The ALS Algorithm
and Post Resuscitation
Care
CNHE - Ballarat Health Services
Valid from 1st March 2016 to 31st June 2018
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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+ -200 joules
Defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT (ARC, 2010).
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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
COACHED
Continue Chest Compressions
Oxygen Away
All Else Clear
Charging
Hands Off
Evaluate the Rhythm – Shockable vs. Non-
Shockable
Defibrillate or Disarm
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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
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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 - 200 joules)
Adrenaline 1 mg - repeat 4 minutely
Immediate CPR for 2 minutes
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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.
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Reversible Causes
4 H’s Hyper/ Hypokalaemia
Hyper/ Hypothermia
Hypovolaemia
Hypoxia
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Reversible Causes
4 T’s Tension pneumothorax
Tamponade
Toxins
Thrombosis (pulmonary/ coronary)
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 arrest12
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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.
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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)
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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 10-12 breaths per minute Paediatric
Avoid hyperventilation - aim for normocarbia
(PaCO2 35 - 40 mmHg)
Do not pause for ventilation when an advanced
airway is insitu
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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 co-
ordinated by team leader
DO NOT delay chest compressions to recheck
rhythm
Charge Defib while doing chest compressions
(COACHED)
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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 32-36 degrees for 24 hours
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Post Resuscitation Care
Principles
Avoid hypotension
Avoid hyperventilation - ventilate to
normocarbia CO2 (e.g. 35-40mmHg)
Avoid hyperglycaemia/hypoglycaemia
Avoid hyperthermia
Treat seizures
Treat underlying causes
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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
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Post Arrest Care – Therapeutic
Hypothermia (BHS CPG/T014)
Unconscious adult patients with return of
spontaneous circulation should be cooled to 32
- 360 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 O2 consumption - use
sedation and muscle relaxants
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Therapeutic Hypothermia
Cool by
Fans
Ice to axillae, groin and neck
Infusion of IV Hartmann’s at 40C over 30-60 minutes to reduce core temperature ( BHS CPG/T014)
Monitor by
Bladder IDC probe
Rectal probe
Oesophageal NGT probe
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SUMMARY
Things to take away…
1. Ensure effective ventilation and avoid
hyperventilation
2. Early defibrillation improves survival
outcome
3. Minimise interruptions during chest
compressions
Any attempt at
resuscitation is better
than no attempt
Australian Resuscitation Council,
(2016)