ADVANCED CARDIAC LIFE SUPPORT

Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to
a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-
threatening medical emergencies, as well as the knowledge and skills to deploy those
interventions. The goal of Advanced Cardiovascular Life Support (ACLS) is to achieve the
best possible outcome for individuals who are experiencing a life-threatening event. ACLS is
a series of evidence based responses simple enough to be committed to memory and recalled
under moments of stress. These ACLS protocols have been developed through research,
patient case studies, clinical studies, and opinions of experts in the field. The gold standard in
the United States and other countries is the course curriculum published by the American
Heart Association (AHA).

Previously, the AHA released periodic updates to their Cardio Pulmonary Resuscitation
(CPR) and Emergency Cardiovascular Care (ECC) guidelines on a five year cycle, with the
most recent update published in 2015. Moving forward, the AHA will no longer wait five
years between updates; instead, it will maintain the most up-to-date recommendations online
at ECCguidelines.heart.org. Health care providers are recommended to supplement the
materials presented in this handbook with the guidelines published by the AHA and refer to
the most current interventions and rationales throughout their study of ACLS.

Advanced life support (ALS) courses offer training to diagnose and administer care to
adult patients in cardiac and respiratory arrest. ACLS vs. BLS: What’s the Difference?

The basic differences between ACLS and BLS.

When you strip everything down and simply view them in their most basic form, both ACLS
(Advanced Cardiac Life Support) and BLS (Basic Life Support) possess the same objective –
learning the proper techniques to aid in saving the life of someone in cardiac arrest. However,
there are many differences between the two courses that regulate how this overarching
objective is met.

The foremost distinction between ACLS and BLS is the level of advancement between the
two. Essentially, ACLS is a more advanced and sophisticated course that builds upon the
basic fundamentals you develop during BLS – as both of the names suggest. However,
there’s much more to it than that. In this article, we’ll explain the main purpose of both an
ACLS certification course and a BLS certification course. More importantly, we’ll pinpoint
the main features that distinguish the two from each other.

Audience

BLS is intended to be for anyone who needs to know the basic principles of CPR, AED usage
and other primary methods of lifesaving skills. BLS is often performed in out-of-hospital
situations, and may not always be performed by a healthcare professional. While BLS is often
required for medical professionals, BLS / CPR courses are commonly completed by teachers,
coaches, lifeguards, babysitters, and more. Conversely, ACLS is designed specifically for
healthcare professionals. This includes physicians, nurses, anesthesiologists, paramedics,
dentists and more.

Background Medical Knowledge Needed

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Having some medical knowledge is helpful going into both courses, but it’s not necessarily
required for BLS. ACLS on the other hand, demands at least a basic foundation of medical
knowledge that will allow you to absorb the material and successfully complete the course. It
is common for ACLS participants to have completed a BLS Certification prior to beginning
their ACLS course – and ACLS Certification courses often include a review of BLS course
material. For example, understanding basic ECGs is a major component to any ACLS exam.
While you will spend time studying them during the course, it’s important that you enter the
exam already having a basic familiarity with ECGs and how to read them.

Pharmaceuticals

Whereas a BLS Certification does not give the provider recommendations for administering
medications, an ACLS certification does. During your ACLS course, you will study multiple
pharmaceutical drugs, the situations that call for particular pharmaceuticals, correct dosages,
and recommendations for drug administration.

Key Principles in the Application of ACLS

The Importance of Time

The passage of time drives all aspects of ECC. The final outcomes are determined by the
intervals between collapse or onset of the emergency and the delivery of basic and advanced
interventions. The probability of survival declines sharply with each passing minute of
cardiopulmonary compromise. Some interventions, like basic CPR, slow the rate at which
this decline in probability occurs. CPR makes this contribution by supplying some blood flow
to the heart and brain. Some single interventions, such as tracheal intubation, clearing an
obstructed airway, or defibrillating a heart in VF, are sufficient alone to restore a beating
heart. For all of these interventions, independently sufficient or simply contributory, the
longer it takes to administer these therapies, the lower the chances of benefit.

The “Peri-arrest” Period

Emergency cardiovascular care no longer focuses only on the patient in cardiac arrest.
Emergency care providers cannot narrow their objectives to only the arrest state. They must
recognize and treat effectively those patients “on their way to a cardiac arrest” and those
recovering in the immediate post-resuscitation period. Once these patients are identified,
ECC personnel must be able to rapidly initiate appropriate therapy. If responders treat critical
conditions properly in this “peri-arrest” or “prearrest” period, they can prevent a full
cardiopulmonary arrest from occurring.

Consequently, the international ACLS recommendations present the science-based clinical

guidelines and some educational material for these periarrest conditions:

 Acute coronary syndromes

 Acute pulmonary oedema, hypotension, and shock
 Symptomatic bradycardias
 Stable and unstable tachycardias
 Acute ischemic stroke
 Impairments of rate, rhythm, or cardiac function in the postresuscitation period (by
definition a periarrest/prearrest condition)

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Other parts of the ECC and CPR guidelines present guidelines for more specific causes of
cardiac arrest, such as electrolyte abnormalities, drug toxicity or overdoses, and toxic
ingestions.

Never Forget the Patient

Resuscitation challenges care providers to make decisions quickly and under pressure.
Providers must occasionally limit their focus for a brief time to a specific aspect of the
resuscitative attempt: getting the IV infusion line started, placing the tracheal tube,
identifying the rhythm, and remembering the “right” medication to order. But rescuers
constantly must return to an overall view of each resuscitative attempt. The flow diagrams or
algorithms focus the learner on the most important aspects of a resuscitative effort: airway
and ventilation, basic CPR, defibrillation of VF, and medications suitable for a particular
patient under specific conditions.

Code Organization: Using the Primary and Secondary ABCD Surveys

The International Perspective

Many approaches to code organization exist. The section that follows describes the approach
taught in AHA courses for ACLS and paediatric resuscitation. This does not imply that
methods of code organization used in other countries are incorrect or less successful.

Why Is Training in ACLS Intentionally Multidisciplinary?

An understandable tendency exists internationally to separate the highly trained professional

from less skilled personnel during ACLS training. Such a practice, however, would
jeopardize one of the most important objectives of resuscitation training. This objective is to
have each member of the multidisciplinary response team know and understand the skills and
roles of each of the other team members. An accomplished senior physician may claim, “I
already know the resuscitation guidelines and already possess the psychomotor skills. Why
must I attend a learning session with less trained responders who are not authorized to
perform tracheal intubation, start an IV drip, or order medications?” An experienced
instructor might respond in several ways, but the response should remind the expert that he or
she must still work with the entire responding team. The expert must know what the other
team members can and cannot perform so that attempted resuscitation proceeds smoothly,
quietly, and effectively.

Of even greater importance, the ACLS team member who possesses the lowest level of
professional training will attend future resuscitative attempts as a critical quality control
agent. Nurses, for example, who work in critical care and emergency care areas may not
perform intubation or defibrillation in some settings, but they can detect with surprising speed
and accuracy when other team members attempt the procedure incorrectly! In American
hospitals, particularly academic teaching centres, nurses prevent innumerable medical
mishaps during resuscitative attempts. They gently (and sometimes not so gently) point out
when the tracheal tube is misplaced, the IV line has become a subcutaneous line, CPR is
inadequate, or the medication ordered was incorrect or wrongly dosed.

While emergency personnel are encouraged to know and experience the role of team leader,
training should concentrate on the team aspects of resuscitative efforts. The course of

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resuscitative attempts may be complex and unpredictable. Indeed, a good resuscitation team
has been likened to a fine symphony orchestra. The team recognizes the team leader for broad
skills of organization and performance. They recognize the individual team member for
specific performance skills. Like an orchestra, all are performing the same piece, polished by
practice and experience, with attention to both detail and outcome. There is no excuse for a
disorganized and frenetic code scene.

The team leader should be decisive and composed. The team should stick to the CABs
(circulation, airway, and breathing) and keep the resuscitation room quiet so that all
personnel can hear without repetitious commands. Team members should

 State the vital signs every 5 minutes or with any change in the monitored parameters
 State when procedures and medications are completed
 Request clarification of any orders
 Provide primary and secondary assessment information

The team leader should communicate her or his observations and should actively seek
suggestions from team members. Evaluation of airway, breathing, and circulation should
guide the efforts whenever the vital signs are unstable, when treatment appears to be failing,
before procedures, and for periodic clinical updates.

The next section describes the Primary and Secondary ABCD Surveys. This aide-mémoire
provides an easily remembered listing of the content and sequence of the specific assessment
and management steps of a resuscitative attempt.

The Primary and Secondary ABCD Surveys

All who respond to cardiorespiratory emergencies should arrive well trained in a simple,
easy-to-remember approach. The ACLS Provider Course teaches the Primary and Secondary
Survey Approach to emergency cardiovascular care. This memory aid describes 2 sets of 4
steps: A-B-C-D (8 total steps). With each step the responder performs an assessment and then,
if the assessment so indicates, a management.

Conduct the Primary ABCD Survey

The Primary ABCD Survey requires your hands (gloved!), a barrier device for CPR, and an
AED for defibrillation. The Primary ABCD Survey assesses and manages most immediate
life threats:

 Airway: Assess and manage the Airway with noninvasive techniques.

 Breathing: Assess and manage Breathing with positive-pressure ventilations.
 Circulation: Assess and manage the Circulation, performing CPR until an AED is
brought to the scene.
 Defibrillation: Assess and manage Defibrillation, assessing the cardiac rhythm for
VF/VT and providing defibrillatory shocks in a safe and effective manner if needed.

Conduct the Secondary ABCD Survey

This survey requires medically advanced, invasive techniques to again assess and manage the
patient. The rescuer attempts to restore spontaneous respirations and circulation to the patient

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and when successful, continues to assess and manage the patient until relieved by appropriate
emergency professionals. In brief: resuscitate, stabilize, and transfer to higher-level care.

 Airway: Assess and manage. Advanced rescuers manage a compromised airway by

placing a tracheal tube.
 Breathing: Assess and manage. Assess adequacy of breathing and ventilation by
checking tube placement and performance; correct all problems detected. Manage
breathing by treating inadequate ventilation with positive-pressure ventilations
through the tube.
 Circulation: Assess and manage the circulation of blood and delivery of medications
by —Starting a peripheral IV line —Attaching ECG leads to examine the ECG for the
most frequent cardiac arrest rhythms (VF, pulseless VT, asystole, and PEA) —
Administering appropriate rhythm-based medications

 Differential Diagnosis: Assess and manage the differential diagnoses that you develop
as you search for, find, and treat reversible causes.

The Resuscitation Attempt as a “Critical Incident”: Code Critique and Debriefing

After any resuscitation attempt team members should perform a code critique. In busy
emergency or casualty departments, carving out the necessary few minutes can be difficult.
The lead physician, however, should assume responsibility to gather as many team members
as possible for at least a pause to reflect. This debriefing provides feedback to prehospital and
in-hospital personnel, gives a safe venue to express grieving, and provides an opportunity for
education. Table 1⇓ provides information on critical incident stress debriefing.

Family Presence in the Resuscitation Area

In a number of countries, hospitals have begun to allow family members and loved ones to
remain in the resuscitation suite during procedures and actual resuscitative efforts.
Evaluations of these programs, pioneered by critical care and emergency nurses, have
confirmed a remarkable level of approval and gratitude by participating family members.
These evaluations, mostly in paediatric cases, have noted significant reduction in
posttraumatic stress and self-reports of a greater sense of resolution and fulfilment. In the
2000 paediatric resuscitation guidelines, family presence in the resuscitation area has a Class
IIb positive recommendation. Provision must be made for a professional to accompany the
family members during these observed attempts, to direct positioning, to answer questions,
and to explain procedures. In addition, the accompanying professional can observe for signs
of acute discomfort in the family members and can end the observations.

There is the lack sufficient evidence about family presence during adult resuscitations, but
this is simply due to an absence of research in adults. Success in such programs for adults is
predictable, provided that the professionals involved demonstrate the same high level of care
and concern as shown by nurses and social workers involved in paediatric resuscitative
attempts.

Ethics and the Clinical Practice of BLS and ACLS: Do Resuscitation Efforts “Fail”?
Of major importance, but often neglected in the rush to learn all of advanced resuscitation
training, we must not forget the resuscitation team and team members, as well as the
surviving friends and relatives. As soon as you declare death for the arrest victim, you

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immediately acquire a new set of patients—the family, friends, and loved ones of the person
who dies. Remember that when the heart or brain of a person in arrest cannot be restarted, do
not use the word fail. The team did not fail to restore the heartbeat, nor did the heart itself fail
to respond to the efforts. Instead think in terms of an attempt to restore a “heart too good to
die” rather than a “heart too sick to live.” At the start, however, the clinical reality is
unknown; caregivers have no way of knowing the status of suddenly arrested hearts when
they arrive on the scene of a cardiac emergency.

In the past we used the phrase “give a trial of CPR”; the only way to recognize “too good to
die” versus “too sick to live” was to give the patient a rapid, aggressive evaluation period of
BLS and ACLS. If spontaneous circulation did not return quickly, then we assumed that the
verdict in the trial of CPR was “person at the end of his or her life.” In such a situation
continued resuscitative efforts are inappropriate, futile, undignified, and demeaning to both
patient and rescuers. “Part 2: Ethical Aspects of CPR and ECC” provides an ethical
framework with which to consider resuscitative efforts and presents specific
recommendations for prehospital and in-hospital care providers.

Algorithms
The current ACLS guidelines are set into several groups of "algorithms" - a set of instructions
that are followed to standardize treatment, and increase its effectiveness. These algorithms
usually come in the form of a flowchart, incorporating 'yes/no' type decisions, making the
algorithm easier to memorize.

Types of algorithms

Cardiac Arrest Algorithm

Acute Coronary Syndromes Algorithm
PEA/Asystole Algorithm
VF/Pulseless VT Algorithm
Bradycardia Algorithm
Tachycardia Algorithms
Respiratory Arrest Algorithm
Opioid Emergency Algorithm
Suspected Stroke Algorithm

Using the algorithm

Search for and correct potentially reversible causes of arrest, Brady/tachycardia.

Exercise caution before using epinephrine in arrests associated with cocaine or other
sympathomimetic drugs. Epinephrine is not required until after the second DC shock in
standard ACLS management as DC shock in itself releases significant quantities of
epinephrine.
Administration of atropine 1 mg dose (IV) bolus for asystole or slow PEA (rate<60/min) is
no longer recommended.
In PEA arrests associated with hyperkalaemia, hypocalcemia. or Ca2+
channel blocking drug overdose, give 10mL 10% calcium chloride (IV) (6.8 mmol/L)
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Consider amiodarone for ventricular fibrillation/pulseless ventricular tachycardia after 3

attempts at defibrillation, as there is evidence it improves response in refractory VF / VT.
(Note: as of the 2010 guidelines, amiodarone is preferred as the first-line antiarrythmic,
moving lidocaine to a second-line backup if amiodarone is unavailable

 For torsades de pointes, refractory VF in people with digoxin toxicity or

hypomagnesemia, give IV magnesium sulfate 8 mmol (4mL of 50% solution)
 In the 2010 ACLS pulseless arrest algorithm, vasopressin may replace the first or
second dose of epinephrine.

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