ARC Advanced Life Support Level 1: Immediate Life Support Course Recertification Course

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

ILS course learning outcomes By the end of this course the candidate will have refreshed: Recognition and assessment of the deteriorating patient Prevention of cardiac arrest Know when to commence CPR measures Performing standardised CPR for adults Performing safe defibrillation (AED and/or manual) Performing in the roles of resuscitation team members

Chain of survival

Causes and Prevention of Cardiac Arrest

The ABCDE approach to the deteriorating patient Airway Breathing Circulation Disability Exposure

ABCDE approach Underlying principles: Complete initial assessment Treat life-threatening problems Reassessment Assess effects of treatment/interventions Call for help early

ABCDE approach Personal safety Patient responsiveness First impression Vital signs Respiratory rate, SpO2, pulse, BP, GCS, temperature Circled by Carl

ABCDE approach Airway Recognition of airway obstruction: Talking Difficulty breathing, distressed, choking Shortness of breath Noisy breathing Stridor, wheeze, gurgling See-saw respiratory pattern, accessory muscles

ABCDE approach Airway Treatment of airway obstruction: Airway opening Head tilt, chin lift, jaw thrust Simple adjuncts Advanced techniques e.g. LMA, tracheal tube Oxygen Circled by Carl

ABCDE approach Breathing Recognition of breathing problems: Look Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level Listen Noisy breathing, breath sounds Feel Expansion, percussion

ABCDE approach Breathing Treatment of breathing problems: Airway Oxygen Treat underlying cause Support breathing if inadequate e.g. ventilate with bag-mask

ABCDE approach Circulation Recognition of circulation problems: Look at the patient Pulse - tachycardia, bradycardia Peripheral perfusion - capillary refill time Blood pressure Organ perfusion Chest pain, mental state, urine output Bleeding, fluid losses

Hypovolaemia One of most common causes of crisis Fluid loss not always obvious: Haemorrhagic – blood loss external or within body Distributive Shock - vasodilation Cardiogenic Shock – myocardial insufficiency Restrictive Shock – pericardial effusion Obstructive Shock – Emboli Relative Shock – anaemia

ABCDE approach Circulation Treatment of circulation problems: Airway, Breathing Oxygen if needed IV/IO access, take bloods Call for help Treat cause Fluid challenge

ABCDE approach Circulation Acute Coronary Syndromes Unstable angina or myocardial infarction Treatment Aspirin 300 mg orally (crushed/chewed) Nitroglycerine (GTN spray or tablet if first dose ever) Oxygen (guided by pulse oximetry if uncomplicated) Give if in shock/heart failure/Saturations indicate Morphine (or fentanyl) Consider reperfusion therapy (PCI, thrombolysis)

ABCDE approach Disability (Drugs/Diabetes/Documentation) Recognition AVPU or GCS Pupils Blood sugar Check drug chart Check for any history (documentation, alert jewellery) Treatment ABC Treat underlying cause Blood glucose If < 4 mmol l-1 give glucose Consider lateral position

ABCDE approach Exposure Remove clothes to enable examination e.g. injuries, bleeding, rashes Check all Look at and examine surface, orifice, extremity and cavity Avoid excessive heat loss Maintain dignity

Advanced Life Support Algorithm

ALS algorithm ILS providers should use those skills in which they are proficient If using an AED – switch on and follow the prompts Ensure high quality chest compressions Ensure expert help is coming

Adult ALS Algorithm

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

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 5 cm depth/one third total approximately 100 min-1 (but no faster than 120 min-1 - 2 per second ) Maintain high quality compressions with minimal interruptions Continuous compressions once airway secured Switch compressions provider every 2 min cycle to avoid fatigue

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

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

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

Automated External Defibrillation If not confident in rhythm recognition use an AED Start CPR whilst awaiting AED to arrive Switch on and follow AED prompts

AED algorithm Follow AED prompts Will need to pause compressions for rhythm analysis Following shock immediately recommence compressions/CPR

Manual defibrillation Plan all pauses in chest compressions Do chest compressions when charging Visual sweep to check bed area when charging Ensure no-one touches patient during shock delivery Pause in compressions to check rhythm Deliver shock (or Disarm/“Dump” charge) Resume compressions immediately after the shock If no shock check patient/pulse

Shout “(Compressions Continue) Stand Clear” Shockable (VF / VT) Shockable (VF / VT) Shout “(Compressions Continue) Stand Clear” Assess rhythm

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

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

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

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

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

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

Defibrillation energies 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…

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

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

DUMP/DISCHARGE ENERGY Non-Shockable DUMP/DISCHARGE ENERGY Assess rhythm Shockable (VF / Pulseless VT) Non-Shockable (PEA / Asystole) 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 alternate loop

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

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

Reversible Causes /Hyperthermia Reversible causes /Hypokalaemia – metabolic disorders Reversible causes

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 Capnography - waveform

Immediate post-cardiac arrest treatment

ISBAR I = Identify S = Situation B = Background A = Assessment Include specific observations and vital sign/observations values based on ABCDE approach R = Response/Requirement State explicitly what you want the person you are calling to do I = Identify Identify the patient you are calling about S = Situation Say what you think the current problem is/appears to be B = Background Information about the patient A = Assessment Include specific observations and vital sign/observations values based on ABCDE approach R = Response/Requirement State explicitly what you want the person you are calling to do

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

Any questions?

Summary Aim to prevent need for resuscitation Use the ABCDE approach to recognise and treat the deteriorating patient Ensure high quality chest compressions with minimal interruption VF/pulseless VT are shockable rhythms PEA and asystole are non-shockable rhythms Ensure help on the way

Immediate Life Support Course Slide set All rights reserved © Australian Resuscitation Council & Resuscitation Council (UK) 2010