ALS Recertification Course

ARC ALS level 2/ALS

Course Health & SafetyRequirement to Cover

Report Pre-existing Injury

or

Injury Sustained During Course Immediately

Latex or Other Allergy

Defibrillator Safety

• Standardised CPR for adults

• Update on clinical changes to resuscitation guidelines

• Re-evaluation of knowledge and practical skills acquisition

• Assessment

ALS recertification course learning outcomes

ALS recertification course format

• Manual

• Lectures

• Skill stations

• Cardiac Arrest Simulation (CAS) training

ALS recertification course assessment

• MCQ

• Practical skills (continuous assessment)• Airway management• Initial assessment and resuscitation

• Cardiac Arrest Simulation (CASTest)

• Provider certificate valid for 4 years

Causes and Prevention of Cardiac Arrest

Early recognition ofthe deteriorating patient

• Most arrests are predictable

• Deterioration prior to 50 - 80% of cardiac arrests

• Hypoxia and hypotension are common antecedents

• Delays in referral to higher levels of care

Recognition of the deteriorating patient -Early Warning Scoring Systems

Example Escalation Protocol based on early warning score (EWS)Total Early Warning Score Dictates:

•3-5 Inform Nurse in-charge

•6 Doctor to see within the hour

•7-8 Doctor to see within 30 minutes with senior doctor

•>8 Doctor to see within 15 minutes

Example of early warning scoring (EWS) system** From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7

The ABCDE approach to the deteriorating patient

Airway

Breathing

Circulation

Disability

Exposure

ALS Algorithm

• Patient response

• Open airway

• Check for normal breathing• Caution agonal breathing

• Check circulation

• Monitoring

To confirm cardiac arrest…Unresponsive?Not breathing or

only occasional gasps

Cardiac arrest confirmedUnresponsive?Not breathing or

only occasional gasps

Call resuscitation team

Cardiac arrest confirmedUnresponsive?Not breathing or

only occasional gasps

Call resuscitation team

CPR 30:2Attach defibrillator / monitor

Minimise interruptions

Chest compression• 30:2• Compressions

• Centre of chest• Min 5cm depth/one third total• Approximately 100min-1

- About 2 per second (not faster than 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

Adult ALS Algorithm

Resuscitation team

• Roles planned in advance• Identify team leader• Importance of non-technical skills

• Task management• Team working• Situational awareness• Decision making

• Structured communication

Shockable and Non-Shockable

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Charge START Defibrillator

Assessrhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

CPR

• Uncoordinated electrical activity

• Coarse/fine• Exclude artefact

• Movement• Electrical interference

Shockable (VF)Shockable

(VF)

• Bizarre irregular waveform• No recognisable QRS

complexes• Random frequency and

amplitude

Shockable (VT)Shockable

(VT)

• Polymorphic VT• Torsade de pointes

• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology

Shockable (VF / VT)

Shout “(Compressions Continue) Stand Clear”

Assessrhythm

Shockable

(VF / VT)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Shockable (VT)

CHARGE DEFIBRILLATOR

Assessrhythm

Shockable

(VF / VT)

Shockable (VT)

Assessrhythm

Shockable

(VF / VT)

Shout “Hands Off”

CHARGE DEFIBRILLATOR

Shockable (VF / VT)

Assessrhythm

Shockable

(VF / VT)

Confirmed Hands Off“I’m Safe”

Shockable (VF / VT)

DELIVER SHOCK

Assessrhythm

Shockable

(VF / VT)

Shockable (VF / VT)

IMMEDIATELY RESTART CPR

Assessrhythm

Shockable

(VF / VT)

Shockable (VF / VT)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Assessrhythm

Shockable

(VF / VT)

IMMEDIATELY RESTART CPR

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

• Vary with manufacturer

• Check local equipment• Defibrillator energy 200 Joules

• unless manufacturer demonstrates better outcomes with alternate energy level

• If unsure, deliver 200 Joules• DO NOT DELAY SHOCK

• Energy levels for defibrillators on this course…

Defibrillation energies

Special Circumstances

Well perfused and oxygenated patient pre-arrestPresenting arrest shockable

• Three stacked shocks•First shock delivered within 20 seconds of onset of arrest•Rapid charging defibrillator (<3 to 5 seconds)

• Precordial thump•Pulseless VT only•Defibrillator unavailable •Delivered within 20 seconds of onset of arrest

• 2nd and subsequent shocks• 200 J biphasic• 360 J monophasic

• Give adrenaline and after 2nd shock during CPR then alternate loops thereafter

• Give amiodarone after 3rd shock during CPR

If VF / VT persists

CPR for 2 minDuring CPR

Adrenaline 1 mg IV

CPR for 2 minDuring CPR

Amiodarone 300 mg IV

Deliver 2nd shock

Deliver 3rd shock

Non-Shockable

Assessrhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Non-Shockable

Assessrhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

DUMP/DISCHARGE

ENERGY

• Absent ventricular (QRS) activity• Atrial activity (P waves) may persist• Rarely a straight line trace

• Adrenaline 1 mg IV then every alternate loop

Non-shockable (Asystole)Non-Shockable

(Asystole)

• Clinical features of cardiac arrest• ECG normally associated with an output• Adrenaline 1 mg IV then every alternate loop

Non-shockable (Asystole)Non-Shockable

(PEA)

During CPRDuring CPR

Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO accessPlan actions before interrupting compressions

(e.g. charge manual defibrillator)Drugs

Shockable• Adrenaline 1 mg after 2ndshock (then every 2nd loop)• Amiodarone 300 mg after 3rd shock Non Shockable• Adrenaline 1 mg immediately (then every 2nd loop)

Airway and ventilation

• Secure airway:• Supraglottic airway device • 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

• Waveform capnography

Vascular access

• Peripheral versus central veins

• Intraosseous

Reversible causesHyperthermia

Hypokalaemia/metabolic

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• Haemorrhage not only cause

• 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

Hyperthermia (Core temp >40.6 C)

• Heat stroke can resemble septic shock

• Rhabdomyolysis, coagulopathy issues

• Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm

• Rapid cooling to 39 C (similar approaches/techniques to hypothermia)

• Large fluid volumes required

• Correct electrolyte abnormalities/acidosis

Tension pneumothorax

• Check tube position if intubated

• Clinical signs (some/all not be present peri-arrest)

• Decreased breath sounds• Hyper-resonant percussion note• Tracheal deviation

• Initial treatment with needle decompression or thoracostomy• Follow up with Chest Tube

Tamponade, cardiac

• Difficult to diagnose without echocardiography

• Consider if penetrating chest trauma or after cardiac surgery• Also:

- Recent Myocardial Infarct- Blunt Chest Trauma- Procedural – Cardiac

Catheter/Pacing Wire etcTreat with needle pericardiocentesis or resuscitative thoracotomy

Toxins

• Rare unless evidence of deliberate overdose

• Presenting history may give clues

• Review drug chart

• Toxicology screens take time

Thrombosis

• If high clinical probability for PE consider fibrinolytic therapy

If fibrinolytic therapy is given then consideration may be required for continuing CPR for up to 60-90 min

Ultrasound

• In skilled hands may identify reversible causes

• In particular Tamponade, Tension Pneumothorax Hypovolaemia, and Thrombosis

• Obtain images during rhythm checks and CPR

• Do not interrupt CPR

Post Resuscitation Care

Post resuscitation care

The goal is to restore:

• Normal cerebral function

• Stable cardiac rhythm

• Adequate organ perfusion

• Quality of life

• FOLLOW ABCDE approach

Post cardiac arrest syndrome

• Post cardiac arrest brain injury:• Coma, seizures, myoclonus

• Post cardiac arrest myocardial dysfunction

• Systemic ischaemia-reperfusion response• ‘Sepsis-like’ syndrome

• Persistence of precipitating pathology

Therapeutic hypothermiaWho to cool?

• Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC

• May benefit patients after non-shockable/in-hospital cardiac arrest

• Exclusions: severe sepsis, pre-existing medical coagulopathy

• Start as soon as possible and continue for 24 h

• Rewarm slowly 0.25oC h-1

Therapeutic hypothermiaPhysiological effects and complications

• Shivering: sedate +/- neuromuscular blocking drug

• Bradycardia and cardiovascular instability• Infection• Hyperglycaemia• Electrolyte abnormalities• Increased amylase values• Reduced clearance of drugs

Any questions?

• The ALS algorithm

• Importance of high quality chest compressions

• Treatment of shockable and non-shockable rhythms

• Administration of drugs during cardiac arrest

• Potentially reversible causes of cardiac arrest

• Resuscitation does not end with ROSC

• Role of resuscitation team

Summary

Peri-Arrest

Bradycardia / Tachyarrhythmia algorithm

Bradycardia algorithmIncludes rates inappropriately slow for haemodynamic state

Interim measures:

•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing

Interim measures:

•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing

Tachycardia algorithm (with pulse)

Tachycardia algorithm

Stable broad-complex tachycardia

Stable narrow-complex tachycardia

Any questions?

Summary

• Modifications to ALS are based upon current evidence

• Focus is on standardised CPR for adults

Advanced Life Support Recertification Course

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© Australian Resuscitation Council and Resuscitation Council (UK) 2010