Advanced Cardiovascular Life Support (ACLS) Overview
Advanced Cardiovascular Life Support (ACLS) is a systematic approach to managing cardiac arrest that emphasizes high-quality CPR, early defibrillation for shockable rhythms, medication administration, airway management, and addressing reversible causes to optimize patient survival and neurological outcomes. 1
Core Components of ACLS
High-Quality CPR
- Push hard (at least 2 inches/5 cm) and fast (100-120/min)
- Allow complete chest recoil after each compression
- Minimize interruptions in compressions (< 10 seconds)
- Avoid excessive ventilation
- Rotate compressor every 2 minutes to prevent fatigue 1
- For patients without advanced airway: 30:2 compression-ventilation ratio
- After advanced airway placement: continuous compressions with 1 breath every 6 seconds (10 breaths/min) 1
Defibrillation Strategy
- Single-shock strategy (rather than stacked shocks) followed by immediate CPR 2
- If first shock is unsuccessful and the defibrillator can deliver higher energy, it's reasonable to increase energy for subsequent shocks 2
- Minimize interruptions to chest compressions during defibrillator use
Medication Administration
Antiarrhythmic drugs for shock-refractory VF/pVT:
- Either amiodarone or lidocaine may be considered (2018 updated recommendation) 2
- Amiodarone IV/IO dose: First dose 300 mg bolus, Second dose 150 mg 2
- Lidocaine IV/IO dose: First dose 1-1.5 mg/kg, Second dose 0.5-0.75 mg/kg 2
- Recent evidence suggests lidocaine may be associated with higher rates of ROSC, survival to discharge, and favorable neurologic outcomes for in-hospital cardiac arrests 3
Vasopressors:
- Epinephrine 1 mg IV/IO every 3-5 minutes 1
Airway Management
- Options include bag-mask device, supraglottic airway (SGA), or endotracheal intubation
- Use waveform capnography to confirm and monitor advanced airway placement 2
- Suggest using highest possible inspired oxygen concentration during CPR 2
Monitoring During CPR
- Quantitative waveform capnography
- PETCO₂ < 10 mm Hg indicates need to improve CPR quality
- Abrupt sustained increase in PETCO₂ (typically > 40 mm Hg) suggests ROSC 2
- Cardiac ultrasound may be considered to identify potentially reversible causes if it doesn't interfere with standard ACLS protocol 2
- Avoid using ETCO₂ cutoff values alone as mortality predictor or to stop resuscitation 2
Reversible Causes (H's and T's)
- Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia
- Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) 1
Special Circumstances
Pregnant Patients
- For pregnant women in cardiac arrest in the second half of pregnancy, perform perimortem cesarean delivery 2
- Perform continuous manual left uterine displacement during resuscitation 1
Post-Resuscitation Care
- Avoid hypoxia and hyperoxia in adults with ROSC 2
- Suggest using 100% oxygen until arterial oxygen saturation can be reliably measured 2
- Maintain PaCO₂ within normal physiological range 2
- Consider hemodynamic goals during post-resuscitation care 2
Mechanical Support Considerations
- Automated mechanical chest compression devices are not recommended for routine use but are reasonable alternatives when sustained high-quality manual compressions are impractical or compromise provider safety 2
- ECPR (Extracorporeal CPR) may be considered as a rescue therapy for select patients when initial conventional CPR is failing in settings where it can be implemented 2
Team Dynamics
- Effective communication and role clarity are essential
- Minimize interruptions to chest compressions
- Continually look for reversible causes of cardiac arrest 4
ACLS is a critical component of the chain of survival, building upon Basic Life Support (BLS) with advanced interventions to increase the likelihood of successful resuscitation and favorable neurological outcomes.