Advanced Cardiovascular Life Support · 2020. 10. 28. · ACLS Provider Manual 9 2017 ACLS...

© 2020 American Resuscitation Council. All Rights Reserved. resuscitation.org

Provider Manual

Advanced CardiovascularLife Support

ACLS Provider Manual

2 © 2020 American Resuscitation Council

Table of ContentsUnit One: ACLS Overview .................................................................................................................................. 6

Preparing for ACLS ......................................................................................................................................................................................6

Organization of the ACLS Course ............................................................................................................................................................6

Delivering the Most Up-to-Date Guidelines Available .........................................................................................................................7

2015 ACLS Guideline Changes ..................................................................................................................................................................7

ACLS Guideline Changes since 2015 ........................................................................................................................................................8

Unit Two: BLS and ACLS Surveys....................................................................................................................10

BLS Survey ................................................................................................................................................................................................. 10

Adult BLS/CPR ........................................................................................................................................................................................... 11

ACLS Survey ............................................................................................................................................................................................... 12

Primary Assessment ................................................................................................................................................................................ 13

Secondary Assessment ........................................................................................................................................................................... 14

Unit Three: Team Dynamics .............................................................................................................................15

Unit Four: Systems of Care ..............................................................................................................................17

Post-Cardiac Arrest Care ......................................................................................................................................................................... 17

Acute Coronary Syndromes (ACS) ......................................................................................................................................................... 18

Acute Stroke Care .................................................................................................................................................................................... 18

Education and Teams ............................................................................................................................................................................... 19

Unit Five: ACLS Cases ........................................................................................................................................20

BLS and ACLS Surveys ............................................................................................................................................................................. 20

Respiratory Arrest .................................................................................................................................................................................... 20

Basic Airway Management ..................................................................................................................................................................... 22

Oropharyngeal Airway ............................................................................................................................................................................ 22

Nasopharyngeal Airway .......................................................................................................................................................................... 23

Advanced Airway Management ............................................................................................................................................................ 24

Suctioning the Airway ............................................................................................................................................................................. 25

Ventricular Fibrillation, Pulseless Ventricular Tachycardia, PEA and Asystole ............................................................................ 26

Cardiac Arrest: Ventricular Fibrillation (VF) with CPR and AED ...................................................................................................... 26

Adult BLS/CPR ........................................................................................................................................................................................... 26

Using the Automated External Defibrillator ...................................................................................................................................... 27

Cardiac Arrest ........................................................................................................................................................................................... 29

Manual Defibrillation for VF or Pulseless VT ..................................................................................................................................... 33

Routes of Access for Medication Administration .............................................................................................................................. 33


www.resuscitation.org 3

Insertion of an IO Catheter .................................................................................................................................................................... 34

Monitoring During CPR ........................................................................................................................................................................... 35

Medications Used during Cardiac Arrest ............................................................................................................................................. 35

When to Terminate Resuscitation Efforts ........................................................................................................................................... 35

Post-Cardiac Arrest Care ......................................................................................................................................................................... 36

Acute Coronary Syndrome (ACS) .......................................................................................................................................................... 38

ACS Algorithm ........................................................................................................................................................................................... 38

Bradycardia ................................................................................................................................................................................................ 41

Stable and Unstable Tachycardia .......................................................................................................................................................... 43

Tachycardia Algorithm ............................................................................................................................................................................ 44

Opioid Overdose Algorithm ................................................................................................................................................................... 46

Acute Stroke .............................................................................................................................................................................................. 47

Suspected Stroke Algorithm .................................................................................................................................................................. 48

Unit Six: Commonly Used Medications in Resuscitation .........................................................................50

Unit Seven: Rhythm Recognition ...................................................................................................................53

Sinus Bradycardia ..................................................................................................................................................................................... 54

Sinus Tachycardia ..................................................................................................................................................................................... 55

Sinus Rhythm with First Degree Heart Block ..................................................................................................................................... 55

Second Degree AV Heart Block ............................................................................................................................................................. 56

Third Degree Heart Block ....................................................................................................................................................................... 57

Supraventricular Tachycardia (SVT) ...................................................................................................................................................... 57

Atrial Fibrillation (AF) .............................................................................................................................................................................. 58

Atrial Flutter .............................................................................................................................................................................................. 58

Asystole ...................................................................................................................................................................................................... 58

Pulseless Electrical Activity (PEA) ......................................................................................................................................................... 59

Ventricular Tachycardia (VT) .................................................................................................................................................................. 59

Ventricular Fibrillation (VF) .................................................................................................................................................................... 59

Myocardial Infarction (MI) ...................................................................................................................................................................... 60

References ............................................................................................................................................................61



List of FiguresFigure 1: BLS Survey Tasks ..................................................................................................................................................................... 10

Figure 2: ACLS Survey Tasks ................................................................................................................................................................... 12

Figure 3: Team Location .......................................................................................................................................................................... 15

Figure 4: In-Hospital Cardiac Arrest Chain of Survival ...................................................................................................................... 17

Figure 5: Outside-of-Hospital Cardiac Arrest Chain of Survival ...................................................................................................... 17

Figure 6: One-Rescuer Ventilation ........................................................................................................................................................ 21

Figure 7: Two-Rescuer Ventilation ........................................................................................................................................................ 21

Figure 8: Oropharyngeal Airway ........................................................................................................................................................... 22

Figure 9: Nasopharyngeal Airway ......................................................................................................................................................... 23

Figure 10: BLS AED Algorithm ............................................................................................................................................................... 28

Figure 11: ACLS Cardiac Arrest PEA and Asystole Algorithm ......................................................................................................... 31

Figure 12: ACLS Cardiac Arrest VT and VF Algorithm ....................................................................................................................... 32

Figure 13: Intraosseous Access ............................................................................................................................................................. 34

Figure 14: ACLS Post-Cardiac Arrest Care Algorithm........................................................................................................................ 37

Figure 15: ACLS Acute Coronary Syndrome Algorithm .................................................................................................................... 40

Figure 16: ACLS Bradycardia Algorithm ............................................................................................................................................... 42

Figure 17: ACLS Tachycardia Algorithm ............................................................................................................................................... 45

Figure 18: BLS Suspected Opioid Overdose Algorithm .................................................................................................................... 46

Figure 19: Stroke Chain of Survival ....................................................................................................................................................... 47

Figure 20: Timeline for Treatment of Stroke ...................................................................................................................................... 47

Figure 21: Standard ECG ......................................................................................................................................................................... 53

Figure 22: Normal Sinus Rhythm ........................................................................................................................................................... 54

Figure 23: Sinus Bradycardia .................................................................................................................................................................. 54

Figure 24: Sinus Tachycardia .................................................................................................................................................................. 55

Figure 25: First Degree Heart Block ..................................................................................................................................................... 55

Figure 26: Second Degree Heart Block Type I .................................................................................................................................... 56

Figure 27: Second Degree Heart Block Type II ................................................................................................................................... 56

Figure 28: Third Degree Heart Block .................................................................................................................................................... 57

Figure 29: Supraventricular Tachycardia.............................................................................................................................................. 57

Figure 30: Atrial Fibrillation ................................................................................................................................................................... 58

Figure 31: Atrial Flutter ........................................................................................................................................................................... 58

Figure 32: Ventricular Tachycardia........................................................................................................................................................ 59

Figure 33: Ventricular Fibrillation ......................................................................................................................................................... 59

Figure 34: Comparison of Normal, STEMI and NSTEMI ECG Tracings ............................................................................................ 60



List of TablesTable 1: Comparison of ACLS Guidelines ................................................................................................................................................8

Table 2: ACLS Guideline Changes Since 2015 ........................................................................................................................................8

Table 3: Primary Assessment ................................................................................................................................................................. 13

Table 4: Secondary Assessment ............................................................................................................................................................ 14

Table 5: Team Dynamics .......................................................................................................................................................................... 16

Table 6: Hs and Ts as Causes of PEA ..................................................................................................................................................... 30

Table 7: Routes for Medication Administration ................................................................................................................................. 33

Table 8: ACS Categorization ................................................................................................................................................................... 39

Table 9: Signs and Symptoms of Bradycardia ..................................................................................................................................... 41

Table 10: Signs and Symptoms of Tachycardia ................................................................................................................................... 43

Table 11: ACLS Resuscitation Medications ......................................................................................................................................... 50



Unit One: ACLS Overview Advanced cardiovascular life support (ACLS) teaches the student to identify and intervene in cardiac dysrhythmias,

cardiopulmonary arrest, stroke, and acute coronary syndrome (ACS). The purpose of the training is to increase adult

survival rates for cardiac and neurologic emergencies.

In the ACLS course, the student will learn the appropriate use of:

• Basic life support (BLS) survey

• ACLS survey

• High-quality CPR

• ACLS cases for specific disorders

• Post-cardiac arrest care.

Preparing for ACLS

The ACLS course assumes basic knowledge in several areas. It is recommended that the student has a sound knowledge

of the following areas before beginning the ACLS course:

• BLS skills

• ECG rhythm recognition

• Airway equipment and management

• Adult pharmacology including the common drugs and dosages used in resuscitation.

Organization of the ACLS Course

Instruction in BLS (both one- and two-rescuer) will not occur in a classroom ACLS course; however, the skills are tested

in the appropriate skills stations.

In ACLS, the student must demonstrate competency in the following learning stations that reflect the cases. In a

classroom setting, the student will be required to show proficiency in a megacode, respiratory arrest, and CPR and AED

skills for each of the following cases:

• Ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT)

• Pulseless electrical activity (PEA)/asystole

• Bradycardia

• Tachycardia

• Post-cardiac arrest care.

At the end of the course, the student will be required to pass a written exam that evaluates their knowledge of the

cognitive components of the course. While it is not directly tested, the learner is strongly encouraged to participate in

our megacode simulators.



Delivering the Most Up-to-Date Guidelines Available

The International Liaison Committee on Resuscitation (ILCOR) has been the definitive source for resuscitation

guidelines for decades, delivering recommendations based on cutting edge biomedical and clinical research.

Organizations such as the American Heart Association (AHA) and the European Resuscitation Council (ERC) contribute

to Consensus on Science and Treatment Recommendations (CoSTR) and subsequently publish their findings in the

journals Circulation and Resuscitation, respectively.

For decades, ILCOR conducted a scientific review process every five years (i.e. 2005, 2010, 2015) and published their

results. These results were made into provider training manuals, student training manuals, and other resources. In

fact, American Resuscitation Council used these peer-reviewed publications to create our learning materials, provider

manuals, and exam questions. In 2016, however, ILCOR decided to update and publish their guidance every year to

keep up with advancements in the field of resuscitation research. We, too, are dedicated to staying at the forefront of

science. As such, we will update all of our education materials as ILCOR publishes new guidelines each year.

2015 ACLS Guideline Changes

The last time ILCOR published 5-year guidance was in 2015, when the ACLS guidelines replaced 2010 (and older)

guidelines. More recent guidelines are detailed in Table 1. Any 2015 guidelines that have been updated since 2015 are

crossed out.

• Research shows that starting compressions earlier in the resuscitation process tends to increase survival rates.

• The assessment of the victim’s breathing has been removed since responders often mistake gasping breathing for

effective breathing.

• Experts define high-quality CPR for an adult as:

• A compression rate of 100 to 120 compressions per minute

• A compression depth of 2 to 2.4 inches (5-6 cm)

• Allowing the chest to return to normal position after each compression

• Avoid interruption of CPR for specific treatments such as intravenous catheter insertions, delivery of

medications, and insertion of advanced airways; instead, wait until preparation for defibrillation and do

treatments during that lull in CPR

• Decreasing excessive ventilation.

• The pulse check is less critical since many providers cannot reliably detect a pulse in an emergency.

• Post-cardiac arrest care is formally started as soon as return of spontaneous circulation (ROSC) occurs.

• Administer a vasopressor (usually epinephrine) every 3 to 5 minutes via endotracheal (ET) tube, if available, until IV

access is established.



Guideline Old Guideline 2015 Guideline

Sequence CAB (compressions, airway, breathing) Confirmed in the 2015 guidelines; do not

delay the first 30 chest compressions

Compression depth At least 2 inches in adults Between 5 cm and 6 cm (2 inches and 2.4

inches) in adults

Compression frequency At least 100 compressions per minute No less than 100, no more than 120

Chest recoil Allow the chest to fully recoil between

compressions

Confirmed in the 2015 guidelines; do not

lean on the chest between compressions;

allow the heart to fully fill with blood

Vasopressin Vasopressin may replace first or second

dose of epinephrine

Vasopressin plus epinephrine provides no

advantage as a substitute for epinephrine

Epinephrine CPR was recommended over epinephrine Administer epinephrine ASAP for non

shockable cardiac arrest rhythm

Delayed ventilation New recommendation for 2015 Witnessed cardiac arrest with shockable

rhythm, EMS may delay positive-pressure

ventilation for up to 3 cycles of 200

continuous chest compressions

Advanced airway When using an advanced airway, give 1

breath every 6 to 8 seconds or 8 to 10

breaths a minute

Deliver 1 breath every 6 seconds (10 per

minute) when using an advanced airway

during CPR

Chain of survival Same chain of survival for in-hospital and

out-of-hospital cardiac arrest

In-hospital and out-of-hospital cardiac

arrest chain of survival are different;

primary providers and lay rescuers provide

immediate care and then transfer care to

the code team or EMS crew, respectively

Extracorporeal CPR Insufficient information to recommend

routine use of extracorporeal CPR

Extracorporeal CPR may be considered

instead of regular CPR for reversible cardiac

arrest

Post-cardiac arrest New recommendation for 2015 Inadequate evidence to support the routine

use of lidocaine and/or beta-blocker

Post-cardiac arrest Comatose patients should be cooled to

between 32°C and 34°C for 12-24 hours

Comatose patients with ROSC should be

cooled to between 32°C and 36°C for >24 hrs

Post-cardiac arrest New recommendation for 2015 Consider avoiding/correcting hypotension

systolic BP



2017 ACLS Guidelines (BLS Update) 1-3

Bystanders who are trained, able, and willing to give rescue breaths and chest compressions should do so for all adult patients in cardiac

arrest

Bystanders should provide CPR with ventilation for infants and children less than 18 years of age with OHCA

Bystanders who cannot provide rescue breaths as part of CPR for infants and children less than 18 years of age with OHCA, should at least

provide chest compressions

Before placement of an advanced airway (supraglottic airway or tracheal tube), EMS providers should perform CPR with cycles of 30

compressions and 2 breaths

EMS providers should perform CPR with 30 compressions to 2 ventilations or continuous chest compressions with positive pressure

ventilation (PPV) without pausing chest compressions until a tracheal tube or supraglottic device is placed

For EMS systems, a reasonable alternative to conventional CPR for witnessed shockable OHCA is minimally interrupted cardiac

resuscitation

Whenever an advanced airway (tracheal tube or supraglottic device) is inserted during CPR, it may be reasonable for providers to perform

continuous compressions with PPV delivered without pausing chest compressions

After placement of an advanced airway, it may be reasonable for the provider to deliver 1 breath every 6 s (10 breaths per min) while

continuous chest compressions are being performed

2018 ACLS Guidelines 4,5

Adult Cardiac Arrest Algorithm was changed (see text for details)

Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that does not respond to

defibrillation. These drugs may be particularly useful for patients with witnessed arrest when the time to drug administration may be

shorter

The routine use of magnesium for cardiac arrest is not recommended in adult patients

There is insufficient evidence to support or refute the routine use of lidocaine within the first hour after ROSC

There is insufficient evidence to support or refute the routine use of a β-blocker within the first hour after ROSC

2019 ACLS Guidelines 6-11

EMS dispatchers should offer dispatcher-assisted CPR instructions for presumed pediatric cardiac arrest

EMS dispatchers should offer dispatcher-assisted CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress

Either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting

If an advanced airway is used, the supraglottic airway should be used for adults with out-of-hospital cardiac arrest where the likelihood of

successful tracheal intubation is low. Either device may be used if the likelihood of successful tracheal intubation is high

Expert, experienced providers may place either the supraglottic airway or endotracheal tube in-hospital

EMS systems should track overall supraglottic airway and endotracheal tube placement success rates

Epinephrine should be administered to patients in cardiac arrest (1 mg every 3 to 5 minutes); high-dose epinephrine is not recommended

for routine use in cardiac arrest

Vasopressin may be considered in cardiac arrest but offers no advantage over epinephrine either alone or in combination with epinephrine

Administer epinephrine as soon as feasible for patients with cardiac arrest with a non-shockable rhythm

Administer epinephrine for patients with cardiac arrest with a shockable rhythm after initial defibrillation attempts have failed

There is insufficient evidence to recommend the routine use of extracorporeal CPR for patients with out-of-hospital cardiac arrest in

pediatrics, or any cardiac arrest in adults

Extracorporeal CPR may be considered for select pediatric patients with in-hospital cardiac arrest as a rescue therapy when conventional

CPR is failing, and it can be implemented competently and efficiently

2020 ACLS Guidelines

Awaiting peer-reviewed publication of 2020 ILCOR Updates

Table 2: ACLS Guideline Changes Since 2015

Advanced Cardiovascular Life Support · 2020. 10. 28. · ACLS Provider Manual 9 2017 ACLS...

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