ACLS 2020 Instructor Update

ACLS 2020 Instructor Update

The American Heart Association has made many new science and education recommendations that are relevant to the 2020 Advanced Cardiovascular Life Support (ACLS) courses.

These updates are documented in the 2020 AHA Guidelines for CPR and ECC.

• Identify the ACLS 2020 science updates
• Describe the rationale for these updates
• Apply the updates to your training
• Identify the 2020 education updates
• Describe the rationale for these updates

Systems of Care: Using Mobile Devices to Summon Rescuers

2020 (New): The use of mobile phone technology by emergency dispatch systems to alert willing bystanders to nearby events that may require CPR or AED use is reasonable.

Why: Most communities experience low rates of bystander CPR and AED use.

A recent systematic review from the International Liaison Committee on Resuscitation (ILCOR) found that notification of lay rescuers via a smartphone app or text message alert is associated with shorter bystander response times, higher bystander CPR rates, shorter time to defibrillation, and higher rates of survival to hospital discharge for individuals who experience out-of-hospital cardiac arrest.

Systems of Care: Data Registries to Improve System Performance

2020 (New): It is reasonable for organizations that treat cardiac arrest patients to collect processes-of-care data and outcomes.

Why: Many industries, including healthcare, collect and assess performance data to measure quality and identify opportunities for improvement. This can be done through participation in data registries that collect information on processes of care (CPR performance data, defibrillation times, adherence to guidelines) and outcomes of care (return of spontaneous circulation [ROSC], survival) associated with cardiac arrest. The AHA Get With the Guidelines®-Resuscitation registry (for in-hospital cardiac arrest) and the Resuscitation Outcomes Consortium Cardiac Epistry and AHA Cardiac Arrest Registry to Enhance Survival registry (for out-of-hospital cardiac arrest) are 3 such initiatives, and many regional databases also exist.

Adult Chains of Survival

A sixth link, recovery, was added to the in-hospital and out-of-hospital Chains of Survival.

Adult Cardiac Arrest Algorithm

The Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for patients with nonshockable rhythms.

Changes include:

• Amiodarone and lidocaine are now equivalent as antiarrhythmics in cardiac arrest
• Added a step to consider appropriateness of continued resuscitation
• Moved epinephrine to as soon as possible for nonshockable rhythms to emphasize early administration after starting CPR

Post–Cardiac Arrest Care Algorithm

The Post–Cardiac Arrest Care Algorithm is updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension.

Changes include:

• Oxygen saturation of 92% to 98%
• Separated out initial stabilization phase to include “Manage airway,” “Manage respiratory parameters,” and “Manage hemodynamic parameters”
• Added step to consider emergent cardiac interventions
• Added “Obtain brain CT,” “EEG monitoring,” and “Other critical care management” if patient is comatose
• Added guidance on reversible etiologies
• Removed Doses and Details boxes on right
• Added sections on Initial Stabilization Phase and Continued Management and Additional Emergent Activities on right

Opioid-Associated Emergency for Healthcare Providers Algorithm

The 2020 Guidelines include an opioid-associated resuscitation emergency algorithm for healthcare providers, shown here. A version for lay rescuers is also included in the Guidelines.

Changes include:

• There is a clear step now to prevent deterioration, with an initial assessment more clearly laid out.
• Respiratory arrest is more prominently addressed in the beginning, with “Is the person breathing normally?” as an initial decision.
• Although naloxone is still recommended for opioid-associated emergencies, it should be considered for preventing deterioration and cardiac arrest, and given during respiratory arrest.

Adult Bradycardia Algorithm

The Adult Bradycardia Algorithm includes updates to dosages.

Changes include:

• Atropine dose changed from 0.5 mg to 1 mg
• Dopamine dose changed from 2-20 mcg/kg per minute to 5-20 mcg/kg per minute
• Under “Identify and treat underlying cause,” added “Consider possible hypoxic and toxicologic causes”

Adult Tachycardia With a Pulse Algorithm

The Adult Tachycardia With a Pulse Algorithm includes updates to IV access and provided additional guidance if refractory.

Changes include:

• Moved IV access and 12-lead ECG to step 2 (earlier in the algorithm)
• Added step 5 to guide on what to do if refractory (if synchronized cardioversion is not working, or if have wide QRS and adenosine/antiarrhythmic infusion is not working)

Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm

A revised algorithm is provided for cardiac arrest in pregnancy.

Changes include:

• Layout is more streamlined
• Added step for administering 100% O2 and avoiding excessive ventilation
• Removed step to assess for hypovolemia/treatment
• Changed “If no ROSC in 4 minutes” to “5 minutes”
• Maternal Cardiac Arrest box that highlights:
  • Team planning
  • Priorities of high-quality CPR and relief of aortocaval compressions with lateral uterine displacement
  • Goal of perimortem cesarean delivery
  • Deliver in 5 minutes (depending on provider resources and skill sets)

Acute Coronary Syndromes Algorithm

An updated algorithm is provided for acute coronary syndromes.

Changes include:

• Upon EMS arrival at the hospital, transport to the emergency department or cath lab per protocol. Best practice is to deliver directly to the cath lab, as long as personnel are present for the procedure, to shorten the time to treatment
• First medical contact–to–balloon inflation (percutaneous coronary intervention) goal of 90 minutes or less
• 12-lead electrocardiographic analysis is now classified into 2 main categories, ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation acute coronary syndromes (NSTE-ACS). NSTE-ACS has 2 branches under it, attempting to have emergency departments conduct further testing before release

Adult Suspected Stroke Algorithm

An updated algorithm is provided for adult suspected stroke.

Changes include:

• EMS should now use a stroke severity tool after performing a stroke screening to determine if a large-vessel occlusion exists
• New EMS stroke routing algorithm should be used to determine the hospital destination
• Upon EMS arrival at the hospital, transport to the emergency department or imaging lab per protocol. Best practice is to deliver directly to the imaging lab to shorten the time to treatment
• Patients can be treated with alteplase and endovascular therapy if time goals are met and contraindications do not exist
• The window for conducting endovascular therapy has been extended to up to 24 hours

Neuroprognostication

A diagram is provided to guide and inform neuroprognostication.

Because any single method of neuroprognostication has an intrinsic error rate and may be subject to confounding, multiple modalities should be used to improve decision-making accuracy.

Real-Time Audiovisual Feedback

2020 (Unchanged/Reaffirmed): It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Why: A recent randomized controlled trial (RCT) reported a 25% increase in survival to hospital discharge from in-hospital cardiac arrest with audio feedback on compression depth and recoil.

Physiologic Monitoring of CPR Quality

2020 (Updated): It may be reasonable to use physiologic parameters such as arterial blood pressure or end-tidal CO2 when feasible to monitor and optimize CPR quality.

2015 (Old): Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC.

Why: Similar to the above, although the use of physiologic monitoring such as arterial blood pressure and/or end-tidal CO2 to monitor CPR quality is an established concept, new data support its inclusion in the Guidelines. Data from the AHA Get With the Guidelines-Resuscitation registry show higher likelihood of ROSC when CPR quality is monitored by using either end-tidal CO2 or diastolic blood pressure. This monitoring depends on the presence of an endotracheal tube or arterial line, respectively. Targeting compressions to an end-tidal CO2 value of at least 10 mmHg, and ideally 20 mm Hg or greater, may be useful as a marker of CPR quality. An ideal target has not been identified.

Double Sequential Defibrillation Not Supported

2020 (New): The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established.

Why: Double sequential defibrillation is the practice of applying near-simultaneous shocks with 2 defibrillators. Although some case reports have shown good outcomes, a 2020 ILCOR systematic review found no evidence to support double sequential defibrillation and recommended against its routine use. Existing studies are subject to multiple forms of bias, and observational studies do not show improvements in outcome. A recent pilot randomized clinical trial suggested that changing the direction of defibrillation current by repositioning the pads may be as effective as double sequential defibrillation, while avoiding the risks of harm from increased energy and damage to defibrillators. Based on current evidence, it is not known whether double sequential defibrillation is beneficial.

Intravenous Access Preferred Over Intraosseous

2020 (New): It is reasonable for providers to first attempt establishing IV access for drug administration in cardiac arrest.

2020 (Updated): IO access may be considered if attempts at IV access are unsuccessful or not feasible.

2010 (Old): It is reasonable for providers to establish IO access if IV access is not readily available.

Why: A 2020 ILCOR systematic review comparing IV vs IO (principally pretibial placement) drug administration during cardiac arrest found the IV route was associated with better clinical outcomes in 5 retrospective studies; subgroup analyses of RCTs that focused on other clinical questions found comparable outcomes when IV or IO were used for drug administration. Although IV access is preferred, there are situations in which IV access is difficult, and in such situations IO access is a reasonable option.

Do Not Use Point-of-Care Ultrasonography for Prognostication During Resuscitation

2020 (New): The AHA suggests against the use of point-of-care ultrasound for prognostication during cardiopulmonary resuscitation. This recommendation does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or detect ROSC.

2020 (New): If an experienced sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation, although its usefulness has not been well established.

Why: Point-of-care cardiac ultrasound can identify cardiac tamponade or other potentially reversible causes of cardiac arrest and identify cardiac motion in patients with pulseless electrical activity. However, cardiac ultrasound is also associated with longer interruptions in chest compressions. A single small RCT found no improvement in outcomes with use of cardiac ultrasound during CPR. A recent systematic review found that no sonographic finding had consistently high sensitivity for clinical outcomes to be used as the sole criterion to terminate cardiac arrest resuscitation.

Care and Support During Recovery

2020 (New): The AHA recommends that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary, and cognitive impairments before discharge from the hospital.

2020 (New): The AHA recommends that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations.

Why: The process of recovery from cardiac arrest extends long after the initial hospitalization. Support is needed during recovery to ensure optimal physical, cognitive, and emotional wellbeing and return to social/role functioning. This process should be initiated during the initial hospitalization and continue as long as needed. These themes are explored in greater detail in a 2020 AHA Scientific Statement (Sawyer 2020).

Debriefing for Rescuers

2020 (New): Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.

Why: Rescuers may experience anxiety or post-traumatic stress about providing or not providing basic life support. Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest. Team debriefings may allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death.

Cardiac Arrest in Pregnancy

2020 (New): Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy.

2020 (New): Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy.

Why: Recommendations for the management of cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and a 2015 AHA Scientific Statement (Jeejeebhoy 2015). Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy due to increased maternal metabolism, decreased functional reserve capacity due to the gravid uterus, and the risk of fetal brain injury from hypoxemia. Evaluation of the fetal heart is not helpful during maternal cardiac arrest and may distract from necessary resuscitation elements.

Cardiac Arrest in Pregnancy (continued)

2020 (New): The AHA recommends targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest.

2020 (New): During targeted temperature management of pregnant patients, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought.

Why: In the absence of data to the contrary, pregnant women who survive cardiac arrest should receive targeted temperature management as any other survivors, with attention paid to the status of the fetus, who may remain in utero.

Ventilation in Respiratory and Cardiac Arrest

Respiratory Arrest

If an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, it may be reasonable for the healthcare provider to give rescue breaths at a rate of about 1 breath every 6 seconds, or about 10 breaths/min.

Cardiac Arrest

It may be reasonable for EMS providers to use a rate of 10 breaths/min (1 breath every 6 seconds) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway.

If an advanced airway is in place, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are being performed.

Why: Studies have indicated that 1 breath every 6 seconds (10 breaths/min) improves survival and neurologic outcomes.

Epinephrine Administration in Cardiac Arrest

For educational purposes, instructors and healthcare providers can administer epinephrine in cardiac arrest by using a mid range of every 4 minutes to match every other rhythm check.

Oxygen Administration

• Greater than 94% for stroke and general care
• 92% to 98% for post–cardiac arrest care
• Less than 90% for ACS

Waveform Capnography

The AHA now recommends the use of waveform capnography with a bag-mask device to increase the use of waveform capnography which can lead to better outcomes.

Deliberate Practice and Mastery Learning

Recommendation: Incorporating a deliberate practice and mastery learning model into basic or advanced life support courses may be considered for improving skill acquisition and performance.

Why: Deliberate practice is a training approach where learners are given (1) a discrete goal to achieve, (2) immediate feedback on their performance, and (3) ample time for repetition to improve performance. Mastery learning is defined as the use of deliberate practice training along with testing that uses a set of criteria to define a specific passing standard that implies mastery of the tasks being learned. Evidence suggests that incorporating a deliberate practice and mastery learning model into basic or advanced life support courses improves multiple learning outcomes.

Booster Training and Spaced Learning

2020 (New): It is recommended to implement booster sessions when using a massed learning approach for resuscitation training.

2020 (New): It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.

Why: The addition of booster training sessions (ie, brief, frequent sessions focused on repetition of prior content) to resuscitation courses improves the retention of CPR skills. Studies show that spaced learning courses (ie, separation of training into multiple sessions) are of equal or greater effectiveness when compared with courses delivered as a single training event. Learner attendance across all sessions is required to ensure course completion because new content is presented at each session.

In Situ Education

2020 (New): It is reasonable to conduct in situ simulation-based resuscitation training in addition to, or in place of, traditional training.

Why: In situ simulation refers to training activities that are conducted in actual patient care areas. New evidence shows that training in the in situ environment, either alone or in combination with traditional training, can have a positive impact on learning outcomes (eg, faster time to perform critical tasks and team performance) and patient outcomes. When conducting in situ simulation, instructors should be wary of potential risks, such as mixing training supplies with real medical supplies.

EMS Practitioner Experience and Exposure to Out-of-Hospital Cardiac Arrest

2020 (New): It is reasonable for EMS systems to monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in the management of cardiac arrest cases. Competence of teams may be supported through staffing or training strategies.

Why: A recent systematic review found that EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes, including rates of return of spontaneous circulation and survival. Because exposure can be variable, the AHA recommends that EMS systems monitor provider exposure and develop strategies to address low exposure.

ACLS Course Participation

2020 (New): It is reasonable for healthcare professionals to take an adult ACLS course or equivalent.

Why: For more than 3 decades, the ACLS course has been recognized as an essential component of resuscitation training for acute care providers. Studies show that resuscitation teams with 1 or more team members trained in ACLS have better patient outcomes.

Online Exams

• Exam security
• Key performance data

While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam.

See the AHA Instructor Network website for more information.

Online Course Videos

Course Video Formats

Available in digital format online and on DVD

Instructor Manual Part 1: General Concepts

• Science and educational principles of resuscitation training
• Basic logistics for conducting any AHA course

Students review course content before they enter the classroom.

Pre-briefing

I introduced myself

Described the simulation environment

and what would be expected during the learning activity

Introduced the objectives and

Clarify Issues of Confidentiality

I explained the strengths and weakness of the simulation and what the participants could do to get the most our of the simulated clinical experiences

Structured and Supported Debriefing

Structured and supported debriefing is an organized, evidence based student focused process that takes place in a nonthreatening environment.

Learning Stations

CPR Coach

• New role
• Promotes the delivery of high-quality CPR
• Focuses on only the BLS skills being performed by the team
• Allows the Team Leader to focus on other areas of critical care

Audiovisual feedback devices

• Required since 2018
• Provide immediate guidance and encouragement on both compressions and ventilation

Included in the following stations

• High-Quality BLS Learning and Testing Station
• Airway Management Learning and Testing Station
• Cariac Arrest and Post–Cardiac Arrest Care Learning Station
• Megacode Practice and Testing Station
• High-Quality BLS Skills
  
  • Focuses on continuous high-quality chest compressions
  • Use of a required audiovisual feedback device to increase quality

  Airway Management Skills

  • Focuses on the timing and volume of ventilations
  • CPR Coaches will focus on rate and volume of ventilations
  • Optional use of a feedback device for rate and volume or a timer for rate of ventilations

The High-Quality BLS Skills Testing Station includes a focus on continuous compressions.

All ACLS Course students must pass the Airway Management Skills Test that includes bag-mask ventilation with OPA/NPA insertion, regardless of the method of preparation or prior airway training. Ventilation should be timed to meet objective testing criteria. The focus should be on timing the breaths to make sure they’re 1 every 6 seconds.

• Megacode Testing now focuses more on testing as a team, rather than testing only the Team Leader.
• The team needs to work together to achieve a new objective goal of chest compression fraction of greater than 80% to pass the Megacode Test.
• Megacode Testing is focused more on objective testing than on subjective testing.
• At the end of the course, students will participate in a Megacode Testing Station to validate their achievement of the course objectives.
  • CPR quality and timing (meeting objective goals by using a feedback device/timer)
  • Achieving a chest compression fraction of greater than 80% (objective measure)
  • Team communication
  • Knowledge of core case material and skills
  • Knowledge of algorithms
  • Arrhythmia interpretation
  • Use of appropriate basic ACLS drug therapy
  • Performance as an effective member of a high-performance team (within the team member’s scope of practice)
  • Performance of the team working together to achieve prebriefing goals

It is important to note that there is ample opportunity for an instructor to evaluate and decide if a student should continue the class. If a student is having trouble mastering skills, the instructor should address this well before the student moves all the way through the course to the Megacode Test.

There is ample opportunity for an instructor to evaluate and decide if a student should continue the class. If a student is having trouble mastering skills, the instructor should address this well before the student reachesthe Megacode Test.

For more information on Megacode Testing, consult your ACLS Instructor Manual.

Provider Manual Updates

New ACLS Provider Manual:

• Highlights 2 main themes: preventing arrest and high-performance teams
• New information under “Cardiac Arrest: Selected Special Situations”
  • Maternal cardiac arrest
  • Ventricular assist devices
• Revised illustrations
• CPR Coach
• Expanded information on high-performance teams

eCards

Course completion cards are available in eCard format.

Cards may only be issued from a valid AHA Training Center and instructors aligned with that Training Center.

Conclusion

2020 Guidelines and Guidelines Highlights summary:
eccguidelines.heart.orgOpens in a new window

Resuscitation Education resources:
cpr.heart.orgOpens in a new window

Interim training materials:
AHA Instructor Network websiteOpens in a new window

Select Exit Exercise at the top right to return to the course home page, where you will

• Complete the course evaluation
• Obtain your certificate of completion
• Claim continuing education (CME/CE) credit if applicable

The American Heart Association thanks the following people for their contributions to the development of this course: Sallie Johnson, PharmD, BCPS; Kelly D. Kadlec, MD, MEd; Kenneth Navarro, MEd, LP; Jeanette Previdi, MPH, RN; Principled Technologies; and the AHA 2020 Instructor Update Project Team.