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Participant Information 5

Process for Medical ALS 10

Cardiac Arrest Management Processes 12

Basic Life Support 24

Summary of Changes to BLS 33

New Initiatives in Post Resuscitation Care 38

Rh th I t t ti 41

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,,

Cardioversion Procedure

MO explains procedure and obtains consent

Nil by mouth for at least 6 hours prior to procedure unless emergencycardioversion is required

IV cannula inserted Pathology Blood for electrolytes (hyper/hypokalemia, hypocalcaemia,

Hypomagnesemia)Full blood count (anaemia can cause arrhythmias)ABGCoagulation screen

Consider anticoagulation, as cardioversion of AF can cause thromboemboliceffects. This should be administered for minimum of 48 hours prior to the

procedure if possible Record vitals

Baseline ECG and post cardioversion ECG Continuous cardiac monitoring is required during procedure Pre oxygenate via BVM 15 litres Select synchronise mode on defibrillator Give sedation

Have emergency equipment and drugs ready Minimal current is used

Post cardioversion care regular observation, monitoring, give anti-arrhythmic as needed

Energy Setting

The usual range of joules for defibrillation in a cardiac arrest is 200 joules in a

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!Non Invasive Pacing

! The purpose of the cardiac pacemaker is to provide an artificial electrical

stimulus to the heart muscle when either the impulse initiation or intrinsicconduction system is defective.

Primarily used for emergency treatment of symptomatic bradyarrhythmia,unresponsive to pharmacological intervention.

The electrical current is passed from an external pulse generator via cable to

adhesive electrodes thru the chest wall to the heart. NOTE: The pads deliver the energy; the patient must have monitoring

electrodes on as well.

There are 2 different modes of transcutaneous pacing Demand and Nondemand

Pad placement is anterior posterior positioning.

Demand Pacing

The pacemaker delivers an impulse only when required or on demand. Thepacemaker searches for intrinsic cardiac activity if it does not detect or sense a beatwithin a designated interval it will deliver a paced impulse.

All lifepaks in the district default to demand pacing.

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External pacing should not continue past 24hrs.

Care must be taken to monitor the patients response to external pacing eg captureis maintained. Sometimes ma needs to be increased to keep capture. Care must be

given when ma required maintaining capture reaches in excess of 120ma.

Not all Lifepaks have the capacity to pace. Machines with pacing capabilitiesare located in the Emergency departments, IC/CCU, OT and Mental Health.

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Drugs used in Cardiac Arrests

Whilst the listed drugs have theoretical benefits in selected situations, no medicationhas been shown to improve long term survival in humans after cardiac arrest.Priorities are defibrillation with external cardiac compressions (oxygenation andventilation together).

If there are no peripheral veins, an IO should be inserted. If a central line/PICC isavailable it should be used.

Administration of IV/IO medication in a cardiac arrest situation is always followed bya 30mL flush. It is easier to hang a bag of saline rather than having to draw up30mLin a syringe each time.

Avoid glucose which is redistributed away from the intravascular space rapidly andcauses hyperglycaemia, which may worsen neurological outcome after cardiacarrest.

All resuscitation trolleys in the Wide Bay Health Service - Fraser Coast Campus areequipped with emergency drugs, the following drugs are in the top drawer of everytrolley.

Mini jets

Atropine, 1mg

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Administration of Drugs via Intraosseous

If IV access cannot be obtained, intraosseous access is a safe and effective methodfor administration of resuscitation drugs, laboratory evaluation and is attainable in allage groups.

If pathology is taken from Intra-osseous make sure this is written on the pathologyform.

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8 Sites

Proximal HumerusPreferred site foradultsOptimal site for highflow and quick druguptakeAwake, responsivepatientsLess painful

Site selection

Dependent upon:No previous IO in 48 hoursAbsence ofcontraindicationsAccessibilityAbility to secure & monitor

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!

Administration of Drugs via ETT

ETT administration is acceptable if both IV and IO access cannot be obtained.

Procedure

1. Suction the airway if possible

2. Insert a clean suction catheter beyond the tip of the ETT and instil themedication via the catheter

3. Administer THREE times the IV Dosage, diluted to 10 mL in water(evidence suggest better drug absorption takes place when diluted with waterrather than saline)

4. Followed by at least two vigorous ventilations to disperse the drug.

5. Ensure eye and mucous membrane protection when opening airway forinstillation of drugs.

Drugs able to be administered down the ETT

Adrenaline

Lignocaine

Atropine

N l

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D:\userdata\LearyE\temp\XPgrpwise\ALS manual 2013 Revised.doc

Page 96 of 135

First Line Drugs used in a Cardiac Arrest

DRUGLIST TWO

INDICATIONS FORUSE

IV DOSE ETT DOSE MECHANISM OF ACTION LIST TWO UNDESIRED EFFECTS

Adrenaline Asystole

VF/VT arrest

PEA

Second line drug inbradycardia

1 mg bolus every 4mins in an arrest

0.1 mg as secondline drug inbradycardia

Infusion1 -20 mcg/min

3 mg bolus dilutedin 10 mLH0

Every 4 minutes inarrest

Alpha & beta stimulantcausing vasoconstriction,therefore improvingmyocardial & cerebral bloodflow facilitates defibrillation

Increased A-V conduction,Increased contractilityIncreased automaticity initiatecardiac rhythm

Increases ventricular irritabilityconverts fine VF to coarse

Bronchodilation

Necrosis if extravasation occurs (give viacentral line ASAP)

Tachycardia, tachyarrythmias

Severe hypertension after resuscitation

Agitation

Do not mix with sodium bicarbonate itinactivates it

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Page 97 of 135

DRUGLIST TWO

INDICATIONS FORUSE

IV DOSE ETT DOSE MECHANISM OF ACTION LIST TWO UNDESIRED EFFECTS

Atropine Symptomaticbradycardia

0.5mg every4 mins(maximum of3mg)

1.5 mg bolusdiluted in 10mLH2O

Parasympathetic antagonistthat blocks action of vagusnerve on the heart

Anticholinergic

Allows SNS to increase HR&BP

Increased A-V conduction

Dry mouth

Urinary retention

Tachycardia ,hypotension

Excitement /delirium

Hyperthermia in large doses

Raises intraocular pressure in pt withglaucoma. Treat with pilocarpine eyedrops if necessary

Dilated pupils

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Page 98 of 135

Second Line Drugs used in a Cardiac Arrest

DRUGINDICATIONS

FOR USEIV DOSE ETT DOSE MECHANISM OF ACTION ADVERSE EFFECTS

!Amiodarone

Class IIIantiarrhythmic

VT with pulse

In VF/VT arrestwhen no responseto defibrillation &adrenaline

300mg bolus(5mg/kg )

in 20mL5%glucose

over 2 mins(in arrest)

Same doseDilute 50mL

Over 20 minsConscious

VT/SVT

repeat dose (150mg)

maintenanceinfusion 10-15mg

/kg/day

NOT able to begiven by ETT

Antiarrhythmic complexpharmacokinetic

Effects sodium ,potassium &calcium channels

Blocks alpha & beta adrenergicblocking properties

Bradycardia / heart block

Hypotension

Phlebitis/ pain at IV site(should be giventhrough central line ASAP)

Us Non PVC infusion sets

Dilute in glucose 5 % only

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Page 99 of 135

DRUGINDICATIONS

FOR USEIV DOSE ETT DOSE MECHANISM OF ACTION ADVERSE EFFECTS

Lignocaine VT with pulse

In VF/VT arrestwhen no responseto defibrillation &adrenaline

1mg/kg 3mg /kg Antiarrhythmic complexpharmacokinetic

Membrane stabilising agent inhibitsthe fast inward sodium movementand thus decreases the rate ofdepolarisation, particularly inischemic tissue. Class 1 b anti arrthymic

Respiratory depression

Hypotension, bradycardia, heart block,asystole

Drowsiness, confusion, twitching

Blurred vision

Numbness

Slurred speech

NOTE: Lignocaine is now only recommended when Amiodarone is unavailable, or ETT administration of anantiarrhythmic is required.

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Page 100 of 135

ElectrolytesElectrolyte High Levels Low Levels Use Administration Adverse Effects

Potassium

Essential for membranestability

P waves K+ >8flattened / no P waves

PR - prolongedQRS K+ > 10 widenedST depressionT waves - tallsymmetricalAV blocks

PACs & PVCs

ST depressionT waves flat, broadU waves appear

Cardiac arrest with

Hypokalemia

Digoxin toxicity

Hypomagnesaemia

Persistent VF/VT low K+

Fast bolus infusion of5 mmol over 2 mins

(50mLof prepacked10 mmol in 100mLbag )

Note : 10mmol ampoulesare available in ED/ICU only

Necrosis ifextravasates

Excess=bradycardia& hypotension

Magnesium

Essential for membranestability

Hypomagnesaemiacauses cardiachyperexcitabilityparticularly in presenceof hypokalemia &digoxin

BradycardiaPRinterval - prolonged

QRS widened

T waves - tall

AV blocks & PVCs

PR interval - prolongedQT interval prolonged

(" risk of Torsades)QRS widenedST depression

T waves inversion flatbroadU waves appearPVCs

Torsades de Pointes

Hypomagnesaemia

Hypokalemia

Digoxin toxicity

In VF/VT when noresponse to defib &adrenaline

5mmol over 2 mins

repeat x1

then 20mmol over

4 hours if required

Bradycardia

Respiratory muscleweakness Dilute &give slowly

Dont mix with calcium

Calcium Chloride 5 mL over 2 mins

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Page 101 of 135

Electrolyte Use Administration Adverse Effects%

SodiumBicarbonate

Alkalising agent

!

Cardiac arrest with

Hyperkalemia

Documented severemetabolic acidosis

Protracted arrest (morethan 15 min)

overdose of tricyclicantidepressants

1mmol/kgover 2 mins

further administration guided by

ABGs

Risk of alkalosis, hypernatremia andhyper osmolality

Acidosis may worsen when CO2 is

liberated from NaHCO3 and freelyenters the cells

Sodium bicarbonate and adrenaline (orcalcium) when mixed may inactivateeach other, precipitate and block the IVline

Note: All electrolytes are to be diluted into at least 20 mL of saline, for ease of administration

ABG analysis is an inaccurate measure of the magnitude of tissue necrosis in arrest situation! Use Dosage Adverse EffectsADENOSINE

Note: WBHSD-FCC policystates that ALSNurses are NOTauthorised to order/ administerAdenosine without

a written or verbalorder from aMedical Officer

SVT

Atrial tachycardia

To differentiate diagnosisin broad complextachycardia

6mg, then 12 mg,12mgrapid bolus in large vein with a

three way tap, with a 30 mL flushsimultaneously

Flush feeling / impending doom

ventricular standstill /asystole

dyspnoea

chest pain

contraindicated in asthma/wheezing

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WBHSD-FCC algorithms have been produced in line with ARC Guidelines to support the WBHSD-FCCALS policy for nurses.

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BLS until defibrillator attached

6'#&$*789*:Ventilate 100% O2

Defibrillate 200j 2 mins CPR

IV access & pathology

Intubate (

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&216&,28697&216&,28697&216&,28697&216&,28697Valsalva Manoeuvre

High flow O2IV/IO access & pathology

Severely compromised?

IV Amiodarone 300mgin 50 mls of 5% Glucose over

If the patientbecomes ;&20 < !%,'# ='"),

NO YES

Signs of CompromiseHypotension < 90 SBPHeart failureChest pain

DizzinessALOC

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Valsalva Manoeuvre

High flow O2IV access & pathology

NO Severely compromised? YES

Signs of CompromiseHypotension < 90 SBPHeart failureChest painDizzinessALOC

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!

Basic Airway Management

!

Insertion of Oropharyngeal Airway Guedels

Determine the patients mouth width and length, measure the airway from the corner of thepatients mouth to the ear lobe.

Insertion of a Guedels airway that is too large can obstruct respirations while one that is too small

will not hold the tongue in appropriate position.

Average size for adults Female size 3Male size 4

The airway is now placed in the mouth facing the side of the mouth and then turned over to reston top of the tongue, rather than the old way in which it was placed facing towards the roof of themouth and then twisted.

Insertion of Nasopharyngeal Airway

Determine the patients size, nasal structure, sex, age, check by measuring airway from nasalopening to the ear lobe.

Small (size 5-6mm) for under 45kg with a small bone structureM di ( i 7 8 ) f d 70k i h ll b

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Oxygen Delivery Systems

The following table summarises the non invasive O2 delivery systems, flow rates, percentage of oxygendelivered and features of each device.

%%%%%

%%%%%%%%%%%%%%%

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%%%

%%%%%%%%%%

!!!

!!NOTE:- Nasal prong O2 flow rate is not more than 4lpm & when using the non- rebreather mask,the flow rate should not be less than 10lpm minimum

Bag Valve Mask

Oxygen should be set to 15 Litres per min

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Cricoid Pressure

Aim

The aim of the application of cricoid pressure is to:

Prevent the regurgitation of gastric contents during induction and intubation.

It is also to provide a better view of the cords for the person performing the intubation.

Provide pressure in an upwards, backwards movement.

This is achieved by the application of pressure over the cricoid cartilage which occludes the lumen of theoesophagus until the respiratory tree is isolated by an endotracheal tube.

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Endotracheal Intubation

%Benefits

The major benefits of endotracheal intubation are that the patient is being ventilated with 100% oxygendirectly into the lungs and the cuff provides protection for the lungs from gastric contents. This procedureprovides a much safer and more effective method of ventilating a patient during cardiac arrest.

Size

When preparing for intubation the appropriate size ETT should be selected. The ET tube is sizedaccording to the internal diameter.

Usual adult sizes female 7- 8 mm Male 8 - 9 mm

To inflate the cuff most ETT require approximately 10mL of air. Inflate until you can no longer heargurgling then add an addition 1mL.

Assessing placement of Endotracheal Intubation

Listen for air entry

Look for bilateral rise and fall of the chest

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Sequence of Intubation

1. Equipment selection

Correct size ETT tube - Adult Male - 8 - 9mm

- Adult Female - 7 - 8mm

10mLSyringe

Tape

Laryngoscope

Bag-Valve-Mask equipment

O2 & suction

Introducer

Stethoscope

2. Equipment preparation

Ensure cuff can be inflated / deflated

Ensure suction is on and accessible

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RECOGNITION OF UPPER AIRWAY OBSTRUCTION

Airway obstruction may be partial or complete and may present in the conscious or the unconsciousvictim. Some typical causes of airway obstruction may include, but are not limited to:

Relaxation of the airway muscles due to unconsciousness

Inhaled foreign body

Trauma to the airway

Anaphylactic reaction

The signs and symptoms of obstruction will depend on the cause and severity of the condition. Airwayobstruction may be gradual or sudden in onset and lead to complete obstruction within a few seconds.Consequently the victim should be observed continually.

In the conscious victim who has inhaled a foreign body, for example, there may be extreme anxiety,agitation, gasping sounds, coughing or loss of voice. This may progress to the universal choking sign(clutching the neck with the thumb and fingers).

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A Foreign Body Airway Obstruction (FBAO) is a life-threatening emergency. Chest thrusts and backblows, effective for relieving FBAO in conscious adults and children > 1 year of age, although injuries

have been reported with the abdominal thrust {LOE IV} {Class A; LOE IV}

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@)3*)9.716!!

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Leadership

Dont Panic!!

The Team Leader is responsible for:

1. Allocating the roles2. Directing and coordinating the resuscitation attempt

3. The safety of the resuscitation team at the cardiopulmonary arrest4. Ending the resuscitation attempt when indicated, always in consultation with other resuscitationteam members and medical staff otherwise in charge of the patient.

5. Documenting (including audit forms) and for communication with relatives and other healthcareprofessional involved in the patients management.

6. Encourage all team members to contribute7. Organising resuscitation team debriefing.8. Allocating a nurse to stay with family if they are present during the arrest

Take control of the situation

There should be one team leader If you are unsure ask for help, it is better than saying nothing or doing the wrong thing.

Listen to the other staff, ask for consensus?

Allocate tasks to others. If possible, the team leaders should step back and provide overall direction.

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Dont forget to document appropriately and send photocopy of arrest record to CE-ALS

Talk to the family and offer support

Debrief and discuss process with team members.

Reflective practice what areas could you have done better?

Think about your performance from different perspectives

How did you perform clinically, did you provide good leadership etc.

Was there anything that you were unsure about?

Identify and action training needs

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Additional Resources

Websites

Qheps http://qheps.health.qld.gov.au

Australian Resuscitation Council www.resus.org.au

European Resuscitation Council https://www.erc.edu

American Heart Association http://www.americanheart.org

Advanced Paediatric Life Support http://www.apls.org.au

Gold Coast Emergency Department http://emergencyweb.net/login.php?u

Skills Development Centre http://www.sdc.qld.edu.au/

Texts

ARC Manual is located in each Clinical Unit

Advance Paediatric Life Support, Practical Approach 4th Edition (located in the ACLSClinical Educators Office, ERC Maryborough Hospital)

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"66)%*1#).!!!!

Participant Program Outline Fast track - Adult ALS

Fast Track Course (by request only)

Sessions

0800 0815 Welcome , Health & Safety ,session objectives

0815 - 0900 BSL demonstration & assessments

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!

ALS Certification Guidelines Clinical Scenarios

Two types of scenarios

Each participant must successfully complete one shockable and one non-shockable scenario to pass.If a resit is required - it must be from the similar type of scenario.

All mandatory criteria must be achieved

First line drug administrationDefibrillation indications, procedure & safetyRhythm recognition.Workplace health & safety requirementsLeadership

Team members are not allowed to prompt the team leader.

The team leader must demonstrate appropriate leadership skills i.e. checking on other teammembers, giving requests in clear firm voice etc.

During assessment - You will not be expected to work outside of your scope of practice eg nursesmust receive a verbal/written order before ordering/administering Adenosine. Please refer to the ALSPolicy regarding scope of practice.

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AUSTRALIAN RESUSCITATION COUNCIL

SUMMARY OF MAJOR CHANGES TO ADVANCED LIFE SUPPORT GUIDELINES

DECEMBER 2010In December 2010 the New Zealand Resuscitation Council and Australian Resuscitation Councilpublished their combined and updated ALS guidelines. These revised evidence based guidelinesincorporate the published literature including the evidence evaluated as part of the international evidence

consensus process (published in October 2010).The main changes in these guidelines are outlined below, grouped according to the relevant guideline.

Guideline 11.1: Introduction to Advanced Life Support

Increased emphasis on:

Monitoring the effectiveness of compressions, adequacy of ventilation and quality of CPR and timing of

defibrillation

The early detection and prevention of cardiac arrest in the pre-hospital and in-hospital settings

Guideline 11.1.1: CPR for ALS Providers

CPR to commence with chest compressions rather than ventilation

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Increased emphasis on:

High-quality chest compressions with minimal interruptions

Fallibility of pulse check even in the hands of clinicians

Guideline 11.2: Protocols for Adult Advanced Life Support (inc ALS Flowchart)

New co-badged ALS flow chart, designed to be easier to follow, and to increase the awareness of theimportance of post-resuscitation care.

Only single shocks are recommended (stacked shocks considered only in specific specialcircumstances)

Continuing compressions during defibrillator charging to minimise interruptions

Adrenaline still recommended at same points in the arresto

Non-shockable rhythm: 1 mg immediately for non-shockable rhythms then every 35 min: alternatecycles of CPRo

Shockable rhythms (VF/VT): 1 mg after the second shock then every 35 min: alternate cycles of CPR.o

Timing of drug administration now recommended being at the time of recommencement of CPR.

Amiodarone 300mg is still recommended after the third shock, but timing of drug administration now

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Guideline 11.4: Electrical therapy for Adult Advanced Life Support

For defibrillation when using biphasic defibrillators, self-adhesive defibrillation pads are safe andeffective and offer advantages (eg. facilitating pacing, charging during compressions, safety [includingremoving risk of fires]) over defibrillation paddles.

Single (non-stacked) shocks are recommended (as for 11.2 above).

CPR should be continued during charging of the defibrillator, and CPR should not be interrupted untilrhythm reanalysis is undertaken (as for 11.2 above)

Reiterated:

Monophasic defibrillation: to use 360 joules for all shocks (as for 11.2 above)

Biphasic defibrillation: to use 200 joules for all shocks unless clinical evidence of other energy level for aspecific device (as for 11.2 above)

Guideline 11.5: Medications in Adult Advanced Life Support

Drug administration via IV or intra-osseous route, with the endotracheal route de-emphasised.

Adrenaline and Amiodarone as for 11.2 above.

Other drugs not recommended for routine use, but may have value for other specific reversible causes.

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Guideline 11.5: Medications in Adult Advanced Life Support

Drug administration via IV or intra-osseous route, with the endotracheal route de-emphasised.

Adrenaline and Amiodarone as for 11.2 above.

Other drugs not recommended for routine use, but may have value for other specific reversible causes.

Guideline 11.6: Equipment and Techniques in Adult Advanced Life Support

Decreased emphasis on the role of early tracheal intubation.

A supraglottic airway device may be considered by healthcare professionals trained in its use as analternative to bag-mask ventilation during cardiopulmonary resuscitation, or for definitive airwaymanagement during cardiac arrest and as a backup or rescue airway in a difficult or failed trachealintubation.

Waveform capnography is recommended to confirm and continuously monitor the position of a tracheal

tube in victims of cardiac arrest and it should be used in addition to clinical assessment (auscultation anddirect visualization is suggested). It is also recommended to confirm and continually monitor trachealtube placement, quality of CPR, and to provide early indication of ROSC.

Potential role of CPR prompt devices to monitor and improve quality of CPR (as for 11.1.1 above).

Increased role of investigations (including intra-arrest ultrasound) to assist in detection of potentiallyreversible causes.

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Reiterated:

Recommendation for routine use of therapeutic hypothermia for comatose survivors of out-of-hospital

cardiac arrest due to ventricular fibrillation

Consideration of routine use of therapeutic hypothermia for comatose survivors of cardiac arrest of anyrhythm for in and out-of-hospital cardiac arrest irrespective of aetiology.

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SUMMARY OF MAJOR CHANGES TO BASIC LIFE SUPPORT

GUIDELINESNOVEMBER 2010GUIDELINE 2 - Priorities in anEmergency

Focus changed to cover a range of emergencysituations not just cardiac arrest and includes collapsed andinjured victims.

GUIDELINE 3 - UnconsciousnessFocus now on the breathing unconscious victim (the

non breathing unconscious victim will now fall underGuideline 8: CPR)

GUIDELINE 4 - AirwayMinor error in FBAO flowchart corrected

GUIDELINE 5 - BreathingReferences to signs of life removed as these are

open to interpretation and feedback from memberorganisations suggests that the term signs of life isconfusing.

Focus on unresponsive and not breathing normally asthe indicators for resuscitation.

GUIDELINE 6 - Compressions

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SUMMARY OF MAJOR CHANGES TO BASIC LIFE SUPPORT

GUIDELINESGUIDELINE 8 - CPR Changes as per airway, breathing, compressions and AEDguidelines

Increase emphasis on bystander CPR as life savingintervention.

Compression: rescue breathing ratio remains at 30:2Steps in resuscitation are now DRS ABCDcheck for Danger

check for ResponseS has been added for Send for helpA directs rescuers to open the AirwayB directs rescuers to check Breathing but no need to

deliver two rescue breathsC directs rescuers to perform 30 Compressions to

victims who are unresponsive and not breathing normally,followed by 2 breaths

D directs rescuers to attach an AED as soon as it isavailable

The major change is that in the victim who isunresponsive and not breathing normally, CPR commenceswith chest compressions rather than rescue breaths.

If unwilling / unable to perform rescue breathing, thenperform compression only CPR.

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SUMMARY OF MAJOR CHANGES TO BASIC LIFE SUPPORTGUIDELINES

GUIDELINE 10.2 - CPR InstructorCompetencies DELETE

GUIDELINE 10.3 - Cross InfectionRisks & Manikin Disinfection No major changes

GUIDELINE 10.5 - Legal AndEthical Issues Is undergoing a major re-write

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