Editing Advanced cardiac life support

{{Short description|Emergency medical care}}
{{Infobox medical intervention (new)
| name          = Advanced Cardiac Life Support
| synonyms      = Advanced Cardiovascular Life Support, ACLS
| image         = Afghanistan - cardiopulmonary resuscitation.jpg
| caption       = Cardiopulmonary resuscitation of an avalanche victim who was medically evacuated to Craig Joint Theater Hospital in February 2010
| alt           =
| pronounce     =
| specialty     = Emergency Medicine, Cardiology, Critical Care, Anesthesia
| uses          = Cardiac arrest treatment, Cardiovascular emergency treatment
| complications =
| approach      =
| types         =
| recovery time =
| other options =
| outcomes      =
| frequency     = Common
| cost          =
}}
'''Advanced cardiac life support''',  '''advanced cardiovascular life support''' ('''ACLS''') refers to a set of clinical guidelines established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused [[cardiac arrest]], using advanced medical procedures, medications, and techniques. ACLS expands on [[Basic life support|Basic Life Support]] (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;<ref>{{Cite journal|last1=Ryynänen|first1=Olli-Pekka|last2=Iirola|first2=Timo|last3=Reitala|first3=Janne|last4=Pälve|first4=Heikki|last5=Malmivaara|first5=Antti|date=2010|title=Is advanced life support better than basic life support in prehospital care? A systematic review|journal=Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine|language=en|volume=18|pages=62|doi=10.1186/1757-7241-18-62|pmid=21092256|pmc=3001418 |doi-access=free }}</ref> 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), when used distinctly, ACLS tends to refer to the immediate cardiac care, while ALS tends to refer to more specialized resuscitation care such as [[Extracorporeal membrane oxygenation|ECMO]] and [[Percutaneous coronary intervention|PCI]]. In the EMS community, "ALS" may refer to the advanced care provided by [[paramedic]]s while "BLS" may refer to the fundamental care provided by [[Emergency medical technician|EMTs]] and [[Emergency medical responder|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 [[Electrocardiography|EKG]] rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include: [[ventricular tachycardia]], [[ventricular fibrillation]], [[Pulseless electrical activity|Pulseless Electrical Activity]], and [[asystole]]. Dangerous, non-arrest rhythms typically covered includes: [[Supraventricular tachycardia|narrow]]- and wide-complex [[tachycardia]]s, [[Torsades de pointes|torsades de pointe]], [[atrial fibrillation]]/[[Atrial flutter|flutter]] with rapid ventricular response, and [[bradycardia]].<ref name=":0" />

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.<ref>{{Cite journal|last1=Prince|first1=Cynthia R.|last2=Hines|first2=Elizabeth J.|last3=Chyou|first3=Po-Huang|last4=Heegeman|first4=David J.|date=September 2014|title=Finding the Key to a Better Code: Code Team Restructure to Improve Performance and Outcomes|journal=Clinical Medicine & Research|volume=12|issue=1–2|pages=47–57|doi=10.3121/cmr.2014.1201|issn=1539-4182|pmc=4453307|pmid=24667218}}</ref> 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.<ref name=":0">{{Cite web|title=Part 3: Adult Basic and Advanced Life Support|url=https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support|access-date=2022-01-25|website=cpr.heart.org|language=en}}</ref> 
{| class="wikitable"
|+
!ACLS Component
!Possible Interventions
!Goals of care
|-
|Rhythm diagnosis
|EKG, clinical exam
|Diagnosis of malignant arrhythmia. 
|-
|CPR
|[[Cardiopulmonary resuscitation|Chest Compressions]], [[LUCAS device|mechanical CPR]]
|Perfusion of blood before [[Return of spontaneous circulation|ROSC]] is achieved. Note: chest compressions are not different in ACLS vs BLS, but continue to be a fundamental part of cardiac arrest care even when ACLS is being executed.
|-
|Electrotherapy
|Mono- or biphasic [[defibrillation]], double sequential defibrillation, [[transvenous pacing]], [[transcutaneous pacing]]
|Termination of shockable rhythms. Note: not all cardiac arrest rhythms can be treated with defibrillation.
|-
|Airway Management
|[[Tracheal intubation|Endotracheal intubation]], [[Airway management|supraglottic airway]] placement, [[Cricothyrotomy]], [[Capnography|waveform capnography]], tracheal suctioning, [[Nasopharyngeal airway|naso]]- or [[Oropharyngeal airway|oropharygeal airway]] placement
|Cleat and protect the airway to allow for adequate ventilation.
|-
|Ventillation
|[[Bag valve mask|Bag-valve-mask]], [[ventilator]] management, [[oxygen therapy]]
|Ventilate the lungs to allow for subsequent oxygenation of the blood.
|-
|Medications
|[[Adrenaline|Epinephrine]], [[norepinephrine]], [[vasopressin]], [[atropine]], [[amiodarone]], [[lidocaine]], [[procainamide]], [[sotalol]], [[Salbutamol|albuterol]], [[calcium chloride]], [[Magnesium chloride|magnesium]], [[Fluid replacement|crystalloid fluids]], [[Intraosseous infusion|intraosseous access]]
|Stabilizes arrhythmia, promote ROSC and increase perfusion.
|-
|Specialized Resuscitation Techniques
|[[Echocardiography]], [[Transesophageal echocardiogram|TEE]], [[Percutaneous coronary intervention|PCI]], [[Extracorporeal membrane oxygenation|ECMO]], [[Targeted temperature management|TTM]], [[Central venous catheter|central venous access]]
|Identification of underlying cause of cardiac arrest, augmentation of perfusion and/or treatment of [[Post-Cardiac Arrest Syndrome|PCAS]].
|}

<!-- Deleted image removed: [[File:ACLSalgorithm.png|border|none|thumb|237x237px|Example ACLS algorithm]] -->

== 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.<ref>{{Cite journal|last1=Sodhi|first1=Kanwalpreet|last2=Singla|first2=Manender Kumar|last3=Shrivastava|first3=Anupam|date=October 2011|title=Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital|journal=Indian Journal of Critical Care Medicine |language=en|volume=15|issue=4|pages=209–212|doi=10.4103/0972-5229.92070|issn=0972-5229|pmid=22346031|pmc=3271556 |doi-access=free }}</ref>  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.<ref>{{Cite web|title=FAQs about AHA Training|url=https://cpr.heart.org/en/resources/faqs/course-faqs|access-date=2022-01-25|website=cpr.heart.org|language=en}}</ref> The ACLS course covers BLS, airway management, advanced cardiovascular interventions (bradycardia, tachycardia, cardiac arrest), a Mega Code skills test, and a written multiple-choice exam.<ref>{{Cite web|title=Basic Life Support (BLS) Course Overview|url=https://shifafoundation.org/acls-bls-training-islamabad/|website=Shifa LiST Center|language=en}}</ref> 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.<ref>{{Cite web|title=Advanced Cardiovascular Life Support (ACLS) Course Options|url=https://cpr.heart.org/en/courses/advanced-cardiovascular-life-support-course-options|access-date=2022-01-25|website=cpr.heart.org|language=en}}</ref> 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 simply attests a provider was tested on knowledge and application of ACLS guidelines. The certification does ''not'' supersede a provider's [[scope of practice]] as determined by state law or employer protocols; and does not, itself, provide any [[Medical license|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;<ref>{{Cite journal|last1=Sanders|first1=A. B.|last2=Berg|first2=R. A.|last3=Burress|first3=M.|last4=Genova|first4=R. T.|last5=Kern|first5=K. B.|last6=Ewy|first6=G. A.|date=January 1994|title=The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community|url=https://pubmed.ncbi.nlm.nih.gov/8273960/|journal=Annals of Emergency Medicine|volume=23|issue=1|pages=56–59|doi=10.1016/s0196-0644(94)70009-5|issn=0196-0644|pmid=8273960}}</ref> however a large study of [[Resuscitation Outcomes Consortium|ROC]] patients showed that this effect may only be if ACLS is delivered in the first six minutes of arrest.<ref>{{Cite journal|last1=Kurz|first1=Michael Christopher|last2=Schmicker|first2=Robert H.|last3=Leroux|first3=Brian|last4=Nichol|first4=Graham|last5=Aufderheide|first5=Tom P.|last6=Cheskes|first6=Sheldon|last7=Grunau|first7=Brian|last8=Jasti|first8=Jamie|last9=Kudenchuk|first9=Peter|last10=Vilke|first10=Gary M.|last11=Buick|first11=Jason|date=July 2018|title=Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium|journal=Resuscitation|volume=128|pages=132–137|doi=10.1016/j.resuscitation.2018.04.031|issn=1873-1570|pmid=29723609|s2cid=19150010|doi-access=free}}</ref> 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.<ref>{{Cite journal|last1=Kidd|first1=Tracy|last2=Kendall|first2=Sharon|date=January 2007|title=Review of effective advanced cardiac life support training using experiential learning|url=https://pubmed.ncbi.nlm.nih.gov/17181667/|journal=Journal of Clinical Nursing|volume=16|issue=1|pages=58–66|doi=10.1111/j.1365-2702.2006.01571.x|issn=0962-1067|pmid=17181667}}</ref> 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.<ref>{{Cite journal|last1=van Walraven|first1=C.|last2=Stiell|first2=I. G.|last3=Wells|first3=G. A.|last4=Hébert|first4=P. C.|last5=Vandemheen|first5=K.|date=November 1998|title=Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group|url=https://pubmed.ncbi.nlm.nih.gov/9795316/|journal=Annals of Emergency Medicine|volume=32|issue=5|pages=544–553|doi=10.1016/s0196-0644(98)70031-9|issn=0196-0644|pmid=9795316}}</ref>

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,<ref>{{Cite journal|last1=Jung|first1=Julianna|last2=Rice|first2=Julie|last3=Bord|first3=Sharon|date=December 2018|title=Rethinking the role of epinephrine in cardiac arrest: the PARAMEDIC2 trial|journal=Annals of Translational Medicine|language=en|volume=6|issue=Suppl 2|pages=S129|doi=10.21037/atm.2018.12.31|pmid=30740450|pmc=6330609 |doi-access=free }}</ref> ideal airway use<ref>{{Cite journal|last1=Carlson|first1=Jestin N.|last2=Wang|first2=Henry E.|date=October 2020|title=Optimal Airway Management in Cardiac Arrest|url=https://pubmed.ncbi.nlm.nih.gov/32892823/|journal=Critical Care Clinics|volume=36|issue=4|pages=705–714|doi=10.1016/j.ccc.2020.07.008|issn=1557-8232|pmid=32892823|s2cid=221523919}}</ref> and different waveforms for defibrillation.<ref>{{Cite journal|last1=Hagihara|first1=Akihito|last2=Onozuka|first2=Daisuke|last3=Ono|first3=Junko|last4=Nagata|first4=Takashi|last5=Hasegawa|first5=Manabu|date=January 2018|title=Interaction of defibrillation waveform with the time to defibrillation or the number of defibrillation attempts on survival from out-of-hospital cardiac arrest|url=https://pubmed.ncbi.nlm.nih.gov/29175354/|journal=Resuscitation|volume=122|pages=54–60|doi=10.1016/j.resuscitation.2017.11.053|issn=1873-1570|pmid=29175354}}</ref>

== 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 ===
[[International Liaison Committee on Resuscitation|ILCOR]] serves as a way for international resuscitation organizations to communicate and collaborate.<ref name=":04">{{Cite web|title=International Liaison Committee on Resuscitation|url=https://ilcor.org/about|url-status=live|access-date=2021-11-13|website=www.ilcor.org/about|archive-url=https://web.archive.org/web/20200815104032/https://www.ilcor.org/about |archive-date=2020-08-15 }}</ref> ILCOR publishes [[scientific evidence]] reviews on resuscitation known as "Continuous Evidence Evaluation (CEE) and Consensus on Science with Treatment Recommendations (CoSTRs)".<ref>{{Cite web|title=ILCOR CoSTR|url=https://costr.ilcor.org/about|url-status=live|access-date=2021-11-13|website=www.costr.ilcor.org|archive-url=https://web.archive.org/web/20180626031107/https://costr.ilcor.org/about |archive-date=2018-06-26 }}</ref> ILCOR uses 6 international task forces to review over 180 topics through a structured [[Systematic review|systematic-review]] process. ILCOR traditionally published updates and recommendations every five years but now conducts continuous review work.<ref>{{Cite journal|last1=Nolan|first1=Jerry P.|last2=Maconochie|first2=Ian|last3=Soar|first3=Jasmeet|last4=Olasveengen|first4=Theresa M.|last5=Greif|first5=Robert|last6=Wyckoff|first6=Myra H.|last7=Singletary|first7=Eunice M.|last8=Aickin|first8=Richard|last9=Berg|first9=Katherine M.|last10=Mancini|first10=Mary E.|last11=Bhanji|first11=Farhan|date=2020-10-20|title=Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations|journal=Circulation|volume=142|issue=16_suppl_1|pages=S2–S27|doi=10.1161/CIR.0000000000000890|pmid=33084397|s2cid=224828809|doi-access=free}}</ref> ILCOR produces international recommendations which are then adopted by regional resuscitation committees which publish guidelines.<ref>{{Cite web|title=ILCOR FAQs|url=https://cpr.heart.org/en/resuscitation-science/ilcor/ilcor-faqs|access-date=2022-01-25|website=cpr.heart.org|language=en}}</ref> Regional guidelines can have more [[Duty of care|medicolegal bearing]] than ILCOR recommendations.<ref>{{Cite journal|last=Recupero|first=Patricia R.|date=2008-09-01|title=Clinical Practice Guidelines as Learned Treatises: Understanding Their Use as Evidence in the Courtroom|url=http://jaapl.org/content/36/3/290|journal=Journal of the American Academy of Psychiatry and the Law Online|language=en|volume=36|issue=3|pages=290–301|issn=1093-6793|pmid=18802175}}</ref> ILCOR is composed of the following regional organizations:

{| class="wikitable"
|+
!Regional Organization
!Affiliated Nations
|-
|American Heart Association (AHA)
|United States
|-
|European Resuscitation Council (ERC)<ref>{{Cite web|title=National Resuscitation Councils|url=https://www.erc.edu/about/national-resuscitation-councils|access-date=25 January 2022|website=European Resuscitation Council}}</ref>
|Austria, Belgium, Bosnia & Herzegovina, Croatia, Cyprus, Czechoslovakia, Denmark, Egypt, Finland, France, Germany, Hungary, Iceland, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sudan, Sweden, Switzerland, Tunisia, Turkey, Ukraine, United Kingdom
|-
|Heart and Stroke Foundation of Canada (HSFC)
|Canada
|-
|Australian Resuscitation Council
|Australia
|-
|New Zealand Resuscitation Council
|New Zealand
|-
|Resuscitation Council of Southern Africa (RCSA)
|South Africa
|-
|InterAmerican Heart Foundation (IAHF)<ref>{{Cite web|title=Members & Alliances – InterAmerican Heart Foundation|url=https://interamericanheart.org/alliances/|access-date=2022-01-25|language=en-US}}</ref>
|Argentina, Barbados, Bolivia, Jamaica, Trinidad and Tobago, United States
|-
|Resuscitation Council of Asia (RCA)<ref>{{Cite web|title=Members|url=http://resuscitationcouncil.asia/members.html|access-date=2022-01-25|website=Resuscitation Council of Asia|language=en}}</ref>
|Hong Kong, Japan, Korea, Philippines, Singapore, Thailand, Taiwan
|}

==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.<ref name=":04" />

=== 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.<ref>{{cite journal |author =Mutchner L |title=The ABCs of CPR – again |journal=Am J Nurs |volume=107 |issue=1 |pages=60–69; quiz 69–70 |date=January 2007 |pmid=17200636 |doi=10.1097/00000446-200701000-00024 }}</ref> 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.<ref name=":12">{{Cite journal|last1=Merchant|first1=Raina M.|last2=Topjian|first2=Alexis A.|last3=Panchal|first3=Ashish R.|last4=Cheng|first4=Adam|last5=Aziz|first5=Khalid|last6=Berg|first6=Katherine M.|last7=Lavonas|first7=Eric J.|last8=Magid|first8=David J.|last9=null|first9=null|date=2020-10-20|title=Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care|journal=Circulation|volume=142|issue=16_suppl_2|pages=S337–S357|doi=10.1161/CIR.0000000000000918|pmid=33081530|s2cid=224824546|doi-access=free}}</ref>

=== ERC Guidelines ===
The first version of the [[European Resuscitation Council]] (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.<ref>{{Cite journal|last1=Perkins|first1=Gavin D.|last2=Gräsner|first2=Jan-Thorsen|last3=Semeraro|first3=Federico|last4=Olasveengen|first4=Theresa|last5=Soar|first5=Jasmeet|last6=Lott|first6=Carsten|last7=Voorde|first7=Patrick Van de|last8=Madar|first8=John|last9=Zideman|first9=David|last10=Mentzelopoulos|first10=Spyridon|last11=Bossaert|first11=Leo|date=2021-04-01|title=European Resuscitation Council Guidelines 2021: Executive summary|url=https://www.resuscitationjournal.com/article/S0300-9572(21)00055-1/abstract|journal=Resuscitation|language=English|volume=161|pages=1–60|doi=10.1016/j.resuscitation.2021.02.003|issn=0300-9572|pmid=33773824|s2cid=232407605|doi-access=free}}</ref>

==See also==
* [[Cardiopulmonary resuscitation]] (CPR)
* [[Cardioversion]]
* [[Defibrillation]]
* [[British Heart Foundation]]
* [[Indian Heart Association]]
* [[Pediatric Advanced Life Support]]
* [[Resuscitation Council (UK)]]

==References==
{{Reflist|30em}}

==External links==
* [http://cprguidelines.eu 2015 Guidelines] from [[European Resuscitation Council]]
* [http://cpr.heart.org/AHAECC/CPRAndECC/ResuscitationScience/UCM_473200_Resuscitation-Science.jsp 2015 Guidelines from the AHA]
* [https://www.ahajournals.org/toc/circ/142/16_suppl_2 2020 Guidelines from the AHA]

{{Emergency medicine}}
{{Authority control}}

{{DEFAULTSORT:Advanced Cardiac Life Support}}
[[Category:American Heart Association]]
[[Category:Cardiology]]
[[Category:Medical emergencies]]
[[Category:Emergency medical services]]
[[Category:Emergency medicine courses]]
[[Category:Emergency life support]]

[[de:Advanced Life Support]]