Transcript Shockable - the Australian Resuscitation Council

ALS Algorithm
Learning outcomes
• 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
Adult ALS Algorithm
Unresponsive?
Not breathing or
To confirm cardiac arrest…
only occasional gasps
• Patient response
• Open airway
• Check for normal breathing
• Caution agonal breathing
• Check circulation
• at same time as breathing
• Monitoring
Unresponsive?
Not breathing or
Cardiac arrest confirmed
only occasional gasps
Call
resuscitation team
Unresponsive?
Not breathing or
Cardiac arrest confirmed
only occasional gasps
Call
resuscitation team
CPR 30:2
Attach defibrillator / monitor
Minimise interruptions
Chest compression
• 30:2
• Compressions
• Centre of chest
• Min 5-6 cm depth/one third total
• 2 per second (100-120 min-1)
• Maintain high quality
•
•
compressions with minimal
interruptions
Continuous compressions once
airway secured
Switch CPR provider every 2 min
cycle to avoid fatigue
Shockable and Non-Shockable
START
Charge Defibrillator
Shockable
(VF / Pulseless VT)
CPR
Assess
rhythm
Non-Shockable
(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Shockable
Shockable
(VF)
(VF)
• Bizarre irregular waveform
• No recognisable QRS
•
complexes
Random frequency and
amplitude
• Uncoordinated electrical
activity
• Coarse/fine
• Exclude artefact
• Movement
• Electrical interference
Shockable
Shockable
(VT)
(VT)
• Monomorphic VT
• Broad complex rhythm
• Rapid rate
• Constant QRS morphology
• Polymorphic VT
• Torsade de pointes
Shockable
Shockable
(VF / VT)
(VF / VT)
Shout “(Compressions
Continue) Stand Clear”
Assess
rhythm
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Shockable
Shockable
(VT)
(VF / VT)
CHARGE
DEFIBRILLATOR
Assess
rhythm
Shockable
Shockable
(VT)
(VF / VT)
CHARGE
DEFIBRILLATOR
Assess
rhythm
Shout “Hands Off”
Shockable
Shockable
(VF / VT)
(VF / VT)
Assess
rhythm
Confirmed Hands Off
“I’m Safe”
Shockable
Shockable
(VF / VT)
(VF / VT)
DELIVER
SHOCK
Assess
rhythm
Shockable
Shockable
(VF / VT)
(VF / VT)
IMMEDIATELY
RESTART CPR
Assess
rhythm
Shockable
Shockable
(VF / VT)
(VF / VT)
IMMEDIATELY
RESTART CPR
Assess
rhythm
MINIMISEINTERRUPTIONS
INTERRUPTIONSIN
INCHEST
CHESTCOMPRESSIONS
COMPRESSIONS
MINIMISE
Defibrillation energies
• 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…
Special Circumstances
Well perfused and oxygenated patient pre-arrest
Presenting 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
If VF / VT persists
Deliver
2nd
shock
• 2nd and subsequent
shocks
• 150 – 360 J biphasic
• 360 J monophasic
CPR for 2 min
During CPR
Adrenaline 1 mg IV
Deliver
3rd
shock
CPR for 2 min
During CPR
Amiodarone 300 mg IV
• Give adrenaline and
•
after 2nd shock during
CPR then alternate loops
thereafter
Give amiodarone after
3rd shock during CPR
DUMP/DISCHARG
Non-Shockable
E ENERGY
Shockable
(VF / Pulseless VT)
Assess
rhythm
Non-Shockable
(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Non-Shockable
Non-shockable
(Asystole)
(Asystole)
• 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
Non-shockable
(Asystole)
(PEA)
• Clinical features of cardiac arrest
• ECG normally associated with an output
• Adrenaline 1 mg IV then every alternate loop
During CPR
During CPR
Airway adjuncts (LMA / ETT)
Oxygen
Waveform capnography
IV / IO access
Plan actions before interrupting compressions
(e.g. charge manual defibrillator)
Drugs
Shockable
• Adrenaline 1 mg after 2ndshock (then every 2nd cycle)
• Amiodarone 300 mg after 3rd shock
Non Shockable
• Adrenaline 1 mg immediately (then every 2nd cycle)
Airway and ventilation
• Secure airway:
• Supraglottic airway device e.g. LMA, i-gel
• 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
• Capnography
Vascular access
• Peripheral versus central
veins
• Intraosseous
Reversible causes
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
• Rapid cooling to 39 C
resemble septic shock
• Core temp >40.6 C
• Rhabdomyolysis,
coagulopathy issues
• Consider Drug toxicity,
MDMA, malignant
hyperthermia, thyroid
storm
•
•
•
•
(similar
approaches/techniques to
hypothermia)
Large fluid volumes
Correct electrolyte
abnormalities/acidosis
Dantrolene for some
MDMA/anaesthetic agent
reactions
No specific medications for
heat stroke effective
Tension pneumothorax
• Check tube position if
intubated
• Clinical signs
• Decreased breath sounds
• Hyper-resonant percussion
note
• Tracheal deviation
• Initial treatment with
needle decompression or
thoracostomy
Tamponade, cardiac
• Difficult to diagnose
without echocardiography
• Consider if penetrating
chest trauma or after
cardiac surgery
• Treat with needle
pericardiocentesis or
resuscitative thoracotomy
Toxins
• Rare unless evidence of
deliberate overdose
• Review drug chart
Thrombosis
• If high clinical probability
for PE consider fibrinolytic
therapy
• If fibrinolytic therapy given
continue CPR for up to
60-90 min before
discontinuing resuscitation
Ultrasound
• In skilled hands may
identify reversible
causes
• 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?
Summary
• 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
Advanced Life Support Course
Slide set
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© Australian Resuscitation Council and Resuscitation Council (UK) 2010