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ALS Recertification Course ARC ALS level 2/ALS Course Health & Safety Requirement to Cover Latex or Other Allergy Report Pre-existing Injury or Injury Sustained During Course Immediately Defibrillator Safety ALS recertification course learning outcomes • Standardised CPR for adults • Update on clinical changes to resuscitation guidelines • Re-evaluation of knowledge and practical skills acquisition • Assessment ALS recertification course format • Manual • Lectures • Skill stations • Cardiac Arrest Simulation (CAS) training ALS recertification course assessment • MCQ • Practical skills (continuous assessment) • Airway management • Initial assessment and resuscitation • Cardiac Arrest Simulation (CASTest) • Provider certificate valid for 4 years Causes and Prevention of Cardiac Arrest Early recognition of the deteriorating 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 Recognition of the deteriorating patient Early Warning Scoring Systems Example Escalation Protocol based on early warning score (EWS) Total Early Warning Score Dictates: • 3-5 Inform Nurse in-charge • 6 Doctor to see within the Example of early warning scoring (EWS) system* * From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7 hour • 7-8 Doctor to see within 30 minutes with senior doctor • >8 Doctor to see within 15 minutes The ABCDE approach to the deteriorating patient Airway Breathing Circulation Disability Exposure ALS Algorithm Unresponsive? Not breathing or To confirm cardiac arrest… only occasional gasps • Patient response • Open airway • Check for normal breathing • Caution agonal breathing • Check circulation • Monitoring Unresponsive? Not breathing or only occasional gasps Cardiac arrest confirmed Call resuscitation team Unresponsive? Not breathing or only occasional gasps Cardiac arrest confirmed Call resuscitation team CPR 30:2 Attach defibrillator / monitor Minimise interruptions Chest compression • 30:2 • Compressions • Centre of chest • Min 5cm depth/one third total • Approximately 100min-1 - About 2 per second (not faster than 120 min-1) • Maintain high quality • • compressions with minimal interruptions Continuous compressions once airway secured Switch CPR provider every 2 min cycle to avoid fatigue Adult ALS Algorithm Resuscitation team • Roles planned in advance • Identify team leader • Importance of non-technical skills • • • • Task management Team working Situational awareness Decision making • Structured communication Shockable and Non-Shockable Charge START Defibrillator Shockable (VF / Pulseless VT) CPR Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Shockable Shockable (VF) (VF) • Bizarre irregular waveform • No recognisable QRS • complexes Random frequency and amplitude • Uncoordinated electrical activity • Coarse/fine • Exclude artefact • Movement • Electrical interference Shockable Shockable (VT) (VT) • Monomorphic VT • Broad complex rhythm • Rapid rate • Constant QRS morphology • Polymorphic VT • Torsade de pointes Shockable Shockable (VF / (VF / VT) VT) Shout “(Compressions Continue) Stand Clear” Assess rhythm MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Shockable Shockable (VT) (VF / VT) CHARGE DEFIBRILLATOR Assess rhythm Shockable Shockable (VT) (VF / VT) CHARGE DEFIBRILLATOR Assess rhythm Shout “Hands Off” Shockable Shockable (VF (VF / VT) / VT) Assess rhythm Confirmed Hands Off “I’m Safe” Shockable Shockable (VF (VF / VT) / VT) DELIVER SHOCK Assess rhythm Shockable Shockable (VF (VF / VT) / VT) IMMEDIATELY RESTART CPR Assess rhythm Shockable Shockable (VF (VF / VT) / VT) IMMEDIATELY RESTART CPR Assess rhythm MINIMISEINTERRUPTIONS INTERRUPTIONSIN INCHEST CHESTCOMPRESSIONS COMPRESSIONS MINIMISE Defibrillation energies • 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… Special Circumstances Well perfused and oxygenated patient pre-arrest Presenting 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 If VF / VT persists Deliver 2nd shock • 2nd and subsequent shocks • 200 J biphasic • 360 J monophasic CPR for 2 min During CPR Adrenaline 1 mg IV Deliver 3rd shock CPR for 2 min During CPR Amiodarone 300 mg IV • Give adrenaline and • after 2nd shock during CPR then alternate loops thereafter Give amiodarone after 3rd shock during CPR Non-Shockable Shockable (VF / Pulseless VT) Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS DUMP/DISCHARG Non-Shockable E ENERGY Shockable (VF / Pulseless VT) Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS Non-Shockable Non-shockable (Asystole) (Asystole) • 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 Non-shockable (Asystole) (PEA) • Clinical features of cardiac arrest • ECG normally associated with an output • Adrenaline 1 mg IV then every alternate loop During CPR During CPR Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO access Plan actions before interrupting compressions (e.g. charge manual defibrillator) Drugs Shockable • Adrenaline 1 mg after 2ndshock (then every 2nd loop) • Amiodarone 300 mg after 3rd shock Non Shockable • Adrenaline 1 mg immediately (then every 2nd loop) Airway and ventilation • Secure airway: • Supraglottic airway device • 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 • Waveform capnography Vascular access • Peripheral versus central veins • Intraosseous Reversible causes Hyperthermia Hypokalaemia/metabolic Hypoxia • Ensure patent airway • Give high-flow supplemental oxygen • Avoid hyperventilation Hypovolaemia • Seek evidence of hypovolaemia • History • Examination - Internal haemorrhage - External haemorrhage - Check surgical drains • Control haemorrhage • Haemorrhage not only cause • If hypovolaemia suspected give intravenous fluids Hypo/hyperkalaemia and metabolic disorders • Near patient testing for K+ and glucose • Check latest laboratory results • Hyperkalaemia • Calcium chloride • Insulin/dextrose • Hypokalaemia/ Hypomagnesaemia • Electrolyte supplementation Hypothermia • Rare if patient is an in-patient • Use low reading thermometer • Treat with active rewarming techniques • Consider cardiopulmonary bypass Hyperthermia (Core temp >40.6 C) • Heat stroke can resemble septic shock • Rapid cooling to 39 C (similar approaches/techniques to hypothermia) • Rhabdomyolysis, coagulopathy issues • Large fluid volumes required • Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm • Correct electrolyte abnormalities/acidosis Tension pneumothorax • Check tube position if intubated • Clinical signs (some/all not be present peri-arrest) • Decreased breath sounds • Hyper-resonant percussion note • Tracheal deviation • Initial treatment with needle decompression or thoracostomy • Follow up with Chest Tube Tamponade, cardiac • Difficult to diagnose without echocardiography • Consider if penetrating chest trauma or after cardiac surgery • Also: - Recent Myocardial Infarct - Blunt Chest Trauma - Procedural – Cardiac Catheter/Pacing Wire etc Treat with needle pericardiocentesis or resuscitative thoracotomy Toxins • Rare unless evidence of deliberate overdose • Presenting history may give clues • Review drug chart • Toxicology screens take time Thrombosis • If high clinical probability for PE consider fibrinolytic therapy If fibrinolytic therapy is given then consideration may be required for continuing CPR for up to 60-90 min Ultrasound • In skilled hands may identify reversible causes • In particular Tamponade, Tension Pneumothorax Hypovolaemia, and Thrombosis • Obtain images during rhythm checks and CPR • Do not interrupt CPR Post Resuscitation Care Post resuscitation care The goal is to restore: • Normal cerebral function • Stable cardiac rhythm • Adequate organ perfusion • Quality of life • FOLLOW ABCDE approach Post cardiac arrest syndrome • Post cardiac arrest brain injury: • Coma, seizures, myoclonus • Post cardiac arrest myocardial dysfunction • Systemic ischaemia-reperfusion response • ‘Sepsis-like’ syndrome • Persistence of precipitating pathology Therapeutic hypothermia Who to cool? • Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC • May benefit patients after non-shockable/in-hospital cardiac arrest • Exclusions: severe sepsis, pre-existing medical coagulopathy • Start as soon as possible and continue for 24 h • Rewarm slowly 0.25oC h-1 Therapeutic hypothermia Physiological effects and complications • Shivering: sedate +/- neuromuscular blocking • • • • • • drug Bradycardia and cardiovascular instability Infection Hyperglycaemia Electrolyte abnormalities Increased amylase values Reduced clearance of drugs Any questions? 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 • Resuscitation does not end with ROSC • Role of resuscitation team Peri-Arrest Bradycardia / Tachyarrhythmia algorithm Bradycardia algorithm Includes rates inappropriately slow for haemodynamic state Interim measures: • • • • Atropine 500 - 600 mcg IV repeat to maximum of 3 mg Isoprenaline 5 mcg min-1 IV Adrenaline 2-10 mcg min-1 IV Alternative drugs * OR • Transcutaneous pacing Tachycardia algorithm (with pulse) Tachycardia algorithm Stable broad-complex tachycardia Stable narrow-complex tachycardia Any questions? Summary • Modifications to ALS are based upon current evidence • Focus is on standardised CPR for adults Advanced Life Support Recertification Course Slide set All rights reserved © Australian Resuscitation Council and Resuscitation Council (UK) 2010