1. ALS

2. Objectives Prevention of cardiac arrest Revision of BLS ALS algorithms
- shockable ryhthms
- non-shockable rhythms
Potential reversible causes of cardiac arrest
Safe debrillation (Zoll and AED)
Practice ALS scenarios

3. Early recognition of the critically ill 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

4. Early recognition prevents:
Call for help early!!!!!
Early recognition prevents:
Cardiac arrests and deaths
Admissions to ICU, inappropriate resuscitations

6. Confirm cardiorespiratory arrest
Check for danger
Check for response - if unresponsive
Call for help/met call – 666 at Liverpool
Open airway
Check for normal breathing
Start CPR – 30 chest compressions, then 2 breaths (30:2)
Attach AED/defib

7. Basic Life Support Compressions lower ½ sternum
>/= 5 cm depth (1/3 depth chest)
100 min-1
Ratio 30:2 breaths until airway secured
Avoid!
Interruptions (<10 seconds)
Provider fatigue (swap every cycle)

8. Airway and ventilation
Oxygenation important NOT intubation
No evidence that intubation improves outcome (& may interrupt compressions)
Open airway, place Guedel then Bag-Valve mask ventilation is ok initially
Met team may consider advanced airway: LMA (or ETT)
Avoid hyperventilation (6-10/min max)
Avoiding hyperventilation refers to making sure that large volumes and high rates are not used as these will increase intrathoracic pressure, reducing venous return and coronary perfusion.

10. Rhythm ? – Shockable or Non-Shockable

11. Shockable Ventricular Fibrillation: Bizarre irregular waveform
No recognisable QRS complexes
Random frequency and amplitude
Uncoordinated electrical activity

12. Rhythm ? – Shockable or Non-Shockable

13. Shockable VT (monomorphic) broad complex regular rhythm rapid rate
constant QRS morphology

14. Defibrillation
Must be safe – live current!! –all hands off patient, 02 away
Energy varies with manufacturer - Check local equipment
Biphasic (Zoll) give 200 J standard (can alter energy level manually)
AED – automatic – set at 200J
Must do 2 mins CPR after any shock before checking rhythm

15. Rhythm ? – Shockable or Non-Shockable

16. Non-shockable Asystole: Absent ventricular (QRS) activity
Atrial activity (P waves) may persist
Rarely a straight line trace

17. Non-shockable Pulseless electrical activity:
Clinical features of cardiac arrest
ECG normally associated with an output

18. CORRECT REVERSIBLE CAUSES
Hypoxaemia
Hypovolaemia
Hypo/hyperthermia
Hypo/hyperkalaemia & other
metabolic disorders
Tamponade
Tension pneumothorax
Toxins / Poisons / Drugs
Thrombus - pulmonary / coronary

19. Adrenaline Dose: 1mg IV VF/VT – give after 2nd shock
Non VF/VT – give immediately
Repeat every 3-5 min
ie alternate cycles

20. Any questions

21. Summary
ALS algorithm provides a standardised approach to the treatment of cardiac arrest in adults
Shockable rhythms (VF/pulseless VT)
Non-shockable rhythms
Reversible causes of cardiac arrest
Common drugs used