als algorithm. the als algorithm importance of high quality chest compressions treatment of...
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ALS Algorithm
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• 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
Learning outcomes
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Adult ALS Algorithm
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• Patient response
• Open airway
• Check for normal breathing• Caution agonal breathing
• Check circulation • at same time as breathing
• Monitoring
To confirm cardiac arrest…Unresponsive?Not breathing or
only occasional gasps
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Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
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Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
CPR 30:2Attach defibrillator / monitor
Minimise interruptions
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Chest compression
• 30:2• Compressions
• Centre of chest• Min 5-6 cm depth/one third total• 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
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Shockable and Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
START Charge Defibrillator
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
CPR
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• 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
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Shockable (VT)Shockable
(VT)
• Polymorphic VT• Torsade de pointes
• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology
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Shockable (VF / VT)
Shout “(Compressions Continue) Stand Clear”
Assessrhythm
Shockable
(VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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Shockable (VT)
CHARGE DEFIBRILLATOR
Assessrhythm
Shockable
(VF / VT)
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Shockable (VT)
Assessrhythm
Shockable
(VF / VT)
Shout “Hands Off”
CHARGE DEFIBRILLATOR
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Shockable (VF / VT)
Assessrhythm
Shockable
(VF / VT)
Confirmed Hands Off“I’m Safe”
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Shockable (VF / VT)
DELIVER SHOCK
Assessrhythm
Shockable
(VF / VT)
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Shockable (VF / VT)
IMMEDIATELY RESTART CPR
Assessrhythm
Shockable
(VF / VT)
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Shockable (VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assessrhythm
Shockable
(VF / VT)
IMMEDIATELY RESTART CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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• 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
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Special Circumstances
Well perfused and oxygenated patient pre-arrest Presenting arrest shockable
• Three stacked shocks•First shock delivered within 20 seconds of onset of arrest
• Precordial thump•Pulseless VT only•Defibrillator unavailable •Delivered within 20 seconds of onset of arrest
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• 2nd and subsequent shocks• 150 – 360 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
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Non-Shockable
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
DUMP/DISCHARGE
ENERGY
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• 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)
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• 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)
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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 cycle)• Amiodarone 300 mg after 3rd shock Non Shockable• Adrenaline 1 mg immediately (then every 2nd cycle)
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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
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Vascular access
• Peripheral versus central veins
• Intraosseous
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Reversible causes
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Hypoxia
• Ensure patent airway
• Give high-flow supplemental oxygen
• Avoid hyperventilation
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Hypovolaemia
• Seek evidence of hypovolaemia• History• Examination
- Internal haemorrhage- External haemorrhage- Check surgical drains
• Control haemorrhage
• If hypovolaemia suspected give intravenous fluids
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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
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Hypothermia
• Rare if patient is an in-patient
• Use low reading thermometer
• Treat with active rewarming techniques
• Consider cardiopulmonary bypass
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Hyperthermia• Heat stroke can
resemble septic shock
• Core temp >40.6 C
• Rhabdomyolysis, coagulopathy issues
• Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm
• Rapid cooling to 39 C (similar approaches/techniques to hypothermia)
• Large fluid volumes• Correct electrolyte
abnormalities/acidosis• Dantrolene for some
MDMA/anaesthetic agent reactions
• No specific medications for heat stroke effective
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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
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Tamponade, cardiac
• Difficult to diagnose without echocardiography
• Consider if penetrating chest trauma or after cardiac surgery
• Treat with needle pericardiocentesis or resuscitative thoracotomy
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Toxins
• Rare unless evidence of deliberate overdose
• Review drug chart
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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
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Ultrasound
• In skilled hands may identify reversible causes
• Obtain images during rhythm checks
• Do not interrupt CPR
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Immediate post-cardiac arrest treatment
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Resuscitation team
• Roles planned in advance• Identify team leader• Importance of non-technical skills
• Task management• Team working• Situational awareness• Decision making
• Structured communication
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Any questions?
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• 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
Summary
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Advanced Life Support Course Slide set
All rights reserved© Australian Resuscitation Council and Resuscitation Council (UK) 2010