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 device

• 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 Airways

• Esophageal –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 Intubation

• Drugs thru ETT • Male adult size 8.0-

– Naloxone 8.5 mm ID
– Atropine • Female adult size 7.0-
– Vasopressin 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, Subclavian
external jugular femoral ,
– Circulation time Supraclavicular
increased – Rapid arrival of drug
– Easier to learn , few at site of action
complications – Increase risk of
– No interruption CPR 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