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Advanced Cardiac Life Support, TL;DR

It is easy to memorize the ACLS algorithm, but actually running a code blue in real life is very challenging as it involves leading the team and performing an oddly specific list of on-the-fly assessments/investigations. Knowing the 4H’s and 4T’s is not enough – it is how you apply it to a specific scenario that counts.

This post assumes prior knowledge of the ACLS algorithm. It assumes you are the team leader running the scenario / CPR. As a rule, do not get involved in the minutiae of resuscitation – take two steps back from the foot of the bed to maintain a good global view and situational awareness. As the team leader you will need to be able to initiate the resuscitation and ensure good going CPR, then run down the differentials slickly, which is what the first part of this article is all about.

This article comprises three main parts:
1) A polished ACLS script – what to say after the pads are on, and after the first charge/disarm cycle. Integrating the 4H’s and 4Ts seamlessly. For exam candidates, it is one way to sound slick at this.
2) ACLS in special situations – criteria for prolonged CPR, pregnancy, asthma, TDP, anaphylaxis, antidotology summary for LA/TCA/BB/CCB, Eclampsia, digoxin, spiderbite, jellyfish (Chironex).
3) When to stop CPR/ACLS – subjective and objective criteria. What information to gather.

Part 1: A Polished ACLS / CPR Spiel

[Initial Spiel For Prearrivals]
“I will employ a team approach with closed loop communication and a shared mental model”
“As my ED staff are ACLS trained”
“I will assume leadership and allocate roles”
              “My priorities are good uninterrupted chest compressions, and early Defibrillation”
              “Doctor for airway, doctor for circulation. Nurse for airway, drugs, and scribe.”
              “Delegate to get the crash cart, difficult airway trolley, and defibrillator.”

[DURING INITIATION OF CPR]
(ie. you just walked into a live resus)

[Ensure Good Compressions]
“Lower 1/3^rd of sternum, compressing 1/3^rd depth of chest”
“at a rate of 100/min”
“30:2 for adults”  (15:2 children, 3:1 infants/neonates)

[Attend to ABCs]
A/B:      “Insert airway adjuncts. Guedel and NPA to optimize BVM ventilation”
C:          “Obtain IV access. Intraosseous to be used if first attempt at cannula unsuccessful.”
D:          “Take a blood gas and check glucose when IV sited. Check temperature.”.
“Draw drugs 1g (10ug/kg) adrenaline, and 300mg (5mg/kg) amiodarone on standby”

[Hypoxia]
“I will optimize oxygenation using the two handed BVM technique with 100% FiO2, along with airway adjuncts – a NPA and Guedel”
“5s attempt to intubate only. Compressions are a priority. If successful, 10 breaths/min via ETT”

[PADS ARE NOW ON]
“We will be assessing rhythm with the COACHED mnemonic.”
“Continue compressions. Oxygen away. All else clear. Charging to 200J (4J/kg). Hands off.”
“Evaluating rhythm”
“Dump Charge / Defibrillate”
              VT/VF >> “Defib/Shocking. Recommence CPR immediately” (regardless or post defib rhythm)
              PEA/Asystole, or dubious pulse >> “Dumping charge. Recommence CPR immediately”
              Organized rhythm + Pulse Present >> “Dump charge. We have ROSC”

[INSTRUCT DOCTOR GIVING DRUGS]
              “Insert a cannula and take an urgent blood gas”
              1) [for VT/VF], give start Adrenaline after the second shock. [for PEA], start Adrenaline immediately.
              2) continue giving Adrenaline every 4 minutes (two loops) from the first dose regardless of initial rhythm.
              3) give amiodarone 300mg (5mg/kg) after the pt’s 3^rd shock.

*The decision tree for drugs may seem complex, but is actually very simple in real life. The three statements above are all you need to action even if a patient is fluctuating between PEA/VT/VF every cycle.

[WHAT TO SAY AFTER FIRST RHYTHM CHECK]
“We will now be simultaneously assessing the 4H’s and 4T’s, with closed loop communication”

[Hypovolaemia/Hypotension]
“Is there any bleeding or signs of blood loss / trauma?
“Any rash or angioedema to suggest distributive shock / anaphylaxis?”
>> 1L Normal Saline Stat, and give Adrenaline 1mg stat if signs of anaphylaxis.

[HypoGluCaK]
“What is the glucose, calcium and potassium on the blood gas?”
>> hyperK: 30ml (6.6mmol) Ca Gluconate, 10u actrapid, 50ml 50% glucose, 100ml 8.4% SodiBic
>> critical hypoK: 5mmol K slow push over 1minute. 5mmol Mg slow push.

[Hypothermia]
“Nurse, could you please check patient’s temperature.”

[Tension PTX]
“Airway team, any signs of pneumothorax? Is the chest rising equally with no tracheal deviation?
>> Finger thoracotomy if detected.

[Thrombosis]
“Any signs of acute ischaemia on pre-arrest ECGs? Any chest pain prior?”
>> Tenecteplase (weight / 2) mg, up to 50mg.
“Is there any sign of one sided swelling in the limbs?” “im looking for a dilated RV on the TTE”
>> Alteplase 1.5mg/kg (max 90mg), with 10% as bolus, and remainder over 2 hours.

[Toxins]
“Check collateral history for any suggestion of overdose / toxic ingestion”

[Tamponade]
“I would perform a bedside ultrasound to look for a massive pericardial effusion”.
>>Pericardiocentesis with a long 16G cannula under the xiphisternum directed towards the left shoulder, under US guidance.

Part 2: ACLS in Special Situations

ACLS in special situations. Criteria for prolonged CPR, Pregnancy, Asthma, Torsades, Anaphylaxis, Summary of Available Antidotes.
also Part 3: When To stop CPR