# Advanced Cardiac Life Support

## Overview

This module describes how to perform Advanced Cardiac Life Support (ACLS) to resuscitate a patient in cardiac arrest.

## Indications

1. Any patient who becomes unresponsive or collapses in hospital

## Contraindications

1. See Patient information & Consent

## Patient information and consent

This procedure is done when a patient is in cardiac arrest, so consent is generally implied. However, check for “Do Not Resuscitate” (DNR) orders, “Not For Max” orders, or living wills that specify that no resuscitation may be performed.

##

## Preparation

Manual defibrillation is an emergency procedure. Always:

1. Know where defibrillators, transcutaneous pads, and red trolleys are kept. Know the relevant staff and keep your seniors’ contact details close at hand.

2. Familiarise yourself with the defibrillators in your work area. Check that they are maintained regularly and have pads and the correct connections.

3. Keep unstable patients in resuscitation bays with continuous monitoring.

## Site & Positioning

To perform Advanced Cardiac Life Support, a patient should be lying flat on their back on a firm surface. There should be space behind the head of the bed for staff to give rescue breaths.

## Procedure

Use medical asepsis with non-sterile gloves.

1. Hazards: look for any body fluid spills, trip hazards etc. and put on gloves. Follow Transmission-Based Precautions as required.

2. Hello:

   1. Tap the patient’s shoulder and call hello. Look for a response. If response noted, stop the ACLS algorithm.
   2. Feel and listen for breathing with your ear close to the patient’s mouth. If breathing noted but patient not responding, call for help and place the patient in the recovery position.
   3. Look for chest rise. Don’t take more than 10 seconds.
   4. Feel for a pulse on the neck or groin. Don’t take more than 10 seconds. If there is no breathing but a pulse, start performing rescue breaths.

3. Help: Call for assistance from other healthcare workers. Get someone to bring a defibrillator. Get someone more senior than yourself involved.

4. Chest compressions: Give 30

   chest compressions
   chest compressions

   at a rate of almost 2 per second. Minimise interruptions.

5. Rescue breaths: Give 2 rescue breaths after every 30 compressions at a rate of 1 per second.

6. Reassess the patient every

   2 mins
   2 mins

   Time keeping is important. Use a watch, clock or AED mode to keep to two minute cycles, or assign a time keeper who can also keep note of times if possible.

   with a very quick (5 seconds or less) central pulse & rhythm check on the monitor while rotating chest compressor (sooner if tired).

7. Repeat 4-5 until the defibrillator arrives. Attach it immediately and follow the Manual Defibrillation algorithm.

8. Resume chest compressions after defibrillation, and continue steps 4-5 for 2 mins before evaluating for defibrillation again. Repeat the cycles of CPR and defibrillation until signs of life are present, or until your senior declares death.

While performing CPR:

1. Obtain IV or intraosseous access to give drugs. Draw an arterial or venous blood gas sample to search for contributory causes.

2. If shockable rhythm (VT/VF):

3. Connect O2 to the bag valve mask resuscitator. Consider a supraglottic airway (such as LMA) or endotracheal intubation without interrupting chest compressions. Once LMA or endotracheal tube is in situ, give continuous rescue breaths every 6 seconds along with continuous chest compressions. Connect capnography if available, aiming for ETCO2 above 10mmHg.

4. Find and correct contributory causes “6 Hs and 6 Ts”:

   1. Hypoxia
   2. Hypovolemia
   3. Hypothermia
   4. Hydrogen ion (acidosis)
   5. Hyper-/hypokalaemia
   6. Hypoglycaemia
   7. Tension pneumothorax
   8. Tamponade (cardiac)
   9. Toxins
   10. Trauma
   11. Thrombosis (coronary)
   12. Thrombosis (pulmonary)

## Troubleshooting

I’m unsure about the quality of my chest compressions.

Check the following:

1. Centre compressions on the lower half of the sternum, compressing ⅓ of the depth of the chest.

2. Ensure good chest recoil (don’t lean on the chest between compressions).

3. Your shoulders should be directly above your hands, elbows straight.

4. Stand on a step or kneel on the bed so that your hips are higher than the patient’s chest.

5. Minimise interruptions.

6. Change chest compressors every 2 min to avoid fatigue.

I’m unsure about the quality of my rescue breaths.

Ensure correct head position. Consider using an oropharyngeal or nasopharyngeal airway. Ensure that you are pulling the face into the mask using an EC grip, rather than leaning on the patient’s face. Continuously monitor chest rise.

My patient is moving but I still can’t find a pulse.

Patients in cardiac arrest may have movements such as twitching or writhing. If there is no pulse and the patient is not responding to your prompts, continue CPR.

I heard something crack under my hands.

Rib and sternal fractures are not uncommon. Continue CPR, but ensure your hand placement is correct.

## Risks

1. Unsuccessful CPR

2. Bruising

3. Rib/sternal fractures

4. Pneumothorax

5. Defibrillator burns

6. Healthcare worker exposed to infectious substances

## References

1. Resuscitation Council of Southern Africa. Advanced Cardiac Arrest Algorithm, Adult and Paediatric. 2021.