Professional Documents
Culture Documents
ACLS is a course dedicated to sharing a core of advanced information regarding respiratory and cardiac
emergencies. It is taught according to the most current guidelines approved by the American Heart Association as
a uniform approach to the treatment of these emergencies.
Because of the volume of materials to be covered in this course, the following skills are STRONGLY recommended
as prerequisites to attending ACLS:
(a) BLS - it is highly recommended that you have attended a BLS course within the last two years. You will be
expected to perform BLS during the case studies and you must be able to perform BLS flawlessly during
the Mega VF and BLS/AED evaluation stations.
(b) Arrhythmia recognition - you MUST be able to easily recognize arrhythmias to successfully complete
ACLS. If you do not work with arrhythmias on a regular basis, it is STRONGLY suggested that you
consider attending Essentials of Resuscitation and a Basic Arrhythmia Course prior to attending ACLS.
(c) Pharmacology - you MUST be comfortable with the drugs used in ACLS. If you do not work with these
drugs on a regular basis, it is STRONGLY suggested that you spend time reviewing a pharmacology text.
Bring your completed exams with you—they are your “entrance tickets” into class.
TEXTS
The following texts are required for all ACLS Provider Courses and recommended but optional for all ACLS
Renewal Courses:
ACLS Provider Manual
Handbook of Emergency Cardiovascular Care (ECC Handbook)
** DRUGS ACCEPTABLE VIA ETT ROUTE: Drugs given via endotracheal tube should be given at 2 to 2.5
times the IV dose and diluted in 10 ml. of saline.
Epinephrine** Lidocaine
1 mg q. 3-5 min. 2-4 mg/min. Mix 1-2 gm/250 cc. of D5W
Vasopressin Procainamide
40 units, single dose, one time only (VF only) 1-4 mg/min. Mix 1-2 gm/250 cc of D5W
Atropine** Dopamine
0.5-1 mg q. 3-5 min, up to a total of 0.04 mg/kg 5-10 mcg/kg/min. Mix 400 mg/250 cc of D5W
Amiodarone Epinephrine
(VF/VT) 300 mg, consider repeating 150 mg in 3- 2-10 mcg/min. Mix 1-2 mg/250 cc of D5W
5 min.
Amiodarone
Lidocaine** Rapid infusion (non-VF): 150 mg over 10 min, may
1-1.5 mg/kg; repeat at 0.5-1.5 mg/kg q. 5-10 min. repeat every 10 mins prn.
up to 3 mg/kg max Maintenance infusion: 1 mg/min for 6 hrs
decreasing to 0.5 mg/min for 18 hrs.
Procainamide Max cumulative dose 2.2 gm IV/24 hrs.
20-50 mg/min, up to a total of 17 mg/kg
Magnesium Sulfate
1-2 gm in 10 ml of D5W over 1-2 min.
Sodium Bicarbonate
1 mEq/kg; repeat at 0.5 mEq/kg q. 10 mins.
Adenosine
6 mg over 1-3 sec. followed by saline bolus to
flush; repeat at 12 mg. after 1-2 min. twice (30
mg total)
Further information on ACLS Pharmacology can be found in the ECC Handbook, pgs. 54-72.
C CPR
O Oxygen
T Tubes: ET, IV
The central concept is that the COTE mnemonic is the core treatment of all non-perfusing rhythms with the
additions listed in line with each particular rhythm. Remember:
1) V-Fib rhymes with Defib and there should be a direct neurologic synapse between them. Next go to COTE
then think Defib - Drug - Defib - Drug - etc.
2) Asystole goes straight to COTE then out to Atropine, which also begins with an A.
3) PEA goes straight to COTE then out to Etiology and then to Atropine if the rate is less than 60.
Unresponsive—911---AED:
• Check if unresponsive
• Call 911
• Get AED
• Identify and respond to special situations
Unresponsive
Start ABCDs:
• Airway: open airway, hold it open
• Breathing: look, listen and feel for breathing
Circulation
YES NO
ACT QUICKLY!
PATIENT WILL DIE
IF NO AIRWAY
IS ESTABLISHED
Reposition airway---head-tilt/chin-lift
Continue ventilations w/ 100% oxygen Consider oral airway, use 2 people
Squeeze bag slowly and gently, use 2 people Rapidly assess for airway obstruction
Maintain head-tilt/chin-lift, consider oral airway Immediately intubate if no obstruction
Consider quickly reversible causes of apnea: Prepare for alternative airway access:
narcotic OD, hypoglycemia, hypercarbia, hypoxia LMA, Combitube, needle cricothyrotomy,
Consider intubation by most experienced person emergent tracheotomy @ bedside
Continue bag-mask ventilation and call anesthesia
if no experienced person present
Assess ABCs
Oxygen—IV access—monitor—fluids
Vital signs, pulse oximetry, monitor
BP
Narrow-complex Wide-complex
May go directly
Consider vagal maneuvers to cardioversion
Adenosine 6 mg rapid IV push + flush, may
amiodarone 150 mg over 10 mins
be repeated in 1 to 2 mins at 12 mg x 2.
lidocaine 1.0-1.5 mg/kg, may repeat at ½
original dose in 5 mins x 2
procainamide 20-50 mg/min up to 17 mg/kg
amiodarone 150 mg over 10 mins magnesium 1-2 gm over 1-2 mins
β blockers
calcium channel blockers Additional options if Torsades suspected:
digoxin overdrive pacing
procainamide isoproterenol drip
phenytoin
lidocaine
Synchronized cardioversion
100 J
200 J
300 J
360 J
Assess ABCs
Oxygen—IV—Monitor
Sedate if possible
DO NOT DELAY CARDIOVERSION!
Have ready:
Functional suction unit
Bag-valve-mask
Intubation equipment
Synchronized cardioversion
• Ventricular Tachycardia
• Atrial flutter
Considerations:
Effective regimens have included a sedative (eg, diazepam, midazolam, barbiturates, etomidate,
ketamine, methohexital) with or without an analgesic agent (eg, fentanyl, morphine, meperidine). Many
experts recommend anesthesia if service is readily available.
Treat polymorphic ventricular tachycardia (irregular form and rate) like ventricular fibrillation: see
VF/pulseless VT algorithm.
PSVT and Atrial flutter often respond to lower energy levels (50 J).
If the use of electricity is considered, trancutaneous pacing should be performed immediately upon
diagnosis of asystole. Insufficient data to support use of defibrillation to rule out “ultra-fine” VF.
If asystole persists:
Cease resuscitation efforts?
• Consider quality of resuscitation/Reassess
ABCs/Recheck end-tidal CO2 detector
• Consider termination if no response after 10 mins
• Atypical clinical features present?
• Hypothermia
• Drug OD
• Near Drowning
• In the field: termination protocols in place?
Immediate general assessment: <10 mins from arrival Immediate neuro assessment: <25 mins from arrival
Assess ABCs, vital signs Review patient history
Oxygen—IV--Monitor Establish onset (<3 hours required for fibrinolytics)
LABS: CBC, Lytes, coag studies Physical examination
Check blood sugar; treat if indicated Perform neurological examination:
*check level of consciousness (Glasgow Coma Scale)
*check level of stroke severity (NIH Stroke Scale or
Hunt and Hess Scale)
12-lead EKG; check for arrhythmias Urgent noncontrast CT
Alert Stroke Team --door-to-CT performed goal: <25 minutes
Read CT scan
--door-to-CT read goal: <45 minutes
Perform lateral cervical spine xray (pt.comatose/hx of trauma)
Cincinnati Prehospital Stroke Scale (72% probability with one positive marker)
Facial Droop: Have patient smile or show teeth
Arm Drift: Have patient hold both arms straight out for 10 seconds with eyes closed
Abnormal Speech: Have patient repeat the phrase, “You can’t teach an old dog new tricks.”
Defibrillate ASAP
200 J
200 J (BIPHASIC)
200 J
ANTIARRHYTHMIC CHOICES: