Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
ALS Algorithm Learning outcomes • 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 Adult 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 • at same time as breathing • Monitoring Unresponsive? Not breathing or Cardiac arrest confirmed only occasional gasps Call resuscitation team Unresponsive? Not breathing or Cardiac arrest confirmed only occasional gasps Call resuscitation team CPR 30:2 Attach defibrillator / monitor Minimise interruptions Chest compression • 30:2 • Compressions • Centre of chest • Min 5-6 cm depth/one third total • 2 per second (100-120 min-1) • Maintain high quality • • compressions with minimal interruptions Continuous compressions once airway secured Switch CPR provider every 2 min cycle to avoid fatigue Shockable and Non-Shockable START Charge 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 / VT) (VF / 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 / VT) (VF / VT) Assess rhythm Confirmed Hands Off “I’m Safe” Shockable Shockable (VF / VT) (VF / VT) DELIVER SHOCK Assess rhythm Shockable Shockable (VF / VT) (VF / VT) IMMEDIATELY RESTART CPR Assess rhythm Shockable Shockable (VF / VT) (VF / 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 • 150 – 360 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 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 cycle) • Amiodarone 300 mg after 3rd shock Non Shockable • Adrenaline 1 mg immediately (then every 2nd cycle) Airway and ventilation • Secure airway: • Supraglottic airway device e.g. LMA, i-gel • 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 • Capnography Vascular access • Peripheral versus central veins • Intraosseous Reversible causes 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 Dantrolene for some MDMA/anaesthetic agent reactions No specific medications for heat stroke effective 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 Tamponade, cardiac • Difficult to diagnose without echocardiography • Consider if penetrating chest trauma or after cardiac surgery • Treat with needle pericardiocentesis or resuscitative thoracotomy Toxins • Rare unless evidence of deliberate overdose • Review drug chart Thrombosis • If high clinical probability for PE consider fibrinolytic therapy • If fibrinolytic therapy given continue CPR for up to 60-90 min before discontinuing resuscitation Ultrasound • In skilled hands may identify reversible causes • 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 Advanced Life Support Course Slide set All rights reserved © Australian Resuscitation Council and Resuscitation Council (UK) 2010