The ALS Algorithm

and Post Resuscitation

Care

CNHE - Ballarat Health Services

Valid from 1st March 2016 to 31st June 2018

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Defibrillation

Produces simultaneous mass depolarisation of myocardial cells and may enable resumption of organised electrical activity.

Successful defibrillation is termination of Ventricular Fibrillation for greater than 5 seconds, a recognisable electrical rhythm, followed by spontaneous cardiac output

Biphasic defibrillators:

- Philips Heartstart MRx -200 joules

-Philips Heartstart XL -200 joules

-Lifepak -200 joules

-Philips Heartstart XL+ -200 joules

Defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT (ARC, 2010).

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Defibrillation – easy as 1, 2, 3

Follow ARC approved ALS protocol at all times when manually defibrillating

Step 1: Select energy (200J)

Step 2: Press “Charge” soft key

Step 3: Press soft key “shock”

when a continuous high pitch audible sound is heard and the Shock symbol is flashing

Use the COACHED principal to ensure safe defibilation

COACHED

Continue Chest Compressions

Oxygen Away

All Else Clear

Charging

Hands Off

Evaluate the Rhythm – Shockable vs. Non-

Shockable

Defibrillate or Disarm

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Monitored Arrest

A precordial thump may be administered for

pulseless VT if the defibrillator is not

immediately available (within 15 seconds)

Deliver 1 shock at the energy level

determined by the manufacturer

(BHS: Philips – 200J)

All subsequent shocks are delivered as single

shocks

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Shockable

VF/Pulseless VT (unwitnessed / unmonitored)

Defibrillation one shock (Philips -200 joules)

Immediate CPR for 2 minutes

Establish IV access

If IV access not gained in 90sec – I/O should be

used

Consider advanced airway management

Defibrillation one shock (Philips - 200 joules)

Adrenaline 1 mg - repeat 4 minutely

Immediate CPR for 2 minutes

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Shockable

VF/Pulseless VT (unwitnessed / unmonitored)

Consider antiarrhythmic post third shock

Look for and treat reversible causes

Consider electrolyte therapy

Defibrillation one shock (Philips 200 joules)

Continuous repeating of the sequence of

defibrillation, CPR, adrenaline and

resuscitation adjuncts until clear signs of life

are apparent, or the multidisciplinary team

considers any further resuscitation futile.

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Reversible Causes

4 H’s Hyper/ Hypokalaemia

Hyper/ Hypothermia

Hypovolaemia

Hypoxia

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Reversible Causes

4 T’s Tension pneumothorax

Tamponade

Toxins

Thrombosis (pulmonary/ coronary)

Reversible Causes

Treat these as you consider them Hang fluids to address Hypovolaemia

Ensure ventilation is adequate by auscultation

The H’s and T’s are there to aid you in

diagnosing and treating the underlying cause

of the arrest

It is important that you rule out all of these

even if you have a good idea of the cause of

the arrest12

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Non Shockable

Pulseless Electrical Activity (PEA) / Asystole

Immediate CPR for 2 minutes

Establish IV access

Consider advanced airway management

1 mg Adrenaline Immediately- then repeat 4 minutely

Recheck rhythm & cardiac output after 2 minutes of CPR

Rhythm check should not delay CPR

Ensure the defib is fully charged before each rhythm check (COACHED)

Correct reversible causes

4 H’s & 4 T’s

Consider electrolyte therapy

Consider pacing for asystole / bradycardia

Continually repeat the sequence of CPR, adrenaline and resuscitation adjuncts until clear signs of life are apparent, or the multidisciplinary team considers any further resuscitation futile.

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Reversible Causes

“H’s & T’s”

Hypovolaemia

Hypoxaemia

Hypo/Hyperthermia

Hypo/Hyperkalaemia

and other metabolic

disorders

Tension Pneumothorax

Tamponade

Thrombosis

(Pulmonary/Coronary)

Toxins

(Poisons/Drugs/Anaphylaxis)

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Secure Advanced Airway-

Endotracheal Tube (ETT),

Laryngeal Mask Airway (LMA)

CPR should not be interrupted for more than 5

seconds to establish an airway

Once advanced airway is insitu – aim for a minimum

speed of 100 chest compressions per minute

and 8-10 breaths per minute Adult

and 10-12 breaths per minute Paediatric

Avoid hyperventilation - aim for normocarbia

(PaCO2 35 - 40 mmHg)

Do not pause for ventilation when an advanced

airway is insitu

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Points of Emphasis for

CPR / ALS

At all times reduce “hands off the chest” time when

resuscitating

Minimise “hands off the chest time” when changing

chest compression operator, needs to be co-

ordinated by team leader

DO NOT delay chest compressions to recheck

rhythm

Charge Defib while doing chest compressions

(COACHED)

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Post-resuscitation Care

Aims

continue respiratory support

AIM SaO2

maintain cerebral perfusion

treat and prevent cardiac arrhythmias

determine and treat cause of the arrest

Cool patient 32-36 degrees for 24 hours

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Post Resuscitation Care

Principles

Avoid hypotension

Avoid hyperventilation - ventilate to

normocarbia CO2 (e.g. 35-40mmHg)

Avoid hyperglycaemia/hypoglycaemia

Avoid hyperthermia

Treat seizures

Treat underlying causes

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Post Resuscitation Care

Commence an infusion of the antiarrhythmic

that successfully restored a stable rhythm

with output if appropriate. Amiodarone

300mg in 5%Glucose to total 100mls (3mg/ml)

15mg/kg for 12-24hours

Lignocaine

1gm in 5%Glucose to total 100mls (10mg/ml)

2-4mg/min for 12-24hrs

To prevent recurrent VF consider an

antiarrhythmic infusion if not already in

progress

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Post Arrest Care – Therapeutic

Hypothermia (BHS CPG/T014)

Unconscious adult patients with return of

spontaneous circulation should be cooled to 32

- 360 C for 24 hours

Cooling should be instituted within 6 hours of

ROSC (return of spontaneous circulation)

Improves survival and neurological outcomes

Shivering must be avoided – increase metabolic

rate and increases O2 consumption - use

sedation and muscle relaxants

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Therapeutic Hypothermia

Cool by

Fans

Ice to axillae, groin and neck

Infusion of IV Hartmann’s at 40C over 30-60 minutes to reduce core temperature ( BHS CPG/T014)

Monitor by

Bladder IDC probe

Rectal probe

Oesophageal NGT probe

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SUMMARY

Things to take away…

1. Ensure effective ventilation and avoid

hyperventilation

2. Early defibrillation improves survival

outcome

3. Minimise interruptions during chest

compressions

Any attempt at

resuscitation is better

than no attempt

Australian Resuscitation Council,

(2016)