Advanced Life Support

Advanced life support protocols are for use in patients suffering a cardiac arrest.

The up-to-date guidelines for Advanced Life Support must be consulted. These are available from the UK Resuscitation Council website www.resus.org.uk

2021 guidelines (1) recommend:

• CPR before defibrillation
  • during CPR, start with basic airway techniques and progress stepwise according to the skills of the rescuer until effective ventilation is achieved.
• Continue CPR while a defibrillator is retrieved, and pads applied.
• Give a shock as early as possible when appropriate.
• Deliver shocks with minimal interruption to chest compression and minimise the pre-shock and post-shock pause.
• This is achieved by continuing chest compressions during defibrillator charging, delivering defibrillation with an interruption in chest compressions of less than 5 seconds and then immediately resuming chest compressions.
• defibrillation strategy (1)
  • increased emphasis has been placed on minimally interrupted high-quality chest compressions with brief pauses only for specific interventions.
  • chest compressions are continued until defibrillator charges
  • reduced emphasis on pre-cordial thump
• ultrasound (1)
  • the potential benefit of ultrasound imaging during ALS is recognised.
• Only skilled operators should use intra-arrest point-of-care ultrasound (POCUS).
• POCUS must not cause additional or prolonged interruptions in chest compressions.
• airway management (1)
• If an advanced airway is required, only rescuers with a high tracheal intubation success rate should use tracheal intubation.
• The expert consensus is that a high success rate is over 95% within two attempts at intubation.
• Aim for less than a 5 second interruption in chest compression for tracheal intubation.
• use capnography for the confirmation and monitoring of tracheal tube placement, quality of CPR, and provide early indication of return of spontaneous circulation (ROSC).
• drugs (1)
• Give adrenaline 1 mg IV as soon as possible for adult patients in cardiac arrest with a non-shockable rhythm.
• Give adrenaline 1 mg IV after the 3rd shock for adult patients in cardiac arrest with a shockable rhythm.
• Repeat adrenaline 1 mg IV every 3-5 minutes whilst ALS continues.
• Give amiodarone 300 mg IV for adult patients in cardiac arrest who are in VF/pVT after three shocks have been administered.
• Give a further dose of amiodarone 150 mg IV for adult patients in cardiac arrest who are in VF/pVT after five shocks have been administered.
• Lidocaine 100 mg IV may be used as an alternative if amiodarone is not available or a local decision has been made to use lidocaine instead of amiodarone. An additional bolus of lidocaine 50 mg can also be given after five defibrillation attempts.
• Consider thrombolytic drug therapy when pulmonary embolus is the suspected or confirmed as the cause of cardiac arrest.
• Consider CPR for 60-90 minutes after administration of thrombolytic drugs.

Post-resuscitation care (2)

If return of spontaneous circulation (ROSC) is achieved, post-resuscitation care should be instigated immediately. This involves continued monitoring, organ support, correction of electrolyte imbalances and acidosis, and safe transfer to a critical care environment. A thorough search for potential aetiologies should be conducted, and risk factors for sudden cardiac arrest should be modified or treated.

A 12-lead ECG is recommended immediately after ROSC to determine whether signs of ST-elevation myocardial infarction (STEMI) are present.

References:

1. Resuscitation Council (UK). Resuscitation Guidelines 2021.
2. Panchal AR et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-468.