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

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

3. 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

4. Chain of survival

5. Causes and Prevention of Cardiac Arrest

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

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

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

9. 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

10. 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

11. 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

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

13. 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

14. 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

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

16. 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)

17. 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

18. 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

19. Advanced Life Support Algorithm

20. 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

22. Adult ALS Algorithm

23. 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

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

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

26. 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 per second )
Maintain high quality compressions with minimal interruptions
Continuous compressions once airway secured
Switch compressions provider every 2 min cycle to avoid fatigue

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

28. 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

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

30. 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

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

32. 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

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

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

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

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

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

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

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

40. 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…

41. 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

42. 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

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

44. 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

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

46. 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)

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

48. 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

49. Immediate post-cardiac arrest treatment

50. 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

51. 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

52. Any questions?

53. 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

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