ACLS CE

Part II of III
ACLS in Acute Coronary Syndromes

Prepared and presented by

Marc Imhotep Cray, M.D.

Objectives
Review the importance of CPR / BLS in ALCS (AHA BLS
guidelines)
Describe the relationship of the chain of survival to
successful resuscitation of the cardiac arrest patient
Discuss the interventions required to ensure good
outcomes with Return of Spontaneous Circulation

Heart Disease
Cardiovascular disease is the number one cause of
death in the U.S., and many times the first indication
of this disease is an acute coronary event
Cardiac arrest is the most severe manifestation of an
acute coronary syndrome, and with rapid
intervention EMS providers can make the difference
between life and death

Heart Disease(2)
While EMT will occasionally be called to a patient
who is in cardiac arrest, or to a patient who goes into
cardiac arrest at scene or en route to the hospital
More often the call will be to a responsive
patient who has signs and symptomsparticularly
chest discomfort or painthat may be caused by
heart disease

Heart Disease (3)

Not every cardiac arrest is preceded by chest pain or
discomfort, nor do all patients with chest discomfort or
pain proceed to cardiac arrest, but for those who do,
rapid intervention is vital
Without it, such patients will almost surely die
As such, EMT are taught they must be prepared to
treat all patients with signs and symptoms of cardiac
compromise as cardiac emergencies

American Heart Association Facts

7 to 8 million people a year seek treatment for chest
pain.
Of these, 2 million will actually have a cardiac
condition that affects the coronary arteries.
About 1.5 million will suffer a heart attack.
500,000 of these heart attack patients will die.
250,000 of these patients will die within the first hour
of symptom onset.

Definition of ACLS
Advanced cardiac life support or advanced
cardiovascular life support (ACLS) refers to a set
of clinical interventions for the urgent treatment of
cardiac arrest, stroke and other life-threatening
medical emergencies, as well as the knowledge
and skills to deploy those interventions.
From: http://en.wikipedia.org/wiki/Advanced_cardiac_life_support

ACLS Guidelines
American Heart Association (AHA) and International Liaison
Committee on Resuscitation (ILCR) performs a science
review every five years and publishes an updated set of
recommendations and educational materials
ACLS guidelines were last updated by the American Heart
Association and the International Liaison Committee on
Resuscitation in 2010
New ACLS guidelines focus on BLS as the core component
of ACLS
See: Berg RA et.al. Part 5: Adult basic life support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010;122(suppl 3):S685S705.
http://circ.ahajournals.org/content/122/18_suppl_3/S685
8

Current Guidelines
2010 American Heart Association (AHA) Guidelines
for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiovascular Care (ECC)
2010 AHA Guidelines for CPR and ECC

Access the full 2010 AHA Guidelines for CPR &

ECC, published in the journal Circulation on
October 18, 2010.

Importance of BLS in ACLS

10

Importance of BLS in ALS

BASIC LIFE SUPPORT
ACLS is built heavily upon the foundation of BLS
New AHA ACLS guidelines focus on BLS as the core
component of ACLS
See: Berg RA et.al.. Part 5: Adult basic life support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010;122(suppl 3):S685S705.
http://circ.ahajournals.org/content/122/18_suppl_3/S685

11

Adult CPR
1.
2.
3.
4.

Make sure the scene is SAFE!

Check responsiveness and breathing
If alone call 9-1-1 and get an AED
Check for a pulse and if no pulse present begin
CPR
Always start CPR with Compressions First!

12

Chest Compressions
Always start CPR with
Compressions First!
Push hard and fast
Rate should be at least 100
per minute
Provide 30 compressions
then 2 breaths
Make sure the chest is
allowed to re-expand
completely at the end of
each compression

13

CPR
Chest compressions and breaths are the same for
adults, child, and infant if you are alone
Adult age starts at the onset of puberty
(12-14 years of age)

Child is age 1 year to the onset of puberty

Infant is anyone under the age of 1year

14

Adult CPR
5.
6.
7.
8.

Open the airway with head tilt-chin lift

Place the mask on the patients face
Use the E-C clamp technique
Deliver each breath over 1 second

15

Relationship of chain of survival to

successful resuscitation of cardiac
arrest patient

16

AHA ECC Adult Chain of Survival

The links in the new AHA ECC Adult Chain of Survival are
as follows:
1. Immediate recognition of cardiac arrest and activation of the
emergency response system
2. Early CPR with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated postcardiac arrest care
Source: 2010 AHA Guidelines for CPR and ECC

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Interventions required to ensure

good outcomes with Return of
Spontaneous Circulation

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Immediate Post Arrest Care Return

of Spontaneous Circulation (ROSC) (1)
Optimize ventilation and oxygenation
O2 Saturation > 94%
Advanced Airway
10-12 per minute
PETCO2 35-40 mm/Hg
Do not hyperventilate
< cerebral perfusion
Oxygen toxic
19

Immediate Post Arrest Care Return

of Spontaneous Circulation (ROSC)(2)
Treat hypotension (SBP <90 mm Hg)
Fluid Bolus 1-2 liters
Vasopressors
Epinephrine 0.1-0.5 mcg/kg/minute
Dopamine 5-10 mcg/kg/minute

20

Immediate Post Arrest Care Return

of Spontaneous Circulation (ROSC)(3)
Induced Hypothermia
If not following commands
Improved neurological recovery
32 - 34 C for 12-24 hours
Coronary reperfusion
If STEMI
May do concurrently with hypothermia
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Cardiac Arrest
Few cardiac arrest patients survive outside a hospital
without a rapid sequence of events
Chain of survival:
Early recognition and activation of EMS
Immediate bystander CPR
Early defibrillation
Early advanced cardiac life support
Integrated post-arrest care

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Early CPR
Why is CPR Important
Studies have shown that the general population will
start CPR only 1/3 of the time and only 15% of that
total is done correctly
Chest Compressions can be started within 18 seconds
of arriving at the patient, whereas airway
management first can delay compressions by 1-2
minutes or more
CPR prolongs the period during which defibrillation
can be effective
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Rationale for Early Defibrillation

Ventricular fibrillation is the most frequent
rhythm found in cardiac arrest
Defibrillation is the most effective treatment
for VF
Probability of successful defibrillation
diminishes with time
VF will lead to asystole quickly without proper
treatment
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Early Defibrillation Impacts Survival

Hearts and Brains are going to die Peter Safar MD

EMS has the most opportunity to perform CPR, so we

should be good at performing good, quality CPR
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Adult Cardiac Arrest

AHA ACLS Managements Guidelines

ACLS in Acute Coronary Syndromes

Reference: O'Connor, RE et.al. 2010 American
Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Science
Part 10: Acute Coronary Syndromes
Available at http://circ.ahajournals.org/content/122/18_suppl_3/S787.full

Adult Cardiac Arrest

ACLS GUIDELINES
"2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science". Circulation 122 (18 Suppl 3).
November 2010.
doi:10.1161/CIRCULATIONAHA.110.970889.

Adult Cardiac Arrest Protocol V-Fib /

Pulseless V-Tach (1)
(9 STEP Sequence)
1. Initiate CPR and attach monitor/defibrillator
2. Defibrillate at 360j or equivalent biphasic shock
3. Resume CPR immediately following defibrillation
and continue for 2 minutes

Adult Cardiac Arrest Protocol V-Fib /

Pulseless V-Tach (2)
4. Initiate vascular access; manage airway
5. Reevaluate rhythm; defibrillate if needed;
resume CPR
6. Administer Epinephrine 1mg every 3-5
minutes

Adult Cardiac Arrest Protocol V-Fib /

Pulseless V-Tach (3)
7. Defibrillate if needed; resume CPR
8. Administer Amiodarone 300mg; may repeat
at 150 mg IV/IO in 5 minutes if needed.
9. Continue cycles of CPR and defibrillation as
needed

Adult Cardiac Arrest Protocol

Asystole / PEA
1. Initiate CPR and attach monitor/defibrillator
2. Initiate vascular access; manage airway
3. Administer Epinephrine 1mg every 3-5
minutes
4. Consider possible causes and treatments
Hs and Ts

Reversible Causes Hs and Ts

Hypovolemia (Volume infusion)

Hypoxia (Ventilation and oxygenation)
Massive Myocardial Infarction (Volume infusion)
Tension Pneumothorax (Needle decompression)
Acidosis/Hyperkalemia (Hyperventilation)
Drug Overdose (Refer to appropriate protocol)
Hypothermia (Refer to appropriate protocol)
Pericardial Tamponade (Rapid transport)
Massive Pulmonary Embolism (Ventilation, Volume
infusion)

End of ACLS CE Part II

THANK YOU FOR YOUR ATTENTION

See Part III

Defibrillation and ACLS Drug Therapy

References and further study next slide

34

References and further study:

1. Berg et.al. 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science Part 5: Adult Basic
Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
Available at: http://circ.ahajournals.org/content/122/18_suppl_3/S685
2. Neumar,RW et.al. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care SciencePart
8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
Available at: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full
3. 2010 AHA Guidelines for CPR and ECC
4. O'Connor, RE et.al. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 10: Acute Coronary Syndromes
Available at http://circ.ahajournals.org/content/122/18_suppl_3/S787.full

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ACLS Precourse Self-Assessment Test

ACLS Supplementary Materials
ACLS Core Drugs
ACLS Science Overview Video

BLS for Healthcare Providers Videos

Adult 1-Rescuer CPR Demo
Adult Compressions
Adult Breaths With Mask
Adult Compressions and Breaths
Adult Assessment
Adult Rescue Breathing With Bag Mask
Adult 2-Rescuer CPR Demo
Adult 2-Rescuer CPR and AED Demo
Adult 2-Rescuer CPR With an Advanced Airway
2006 American Heart Association

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