What are the most recent ACLS recommendations?

2020 AHA Guideline Updates

The AHA has released revised guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, which became official on October 21, 2020. For your convenience, we have provided a summary of the ACLS Academy’s reaction as well as revisions to the guidelines below.

ACLS Academy – Classes updated to the 2020 AHA Guidelines

The AHA Faculty of Instructors and the ACLS Academy Training Center have completed instructor updates in their respective disciplines.

As soon as new learning resources for 2020 are made available, we will immediately begin updating our existing learning tools (DVDs, examinations, posters).

On November 1, we emailed a document to everyone who had finished the course with us in 2020, informing them of all the changes that would be included in the update.

The 2020 AHA Updates offer information about the following:

Science Updates

  • In the event that an infant, child, or adolescent experiences a cardiac arrest while in the hospital, a new pediatric chain of survival has been developed.
  • Regeneration has been included as the sixth link to each of the four chains that make up survival.
  • An adjustment has been made to the emergency algorithm for opioid healthcare providers.
  • Recurrent cardiac arrest in pregnancy.
  • One rescuer may now compress children using either their two thumbs or the heel of one hand.
  • Alterations were made to the standard protocol for assisted ventilation in pediatric patients.
  • Recently, there has been a shift toward placing a greater focus on debriefing for paramedics.

Top ten facts

The algorithms used to treat cardiac arrest did not undergo any changes in 2015.

The algorithm for treating adult bradycardia in 2020 increased the atropine dose to 1 mg (from 0.5–1 mg), but the dosing frequency remained the same as every 3–5 minutes, with a maximum dose of 3 mg.

It was determined that epinephrine was present. To be more specific, epinephrine should be given as quickly as feasible and in shockless rhythms (pulseless electrical activity and asystole). When it comes to shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia, the timing is less certain; however, it is fair to administer the first dose after the early attempts to defibrillate the patient have been unsuccessful. The first dosage of epinephrine is administered after the second shock according to the algorithm for shock rhythms that is currently being used.

Because some limited observational studies found that intraosseous (IO) cannulation produced less favorable effects, intravenous delivery of the medication is favored over intraosseous (IO) administration of the medicine. You should try to get an IV if possible, but you can always resort to using IO if necessary. It is still not suggested to place central venous catheters during the code unless it is possible to gain access to another vein.

Performing double sequential defibrillation in refractory VF is not recommended because there is insufficient evidence to support its use. Double sequential defibrillation involves the use of two sets of electrodes and two separate defibrillators to deliver defibrillation either in rapid succession or simultaneously.

It is permissible to utilize physiological markers such as end-tidal carbon dioxide (EtCO2) or arterial blood pressure to monitor the quality of cardiopulmonary resuscitation (CPR). The desired EtCO2 should be larger than 10 mm Hg, but ideally, it should be greater than 20 mm Hg; hence, you should use more force and/or move more quickly if you are not reaching the ideal. It is important to note that in order to monitor arterial blood pressure, an arterial line needs to be placed in the patient. Additionally, the patient needs to be intubated with an EtCO2 monitor attached in order to guarantee that proper monitoring of EtCO2 is being performed.

It is still unclear whether or not intubation is necessary and when it should be performed. The American Heart Association highly recommends a mask with a bag valve or an advanced airway.

When a pregnant patient goes into cardiac arrest, the focus should be on providing high-quality CPR and relieving aortocaval compression by shifting the patient’s uterus to the left laterally while they are in the supine position. This indicates that a medical team member will stand on the left side of the patient, hold the uterus, and pull it up and to the left to do the procedure. Alternately, if you are standing to the right of the patient, you should push the uterus to the left and up from the maternal vasculature. This should be done if you are performing the procedure while facing the patient.

AHA In light of the current crisis, new algorithms for preventing opioid overdoses has been released. Do not wait for the effects of naloxone to begin CPR because there is no evidence that naloxone is beneficial in the event of cardiac arrest. Instead, focus on doing normal resuscitation procedures before beginning CPR. However, in the event that an overdose is suspected, the administration of naloxone is still the best course of action.

Before doing a multimodal neuro-prognosis, clinicians should wait for a minimum of 72 hours after the patient has returned to normothermia. This enables potentially misleading aspects, such as drugs, to be eliminated, which results in improved accuracy.

Updated ACLS Guidelines Emphasize Out-of-Hospital Actions

According to Cameron Berg, MD, an emergency medicine physician in Minneapolis, Minnesota, who gave a virtual presentation at the American College of Emergency Physicians (ACEP) 2021 Scientific Meeting, the Advanced Cardiac Life Support (ACLS) guidelines went through a comprehensive 5-year update in 2020. However, targeted updates for 2021 will emphasize the chain of survival, both in-hospital and out-of-hospital. Berg stated that the ACLS recommendations reference publications regarding cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) from the American College of Cardiology and the American Heart Association. According to him, thorough updates of the ACLS are distributed once every five years, and the publication that is due out in 2020 is meant to serve as the primary guide through the year 2025.

Berg highlighted several updates that were made this year related to adult life support and basic life support, resuscitation science, and systems of care. The complete ACLS guidelines include information on basic and advanced life support for neonates and children, but Berg focused on the adult updates. According to Berg, it is up to the clinician to evaluate which of the subjects included in the evidence-based guidelines have the best potential applicability when they are examining the guidelines.

“I would like to challenge you to remember the chains of survival that were part of the instructions for the last two cycles,” he said to them. “I would like to challenge you to recall the chains of survival.”

The chain of survival for adult in-hospital cardiac arrest (IHCA) involves early recognition and prevention, activation of emergency response systems, high-quality cardiopulmonary resuscitation, defibrillation, post-cardiac arrest treatment, and recovery. The activation of emergency response, followed by high-quality cardiopulmonary resuscitation (CPR), is the first step in the chain of survival for an out-of-hospital cardiac arrest (OHCA). According to Berg, the 2021 OHCA changes place a particular emphasis on performing chest compressions in the event that cardiac arrest is suspected.

Out-of-Hospital Actions

Despite recent improvements, less than forty per cent of adults receive lay CPR, and less than twelve per cent have an automated external defibrillator applied before emergency medical services arrive, according to Berg. “This is a significant piece of information. If we wish to have positive effects on the public as a whole, bystander CPR is very necessary.” All OHCA updates are about chest compressions, he noted. The findings provide credence to the practice of manual cardiopulmonary resuscitation (CPR), and according to Berg, training for law enforcement, firefighters, and other first responders as well as laypeople is “important.” “Teach everyone in your life to execute high-quality chest compressions,” it says. “It could save a life.”

He continued by saying, “Both seconds and minutes are important.” When the patient has a pulse but has experienced an opioid overdose, it is suggested that basic life support be administered in the form of naloxone (Narcan). Berg made a passing mention of this. According to him, lay responders like law enforcement and firefighters can save lives by administering naloxone to opioid overdose victims.

Berg mentioned that the recommendations for prehospital ACLS include algorithms for the basic cessation of life-sustaining resuscitation. “the possibility of survival is so low, field termination is appropriate to consider,” Berg said, adding that if cardiac arrest is not witnessed and bystander CPR has not occurred, as well as if there is no recovery of spontaneous circulation and shock before the transfer, “the chance of life is so low.” According to what he mentioned, those fundamental algorithms have been published as part of the standards for BLS and ACLS.

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