1. ALS Algorithm

2. 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 Role of resuscitation team Learning outcomes

4. Adult ALS Algorithm

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

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

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

8. Chest compression 30:2 Compressions Centre of chest Min 5-6 cm depth/one third total 2 per second (100-120 min -1 ) Maintain high quality compressions with minimal interruptions Continuous compressions once airway secured Switch CPR provider every 2 min cycle to avoid fatigue

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

10. 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

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

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

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

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

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

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

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

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

19. 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

20. 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 Precordial thump Pulseless VT only Defibrillator unavailable Delivered within 20 seconds of onset of arrest

21. 2 nd and subsequent shocks 150 – 360 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

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

23. 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)

24. 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)

25. 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 cycle) Amiodarone 300 mg after 3rd shock Non Shockable Adrenaline 1 mg immediately (then every 2nd cycle)

26. 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

27. Vascular access Peripheral versus central veins Intraosseous

28. Reversible causes

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

30. Hypovolaemia Seek evidence of hypovolaemia History Examination -Internal haemorrhage -External haemorrhage -Check surgical drains Control haemorrhage If hypovolaemia suspected give intravenous fluids

31. 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

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

33. Hyperthermia Heat stroke can resemble septic shock Core temp >40.6 C Rhabdomyolysis, coagulopathy issues Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm Rapid cooling to 39 C (similar approaches/techniques to hypothermia) Large fluid volumes Correct electrolyte abnormalities/acidosis Dantrolene for some MDMA/anaesthetic agent reactions No specific medications for heat stroke effective

34. Tension pneumothorax Check tube position if intubated Clinical signs Decreased breath sounds Hyper-resonant percussion note Tracheal deviation Initial treatment with needle decompression or thoracostomy

35. Tamponade, cardiac Difficult to diagnose without echocardiography Consider if penetrating chest trauma or after cardiac surgery Treat with needle pericardiocentesis or resuscitative thoracotomy

36. Toxins Rare unless evidence of deliberate overdose Review drug chart

37. Thrombosis If high clinical probability for PE consider fibrinolytic therapy If fibrinolytic therapy given continue CPR for up to 60-90 min before discontinuing resuscitation

38. Ultrasound In skilled hands may identify reversible causes Obtain images during rhythm checks Do not interrupt CPR

39. Immediate post-cardiac arrest treatment

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

41. Any questions?

42. 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 Role of resuscitation team Summary

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