Download Shockable - the Australian Resuscitation Council

ALS Recertification Course
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
Outcome after in-hospital
cardiac arrest
VF/VT
Non-VF/VT
Number of patients
570 (18%)
2,614 (82%)
ROSC > 20 min
385 (68%)
689 (26%)
Survival to hospital discharge
251 (44%)
179 (7%)
Source: UK National Cardiac Arrest Audit (NCAA) 2010
•No national data for Australia
•Pockets of data report similar results
•Development of Clinical Indicators/Audits by Australian Council on Healthcare
Standards (
ACHS) and Australian Commission on Safety and Quality in Health Care
(ACSQHC) will provide future results
Recognition of the deteriorating patient Early Warning Scoring Systems
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
Recognition of the deteriorating patient Early Warning Scoring Systems
Example Escalation Protocol based on early warning score (EWS)
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
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
• 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
• 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
• Heat stroke can
• Rapid cooling to 39 C
resemble septic shock
• Core temp >40.6 C
• Rhabdomyolysis,
coagulopathy issues
• Consider Drug toxicity,
MDMA, malignant
hyperthermia, thyroid
storm
•
•
(similar
approaches/techniques to
hypothermia)
Large fluid volumes
Correct electrolyte
abnormalities/acidosis
Medications:
• No effective medications for heat
stroke
• Dantrolene for some
anaesthetic/MDMA reactions
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 given
then consideration for
continuing CPR for up to
60-90 min before halting
resuscitation attempts
Ultrasound
• In skilled hands may
identify reversible
causes
• In particular Tamponade,
Tension Pneumothorax and
Thrombosis
• Obtain images during
rhythm checks
• Do not interrupt CPR
Immediate post-cardiac arrest treatment
Resuscitation team
• Roles planned in advance
• Identify team leader
• Importance of non-technical skills
•
•
•
•
Task management
Team working
Situational awareness
Decision making
• Structured
communication
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
• Role of resuscitation team
Peri-Arrest
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
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© Australian Resuscitation Council and Resuscitation Council (UK) 2010