Advanced Cardiac Life Support (ACLS) involves advanced procedures beyond Basic Life

Support (BLS). It includes skills such as invasive airway management (e.g., intubation), the
administration of medications, establishing IV access, and utilizing protocols for managing
lifethreatening cardiac emergencies.

FIRST COLUMN PRE- ARREST ACLS SURVEY

1. Scenario: The team leader will arrive and assess the patient (Describe how the
patient appears).
Visualize (Objective) Verbalize (Subjective) Vital Signs (Objective)
2. TL: Visualize (So first, let’s assess the male/female adult patient showing signs of:)
- Cyanotic: which is a bluish or purplish discoloration of nails and lips due to
inadequate oxygen levels in the blood.
- Facial grimace: either voluntary or involuntary distortion of the face, typically
caused by pain or discomfort
- Agitated: Our patient is also agitated, restless and unable to stay still, possibly
due to hypoxia
- Diaphoresis: Diaphoretic din siya meaning excessive sweating, kahit hindi
naman siya physically exhausted
- Dyspnea: lastly, shortness of breath
3. TL: Verbalization ● Good afternoon/morning. I’m [Angelica Verzosa], your nurse who
will be assessing you today. I just have a few questions
- Do you have any pain?
-On a scale of 1 to 10, with 10 being the worst pain, how would you rate your pain?
-Where exactly are you feeling the pain, and how long have you been experiencing it?
What kind of pain are you feeling? Is it more like a stabbing pain, or something else?
-Does it radiate to any other part?
4. TL: Vital signs I will now take your vital signs sir/maam, such as the Bp, Temp, Pulse,
Respiratory rate, O2 saturation”.
5. TL: 02 Sat therapy (if <94%)
●Since the oxygen saturation of the patient is below 95%, I am going to begin oxygen
therapy to enhance tissue oxygenation via:
• Nasal Cannula – which delivers 2-4 liters per minute of oxygen used for mild to
moderate oxygen needs
• Face mask - 6-10 liters per minute used for higher oxygen needs
• Non – rebreather mask - administers 11-15 liters per minute used for severe
hypoxia and emergency purposes
HOW TO APPLY:
Nasal Cannula - Gather the supplies, connect the nasal cannula tubing to the flow
meter and set the oxygen flow to the prescribed rate of 2 to 4 liters per minute. Place the
prongs into the patient’s nares, fit the tubing around the patient’s ears, and secure it with a
gauze pad, particularly around the bony prominences.
Face mask - Gather the supplies. connect the tubing to the flow meter and set the
oxygen flow to the prescribed rate of 6 to 10 liters per minute. Place the mask over the
patient’s mouth and nose, and secure a firm seal and tightening the straps around the
patient’s head
 Non – rebreather mask – connect the tubing to the flow meter and set the oxygen flow
to the prescribed rate of 11 to 15 liters per minute. Partially inflate the reservoir bag. Place
the mask over the patient's mouth and nose, and secure a firm seal. Position the patient
upright as clinically appropriate

PARTS AND FUNCTION OF AN OXYGEN TANK

• Pressure Gauge: Measures the pressure of the

oxygen inside the cylinder. It helps in determining
how much oxygen is left.

• Wheel-type Knob Valve: This is the main valve

used to open or close the flow of oxygen from the
cylinder.

• Flow Meter: Regulates the flow of oxygen to the

patient, typically measured in liters per minute
(L/min).

• Flow Adjuster: Allows for manual adjustment of

the oxygen flow, often located below the flow meter.

• Humidifying Cup: Contains sterile water to humidify the oxygen before it is delivered to
the patient, preventing dry nasal passages or discomfort.

• Oxygen Output: This is where the oxygen flows out and is connected to tubing leading to
the patient's mask or nasal cannula.

• Screw Cap: Secures the pressure-reducing valve to the cylinder.

• Pressure Reducing Valve: Reduces the high pressure of oxygen stored in the cylinder to a
lower, safer pressure suitable for patient use.

• Safety Valve: A protective feature that prevents excess pressure from building up, ensuring
safe operation of the cylinder.

• Oxygen in Pipe: The pipe that transfers the oxygen from the cylinder through the flow
regulator system.

• Cylinder: The tank that stores the oxygen under high pressure for medical use.

● For the nursing responsibility naman:

- we need to check if the equipment is properly functioning.
- for the patency of the tubing: check for the kinks or bend sa tube, test the air
flow by placing your hand near the end of the tubing.
- No smoking near the oxygen tank.
 - Always monitor the vital signs of the pt, para malaman na’tin if effective ba
yung oxygen therapy na ginagawa.
- Monitoring the pt for signs of oxygen toxicity, such as difficulty breathing,
persistent dry cough, seizures.

6. TL: Monitor by putting the pads on the chest.

● This is where we start Cardiac Monitoring using 3 lead
ECG to continuously track heart rate and rhythm and
detect arrhythmias
● WHITE ON THE RIGHT, BLACK ON THE LEFT, RED ON
THE LEFT LOWER QUADRANT
7. TL: Establish IV/ Intraossious (direct to the bone)
TL: (will state vital signs that are in the monitor and identify what type of ECG reading is
there)
● We will now establish an IV line, but after 3 failed attempts of IV,
proceed to IO which is direct to the bone for infusion of medical
therapeutic agents and laboratory testing on different areas:
sternum, proximal humerus, distal femur, proximal tibia, distal
tibia, and calcaneus
● If nakapaglagay na ng IV, no need the IO (intraossious)

● HOW TO APPLY: Gather supplies such as IV fluid, IV catheter,

IV tubing, tourniquet, tape, and antiseptic. Put on gloves. Connect
the IV tubing to the bag. Flush the line. Choose a vein in the crook of the left arm.
Apply the tourniquet snugly 20-25 cm above the insertion site. Feel for the vein.
Disinfect the insertion site with an alcohol pad in the direction of venous flow. Allow
the skin to dry. Pull the skin taut to stabilize the vein. Insert the catheter at a 15- to
30-degree angle, bevel up, directly on top of the vein. Once insertion is done, untie
the tourniquet. Slide the needle slightly. Confirm backflow, then remove the needle.
Press a finger over the inserted catheter. Then connecting the tubing. Securing the
catheter, loosening the clamp and start the infusion.

8. TL: Treatment
● Since pt has sinus bradycardia heart rhythm we will proceed with the
ATDE interventions:
- A - Atropine Sulphate (ATSO4) → 0.5mg - 3mg with 20cc of PNSS for
flushing. Can be given a total of 6 doses, 3 to 5 mins interval. Used to treat
low heart rate
- If bradycardia is unresponsive to atropine sulfate, alternatives are:
- T - transcutaneous facing - (delivers small electrical current to temporarily
restore the electrical activity of the heart)
● Demand mode: delivers electrical stimulus only when needed.
● Fixed mode: delivers electrical stimuli at a selected rate regardless of
patient’s intrinsic cardiac activity.
- D – dopamine infusion → for improving cardiac output and blood pressure
 - max dose: 1mg
● Renal → 2mcg
● Cardio → 5mcg
● Vasopressin → 10mcg/1mg
- E - epinephrine infusion → increased heart rate.
- 2 to 10mcg + 20cc of PNSS for flushing
Initial: 2 mcg/ min
Max: 10 mcg/min
- 10,000ml: 1 dilution/ampule of epi (if incorporate) (AHA)
- 1,000ml: 1 dilution/ampule of epi (if incorporate) (Philippines)
● It can increase up to 4 mcg/min if the client does not respond to the
medication. Stop if there’s a response.

9. CI: babaguhin yung heart rhythm, gagawing VTAC (Ventricular Tachycardia) or SVT
(Supraventricular tachycardia)
● Kapag Ventricular tachycardia (VTAC) and
ventricular fibrillation, this is a wide complex.

● Kapag Supraventricular Tachycardia (SVT)

naman, narrow complex.
● Systolic pressure > 90mmHg = Stable; Systolic
pressure < 90mmHg = unstable.
- Stable: Physiologic and Pharmacologic
- Unstable: Sedation and Synchronized Cardio Version

For Fast Rhythm (Tachycardia)

Management:
1. For Stable (90 above BP)

TL: The patient's BP is (state BP as seen on the monitor). The patient is stable. We will start
with physiological treatment, which is a vagal maneuver to restore a normal heart rhythm —
specifically, a carotid massage. Extend the patient's neck toward the opposite side and ensure
there is no carotid bruit. (Place the stethoscope on the patient's neck and check for a
whooshing sound.) Apply firm pressure on the carotid sinus. (Count 1001-1009.) Carotid
massage is complete. Sir, can you cough? (Patient cannot.)
TL: "I will proceed to pharmacologic treatment. I am going to give the first dose of
adenosine, 6 mg, administered rapidly via IV push, followed by a PNSS flush. if 1st dose
ineffective, i will administer 12 mg of adenosine via rapid IV push.

2. For Unstable (90 below BP)

CI: babaguhin ulit yung heart rhythm into supraventricular tachycardia (SVT) or Ventricular
Tachycardia (VTAC)
TL: If unstable yung BP ng patient, ang need is to do sedation and synchronized version. "I
will proceed to sedation. I am going to administer 5 mg of Diazepam. If unavailable, I can
also use 5 mg of Midazolam or 50 mg of Demerol." Midazolam and Diazepam is a
benzodiazepine used for its sedative while Demerol an opioid analgesic used for pain relief.
TL: "After sedating the patient, I will proceed to synchronized cardioversion. Engage
synchronization mode by pressing the sync button."

Sa synchronized cardio version naman, we will based on the doctor’s order.

● SVT: 50-100 Joules
● VT: 100-120 Joules

Second Column: ARREST BLS SURVEY

CI: Ic-change yung heart rhythm into Ventricular Fibrillation. Nag-agunal gasp yung pt.
Proceed with BLS survey!
10. TL: Since the patient heart rhythm is in ventricular fibrillation, I will proceed with the BLS
SURVEY
a. Check for response: “Hey, hey, hey, are u ok? Hey, hey, hey, are u alright?”
b. No response
c. Check for carotid pulse: “1001, 1002, 1003, 1004, 1005, 1006!”
d. No pulse, no breathing.
e. Activate code blue
f. Start high quality CPR = 30:2 (push hard, push fast, interruption should be less than
10 secs. Avoid excessive ventilation. And there should be chest recoil and rising of
chest).

CI: And the team arrives!

Position yung mga members:

● Airway - sa ulunan ng pt.
● IV Nurse - katabi ng IV line
● Compressor - tatabi sa team leader ● Defibrillator - magkatapat sila ng

compressor ● Observer/Recorder - sa paanan ng pt.

11. TL: “Let’s switch in 3: 1, 2, 3!”

12. Shockable Ventricular Fibrillation / Pulseless VT

SHOCKABLE RHYTHMS Include ventricular
fibrillation (VF) and pulseless ventricular
tachycardia (VT).

● Defib: The patient is in ventricular fibrillation.

● TL: Okay, continue high quality CPR! Charge 360 joules
● Defib: Charging 360. Is everybody clear?
● Everyone: Clear!
● Defib: Initiating shock in 3: 1, 2, 3! Shock delivered!
● TL: Continue High quality CPR

(compressor nagc-compress)
● CI: 2 mins
● TL: Stop, analyze, switch.
● Airway: Still no breathing
● Compressor: Still in ventricular fibrillation
● TL: ok, continue high quality CPR, charge 360. And prepare 1mg of epinephrine.
(defib magc-compress)
● Compressor: (pindot) Charging 360.
● IV nurse: Administering 1mg of Epinephrine : Flushing w/ 20CC of PNSS “Elevating
the hand of the client”
● Compressor: Is everybody clear?
● Everyone: Clear!
● Compressor: Initiating shock in 3: 1, 2, 3! (defib pindot) Shock delivered!
● TL: Continue High quality CPR administer epinephrine 1mg.
● IV nurse: Administering 1mg of epinephrine flushing of 20cc PNSS and elevating the
hand of the client.

(defib nagc-compress)
● CI: 2 mins
● TL: Stop, analyze, switch.
● Airway: Still no breathing
● Defib: Still in ventricular fibrillation
● TL: ok, continue high quality CPR, charge 360. Prepare amiodarone 300mg.
(compressor nagc-compress)
● Defib: (pindot) Charging 360.
● ● IV nurse: Preparing amiodarone 300mg.
● Defib: Is everybody clear?
● Everyone: Clear!
● Defib: Initiating shock in 3: 1, 2, 3! (defib pindot) Shock delivered!
● TL: Continue High quality CPR administer amiodarone 300mg.
● IV nurse: Administering 300mg of amiodarone flushing of 20cc PNSS

(compressor nagc-compress)
● CI: 2 mins
● TL: Stop, analyze, switch.
● Airway: Still no breathing
● Compressor: Still in ventricular fibrillation
● TL: ok, continue high quality CPR, charge 360. Prepare 1mg of epinephrine. (defib
nagc-compress)
● Compressor: (pindot) Charging 360.
● IV nurse: Preparing 1mg of epinephrine.
● Compressor: Is everybody clear?
● Everyone: Clear!
● Compressor: Initiating shock in 3: 1, 2, 3! (defib pindot) Shock delivered!
● TL: Continue High quality CPR administer epinephrine 1mg.
● IV nurse: Administering 1mg of epinephrine flushing of 20cc PNSS and elevating the
hand of the client.

(defib nagc-compress)
● CI: 2 mins
● TL: Stop, analyze, switch.
● Airway: Still no breathing
● Defib: Still in ventricular fibrillation
● TL: ok, continue high quality CPR, charge 360. Prepare amiodarone 150mg.
(compressor nagc-compress)
● Defib: (pindot) Charging 360
● IV nurse: Preparing amiodarone 150mg.
● Defib: Is everybody clear?
● Everyone: Clear!
● Defib: Initiating shock in 3: 1, 2, 3! (defib pindot) Shock delivered!
● TL: Continue High quality CPR administer amiodarone 150mg.
● IV nurse: Administering 150mg of amiodarone flushing of 20cc PNSS and elevating
the hand of the client.

NON-SHOCKABLE (ASYSTOLE AND PULSELESS ELECTRICAL ACTIVITY (PEA)

13. (Naging ventricular asystole yung heart rhythm ng

pt)
CI: Leader what rhythm is this?
TL: Ventricular asystole
CI: Shockable or non-shockable
TL: non-shockable
CI: Management?
● TL: 1mg of epinephrine every 3 to 5minutes
● TL: Continue high quality CPR, prepare and administer 1mg of epinephrine during
ventricular asystole
● IV: Preparing and administering 1st dose of 1mg epinephrine with 20cc of PNSS for
flushing and elevating the hand of the pt. 1st dose of epinephrine given at… (time)
during ventricular asystole
(after 5 mins)
● TL: Continue high quality CPR, prepare 2nd dose of 1mg epinephrine during
ventricular asystole
● IV: Preparing and administering 2nd dose of 1mg epinephrine with 20cc of PNSS for
flushing and elevating the hand of the pt. 2nd dose of epinephrine given at… (time)
during ventricular asystole
(after 5 mins)
 ● TL: Continue high quality CPR, prepare 3rd dose of 1mg epinephrine during
ventricular asystole
● IV: Preparing and administering 3rd dose of 1mg epinephrine with 20cc of PNSS for
flushing and elevating the hand of the pt. 3rd dose of epinephrine given at… (time)
during ventricular asystole
• CI: What rhythm is this?
• TL: sinus bradycardia (since nabuhay si patient)
• CI: What are the treatable and reversible H and T’s?

14. Treat reversible causes: H's and T’s (ALL MEMBERS EXCEPT TEAM LEADER)
● Hypoxia: low oxygen level in the blood
● Hyperkalemia: elevated potassium levels in the blood / Hypokalemia: low level of
potassium in the blood
● Hydrogen Ions (acidosis): too much acid in the blood
● Hypothermia: abnormally low blood temp
● Hypovolemia: low blood volume in the body

● Tension pneumothorax: air accumulation in the pleural space which results to lung
collapse
● Cardiac tamponade: fluid accumulation in the pericardial sac which compresses the
heart
● Pulmonary thrombosis: blood clot in the lungs
● Coronary thrombosis: blood clot in the coronary arteries
● Toxins: harmful substances that the body produces

THIRD COLUMN POST ARREST

14. ROSC (Return of Spontaneous Circulation)
CI: What is ROSC?
ANY MEMBER, SI MAAM MAMIMILI: Return of Spontaneous Circulation
CI: What are you going to check during ROSC?
ANY MEMBER, SI MAAM MAMIMILI: I am going to check for the blood pressure and
pulse of the patient as well as the PETCO (partial end tidal carbon dioxide) ranging 35 –
45mmHg to ensure adequate ventilation and circulation
BP UNSTABLE

C AIRWAY: I am going to administer the following:

• Fluids: Administer 1-2 liters of fluids (PNSS/PLRS) to help
stabilize blood pressure.
• Medicines
● Dopamine: 10 mcg/kg/min to support blood pressure and
cardiac output.
● Epinephrine: 2-10 mcg/min for vasopressor support.
● Norepinephrine: 2-10 mcg/min to further support blood
pressure.
 AB (Airway Breathing):

AB AIRWAY: And now, we are going to access the breathing of the

client. (DO the 4-point auscultation).
-1st ambu: place the diaphragm of the stethoscope below the right
clavicle in the upper lobe of the lung. = NEGATIVE
-2nd ambu: move on the left side, just below the left clavicle, in the
upper lobe. = NEGATIVE
-3rd ambu: below the right side of the chest = NEGATIVE
-4th ambu: below the left side of the chest = NEGATIVE

All quadrants are negative meaning there’s no breath sounds

indicating airway obstruction or lung collapse (pneumothorax).

AIRWAY: We are going to the advanced airway by means of

intubation. Gather materials such as:
1. Laryngoscope
• to visualize the larynx and facilitate endotracheal intubation.
2. ET Tube (Endotracheal Tube)
• to secure the airway and allow for mechanical ventilation.
ET tubes come in various sizes and have a cuff that can be
inflated to prevent air leaks and secure the tube in place.
3. 10 cc Syringe
• for inflating the cuff of an ET tube and administering
medications
4. William Green's Stylet
• to help guide the tube.
5. Sterile Gloves
• to maintain sterility
6. Bag-Valve Mask (BVM)
• to provide positive pressure ventilation to patients who are
not breathing adequately.
7. PetCO Detector (Capnometer)
• to confirms correct placement of the ET tube
8. Leukoplast
• a waterproof adhesive tape, often for securing tubes
PROCEDURE:
- the patient ideally in a supine position
- don sterile gloves
- hold the laryngoscope in dominant hand and insert the blade into
the mouth, sweeping the tongue to the left to visualize the larynx
slightly extend the neck to expose the epiglottis and vocal cords
- sing a stylet, insert it into the ET tube to shape through the
mouth, passing it between the vocal cords until it reaches the
trachea (usually 21-24 cm for adults size)
-remove laryngoscope then use the 10 cc syringe to inflate the cuff
 on the ET tube to lock the tubing and prevent air leaks and
aspiration
AIRWAY: Check the placement and intactness by doing 5-point
auscultation
- inject 10cc of air to inflate then listen to sound, (+) for gurgling
sound on the 5th spot, remove the ambu bag and deflate, remove
the air and retract 1 inch listen for the sounds again if (-) it is
already intact and does not reach the stomach area, this is to avoid
GASTRIC DISTENSION
-secure it using leukoplast
- Attach the PetCO detector to the ET tube and ventilate the
patient.
Qualitative: Verify the presence of yellow in the endotracheal
tube's color indicator.
● The yellow color typically indicates that the tube is correctly
placed in the trachea and not in the esophagus
Quantitative: End-tidal CO₂ should be between 35-40 mmHg to
confirm adequate ventilation
ANY MEMBER: We’ll now move to treat disability by treating

D hypothermia. Fist assess neurological status using GCS the criteria

are:
CI: Management?
GCS (Glasgow Coma Scale):
● Highest GCS is 15
● GCS 8-12 (50-50)
● Vegetative (GCS 3)
Therapeutic Hypothermia:
● We are going to give
PNSS/PLRS, 30CC/KG, 4°C
● Maintain for 12 - 24 HOURS
to help reduce neurological
damage.
● Core Body Temp: Target a temperature of 32-36°C to protect the
brain.

15. Sign of the cross

CI: And now do the sign of the cross
● Mouth = NGT (contraption)
-types: levin tube (single), millerr abbott
-sizes:
*below 5 yrs (French 8 for feeding & French 8-10 for
decompression)
*above 5 yrs (French 8-10 for feeding & 10-14 for
decompression)
 ● Down = Foley catheter (contraption)
male:
-position: frog-like
-insertion: 6-9 inch
-size: fr 16-18
female:
-position: dorsal recumbent/supine
-insertion: 3-4 inch
-size: fr 12-14
● Left shoulder = 12 leads ECG (diagnostic)

● Right shoulder = x-ray/CVP (diagnostic)

- Central Venous Pressure (CVP): measurement of the pressure in the
central vein that carries blood to the heart to understand how well the heart is
working to pump blood and how much blood is returning to the heart
Insertion Sites: Internal Jugular vein, Subclavian Vein, Femoral Vein
Normal: 2-6mmHg High CVP= Volume overload
(Sternum: 0- 14 cm H2O, Midaxillary line: 8-15 cm H2O
20. Refer to ICU for admission
Prepare:
-Nursing procedure
-Lab results
-Doctors order for transfer