Webinar ACLS

Quick Review of Updated ACLS
2020 for General Practitioner

dr. Sony Hilal Wicaksono, SpJP(K)

What’s the difference

between AHA 2015
and AHA 2020?
1. Epinephrine could be given ASAP
in non-shockable rhythm
2. Chain of survival has become 6
steps
3. Detailed management of cardiac
arrest in pregnancy
4. Separate section of management
of cardiac arrest in pediatrics
5. Additional algorithms in ROSC
Prakoso R, Rizki, Fauzan F, Satria M, Priyanti DA, Firsty TE. Panduan khusus bantuan hidup jantung dasar. Jakarta: PERKI; 2021
02 04
CONTENTS Cardiac Arrest Tachyarrhythmia
Algorithm and
Bradyarrhythmia
01 03 05
High Quality BLS Cardiac Arrest in Cardiac Arrest in
Pregnancy Pediatric
01
High Quality BLS
High Quality of BLS
Now, chain of survival

has become 6 steps
Panchal A, Bartos J, Cabañas J, Donnino M, Drennan I, Hirsch K et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2).
BLS Termination of Resuscitation
02
Cardiac Arrest Algorithm
The Cardiac Arrest Rhythm - Shockable
Ventricles consist of areas of normal myocardium alternating with areas of ischemic, injured, The Cardiac Arrest Rhythm - Non Shockable
or infarcted myocardium, leading to chaotic pattern of ventricular depolarization
Early de brillation is essential
Pulse disappears with onset

of VF - no need to check coarse VF
pulse Cardiac conduction impulses occur in organized pattern, but this fails
to produce myocardial contraction (former “electromechanical
dissociation”)
ne VF
Asystole
pulseless VT
fi
fi
Adult Cardiac Arrest
Algorithm 2020
Epinephrine could be
given ASAP in non-
shockable rhythm

ACLS Termination of Resuscitation
Adult Cardiac Arrest Circular Algorithm
Additional algorithms
in ROSC
Adult Post-Cardiac Arrest Care Algorithm
Adult Post-Cardiac Arrest Care Algorithm
03
Cardiac Arrest in Pregnancy
AHA 2020
Gives the detailed management of
cardiac-arrest in pregnancy
Cardiac-Arrest in Pregnancy In-Hospital ACLS Algorithm
04
Tachyarrhythmia and Bradyarrhytmia
Atrial Fibrillation
Atrial impulses faster than SA nodes impulse

Impulses take multiple, chaotic, random pathways through the atria
irregularly irregular
variation in RR interval
no P waves, only chaotic Afib waves only
Atrial Flutter
Impulses take a circular course around the atria, setting up the flutter waves
Regular (unlike atrial fibrillation)
Ventricular rhythm often regular, set ratio to atrial rhythm, eg, 2-to-1 or 3-to-1
No true P waves seen, flutter waves seen in classic “sawtooth pattern”
Supraventricular Tachycardia
Reentry phenomenon: impulses arise and recycle repeatedly in the AV node

because of areas of unidirectional block in the Purkinje fibers
Regular, narrow-complex tachycardia without P-waves (seldom seen because
rapid rate causes P wave loss in preceding T waves or because the origin is low in
the atrium)
Monomorphic VT
QRS complex -> wide
Opposite polarity T waves
Impulse conduction is slowed around areas of ventricular injury, infarct, or ischemia

These areas also serve as source of ectopic impulses (irritable foci) - can cause the
impulse to take a circular course (reentry) and rapid repetitive depolarizations
No atrial activity seen, only regular ventricular
QRS complex: wide and bizarre, “PVC-like” complexes >0.12 sec, with large T wave
of opposite polarity from QRS
Monomorphic: The same morphology, or shape, is seen in every QRS complex
Polymorphic VT
Multiple ventricular foci with the resultant QRS complexes varying in amplitude, axis
and duration
Marked variation and inconsistency seen in the QRS complexes
Rare asymptomatic
Majority of times: symptoms of decreased cardiac output (orthostasis, hypotension,
syncope, exercise limitations, etc) are seen
Tends toward rapid deterioration to pulseless VT or VF
Torsades de Pointes
End of “node”; start of next “spindle”; note
positive initial deflection; increase-decrease
in QRS amplitude
Start of a “spindle”; note End of “spindle”,

negative initial deflection; start of “node
note increasing QRS
amplitude
long QT -> increase in the relative refractory period (“vulnerable period”) of the cardiac
cycle - Increases probability that an irritable focus (PVC) will occur on the T-wave
(“vulnerable period” or “R-on-T phenomenon”
“spindle-node” or twisting pattern
VT amplitude increases then decreases in regular pattern
Adult Tachycardia
With a Pulse
Algorithm
Bradyarrhythmia
Adult Bradycardia Algorithm
05
Cardiac Arrest in Pediatric
AHA 2020
Separate Section of Management

Cardiac Arrest in Pediatric
Single rescuer
Start CPR in pediatric

when HR less than 60
per mins with poor
perfusion
Topijian et al. Pediatric Basic and Advanced Life support: 2020 AHA Guidelines for CPR and ECC. Circulation.2020; 142(suppl2):S469-523
Title Text
● Body Level One
○ Body Level Two
2 or more rescuer
■ Body Level Three
● Body Level Four
○ Body Level
Five

Title Text
IMPORTANT NOTES!
For pediatric
populations
One rescuer 30:2
● Two
Body Level 15:2
rescuer One
○ Body Level Two
● Body Level Four
○ Body Level
Five

Title Text
Early
defibrillation is
● Body Level One Drugs and shock in
essential
○ Body Level Two pediatric is weight-
dependent
● Body Level Four
○ Body Level
Five

Title Text
● Body Level One

○ Body Level Two
● Body Level Four
○ Body Level
Five

Bradycardia and
Tachycardia
Title Text
Cardiopulmonary
compromise signs in
pediatrics differs from
than that of adults
If the heart rate is <60
beats/min with
● Body Level One cardiopulmonary
○ Body Level Two compromise despite
■ Body Level Three effective ventilation with
● Body Level Four oxygen, start CPR
○ Body Level
Five
American Heart Association. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Pediatric Basic and Advanced Life Support. Circulation. 2020.

Title Text
● Body Level One

○ Body Level Two
● Body Level Four
○ Body Level
Five

Title Text
● Body Level One

○ Body Level Two
● Body Level Four
○ Body Level
Five

Title Text
● Body Level One

○ Body Level Two
● Body Level Four
○ Body Level
Five

“You were born with the ability

to change someone’s life,
don’t ever waste it.”
- Dale Partridge
Case 1
Case 2
Case 3

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Webinar ACLS

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Quick Review of Updated ACLS

2020 for General Practitioner

What’s the difference

Now, chain of survival

Early de brillation is essential

Pulse disappears with onset

Atrial impulses faster than SA nodes impulse

Reentry phenomenon: impulses arise and recycle repeatedly in the AV node

Opposite polarity T waves

Impulse conduction is slowed around areas of ventricular injury, infarct, or ischemia

Start of a “spindle”; note End of “spindle”,

Separate Section of Management

Start CPR in pediatric

● Body Level One

● Body Level One

● Body Level One

● Body Level One

“You were born with the ability

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