BACHELOR OF SCIENCE IN NURSING:

CRITICAL CARE NURSING
COURSE MODULE COURSE UNIT WEEK
3 8 17

ADVANCED CARDIOVASCULAR LIFE SUPPORT

ü Read course and unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to unit
terminologies for jargons
ü Proactively participate in classroom discussions
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Define Cardiac arrest
2. Discuss the characteristics of cardiac arrest
3. Review the etiological factors
4. Identify the signs and symptoms of cardiac arrest.

 
Affective:
1. Listen attentively to the discussions and opinions in the class
2. Initiate asking questions that challenge class thinking
3. Express freely the personal opinion with respect to others opinion

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

 
Chulay, Marianne, Burns Suzanne (2011) . AACN Essentials of Critical Care
Nursing (2nd edition). International: McGraw-Hill Medical

ADVANCED CARDIOVASCULAR LIFE SUPPORT

DEFINITION

Advanced Cardiovascular Life Support

• refers to a set of clinical interventions for the
urgent treatment of life-threatening medical
emergencies

Pulseless Arrest Algorithm for VF and Pulseless VT

Using the Pulseless Arrest Algorithm for Managing
Ventricular Fibrillation and Pulseless Ventricular
Tachycardia

Using the Pulseless Arrest Algorithm for

Managing VF and Pulseless VT
The ACLS Pulseless Arrest Algorithm is the most
important algorithm to know when resuscitating
adults. The algorithm steps through the assessment
and management of a patient with no pulse who

 
does not respond to the interventions of the primary survey, including an initial shock from an
automated external defibrillator (AED). Pulseless ventricular tachycardia (VT) is included in the
algorithm with ventricular fibrillation (VF). For treatment purposes, pulseless VT is treated the
same as ventricular fibrillation

The Pulseless Arrest Algorithm follows after the primary survey has already been conducted:

• The emergency response system has been activated

• CPR is being performed
• An AED has been attached
• The first shock has been given

Steps
Maintain CPR. Interrupt chest compressions only for ventilation, rhythm checks, and actual
shock delivery. CPR should never be interrupted for more than 10 seconds. Remind team
members that they must prepare the drugs that will be used ahead of time and minimize the
time that the patient is without CPR.

1. Begin 5 cycles of CPR (approximately 2 minutes) immediately after the first shock.
Each cycle contains 30 chest compressions followed by 2 breaths.
2. Attach the patient to the monitor/defibrillator and analyze the patient’s rhythm.
3. Check the patient's rhythm in less than 10 seconds.

Rhythm Condition Action

Non-shockable rhythm is AND QRS complexes appear Check for a pulse
present regular and narrow
Non-shockable rhythm is WITHOUT pulse Follow treatment for PEA or
present asystole
If a shockable rhythm is WITHOUT pulse Continue CPR while
present defibrillator is charging

1. Continue CPR until the defibrillator has been charged.

o Turn oxygen away from the patient's chest OR turn it off.
o Make sure the source of oxygen is removed from the patient when you clear to
shock.
o Check to see that no caregivers are touching the patient.
o Shock. If using biphasic, use manufacturer recommended dosage. Press the
shock button.
2. Immediately resume CPR for 5 cycles.
3. If IV/IO is available, administer epinephrine 1mg IV/IO during the CPR cycle (see drug
administration in PDF file on right).

 
 4. Check rhythm in less than 10 seconds.
5. If a shockable rhythm is present, give 1 shock.
o Continue CPR while the defibrillator is charging.
o Clear the patient for shock.
o Deliver the shock.
o Resume CPR immediately after shock, 5 cycles.

Management of Cardiac Arrest

Definition
Cardiac arrest is the sudden loss of heart function in a person with or without known cardiac
disease. The entity must be differentiated from a heart attack that refers to the compromised
blood supply to the heart musculature.

Important Principles Related to the Management of Cardiac Arrest

Before we talk about the different medications, algorithms and systematic approaches
available for the treatment of cardiac arrest, it is important to emphasize that basic
cardiopulmonary resuscitation and early defibrillation for shockable cardiac arrest
rhythms are of profound importance for survival. The survival from a cardiac arrest is
dependent on the prompt and early application of basic life support and advanced
cardiovascular life support algorithms.
Once cardiopulmonary resuscitation is initiated, and defibrillation has been attempted,
intravenous access should be established. This can be central or peripheral, and we will
discuss the advantages and disadvantages of both lines in the coming section. Administration
of drugs can be attempted at this stage.

Note: “ABC” is not used for patients in cardiac arrest. When there are no signs of life, think of
CAB.
Circulation first
Does the patient have a pulse?
• The duration of a carotid pulse check must take less than 10 seconds!
If there is no pulse, or you are uncertain then start with CPR!

Airway / Breathing second

Is respiratory effort present?
• Observe for signs of breathing during pulse check.
Patients in an arrest may have agonal respiration or gasping.

If normal breathing is present, check the pulse again—it´s not a cardiac arrest!

Central versus Peripheral Intravenous Access

 
Central line access is not needed in most patients. Before considering a central line, one
should attempt to insert a large peripheral venous catheter for the infusion of drugs. The
establishment of a central line usually requires the interruption of cardiopulmonary
resuscitation, which explains why a peripheral venous line is favorable to a central line in the
case of cardiac arrest. A central line refers to the introduction of a flexible tube into the large
vessels that drain directly into the heart. This allows infusion of large amounts of supplements
and electrolytes but also posses a great danger to the easy introduction of infection to the
body.

Cardiac Arrest Rhythms

Ventricular fibrillation/tachycardia

Disorganized or deranged electrical

activity originating in the ventricles.

Pulseless electrical activity

Absence of clinical perfusion despite the

presence of organized electrical activity in
the heart.

Asystole
Absence of electrical activity in the
heart.

Ventricular fibrillation/tachycardia
• Usually caused by primary cardiac disease, most commonly ischemia.
• Can also be caused by structural heart disease or channelopathies.
• Less commonly caused by systemic conditions (electrolyte disturbances, toxins,
autoimmunity).
Ventricular fibrillation is randomly fluctuating, has no pattern and no QRS complexes.
Also, there is no mechanical contraction, which means no pulse. It is incompatible with life.
Ventricular tachycardia has a rapid rate (> 100 by definition, usually > 150), wide, bizarre QRS
complexes but organized and regular. It may be pulseless, stable or unstable.

 
Algorithm
Ventricular fibrillation/tachycardia algorithm

Pulseless electrical activity

Note: Electrical activity on the monitor + no pulse on exam = PEA
Mechanisms of PEA

“Empty heart”
Electrical conduction in the heart is normal.
Contraction occurs but is ineffective because the heart does not fill.
Caused by hypovolemia or extracardiac obstruction to filling (e.g., tamponade, tension
pneumothorax, etc.)

Electromechanical dissociation
Electrical conduction in the heart is normal. Action potentials yield little or no cardiac myocyte
contraction. Causes by systemic derangements that impair energy metabolism or directly
impair myocyte function in the heart.

Asystole

• Management is the same as PEA: CPR, epinephrine, search for and treat the
cause.
• Differential diagnosis is also the same as PEA.
• Pay particular attention to oxygenation and ventilation.
• Verify asystole in at least two leads.

 
 • Note:Asystole is more commonly a confirmation of death rather than a disease
to be treated. Terminate resuscitation when appropriate.
•
Management of Pulseless Cardiac Arrest

The management of the four arrest rhythms share a common first step which
involves the following points:

• Adequately checking for a pulse in the carotid or other major arteries

• Initiation of the basic life support algorithm, call for help and starting
cardiopulmonary resuscitation
• Administration of oxygen
• Attachment of a cardiac rhythm monitor and preparation of the defibrillator

The second step in the management of pulseless cardiac arrest is to check for a
shockable arrest rhythm. The shockable rhythms include ventricular tachycardia,
whereas, the not shockable rhythms are asystole and pulseless electrical activity.

If a shockable rhythm is identified, the following points should be taken into

consideration as the next step in the management:

 Step    1  shock  by  the  defibrillator  with  manual  biphasic  200  J,  or  monophasic  360  J.
1

 Step    Resume  cardiopulmonary  resuscitation  immediately

2

 Step   •  Five  cycles  of  cardiopulmonary  resuscitation  should  be  given  

3 • Check  again  for  a  pulse  and  for  a  shockable  rhythm.

 Step   • The  patient  is  still  in  cardiac  arrest  and  has  a  shockable  rhythm,  another  
4 shock  should  be  given  
• Resume  cardiopulmonary  resuscitation

 Step   •  Intravenous  access  line  is  available:    vasopressor  should  be  administered  
5 during  the  cardiopulmonary  resuscitation  

 
 • Epinephrine  1  mg  IV  and  repeat  every  3  to  5  minutes  or  1  dose  of  
vasopressin  40  U  IV  in  place  of  the  first  or  second  dose  of  epinephrine.

 Step   • 5  cycles  of  cardiopulmonary  resuscitation  should  be  given  

6 • The  patient  is  still  in  a  shockable  cardiac  arrest  rhythm:  amiodarone  or  
lidocaine,  magnesium  might  be  considered.

 Step      If  still  in  a  shockable  rhythm,  repeat  this  algorithm.

7

If the patient has a non-shockable rhythm or changes from a shockable

rhythm to a not shockable rhythm, the following approach is recommended:

• Resume cardiopulmonary resuscitation immediately for 5 cycles and

administer epinephrine or vasopressin.
• Consider atropine 1 mg IV for asystole or slow pulseless electrical activity rate
and repeat up to 3 doses.
• If at any moment the patient converts to a shockable rhythm, the shockable
rhythm algorithm should be followed.
Once the patient gets a pulse, one should start post-resuscitation care.

During cardiopulmonary resuscitation, the following should be taken into

consideration:

The chest compressions should be hard and fast, compressing more than a third of
the anteroposterior width of the chest and up to 100
compressions per minute. The goal of chest
compression is to take up the function of the heart in
pumping blood all over the body and thus ensure full
chest recoil between each compression to allow for
venous return. Minimize the interruptions in chest
compressions. Chest compressions are more important
than breaths. A cycle of cardiopulmonary resuscitation

 
consists of 30 compressions then 2 breaths. Therefore, the duration of 5 cycles is
around 2 minutes.

While checking the rhythm after 5 cycles, one should secure the airway and confirm
the placement of an airway. Hyperventilation should be avoided. Once an advanced
airway is placed, do not interrupt compressions. Give continuous chest
compressions in addition to 8 to 10 breaths per minute and stop the compressions
every 2 minutes to check the rhythm. Those responsible for the administration of the
chest compressions should be rotated every 2 minutes to avoid fatigue.

The Hs and Ts that are known to be associated with cardiac arrest should be
searched for and treated during the cardiopulmonary resuscitation of the patient.

They can be summarized in the following: Hypoxia, Hypovolemia, Hydrogen ion

excess or acidosis, Hypo or hyperkalemia, Hypoglycemia, Hypothermia, Toxins,
Tamponade, Tension pneumothorax, Thrombosis of coronary or pulmonary arteries
and Trauma.

Other causes of cardiac arrest may include:

• Cardiac causes such as coronary heart disease, congenital heart diseases,
cardiomyopathies, and valvular heart diseases.
• Other causes such as electrocution and excessive hemorrhage.
When Should Resuscitative Efforts Stop?
This question is not an easy one. If the patient has clearly expressed his or her decision to not
perform cardiopulmonary resuscitation, and the patient was considered as mentally competent
at the time of that decision, then this should be respected.
Moreover, to think of the duration of cardiopulmonary and advanced cardiac life support as the
main factor in stopping resuscitative efforts is not recommended. One should use clinical
judgment, in addition to respect for human dignity when making the decision of stopping
resuscitative efforts.
Another important point to emphasize here is that if advanced cardiac life support was
administered following the previously mentioned algorithms in the field of cardiac arrest, and
the patient did not recover or develop a pulse, it might be futile to transfer the patient to the
emergency department. In other words, the patient will not get any added benefit from a
referral to the emergency department and he can be announced dead at the field.
Interventions that are not Supported by Evidence in the Management of Cardiac Arrest
Some common treatments for cardiac arrest should be abandoned because they are not based

 
on good evidence like pacing during asystole. It is not beneficial and should not be performed
routinely in patients with asystole. Also, the use of procainamide in ventricular fibrillation and
pulseless ventricular tachycardia is supported by a single retrospective study of 20 patients.
Therefore, it is still not recommended in the advanced cardiac life support algorithm.
Norepinephrine use in the management of cardiac arrest should be discouraged for two
reasons:
• It has no benefits
• It has been associated with an increased risk of neurological deficits post-resuscitation

Precordial Thump for ventricular fibrillation and ventricular tachycardia might be either not
beneficial, or according to some case studies harmful to the patient. It might convert a
ventricular tachycardia to ventricular fibrillation.
Moreover, it can cause rib fractures.

Adult bradycardia with a Pulse algorithm

1. Assess clinical condition. Perform an
assessment for a clinical condition. A heart
rate less than 50 beats per minute is more
likely to be symptomatic.
2. Identify and treat underlying
cause. Maintain the airway and give the
patient oxygen if indicated. Place the patient
on cardiac monitors to identify the rhythm
and monitor blood pressure and oxygen
saturation. Next, obtain a 12-lead ECG and
establish IV access.It’s important to
determine whether the bradycardia is causing
the patient’s symptoms or if some other
illness is causing the bradycardia. Treat any
underlying cause.
3. Is persistent bradyarrhythmia causing
symptoms? Decide if the persistent
bradyarrhythmia is causing signs or
symptoms due to poor perfusion, such as
hypotension, an altered mental state, shock, chest discomfort, or acute heart failure.
4. No. Monitor and observe. If the patient has adequate perfusion, monitor and observe.
5. Yes. Administer drug treatment. If the patient has poor perfusion, administer .5 milligrams
of atropine through the IV every 3 to 5 minutes until a maximum of 3 milligrams have been
given. If the atropine is ineffective, implement transcutaneous pacing or administer a
dopamine infusion of 2 to 20 micrograms per kilogram per minute or an epinephrine
infusion of 2 to 10 micrograms per minute. Titrate to the patient’s response.

 
 6. Other considerations. Consult an expert for further diagnosis and treatment, and consider
transvenous pacing.

ACLS Tachycardia Algorithm

The ACLS Tachycardia Algorithm is used

for patients who have marked tachycardia,
usually greater than 150 beats per minute,
and a palpable pulse.
Some patients may have cardiovascular
instability with tachycardia at heart rate less
than 150 bpm. It is important to consider
the clinical context when treating adult
tachycardia.
If a pulse cannot be felt after palpating for
up to 10 seconds, move immediately to the
ACLS Cardiac Arrest VTach and VFib
Algorithm to provide treatment for pulseless
ventricular tachycardia.

The immediate response to an adult patient

with tachycardia and a palpable pulse is:
• To maintain an open airway
• Assist breathing if necessary
• Apply monitors to assess cardiac rhythm, blood pressure, blood oxygenation
• Provide supplement oxygen to maintain O2 saturation between 94% and 99%
The main assessment in adult patients with tachycardia is to determine whether the patient is
stable or not. Signs of cardiovascular instability are hypotension, signs of shock or acute heart
failure (flash pulmonary edema, jugular venous distention), altered mental status, or ischemic
chest pain.
Unstable patients with tachycardia should be treated with synchronized cardioversion as soon
as possible.

Cardioversion Rules
QRS narrow and regular 50-100 Joules
QRS narrow and irregular 120-200 Joules
QRS wide and regular 100 Joules
QRS wide and irregular Turn off the synchronized mode and
defibrillate immediately

 
Stable patients with tachycardia with a palpable pulse can be treated with more conservative
measures first.
• Attempt vagal maneuvers
• If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush
• If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline flush
• Beta-blockers and calcium channel blockers may be considered for narrow QRS tachycardia
(QRS <0.12 sec)
• For stable, wide QRS complex tachycardia (QRS ≥0.12 sec)
• Strongly consider expert consultation
• Consider procainamide 20-50 mg/min IV, OR
• Amiodarone 150 mg IV over 10 minutes, OR
Sotalol 100 mg (1.5 mg/kg) over 5 minutes

Hypoglycemia also called low blood glucose or low blood sugar, occurs when the level of glucose
in your blood drops below normal.

Reading assignment Basic electrophysiology Chapters 3. 2nd edition AACN Essentials of Critical
Care Nursing by Marianne Chulay and Suzanne M. Burns

Study Questions

• Choose 1 algorithm and make a scenario and apply the concept of ACLS.

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