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Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused
cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and poss ...
, using advanced medical procedures, medications, and techniques. ACLS expands on
Basic Life Support Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be p ...
(BLS) by adding recommendations on additional medication and advanced procedure use to the CPR guidelines that are fundamental and efficacious in BLS. ACLS is practiced by advanced medical providers including physicians, some nurses and paramedics; these providers are usually required to hold certifications in ACLS care. While "ACLS" is almost always semantically interchangeable with the term "
Advanced Life Support Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing). Components These include: * Tracheal in ...
" (ALS), when used distinctly, ACLS tends to refer to the immediate cardiac care, while ALS tends to refer to more specialized resuscitation care such as
ECMO Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequat ...
and PCI. In the EMS community, "ALS" may refer to the advanced care provided by
paramedic A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research. Not all ambulance personnel are p ...
s while "BLS" may refer to the fundamental care provided by
EMTs An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics are ...
and EMRs; without these terms referring to cardiovascular-specific care.


Overview

Advanced cardiac life support refers to a set of guidelines used by medical providers to treat life-threatening cardiovascular conditions. These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri-cardiac arrest care: Airway management, ventilation, CPR compressions (continued from BLS), defibrillation, and medications. Due to the seriousness of the diseases treated, the paucity of data known about most ACLS patients, and the need for multiple, rapid, simultaneous treatments, ACLS is executed as a standardized, algorithmic set of treatments. Successful ACLS treatment starts with diagnosis of the correct EKG rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include:
ventricular tachycardia Ventricular tachycardia (V-tach or VT) is a fast heart rate arising from the lower chambers of the heart. Although a few seconds of VT may not result in permanent problems, longer periods are dangerous; and multiple episodes over a short perio ...
,
ventricular fibrillation Ventricular fibrillation (V-fib or VF) is an abnormal heart rhythm in which the ventricles of the heart quiver. It is due to disorganized electrical activity. Ventricular fibrillation results in cardiac arrest with loss of consciousness and n ...
,
Pulseless Electrical Activity Pulseless electrical activity (PEA) refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 55% of people in cardiac arrest. ...
, and asystole. Dangerous, non-arrest rhythms typically covered includes: narrow- and wide-complex
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
s, torsades de pointe, atrial fibrillation/ flutter with rapid ventricular response, and bradycardia. Successful ACLS treatment generally requires a team of trained individuals. Common team roles include: Leader, back-up leader, 2 CPR performers, an airway/respiratory specialist, an IV access and medication administration specialist, a monitor/ defibrillator attendant, a pharmacist, a lab member to send samples, and a recorder to document the treatment. For in-hospital events, these members are frequently physicians, mid-level providers, nurses and allied health providers; while for out-of-hospital events, these teams are usually composed of a small number of EMTs and paramedics.


Scope

ACLS algorithms include multiple, simultaneous treatment recommendations. Some ACLS providers may be required to strictly adhere to these guidelines, however physicians may generally deviate to pursue different evidence-based treatment, especially if they are addressing an underlying cause of the arrest and/or unique aspects of a patient's care. ACLS algorithms are complex but the table, below, demonstrates common aspects of ACLS care.


ACLS Certification

Due to the rapidity and complexity of ACLS care, as well as the recommendation that it be performed in a standardized fashion, providers must usually hold certifications in ACLS care. Certifications may be provided by a few different, generally national, organizations but their legitimacy is ultimately determined by hospital hiring and privileging boards; that is, ACLS certification is frequently a requirement for employment as a health care provider at most hospitals. ACLS certifications usually provide education on the aforementioned aspects of ACLS care ''except'' for specialized resuscitation techniques. Specialized resuscitation techniques are not covered by ACLS certifications and their use is restricted to further specialized providers. ACLS education is based on ILCOR recommendations which are then adapted to local practices by authoritative medical organizations such as the American Red Cross, the European Resuscitation Council, or the Resuscitation Council of Asia''.'' BLS proficiency is usually a prerequisite to ACLS training; however the initial portions of an ACLS class may cover CPR. Initial training usually takes around 15 hours and includes both classroom instruction and hands-on simulation experience; passing a test, with a practical component, at the end of the course is usually the final requirement to receive certification. After receiving initial certification, providers must usually recertify every two years in a class with similar content that lasts about seven hours. Widely accepted providers of ACLS certification include, non-exclusively: American Heart Association, American Red cross, European Resuscitation Council or the Australian Resuscitation Council. Holding ACLS certification is a testament to a provider's education on ACLS guidelines. The certification does ''not'' superseded a provider's
scope of practice Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. The scope of practice is limited to that which the law allows for ...
as determined by state law or employer protocols; and does not, itself, provide any license to practice.


Efficacy of ACLS

Like a medical intervention, researchers have had to ask whether ACLS is effective. Data generally demonstrates that patients have better survival outcomes (increased ROSC, increased survival to hospital discharge and/or superior neurological outcomes) when they receive ACLS; however a large study of ROC patients showed that this effect may only be if ACLS is delivered in the first six minutes of arrest. This study also found that ACLS increases survival but does not produce superior neurological outcomes. Some studies have raised concerns that ACLS education can be inconstantly or inadequately taught which can result in poor retention, leading to poor ACLS performance. One study from 1998 looked at the ACLS use of epinephrine, atropine, bicarbonate, calcium, lidocaine, and bretylium in cardiac arrests and found that these medications were not associated with higher resuscitation rates. Research on ACLS can be challenging because ACLS is a bundle of care recommendations; with each individual treatment component being profoundly consequential. There is active debate within the resuscitation research community about the value of certain interventions. Active areas of research include determining the value of vasopressors in arrests, ideal airway use and different waveforms for defibrillation.


International guidelines

Stemming from the need for standardized, evidence based ACLS guidelines, an international network of academic resuscitation organizations was created. The International Liaison Committee on Resuscitation (ILCOR) is the central, international institution that regional resuscitation committees strive to contribute to and disseminate information from. The centralization of resuscitation research around ILCOR reduces redundant work internationally, allows for collaboration between experts from many regional organizations, and produces higher quality, higher powered research.


International Liaison Committee on Resuscitation

ILCOR serves as a way for international resuscitation organizations to communicate and collaborate. ILCOR publishes scientific evidence reviews on resuscitation known as "Continuous Evidence Evaluation (CEE) and Consensus on Science with Treatment Recommendations (CoSTRs)". ILCOR uses 6 international task forces to review over 180 topics through a structured systematic-review process. ILCOR traditionally published updates and recommendations every five years but now conducts continuous review work. ILCOR produces international recommendations which are then adopted by regional resuscitation committees which publish guidelines. Regional guidelines can have more medicolegal bearing than ILCOR recommendations. ILCOR is composed of the following regional organizations:


History


ILCOR

The International Liaison Committee on Resuscitation (ILCOR) was established 1992 to serve as a way for international resuscitation organizations to communicate and collaborate.


AHA Guidelines

The ACLS guidelines were first published in 1974 by the American Heart Association and were updated in 1980, 1986, 1992, 2000, 2005, 2010, 2015. In the 2020 update the guidelines were restructured to align with ILCOR recommendations. These changes include the transition since 2015 away from the previous 5-year update cycle to an online format that can be updated as indicated by continuous evidence review.


ERC Guidelines

The first version of the
European Resuscitation Council The European Resuscitation Council (ERC) is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care Emergency medicine is the medical speciality concerned with the care of illness A disease is a ...
(ERC) guidelines were developed in 1992. The 2000 ERC guidelines were developed in collaboration with ILCOR. 5-year updates were published from 2000 to 2015 and annual updates have been published since 2017.


See also

*
Cardiopulmonary resuscitation Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spon ...
(CPR) *
Cardioversion Cardioversion is a medical procedure by which an abnormally fast heart rate ( tachycardia) or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs. Synchronized electrical cardioversion uses a therapeutic dose ...
* Defibrillation *
British Heart Foundation The British Heart Foundation (BHF) is a cardiovascular research charity in the United Kingdom. It funds medical research related to heart and circulatory diseases and their risk factors, and runs influencing work aimed at shaping public policy ...
* Indian Heart Association *
Pediatric Advanced Life Support Pediatric advanced life support (PALS) is a course offered by the American Heart Association (AHA) for health care providers who take care of children and infants in the emergency room, critical care and intensive care units in the hospital, and ou ...
*
Resuscitation Council (UK) Resuscitation Council UK (RCUK) is a healthcare charity focused on resuscitation education and training for healthcare professionals and bystander CPR awareness for the public. It is the United Kingdom body responsible for setting central standards ...


References


External links


2015 Guidelines
from
European Resuscitation Council The European Resuscitation Council (ERC) is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care Emergency medicine is the medical speciality concerned with the care of illness A disease is a ...

2015 Guidelines from the AHA
{{DEFAULTSORT:Advanced Cardiac Life Support American Heart Association Cardiology Medical emergencies Emergency medical services Emergency medicine courses Emergency life support de:Advanced Life Support