1. Advanced Life Support

2. Introduction
ALS definition : 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).
ALS assumes that BLS are administered.
Who performs ALS ?
highly trained health care –providers.
Where ? In hospital and health centers while BLS can be done anywhere.

3. Introduction
The first step toward the goal of complete recovery from cardiac arrest is ROSC (return of spontaneous circulation). And this is done by identifying and reverse the underlying cause of the cardiac arrest using defibrillator , airway devices ,oxygen , IV cannulation and drugs.

5. Drug Therapy
Drug therapy in ALS: in attempts to restore circulation ,drug therapy is secondary to other interventions like effective chest compression and defibrillation .
The preferred route of administration of all drugs during CPR is IV. And the first choice is in external jugular vein or antecubital vein because of rapid action compared to the peripheral veins in which longer time is needed due to the non-effective circulation in those who are arrested.
Intraosseous or endotracheal are other routes when IV cant be established.

6. Drug Therapy…cont
1) Epinephrine : the efficacy of epinephrine lies entirely in its alpha adrenergic propertiesperipheral vasoconstriction leads to an increase in aortic diastolic pressure cause an increase in coronary perfusion pressure and myocardial blood flow. dose:non-shockable rhythm: 1 mg immediately for non-shockable rhythms then every 3–5 min. shockable rhythms (VF/VT): 1 mg after the second shock then every 3–5 min Other drugs with alpha adrenergic properties norepinephrine,dopamine,phenylephrine. Beta adrenergic drugs without alpha effect like doputamine and isoproterenol ,have no role in restoring spontaneous circulation in arrested pts.

7. Drug Therapy…cont
2) Vasopressin (ADH) : recommended as alternative to 1st or 2nd dose epinephrine. Acts on V1 receptors in vascular smooth muscles causing vasoconstriction. Dose : 40 U 3) Amiodarone : Amiodarone 300mg is recommended after the third shock for treatment of atrial and ventricular dysrythmias. 4) Other drugs : lidocaine ,sodium bicarbonate.

8. Advanced Airways
1)The endotracheal tube has been considered the optimal method for managing airway in arrested patients. 2) Oropharyngeal and nasopharyngeal tubes. 3) LMA (laryngeal mask airway). Note : 8-10 breaths per minute with continuous chest compressions. -wave form capnography :monitoring of PCO2 in the patient’s exhaled air. 1)Indirectly, it reflects the production of CO2 by tissues and the circulatory transport of CO2 to the lungs. 2) Capnography provides a rapid and reliable method to detect life-threatening conditions (malposition of tracheal tubes, unsuspected ventilatory failure)

9. Return of spontaneous circulation (ROSC) is resumption of sustained perfusing cardiac activity associated with significant respiratory effort after cardiac arrest.[1] Signs of ROSC include breathing, coughing, or movement and a palpable pulse or a measurable blood pressure.

10. The step by step management in ALS
The most important first step in ALS is to identify the cardiac arrest rhythm, which can belong to one of two groups:
Shockable : ventricular fibrillation (VF) , pulseless ventricular tachycardia (VT).
Non-shockable : asystole and pulseless electrical activity.

12. Post Resuscitation Care
Optimize oxygenation and ventilation:
Maintain O2 saturation at least 94% .
Consider advanced airway and capnography
DO NOT hyperventilate.
2) Treat hypotension (SBP < 90 mm Hg) :
IV/IO boluses
Vasopressor infusion
Consider treatable causes
12 lead ECG
Induced hypothermia (lowers a patient's body temperature between celsius in order to help reduce the risk of tissue injury from lack of blood flow)
Coronary reperfussion if high suspicion of MI.