Unit 

01: Advanced Cardiac Life

Support
Author:

Takeesha Roland-Jenkins, MD

Credits Available:

Physicians: 4.25 AMA Category 1 PRA CME Nurses: 4.25 CE

Course Availability:

4/29/2021 thru 4/28/2024

Target Audience and Goal Statement:

This activity is intended for physicians and other healthcare professionals

who may need to recognize and treat adult patients suffering from cardiac
arrest and other cardiopulmonary emergencies. The activity is intended to
provide instructional material to physicians and other healthcare
professionals to guide them in performing Advanced Cardiac Life Support.
Upon completing this activity, participants will be able to analyze
cardiopulmonary emergencies to reduce fatal outcomes. After completing
this activity, the participant should be able to:

 Improve survival rates for adults who experience cardiac and neurologic
emergencies.
 Recognize and initiate early management of cardiac conditions that may result in
cardiac arrest.
 Demonstrate proficiency in providing Basic Life Saving skills
 Manage cardiac arrest until return of spontaneous circulation

Accreditation Statement:
  TeamHealth Institute is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for
physicians (#0001513)
 TeamHealth Institute designates this live activity for a maximum of 4.25 AMA
PRA Category 1 credits™.
 Physicians should only claim credit commensurate with the extent of their
participation in the activity.
 Save your certificate and the course objectives in case you are audited for your
state licensure or national certification.

Medical Reviewers and Disclosures:

Name of Planners/Reviewers Reported Financial Relationship

 Andrew Prolux, MD - Author Nothing to disclose

 Susanne J. Danis, APRN-C, CDE - Reviewer Nothing to disclose
 Raghavendra Kulkarni, MD - Reviewer Nothing to disclose
 Cyrus Yau, MD - Editor Nothing to disclose
 Paige Fillio, PA - Contributor Nothing to disclose

Instructions for Participation and Credit:

To successfully earn credit, participants must read the course content outlined within
the modules and achieve a minimum score of 80% on the post-test.

Follow these steps to earn CME/CE credit:

1. Review the target audience, learning objectives, and author disclosures.

2. Study the educational content online
3. Choose the best answer to each question in the post-test. To receive
credit, you must obtain a passing score as described at the start of the
test.

Once completed, you can now view or download the certificate. Alteration of
the certificate in any way is not permitted. Your completed certificates will
automatically save in Certificate Tracker. *The credit you receive will be based
on your designation set in your profile.

Unit 02: ACLS Overview
Advanced cardiac life support (ACLS)

Also known as cardiovascular life support, is a set of clinical guidelines for the
identification and intervention of cardiac dysrhythmias such as:

 Stroke
 Acute Coronary Syndrome (ACS)
 Cardiopulmonary Arrest

Focus

This training focuses on improving survival rates for adults who experience
cardiac and neurologic emergencies. The ACLS course entails teaching
students the following skill sets:

 Basic life support (BLS) survey

 ACLS survey
 ACLS cases for specific disorders

 High-quality cardiopulmonary resuscitation (CPR)

 Post-cardiac arrest care

Course Prerequisites

It is recommended that students have a basic knowledge of the following subjects

before taking this course:

 BLS skills
 Electrocardiogram (ECG) rhythm recognition and management
 Utilization of airway equipment and management procedures
 An understanding of adult pharmacology, including common emergency drugs
and dosages used for resuscitation.

Course Structure

Students who take this course will review course modules through which proficiency
and competency in respiratory arrest, CPR, and Automated External Defibrillator (AED)
use will be required in response to the following types of incidents:


 o Bradycardia

o Tachycardia
o Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (VT)
o Pulseless Electrical Activity (PEA)/asystole
o Post-cardiac arrest care
o Opiate Associated Emergency (for health care providers)
o Cardiac arrest in pregnancy

Training in BLS (for one or two rescuers) will not be covered in this course.

"Though students will not be directly tested on megacode, they are strongly encouraged
to participate in these training sessions at their local institutions."
To complete the ACLS course, students will be required to pass a final exam that
encompasses the curriculum's cognitive components.
Guidelines as of
Strategy/Intervention Old Guideline
2018

Amiodarone and Amiodarone may be considered for VF/PVT unresponsive to Amiodarone or

Lidocaine CPR, defibrillation, and vasopressor therapy (Class IIb, LOE B- lidocaine may be
R). considered for
VF/PVT that is
unresponsive to
defibrillation. These
drugs may be
beneficial for
patients with
witnessed arrest, for
whom time to drug
administration may
be shorter (Class IIb,
LOE B-R)
Amiodarone IV/IO
dose: First dose –
300 mg bolus,
Second dose – 150
mg Lidocaine IV/IO
dose: First dose – 1-
1.5 mg/kg, Second
dose – 0.5-0.75
 Guidelines as of
Strategy/Intervention Old Guideline
2018

mg/kg

The routine use of

magnesium for
cardiac arrest is not
recommended in
adult patients (Class
III: No Benefit, LOE
C-LD). Magnesium
may be considered
The routine use of magnesium for VF/PVT is not for torsades de
Magnesium recommended in adult patients (Class III: No Benefit, LOE B- pointes (e.g.,
R). polymorphic VT
associated with long
QT interval) (Class
IIb, LOE C-LD). The
wording of this
recommendation is
consistent with the
AHA’s 2010 ACLS
guidelines.

There is insufficient
There is inadequate evidence to support the routine use of a
evidence to support
β-blocker after cardiac arrest. However, the initiation or
or refute the routine
ocker continuation of an oral or intravenous β-blocker may be
use of a β-blocker
considered early after hospitalization from cardiac arrest due
early (within the first
to VF/PVT (Class IIb, LOE C-LD).
hour) after ROSC.

Lidocaine There is inadequate evidence to support the routine use of There is insufficient
lidocaine after cardiac arrest. However, the initiation or evidence to support
continuation of lidocaine may be considered immediately or refute lidocaine’s
after ROSC from cardiac arrest due to VF/PVT (Class IIb, LOE routine use early
CLD). (within the first hour)
after ROSC. In the
 Guidelines as of
Strategy/Intervention Old Guideline
2018

absence of
contraindications,
the prophylactic use
of lidocaine may be
considered in
specific
circumstances
(such as during
emergency medical
services transport)
when treatment of
recurrent VF/PVT
might prove to be
challenging (Class
IIb, LOE C-LD).

Push hard (at least 2 inches [5 cm]) and fast

Between 5 cm and 6 cm (2 inches
(100-120/min) and allow complete chest
and 2.4 inches) in adults, no less than
recoil Minimize interruptions in compressions
100, no more than 120 Do not lean on
Avoid excessive ventilation Change
the chest between compressions;
compressor every 2 minutes, or sooner if
allow the heart to fill with blood.
fatigued. If no advanced airway, 30:2
Rotate compressor every 2 minutes,
compression-ventilation ratio
or sooner if fatigued

Advanced airway Once an advanced airway is in place, give 1 Endotracheal

breath every 6 to 8 seconds or 8 to 10 breaths intubation or
a minute. supraglottic
advanced airway
Waveform
capnography or
capnometry to
confirm and monitor
ET tube placement.
Once an advanced
airway is in place,
 Guidelines as of
Strategy/Intervention Old Guideline
2018

give 1 breath every 6

seconds (10
breaths/minute)
with continuous
chest
compressions.

For a witnessed
OHCA with a
shockable rhythm, it
may be reasonable
for EMS systems
with a priority-
2015 guideline: For a witnessed out-of- based, multitiered
hospital cardiac arrest (OHCA) with a response to delay
Delayed ventilation shockable rhythm, EMS may delay positive- positive-pressure
pressure ventilation for up to 3 cycles of 200 ventilation for up to
continuous chest compressions three cycles of 200
continuous
compressions with
passive oxygen
insufflation and
airway adjuncts
(class IIb)

Extracorporeal CPR
may be considered
In 2015, there was insufficient information to
instead of regular
Extracorporeal CPR recommend the routine use of extracorporeal
CPR for cardiac
CPR
arrest that appears
to be reversible

Epinephrine In 2015, CPR was recommended over  the use Administer

of epinephrine epinephrine as soon
as possible (ASAP)
 Guidelines as of
Strategy/Intervention Old Guideline
2018

for non-shockable
cardiac arrest
rhythm IV/IO dose 1
mg every 3-5
minutes

The combination of
vasopressin and
epinephrine have
2015 guideline: Vasopressin may replace the
Vasopressin not been shown to
first or second dose of epinephrine
provide advantages
over the use of
epinephrine alone

In-hospital and out-

of-hospital cardiac
arrest chain of
survival are
different; primary
2015 guideline: The same chain of survival
providers and lay
Chain of survival was recommended for in-hospital and out-of-
rescuers provide
hospital cardiac arrest
immediate care and
then transfer care to
the code team or
EMS crew,
respectively.

Post-cardiac arrest 2015 guideline: Inadequate evidence to Comatose patients

support the routine use of lidocaine and/or with ROSC should
beta-blocker Comatose patients should be be cooled to
cooled to between 32°C and 34°C for 12-24 between 32°C and
hours. 36°C for >24 hours.
Consider
avoiding/correcting
hypotension systolic
 Guidelines as of
Strategy/Intervention Old Guideline
2018

BP <90 or mean
arterial pressure <65

Key Points

 According to research, starting chest compressions early on during the

resuscitation process helps improve survival rates.
 The evaluation of a victim’s breathing has been omitted as first responders often
misinterpret gasping for air as efficient breathing.
 High-quality CPR for adults is defined by medical experts as:
 A chest compression rate of 100-120 compressions per minute.
 A compression depth of at least 2 inches [5 cm].
 Allowing complete chest recoil after each compression.
 Avoiding excessive ventilation during CPR.
 Minimizing interruptions in compressions for treatments such as:
 Administration of medications
 Placement of advanced airways
 Insertion of intravenous catheters. It is recommended to wait until
the defibrillator is prepared and perform any necessary treatments
during that phase of the CPR.
 Checking for a pulse is no longer critical as many providers are unable to detect a
pulse during an emergency reliably.
 As soon as the Return of Spontaneous Circulation (ROSC) arises, post-cardiac
arrest care should formally start.
 A vasopressor (e.g., epinephrine) should be administered every 3 to 5 minutes
along with the use of an Endotracheal Tube (ET) if available until IV access has
been established.
 Care and Support During Recovery
 All cardiac arrest survivors should receive:
 Multimodal rehabilitation assessment and treatment
 Comprehensive, multidisciplinary discharge planning for both
patients and caregivers.
 Assessment for anxiety, depression, PTSD, and fatigue
 Cardiac Arrest in Pregnancy
 Oxygenation and airway should be prioritized due to the increased risk of
hypoxia.
 Fetal monitoring should not be obtained during cardiac arrest.
 
 Targeted temperature management if a pregnant patient remains
comatose.
 During this treatment, monitoring for fetal bradycardia is
recommended.
 Prepare for perimortem caesarian delivery if necessary to save the infant
and improve resuscitative changes for the mother.
 Post-resuscitation debriefing
 After resuscitation, debriefing of lay rescuers and healthcare workers may
be beneficial to their mental health and wellbeing.
 Opiate Associated Emergency
 Algorithms for both lay responders and health care providers

Unit 03: BLS and ACLS Surveys

Primary Goal

Prepare students to competently and quickly assist victims who are in cardiac
arrest. The aim is to:

 improve survival rates

 ensure positive, high-quality outcomes.

Students will learn systematic strategies that allow them to provide

immediate care using BLS and ACLS surveys.

“Accordingly, if a patient is unresponsive, the BLS survey should be utilized

first.”
After the completion of the BLS survey or when the victim is responsive and
awake, the ACLS survey is the next step that entails providing advanced
treatment approaches.

The BLS Survey

Research pertaining to conducting BLS for adults indicates that the probability
of only one responder being available during an incident that requires BLS is
rare.
 “Therefore, emphasis is placed on performing several actions simultaneously
during the resuscitation process as two responders are often available.”
However, each student must be able to demonstrate both one-and two-responder resuscitation
skills. The specific tasks that are required are presented below in Figure 1:

FIGURE 1: TASKS FOR BLS SURVEY

Adult BLS/CPR

The last part of the BLS survey involves starting CPR. BLS training manuals offer a more
comprehensive description of CPR. During the class as well as at testing, students will
be required to demonstrate competency in performing CPR effectively.

Step by Step CPR Review

 1. Try to locate the carotid pulse behind the trachea on the side of the neck. A pulse
may be hard to detect. Therefore, an attempt to feel the pulse should only be
performed for about 5-10 seconds.
2. If the victim is not lying on the back, place the victim’s back on a surface that will
not compress as CPR is being performed.
3. If a pulse cannot be distinctly detected, assume that there is no pulse. Start
alternating 30 chest compressions and 2 breaths.
4. Open the victim’s airway by slightly lifting the chin.
5. Place the heel of the right hand on the bottom of the victim’s breastbone and
then place the heel of left hand on top of the right hand.
6. Make sure the arms and shoulders are straight and begin the chest
compressions hard and fast. Effective chest compressions will be at least 2
inches deep for adults.
7. Furthermore, the frequency of chest compressions should be 100 to 120 per
minute. The chest needs to fully expand between each compression to allow
blood to flow into the victim’s heart. Do not lean on the chest at any time during
CPR. 
8. After performing 30 hard and fast chest compressions, tilt the head and chin to
make sure the victim’s airway is still open. If the victim appears to have a neck
injury, perform a jaw thrust to open the airway by gently moving the jaw forward. 
9. If a barrier device is available, place it on the victim’s mouth and nose. 
10. Deliver one slow deep breath for 1 second and watch the victim’s chest expand.
Deliver a-second-deep breath. 
11. Perform another round of 30 chest compressions followed by 2 breaths that are
1 second each. 
12. If two or more responders are available, switch out every 2 minutes. 
13. As soon as a responder arrives with a defibrillator and cardiac rhythm is assessed,
defibrillation should be performed quickly and as directed. 
14. Ensure that CPR interruptions are minimal.  

ACLS Survey
After completing the BLS survey, or if the victim is responsive, conscious, or awake, the
responder should begin the ACLS survey. Focus needs to be placed on identifying and treating
the underlying cause of the victim’s problem. 
 FIGURE 2: TASKS FOR ACLS SURVEY

1.  Regarding assessing the victim’s airway: 

 Try to use the least advanced airway as possible to maintain an open airway and
efficient oxygenation (e.g., laryngeal tube, laryngeal mask, or esophageal tracheal
tube).

2.  Regarding assessing the victim’s breathing: 

 Carefully monitor the placement of the tube as well as oxygenation by using

waveform capnography if it is available and try to avoid excessive ventilation. 

3.  Regarding assessing the victim’s circulation: 

 Perform CPR, administer medications and fluids, and perform defibrillation when
needed and according to the ACLS survey indications. 

4.  Try to determine the cause of the cardiac arrest, arrhythmia, or other symptoms and
treat the causes.