Welcome to ASHI ACLS!


 The American Safety and Health Institute (ASHI)
resuscitation training programs are developed and
administered by the Health and Safety Institute (HSI).
 HSI is a major US provider of CPR training programs.*
 ASHI resuscitation training programs are equivalent to
the training programs developed and administered by
the American Heart Association,® Inc. and the American
National Red Cross.

*Anderson ML, et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014 Feb
1;174(2):194-201

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 Accreditation
 HSI is a nationally accredited organization of the
Commission on Accreditation of Pre-Hospital Continuing
Education (CAPCE, formerly CECBEMS). CAPCE is the
national accrediting body for Emergency Medical
Services (EMS) continuing education courses and
course providers. CAPCE accreditation requires an
evidence-based peer-review process for continuing
education programs comparable to all healthcare
accreditors. ASHI BLS and ACLS are CAPCE approved.

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 Course Prerequisites
 Competency in:
 High quality basic life support (BLS) skills, including
bag-mask ventilation
 Reading and interpreting electrocardiograms
 Cardiovascular pharmacology

 Verification of:
 Completion of the self-directed 50-question multiple
choice Post Test (ACLS Study Guide, Chapter 9,
Aehlert, 2017)

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 Minimum Requirements
for ASHI ACLS Certification
 Earn a passing score on the written exam.

 Given a patient situation, and working in a team

setting, verbalize and perform necessary skills in the
initial emergency care (including mechanical,
pharmacological, and electrical therapy where
applicable) for each of the following situations:
 High quality BLS
 Respiratory arrest
 Cardiac rhythm management including pVT/VF and two
other rhythms

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 Chapter 1

Emergency Cardiovascular Care

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 Objectives
 Define cardiovascular collapse, cardiac arrest,
sudden cardiac death (SCD), and sudden
cardiac arrest.
 Discuss the phases of a cardiac arrest.
 Discuss the prearrest factors that influence
survival in out-of-hospital cardiac arrest (OHCA).
 Identify the initial cardiac rhythms that are
typically recorded in OHCA.

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 Objectives (Cont.)
 Discuss the prearrest factors that influence survival in in-
hospital cardiac arrest (IHCA).
 Identify the initial cardiac rhythms that are typically
recorded in IHCA.
 Describe the links in the Chain of Survival.
 Discuss the requirements for performing high-quality
cardiopulmonary resuscitation.
 Discuss common barriers to effective CPR and possible
actions that can be taken to overcome them.
 Explore the use of feedback devices during CPR.

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 Objectives (Cont.)
 Discuss the use of continuous end-tidal carbon dioxide
(EtCO2) monitoring during resuscitation efforts.
 Discuss the use of mechanical chest compression
devices during resuscitation efforts.
 State three areas to assess when forming a general
impression of a patient.
 Differentiate between the purposes and components of
the primary and secondary surveys.
 Discuss a systematic approach to the initial emergency
care of an unresponsive patient.

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 Cardiovascular Disease
 Cardiovascular disease (CVD)
 A collection of conditions that involve the circulatory system,
which contains the heart (cardio) and blood vessels (vascular).
 Coronary heart disease (CHD)
 Disease of the coronary arteries and their resulting
complications, such as angina pectoris and acute myocardial
infarction.
 Coronary artery disease (CAD)
 Disease that affects the arteries that supply the heart muscle
with blood.

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 Cardiac Arrest
 Cardiovascular collapse
 A sudden loss of effective blood flow that is caused by cardiac
factors, peripheral vascular factors, or both, that may revert
spontaneously (eg, syncope) or only with interventions (eg,
cardiac arrest).
 Cardiopulmonary (cardiac) arrest
 The absence of cardiac mechanical activity as confirmed by the
absence of a detectable pulse, unresponsiveness, and apnea or
agonal, gasping breathing.
 Sudden cardiac death
 A natural death of cardiac cause that is preceded by an abrupt
loss of consciousness within 1 hour of the onset of an acute
change in cardiovascular status.

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The Relationships among CAD and Its
Major Sequelae

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 Phases of Cardiac Arrest
Phase Interval Focus of Care
Prearrest Period before the arrest Identify, anticipate, and manage factors that
may result in cardiac arrest (e.g., use of rapid
response teams to recognize and treat
patients at risk of deterioration)

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 Phases of Cardiac Arrest (Cont.)
Phase Interval Focus of Care
Prearrest Period before the Identify, anticipate, and manage factors that
arrest may result in cardiac arrest (e.g., use of rapid
response teams to recognize and treat patients
at risk of deterioration)
No flow Untreated cardiac Prompt initiation of basic life support upon
arrest recognition of the arrest by a bystander or
healthcare professional

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 Phases of Cardiac Arrest (Cont.)
Phase Interval Focus of Care
Prearrest Period before the arrest Identify, anticipate, and manage factors
that may result in cardiac arrest (e.g., use of
rapid response teams to recognize and
treat patients at risk of deterioration)
No flow Untreated cardiac arrest Prompt initiation of basic life support upon
recognition of the arrest by a bystander or
healthcare professional
Low flow Onset of cardiopulmonary Delivery of high-quality chest compressions
resuscitation to optimize myocardial and cerebral
perfusion

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 Phases of Cardiac Arrest (Cont.)
Phase Interval Focus of Care
Prearrest Period before the Identify, anticipate, and manage factors
arrest that may result in cardiac arrest (e.g., use
of rapid response teams to recognize and
treat patients at risk of deterioration)
No flow Untreated cardiac Prompt initiation of basic life support
arrest upon recognition of the arrest by a
bystander or healthcare professional
Low flow Onset of Delivery of high-quality chest
cardiopulmonary compressions to optimize myocardial and
resuscitation cerebral perfusion
Postresuscitation Return of Identify and treat the cause of the arrest,
spontaneous preserve neurologic function, support
circulation end-organ perfusion and function

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 Cardiac Arrest Rhythms
 Shockable rhythms
 Pulseless ventricular tachycardia (pVT)
 Ventricular fibrillation (VF)

 Nonshockable rhythms
 Asystole
 Pulseless electrical activity (PEA)

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 Out-of-Hospital Cardiac Arrest
 Most nontraumatic OHCAs in the United States
are the result of a primary cardiac arrest, rather
than secondary to respiratory arrest.

 Primary cardiac arrest

 An unexpected witnessed (seen or heard) collapse in
an individual who is not responsive (Ewy, 2012)

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Out-of-Hospital Cardiac Arrest (Cont.)
 Prearrest factors that influence survival in OHCA
include the following:
 Performance of bystander CPR
 Mode of arrest (ie, respiratory versus cardiac)
 Witnessed arrest
 Age (older age associated with worsened survival)
 Initial presenting rhythm of VF
 Short response times to defibrillation
 Location of the arrest
 Time of day

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 In-Hospital Cardiac Arrest
 Common causes of IHCA:
 Cardiac arrhythmia
 Acute respiratory insufficiency
 Hypotension

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 In-Hospital Cardiac Arrest (Cont.)
 Prearrest factors that influence survival in IHCA
include the following:
 Initial presenting rhythm of VF
 Time to CPR and defibrillation
 Location
 Time of day
 Automated external defibrillator (AED) use

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Initial Adult Cardiac Arrest Rhythm
 Out-of-hospital arrest
 Asystole (45.6%)
 Idioventricular rhythm/PEA (21.4%)
 VF/pVT/unknown shockable rhythm (20.4%)
 Unknown nonshockable rhythm (12.5%)

 In-hospital arrest
 Asystole and PEA are more common than VF or pVT

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Chain of Survival

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 Chain of Survival
 The Chain of Survival represents the essential
elements of a system of care that are necessary
to link the victim of sudden cardiac arrest with
survival.

 Two separate chains are used to reflect the

actions needed when responding to a cardiac
arrest out of the hospital and in the hospital.

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 Out-of-Hospital Chain of Survival
 Early recognition and activation of the
emergency medical services (EMS) system
 Recognition of signs and symptoms
 Recognition of the need to seek medical assistance
 Emergency dispatchers
• Link between the call for help and the arrival of medical
assistance
• Can provide real-time CPR instructions
• Use of social media to summon volunteer rescuers

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Out-of-Hospital Chain of Survival (Cont.)

 Early cardiopulmonary resuscitation

 Compress the chest at an adequate rate and depth
• Rate for adults: 100 to 120/min
• Depth for adults: at least 2 inches, not to exceed 2.4 inches

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Out-of-Hospital Chain of Survival (Cont.)

 Rapid defibrillation

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Out-of-Hospital Chain of Survival (Cont.)

 Effective advanced life support

 Chest compressions
 Airway management
 Electrocardiographic monitoring and defibrillation
 Vascular access and drug administration

 Integration of post–cardiac arrest care

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 In-Hospital Chain of Survival
 Surveillance and prevention of cardiac arrest
 Prompt notification and response when a
cardiac arrest occurs
 Performance of high-quality CPR
 Prompt defibrillation
 Intra-arrest and post–cardiac arrest care

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Cardiopulmonary Resuscitation

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 Cardiopulmonary Resuscitation
 Myocardial blood flow is dependent on
coronary perfusion pressure.

 Coronary perfusion pressure is a key

determinant of the success of resuscitation.

 Adequate cerebral and coronary perfusion

pressures are critical to neurologically
normal survival.

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 High-Quality CPR
 Compress the chest at an adequate rate and
depth.

 Allow full chest recoil after each compression.

 Minimize interruptions in chest compressions.

 Avoid excessive ventilation.

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 Barriers to Effective
Cardiopulmonary Resuscitation
 Infrequent training
 Lack of awareness of the quality of CPR during
resuscitation
 Inadequate team leadership during resuscitation
efforts
 Rescuer fatigue
 Interruptions when performing chest
compressions
 Incomplete chest recoil after each compression

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Feedback during Cardiopulmonary
Resuscitation

 Several defibrillators
are equipped with a
chest compression
pad that enables
monitoring of the
quality of chest
compressions and
provides corrective
feedback to rescuers.

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Feedback during Cardiopulmonary
Resuscitation (Cont.)
 For intubated patients, continuous EtCO2
monitoring should be used to monitor the quality
of compressions during resuscitation efforts.

 EtCO2:
 Falls sharply with the onset of cardiac arrest.
 Increases when effective CPR is delivered (generally
10 to 20 mm Hg).
 Returns to physiologic levels (35 to 40 mm Hg) with
the ROSC.

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Mechanical Chest Compression Devices
 Alternative to manual
compressions to improve
compression depth, rate, and
consistency.
 Training should be provided to
reduce the time needed for device
deployment.
 Training should also stress the
importance of minimizing
interruptions in chest
compressions while the device is
in use.

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Patient Assessment

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 General Impression
 Appearance
 Mental status, muscle tone, and body position

 (Work of) Breathing

 Body position, visible movement of chest and
abdomen, ventilatory rate, ventilatory effort, and
audible airway sounds

 Circulation
 Skin color

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 Primary Survey
 Primary survey:
 Rapid hands-on assessment
 Usually requires less than 60 seconds to complete
 Purposes are to detect the presence of life-
threatening problems and to immediately correct them

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 Primary Survey (Cont.)
 Assess responsiveness
 Gently tap or squeeze the victim’s shoulder and ask,
“Are you all right?” or “Can you hear me?”

 Use the AVPU acronym:

 A = Alert
 V = Responds to Verbal stimuli
 P = Responds to Painful stimuli
 U = Unresponsive

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 Primary Survey (Cont.)
 Responsive patient
 Airway
 Breathing
 Circulation
 Disability
 Exposure

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 Primary Survey (Cont.)
 Unresponsive patient
 Circulation
 Airway
 Breathing
 Defibrillation

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 Patient Assessment
 When to repeat the primary survey:
 With any sudden change in the patient’s condition
 When interventions do not appear to be working
 When the patient’s vital signs are unstable
 Before any procedures are performed
 When a change in rhythm is observed on the
cardiac monitor

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 Secondary Survey
 Airway
 Breathing
 Circulation
 Differential Diagnosis and diagnostic procedures
 Evaluate interventions and pain management
 Facilitate family presence for invasive and
resuscitative procedures

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 Questions?

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