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The 2020 AHA ACLS Guidelines update introduced several key revisions aimed at enhancing resuscitation practices and patient care outcomes.

Key Changes to Guidelines:

• Post-Cardiac Arrest Care: Emphasis on managing oxygen saturation (92-98%) and stabilizing airway, respiratory, and hemodynamic parameters, with added steps for brain imaging and other critical care for comatose patients.

• Adult Bradycardia: Atropine dose increased to 1 mg; dopamine adjusted to 5-20 mcg/kg per minute; hypoxic/toxic causes and transcutaneous pacing options revised.

• Adult Tachycardia: Reorganized steps for IV access and 12-lead ECG; added guidance on refractory cases.

• Cardiac Arrest in Pregnancy: New protocol for 100% oxygen and updated timelines for CPR and cesarean delivery.

• Acute Coronary Syndromes: Preferred catheterization lab protocol; revised time goals for balloon inflation and STEMI/NSTE-ACS classification.

• Suspected Stroke: EMS now uses stroke severity tools; extended window for endovascular therapy to 24 hours.

• Neuroprognostication: New visual aid and recommendation to use multiple assessment methods.

• CPR Quality: Focus on physiologic parameters like blood pressure or end-tidal CO2 for monitoring.

• Double Sequential Defibrillation: Not established for effectiveness in shockable rhythm.

• IV vs. IO Access: IV preferred; IO considered if IV access fails.

• Point-of-Care Ultrasound: Cautioned use during resuscitation unless to identify reversible causes.

• Survivor Care: Multimodal rehabilitation and comprehensive discharge planning recommended.

• Ventilation: Revised rates for rescue breaths during respiratory and cardiac arrest.

• Epinephrine and Oxygen Administration: Epinephrine every 4 minutes, oxygen goal 92-98% post-cardiac arrest and greater than 94% for stroke care.

The 2022 Interim COVID-19 Guidelines Update for ACLS includes essential adaptations to resuscitation practices to protect healthcare providers and deliver effective care amid COVID-19 risks. These updates are based on epidemiological data and healthcare feedback and are seen as best practices rather than formal guidelines.

Key Recommendations:

• PPE Usage: Providers must wear N95 respirators and full PPE during resuscitation of suspected or confirmed COVID-19 cases, particularly in aerosol-generating procedures (AGPs).

• Provider Safety: Ensure PPE availability and proper training in its use, conduct vaccination and booster updates, and use mechanical CPR if trained.

• Timely Resuscitation: Initiate chest compressions without delay while using PPE; communicate patient COVID-19 status to all responders.

Specific Resuscitation Updates:

• Pediatric & Adult Cardiac Arrest: Use defibrillation with PPE, HEPA filters for ventilation, and minimize airway circuit interruptions.

• Out-of-Hospital Cardiac Arrest: Prioritize chest compressions and oxygenation with HEPA filtration, especially for pediatrics.

• Neonatal Resuscitation: Use standard non-AGP procedures, avoid routine suctioning, and use IV medication when needed.

• Maternal Cardiac Arrest: Aim for perimortem cesarean within 5 minutes if no return of spontaneous circulation, focusing on oxygenation and left lateral uterine displacement during CPR for pregnant women with COVID-19 symptoms.

ACLS Part 1: Overview of BLS and ACLS

The goal of Advanced Cardiovascular Life Support (ACLS) and Basic Life Support (BLS) is to provide a systematic approach to treat cardiopulmonary arrest and acutely-ill patients, aiming to restore oxygenation, ventilation, and circulation while preserving neurological function. Key components of ACLS include:

1. BLS Assessment: Prioritizes early CPR and defibrillation for unresponsive patients, focusing on:

   • Checking responsiveness

   • Activating emergency response and retrieving an AED

   • Assessing circulation and breathing

   • Using defibrillation if needed

2. Primary Assessment (ABCDE):

   • Airway: Maintain or secure the airway.

   • Breathing: Assess and support breathing without overventilation.

   • Circulation: Check CPR quality, establish IV/IO access, monitor ECG, and manage defibrillation if indicated.

   • Disability: Neurological check for responsiveness and pupil response (AVPU method).

   • Exposure: Visual exam to identify trauma or medical alerts.

3. Secondary Assessment (SAMPLE, H’s and T’s):

   • SAMPLE: Assess signs, allergies, medications, past history, last meal, and events leading up.

   • H’s and T’s: Identify and treat reversible causes of cardiac arrest, such as Hypovolemia, Hypoxia, Tension Pneumothorax, Tamponade, Toxins, and Thrombosis.

ACLS combines immediate BLS response with advanced interventions for a structured, effective approach to life-saving care.

ACLS Part 2: Team Resuscitation Dynamics

Effective resuscitation depends on coordinated efforts among healthcare professionals, emphasizing teamwork, communication, and clear role delegation. Understanding and applying these dynamics improve patient outcomes and ensure a smooth, efficient response.

Key Elements of Team Resuscitation Dynamics:

1. Roles of the Team Leader:

   • Coordinate team activities and monitor individual performance.

   • Provide support, guidance, and education to team members.

   • Model effective behavior and communication.

   • Address challenges post-resuscitation and foster team preparation for future events.

2. Roles of Team Members:

   • Clearly understand and fulfill assigned roles within skillsets.

   • Communicate task completion to the leader and confirm orders when necessary.

   • Seek help or advice early and share relevant information with the team.

   • Respect teammates, express gratitude, and maintain professional tone and conduct.

3. Effective Communication:

   • Use a closed-loop communication system:

     • Team leader gives clear orders.

     • Team member acknowledges and confirms understanding.

     • Team leader confirms task completion before issuing further instructions.

   • Share critical updates on patient status with the team.

   • Ensure clarity and mutual respect in all communications.

Critical Concepts:

• Communication saves lives: Clear, respectful, and precise communication ensures tasks are performed effectively.

• Teamwork: A cohesive team prioritizes the patient’s wellbeing, shares responsibility, and supports each other.

• Patient-Centered Focus: Keep the patient’s needs and safety as the central priority, maintaining professionalism and objectivity.

Summary of ACLS Part 3: Systems of Care and ACLS

Overview:
“Systems of care” in ACLS emphasize the collaboration of healthcare professionals to enhance survival and outcomes for patients experiencing cardiac arrest, acute coronary syndrome (ACS), or acute stroke.

Key Components:

1. Chain of Survival:

   • Immediate recognition of cardiac arrest and emergency system activation.

   • Early CPR with effective compressions.

   • Rapid defibrillation.

   • Advanced cardiovascular life support.

   • Coordinated post-arrest care.

2. Rapid Response Teams (RRTs) and Medical Emergency Teams (METs):

   • Provide early intervention for in-hospital cardiac arrests by recognizing abnormal vital signs.

   • Address clinical deterioration proactively, preventing cardiac arrest.

3. Quality Indicators in Resuscitation:

   • Use data registries (e.g., CARES, “Get with The Guidelines®”) to monitor benchmarks like survival rates, bystander CPR, and defibrillation response times.

   • Identify and address weaknesses in resuscitation performance through comprehensive reviews.

4. Post-Resuscitation Care:

   • Focus on coronary reperfusion, therapeutic hypothermia, neurologic care, and respiratory/hemodynamic optimization to improve outcomes.

Acute Conditions:

1. Acute Coronary Syndromes (ACS):

   • Goals include minimizing myocardial damage, preventing adverse cardiac events, and treating complications like arrhythmias and cardiogenic shock.

   • EMS and hospital protocols prioritize rapid reperfusion and ICU care.

2. Acute Stroke:

   • Emphasizes public education, rapid EMS response, and access to stroke centers.

   • Telemedicine and partnerships facilitate timely administration of rTPA and advanced care.

Rapid Response System:

Designed to monitor physiological criteria and trigger early interventions for deteriorating patients. Key indicators include airway compromise, bradypnea, tachypnea, bradycardia, hypotension, altered mental status, seizures, and diminished urine output.

Critical Concepts:

• Collaboration through the Chain of Survival is vital.

• Quality improvement relies on benchmarking and registries.

• RRTs and METs are essential for early detection and intervention, preventing cardiac arrests.