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Advanced cardiac life support

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Advanced cardiac life support
Cardiopulmonary resuscitation of an avalanche victim who was medically evacuated to Craig Joint Theater Hospital in February 2010
Other namesAdvanced Cardiovascular Life Support, ACLS
SpecialtyEmergency Medicine, Cardiology, Critical Care, Anesthesia
UsesCardiac arrest treatment, Cardiovascular emergency treatment
FrequencyCommon

Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques. ACLS expands on Basic Life Support (BLS) by adding recommendations on additional medication and advanced procedure use to the CPR guidelines that are fundamental and efficacious in BLS. ACLS is practiced by advanced medical providers including physicians, some nurses and paramedics;[1] these providers are usually required to hold certifications in ACLS care.

While "ACLS" is almost always semantically interchangeable with the term "Advanced Life Support" (ALS), when used distinctly, ACLS tends to refer to the immediate cardiac care, while ALS tends to refer to more specialized resuscitation care such as ECMO and PCI. In the EMS community, "ALS" may refer to the advanced care provided by paramedics while "BLS" may refer to the fundamental care provided by EMTs and EMRs; without these terms referring to cardiovascular-specific care.

Overview

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Advanced cardiac life support refers to a set of guidelines used by medical providers to treat life-threatening cardiovascular conditions. These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri-cardiac arrest care: Airway management, ventilation, CPR compressions (continued from BLS), defibrillation, and medications. Due to the seriousness of the diseases treated, the paucity of data known about most ACLS patients, and the need for multiple, rapid, simultaneous treatments, ACLS is executed as a standardized, algorithmic set of treatments. Successful ACLS treatment starts with diagnosis of the correct EKG rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include: ventricular tachycardia, ventricular fibrillation, Pulseless Electrical Activity, and asystole. Dangerous, non-arrest rhythms typically covered includes: narrow- and wide-complex tachycardias, torsades de pointe, atrial fibrillation/flutter with rapid ventricular response, and bradycardia.[2]

Successful ACLS treatment generally requires a team of trained individuals. Common team roles include: Leader, back-up leader, 2 CPR performers, an airway/respiratory specialist, an IV access and medication administration specialist, a monitor/ defibrillator attendant, a pharmacist, a lab member to send samples, and a recorder to document the treatment.[3] For in-hospital events, these members are frequently physicians, mid-level providers, nurses and allied health providers; while for out-of-hospital events, these teams are usually composed of a small number of EMTs and paramedics.

Scope

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ACLS algorithms include multiple, simultaneous treatment recommendations. Some ACLS providers may be required to strictly adhere to these guidelines, however physicians may generally deviate to pursue different evidence-based treatment, especially if they are addressing an underlying cause of the arrest and/or unique aspects of a patient's care. ACLS algorithms are complex but the table, below, demonstrates common aspects of ACLS care.[2]

ACLS Component Possible Interventions Goals of care
Rhythm diagnosis EKG, clinical exam Diagnosis of malignant arrhythmia.
CPR Chest Compressions, mechanical CPR Perfusion of blood before ROSC is achieved. Note: chest compressions are not different in ACLS vs BLS, but continue to be a fundamental part of cardiac arrest care even when ACLS is being executed.
Electrotherapy Mono- or biphasic defibrillation, double sequential defibrillation, transvenous pacing, transcutaneous pacing Termination of shockable rhythms. Note: not all cardiac arrest rhythms can be treated with defibrillation.
Airway Management Endotracheal intubation, supraglottic airway placement, Cricothyrotomy, waveform capnography, tracheal suctioning, naso- or oropharygeal airway placement Cleat and protect the airway to allow for adequate ventilation.
Ventillation Bag-valve-mask, ventilator management, oxygen therapy Ventilate the lungs to allow for subsequent oxygenation of the blood.
Medications Epinephrine, norepinephrine, vasopressin, atropine, amiodarone, lidocaine, procainamide, sotalol, albuterol, calcium chloride, magnesium, crystalloid fluids, intraosseous access Stabilizes arrhythmia, promote ROSC and increase perfusion.
Specialized Resuscitation Techniques Echocardiography, TEE, PCI, ECMO, TTM, central venous access Identification of underlying cause of cardiac arrest, augmentation of perfusion and/or treatment of PCAS.


ACLS Certification

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Due to the rapidity and complexity of ACLS care, as well as the recommendation that it be performed in a standardized fashion, providers must usually hold certifications in ACLS care. Certifications may be provided by a few different, generally national, organizations but their legitimacy is ultimately determined by hospital hiring and privileging boards; that is, ACLS certification is frequently a requirement for employment as a health care provider at most hospitals.[4] ACLS certifications usually provide education on the aforementioned aspects of ACLS care except for specialized resuscitation techniques. Specialized resuscitation techniques are not covered by ACLS certifications and their use is restricted to further specialized providers. ACLS education is based on ILCOR recommendations which are then adapted to local practices by authoritative medical organizations such as the American Red Cross, the European Resuscitation Council, or the Resuscitation Council of Asia.

BLS proficiency is usually a prerequisite to ACLS training; however the initial portions of an ACLS class may cover CPR.[5] Initial training usually takes around 15 hours and includes both classroom instruction and hands-on simulation experience; passing a test, with a practical component, at the end of the course is usually the final requirement to receive certification.[6] After receiving initial certification, providers must usually recertify every two years in a class with similar content that lasts about seven hours. Widely accepted providers of ACLS certification include, non-exclusively: American Heart Association, American Red cross, European Resuscitation Council or the Australian Resuscitation Council.

Holding ACLS certification simply attests a provider was tested on knowledge and application of ACLS guidelines. The certification does not supersede a provider's scope of practice as determined by state law or employer protocols; and does not, itself, provide any license to practice.

Efficacy of ACLS

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Like a medical intervention, researchers have had to ask whether ACLS is effective. Data generally demonstrates that patients have better survival outcomes (increased ROSC, increased survival to hospital discharge and/or superior neurological outcomes) when they receive ACLS;[7] however a large study of ROC patients showed that this effect may only be if ACLS is delivered in the first six minutes of arrest.[8] This study also found that ACLS increases survival but does not produce superior neurological outcomes.

Some studies have raised concerns that ACLS education can be inconstantly or inadequately taught which can result in poor retention, leading to poor ACLS performance.[9] One study from 1998 looked at the ACLS use of epinephrine, atropine, bicarbonate, calcium, lidocaine, and bretylium in cardiac arrests and found that these medications were not associated with higher resuscitation rates.[10]

Research on ACLS can be challenging because ACLS is a bundle of care recommendations; with each individual treatment component being profoundly consequential. There is active debate within the resuscitation research community about the value of certain interventions. Active areas of research include determining the value of vasopressors in arrests,[11] ideal airway use[12] and different waveforms for defibrillation.[13]

International guidelines

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Stemming from the need for standardized, evidence based ACLS guidelines, an international network of academic resuscitation organizations was created. The International Liaison Committee on Resuscitation (ILCOR) is the central, international institution that regional resuscitation committees strive to contribute to and disseminate information from. The centralization of resuscitation research around ILCOR reduces redundant work internationally, allows for collaboration between experts from many regional organizations, and produces higher quality, higher powered research.

International Liaison Committee on Resuscitation

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ILCOR serves as a way for international resuscitation organizations to communicate and collaborate.[14] ILCOR publishes scientific evidence reviews on resuscitation known as "Continuous Evidence Evaluation (CEE) and Consensus on Science with Treatment Recommendations (CoSTRs)".[15] ILCOR uses 6 international task forces to review over 180 topics through a structured systematic-review process. ILCOR traditionally published updates and recommendations every five years but now conducts continuous review work.[16] ILCOR produces international recommendations which are then adopted by regional resuscitation committees which publish guidelines.[17] Regional guidelines can have more medicolegal bearing than ILCOR recommendations.[18] ILCOR is composed of the following regional organizations:

Regional Organization Affiliated Nations
American Heart Association (AHA) United States
European Resuscitation Council (ERC)[19] Austria, Belgium, Bosnia & Herzegovina, Croatia, Cyprus, Czechoslovakia, Denmark, Egypt, Finland, France, Germany, Hungary, Iceland, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sudan, Sweden, Switzerland, Tunisia, Turkey, Ukraine, United Kingdom
Heart and Stroke Foundation of Canada (HSFC) Canada
Australian Resuscitation Council Australia
New Zealand Resuscitation Council New Zealand
Resuscitation Council of Southern Africa (RCSA) South Africa
InterAmerican Heart Foundation (IAHF)[20] Argentina, Barbados, Bolivia, Jamaica, Trinidad and Tobago, United States
Resuscitation Council of Asia (RCA)[21] Hong Kong, Japan, Korea, Philippines, Singapore, Thailand, Taiwan

History

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ILCOR

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The International Liaison Committee on Resuscitation (ILCOR) was established 1992 to serve as a way for international resuscitation organizations to communicate and collaborate.[14]

AHA Guidelines

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The ACLS guidelines were first published in 1974 by the American Heart Association and were updated in 1980, 1986, 1992, 2000, 2005, 2010, 2015.[22] In the 2020 update the guidelines were restructured to align with ILCOR recommendations. These changes include the transition since 2015 away from the previous 5-year update cycle to an online format that can be updated as indicated by continuous evidence review.[23]

ERC Guidelines

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The first version of the European Resuscitation Council (ERC) guidelines were developed in 1992. The 2000 ERC guidelines were developed in collaboration with ILCOR. 5-year updates were published from 2000 to 2015 and annual updates have been published since 2017.[24]

See also

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References

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  1. ^ Ryynänen, Olli-Pekka; Iirola, Timo; Reitala, Janne; Pälve, Heikki; Malmivaara, Antti (2010). "Is advanced life support better than basic life support in prehospital care? A systematic review". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18: 62. doi:10.1186/1757-7241-18-62. PMC 3001418. PMID 21092256.
  2. ^ a b "Part 3: Adult Basic and Advanced Life Support". cpr.heart.org. Retrieved 2022-01-25.
  3. ^ Prince, Cynthia R.; Hines, Elizabeth J.; Chyou, Po-Huang; Heegeman, David J. (September 2014). "Finding the Key to a Better Code: Code Team Restructure to Improve Performance and Outcomes". Clinical Medicine & Research. 12 (1–2): 47–57. doi:10.3121/cmr.2014.1201. ISSN 1539-4182. PMC 4453307. PMID 24667218.
  4. ^ Sodhi, Kanwalpreet; Singla, Manender Kumar; Shrivastava, Anupam (October 2011). "Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital". Indian Journal of Critical Care Medicine. 15 (4): 209–212. doi:10.4103/0972-5229.92070. ISSN 0972-5229. PMC 3271556. PMID 22346031.
  5. ^ "FAQs about AHA Training". cpr.heart.org. Retrieved 2022-01-25.
  6. ^ "Advanced Cardiovascular Life Support (ACLS) Course Options". cpr.heart.org. Retrieved 2022-01-25.
  7. ^ Sanders, A. B.; Berg, R. A.; Burress, M.; Genova, R. T.; Kern, K. B.; Ewy, G. A. (January 1994). "The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community". Annals of Emergency Medicine. 23 (1): 56–59. doi:10.1016/s0196-0644(94)70009-5. ISSN 0196-0644. PMID 8273960.
  8. ^ Kurz, Michael Christopher; Schmicker, Robert H.; Leroux, Brian; Nichol, Graham; Aufderheide, Tom P.; Cheskes, Sheldon; Grunau, Brian; Jasti, Jamie; Kudenchuk, Peter; Vilke, Gary M.; Buick, Jason (July 2018). "Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium". Resuscitation. 128: 132–137. doi:10.1016/j.resuscitation.2018.04.031. ISSN 1873-1570. PMID 29723609. S2CID 19150010.
  9. ^ Kidd, Tracy; Kendall, Sharon (January 2007). "Review of effective advanced cardiac life support training using experiential learning". Journal of Clinical Nursing. 16 (1): 58–66. doi:10.1111/j.1365-2702.2006.01571.x. ISSN 0962-1067. PMID 17181667.
  10. ^ van Walraven, C.; Stiell, I. G.; Wells, G. A.; Hébert, P. C.; Vandemheen, K. (November 1998). "Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group". Annals of Emergency Medicine. 32 (5): 544–553. doi:10.1016/s0196-0644(98)70031-9. ISSN 0196-0644. PMID 9795316.
  11. ^ Jung, Julianna; Rice, Julie; Bord, Sharon (December 2018). "Rethinking the role of epinephrine in cardiac arrest: the PARAMEDIC2 trial". Annals of Translational Medicine. 6 (Suppl 2): S129. doi:10.21037/atm.2018.12.31. PMC 6330609. PMID 30740450.
  12. ^ Carlson, Jestin N.; Wang, Henry E. (October 2020). "Optimal Airway Management in Cardiac Arrest". Critical Care Clinics. 36 (4): 705–714. doi:10.1016/j.ccc.2020.07.008. ISSN 1557-8232. PMID 32892823. S2CID 221523919.
  13. ^ Hagihara, Akihito; Onozuka, Daisuke; Ono, Junko; Nagata, Takashi; Hasegawa, Manabu (January 2018). "Interaction of defibrillation waveform with the time to defibrillation or the number of defibrillation attempts on survival from out-of-hospital cardiac arrest". Resuscitation. 122: 54–60. doi:10.1016/j.resuscitation.2017.11.053. ISSN 1873-1570. PMID 29175354.
  14. ^ a b "International Liaison Committee on Resuscitation". www.ilcor.org/about. Archived from the original on 2020-08-15. Retrieved 2021-11-13.
  15. ^ "ILCOR CoSTR". www.costr.ilcor.org. Archived from the original on 2018-06-26. Retrieved 2021-11-13.
  16. ^ Nolan, Jerry P.; Maconochie, Ian; Soar, Jasmeet; Olasveengen, Theresa M.; Greif, Robert; Wyckoff, Myra H.; Singletary, Eunice M.; Aickin, Richard; Berg, Katherine M.; Mancini, Mary E.; Bhanji, Farhan (2020-10-20). "Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations". Circulation. 142 (16_suppl_1): S2–S27. doi:10.1161/CIR.0000000000000890. PMID 33084397. S2CID 224828809.
  17. ^ "ILCOR FAQs". cpr.heart.org. Retrieved 2022-01-25.
  18. ^ Recupero, Patricia R. (2008-09-01). "Clinical Practice Guidelines as Learned Treatises: Understanding Their Use as Evidence in the Courtroom". Journal of the American Academy of Psychiatry and the Law Online. 36 (3): 290–301. ISSN 1093-6793. PMID 18802175.
  19. ^ "National Resuscitation Councils". European Resuscitation Council. Retrieved 25 January 2022.
  20. ^ "Members & Alliances – InterAmerican Heart Foundation". Retrieved 2022-01-25.
  21. ^ "Members". Resuscitation Council of Asia. Retrieved 2022-01-25.
  22. ^ Mutchner L (January 2007). "The ABCs of CPR – again". Am J Nurs. 107 (1): 60–69, quiz 69–70. doi:10.1097/00000446-200701000-00024. PMID 17200636.
  23. ^ Merchant, Raina M.; Topjian, Alexis A.; Panchal, Ashish R.; Cheng, Adam; Aziz, Khalid; Berg, Katherine M.; Lavonas, Eric J.; Magid, David J.; null, null (2020-10-20). "Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 142 (16_suppl_2): S337–S357. doi:10.1161/CIR.0000000000000918. PMID 33081530. S2CID 224824546.
  24. ^ Perkins, Gavin D.; Gräsner, Jan-Thorsen; Semeraro, Federico; Olasveengen, Theresa; Soar, Jasmeet; Lott, Carsten; Voorde, Patrick Van de; Madar, John; Zideman, David; Mentzelopoulos, Spyridon; Bossaert, Leo (2021-04-01). "European Resuscitation Council Guidelines 2021: Executive summary". Resuscitation. 161: 1–60. doi:10.1016/j.resuscitation.2021.02.003. ISSN 0300-9572. PMID 33773824. S2CID 232407605.
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