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Provider Handbook

By Dr. Karl Disque

Advanced Cardiac

Life Support

ACLS

Guidelines and

Standards

Provider Handbook

By Dr. Karl Disque

Advanced Cardiac

Life Support

ACLS

Introduction to ACLS....... 5

The Initial Assessment....... 6

Basic Life Support....... 7 Initiating the Chain of Survival – 7 2020 BLS Guideline Changes – 8 BLS for Adults – 9 One-Rescuer Adult BLS/CPR Two-Rescuer Adult BLS/CPR Adult Mouth-to-Mask Ventilation Adult Bag-Mask Ventilation in Two-Rescuer CPR BLS for Children/Infants – 15 One-Rescuer Child BLS/CPR One-Rescuer Infant BLS/CPR Child/Infant Mouth-to-Mask Ventilation Child/Infant Bag-Valve-Mask Ventilation in Two-Rescuer CPR Self-Assessment for BLS – 20 Advanced Cardiac Life Support....... 22 Normal Heart Anatomy and Physiology – 22 ACLS Rhythms and Interpretation – 23 The ACLS Survey (ABCD) – 30 Airway Management – 31 Basic Airway Adjuncts Basic Airway Technique Advanced Airway Adjuncts Routes of Access – 35 Intravenous Route Intraosseous Route Pharmacological Tools – 36 Self-Assessment for ACLS – 37 Principles of Early Defibrillation....... 38 Keys to Using an Automated External Defibrillator – 39 Criteria to Apply AED Basic AED Operation

Chapter (^1)

2

3

4

5

TABLE of^ CONTENTS

Systems of Care....... 41 Cardiopulmonary Resuscitation – 42 Initiating the Chain of Survival Post-Cardiac Arrest Care – 43 Targeted Temperature Management Optimization of Hemodynamics and Ventilation Percutaneous Coronary Intervention Neurologic Care Acute Coronary Syndrome – 44 Goals of ACS Treatment Acute Stroke – 45 Goals of Acute Ischemic Stroke Care The Resuscitation Team – 47 Education, Implementation, Teams – 48 Self-Assessment for Systems of Care – 49

ACLS Cases....... 50 Respiratory Arrest – 50 Pulseless Ventricular Tachycardia and Ventricular Fibrillation – 54 Pulseless Electrical Activity and Asystole – 56 Post-Cardiac Arrest Care – 60 Blood Pressure Support and Vasopressors Hypothermia Airway Management Symptomatic Bradycardia – 64 Tachycardia – 67 Symptomatic Tachycardia Stable and Unstable Tachycardia Acute Coronary Syndrome – 71 Acute Stroke – 73 Self-Assessment for ACLS Cases – 77

ACLS Essentials....... 80

Additional Tools....... 81 MediCode – 81 CertAlert+ – 81 ACLS Review Questions....... 82

Chapter (^6)

8

9

10

TABLE of^ CONTENTS

7

Determining whether an individual is conscious or unconscious can be done very quickly. If you notice someone in distress, lying down in a public place, or possibly injured, call out to them.

If the individual is unconscious, then start with the BLS Survey (Figure 20) and move on to the ACLS Survey (Figure 9).

If they are conscious and responsive, obtain consent to provide care and continue assessment and questioning to determine next steps.

THE INITIAL

ASSESSMENT

CHAPTER

- Make sure the scene is safe before approaching the individual and _conducting the BLS or ACLS Survey.

• When encountering an individual_ who is “down,” the first assessment to make is whether they are conscious or unconscious.

The ILCOR has updated the Basic Life Support (BLS) course over the years as new research in cardiac care has become available. Cardiac arrest continues to be a leading cause of death in the United States. BLS guidelines have changed dramatically, and the elements of BLS continue to be some of the most important steps in initial treatment. General concepts of BLS include:

• Quickly starting the Chain of Survival.
• Delivering high-quality chest compressions for adults, children, and infants.
• Knowing where to locate and understanding how to use an Automated External Defibrillator (AED).
• Providing rescue breathing when appropriate.
• Understanding how to perform as a team.
• Knowing how to treat choking.

INITIATING THE CHAIN OF SURVIVAL Early initiation of BLS has been shown to increase the probability of survival for an individual dealing with cardiac arrest. To increase the odds of surviving a cardiac event, the rescuer should follow the steps in the Adult Chain of Survival (Figure 1).

Adult Chain of Survival

BASIC LIFE

SUPPORT

CHAPTER

RECOVERY

POST-CARDIAC ARREST CARE

ADVANCED LIFE SUPPORT

DEFIBRILLATE WITH AED

PERFORM EARLY CPR

RECOGNIZE SYMPTOMS & ACTIVATE EMS

Figure 1

BLS FOR ADULTS

BLS for adults focuses on doing several tasks simultaneously. In many situations, more than one person is available to do CPR. This choreographed method includes performing chest compressions, managing the airway, delivering rescue breaths, and using the AED, all as a team. As a team, your primary objective for CPR is to maximize chest compression time and minimize any pauses. By coordinating efforts, a team of rescuers can save valuable seconds when time lost equals damage to the heart and brain.

Simple Adult BLS Algorithm

3

BASIC LIFE SUPPORT

• MONITOR RHYTHM
• SHOCK IF NEEDED
• REPEAT AFTER 2 MIN

GET AED AND START CPR

ACTIVATE EMERGENCY RESPONSE

UNRESPONSIVE: NO

BREATHING OR ONLY

GASPING

Push Hard And Fast Figure 3

ONE-RESCUER BLS/CPR FOR ADULTS

Be Safe

• If inside, watch for dangers such as construction debris, unsecured weapons, violent individuals, electrical hazards.
• If outside, watch out for downed electrical wires, leaking fuel from car accidents, building collapse, or natural disaster/dangerous weather conditions. (Drowning persons should be removed from the water and dried off; they should also be removed from standing water, such as puddles, pools, gutters, etc.).
• Be sure you do not become injured yourself.

Assess the Person

• Tap hard on their shoulder and shout “Hey, are you OK?” Yell their name if you know it.
• Check to see if the person is breathing. (Agonal breathing, which is occasional gasping and is ineffective, does not count as breathing.)

Call EMS

• Send someone for help and to get an AED.
• If alone, call for help while assessing for breathing and pulse. (The ILCOR emphasizes that cell phones are available everywhere now and most have a built-in speakerphone. Call for help without leaving the person.)

CPR

• Check pulse simultaneously with checking for breathing. Do not pause more than 10 seconds to check for breathing and pulse.
• Begin chest compressions and delivering breaths.

Defibrillate

• Turn on AED upon arrival and attach the AED when available.
• Listen and perform the steps as directed.

TWO-RESCUER BLS/CPR FOR ADULTS

Many times there will be a second person available who can act as a rescuer. The ILCOR emphasizes that cell phones are available everywhere now and most have a built-in speakerphone. Direct the second rescuer to call 911 or your local EMS number without leaving the person while you begin CPR. This second rescuer can also find an AED while you stay with the person. When the second rescuer returns, the CPR tasks can be shared:

1. The second rescuer prepares the AED for use.
2. You begin chest compressions and count the compressions out loud.
3. The second rescuer applies the AED pads.
4. The second rescuer opens the person’s airway and gives rescue breaths.
5. Switch roles after every five cycles of compressions and breaths. One cycle consists of 30 compressions and two breaths for Adults.
6. Be sure that between each compression you completely stop pressing on the chest and allow the chest wall to return to its natural position. Leaning or resting on the chest between compressions can keep the heart from refilling in between each compression and make CPR less effective. Rescuers who become tired may tend to lean on the chest more during compressions; switching roles helps rescuers perform high-quality compressions.
7. Quickly switch between roles to minimize interruptions in delivering chest compressions.
8. When the AED is connected, minimize interruptions of CPR by switching rescuers while the AED analyzes the heart rhythm. If a shock is indicated, minimize interruptions in CPR. Resume CPR as soon as possible with chest compressions.

Figure 5

ADULT MOUTH-TO-MASK VENTILATION

In one-rescuer CPR, breaths should be supplied using a pocket mask, if available.

1. Give 30 high-quality chest compressions.
2. Seal the mask against the person’s face by placing four fingers of one hand across the top of the mask and the thumb of the other hand along the bottom edge of the mask (Figure 5a).
3. Using the fingers of your hand on the bottom of the mask, open the airway using the head-tilt/chin-lift maneuver. If a cervical injury is suspected, consider alternative methods. (Figure 5b).
4. Press firmly around the edges of the mask and ventilate by delivering a breath over one second as you watch the person’s chest rise (Figure 5c).
5. If there is disinterest (because of an air-borne illness suspicion) in providing ventilation, hands-only CPR would be an equivalent option.

ADULT BAG-MASK VENTILATION IN TWO-RESCUER CPR

If two people are present and a bag-mask device is available, the second rescuer is positioned at the victim’s head while the other rescuer performs high-quality chest compressions. Give 30 high- quality chest compressions.

1. Deliver 30 high-quality chest compressions while counting out loud (Figure 6a).
2. The second rescuer holds the bag-mask with one hand using the thumb and index finger in the shape of a “C” on one side of the mask to form a seal between the mask and the face, while the other fingers open the airway by lifting the person’s lower jaw (Figure 6b). If possible, keep the mask on the face at all times, only remove if necessary, to reduce gross exhalation exposure to rescuers.
3. The second rescuer gives two breaths over one second each as you watch the person’s chest rise (Figure 6c).
4. Practice using the bag valve mask; it is essential to forming a tight seal and delivering effective breaths.

Figure 6

A B C

A B C

3

BASIC LIFE SUPPORT

3

BASIC LIFE SUPPORT

BLS FOR CHILDREN/INFANTS

BLS for children and infants also focuses on doing several tasks simultaneously. In many situations, more than one person is available to do CPR.

This simultaneous and choreographed method includes performing chest compressions, managing the airway, delivering rescue breaths, and using the AED, all as a team. By coordinating efforts, a team of rescuers can save valuable seconds when time lost equals damage to the heart and brain.

ONE-RESCUER BLS/CPR FOR CHILDREN (AGE 1 TO PUBERTY)

Be Safe

• Move the child out of traffic or any unsafe situation.
• Move the child out of water and dry the child. (Drowning children should be removed from the water and dried off; they should also be removed from standing water, such as puddles, pools, gutters, etc.)
• Be sure you do not become injured yourself.

Assess the Child

• Tap hard on their shoulder and talk to them loudly, saying their name.
• Check to see if the child is breathing while simultaneously checking their carotid pulse. (Agonal breathing, which is occasional gasping and is ineffective, does not count as breathing.)
• Keep in mind not to waste time trying to feel for a pulse; feel for at least 5 seconds but no more than 10 seconds. If you are not sure you feel a pulse, begin CPR with a cycle of 30 chest compressions and two breaths.

Call EMS

• Send someone for help and to get an AED.
• If alone, shout for help while assessing for breathing and pulse. (The ILCOR emphasizes that cell phones are available everywhere now and most have a built-in speakerphone. Call for help without leaving the child.)
• If no one answers and you do not have a cell phone available, perform 2 minutes of CPR before taking a moment to find help.

CPR

• Begin CPR with chest compressions and delivering breaths in a ratio of 30:2.

Defibrillate

• Attach the AED when it becomes available. Use pediatric pads for children under the age of 8 and less than 55 pounds (25 kg).
• Listen to the AED and perform the steps as directed.

CPR STEPS FOR CHILDREN

1. Use the heel of one hand on the lower half of the sternum in the middle of the chest.
2. Put your other hand on top of the first hand.
3. Straighten your arms and press straight down. Compressions should be about two inches (5 cm) into the child’s chest and at a rate of 100 to 120 compressions per minute.
4. Be sure that between each compression you completely stop pressing on the chest and allow the chest wall to return to its natural position. Leaning or resting on the chest between compressions can keep the heart from refilling in between each compression and make CPR less effective.
5. After 30 compressions, or 15 compressions for two rescuers, stop compressions and open the airway by tilting the head and lifting the chin.

a. Put your hand on the child’s forehead and tilt the head back. Lift the child’s jaw by placing your index and middle fingers on the lower jaw; lift up.

b. If their lips are closed, open the lower lip using your thumb.

6. Give a breath while watching the chest rise. Repeat while giving a second breath. Breaths should be delivered over one second.
7. Resume chest compressions. Switch quickly between compressions and rescue breaths to minimize interruptions in chest compressions.

CPR STEPS FOR INFANTS

1. Place 2 or 3 fingers of one hand on the sternum in the middle of the nipple line (Figure 47).
2. Press straight down. Compressions should be 1.5 inches (4 cm) into the infant’s chest (or about 1/3 the diameter of the chest) and at a rate of 100 to 120 compressions per minute.
3. Be sure that between each compression you completely stop pressing on the chest and allow the chest wall to return to its natural position. Leaning or resting on the chest between compressions can keep the heart from refilling in between each compression and make CPR less effective.
4. After 30 compressions, or 15 compressions for 2 rescuers, stop compressions and open the airway by tilting the head and lifting the chin.

a. Put your hand on the infant’s forehead and tilt the head back. Lift the infant’s jaw by placing your index and middle fingers on the lower jaw; lift up. Aim for a neutral neck position and do not overextend the neck.

b. If their lips are closed, open the lower lip using your thumb.

5. Give a breath while watching the chest rise. Repeat while giving a second breath. Breaths should be delivered over one second.
6. Resume chest compressions. Switch quickly between compressions and rescue breaths to minimize interruptions in chest compressions.

Figure 47

3

BASIC LIFE SUPPORT

Figure 48

Figure 49

CHILD/INFANT MOUTH-TO-MASK VENTILATION

In one-rescuer CPR, breaths should be supplied using a pediatric pocket

mask, if available.

1. Deliver 30 (or 15 if there are two providers) high-quality chest compressions while counting out loud.
2. Seal the mask against the child’s face by placing four fingers of one hand across the top of the mask and the thumb of the other hand along the bottom edge of the mask (Figure 48).
3. Using the fingers of your hand on the bottom of the mask, open the airway using the head-tilt/chin-lift maneuver. (Don’t do this if you suspect the child may have a neck injury).
4. Press firmly around the edges of the mask and ventilate by delivering a breath over one second as you watch the child’s chest rise.
5. Practice using the pocket mask; it is essential to form a tight seal in delivering effective breaths.

CHILD/INFANT BAG-VALVE-MASK VENTILATION IN TWO-RESCUER CPR

If two people are present and a bag-valve-mask device (BVM) is available, the second rescuer is positioned at the victim’s head while the other rescuer performs high-quality chest compressions.

1. Deliver 15 high-quality chest compressions while counting out loud.
2. The second rescuer holds the BVM with one hand using the thumb and index finger in the shape of a “C” on one side of the mask to form a seal between the mask and the face (Figure 49) , while the other fingers open the airway by lifting the child’s lower jaw.
3. The first rescuer squeezes the bag giving two breaths over one second each. Watch for chest rise.
4. Practice using the BVM; it is essential to form a tight seal in delivering effective breaths.