ACLS

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES

AHA ECC Adult Chain of Survival New

Identification of cardiac
arrest
Short period of seizure-like activity or
agonal gasps
unresponsive with no breathing

Activation of Emergency Response

System
should not delay activation of the
emergency response system
check the victim for response and
check for no breathing or no normal
breathing
If the healthcare provider does not
feel a pulse within 10 seconds, the
provider should begin CPR and use
the AED when it is available

Emphasis on High-Quality CPR

1) PUSH HARD AND PUSH FAST
- At least 100 COMPRESSIONS / MINUTE
2) Allow the chest to recoil -- equal compression
and relaxation times
- <10 seconds for pulse checks or rescue breaths
3)Compression Depth
- Adults 2
- Child/Infant 1/3 depth of chest 1.5" infant 2" child
4) Avoid excessive ventilations
5) Minimizing interruptions in chest compressions

 total number of compressions

delivered during resuscitation is an
important determinant of survival
from cardiac arrest
determinant of return of spontaneous
circulation (ROSC) and survival with
good neurologic function

 actual number of chest compressions

delivered per minute is determined
by the rate of chest compressions
and the number and duration of
interruptions in compressions (eg, to
open the airway, deliver rescue
breaths, or allow AED analysis)

A Change From A-B-C to C-A-B

High survival rate from cardiac arrest
are reported among patients of all
ages who have a witnessed arrest
and an initial rhythm of ventricular
fibrillation (VF) or pulseless
ventricular tachycardia (VT)
Majority of cardiac arrests occur in
adults

No cricoid pressure
Cricoid pressure is a technique of applying pressure to
the victims cricoid cartilage to push the trachea
posteriorly and compress the esophagus against the
cervical vertebrae.
prevent gastric inflation and reduce the risk of
regurgitation and aspiration but it may also impede
ventilation.
Seven randomized studies showed that cricoid pressure
can delay or prevent the placement of an advanced
airway and that some aspiration can still occur despite
application of cricoid pressure.
It is difficult to appropriately train rescuers in use of the
maneuver

ELECTRICAL
THERAPIES
Automated External Defibrillators
a goal of shock delivery 3 minutes
from collapse

Shock First vs CPR First

start CPR with chest compressions and use
the AED as soon as possible
early CPR and early defibrillation
the time from VF to shock delivery should
be under 3 minutes, and CPR should be
performed while the defibrillator is readied.
VF is present for more than a few minutes,
the myocardium is depleted of oxygen and
energy

1-Shock Protocol vs 3-Shock

Sequence
International Liaison Committee on
Resuscitation (ILCOR) 2010,
International Consensus Conference
on CPR and ECC SciencebWith
Treatment Recommendations, 2 new
published human studies compared a
1-shock protocol versus a 3stackedshock protocol for treatment
of VF cardiac arrest.

 Evidence from these 2 studies suggests

significant survival benefit with a singleshock defibrillation protocol compared
with a 3-stackedshock protocol.
If 1 shock fails to eliminate VF, the
incremental benefit of another shock is
low, and resumption of CPR is likely to
confer a greater value than another
immediate shock

Use of pericordial thump

precordial thump has been reported to
convert ventricular tachyarrhythmias
precordial thump did not result in
ROSC for cases of VF.
Reported complications associated
with precordial thump include sternal
fracture, osteomyelitis, stroke, and
triggering of malignant arrhythmias in
adults and children

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES

ACLS
Simplified algorithm
Optimized CPR quality with monitoring
Waveform capnography (>12 mmHg)
Atropine deleted (PEA/Asystole)
Chronotropic drugs for brady, then pacing
Adenosine safe for monomorphic wide
tachs
Post-cardiac arrest

ACLS Cardiac Arrest Algorithm.

VENTRICULAR FIBRILLATION

Pulseless Electrical Activity

(PEA)

ACLS Cardiac Arrest Circular Algorithm.

Tachycardia Algorithm.

SVT

Monomorphic Ventricular
Tachycardia- VT (SUSTAINED)

Polymorphic Ventricular
Tachycardia- VT

Tachycardia
Immediate synchronized
cardioversion for unstable
tachyarrhythmia
- 120 200J for AF
- 100J for monomorphic VT
- 50 100J for atrial flutter/ other SVT
Unsynchronized shock for unstable
polymorphic VT

Bradycardia Algorithm.

First Degree Heart Block

(1)

Second Degree Heart Block

(2)

Third Degree Heart Block (3)

(Complete)

ADVANCED CARDIOVASCULAR
LIFE SUPPORT
Quantitative waveform capnography
is recommended for confirmation and
monitoring of endotracheal tube
placement and CPR quality.
Atropine is no longer recommended
for routine use in the management of
pulseless electrical activity
(PEA)/asystole.

 Chronotropic drug infusions are

recommended as an alternative to
pacing in symptomatic and unstable
bradycardia.
Adenosine is recommended as safe and
potentially effective for both treatment
and diagnosis in the initial management
of undifferentiated regular monomorphic
widecomplex tachycardia

 Systematic postcardiac arrest care

after ROSC should continue in a
critical care unit with expert
multidisciplinary management and
assessment of the neurologic and
physiologic status of the patient.
This often includes the use of
therapeutic hypothermia.

Capnography
confirming tracheal tube placement
and for monitoring CPR quality and
detecting ROSC based on end-tidal
carbon dioxide (PETCO2) values

CAPNOGRAPHY

De-emphasis of Devices, Drugs, and

Other Distracters
Atropine is not recommended for
routine use in the management of
PEA/asystole and has been removed
from the ACLS Cardiac Arrest
Algorithm

Initial and Later Key Objectives of

PostCardiac Arrest Care
1. Optimize cardiopulmonary function and vital
organ perfusion after ROSC
2. Transport/transfer to an appropriate hospital or
critical care unit with a comprehensive postcardiac
arrest treatment system of care
3. Identify and treat ACS and other reversible causes
4. Control temperature to optimize neurologic
recovery
5. Anticipate, treat, and prevent multiple organ
dysfunction. This includes avoiding excessive
ventilation and hyperoxia.

Therapeutic Hypothermia
Clear benefit for comatose survivors
of witnessed, v-fib arrest
Goal temperature is 33 degrees
celcius
Cool ASAP for 24 hrs

Oxygenation
Excessive Oxygen in unnecessary and
may be harmful
Can act to vasoconstrict coronary
arteries
After ROSC, O2 sats should be
monitored and titrated to 94%
Supplementary O2 is NOT needed if no
respiratory distress or when O2 sat is
94% inperiarrest or ROSC patients.

Glycemic Control
Hyperglycemia associated with
higher mortality and worsened
neurological outcome
Maintain serum glucose level 8
10mmol/L

Seizure Management
Seizure may occur in 520% of
comatose cardiac arrest victims after
ROSC
EEG for diagnosis and frequent
monitoring in comatose patients
after ROSC (Class I, LOE C)