Advanced Life Support
Encyclopedia
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
to further support the circulation and provide an open airway and adequate ventilation (breathing).
Components of ALS
These include:- Cardiac monitoring
- Cardiac defibrillation
- Transcutaneous pacingTranscutaneous pacingTranscutaneous pacing is a temporary means of pacing a patient's heart during a medical emergency. It is accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract....
- Intravenous cannulation (IV)
- Intraosseous (IO) access and intraosseous infusionIntraosseous infusionIntraosseous infusion is the process of injection directly into the marrow of a bone. This technique is used in emergency situations to provide fluids and medication when intravenous access is not available or not feasible.-History:...
- Surgical cricothyrotomy
- Needle cricothyrotomy
- needle decompression of tension pneumothorax
- Advanced medicationMedicationA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
administration through parenteralParenteralParenteral is a route of administration that involves piercing the skin or mucous membrane. Parenteral nutrition refers to providing nutrition via the veins.-Etymology:...
and enteralEnteralIn pharmacology, Enteral is a term used to describe routes of drug administration that involve absorption of the drug through the gastrointestinal tract. The term may also be used to describe something as residing in the gastrointestinal tract...
routes (IV, IO, PO, PR, ET, SL, topical, and transdermal) - Advanced Cardiac Life SupportAdvanced cardiac life supportAdvanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
(ACLS) - Pediatric Advanced Life SupportPediatric Advanced Life SupportPediatric Advanced Life Support is a 2 day American Heart Association training program. The goal of the course is to aid the pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and children, resulting in...
(PALS) or Pediatric Emergencies for Pre-Hospital Providers (PEPP) - Pre-Hospital Trauma Life Support (PHTLS), Basic Trauma Life Support (BTLS) or International Trauma Life Support (ITLS)
2010 changes
ALS is a treatment consensus for cardiopulmonary resuscitationCardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
in cardiac arrest
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
and related medical problems, as agreed in Europe by the European Resuscitation Council
European Resuscitation Council
The European Resuscitation Council is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was established in 1989....
, most recently in 2010.
2010 revisions include:
- greater emphasis on continuous (uninterrupted) chest compression
- less emphasis on airway and breathing
- promotion of the intraosseous infusionIntraosseous infusionIntraosseous infusion is the process of injection directly into the marrow of a bone. This technique is used in emergency situations to provide fluids and medication when intravenous access is not available or not feasible.-History:...
of drugs and fluids if IV access not readily available - further demotion of the precordial thumpPrecordial thumpThe precordial thump is a medical procedure that may used by healthcare professionals, to respond to ventricular fibrillation or ventricular tachycardia under certain conditions. The procedure is outside the scope of first-aid treatment and requires, at minimum, training in advanced cardiac life...
- ongoing simplification
- expanded role for post-arrest hypothermia and emphasis on post-arrest normo-glycaemial
ALS algorithms
ALS assumes that basic life supportBasic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
(bag-mask administration of oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
and chest compressions) are administered.
The main algorithm
Algorithm
In mathematics and computer science, an algorithm is an effective method expressed as a finite list of well-defined instructions for calculating a function. Algorithms are used for calculation, data processing, and automated reasoning...
of ALS, which is invoked when actual cardiac arrest
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
has been established, relies on the monitoring of the electrical activity of the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
on a cardiac monitor. Depending on the type of cardiac arrhythmia, defibrillation
Defibrillation
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator...
is applied, and medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
is administered. Oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
is administered and endotracheal intubation may be attempted to secure the airway. At regular intervals, the effect of the treatment on the heart rhythm, as well as the presence of cardiac output
Cardiac output
Cardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...
, is assessed.
Medication that may be administered may include adrenaline (epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
), amiodarone
Amiodarone
Amiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias , both ventricular and supraventricular arrhythmias. Discovered in 1961, it was not approved for use in the United States until 1985...
, atropine
Atropine
Atropine is a naturally occurring tropane alkaloid extracted from deadly nightshade , Jimson weed , mandrake and other plants of the family Solanaceae. It is a secondary metabolite of these plants and serves as a drug with a wide variety of effects...
, bicarbonate
Bicarbonate
In inorganic chemistry, bicarbonate is an intermediate form in the deprotonation of carbonic acid...
, calcium
Calcium in biology
Calcium plays a pivotal role in the physiology and biochemistry of organisms and the cell. It plays an important role in signal transduction pathways, where it acts as a second messenger, in neurotransmitter release from neurons, contraction of all muscle cell types, and fertilization...
, potassium
Potassium
Potassium is the chemical element with the symbol K and atomic number 19. Elemental potassium is a soft silvery-white alkali metal that oxidizes rapidly in air and is very reactive with water, generating sufficient heat to ignite the hydrogen emitted in the reaction.Potassium and sodium are...
and magnesium
Magnesium
Magnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
. Saline
Saline (medicine)
In medicine, saline is a general term referring to a sterile solution of sodium chloride in water but is only sterile when it is to be placed intravenously, otherwise, a saline solution is a salt water solution...
or colloids may be administered to increase the circulating volume.
While CPR is given (either manually, or through automated equipment such as AutoPulse
AutoPulse
The AutoPulse is an automated, portable, battery-powered cardiopulmonary resuscitation device created by Revivant and subsequently purchased and currently manufactured by ZOLL Medical Corporation...
), members of the team consider eight forms of potentially reversible causes for cardiac arrest, commonly abbreviated as "6Hs & 5Ts" according to the new 2005 AHA ACLS .
Note these reversible causes are usually taught and remembered as 4Hs and 4Ts—including hypoglycaemia and acidosis with hyper/hypokalaemia and 'metabolic causes' and omitting trauma from the T's as this is redundant with hypovolaemia—this simplification aids recall during resuscitation.
Hs and Ts
Hs- HypoxiaHypoxia (medical)Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...
: low oxygen levels in the blood - HypovolemiaHypovolemiaIn physiology and medicine, hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma...
: low amount of circulating blood, either absolutely due to blood loss or relatively due to vasodilationVasodilationVasodilation refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When... - HyperkalemiaHyperkalemiaHyperkalemia refers to the condition in which the concentration of the electrolyte potassium in the blood is elevated...
or hypokalemiaHypokalemiaHypokalemia or hypokalaemia , also hypopotassemia or hypopotassaemia , refers to the condition in which the concentration of potassium in the blood is low...
: disturbances in the level of potassiumPotassiumPotassium is the chemical element with the symbol K and atomic number 19. Elemental potassium is a soft silvery-white alkali metal that oxidizes rapidly in air and is very reactive with water, generating sufficient heat to ignite the hydrogen emitted in the reaction.Potassium and sodium are...
in the blood, and related disturbances of calciumCalcium in biologyCalcium plays a pivotal role in the physiology and biochemistry of organisms and the cell. It plays an important role in signal transduction pathways, where it acts as a second messenger, in neurotransmitter release from neurons, contraction of all muscle cell types, and fertilization...
or magnesiumMagnesiumMagnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
levels. - HypothermiaHypothermiaHypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as . Body temperature is usually maintained near a constant level of through biologic homeostasis or thermoregulation...
/HyperthermiaHyperthermiaHyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate...
: body temperature not maintained - HydrogenHydrogenHydrogen is the chemical element with atomic number 1. It is represented by the symbol H. With an average atomic weight of , hydrogen is the lightest and most abundant chemical element, constituting roughly 75% of the Universe's chemical elemental mass. Stars in the main sequence are mainly...
ions (AcidosisAcidosisAcidosis is an increased acidity in the blood and other body tissue . If not further qualified, it usually refers to acidity of the blood plasma....
) - HypoglycemiaHypoglycemiaHypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
: Low blood glucose levels
Ts
- Tension pneumothorax: tear in the lungHuman lungThe human lungs are the organs of respiration in humans. Humans have two lungs, with the left being divided into two lobes and the right into three lobes. Together, the lungs contain approximately of airways and 300 to 500 million alveoli, having a total surface area of about in...
leading to collapsed lung and twisting of the large blood vessels - TamponadeCardiac tamponadeCardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....
: fluid or blood in the pericardiumPericardiumThe pericardium is a double-walled sac that contains the heart and the roots of the great vessels.-Layers:...
, compressing the heartHeartThe heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions... - ToxicPoisonIn the context of biology, poisons are substances that can cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism....
and/or therapeuticMedicationA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
: chemicals, whether medication or poisoning - ThromboembolismPulmonary embolismPulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
and related mechanical obstruction (blockage of the blood vessels to the lungs or the heart by a blood clotThrombusA thrombus , or blood clot, is the final product of the blood coagulation step in hemostasis. It is achieved via the aggregation of platelets that form a platelet plug, and the activation of the humoral coagulation system...
or other material)
As of December 2005, Advanced Life Support guidelines have changed significantly. A major new worldwide consensus has been sought based upon the best available scientific evidence. The ratio of compressions to ventilation's is now recommended as 30:2 for adults, to produce higher coronary and cerebral perfusion pressures. Defibrillation
Defibrillation
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator...
is now administered as a single shock, each followed immediately by two minutes of CPR before rhythm is re-assessed (five cycles of CPR). See Advanced Cardiac Life Support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
Other conditions
ALS also covers various conditions related to cardiac arrest, such as cardiac arrhythmias (atrial fibrillationAtrial fibrillation
Atrial fibrillation is the most common cardiac arrhythmia . It is a common cause of irregular heart beat, identified clinically by taking a pulse. Chaotic electrical activity in the two upper chambers of the heart result in the muscle fibrillating , instead of achieving coordinated contraction...
, ventricular tachycardia
Ventricular tachycardia
Ventricular tachycardia is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart...
), poison
Poison
In the context of biology, poisons are substances that can cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism....
ing and effectively all conditions that may lead to cardiac arrest if untreated, apart from the truly surgical emergencies
Surgical emergency
Surgical emergency is a medical emergency which requires immediate surgical intervention .The following conditions are surgical emergencies:* Acute trauma* Accidental amputation* Acute appendicitis...
(which are covered by Advanced Trauma Life Support
Advanced Trauma Life Support
Advanced Trauma Life Support is a training program for medical doctors in the management of acute trauma cases, developed by the American College of Surgeons. Similar programs exist for nurses and paramedics...
).
Who performs ALS
Many healthcare providers are trained to administer some form of ALS.In out-of-hospital settings trained emergency medical technician
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
s, paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
s or medic
Medic
Medic is a general term for a person involved in medicine, especially emergency or first-response medicine, such as an emergency medical technician, paramedic, or a military member trained in battlefield medicine. Also the term is used toward a Nurse in pre-hospital care and/or emergency...
s typically provide this level of care. Canadian paramedics may be certified in either ALS (Advance Care Paramedic-ACP) or in Basic Life Support
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
(Primary Care Paramedic-PCP) (see paramedics in Canada
Paramedics in Canada
In Canada the paramedic is a health professional, providing pre-hospital assessment and medical care to the victims of illnesses or injuries. The term is generally limited to include those who work on emergency and non-emergency patient transport service environment ambulances...
). Emergency medical technician
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
s (EMTs) are often skilled in ALS, although they may employ slightly modified version of the Medical algorithm
Medical algorithm
A medical algorithm is any computation, formula, statistical survey, nomogram, or look-up table, useful in healthcare. Medical algorithms include decision tree approaches to healthcare treatment and also less clear-cut tools aimed at reducing or defining uncertainty.-Scope:Medical algorithms are...
. In the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, Paramedic level services are referred to as Advanced Life Support (ALS). Services staffed by basic EMTs are referred to as Basic Life Support
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
(BLS), as those staffed by EMT-Intermediates are called Intermediate Life Support (ILS). This terminology extends beyond emergency cardiac care to describe all capabilities of the providers.
In hospitals, ALS is usually given by a team of physicians and nurses. These cardiac arrest teams generally include junior doctors from various specialties such as anesthetics, general or internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...
.