American Heart Association
BLS/ACLS/PALS Update
Janet Smith
Forget everything you know
Instructor Goals
Incorporate the previous changes from
2001 & present 2005 revisions
Less number of algorithms
Review Acute Pulmonary Edema,
Hypotension, & Shock combined
algorithms, & Hypothermia algorithm
Stroke algorithm less busy & ACS not
much change
February 24, 2006 - Rollout
First session BLS changes
Second session ACLS & PALS update
Begin new test – revised 2005
Handbook of Emergency Cardiovascular
Care – includes Guidelines CPR/ECC
2005. Nice addition cardiac markers,
Treatment w/ Non-ST-segment
Elevation MI
Instructor Objectives
Fit the course to your needs
Adult learners need positive
reinforcement & deal well with
scenarios
Understand the exam (new & improved)
What is your environment
Student Objectives
Discuss new basic life support
guidelines
Discuss patient assessment & survey
Discuss the use of ACLS drugs
Stations: Determine competency
Discuss the ethical considerations in
resuscitation
What type of course do you need?
Recertification
versus full course
Utilize your study
guides or “cheat
sheets”
Review pretest
written exam
Provide scenarios
ACLS goals
Emphasis on trained & equipped Health
Care Professional (HCP), but only in
conjunction with trained lay rescuer &
reduce time to CPR and shock delivery
& obtain ultimate success
Effective ACLS begins with high-quality
CPR
Drug changes 2005
Most drug doses are the same as those
recommended in 2000 – except use
Atropine 0.5 mg IV for Bradycardia. May
repeat to a total of 3 mg. Epinephrine
or dopamine may be administered while
waiting for a pacemaker
Early intervention &
effective CPR
5 major changes 2005 guidelines
Emphasis on, & recommendations to
improve, delivery of effective chest
compressions
A single compression-to-ventilation ratio
for all single rescuers for all victims
(except newborns)
5 major changes 2005 guidelines
Recommendation that each rescue
breath be given over 1 second & should
produce visible chest rise
A new recommendation that single
shock, followed by immediate CPR, be
used to attempt defibrillation for VF
cardiac arrest. Rhythm checks should
be performed every 2 minutes
5 major changes 2005 guidelines
Endorsement of the 2003 ILCOR
recommendations for use of AEDs in
children 1 to 8 years old (and older);
use a child dose-reduction system if
available
5 major changes continued: AED –
teaching point
Some AED’s have shown to be very
accurate in recognizing pediatric
shockable rhythms & may be used with
regular adult pads
Age Definition
“Child” CPR guidelines apply to victims
1 year to the onset of puberty (about
12 – 14 years old)
Chest compressions are recommended
if the heart rate is less than 60 per
minute with signs of poor perfusion
Effective chest compressions
“push hard & push fast” & chest
compress the chest @ a rate of about
100 per minute (except newborns)
Use 1 or 2 hands with a child (Use
technique that gives best results)
Allow the chest to recoil
Limit interruptions in chest compression
Effective chest compressions
Chest compressions create a small
amount of blood flow to vital organs –
the better the chest compressions
(adequate rate, depth, & allowing for
recoil) the more blood flow is produced
Arterial and central venous pressure waveforms during external closed chest
compression
Idris, A. H. et al. Circulation 1996;94:2324-2336
Copyright ©1996 American Heart Association
Universal Compression-toVentilation – all lone rescuers
One universal compression-toventilation ratio for all lone rescuers:
Single compression to ventilation ration
of 30:2 for single rescuers of victims of
all ages
Teaching point: Simplify CPR & increase
blood flow to the heart
1-Second breaths during all CPR
All breaths should be given over 1
second w/ significant volume to achieve
visible chest rise
Teaching point: During CPR, blood flow
to the lungs is much less than normal,
so the victim needs less ventilation than
normal
Review of BLS guidelines
Determine if you require BLS proof
prior to your course
Basic Life Support – Teaching
concepts
Early bystander CPR can double or
triple the victim’s survival from VF &
Sudden cardiac arrest (SCA)
CPR plus defibrillator within 3 – 5
minutes of collapse can produce
survival rates as high as 49% to 75%
Basic Life Support – Calling for help
Lone Healthcare provider: Sudden
collapse – Phone 911 & get an AED
available & then return to victim to
begin CPR
Unresponsive victim w/ likely drowning
– deliver about 5 cycles (about 2
minutes) of CPR prior to phoning 911 to
get the AED & then return to CPR
Lone Healthcare Provider/CPR
Scenario: Patient unresponsive & nonbreathing the Lone Healthcare provider
will give 2 rescue breaths & then feel a
pulse for no more than 10 seconds. If
no pulse – begin compression
Adult: 30:2
Child: 15:2 (two rescuers)
HCP- Rescue breathing
Deliver rescue breath over 1 second
Rescue breathing for a victim w/pulse
Adult:
10 to 12 breaths/minute
Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than
normal & not as effective as
compressions
Chest compressions – components
Adult: Center chest & @ nipple line & 1
½ to 2 inches using heel of both hands
& lower half of sternum
Child: 1/3 to ½ depth of chest & using
heel of one hand
Rate: 100 on all patients
HCP Chest compressions
Compression during CPR & NO
advanced airway is present:
Deliver cycles of compressions 30:2
Compression during CPR & advanced
airway IS present: No longer use cycles
or pausing for rescue breathing.
Deliver 100 compressions/minute w/ 810 breaths/minute
Lay Rescuers CPR – may include
information with your course
Lay rescuers should immediately begin cycles
of chest compressions after delivering 2
rescue breaths in the unresponsive victim.
Lay rescuers are not taught to assess for
pulse or sings or circulation
Research notes that the lay public has a
difficult time locating the correct place for
palpation
Defibrillation
One shock followed by immediate CPR
beginning w/ chest compressions & 5
cycles or 2 minutes
Monophasic: 360 J
Biphasic: 150 to 200 J
AED Review
Use the model for
teaching & state the
proper order 4-Universal steps:
Power AED
Attach to victim
Analyze rhythm
Deliver shock if
indicated
Use of the AED
Use adult pads on adults
Use AED after 5 cycles of CPR (out of
hospital)
No recommendation for infants < 1
year of age
Children 1 to 8 Use an AED with
pediatric dose-attenuator
Electrical Therapies
Defibrillation involves delivery of current
through the chest & to the heart to
depolarize myocardial cells & eliminate
VF
Monophasic – Deliver current to one
polarity & higher energy level
Biphasic – Lower energy & are more in
current use
Management of Pulseless Arrest
5 cycles or 2 minutes or uninterrupted
CPR & should resume immediately after
deliver 1 shock
Pulse & rhythm are NOT checked after
shock
Management of cardiac arrest
Drug administration is of 2nd importance
NO IV access: Lidocaine, epinephrine,
atropine, narcan, & vasopression are
absorbed via the trachea w/typical dose
2 to 2 ½ times the recommended IV
dose & should dilute with water or NS
Administer drugs during CPR
HCP- Rescue breathing
Deliver rescue breath over 1 second
Rescue breathing for a victim w/pulse
Adult:
10 to 12 breaths/minute
Infant/child: 12 to 20 breaths/minute
Teaching point: Less ventilation than
normal & not as effective as
compressions
Airway management - review &
observe student performance
Demonstrate the BVM
Intubation techniques
Secondary confirmation techniques
Securing the ETT
C-Spine precautions & trauma
5-point chest exam
Airway & C-spine management
Use head tilt-chin lift technique to open
the airway of trauma victim unless
cervical spine injury is suspected
Teaching point: Jaw thrust is a difficult
maneuver & may not be an effective
way to open the airway
Airway station – Use BVM
Anyone providing prehospital care for
adult, children, or infants should be
trained to deliver effective oxygenation
& ventilation
The use of BVM should be considered to
be the primary method of venilatory
support, especially if transport times are
short
Airway Management – Issues to
discuss during the station:
BVM can be as effective as ETT
A study noted 25% intubations were
found to have esophageal/pharyngeal
tube placement
Secondary confirmation involves the use
of end-tidal CO2 detectors
Review tube holder & LMA
Verify correct ETT placement
To reduce the risk of esophageal
misplacement or displacement –
Confirm the placement immediately
after insertion, in the transport vehicle,
& whenever the patient is moved
Acute Coronary Syndromes - goals
Reduce the amount of myocardial
necrosis & preserve LV function
Prevent Major adverse cardiac events
“MACE”
Review new ACS algorithm
Acute Coronary Syndromes
M – O – N – A = Same Rx
Each minute the patient is in VF has
10% decrease of chance of survival
EMS: Monitor, support ABCs, CPR, &
defibrillation
Goal: Door-balloon 90 minutes & Doorneedle 30 minutes
Stroke
Intravenous tPA who meet (NINDS) is
administered by physicians w/ defined
protocol, knowledgeable team, &
institutional commitment
Stroke patients should be admitted to
Stroke Units
Acute Ischemic Stroke
Lower blood sugar (> 200mg/dL)
Orders urgent CT Scan < 25 minutes
Reads CT scan < 45 minutes
If scan shows ICH/SAH call
Neurosurgery
If no hemorrhage, continues protocol
Symptom onset > 3 hours?
Algorithm Review
Treatment of Wide Complex
Tachycardias
ACLS providers should make a
reasonable attempt to distinguish
hemodynamically stable VT from SVT
with aberrancy. History of CAD suggest
ventricular origin.
Obtain a 12-lead (when possible) &
note the QRS yet accuracy requires
experience
Tachycardia with Pulses
Treatment summarized in a single
algorithm – Immediate synchronized
cardioversion for unstable patient
Narrow versus Wide Complex – Control
rate (Diltiazem review)
Treat contributing factors
Unstable
Tachycardia/Cardioversion
Primary & Secondary ABCs
D = Determine Defibrillation
Determine Sedatives & Analgesics
Know rapid infusion of antiarrhythmic
agents
Post cardioversion care
Change unsynchronized mode
Pulseless Arrest VF/VT
5 cycles of CPR prior to defibrillation &
minimize interruptions
Deliver 1 shock (120 or 200j) & resume
CPR immediately
Epinephrine 1mg or vasopressin 40 U
IV/IO to replace 1st dose of Epinephrine
May shock either 200j (unknown
biphasic device) or 360j
Asystole/PEA
Attach monitor/defibrillator
Shockable
Epinephrine & Vasopressin
Consider Atropine 1 mg IV/IO for
asystole or slow PEA rate
Asystole
Advanced airway control
Establish IV – Epinephrine & Atropine
Consider TCP (start @ once)
Consider differential diagnosis
Look for specific causes – The H’s & T’s
with new addition
Pulseless Electrical Activity
Primary & Secondary
Airway control
IV access – Epinephrine 1 mg IVP
Atropine 1 mg IVP (if rate is slow)
6 H’s & 5 T’s
Act upon differential diagnosis when
reasonable
Correct contributing factors
Hypovolemia
Hypoxia
Hydrogen
Hypo/Hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade
Tension pneumo
Thrombosis
(coronary or
pulmonary)
Trauma
Bradycardia
Prepare TCP without delay
Recognize 2nd & 3rd Degree Blocks
Atropine 0.5 mg IV while waiting TCP
(total dose 3mg)
Epinephrine 2 to 10 mcg/min or
Dopamine infusion 2 to 10 mcg
Search contributing factors
Medication Review
Anti-arrhythmic agents
Lidocaine – Alternative to Amiodarone
Adenosine – Slow AV nodal conduction
Procainamide – Supraventricular
arrhythmias & VT 20 mg/min total
17mg/kg
Amiodarone – Is effective with SVT
because it alters conduction through
the accessory pathway
Dobutamine
Indication – Pump problems (CHF,
Pulmonary congestion) SBP 70 to 100
mm Hg & no signs of shock
Precautions – May cause
tachyarrhythmias, fluctuations in blood
pressure, headache, & nausea
2 to 20 mcg/kg/minute
Dopamine
Second-line drug for symptomatic
bradycardia (after atropine)
Use for hypotension SBP , 70 to 100
mm Hg) with signs & symptoms of
shock
Correct hypovolemia with volume
replacement
2 to 20 mcg/kg/minute
Amiodarone
Recurrent VF & recurrent
hemodynamically unstable VT
Requires several time consuming steps
for administration (Glass ampule, etc)
Cardiac arrest: 300 mg IV initial dose &
ONE 150 mg IVP in 3-5 minutes
Recurrent Ventricular arrhythmias: 150
mg IV over 10 minutes
Magnesium
Use in cardiac arrest
only if Torsades de
Pointes is suspected or
Hypomagnesaemia is
present
Life-threatening
digitalis toxicity
1-2 g over 5 -20 min
Diltiazem
Indications: To control ventricular rate
in atrial fibrillation & atrial flutter
Rate control: 15 to 20 mg (0.25 mg/kg)
IV over 2 minutes
Caution: Avoid in patient receiving or
Beta blockers, B/P may drop due to
peripheral vasodilation
Epinephrine
Cardiac arrest: VF, Pulseless VT,
Asystole, PEA
Symptomatic bradycardia: after atropine
& an alternative infusion to dopamine
Dose: IV/IO 1 mg (10 mL of 1:10,000)
every 3-5 minutes
Vasopressin
Indications: Alternative pressor to
epinephrine in treatment of adult shockrefractory VF
Dose: 40 U IV/IO push may replace
either first or second dose of
epinephrine
Fibinolytic Agents (Activase, tPA)
Indications: For AMI in Adults –
ST elevation ( > 1 mm in 2 leads) or new
LBB, in context of S & S of AMI, Time of
onset of symptoms < 12 hours
Indications: For Acute Ischemic Stroke
Focal neurologic deficits, Absence of
Intracerbral or SAH on CT, & nonimproving symptoms < 3 hours onset
“Flat Line Protocol”
The sensitivity or “gain” displayed on
the monitor is one of the important
things to check or confirm true asystole.
Check the POWER (on/off)
Battery supply & lead select (if set to
paddles)
Postresuscitation support
Vasoactive support
Induced hypothermia cooled to 32 to
34C for 12 to 24 hours after ROSC
Ace Inhibitors: Reduces mortality & CHF
with AMI (Angiotensin or ACE is a
chemical that causes the heart to
contract such as Vasotec)
Ethical Considerations
Do not resuscitate
Family presence – Let the family view
all of your care & include in decision
making if possible
Family & staff grief counseling
CISD assistance
The written exam
Review EID & hypopharyngeal
intubation (esophageal)
Hypovolemia easy to treat
Prehospital asystole = drug overdose
Non-contrast CT
Review Retavase & Heparin
CVA v insulin-induced hypoglycemia
The written exam
Cannot be open book or use of notes
Be prepared to deal with the student
that challenges the exam or the
answers
How do you deal with the student who
fails the exam?
What can you expect in the course
Decreased lectures
More “hands on”
Role-play
Scenario review
Group involvement
Questions?