ACLS The science behind the changes

Michele Vicari-Christensen DNP ARNP
August 17th 2013
1) Discuss the recent changes in ACLS
2) Understand the scientific rationale for
the changes presented
3) Explain the use of capnography and
4) Explore the rationale for key
pharmacological changes in the
5) Illustrate the Chain of Survival
CPR Quality-Concensus Statement Circulation June 2013
Must use a systematic approach to assess and treat
arrest and acutely ill or injured patients for optimum
care which includes:
-High quality CPR
-Optimal glycemic control
-Appropriate algorithms and pharmolcological
2) Goal of any resuscitative action is return of
spontaneous circulation (ROSC) and neurological
1) Minimize any interruptions in effective chest
2) Provide compressions of adequate rate and
3) Avoid leaning between compressions
4) Allow complete chest recoil after each
5 Avoid excessive ventilation
CPR survival is dependent on adequate myocardial
oxygen delivery and myocardial blood flow:
Chest compression fraction (CCF) of >80%-minimal
Chest compression rate of 100-120
Compression depth of 50 mm or 2 inches in adults (1/3
anterior, posterior dimension of chest
No Leaning causes lack of recoil
Excessive ventilation decreases depth and recoil
Quantitative waveform capnography is the
continuous, noninvasive measurement and
graphical display of end-tidal carbon
dioxide/ETCO2 (also called PetCO2).
Capnography uses a sample chamber/sensor
placed for optimum evaluation of expired CO2.
The inhaled and exhaled carbon dioxide is
graphically displayed as a continuous waveform
on the monitor along with its corresponding
numerical measurement
Circulation. Blood must be moving in order to
deliver CO2 from the tissues to the alveoli.
Circulation requires blood, an effective heartbeat
and blood pressure. Preload plus afterload equals
circulation. Mimic in compressions.
In the acute setting, PetCO2 is a function of
cardiac output
Ventilation. Air must move in and out of the
alveoli effectively to get rid of carbon dioxide and
other waste products, and to inhale fresh oxygen.
1) Qualitative waveform capnography (PETC02)
provides a quality measure for CPR
2) Optimal goal for CPR is PETC02 of 35-40 mmHg
equates to same as when ROSC
3) If PET Co2 is < 10 mmHg attempt to improve
CPR-a PetC02 is 10 or less after initiation of
ACLS is associated with poor outcomes.
The new guidelines recommend
cooling comatose adult patients with
ROSC after out of hospital VF, PEA and
Asystole cardiac arrest to 32-34 degrees
C (89-93 degrees F) for up to 12-24
Side Effects and Complications
Higher Systemic Vascular Resistance,
Lower Cardiac Index
Skin Breakdown
1) Target glycemic control 10 144-180
mg/dl in an adult patients after
cardiac arrest and ROSC.
2) Avoid lower blood sugars in ranges
of 80-110 mg/dl
Hypoglycemia causes cerebral cellular
fuel deprivation and cellular death as
well as an increase in cerebral cellular
excitability and seizures.
Henderson-Hasselbalch Equation
Regulation of Carbonic Acid/Bicarbonate buffer
Parasympatholytic agent. Research
supports only effective utilization is
in symptomatic bradycardia
2) There is no benefit in pulseless
electrical activity or asystole
ACLS extends to Acute Coronary Syndrome and
Cerebral Vascular Accidents
Guidelines for CPR and ECC (2010). American
Heart Association.
Field et al. (2010). Executive Summary- American
Heart Association
Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiac Care. (2010). Circulation.
November 2, 2010; pp. S640-S729.
CPR Quality-Improving Cardiac Resuscitation
Outcomes Both inside and Outside the Hospital: A
Concensus Statement from the American Heart
Association. (2013).Circulation. June 25, 2013. pp. 1-19

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