ACS, Stroke & Post-Arrest Care
ACLS extends beyond the arrest itself to the time-critical emergencies around it — acute coronary syndromes, acute stroke, and the fragile period after ROSC. Each has its own chain of survival built on speed.
Acute coronary syndromes and acute stroke
In suspected ACS, obtain and interpret a 12-lead ECG within 10 minutes of presentation. Give aspirin 162–325 mg (chewed) early; give oxygen only if SpO2 is below 90%; use nitroglycerin only with SBP of at least 90 mm Hg and no suspected right ventricular infarction or recent PDE5-inhibitor use. For STEMI, the goal is primary PCI with first-medical-contact-to-device time of 90 minutes or less (120 at most for direct transport); if PCI would be delayed beyond 120 minutes and symptoms began under 12 hours ago, fibrinolytic therapy is recommended. For acute stroke, establish when symptoms began (or when the patient was last known well), call EMS, and obtain brain imaging to exclude bleeding before any clot-dissolving drug; the 2026 AHA/ASA guideline revised thrombolytic and thrombectomy eligibility, so follow current protocols.
Post-cardiac-arrest care
After ROSC, the goal shifts to protecting the brain and preventing re-arrest. Give 100% oxygen until saturation can be measured reliably, then target an SpO2 of 90% to 98%; ventilate to normocapnia (PaCO2 35–45 mm Hg) and avoid hyperventilation. Keep the mean arterial pressure at least 65 mm Hg — the 2025 Guidelines removed the old systolic target. Obtain a 12-lead ECG early: STEMI needs early coronary angiography and PCI. For adults who do not follow commands, maintain temperature control between 32 °C and 37.5 °C for at least 36 hours, obtain an EEG for myoclonus, and avoid prognostic conclusions before 72 hours or from any single test.
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