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ALS (Advanced Life Support)

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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

Significant changes in the 2010 guidelines include:

  • CPR before defibrillation
    • the recommendation made on the 2005 guidelines for a specific period of CPR before before out-of-hospital defibrillation, following cardiac arrest unwitnessed by the emergency medical services (EMS), has been removed (1)
  • 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
    • recommended three quick successive (stacked) shocks for VT/VF arrests occurring in the cardiac catheterisation laboratory or in the immediate post-operative period following cardiac surgery.
  • ultrasound (1)
    • the potential benefit of ultrasound imaging during ALS is recognised.
  • airway management (1)
    • reduced emphasis in early tracheal intubation unless attempted by highly skilled individuals with minimal interruption to chest compressions.
    • increased emphasis in the use of 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)
    • intra-tracheal administration of drugs are no longer recommended. Intraosseous(IO) route is recommended if IV access is not available.
    • adrenaline is recommended to be given AFTER chest compressions have resumed after the 3rd shock instead of BEFORE the 3rd shock as stated in the previous recommendation. This change was made to separate the timing of drug delivery from shock delivery in an attempt to reduce delay in chest compression and more efficient shock deliver.
    • atropine is no longer recommended for routine use in asystole or pulseless electrical activity (PEA).
  • post-resuscitation care
    • the potential harm caused by hyperoxaemia after ROSC is achieved is now recognised: once ROSC has been established and the oxygen saturation of arterial blood (SaO2) is titrated (by Pulse Oximetry and/or arterial blood gas analysis) to achieve a SaO2 of 94 - 98%.
    • there is much greater detail and emphasis on the treatment of the postcardiac-arrest syndrome.
    • there is increased emphasis on the use of primary percutaneous coronary intervention in appropriate, but comatose, patients with sustained ROSC after cardiac arrest.
    • revision of the glyciemic control has changed: in adults with sustained ROSC after cardiac arrest, blood glucose values >10 mmol l-1 should be treated but hypoglycaemia must be avoided.
    • use of therapeutic hypothermia now includes comatose survivors of cardiac arrest associated initially with non-shockable rhythms as well as shockable rhythms. The lower level of evidence for use after cardiac arrest from nonshockable rhythms is acknowledged.
    • it is recognised that many of the accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia.

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