2. ALS Subcommittee 2010
OBJECTIVES
Upon completion of this session, you will be able
to:
List the 4 arrhythmias leading to cardiac arrest
State the treatment algorithms for VF/ pulseless
VT, PEA and Asystole
Understand the principles of management of
tachy and brady arrythmias
3. ALS Subcommittee 2010
Cardiac Arrest
Occurs with one of 4 arrhythmias:
ventricular fibrillation (VF)
pulseless ventricular tachycardia (VT)
pulseless electrical activity (PEA)
asystole
5. 1. DANGER
2. RESPONSIVENESS
3. SHOUT FOR HELP AND DEFIBRILLATOR
4. AIRWAY OPENING
5. BREATHING
6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION
Push hard 5cm deep,
Push fast 100 per minute
Minimize interruption of chest compression
Allow complete chest recoil
Do NOT hyperventilate
Compression to ventilation ratio 30:2 if not intubated
DEFIBRILLATION
360J for monophasic, 120-200J for biphasic
IV or IO ACCESS
DRUGS
IV Adrenaline 1 mg push
IV Vasopressin 40 U (as first or second drug after Adrenaline
IV AMIODARONE 300mg bolus, 150 mg second dose
6. 1. DANGER
2. RESPONSIVENESS
3. SHOUT FOR HELP AND DEFIBRILLATOR
4. AIRWAY OPENING
5. BREATHING
6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION
Push hard 5cm deep,
Push fast 100 per minute
Minimize interruption of chest compression
Allow complete chest recoil
Do NOT hyperventilate
Compression to ventilation ratio 30:2 if not intubated
IV or IO ACCESS
DRUGS
IV Adrenaline 1 mg push
IV Vasopressin 40 U (as first or second drug after
Adrenaline
IV AMIODARONE 300mg bolus, 150 mg second dose
Hydrogen ion
Hypoxia
Hypothermia
Hypovolemia
Hypo/hyperkalemia
Hypoglycemia
Trauma
Tension pneumothorax
Thrombosis(coronary)
Thrombosis(pulmonary)
Tamponade
10. ALS Subcommittee 2010
Right Left
A: Air under
tension in left
thorax
A
Pleural
margin;
partial
lung
collapse
Tension Pneumothorax
11. ALS Subcommittee 2010
Asystole Algorithm
Adrenaline 1 mg IV push,
repeat every 3 to 5 minutes,
Vasopression 40U may replace 1
dose of adrenaline
If Asystole persists
Withhold or cease resuscitation efforts?
•Consider quality of resuscitation?
•Atypical clinical features present?
•Search for DNR order
13. ATROPINE 0.5mg to 3mg OR
DOPAMINE 5 to 10mcg.kg.min OR
ADRENALINE 2-10 mcg/kg/min
Assess clinically
Identify and treat
underlying cause
Ensure airway patency
Oxygen supplement
Cardiac monitor
Establish IV access
Perform 12 lead ECG
Hemodynamic instability
- Hypotension
- altered mental status
- signs of shock
- acute heart failure
14. ALS Subcommittee 2010
Tachyarrhythmia
Is patient stable or unstable?
Patient has serious signs or symptoms?
Chest pain (ischemic? possible ACS?)
Shortness of breath (lungs getting ‘wet’? possible CCF?)
Low blood pressure (orthostatic? dizzy? lightheaded?)
Decreased level of consciousness (poor cerebral perfusion?)
Clinical shock (cool and clammy? peripheral vasoconstriction?)
Are the signs and symptoms due to the rapid
heart rate?
16. Unstable, with serious signs or
symptoms
ie : Heart failure, SBP<90, In shock
Tachycardia Algorithm
Immediate
synchronised
cardioversion
Narrow Complex
Tachycardia
•Assess: Responsiveness • ECG monitor
•Shout: Help/defibrillator • Assess vital signs
•Assess: ABC • Review history
•Administer oxygen • Perform physical exam
•Establish IV • Do 12 Lead ECG
Wide Complex
Tachycardia
Polymorphic VT
Yes
No
17. ALS Subcommittee 2010
Postresuscitation Stabilisation
• Support of `stunned’ myocardium - may
require vasoactive support
• Keep hypothermic (32-34°C) for VF or
non VF arrest for 12 to 24h
• Maintain strict glucose control (4 -
6mmol/l)
• Monitor clinical signs
18. ALS Subcommittee 2010
SUMMARY
• Effective ALS begins with high quality CPR
• Uninterrupted high quality chest compressions
improve outcome
– Rhythm check, rescue breath, even drug administration
should NOT interrupt compressions
• Early recognition & treatment of arrhythmias
give the best chance of survival
• Search for treatable causes of PEA
• Post-resuscitation period is important
• Know algorithms well
19. ALS Subcommittee 2010
THANK YOU
NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
Dr Tan Cheng Cheng
Dr Luah Lean Wah
Dr Ismail Tan
Dr Wan Nasrudin
Dr Chong Yoon Sin
Dr Priya Gill
Dr Ridzuan bin Dato’ Mohd Isa
Dr Thohiroh Abdul Razak
Dr Adi Osman