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Updates to ACLS – 2020

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Updates to ACLS – 2020

AHA and ILCOR combined the ACLS and BLS updates to create the updated ACLS guidelines. Although care has been taken to update this guide throughout, 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, encouraging the need to prevent hypoxemia, hypotension, and hyperoxia
  • New Cardiac Arrest in Pregnancy algorithm
  • New visual with information about neuroprognostication after ROSC
  • Stroke algorithm revised
  • ACS algorithm revised to categorize ECG results to STEMI and NST-ACS.

Key Guideline 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 individual with presumed cardiac arrest. The risk of CPR causing harm without a cardiac arrest is low.
  • Recommendation for 1 breath every 6 seconds with bag-mask or advanced airway.
  • Early administration of epinephrine: For patients with 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.
  • Atropine dose changed from 0.5 mg to 1 mg
  • Dopamine dosing changed from 2–20 mcg/kg/min to 5–20 mcg/kg/min.
  • Amiodarone and lidocaine now considered equivalent for treatment
  • Sequential defibrillation: There is no evidence to support the use of applying two nearly simultaneous shocks for shockable rhythms in cardiac arrest.
  • Change from set cardioversion doses to recommendation to follow the device-specific recommended energy level.
  • IV access over IO access: In cardiac arrest, IV access may be attempted first since it has been found to result in better clinical outcomes than IO. If an IV cannot be established, the team 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 providing debriefings for medical team members has been a recommendation, AHA and ILCOR now recommend debriefings for lay rescuers, EMS personnel, and hospital staff 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.
  • Post-cardiac arrest care SpO2 target is now 92–98% (was > 94%)
  • ACS target SpO2 is now > 90% (was 94–99%)
  • Both alteplase and EVT should be provided if indicated