The document outlines advanced cardiovascular life support (ACLS) techniques, covering topics such as basic life support (BLS), the chains of survival for out-of-hospital and in-hospital cardiac arrests, and the importance of immediate CPR and defibrillation. It details specific procedures for responding to cardiac arrest, including the use of automated external defibrillators, and the administration of medications like epinephrine and amiodarone during resuscitation efforts. The document also emphasizes the significance of post-cardiac arrest care and neuroprognostication in improving survival and recovery outcomes.

1. Advanced Cardiovascular Life
Support (ACLS)
Presenter:
Dr. Rebil Heiru IM R3
Moderators:
Dr Endashaw Abebe (Internist, Assistant Professor)
&
Dr Dejene (Anestheologist, Assistant professor)

2. Outline
• Introduction
• BLS
• ACLS
• Pulseless Arrest
• Bradycardia
• Tachycardia
• Post cardiac arrest care
• Take Home message

3. Introduction
• BLS: providing care to a choking victim or to someone who needs
cardiopulmonary resuscitation (CPR).
• ACLS (advanced cardiac life support): an orderly approach to
providing advanced emergency care to a patient who is experiencing a
cardiac-related problem
Cardiac monitoring
Intravenous fluids and medications
Advanced airway adjuncts

4. Introduction…
Cardiac arrest -Abrupt cessation of cardiac function resulting in loss
of effective circulation.
Cardiovascular collapse-is Sudden loss of effective circulation due to
cardiac and/or peripheral vascular factors
Sudden cardiac death-is Sudden unexpected death attributed to cardiac
arrest.

6. Adult chain of survival
• 2015 : Separate Chains of Survival have been recommended that
identify the different pathways of care for patients who experience
cardiac arrest in the hospital as distinct from out-of-hospital settings

9. “Chain of Survival”
out-of-hospital cardiac arrest (OHCA)
• Immediate recognition of cardiac arrest and activation of the
emergency response system
• Early CPR that emphasizes chest compressions
• Rapid defibrillation if indicated
• Effective advanced life support
• Integrated post cardiac arrest care
• Recovery*

10. “Chain of Survival” in-hospital cardiac arrest
(IHCA)
• Surveillance for cardiac arrest
• Activate code (multidisciplinary team)
• Initiate CPR by professional providers
• Early defibrillation
• Integrated post cardiac arrest care
• Recovery*

11. Adult Basic Life Support
(BLS)

12. Basic Life Support
• Used for patients with life-threatening illness or injury
before the patient can be given full medical care
• Generally used in the pre-hospital setting, and can be
provided without medical equipment
• Generally does not include the use of drugs or invasive
skills

13. unresponsesive
Breathing
and pulse
30:2 x 5 cycle
Call for help and AED
Pulse :breathing
5-6 sec
No pulse : CPR

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15. • Resuming CPR immediately after a shock is more likely to be beneficial than another shock.
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16. Chest compression

17. Chest compression
At least 5 cm (2inches) Full chest recoil

18. Chest compression
100-120 compression
per minute

19. Airway
Head tilt
Chin lift

20. Jaw thrust for suspected C-spine injury

21. Breathing

22. • Be sure to open the airway adequately with a head tilt–chin lift, lifting the jaw
against the mask and holding the mask against the face, creating a tight seal.
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• Do not over ventilate (i.e., give too many breaths per minute or too large
volume per breath).

24. BLS Dos and Don’ts of Adult High-Quality CPR
Rescuers Should Rescuers Should Not
perform chest compressions at a
rate of 100-120/min
Compress at a rate slower than 100/min or
faster than 120/min
Compress to a depth of at least 2 inches (5
cm)
Compress to a depth of less than 2 inches (5
cm) or greater than 2.4 inches (6 cm)
Allow full recoil after each compression Lean on the chest between compressions
Minimize pauses in compressions Interrupt compressions for greater than 10
seconds
Ventilate adequately (2 breaths after 30
compressions, each breath
delivered over 1 second, each causing chest
rise)
Provide excessive ventilation
(ie, too many breaths or breaths with
excessive force)

25. AED (Automated External Defibrillator)
1. Power on, AED
2. Stick paddle according
to the picture
3. The machine will
analyze whether to
shock or not.
4. If the device can give
shock press the shock
button

26. AED (Automated External Defibrillator)
press the power button and
turn the AED on
AED ON

27. AED (Automated External Defibrillator)
Attach pad to sternum
/apex

28. AED (Automated External Defibrillator)
Connect the electrode pad
cable to the electrode cable
of the machine.

29. AED (Automated External Defibrillator)
• The analyzer will report on the monitor what kind of ECG it is and
recommend it.
• Defibrillation If the ECG is of type VF or VT
• Do not touch the patient as the machine will misread the EKG.
• If the EKG is VF or VT type, it will provide a power charge.
• If the EKG is an asystole, the machine will continue CPR for 2 minutes
and then analyze the EKG again.

30. AED (Automated External Defibrillator)
Press to
shock!

31. Advanced Cardiovascular Life
Support: ACLS

32. Advanced Cardiovascular Life Support:
ACLS
•Pulseless Arrest
•Bradycardia with Pulse
•Tachycardia with Pulse

33. Team Work

37. Defibrillation
• Defibrillation is the non-synchronized delivery of a shock randomly during the
cardiac cycle in arrhythmias.
• A defibrillator is a device that is used to deliver a shock to eliminate an abnormal
heart rhythm.
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38. Defibrillation
• We paralyze the heart, to let S. A. Node to start working again
• The delay in DC >>>the sever the arrhythmia >>> less favorable prognosis & less
responsive to treatment.
1. Synchronized Cardio-version:
1. used to convert Atrial or ventricular tach.,
2. shock synchronized to occur with the R wave of the ECG rather than with
the T wave.
2. Asynchronized Cardio-version: at any ECG phase & it can cause ventricular
fibrillation.
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39. Cont..
• Mechanism of action:
• 1. Monophasic:-- receive single burst, 1 pad to another & don’t come back.
• 2. Biphasic :--less Jules (electric shock waves move from 1 pad to the other then go
in reverse direction).
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40. Defibrillation
Types of Biphasic Defibrillator:--
1. Manual (which we are using).
2. Shock Advisor (for non-expert people),with big electrodes they can read the
rhythm then talk or write the order to be done.
3. Automated External (you just connect it to the patient & it will work & calculate
the electric wave by it self & when to give it).
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41. 5/14/2023 ACLS-2021 G.C. 41
CPR should be resumed immediately after shock delivery.

42. Shock Energy
Biphasic:
• Biphasic delivery of energy during defibrillation is more effective than older
monophasic waveforms.
• Initial dose of 120 to 200 J; if unknown, use maximum available.
• Second and subsequent doses should be equivalent, and higher doses should be
considered.
 Monophasic: 360 J
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43. Cont..
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44. Defibrillator

45. Defibrillator
1. Right of the upper sternum below the clavicle
2. left 5th IC space ant. Axillary's line.
• Technique:
1. Apply pressure to the paddle [10kg] to decrease thoracic
impedance (the distance by pr. The fat).
2. keep the defibrillator paddles at least 12.5 cm from the
pace maker if there is.
3. Keep oxygen flow away from paddle and area of the
patient’s bed ; and place them at least 3.5 to 4 feet away from
the patient’s chest.
4. Don’t remove the paddle until 3 DC shock performed.

46. Drug therapy for VF/VT
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Vasopressin combined with epinephrine may be considered in cardiac arrest, but it
offers no advantage as a substitute for epinephrine alone.
Epinephrine : 1 mg IV q 3-5 min while CPR is performed continuously

47. Management of specific arrythmias
• VF/PVT-Ventricular fibrillation (VF) and pulseless ventricular
tachycardia (VT) are life-threatening cardiac rhythms that result in
ineffective ventricular contractions.
• VF is a rapid quivering of the ventricular walls that prevents them
from pumping not synchronized with atrial contractions.
• VT is a condition in which the ventricles contract more than 100 times
per minute.
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48. • VF and pulseless VT are both shockable rhythms.
• Antiarrhythmic drugs are considered after a second unsuccessful defibrillation
attempt in anticipation of a third shock.
• Little survival benefit in refractory VF or pulseless VT.
• Amiodarone -First-line anti arrhythmic agent given during cardiac arrest.
• Considered for VF or pulseless VT unresponsive to CPR, defibrillation, vasopressor therapy
• Lidocaine may be considered if amiodarone is not available.
• The recommended dose of lidocaine is 1.0 to 1.5 mg/kg IV/IO for the first dose and 0.5 to
0.75mg/kg IV/IO for a second dose if required.
• Magnesium sulfate 2 g IV, followed by a maintenance infusion for polymorphic
VT
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49. Pulseless Arrest

50. shock
Amiodarone
300 mg----
150 mg
5 Hs, 5Ts
 Hypovolemia
 Hypoxia
 Hydrogen ions (acidosis)
 Hyper/hypokalemia
 Hypothermia
 Toxins
 Tamponade
 Tension PTX
 Thrombosis (coronary)
 Thrombosis (pulmonary)
Pulse/BP
EtCO2>40 mmHg
A-line wave form

51. BRADYCARDIA WITH PULSE

52. Unstable
bradycardia

53. TACHYCARDIA WITH PULSE

54. Unstable
Tachycardia
Narrow regular
50-100 j
Narrow irregular
120-200 j
(mono 200j)
Wide regular
100 j
Wide irregular
DF

55. Quantitative Waveform Capnography
• Confirmation and monitoring ETT placement
• Evaluating the effectiveness of chest compressions
ETCO2 value is at least 10-20 mmHg.
• Identification of ROSC
• Failure to achieve an ETCO2of greater than 10 mm Hg by waveform
capnography after 20 minutes of CPR decide to end resuscitative
efforts but should not be used in isolation

56. Capnography Recommendation

57. CPR Quality
• Quantitative waveform capnography
• If Petco2<10 mm Hg, attempt to improve CPR quality
• Intra-arterial pressure
• If relaxation phase (diastolic) pressure <20 mm Hg,
attempt to improve CPR quality

59. SPO2
SBP >90 mmHg
MAP>65 mmHg
BT 32C-36C
at least 24 hr

60. TERMINATION OF RESUSCITATIVE EFFORTS
• Duration of resuscitative effort >20 minutes without a sustained perfusing
rhythm
• Initial EKG rhythm of asystole.
• Prolonged interval between estimated time of arrest and initiation of
resuscitation.
• Patient age and severity of comorbid disease.
• Absent brainstem reflexes.
• Normothermia.
• From objective endpoints best predictor of outcome may be the end-tidal carbon
dioxide (EtCO2 <10 mmHg) level following 20 minutes of resuscitation.
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62. PROGNOSIS
Poor prognostic features in patients
with SCA who survive until admission
Persistent coma after CPR
Hypotension,
pneumonia, and/or renal failure
after CPR
Need for intubation or pressors
History of class III or IV heart
failure and Older age
Greater likelihood of survival to
hospital discharge
Witnessed arrest
Ventricular tachycardia or
ventricular fibrillation as initial
rhythm
Pulse regained during first 10
minutes of CPR
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Despite advances in the treatment of heart disease, the outcome of
patients experiencing sudden cardiac arrest (SCA) remains poor.

63. • Factors identified predicting a lower likelihood of survival to hospital discharge:
• Longer duration of overall resuscitation efforts & Multiple resuscitation efforts
Success is best for VT (25–30%), worse for VF and poor for PEA and asystole
(<5%).
Although advances in CPR and post-resuscitation care have improved survival
rates after cardiac arrest, 90% of patients will not survive to be discharged from
the hospital.
Of those that survive, ~20% are left with severe neurologic and/or physical
disability
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64. Neuroprognostication
• Hypoxic Ischemic brain
injury…. Leading cause
of death in OHCA

65. The score for all variables in a patient should be
summed interpreted using the following categories:
Good Outcome Following Attempted
Resuscitation;
Very low
likelihood of
survival (<1%)
Score of 24 or
greater.
Low likelihood of
survival (1 to 3%)
Score 14 to 23.
Average
likelihood of
survival (>3 to
15%)
Score –5 to 13.
Higher than
average likelihood
of survival
(>15%) –
Score –15 to –6.
GO-FAR score to predict neurologically
intact survival-following IHCA
Variable GO-FAR score
Neurologically intact or with minimal
deficits at admission
_15
Major trauma 10
Acute stroke 8
Metastatic or hematologic cancer 7
Septicemia 7
Medical non-cardiac diagnosis 7
Hepatic insufficiency 6
Admit from skilled nursing facility 6
Hypotension or hypoperfusion 5
Renal insufficiency or dialysis 4
Respiratory insufficiency 4
Pneumonia 1
Age, yr (70-74),(75-79),(80-
84),(>85).
(2,5,6,11)
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66. Prevention
• Beta-adrenergic blockers
• ACEI, aldosterone antagonists, and angiotensin-receptor/neprilysin inhibitors
• Coronary artery bypass grafting
• For patients whose disease continues to confer substantial risk of sustained VT or
VF on optimal medical therapy, an ICD is recommended.
• Communicate with family and loved ones throughout resuscitative efforts
• Allow family to be present during resuscitative efforts, if appropriate
• Assess likely outcome, based on scientific evidence
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67. TOP 10 TAKE-HOME MESSAGES FOR
ADULT
CARDIOVASCULAR LIFE SUPPORT
1. On recognition of a cardiac arrest event, and promptly activate the emergency
response system and initiate CPR.
2. Performance of high-quality CPR
3. Early defibrillation with concurrent high-quality CPR.
4. Administration of epinephrine with concurrent high-quality CPR.
5. Recognition that all cardiac arrest & specialized mgt for each diseases

68. Cont…
6. Activation of emergency care and high quality CPR in OHCR due to opioid
poisoning
7. Post–cardiac arrest care is a critical component of the Chain of Survival and
demands a comprehensive, MDT treatment.
8. Prompt initiation of targeted temperature management
9. Accurate neurological prognostication
10.Recovery expectations and survivorship plans that address treatment,
surveillance, and rehabilitation.

69. Thank you!

70. References
• Harrison Principles of Internal Medicine, 20th ed
• Up to date 2018
• 2019 and 2020 AHA Guidelines Update for CPR and ECC
• 2015 ECC Guidelines
• Journals
• ACLS provider hand book
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