als recertification course. standardised cpr for adults update on clinical changes to resuscitation...

ALS Recertification Course

• Standardised CPR for adults

• Update on clinical changes to resuscitation guidelines

• Re-evaluation of knowledge and practical skills acquisition

• Assessment

ALS recertification course learning outcomes

ALS recertification course format

• Manual

• Lectures

• Skill stations

• Cardiac Arrest Simulation (CAS) training

Andy Lockey

do we have workshops on recert course? if not, this line can be removed

ALS recertification course assessment

• MCQ

• Practical skills (continuous assessment)• Airway management• Initial assessment and resuscitation

• Cardiac Arrest Simulation (CASTest)

• Provider certificate valid for 4 years

Causes and Prevention of Cardiac Arrest

Early recognition ofthe deteriorating patient

• Most arrests are predictable

• Deterioration prior to 50 - 80% of cardiac arrests

• Hypoxia and hypotension are common antecedents

• Delays in referral to higher levels of care

Outcome after in-hospital cardiac arrest

VF/VT Non-VF/VT

Number of patients 570 (18%) 2,614 (82%)

ROSC > 20 min 385 (68%) 689 (26%)

Survival to hospital discharge 251 (44%) 179 (7%)

Source: UK National Cardiac Arrest Audit (NCAA) 2010

•No national data for Australia

•Pockets of data report similar results

•Development of Clinical Indicators/Audits by Australian Council on Healthcare Standards (ACHS) and Australian Commission on Safety and Quality in Health Care (ACSQHC) will provide future results

Recognition of the deteriorating patient -Early Warning Scoring Systems

Example of early warning scoring (EWS) system** From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7

Recognition of the deteriorating patient -Early Warning Scoring Systems

Example Escalation Protocol based on early warning score (EWS)

The ABCDE approach to the deteriorating patient

Airway

Breathing

Circulation

Disability

Exposure

ALS Algorithm

• Patient response

• Open airway

• Check for normal breathing• Caution agonal breathing

• Check circulation

• Monitoring

To confirm cardiac arrest…Unresponsive?Not breathing or

only occasional gasps

Cardiac arrest confirmedUnresponsive?Not breathing or


Call resuscitation team

Cardiac arrest confirmedUnresponsive?Not breathing or


Call resuscitation team

CPR 30:2Attach defibrillator / monitor

Minimise interruptions

Chest compression• 30:2• Compressions

• Centre of chest• Min 5cm depth/one third total• Approximately 100min-1

- About 2 per second (not faster than 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

Adult ALS Algorithm

Shockable and Non-Shockable

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Charge START Defibrillator

Assessrhythm

Shockable(VF / Pulseless VT)

Non-Shockable(PEA / Asystole)

CPR

• Uncoordinated electrical activity

• Coarse/fine• Exclude artefact

• Movement• Electrical interference

Shockable (VF)Shockable(VF)

• Bizarre irregular waveform• No recognisable QRS

complexes• Random frequency and

amplitude

Shockable (VT)Shockable(VT)

• Polymorphic VT• Torsade de pointes

• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology

Shockable (VF / VT)

Shout “(Compressions Continue) Stand Clear”

Assessrhythm

Shockable(VF / VT)


Shockable (VT)

CHARGE DEFIBRILLATOR

Assessrhythm

Shockable(VF / VT)

Shockable (VT)

Assessrhythm

Shockable(VF / VT)

Shout “Hands Off”

CHARGE DEFIBRILLATOR

Shockable (VF / VT)

Assessrhythm

Shockable(VF / VT)

Confirmed Hands Off“I’m Safe”

Shockable (VF / VT)

DELIVER SHOCK

Assessrhythm

Shockable(VF / VT)

Shockable (VF / VT)

IMMEDIATELY RESTART CPR

Assessrhythm

Shockable(VF / VT)

Shockable (VF / VT)


Assessrhythm

Shockable(VF / VT)

IMMEDIATELY RESTART CPR


• 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…

Defibrillation energies

Special Circumstances

Well perfused and oxygenated patient pre-arrestPresenting 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

• 2nd and subsequent shocks• 200 J biphasic• 360 J monophasic

• Give adrenaline and after 2nd shock during CPR then alternate loops thereafter

• Give amiodarone after 3rd shock during CPR

If VF / VT persists

CPR for 2 minDuring CPR

Adrenaline 1 mg IV

CPR for 2 minDuring CPR

Amiodarone 300 mg IV

Deliver 2nd shock

Deliver 3rd shock

Non-Shockable

Assessrhythm




Non-Shockable

Assessrhythm




DUMP/DISCHARGE

ENERGY

• 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 (Asystole)Non-Shockable(Asystole)

• Clinical features of cardiac arrest• ECG normally associated with an output• Adrenaline 1 mg IV then every alternate loop

Non-shockable (Asystole)Non-Shockable(PEA)

During CPRDuring CPR

Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO accessPlan actions before interrupting compressions

(e.g. charge manual defibrillator)Drugs

Shockable• Adrenaline 1 mg after 2ndshock (then every 2nd loop)• Amiodarone 300 mg after 3rd shock Non Shockable• Adrenaline 1 mg immediately (then every 2nd loop)

Airway and ventilation

• Secure airway:• Supraglottic airway device • 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

• Waveform capnography

Vascular access

• Peripheral versus central veins

• Intraosseous

Reversible causesHyperthermia

Hypokalaemia/metabolic

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

resemble septic shock

• Core temp >40.6 C

• Rhabdomyolysis, coagulopathy issues

• Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm

• Rapid cooling to 39 C (similar approaches/techniques to hypothermia)

• Large fluid volumes• Correct electrolyte

abnormalities/acidosis

Medications:• No effective medications for heat

stroke• Dantrolene for some

anaesthetic/MDMA reactions

Tension pneumothorax

• Check tube position if intubated

• Clinical signs (some/all not be present peri-arrest)

• Decreased breath sounds• Hyper-resonant percussion note• Tracheal deviation

• Initial treatment with needle decompression or thoracostomy• Follow up with Chest Tube

Tamponade, cardiac

• Difficult to diagnose without echocardiography

• Consider if penetrating chest trauma or after cardiac surgery• Also:

- Recent Myocardial Infarct- Blunt Chest Trauma- Procedural – Cardiac

Catheter/Pacing Wire etc• Treat with needle

pericardiocentesis or resuscitative thoracotomy

Toxins

• Rare unless evidence of deliberate overdose

• Presenting history may give clues

• Review drug chart

• Toxicology screens take time

Thrombosis

• If high clinical probability for PE consider fibrinolytic therapy

• If fibrinolytic therapy given then consideration for continuing CPR for up to 60-90 min before halting resuscitation attempts

Ultrasound

• In skilled hands may identify reversible causes

• In particular Tamponade, Tension Pneumothorax and Thrombosis

• 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?

• 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

Summary

Peri-Arrest

Bradycardia algorithmIncludes rates inappropriately slow for haemodynamic state

Interim measures:

•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing

Tachycardia algorithm (with pulse)

Tachycardia algorithm

Stable broad-complex tachycardia

Stable narrow-complex tachycardia

Any questions?

Summary

• Modifications to ALS are based upon current evidence

• Focus is on standardised CPR for adults

als recertification course. standardised cpr for adults update on clinical changes to resuscitation...

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