Emergency medical technician (EMT) and ambulance technician are terms used in some

countries to denote a health care providerof emergency medical services.[1] EMTs are clinicians,
trained to respond quickly to emergency situations regarding medical issues, traumatic injuries and
accident scenes. Under the British system and those that are influenced by it, they are referred to as
ambulance technicians (often shortened to techs), whereas in the American system and its
influenced countries, they are known as emergency medical technicians.
EMTs are most commonly found working in ambulances, but should not be confused with
"ambulance drivers" or "ambulance attendants" ambulance staff who in the past were not trained in
emergency care or driving.[2] EMTs are often employed by ambulance services,governments,
and hospitals, but are also often employed by fire departments (and seen on fire apparatus),
in police departments (and seen on police vehicles), and there are many firefighter/EMTs and police
officer/EMTs.[1] EMTs operate under a limited scope of practice. EMTs are typically supervised by
a medical director, who is a physician.[3][4]
Some EMTs are paid employees, while others (particularly in rural areas) are volunteers.[1]
Contents
[hide]

1Canada
o

1.1Emergency Medical Responder

1.2Primary care paramedics

1.3Advanced Care Paramedics

1.4Critical Care Paramedic

1.5Training

2Ireland

3United Kingdom

4United States
o

4.1History

4.2Certification

4.3Levels

4.3.1Transition to new levels

4.3.2EMR

4.3.3EMT

4.3.4Advanced EMT

4.3.5Paramedic

4.3.6Staffing levels

4.4Education and training

4.5Medical direction

4.6Employment

5See also

6References and notes

7External links

Canada[edit]
There is considerable degree of inter-provincial variation in the Canadian Paramedic practice.
Although a national consensus (by way of the National Occupational Competency Profile) identifies
certain knowledge, skills, and abilities as being most synonymous with a given level of Paramedic
practice, each province retains ultimate authority in legislating the actual administration and delivery
of emergency medical services within its own borders. For this reason, any discussion of Paramedic
Practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions
related to Paramedic practice can only definitively be answered by consulting relevant provincial
legislation, although provincial Paramedic Associations may often offer a simpler overview of this
topic when it is restricted to a province-by-province basis.
In Canada, the levels of paramedic practice as defined by the National Occupational Competency
Profile are: Emergency Medical Responder (EMR), Primary Care Paramedic, Advanced Care
Paramedic, and Critical Care Paramedic
Regulatory frameworks vary from province to province, and include direct government regulation
(such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced
Emergency Medical Care Assistant) to professional self-regulating bodies, such as the Alberta
College of Paramedics. Though the title of Paramedic is a generic description of a category of
practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual
titles that are ascribed to different levels of practitioners. For example, the province of Alberta has

legally adopted the title "Emergency Medical Technician", or 'EMT', for the Primary Care Paramedic;
and 'Paramedic' only for those qualified as Advanced Care Paramedics Advanced Life
Support (ALS) providers. Only someone registered in Alberta can call themselves an EMT or
Paramedic in Alberta, the title is legally protected. Almost all other provinces are gradually moving to
adopting the new titles, or have at least recognized the NOCP document as a benchmarking
document to permit inter-provincial labour mobility of practitioners, regardless of how titles are
specifically regulated within their own provincial systems. In this manner, the confusing myriad of
titles and occupational descriptions can at least be discussed using a common language for
comparison sake.

Emergency Medical Responder[edit]

Main Article: Emergency Medical Responder
Most providers that work in ambulances will be identified as 'Paramedics' by the public. However, in
many cases, the most prevalent level of emergency prehospital care is that which is provided by the
Emergency Medical Responder (EMR). This is a level of practice recognized under the National
Occupational Competency Profile, although unlike the next three successive levels of practice, the
EMR is not specifically considered a Paramedic, per se. The high number of EMRs across Canada
cannot be ignored as contributing a critical role in the chain of survival, although it is a level of
practice that is least comprehensive (clinically speaking), and is also generally not consistent with
any medical acts beyond advanced first-aid and oxygen therapy, with the exception of automated
external defibrillation (which is still considered a regulated medical act in most provinces in Canada).

Primary care paramedics[edit]

Primary care paramedics (PCP) are the entry-level of paramedic practice in Canadian provinces.
The scope of practice includes performing semi-automated external defibrillation, interpretation of 4lead ECG's, administration of Symptom Relief Medications for a variety of emergency medical
conditions (these
include oxygen, epinephrine,dextrose, glucagon, salbutamol, ASA and nitroglycerine),
performing trauma immobilization (including cervical immobilization), and other fundamental basic
medical care. Primary Care Paramedics may also receive additional training in order to perform
certain skills that are normally in the scope of practice of Advanced Care Paramedics. This is
regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an
aspect of medical oversight by a specific body or group of physicians. This is often referred to
as Medical Control, or a role played by a base hospital. For example, in the provinces of Ontario and
Newfoundland and Labrador, many paramedic services allow Primary Care Paramedics to perform
12-lead ECG interpretation, or initiate intravenous therapy to deliver a few additional medications.

Advanced Care Paramedics[edit]

The Advanced Care Paramedic is a level of practitioner that is in high demand by many services
across Canada. However, still not all provinces and jurisdictions have ACPs (Quebec, New
Brunswick). The ACP typically carries approximately 20 different medications, although the number
and type of medications may vary substantially from region to region. ACPs perform advanced
airway management including intubation, surgical airways, intravenous therapy, place external
jugular IV lines, perform needle thoracotomy, perform and interpret 12-lead ECGs, perform
synchronized and chemical cardioversion, transcutaneous pacing, perform obstetrical assessments,
and provide pharmacological pain relief for various conditions. Several sites in Canada have
adopted pre-hospital fibrinolytics and rapid sequence induction, and prehospital medical research
has permitted a great number of variations in the scope of practice for ACPs. Current programs
include providing ACPs with discretionary direct 24-hour access to PCI labs, bypassing the
emergency department, and representing a fundamental change in both the way that patients with
S-T segment elevation myocardial infarctions (STEMI) are treated, but also profoundly affecting
survival rates.[12] as well as bypassing a closer hospitals to get an identified stroke patient to a
stroke centre.

Critical Care Paramedic[edit]

Critical Care Paramedics (CCPs) are paramedics who generally do not respond to 9-1-1 emergency
calls, with the exception of helicopter "scene" calls. Instead they focus on transferring patients from
the hospital they are currently in to other hospitals that can provide a higher level of care. CCPs
often work in collaboration with registered nurses and respiratory therapists during hospital transfers.
This ensures continuity of care. However, when acuity is manageable by a CCP or a registered
nurse or respiratory therapist is not available, CCPs will work alone. Providing this care to the patient
allows the sending hospital to avoid losing highly trained staff on hospital transfers. CCPs are able to
provide all of the care that PCPs and ACPs provide. That being said, CCPs significantly lack
practical experience with advanced skills such as IV initiation, peripheral access to cardiovascular
system for fluid and drug administration, advanced airway, and many other techniques. Where an
PCP and ACP may run 40-50 medical codes per year a CCP may run 1-2 in an entire career. IV/IO
starts are nearly non-existent in the field and for this reason CCPs are required to attend nearly
double the amount of time in classroom situations or in hospital to keep current. In addition to this
they are trained for other skills such as medication infusion pumps, mechanical ventilation and
arterial line monitoring.[13] CCPs often work in fixed and rotary wing aircraft when the weather
permits and staff are available, but systems such as the Toronto EMS Critical Care Transport
Program work in land ambulances. ORNGE Transport operates both land and aircraft in Ontario. In
British Columbia, CCP's work primarily in aircraft with a dedicated Critical Care Transport crew in
Trail for long-distance transfers and a regular CCP street crew stationed in South Vancouver that
often also performs medevacs, when necessary.

Training[edit]

Paramedic training in Canada varies regionally; for example, the training may be six months (British
Columbia) or two to four years (Ontario, Alberta) in length. The nature of training and how it is
regulated, like actual paramedic practice, varies from province to province.

Ireland[edit]
Main article: PHECC
Emergency Medical Technician is a legally defined title in the Republic of Ireland based on the
standard set down by the Pre-Hospital Emergency Care Council (PHECC). Emergency Medical
Technician is the entry-level standard of practitioner for employment within the ambulance service.
Currently, EMTs are authorised to work on non-emergency ambulances only as the standard for
emergency (999) calls is a minimum of a two-paramedic crew. EMTs are a vital part of the voluntary
and auxiliary services where a practitioner must be on board any ambulance in the process of
transporting a patient to hospital.

PHECC Responder Levels

Responder Title

CARDIAC FIRST
RESPONDER

OCCUPATIONAL FIRST
AIDER

EMERGENCY FIRST
RESPONDER

Abb

Level of Care

CFR

OFA

EFR

Trained in BLS with emphasis on CPR and the Automated

External Defibrillator

Trained as CFR with additional training in management of

bleeding, fractures etc. particularly in the workplace

Extensive first aid and BLS training with introduction

to Oxygen therapy and assisting practitioners with care

PHECC Practitioner Levels

Practitioner
Title

Abb
r

Level of Care

EMERGENC
Y MEDICAL
TECHNICIA

Entry-level EMS Healthcare professional. Trained

EMT

in BLS, Anatomy/Physiology, Pathophysiology, Pharmacology, ECG Monito

ring, advancedAirway management (Supraglottic Airways) and Spinal
Immobilization

PARAMEDIC

ADVANCED
PARAMEDIC

AP

Emergency Ambulance Practitioner. Trained in advanced Pharmacology,

advanced Airway management etc.

Trained to Paramedic level plus IV & IO access, a wide range of

Medications, tracheal intubation, Manual Defib etc.

United Kingdom[edit]
Main article: Emergency medical personnel in the United Kingdom
Emergency Medical Technician is a term that has existed for many years in the United Kingdom.
Some National Health Service ambulance services are running EMT conversion courses for staff
who were trained by the Institute of Healthcare Development (IHCD) as Ambulance Technicians and
Assistant Ambulance Practitioners. Ambulance trusts such as the London Ambulance Service and
the North West Ambulance Service are in the process of converting existing Ambulance Technicians
into Emergency Medical Technician grades 1,2,3 or 4, based on their level of experience; in many
cases providing a similar level of care to that of a Paramedic.
Emergency Medical Technicians are still widely deployed in private ambulance companies with IHCD
NHS trained Emergency Technicians being particularly sought after. There also many newer EMT
training courses available. IHCD Ambulance Technicians and Assistant Ambulance Practitioners still
exist within other UK ambulance services withEmergency Care Assistants employed in some areas
as support, however, this grade of staff is now being phased out and replaced with a much lower
qualified Emergency care assistants. The exception to this is the East of England Ambulance
Service, who have actively stopped training Emergency Care Assistants, and is upskill training them
to Emergency Medical Technician level. With the intention being to convert EMTs to Paramedics,
thus up-skilling the entire workforce.
Examples of skills that may be had by an Emergency Medical Technician in the UK are:

Administration of selected drugs (Usually not IV Medications)

Intermediate life support, including manual defibrillation and superglottic airway adjuncts

Ability to discharge patient to different care pathways

IV Cannulation (Usually hospital EMT skill).

United States[edit]
See also: Emergency medical services in the United States

History[edit]
EMT program in the United States began as part of the "Alexandria Plan" in the early 70's, in
addition to a growing issue with injuries associated with car accidents. Emergency medicine (EM) as
a medical specialty is relatively young. Prior to the 1960s and 70s, hospital emergency departments
were generally staffed by physicians on staff at the hospital on a rotating basis, among them general
surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents),
foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM
was born as a specialty in order to fill the time commitment required by physicians on staff to work in
the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of
physicians began to emerge who had left their respective practices in order to devote their work
completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along
with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade,
and Dr. Steven Bednar at Alexandria Hospital, VA established 24/7 year round emergency care
which became known as the "Alexandria Plan". It was not until the establishment of American
College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs
by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties
that EM became a recognized medical specialty. The nation's first EMT's were from the Alexandria
plan working as Emergency Care Technicians serving in the Alexandria Hospital Emergency Room.
The training for these technicians was modeled after the established "Physician Assistant" training
program and later restructured to meet the basic needs for emergency pre-hospital care. On June
24, 2011, The Alexandria Hospital Celebrated the 50th Anniversary of the Alexandria Plan. In
attendance were three of the nation's first ECTs/EMTs: David Stover, Larry Jackson, and Kenneth
Weaver.

Certification[edit]
In the United States, EMTs are certified according to their level of training. Individual states set their
own standards of certification (or licensure, in some cases) and all EMT training must meet the
minimum requirements as set by the National Highway Traffic Safety Administration's (NHTSA)
standards for curriculum.[5] The National Registry of Emergency Medical Technicians (NREMT) is a
private organization[6] which offers certification exams based on NHTSA education guidelines.
[7]

Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more

EMT certification levels.[8] A NREMT exam consists of skills and patient assessments as well as a
written portion.
In order to apply for the NREMT Certification applicants must be 18 years of age or older. Applicants
must also successfully complete a state-approved EMT course that meets or exceeds the NREMT
Standards within the past 2 years. Those applying for the NREMT Certification must also complete a
state-approved EMT psychomotor exam.[9]
The Veteran Emergency Medical Technician Support Act of 2013, H.R. 235 in the 113th United
States Congress, would amend the Public Health Service Act to direct theSecretary of Health and
Human Services to establish a demonstration program for states with a shortage of emergency
medical technicians to streamline state requirements and procedures to assist veterans who
completed military EMT training while serving in the Armed Forces to meet state EMT certification
and licensure requirements. The bill passed in the United States House of Representatives, but has
not yet been voted on in the United States Senate.[10]
See also: Emergency medical responder levels by U.S. state and Paramedics in the United States

Levels[edit]
The NHTSA recognizes four levels of Emergency Medical Technician:[5]

EMR (Emergency Medical Responder)

EMT (Emergency Medical Technician)

AEMT (Advanced Emergency Medical Technician)

Paramedic

Some states also recognize the Advanced Practice Paramedic[11] or Critical Care Paramedic[12] level
as a state-specific licensure above that of the Paramedic. These Critical Care Paramedics generally
perform high acuity transports that require skills outside the scope of a standard paramedic. [13] In
addition, EMTs can seek out specialty certifications such as Wilderness EMT, Wilderness
Paramedic, Tactical EMT, and Flight Paramedic.
Transition to new levels[edit]
In 2009, the NREMT posted information about a transition to a new system of levels for emergency
care providers developed by the NHTSA with the National EMS Scope of Practice project. [14] By
2014, these "new" levels will replace the fragmented system found around the United States. The
new classification will include Emergency Medical Responder (replacing first responder), Emergency
Medical Technician (replacing EMT-Basic), Advanced Emergency Medical Technician (replacing

EMT-Intermediate/85), and Paramedic (replacing EMT-Intermediate/99 and EMT-Paramedic).

Education requirements in transitioning to the new levels are substantially similar.[15]
EMR[edit]
EMR (Emergency Medical Responder) is the most basic, entry level of EMS. EMRs, many of whom
are volunteers, provide basic, immediate lifesaving care including bleeding control, splinting, eye
irrigation, taking vital signs, supplemental oxygen administration, oral suctioning, positive pressure
ventilation with a bag valve mask, oropharyngeal airway,nasopharyngeal airway, cardio-pulmonary
resuscitation (CPR), automated external defibrillator (AED) usage, childbirth, and administration of
basic medications such asepinephrine auto-injectors, rescue inhalers, and oral glucose. Due to the
opioid crisis, an increasing number of EMRs are now being trained in and allowed to administer
intranasal naloxone. The skills allowed at this level are almost identical to that of the EMT level with
some exceptions, but the training is significantly shorter and more condensed. An EMR can assume
care for a patient while more advanced resources are on the way, and then can assist EMTs and
Paramedics when they arrive. Training requirements and treatment protocols vary from area to area.
EMT[edit]

EMTs tend to a woman with a spiral fracture at a roller derby bout.

EMT is the main entry level of EMS.[16] The procedures and skills allowed at this level are generally
non-invasive such as bleeding control,positive pressure ventilation with a bag valve
mask, oropharyngeal airway, nasopharyngeal airway, supplemental oxygen administration, taking
vital signs, pulse oximetry, glucometry, oral suctioning, eye irrigation, cardio-pulmonary
resuscitation (CPR), use of an automated external defibrillator (AED), splinting (including full spinal
immobilization), traction splinting, childbirth, and medication administration (such as epinephrine
auto-injectors, oral glucose, aspirin, nitroglycerin, and albuterol). Some areas may add to the scope
of practice for EMT's, including intransal nalaxone administration, use of mechanical CPR devices,
insertion of additional airway devices, and CPAP. Training requirements and treatment protocols
vary from area to area.[17][18]
Advanced EMT[edit]

Advanced EMT is the levels of training between EMT and Paramedic. They can provide
limited advanced life support (ALS) care including obtaining intravenous access, use of advanced
airway devices, limited medication administration, and basic cardiac monitoring. [19]
Paramedic[edit]
Paramedics, represents the highest level of EMT, and in general, the highest level of prehospital
medical provider, though some areas utilize physicians as providers on air ambulances or as a
ground provider.[20] Paramedics perform a variety of medical procedures such as endotracheal
intubation, fluid resuscitation, drug administration, obtainingintravenous access, cardiac
monitoring (continuous and 12-lead), cardioversion, transcutaneous pacing, cricothyrotomy, manual
defibrillation, chest needle decompression, and other advanced procedures and assessments. [21]
Staffing levels[edit]
An ambulance with only EMTs is considered a Basic Life Support (BLS) unit, an ambulance utilizing
AEMTs is dubbed an Intermediate Life Support (ILS), or Limited Advanced Life Support (LALS) unit,
and an ambulance with Paramedics is dubbed an Advanced Life Support (ALS) unit. Some states
allow ambulance crews to contain a mix of crews levels (e.g. an EMT and a Paramedic or an AEMT
and a Paramedic) to staff ambulances and operate at the level of the highest trained provider. There
is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an
ALS ambulance is required to have two Paramedics, then it is acceptable to have two Paramedics
and an EMT). An emergency vehicle with only EMRs or a combination of both EMRs and EMTs is
still dubbed a Basic Life Support (BLS) unit.

Education and training[edit]

EMT training programs for certification vary greatly from course to course, provided that each course
at least meets local and national requirements. In the United States, EMR's receive at least 2460
hours of classroom training, EMTs receive at least 120180 hours of classroom training. AEMTs
generally have 200500 hours of training, and Paramedics are trained for 1,0001800 hours or
more. In addition, a minimum number of continuing education (CE) hours are required to maintain
certification. For example, to maintain NREMT certification, EMTs must obtain at least 48 hours of
additional education and either complete a 24-hour refresher course or complete an additional 24
hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course
would.[22] Recertification for other levels follows a similar pattern.
EMT training programs vary greatly in calendar length (number of days or months). For example,
fast track programs are available for EMTs that are completed in two weeks by holding class for 8 to
12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for
Paramedics in an associate degree program. In addition to each level's didactic education, clinical
rotations may also be required (especially for levels above EMT). Similar in a sense to medical
school clinical rotations, EMT students are required to spend a required amount of time in an

ambulance and on a variety of hospital services (e.g. obstetrics, emergency

medicine, surgery, psychiatry) in order to complete a course and become eligible for the certification
exam. The number of clinical hours for both time in an ambulance and time in the hour vary
depending on local requirements, the level the student is obtaining, and the amount of time it takes
the student to show competency.[5][23][24][25] EMT training programs take place at numerous locations,
such as universities, community colleges, technical schools, hospitals or EMS academies. Every
state in the United States has an EMS lead agency or state office of emergency medical services
that regulates and accredits EMT training programs. Most of these offices have web sites to provide
information to the public and individuals who are interested in becoming an EMT.

Medical direction[edit]
In the United States, an EMT's actions in the field are governed by state regulations, local
regulations, and by the policies of their EMS organization. The development of these policies are
guided by a physician medical director, often with the advice of a medical advisory committee.[26]
In California, for example, each county's Local Emergency Medical Service Agency (LEMSA) issues
a list of standard operating procedures or protocols, under the supervision of the California
Emergency Medical Services Authority. These procedures often vary from county to county based
on local needs, levels of training and clinical experiences.[27] New York State has similar procedures,
whereas a regional medical-advisory council ("REMAC") determines protocols for one or more
counties in a geographical section of the state.[28]
Treatments and procedures administered by Paramedics fall under one of two categories, off-line
medical orders (standing orders) or on-line medical orders. On-line medical orders refers to
procedures that must be explicitly approved by a base hospital physician or registered nurse through
voice communication (generally by phone or radio) and are generally rare or high risk procedures
(e.g. rapid sequence induction or cricothyrotomy).[29] In addition, when multiple levels can perform the
same procedure (e.g. AEMT-Critical Care and Paramedics in New York), a procedure can be both an
on-line and a standing order depending on the level of the provider.[30] Since no set of protocols can
cover every patient situation, many systems work with protocols as guidelines and not "cook book"
treatment plans.[31] Finally, systems also have policies in place to handle medical direction when
communication failures happen or in disaster situations. [32] The NHTSA curriculum is the foundation
Standard of Care for EMS providers in the US.

Employment[edit]
EMTs and Paramedics are employed in varied settings, mainly the prehospital environment such as
in EMS, fire, and police agencies. They can also be found in positions ranging from hospital and
health care settings, to [1] industrial and entertainment positions.[33] The prehospital environment is
loosely divided into non-emergency (e.g. patient transport) and emergency (9-1-1 calls) services, but
many ambulance services and EMS agencies operate both non-emergency and emergency care.

In many places across the United States, it is not uncommon for the primary employer of EMRs,
EMTs, and Paramedics to be the fire department, with the fire department providing the primary
emergency medical system response including "first responder" fire apparatus, as well as
ambulances.[34] In other locations, such as Boston,Massachusetts, emergency medical services are
provided by a separate, or third-party, municipal government emergency agency (e.g. Boston
EMS).[35] In still other locations, emergency medical services are provided by volunteer agencies.
College and university campuses may provide emergency medical responses on their own campus
using students.[36]
In some states of the US, many EMS agencies are run by Independent Non-Profit Volunteer First Aid
Squads that are their own corporations set up as separate entities from fire departments. In this
environment, volunteers are hired to fill certain blocks of time to cover emergency calls. These
volunteers have the same state certification as their paid counterparts. [37]

2015-2020 ACLS Guideline Changes Update

In October 2015 the American Heart Association released their new 2015 guidelines
for BLS and ACLS. These guidelines will be good through 2020. There were some
minor changes to both the BLS and ACLS Guidelines. The links below review
changes that occurred with the release of the 2015 ACLS & BLS Guidelines. The
article content was developed from information released by the American Heart
Association in their Executive Summary: 2015 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
and cited references from the executive summary. Use the links below to access the
articles.
This 6 minute video covers all the 2015 guideline changes listed below.
BLS and CPR Quality Changes

There are several guideline changes that will affect the providers interventions with
CPR. The link provided above will provide you with a review of these changes which
include changes in chest compression depth, rate, and quality. There are minor
changes directed toward health care providers and their use of BLS and finally new
recommendations for ventilation for the patient with an advanced airway in place.
Cardiac Arrest Medication Changes

This page reviews changes made to the cardiac arrest algorithm that involve
emergency medications including vasopressin and epinephrine.
Post-Cardiac Arrest Management Changes

There were some changes related to multiple aspects of the post-cardiac arrest
phase. These changes include minor revisions in the administration of therapeutic
hypothermia, hemodynamic goals, and post-arrest medication use. Post-Cardiac
Arrest Management Changes.
Other 2015-2020 Guideline Changes

Several other important changes were made to the AHA BLS and ACLS Guidelines.
This changes include revision of the chain of survival, and end tidal CO2 as a
resuscitation success predictor. Other Important Changes.
All new 2015 AHA BLS and ACLS changes have been incorporated into the Practice
Tests, Megacode Scenarios, and ACLS Review Videos found on the pages of this
website.

The Systematic Approach to ACLS

Foundational to every ACLS Algorithm is the BLS Assessment. The BLS Assessment
is the first step that you will take when treating any emergency situation, and there
are 4 main assessment steps to remember.

This is an outline of the 4 steps in the BLS Assessment :

(1) Check responsiveness by tapping and shouting, Are you all right? Scan the
patient for absent or abnormal breathing (scan 5-10 seconds).
(2) Activate the emergency response system and obtain a AED . If there is more than one
rescuer, have the second person activate emergency response and get the
AED/Defibrillator.
(3) Circulation: Check for a carotid pulse. This pulse check should not take more than
5-10 seconds. If no pulse is palpable begin CPR.
(4) Defibrillation: If there is no pulse, check for a shockable rhythm with the AED or
defibrillator as soon as it arrives. Follow the instructions provided by the AED or
begin ACLS Protocol.
For a more in-depth review of BLS refer to the American Heart Associations BLS
Provider Manual.
Remember to assess first then perform appropriate actions, and after each action
reassess.

The Primary Assessment uses the ABCDE model to systematize the assessment
process. The ABCDEs of the Primary Assessment are:
(A) Airway: Maintain airway and use advanced airway if needed. Ensure confirmation
of placement of an advanced airway and secure the advanced airway device.
(B) Breathing: Give bag-mask ventilation, provide supplemental oxygen, and avoid
excessive ventilation. Also, adequacy of ventilation and oxygenation should be
monitored during this step.
(C) Circulation: Obtain IV access, attach ECG leads, identify and monitor arrhythmias,
giving fluids if needed, and use defibrillation if appropriate.
(D) Disability: Perform a general neurological assessment which should include
assessment of responsiveness, level of consciousness, and pupil reflex. AVPU
acronym may help. (Alert, Voice, Painful, Unresponsive)
(E)Exposure: Ensure that clothing is removed so that a complete visual assessment
can be performed. This visual assessment should include looking for signs of
trauma, bleeding, burns, or medical alert bracelets.
The Primary Assessment is included in every ACLS algorithm and like the BLS
Assessment, it helps to systematize the resuscitation process and improve patient
outcomes.

The secondary assessment includes a search for underlying causes for the
emergency and if possible a focused medical history. This search for for underlying
causes, also known as differential diagnosis, requires a review of all of the Hs and
Ts of ACLS. Visit Hs and Ts page for a full review.
Performing the focused medical history can be simplified using the acronym SAMPLE.
(S)Signs and symptoms; (A)Allergies; (M)Medications; (P)Past Illnesses; (L)Last Oral
Intake; (E)Events Leading Up To Present Illness.
Use the links to the left for further details of ACLS Protocol and specific interventions
in each ACLS algorithm.
The objective of the review of these ACLS Algorithms is to help prepare you for the
ACLS written test and the ACLS Megacode. After reviewing, you can test your skills
and knowledge by accessing the ACLS Megacode Simulator and ACLS practice exams.

Hs and Ts of ACLS
Knowing the Hs and Ts of ACLS will help prepare you for any ACLS scenario. The
Hs and Ts of ACLS is a mnemonic used to help recall the major contributing factors
to pulseless arrest including PEA, Asystole, Ventricular Fibrillation, and Ventricular
Tachycardia. These Hs and Ts will most commonly be associated with PEA, but they
will help direct your search for underlying causes to any of arrhythmias associated
with ACLS. Each is discussed more thoroughly below.

Hypovolemia, Hypoxia, Hydrogen ion

(acidosis), Hyper-/hypokalemia, Hypoglycemia, Hypothermia.
Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and
pulmonary), and Trauma.
The Hs include:

Hypovolemia
Hypovolemia or the loss of fluid volume in the circulatory system can be a major
contributing cause to cardiac arrest. Looking for obvious blood loss in the patient
with pusleless arrest is the first step in determining if the arrest is related to
hypovolemia. After CPR, the most import intervention is obtaining intravenous
access/IO access. A fluid challenge or fluid bolus may also help determine if the
arrest is related to hypovolemia.
Hypoxia
Hypoxia or deprivation of adequate oxygen supply can be a significant contributing
cause to cardiac arrest. You must ensure that the patients airway is open, and that
the patient has chest rise and fall and bilateral breath sounds with ventilation. Also
ensure that your oxygen source is connected properly.
Hydrogen ion (acidosis)
To determine if the patient is in respiratory acidosis, an arterial blood gas evaluation
must be performed. Prevent respiratory acidosis by providing adequate ventilation.
Prevent metabolic acidosis by giving the patient sodium bicarbonate.
Hyper-/hypokalemia
Both a high potassium level and a low potassium level can contribute to cardiac
arrest. The major sign of hyperkalemia or high serum potassium is taller and peaked

T-waves. Also, a widening of the QRS-wave may be seen. This can be treated in a
number of ways which include sodium bicarbonate (IV), glucose+insulin, calcium
chloride (IV), Kayexalate, dialysis, and possibly albuterol. All of these will help
reduce serum potassium levels.
The major signs of hypokalemia or low serum potassium are flattened T-waves,
prominent U-waves, and possibly a widened QRS complex. Treatment of
hypokalemia involves rapid but controlled infusion of potassium. Giving IV
potassium has risks. Always follow the appropriate infusion standards. Never give
undiluted intravenous potassium.
Hypoglycemia
Hypoglycemia or low serum blood glucose can have many negative effects on the
body, and it can be associated with cardiac arrest. Treat hypoglycemia with IV
dextrose to reverse a low blood glucose. Hypoglycemia was removed from the Hs
but is still to be considered important during the assessment of any person in
cardiac arrest.
Hypothermia
If a patient has been exposed to the cold, warming measures should be taken. The
hypothermic patient may be unresponsive to drug therapy and electrical therapy
(defibrillation or pacing). Core temperature should be raised above 86 F (30 C) as
soon as possible.
The Ts include:

Toxins

Accidental overdose of a number of different kinds of medications can cause

pulseless arrest. Some of the most common include: tricyclics, digoxin,
betablockers, and calcium channel blockers). Street drugs and other chemicals can
precipitate pulseless arrest. Cocaine is the most common street drug that increases
incidence of pulseless arrest. ECG signs of toxicity include prolongation of the QT
interval. Physical signs include bradycardia, pupil symptoms, and other neurological
changes. Support of circulation while an antidote or reversing agent is obtained is of
primary importance. Poison control can be utilized to obtain information about
toxins and reversing agents.
Tamponade
Cardiac tamponade is an emergency condition in which fluid accumulates in the
pericardium (sac in which the heart is enclosed). The buildup of fluid results in
ineffective pumping of the blood which can lead to pulseless arrest. ECG symptoms
include narrow QRS complex and rapid heart rate. Physical signs include jugular
vein distention (JVD), no pulse or difficulty palpating a pulse, and muffled heart
sounds due to fluid inside the pericardium. The recommended treatment for cardiac
tamponade is pericardiocentesis.
Tension Pneumothorax
Tension pneumothorax occurs when air is allowed to enter the plural space and is
prevented from escaping naturally. This leads to a build up of tension that causes
shifts in the intrathroacic structure that can rapidly lead to cardiovascular collapse
and death. ECG signs include narrow QRS complexes and slow heart rate. Physical
signs include JVD, tracheal deviation, unequal breath sounds, difficulty with
ventilation, and no pulse felt with CPR. Treatment of tension pneumothorax is
needle decompression.
Thrombosis (heart: acute, massive MI)
Coronary thrombosis is an occlusion or blockage of blood flow within a coronary
artery caused by blood that has clotted within the vessel. The clotted blood causes
an acute myocardial infarction which destroys heart muscle and can lead to sudden
death depending on the location of the blockage.
ECG signs during PEA indicating coronary thrombosis include ST-segment changes,
T-wave inversions, and/or Q waves. Physical signs include: elevated cardiac markers
on lab test.
For patients with cardiac arrest and without known pulmonary embolism (PE),
routine fibrinolytic treatment given during CPR has shown no benefit and is not
recommended.

Treatments for coronary thrombosis before cardiac arrest include use of fibrinolytic
therapy, or PCI (percutaneous coronary intervention). The most common PCI
procedure is coronary angioplasty with or without stent placement.
Thrombosis (lungs: massive pulmonary embolism)
Pulmonary thrombus or pulmonary embolism (PE) is a blockage of the main artery
of the lung which can rapidly lead to respiratory collapse and sudden death. ECG
signs of PE include narrow QRS Complex and rapid heart rate. Physical signs include
no pulse felt with CPR. distended neck veins, positive d-dimer test, prior positive
test for DVT or PE. Treatment includes surgical intervention (pulmonary
thrombectomy) and fibrinolytic therapy.
Trauma
The final differential diagnosis of the Hs and Ts is trauma. Trauma can be a cause
of pulseless arrest, and a proper evaluation of the patients physical condition and
history should reveal any traumatic injuries. Treat each traumatic injury as needed
to correct any reversible cause or contributing factor to the pulseless arrest. Trauma
was removed from the Ts but is still to be considered important during the
assessment of any person in cardiac arrest.

Review of Respiratory Arrest

Respiratory Arrest simply means cessation of breathing. In ACLS, respiratory arrest
typically means that a patients respirations are completely absent or inadequate to
maintain oxygenation, but a pulse is present.
Management of respiratory arrest includes the following interventions:
Give oxygen
Open the airway

Provide basic ventilation

Provide respiratory support with the use of artificial airways (OPA and NPA)
Suction to maintain a clear airway
Maintain airway with advanced airways

During respiratory arrest, the ACLS provider should avoid hyperventilation of the
patient. Hyperventilation is providing too many breaths per minute or too large of a
volume per breath during ventilation. Hyperventilation may lead to increased
intrathoracic pressure, decreased venous return to the heart, diminished cardiac
output, and increased gastric inflation, all of which can decrease the likelihood of
positive outcomes.
For patients with a perfusing rhythm deliver 1 breath every 5 to 6 seconds.
Opening Airway
The most common cause of airway obstruction in a patient that is unresponsive is
the loss of tone in the throat muscles. When loss of throat muscle tone occurs the
tongue can fall back and obstruct the airway.
This type of obstruction is easily prevented with a basic airway opening technique
called the head tilt-chin lift. In the case that spinal injury is suspected, the jaw thrust
maneuver can be utilized. This jaw thrust maneuver allows the BLS/ACLS provider to
maintain a stable cervical spine.
ACLS Ventilation
There are 5 basic airway skills used to ventilate a patient. Basic ventilation skills are
discussed in the BLS course and will not be discussed in detail here. The following is
a list of the 5 basic airway skills: 1.) Head tilt-chin lift; 2.) Jaw thrust without head
extension for possible cervical spine injury; 3.) Mouth-to-Mouth ventilation; 4.)
Mouth-to-Barrier device (using a pocket mask); and 5.) Bag-mask ventilation.
Bag-Mask ventilation
Bag-Mask ventilation is the most common method of providing positive-pressure
ventilation. Both the oropharyngeal airway and the nasopharyngeal airway may be
used as adjuncts to improve effectiveness of patient ventilation. The oropharyngeal
airway may only be used on the unconscious patient because it can stimulate
gagging and vomiting in a conscious patient. The nasopharyngeal airway may be
used on the unconscious patient or on the semiconscious patient and is also
indicated if a patient has massive trauma around the mouth or wiring of the jaws.
Suctioning
If the airway is being maintained with the basic airway skills listed above, blood,
secretions, and vomit become the primary causes of an obstructed airway in the

unconscious patient. Suctioning should be used to clear the airway if it becomes

occluded with these body fluids.
Limit oral and endotracheal suctioning to 10 seconds or less to reduce the risks of
hypoxemia. Monitor for changes in heart rate as oropharyngeal suctioning can
cause vagal stimulation resulting in bradycardia.
Advanced Airways
Advanced Airways used during ACLS include Combitube, LMA (Laryngeal mask
airway), and ET tube (endotracheal tube). Once an advanced airway is in place,
chest compressions are no longer interrupted for ventilations. 1 breath should be
given every 6-8 seconds (8-10 breaths per minute).
You should be given adequate time to practice with these devices during your ACLS
training before ACLS megacode testing.

VF treated with CPR/AED

Ventricular Fibrillation which occurs in the out-of-hospital setting should be treated

with CPR and an AED. Effective CPR and early defibrillation are the key to positive
outcomes for the unresponsive patient who is in ventricular fibrillation.
This ACLS scenario will usually involve one or two rescuers in an out-of-hospital
setting. Ideal equipment would be an AED and a pocket mask. Rapid assessment
and treatment using the CAB sequence of BLS should be performed as the first
intervention.
CPR
CPR will be initiated if the patient does not have a palpable pulse or if it is
undetermined if the patient has a pulse. Delaying CPR reduces the chances of a
successful resuscitation thus, it is better to give unnecessary CPR than to delay CPR
in questionable cases.
CPR may be needed after successful defibrillation since spontaneous rhythms after
defibrillation may not always produce adequate perfusion for several minutes.
The AED
AEDs should be used when the following 3 clinical findings exist:
Patient is not responsive
Patient is not breathing
Patient has no pulse
Most AEDs or External Automated Defibrillators provide voice instructions from the
point of turning on the machine. The machine will perform the rhythm interpretation
and will also instruct you when to shock the patient. It should also instruct you to
resume CPR when necessary.
While using the AED, BLS should be maintained by giving high quality chest
compressions and using basic airway skills such as the head-tilt chin lift and mouthto-barrier device resuscitation.
Emergencies are treated in the following order: Check patient responsiveness,
activate EMS, and get the AED, then perform CABDs of the BLS Primary Survey.

Cardiac Arrest Algorithm

The Cardiac Arrest Algorithm takes its place as the most important algorithm in the
ACLS Protocol. There are 4 rhythms that are seen with pulseless cardiac arrest.
These four rhythms are pulseless ventricular tachycardia (VT), ventricular fibrillation (VF), asystole,
and pulseless electrical activity (PEA). Visit the links above for detailed information about
each of the rhythms and their treatment in the ACLS protocol.
The majority of patients that experience sudden cardiac arrest will be treated with
the Cardiac Arrest Algorithm. Therefore, mastery of this algorithm is very important.
There are 2 branches to the Cardiac Arrest Algorithm, the left and right branch. The
left branch is used for the treatment of pulseless ventricular tachycardia and
ventricular fibrillation, and the right branch is used for the treatment of PEA and
Asystole. Watch Part 1 and Part 2 of the Cardiac Arrest Video Review.
Within ACLS Protocol, there is also a Simplified Cardiac Arrest Algorithm that
simplifies and streamlines uncomplicated cardiac arrest. Use this link to watch a short
video that reviews the 2015 Simplified Cardiac Arrest Algorithm.

VF/Pulseless VT
Treatment of Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT)
is included in the Cardiac Arrest Algorithm. VF and pulseless VT are shockable
rhythms and treated in similar fashion. Asystole and PEA are also included in the
cardiac arrest algorithm but are nonshockable rhythms.
Ventricular fibrillation and pulseless ventricular tachycardia are treated using the
left branch of the cardiac arrest arrest algorithm. Click below to view the cardiac
arrest algorithm diagram. When done click again to close the diagram. Cardiac
Arrest Algorithm Diagram or Members Download the Hi-Resolution PDF Here.
Many of the patients that experience sudden cardiac arrest demonstrate VF at some
point in their arrest, therefore, training emphasis is placed on the cardiac arrest
algorithm.
Rapid treatment of VF using the cardiac arrest algorithm has been established as
the best scientific approach to restoring spontaneous circulation.
There are several important points that should be considered when initiating the
cardiac arrest algorithm:
High-quality CPR should be performed until the defibrillator is attached the patient.
Interruptions in chest compressions should be kept to a minimum.
Rapid use of the defibrillator should be emphasized.
If possible, use a manual defibrillator over an AED since the use of the AED can
result in prolonged interruptions in chest compressions for rhythm analysis and
shock administration.
CPR is always immediately resumed for 5 cycles between each shock.
Defibrillation and the Shock
Most defibrillators used today are biphasic. Biphasic means that the electrical
current travels from one paddle to the other paddle and then back in the other
direction. The biphasic shock also requires less energy to restore normal heart
rhythm and helps to reduce skin burns and cellular damage to the heart. When
using a biphasic defibrillator with VF or pulseless VT, you will start with 120-200 J
and increase the dosing in a stepwise fashion as needed. (Example: 120 J 200 J
300 J 360 J.)
To ensure safety during the shock, providers should always announce the following
statement, I am going to shock on three. One, Im clearTwo, youre clearThree,
everybody is clear.

Do you know the difference between defibrillation, synchronized cardioversion, and

unsynchronized cardioversion? Find out here.
Vasopressors
A vasopressor is a medication that produces vasoconstriction and a rise in blood
pressure. The vasopressor that is used for the treatment of VF/Pulseless VT is
epinephrine. Epinephrine is primarily used for is vasoconstrictive effects.
Vasoconstriction is important during CPR because it will help increase blood flow to
the brain and heart.
Rhythm checks should be performed after 5 cycles of CPR. Limit rhythm checks to
less than 10 seconds to minimize interruptions in CPR. Pulse checks should be
performed when a rhythm check reveals a change in the rhythm to a rhythm that is
organized and could be generating a pulse.
Antiarrhythmic Drugs
Amiodarone, lidocaine, and magnesium are antiarrhythmic medications that are
used in the left branch of the Cardiac Arrest Algorithm.

Asystole and Its Treatment in ACLS

Asystole is defined as a cardiac arrest rhythm in which there is no discernible
electrical activity on the ECG monitor. Asystole is sometimes referred to as a flat
line. Confirmation that a flat line is truly asystole is an important step in the ACLS
protocol.
Ensure that asystole is not another rhythm that looks like a flat line. Fine VF can
appear to be asystole, and a flat line on a monitor can be due to operator error or
equipment failure
The following are common causes of an isoelectric line that is not asystole: 1. loose
or disconnected leads; 2. loss of power to the ECG monitor; 3. low signal gain on the
ECG monitor.
Asystole for many patients is the result of a prolonged illness or cardiac arrest, and
prognosis is very poor. Few patients will likely have a positive outcome and
successful treatment of cardiac arrest with asystole will usually involve identification
and correction of an underlying cause of the asystole.
The Hs and Ts of ACLS should be reviewed to identify any underlying cause that
could have precipitated the asystole.
Some of the most common reasons to stop or withhold resuscitative efforts are:
DNR status
Threat to the safety of rescuers
Family or personal information such as a living will or advanced directive
Rigor mortis
Asystole is treated using the right branch of the Cardiac Arrest Algorithm. Click
below to view the Cardiac Arrest Algorithm diagram. When done click again to close
the diagram.
Cardiac Arrest Algorithm Diagram. or Members Download the Hi-Resolution
PDF Here.
Vasopressors

A vasopressor is a medication that produces vasoconstriction and a rise in blood

pressure. The vasopressor that is used for the treatment within the right branch of
the Cardiac Arrest Algorithm is epinephrine.
Epinephrine is primarily used for is vasoconstrictive effects. Vasoconstriction is
important during CPR because it will help increase blood flow to the brain and heart.
When treating asystole, epinephrine can be given as soon as possible but its
administration should not delay initiation or continuation of CPR. After the initial
dose, epinephrine is given every 3-5 minutes.
Rhythm checks should be performed after 5 cycles of CPR. Limit rhythm checks to
less than 10 seconds to minimize interruptions in CPR. Pulse checks should be
performed when a rhythm check reveals a change in the rhythm to a rhythm that is
organized and could be generating a pulse.

PEA (Pulseless Electrical Activity)

PEA is defined as any organized rhythm without a palpable pulse and is the most
common rhythm present after defibrillation. PEA along with asystole make up half of
the Cardiac Arrest Algorithm with VF and VT consisting of the other half. Patients
with PEA usually have poor outcomes.
Positive outcome of an attempted resuscitation depends primarily on two actions: 1.
Providing effective CPR; and 2. Identification and correction of the cause of PEA.
Medications used in PEA
Vasopressors
A vasopressor is a medication that produces vasoconstriction and a rise in blood
pressure. The vasopressor that is used for the treatment within the right branch of
the Cardiac Arrest Algorithm is epinephrine.
Epinephrine is primarily used for is vasoconstrictive effects. Vasoconstriction is

important during CPR because it will help increase blood flow to the brain and heart.
When treating PEA, epinephrine can be given as soon as possible but its
administration should not delay initiation or continuation of CPR. High-quality CPR
should be administered while giving epinephrine, and after the initial dose,
epinephrine is given every 3-5 minutes.
For PEA a rhythm and pulse check should be performed after 5 cycles of CPR. Limit
the rhythm/pulse check to less than 10 seconds to minimize interruptions in CPR.
The pulse check should be performed simultaneously with the rhythm check when
treating PEA since by definition PEA is an organized rhythm and could have a pulse
that generates blood perfusion.
Click below to view the cardiac arrest algorithm diagram. When done click again to close the
diagram. Cardiac Arrest Algorithm Diagram or Members Download the Hi-Resolution
PDF Here.

Hs and Ts
The identification and correction of the causes of PEA should be a high priority as a
cardiac emergency progresses. One easy way to remember the most common
causes of PEA as well as other cardiac emergencies is the Hs and Ts of ACLS. See
the Hs and Ts page for more information on the causes and treatment of PEA.

Bradycardia Algorithm Review

(includes 2010 AHA Guideline Update)
The major ECG rhythms classified as bradycardia include:
Sinus Bradycardia
First-degree AV block
Second-degree AV block
Type I Wenckenbach/Mobitz I
Type II Mobitz II

Third-degree AV block complete block

(See the ECG Interpretation section for images and more detailed information on rhythms)
Bradycardia vs. Symptomatic Bradycardia
Bradycardia is defined as any rhythm disorder with a heart rate less than 60 beats
per minute. (Typically it will be <50/min) This could also be called asymptomatic
bradycardia. Bradycardia can be a normal non-emergent rhythm. For instance, well
trained athletes may have a normal heart rate that is less than 60 bpm.
Symptomatic bradycardia however is defined as a heart rate less than 60/min that
elicits signs and symptoms, but the heart rate will usually be less than 50/min.
Symptomatic bradycardia exists when the following 3 criteria are present: 1.) The
heart rate is slow; 2.) The patient has symptoms; and 3.) The symptoms are due to
the slow heart rate.
Functional or relative bradycardia occurs when a patient may have a heart rate within

normal sinus range, but the heart rate is insufficient for the patients condition. An
example would be a patient with an heart rate of 80 bpm when they are
experiencing septic shock.
Bradycardia Pharmacology

There are 3 medications that are used in the Bradycardia ACLS Algorithm. They are
atropine, dopamine (infusion), and epinephrine (infusion). More detailed ACLS
pharmacology information can be found here.
2010 AHA Update: For symptomatic bradycardia or unstable bradycardia IV infusion

chronotropic agents (dopamine & epinephrine) is now recommended as an equally

effective alternative to external pacing when atropine is ineffective.
Atropine: The first drug of choice for symptomatic bradycardia. Dose in the

Bradycardia ACLS algorithm is 0.5mg IV push and may repeat up to a total dose of
3mg.
Dopamine: Second-line drug for symptomatic bradycardia when atropine is not

effective. Dosage is 2-20 micrograms/kg/min infusion.

Epinephrine: Can be used as an equal alternative to dopamine when atropine is not

effective. Dosage is 2-10 micrograms/min.

Bradycardia Algorithm
The decision point for ACLS intervention in the bradycardia algorithm is
determination of adequate perfusion. For the patient with adequate perfusion, you
should observe and monitor. If the patient has poor perfusion, preparation for
transcutaneous pacing should be initiated, and an assessment of contributing
causes (Hs and Ts) should be carried out.
Click below to view the bradycardia algorithm diagram. When done click again to close the
diagram.Bradycardia Algorithm Diagram or Members Download the Hi-Resolution PDF Here

Transcutaneous pacing (TCP)

Preparation for TCP should be taking place as atropine is being given. If atropine
fails to alleviate symptomatic bradycardia, TCP should be initiated. Ideally the
patient should receive sedation prior to pacing, but if the patient is deteriorating
rapidly, it may be necessary to start TCP prior to sedation.
For the patient with symptomatic bradycardia with signs of poor perfusion,
transcutaneous pacing is the treatment of choice.
Do not delay TCP for the patient with symptomatic bradycardia with signs of poor
perfusion. TCP rate should use 60/min as a starting rate and adjust up or down
based on the patients clinical response. The dose for pacing should be set at 2mA
(milliamperes) above the dose that produces observed capture.
TCP is contraindicated for the patient with hypothermia and is not a recommended
treatment for asystole.

A carotid pulse should not be used for assessment of circulation as TCP can create
muscular movements that may feel like a carotid pulse. Assess circulation using the
femoral pulse.
Identification of contributing factors for symptomatic bradycardia should be
considered throughout the ACLS protocal since reversing of the cause will likely
return the patient to a state of adequate perfusion.

Tachycardia and its ACLS Algorithm

Tachycardia/tachyarrhythmia is defined as a rhythm with a heart rate greater than
100 bpm.
An unstable tachycardia exists when cardiac output is reduced to the point of
causing serious signs and symptoms.
Serious signs and symptoms commonly seen with unstable tachycardia are: chest
pain, signs of shock, SOA (short of air), altered mental status, weakness, fatigue,
and syncope
One important question you may want to ask is: Are the symptoms being caused
by the tachycardia? If the symptoms are being caused by the tachycardia treat the
tachycardia.
There are many causes of both stable and unstable tachycardia and appropriate
treatment within the ACLS framework requires identification of causative factors.
Before initiating invasive interventions, reversible causes should be identified and
treated.
Causes
The most common causes of tachycardia that should be treated outside of the ACLS
tachycardia algorithm are dehydration, hypoxia, fever, and sepsis. There may be
other contributing causes and review of the Hs and Ts of ACLS should take place as
needed.

Administration of OXYGEN and NORMAL SALINE are of primary importance for the
treatment of causative factors of sinus tachycardia and should be considered prior
to ACLS intervention.
Once these causative factors have been ruled out or treated, invasive treatment
using the ACLS tachycardia algorithm should be implemented.
Associated Rhythms
There are several rhythms that are frequently associated with stable and unstable
tachycardia these rhythms include:
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type
Visit the links above to learn about each specific rhythm.
ACLS Treatment for Tachycardia
Click below to view the tachycardia algorithm diagram. When done click again to
close the diagram.Tachycardia Algorithm Diagram. or Members Download the HiResolution PDF Here
The fist question that should be asked when initiating the ACLS tachycardia
algorithm is: Is the patient stable or unstable? The answer to this question will
determine which path of the tachycardia algorithm is executed.
Unstable Tachycardia
Patients with unstable tachycardia should be treated immediately
with synchronized cardioversion. If a pulseless tachycardia is present patients
should be treated using the cardiac arrest algorithm.
The initial recommended synchronized cardioversion voltage doses are as follows:
narrow regular: 50-100 J; i.e., SVT and atrial flutter
Narrow irregular: 120-200 J biphasic or 200 J monophasic; i.e., atrial fibrillation
Wide regular: 100 J; i.e., monomorphic VT

Wide irregular: defibrillation dose (not synchronized)

Patients with stable tachycardia are treated based upon whether they have a
narrow or wide QRS complex. The following flow diagram shows the treatment
regimen for stable tachycardia with narrow and wide QRS complex.
Stable (narrow QRS complex) vagal maneuvers adenosine (if regular)
beta-blocker/calcium channel blocker get an expert
Stable (wide/regular/monomorphic) adenosine consider antiarrhythmic
infusion get an expert

ACLS Drugs
Each of the ACLS Algorithms utilizes a number of drugs which we will classify
as primary drugs. The primary drugs are the medications that are used directly in
an ACLS Algorithm. Here are the Primary ACLS drugs broken down by ACLS
Algorithm.
Each is a link to its respective page which covers, in detail, all
aspects of the medication and it use in each ACLS algorithm
and in post resuscitation efforts.
ACLS Algorithms and Their Primary Drugs
Vent. Fib./Tach.
Epinephrine
Vasopressin
Amiodarone
Lidocaine

Magnesium

Asystole/PEA
Epinephrine
Vasopressin

Atropine (removed from algorithm per 2010 ACLS Guidelines)

Bradycardia
Atropine
Epinephrine

Dopamine
Tachycardia
adenosine

Diltiazem
Beta-blockers
amiodarone

Digoxin
Verapamil
Magnesium
Acute Coronary Syndromes
Oxygen
Aspirin
Nitroglycerin
Morphine
Fibrinolytic therapy
Heparin
Beta-Blockers
Acute Stroke
tPA-tissue plasminogen activator
Glucose (D50)
Labetalol
Nitroprusside
Nicardipine
Aspirin

Quantitative Waveform Capnography

The 2010-2015 AHA Guidelines for ACLS now recommend using quantitative
waveform capnography in intubated patients during CPR. Waveform capnography
allows providers to monitor CPR quality, optimize chest compressions, and detect
ROSC (return of spontaneous circulation) during chest compressions.
Also, according to the AHA, continuous waveform capnography along with clinical
assessment is the most reliable method of confirming and monitoring correct
placement of an ET tube.
What is Waveform Capnography
Quantitative waveform capnography is the continuous, noninvasive measurement
and graphical display of end-tidal carbon dioxide/ETCO2 (also called PetCO2).
Capnography uses a sample chamber/sensor placed for optimum evaluation of
expired CO2. The inhaled and exhaled carbon dioxide is graphically displayed as a
waveform on the monitor along with its corresponding numerical measurement.

As an assessment tool during CPR, capnography can help the ACLS provider
determine a number of things. It is a direct measurement of ventilation in the lungs,
and it also indirectly measures metabolism and circulation. For example, a decrease
in perfusion (cardiac output) will lower the delivery of carbon dioxide to the lungs.
This will cause a decrease in the ETCO2 (end-tidal CO2), and this will be observable
on the waveform as well as with the numerical measurement.
Normal ETCO2 in the adult patient should be 35-45 mmHg.
Two very practical uses of waveform capnography in CPR are: 1.) evaluating the
effectiveness of chest compressions; and 2.) identification of ROSC. Evaluating
effectiveness of chest compressions is accomplished in the following manner:
Measurement of a low ETCO2 value (< 10 mmHg) during CPR in an intubated
patient would indicate that the quality of chest compressions needs improvement.
High quality chest compressions are achieved when the ETCO2 value is at least 1020 mmHg.
When ROSC occurs, There will be a significant increase in the ETCO2. (35-45 mmHg)
This increase represents drastic improvement in blood flow (more CO2 being
dumped in the lungs by the circulation) which indicates circulation.
For the intubated patient in cardiac arrest, quantitative waveform capnography, is
now considered the desired method for monitoring quality of chest compressions
and determining when the patient has a ROSC.
This video explains waveform capnography, it benefits, and various applications.

Post Cardiac Arrest Care

Integrated post-cardiac arrest care is now the 5th link in the AHA adult chain of
survival. Topics of focus for post-cardiac arrest care include (TTM) Targeted
Temperature Management, hemodynamic and ventilation optimization, immediate
coronary reperfusion with PCI (percutaneous coronary intervention), glycemic control,
neurologic care and other technical interventions. To be successful, post-cardiac
arrest care requires an integrated multidisciplinary approach.
For the purposes of this site, the review of post-cardiac arrest care interventions will
focus primarily on immediate post arrest interventions and aspects that you will
most likely be tested on.
For a complete review of the subject refer to your AHA provider manual. (pages: 2829, 72-77, and 164)
(TTM) Targeted Temperature Management

TTM which was previously called therapeutic hypothermia is the only intervention
that has been shown to improve neurological outcomes after cardiac arrest. Induced
hypothermia should occur soon after ROSC (return of spontaneous circulation). The
decision point for the use of therapeutic hypothermia is whether or not the patient
can follow commands. (lack of meaningful response to verbal commands)
One of the most common methods used for inducing therapeutic hypothermia is
rapid infusion of ice-cold (4 C), isotonic, non-glucose-containing fluid to a volume of
30 ml/kg. The optimum temperature for therapeutic hypothermia is 32-36 C (89.6
to 96.8 F). A single target temperature, within this range should be selected,
achieved, and maintained for at least 24 hours.
During induced TTM, the patients core temperature should be monitored with any
one of the following: esophageal thermometer, a bladder catheter in the nonanuric
patients, or a pulmonary artery catheter if one is already in place.
Axillary and oral temperatures are inadequate for monitoring core temperatures.
Ventilation Optimization
During the post-cardiac arrest phase inspired oxygen should be titrated to maintain
an arterial oxygen saturation of 94%. This reduces the risk of oxygen toxicity.
Excessive ventilation should also be avoided because of the potential for reduced
cerebral blood flow related to a decrease in PaCO2 levels. Also, excessive ventilation
should be avoided because of the risk of high intrathoracic pressures which can lead
to adverse hemodynamic effects during the post arrest phase. Quantitative
waveform capnography can be used to regulate and titrate ventilation rates during
the post-arrest phase. Visit the link for more details about waveform capnography.
Hemodynamic Optimization
Hypotension, a systolic blood pressure < 90 mmHg should be treated and the
administration of fluids and vasoactive medications can be used to optimize the
patients hemodynamic status. While the optimal blood pressure during the postcardiac arrest phase is not known, the primary objective is adequate systemic
perfusion, and a mean arterial pressure of 65 mmHg should accomplish this. A
systolic blood pressure greater than 90 mmHg and a mean arterial pressure greater
than 65 mmHG should be maintained during the post-cardiac arrest phase.
The goal of post-cardiac arrest care should be to return the patient to a level of
functioning equivalent to their prearrest condition.
Other considerations
Moderate glycemic control measures should be implemented to maintain glucose
levels from 144-180 mg/dL, and since there is an increased risk for hypoglycemia in
the post-arrest phase these more moderate levels should be maintained rather than
normal levels of 80-110 mg/dL

Every effort should be made to provide coronary reperfusion (PCI), and interventions
should be directed with this goal in mind. PCI has been shown to be safe and
effective in both the alert and comatose patient, and hypothermia does not
contraindicate PCI.

Adult Stroke Algorithm

The acute adult stroke diagram below outlines all of the steps for assessment and treatment
of ischemic stroke according to AHA guidelines.
Hover over and click on each box in the diagram to review details of the stroke
protocol.

How to get ACLS Certification or

Recertification
ACLS Certification is required by health care providers working in acute care
settings and also by providers of emergency services.

The majority of hospitals and emergency services within the United

States require that this certification be obtained through the American

Heart Association (AHA).

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400px) 100vw, 400px" style="box-sizing: border-box; border: 0px; max-width:
100%; height: auto; float: right; text-align: right; margin: 0px 0px 24px 24px;">
Dont be fooled by Non-AHA imitations.

There are a number of ways to obtain AHA approved ACLS certification.

Below is a breakdown of what is required and how it can be obtained. Also
included are some cautions about online certification.

Attend a local class

1. The safest way to obtain AHA ACLS certification is by attending a class
in your local area. Many hospitals provide the course at a discount to

their employees. You can also check your yellow pages for education
facilities that provide BLS, ACLS, and first aid training. Cost for the class
usually ranges from $ 150-200.
Ask your education department about opportunities for fee
reimbursement or fee assistance.
2. When looking for a course in your local area, you should make sure to
ask if the certification is AHA approved since nearly all hospitals and
emergency services in the United States require AHA approved ACLS
certification.
AHA approved certification always requires a written exam and hands-on skills
station test.

Online Certification:
1. You should be very cautious about online ACLS certification. There are
quite a number of websites that offer ACLS Certification but are not
AHA approved. Some may even say approved by AHA certified
physicians or AHA physicians recommend this course. Beware of
these sites. Most hospitals and health care facilities will not recognize
these certifications.

2. There are several online courses that are AHA approved and they will
say so right up front. They want you to know they are approved and they
will always make that clear.
3. AHA does offer an online course or CD called HeartCode ACLS Part 1.
If
This is the American Heart Association self-directed learning program.
The cost of Part 1 is $120 and includes CME/CE credits. To complete
AHA ACLS certification, there are two parts to the program. Part 1 is the
online or CD-based learning component that allows users to work
through the ACLS curriculum at their own pace. Part 2 is the hands-on
skills evaluation session usually costs around $50.

Conclusion
ACLS certification is a great way to expand your knowledge base as a health
care professional, and it will help prepare you to be ready to perform
advanced resuscitation in the health care setting. If you have any questions
please feel free to contact me.

ACLS-Algorithms.com is here to provide you with the best web-based ACLS

training available. Try theMegacode Simulator or watch a video about the new
2015-2020 ACLS guidelines for pulseless arrest algorithm.

ACLS Study Guide

If you are not sure how to effectively use this site, this ACLS study guide will help you
navigate through the site and make the most of your time here. First, make sure that the
download the checklist located in the download library here. This checklist will ensure that
you cover all of the content on the site.
This website was created with the intent purpose of being a complete ACLS training resource
in your preparation for ACLS certification. If you have no experience with ACLS (Advanced
Cardiac Life Support), your first step will be to review the knowledge base in the left hand
navigation on this site.
Step 1: Review the Knowledge Base.
In the knowledge base you will find up-to-date information about all of the major ACLS
algorithms. You will also find a comprehensive review of ECG rhythms seen when using ACLS
protocol.

Step 2: Test your knowledge in the Quizzes and

Scenarios Department.
The second step in the ACLS study guide will be
to access the Quizzes and Scenarios
department located in the left hand navigation.
In this section start with all of the ACLS Quizzes and then work your way in to the megacode
scenarios.
The quizzes and megacode scenarios are
multiple choice tests that will challenge your
knowledge and prepare you for ACLS
certification testing.
Step 3: Use the video department to achieve
mastery of your skills.
The third step you will take in this ACLS study guide will be to access the video department
of this site located in the left hand navigation. In the video department, you will be even
further challenged with the Megacode and Rapid Rhythm Identification scenarios. These
videos take you through real time megacode scenarios and rhythm reviews that will help you
master all of the ACLS algorithms.
Also found in the video department, are
video reviews of the ACLS algorithms and other
important content that you will need to know
for ACLS certification.
Use this brief ACLS study guide to help direct
your use of this site so that you can learn and
mast ACLS.