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Chapter 5. Advanced Cardiac Life Support

Darrel W. Hughes; Rebecca L. Attridge

  • 4 rhythms produce pulseless cardiac arrest: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA), & asystole
  • Key elements to survival (chain of survival) in patient with cardiac arrest (JAMA 1984;251:1723)
    • Early access; early cardiopulmonary resuscitation (CPR): compressions, airway, breathing (CAB) (Circulation 2010; 122:S250); early defibrillation (10% ↓ in successful intervention for every 1min delay); early advanced cardiac life support (ACLS)
  • Other elements associated with survival
    • Location of cardiac arrest: in-hospital > community (3–4-fold delay in initiation of pharmacotherapy for community cardiac arrest); witnessed > unwitnessed
    • Initial cardiac rhythm
    • Preexisting medical conditions
  • Adult cardiopulmonary arrest usually results from an arrhythmia secondary to thrombosis or pulmonary embolism
  • Goals of ACLS: sustained return of spontaneous circulation (ROSC), limiting end-organ damage, survival to hospital discharge
  • Role of drug therapy: enhance chance of ROSC, facilitate defibrillation
  • Prompt delivery of CPR followed by defibrillation ↑ survival in patients with pulseless VT/VF

Table 5-1 Hemodynamic Parameters
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Table 5-1 Hemodynamic Parameters

Parameter

Abbreviation

Normal Values

Measured Parameters

Systolic blood pressure

SBP

120mmHg

Diastolic blood pressure

DBP

80mmHg

Cardiac output

CO

4–6L/min

Heart rate

HR

60–100bpm

Pulmonary capillary wedge pressure

PCWP

6–12mmHg

Central venous pressure

CVP

1–6mmHg

Body surface area

BSA

1.73m2

Parameter

Abbreviation

Formula

Normal Values

Calculated Parameters

Mean arterial pressure

MAP

MAP = 1/3 (SBP – DBP) + DBP

MAP = CI × SVRI

90mmHg

Cardiac output

CO

CO = HR × SV

4–6L/min

Cardiac index

CI

CI = CO/BSA

2.5–4L/min/m2

Systemic vascular resistance

SVR

SVR = [(MAP – CVP) × 79.9]/CO

770–1500dyne × s/cm5

Systemic vascular resistance index

SVRI

SVR = [(MAP – CVP) × 79.9]/CI

1200–2500dyne × s/cm5 × m2

Table 5-2 Evidence-Based Treatment Recommendations (Circulation 2005;112:IV1–203)*
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Table 5-2 Evidence-Based Treatment Recommendations (Circulation 2005;112:IV1–203)*

Recommendation

Immediate bystander CPR

(Class I)

Perform high-quality CPR with minimal interruption in chest compressions & defibrillation

Epinephrine

(Class IIb)

Administer 1mg IV/IO Q3–5min in patients with VF, PVT, PEA, or asystole

Vasopressin

(Class indeterminate)

40 units IV/IO can replace 1st or 2nd dose of epinephrine in patients with VF, PVT, or asystole; insufficient evidence for use in PEA

Amiodarone

(Class IIb)

300mg IV/IO can be followed by 150mg IV/IO in patients with VF/PVT unresponsive to CPR, shock & a vasopressor

Lidocaine

(Class indeterminate)

Alternative if amiodarone unavailable in patients with VF/PVT

Initial dose is 1–1.5mg/kg IV; additional doses of 0.5–0.75mg/kg can be administered at 5- to 10-min intervals to a maximum dose of 3mg/kg if VF/PVT persists

Magnesium

(Class IIa)

Recommended for VF/PVT caused by torsades de pointes; give 1–2g diluted in 10mL D5W IV/IO push over 5–20min; clinical studies have not demonstrated a benefit when Mg2+ routinely administered during CPR without TdP

Thrombolysis

(Class IIa)

Consider on case-by-case basis when pulmonary embolism is suspected

Therapeutic hypothermia

(Class IIa)

(Class IIb)

Implement in unconscious adult patients with ...

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