ADULT ALS

Question 1

What is ALS?

Answer 1

ALS builds on BLS to increase liklihood of survival of cardiac arrest

it takes over from BLS once chest compressions have commenced and a defib is attached.

It focuses on more advanced airway management, adding in drugs for shockable and non-shockable rhythms and correcting reversible causes of cardiac arrest

Question 2

what airway adjuncts may you use in ALS

Answer 2

oropharyngeal

nasopharyngeal

i-gel/LMA

endotracheal intubation

Question 3

what defined roles are there in ALS

Answer 3

Team leader
Timer and scribe
Airway
CPR1/defib
CPR2
IV access/bloods/gases/Drugs

Question 4

what rhythms are shockable rhythms

Answer 4

pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF)

Question 5

what should the team leader do?

Answer 5

delegate tasks
ask people to say when theyve completed a task/cycle
coordiante tasks
go through reversible causes

Question 6

in what circumstances should chest compressions be continuous

Answer 6

Chest compressions should be continuous once the airway is secured with endotracheal tube/ with an iGel

Question 7

under what circumstances/for what things do you pause compressions for

Answer 7

ONLY stop CPR for rhythm checks, electrical shocks, and the 2 rescue breaths. Ask the person doing compressions to tell the airway person each time 30 compressions are complete.

Question 8

what do you do with defib if pt has a pacemaker?

Answer 8

if a pacemaker is present, ensure pads are >8cm away from it (you can put the pads on AP if needed)

Question 9

what are the cycles of ALS, when do they start?

Answer 9

a cycle = 2 minutes of CPR/rescue breaths

Cycle 1 starts when the defibrillator is connected.

Perform a rhythm check ± shock every 2 minutes

Question 10

Management of a shockable rhythm

Answer 10

2 minute cycles of cpr followed by rhythm check

If the initial rhythm is shockable, provide one shock (at the recommended joules for your equipment)

resume cycles

After the third shock, give 300mg amiodarone and 1mg adrenaline IV/IO

Continue adrenaline every 3-5min

After the fifth shock, administer amiodarone 150mg

Question 11

How to manage a non-shockable rhythm?

Answer 11

2 minute cycles of cpr followed by rhythm check

Give adrenaline 1mg IV/IO every 3 – 5 minutes

Question 12

what is the dosing of adrenaline used in ALS

Answer 12

Adrenaline 1mg IV (10ml of 1:10,000)

Question 13

what is the dosing of amiodarone used in ALS

Answer 13

Amiodarone 300mg IV after 3rd shock

Repeat 150mg IV after 5th shock if ongoing

Question 14

when should adrenaline be used in ALS

Answer 14

Adrenaline 1mg IV (10ml of 1:10,000)

Shockable rhythm: give after 3rd shock (during CPR). Flush with 20ml saline.

Non-shockable rhythm: give as soon as IV access is established. Flush with 20ml saline.

Repeat adrenaline dose during every other CPR cycle thereafter (i.e. repeat every 3-5 minutes once given, regardless of rhythm)

Question 15

when should amiodarone be used in ALS

Answer 15

Amiodarone 300mg IV: if shockable rhythm only. Give after 3rd shock (during CPR). Repeat 150mg IV after 5th shock if ongoing.

Question 16

what are the reverisble cuases of cardiac arrest taht should be identified and worked through by the team leader

Answer 16

Hypoxia
Hypovolaemia
Hypokalaemia/hyperkalaemia
Hypothermia/hyperthermia
Thrombosis
Tension pneumothorax
Tamponade (cardiac)
Toxins

Question 17

How should the team leader assess and treat hypoxia

Answer 17

assess: ventilation adequacy, o2 flow rate, abg

treat: 15L/min O2, good ventilation, i-gel

Question 18

How should the team leader assess and treat hypovolemia

Answer 18

assess: history, drains, haemorrhage, fluid collections (expose pt)

treat: fluid resuscitation, blood if haemorrhage, stop bleeding

Question 19

how should the team leader assess and treat hypo/hyperkalaemia

Answer 19

ABG and latest blood results

if hyperkalaemic:
- Protect the heart: calcium chloride
- Shift K into cells: insulin and glucose, sodium bicarbonate
- Remove K from the body: consider dialysis for refractory hyperkalameic cardiac arrest

10 mL calcium chloride 10% IV by rapid bolus injection

10 units soluble insulin and 25 g glucose IV by rapid injection. Monitor blood glucose. Administer 10% glucose infusion guided by blood glucose to avoid hypoglycaemia.

50 mmol sodium bicarbonate (50 mL 8.4% solution) IV by rapid injection.

if hypokalaemic: 20mmol KCl over 10 mins

Question 20

how should the team leader assess and treat hypo/hyperthermia

Answer 20

assess: pts temp on recent obs, warmth to touch

treat:
hypo = warm pt, extracorporeal CPR

hyper: cool pt, IV fluids

Question 21

how does the team leader assess and treat tension pneumothorax

Answer 21

assess: tracheal deviation, unilateral hyper-resonance and decreased breath sounds

treat: insert cannula into second intercostal space mid clavicualr line

Question 22

how should the team leader assess and treat cardiac tamponade

Answer 22

assess: recent chest trauma/surgery/pacemaker insertion/PCI
cardias USS if there is a risk

treat: pericardiocentesis

Question 23

how should the team leader assess and treat toxins

Answer 23

assess: history, drug chart, capilalry glucose

treat: treat toxaemia eg naloxone for opiods

Question 24

when is ECMO considered

Answer 24

Extracorporeal CPR using extracorporeal membrane oxygenation (ECMO) device may be considered where available for select patients to facilitate other definitive treatments, e.g. PCI, pulmonary thrombectomy for massive PE, rewarming for hypothermia

Question 25

for how long should you do CPR? who decides when to stop?

Answer 25

In general, CPR should be continued as long as there is a shockable rhythm (mechanical compression device may be used)

Only stop if a registrar or above makes the decision with the team

Question 26

defibrilation vs cardioversion

Answer 26

Defibrillation vs cardioversion – defibrillation is a general term often used to describe the shock given to the heart, and more specifically it describes an ‘unsynchronised ‘shock. Cardioversion refers to this shock when it is applied at a specific time in the ECG cycle (a ‘synchronised’ shock).

Question 27

what are the shockable rhythms

Answer 27

Ventricular fibrillation
Pulseless ventricular tachycardia

Question 28

what are non-shockable rhythms

Answer 28

PEA – pulseless electrical activity – this means any electrical activity that appears on an ECG like it should be producing a pulse, but it is not. (all electrical activity except VF/VT, including sinus rhythm without a pulse) The most common cause is hypovolaemia.

Asystole – no rhythm present