This document summarizes updates to the Advanced Life Support guidelines from 2015 to 2020. Key changes include: - Lignocaine dosage recommendations for IV/IO administration were updated. - Emphasis on early adrenaline administration for non-shockable and shockable rhythms. - Double sequential defibrillation is not recommended. - Standard adrenaline dosing remains 1mg every 3-5 minutes but high dose is not routinely advised. - Amiodarone and lidocaine can be considered for refractory ventricular fibrillation/pulseless ventricular tachycardia.

1. Advanced Life Support Course
(updated 2020)

2. ,

4. 2015
2020

5. 2020
Lignocaine IV/IO
1stdose 1–1.5mg/kg
2nddose 0.5–0.75mg/kg

8. NEW

9. Reversible Causes
• Hypovolemia  is the IV drip running? Any bleeding? Sign
of dehydration
• Hypoxia O2 connected? How’s bagging? Chest rise?
• Hydrogen ion (acidosis) VBG/ABG?
• Hypo-/hyperkalemia  RP/K+ level?
• Hypothermia  Temperature?
• Tension pneumothorax trachea central? Hyper-
resonance? No air entry?
• Tamponade, cardiac  Ultrasound? Beck’s triad?
• Toxins  history from witness?
• Thrombosis, pulmonary  history? Risk factor? Ultrasound?
• Thrombosis, coronary  history? ECG prior (if any)?

10. EmphasisonEarlyAdrenaline
2020(Unchanged/Reaffirmed):
NON-SHOCKABLE RHYTHM:
Itisreasonable to administer epinephrine as soonas
feasible.
SHOCKABLERHYTHM:
It may be reasonable to administer epinephrine after initial
defibrillation attemptshave failed

11. Importance
of Early
Defibrillation

12. DoubleSequentialDefibrillation
–Not Recommended
2020 (New):
2020 ILCOR systematic review found no evidence
to support and recommended against its routine
use.
A recent pilot RCT suggests that changing
the direction of defibrillation current by repositioningthepads may be as
effective & avoiding the risks of harm from increased energy and damage
to defibrillators.

13. RR10bpm Spo2 92 –98%
PCo2 35–45mmHgor
ETCO2 30–40mmHg
SBP >90mmHg
MAP >65mmHg

15. Standard dose adrenaline
• Standard-dose epinephrine (1 mg every 3 to
5minutes) may be reasonable for patients in
cardiac arrest (Class IIb, LOE B-R).
• High-dose epinephrine is not recommended
for routine use in cardiac arrest (Class III: No
Benefit,LOE B-R).

16. Early adrenaline?
• For initial non-shockable rhythm: It may be
reasonable to administer adrenaline as soon as
feasible after the onset of cardiac arrest (Class
IIb,LOE C-LD).
• For initial shockable rhyhtm: There is insufficient
evidence to make a recommendation as to the
optimal timing of adrenaline, particularly in
relation to defibrillation

17. Amiodarone & Lidocaine
• Amiodarone may be considered for VF/pVT
that is unresponsive to CPR, defibrillation, and
a vasopressor therapy (Class IIb, LOE B-R).
• Lidocaine may be considered as an alternative
to amiodarone for VF/pVT that is unresponsive
to CPR, defibrillation, and vasopressor therapy
(Class IIb, LOE C-LD).

18. IV access
• “…none (of the antiarrhythmics) have yet been
proven to increase long term survival or
survival with good neurologic outcome. Thus
establishing vascular access to enable drug
administration should not compromise the
quality of CPR or timely defibrillation, which
are known to improve survival.”

19. FOCUS ECHOCARDIOGRAPHIC
EVALUTION IN LIFE SUPPORT = FEEL
Ultrasound (cardiac or noncardiac )may be
considered during the management of
cardiac arrest, although its usefulness has
not been well established (Class IIb, LOE CEO).
If a qualified sonographer is present and
use of ultrasound does not interfere with the
standard cardiac arrest treatment protocol,
then ultrasound may be considered as an
adjunct to standard patient evaluation (Class
IIb, LOE C-EO).

20. Hypothermia post ROSC
“…..Nevertheless, it is important to acknowledge
that there may be a clinically relevant benefit of
controlling the body temperature at 36°C,
instead of allowing fever to develop in patients
who have been resuscitated after cardiac
arrest.”
- No fever please.

29. Synchronized Cardioversion

31. • Updated 2020:
- Dr Sazwan RS
- Dr Lim See Choo