lecture als algorithm. learning outcomes the als algorithm importance of high quality chest...
TRANSCRIPT
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Lecture
ALS Algorithm
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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
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Adult ALS Algorithm
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To confirm cardiac arrest…
Patient response
Open airway
Check for normal breathing– Caution agonal
breathing
Check circulation
Monitoring
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Cardiac arrest confirmed
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Cardiac arrest confirmed
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Chest compression
30:2Compressions– Centre of chest– 5-6 cm depth– 2 per second (100-120 min-
1)
Maintain high quality compressions with minimal interruptionsContinuous compressions once airway securedSwitch CPR provider every 2 min cycle to avoid fatigue
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Shockable and Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
START PAUSE
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
CPR
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Shockable (VF)
Uncoordinated electrical activityCoarse/fineExclude artefact– Movement– Electrical interference
Bizarre irregular waveformNo recognisable QRS complexesRandom frequency and amplitude
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Shockable (VT)
Monomorphic VT– Broad complex rythm– Rapif rate– Constant QRS morphology
Polymorphic VT– Torsade de pointes
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Shockable (VF / VT)
RESTARTCPR
Assessrhythm
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Shockable (VT)
CHARGE DEFIBRILLATOR
Assessrhythm
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Shockable (VF / VT)
DELIVER SHOCK
Assessrhythm
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Shockable (VF / VT)
IMMEDIATELY RESTART CPR
Assessrhythm
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Shockable (VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assessrhythm
IMMEDIATELY RESTART CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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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…
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If VF / VT persists
2nd and subsequent shocks– 150 – 360 J biphasic– 360 J monophasic
Give adrenaline and amiodarone after 3rd shock during CPR
CPR for 2 min
CPR for 2 minDuring CPR
Adrenaline 1 mg IVAmiodarone 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
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Non-shockable (Asystole)
Absent ventricular (QRS) activityAtrial activity (P waves) may persistRarely a straight line trace
Adrenaline 1 mg IV then every 3-5 min
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Non-shockable (Pulseless Electrical Activity)
Clinical features of cardiac arrestECG normally associated with an outputAdrenaline 1 mg IV then every 3-5 min
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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
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Airway and ventilation
Secure airway:– Supraglottic airway device e.g. LMA, LT, 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 andmetabolic disorders
Near patient testing for K+ and glucoseCheck latest laboratory resultsHyperkalaemia– 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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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 advanceIdentify team leaderImportance of non-technical skills– Task management– Team working– Situational awareness– Decision making
Structured communication
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Any questions?
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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