ACLS

(Advanced cardiac life support)

BLS ????

CHAIN OF SURVIVAL IN
BLS

SEQUENCE OF BLS
C
A
B
D

CIRCULATION
AIRWAY
BREATHING
DEFIBRILLATION

Effective chest
compressions
Start compressions within
10
seconds of recognition of
cardiac
arrest.
Push hard, push fast: Compress at
a rate of atleast 100/min with
depth of atleast 2inches (5cm).
Allow complete chest recoil after
each compression.
Minimize
interruptions
in

Highlights of 2010

Change from ABC to CAB

Ethical issues addressed
The BLS algorithm has been simplified,
Look, Listen and Feel has been removed
from the algorithm
AHA Guidelines for CPR and ECC stress
immediate activation of the emergency
response system and starting chest
compressions for any unresponsive adult
victim with no breathing or no normal
breathing (i.e., only gasps).

Contd
Encourage
Hands-Only
(compression only) CPR for the
untrained lay rescuer.
High-quality CPR
Healthcare provider training should
focus on building the team as each
member
arrives
or
quickly
delegating roles if multiple rescuers
are present.

DIFFERENCES BETWEEN ADULTS / CHILDREN / INFANTS

COMPONENT

ADULT
Lay rescuer
8yrs
HCP: Adolescent
& older

CHILD
INFANT
Lay rescuer :1- Under 1 yr of
8 yrs, HCP:
age
1yr-adolescent

RECOGNITION
UNRESPONSIVE (for all ages)
RESPONSIVENES
No Breathing
No breathing or only gasping
S
or no normal
BREATHING
breathing
CPR SEQUENCE

C-A-B SEQUENCE

COMPRESSION
RATE

AT LEAST 100 /min

COMPRESSION
DEPTH

At least 2
At least 1/3 AP dia
inches / 5cm AP dia
About 2 inches
inches
(5 cm)

At least 1/3
About 1.5
(4cm)

DIFFERENCES BETWEEN ADULTS / CHILDREN / INFANTS

COMPONENT

ADULT
Lay rescuer
8yrs
HCP: Adolescent
& older

CHILD
Lay rescuer :18 yrs
HCP: 1yradolescent

INFANT
Under 1 yr of
age

CHEST WALL
RECOIL

Allow complete recoil between compressions

HCPs rotate compressors every 2 minutes

COMPRESSION
INTERRUPTIONS

Minimize interruptions
Attempt to limit interruptions to 10seconds

AIRWAY

COMPRESSION
to VENTILATION
RATIO

HEAD TILT CHIN LIFT

(HCP In suspected trauma: Jaw Thrust)

30:2
1 or 2 rescuers

30:2 (Single Rescuer)

15:2 (Double Rescuer)

DIFFERENCES BETWEEN ADULTS / CHILDREN / INFANTS

COMPONENT

ADULT
Lay rescuer
8yrs
HCP: Adolescent
& older

CHILD
Lay rescuer :18 yrs
HCP: 1yradolescent

INFANT
Under 1 yr of
age

VENTILATIONS
WITH ADVANCED
AIRWAY (HCP)

1 Breath every 6-8 seconds

(8-10 breaths / min)
Asynchronous with Chest compressions
About 1 sec per breath
Visible Chest Rise

VENTILATIONS:
WHEN RESCUER
UNTRAINED

COMPRESSIONS ONLY

DEFIBRILLATION

Attach & use AED as soon as available

Minimize interruptions in chest compressions
before & after shock;
Resume CPR beginning with compressions after
each shock

RECOVERY POSITION

ACLS
(Advanced cardiac
life support)

ACLS
ACLS requires equipment and
particular skills.
It is designated
to provide
airway security, sophisticated
artificial
ventilation
and
circulatory
support
while
restoring
a
spontaneous
heartbeat and respiration.

ADULT
ACLS

Chain of survival

Integrated
post cardiac
arrest care
Postcardiac arrest
care has significant potential
to reduce early mortality caused by
hemodynamic instability and later morbidity and
mortality from multiorgan failure and brain injury

Organized Post cardiac

arrest care
Treatment
should
include
cardiopulmonary and neurological support
THERAPEUTIC
HYPOTHERMIA
&
PCI
(percutaneous intervention) should be
provided when indicated

Because seizures are common after

cardiac arrest an EEG for the diagnosis of
seizures should be performed with prompt
interpretation as soon as possible.

Post cardiac arrest

care
The health care team should
implement
a
comprehensive,
structured,
multidisciplinary
system of care in a consistent
manner for the treatment of postcardiac arrest patients.

It includes:
Therapeutic hypothermia
Hemodynamic and ventilation
optimization
Immediate coronary reperfusion
Glycemic control
Neurologic care
Prognostication

Therapeutic
hypothermia
AHA
recommends
cooling
comatose adult patient with ROSC
after cardiac arrest to

32o C to 34oC (89.6oF to

93.2oF)
for 12-24 hrs.

Hemodynamic and
ventilation
optimization
Provide 100% oxygen during the

initial resuscitation.
Then titrate the inspired oxygen
during post cardiac arrest care to the
lowest level required to achieve an
arterial oxygen saturation of 94%.
Ventilation rates should be started
from 10-12breaths/min and then
titrate to achieve a PET CO2 of 3540mm Hg or a PaCo2 of 40-45mm

New ACLS algorithm

Presented in the traditional boxand-line format and a new in

circular format.
Facilitate easy learning and
memorization of the treatment
recommendations
Simplified and redesigned to
emphasize the importance of
high-quality
CPR
that
is

Overview to the advanced

airway management
Optimal timing for an advanced airway placement is still
controversial.
Indication for an advanced airway in CPR is ONLY WHEN
VENTILATION WITH BAG MASK DEVICE IS
INADEQUATE .
If at all ,intubation is indicated..
GOAL SHOULD BE TO LIMIT INTERRUPTIONS TO
NO MORE THAN 10 SECONDS

The role of supraglottic devices

has been emphasized
Use is simpler
Can be inserted without interruptions in chest
compressions.
Regurgitation is less likely.
Aspiration is uncommon

Increased emphasis on physiological

monitoring to optimize CPR quality and
detect ROSC
Et CO2
Coronary perfusion pressure and arterial
pressure(intra arterial line)
Oxygen saturation levels

Continuous quantitative waveform

Capnography
Most reliable method of confirming and

monitoring
correct
placement
of
endotracheal tube following insertion
and during transport.

As a tool to monitor :

CPR quality
Optimize chest compressions
Detect ROSC

 Atropine
is now not
New Medication
recommended
for
Protocol
routine
use
in
the
management
of
PEA/Asystole.
Current evidence suggest
that they are unlikely to
have a therapeutic benefit

Multiple system approach to

Post cardiac arrest care

Maintain adequate oxygenation and

minimize FiO2
SpO2 94% and PaO2 100 mm Hg
Reduce FiO2 as tolerated
PaO2/FiO2 ratio to follow acute lung
injury

PULSE
OXIMETRY/ABG
CAPNOGRAPHY

Confirm secure airway and titrate

ventilation
Pet CO2 35-40 mm Hg
PaCO2 40-45 mmHg

CHEST X-RAY

Confirm secure airway and detect

causes or complications of
arrest :pneumonitis, pneumonia,
pulmonary edema

Ventilation

Minimize acute lung injury, potential

oxygen toxicity
TV-6-8 ml/kg
Titrate minute ventilation to PetCO2 35
40 mm Hg and Paco2 4045 mm Hg
Reduce Fio2 as tolerated to keep Spo2
or Sao2 94%

MECHANICA
L
VENTILATIO
N

Contd

Frequent Blood
Pressure
Monitoring/Arterial-line

Maintain perfusion and prevent

recurrent hypotension
Mean arterial pressure 65 mm
Hg or systolic blood pressure
90 mm Hg

Treat
hypotension

Maintain perfusion
Fluid bolus if tolerated
Dopamine 510 mcg/kg per min

Nor
epinephrine
0.10.5
mcg/kg/per min
Epinephrine 0.10.5 mcg/kg/min

Hemodynamics

 Detect global stunning, wall motion

abnormalities, structural problems and
cardiomyopathy
Aspirin/heparin
Transfer to acute coronary treatment center
Consider emergent PCI or fibrinolysis

To detect ACS/ST elevation

Myocardial infarction/assess QT
interval

Detect recurrent arrhythmias

Treat arrthymias as required and
remove reversible cause

Echocardiogra
m
Treat acute
coronary
syndrome
12 lead
)
ECG/Troponin
Continuous
cardiac
monitoring

Cardiovascular

Minimize brain injury and improve outcome

Prevent hyperpyrexia>37.7 c
Induce therapeutic hypothermia if no C/I
Cold IV fluid bolus 30 ml/kg if no C/I
Surface or endovascular cooling for 32C
34C24 hours

Rationale-exclude seizures
Anticonvulsants if seizing
Serial examinations define coma, brain injury
and prognosis
Response to verbal commands and physical
stimulation
Pupillary light and corneal reflex,
spontaneous eye movements
Gag ,cough, spontaneous breaths

EEG
monitoring
if
Core
comatosed
temperat
ure:
measure
ment if
comatose

Serial
neurolog
ical
exam

Neurological

 Detect acute kidney injury

Maintain euvolemia
Renal replacement therapy

Avoid hyperkalemia which promotes

arrhythmias
Replace to maintain K> 3.5 mEq /l

Confirm adequate perfusion

Urine
output/seru
m
creatinine
Serum
potassium
Serial
lactate

Metabolic

 May
increase
edema
including cerebral edema
Detect
hyperglycemia
and
hypoglycemia
Treat hypoglycemia (80 mg/dL)
with dextrose
Treat hyperglycemia to target
glucose 144180 mg/dL

Avoid
hypotonic
fluid
Serum
glucose

Contd.

DIFFERENT CASES

VF/ Pulseless VT
Pulseless Electrical activity
Asystole
Acute Coronary Syndrome (ACS)
Bradycardia
Unstable Tachycardia
Stable Tachycardia
Stroke

VF/ Pulseless VT

Pulseless Electrical
Activity
&
Asystole

Acute Coronary
Syndrome

The STEMI chain of

survival

Drugs used in ACS

Oxygen therapy
Aspirin
Nitroglycerin
Morphine
Fibrinolytic therapy
Heparin
- blockers
Adenosine diphosphate (ADP) antagonists
ACE inhibitors
HMG-CoA reductase inhibitors

Bradycardia
HR < 50/min

ECG rhythms for

bradycardia
Sinus bradycardia
First-degree AV block
Second degree AV block
Type I (Wenckebach/ Mobitz I)
Type II (Mobitz II)

Third degree AV block

Signs & Symptoms of

bradycardia

Chest discomfort
Shortness of breath
Decreased level of consciousness
Weakness
Fatigue
Lightheadedness
Dizziness
Presyncope or syncope

Tachycardia
HR>100/min

ECGs rhythms for

Tachycardia

AF
Atrial flutter
SVT
Monomorphic VT
Polymorphic VT

Unstable

Stable

Unstable Tachycardia
Rate related cardiovascular
compromise
Hypotension
Altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
PROCEED TO IMMEDIATE
SYNCHRONIZED CARDIOVERSION

Stroke

Stroke
Out of hospital acute stroke
focuses on:
Rapid identification and
assessment of patient with stroke
Rapid transportation

In- hospital acute stroke care

includes:
Ability to rapidly determine patient
eligibility for fibrinolytic therapy

Stroke
The 8 Ds of Stroke Care remain the
major steps in diagnosis and
treatment of stroke and identify the
key points at which delays can occur.
Detection: Rapid recognition of
stroke symptoms
Dispatch: Early activation and
dispatch of emergency medical
services (EMS) system by calling 911
Delivery: Rapid EMS identification,
management, and transport

Contd
Door: Appropriate triage to stroke
center
Data: Rapid triage, evaluation, and
management within the emergency
department (ED)
Decision: Stroke expertise and
therapy selection
Drug: Fibrinolytic therapy, intraarterial strategies
Disposition: Rapid admission to
stroke unit, critical-care unit

The time-sensitive nature of

stroke care is central to the
establishment
of
successful
stroke systems, hence the
commonly used refrain

Time is Brain.

CHAIN OF SURVIVAL

Stroke chain of survival

Rapid recognition and reaction to
stroke warning signs
Rapid EMS dispatch
Rapid EMS system transport and
prearrival notification to the
receiving hospital

Interpretation: If any 1 of these 3 signs is abnormal, the

probability of a stroke is 72%. The presence of all 3 findings
indicates that the probability of stroke is 85%

FACIAL DROOP

One sided motor weakness

Drugs used in stroke

Approved Fibrinolytic therapy

Glucose
Labetalol
Nicardipine
Aspirin
Nitroprusside

ANY QUERY?????

THANK
U