als recertification course arc als level 2/als. course health & safety requirement to cover...
TRANSCRIPT
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ALS Recertification Course
ARC ALS level 2/ALS
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Course Health & SafetyRequirement to Cover
Report Pre-existing Injury
or
Injury Sustained During Course Immediately
Latex or Other Allergy
Defibrillator Safety
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• Standardised CPR for adults
• Update on clinical changes to resuscitation guidelines
• Re-evaluation of knowledge and practical skills acquisition
• Assessment
ALS recertification course learning outcomes
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ALS recertification course format
• Manual
• Lectures
• Skill stations
• Cardiac Arrest Simulation (CAS) training
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ALS recertification course assessment
• MCQ
• Practical skills (continuous assessment)• Airway management• Initial assessment and resuscitation
• Cardiac Arrest Simulation (CASTest)
• Provider certificate valid for 4 years
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Causes and Prevention of Cardiac Arrest
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Early recognition ofthe deteriorating patient
• Most arrests are predictable
• Deterioration prior to 50 - 80% of cardiac arrests
• Hypoxia and hypotension are common antecedents
• Delays in referral to higher levels of care
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Recognition of the deteriorating patient -Early Warning Scoring Systems
Example Escalation Protocol based on early warning score (EWS)Total Early Warning Score Dictates:
•3-5 Inform Nurse in-charge
•6 Doctor to see within the hour
•7-8 Doctor to see within 30 minutes with senior doctor
•>8 Doctor to see within 15 minutes
Example of early warning scoring (EWS) system** From Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7
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The ABCDE approach to the deteriorating patient
Airway
Breathing
Circulation
Disability
Exposure
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ALS Algorithm
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• Patient response
• Open airway
• Check for normal breathing• Caution agonal breathing
• Check circulation
• Monitoring
To confirm cardiac arrest…Unresponsive?Not breathing or
only occasional gasps
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Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
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Cardiac arrest confirmedUnresponsive?Not breathing or
only occasional gasps
Call resuscitation team
CPR 30:2Attach defibrillator / monitor
Minimise interruptions
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Chest compression• 30:2• Compressions
• Centre of chest• Min 5cm depth/one third total• Approximately 100min-1
- About 2 per second (not faster than 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
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Adult ALS Algorithm
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Resuscitation team
• Roles planned in advance• Identify team leader• Importance of non-technical skills
• Task management• Team working• Situational awareness• Decision making
• Structured communication
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Shockable and Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Charge START Defibrillator
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
CPR
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• Uncoordinated electrical activity
• Coarse/fine• Exclude artefact
• Movement• Electrical interference
Shockable (VF)Shockable
(VF)
• Bizarre irregular waveform• No recognisable QRS
complexes• Random frequency and
amplitude
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Shockable (VT)Shockable
(VT)
• Polymorphic VT• Torsade de pointes
• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology
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Shockable (VF / VT)
Shout “(Compressions Continue) Stand Clear”
Assessrhythm
Shockable
(VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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Shockable (VT)
CHARGE DEFIBRILLATOR
Assessrhythm
Shockable
(VF / VT)
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Shockable (VT)
Assessrhythm
Shockable
(VF / VT)
Shout “Hands Off”
CHARGE DEFIBRILLATOR
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Shockable (VF / VT)
Assessrhythm
Shockable
(VF / VT)
Confirmed Hands Off“I’m Safe”
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Shockable (VF / VT)
DELIVER SHOCK
Assessrhythm
Shockable
(VF / VT)
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Shockable (VF / VT)
IMMEDIATELY RESTART CPR
Assessrhythm
Shockable
(VF / VT)
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Shockable (VF / VT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assessrhythm
Shockable
(VF / VT)
IMMEDIATELY RESTART CPR
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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• 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…
Defibrillation energies
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Special Circumstances
Well perfused and oxygenated patient pre-arrestPresenting arrest shockable
• Three stacked shocks•First shock delivered within 20 seconds of onset of arrest•Rapid charging defibrillator (<3 to 5 seconds)
• Precordial thump•Pulseless VT only•Defibrillator unavailable •Delivered within 20 seconds of onset of arrest
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• 2nd and subsequent shocks• 200 J biphasic• 360 J monophasic
• Give adrenaline and after 2nd shock during CPR then alternate loops thereafter
• Give amiodarone after 3rd shock during CPR
If VF / VT persists
CPR for 2 minDuring CPR
Adrenaline 1 mg IV
CPR for 2 minDuring CPR
Amiodarone 300 mg IV
Deliver 2nd shock
Deliver 3rd shock
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Non-Shockable
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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Non-Shockable
Assessrhythm
Shockable
(VF / Pulseless VT)
Non-Shockable
(PEA / Asystole)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
DUMP/DISCHARGE
ENERGY
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• 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 (Asystole)Non-Shockable
(Asystole)
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• Clinical features of cardiac arrest• ECG normally associated with an output• Adrenaline 1 mg IV then every alternate loop
Non-shockable (Asystole)Non-Shockable
(PEA)
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During CPRDuring CPR
Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO accessPlan actions before interrupting compressions
(e.g. charge manual defibrillator)Drugs
Shockable• Adrenaline 1 mg after 2ndshock (then every 2nd loop)• Amiodarone 300 mg after 3rd shock Non Shockable• Adrenaline 1 mg immediately (then every 2nd loop)
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Airway and ventilation
• Secure airway:• Supraglottic airway device • 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
• Waveform capnography
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Vascular access
• Peripheral versus central veins
• Intraosseous
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Reversible causesHyperthermia
Hypokalaemia/metabolic
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Hypoxia
• Ensure patent airway
• Give high-flow supplemental oxygen
• Avoid hyperventilation
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Hypovolaemia
• Seek evidence of hypovolaemia• History• Examination
- Internal haemorrhage- External haemorrhage- Check surgical drains
• Control haemorrhage• Haemorrhage not only cause
• If hypovolaemia suspected give intravenous fluids
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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
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Hypothermia
• Rare if patient is an in-patient
• Use low reading thermometer
• Treat with active rewarming techniques
• Consider cardiopulmonary bypass
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Hyperthermia (Core temp >40.6 C)
• Heat stroke can resemble septic shock
• Rhabdomyolysis, coagulopathy issues
• Consider Drug toxicity, MDMA, malignant hyperthermia, thyroid storm
• Rapid cooling to 39 C (similar approaches/techniques to hypothermia)
• Large fluid volumes required
• Correct electrolyte abnormalities/acidosis
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Tension pneumothorax
• Check tube position if intubated
• Clinical signs (some/all not be present peri-arrest)
• Decreased breath sounds• Hyper-resonant percussion note• Tracheal deviation
• Initial treatment with needle decompression or thoracostomy• Follow up with Chest Tube
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Tamponade, cardiac
• Difficult to diagnose without echocardiography
• Consider if penetrating chest trauma or after cardiac surgery• Also:
- Recent Myocardial Infarct- Blunt Chest Trauma- Procedural – Cardiac
Catheter/Pacing Wire etcTreat with needle pericardiocentesis or resuscitative thoracotomy
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Toxins
• Rare unless evidence of deliberate overdose
• Presenting history may give clues
• Review drug chart
• Toxicology screens take time
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Thrombosis
• If high clinical probability for PE consider fibrinolytic therapy
If fibrinolytic therapy is given then consideration may be required for continuing CPR for up to 60-90 min
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Ultrasound
• In skilled hands may identify reversible causes
• In particular Tamponade, Tension Pneumothorax Hypovolaemia, and Thrombosis
• Obtain images during rhythm checks and CPR
• Do not interrupt CPR
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Post Resuscitation Care
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Post resuscitation care
The goal is to restore:
• Normal cerebral function
• Stable cardiac rhythm
• Adequate organ perfusion
• Quality of life
• FOLLOW ABCDE approach
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Post cardiac arrest syndrome
• Post cardiac arrest brain injury:• Coma, seizures, myoclonus
• Post cardiac arrest myocardial dysfunction
• Systemic ischaemia-reperfusion response• ‘Sepsis-like’ syndrome
• Persistence of precipitating pathology
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Therapeutic hypothermiaWho to cool?
• Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC
• May benefit patients after non-shockable/in-hospital cardiac arrest
• Exclusions: severe sepsis, pre-existing medical coagulopathy
• Start as soon as possible and continue for 24 h
• Rewarm slowly 0.25oC h-1
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Therapeutic hypothermiaPhysiological effects and complications
• Shivering: sedate +/- neuromuscular blocking drug
• Bradycardia and cardiovascular instability• Infection• Hyperglycaemia• Electrolyte abnormalities• Increased amylase values• Reduced clearance of drugs
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Any questions?
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• 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
• Resuscitation does not end with ROSC
• Role of resuscitation team
Summary
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Peri-Arrest
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Bradycardia / Tachyarrhythmia algorithm
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Bradycardia algorithmIncludes rates inappropriately slow for haemodynamic state
Interim measures:
•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing
Interim measures:
•Atropine 500 - 600 mcg IV repeat to maximum of 3 mg •Isoprenaline 5 mcg min-1 IV •Adrenaline 2-10 mcg min-1 IV•Alternative drugs *OR •Transcutaneous pacing
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Tachycardia algorithm (with pulse)
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Tachycardia algorithm
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Stable broad-complex tachycardia
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Stable narrow-complex tachycardia
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Any questions?
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Summary
• Modifications to ALS are based upon current evidence
• Focus is on standardised CPR for adults
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Advanced Life Support Recertification Course
Slide setAll rights reserved
© Australian Resuscitation Council and Resuscitation Council (UK) 2010