Do you need a cardiopulmonary resuscitation (CPR) certification? If so, you may be wondering if you should take a traditional American Heart Association (AHA) course or an online AHA course.
Both types of courses offer the same certification, but there are some key differences that you should know about before making your decision.
In this blog post, we will discuss the pros and cons of each type of course so that you can make the best decision for yourself!
What is a traditional AHA course?
A traditional AHA course is a classroom-based course that is taught by an instructor. The class typically lasts for about 12 to 16 hours over two days, and you will receive your certification at the end of the course.
Pros:
- You will have the opportunity to ask the instructor questions and get feedback in real-time.
- You will be able to practice the skills you learn with other students in the class.
- You will receive your certification immediately after completing the course.
Cons:
- The courses are often expensive, ranging from $100 to $300.
- The courses are only offered at certain times and locations, so you may have to travel to take the course.
- The courses are typically very long, so you will need to dedicate a significant amount of time to complete the course.
What is an online AHA course (HeartCode)?
An online AHA course known as HeartCode is a self-paced, online version of the traditional AHA course. The course is typically divided into modules, and you can complete the course at your own pace.
Pros:
- The courses are often less expensive than traditional courses, ranging from $32.50 to $151.
- The courses are offered online, so you can complete the course at any time and from anywhere.
- The courses are typically shorter than traditional courses, so you will not need to dedicate as much time to complete the course.
Cons:
- You will not have the opportunity to ask the instructor questions or get feedback in real-time during the online portion.
- You will be required to attend a skills check-off portion which will be an additional cost. Pricing can range from $50 to $100 dollars sometimes more.
So, what's the difference between traditional AHA courses vs online AHA courses?
The main differences are the cost, time commitment, and availability of the courses.
Both types of courses offer the same certification, but it’s important to consider your needs before making a decision. If you need more flexibility, then an online AHA course might be the best option for you. But if you want the opportunity to ask questions and get feedback in real-time, then a traditional AHA course might be the better choice.
No matter which type of course you choose, you will be prepared to save a life!
Do you know what an ECG rhythm is? If not, don’t worry! You are not alone.
Many people do not know the answer to this question.
An ECG rhythm is simply the pattern of electrical activity that occurs in the heart.
In this blog post, we will teach you how to identify different ECG rhythms in under five minutes!
What is an electrocardiogram rhythm and what does it mean?
An electrocardiogram (ECG) is a test that measures the electrical activity of the heart.
The test is non-invasive, meaning that it does not require surgery or needles.
An ECG can be used to diagnose heart conditions, such as arrhythmias.
Electricity through the Heart
The heart is a muscle that pumps blood through the body.
The heart has its own electrical system that controls the rhythm of the heartbeat.
This electrical system is made up of the sinoatrial (SA) node, the atrioventricular (AV) node, the Bundle of His, and the Purkinje system.
The SA node is located in the right atrium of the heart.
- The SA node is the main pacemaker of the heart, meaning that it sets the pace of the heartbeat.
- The heart rate with the SA node being the primary pacemaker is between 60 to 100 beats per minute.
The AV node is located in the Koch triangle near the coronary sinus on the interatrial septum.
- The AV node delays the electrical signal from the atria to the ventricles. This delay allows the atria to contract and fill the ventricles with blood before the ventricles contract.
- The AV node will take over as the primary pacemaker if the SA node fails to fire.
- The heart rate for the AV node being the primary pacemaker is between 40 to 60 beats per minute.
The Bundle of His is a bundle of fibers that connect the AV node to the Purkinje system.
The Purkinje system is made up of a network of fibers that conduct electrical signals from the AV node to the ventricles.
- The Purkinje system is the final pathway for electrical signals before they reach the ventricles.
- The Purkinje system will take over as the primary pacemaker if the SA and AV nodes fail to fire.
- The heart rate for the Purkinje system being the primary pacemaker is 20 to 40 beats per minute.
Now that you know a little bit about the electrical system of the heart, let’s learn how to identify different ECG rhythms!
Depolarization versus Repolarization
There are two principles of contraction and relaxation in the cardiovascular system: depolarization and repolarization.
Depolarization is the process of the electrical signal moving from the SA node through the AV node and into the ventricles causing contraction.
This causes the ventricles to pump blood out of the heart and into the lungs and body.
Repolarization is the process of allowing the muscle cells in the ventricles to regain their ability to depolarize again (relax).
This allows the ventricles to fill with blood from the atria and lungs.
Normal Electrocardiogram Waveforms
There are three main waveforms that make up a normal ECG: P waves, QRS complexes, and T waves.
P waves are small waves that represent the electrical activity of the atria.
- The P wave occurs during atrial depolarization.
- The atrial electrical impulse is conducted in ring-like waves from the SA node.
- The waveform is visualized as a slower, rounded deflection when compared to the ventricles.
QRS complexes are larger waves that represent the electrical activity of the ventricles during contraction.
- The QRS complex occurs during ventricular depolarization.
- As the conduction reaches the larger ventricular conduction pathway, the bundle branches and Purkinje fibers produce a greater and more rapid depolarization compared to the atria. This depolarization causes a large spike in an ECG.
T waves are smaller waves that represent the electrical activity of the ventricles during relaxation.
- The T wave occurs during ventricular repolarization.
- At the same time, the ventricles are depolarizing, the atria are repolarizing. This repolarization causes a waveform visualized rounded deflection we see.
Electrocardiogram Graph Paper Measuring
Now that we know what the different waveforms represent, let’s learn how to measure them!
Each small square on an ECG graph paper represents 0.04 seconds.
Each large square (made up of 5 squares across and 5 squares up) on an ECG graph paper represents 0.20 seconds.
The height of each small square represents 0.01 mV.
The height of each large square (made up of five squares) represents 0.05 mV.
Calculating Heart Rate on a 6-Second Strip
To easiest method to calculate the heart rate, you will need to count the number of QRS complexes in six seconds and multiply by ten.
To do this, find a six-second section of the ECG that has clear QRS complexes and count the number of complexes.
Once you have counted the number of complexes, multiply by ten to get the heart rate in beats per minute.
For example, if there are twelve QRS complexes in six seconds, the heart rate would be 120 beats per minute.
Calculating the PR Interval
The PR interval is the time it takes for an electrical impulse to travel from the SA node through the AV node.
A normal PR interval is 0.12 to 0.20 seconds or three to five small squares on an ECG graph paper.
To calculate the PRI interval, you will need to find the distance between a P wave and the first QRS complex after that P wave.
Once you have found those two waveforms, count the number of small squares between them.
Each small square on an ECG graph paper represents 0.04 seconds, so you will need to multiply the number of squares by 0.04 to get the PR interval in seconds.
For example, if there are five small squares between the P wave and QRS complex, the PR interval would be 0.20 seconds.
Calculating the QRS Interval
The QRS interval is the time it takes for an electrical impulse to travel through the ventricles.
A normal QRS interval is 0.08 to 0.10 seconds or one to three small squares on an ECG graph paper.
To calculate the QRS interval, you will need to find the distance between the beginning of the QRS complex and the end of that same QRS complex.
Once you have found the waveform, count the number of small squares between them.
Each small square on an ECG graph paper represents 0.04 seconds, so you will need to multiply the number of squares by 0.04 to get the QRS interval in seconds.
For example, if there are two small squares between the beginning and end of the QRS complex, the QRS interval would be 0.08 seconds.
Calculating the QT Interval
The QT interval is the time it takes for an electrical impulse to travel through the ventricles and then be repolarized.
A normal QT interval is 0.36 to 0.44 seconds or nine to eleven small squares on an ECG graph paper.
To calculate the QT interval, you will need to find the distance between the beginning of the QRS complex and the end of the T wave.
Once you have found those two waveforms, count the number of small squares between them.
Each small square on an ECG graph paper represents 0.04 seconds, so you will need to multiply the number of squares by 0.04 to get the QT interval in seconds.
For example, if there are ten small squares between the QRS complex and the end of the T wave, the QT interval would be 0.40 seconds.
Importance of the ST Segment
The ST segment is the flat line between the QRS complex and the T wave.
A normal ST segment should be level with the isoelectric line, which is the flat line on an ECG graph paper.
The ST segment can be used to identify ischemia, which is a decrease in blood flow to the heart.
An ST segment that is elevated above the isoelectric line may be a sign of myocardial infarction or a heart attack.
An ST segment that is depressed below the isoelectric line may be a sign of myocardial ischemia.
The 7 Most Common Types of ECG Rhythms
There are seven types of ECG rhythms that you should be able to identify:
- Normal sinus rhythm
- Sinus bradycardia
- Sinus tachycardia
- Supraventricular tachycardia
- Ventricular Tachycardia
- Ventricular fibrillation
- Asystole
Normal Sinus Rhythm
Normal sinus rhythm is the most common type of ECG rhythm.
It is characterized by a normal P wave, a normal QRS complex, and a normal T wave. Each P wave and QRS wave should be equal distance apart from their corresponding P waves and QRS waves.
The P wave should be upright in leads II, III, and aVF.
The QRS complex should be less than 0.12 seconds or three small squares on an ECG graph paper.
The PR interval should be 0.12 to 0.20 seconds or three to five small squares on an ECG graph paper.
The QT interval should be less than 0.44 seconds or eleven small squares on an ECG graph paper.
Sinus Bradycardia
Sinus bradycardia is characterized by a slow heart rate.
The heart rate should be less than 60 beats per minute. Each P wave and QRS wave should be equal distance apart from their corresponding P waves and QRS waves.
The P wave should be upright in leads II, III, and aVF.
The QRS complex should be less than 0.12 seconds or three small squares on an ECG graph paper.
The PR interval should be 0.12 to 0.20 seconds or three to five small squares on an ECG graph paper.
The QT interval should be less than 0.44 seconds or eleven small squares on an ECG graph paper.
Sinus Tachycardia
Sinus tachycardia is characterized by a fast heart rate.
The heart rate should be greater than 100 beats per minute but less than 150 beats per minute. Each P wave and QRS wave should be equal distance apart from their corresponding P waves and QRS waves.
The P wave should be upright in leads II, III, and aVF.
The QRS complex should be less than 0.12 seconds or three small squares on an ECG graph paper.
The PR interval should be 0.12 to 0.20 seconds or three to five small squares on an ECG graph paper but may be smaller due to the faster heart rate.
The QT interval should be less than 0.44 seconds or eleven small squares on an ECG graph paper.
Supraventricular Tachycardia
Supraventricular tachycardia is characterized by a fast heart rate originating in the atria.
The heart rate should be greater than 150 beats per minute. The P waves may be absent, inverted, or have a different shape than normal.
Each QRS wave should be an equal distance apart from its corresponding QRS waves.
The QRS complex should be less than 0.12 seconds or three small squares on an ECG graph paper.
The PR interval may not be present due to the fast heart rate.
The QT interval may not be present due to the fast heart rate.
Ventricular Tachycardia
Ventricular tachycardia is characterized by a fast heart rate originating in the ventricles.
The heart rate should be greater than 150 beats per minute. The P waves may be absent, inverted, or have a different shape than normal.
Each QRS wave should be an equal distance apart from its corresponding QRS waves.
The QRS complex should be wide and greater than 0.12 seconds or three small squares on an ECG graph paper.
The PR interval will not be present due to the fast heart rate.
The QT interval will not be present due to the fast heart rate.
This can be a life-threatening condition and requires immediate medical attention.
Ventricular Fibrillation
Ventricular fibrillation is characterized by an irregular heart rhythm originating in the ventricles.
The P waves will be absent and the QRS waves will be irregular.
You will not be able to identify any regularity in the QRS waves due to the erratic fibrillation occurring in the ventricles.
This is a life-threatening condition and requires immediate medical attention.
Asystole
Asystole is characterized by a complete absence of electrical activity in the heart.
The P waves and QRS waves will be absent.
There will be a flat line on the ECG tracing.
This is a life-threatening condition and requires immediate medical attention.
If you are a healthcare professional, it is important that you have a working knowledge of Basic Life Support (BLS).
BLS is a set of life-saving protocols that can be used to treat patients who are in cardiac arrest or who are experiencing other life-threatening emergencies.
In this blog post, we will provide an overview of BLS and discuss the steps involved in providing basic care to patients. We will also provide tips for preparing for a BLS certification exam.
Adult Basic Life Support Guidelines
Adult BLS Assessment
The basic steps of BLS are:
- Verify scene safety
- Check for responsiveness
- Call for help (Activate the Emergency Response System)
- Check for breathing and pulse
- Begin chest compressions
- Provide rescue breaths
- Continue chest compressions and rescue breaths until help arrives or the patient begins to breathe on their own
Verify scene safety
Many times you may find that the scene may be unsafe with locations such as in the water, in the middle of the road, etc. If it is not safe, make the scene safe and move the person prior to starting interventions.
Check for Responsiveness
Tap the shoulders and shout “Are you okay?”
If the patient does not respond, then they are unresponsive.
Activating the Emergency Response System
The first step in any emergency is to call for help.
You have two options
- If you have someone near you, have them get help and obtain an AED/Defibrillator
- If you are by yourself, perform a round of CPR then call for help and obtain an AED/Defibrillator
Checking for Breathing and a Pulse
To check for breathing, look for the rise and fall of the chest.
To check for a pulse, place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse.
These actions should be performed for a maximum of no more than 10 seconds.
If no breathing or pulse is present, immediately begin cardiopulmonary resuscitation (CPR).
Compressions, Airway, Breathing (CAB)
Chest Compressions Ratios and Placement
For adults, the compression-to-ventilation ratio is 30:2 (30 compressions followed by two breaths).
Begin by placing the palm of your hand over the patient’s sternum just above the xiphoid process. The previous indicator was to place the palm of your hands on the mid-nipple line; however, due to the increase in obesity the nipple line may no longer be the best indicator.
Disclaimer regarding rescue breaths: According to guidelines posted by the American Heart Association on January 24, 2022, appropriate precautions should be worn when providing BLS, ACLS, and PALS standards with potential and confirmed COVID-19 positive patients. All providers should wear a respirator (i.e. N95), gown, gloves, and eye protection for suspected or confirmed COVID-19 infections when performing aerosol-generating procedures (AGP)s. Out of hospital cardiac arrest is dependent on early initiation of CPR including chest compression. It is not recommended for mouth-to-mouth resuscitation at this time but all patients should receive the best resuscitative efforts.
Depth of Chest Compressions
For adults, the depth of chest compressions should be at least two inches (five centimeters).
Chest Compression Rate
The compression rate should be 100-120 compressions per minute.
You can keep track of the rate by counting out loud or using a metronome.
Allow for full chest recoil between compression and minimize interruptions to less than 10 seconds.
Be sure to switch compression team members every 2 minutes.
Airway and Breathing (CAB)
Utilize the head tilt-chin lift or jaw thrust (trauma to the cervical spine).
Rescue breaths are one breath every 5 to 6 seconds. You will want to see visible chest rise and fall within each rescue breath.
It is important to avoid excess ventilation because it can decrease coronary perfusion pressure and a reduction of cerebral blood flow causing PaCO2 to decrease.
How to use an AED/Defibrillator
When the AED arrives, review the instructions with the bystander.
If you are alone, perform one minute of CPR before using the AED.
Step One: Turn on the AED and follow the prompts.
Step Two: After removing the person’s shirt, apply the electrode pads to the patient’s bare chest in accordance with the instructions and plug in the connector. It is important to remove any wet barriers or medication patches before applying the pads.
Step Three: Stop chest compressions and confirm everyone is clear by saying “Stand Clear.”
Step Four: Push the analyze button and the AED will analyze the patient’s heart rhythm and, if needed, deliver a shock.
Step Five: if a shock is recommended, make sure no one is touching the person and repeat “Stand Clear.” Once clear, press the shock button.
Step Six: Immediately begin CPR following the shock or if no shock is advised. Perform another two minutes of CPR and follow the AED prompts again.
Definition of Neonate, Infant, Child, and Adolescent in PALS
Neonate: A baby who is younger than 28 days old
Infant: A child who is between 29 days and 12 months old
Child: A child who is between 13 months and 12 years old (approximately age prior to puberty)
Adolescent: A teenager who is between 13 and 18 years old (when puberty is present either through armpit hair or breast development)
Basic Pediatric Life Support Guidelines
Pediatric BLS Assessment
The basic steps of Pediatric BLS are:
- Verify Scene Safety
- Check for responsiveness
- Call for help (Activate the Emergency Response System)
- Check for breathing and pulse
- Begin chest compressions
- Provide rescue breaths
- Continue chest compressions and rescue breaths until help arrives or the patient begins to breathe on their own
Verify the scene is safe
Many times you may find that the scene may be unsafe with locations such as in the water, in the middle of the road, etc. If it is not safe, make the scene safe and move the person prior to starting interventions.
Check for Responsiveness
Tap the shoulders of a child or the heel of an infant and shout “Are you okay?”
If the patient does not respond, then they are unresponsive.
If the person does not respond, shout for nearby help and activate the emergency response system.
If no one responds, DO NOT LEAVE THE CHILD. Perform one round of CPR prior to finding help.
Activating the Emergency Response System
The first step in any emergency is to call for help.
You have two options
- If you have someone near you, have them get help and obtain an AED/Defibrillator
- If you are by yourself and have a mobile phone, call for emergency medical services and perform CPR
Checking for Breathing and a Pulse
To check for breathing, look for the rise and fall of the chest.
To check for a pulse, the placement of your fingers will be dependent on the person’s age.
- Infant: palpate the brachial pulse
- Child: palpate the carotid or femoral pulse
These actions should be performed for a maximum of no more than 10 seconds.
If no breathing and pulse are present, immediately begin cardiopulmonary resuscitation (CPR).
Compressions, Airway, Breathing (CAB)
Chest Compressions Ratios, Placement, and Depth
For pediatric persons, there are three options for single-rescuer infant CPR.
30 chest compression: 2 breaths and 1 1/2 inches or 4cm in depth
- 2 fingers in the center of the infant’s chest, the lower half of the breast bone
- 2 thumbs in the center of the infant’s chest, the lower half of the breastbone
- 1 hand in the center of the infant’s chest, the lower half of the breastbone
Two-rescuer infant CPR
15 chest compressions: 2 breaths and 1 1/2 inches or 4cm in depth
- 2 thumbs in the center of the infant’s chest, the lower half of the breastbone
Children CPR Standards
30 chest compressions: 2 breaths and 2 inches or 5cm in depth
- 1 or 2 hand(s) in the center of the child’s chest, the lower half of the breast bone
Disclaimer regarding rescue breaths: According to guidelines posted by the American Heart Association on January 24, 2022, appropriate precautions should be worn when providing BLS, ACLS, and PALS standards with potential and confirmed COVID-19 positive patients. All providers should wear a respirator (i.e. N95), gown, gloves, and eye protection for suspected or confirmed COVID-19 infections when performing aerosol-generating procedures (AGP)s. Out of hospital cardiac arrest is dependent on early initiation of CPR including chest compression. It is not recommended for mouth-to-mouth resuscitation at this time but all patients should receive the best resuscitative efforts.
Chest Compression Rate
The compression rate should be 100-120 compressions per minute for infants, children, and adolescents.
You can keep track of the rate by counting out loud or using a metronome.
Allow for full chest recoil between compression and minimize interruptions to less than 10 seconds.
Be sure to switch compression team members every 2 minutes.
Airway and Breathing (CAB)
Utilize the sniffing position which requires flexion of the cervical spine and extension of the atlantooccipital joint.
Rescue breaths are one breath every 2 to 3 seconds regardless if there is an advanced airway present or not. You will want to see visible chest rise and fall within each rescue breath.
It is important to avoid excess ventilation because it can decrease coronary perfusion pressure and a reduction of cerebral blood flow causing PaCO2 to decrease.
How to use an AED/Defibrillator
When the AED arrives, review the instructions with the bystander.
Step One: Turn on the AED and follow the prompts.
Step Two: After removing the person’s shirt, apply the electrode pads to the patient’s bare chest in accordance with the instructions and plug in the connector. It is important to remove any wet barriers or medication patches before applying the pads.
- If the person is under 8 years old, use the child pads if available. If child pads are not available, you may use adult pads. Place pads so they do not touch each other. One pad is placed on the chest and the other pad is placed on the back. Pads should sandwich the heart when placed appropriately.
- If the person is 8 years old or older, use the adult pads. Do not use child pads as the shock will be too low of a dose
Step Three: Stop chest compressions and confirm everyone is clear by saying “Stand Clear.”
Step Four: Push the analyze button and the AED will analyze the patient’s heart rhythm and, if needed, deliver a shock.
Step Five: if a shock is recommended, make sure no one is touching the person and repeat “Stand Clear.” Once clear, press the shock button.
Step Six: Immediately begin CPR following the shock or if no shock is advised. Perform another two minutes of CPR and follow the AED prompts again.
Agonal Breathing with a Pulse
If you see agonal breathing, it is still important to provide rescue breaths if there is a pulse present. Agonal breathing is an abnormal pattern of gasping and is not considered effective breathing.
Provide one rescue breath every 2 to 3 seconds with or without an advanced airway.
Foreign Airway Obstruction
Adult and Children Foreign Body Airway Obstruction
Conscious
Step One: Ask the person “Are you choking?” If the person nods “yes” and cannot talk, severe airway obstruction is present.
Step Two: Ask the person if they would like help. If they nod “yes,” move on to step three. If they nod “no,” then you must respect their wishes.
- Important to note: if you help a person who does not want help this can be considered battery
Step Three: Provide up to five abdominal thrusts (Heimlich maneuver) or chest thrusts for pregnant or obese persons who are responsive.
Step Four: If the object does not dislodge after five abdominal thrusts or chest thrusts, call 911 and continue with abdominal thrusts.
Unconscious
Step One: Activate the emergency response system through your mobile phone or send someone for help.
Step Two: Begin CPR starting with compressions.
- Important to note: if the person originally said no to help when they were conscious, when the person falls unconscious consent in implied at this point and you should begin CPR
Step Three: If you see the object, remove it if possible. If you cannot see the object and do not have gloves, do not attempt to remove the object.
Step Four: If you have gloves and can see the object, attempt to remove it. If unsuccessful, continue with CPR until there is return of breathing and pulse.
Infant Foreign Body Airway Obstruction
Conscious
Step One: If the person cannot make any sounds or breathe, severe airway obstruction is present.
Step Two: Hold the infant face-down in your hand while supporting the head and provide five back slaps between the shoulder blades with the heel of your hand.
Step Three: If the object does not dislodge, turn the infant over and give five chest thrusts in the center of the chest.
Step Four: Begin Pediatric CPR Guidelines if you lose the pulse and breathing.
If you work in the medical field, then you have probably heard of ACLS. But what exactly is it?
Advanced Cardiac Life Support (ACLS) is a set of guidelines that healthcare providers use to treat cardiac arrest and other life-threatening cardiovascular emergencies.
In this blog post, we will provide an overview of what you need to know about ACLS. We will discuss the history of ACLS, the goals of the program, and the basic steps involved in providing treatment.
Disclaimer: The information covered in this post is in line with the 2020 American Heart Association ACLS guidelines.
ACLS History and Goals
ACLS was created in the 1970s in response to the growing number of cardiac arrests that were occurring outside of the hospital setting.
The goal of ACLS is to improve patient outcomes by providing high-quality care in a timely manner.
One of the key ways that ACLS achieves this goal is by standardizing the care that is provided.
The ACLS guidelines are based on the latest evidence and best practices.
They are regularly updated to ensure that healthcare providers are using the most effective treatments.
To learn more about Basic Life Support (BLS)? ^^^ Click the Title above ^^^
Adult BLS Assessment
The basic steps of BLS are:
- Verify scene safety
- Check for responsiveness
- Call for help (Activate the Emergency Response System)
- Check for breathing and pulse
- Begin chest compressions
- Provide rescue breaths
- Continue chest compressions and rescue breaths until help arrives or the patient begins to breathe on their own
Verify scene safety
Many times you may find that the scene may be unsafe with locations such as in the water, in the middle of the road, etc. If it is not safe, make the scene safe and move the person prior to starting interventions.
Check for Responsiveness
Tap the shoulders and shout “Are you okay?”
If the patient does not respond, then they are unresponsive.
Activating the Emergency Response System
The first step in any emergency is to call for help.
You have two options
- If you have someone near you, have them get help and obtain an AED/Defibrillator
- If you are by yourself, perform a round of CPR then call for help and obtain an AED/Defibillator
Checking for Breathing and a Pulse
To check for breathing, look for the rise and fall of the chest.
To check for a pulse, place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse.
These actions should be performed a maximum of no more than 10 seconds.
If no breathing and pulse are present, immediately begin cardiopulmonary resuscitation (CPR).
Compressions, Airway, Breathing (CAB)
Chest Compressions Ratios and Placement
For adults, the compression-to-ventilation ratio is 30:2 (30 compressions followed by two breaths).
Begin by placing the palm of your hand over the patient’s sternum just above the xiphoid process. Previous indicator was to place the palm of your hands on the mid-nipple line; however, due to the increase in obesity the nipple line may no longer be the best indicator.
Disclaimer regarding rescue breaths: According to guidelines posted by the American Heart Association on January 24, 2022, appropriate percautions should be worn when providing BLS, ACLS, and PALS standards with potential and confirmed COVID-19 positive patients. All providers should wear a respirator (i.e. N95), gown, gloves, and eye protection for suspected or confirmed COVID-19 infections, when performing aerosol-generating procedures (AGP)s. Out of hospitla cardiac arrest is dependent on early initiation of CPR including chest compression. It is not recommend for mouth to mouth resuscitation at this time but all patients should receive the best resuscitative efforts.
Depth of Chest Compressions
For adults, the depth of chest compressions should be at least two inches (five centimeters).
Chest Compression Rate
The compression rate should be 100-120 compressions per minute.
You can keep track of the rate by counting out loud or using a metronome.
Allow for full chest recoil between compression and minimize interruptions to less than 10 seconds.
Be sure to switch compression team members every 2 minutes.
Airway and Breathing (CAB)
Utilize the head tilt-chin lift or jaw thrust (trauma to the cervical spine).
Rescue breaths are one breath every 5 to 6 seconds. You will want to see visible chest rise and fall within each rescue breath.
It is important to avoid excess ventilation because it can decrease coronary perfusion pressure and a reduction of cerebral blood flow causing PaCO2 to decrease.
How to use an AED/Defibrillator
When the AED arrives, review the instructions with the bystander.
If you are alone, perform one minute of CPR before using the AED.
Step One: Turn on the AED and follow the prompts.
Step Two: After removing the person’s shirt, apply the electrode pads to the patient’s bare chest in accordance with the instructions and plug in the connector. It is important to remove any wet barriers or medication patches before applying the pads.
Step Three: Stop chest compressions and confirm everyone is clear by saying “Stand Clear.”
Step Four: Push the analyze button and the AED will analyze the patient’s heart rhythm and, if needed, deliver a shock.
Step Five: if a shock is recommended, make sure no one is touching the person and repeat “Stand Clear.” Once clear, press the shock button.
Step Six: Immediately begin CPR following the shock or if no shock is advised. Perform another two minutes of CPR and follow the AED prompts again.
Bradycardic Rhythms in ACLS
Some bradycardic rhythms you may encounter in ALCS include sinus bradycardia, first-degree heart block, second-degree heart block type I, second-degree heart block type II, and third-degree heart block.
Sinus Bradycardia is defined as a heart rate of less than 60 bpm and the QRS complex is normal. The patient may or may not have symptoms.
First-degree heart block is defined as a PR interval greater than 0.20 seconds but less than 0.30 seconds with a normal QRS complex. The patient usually has no symptoms.
Second-degree heart block type I is defined as a PR interval greater than 0.20 seconds with some occasional dropped QRS complexes.
Second-degree heart block type II is defined as a constant PR interval greater than 0.20 seconds with consistently dropped QRS complexes.
Third-degree heart block is defined as a complete absence of electrical conduction from the atria to the ventricles. The atrial rhythm is regular and the QRS complex is regular with a rate of less than 60 bpm. The conduction in the atria is not communicating with the conduction system in the ventricles.
Bradycardic Rhythm Interventions
Atropine
If symptomatic, the ACLS guideline’s first drug of choice recommends atropine for bradycardia interventions. The initial dose is 1 mg (maximum of 3 mg) and may be given every three to five minutes.
Second-degree type II and third-degree heart blocks do not typically respond to atropine.
If the patient is unresponsive to atropine or has a high-degree heart block, you will need to place transcutaneous pacing pads.
Transcutaneous Pacing
Transcutaneous pacing is an external form of pacing that uses electrical current to stimulate the heart through the skin. This is considered a temporizing measure and is not a definitive treatment.
The pads are placed in the anterolateral position on the patient’s chest and plugin the pacing unit.
The unit will automatically deliver a pacing stimulus/demand rate at 60-100 bpm.
Pacer current (mA) output is also important as it determines the strength of the electrical impulse being delivered to the heart. The higher the number, the greater current being delivered which can cause burns if used for too long.
The recommended settings for an adult are:
-Pacing mode: demand
-Pacing rate: 60-100 bpm (can be set lower if the patient has a pre-existing tachycardia)
-Pacer output: 50-80 mA
Transcutaneous pacing should be continued until the patient’s condition improves, a transvenous pacemaker can be placed, or for no more than 45 minutes to avoid skin burns and patient discomfort.
Transcutaneous Precautions
Conscious paced patients may require additional analgesics for pacing discomfort. Also, you will want to avoid palpating the carotid pulses to confirm capture as the electric impulses cause muscle jerking that may mimic a pulse.
Dopamine
Dopamine is the second drug of choice for symptomatic bradycardia. The starting dose is low at 5 to 20 mcg/kg/min and should be titrated slowly based on the patient’s blood pressure/hemodynamics.
It is important to correct any hypovolemia with adequate fluid replacement prior to starting any dopamine drip. Use this medication cautiously with cardiogenic shock with congestive heart failure.
For additional precautions, please reference an up-to-date drug guide.
Epinephrine
Epinephrine is an alternative drug choice for symptomatic bradycardia in place of dopamine when not appropriate. This alternative is usually used when pacing and atropine fail as well as in cases of severe hypotension.
The recommended dose is 2 to 10 mcg/min infusion and should be titrated slowly based on the patient’s blood pressure/hemodynamics.
Use epinephrine cautiously as raising blood pressures with an increase in heart rate can cause angina, myocardial ischemia, and increase oxygen demand.
For additional precautions, please reference an up-to-date drug guide.
Tachycardic Rhythms in ACLS
One of the most common tachycardic rhythms you may encounter in ALCS includes supraventricular tachycardia.
Supraventricular Tachycardia is defined as tachycardia that originates from above the ventricles in the atria or AV node.
Tachycardic Rhythm Interventions
Oxygenation and Ventilation
The first and most important intervention for any patient in tachycardia is to ensure they are adequately oxygenated and ventilated.
As the oxygen demand on the heart increases with tachycardia, it is important to ensure they are receiving as much oxygen as possible.
Be sure to monitor the patient’s oxygen saturation for any changes in condition or fluctuation that may require supplemental oxygen.
Vagal Maneuvers
Vagal maneuvers are a physical intervention used to decrease the heart rate by stimulating the vagus nerve.
The most common maneuver is the Valsalva maneuver which is performed by having the patient:
- Take a deep breath in
- Attempt to exhale by bearing down or blowing through an occluded 10mL syringe for 15 to 20 seconds
This should result in a decrease in heart rate by decreasing the conduction of electrical impulses through the AV node.
Additional vagal techniques include coughing, a cold stimulus to the face, carotid massage, and gagging.
Adenosine
If unsuccessful vagal maneuvers are unsuccessful, the next step is to administer adenosine.
Adenosine is a medication that works by decreasing the conduction of electrical impulses through the AV node.
The recommended initial dose is 6 mg given as a rapid IV push followed by a 20 mL saline flush. It also helps to elevate the extremity after administration.
The recommended second dose is 12 mg given as a rapid IV push followed by a 20 mL saline flush. Typically, you will wait for 1 to 2 minutes between doses as needed.
Synchronized Cardioversion
If the patient remains unstable or unresponsive to previous interventions, synchronized cardioversion may be necessary.
Cardioversion is a procedure that uses electrical shocks to reset the heart’s electrical impulses and rhythm.
It is important to note that this should only be done when the patient is unstable or unresponsive as it can be a painful and traumatic experience for the patient.
The recommended dose of electricity is 50-100 J for monophasic defibrillators and 100- J for biphasic defibrillators. However, always follow your facility’s guidelines for the most accurate doses.
Initial recommended voltage doses
- Narrow regular (SVT): 50 – 100 joules (SVT or Atrial Flutter)
- Narrow irregular: 120 – 200 joules biphasic or 200 joules monophasic (atrial fibrillation)
- Wide regular: 100 -360 joules (monomorphic ventricular tachycardia)
- Wide irregular: defibrillation dose (not synchronized cardioversion)
Synchronized Cardioversion Procedure
- Obtain a 12-Lead ECG if the patient is stable
- Prepare proper sedation since cardioversion is painful and have emergency equipment ready in case of complications
- Place defibrillator pads on the patient and set the monitor to synchronized (sync) mode. Engage the synch mode before each attempt.
- Look for sync markers above each R wave.
- Set your dose of electricity/voltage
- Clear all personnel from the patient prior to the shock
- Press the “charge” button, “clear” the patient, and press the “shock” button
- Reassess the patient after each shock
ACLS Shockable Rhythms
There are two shockable rhythms in the AHA ACLS guidelines that you may encounter in ACLS: pulseless ventricular tachycardia and ventricular fibrillation.
Pulseless Ventricular Tachycardia is defined as a wide complex tachycardia with a heart rate of >100 bpm in the absence of a pulse.
Ventricular Fibrillation is defined as a rapid, erratic, and chaotic electrical activity in the ventricles that results in the loss of coordinated contractions.
ACLS Shockable Rhythm Interventions
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.
Review the Basic Life Support Guidelines for CPR detail
Defibrillation
Defibrillation is the use of electrical shocks to reset the heart’s electrical impulses and rhythm without syncing to the patient’s intrinsic rhythm.
The recommended dose of electricity is 120-200 J for biphasic machines and up to 360 J for monophasic.
Defibrillation Procedure
- Turn on the defibrillator and set the joules based on the machine used
- Place adhesive pads on patient: one on the right anterior chest wall and one on the left axillary position
- Announce to the team “Charging defibrillator” and press the charge button
- When the defibrillator is fully charged, verify all team members are clear by announcing the shock. Once the team announces all clear and you have verified the team is not touching the patient or bed, call “All Clear!”
- Press the shock button on the defibrillator
- Immediately after shock is delivered, resume CPR for 5 cycles (2 minutes) then reassess rhythm
Epinephrine
Epinephrine is a medication that is used to stimulate the heart and increase blood pressure.
The recommended dose is 1 mg administered every 3 to 5 minutes during resuscitation. Follow each dose with a 20 mL flush and elevate the arm for 10 to 20 seconds.
Amiodarone
Amiodarone is a medication that is used to slow the heart rate and improve cardiac output.
The recommended initial dose is 300 mg IV or IO push.
The second dose is 150 mg IV or IO push.
The maximum dosage for amiodarone is 450 mg IV over 24 hours.
Lidocaine
Lidocaine is a medication that is used to treat ventricular arrhythmias and is considered immediately after the return of spontaneous circulation (ROSC).
The recommended initial dose during active CPR is 1 to 1.5 mg/kg IV or IO.
Refractory Ventricular Fibrillation doses can be provided. This dose is 0.5 to 0.75 mg/kg IV push every 5 to 10 minutes (maximum 3 doses or total of 3 mg/kg).
Lidocaine can also be used for maintenance post-cardiac arrest is 1 to 4 mg/min (30 to 50 mcg/kg/min).
ACLS Non-Shockable Rhythms
There are two non-shockable rhythms in the AHA ACLS guidelines that you may encounter in ACLS: asystole and pulseless electrical activity.
Asystole is defined as a heart rhythm that is not amenable to defibrillation also known as a flat line.
Pulseless Electrical Activity (PEA) is defined as electrical activity on the monitor but no mechanical activity.
ACLS Non-Shockable Rhythm Interventions
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.
Review the Basic Life Support Guidelines for CPR detail.
Epinephrine
Epinephrine is a medication that is used to stimulate the heart and increase blood pressure.
The recommended dose is 1 mg administered every 3 to 5 minutes during resuscitation. Follow each dose with a 20 mL flush and elevate the arm for 10 to 20 seconds.
Consider your H and T causes
It is important to consider your H’s and T’s for these rhythms and treat accordingly.
H’s and T’s are mnemonics for the major causes of arrest:
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hyperkalemia or hypokalemia
- Hypothermia
- Tamponade (cardiac, tension)
- Toxins
- Tension pneumothorax
- Thrombosis (coronary, pulmonary)
ACLS Post Cardiac Arrest / Return of Spontaneous Circulation (ROSC)
Once the patient has been successfully resuscitated, it is important to focus on post-arrest care.
This includes:
Brain Management
- Targeted Temperature Management is the current standard of care for comatose post-cardiac arrest patients.
- The AHA recommends a target temperature of 33 degrees Celsius for 24 hours be used in comatose patients.
Heart Management
- Coronary intervention should be considered in all patients who remain unstable after resuscitation.
- This can be done via angioplasty or thrombectomy.
- Treat hypotension with systolic blood pressure less than 90 mmHg.
- Obtain a 12-Lead ECG
Intensive Care Management
- Respiratory Failure – Maintaining the patient’s airway, mechanical ventilation
- Liver Failure – Monitor for signs and symptoms, maintain adequate nutrition
- Renal Failure – Monitor for signs and symptoms, maintain hydration, dialysis if needed
AHA ACLS Acute Coronary Syndrome (ACS)
The AHA released updated guidelines for the management of ACS in 2020.
Acute Coronary Syndrome (ACS) is defined as a sudden onset of coronary artery disease that can lead to myocardial infarction (heart attack).
The mainstay of therapy for ACS is:
- Obtain a 12-Lead ECG
- Provide oxygen if oxygen is less than 94%
- Aspirin 160-325 mg if no contraindications
- Pain Control (morphine)
- Nitroglycrin sublingual or spray
Obtain a 12-Lead ECG
The AHA recommends that all patients with ACS receive a 12-Lead ECG to assess for ST-segment elevation.
If the patient has ST-segment elevation, they should be treated with early reperfusion therapy.
Oxygenation
The first and most important intervention for any patient in tachycardia is to ensure they are adequately oxygenated and ventilated.
As the oxygen demand on the heart increases, it is important to ensure they are receiving as much oxygen as possible.
Aspirin
The AHA recommends that all patients with ACS be treated with aspirin 162 to 325 mg as soon as possible.
There are very few contraindications to aspirin and it has been shown to decrease mortality in ACS.
Morphine Pain Control
Morphine is the preferred pain control agent in ACS.
It has been shown to decrease mortality and myocardial oxygen demand.
Nitroglycerin
Nitroglycerin is a medication that is used to decrease the workload on the heart and coronary dilation.
It can be given sublingually or as a spray. The AHA recommends that all patients with ACS be treated with nitroglycerin.
Contraindications for nitroglycerin inclde right ventircular acute myocardial infarction and sexual enhancement medication use such as Cialis and Viagra.
STEMI (ST Elevation MI) Interventions
The AHA recommends early reperfusion for all patients with ST-segment elevation myocardial infarction.
Reperfusion can be done via thrombolytics or primary percutaneous coronary intervention.
- Door to ballon inflation (PCI) goal is 90 minutes
- Door to needle (fibrinloysis) goal is 30 minutes
ACLS Dynamic Teams
ACLS is a team-based approach to resuscitation.
The most important part of ACLS is the development of a well-functioning team that can work together to provide the best care for the patient.
The AHA recommends that all ACLS teams have a designated team leader.
The team leader is responsible for coordinating the efforts of the team and ensuring that all members are aware of their roles.
The AHA also recommends that all ACLS teams have a designated medical director.
The medical director is responsible for the overall medical care of the patient and for the development of ACLS protocols.
If a person is given an assignment outside of their scope of practice or are not knowledge, it is the person’s responsibility to ask for another role.
Lastly, closed loop communication is vitally important during resuscitation efforts. The person performing an action should repeat back what the person has called and advised for clarification or when an action is being performed.
ACLS Stroke Guidelines
The AHA released updated guidelines for the management of stroke in 2020.
The mainstay of therapy for stroke is:
- Rapid identification and assessment
- Determining the time of last known well (LKW)
- Immediate blood pressure control if systolic blood pressure is greater than 185 mmHg or diastolic blood pressure is greater than 110 mmHg
- CT scan with no contrast to be performed immediately upon arrival
- Provide fibrinolytic therapy immediately as long as no contraindications are noted
- Rapid transfer to a comprehensive stroke center if one is available
- The AHA also recommends the use of telemedicine for the evaluation of stroke patients when a comprehensive stroke center is not available.
ACLS Mega Code Survey
The ACLS mega code survey is a tool that can be used to assess the knowledge of ACLS providers.
The ACLS Megacode survey consist of a primary survey and secondary survey.
ACLS Primary Survey (ABCDE)
The ACLS Primary Survey is ABCDE (Airway, Breathing, Circulation, Disability, and Exposure).
Airway
The airway should be assessed for patency and the presence of foreign bodies.
- Maintain airway patency in unconscious patients
- Use advanced airway if needed
- Confirm CPR/Ventilation/Secure Device
- Monitor Airway Placement with continuous quantitative waveform capnography
Breathing
The breathing should be assessed for the quality of breathing
- Give supplementary oxygen as needed
- 100% oxygen for cardiac arrest patients
- Titrate oxygen for stable patients
- Avoid excessive ventilations
- IMPORTANT: AGONAL GASPS ARE NOT NORMAL (FIRST SIGNS OF IMPENDING CARDIAC ARREST). START CPR IMMEDIATELY.
Circulation
The circulation should be assessed for blood pressure, heart rate, and pulse quality.
Monitor CPR quality
- Minimize interruptions and checking pulse no more than 10 seconds
- If person performing CPR starts to provide ineffective chest compressions: Give constructive feedback
Attach Monitor/Defibrillator/AED
- First Step to using AED is turning on the device. Then follow the prompts.
Obtain IV/IO Access
- Give Appropriate medications
- Administer IV/IO fluids
Check glucose levels/temperature/ capillary refill
IMPORTANT: BLOOD PRESSURE MINIMUM IS 90 mmHg
Disability
The disability should be assessed for the level of consciousness and the presence of seizures.
- Check for neurological function
- Quickly assess for responsiveness (LOC, Pupil Dilation)
AVPU
- Alert
- Verbal stimulation
- Painful stimulation
- Unresponsive
Exposure
The exposure should be assessed for the presence of signs and symptoms of injuries.
Remove clothing: Assess for obvious signs of trauma, bleeding, burns, markings, medical alert bracelet.
ACLS Secondary Survey (SAMPLE)
The ACLS Secondary Survey is SAMPLE (signs and symptoms; allergies; medications, past medical history; last meal, liquid consumed; and events).
Signs and Symptoms
The signs and symptoms should be assessed for the presence of any changes.
- Objective information from what we see
- Subjective information from family or the ambulance
Allergies
The allergies should be assessed for any food, medication, or environmental causes.
Medications
The medications should be assessed any medication causes.
- Over the counter medications
- Vitamins
- Supplements
- Prescribed Medications
- Any medications not prescribed that may have been ingested or used
Past Medical History
The past medical history should be assessed pre-existing conditions.
- Medical conditions
- Surgical history
- Previous hospitalizations
- Clinical procedures
Last Meal, Liquid Consumed
The last meal, liquid consumed should be assessed for the time of the last meal or drink.
- Time of last meal
- Type of food or drink consumed
Events
The events should be assessed for any changes that lead up to the current presentation.
- Headache
- Dizziness
- Nausea/vomiting
- Visual changes
- Sudden onset of symptoms (e.g., slurred speech)
Conclusion
ACLS algorithms are standardized protocols that guide the management of a variety of cardiac and non-cardiac emergencies. These ACLS algorithms provide a framework for the delivery of care, but they do not replace the need for clinical judgment. The ACLS provider must be able to assess the patient, identify the problem, and select the appropriate ACLS intervention.
The ACLS provider must also be familiar with the basic concepts of advanced airway management, defibrillation, and intravenous access. These ACLS interventions are the cornerstone of care for cardiac and non-cardiac emergencies.
If you are a healthcare professional who works with children, then you need to know about Pediatric Advanced Life Support (PALS).
PALS is a course that provides training in advanced life support for infants and children. It covers topics such as cardiac arrest, respiratory emergencies, shock, and more.
In this blog post, we will provide an overview of PALS and discuss everything that you need to know about it!
PALS History and Goals
The American Heart Association (AHA) created the PALS course in 1988 and is updated approximately every 5 five with the latest guidelines.
The goal of PALS is to improve the care of infants and children who are experiencing life-threatening events.
PALS is designed for healthcare professionals who work in:
- Emergency departments
- Intensive care units
- All pediatric care units and settings
- Pre-hospital settings (e.g., paramedics, EMTs)
Definition of Neonate, Infant, Child, and Adolescent in PALS
Neonate: A baby who is younger than 28 days old
Infant: A child who is between 29 days and 12 months old
Child: A child who is between 13 months and 12 years old (approximately age prior to puberty)
Adolescent: A teenager who is between 13 and 18 years old (when puberty is present either through armpit hair or breast development)
Basic Pediatric Life Support Guidelines
Pediatric Patient Assessment
The basic steps of Pediatric BLS are:
- Verify Scene Safety
- Check for responsiveness
- Call for help (Activate the Emergency Response System)
- Check for breathing and pulse
- Begin chest compressions
- Provide rescue breaths
- Continue chest compressions and rescue breaths until help arrives or the patient begins to breathe on their own.
Verify the scene is safe
Many times you may find that the scene may be unsafe with locations such as in the water, in the middle of the road, etc. If it is not safe, make the scene safe and move the person prior to starting interventions.
Check for Responsiveness
Tap the shoulders of a child or the heel of an infant and shout “Are you okay?”
If the patient does not respond, then they are unresponsive.
If the person does not respond, shout for nearby help and activate the emergency response system.
If no one responds, DO NOT LEAVE THE CHILD. Perform one round of CPR prior to finding help.
Activating the Emergency Response System
The first step in any emergency is to call for help.
You have two options
- If you have someone near you, have them get help and obtain an AED/Defibrillator
- If you are by yourself and have a mobile phone, call for emergency medical services and perform CPR.
Checking for Breathing and a Pulse
To check for breathing, look for the rise and fall of the chest.
To check for a pulse, the placement of your fingers will be dependent on the person’s age.
- Infant: palpate the brachial pulse
- Child: palpate the carotid or femoral pulse
These actions should be performed for a maximum of no more than 10 seconds.
If no breathing and pulse are present, immediately begin cardiopulmonary resuscitation (CPR).
Compressions, Airway, Breathing (CAB)
Chest Compressions Ratios, Placement, and Depth
For pediatric persons, there are three options for single-rescuer infant CPR.
30 chest compression: 2 breaths and 1 1/2 inches or 4cm in depth
- 2 fingers in the center of the infant’s chest, lower half of the breast bone
- 2 thumbs in the center of the infant’s chest, the lower half of the breastbone
- 1 hand in the center of the infants chest, lower half of the breastbone
Two-rescuer infant CPR
15 chest compressions: 2 breaths and 1 1/2 inches or 4cm in depth
- 2 thumbs in the center of the infant’s chest, the lower half of the breastbone
Children CPR Standards
30 chest compressions: 2 breaths and 2 inches or 5cm in depth
- 1 or 2 hand(s) in the center of the child’s chest, the lower half of the breast bone
Disclaimer regarding rescue breaths: According to guidelines posted by the American Heart Association on January 24, 2022, appropriate precautions should be worn when providing BLS, ACLS, and PALS standards with potential and confirmed COVID-19 positive patients. All providers should wear a respirator (i.e. N95), gown, gloves, and eye protection for suspected or confirmed COVID-19 infections when performing aerosol-generating procedures (AGP)s. Out of hospital cardiac arrest is dependent on early initiation of CPR including chest compression. It is not recommended for mouth-to-mouth resuscitation at this time but all patients should receive the best resuscitative efforts.
Chest Compression Rate
The compression rate should be 100-120 compressions per minute for infants, children, and adolescents.
You can keep track of the rate by counting out loud or using a metronome.
Allow for full chest recoil between compression and minimize interruptions to less than 10 seconds.
Be sure to switch compression team members every 2 minutes.
Airway And Breathing (CAB)
Utilize the sniffing position which requires flexion of the cervical spine and extension of the atlantooccipital joint.
Rescue breaths are one breath every 2 to 3 seconds regardless if there is an advanced airway present or not. You will want to see visible chest rise and fall within each rescue breath.
It is important to avoid excess ventilation because it can decrease coronary perfusion pressure and a reduction of cerebral blood flow causing PaCO2 to decrease.
How to use an AED/Defibrillator
When the AED arrives, review the instructions with the bystander.
Step One: Turn on the AED and follow the prompts.
Step Two: After removing the person’s shirt, apply the electrode pads to the patient’s bare chest in accordance with the instructions and plug in the connector. It is important to remove any wet barriers or medication patches before applying the pads.
- If the person is under 8 years old, use the child pads if available. If child pads are not available, you may use adult pads. Place pads so they do not touch each other. One pad is placed on the chest and the other pad is placed on the back. Pads should sandwich the heart when placed appropriately.
- If the person is 8 years old or older, use the adult pads. Do not use child pads as the shock will be too low of a dose.
Step Three: Stop chest compressions and confirm everyone is clear by saying “Stand Clear.”
Step Four: Push the analyze button and the AED will analyze the patient’s heart rhythm and, if needed, deliver a shock.
Step Five: if a shock is recommended, make sure no one is touching the person and repeat “Stand Clear.” Once clear, press the shock button.
Step Six: Immediately begin CPR following the shock or if no shock is advised. Perform another two minutes of CPR and follow the AED prompts again.
Agonal Breathing with a Pulse
If you see agonal breathing, it is still important to provide rescue breaths if there is a pulse present. Agonal breathing is an abnormal pattern of gasping and is not considered effective breathing.
Provide one rescue breath every 2 to 3 seconds with or without an advanced airway.
Bradycardic Rhythms in PALS
One of the most common bradycardic rhythms you may encounter in PALS is sinus bradycardia.
Sinus Bradycardia is defined as a heart rate of less than 60 bpm and the QRS complex is normal. The patient may or may not have symptoms.
Bradycardic Rhythm Interventions
Atropine
If symptomatic, the PALS guideline’s first drug of choice recommends atropine for bradycardia interventions. The initial dose is 0.02 mg/kg IV (maximum of 0.5 mg) and may be repeated once.
Important to note: Atropine can have a reverse effect in children causing cardiac arrest.
If the patient is unresponsive to atropine or has a high-degree heart block, you will need to place transcutaneous pacing pads.
Epinephrine
Epinephrine is an alternative drug choice for symptomatic bradycardia.
The recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of the 0.1 mg/mL concentration) and can be repeated 3 to 5 minutes
- ET Dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration)
Use epinephrine cautiously as raising blood pressures with an increase in heart rate can cause angina, myocardial ischemia, and increase oxygen demand.
For additional precautions, please reference an up-to-date drug guide.
Transcutaneous Pacing
Transcutaneous pacing is an external form of pacing that uses electrical current to stimulate the heart through the skin. This is considered a temporizing measure and is not a definitive treatment.
The pads are placed based on package instructions for pediatrics.
The unit will automatically deliver a pacing stimulus/demand rate at 60-100 bpm.
Pacer current (mA) output is also important as it determines the strength of the electrical impulse being delivered to the heart. The higher the number, the greater current being delivered which can cause burns if used for too long.
The recommended settings for an adult are:
-Pacing mode: demand
-Pacing rate: 60-100 bpm (can be set lower if the patient has a pre-existing tachycardia)
-Pacer output: 50-80 mA
Transcutaneous pacing should be continued until the patient’s condition improves, a transvenous pacemaker can be placed, or for no more than 45 minutes to avoid skin burns and patient discomfort.
Transcutaneous Precautions
Conscious paced patients may require additional analgesics for pacing discomfort. Also, you will want to avoid palpating the carotid pulses to confirm capture as the electric impulses cause muscle jerking that may mimic a pulse.
Trachycardic Rhythms in PALS
Two of the most common tachycardic rhythms you may encounter in PALS include supraventricular tachycardia and ventricular tachycardia with a pulse.
Supraventricular Tachycardia is defined as tachycardia that originates from above the ventricles in the atria or AV node.
Ventricular Tachycardia is defined as tachycardia that originates from the ventricles. This rhythm can become lethal if left untreated.
Tachycardic Rhythm Interventions
Vagal Maneuvers
Vagal maneuvers are a physical intervention used to decrease the heart rate by stimulating the vagus nerve.
The most common maneuver is the Valsalva maneuver which is performed by having the person:
- Take a deep breath in
- Attempt to exhale by bearing down or blowing through an occluded 10mL syringe for 15 to 20 seconds
This should result in a decrease in heart rate by decreasing the conduction of electrical impulses through the AV node.
Additional vagal techniques include coughing, a cold stimulus to the face, carotid massage, and gagging.
Adenosine
If unsuccessful vagal maneuvers are unsuccessful, the next step is to administer adenosine.
Adenosine is a medication that works by decreasing the conduction of electrical impulses through the AV node.
The recommended initial dose is 0.1 mg/kg given as a rapid IV push followed by a 10-20 mL saline flush (maximum dose 6mg). It also helps to elevate the extremity after administration.
The recommended second dose is 0.2 mg/kg given as a rapid IV push followed by a 20 mL saline flush (maximum dose 12mg).
Synchronized Cardioversion
If the patient remains unstable or unresponsive to previous interventions, synchronized cardioversion may be necessary.
Cardioversion is a procedure that uses electrical shocks to reset the heart’s electrical impulses and rhythm.
It is important to note that this should only be done when the person is unstable or unresponsive as it can be a painful and traumatic experience for the person.
Initial recommended voltage doses
- 0.5 to 1 joule/kg
- If the initial dose is not effective, increase to 2 joules/kg
Synchronized Cardioversion Procedure
- Obtain a 12-Lead ECG if the patient is stable
- Prepare proper sedation since cardioversion is painful and have emergency equipment ready in case of complications
- Place defibrillator pads on the person and set the monitor to synchronized (sync) mode. Engage the synch mode before each attempt.
- Look for sync markers above each R wave.
- Set your dose of electricity/voltage
- Clear all personnel from the patient prior to the shock
- Press the “charge” button, “clear” the patient, and press the “shock” button
- Reassess the patient after each shock
PALS Shockable Rhythms
There are two shockable rhythms in the AHA PALS guidelines that you may encounter in PALS: pulseless ventricular tachycardia and ventricular fibrillation.
Pulseless Ventricular Tachycardia is defined as a wide complex tachycardia with a heart rate of >100 bpm in the absence of a pulse.
Ventricular Fibrillation is defined as a rapid, erratic, and chaotic electrical activity in the ventricles that results in the loss of coordinated contractions.
PALS Shockable Rhythm Interventions
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.
Review the Basic Life Support Guidelines for CPR here
Defibrillation
Defibrillation is the use of electrical shocks to reset the heart’s electrical impulses and rhythm without syncing to the person’s intrinsic rhythm.
The recommended dose of electricity
- Initial Dose: 2 Joules/kg
- Second Dose: 4 Joules/kg
- Subsequent Dose: > or = to 4 Joules/kg
- Maximum Dose: 10 Joules/Kg
- Remember the mnemonic: 2, 4, 6, 8 – That’s the dose we defibrillate.
Defibrillation Procedure
- Turn on the defibrillator and set the joules based on the machine used
- Place adhesive pads on the person based on the pad’s package instructions
- Announce to the team “Charging defibrillator” and press the charge button
- When the defibrillator is fully charged, verify all team members are clear by announcing the shock. Once the team announces all clear and you have verified the team is not touching the person or bed, call “All Clear!”
- Press the shock button on the defibrillator
- Immediately after shock is delivered, resume CPR for 5 cycles (2 minutes) then reassess rhythm
Epinephrine
Epinephrine is a drug choice for cardiac arrest interventions.
The recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of the 0.1 mg/mL concentration) and can be repeated 3 to 5 minutes
- ET Dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration)
Use epinephrine cautiously as raising blood pressures with an increase in heart rate can cause angina, myocardial ischemia, and increase oxygen demand.
For additional precautions, please reference an up-to-date drug guide.
Amiodarone
Amiodarone is a medication that is used to slow the heart rate and improve cardiac output.
The recommended initial dose is 5 mg/kg IV or IO bolus.
The dose may be repeated up to 3 total doses for refractory ventricular fibrillation and pulseless ventricular tachycardia.
Lidocaine
Lidocaine is a medication that is used to treat ventricular arrhythmias and is considered immediately after the return of spontaneous circulation (ROSC).
The recommended initial dose during active CPR is 1 mg/kg IV or IO loading dose.
PALS Non-Shockable Rhythms
There are two non-shockable rhythms in the AHA PALS guidelines that you may encounter in PALS: asystole and pulseless electrical activity.
Asystole is defined as a heart rhythm that is not amenable to defibrillation also known as a flat line.
Pulseless Electrical Activity (PEA) is defined as electrical activity on the monitor but no mechanical activity.
PALS Non-Shockable Rhythm Interventions
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation (CPR) is the first line of defense for both of these rhythms as it provides oxygen to the heart and brain.
Review the Basic Life Support Guidelines for CPR here
Ephinephrine
Epinephrine is a drug choice for cardiac arrest interventions.
The recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of the 0.1 mg/mL concentration) and can be repeated 3 to 5 minutes
- ET Dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration)
Use epinephrine cautiously as raising blood pressures with an increase in heart rate can cause angina, myocardial ischemia, and increase oxygen demand.
For additional precautions, please reference an up-to-date drug guide.
Consider your H and T causes
It is important to consider your H’s and T’s for these rhythms and treat accordingly.
H’s and T’s are mnemonics for the major causes of arrest:
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hyperkalemia or hypokalemia
- Hypothermia
- Hypoglycemia
- Tamponade (cardiac, tension)
- Toxins
- Tension pneumothorax
- Thrombosis (coronary, pulmonary)
PALS Post Cardiac Arrest / Return of Spontaneous Circulation (ROSC)
Once the person has been successfully resuscitated, it is important to focus on post-arrest care.
This includes oxygenation and ventilation, hemodynamic monitoring, targeted temperature management, neuromonitoring, electrolytes and glucose, sedation, and prognosis.
Oxygenation and Ventilation
The first and most important intervention for any person with ROSC is to ensure they are adequately oxygenated and ventilated.
Be sure to monitor the patient’s oxygen saturation for any changes in condition or fluctuation that may require supplemental oxygen.
Hemodynamic Monitoring
It is important to monitor the patient’s hemodynamic status as this will give you insight into their cardiac output and tissue perfusion.
This includes cardiac telemetry, arterial blood pressure, and blood collection lactate and urine output.
Targeted Temperature Management / Brain Management
- Targeted Temperature Management is the current standard of care for comatose post-cardiac arrest patients.
- The AHA recommends a target temperature of 33 degrees Celsius for 24 hours be used in comatose patients.
Neuromonitoring
Neuromonitoring is important in post-arrest care as it can help to identify any neurological changes that may occur.
This includes continuous electroencephalogram, treating seizures, and brain imaging.
Electrolytes and Glucose
It is important to monitor the patient’s electrolytes and glucose levels as they can be easily disturbed in post-arrest care.
Be sure to monitor potassium, calcium, magnesium, phosphorus, and glucose levels.
Sedation
Sedation is often necessary for post-arrest care to ensure the person is comfortable and to prevent further neurological injury.
Prognosis
The final step in post-arrest care is to assess the person’s prognosis.
This includes looking at the person’s age, comorbidities, arrest factors, and response to treatment.
Pediatric Respiratory Emergencies
Upper Airway Obstructions
The most common cause of upper airway obstruction in children is the tongue.
Other causes include foreign bodies, such as food or toys, croup, anaphylaxis, and enlarged tonsils or adenoids.
The signs and symptoms of upper airway obstruction include stridor – hallmark sign, barking cough, hoarseness, drooling, snoring, gurgling, increased work of breathing, retractions, and cyanosis.
The first step in the management of upper airway obstruction is to ensure the child has a patent airway.
If the child is not able to maintain their own airway, they will need to be intubated.
The next step is to treat the underlying cause of the obstruction.
This may include removing a foreign body, administering medication for croup or anaphylaxis, or managing enlarged tonsils or adenoids.
Lower Airway Obstructions
The most common cause of lower airway obstruction in children is bronchiolitis.
Other causes include asthma, foreign body aspiration, and pneumonia.
The signs and symptoms of lower airway obstruction include expiratory wheezing/prolonged expiratory phase – hallmark sign, and increased work of breathing.
The first step in the management of lower airway obstruction is to ensure the child has a patent airway.
If the child is not able to maintain their own airway, they will need to be intubated.
The next step is to treat the underlying cause of the obstruction.
This may include administering medication for asthma or bronchiolitis, removing a foreign body, or treating pneumonia.
Lung Tissue Disease
Lung tissue disease is defined as any disease that affects the structure or function of the lungs. The lungs become stiff due to fluid accumulation in the alveoli, interstitium, or both.
The most common cause of lung tissue disease in children is pneumonia.
Other causes include pulmonary edema, pneumonitis, and acute respiratory distress syndrome (ARDS).
The signs and symptoms of lung tissue disease include increased work of breathing, tachypnea, crackles, grunting, and decreased breath sounds.
You will begin by treating the underlying cause of the obstruction.
This may include administering antibiotics for pneumonia, diuretics for pulmonary edema, or corticosteroids for pneumonitis.
Disorder Control of Breathing
Disordered control of breathing is defined as any disorder that affects the ability to control the depth or rate of breathing. This can include neurological disorders.
Other causes include metabolic abnormalities, drug overdoses, and poisoning.
The signs and symptoms of disordered control of breathing include variable/decreased respiratory rate and effort with normal breath sounds.
You will begin by treating the underlying cause of the disorder.
This may include avoiding hypoxemia/hypercarbia/hyperthermia for a neurological disorder, giving antidotes for poisoning or overdose, and ventilatory support for neuromuscular disease.
Intubation of Pediatric Persons
The process of intubation involves passing a tube through the mouth and into the trachea.
This is done in order to provide a patent airway and to allow for mechanical ventilation.
While the process of intubation is not covered, the complications that may occur are. Sudden deterioration in an intubated person can be detected during the DOPE mnemonic (displacement of the tube, obstruction of the tube, pneumothorax, and equipment failure).
Displacement of the Tube
The most common complication of intubation is the displacement of the tube (specifically displaced in the right bronchus).
This can occur due to coughing, vomiting, or suctioning.
If the tube is displaced, it will no longer be in the trachea and will need to be replaced.
Obstruction of the Tube
The second most common complication of intubation is obstruction of the tube.
This can occur due to secretions, mucus, blood, or vomit.
If the tube is obstructed, it will need to be suctioned.
Pneumothorax
Pneumothorax is a complication that can occur if the tube is placed too deeply in the trachea.
This can cause the lung to collapse.
There are two types of pneumothoraces: simple and tension.
- Simple pneumothorax is when the lung collapses but there is no tension on the heart. Sudden deterioration in oxygen, decreased chest expansion, and loss of breath sounds on the involved side can be noted.
- Tension pneumothorax is when the lung collapses and there is tension on the heart. Sudden deterioration is evident by hypotension and a decrease in cardiac output.
If a pneumothorax occurs, the tube will need to be removed and the person will need to be treated for the pneumothorax via a chest tube.
Equipment Failure
The final complication of intubation is equipment failure.
This can occur due to a number of reasons such as power failure, malfunctioning equipment, or human error.
If equipment fails, it will need to be replaced.
AHA PALS Shock Emergencies
Shock is a condition in which the body is not getting enough blood flow.
This can be due to a number of reasons such as cardiac arrest, anaphylaxis, or trauma.
There are four kinds of shock: hypovolemia, cardiogenic, distributive, and obstructive shock.
Hypovolemic Shock
Hypovolemic shock is when there is a decrease in blood volume.
This can be due to blood loss, dehydration, or third spacing.
The signs and symptoms of hypovolemic shock include tachycardia, hypotension, and decreased urine output.
The treatment for hypovolemic shock is to replace the fluid that has been lost.
This can be done via IV fluids or blood transfusion.
Cardiogenic Shock
Cardiogenic shock is when the heart is unable to pump enough blood to meet the body’s needs.
This can be due to myocardial infarction, cardiac tamponade, congenital heart disease, myocarditis, cardiomyopathy, or pulmonary embolism.
The signs and symptoms of cardiogenic shock include tachycardia, bradyarrhythmia, hypotension, and decreased cardiac output.
The treatment for cardiogenic shock is to support the heart and to treat the underlying cause.
This can be done via IV fluids, inotropes, and mechanical support.
Distributive Shock
Distributive shock is when there is a decrease in perfusion to the tissues.
This can be due to sepsis, anaphylaxis, neurogenic shock, or spinal cord injury.
The signs and symptoms of distributive shock include tachycardia, hypotension, and decreased urine output.
The treatment for distributive shock is to treat the underlying cause.
This can be done via IV fluids, antibiotics, antihistamines, epinephrine, and vasopressors.
Obstructive Shock
Obstructive shock is when there is an obstruction in the blood flow.
This can be due to tension pneumothorax, cardiac tamponade, ductal-dependent left ventricle obstruction, pulmonary embolism, or thrombosis.
The signs and symptoms of obstructive shock include tachycardia, bradyarrhythmia, hypotension, and decreased cardiac output.
The treatment for obstructive shock is to treat the underlying cause.
This can be done via an IV fluid, chest tube, pericardiocentesis, needle decompression, thrombolytic, or surgery.
AHA PALS Systematic Approach for Megacode
The systematic approach for megacode can help identify a potentially life-threatening emergency through the use of identifying, intervening, and evaluating.
Initial Impression (A, B, C)
The first step is to identify the person and the problem. This is done by assessing the person’s initial impression through appearance, breathing, and circulation.
Appearance
The person’s appearance includes the level of consciousness and ability to interact.
This can be done by using the Glasgow Coma Scale.
Breathing
The person’s breathing includes the rate, depth, and quality of breathing.
This can be done by observing the person’s chest rise and fall and listening for any audible breath sounds including wheezing, grunting, and stridor.
Circulation
The person’s circulation includes the skin color and condition.
This can be done by noting any pallor, petechiae, bleeding, and/or wounds.
Primary Assessment Survey (A, B, C, D, E)
The PALS Primary Survey is ABCDE (Airway, Breathing, Circulation, Disability, and Exposure).
Airway
The airway should be assessed for patency and the presence of foreign bodies.
- Maintain airway patency in unconscious patients
- Is there good flow in the trachea? The cricoid cartilage is the narrowest point in a pediatric airway. The pediatric head, tongue, and epiglottis are larger than those of adults.
- Use advanced airway if needed
- Confirm CPR/Ventilation/Secure Device
- Monitor Airway Placement with continuous quantitative waveform capnography
Breathing
The breathing should be assessed for the quality of breathing
- Is the respiratory rate regular, increased, or decreased? Is breathing effort unlabored? Is the chest expanding appropriately? Are there any adventitious breath sounds?
- Give supplementary oxygen as needed
- 100% oxygen for cardiac arrest patients
- Titrate oxygen for stable patients
- Avoid excessive ventilation
- IMPORTANT: AGONAL GASPS ARE NOT NORMAL (FIRST SIGNS OF IMPENDING CARDIAC ARREST). START CPR IMMEDIATELY.
Circulation
The circulation should be assessed for blood pressure, heart rate, and pulse quality.
- Is the heart rate regular, increased, or decreased? Heart rate greater than 180/min in an infant or toddler and 160/min in a child older than two years old warrants assessment.
- Is the heart rhythm regular or irregular?
- Pulses equal both peripherally and centrally
- Is the blood pressure hypotensive or hypertensive? Low systolic blood pressure is a late sign that something is wrong. Low systolic blood pressure is less than 70 + 2x(Age of Years of Child). Exceptions: neonates <60, infants <70, children ages 10 and older <90.
- Skin color and temperature
- Capillary refill
Disability
The disability should be assessed for the level of consciousness and the presence of seizures.
- Check for neurological function – level of consciousness, pupillary responsiveness
- AVPU – Alert, Verbal stimulation, Painful stimulation, Unresponsive
- Monitor blood glucose – neonate <45, infant/child < or = 60
Exposure
The exposure should be assessed for the presence of signs and symptoms of injuries.
- Body temperature
- Remove clothing: Assess for obvious signs of trauma, bleeding, burns, markings, medical alert bracelet
PALS Secondary Survey (SAMPLE)
The PALS Secondary Survey is SAMPLE (signs and symptoms; allergies; medications, past medical history; last meal, liquid consumed; and events).
Signs and Symptoms
The signs and symptoms should be assessed for the presence of any changes.
- Objective information of what we see
- Subjective information from family or the ambulance
Allergies
The allergies should be assessed for any food, medication, or environmental causes.
Medications
The medications should be assessed for any medication causes.
- Over the counter medications
- Vitamins
- Supplements
- Prescribed Medications
- Any medications not prescribed that may have been ingested or used
Past Medical History
The past medical history should be assessed pre-existing conditions.
- Medical conditions
- Surgical history
- Previous hospitalizations
- Clinical procedures
- Immunizations up to date
Last Meal, Liquid, Pee, Poop
The last meal or liquid consumed should be assessed for the time of the last meal or drink.
- Time of last meal
- Type of food or drink consumed
The last pee or poop should be assessed
- When was the last pee, poop, or wet diaper?
- How much was it?
Events
The events should be assessed for any changes that lead up to the current presentation.
- Headache
- Dizziness
- Nausea/vomiting
- Visual changes
- Sudden onset of symptoms (e.g., slurred speech)