Basic Life Support (BLS) Advanced Life Support (ALS) Dr. Yasser Mostafa Prof. of Chest Diseases Ain Shams University.

The 2011 ACLS guideline addressed the following aspects of the vital fourth link of the chain of survival: Immediate actions following cardiac arrest Airway Breathing (ventilation) Supporting the Circulation during cardiac arrest Peri-arrest arrhythmias Identifying reversible causes Post-resuscitation care Organ donation. Cardiac Arrest Managment

Cardiac Arrest management The principles of good resuscitation practice require clear emphasis. The foundations of advanced cardiac life support include the following: Consistent performance of high-quality CPR: Early defibrillation in the presence of VF / pulseless VT An organised system of ACLS management Integrated post-cardiac arrest care

Cardiac Arrest management Consistent performance of high-quality CPR : Each compression to be at least 5 cm depth and at a rate of 100 per minute with complete chest recoil after each compression, minimizing interruptions to chest compressions Ventilating at 30:2 in absence of advanced airway, and continuous chest compressions with ventilations interposed every 6 – 8 seconds with either an ETT or a supraglottic airway Implementing monitoring of CPR quality as part of the culture of good resuscitation practice.

DEFIBRILLATION The aim of defibrillation is to depolarise the myocardium to hopefully allow the native pacemakers to restore a normal rhythm. There are strategies to improve current flow across the chest

Paddles vs pads Several studies have compared handheld paddles with self-adhesive pads and generally find higher reversion rates with pads. Moreover, hands-free pads have simplicity and safety advantages.

Paddles vs pads

Paddle/pad position Commonly, one pad is placed at the right parasternal area (second intercostal space) and the other in the mid-axillary line (sixth intercostal space). If there is a pacemaker/ICD box, the pad/paddle should be at least 8 cm away from it.

Monophasic/biphasic defibrillators There are various electrical waveforms that can be produced by these machines and newer devices produce a ‘biphasic’ electrical discharge, which is probably superior in terms of reversion rates. – In VF/VT, biphasic shocks should be delivered at 150 J and monophasic at 360 J. – If you are not certain what sort of device you have, it is generally the case that the maximum possible on a biphasic is 150–200 J (for monophasic it’s 360 J).

Cardiac Arrest management Early defibrillation in the presence of VF /Pulseless VT For monophasic defibrillation at 360 joules per shock For biphasic defibrillation with an initial dose of between 150 joules with consideration for escalating higher energy defibrillation up to a maximum of 360 joules, if desired. Every shock to be followed immediately by at least 1 minute of good quality CPR