Advanced Cardiac

Life Support
Dr. S.K. Ng
Consultant Anaesthetist,
Department of Anaesthesia & Intensive Care,
Prince of Wales Hospital.
Scope of ACLS
 Basic life support
 ECG monitoring, interpretation and
arrhythmia recognition
 Advanced equipment and
techniques for ventilation and
circulation
 Therapies for respiratory or cardiac
arrests
 Treatment of acute coronary
syndromes
 Treatment with tPA for eligible
stroke patients
Scope of ACLS
 Basic life support
 ECG monitoring, interpretation and
arrhythmia recognition
 Advanced equipment and
techniques for ventilation and
circulation
 Therapies for respiratory or cardiac
arrests
 Treatment of acute coronary
syndromes
 Treatment with tPA for eligible
stroke patients
International Guidelines 2000
Conference on Cardio-pulmonary
Resuscitation and Emergency
Cardiovascular Care
 International
 AHA, ERC, HSFC,
RCSA, ARC, CLAR
 Evidence-based
 Updated recom-
mendations by:
 AHA: 1974, 1980,
1986, 1992
 ERC: 1992, 1996,
1998
The 3 Unequivocally
Effective Interventions
 Basic cardiopulmonary
resuscitation
 Oxygenation and ventilation of
the lungs through a patent
secure airway
 Defibrillation for ventricular
fibrillation or pulseless
ventricular tachycardia
 Advanced Equipment &
Techniques for Ventilation
& Circulation
Airway Adjuncts
 Oropharyngeal airways
 Nasopharyngeal airways
 Laryngeal mask airway
64-100% success
 Combitube
69-100% success
 Cuffed oropharyngeal
airways (COPA)
 Suction devices
Combitube
Endotracheal Intubation
 Optimal airway
 Secure and clear airway
 Protect airway
 No gastric inflation
 Drug
 Bronchial toilet
 Need 3 minutes of preoxygenation
 Ventilation should not be
interrupted for > 30 seconds
 Cricoid pressure
 Use of stylet or gum elastic bougie
 Confirm and secure tube position
Breathing
 FiO2 of 1.0
 Manual resuscitators or
ventilators
 12-15 breaths/minute
 Tidal Volume
10-12 ml/kg, if intubated
6-7 ml/kg, if not unintubated
Circulation
 Closed chest compression at
100/minute
 Open chest CPR should be
restricted to operating theatre
and selected instances of
penetrating thoracic injury
Specific Drug Therapy
Meticulous, systematic review
reveals that relevant, valid,
and credible evidence to
confirm a benefit due to these
agents simply does NOT exist.
Routes of Drug
Administration
 Peripheral veins
 Central veins
 Tracheal
 Intraosseous
 Intracardiac
Peripheral Venous Route
 Peak effect 1.5-3 min. after
injection at antecubital fossa
 IV push
20 ml NS flush after drug
injection
 circulation time by 40%
Comparable to drug delivery
through a central vein
Central Venous Route
 Faster, higher peak concentration
and more potent effect compared
to peripheral injection
 Should be used if it is already in
situ
 Inserting a central line is
associated with problems of
interrupting CPR, bleeding
arterial puncture and air
embolism
Tracheal Route
 Second line route due to impaired
absorption and unpredictable
pharmacodynamics
 Need 2-3 times the IV dose, diluted
to at least 10 ml in 0.9% NS
 Non-ionic drugs only:
 adrenalin, atropine, lignocaine and
naloxone
 NEVER calcium or sodium
bicarbonate
Intracardiac Route
 NOT recommended
 May produce pneumothorax,
injury to a coronary artery and
prolonged interruption of
cardiac massage.
 Inadvertent injection into the
myocardium may produce
intractable arrhythmias
Drugs for Resuscitation
 Vasopressors
Adrenaline
Vasopressin
 Other Agents
Atropine
Buffer agents
Calcium
Adrenaline
 Adrenaline 1 mg (10 ml of 1:10,000
dilution) IV boluses every three
minutes until pulse returns
 Short half life of 3-5 minutes
 -effect (vasoconstriction)
  aortic pressure to maintain
myocardial and cerebral blood flow
 Cautions: solvent abuse, cocaine
and other sympathomimetic drugs
Vasopressin
 40 U IV: powerful vasoconstriction
 V1 receptors in smooth muscle
 Longer half-life of 10-20 minutes
 If there is no response 10-20 min.
after 40 U of IV vasopressin, resume
epinephrine 1 mg IV push every
3 to 5 minutes
 Used in VF/VT
 ? role in asystole or PEA
Antiarrhythmic Drugs
Drug Fibrillation Defibrillation Proarrhythmo
threshold threshold -genicity
Quinidine ++ +++ +
Procainamide ++ 0 +
Flecainide ++ +++ +
Lignocaine ++ + +
Bretylium ++ - +
Amiodarone ++ - 0/+
Verapamil + ++ 0
Diltiazem + ++ 0
Nifedipine + 0 0
Adrenergic - 0 +
agents
Beta-blockers ++ + 0
Sotolol + - +
Antiarrhythmic Drugs
Drug Fibrillation Defibrillation Proarrhythmo
threshold threshold -genicity
Quinidine ++ +++ +
Procainamide ++ 0 +
Flecainide ++ +++ +
Lignocaine ++ + +
Bretylium ++ - +
Amiodarone ++ - 0/+
Verapamil + ++ 0
Diltiazem + ++ 0
Nifedipine + 0 0
Adrenergic - 0 +
agents
Beta-blockers ++ + 0
Sotolol + - +
Drugs for Persistent VF
 Amiodarone
 Class IIb
 Rapid infusion of 300 mg in 20-30 ml
NS IV push (cardiac arrest dose)
 If VF/pulseless VT recurs,
Supplementary doses of 150 mg IV
by rapid infusion
Followed by 1 mg/min for 6 hours
and then 0.5 mg/min
Maximum daily dose of 2 g
 Lignocaine
 Class indeterminate
 Initial bolus of 1.0-1.5 mg/kg
 Additional bolus of 0.5-0.75 mg/kg
 Maximum total of 3 mg/kg
 Maintenance infusion of 1-4 mg/min
 Magnesium sulphate
 1-2 g diluted in 100 ml D5 over
1-2 minutes
 Class IIb in torsades de pointes or
suspected hypomagnesaemia or severe
refractory VF
Atropine
 Good for haemodynamically
significant bradycardia from
high vagal tone, hypoxia or
nodal ischaemia
 ? For asystole or PEA
 1 mg up to 3 doses or single
dose of 3 mg will produce a
fully vagolytic effect
Buffer Agents
 8.4% sodium bicarbonate solution
 Initial dose of 1 mEq/kg
 Problems
 Left shift of Hb dissociation curve
 Paradoxical intracerebral acidosis
 High osmolality and Na load
 Inactivate simultaneously
administered catecholamines
Indications of NaHCO3
 Class I
 Preexisting hyperkalemia
 Pexisting bicarbonate-responsive
acidosis
 Alkaline diuresis; overdose of tricyclic
antidepressant, aspirin, etc.
 Class IIb
 Long arrest interval
 In intubated and ventilated patients
 On return of circulation
 Class III
 Hypercarbic acidosis
Calcium
 Only used in hypocalcaemia,
hyperkalaemia and calcium
antagonist overdose
 10% CaCl2 at 2-4 mg/kg repeated as
necessary at 10-minute intervals
 Worries regarding the role of Ca++ in
ischaemic cell damage during
reperfusion to the heart and the
brain
Universal
Advanced
Life
Support
Algorithm
The Universal Advanced
Life Support Algorithm
 Two arrest rhythms
VF/Pulseless VT
Ventricular fibrillation
Pulseless ventricular
tachycardia
Non-VF/VT
Pulseless electrical activity
Asystole
VF / Pulseless VT
 VF: commonest primary arrest
rhythm
 VF/VT: 85% to 95% of the
survivors from cardiac arrest
 Pulseless VT deteriorates rapidly
to VF and treatment is identical to
that of VF
Management of
VF / Pulseless VT
 Electrical defibrillation is the
most effective treatment for VF
 CPR unlikely to convert VF
 Speed of defibrillation is the
major determinant of success
of VF treatment
Survival rates after VF arrest
 7-10 %/min
 In-hospital
Cardiac Arrest
VF/VT EMD/Asystole
Number 422 (32%) 903 (68%)

ROSC 298 (71%) 344 (38%)

Survive 179 (42%) 58 (6%)

discharge

• 1325 Resuscitation attempts using 1997 Guidelines

• Updated from: Gwinnutt C et al. Resuscitation 1998; 37: S64
Cardiac Arrest Time
before Defibrillation

Yakaitis et al. Crit Care Med 1982;8:157-163.

Principles of
Defibrillation
 Electric shock will terminate
ventricular fibrillation by
transmural current flow
 Entire myocardium is
depolarised into refractoriness.
The SA node, as the fastest
pacemaker, may resume
pacing function
Safe Defibrillation
 To avoid accidental shocks to
rescuer and patient injury
 Safe environment, away from
pooled water or metal surface under
patient or rescuer
 Apply conductive material
 Turn on defibrillator, select energy
and charge defibrillator
 Proper electrode placement
 Apply firm pressure on electrodes
 Make sure no smearing of
conductive gel
 Remove transdermal patches
 Keep paddles >12 cm away from
implanted cardiac pacemakers
 Make sure no personnel are directly
in contact with the patient, clearing
chant
 Ensure VF or pulseless VT
 Depress both discharge buttons
simultaneously and deliver the
electric shock
Defibrillation Energy
 Balance between electrical
injury and efficiency of
defibrillation
 Damage related to the peak
current, not the energy
delivered
Defibrillation Energy

Weaver et al. N Engl J Med 1982;307:1101

Morbidity & Mortality

Dahl et al. Circulation 50:956.

Ehsani et al. Am J Cardiol 37:12.
Warner et al. Arch Pathol 99:55.
Defibrillation Energy
 Adults
 200J 200/300J 360J  360J
thereafter (monophasic)
 Non-escalating 150J (biphasic)
 Children
 2J/kg  2-4J/kg 4J/kg 4J/kg
thereafter
Some Determinants of
Defibrillation Dose
 Chest impedance
 Electrode size and location
 Type of waveform
 Disease, drugs, metabolic state
of the subject
Transthoracic
Impedance
Energy (joules)
Current 
Resistance (ohms) * Duration(sec)

 70-80 (range 15-143)

  impedance   current
 Current-based defibrillation
30-40A MDS
Factors Reducing
Transthoracic Impedance
 Appropriate electrode size
 Coupling medium between
electrodes and chest wall
 Repeated shocks
 Expiratory phase of respiration
 Electrode-chest wall contact
pressure (>10 kg)
 Post-cardiac surgery
Electrode Size
  diameter of electrode
  impedance and  defibrillation
threshold
 In animals:
8 cm : 71% defib success
12.8 cm : 88% defib success
 Very large electrodes
  impedance, but…
  in current density 
 defibrillation success
 Inadequate contact with chest wall
Coupling Medium
 Electrode paste (e.g. Redux paste)
 Electrode paste resulted in
significantly lower impedance than
the disposable defibrillation pads. No
difference in defibrillation success.
 Beware of paste spread across the
chest wall during CPR
 Disposable coupling pads
(e.g. Defib-Pads)
 Adhesive pads
Self-adhesive pads
 Advantages
 Prophylactic placement in high risk
patients
 Less interference with external
cardiac massage
 Incorrect coupling gel avoided
 Better operator safety
 Disadvantages
 Special connection
 Lack of firm pressure
 High impedance
 Hairy skin
Electrode Position
 Proper polarity facilitates ECG
interpretation. It does not
affect success of defibrillation
 Three acceptable positions
Sternal-apical
Left-anterior-posterior
Apical –posterior
Sternal-apical
 Below the outer right clavicle
 Cardiac apex
Left-anterior-posterior
 Anterior apex just left of
palpable cardiac apex
 Back inferior to the left scapula
Apical–posterior
 Left ventricular apex
 Back inferior to the left scapula
If VF Persists:
 Secure airway, ventilatory and
circulatory support, IV access
 Appropriate medications to maintain
myocardial and cerebral viability
 Detect and treat potentially
reversible underlying causes
 Resume defibrillation attempts
 After each minute of CPR, or after
each medication
 The best prospects for restoring a
perfusing rhythm still remain with
defibrillation
 Defibrillation vs.
Cardioversion
Defibrillation  Electric shock delivered
without synchronization
with ECG activity
 Used in VF or pulseless VT

Synchronized  Electric shock delivered

with synchronization with
Cardio- R wave to avoid the R on
version T phenomenon
 Used in unstable
tachyarrhytmias other
than VF or pulseless VT
 Non-
VF/VT
Rhythms
Universal
Advanced
Life Support
Algorithm
Non-VF/VT Rhythms
 Defibrillation is NOT indicated
 Prognosis much poorer than VF/VT
 Secure basic life support, airway,
oxygen, ventilation, IV access
 Detect and treat potentially
reversible conditions
 Consider:
 Atropine: 3 mg bolus given once or
1 mg bolus to a maximum of 3 mg
 Pacing if P waves are present
Pulseless
Electrical Activity (PEA)
 Absence or undetectable mechanical
activity in the presence of
coordinated electrical activity
 Includes
 Pseudo-EMD
 Idioventricular rhythms
 Ventricular escape rhythms
 Postdefibrillation idioventricular
rhythms
 Bradyasystolic rhythms
 Rhythm of survival if a reversible
cause of PEA is identified and
treated appropriately
Possible Underlying
Reversible Causes
H’s T’s
 Hypovolemia  Toxins/tablets
 Hypoxia (drug overdose)
 Hydrogen ion  Tamponade,
(acidosis) cardiac
 Hyperkalemia/  Tension
hypokalemia/ pneumothorax
metabolic  Thrombosis,
disorders coronary
 Hypothermia/  Thrombosis,
hyperthermia pulmonary
Asystole
 Primary rhythm in up to 25%
inhospital arrests
 Most commonly seen in outpatients
with VF who have not been
resuscitated successfully
 Low survival rate 1-2 out of 100
cardiac arrests
 Identify and treat a reversible cause
 Consider “not starting” and “when
to stop”
Post-resuscitation Care
 CNS is most vulnerable for
ischaemic-hypoxic damage during
cardiac arrest
 ICU or CCU admission
 Avoid and correct hypotension,
hypoxia, hypercarbia, electrolyte
imbalance, hypoglycaemia and
hyperglycaemia
 Control convulsions with
anticonvulsants
 No drugs have been demonstrated
to reduce cerebral complications
In Summary
 Perform CPR at all times for
pulseless patients
 Defibrillate VF/VT until it is no
longer present
 Gain airway control and
provide adequate oxygenation
and ventilation
 Give IV boluses of epinephrine
 Correct reversible causes
Universal
Advanced
Life
Support
Algorithm
Possible Underlying
Reversible Causes
H’s T’s
 Hypovolemia  Toxins/tablets
 Hypoxia (drug overdose)
 Hydrogen ion  Tamponade,
(acidosis) cardiac
 Hyperkalemia/  Tension
hypokalemia/ pneumothorax
metabolic  Thrombosis,
disorders coronary
 Hypothermia/  Thrombosis,
hyperthermia pulmonary
Reference
 Circulation. 2000; 102 (Suppl 1):I-1-
384.
 The 1998 European Resuscitation
Council guidelines for adult
advanced life support. BMJ: 1998;
316:1863-1869.
 ILCOR advisory statement.
Circulation. 1997;95(8):2172-2210.
 BJA, 1997; 79:149-213.
(Postgraduate educational issue,
resuscitation)