Advanced Cardiovascular Life Support Provider Manual - 2015

5/24/23, 6:27 PM Advanced Cardiovascular Life Support Provider Manual
https://ebooks.heart.org/contentresolver/epub/50044708/OEBPS/Appendix.html 1/24
Airway Management
Skills Testing Checklist
Student Name ___________________ Date of Test ___________________
Critical Performance Steps ✓ if done correctly
BLS Assessment and Interventions

Checks for responsiveness
Taps and shouts, “Are you OK?”
Activates the emergency response system

Shouts for nearby help/Activates the emergency response system and gets the AED
or
Directs second rescuer to activate the emergency response system and get the AED
Checks breathing
Scans chest for movement (5-10 seconds)
Checks pulse (5-10 seconds)

Breathing and pulse check can be done simultaneously
Notes that pulse is present and does not initiate chest compressions or attach AED
Inserts oropharyngeal or nasopharyngeal airway
Administers oxygen
Performs effective bag-mask ventilation for 1 minute

Gives proper ventilation rate (once every 5-6 seconds)
Gives proper ventilation speed (over 1 second)
Gives proper ventilation volume (~half a bag)
Megacode Testing Checklist: Scenarios 1/3/8

Bradycardia ➔ Pulseless VT ➔ PEA ➔ PCAC
Team Leader
Ensures high-quality CPR at all times
Assigns team member roles
Ensures that team members perform well
Bradycardia Management
Starts oxygen if needed, places monitor, starts IV
Places monitor leads in proper position
Recognizes symptomatic bradycardia
Administers correct dose of atropine
Prepares for second-line treatment
Pulseless VT Management
Recognizes pVT
Clears before analyze and shock
Immediately resumes CPR after shocks
Appropriate airway management
Appropriate cycles of drug–rhythm check/shock–CPR
Administers appropriate drug(s) and doses
PEA Management
Recognizes PEA
Verbalizes potential reversible causes of PEA (H’s and T’s)
Immediately resumes CPR after rhythm checks
Post–Cardiac Arrest Care

Identifies ROSC
Ensures BP and 12-lead ECG are performed, O2 saturation is monitored, verbalizes need
for endotracheal intubation and waveform capnography, and orders laboratory tests
Considers targeted temperature management
Megacode Testing Checklist: Scenarios 2/5

Bradycardia ➔ VF ➔ Asystole ➔ PCAC

Team Leader
VF Management
Recognizes VF
Asystole Management
Recognizes asystole
Verbalizes potential reversible causes of asystole (H’s and T’s)

Identifies ROSC
Megacode Testing Checklist: Scenarios 4/7/10

Tachycardia ➔ VF ➔ PEA ➔ PCAC
Team Leader
Tachycardia Management
Recognizes unstable tachycardia
Recognizes symptoms due to tachycardia
Performs immediate synchronized cardioversion
VF Management
Recognizes VF
PEA Management
Recognizes PEA


Identifies ROSC
Megacode Testing Checklist: Scenarios 6/11

Bradycardia ➔ VF ➔ PEA ➔ PCAC

Team Leader
VF Management
Recognizes VF
PEA Management
Recognizes PEA

Identifies ROSC
Megacode Testing Checklist: Scenario 9

Tachycardia ➔ PEA ➔ VF ➔ PCAC

Team Leader
Tachycardia Management
Recognizes tachycardia (specific diagnosis)
Recognizes no symptoms due to tachycardia
Considers appropriate initial drug therapy
PEA Management
Recognizes PEA
Immediately resumes CPR after rhythm and pulse checks

VF Management
Recognizes VF

Identifies ROSC
Megacode Testing Checklist: Scenario 12

Bradycardia ➔ VF ➔ Asystole/PEA ➔ PCAC
Team Leader
VF Management
Recognizes VF
Asystole and PEA Management

Recognizes asystole and PEA
Verbalizes potential reversible causes of asystole and PEA (H’s and T’s)

Identifies ROSC
Cardiac Arrest VF/Pulseless VT Learning Station Checklist
Adult Cardiac Arrest Algorithm—2015 Update
Cardiac Arrest Asystole/PEA Learning Station Checklist
Adult Cardiac Arrest Algorithm—2015 Update
Bradycardia Learning Station Checklist
Adult Bradycardia With a Pulse Algorithm
Tachycardia Learning Station Checklist
Adult Tachycardia With a Pulse Algorithm
Immediate Post–Cardiac Arrest Care Learning Station Checklist
Adult Immediate Post–Cardiac Arrest Care Algorithm—2015 Update
ACLS Pharmacology Summary Table

Drug Indications Precautions/Contraindica Adult Dosage
tions
Adenosine First drug for most forms Contraindicated in IV Rapid Push
of stable narrow-complex poison/drug-induced Place patient in mild reverse
SVT. Effective in tachycardia or second- or Trendelenburg position
terminating those due to third-degree heart block before administration of drug
reentry involving AV node Transient side effects Initial bolus of 6 mg given
or sinus node include flushing, chest rapidly over 1 to 3 seconds
May consider for unstable pain or tightness, brief followed by NS bolus of 20
narrow-complex reentry periods of asystole or mL; then elevate the
tachycardia while bradycardia, ventricular extremity
preparations are made for ectopy A second dose (12 mg) can
cardioversion Less effective (larger be given in 1 to 2 minutes if
Regular and monomorphic doses may be required) in needed
wide-complex tachycardia, patients taking
thought to be or previously theophylline or caffeine Injection Technique
defined to be reentry SVT Reduce initial dose to 3 Record rhythm strip during
Does not convert atrial mg in patients receiving administration
fibrillation, atrial flutter, or dipyridamole or Draw up adenosine dose and
VT carbamazepine, in heart flush in 2 separate syringes
Diagnostic maneuver: transplant patients, or if Attach both syringes to the
stable narrow-complex given by central venous IV injection port closest to
SVT access patient
If administered for Clamp IV tubing above
irregular, polymorphic injection port
wide-complex Push IV adenosine as
tachycardia/VT, may quickly as possible (1 to 3
cause deterioration seconds)
(including hypotension) While maintaining pressure
Transient periods of sinus on adenosine plunger, push
bradycardia and NS flush as rapidly as
ventricular ectopy are possible after adenosine
common after termination Unclamp IV tubing
of SVT
Safe and effective in
pregnancy
Amiodarone Because its use is Caution: Multiple complex VF/pVT Cardiac Arrest
associated with toxicity, drug interactions Unresponsive to CPR, Shock,
amiodarone is indicated for Rapid infusion may lead to and Vasopressor
use in patients with life- hypotension First dose: 300 mg IV/IO
threatening arrhythmias push
With multiple dosing,
when administered with
cumulative doses >2.2 g Second dose (if needed):
appropriate monitoring:
over 24 hours are 150 mg IV/IO push
VF/pulseless VT associated with significant
Life-Threatening Arrhythmias
unresponsive to shock hypotension in clinical
Maximum cumulative dose:
delivery, CPR, and a trials
2.2 g IV over 24 hours. May be
vasopressor Do not administer with
administered as follows:
Recurrent, other drugs that prolong
hemodynamically unstable QT interval (eg, Rapid infusion: 150 mg IV
VT procainamide) over first 10 minutes (15 mg
Terminal elimination is per minute). May repeat
With expert consultation,
extremely long (half-life rapid infusion (150 mg IV)
amiodarone may be used for
lasts up to 40 days) every 10 minutes as needed
treatment of some atrial and
ventricular arrhythmias Slow infusion: 360 mg IV
over 6 hours (1 mg per
minute)
Maintenance infusion: 540
mg IV over 18 hours (0.5 mg
per minute)
Atropine Sulfate First drug for symptomatic Use with caution in Bradycardia
Can be given via sinus bradycardia presence of myocardial (With or Without ACS)
endotracheal tube May be beneficial in ischemia and hypoxia. 0.5 mg IV every 3 to 5
presence of AV nodal Increases myocardial minutes as needed, not to
block. Not likely to be oxygen demand exceed total dose of 0.04
effective for type II Avoid in hypothermic mg/kg (total 3 mg)
second-degree or third- bradycardia Use shorter dosing interval
degree AV block or a May not be effective for (3 minutes) and higher doses
block in nonnodal tissue infranodal (type II) AV in severe clinical conditions
Routine use during PEA or block and new third-
Organophosphate Poisoning
asystole is unlikely to have degree block with wide
a therapeutic benefit QRS complexes. (In these Extremely large doses (2 to 4
patients, may cause mg or higher) may be needed
Organophosphate (eg,
nerve agent) poisoning: paradoxical slowing. Be
extremely large doses prepared to pace or give
may be needed catecholamines)
Doses of atropine <0.5 mg
may result in paradoxical
slowing of heart rate
Dopamine Second-line drug for Correct hypovolemia with IV Administration

IV infusion symptomatic bradycardia volume replacement Usual infusion rate is 2 to 20
(after atropine) before initiating dopamine mcg/kg per minute
Use for hypotension (SBP Use with caution in Titrate to patient response;
≤70 to 100 mm Hg) with cardiogenic shock with taper slowly
signs and symptoms of accompanying CHF
shock May cause
tachyarrhythmias,
excessive vasoconstriction
Do not mix with sodium
bicarbonate
Epinephrine Cardiac arrest: VF, Raising blood pressure Cardiac Arrest

Can be given via pulseless VT, asystole, and increasing heart rate IV/IO dose: 1 mg (10 mL of
endotracheal tube PEA may cause myocardial 1:10 000 solution)
Symptomatic ischemia, angina, and administered every 3 to 5
Available in 1:10 000 bradycardia: Can be increased myocardial minutes during resuscitation.
and 1:1000 considered after atropine oxygen demand Follow each dose with 20 mL
concentrations as an alternative infusion High doses do not flush, elevate arm for 10 to
to dopamine improve survival or 20 seconds after dose
Severe hypotension: neurologic outcome and Higher dose: Higher doses
Can be used when pacing may contribute to (up to 0.2 mg/kg) may be
and atropine fail, when postresuscitation used for specific indications
hypotension accompanies myocardial dysfunction (β-blocker or calcium
bradycardia, or with Higher doses may be channel blocker overdose)
phosphodiesterase required to treat Continuous infusion: Initial
enzyme inhibitor poison/drug-induced rate: 0.1 to 0.5 mcg/kg per
Anaphylaxis, severe shock minute (for 70-kg patient: 7
allergic reactions: to 35 mcg per minute); titrate
Combine with large fluid to response
volume, corticosteroids, Endotracheal route: 2 to
antihistamines 2.5 mg diluted in 10 mL NS
Profound Bradycardia or
Hypotension
2 to 10 mcg per minute infusion;
titrate to patient response
Lidocaine Alternative to amiodarone Contraindication: Cardiac Arrest From VF/pVT

Can be given via in cardiac arrest from Prophylactic use in AMI is Initial dose: 1 to 1.5 mg/kg
endotracheal tube VF/pVT contraindicated IV/IO
Stable monomorphic VT Reduce maintenance For refractory VF, may give
with preserved ventricular dose (not loading dose) in additional 0.5 to 0.75 mg/kg
function presence of impaired liver IV push, repeat in 5 to 10
Stable polymorphic VT function or LV dysfunction minutes; maximum 3 doses
with normal baseline QT Discontinue infusion or total of 3 mg/kg
interval and preserved LV immediately if signs of
Perfusing Arrhythmia
function when ischemia is toxicity develop
treated and electrolyte For stable VT, wide-complex
balance is corrected tachycardia of uncertain type,
significant ectopy:
Can be used for stable
Doses ranging from 0.5 to
polymorphic VT with
0.75 mg/kg and up to 1 to 1.5
baseline
mg/kg may be used
QT-interval prolongation if
Repeat 0.5 to 0.75 mg/kg
torsades suspected
every 5 to 10 minutes;
maximum total dose: 3
mg/kg
Maintenance Infusion
1 to 4 mg per minute (30 to 50
mcg/kg per minute)
Magnesium Sulfate Recommended for use in Occasional fall in blood Cardiac Arrest
cardiac arrest only if pressure with rapid (Due to Hypomagnesemia or
torsades de pointes or administration Torsades de Pointes)
suspected Use with caution if renal 1 to 2 g (2 to 4 mL of a 50%
hypomagnesemia is failure is present solution diluted in 10 mL [eg,
present D5W, normal saline] given
Life-threatening ventricular IV/IO)
arrhythmias due to
Torsades de Pointes With a
digitalis toxicity
Pulse or AMI With
Routine administration in Hypomagnesemia
hospitalized patients with
Loading dose of 1 to 2 g
AMI is not recommended
mixed in 50 to 100 mL of
diluent (eg, D5W, normal
saline) over 5 to 60 minutes
IV
Follow with 0.5 to 1 g per
hour IV (titrate to control
torsades)
2015 Science Summary Table

Topic 2010 2015
Systematic Approach: BLS 1-2-3-4 Check responsiveness
Assessment Check responsiveness: – Tap and shout
(name change) – Tap and shout Shout for nearby help/activate
– Scan chest for movement emergency response system/get AED
Activate the emergency response Check breathing and pulse
system and get an AED (simultaneously)
Circulation: Check the carotid pulse. If Defibrillation: If indicated, deliver a
you cannot detect a pulse within 10 shock with an AED or defibrillator
seconds, start CPR, beginning with
chest compressions, immediately
Defibrillation: If indicated, deliver a
shock with an AED or defibrillator
Systematic Approach: Airway Airway

Primary Assessment Breathing Breathing
(name change) Circulation Circulation
Differential diagnosis (H’s and T’s) Disability
Exposure
Systematic Approach: NA SAMPLE

Secondary Assessment H’s and T’s
(new)
BLS: High-Quality CPR A rate of at least 100 chest A rate of 100 to 120 chest
compressions per minute compressions per minute
A compression depth of at least 2 A compression depth of at least 2
inches in adults inches in adults*
Allowing complete chest recoil after Allowing complete chest recoil after
each compression each compression
Minimizing interruptions in Minimizing interruptions in
compressions (10 seconds or less) compressions (10 seconds or less)
Avoiding excessive ventilation Avoiding excessive ventilation
Switching provddiac arrest with aiers Chest compression fraction of at least
about every 2 minutes to avoid fatigue 60% but ideally greater than 80%
Switch compressor about every 2
minutes or sooner if fatigued
Use of audio and visual feedback
devices to monitor CPR quality
*When a feedback device is available,

adjust to a maximum depth of 2.4 inches
[6 cm]) in adolescents and adults.
ACLS: Immediate Post– Consider therapeutic hypothermia Consider targeted temperature
Cardiac Arrest Care (32°C to 34°C for 12 to 24 hours) to management to optimize survival and
optimize survival and neurologic neurologic recovery in comatose
recovery in comatose patients patients—cool to 32°C to 36°C for at
least 24 hours
Out-of-hospital cooling of patients with
rapid infusion of cold IV fluids after
ROSC is not recommended
ACLS: Managing the Airway For cardiac arrest with an advanced For cardiac arrest with an advanced
airway in place, ventilate once every 6 airway in place, ventilate once every 6
to 8 seconds seconds
ACLS: Bradycardia Dopamine dosing: 2 to 10 mcg/kg per Dopamine dosing: 2 to 20 mcg/kg per
minute minute
ACLS: ACS NSTEMI NSTE-ACS

Titrate O2 saturation to ≥94% Titrate O2 saturation to ≥90%
Topic 2015
ACLS: Cardiac Arrest Removed vasopressin from the Cardiac Arrest Algorithm
Administer epinephrine as soon as feasible after the onset of cardiac arrest due to
an initial nonshockable rhythm
Added Opioid-Associated Life-Threatening Emergency (Adult) Algorithm
Healthcare providers tailor the sequence of rescue actions based on the presumed
etiology of the arrest. Moreover, ACLS providers functioning within a high-
performance team can choose the optimal approach for minimizing interruptions in
chest compressions (thereby improving chest compression fraction [CCF]). Use of
different protocols, such as 3 cycles of 200 continuous compressions with passive
oxygen insufflation and airway adjuncts, compression-only CPR in the first few
minutes after arrest, and continuous chest compressions with asynchronous
ventilation once every 6 seconds with the use of a bag-mask device, are a few
examples of optimizing CCF and high-quality CPR. A default compression-to-
ventilation ratio of 30:2 should be used by less-trained healthcare providers or if 30:2
is the established protocol.
Consider using ultrasound during arrest to detect underlying causes (eg, PE)
Extracorporeal CPR may be considered among select cardiac arrest patients who
have not responded to initial conventional CPR, in settings where it can be rapidly
implemented
Consider administering intravenous lipid emulsion, concomitant with standard
resuscitative care, to patients who have premonitory neurotoxicity or cardiac arrest
due to local anesthetic toxicity or other forms of drug toxicity and who are failing
standard resuscitative measures
ACLS: Stroke Endovascular therapy (treatment window up to 6 hours)
Glossary
A
Acute Having a sudden onset and short course
Acute myocardial infarction (AMI) The early critical stage of necrosis of heart muscle tissue caused by blockage
of a coronary artery
Advanced cardiovascular life support Emergency medical procedures in which basic life support efforts of CPR are
(ACLS) supplemented with drug administration, IV fluids, etc
Asystole Absence of electrical and mechanical activity in the heart
Atrial fibrillation In atrial fibrillation the atria “quiver” chaotically and the ventricles beat
irregularly
Atrial flutter Rapid, irregular atrial contractions due to an abnormality of atrial excitation
Atrioventricular (AV) block A delay in the normal flow of electrical impulses that cause the heart to beat
Automated external defibrillator A portable device used to restart a heart that has stopped
(AED)
B
Basic life support (BLS) Emergency treatment of a victim of cardiac or respiratory arrest through
cardiopulmonary resuscitation and emergency cardiovascular care
Bradycardia Slow heartbeat, whether physiologically or pathologically
C
Capnography The measurement and graphic display of CO2 levels in the airways, which can
be performed by infrared spectroscopy
Cardiac arrest Temporary or permanent cessation of the heartbeat
Cardiopulmonary resuscitation (CPR) A basic emergency procedure for life support, consisting of mainly manual
external cardiac massage and some artificial respiration
Coronary syndrome A group of clinical symptoms compatible with acute myocardial ischemia. Also
called coronary heart disease.
Coronary thrombosis The blocking of the coronary artery of the heart by a thrombus
E
Electrocardiogram (ECG) A test that provides a typical record of normal heart action
Endotracheal (ET) intubation The passage of a tube through the nose or mouth into the trachea for
maintenance of the airway
Esophageal-tracheal tube A double-lumen tube with inflatable balloon cuffs that seal off the hypopharynx
from the oropharynx and esophagus; used for airway management
H
Hydrogen ion (acidosis) The accumulation of acid and hydrogen ions or depletion of the alkaline
reserve (bicarbonate content) in the blood and body tissues, decreasing the
pH
Hyperkalemia An abnormally high concentration of potassium ions in the blood. Also called
hyperpotassemia.
Hypoglycemia An abnormally low concentration of glucose in the blood

Hypokalemia An abnormally low concentration of potassium ions in the blood. Also called
hypopotassemia.
Hypothermia When the patient’s core body temperature is below 96.8°F (36°C)
Hypovolemia A decrease in the volume of circulating blood
Hypoxia A deficiency of oxygen reaching the tissues of the body
I
Intraosseous (IO) Within a bone
Intravenous (IV) Within a vein
M
Mild hypothermia When the patient’s core body temperature is between 93.2°F and 96.8°F
Moderate hypothermia When the patient’s core body temperature is from 86°F to 93.2°F
N
Nasopharyngeal Pertaining to the nose and pharynx
O
Oropharyngeal airway A tube used to provide free passage of air between the mouth and pharynx
P
Perfusion The passage of fluid (such as blood) through a specific organ or area of the
body (such as the heart)
Prophylaxis Prevention of or protection against disease

Pulmonary edema (PE) A condition in which fluid accumulates in the lungs
Pulseless electrical activity (PEA) Continued electrical rhythmicity of the heart in the absence of effective
mechanical function
R
Recombinant tissue plasminogen A clot-dissolving substance produced naturally by cells in the walls of blood
activator (rtPA) vessels
S
Severe hypothermia When the patient’s core body temperature is below 86°F
Sinus rhythm The rhythm of the heart produced by impulses from the sinoatrial node
Supraglottic Situated or occurring above the glottis
Synchronized cardioversion Uses a sensor to deliver a shock that is synchronized with a peak in the QRS
complex
Syncope A loss of consciousness over a short period of time, caused by a temporary

lack of oxygen in the brain
T
Tachycardia Increased heartbeat, usually ≥100/min
Tamponade (cardiac) A condition caused by accumulation of fluid between the heart and the
pericardium, resulting in excess pressure on the heart. This impairs the heart’s
ability to pump sufficient blood.
Tension pneumothorax Pneumothorax resulting from a wound in the chest wall which acts as a valve
that permits air to enter the pleural cavity but prevents its escape
Thrombus A blood clot formed within a blood vessel
Unsynchronized shock An electrical shock that will be delivered as soon as the operator pushes the
shock button to discharge the defibrillator. Thus, the shock can fall anywhere
within the cardiac cycle.
V
Ventricular fibrillation (VF) Very rapid uncoordinated fluttering contractions of the ventricles
Ventricular tachycardia (VT) A rapid heartbeat that originates in one of the lower chambers (ventricles) of
the heart

Advanced Cardiovascular Life Support Provider Manual - 2015

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Advanced Cardiovascular Life Support Provider Manual - 2015

Uploaded by

Copyright:

Available Formats

5/24/23, 6:27 PM Advanced Cardiovascular Life Support Provider Manual

Student Name ___________________ Date of Test ___________________

Critical Performance Steps ✓ if done correctly

BLS Assessment and Interventions

Activates the emergency response system

Checks pulse (5-10 seconds)

Inserts oropharyngeal or nasopharyngeal airway

Performs effective bag-mask ventilation for 1 minute

Megacode Testing Checklist: Scenarios 1/3/8

Student Name ___________________ Date of Test ___________________

Critical Performance Steps ✓ if done correctly

Assigns team member roles

Ensures that team members perform well

Places monitor leads in proper position

Recognizes symptomatic bradycardia

Administers correct dose of atropine

Prepares for second-line treatment

Clears before analyze and shock

Immediately resumes CPR after shocks

Appropriate airway management

Appropriate cycles of drug–rhythm check/shock–CPR

Administers appropriate drug(s) and doses

Verbalizes potential reversible causes of PEA (H’s and T’s)

Administers appropriate drug(s) and doses

Immediately resumes CPR after rhythm checks

Post–Cardiac Arrest Care

Considers targeted temperature management

Megacode Testing Checklist: Scenarios 2/5

Student Name ___________________ Date of Test ___________________

Critical Performance Steps ✓ if done correctly

Assigns team member roles

Ensures that team members perform well

Places monitor leads in proper position

Recognizes symptomatic bradycardia

Administers correct dose of atropine

Prepares for second-line treatment

Clears before analyze and shock

Immediately resumes CPR after shocks

Appropriate airway management

Appropriate cycles of drug–rhythm check/shock–CPR

Administers appropriate drug(s) and doses

Verbalizes potential reversible causes of asystole (H’s and T’s)

Administers appropriate drug(s) and doses

Immediately resumes CPR after rhythm checks

Post–Cardiac Arrest Care

Considers targeted temperature management

Megacode Testing Checklist: Scenarios 4/7/10

Student Name ___________________ Date of Test ___________________

Critical Performance Steps ✓ if done correctly

Assigns team member roles

Ensures that team members perform well

Places monitor leads in proper position

Recognizes unstable tachycardia

Recognizes symptoms due to tachycardia

Performs immediate synchronized cardioversion

Clears before analyze and shock

Immediately resumes CPR after shocks

Appropriate airway management

Appropriate cycles of drug–rhythm check/shock–CPR

Administers appropriate drug(s) and doses

Verbalizes potential reversible causes of PEA (H’s and T’s)

Administers appropriate drug(s) and doses

Student Name _ Date of Test _

Student Name _ Date of Test _

Student Name _ Date of Test _

Student Name _ Date of Test _

Student Name _ Date of Test _

Student Name _ Date of Test _

Student Name _ Date of Test _