Lecture. ALS Algorithm

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1 Lecture ALS Algorithm 1

2 Learning outcomes The ALS algorithm Treatment of shockable and non-shockable rhythms Potentially reversible causes of cardiac arrest 2

3 Adult ALS Algorithm 3

4 To confirm cardiac arrest Unresponsive? Not breathing or only occasional gasps? Patient response Open airway Check for normal breathing Check circulation 4

5 To confirm cardiac arrest 5

6 Cardiac arrest confirmed 6

7 Shockable and Non-Shockable START PAUSE CPR Assess rhythm Shockable (VF / Pulseless VT) Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS 7

8 Shockable (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Uncoordinated electrical activity Coarse/fine Exclude artefact Movement Electrical interference 8

9 Shockable (VT) Monomorphic VT Polymorphic VT Broad complex rythm Torsade de pointes Rapid rate Constant QRS morphology 9

10 Shockable (VF / VT) STOP CPR RESTART CPR Assess rhythm 10

11 Shockable (VT) CHARGE DEFIBRILLATOR Assess rhythm 11

12 Shockable (VF / VT) DELIVER SHOCK Assess rhythm 12

13 Shockable (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm 13

14 Shockable (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS 14

15 Defibrillation energies 150 J 360 J biphasic (360 J monophasic) If unsure, deliver highest available energy DO NOT DELAY SHOCK 15

16 Persisting VF / VT (2 nd shock) 2nd and subsequent shocks J biphasic 360 J monophasic Assess rhythm MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS 16

17 Persisting VF / VT (3 rd shock) Give adrenaline and Amiodarone after 3 rd shock during CPR Assess rhythm MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS 17

18 Non-Shockable Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS 18

19 Non-Shockable (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 19

20 Non-shockable (Pulseless Electrical Activity) Clinical features of cardiac arrest ECG normally associated with an output Adrenaline 1 mg IV then every 3-5 min 20

21 During CPR 21

22 Resuscitation team Roles planned in advance Identify team leader Importance of non-technical skills Task management Team working Situational awareness Decision making Structured Communication 22

23 Reversible causes 23

24 Hypoxia Ensure patent airway Give high-flow supplemental oxygen Avoid hyperventilation 24

25 Hypovolaemia Seek evidence of hypovolaemia History Examination Internal haemorrhage External haemorrhage Check surgical drains Control haemorrhage If hypovolaemia suspected give intravenous fluids 25

26 Near patient testing for K + and glucose Check latest laboratory results Hyperkalaemia Calcium chloride Insulin/dextrose Hypokalaemia/ Hypomagnesaemia Electrolyte supplementation Hypo/hyperkalaemia and metabolic disorders 26

27 Hypothermia Rare if patient is an in-patient Use low reading thermometer Treat with active rewarming techniques Consider cardiopulmonary bypass 27

28 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 28

29 Tamponade, cardiac Difficult to diagnose without echocardiography Consider if penetrating chest trauma or after cardiac surgery Treat with needle pericardiocentesis or resuscitative thoracotomy 29

30 Toxins Rare unless evidence of deliberate overdose Review drug chart 30

31 Thrombosis If high clinical probability for PE consider fibrinolytic therapy If fibrinolytic therapy given continue CPR for up to min before discontinuing resuscitation 31

32 Ultrasound Do not interrupt CPR Obtain images during rhythm checks In skilled hands may identify reversible causes 32

33 Immediate post-cardiac arrest treatment 33

34 Any questions? 34

35 Summary The ALS algorithm Treatment of shockable and non-shockable rhythms Potentially reversible causes of cardiac arrest 35

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