Update2015 AHA BLS and40 l Nursing2016 l Volume 46, Number 2Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2016.com
ACLS guidelinesBy Karen Jean Craig-Brangan, BS, RN, EMT-P,and Mary Patricia Day, MSN, RN, CRNAMONKEYBUSINESSIMAGES /iSTOCKADVANCED CARDIOVASCULAR life support(ACLS) encompasses the entire spectrum of carefrom basic life support (BLS) to postcardiac arrestcare. The 2015 American Heart Association(AHA) guidelines include recommendations onthe use of I.V./intraosseous (I.O.) epinephrine,I.V./I.O. vasopressin during cardiac arrest, andend-tidal carbon dioxide (ETCO2) measurementsto predict patient outcome.1 Let’s take a closerlook at these changes and more.Managing cardiac arrest in an adultThe Adult Cardiac Arrest Algorithm outlines aplan of care for the patient in cardiac arrest secondary to pulseless ventricular tachycardia (pVT)/ventricular fibrillation (VF). After determiningunresponsiveness, apnea, and pulselessness, theclinician administers chest compressions andventilations at a ratio of 30:2 respectively untilan advanced airway is in place. Advanced airways include an endotracheal tube (ETT) orsupraglottic airway (SGA) device such as a laryngeal mask airway, laryngeal tube, or esophagealobturator airway.The new BLS guidelines recommend a compression rate of at least 100/minute and no greater than 120/minute, and a compression depthof at least 2 in (5 cm) and no greater than 2.4 in(6 cm) for an average adult.2 Upper limits for bothcompression rate and depth have been providedin the updated guidelines based on preliminarydata suggesting that excessive compressionrates and depths can adversely affect patient outcomes. Push hard and fast, rotating the compressor role every 2 minutes to prevent fatigue. Avoidexcessive positive pressure ventilations, whichFebruary l Nursing2016 l 41www.Nursing2016.comCopyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
can increase intrathoracic pressureand reduce cardiac output, andprovide oxygen when available atmaximum concentration by bagvalve mask or advanced airway tomaximize the oxygen content of arterial blood.2Attach the monitor/defibrillator assoon as it’s available and analyze thecardiac rhythm. Treat pVT/VFwith defibrillation. Based on theirgreater success in dysrhythmia termination, defibrillators using biphasicwaveforms (biphasic truncated exponential or rectilinear biphasic) arepreferred to monophasic defibrillators. The recommended energy dosefor biphasic defibrillators is 120 to200 joules (J); if the manufacturer’srecommended energy dose is unknown, using the maximum energydose available should be considered.Subsequent defibrillation energydoses should be equivalent or higher.The shock energy dose for a monophasic defibrillator is 360 J. PerformCPR for 2 minutes after defibrillationand obtain I.V. or I.O. access if notalready established.If VF/pVT persists with a rhythmcheck during the compressor rolechange at 2 minutes, defibrillateagain. Biphasic doses can be equivalent to the first shock administered(120 to 200 J) or higher. Monophasic doses remain at 360 J. If thedefibrillator unit is capable of escalating energies, it’s reasonable to usethem for the second and thirdshock.1After the second defibrillationattempt, continue CPR for 2 minutes and administer I.V./I.O. epinephrine 1 mg. This dose may berepeated every 3 to 5 minutes. Epinephrine’s vasoconstrictor effects,which increase coronary and cerebral perfusion pressure during CPR,are beneficial in cardiac arrest. However, current research doesn’t support the routine use of high-doseI.V./I.O. epinephrine (range of 0.1 to0.2 mg/kg). In clinical trials, high-Avoid excessive positivepressure ventilations,which can increaseintrathoracic pressureand reduce cardiacoutput.dose epinephrine was no more beneficial than standard-dose epinephrine in terms of survival to dischargewith good neurologic recovery, survival to discharge, or survival tohospital admission.A single dose of I.V./I.O. vasopressin was an option to consider inpVT/VF, pulseless electrical activity(PEA), and asystole to replace eitherthe first or second dose of I.V./I.O.epinephrine in the 2010 guidelines.However, one notable change in the2015 guidelines is the removal ofvasopressin from the adult cardiacarrest algorithm. Studies indicatethat vasopressin has no advantageover epinephrine and has been removed to simplify the cardiac arrestalgorithm.1The team leader may considerplacing an advanced airway andusing ETCO2 measurements duringthe cardiac arrest. The choice of anadvanced airway depends on theskill level and training of the clinician placing it. No high-qualityevidence supports favoring endotracheal intubation over bag-maskventilation or another advancedairway device in relation to overallsurvival or a good neurologicoutcome.1Continuous waveform capnography for ETCO2 measurementsremains the most reliable methodof confirming and monitoring ETTplacement when used in additionto clinical assessment. If continuous waveform capnography isn’tavailable, clinicians may use acolorimetric and nonwaveform CO2detector, an esophageal detectordevice, or an ultrasound transducerplaced transversely on the anteriorneck above the suprasternal notchto identify endotracheal or esophageal intubation.1After an advanced airway isproperly placed, the patient shouldbe ventilated at a rate of 1 breathevery 6 seconds (10 breaths/minute) while continuous chestcompressions are being performed.This is a change from the previously recommended 1 breath every6 to 8 seconds (8 to 10 breaths/minute), again to simplify thealgorithm for learners.Continuous waveform capnography can be used to evaluate thequality of CPR; for instance, anETCO2 less than 10 mm Hg or anarterial relaxation diastolic pressureless than 20 mm Hg indicates aneed to improve CPR quality byoptimizing chest compressionparameters. For example, assesscompression rate, depth, andchest recoil.If pVT/VF persists, another shockis administered after 2 minutes ofCPR. At this time, an antiarrhythmicagent may be considered. Recommendations include I.V./I.O. amiodarone; I.V./I.O. lidocaine may be42 l Nursing2016 l Volume 46, Number 2Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2016.com
considered as an alternative to amiodarone for pVT/VF unresponsive toCPR, defibrillation, and vasopressortherapy.The patient should be evaluatedfor an underlying reversible causeof the persistent dysrhythmia usingthe “Hs and Ts” as recommendedin the 2010 AHA guidelines.3 (SeeReversible causes of cardiac arrest inan adult.)Once return of spontaneous circulation (ROSC) from cardiac arrestdue to pVT/VF is achieved, the2015 guidelines state that evidenceis inadequate to support routineuse of lidocaine or beta-blockers.In addition, no data support theroutine use of steroids alone forpatients experiencing in-hospitalcardiac arrest.1Asystole/PEAThe adult cardiac arrest algorithmalso outlines a plan of care for thepatient presenting with asystole orPEA. This involves high-quality CPRas previously described.After I.V./I.O. access is established, epinephrine 1 mg is recommended every 3 to 5 minutes. Theuse of vasopressin as an alternativeto epinephrine has been removedfrom the asystole/PEA algorithm inthe 2015 guidelines.1 An advancedairway (ETT or SGA device) withcontinuous waveform capnographyshould be considered as the resuscitative effort continues. The patient isreevaluated every 2 minutes for thepresence of a shockable rhythm. Reversible causes should be consideredusing the Hs and Ts.Postcardiac arrest careIn ROSC, ETCO2 increases abruptly(typically to 40 mm Hg or more)and a spontaneous arterial pressurewaveform is present with intraarterial monitoring.1 After ROSC,patient-care goals include optimizing ventilation and oxygenation,treating hypotension, and evaluatingthe need for targeted temperaturemanagement (TTM) and interventions for ST-elevation myocardialinfarction (STEMI).Avoiding hypoxemia that canworsen organ injury is a top priority. Administer the highest availableoxygen concentration until thearterial oxyhemoglobin saturationor the partial pressure of arterialoxygen (PaO2) can be measured.At that point, decrease the FiO2 tomaintain a saturation of 94% to99%. Remember, peripheralvasoconstriction may make usingpulse oximetry difficult immediately after ROSC.Recommended ventilation goalsinclude the maintenance of normocarbia (ETCO2, 30 to 40 mm Hg orPaCO2, 35 to 45 mm Hg). Modifythese goals as needed based on suchfactors as acute lung injury, high airway pressures, or cerebral edema.4Keep in mind that if the patient’stemperature is below normal, PaCO2lab values may be higher than thepatient’s actual values.Managing BP is particularlyimportant. Studies demonstrate asignificant relationship betweensystolic BP and mean arterial pressure (MAP) and patient outcomes.Immediately correct hypotension,defined as a systolic pressure of lessthan 90 mm Hg or MAP less than65 mm Hg.4The 2010 guidelines encouragedconsideration of induced hypothermia (32 to 34 C [89.6 to 93.2 F]for 12 to 24 hours) for most comatose patients after cardiac arrest toimprove neurologic outcomes. Theterm targeted temperature management (TTM) is now used to refer tothe range of temperature targets recommended in the postresuscitationperiod. TTM is recommended forcomatose adult patients with ROSCafter cardiac arrest. TTM involvesselecting a temperature between 32and 36 C (89.6 and 96.8 F) andmaintaining that temperature for atReversible causesof cardiac arrestin an adult1Assess adults with persistentdysrhythmias for the followingpotentially reversible “Hs and Ts”and initiate appropriateinterventions. hypovolemia hypoxia hydrogen ion (acidosis) hypo-/hyperkalemia hypothermia tension pneumothorax tamponade, cardiac toxins thrombosis, pulmonary thrombosis, coronary.least 24 hours. Outcome predictionfor patients not treated with TTMshould occur no earlier than 72hours after cardiac arrest. Patientstreated with TTM are typically evaluated at 4.5 to 5 days after ROSC.The 2015 guidelines recommend against the routine initiationof induced cooling in the prehospital setting. After rewarming fromTTM to normothermia, fever,which is associated with worsening ischemic brain injury, shouldbe prevented.The 2015 postcardiac arrestguidelines also address seizuredetection and treatment. Electroencephalography (EEG) should bepromptly performed and interpreted in comatose patients after ROSCand monitored frequently or continuously to diagnose seizure activity.4 The guidelines recommendtreating status epilepticus in ROSCwith the same antiepileptic drugtherapy used for status epilepticuscaused by other etiologies.Acute coronary syndromes (ACS)are often a cause of cardiac arrest.A 12-lead ECG obtained early afterROSC will identify patients withST-segment elevation and facilitaterapid coronary angiography andFebruary l Nursing2016 l 43www.Nursing2016.comCopyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
intervention. Emergent coronaryangiography and intervention canbe performed whether the patient isconscious or comatose.4Termination of effortsAs the 2015 guidelines recommend, ETCO2 readings obtainedby continuous waveform capnography can be used as a componentto guide the decision to terminateresuscitative efforts in the intubated patient. Failure to achieve anETCO2 of greater than 10 mm Hgafter 20 minutes of CPR may beused as a component to decide toterminate care. However, it’s important not to use ETCO2 measurements in isolation. ETCO2measurements can’t be used in patients who aren’t intubated becausestudies included only intubatedpatients.1The 2010 recommendations fortreatment of patients with stableand unstable bradycardia or tachycardia with a pulse remain unchanged. The 2015 AHA guidelinesdo, however, address the care ofpatients with stroke or ACS, andpregnant patients.Recommendations for strokeBecause stroke is a leading cause ofdeath and disability in the UnitedStates, the 2015 AHA guidelineshave placed an increased emphasison stroke symptom recognitionfor faster diagnosis and treatment.The Face, Arm, Speech, Time(FAST) and Cincinnati PrehospitalStroke Scale (CPSS), two strokeassessment systems, are now recommended for use by first aidproviders.5Recommendations for ACSThe 2015 AHA guidelines for ACScan be utilized by all providersinvolved in the care of the patient,from initial medical contact untiltransfer from the ED. These guidelines stress the need for a prehospitalencourage the patient with chestpain to chew and swallow 1 adult325-mg aspirin or 2 to 4 low-dose“baby” aspirin (81 mg each) if thepatient has no history of aspirinallergy or other contraindicationsto aspirin use.6The 2015 guidelinesrecommend againstthe routine initiation ofinduced cooling in theprehospital setting.12-lead ECG as early as possiblein patients with suspected ACSwith interpretation by an appropriately trained healthcare providerin conjunction with computerassisted ECG interpretation. This12-lead ECG will facilitate the early diagnosis and treatment of patients with STEMI, reducing timeto first medical contact as well asdoor-to-needle (fibrinolysis) anddoor-to-balloon (percutaneouscoronary intervention) time whenappropriate.The 2015 guidelines also addressearly aspirin administration by firstaid providers to patients with chestpain due to probable myocardialinfarction. Research indicatesthat early aspirin administrationsignificantly reduces mortality. It’srecommended that while waitingfor the arrival of emergency medical services, first aid providers mayRecommendations forpregnant patientsPriorities in the resuscitation ofthe pregnant patient include highquality CPR and the relief of aortocaval compression with manual leftlateral uterine displacement (LUD)during chest compressions if thefundus height is at or above thelevel of the umbilicus. In cases ofnonsurvivable maternal trauma orprolonged pulselessness, deliveryby cesarean section should be considered if the fundus height is ator above the umbilicus and ROSChasn’t been achieved with adequateresuscitative efforts. Typically, Csection delivery should be considered 4 minutes after cardiac arrestor resuscitative efforts and manualLUD. When resuscitation efforts aredeemed futile (as in nonsurvivalmaternal trauma or prolongedpulselessness), there is no reasonto delay cesarean delivery. With awitnessed arrest, cesarean deliveryshould be considered 4 minutesafter the start of resuscitative measures or onset of cardiac arrest.7Current and future changesIn summary, the 2015 AHA guidelines for ACLS contain some newrecommendations, such as the removal of vasopressin from the AdultCardiac Arrest Algorithm and achange in the ventilation rate for theintubated patient during CPR to asimplified 10 breaths/min (1 every 6seconds), and a temperature range of32 to 36 C for 24 hours when usingTTM after ROSC.What does the future hold?History tells us we can expect theintegration of new approaches to44 l Nursing2016 l Volume 46, Number 2Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2016.com
resuscitative efforts. Research alsosuggests that our educational approach to teaching BLS and ACLSmay change in structure. For instance, shorter, more frequent educational sessions, such as rovingBLS scenarios or ACLS mock codes,may be more efficient and costeffective strategies for keeping keyconcepts fresh in our minds. REFERENCES1. Link MS, Berkow LC, Kudenchuk PJ, et al. Part7: Adult Advanced Cardiovascular Life Support:2015 American Heart Association GuidelinesUpdate for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care. Circulation.2015;132(18 suppl 2):S444-S464.2. Kleinman ME, Brennan EE, GoldbergerZD, et al. Part 5: Adult Basic Life Support andCardiopulmonary Resuscitation Quality: 2015American Heart Association Guidelines Update forCardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2015;132(18suppl 2):S414-S435.3. Neumar RW, Otto CW, Link MS, et al. Part 8:Adult Advanced Cardiovascular Life Support:2010 American Heart Association Guidelines forCardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2010;122(18suppl 3):S729-S767.4. Callaway CW, Donnino MW, Fink EL, et al.Part 8: Post-Cardiac Arrest Care: 2015 AmericanHeart Association Guidelines Update forCardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2015;132(18suppl 2):S465-S482.5. Singletary EM, Charlton NP, Epstein JL,et al. Part 15: First Aid: 2015 American HeartAssociation and American Red Cross GuidelinesUpdate for First Aid. Circulation. 2015;132(18suppl 2):S574-S589.6. O’Connor RE, Al Ali AS, Brady WJ, et al. Part9: Acute Coronary Syndromes: 2015 AmericanHeart Association Guidelines Update forCardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2015;132(18suppl 2):S483-S500.7. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part10: Special Circumstances of Resuscitation: 2015American Heart Association Guidelines Update forCardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2015;132(18suppl 2):S501-S518.Karen Jean Craig-Brangan is owner/president andCEO of EMS Educational Services, Inc., in Cheltenham, Pa., and AHA training center manager, TempleUniversity Health System, Philadelphia, Pa. MaryPatricia Day is a certified registered nurse anesthetistat Temple University Hospital in Philadelphia, Pa.The authors and planners have disclosed no potentialconflicts of interest, financial or February l Nursing2016 l 45www.Nursing2016.comCopyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
The 2015 American Heart Association (AHA) guidelines include recommendations on the use of I.V./intraosseous (I.O.) epinephrine, . The new BLS guidelines recommend a com-pression rate of at least 100/minute and no great-er than 120/minute, and a compression depth of at least 2 in (5 cm) and no greater than 2.4 in .