AHA ACLS Advanced Cardiac Life Support 1 Day Initial Certification (INCLUDES Provider Manual E-Book and FREE BLS)

AHA ACLS Advanced Cardiac Life Support 1 Day Initial Provider Certification (INCLUDES Provider Manual E- Books and FREE BLS) at Saving American Hearts, INC.  *** NEW ADDRESS *** 1301 S. 8th Street Suite 116, Colorado Springs, Colorado 80905.   

Be sure to download the confirmation letter, study guide, agenda, ebook and more after your purchase!

*ACTION REQUIRED*

The precourse work is now required and is in two parts. Part 1 is an hour long pretest and Part 2 you will watch the course videos online before attending the class. Here's a link to the Pre-Course work. Be sure to create an account, or log in before you start. https://elearning.heart.org/course/1551 Take a picture of your certificate and email it to me before your class. Class will focus on the hands on teaching and testing portion of the class. The precourse work takes hours. Once you begin the pretest, you must complete it in one sitting. The second portion includes all the course videos and can be broken up if necessary. If you have any questions, please email Catherine Brinkley at admin@savingamericanhearts.com

AHA ACLS Advanced Cardiac Life Support 1 Day Initial Certification is an advanced, instructor-led classroom course that highlights the importance of team dynamics and communication, systems of care and immediate post-cardiac-arrest care. Advanced Cardiovascular Life Support (ACLS) builds on the foundation of Basic Life Support (BLS), emphasizing the importance of continuous, high-quality CPR. The hands-on instruction and simulated cases in this advanced course are designed to help enhance their skills in the recognition and intervention of cardiopulmonary arrest immediate post-cardiac arrest, acute arrhythmia, stroke, and acute coronary syndromes. We will teach you all the information you need to successfully manage emergencies such as cardiac arrest, respiratory arrest, heart attack and stroke. This ACLS Advanced Cardiac Life Support course is designed for healthcare providers who participate in resuscitation of patients in hospital, medical offices, or in settings where conscious sedation is administered and has not previously taken this course or one who has not taken it for over two years. It covers identification and treatment of patients with medical conditions who are at risk for cardiac arrest, primary and secondary assessment survey and actions needed, algorithms for treatment of emergency situations and effective resuscitation team dynamics. Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. Although arrhythmia recognition will be reviewed, it is expected that the participant will have a working knowledge of EKG rhythms. Practice with defibrillators and external pacemaker is included. Assessment and care for the patient experiencing an Acute Coronary Syndrome or Stroke will be included in this course.  Upon successful completion of the ACLS Provider course, students will be issued their AHA ACLS Provider Card via email shorly after class. We structure this class to meet all of the AHA guidelines and requirements. All scenarios are designed for the work place of the individual participant. Our goal is that each participant will feel comfortable in handling life threatening emergencies in their own setting. You'll learn the 2020 ACLS Algorithms, drug dosages and usage, how to successfully perform cardioversion, defibrillate and perform external pacing as well as basic CPR, using a bag mask device and an AED. The course includes watching the Advanced Cardiac Life Support (ACLS) full course video, learning stations for Basic Life Support (BLS), CPR and the use of an AED. You will actively participate in the learning stations for the Advanced Cardiac Life Support (ACLS) algorithms, review of medications used in Advanced Cardiac Life Support, how to manage respiratory emergencies and insert and manage advanced airway devices. You will practice hands on techniques before taking the written exam and the hands on skills testing portion of the class. At the end of the class you will take a written test of 50 questions and successfully perform as a team leader in a case scenario. As the team leader, you may use your book, or your notes for referrence as the "megacode" is also open book and open resource.

Skills to be practiced during the course include:

CPR Coach

Airway Management

Rhythm Recognition

Defibrillation

IV and Intraosseous Access

Use of Medications

Cardioversion

Transcutaneous Pacing

1-rescuer CPR and AED

Team Resuscitation Concept (Team Leader and Team Member)

Immediate Post-Cardiac Arrest Care

1-Rescuer CPR and AED use

Respiratory Arrest

Peri-arrest Rhythms (Tachycardia, Bradycardia)

Arrest Rhythms (VF, PVT, PEA, Asystole)

Acute Coronary Syndromes (ACS)

Stroke

You must obtain a passing score of 70% or greater. The pretest is free and can be taken as many times as needed to pass. Print your scores for the Pre-course Self-Assessment and bring them with you to class. You may also text a picture of your certificate to Catherine Brinkley at (719) 551-1222.

What to Wear

Please wear loose, comfortable clothing to class. You will be practicing skills that require you to work on your hands and knees, and the course requires bending, standing, and lifting. If you have any physical condition that might prevent you from engaging in these activities, please tell an instructor. The instructor may be able to adjust the equipment if you have back, knee, or hip problems.

The course is taught in a STRESS FREE, FUN environment. I want you to leave class feeling like you're glad you came, you learned a lot and you ACTUALLY HAD FUN !!! You will MASTER all the skills you need to run a code and learn all the rhythms and drugs to treat them. IT'S A PIECE OF CAKE !!! STRESS FREE ! FUN !! If you have any questions about the course, please call Catherine Brinkley RN at (719) 551-1222.

Your ebook, agenda and confirmation letter is set up for immediate download once your purchase has been made.

New 2025 Guidelines for ACLS

New Chain of Survival

Foreign-Body Airway Obstruction: Adults, Children and Infants
New 2025: For adults with severe foreign-body airway obstruction (FBAO), repeated
cycles of back blows followed by 5 abdominal thrusts should be performed until the
object is expelled or the person becomes unresponsive.

AED Pad Placement
Anterolateral (High right, low left) or Anteroposterior (AP) Placement - 2 options
1). Center of the chest and center of the back
2) Place one on the upper left chest above the nipple and the other on the left side of
the back near the spine.
It is reasonable to adjust the position of a patient's bra instead of removing it when
placing pads

Rigid cervical collars are no longer recommended for neck or spinal injuries as the
can make it more difficult to maintain a patent airway.

Mouth-to-nose ventilation may be necessary if ventilation through the person’s
mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. A
case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and
effective.

After identifying an adult in cardiac arrest, a lone responder should activate the
emergency response system first, then immediately begin CPR.
In adult cardiac arrest, rescuers should perform chest compressions with the
patient’s torso at approximately the level of the rescuer’s knees.

CPR for adult cardiac arrest patients with obesity should be provided by using the
same techniques as for the average weight patient.

Higher first-shock energy settings (≥200 J) are preferable to lower settings for
cardioversion of atrial fibrillation and atrial flutter.

Updated termination of resuscitation (TOR) guidelines emphasize rule application
based on emergency medical services (EMS) scope of practice (basic life support
[BLS], ALS, or universal TOR rule [UTOR]), and that end-tidal carbon dioxide (ETCO2)
should not be used in isolation to end resuscitative efforts.

Administration of intra-arrest medications via an in-place endotracheal tube) have
been removed.

Use of point of care ultrasonography (POCUS) by experienced professionals during
cardiac arrest may be considered to diagnose reversible causes if it can be done
without interrupting resuscitative efforts (ie, CPR).

Polymorphic ventricular tachycardia is always unstable and should be treated
immediately with defibrillation, because delays in shock delivery worsen outcomes.

Intravenous (IV) access remains the first-line choice for drug administration during
cardiac arrest; however, intraosseous (IO) access is a reasonable alternative if IV
access is not feasible or delayed.

Post Cardiac Arrest Care - Maintain MAP >65 and target SPO2 90%-98%. Maintain
100% FIO2 until reliable SPO2 can be measured.

Unstable Tachycardia is now defined as SBP below 80 and should be synchronized
cardioverted.

Stable Tachycardia Cardiovert / Adenosine 6 mg, 12 mg then start a Procainamide OR
Amiodarone drip.

(For synchronized cardioversion of atrial flutter in adults, an initial energy setting of
200 J may be reasonable and incremented in the event of shock failure, depending
on the biphasic defibrillator used.)

Review New Adult and Pediatric Ventricular Assist Device Algorithm

Therapeutic Hypothermia has been extended to a minimum of 36 hours.

Adults and Children with Life Threatening Asthma Exacerbations refractory to
standard therapy may benefit from EMCO.

Hyperthermia: Adults and children with life-threatening hyperthermia from
environmental causes, cocaine poisoning, or sympathomimetic poisoning should be
rapidly cooled, ideally at a rate of at least 0.15 °C/min (0.27 °F/min). This is best
achieved with immersion in ice water.

It is recommended that health care professionals first attempt establishing IV access
for drug administration in adult patients in cardiac arrest. Intraosseous (IO) access is
reasonable if initial attempts at IV access are unsuccessful or not feasible for adult
patients in cardiac arrest.

This concludes the NEW 2025 Changes for ACLS

SAVING AMERICAN HEARTS ADVANCED CARDIAC LIFE SUPPORT STUDY GUIDE AND ACLS SUPPLEMENTARY MATERIAL Based on the 2020 Guidelines of the American Heart Association

Always begin Basic Life Support with chest compressions, not breaths. Give 30 compressions and 2 breaths. 5 cycles of 30 compressions and 2 breaths = 2 minutes. Check for a pulse every 2 minutes, and switch providers every 2 minutes so that the person giving compressions does not get too tired. Good quality compressions must be given.

For adults, compress at least 2 inches or 5 cm. Always let the chest completely recoil. Provide at least 100 to 120 compressions per minute. Do not spend more than 10 seconds assessing the patient, or checking for a pulse. If you are unsure if they have a pulse, begin chest compressions. Keep interruptions in chest compressions to 10 seconds or less.

WAVEFORM CAPNOGRAPHY

Waveform capnography is written as PETCO2 (Patient End Tidal CO2) The normal is 35-40. If your PETCO2 number is less than 10, this indicates ineffective chest compressions. Waveform capnography is used to measure CPR quality and determine ROSC (Return of Spontaneous Circulation). Waveform capnography is the MOST reliable indicator of ETT placement. If the person doing the intubation happens to get the ETT into the esophagus vs the trachea, there would be no waveform capnography reading.

RESCUE BREATHING

When providing breaths, if doing compressions give 30 compressions and 2 breaths. Each breath should be given over 1 second, and only until you see the chest rise. Giving a bigger breath will only fill the stomach with air which will compress the diaphragm, chest and lungs making it difficult to resuscitate your patient.

If your patient has a pulse and simply cannot breath, provide breaths at a rate of 1 breath every 6 seconds.

If your patient is intubated (has an advanced airway ), provide 1 breath every 6 seconds.

When an advanced airway is in place, compressions should not be paused to give breaths.

GUIDELINES FOR SYNCHRONIZED CARDIOVERSION

UNSTABLE ATRIAL FIBRILATION

The initial BIPHASIC energy dose should be between 120-200 Joules

UNSTABLE SVT OR UNSTABLE ATRIAL FLUTTER   

The initial BIPHASIC energy dose should be between 50-100 Joules

RHYTHMS WITH MONOPHASIC WAVEFORMS

The initial MONOPHASIC or BIPHASIC energy dose should begin with 200 Joules and increase in a stepwise fashion if not successful

UNSTABLE MONOMORPHIC VT

The initial MONOPHASIC or BIPHASIC energy dose of 100 Joules If the initial shock fails, always increase the dose in a stepwise fashion.

THERAPUTIC HYPOTHERMIA

(The NEW 2020 Guidelines has renamed this "Targeted Temperature Management" Used only when your patient remains unresponsive following cardiac arrest, especially those who presented with an initial rhythm of v-fib. These patients are cooled to 32-36 degrees celsius for at lease 24 hours. If your patient wakes up and follow commands, do not start hypothermia protocol.

CHEST PAIN

Any patient having chest pain should have an EKG first. You must know if they are having a STEMI and will require transport to a hospital that has a cath lab. STEMI (ST segment elevation) must go to the cath lab for an angiogram or they will die. The heart muscle is not perfusing. NSTEMI (ST depression) usually are able to go home on blood thinners after a preventive angiogram, PCI or heart cath.

The only exception to the EKG first, is a patient where the chest pain is caused by their heart rate. If they are unstable, synchronized cardio version should be the first treatment. So, if an ambulance is bringing you a STEMI patient, and your facility does not have the capabilities to do a heart cath, or angiogram, these patients need to be diverted to a specialty cardiac hospital even if it’s an hour away. If you accept the patient, you then have to get admit orders, have consents signed, do the whole med rec and then get transfer orders, find an accepting doctor and transfer the patient anyway. The patient would be better off getting closer to the special hospital.

STROKE

The same goes for the stroke patients, if your hospital's CT scan is broken, you need to divert them as well. Anyone with stroke symptoms should have their blood sugar checked FIRST. Numerous people come to ER with decreased LOC, slumping to one side and slurred speech because they took their insulin this morning and haven’t eaten all day. Checking blood sugar is a really fast way to rule out a stroke. The SECOND thing you want to do is called a Cincinnati Pre-Hospital Stroke Assessment Scale. It's a very quick assessment Check for FACIAL DROOP, SLURRED SPEECH, and ARM DRIFT. The THIRD thing you need to do is get that CT SCAN. You need to know if they are having an ischemic stroke or a hemorrhagic stroke. If they are bleeding, they will not get the fibrinolytics.

Atropine is no longer used in the AYSTOLE/PEA Algorithm The American Heart Association defines PEA as sinus rhythm without a pulse. Atropine is the first line treatment for any bradycardia regardless of the type, a dopamine drip should be started at 2-10 mcg/kg/min if the rhythm is a 3rd degree block. Run the dopamine until pacing begins. The preferred method of epinephrine administration is via peripheral. During a code there is no time to obtain central venous access. When attempting IV access, peripheral access should be tried first, if that is unsuccessful move to I/O access. The recommended fluid bolus for a patient who achieves ROSC and is hypotensive is 1-2 Liters. You want to get a minimal SBP of at least 90 to ensure perfusion.

Once your patient achieves ROSC you need to make sure they are oxygenated and ventilated. This is now your first priority. Providing quality chest compressions immediately before a defibrillation attempt will improve successful conversion of V-Fib.

The American Heart Association says that it is acceptable to stop resuscitation efforts if the patient has not had a pulse for 15 consecutive minutes. Except in special cases of drowning or hypothermia.

Always be aware of safety hazards. Don't ever cut adult pads in half or shock a patient if there is oxygen blowing across their chest. The oxygen combined with the electric spark could cause a small explosion or ball of fire that injures everyone in the room. When possible, use the hands free pads. Paddles take much longer to deliver a shock because you must add the conduction jelly and after the shock is delivered, someone is stuck holding them. Always provide chest compressions while the defibrillator is charging. The time it takes to analyze is several seconds, you want to make the hands-off period of time as short as possible. Some defibrillators can take up to 45 seconds to charge. Remember when suctioning a patient, do not suction for longer than 10 seconds. Always make sure you have a 6 second rhythm strip if you are going to be counting the QRSs by 10 to get your heart rate. If you have a 12 second strip and do this you are likely to end up with a heart rate of 80 when it's actually only 40. The treatment is significantly different.

Always make sure the scene is safe before providing any help to someone. It would not do anyone any good if you ran out into the middle of the street to save someone and get hit by a car. Make sure You assess the scene for safety hazards first.

The initial priority for ANY tachycardia is do they have a pulse or not. The treatment for each is completely different. The only rhythm you will ever shock is V-Fib and pulseless V-Tach. The only rhythm you will ever cardiovert is an unstable tachycardia whether it's SVT or atrial does not matter.

Cricoid pressure is no longer recommended. It used to be done routinely, when providers were attempting to occlude the esophagus and prevent vomiting, however inexperienced providers were also unknowingly occluding their airway too. So It is not longer recommended.

If you have any questions please let me know. You can call Catherine Brinkley at (719) 551-1222 or email: admin@savingamericanhearts.com

Saving American Hearts, Inc 6165 Lehman Drive Suite 202 Colorado Springs, Colorado 80918. 

See our live calendar of classes here:

https://www.keepandshare.com/calendar/show.php?i=2091851&vw=month&ign=y

If you have a current AHA ACLS card and need a renewal class, you can also visit

https://savingamericanhearts.com/aha-acls-renewal/

And, if you want to take the online course at www.elearning.heart.org you can do the online course and then just come in for the in-person hands on practice and testing session.  There are two separate fees, and this is the most expensive way to go, so do a little research first. The classroom courses are much cheaper.

Here's our class dates for the ACLS Skills Sessions

https://savingamericanhearts.com/aha-acls-skills-session/

https://youtu.be/lO4rdC-fKsI

AHA Advanced Cardiac Life Support 2020 Guidelines or ACLS was created by the American Heart Association. ACLS Initial Certification is a classroom course that awards a 2 year ACLS certification for those who work in critical areas of the hospital such as ICU, Telemetry, ER, CCU and outpatient surgery areas. Most hospitals require doctors, nurses, anesthesiologists and charge nurses to have this certification. This course teaching advanced Life Support measures such as drug administration for arrhythmias, cardioversion, defibrillation, CPR, and advanced airways as well as heart rhythm recognition.

• For healthcare professionals who either direct or participate in the management of cardiopulmonary arrest or other cardiovascular emergencies and for personnel in emergency response.

This course teaches the importance of preventing cardiac arrest, high-performance teams, continuous high-quality CPR, systems of care, recognition and intervention of cardiopulmonary arrest, post-cardiac arrest care, acute dysrhythmias, stroke, and acute coronary syndromes (ACS)

• Updated to reflect new science in the 2020 American Heart Association Guidelines for CPR & ECC, as well as the Update to the ASA Ischemic Stroke Guidelines
• This course is designed for healthcare professionals who direct or manage cardiopulmonary arrest or other cardiovascular emergencies; personnel in emergency response, emergency medicine, intensive care, and critical care units; physicians, nurses, and paramedics; and others who need an ACLS course completion card for job or other requirements
• This manual includes the systematic approach to a cardiopulmonary emergency, effective team communication, and the ACLS cases and algorithms.

Key Components of ACLS

1. High-Quality CPR

• Deliver chest compressions at a depth of at least 2 inches (5 cm) and a rate of 100–120 per minute.
• Ensure full chest recoil between compressions.
• Minimize interruptions in compressions.
• Rotate compressors every 2 minutes to prevent fatigue.
• Avoid excessive ventilation; provide just enough to see chest rise.

2. Airway Management

• Begin with basic airway techniques, such as using a bag-mask device.
• Consider advanced airway placement (e.g., endotracheal intubation) if necessary.
• Monitor end-tidal CO₂ to assess the effectiveness of CPR and ventilation.

3. Cardiac Arrest Algorithms

• Shockable Rhythms (Ventricular Fibrillation/Pulseless Ventricular Tachycardia):
• Immediate defibrillation.
• Administer epinephrine 1 mg IV/IO every 3–5 minutes.
• Consider antiarrhythmic drugs like amiodarone or lidocaine if arrhythmia persists.
• Non-Shockable Rhythms (Asystole/Pulseless Electrical Activity):
• Continue high-quality CPR.
• Administer epinephrine 1 mg IV/IO every 3–5 minutes.
• Identify and treat reversible causes (e.g., hypoxia, hypovolemia, acidosis).

4. Post-Cardiac Arrest Care

• Optimize oxygenation and ventilation.
• Maintain blood pressure and perfusion.
• Consider targeted temperature management (32–36°C) to improve neurological outcomes.
• Evaluate for coronary reperfusion if indicated.5. Team Dynamics and Communication

• Assign clear roles during resuscitation efforts.
• Use closed-loop communication to confirm tasks.
• Conduct regular debriefings to improve future performance.

• Epinephrine: Continues to be recommended for cardiac arrest; high-dose epinephrine is not advised for routine use.
• Antiarrhythmics: Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia unresponsive to defibrillation.
• Extracorporeal CPR (ECPR): May be considered in settings with available resources for patients with refractory cardiac arrest.

For comprehensive information and training resources, visit the AHA's official ACLS page: cpr.heart.org.

Course content: After completing the course, students should be able to:

• Define systems of care
• Apply the BLS, Primary, and Secondary Assessments sequence for a systematic evaluation of adult patients
• Discuss how the use of a rapid response team (RRT) or medical emergency team (MET) may improve patient outcomes
• Discuss how the use of a rapid response team (RRT) or medical emergency team (MET) may improve patient outcomes
• Discuss early recognition and management of ACS, including appropriate disposition
• Discuss early recognition and management of stroke, including appropriate disposition
• Recognize bradycardias and tachycardias that may result in cardiac arrest or complicate resuscitation outcome
• Perform early management of bradycardias and tachycardias that may result in cardiac arrest or complicate resuscitation outcome
• Model effective communication as a member or leader of a high-performance team
• Recognize the impact of team dynamics on overall team performance
• Recognize respiratory arrest
• Perform early management of respiratory arrest
• Recognize cardiac arrest
• Perform prompt, high-quality BLS including prioritizing early chest compressions and integrating early automated external defibrillator (AED) use
• Perform early management of cardiac arrest until termination of resuscitation or transfer of care, including immediate post–cardiac arrest care
• Evaluate resuscitative efforts during a cardiac arrest through continuous assessment of CPR quality, monitoring the patient’s physiologic response, and delivering real-time feedback to the team

 At the end of this class students will lead the team in a respiratory case scenario and a megacode scenario as well as a 50 question open book test.

New 2025 Guidelines for ACLS

Foreign-Body Airway Obstruction: Adults, Children and Infants
New 2025: For adults with severe foreign-body airway obstruction (FBAO), repeated
cycles of back blows followed by 5 abdominal thrusts should be performed until the
object is expelled or the person becomes unresponsive.

AED Pad Placement
Anterolateral (High right, low left) or Anteroposterior (AP) Placement - 2 options
1). Center of the chest and center of the back
2) Place one on the upper left chest above the nipple and the other on the left side of
the back near the spine. 

It is reasonable to adjust the position of a patient's bra instead of removing it when
placing pads.

Rigid cervical collars are no longer recommended for neck or spinal injuries as the can make it more difficult to maintain a patent airway. Mouth-to-nose ventilation may be necessary if ventilation through the person’s mouth is impossible because of trauma, positioning, or difficulty obtaining a seal.

A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR. In adult cardiac arrest, rescuers should perform chest compressions with the patient’s torso at approximately the level of the rescuer’s knees.

CPR for adult cardiac arrest patients with obesity should be provided by using the same techniques as for the average weight patient.

Higher first-shock energy settings (≥200 J) are preferable to lower settings for cardioversion of atrial fibrillation and atrial flutter. Updated termination of resuscitation (TOR) guidelines emphasize rule application based on emergency medical services (EMS) scope of practice (basic life support [BLS], ALS, or universal TOR rule [UTOR]), and that end-tidal carbon dioxide (ETCO2) should not be used in isolation to end resuscitative efforts.

Administration of intra-arrest medications via an in-place endotracheal tube) have been removed.

Use of point of care ultrasonography (POCUS) by experienced professionals during cardiac arrest may be considered to diagnose reversible causes if it can be done without interrupting resuscitative efforts (ie, CPR). Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation, because delays in shock delivery worsen outcomes.

Intravenous (IV) access remains the first-line choice for drug administration during cardiac arrest; however, intraosseous (IO) access is a reasonable alternative if IV access is not feasible or delayed.

Post Cardiac Arrest Care - Maintain MAP >65 and target SPO2 90%-98%. Maintain 100% FIO2 until reliable SPO2 can be measured.

Unstable Tachycardia is now defined as SBP below 80 and should be synchronized cardioverted.

Stable Tachycardia Cardiovert / Adenosine 6 mg, 12 mg then start a Procainamide OR
Amiodarone drip.
(For synchronized cardioversion of atrial flutter in adults, an initial energy setting of
200 J may be reasonable and incremented in the event of shock failure, depending
on the biphasic defibrillator used.)
Review New Adult and Pediatric Ventricular Assist Device Algorithm
Therapeutic Hypothermia has been extended to a minimum of 36 hours.
Adults and Children with Life Threatening Asthma Exacerbations refractory to
standard therapy may benefit from EMCO.
Hyperthermia: Adults and children with life-threatening hyperthermia from
environmental causes, cocaine poisoning, or sympathomimetic poisoning should be
rapidly cooled, ideally at a rate of at least 0.15 °C/min (0.27 °F/min). This is best
achieved with immersion in ice water.
It is recommended that health care professionals first attempt establishing IV access
for drug administration in adult patients in cardiac arrest. Intraosseous (IO) access is
reasonable if initial attempts at IV access are unsuccessful or not feasible for adult
patients in cardiac arrest.
This concludes the NEW 20250 Changes for ACLS

When Performing CPR
Always begin with chest compressions, not breaths. Give 30 compressions and 2
breaths.
5 cycles of 30 compressions and 2 breaths = 2 minutes.
Check for a pulse every 2 minutes, and switch providers every 2 minutes so that the
person giving compressions does not get too tired. High quality compressions must
be given.
For adults, compress at least 2 inches or 5 cm. Do not compress more than 2.4 inches
or 6 CM. Always let the chest completely recoil between compressions. Provide 100 to
120 compressions per minute.
Don't spend more than 5 - 10 seconds assessing the patient, and checking for a pulse,
or switching compressors. 

If you are unsure if they have a pulse, begin chest compressions. Keep interruptions
in chest compressions to 10 seconds or less.

WAVEFORM CAPNOGRAPHY
Waveform capnography is written as PETCO2 (Partial End Tidal Carbon Dioxide)
Waveform capnography is used to measure CPR quality and determine ROSC (Return
of Spontaneous Circulation).
Think of ROSC as "Return of Life". If CPR is being done, and the patient's heart starts
beating again on it's own, the patient has achieved ROCS, or return of life.
Waveform capnography is the MOST reliable indicator of ETT placement. If the
person doing the intubation happens to get the ETT into the esophagus vs the
trachea, there would be no waveform capnography reading.
A PETCO2 of less than 10 indicates ineffective chest compressions. Treatment should
focus on improving the quality of chest compressions. A PETCO2 greater than 10
indicates effective chest compressions . Normal PETCO2 is 35-40mmHg.
Don't get the waveform capnography confused with the colormetric device. A
colormetric device only changes color and indicates the detection of CO2 in the tube.

RESCUE BREATHING
When providing breaths, if doing compressions give 30 compressions and 2 breaths.
Each breath should be given over 1 second, and only until you see the chest rise.
Giving a bigger breath will only fill the stomach with air which will crush the
diaphragm, chest, lungs, and crush the heart making it difficult to resuscitate your
patient and decreasing cardiac output.
If your patient has a pulse and simply cannot breath, provide rescue breaths at a rate
of 1 breath every 6 seconds. This gives you 10 breaths/min
If your patient is intubated (has an advanced airway), provide 1 breath every 6 seconds
= 10/min. When an advanced airway is in place, compressions should not be paused
to give breaths.
If your patient has agonal gasps, this is NOT normal breathing and is a sign of cardiac
arrest. Start CPR.

GUIDELINES FOR SYNCHRONIZED CARDIOVERSION AND DEFIBRILLATION
The only difference between defibrillation and cardioversion is: One is synchronized,
and one is not.
Synchronized cardioversion is a LOW ENERGY SHOCK that uses a sensor to deliver
electricity that is synchronized with the peak of the QRS complex (the highest point
of the R-wave).
If the patient has a pulse, you must push the synchronize button on your defibrillator,
before you deliver the shock. This will ensure that the shock lands on the R-wave of
the heart beat.
If you do not synchronize the shock on someone with a pulse, the shock could hit the
heartbeat on the T-wave and cause the patient to go into ventricular fibrillation. This
will be bad. Very, very bad.
So just remember, you can’t synchronize dead. If the patient has a pulse, you must
synchronize the shock. 

HOW MANY JOULES DO YOU USE?
Start with 200 Joules
If the initial shock fails, always increase the dose in a stepwise fashion.

THERAPEUTIC HYPOTHERMIA
Used only when your patient remains unresponsive following cardiac arrest,
especially those who presented with an initial rhythm of v-fib.
These patients are cooled to 32-34 degrees celsius for at least-36 hours.
If your patient wakes up and follow commands, do not start hypothermia protocol.
Therapeutic Hypothermia can be combined with PCI (Percutaneous Coronary
Intervention) or "heart cath" or "angiogram". Therapeutic hypothermia can be started
after return of ROSC and then can be continued in the Catheterization Lab.

CHEST PAIN
Any patient having chest pain should have an EKG first. You must know if they are
having a STEMI.
STEMI (ST segment elevation) must go to the cath lab for an angiogram or they will
die. The heart muscle is not perfusing. Just remember, if the ST segment is elevated
and pointing toward heaven, your patient is GOING TO HEAVEN without immediate
intervention.
NSTEMI (ST depression) usually are able to go home on blood thinners. Having a
depressed ST is not as life threatening as "going to heaven".
The only exception to the EKG first, is a patient where the chest pain is caused by
their increased heart rate.
If they are in an unstable tachycardia WITH A PULSE, synchronized cardioversion
should be the first treatment.
So, if an ambulance is bringing you a STEMI patient, and your facility does not have
the capabilities to do a heart cath, or angiogram, these patients need to be diverted
to a specialty cardiac hospital even if it’s an hour away. If you accept the patient, you
then have to get admit orders, have consents signed, do the whole medication
reconciliation, then get transfer orders, find an accepting doctor and transfer the
patient anyway.
Door to balloon inflation time should be 90 minutes or less. The patient would be
better off getting closer to a hospital that specializes in handling an acute heart
attack, or M.I. (Myocardial Infarction or "heart muscle damage/death", and has a
catheterization lab. 

Suspected Stroke

Assess Facial droop, arm drift, slurred speech and get the time the symptoms first
started. This is super important! Get the time.
Some facilities call this a "FAST" or Cincinnati Stroke Scale If the CT scan is negative
and there is no sign of hemorrhage, Fibrinolytics should be started as soon as
possible.
The THIRD thing you need to do is get that CT SCAN. The CT scan should be done
within 25 minutes of the patients arrival in the ED. You need to know if they are
having an ischemic stroke or a hemorrhagic stroke. If they are bleeding, they will not
get the fibrinolytics. Once the CT is done, there is no sign of bleeding and no
contraindications, administer the fibrinolytics as soon as possible.
The American Heart Association defines PEA as sinus rhythm without a pulse. During
a CODE situation, you should check a pulse EVERY 2 MINUTES. If the monitor shows
sinus rhythm or sinus bradycardia and there is no pulse, your patient is dead !
Continue chest compressions and administer 1 mg of Epinephrine. Reassess the
rhythm and the pulse EVERY 2 MINUTES and follow the cardiac arrest algorithm.
Atropine is the first line treatment for any bradycardia regardless of the type, if
Atropine is ineffective a dopamine drip should be started at 2-20 mcg/kg/min. A good
place to start is at 5mcg/kg/min. Titrate to desired heart rate. If the heart rate does not
increase, increase the dopamine drip rate. If the heart rate is too fast, decrease the
dopamine drip rate. Run the dopamine until external pacing begins. 

HOW TO PERFORM EXTERNAL PACING

STEP 1: Turn on defibrillator and set to PACER mode.
STEP 2: Place defib pads on your patient AND the 3 leads: red, white and black.
STEP 3: Get a doctor's order to pre-medicate your patient. Pacing is VERY PAINFUL !
STEP 4: Begin pacing. PRESS THE START BUTTON ! Your pacer should have default
settings of a heart rate between 60-70 and a millivolt setting anywhere between 5
and 30.
STEP 5: If your patient's heart rate does not increase, increase the millivolts by 5 every
couple of heart beats until your patient is 100% paced. 

NOTE: You must have defib pads AND the 3 leads connected to your patient. BOTH of
these must be connected to the defibrillator. The 3 leads (red, white and black) sense
what your patient's heart rate is. So if your patient's heart rate is 40 and your pacer is
set to a heart rate of 60, the pacer will shock them 20 times per minute for a total of
60/bpm. If your patient's heart rate gets up to 61 nothing will happen. If their heart
rate drops to 59 they get shocked once per minute. If it drops to 58 they get shocked
twice per minute and so on. Without the red, white and black lead, your pacemaker
will not know what to do. (If you can remember: White on the right, and smoke
above the fire")
Provide a fluid bolus of 1-2 liters if the patient remains hypotensive after ROSC.
If you are going to induce therapeutic hypothermia, use COLD saline for the bolus.
The minimum systolic BP to achieve is 90mmHg.
Providing quality chest compressions immediately before a defibrillation attempt
and giving drugs during compressions will improve successful conversion of V-Fib
and the return of ROSC.
The American Heart Association says that it is acceptable to stop resuscitation efforts
if the patient has not had a pulse for 15 consecutive minutes. Except in special cases
of drowning or hypothermia.
Always be aware of safety hazards. Don’t ever cut adult pads in half or shock a
patient if there is oxygen blowing across their chest. The oxygen combined with the
electric spark could cause a small explosion or ball of fire that injures everyone in the
room.
Always provide chest compressions while the defibrillator is charging. The time it
takes to analyze is several seconds, you want to make the hands-off period of time as
short as possible. Some defibrillators can take up to 45 seconds to charge.
Always make sure you have a 6 second rhythm strip if you are going to be counting
the QRSs by 10 to get your heart rate. If you have a 12 second strip and do this you are
likely to end up with a heart rate of 80 when it’s actually only 40. The treatment is
significantly different.

WHAT'S THE DIFFERENCE BETWEEN DEFIBRILLATING AND CARDIOVERSION?
There are 2 types of shocks. One is synchronized and one is not.
A synchronized shock is called cardioversion. A blind shock is defibrillation.
If I blindly charge the defibrillator and shock them, if the shock happens to land on
the last part of the heartbeat called the "T-wave" this will change their rhythm to
V-Fib. This would be bad !
But if I "Synchronize" the shock by pushing the "synch" button on the defibrillator, a
small dot or line will appear above every "R-wave" (which is the tallest portion of the
heartbeat). Then when I push the shock button, the machine will automatically
synchronize the shock so that it lands on the "R" wave
Now, do you see how you can't synchronize dead? You can't synchronize a shock to
land on a particular part of a heartbeat if there is no heartbeat.
MORE AWESOME TIPS:
Always allow the chest to completely recoil when doing compressions. Say there was
a small fire, and you had a water bottle full of water. Would it make sense to squeeze
tiny amounts out really really fast? Or, would it make more sense to give the bottle a
good squeeze and force out as much water as you can at one time, and repeat?
When you compress the chest, it squeezes a small amount of blood out. By letting
the chest completely recoil with each compression, more blood is squeezed out with
every compression.
The only rhythm you will ever shock is V-Fib and pulseless V-Tach (Because you can't
synchronize DEAD)
The biggest misconception people have is that when you shock someone, you jump
start the heart just like you would jump start a car. This is not true. When the heart is
in Ventricular Fibrillation or Pulseless
Ventricular Tachycardia the heart is quivering. The heart is getting told to contract
too fast, from too many different cells that it can't possibly keep up and just begins to
vibrate. For example: My computer gets a virus. The first thing I want to do is pull the
cord from the wall and stop the virus. I don't want to start opening other programs
and get them running too. The same goes for V-Fib and Pulseless V-Tach.
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The shock stops the heart completely, giving it a chance to start over and hopefully
produce a normal organized rhythm. So if defibrillating actually stops the heart, do
you see why shocking someone in asystole doesn't make any sense? Why shock
someone to stop the heart, when their heart is already stopped.
So remember V-Fib = DEFIB.

For every heart rhythm 

Pulse or not - no pulse, start CPR

If they have a pulse, is it too fast or too slow

Is it Vfib or Pulseless Vtach - they need a shock

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