ARC Advanced Life Support Level 1:Immediate Life Support Course

Recertification Course

Course Health & SafetyRequirement to Cover

Report Pre-existing Injury

or

Injury Sustained During Course Immediately

Latex or Other Allergy

Defibrillator Safety

By the end of this course the candidate will have refreshed:

•Recognition and assessment of the deteriorating patient

•Prevention of cardiac arrest

•Know when to commence CPR measures

•Performing standardised CPR for adults

•Performing safe defibrillation (AED and/or manual)

•Performing in the roles of resuscitation team members

ILS course learning outcomes

Chain of survival

Causes and Prevention of Cardiac Arrest

The ABCDE approach to the deteriorating patient

Airway

Breathing

Circulation

Disability

Exposure

ABCDE approach

Underlying principles:

• Complete initial assessment

• Treat life-threatening problems

• Reassessment

• Assess effects of treatment/interventions

• Call for help early

ABCDE approach

• Personal safety

• Patient responsiveness

• First impression

• Vital signs• Respiratory rate, SpO2, pulse, BP, GCS, temperature

ABCDE approachAirway

Recognition of airway obstruction:

• Talking

• Difficulty breathing, distressed, choking

• Shortness of breath

• Noisy breathing• Stridor, wheeze, gurgling

• See-saw respiratory pattern, accessory muscles

ABCDE approachAirway

Treatment of airway obstruction:

• Airway opening• Head tilt, chin lift, jaw thrust

• Simple adjuncts

• Advanced techniques• e.g. LMA, tracheal tube

• Oxygen

ABCDE approachBreathing

Recognition of breathingproblems:• Look

• Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level

• Listen • Noisy breathing, breath

sounds

• Feel • Expansion, percussion

ABCDE approachBreathing

Treatment of breathingproblems:• Airway

• Oxygen

• Treat underlying cause

• Support breathing if inadequate • e.g. ventilate with bag-mask

ABCDE approachCirculation

Recognition of circulation problems:

• Look at the patient• Pulse - tachycardia, bradycardia• Peripheral perfusion - capillary refill time• Blood pressure• Organ perfusion

• Chest pain, mental state, urine output

• Bleeding, fluid losses

Hypovolaemia

One of most common causes of crisis

Fluid loss not always obvious:•Haemorrhagic – blood loss external or within body•Distributive Shock - vasodilation•Cardiogenic Shock – myocardial insufficiency•Restrictive Shock – pericardial effusion•Obstructive Shock – Emboli•Relative Shock – anaemia

ABCDE approachCirculation

Treatment of circulation problems:

• Airway, Breathing• Oxygen if needed• IV/IO access, take bloods• Call for help• Treat cause• Fluid challenge

ABCDE approachCirculation

Acute Coronary Syndromes

• Unstable angina or myocardial infarction

• Treatment• Aspirin 300 mg orally (crushed/chewed)• Nitroglycerine (GTN spray or tablet if first dose ever)• Oxygen (guided by pulse oximetry if uncomplicated)

- Give if in shock/heart failure/Saturations indicate• Morphine (or fentanyl)

• Consider reperfusion therapy (PCI, thrombolysis)

ABCDE approachDisability

(Drugs/Diabetes/Documentation)

Recognition

• AVPU or GCS• Pupils• Blood sugar • Check drug chart• Check for any history

(documentation, alert jewellery)

Treatment

• ABC• Treat underlying cause• Blood glucose

• If < 4 mmol l-1 give glucose

• Consider lateral position

ABCDE approachExposure

• Remove clothes to enable examination• e.g. injuries, bleeding, rashes

• Check all • Look at and examine surface, orifice, extremity and

cavity

• Avoid excessive heat loss

• Maintain dignity

Advanced Life Support Algorithm

ALS algorithm

• ILS providers should use those skills in which they are proficient

• If using an AED – switch on and follow the prompts

• Ensure high quality chest compressions

• Ensure expert help is coming

Adult ALS Algorithm

• 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 oronly occasional gasps

Cardiac arrest confirmedUnresponsive?

Not breathing oronly occasional gasps

Call resuscitation team

Cardiac arrest confirmedUnresponsive?

Not breathing oronly occasional gasps

Call resuscitation team

CPR 30:2Attach defibrillator / monitor

Minimise interruptions

Chest compression

• 30:2• Compressions

• Centre of chest• Min 5 cm depth/one third total• approximately 100 min-1 (but no faster

than 120 min-1 - 2 per second )

• Maintain high quality compressions with minimal interruptions

• Continuous compressions once airway secured

• Switch compressions provider every 2 min cycle to avoid fatigue

Shockable and Non-Shockable

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

START Charge 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

Automated External Defibrillation

• If not confident in rhythm recognition use an AED

• Start CPR whilst awaiting AED to arrive

• Switch on and follow AED prompts

AED algorithm

• Follow AED prompts

• Will need to pause compressions for rhythm analysis

• Following shock immediately recommence compressions/CPR

Manual defibrillation• Plan all pauses in chest compressions

• Do chest compressions when charging

• Visual sweep to check bed area when charging

• Ensure no-one touches patient during shock delivery

• Pause in compressions to check rhythm

• Deliver shock (or Disarm/“Dump” charge)• Resume compressions immediately after the shock

• If no shock check patient/pulse

Shockable (VF / VT)

Shout “(Compressions Continue) Stand Clear”

Assessrhythm

Shockable

(VF / VT)

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

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 – During CPR

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

/Hyperthermia

/Hypokalaemia – metabolic disordersReversible 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 - waveform

Immediate post-cardiac arrest treatment

ISBAR• I = Identify• S = Situation• B = Background• A = Assessment

• Include specific observations and vital sign/observations values based on ABCDE approach

• R = Response/Requirement• State explicitly what you want the person you are calling

to do

Resuscitation team

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

communication• ISBAR or RSVP

Any questions?

• Aim to prevent need for resuscitation• Use the ABCDE approach to recognise and treat the

deteriorating patient

• Ensure high quality chest compressions with minimal interruption

• VF/pulseless VT are shockable rhythms

• PEA and asystole are non-shockable rhythms

• Ensure help on the way

Summary

Immediate Life Support Course Slide set

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