ADVANCED LIFE SUPPORT

ALS
• Systematic approach to assessment and
management of cardiopulmonary emergencies
• Continuation of Basic Life Support
• Resuscitation efforts aimed at restoring
spontaneous circulation and retaining intact
neurologic function

ABCD
2
CHAIN OF SURVIVAL
RECOVERY POSITION
Basic Rhythm Analysis

7
 Basic Rhythm Analysis
• Rate – too fast or too slow?
• Rhythm – regular or irregular?
• Is there a normal looking QRS? Is it wide or
narrow?
• Are P waves present?
• What is the relationship of the P waves to the
QRS complex?

8
 Rhythm Analysis
Lethal vs non-lethal?

Shockable vs. non-shockable? Too fast vs too slow?

Symptomatic vs. asymptomatic?

9
 Lethal Rhythms
• Shockable (Defibrillation)
– Ventricular fibrillation
– Pulseless ventricular tachycardia
• Non-shockable
– Asystole
– Pulseless electrical activity

10
 Non-Lethal Rhythms
• Too fast (tachycardias)
– Sinus
– Supraventricular (including a-fib/flutter)
– Ventricular
• Too slow (bradycardias)
– Sinus
– Heart block (1°, 2°, 3° AV block)

11
 What is a Symptomatic Dysrhythmia?

• Any abnormal rhythm that produces signs or

symptoms of hypoperfusion
– Chest Pain/ischemic EKG changes
– Shortness of Breath
– Decreased level of consciousness
– Syncope/pre-syncope
– Hypotension
– Shock - decreased Uop, cool extremities, etc.
– Pulmonary Congestion/CHF

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Name that rhythm…

13
 63 yo man with a witnessed collapse while
mowing the lawn

What is the rhythm?

What is the management?

Chikumaya, Wikimedia Commons 14

 Ventricular Fibrillation

• Rapid and irregular

• No normal P waves or QRS complexes

Jer5150, Wikimedia Commons 15

 VF / Pulseless VT
Secondary Survey - ABC

Primary Survey - ABC 16

Source unknown
 ACLS Algorithm
• Primary Survey
• Shock – 360 J
• Secondary Survey
• Vasopressor - Epi IV
• Shock 360J
• Antiarrhythmic – Amiodarone, Lidocaine or
Magnesium Sulfate IV
• Shock 360J

17
 79yo man s/p NSTEMI

What is the rhythm?

What is the management?

Glenlarson, Wikimedia Commons 18

 Ventricular Tachycardia

• Rapid and regular

• No P waves
• Wide QRS complexes

Ksheka, Wikimedia Commons 19

 Ventricular Tachycardia
• Monomorphic VT

Ksheka, Wikimedia Commons

• Polymorphic VT

20
Displaced, Wikimedia Commons
 Ventricular Tachycardia
• Assume any wide complex tachycardia is VT
until proven otherwise
– SVT with aberrant conduction may also have wide
QRS complexes
• Attempt to establish the diagnosis
– Ischemia risk and VT go together

21
 Treatment of VT
• If pulseless - follow VF algorithm
• If stable try anti-arrhythmics
– Amiodarone
– Lidocaine
– Procainamide?
• If patient has a pulse, but is unstable or not
responding to meds - shock

22
 Treatment of VT
• Anti-arrhythmics are also pro-arrhythmic
• One antiarrhythmic may help, more than one
may harm
• Anti-arrhythmics can impair an already impaired
heart
• Electrical cardioversion should be the second
intervention of choice

23
 60yo diabetic man with chest pain

What is the rhythm?

What is the management?

Knutux, Wikimedia Commons 24

 Normal Sinus Rhythm

• Regular rate and rhythm

• Normal P waves and QRS
• Evaluate for cause of chest pain and monitor for
change in rhythm

Knutux, Wikimedia Commons 25

 40 yo woman found down, pulseless and
apneic

What is the rhythm?

What is the management?

Masur, Wikimedia Commons 26

 Pulseless Electrical Activity
• Any organized (or semi-organized) electrical
activity in a patient without a detectable pulse
• Non-perfusing

• Treat the patient NOT the monitor

• Find and treat the cause!!!!!

27
 PEA and Asystole
Secondary Survey - ABCD

Primary Survey - ABC

28
Source unknown
 PEA
Primary Survey

Secondary Survey

Search for and Treat Causes

Epinephrine 1 mg IVP
repeat every 3-5 minutes

Atropine 1 mg IVP
if PEA is slow

29
 Find and Treat the Cause
• Non-shockable rhythm
• The most effective treatment is to find and fix
the underlying problem

30
Rama, Wikimedia Commons
 So what causes PEA?
• #1 cause of PEA in adults is hypovolemia
• #1 cause in children is hypoxia/respiratory
arrest

• Other causes?

31
 The H’s and T’s
• Hypovolemia • Toxins
• Hypoxia • Tamponade
• Hydrogen ion (acidosis) • Tension pneumothorax
• Hyper-/hypokalemia • Thrombosis (coronary or
• Hypothermia pulmonary)
• Hypoglycemia (rare) • Trauma

32
 Treat the H’s and T’s
• Hypovolemia • Toxins
– Volume – IVF, PRBC’s – Check levels
• Hypoxia – Charcoal
– Oxygenate/Ventilate – Antidotes
• Hydrogen ion (acidosis) • Tamponade
– Sodium bicarbonate – pericardiocentesis
– Hyperventilation • Tension pneumothorax
• Hyper-/hypokalemia – Needle decompression
– Sodium bicarbonate – Tube thoracostomy
– Insulin/glucose • Thrombosis (coronary or
– Calcium pulmonary)
• Hypothermia – Thrombolytics
– Warm -- invasive – OR/cath lab
• Hypoglycemia • Trauma
– Dextrose

33
 19yo man with palpitations

What is the rhythm?

What is the management?

34
Displaced, Wikimedia Commons
 Supraventricular Tachycardia

• Rapid (usually 150-250 bpm) and regular

• P waves cannot be positively identified
• QRS narrow

35
Displaced, Wikimedia Commons
 Treatment of Stable SVT
• Consider vagal maneuvers
– Carotid sinus massage
– Valsalva
– Eyeball massage
– Ice water to face
– Digital rectal exam
• Adenosine
– 6 mg, 12 mg, 12 mg

36
 Treatment of Unstable SVT
• Electrical Cardioversion
• Cardioversion is not defibrillation
• Use defibrillator in “sync” mode
– prevents delivering energy in the wrong part of the
cardiac cycle (R on T phenomenon)

37
 Electrical Cardioversion
• Energy level – somewhat controversial
• 100 J→200J→300J→360J
• Atrial flutter may convert with lower energy
– 50J
• For polymorphic VT – start with 200J
• The EP guys tend to start with 360J

38
 Electrical Cardioversion
• Be prepared
– Patient on monitor, IV, Oxygen
– Suction ready and working
– Airway supplies ready
• Pre-medicate whenever possible
– Conscious sedation
– Electrical shocks are painful!

39
 Tachycardia
Evaluate Patient

Stable? Unstable?

Lots of options Shock

based on rhythm

• Treat the patient NOT the monitor!!!

40
 Stable Tachycardias
• Narrow complex? • Wide complex?
– Regular rhythm – Uncertain rhythm –
• Sinus tachycardia assume VT
• SVT – Narrow complex
• AV nodal reentry tachycardia with
– Irregular rhythm aberrancy
• Atrial fibrillation – Ventricular tachycardia
• Atrial flutter • Monomorphic or
polymorphic

41
 56 yo woman with shortness of breath and
chest pain

What is the rhythm?

What is the management?

42
J. Heuser, Wikimedia Commons
 Atrial fibrillation/flutter

J. Heuser, Wikimedia Commons

James Heilman, MD, Wikimedia Commons

• May be rapid
• Irregular (fib) or more regular (flutter)
• No P waves, narrow QRS
43
 Atrial fibrillation/flutter
• Treatment based on patient’s clinical picture
– Unstable = Immediate electrical cardioversion
– Stable
• Control the rate
– Diltiazem
– Esmolol (not if EF < 40%)
– Digoxin
• Provide anticoagulation

• Treat the patient NOT the monitor!!!

44
 78yo man found down, pulseless and
apneic, unknown duration

What is the rhythm?

What is the management?

D Dinneen, Wikimedia Commons 45

 Asystole

• Is it really asystole?
• Check lead and cable connections.
• Is everything turned on?
• Verify asystole in another lead.
• Maybe it is really fine v-fib?

D Dinneen, Wikimedia Commons 46

 68 yo woman with h/o hypertension
presents with dizziness

What is the rhythm?

What is the treatment?

Mysid, Wikimedia Commons 47

 Sinus Bradycardia

• Slow and regular

• Normal P waves and QRS complexes

Mysid, Wikimedia Commons 48

 Bradycardias
• Many possible causes
– Enhanced parasympathetic tone
– Increased ICP.
– Hypothyroidism
– Hypothermia
– Hyperkalemia
– Hypoglycemia
– Drug therapy

49
 Bradycardias
• Treat only symptomatic bradycardias
– Ask if the bradycardia causing the symptoms
• Recognize the red flag bradycardias
– Second degree type II block
– Third degree block

50
 51
Source unknown
 Transcutaneous pacing
• Class I for all symptomatic bradycardias
• Always appropriate
• Doesn’t always work
• Technique
– Attach pacer pads
– Set a rate to 80 bpm
– Turn up the juice (amps) until you get capture
• Painful – may need sedation / analgesia

52
 Transvenous Pacing
• Invasive
• Time-consuming to establish
• Skilled procedure
• Better long-term than transcutaneous
• May have better capture than transcutaneous
pacing

53
 Bradycardia Treatment

• Medications
– Vagolytic
• Atropine
– Adrenergic
• Epinephrine
• Dopamine

54
 29 yo asymptomatic female

What is the rhythm?

What is the management?

Steven Fruitsmaak, Wikimedia Commons 55

 1° AV block

• Regular rate and rhythm

• Normal P wave with long PR interval (>0.2msec/1 big
box)
• Normal QRS

Steven Fruitsmaak, Wikimedia Commons 56

 58yo asymptomatic woman

What is the rhythm?

What is the management?

Jer5150, Wikimedia Commons 57

 2° AV Block - Type I

• aka Wenckebach
• Regular rate and rhythm
• Normal P waves and QRS complexes
• Increasing PR interval until QRS dropped

Jer5150, Wikimedia Commons 58

 80 yo man with syncope

What is the rhythm?

What is the management?

Jer5150, Wikimedia Commons 59

 2° AV Block – Mobitz Type II

• Regular atrial rate with normal P wave

• Consistent PR interval
• Random QRS dropped

Jer5150, Wikimedia Commons 60

 Another 80 yo man with syncope

What is the rhythm?

What is the management?

MoodyGroove, Wikimedia Commons 61

 3° AV Block

• Normal P waves
• Normal QRS
• No relationship between P and QRS
• aka complete heart block

MoodyGroove, Wikimedia Commons 62

 Know When To Stop
• With return of spontaneous circulation
• No ROSC during or after 30 minutes of
resuscitative efforts
– Possible exceptions include near-drowning, severe
hypothermia, known reversible cause, some
overdoses
• DNR orders presented
• Obvious signs of irreversible death

63
 Take Home Points
• Assess and manage at every step before moving
on to the next step
• Rapid defibrillation is the ONLY effective
treatment for VF/VT
• Search for and treat the cause
• Treat the patient not the monitor
• Reassess frequently
• Minimize interruptions to chest compressions
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