ADVANCED CARDIAC LIFE SUPPORT
Advanced cardiac life support or advanced cardiovascular life support
(ACLS) refers to a set of clinical interventions for the urgent
treatment of cardiac arrest and other life-threatening medical
emergencies, as well as the knowledge and skills to deploy those
ACLS is a series of evidence based responses simple enough to be
committed to memory and recall under moments of stress.
AMERICAN HEART ASSOCIATION (AHA) protocols are considered
to be the GOLD standard ACLS protocols
It gets reviewed every 5 year, now latest advancements in
Positioning for CPR:
CPR is most easily and effectively performed by laying the patient supine
on a relatively hard surface, which allows effective compression of the
Delivery of CPR on a mattress or other soft material is generally less
The person giving compressions should be positioned high enough above
the patient to achieve sufficient leverage, so that he or she can use body
weight to adequately compress the chest.
Remember to spell C-A-B
Compressions: Restore blood circulation
1. Place the heel of one hand over the center of the person's chest,
between the nipples. Place other hand on top of the first hand. Keep
elbows straight and position shoulders directly above hands.
2. Use upper body weight (not just arms) as pushing straight down on
(compress) the chest
In adult victims of cardiac arrest, it is reasonable for rescuers to
perform chest compressions at a rate of 100 to 120/min.
During manual CPR, rescuers should perform chest compressions to a
depth of at least 2 inches (5 cm) for an average adult, while avoiding
excessive chest compression depths (greater than 2.4 inches [6 cm])
It is reasonable for rescuers to avoid leaning on the chest between
compressions, to allow full chest wall recoil for adults in cardiac arrest.
If not trained in CPR, continue chest compressions until there are signs
of movement or until emergency medical personnel take over.
Airway: Open the airway
Some signs of obstructed airway include poor air exchange, high pitch
noise while breathing and inability to speak.
If rescuer trained in CPR and performed 30 chest compressions, open the
person's airway using the head-tilt, chin-lift maneuver. Put palm on the
person's forehead and gently tilt the head back. Then with the other hand,
gently lift the chin forward to open the airway.
Breathing: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose
breathing if the mouth is seriously injured or can't be opened.
With the airway open (using the head-tilt, chin-lift maneuver), pinch
the nostrils shut for mouth-to-mouth breathing and cover the person's
mouth with yours, making a seal.
Prepare to give two rescue breaths. Give the first rescue breath
It may be reasonable for the provider to deliver 1 breath every 6
seconds (10 breaths per minute) while continuous chest compressions
are being performed (i.e., during CPR with an advanced airway).
The adequacy of breath given can be determined by observing for rise
in victims chest.
Continue CPR until there are signs of movement or emergency medical
personnel take over
The recovery position refers to one of a series of variations on
a lateral recumbent or three-quarters prone position of the body. If
a person is unconscious but is breathing and has no other life-
threatening conditions, they should be placed in the recovery
position. Putting someone in the recovery position will keep their
airway clear and open. It also ensures that any vomit or fluid won't
cause them to choke.
Before you begin
Immediately upon seeing the victim and Before starting CPR, check:
Is the environment safe for the person?
Is the person conscious or unconscious?
If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are
Check carotid pulse for 10 seconds.
If the person doesn't respond and two people are available, have one person call 108 or the
local emergency number and have the other person begin CPR.
If alone and have immediate access to a telephone, call 108 or local emergency number
before beginning CPR. Get the AED, if one is available.
As soon as an AED is available, deliver one shock if instructed by the device, then begin
Put the person on his or her back on a firm surface.
Kneel next to the person's neck and shoulders.
Biphasic wave form: 120- 200 J
Monophasic wave form: 360 J
AED- device specific
Failure of a single adequate shock to restore a pulse should be
followed by continued CPR and second shock delivered after five
cycles of CPR
HOW TO USE DEFIBRILLATOR
If patient not intubated remove o2 delivery devices
If intubated either leave bag valve resuscitator attached to
ET or remove it
If available use self adhesive defibrillation pads
Do not place over pacemakers
Remove transdermal patches.
Place sternal paddle over right of the sternum below clavicle
Place apical paddle in mid axillary line in 5th IC space
Switch on the defibrillator
Charge the defibrillator to 200J or 360J
Warn all other rescuers to stand clear- ‘ARE YOU CLEAR’
Visually check all are clear
Ensure yourself you are not touching patient or bed ‘I AM CLEAR’
Restart CPR with out checking pulse.
Automatic External Defibrillator (AED)
An automated external defibrillator (AED) is a portable electronic device
that automatically diagnoses the life-threatening cardiac arrhythmias of
ventricular fibrillation (VF) and pulseless ventricular tachycardia, and is
able to treat them through defibrillation Switch onAED.
Attach electrode pads.
Place electrodes as that of manual one
Follow voice commands
Make sure no one in contact with patient
Push shock button.
Routes of Administration
Peripheral IV – must followed by 20 ml NS push Central IV –
fast onset of action, but do not wait or waste time for CV line
Intraosseous – alternative IV route in peds, also in Adult
Intratracheally (down an ET tube)- not
recommended now a days
Can be toxic so no longer given prophylactically
IV dose :
1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min
Can be given down ET tube
Signs of toxicity:
slurred speech, seizures, altered consciousness
Used for refractory VF or VT caused by hypomagnesemia and Torsades de
1-2 grams over 2 minutes
• Beta blocker that may be useful for VF and VT that has not responded to other
Very useful for patients whose cardiac emergency was precipitated by
Alpha, beta-1, and beta-2 stimulation
Increases heart rate, stroke volume and blood pressure
1 mg every 3-5 minutes
May increase ischemia because of increased O2 demand by the heart
Slows conduction time through the A-V node, can interrupt the reentry
pathways through the A-V node
Potassium channel opener and hyperpolarization
6 mg rapid iv push, follow with NS flush..
Second dose 12 mg
Side effects:- Flushing of face, bronchospasm
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
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
Cardiopulmonary arrest is loss of airway, breathing, or
meaningful circulation. Cardiopulmonary resuscitation (CPR) is
the use of therapeutic interventions, primarily BLS that are
designed to restore spontaneous circulation following cardiac or