Essentials of Advanced Cardiac Life Support

Ashok N

Consultant and Clinical Lead, Department of Emergency Medicine, Kauvery Hospital, Alwarpet

Introduction

Basics: 4 Cardiac arrest rhythms

2 Shockable

Pulseless Ventricular tachycardia (pVT)

Ventricular fibrillation (VF)

2 Non shockable

Asystole

Pulseless electrical activity (PEA)

Most important points

  1. Excellent cardiopulmonary resuscitation and
  2. Early defibrillation – for appropriately shockable rhythm

They remain the cornerstones of basic life support BLS and ACLS.

CPR

  • Anything short of excellent CPR does not achieve adequate cerebral and coronary perfusion.
  • Chest compressions must be performed throughout the resuscitation without interruption,
  • using proper timing (100 to 120 compressions per minute) and force (5 to 6 cm [2 to 5 inches] depth), and allowing for complete chest recoil.
  • Interruptions should be less than 10
  • Excellent chest compressions take priority over ventilation
  • CPR is continued for 2 minutes, Before pulse check and Switching roles between the individual providing ventilation and the chest compression provider.

Early defibrillation

  • Defibrillate Ventricular fibrillation and pulseless Ventricular tachycardia as rapidly as possible.
  • Critical point: Do not stop compressions while defibrillator is being
  1. Charge the pads before the pulse
  2. If shockable rhythm, deliver the shock and resume
  3. If non-shockable, discharge it back to the
  • Post-defibrillation pulse and rhythm checks are performed only after two minutes of additional excellent CPR.
  • Rationale: There is a delay between the return of an organized electrical rhythm and effective myocardial contractions.
  • Refractory pulseless ventricular tachycardia or ventricular fibrillation – Coronary artery disease and myocardial infarction are common causes of shock-refractory VT/VF.
  • In such circumstances, changing the the defibrillator pads to the anterior-posterior (AP) position from the anterior-lateral position (termed “vector change”) may improve the chances of successful

Pacer pad position configuration and results of transcutaneous pacing trials in the anterolateral (AL) and anteroposterior (AP) positions

While the Excellent CPR is ongoing, consider reversible causes, Include the 5 H’s and 5 T’s

5 H’s5 T’s
HypoxiaTension pneumothorax
HypovolemiaTamponade-cardiac
Hydrogen ions (acidosis)Toxins
Hyper/Hypo-kalemiaThrombosis-coronary (MI)
HypothermiaThrombosis-pulmonary (PE)

The “mantra” reminds us of circulation, airway, and breathing (C-A-B). Once unresponsiveness is recognized, resuscitation begins by addressing circulation (excellent chest compressions), followed by airway opening and rescue breathing.

Advanced airway management may be delayed if there is adequate rescue breathing without an advanced airway in place.

Big Value Mask Ventilation (BVM)

  • BMV is the single most important technique for emergency airway
  • Manually opening the airway,
  • Properly positioning the head and neck,
  • Placing an oropharyngeal airway device, and
  • Achieving a tight face mask seal are the keys to good
  • Ventilations must be performed using
  1. Proper timing (6 to 8 breaths per minute in the intubated patient/Supraglottic airway;
  2. Ratio of 30 compressions to 2 ventilations if not intubated and
  3. Force (deliver each breath over one second, and only until chest begins to rise).
  • Avoid
  • Tidal volumes of approximately 600 mL delivered in a controlled fashion such that chest rise occurs over no more than one
  • Overzealous ventilation (excess volume and/or frequency) elevates intrathoracic pressure, thereby decreasing venous return, ventricular filling, and stroke volume with compressions; all of which result in inadequate cerebral perfusion.
  • In addition, overventilation can cause gastric inflation, which increases the risk of regurgitation and aspiration.
  • A blindly inserted extraglottic airway, for example, laryngeal mask airway (LMA) can be placed without interrupting excellent chest compressions. It provides adequate ventilation in most cases, and may reduce the risk of aspiration compared with BVM
  • Oropharyngeal and nasopharyngeal airways can improve the quality of BVM ventilation and should be used whenever possible.

Drugs in cardiac arrest: (Guidelines do not recommend any infusions)

  • Adrenaline – 1mg of 1:10000
  • Anti-arrhythmics: Amiodarone (300 mg IV/IO bolus with a repeat dose of 150 mg IV as indicated) or Lidocaine (1 to 5 mg/kg IV/IO bolus, then 0.5 to 0.75 mg/kg every 5 to 10 min) should be administered in VT/VF unresponsive to defibrillation, CPR, and adrenaline.
  • Atropine – Not recommended
  • Calcium and sodium bicarbonate – Routinely not
  • Adrenaline is loaded by diluting 1mg of 1:1000 (1ml) with 9ml of saline, making it 1mg of 1:10000 (10ml).
  • Whole of the 10ml should be administered as indicated, every 3 to 5

Capnography – End-tidal CO2 (EtCO2) measurement

  • Assessment of waveform end-tidal carbon dioxide (EtCO2) may be used as an adjunct to pulse checks if the patient is intubated (receiving asynchronous ventilation)
  • In a systematic review of 17 observational studies including over 6100 adults with cardiac arrest, which included metaanalyses of data from five studies, EtCO2 ≥10 to 20 mmHg during CPR was strongly associated with ROSC.
  • EtCO2 less than 10mmHg suggests inadequate cardiac output and the need to improve CPR quality or provide other interventions such as needle thoracostomy.
  • Sudden, sustained increases in EtCO2 >10 mmHg during CPR likely indicate ROSC.
  • In several prospective, observational studies, EtCO2 levels of ≤10 mmHg measured 20 minutes after the initiation of advanced cardiac life support accurately predicted death in adult patients with cardiac

Arterial catheter

  • Measurements obtained from Arterial catheters already in place can provide useful feedback about the quality of CPR and ROSC.
  • CPR should not be interrupted to place arterial or central venous
  • Arterial diastolic pressure is a reasonable proxy for coronary perfusion pressure. A reasonable goal is to maintain an arterial diastolic pressure above 20 mmHg.

Alternative methods for medication administration

  • IO Access
  • Multiple studies have demonstrated that lidocaine, adrenaline, and naloxone are absorbed via the trachea; however, the serum drug concentrations achieved using this route are unpredictable.
  • Doses for tracheal administration are 2 to 2.5 times the standard IV doses, and medications should be diluted in 5 to 10 mL of sterile water or normal saline before injection down the tracheal tube.

Use of USG and Echocardiography

Must never interfere with resuscitation efforts and should not interrupt or delay resumption of cardiopulmonary resuscitation (CPR)

  • Is done to confirm absence of cardiac activity when a decision to terminate or decide to not resuscitate.
  • To help in identify reversible causes (eg, cardiac tamponade, tension pneumothorax, pulmonary embolism) and treat them.

Termination of Resuscitative efforts

  • Factors influencing the decision to stop resuscitative efforts include
  • Duration of resuscitative effort >30 minutes without a sustained perfusing rhythm
  • Unwitnessed collapse with an initial ECG rhythm of asystole
  • Prolonged interval between time of collapse and initiation of cardiopulmonary resuscitation (CPR)
  • Patient age, severe comorbid disease, or prior functional dependence
  • More objective endpoints of resuscitation have been Of these, the best predictor of outcome may be the end-tidal carbon dioxide (EtCO2) level following 20 minutes of resuscitation.

Resuscitation team

  • Team Leader should assign individual
  • Time keeper plays a key

Team dynamics

  • Clear messages
  • “closed-loop”
  • Knowing individual limitations
  • Mutual respect
  • Constructive intervention
  • Knowledge sharing
  • Debriefing

2023 AHA Focused updates

  • Use of extracorporeal cardiopulmonary resuscitation for patients with cardiac arrest refractory to standard advanced cardiovascular life support is reasonable in select patients when provided within an appropriately trained and equipped system of care.
  • Maintaining a constant core temperature between 32° C and 5° C during post-arrest temperature control.
  • It is recommended that all adults who do not follow commands after ROSC, receive treatment that includes a deliberate strategy for temperature control for better neurological outcome.
  • Emergency coronary angiography is recommended, when they exhibit ST-segment–elevation myocardial infarction, shock, electrical instability, signs of significant myocardial damage, or ongoing ischemia.

Dr. Ashok N
Consultant and Clinical Lead

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