Advanced

Cardiac Life
Support
Dr. Mohammad Taraz
Tehran University of Medical Science
PRINCIPLES OF MANAGEMENT

Excellent basic life support & its

importance
Excellent CPR & early defibrillation for treatable
arrhythmias remain the cornerstones of basic & ACLS.

Although the 2010 American Heart Association (AHA)

Guidelines for ACLS suggest several revisions, including
medications, electrical therapy, & monitoring, the emphasis on
excellent CPR & its critical role in resuscitative efforts remains
unchanged.
 In the past, clinicians frequently interrupted CPR to check for
pulses, perform tracheal intubation, or obtain venous
access.

The 2010 ACLS Guidelines strongly recommend that every effort

be madeNOTto interrupt CPR; other less vital interventions
(eg, tracheal intubation or administration of medications to treat
arrhythmias) are made either while CPR is performed or
during the briefest possible interruption.

Interventions that cannot be performed while CPR is in progress

(eg, defibrillation) should be performed during brief
interruptions at two minute intervals (after the completion of
a full cycle of CPR).
 Studies in both the in-hospital & prehospital settings
demonstrate that chest compressions are often
performed incorrectly, inconsistently, & with excessive
interruption.

Chest compressions must be of sufficient depth (at least 5

cm, or 2 inches) & rate (at least 100 per min), & allow for
complete recoil of the chest between compressions, to
be effective.

A single biphasic defibrillation remains the recommended

treatment for ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT).
 CPR should be performed until the defibrillator is ready
for immediate discharge & resumed immediately after
the shock is given, without pausing to recheck a pulse at
that moment.

Interruptions in CPR (eg, for subsequent attempts at

defibrillation or pulse checks) should occur no more
frequently than every two minutes, & for the shortest
possible duration.

Patients are often over-ventilated during resuscitations,

which can compromise venous return resulting in
reduced cardiac output & inadequate cerebral &
cardiac perfusion.
 A 30 to 2 compression to ventilation ratio (one
cycle) is recommended in patients without advanced
airways.

According to the 2010 ACLS Guidelines, asynchronous

ventilations at 8 to 10 per minute are administered if
an endotracheal tube or extraglottic airway is in place,
while continuous chest compressions are
performed simultaneously.

We believe that 6 to 8 ventilations per minute are

sufficient in the low-flow state of cardiac resuscitation &
help to prevent over-ventilation.
 Key principles in the performance of ACLS
Excellent CPR is crucial.
Excellent chest compressionsmustbe performed throughout the
resuscitation without interruption, using proper timing (100
compressions per minute) and force (5 cm depth), and allowing for
complete chest recoil.
Donotstop compressions until the defibrillator is fully charged.
Anything short of excellent CPR does not achieve adequate cerebral
and coronary perfusion.
Excellent chest compressions take priority over ventilation. If a second
rescuer is present, ventilations must be performed using proper timing
(6 to 8 breaths per minute in the intubated patient; ratio of 30
compressions to 2 ventilations if not intubated) and force (each breath
delivered over a full 1 to 2 seconds); avoid hyperventilation.
Defibrillate VF and pulseless VT as rapidly as possible.
Rapidlyidentify and treat causes of non-shockable arrest (PEA,
asystole).
Important causes include the 5 H's and 5 T's:
Hypoxia, Hypovolemia, Hydrogen ions (acidosis), Hyper/Hypo-kalemia,
Hypothermia;
Tension pneumothorax, Tamponade-cardiac, Toxins, Thrombosis-coronary
(MI), Thrombosis-pulmonary (PE).
Resuscitation team
management
The resuscitation of a sudden cardiac arrest (SCA), by its
nature a low frequency, high acuity event, is often chaotic.

A growing body of literature demonstrates that by employing

the principles of Crisis Resource Management (CRM),
adapted from the aviation industry & introduced into medical
care by anesthesiologists, disorganization during resuscitation
decreases & patient care improves.

Training in these principles to improve the quality of ACLS

performed by healthcare clinicians is feasible & recommended.
 Two principles provide the foundation for CRM: leadership &
communication.
Resuscitations usually involve a number of healthcare providers
from different disciplines, sometimes from different areas of an
institution, who may not have worked together previously.
Under these circumstances, role clarity can be difficult to
establish.

In CRM, it is imperative that one person assumes the role of

team leader. This person is responsible for the global
management of the resuscitation, including: ensuring that all
required tasks are carried out competently; incorporating new
information & coordinating communication among all team
members; developing & implementing management strategies
that will maximize patient outcome; & reassessing performance
throughout the resuscitation.
 The team leader should avoid performing technical
procedures, as performance of a task inevitably shifts
attention from the primary leadership responsibilities.

In circumstances where staffing is limited (eg, small

community hospital), the team leader may be required to
perform certain critical procedures.

In these situations, leadership may be temporarily transferred

to another clinician or the team leader may be forced
temporarily to perform both roles, although this
compromises the ability to provide proficient
leadership.
 In CRM, communication is organized to provide effective &
efficient care. All pertinent communication goes through the
team leader & the team leader shares important
information with the team.

When the team leader determines the need to perform a task,

the request is directed to a specific team member,
ideally by name.

That team member verbally acknowledges the request &

performs the task or, if unable to do so, informs the team
leader that someone else should be assigned.
 Specific emphasis is placed on the assigned team member
repeating back medication doses & defibrillator energy
settings to the team leader. This "closed-loop"
communication leads to a more orderly transfer of information
& is the appropriate standard for all communication during
resuscitations.

Though most decisions emanate from the team leader, a good

team leader enlists the collective wisdom & experience of the
entire team as needed.

Extraneous personnel not involved with patient care are asked

to leave in order to reduce noise & to ensure that orders
from the leader & feedback from the resuscitation team
can be heard clearly.
Initial management & ECG
interpretation
In the 2010 ACLS Guidelines, circulation has taken a more
prominent role in the initial management of cardiac arrest. The
new mantra is: circulation, airway, breathing (C-A-B).

Once unresponsiveness is recognized, resuscitation

begins by addressing circulation (chest compressions),
followed by airway opening, & then rescue breathing.

The 2010 ACLS Guidelines emphasize the importance of

excellently performed, uninterrupted chest
compressions & early defibrillation. Rescue breathing is
performed after the initiation of excellent chest compressions
& definitive airway management may be delayed if there is
adequate rescue breathing without an advanced airway in
place.
 In the non-cardiac arrest situation, the other initial
interventions for ACLS include :
administering oxygen
establishing vascular access
placing the patient on a cardiac & oxygen saturation
monitor
obtaining an ECG

Unstable patients must receive immediate care, even when

data are incomplete or presumptive.
 Stable patients require an assessment of their
electrocardiogram in order to provide appropriate treatment
consistent with ACLS guidelines. Although it is best to make a
definitive interpretation of the ECG prior to making
management decisions, the settings in which ACLS guidelines
are commonly employed require a modified, empirical
approach. Such an approach is guided by the following
questions:
Is the rhythm fast or slow?
Are the QRS complexes wide or narrow?
Is the rhythm regular or irregular?

The answers to these questions often enable the clinician to

make a provisional diagnosis & initiate appropriate therapy.
Airway Management During ACLS

Ventilation is performed during CPR to maintain adequate

oxygenation & eliminate carbon dioxide.

Nevertheless, during the first few minutes following sudden

cardiac arrest (SCA), oxygen delivery to the brain is limited
primarily by reduced blood flow.

Therefore, in adults, the performance of excellent chest

compressions takes priority over ventilation during the initial
period of basic life support. In settings with multiple
rescuers or clinicians, ventilations & chest
compressions are performed simultaneously.
 Although research has yet to identify the preferred parameters for
ventilation (eg, respiratory rate, tidal volume, inspired oxygen
concentration), it is widely believed that a lower minute
ventilation is needed for patients in cardiac arrest.

Therefore, lower respiratory rates are used (the 2010 ACLS

Guidelines recommend 8 to 10 breaths per minute with an
advanced airway in place; we believe 6 to 8 breaths are adequate).

In addition, we know that hyperventilation is harmful, as it leads to

increased intrathoracic pressure, which decreases venous return &
compromises cardiac output. Tidal volumes of approximately
600 mL delivered in a controlled fashion such that chest rise
occurs over no more than one second is recommended in the 2010
ACLS Guidelines.
 Taking these principles into account, the 2010 ACLS Guidelines
support the use of a bag-mask device or a blindly placed
supraglottic airway for ventilation during the initial management
of SCA, deferring placement of an endotracheal tube, unless
intubation can be performed without interrupting chest
compressions.

A blindly inserted supraglottic airway (eg, laryngeal mask airway,

Combitube, laryngeal tube) can be placed without interrupting
chest compressions, provides adequate ventilation in most cases,
& reduces the risk of aspiration compared to bag-mask ventilation.

Therefore, clinicians may prefer to ventilate with a supraglottic

device while CPR is ongoing, rather than performing tracheal
intubation.
 If rescuers decide that tracheal intubation is necessary during
CPR, an experienced intubator should perform the
procedure.

Ideally, intubation is performed while excellent chest

compressions continue uninterrupted. However, if the operator
is unable to intubate during the performance of chest
compressions, further attempts should be deferred to the two
minute interval (after a complete cycle of CPR) when
defibrillation or patient reassessment is performed.

This approach minimizes loss of perfusion. Attempts at

intubation should last no longer than 10 seconds.
 Management Of
Specific Arrhythmias
Ventricular fibrillation & pulseless
ventricular tachycardia

VF & pulseless VT are nonperfusing rhythms emanating from

the ventricles, for which early rhythm identification, defibrillation,
& CPR are the mainstays of treatment.

Early defibrillation is the most critical action in the resuscitation

effort, followed by the performance of excellent CPR. Manage
potentially treatable underlying causes as appropriate.

Begin performing excellent chest compressions as soon as SCA is

recognized & continue while the defibrillator is being attached. If a
defibrillator is not immediately available, continue CPR until one
is obtained. As soon as a defibrillator is available, attach it to the
patient, charge it, assess the rhythm, & treat appropriately (eg,
defibrillate VF or pulseless VT; continue CPR if asystole or PEA).
Resume CPR immediately after any shock is given.
Ventricular fibrillation
 In the case of a witnessed cardiac arrest, perform defibrillation as
quickly as possible. Decreased time to defibrillation improves
the likelihood of successful conversion to a perfusing
rhythm & of patient survival.

Biphasic defibrillators are recommended because of their

increased efficacy at lower energy levels. The 2010 ACLS
Guidelines recommend that when employing a biphasic
defibrillator clinicians use the initial dose of energy recommended
by the manufacturer (120 to 200 J).

If this dose is not known, the maximal dose may be used. We

suggest a first defibrillation using 200 J with a biphasic defibrillator
or 360 J with a monophasic defibrillator for VF or pulseless VT.
It should be noted that many automated external defibrillators
(AEDs) do not allow for adjustment of the shock output.
 The 2010 ACLS Guidelines recommend the resumption of
CPR immediately after defibrillation without rechecking
for a pulse. CPR should not be interrupted to assess the
rhythm & additional shocks should be considered no
more frequently than every two minutes.

If VF or pulseless VT persists after at least one attempt at

defibrillation & two minutes of CPR, giveepinephrine(1
mg IV every 3 to 5 min) while CPR is performed continuously.

Vasopressin (40 units IV) may replace the first or second

dose of epinephrine.
 Evidence suggests that antiarrhythmic drugs provide little survival
benefit in refractory VF or pulseless VT. Nevertheless, the current
ACLS Guidelines state that they may be used in certain
situations. The timing of antiarrhythmic use is not specified.

We suggest that antiarrhythmic drugs be considered after a second

unsuccessful defibrillation attempt in anticipation of a third
shock.

Amiodarone(300 mg IV with a repeat dose of 150 mg IV as indicated)

may be administered in VF or pulseless VT unresponsive to defibrillation,
CPR, & epinephrine.
Lidocaine(1 to 1.5 mg/kg IV, then 0.5 to 0.75 mg/kg every 5 to 10 min)
may be used ifamiodaroneis unavailable.
Magnesium sulfate(2 g IV, followed by a maintenance infusion) may
be used to treat polymorphic ventricular tachycardia consistent with
torsade de pointes.
Asystole & pulseless
electrical activity
Asystole is defined as a complete absence of
demonstrable electrical & mechanical cardiac activity.

Pulseless electrical activity (PEA) is defined as any one

of a heterogeneous group of organized
electrocardiographic rhythms without sufficient
mechanical contraction of the heart to produce a
palpable pulse or measurable blood pressure.

By definition, asystole & PEA are non-perfusing

rhythms requiring the initiation of excellent CPR
immediately when either is present.
 After initiating CPR, treat reversible causes as appropriate &
administerepinephrine(1 mg IV every three to five minutes).

The 2010 ACLS Guidelines state that vasopressin may be

given (40 units for the first 10 minutes of resuscitation) in
place of the first or second epinephrine dose.

Neither asystole nor PEA responds to defibrillation.

Atropineis no longer recommended for the treatment

of asystole or PEA. Cardiac pacing is ineffective for cardiac
arrest & not recommended in the 2010 ACLS Guidelines.
Monitoring

The 2010 ACLS Guidelines encourage the use of clinical &

physiologic monitoring to optimize the performance of CPR &
to detect the return of spontaneous circulation (ROSC).

End-tidal carbon dioxide (EtCO2) measurements from

continuous waveform capnography accurately reflect cardiac
output & cerebral perfusion pressure, & therefore the quality
of CPR.

Sudden, sustained increases in EtCO2 during CPR indicate a

ROSC while decreasing EtCO2 during CPR may indicate
inadequate compressions.
 Data from other physiologic monitors is less likely to be
available in patients with SCA, but measurements obtained
from arterial & central venous catheters provide useful
feedback about the quality of CPR & ROSC.

Measurements of arterial relaxation provide a reasonable

approximation of coronary perfusion pressure. During CPR, a
reasonable goal is to maintain the arterial relaxation (or
diastole) pressure above 20 mmHg.

Central venous oxygen saturation (SCVO2) provides

information about oxygen delivery & cardiac output. During
CPR, a reasonable goal is to maintain SCVO2 above 30 %.
Bradycardia
Bradycardia is defined conservatively as a heart rate below 60
beats per minute, but symptomatic bradycardia generally
entails rates below 50 beats per minute.

The 2010 ACLS Guidelines recommend that clinicians not

intervene unless the patient exhibits evidence of inadequate
tissue perfusion thought to result from the slow heart rate.

Signs & symptoms of inadequate perfusion include hypotension,

altered mental status, signs of shock, ongoing ischemic chest
pain, & evidence of acute pulmonary edema. Hypoxemia is a
common cause of bradycardia; look for signs of labored
breathing (eg, increased respiratory rate, retractions,
paradoxical abdominal breathing) & low oxygen saturation. Mild
symptoms may not warrant treatment.
Tachycardia
Tachycardia is defined as a heart rate above 100 beats per
minute, but symptomatic tachycardia generally involves rates
over 150 beats per minute, unless underlying ventricular
dysfunction exists.

Management of tachyarrhythmias is governed by the presence

of clinical symptoms & signs caused by the rapid heart rate.

The fundamental approach is as follows: First determine if the

patient is unstable (eg, manifests ongoing ischemic chest pain,
acute mental status changes, hypotension, signs of shock, or
evidence of acute pulmonary edema). Hypoxemia is a
common cause of tachycardia; look for signs of labored
breathing (eg, increased respiratory rate, retractions,
paradoxical abdominal breathing) & low oxygen saturation.
POST-RESUSCITATION CARE
The 2010 ACLS Guidelines recommend a combination
of goal-oriented interventions provided by an
experienced multidisciplinary team for all cardiac arrest
patients with return of spontaneous circulation.

Important objectives for such care include:

Optimizing cardiopulmonary function & perfusion of
vital organs
Managing acute coronary syndromes
Implementing strategies to prevent & manage organ
system dysfunction & injury
 TERMINATION OF RESUSCITATIVE
EFFORTS
Determining when to stop resuscitation efforts in cardiac arrest
patients is difficult, & little data exist to guide decision-making.

Physician survey data & clinical practice guidelines suggest

that factors influencing the decision to stop resuscitative
efforts include:
Duration of resuscitative effort >30 min without a sustained
perfusing rhythm
Initial electrocardiographic rhythm of asystole
Prolonged interval between estimated time of arrest & initiation of
resuscitation
Patient age & severity of comorbid disease
Absent brainstem reflexes
Normothermia
 More objective endpoints of resuscitation have been proposed.
Of these, the best predictor of outcome may be the end tidal
CO2 level following 20 min of resuscitation.

End tidal CO2 values are a function of CO2 production &

venous return to the right heart & pulmonary
circulation. A very low end tidal CO2 (<10 mmHg) following
prolonged resuscitation (>20 min) is a sign of absent
circulation & a strong predictor of acute mortality.

It is crucial to note that low end tidal CO2 levels may also be
caused by a misplaced (esophageal) endotracheal tube, & this
possibility needs to be excluded before the decision is made to
terminate resuscitative efforts.
END