ALS Algorithm

1. Lecture
ALSAlgorithm
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2. Learning outcomes
By the end of this lecture you should:
• Know the ALS algorithm
• Understand the treatment of shockable and non-
shockable rhythms
• Know potentially reversible causes of cardiac arrest
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3. Adult ALS Algorithm
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4. To confirm cardiac arrest…
• Patient response
• Open airway
• Check for normal breathing
• Check circulation
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5. To confirm cardiac arrest…
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6. Cardiac arrest confirmed
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7. Shockable and Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
START STOP
Assess
rhythm
Shockable
(VF / PulselessVT)
Non-Shockable
(PEA / Asystole)
CPR
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8. Shockable (VF)
• Uncoordinated
electrical activity
• Coarse/fine
• Exclude artefact
– Movement
– Electrical interference
• Bizarre irregular
waveform
• No recognisableQRS
complexes
• Random frequency and
amplitude
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9. Shockable (pVT)
• MonomorphicVT
– Broad complex rythm
– Rapid rate
– Constant QRS morphology
• PolymorphicVT
– Torsade de pointes
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10. Shockable (VF / pVT)
START
CPR
Assess
rhythm
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STOP
CPR
< 2 sec

11. Shockable (VF / pVT)
CHARGE
DEFIBRILLATOR
Assess
rhythm
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< 2 sec

12. Shockable (VF / pVT)
DELIVER
SHOCK
Assess
rhythm
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< 2 sec
STOP
CPR
< 3 sec

13. Shockable (VF / pVT)
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IMMEDIATELY
RESTART CPR
Assess
rhythm
< 2 sec < 3 sec

14. Shockable (VF / pVT)
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
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IMMEDIATELY
RESTART CPR
Assess
rhythm

15. Defibrillation energies
• Defined by manufacturer
• 150 J – 360 J biphasic (360 J monophasic)
• If unsure, deliver highest available energy
• DO NOT DELAY SHOCK
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16. PersistingVF / pVT (2nd shock)
2nd and subsequent shocks
• 150 – 360 J biphasic
• 360 J monophasic
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MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assess
rhythm

17. PersistingVF /VT (3rd shock)
Give adrenaline and
amiodarone after 3rd
shock during CPR
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MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assess
rhythm

18. Non-Shockable
MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS
Assess
rhythm
Non-Shockable
(PEA / Asystole)
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19. Non-Shockable (Asystole)
• Absent ventricular (QRS) activity
• Atrial activity (P waves) may persist
• Rarely a straight line trace
• Adrenaline 1 mg IV then every 3-5 min
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20. Non-shockable
(Pulseless Electrical Activity)
• Clinical features of cardiac arrest
• ECG normally associated with an output
• Adrenaline 1 mg IV then every 3-5 min
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21. During CPR
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22. 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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23. Reversible causes
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24. Hypoxia
• Ensure patent airway
• Give high-flow
supplemental oxygen
• Avoid hyperventilation
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25. Hypovolaemia
• Seek evidence of hypovolaemia
– History
– Examination
• Internal haemorrhage
• External haemorrhage
• Check surgical drains
• Control haemorrhage
• If hypovolaemia suspected
give intravenous fluids
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26. 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
• Patient history (vomiting, diarrhoea, dialysis etc.)
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27. Hypothermia
• Rare if patient is an
in-patient
• Use low reading thermometer
• Treat with active
rewarming techniques
• Consider cardiopulmonary
bypass
• Consider tansport with ongoing
CPR in pre-hospital care
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28. 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
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29. Tamponade, cardiac
• Difficult to diagnose without
echocardiography
• Consider if penetrating
chest trauma or after
cardiac surgery
• Treat with needle
pericardiocentesis or
resuscitative thoracotomy
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30. Toxins
• Rare unless evidence
of deliberate overdose
• Review drug chart
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31. 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
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32. Immediate post-cardiac arrest
treatment
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33. Any questions?
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34. Summary
You should now:
• Know the ALS algorithm
• Understand the treatment of shockable and non-
shockable rhythms
• Know potentially reversible causes of cardiac arrest
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