SAVING AMERICAN HEARTS, Inc

Advanced Cardiac Life Support (ACLS)

Study Guide

NEW 2020 Guidelines of the American Heart Association

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This study guide was not written or produced by the American Heart Association. This study guide was created by Saving American Hearts, Inc. This study guide is a supplement to your provider manual. It is not a substitute for the New 2015 Guidelines ACLS Provider Manual.

New 2020 Changes for ACLS

(If you are new to ACLS, please begin on page 4 and come back for pages 1 to 3 so you will understand things better.)

• Amiodarone and lidocaine are now equivalent 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 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,” Intubate, obtain PETCO2 and goal SPO2 92% to 98%: PaCO2 of 35 to 45mmHg and “Manage hemodynamic parameters” Administer fluids and or vasopressors for goal systolic BP or 90 or greater or MAP greater than 65. Obtain 12 Lead EKG
• 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

Adult Bradycardia AlgorithmChanges include:

• Atropine dose is now 1 mg
• Dopamine dose changed to 5-20 mcg/kg per minute
• Under “Identify and treat underlying cause,” added “Consider possible hypoxic and toxicologic causes”
• Under “Atropine,” transcutaneous pacing has “and/or” for dopamine or epinephrine (changed from “or”)

Acute Coronary Syndromes Algorithm 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

Adult Tachycardia With a Pulse Algorithm 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 Changes include:

• 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 left lateral uterine displacement
• Goal of perimortem cesarean delivery
• Deliver in 5 minutes (depending on provider resources and skill sets)

Adult Suspected Stroke Algorithm 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

Double Sequential Defibrillation Not Supported

Intravenous Access Preferred Over Intraosseous

Do Not Use Point-of-Care Ultrasonography for Prognostication During 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. Cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations.

Respiratory and Cardiac Arrest

Use a breathing rate of 1 breath every 6 seconds whether intubated or not. If CPR is being performed continue with the same rate as before, 30 Compressions to 2 Breaths.

Oxygen Administration

Greater than 94% for stroke and general care. 92% to 98% for post–cardiac arrest care.

This concludes the NEW 2020 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.

Purple indicates a "problem"

a urine color indicates "you're in" or GOLD is "good"

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 cardioversionis a LOW ENERGY SHOCK that uses a sensor to deliver electricity that issynchronized 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?

If the QRS is narrow go low (Start with 100 Joules)

If the QRS is wide go high (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 32-36 degrees celsius for at least-24 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.

HEART BLOCKS

This is a 1^st Degree Heart Block. See the distance from the P-wave to the QRS is greater than one of the bigger blocks, or more than 0.20 Seconds.

This is a 2^nd Degree Block also called Mobitz I or Wenckebach (Winky Bok)

Remember, if you *wink* at someone, you only close ONE eye. (For Mobitz I)

Look at the distance of the P-wave to the very first QRS on the strip. Now, see that the next P-R is longer,

and the next is even longer. So remember, “Longer, Longer Drop is Wenckebach.

This is a 2^nd Degree Block also called Mobitz Type II

First of all, think of the Roman numeral II and not the number 2. This will help you to remember that the

distance from each p wave, to the QRS is the same, across the whole strip. The QRSs still get dropped.

This is a 3^rd Degree Heart Block, also called AV Disassociation because the Atrias and Ventricals stop talking to each other. Because of this, they can actually both contract at the same time.

Notice there are a lot more Ps than there are QRSs. BUT! None of the QRSs are dropped. They are all exactly the same distance apart. If there is a QRS missing, it’s not a 3^rd degree block, it’s one of the 2^nd degree blocks.

Remember, if the Ps and Qs don’t agree, it’s a 3^rd Degree!

This is also a 3^rd degree. See how all the QRS are the same distance apart, and none are missing. Also, see that all the P waves are the same distance apart and none are missing, they are all the same distance apart.

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.

Some facilities call it a "FAST" the "T" is added for TIME. 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.

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.

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. If the scene is not safe, it is acceptable to withhold resuscitation.

The initial priority for ANY tachycardia is do they have a pulse or not

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. Almost like seeing someone on TV getting touched with a tazer. The heart just vibrates. The only way to correct all the overstimulation is to stop all of the electricity in the heart. 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.

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.

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.

For example: Here is a heartbeat.

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 can 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 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. It doesn't do much good to give your patient oxygen if you haven't confirmed that the oxygen is getting in their lungs.

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.

This is monomorphic V-Tach or Ventricular Tachycardia

This is MONO (which means 1) MORPHIC (which means shape)

So for EVERY Tachycardia, “Do they have a pulse, and are they stable or not. The algorithm for Tachycardia is the next to the last page of this study guide.

This is V-Fib For V-Fib Defib This does look like a V-Tach, Polymorphic V-tach and close to Torsades, but

according to AHA, this is V-Fib or Ventricular Fibrillation (If it looks like a 2 year old is trying to draw a straight line with a crayon - It's V-Fib. It's a scribbly uneven wiggly line that really has no P QRS or a T

This is a supraventricular tachycardia Supra means above so this rhythm arises from above the ventricles, or the atria, which is above the ventricles. Follow the Tachycardia algorithm

								V-FIB / Pulseless V-Tach Start CPR, SHOCK, wait 2 min Check rhythm, SHOCK, CPR, give Epi 1 mg IV Check rhythm, shock, CPR, give Amiodarone 300mg Check rhythm, shock, CPR, give Epi 1 mg Check rhythm, shock, CPR, give Amiodarone 150mg Check rhythm, SHOCK, CPR give Epi 1mg

ASYSTOLE / PEA

Push Epi Always

0800 0800 Find unresponsive, not breathing

Call a CODE

Start CPR

Attach monitor – monitor shows ASYSTOLE / PEA

Give Epi 1 mg IV q 3-5 min (no maximum)

0802 Check Rhythm + Pulse

Monitor shows ASYSTOLE / PEA

Continue CPR

0803 Give Epi 1 mg IV q 3-5 min (no maximum)

0804 Check Rhythm + PULSE

Monitor shows ASYSTOLE / PEA

Continue CPR

0806 0806 Check Rhythm + PULSE

Monitor shows ASYSTOLE / PEA

Continue CPR

Give Epi 1 mg IV q 3-5 min (no maximum)

0808 Check Rhythm + PULSE

Monitor shows ASYSTOLE / PEA

Continue CPR

0809 Give Epi 1 mg IV q 3-5 min (no maximum)

0810 Check Rhythm + PULSE Continue CPR

BRADYCARDIA

Atropine is the drug of choice for all symptomatic

Bradycardias regardless of type

Atropine 1.0 mg IV q 3-5 min

(Max 3 mg total)

(Remember: If your patient’s Heart Rate is

20 your patient is probably purple)

If atropine is ineffective you have 3 other options:

Hang a Dop/a/mine gtt at 5-20 mcg/kg/min

if ineffective begin external pacing

Remember Atropine, Dopamine, Pace

TACHYCARDIA

(With any tachycardia, the first thing you need to know is:

PULSE / NOT

STABLE / NOT

REGULAR / NOT

V-FIB / PULSELESS V-TACH

0800 Call a CODE / CORE

Begin CPR

When code team arrives with crash cart: Attach monitor and start IV

Monitor shows V-FIB / PULSELESS V-TACH

Defibrillate and immediately resume CPR for 2 minutes

0802 Check Rhythm + PULSE

Patient remains in V-Fib

Defibrillate and immediately resume CPR

Give Epi 1 mg IV q 3-5 min (no maximum dose)

0804 Check Rhythm + PULSE

Patient remains in V-Fib

Defibrillate and immediately resume CPR

Give Amiodarone 300mg IV

0806 Check Rhythm + PULSE

Patient remains in V-Fib

Defibrillate and immediately resume CPR

Give Epi 1 mg IV q 3-5 min (no maxium dose)

0808 Check Rhythm + PULSE

Patient remains in V-Fib

Defibrillate and immediately resume CPR

Give 2^nd Dose of Amiodarone 150mg IV

0810 Check Rhythm + PULSE

Patient remains in V-Fib

Defibrillate and immediately resume CPR

0812 Give Epi 1 mg IV q 3-5 min (no maximum dose)

Check Rhythm + PULSE Patient remains in V-Fib Defibrillate and immediately resume CPR