ALS Algorithm

ALS Algorithm Learning outcomes • 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 • Role of resuscitation team Resuscitation team • Roles planned in advance • Identify team leader • Importance of non-technical skills • • • • Task management Team working Situational awareness Decision making • Structured communication 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… Chain of survival Early recognition prevents: • Cardiac arrests and deaths • Admissions to ICU • Inappropriate resuscitation attempts Adult ALS Algorithm Unresponsive? To confirm cardiac arrest… Not breathing or only occasional gasps • Patient response • Open airway • Check for normal breathing • Caution agonal breathing • Check circulation • Monitoring Unresponsive? Cardiac arrest confirmed Not breathing or only occasional gasps Call resuscitation team 2222 Unresponsive? Cardiac arrest confirmed Not breathing or only occasional gasps Call resuscitation team CPR 30:2 Attach defibrillator / monitor Minimise interruptions 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 Shockable and Non-Shockable START PAUSE Shockable (VF / Pulseless VT) CPR Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Shockable Shockable (VF) (VF) • Bizarre irregular waveform • No recognisable QRS • complexes Random frequency and amplitude • Uncoordinated electrical • • activity Coarse/fine Exclude artefact • Movement • Electrical interference Shockable Shockable (VT) (VT) • Monomorphic VT • Broad complex rhythm • Rapid rate • Constant QRS morphology • Polymorphic VT • Torsade de pointes Shockable Shockable (VF / VT) (VF / VT) RESTART CPR Assess rhythm Shockable Shockable (VT) (VF / VT) CHARGE DEFIBRILLATOR Assess rhythm Shockable Shockable (VF / VT) (VF / VT) DELIVER SHOCK Assess rhythm Shockable Shockable (VF / VT) (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm Shockable Shockable (VF / VT) (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm MINIMISE MINIMISE INTERRUPTIONS INTERRUPTIONS IN IN CHEST CHEST COMPRESSIONS COMPRESSIONS If VF / VT persists Deliver 2nd shock • 2nd and subsequent shocks CPR for 2 min Deliver 3rd shock CPR for 2 min During CPR Adrenaline 1 mg IV Amiodarone 300 mg IV • 150 – 360 J biphasic • 360 J monophasic • Give adrenaline and amiodarone after 3rd shock during CPR Non-Shockable Shockable (VF / Pulseless VT) Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Non-Shockable Non-shockable (Asystole) (Asystole) • Absent ventricular (QRS) activity • Atrial activity (P waves) may persist • Rarely a straight line trace • Adrenaline 1 mg IV then every 3-5 min Non-Shockable Non-shockable (Asystole) (PEA) • Clinical features of cardiac arrest • ECG normally associated with an output • Adrenaline 1 mg IV then every 3-5 min Treatment of shockable rhythms (VF/VT) • Confirm cardiac arrest – check for signs of life and normal breathing, and if trained to do so check for breathing and a pulse simultaneously. • Call resuscitation team. • Perform uninterrupted chest compressions while applying selfadhesive defibrillation/monitoring pads – one below the right clavicle and the other in the V6 position in the midaxillary line. • Plan actions before pausing CPR for rhythm analysis and communicate these to the team. • Stop chest compressions; confirm VF/pVT from the ECG. This pause in chest compressions should be brief and no longer than 5 seconds. • Resume chest compressions immediately; warn all rescuers other than the individual performing the chest compressions to “stand clear” and remove any oxygen delivery device as appropriate. Treatment of shockable rhythms (VF/VT) Continue • The designated person selects the appropriate energy on the defibrillator and presses the charge button. Choose an energy setting of at least 150 J for the first shock, the same or a higher energy for subsequent shocks, or follow the manufacturer’s guidance for the particular defibrillator. If unsure of the correct energy level for a defibrillator choose the highest available energy. • Ensure that the rescuer giving the compressions is the only person touching the patient. • Once the defibrillator is charged and the safety check is complete, tell the rescuer doing the chest compressions to “stand clear”; when clear, give the shock. • After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest compressions. Do not pause to reassess the rhythm or feel for a pulse. The total pause in chest compressions should be brief and no longer than 5 seconds. • Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR. • Pause briefly to check the monitor. • If VF/pVT, repeat steps 6–12 above and deliver a second shock. Treatment of shockable rhythms (VF/VT) Continue • If VF/pVT persists, repeat steps 6–8 above and deliver a third shock. Resume chest compressions immediately. Give adrenaline 1 mg IV and amiodarone 300 mg IV while performing a further 2 min CPR. Withhold adrenaline if there are signs of return of spontaneous circulation (ROSC) during CPR. • Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/pVT persists. • Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5 min). • If organised electrical activity compatible with a cardiac output is seen during a rhythm check, seek evidence of ROSC (check for signs of life, a central pulse and endtidal CO2 if available). • If there is ROSC, start post-resuscitation care. • If there are no signs of ROSC, continue CPR and switch to the non-shockable algorithm. • If asystole is seen, continue CPR and switch to the non shockable algorithm. Treatment of shockable rhythms (VF/VT) Continue • The designated person selects the appropriate energy on the defibrillator and presses the charge button. Choose an energy setting of at least 150 J for the first shock, the same or a higher energy for subsequent shocks, or follow the manufacturer’s guidance for the particular defibrillator. If unsure of the correct energy level for a defibrillator choose the highest available energy. • Ensure that the rescuer giving the compressions is the only person touching the patient. • Once the defibrillator is charged and the safety check is complete, tell the rescuer doing the chest compressions to “stand clear”; when clear, give the shock. • After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest compressions. Do not pause to reassess the rhythm or feel for a pulse. The total pause in chest compressions should be brief and no longer than 5 seconds. • Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR. • Pause briefly to check the monitor. • If VF/pVT, repeat steps 6–12 above and deliver a second shock. Treatment of PEA and asystole • Start CPR 30:2 • Give adrenaline 1 mg IV as soon as intravascular access is achieved • Continue CPR 30:2 until the airway is secured – then continue chest compressions without pausing during ventilation • Recheck the rhythm after 2 min: • a. If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life i. If a pulse and/or signs of life are present, start post resuscitation care ii. If no pulse and/or no signs of life are present (PEA OR asystole): • Continue CPR • Recheck the rhythm after 2 min and proceed accordingly • Give further adrenaline 1 mg IV every 3–5 min (during alternate 2-min loops of CPR) • b. If VF/pVT at rhythm check, change to shockable side of algorithm. During CPR 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, 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 • Capnography Vascular access • Peripheral versus central veins • Intraosseous Reversible causes Hypoxia • Ensure patent airway • Give high-flow supplemental oxygen • Avoid hyperventilation 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 thoracostomy Tamponade, cardiac • Difficult to diagnose without echocardiography • Consider if penetrating chest trauma or after cardiac surgery • Treat with needle pericardiocentesis or resuscitative thoracotomy Toxins • Rare unless evidence of deliberate overdose • Review drug chart 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 Ultrasound • In skilled hands may identify reversible causes • Obtain images during rhythm checks • Do not interrupt CPR Immediate post-cardiac arrest treatment Any questions? Summary • 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 • Role of resuscitation team