Introduction

•ACLS is a series of
evidence-based responses
simple enough to be
committed to memory
and recalled under
moments of stress.
Definition
• Advanced cardiac life support,
refers to a set of clinical guidelines
for the urgent and emergent
treatment of life-threatening
cardiovascular conditions that
will cause or have caused cardiac
arrest, using advanced medical
procedures, medications, and
techniques.
Purpose of ACLS
• The goal of ACLS is to provide fast and
effective interventions. It restores normal
circulation and breathing in cardiac or
respiratory arrest patients.
• To achieve the best possible outcome for
individuals who are experiencing a life-
threatening events.
• To recognise patient condition immediately
and stabilize the condition by immediately
restoring vitals and alertness .
Indications of ACLS
Pulseless Ventricular Tachycardia
(pVT)
Ventricular Fibrillation (VF)
Asystole.
Pulseless Electrical Activity (PEA)
• Bradycardia.
• Cardiac arrest.
Contraindications
• DNR – Do not Resuscitate
• Patient declared dead.
• Clinical justification
against CPR
• Spontaneous breathing or
recovery
Chain of Survival
Systematic approach
•Primary Assessment
1. Airway- head tilt chin lift (use of basic
or advanced airway )
2. Breathing-O2 administration
3. Circulation- compression, IV
administration
4. Disability- check neurologic function
AVPU -alert voice pain responsiveness
5. Exposer – head to toe assessment , look for
trauma bleeding unusual markings
Secondary assessment
1.Signs and symptoms
2.Allergies
3.Medications
4.Past medical history
5.Last meal consumed
6.Events
BLS Assessment
1. Assess the situation
Make sure the person is on a firm
surface
• Tap the person on the shoulder and
confirm that they need help.
• 2. Call for help
• Look for someone who can get an
automated external defibrillator
(AED) if available at the nearest
emergency medical care center.
3. Open the airway
Lay the person on their back, and tilt
their head back to lift their chin.
• Remove any obvious blockages in the
mouth or nose, such as vomit, blood,
food, or loose teeth.
• 4. Check for breathing
• Listen carefully for breathing sounds
for at least 10 seconds (except for
occasional gasping sounds).
• If you cannot hear breathing sounds,
begin CPR.
5. Start chest compressions
Kneel next to the person’s neck and shoulders.
Position both of your hands (lower palms) on top of
each other in the middle of the person’s chest.
Compress (push straight down) the chest at least 2
inches (5 cm) but no more than 2.4 inches (6 cm).
Use your entire body weight (not just your arms) to
deliver pressure at a rate of at least 100
compressions per minute.
Push hard and fast.
• Allow a few seconds after each push so that the
chest springs back.
6. Deliver rescue breaths
Tilt the person’s head back, lift their chin, pinch their nose shut, and
place your mouth over their mouth to make a complete seal.
After mouth-to-mouth contact, blow to make the person’s chest rise.
If the chest rises, deliver a second breath.
• Deliver at least two rescue breaths first, then continue compressions.

• 7. Continue CPR steps

• Continue with the chest compressions cycles and breathing until:
• The person exhibits signs of life, such as breathing or movement.
• An AED becomes available.
• Emergency medical services or a trained medical responder arrives
on the scene and takes over.
 What is CPR?
• CPR – or Cardiopulmonary
Resuscitation – is an
emergency lifesaving
procedure performed when
the heart stops beating.
Immediate CPR can double
or triple chances of survival
after cardiac arrest.
Before you begin
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 their shoulder and ask loudly, “Are you
OK?”
• If the person doesn’t respond and you’re
with another person who can help, have one
person call 108 or the local emergency
number and get the AED, if one is available.
Have the other person begin CPR.
Remember to spell CAB
The American Heart Association uses
the letters C-A-B to help people
remember the order to perform the
steps of CPR.
C: compressions
A: airway
•B: breathing
Compressions: Restore
blood flow Compressions means you
use your hands to push down hard and fast in a
specific way on the person’s chest. Compressions
are the most important step in CPR. Follow these
steps for performing CPR compressions:
Put the person on their back on a firm surface.
Kneel next to the person’s neck and shoulders.
• Place the lower palm of your hand over the
center of the person’s chest, between the
nipples.
Place your other hand on top of the first hand. Keep
your elbows straight. Place your shoulders directly
above your hands.
Push straight down on the chest at least 2 inches (5
centimetres) but no more than 2.4 inches (6
centimetres). Use your entire body weight, not just
your arms, when doing compressions.
Push hard at a rate of 100 to 120 compressions a
minute.
• If you haven’t been trained in CPR, continue chest
compressions until there are signs of movement or
until emergency medical personnel take over. If you
have been trained in CPR, go on to opening the
airway and rescue breathing.
Hand
placement
and
position
Airway: Open the airway
• If you’re trained in CPR and
you’ve performed 30 chest
compressions, open the person’s
airway using the head-tilt, chin-lift
maneuver. Put your 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.
Head tilt chin lift
maneuver
 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. Current
recommendations suggest performing rescue
breathing using a bag-mask device with a high-
efficiency particulate air (HEPA) filter.
After opening the airway (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 — lasting one second — and watch to
see if the chest rises.
• If the chest rises, give a second breath.
If the chest doesn’t rise, repeat the head-tilt,
chin-lift maneuver and then give a second
breath. Thirty chest compressions followed
by two rescue breaths is considered one
cycle. Be careful not to provide too many
breaths or to breathe with too much force.
Continue chest compressions to restore blood
flow.
As soon as an automated external
defibrillator (AED) is available, apply it and
follow the prompts. Give one shock, then
continue chest compressions for two more
minutes before giving a second shock
• Continue CPR until there are signs of
movement or emergency medical personnel
take over.
•BLS only provides 15
to 20 percentage of
normal cardiac output
and should be
regarded as buying
time until the
commencement of
ACLS.
BLS
Algorithm
Advanced cardiac life support
• ADVANCE LIFE SUPPORT
INCLUDE USE OF
ADJUNCTIVE EQUIPMENTS
AND TECHNIQUES FOR
1. Assisting ventilation and
circulation
2. ECG monitoring with
dysrhythmia recognition and
defibrillation
3. Establishment of IV access and
pharmacologic therapy in
addition to BLS skills
Advance
cardiac life
support
Algorithm
ACLS INCLUDES
1. Circulation by cardiac
compression
2. Airway management by
equipments
3. Breathing by advance technique
4. Defibrillation by manual
defibrillators
5. Drugs
1. Chest Compression

• Rate – 100-120/ min

• Place- Mid of sternum
• Depth- at least 5 cm or
1/3 rd of AP diameter of
chest
2. Precordial Thump
• Precordial thump is a medical procedure used
in the treatment of ventricular fibrillation or
pulseless ventricular tachycardia under certain
conditions. The procedure has a very low
success rate, but may be used in those with
witnessed, monitored onset of one of the
“shockable” cardiac rhythms if a defibrillator
is not immediately available.It should not delay
cardiopulmonary resuscitation (CPR) and
defibrillation, nor should it be used in those
with unwitnessed out-of-hospital cardiac arrest.
Procedure
• In a precordial thump, a
provider strikes at the middle
of a person’s sternum with
the ulnar aspect of the fist.
The intent is to interrupt a
potentially life-threatening
rhythm. The thump is
thought to produce an
electrical depolarization of 2
to 5 joules
2. Airway management
• Various devices
used for airway
management
are:-
1. Guedel’s
airway
2. Laryngeal
mask airway
3. Endotracheal
tube
Guedel’s Airway
Laryngeal mask Airway
Endotracheal Tubes
Procedure
of Airway
Insertion
3. Breathing
• Breathing can be accomplished by
1. Bag and mask ventilation
2. Ventilation by advanced methods
• ET tube intubation is most
definitive and best method for
ventilation
• Laryngeal mask airway (LMA)
• Tracheostomy tube
• Ventilation by automatic
ventilators
Tracheostomy tubes
Ventilator
4. Defibrillation
• Defibrillation is the use of an electrical
current to help your heart return to a
normal rhythm when a potentially fatal
arrhythmia (abnormal heart rhythm) is
happening in your heart’s lower
chambers (ventricles).
• The defibrillator depolarizes the critical
mass of myocardial tissue at once .when
they repolarize the sinus node recaptures
its role as the pacemaker.
6 Types of Defibrillators
#The six main types of defibrillators are:
1.Automated external defibrillators
2.Semi automated external defibrillator
3.Implantable cardioverter-defibrillators
4.Manual external defibrillators
5. Manual internal defibrillator
6.Wearable defibrillators
Sem

Semi automated
defibrillator
Manual internal defibrillator
Types of Defibrillation
Difference between Monophasic and Biphasic
Defibrillation
Monophasic Biphasic
1. Current travels only in one 1. Deliver’s current in two
direction direction
2. Uses 360 joule. 2. Uses 120-200 joule.
3. It causes more trauma 3. Causes less trauma.
4. First shock success rate is 4. First choice success rate is
60% 90%
Shock able rhythms
• Ventricular tachycardia is an abnormal heart rhythm marked by an
uncharacteristically fast heartbeat. Instead of beating 60-100 times per
minute, a heart in Ventricular Tachycardia usually beats over 100 times
or more per minute. VT is caused by irregular electrical impulses
within the heart’s lower chambers. Sometimes, VT, will cause blood to
stop flowing through the body.
• Torsades de Pointes is a type of polymorphic
ventricular tachycardia characterized by a gradual
change in amplitude and twisting of the QRS
complexes around an isoelectric line on the
electrocardiogram.
• Ventricular fibrillation an abnormal heart rhythm
where the heart’s lower chambers, or ventricles, twitch
but don’t perform an effective heartbeat. Often brought
on during or shortly after a heart attack, Ventricular
Fibrillation is the leading cause of sudden cardiac
death.
Non shockable rhythms
• Asystole — rhythm means that the heart’s electrical system
has shut down and there is no heartbeat. Asystole can be the
result of untreated VT or VF. If someone experiences
Asystole, CPR should be initiated immediately to provide the
best chances of survival. If an Asystole rhythm is detected by
an AED, it will not shock the patient, as defibrillation is not a
viable treatment here.
• Pulse less electrical activity— another type of irregular heartbeat
caused by an electrical problem in the heart. In PEA, the heart’s
electrical activity is too weak to continue pumping blood throughout
the body. Like with Asystole, an AED will not correct this arrhythmia,
and CPR should be administered as soon as possible to provide the
best patient outcome.
How to use automatic
external defibrillator AED
1. Switch on AED and follow the commands
2. Attach electrode pads
3. Adult pad placement anteriolaterally
4. Child / infant ( 8 years below )and antero
posteriorly
5. Make sure no one is in contact with the patient
6. Confirm by saying, I clear ,you clear ,all clear.
7. Push the shop button and continue CPR if
prompted
8. Reconfirm pulse and respiration every 2 minutes
Paddle placement
1. Place the sternal paddle over the right of the sternum below
the clavicle
2. Place apical paddle in mid axillary line in 5th intercostal
space.
3. Paddle should be applied with pressure equivalent to 10 kg.
Paddle size
4. Adult -13 cm
5. Child- 8 cm
6. Infant -4.5 cm
Defibrillation key points
• Remove hairs from the chest.
• Remove the medicinal patches.
• Wipe the sweat or water from chest
quickly.
• If the patient is not integrated remove
O2 delivery.
• If available you self adhesive
defibrillation pads.
• Do not place over pacemakers.
• Remove transdermal patches.
 Nursing responsibilities in
Defibrillation
• Apply conducting jelly between the paddle and the
skin
• Place the paddle so that they don’t touch patience
clothing , bed linen and aren’t near the medication
and direct oxygen flow.
• Ensure that Defibrillator is not in synchronised
mode.
• Do not charge the device until ready to shock , keep
the thumbs and fingers of discharge button until
paddle are on the chest.
Before pressing the discharge button call ‘all
clear’ three times
• First clear – Ensure you aren’t touching patient, bed ,
equipments
• Second clear- Ensure no one is touching patient, bed or
equipments.
• Third clear- Ensure you and everyone else are clear of
the patient and everything touching the patient
• Record the delivered energy and result ( cardiac
rhythm and pulse)
• After the event is complete inspect the skin under the
pad and paddles for burns and if any detected consult
about the treatment.
Complications of Defibrillation
1. Skin burn
2. Myocardial necrosis
3. Myocardial dysfunction
4. Pulmonary edema
5. Injury to heart
muscles, abnormal
heart rhythms and
blood clots.
Drugs used in ACLS
1.Amiodarone
Amiodarone is the preferred medication for heart arrhythmias,
including pulseless V-Tach, V-Fib and tachycardia. It is usually
given in a dose of 300 milligrams through the IV. Continuous
infusions are occasionally chosen by the doctor for atrial
fibrillation or for arrhythmias that could become problematic.

2.Epinephrine
Epinephrine is seen commonly in
several algorithms and is most
commonly used to treat ventricular
tachycardia or ventricular fibrillation.
It’s also used for asystole or pulseless
3.Atropine
Atropine is the drug of choice for
improving very slow heart rates. It is
used as part of the symptomatic
bradycardia algorithm and is
provided as a 0.5 mg IV bolus that can
be repeated every three to five
minutes for a maximum of six doses.

4.Lidocaine
Lidocaine is also used for V-Fib and
5.Dopamine
• Dopamine is commonly used to treat
symptomatic bradycardia or hypotension that
occurs following the return of spontaneous
circulation (ROSC). Along with other
medications, dopamine can be used to manage
shock following successful resuscitation.
6.Magnesium sulphate
• Magnesium is often used as an antiarrhythmic
agent in the treatment of Torsades de pointes
during cardiac arrest. It is also used in patients
suffering from arrhythmias related to
hypomagnesaemia and to treat digitalis toxicity.
Nursing responsibilities while
administrating cardiac drugs
1. Assess closely patients heart rate and blood pressure to identify
cardiovascular changes
2. Auscultate heart sounds to know the presence of abnormal sounds
and possible conduction problems
3. Determine urinary pattern and output to assess gross indications of
renal function
4. Monitor serum electrolytes and renal function test results to
determine whatever changes in drug dose is needed or not.
5. Count apical pulse for one full minute before administrating drugs
to monitor for adverse effects
6. Weigh the patient to monitor for fluid retention and heart failure.
7. check drug dose and preparation carefully to avoid medication
errors because these drugs have narrow safety margin.
8. Administer the drug in prescribe doors and rate for example KCL is
administered slowly.
Treatable causes of cardiac
arrest
Cardiac tamponade
When to stop CPR
• S-spontaneous signs of circulation
are restored
• T- Turned over to medical service.
• O- Operator is already exhausted
and cannot continue CPR.
• P- Physician assume responsibility
• S- Scene becomes unsafe.
• S- Signed waiver to stop CPR
Signs of successful
CPR (ROSC)
1. Perceptive lung expansion
2. Palpable pulse
3. Pupil will react to light or will
appear normal
4. Normal heart rate will return
5. Spontaneous grasper breath will
occur
6. Moment in body parts
7. Colour may improve from cynosis
Post Resuscitation care
1. Optimising vital organ perfusion
2. Maintain O2 saturation more
than or equal to 94 percentage
3. Temperature control
4. Transport to comprehensive post
cardiac arrest system of care
5. Anticipation treatment and
prevention of multi organ
dysfunction.
After care of patient
1. The patient should be continuously watched
by skill person over a period of 48 to 72 hours
2. If the patient is not intensive care unit shift
into the ICU for constant observation and
expert care
3. Give oxygen continuously 48 hours following
Resuscitation for sometimes after cardiac
arrest.
4. Frequently checking the victims had and job
position because is tongue may for back and
obstruct the airway.
5. Assess the patient’s respiration by rhythm,
rate and depth.
6. Check the colour of skin
persistent cyanosis indicate
which inadequate oxygenation of
blood
7. Watch for the signs of restore
circulation and respiration by
• Improved colour
• Contraction of pupils
• Change in quality of pulse
Nursing responsibilities during ACLS
1. Maintain airway patency with the use of airway adjuncts
as required, suction, high flow oxygen, bag valve mask
ventilation.
2. Assist with intubation and securing of ET tube .Insert
gastric tube and facilitate gastric decompression past
intubation as required
3. Assist with ongoing management of airway and adequate
ventilation
4. Support less experience staff by coaching and guidance
5. If a shockable rhythm is present ensure manual
defibrillator pads are applied and connected.
6.Prepare and document IV fluids
administered.
7.Document medication administered
during this time.
8.Maintain IV line and prepare crash
card.
9. Assist doctor in the whole
procedure.
10. Monitor vital signs every half
hourly.
Conclusion
• ACLS expands on Basic Life Support
(BLS) by adding recommendations on
additional medication and advanced
procedure use to the CPR guidelines
that are fundamental and efficacious
in BLS. ACLS is practiced by
advanced medical providers including
physicians, some nurses and
paramedics ;these providers are
usually required to hold certifications
in ACLS care.
Thank you