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PHI LIPP INE H EA HT ASSOC IAT ION , INC.
l' H ILI P PI NR COLL.EGE OF CARD IOLOGY
COU NC IL ON CARDIO Pl JI .M ONA.R Y RESUSCITATIO N
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AIIUia«· of the h1t~:~::~~:~ (ILCOR)

MANUAL
ON

BASIC AND ADVAN CED

CARDIAC LIFE SUPPORT
 Table of Contents

I. Sudden Cardiac Arrest and CPR Awareness .................. ... ........... ................ .. 6

II. The C~ain of Survival ..................... ............ ........ ...... ....... .............................. .. 8

111. Steps in Basic Life Support for Healthcare Providers .. .............. .. .................... g

IV. The New Step by Step Guide in CPR for Lay/Untrained Rescuers ............. .. 12

v. The New Step by Step Guide in CPR for Trained Rescuers .......... .... ........... 12

VI. Algorithm Adult BLS Healthcare Providers .... ................................................ 15

VII . Algorithm Pediatric BLS- Single Rescuer ........ ................. ............................. 16

VIII. Algorithm Pediatric BLS - 2 Rescuer ............................................................ 17

IX. Advanced Cardiac Life Support ........ ........... ................................. ................. 18

X. Simple Approach to ECG Recognition of the Arrhythmias

During the ACLS ............................... ....................... ................................... 19

XI. Defibrillation .... .... .................... ..................... .................................................. 28

XI I. Cardiac Drugs .......................................................................... .. ............... ..... 30

XIII. Pulseless Cardiac Arrest Algorithm "Adult Cardiac Arrest" ............................ 35

XIV. Tachycardia Algorithm ................. ...................... ..................-.......................... 36

XV. Bradycardia Algorithm ............... .................................... .... .......... ................... 37

XVI. Post Cardiac Care Algorithm ............................... ............. ............................. 38

XVII. Acute Coronary Syndromes Algorithm .................................... ....................... 39

XVII 1. First Aid .................................... ..... ............ ......................... ........ ...... .............. 40

XIX. Ethics in Resuscitation ..... .. .............. .............................................................. 45

Manual on Basic and Advanced Cardiac Life Support

5
 SUDDEN CARDIAC ARREST ANO CPR AWARENESS
NO CPA

--
o.iaved Delbrllallon
BACKGROUND c,eftbtlllaliOn
0-:r.t.

Heart diseases are the number 1 killer in our country, accounting for close to 20% of all causes
of death according to the latest Department of Health statistics.

Approximately half of all deaths from cardiovascular disease occur as Sudden Cardiac Arrest.

Sudden cardiac arrest

• can happen at any time, to anyone, anywhere without warning
-
2..,.,

.........
~

• most common mode of death in patients with coronary artery disease

~
• although pre-existing heart disease is a common cause, it may strike people with no

•
history of cardiac disease or cardiac symptoms.
In sudden cardiac arrest or sudden cardiac death, the heart usually goes into a fatal
........
30'1,

arrhythmia called "Ventricular Fibrillation" (VF) wherein it suddenly goes into very irregular
fast ineffective contractions, the heart stops beating, the victim loses consciousness, and
if untreated, dies. • I 8 • 10

Despite advances in Emergency Medical Systems and in the technology of resuscitation, If bystander CPR is not provided, a cardiac arrest victim's chances of survival fall 7 % to 10 %
sudden cardiac arrest remains a major public health problem. It is associated with low survival for every minute of delay until defibrillation.
rate, and major long term severe mental impairment due to delays in cardiopulmonary
resuscitation (CPR) and treatment.

Majority of cardiac arrests occur outside the hospital- at home, in the workplace, in public
institutions.
Almost 70 percent of out-of-hospital cardiac arrests occur at home and are
witnessed by a family member and approximately 50% are unwitnessed.
Only 10.8% of Out-of Hospital Cardiac Arrest (OHCA) who have received CPR from
(EMS) survive to hospital discharge .
In-hospital cardiac arrest (/HCA) has a better outcome, with 22.3% to 25.5% of
adults surviving to discharge

Unfortunately, approximately less than 10 percent of sudden cardiac arrest victims survive
because majority of those witnessing the arrest are people who do not know how to perform
CPR.

CPR or cardiopulmonary resuscitation is an emergency procedure used when someone's heart

stops beating.
• it is a simple inexpensive procedure that can be learned by anyone, and consists of a
manual technique using repetitive pressing to the chest and breathing into the person 's
airways that keeps enough oxygen and blood flowing to the brain
• requires no special medical skills and training is available for the ordinary person
nationwide.
• if eff~ctively done immediately after cardiac arrest, ii can double a victim's chance of
survival.

Early CPR_and defibrillation within the first 3-5 minutes after collapse plus early advanced care
can result in high (greater th 50 . '
fibrillation (VF). an percent) long-term survival rates for witnessed ventricular

7
6 Manual on Basic and Advanced Cardiac Life Support
Manual on Basic and Advanced Cardiac Life Support
 THE CHAIN OF SURVIVAL STEPS IN BASIC LIFE SUPPORT FOR HEALTHCARE PROVIDERS

IF YOU SEE A PERSON DROP DEAD, OR LOSE CONSCIOUSNESS,

WITH PRESUMED SUDDEN CARDIAC ARREST,

~(«~ ~
1 SAFETY.
CHEC« AREA
-·..----·-
---.,-~
SWw)'llle- NON-RESPONSIVE,

~=---
NO NORMAL BREATHING

~
__.. ~ :
~
-~~ ....:=.. ........,_
iiw...
'=':
Ba ➔
------
~ ....._.,,.._
~
..-.._ _
....;;;;:;:..
__,,
.......__

••JRC>
2~
CHECK __-,. -
....__ - - •m-Ol(P• _,_.._,.
....._, __....
881 I Dlllbrlllatorr
This Is a conoept which aims to improve the outcome fo r victims o f card10pvtmon11-ry 11rr11s1 ,.., I ~ ..-, n, -AC11VAJIIJIIN
AEDI
3 ~
ton6i+ ~..
,..,_,,,. ~ . _,,NM;V_DICAL
_ ._ ~

It ,rivolves a senes of e vents which are interconnected lo each other hke the link s of 9 chall'I 6.eap.c,Senona. - - ,r,i .~. ;
I ~ -- \,~.Y. \\...,1<
The 5 hnks In the Chain of Survival (Top figure) are described speofic:afly as ( 1) eat1y IKOllU.
(2) earty CPR (3) earty defibrillation. and (4) early A CLS ., (5) lnlograled pos1~rdt1>c: 1l-1TVSI care k;' -- - - -- -PULSE-CHEC~ ,,. - - - - - --;,~;,,-,.,;::,.;,,
Based on the new 2015 AHA CPRIECC Guidelines, the y ha ve recommonded s.p.,..,. CMln, - I II I but no - - - ~ - - II
lnathlng
o f Survw al th at identify the differen t pathways of care to r pallents ,'llho OXJ>Etneoood Cart,&OC • Palpate for Carotid Pulse I I I
Arrest in the Hospital (IHCA) and Oul of Hospital (OHCA ) settings . (Len and nght figuras) wlltlSl 10 seconds ,~ ~ " Do Mouth to Mouth
Tile care tor all posl cardiac arrest patients (IHCA and OHCA) all conv~e ,n t.no nosp,tat ICU • (at the aame Ume I I Breathing I
settmg Patients who had an OHCA depend on their community for supp()l1 where Lay r&SCUers CHECKFOR I I
musl recognize the arrest, call tor help and initia te CPR and apply Pubhc AED pmlocols vnlJI BREATHING) I • Give one breeth flWKY
I 5-8 IIICS (llboli 12
EMS arrives and patient ultimately transferred to Hospital The palienrs who had IHCA depend • For trelned hNlthcarw I I bnlathalmln)
on a system of appropriate surveillance (e.g . rapid response or earty warning system) 10 prevent p,oYlders only I i==-----___J • Rechedc pulse flWKY 2 I
cardiac arrest All IHCA patients depend on a smooth multidlsciplmary In1eractJOn among the
department services and allied health providers including physicians. nurses. respiratory
therapists and others.
,~'/. . ' - - - - - - - ~~- - - -~\\,'/.,...~'
- - - - - - - - - - - - - \t,..._y
The First l..Jnk- Early Access
• A well-informed person - key in the early access link. I ,. MOUTH TO MOUTH BREATHING and ... ,
PULSE CHECK I
Nttlf determkllng unconeclou8MU.
Recognition of signs of heart attack and respiratory failure
Call for help immediately if needed I
I
C-A-B
• Actrvate the Emergency Medical System Do cheat
I C. COMPRESSION
• For trained healthcare providers only
• As short and quick as possible CompNHlona llnt
Second l..lnk - Early CPR I
• Pulse checJc not more than 10 seconds
I
A. N#NIAY eo.a the vlc1lm have 1n
• Lrfe saving technrque for cardiac & respiratory arrest open airway (alt paauge
Chest compressions +/- Rescue breathing • If unsure, proceed directly to CHEST
that allowS the vlc1lm to
1 COMPRESSIONS!
1

; breathe)?
Wt,y rs early CPR rmportanl? \
B. BREATIING la the vlc1lm brHthlng? ~
• CPR rs the best tre t f · .
a ment or cardrac arrest until the arrival of Advanced Life Suppo rt.
• prevents VF from deteriorating to asystole
' - - - - - - - - - - - - -.~
v~_.:1. \\~;
may increase the chance of defibrillation
• Sigruficantly rmproves survival

~ 9
Manual on Basic and Advanced Cardiac Life Support Manual on Basic a nd Advanced Ca rd iac Life Support
 Chest Compressions
.......
B - BREATHING Olv9 2one ••cond
C- CoMPRESSION
(to assist CntcuunON)
Aftw det91mlnl119 unc:onaclouanea mi~~ ..._way

.......
0pen.,,,.._
Plnd,,-llg

_
1111 tW,1--
Md calling for help,
in.i.--..
proceed Immediately to do

CoMPRESSIONSI,•~
CHEST
\..,_,..,
_._ -

· yourh.andonthe-
Placethelleefol

handontopofthe
nrst wtth your
L/

center of the victim's

chest. Put your other

fl_r>!!US Interlaced.
/ ] ~ ~
Hand Location

..._
~

, ,!i·
""'
·
1
_..._

~
,.-,.t'},,,
·

~~
• ~Ill
\ \~ .;/.
'
-
culilldeolwan

G M2Ubl'ellh
(1a.:Jin.i)
OIINrwcharlee&
flll: ...... & .... for
-.v•
~
~
\~
Repeat cycles of 30 compressions ~
& 2 breaths \~

Give 30Comp1~S::..- 2 - 2.o -

..,, PULSE CHECK CONTINUE CPR
• RECHECK PULSE EVERY 2 MINUTES
• (30 aio,µ_IS 5/Qild !Ml 15-18 sec) (equivalent to 5 cycles CPR)
,........ .,...
c_,.,....._ ••, UNTL...
,....u...,..,...,fl. .......,..._.~.,.
,,_
• Count aloud -1. 2. 3, 4,
• Very brief pulse check - should take
less than 10 seconds (at the same time •HELP ARRIVES.
...... .. ....
..., ........ttlll
~,,.,.,..,
IUNltaetwftlildtNCataU 4,a,7,U,10,11,12. 1~. 1◄ ,15, 1e. 17,18, 19,
20,21.22,23,2◄,25,26,27,28,29, - check for normal breathing) (Erw'gelrcySeMcla,Arnbulancle,Doctor.AED)

~--N.4-.. .
_, ONEr • In case there is any doubt about the
Giw. Chest Compressions at 100 - 120 i-- minute
.--upl!OM presence or absence of pulse,
c:o.,,.e.e1 • .-o1.-1.,,.,.....(5.f-
C..-31 ..... .....,
l,ao,, the chest to rwtum
.,_
to Its normal poslHon <®> ·----~.\ \\.~ I
CONTINUE CHEST COMPRESSIONS
• For trained healthcare providers only
~
'~
•PERSON IS REVIVED.

~
Open the Nrway:
A - AIRWAY u.. the bud 111ttc:hm Head Tilt Chin Lift Maneuver If the victim Is bNathlng MEMORIZE THE STEPS!

~ ~,I
llftmelhod SU-..y the scene.
Check .-ponsivenesa -hey hey ant )'OU ok?
• Pllce one hind on Call ror ,.,._,, ~ EMS
thtw:llm'Sfor"-1 . ~~~~~.~ il.'t'sr---'°'
C - Chest Comoressioos: 30 x;. 10Cl.mn 2 inchN deeo·

•c---30•
• Pllce llngln d GIiier push hald and lase. Coen 1-2-3-4-... 26-27-28-29-ancr'I!
hind..- the bony • A. Auway: hNd tit chin 11ft
part d loMr jaw THI! RECOVERY POSIT10N • B - B r ~: 2 brNth5 (1 sec:oncl,tJreath)
,_cNn
Melntllln open ..-ya ,-111on 111e v1ct1m

-'5-
~~
7
:~~.ia r--vantiallon. Count 1-2-3-
• Tit~ - lltjaw- • T h a ~ l l d l l ... . . . , _ . • !Quick cll<!Ck pulse ,,.,e,ry 2 mons - -oximately 5 cycles!
-Mlld aa,g reepnllonalhol.lldbepla0edlnh~ • If no b<eath,ng_ but v.ith culse. do artificial b<eathina: give 1
poelllon If nooeMQel nurna I I ~ b<eath evwy 5 secon<IL Cou,t 1-2-3-1-blow, ... up lo l-2-3-

.~
~~ 12-blow. (12 cyde5)
• Pleoemenl In . . poelllon - - - '1 ~ ...
f:~
•t 'A "
,~~ {~ ' lldllonlohllorhlrlldelo.,_~.,_ . u~
- eMs • n~s (AEO. doctor, ambulo~)
airway. \~, - Pa!tenlhM~orMa \ $.. _ ~

'\O 11
~
Manual on Basic and Advanced Cardiac Life Support
Manual on Basic and Advanced Cardiac Life Support
 THE NEW STEP BY STEP GUIDE IN CPR FOR LAY I UNTRAINED RESCUERS:
Basic Life Support Sequence
IF A PATIENTNICTIM SUDDENLY DROPS UNCONSCIOUS OR IS SEEN UNCONSCIOUS:
Step Lay Rescuer Not Trained Lay Rescuer Trained Healthcare Provider
1. Survey the scene to see if it's safe to do CPR. 1 Ensure scene safety. Ensure scene safety. Ensure scene safety.
2. Check victim's unresponsiveness. If unresponsive, roll victim on his/her back.
2 Check for response. Check for response. Check for response.
3_ Call for help; activate the emergency medical services; call for an ambulance/doctor.
4. Start chest compressions. Place the heel of your hand on the center of the victim's ch t Shout for nearby help. Shout for nearby help and
Put your other hand on top of the first with your fingers interlaced. es · Phone or ask someone to activate the emergency Shout for nearby help/
5. Press down and compress the chest at least 2 to 2.4 inches in adults. Allow complete . response system (9-1-1 , activate the resuscitation
phone 9-1 -1 (the phone
after each compression. Compress continuously with both hands at a rate of 100 _120;eco,I emergency response). If team; can activate the
3 or caller with the phone
someone responds, ensure resuscitation team at this
minute (Compress to the tune of Bee Gee's song "Stayin' Alive.") remains at the victim's
that the phone is at the time or after checking
6. For lay or untrained rescuers, continue this Hands Only CPR - do continuous chest side, with the phone on
side of the victim if at all breathing and pulse.
compressions until help arrives, an automated external defibrillator (AED) is available th speaker).
possible.
emergency personnel arrives, or the victim is revived back to life. or e
Check for no breathing
or only gasping and
check pulse (ideally
THE NEW STEP BY STEP GUIDE IN CPR FOR TRAINED RESCUERS: simultaneously). Activation
and retrieval of the AED/
IF A PATIENTNICTIM SUDDENLY DROPS UNCONSCIOUS OR IS SEEN UNCONSCIOUS: emergency equipment by
Check for no breathing or
Follow the dispatcher's either the lone healthcare
4 only gasping; if none, begin
1. Survey the scene to see if it's safe to do CPR. instructions. provider or by the second
CPR with compressions.
2. Check victim's unresponsiveness. If unresponsive, roll victim on his/her back. person sent by the rescuer
3. Call for help; activate the emergency medical services; call for an ambulance/doctor. must occur no later than
immediately after the check
4. Start chest compressions. Place the heel of your hand on the center of the victim's chest.
for no normal breathing
Put your other hand on top of the first with your fingers interlaced.
and no pulse identifies
5. Press down and compress the chest at least 2 to 2.4 inches in adults. Allow complete recoil cardiac arrest.
after each compression. Compress 30 times with both hands at a rate of 100 - 120/minute or
more (Compress to the tune of Bee Gee's song "Stayin' Alive."). Look for no breathing Answer the dispatcher's Immediately begin
5 or only gasping, at the questions, and follow the CPR, and use the AED/
6. After 30 compressions, you can now open the airway with a head tilt and chin lift.
direction of the dispatcher. dispatcher's instructions. defibrillator when available.
7. Pinch to close the nose of the victim. Take a normal breath, cover the victim's mouth with
yours to create an airtight seal, and then give two, one-second breaths as you watch the When the second rescuer
Send the second person to
chest rise. Follow the dispatcher's arrives, provide 2-person
8 6 retrieve an AED, if one is
instructions. CPR and use AED/
- Co_ ntinue cycles of compressions and breaths - 30 compressions, two breaths - until help available.
defibrillator.
arrives, until an automated external defibrillator (AED) is available, until the victim is revived
back to life, or until the emergency medical personnel takes over. • AED indicates automated external defibrillator; and CPR, cardiopulmonary resuscitation.

If the rescuer is unsure or t fid .

I
does not have a barrier
. no
de con
· f ent or hesitant about doing mouth to mouth breathing, or
Hands Only CPR· th
h vice or mou to mouth, he may just do compression only, or
nd st
hands compressing~~:s~he~d ~ fa in the center of the chest by pres.s ing down with two
2
o 2.4 inches at a rate of 100 - 120 per minute.
r

12
I
Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 13
 Infants
BLS Healthcare Provider
Adults and Children Adult Cardiac Arrest Algorlthm -2015 Update
(Age less than 1 Year
(Age 1 Year to Puberty)

-----
Component Adolescents
• &- Excluding Newbornsj
( Verify scene safety. )
Make sure the envIronment Is safe I0 r fescuers and vIc Ims
Scene Safely
Recognition of
Check for responsiveness i
Victim is unresponsive.
No breathing or only gasping (ie, no normal brathing)
cardiac arTest No definite pulse felt within 10 seconds Shout for nearby help.
Activate emergency response system
(Breathing and pulse check can be performed simultaneously in less than 10 secondc) 'lia mobile device (if appropriate).
If you are alone with no Witnessed collapse Get AED and emergency equipment
Activation of /or send someone to do so). Provide rescue breathing:
mobile phone. leave the victim Follow steps for adults and adolescents on the left 1 breath every ~ seconds. or
emergency
to activate the emergency
I
response system about 10-12 breaths/min.
response system and get the Unwitnessed collapse Normal No normal • Activate emergency response
AED before beginning CPR Give 2 minutes of CPR breathing, Look for no breathing br9athlng, system (d not ai'Bady done)
Monitor until has pUIH or only gasping .-id check has puls e after 2 minutes.
emergency pulse (simultaneously). • Continue rescue breathing;
Otherwise, send someone and Leave the victim to activate the emergency response system and
responders arrive. Is pulse definitely felt check pulse about every
begin CPR immediately; use the get theAED 2 minutes. If no pulse, begin
within 1O seconds?
AED as soon as ii is available Return to the child or infant and resume CPR; CPR (go to "CPR" box).
use the AED as soon as it is available • If possible opioid Olle<dose,
No br9athin9 adminster naloxone if
Compression- 1 or 2 rescuers 1rescuer available , - protocol.
or only gasping,
ventilation ratio 30:2 30:2 no puis.
without advanced
airway 2 or more rescuers
15:2
Compression- Continuous compressions at a rate of 100-120/min By this time in all scenarios. eme,yency
ventilation ratio response system or backup is activated,
'
with advanced Give 1 breath every 6 seconds (10 breaths/min) and AED and emergency equipment are
airway retrieved or someone is retrieving them.
CPA
Compression rate 100-120/min Begin cycles of
Compression At least 2 inches (5 cm)' 30 compressions and 2 breaths.
At least one third AP diameter I At least one third AP diameter Use AEO as soon as it is available-
depth
of chest of chest
About 2 inches (5 cm) About 1½ inches (4 cm)
Hind placement 2 hands on the lower half of the 2 hands or 1 hand (optional for 1 rescuer AED arrives.
breastbone (sternum) very small child) on the lower 2 fingers in lhe center of the
half of the breastbone (sternum) chest, just below the nipple line
Check rhythm.
2 or more rescuers Shockable rhythm?
2 thumb-encircling hands In the
center of the chest, Just below ""··
ehooka.ble
Chest recoil Allow full recoil of ch ft the nipple line
esI a er each compress· . d Give 1 shock. Resume CPR Resume CPR immediately for
Minimizing ion, o not lean on the chest after each compression
Interruptions

'Compression depth should be

Ablxeviatioos:
limit interruption · h

no fllO<e than 2.4 inche

AEO, au1omate<1 external defibnllat
or. AP, anteroposterior CPR
s (S cm).
s in c est compressions to less than 10 seconds
I immediately for about 2 minutes
(until prompted by A ED to allow
rhythm c heck).
Continue until ALS providers take
about 2 minutes (until prompted
by AED to allow rhythm check).
Continue until ALS providers take
over or victim starts to move.
over or victim starts to move,
·
. . cardiopulmonary resuscitation.
O 2015 Amt1ic.ln He..vt Association

14

- Manual on Basic nd
a Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 15
 8 LS. H~althcare Provider
d" A~st Algorithm for the Single Rescuer-2015 Update
Ped1atnc Car 1ac "~

Verify scene safety. BLS Healthcare Provider

Victim is unresponsive.
Shout for nearby help.
.._
(
______
Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers-2015 Update

Verify scene safety. )

Aclivale emergency response system

via mobile device Qf appropriate).
J
Provide rescue breathing: Victim is unresponsive.
1 breath eve,y 3-5 seconds, or Shout for nearby help.
about 12-20 breaths/min.
Activate emergency l
Normal
J No normal • Add compressions if pulse
First rescuer remams wrth victim .
Second rescuer activates emergency
response system ' / breathing, Look for no breathing breathing, remains ,;60/min with signs response system and retrieves AED
Qf not already done). has pulse or only gasping and check has pulse of poor pe,fusion. and emergency equipment.
Return to victim pulse (simultaneously). Provid e rescue breathing:
• Activate emergency response
and monitor untR
emergency
respondets ...,;1111,
Is pulse definitely felt
within 1o seconds?
system (If not already done)
after 2 minutes.
• Continue rescue breathing;
check pulse about eve,y
I Normal
breathing, Look for no breathing
No n ormal
breathing,
1 breath every 3-5 seconds. or
about 12-20 breaths/m in.
• Add compressions if pulse
remains ,;60/m in with signs
No breathing
or only gasping,
2 minutes. If no pulse, begin
CPA (go to "CPR" box).
Monitor until
emergency
resp_onders arrive.
has pulse or only gasping and check
pulse (simultaneously).
Is pulse definitely felt
has p u l se
'I-- - - - • 1 of poor perfusion.
Activate emergency response
system (If not already done)
no pulse
within 10 seconds? after 2 m inutes.
• Continue rescue breathing;
Activate emergency response check pulse about every
Witnessed sudden Vos
system Qt not already done), No breathing 2 minutes. If no pulse. begin
collapse? or only gasping, CPA (go to "CPR" box).
and retrieve AED/defibrillator.
no pulse
Ho
CPA
CPR
First rescuer begins C PA with
1 rescuer: Begin cycles of
30:2 ratio (compressions to breaths).
30 compressions and 2 breaths.
When second rescuer returns. use
(Use 15:2 ratio if second rescuer arrives.)
15:2 ratio (compressions to breaths).
Use AED as soon as it is available.
Use N=D as saon as It is allllilab/e.

After about 2 minutes, if still alone, activate

emergency response system and retrieve AED AED analyzes rhythm.
(d not already done). Shockable rhythm?
Yes, No,
shockable nonsbockahle
AED analyzes rhythm. I
•hockable
v••, I Shockab1 rhyth
Ho,
r Give 1 shock. Resume CPR
immediately for about 2 minutes
(until prompted by AED to allow
Resume CPR immediately for
about 2 minutes (until prompted
by AED to allow rhythm check).
,-:-:------L _
. Give 1 •hock. Resume CPA
nonahookabla I
i
rhythm check). Continue until ALS providers take
,- : - - -- " -- - -- - - - Continue until ALS providers take over or victim starts t o move.
,mmadiately for •bout 2 minutes Resume CPR immediately for over or victim starts to move.
(unM prompted by AED to allow about 2 minutes (until prompted
C . rhythm check). by AED to allow rhythm check)
::: ~ti! AI..S providers take Continue until AI.S providers tak~
0201 5 A.Jntuican Ha.art Association

Vletim •tarts to move. \. over or victim starts to move,

C 2015hnenc.nHean k ~ tion

16
Manual on Basic
and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support
17
 ADVANCED CARDIAC LIFE SUPPORT
SIMPLE APPROACH TO ECG RECOGNITION OF THE ARRHYTHMIAS DURING ACLS
ACLS includes
Steps In the Systematic ECG Interpretation of the ACLS Rhythms
Regularity? Is it regular or irregular?
1. Basic Life Support (BLS)
Rate? Is it fast or slow or normal?
2. The use of adjunctive equipment and special techniques for establishing and maintainin
· Iat·ion . g Rhythm? Is it Sinus?
effective ventilation and cIrcu
Check the waveforms. Is there a P wave followed by a QRST?
3. Electrocardiographic (ECG) monitoring and arrhythmia recognition .
Measure the Intervals: PR , QRS , QT
4. Establishment and maintenance of intravenous (IV) access.
Is there a Rhythm abnormality?
5. Therapies for emergency treatment of patients with cardiac or respiratory arrests
Correlate clinically.
(including stabilization in the post arrest phase) and ,
6. Treatment for patients with suspected Acute Myocardial Infarction and stroke.
SINUS RHYTHM
ACLS includes the ability to perform these skills, and the knowledge , training , and t There is a P wave , followed by a QRS complex at a regular rhythm and rate of 60-100
judgment about when and how to use them . bpm

The Algorithm Approach to Emergency Cardiac Care (ECC)

The following clinical recommendations apply to all treatment algorithms.

- - SR
• First, treat the patient not the monitor.

• Algorithms for cardiac arrest presume that the condition under discussion continually SINUS BRADYCARDIA _
persists, that the patient remains in cardiac arrest, and that CPR is always performed . There is a regular p wave followed by a regularly occurring QRST, but the rate Is < 60
bpm
• Apply different interventions whenever appropriate indications exist.

• Adequate airway, ventilation , oxygenation , chest compressions , and defibrillation are

•
more important than administration of medications and take precedence over initiating
an intravenous line or injecting pharmacologic agents.
~
Several medications (epinephrine, lidocaine, and atropine) can be administered via the
/endotracheal tube , but the dose must biiY2 - 2.5 times the intravenous dose. (Use a
catheter or suction tip which should be passed beyond the tip of the endotracheal tube .
ltwt IRM 11 U444-L
'.. f • ii

Dilute w ith water instead of NSS for endotracheal route . ) SINUS TACHYCARDIA . . >
There is a regular p wave followed by a regularly occumng QRST, but the rate 1s
100 bpm
• With a few exceptions , intravenous medications should always be administered rapidly,
in boius method .

• After each intravenous medication , give a 20-30 ml bolus of intravenous fluid a nd

immediately elevate the extremity. This will enhance delivery of drugs to the central
circulation , which may take 1-2 minutes .

• Last, treat the patient, not the monitor.

19
Manual on Basic and Advanced Cardiac Life Support
18 Manual on Basic and Advanced Cardiac Life Support
SLOWACLS RHYTHM$• BRADYCABPIA SECOND DEGREE AV BLOCK MOBITZ I (WENCKEBACH)
• Sinus bradycardia Progressive lengthening of the PR interval followed by intermittent dropped beats (a P
, Sinus pause wave NOT followed by a ORS)
• Escape rhythms:
► Junctional rhythm
► ldioventricular rhythm
• Heart blocks
► 1" degree AV block ~
bt-dl,~1¥.IJ'l~~~,~1£.l',.'),41
1-~
-• ~ ·w,~"' ..
► 2nd degree AV block ,~I
·::i :. iii !:, · ! " ! . r, ! I ,,. 1- - . .,
' J , I ' IA '
1:7. I .
J .. I j
i ·; " 2nd deg AV block Mobitz I
Mobitz I or Wenckebach
Mobitz II SECOND DEGREE AV BLOCK MOBITZ II
► 3"' degree or complete AV block Fixed PR interval (NO progressive lengthening) w/ intermittent dropped beats

■I lIl·ltttlM11~Im
1
SINUS PAUSE (SINUS ARREST)
, There is a P wave followed by a ORST, but at some point there is irregularity and
slowing of the heart rate , and the ECG shows no P wave and no ORS. In other words
it simply PAUSED! ' ➔

Important point: 2nd degree AV block is ALWAYS IRREGULAR and usually presents with
GROUP BEATING.

2:1 AV BLOCK
JUNCTIONAL RHYTHM Y\ · 2 P waves for every 1 ORS complex (every other P wave is blocked )
• This is an escape rhythm; Impulses come from th~ode
• Usually a regular slo~art rate , < 60 bpm (rate is usually between 40-50 bpm). ORS
are.D.fil[QYJ. There ar no iscernible P waves (actually the P waves are inverted or
buried w/in ORS or foli o s the ORS)

HIGH GRADE AV BLOCK

'-----'--L...-L..--L__J_j___,_-1._L-..1-....L-1___.:.L.w.illllli!lJ Junctional Atrio-ventricular conduction ratio is 3: 1 or higher
IDIOVENTRICULAR RHYTHM 3:1, 4:1, 5:1 AV block and anything higher is called High Grade AV block

I~
•
•
Another escape rhythm ; Impulse i~ i n origin
R_egular slow heart rate , < 40 bpm (usually between 20-40 bpm), wide ORS and no
~
-h+t - ·•l- - - -
d1scern1ble P waves; ORS duration > 0.1O sec
. ·t ·! -~~! . .,
-h I ~ "~"'""'eAVblock
-· -· ·- . J(
' - ' - - ' - = --'---_;__ _..L-1...::::i,~ L...L-1._ L_L1.:.!:lJJJ.ltH,bJl ldioventricular
,l THIRD DEGREE AV BLOCK OR COMPLETE HEART BLOCK
FIRST DEGREE AV BLOCK
No recognizable consistent or meaningful relationsh ip between atrial and ventricular
There is_a normal regular P wave , followed by a regular ORS complex , but the PR activity (there is ATRIO-VENTRICULAR DISSOCIATION)
interval 1s > 0.20 sec (>5 small squares in the ECG strip)
There are regularly occurring P waves , there are regularly occurring ORS complexes ,

mllla,,.degAVblock
but they are not related to each other (in other words , they are dissociated)
• ~orphology is constant; ORS rate constant (15-60 beats/min); atrial rate is usually
~ h a n ventricular rate , but the atrial and ventricular rhythms are independent of
each other; ventricular rhythm is maintained by a junctional or idioventricular escape
rhythm or a ventricular pacemaker

20 Manual on Basic and Advanced Cardiac Life Support 21

Manual on Basic and Advanced Cardiac Life Support
 SUPRAVENTRICULAR TACHYCARDIA
Regular narrow ORS complex tachycardia, usually with sudden onset and termination,
with a rate of 150-250 beats/min
No discernible P waves
P waves are generally buried in the ORS complex. Often, P wave is seen just
prior to or just after the end of the ORS and causes a subtle alteration in the
CHB
ORS complex that results in a pseudo-S or pseudo-r
(upper arrows point to P waves; lower arrows point to ORS complexes)

·'
1-rf:;r-<-- -11 . +· +- - -~+--~- -
l I

,
I f
I
I' ' .
'ii
-i--
.- .
\
• .
IL I\ \ j '!- •• i - ......

1- ~ ' ➔ " 1-+ ~ , J --t 1- _,.... ·- ,_ •. -

i.
' \

I- . i ( I ! 7 -I j
,;,,. ::: -·~ •
,, i,-
-· -
,....~ CHB SVT
Complete heart block with a ventricular escape rhythm

FAST ACLS RHYTHMS - TACHYCARDIA

Sinus tachycardia ATRIAL FIBRILLATION
Supraventricular tachycardia Irregularly irregular narrow complex tachycardia with no discernible P waves
Atrial fibrillation Chaotic irregular atrial fibrillatory waves
Atrial flutter
Multifocal atrial tachycardia
Ventricular tachycardia

TACHYCARDIA - divided into Narrow complex and Wide complex Tachycardia

AF

µ 1
N .f"
lJ,J~I I~ ~
~--------------' == ..- - .. •--- ..--.
Narrow QRS Complex Tachycardia
(QRS duration < 0.12 secs)
. - -·
- ~·- '.. - -·'
Wide QRS Complex Tachycardia
(QRS duration ~0.1 2 secs )
. -::'. ~ -=~ ~~
·- :- ~
• ~h : ~
.-
-';_~L '- '. ,'. :-_ .
!c= - C"' ; •
;p~ -:-:!:. ~=-- ~;r~· F- '. . ~-
!~ ! 1~ 1 :~ ,I .
....,..iULlC:,-.lt..-J'-...,..J ;
. . ; : . t :
I

1 I . ;·
C :
.,
;
..

·-r :..
~ ~
•

r ~.
.

AF

ATRIAL FLUTTER
TACHYCARDIA Narrow complex tachycardia, regularity and rate depends on the degree of AV
I
1 1 • e-~:~n= 220-350/min (Pas flutter w a v e s ) ~ r response usually 1fill:1.fil)
NarrowQRS WldeQRS
I I Look closely for your beautiful sawtooth flutter waves
+ + + +
Regular rhythm Grouly Irregular Regular rhythm Irregular Rhythm
Rhythm
+ + + +

MAT
f7 AF
VT
Mwtth
lbtmncy
PrNxcltld AF
AF with aberrlncy
Tollldt

l l i
Slnu, Paroay11111I SVT
TKh Flutltr
(1Nlllrlnll

22 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 23
MULTIFOCAL ATRIA.L TACHYCARDIA PULSELESS VENTRICULAR TACHYCARDIA
• Impulses origlnate Irregularly and rapidly at different point~ in the atrium Rapid, bizarre, wide QRS complexes firing In succession at a rate of >100 bpm , but
Irregularly irregular narrow complex tachycardia with varying P wave , PR, PP and RR the patient has NO PULSE and NO BLOOD PRESSURE . Patient Is also In CARDIAC
intervals, and 3 or more different P wave morphologies ARRESTI Treat as VF!

JJJlU,,iJJL I-

L_- - - - - - - - - - - - - ' - - - - - - - ~ M~
f I

VENTRICULAR TACHYCARDIA
At least 3 consecutive PVC's
Rapid, bizarre, wide QRS complexes firing in succession at a rate of >100 bpm; usually PULSELESS ELECTRICAL ACTIVITY
no discernible P wave ECG shows an organized electrical activity (NOT VF or pulseless VT); either a narrow
L.' QRS or wide QRS rhythm ; fast (>100 beats/min) or slow (<60 beats/min).

There is organized cardiac electrical impulses but no effective myocardial contraction

is produced (also known as "electromechanical dissociation"); patient has ZERO blood
pressure and ZERO heart rate, in other words, PATIENT IS IN CARDIAC ARREST!

VT

ARREST RHYTHMS - there are only 4: PEA

Asystole ECG of a patient with PEA- may show either bradycardia (commonly idioventricular or
Pulseless electrical activity junctional) or tachycardia (other than VT) but the patient has NO pulse and is in cardiac arrest.
Ventricular fibrillation
Pulseless VT

ASYSTOLE MISCELLANEOUS ACLS RHYTHMS

The easiest rhythm to identify! There is no discernible electrical activity. ECG shows a
WOLFF PARKINSON WHITE (WPW) ECG (PREE ION)
flat line. The patient is in CARDIAC ARREST!
ECG shows short PR interval (<0.12 secs delta ve (upward slurring of the QRS
complexes as indicated by arrows) and wide S complexes. These patients have
an extra accessory pathway or bypass tract that may conduct impulses rapidly. They
may present with supraventricular tachycardia (usual narrow QRS tachycardia) or with
preexcited rapid atrial fibrillation which presents as irregular wide complex tachycardia
(see below) and may be mistaken as VT or VF. In reality, such rapid preexcited AF may
VENTRICULAR FIBRILLATION actually lead to VF and sudden death .

- WPW
Associated with coarse or fine chaotic undulations of the ECG baseline. There are
no P waves and no true ORS complexes. The rate is indeterminate. The patient is in
CARDIAC ARREST!

~==r==r=A~~R~=§~~~~~~~~~~~ VF

~~~~=-L..a=-<-=.J..-=..1-=..L=J.=.L~~~~k::.i:b.i.L£l.11:Glf:L!!i:Jlliill:::lgj:ill;±J:llitl VF
24 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 25
 PREEXCITED RAPID ATRIAL FIBRILLATION .
FOLLOW THE SIMPLE ALGORITHM BELOW FOR EASY AND RAPID RECOGNITION OF
Rapid atrial fibrillation in a patient with WPW syndrome presents as wide complex
THE ACLS RHYTHMS
tachycardia that may look like VFNT. Just reme~ber the acronym F-B-1: Fast-Broad-
Irregular for preexcited tachycardia. Important point to remember: DO NOT GIVE
digoxin or calcium channel blockers because these may convert the arrhythmia into VF! HR<60
What to do: either IV procainamide, IV am1odarone, or Card1overt the patient!
SLOW

WPWAF

PACEMAKER RHYTHM
ECG of a patient with an artificial pacemaker which is inserted for significant With Pwave
No P wave
bradycardia. Tracing shows a sharp pacemaker potential or spike (as indicated by the Abnormal PR
arrows) followed by a wide QRS complex which indicate "capture" of the ventricle.

P-QRS NarrowQRS Wide QRS

Group beating

jU(f(l\1;1
W..;.~1.L:l.:::..:..iittl:bfilitti:tttJ:ttttttt±ttffllttl:ttttttl:ttttttt:ttlittr:f:titctJ Paced
1y1¥£l'
TORSADE POINTES Sinus ldio- 3rd degree 2"" degree
Junctlonal Slow AF
Brady ventricular AV Block AV Block
Polymorphic VT occurring in patients with long QT interval. ECG shows also irregular
bizarre rapid wide QRS complexes, hence also Fast-Broad-Irregular (F-B-1). But take
note that the QRS complexes seem to change from a positive to a negative axis around
a certain point (twist around a point).Torsade pointes means ''twisting of the points". HR> 100
1
' I ' I
l : I I '
~ • .
' •
1- ,

, •
~/\1\ \J\1~,.'\\~~
f\ ' ,\f''J\ ~I',\ •(\/\'fV\1 1:•111./~~;
1
.
'~1,n'~)rr~tu~v'\iv.~\ J,
1~ 1
' • • I
¥ I 'I '' 1 1
'• l:I
i ;.I J
'
TDP
WideQRS

VT

Pwave No P Wave Pwave No PWave Flutter waves

ORS Different P orphologies

Sinus tach SVT MAT Rapid AF Atrial flutter

26 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 27
 DEFIBRILLATION ENERGY REQUIREMENTS
The recommended energy for the first and succeeding defibrillation attempts is 360J mon h ·
G) Defibrillation or 200J biphasic. CPR should be continued immediately after defibrillation, for 2 minutes, f~iio!!~
therapeutic use of electric current delivered in large amounts over very brief periods of time. by rhythm check.
temporarily "stuns" an irregularly beating heart and allows more coordinated contractile
activity to resume. Biphasic waveform _defibrillatio~ with shock_s of < 200J is safe and has equivalent or higher
termination of VF for at least 5 seconds following the shock efficacy for termination of ventricular fibnllat,on (VF) compared with higher-energy monophasic
- waveform shocks.
Rapid defibrillation is the major determinant of survival in cardiac arrest due to ventricular
fibrillation (VF). SHOCK ENERGIES
The optimal energy for first shock biphasic waveform defibrillation has not been determined.
Early defibrillation is critical for several reasons: Biphasic: 120-200J (Class I LOE C)
If Manufacturer's recommendation not known: Use maximal dose (Class lib)
1. Ventricullar fibrillation (VF)- most frequent initial rhythm in sudden cardiac arrest (SCA) Monophasic: 360J
2. Treatment of VF is electrical defibrillation
3. Probability of successful defibrillation diminishes rapidly overtime PEDIATRIC
4. VF tends to deteriorate to asystole w ithin a few minutes VF is uncommon in children
5. CPR prolongs VF, delays the onset of asystole, and extends the window of time during which 2-4 Joules/kg is recommended
defibrillation can occur.
G) SYNCHRONIZED CARDIOVERSION
In witnessed arrest, defibrillation should be applied immediately after the onset of VF, i.e. Synchronizad cardioversion is delivery of electrical shock timed to the peak of the QRS
before the heart becomes anoxic and acidotic, which would make successful defibrillation and complex.
resumption of cardiac activity less likely.
Synchronization of delivered energy reduces the possibility of induction of VF, which can occur
Defibrillation is accomplished by passage of sufficient electric current (amperes) through the when a shock impinges on the relative refractory period of the cardiac electrical activity.
heart.
Current flows determined by the energy chosen 0oules) and transthoracic impedance (ohms), Thus, synchronization is recommended for unstable supraventricular tachycardia, atrial
a resistance to current flow. fibrillation , atrial flutter, and monomorphic ventricular tachycardia.
Factors that determine transthoracic impedance include:
1. energy selected ENERGIES FOR SYNCHRONIZED CARDIOVERSION
2. electrode size Atrial flutter and SVT (narrow regular) - 50 J to 100 J (monophasic or biphasic)
3. paddle-skin coupling material (gel/cream or saline-solution gauze) Atrial fibrillation (narrow irregular) - 120J to 200J (biphasic) OR 200J (monophasic)
4. number and time interval of previous shocks Monomorphic VT (wide regular) - 100J
5. phase of ventilation Polymorphic VT (wide irregular) - defibrillation dose, NOT SYNCHRONIZED
6. distance between electrodes (chest size)
7. paddle electrode pressure. TECHNIQUE FOR EXTERNAL ELECTRICAL DEFIBRILLATION

ELECTRODE POSITION 1. Turn the main power switch on. Turn the synchronize switch of the defibrillator off.
2. Set the energy to be delivered at 360J (for adults) or equivalent biphasic waveform shock at
Electrodes should be placed to maximize 200J .
current flow through the myocardium. The 3. Lubricate the paddle with electrode gel.

standard placement is one electrode just to the
upper part of the sternum below the clavicle
and the other to the left of the nipple with the
center of the electrode in the mid-axillary line.
Care should be taken that the electrodes are
well separated and that paste or gel is not
smeared between the paddles on the chest.
Otherwise, current may flow preferentially
along the chest wall, "missing" the heart
(1_··:~- )I
4. Charge paddles. Someone should continue CPR while you are charging the defibrillator.
5. Interrupt chest compressions (preferably 10 seconds, maximally 20 seconds) for the
defibrillation. Place one paddle just lo the right of the upper sternum below the right clavicle,
the other paddle just below and to the left of the left nipple as indicated in the paddles.
6. Apply firm pressure with paddles against the chest to reduce lung volume and electric
resistance.
I .•. , 7. Confirm ECG diagnostic of VT or VF (Pulseless ventricular tachycardia or ventricular
fibrillation)
8. Clear the area with no one touching the patient. Shout: "I am going to shock the patient on
three/ One I'm clear! Two you are clear! Three everybody clear!"

28 Manual on Basic and Advanced Cardiac Life Support 29

Manual on Basic and Advanced Cardiac Life Support
 9. Discharge the defibrillator by pushing the appropriate triggers on the paddles simultaneously. Hypotension (SBP 70-100mmHg)
10. After defibrillation, immediately continue CPR. Symptomatic significant bradycardia
11 . Check rhythm after each 5 cycles (2mins) of CPR and proceed accordingly. (See VF/VT After ROSC (Return of Spontaneous Circulation)
Algorithm) • Dose: - 2 - 20 mcg/kg/min infusion, titrate to patient response
• Note: Do not administer in same IV line as Na Bicarbonate
TO DO SYNCHRONIZED CARDIOVERSION , tum the "Synchronize" switch or "SYNC" ON and
select the desired energy for cardioversion. Continue with steps 3 to 9 above. When discharging, (3) Dobutamine
place the paddles on the chest longer, and firmly. • MOA - synthetic sympathomimetic amine with positive inotropic action and minimal
positive chronotropic activity at low doses (2.5 ug/kg per min), but moderate
IMPORTANT NOTES: chronotropic activity at higher doses
• Pulseless VT is treated as VF-+ Defibl • Indication:
• Unstable monomorphic (regular) VT with pulse -+synchronized cardioversion (100J, Severe systolic heart failure (SBP 70-100mmHg)
increase dose If no response to the 1"' shock) • Dose : 2-20 ug/kg/min
• Unstable polymorphic (irregular) VT w/ or w/o pulse- Defibl • Note: vasodilating activity precludes its use when a vasoconstrictor effect is required
• If there is any doubt if monomorphic or polymorphic VT in unstable patient, DO NOT DELAY • Do not administer in same IV line as Na Bicarbonate
shock delivery, provide high energy unsynchronized shocks (ie, defibrillation doses) ~1,,1c~1S :
0Buff~rs: Sodi~m. Bicarbonate .
~• Little data Ind1cates that therapy with buffers improves outcome
CARDIAC DRUGS • Does not improve ability to defibrillate or improve survival rates in animals
• Can compromise coronary perfusion pressure
IMPORTANT PRINCIPLE: DURING A CARDIAC ARREST, DRUG INTERVENTION IS • May cause adverse effects due to extracellular alkalosis, including shifting the
SECONDARY ONLY TO OTHER INTERVENTIONS. MOST IMPORTANT ASPECT IS STILL oxyhemoglobin saturation curve
HIGH QUALITY CHEST COMPRESSIONS AND EARLY DEFIBRILLATIONI • May induce hyperosmolality and hypematremia
~ • Produce carbon dioxide
G) Epinephrine • May inactivate simultaneously administered catecholamine
• MOA - Increases SVR, BP, HR, Contractility, automaticity • MOA : Reverses acidosis caused by global hypoperfusion
Increases blood flow to heart & brain, AV conduction velocity • Indications:
Alpha-adrenergic effects can increase coronary & cerebral perfusion pressure during Hyperkalemia
CPR Tricyclic or phenobarbital overdose
Beta-adrenergic effects may increase myocardial work & reduce subendocardial Patients with pre-existing metabolic acidosis
perfusion ? After a protracted arrest or long resuscitative efforts
• No evidence to show that it improves survival • Dose: 1 mEq/kg
• Dose: 1 mg IV ~every 3-5 mins ~DJ\,t-f..y lr'01"V1A'.
@Diuretics: Furosemide
*Vasopressin already removed in Cardiac medication for Cardiac arrest • Potent diuretic
based on latest 2015 guidelines • Direct venodilating effect in patients with acute pulmonary edema
~\\tXJl-- • Transient vasoconstrictor effect when heart failure is chronic
0 Norepinephrine
• MOA - Naturally occurring potent vasoconstrictor and inotropic agent
•
•
Onset of vascular effect is within 5 minutes
Dose: 0.5 - 1 mg/kg IV injected slowly
Usually induces renal and splanchnic vasoconstriction @fl ~ ~ ' 1 \ , 5 '-
• Indications: Adenosine
Severe hypotension (SBP < ?0mmHg) • MOA : Depresses AV node & sinus node activity
Low total peripheral resistance • Half-life is < 5 seconds (degraded in the blood & periphery)
• Dose: - 0.1 - 0.5 mcg/kg/min infusion • Indications: Should be used if SVT is suspected
• Note: Not used for cardiac arrest •Note : 2010 CPR Guideline with no 2015 update changes
• Do not administer in same IV line as Na Bicarbonate Recommended in the initial diagnosis & treatment of stable, undifferentiated
regular, monomorphic wide-complex tachycardia
~Dopamine • Dose: §..m.g rapid IV push in 2-3 seconds, followed by 20ml saline flush, raise the
• MOA - Catecholamine, alpha and beta-adrenergic receptor agonist and peripheral extremity for at least 30 seconds after push
dopamine receptor agonist • If no response may give 2nd dose: 1.1..mg after 1-2 minutes.May give a 3,d dose: 12 mg
• Indications: if still no response

30 Manual on Basic and Advanced Cardiac Life Support

Manual on Basic and Advanced Cardiac Life Support 31
 f.i\ Calcium Channel Blockers _ . Prolongs action potentia~·on, refractory period, decreases AV node conduction
\J • MOA : Slow conduction & increase refractonness in the AV node and sinus node fu,!Wp<;>n 3
• May also control ventricular response rate in patients with AF, Flutter, or MAT • Indications: AfterABefibri · n and epinephrine in cardiac arrest with persistent
• Systemic vasodilation pulseless VT or VF, stable/unstable VT Ventricular rate control of rapid atrial
• Negative lnotropic effect arrhythmias in severely impaired LV function
Adjunct to electrical cardioversion in refractory PSVT's, atrial tachycardia &
r;;:.., Verapamil pharmacologic cardioversion of AF
V • Indications: • S~ects are hypotension and bradycard_ia
Effective in stable narrow complex PSVT • (y Dose: VT with pulse - 150mg IV over 10m1ns followed by 1mg/min infusion for 6
Alternative drug after Adenosine hours, then 0.Smg/min
• Contraindications fiPulseless VTNF - 300mg IV push then 150mg IV - 2nd dose if needed after another
Should not be given in patients with impaired ventricular function or heart failure cycle'is( CPR
Should not be given if hypotensive
Dose: 2.5 - 5 mg IV given in 2 minutes. f'h Lidocaine
Administered every 15 - 30 mins to a max of 20 mg U • Indications:
/ VF/ pulseless VT that persist after defibrillation and administration of epinephrine
@B-Adrenergic Blockers /control of hemodynamically compromising PVC's
• Indications: /Hemodx,_?,i3mically stable VT
Class I in acute coronary syndromes , Alternat1il~~f Amiodarone unavailable
To slow ventricular response (AF/ flutter.MAT) • Dose: Initial bolus of 1 - 1.5 mg/ kg IV. Additional bolus of 0.5 to 0.75mg/ kg can be
Also to convert SVT given over 3 - 5 minutes for refractory VT/ VF.
• Second line after adenosine • Narrow toxic-to-therapeutic range
• *Labetalol recommended for emergency anti-hypertensive therapy for hemorrhagic and • Routine use in AMI is not recommended ~ ~~ae l~Oi'l .
acute ischemic stroke • No proven short-term or long-term efficacy in cardiac arrest
• Contraindications • CNS Toxicity: muscle twitching, slurred speech , resp. arrest, altered consciousness,
Hemodynamic instability seizures
2° and 3° AV block
Asthma 0Magnesium
Cocaine-induced ACS • Effectively terminates torsades de pointes
• Not effective in irregular/ polymorphic VT in patients with normal QT
Labetalol Dose: 10 mg IV push (1 -2mins), maybe repeated or doubled every 10 mins; • Not recommended in cardiac arrest except when arrhythmias are suspected to be
max dose 150mg OR same initial bolus then infusion at 2-8mg/min caused by magnesium deficiency
• Esmolol Dose: 0.5 mg/ kg loading dose 50 mcg/ kg per minute maintenance infusion • Dose: 1 -2 gm (8-16meqs) mixed in 50 - 100 ml D5W given over 15 to 60 mins .
> 2"" bolus of 0.5 mg/ kg infused in 1 minute repeated every 4 minutes for a total Followed by 0.5 to 1gm IV infusion
maximum of 300 mcg/ kg per minute • 1 to 2 gm diluted in 100 ml D5W administered over 1 - 2 mins in emergency situations
.f,~4~1\5 :
• B-Adrenergic Blockers fiKAtropine
> Class I in acute coronary syndromes V • MOA : Parasympatholytic action:
• Metoprolol Dose: 5 mg IV every 5 minute interval for total of 15 mg (IV form not Accelerates rate of sinus node discharge
available locally) Improves AV conduction
• Propranolol Dose: 0.1 mg/ kg IV every 2-3 minute interval (IV form not available locally) Reverses cholinergic-mediated decreases in heart rate , systemic vascular
• Esmolol Dose: 0.5 mg/ kg loading dose 50 mcg/ kg per minute maintenance resistance, & blood pressure
infusion
• 2"" bolus of 0.5 mg/ kg infused in 1 minute repeated every 4 minutes for a total • Indications : Symptomatic sinus bradycardia (Class I)
maximum of 300 mcg/ kg per minute AV block Nodal level
Use with caution in AMI
fl)) Amiodarone Should not be relied fully in Mobitz type II block
LSI • Class Ill anti-arrhythmic • Dose: 0.5 mg every 3 - 5 mins
• MOA - Affects Na, K and Ca channels as well as alpha and beta adrenergic blocking • A total dose of 3 mg (0.04 mg/kg) results in full vagal blockade in humans
properties If atropine is not effective, may give epinephrine infusion for symptomatic bradycardia as an
alternative to pacing (see Bradycardia algorithm)

32 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 33
 O·
Epinephrine Dose : 2- 10 mcg/min (1 mg in 500cc of 05 W or normal saline by
continuous infusion) titrate to patient's response

{jii:') Epinephrine Adult Cardiac Arrest Algorlthm-2015 Update

\:.Y • MOA - Increases SVR, BP, HR, Contractility, automaticity CPR Quality

• Push hard (at IMSt 2 Inches

Increases blood flow to heart & brain, AV conduction velocity (5 cmD and fast (100-120/m in)
• Alpha-adrenergic effects can increase coronary & cerebral perfusion pressure during Start CPR
and allow complete cheet recoil.
• Minimize lntem.iptlol"l9 In
CPR o -oovO-OltrrJ I-WI\ • Give oxygen comp,essk>na.
• Attach mooltor/ deflbrlllator • Avoid exc.esSNe ventilation.
• Dose: 2-10 mcg/min (1 mg in 500cc of 05 W or normal saline by continuous infusion) • Rotat& compressor every
titrate to patient's response 2 minutes, or soooer 11 latlgued .
• 11 no advanced airway,
• 'Note: 2010 CPR guideline changes with no 2015 update changes Yes Rhythm No 30:2 compre,MK>n-veotllatlon
raliO.
If atropine is not effective, may give epinephrine infusion for symptomatic bradycardia 2 ahockable? • Ouantttativa waveform
9
as an alternative to pacing VF/pVT Allystole/PEA capnogaphy
- If PEToo, <10 mm Hg. attempt

~~~
to Improve CPA quality.
• Intra- arterial pressure
kfiigoxin 3 - II r9'axatlon phaSe (dia-
st Olic) Pf95Sure <20 mm Hg,
• MOA: enhances central and peripheral vagal tone , slows SA node discharge rate, , Shock
attempt to improve CPR
shortens atrial refractoriness , and prolongs AV nodal refractoriness through ANS effect 4 t quality.

• Indication : supraventricular arrhythmias (AF/flutter) CPR2min Shock Energy for Oe11brillatlon

• Peak effect - after 1 .5 - 3 hours • IV/10 access • BlphNk:: Manufacturer

t8C0m mendatlon (eg, inffial
• Less effective than adenosine, verapamil , or beta blockers. do$8 of 120-200 J); ii unknown.
• Dose : Acute loading dose 0.5 to 1.0 mg IV or PO use mmdmum available.
Second and Stbsequant doses
o 0.004 to 0.006rng/kg initially over 5 min . Rhythm No
should be eqtivaient. and ~
ehoc kable? doses may be considerad.
o Then 0 .002 to 0 .003mg/kg at 4-Bhr interval. • Monophaslc: 360 J
o Total of 0.008 to 0.012mg/kg divided to 8 to 16hrs Yes
Drug Therapy
5
, . Shock
• Epinephrine ivno _,
liC'i Nitroglycerine 6 10 1 mg fWfK'/ 3--5 minutes
V • Decreases chest pain in ACS
CPR2min CPR2min
• -IV/IOdose: Fl!St
dose: 3XJ mg baus. Second
• Indication : ACS , CHF, Hypertensive urgency w/ ACS • Eplneplvlne fNery 3-5 min • IV/Kl access dose: 150 mg.

• Consider advanced aliway, • EplneptWtne £Nery 3-6 min

• MOA capnography • ca-advanced airway,
Advancod Airway

Increases venous dilation capnogral)l1y • Endotracheal Intubation or

sup,aglottic aovanced airway
Decreases preload & 02 consumption • wavelonn capnography or
Dilates Coronary Arteries No Rhythm Yes capnometry to confirm and
Rhythm monitor ET tube placement
Increases Collateral flow in Ml ahockable? shockable? • Once advanced airway In plaee,
give l btealh every 6 seconds
• Tolerance may develop Yes (10 btealhslmin) with continuous
• IV bolus - 12.5 to 25 mcg (if no SL or spray given) chest compressions

~
7
Shock No
• Infusion - 10mcg/min titrate to effect Return of Spontaneous
8 11 Circulation (ROSC)
• Increase by 10 mcg /min every 3-5min until desired effect
•Puseandbk>od -
• Max dose 200mcg/min CPR2min CPR 2min • Abrupt sustained increase in
• Arnk>darone • Treat reversible causes
• Sublingual Tablet (0.3-0.4mg) 1 tab every 5min • Treat reversible cauaas
PETco 2 (typicaly 240 m m Hg)
• Spontaneous art erial pressure
• Spray - 1-2 sprays for 0 .5-1sec every 5min , Max of 3 doses waves with intra-artenal
monitoring

Rovors1ble Causes

• Hypovolemia
• HypoxJa
12 • Hydrogen ion (acidosis)
• Hypo-lhyperkal«nia
• If no signs of return of • Hypothermia
~ eumolhorax
spontaneous circt..llallon
(ROSC). go to t O or 11 • Tamponade, cardiac J
• Toxins
• If ROSC, go to
• Thrombosis. pulmonary
Post-Cardiac Arrest Care • Thrombosis, coronary
Cl 20 15 Arlllrican Heart As.aocialkln

34 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support
35
k
f M'\J r"4&,v0,j<., l!J "-'-t•lf ~• ,,c, \l"V\I"'~ t ut,,ci,/11 ~ · ... 1..1~11.C -'d1V'-<i ITl'I ~ ~ ,ti, l,rU~ (cfl,,A, !lb IUJ?-e.)
~ ' /~11)~:
. I ~ ll,t
-
~ ~~~ vr'j(F
v, •

= 't,'\1\-½,Q tw ..e.-- vr ,i,\16 t'':~:,

-w-~r.
ilnL. '.
+u-~ vr/ff
r~, It Ii
"4)/\Jlf.' ,- l!S •
~,-J
W).A

_) • &.,w ~ Jf ~ ,oM,.c.1 -41 ~ ~ : vf o, fl{'~ q,s ~fbt-1/m

~fR'~ W/~ vr/Mf\t~fe.~. (,,W. ~,iv()~
TACHYCARDIA ALGORITHM BRADYCARDIA ALGORITHM

Adult Bradycardia
Doses/Dttall,
Assess appropriateness for clinical condition. Synchronized (With Pulse)
Heart rate typically~ 150/min ~ tachyarrhythmia. Cudloverslon
Initial recommended
doses:
• Narrow r<gula,: 50-12~. Assess appropriateness for clinical condition.
Heart rate typically < 50/min rf bradya,rhythmia
Identify and treat underlying cause
• Maintain patienl airway; assist breathing as
necessary
2
• Oxygen (~ hypoxemic)
• Cardrac monitor to identify rhythm; mon~or blood ldentlfy and treat underlying cause
pressure and oximetry • •Aaimam patent a t ~ assist breathing as
necessart
Adenosine rv Dose: • Oxygen CTI nypoxerruc)
First dose: 6 mg rapid IV • ~ monrtor lo rdelltify rhythm; mo.irtor blood
push; follow with NSS pressure and oximeny
flush • ~, access
Second dose: 12 mg if • 12-'ead c:CG ~ available; don t delay therapy
tent tachyarmythmia required. (.-\i-
Synchronized cardioversion i1'iB1)
tnsion? • Consider sedation
Iy altered mental statu
of shock?
• If regular narrow complex, consider
I~~~~ ~
rrc chest discomfort?
adenosine P~~
Procalnamlde IV Dose:
20-50 mg/min until
t bradyarrhythmia ~
arrhythmia suppressed, ilon?
hypotension ensues,
ORS duration increases
4
Monitor and observe
arterad mental Sta'
oi shed<'
f~
> 50%, or maximum ches: d&omion? ~~~
dose 17 mg/kg given.
• IV access and 12-lead ECG if Maintenance infusion:
Yes available 1-4 mg/min. Avoid if
• Consider adenosine only~ regular prolonged QT or CHF.
and monomorphic
:Amlodarone IV Dose: Yes
• Consider antiarrhythmic infusion
First dose: 150 fl)!l 9,Ve
• Consider expert consultation 10 minutes. .f(\I r ; t> (lUI\!, ' ,pine

~~
Repeal as needed if VT If auop,ne rneilecove: Ooses/Dtlail.s
No recurs. - • Trascutaneous pacing Alroplne IV Dose:

• IV access and 12~ead ECG~

Followed by maintenance
Infusion of ~ f o r
fi~.'.«'i!
-,~ii- OR
• Dopamine infllsioo
OR
Frral dose 0.5 mg bolus
Repeat eveiy 3-5
minutes
available
/MU~ ·
• Epinephrine rnius,on Maxlm1Jm: 3mg
• Adenosine (~ regular) Solalol IV Dose:
100 mg (1.5 mgllcg) over
• j,-Bloci<er or calcium channel OopamiM IV inluaion:
5 mlnules. 2-10 mcg,1<g per minute
blocker Avoid ii prolonged QT
• Consider expert consultation
Epinlpllrino IV
Consider: Infusion:
• Expert coosuitauon 2-10 n,cg per mirute

~l(i.S
(
'> ✓ ~flll<l~ •
1rN~•v•~L¼~)r
Figure reprinted from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Science, Circulation vol 122, no. 18, supplement 3 l..nn'. , ~\tlifllltrll~
• Transvenous pacing

Figure reprinted from 2010 American Htlart Ass-."Cratio,1 Gurdtlhnes for Cardr0pulmonary Resusc,tation and Emergency Cardiovascular Care
~I ~f\O I 1ff\.D; Iv). ~ Science, Crrculalion vol 122, no. 18, supplement 3

\hj\~ ~ ~UJ\'.J,\cl'MI
Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 37
36
 ~6(L{~ ~
~
~
~i ~fl'§.-.
IL4J\}fl~\~)\_Q_
~W«M'"1VWJ! ~~l/4ti~
10,Ptl-~
✓1-W}U- ~~ ~-cc,,,(U .
.V'I{ ~\\\~i
~
. T l~~w,€,M&
• lr.\\~ #.~ 's.: @ 18-< ,.4..,t. t
~ i ·'~ ~(I.A.\{
rfi - "-j("t1,,·r'Oi· ~~~\~))
flv-li'< ~ i ~hi/~~
tl'!-~ 1 W
- t',f1.l'f,,_,.IAf_uN'
. ~«-"1' .C.JJ JI~ 111-.l A.CUTE COBONABY SYNQB9NfS ALGORITHM
~~
• Ci~ i , . i . ~ •
. '1~ ()~ ~ t& ru•r "c
o,,~
.
···1i
POST-CARDIAC ARREST CARE ALGORITHM
Symptoms 1u;gntfv1 of lschtmla or lnflrttlon

EMS assenmtnt and eart and hotpltal preparation

• "'"'·"'' suppo,t ASCs ee p,epared to provide CPR ar<1 deM>nllation
Doses/Details • Adrr.11".,ste· aspirin and consider oxygen. nitrogtyGerin and morphine if needed
Return of Spontaneous Circulation (ROSC) Ventilation/Oxygenation • Qb!a;n 12-~acl ECG. WST elevation:
• Notify receMng hospital with transmission o, interpretation. note time of onset and firsl medical contact
Avoid excessive • Nobfied hospital should mobilize t.osp;tal resour<es to resj)OOd to STEMI
venlilalioo • Hrons,derir<! 1)(8 hosp,1al fibrinolysis, use fibnnolytlc ched<Jlsl
Start al 10-12 breaths/m"
Optimize ventilation and oxygenation and titrate lo target
PETCO, of 3f>.40 mm Hg. Concurrent ED uan1ment (>10 mlnutn) lmmtdiltt ED gtntrll treatment~
When feasible. Wate FrO, • Chea vital signs; evaluate oxygen saturation • if o2 sat < 94%. start oxygen 4 Umi titrate
• Maintain oxygen saturation :!_94%
• Consider advanced airway and waveform
to minimum necessary to"
achifve SPo, ~
• Eslablish IV access
• Perform brief, targeted hlSIOl"f, physical exam
• Aspirin 160 to 325 ~ fil not g
• Nltrogtycerln sublilJual or spray
EMS) 1/1/rN
capnography • Re,ew/complele fibfinolytic cheddist (F ~): checl< • Morphine IV 11discomfort not relieYed by nitroglycerin
• Do not hyperventilate contra1nchcatioos tTable 5)
N Bolus
• Oblain po,table chest x-ray (>30 mmu!es)
1-2 L normal salme °'
lactated Ringer's
If induti'9 hypolhen'r,a.
Treat hypotenslon (SBP <90 mm Hg) may use 4'C ~ ECG lnlll<proi.tlon

• IV/1O bolus Epinephrine N Infusion

• Vasopressor infusion 0 1-0 5 mcg,\g per monute
• Consider treatable causes (r, 70-kg adull 7.35 mo, 13

• 12-Lead ECG per ITWlutB) ST tl1Yatlon or new or prnumabty new ST depression or dynamic T-wave Inversion; strongly
Normal or non diagnostic: c:hangn In
LBBB; strongly suspicious for Injury Slllplcious for IKhtmia
H!ettd:5t unstablt ,meina/ ST tegment or Twan
Dopamint N Infusion SI-tltv«aa Mf CSTfM/1 LoW:Oattcrnectiltt-dst ACS
~ 10 mcg,\g per mmute non..5T-tltmiAn Ml /UA/HSTEMO
10 14
;2,_-7,c,' NO<tpintphrine N
• Start adjunctive therapln H
No Infusion indicated (see b:t) Consider admission to ED c:hnt pain un
Troponln 16r/ated or high-risk patient {Table 3, 4 for
0.1-0 5 mcg/l<g per o,nute • Do not delay repertusion or to appropt1atl bed and follow:
Consider induced hypothermia risJ< strabflCation).
(in 70-kg adult 7-35 mo, • Senal cardiac markers (induding tropomn
Consider eariy '1Vasive strategy rt
per minute) • Repeat ECG/ continous ST-segment
• Relraciofy ISC!lerrnc cnest discomlon
morutoring

i~~
Rtversible Cau,es
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
Yes • Hypo-/hyper1<alemia
Coronary_repurfusroo • Hypolhenmia
• Tension pneumolhorax
• Tamponade, cardiac
• Toxins
• Thr0<nbosis, pulmonary
• Thrombosis, coronary
Advanced critical care
Frgure reprinted from 2010 American Heart Association Guidelines for Cardiopulmrooary Resusci1atioo and Emergency Cardiovascular Care
Science, Circulation vol 122, no. 18, supplement 3
• Reo.lrrentfpersislent ST deviation
• Consider non-Invasive diagnostic test
> 12 hours • Ventricular laehyc:ardia
• Hemodynamic i1slability
• 5,gns of hean failure
11 Yos
Start adjunc:tive treatments as Indicated (see text)
• Nl!rogtycann
i 12hours • Hepar,n (UFH or LMWH)
• Cons.iec PO ll- blockefs
• Consodec Ctop,dogret
• Consider: Gtycoprotein llbilla inhibitor
12
Rtper1uslon gools:
Admit to monitored bed
Therapy de!ned by patienl and center
Asstts risk status (Tables 3. 4) Yes
cfiteria (Table1)
Continue ASA, tltpuin and oll>tf ltltraplts as Indicated
· ~ Inflation
~ -I!:£!) goo!

rolysls) gool of
• ACE i,.;,;bito</ARB
• HMG CoA reduclas, mhibito< (slatJn lherapy)
Not at high risJ<. cal1fiology to risJ< strabfy

If no evldtnce of tlChemla or infarction by

ttJtlng, can dl1c:twge wtth fc'low--up

Figure reprinted from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Science, Circulation vol 122, no. 18, supplement 3

38 Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support 39
 FIRST AID Cardiovascular Emergencies
UPDATED GUIDELINES 2015 ► Chest Discomfort (Angina)
❖ Sublingual nitrates, Aspirin. Call and activate EMS

Definition :
• Neurologic Emergencies
First Aid .
• System of assessments and interv_entIons _that can be performed by a bystander (or by , Stroke
the victim) with minimal or no medical equipment. . . . ❖ Weakness or paralysis on one side. Difficulty speaking, Salivation,
Helping behaviors and initial care provided for an acute illness or 1nJu~. Decreased level of consciousness, Headache, Seizure
has been expanded to include any person, from layperson to professional healthcare ❖ FAST Assessment - Face, Arm , Speech, Time or Cincinnati
provider, in a setting where first aid is needed. . . . . Prehospital Stroke Scale (GPSS) - new recommendation 2015
Basic tenet of first aid is the delivery of care using minimal or no equipment, it is guidelines
increasingly recognized that in some cases first aid providers may have access • Evidence shows that the early recognition of stroke by using
to various adjuncts, such as commercial tourniquets, glucometers, epinephrine a stroke assessment system decreases the interval between
autoinjectors, or oxygen. the time of stroke onset and arrival at a hospital and definitive
• The use of any such equipment mandates training, practice, and, in some cases, treatment.
medical or regulatory oversight related to use and maintenance of that equipment. • More than 94% of lay providers trained in a stroke assessment
First Aid Provider system are able to recognize signs and symptoms of a stroke,
• someone with formal training in first aid, emergency care, or medicine who provides and this ability persists at 3 months after training. The use
first aid. of a stroke assessment system by first aid providers is
• One of the primary equipment in First Aid is the triangular bandage. recommended (Class I, LOE B-NR) .
❖ Treatment
... Evidence shows that education in first aid can increase survival rates, improve • Transport immediately
recognition of acute illness, and resolve symptomatology. We recommend that first aid • Place paralyzed side with padding
education be universally available (Class I, LOE C-EO). • Consider head support
❖ Compared to stroke assessment systems without glucose
Cardinal Principle : " Primum Non Nocere" - FIRST DO NO HARM measurement. assessment systems that include glucose measurement
have similar sensitivity but higher specificity for recognition of stroke
Recognition and Patient Assessment ,/
► Seizures
• Scene size-up ❖ Do not restrain .
• Primary Survey : ❖ Do not place any object between the patient's teeth.
o ABCs ❖ Ensure open airway.
o Mechanism of Injury ( Trauma ) ❖ Patient may be unresponsive for a short while after seizure.
o Nature of Illness ( Medical )
• Focused Physical exam • Allergies/Anaphylaxis
• Check Interventions ► Allergen Categories
❖ Insect bites and stings, Medications, Plants. Food, Chemicals
Medical Emergencies ► Anaphylaxis
❖ Extreme allergic reaction
• Respiratory Emergencies . . . If ❖ Involves multiple organs and can rapidly result in death
;... Asthma/COPD with Breathing difficulty - assist with inhaler or nebulizer. ❖ Most common signs: Wheezing, Urticaria (hives)
impending arrest, call EMS -,.. Signs and Symptoms
;... There is no evidence of any benefit from routine administration of ❖ Widespread urticaria
supplementary oxygen by first aid providers. . ❖ Wheals , Swelling of the lips and tongue
;... Limited evidence shows benefit from use of oxygen for decompression ❖ Chest tig htness and coughing
sickness in the first aid setting. The use of supplementary oxygen by firS t ❖ Abdominal cramps
aid providers with specific training (eg, a diving first aid oxygen course) is ❖ Flushing , itching, or burning skin
reasonable for cases of decompression sickness. . ❖ Warm , tingling feeling in the face, mouth , chest, feet, hands
;... Limited evidence suggests that supplementary oxygen may be effective ❖ Sneezing or itchy, runny nose
for relief of dyspnea in advanced lung cancer patients with dyspnea a nd ❖ Rapid , labored, or noisy respirations
associated hypoxia, but not for similar patients without hypoxia. J.. Treatment
❖ For Anaphylaxis : Epinephrine IM injection 0.3mg for adults and
40
Manual on Basic and Advanced Cardiac Life Support Manual on Basic and Advanced Cardiac Life Support
41
 'ld n >30kg and 0.15mg IM for children 15-30kg
c h I re dd f · h· f
❖ Evidence supports the need for a s~con ose o epmep nne or acute
anaphylaxis in persons not res~onding to a first dose. . ..
❖ When a person with anaphylaxIs does not respond_to the 1mbal dose
and arrival of advanced care will exceed 5 to 10 minutes, a repeat
dose may be considered (Class llb, LOE C-LD).
• Hypoglycemia · .
► Condition that is commonly encountered by ~rst aid provider~.
► severe hypoglycemia, which may present with loss of ~onsc1ousness or
seizures, typically requires management by EMS prov1d~~s. .
► If a person with diabetes reports low blood ~ugar or exh1bIts signs or symptoms
of mild hypoglycemia and is able to follow simple commands a~d swallow, oral
glucose should be given to attempt to resolve the hypoglycemia. . .
► Glucose tablets, if available, should be used to reverse hypoglycemia in a
patient who is able to take these orally (Class I, LOE B-R).
► If glucose tablets are not available, other specifically evaluated forms of
sucrose- and fructose-containing foods, liquids, and candy can be effective as
an alternative to glucose tablets for reversal of mild symptomatic hypoglycemia.
• Exertional Dehydration
► Evidence from the 2015 ILCOR systematic review shows that ingestion of 5%
to 8% carbohydrate-electrolyte (CE) solutions facilitates rehydration after
exercise-induced dehydration and is generally well tolerated.
► Lemon tea-based CE drinks and Chinese tea with caffeine have been found
to be similar to water for rehydration. Other beverages, such as coconut water
and 2% milk, have also been found to promote rehydration after exercise-
associated dehydration.
► If these alternative beverages are not available, potable water may be used
(Class lib, LOE B-R).
• Toxic Eye Injury
► Chemical injury to the eye occurs most commonly from chemicals in powder
and liquid form.
► It can be beneficial to rinse eyes exposed to toxic chemicals immediately and
with a copious amount of tap water for at least 15 minutes or until advanced
medical care arrives (Class Ila, LOE C-LD).
► If ta~ ~at~r is not available, normal saline or another commercially available
eye 1mgat1on solution may be reasonable (Class llb,LOE C-LD).
Traumatic Emergencies
► Bleeding
• Control of bleeding is an important first aid skill.
Slandard first aid bleeding control includes applying direct pressure with or
without gauze.
• Direct_Pressure, Pressure Points, Elevation
• Locaflzed Cold therapy (Class Ila, LOE C-LD)
• Tourniquets - first aid providers may consider the use of a
tourniquet when standard first aid hemorrhage control does not
control severe external limb bleeding (Class \lb, LOE C-LD).
42
Manual on Basic and Advanced Cardiac Life Support
• Hemostatic dressings - Newer-generation hemostatic agent-
impregnated dressings have been shown to cause fewer
complications and adverse effects and are effective in providing
hemostasis in up to 90% of subjects in case series. First aid
providers may consider use of hemostatic dressings when
standard bleeding control (with direct pressure) is not effective.
► Open Chest wounds
The improper use of an occlusive dressing or device with potential
subsequent development of unrecognized tension pneumothorax is of
great concern.
There are no human studies comparing the application of an occlusive
dressing to a nonocclusive dressing, and only a single animal study
showed benefit to use of a nonocclusive dressing.
As a result of the lack of evidence for use of an occlusive dressing and the
risk of unrecognized tension pneumothorax, we recommend against the
application of an occlusive dressing or device by first aid providers
for an individual with an open chest wound.
► Concussion
The myriad of signs and symptoms of concussion can make recognition of
this injury a challenge.
A simple validated single-stage concussion scoring system could possibly
help first aid providers in the recognition of concussion, there is no
evidence to support the use of such a scoring system.
Therefore, it is recommended that a healthcare provider evaluate as soon
as possible any person with a head injury that has resulted jn a change
in level of consciousness, who has progressive development of signs or
symptoms of a concussion or traumatic brain injury, or who is otherwise a
cause for concern to the first aid provider.
► Spinal motion restriction
The use of cervical collars as a component of spinal motion restriction for
blunt trauma was reviewed for the 2015 ILCOR consensus.
No evidence was identified that showed a decrease in neurologic injury
with use of a cervical collar. Evidence demonstrates adverse effects
from use of a cervical collar. such as increased intracranial pressure and
potential airway compromise.
The ILCOR First Aid Task Force also expressed concern that proper
techniqL1e for application of a cervical collar in high-risk individuals requires
significant training and practice to be performed correctly and is not
considered a standard first aid skill.
Because of these concerns, and with a growing body of evidence
demonstrating harmful effects and no good evidence showing clear benefit,
we recommend against routine application of cervical collars by first
aid providers.
;.. Dental Avulsion
Dental avulsion can result in permanent loss of a tooth.
First aid providers may not be able to reimplant an avulsed tooth because
of lack of training, skill, or personal protective equipment, or they may be
Manual on Basic and Advanced Cardiac Life Support
43
 reluctant to perform a painful procedure.
The storage of an avulsed tooth in a variety of solutions (compared with
saliva or milk) has been shown to prolong viability of dental cells by 30 to
120 minutes.
In situations that do not allo~ for immediate reimplantation, the temporary
storage of an avulsed tooth in one of these solutions may afford time until
the tooth can be reimplanted.
► Long Bone Fractures
• In general, first aid providers should not move or try to straighten an injured
extremity (Class Ill: Harm, LOE C-EO).
Based on training and circumstance, some first aid providers may need
to move an injured limb or person. In such situations, providers should
protect the injured person, including splinting in a way that limits pain,
reduces the chance for further injury, and facilitates safe and prompt
transport (Class I, LOE C-EO).
If an injured extremity is blue or extremely pale, activate EMS immediately
(Class I, LOE C-EO).
► Bums
Thermal Bums : Cooling
• Cool thermal burns with cool or cold potable water as soon as
possible and for at least 10 minutes (Class I, LOE B-NR).
• If cool or cold water is not available, a clean cool or cold, but
not freezing, compress can be useful as a substitute for cooling
thermal burns (Class Ila, LOE B-NR).
Burn Dressings
• After cooling of a burn, it may be reasonable to loosely cover the
burn with a sterile, dry dressing (Class lib, LOE C-LD).
• It may be reasonable to avoid natural remedies, such as honey or
potato peel dressings (Class lib, LOE C-LD). However, in remote
or wilderness settings where commercially made topical antibiotics
are not available, it may be reasonable to consider applying honey
topically as an antimicrobial agent (Class lib, LOE C-LD).
Advanced Care Needed
• Burns associated with or involving :
o Blistering or broken skin
o Difficulty breathing
o The face, neck, hands, or genitals
o A larger surface area, such as trunk or extremities
should be evaluated by a healthcare provider (Class I, LOE C-EO).
44
Manual on Basic and Advanced Cardiac Life Support
~
ETHICAL ISSUES IN RESUSCITATION
► Ethical Principles
o Respect for Autonomy
Receives and understands accurate information about his or her
condition, prognosis, nature of any proposed interventions, alternatives
and risks and benefits
Patient is asked to paraphrase the information to give providers the
opportunity to assess the patient's understanding and correct any
misimpressions
Patient deliberates and chooses among alternatives and justifies his or
her decisions
► Withholding and withdrawing CPR related to OHCA
o While the general rule is to provide emergency treatment to a victim of cardiac
arrest, there are a few exceptions where withholding CPR would be considered
appropriate:
Situations where attempts to perform CPR would place the rescuer at
risk of serious injury or mortal peril (eg, exposure to infectious diseases).
Obvious clinical signs of irreversible death (eg, rigor mortis, dependent
lividity, decapitation, transaction, decomposition).
A valid advance directive, a Physician Orders for Life- Sustaining
Treatment (POLST) form indicating that resuscitation is not desired , or a
valid Do Not Attempt Resuscitation (DNAR) order.
► Withholding and withdrawing CPR related to IHCA
o If the patient is determined to be brain dead, if the physician and patient or
surrogate agree that treatment goals cannot be met, or if the burden to the
patient of continued treatment is believed to exceed any benefits.
o Patients in the end stage of an incurable disease should receive care that
ensures their autonomy, comfort, and dignity.
o Interventions that minimize suffering and pain, dyspnea, delirium, convulsions,
and other terminal complications should always be provided.
o For such patients it is ethically acceptable to gradually increase the doses of
narcotics and sedatives to relieve pain and other suffering.
o In the absence of evidence of an incurable disease in the end stage, decisions
to withdraw or limit interventions in the post-arrest patient are often challenging,
given the difficulties of accurate prognostication, especially in the era of treatment
advances such as therapeutic hypothermia
► Terminating Resuscitative Effort in Adult IHCA
o There is insufficient evidence to recommend for or against specific interventions
due to the uncertainty of determining a prognosis and predicting a particular
outcome.
o As such, a solid understanding of the ethical principles surrounding autonomy and
decision making must be coupled with the best information available at the time.
Beyond decisions regarding the initiation and termination of life support, family
presence during resuscitations and organ donation also require healthcare
providers to consider both science and ethics when providing patient-centered
care.
Manual on Basic and Advanced Cardiac Life Support
45
 0 As the science that informs resuscitation efforts continues to advance, so too \
must our efforts to understand the ethical implications that accompany them.

;... Predicting Neurologic outcomes in Adult Patients after Cardiac Arrest

0 There is no one specific test that can predict with certainty a poor neurologic
recovery in this patient population.
0 In making decisions. particularly the decision of whether to continue or withdraw
life-sustaining therapies. clinicians and families need the most accurate
information possible; typically, this information is an aggregate of clinical.
electrographic, radiographic, and laboratory (eg, biomarkers) findings.
0 Timing of prognostication in post cardiac arrest adults
• The earliest time for prognostication in patients treated with TTM
using clinical examination where sedation or paralysis could be a
confounder may be 72 hours after return to normothem1ia. ~
Ub, LOE C-EQI
•
Useful Clinical Findings
That Are Associated With
Poor Neurologic Outcome*
• Absence ol pup1llary rellcx to hght a: n hours or more alter carct,ac arrest
• Presence ol status rnyoclonus (tl;llcrc:nt ltom 1sol.1tc<l myoclomc 1crks)
during the lirst 72 hours alter caro1ac arrest
• Absence ol the N20 somatosensory c,,o;cd po1cn11at corhcal wave 24 to 72
hours alter cardiac arrest or alter rcwannmg
• Presence ol a marked rectucllon ol the g1ay-'lllt111c ratio on brain CT
obtained within 2 hours alter cardiac arrest
• Extensive restriction ol dillus1on on brain MRI at 2 10 6 days alter cardiac
arrest
• Persistent absenceol EEG reactivity 10 external stimuli at 72 hours alter
cardiac arrest
• Persistent burst suppression or intractable status epilepticus on EEGalter
rewarming
Absent motor movements. extensor posturing, or myoclonus should not
beused alone for predicting outcome.
"Shock, temperature, metabolic derangement, prior sedatives or
neuromuscular blockers, and other clinical factors should be considered
carefully because they may affect results or interpretation of some tests.
Abbreviations: CT, computed tomography; EEG, electroencephalogram; MRI,
magnetic resonance imaging.

► Ethics of organ and tissue donation

0
All patients who are resuscitated from cardiac arrest but who subsequently
pro~ress to death or brain death should evaluated as potential organ don~r. .
0
Patient who do not achieve ROSC and who would otherwise have resuscitation
terminate~ may be considered as potential kidney or liver donors in settings
where rapid organ recovery programs exis

46 Manual on Basic and Advanced Cardiac Life Support