(ACLS)
PROVIDER HANDBOOK

PRESENTED BY:

NATIONAL HEALTH CARE PROVIDER SOLUTIONS (NHCPS)

WRITTEN BY:
DR. KARL “FRITZ” DISQUE

Copyright © 2013 Satori Continuum Publishing

All rights reserved. Except as permitted under U.S. Copyright Act of 1976, no part of this publication can be reproduced, distributed, or transmitted in any form or by any means, or stored in a database or retrieval system, without the prior consent of the publisher.

ISBN: 978-0-9892679-1-5

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Educational Service Disclaimer

This Provider Handbook is an educational service provided by Satori Continuum Publishing. Use of this service is governed by the terms and conditions provided below. Please read the statements below carefully before accessing or using the service. By accessing or using this service, you agree to be bound by all of the terms and conditions herein.

The material contained in this Provider Manual does not contain standards that are intended to be applied rigidly and explicitly followed in all cases. A health care professional’s judgment must remain central to the selection of diagnostic tests and therapy options of a specific patient’s medical condition. Ultimately, all liability associated with the utilization of any of the information presented here rests solely and completely with the health care provider utilizing the service.

NOTE FROM THE AUTHOR

Thank you for your purchase of the Advanced Cardiac Life Support (ACLS) Provider Handbook, presented to you by National Health Care Provider Solutions (NHCPS). NHCPS and I are very excited to deliver this invaluable resource to you. We hope it will not only aid you with any upcoming ACLS Certification or Recertification course you have enrolled in, but also that it will serve as a reference you can utilize on a repeated basis thereafter.

Additionally, as a token of our gratitude, we would like to extend an exclusive discount for any Certification or Recertification needs you may have. NHCPS is the premier online provider for Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) Certification and Recertification Courses. All of our courses can be completed 100% online, were created by board certified medical professionals, and adhere to the latest American Heart Association standards and guidelines.

To all who have purchased our handbook, we are offering a 15% discount for all Certification and Recertification Courses provided through our website: www.nhcps.com. To redeem this offer, please search “National Health Care Provider Solutions” in your Internet browser, or follow this link: https://www.nhcps.com/. Select the course(s) needed and on the checkout page, enter the Coupon Code: ACLSHANDBOOK. The discount will automatically be added to your total, and will be visible prior to completing your purchase.

If you are already registered for an ACLS Certification or Recertification course, you can still take advantage of this offer. User accounts on our site never expire, so you can purchase your course today, and it will remain in your account until the day you need it.

I sincerely hope you enjoy the ACLS Provider Handbook, and hope it serves as a valuable resource for you. Thank you again for your support, and please continue saving lives! You are an inspiration to all of us at NHCPS.

Sincerely,
Dr. Karl “Fritz” Disque
Co-Founder & Chief Medical Officer of NHCPS

EXCLUSIVE OFFER!
15% Off BLS, ACLS and/or PALS Certification and Recertification Courses
Available at www.nhcps.com
Coupon Code: ACLSHANDBOOK

INTRODUCTION

The goal of Advanced Cardiovascular Life Support (ACLS) is to achieve the best possible outcome for patients who are experiencing a life-threatening cardiac event. ACLS is a series of responses to discrete clinical events. These responses are designed to be simple enough to be committed to memory and recalled under moments of stress. ACLS protocols have been developed from thorough review of basic research, patient case studies, clinical studies, and reflect the consensus opinion of experts in the field. The gold standard in the United States and other countries is the course curriculum published by the American Heart Association (AHA). Approximately every five years the AHA updates the guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). The content contained herein is based on the most recent AHA publication on ACLS and will periodically compare old versus new recommendations for a more comprehensive review. ¹

• IMPORTANT: Refer to the Basic Life Support (BLS) Provider Handbook, presented by NHCPS, for a more comprehensive review of the BLS Survey if warranted. This handbook specifically covers ACLS algorithms and only briefly describes BLS. All ACLS providers are assumed to be able to perform BLS appropriately. While this guide covers BLS basics, it is recommended that ACLS providers be proficient in BLS first.

While ACLS providers should always be mindful of timeliness, it is important to provide the intervention that most appropriately fits the needs of the patient. Proper utilization of ACLS requires rapid and accurate assessment of the patient’s condition. This not only applies to the provider’s initial assessment of a patient in distress, but also to reassessment throughout the course of treatment with ACLS.

ACLS protocols assume the provider may not have all of the information needed from the victim and resources needed to properly utilize ACLS in all cases. For example, if a provider is utilizing ACLS on the side of the road, they will not have access to sophisticated devices to measure breathing or arterial blood pressure. In these situations, ACLS providers have the framework to provide the best possible care in the given circumstances. Again, the algorithms are based on past performance in similar life-threatening cases and are intended to achieve the best possible outcome for the patient during emergency. The foundation of all algorithms involve the systematic approach of the BLS Survey (using steps 1, 2, 3, 4) and the ACLS Survey (using steps A, B, C, D).

THE FIRST ASSESSMENT

Determining whether a patient is conscious or unconscious can be done very quickly. If you notice a person looks like they are in distress, you find them lying down in a public place, or you think they might be injured, call out to them.

• When encountering a person who is “down,” the first assessment to make is whether the patient is conscious or unconscious.
  
• Make sure the scene is safe before conducting the BLS or ACLS Survey.

BASIC LIFE SUPPORT

THE BLS SURVEY (1-2-3-4)

Basic Life Support (BLS) utilizes Cardiopulmonary Resuscitation (CPR) and cardiac defibrillation. Both of these can be performed anywhere an Automated External Defibrillator (AED) is available. AEDs can be found in an increasing number of public places ranging from airports to grocery stores. The BLS Survey uses a systematic approach of assessment followed by appropriate action, focusing on early CPR as well as defibrillation. It does not involve advanced interventions, such as advanced airway devices or cardiovascular medications. BLS can be learned and used by everyone, not just health care professionals. BLS is usually the life support method used outside of hospitals when there is limited access to medications and monitors. In general, BLS is performed until EMS arrives and/or ACLS begins.

• BLS Survey focuses on early CPR and early defibrillation.
  
• Remember assess then perform appropriate action.

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ONE-RESCUER ADULT BLS/CPR

1. Check for the carotid pulse on the side of the neck. Remember not to waste time trying to feel for a pulse; feel for NO MORE THAN 10 seconds. If you are not sure you feel a pulse, begin CPR with a cycle of 30 chest compressions and two breaths.
   
2. Use the heel of one hand on the lower half of the sternum in the middle of the chest.
   
3. Put your other hand on top of the first hand.
   
   
   
   
   
4. Straighten your arms and press straight down. Compressions should be AT LEAST two inches into the victim’s chest and a rate of AT LEAST 100 per minute.
   
5. Stop pressing and let the chest expand after each compression – this will allow the blood back into the heart.
   
6. After 30 compressions, stop compressions and open the airway by tilting the head and lifting the chin.
   
   
   
   1. Put your hand on the victim’s forehead and tilt the head back.
      
   2. Lift the victim’s jaw by placing your index and middle fingers on the lower jaw; lift up.
      
   3. Do not perform head tilt/chin lift if you suspect the victim may have a neck injury.
      
      
      
   
   
7. Give a breath while watching the chest rise. Repeat while giving a second breath.
   
8. Begin compressions.

TWO-RESCUER ADULT BLS/CPR

Many times, there will be a second person available that can act as a second team member. Send this person to call EMS and find an AED while you begin CPR. When the second rescuer returns, the CPR tasks can be shared:

1. Have the second rescuer prepare the AED for use.
   
2. Begin chest compressions and count the compressions aloud.
   
3. The second rescuer should apply the AED pads.
   
4. The second rescuer should open the victim’s airway and give rescue breaths.
   
5. Switch positions after every five cycles of compressions and breaths.
   
6. When the AED is connected, minimize interruptions of CPR by switching rescuers while the AED analyzes the heart rhythm.

ADULT MOUTH-TO-MASK VENTILATION

In one-rescuer CPR, breaths should be supplied using a pocket mask.

1. Give 30 high-quality compressions.
   
2. Seal the mask against the victim’s face by placing four fingers of one hand across the top of the mask and the thumb of the other hand along the bottom edge of the mask.
   
3. Using the fingers of your hand on the bottom of the mask, open the airway using a head tilt/chin lift (do not do this if you suspect the victim may have a neck injury).
   
4. Press firmly around the edges of the mask and ventilate over 1 second as you watch the victim’s chest rise.

ADULT BAG-MASK VENTILATION IN TWO-RESCUER CPR

If two people are available and you have a bag-mask device, the second rescuer should be at the victim’s head while you do high-quality chest compressions.

1. Do 30 high-quality compressions saying the numbers aloud.
   
2. The second team member holds the mask with one hand using the thumb and index finger in the shape of a “C” on one side of the mask. Form a seal between the mask and the face while the other fingers open the airway by lifting the victim’s lower jaw.
   
3. The second team member gives two breaths over one second each.

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ADVANCED CARDIAC LIFE SUPPORT

NORMAL HEART ANATOMY AND PHYSILOGY

Understanding the hearts normal anatomy and physiology is an important component to interpreting and performing Advanced Cardiac Life Support (ACLS). The heart is a hollow muscle comprised of four chambers delineated by thick walls of tissue (septum). The atria are the two upper chambers whereas the ventricles are the two lower chambers. The left and right halves of the heart work together to pump blood throughout the body. The right atrium (RA) and right ventricle (RV) pump deoxygenated blood to the lungs to be oxygenated after which the left atrium (LA) and left ventricle (LV) receive then pump the newly oxygenated blood throughout the rest of the body. Valves between each pair of connected chambers prevent reverse blood flow. The two atria contract simultaneously, as do the ventricles, making the contractions of the heart go from top to bottom. Each beat begins in the RA. The LV is the largest and thickest-walled of the four chambers, as it is responsible for pumping the newly oxygenated blood to the rest of the body. The sinoatrial node (SA node) in the RA creates the strong and organized rhythm of electrical activity for the rest of the cardiac cells to follow. This pulse then carries to the atrioventricular node (AV node), which is between the atria and ventricles. After remaining there briefly, it moves on to the Purkinje system, which is the group of cells that branches into the LV and RV stimulating them to contract and pump blood.

By comprehending the normal electrical pathways in the heart, it will be easier to detect sudden abnormal functions. When blood enters the atria of the heart, an electrical impulse is sent out from the SA node that conducts through the atria resulting in atrial contraction. This atrial contraction registers on an ECG strip as the P wave. This impulse then travels to the AV node, which in turn sends out an electrical impulse that travels through the Bundle of His, bundle branches, and through the Purkinje fibers of the ventricles resulting in ventricular contraction. The time between atrial and ventricular contraction registers on an ECG strip as the PR interval. The ventricular contraction registers on the ECG strip as the QRS complex. Following ventricular contraction, the ventricles rest and repolarize, which is registered on the ECG strip as the T wave. The atria repolarize also, but this coincides with the QRS complex and therefore cannot be observed on the ECG strip. Together a P wave, QRS complex, and T wave are indicative of Normal Sinus Rhythm (NSR).

THE ACLS SURVEY (A – B – C – D)

AIRWAY

Monitor and maintain an open airway at all times. The provider must decide if the benefit of adding an advanced airway is worth the risk of pausing CPR. If the victim’s chest is rising without using an advanced airway, continue giving CPR without pausing. However, if you are in a hospital or near trained professionals who can insert and use the airway, consider pausing CPR.

BREATHING

In cardiac arrest, administer 100% oxygen. Keep blood O₂ sats ≥ 94% measured by a pulse oximeter. Use quantitative waveform capnography when possible. Normal partial pressure of CO₂ is between 35 and 40 mmHg, but the target during CPR is above 10 mmHg.

CIRCULATION

Obtain intravenous (IV) access when possible; intraosseus (IO) is also acceptable. Monitor blood pressure with a blood pressure cuff or intra-arterial line if available. Monitor the heart rhythm using pads. When using an AED, follow the directions (i.e., shock a shockable rhythm). Give fluids when appropriate. Use cardiovascular medications when indicated.

DIFFERENTIAL DIAGNOSIS

Start with the most likely cause of the arrest and then assess for less likely causes. Treat reversible causes and remember to continue CPR as you create a differential diagnosis. Stop only briefly to confirm a diagnosis or to treat reversible causes.

AIRWAY MANAGEMENT

If bag-mask ventilation is adequate, providers may defer insertion of an advanced airway. Health care providers should make the decision as to the appropriateness of placement an advanced airway during the ACLS Survey.

Basic airway equipment includes the oropharyngeal airway (OPA) and the nasopharyngeal airway (NPA). The primary difference between an OPA (Figure 2) and a NPA (Figure 3) is that an OPA is placed in the mouth (Figure 4), while a NPA is inserted through the nose (Figure 5). Both terminate in the pharynx. The main advantage of an NPA over an OPA is that it can be used in either conscious or unconscious patients because the device does not stimulate the gag reflex.

Advanced airway equipment includes the laryngeal mask airway, laryngeal tube, esophageal-tracheal tube, and endotracheal tube. If it is within your scope of practice, you may use advanced airway equipment when appropriate and available.

BASIC AIRWAY ADJUNCTS

OROPHARYNGEAL AIRWAY (OPA)

The OPA is used in patients who are at risk for developing airway obstruction from the tongue or from relaxed upper airway muscle. This J-shaped device fits over the tongue to hold it and the soft hypopharyngeal structures away from the posterior wall of the pharynx.

The OPA is used in unconscious patients if efforts to open the airway fail to provide and maintain a clear, unobstructed airway. An OPA should not be used in a conscious or semiconscious patient because it may stimulate gagging and vomiting. The key assessment is to check whether the patient has an intact cough and gag reflex. If so, do NOT use an OPA. A properly sized and inserted OPA results in proper alignment with the glottis opening.

NASOPHARYNEGEAL AIRWAY (NPA)

The NPA is used as an alternative to an OPA in patients who need a basic airway management adjunct. The NPA is a soft rubber or plastic uncuffed tube that provides a conduit for airflow between the nares and the pharynx.

Unlike the oral airway, NPAs may be used in conscious or semiconscious patients (patients with intact cough and gag reflex). The NPA is indicated when insertion of an OPA is technically difficult or dangerous.

SUCTIONING

Suctioning is an essential component of maintaining a patient’s airway. Providers should suction the airway immediately if there are copious secretions, blood, or vomit. Attempts at suctioning should not exceed 10 seconds. To avoid hypoxemia, follow suctioning attempts with a short period of 100% oxygen administration.

Monitor the patient’s heart rate, pulse oxygen saturation, and clinical appearance during suctioning. If a change in monitoring parameters is seen, interrupt suctioning and administer oxygen until the heart rate returns to normal and clinical condition improves. Assist ventilation as warranted.

• Only use OPA in unresponsive patients with NO cough or gag reflex. Otherwise, OPA may stimulate vomiting and laryngeal spasm.
  
• NPAs may be used in conscious patients with intact cough and gag reflex. However, use carefully in patients with facial trauma because of risk of displacement.
  
• Remember patient is not receiving 100% oxygen while suctioning. Interrupt suctioning and administer oxygen if any change in monitoring parameters is witnessed during suctioning.

BASIC AIRWAY TECHNIQUE

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