Advanced Life
Support Algorithm
Emergency Medicine Department
FOM - SCUH
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
MET
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
Unresponsi
ve
Open airway
Determination of signs of Call
ALS life resuscitation
team
Algorith CPR 30:2
Until defibrillator/monitor
m is attached
Assess
rhythm
Shockable Non shockable
(VF/VT without (PEA/
pulse) During CPR
Asystole)
Ensure high-quality CPR: rate,
depth, recoil
Plan actions before interrupting
1 Shock CPR
150-200 J Biphasic Give oxygen
or 360 J Monophasic Consider advanced airway
Continuous chest compressions
when advanced airway in place
Immediately Vascular access (intravenous, Immediately
resume
intraosseous)
Give adrenaline every 3-5 min
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
(VF/VT shockable
without (PEA/
pulse) Asystole)
Minimize Interruptions in Chest
Compressions
Shockable rhythm(VF)
Bizarre irregular waveform
No recognisable QRS
complexes
Random frequency and
amplitude
Shockable rhytm(VT)
Broad complex rhythm
Rapid rate
Constant QRS morphology
1-Monomorphic /2- polymorphic
Shockable
rhythm(VF/pulseless
VT )
Assess
rhythm
Shockable
(VF/VT without
First defibrillation
pulse) • 150-200 J biphasic
• 360 J monophasic
1 Shock
150-200 J Biphasic
Continue CPR for
or 360 J Monophasic
the 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
Give adrenaline and
Deliver 3rd shock
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
Non shockable
• Check for electrode (PEA/
connection Asystole)
• Adrenaline only 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
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
4 Hs
4 Ts
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
Ex .opiod
ttt:naloxone
Immediate post-cardiac arrest treatment
Use ABCDE
approach
Controlled
oxygenation and
ventilation
12 lead ECG
Treat precipitating
cause
Temperature control
/ therapeutic
hypothermia
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
