ACLS Guidelines Overview

Jul 23, 2025

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Overview

This lecture provides a comprehensive review of Advanced Cardiac Life Support (ACLS) guidelines, algorithms, and best practices, focusing on systematic assessment, reversible causes of cardiac arrest, and the management of cardiac emergencies using American Heart Association (AHA) protocols.

ACLS Systematic Approach

  • Begin with an initial impression and rapid assessment: check consciousness, breathing, and circulation.
  • If unconscious, call for help and start Basic Life Support (BLS).
  • BLS: assess breathing and pulse together in ≤10 seconds; start CPR if no pulse.
  • Perform high-quality chest compressions at 100–120/min, at least 2 inches deep, allowing full recoil, and minimize interruptions.
  • Use AED/defibrillator as soon as available; early defibrillation is critical.
  • Primary assessment (ABCDE): Airway, Breathing, Circulation, Disability (neuro checks), Exposure (look for trauma, etc.).
  • Secondary assessment: identify underlying causes (focused SAMPLE history) and reversible causes (H's & T's).

Reversible Causes of Cardiac Arrest: H's & T's

  • H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypoglycemia, Hypothermia.
  • T's: Toxins, Tamponade, Tension pneumothorax, Thrombus (coronary/pulmonary), Trauma.
  • Rapid identification and treatment of reversible causes can restore circulation.

Cardiac Arrest Algorithm

  • For pulseless patients, follow cardiac arrest algorithm.
  • Identify rhythm: shockable (VFib/pulseless VT) vs. non-shockable (PEA/asystole).
  • Shockable: Immediate defibrillation (120–200 J biphasic), resume CPR, obtain IV/IO access, give epinephrine 1 mg IV every 3–5 min, consider amiodarone (300 mg, then 150 mg).
  • Non-shockable: High-quality CPR, epinephrine, consider reversible causes.
  • Continue cycles of CPR, rhythm checks, and interventions until ROSC or code is terminated.

Bradycardia Algorithm

  • Bradycardia: HR <50/min with symptoms (hypotension, shock, altered mental status).
  • Ensure airway, oxygen, monitors, establish IV/IO access, and obtain 12-lead ECG if possible.
  • First-line: Atropine 1 mg IV every 3–5 min (max 3 mg).
  • If ineffective, use transcutaneous pacing or infusions (dopamine 5–20 mcg/kg/min or epinephrine 2–10 mcg/min).
  • Consider expert consultation for persistent/refractory bradycardia.

Tachycardia Algorithm

  • Tachycardia: HR >150/min with possible symptoms of poor perfusion.
  • Assess stability: unstable (shock, chest pain, altered mental status) = immediate synchronized cardioversion.
  • If stable, determine QRS width:
    • Wide QRS: consider antiarrhythmics (amiodarone, procainamide, sotalol), adenosine if regular/monomorphic, consult cardiology.
    • Narrow QRS: vagal maneuvers, adenosine for regular rhythm, consider beta/calcium channel blockers.

Post Cardiac Arrest Care

  • Ensure airway, ventilation, and oxygenation (target O2 sat ≥94%, ETCOâ‚‚ 35–40 mmHg).
  • Treat hypotension: SBP ≥90 mmHg or MAP ≥65 mmHg with fluids and vasopressors.
  • Identify/treat underlying causes; obtain 12-lead ECG to detect STEMI.
  • Assess for targeted temperature management if not following commands.
  • Transfer to ICU for continued care.

Acute Coronary Syndrome (ACS) Algorithm

  • Recognize MI symptoms: chest pain, radiation, shortness of breath, etc.
  • Immediate actions: 12-lead ECG, vitals, prepare for CPR/defibrillation.
  • Medications: aspirin, nitroglycerin, morphine as needed.
  • Early IV access, lab draws, and chest x-ray; evaluate for STEMI or NSTEMI.
  • STEMI: activate cath lab (goal door-to-balloon ≤90 min) or give fibrinolytics within 30 min.
  • NSTEMI: risk stratify, consider early invasive strategy if high-risk.

Acute Stroke Algorithm

  • Recognize signs (FAST: Face droop, Arm weakness, Speech difficulty, Time to act).
  • Support ABCs, vitals, oxygen if hypoxic, IV access, labs, quick neuro assessment, emergent CT scan (read <45 min).
  • If hemorrhagic: consult neurology/neurosurgery, admit to stroke unit/ICU.
  • If eligible for fibrinolytics: assess contraindications, administer tPA within 60 min.
  • Monitor closely for neurological changes and blood pressure.

Key Terms & Definitions

  • ROSC (Return of Spontaneous Circulation) — Return of effective blood flow after cardiac arrest.
  • BLS (Basic Life Support) — Initial CPR and emergency cardiovascular care.
  • ABCDE — Airway, Breathing, Circulation, Disability, Exposure assessment.
  • VFib/VT (Ventricular Fibrillation/Tachycardia) — Shockable cardiac arrest rhythms.
  • PEA (Pulseless Electrical Activity) — Cardiac arrest with organized rhythm but no pulse.
  • Asystole — Cardiac arrest with no electrical activity (flatline).
  • AED/Defibrillator — Device to deliver an electric shock to correct certain arrhythmias.
  • Atropine — Medication to increase heart rate in bradycardia.
  • Adenosine — Antiarrhythmic for SVT (supraventricular tachycardia).
  • Amiodarone — Antiarrhythmic for shock-refractory VF/VT.
  • Targeted Temperature Management (TTM) — Post-arrest hypothermia protocol to preserve neurological function.

Action Items / Next Steps

  • Memorize the H's and T's (11 reversible causes) for cardiac arrest.
  • Review ACLS algorithms and familiarize yourself with defibrillator functions and pacing techniques.
  • Practice rhythm recognition on ECG.
  • Read AHA ACLS provider manual for in-depth algorithm details.
  • Prepare for practical scenarios and regular algorithm drills.

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