ADVANCED CARDIAC LIFE SUPPORT

Advanced cardiac life support or advancedcardiovascular

life support (ACLS) refers to a set of clinical
interventions for the urgent treatment of cardiac arrest
and other life-threatening medical emergencies, as well
as the knowledge and skills to deploy those interventions.
ACLS is a series of evidence based responses simple
enough to be committed to memory and recall under
moments of stress.
AMERICAN HEART ASSOCIATION (AHA) protocols are
considered to be the GOLD standard ACLS protocols
It gets reviewed every 5 year, now latest advancements in
ecgguidelines.health.org
IMPORTANCE OF BLS IN ACLS

ACLS is built heavily upon the foundation of BLS

AHA Adult Chain of Survival
1. Immediate recognition of cardiac arrest and
activation of the emergency response system
2. Early CPR with an emphasis on chest
compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post cardiac arrest care
AHA PEDIATRIC Chain of
Survival
COMPONENT OF HIGH QUALITY CPR IN BLS
Scene safety:
1. Make sure the environment is safe for rescuers and
victim
Recognition of cardiac arrest:
1. Check for responsiveness
2. No breathing or only gasping ( ie, no normal breathing)
3. No definite pulse felt within 10 secs ( Carotid or femoral
pulse)
4. (Breathing and pulse check can be performed
simultaneously within 10 secs)
 Activation of emergency response system:
If alone with no mobile phone, leave the victim to
activate the emergency response system and get
the AED before beginning CPR
Otherwise, send someone and begin CPR
immediately; use the AED as soon as it is
available
WITNESSED VS UNWITNESSED
WITNESSED
IF ALONE
ACTIVATE EMS
THEN CPR
IF 2 RESCUERS
START CPR
SECOND ONE ACTIVATE EMS

UNWITNESSED
START CPR
GIVE FOR 2 MINS
ACTIVATE EMS
 Chest compression-
Adult- 30:2
Children or infant- 30:2 if one rescuer
15:2 if more than one rescuer
Compression rate:
100-120/ min
Compression depth:
Adult- at least 5 cm
Children or infant- at least 1/3rd AP diameter of chest
 Hand placement:
Adult - 2 hands on the lower half of the sternum
Children 1 or 2 hands on the lower half of the sternum
Infants 2 fingers or 2 thumb defending of the number of
rescuers
Chest recoil:
allow full recoil of chest after each compression; do not
lean on the chest after each compression.
Minimizing interruption: Limit interruptions in chest
compressions to less than 10 secs.
Adult advanced cardiovascular
life support
 Shockable

VT VF
Monomorphic Fine or Coarse
or polymorphic VF
Ventricular tachycardia

.R-R interval usually regular, not always

QRS not preceded by p wave.
Wide and bizzare QRS.
Difficult to find seperation between QRS and T
wave
Rate=100-250bpm
Torsades de Pointes

Ttwisting of points, is a distinctive form of polymorphic ventricular

tachycardia characterized by a gradual change in the amplitude
and twisting of the QRS complexes around the isoelectric line.
Rate cannot be determined.
Ventricular fibrillation

A severely abnormal heart rhythm (arrhythmia) that can

be life-threatening.
No identifiable P, QRS or T wave
Emergency- requires Basic Life Support
Rate cannot be discerned, rhythm unorganized
 Unshockable

PEA- pulseless
electrical activity or
Asystole EMD-
electromechanical
dissociation
Asystole

a state of no cardiac electrical activity, hence no

contractions of the myocardium and no cardiac
output or blood flow.
Rate, rhythm, p and QRS are absent
Pulseless electrical activity

Pulseless electrical activity (PEA)

unresponsiveness and no palpable pulse
some organized cardiac electrical activity.
previously referred to as electromechanical
dissociation
 Deliver single defibrillitor
shock CPR-2 mins
Check rhythm

Deliver single shock- if VT

/VF persist---CPR 2 mins
Continue CPR 2 min and give EPINEPHRINE 1
mg

Amiodarone/ Lidocaine/ Magnesium sulfate

Vt/ vf Defibrillate: Drug---Shock---Drug----

Shock
Asystole/PEA

Identify and Continue

Continue CPR (Intubate
RX reversible CPR if
and establish IV access)
causes asystole/PEA
Treatable Causes of Cardiac
A e : T eH a dT
Hs Ts

Hypoxia Toxins
Hypovolemia Tamponade (cardiac)
Hydrogen ion(acidosis) Tension pneumothorax
Hypo-/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
DEFIBRILLATION
Defibrillation
Biphasic wave form: 120- 200 J
Monophasic wave form: 360 J
AED- device specific

Failure of a single adequate shock to restore a

pulse should be followed by continued CPR and
second shock delivered after five cycles of CPR
HOW TO USE DEFIBRILLATOR
SAFETY

If patient not intubated remove o2 delivery devices

If intubated either leave bag valve resuscitator
attached to Et or remove it
If available use self adhesive defibrillation pads
Do not place over pacemakers
Remove transdermal patches.
 PROCEDURE
Place sternal paddle over right of the sternum
below clavicle
Place apical paddle in mid axillary line in 5th IC
space
Switch on the defibrillator
Charge the defibrillator to 200J or 360J
Warn all other rescuers to stand clear- ARE YOU
CLEAR
Visually check all are clear
Ensure yourself you are not touching patient or
bed I AM CLEAR
Deliver shock
Restart cpr with out checking pulse.
Automatic External Defibrillator

Switch on AED.
Attach electrode pads.
Place electrodes as that of
manual one
Follow voice commands
Make sure no one in contact
with patient
Push shock button.
1-Shock Protocol Versus 3-
Shock Sequence
Evidence from 2 well-conducted pre/post design
studies suggested significant survival benefit with
the single shock defibrillation protocol compared
with 3-stacked-shock protocols

If 1 shock fails to eliminate VF, the incremental

benefit of another shock is low, and resumption of
CPR is likely to confer a greater value than
another shock
Airway and Ventilations

Opening airway Head tilt, chin lift or jaw thrust, in

addition explore the airway for foreign bodies, dentures
and remove them.
 Breathing devices

BASIC AIRWAYS

Oropharyngeal airway
Nasopharyngeal airway

ADVANCED
Endotracheal tube
Laryngeal mask airway
Laryngeal tube
Esophageal tracheal tube
Nasopharyngeal airway
 commonly 6 7 mm in an adult female and 7 8 mm for an
adult male
OROPHARYNGEAL AIRWAY
ENDOTRACHEAL TUBE
Laryngeal mask airway
Laryngeal tube
90-115cm

105-130

122-155
Esophageal tracheal tube
Pharmacotherapy
Routes of Administration
Peripheral IV must followed by 20 ml NS push
Central IV fast onset of action, but do not wait or
waste time for CV line
Intraosseous alternative IV route in peds, also in
Adult
Intratracheally (down an ET tube)- not
recommended now a days
Oxygen

IV Fluids
 Amiodarone (Cordarone)

Indications:
Vtach, Vfib

IV Dose:
300 mg in 20-30 ml of N/S
Supplemental dose of 150 mg in 20-30 ml of N/S
Followed with continuous infusion of 1 mg/min for 6
hours then .5mg/min to a maximum daily dose of
2grams

Contraindications:
 Lidocaine
Indications:
VT, VF
Can be toxic so no longer given prophylactically

IV dose :
1-1.5 mg/kg bolus then continuous infusion of 2-4
mg/min
Can be given down ET tube

Signs of toxicity:
slurred speech, seizures, altered consciousness
 Magnesium

Used for refractory VF or VT caused by hypomagnesemia

and Torsades de Pointes

Dose:
1-2 grams over 2 minutes

Side Effects
Hypotension
Asystole
Propranolol/ Esmolol

Beta blocker that may be useful for VF and VT that

has not responded to other therapies
Very useful for patients whose cardiac emergency
was precipitated by hypertension
 Epinephrine

Alpha, beta-1, and beta-2 stimulation

Increases heart rate, stroke volume and blood pressure

IV Dose:
1 mg every 3-5 minutes
May increase ischemia because of increased O2
demand by the heart
 Sodium Bicarbonate

METABOLIC acidosis / hyperkalemia

Airway and ventilation have to be functional

IV Dose:
1 mEq/kg

Side effects:
Metabolic alkalosis
Increased CO2 production
Synchronised cardioversion - shock delivery that
is timed (synchronized) with the QRS complex
Narrow regular : 50 100 J
Narrow irregular : Biphasic 120 200 J and
Monophasic 200 J
Wide regular 100 J
Wide irregular defibrillation dose
 ADENOSINE

Slows conduction time through the A-V node, can

interrupt the reentry pathways through the A-V node
Pottasium channel opener and hyperpolarisation

IV Dose:
6 mg rapid iv push, follow with NS flush..
Second dose 12 mg

Side effects:- Flushing of face, bronchospasm

Cardiac Arrest Associated
With Pregnancy
causes
B Bleeding/ DIC
E Embolism( pulmonary, coronary , amniotic )
A Anesthetic complications
U Uterine atony

C Cardiac disease( MI/Aortic

dissection/Cardiomyopathy)
H Hypertension ( Pre eclampsia/ Eclampsia )
O Other reversible causes
Recommendation for emergency
caesarean section

Recommendation
When the gravid uterus is large enough to cause
maternal hemodynamic changes due to
aortocaval compression,
emergency caesarean section should be
considered, regardless of fetal viability
POST CARDIAC ARREST
CARE
Objectives
Optimize cardiopulmonary function and vital organ
perfusion.

After out-of-hospital cardiac arrest, transport

patient to an appropriate hospital with a
comprehensive post cardiac arrest treatment

Transport the in-hospital post cardiac arrest

patient to an appropriate critical-care unit

Try to identify and treat the precipitating causes of

the arrest and prevent recurrent arrest
 Action in time can save a
life!!!
THANK YOU