Advanced Cardiac Life Support

Information from American Heart

Association, Advanced Cardiac
Life Support, 2006

By Cynthia Grice, R.N.,

M.S.N.
Establish unresponsiveness, not
breathing and pulselessness.
Begin CPR per BCLS standards
 Respiratory Arrest
Both BCLS and ACLS interventions
Give O2
Open airway
Provide basic ventilation
Use airway if needed
Suctioning
Intubate if needed
Give 1 breath every 5-6 seconds
Hyperventilation can be harmful because it increases
intrathoracic pressure, decreases venous return to the
heart, and diminishes cardiac output. It may also
increase gastric inflation and predispose the patient to
vomiting and aspiration of gastric contents
 Resp. arrest cont’d
During CPR the compression to
ventilation ratio is 30:2. But once an
advanced airway is in place, chest
compressions are no longer interrupted
for ventilations.
With ETT in place, give 1 breath every 6-
8 seconds approximately 10 breaths per
minute
 Circulation
Check the patient’s carotid pulse for 5-10
seconds
If no pulse, start compressions 30:2 ratio
Perform chest compressions at a depth of
1 1/2 to 2 inches at a rate of 100/minute
 Defibrillation
Defibrillation does not restart the heart.
Defibrillation stuns the heart and briefly
terminates all electrical activity, including VF
and VT. If the heart is still viable, its normal
pacemakers may eventually resume electrical
activity, return of spontaneous rhythm, that
ultimately results in a perfusing rhythm. In the
first few minutes after successful defibrillation,
however, any spontaneous rhythm is typically
slow and does not create pulses or perfusion.
CPR is needed for several minutes until
adequate heart function resumes. This is the
rationale for resuming immediate high quality
chest compressions after a shock.
 Defibrillation
The earlier defibrillation occurs, the
higher the survival rate. When VF is
present, CPR can provide a small amount
of blood flow to the heart and brain but
cannot directly restore an organized
rhythm. Restoration of a perfusing
rhythm requires immediate CPR and
defibrillation within few minutes of the
initial arrest.
Be familiar with the AED
 Defibrillation
Monophasic- defibrillate at 360 volts
Biphasic-defibrillate at 150 volts
Defib V tac or V fib
Give epinephrine, may also give
amiodarone
Defib and continue CPR in between
Stop for a few seconds, no more than 10,
if a rhythm is seen to feel for a pulse
May also give atropine or vasopressin
If acidotic give HCO3
 Drugs-Vasopressors
Epinephrine 1mg IV/IO-repeat every 3-
5 minutes OR
Vasopressin 40 U IV/IO- may
substitute for the first or second dose
of epinephrine
Epinephrine may be given down the
ETT tube in there is no IV/IO access
1:1000, 2 to 2.5mg diluted in 5-10 ml
of NS injected into the ET tube
 Epinephrine
Epinephrine Hydrochloride is used during
resuscitation primarily for its adrenergic
effects, ie, vasoconstriction.
Vasoconstriction increases cerebral and
coronary blood flow during CPR as mean
arterial pressure and aortic diastolic pressure
are increased.
Stimulates adrenergic receptors, producing
vasoconstriction, increasing blood pressure
and heart rate, and improving perfusion
pressure to the brain and heart.
Repeat epinephrine 1mg IV/IO every 3 to 5
minutes during cardiac arrest
 Vasopressin
A nonadrenergic peripheral
vasoconstrictor. Overall, vasopressin
effects have not been shown to differ
from epinephrine.
Causes coronary and renal
vasoconstriction.
Dose 40 U IV/IO
 Anticoagulents
Aspirin and Plavix are both antiplatlets or
prevent platlet aggregation
Heparin and coumadin are anticoagulents
Monitor heparin with APTT
Monitor coumadin with INR and PT
 Antiarrhythmic Agents
Amiodarone
Magnesium sulfate
Lidocaine
 Amiodarone
Consider amiodarone for treatment of VF or
pulseless VT unresponsive to shock delivery,
CPR, and a vasopressor. Amiodarone is a
complex drug that affects potassium, and
calcium channels. It also has adrenergic and B-
adrenergic blocking properties. Amiodarone is
available in vials and prefilled syringes. During
cardiac arrest amiodarone 300mg IV/IO push
for the first dose. If VF/pulseless VT persists,
consider giving a second dose of 150mg IV/IO
in 3-5 minutes.
 Postresuscitation Maintenance
Therapy
Amiodarone for recurrent VF/VT:
Maximum cumulative dose: 2.2g over 24 hours
Start with IV bolus of 150 mg IV over 10 minutes
Follow by slow infusion of 360mg IV over the next 6
hours: 1mg/min.
Then a maintenance infusion of 540 mg IV over the
next 18 hours: 0.5 mg/min
The arrest dose is 300 mg IV/IO, repeated once if
necessary at 150mg IV/IO. If the drug has been given
during cardiac arrest, start infusion as indicated. May
give one 150mg IV bolus for recurrent VF/VT; then
seek expert consultation
Monitor for hypotension bradycardia and
gastrointestinal toxicity
 Lidocaine
Lidocaine is an alternative antiarrhythmic of
long standing and widespread familarity. It has
no proven short term or long term efficacy in
cardiac arrest. Lidocaine is still included as an
alternative to amiodarone in settings where
amiodarone is not available.
Give lidocaine in a dose of 1 to 1.5 mg/kg
IV/IO. Repeat if indicated at 0.5 to 0.75 mg/kg
IV/IO over 5 to 10 minute intervals to a
maximum of 3 doses or 3mg/kg. If IV/IO
access is available, then the dose for ET
administration is 2 to 4 mg/kg.
 Postresuscitation Maintenance
Therapy
If the patient has not received lidocaine during
the arrest:
Start with a loading dose of 1 to 1.5 mg/kg
every 5 to 10 minutes if needed to a total of 3
mg/kg
Follow with a continuous infusion of 1 to 4
mg/min.
If the drug has been used during cardiac
arrest, start infusion as indicated. May give
additional bolus for recurrent VF or VT up to 3
mg/kg; seek expert consultation.
 Magnesium Sulfate
IV magnesium may terminate or prevent recurrent torsades de
pointes in patients who have a prolonged QT interval during
normal sinus rhythm. When VF/pulseless VT cardiac arrest is
associated with torsades de pointes, give magnesium sulfate at a
loading dose of 1 to 2 g IV/IO diluted in 10 ml D5W given over 5
to 20 minutes. If a prearrest 12 lead EKG is available for review.
Check the QT interval for prolongation. Remember that pulseless
VT is treated with an immediate high-energy shock, whereas
magnesium is an adjunctive agent to prevent recurrent or treat
persistent VT associated with torsades de pointes.
Magnesium sulfate is alos indicated for patients with known or
suspected low serum magnesium, such as patients with alcoholism
or other conditions associated with malnutrition or
hypomagnesemic states. For patients in refractory VF pulseless
VT, check the patient for history, if available, for one of these
conditions that suggest the presence of a reversible electrolyte
abnormality.
 Pulseless Arrest
Initiate high quality CPR, check every 10
seconds for a pulse, advanced airway
placement
As soon as IV/IO access available give a
vasopressor: Epinephrine 1mg IV/IO repeat
every 3 to 5 minutes OR
Vasopressin 40 U IV/IO to replace first or
second dose of epinephrine
Give vasopressin only once.
If PEA is slow give Atropine 1 mg IV/IO, may
repeat every 3 to 5 minutes up to 3 doses
If still no pulse, continue CPR and epinephrine
 Pulseless Electrical Activity (PEA)
Patients with PEA have poor outcomes. Rapid
assessments and aggressive management offer
the best chance of success. PEA may be
caused by a reversible problem. If you can
quickly identify a specific condition that has
caused or is contributing to PEA and correct it,
you may achieve resuscitation.
Consider frequent causes of PEA by recalling
the H’s and T’s
Analyze EKG for clues to the underlying cause
Recognize hypovolemia
Recognize drug overdose/poisonings
 H’s
Hypovolemia
Hypoxia
Hydrogen ion ( acidosis)
Hyper/hypokalemia
Hypoglycemia
Hypothermia
 T’s
Toxins
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (coronary and pulmonary)
Trauma
 Terminating Resuscitative Efforts
If a reversible cause is not rapidly identified and the
patient fails to responds to the BLS Primary Survey and
the ACLS Secondary Survey management, termination
of resuscitative efforts may be appropriate. The
decision to terminate resuscitative efforts rests with the
treating physician in the hospital and is based on
consideration of many factors including:
Time to CPR
Time to defibrillation
Comorbid disease
Prearrest state
Initial arrest rhythm
Response to resuscitative measures
 Acute Coronary Syndromes
Unstable plaque
Plaque rupture
Unstable angina
Microemboli
Occlusive thrombus
Treat with O2, aspirin, nitroglycerin,
morphine, TPA Heparin/levenox, beta
blockers, plavix, ACE inhibitors, statin
therapy-lipitor, etc. Remember that
morphine is a venodilator
Critical time period for TPA for CVA
The critical time period for administration of
intravenous fibrinolytic therapy begins with the
onset of symptoms.
Immediate general assessment 10min.
Immediate neurologic assessment 25 min
CT of head 25 min
Interpretation of CT of head 45 min
Admin of TPA, timed from ED arrival 60 min
Admin. Of TPA, timed from onset of symptoms
3 hours
Admission to ICU 3 hours