2015 Interim Training Materials

ACLS Provider Manual and ACLS EP Manual Comparison Chart

New Old Rationale

BLS Changes
Assessment Healthcare providers (HCPs) must The HCP should check for response The intent of the recommendation change
sequence call for nearby help upon finding the while looking at the patient to is to minimize delay and to encourage
victim unresponsive, but it would be determine if breathing is absent or fast, efficient, simultaneous assessment
(ACLS
practical for an HCP to continue to not normal. and response rather than a slow,
Provider assess the breathing and pulse methodical, step-by-step approach.
Manual, simultaneously before fully activating
Part 2: The the emergency response system (or
Systematic calling for backup).
Approach, and
Part 5: The These recommendations allow
flexibility for activation of the
ACLS Cases)
emergency response system to better
match the HCPs clinical setting.

Trained rescuers are encouraged to

simultaneously perform some steps
(ie, checking for breathing and pulse
at the same time), in an effort to
reduce the time to first chest
compression.

Integrated teams of highly trained

rescuers may use a choreographed
approach that accomplishes multiple
steps and assessments simultaneously
rather than the sequential manner
used by individual rescuers (eg, one
ACLS Provider Manual and ACLS EP Manual Comparison Chart 1
 New Old Rationale
rescuer activates the emergency
response system while another begins
chest compressions, a third either
provides ventilation or retrieves the
bag-mask device for rescue breaths,
and a fourth retrieves and sets up a
defibrillator).
Compression In adult victims of cardiac arrest, it is It is reasonable for lay rescuers and The minimum recommended compression
rate reasonable for rescuers to perform HCPs to perform chest compressions rate remains 100/min. The upper limit rate
chest compressions at a rate of 100 to at a rate of at least 100/min. of 120/min has been added because 1
(ACLS
120/min. large registry series suggested that as the
Provider compression rate increases to more than
Manual, 120/min, compression depth decreases in
Part 2: The a dose-dependent manner. For example,
Systematic the proportion of compressions of
Approach, and inadequate depth was about 35% for a
Part 5: The compression rate of 100 to 119/min but
increased to inadequate depth in 50% of
ACLS Cases) compressions when the compression rate
was 120 to 139/min and to inadequate
depth in 70% of compressions when the
compression rate was more than 140/min.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 2

 New Old Rationale
Chest Perform chest compressions to a depth of The adult sternum should be depressed A compression depth of approximately 5 cm
at least 2 inches/5 cm for an average at least 2 inches (5 cm). is associated with greater likelihood of
compression
adult. Avoid excessive chest compression favorable outcomes compared with shallower
depth depths of more than 2.4 inches/6 cm compressions. While there is less evidence
when a feedback device is available. about whether there is an upper threshold
(ACLS beyond which compressions may be too deep,
a recent very small study suggests potential
Provider injuries (none life-threatening) from excessive
Manual, chest compression depth (greater than 2.4
Part 2: The inches/6 cm). Compression depth may be
Systematic difficult to judge without use of feedback
devices, and identification of upper limits of
Approach, and compression depth may be challenging. It is
Part 5: The important for rescuers to know that chest
ACLS Cases) compression depth is more often too shallow
than too deep.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 3

 New Old Rationale
ACLS Changes
Advanced It may be reasonable for the provider When an advanced airway (ie, This simple single raterather than a
airway to deliver 1 breath every 6 seconds endotracheal tube, Combitube, or range of breaths per minuteshould be
(10 breaths per minute) while laryngeal mask airway) is in place easier to learn, remember, and perform.
ventilation rate
continuous chest compressions are during 2-person CPR, give 1 breath
(ACLS being performed (ie, during CPR with every 6 to 8 seconds without
Provider an advanced airway). attempting to synchronize breaths
Manual, between compressions (this will
Part 5: The result in delivery of 8 to 10 breaths
ACLS Cases) per minute).
Targeted All comatose (ie, lacking meaningful Comatose (ie, lacking meaningful Initial studies of TTM examined cooling
temperature response to verbal commands) adult response to verbal commands) adult to temperatures between 32C and 34C
patients with return of spontaneous patients with ROSC after out-of- compared with no well-defined TTM and
management
circulation (ROSC) after cardiac hospital ventricular fibrillation found improvement in neurologic
(ACLS arrest should have targeted cardiac arrest should be cooled to outcome for those in whom hypothermia
Provider temperature management (TTM), 32C to 34C for 12 to 24 hours. was induced.
Manual, with a target temperature between Induced hypothermia also may be
Part 5: The 32C and 36C selected and achieved, considered for comatose adult A recent high-quality study compared
ACLS Cases) and then maintained constantly for at patients with ROSC after IHCA of temperature management at 36C and at
least 24 hours. any initial rhythm or after OHCA 33C and found outcomes to be similar
with an initial rhythm of pulseless for both. Taken together, the initial studies
electrical activity or asystole. suggest that TTM is beneficial, so the
recommendation remains to select a single
target temperature and perform TTM.
Given that 33C is no better than 36C,
clinicians can select from a wider range of
target temperatures. The selected
temperature may be determined by
clinician preference or clinical factors.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 4

 New Old Rationale
Out-of-hospital The routine prehospital cooling of Comatose (ie, lacking meaningful Before 2010, cooling patients in the
cooling patients with rapid infusion of cold response to verbal commands) adult prehospital setting had not been
intravenous (IV) fluids after ROSC is patients with ROSC after out-of- extensively evaluated. It had been
(ACLS
not recommended. hospital ventricular fibrillation assumed that earlier initiation of cooling
Provider cardiac arrest should be cooled to might provide added benefits and also that
Manual, 32C to 34C for 12 to 24 hours. prehospital initiation might facilitate and
Part 5: The Induced hypothermia also may be encourage continued in-hospital cooling.
ACLS Cases) considered for comatose adult Recently published high-quality studies
patients with ROSC after IHCA of demonstrated no benefit to prehospital
any initial rhythm or after OHCA cooling and also identified potential
with an initial rhythm of pulseless complications when using cold IV fluids
electrical activity or asystole. for prehospital cooling.
Pharmacology Changes
Vasopressors Vasopressin in combination with One dose of vasopressin 40 units Both epinephrine and vasopressin
for epinephrine offers no advantage as a IV/intraosseously may replace either administration during cardiac arrest have
substitute for standard-dose the first or second dose of been shown to improve ROSC. Review of
resuscitation:
epinephrine in cardiac arrest. epinephrine in the treatment of the available evidence shows that efficacy
vasopressin cardiac arrest. of the 2 drugs is similar and that there is
(ACLS no demonstrable benefit from
Provider administering both epinephrine and
Manual, vasopressin as compared with epinephrine
Part 5: The alone. In the interest of simplicity,
ACLS Cases) vasopressin has been removed from the
Adult Cardiac Arrest Algorithm.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 5

 New Old Rationale
Vasopressors It may be reasonable to administer Epinephrine should be given for A very large observational study of
for epinephrine as soon as feasible after pulseless cardiac arrest. cardiac arrest with nonshockable rhythm
the onset of cardiac arrest due to an compared epinephrine given at 1 to 3
resuscitation:
initial nonshockable rhythm. minutes with epinephrine given at 3 later
epinephrine time intervals (4 to 6, 7 to 9, and greater
(ACLS than 9 minutes). The study found an
Provider association between early administration
Manual, of epinephrine and increased ROSC,
Part 5: The survival to hospital discharge, and
ACLS Cases) neurologically intact survival.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 6

 New
Cardiac Arrest Changes
Cardiac arrest Patients with no definite pulse may be
in patients with in cardiac arrest or may have an
undetected weak or slow pulse. These
known or
patients should be managed as cardiac
suspected arrest patients. Standard resuscitative
opioid overdose measures should take priority over
(ACLS EP naloxone administration, with a focus
Manual) on high-quality CPR (compressions
plus ventilation). It may be reasonable
to administer intramuscular (IM) or
intranasal (IN) naloxone based on the
possibility that the patient is in
respiratory arrest, not in cardiac
arrest. Responders should not delay
access to more-advanced medical
services while awaiting the patients
response to naloxone or other
interventions.
ACLS Provider Manual and ACLS EP Manual Comparison Chart
Old Rationale
Naloxone administration has not
previously been recommended for first aid
providers, non-HCPs, or BLS providers.
However, naloxone administration
devices intended for use by lay rescuers
are now approved and available for use in
the United States, and the successful
implementation of lay rescuer naloxone
programs has been highlighted by the
Centers for Disease Control. While it is
not expected that naloxone is beneficial in
cardiac arrest, whether or not the cause is
opioid overdose, it is recognized that it
may be difficult to distinguish cardiac
arrest from severe respiratory depression
in victims of opioid overdose. While there
is no evidence that administration of
naloxone will help a patient in cardiac
arrest, the provision of naloxone may help
an unresponsive patient with severe
respiratory depression who only appears
to be in cardiac arrest (ie, it is difficult to
determine if a pulse is present).
7
 New Old Rationale
Cardiac arrest Priorities for the pregnant woman in To relieve aortocaval compression Recognition of the critical importance of
in pregnancy: cardiac arrest are provision of high- during chest compressions and high-quality CPR and the incompatibility
quality CPR and relief of aortocaval optimize the quality of CPR, it is of the lateral tilt with high-quality CPR
provision of
compression. If the fundus height is at reasonable to perform manual left has prompted the elimination of the
CPR or above the level of the umbilicus, uterine displacement in the supine recommendation for using the lateral tilt
(ACLS EP manual left uterine displacement can position first. If this technique is and the strengthening of the
Manual) be beneficial in relieving aortocaval unsuccessful and an appropriate recommendation for lateral uterine
compression during chest wedge is readily available, then displacement.
compressions. providers may consider placing the
patient in a left lateral tilt of 27 to
30, using a firm wedge to support
the pelvis and thorax.
Opioid It is reasonable to provide opioid
overdose overdose response education, either
alone or coupled with naloxone
education and
distribution and training, to persons at
naloxone risk for opioid overdose (or those
training and living with or in frequent contact with
distribution such persons). It is reasonable to base
(ACLS EP this training on first aid and non-HCP
Manual) BLS recommendations rather than on
more advanced practices intended for
HCPs.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 8

 New Old Rationale
Opioid Empiric administration of IM or IN
overdose naloxone to all unresponsive victims
of possible opioid-associated life-
treatment
threatening emergency may be
(ACLS EP reasonable as an adjunct to standard
Manual) first aid and non-HCP BLS protocols.
For patients with known or suspected
opioid overdose who have a definite
pulse but no normal breathing or only
gasping (ie, a respiratory arrest), in
addition to providing standard care, it
is reasonable for appropriately trained
rescuers to administer IM or IN
naloxone to patients with an opioid-
associated respiratory emergency.
Responders should not delay access to
more advanced medical services
while awaiting the patients response
to naloxone or other interventions.
Empiric administration of IM or IN
naloxone to all unresponsive opioid-
associated resuscitative emergency
patients may be reasonable as an
adjunct to standard first aid and non-
HCP BLS protocols. Standard
resuscitation procedures, including
EMS activation, should not be
delayed for naloxone administration.

ACLS Provider Manual and ACLS EP Manual Comparison Chart 9