ALS : Advanced Life Support

 To confirm cardiac arrest…

 Patient response
 Open airway
 Check for normal breathing : Caution agonal breathing
 Check circulation
 Monitoring
 Chest compression
 30:2
 Compressions
 Centre of chest(the middle of the lower half of the sternum)
 5-6 cm depth
-1
 2 per second (100-120 min )
 Maintain high quality compressions with minimal interruptions
 Continuous compressions once airway secured
 Switch CPR provider every 2 min cycle to avoid fatigue
 Shockable and Non-Shockable
 Shockable VF Shockable VT

 Uncoordinated electrical activity  Monomorphic VT

 Coarse/fine Broad complex rythm
 Exclude artefact Constant QRS morphology
Movement  Polymorphic VT
Electrical interference Torsade de pointes
 Bizarre irregular waveform
 No recognisable QRS complexes
 Random frequency and amplitude

 Defibrillation energies
 Vary with manufacturer
 Check local equipment
 If unsure, deliver highest available energy
 DO NOT DELAY SHOCK
 Energy levels for defibrillators on this course…
2nd and subsequent shocks
150 – 360 J biphasic
360 J monophasic

 If VF / VT persists 

Non-shockable (Asystole) Non-shockable (Pulseless Electrical Activity)

 Absent ventricular (QRS) activity  Clinical features of cardiac arrest

 Atrial activity (P waves) may persist  ECG normally associated with an output
 Rarely a straight line trace  Adrenaline 1 mg IV then every 3-5 min
 Adrenaline 1 mg IV then every 3-5 min
During CPR
 Ensure high-quality CPR: rate, depth, recoil
 Plan actions before interrupting CPR
 Give oxygen
 Consider advanced airway and capnography
 Continuous chest compressions when advanced airway in place
 Vascular access (intravenous, intraosseous)
 Give adrenaline every 3-5 min
 Correct reversible causes
  Airway and ventilation
 Secure airway:
Supraglottic airway device e.g. LMA, LT,
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
 Vascular access
 Peripheral versus central veins
 Intraosseous
 Reversible causes
 Hypoxia  Tension pneumothorax
 Ensure patent airway  Check tube position if intubated
 Give high-flow supplemental oxygen  Clinical signs
 Avoid hyperventilation  Decreased breath sounds
 Hypovolaemia  Hyper-resonant percussion note
 Seek evidence of hypovolaemia  Tracheal deviation
 History & Examination  Initial treatment with needle decompression or
 Internal haemorrhage & External thoracostomy
haemorrhage  Tamponade, cardiac
 Check surgical drains  Difficult to diagnose without echocardiography
 Control haemorrhage  Consider if penetrating chest trauma or after
 If hypovolaemia suspected give intravenous fluids cardiac surgery
 Hypo/hyperkalaemia and  Treat with needle pericardiocentesis or
metabolic disorders resuscitative thoracotomy
 Near patient testing for K+ and glucose  Toxins
 Check latest laboratory results  Rare unless evidence of deliberate overdose
 Hyperkalaemia  Review drug chart
 Calcium chloride  Thrombosis
 Insulin/dextrose
 If high clinical probability for PE consider fibrinolytic
 Hypokalaemia/ Hypomagnesaemia
therapy
 Electrolyte supplementation
 If fibrinolytic therapy given continue CPR for up to
 Hypothermia 60-90 min before discontinuing resuscitation
 Rare if patient is an in-patient
 Use low reading thermometer
 Treat with active rewarming techniques
 Consider cardiopulmonary bypass