Advanced cardiac life support

Advanced cardiac life support or (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.&lt;ref name=ACLS_2003_1&gt;ACLS: Principles and Practice. p. 1. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.&lt;/ref&gt;

Extensive medical knowledge and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers (e.g. physicians, paramedics, nurses, respiratory therapists, clinical pharmacists, physician assistants, nurse practitioners and other specially trained health care providers) can provide ACLS, as it requires the ability to manage the patient's airway, initiate IV access, read and interpret electrocardiograms, and understand emergency pharmacology. Some health professionals, or even lay rescuers, may be trained in basic life support (BLS), especially cardiopulmonary resuscitation or CPR. When a sudden cardiac arrest occurs, immediate CPR is a vital link in the chain of survival. Another important link is early defibrillation, which has improved greatly with the widespread availability of AEDs.

ACLS is an extension of BLS. It often starts with analysing patient's heart rhythms with a manual defibrillator. In contrast to an AED in BLS, where the machine decides when and how to shock a patient, the ACLS team leader makes those decisions based on rhythms on the monitor and patient's vital signs. The next steps in ACLS are insertion of intravenous (IV) lines and placement of various airway devices. Commonly used ACLS drugs, such as epinephrine, atropine and amiodarone, are then administered. At this time, the ACLS personnel quickly search for possible causes of cardiac arrest (e.g., a heart attack, drug overdose, or trauma). Based on their diagnosis, more specific treatments are given. These treatments may be medical such as IV injection of an antidote for drug overdose, or surgical such as insertion of a chest tube for those with tension pneumothoraces or hemothoraces. While the above mentioned ACLS steps are being carried out, it is crucial to continue chest compression with minimal interruptions. This point is emphasized repeatedly in the new ACLS guidelines.

2005 guidelines
The 2005 guidelines acknowledged that high quality chest compressions and early defibrillation were the key to positive outcomes while other "typical ACLS therapies ... "have not been shown to increase rate of survival to hospital discharge".&lt;ref&gt;AHA. (2005). Part 7.2: Management of Cardiac Arrest. Circulation. Free full text.&lt;/ref&gt; In 2004 a study found that the basic interventions of CPR and early defibrillation and not the advanced support improved survival from cardiac arrest.&lt;ref&gt;Stiell IG, Wells GA, Field B, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004; 351:647-56.Article&lt;/ref&gt;

The new guidelines for managing cardiac arrest were published in December 2005 and may be found in Circulation &lt;ref&gt;Circulation 112: Issue 24 Supplement; December 13, 2005 Issue.&lt;/ref&gt;. The major source for ACLS courses and textbooks in the United States is the American Heart Association; in Europe, it is the European Resuscitation Council (ERC). Most institutions expect their staff to recertify at least every two years. Many sites offer training in simulation labs with simulated code situations with a dummy. Other hospitals accept software-based courses for recertification. An ACLS Provider Manual reflecting the new Guidelines is now available.

Current ACLS Algorithms
The current ACLS guidelines are set into several groups of 'algorithms' - a set of instructions that are followed to standardize treatment, and increase it's effectiveness. These algorithms usually come in the form of a flowchart, incorporating 'yes/no' type decisions, making the algorithm easier to memorize.

Notes on using the ACLS algorithm


 * The most common reason that defibrillation is unsuccessful is the failure of providers to recognize and treat the underlying cause of the arrhythmia.
 * Search for and correct potentially reversible causes of arrest, brady/tachycardia.
 * Exercise caution before using epinephrine in arrests associated with cocaine or other sympathomimetic drugs.
 * Give atropine 1mg dose (IV) for asystole or slow PEA (rate&lt;60/min)
 * In PEA arrests associated with hyperkalemia, hypocalcaemia. or Ca2+ channel blocking drug overdose, give 10mL 10% calcium chloride (IV) (6.8mmol/L)
 * Consider amiodarone for ventricular fibrillation/pulseless ventricular tachycardia after 3 attempts at defibrillation.
 * For torsades de pointes, refractory VF in patients with digoxin toxicity or hypomagnesaemia, give IV magnesium sulphate 8mmol (4mL of 50% solution)

History
The ACLS guidelines were first published in 1974 by the American Heart Association and were updated in 1980, 1986, 1992, 2000, and 2005.&lt;ref&gt;&lt;/ref&gt;