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Introduction:-
Advanced Life Support (ALS), also referred to as Advanced Cardiac Life Support (ACLS), is a
set of life-saving protocols and skills that extend beyond Basic Life Support (BLS). It is used to
provide urgent treatment to cardiac emergencies such as cardiac arrest, stroke, myocardial
infarction, and other conditions.ALS is one of the vital steps in the American Heart
Association's Chain of Survival, which is a sequence of actions that can increase survival rates
of sudden cardiac arrest (SCA) and other emergencies. The five critical actions include:

1. Immediate recognition of cardiac arrest and activation of the emergency response system
2. Early high-quality CPR with an emphasis on chest compressions

3. Rapid defibrillation

4. Effective advanced life support

5. Integrated post-cardiac arrest care

Cardiopulmonary resuscitation (CPR)

CPR is an emergency procedure consisting of chest compressions often combined with artificial
ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further
measures are taken to restore spontaneous blood circulation and breathing in a person who is
in cardiac arrest. It is recommended for those who are unresponsive with no breathing or abnormal
breathing, for example, agonal respirations.

CPR involves chest compressions for adults between 5 cm (2.0 in) and 6 cm (2.4 in) deep and at a
rate of at least 100 to 120 per minute. The rescuer may also provide artificial ventilation by either
exhaling air into the subject's mouth or nose (mouth-to-mouth resuscitation) or using a device that
pushes air into the subject's lungs (mechanical ventilation).

Objective:-
To bring back heart and ventilator function of patient.
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Indications

CPR is indicated for any person unresponsive with no breathing or breathing only in

occasional agonal gasps, as it is most likely that they are in cardiac arrest. If a person still has
a pulse but is not breathing (respiratory arrest) artificial ventilations may be more appropriate,
but, due to the difficulty people have in accurately assessing the presence or absence of a pulse,
CPR guidelines recommend that lay persons should not be instructed to check the pulse, while
giving healthcare professionals the option to check a pulse. In those with cardiac arrest due

to trauma, CPR is considered futile but still recommended. Correcting the underlying cause such

as a tension pneumothorax or pericardial tamponade may help.

Pathophysiology:-

CPR is used on people in cardiac arrest to oxygenate the blood and maintain a cardiac output to
keep vital organs alive. Blood circulation and oxygenation are required to transport oxygen to the
tissues. The physiology of CPR involves generating a pressure gradient between the arterial and
venous vascular beds; CPR achieves this via multiple mechanisms. The brain may
sustain damage after blood flow has been stopped for about four minutes and irreversible
damage after about seven minutes. Typically if blood flow ceases for one to two hours, then
body cells die. Therefore, in general CPR is effective only if performed within seven minutes of
the stoppage of blood flow. The heart also rapidly loses the ability to maintain a normal rhythm.
Low body temperatures, as sometimes seen in near-drownings, prolong the time the brain
survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to
delay brain stem death, and allows the heart to remain responsive to defibrillation attempts. If
an incorrect compression rate is used during CPR, going against standing AHA guidelines of
100-120 compressions per minute, this can cause a net decrease in venous return of blood, for
what is required, to fill the heart. For example, if a compression rate of above 120 compressions
per minute is used consistently throughout the entire CPR process, this error could adversely
affect survival rates and outcomes for the victim.
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Methods:-

In 2010, the American Heart Association and International Liaison Committee on

Resuscitation updated their CPR guidelines. The importance of high quality CPR (sufficient rate

and depth without excessively ventilating) was emphasized. The order of interventions was
changed for all age groups except newborns from airway, breathing, chest compressions

(ABC) to chest compressions, airway, breathing (CAB). An exception to this recommendation is

for those believed to be in a respiratory arrest (airway obstruction, drug overdose, etc.). The
most important aspects of CPR are: few interruptions of chest compressions, a sufficient speed
and depth of compressions, completely relaxing pressure between compressions, and not

ventilating too much. It is unclear if a few minutes of CPR before defibrillation results in
different outcomes than immediate defibrillation.

CPR Procedure:-

Remember the order when performing the steps of CPR. American Heart Association employs
the short form ‘CAB’ — ‘Compressions, Airway, Breathing’ to help the rescuers in
remembering the order when performing CPR.

Compressions – helps in restoring the blood circulation

 Lay the victim on his back on a hard surface

 Kneel beside him

 Now place the heel of your one hand right on the centre of the victim’s chest. Place your
other hand on top of your first hand. Now position your shoulder directly and straight
above your and hand. Keep your elbows straight

 Utilize your full upper body weight and start compressing the chest. Push hard. Push the
chest at the rate of around 100 compressions per minute.
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If you are not a trained CPR, continue this compression method till professional help arrives. On
the other hand; if you are trained in CPR, move on to the next step of clearing the airway and
rescue breathing.

Airway – Clear the passage

If you have performed at least 30 compressions and if you are trained in CPR then it’s time for
you to clear the victim’s airway passage by employing the head-tilt and chin-lift maneuver.

 Place your palm right on the person’s forehead. Tilt the head back gently
 Now with the other hand, lift the chin forward in order to open up the airway passage.

 Take 5-10 seconds to check for breathing. Take closer look at the chest motion, listen for
breathing sounds and feel for his breath on your ear and cheeks.

Remember; gasping should not be considered as normal breathing. Check for breathing and if the
victim is not breathing and if you trained in CPR then move on to ‘mouth-to-mouth’ breathing.

Breathing – mouth-to-mouth rescue breathing

Also known as rescue breathing it should be performed mouth to mouth or mouth to nose (if
incase mouth can’t be opened due to injury or for any other reason)

 Using the chin lift and head tilt maneuver clear the airway passage
 Now shut the nostrils by gently pinching them

 Cover the victim’s mouth with your mouth

 Give 2 rescue breaths

Give the first rescue breath for 1 second and watch whether or not the chest rises. If the chest
does not rise, use the chin lift and head tilt maneuver and give one more rescue breath.

Remember; 30 chest compressions followed by 2 rescue breaths = 1 CPR Cycle. Continue the
CPR cycle till there are any clear signs of improvement or till medical help arrives.

CPR on a child
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The overall process for performing CPR to a child ( age 1 – 8) is almost the same as that for an
adult with a few differences such as –

 Use just one hand for performing chest compressions

 Breathe gently

For a child, use 30 chest compressions followed by 2 rescue breaths for completing 1 CPR Cycle
and if there is no improvement begin the next cycle immediately. Continue till help arrives or the
child moves.

CPR on a baby

Research data demonstrates, most cardiac arrest in babies occurs due to chocking or drowning. If
you are aware that the baby has an airway obstructions then give the baby the first aid for
choking; however if you are unsure about why the baby is not breathing then perform CPR.

 To start with, assess the situation carefully.

 Do not shake the baby. Simply stroke the baby gently and watch for movement.

 If there is no response follow the CAB procedures and call emergency help.

Compressions – helps in restoring the blood circulation

 Put the baby on a flat and rigid surface

 Kneel down beside the baby

 Place two fingers of one hand right at the centre of the baby’s chest

 Compress the chest gently

 Pump at a rapid rhythm of 100 compressions a minute.

Airway – Clear the passage

 Tilt up the head and lift the chin forward

 Place your ear near the baby’s mouth and check for breathing

 Look for chest motion

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Breathing – mouth-to-mouth rescue breathing

 Cover the baby’s nose and mouth with your mouth

 Give two rescue breaths

 Do not give deep breaths from your lungs. Instead deliver gentle puffs of air with your
mouth

Continue CPR till you see the signs of movements or till help arrives
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Drug Therapy

 Epinephrine IV/IO Dose: 1 mg, administer as soon as possible then every 3 to 5 minutes
after
 Amiodarone IV/IO Dose: first dose is 300 mg bolus, second dose is 150 mg

 Lidocaine: 1st dose: 1-1.5 mg/kg, second dose: 0.5-0.75 mg/kg

Dos and Don’ts of performing CPR

should
 Perform the chest compression at the rate of 100-120/min
 Perform the chest compression to the depth of 2 inches at least

 Fully recoil after each compression

 Minimize the pauses in compressions

should not
 Perform the chest compression at the rate less than 100/ min or faster than 120/min
 Perform the chest compression to the depth of less than 2 inches or more than 2.4 inches

 Lean on the chest between each compression

 Maximize the pauses in compressions

Nursing Care:-

Monitoring Vital Signs:

 Continuously monitor the patient's heart rate, blood pressure, respiratory rate, and oxygen
saturation.
 Assess the patient's level of consciousness and neurological status.
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Airway Management:

 Ensure a patent airway, and if needed, administer supplemental oxygen.

 Monitor for any signs of airway obstruction or respiratory distress.

Breathing Support:

 Assist ventilation if necessary, using a bag-valve mask or mechanical ventilator.

 Monitor for signs of respiratory distress or failure.

Cardiac Monitoring:

 Continue to monitor the cardiac rhythm through ECG.

 Administer medications as prescribed for post-cardiac arrest care.

Temperature Control:

 Manage the patient's temperature to prevent hyperthermia or hypothermia.

 Use cooling or warming measures as needed.

Fluid and Electrolyte Management:

 Administer fluids and electrolytes to maintain hemodynamic stability.

 Monitor for signs of fluid overload or dehydration.

Neurological Assessment:

 Perform regular neurologic assessments to detect any changes in the patient's mental
status.
 Monitor for signs of cerebral edema or neurological deficits.

Continuous ECG Monitoring:

 Maintain continuous ECG monitoring to detect any arrhythmias or changes in cardiac

status.
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 Administer antiarrhythmic medications as prescribed.

Pain Management:

 Assess and manage any pain or discomfort the patient may experience.
 Administer analgesics as prescribed.

Psychosocial Support:

 Provide emotional support to the patient and their family.

 Offer information and education about the patient's condition and recovery process.

Diagnostic Tests:

 Order and interpret diagnostic tests as needed (e.g., blood tests, imaging studies).
 Adjust treatment plans based on test results.

Mobility and Skin Care:

 Turn and reposition the patient regularly to prevent pressure ulcers.

 Encourage early mobility when appropriate.

Collaboration with Multidisciplinary Team:

 Collaborate with physicians, respiratory therapists, physical therapists, and other

healthcare professionals to optimize care.

 Participate in care conferences to discuss the patient's progress and plan of care.
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CONCLUSION:-

In conclusion, mastering CPR ALS (Advanced Life Support) skills is crucial for individuals
involved in emergency response and healthcare. The ability to perform these life-saving
techniques can make a significant difference in improving outcomes for those facing cardiac arrest
or other critical medical situations. Continuous training, staying informed about updated
guidelines, and maintaining a calm and confident approach are key elements in ensuring effective
CPR ALS interventions, ultimately contributing to saving lives in critical moments.

BIBLIOGRAPHY

1. Smith, John A.Emergency Cardiac Care: A Comprehensive Guide.3rd Edition.New York,

NY.Lifesaver Publications.2020.Pages: 145-162.
2. Basheer Shebeer. P, Khan S. Yaseen. “A Concise Text book of Advanced Nursing
Practice.” 2nd Edition. Mahalakshmipuram, Bangalore:Emmess Medical Publishers;
2017. Page no 323 to 338.
3. Rodriguez, Maria C.Advanced Life Support Techniques in Critical Care.1st Edition.
Chicago, IL.Critical Care Press.2018.Pages: 220-235.