Advanced cardiac life support
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. In the UK, a parallel protocol (advanced life support) is used.
Only qualified health care providers can provide ACLS, as it requires the ability to manage the patient's airway, initiate IV access, read and interpret electrocardiograms, and understand emergency pharmacology; these include physicians (DOs and MDs), pharmacists (PharmDs), dentists (DDS and DMDs), advanced practice providers (PAs and NPs), respiratory therapists (RTs), nurses (RNs), paramedics (EMT-Ps) and advanced emergency medical technicians (AEMTs). Other emergency responders may also be trained.
Some health professionals, or even lay rescuers, may be trained in basic life support (BLS), especially cardiopulmonary resuscitation or CPR. When a sudden cardiac arrest occurs, immediate CPR is a vital link in the chain of survival. Another important link is early defibrillation, which has improved greatly with the widespread availability of Automated External Defibrillators (AEDs).
ACLS often starts with analyzing the patient's heart rhythms with a manual defibrillator. In contrast to an AED in BLS, where the machine decides when and how to shock a patient, the ACLS team leader makes those decisions based on rhythms on the monitor and patient's vital signs. The next steps in ACLS are insertion of intravenous (IV) lines and placement of various airway devices. Commonly used ACLS drugs, such as epinephrine and amiodarone, are then administered. The ACLS personnel quickly search for possible reversible causes of cardiac arrest (i.e. the H's and T's, heart attack). Based on their diagnosis, more specific treatments are given. These treatments may be medical such as IV injection of an antidote for drug overdose, or surgical such as insertion of a chest tube for those with tension pneumothoraces or hemothoraces.
The American Heart Association and the International Liaison Committee on Resuscitation performs a science review every five years and publishes an updated set of recommendations and educational materials. Following are recent changes.
The ACLS guidelines were updated by the American Heart Association and the International Liaison Committee on Resuscitation in 2010. New ACLS guidelines focus on BLS as the core component of ACLS. Foci also include end tidal CO
2 monitoring as a measure of CPR effectiveness, and as a measure of ROSC. Other changes include the exclusion of atropine administration for pulseless electrical activity (PEA) and asystole. CPR (for ACLS and BLS) was reordered from "ABC" to "CAB" (circulation, airway, breathing) to bring focus to chest compressions, even recommending compression-only CPR for laypersons. (note, however, that in pediatric resuscitation, respiratory arrest is more likely to be the main cause of arrest than adults.)
The 2005 guidelines acknowledged that high quality chest compressions and early defibrillation are the key to positive outcomes while other "typical ACLS therapies ... "have not been shown to increase rate of survival to hospital discharge". In 2004 a study found that the basic interventions of CPR and early defibrillation and not the advanced support improved survival from cardiac arrest.
The 2005 guidelines were published in Circulation. The major source for ACLS courses and textbooks in the United States is the American Heart Association; in Europe, it is the European Resuscitation Council (ERC). Most institutions expect their staff to recertify at least every two years. Many sites offer training in simulation labs with simulated code situations with a dummy. Other hospitals accept software-based courses for recertification. An ACLS Provider Manual reflecting the new Guidelines is now available.
Stroke is also included in the ACLS course with emphasis on the stroke chain of survival.
The current ACLS guidelines are set into several groups of "algorithms" - a set of instructions that are followed to standardize treatment, and increase its effectiveness. These algorithms usually come in the form of a flowchart, incorporating 'yes/no' type decisions, making the algorithm easier to memorize.
Types of algorithms
Cardiac Arrest Algorithm
Acute Coronary Syndromes Algorithm
VF/Pulseless VT Algorithm
Suspected Stroke Algorithm
Notes on using the ACLS algorithm
- Search for and correct potentially reversible causes of arrest, brady/tachycardia.
- Exercise caution before using epinephrine in arrests associated with cocaine or other sympathomimetic drugs. Epinephrine is not required until after the second DC shock in standard ACLS management as DC shock in itself releases significant quantities of epinephrine
- Give atropine 1 mg dose (IV) bolus for asystole or slow PEA (rate<60/min) (No longer recommended.)a
- In PEA arrests associated with hyperkalemia, hypocalcemia. or Ca2+
channel blocking drug overdose, give 10mL 10% calcium chloride (IV) (6.8 mmol/L)
- Consider amiodarone for ventricular fibrillation/pulseless ventricular tachycardia after 3 attempts at defibrillation, as there is evidence it improves response in refractory VF / VT.(Note: as of the 2010 guidelines, amiodarone is preferred as the first-line antiarrythmic, moving lidocaine to a second-line backup if amiodarone is unavailable
- For torsades de pointes, refractory VF in patients with digoxin toxicity or hypomagnesemia, give IV magnesium sulfate 8 mmol (4mL of 50% solution)
- In the 2010 ACLS pulseless arrest algorithm, vasopressin may replace the first or second dose of epinephrine. The inclusion of vasopressin is due to its theoretical benefit over epinephrine in cardiac arrest. Vasopressin lacks intrinsic activity at cardiac beta-1 receptors, reducing myocardial and cerebral oxygen demand compared to epinephrine in an oxygen-deprived state. Studies in humans have failed to demonstrate a clinical benefit over epinephrine. In a systematic review and meta-analysis (Aung and Htay, 2005), five key variables were reviewed and were found to have no significant difference between epinephrine and vasopressin, regardless of the initial cardiac rhythm which initiated the code (Ventricular Fibrillation/Tachycardia, Pulseless Electrical Activity, or Asystole). Variables analyzed included failure of return of spontaneous circulation (ROSC) (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.58-1.12), death before hospital admission (RR, 0.72; 95% CI, 0.38-1.39), death within 24 hours (RR, 0.74; 95% CI, 0.38-1.43), death before hospital discharge (RR, 0.96; 95% CI, 0.87-1.05), or combination of number of deaths and neurologically impaired survivors (RR, 1.00; 95% CI, 0.94-1.07).
- Patient’s with a PETCO2 levels less than 10 mm Hg during CPR will not achieve ROSC (return of spontaneous circulation). It is recommended to switch the rescuer performing chest compressions, to improve the PETCO2.
- ACLS: Principles and Practice. Dallas: American Heart Association. 2003. p. 1. ISBN 0-87493-341-2.
- Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. “Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S685–S705. http://circ.ahajournals.org/content/122/18_suppl_3/S685
- NeumarRW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, OrnatoJP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, SinzE, Morrison LJ. "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" Circulation 2010; 122(suppl 3) S729–S767.
- Field JM, Hazinski MF, Sayre MR, et al. (November 2010). "Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 122 (18 Suppl 3): S640–56. doi:10.1161/CIRCULATIONAHA.110.970889. PMID 20956217.
- Hazinski MF, Nolan JP, Billi JE, et al. (October 2010). "Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations". Circulation 122 (16 Suppl 2): S250–75. doi:10.1161/CIRCULATIONAHA.110.970897. PMID 20956249.
- Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth to mouth ventilation N Engl J Med. 2000;342:1546-1553
- 2005 American Heart Association Guidelines, p. IV-58 Part 7.2: Management of Cardiac Arrest
- Stiell IG, Wells GA, Field B, et al. (August 2004). "Advanced cardiac life support in out-of-hospital cardiac arrest". N. Engl. J. Med. 351 (7): 647–56. doi:10.1056/NEJMoa040325. PMID 15306666.
- 2005 American Heart Association Guidelines, p. IV-58
- Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. “Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S818–S828. http://circ.ahajournals.org/content/122/18_suppl_3/S818
- Bode, F. "Differential effects of defibrillation on systemic and cardiac sympathetic activity".
- Neumar RW, Otto CW, Link MS, et al. (November 2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224.
- ACLS Subcommittee 2010-2011, Clifton W. Callaway, MD, PhD, Chair et al. (2011). Advanced Cardiovascular Life Support Provider Manual, Professional. p. 72.
- Aung K, Htay T. (2005). "Vasopressin for Cardiac Arrest: A Systematic Review and Meta-analysis". Arch Intern Med. 165 (1): 17–24. doi:10.1001/archinte.165.1.17. PMID 15642869.
- Mutchner L (January 2007). "The ABCs of CPR—again". Am J Nurs 107 (1): 60–9; quiz 69–70. doi:10.1097/00000446-200701000-00024. PMID 17200636.
- "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science". Circulation 122 (18 Suppl 3). November 2010.
- Ecc Committee, Subcommittees and Task Forces of the American Heart Association (December 2005). "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 112 (24 Suppl): IV1–203. doi:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375.
- European 2005 guidelines from European Resuscitation Council