###### Created: 2024-05-21 13:34 ###### Areas & Topics: #medicine #emergency ###### Note Type: #permanent ###### Connected to: [[Reversible Causes of Pulseless Electrical Activity (PEA)]] - Adult Advanced Life Support (AALS) are the set of protocols and systems created to add to basic life-support techniques (e.g. ABCDE, CPR) and provide further support and protection to the airways and circulation of deteriorating patients. - These guidelines are used in the resuscitation of in-hospital patients. The most important factors for improving survival in cardiac arrest patients are: 1. Prompt and effective bystander CPR. 2. Uninterrupted, high quality chest compressions. 3. Early defibrillation for VF/VT. - The use of adrenaline has been shown to increase return of spontaneous circulation (ROSC), but all other resuscitation drugs and airway techniques have not been shown to improve survival. - This means that the top priority for resuscitation is always high quality and prompt CPR along with appropriate and early defibrillation, followed secondarily by the other included management. ### Chest Compressions - CPR is always given with 30 chest compressions to 2 rescue breaths. - Chest compressions should be delivered at a depth of 5 to 6cm and a rate of 100 to 120bpm. - There should be as little interruption to CPR as possible, as high quality chest compression is an important prognostic factors in cardiac arrest outcomes. - Whilst CPR is being given, a defibrillator should be attached to the patient and charged, ready for if shock is needed. ### Airway and Ventilation - A bag-valve mask, or preferably supraglottic airway device (e.g. oropharyngeal airway, i-gel, laryngeal mask) should be used in the first instance if tracheal intubation is not immediately available. - The gold standard for airway management in cardiac arrest is tracheal intubation (see [[Airway Management]] for further details), which should be administered ONLY by a practitioner with a high success rate in the procedure. - When appropriate airway management is in place, the lungs should be ventilated at a rate of 10 breaths per minute, with no pausing of compressions during ventilation. ### Defibrillation - Cardiac defibrillation is the process of administering a transthoracic electrical current to a patient experiencing ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). - There is a misconception that defibrillation 'jump-starts' the heart. - In actuality, the electrical shock delivered to the heart is causing simultaneous depolarisation of the majority of myocardial tissue. - This, for a very short instance, ceases all activity in the heart. - This then allows a normal area of the heart's electrical system to initiate an electrical impulse, resulting in the rest of system being activated and, in ideal circumstances, starting a normal cardiac cycle and rhythm for the patient. #### Energy Levels - There is a wide range of recommendations from manufacturers and guidelines regarding what energy level to use whilst operating a defibrillator. - In the absence of clear instruction, any amount of energy between 120 to 360J is acceptable for a first shock. - Subsequent shocks should either be fixed to a certain amount of energy or escalated to the maximum amount of energy permitted. #### Safety Tips When ready to administer a shock: 1. Take off any oxygen administering devices and place them at least 1m away from the patient while shocking. 2. Tell all practitioners to 'clear' themselves from the patient before shocking. ### Shockable and Non-Shockable Rhythms - AALS divides patients into those with shockable rhythms and non-shockable rhythms. #### Shockable Rhythms - The shockable rhythms are ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). - Ventricular fibrillation (VF) typically occurs where there is a disruption to the normal electrical signalling in the heart, causing multiple dysrhythmic firing from multiple nodes in the heart, leading to the fibrillation or 'quivering' of the ventricles. - Pulseless ventricular tachycardia (VT) is where the ventricles of the heart are contracting too quickly, stopping adequate filling and thereby not allowing blood to be pumped around the body resulting in a lack of a pulse. - Both of these conditions are treatable with defibrillation as the electrical system of the heart is still intact and therefore can benefit from simultaneous depolarisation and re-initiation. #### Non-Shockable Rhythms - The non-shockable rhythms are asystole and pulseless electrical activity (PEA) - Asystole is where electrical activity in the heart is disrupted, leading to a total cessation of electrical and mechanical activity. - Asystole is non-shockable as the electrical system of the heart is not functional, so causing wide-scale depolarisation would not lead to the heart conducting electrical impulses again and therefore would not restart the cardiac cycle. - Pulseless electrical activity (PEA) is where there is electrical activity occurring in the heart, but the heart musculature is not able to contract well enough to generate adequate blood flow or a pulse. - PEA is non-shockable as the mechanical ability of the heart is stopping adequate contraction of circulation rather than dysregulation of damage to the electrical system of the heart, so a change to the electrical system with defibrillation would be ineffective. ### Drug Delivery - In a patient requiring AALS, intravenous (IV) access should be obtained as soon as possible. - If IV access is not possible, intra-osseous (IO) access is second-line. #### Adrenaline - Adrenaline 1mg IV/IO is the only vasopressor given in AALS. - Give adrenaline 1 mg IV (IO) ASAP for adult patients in cardiac arrest with a non-shockable rhythm. - Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients in cardiac arrest with a shockable rhythm. - Repeat adrenaline 1 mg IV (IO) every 3-5 minutes whilst ALS continues. #### Amiodarone - Give amiodarone 300 mg IV/IO after the 3rd shock for adult patients in cardiac arrest with a shockable rhythm. - Give a further dose of amiodarone 150 mg IV/IO after the 5th shock for adult patients in cardiac arrest with a shockable rhythm. - Lidocaine 100 mg IV/IO may be used as an alternative if amiodarone is not available or a local decision has been made to use lidocaine instead of amiodarone. - An additional bolus of lidocaine 50 mg can also be given after five defibrillation attempts. #### Thrombolytics - If a pulmonary embolus is the suspected or confirmed cause of cardiac arrest, consider thrombolytic drug therapy. - After administration of thrombolytic drugs, consider CPR for 60 to 90 minutes. #### Fluids - IV or IO fluids should only be given if the cardiac arrest is caused by or possibly caused by hypovolaemia. ### AALS Step-By-Step Management After recognising a patient having a cardiac arrest by checking signs of life for 10 seconds: 1. Help (Call for Help and inform 2222) 2. CPR (start CPR immediately) 3. Defibrillate (attach pads whilst CPR is on-going and defibrillate if appropriate) If rhythm is shockable: 1. 1 Shock 2. CPR (immediately restart CPR for 2 minutes) 3. Assess Rhythm 4. Repeat (repeat steps 1 to 3 if there has been no ROSC and patient is still suitable for a 2nd shock) 5. Repeat Again (repeat steps 1 to 3 if there has been no ROSC and patient is still suitable for a 3nd shock) 6. Adrenaline and Amiodarone (following the 3rd shock, if no ROSC then continue CPR and administer adrenaline 1mg IV and amiodarone 300mg IV) 7. Repeat Again (repeat steps 1 to 3 if there has been no ROSC and patient is still in VF/VT) 8. Adrenaline Again (administer adrenaline 1mg IV following every alternate shock whilst continuing CPR) If Rhythm is non-shockable: 1. CPR (start CPR immediately) 2. Adrenaline (administer adrenaline 1mg IV/IO as soon as access is obtained) 3. Airway (continue CPR with as little disruption until the airway is secure) 4. Rhythm Check (after airway is secure continue CPR for 2 minutes before re-checking rhythm) 5. Adrenaline (if there is no ROSC then continue CPR and administer further adrenaline 1mg IV/IO every alternate cycle of CPR) N.B. If a cardiac arrest is witnessed in a monitored patient area with defibrillation immediately available (e.g. a coronary care unit (CCU) or high dependency unit (HDU)) and the patient is in a shockable rhythm, administer 3 stacked shocks (considered as the first initial shock) before continuing through the AALS pathway. N.N.B. Whilst using the algorithm make sure to consider the [[Reversible Causes of Pulseless Electrical Activity (PEA)]], as these can be implicated in multiple conditions leading to cardiac arrest. ![[pdd964b.png]] ### Resources Adult advanced life support Guidelines: https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines Advanced Life Support Algorithm https://lms.resus.org.uk/modules/m25-v2-als-algorithm/11118/resources/chapter_6.pdf Goyal A, Chhabra L, Sciammarella JC, et al. Defibrillation. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499899/ Foglesong A, Mathew D. Pulseless Ventricular Tachycardia. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554467/ Jordan MR, Lopez RA, Morrisonponce D. Asystole. [Updated 2024 Apr 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430866/ Oliver TI, Sadiq U, Grossman SA. Pulseless Electrical Activity. [Updated 2023 Apr 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513349/ Geeky Medics Shockable vs. Non-shockable Rhythms in Cardiac Arrest https://geekymedics.com/shockable-vs-non-shockable-rhythms-in-cardiac-arrest/ Airway Management and Ventilation https://lms.resus.org.uk/modules/m65-non-technical-skills/resources/chapter_7.pdf