Advance Cardiac Life

Support
an overview
Roderick T. Vito M.D.
Department of Emergency Medicine
ACLS

• Basic Life Support

• Use of Adjunctive equipment and
Techniques in maintaining effective
ventilation and circulation
• Electrocardiographic monitoring and
arrhythmia recognition
• Establishment and maintenance of IV
fluids
• Post-Arrest stabilization
• Treatment of patients with suspected MI
Airway Adjuncts and
Ventilation
• Maintain oxygenation and elimination of
Carbon dioxide
• Not as important as chest compression in
SCA
• Exceptions are prolonged VF in SCA and
asphyxial arrest
Oxygen
• Not established the optimal oxygen
concentration during CPR
• Empirical use of 100% Oxygen optimized
oxyhemoglobin content -> oxygen delivery
• Hypoxemia leads to anaerobic metabolism may
blunt benefits of chemical and electrical therapy
• Underlying respiratory disease, low cardiac
output, intrapulmonary shunting and
Ventilation-perfusion mismatch
• Rescue breathing uses exhaled air at 16-17%
oxygen
Ventilation

• Masks :
• Tight fitting
transparent
• one way-valve:
diverts patients
exhaled gas
Ventilatory devices

• Bag-Valve Devices
• Self Inflating bag, non-
rebreathing valve
maybe used with a ET
or mask
• 2 operators to be
effective
• 1-2 L of O2 bag
capacity  deliver
600ml of O2.
Airway Adjuncts
• Oropharyngeal and
Nasopharyngeal
airways
• Patients not intubated
• Oral Airways are for
unconscious patients
• Nasal Airways are for
patients with trismus
and biting
Advance airways

• Risk and benefits in the insertion of

advance airways
• Minimal interruption of cardiac
compression should be observed
dependent on the skills of the operator
Supraglottic airway

• Maintain open airway and facilitate

ventilation
• No need to visualize glottic area when
inserting tube
• Does not interrupt compression during
insertion
 Supraglottic
• Esophageal Airways
–Tracheal Combitube
• Isolates the airway
• Low risk of aspiration
• Easy to use
• Disad: identify
incorrectly the trachea
and esophagus
• Laryngeal mask
airway:
• more secure and
reliable than BVM
• LMA equavalent
ventilation than ET.
• LMA not require
larygonscopy and
visualization of vocal
cords
Endotracheal Intubation

• A Skilled operator will insert a tube thru oral

or nasal approach which would enter the
trachea providing oxygenation to the lungs
• Isolates the airway, keeping it patent, reduce
risk of aspiration, provides conduit for
suctioning secretions, delivers high
concentration of oxygen, provides route for
drug administration and ensures delivery of
selected tidal lung volume to maintain lung
inflation
Endotracheal tube with
stylet
 “Epiglottoscopy”

• Blade inserted with • Tip of blade gets • With full insertion of

laryngoscope handle around base of curved blade into
pointed at the tongue, permitting vallecula the angle of
patient’s feet. change in angle of lifting changes to
• Tongue and jaw are lifting and better ~40 degrees from
distracted downward mechanical the horizontal.
to insert the blade. advantage. • Now the lifting force
• Minimal force • Epiglottis edge lifted can be increased as
required off pharyngeal wall. needed.
(Epiglottis often • Tip position (not
camouflaged against force) is the main
mucosa of posterior determinant of glottic
Lifting the Scope
 Inserting Laryngoscope

Macintosh Blade in Vallecula Miller Blade Under

Epiglottis
Inserting Endotracheal Tube

Yes,
good

No, bad
Endotracheal Intubation

• Drugs thru ETT • Male adult size 8.0-

• Naloxone 8.5 mm ID
• Atropine • Female adult size
• Vasopressin 7.0-7.5 mm ID
• Epinephrine • Pediatric patients
• Lidocaine • <6 yo age/3 + 3.5
• > 6yo age /4 + 4.5
Continous waveform
capnography
• Most reliable method
of confirming and
determining ET
placement
Confirm ET tube placement

• Assessment by physical examination

• Five point auscultation
• Use of Devices
• Waveform capnography
• Exhaled CO2 detectors
• Esophageal Detector Device
Postintubation care

• Record the depth

of the ET
• Secure the ET
using tapes
• Chest X-Ray for
confirm position
Electrical Therapies

• Early defibrillation is critical to survival

from sudden cardiac arrest
• Survival rates decreases by 7-10% for
every minute delay in defibrillation without
CPR
• Survival rates decreases by 3-4% for
every minute delay in defibrillation with
CPR
Arrhythmia Recognition
Arrhythmia Recognition

• Four Arrest Rhythms :

• Ventricular Fibrillation
• Ventricular Tachycardia
• Pulseless Electrical Activity
• Asystole
Automated External
Defibrillators (AED)
• Devices that safely defibrillate
• Automated rhythm analysis
• Lay rescuer AED program
• AED use in children
• In hospital use of AED
Defibrillation

• Shock first vs. CPR

first
• 1 shock protocol vs. 3
shock sequence
• Transthoracic
impedance
 Intravenous Access
• Peripheral • Central
• Antecubital or • Jugular,
external jugular Subclavian
• Circulation time femoral ,
increased Supraclavicular
• Easier to learn , • Rapid arrival of
few complications drug at site of
• No interruption action
CPR • Increase risk of
complications :
subcutaneous
emphysema,
pneumothorax
Intraoseous Access

• Venous access is not achieved

• Gauge 20 spinal or bone marrow needle or
Jamshidi needle inserted at the proximal
tibia below the tuberosity or at the distal
femur
• Pediatric patients
• Same amount as in IV infusion
• Complications : osteomyelitis
Intravenous Fluids

• Adults :
• Volume Expanders : Fresh Whole Blood,
Crystalloid solutions, Colloid Solutions
• Plain NSS or LR preferred for CPR
• Volume administration is not
recommended in routine cardiac arrest
without indication of volume depletion
• Hyperglycemia has worse neurologic
outcome
• Sodium overload is rare
Intravenous Fluid

• Pediatrics :
• Avoid giving large glucose volume may
cause osmotic diuresis potential poor
neurologic outcome
• Volume Expanders : Crystalloid ,
colloid solutions
• Blood : severe acute hemorrhage
Intravenous Fluids

• Neonates:
• Volume expanders is indicated when there
is evidence or suspicion of acute blood loss
with poor response to resuscitation
• Dose 10 ml / kg
• Plain NSS or PLR
• 5% Albumin Saline or Plasma substitute
• “O” negative blood crossmatched with
mothers blood
Medications

• Control of Heart Rhythm and Rate:

• Lidocaine
• Amiodarone
• Adenosine
• Beta-Blockers
• Procainamide
• Atropine
• Verapamil/ Diltiazem
Medications

• Improved Cardiac Output and Blood

Pressure
• Epinephrine
• Norepinephrine
• Dopamine
• Dobutamine
• Sodium Nitroprusside
• Nitroglycerine
• Digitalis
• Diuretics
Medications

• Myocardial Infarction
• Morphine SO4
• Oxygen
• Nitroglycerine
• Aspirin
• Thrombolytic agents : Streptokinase, r-
TPA, Heparin
• Glycoprotein IIb/IIIa inhibitors
• Beta Blockers
 Post cardiac arrest care
• Insertion of an NGT 
decompress the stomach of
air due BVM ventilation
• Insertion of foley catheter
measure urine output
• Take a 12 lead ECG
• Do portable chest radiographs
• Therapeutic hypothermia
• Antibiotics
• Nutrition
Thank
You