Basic Life Support (BLS) and

Advanced Cardiovascular Life Support

(ACLS)
Case Scenario 1
65-year old male come to ED with c/o several episodes of syncope. Upon
attending the patient, he complains of chest pain.
BP: 70/33, RR 28, PR 128

What is your next management?

 Case Scenario 2
A 45-year-old woman with a history of palpitations develops light-headedness
and palpitations. She is alert and oriented.
BP is 138/84. Pulse is 150.

What is your next management?

 Case Scenario 3
You attend a 56-year-old diabetic woman with dizziness and sudden onset of chest
pain. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac
monitor documents the rhythm below. She is receiving oxygen at 4 L/min by nasal
cannula and an IV has been established.

What is your next management?

Case Scenario 4

A 40 year-old man is brought to your tertiary ED after being found unconscious.

PR no pulse

What is your next management?

 Overview
1. The BLS survey
2. High quality cardiopulmonary resuscitation
(CPR)
3. The ACLS Survey
4. The ACLS algorithms
5. Immediate post-cardiac arrest care
6. Case scenario
 AHA 2010 Adult Chain of Survival
1. Immediate recognition of cardiac arrest and
activation of emergency response system
2. Early CPR with emphasis on chest
compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care
 Systematic Approach
If the patient appears unconscious:
- Use the BLS survey for initial management
- Proceed with ACLS survey for more advanced
assessment and treatment

If the patient appears conscious:

- Use the ACLS Survey for initial management
Key changes from the 2005 BLS Guidelines

• Immediate recognition of cardiac arrest based on

assessing unresponsiveness and absence of normal
breathing
• “Look, listen and feel” removed from the BLS algorithm
• Sequence change from ABC to CAB
• Healthcare providers continue effective chest
compressions until return of spontaneous circulation or
termination of resuscitative efforts
 High quality cardiopulmonary resuscitation (CPR)

• Compress the chest hard and fast “Push hard, Push fast”
- Compress the center of the chest with at least 100
compressions per minute at a depth of at least 2 inches
• Allow complete chest recoil after each compression
• Minimize interruptions in compressions (10 seconds or
less)
• Switch providers about every 2 minutes to avoid fatigue
• Avoid excessive ventilation
 The ACLS survey
(A) Airway: Maintain airway and use advanced airway if needed.
Ensure confirmation of placement of an advanced airway and secure
the advanced airway device.
(B) Breathing: Give bag-mask ventilation, provide supplemental
oxygen, and avoid excessive ventilation. Also, adequacy of ventilation
and oxygenation should be monitored during this step.
(C) Circulation: Obtain IV access, attach ECG leads, identify and
monitor arrhythmias, giving fluids if needed, and use defibrillation if
appropriate.
(D) Differential diagnosis: Look for reversible causes and contributing
factors for the emergency.
Effective Resuscitation Team Dynamics
Members of the resuscitation
team
- Team leader
- Airway or ventilator
- Defibrillator
- Compressor
- Medicator
- Recorder or observer
Elements of an effective team
- Closed loop communication
- Clear messages
- Clear roles and responsibilities
- Knowing one limitation
- Knowledge sharing
- Constructive intervention
- Reevaluation and summarizing
- Mutual respect
 ACLS scenario
1. Respiratory arrest
2. Cardiac arrest (Pulseless arrest)
- VF / Pulseless VT
- Asystole or PEA
3. Bradycardia
4. Tachycardia – Unstable and stable
The ACLS cases: Respiratory arrest
• Management of respiratory arrest includes
both BLS and ACLS interventions
• Interventions include:
- Giving supplementary oxygen
- Opening the airway
- Providing basic ventilation
- Using basic airway adjuncts (OPA and NPA)
- Suctioning
 The ACLS cases: Respiratory arrest
Providing Ventilation with an Advanced Airway
- Laryngeal mask airway
- Laryngeal tube
- Esophageal-tracheal tube
- Enotracheal tube
Once an advanced airway is in place, chest compressions are no
longer interrupted for ventilations
Airway device Ventilation during Ventilation during
cardiac arrest respiratory arrest
Bag-mask 2 ventilations after every 1 ventilation every 5 to 6
30 compressions seconds
Any advanced airway 1 ventilation every 6 to 8 (10 to 12 breaths per
seconds minute)
(8 to 10 breaths per
minute)
The ACLS cases:
Cardiac arrest
There are 4 rhythms seen in
pulseless cardiac arrest:

1. Pulseless Ventricular
Tachycardia (VT)
2. Ventricular Fibrillation (VF)
3. Asystole
4. Pulseless Electrical Activity
(PEA)
 Reversible causes of cardiac arrest
5H 5T
Hypovolaemia Toxins
Hypoxia Tamponade (cardiac)
Hydrogen ion (Acidosis) Tension pneumothorax
Hyper/hypo-kalaemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
 The ACLS cases:
Bradycardia

Transcutaneous
pacing : Indication
• Hemodynamically
unstable
bradycardia
• Symptomatic
bradycardia
• Heart block
Mobitz Type II 2nd
Degree heart block
3rd Degree heart
block
The ACLS cases:
Tachycardia
 DEFIBRILLATOR

1. Attach electrodes to patient’s chest and turn on

2. Analyse the rhythm ?shockable
3. Apply coupling agent or pads to patient’s chest
4. Select energy level – 200Joule
5. Apply paddles to chest
6. Charge the paddles
7. The “Clear” chant
8. Check monitor again
9. Discharge shock and return paddles to machine
 DRUGS
• Adenosine
• Amiodarone
• Dopamine
• Adrenaline
• Atropine
 Adenosine
• Preparation
1 Ampoule = 2mls = 6mg
1mls = 3mg
bolus , no need mix

• Dosage
1st = 6mg
2nd = 12mg

• Instruction
20cc NS flush fast after given bolus
 Amiodarone
• Preparation
1 Ampoule = 3mls = 150mg
1mls = 50mg
2 Ampoules = 300mg + 100cc D5% , run 1
hour

Dosage
1st 300mg over 1 hour
2nd 150mg over 1 hour
 Adrenaline
• Preparation
1 Ampoule = 1mls = 1mg

Dosage
every 3-5 mins during resuscitation
 Atropine
• Preparation
1Ampoule =1mls =1mg

Dosage
0.5mg IV every 3-5mins
Dopamine
• Preparation
1Ampoule = 5mls = 200mg
5mls + 45mls = 50mls  50cc syringe
50cc = 200mg
1cc / hour = 4mg = 4000mcg
4000mcg / 60 min = 66.6mcg / min

Dosag
5-20mcg / kg / min
Case Scenario 1
65-year old male come to ED with c/o several episodes of syncope. Upon
attending the patient, he complains of chest pain.
BP: 70/33, RR 28, PR 128

What is your next management?

 Case Scenario 2
A 45-year-old woman with a history of palpitations develops light-headedness
and palpitations. She is alert and oriented.
BP is 138/84. Pulse is 150.

What is your next management?

 Case Scenario 3
You attend a 56-year-old diabetic woman with dizziness and sudden onset of chest
pain. She is pale and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac
monitor documents the rhythm below. She is receiving oxygen at 4 L/min by nasal
cannula and an IV has been established.

What is your next management?

Case Scenario 4

A 40 year-old man is brought to your tertiary ED after being found unconscious.

PR no pulse

What is your next management?

Thank you!