Advanced Cardiac Life Support

(ACLS)

Part One
Advanced Cardiac Life Support (ACLS)

❑ ACLS is composed of interventions to:

I. Prevent Cardiac Arrest
▪ Include airway management, ventilation support &
treatment of bradyarrhythmias & tachyarrhythmias.
II. Treat Cardiac Arrest
▪ Include recognition of cardiac arrest, activation of
the emergency response system, early CPR, & rapid
defibrillation, drug therapy, advanced airway
management, & physiologic monitoring.
III. Improve outcomes of patients who achieve
return of spontaneous circulation (ROSC) after
cardiac arrest.
I-Ventilation & Oxygen Administration During
CPR

▪ The purpose of Ventilation during CPR is to

maintain:
• Adequate Oxygenation.
• Sufficient elimination of carbon dioxide.
➢ Advanced airway placement in cardiac arrest
should NOT delay initial CPR & defibrillation, if
required.
• The use of 100% inspired oxygen as soon as it
becomes available is reasonable during
resuscitation from cardiac arrest.
 Oxygen Delivery During CPR
Bag-Valve-Mask(BVM)

• BVM is an acceptable method of providing

ventilation & oxygenation during CPR.
• Use an adult (1 to 2L) bag.
• The provider should deliver approximately 600 mL
of tidal volume to produce chest rise over 1 second
• During CPR give 2 breaths (each 1 second) after
every 30 chest compressions. ( ratio is 30 :2)
• Is not recommended for one provider, ventilations
best to be mouth-to-mask using face mask.
• Complications including aspiration,
& pneumonia.
 One & Two person BVM Technique

▪ The mask is placed on the face of the patient with the narrow end
over the nose, & the wide end positioned just below the lower lip.
▪ Using the thumb & forefinger of the hand holding the mask (forming
a “C”), the rescuer presses directly down on the mask.
▪ Using the other three fingers of the same hand (forming an “E”), the
rescuer then grasps the bony part of the mandible, pulling the angle
of the jaw up & back.
▪ With 2 providers, one opens the airway & seals the mask to the
face while the other squeezes the bag.
 Opening the Airway

▪ Open patients airway using head tilt–chin lift maneuver

(jaw thrust without head extension for patients with or
suspected to have cervical spine injuries).

Jaw thrust maneuver Head tilt-chin lift maneuver

 Airway Adjuncts/ Oropharyngeal Airways

▪ May aid in the delivery of adequate ventilation with a

bag-mask device by preventing the tongue from
occluding the airway.
▪ Can be used in unconscious (unresponsive) patients with
no cough or gag reflex.
▪ Should be inserted only by persons trained in their use
as incorrect insertion can cause airway obstruction.
▪ Preferred in the presence of known or suspected basal
skull fracture or severe coagulopathy.
 Airway Adjuncts/Nasopharyngeal Airways

• Particularly useful when conditions such as a clenched jaw

& in patients who are not deeply unconscious.
• Better tolerated than oropharyngeal airways in awake or
lightly anesthetized patients.
• To determine the correct size, measure from the tip of
your patient’s nose to the tip of their earlobe.
Advanced Airways/Endotracheal Tube (ET)

• Advantages of ET
– keeps the airway patent, permits suctioning of airway
secretions, enables delivery of a high concentration of
oxygen, provides an alternative route for the administration
of some drugs, facilitates delivery of a selected tidal volume,
&, with use of a cuff, may protect the airway from aspiration.

• Complications of ET intubation
– Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea
– Esophageal intubation, Vomiting & Aspiration
– Arrhythmias
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 Advanced Airways/ ET

• ET insertion should be delayed if insertion will interrupt

chest compressions.
• Providers may consider its insertion until the patient fails
to respond to initial CPR & defibrillation attempts.
– Intubation attempts should be interrupted to provide
oxygenation & ventilation as needed.
– Once inserted, assessment of ET position should be
done without interrupting chest compressions.
– Assessment consists of visualizing chest expansion
bilaterally, listening over the epigastrium (no breath
sounds) & the lung fields bilaterally (breath sounds
should be equal & adequate), & by exhaled Co2
detectors (Capnography).
Advanced Airways/ ET

• It is reasonable to choose cuffed ETTs over uncuffed

ETTs for intubating infants and children. When a cuffed
ETT is used, attention should be paid to ETT size,
position, and cuff inflation pressure (usually <20-25 cm
H2O). (2020 guidelines)

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 Exhaled Co2 Detectors

▪ Colorimetric Monitors: Designed to detect the presence of CO2

only & do not measure the quantity of CO2 molecules.
• Change color from blue or purple to yellow when exposed to CO2 &
can be attached to an ETT or to a resuscitation bag.

Before Intubation After Intubation

 Exhaled Co2 Detectors

▪ Capnography:
• Is a noninvasive method attached to ET for monitoring the
level of Carbone dioxide in exhaled breath (End- tidal Co2
ETCo2) to assess ventilation status.
• Capnometer/Capnogram: gives both a numerical reading
value of ETCo2 as well as a waveform.
• The presence of waveform indicates that ET is correctly
placed in the trachea.
Capnography Waveform
 Advanced Airways/ET

▪ If there is doubt about correct tube placement then:

o Use the laryngoscope to visualize the tube passing
through the vocal cords.
o If still in doubt, remove the tube & provide bag-mask
ventilation until the tube can be replaced.
o Intubation attempt should not last >30 sec. Make no
more than 2 attempts per, hyperoxygenate for one min
between attempts
 Advanced Airways/ Supraglottic Airway

• Placement of a supraglottic airway is a reasonable

alternative to ET & can be done successfully without
interrupting chest compressions.
• Includes laryngeal tube which is Easier in insertion than ET

• Considered acceptable alternatives to bag-mask

ventilation or ET in cardiac arrest.
 Advanced Airways

• Once an advanced airway (ET or Supraglottic) is in

place, the 2 providers should no longer deliver CPR
in cycles;
– Chest compressions are given at a rate of at
least 100 per minute (range 100- 120),
without pauses for ventilation.
– Ventilation rate should be 1 breath every 6
seconds (10 breaths per minute).
• The 2 providers should change compressor &
ventilator roles approximately every 2 minutes to
prevent fatigue & deterioration in quality & rate of
chest compressions.
 II-Management of Cardiac Arrest

▪ Cardiac arrest includes 4 rhythms:

o Ventricular Fibrillation (VF)
o Pulseless Ventricular Tachycardia (PVT)
o Pulseless Electric Activity (PEA)
o Asystole
• Pluseless arrhythmia mean absence or insufficient
mechanical ventricular activity to generate a
clinically detectable pulse.
• A successful management depends on high quality
CPR, & for VF/pulseless VT, attempted
defibrillation within minutes of collapse.
 II-Management of Cardiac Arrest

❑ High quality CPR during ACLS means:

▪ Push hard (at least 2 inches [5 cm]) & fast (100-
120/min) & allow complete chest recoil.
▪ Minimize interruptions in compressions.
▪ Avoid excessive ventilation.
▪ Rotate compressor every 2 minutes.
▪ If no advanced airway,30:2 compression-ventilation
ratio.
▪ Attempt to improve CPR quality if ETCO2 (VIA
quantitative waveform capnography) <10 mm Hg, &/or
intra-arterial pressure –(diastolic pressure) <20 mm Hg.
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 Management of Cardiac Arrest
Pulseless V Tach or V Fib

▪ Sequence of Management
1- When a rhythm reveals VF/VT, the first provider
should resume CPR while the second provider charges
the defibrillator.
2- Once the defibrillator is charged, CPR is paused to
“clear” the patient for shock delivery. After the “clear,”
the second provider gives a single shock as quickly as
possible to minimize the interruption in chest
compressions (“hands-off interval”).
3- The first provider resumes CPR immediately after
shock delivery (without a rhythm or pulse check) &
continues for 2 minutes.
 Management of Cardiac Arrest
Pulseless V Tach or V Fib

• Sequence of Management
4- After 2 minutes of CPR the sequence is repeated,
beginning with a rhythm check.
➢ Defibrillation Strategies
– The shorter the time interval between the last
chest compression & shock delivery, the more
likely the shock will be successful.

VF VT
Management of Cardiac Arrest/Pulseless V Tach
or V Fib/ Defibrillation Dose

▪ Biphasic Defibrillator
• Use the manufacturer's recommended energy dose
(eg, initial dose of 120 to 200 J) for terminating VF.
• If the provider is unaware of the effective dose range,
the provider may use the maximal dose.
• Second & subsequent energy levels should be at least
equivalent, & higher energy levels may be considered.
• If VF is terminated by a shock but then recurs later in
the arrest, deliver subsequent shocks at the previously
successful energy level.
• Monophasic Defibrillator
• Deliver an initial shock of 360 J & use that dose for all
subsequent shocks.
 Management of Cardiac Arrest
Pulseless V Tach or V Fib

▪ Drug Therapy
• There is insufficient evidence to recommend a specific
timing or sequence (order) of drug administration &
advanced airway placement during cardiac arrest.
• If a shock fails to generate a perfusing rhythm, then giving
a Epinephrine soon after the shock (without interrupting
CPR) will optimize the potential impact of increased
myocardial blood flow before the next shock.
• Vasopressin offers no advantage as a substitute for
Epinephrine in cardiac arrest . Vasopressin has been
removed from adult cardiac arrest algorithm.
• Amiodarone/ Lidocaine may be considered when VF/VT is
unresponsive to CPR, & defibrillation therapy.
 Management of Cardiac Arrest
Asystole, PEA

• When a rhythm check reveals an organized rhythm, a

pulse check is performed.

• If a pulse is detected, post– cardiac arrest care should

be initiated immediately.

• If the rhythm is asystole or the pulse is absent (e.g.,

PEA),

– With respect to timing, for cardiac arrest with a

nonshockable rhythm, it is reasonable to administer
epinephrine as soon as feasible.
– CPR should be resumed immediately, beginning with
chest compressions, & should continue for 2 minutes
before the rhythm check is repeated.
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Management of Cardiac Arrest/Asystole, PEA

▪ Drug Therapy
– Epinephrine I mg Q 3-5 min IV.
– Atropine during PEA or or asystole is unlikely to
have a therapeutic benefit. For this reason
Atropine has been removed (in 2020) from the
cardiac arrest algorithm.
– Vasopressin offers no advantage as a substitute
for Epinephrine in cardiac arrest . Vasopressin
has been removed (in 2020) from adult
cardiac arrest algorithm.
Management of Cardiac Arrest/Asystole, PEA

• Treating potentially reversible causes of

VF/pulseless VT, PEA/asystole.

Treatable Causes of Cardiac Arrest: The H’s & T’s

H’s T’s
Hypoxia Toxins
Hypovolemia Tamponade (cardiac)
Hydrogen ion (Acidosis) Tension pneumothorax
Hypo-/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
 Management of Cardiac Arrest

▪ Consider:
• Reperfusion strategies such as coronary angiography &
PCI during CPR or emergency cardiopulmonary bypass
• Fibrinolytic therapy with pulmonary thrombosis
• Placement of an advanced airway might be necessary
to achieve adequate oxygenation or ventilation.
• PEA caused by severe volume loss or sepsis will
potentially benefit from administration of IV Crystalloid.
• If tension pneumothorax is clinically suspected as the
cause of PEA, initial management includes needle
decompression.
 II-Management of Cardiac Arrest
Monitoring During CPR

▪ Pulse
• No validity of checking pulses during ongoing CPR
• The healthcare provider should take no more than 10
seconds to check for a pulse, & if it is not felt within
that time period chest compressions should be started.
• Upon completion of five cycles of CPR, the patient’s
rhythm is again assessed.
• Pulses are only checked if a perfusing rhythm (ie,
normal sinus rhythm, bradycardia, tachycardia) is
detected after 2 minutes of CPR.
• If the rhythm remains unchanged (VF or PVT), then
there is no pulse check before the next defibrillation.
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 II-Management of Cardiac Arrest
Monitoring During CPR
▪ It may be reasonable to use physiologic parameters such as arterial
blood pressure or ETCO2 when feasible to monitor and optimize
CPR quality.
▪ End-Tidal CO2 ETCO2
▪ ETCO2 is the concentration of carbon dioxide in exhaled air at the end
of expiration.
• Under normal conditions ETCO2 is in the range of 35 to 40 mm Hg.
• In general , If PETCO2 is 10 mm Hg, then try to improve CPR quality
by optimizing chest compression parameters.
• If ETCO2 abruptly increases to a normal value (35 to 40 mm Hg),
you may consider that this is an indicator of ROSC (return of
spontaneous circulation).
• An air leak during bag-mask ventilation or ventilation with a
supraglottic airway could result in lower ETCO2 values.
 Monitoring During CPR

▪ ABG
– Arterial blood gas monitoring during CPR is
not a reliable indicator of the severity of
tissue hypoxemia, hypercarbia (and
therefore adequacy of ventilation during
CPR).
• Pulse Oximetry
– During cardiac arrest, pulse oximetry
typically does not provide a reliable signal
because pulsatile blood flow is inadequate
in peripheral tissue beds.
 Access for Parenteral Medications during
Cardiac Arrest
▪ A peripheral Venous Route
• A drug should be administered by bolus injection & followed
with a 20-mL bolus of IV fluid to facilitate the drug flow from
the extremity into the central circulation.
• Briefly elevating the extremity during & after drug administration

▪ Central line (internal jugular or subclavian) during cardiac

arrest, unless there are contraindications.
▪ IO ( intraosseous) Drug Delivery
• IO access is established if IV access is not readily available
• All ACLS drugs can be given IO in the clinical setting
• Little information is available on the efficacy & effectiveness of
such administration during ongoing CPR.
 Access for Parenteral Medications during
Cardiac Arrest

▪ ET
– Lidocaine, Epinephrine, Atropine, & Naloxone are
absorbed via the trachea.
– Administration of resuscitation drugs into the
trachea results in lower blood concentrations than
when the same dose is given intravascularly.
– Typically the dose given by the ET is 2 to 2.5 times
the recommended IV dose.
– Providers should dilute the recommended dose in 5
to 10 mL of sterile water or normal saline & inject
the drug directly into the ET.
 II-Management of Cardiac Arrest

▪ Medications for Arrest Rhythms

• Epinephrine: adrenergic receptor-stimulating (ie, vasoconstrictor)
properties, consider administering a 1 mg dose of IV/IO
Epinephrine every 3 to 5 minutes during adult cardiac arrest.
▪ Antiarrhythmics:
• Amiodarone, It can be considered for treatment of VF or pulseless
VT unresponsive to shock delivery, & CPR.
• An initial dose of 300 mg IV/IO can be followed by 1 dose of 150
mg IV/IO.
• Lidocaine, may be considered if Amiodarone is not available.
o The initial dose is 1 to 1.5 mg/kg IV.
o If VF/pulseless VT persists, additional doses of 0.5 to 0.75 mg/kg
IV push may be administered at 5- to 10-minute intervals to a
maximum dose of 3 mg/kg.
II-Management of cardiac arrest/ Antiarrhythmics

▪ Magnesium Sulfate can facilitate termination of

torsades de pointes (irregular/polymorphic VT),
dose of 1 to 2 g diluted in 10 mL D5W
 II-Management of Cardiac Arrest

• Interventions Not Recommended for

Routine Use during Cardiac Arrest:
– Atropine
– Sodium Bicarbonate
– Pacing
– Calcium
– Fibrinolysis
– Precordial Thump
 Targeted Temperature Management
(TTM)
▪ TTM one of several treatments post-ROSC, is indicated when
resuscitated pt is unresponsive, indicating neurologic compromise
▪ The cerebral metabolic rate for oxygen, or CMRO2, is reduced when
the body temperature is reduced.
▪ Apoptosis (programmed cell death) & the production of free radicals
are reduced in a hypothermic state.
▪ TTM protocols: the systematic lowering of a patient’s core
temperature to 32°C to 36°C
▪ This cooling can be accomplished by various methods, including ice
packs, cooling blankets & endovascular cooling devices.
▪ The patient remains in this hypothermic state at least 24 hours.
▪ Passive rewarming is then allowed to occur over the next 8 to 12
hours; actively or rapidly rewarming patients is not recommended.

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 Debriefing

▪ Current guidelines suggest that timely & focused

debriefing after any cardiopulmonary arrest
response can increases survival outcomes.
▪ It may be reasonable to use audiovisual feedback
devices during CPR for real-time optimization of
CPR performance.
▪ After the code, the responding staff often scatter,
& the opportunity for evaluation & learning is lost.
▪ Debriefing should occur as soon as possible, &
include what went well, what can be improved, &
whether there were any safety, procedural, or
equipment issues.

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 Debriefing
▪ Debriefing should not be used as a forum for
pointing fingers & assigning blame. Instead, it is an
opportunity for all staff involved to improve their
performance in preparation for future events.
▪ It is best if all members of the team can be
debriefed together, because this promotes more
effective teamwork.
▪ Nursing staff should hold their own nursing
debriefing session
• Debriefings and referral for follow up for emotional
support for lay rescuers, EMS providers, and
hospital-based healthcare workers after a cardiac
arrest event may be beneficial.

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Family Presence in Cardiac Arrest Situations

• More informed decision about the continuation of

resuscitation
• Reassures family all efforts were attempted
• Give them a chance to say goodbye.
• Families want to make sure the death is painless.
• Many nurses & physicians believe that family presence
during CPR detracts from their performance.
• Rules must be in place to escort family members from
the room if the rescuers cannot perform resuscitative
measures effectively.

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When Should Resuscitative Efforts Stop?

o The final decision to stop can never rest on a single

parameter, such as duration of resuscitative effort.

o In intubated patients, failure to achieve an ETCO2 of

greater than 10 mm Hg by waveform capnography after
20 minutes of CPR may be considered as one component
of a multimodal approach to decide when to end
resuscitative efforts, but it should not be used in
isolation.

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Copyright © 2018 Wolters Kluwer • All Rights Reserved
2020 guidelines

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2020 guidelines

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 References

• Part 7: Adult Advanced Cardiovascular Life Support 2020

American Heart Association Guidelines Update for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation 2020, 132[suppl 2]:S444–S464

• Part 8: Adult Advanced Cardiovascular Life Support: 2010

American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency. Circulation 2010, 122:S729-S767