Updated 2015 als algorythm

Updated 2015

Reversible Causes

• Hypovolemia is the IV drip running? Any bleeding? Sign of dehydration• Hypoxia O2 connected? How’s bagging? Chest rise?• Hydrogen ion (acidosis) VBG/ABG?• Hypo-/hyperkalemia RP/K+ level?• Hypothermia Temperature?• Tension pneumothorax trachea central? Hyper-resonance? No air entry?• Tamponade, cardiac Ultrasound? Beck’s triad?• Toxins history from witness?• Thrombosis, pulmonary history? Risk factor? Ultrasound?• Thrombosis, coronary history? ECG prior (if any)?

AHA 2015 Guidelines Recommendations

• When supplementary oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR.• Evidence for possible detrimental effects of hyperoxia in the immediate post-cardiac arrest period should not be extrapolated to CPR context.Post-CPR:• When resources are available to titrate FiO2, it is reasonable to decrease FiO2 when SaO2 is 100% provided the SaO2 is maintained at 94% or greater.

Mechanisms of Injury of Hyperoxia

• Hyperoxia induce vasoconstriction by acting directlyon L-type Ca2+ channels.• Hyperoxia increases releases of angiotensin II– AT II promotes endothelin-1 release ! vasoconstriction.• Hyperoxia increases 20-hydroxyeicosatetraeonic acid (20-HETE)– 20-HETE is an arachidonic acid metabolite and a potent vasoconstrictor

Standard dose adrenaline

• Standard-dose epinephrine (1 mg every 3 to 5minutes) may be reasonable for patients in cardiac arrest (Class IIb, LOE B-R).

• High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III: No Benefit,LOE B-R).

Early adrenaline?

• For initial non-shockable rhythm: It may be reasonable to administer adrenaline as soon as feasible after the onset of cardiac arrest (Class IIb,LOE C-LD).

• For initial shockable rhyhtm: There is insufficient evidence to make a recommendation as to the optimal timing of adrenaline, particularly in relation to defibrillation

Amiodarone & lidocaine

• Amiodarone may be considered for VF/pVT that is unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb, LOE B-R).

• Lidocaine may be considered as an alternative to amiodarone for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb, LOE C-LD).

IV access

• “…none (of the antiarrhythmics) have yet been proven to increase long term survival or survival with good neurologic outcome. Thus establishing vascular access to enable drug administration should not compromise the quality of CPR or timely defibrillation, which are known to improve survival.”

FOCUS ECHOCARDIOGRAPHIC EVALUTION IN LIFE SUPPORT = FEEL

Ultrasound (cardiac or noncardiac )may beconsidered during the management of

cardiac arrest, although its usefulness hasnot been well established (Class IIb, LOE CEO).

If a qualified sonographer is present anduse of ultrasound does not interfere with thestandard cardiac arrest treatment protocol,

then ultrasound may be considered as anadjunct to standard patient evaluation (Class

IIb, LOE C-EO).

Hypothermia post ROSC

“…..Nevertheless, it is important to acknowledgethat there may be a clinically relevant benefit ofcontrolling the body temperature at 36°C, instead of allowing fever to develop in patients who have been resuscitated after cardiac arrest.”- No fever please.

• Updated 2015:-Dr Sazwan RS- Dr K.S. Chew (slidesharing)