ALS Recertification Course ARC ALS level 2/ALS

Course Health & Safety Requirement to Cover Report Pre-existing Injury or Injury Sustained During Course Immediately Latex or Other Allergy Defibrillator Safety

Standardised CPR for adults Update on clinical changes to resuscitation guidelines Re-evaluation of knowledge and practical skills acquisition Assessment ALS recertification course learning outcomes

ALS recertification course format Manual Lectures Skill stations Cardiac Arrest Simulation (CAS) training

ALS recertification course assessment MCQ Practical skills (continuous assessment) Airway management Initial assessment and resuscitation Cardiac Arrest Simulation (CASTest) Provider certificate valid for 4 years

Causes and Prevention of Cardiac Arrest

Early recognition of the deteriorating patient Most arrests are predictable Deterioration prior to % of cardiac arrests Hypoxia and hypotension are common antecedents Delays in referral to higher levels of care

Recognition of the deteriorating patient - Early Warning Scoring Systems Example Escalation Protocol based on early warning score (EWS) Total Early Warning Score Dictates: 3-5  Inform Nurse in-charge 6  Doctor to see within the hour 7-8  Doctor to see within 30 minutes with senior doctor >8  Doctor to see within 15 minutes Example of early warning scoring (EWS) system* * From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7

The ABCDE approach to the deteriorating patient A irway B reathing C irculation D isability E xposure

ALS Algorithm

Patient response Open airway Check for normal breathing Caution agonal breathing Check circulation Monitoring To confirm cardiac arrest… Unresponsive? Not breathing or only occasional gasps

Cardiac arrest confirmed Unresponsive? Not breathing or only occasional gasps Call resuscitation team

Cardiac arrest confirmed Unresponsive? Not breathing or only occasional gasps Call resuscitation team CPR 30:2 Attach defibrillator / monitor Minimise interruptions

Chest compression 30:2 Compressions Centre of chest Min 5cm depth/one third total Approximately 100min -1 -About 2 per second (not faster than 120 min -1 ) Maintain high quality compressions with minimal interruptions Continuous compressions once airway secured Switch CPR provider every 2 min cycle to avoid fatigue

Adult ALS Algorithm

Resuscitation team Roles planned in advance Identify team leader Importance of non-technical skills Task management Team working Situational awareness Decision making Structured communication

Shockable and Non-Shockable MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Charge START Defibrillator Assess rhythm Shockable (VF / Pulseless VT) Non-Shockable (PEA / Asystole) CPR

Uncoordinated electrical activity Coarse/fine Exclude artefact Movement Electrical interference Shockable (VF) Shockable (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude

Shockable (VT) Shockable (VT) Polymorphic VT Torsade de pointes Monomorphic VT Broad complex rhythm Rapid rate Constant QRS morphology

Shockable (VF / VT) Shout “(Compressions Continue) Stand Clear” Assess rhythm Shockable (VF / VT) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Shockable (VT) CHARGE DEFIBRILLATOR Assess rhythm Shockable (VF / VT)

Shockable (VT) Assess rhythm Shockable (VF / VT) Shout “Hands Off” CHARGE DEFIBRILLATOR

Shockable (VF / VT) Assess rhythm Shockable (VF / VT) Confirmed Hands Off “I’m Safe”

Shockable (VF / VT) DELIVER SHOCK Assess rhythm Shockable (VF / VT)

Shockable (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm Shockable (VF / VT)

Shockable (VF / VT) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Assess rhythm Shockable (VF / VT) IMMEDIATELY RESTART CPR MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Vary with manufacturer Check local equipment Defibrillator energy 200 Joules unless manufacturer demonstrates better outcomes with alternate energy level If unsure, deliver 200 Joules DO NOT DELAY SHOCK Energy levels for defibrillators on this course… Defibrillation energies

Special Circumstances Well perfused and oxygenated patient pre-arrest Presenting arrest shockable Three stacked shocks First shock delivered within 20 seconds of onset of arrest Rapid charging defibrillator (<3 to 5 seconds) Precordial thump Pulseless VT only Defibrillator unavailable Delivered within 20 seconds of onset of arrest

2 nd and subsequent shocks 200 J biphasic 360 J monophasic Give adrenaline and after 2 nd shock during CPR then alternate loops thereafter Give amiodarone after 3 rd shock during CPR If VF / VT persists CPR for 2 min During CPR Adrenaline 1 mg IV CPR for 2 min During CPR Amiodarone 300 mg IV Deliver 2 nd shock Deliver 3 rd shock

Non-Shockable Assess rhythm Shockable (VF / Pulseless VT) Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Non-Shockable Assess rhythm Shockable (VF / Pulseless VT) Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS DUMP/DISCHARG E ENERGY

Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace Adrenaline 1 mg IV then every alternate loop Non-shockable (Asystole) Non-Shockable (Asystole)

Clinical features of cardiac arrest ECG normally associated with an output Adrenaline 1 mg IV then every alternate loop Non-shockable (Asystole) Non-Shockable (PEA)

During CPR Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO access Plan actions before interrupting compressions (e.g. charge manual defibrillator) Drugs Shockable Adrenaline 1 mg after 2ndshock (then every 2nd loop) Amiodarone 300 mg after 3rd shock Non Shockable Adrenaline 1 mg immediately (then every 2nd loop)

Airway and ventilation Secure airway: Supraglottic airway device 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

Vascular access Peripheral versus central veins Intraosseous

Reversible causes Hyperthermia Hypokalaemia/metabolic

Hypoxia Ensure patent airway Give high-flow supplemental oxygen Avoid hyperventilation

Hypovolaemia Seek evidence of hypovolaemia History Examination -Internal haemorrhage -External haemorrhage -Check surgical drains Control haemorrhage Haemorrhage not only cause If hypovolaemia suspected give intravenous fluids

Hypo/hyperkalaemia and metabolic disorders Near patient testing for K + and glucose Check latest laboratory results Hyperkalaemia Calcium chloride Insulin/dextrose Hypokalaemia/ Hypomagnesaemia Electrolyte supplementation

Hypothermia Rare if patient is an in-patient Use low reading thermometer Treat with active rewarming techniques Consider cardiopulmonary bypass

Hyperthermia (Core temp >40.6 C) Heat stroke can resemble septic shock Rhabdomyolysis, coagulopathy issues Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm Rapid cooling to 39 C (similar approaches/techniques to hypothermia) Large fluid volumes required Correct electrolyte abnormalities/acidosis

Tension pneumothorax Check tube position if intubated Clinical signs (some/all not be present peri-arrest) Decreased breath sounds Hyper-resonant percussion note Tracheal deviation Initial treatment with needle decompression or thoracostomy Follow up with Chest Tube

Tamponade, cardiac Difficult to diagnose without echocardiography Consider if penetrating chest trauma or after cardiac surgery Also: -Recent Myocardial Infarct -Blunt Chest Trauma -Procedural – Cardiac Catheter/Pacing Wire etc Treat with needle pericardiocentesis or resuscitative thoracotomy

Toxins Rare unless evidence of deliberate overdose Presenting history may give clues Review drug chart Toxicology screens take time

Thrombosis If high clinical probability for PE consider fibrinolytic therapy If fibrinolytic therapy is given then consideration may be required for continuing CPR for up to min

Ultrasound In skilled hands may identify reversible causes In particular Tamponade, Tension Pneumothorax Hypovolaemia, and Thrombosis Obtain images during rhythm checks and CPR Do not interrupt CPR

Post Resuscitation Care

Post resuscitation care The goal is to restore: Normal cerebral function Stable cardiac rhythm Adequate organ perfusion Quality of life FOLLOW ABCDE approach

Post cardiac arrest syndrome Post cardiac arrest brain injury: Coma, seizures, myoclonus Post cardiac arrest myocardial dysfunction Systemic ischaemia-reperfusion response ‘Sepsis-like’ syndrome Persistence of precipitating pathology

Therapeutic hypothermia Who to cool? Unconscious adults with ROSC after VF arrest should be cooled to o C May benefit patients after non-shockable/in-hospital cardiac arrest Exclusions: severe sepsis, pre-existing medical coagulopathy Start as soon as possible and continue for 24 h Rewarm slowly 0.25 o C h -1

Therapeutic hypothermia Physiological effects and complications Shivering: sedate +/- neuromuscular blocking drug Bradycardia and cardiovascular instability Infection Hyperglycaemia Electrolyte abnormalities Increased amylase values Reduced clearance of drugs

Any questions?

The ALS algorithm Importance of high quality chest compressions Treatment of shockable and non-shockable rhythms Administration of drugs during cardiac arrest Potentially reversible causes of cardiac arrest Resuscitation does not end with ROSC Role of resuscitation team Summary

Peri-Arrest

Bradycardia / Tachyarrhythmia algorithm

Bradycardia algorithm Includes rates inappropriately slow for haemodynamic state Interim measures: Atropine mcg IV repeat to maximum of 3 mg Isoprenaline 5 mcg min -1 IV Adrenaline 2-10 mcg min -1 IV Alternative drugs * OR Transcutaneous pacing Interim measures: Atropine mcg IV repeat to maximum of 3 mg Isoprenaline 5 mcg min -1 IV Adrenaline 2-10 mcg min -1 IV Alternative drugs * OR Transcutaneous pacing

Tachycardia algorithm (with pulse)

Tachycardia algorithm

Stable broad-complex tachycardia

Stable narrow-complex tachycardia

Any questions?

Summary Modifications to ALS are based upon current evidence Focus is on standardised CPR for adults

Advanced Life Support Recertification Course Slide set All rights reserved © Australian Resuscitation Council and Resuscitation Council (UK) 2010