Chapter 10 – ACLS Updates

ACLS documentation is revised every five years based on current research. Every year, ILCOR evaluates the scientific evidence and provides brief updates to the ACLS guidelines. This review ensures that scientific research steers the ACLS guidelines without having to wait five years until a full revision is complete. An ACLS provider must maintain current knowledge based on the most current scientific research.

Updates to ACLS – 2020

In the updates to the guidelines for ACLS, the AHA and ILCOR combined the ACLS and BLS updates. Although care has been taken to update this guide, an overview of the changes is included here:

Changes in Visuals and Algorithms

Addition of a Recovery link In the IHCA and OHCA Chains of Survival
Modification of the Cardiac Arrest algorithm to encourage early administration of epinephrine for nonshockable rhythms
New lay-rescuer Opioid-Associated Arrest Algorithm
· New trained rescuer Opioid-Associated Arrest Algorithm
Modification of the Post-Cardiac Arrest Care algorithm to encourage the need to prevent hypoxemia, hypotension, and hyperoxia
New Cardiac Arrest in Pregnancy algorithm
New visual with information about neuroprognostication after ROSC

Key Changes

In addition to the new algorithms and modifications to the existing algorithms, additional changes to the guidelines include:

Lay-rescuer initiation of CPR: AHA and ILCOR recommend that lay rescuers perform CPR on any victim with presumed cardiac arrest. The risk of harm from CPR on a victim without a cardiac arrest is low.
Early administration of epinephrine: For victims in nonshockable cardiac arrest rhythms, epinephrine should be administered as soon as possible. For those with a shockable rhythm, epinephrine may be administered after defibrillation has failed.
Use of audiovisual feedback devices: The use of feedback devices may improve CPR performance and survival to hospital discharge.
Monitoring of CPR quality: Improved data supports the use of arterial blood pressure and end-tidal CO2 monitoring (at least 10 mm Hg but > 20 mm Hg is ideal) to monitor the quality of CPR and improve the likelihood of ROSC.
Sequential defibrillation: There is no evidence to support the use of applying two nearly simultaneous shocks for shockable rhythms in cardiac arrest.
IV access over IO access: In cardiac arrest, IV access may be attempted first during cardiac arrest since the IV route has been found to have better clinical outcomes than IO. If an IV cannot be established, providers should consider IO access.
Support during recovery: This new guideline adds a recovery component to the IHCA and OHCA chains of survival. This recommendation includes rehabilitation assessment and treatment before hospital discharge for cardiac arrest survivors and their families. This would include cardiopulmonary, neurologic, return to work, post traumatic stress, and assessment and treatment of fatigue.
Lay-rescuer debriefings: Although debriefings for providers has been a recommendation, AHA and ILCOR now recommend debriefings for lay-rescuers, EMS personnel, and hospital providers following a cardiac arrest.
Cardiac arrest during pregnancy: There is a new algorithm for the in-hospital pregnant patient in cardiac arrest. In the pregnant patient with cardiac arrest, airway and oxygenation management must be prioritized. Fetal monitoring should not be initiated. After ROSC, targeted temperature management should be initiated with continuous fetal monitoring for bradycardia.

ACLS Topic	2010	2015	2018
BLS Assessment	1-2-3-4 Determine Responsiveness Activate Emergency Response system Obtain AED Check pulse and start CPR if no pulse within 10 seconds Defibrillate as indicated	Determine responsiveness Shout for help/activate emergency response/get AED Check pulse and respirations at same time Defibrillate as indicated	Determine responsiveness Shout for help/activate emergency response/get AED Check pulse and respirations at same time Defibrillate as indicated
Primary Assessment	Airway Breathing Circulation Diagnosis: H’s and T’s	Airway Breathing Circulation Disability Exposure	Airway Breathing Circulation Disability Exposure
Secondary Assessment		SAMPLE mnemonic H’s and T’s	SAMPLE mnemonic H’s and T’s
High-Quality CPR	Compressions: At least 100/minute Depth at least 2 inches for adults Complete chest recoil after each compression Minimize CPR interruptions to less than 10 seconds Avoid excessive ventilations Switch compressors every 2 min.	Compressions: 100-120/min Depth at least 2 inches for adults Complete chest recoil after each compression Minimize CPR interruptions to less than 10 seconds Avoid excessive ventilations Switch compressors every 2 min. Chest compression fraction at least 60% but best if >80% Use audio/visual feedback to monitor CPR	Compressions: 100-120/min Depth between 2-2.4 inches for adults Complete chest recoil after each compression Minimize CPR interruptions to less than 10 seconds Avoid excessive ventilations Switch compressors every 2 min. Chest compression fraction at least 60% but best if >80% Use audio/visual feedback to monitor CPR
Airway Management	With advanced airway, ventilate once every 6-8 seconds	With advanced airway, ventilate once every 6 seconds	With advanced airway, ventilate once every 6 seconds
Post-Cardiac Care After ROSC	Consider therapeutic hypothermia (32-34 degrees C) for 12-24 hours	Consider therapeutic hypothermia (32-36 degrees C) for at least 24 hours in comatose patient	Consider targeted temperature management (32-36 degrees C) for at least 24 hours in comatose patients
Bradycardia	Dopamine: dose of 2-10 mcg/kg/minute	Dopamine: dose of 2-20 mcg/kg/minute	Dopamine: dose of 2-20 mcg/kg/minute
ACS	NSTEMI Oxygen titration to 94%	NSTE-ACS Oxygen titration to 90%	NSTE-ACS Oxygen titration to 90%
Other Changes in Cardiac Arrest		Vasopressin no longer indicated Early administration of epinephrine Provider should adjust the sequence of actions based on etiology Addition of Opioid-Associated algorithm Consider using ultrasound technology during arrest to determine cause If extracorporeal CPR can be quickly implemented, consider it for patients unresponsive to CPR Consider IV lipids for patients with probable drug toxicity not responsive to CPR	Vasopressin no longer indicated Early administration of epinephrine Provider should adjust the sequence of actions based on etiology Addition of Opioid-Associated algorithm Consider using ultrasound technology during arrest to determine cause If extracorporeal CPR can be quickly implemented, consider it for patients unresponsive to CPR Consider IV lipids for patients with probable drug toxicity not responsive to CPR Routine magnesium is not recommended but consider for torsades de pointes Consider amiodarone or lidocaine for VF/pVT unresponsive to defibrillation No evidence to support the use of beta blockers after ROSC No evidence to support the use of lidocaine within the first hour after ROSC
Stroke		Increase therapy window up to 6 hours	Increase therapy window up to 6 hours

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Chapter 10 – ACLS Updates

Chapter 10 – ACLS Updates

Updates to ACLS – 2020

Changes in Visuals and Algorithms

Key Changes

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