Advanced Life Support
Algorithm
Emergency Medicine Department
Dr – Sherif Elfayoumy
Learning objectives
The ALS Algorithm
Treatment of shockable and non-shockable rhythms
Potentially reversible causes of cardiac arrest
post-cardiac arrest treatment
CPR is a series of lifesaving actions that improve the chance
of survival following cardiac arrest.
Successful resuscitation requires an integrated set of
coordinated actions represented by the links in the
Chain of survival
Chain of survival
Early recognition and activation of EMT
Immediate bystander CPR
Early defibrillation
Early advanced life support
Integrated post-arrest care
Chain of survival
The goal is to restore:
Normal cerebral function
Stable cardiac rhythm
Adequate organ perfusion
Quality of life
Unresponsive
Open airway
Determination of signs of life Call
ALS resuscitation team
Algorithm CPR 30:2
Until defibrillator/monitor is
attached
Assess
rhythm
Shockable Non shockable
(VF/VT without pulse) (PEA/ Asystole)
During CPR
Ensure high-quality CPR: rate, depth,
recoil
Plan actions before interrupting CPR
1 Shock Give oxygen
150-200 J Biphasic Consider advanced airway
or 360 J Monophasic
Continuous chest compressions when
advanced airway in place
Vascular access (intravenous,
Immediately resume
intraosseous)
Give adrenaline every 3-5 min
Immediately resume
CPR 30:2 Correct reversible causes CPR 30:2
2 min. 2 min.
Check for sign of life
Patient response
Provide airway patency
Check for normal
breathing
• Using look, listen, and
feel technique for not
more than 10 sec.
Check circulation
No signs of life
Unresponsive
Determination of signs of
life
Call
resuscitation
team
Cardiac arrest
confirmation
Unresponsive
Determination of signs of
life
Call
resuscitation
team
CPR 30:2
Until
defibrillator/monitor is
attached
Chest compression
30:2
Compressions
Centre of chest
5-6 cm depth
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
Quick Evaluation of
rhythm
Conduct ECG, classic
electrodes, or self adhesive
electrodes.
Quick Evaluation of
rhythm
Assess
rhythm
Shockable Non shockable
(VF/VT (PEA/
without pulse) Asystole)
Minimize Interruptions in Chest Compressions
Shockable rhythm(VF)
Bizarre irregular waveform
No recognisable QRS complexes
Random frequency and amplitude
Coarse/fine
Shockable rhytm(VT)
Broad complex rhythm
Rapid rate
Constant QRS morphology
Monomorphic / polymorphic
Shockable
rhythm(VF/pulseless VT )
Assess
rhythm
Shockable First defibrillation
(VF/VT without pulse)
• 150-200 J biphasic
• 360 J monophasic
1 Shock
150-200 J Biphasic Continue CPR for the
or 360 J Monophasic
next 2 min
Immediately resume
CPR 30:2
2 min.
If VF / VT persists
Deliver 2nd shock 2nd and subsequent
shocks
• 200 – 360 J biphasic
CPR for 2 min
• 360 J monophasic
Deliver 3rd shock
Give adrenaline and
amiodarone after 3rd shock
during CPR
CPR for 2 min
During CPR
Adrenaline 1 mg IV
Amiodarone 300 mg IV
Non-shockable (Asystole)
Absent ventricular (QRS) activity
Atrial activity (P waves) may
persist
Rarely a straight line trace
Non-shockable (Pulseless
Electrical Activity)
Clinical features of
cardiac arrest
ECG normally
associated with an
output
Non-shockable
(PEA/Asystole)
Assess
rhythm
During CPR
• Check for electrode Non shockable
(PEA/ Asystole)
connection
• Adrenaline 1 mg IV then
every 3-5 min
Immediately resume
CPR 30:2
2 min.
Airway and ventilation
during CPR
Secure airway:
Supraglottic airway device e.g.
LMA, LT, 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
Key points during CPR
Ensure high-quality CPR: rate, depth, recoil
Plan actions before interrupting CPR
Give oxygen
Consider advanced airway
With advanced airway, compressions at 100-120/min ventilations
at 10-12 breaths /min
Vascular access (intravenous, intraosseous)
Drugs in peripheral lines- 20 ml chase fluids and elevate limb
Give adrenaline every 3-5 min
Avoid provider fatigue by rotation
Rule out the 4Hs and 4Ts reversible causes
Reversible causes
Hypoxia
Ensure patent airway
Give high-flow
supplemental oxygen
Avoid hyperventilation
Hypovolaemia
Seek evidence of
hypovolaemia
History
Examination
• Internal haemorrhage
• External haemorrhage
• Check surgical drains
Control haemorrhage
If hypovolaemia
suspected give
intravenous fluids
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
Hypothermia
Rare if patient is an
in-patient
Use low reading
thermometer
Treat with active
rewarming techniques
Consider
cardiopulmonary bypass
Tension pneumothorax
Check tube position if
intubated
Clinical signs
Decreased breath
sounds
Hyper-resonant
percussion note
Tracheal deviation
Initial treatment with
needle decompression or
tube thoracostomy
Cardiac tamponade
Difficult to diagnose
without
echocardiography
Consider if penetrating
chest trauma or after
cardiac surgery
Treat with needle
pericardiocentesis or
resuscitative
thoracotomy
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
Toxins
Rare unless evidence of
deliberate overdose
Review drug chart
Immediate post-cardiac arrest
treatment
Use ABCDE approach
Controlled oxygenation
and ventilation
12 lead ECG
Treat precipitating cause
Temperature control /
therapeutic hypothermia
Any
questions
Summary
The ALS algorithm
Treatment of shockable and
non-shockable rhythms
Administration of drugs
during cardiac arrest
Potentially reversible causes
of cardiac arrest
post-cardiac arrest
treatment
