ADVANCED
LIFE
SUPPORT
Roll No.20046-20050
ADVANCED LIFE SUPPORT
• Advanced life support refers to a set of
clinical interventions for the urgent
treatment of life threatening medical
emergencies as well as the knowledge
and skills to deploy those interventions.
• Advanced life support is only to be
performed by trained medical personnel.
• The advanced life support aims to
restore the normal cardiac rhythm by
defibrillation when the cause of
cardiac arrest is a tachyarrythmia or
to restore cardiac output by
correcting other reversible causes of
cardiac arrest.
ACLS Survey
• After the completion of the Basic life
support the responder conduct the ACLS
survey with a focus on identification and
treating the underlying cause of patients
problem.
Team dynamics
• In order to provide optimal outcomes each
team member must be able to perform the
functions of his role and must understand how
his role interface with other roles in the team.
• Teams members should be assigned to roles
based on their scope of practice and training
for assigned task.
The end purpose of ACLS is to intervene early for
the victim in cardiac arrest.The intent is to
increase survival rate and ensure quality
outcome.
INDICATIONS
• Cardiac arrest
-Pulmonary artery disease[arteriosclerosis,atherosclerosis].
-Coronary artery disease[angina,MI].
-Significant hypoxia in neonate.
• Stroke
• Shock
• Respiratory arrest
-Drowning.
-Poisoning.
-Suffocation.
-Sudden Infant.
COMPONENTS
• The most important components of
advanced life support techniques are:
• 1.High quality CPR.
• 2.Airway Management.
• 3.Defilbrillation.
• 4.Drug therapy.
ACLS in Adults
AHA Adult Chain of Survival
Component of high quality CPR in BLS
Activation of emergency response system
Witnessed Unwitnessed
• If alone – 1st activate EMS • Start CPR
then start CPR .
• If 2 rescuers
• Give for 2
- one should start
CPR minutes
- other should
activate • Activate EMS
EMS .
Chest compressions
• Ratio – 30 : 2
• Rate – 100 – 120/ min
• Depth – at least 1/3rd of AP
diameter of chest
• Hand placement – both hands
on lower half of sternum
• Chest recoil – Allow full recoil
of chest after each
compression ( don’t lean on
chest after each compression ) .
• Minimal interruptions - <10 sec
.
BLS healthcare
provider adult
cardiac arrest
algorithm
Adult ACLS
Shockable
Unshockable
Asystole /
VT/VF
PEA
Deliver single defibrillator Continue CPR
shock ( intubate & establish IV access )
CPR – 2 min
Check rhythm Identify & treat reversible causes
Deliver single shock – if
VT/VF persist – CPR 2 min Continue CPR if asystole /PEA
& give Epinephrine 1mg
Continue CPR 2 min
Amiodarone / Lidocaine /
MgSO4
Defibrillate
Drug-Shock-Drug- Shock
DEFIBRILLATION
TYPES
1. BIPHASIC WAVEFORM- 120-200 J
2. MONOPHASIC WAVEFORM- 360J
3. AED- Device specific
INDICATION- Failure of a single adequate
shock to restore a pulse should be followed
by continued CPR & second shock continued
delivered after 5 cycles of CPR
PROCEDURE
• Place sternal paddle over right of the sternum below clavicle
• Place apical paddle in mid axillary line in 5th ICS
• Switch on defibrillator
• Charge the defibrillator to 200-360J
• Warn all the other rescuers to stand clear- ‘ARE YOU CLEAR’
• Visually check all clear
• Ensure yourself you are not touching the patient or the bed-
‘I AM CLEAR’
• Deliver shock
• Restart CPR w/o checking the pulse
Automatic External Defibrillator
• Switch on AED
• Attach electrode pads
• Place electrode pads as that of manual one
• Follow voice commands
• Make sure no one is in contact with the
patient
• Push shock button
AIRWAY & VENTILATION
OPENING THE AIRWAY- Head tilt, chin lift, or jaw thrust, in addition
explore the airway for any foreign bodies, dentures and remove them
BASIC AIRWAY ADVANCED
• Oropharyngeal • Endotracheal
airway tube
• Nasopharyngeal • Laryngeal mask
airway airway
• Laryngeal tube
• Oesophageal
tracheal tube
Nasopharyngeal
airway
Oropharyngeal
airway
Endotracheal
tube
Esophageal
tracheal tube
Laryngeal mask
airway
Laryngeal tube
PHARMACOTHERAPY
ROUTE FOR ADMINSTRATION-
AMIADARONE-
• INDICATONS- ventricular tachycardia, ventricular
fibrillation
• IV DOSE-
LIDOCAINE-
• INDICATIONS- VT, VF (can be toxic so no longer given
prophylactically)
• IV DOSE-
• Signs of toxicity- slurred speech, seizures, altered
consciousness
MAGNESIUM-
• Used for refractory VT or VF caused by
hypomagnesia and Torsades de pointes
• DOSE- 1-2g over 10 mins
• S/E- hypotension, asystole
PROPANALOL/ ESMOLOL-
• Maybe useful for VT & VF that has not responded to
other therapies
• Very useful for patients whose cardiac arrest is
precipitated by hypertension
EPINEPHRINE-
• Increase heart rate, blood pressure, stroke volume
• IV DOSE-
SODIUM BICARBONATE-
• Metabolic acidosis/ hyperkalemia
• IV DOSE- 1mEq/kg
• S/E- metabolic alkalosis
increased CO2 production
ADENOSINE-
• IV DOSE- 6mg rapid iv rush followed by NS
flush
Second dose 12mg
• S/E- flushing of face, bronchospasm
Pediatric Advance Life
Support
ROLLNO. 20049
20050
PALS-Refers to the assessment and support of
pulmonary and circulatory function in the period
before, during and after an arrest.
Pediatric chain of survival include 6 components:
a)Early recognition and prevention of cardiac
arrest
b)Activation of emergency response
c)High quality CPR
d)Advance resuscitation
e)Post arrest care
f)Recovery
Adjuncts for airway and
ventilation
• Oxygen should be given to all serious or
injured children with respiratory
insufficiency, shock and trauma
• During mouth to mouth rescue breathing,
only 16-17%oxygen is delivered with alveolar
pressure of 80mmHg
• Ventilation-perfusion mismatch during CPR
and underlying respiratory disorder causes
right to lest shunting that reduces
oxygenation.
Endotracheal Intubation
It is most effective & reliable method of
ventilation
• Indications of ET:
1)Excessive work of breathing leading fatigue
2)Inadequate neurological control of ventilation,
and poor respiratory effort
3)Functional or anatomical airway obstruction
4)Lack of protective airway reflexes
5For prolongation cardiopulmonary resuscitation
Advantage of ET:
• It ensures adequate ventilation
• Reduce risk of aspiration
• Suction can be done to keep airway patent
• Positive end expiratory pressure can be
provided
However skilled person is required for
intubation so bag and mask used in children
who require ventilation in out of hospital
setting
• Beyond 1 year size of uncuffed
tube is:
Tracheal tube size(mm)= (age in
year) +4
4
• Size of cuffed ET tube is less than 0.5-
1mm of the uncuffed ET tube
• Size of suction catheter is usually twice
the diameter of ET tube
• Cuffed ET tube help in decreasing
ventilator associated pneumonia.
Pressure should be maintained <20-
25cmwater to prevent airway necrosis
• Depth of insertion=3 times its inner
diameter
In neonates depth of insertion:
Depth of insertion(cm)=birth weight(kg)
+6
In children>2year:
Depth of insertion(cm)= (age in year)
+12
2
Tube placement is confirmed by looking
symmetrical rise of chest or auscultating
air entry on both side
Other marker of proper tube
placement is:
Improving heart rate, colour,
perfusion and oxygen saturation
and detection of end tidal CO2 by
capnography or can be confirmed
by chest radiograph
Vascular access
• During CPR preferred vascular access is the
largest easily accessible vein, cannulating
which does not require interruption of
resuscitation
• All the resuscitation drugs can be given
through peripheral venous line.
• If central or peripheral line not achieved
than intraosseous access should be secured
• Site of this is upper end of tibia medial to
tibial tuberosity
• Other site include: distal end of
femur, lower end of above medial
malleolus and anterior superior iliac
spine
• If intravenous or intraosseous access
is not established, tracheal tube may
be used for lipid soluble agents like
lidocaine, epinephrine, atropine and
naloxane
Post-arrest Care
• Fever is common after cardiac arrest and
should be controlled aggressively.
• After return of spontaneous circulation,
hypoxia or hyperoxia should be avoided and
oxygen saturation should be maintained
between 94 and 99%.
• Continuous arterial pressure monitoring is
done to maintain blood pressure above the
5th centile.
Fluid Therapy
• Early restoration of the circulating blood
volume is important to prevent progression
to refractory shock or cardiac arrest.
• An initial fluid bolus of 10-20 mL/kg is
recommended in shock, and after each
bolus, the patient is reassessed.
• Volume expansion is best achieved with
isotonic crystalloid fluids, such as Ringer
lactate or normal saline.
• Blood replacement is indicated in patients with
severe hemorrhagic shock who remain in
shock despite infusing 40-60 mL/kg of
crystalloids.
• Dextrose solutions should not be used for
initial resuscitation as they do not extend the
intravascular volume effectively and may cause
hyperglycemia.
• Hypoglycemia, if suspected or documented,
should be managed rapidly with intravenous
glucose and measures to prevent recurrence.
Drugs used during Cardiopulmonary
resuscitation:
Arrhythmias
• Most pediatric arrhythmias are the consequence
of hypoxemia, acidosis or hypotension.
• Children with myocarditis, cardiomyopathy or
following cardiac surgery are also at risk of
arrhythmia.
• Drugs in toxic doses can cause arrhythmia.
• About 10% of pediatric cardiac arrest patients
have ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT).
Bradyarrhythmia
• Hypoxemia, hypothermia, acidosis,
hypotension and hypoglycemia depress sinus
node function and slow conduction through
the myocardium.
• Excessive vagal stimulation, raised
intracranial pressure or brainstem
compression may cause bradycardia.
• Epinephrine is the most useful drug in treating
symptomatic bradycardia.
• For bradycardia due to vagal overtone
Pulseless electrical activity
• It is a state of electrical activity observed
on a monitor or ECG in absence of
detectable cardiac activity.
• This is often a preterminal state preceding
asystole, representing the electrical activity
of a hypoxic and acidotic myocardium.
• Occasionally, pulseless electrical activity
may be due to sudden impairment of
cardiac output with normal ECG rhythm,
with heart rate increased or rapidly
decreasing.
• Reversible causes of electromechanical
dissociation are best remembered as 6Hs
and 5Ts.
6Hs 5Ts
Severe Hypovolemia Tension pneumothorax
Hypoxia Toxins and drugs
Hypothermia Pericardial Tamponade
Hypo/Hyperkalemia Pulmonary Thrombosis
Hydrogen ion(acidosis) Coronary Thrombosis
Hypoglycemia
Defibrillation
• Defibrillation is the asynchronous depolarization
of a critical mass of myocardium in order to
terminate VF or pulseless VT.
• It is successful in cases of sudden onset VF having
oxygenated normothermic myocardium without
significant acidosis.
• Larger size defibrillator paddles, 8 to 10 cm in
diameter, are recommended in children weighing
more than 10 kg to maximize current flow.
• Smaller paddles are used in infants.
• One paddle is placed over the right side of
the upper chest and the other over the apex
of the heart.
• Alternatively, electrodes are placed in
anterior-posterior position with one placed
to the left of the sternum and the other one
over the back.
• Initial dose of 2 J /kg, second dose of 4 J /kg
and subsequent doses of >4 J /kg, to a
maximum of 10 J /kg (adult dose).
• Children >8-year-old or those weighing >50 kg
should receive adult doses of defibrillation.
• Single shock strategy followed by immediate
CPR (beginning with chest compressions) is
recommended for children with out-of-
hospital or inhospital VF/pulseless VT.
