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 cardiovascular emergencies, as well as the knowledge and skills to deploy those interventions. Outside North America, Advanced Life Support is used.
Only qualified health care providers can provide ACLS, as it requires the ability to manage the person's airway, initiate intravenous (IV) access, read and interpret electrocardiograms, and understand emergency pharmacology; these include physicians, pharmacists (PharmDs), dentists, advanced practice providers (PAs and NPs), respiratory therapists (RTs), nurses (RNs,LVNs), paramedics (EMT-Ps) and Advanced EMT’s (AEMT’s). 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, which makes up the core foundation of ACLS. 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 makes the determination as to when to defibrillate (shock) a patient, the ACLS team leader makes those decisions based on rhythms on the monitor and the patient's vital signs. The next steps in ACLS are insertion of intravenous (IV) lines and placement of various airway devices, such as an endotracheal tube (an advanced airway used in intubations). 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. These guidelines are often synonymously referred to as Emergency Cardiovascular Care (ECC) Guidelines. Following are recent changes.
The 2015 ACLS guidelines promoted minor tweaks and improvements to the 2010 guidelines with no major changes. Some changes included:
- In conjunction with the BLS guidelines, the update promoted the use of mobile phones to activate the Emergency Response System as well as notify nearby rescuers.
- It was recommended that emergency medical dispatchers receive better guidance on recognizing potential Cardiac Arrests and agonal breathing to promote more immediate CPR instructions.
- Lay persons are further encouraged to perform continuous hands-only CPR at a minimum until EMS arrival.
- An upper boundary for the number of chest compressions was added at 120 per minute, making the current recommendation 100-120 per minute. The 2010 guidelines only stated 100+ per minute.
- An upper boundary on the depth of chest compressions was added at 2.4 inches, making the current recommendation 2-2.4 inches. The 2010 guidelines only stated at least 2 inches.
- Added BLS and lay person administration of naloxone (IM or IN) for suspected opiate overdoses.
- For simplicity, vasopressin was removed from the Cardiac Arrest Algorithm.
- Waveform capnography was further emphasized and an ETCO2 of less than 10 mmHg after 20 minutes of resuscitation was added as legitimate factor in the decision to terminate resuscitation.
- Targeted temperature management was further refined with a new goal range 32-36 °C.
- Routine atropine use in intubations is no longer recommended unless there is a high risk for bradycardia.
- The OHCA and IHCA (Out of hospital cardiac arrest) and (In Hospital Cardiac arrest) Chain also has been added as different ones. Separate Chains of Survival have been recommended that identify the different pathways of care for patients who experience cardiac arrest in the hospital as distinct from out-of-hospital settings.
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
Pulseless Electrical Activity (PEA)/Asystole Algorithm
Ventricular Fibrillation (VF)/Pulseless Ventricular Tachycardia (VT) Algorithm
Respiratory Arrest Algorithm
Opioid Emergency Algorithm
Post-Cardiac Arrest Algorithm
Suspected Stroke Algorithm
Using the algorithm
- Search for and correct potentially reversible causes of arrest, brady/tachycardia.The reversible causes of cardiac arrests are colloquially referred to as the 5 Hs and Ts. The H’s stand for the following: Hypovolemia; Hypoxia/Hypoxemia; Hydrogen Ion Excess (Acidosis); Hypokalemia/Hyperkalemia; and Hypothermia while the T’s represent: Tamponade (Cardiac); Toxins; Tension Pneumothorax; and Thrombosis (Coronary or Pulmonary).
- 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
- Administration of atropine 1 mg dose (IV) bolus for asystole or slow PEA (rate<60/min) is no longer recommended.
- 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 people 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.
- British Heart Foundation
- Indian Heart Association
- Resuscitation Council (UK)
- Pediatric Advanced Life Support
- 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.
- "HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC" (PDF). American Heart Association. 2015. Retrieved March 1, 2016.
- "Executive Summary of the 2015 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care". www.jems.com. Retrieved 2016-03-02.
- 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 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.