1

2016
ACLS Study Guide

Realistic, Practical & Essential Education

Saving Chicago CPR

5526 N. Milwaukee Ave.
Chicago, IL 60630
(773) 969-6846

SavingChicagoCPR.com
ACLS Study Guide

Course Overview

This study guide is an outline of content that will be covered in an Advance Cardiac Life
Support (ACLS) Course. It is intended to summarize important content, but since all
ACLS content cannot possibly be absorbed in a class given every two years, it is
expected that the student will use the appropriate ACLS student manual for the course
they are taking the class through.

BLS Survey

The BLS Survey starts with CPR in the C-A-B sequence.

Critical Concepts - High Quality CPR

- Hard and fast chest compressions
- Allow the chest to come back to its resting position
after every compression

- Interruptions should be minimized to 10 seconds or

less

- Compressors should be switched approximately every

2 minutes to avoid excessive fatigue

- Excessive ventilation needs to be avoided

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 C-A-B Sequence (Compressions, Airway, Breathing)
Check Shake and shout, Are you ok?
Responsiveness
Activate the Activate emergency response (911 or calling a code) and get an AED if
Emergency available or send someone else to active the emergency response system
Response System / and bring back an AED.
get an AED

Simultaneously:

Check the carotid pulse for no more than 10 seconds

Look at the chest for absent or abnormal breathing (5 - 10 seconds)

If no pulse or if you are unsure if you feel a pulse within 10 seconds, begin
CPR. Starting with 30 chest compressions then 2 breaths (30:2).

Compress the center of the chest in the lower half of the sternum.

Press hard and fast with a compressions rate of at least 100 - 120
compressions per minute

Circulation To a depth of at least 2 inches.

Allow the chest to recoil completely after compression

Minimize interruptions in chest compressions to 10 seconds or less

Compressors should be switched approximately every 2 minutes to avoid

rescuer fatigue

Excessive ventilation should be avoided

If a pulse is felt, provide rescue breaths with 1 berth every 5 to 6 seconds

(about 10 to 12 breaths per minute). Reassess the patient for a pulse every
2 minutes.

If no pulse is present, attach an AED/defibrillator as soon as one is available

Defibrillation After a shock is delivered, immediately resume CPR, starting with chest
compressions

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ACLS Survey

For the unconscious patient in cardiopulmonary arrest:

The ACLS survey should be conducted only after the BLS survey has been
completed.

For the conscious patient who is in a periarrest emergency:

The ACLS survey should be conducted first.

The differential diagnosis is an important part of the ACLS survey. This is
where identification and treatment of underlying causes can be critical to
patient outcomes.
- The ACLS survey uses the ABCD to provide a systematic approach to patient
care.

Maintain an open airway

If needed, use an advanced airway
Airway Secure placement of the advanced airway
Verify correct placement of the advanced airway

Provide ventilations via a bag-mask

Breathing Administer supplemental oxygen
Avoid excessive ventilation

Establish IV/IO access

Attach ECG limb leads
Circulation Identify heart rhythm
Give IV fluids if needed
Defibrillate if appropriate

Differential
Identify and treat any reversible causes (Hs and Ts)
dianosis

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Effective resuscitation team dynamics
- Role of the Team Leader
The team leader is all encompassing. An effective team leader:
- Keeps the group organized
- Monitors performance of individual team members
- Is able to encourage team members
- Possesses excellent team behavior
- Takes time to train and coach team members
- Carefully facilitates understanding of team members
- Focus on comprehensive patient care and outcomes
- Role of Team Member
Should be assigned roles they will be proficient in and allowed to perform by
their scope of practice.
Effective Team Members should:
- Have a clear understanding of their assigned role
- Be prepared to fulfill their role with great skill and knowledge
- Be well practiced in resuscitation skills
- Have knowledge of the ACLS and BLS algorithms
- Be committed to successful patient outcomes
- Closed - Loop Communications
When a task is assigned by the team leader, the team member repeats the
task to the team leader to confirm. The team leader then acknowledges that
the team member heard the task correctly.
- EX:
Team Leader: Draw up 1mg of Epinephrine 1:10,000 that will be given
after the next pulse check, via the IV.
Team Member: I will draw up 1mg of Epinephrine, 1:10,000, that I will
give after the next pulse check, via the IV.
Team Leader: Ok

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 - Clear Messages
Clear, specific and concise communication spoken in a distinctive tone. All
messages should be delivered in a direct and calm manner.
- Clear Roles and Responsibilities
Roles need to be fully understood by each team member. Each team
members role is critical to the total performance of the team.
Signs that a team member is unclear of their role include:
- Failure to preform essential tasks
- Team member freelancing
- Repetition of tasks
- Knowing Ones Limitations
Every team member should understand their personal capabilities and
limitations. The team leader should also be aware of these limitations.
- Knowledge Sharing
Information sharing is critical for effective team performance.
When a team leader becomes trapped in a specific diagnostic approach, this is
a common human error known as a fixation error.
- Constructive Intervention
At any time, any team member should intervene if any action may be
inappropriate for the patient. Ensure that all interventions are tasteful,
appropriate and precise.
- Reevaluation and Summarizing
It is essential that a team leader reevaluates and monitors:
- Patient condition findings
- All interventions
- The patients condition and status
- Mutual Respect
Effective teams are comprised of members that share mutual respect for one
another and work together in a supportive manner. In order to have a high
performing team, all team members need to leave their egos behind and
respect one another, regardless of additional experience and/or training that
anyone may possess.

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 System of care

Rapid Response Team (RRT) and/or Medical Emergency Team (MET)

- Many healthcare facilities use RRTs and METs with the purpose of improving
patient outcomes by treating early patient deterioration. When cardiac arrest
occurs in-hospital, it is commonly preceded by physiological changes.

The ACLS Survey

Waveform Airway Management in Respiratory Arrest

Capnography - If ventilations by a BVM (Bag-Valve-Mask) are adequate, healthcare
workers may delay the insertion of any advanced airway. Advanced
Waveform capnography airways include, but are not limited to: Endotracheal tubes, laryngeal
can and should be used
mask airways, esophageal-tracheal tubes and laryngeal tubes.
during a resuscitation to
measure the quality of
compressions.
Basic Airway Adjuncts
- Oropharyngeal Airway (OPA)
Patients with a
PETCO2 of less than OPAs are most commonly used in patients that are high risk for the
10mm Hg will not
tongue or relaxed upper airway muscle obstructing the airway. The J-
achieve a ROSC
shaped device sits on top of the tongue and holds it in place, away
If a patient has less from the posterior wall of the pharynx.
than 10mm Hg Sizing OPAs & NPAs
PETCO2, improve This device is contraindicated in patients with a cough
the quality of CPR by or gag reflex.
compressing harder OPA
or switching - Nasopharyngeal Airway (NPA) Measured from the
center of the mouth
NPAs are an alternative to OPAs. NPAs are a soft or to the angle of the
ridged rubber/plastic tube that is inserted into the jaw
OR
patients nose. NPAs can be used in conscious patients
From the corner of
or patients with a cough or gag reflex. the mouth to the
earlobe.
This device is contraindicated in patients with
suspected facial trauma. NPA
Measured from the
nostril to the
earlobe

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 Bradycardia with suctioning
Stop suctioning immediately if
Suctioning a patient develops:
bradycardia
- Suctioning is a key component in maintaining a patent sudden drop in O2 saturation
airway. Patients should be suctioned without delay if
there are secretions, vomit and/or blood in the mouth. Administer high flow Oxygen until
- Suction attempted should not exceed 10 seconds the heart rate and SPO2
normalize.
- Providing Ventilation with an Advanced Airway
There are many types of advanced airway devices available to
healthcare providers. The type of device you use depends on what
Cricoid Pressure equipment is available, the providers scope of practice and training.
Cricoid pressure is NOT Laryngeal Mask Airway (LMA)
recommended
May provide some -This advanced airway is a common alternative to endotracheal tubes
aspiration and gastric and will provide adequate ventilations. It is commonly used in day
inflation protection surgery with NPO patients or as an emergency airway, during cardiac
during bag-mask arrest.
ventilation.
May interfere with ET Laryngeal tube
intubation
-The laryngeal tube is similar to an esophageal-tracheal tube. The
laryngeal tube is becoming more popular recently. This device is more
compact and less complicated to insert than an esophageal-tracheal tube.
Esophageal-tracheal Tube
- This advanced airway is a double lumen tube that can be blindly inserted
and can come to rest in either the esophagus or the trachea to ventilate the
patient.
Endotracheal Tube (ET or ET Tube)
- The following is a brief summary of the steps to preform an ET intubation
Prepare for the intubation by checking and assembling all required and
needed equipment
Perform the intubation
Inflate the cuff of the ET tube
Attach a ventilation bag to the ET tube
Confirm proper tube placement by use of a confirmation device. Continuos
waveform capnography is strongly recommend, along with clinical
assessment, and is the most reliable method of confirming the correct
placement of the ET tube.
Secure the ET tube
Continually monitor the ET tube for proper placement

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Purpose of defibrillation

Contrary to popular belief, defibrillation does not restart the heart. Defibrillation
shocks the heart and for a short period of time, terminates all electrical activity,
including Ventricle Tachycardia and Ventricle Fibrillation. A viable heart will resume
with its normal pacemaker and ultimately result in a return of
spontaneous circulation (ROSC).
AED Malfunctions
Principle of early defibrillation If an AED does not
- The earlier a patient is defibrillated, the higher the increase in analyze a patients
heart rhythm, quickly:
survival. When a patient is in V-fib, CPR provides a small
amount of blood to the brain and heart, but cannot directly Start high-quality CPR
restore an organized heart rhythm. The highest chance of Check the AED pads
obtaining a perfusing rhythm is with immediate CPR and prompt and cables to make
defibrillation. sure everything is
correctly connected
Delivering shock NEVER delay CPR to
fix a malfunctioning
- The amount of energy used by the defibrillator depends on the AED.
manufacturer of the device and whether or not the device is
monophasic or biphasic.

Monophasic defibrillators should deliver a single shock at 360J. The same

energy should be used for all subsequent shocks.

Biphasic defibrillators use manufacturer recommendations to all deliver

effective shocks, but at various dose ranges. Most monitors will display the
recommend energy on the face of the defibrillator. (eg, 100J to 200J for initial
shock). If the manufacturer recommendation is unknown, use the
maximum amount of energy,
- Rescuers should continue to preform CPR while a defibrillator is charging,
stopping CPR before the shock is administered. As soon as a defibrillation is
delivered, immediately resume CPR for 2 minutes (approximately 5 cycles).

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Synchronized vs. Unsynchronized shocks
- Synchronized
Synchronized cardioversion relies on a sensor in the monitor to deliver a shock
on the patients R wave in their QRS complex.

A lower energy dose is used than with defibrillation.

Heart rhythms that require synchronized cardioversion include:
- Unstable Atrial Fibrillation
- Unstable Atrial Flutter
- Unstable Supraventricle Tachycardia (SVT)
- Unstable Ventricle Tachycardia with a pulse
- Unsynchronized
Called defibrillation (defib), unsynchronized and asynchronized shocks
A defibrillation is delivered as soon as the shock button as pressed, meaning
the shock can fall anywhere in the heart rhythm.

Heart rhythms that require a defibrillation include:

- Ventricle Fibrillation
- Pulseless Ventricle Tachycardia

Code Basics
Do not pause CPR for more After the first cycle of CPR, a Only check for a pulse during
than 10 seconds when check should be completed, a rhythm analysis and only if
performing a pulse check at the carotid artery there is an organized rhythm

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Routes of Access for Drugs

For many years, ACLS drugs were administered via an IV or an ET tube. Drug
absorption via an endotracheal tube is very poor and the correct dosing is not
100% known. To give patients the highest chance of survival, drugs should be
administered via an intraosseous (IO) line if an IV is not available. The
preferred drug administration routes, in order, are:
- IV Route
An IV is the preferred method of drug administration. IVs should be peripheral,
large bore if applicable. A central line is not practical or necessary in most
cardiac arrest patients

- IO Route
An IO is a safe vascular access technique that can be used when an IV cannot
be established. Any drug that can be administered via an IV can be given in
the same dose and concentration as via an IO.

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ACLS Algorithm Review

Acute coronary syndrome (ACS)

- ACLS courses provide students with a very basic knowledge, just skimming the
surface of ACS. The focus in the course is on early treatment and recognition;
rapid reperfusion, relief of ischemic pain and discomfort, and the early treatment
of life threatening conditions. Reperfusion can include the use of fibrinolytics or
angiography with percutaneous coronary intervention (PCI).
- Symptoms suggestive of ischemia or infarction
Monitor the patient
Support the ABCs
Be prepared to provide BLS skills (CPR and AED use)
Administer aspirin (ASA) at a dose of 160mg to 325mg
Consider Oxygen
Administer nitroglycerin and morphine if indicated by chest pain
Obtain a 12-lead ECG
Transport to a facility capable of PCI, if available
- The Use of Fibrinolytic therapy
Fibrinolytic agents (clot busters) are administered to patients that have a J-
point ST elevation that is greater than 2mm in leads V2 and V3 and 1mm of
elevation or more in all other leads. They are also indicated in new Left Bundle
Branch Blocks (LBBB) without any contraindications.
- Use of PCI
Coronary intervention with a stent is the most common form of PCI. PCI is
used as an alternative to fibrinolytic therapy, not along with. A form of PCI
called Rescue PCI can be used very early after fibrinolytics if a patient is not
reperfusing with fibrinolytic therapy.
- Adjunction Treatment
Other drugs that may be considered for ACS include:
- Heparin - Statins
- Clopidogrel - ACE inhibitors
- IV nitroglycerin - -Blockers

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 Acute stroke
- What is happening?
Stroke is a neurological deficit that follows an interruption of blood flow to the
brain.
- Two types of stroke
Ischemic
- Ischemic stroke accounts for 87% of strokes and is caused by a blocked
artery that supplies blood to the brain.

Hemorrhagic stroke
- Hemorrhagic stroke account for 13% of all strokes and is caused by a blood
vessel in the brain that has suddenly ruptured.

Stroke treatments goal is to minimize any injury to the brain and maximize a
patients recovery.

Important goals:
- Immediate recognition of stroke symptoms by family and medical personnel
- Immediate dispatch of EMS
- Immediate transport by EMS to an appropriate facility with advanced notice
of the patient
- Immediate diagnosis and appropriate treatment by hospital staff.

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Cardiac Rhythms

Sinus Bradycardia
- What is happening?
Bradycardia is a resting heart rate of typically less than 50 beats per minute
(BPM). It is common for a highly trained athlete to have a resting heart rate
below 50. If the patient is asymptomatic, no immediate intervention is needed.

If patient is symptomatic, give patient oxygen, give atropine at 0.5mg to a

maximum total dose of 3mg and get a transcutaneous pacemaker or an
infusion of epinephrine or dopamine.
- Treatment for a Sinus Bradycardia
Symptomatic
- Atropine at 0.5mg IV up to a maximum total dose of 3mg
Rapidly deteriorating or unresponsive patient treatment includes:
- Transcutaneous pacing
- Epinephrine at 2 - 10 mcg/minute
- Dopamine at 2 - 20 mcg/kg/minute
Sinus tachycardia
- What is happening?
Sinus tachycardia is generally a sinus rhythm with a heart rate between 101
and 150 BPM. Sinus tachycardia will have a P wave, a QRS complex and a T
wave.
- Treatment for Sinus tachycardia
Treat the underlying cause
- Extreme activity
- Fever
- Pain

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 Supraventricular Tachycardia (SVT)
- What is happening?
Rapid heart rhythm originating at or above the AV node
Determine if non-symptomatic/stable, symptomatic or unstable (hyptotension,
altered mental status, chest pain)
SVT MUST be treated, even if the patient is asymptomatic
- Treatment for SVT
If stable
- Vagal maneuvers
Bare down
Ice to face
Blow through a coffee stirrer
- Medications
6mg of Adenosine
12mg of Adenosine
- Synchronized cardioversion
1st shock at 50-100J
2nd shock at 150J
3rd shock and all subsequent shocks at 200J
Unstable
- Immediate synchronized cardioversion
1st shock at 50-100J
2nd shock at 150J
3rd shock and all subsequent shocks at 200J
- What does it look like?

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 Ventricular Fibrillation (VF or VFib)
- What is happening?
Vfib is the most common heart rhythm that occurs following cardiac arrest. The
ventricles are quivering and cannot properly contract which makes them
unable to pump blood to the body. This is why CPR is done during VF, to
supply blood to the heart and brain. A victims chances of survival rapidly
deteriorate for each minute that goes by while in Vfib. This is why rapid
defibrillation is vital.

There are two types of ventricular fibrillation. Both are treated the same, they
just look slightly different

- Course VF is most common immediately following cardiac arrest and has a

higher chance of survival.
- Fine VF occurs after a prolonged cardiac arrest and is difficult to convert into
a perfusing rhythm
- Treatment
CPR/BLS
Immediate defibrillation
- Use the manufacturer recommendation if available. If unknown, use the
maximum amount of energy (eg 360J).

Medications
- Epinephrine (1mg 1:10,000 IV/IO every 3-5 minutes)
- Amiodarone (First dose of 300mg IV/IO, second dose 150mg IV/IO)
- Identify and treat any reversible causes (Hs and Ts)
- What does it look like?

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 Ventrical tachycardia (VT or Vtach)
- What is happening?
Vtach can occur with or without a pulse. If there is no pulse present, it is
treated the same as VF.

During VT abnormal tissues in the ventricles are generating a rapid heart

rhythm.
- Treatment
Stable
- Seek expert consultation. Be prepared for the patient to become unstable,
as patients will most likely not remain asymptomatic for very long.

Symptomatic
- Identify and treat and reversible causes (Hs and Ts)
- Medications
Amiodarone (150mg IV infusion over 10 minutes, supplementary infusions
may be given to effect for resistant arrhythmias and a maintenance
infusion of 1mg/minute for the first 6 hours, not to exceed the maximum
total daily IV dose of 2.2g)

Unresponsive or rapidly deteriorating

- Immediate synchronized cardioversion
Recommended initial dose of 100J
Increase shocks to a recommended maximum dose of 200J
- What does it look like?

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 Pulseless Electrical Activity (PEA)
- What is happening?
PEA is a condition that happens when the heart has electrical activity, but the
patient has no pulse.
- Treatment
BLS (CPR)
1mg of epinephrine every 3-5 minutes
Identify and treat reversible causes (Hs and Ts)
Asystole
- What is happening?
Asystole is the absence of electrical activity in the heart. Asystole can happen
immediately following cardiac arrest, VF, or PEA.
- Treatment
Treatment is the same for PEA and Asystole
BLS (CPR)
1mg of epinephrine every 3-5 minutes
Identify and treat reversible causes (Hs and Ts)
- Terminating resuscitation efforts
The American Heart Association has made a recommendation that after
sustained Asystole for 15 minutes, termination of resuscitation efforts is
reasonable.
- What does it look like?

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Application of the immediate post-cardiac arrest algorithm

After a patient achieves a ROSC it is essential to maintain the brain and other
organs. Targeted Temperature Management, previously called therapeutic
hypothermia should be started on any patient who remains unresponsive
after ROSC.

- Patients should be cooled to temperature of 32C to 36C for at least hours.

- The only post arrest intervention that has been proven to improve neurological
outcomes after a cardiac arrest is therapeutic hypothermia
- PCI and therapeutic hypothermia can be combined safety.

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