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Adult Advanced Cardiovascular Life Support
2015
American Heart Association Guidelines for
Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
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Pulseless
Arrest
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 4 rhythms produce
pulseless cardiac arrest:
 Ventricular fibrillation (VF)
 Rapid ventricular tachycardia (VT)
 Pulseless electrical activity (PEA)
 Asystole
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Survival from these arrest
rhythms requires both basic life
support (BLS) and advanced
cardiovascular life support
(ACLS).
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For victims of witnessed VF arrest,
prompt bystander :
1. CPR
2. Early defibrillation
can significantly increase the chance for
survival to hospital discharge.
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In comparison, typical ACLS
therapies, such as:
 insertion of advanced airways and
 pharmacologic support of the
circulation,
increase ROSC but have not been
shown to increase rate of survival
to hospital discharge.
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
Central line access is not needed in
most resuscitation attempts.
 Drugs typically require 1 to 2 minutes
to reach the central circulation when
given via a peripheral vein but require less
time when given via central venous
access.
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peripheral venous route:
1. Follow with a 20 ml bolus of IV fluid
2. Elevate the extremity for 10 to 20
seconds to facilitate drug delivery to
the central circulation.
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Intraosseous (IO)
cannulation provides access to a
noncollaps-ible venous plexus,
enabling drug delivery similar
to that achieved by central
venous access.
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If IV and IO access cannot be
established, some resuscitation
drugs may be administered by
the endotracheal route
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E T route:
Lidocaine
Epinephrine
 Atropine
Naloxone
 Vasopressin
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The optimal endotracheal dose of most
drugs is unknown,but typically the
dose given by the endotracheal
route is 2 to2.5 times the
recommended IV dose.
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Providers should dilute the
recommended dose in
5 to 10 mL of water or normal
saline
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Treatable Causes of Cardiac Arrest:
The H's and T's
1.
Toxins
1. Hypoxia
2. Tamponad
2. Hypovolemia
(cardiac)
3. Hydrogen Ion 3. Tension
(Acidosis)
Pneumothorax
4. Thrombosis
4. Hypo/
Hyper Kalemia (coronary)
5. Thrombosis
5. Hypothermia
(pulmonary)
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 complete cessation of myocardial
electrical activity
 End-stage rhythm
 َAsystole should always be
confirmed in at least two limb leads
 It may be difficult to distinguish
between extremely fine VF and
asystole
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 PEA is defined as non-coordinated groups of
electrical activity of the heart (other than VT/VF)
without a palpable pulse: EMD + pseudo EMD
 EMD = Electro Mechanical Dissociation : no
myocardial contractions occur
 Pseudo-EMD : myocardial contractions occur but
no pulse can be palpated
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 Idioventricular rhythms
 Ventricular escape rhythms
 Postdefibrillation idioventricular
rhythms
 Brady-asystolic rhythms
 Agonal rhythms
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 Global myocardial dysfunction
 Papillary muscle and myocardial wall
rupture
 Hypovolemia, tension pneumothorax,
pericardial tamponade, and massive PE
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ASYSTOLE/PEA MANAGEMENT
 Patients who have either asystole or PEA will
not benefit from defibrillation attempts
 A vasopressor (epinephrine ) may be
administered at this time.
 Epinephrine can be administered
approximately every 3 to 5 minutes during
cardiac arrest
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 When supplementary oxygen is available, it may be
reasonable to use the maximal feasible inspired oxygen
concentration during CPR
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 In intubated patients, failure to achieve an ETCO2
 of greater than 10 mm Hg by waveform capnography
after 20 minutes of CPR may be considered as one
component of a multimodal approach to decide when
to end resuscitative efforts, but it should not be used
in isolation
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 if the arterial relaxation “diastolic” pressure is <20 mm
Hg, it is reasonable to consider trying to improve
quality of CPR by optimizing chest compression
parameters or giving a vasopressor or both
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 Emphasis on effective chest
compression
 One universal compression-to-
ventilation 30/2
 Recommendation for 1-second breaths
during all CPR
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 Rescuers should change
compressors every 2 min
 Compression should ideally be
interrupted only for rhythm check
and shock delivery
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 Providers do not attempt a pulse or
check the rhythm after shock
delivery
 Drug should be delivered during
CPR, as soon as possible after
rhythm check
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 Antiarrhythmics: Amiodarone is
preferred to lidocaine , but either is
acceptable
 Deliver 1 shock , then immediate
CPR and NO check pulse
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1-Epinephrine
2-Amiodarone
3-Lidocaine
4-Magnesium
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 When VF/pulseless VT cardiac arrest is
associated with torsades de pointes,
providers may administer magnesium
sulfate at a dose of 1 - 2 g diluted in 10
mL D5W IV/IO push
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 When torsades is present in the
patient with pulses, the same 1 - 2
g is mixed in 50 to 100 mL of D5W
and given as a loading dose.
 It can be given more slowly (eg,
over 20 to 60 minutes IV)
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Resuscitation of the
Pregnant Patient
Key Points
 During resuscitation there are two patients, mother &
fetus
 The best hope of fetal survival is maternal survival
 Consider the physiologic changes due to pregnancy
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 Successful resuscitation of a pregnant woman &
survival of the fetus require prompt & excellent
CPR with some modifications in techniques
 By the 20th week of gestation, the gravid uterus
can compress the IVC & aorta, obstructing venous
return & arterial blood flow
 Rescuers can relieve this compression by
positioning the woman on her side or by pulling
the gravid uterus to the side
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Defibrillation
 Defibrillate using standard ACLS defibrillation doses
 There is no evidence that shocks from a direct current
defibrillator have adverse effects on the heart of the
fetus
 If fetal or uterine monitors are in place, remove them
before delivering shocks
Summary
 Defibrillation & medication doses used for
resuscitation of the pregnant woman are the same as
those used for other adults
 Rescuers should consider the need for ER Caesarian
Delivery as soon as the pregnant woman develops
cardiac arrest
 Rescuers should be prepared to proceed if the
resuscitation is not successful within 4 minutes
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 BLS treatment of cardiac arrest in asthmatic patients is
unchanged
 Standard ACLS guidelines should be followed
 Auto PEEP
 tension pneumothorax
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 management of cardiac arrest secondary to
anaphylaxis should be treated with standard BLS and
ACLS
 Airway
 The intramuscular (IM) administration of epinephrine
 Fluid Resuscitation
 Vasopressors
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 Adjuvant use of antihistamines (H1 and H2
antagonist), inhaled -adrenergic agents,
and IV corticosteroids has been successful
in management of the patient with
anaphylaxis and may be considered in
cardiac arrest due to anaphylaxis
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 CPR for drowning victims should use the traditional
A-B-C approach in view of the hypoxic nature of the
arrest
 The first and most important treatment of the
drowning victim is the immediate provision of
ventilation.
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 Attempts to remove water from the breathing
passages by any means other than suction (eg,
abdominal thrusts or the Heimlich maneuver) are
unnecessary and potentially dangerous
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 As soon as the unresponsive victim is removed
from the water, the rescuer should open the airway,
check for breathing, and if there is no breathing,
give 2 rescue breaths that make the chest rise
 Victims in cardiac arrest may present with
asystole, PEA, or pulseless VT/VF. For treatment of
these rhythms, follow the appropriate ACLS
guidelines
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 AED?
 Cervical imobilization?
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DEFIBRILLATION
Some AEDs will
automatically
switch themselves on when
the lid is opened
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Stand clear
Deliver shock
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defibrillation
DEFIBRILLATION
 The most effective treatment of VF is timely defibrillation
 early defibrillation :defined as defibrillation under 4 minutes of
onset

successful defibrillation implies delivering the appropriate
amount of current or energy to the fibrillating myocardium,
such that the chaotic electrical activity is terminated and a
supraventricular perfusing rhythm is established
CPR prior to
defibrillation
 Lack of success for in-hospital resuscitation appears to
result from delays in time to first shock from collapse.
Defibrillation Equipment
List of Materials for Defibrillation
 Defibrillator/ECG monitor

Handheld defibrillation electrodes “quick-look”
paddles

Patient interface cables; multifunctional for ECG
monitoring and defibrillation
 Electrodes and pads for ECG signal acquisition and
defibrillation
 Conductive gel (not ultrasound gel)

always kept in a constant state of readiness
 Wherever possible, the defibrillator ,patient
cables, quick-look electrode paddles and
ECG and defibrillation electrodes and pads
should be preconnected and labeled to
facilitate application to the patient
 members of the designated resuscitation
team should check the equipment at the
beginning of their clinical shifts
Multifunction defibrillator/monitor
Defibrillator monitor capable of 12-lead
ECG/cardioversion/pacing/limited ECG
interpretation.
Defibrillator Types
Defibrillators (operational characteristics)
Manual
Semiautomated
fully automatic
Monophasic damped sinusoidal (MDS) and
monophasic truncated exponential(MTE)
waveforms
Biphasic waveforms.
 Monophasic or Biphasic
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 no specific waveform has been
proved to be superior to another
regarding survival from SCA or for
the return of spontaneous
circulation
 biphasic waveforms have been
shown to be more efficient in
achieving first-shock termination
of VF than monophasic
waveforms.
Monophasic Defibrillators/Energy Selection
 first type introduced
 still available in various patient care
settings
 MDS waveform for defibrillation
 an energy level of 360 J be used for the
first shock
Biphasic Defibrillators
 Defibrillator today are primarily biphasic
 an output waveform that flows back and forth between
the electrodes
 more successful defibrillation shock /less energy /
better first-shock defibrillation success
 an optimal energy level for first-shock for VF has not
been established, several studies have demonstrated
that using relatively low energy of 200 J or less
Energy Selection
 device-specific effective waveform dose range
 biphasic rectilinear waveform
120 J
 unaware of waveform dose range, a
consensus default of 200 J should be used
for the initial shock
Energy Selection
 CHILDREN?
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Manual Defibrillation
Attach Electrodes to patient
Select DEFIB Unit automatically defaults to first
shock setting determined in Configuration
(typically 120J, 150J, 200J)
To change energy setting, use UP/DOWN
ARROWS. Selected energy is displayed as
“DEFIB xxxJ SEL”
Press CHARGE
Make sure everyone is clear
When SHOCK button lights, press SHOCK
Manual Defibrillation with Paddles
 Select DEFIB Unit automatically defaults to





first shock setting
To change energy setting, use UP/DOWN
ARROWS
Press CHARGE on the panel or on the apex
handle
Apply electrolyte gel to the paddles and
apply paddles to chest
Make sure everyone is clear
When SHOCK button lights, place paddles
on chest with 25 lb pressure and
simultaneously press SHOCK on both
paddles
Correct position for electrode/paddle
placement
Use of quick-look paddle electrodes for
rhythm (ECG) determination and
defibrillation
Front/back position of electrodes on patient
(alternate position).
Asystole
or Fine VF
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Post–Cardiac Arrest Care
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•Ventilation
•Hemodynamics
•Cardiovascular
•Neurological
•Metabolic
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