1. S.Wilkinson - Bishops Court Education & Development Centre Resuscitation Guidelines 2005 Adult ALS

2. S.Wilkinson - Bishops Court Education & Development Centre Resuscitation Guidelines CPR before defibrillation In the case of out-of-hospital arrest attended, but not witnessed by healthcare professionals equipped with manual defibrillators, give CPR for 2 min (approx. 5 cycles of 30:2) before defibrillation.

3. S.Wilkinson - Bishops Court Education & Development Centre Guideline Changes Defibrillation strategy: Treat VF / VT with a single shock, followed by immediate resumption of CPR. Do not reassess the rhythm or feel for a pulse. After 2 min CPR, check rhythm and give another shock (if required) Following advice from Medtronic, EMAS have elected to use escalating energy levels of 200J, 300J, 360J

4. S.Wilkinson - Bishops Court Education & Development Centre Adult ALS Algorithm CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) 1 Shock 200, 300, 360 Joules Open Airway Look for signs of life Immediately resume CPR 30:2 for 2 min Call Resuscitation Team During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, (magnesium) Immediately resume CPR 30:2 for 2 min

5. S.Wilkinson - Bishops Court Education & Development Centre …. to confirm cardiac arrest Patient response (AVPU) Open airway Check for normal breathing – (caution agonal breathing) Check circulation Monitoring Open Airway Look for signs of life

6. S.Wilkinson - Bishops Court Education & Development Centre CPR 30:2 Until defibrillator / monitor attached Open Airway Look for signs of life Cardiac Arrest Confirmed

7. S.Wilkinson - Bishops Court Education & Development Centre

8. Chest compression 30:2 Compressions – Centre of chest – 4-5 cm depth – 100 min -1 Uninterrupted compressions when airway secured Avoid: – Provider fatigue – Interruptions

9. S.Wilkinson - Bishops Court Education & Development Centre CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole ) Open Airway Look for signs of life ALS Algorithm

10. S.Wilkinson - Bishops Court Education & Development Centre Shockable (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Uncoordinated electrical activity Coarse / fine Exclude artifact – movement – electrical interference

11. S.Wilkinson - Bishops Court Education & Development Centre Shockable (VT) Monomorphic VT – broad complex rhythm – rapid rate – constant QRS morphology Polymorphic VT – torsade de pointes VT is shockable when it is PULSELESS

12. S.Wilkinson - Bishops Court Education & Development Centre Precordial Thump –Rapid treatment of a witnessed and monitored VF/VT cardiac arrest –Used if defibrillator not immediately available

13. S.Wilkinson - Bishops Court Education & Development Centre 1 st shock: 200 Joules Assess Rhythm Shockable ( VF/Pulseless VT ) 1 Shock 200 Joules Immediately resume CPR 30:2 for 2 min

14. S.Wilkinson - Bishops Court Education & Development Centre If VF/VT persists Minimise delays between CPR and shocks (< 10 s) Do not delay shock to give adrenaline Give Amiodarone before 4 th shock Deliver 2 nd shock (300 Joules) Deliver 3 rd shock (360 Joules) CPR for 2 min If VF/VT persists Adrenaline 1mg IV

15. S.Wilkinson - Bishops Court Education & Development Centre After delivery of each shock Continue CPR for another 2 min – stop CPR only if patient shows signs of life After 2 min, assess rhythm: If still in VF continue shocks and 2 mins CPR following each shock. –Give adrenaline every 3 – 5 mins (alternate shocks)

16. S.Wilkinson - Bishops Court Education & Development Centre If organised electrical activity, check for signs of life: – if ROSC start post resuscitation care – if no ROSC go to non VF/VT algorithm If asystole, go to non VF/VT algorithm

17. S.Wilkinson - Bishops Court Education & Development Centre Asystole Pulseless electrical activity (PEA) Assess Rhythm Non-shockable (PEA/Asystole) Immediately resume CPR 30:2 for 2 min

18. S.Wilkinson - Bishops Court Education & Development Centre Non-shockable Asystole Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace Treat fine VF as asystole

19. S.Wilkinson - Bishops Court Education & Development Centre Asystole During CPR: Check leads are attached Adrenaline 1 mg IV (IO) every 3 – 5 min (every other cycle of 2 mins CPR) Atropine 3 mg IV (IO)

20. S.Wilkinson - Bishops Court Education & Development Centre Non-shockable (PEA) Clinical features of cardiac arrest ECG normally associated with an output

21. S.Wilkinson - Bishops Court Education & Development Centre Pulseless electrical activity Exclude / treat reversible causes Adrenaline 1 mg IV every 3-5 min Atropine 3 mg if PEA with rate <60 min -1

22. S.Wilkinson - Bishops Court Education & Development Centre During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine

23. S.Wilkinson - Bishops Court Education & Development Centre Potential reversible causes: Hypoxia Hypovolaemia Hypo/hyperkalaemia & metabolic disorders Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis (coronary or pulmonary)

24. S.Wilkinson - Bishops Court Education & Development Centre Airway and ventilation Secure airway: –Endotracheal tube –Supraglottic airway device e.g. LMA Once airway secured, if possible, do not interrupt chest compressions for ventilation

25. S.Wilkinson - Bishops Court Education & Development Centre Intravenous access

26. S.Wilkinson - Bishops Court Education & Development Centre Drugs used in Cardiac Arrest Adrenaline Atropine Amiodarone

27. S.Wilkinson - Bishops Court Education & Development Centre Adrenaline

28. S.Wilkinson - Bishops Court Education & Development Centre Adrenaline Actions:  agonist arterial vasoconstriction  systemic vascular resistance  cerebral and coronary blood flow  agonist  heart rate  force of contraction  myocardial O 2 demand (may increase ischaemia)

29. S.Wilkinson - Bishops Court Education & Development Centre Adrenaline Indications during cardiac arrest: –VF/VT – give before 3 rd shock –Non VF/VT – give immediately –Repeat every 3-5 min (alt. cycles) –1 mg IV (IO)

30. S.Wilkinson - Bishops Court Education & Development Centre Amiodarone

31. S.Wilkinson - Bishops Court Education & Development Centre Amiodarone Actions: Lengthens duration of action potential Prolongs QT interval Mild negative inotrope - may cause hypotension

32. S.Wilkinson - Bishops Court Education & Development Centre Amiodarone Indications: Shock refractory VF/VT 300 mg IV Give before 4 th shock (If unavailable give lidocaine 100 mg IV)

33. S.Wilkinson - Bishops Court Education & Development Centre Atropine

34. S.Wilkinson - Bishops Court Education & Development Centre Atropine Actions: Blocks effects of vagus nerve Increases sinus node automaticity Increases atrioventricular conduction

35. S.Wilkinson - Bishops Court Education & Development Centre Atropine Indications: Cardiac arrest –Asystole or PEA rate < 60 min -1 –3 mg IV

36. S.Wilkinson - Bishops Court Education & Development Centre Adult ALS Algorithm CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) 1 Shock 200, 300, 360 Joules Open Airway Look for signs of life Immediately resume CPR 30:2 for 2 min Call Resuscitation Team During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, (magnesium) Immediately resume CPR 30:2 for 2 min

37. S.Wilkinson - Bishops Court Education & Development Centre During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine.

38. S.Wilkinson - Bishops Court Education & Development Centre Any Questions?

39. S.Wilkinson - Bishops Court Education & Development Centre Paediatric Basic & Advanced Life Support

40. S.Wilkinson - Bishops Court Education & Development Centre Pathways to Cardiac Arrest in Childhood Cardiac Arrest Circulatory Failure Fluid Maldistribution Septic shock Anaphylaxis Cardiac disease Fluid Loss Blood loss Burns Respiratory Failure Respiratory Depression Convulsions Poisoning Respiratory Distress Foreign Body Asthma

41. S.Wilkinson - Bishops Court Education & Development Centre Paediatric Basic Life Support Resuscitation Guidelines 2005 Guideline Changes: An infant is a child under 1 year A child is between 1 year and puberty Lay rescuers should use a ratio of 30 compressions to 2 ventilations Two or more rescuers with a duty to respond should use a ratio of 15 compressions to 2 ventilations

42. S.Wilkinson - Bishops Court Education & Development Centre Paediatric Basic Life Support Resuscitation Guidelines 2005 A standard AED can be used in children over 8 years Purpose-made paediatric pads, or programs which attenuate the energy output of an AED, are recommended for children between 1 and 8 years If no such system or manually adjustable machine is available, an unmodified adult AED may be used for children older than 1 year There is insufficient evidence to support a recommendation for or against the use of AED’s in children less than 1 year

43. S.Wilkinson - Bishops Court Education & Development Centre Healthcare professionals with a duty to respond

44. S.Wilkinson - Bishops Court Education & Development Centre Basic Life Support Infant <1yr Child 1year-puberty Airway Head-tilt position NeutralHead tilt / chin lift Breathing Blow steadily (1 – 1.5 seconds) 5 initial followed by 2 5 initial followed by 2 Circulation Pulse check (if trained) Landmark Brachial 1 finger above xiphisternum (Lower third of sternum) Carotid 1 finger above xiphisternum (Lower third of sternum) Technique2 fingers ( two thumbs, if 2 rescuers) One or two hands as needed CPR ratio15:2 (If “duty to respond”) 30:2 (If lay responder) 15:2 (If “duty to respond”) 30:2 (If lay responder)

45. S.Wilkinson - Bishops Court Education & Development Centre Paediatric ALS Algorithm CPR 15:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) 1 Shock 4 joules/kg Open Airway Look for signs of life Immediately resume CPR 15:2 for 2 min Call Resuscitation Team During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium Immediately resume CPR 15:2 for 2 min

46. S.Wilkinson - Bishops Court Education & Development Centre Paediatric Advanced Life Support Resuscitation Guidelines 2005 Give 0.1mls/Kg (10 mcg/Kg) of adrenaline 1:10,000 every 3- 5mins. (In JRCALC pocket book Age Per Page) Amiodarone (5mg/Kg) prior to 4 th shock (Age per page) Given lack of evidence for the effectiveness of ET route, this is no longer recommended. 4 Joules/kg Manual Defibrillation.(Age per page) 2(Age + 4)= weight (kg)

47. S.Wilkinson - Bishops Court Education & Development Centre Any Questions?