ALS Algorithm Flashcards
Defib pad placement sites
- One below right clavicle
- One in v6 position in the mid axillary line
Level of energy for defibrillator
- 200 J biphasic for first shock
- May increase to maximum 360 J for subsequent shocks
How often to do a rhythm check
- Initially as son as defib is attached
- Following this every 2 minutes
Standard drugs in shockable rhythm algorithm
- Adrenaline 1mg IV/IO after 2nd shock then after every second shock
- Amiodarone 300mg IV after 3rd shock (do not have to be 3 consecutive shocks). Can give a second dose of 150mg amiodarone after 5 shocks if VF/pVT persists
- Lignocaine 1mg / kg can be used as an alternative if amiodarone is not available, but do not give lignocaine if amiodarone has already been given.
What to check in refractory VF/pVT not responding to shocks
- Position and contact of defib pads
- Resus should usually be continued as long as pt is in VF/pVT
What to do if a non-shockable rhythm is identified and rhythm is one that could be compatible with a pulse (i.e. organised electrical activity)
- Disarm defib
- Seek evidence of ROSC:
1) signs of life
2) central pulse
3) sudden increase in end-tidal CO2
If there is any doubt about the presence of a palpable pulse resume CPR
What to do if a rhythm compatible with a pulse is seen during a 2-min CPR period
- Do not interrupt chest compressions to palpate a pulse unless the patient shows signs of life suggesting ROSC
What to do if unsure whether rhythm is asystole or extremely fine VF
- Don’t shock
- Continue CPR
(this may make the VF more obvious - if can be clearly identified as VF then shock)
Indications for precordial thump
While awaiting arrival of defib in a monitored pVT arrest
Management of a witnessed cardiac arrest whilst monitored and in a critical area
DRS - D
- Danger
- Response
- Send for help
- Defib
1) three quick successive (stacked) shocks if the first shock can be delivered within 20 seconds of arrest
2) assess for rhythmn change and signs of ROSC after each shock
3) start CPR and usual ALS algorhithm if 3rd shock is unsuccessful (treat the 3 stacked shocks as a single shock for algorithm purpose)
What is pulseless electrical activity (PEA)
- Cardiac arrest in presence of electrical activity (other than VT) that would normally be associated with a palpable pulse (may be some myocardial contractions but they are too weak to produce a detectable pulse or BP)
- May be caused by reversible conditions that can be treated
- Survival following arrest with asystole or PEA is unlikely unless a reversible cause can be found and treated quickly
What is asystole
Absence of electrical activity on the ECG trace
What to check if rhythm is asystole
- pad position and contact
- monitoring setting
- gain setting
- whether any evidence of P waves (i.e. = ventricular stand still - may be treated effectively by cardiac pacing
COACHED mnemonic
C: Compressions Continue O: Oxygen away (if free flowing BVM) A: All others clear C: Charging defibrillator (200J) H: Hands off (compressor should say I’m safe) E: Evaluating rhythm D: Defibrillate or Disarm
Standard drugs in non-shockable rhythm algorithm
- Adrenaline 1mg IV/IO immediately (as soon as access established)
- Then every second shock
What to do if can see rhythm is VF during pauses for breaths with 30:2 CPR
- Do not interrupt cycle to shock at this stage
- Continue CPR until 2 min period is complete
Rate of compressions in CPR
100-120 compressions/min
Management of airway and ventilation
If not able to intubate
- Bag mask with guedell or preferably
- LMA
Ventilate at 10 breaths/min
If attempting to intubate don’t interrupt for more than 5 seconds - only when trying to pass tube between cords
Waveform capnography during ALS - what does it measure, when can you use it?
- Measures end-tidal CO2 (which reflects cardiac output and pulmonary blood flow)
- Values are typically low during arrest
- Can be used with bag mask, LMA or ETT, but is most reliable in patients with a tracheal tube.
Roles of waveform capnography during ALS
- Ensuring tracheal tube placement
- Monitoring ventilation rate during CPR
- Monitoring quality of chest compressions during CPR (greater depth / rate of compressions will increase end tidal C02
- Identifying ROSC - increase in end tidal C02 to near normal (35-45)
- Prognostication during CPR (e.g. poor outcome likely if end tidal CO2 <10 after 20 mins of CPR
What to do if signs of life noted during CPR (e.g. regular respiratory efforts, movement; or increase in end-tidal C02 or arterial blood pressure waveform)
- Pause CPR
- Rhythm check
- If Rhythm potentially compatible with pulse, pulse check (otherwise recommence CPR)
- If pulse is palpable = post-resus care approach
Drug administration during CPR via IV route - notes on flush
Requires flush of at least 20ml , may be easier to have a continuously running in IV line
Drug administration during via IO route - notes on pressure
Can use either a pressure bag or syringe
Sites for IO access
1) proximal or distal tibia (preferable during CPR)
2) proximal humerus
Contraindications to IO access
- trauma/fracture
- prosthesis
- prior failed attempt at the site
4Hs and 4Ts
- Hypovolaemia
- Hypoxia
- Hypothermia
- Hypo/hyper-kalaemia, hypoglycaemia, hypocalcaemia, hydrogen ion (acidaemia)
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade (cardiac)
- Toxins
Hypoxia - considerations
- Ventilate with 100% 02 during CPR
- Ensure adequate chest rise and bilateral breath sounds
- Ensure correct placement of ETT
- Post ROSC aim sats 94-98
Hypovolaemia - considerations
- Many hypovolaemic arrests present with PEA, however, shockable rhythms are possible/may develop
Causes:
- haemorrhage
- distributive shock (anaphylaxis, sepsis)
Haemorrhage
- E.g. trauma, AAA
- Examine - quick top-to-toe, abdo exam, log roll
- Control bleeding urgently
- Restore IV volume rapidly with blood/fluids
Other causes of hypovolaemia include distributive shock
- Fluid resus
Once ROSC is achieved consideration needs to be given to:
- Interventional procedures
- Inotropes
- Invasive monitoring
Hyper/hypo-kalaemia, hypoglycaemia, hypocalcaemia, hydrogen ion (acidaemia) - i.e. metabolic disorders
Get a VBG
Hyperkalaemia K > 6.5
- Calcium = 10ml calcium chloride 10% (preferable during arrest, otherwise give 10ml calcium gluconate 10%)
- Insulin = 10 units act rapid in 50ml of 50% dextrose
- Sodium bicarbonate - consider giving 50mmol IV if severe acidosis or renal failure are present
- Dialysis
