ADVANCED

CARDIAC LIFE
SUPPORT

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• ACLS is systematic approach to assess and treat
cardiac arrest and acutely ill patients.

• It is built heavily upon the foundation of BLS

PRIMARY
BLS ASSESSMENT

SECONDARY
ASSESSMENT

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 BLS ACLS

• Non-invasive • Invasive maneuvers

• No medications • Along with medications
administered • Medical personnel specialized
• Can be done by anyone • Defibrillator, cardiac monitors used
trained • Team of workers- doctors, nurses,
• No advanced equipments paramedic, emergency medical
• Two person/ technician technician
suffice • Basic treatments for cuts and
• No right to give basic injuries can be given
treatment

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 Introduction : ACLS

• Advanced cardiac life support or advanced

cardiovascular life support protocols refer to a series
of evidence based responses simple enough to be
committed to memory, recall and execute under
moments of stress.

• AMERICAN HEART ASSOCIATION (AHA) protocols are

considered to be the GOLD standard ACLS protocols,
it gets reviewed every 5 year.

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5
 OBJECTIVES

• On recognition of a cardiac arrest event, a layperson should

simultaneously and promptly activate the emergency response system
and initiate cardiopulmonary resuscitation (CPR).
• Performance of high-quality CPR includes adequate compression
depth and rate while minimizing pauses in compressions,
• Early defibrillation with concurrent high-quality CPR is critical to
survival when sudden cardiac arrest is caused by ventricular
fibrillation or pulseless ventricular tachycardia.
• Administration of epinephrine with concurrent high-quality CPR
improves survival, particularly in patients with non-shockable
rhythms.

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• Post–cardiac arrest care is a critical component of the Chain of
Survival and demands a comprehensive, structured, multidisciplinary
system that requires consistent implementation for optimal patient
outcomes.
• Prompt initiation of targeted temperature management is necessary
for all patients who do not follow commands after return of
spontaneous circulation to ensure optimal functional and
neurological outcome.
• Accurate neurological prognostication in brain-injured cardiac arrest
survivors is critically important to ensure that patients with
significant potential for recovery are not destined for certain poor
outcomes due to care withdrawal.
• Recovery expectations and survivorship plans that address treatment,
surveillance, and rehabilitation need to be provided to cardiac arrest
survivors and their caregivers at hospital discharge to optimize
transitions of care to home and to the outpatient setting.

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AHA Adult Chains of Survival

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 Team dynamics : 6 members
1. Team leader :
• assign roles
• Monitoring
• Encouraging
• Debriefing
2. Chest Compressions
3. Airway
4. Breathing
5.Defibrillation
6. Iv line and medication
7. Recording events
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• ROLE :
• Should have specific role and responsibilities
• Knowing your limitations
• Constructive intervention (positive feedback)
• What to communicate :
• Knowledge sharing
• Summarise and re-evaluate
• How to communicate :
• Closed loop communication
• Mutual respect
• De briefing

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Adult Cardiac Arrest Algorithm

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 CIRCULATION
 Are chest compressions effective?
 What is the cardiac rhythm?
 Is defibrillation or cardioversion indicated?
 Has IV/IO access been established?
 Is ROSC present?
 Is the patient with a pulse unstable?
 Are medications needed for rhythm or blood pressure?
Does the patient need volume (fluid) for resuscitation

AIRWAY
 Is the airway patent? BREATHING
 Is an advanced airway  Are ventilation and oxygenation
indicated? adequate?
 Is proper placement of airway  Are quantitative waveform
device confirmed? capnography and oxyhemoglobin
 Is tube secured and placement saturation monitored
reconfirmed frequently

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PUSH HARD, PUSH FAST!!
• Place the heel of the dominating
hand on the lower half of the
sternum
• Place other hand on top
• Interlock fingers
• Compress the chest

• Rate 100 per min

• Depth 2-2.4 inches for adults, not
greater than 2.5 inches or 6cm
• Depth of 1.5 inches of infants
• When possible change Operator
every 2 min.
 HIGH QUALITY CPR

• Compress the center of the chest HARD and FAST

• 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
 Defibrillation
• Defibrillation is a shock that does not synchronize with R wave.

Defibrillation
• Biphasic wave form: 120- 200 J
• Monophasic wave form: 360 J
• AED- device specific

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Monophasic vs biphasic

• Monophasic defibrillation delivers a charge in only one

direction.

• Biphasic defibrillation delivers a charge in one

direction for half of the shock and in the electrically
opposite direction for the second half.

• Biphasic waveforms defibrillate more effectively and at

lower energies than monophasic waveforms

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 HOW TO USE DEFIBRILLATOR
• Safety precautions :

• If patient not intubated remove O2 delivery devices.

• If available use self adhesive defibrillation paddles.

• Do not place over pacemakers.

• Remove transdermal patches.

• Do not defibrillate in the presence of inflammable agents

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 PROCEDURE
• Place sternal paddle over right border of sternum below clavicle
• Place apical paddle in mid axillary line in 5th IC space
• Switch on the defibrillator
• Charge the defibrillator to 200J or 360J
• Warn all other rescuers to stand clear-
‘ARE YOU CLEAR’ (Visually check all are clear)
• Ensure yourself you are not touching patient or bed
‘I AM CLEAR’
• Deliver shock
• Restart cpr with out checking pulse.

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Complications :
• Skin burns
• Electrocution
• Post shock arrhythmias
• Myocardial injury
• Pulmonary embolism
• Transient hypotension

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Pharmacotherapy

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Routes of Administration

• Peripheral IV – must be followed by 20 ml

NS push
• Central IV – faster onset of action, (not to
wait or waste time for securing a CV line)
• Intraosseous – alternative IV route in
pediatric age group, also in Adult
• Intratracheally (down an ET tube)- not
recommended

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Intra osseous access

• Only a temporary measure

• Large bore ( 8-10 Fr) and stout
• needle is used
• Site :
• tibial tuberosity (shin of tibia)
• Humerus
• Sternum
• hip
• Procedure : enter full depth
• in rotatory motions perpendicularly
• Confirmation : thick blood (marrow)
• Complications : compartment syndrome
• It can be retained untill patient is resuscitated/ visible veins/iv line secured (
max 24hrs)
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 Epinephrine

• Alpha, beta-1, and beta-2 stimulation

• Increases heart rate, stroke volume and blood
pressure
• IV or IO Dose: 1 mg every 3-5 minutes
• May increase ischemia because of increased O2 demand
by the heart
• Paediatric iv or io dose : 0.01mg/kg every 3-5min
• Endotracheal dose : 0.1mg/kg and 2-2.5mg in adults

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 Amiodarone
• Indications:
VT, VF
• Adult :
• First dose : 300 mg in 20-30 ml of NS bolus
• Supplemental dose of 150 mg in 20-30 ml of NS
• Paediatric :
• 5mg/kg bolus, may repeat upto 3 total doses for
refractory VF or pVT

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 Lidocaine
• Decreases phase 4 of depolarisation
• Depresses conduction in re entry pathways
• Use only after ROSC

• Adult IV dose :
• 1st dose : 1-1.5 mg/kg bolus
• 2nd dose : 0.5-0.75 mg/kg
• Paediatric dose :
• 1mg/kg loading dose

• Signs of toxicity: slurred speech, seizures, altered consciousness

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 AIRWAY MANAGEMENT

AIRWAY MANEUVERS
BAG AND MASK
ORO PHARYNGEAL AIRWAY
SUPRA GLOTTIC AIRWAY DEVICES
DEFINITIVE AIRWAY
PERCUTANEOUS
CRICOTHYROTOMY
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AIRWAY MANEUVERS
• Opening airway – Head tilt, chin lift or jaw thrust
• Explore the airway for foreign bodies, dentures and
remove them.

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 Ventilating with an ETT
• The volume should cause visible chest rise
• Provide slightly higher volume for obese patients

• Rate : 1 breath every 6 seconds when delivering

ventilation during CPR.

• Compression-ventilation cycles : once an advanced

airway is in place, the health care provider should
provide continous compressions and asynchronous
ventilations once in every 6 seconds

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 Return of spontaneous circulation

• Palpable pulse and recordable blood pressure

• Abrupt sustained increase in ETCO2 (>40mmhg)
• Spontaneous arterial pressure waves with intra
arterial monitoring

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 Early recognition and prevention

5H’s 5T’s
• Hypovolemia • Tension pneumothorax
• Hypoxia • Tamponade-cardiac
• Hydrogen ion(acidosis) • Toxins
• Hypo/hyperkalemia • Thrombosis-pulmonary
• Hypothermia • Thrombosis-coronary

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1.Start CPR. Start CPR with hard and fast compressions,
around 100 to 120 per minute, allowing the chest to
completely recoil.

2.Give the patient oxygen and attach a monitor or

defibrillator.

3.Make sure to minimize interruptions in chest

compressions and avoid excessive ventilation, using a 30
to 2 compression-to-ventilation ratio if no airway is
established.

4.Rhythm shockable? Conduct a rhythm check, making sure

the pause in chest compressions is not more than 10
seconds. 33
VF/pVT (Shockable rhythm).

If a shockable rhythm is present, either v-fib or pulseless v-tach, begin

the charging sequence on the defibrillator and resume chest
compressions until the defibrillator is charged.

1. Shock. When the defibrillator is charged, announce the shock

warning and make sure no one is touching the patient. Shock
the patient with an initial dose of 120 to 200 joules.

2. CPR – 2 min. Immediately resume CPR for 2 minutes, and

establish IV access.

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3. Rhythm Shockable? Check for pulse and rhythm for no more
than 10 seconds every 2 minutes.

• No. If the patient shows signs of return of spontaneous

circulation, or ROSC, administer post-cardiac care. If a
nonshockable rhythm is present and there is no pulse,
continue with CPR and move to the algorithm for asystole or
PEA.
• Yes – Shock. If the rhythm is shockable, announce the shock
warning and make sure no one is touching the patient.
Administer the shock.

• CPR – 2 min. Continue with CPR for 2 minutes. Give the

patient a vasopressor such as epinephrine every 3 to 5
minutes, and consider advanced airway and capnography,
giving 1 breath every 6 seconds once the advanced airway is
in place.
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4. Rhythm Shockable? Check for pulse and rhythm for no more
than 10 seconds every 2 minutes.

• No. If the patient shows signs of return of spontaneous

circulation, or ROSC, administer post-cardiac care. If a
nonshockable rhythm is present and there is no pulse, continue
with CPR and move to the algorithm for asystole or PEA.
• Yes – Shock. If the rhythm is shockable, announce the shock
warning and make sure no one is touching the patient. Administer
the shock.
• CPR – 2 min. Continue with CPR for 2 minutes. Consider giving the
patient an antiarrhythmic drug such as amiodarone for refractory
v-fib or pulseless v-tach, and treat reversible causes :
hypovolemic, hypoxia, hydrogen ions, hypo and hyperkalemia,
hypothermia, tension pneumothorax, tamponade, toxins, and
thrombosis.

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Asystole/PEA. (non shockable)

If a nonshockable rhythm is present, and the rhythm is organized,

check for a pulse. Make sure the pause in chest compressions to
check the rhythm is not more than 10 seconds.

• CPR – 2 min. Continue with CPR for 2 minutes, and establish IV

access. Give the patient a vasopressor such as epinephrine every
3 to 5 minutes, and consider advanced airway and capnography,
giving 1 breath every 6 seconds once the advanced airway is in
place.

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• Rhythm Shockable? Check for pulse and rhythm for no more
than 10 seconds every 2 minutes.
• Yes. If the rhythm changes to a V-fib or V-tach shockable
rhythm, move to that algorithm and prepare to shock the
patient.
• CPR – 2 min. If a nonshockable rhythm is still present with no
pulse, continue with CPR for 2 minutes, and treat reversible
causes.

• Rhythm Shockable? Check for pulse and rhythm for no more

than 10 seconds every 2 minutes.
• Yes. If the rhythm changes to a V-fib or V-tach shockable
rhythm, move to that algorithm and prepare to shock the
patient.
• CPR – 2 min. If the patient shows signs of return of
spontaneous circulation, or ROSC, administer post-cardiac
care. If a nonshockable rhythm is present and there is no
pulse, continue with CPR.
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Adult Post–Cardiac Arrest Care Algorithm

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• The control of core body temperature by targeted
temperature management (TTM) has been an important
neuroprotective strategy in postresuscitation care.

• Options in temperature management comprise targeted

hypothermia, usually defined as lowering core body
temperature to 32 °C to 36 °C, and targeted normothermia,
which aims for a core body temperature of <37.7 °C, with
fever prevention in the further course of treatment.

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Cooling techniques for targeted temperature
management.
A.Ice packs applied to the torso, neck, and proximal limbs.
B.Infusion of cold saline via central access.
C.Surface‐based cooling system using circulating water/air
or gel pads in conjunction with computerized temperature
control unit.
D.Cooling catheter inserted into the femoral vein with
closed‐loop intravascular circulation of cooling fluids.
E.Intranasal cooling system featuring evaporated liquid
coolant mixed with air
F.Heat exchanger module directly incorporated in an
extracorporeal life support circuit.
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 Monitoring and Recognition of
Arrhythmia

• ACLS often starts with analyzing the patients heart rhythms with
a manual defibrillator.

• In contrast to an AED in BLS, where the machine makes the

determination as to when to defibrillate a patient ,the ACLS team
leader makes those decisions based on the rhythms on the
monitor and the patients vital signs.

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 Monitoring and Recognition of
Arrhythmia
Bradyarrhythmias Tachyarrhythmias
• Sinus bradycardia Narrow QRS complex Wide QRS complex
(SVT) tachycardias tachycardias (QRS >
0.12 second)
• Various forms of (QRS<0.12 second)
heart block 1. Ventricular premature
1. Sinus tachycardia beat (VPB) /
Ventricular
1. First degree 2. Atrial premature beat extrasystole
2. Second degree
3. Atrial tachycardia 2. Ventricular
3. Complete tachycardia(VT)
4. BBB 4. Atrial flutter
3. Ventricular fibrillation
5. Atrial fibrillation 4. Torsades de pointes

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 Identifying arrythmias

Shockable Non shockable

• Ventricular tachycardia • Asystole
• Ventricular fibrillation • PEA- pulselesselectrical
activity or EMD
(electromechanical
Dissociation)

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 Ventricular tachycardia
• R-R interval usually regular(not always)
• QRS not preceded by P wave
• Wide and bizzare QRS.
• Difficult to find seperation between QRS and T
wave
• Rate=100-250bpm

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Torsades de Pointes
• It is a distinctive form of polymorphic ventricular tachycardia
characterized by a gradual change in the amplitude and twisting
of the QRS complexes around the isoelectric line.

•Rate cannot be determined.

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 Ventricular fibrillation

• A severely abnormal heart rhythm (arrhythmia)

that can be life-threatening (results in absence of
cardiac output )
• No identifiable P, QRS or T wave
• Emergency- requires Basic Life Support
• Rate cannot be determined , rhythm unorganized
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 Vagal maneuvers
• ECG should be continuously monitored

• Infant and younger children :

• Application of bag filled with ice and cold water over the face
for 15 to 30 seconds
• Rectal stimulation using a thermometer

• Older children :
• Bearing down (valsalva maneuver) for 15 to 20 seconds

• Carotid massage and orbital pressure (not to be done in children)

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 Asystole
•A state of no cardiac electrical activity,
•Rate, rhythm, p and QRS are absent
•Rule out : disconnected leads

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 Pulseless electrical activity
• Pulseless electrical activity (PEA)

• unresponsiveness and no palpable pulse

• some organized cardiac electrical activity.

• previously referred to as electromechanical dissociation

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• RATE: <60/min
• Rhythm: sinus
• PR : Regular (0.12-0.2s)
• P waves : size and shape normal: every P wave
followed by QRS complex
• QRS complex : Narrow<0.12 s(often)in absence of
intraventricular conduction defect
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Rate : seen with both tachy and bradycardia

Rhythm: sinus, regular

PR: Prolonged >0.20s and fixed

P waves: size and shape normal

every QRS complex is preceded by P wave

QRS complex: Narrow<0.12s in absence of intraventricular

conduction defect
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• Rate: atrial rate slightly faster than ventricular rate(due to
dropped conduction,)usually within normal range

• Rhythm: irregular with intermediate conduction of p waves

• PR: progressive prolonging of PR interval occurs from cycle to

cycle, until one P wave is not followed by QRS
complex(dropped beat)

• P waves: size and shape normal

• QRS complexes : <0.12s 54

• Rate : variable
• Rhythm: Atrial : regular, constant p-p interval
Ventricular : irregular , 2:1 or 3:1 block

• PR: no progressive prolongation

• Pwaves: typical in size and shape , some P waves will not be

conducted , therefore not followed by QRS complex

• QRS complex: Narrow(<0.12s) implies high block relative to AV node

Wide(>0.12s) implies low block relative to AV node

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• Atrial rate : 60-100bpm; impulses are completely dissociated
from the slower ventricular rate

• Ventricular rate: ventricular escape rate is usually 25-45 per

min

• Rhythm : independent atrial and ventricular rhythm

• No relationship between p wave and qrs complex

• Pwaves : normal with atrial rate greater than ventricular rate

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Adult Bradycardia Algorithm

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 Sinus tachycardia :
• Rate : > 100bpm
• Rhythm : regular
• P wave : identical , all followed by qrs complex
• PR interval : 0.12-0.20 sec
• QRS < 0.12sec

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 Atrial fibrilation Atrial flutter

Atrial Rate 300-400beats/min 240-350beats/min

QRS : 160-180 bpm QRS : around 150bpm
Rhythm irregular regular

Pwaves Fibrillatory waves only No true P wave,

Fine oscillations at the flutter wave in classic
baseline “sawtooth” pattern
PR Can’t measure Can’t measure

QRS Remains <0.12s unless QRS Remains <0.12s unless QRS

complex is distorted by complex is distorted by
fibrillation flutter waves
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Adult Tachycardia With a Pulse Algorithm

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ACLS Termination of Resuscitation

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References
• ACLS focused update 2019.
• Emergency and critical care pocket guide 8th ed
• Adult ACLS 2020 AHA guidelines for CPR AND ECC
• Miller's_Anesthesia,_9th_Ed
• Morgan Clinical Anaesthesiology 6th ed
• The ECG made easy John R. Hampton 8th ed

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