ACLS ... Every doctor must know

1. ADVANCED CARDIAC LIFE
SUPPORT(ACLS) - 2010
Speaker – Dr Omar Kamal
DNB anaesthesiology

2. ADVANCED CARDIAC LIFE SUPPORT
 ACLS impacts multiple key links in the chain of
survival that include interventions to prevent cardiac
arrest, treat cardiac arrest, and improve outcomes
of patients who achieve return of spontaneous
circulation (ROSC) after cardiac arrest
 Interventions aimed at preventing cardiac arrest
include airway management, ventilation support,
and treatment of bradyarrhythmias and
tachyarrhythmias.

3. 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

4. CARDIOPULMONARY RESUSCITATION (CPR)
 Cardiopulmonary resuscitation (CPR) is a series of
life saving actions that improve the chance of
survival following cardiac arrest

7. KEY CHANGES FROM THE
2005 BLS GUIDELINES
● Immediate recognition of SCA based on assessing
unresponsiveness and absence of normal breathing
● “Look, Listen, and Feel” removed from the BLS
algorithm
● Encouraging Hands-Only (chest compression only)
CPR
● Sequence change CAB rather than ABC
● Health care providers continue effective chest
compressions/ CPR until return of spontaneous
circulation or termination of resuscitative efforts

8. ● Increased focus on high-quality CPR
● Continued de-emphasis on pulse check for health
care providers
● A simplified adult BLS algorithm is introduced with
the revised traditional algorithm

9. A CHANGE FROM A-B-C TO C-A-B

10. CHEST COMPRESSIONS
 Chest compressions consist of forceful rhythmic
applications of pressure over the lower half of the
sternum.
 Technique ..?

12. MONITORING DURING CPR
Physiologic parameters
 Monitoring of PETCO2 (35 to 40 mmHg)
 Coronary perfusion pressure (CPP) (15mmHg)
 Central venous oxygen saturation (ScvO2)
 Abrupt increase in any of these parameters is a
sensitive indicator of ROSC that can be monitored
without interrupting chest compressions

13. Quantitative waveform capnography
 If Petco2 <10 mm Hg, attempt to improve CPR
quality
Intra-arterial pressure
 If diastolic pressure <20 mm Hg, attempt to improve
CPR quality
 If ScvO2 is < 30%, consider trying to improve the
quality of CPR

15. HIGH QUALITY CPR
 Chest compressions of adequate rate 100/min
 A compression depth of at least 2 inches (5 cm) in
adults and in children, a compression depth of at
least 1.5 inches [4 cm] in infants
 Complete chest recoil after each compression,
 Minimizing interruptions in chest compressions
 Avoiding excessive ventilation
 If multiple rescuers are available, rotate the task of
compressions every 2 minutes.

16. AIRWAY AND VENTILATIONS
 Opening airway – Head tilt, chin lift or jaw thrust
 The untrained rescuer will provide Hands-Only
(compression-only) CPR
 The Health care provider should open the airway
and give rescue breaths with chest compressions

18. RESCUE BREATHS
 By mouth-to-mouth or bag-mask
 Deliver each rescue breath over 1 second
 Give a sufficient tidal volume to produce visible
chest rise
 Use a compression to ventilation ratio of 30 chest
compressions to 2 ventilations
 After advanced airway is placed, rescue breaths
given asynchronus with ventilation
 1 breath every 6 to 8 seconds (about 8 to 10
breaths per minute)

19. CARDIAC ARREST
 Cardiac arrest can be caused by 4 rhythms:
1. Ventricular fibrillation(VF),
2. Pulseless ventricular tachycardia (VT),
3. Pulseless electric activity (PEA), and
4. Asystole.
How to recognise cardiac arrest ..?

20. TREATABLE CAUSES OF CARDIAC ARREST:
THE H’S AND T’S
H’s T’s
 Hypoxia Toxins
 Hypovolemia Tamponade (cardiac)
 Hydrogen ion(acidosis) Tension pneumothorax
 Hypo-/hyperkalemia Thrombosis, pulmonary
 Hypothermia Thrombosis, coronary

24. DEFIBRILLATION
 Defibrillation is defined as termination of VF for at
least 5 seconds following the shock.
 Early defibrillation remains the cornerstone therapy
for ventricular fibrillation and pulseless ventricular
tachycardia

25. ELECTRODE PLACEMENT
4 pad positions
 anterolateral,
 anteroposterior,
 anterior-left infrascapular, and
 anterior-rightinfrascapular
 For adults, an electrode size of 8 to 12 cm is
reasonable (Class IIa, LOE B).
 Any of the 4 pad positions is reasonable for
defibrillation (Class IIa, LOE B).

26.  Defibrillation Sequence
● Turn the AED on.
● Follow the AED prompts.
● Resume chest compressions immediately after the
shock(minimize interruptions).
Shock Energy
 Biphasic : Manufacturer recommendation (eg,
initial dose of 120-200 J), if unknown, use maximum
available.
 Second and subsequent doses should be equivalent,
and higher doses may be considered.
 Monophasic : 360 J

27. 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

28. DRUG THERAPY
1. Peripheral IV Drug Delivery
2. IO Drug Delivery - IO cannulation provides
access to a noncollapsible venous plexus
3. Central IV Drug Delivery - It can be used to
monitor ScvO2 and estimate CPP during CPR,
both of which are predictive of ROSC
4. Endotracheal Drug Delivery - lidocaine,
epinephrine, atropine, naloxone, and vasopressin
 Dose : 2 to 2 ½ times the recommended IV dose

29. VASOPRESSORS
Drug Therapy
 Epinephrine IV/IO Dose: 1 mg every 3-5 minutes
 Vasopressin IV/IO Dose: 40 units can replace first
or second dose of epinephrine
 Amiodarone IV/IO Dose: First dose: 300 mg bolus.
Second dose: 150 mg.

30. KEY CHANGES FROM THE 2005 ACLS
GUIDELINES
 Continuous quantitative waveform capnography is
recommended
 Cardiac arrest algorithms are simplified and
redesigned to emphasize the importance of high
quality CPR
 Atropine is no longer recommended for routine use
in the management of pulseless electrical activity
(PEA)/asystole

31.  Increased emphasis on physiologic monitoring to
optimize CPR quality and detect ROSC
 Chronotropic drug infusions are recommended as
an alternative to pacing in symptomatic and
unstable bradycardia.
 Adenosine is recommended as a safe and
potentially effective therapy in the initial
management of stable undifferentiated regular
monomorphic wide-complex tachycardia

32. CARDIAC ARREST ASSOCIATED
WITH PREGNANCY
 The overall maternal mortality rate was calculated
at 13.95 deaths per 100 000 maternities.
 There were 8 cardiac arrests with a frequency
calculated at 0.05 per 1000 maternities, or 1:20
000.
 The frequency of cardiac arrest in pregnancy is on
the rise with previous reports estimating the
frequency to be 1:30 000 maternities
 Department of Health, Welsh Office, Scottish Office. Report on confidential
enquiries into maternal deaths in the United Kingdom 2000–2002. London
(UK): The Stationery Office; 2004.

35. 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
P – Placenta praevia/ abruptio
S -- Sepsis

36. 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

37.  Several case reports of emergency cesarean section in
maternal cardiac arrest indicate a return of spontaneous
circulation or improvement in maternal hemodynamic
status only after the uterus has been emptied.
 In a case series of 38 cases of perimortem cesarean
section, 12 of 20 women for whom maternal outcome
was recorded had return of spontaneous circulation
immediately after delivery.
McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of
successful outcomes in association with perimortem Caesarean delivery.
Br J Anaesth. 2009;103:406–409.

40.  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 : 6 mg rapid iv push, follow with NS
flush.. Second dose 12 mg

41. INITIAL OBJECTIVES OF POST– CARDIAC
ARREST CARE
 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

43. THANK YOU