Advanced Life Support

• Cardiac arrest


  Result of the heart ceasing to beat, or alternatively beating too fast, ultimately resulting in inadequate tissue perfusion - particularly to the brain

  
• Importance of cardiac arrest

  • Our brain requires oxygen and nutrients when cardiac arrest occurs it does not receive these. After around 2 - 3 minutes without oxygen brain injury begins to occur. After 8 - 10 minutes irreparable brain damage can occur and chances of recovery plummet.
• Causes of cardiac arrest

  • Ischemic heart disease (such as CAD or atherosclerosis)
  • Congestive heart failure
  • ACS (such as AMI or unstable angina)
  • Congenital defects
  • Inflammation/infection (pericarditis, endocarditis, etc)
  • Lifestyle factors (such as high cholesterol, high blood pressure and poor diet)
  • Reversible causes --> 4 H's & 4 T's
  • Acute dissecting AAA

  
• Recognition of cardiac arrest

  • Unresponsive
  • Not breathing normally
  • Carotid pulse unable to be palpated confidently
  • Pallor (unhealthy pale appearance) or central cyanosis
  • Inadequate pulse (<40 bpm in a child/adult, <60 bpm in an infant, <100 bpm in a newborn)

  
• Key CPR aspects


  • Ventilation duration 1 second
  • Consider use of metronome and count aloud from 20 to determine next ventilation
  • Swap compressors every 2 minutes
  • Minimise hands-off chest time
  • CPR should commence immediately after a shock is delivered
  • Rate: 100 - 120 compressions per minute
  • Depth 1/3 chest depth
  • Maintain full recoil (no leaning)
  • Compression lower ½ sternum
• ALS differences


  • Use of manual defibrillation
  • Use of advanced airways (supraglottic airways)
  • Intravenous cannulation
  • Drug administration
  • Waveform Capnography
  • Larger range of considerations

  
• Defibrillation


  The goal is to cease the dysrhythmia, so the heart can restart in a perfusing rhythm
• Rhythm categories


  • Shockable (Ventricular fibrillation, Pulseless ventricular tachycardia)
  • Non-shockable (Everything else, ranging from asystole to normal sinus)
• Manual defibrillation


  • Ensure pads are applied correctly
  • Have an energy select button, charge button, and shock button
  • Analyse every 2 minutes (equivalent to 5 cycles of 30:2 CPR)
• Coached method


  1. Continue Compressions

  2. Oxygen Away

  3. All Else Clear

  4. Charging

  5. Hands off

  6. Evaluate Rhythm

  7. Defibrillate/ Disarm
• Advanced airways


  • Switch to continuous compressions
  • Ventilate once every 6 seconds
  • Do not squeeze the bag too hard
  • No need to remove oxygen when defibrillating
  • Be careful with SGA (Superaglottic airway) positioning and perform patency checks
• Cannulation


  • Patient likely peripherally shut down, making access harder
  • Use a large bore cannula if possible
  • Consider timing relative to defibrillation
  • Prioritise safety and prepare for success
• Drugs


  • Adrenaline
  • Amiodarone
  • Fluids
• Adrenaline


  Helps in cardiac arrest by increasing arterial pressure and coronary perfusion. Dose: 1mg administered via IV every 4 minutes (every second cycle)
• Amiodarone


  An antiarrhythmic that works by slowing down cardiac cell metabolism, to help slow the heart down. In paramedic scope only.
• Fluids


  Can cause injury or poor morbidity when used inappropriately, so use with caution.
• Waveform Capnography


  Measurement of exhaled carbon dioxide (CO2), displayed as a waveform and mmHg value on the monitor. Provides valuable information on patient's ventilation status.
• Use of waveform capnography in cardiac arrest

  • Indicator for effectiveness of compression (aim for output of 20 mmHg or more, minimum of 10 mmHg)
  • One of the most effective and reliable indicators for ROSC (sudden increase indicates rebreathing)
  • Normal EtCO2 is 35-40mmHg

  
• Paediatric considerations


  • Not a full head tilt in paediatrics, neutral position in infants
  • Anterior posterior pad placement when <8 years
  • One hand technique for <8 years and small children, two finger for infants
  • Two initial rescue breaths prior to commencing CPR
  • 2:15 ventilation to compression ratio (no pause when advanced airway in situ)
  • Defibrillation Joules: 4 J/kg
  • No cannulation and drug administration for paediatrics

  
• Correctable causes of cardiac arrest (Hs & Ts)

  • Things to consider as causes for the arrest, some can be fixed

  
• Post ROSC cares


  • Prepare for rearrest
  • Manage patient with advanced airway supine
  • Work out resp rate and supplement if needed
  • Measure appropriate vital signs early and repeatedly
  • Obtain 12-lead early
  • Treat precipitating causes of arrest (think Hs and Ts)
  • Aim for Sp02 94-98%, normocapnia, normoglycaemia
  • Provide temperature management (aim for 32-36 degrees Celsius)

  
• During CPR

  1. Airway Adjuncts (LMA / ETT)
  2. O2
  3. Waveform Capnography
  4. IV/IO access
  5. Plan actions before interruptions compressions (e.g charge manual defib)
• Drugs


  Shockable rhythms

  • Adrenaline (1 mg after 2nd shock, then every 2nd loop)
  • Amiodarone (300mg after 3 shocks, Only in paramedic scope)

  Non-shockable rhythms

  • Adrenaline (1mg immediately, then every 2nd loop)
• Why do we shock these Rhythms?

  The hope is that once defibrillation has knocked out all electrical activity, one of the hearts intrinsic pacemaker sites (preferably the SA node or at least the AV node) will resume function and set a more normal rhythm
• Defibrillation Considerations


  • Do not defib conscious pts in our setting
  • Sedative is generally administered if necessary to shock a conscious pt → prepare for potential asystole
  • Do not defib pulse-producing rhythm even if the rhythm is weak and may deteriorate → natural pacemaker rhythm is better than manual cardiac compressions
• Manual Defibrillation


  1. Operator(s) must determine whether ECG is pulseless VT, TdP or VF

  2. If one of these rhythms, administer shock

  3. If not a shockable rhythm, defib must be disarmed and compressions continued

  
• Paediatrics


  1. Rhythm analysis performed using AED

  2. Operator turn to manual defib to adjust the correct joules of defib for pt weight

  3. Proceed in AED setting for first shock before switching to manual
• Reversible Causes (4 Hʼs and 4Tʼs)

  • Hypovolemia
  • Hypoxia
  • Hydrogen Ions
  • Hypo/Hyperkalemia
  • Hypoglycaemia
  • Hypothermia
  • Toxins
  • Tamponade
  • Tension Pneumothorax
  • Thrombosis PE
• Hypovolemia


  • Decreased volume in vasculature Less blood in blood vessels
  • Decreased tissue perfusion Less blood flow to bodyʼs tissues
• Hypoxia


  • Low lvls of O2 in tissues of body
  • Body tissues are not getting enough oxygenated blood flow and oxygen supply
• Hydrogen Ions


  Acidosis in the blood → making blood acidic
• Hypo/Hyperkalemia

  • Hypo = 3.5 seconds ECG changes<2.7
  • Hyper = 5.5 seconds
• Hypoglycaemia

  Low blood sugar
• Hypothermia

  Temp 35 degrees
• Toxins

  • Calcium channel blockers
  • Beta blockers
  • Digoxin
  • TCAs
  • Cocaine
• Tamponade


  • Fluid buildup around heart
  • Prevents filling of heart → reduced cardiac output CO
• Tension Pneumothorax


  Can happen during broken ribs from CPR that puncture lung or over-ventilation. Over-ventilation can cause alveoli in lungs to rupture
• Thrombosis PE


  Partial or complete pulmonary vessel blockage Stops or reduce flow of blood back to heart Pulmonary Vessel Occlusion)
• COACHED - Process of pausing for rhythm check and defib

  1. Continue compressions

  2. Oxygen away (only from free-flowing BVM

  3. All else clear

  4. Charging defib 200 joules)

  5. Hands off

  6. Evaluate rhythm

  7. Defib
• POST-ROSC Care


  • Response
  • Airway
  • Breathing
  • Circulation
  • Decision / Disability