ACLS 2010 Guidelines AHA

• 1. Responsive? Breathing (5-10 sec chest scan)
• 2. Emergency response, AED
• 3. Pulse (5-10 sec, carotid adult/child, brachial infant)
• 4. AED upon arrival (compress while charging)
• 5. No shock - recheck q2min, resume CPR

• 1. 100/min
• 2. at least 2" in adult, at least 1/3 AP diameter in kids (about 2" in children or about 1.5" in infants)
• 3. complete chest recoil
• 4. min interruptions < 10 s
• 5. switch q2min (5 cycles)
• 6. Avoid excessive ventilation

• 30:2 bag maks
• advanced cardiac arrest - q6-8s (8-10/min)
• advanced resp arrest - q 5-6 s(10-12/min)

• adult lone - 30:2, 2 rescuer - 30:2
• child lone - 30:2, 2 rescuer - 15:2
• infant lone - 30:2 (2 finger)
• infant 2 rescuer - 15:2 (encircling)

collapse: emergency resp/AED 1st, then CPR (child is in cardiac arrest!)

hypoxia: 5 cycles CPR then emergency resp/AED

conscious - ACLS first

unconscious - BLS, then ACLS

• 1. Airway
• 2. Breathing 
• 3. Circulation
• 4. Differential Dx

• 1. Patent in unconscious pt? - head tilt/chin lift (or jaw thrust), OPA, NPA
• 2. Advanced airway? - laryngeal mask, laryngeal tube, esophageal-tracheal tube (placed w/o interrupting compressions)
• 3. Placement? - phys exam, QWC
• 4. Secure device, monitor placement - QWC

• 1. Are you OK?
• 2. abdominal thrusts (chest thrusts if large)
• 3. unresponsive - witness activate emerg resp/AED, if no breathing begin CPR (no pulse check)
• 4. Before breaths check for foreign body, remove if visible only
• 5. Lone - activate emerg resp/AED after 5 cycles

• 1. Confirm obstruction (difficulty breathing, silent/weak cry/cough)
• 2. 5 back slaps/chest thrusts (support head)
• 3. unresponsive - witness activate emerg resp/AED, if no breathing begin CPR (no pulse check)4. Before breaths check for foreign body, remove if visible only
• 5. Lone - activate emerg resp/AED after 5 cycles

• 1. Suppl ox - a) 100% CA, b) non CA - titrate to at least 94% SaO2
• 2. ventilation/oxygenation adequate? - chest rise, cyanosis, QWC, SaO2
• 3. Avoid excessive ventilation

• 1. effective compr? QWC PETCO2 at least 10, IAP at least 20 mm Hg
• 2. CA rhythms - VF, pulseless VT, PEA, asystole
• 3. Defib/cardioversion
• 4. IV/IO access, vasopressors, antiarrhythmics
• 5. ROSC? pt with pulse stable? give fluids/drugs

- what caused arrest?

- is cause reversible

• 1. Know your role and those of others (leader, observer, comp, airway, IV/IO, defib/monitor) 
• 2. Closed-loop communication, eye contact, confirm actions
• 3. Clear messages/repeat orders/question orders
• 4. Know limitations, ask for help
• 5. Share knowledge
• 6. Constructive intervention
• 7. Re-evaluation/Summary
• 8. Mutual respect

• 1. Recognition of CA, emerg resp
• 2. Early high quality CPR, emphasize comp
• 3. Defib
• 4. ACLS
• 5. Post CA care

• 1. Evaluate resusc/outcome (Ulstein, CPR rate, time to defib, survival to hosp DC), info sharing of dispatch, EMS, hosp
• 2. Benchmarking (CARES CA Registry to Enhance Survival out of hosp, Get With the Guidelines in hosp)
• 3. Address deficiencies

• 1. Therapeutic hypothermia
• 2. Hemodynamic and ventilation optimization
• 3. Immediate coronary reperfusion with PCI
• 4. Glycemic control
• 5. Neuro care/prognostication

• - Comatose adult pt w/o meaningful response to commands 
• - ROSC achieved after out of hospl initial VF rhythm
• - 32-34 C (89.6-93.2 F) for 12-24 hours
• - (Consider for other rhythms in and out of hosp too)

• 1. In resucs - 100% Ox, in Post CA care titrate to arterial ox sat at least 94%
• 2. Start vent 10-12 br/min, titrate to PETCO2 35-40 or PaCO2 40-45 mm Hg
• 3. Titrate fluid, vasoactive/inotropics to optimize BP, CO, systemic perfusion (MAP at least 65%)

PCI center, can be concurrent with hypothermia

Within 3 hours from onset of symptoms (4.5 hrs for some pts)

Do aim fr 144-180 mg/dL

Don't go lower (80-100 mg/dL) - increased risk of hypoglycemia

Reliable early prognostication of neuro outcome is essential

• 1. Responsiveness/breathing (5-10 s chest scan)
• 2. Activate ERS/AED
• 3. Carotid pulse 5-10s (YES in this case)
• 4. 1 breath q5-6s or 10-12/min if bag/mask or advanced airway
• 5. Check pulse q2min (if not, CPR/AED)

• 1.Patent? Use head tilt-chin lift, OPA, or NPA
• 2.Advanced? laryngeal mask tube, laryngeal tube, esophageal-tracheal tube
• 3. Placement? QWC + phys exam
• 4. Secure/Monitor placement?

• 1. Vent/ox adequate? (100% CA), Resp arrest - titrate to achieve at least 94% pulse ox; chest rise, cyanosis? 
• 2. QWC/oxyhemoglobin sat
• 3. Avoid excessive vent -  Ventilate q5-6 s or 10-12/min, 1 s per breath, visible chest rise

• 1. head tilt-chin lift (jaw thrust w/o head extension if head trauma)
• 2. Bag mask - 600 ml tidal vol over 1s
• 3. OPA
• 4. NPA

• 1. pts at risk for obstruction
• 2. UNconscious pts (otherwise stimulates gag)
• 3. OK during bag-mask vent
• 4. OK to use during suctioning of intubated pt (prevents biting/occluding ET)

• 1. Clear mouth/throat of secretions
• 2. Size - tip OPA at mouth corner, flange at angle of mandible
• 3. Insert curve up (or side), rotate to curve down
• 4. Alt - hold tongue down with depressor, insert straight in
• 5. monitor head/jaw position, suction prn (-80 to -120 mm Hg)
• 6. Check fro spontaneous resp, pos pressure vent if not

• 1. OK conscious or unconscious pts
• 2. Size - should not blanch nostrils (diam smallest pt finger); length tip of nose to earlobe
• 3. lubricate
• 4. insert along floor of noasopharynx
• 5. If resistance rotate and/or try other nostril (may be bigger)
• 6. Maintain head position, suction prn (-80 to -120 mm Hg)
• 7. Check for spontaneous resp, pos pressure vent if not
• 7. CAUTION if facial trauma - may go into brain

• 1. Responsive? Breathing?
• 2. Activate ERS/get AED
• 3. Check pulse (compress while charging?), none in this case
• 4. If shockable deliver shock, resume CPR 2 min
• 5. If not shockable, resume CPR 2 min
• 6. If ROSC, 1 breath q5-6s, check pulse q2min
• 7. If starts breathing recovery position, recheck

• 1. On
• 2. Attach pads to bare chest (wipe if covered with water/sweat)
• 3. Attach pad cables to AED
• 4. Analyze rhythm, be clear
• 5. Compress while charging
• 6. Shock if advised, everyone clear
• 7. Resume CPR immediately

• 1. Wipe water/sweat from chest
• 2. "wax" with pads, get new pads, or shave
• 3. pull pt out of water
• 4. OK to use on ice/small puddle
• 5. Not on top of pacemaker, shock 30-60 s after implanted defib shocks pt
• 6. Not on top of med patch, remove patch and wipe, if necessary

• USE ADULT CA ALGORITHM:
• 1. CPR, give O2, attach monitor/defib
• 2. Shockable? (do not interrupt comp > 10 s) If VF/pulseless VT then shock, obtain access and give drugs in 2 min between rhythm checks, consider advanced airway, breaths q6-8s, confirm with QWC
• 3. If not shockable, and rhythm organized (regular and narrow) check pulse
•  a) if no pulse resume CPR, obtain access, give drugs btwn rhythm checks q2min, consider advanced airway, breaths q6-8s, confirm with QWC
•  b) if pulse, proceed with post CA care
• 4. Repeat until ROSC
• 5. Post CA care after ROSC
• 6. Shocks: Biphasic - 120-200 J, Monophasic - 360 J

• Return of spontaneous circulation
• - CHeck pulse and BP
• - shown by abrupt sustained increase in PETCO2, usually greater than 40 mmHg
• - spontaneous arterial pressure waves

1. Vasopressors - a) Epinephrine IV/IO - 1 mg q 3-5 min, b) Vasopressin IV/IO 40 mg can replace 1st or 2nd dose epi

2. Amiodarone - 1st 300mg bolus, second 150 mg bolus, NO MORE

3. If no amiodarone, lidocaine 1st 1-1.5 mg/kg IV/IO (then 0.5-0.75 mg/kg IV/IO q5-10 min) to max of 3 mg/kg

4. Mag sulfate for torsades de pointes, loading 1-2 g IV/IO diluted in 10 mL D5W as IV/IO bolus over 5-20 min

• Hypovolemia
• Hypoxia
• Hypothermia
• Hydrogen ion (acidosis)
• Hypo/hyperkalemia
• Tension pneumothorax
• Tamponade, cardiac
• Toxins
• Thrombosis, coronary or pulmonary

• - ONLY if nonshockable rhythm AND organized (regular and narrow)
• - done during rhythm analysis
• - if pulse, proceed to post CA care
• - if nonshockable and no pulse or any doubt, proceed to PEA/asystole pathway

• - normal 35-40 mm Hg
• - indicates ROSC when abruptly increases
• - indicates ET placement
• - if <10 mm Hg, need to improve compressions

• - surrogate for CPP (coronary perfusion pressure)
• - if <20 mm Hg need to improve compressions

• - Central venous O2 Sat
• - normal 60-80%
• - if <30% need to improve compressions

• - severe hypothermia = <30 C (86 F)
•   - shock while engaged in active core rewarming
•   - pt has dec. drug metabolism, need to lower dose
•   - do NOT give antiarrhythmics, give vasopressors and warm up pt!
• - moderate hypothermia - 30-34 C (86-93.2 F)
•   - space meds at longer intervals, core rewardming

• - 1-2 mins to reach central circulation
• - several CPR cycles to take effect
• - give by IV bolus unless otherwise specified
• - follow with 20 ml IV fluid
• - elevate above heart 10-20 s

• - only done if cannot establish IV or IO access
• - exact dosages unknown, variable by pt
• - usually dosed 2-2.5x IV/IO dose
• - must dilute in 5-10 ml NS or sterile water
• - inject directly into trachea

- 1mg IV/IO q3-5 mins

- vasoconstriction, increases HR/BP, increases perfusion to heart/brain

- 40 Units IV/IO can replace 1st or 2nd dose epinephrine

- same effect as epinephrine

- antiarrhythmic

- given after vasopressors

• - 1st dose 300 mg IV/IO push
• - 2nd dose 150 mg IV/IO push given 3-5 mins after 1st dose, if needed - NO MORE!

- given if Amiodarone not available

- 1st dose 1.0- 1.5 mg/kg IV/IO 

- then 0.5 - 0.75 mg/kg IV/IO q5-10 mins

- max dose 3mg

- if given ET route dose is 2-4 mg/kg

• - only given for torades de pointes with prolonged QT in NSR (or Mg depletion, hypokalemia, etc)
• - 1-2 g IV/IO diluted in 10ml D5W over 5-20 mins

• - If unconscious/unresponsive need advanced airway:
•    - vent 10-12 br/min (q8-10s) and titrate to:
•        - PETCO2 35-40, PaCO 40-45 mm Hg
•        - titrate FiO2 to achieve SaO2 94% or >
•        (if unable to titrate give 100% O2)

• - maintain SBP > 90
• - bolus 1-2 L NS or LR
• - if inducing hypothermia give fluid 4 deg C

Epinephrine 0.1-0.5 mcg/kg/min (7-35 mcg/min in 70 kg adult)

Dopamine 5-10 mcg/kh/min

• Norepinephrine same dose as epi
• - use if severe hypotension with SBP <70 and epi ineffective

• - ONLY intervention to improve neurologic recovery
• - consider if comatose (pt does not give meaningful responses to commands)
• - target temp 32-34 C for 12-24 hrs
• - use any combo of: rapid infusion of ice cold isotonic non-glucose fluid, endovascular catheter, surface cooling devices
• - if comatose pt spontaneously develops mild hypothermia, do not rewarm for 12-24 hrs >ROSC
• - monitor with esophageal thermometer, bladder cath (in nonanuric pt), pulm art cath if already in place
• - PCI and hypothermia OK togther

• - TREAT THE CAUSE
• - IV/IO access priority over advanced airway unless:
•    - bag-mask ineffective
•    - arrest caused by hypoxia

• - check only if you see ORGANIZED rhythm (regular, narrow complexes)
• - if no pulse, back to CPR/drugs
• - if pulse, go to post CA care

• Hypoxia**
• Hypovolemia**
• Toxicity*
• Hypothermia
• Hydrogen ion (acidosis)
• Hypo/hyperkalemia

• Tension pneumothorax
• Tamponade
• Thrombosis, coronary
• Thrombosis, pulmonary

- If narrow QRS, probably NOT cardiac in origin!

• - narrow complex, rapid rate
• - flat neck veins
• - increasing DBP, decreasing SBP until BP not detectable
• - TR with volume infusion (consider occult internal hemorrhage, severe dehydration)

• - slow rate
• - cyanosis, Bl gases, airway problems
• - TR: O2 via advanced airway

• - slow rate, often prolonged QT
• - neuro exam, pupils, may be hypotensive
• - bottles/drugs at scene
• - TR: drug specific antidotes, intubate, prolonged CPR, CP bypass, dialysis, TCP, correct electrolytes, Narcan

• - low amplitude QRS
• - hx DM, acidosis (responsive to bicarb), renal failure
• -TR; Na bicarb, O2

• - tall, peaked T waves, P's get smaller, QRS widens
• - sine wave PEA
• - hx renal failure, recent dialysis, fistulas, DM, meds
• - TR: CaCl, Na bicarb, glucose + insulin, maybe albuterol

• - T's flatten, prominent U's, QRS widens, QT prolonged, wide complex tachycardia
• - hx diuretics
• - TR: Mg if in CA

• - J/Osborne waves (pos wave btwn QRS and T)
• - hx cold exposure, low temp
• -TR: hypothermia algorithm

• - hypoxia (slow rate) - VS tamponade (rapid)
• - narrow
• - no pulse with CPR, neck vein distension
• - trachael deviation
• - unequal breath sounds
• - difficult to ventilate
• - TR if US confirmation: needle decompression, chest tube thoracostemy

• - rapid rate (vs. tension pneumothorax)
• - narrow
• - no pulse with CPR
• - neck vein distention
• - TR if confirmed with US: pericardiocentesis, give volume while initiating treatment

• - rapid, narrow
• - prior pos test for DVT or PE (vs. tamponade)
• - no pulse with CPR
• - distended neck veins
• - TR: fibrinolytics, surgical embolectomy

• - ECG data, Q, ST changes, T inversions
• - cardiac markers
• - good pulse with CPR
• - TR: ACS algorithm (fibrinolytics, PCI)

• - IV/IO access priority over advanced airway unless asystole caused by hypoxia
• - TREAT UNDERLYING CAUSE (H/T)
• - STOP: - rigor mortis, DNAR, unsafe for providers
• - consider longer resusc. effort if:
•    - hypothermia, drug OD, other reversible causes
•    - ROSC of any duration achieved
•    - possibility of fine VF, not asystole (if in doubt treat as VF)

• - rapidly deteriorates to VF or hypotensive bradyarrythmia - be prepared to tr these (drug/defib)
• - focus on ECG, rapid reperfusion (fibrinolytics, PCI), relief of ischemic pain, tr early life threatening complications
• - drugs: O2, ASA, nitroglycerin, morphine, fibrinolytics, heparin, adjuncts (B-blockers, ADP antagonists, ACE-inh, statins)
• - **chest discomf suggests ischemia, tr as MI**

• chest discomfort: pain, pressure, tightness for more than a few minutes
• - radiates to back, btwn shoulder blades, neck, jaw, arms
• - light headedness, fainting, sweating, NV with chest discomfort
• - unexplained SOB w or w/o chest discomfort
• - symptoms may also suggest MI mimics (aortic dissection, PE, tamponade, pneumothorax)

• - ASA 160-325 mg chewed or 300 mg PR if N/V, peptic ulcer, other UGI disease; X if allergy, active or recent GI bleeding
• - O2 4L/min (100% in CA) if dyspneic, hypoxic, HF, SaO2 <94% (or unknown); not given routinely
• - nitroglycerin 1 tab/spray q 3-5 min up to 3 doses
•   - must have SBP >90, no lower than 30 mm Hg below baseline if known, HR 50-100
•    - caution/contraindicated:
•        - inferior wall MI
•        - acute RV infarct (also no morphine, diuretics, other vol depleters)
•       - SB <90, HR <50 or >100
•       - recent phosphodiesterase inh (sildenafil, vardenafil in 24 hrs, tadalafil in 48 hrs)
• - morphine: use if chest discomfort not relieved by nitro
•     - caution: UA/NSTEMI, acute RV infarction (give fluid if hypotension develops)

• - ED evaluation - 10 mins
• - fibrinolytics- 30 mins to needle
• - PCI - 90 mins to balloon inflation (limited to 12 hours form onset of symptoms, usually)
• - consult should not delay tr unless very tricky case
• - 4Ds of tr delay: door-data-decision-drug

• 1)STEMI - ST elevation  on 2 or more contiguous leads or LBBB (V1 neg R, V6 double R)
•  - 2mm (0.2 mV) on V2 or V3,  1mm in all other leads
•  - 2.5 mm (0.25 mV in men < 40), 1 .5 mm (0.15 in women) on V2/V3

• - ST depression at least 0.5mm (0.05mV), OR
• - dynamic T wave inversion + chest discomfort, OR
• - transient ST elevation at least 0.5mm (0.05 mV) fro < 20 minutes

• - need serial cardiac markers, functional testing for further risk stratification (new data may change risk category)
• - normal ECG
• - ST deviation either direction < 0.5mm (0.05 mV)
• - T inversion 2mm or less (0.2 mV)

• - fibrin specific: rtPA, reteplase, tenecteplase
• - non-fibrin specific: streptokinase (most common)
•  1) STEMI, onset of symptoms <12 hrs, qualifying ECG, PCI unavailable in 90 min of 1st med contact
• 2) "STEMI" on posterior wall (ST elevation in early precordial leads V1-V6), < 12hrs, qualifying ECG
• 3)>12 hrs IF persistent chest discomfort + STE

• - any prior intracranial bleed
• - cerebral vascular lesion
• - malignant intracranial neoplasm
• - ischemic stroke within 3 mo (unless within 3 hrs)
• - aortic dissection
• - active bleeding
• - major closed head/face traums w/in 3 mo
• - >24 hrs from onset of symptoms
• - ST depression (unless true posterior wall MI)

• - chronic severe HTN (hx or current) >180/110
• - dementia or other intracranial pathology
• - traumatic.prolonged CPR/major surgery last 3 wks
• - recent int bleeding (2-4 w)
• - noncompressible vascular puncture
• - prior fibrinolytics with poor allergic response
• - pregnancy
• - current anticoags with elevated INR

• Percutaneous coronary intervention - balloon inflation and stent placement
• - Primary - preferred over fibrinolytics if <3hrs from onset of symptoms or contraindications to fibrinolytics
• - Rescue PCI - fibrinolytics fail

• - not routinely used
• - used if chest discomfort persist after SL/spray nitro
• - used in STEMI complicated by pulm edema or HTN
• - management: titrate to effect, keep SB >90, limit drop in SBP to 30 mm Hg below BL in hypertensives, 10% drop in normotensives

• - routinely given as adjunct for PCI and fibrinolytics
• - be careful!!! incorrect dosing/monitoring leads to hemorrhage!

• - true symptomatic brady if: rate < 50, pt syptomatic, symptoms due to brady
• - if HR <50 then symptoms probably related to brady
• - 1st line drug = atropine
• - may use TCP, epinephrine, or dopamine
• - may need expert consult
• - recognition of brady due to VA block takes priority over ID type of AV block
• - HURRY - if symptomatic may rapidly progress to CA

• - symptoms: chest discomfort, SOB, dec LOC, weakness, fatigue, light headedness, presyncope/syncope
• - signs: hypotension, orthostatic hypo, diaphoresis, pulmonary congestion, CHF, pulm edema
• - may have bradycardia related (escape) ventricular rhythms (PVC, VT)

• - Adequate perfusion? BP WNL, OK mental status, warm extensions, cap refill < 3s, no pallor/cyanosis, periph pulses, urine output >30 ml/hr, no edema
• - if yes, observe and monitor
• - if no, ATROPINE 1st dose 0.5 mg bolus, repeat 3-5 min to 3 mg total, but do not delay TCP fr atropine if unstable/poor perfusion
• - atropine effective? If not, TCP or epi or Dop 2-10 mcg/kg/min
• - use caution w atropine in acute coronary ischemia or MI
• - do NOT rely on atropine in 2 deg type ii or 3 deg AV block with new wide QRS

• - give analgesics/sedatives if possible
• - IMMEDIATELY in unstable pts with higher degree heart block, if IV unavailable, if atropine ineffective
• - after TCP confirm capture
• - reassess for improvement/hemodynamic stability
• - if both atropine and TCP ineffective, need consult, consider epi pr dop 2-10 mcg/kg/min and titrate to effect, prepare for transvenous pacing

• - hemodynamically unstable bradycardia
• (hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure)
• - AMI with symptomatic brady
• - 2nd deg type 2
• - 3rd deg AV block
• - new BBB
• - brady with V escape rhythms (PVC)

• X severe hypothermia, asystole
• - requires analgesia/sedatives if possible
• - carotid pulse inadequate to confirm capture
• - if ACS, pace with lowest HR for stability of high O2 demand!

• - electrodes on
• - pacer on
• - rate 60/min (adjust) - if symptoms are due to brady, should see improvement at rate 60-70/min
• - set to 2mA> dose at which capture occurs
• - don't target HR, look fr improvement in clinical status

• - fail to respond to drugs
• - can deteriorate to VT or VF
• - TCP may eliminate them