Advanced Life Support Algorithm

Question 1

In a shockable rhythm (VF or pVT), which medications are given and when?

Answer 1

The first dose of adrenaline 1mg IV is given during the 2 min cycle of CPR after delivery of the third shock. Amiodarone 300mg is given after 3 defibrillation attempts (so if giving stacked shocks intiailly then amiodarone would be given during first CPR cycle). Subseqent doses of adrenaline are given after alternate 2 min cycles of CPR (every 3 to 5 minutes) for as long as cardiac arrest persists. A further dose of 150mg amiodarone may be given after a total of five defibrillation attempts.

Question 2

How is management of shockable rhythms different if the arrest is witnessed and monitored?

Answer 2

• If initial rhythm is VF/pVT, give up to three quick successive (stacked) shocks
• Rapidly check for a rhythm change and, if appropriate, check for a pulse and other signs of life after each defibrillation attempt.
• If this initial three shock strategy is unsucessful, follow the ALS algorithm and treat these three-shicks as if only the first single shock has been given.
• The first dose of adrenaline should be given after another two shock attempts if VF/pVT persists.
• Amiodarone is given after three shock attemps irrespective of when they are given during the cardiac arrest.

Question 3

In a non-shockable rhythm (asystole or PEA), which medications are given and when?

Answer 3

Adrenaline 1mg IV is given as soon as IV access is achieved and then during alternate 2 minute cycles of CPR.

Question 4

What should the depth and rate of chest compressions be?

Answer 4

Depth of 5 to 6cm.
Rate 100 to 120 per minute.

Question 5

At what rate should ventiallation occur?

Answer 5

Initially 30 compression: 2 breaths. Once a SGA has been inserted, attempt to delver continuous chest compression, uninterrupted during ventilation. Ventilate at 10 breaths per minute.

Question 6

What measures can help peripherally injected medications to be delivered to the central circulation?

Answer 6

Drugs injected peripherally should be followed by a flush of at least 20mls fo fluid and elevation of the extremity for 10-20s.

Question 7

What are the 4 H’s and 4 T’s?

Answer 7

• Hypoxia
• Hypovolaemia
• Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, and other metabolic disorders
• Hypothermia/hyperthermia
• Thrombosis (pulmonary or coronary)
• Tension pneumothorax
• Tamponade - cardiac
• Toxins

Question 8

How can ultrasound be useful during advanced life support?

Answer 8

In skilled hands, focused echocardiography/ultrasound can be useful for the detection of potentially reversible causes of cardiac arrest:
* cardiac tamponade
* pulmonary embolism
* ischaemia (regional wall motion abnormality)
* aortic dissection
* hypovolaemia
* pneumothorax