Advanced Cardiac

Life Support

Dr O.N. Akanmu (MB,Ch.B, MPH,FMCA)

Senior Lecturer
Consultant in Anaesthesia
- AHA-ALS, APLS Certified
 Lecture objective
 At the end of the lecture, the participant should
be able to understand the rationale for and
correctly enumerate the various steps in
Advanced Cardiac Life Support (ACLS) in
adult patient

CPR 2020 JAN

22ND
 Course outline
 - Advanced airway options
 - Ventilation during ACLS
 - Cardiac arrest rhythms and their management
 - Drugs in ACLS – dosages. Frequency of
administration, routes of administration
 - Reversible causes of cardiac arrest

CPR 2020 JAN 22ND

 AIMS OF ACLS
 TO STABILISE THE HEART AFTER
ACHIEVING A PERFUSING RHYTHM.
[ROSC]

 MEANS OF RESTORING ADEQUATE

VENTILATION, CIRCULATION AND
PERFUSION USING NECESSARY
ADJUNCTS,EQUIPMENTS AND DRUGS.

CPR 2020 JAN 22ND

 Basic Life Support – Establishment of
oxygenation and circulation without the use of
any equipment

 In-hospital BLS – use of oxygen, airway

adjuncts and AED

 Advanced Life Support – Improvement on

BLS with the use of equipment, drugs and
defibrillator.
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 Aims :
- To improve on all aspects of BLS
- To stabilise circulation

CPR 2020 JAN 22ND

Chain of Survival

Effective Advanced Life Support

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Airway
 Oropharyngeal airway
 Naso “ “ -C/I in # base of skull
 Laryngeal mask airway

 Combitube

 Endo-tracheal tube – optimal method if

skilled and done with minimum interruptions
to compression*
 Cricothyroidotomy

CPR 2020 JAN 22ND

 Undertake laryngoscopy with minimal
interruption of compressions.
 Intubation attempt should not interrupt
chest compressions for more than 10
seconds*
 Use of capnography

CPR 2020 JAN 22ND

Ventilation (Breathing)
 High flow O2 - 10-15L/min
 Suction apparatus
 Ventilation - Ambu (Self-inflating) bag

 Once trachea has been intubated, ventilation

should be independent of compression
(Compression 100/min, ventilation 10/min)
 Insp time 1sec- enough for chest to rise

 Avoid hyperventilation

CPR 2020 JAN 22ND

Monitoring
 ECG - rhythm recognition

1) Ventricular fibrillation
2) Pulseless ventricular tachycardia
3) Asystole
4) Pulseless electrical activity

 1 & 2 are shockable

 3 & 4 are non-shockable
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Ventricular Fibrillation

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Pulseless Ventricular Tachycardia

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Asystole

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Pulseless Electrical Activity

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Drug Delivery
 IV – peripheral vein(flush with 20mls saline)
- or central vein (if skilled, minimum
interruption)
- avoid intra-cardiac injection
 Intraosseous (tibia, humerus) –if IV route
cannot be obtained within 2 minutes*
 Can be employed for both adults & paeds
 Tracheal route - no longer recommended *

-unpredictable drug absorbtion

CPR 2020 JAN 22ND
 Adrenaline – improves coronary
perfusion pressure → myocardial O2
- ↑ chances of successful defibrillation
with the next shock.
 Defibrillation – converts heart to
perfusing rhythm
 Anti-arrhythmic – stabilise converted
rhythm

CPR 2020 JAN 22ND

Drugs
 Adrenaline - 1mg after 3rd shock (for
shockable rhythm) once chest compression
has restarted.
- 1mg when venous access is achieved in
non-shockable rhythms
- Repeat every 3 – 5 minutes( every other
loop)
 OR Vasopressin – 40 iu given once

CPR 2020 JAN 22ND

 Amiodarone – 300mg for refractory VF, PVT.
After 3rd shock*.
- further 150mg for recurrence then 900mg
over 24 hrs if needed
 OR Lignocaine - 1mg/ kg boluses till 3mg/kg

 Atropine – 0.6mg for treatment of bradycardia.

No longer recommended for PEA or asystole

CPR 2020 JAN 22ND

 NaHCO3- for hypokalaemic, TCA overdose
cardiac arrest
 worsens intracellular acidosis, so ensure
assisted vent with O2 & effective BLS and
systemic perfusion before admin
 Negative inotropic action on ischaemic
myocardium
 Shifts ODC to Lt → impairs O 2 release to tissues

 Admin guided by serial blood gas analysis

CPR 2020 JAN 22ND

 Ca Chloride - 10 ml 10% calcium chloride
 in cardiac arrest caused by hyperK, hypoCa,
or overdose of Ca channel-blocking drugs
 Harmful to ischaemic myocardium, impairs
cerebral recovery

 MgSO4 – refractory VF due to hypoMg,

4
Torsades de Pointes VT
 IV 2g, repeated 10 – 15 mins

CPR 2020 JAN 22ND

Fluids – saline, Hartmanns solution,
colloids
 avoid dextrose containing solutions →
hyponatremia, hyperglycaemia → worsen
neurological outcome

Do not interrupt compressions to give

drugs

CPR 2020 JAN 22ND

 Defibrillation
 Minimise duration of pre and post-shock pauses
 Continue CC while applying pads and during
charging of defibrillator
 Plan action before stopping CC
 Brief preshock safety check
 Immediate resumption of CC after defibrillation
 Dose depends on whether monophasic or
biphasic defibrillator
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 Defibrillator pad positions
 Anterolateral

 Anteroposterior

 Anterior- right/ left infrascapular

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 Do not reassess rhythm or feel for pulse after
shock- continue CPR x 2 mins, then pause to
perform rhythm check
 If organised electrical activity compatible with
cardiac output occurs during rhythm check –
seek evidence of ROSC (pulse, pt movt)
 If organised electrical activity compatible with
cardiac output occurs during a 2 min period of
CPR, do not interrupt CC to palpate pulse
unless patient shows signs of life

CPR 2020 JAN 22ND

 Defibrillation – 360J – shock 1
 Chest compression 30:2 without checking pulse or
rhythm x 2 mins
 Check monitor after 2 mins
 Further defib- 360J – shock 2
 Resume CPR x 2 mins,
 Check monitor
 Further defib – 360J- shock 3, Give adrenaline 1mg,
amiodarone once compressions have restarted.
 Resume CPR x 2 mins
 Check monitor
 Shock 4
 Resume CPR x 2 mins
 Shock 5-
 Resume CPR x 2 mins
CPR 2020 JAN 22ND
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Reversible Causes (4H’s & 4T’s)
 Hypoxia
 Hypovolaemia
 Hyper/ hypoK , HypoCa, acidaemia, metabolic
disorders
 Hypothermia
 Tension pneumothorax
 Tamponade cardiac
 Toxins
 Thromboembolism (pulmonary/ coronary)
CPR 2020 JAN 22ND
 Hypoxia – 100% O2, ensure adeq ventilation
 Hypovolaemia – volume replacement, surgical
intervention
 Hyper/ hypoK , metabolic disorders – appropriate
Rx
 Hypothermia – warm, prolonged resuscitation
 Tension pneumothorax – needle thoracocentesis
 Tamponade cardiac – pericardiocentesis,
resuscitative thoracotomy
 Toxins – antidote, supportive Rx
 Thromboembolism (pulmonary/ coronary) -
thrombolysis
CPR 2020 JAN 22ND
 Conclusion
 The foundation of successful ALS is good
Basic Life Support
 ALS should be promptly commenced to
achieve a good outcome
 ROSC can only be maintained if post-
resuscitation care is optimal
 A chain is only as strong as its weakest link!!

CPR 2020 JAN 22ND

 A 34 year old is expected in the A&E in
cardiac arrest. BLS is being delivered by the
LASAMBUS crew. How would you prepare for
the resuscitation of this patient?
 Estimated wt

 TT size

 Dose of adrenaline

 Dose of atropine

 Fluid boluses

 Defibrillation dose

 Dose of amiodarone
CPR 2020 JAN 22ND
 A 45 year old man is rescued from a
swimming pool lifeless. BLS has been on-
going for 5 mins before the ALS team arrives.
What would be their management?

CPR 2020 JAN 22ND

 IN SUMMARY,

 THE AIM OF ADVANCED LIFE SUPPORT

IS TO SUSTAIN CARDIAC
PERFORMANCE WITH THE AID OF
ADJUNCTS, EQUIPMENTS AND DRUGS.

CPR 2020 JAN 22ND

 Thank you for Listening!
I got It! I didn’t !

CPR 2020 JAN 22ND