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Core ACLS Concepts

The chain of survival has 4 links applied to

all CPR settings (hospital, ER (A&E), ICU, CCU, or community)

Early Access

Early Early CPR Defibrillation

Early Advanced care

Advanced Cardiovascular/Cardiac Life Support

Is a training program that generally aims to

develop the knowledge and skills of health care providers as they make effective use of themselves when assisting in a code situation.

Definition of Terms:

Iincludes the knowledge and skills necessary to provide the appropriate early treatment for cardiopulmonary current which reduces BLS and use of adjunctive equipment and special technique to establish and maintain ventilation and circulation.

Cardioversion - The discharge of electrical energy synchronized on the R wave of the electrocardiogram. Defibrillation - use of unsynchronized electrical energy for revision of cardiac arrhythmias. Algorithm sets of step-by-step procedure guides to assist caregivers in making informed decisions regarding the diagnosis and treatment of disease.

ECC (Emergency Cardiac Care) includes all responses necessary to deal with sudden and often life threatening events affecting the cardiovascular and pulmonary system. Megacode - situation wherein the algorithm will be applied and an individual will be tested on his ability to recite the exact sequences of an algorithm.

Resuscitation (Code Red) General Policy: The Cardiac Code teams goals are to preserve life, restore health, relieve suffering and limit disability. These goals shall be carried out promptly with patient safety foremost in the mind.

A team is composed of : 1. Person for chest compression 2. Ventilator 3. Person to insert IV lined and will administer medications. 4. Person to monitor the cardiac and will do the defibrillation . 5. Recorder

Role of the Nurses: 1.Prepares and set-up all equipments necessary for resuscitation. 2. Regular checking of E-cart (every shift before receiving the endorsement) 3.Document Checklist 4,Location of E-cart 5.Administer assist BLS measure 6.Carries out Doctors order and record the chronological event using the CPR Record Form

.7. Arranges all matters pertinent to the ad mission and transfer of patient when necessary 8.Arranges all matters pertinent to the discharge of patient(expired patient) 9. Autopsy, DOA, HAMA 10. REPLENISHES AND CHARGES ALL ITEMS USED

GENERAL GUIDELINES FOR ALL TEAMS Maintain quiet, orderly and professional environment Patient should be automatically hooked to EKG, cardiac monitor,defibrillator and pulse oximeter State vital signs every 5 minutes / PRN State each medication given Document

GENERAL GUIDELINES FOR ALL TEAMS Maintain quiet, orderly and professional environment Patient should be automatically hooked to EKG, cardiac monitordefibrillator and pulse oximeter State vital signs every 5 minutes of PRN State each medication given Document

Request clarification of any order if not clearly understood Limit traffic Comfort relatives and advise to stay outside the room

EQUIPMENT E-cart Pulse oximeter Cardiac monitor with defibrillator Ambu-bag

DOCUMENTATION CPR Record Form Nurse fills up the data and activities Team leader documents the CPR outcome

The algorithm Approach Emergency Cardiac Care(ECC)

The following clinical recomendations apply to all treament algorithms First, treat the patient not the monitor. Algorithms for cardiac arrest presume that the condition under discussion continually persists, that the patient remains in cardiac arrest, and that CPR is always perform.

Apply different interventions whenever appropriate indications exist. The flow diagrams present mostly Class I(acceptable, definitely effective)recomendations. The footnotes present Class IIa(acceptable, probably effective), band Class Iib (acceptable, possibly effective), and Class III (not indicated, may be harmful) recomendations.

Adequate oxygenation,airway, ventilation,. Chest compressions, and defibrillation are more important than administration of medications and takes precedence over initiating an intravenous line or ejecting pharmacologic agents. Several medications (epinephrine. Lidocaine, and atropine) can be administered via the endotracheal tube but the dose must be 2 2.5 times the intravenous dose. (use a catheter or suction tip which be passed beyond the tip of the endoctracheal tube.)

With a few exceptions, intravenous medications should always be administered rapidly, in bolus method. After each intravenous medication, give a 20-30 ml bolus of intraveus fluid and immediately elevate the extremity. This will enhance the delivery of drugs to the central circulation, which may take 1-2 minutes. Last, treat the patient, not the monitor.

Core ACLS Concepts

The Most Important Goal : > Cerebral The Patients :


For Many >> Their hearts should be too good to die. u For Some >> The last heartbeat should be the last.

Treat the patient, not the monitor

Cardio-pulmonary-cerebral resuscitation

purpose : to return the patient to his/her best possible neurological outcome.

Arrythmia Recognition

Important in any ACLS/ CPR sequence All algorithms start with identifying rhythm Cannot identify arrhytthmais- cannot mange corrrectly

The Beating Heart Electrophysiology

Electrical Stimulation & Contraction



Pacemaker impulses are initiated in the SA node, travelling through atrial pathways, at frequencies between 60-100bpm There is the presence of a P wave, followed by a QRS complex at a regular rate

Normal Sinus Rhythm

Look at the P waves ; rate is 60-100/min Cycle length do not vary by 10% PR interval is 0.12 0.20sec.

During ACLS/BLS: Patient is hooked to cardiac monitor/ defibrillator Patients heart rate is automatically detected Normal HR = 60 to 100 bpm

MANAGEMENT: A. No specific drug treatment B. Identification of cause C. Treatment of underlying cause D. Check hemodynamics

Characterized by tachycardia with a narrow QRS complex Sudden onset and termination 150-250 beats/min (180-200 bpm in adults) Regular rhythm QRS complex is normal in contour and duration No P waves

P waves are generally buried in the QRS complex Often, P wave is seen just prior to or just after the end of the QRS and cause a subtle alteration in the QRS complex that results in pseudo- s or pseudo - r

B. C. D.

Cardiovert the patient! Defibrillate the patient! Give Verapamil! Check hemodynamics

Prematurely occurring complex

Wide, bizarre looking QRS complex

Usually no preceding P waves T wave opposite in deflection to the QRS complex Complete compensatory pause following every premature beat

Before starting any resuscitative effort, the minimum personal protective equipment should include: u Gloves u Face mask u Goggles u Splash gown

Adult (1 to 2L) bag and the provider should deliver approximately 600 ml of tidal volume sufficient to produce chest rise over 1 second Open the airway adequately with a head tilt-chin lift, lifting the jaw against the mask and holding the mask against the face, creating a tight seal During CPR give 2 breaths (each 1 second) during a brief ( about 3 to 4 seconds) pause after every 30 chest compressions.

Use of 100% inspired oxygen (FiO2 1.0) as soon as it becomes

available is reasonable during resuscitation from cardiac arrest (Class IIa, LOE C)
Titrate oxygen administration to achieve arterial

oxyhemoglobin saturation > 94%

To facilitate delivery of ventilations with a bag-mask device, the nasopharyngeal airway can be used in patients with a compromised airway In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preffered (Class II a, LOE C)

ADVANTAGES Keeps airway patent Permits suctioning of airway secretions Enables delivery of a high concentration oxygen Provides an alternative route for administration of some drugs Facilitates delivery of a selected tidal volume With use of a cuff, may protect the airway from aspiration

Epinephrine Lidocaine Vasopressin

Endotracheal intubation is frequently associated with interruption of compressions for many seconds Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressionsa

Rescuer should record the depth of the tube as marked at the front of the teeth and secure it. Providers should verify correct placement of all advanced airways after insertion and whenever the patient is moved.


Chest x-ray Rationale: Confirm secure airway and detect causes or complications of arrest: pneumonitis, pneumonia, pulmonary edema.

After ROSC, routine hyperventilation leading to hypocapnia should be avoided to prevent additional cerebral ischemia. CONTROLLED OXYGENATION There is insufficient evidence to support or refute the use of titrated inspired oxygen content in the early care of cardiac arrest patients following sustained ROSC


Mechanical Ventilation o Rationale: Minimize acute lung injury, potential oxygen toxicity o Tidal volume 6 9ml/kg o Titrate minute ventilation to - PETCO2 35- 40 mm Hg - PaCO2 40- 45 mm Hg o Reduce FiO2 as tolerated to keep SpO2 or SaO2 > 94%


Electrical Therapies
Defibrillation Cardioversion Cardiac Pacing

Key Challenges (2010 Guidelines)

Improve time for Defibrillator Availability - Immediate AED availability - Improve response time and training Decrease interruptions in chest compressions pre and post shocks

Is the therapeutic use of electric current delivered in large amounts over very brief periods of time. Temporarily stuns an irregularly beating heart and allows more coordinated contractile activity to resume. Termination of VF for at least 5 seconds follwing the shock.


Sophisticated, reliable computerized devices that use voice and visual prompts to guide lay rescuers and health care providers to safely defibrillate VF SCA Recorded information about frequency and depth of chest compressions during CPR.


Defibrillation with biphasic waveforms uses relatively low energy ( < 200 J ) that is safe and has equivalent or higher efficacy for termination of VF than monophasic waveform shocks (class llb)

Synchronization avoids shock delivery during the relative refractory portion of the cardiac cycle, when a shock could produce VF. The energy (shock dose) used for a synchronized shock is lower than that used for unsynchronized shocks (defibrillation)


Deliver an electric stimulus through electrodes to the heart causing electrical depolarizations and subsequent cardiac contraction


Administer drugs by Bolus
20cc of saline or distilled water

Elevate the extremity for 10-20 seconds

Tracheal Drug Administration

NAVEL (Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine) Administer 2 to 2.5 times the recommended IV dose diluted in 10ml NSS or distilled water

ACLS DRUGS Agents used to Optimize Cardiac Output and blood pressure Agents used to treat Arrhythmias

Cardiac Arrest

Shock Heart Failure/ Pulmonary Edema, Misc; buffers




Deliver current of one polarity Monophasic damped sinusoidal waveforms (MDS) returns to zero gradually, whereas the Monophasic truncated exponential waveform current is abruptly returned to baseline to zero current flow. Initial shock is 360J and if VF persists, the subsequent shocks should be 360J

Time Sequence & Estimated Probability of Survival

Eisenberge, et al 1990



CPR Team & Organization

BLS & ACLS Training & Retraining, CPR Code Organization, Performance Evaluation & Peers Review

Core ACLS Concepts

Classification of Therapeutic Interventions in CPR & ECC Class I : acceptable, definitely effective Class II : acceptable, uncertain efficacy II a > probably effective II b > possibly effective & not harmful Class III : inappropriate & may be harmful

The Algorithm Approach in ACLS & ECC


the patient, not the monitor

Continue CPR (include defibrillation) is more important than the procedure and pharmacologic agents Flow diagrams: mostly class I, footnotes: class IIa, IIb, or III Most ACLS medications(but few exceptions) should be given as iv. bolus 2nd Syringe Technique for 20-30 ml. iv. bolus after each iv. medications Epinephrine, lidocaine, atropine, etc can be given via ET tube at 2-2.5 times of iv. Route

Summary : Ten Commandments for ACLS

1. Do good CPR : do CPR when indicated, not do when not indicated, and do well 2. Highest priority is the primary C A-B-D* survey & hunt for VF 3. The next highest priority is the secondary CA-B--D** survey 4. Know the defibrillator! : familiarize and daily maintenance check 5. Search for reversible or treatable causes.

Summary : Ten Commandments for ACLS

6. Know the ECC medications : Why?, When?, How?, and Watch out?!? 7. Be a good team : conductor or member 8. Practice the phase response resuscitation format : anticipation/entry/resuscitation/maintena nce/ family notification/transfer/critique 9. Determined code status in advance

Summary : Ten Commandments for ACLS


Learn and practice the most difficult resuscitation skills*:


not to start CPR when to stop CPR how to tell the family members how to talk with your colleagues

Even though its the most difficult,

but its more important & more challenging!