1. ALS Algorithm

2. 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

3. 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

4. Adult ALS algorithm

5. 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

6. Cardiac arrest confirmed

7. Cardiac arrest confirmed

8. Chest compression 30:2 compressions
centre of chest
one third total depth/ >5 cm
rate 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

9. START
CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

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

11. 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

12. IMMEDIATELY RESTART CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

13. 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

14. 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…

15. 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

16. START
CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

17. 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

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

19. Vascular access
peripheral versus central veins
intraosseous

20. 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

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

22. Hypokalaemia & metabolic disorders
& Hyperthermia

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

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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

33. 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

34. 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

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

36. Thrombosis
seek evidence
history
examination
ultrasound may help

37. 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 minutes

38. 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

39. 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

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

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

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

43. Any questions?

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

45. Advanced Life Support Course Slide set
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© Australian Resuscitation Council (January 2016)