probability of acute is chemic s troke
remains . Review inclusion and exclusion criteria for IV fibrinolytic therapy (Table 5) and
repeat the neurologic exam (NIHSS or Canadian Neurological Scale).
If the patients neurologic function is rapidly improving toward normal, fibrinolytics
may be unneces s ary.
Ta b le 5 . Inc lus io n a nd Exc lus io n Cha ra c te ris tic s o f P a tie nts With Is c he m ic Stro ke Who Co uld Be
Tre a te d With rtPA Within 3 Hou rs Fro m Sym p to m Ons e t*
In c lu s io n Cr it e r ia
Diagnos is of is chemic s troke caus ing meas urable neurologic deficit
Ons et of s ymptoms <3 hours before beginning treatment
Age 18 years
Exc lu s io n Cr it e r ia
Head trauma or prior s troke in previous 3 months
Symptoms s ugges t s ubarachnoid hemorrhage
Arterial puncture at noncompres s ible s ite in previous 7 days
His tory of previous intracranial hemorrhage
Elevated blood pres s ure (s ys tolic >185 mm Hg or dias tolic >110 mm Hg)
Evidence of active bleeding on examination
Acute bleeding diathes is , including but not limited to
Platelet count <100 000/mm 3
Heparin received within 48 hours , res ulting in an aPTT greater than the upper
limit of normal
Current us e of anticoagulant with INR >1.7 or PT >15 s econds
Blood glucos e concentration <50 mg/dL (2.7 mmol/L)
CT demons trates multilobar infarction (hypodens ity > cerebral hemis phere)
(continued)
143
P a r t
5
(continued)
Re la t ive Exc lu s io n Cr it e r ia
Recent experience s ugges ts that under s ome circums tances with careful cons ideration and weighing of ris k to benefitpatients may receive fibrinolytic therapy des pite 1
or more relative contraindications . Cons ider ris k to benefit of rtPA adminis tration carefully if any one of thes e relative contraindications is pres ent:
Only minor or rapidly improving s troke s ymptoms (clearing s pontaneous ly)
Seizure at ons et with pos tictal res idual neurologic impairments
Major s urgery or s erious trauma within previous 14 days
Recent gas trointes tinal or urinary tract hemorrhage (within previous 21 days )
Recent acute myocardial infarction (within previous 3 months )
Abbreviations : aPTT, activated partial thromboplas tin time; INR, international normalized ratio; PT, prothrombin time; rtPA, recombinant tis s ue plas minogen activator.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Ros enwas ser RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart Ass ociation/
American Stroke Ass ociation Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vascular Disease and Quality of Care Outcomes in
Research Interdisciplinary Working Groups . Stroke. 2007;38:1655-1711.
P o t e n t ia l Ad ve r s e
Effe c t s
As with all drugs , fibrinolytics have potential advers e effects . At this point weigh the
patients ris k for advers e events agains t the potential benefit and dis cus s with the patient
and family.
Confirm that no exclus ion criteria are pres ent (Table 5).
Cons ider ris ks and benefits .
Be prepared to monitor and treat any potential complications .
The major complication of IV rtPA for s troke is intracranial hemorrhage. Other bleeding
complications may occur and may range from minor to major. Angioedema and trans ient
hypotens ion may occur.
P a t ie n t Is a
Ca n d id a t e fo r
Fib r in o lyt ic Th e r a p y
(Bo xe s 8 a n d 1 0 )
If the patient remains a candidate for fibrinolytic therapy (Box 8), dis cus s the ris ks and
potential benefits with the patient or family if available (Box 10). After this dis cus s ion, if
the patient or family members decide to proceed with fibrinolytic therapy, give the patient
rtPA. Begin your ins titutions s troke rtPA protocol, often called a pathway of care.
Do n ot a d m in is te r a n tic oa g u la n ts or a n tip la te le t tre a tm e n t for 24 h ou rs a fte r
a d m in is tra tion of rtPA, typ ic a lly u n til a follow-u p CT s c a n a t 24 h ou rs s h ows n o
in tra c ra n ia l h e m orrh a g e .
Ext e n d e d IV
r t PA Win d o w
3 t o 4 .5 Ho u r s
144
Treatment of carefully s elected patients with acute is chemic s troke with IV rtPA between 3
and 4.5 hours after ons et of s ymptoms has als o been s hown to improve clinical outcome,
although the degree of clinical benefit is s maller than that achieved with treatment within 3
hours . Data s upporting treatment in this time window come from a large, randomized trial
(ECASS-3 [European Cooperative Acute Stroke Study]) that s pecifically enrolled patients
between 3 and 4.5 hours after s ymptom ons et, as well as a meta-analys is of prior trials .
Th e ACLS Ca s e s : Ac u te Stroke
At pres ent, us e of IV rtPA within the 3- to 4.5-hour window has not yet been approved
by the US Food and Drug Adminis tration (FDA), although it is recommended by an AHA/
American Stroke As s ociation s cience advis ory. Adminis tration of IV rtPA to patients with
acute is chemic s troke who meet the NINDS or ECASS-3 eligibility criteria (Table 6) is recommended if rtPA is adminis tered by phys icians in the s etting of a clearly defined protocol, a knowledgeable team, and ins titutional commitment.
Ta b le 6 . Inc lus io n a nd Exc lus io n Cha ra c te ris tic s o f P a tie nts With Is c he m ic Stro ke Who Co uld Be
Tre a te d With rtPA Fro m 3 to 4.5 Ho urs Fro m Sym p to m Ons e t*
In c lu s io n Cr it e r ia
Diagnos is of is chemic s troke caus ing meas urable neurologic deficit
Ons et of s ymptoms 3 to 4.5 hours before beginning treatment
Exc lu s io n Cr it e r ia
Age >80 years
Severe s troke (NIHSS >25)
Taking an oral anticoagulant regardles s of INR
His tory of both diabetes and prior is chemic s troke
No te s
The checklis t includes s ome US FDAapproved indications and contraindications
for adminis tration of rtPA for acute is chemic s troke. Recent AHA/ASA guideline
revis ions may differ s lightly from FDA criteria. A phys ician with expertis e in acute
s troke care may modify this lis t.
Ons et time is either witnes s ed or las t known normal.
In patients without recent us e of oral anticoagulants or heparin, treatment with rtPA
can be initiated before availability of coagulation s tudy res ults but s hould be dis continued if INR is >1.7 or PT is elevated by local laboratory s tandards .
In patients without a his tory of thrombocytopenia, treatment with rtPA can be initiated before availability of platelet count but s hould be dis continued if platelet
count is <100 000/mm 3 .
Abbreviations : FDA, Food and Drug Adminis tration; INR, international normalized ratio; NIHSS, National
Ins titutes of Health Stroke Scale; PT, prothrombin time; rtPA, recombinant tis s ue plas minogen activator.
*del Zoppo
GJ , Saver J L, J auch EC, Adams HP J r; on behalf of the American Heart As s ociation Stroke
Council. Expans ion of the time window for treatment of acute is chemic s troke with intravenous tis s ue plas minogen activator: a s cience advis ory from the American Heart As s ociation/American Stroke
As s ociation. Stroke. 2009;40:2945-2948.
In t r a -a r t e r ia l r t PA
Improved outcome from us e of cerebral intra-arterial rtPA has been documented. For
patients with acute is chemic s troke who are not candidates for s tandard IV fibrinolys is ,
cons ider intra-arterial fibrinolys is in centers with the res ources and expertis e to provide it
within the firs t 6 hours after ons et of s ymptoms . Intra-arterial adminis tration of rtPA is not
yet approved by the FDA.
145
P a r t
Ge n e r a l S t ro k e Ca re (Bo xe s 1 1 a n d 1 2 )
In t r o d u c t io n
The general care of all patients with s troke includes the following:
Begin s troke pathway.
Support airway, breathing, and circulation.
Monitor blood glucos e.
Monitor blood pres s ure.
Monitor temperature.
Perform dys phagia s creening.
Monitor for complications of s troke and fibrinolytic therapy.
Trans fer to general intens ive care if indicated.
Be g in S t r o k e
P a t h w a y (Bo xe s 1 1
and 12)
Admit patients to a s troke unit (if available) for careful obs ervation (Box 11), including
monitoring of blood pres s ure and neurologic s tatus . If neurologic s tatus wors ens , order an
emergent CT s can. Determine if cerebral edema or hemorrhage is the caus e; cons ult neuros urgery as appropriate.
Additional s troke care includes s upport of the airway, oxygenation, ventilation, and nutrition. Provide normal s aline to maintain intravas cular volume (eg, approximately 75 to
100 mL/h) if needed.
Mo n it o r Blo o d
Glu c o s e
Hyperglycemia is as s ociated with wors e clinical outcome in patients with acute is chemic s troke. But there is no direct evidence that active glucos e control improves clinical
outcome. There is evidence that ins ulin treatment of hyperglycemia in other critically ill
patients improves s urvival rates . For this reas on, cons ider giving IV or s ubcutaneous ins ulin to lower blood glucos e in patients with acute is chemic s troke when the s erum glucos e
level is >185 mg/dL.
Mo n it o r fo r
Co m p lic a t io n s
of Stroke a n d
Fib r in o lyt ic Th e r a p y
Prophylaxis for s eizures is not recommended. But treatment of acute s eizures followed by
adminis tration of anticonvuls ants to prevent further s eizures is recommended. Monitor the
patient for s igns of increas ed intracranial pres s ure. Continue to control blood pres s ure to
reduce the potential ris k of bleeding.
Hyp e r t e n s io n
Ma n a g e m e n t in r t PA
Ca n d id a t e s
Although management of hypertens ion in the s troke patient is controvers ial, patients who
are candidates for fibrinolytic therapy s hould have their blood pres s ure controlled to lower
the ris k of intracerebral hemorrhage following adminis tration of rtPA. General guidelines for
the management of hypertens ion are outlined in Tables 7 and 8.
If patient is eligible for fibrinolytic therapy, blood pres s ure mus t be 185 mm Hg s ys tolic and 110 mm Hg dias tolic to limit the ris k of bleeding complications . Becaus e the
maximum interval from ons et of s troke until effective treatment of s troke with rtPA is limited, mos t patients with s us tained hypertens ion above thes e levels will not be eligible for
IV rtPA.
146
Th e ACLS Ca s e s : Ac u te Stroke
Ta b le 7 . P o te ntia l Ap p ro a c he s to Arte ria l Hyp e rte ns io n in P a tie nts With Ac ute Is c he m ic Stro ke
Who Are P ote ntia l Ca nd id a te s fo r Ac ute Re p e rfus io n The ra p y*
Patient otherwis e eligible for acute reperfus ion therapy except that blood pres s ure is
>185/110 mm Hg:
Labetalol 10-20 mg IV over 1-2 minutes , may repeat 1, or
Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes ,
maximum 15 mg per hour; when des ired blood pres s ure is reached, lower to 3 mg
per hour, or
Other agents (hydralazine, enalaprilat, etc) may be cons idered when appropriate
If blood pres s ure is not maintained at or below 185/110 mm Hg, do not adminis ter rtPA.
Management of blood pres s ure during and after rtPA or other acute reperfus ion therapy:
Monitor blood pres s ure every 15 minutes for 2 hours from the s tart of rtPA therapy,
then every 30 minutes for 6 hours , and then every hour for 16 hours .
If s ys tolic blood pres s ure 180-230 mm Hg or dias tolic blood pres s ure 105-120 mm Hg:
Labetalol 10 mg IV followed by continuous IV infus ion 2-8 mg per minute, or
Nicardipine IV 5 mg per hour, titrate up to des ired effect by 2.5 mg per hour every
5-15 minutes , maximum 15 mg per hour
If blood pres s ure not controlled or dias tolic blood pres s ure >140 mm Hg, cons ider
s odium nitroprus s ide.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgens tern LB, Qures hi AI, Ros enwas s er RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart As s ociation/
American Stroke As s ociation Stroke Council, Clinical Cardiology Council, Cardiovas cular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vas cular Dis eas e and Quality of Care Outcomes in
Res earch Interdis ciplinary Working Groups . Stroke. 2007;38:1655-1711.
Ta b le 8 . Ap p ro a c h to Arte ria l Hyp e rte ns io n in P a tie nts With Ac ute Is c he m ic Stro ke Who Are Not
P o te ntia l Ca nd id a te s fo r Ac ute Re p e rfus io n The ra p y*
Cons ider lowering blood pres s ure in patients with acute is chemic s troke if s ys tolic
blood pres s ure >220 mm Hg or dias tolic blood pres s ure >120 mm Hg.
Cons ider blood pres s ure reduction as indicated for other concomitant organ s ys tem
injury:
Acute myocardial infarction
Conges tive heart failure
Acute aortic dis s ection
A reas onable target is to lower blood pres s ure by 15% to 25% within the firs t day.
*Adams HP J r, del Zoppo G, Alberts MJ , Bhatt DL, Bras s L, Furlan A, Grubb RL, Higas hida RT, J auch EC,
Kidwell C, Lyden PD, Morgens tern LB, Qures hi AI, Ros enwas s er RH, Scott PA, Wijdicks EFM. Guidelines
for the early management of adults with is chemic s troke: a guideline from the American Heart As s ociation/
American Stroke As s ociation Stroke Council, Clinical Cardiology Council, Cardiovas cular Radiology and
Intervention Council, and the Atheros clerotic Peripheral Vas cular Dis eas e and Quality of Care Outcomes in
Res earch Interdis ciplinary Working Groups . Stroke. 2007;38:1655-1711.
147
P a r t
Ap p e n d ix
149
Ma n a g e m e n t o f Re s p ir a t o r y Ar re s t
Ba g -Ma s k Ve n t ila t io n Te s t in g Ch e c k lis t
Student Name: ______________________________________________________________ Tes t Date: _______________________
if d o n e
c o r re c t ly
P e r fo r m a n c e Gu id e lin e s a n d Cr it ic a l Ac t io n s
BLS S u r ve y a n d In t e r ve n t io n s
Checks for res pons ivenes s
Taps and s houts , Are you all right?
and
Scans ches t for movement (5-10 s econds )
Activates the emergency res pons e s ys tem
Activates the emergency res pons e s ys tem and gets the AED
or
Directs s econd res cuer to activate the emergency res pons e s ys tem and get the AED
Checks carotid puls e (5-10 s econds ). Notes that puls e is pres ent
Does not initiate ches t compres s ions or attach AED
Performs ventilations at the correct rate of 1 breath every 5-6 s econds
(10-12 breaths per minute)
ACLS S u r ve y Ca s e S k ills
Ins erts oropharyngeal or nas opharyngeal airway
Adminis ters oxygen
Performs correct bag-mas k ventilation for 1 minute
Cr it ic a l Ac t io n s
Effectively ventilates with a bag-mas k device for 1 minute
Gives proper ventilationrate and volume
STOP TEST
Te s t Re s ults
NR
151
CP R a n d AED S k ills Te s t
1 -Re s c u e r Ad u lt CP R a n d AED Ch e c k lis t
Student Name: ______________________________________________________________ Tes t Date: _______________________
S k ill
Ste p
if d o n e
c o r re c t ly
Cr it ic a l P e r fo r m a n c e S t e p s
BLS S u r ve y a n d In t e r ve n t io n s
1
Checks for res pons ivenes s : Taps and shouts, Are you all right? and
scans the chest for movement (5-10 seconds)
Tells s omeone to activate the emergency res pons e s ys tem and get an AED
Delivers firs t cycle of compres s ions at correct rate (acceptable: 18 seconds or less
for 30 compressions)
AED Ar r ive s
AED
1
Turns AED on, s elects proper pads , and places pads correctly
AED
2
AED
3
Clears patient to s hock/pres s es s hock button (must be visible and verbal check;
maximum time from AED arrival less than 45 seconds)
S t u d e n t Co n t in u e s CP R
7
Delivers s econd cycle of compres s ions at correct hand pos ition (acceptable: greater
than 23 of 30 compressions)
The next step is performed only if the manikin is equipped with a feedback device, such as a clicker or light. If there is
no feedback device, STOP THE TEST.
9
Delivers third cycle of compres s ions of adequate depth with complete ches t recoil
(acceptable: greater than 23 compressions)
STOP TEST
Te s t Re s ults
NR
152
Me g a c o d e Te s t in g Ch e c k lis t 1 / 2
Br a d yc a rd ia
VF/ P u ls e le s s VT
As ys t o le
ROS C
Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well
Br a d yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes s ymptomatic bradycardia
Adminis ters correct dos e of atropine
Prepares for s econd-line treatment
VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es
As ys t o le Ma n a g e m e n t
Recognizes as ys tole
Verbalizes potential revers ible caus es of as ys tole/PEA (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm checks
P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults
NR
153
Me g a c o d e Te s t in g Ch e c k lis t 3
Ta c h yc a rd ia
VF/ P u ls e le s s VT
P EA
ROS C
Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well
Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes uns table tachycardia
Recognizes s ymptoms due to tachycardia
Performs immediate s ynchronized cardiovers ion
VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es
P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks
P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults
NR
154
Me g a c o d e Te s t in g Ch e c k lis t 4
Ta c h yc a rd ia
VF/ P u ls e le s s VT
P EA
ROS C
Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well
Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes tachycardia (s pecific diagnos is )
Recognizes no s ymptoms due to tachycardia
Attempts vagal maneuvers
Gives appropriate initial drug therapy
VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es
P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks
P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults
NR
Me g a c o d e Te s t in g Ch e c k lis t 5
Ta c h yc a rd ia
VF/ P u ls e le s s VT
P EA
ROS C
Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well
Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes uns table tachycardia
Recognizes s ymptoms due to tachycardia
Performs immediate s ynchronized cardiovers ion
VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es
P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks
P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults
NR
156
Me g a c o d e Te s t in g Ch e c k lis t 6
Ta c h yc a rd ia
VF/ P u ls e le s s VT
P EA
ROS C
Cr it ic a l P e r fo r m a n c e S t e p s
Te a m Le a d e r
Ens ures high-quality CPR at all times
As s igns team member roles
Ens ures that team members perform well
Ta c h yc a rd ia Ma n a g e m e n t
Starts oxygen if needed, places monitor, s tarts IV
Places monitor leads in proper pos ition
Recognizes tachycardia (s pecific diagnos is )
Recognizes no s ymptoms due to tachycardia
Gives appropriate initial drug therapy
VF/ P u ls e le s s VT Ma n a g e m e n t
Recognizes VF
Clears before ANALYZE and SHOCK
Immediately res umes CPR after s hocks
Appropriate airway management
Appropriate cycles of drugrhythm check/s hockCPR
Adminis ters appropriate drug(s ) and dos es
P EA Ma n a g e m e n t
Recognizes PEA
Verbalizes potential revers ible caus es of PEA/as ys tole (Hs and Ts )
Adminis ters appropriate drug(s ) and dos es
Immediately res umes CPR after rhythm and puls e checks
P o s t Ca rd ia c Ar re s t Ca re
Identifies ROSC
Ens ures BP and 12-lead ECG are performed, O 2 s aturation is monitored, verbalizes need for
endotracheal intubation and waveform capnography, and orders laboratory tes ts
Cons iders therapeutic hypothermia
STOP TEST
Te s t Re s ults
NR
157
Ca rd ia c Ar re s t VF/ P u ls e le s s VT Le a r n in g S t a t io n Ch e c k lis t
CP R Qua lity
Sta rt CP R
No
Ye s
ETCO
3
Sh oc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
ETCO
No
Sho c k Ene rg y
Ye s
Sh oc k
10
6
Ep ine p hrine
Ep ine p hrine
Drug The ra p y
No
Ye s
Ye s
Sh oc k
No
11
No
Ye s
12
Go to 5 o r 7
10
158
11
H
H
H
H
H
T
T
T
T
T
Ca rd ia c Ar re s t P EA/ As ys t o le Le a r n in g S t a t io n Ch e c k lis t
CP R Qua lity
Ad ult Ca rd ia c Arre s t
Shout for He lp/Ac tiva te Em e rge nc y Re s po ns e
compres s ions
Sta rt CP R
30:2 compres s ionYe s
No
Rhythm
s ho c ka b le ?
ETCO2
VF/VT
capnography
attempt to improve
As ys to le /P EA
3
Shoc k
Re turn o f Sp o nta ne o us
Circ ula tio n (ROSC)
CP R 2 m in
increas e in P ETCO 2
Rhythm
s ho c ka b le ?
No
Sho c k Ene rg y
Ye s
Shoc k
10
CP R 2 m in
CP R 2 m in
capnography
Drug The ra p y
capnography
Rhythm
s ho c ka b le ?
360 J
Va s o p re s s in
No
Rhythm
s ho c ka b le ?
Ye s
epinephrine
Ye s
Shoc k
No
Ad va nc e d Airwa y
11
CP R 2 m in
CP R 2 m in
Am io d a ro ne
compres s ions
No
Rhythm
s ho c ka b le ?
Ye s
12
Go to 5 o r 7
10 or 11
Re ve rs ib le Ca us e s
H
H
H
H
Hypothermia
T
T
T
T
T
159
Im m e d ia t e P o s t Ca rd ia c Ar re s t Ca re Le a r n in g S t a t io n Ch e c k lis t
2
Op tim ize ve ntila tio n a nd o xyg e na tio n
Maintainoxygens aturation94%
Cons ideradvancedairwayandwaveformcapnography
Donothyperventilate
3
Tre a t hyp o te ns io n (SBP <90 m m Hg )
IV/IObolus
Vas opres s orinfus ion
Cons idertreatablecaus es
12-LeadECG
5
No
Fo llo w
c o m m a nd s ?
7
Ye s
Co ro na ry re p e rfus io n
Ye s
STEMI
OR
highs us picionofAMI
No
Ad va nc e d c ritic a l c a re
160
Do s e s /De ta ils
Ve ntila tio n/Oxyg e na tio n
Avoidexces s iveventilation.
Startat10-12breaths /min
andtitratetotargetP e t c o 2
of35-40mmHg.
Whenfeas ible,titrateFio 2
tominimumneces s aryto
achieveSp o 2 94% .
IV Bo lus
1-2Lnormals aline
orlactatedRingers .
Ifinducinghypothermia,
mayus e4Cfluid.
Ep ine p hrine IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcg
perminute)
Do p a m ine IV Infus io n:
5-10mcg/kgperminute
No re p ine p hrine
IV Infus io n:
0.1-0.5mcg/kgperminute
(in70-kgadult:7-35mcg
perminute)
Re ve rs ib le Ca us e s
Hypovolemia
Hypoxia
Hydrogenion(acidos is )
Hypo-/hyperkalemia
Hypothermia
Tens ionpneumothorax
Tamponade,cardiac
Toxins
Thrombos is ,pulmonary
Thrombos is ,coronary
Br a d yc a rd ia Le a r n in g S t a t io n Ch e c k lis t
Ad ult Bra d yc a rd ia
(With Puls e)
2
Id e ntify a nd tre a t und e rlying c a us e
Maintainpatentairway;as s is tbreathingas neces s ary
Oxygen(ifhypoxemic)
Cardiacmonitortoidentifyrhythm;monitorbloodpres s ureandoximetry
IVacces s
12-LeadECGifavailable;dontdelaytherapy
3
P e rs is te nt b ra d ya rrhythm ia
c a us ing :
4
Mo nito r a nd o b s e rve
No
Hypotens ion?
Acutely altered mental s tatus ?
Signs of s hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s
Atro p ine
Ifatropineineffective:
Trans cutaneous pacing
OR
Do p a m ine infus ion
OR
Ep ine p hrine infus ion
Do s e s /De ta ils
Atro p ine IV Do s e :
Firs tdos e:0.5mgbolus
Repeatevery3-5minutes
Maximum:3mg
Do p a m ine IV Infus io n:
2-10mcg/kgperminute
Ep ine p hrine IV Infus io n:
2-10mcgperminute
6
Co ns id e r:
Expertcons ultation
Trans venous pacing
2010 American Heart As s ociation
161
Ta c h yc a rd ia Le a r n in g S t a t io n Ch e c k lis t
Ad ult Ta c hyc a rd ia
(With Puls e)
1
As s es s appropriatenes s for clinical cond ition.
Heart rate typically 150/min if tachyarrhythmia.
2
Id e ntify a nd tre a t und e rlying c a u s e
Do s e s /De ta ils
3
4
P e rs is te nt ta c hya rrhythm ia
c a us ing :
Hypotens ion?
Acutely altered mental s tatus ?
Signs ofs hock?
Is chemicches t dis comfort?
Acuteheartfailure?
Ye s
No
Wid e QRS?
0.12 s e c o nd
Ye s
IVacces s and12-leadECG
ifavailab le
C ons ideradenos ineonlyif
regularandmonomorp hic
Cons iderantiarrhythmicinfus ion
Cons iderexp ertcons ultation
No
IVacces s and12-leadECGifavailable
Vagalmaneuvers
Adenos ine(ifregular)
-Blockerorcalciumchannelblocker
Cons id erexpertcons ultation
162
Ad e no s ine IV Do s e :
Firs tdos e:6mgrapidIVpus h;follow
withNSflus h.
Seconddos e:12mgifrequired .
2 0 0 5 Gu id e lin e s
2 0 1 0 Gu id e lin e s
A-B-C-D:Airway,Breathing,
Circulation,Defibrillation
Look,lis ten,andfeelfor
breathingandgive2res cue
breaths
1-2-3-4
1. Che c k re s p o ns ive ne s s .
2. Ac tiva te the e m e rg e nc y
re s p o ns e s ys te m a nd g e t a n
AED.
3. Circ ula tio n: Checkthecarotid
puls e.Ifyoucannotdetecta
puls ewithin10s econds ,s tart
CPR,beginningwithches t
compres s ions ,immediately.
4. De fib rilla tio n:Ifindicated,
deliveras hockwithanAEDor
defibrillator.
To p ic
BLS:
Hig h-Qua lity CP R
2 0 1 0 Gu id e lin e s
Arateofa t le a s t 100ches tcompres s ions perminute
Acompres s iondepthofa t le a s t 2 inc he s inadults
Allowingcompleteches trecoilaftereachcompres s ion
Minimizinginterruptions incompres s ions (10s econds orles s )
Switchingproviders aboutevery2minutes toavoidfatigue
Avoidingexces s iveventilation
ACLS:
Ca rd ia c Arre s t
a nd Bra d yc a rd ia
Alg o rithm s
163
(continued)
To p ic
ACLS:
Ta c hyc a rd ia
Sync hro nize d
Ca rd io ve rs io n
2 0 1 0 Gu id e lin e s
The 2010 AHA Guidelines for CPR and ECC s implifies the Tachycardia
Algorithm.
For cardiovers ion of uns table atrial fibrillation, the 2010 AHA Guidelines
for CPR and ECC recommends that the initial biphas ic energy dos e be
between 120 and 200 J . Cardiovers ion with monophas ic waveforms
s hould begin at 200 J and increas e in a s tepwis e fas hion if not s ucces s ful.
For cardiovers ion of uns table SVT or uns table atrial flutter, the 2010 AHA
Guidelines for CPR and ECC recommends that the initial monophas ic or
biphas ic energy dos e be between 50 to 100 J .
The 2010 AHA Guidelines for CPR and ECC als o recommends
cardiovers ion for uns table monomorphic VT, with an initial energy dos e of
100 J .
If the initial s hock fails , providers s hould increas e the dos e in a s tepwis e
fas hion.
ACLS:
P o s tCa rd ia c
Arre s t Ca re
A new s ection focus ing on pos tcardiac arres t care was introduced in
the 2010 AHA Guidelines for CPR and ECC. Recommendations aimed at
improving s urvival after ROSC include
Optimizing cardiopulmonary function and vital organ perfus ion, es pecially
to the brain and heart
Trans porting out-of-hos pital cardiac arres t patients to an appropriate
facility with pos tcardiac arres t care that includes acute coronary
interventions , neurologic care, goal-directed critical care, and hypothermia
Trans porting in-hos pital cardiac arres t patients to a critical care unit
capable of providing comprehens ive pos tcardiac arres t care
Identifying and treating the caus es of the arres t and preventing recurrence
Cons idering therapeutic hypothermia to optimize s urvival and neurologic
recovery in comatos e patients
Identifying and treating acute coronary s yndromes
Optimizing mechanical ventilation to minimize lung injury
Gathering data for prognos is
As s is ting patients and families with rehabilitation s ervices if needed
Critic a l a c tio ns fo r p o s tc a rd ia c a rre s t c a re :
Hemodynamic optimization, including a focus on treating hypotens ion
Acquis ition of a 12-lead ECG
Induction of therapeutic hypothermia
Monitoring advanced airway placement and ventilation s tatus with
quantitative waveform capnography in intubated patients
Optimizing arterial oxygen s aturation
ACLS:
Ma na g ing
the Airwa y
The 2010 AHA Guidelines for CPR and ECC recommends us ing waveform
capnography to monitor the amount of carbon dioxide exhaled by the
patient and to verify placement of an endotracheal tube.
Cricoid pres s ure s hould not be us ed routinely during cardiac arres t. This
technique is difficult to mas ter and may not be effective for preventing
as piration. It may als o delay or prevent placement of an advanced airway.
Agonal gas ps are not effective breaths and s hould not be confus ed with
normal breathing.
ACLS P h a r m a c o lo g y S u m m a r y Ta b le
Dr u g
Ad e no s ine
Am io d a ro ne
In d ic a t io n s
P re c a u t io n s /
Co n t r a in d ic a t io n s
Ad u lt Do s a g e
Contraindicatedinpois on/
drug-inducedtachycardiaor
s econd-orthird-degreeheart
block
Trans ients ideeffects include
flus hing,ches tpainortightnes s ,briefperiods ofas ys tole
orbradycardia,ventricular
ectopy
Les s effective(largerdos es
mayberequired)inpatients
takingtheophyllineorcaffeine
Reduceinitialdos eto3mgin
patients receivingdipyridamoleorcarbamazepine,inheart
trans plantpatients ,orifgiven
bycentralvenous acces s
Ifadminis teredforirregular,
polymorphicwide-complex
tachycardia/VT,maycaus e
deterioration(including
hypotens ion)
Trans ientperiods ofs inus
bradycardiaandventricular
ectopyarecommonafter
t erminationofSVT
Safeandeffectivein
pregnancy
IV Ra p id P us h
Placepatientinmildrevers e
Trendelenburgpos itionbefore
adminis trationofdrug
Initialbolus of6mggivenrapidlyover1to3s econds followedbyNSbolus of20mL;
thenelevatetheextremity
As econddos e(12mg)can
begivenin1to2minutes if
needed
Ca u tion : Multip le c o m p le x
d rug inte ra c tio ns
VF/VT Ca rd ia c Arre s t
Unre s p o ns ive to CP R, Sho c k,
a nd Va s o p re s s o r
Rapidinfus ionmayleadto
hypotens ion
Withmultipledos ing,cumulativedos es >2.2gover24
hours areas s ociatedwiths ig VF/puls eles s VTunres pons ive
nificanthypotens ioninclinical
tos hockdelivery,CPR,anda
trials
vas opres s or
Donotadminis terwithother
Recurrent,hemodynamically
drugs thatprolongQTinterval
uns tableVT
(eg,procainamide)
With expert consultationamiod Terminaleliminationis
aronemaybeus edfortreatment
extremelylong(half-lifelas ts
ofs omeatrialandventricular
upto40days )
arrhythmias
Firs t d o s e :300mgIV/IO
pus h
Se c o nd d o s e (if ne e d e d ):
150mgIV/IOpus h
Life -Thre a te ning Arrhythm ia s
Ma xim um c um ula tive d o s e :
2.2gIVover24hours .Maybe
adminis teredas follows :
Ra p id infus io n:150mgIV
overfirs t10minutes (15mg
perminute).Mayrepeatrapid
infus ion(150mgIV)every10
minutes as needed
Slo w infus io n:360mg
IVover6hours (1mgper
minute)
Ma inte na nc e infus io n:540
mgIVover18hours (0.5mg
perminute)
(continued)
165
(continued)
Dr u g
Atro p ine
Sulfa te
Can be given
via endotracheal tube
In d ic a t io n s
Firs tdrugfors ymptomatic
s inus bradycardia
Maybebeneficialinpres ence
ofAVnodalblock.No t like ly
to b e e ffe c tive fo r typ e II
s e c o nd -d e g re e o r third d e g re e AV b lo c k o r a b lo c k
in no n-no d a l tis s ue
Routineus eduringPEAor
as ys toleis unlikelytohavea
therapeuticbenefit
Organophos phate(eg,nerve
agent)pois oning:extremely
largedos es maybeneeded
P re c a u t io n s /
Co n t r a in d ic a t io n s
Us ewithcautioninpres ence
ofmyocardialis chemiaand
hypoxia.Increas es myocardial
oxygendemand
Avoidinhypothermic
bradycardia
Maynotbeeffectivefor
infranodal(typeII)AVblock
andnewthird-degreeblock
withwideQRScomplexes .
(Inthes epatients maycaus e
paradoxicals lowing.Be
preparedtopaceorgive
catecholamines )
Dos es ofatropine<0.5mg
mayres ultinparadoxical
s lowingofheartrate
Ad u lt Do s a g e
Bra d yc a rd ia (With o r
Witho ut ACS)
0.5mgIVevery3to5minutes as needed,nottoexceed
totaldos eof0.04mg/kg(total
3mg)
Us es horterdos inginterval(3
minutes )andhigherdos es in
s evereclinicalconditions
Org a no p ho s p ha te P o is o ning
Extremelylargedos es (2to4
mgorhigher)maybeneeded
Do p a m ine
IV infusion
Ep ine p hrine
Can be given
via endotracheal tube
Available
in 1:10 000
and 1:1000
concentrations
P ro fo und Bra d yc a rd ia o r
Hyp o te ns io n
2to10mcgperminuteinfus ion;
titratetopatientres pons e
(continued)
166
(continued)
Dr u g
Lid o c a ine
Can be given
via endotracheal tube
In d ic a t io n s
Alternativetoamiodaronein
cardiacarres tfromVF/VT
StablemonomorphicVTwith
pres ervedventricularfunction
StablepolymorphicVTwith
normalbas elineQTinterval
andpres ervedLVfunction
whenis chemiais treated
andelectrolytebalanceis
corrected
Canbeus edfors tablepolymorphicVTwithbas eline
QT-intervalprolongationiftors ades s us pected
P re c a u t io n s /
Co n t r a in d ic a t io n s
Co ntra ind ic a tio n:
Prophylacticus einAMIis
contraindicated
Reducemaintenancedos e
(notloadingdos e)inpres ence
ofimpairedliverfunctionorLV
dys function
Dis continueinfus ionimmediatelyifs igns oftoxicity
develop
Ad u lt Do s a g e
Ca rd ia c Arre s t Fro m VF/VT
Initialdos e:1to1.5mg/kg
IV/IO
ForrefractoryVFmaygive
additional0.5to0.75mg/kgIV
pus h,repeatin5to10minutes ;maximum3dos es or
totalof3mg/kg
P e rfus ing Arrhythm ia
Fors tableVT,wide-complex
tachycardiaofuncertaintype,
s ignificantectopy:
Dos es rangingfrom0.5to
0.75mg/kgandupto1to1.5
mg/kgmaybeus ed
Repeat0.5to0.75mg/kg
every5to10minutes ;maximumtotaldos e:3mg/kg
Ma inte na nc e Infus io n
1to4mgperminute(30to50
mcg/kgperminute)
Ma g ne s ium
Sulfa te
Va s o p re s s in
Can be given
via endotracheal tube
Ca rd ia c Arre s t
(Due to Hyp o m a g ne s e m ia o r
To rs a d e s d e P o inte s )
1to2g(2to4mLofa50%
s olutiondilutedin10mL[eg,
D5 W,normals aline]givenIV/IO)
To rs a d e s d e P o inte s
With a P uls e o r AMI With
Hyp o m a g ne s e m ia
Loadingdoseof1to2gmixed
in50to100mLofdiluent
(eg,D5 W,normals aline)over
5to60minutes IV
Followwith0.5to1gper
hourIV(titratetocontrol
tors ades )
IV Ad m inis tra tio n
Ca rd ia c a rre s t:Onedos eof40
units IV/IOpus hmayreplace
eitherfirs tors econddos eof
epinephrine.Epinephrinecanbe
adminis teredevery3to5minutes duringcardiacarres t
Va s o d ila to ry s ho c k:
Continuous infus ionof0.02to
0.04units perminute
167
Glo s s a r y
A
Ac ute
The early critical s tage of necros is of heart mus cle tis s ue caus ed by blockage of a
coronary artery
Ad va nc e d c a rd io va s c ula r life
s up p o rt (ACLS)
Emergency medical procedures in which bas ic life s upport efforts of CPR are s upplemented with drug adminis tration, IV fluids , etc
As ys to le
In atrial fibrillation the atria quiver chaotically and the ventricles beat irregularly
Atria l flutte r
A delay in the normal flow of electrical impuls es that caus e the heart to beat
B
Ba s ic life s up p o rt (BLS)
Emergency treatment of a victim of cardiac or res piratory arres t through cardiopulmonary res us citation and emergency cardiovas cular care
Bra d yc a rd ia
C
Ca p no g ra p hy
The meas urement and graphic dis play of CO 2 levels in the airways , which can be performed by infrared s pectros copy
Ca rd ia c a rre s t
Ca rd io p ulm o na ry
re s us c ita tio n (CP R)
A bas ic emergency procedure for life s upport, cons is ting of mainly manual external
cardiac mas s age and s ome artificial res piration
Co ro na ry s ynd ro m e
A group of clinical s ymptoms compatible with acute myocardial is chemia (als o called
coronary heart disease)
Co ro na ry thro m b o s is
168
Enc e p ha lo p a thy
The pas s age of a tube through the nos e or mouth into the trachea for maintenance of
the airway
Es o p ha g e a l d e te c to r d e vic e
A dis pos able tool us ed to verify proper endotracheal tube placement by us ing the
anatomical differences between the trachea and es ophagus
Es o p ha g e a l-tra c he a l tub e
A double-lumen tube with inflatable balloon cuffs that s eal off the hypopharynx from
the oropharynx and es ophagus ; us ed for airway management
H
Hyd ro g e n io n (a c id o s is )
The accumulation of acid and hydrogen ions or depletion of the alkaline res erve
(bicarbonate content) in the blood and body tis s ues , decreas ing the pH
Hyp e rka le m ia
An abnormally high concentration of potas s ium ions in the blood. Als o called
hyperpotassemia.
Hyp o g lyc e m ia
Hyp o ka le m ia
An abnormally low concentration of potas s ium ions in the blood. Als o called
hypopotassemia.
Hyp o the rm ia
A potentially fatal condition that occurs when body temperature falls below 95F
(35C)
Hyp o vo le m ia
Hyp o xia
I
Intra o s s e o us (IO)
Within a bone
Intra ve no us (IV)
Within a vein
M
Mild hyp o the rm ia
Mo d e ra te hyp o the rm ia
N
Na s o p ha ryng e a l
O
Oro p ha ryng e a l a irwa y
A tube us ed to provide free pas s age of air between the mouth and pharynx
P
P e rfus io n
The pas s age of fluid (s uch as blood) through a s pecific organ or area of the body
(s uch as the heart)
P ro p hyla xis
P ulm o na ry e d e m a
Continued electrical rhythmicity of the heart in the abs ence of effective mechanical
function
R
Re c o m b ina nt tis s ue
p la s m ino g e n a c tiva to r (rtPA)
A clot-dis s olving s ubs tance produced naturally by cells in the walls of blood ves s els
S
Se ve re hyp o the rm ia
Sinus rhythm
The rhythm of the heart produced by impuls es from the s inoatrial node
Sup ra g lo ttic
Us es a s ens or to deliver a s hock that is s ynchronized with a peak in the QRS complex
169
Sync o p e
A los s of cons cious nes s over a s hort period of time, caus ed by a temporary lack of
oxygen in the brain
T
Ta c hyc a rd ia
Ta m p o na d e (c a rd ia c )
A condition caus ed by accumulation of fluid between the heart and the pericardium,
res ulting in exces s pres s ure on the heart. This impairs the hearts ability to pump s ufficient blood.
Te ns io n p ne um o tho ra x
Pneumothorax res ulting from a wound in the ches t wall which acts as a valve that permits air to enter the pleural cavity but prevents its es cape
Thro m b us
U
Uns ync hro nize d s ho c k
An electrical s hock that will be delivered as s oon as the operator pus hes the SHOCK
button to dis charge the defibrillator. Thus , the s hock can fall anywhere within the cardiac cycle.
170
A rapid heartbeat that originates in one of the lower chambers (ventricles ) of the heart
Fo u n d a t io n In d e x
A
Acute coronary s yndromes
91
Amiodarone
72
Antiarrhythmic drugs
71
As pirin
97
As ys tole
86
105
Atropine
110
B
Bag-mas k
42
Bradycardia
104
D
Defibrillation
54
Dopamine
76, 112
E
Endotracheal tube s uctioning procedure
46
Epinephrine
65
Es ophageal-tracheal tube
48
F
Fibrinolytic therapy
102
105
H
Head tiltchin lift
40
Heparin
104
I
IV/IO acces s
69
L
Laryngeal mas k airway
47
Lidocaine
72
14
M
Magnes ium s ulfate
72
Morphine
97
N
Nitroglycerin
97
O
Oropharyngeal s uctioning procedure
46
Oxygen
38
171
P
Paddles vers us pads
64
78
Puls eles s VT
59
R
Recombinant tis s ue plas minogen activator (rtPA)
144
Refractory VF
59
Reteplas e
102
S
Second-degree AV block
105
Streptokinas e
102
101
T
Tachycardia
114
Tenecteplas e
102
Third-degree AV block
105
111
V
Vas opres s in
65
65
59
128
Y
Yankauer
172
45
In d e x
Abbreviations us ed, 7-9
ABCD approach, 7, 163
Accelerated idioventricular rhythm (AIVR), 7, 113
ACE inhibitors in acute coronary s yndromes , 94, 103
Acetyls alicylic acid
pathophys iology o , 93
Acidos is , 169
as ys tole/PEA in, 83
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
on as ys tole, 86-91
on bradycardia, 104-114
on lone res cuer CPR and AED us e in VF/puls eles s VT, 49-58
overview o , 33
Agonal gas ps , 55
in s troke, 146
I n d e x
AIVR (accelerated idioventricular rhythm), 7, 113
Algorithms
on s troke, 133-147
de nition o , 168
As pirin
in acute coronary s yndromes , 96, 100
in s troke, 131, 134, 141
As ys tole, 86-91
as agonal rhythm con rming death, 90
Cardiac Arres t Algorithm on, 60, 61, 79, 86, 88-89, 159
de nition o , 168
de nition o , 168
drug therapy in, 86, 88; algorithm on, 61, 80, 82, 159
-Blockers
de nitions o , 168
Atrioventricular block
174
in s troke, 146-147
de nition o , 168
In d e x
Algorithm on, 61, 80, 82, 158, 159; during CPR, 67-69;
109, 163
and pos tcardiac arres t care, 28-29, 72-77 (see also Pos t
revers ible caus es o , 61, 66, 73, 80, 82; learning s tation
in as ys tole, 86, 88, 89-90; algorithm on, 61, 80, 82, 159
Capnography
in puls eles s electrical activity, 79, 81; algorithm on, 61, 80,
82, 159
in res piratory arres t, 34, 35, 36, 37, 40; and advanced
airway, 48
in s troke, 136
175
I n d e x
s ummary o 2010 Guidelines on, 163
53, 54, 57; Cardiac Arres t Algorithm on, 61, 62-63, 66,
158; drug therapy with, 65-66; and lone res cuer, 49-58;
Circulation
s equence, 66
in bradycardia, 110
Cardiovers ion
in s table tachycardia, 116
s ynchronized: changes in 2010 Guidelines , 164; compared
122-123
120, 121
Carotid puls e, 13
or airway s uctioning, 45
AED us e, 52, 53, 56, 57; in cycles o CPR, 56, 64, 65;
67-69
Def brillation, 13
In d e x
BLS Survey, 51; clearing warning in, 56, 64; and drug
thromboembolis m
Emergency department as s es s ment and treatment
in bradycardia, 108
Encephalopathy, 168
de nition o , 168
in puls eles s electrical activity, 78, 81; algorithm on, 61, 80,
82, 159
Epinephrine, 166
in ventricular brillation/puls eles s VT, 61, 65, 66, 70, 71, 158
Electrocardiography, 8, 168
in as ys tole, 86, 87
in bradycardia, 105, 106, 110; algorithm on, 109, 161
de nition o , 168
Fibrillation
Fibrinolytic therapy
in acute coronary s yndromes , 92, 93, 102; in prehos pital
care, 98; in ST-s egment elevation, 100, 101, 102
177
I n d e x
in acute s troke, 130, 131, 141, 143-145; advers e e ects
in hypovolemia, 84
Hypothermia, 169
bradycardia and trans cutaneous pacing contraindication in,
112
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
de brillation in, 69
routes o , 70
in s troke, 146
electrocardiography in, 83
Gas ps , agonal, 55
Hypovolemia, 169
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
in s troke, 141
Hyperkalemia, 169
as ys tole/PEA in, 83
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
in s troke, 140
Hypokalemia, 169
as ys tole/PEA in, 83
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Pos tCardiac Arres t Care Algorithm on, 73, 160
Hypomagnes emia, 72, 167
Hypotens ion
In d e x
precautions in, 45
Lidocaine, 167
s ize s election, 44
141, 143
NINDS (National Ins titute o Neurological Dis orders and
algorithm on, 94
MERIT trial, 32
precautions in, 97
73, 77
indications or, 42
101-102
in erior wall, 97
Oxygen
right ventricular, 97
160
Oxygen therapy, 15
in acute coronary s yndromes , 94, 96, 97, 100
time to treatment in, 94, 95, 99, 100, 101; and f brinolytic
102-103
162
toxicity o , 28
Pacing
with implanted pacemaker, AED us e in, 58
179
I n d e x
trans cutaneous , 9; in as ys tole, 89; in bradycardia, 108, 109,
110, 111, 112-114, 161
trans venous , in bradycardia, 108, 109, 112, 161
Paddles and pads o def brillators , 64
o automated external def brillators , 55, 56, 57
Webs ite)
or updating and re res hing s kills , 7
Pulmonary edema, def nition o , 169
Pulmonary thromboembolis m, 9
as ys tole/PEA in, 83, 84, 85
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
Puls e checks , 13
in as ys tole, 86, 88
on, 52, 53; ches t compres s ion interruption or, 62, 64, 65
Puls eles s electrical activity, 9, 78-85
Cardiac Arres t Algorithm on, 60, 61, 78, 79-82
common caus es o , 82-85
def nition o , 169
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
re ractory, 59-77
in cardiac arres t, 32
in s troke, 30
des cription o , 1
In d e x
in res piratory arres t, 34, 35, 36; and advanced airway, 36,
47, 48; exces s ive ventilation in, 38; rate o , 35, 36, 37,
38, 47, 48; ratio to ches t compres s ions , 48; without
ches t compres s ions , 48
in ventricular f brillation/puls eles s VT: and AED us e, 56; rate
o , 51
Res cuer, lone. See Lone res cuer
in hypovolemia, 84
Sotalol in tachycardia with puls e, 129
algorithm on, 118, 127, 162
Speech dis orders in s troke, 136, 137
Spinal injuries , cervical
airway as s es s ment and management in, 39, 40, 49
immobilization in, 49
ST-s egment depres s ion myocardial in arction, 91, 94, 101, 102
algorithm on, 94
99-100
in trauma, 39, 49
Sedation
144-145
emergency medical s ervices in, 30, 130, 132, 134, 135;
activation o , 136; critical actions in, 138-139
general care in, 134, 146-147
Shock
in bradycardia, 113, 161
in tachycardia, 115, 117, 119; algorithm on, 118, 127, 162
Sinus bradycardia, 105, 106, 107
Sinus rhythm, def nition o , 169
Sinus tachycardia, 115, 124
cardiovers ion in, 116
caus es o , 125
I n d e x
regionalization o care in, 30
time to treatment in, 132, 133, 134, 135, 138, 139, 143,
144-145
trans port o patients in, 136; to s troke centers and s troke
units , 138, 139
Student Webs ite, 2, 3, 5-6
on bag-mas k ventilation, 42
on BLS Survey, 12
on endotracheal intubation, 48
on es ophageal-tracheal tube, 48
118, 119
on laryngeal intubation, 47
on oxygen therapy, 38
on team approach, 18
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
in as ys tole, 86
regional, 32
in s troke, 30
Tachycardia, 114-130
def nition o , 115, 118, 170
Thrombos is
hypovolemia, 84
s table, 124-130; advanced management in, 130; algorithm
on, 118, 126-130; cardiovers ion in, 116; clas s if cation
182
In d e x
Cardiac Arres t Algorithm on, 61, 66, 80, 82, 158, 159
drug therapy in, 60, 65-66, 69-72; algorithm on, 61, 65-66,
in hypothermia, 69
in cardiac arres t, 91
manual def brillators in, 59, 61, 62-63; biphas ic, 61, 63,
re ractory, 59-77
team res pons e to, 59
time to def brillation and CPR in, 54
treatment s equence in, 57, 66, 69
in as ys tole, 88
in as ys tole, 87
pos tcardiac arres t, 29
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