Advanced cardiac life support
In healthcare, Advanced cardiac life support is "the use of sophisticated methods and equipment to treat cardiopulmonary arrest. Advanced Cardiac Life Support (ACLS) includes the use of specialized equipment to maintain the airway, early defibrillation and pharmacological therapy."
Treatment
Basic life support should include chest compressions done for at least 60% of the duration of the period without pulse.[1] The effect of chest compressions may be helped by active compression-decompression with a device such as ResQPOD.[2][3][4]
Artificial respiration may be needed.
Clinical practice guidelines for advanced cardiovascular life support by the American Heart Association provide treatment algorithms:[5]
- Adult BLS Healthcare Provider Algorithm[6]
- Pulseless Arrest Algorithm[7]
- Bradycardia Algorithm.[8]
- ACLS Tachycardia Algorithm.[8]
- For regular, wide complex (≥0.12 seconds), adenosine will
- help if the underlying rhythm is supraventricular tachycardia with aberrant conduction
- neither help nor hurt if the underlying rhythm is ventricular trachycardia
- For regular, wide complex (≥0.12 seconds), adenosine will
Ethical issues
When not to start ACLS
In a particular jurisdiction, this may have legal constraints, or operational ones such as standing orders from the medical director of an emergency medical system (EMS). This kind of emotionally draining decision is apt to be most straightforward when a patien's medical records are readily available and contain an explicit "Do Not Resuscitate" (DNR) or "Do Not Attempt Resuscitation" request from the patient or a surrogate with the appropriate authority.
This can be much more difficult in the field. Most EMS systems have rules for the obvious cases when any life support would be futile, such as decapitation or decomposition. A current controversy deals with certain kinds of trauma, where, variously,
- With reasonable medical certainty, there is no possibility of resuscitation with all possible resources. Finding a victim who is pulseless and has sustained major blunt chest trauma is the usual example where death is not obvious
- Studies are ongoing about when ACLS is futile for out-of-hospital arrests.[9]
- Situations where ACLS will not help, but immediate surgical intervention has some chance. Current thinking is that the appropriate treatment for exsanguinating hemorrhage is not fluids, not ACLS, but immediately opening the chest for manual heart compression and, perhaps, emergency repair or control of a vascular injury. In such a situation, if there is minimal but not absent cardiac activity, and there is a facility nearby prepared for emergency thoracotomy, the ACLS "treat until stable" is less appropriate than "scoop and run".
When to terminate ACLS
A clinical prediction rule suggests advice about stopping ACLS that is in progress.[10][11]
The Ontario Prehospital Advanced Life Support (OPALS) recommendation is "termination of resuscitation when there was no return of spontaneous circulation prior to transport, no shock was given and the arrest was not witnessed by Emergency Medical Services personnel."[11]
References
- ↑ Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J et al. (2009). "Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.". Circulation 120 (13): 1241-7. DOI:10.1161/CIRCULATIONAHA.109.852202. PMID 19752324. Research Blogging.
- ↑ Wolcke BB, Mauer DK, Schoefmann MF, Teichmann H, Provo TA, Lindner KH et al. (2003). "Comparison of standard cardiopulmonary resuscitation versus the combination of active compression-decompression cardiopulmonary resuscitation and an inspiratory impedance threshold device for out-of-hospital cardiac arrest.". Circulation 108 (18): 2201-5. DOI:10.1161/01.CIR.0000095787.99180.B5. PMID 14568898. Research Blogging.
- ↑ Lurie KG, Shultz JJ, Callaham ML, Schwab TM, Gisch T, Rector T et al. (1994). "Evaluation of active compression-decompression CPR in victims of out-of-hospital cardiac arrest.". JAMA 271 (18): 1405-11. PMID 8176802.
- ↑ Plaisance P, Lurie KG, Vicaut E, Adnet F, Petit JL, Epain D et al. (1999). "A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group.". N Engl J Med 341 (8): 569-75. PMID 10451462.
- ↑ (December 2005) "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 112 (24 Suppl): IV1–203. DOI:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. Research Blogging.
- ↑ (December 2005) "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 4: Adult Basic Life Support". Circulation 112 (24 Suppl): IV1–203. DOI:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. Research Blogging.
- ↑ (December 2005) "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 7.2: Management of Cardiac Arrest". Circulation 112 (24 Suppl): IV1–203. DOI:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. Research Blogging.
- ↑ 8.0 8.1 (December 2005) "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 7.3: Management of Symptomatic Bradycardia and Tachycardia". Circulation 112 (24 Suppl): IV1–203. DOI:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. Research Blogging.
- ↑ Herlitz J, Engdahl J, Svensson L, Young M, Ängquist K-A, Holmberg S (2004 October), "Can we define patients with no chance of survival after out-of-hospital cardiac arrest?", Heart 90 (10), PMCID PMC1768510, DOI:10.1136/hrt.2003.029348. pp. 1114–1118
- ↑ Sasson C, Hegg AJ, Macy M, Park A, Kellermann A, McNally B (September 2008). "Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest". JAMA : the journal of the American Medical Association 300 (12): 1432–8. DOI:10.1001/jama.300.12.1432. PMID 18812534. Research Blogging.
- ↑ 11.0 11.1 Morrison LJ, Verbeek PR, Zhan C, Kiss A, Allan KS (March 2009). "Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers". Resuscitation 80 (3): 324–8. DOI:10.1016/j.resuscitation.2008.11.014. PMID 19150167. Research Blogging.