BLS ACLS Complilation

COLLEGE OF NURSING
Silliman University
Dumaguete City
CARDIOPULMONARY RESUSCITATION (CPR)

Definition: Cardiopulmonary resuscitation (CPR) is a lifesaving technique or an emergency procedure which is a
combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest or
respiratory or cardio-respiratory arrest. CPR is also referred to as Basic Life Support.
Purposes:
1. To promote patient’s circulation in order to maintain perfusion of blood and oxygen to the brain, heart
and other vital organs.
2. To restore patient’s breathing.
3. To maintain life until a victim/patient recovers, or advanced cardiac life support is available.
Equipment:
1. Bag valve mask (optional)
2. Pocket mask (optional)
3. Clean gloves (optional)
STEPS PRINCIPLE/RATIONALE
1. Stay safe. Follow universal precautions and The worst thing that a rescuer can do is that which
wear personal protective equipment if you makes him/her become another victim.
have it. Use common sense and stay away
from potential hazards.
2. Assess the patient for a response and check This prevents injury from attempted resuscitation of a
for normal breathing. Tap the patient’s person who has not suffered a cardiac or respiratory
shoulders and shout, “Are you okay?”, twice arrest.
while scanning the chest for movement.
3. If patient is unresponsive, call for help. For In- This activates mechanism for additional personnel.
hospital cardiac arrest (IHCA), call for a
“code”. For out-of-hospital cardiac arrest
(OHCA), have somebody call emergency
phone number. As much as possible, do not
leave patient alone.
4. Place patient in a supine position on a firm This position facilitates rescue breathing and
flat surface. In hospital setting, a backboard subsequent external compressions of the heart as
or cardiac board is used. necessary, it allows heart to be compressed between
sternum and the firm surface.
5. Assess for presence of pulse and for absence Assessing the pulse accurately ensures that the chest
of breathing or for presence of only gasping compressions are not performed on a patient who
for 10 seconds, simultaneously. has a pulse which may result in serious medical
complications. Carotid pulse is most central and
accessible artery in adults and children over one
year old. Carotid artery pulse will persist when
peripheral pulses are no longer palpable.
For Adults – palpate the carotid pulse by

placing your index fingers in the groove
between the windpipe and the muscle next
to it on your side of the patient’s neck.
6. If patient is pulseless, begin external cardiac

compression.
a. Kneel alongside the patient. This position will allow you to comfortably apply
vertical pressure during compression.
b. Spread your knees apart. To ensure a wide base of support.
c. Visualize the center of the patient’s chest. For proper placement of the hands.
d. Place heel of one hand in the center of Allows placement of the hands right above the
the patient’s chest. Keep that hand in heart. Proper hand position reduces the risk of rib
position and place the heel of the other fracture, punctured lung or a ruptured liver.
hand on top of it. Interlock the fingers of
both hands.
e. Lock elbows. Keep arms straight and Thrust for each chest compression is straight down
directly over the hands on the patient’s the sternum. Complete chest recoil allows the heart
sternum. Using the weight of your upper to fill with blood. This will Increase blood flow that will
body, compress the patient’s chest at subsequently increase perfusion to the brain, heart
least 2 inches (5 cm). and other vital organs.
Note: For chest compressions, PUSH HARD AND FAST.

Compress at the rate of 100-120 compressions/min.
Allow chest to recoil completely after each
compression. Minimize interruptions in compressions.
7. Open patient’s airway using either of the

following techniques:
a. Head tilt-chin lift maneuver

Place one hand on the patient’s This is the safest technique to opening the airway of
forehead and apply firm and backward the victim with suspected spinal chord injury (SCI)
pressure with the palm to tilt the head because it can usually be accomplished without
back. Place fingers of the other hand on extending the neck.
the bony part of lower jaw near chin. Lift
the jaw to bring the chin forward.
b. Jaw-thrust Maneuver
Place one hand on each side of the This is used when the head tilt-chin lift doesn’t work,
victim’s head. You may set your elbows or a spinal injury is suspected. In neck injuries, moving
on the surface on which the victim is lying. the head can cause paralysis or death.
Put your fingers under the angles of the
victim’s lower jaw and lift with both hands,
displacing the jaw forward. If the lips
close, push lower lip with your thumb to
open the lips. (Jaw-thrust maneuver is
done by trained CPR providers)
8. Give two rescue breaths after 30

compressions.
Mouth to mouth resuscitation

a. Pinch patient’s nose with the thumb Proper airtight seal prevents air from escaping.
and index fingers, with the hand on patient’s
forehead. Take a regular breath (do not
deep breathe) and seal lips around patient’s
mouth, creating an airtight seal. Deliver first In most adults this volume of air is 800 mL and is
breath to patient lasting for approximately 1 enough to make the chest rise. Adequate
second and enough to make the chest rise. ventilation is indicated by observing chest rise and
fall and having air escape during exhalation.
Note: If the chest does not rise, reposition head to Excessive, forceful and rapid volume of breaths may
open airway through head tilt-chin lift/jaw-thrust cause pharyngeal pressure to exceed esophageal
maneuver. pressures allowing air to enter stomach, rather than
the lungs. This can cause gastric inflation which can
b. Break contact with the patient’s result in complications such as vomiting, aspiration
mouth and allow patient’s chest to relax. and pneumonia.
c. Take a regular breath and seal lips.
Mouth-to-mask breaths using a pocket mask

a. Position yourself at the victim’s side.
b. Put pocket mask on victim’s face, with
the bridge of the nose as guide for proper
position
c. Seal the pocket mask against the
face: With the use of your hand that is closer
to the top of the victim’s head, place the
index finger and thumb laterally at the edge
of the mask. Place the thumb of the other
hand along the edge of the mask.
d. Place the rest of the fingers of the
second hand along the bony margin of the
jaw and lift the jaw. Perform a head-tilt chin
lift to open the airway.
e. As you lift the jaw, press firmly and
completely around the outside edge of the
mask to seal the pocket mask against the
face.
f. Deliver each breath over 1 second,
just enough to make the victims chest rise.
9. Observe for rise and fall of chest wall with To ensure that artificial respirations are entering the
each respiration. If lungs do not inflate after lungs.
first two rescue breaths, reposition head and
neck and check for visible, airway obstruction
such as vomitus, food, loose dentures and the
like.
10. Suction any secretions from airway. If suction Suctioning/removing object from patient’s mouth
is unavailable, turn patient’s head to one prevents airway obstruction. Turning patient’s head
side. If foreign object is seen in patient’s to one side allows drainage of secretions by gravity.
mouth remove it
11. Continue CPR for a total of 5 cycles at 30:2

compressions to ventilation ratio. Do not
change your hand position during
compressions.
12. Reassess patient after 5 complete cycles (30:2 CPR must be continued until one of the following
each cycle). Every two (2) minutes CPR, for occurs:
chest movement and pulse. 1. The patient resumes breathing and pulse
returns.
2. Rescuers able to turn over CPR to an
Emergency Medical Service ( EMS) provider.
3. Rescuer becomes exhausted.
13. Minimize interruptions. Try to keep
interruptions to 10 seconds or less. If you
detect a pulse but no breathing, give 10-12
rescue breaths per minute and check pulse.
If you still don’t detect a pulse, continue CPR
in cycles of 30 compressions and 2 rescue
breaths, beginning with compression.
14. Let the patient assume a recovery position.
Note: For Adults 2-rescue CPR.

One person is positioned at patient’s side and
performs external cardiac compression, while the
other is positioned at the patient’s head to maintain
an open airway, give breaths and monitor the
carotid pulse. The compression rate is at 100-
120/minute. Compression ventilation ratio at 30:2.
When only 2 rescuers are available, switch
compressors about every 5 cycles or every 2 minutes,
taking less than 5 seconds to switch.
Revised by: Asst. Prof. Chereisle G. Pyponco

September 2020
References:
1. Basic Life Support: Provider manual. 2016. USA. American Heart Association
2. SUCN Procedure Manual on CPR. 2015. Revised by Asst. Prof. Veveca V. Bustamante
COLLEGE OF NURSING
Silliman University
Dumaguete City
CARDIOPULMONARY RESUSCITATION (CPR) CHECKLIST
Criteria Excellent Satisfactory Below Needs major Total Remarks

Satisfactory remediation Score
1. Stayed safe. Followed universal
precautions and wore personal ______ ______ ______ ______ ______
protective equipment.
2. Tapped patient’s shoulders and shouted ______ ______ ______ ______ ______
“Are you okay?” twice and scanned the
chest for movement.
3. Called for help. ______ ______ ______ ______ ______
4. Placed patient in supine position on a firm, ______ ______ ______ ______ ______
flat surface. Used a cardiac board.
5. Assessed for carotid pulse and absence

of breathing or only gasping for not more ______ ______ ______ ______ ______
than 10 seconds.
6. Began external cardiac compression (if

pulseless and breathless)
a. Knelt alongside the patient ______ ______ ______ ______ ______
b. Widened base of support. ______ ______ ______ ______ ______
c. Visualized the center of the patient’s ______ ______ ______ ______ ______
chest.
d. Placed the heel of one hand at the
center of the patient’s chest and kept ______ ______ ______ ______ ______
the hand in position. Placed the other
hand on top of the first, with fingers
interlocked.
e. Locked elbows. Used weight of the
upper body and compressed at the ______ ______ ______ ______ ______
depth of at least 2 inches.
7. Opened patient’s airway
a. Head-tilt/chin-lift maneuver or ______ ______ ______ ______ ______

b. Jaw-thrust maneuver ______ ______ ______ ______ ______
8. Gave 2 rescue breaths after 30

compressions
For Mouth-to-mouth resuscitation: ______ ______ ______ ______ ______
a. Pinched patient’s nose with the

thumb and index fingers of the hand
on patient’s forehead. ______ ______ ______ ______ ______
b. Sealed lips around patient’s mouth. ______ ______ ______ ______ ______
c. Delivered first breath to patient lasting
for approximately 1 second enough
to make the chest rise. ______ ______ ______ ______ ______
d. Broke contact with patient’s mouth
______ ______ ______ ______ ______
For Mouth-to-mask breaths using a
pocket mask:
a. Positioned onerself at the victim’s ______ ______ ______ ______ ______

side.
b. Put pocket mask on victim’s face, ______ ______ ______ ______ ______
with the bridge of the nose as guide
for proper position ______ ______ ______ ______ ______
c. Sealed the pocket mask against the
face: With the use of your hand that
is closer to the top of the victim’s
head, place the index finger and
thumb laterally at the edge of the
mask. Placed the thumb of the other
hand along the edge of the mask.
d. Placed the rest of the fingers of the ______ ______ ______ ______ ______
second hand along the bony margin
of the jaw and lift the jaw. Perform a
head-tilt chin lift to open the airway.
e. Lifted the jaw, pressed firmly and ______ ______ ______ ______ ______
completely around the outside edge
of the mask to seal the pocket mask
against the face.
f. Delivered each breath over 1 ______ ______ ______ ______ ______
second, just enough to make the
victims chest rise.
9. Observed for rise and fall of chest wall ______ ______ ______ ______ ______
each respiration.
SCENARIO: AED arrived. Pads were

attached to chest. Defibrillated patient.
AED prompts HCP to resume compression.
10. Continued CPR for a total of 5 cycles at ______ ______ ______ ______ ______
30:2, compressions to ventilation ratio.
11. Ventilated lungs with two rescue breaths. ______ ______ ______ ______ ______
12. Reassessed patient after 5 complete

cycle (30 compression, 2 ventilations ______ ______ ______ ______ ______
each cycle). Every 2 minutes of CPR, HCP
checked for chest movement and pulse.
13. Minimized interruptions. Tried to keep

interruptions to 10 seconds or less. ______ ______ ______ ______ ______
SCENARIO: If patient has pulse:

- Gave rescue breaths every 5-6
seconds
- Rechecked patient after 2 minutes
14. Allowed the patient to assume the

recovery position. ______ ______ ______ ______ ______
NOTE: The student needs to do remediation by repeating the procedure if he/she does not attain at least 75%
satisfactory marks. Otherwise, the instructor only needs to remediate in portions of the procedure.
___________________________________ ____________________________________
Student’s Name Instructor’s Name and Signature
Nursing Care Management 106B
First Semester, SY 2020-2021
Facilitator: Asst. Prof. Chereisle G. Pyponco

Prepared by: Asst. Prof. Veveca V. Bustamante
First aid procedure intended to revive a heart
and lung arrest within 3-4 minutes, from the
time the heartbeat and breathing stops to
prevent death or irreversible brain damage.
How long can the brain go without
oxygen before serious damage occurs?
Source:
http://www.med.umich.edu/trans/transweb/faq/q3.
shtml
1. Five Links of ADULT CHAIN OF SURVIVAL
2. Look, listen, and feel for breathing has been

removed from the algorithm.
3. Continued emphasis has been placed on high-

quality CPR
Highlights of the
Adult CPR Guideline
2015 Cont’d
4. C-A-B rather
than A-B-C
5. Rate is at least
100/min and
depth of at least
2 inches
1. Compression of the chest
cavity can create blood
flow.
2. Combined rescue breaths
and chest compressions
are capable of providing
some oxygen.
3. Immediate CPR could double or triple the chances

of survival.
To maximize internal blood flow:
1. Chest compressions:
performed HARD and FAST.
Face- 2. Full chest recoil at the top of
up
each compression.
3. Minimize any
interruptions to
Firm compressions.
surface
2 inches
Chin Don’t press
Lift too hard!
Head
Tilt
1 breath: 1
second duration
Chest
rise Barrier
devices
Face
Mask
Face
Shield
1-2 L
Capacity
Mouth cannot be opened, victim is in water, or
mouth-to-mouth seal is difficult to achieve.
1. Approach Safely “The scene is safe. Stand Clear!...”
2. Check for Responsiveness and Normal Breathing
▪ 3-5 seconds
▪ Gently shake the shoulders and ask loudly,
“HEY! HEY! ARE YOU OK?” (TWICE)
while SCANNING THE CHEST for
NORMAL BREATHING
▪ “Patient is unresponsive and breathless…”
Steps of CPR
Cont’d
3. Shout for Help
“HELP! CALL 911!

ACTIVATE EMS and
GET THE A.E.D.”
Hospital: “HELP!
Activate the code and
GET THE A.E.D.”
Steps of
CPR Cont’d
4. Check for carotid pulse and breathing
Not more than 10

seconds
Rate:
100-
120/min
5. Give 30 compressions
Steps of
CPR Cont’d
6. Open the Airway
Head-Tilt Jaw
Chin Lift Trained Thrust
Untrained
Steps of
CPR Cont’d
7. Give 2 Rescue Breaths

after 30 Compressions
DELIVER BREATHS SLOWLY

Steps of
CPR Cont’d
8. Continue CPR for a total of 5 cycles at 30:2.

Compression to Ventilation Ratio.
▪ When possible, change CPR

operator every 2 minutes
▪ 5 cycles = within 2 minutes
▪ 1 cycle= in less than 18 seconds
▪ 1 minute= at least 100
compressions
Steps of
CPR Cont’d
9. Reassess for Breathing and Pulse.
A. If breathless and pulseless:

Repeat another 5 cycles for 2 minutes at 30:2
ratio
B. If with pulse but no breathing:
Provide ventilation at 1 every 5-6 seconds for 2
minutes
C. If with spontaneous pulse and breathing:
Place patient in recovery
position
Steps of
CPR Cont’d
10. Recovery Position
UNINJURED PATIENT
Steps of
CPR Cont’d INJURED PATIENT
10. Recovery Position
Steps of
CPR Cont’d
*NOTE: Attach and use AED as soon as it is available.

If AED arrives:
▪ Stop CPR
▪ Place the patches
▪ Follow voice
prompt of the
AED.
***If SHOCK is advised, stay clear***
Steps of
CPR Cont’d
After
defibrillating,
continue CPR for
5 cycles again.
pontaneous breathing and pulse is present.
eam (EMS) arrives.
ver-exhaustion of the rescuer.
hysician declares the patient dead.
cene is unsafe.
ractured ribs.
acerated liver.
telectasis (punctured lungs).
astric distention.
Infant CPR
Cont’d
1. Tap the infant’s foot and shout “Baby, baby are

you OK?” while scanning chest for movement.
2. If the infant is unconscious, call

for help.
3. Place the infant on a
table or on a firm,
flat surface.
4. Check for the brachial pulse.
Infant CPR
Cont’d
5. Place 3 fingers
directly below and
perpendicular to the
nipple line.
6. Raise your index finger so that the middle
and index fingers are a width below the
nipple line.
7. Compress for approx. 1 ½ inches
or 4 cm.
8. If the patient is not breathing prepare for
artificial respirations.
Infant CPR
Cont’d
9. Seal infant’s nose and

mouth using BVM.
10. Deliver 2 gentle puffs of

air at 1 second interval.
11. Reassess the infant after

5 cycles.
Component Adults Children Infants
Unresponsive (for all ages)
Recognition
No breathing or no normal No breathing or only gasping
breathing (i.e. only gasping)
No pulse palpated within 10 seconds for all ages (HCP only)

CPR sequence C-A-B
Compression Rate At least 100/min
Compression Depth At least 2 inches At least ½ AP diameter At least ½ AP diameter
About 2 inches (5cm) About 1 1/2 inches (4cm)
Chest wall recoil Allow complete recoil between compressions

HCPs rotate compressors every 2 minutes
Compression Interruptions Minimize interruptions Attempt to limit interruptions to <10 seconds
Airway Head tilt-chin lift (HCP suspected trauma: jaw thrust)

Compression-to-ventilation 30:2 Single rescuer
ratio 30:2 15:2 2HCP rescuers
(until advanced airway placed)
Ventilations: when R untrained

or trained & not proficient Compressions only
Ventilations with advanced 1 breath every 6-8 seconds (8-10 breaths/min) Asynchronous with chest compressions
airway (HCP) About 1 second per breath Visible chest rise
Defibrillation Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after
shock; resume CPR beginning with compressions immediately after each shock.
 FBAO for conscious victim
 Obese victim
 Pregnant victim
 The precordial thump should no be used
for unwitnessed Out- of -Hospital Cardiac
arrest.
The precordial thump maybe considered for
patients with witnessed,monitored,unstable
VT(including pulseless VT) if defibrillator is
not immediately ready for use,but it should not
delay CPR and shock delivery.
▪ Calumpang, D. & Toble, P. 2006 ed. Philippine National Red Cross, Basic
Life Support – Cardiopulmonary Resuscitation.
▪ Hazinski, Mary Fran, Gonzales, Louis & O’Neill, Lindy. AHA, Learn and
Live, BLS (Basic Life Support) for Health Care Providers. 2006.
▪ Mutchner, Linda. The ABCs of CPR Again. American Journal of Nursing.
Vol. 107. No. 1, Jan. 2007, pp 61-68.
▪ Taylor, Nicole T. For New CPR Guidelines, Think 30. Critical Care, Spring
2006. Lippincott. Williams & Williams. p. 21.
▪ Retrieved: www.cpr.org.
▪ American Heart Association and ECC CPR Guidelines2010
▪ NC-CLEX: Handouts 2011
▪ American Heart Association and ECC CPR Guidelines 2015
CARDIOPULMONARY RESUSCITATION
Definition
• First aid procedure intended to revive a heart

and lung arrest within 3-4 minutes, from the
time the heartbeat and breathing stops to
prevent death or irreversible brain damage.
Purposes
1. To restore patient’s breathing.

2. To assist patient’s blood circulation by keeping
the brain, heart and other vital organs supplied
with blood and oxygen.
3. To maintain life until a victim recovers or
advanced life support is available.
Highlights of the adult CPR 2010
1. Five Links of ADULT CHAIN OF SURVIVAL

2. “Look, listen, and feel for breathing” has been
removed from the algorithm
3. Continued emphasis has been placed on high-
quality CPR
4. C-A-B rather than A-B-C
5. Rate is at least 100/min and depth of at least 2
inches
5 links of the Adult Chain of Survival
• Immediate Recognition of Cardiac Arrest and Early
Access- The chain of survival begins with immediate
recognition of cardiac arrest and rapid activation of EMS
or an Emergency Action Plan.
• Early CPR- Early CPR with emphasis on compression.
5 links of the adult chain of survival
• Rapid Defibrillation- Survival rates: highest if CPR is
started immediately & defibrillation is done w/in 3-5
mins.
• Early Advance Life Support (ALS) - involves medical

procedures and medications used by paramedics, RNs
and MDs.
5 links of the adult chain of survival
• Integrated Post-Cardiac Arrest Care- A bundled
treatment strategy after cardiac arrest that allows the
patient’s status to return to normal or near-normal.
PROBABILITY OF SURVIVAL- VF
BENEFITS OF CPR
• Compression of the chest cavity
can create blood flow
• Combined rescue breaths and
chest compressions are capable of
providing some oxygen
• Immediate CPR could double or
triple the chances of survival.
CABs of CPR
CIRCULATION
• Victims must be face-up and lying flat on a firm
surface.
To maximize internal blood flow:

• Chest compressions: performed hard and fast.
• Full chest recoil at the top of each compression.
• Minimize any interruptions to compressions.
2 inches
CABs of CPR
AIRWAY
head tilt-chin lift maneuver to open the airway
of a victim without evidence of head or neck
trauma.
- one hand on client’s forehead, tilt head with palm
using firm backward pressure
- fingers of other hand under lower jaw; tilt jaw
to bring teeth almost to occlusion.
CABs of CPR
AIRWAY
• Tilting the head and lifting the chin will pull the
tongue away from the back of the throat and
open the airway.
• Don’t press too hard on the soft area under the
chin. Doing so can block the airway.
CABs of CPR
Jaw- thrust Maneuver
 use in suspected spinal cord injury.
Open the airway without head extension.
Stay at client’s head part, elbows on the
ground/bed, grasp both angles of the lower jaw,
lift both hands displacing the mandibles forward
and tilting head
CABs of CPR
BREATHING
• Rescue breath uses your own exhaled air to force
oxygen into the lungs
• Give each breath in one second duration.
• Allow the victim to exhale completely between
breaths.
• It is recommended to use a barrier device
CABs of CPR
BREATHING
• Deliver each rescue breath over a period of 1
second.
• Give a sufficient tidal volume (by mouth-to-

mouth/mask or bag mask with or without
supplementary oxygen) to produce visible chest
rise.
• Avoid rapid or forceful breaths.

Ventilation With Bag and Mask
made of transparent material
with 1-2 L capacity
When using a bag-mask device,

deliver each breath over a
period of 1 second and provide
sufficient tidal volume to
cause visible chest rise.
Mouth-to-Barrier
Device Breathing
• Barrier devices may not
reduce the risk of infection
transmission, and some may
increase resistance to air
flow.
• 2 types: face shields and face
masks.
Mouth-to-Nose
Ventilation
- mouth cannot be opened,

victim is in water, or mouth-
to-mouth seal is difficult to
achieve
Mouth-to-Stoma Ventilation
Mouth-to-stoma rescue breaths

- reasonable alternative is to
create a tight seal over the
stoma with a round pediatric
face mask
- no published evidence on the
safety, effectiveness, or
feasibility of mouth-to-stoma
ventilation.
STEPS OF CPR
1. Approach Safely
• “The scene is safe. Stand Clear!...”
2. Check for Responsiveness and Normal Breathing

• 3-5 seconds
• Gently shake the shoulders and ask loudly, “HEY! HEY!
ARE YOU OK?” (TWICE) while SCANNING THE CHEST for
NORMAL BREATHING
• “Patient is unresponsive and breathless…”
3. Shout for Help
• “HELP! CALL 911! ACTIVATE EMS and GET THE A.E.D.”
• In-hospital Scenario:
• “HELP, Activate the code and get an AED!”
• IF YOU OR SOMEONE ELSE HAS CALLED THE EMERGENCY

RESPONSE NUMBER, KNEEL AT THE VICTIM’S SIDE NEAR THE
HEAD, AND START CPR.
CPR
4. Check Carotid Pulse
Pulse Check: 5 - 10 secs 2 inches
5. Give 30 compressions
• Place the heel of one hand
@ the center of the chest
• Place other hand on top
• Interlock/interlace fingers
• Compress the chest
– a. Rate of at least 100/min
– b. Depth of at least 2 inches
CPR
6. Open the Airway
• Victim must be face up, on a firm, flat
surface.
• If victim is lying face down: roll him or
her over.
• Minimize turning or twisting of the
head and neck.
• Blockage: common cause  tongue.
• Untrained Responder: HTCL
• Trained Responder: HTCL or JTM for
suspected SCI
CPR
7. Give 2 Rescue Breaths after
30 Compressions
GIVE 2 SLOW RESCUE BREATHS via:
1. mouth to barrier
2. bag mask technique
*DELIVER BREATHS SLOWLY*

STEPS for MOUTH TO BARRIER DEVICE
RESUSCITATION:
• USE: E-C Clamp technique
• Hyperextend patient’s head use:HTCL
• Take a normal breath
• Place lips over one-way valve of the
device
• Blow until the chest rises; take about
1 second
• Allow chest to fall
• Repeat (1 second per breath; 1
second interval)
CPR
8. Continue CPR for a total of 5 cycles at 30:2, Compression to
Ventilation Ratio.
During Chest Compression:
• Do not bend elbows
• Hands facing northward
• Arms of rescuer: perpendicular to client’s sternum- “PUSH DOWN”
• HEEL OVER THE STERNUM
• When possible, change CPR operator every 2 minutes
• 5 cycles = within 2 minutes
• 1 cycle= in less than 18 seconds
CPR
9. Reassess for breathing and pulse
A. If breathless and pulseless:

Repeat another 5 cycles for 2 minutes at 30:2 ratio
B. If with pulse but no breathing:
Provide ventilation at 1 every 5-6 seconds for 2 minutes
C. If with spontaneous pulse and breathing:
Place on recovery position
CPR: Recovery Position:
Uninjured Patient
1. Kneel beside the
victim; make sure
both legs are
straight. Place the
arm nearest to you
out at a right angle
to the body, elbow
bent palm up
Uninjured Patient
2. Bring far arm across

chest; hold back of
hand against victim’s
cheek nearest you.
With your other hand,
grasp far leg just
above knee and pull
up
Uninjured Patient
3. Keeping victim’s hand

pressed against the
cheek, pull on far leg to
roll victim towards you.
Adjust the upper leg so
both the hip and the
knee are bent at right
angles
Injured Patient
1. Kneel beside the
victim. Place the
victim’s closest arm
above the head and the
furthest arm across the
chest. Bend the victim’s
nearest leg at the knee.
Injured Patient
2. Place your hand under

the hollow of the victim’s
neck to help stabilize. Roll
patient towards you so
that the head rests on
the extended arm.
Injured Patient
3. Bend legs at the

knees to stabilize the
victim.
CPR *NOTE:
Attach and use AED as soon as it
is available
• If AED arrives:
• Stop CPR,
• Place the patches
• Follow voice prompt of the AED.
***If SHOCK is advised, stay clear***
• After defibrillating, continue CPR for 5

cycles again.
CPR
CPR WHEN TO STOP CPR?
• Spontaneous breathing and
pulse is present
• Team (EMS) arrives
• Over-exhaustion of the rescuer
• Physician declares the patient
dead
• Scene is unsafe
CPR COMPLICATIONS OF CPR
• Fractured Ribs
• Lacerated Liver
• Atelectasis (punctured lungs)
• Gastric Distention
Infant
CPR
INFANT CPR (0 – 12 months)
1. Tap the infant’s foot and shout
“Baby, baby are you OK?” while
scanning chest for movement.
2. If the infant is unconscious,

call for help.
3. Place the infant on a table
or on a firm, flat surface.
4. Check for the brachial

pulse.
5. Place 3 fingers directly at

the center of the chest
(nipple line).
6. Raise your index finger so
that the middle and
index fingers are a width
below the nipple line.
7. Compress for approx.

1 ½ inches or 4 cm.
8. If the patient is not breathing
prepare for artificial
respirations.
9. Seal infant’s nose and mouth

using BVM.
10. Deliver 2 gentle puffs of air at

1 second interval.
11. Reassess the infant after 5

cycles.
compression ventilation depth Used in Cycles
compression
1-man 30 2 2 (5cm) Both 5

adult hands
2-man 30 2 2 (5cm) Both 5
adult hands
1-man 30 2 2 (5cm) One hand 5

child
2-man 15 2 2 (5cm One hand 10
child
1-man 30 2 1.5 (4cm) Mid & ring 5
infant finger
2-man 15 2 1.5 (4cm) Both 10
infant thumbs
Component Adults Children Infants
Unresponsive (for all ages)
Recognition
Title
No breathing or no normal breathing
(i.e. only gasping)
No breathing or only gasping
No pulse palpated within 10 seconds for all ages (HCP only)
CPR sequence C-A-B
Compression Rate At least 100/min
Compression Depth At least 2 inches At least ½ AP diameter At least ½ AP diameter

About 2 inches (5cm) About 1 1/2 inches (4cm)
Chest wall recoil Allow complete recoil between compressions

HCPs rotate compressors every 2 minutes
Compression Minimize interruptions

Interruptions Attempt to limit interruptions to <10 seconds
Airway Head tilt-chin lift (HCP suspected trauma: jaw thrust)
Compression-to-
ventilation ratio 30:2 30:2 Single rescuer
15:2 2HCP rescuers
(until advanced
airway placed)
Ventilations: when
rescuer untrained or Compressions only
trained and not
proficient
Ventilations with 1 breath every 6-8 seconds (8-10 breaths/min)
advanced airway Asynchronous with chest compressions
About 1 second per breath
(HCP)
Visible chest rise
Defibrillation Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock;
resume CPR beginning with compressions immediately after each shock.
SOURCES:
1. Calumpang, D. & Toble, P. 2006 ed. Philippine National Red Cross, Basic Life Support –
Cardiopulmonary Resuscitation.
2. Hazinski, Mary Fran, Gonzales, Louis & O’Neill, Lindy. AHA, Learn and Live, BLS (Basic Life
Support) for Health Care Providers. 2006.
3. Mutchner, Linda. The ABCs of CPR Again. American Journal of Nursing. Vol. 107. No. 1, Jan.
2007, pp 61-68.
4. Taylor, Nicole T. For New CPR Guidelines, Think 30. Critical Care, Spring 2006. Lippincott.
Williams & Williams. p. 21.
5. www.cpr.org.
6. American Heart Association and ECC CPR Guidelines 2010
7. NC-CLEX: Handouts 2011

Summary of High-Quality CPR
Components for BLS Providers
Infants
Adults and Children
Component (age less than 1 year,
adolescents (age 1 year to puberty)
excluding newborns)
Verifying scene safety Make sure the environment is safe for rescuers and victim
Recognizing cardiac arrest Check for responsiveness

No breathing or only gasping (ie, no normal breathing)
No definite pulse felt within 10 seconds
(Breathing and pulse check can be performed simultaneously in less than 10 seconds)
Activating emergency If a mobile device is available, phone emergency services (9-1-1)

response system
If you are alone with no Witnessed collapse
mobile phone, leave Follow steps for adults and adolescents on the left
the victim to activate the Unwitnessed collapse
emergency response Give 2 minutes of CPR
system and get the AED
Leave the victim to activate the emergency response system
before beginning CPR
and get the AED
Otherwise, send
Return to the child or infant and resume CPR;
someone and begin CPR
use the AED as soon as it is available
immediately; use the AED
as soon as it is available
Compression-ventilation 1 or 2 rescuers 1 rescuer

ratio without advanced 30:2 30:2
airway 2 or more rescuers
15:2
Compression-ventilation Continuous compressions Continuous compressions at a rate of 100-120/min

ratio with advanced airway at a rate of 100-120/min Give 1 breath every 2-3 seconds (20-30 breaths/min)
Give 1 breath every
6 seconds (10 breaths/min)
Compression rate 100-120/min
Compression depth At least 2 inches (5 cm)* At least one third AP At least one third AP
diameter of chest diameter of chest
Approximately 2 inches (5 cm) Approximately 1½ inches (4 cm)
Hand placement 2 hands on the 2 hands or 1 hand 1 rescuer

lower half of the (optional for very 2 fingers or 2 thumbs in the
breastbone (sternum) small child) on the center of the chest, just
lower half of the below the nipple line
breastbone (sternum) 2 or more rescuers
2 thumb–encircling hands in
the center of the chest, just
below the nipple line
If the rescuer is unable to
achieve the recommended
depth, it may be reasonable
to use the heel of one hand
Chest recoil Allow complete recoil of chest after each compression;

do not lean on the chest after each compression
Minimizing interruptions Limit interruptions in chest compressions to less than 10 seconds with a CCF goal of 80%
*Compression depth should be no more than 2.4 inches (6 cm).

Abbreviations: AED, automated external defibrillator; AP, anteroposterior; CCF, chest compression fraction;
CPR, cardiopulmonary resuscitation.
© 2020 American Heart Association
ACLS CARDIO
PHARMACOLOGY
Dr. Freslyn Lim-Saco

Asst. Professor/Nurse Professor
Silliman University College of
Nursing
February 2021
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
ACLS MEDICATIONS
VENTRICULAR FIBRILLATION &
PULSELESS VENTRICULAR TACHYCARDIA
DRUG INITIAL SUBSEQUENT INTERVAL MAXIMUM
E PINEPHRINE 1mg 1mg 3-5min. None
A MIODARONE 300mg 150mg 10min. 2.2g in 24

hrs.
L IDOCAINE 1-1.5 0.5-0.75 5-10 min. 3mg./kg.

mg/kg mg/kg.
VENTRICULAR TACHYCARDIA
with PULSE
A DENOSINE 6mg 12mg 2 min. 3rd dose
A MIODARONE 150mg 150mg 10min. 2.2g in 24

hrs.
L IDOCAINE 1-1.5 0.5-0.75 5-10min. 3mg. /kg.
mg/kg mg/kg
P ROCAINAMIDE
20mg/min Depends on 17mg/kg
drip
pt. response
ATRIAL TACHYCARDIA / SVT
ADENOSINE 6mg 12mg 2min. 2 doses

ATRIAL FIBRILLATION and
ATRIAL FLUTTER
V ERAPAMIL 2.5-5mg 5-10mg 15-30min 20mg
I NDERAL 0.1mg/kg divided in 2min. 3rd dose

3doses
D ILTIAZEM 15-20mg 20-25mg 15-30min 5-15mg/hr
. IV infusion
ASYSTOLE and
Pulseless Electrical Activity
EPINEPHRINE 1mg 1mg 3-5min. None

SINUS BRADYCARDIA
ATROPINE 0.5mg 0.5mg 3-5min. 3mg (6

doses)
DOPAMINE 5 mcg/ 5 mcg/kg/min Depends on pt.
kg/min response
DRIP
(cardiac
dose)
HYPOTENSION
DOPAMINE
10 mcg/ 5mcg/ Titrate or taper
DRIP
kg/min kg/min depending on the
patient’s response
400mg in
250ml D5W
FOR MORE INFORMATION ON ACLS DRUGS ACCESS THE FF:
◼ https://www.acls-pals-bls.com/drugs/
◼ https://acls-algorithms.com/acls-drugs/
◼ https://rescue-one.com/wp-content/uploads/2014/10/ACLS%20Dru
g%20Overview.pdf
◼ https://www.learncprnyc.com/uploads/3/0/4/8/30480308/acls-dru
gs.pdf
◼ https://nhcps.com/lesson/acls-pharmacological-tools/
Topics
Adult Pediatric
Basic and Basic and Resuscitation
Neonatal Life Systems of
Advanced Advanced Education
Support Care
Life Support Life Support Science
Introduction
These Highlights summarize the key issues and changes in the 2020 American Heart Association (AHA) Guidelines for
Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). The 2020 Guidelines are a comprehensive
revision of the AHA’s guidelines for adult, pediatric, neonatal, resuscitation education science, and systems of care topics.
They have been developed for resuscitation providers and AHA instructors to focus on the resuscitation science and guide-
lines recommendations that are most significant or controversial, or those that will result in changes in resuscitation training
and practice, and to provide the rationale for the recommendations.
Because this publication is a summary, it does not reference the supporting published studies and does not list Classes
of Recommendation (COR) or Levels of Evidence (LOE). For more detailed information and references, please read the 2020
AHA Guidelines for CPR and ECC, including the Executive Summary,1 published in Circulation in October 2020, and the
detailed summary of resuscitation science in the 2020 International Consensus on CPR and ECC Science With Treatment
Recommendations, developed by the International Liaison Committee on Resuscitation (ILCOR) and published simultaneously
in Circulation2 and Resuscitation3 in October 2020. The methods used by ILCOR to perform evidence evaluations4 and by the
AHA to translate these evidence evaluations into resuscitation guidelines5 have been published in detail.
The 2020 Guidelines use the most recent version of the AHA definitions for the COR and LOE (Figure 1). Overall, 491
specific recommendations are made for adult, pediatric, and neonatal life support; resuscitation education science; and
systems of care. Of these recommendations, 161 are class 1 and 293 are class 2 recommendations (Figure 2). Additionally, 37
recommendations are class 3, including 19 for evidence of no benefit and 18 for evidence of harm.
The American Heart Association thanks the following people for their contributions to the development of this publication: Eric J. Lavonas,
MD, MS; David J. Magid, MD, MPH; Khalid Aziz, MBBS, BA, MA, MEd(IT); Katherine M. Berg, MD; Adam Cheng, MD; Amber V.
Hoover, RN, MSN; Melissa Mahgoub, PhD; Ashish R. Panchal, MD, PhD; Amber J. Rodriguez, PhD; Alexis A. Topjian, MD, MSCE;
Comilla Sasson, MD, PhD; and the AHA Guidelines Highlights Project Team.
© 2020 American Heart Association
eccguidelines.heart.org 1
Figure 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic
Testing in Patient Care (Updated May 2019)*
2 American Heart Association

Figure 2. Distribution of COR and LOE as percent of 491 total recommendations in the 2020 AHA Guidelines for CPR and ECC.*
*Results are percent of 491 recommendations in Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life
Support, Resuscitation Education Science, and Systems of Care.
Abbreviations: COR, Classes of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, Randomized.
About the Recommendations

The fact that only 6 of these 491 recommendations (1.2%) are based on Level A evidence (at least 1 high-quality randomized
clinical trial [RCT], corroborated by a second high-quality trial or registry study) testifies to the ongoing challenges in perform-
ing high-quality resuscitation research. A concerted national and international effort is needed to fund and otherwise support
resuscitation research.
Both the ILCOR evidence-evaluation process and the AHA guidelines-development process are governed by strict AHA
disclosure policies designed to make relationships with industry and other conflicts of interest fully transparent and to
protect these processes from undue influence. The AHA staff processed conflict-of-interest disclosures from all participants.
All guidelines writing group chairs and at least 50% of guidelines writing group members are required to be free of all
conflicts of interest, and all relevant relationships are disclosed in the respective Consensus on Science With Treatment
Recommendations and Guidelines publications.
Adult Basic and Advanced Life Support
Summary of Key Issues and Major Changes pressure control, evaluation for percutaneous coronary
In 2015, approximately 350 000 adults in the United States intervention, targeted temperature management, and
experienced nontraumatic out-of-hospital cardiac arrest multimodal neuroprognostication.
(OHCA) attended by emergency medical services (EMS) • Because recovery from cardiac arrest continues long
personnel. Despite recent gains, less than 40% of adults after the initial hospitalization, patients should have formal
receive layperson-initiated CPR, and fewer than 12% have assessment and support for their physical, cognitive, and
an automated external defibrillator (AED) applied before EMS psychosocial needs.
arrival. After significant improvements, survival from OHCA
• After a resuscitation, debriefing for lay rescuers, EMS
has plateaued since 2012.
providers, and hospital-based healthcare workers may be
In addition, approximately 1.2% of adults admitted to US beneficial to support their mental health and well-being.
hospitals suffer in-hospital cardiac arrest (IHCA). Outcomes
from IHCA are significantly better than outcomes from OHCA, • Management of cardiac arrest in pregnancy focuses on
and IHCA outcomes continue to improve. maternal resuscitation, with preparation for early perimortem
cesarean delivery if necessary to save the infant and
Recommendations for adult basic life support (BLS) and
improve the chances of successful resuscitation of
advanced cardiovascular life support (ACLS) are combined
the mother.
in the 2020 Guidelines. Major new changes include the
following:
Algorithms and Visual Aids
• Enhanced algorithms and visual aids provide easy-to- The writing group reviewed all algorithms and made focused
remember guidance for BLS and ACLS resuscitation improvements to visual training aids to ensure their utility as
scenarios. point-of-care tools and reflect the latest science. The major
• The importance of early initiation of CPR by lay rescuers changes to algorithms and other performance aids include
has been re-emphasized. the following:
• Previous recommendations about epinephrine • A sixth link, Recovery, was added to the IHCA and OHCA
administration have been reaffirmed, with emphasis on Chains of Survival (Figure 3).
early epinephrine administration. • The universal Adult Cardiac Arrest Algorithm was modified
• Use of real-time audiovisual feedback is suggested as a to emphasize the role of early epinephrine administration for
means to maintain CPR quality. patients with nonshockable rhythms (Figure 4).
• Continuously measuring arterial blood pressure and end- • Two new Opioid-Associated Emergency Algorithms have
tidal carbon dioxide (ETCO2) during ACLS resuscitation been added for lay rescuers and trained rescuers
may be useful to improve CPR quality. (Figures 5 and 6).
• On the basis of the most recent evidence, routine use of • The Post–Cardiac Arrest Care Algorithm was updated to
double sequential defibrillation is not recommended. emphasize the need to prevent hyperoxia, hypoxemia, and
hypotension (Figure 7).
• Intravenous (IV) access is the preferred route of medication
administration during ACLS resuscitation. Intraosseous (IO) • A new diagram has been added to guide and inform
access is acceptable if IV access is not available. neuroprognostication (Figure 8).
• Care of the patient after return of spontaneous circulation • A new Cardiac Arrest in Pregnancy Algorithm has been
(ROSC) requires close attention to oxygenation, blood added to address these special cases (Figure 9).

Despite recent gains, less than 40%

of adults receive layperson-initiated
CPR, and fewer than 12% have an
AED applied before EMS arrival.
Figure 3. AHA Chains of Survival for adult IHCA and OHCA.
Figure 4. Adult Cardiac Arrest Algorithm.

Figure 5. Opioid-Associated Emergency for Lay Responders Algorithm.
Figure 6. Opioid-Associated Emergency for Healthcare Providers Algorithm.

Figure 7. Adult Post–Cardiac Arrest Care Algorithm.
Figure 8. Recommended approach to multimodal neuroprognostication in adult patients after cardiac arrest.

Figure 9. Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm.
Major New and Updated and unfavorable neurologic outcome in when feasible to monitor and optimize
the epinephrine group. CPR quality, guide vasopressor therapy,
Recommendations
Of 16 observational studies on and detect ROSC.
Early Initiation of CPR by Lay Rescuers timing in the recent systematic review, Why: Although the use of physiologic
all found an association between monitoring such as arterial blood
2020 (Updated): We recommend that earlier epinephrine and ROSC for pressure and ETCO2 to monitor CPR
laypersons initiate CPR for presumed patients with nonshockable rhythms, quality is an established concept,
cardiac arrest because the risk of harm although improvements in survival new data support its inclusion in the
to the patient is low if the patient is not were not universally seen. For patients guidelines. Data from the AHA’s Get
in cardiac arrest. with shockable rhythm, the literature With The Guidelines®-Resuscitation
2010 (Old): The lay rescuer should not supports prioritizing defibrillation and registry show higher likelihood of
check for a pulse and should assume CPR initially and giving epinephrine ROSC when CPR quality is monitored
that cardiac arrest is present if an adult if initial attempts with CPR and using either ETCO2 or diastolic blood
suddenly collapses or an unrespon- defibrillation are not successful. pressure.
sive victim is not breathing normally. Any drug that increases the rate This monitoring depends on the
The healthcare provider should take of ROSC and survival but is given presence of an endotracheal tube (ETT)
no more than 10 seconds to check for after several minutes of downtime or arterial line, respectively. Targeting
a pulse and, if the rescuer does not will likely increase both favorable and compressions to an ETCO2 value of at
definitely feel a pulse within that time unfavorable neurologic outcome. least 10 mm Hg, and ideally 20 mm Hg
period, the rescuer should start chest Therefore, the most beneficial or greater, may be useful as a marker
compressions. approach seems to be continuing of CPR quality. An ideal target has not
to use a drug that has been shown been identified.
Why: New evidence shows that the risk
of harm to a victim who receives chest to increase survival while focusing
compressions when not in cardiac broader efforts on shortening time Double Sequential Defibrillation
arrest is low. Lay rescuers are not able to drug for all patients; by doing so, Not Supported
to determine with accuracy whether more survivors will have a favorable
a victim has a pulse, and the risk of neurologic outcome. 2020 (New): The usefulness of double
withholding CPR from a pulseless victim sequential defibrillation for refractory
exceeds the harm from unneeded chest Real-Time Audiovisual Feedback shockable rhythm has not been
compressions. established.
2020 (Unchanged/Reaffirmed): It may be
Why: Double sequential defibrillation
Early Administration of Epinephrine reasonable to use audiovisual feedback
is the practice of applying near-
devices during CPR for real-time
simultaneous shocks using 2
2020 (Unchanged/Reaffirmed): With optimization of CPR performance.
defibrillators. Although some case
respect to timing, for cardiac arrest Why: A recent RCT reported a 25% reports have shown good outcomes,
with a nonshockable rhythm, it is increase in survival to hospital dis- a 2020 ILCOR systematic review found
reasonable to administer epinephrine charge from IHCA with audio feedback no evidence to support double sequen-
as soon as feasible. on compression depth and recoil. tial defibrillation and recommended
2020 (Unchanged/Reaffirmed): With against its routine use. Existing studies
respect to timing, for cardiac arrest with Physiologic Monitoring of CPR Quality are subject to multiple forms of bias,
a shockable rhythm, it may be reason- and observational studies do not show
able to administer epinephrine after 2020 (Updated): It may be reasonable to improvements in outcome.
initial defibrillation attempts have failed. use physiologic parameters such as A recent pilot RCT suggests that
arterial blood pressure or ETCO2 when changing the direction of defibrillation
Why: The suggestion to administer feasible to monitor and optimize
epinephrine early was strengthened current by repositioning the pads may
CPR quality. be as effective as double sequential
to a recommendation on the basis of a
systematic review and meta-analysis, 2015 (Old): Although no clinical study has defibrillation while avoiding the risks
which included results of 2 randomized examined whether titrating resuscita- of harm from increased energy and
trials of epinephrine enrolling more than tive efforts to physiologic parameters damage to defibrillators. On the basis
8500 patients with OHCA, showing during CPR improves outcome, it may of current evidence, it is not known
that epinephrine increased ROSC and be reasonable to use physiologic whether double sequential defibrillation
survival. At 3 months, the time point felt parameters (quantitative waveform cap- is beneficial.
to be most meaningful for neurologic nography, arterial relaxation diastolic
recovery, there was a nonsignificant in- pressure, arterial pressure monitoring,
crease in survivors with both favorable and central venous oxygen saturation)

IV Access Preferred Over IO The 2020 Guidelines evaluate 19 improvement) as well as recognition of
different modalities and specific the natural stressors associated with
2020 (New): It is reasonable for providers findings and present the evidence caring for a patient near death. An AHA
to first attempt establishing IV access for each. A new diagram presents scientific statement devoted to this
for drug administration in cardiac arrest. this multimodal approach to topic is expected in early 2021.
2020 (Updated): IO access may be neuroprognostication.
considered if attempts at IV access are Cardiac Arrest in Pregnancy
unsuccessful or not feasible. Care and Support During Recovery
2020 (New): Because pregnant patients
2010 (Old): It is reasonable for providers 2020 (New): We recommend that cardiac are more prone to hypoxia, oxygenation
to establish intraosseous (IO) access arrest survivors have multimodal reha- and airway management should be
if intravenous (IV) access is not readily bilitation assessment and treatment for prioritized during resuscitation from
available. physical, neurologic, cardiopulmonary, cardiac arrest in pregnancy.
Why: A 2020 ILCOR systematic review and cognitive impairments before 2020 (New): Because of potential
comparing IV versus IO (principally discharge from the hospital. interference with maternal resusci-
pretibial placement) drug administra- 2020 (New): We recommend that cardiac tation, fetal monitoring should not be
tion during cardiac arrest found that arrest survivors and their caregivers undertaken during cardiac arrest in
the IV route was associated with better receive comprehensive, multidisci- pregnancy.
clinical outcomes in 5 retrospective plinary discharge planning, to include 2020 (New): We recommend targeted
studies; subgroup analyses of RCTs medical and rehabilitative treatment temperature management for pregnant
that focused on other clinical questions recommendations and return to women who remain comatose after
found comparable outcomes when IV activity/work expectations. resuscitation from cardiac arrest.
or IO were used for drug administration.
Although IV access is preferred, for 2020 (New): We recommend structured 2020 (New): During targeted tempera-
situations in which IV access is difficult, assessment for anxiety, depression, ture management of the pregnant
IO access is a reasonable option. posttraumatic stress, and fatigue for patient, it is recommended that the
cardiac arrest survivors and their fetus be continuously monitored for
Post–Cardiac Arrest Care and caregivers. bradycardia as a potential complication,
Neuroprognostication Why: The process of recovering from and obstetric and neonatal consultation
cardiac arrest extends long after the should be sought.
The 2020 Guidelines contain signifi- initial hospitalization. Support is needed Why: Recommendations for manag-
cant new clinical data about optimal during recovery to ensure optimal ing cardiac arrest in pregnancy were
care in the days after cardiac arrest. physical, cognitive, and emotional reviewed in the 2015 Guidelines Update
Recommendations from the 2015 well-being and return to social/role and a 2015 AHA scientific statement.7
AHA Guidelines Update for CPR and functioning. This process should be Airway, ventilation, and oxygenation
ECC about treatment of hypotension, initiated during the initial hospitalization are particularly important in the setting
titrating oxygen to avoid both hypoxia and continue as long as needed. These of pregnancy because of an increase
and hyperoxia, detection and treatment themes are explored in greater detail in in maternal metabolism, a decrease in
of seizures, and targeted temperature a 2020 AHA scientific statement.6 functional reserve capacity due to the
management were reaffirmed with new gravid uterus, and the risk of fetal brain
supporting evidence. Debriefings for Rescuers injury from hypoxemia.
In some cases, the LOE was Evaluation of the fetal heart is not
2020 (New): Debriefings and referral for
upgraded to reflect the availability of helpful during maternal cardiac arrest,
follow up for emotional support for
new data from RCTs and high-quality lay rescuers, EMS providers, and and it may distract from necessary
observational studies, and the post– hospital-based healthcare workers resuscitation elements. In the absence
cardiac arrest care algorithm has after a cardiac arrest event may be of data to the contrary, pregnant
been updated to emphasize these beneficial. women who survive cardiac arrest
important components of care. To be should receive targeted temperature
reliable, neuroprognostication should Why: Rescuers may experience anxiety management just as any other survivors
be performed no sooner than 72 or posttraumatic stress about providing would, with consideration for the status
or not providing BLS. Hospital-based of the fetus that may remain in utero.
hours after return to normothermia,
care providers may also experience
and prognostic decisions should be
emotional or psychological effects of
based on multiple modes of patient
caring for a patient with cardiac arrest.
assessment.
Team debriefings may allow a review of
team performance (education, quality
Pediatric Basic and Advanced Life Support
Summary of Key Issues and Major Changes or norepinephrine infusions if vasopressors are needed,
More than 20 000 infants and children have a cardiac arrest is appropriate in resuscitation from septic shock.
each year in the United States. Despite increases in survival • On the basis largely of extrapolation from adult data,
and comparatively good rates of good neurologic outcome balanced blood component resuscitation is reasonable
after pediatric IHCA, survival rates from pediatric OHCA for infants and children with hemorrhagic shock.
remain poor, particularly in infants. Recommendations
• Opioid overdose management includes CPR and the timely
for pediatric basic life support (PBLS) and CPR in infants,
administration of naloxone by either lay rescuers or trained
children, and adolescents have been combined with rec-
rescuers.
ommendations for pediatric advanced life support (PALS)
in a single document in the 2020 Guidelines. The causes • Children with acute myocarditis who have arrhythmias, heart
of cardiac arrest in infants and children differ from cardiac block, ST-segment changes, or low cardiac output are at
arrest in adults, and a growing body of pediatric-specif- high risk of cardiac arrest. Early transfer to an intensive care
ic evidence supports these recommendations. Key issues, unit is important, and some patients may require mechanical
major changes, and enhancements in the 2020 Guidelines circulatory support or extracorporeal life support (ECLS).
include the following: • Infants and children with congenital heart disease and
• Algorithms and visual aids were revised to incorporate single ventricle physiology who are in the process of staged
the best science and improve clarity for PBLS and PALS reconstruction require special considerations in PALS
resuscitation providers. management.
• Based on newly available data from pediatric resuscitations, • Management of pulmonary hypertension may include the
the recommended assisted ventilation rate has been use of inhaled nitric oxide, prostacyclin, analgesia, sedation,
increased to 1 breath every 2 to 3 seconds (20-30 breaths neuromuscular blockade, the induction of alkalosis, or
per minute) for all pediatric resuscitation scenarios. rescue therapy with ECLS.
• Cuffed ETTs are suggested to reduce air leak and the need Algorithms and Visual Aids
for tube exchanges for patients of any age who require
The writing group updated all algorithms to reflect the latest
intubation.
science and made several major changes to improve the
• The routine use of cricoid pressure during intubation is no visual training and performance aids:
longer recommended.
• A new pediatric Chain of Survival was created for IHCA in
• To maximize the chance of good resuscitation outcomes, infants, children, and adolescents (Figure 10).
epinephrine should be administered as early as possible,
• A sixth link, Recovery, was added to the pediatric OHCA
ideally within 5 minutes of the start of cardiac arrest from
Chain of Survival and is included in the new pediatric IHCA
a nonshockable rhythm (asystole and pulseless
Chain of Survival (Figure 10).
electrical activity).
• The Pediatric Cardiac Arrest Algorithm and the Pediatric
• For patients with arterial lines in place, using feedback from
Bradycardia With a Pulse Algorithm have been updated to
continuous measurement of arterial blood pressure may
reflect the latest science (Figures 11 and 12).
improve CPR quality.
• The single Pediatric Tachycardia With a Pulse Algorithm
• After ROSC, patients should be evaluated for seizures; status
now covers both narrow- and wide-complex tachycardias in
epilepticus and any convulsive seizures should be treated.
pediatric patients (Figure 13).
• Because recovery from cardiac arrest continues long
• Two new Opioid-Associated Emergency Algorithms have
after the initial hospitalization, patients should have formal
been added for lay rescuers and trained rescuers (Figures 5
assessment and support for their physical, cognitive, and
and 6).
psychosocial needs.
• A new checklist is provided for pediatric post–cardiac arrest
• A titrated approach to fluid management, with epinephrine
care (Figure 14).

The causes of cardiac arrest in infants

and children differ from cardiac
arrest in adults, and a growing body of
pediatric-specific evidence supports
these recommendations.
Figure 10. AHA Chains of Survival for pediatric IHCA and OHCA.
Figure 11. Pediatric Cardiac Arrest Algorithm.

Figure 12. Pediatric Bradycardia With a Pulse Algorithm.
Figure 13. Pediatric Tachycardia With a Pulse Algorithm.

Figure 14. Pediatric Post–Cardiac Arrest Care Checklist.
Major New and Updated Cuffed ETTs Emphasis on Early
Recommendations Epinephrine Administration
2020 (Updated): It is reasonable to
choose cuffed ETTs over uncuffed 2020 (Updated): For pediatric patients in
Changes to the Assisted Ventilation ETTs for intubating infants and children. any setting, it is reasonable to admin-
Rate: Rescue Breathing When a cuffed ETT is used, attention ister the initial dose of epinephrine
should be paid to ETT size, position, within 5 minutes from the start of chest
2020 (Updated): (PBLS) For infants and and cuff inflation pressure (usually
children with a pulse but absent or compressions.
<20-25 cm H2O).
inadequate respiratory effort, it is rea- 2015 (Old): It is reasonable to administer
sonable to give 1 breath every 2010 (Old): Both cuffed and uncuffed epinephrine in pediatric cardiac arrest.
2 to 3 seconds (20-30 breaths/min). ETTs are acceptable for intubating
infants and children. In certain circum- Why: A study of children with IHCA
2010 (Old): (PBLS) If there is a palpa- stances (eg, poor lung compliance, high who received epinephrine for an initial
ble pulse 60/min or greater but there airway resistance, or a large glottic air nonshockable rhythm (asystole and
is inadequate breathing, give rescue leak) a cuffed ETT may be preferable to pulseless electrical activity) demon-
breaths at a rate of about 12 to 20/min an uncuffed tube, provided that atten- strated that, for every minute of delay
(1 breath every 3-5 seconds) until tion is paid to [ensuring appropriate] in administration of epinephrine, there
spontaneous breathing resumes. ETT size, position, and cuff inflation was a significant decrease in ROSC,
pressure. survival at 24 hours, survival to dis-
Changes to the Assisted Ventilation charge, and survival with favorable
Why: Several studies and systematic neurological outcome.
Rate: Ventilation Rate During CPR reviews support the safety of cuffed
With an Advanced Airway Patients who received epinephrine
ETTs and demonstrate decreased need
within 5 minutes of CPR initiation
for tube changes and reintubation.
2020 (Updated): (PALS) When perform- compared with those who received
Cuffed tubes may decrease the risk of
ing CPR in infants and children with an aspiration. Subglottic stenosis is rare epinephrine more than 5 minutes
advanced airway, it may be reasonable when cuffed ETTs are used in children after CPR initiation were more likely
to target a respiratory rate range of and careful technique is followed. to survive to discharge. Studies of
1 breath every 2 to 3 seconds pediatric OHCA demonstrated that
(20-30/min), accounting for age and Cricoid Pressure During Intubation earlier epinephrine administration
clinical condition. Rates exceeding increases rates of ROSC, survival to
these recommendations may 2020 (Updated): Routine use of cricoid intensive care unit admission, survival
compromise hemodynamics. pressure is not recommended during to discharge, and 30-day survival.
2010 (Old): (PALS) If the infant or child is endotracheal intubation of pediatric In the 2018 version of the Pediatric
intubated, ventilate at a rate of about patients. Cardiac Arrest Algorithm, patients
1 breath every 6 seconds (10/min) 2010 (Old): There is insufficient evidence with nonshockable rhythms received
without interrupting chest to recommend routine application of epinephrine every 3 to 5 minutes, but
compressions. cricoid pressure to prevent aspiration early administration of epinephrine
during endotracheal intubation in was not emphasized. Although
Why: New data show that higher
children. the sequence of resuscitation has
ventilation rates (at least 30/min in
not changed, the algorithm and
infants [younger than 1 year] and at Why: New studies have shown that
least 25/min in children) are associated recommendation language have been
routine use of cricoid pressure reduces updated to emphasize the importance
with improved rates of ROSC and intubation success rates and does not
survival in pediatric IHCA. Although of giving epinephrine as early as
reduce the rate of regurgitation. The
there are no data about the ideal possible, particularly when the rhythm
writing group has reaffirmed previous
ventilation rate during CPR without is nonshockable.
recommendations to discontinue
an advanced airway, or for children in cricoid pressure if it interferes with
respiratory arrest with or without an ad- ventilation or the speed or ease of Invasive Blood Pressure Monitoring to
vanced airway, for simplicity of training, intubation. Assess CPR Quality
the respiratory arrest recommendation
was standardized for both situations. 2020 (Updated): For patients with
continuous invasive arterial blood
pressure monitoring in place at the
time of cardiac arrest, it is reasonable
for providers to use diastolic blood
pressure to assess CPR quality.

2015 (Old): For patients with invasive treatment of status epilepticus is Corticosteroid Administration
hemodynamic monitoring in place at beneficial in pediatric patients in
the time of cardiac arrest, it may be general. 2020 (New): For infants and children with
reasonable for rescuers to use blood septic shock unresponsive to fluids and
pressure to guide CPR quality. Evaluation and Support for requiring vasoactive support, it may be
Cardiac Arrest Survivors reasonable to consider stress-dose
Why: Providing high-quality chest
corticosteroids.
compressions is critical to successful
resuscitation. A new study shows that, 2020 (New): It is recommended that Why: Although fluids remain the main-
among pediatric patients receiving pediatric cardiac arrest survivors be stay of initial therapy for infants and
CPR with an arterial line in place, evaluated for rehabilitation services. children in shock, especially in hypovo-
rates of survival with favorable neu- 2020 (New): It is reasonable to refer lemic and septic shock, fluid overload
rologic outcome were improved if the pediatric cardiac arrest survivors for can lead to increased morbidity. In
diastolic blood pressure was at least ongoing neurologic evaluation for at recent trials of patients with septic
25 mm Hg in infants and at least least the first year after cardiac arrest. shock, those who received higher fluid
30 mm Hg in children.8 volumes or faster fluid resuscitation
Why: There is growing recognition that were more likely to develop clinically
Detecting and Treating recovery from cardiac arrest continues significant fluid overload and require
long after the initial hospitalization. mechanical ventilation. The writing
Seizures After ROSC Survivors may require ongoing integrat- group reaffirmed previous recommen-
ed medical, rehabilitative, caregiver, and dations to reassess patients after each
2020 (Updated): When resources are
community support in the months to fluid bolus and to use either crystalloid
available, continuous electroencepha-
years after their cardiac arrest. A recent or colloid fluids for septic shock resus-
lography monitoring is recommended
AHA scientific statement highlights the citation.
for the detection of seizures following
importance of supporting patients and
cardiac arrest in patients with Previous versions of the Guidelines
families during this time to achieve the
persistent encephalopathy. did not provide recommendations
best possible long-term outcome.6
about choice of vasopressor or the
2020 (Updated): It is recommended to
Septic Shock use of corticosteroids in septic shock.
treat clinical seizures following
cardiac arrest. Two RCTs suggest that epinephrine
Fluid Boluses is superior to dopamine as the initial
2020 (Updated): It is reasonable to treat vasopressor in pediatric septic shock,
nonconvulsive status epilepticus 2020 (Updated): In patients with septic and norepinephrine is also appropriate.
following cardiac arrest in consultation shock, it is reasonable to administer Recent clinical trials suggest a benefit
with experts. fluid in 10 mL/kg or 20 mL/kg aliquots from corticosteroid administration in
2015 (Old): An electroencephalography with frequent reassessment. some pediatric patients with refractory
for the diagnosis of seizure should be septic shock.
2015 (Old): Administration of an initial
promptly performed and interpreted fluid bolus of 20 mL/kg to infants and
and then should be monitored frequent- children with shock is reasonable,
Hemorrhagic Shock
ly or continuously in comatose patients including those with conditions such
after ROSC. 2020 (New): Among infants and children
as severe sepsis, severe malaria, and with hypotensive hemorrhagic shock
2015 (Old): The same anticonvulsant dengue. following trauma, it is reasonable to
regimens for the treatment of status administer blood products, when avail-
epilepticus caused by other etiologies Choice of Vasopressor able, instead of crystalloid for ongoing
may be considered after cardiac arrest. volume resuscitation.
2020 (New): In infants and children with
Why: For the first time, the Guidelines Why: Previous versions of the
fluid-refractory septic shock, it is rea-
provide pediatric-specific recommen- Guidelines did not differentiate the
sonable to use either epinephrine or
dations for managing seizures after treatment of hemorrhagic shock from
norepinephrine as an initial vasoactive
cardiac arrest. Nonconvulsive sei- other causes of hypovolemic shock. A
infusion.
zures, including nonconvulsive status growing body of evidence (largely from
epilepticus, are common and cannot 2020 (New): In infants and children
adults but with some pediatric data)
be detected without electroenceph- with fluid-refractory septic shock, if
suggests a benefit to early, balanced
alography. Although outcome data epinephrine or norepinephrine are un-
resuscitation using packed red blood
from the post–cardiac arrest popula- available, dopamine may be considered.
cells, fresh frozen plasma, and platelets.
tion are lacking, both convulsive and Balanced resuscitation is supported by
nonconvulsive status epilepticus are recommendations from the several US
associated with poor outcome, and and international trauma societies.
Opioid Overdose for managing children with respiratory Single Ventricle: Recommendations
arrest or cardiac arrest from opioid for the Treatment of Preoperative
2020 (Updated): For patients in overdose.
respiratory arrest, rescue breathing and Postoperative Stage I Palliation
These recommendations are
or bag-mask ventilation should be identical for adults and children, except (Norwood/Blalock-Tausig Shunt) Patients
maintained until spontaneous breathing that compression-ventilation CPR is
returns, and standard PBLS or PALS 2020 (New): Direct (superior vena cava
recommended for all pediatric victims
measures should continue if return of catheter) and/or indirect (near infrared
of suspected cardiac arrest. Naloxone
spontaneous breathing does not occur. spectroscopy) oxygen saturation
can be administered by trained
monitoring can be beneficial to trend
2020 (Updated): For a patient with providers, laypersons with focused and direct management in the critically
suspected opioid overdose who has a training, and untrained laypersons. ill neonate after stage I Norwood
definite pulse but no normal breathing Separate treatment algorithms palliation or shunt placement.
or only gasping (ie, a respiratory arrest), are provided for managing opioid-
in addition to providing standard PBLS associated resuscitation emergencies 2020 (New): In the patient with an appro-
or PALS, it is reasonable for responders by laypersons, who cannot reliably priately restrictive shunt, manipulation
to administer intramuscular or intrana- check for a pulse (Figure 5), and by of pulmonary vascular resistance
sal naloxone. trained rescuers (Figure 6). Opioid- may have little effect, whereas low-
associated OHCA is the subject of a ering systemic vascular resistance
2020 (Updated): For patients known or with the use of systemic vasodilators
suspected to be in cardiac arrest, in the 2020 AHA scientific statement.10
(alpha-adrenergic antagonists and/or
absence of a proven benefit from the phosphodiesterase type III inhibitors),
use of naloxone, standard resuscitative Myocarditis with or without the use of oxygen, can
measures should take priority over be useful to increase systemic delivery
naloxone administration, with a focus 2020 (New): Given the high risk of cardiac
arrest in children with acute myocarditis of oxygen (DO2.)
on high-quality CPR (compressions plus
ventilation). who demonstrate arrhythmias, heart 2020 (New): ECLS after stage I Norwood
block, ST-segment changes, and/or low palliation can be useful to treat low
2015 (Old): Empiric administration of cardiac output, early consideration of systemic DO2.
intramuscular or intranasal naloxone transfer to ICU monitoring and therapy
to all unresponsive opioid-associated 2020 (New): In the situation of known
is recommended.
life-threatening emergency patients or suspected shunt obstruction, it
may be reasonable as an adjunct to 2020 (New): For children with myocarditis is reasonable to administer oxygen,
standard first aid and non–healthcare or cardiomyopathy and refractory low vasoactive agents to increase shunt
provider BLS protocols. cardiac output, prearrest use of ECLS perfusion pressure, and heparin
or mechanical circulatory support can (50-100 units/kg bolus) while preparing
2015 (Old): ACLS providers should be beneficial to provide end-organ for catheter-based or surgical
support ventilation and administer support and prevent cardiac arrest. intervention.
naloxone to patients with a perfusing
cardiac rhythm and opioid-associated 2020 (New): Given the challenges to 2020 (Updated): For neonates prior to
respiratory arrest or severe respiratory successful resuscitation of children stage I repair with pulmonary over-
depression. Bag-mask ventilation with myocarditis and cardiomyopathy, circulation and symptomatic low
should be maintained until spontaneous once cardiac arrest occurs, early systemic cardiac output and DO2, it is
breathing returns, and standard ACLS consideration of extracorporeal reasonable to target a Paco2 of 50 to
measures should continue if return of CPR may be beneficial. 60 mm Hg. This can be achieved during
spontaneous breathing does not occur. Why: Although myocarditis accounts mechanical ventilation by reducing
for about 2% of sudden cardiovascular minute ventilation or by administering
2015 (Old): We can make no analgesia/sedation with or without neu-
recommendation regarding the deaths in infants,11 5% of sudden car-
diovascular deaths in children,11 and 6% romuscular blockade.
administration of naloxone in confirmed
opioid-associated cardiac arrest. to 20% of sudden cardiac death in ath- 2010 (Old): Neonates in a prearrest
letes, previous12,13 PALS guidelines did state due to elevated pulmonary-
Why: The opioid epidemic has not not contain specific recommendations to-systemic flow ratio prior to Stage I
spared children. In the United States for management. These recommenda- repair might benefit from a Paco2 of
in 2018, opioid overdose caused 65 tions are consistent with the 2018 AHA 50 to 60 mm Hg, which can be achieved
deaths in children younger than 15 scientific statement on CPR in infants during mechanical ventilation by reduc-
years and 3618 deaths in people 15 to and children with cardiac disease.14 ing minute ventilation, increasing the
24 years old,9 and many more children inspired fraction of CO2, or administer-
required resuscitation. The 2020 Guide- ing opioids with or without chemical
lines contain new recommendations paralysis.

Neonatal Life Support
Single Ventricle: Recommendations for PALS care. Previous PALS guidelines administration can be useful while
the Treatment of Postoperative Stage II did not contain recommendations for pulmonary-specific vasodilators are
this specialized patient population. administered.
(Bidirectional Glenn/Hemi-Fontan) and These recommendations are con-
Stage III (Fontan) Palliation Patients 2020 (New): For children who develop
sistent with the 2018 AHA scientific
refractory pulmonary hypertension,
statement on CPR in infants and
2020 (New): For patients in a prearrest including signs of low cardiac output
children with cardiac disease.14
state with superior cavopulmonary or profound respiratory failure despite
anastomosis physiology and severe optimal medical therapy, ECLS may
Pulmonary Hypertension be considered.
hypoxemia due to inadequate pul-
monary blood flow (Qp), ventilatory 2020 (Updated): Inhaled nitric oxide or 2010 (Old): Consider administering
strategies that target a mild respiratory prostacyclin should be used as the inhaled nitric oxide or aerosolized
acidosis and a minimum mean airway initial therapy to treat pulmonary hyper- prostacyclin or analogue to reduce
pressure without atelectasis can be tensive crises or acute right-sided heart pulmonary vascular resistance.
useful to increase cerebral and system- failure secondary to increased pulmo-
ic arterial oxygenation. Why: Pulmonary hypertension, a rare
nary vascular resistance.
disease in infants and children, is
2020 (New): ECLS in patients with su- 2020 (New): Provide careful respiratory associated with significant morbidity
perior cavopulmonary anastomosis or management and monitoring to avoid and mortality and requires specialized
Fontan circulation may be considered hypoxia and acidosis in the postoper- management. Previous PALS guidelines
to treat low DO2 from reversible causes ative care of the child with pulmonary did not provide recommendations for
or as a bridge to a ventricular assist hypertension. managing pulmonary hypertension in
device or surgical revision. infants and children. These recommen-
2020 (New): For pediatric patients
Why: Approximately 1 in 600 infants and dations are consistent with guidelines
who are at high risk for pulmonary
children are born with critical con- on pediatric pulmonary hypertension
hypertensive crises, provide adequate
genital heart disease. Staged surgery published by the AHA and the
analgesics, sedatives, and neuromus-
for children born with single ventricle American Thoracic Society in 2015,16
cular blocking agents.
physiology, such as hypoplastic left and with recommendations contained
heart syndrome, spans the first several 2020 (New): For the initial treatment of in a 2020 AHA scientific statement on
years of life.15 Resuscitation of these pulmonary hypertensive crises, oxygen CPR in infants and children with
infants and children is complex and administration and induction of alka- cardiac disease.14
differs in important ways from standard losis through hyperventilation or alkali
Neonatal Life Support

There are over 4 million births every The process of facilitating Summary of Key Issues
year in the United States and Canada. transition is described in the Neonatal
and Major Changes
Up to 1 of every 10 of these newborns Resuscitation Algorithm that starts
will need help to transition from the with the needs of every newborn • Newborn resuscitation requires
fluid-filled environment of the womb and proceeds to steps that address anticipation and preparation by
to the air-filled room. It is essential the needs of at-risk newborns. In providers who train individually and
that every newborn have a caregiver the 2020 Guidelines, we provide as teams.
dedicated to facilitating that transition recommendations on how to follow • Most newly born infants do not
and for that caregiver to be trained and the algorithm, including anticipation require immediate cord clamping or
equipped for the role. Also, a signifi- and preparation, umbilical cord resuscitation and can be evaluated
cant proportion of newborns who need management at delivery, initial actions, and monitored during skin-to-skin
facilitated transition are at risk for com- heart rate monitoring, respiratory contact with their mothers after birth.
plications that require additional trained support, chest compressions,
personnel. All perinatal settings should intravascular access and therapies, • Prevention of hypothermia is
be ready for this scenario. withholding and discontinuing an important focus for neonatal
resuscitation, postresuscitation care, resuscitation. The importance of
and human factors and performance. skin-to-skin care in healthy babies is
Here, we highlight new and updated reinforced as a means of promoting
recommendations that we believe will parental bonding, breastfeeding, and
have a significant impact on outcomes normothermia.
from cardiac arrest.
• Inflation and ventilation of the lungs Major New and Updated Clearing the Airway When
are the priority in newly born infants Recommendations Meconium Is Present
who need support after birth.
• A rise in heart rate is the most Anticipation of Resuscitation Need 2020 (Updated): For nonvigorous new-
important indicator of effective borns (presenting with apnea or
ventilation and response to 2020 (New): Every birth should be at- ineffective breathing effort) delivered
resuscitative interventions. tended by at least 1 person who can through MSAF, routine laryngoscopy
perform the initial steps of newborn with or without tracheal suctioning is
• Pulse oximetry is used to guide resuscitation and initiate PPV and not recommended.
oxygen therapy and meet oxygen whose only responsibility is the care of
saturation goals. 2020 (Updated): For nonvigorous new-
the newborn. borns delivered through MSAF who
• Routine endotracheal suctioning for Why: To support a smooth and safe have evidence of airway obstruction
both vigorous and nonvigorous infants newborn transition from being in the during PPV, intubation and tracheal
born with meconium-stained amniotic womb to breathing air, every birth suction can be beneficial.
fluid (MSAF) is not recommended. should be attended by at least 1 person 2015 (Old): When meconium is present,
Endotracheal suctioning is indicated whose primary responsibility is to the routine intubation for tracheal suction
only if airway obstruction is suspected newly born and who is trained and in this setting is not suggested because
after providing positive-pressure equipped to begin PPV without delay. there is insufficient evidence to
ventilation (PPV). Observational and quality-improvement continue recommending this practice.
• Chest compressions are provided if studies indicate that this approach
enables identification of at-risk Why: In newly born infants with MSAF
there is a poor heart rate response who are not vigorous at birth, initial
newborns, promotes use of checklists
to ventilation after appropriate steps and PPV may be provided. Endo-
to prepare equipment, and facilitates
ventilation-corrective steps, which tracheal suctioning is indicated only if
team briefing. A systematic review of
preferably include endotracheal airway obstruction is suspected after
neonatal resuscitation training in low-
intubation. providing PPV. Evidence from RCTs
resourced settings showed a reduction
• The heart rate response to in both stillbirth and 7-day mortality. suggests that nonvigorous newborns
chest compressions and delivered through MSAF have the same
medications should be monitored Temperature Management for outcomes (survival, need for respiratory
electrocardiographically. support) whether they are suctioned
Newly Born Infants before or after the initiation of PPV.
• When vascular access is required Direct laryngoscopy and endotracheal
in newly born infants, the umbilical 2020 (New): Placing healthy newborn
suctioning are not routinely required for
venous route is preferred. When IV infants who do not require resuscitation
newborns delivered through MSAF, but
access is not feasible, the IO route skin-to-skin after birth can be effective
they can be beneficial in newborns who
in improving breastfeeding, tempera-
may be considered. have evidence of airway obstruction
ture control, and blood glucose stability.
• If the response to chest while receiving PPV.
compressions is poor, it may be Why: Evidence from a Cochrane
systematic review showed that Vascular Access
reasonable to provide epinephrine,
early skin-to-skin contact promotes
preferably via the intravascular route.
normothermia in healthy newborns. In 2020 (New): For babies requiring vascular
• Newborns who fail to respond to addition, 2 meta-analyses of RCTs and access at the time of delivery, the um-
epinephrine and have a history or an observational studies of extended skin- bilical vein is the recommended route.
exam consistent with blood loss may to-skin care after initial resuscitation If IV access is not feasible, it may be
require volume expansion. and/or stabilization showed reduced reasonable to use the IO route.
mortality, improved breastfeeding,
• If all these steps of resuscitation Why: Newborns who have failed to respond
shortened length of stay, and improved
are effectively completed and there to PPV and chest compressions require
weight gain in preterm and low-birth-
is no heart rate response by 20 vascular access to infuse epinephrine and/
weight babies.
minutes, redirection of care should be or volume expanders. Umbilical venous
discussed with the team and family. catheterization is the preferred technique in
the delivery room. IO access is an alter-
native if umbilical venous access is not
feasible or care is being provided outside
of the delivery room. Several case reports
have described local complications associ-
ated with IO needle placement.

Resuscitation Education Science
Termination of Resuscitation reason, a time frame for decisions advantages in psychomotor perfor-
about discontinuing resuscitation mance and knowledge and confidence
2020 (Updated): In newly born babies efforts is suggested, emphasizing when focused training occurred every
receiving resuscitation, if there is no engagement of parents and the resus- 6 months or more frequently. It is
heart rate and all the steps of resusci- citation team before redirecting care. therefore suggested that neonatal
tation have been performed, cessation resuscitation task training occur more
of resuscitation efforts should be Human and System Performance frequently than the current 2-year
discussed with the healthcare team and interval.
the family. A reasonable time frame for 2020 (Updated): For participants who
Why: Educational studies suggest that
this change in goals of care is around have been trained in neonatal resus-
cardiopulmonary resuscitation knowl-
20 minutes after birth. citation, individual or team booster
edge and skills decay within 3 to 12
training should occur more frequently
2010 (Old): In a newly born baby with no months after training. Short, frequent
than every 2 years at a frequency that
detectable heart rate, it is appropriate booster training has been shown to
supports retention of knowledge, skills,
to consider stopping resuscitation if the improve performance in simulation
and behaviors.
heart rate remains undetectable for studies and reduce neonatal mortality
10 minutes. 2015 (Old): Studies that explored how in low-resource settings. To anticipate
frequently healthcare providers or and prepare effectively, providers and
Why: Newborns who have failed to
healthcare students should train teams may improve their performance
respond to resuscitative efforts by
showed no differences in patient with frequent practice.
approximately 20 minutes of age have
outcomes but were able to show some
a low likelihood of survival. For this

Effective education is a key variable support training, and incorporating • Virtual reality, which is the use of
in improving survival outcomes from repetition with feedback and minimum a computer interface to create
cardiac arrest. Without effective passing standards, can improve skill an immersive environment, and
education, lay rescuers and acquisition. gamified learning, which is play and
healthcare providers would struggle • Booster training (ie, brief retraining competition with other students, can
to consistently apply the science sessions) should be added to massed be incorporated into resuscitation
supporting the evidence-based learning (ie, traditional course based) training for laypersons and healthcare
treatment of cardiac arrest. Evidence- to assist with retention of CPR skills. providers.
based instructional design is critical to Provided that individual students can • Laypersons should receive training in
improving provider performance and attend all sessions, separating training how to respond to victims of opioid
patient-related outcomes from cardiac into multiple sessions (ie, spaced overdose, including the administration
arrest. Instructional design features are learning) is preferable to massed of naloxone.
the active ingredients, the key elements learning.
of resuscitation training programs that • Bystander CPR training should target
determine how and when content is • For laypersons, self-directed training, specific socioeconomic, racial,
delivered to students. either alone or in combination and ethnic populations who have
In the 2020 Guidelines, we provide with instructor-led training, is historically exhibited lower rates of
recommendations about various recommended to improve willingness bystander CPR. CPR training should
instructional design features in and ability to perform CPR. Greater address gender-related barriers to
resuscitation training and describe use of self-directed training may improve rates of bystander CPR
how specific provider considerations remove an obstacle to more performed on women.
influence resuscitation education. widespread training of laypersons in • EMS systems should monitor how
Here, we highlight new and updated CPR. much exposure their providers
recommendations in education that we • Middle school– and high school–age receive in treating cardiac arrest
believe will have a significant impact on children should be trained to provide victims. Variability in exposure among
outcomes from cardiac arrest. high-quality CPR. providers in a given EMS system
• In situ training (ie, resuscitation may be supported by implementing
Summary of Key Issues targeted strategies of supplementary
education in actual clinical spaces)
and Major Changes can be used to enhance learning training and/or staffing adjustments.
• The use of deliberate practice outcomes and improve resuscitation • All healthcare providers should complete
and mastery learning during life performance. an adult ACLS course or its equivalent.
• Use of CPR training, mass training, The frequency of booster sessions In Situ Education
CPR awareness campaigns, and should be balanced against student
hands-only CPR promotion should availability and the provision of 2020 (New): It is reasonable to conduct
continue on a widespread basis to resources that support implementation in situ simulation-based resuscitation
improve willingness to provide CPR of booster training. Studies show that training in addition to traditional train-
to cardiac arrest victims, increase the spaced-learning courses, or training ing.
prevalence of bystander CPR, and that is separated into multiple sessions, 2020 (New): It may be reasonable to
improve outcomes from OHCA. are of equal or greater effectiveness conduct in situ simulation-based resus-
when compared with courses delivered citation training in place of traditional
Major New and Updated as a single training event. Student training.
Recommendations attendance across all sessions is
required to ensure course completion Why: In situ simulation refers to train-
ing activities that are conducted in
Deliberate Practice and because new content is presented at
actual patient care areas, which has the
Mastery Learning each session.
advantage of providing a more realistic
training environment. New evidence
2020 (New): Incorporating a deliberate Lay Rescuer Training shows that training in the in situ envi-
practice and mastery learning model ronment, either alone or in combination
into basic or advanced life support 2020 (Updated): A combination of
with traditional training, can have a
courses may be considered for improv- self-instruction and instructor-led
positive impact on learning outcomes
ing skill acquisition and performance. teaching with hands-on training is
(eg, faster time to perform critical tasks
recommended as an alternative to
Why: Deliberate practice is a training and team performance) and patient
instructor-led courses for lay rescuers.
approach where students are given a outcomes (eg, improved survival, neu-
If instructor-led training is not available,
discrete goal to achieve, immediate rological outcomes).
self-directed training is recommended
feedback on their performance, and for lay rescuers. When conducting in situ simulation,
ample time for repetition to improve instructors should be wary of potential
performance. Mastery learning is 2020 (New): It is recommended to train risks, such as mixing training supplies
defined as the use of deliberate middle school– and high school–age with real medical supplies.
practice training and testing that children in how to perform high-quality
includes a set of criteria to define CPR. Gamified Learning and Virtual Reality
a specific passing standard, which 2015 (Old): A combination of self-
implies mastery of the tasks being instruction and instructor-led 2020 (New): The use of gamified learning
learned. teaching with hands-on training can and virtual reality may be considered for
Evidence suggests that incorporating be considered as an alternative to basic or advanced life support train-
a deliberate practice and mastery traditional instructor-led courses for lay ing for lay rescuers and/or healthcare
learning model into basic or advanced providers. If instructor-led training is not providers.
life support courses improves multiple available, self-directed training may be Why: Gamified learning incorporates
learning outcomes. considered for lay providers learning competition or play around the topic of
AED skills. resuscitation, and virtual reality uses a
Booster Training and Why: Studies have found that self- computer interface that allows the user
Spaced Learning instruction or video-based instruction to interact within a virtual environment.
is as effective as instructor-led training Some studies have demonstrated
2020 (New): It is recommended to imple- for lay rescuer CPR training. A shift positive benefits on learning outcomes
ment booster sessions when utilizing a to more self-directed training may (eg, improved knowledge acquisition,
massed-learning approach for resusci- lead to a higher proportion of trained knowledge retention, and CPR skills)
tation training. lay rescuers, thus increasing the with these modalities. Programs
chances that a trained lay rescuer looking to implement gamified learning
2020 (New): It is reasonable to use a
will be available to provide CPR when or virtual reality should consider
spaced-learning approach in place of a
needed. Training school-age children high start-up costs associated with
massed-learning approach for resusci-
to perform CPR instills confidence and purchasing equipment and software.
tation training.
a positive attitude toward providing
Why: The addition of booster training CPR. Targeting this population with CPR
sessions, which are brief, frequent training helps build the future cadre of
sessions focused on repetition of prior community-based, trained lay rescuers.
content, to resuscitation courses im-
proves the retention of CPR skills.

Bystander CPR training should target

specific socioeconomic, racial,
and ethnic populations who have
historically exhibited lower rates of
bystander CPR. CPR training should
address gender-related barriers
to improve rates of bystander CPR
performed on women.
Opioid Overdose Training for stander CPR and CPR training. Women ommend that EMS systems monitor
Lay Rescuers are also less likely to receive bystander provider exposure and develop strate-
CPR, which may be because bystand- gies to address low exposure.
2020 (New): It is reasonable for lay rescuers fear injuring female victims or being
ers to receive training in responding to accused of inappropriate touching. ACLS Course Participation
opioid overdose, including provision of Targeting specific racial, ethnic,
naloxone. and low-socioeconomic populations 2020 (New): It is reasonable for health-
for CPR education and modifying care professionals to take an adult
Why: Deaths from opioid overdose in the ACLS course or equivalent training.
education to address gender
United States have more than doubled
in the past decade. Multiple studies differences could eliminate disparities Why: For more than 3 decades, the
have found that targeted resuscita- in CPR training and bystander CPR, ACLS course has been recognized as
tion training for opioid users and their potentially enhancing outcomes from an essential component of resuscita-
families and friends is associated with cardiac arrest in these populations. tion training for acute care providers.
higher rates of naloxone administration Studies show that resuscitation teams
in witnessed overdoses. EMS Practitioner Experience with 1 or more team members trained in
and Exposure to Out-of-Hospital ACLS have better patient outcomes.
Disparities in Education Cardiac Arrest Willingness to Perform Bystander CPR
2020 (New): It is recommended to target 2020 (New): It is reasonable for EMS
and tailor layperson CPR training to 2020 (New): It is reasonable to increase
systems to monitor clinical personnel’s
specific racial and ethnic populations bystander willingness to perform
exposure to resuscitation to ensure
and neighborhoods in the United CPR through CPR training, mass CPR
treating teams have members com-
States. training, CPR awareness initiatives, and
petent in managing cardiac arrest
promotion of Hands-Only CPR.
2020 (New): It is reasonable to address cases. Competence of teams may be
barriers to bystander CPR for female supported through staffing or training Why: Prompt delivery of bystander CPR
victims through educational training strategies. doubles a victim’s chances of survival
and public awareness efforts. from cardiac arrest. CPR training, mass
Why: A recent systematic review found
CPR training, CPR awareness initiatives,
Why: Communities with low socio- that EMS provider exposure to cardiac
and promotion of Hands-Only CPR are
economic status and those with arrest cases is associated with im-
all associated with increased rates of
predominantly Black and Hispanic proved patient outcomes, including
bystander CPR.
populations have lower rates of by- rates of ROSC and survival. Because
exposure can be variable, we rec-
Systems of Care
Survival after cardiac arrest requires an • Early warning scoring systems and rescuers via a smartphone app or
integrated system of people, training, rapid response teams can prevent text message alert is associated with
equipment, and organizations. Willing cardiac arrest in both pediatric and shorter bystander response times,
bystanders, property owners who adult hospitals, but the literature higher bystander CPR rates, shorter
maintain AEDs, emergency service is too varied to understand what time to defibrillation, and higher rates of
telecommunicators, and BLS and ALS components of these systems are survival to hospital discharge for people
providers working within EMS systems associated with benefit. who experience OHCA. The differences
all contribute to successful resuscita- in clinical outcomes were seen only
• Cognitive aids may improve in the observational data. The use of
tion from OHCA. Within hospitals, the resuscitation performance by
work of physicians, nurses, respirato- mobile phone technology has yet to be
untrained laypersons, but in simulation studied in a North American setting, but
ry therapists, pharmacists, and other settings, their use delays the start of the suggestion of benefit in other coun-
professionals supports resuscitation CPR. More development and study are tries makes this a high priority for future
outcomes. needed before these systems can be research, including the impact of these
Successful resuscitation also fully endorsed. alerts on cardiac arrest outcomes in
depends on the contributions diverse patient, community, and geo-
of equipment manufacturers, • Surprisingly little is known about
the effect of cognitive aids on the graphic contexts.
pharmaceutical companies,
resuscitation instructors, guidelines performance of EMS or hospital-
based resuscitation teams. Data Registries to Improve
developers, and many others. Long-
System Performance
term survivorship requires support • Although specialized cardiac
from family and professional caregivers, arrest centers offer protocols and New (2020): It is reasonable for organiza-
including experts in cognitive, physical, technology not available at all tions that treat cardiac arrest patients
and psychological rehabilitation and hospitals, the available literature to collect processes-of-care data and
recovery. A systems-wide commitment about their impact on resuscitation outcomes.
to quality improvement at every outcomes is mixed.
level of care is essential to achieving Why: Many industries, including health-
• Team feedback matters. Structured care, collect and assess performance
successful outcomes.
debriefing protocols improve the data to measure quality and identify
performance of resuscitation teams in opportunities for improvement. This
Summary of Key Issues
subsequent resuscitation. can be done at the local, regional, or
and Major Changes national level through participation in
• System-wide feedback matters.
• Recovery continues long after the Implementing structured data data registries that collect informa-
initial hospitalization and is a critical collection and review improves tion on processes of care (eg, CPR
component of the resuscitation performance data, defibrillation times,
resuscitation processes and survival
Chains of Survival. adherence to guidelines) and outcomes
both inside and outside the hospital.
of care (eg, ROSC, survival) associated
• Efforts to support the ability and with cardiac arrest.
willingness of the members of the Major New and Updated
Three such initiatives are the AHA’s
general public to perform CPR and Recommendations
Get With The Guidelines-Resuscitation
use an AED improve resuscitation
registry (for IHCA), the Cardiac Arrest
outcomes in communities. Using Mobile Devices to
Registry to Enhance Survival registry (for
• Novel methods to use mobile phone Summon Rescuers OHCA), and the Resuscitation
technology to alert trained lay Outcomes Consortium Cardiac Epistry
rescuers of events that require New (2020): The use of mobile phone
(for OHCA), and many regional
CPR are promising and deserve technology by emergency dispatch
databases exist. A 2020 ILCOR
more study. systems to alert willing bystanders to
systematic review found that most
nearby events that may require CPR or
• Emergency system telecommunica- AED use is reasonable. studies assessing the impact of data
tors can instruct bystanders to per- registries, with or without public
form hands-only CPR for adults and Why: Despite the recognized role of lay reporting, demonstrate improvement in
first responders in improving OHCA cardiac arrest survival in organizations
children. The No-No-Go framework is
outcomes, most communities experi- and communities that participated in
effective.
ence low rates of bystander CPR and cardiac arrest registries.
AED use. A recent ILCOR systematic
review found that notification of lay

References
1. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press.
2. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press.
3. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science with Treatment Recommendations. Resuscitation. 2020:In press.
4. Morley P, Atkins D, Finn JM, et al. 2: Evidence-evaluation process and management of potential conflicts of interest: 2020 International Consensus on
Cardiopulmonary Resuscitation Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press.
5. Magid DJ, Aziz K, Cheng A, et al. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press.
6. Sawyer KN, Camp-Rogers TR, Kotini-Shah P, et al; for the American Heart Association Emergency Cardiovascular Care Committee; Council on
Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke
Council. Sudden cardiac arrest survivorship: a scientific statement from the American Heart Association. Circulation. 2020;141:e654-e685. doi:
10.1161/CIR.0000000000000747
7. Jeejeebhoy FM, Zelop CM, Lipman S, et al; for the American Heart Association Emergency Cardiovascular Care Committee, Council on
Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology.
Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation. 2015;132(18):1747-1773. doi: 10.1161/
CIR.0000000000000300
8. Berg RA, Sutton RM, Reeder RW, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative
Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation Investigators. Association between diastolic blood pressure during pediatric in-
hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784-1795. doi: 10.1161/CIRCULATIONAHA.117.032270
9. Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep.
2020;69(11):290-297. doi: 10.15585/mmwr.mm6911a4
10. Dezfulian, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for healthcare and public responses: a
scientific statement from the American Heart Association. Circulation. 2020:In press.
11. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities:
task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a
scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e273-e280. doi: 10.1161/
cir.0000000000000239
12. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States,
1980-2006. Circulation. 2009;119(8):1085-1092. doi: 10.1161/CIRCULATIONAHA.108.804617
13. Fung G, Luo H, Qiu Y, Yang D, McManus B. Myocarditis. Circ Res. 2016;118(3):496-514. doi: 10.1161/CIRCRESAHA.115.306573
14. Marino BS, Tabbutt S, MacLaren G, et al; for the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular
Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and
Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary resuscitation in infants and children with cardiac disease: a scientific
statement from the American Heart Association. Circulation. 2018;137(22):e691-e782. doi: 10.1161/CIR.0000000000000524
15. Oster ME, Lee KA, Honein MA, Riehle-Colarusso T, Shin M, Correa A. Temporal trends in survival among infants with critical congenital heart defects.
Pediatrics. 2013;131(5):e1502-e1508. doi: 10.1542/peds.2012-3435
16. Abman SH, Hansmann G, Archer SL, et al; for the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and
Resuscitation; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Radiology and Intervention;
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American Heart Association and American Thoracic Society. Circulation. 2015;132(21):2037-2099. doi: 10.1161/CIR.0000000000000329
Effective Defibrillation and Safety
“Countershock”
 Precordial Thump
 AED (Automated External Defibrillator)
 Defibrillation
 Cardioversion
 AICD (Automated Implantable Cardioverter
Defibrillator)
Principles of Early Defibrillation
 Most frequent initial rhythm in a sudden cardiac arrest
is Ventricular Fibrillation (VF)
 The most effective treatment for VF is Defibrillation
 The success of defibrillation diminishes according to
the time
 VF converts asystole within few minutes
Defibrillation can be accomplished:
 Precordial Thump
 External Countershock using defibrillator
 AED- Automated External Defibrillator
 AICD- Automated Implantable Cardioverter
Defibrillator
Monitored Arrest
The patient is already connected to the monitor at the
time of the arrest.
PRECORDIAL THUMP
Perform by directly hitting the mid-sternum or center of
the sternum using the hypotenar aspect of the fist
(softest side) from a height of no more than 12 inches.
Defibrillation
Is a delicate procedure performed by a competent RN
wherein electrical shock or shocks of short duration
is/are discharged through the heart as an attempt to
terminate death-forming dysrhythmias.
Indications:
 Standard treatment for Ventricular Fibrillation (VF)
 Pulseless Ventricular Tachycardia (VT)

Mechanism of Action
Defibrillation involves the use of electrode paddles or
patch to deliver the electric current through the
client’s heart.
How does Defibrillation work (Purpose)?
The purpose of the delivered current is to temporarily
depolarize critical mass of the myocardial cells when
beating irregularly so that if successful, the non
ventricular pacemaker will resume the control of the
heart’s electrical activities restoring the patient’s
(intrinsic) normal rhythm.
CPR before and after is better (2005 AHA
Guidelines for CPR or ECC)
If a patient with sudden cardiac arrest from VF is
without treatment for 5 minutes or longer, the
outcome may improve if CPR is performed prior to
defibrillation.
Effective chest compressions help deliver blood to the

coronary arteries and brain.
 It is also important to perform CPR after defibrillation
for the patient may experience a period of asystole or
pulseless electrical activity which the CPR may help by
converting to a more perfusing rhythm.
 However basic CPR can not convert VF to a normal

rhythm. The only way to convert VF and restore
normal rhythm is through defibrillation.
The need for SPEED
If the defibrillation is done with VF patient within 5
minutes of cardiac arrest, the survival rate is 50%.
The survival rate decreases by 7 % to 10% for each

minute that the patient is in VF.
AED
Portable defibrillator with microcomputer that senses
and analyzes patient’s heart rhythm and gives step-by-
step directions on how to proceed if defibrillation is
indicated.
Shocks are automatically delivered with the use of

adhesive pads as needed according to the machine’s
own interpretation.
AED (Automated External
Defibrillators)
Fully Automatic
Semi Automatic
How should it be done?
 Attach AED only when the patient has no pulse and
respiration.
 Witnessed cardiac arrest- in the hospital with monitor

 Unwitnessed cardiac arrest – outside the hospital and
no monitor
Witnessed Cardiac Arrest
Initiate CPR immediately and use an AED as soon as
possible.
Unwitnessed Cardiac Arrest
Perform 5 cycles (2 minutes) of CPR before checking the
ECG and attempting to defibrillate.
 Open the pockets containing the two electrode pads.
 Expose the client’s chest.
 Remove the plastic backing from the electrode pads.
 Press the ON button.
 Listen to the computerized voice analyzing the rhythm
5 to 15 seconds.
 If shock is not needed, the AED will advise to continue
CPR.
 If shock is needed, the AED will announce “STAND
CLEAR” message and emit a beep that changes to a
steady tone as it charges.
 When the AED is fully charged, and ready to deliver a
shock, it will prompt you to press the shock button.
 Make sure no one is touching the patient or bed and
call out “I’M CLEAR”, YOU’RE CLEAR, EVERYBODY’S
CLEAR, then press the shock button.
 Resume CPR 5 cycles (about 2 minutes).
Purpose of Adhesive Electrode Pads
 To transmit patient’s rhythm.

 To deliver the shock.
Situations requiring a change in actions when
using AEDs:
1. Child <1 year old (do not use the AED)
2. Lying in water, move the victim first and dry the
chest wall.
3. With AICD, (implanted pacemaker or defibrillator)
place the electrode pad away from the devices.
4. With transdermal medication patch, remove the
patch and clean the chest wall.
Treat the client, not the AED machine
 Example: If the AED reads “flatline”, it may only mean
that one of the cable electrodes is disconnected or it
may read normal and the client is actually on VT.
 Remember that AED only analyzes “rhythm”, it does
not check the pulse.
 CPR is vital and that AED’s purpose is to treat death-
forming dysrhythmias.
Unmonitored / unwitnessed using
conventional defibrillator
 Assess level of responsiveness.
 No response-call 911 and get the AED
 Using manual defibrillator, do “quick look” by simply placing the
paddle on the client’s chest to quickly view the heart’s rhythm.
 With lethal arrhythmias, (pulseless VT) apply the conductive medium.
 Turn the defibrillator on and set at the initial 200 joules, no conversion
increase to 300 joules, no conversion increase to 360 joules. Once 360
joules is used, stay to that level.
 Charge the paddles by pressing the charge buttons on the paddle.
 Press firmly against the client’s chest using 25lbs.
Note: no pulse check needed for the first 3 defibrillations.

The current practice:
Monophasic
Vs
Biphasic
Waveform
Monophasic defibrillators
 Delivers a single current of electricity that travels in
one direction between the two paddles on the patient’s
chest
 To be effective, a large amount of electrical current is
required for monophasic defibrillators.
 3 stacked shocks delivery without pause
a. 200-300 joules
b. 200-300 joules
c. 360 maximum
Biphasic defibrillators
 Pad or paddle placement is the same. However, the
discharged electrical current travels in a positive
direction for a specified duration and then reverses &
flows in a negative direction for the remaining time of
the electrical discharge, thus delivering 2 or double
currents of electricity.
 more successful conversions
Advantages:
 Requires lower threshold of the heart muscle allowing
more successful defibrillation with smaller amounts if
energy.
 It also adjusts for differences of impedance or
resistance reducing the number of shocks needed.
 RECTILINEAR BIPHASIC WAVEFORM
DEFIBRILLATOR
150-200 JOULES
 BIPHASIC TRUNCATED EXPONENTIAL

WAVEFORM (B.E.T.W.)
120 JOULES
Indications:
VENTRICULAR FIBRILLATION
PULSELESS VENTRICULAR TACHYCARDIA

PADDLE PLACEMENT:
 (For standard placement) Antero-Lateral
Right- upper sternum just below the right clavicle
Left- nipple line and mid-axillary
 Anterior / Posterior
 Manage “Arching” by:

a. Necessary amount of gel applied
b. 25 pounds muscle pressure
 Manage transthoracic resistance :
1. by paddle size (adult 8.5-12 cm diameter ; child 8cm;
infant 4.5 cm)
Safety is the first consideration
 Do not use alcohol to clean the paddles.
 Avoid placing the paddles near the monitoring
electrodes.
 Do not tilt the paddles during use to avoid arching.
 Stand clear from the patient and bed when
discharging the device.
 Do not position the pads over the pacemaker.
Post Defibrillation
 Monitor neurological status
 Cardiovascular status
 Respiratory status
 Blood values
Neurological status
 Level of consciousness
 Pupillary reactions
 Motor / Sensory
 Vital signs that could indicate brain damage / IIP
Respiratory
 Breathing pattern / status
 Intubated
 Breath sounds
Cardiovascular
 Pulses
 Heart sounds
 Dysrhythmias
 Medication drips
Synchronized cardioversion
 Cardioversion- “synchronized countershock” is the
delivery of timed but direct electrical shock(s) to the
heart as an emergency or elective treatment performed
by an MD or certified RN
 The electrical charge is delivered to the myocardium at
the peak of R wave causing immediate depolarization
allowing SA node to gain control of the conduction
system.
Elective or emergency electrical therapy procedure is
used to treat VT with pulse that is transient or not
sustained and “tachydysrhythmias” if refractory or not
responding to usual mode of treatments like
medications or valsalva.
“SYNCHRONIZED”
When electrical current is discharged, it only triggers the
client’s QRS complex to avoid accidental electrical
discharge at the repolarization phase (T wave) due to
the danger of converting to death forming
dysrhythmias.
indications:
 Tachydysrhythmias
 Symptomatic
 Refractory to medications
 Conscious or ventricular tachycardia with pulse
What are the 4 usual ways of treating
tachydysrhythmias?
 Valsalva
 Medications
 Cardioversion
 Carotid massage
Preparation:
 Explain the procedure.
 Obtain 12L EKG as baseline.
 Connect client to pulse oximeter and BP cuff.
 Connect to the monitoring leads.
 Turn on the defibrillator and set for the synchronus mode.
 Sedation as ordered.
 Remove dentures / jewelries.
 Empty bladder.
 Check the Digoxin level.
 Prepare by exposing the client’s chest.
 Obtain 12L EKG and write “pre conversion”.
 Have emergency and intubation set ready.
AICD (Automated Implantable Cardioverter
Defibrillator)
Priorities:
 Activation status
 Heart rate cutoff
 Number of shock(s) allowed to deliver
Description:
 Pulse generator + Leads
 Weight – ½ lbs.
 Size: a deck of cards
 Implantation: thoracotomy, sternotomy, transvenous
 CAB via sternotomy
 Pulse generator
 Sensor – monitor client’s EKG continuously:
will deliver countershock within 15-20 seconds
can also cardiovert Vtach with pulse

 Nothing will work, not until medications are used.
 Combination of electrical therapy

SHOCK and Medications
The Resuscitation Team
Slide 1
Goals of the Resuscitation Team
• Reestablish spontaneous circulation and
respiration
• Preserve function in vital organs during

resuscitation
Critical Tasks of Resuscitation
1. Airway management
2. Chest compressions
3. ECG monitoring and defibrillation
4. Vascular access and medication

administration
Team Leader Responsibilities
• Assesses patient
• Orders emergency care according to protocols

• Considers reasons for cardiac arrest
• Supervises team members
• Evaluates adequate chest compressions
• Ensures patient receives 100% oxygen

• Evaluates adequacy of ventilation
• Ensures safe defibrillation

Team Leader Responsibilities
• Ensures correct choice and placement of vascular
access
• Confirms position of advanced airway
• Ensures correct drug, dose, route given
• Ensures safety of team
• Problem-solves
• Decides when to terminate resuscitation efforts

Airway Team Member
• Manual airway • Suctioning
maneuvers
• Cricoid pressure
• Oral airway
• Advanced airway
• Nasal airway placement
– If within scope of
practice
• Oxygen delivery
devices
CPR Team Member
• The ACLS or BLS team member
responsible for CPR must:
– Know how to properly perform CPR
– Provide chest compressions of adequate
rate, force, and depth in the correct location
ECG/Defibrillation Team Member
• Sync vs. unsynchronized shocks
• Pad/paddle placement
• Safety precautions
• Indications/complications of transcutaneous
pacing
• Problem-solving equipment failure

Vascular Access/Meds Team Member
• Sites of first choice for vascular access in cardiac
arrest
• IV fluids of choice
• In cardiac arrest:
– Follow each drug with 20-mL fluid bolus
• Know drugs that can be given by IV, ET, and IO

routes
Support Roles
• Management of supplies
• Assistance with procedures
• Documentation of the resuscitation effort
• Liaison functions
• Crowd control
Code Organization
Phase Response
Slide 14
Phase I—Anticipation
• Analyze initial data
• Assemble resuscitation team
• Identify team leader
• Assign critical resuscitation tasks
• Prepare/check equipment
• Position team leader and team members

Phase II—Entry
• Team leader identified
– Begins to obtain information
– Ensures safe transfer of patient to
resuscitation bed
– Instructs team members to obtain ABCD
information and relay to team leader in ABCD
sequence
Phase III—Resuscitation
• Focuses on the
ABCDs of
resuscitation
• Team leader directs

team through the
various
resuscitation
protocols
Phase IV—Maintenance
• Efforts of resuscitation team should be
focused on:
– Anticipating changes in the patient’s condition
– Repeated reevaluation of the patient’s ABCs
– Stabilizing vital signs
– Securing tubes and lines
– Troubleshooting any problem areas
– Preparing the patient for transport/transfer
Phase V—Family Notification
• Update family members frequently
• Relay results of resuscitation effort

promptly to family
• Enlist assistance of a social worker or

clergy as needed
Phase VI—Transfer
• Responsibility to the patient continues until
patient care is transferred to a team of
equal or greater expertise
Phase VII—Critique
• Team leader responsibility
• Critique provides:
– Opportunity to express grieving
– Opportunity for education (“teachable
moment”)
– Feedback to hospital and prehospital
personnel regarding efforts of team
Helping the Caregivers
• Recognize warning signs of stress in
yourself and others
• Strategies for dealing with stress may

include
– Exercise
– Practicing relaxation techniques
– Talking with family or friends
– Meeting with a qualified mental health
professional
Advanced Cardiac Life
Support Algorithms
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What are the steps of cardiopulmonary resuscitation (CPR)?

What are the steps of cardiopulmonary resuscitation (CPR)?

What are the purposes of CPR?

What are the purposes of CPR?

COLLEGE OF NURSING

CARDIOPULMONARY RESUSCITATION (CPR)

For Adults – palpate the carotid pulse by

6. If patient is pulseless, begin external cardiac

Note: For chest compressions, PUSH HARD AND FAST.

7. Open patient’s airway using either of the

a. Head tilt-chin lift maneuver

8. Give two rescue breaths after 30

Mouth to mouth resuscitation

c. Take a regular breath and seal lips.

Mouth-to-mask breaths using a pocket mask

11. Continue CPR for a total of 5 cycles at 30:2

14. Let the patient assume a recovery position.

Note: For Adults 2-rescue CPR.

Revised by: Asst. Prof. Chereisle G. Pyponco

CARDIOPULMONARY RESUSCITATION (CPR) CHECKLIST

Criteria Excellent Satisfactory Below Needs major Total Remarks

3. Called for help. ______ ______ ______ ______ ______

5. Assessed for carotid pulse and absence

6. Began external cardiac compression (if

7. Opened patient’s airway

a. Head-tilt/chin-lift maneuver or ______ ______ ______ ______ ______

8. Gave 2 rescue breaths after 30

For Mouth-to-mouth resuscitation: ______ ______ ______ ______ ______

a. Pinched patient’s nose with the

a. Positioned onerself at the victim’s ______ ______ ______ ______ ______

SCENARIO: AED arrived. Pads were

12. Reassessed patient after 5 complete

13. Minimized interruptions. Tried to keep

SCENARIO: If patient has pulse:

14. Allowed the patient to assume the

Facilitator: Asst. Prof. Chereisle G. Pyponco

2. Look, listen, and feel for breathing has been

3. Continued emphasis has been placed on high-

3. Immediate CPR could double or triple the chances

2. Check for Responsiveness and Normal Breathing

3. Shout for Help

“HELP! CALL 911!

4. Check for carotid pulse and breathing

Not more than 10

6. Open the Airway

7. Give 2 Rescue Breaths

DELIVER BREATHS SLOWLY

8. Continue CPR for a total of 5 cycles at 30:2.

▪ When possible, change CPR

A. If breathless and pulseless:

*NOTE: Attach and use AED as soon as it is available.

eam (EMS) arrives.

ver-exhaustion of the rescuer.

hysician declares the patient dead.

telectasis (punctured lungs).

1. Tap the infant’s foot and shout “Baby, baby are

2. If the infant is unconscious, call

9. Seal infant’s nose and

10. Deliver 2 gentle puffs of

11. Reassess the infant after

3. Called for help. __

a. Head-tilt/chin-lift maneuver or __

For Mouth-to-mouth resuscitation: __

a. Positioned onerself at the victim’s __

DELIVER BREATHS SLOWLY

If SHOCK is advised, stay clear