adult advanced life support2

8/8/2019 Adult Advanced Life Support2

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Adult Advanced LifeAdult Advanced LifeSupportSupport


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ALS Treatment AlgorithmALS Treatment Algorithm

Arrythmias associated with cardiac arrest are divided Arrythmias associated with cardiac arrest are dividedinto 2 groupsinto 2 groups--1)Shockable rhythms1)Shockable rhythms--VT/VF VT/VF

2)Non2)Non--shockable rhythmsshockable rhythms-- asystole, PEAasystole, PEA

The difference in management is the need for The difference in management is the need forattempted defibrillation in VT/VF.attempted defibrillation in VT/VF.

Subsequent actions, i.e. chest compression, airway mxSubsequent actions, i.e. chest compression, airway mxand ventilation, venous access, adrenalineand ventilation, venous access, adrenalineadministration, and identification and rx of reversibleadministration, and identification and rx of reversiblecauses are common.causes are common.


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Shockable RhythmsShockable Rhythms - -Sequence of ActionsSequence of Actions

Attempt defibrillation: one shock 150 Attempt defibrillation: one shock 150--200J200Jbiphasic or 360J monophasicbiphasic or 360J monophasic

Immediately resume chest compressions(30:2)Immediately resume chest compressions(30:2) without reassessing the rhythm or feeling the without reassessing the rhythm or feeling thepulsepulseContinue CPR for 2min; pause briefly to check Continue CPR for 2min; pause briefly to check the monitor:the monitor:


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Shockable Rhythms (contd)Shockable Rhythms (contd)

If VT/VF persists:If VT/VF persists:Give a 2Give a 2 ndnd shock shock Resume CPR immediately and cont for 2minResume CPR immediately and cont for 2minPause briefly to check monitorPause briefly to check monitor

If VT/VF persists give adrenaline 1mg iv followed immediately by a 3If VT/VF persists give adrenaline 1mg iv followed immediately by a 3rdrd

shock shock Resume CPR for 2minsResume CPR for 2minsPause briefly to check monitorPause briefly to check monitorIf VT/VF persists give amiadarone 300mg iv followed immediately by aIf VT/VF persists give amiadarone 300mg iv followed immediately by ashock(4shock(4 thth))

Resume CPR for 2minsResume CPR for 2minsGive adrenaline 1mg iv immediately before alternate shocks (~every 3Give adrenaline 1mg iv immediately before alternate shocks (~every 3- -5mins)5mins)


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Shockable Rhythms (contdShockable Rhythms (contd) )

If organised electrical activity is seen during thisIf organised electrical activity is seen during thisbrief pause in compressionbrief pause in compression--check for pulsecheck for pulse

If no pulse is present, continue CPR and switchIf no pulse is present, continue CPR and switchto nonto non--shockable algorithmshockable algorithmIf asystole is seen, cont CPR and switch to nonIf asystole is seen, cont CPR and switch to nonshockable algorithmshockable algorithm


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Shockable RhythmsShockable Rhythms

Precordial thumpPrecordial thump

A single precordial thump is considered (by health professionals) A single precordial thump is considered (by health professionals) when cardiac arrest is confirmed rapidly after a witnessed and when cardiac arrest is confirmed rapidly after a witnessed andmonitored sudden collapse, and a defibrillator is not immediately monitored sudden collapse, and a defibrillator is not immediately at hand.at hand.Using the ulnar edge of a tightly clenched fist, a sharp impact isUsing the ulnar edge of a tightly clenched fist, a sharp impact isdelivered to the lower half of the sternum from a height of delivered to the lower half of the sternum from a height of 20cm, then the fist is retracted immediately to create an impulse20cm, then the fist is retracted immediately to create an impulse

like stimuluslike stimulus This is most successful in converting a VT to sinus rhythm. This is most successful in converting a VT to sinus rhythm.Successful rx of VF is less likely. In all reported successful cases,Successful rx of VF is less likely. In all reported successful cases,it was given within the 1it was given within the 1stst 10s of VF.10s of VF.


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D efibrillation strategyD efibrillation strategy

Even if defibrillation is successful in restoring aEven if defibrillation is successful in restoring a

perfusing rhythm it is very rare for a pulse to beperfusing rhythm it is very rare for a pulse to bepalpable immediately and the delay in trying to palpate apalpable immediately and the delay in trying to palpate apulse will further compromise the myocardium if apulse will further compromise the myocardium if aperfusing rhythm has not been established.perfusing rhythm has not been established.

Delivering repeated shocks can increase myocardialDelivering repeated shocks can increase myocardialinjury directly from electrical current and indirectly injury directly from electrical current and indirectly from interruptions to coronary blood flow.from interruptions to coronary blood flow.


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W hen the rhythm is checked 2mins after giving a W hen the rhythm is checked 2mins after giving ashock, if a nonshock, if a non--shockable rhythm is seen and theshockable rhythm is seen and therhythm is organised (narrow and regular complexes) try rhythm is organised (narrow and regular complexes) try to palpate a pulseto palpate a pulseRhythms checks must be brief Rhythms checks must be brief Pulse checks only if theres an organised rhythmPulse checks only if theres an organised rhythmIf organised rhythm is seen during the 2min CPR If organised rhythm is seen during the 2min CPR period, dont interrupt chest compression to palpate aperiod, dont interrupt chest compression to palpate apulse unless patient shows signs of lifepulse unless patient shows signs of life --return of return of spontaneous circulation (ROSC)spontaneous circulation (ROSC)If the patient has ROSC, begin post resuscitation careIf the patient has ROSC, begin post resuscitation care


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A drenaline A drenaline : The alpha adrenergic action of adrenaline: The alpha adrenergic action of adrenalinecauses vasoconstriction which increases myocardial andcauses vasoconstriction which increases myocardial andcerebral perfusion pressures during arrest.cerebral perfusion pressures during arrest.

The recommendation is to give adrenaline immediately The recommendation is to give adrenaline immediately after confirmation of the rhythm and just before shock after confirmation of the rhythm and just before shock delivery delivery (drug(drug--shock shock--CPR CPR--rhythmrhythm--check pulse).check pulse).

Adrenaline given immediately before the shock is Adrenaline given immediately before the shock is

circulated by the CPR that follows the shock.circulated by the CPR that follows the shock. Adrenaline should be made and ready to be given to Adrenaline should be made and ready to be given tominimise delay.minimise delay.


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Vasopressin: Vasopressin: There are no studies to show a There are no studies to show adifference between the use of adrenaline or vasopressin.difference between the use of adrenaline or vasopressin.

Thus adrenaline remains the primary vasopressor used. Thus adrenaline remains the primary vasopressor used.A nti arrhythmic drugs: A nti arrhythmic drugs: If VT/VF persists after 3If VT/VF persists after 3shocks give amiadarone300mg by bolus injectionshocks give amiadarone300mg by bolus injectionduring the brief rhythm analysis before delivery of theduring the brief rhythm analysis before delivery of thefourth shock. A further dose of 150mg may be givenfourth shock. A further dose of 150mg may be givenfor recurrent or refractory VT/VF followed by anfor recurrent or refractory VT/VF followed by an

infusion of 900mg over 24hr.infusion of 900mg over 24hr.L ignocaine:L ignocaine: 1mg/kg may be used as an alternative if 1mg/kg may be used as an alternative if amiadarone is not available, but should not be given if amiadarone is not available, but should not be given if amiadarone is already given.amiadarone is already given.


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If patients rhythm changes to asystole or PEAIf patients rhythm changes to asystole or PEAchange to nonchange to non-- shockable protocolshockable protocol

In both VF/VT and PEA/asystole giveIn both VF/VT and PEA/asystole giveadrenaline 1mg iv every 3adrenaline 1mg iv every 3--5 min (~ every 2min5 min (~ every 2minloop)loop)In pts with spontaneous circulation, dosesIn pts with spontaneous circulation, dosesconsiderably smaller than 1mg iv may beconsiderably smaller than 1mg iv may berequired to maintain BPrequired to maintain BP


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D efibrillationD efibrillation- -StrategiesStrategies

S afe use of oxygenS afe use of oxygenRemove any ORemove any O22 masks or nasal cannulae andmasks or nasal cannulae andkeep at least 1m from patients chest.keep at least 1m from patients chest.Disconnect the ventilation bag from the tubeDisconnect the ventilation bag from the tubeand keep at least 1m away from patients chestand keep at least 1m away from patients chestduring defibrillation.during defibrillation.

Use of self Use of self--adhesive defibrillation pads, ratheradhesive defibrillation pads, ratherthan manual paddles, may minimise the risk of than manual paddles, may minimise the risk of sparks.sparks.


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Chest hair:Chest hair: may be necessary to shave the areamay be necessary to shave the areafor electrode placement, but defibrillationfor electrode placement, but defibrillationshould not be delayed if a razor is not available.should not be delayed if a razor is not available.Paddle forcePaddle force : Apply paddles firmly to the chest: Apply paddles firmly to the chest

wall. The optimal force is 8kg in adults and 5kg wall. The optimal force is 8kg in adults and 5kg in children 1in children 1--8yrs,using adult paddles. Place8yrs,using adult paddles. Place

water water--based gel pads between the paddle andbased gel pads between the paddle andpatients skin.patients skin.


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E lectrode positionE lectrode position ::Place the right sternal electrode to the right of the sternum,Place the right sternal electrode to the right of the sternum,below the clavicle.below the clavicle.Place the apical paddle vertically in the midPlace the apical paddle vertically in the mid--axillary line, approx.axillary line, approx.level with the V6 ECG electrode position. It is important thatlevel with the V6 ECG electrode position. It is important thatthis electrode is placed sufficiently laterally.this electrode is placed sufficiently laterally.

Antero Antero--posterior electrode placement may be more effective inposterior electrode placement may be more effective inthe cardio version of AF.the cardio version of AF.

An implantable medical device (e.g. PPM) may be damaged if An implantable medical device (e.g. PPM) may be damaged if

current is discharged through the electrodes placed directly overcurrent is discharged through the electrodes placed directly overthe device. Place the electrode away from the device or use anthe device. Place the electrode away from the device or use analternative electrode position. Remove any transdermal drug alternative electrode position. Remove any transdermal drug patches on the chest wall before defibrillationpatches on the chest wall before defibrillation


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N onN on- -shockable Rhythmsshockable Rhythms

Pulseless electrical activity(PEA) is cardiacPulseless electrical activity(PEA) is cardiacelectrical activity in the absence of any palpableelectrical activity in the absence of any palpablepulsepulsePEA may be caused by reversible conditionsPEA may be caused by reversible conditionsthat can be treated if they are identified andthat can be treated if they are identified andcorrectedcorrected

Survival following cardiac arrest with PEA orSurvival following cardiac arrest with PEA orasystole is unlikely if no reversible cause can beasystole is unlikely if no reversible cause can befoundfound


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N onN on- -Shockable RhythmsShockable Rhythms- -Sequence of action for peaSequence of action for pea

Start CPR 30:2Start CPR 30:2Give adrenaline 1mg iv as soon as venousGive adrenaline 1mg iv as soon as venous

access is availableaccess is availableContinue CPR 30:2 until airway is secured, thenContinue CPR 30:2 until airway is secured, thencontinue chest compressions without pausing continue chest compressions without pausing during ventilationduring ventilationRecheck the rhythm after 2minsRecheck the rhythm after 2mins


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N onN on- -Shockable RhythmsShockable Rhythms- -Sequence of action for peaSequence of action for pea

oo If there is no change in ECG appearanceIf there is no change in ECG appearanceContinue CPR.Continue CPR.Recheck rhythm after 2min and proceed accordingly.Recheck rhythm after 2min and proceed accordingly.Give further adrenaline 1mg iv every 3Give further adrenaline 1mg iv every 3--5min(alternate loops).5min(alternate loops).

oo If ECGIf ECG changeschanges into organised electrical activity, check for ainto organised electrical activity, check for apulse.pulse.If a pulse is present, start postIf a pulse is present, start post--resuscitation care.resuscitation care.If If nono pulse is present:pulse is present:Continue CPR.Continue CPR.Recheck the rhythm after 2min and proceed accordingly.Recheck the rhythm after 2min and proceed accordingly.Give further adrenaline 1mg every 3Give further adrenaline 1mg every 3--5 min.5 min.


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Sequence of action forSequence of action forAsystole and slow Asystole and slow

PEA(rate


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Potentially ReversiblePotentially ReversibleCausesCauses

HH ypoxiaypoxiaHH ypovolemiaypovolemiaHH ypokalaemia, hyperkalaemia, hypocalcaemia, acidaemia, andypokalaemia, hyperkalaemia, hypocalcaemia, acidaemia, andother metabolic causesother metabolic causesHH ypothermiaypothermia

T T ension Pneumothoraxension Pneumothorax T T amponadeamponade T T oxic substancesoxic substances T T hromboembolism(pulm embolus, coronary thrombus)hromboembolism(pulm embolus, coronary thrombus)


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The 4 H sThe 4 H s

H ypoxiaH ypoxia is minimised by ensuring the patients lungs areis minimised by ensuring the patients lungs are ventilated adequately with 100% O ventilated adequately with 100% O2.2. Make sure there is adequateMake sure there is adequatechest rise and bilateral breath soundschest rise and bilateral breath soundsPEA caused by PEA caused by hypovolaemiahypovolaemia is usually caused by is usually caused by haemorrhage. Infuse fluids rapidly. In initial stages of CPR therehaemorrhage. Infuse fluids rapidly. In initial stages of CPR thereis no advantage in using colloid. Saline or Hartmanns is used.is no advantage in using colloid. Saline or Hartmanns is used.Dextrose is avoided as it can be redistributed away from theDextrose is avoided as it can be redistributed away from theintravascular space rapidly and cause hyperglycaemia.intravascular space rapidly and cause hyperglycaemia.H yperkalaemiaH yperkalaemia and other metabolic disorders are detected by and other metabolic disorders are detected by biochemical tests/ suggested by patients history.biochemical tests/ suggested by patients history.H ypothermiaH ypothermia is suspected in any drowning episodeis suspected in any drowning episode


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The 4 T sThe 4 T s

Tension pneumothorax Tension pneumothorax : possibly following CVP: possibly following CVPinsertion. Diagnosis is clinical. Rx is decompressioninsertion. Diagnosis is clinical. Rx is decompressionrapidly by thoracocentesis and then chest drainrapidly by thoracocentesis and then chest draininsertioninsertionCardiacCardiac tamponade:tamponade: Possible diagnosis in penetrating Possible diagnosis in penetrating chest injuries. Rx is needle pericardiocentesis orchest injuries. Rx is needle pericardiocentesis orresuscitative thoracotomy.resuscitative thoracotomy.

Toxic Toxic substances: when available appropriate antidotessubstances: when available appropriate antidotes

should be used. Often rx is supportive.should be used. Often rx is supportive.Commonest cause of Commonest cause of thromboembolicthromboembolic obstruction isobstruction ismassive pulmonary embolism. Consider giving amassive pulmonary embolism. Consider giving athrombolytic drug immediately.thrombolytic drug immediately.


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Airway Mx and ventilationAirway Mx and ventilation

B asic airway manoeuvres and airway adjuncts:B asic airway manoeuvres and airway adjuncts: Airway assessment; triple manoeuvre; simple airway Airway assessment; triple manoeuvre; simple airway adjuncts.adjuncts.

Ventilation: Ventilation: provide artificial respiration to a patientprovide artificial respiration to a patient who has inadequate or absent spontaneous respiration who has inadequate or absent spontaneous respirationExpired air ventilation (rescue breathing) breathing isExpired air ventilation (rescue breathing) breathing is

effective but the rescuers expired Oeffective but the rescuers expired O 22 concentration isconcentration is1616--17%17% replace as soon as possible with Oreplace as soon as possible with O 22 enrichedenrichedairair


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Assisting Circulation:Assisting Circulation:intravenous accessintravenous access

Peripheral Vs Central Venous drug delivery Peripheral Vs Central Venous drug delivery Intraosseous route: enables withdrawal of Intraosseous route: enables withdrawal of

marrow for venous blood gas analysis andmarrow for venous blood gas analysis andmeasurement of electrolytes and haemoglobin.measurement of electrolytes and haemoglobin. Tracheal route: Adrenaline dose 3mg diluted to Tracheal route: Adrenaline dose 3mg diluted toat least 10ml with sterile waterat least 10ml with sterile water


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Assisting Circulation:Assisting Circulation:D rugsD rugs

A drenaline, A nti A drenaline, A nti--arrhythmicsarrhythmics

Magnesium S ulphate:Magnesium S ulphate: 8mmol8mmol

Refractory VF if hypomagnesaemia is suspectedRefractory VF if hypomagnesaemia is suspected Ventricular tachyarrhythmias with Ventricular tachyarrhythmias with Mg Mg 2+2+

Torsades de pointes Torsades de pointesDigoxin toxicity Digoxin toxicity

B icarbonateB icarbonate --not recommended routinely. 50mmols if cardiacnot recommended routinely. 50mmols if cardiacarrest is associated with K arrest is associated with K ++ or tcad overdose. May be repeatedor tcad overdose. May be repeatedaccording to clinical state of the patient and ABG analysisaccording to clinical state of the patient and ABG analysis


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Assisting Circulation:Assisting Circulation:D rugsD rugs

A tropine: A tropine: Blockade of parasympathetic activity at both SA andBlockade of parasympathetic activity at both SA and AV node may sinus automaticity and facilitate AV node AV node may sinus automaticity and facilitate AV nodeconduction. Dose 3mg iv for adultsconduction. Dose 3mg iv for adultsCalcium:Calcium: resuscitation from PEA if cause isresuscitation from PEA if cause is

HyperkalaemiaHyperkalaemiaHypocalcaemiaHypocalcaemiaOverdose of CaOverdose of Ca--channel blockerschannel blockersMagnesium overdose (rx of eclampsia)Magnesium overdose (rx of eclampsia)

10ml of 10% Ca chloride/gluconate as the initial dose.10ml of 10% Ca chloride/gluconate as the initial dose.In cardiac arrest it can be given rapidly In cardiac arrest it can be given rapidly In spontaneous circulation it should be given slowly In spontaneous circulation it should be given slowly


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PostPost- -resuscitation Careresuscitation Care

This starts when ROSC is achieved. Once This starts when ROSC is achieved. Oncestabilized the patient should be transferred tostabilized the patient should be transferred tothe ICU/CCU for continued monitoring andthe ICU/CCU for continued monitoring andtreatment.treatment.Comprises of airway and breathing, circulation,Comprises of airway and breathing, circulation,and disability (optimising neurological recovery)and disability (optimising neurological recovery)


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PostPost- -resuscitation Care:resuscitation Care:Airway and BreathingAirway and Breathing

Tracheal intubation, sedation and controlled ventilation Tracheal intubation, sedation and controlled ventilationin patients with obtunded cerebral functionin patients with obtunded cerebral function

Adjust ventilation to achieve normocarbia. Monitor Adjust ventilation to achieve normocarbia. Monitor with ETCO with ETCO 22 and ABGand ABG Adjust inspired O Adjust inspired O 22 concentrations to achieve adequateconcentrations to achieve adequatearterial Oarterial O22saturationsaturation

NG tube to decompress stomachNG tube to decompress stomachCXR: position of ETT and CVP, excludeCXR: position of ETT and CVP, excludepneumothorax associated with rib fractures from CPR pneumothorax associated with rib fractures from CPR


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PostPost- -resuscitation Care:resuscitation Care:

CirculationCirculation Arterial line for continuous BP monitoring Arterial line for continuous BP monitoring Infusion of IVF to optimise filling Infusion of IVF to optimise filling However, diuretics and vasodilators may be needed toHowever, diuretics and vasodilators may be needed totreat LVF.treat LVF.Inotropic support to maintain MAP and achieveInotropic support to maintain MAP and achieveadequate UOP.adequate UOP.Maintain serum K Maintain serum K ++ between 4.0between 4.0--4.5mmol/l4.5mmol/l?coronary occlusion?coronary occlusion consider the need for immediateconsider the need for immediaterevascularisation by thrombolytic therapy orrevascularisation by thrombolytic therapy orpercutaneous coronary interventionpercutaneous coronary intervention


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PostPost- -resuscitation Care:resuscitation Care:D isability D isability

(optimising neurological(optimising neurologicalrecovery)recovery)

S edation:S edation: short acting drugs (propofol,short acting drugs (propofol,alfentinil, remifentinil) to enable early alfentinil, remifentinil) to enable early neurological assessment.neurological assessment.

Control of seizures:Control of seizures: benzodiazepines,benzodiazepines,phenytoin, propofol, or a barbiturate as approp.phenytoin, propofol, or a barbiturate as approp.


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PostPost- -resuscitation Care:resuscitation Care:D isability D isability

B lood glucose controlB lood glucose controlBlood glucose levels between 4.4Blood glucose levels between 4.4--6.1mmol/l6.1mmol/lreduces hospital mortality in critically ill pts butreduces hospital mortality in critically ill pts butthis has not been specifically demonstrated inthis has not been specifically demonstrated inpostpost--cardiaccardiac--arrest pts.arrest pts.

Comatose pts are at risk from unrecognisedComatose pts are at risk from unrecognisedhypoglycaemia and the risk of this complicationhypoglycaemia and the risk of this complicationoccurring occurring ses as the target BG conc is loweredses as the target BG conc is lowered


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adult advanced life support2

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