Advanced life support

Reference: UK Resuscitation Council ‘Adult advanced life support’ 2021

Roles of the team leader

• Delegate tasks (leader should be hands-off)
  • Timer and scribe (keep this person close to you and ask them to clearly tell you when each cycle ends, the cycle number and remind you when drugs are due if competent to)
  • Compressions (2-3 people rotating)
  • Airway and ventilation (anaesthetist if present)
  • Defibrillation (if shockable)
  • IV access, bloods/gases and drugs (x 2 people)
• Co-ordinate above tasks
• Go through reversible causes

DR’s ABCD

• Danger: check around patient and environment for danger
• Response: question (e.g. ‘Hello, can you hear me?’), shake and command (e.g. ‘Open your eyes’) 
• Shout: ‘Can I get some help over here please?’ and make the bed flat
• Airway: open airway with head-tilt/chin-lift or jaw-thrust and look for obstructions
• Breathing: assess breathing for up to 10 seconds by listening and feeling with your ear, while watching for chest movements and palpating carotid pulse
  • NB: you should do this while maintaining the head-tilt/chin-lift or jaw-thrust (e.g. place your forearm on the patient’s forehead, apply positive pressure to tilt the head back, and reach around their face to pull up the angle of the jaw with the index and middle fingers, whilst palpating the carotid pulse with the other hand).
• CPR and Call cardiac arrest team: if patient is not breathing, start CPR (described in detail below) and ask a helper to call 2222 and explain there is an adult/paediatric/neonatal/trauma cardiac arrest and the location. Ask the helper to bring the resuscitation trolley back with them. 
• Defibrillation: as described below

Tasks needing to be performed simultaneously are shown below in order of priority:

Chest compressions

Perform 30:2 chest compressions to ventilations (until airway is secure).

• Perform at a rate of 100-120/minute (i.e. 2/second) and a depth of 5-6cm. Fully extend your elbows, wrists and fingers. Have both hands palm downwards with fingers interlocked. Place the carpal area of the hand over the lower sternum and apply all pressure over this point. 
• ONLY stop CPR for rhythm checks, electrical shocks, and the 2 rescue breaths. Ask the person doing compressions to tell the airway person each time 30 compressions are complete. 
• Chest compressions should be continuous once the airway is secured with endotracheal tube
• Switch CPR provider during the rhythm check every 2 minutes (or earlier if they tire)

Defibrillation

Setup

• Working around the person performing compressions, place the two defibrillation pads in the correct positions on the chest (below right clavicle and over cardiac apex). You may need to shave or dry the chest. Leave jewellery on, but move it out the way.
  • NB: if a pacemaker is present, ensure pads are >8cm away from it (you can put the pads on AP if needed)
• Connect pads to defibrillator (and set monitoring trace to ‘pads’ if not already)
• Delegate someone to manage timing, clearly tell the leader when 2 minute cycles are up and remember the cycle number. Cycle 1 starts when the defibrillator is connected.

Rhythm check

• Perform a rhythm check ± shock every 2 minutes
• When pads are in place and defibrillator is on, immediately ask for CPR to be stopped for a rhythm check. Determine if the rhythm is shockable (‘wavy lines’ – VF, VT) or non-shockable (asystole, PEA).
  • If a rhythm that could be compatible with a pulse is seen (i.e. sinus or VT) during the rhythm check, also feel for a central pulse and stop compressions if present
• Then immediately continue CPR 

Shock

If shockable rhythm, follow these extra steps:

• Select correct energy level for device, usually 150J biphasic. If unsure, give the highest energy level shock.
• Ask for oxygen to be removed (unless patient intubated) and everybody except the person doing compressions to move away. Tell the person doing compressions to continue and that you will alert them to move away before the shock.
• Charge defibrillator by pressing ‘charge’ (button 2) and then move hand away from machine
• Once charged, ask the compressions to now be stopped and shout ‘Everybody stand clear!’ 
• Check the area is clear (i.e. check no one is in contact with the patient/bed and that the oxygen is away)
• Deliver shock by pressing ‘shock’ (button 3)
• Immediately ask for CPR to be restarted 

NB: while operating defibrillator, always look outwards around the bed (not at the machine) and never float your hand near the buttons.

Airway management

• Airway options (see procedure notes on airways)
  • Bag valve mask (30 compressions to 2 ventilations): if able to ventilate whilst maintaining seal and jaw-thrust, one person can do this alone. If not, one person should hold the rigid part of the mask with their thumb and index finger (‘C’) and pull the jaw up into the mask with their other fingers (‘E’), while another person ventilates.
    • Consider also placing an oropharyngeal (Guedel) or nasopharyngeal airway under the mask if struggling.
  • Supraglottic airway (usually i-gel): more secure airway and easy to insert
  • Intubation with endotracheal tube (gold standard): only done by experienced personnel. Once placed, ventilate every 6 seconds with continuous chest compressions and oxygen does not need to be removed for shocks.
    • NB: if a supraglottic airway is placed and there is no air leak, compressions can also be continuous and oxygen left connected for shocks. In practice, however, there is usually still some air leak so this is usually not done.

• Attach 15L/minute oxygen 
• Attach waveform capnography if supraglottic mask or endotracheal tube inserted
• Avoid hyperventilation

Drugs

• Obtain IV access and have drugs ready
• If you cannot get IV access after 2 attempts, get intraosseous access via head of humerus or tibial tuberosity
• Take blood from the cannula (VBG + send FBC, U&Es, Mg²⁺, G&S) and give IV fluids
• Adrenaline 1mg IV (10ml of 1:10,000)
  • When to give
    • Shockable rhythm: give after 3^rd shock (during CPR). Flush with 20ml saline.
    • Non-shockable rhythm: give as soon as IV access is established. Flush with 20ml saline.
  • Repeat adrenaline dose during every other CPR cycle thereafter (i.e. repeat every 3-5 minutes once given, regardless of rhythm)
• Amiodarone 300mg IV: if shockable rhythm only. Give after 3^rd shock (during CPR). Repeat 150mg IV after 5^th shock if ongoing.

Consider reversible causes

The team leader should assess the reversible causes by assessing the patient, speaking to nurses/relatives and reviewing their drug chart and notes. Each of the following reversible causes should be eliminated/treated (4 H’s, 4 T’s):

What next?

Return of circulation

• Full ABCDE assessment
• Controlled oxygenation (aim 92-96%)
• Consider therapeutic hypothermia 32-36˚ for 24 hours (avoid hyperthermia)
• Post-arrest investigations
• Treat cause
• Consider transfer to intensive care if still requiring ventilation or high-dependency care if not

No return of circulation

• In general, CPR should be continued as long as there is a shockable rhythm (mechanical compression device may be used)
• Only stop if a registrar or above makes the decision with the team
• Extracorporeal CPR using extracorporeal membrane oxygenation (ECMO) device may be considered where available for select patients to facilitate other definitive treatments, e.g. PCI, pulmonary thrombectomy for massive PE, rewarming for hypothermia
• Afterwards → Retrospectively document everything that happened

Special cases

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