ALS Algorithm

Learning outcomes This lecture should enable you to: Describe the ALS algorithm Recognise the importance of high quality chest compressions Discuss the treatment of shockable and non-shockable rhythms Define when to give drugs during cardiac arrest Identify the treatment of potentially reversible causes of cardiac arrest Discuss the roles within a resuscitation team

Resuscitation team roles planned in advance identify team leader importance of non-technical skills task management team working situational awareness decision making structured communication debrief after event

Adult ALS algorithm

To confirm cardiac arrest… patient response open airway check for normal breathing Caution agonal breathing No longer than 10 seconds check circulation At same time as checking breathing If doubt about pulse = not present monitoring

Cardiac arrest confirmed

Cardiac arrest confirmed

Chest compression 30:2 compressions centre of chest one third total depth/ >5 cm rate 100-120 min-1 maintain high quality compressions with minimal interruptions (<5 s) continuous compressions once airway secured switch CPR provider every 2 min cycle to avoid fatigue

START CPR MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Shockable (VF) bizarre irregular waveform no recognisable QRS complexes random frequency and amplitude uncoordinated electrical activity coarse/fine exclude artefact movement electrical interference

Shockable (pulseless VT) monomorphic VT broad complex rhythm rapid rate constant QRS morphology if tolerating effective compressions - pulseless polymorphic VT may appear similar VF torsade de pointes

IMMEDIATELY RESTART CPR MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Manual Mode Defibrillator Operation Defibrillator Operator calls “Compressions Continue everyone else stand clear” Oxygen Away (if free flowing) Prepare team/environment for safe defibrillator use Charge Defibrillator – press charge button Perform safety checks during charging ensuring no others directly or indirectly touching patient Compression person only touching patient Defibrillator Charged and Ready – “Hands Off” “Hands Off” Called by defibrillator operator Compression person stands Clear and states “I’m Safe” Defibrillator Operator Confirms Compression person safe if “I’m safe” not heard/stated Assess Cardiac Rhythm / Monitor Cardiac rhythm identified (by team leader) First time in sequence rhythm checked Act on rhythm Call “Shockable” – Immediately deliver shock then when safe immediately resume CPR Call “Non-Shockable/PEA” Immediately disarm defibrillator/dump charge learn in defibrillation station safety first – teamwork vital wording / exact language used is less important than communicating principles to ensure safety not a script first time rhythm checked is when compressions are ceased

Defibrillation energies vary with manufacturer check local equipment if unsure, deliver highest available energy DO NOT DELAY SHOCK energy levels for defibrillators on this course…

If VF/pVT persists 2nd and subsequent shocks 200 – 360 J biphasic give adrenaline after 2nd shock during CPR then every second loop give amiodarone after 3 shocks during CPR do not need to be sequential CPR for 2 min During CPR Adrenaline 1 mg IV/IO Amiodarone 300 mg IV/IO Deliver 2nd shock Deliver 3rd shock Give amiodarone after 3 shocks regardless of whether patient has shifted between shockable and non-shockable sides of the algorithm

START CPR MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Non-Shockable (Asystole) absent ventricular (QRS) activity atrial activity (P waves) may persist rarely a straight line trace adrenaline 1 mg IV then every second loop

Non-shockable (PEA) clinical features of cardiac arrest ECG normally associated with an output adrenaline 1 mg IV then every second loop

Vascular access peripheral versus central veins intraosseous

Airway and ventilation secure airway: supraglottic airway device (e.g. LMA, i-gel) tracheal tube do not attempt intubation unless trained and competent to do so once airway secured, if possible, do not interrupt chest compressions for ventilation avoid hyperventilation waveform capnography

Waveform capnography aids confirmation of correct tracheal tube placement monitor ventilation rate monitor quality of CPR identify ROSC prognostication during CPR

Hypokalaemia & metabolic disorders & Hyperthermia

Hypoxia seek evidence of Hypoxia history pre-arrest SpO2 and other observations

Oxygen in Cardiopulmonary Arrest ensure patent airway give as much oxygen as possible No evidence in adults on best FiO2 SpO2 measurement dependent on perfusion consider advanced airway avoid hyperventilation

Hypovolaemia seek evidence of Hypovolaemia other Hypovolaemia causes history examination haemorrhage? internal/external haemorrhage check surgical drains other Hypovolaemia causes including sepsis anaphylaxis

Hypovolaemia control haemorrhage if Hypovolaemia suspected, give intravenous fluids/blood Universal donor - Type specific - Cross Matched distributive shock IV fluids restriction to flow (e.g. Thrombus/Tamponade/Pneumothorax/Pregnancy) consider IV fluids with other therapeutic measures

Hypo/hyperkalaemia and metabolic disorders seek evidence examination near patient testing for K+ and glucose history check latest laboratory results medical history drug chart fluid input/output chart

Potassium Disorders Hyperkalaemia Hypokalaemia/ hypomagnesaemia calcium chloride calcium gluconate – if chloride unavailable IV/IO insulin (10 units - short acting) / dextrose (25g) IV fluids consider sodium bicarbonate Hypokalaemia/ hypomagnesaemia electrolyte supplementation KCL 5 mmol bolus and consider 2g Mg++ Calcium Chloride has more Ca++ (approx. 3x) than Calcium Gluconate

Hypothermia rare if patient is an in-patient evidence touch patient and then take core temperature use low reading thermometer treat with active rewarming techniques avoid warm IV fluids in pre-hospital setting consider cardiopulmonary bypass /ECMO

Hyperthermia core temp >40.6 C consider cause: prolonged exercise in hot conditions/dehydration drug toxicity, MDMA, malignant hyperthermia, thyroid storm heat stroke can resemble septic shock rhabdomyolysis, coagulopathy issues

Hyperthermia Treatment rapid cooling to 39 C (similar techniques to TTM) large fluid volumes & correct electrolyte abnormalities/acidosis no specific medications for heat stroke effective dantrolene for anaesthetic agent reactions (and some MDMA)

Tension pneumothorax seek evidence history examination/clinical signs particular considerations in thoracic trauma/procedural and asthma patients check tube position if intubated examination/clinical signs difficult to ventilate possible – back pressure unilateral chest rise/fall decreased breath sounds hyper-resonant percussion note tracheal deviation

needle 2nd intercostal space – mid clavicular line initial treatment needle decompression, or thoracostomy (if ventilated or expertise available) needle 2nd intercostal space – mid clavicular line follow up with chest drain

Tamponade, cardiac seek evidence examination history chest trauma - penetrating or blunt post cardiac surgery procedural – e.g. PCI/CVC lines, pacing wire insertion (inc. PPM) examination difficult to diagnose without echocardiography

Tamponade, cardiac treat with needle pericardiocentesis or resuscitative thoracotomy skilled techniques for competent operators

Thrombosis seek evidence history examination ultrasound may help

Thrombosis if high clinical probability for PE consider fibrinolytic therapy percuteanous intervention coronary pulmonary if fibrinolytic therapy given minimum of 30 minutes CPR consideration for continuing CPR for up to 60-90 minutes

Toxins seek evidence history examination difficult review all medication prescription charts rare unless evidence of deliberate overdose recreational drugs complicated by purity / polypharmacy examination difficult Newer designer drugs much less detectable Purity Multi drug use NBOMe, Mephadrone, Canaboids

Toxins specific antidotes evidence during arrest poor Problem with Diagnosis – similar physiological presentations NBOMe Altered consciousness Tachycardia Paresthesia, chills, flushing Dilated pupils Hallucinations Erratic behavior Confusion, Anxiety/Paranoia/Panic Syncope Vasoconstriction Shaking, clonus, seizures Cardiac Ischaemia due to vasoconstriction Thrombosis Mephadrone (e.g. Miao Miao) Breathing difficulties Hypertension Anxiety/Paranoia Epistaxis Cold blue fingers – vasoconstriction Seizures Altered body temperature Increased sweating

Other considerations during CPR ultrasound mechanical chest compression devices if prolonged CPR facilitate transport facilitate safe angiography/radiological intervention extracorporeal CPR

Ultrasound in skilled hands may identify reversible causes obtain images during rhythm checks do not interrupt CPR

Post Resuscitation Care Re-evaluate ABCDE 12 lead ECG Treat precipitating causes Aim for: SpO2 94-98%, normocapnia and normoglygaemia Targeted temperature management

Any questions?

Summary the ALS algorithm importance of high quality chest compressions potentially reversible causes of cardiac arrest role of resuscitation team

Advanced Life Support Course Slide set All rights reserved © Australian Resuscitation Council (January 2016)