To facilitate remembering the main, reversible causes of cardiac arrest, they can be organized as the Hs and the Ts. Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern. Some leads may show P waves while most leads do not. Atrial contraction rates may exceed bpm. The ventricular rate often range is between to bpm. Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about bpm.

This often translates to a regular ventricular rate of bpm, but may be far less if there is a or conduction.

By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes called F waves. Narrow QRS complex tachycardias include several different tachyarrhythmias. One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below.

Wide complex tachycardias are difficult to distinguish from ventricular tachycardia. Ventricular tachycardia leading to cardiac arrest should be treated using the ventricular tachycardia algorithm. A wide complex tachycardia in a conscious person should be treated using the tachycardia algorithm.

There are four main types of atrioventricular block: first degree, second degree type I, second degree type II, and third degree heart block. Second degree heart block Mobitz type I is also known as the Wenckebach phenomenon. Atrioventricular blocks may be acute or chronic.

Chronic heart block may be treated with pacemaker devices. From the perspective of ACLS assessment and intervention, heart block is important because it can cause hemodynamic instability and can evolve into cardiac arrest.

In ACLS, heart block is often treated as a bradyarrhythmia. The PR interval is a consistent size, but longer or larger than it should be in first degree heart block. Complete dissociation between P waves and the QRS complex. No atrial impulses reach the ventricle. The results of the ECG will be the primary guidance for how the patient with possible cardiac chest pain is managed. The ECG diagnosis of acute coronary syndrome can be complex. In people who are candidates for fibrinolytics, the goal is to ad mister the agent within 3 hours of the onset of symptoms.

ACLS in the hospital will be performed by several providers. These individuals must provide coordinated, organized care. Providers must organize themselves rapidly and efficiently.

Resuscitation demands mutual respect, knowledge sharing, and constructive criticism, after the code. When performing a resuscitation, the Team Leader and Team Members should assort themselves around the patient so they can be maximally effective and have sufficient room to perform their role.

Advanced Cardiac Life Support, or ACLS, is a system of algorithms and best practice recommendations intended to provide the best outcome for patients in cardiopulmonary crisis. ACLS protocols are based on basic and clinical research, patient case studies, clinical studies, and reflect the consensus opinion of experts in the field. Once you become certified in ACLS, the certification is valid for two years. However, we encourage you to regularly login back in to your account to check for updates on resuscitation science advances.

As we learn more about resuscitation science and medicine, physicians and researchers realize what works best and what works fastest in a critical, life-saving situation. Therefore, it is necessary to periodically update life-support techniques and algorithms. If you have previously certified in advanced cardiovascular life support, then you will probably be most interested in what has changed since the latest update in The table below also includes changes proposed since the last AHA manual was published.

These changes will likely appear in future editions of the provider manual. The Chain of Survival is a sequence of steps or links that, when followed to its completion, increases the likelihood that a victim of a life-threatening event will survive. The adult and pediatricchains of survival are slightly different.

The person who is providing BLS is only responsible for the early links, that is, making sure the person is cared for by emergency personnel. The emphasis on early care is to reinforce that time is a critical factor in life supportcare. The standards include the concept of out of hospital care versus in-hospital care. In fact, it is assumed that all people who are pursuing ACLS will be competent in the techniques of BLS—so much so that it is considered a prerequisite to ACLS The first step in any resuscitation is to make sure the rescuers you!

Assuming you and the victim are in a safe location, the next step is to assess whether the patient is responsiv If patient is not responsive, move to BLS survey If patient is responsive, move to ACLS survey.

Shake and Shout! Check for effective breathing for 5 to 10 seconds. In the community, call and send for an AED 3. Circulation Check the carotid pulse for no more than 10 seconds. If no pulse, begin high quality CPR.

Defibrillation If there is a shockable rhythm, pulseless ventricular tachycardia or ventricular fibrillation, provide a shock. If you are alone and witness a victim suddenly collapse: Assume cardiac arrest with a shockable rhythm. If you are alone and find an unresponsive adult: Tailor response to the prospective cause of injury.

Check to see if the victim is responsive. Shake and shout! Is the victim breathing effectively? Does the victim have a pulse in the carotid artery? If you witnessed the victim suddenly collapse, assume cardiac arrest with a shockable rhythm. Follow directions on the AED. After providing a shock, immediately resume CPR. Keep going until EMS arrives or the victim regains circulation. The other provider s stays with the victim. Provide High Quality CPR includes Fast and deep compressions, compressions per minute Two inches deep, complete rebound If you can provide breaths, 2 breaths for 30 comps If you cannot provide breaths, just give chest comps The provider who retrieved the AED applies the AED and follows directions given by the device.

Check for a pulse and cardiac rhythm every two minutes. If a shock is indicated, clear everyone and administer a shock. After providing a shock, immediately resume Team CPR. In Team CPR, the provider giving chest compressions changes every 2 minutes Keep going until EMS arrives or the victim regains spontaneous circulation.

Cardiac Arrest Cardiac arrest is the sudden sensation cessation of blood flow to the tissues in brain the results from a heart that is not pumping effectively.

Ventricular fibrillation is recognized by a disordered waveform, appearing as rapid peaks and valleys as shown in this ECG rhythm strip: Ventricular tachycardia may provide waveform similar to any other tachycardia; however, the biggest difference in cardiac arrest is that the patient will not have a pulse and, consequently, will be unconscious and unresponsive.

Ventricular Fibrillation and Pulseless Ventricular Tachycardia Algorithm Once you have determined that a patient has a shockable rhythm, immediately provide an unsynchronized shock. If you are using biphasic energy, use recommended settings on the device. If you do not know what that setting is, use the highest available setting, to J. If you are using a monophasic energy source, administer J. Resume CPR immediately after a shock. Minimize interruptions of chest compressions.

Provide 2 rescue breaths for each 30 compressions. Lidocaine may replace amiodarone when amiodarone is not available. First dose: Pulseless Electrical Activity and Asystole Pulseless electrical activity or PEA is a cardiac rhythm that does not create a palpable pulse is even though it should.

After 2 min. Remember, chest compressions are a means of artificial circulation, which should deliver the epinephrine to the heart.

Without chest compressions, epinephrine is not likely to be effective. Chest compressions should be continued while epinephrine is administered. Rhythm checks every 2 min. Respiratory Arrest While cardiac arrest is more common in adults than respiratory arrest, there are times when patients will have a pulse but are not breathing or not breathing effectively e. Airway Management In ACLS, the term airway is used to refer both to the pathway between the lungs and the outside world and victim in the devices that help keep that airway open.

Choose the device that extends from the corner of the mouth to the earlobe Clear the mouth or blood or secretions with suction, if possible. Insert the device so that the point is toward the roof of the mouth or parallel to the teeth Do not press the tongue back into the throat Once the device is almost fully inserted, turn it so that the tongue is cupped by the interior curve of the device.

Choose the device that extends from the tip of the nose to the earlobe. Use the largest diameter device that will fit. Lubricate the airway with a water-soluble lubricant Insert the device slowly, straight into the face not toward the brain!

It should feel snug; do not force the device. If it feels stuck, remove it and try the other nostril. Tips on Suctioning Adequate suctioning usually requires negative pressures of — 80 to mmHg. Wallmounted suction can deliver this, but portable devices may not. When suctioning the oropharynx, do not insert the catheter too deeply. Extend the catheter to the maximum safe depth and suction as you withdraw. Therefore sterile technique should be used.

Each suction attempt should be for no longer than 10 seconds. Monitor vital signs during suctioning and stop suctioning immediately if the patient experiences hypoxemia O2 sats 94 has a new arrhythmia, or becomes cyanotic. You can detect spontaneous circulation by feeling a palpable pulse at the carotid artery. The patient is at risk for reentering cardiac arrest at any time.

Therefore, the patient should be moved to an intensive care unit. If so, it should be placed. If not, there may be neurological compromise. Does the person have signs of myocardial infarction by ECG? Move to ACS algorithm. Rapid Differential Diagnosis of Cardiac Arrest Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate or treat the most typical causes of cardiac arrest.

Bradycardia Bradycardia Algorithm. Bradycardia is any heart rate less than 60 bpm. In practice, however, bradycardia is only a concern if it is unusual or abnormal for the patient or causing symptoms. New cases of bradycardia should be evaluated, but most will not require specific treatment. Evaluation of bradycardia includes cardiac and blood oxygen monitoring and a 12 lead ECG if available. Unstable bradycardia i. Unstable bradycardia is first treated with intravenous atropine at a dose of 0.

Additional doses can be given every 3 to 5 min. Pulseless bradycardia is considered PEA. If atropine is unsuccessful in treating symptomatic, unstable bradycardia, consider transcutaneous pacing, dopamine or norepinephrine infusion, or transvenous pacing. An intensive or cardiologist may need to be consulted for these interventions and the patient may need to be moved to the intensive care unit.

Tachycardia Atrial fibrillation is the most common arrhythmia. Tachycardia Algorithm Tachycardia is any heart rate greater than bpm. In practice, however, tachycardia is usually only a concern if it is New cases of tachycardia should be evaluated with cardiac and blood oxygen monitoring and a 12 lead ECG if available. Consider beta-blocker or calcium channel blocker. Wide QRS tachycardia may require antiarrhythmic drugs.

Acute Coronary Syndrome Acute coronary syndrome or ACS is a spectrum of signs and symptoms ranging from angina to myocardial infarction. Cardiac chest pain any new chest discomfort should be evaluated promptly. This includes high degree of suspicion by individuals in the community, prompt rapid action by EMS personnel, assessment in the emergency department, and definitive treatment. People with symptoms of cardiac ischemia should be given oxygen, aspirin if not allergic , nitroglycerin, and possibly morphine.

The patient should be assessed in the ED within 10 min. Draw and send labs e. Give statin if not contraindicated. Obtain chest Xray. Unstable angina is new onset cardiac chest pain without ECG changes, angina that occurs at rest and lasts for more than 20 min. People with unstable angina will not have elevated cardiac markers.

His may include anti-platelet drug s , anticoagulation, a beta-blocker, an ACE inhibitor, a statin, and either PCI or a fibrinolytic. Patients with unstable angina are admitted and monitored for evidence of MI.

While in transit, the EMS team should try to determine the time at which the patient was last normal, which is considered the onset of symptoms. EMS administer oxygen via nasal cannula or face mask, obtain a fingerstick glucose measurement, and alert the stroke center. Within 10 min. They should obtain vital signs and IV access, draw and send labs e. Within 25 min. Within 45 min. Within 60 min.

Through instruction and active participation in case-based scenarios, learners enhance their skills in the differential diagnosis and treatment of pre arrest, arrest and post arrest patients. Our education training material is created maintained by practicing physicians, adhering to American Heart Association ducks AHA guidelines — This ACLS for health care providers let you know about health care law and ethics.

If you notice someone in distress, lying down in a public place, or possibly injured, call out to them. The content contained herein is based on the most recent AHA publications on ACLS and will periodically compare previous and revised recommendations for a comprehensive review.