RESUS
ALS - ADVANCE LIFE SUPPORT
PromptGood pre- hospital prognostic indicators in out of hospital cardiac arrest
ResponseAge <65
Witnessed arrest
Immediate bystander CPR
Initial shockable rhythm
No asystole
Lack of comorbidities
Signs of life, - tearing, moving arms
Short duration of CPR
Defib/AED immediately available
Witnessed arrest
Immediate bystander CPR
Initial shockable rhythm
No asystole
Lack of comorbidities
Signs of life, - tearing, moving arms
Short duration of CPR
Defib/AED immediately available
PromptTreatment for refractory VF if amiodarone already given
ResponseLignocaine 100 mg IV bolus + repeat at 5 mins
PromptUses of waveform capnography in cardiac arrest
ResponseAdjunct for prognostication (Failure to achieve CO2 > 10 mmHg in 20 min is associated with poor outcomes)
Identifies ROSC (by an increase in CO2 value)
Confirms tracheal position and displacement
Assess the quality of chest compressions
Ventilation rate monitoring
Identifies ROSC (by an increase in CO2 value)
Confirms tracheal position and displacement
Assess the quality of chest compressions
Ventilation rate monitoring
PromptETCO2 signs of ROSC
ResponseRise to 40’s with ROSC
Stop compressions and assess rhythm
Stop compressions and assess rhythm
PromptPros and cons of mechanical CPR device
ResponseNo mortality benefit
No ROSC benefit
No positive neuro outcome benefit
Advantages:
prolonged CPR
When ECMO CPR is being performed
Decreases staff utilisation
Minimises interruptions to CPR (once attached)
Effective and consistent chest compression
Portability during patient transfers
Disadvantages:
De-skills providers
Focuses on device attachment rather than effective CPR and early defibrillation
Device displacement during compressions
Blunt chest and abdominal trauma
Device malfunction
No ROSC benefit
No positive neuro outcome benefit
Advantages:
prolonged CPR
When ECMO CPR is being performed
Decreases staff utilisation
Minimises interruptions to CPR (once attached)
Effective and consistent chest compression
Portability during patient transfers
Disadvantages:
De-skills providers
Focuses on device attachment rather than effective CPR and early defibrillation
Device displacement during compressions
Blunt chest and abdominal trauma
Device malfunction
PromptANZCOR position on mechanical cpr devices
ResponseDoes not suggest routine use
Suggest that automated mechanical CPR devices are reasonable alternatives where sustained high quality CPR are impractical or compromise provider safety. (2018 question!!)
Suggest that automated mechanical CPR devices are reasonable alternatives where sustained high quality CPR are impractical or compromise provider safety. (2018 question!!)
PromptReversible causes of arrest
ResponseHypoxaemia
Hypovolaemia
Hypo/hyperkalemia/Mg/Ca
Hypo/hyperthermia
Tension Ptx
Tamponade
Toxins- CO, TCAs
Thrombosis- MI/PE
Hypovolaemia
Hypo/hyperkalemia/Mg/Ca
Hypo/hyperthermia
Tension Ptx
Tamponade
Toxins- CO, TCAs
Thrombosis- MI/PE
PromptCauses of post arrest hypotension
ResponseCardiogenic
Hypovolaemia/haemorrhage
Obstructive shock - tamponade/tension pneumothorax (secondary to CPR)
SIRS response - distributive/anaphylaxis
Ie: what are the types of shock?
Hypovolaemia/haemorrhage
Obstructive shock - tamponade/tension pneumothorax (secondary to CPR)
SIRS response - distributive/anaphylaxis
Ie: what are the types of shock?
PromptPriorities of post cardiac arrest care
ResponseRe-Evaluate ABCDE
12 lead ECG
Treat precipitating causes
Sats 94-98%
Normoglycaemia
Targeted temperature management
Goals:
Prevent further arrest
Define underlying pathology
Limit organ damage
Predict non survivors
12 lead ECG
Treat precipitating causes
Sats 94-98%
Normoglycaemia
Targeted temperature management
Goals:
Prevent further arrest
Define underlying pathology
Limit organ damage
Predict non survivors
PromptManagement of a patient with ROSC - ongoing resuscitation
ResponseB – lung protective ventilation aiming for normal PaCO2/ETCO2 and O2 Sats 94-98%
C- Maintain normal Rhythm – Amiodarone infusion, check electrolytes and correct abnormalities. Maintain normal BP – with inotropes as necessary
Consider invasive monitoring
D – Start sedation and consider muscle relaxant
E – Investigation: ECG ABG and CXR
Normothermia
Consider most appropriate place for transfer - Cath lab/ICU/CT
Supportive:
Invasive monitoring - CVC+Art line
IDC
Pressure area
Family updates
C- Maintain normal Rhythm – Amiodarone infusion, check electrolytes and correct abnormalities. Maintain normal BP – with inotropes as necessary
Consider invasive monitoring
D – Start sedation and consider muscle relaxant
E – Investigation: ECG ABG and CXR
Normothermia
Consider most appropriate place for transfer - Cath lab/ICU/CT
Supportive:
Invasive monitoring - CVC+Art line
IDC
Pressure area
Family updates
PromptETT vs Supraglottic airway (SGA)
ResponseAIRWAYS-2 Trial (RCT 9269 patients, multi centre)
SGA vs ETT vs ??
Similar neurologic outcome at 30 days
SGA higher success on initial ventilation
SGA vs ETT vs ??
Similar neurologic outcome at 30 days
SGA higher success on initial ventilation
PromptList examples of circumstances requiring modification to ALS
ResponseHypoxia Early effective ventilation with supplemental oxygen
Trauma Prioritise sequence of life-saving measures: hypoxia, tension ptx, tamponade, mTP. Chest compressions should not delay the treatment of reversible causes
PE Fibrinolysis + prolonged CPR
After major cardiac surgery Re-sternotomy within 5 minutes
VT/VF during cardiac cath 3 stacked shocks; mechanical CPR devices
Submersion Prioritise oxygenation and ventilation
Hypokalemia Rapid potassium + mag infusion
Hypothermia Do not delay intubation, Check for signs of life for up to 1minute, Withhold drugs until>30 degrees then double interval, VF: 3 shocks then delay until >30
Tocins HDIT, intralipid, ECMO
See ILCOR/ERC guidelines
Trauma Prioritise sequence of life-saving measures: hypoxia, tension ptx, tamponade, mTP. Chest compressions should not delay the treatment of reversible causes
PE Fibrinolysis + prolonged CPR
After major cardiac surgery Re-sternotomy within 5 minutes
VT/VF during cardiac cath 3 stacked shocks; mechanical CPR devices
Submersion Prioritise oxygenation and ventilation
Hypokalemia Rapid potassium + mag infusion
Hypothermia Do not delay intubation, Check for signs of life for up to 1minute, Withhold drugs until>30 degrees then double interval, VF: 3 shocks then delay until >30
Tocins HDIT, intralipid, ECMO
See ILCOR/ERC guidelines
PromptTermination of resuscitation (TOR) rules
ResponseNo ROSC has occurred
No shock has been administered
The OHCA was not witnessed by EMS
No bystander CPR performed
OHCA not witnessed by bystanders
No shock has been administered
The OHCA was not witnessed by EMS
No bystander CPR performed
OHCA not witnessed by bystanders
PromptList factors you will consider when determining whether to terminate resuscitative measures
ResponsePresence of irreversible pathology (eg: refractory hyperkalaemia or refractory acidosis despite administered therapies
Pre-existing QOL and functional status
Previously expressed/documented wishes regarding ceiling of care
Presence of cardiac activity on POCUS
Presence of life limiting comorbidities with limited life expectancy (Eg: Metastatic cancer, dementia
Pre-existing QOL and functional status
Previously expressed/documented wishes regarding ceiling of care
Presence of cardiac activity on POCUS
Presence of life limiting comorbidities with limited life expectancy (Eg: Metastatic cancer, dementia