Advanced cardiac life support

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Advanced cardiac life support
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Cardiopulmonary resuscitation of an avalanche victim who was medically evacuated to Craig Joint Theater Hospital in February 2010
Other namesAdvanced Cardiovascular Life Support, ACLS
Specialty Emergency Medicine, Cardiology, Critical Care, Anesthesia
UsesCardiac arrest treatment, Cardiovascular emergency treatment
FrequencyCommon

Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques. ACLS expands on Basic Life Support (BLS) by adding recommendations on additional medication and advanced procedure use to the CPR guidelines that are fundamental and efficacious in BLS. ACLS is practiced by advanced medical providers including physicians, some nurses and paramedics; [1] these providers are usually required to hold certifications in ACLS care.

Contents

While "ACLS" is almost always semantically interchangeable with the term "Advanced Life Support" (ALS), when used distinctly, ACLS tends to refer to the immediate cardiac care, while ALS tends to refer to more specialized resuscitation care such as ECMO and PCI. In the EMS community, "ALS" may refer to the advanced care provided by paramedics while "BLS" may refer to the fundamental care provided by EMTs and EMRs; without these terms referring to cardiovascular-specific care.

Overview

Advanced cardiac life support refers to a set of guidelines used by medical providers to treat life-threatening cardiovascular conditions. These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri-cardiac arrest care: Airway management, ventilation, CPR compressions (continued from BLS), defibrillation, and medications. Due to the seriousness of the diseases treated, the paucity of data known about most ACLS patients, and the need for multiple, rapid, simultaneous treatments, ACLS is executed as a standardized, algorithmic set of treatments. Successful ACLS treatment starts with diagnosis of the correct EKG rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include: ventricular tachycardia, ventricular fibrillation, Pulseless Electrical Activity, and asystole. Dangerous, non-arrest rhythms typically covered includes: narrow- and wide-complex tachycardias, torsades de pointe, atrial fibrillation/flutter with rapid ventricular response, and bradycardia. [2]

Successful ACLS treatment generally requires a team of trained individuals. Common team roles include: Leader, back-up leader, 2 CPR performers, an airway/respiratory specialist, an IV access and medication administration specialist, a monitor/ defibrillator attendant, a pharmacist, a lab member to send samples, and a recorder to document the treatment. [3] For in-hospital events, these members are frequently physicians, mid-level providers, nurses and allied health providers; while for out-of-hospital events, these teams are usually composed of a small number of EMTs and paramedics.

Scope

ACLS algorithms include multiple, simultaneous treatment recommendations. Some ACLS providers may be required to strictly adhere to these guidelines, however physicians may generally deviate to pursue different evidence-based treatment, especially if they are addressing an underlying cause of the arrest and/or unique aspects of a patient's care. ACLS algorithms are complex but the table, below, demonstrates common aspects of ACLS care. [2]

ACLS ComponentPossible InterventionsGoals of care
Rhythm diagnosisEKG, clinical examDiagnosis of malignant arrhythmia.
CPR Chest Compressions, mechanical CPR Perfusion of blood before ROSC is achieved. Note: chest compressions are not different in ACLS vs BLS, but continue to be a fundamental part of cardiac arrest care even when ACLS is being executed.
ElectrotherapyMono- or biphasic defibrillation, double sequential defibrillation, transvenous pacing, transcutaneous pacing Termination of shockable rhythms. Note: not all cardiac arrest rhythms can be treated with defibrillation.
Airway Management Endotracheal intubation, supraglottic airway placement, Cricothyrotomy, waveform capnography, tracheal suctioning, naso- or oropharygeal airway placementCleat and protect the airway to allow for adequate ventilation.
Ventillation Bag-valve-mask, ventilator management, oxygen therapy Ventilate the lungs to allow for subsequent oxygenation of the blood.
Medications Epinephrine, norepinephrine, vasopressin, atropine, amiodarone, lidocaine, procainamide, sotalol, albuterol, calcium chloride, magnesium, crystalloid fluids, intraosseous access Stabilizes arrhythmia, promote ROSC and increase perfusion.
Specialized Resuscitation Techniques Echocardiography, TEE, PCI, ECMO, TTM, central venous access Identification of underlying cause of cardiac arrest, augmentation of perfusion and/or treatment of PCAS.


ACLS Certification

Due to the rapidity and complexity of ACLS care, as well as the recommendation that it be performed in a standardized fashion, providers must usually hold certifications in ACLS care. Certifications may be provided by a few different, generally national, organizations but their legitimacy is ultimately determined by hospital hiring and privileging boards; that is, ACLS certification is frequently a requirement for employment as a health care provider at most hospitals. [4] ACLS certifications usually provide education on the aforementioned aspects of ACLS care except for specialized resuscitation techniques. Specialized resuscitation techniques are not covered by ACLS certifications and their use is restricted to further specialized providers. ACLS education is based on ILCOR recommendations which are then adapted to local practices by authoritative medical organizations such as the American Red Cross, the European Resuscitation Council, or the Resuscitation Council of Asia.

BLS proficiency is usually a prerequisite to ACLS training; however the initial portions of an ACLS class may cover CPR. [5] Initial training usually takes around 15 hours and includes both classroom instruction and hands-on simulation experience; passing a test, with a practical component, at the end of the course is usually the final requirement to receive certification. [6] After receiving initial certification, providers must usually recertify every two years in a class with similar content that lasts about seven hours. Widely accepted providers of ACLS certification include, non-exclusively: American Heart Association, American Red cross, European Resuscitation Council or the Australian Resuscitation Council.

Holding ACLS certification simply attests a provider was tested on knowledge and application of ACLS guidelines. The certification does not supersede a provider's scope of practice as determined by state law or employer protocols; and does not, itself, provide any license to practice.

Efficacy of ACLS

Like a medical intervention, researchers have had to ask whether ACLS is effective. Data generally demonstrates that patients have better survival outcomes (increased ROSC, increased survival to hospital discharge and/or superior neurological outcomes) when they receive ACLS; [7] however a large study of ROC patients showed that this effect may only be if ACLS is delivered in the first six minutes of arrest. [8] This study also found that ACLS increases survival but does not produce superior neurological outcomes.

Some studies have raised concerns that ACLS education can be inconstantly or inadequately taught which can result in poor retention, leading to poor ACLS performance. [9] One study from 1998 looked at the ACLS use of epinephrine, atropine, bicarbonate, calcium, lidocaine, and bretylium in cardiac arrests and found that these medications were not associated with higher resuscitation rates. [10]

Research on ACLS can be challenging because ACLS is a bundle of care recommendations; with each individual treatment component being profoundly consequential. There is active debate within the resuscitation research community about the value of certain interventions. Active areas of research include determining the value of vasopressors in arrests, [11] ideal airway use [12] and different waveforms for defibrillation. [13]

International guidelines

Stemming from the need for standardized, evidence based ACLS guidelines, an international network of academic resuscitation organizations was created. The International Liaison Committee on Resuscitation (ILCOR) is the central, international institution that regional resuscitation committees strive to contribute to and disseminate information from. The centralization of resuscitation research around ILCOR reduces redundant work internationally, allows for collaboration between experts from many regional organizations, and produces higher quality, higher powered research.

International Liaison Committee on Resuscitation

ILCOR serves as a way for international resuscitation organizations to communicate and collaborate. [14] ILCOR publishes scientific evidence reviews on resuscitation known as "Continuous Evidence Evaluation (CEE) and Consensus on Science with Treatment Recommendations (CoSTRs)". [15] ILCOR uses 6 international task forces to review over 180 topics through a structured systematic-review process. ILCOR traditionally published updates and recommendations every five years but now conducts continuous review work. [16] ILCOR produces international recommendations which are then adopted by regional resuscitation committees which publish guidelines. [17] Regional guidelines can have more medicolegal bearing than ILCOR recommendations. [18] ILCOR is composed of the following regional organizations:

Regional OrganizationAffiliated Nations
American Heart Association (AHA)United States
European Resuscitation Council (ERC) [19] Austria, Belgium, Bosnia & Herzegovina, Croatia, Cyprus, Czechoslovakia, Denmark, Egypt, Finland, France, Germany, Hungary, Iceland, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sudan, Sweden, Switzerland, Tunisia, Turkey, Ukraine, United Kingdom
Heart and Stroke Foundation of Canada (HSFC)Canada
Australian Resuscitation CouncilAustralia
New Zealand Resuscitation CouncilNew Zealand
Resuscitation Council of Southern Africa (RCSA)South Africa
InterAmerican Heart Foundation (IAHF) [20] Argentina, Barbados, Bolivia, Jamaica, Trinidad and Tobago, United States
Resuscitation Council of Asia (RCA) [21] Hong Kong, Japan, Korea, Philippines, Singapore, Thailand, Taiwan

History

ILCOR

The International Liaison Committee on Resuscitation (ILCOR) was established 1992 to serve as a way for international resuscitation organizations to communicate and collaborate. [14]

AHA Guidelines

The ACLS guidelines were first published in 1974 by the American Heart Association and were updated in 1980, 1986, 1992, 2000, 2005, 2010, 2015. [22] In the 2020 update the guidelines were restructured to align with ILCOR recommendations. These changes include the transition since 2015 away from the previous 5-year update cycle to an online format that can be updated as indicated by continuous evidence review. [23]

ERC Guidelines

The first version of the European Resuscitation Council (ERC) guidelines were developed in 1992. The 2000 ERC guidelines were developed in collaboration with ILCOR. 5-year updates were published from 2000 to 2015 and annual updates have been published since 2017. [24]

See also

Related Research Articles

<span class="mw-page-title-main">Cardiac arrest</span> Sudden failure of heart beat

Cardiac arrest, also known as sudden cardiac arrest (SCA), is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly circulate around the body and the blood flow to the brain and other organs is decreased. When the brain does not receive enough blood, this can cause a person to lose consciousness and brain cells can start to die due to lack of oxygen. Coma and persistent vegetative state may result from cardiac arrest. Cardiac arrest is also identified by a lack of central pulses and abnormal or absent breathing.

<span class="mw-page-title-main">Cardiopulmonary resuscitation</span> Emergency procedure after sudden cardiac arrest

Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. It is recommended for those who are unresponsive with no breathing or abnormal breathing, for example, agonal respirations.

<span class="mw-page-title-main">Defibrillation</span> Treatment for life-threatening cardiac arrhythmias

Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current to the heart. Although not fully understood, this process depolarizes a large amount of the heart muscle, ending the arrhythmia. Subsequently, the body's natural pacemaker in the sinoatrial node of the heart is able to re-establish normal sinus rhythm. A heart which is in asystole (flatline) cannot be restarted by a defibrillator; it would be treated only by cardiopulmonary resuscitation (CPR) and medication, and then by cardioversion or defibrillation if it converts into a shockable rhythm.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

<span class="mw-page-title-main">Ventricular fibrillation</span> Rapid quivering of the ventricles of the heart

Ventricular fibrillation is an abnormal heart rhythm in which the ventricles of the heart quiver. It is due to disorganized electrical activity. Ventricular fibrillation results in cardiac arrest with loss of consciousness and no pulse. This is followed by sudden cardiac death in the absence of treatment. Ventricular fibrillation is initially found in about 10% of people with cardiac arrest.

<span class="mw-page-title-main">Asystole</span> Medical condition of the heart

Asystole is the absence of ventricular contractions in the context of a lethal heart arrhythmia. Asystole is the most serious form of cardiac arrest and is usually irreversible. Also referred to as cardiac flatline, asystole is the state of total cessation of electrical activity from the heart, which means no tissue contraction from the heart muscle and therefore no blood flow to the rest of the body.

<span class="mw-page-title-main">Life support</span> In medicine

Life support comprises the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs. Healthcare providers and emergency medical technicians are generally certified to perform basic and advanced life support procedures; however, basic life support is sometimes provided at the scene of an emergency by family members or bystanders before emergency services arrive. In the case of cardiac injuries, cardiopulmonary resuscitation is initiated by bystanders or family members 25% of the time. Basic life support techniques, such as performing CPR on a victim of cardiac arrest, can double or even triple that patient's chance of survival. Other types of basic life support include relief from choking, staunching of bleeding by direct compression and elevation above the heart, first aid, and the use of an automated external defibrillator.

Basic life support (BLS) is a level of medical care which is used for patients with life-threatening condition of cardiac arrest until they can be given full medical care by advanced life support providers. It can be provided by trained medical personnel, such as emergency medical technicians, qualified bystanders and anybody who is trained for providing BLS and/or ACLS.

Precordial thump is a medical procedure used in the treatment of ventricular fibrillation or pulseless ventricular tachycardia under certain conditions. The procedure has a very low success rate, but may be used in those with witnessed, monitored onset of one of the "shockable" cardiac rhythms if a defibrillator is not immediately available. It should not delay cardiopulmonary resuscitation (CPR) and defibrillation, nor should it be used in those with unwitnessed out-of-hospital cardiac arrest.

Pulseless electrical activity (PEA) is a form of cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 20% of out-of-hospital cardiac arrests and about 50% of in-hospital cardiac arrests.

<span class="mw-page-title-main">Advanced life support</span> Life-saving protocols

Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).

<span class="mw-page-title-main">Agonal respiration</span> Emergent abnormal pattern of breathing

Agonal respiration, gasping respiration, or agonal breathing is a distinct and abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, and is accompanied by strange vocalizations and myoclonus. Possible causes include cerebral ischemia, hypoxia, or anoxia. Agonal breathing is an extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea and heralds death. The duration of agonal respiration can range from two breaths up to several hours of labored breathing.

<span class="mw-page-title-main">ABC (medicine)</span> Mnemonic for Airway, Breathing, and Circulation

ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective: a viable Airway is necessary for Breathing to provide oxygenated blood for Circulation. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.

<span class="mw-page-title-main">AutoPulse</span> Cardiopulmonary resuscitation device

The AutoPulse is an automated, portable, battery-powered cardiopulmonary resuscitation device created by Revivant and subsequently purchased and currently manufactured by ZOLL Medical Corporation. It is a chest compression device composed of a constricting band and half backboard that is intended to be used as an adjunct to CPR during advanced cardiac life support by professional health care providers. The AutoPulse uses a distributing band to deliver the chest compressions. In literature it is also known as LDB-CPR.

The chain of survival refers to a series of actions that, properly executed, reduce the mortality associated with sudden cardiac arrest. Like any chain, the chain of survival is only as strong as its weakest link. The six interdependent links in the chain of survival are early recognition of sudden cardiac arrest and access to emergency medical care, early CPR, early defibrillation, early advanced cardiac life support, and physical and emotional recovery. The first three links in the chain can be performed by lay bystanders, while the second three links are designated to medical professionals. Currently, between 70 and 90% of cardiac arrest patients die before they reach the hospital. However, a cardiac arrest does not have to be lethal if bystanders can take the right steps immediately.

<span class="mw-page-title-main">International Liaison Committee on Resuscitation</span>

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide an opportunity for the major organizations in resuscitation to work together on CPR and ECC protocols. The name was chosen in 1996 to be a deliberate play on words relating to the treatment of sick hearts – "ill cor".

The Hs and Ts is a mnemonic used to aid in remembering the possible reversible causes of cardiac arrest. A variety of disease processes can lead to a cardiac arrest; however, they usually boil down to one or more of the "Hs and Ts".

Extracorporeal cardiopulmonary resuscitation is a method of cardiopulmonary resuscitation (CPR) that passes the patient's blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation (ECMO) device is used as an adjunct to standard CPR. A patient who is deemed to be in cardiac arrest refractory to CPR has percutaneous catheters inserted into the femoral vein and artery. Theoretically, the application of ECPR allows for the return of cerebral perfusion in a more sustainable manner than with external compressions alone. By attaching an ECMO device to a person who has acutely undergone cardiovascular collapse, practitioners can maintain end-organ perfusion whilst assessing the potential reversal of causal pathology, with the goal of improving long-term survival and neurological outcomes.

Vinay M. Nadkarni is an American pediatric critical care physician. He is a Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania and the Medical Director of the Center for Simulation, Advanced Education and Innovation at the Children's Hospital of Philadelphia (CHOP). Nadkarni also holds the institution’s Endowed Chair in Pediatric Critical Care Medicine and is a Fellow of the American College of Critical Care Medicine, the American Academy of Pediatrics, and the American Heart Association.

<span class="mw-page-title-main">LUCAS device</span> Device to provide mechanical CPR

The Lund University Cardiopulmonary Assist System (LUCAS) device provides mechanical chest compressions to patients in cardiac arrest. It is mostly used in emergency medicine as an alternative to manual CPR because it provides consistent compressions at a fixed rate through difficult transport conditions and eliminates the physical strain on the person performing CPR. The first generation of the LUCAS device was pneumatic, while the second and third generations are battery-operated.

References

  1. ↑ Ryynänen, Olli-Pekka; Iirola, Timo; Reitala, Janne; Pälve, Heikki; Malmivaara, Antti (2010). "Is advanced life support better than basic life support in prehospital care? A systematic review". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18: 62. doi: 10.1186/1757-7241-18-62 . PMC   3001418 . PMID   21092256.
  2. 1 2 "Part 3: Adult Basic and Advanced Life Support". cpr.heart.org. Retrieved 2022-01-25.
  3. ↑ Prince, Cynthia R.; Hines, Elizabeth J.; Chyou, Po-Huang; Heegeman, David J. (September 2014). "Finding the Key to a Better Code: Code Team Restructure to Improve Performance and Outcomes". Clinical Medicine & Research. 12 (1–2): 47–57. doi:10.3121/cmr.2014.1201. ISSN   1539-4182. PMC   4453307 . PMID   24667218.
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  6. ↑ "Advanced Cardiovascular Life Support (ACLS) Course Options". cpr.heart.org. Retrieved 2022-01-25.
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  12. ↑ Carlson, Jestin N.; Wang, Henry E. (October 2020). "Optimal Airway Management in Cardiac Arrest". Critical Care Clinics. 36 (4): 705–714. doi:10.1016/j.ccc.2020.07.008. ISSN   1557-8232. PMID   32892823. S2CID   221523919.
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  19. ↑ "National Resuscitation Councils". European Resuscitation Council. Retrieved 25 January 2022.
  20. ↑ "Members & Alliances – InterAmerican Heart Foundation" . Retrieved 2022-01-25.
  21. ↑ "Members". Resuscitation Council of Asia. Retrieved 2022-01-25.
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