Advanced Cardiac life Support (ACLS) Certification & Renewal

ACLS

Course in ACLS, BLS and PALS would help recognizing acute signs of cardiac arrest, arrhythmias, stroke and coronary heart disease. It is designed for healthcare professionals who manage and deliver medical assistance to cardiopulmonary arrest victims or attend to cardiovascular emergencies.

At the conclusion, participants should be able to:

·Assess patient promptly and initiate resuscitation in cardio-pulmonary or cardio-vascular emergencies

·Able to recognize and treat arrhythmias

·Manage patient and team while providing emergency care.

·Able to Monitor and provide emergency care to pediatric patients.

·Able to manage post resuscitation status.

For completing the course successfully participant should score minimum of 75%



Heart Conduction
SA node conduct to atria resulting in atrial contraction, recognized by P waves on electrocardiogram, impulse travels to AV node which conducts the electrical impulse to the bundle of His, Bundle branches and Purkinje fibers of the ventricle causing ventricular contraction. Time between the start of atrial contraction at the start of ventricular contraction is shown on the EKG as PR interval. Ventricular contraction shown on EKG as QRS complex. Ventricular contraction followed by rest and repolarization which is indicated as T waves. Proper timing of P waves QRS complex and T waves indicate normal sinus rhythm. Any deviation from this results in dysrhythmia such as heart block, tachycardia and bradycardia.

Wide, bizarre QRS complexes of supraventricular origin are often the result of intraventricular conduction defect which usually occurs due to right or left bundle branch block. Wide QRS complexes may be seen in aberrant conduction, ventricular pre-excitation and with a cardiac pacemaker.

 

QT Interval

  • The QT interval is the time from the start of the Q wave to the end of the T wave.
  • It represents the time taken for ventricular depolarization and repolarization.
  • The QT shortens at faster heart rates
  • The QT lengthens at slower heart rates
  • An abnormally prolonged QT is associated with an increased risk of ventricular arrhythmias, especially Torsades de Pointes.
  • The recently described congenital short QT syndrome has been found to be associated with an increased risk of paroxysmal atrial and ventricular fibrillation and sudden cardiac death.

·The QT interval is inversely proportional to heart rate

Causes of prolonged QT interval

Electrolyte imbalance such as Hypokalemia, Hypomagnesemia, Hypocalcemia

Hypothermia

Drugs

Post cardiac arrest

Raised intracranial pressure

Congenital long QT syndrome

Short QT interval is seen in Digoxin effect, Hypercalcemia and congenital short QT syndrome




Ventricular Fibrillation (VF)



The heart's electrical activity becomes disordered. The ventricles "fibrillate" rather than beat. The heart pumps little or no blood. Collapse and sudden cardiac arrest follows. 

Some causes of Ventricular fibrillation

  • Lack of proper blood flow to the heart muscle or damage to the heart muscle from a heart attack.
  • Cardiomyopathy
  • Problems with the aorta
  • Drug toxicity
  • Sepsis

Signs of cardiac arrest

  • Sudden loss of responsiveness (no response to tapping on shoulders)
  • No normal breathing (the victim is not breathing or is only gasping)
  • This is sudden cardiac arrest (SCA) -- which requires immediate medical help (CPR and defibrillation)

Treatment for cardiac arrest caused by ventricular fibrillation
Ventricular fibrillation can be stopped with a defibrillator, which gives an electrical shock to the heart. If you see someone experiencing the signs of cardiac arrest:

  • Yell for help. Tell someone to call 911 and get an automated external defibrillator (AED) if one is available. You begin CPR immediately.
  • If you are alone with an adult who has these signs of cardiac arrest, call 911 and get an AED (if one is available) before you begin CPR.
  • When doing CPR, push down on the chest at least 2 inches at a rate of at least 100 compressions a minute. After each compression, let the chest come back up to its normal position.
  • Use an AED as soon as it arrives.
  • Continue CPR until the person starts to respond or trained emergency medical help arrives and takes over.
  • While Hands-Onlyâ„¢ CPR (giving chest compressions alone) may be effective for teens or adults who collapse, the AHA recommends CPR with a combination of compressions and breaths (given as sets of 30 compressions and 2 breaths) for: all infants, children up to puberty, anyone found already unconscious and not breathing normally, and any victim of drowning, drug overdose, collapse due to breathing problems, or prolonged cardiac arrest.


Torsades de pointes (TdP) is polymorphic ventricular tachycardia that may lead to VF, disorder is of QT prolongation

May be caused by electrolyte imbalance and drug effects

Treatment may include giving magnesium, potassium, isoprenaline and pacing



First Degree Heart Block

PR interval >200ms

Most common causes


Second Degree AV Block

AV Block: 2nd degree, Mobitz I (Wenckebach Phenomenon)

  • Progressive prolongation of the PR interval culminating in a non-conducted P wave
  • The PR interval is longest immediately before the dropped beat
  • The PR interval is shortest immediately after the dropped beat

Causes

  • Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
  • Increased vagal tone (e.g. athletes)
  • Inferior MI
  • Myocarditis
  • Following cardiac surgery (mitral valve repair, Tetralogy of Fallot's repair)
  • Mobitz 1 is usually a benign rhythm, causing minimal hemodynamic disturbance and with low risk of progression to third degree heart block.
  • Asymptomatic patients do not require treatment.
  • Symptomatic patients usually respond to atropine.
  • Permanent pacing is rarely required.



Complete Heart Block (Third Degree AV Block)

  • In complete heart block, there is complete absence of AV conduction - none of the supraventricular impulses are conducted to the ventricles.
  • Perfusing rhythm is maintained by a junctional or ventricular escape rhythm. Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).
  • The patient will have severe bradycardia with independent atrial and ventricular rates, i.e. AV dissociation.


Causes

The causes are the same as for Mobitz I and Mobitz II second degree heart block. The most important etiologies are:

  • Inferior myocardial infarction
  • AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin)
  • Idiopathic degeneration of the conducting system (Lenegre's or Lev's disease)
  • Patients with third degree heart block are at high risk of ventricular standstill and sudden cardiac death.
  • They require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker.

Assessment
Early recognition of symptoms, provide prompt CPR activate EMS provide advanced life support and post cardiac arrest care and defibrillate with AED

In 2010 sequence was ABC, Airway Breathing Compression

In 2015 it is CAB, Compression, Airway and Breathing. Activate EMS immediately. In narcotic overdose is expected, trained BLS rescuer may administer Naloxone.

Chest compression 100-220 per minute in adults 2 to 2.4 inches deep. In children 1.5 to 2 inches. Interrupt chest compression only to provide AED shocks.
Compression to ventilation ratio 30 to 2 in individuals without an advance airway in place. If advanced airway is used then continue chest compression with ventilation being delivered at a rate of one every six seconds.
Biphasic defibrillator should be used in life-threatening arrhythmias, follow AED guidelines.
Vasopressor as epinephrine 1 mg every 3 to 5 minutes may be needed. Angiography should be performed in emergency, temperature should be monitored between 32 to 36°C for the first 24 hours while in the hospital. Look listen and feel and carotid pulse check is no longer routinely performed. Pulse checks are limited to 10 seconds. In infants use manual defibrillator according to manufacturer's instructions.

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