The ALS Algorithm and Post Resuscitation Care

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1 The ALS Algorithm and Post Resuscitation Care CET - Ballarat Health Services Valid from 1 st July 2018 to 30 th June 2020

2 2

3 Defibrillation Produces simultaneous mass depolarisation of myocardial cells and may enable resumption of organised electrical activity. Successful defibrillation is termination of Ventricular Fibrillation for greater than 5 seconds, a recognisable electrical rhythm, followed by spontaneous cardiac output Biphasic defibrillators: - Philips Heartstart MRx -200 joules -Philips Heartstart XL -200 joules -Lifepak -200 joules -Philips Heartstart XL joules Defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT (ARC, 2016). 3

4 Defibrillation easy as 1, 2, 3 Follow ARC approved ALS protocol at all times when manually defibrillating Step 1: Select energy (200J) Step 2: Press Charge soft key Step 3: Press soft key shock when a continuous high pitch audible sound is heard and the Shock symbol is flashing Use the COACHED principal to ensure safe defibilation 4

5 COACHED Continue Chest Compressions Oxygen Away All Else Clear Charging Hands Off Evaluate the Rhythm Shockable vs. Non- Shockable Defibrillate or Disarm 5

6 6

7 Monitored Arrest A precordial thump may be administered for pulseless VT if the defibrillator is not immediately available (within 15 seconds) Deliver 1 shock at the energy level determined by the manufacturer (BHS: Philips 200J) All subsequent shocks are delivered as single shocks 7

8 Shockable VF/Pulseless VT (unwitnessed / unmonitored) Defibrillation one shock (Philips -200 joules) Immediate CPR for 2 minutes Establish IV access If IV access not gained in 90sec I/O should be used Consider advanced airway management Defibrillation one shock (Philips joules) Adrenaline 1 mg - repeat 4 minutely Immediate CPR for 2 minutes 8

9 Shockable VF/Pulseless VT (unwitnessed / unmonitored) Consider antiarrhythmic post third shock Look for and treat reversible causes Consider electrolyte therapy Defibrillation one shock (Philips 200 joules) Continuous repeating of the sequence of defibrillation, CPR, adrenaline and resuscitation adjuncts until clear signs of life are apparent, or the multidisciplinary team considers any further resuscitation futile. 9

10 Reversible Causes 4 H s Hyper/ Hypokalaemia Hyper/ Hypothermia Hypovolaemia Hypoxia 10

11 Reversible Causes 4 T s Tension pneumothorax Tamponade Toxins Thrombosis (pulmonary/ coronary) 11

12 Reversible Causes Treat these as you consider them Hang fluids to address Hypovolaemia Ensure ventilation is adequate by auscultation The H s and T s are there to aid you in diagnosing and treating the underlying cause of the arrest It is important that you rule out all of these even if you have a good idea of the cause of the arrest 12

13 Non Shockable Pulseless Electrical Activity (PEA) / Asystole Immediate CPR for 2 minutes Establish IV access Consider advanced airway management 1 mg Adrenaline Immediately- then repeat 4 minutely Recheck rhythm & cardiac output after 2 minutes of CPR Rhythm check should not delay CPR Ensure the defib is fully charged before each rhythm check (COACHED) Correct reversible causes 4 H s & 4 T s Consider electrolyte therapy Consider pacing for asystole / bradycardia Continually repeat the sequence of CPR, adrenaline and resuscitation adjuncts until clear signs of life are apparent, or the multidisciplinary team considers any further resuscitation futile. 13

14 Reversible Causes H s & T s Hypovolaemia Hypoxaemia Hypo/Hyperthermia Hypo/Hyperkalaemia and other metabolic disorders Tension Pneumothorax Tamponade Thrombosis (Pulmonary/Coronary) Toxins (Poisons/Drugs/Anaphylaxis) 14

15 Secure Advanced Airway-Endotracheal Tube (ETT), Laryngeal Mask Airway (LMA) CPR should not be interrupted for more than 5 seconds to establish an airway Once advanced airway is insitu aim for a minimum speed of 100 chest compressions per minute and 8-10 breaths per minute Adult and breaths per minute Paediatric Avoid hyperventilation - aim for normocarbia (PaCO mmhg) Do not pause for ventilation when an advanced airway is insitu 15

16 Points of Emphasis for CPR / ALS At all times reduce hands off the chest time when resuscitating Minimise hands off the chest time when changing chest compression operator, needs to be coordinated by team leader DO NOT delay chest compressions to recheck rhythm Charge Defib while doing chest compressions (COACHED) 16

17 Post-resuscitation Care Aims continue respiratory support AIM SaO2 maintain cerebral perfusion treat and prevent cardiac arrhythmias determine and treat cause of the arrest Cool patient degrees for 24 hours 17

18 18

19 Post Resuscitation Care Principles Avoid hypotension Avoid hyperventilation - ventilate to normocarbia CO 2 (e.g mmHg) Avoid hyperglycaemia/hypoglycaemia Avoid hyperthermia Treat seizures Treat underlying causes 19

20 Post Resuscitation Care Commence an infusion of the antiarrhythmic that successfully restored a stable rhythm with output if appropriate. Amiodarone 300mg in 5%Glucose to total 100mls (3mg/ml) 15mg/kg for 12-24hours Lignocaine 1gm in 5%Glucose to total 100mls (10mg/ml) 2-4mg/min for 12-24hrs To prevent recurrent VF consider an antiarrhythmic infusion if not already in progress 20

21 Post Arrest Care Therapeutic Hypothermia (BHS CPG/T014) Unconscious adult patients with return of spontaneous circulation should be cooled to C for 24 hours Cooling should be instituted within 6 hours of ROSC (return of spontaneous circulation) Improves survival and neurological outcomes Shivering must be avoided increase metabolic rate and increases O 2 consumption - use sedation and muscle relaxants 21

22 Therapeutic Hypothermia Cool by Fans Ice to axillae, groin and neck Infusion of IV Hartmann s at 4 0 C over minutes to reduce core temperature ( BHS CPG/T014) Monitor by Bladder IDC probe Rectal probe Oesophageal NGT probe 22

23 SUMMARY Things to take away 1. Ensure effective ventilation and avoid hyperventilation 2. Early defibrillation improves survival outcome 3. Minimise interruptions during chest compressions 23

24 Any attempt at resuscitation is better than no attempt Australian Resuscitation Council, (2016)

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