ALS

Objectives Prevention of cardiac arrest Revision of BLS ALS algorithms - shockable ryhthms - non-shockable rhythms Potential reversible causes of cardiac arrest Safe debrillation (Zoll and AED) Practice ALS scenarios

Early recognition of the critically ill patient Most arrests are predictable Deterioration prior to 50 - 80% of cardiac arrests Hypoxia and hypotension are common antecedents Delays in referral to higher levels of care

Early recognition prevents: Call for help early!!!!! Early recognition prevents: Cardiac arrests and deaths Admissions to ICU, inappropriate resuscitations

Confirm cardiorespiratory arrest Check for danger Check for response - if unresponsive Call for help/met call – 666 at Liverpool Open airway Check for normal breathing Start CPR – 30 chest compressions, then 2 breaths (30:2) Attach AED/defib

Basic Life Support Compressions lower ½ sternum >/= 5 cm depth (1/3 depth chest) 100 min-1 Ratio 30:2 breaths until airway secured Avoid! Interruptions (<10 seconds) Provider fatigue (swap every cycle)

Airway and ventilation Oxygenation important NOT intubation No evidence that intubation improves outcome (& may interrupt compressions) Open airway, place Guedel then Bag-Valve mask ventilation is ok initially Met team may consider advanced airway: LMA (or ETT) Avoid hyperventilation (6-10/min max) Avoiding hyperventilation refers to making sure that large volumes and high rates are not used as these will increase intrathoracic pressure, reducing venous return and coronary perfusion.

Rhythm ? – Shockable or Non-Shockable

Shockable Ventricular Fibrillation: Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Uncoordinated electrical activity

Rhythm ? – Shockable or Non-Shockable

Shockable VT (monomorphic) broad complex regular rhythm rapid rate constant QRS morphology

Defibrillation Must be safe – live current!! –all hands off patient, 02 away Energy varies with manufacturer - Check local equipment Biphasic (Zoll) give 200 J standard (can alter energy level manually) AED – automatic – set at 200J Must do 2 mins CPR after any shock before checking rhythm

Rhythm ? – Shockable or Non-Shockable

Non-shockable Asystole: Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace

Non-shockable Pulseless electrical activity: Clinical features of cardiac arrest ECG normally associated with an output

CORRECT REVERSIBLE CAUSES Hypoxaemia Hypovolaemia Hypo/hyperthermia Hypo/hyperkalaemia & other metabolic disorders Tamponade Tension pneumothorax Toxins / Poisons / Drugs Thrombus - pulmonary / coronary

Adrenaline Dose: 1mg IV VF/VT – give after 2nd shock Non VF/VT – give immediately Repeat every 3-5 min ie alternate cycles

Any questions

Summary ALS algorithm provides a standardised approach to the treatment of cardiac arrest in adults Shockable rhythms (VF/pulseless VT) Non-shockable rhythms Reversible causes of cardiac arrest Common drugs used