Advanced cardiac life support
Encyclopedia
Advanced cardiac life support or Advanced Cardiovascular Life Support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest
and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
Extensive medical knowledge and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers (e.g. physician
s, paramedic
s, nurses, respiratory therapists, clinical pharmacists, physician assistant
s, nurse practitioner
s, exercise physiologists and other specially trained health care providers) can provide ACLS, as it requires the ability to manage the patient's airway, initiate IV access, read and interpret electrocardiogram
s, and understand emergency pharmacology. 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 AED
s.
ACLS is an extension of BLS. It often starts with analysing 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. At this time, the ACLS personnel quickly search for possible causes of cardiac arrest (e.g., a heart attack
, drug overdose, or trauma). 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
. While the above mentioned ACLS steps are being carried out, it is crucial to continue chest compression with minimal interruptions. This point is emphasized repeatedly in the new ACLS guidelines.
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 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
.
and a new change in arrangement of CPR steps to be CAB rather than ABC.
The 2005 guidelines where 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.
s' - 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.
Notes on using the ACLS algorithm
and were updated in 1980, 1986, 1992, 2000, 2005, and 2010.
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
Extensive medical knowledge and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers (e.g. physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s, paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
s, nurses, respiratory therapists, clinical pharmacists, physician assistant
Physician assistant
A physician assistant/associate ' is a healthcare professional trained and licensed to practice medicine with limited supervision by a physician.-General description:...
s, nurse practitioner
Nurse practitioner
A Nurse Practitioner is an Advanced practice registered nurse who has completed graduate-level education . Additional APRN roles include the Certified Registered Nurse Anesthetist s, CNMs, and CNSs...
s, exercise physiologists and other specially trained health care providers) can provide ACLS, as it requires the ability to manage the patient's airway, initiate IV access, read and interpret electrocardiogram
Electrocardiogram
Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
s, and understand emergency pharmacology. Some health professionals, or even lay rescuers, may be trained in basic life support
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
(BLS), especially cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
or CPR. When a sudden cardiac arrest occurs, immediate CPR is a vital link in the chain of survival
Chain of survival
The chain of survival refers to a series of actions that, when put into motion, reduce the mortality associated with cardiac arrest. Like any chain, the chain of survival is only as strong as its weakest link...
. Another important link is early defibrillation
Defibrillation
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator...
, which has improved greatly with the widespread availability of AED
Automated external defibrillator
An automated external defibrillator or AED is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient, and is able to treat them through defibrillation, the application of...
s.
ACLS is an extension of BLS. It often starts with analysing 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
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
and amiodarone
Amiodarone
Amiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias , both ventricular and supraventricular arrhythmias. Discovered in 1961, it was not approved for use in the United States until 1985...
, are then administered. At this time, the ACLS personnel quickly search for possible causes of cardiac arrest (e.g., a heart attack
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
, drug overdose, or trauma). 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
Chest tube
A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid , or pus from the intrathoracic space...
for those with tension pneumothoraces
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
or hemothoraces
Hemothorax
A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
. While the above mentioned ACLS steps are being carried out, it is crucial to continue chest compression with minimal interruptions. This point is emphasized repeatedly in the new ACLS guidelines.
2010 guidelines
The ACLS guidelines were updated by the American Heart AssociationAmerican Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
and the International Liaison Committee on Resuscitation
International Liaison Committee on Resuscitation
The International Liaison Committee on Resuscitation was formed in 1992 to provide an opportunity for the major organizations in resuscitation to work together on CPR and ECC protocols...
in 2010. New ACLS guidelines focus on BLS as the core component of ACLS. Foci also include end tidal 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
Pulseless electrical activity
Pulseless electrical activity or PEA refers a cardiac arrest situation in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not...
(PEA) and asystole
Asystole
In medicine, asystole is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow...
.
and a new change in arrangement of CPR steps to be CAB rather than ABC.
2005 guidelines
The 2005 guidelines acknowledged that high quality chest compressions and early defibrillation were 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 where published in Circulation. The major source for ACLS courses and textbooks in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
is the American Heart Association
American Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
; in Europe, it is the European Resuscitation Council
European Resuscitation Council
The European Resuscitation Council is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was established in 1989....
(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.
Algorithms
The current ACLS guidelines are set into several groups of 'algorithmAlgorithm
In mathematics and computer science, an algorithm is an effective method expressed as a finite list of well-defined instructions for calculating a function. Algorithms are used for calculation, data processing, and automated reasoning...
s' - 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.
Notes on using the ACLS algorithm
- Search for and correct potentially reversible causes of arrest, brady/tachycardia.
- Exercise caution before using epinephrineEpinephrineEpinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
in arrests associated with cocaine or other sympathomimetic drugs. - Give atropineAtropineAtropine is a naturally occurring tropane alkaloid extracted from deadly nightshade , Jimson weed , mandrake and other plants of the family Solanaceae. It is a secondary metabolite of these plants and serves as a drug with a wide variety of effects...
1 mg dose (IVIntravenous therapyIntravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
) for asystoleAsystoleIn medicine, asystole is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow...
or slow PEAPulseless electrical activityPulseless electrical activity or PEA refers a cardiac arrest situation in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not...
(rate<60/min) (No longer recommended.) - In PEAPulseless electrical activityPulseless electrical activity or PEA refers a cardiac arrest situation in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not...
arrests associated with hyperkalemiaHyperkalemiaHyperkalemia refers to the condition in which the concentration of the electrolyte potassium in the blood is elevated...
, hypocalcemia. or channel blocking drug overdose, give 10mL 10% calcium chlorideCalcium chlorideCalcium chloride, CaCl2, is a salt of calcium and chlorine. It behaves as a typical ionic halide, and is solid at room temperature. Common applications include brine for refrigeration plants, ice and dust control on roads, and desiccation...
(IVIntravenous therapyIntravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
) (6.8 mmol/L) - Consider amiodaroneAmiodaroneAmiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias , both ventricular and supraventricular arrhythmias. Discovered in 1961, it was not approved for use in the United States until 1985...
for ventricular fibrillationVentricular fibrillationVentricular fibrillation is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly. Ventricular fibrillation is a medical emergency and most commonly identified arrythmia in cardiac arrest...
/pulseless ventricular tachycardiaVentricular tachycardiaVentricular tachycardia is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart...
after 3 attempts at defibrillation. - For torsades de pointesTorsades de pointesTorsades de pointes, or simply torsades, is a French term that literally means "twisting of the points". It was first described by Dessertenne in 1966 and refers to a specific, rare variety of ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram .- Presentation...
, refractory VF in patients with digoxinDigoxinDigoxin INN , also known as digitalis, is a purified cardiac glycoside and extracted from the foxglove plant, Digitalis lanata. Its corresponding aglycone is digoxigenin, and its acetyl derivative is acetyldigoxin...
toxicity or hypomagnesemiaHypomagnesemiaHypomagnesemia is an electrolyte disturbance in which there is an abnormally low level of magnesium in the blood. Usually a serum level less than 0.7 mmol/L is used as reference. The prefix hypo- means low . The middle 'magnes' refers to magnesium...
, give IVIntravenous therapyIntravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
magnesium sulfateMagnesium sulfateMagnesium sulfate is a chemical compound containing magnesium, sulfur and oxygen, with the formula MgSO4. It is often encountered as the heptahydrate epsomite , commonly called Epsom salt, from the town of Epsom in Surrey, England, where the salt was distilled from the springs that arise where the...
8 mmol (4mL of 50% solution)
History
The ACLS guidelines were first published in 1974 by the American Heart AssociationAmerican Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
and were updated in 1980, 1986, 1992, 2000, 2005, and 2010.
External links
}}- European 2005 guidelines from European Resuscitation CouncilEuropean Resuscitation CouncilThe European Resuscitation Council is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was established in 1989....