FAQ Regarding Guidelines 2005 ACLS Course
Florida Regional ECC
Last updated
October 18, 2006
The following is a compilation of questions/concerns regarding the new guidelines ACLS course. Following the number of
the question, you’ll see a category of question, such as “science”, “administrative”, “course structure”. Some of the
answers come from Judy Young, Florida ACLS NF, others are from National ECC and/or the ACLS Subcommittee, and
still other answers are combination answers from National and Judy Young. When answers are from someone other than
Judy, they are noted as such. Some of the questions were graciously shared from other states, and answered by
National ECC or that state’s NF. This FAQ document will be sent to all Florida ACLS TCs and RFs as it is updated.
Number
Question/Concern
The ECC Handbook (p.45) states that Amiodarone is only
1.
Science
indicated for ventricular tachycardia/arrhythmia when pt is
hemodynamically unstable or when other antiarrhythmic
agents (or alternative agents) have not been tolerated. The
AHA Guidelines for CPR and ECC (p. IV-74) states that
Amiodarone IV may be given for narrow-complex tachycardias
that originated from a reentry mechanism if the rhythm
remains uncontrolled by adenosine, vagal maneuvers, and AV
nodal blockade in patients with preserved or impaired
ventricular function (class IIb). My question is can we use
Amiodarone in stable narrow complex tachycardia if adenosine
and vagal maneuvers don't work?
2.
How much time do we have to wait before giving epinephrine
after vasopressin in cardiac arrest? Is it 3-5 minutes or 10
minutes?
Science
Answer
I believe the intent is not to give the Amiodarone in narrow complex
tachycardias in the initial management of the case, but that this
drug may be of use by an expert after "expert consultation".
Amiodarone is not listed on the narrow complex side of the
algorithm in either the handbook or the Guidelines 2005 book,
AND, it is not in the algorithm in the new ACLS provider manual.
One thing the NF were told when we received the first science
briefings, was that not ALL scientifically significant findings found
their way into the guidelines and algorithms. So, bottom line, I
believe the statement you quote from the guidelines book meant
that after expert consultation, Amiodarone may be used for narrow
complex tachycardias in patients with preserved or impaired
ventricular function. The drug is not to be taught as part of the
narrow complex tachycardia algorithm.
The 40 unit dose of vasopressin may be used instead of either the
first or second dose of epinephrine, then continuing with the 3-5
minute administration of epinephrine. So, if you give the
vasopressin as the first dose, you may then administer the
epinephrine 3-5 minutes later. If you give the vasopressin as the
2nd dose, you still may administer epinephrine again 3-5 minutes
later and so on. We know it takes approximately 10 minutes for the
vasopressin to start to work, peaking at perhaps 20 minutes.
1
There is a study (Guyett FX, in Resuscitation 2004) that showed an
increase in ROSC in patients with asystole who received
combination administration of both epinephrine and vasopressin.
You do not repeat the vasopressin, just give the single dose of 40
units.
3.
Admin
4.
Science
On our hospital’s Code Blue sheet, the amount of time it takes
until the patient is intubated is recorded. Our hospital uses
AHA ACLS guidelines and the goal to intubation time of 3
minutes. With the new guidelines emphasizing BLS and hands
on time, has the amount of time to intubation guideline been
changed?
There really is not a "time" by which endotracheal intubation must
be done. You'll see that the new course allows for individualization
of the airway management station. For example, folks that don’t
perform ET intubation as part of their job don't have to be trained
and evaluated on inserting ET tubes, but they ARE trained and
tested on adequately managing the airway. So, I don't think we'll
find a recommended number of minutes from CPR to intubation. I
know that the NRCPR, from AHA, is updating its checklists, etc,
and these should be complete soon. Send NRCPR questions to:
scott.strader@heart.org. So, just as a suggestion, I think you might
want to consider deleting a "time" requirement on your checklist,
and instead add something like, "Were adequate ventilations
performed with CPR", and "Was advanced airway management
considered within 3 minutes of CPR initiation". Just some
thoughts, but more importantly than actual ET intubation, is the
adequacy of whatever form of ventilation is being used.
Does the biphasic shock at 200J increase to 360J after the
first shock if there is no change or does it remain at 200J
throughout the code?
Please refer to page IV-37 in 2005 Guidelines for CPR and ECC,
section titled, "Fixed and Escalating Energy". Bottom line is that
multiple prospective human clinical studies and retrospective
studies have failed to identify an optimal biphasic energy level for
first or subsequent shocks. Therefore, AHA doesn’t make a
definitive recommendation for the selected energy for the first or
subsequent biphasic defibrillation attempts. There is a
recommendation, however, based on documented evidence from
two different types of biphasic waveforms: 150 J to 200 J with
biphasic truncated exponential waveforms and 120 J with a
rectilinear biphasic waveform--but these are only for the initial
shock. None of the available evidence has shown superiority of
either nonescalating or escalating energy biphasic waveform
defibrillation for termination of VF. So, AHA states, "Nonescalating
and escalating energy biphasic waveform shocks can be used
safely and effectively to terminate short-duration and long-duration
VF (class IIa)." You'll note that the "Pulseless Arrest" algorithm
2
indicates the dosages I've listed above, but states that if you don't
know if you have Truncated or Rectilinear waveforms, just start at
200 J on the biphasic defibrillator. Also, the algorithm states that
you may continue subsequent shocks at the same or higher
doses...your call. (This is in box 6 of the Pulseless arrest
algorithm).
5.
Science
Why is it listed in the handbook under PALS to administer
adenosine for V-Tach? Shouldn't it be Amiodarone or
Lidocaine like in an adult? What is the science behind this?
Adenosine is used for narrow complex SVTs and why the
change, is this a misprint?
(From Judy, ACLS NF) I'll refer you to page IV-175-178 in the
2005 Guidelines for CPR and ECC book, section "Tachycardia and
Hemodynamic Instability". For many years now in adults, there has
been a recommendation that when there is wide-complex
tachycardia, Adenosine MAY be tried if there is suspicion that the
wide-complex tachycardia is SVT with aberrancy. Because of the
short half-life of Adenosine, it was OK to do this as long as we
didn't delay cardioversion if necessary. In the PALS "Tachycardia
with Pulses and Poor Perfusion", this is the same suggestion,
however, the text goes on to say, "If a second shock is
unsuccessful or if the tachycardia recurs quickly, consider
antiarrhythmic therapy (amiodarone or procainamide) before a third
shock" (Box 11 in the algorithm with expert consultation advised).
Now, you'll notice that in the algorithm for "Tachycardia With
Adequate Perfusion", Adenosine is not included in the treatment of
wide-complex tachycardia. In the unstable scenario, there isn't
time for Amiodarone or Procainamide, and electricity is the
recommended treatment. Because the adenosine is so quick, one
could "try it" while preparing the defibrillator. In this stable
scenario, however, we aren't proceeding to electricity, and there is
time for the Amiodarone or Procainamide. You'll also note that if
these are ineffective, with expert consultation, the algorithm
eventually leads you back to the treatment recommendations for
SVT (and in this case it would be wide, possibly an aberrancy)
where you'll find vagal maneuvers and adenosine listed.
Cardioversion would be a last decision in this case, as it is stable.
(From Ed, PALS NF) As you know, the most likely of SVT or VT in
a child is SVT. The reason that adenosine is mentioned in the "
Possible Ventricular Tachycardia" algorithm is that, if it is actually
SVT, you may correct it in seconds &, if not, you have done no
harm as the medicine is out of the system in 2 seconds. You notice
that we stated that adenosine "may be attempted if it does not
3
delay electrical cardioversion". Basically we're admitting that it
may be difficult to differentiate between SVT & VT so if you have
time you can attempt the least invasive, and painful, modality. If it
works, great; if not, you've lost nothing. In adults, with the average
slower rate of SVT & VT, it is somewhat easier to differentiate one
from the other and we can be more sure in diagnosis and specific
in treatment.
6.
Structure
Is there a separate rhythm test in the new ACLS course like
we had previously, or are rhythms included in the written
exam?
To answer your question, there are three "tests" in the new ACLS
course: 1) BLS skills testing; 2) the written exam, which does
include the rhythm strips; and 3) megacode testing.
You'll also note, when you get your provider manuals that the
students are to complete a rhythm self-assessment program, and a
pharmacology self-assessment program PRIOR to attending the
ACLS course. The intent of this self-assessment is that the
students arrive for the ACLS course with a background knowledge
of these two topics. The course is not designed to teach these two
subjects in detail during the course.
Lastly, I just want to be sure you are aware that in the "old" ACLS
course we were not permitted to require that a student "pass" a
locally developed rhythm test, as part of their passing the ACLS
course. We were permitted to administer rhythm tests as training
tools, but failure to pass these could NOT be used as pass or fail
for the course. Now, with that said, if the student couldn't
recognize rhythms on the monitor and therefore couldn't
appropriately treat the rhythm during skills evaluation (such as in
megacode testing stations), certainly that was grounds for failure.
But a locally developed written rhythm test could not be included in
the pass or fail scores of the student.
7.
Structure
Why no stroke or ACS in the ACLS renewal course?
In fact, the renewal course doesn’t include learning stations for the
individual rhythm cases, such as tachycardias, bradycardias, etc.
It focuses on “what’s new”, mostly the science, BLS and airway
stations then the Megacode teaching and testing stations. Jo Haag
explained that in order to keep the renewal course to 1 day, AND to
teach and test the 2005 Guidelines BLS skills, ACS and Stroke
were left out. However, she continued with the statement that a TC
had the option of adding sections of the course as needed. So, if a
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renewal class of students work in the ER, EMS, ICU, etc., and deal
with ACS and stroke frequently, the TC may want to include the
videos for these two cases. If a facility is a Stroke Center, surely it
will want to have Stroke included in the renewal course. It may
lengthen the hours of the course somewhat. So, bottom line, the
renewal is mostly to teach new BLS skills, and "reverify" megacode
skills using new guidelines. You may add cases as desired.
8.
Admin
9.
Structure
10.
Structure
11.
Admin
May we make copies of the ACLS self-assessment test? One
TC said that some students had trouble opening that
document with their own computers and it would be so helpful
if she could hand them a hard copy when they pick up the
book.
National doesn't want us to make copies of the self-assessment
quiz. Jo explained that the instructions Drenda sent out should be
enough. I told her that I had to download a newer version of
Netscape to get it to open on my computer, but she is certain that
the instructions for opening should fix the problem. If students
continue to have problems opening this, I'll go back to National with
a request to make hard copies of the self-assessment.
Many of you have questioned the instructor-student ratio of the
new ACLS course for the airway and CPR-AED stations. The
ACLS materials recommend 1 instructor to 3 students (1:3) in
these two stations. The instructor to student ratio for the
remaining learning and testing stations in the course is 1:6. It
has been noted that CPR-AED training in the BLS course
recommends a ratio of 1:6. So, the question was why the 1:3
ratio in the ACLS course?
I received clarification from National on this issue. The 1:3 ratio in
these two stations is because of time constraints in these two
stations. Every student must return demonstration in airway
management, and every student must be evaluated on adult CPRAED skills. Many ACLS students may NOT have taken the new
BLS course, so the CPR-AED station will involve teaching AND
testing the new skills. The 1:3 ratio was designed to ensure that all
students are tested in a reasonable rotation schedule. You may
run these two stations with a ratio of 1:6 if you choose to do so.
Just be sure that you allow enough time for each student to
perform required skills.
It is suggested that to accommodate the 1:3 ratio during the
airway and CPR-AED stations, BLS instructors be used. Is
this a requirement?
This is NOT a requirement. You certainly may have all ACLS
instructors teaching these stations. The suggestion for the BLS
instructors is just to ease the strain on those TCs who may have
limited ACLS instructors.
Each provider manual comes with a pre-course preparation
checklist that the student brings to the ACLS course, and turns
in. For those who are permitted to library provider manuals,
can this form be reproduced?
This form may be reproduced for those of you that "library" the
provider manuals. This form is also on the instructor network, and
can be downloaded and reproduced for each student. You may
NOT reproduce the CD that accompanies the provider manual.
So, you will want to emphasize to the student that the manual be
returned WITH the CD.
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12.
Science
13.
Science
14.
Structure
In pulseless arrest (V-fib, asystole), do you have to follow
Vasopressin with Epinephrine? I thought that Vasopressin
was such a strong vasopressor that there was no need to
follow it with Epinephrine.
The intent is to ALWAYS give epinephrine as the pressor agent,
and we MAY substitute either the first or second dose of
epinephrine with one 40 unit dose of vasopressin. So, vasopressin
will not be given alone. Indeed, vasopressin is a potent
vasopressor; however it takes about 10 minutes to start working,
and around 20 minutes for peak effect. Therefore, we are to
continue with the epinephrine protocol after giving the dose of
vasopressin. Most of the studies show that there is no real
evidence that one is better than the other, it is just that the
epinephrine works so much faster. There is a study (Guyett FX, in
Resuscitation 2004) that showed an increase in ROSC in patients
with asystole who received combination administration of both
epinephrine and vasopressin.
I have a question that needs clarification in ACLS regarding
the use of Atropine. In the Handbook on page 46, it states
specifically that Atropine 0.6-1mg IV repeated every 5 minutes
is used in ACS. I cannot find this information in the Circulation
publication about the use of Atropine for ACS. I understand
that in the field, if someone had an MI and is bradycardic, that
atropine may be used if the truck only has Epi and Atropine
available, but I am unfamiliar with the dosage recommended.
Can you provide any clarification on the use of Atropine in
ACS, is it just for the bradycardic patient, or is it indicated for
all MIs?
(From the ACLS subcommittee/editors) I reviewed it and the sheet
should say "discuss" atropine, prepare for pacing. The question
we usually receive is "can we give atropine". This is a complicated
question and, in part, is caused by the uncertainty in making a
quick diagnosis in a symptomatic patient. As you know, AV blocks
are the most difficult rhythms for ACLS providers. For example,
Mobitz 2 is often incorrectly diagnosed (by ACLS P) when it is in
fact 2:1 AV block, or apparent Mobitz II but with a narrow QRS. It is
the infranodal Mobitz II with a wide QRS that will not respond to a
vagolytic drug. Other second degree blocks may respond
depending on their site of origin. So, say "discuss" atropine. This
would enable discussion at several levels. Everyone however has
got it right- TCP is the immediate treatment, if available. The
question again when we have said that, as you might guess, is can we try atropine if pacing is not immediately available. Yes,
because what you see may not be infranodal block and pacing can
be painful to the patient if a slight or modest increase in heart rate
can alleviate the symptoms. In the 1997 text and before, Atropine
was listed as a Class IIB for these reasons.
Must the ACLS course be conducted in the order listed in the
instructor manual?
Lessons 1-7 should be presented in order. Included in Lessons 17 are such topics as megacode review, technology review, and the
airway and CPR/AED cases. The remaining lessons build on
these lessons. Students are expected to manage airway and CPR
through all remaining stations. These lessons should be presented
in order, but there is flexibility in the order of the remaining lessons.
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15.
Admin
16.
Science
Can the ACLS Renewal course be taught, even though it is a
new course and providers will not have been through the new
course previously?
Yes. The instructor manual contains the renewal lesson plans, and
the DVD contains the renewal course videos which may be used
now. The guidelines specify that students must hold a current
ACLS card in order to take a renewal course. TCs may make
exceptions to this policy ONLY if there was no course available for
the student, only a short time has lapsed since recommended
renewal date on the card, and the TC feels the student made every
attempt to renew before expiration date on current card.
It appears that there are some inconsistencies in the new
guidelines for ACLS. On pages 22- 23 in the ACLS
Handbook, it states that if patients in the far right column
(Intermediate/Low risk UA), develop intermediate risk criteria,
adjunctive treatment with NTG, b blockers, clopidogrel,
heparin and GP2b3a inhibitors (Box 10) should be started.
But, on pages 39-40 it states that intermediate risk patients get
Heparin, but not the clopidogrel or GP 2b3a inhibitors. Which
is correct?
(From ACLS Subcommittee/editors) First, I always preface
algorithm comments such as these by noting that the algorithms,
especially ACS, are only general guidelines that are applied by
knowledgeable healthcare providers to individual patients. For
example, adjunctive therapy is always qualified e.g. "as
appropriate", "consider". The algorithms are additionally
complicated by the rapidly changing science in ACS. The ACS
2005 guidelines algorithm on page 23 in the handbook is
reproduced from the Guidelines document page IV 90. The
algorithm on page 40 is an expanded portion of the ACS algorithm
imported from the current ACLS Experienced Provider material
dealing with patients with unstable angina and NSTEMI and as
such cannot be directly compared with the ACS algorithm.
So, for example, a patient at low or intermediate risk who develops
positive markers should receive GP IIB/IIIA inhibitor therapy (and
now clopidogrel) if an invasive strategy is selected. A patient at
intermediate risk by ECG criteria can develop intermediate risk
clinical or marker criteria (e.g. "gray zone troponins) and then
receive heparin and clopidogrel but not GP IIB/IIIA inhibitors (as
these are indicated for troponin + patients with an early invasive
strategy). Again, the healthcare provider would need to know the
background material and be proficient in ACS risk stratification to
properly use the algorithm.
In summary, the two algorithms are not inconsistent but depend on
additional data, information and individual application. I would also
emphasize that this information is part of the EXPERIENCED
PROVIDER material and is not intended for the basic provider
course. EP instructors and students should have this additional
expertise. The basic provider is only instructed on the initial
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treatment strategies, ECG stratification and the STEMI pathway.
Even here, additional knowledge is necessary as clopidogrel, for
example, would be considered (and now FDA approved) when a
fibrinolytic conservative approach is planned. But clopidogrel
administration and dose should be deferred to the cardiologist
when an invasive approach (primary or rescue PCI) is planned and
is contraindicated in shock or preshock patients who may require
emergency surgery until coronary anatomy is defined. This is
covered in the new ACS video when the ED physician tells the
nurse, “and give clopidogrel if requested by the cardiologist".
This question is very good because it points out that a simple
algorithm can only be used as a guide and not a recipe for these
complex clinical situations.
17.
Admin
18.
Admin
19.
Science
20.
Admin
What do we do with the testing checklists after the course is
over?
The management of the testing materials has not changed from
that discussed in the administration section of the PAM. You are
required to keep those testing materials of students who are being
remediated, or fail the course. Otherwise, you are only required to
keep the roster with students pass/fail status, exam score, etc. A
TC may choose to keep the testing checklists for a period of time,
but this is not a requirement by AHA.
Are students required to complete the rhythm and
pharmacology self-assessment modules on the CD prior to
attending the course?
The expectation is that ALL students will arrive at the ACLS course
with adequate knowledge in rhythm identification and pharmcology
to be successful in the ACLS course. You’ll want to require the
self-assessment module completion of most of your students.
However, on an individual basis, if you feel confident that a student
knows the material then it is up to the TCC/TCF to make the
decision of whether or not the self-assessment must be completed.
Some defibrillators take longer to charge than others. Since
the goal of CPR is to limit interruptions to less than 10
seconds, what do you do if your defibrillator takes longer than
10 seconds to charge?
You’ll note on the ACLS Course DVD, a student states, “…since
this defibrillator charges in about 3 seconds, we don’t need to
continue CPR”. So, you’ll want to teach your students that if a
defibrillator takes longer than 10 seconds to charge, CPR should
be continued while the defibrillator is charging.
Since many of us library the provider manuals IAW with AHA
policy, are the student CDs reusable also?
Yes. Students may log onto the self-assessment program as many
times as desired. (They will have to alter their name each time, I
believe) Multiple student use works fine, each student will log in
with their own name.
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21.
Structure
There are only 4 scenarios for megacode learning and testing
stations. What do we do when there are more than 4 students
in each station?
You must use the same algorithm sequence with each student.
However, you may change the patient’s name, location of arrest,
etc. in the scenario, as long as you follow the algorithm sequence.
22.
Will there be an EMS version of the ACLS exams?
Not at this time. The written exams are generic and test basic
ACLS knowledge to include rhythm analysis and pharmacology.
The megacode scenarios exist for both pre and in-hospital
students.
Do we have to adhere to the recommended instructor ratios of
1:6, with 1:3 in the airway and CPR/AED stations?
(See question 9 above for ratios in the airway and CPR/AED
stations.) For the remainder of the stations, you may teach the
class with 1:8. Be aware, this increase in ratio will add 80 minutes
to the course for each student over 6 per group. For example:
You’ll add 160 minutes to the course is your ratio is 1:8. The
sample agenda takes 13.5 hours with breaks. Adding 180 minutes
this agenda will take 16.1 hours with breaks.
Has AHA given any recommendations regarding the Joule
energy setting for synchronized cardioversion of perfusing
rhythms such as PSVT, Atrial Flutter, Atrial Fibrillation,
ventricular tachycardia using the new biphasic defibrillators?
I'll refer you to page IV-42 in 2005 Guidelines for CPR and ECC,
section "Supraventricular Tachycardias (Reentry SVT)". In case
you don't have this book, here are the important statements in this
section that address your question: "Cardioversion with biphasic
waveforms is now available, but the optimal doses for
cardioversion with biphasic waveforms have not been established
with certainty. Extrapolation from published experience with
elective cardioversion of atrial fibrillation using rectilinear and
truncated exponential waveforms supports an initial dose of 100
J to 120 J with escalation as needed. Until further evidence
becomes available, this information can be used to extrapolate
biphasic cardioversion to other tachyarrhythmias."
Admin
23.
Structure
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Science
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