ADVANCED CARDIOVASCULAR

LIFE SUPPORT (ACLS)

Under European Resuscitation Council

Protocol Training

Dr. Mubarik Jama

Emergency & Critical Care Medicine Physician
Licensed — UMDPC
Registered ALS Provider, ERC European
Resuscitation Council .

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OVERVIEW / LEARNING OBJECTIVES for the session
I. Rapid recognition of cardiac arrest and activation of the resuscitation team.
II. Deliver high-quality CPR (rate, depth, minimal interruptions).
III. Airway management Maneuvers During ACLS Protocol.
IV. Differentiate and manage shockable (VF/pulseless VT) vs non-shockable (PEA/asystole)
rhythms.
V. Use defibrillation and drugs appropriately (epinephrine, amiodarone/lidocaine).
VI. Search for and treat reversible causes (the H’s and T’s).
VII. Provide post-ROSC stabilization (airway, oxygenation, MAP, temperature )

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Basic life support (BLS) is the
component of the immediate care
provided for the victims of life-
threatening conditions, leading to
cardiac arrest, and injuries till the
patient can be shifted to a hospital. It
can be given by doctors, nurses,
paramedics, or even by a trained by
stander.
The brain is very sensitive to
hypoperfusion. Therefore, the main
objective of BLS/ACLS is to restore
cerebral perfusion at the earliest

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 BASIC LIFE SUPPORT/CARDIOPULMONARY RESUSCITATION FOR ADULTS
Basic life support consists of the following main parts:
I. Chest compressions
II. Airway
III. Breathing
IV. Defibrillation

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 Initial Basic Life Support Steps

1. Assessment and scene safety.

2. Remove victim from the hazardous environment to a
place where care may be
3. provided without putting the victim or BLS provider
at a risk of harm.
4. Look for response and breathing pattern. If there is
no response and the victim
5. is not breathing or is gasping, shout for help.
6. Check the victim’s carotid pulse (take at least 5
seconds but no more than 10 seconds

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IMMEDIATE ACTIONS (Team roles and first 2 minutes)

check responsiveness. Call for help/activate code

team and request AED/monitor.
Check pulse and breathing quickly (≤10 seconds).
If no pulse or abnormal gasping → start CPR
immediately.
High-quality CPR: compressions at 100–120/min,
depth ≥50 mm (~2 inches) in adults, full chest recoil,
minimize interruptions (compression fraction >80%).
Rotate compressor every 2 minutes. Ventilate without
excessive volumes.
Start ABCDE Protocol and Attach
monitor/defibrillator as soon as available; analyze
rhythm. If AED available Use.

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Chest Compressions
High-quality CPR improves a victim’s chance of survival.
The BLS provider should follow these critical characteristics
of chest compressions while providing highquality CPR ).
1. Start compressions within 10 seconds of recognition of
cardiac arrest.
2. Push hard, push fast: Compress at a rate of at least 100–
120/min with a depth of at least 5 cm (2 inches) for adults,
approximately 5 cm (2 inches) for children, and
approximately 4 cm (1½ inches) for infants.
3. Allow complete chest recoil after each compression.
4. Minimize interruptions in compressions (try to limit
interruptions to <10 s).
5. Give effective breaths that make the chest rise. With an
advanced airway in
6. place, deliver 10 breaths/min or 1 breathe every 6 seconds

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AIRWAY MANAGEMENT& VENTILATION DURING ARREST

Start with basic airway and BVM with high-

flow oxygen. Avoid excessive ventilation (target
=10 breaths/min if advanced airway).
Consider advanced airway (ETT or
supraglottic) if trained personnel available
do not interrupt chest compressions for
airway placement
if advanced airway placed, ventilate at 10
breaths/min (1 every 6 seconds).
Use waveform capnography to confirm/monitor
tube placement; aim PETCO₂ =35–40 mmHg
(useful prognostic/quality measure).

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 Airway Management Maneuvers
In an unresponsive patient, the airway may be occluded due to
decreased tone of the tongue and pharyngeal muscles. There are two
methods of opening the airway to provide rescue breaths

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Rhythm Analysis: Shockable vs Non-Shockable Rhythms

Shockable:
NON- Shockable:
1. Ventricular
Tachycardia (VT) 1. Pulseless
Electrical
2. Ventricular Activity (PEA)
Fibrillation (VF)
2. Asystole

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Ventricular Tachycardia (VT)
Broad QRS complexes (≥0.12 sec), no P waves.
Findings:
•Rate: 100–250 bpm
•Rhythm: Regular (monomorphic) or variable
(polymorphic)
•QRS: Wide (>0.12 sec)

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Ventricular Fibrillation
(VF)
Picture: Chaotic, irregular wave
pattern — no organized QRS.
Findings:
•No P, no QRS, no pulse.

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Asystole
Picture: Flat line
(isoelectric).
Findings:
No electrical activity, no
pulse.

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Pulseless Electrical Activity
(PEA)
Picture: Organized rhythm on
monitor but no palpable pulse.
Findings:
ECG may show NSR, brady, or
slow wide QRS — but no pulse.

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MANGMENT SHOCKABLE RHYTHM (VF / pulseless VT)
Recognize VF/pulseless VT → Shock immediately
(unsynchronized defibrillation). Deliver 1 shock
Resume CPR immediately for 2 minutes after shock
(do NOT pause to check pulse).
IV/IO access during ongoing CPR. Give epinephrine
1 mg IV/IO every 3–5 minutes starting as soon as
access is available (after first cycle if necessary).
After the second shock (if VF/VT persists), consider
antiarrhythmic: Amiodarone 300 mg IV bolus (if
still refractory), then 150 mg if needed; alternatively
lidocaine can be used. Continue CPR 2 minutes
between rhythms checks.
Reassess rhythm every 2 minutes (during rhythm
check, briefly pause, check rhythm and pulse). If still
shockable, shock and continue the cycle. Always
minimize pauses

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 NON-SHOCKABLE RHYTHM (PEA / Asystole )
continue high-quality CPR immediately and
attach monitor.
IV/IO access and give epinephrine 1 mg IV/IO
every 3–5 minutes as soon as possible.
Do NOT shock unless rhythm becomes
shockable. Continue CPR 2 minutes then rhythm
check.
Search for and treat reversible causes (H’s &
T’s)

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DRUGS & DOSES
Epinephrine (adrenaline): 1 mg IV/IO every 3–5 minutes during cardiac
arrest.
Amiodarone: 1st dose 300 mg IV bolus for refractory VF/VT; 2nd dose 150
mg IV bolus if needed.
Lidocaine (alternative): 1–1.5 mg/kg IV bolus, repeat 0.5–0.75 mg/kg up to
max 3 mg/kg; infusion.
Vasopressin no longer recommended as routine replacement for epinephrine in
many algorithms; use per local guideline updates. (Check most recent AHA
updates for local practice.)

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 Treatment of reversible causes ( 5H’ & 5T’)
1. Hypoxia
If oxygen delivery to tissues is inadequate, the heart cannot recover.
Look for poor chest rise, cyanosis, or dislodged airway devices. Manage by ensuring the airway is
open, ventilate with 100 % oxygen, confirm correct endotracheal tube placement using chest rise and
end-tidal CO₂, and provide effective ventilation.
2. Hypovolemia
Severe fluid or blood loss can lead to cardiac arrest
Manage by restoring circulating volume with rapid IV or IO fluids (normal saline or Ringer’s
lactate), controlling external bleeding, and giving blood if hemorrhage is suspected.
3. Hydrogen Ion (Acidosis)
Acidosis reduces cardiac contractility and the effectiveness of medications. Common causes are
prolonged cardiac arrest, DKA, renal failure, or sepsis. Manage with good-quality CPR to improve
perfusion, provide adequate ventilation to remove CO₂, and if severe metabolic acidosis (pH < 7.1) is
present, give sodium bicarbonate 1 mEq/kg IV

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Hypo- or Hyperkalemia

Abnormal potassium levels strongly affect cardiac rhythm.

In hyperkalemia, ECG shows tall peaked T waves, widened QRS, and can progress to sine-wave pattern.
In hypokalemia, the T waves are flattened and U waves may appear.
Treat hyperkalemia with calcium gluconate, insulin with dextrose, and nebulized salbutamol; in severe
cases, dialysis.
Treat hypokalemia by giving IV potassium chloride slowly (10–20 mEq per hour).

Hypothermia

cold, stiff patient with a low core temperature may be in cardiac arrest due to hypothermia.
Check for exposure to cold or prolonged downtime.
Manage by rewarming: give warmed IV fluids, use warm humidified oxygen, apply forced-air warming
blankets, and consider extracorporeal warming if available.

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Tension Pneumothorax

Air trapped in the pleural space compresses the lungs and heart.
Signs include sudden desaturation, absent breath sounds on one side, distended neck veins, and tracheal deviation.
Treat immediately with needle decompression (2nd intercostal space midclavicular line or 5th intercostal space mid-
axillary line) followed by chest tube insertion.

Cardiac Tamponade

Look for muffled heart sounds, distended neck veins, and low blood pressure (Beck’s triad).
Manage with urgent pericardiocentesis and give IV fluids to maintain preload until the tamponade is relieved.

Thrombosis – Coronary (Myocardial Infarction)

A major coronary occlusion can cause arrest.
Look for history of chest pain or ECG changes such as ST-elevation.
Manage by performing immediate reperfusion preferably PCI or give thrombolytics such as alteplase if PCI is
unavailable.

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Thrombosis – Pulmonary (Massive Pulmonary Embolism)

large clot in the pulmonary arteries can cause sudden PEA.

The patient may have had dyspnea or signs of right-heart strain before arrest.
Manage with thrombolysis (for example, alteplase 50 mg IV bolus) and supportive oxygen and
fluids.

Toxins (Drug Overdose)

Certain drugs and poisons can precipitate cardiac arrest.

Clues include history of ingestion, constricted pupils in opioid overdose, wide QRS in tricyclic
toxicity, or bradycardia from beta-blockers.
Treat with specific antidotes: naloxone for opioids, sodium bicarbonate for tricyclics, glucagon for
beta-blockers, and calcium with insulin-glucose therapy for calcium-channel blockers.

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Post Cardiac Arrest Care
Immediate Steps After ROSC – Return of Spontaneous Circulation
ICU Admiting and Transfer the patient

Prepare for ICU admission for post-resuscitation care.

Continuous ECG, BP, SpO₂, EtCO₂, and temperature monitoring.
ABG and lactate every 2–4 hours.
Check electrolytes and glucose (keep 140–180 mg/dL).

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 Maintain oxygen saturation between 94–98% (avoid hyperoxaginated)
If intubated, set appropriate ventilation to maintain PaCO₂ 35–45 mmHg. Avoid
hypocapnia it reduces cerebral blood flow.
Maintain systolic BP ≥ 100 mmHg or MAP ≥ 65 mmHg.
Use vasoactive drugs as needed:
◦ Noradrenaline (norepinephrine): 0.05–1 µg/kg/min (first-line for hypotension).
◦ Dopamine: 5–20 µg/kg/min (alternative if bradycardia).
◦ Adrenaline (epinephrine): 0.05–0.5 µg/kg/min (for refractory hypotension).
◦ Dobutamine: 2–20 µg/kg/min (for myocardial dysfunction or low cardiac output).

Give IV fluids cautiously (avoid overload in cardiac dysfunction)

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Assess neurological status (GCS, pupils, reflexes).
Targeted temperature management (TTM)
◦ Maintain body temperature 32–36°C for 24 hours to protect the brain.
◦ Prevent fever afterward (>37.7°C).
Maintain blood glucose between 140–180 mg/dL (7.8–10
mmol/L).
Treat seizures :
Diazepam 5–10 mg IV bolus or midazolam 2–5 mg IV bolus.
Phenytoin 15–20 mg/kg IV if persistent seizures.

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Metabolic acidosis is common post-cardiac arrest due to hypoperfusion
and lactic acid buildup.

Correct by:
Optimizing oxygenation and ventilation.
Ensuring adequate perfusion and BP with fluids and vasopressors.
Treating the cause (e.g., shock, hypoxia, hypercapnia).
Sodium bicarbonate is only used if pH < 7.1 or severe metabolic
acidosis after circulation is restored.
Dose: 1 mEq/kg IV bolus, repeat guided by ABG (avoid overcorrection).

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Reference Protocols and Books
1. 1. European Resuscitation council Guidline ERC
2. American Heart Association AHA
3. International Liaison Committee on Resuscitation ILCOR
4. Resuscitation Council In UK of ALS (BLS ACLS )
5. Emergency Cardiovascular Care handbook
6. Tintinalli`s Emergency Medicibe 9th addition
7. CMC Vellore Handbook of EMERGENCY MEDICINE

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