ALS Course 15-16th August 2023

Course overview
The systematic approach
Team dynamics
Airway management and ventilation
ALS core ECG rhythms
Electrical therapy
Drugs in resuscitation
ALS Algorithms
Resuscitation in specific circumstances
Post resuscitation care
Ethics in resuscitation

THE SYSTEMATIC APPROACH

BLS Primary Survey – DRS ABCD

Danger – analyze the environment; look for blood spills, sharps, electric wires?
Responsiveness – is the patient responsive? Tap the shoulder
Shout – shout for help if the patient is unresponsive

Airway – open the airway using non-invasive techniques (head tilt-chin lift; jaw thrust if
trauma is suspected)
Breathing – look for normal breathing in not more than 10s while performing head tilt-chin
lift
Circulation – check pulse simultaneously with breathing assessment. Perform a high quality
CPR if not breathing/abnormal breathing
Defibrillation – is there a shockable rhythm? Check with a manual defibrillator/AED

ALS Secondary Survey – ABCD

Airway maintain airway patency in unconscious patient using head tilt-

chin lift/jaw thrust, oropharyngeal airway (OPA) or
nasopharyngeal airway (NPA)
Use advanced airway if needed e.g ETT, SGA

Breathing assess the adequacy of oxygenation and ventilation by;

- Are oxygenation - clinical criteria (color, chest rise, auscultation)
and ventilation - oxygen saturation
adequate? - capnography
- is proper
placement of airway benefit of advanced airway placement is weighed against the
device confirmed? adverse effects of interrupting chest compressions
- is ETT secured?
- is SP02 monitored? if bag-valve mask ventilation is adequate, insertion of an advanced
 airway may be deferred until the patient fails to respond to initial
CPR and defibrillation or until ROSC
once intubated,
- confirm placement by auscultation, chest rise, color
- secure the device to prevent dislodge
- no more cyclical CPR – perform continuous chest compression at
100-120/min and ventilate at a rate of 10 breaths/min

Circulation obtain IV/IO access, give fluids if needed

- what is initial attach ECG leads
cardiac rhythm? appropriate drugs
- what is current inotropes/vasopressors once ROSC
cardiac rhythm?
- IV line?

Differential find and treat reversible causes (5Hs and 5Ts)

Diagnosis
- Why the patient 5H – Hypoxia, H+, Hypothermia, Hypovolemia, Hypo/hyperkalemia
developed cardiac 5T – Tamponade, Tension pneumothorax, Thrombosis (pulmonary
arrest? or coronary), Toxins

AIRWAY MANAGEMENT AND VENTILATION

Oxygen during CPR

- Use the maximal feasible inspired oxygen concentration if available during CPR
- After ROSC, titrate the inspired O2 to achieve SpO2 94 – 98% or PaO2 75 – 100mmHg

Oxygen Delivering Devices

Device Flow Rates (L/min) Delivered Oxygen (%)

Nasal cannula 1 21-24

2 25-28
3 29-32
4 33-36
5 37-40
6 41-44

Simple Face Mask 6-10 35-60

Venturi Mask 4-8 24-40

10-12 40-50

Mask with O2
reservoir
 - rebreathing 10-15 70-80
- non-rebreathing 10-15 95-100

1. Nasal cannula
- every 1L/min increase in O2 flow rate in Fi02 by 4%

2. Simple face mask

- supplies 35-60% O2 with flow rates of 6 to 10L/min

3. Venturi mask
- based on bernoulli’s principle
- O2 passes through a narrowed orifice and this creates a high-velocity stream of gas. This
high-velocity jet stream generates a shearing force known as viscous drag that pulls room air
into the mask through the entrainment ports on the mask
- ideally for patient with COPD

4. Mask with O2 reservoir

- rebreathing and non-rebreathing

Non-invasive Airway Devices

1. Oropharyngeal airway
- used in comatose patients or patients with loss of airway reflex
- may cause laryngospasm in semi-comatose patients
- size: measure from angle of the mouth to angle of jaw

2. Nasopharyngeal airway
- made of soft rubber/plastic
- used when mouth opening is difficult
- size: measure from tip of the nose to the tragus of the ear

3. Bag-mask ventilation
- the bag mask device is held with an EC clamps technique using either 1 or 2 hands
- overventilation may result in gastric inflation with complications e.g
regurgitation/aspiration

4. Supraglottic Airway Devices (SGAs) – Laryngeal Mask Airway (LMA)

- does not require visualization of vocal cords, therefore can minimize chest compression
interruptions
- Size of LMA:

Size Weight of patient Max air in cuff not to exceed

2.5 20-30kg 14ml
3 30-50kg 20ml
4 50-70kg 30ml
5 > 70kg 40ml
5. Endotracheal Tube (ETT)
- gold standard for airway management during cardiac arrest
- use together with laryngoscope: Macintosh blade (curved) for adult and miller blade
(straight) for newborn and infants
- Size:
adult male – 7.5 - 8.0mm, anchor at 20 - 22cm
adult female – 7.0 - 7.5mm, anchor at 18 - 20cm
- Preparation for intubation (MALES):
Mask, Magill forceps
Airways
Laryngoscope, Lubricant gel
Suction, Syringe, Stylet, Stethoscope
- Complications of endotracheal Intubation:

during intubation hypoxia, laryngospasm, bronchospasm

hyper/hypotension, tachy/bradycardia, arrhythmia
trauma to teeth, lips, tongue, mucosa, vocal cords, trachea
vomiting and aspiration
arytenoid dislocation  hoarseness

when ETT in-situ migration to bronchus

obstruction from kinking, secretions or over-inflation of cuff
lip ulcer
infection

after extubation sore throat

hoarseness

long term subglottic stenosis

vocal cord granuloma
laryngeal granuloma

ALS CORE ECG RHYTHMS

1. Normal SR

Rate 60-100
QRS complex Norma and narrow <100ms wide
Rhythm Regular, Sinus Rhythm
P wave is followed by a QRS complex
 P wave P interval is constant (PR interval < 0.2s)
Normal P wave morphology and axis (upright in I and II,
inverted in aVR

2. Sinus arrhythmia

Rate varies
QRS complex Narrow
Rhythm Sinus or irregular
P wave Normal

3. Sinus Tachycardia

Rate > 100/min

QRS complex Normal
Rhythm Sinus, regular
P wave P for every QRS complex
P wave may be hidden within each preceding T wave at the
higher rate

4. Supraventricular tachycardia (SVT)

Rate atrial rate 120 – 150/min or > 150bpm

QRS complex Normal and narrow
Rhythm Regular
P wave seldom seen due to rapid rate because p wave “hidden” in
preceding T waves

5. Sinus bradycardia
 Rate <60bpm
QRS complex Normal
Rhythm Regular sinus
P wave Normal, every p wave followed by QRS complex

6. Premature atrial complexes (PAC)

Rate sinus
QRS complex normal and narrow
Rhythm regular sinus with atrial ectopic beat
P wave normal p wave with presence of ectopic atrial beat

7. Premature Ventricular Complexes (PVC)

Rate sinus rate with presence of ventricular ectopic

QRS complex Normal QRS complex with presence of single broad QRS
complex >120ms with abnormal morphology
Rhythm Regular with extra beats, pause beat
P wave Present before normal QRS complex

8. Atrial fibrillation

Rate variable ventricular rate

QRS complex present, usually <120ms
absent isoelectric baseline
Rhythm Irregular
P wave No p waves
Chaotic atrial fibrillatory waves
Fibrillatory waves may mimic P waves

9. Atrial flutter
 Rate Atrial rate 100 to 350 per minute
QRS complex Present
Rhythm Regular
Ventricular rhythm often regular
set ratio atrial rhythm e.g 2 to 1
P wave No true P waves
Flutter waves in “sawtooth” pattern

10. 1st degree heart block

Rate sinus rate

QRS complex normal and narrow
Rhythm Regular sinus
P wave Normal, every P wave followed by QRS complex
PR Prolonged >0.2s, fixed

11. 2nd degree AV block Mobitz Type I (Wenkebach)

Rate sinus rate

QRS Complex Normal and narrow
Rhythm Regular sinus
P wave P wave not followed by QRS complex
PR Progressive lengthening of PR interval occur from cycle to
cycle, then one P is not followed by QRS complex “dropped
beat”

12. 2nd degree AV block Mobitz Type II

Rate ususally 60-100/min

QRS complex normal and narrow
Rhythm atrial regular, ventricular irregular
P wave some P wave not followed by QRS complex
 PR constant and set, no progressive prolongation

13. 3rd degree heart block

Rate atrial rate 60 – 100/min, dissociated from ventricle rate

ventricle rate depend on rate of ventricle escape beats
QRS complex complete absence of AV conduction – none of the
supraventricular impulses are conducted to the ventricles.
Rhythm atrial and ventricular rate regular but independently
“dissociated”
P wave normal

14. Multifocal ventricular ectopics

Rate sinus rate with presence of ventricular ectopics

QRS complex normal QRS complexes with presence of single broad QRS
complex
Rhythm sinus rate with irregular ventricular rate
P wave present before normal QRS complex

15. Ventricular bigeminy

Rate sinus rate with presence of ventricular ectopic

QRS complex normal QRS complexes with alternating broad QRS complexes
Rhythm sinus rate with alternating ventricular rate
P wave present before normal QRS complex

16. Couplets

Rate sinus rate

 QRS complex normal QRS complexes with presence of broad QRS complexes
in couplet
Rhythm Sinus rate with irregular ventricular ventricular rate
P wave Present before normal QRS complex

17. Monomorphic VT

Rate >100/min, typically 120-250/min

QRS complex wide and bizarre, PVC like complexes >0.12s
Rhythm Regular ventricular rate
P wave seldom seen but present
Fusion beats Occasional chance capture of a conducted P wave
Resulting QRS “hybrid” complex, part normal and part ventricle
Nonsustained VT Last <30s

18. Polymorphic VT

Rate 150-250/min
QRS complex display classic spindle-node pattern
Rhythm Irregular ventricular rhythm
P wave non-existent

19. Torsades De Pointes

Rate 150-250/min
QRS complex QRS showed continually changing of axis (hence ‘turning of
point’)
QT interval Prolonged
Rhythm Irregular ventricular rhythm
P wave Non-existent

20. Ventricular defibrillation

 Rate 150 – 500/min
QRS complex chaotic irregular deflections of varying amplitude.
No identifiable P waves, QRS complexes, or T waves
Rhythm Indeterminate
Amplitude Can be described as fine (peak to through 2 to <5mm), medium
(5 to <10mm), coarse (10 to <15mm) or very coarse (>15mm)

ELECTRICAL THERAPY

1. Defibrillation
- indicated for pulseless VT (pVT) and VF  then followed by chest compression without any
pulse check or rhythm reanalysis
- shock success: termination of VF within 5s after the shock

Ventricular Fibrillation (VF)

- CPR and defibrillation are the mainstay treatment
- use of adrenaline after 2nd shock
- use of antiarrhythmic after 3rd shock

Ventricular Tachycardia
- pulseless VT = treat as VF
- unstable Polymorphic (Irregular) VT, Torsades de Pointes = treat as VF using defibrillation
doses
- unstable monomorphic (regular) VT with a pulse = treat with biphasic waveform
synchronized cardioversion at 120 – 150J

2. Synchronized Cardioversion
- indicated in a hemodynamically unstable patient (low BP) with a rhythm (pulse present)
- indicated in SVT, AF, Atrial tachycardia, monomorphic VT with pulse
- recommended energy level for synchronized cardioversion

waveform biphasic energy monophasic energy

narrow regular (SVT, Atrial 70 – 120J 100J
flutter)
* give shock using stepwise
increase in energy
narrow irregular (Atrial 120 – 150J 200J
fibrillation)
* give initial sync shock at
maximum defibrillator
output rather than an
escalating approach
 Broad complex tachycardia 120 – 150J 200J
(VT)
Monomorphic VT 120 – 150J 200J

DRUGS IN RESUSCITATION

Highlights of 2020 Resuscitation Guidelines on Drugs in Resuscitation

- Use of adrenaline is highly recommended during CPR
- in non-shockable cardiac arrest, adrenaline is to be administered ASAP
- For shockable rhythm, adrenaline should be administered after initial 2 defibrillation
attempts have failed
- Vasopressin is not recommended to replace adrenaline or to be used together with
adrenaline during CPR

Drugs Indications Dose Side-effect and

precautions
Adenosine - 1st drug for most - Rapid IV push 6mg, - transient
- slows transmission form of stable followed by 20ml NS unpleasant side
across AV node but narrow-complex - If unsuccessful, effects; nausea,
has little effect on PSVT give another 12mg flushing, chest
other myocardial - may be considered 1-2mins later discomfort
cells or conduction for narrow complex - if unsuccessful, - caution if need to
pathways re-entry tachycardia give another 18mg be given in
while preparing for 1-2mins later asthmatic patient
cardioversion - in WPW syndrome,
blockage of
conduction across
the AV node by
adenosine may
promote conduction
across an accessory
pathway
- initial dose should
be reduced to 3mg
in patient taking
dipyridamole or
carbamazepine

Adrenaline - Cardiac arrest cardiac arrest - severe

- administer in - Symptomatic - IV/IO 1mg (1ml hypertension
cardiac arrest will bradycardia: can be 1:1000) given every - tachyarrhythmias
cause intense considered after 3-5mins followed by - tissue necrosis if
vasoconstriction atropine as an 20cc flush extravasation occurs
(alpha adrenergic alternative infusion - give ASAP in non-
action) and divert to dopamine shockable rhythm
cardiac output to - severe - give after failed 2nd
vital organ e.g brain hypotension defibrillation in
and heart - anaphylaxis shockable rhythm
- facilitate - if IV/IO is difficult
defibrillation by to establish, can be
improving given through ETT at
myocardial blood dose 2 -2.5mg
flow during CPR - for symptomatic
bradycardia (2nd
degree heart block
type 2 and 3rd
degree heart block),
infusion at rate 2-10
mcg/min, titrated to
response

anaphylactic shock
IM: adult or children
> 12 years give
0.5mg as initial dose
(0.5ml of 1:1000)
IV: titrate 50-
100mcg (0.5-1ml)
according to
response (use 10ml
1:10000)
Aminophylline - alternative drug for IV 100 – 200mg slow - Stimulate CNS
- adenosine receptor severe symptomatic injection causing difficulty to
antagonist and bradycardia not sedate
phosphodiesterase responding to - precipitate
inhibitor atropine arrhythmia
- stimulate cardiac - treat AEBA
muscle =
tachycardia and
increase cardiac
contractility
- relaxes smooth
muscle and
bronchodilator

Amiodarone - refractory VF/pVT - refractory VF/pVT: - Hypotension,

- Act on sodium, after at least 3 shock IV/IO 300mg bolus bradycardia and
potassium and and adrenaline (dilute in 20mls D5% heart block
calcium channels - unstable after 3rd - beware of
- a membrane- tachyarrhythmias defibrillation) accumulation with
stabilising anti- (failed 3x - can repeat after 5th multiple dosing
arrhythmic drug that cardioversion) defibrillation: 150mg (cumulative doses >
increases the - stable - unstable 2.2g are associated
duration of action tachyacchythmias tachyarrhythmias; with hypotension)
potential and 300mg IV over 10 –
refractory period in 20mins
atrial and ventricular - stable
myocardium tachyarrhythmias;
300mg IV over 20-
60mins
- maintenance
infusion; 900mg IV
over 24H

Atropine - first line drug for bradycardia; - use atropine

- anticholinergic symptomatic - 0.5mg IV every 3 – cautiously in the
agent bradycardia 5 mins to a max presence of MI
- antagonizes the - organophosphate total dose of 3mg
action of the Ach at poisoning
muscarinic
receptors, hence it
blocks the effect of
vagus nerve on both
SA node and the AV
node , increasing
sinus automaticity
and facilitating AV
node conduction

Calcium - hyperkalemia - The initial dose of - calcium can slow

- hypocalcemia 10ml 10% calcium heart rate and
- overdose of CCB chloride (6.8mmol precipitate
- hyper-Mg calcium) may be arrhythmias
repeated if - do not give calcium
necessary solutions and
nahco3
simultaneously via
the same route

Dobutamine - in hypotension - 5 – 20mcg/kg/min - may worsen

- used as a positive with poor output as continuous hypotension esp
inotropic drug of state infusion during the start of
choice in the post- - with presence of treatment
resuscitation period pulmonary edema - can increase the
where hypotension risk of arrhythmia
prevents the use of
other vasopressors

Dopamine - 2nd line drug for - usual infusion rate

- chemical precursor symptomatic is 5 – 20
of noradrenaline bradycardia mcg/kg/min and
that stimulates both - use for dose titrated to
alpha and beta hypotension response
adrenergic receptors
- stimulates the
heart through both
alpha and beta
receptors

Lignocaine
Magnesium
Noradrenaline
Sodium Bicarbonate
Verapamil

ALS ALGORHYTHM

RESUSCITATION IN SPECIFIC CIRCUMSTANCES

POST RESUSCITATION CARE