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 a 12-lead ECG within 10 minutes of arrival to identify STEMI. For STEMI, the reperfusion goal is primary PCI within 90 minutes of first medical contact, or fibrinolysis within 30 minutes of arrival when PCI is unavailable. Early aspirin, along with nitroglycerin and oxygen when indicated, supports care. For acute stroke, the priorities are establishing the last-known-well time and obtaining an emergent noncontrast head CT to exclude hemorrhage before any fibrinolytic; rapid door-to-CT and door-to-needle times define good stroke care, and large-vessel occlusions may be candidates for endovascular thrombectomy.
Post-cardiac-arrest care
After ROSC, the goal shifts to protecting the brain and preventing re-arrest. Key elements are optimizing oxygenation (titrate to an SpO2 of 92-98%, avoiding both hypoxia and hyperoxia) and ventilation (target normocapnia), supporting blood pressure (treat hypotension, e.g., systolic below 90 mmHg), and obtaining a 12-lead ECG to identify a STEMI that may need emergent PCI. For patients who remain comatose, targeted temperature management maintains a constant temperature between 32°C and 36°C for at least 24 hours and prevents fever, which improves neurologic outcomes.