Download the new ERC Guidelines for in pdf, e-book or get the printed version. Adult Basic Life Support and Use of AED. Adult Advanced Life Support . A Statement by the Advanced Life Support Working Party of the European Resuscitation Council, Douglas Chamberlain (England) Chairman, Leo. Bendigo Health April Advanced Life Support Education Package. 2 professionals for the practice of Advanced Life Support (ALS).
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Advanced. Life. Support. Dr Jasmeet Soar for normal breathing. • Caution agonal breathing. • Check for signs of life. Unresponsive and not breathing normally. Adult Advanced Life Support. Unresponsive and not breathing normally. Call resuscitation team. CPR Attach defibrillator/monitor. Minimise interruptions. Cardiac arrest is a common emergency in acute hospitals. The Resuscitation Council (UK) Advanced Life Support Guidelines provide a systematic approach to cardiac arrest recognition, treatment and aftercare. Advanced life support treatment algorithm.
Satisfactory Response? Airway Open the airway using non invasive techniques head tilt-chin lift; jaw thrust without head extension if trauma is suspected Look for normal breathing in not more than 10s almost simultaneously when performing head tilt chin lift Perform high-quality CPR if not breathing or abnormal breathing gasps is seen until an AED arrives Provide shocks as indicated Follow each shock immediately with CPR, beginning with chest compressions - Is the patient breathing and are respirations adequate? Circulation ; The cuff of the i-gel does not require inflation; the stem of the i-gel incorporates a bite block and a narrow oesophageal drain tube. Associate membership Full membership. Any unwell child or infant should be assessed in a systematic manner to identify the extent of any physiological disruption and interventions started to correct the situation.
During cardiac arrest, arterial gas values may be misleading and bear little relationship to the tissue acid-base state.
Invasive cardiovascular monitoring in critical care settings e. Invasive arterial pressure monitoring will enable the detection of low blood pressure values when ROSC is achieved.
Waveform capnography during advanced life support Use waveform capnography whenever tracheal intubation is undertaken. Ensuring tracheal tube placement in the trachea although it will not distinguish between bronchial and tracheal placement.
Monitoring ventilation rate during CPR and avoiding hyperventilation. Monitoring the quality of chest compressions during CPR. End-tidal CO 2 values are associated with compression depth and ventilation rate and a greater depth of chest compression will increase the value. Prognostication during CPR. Precise values of end-tidal CO 2 depend on several factors including the cause of cardiac arrest, bystander CPR, chest compression quality, ventilation rate and volume, time from cardiac arrest and the use of adrenaline.
Values are higher after an initial asphyxial arrest, with bystander CPR, and decline over time after cardiac arrest. End-tidal CO 2 values should be considered only as part of a multi-modal approach to decision-making for prognostication during CPR. Defibrillation This section predominantly addresses the use of manual defibrillators.
The importance of early, uninterrupted chest compressions remains emphasised throughout these guidelines, together with minimising the duration of pre-shock and post-shock pauses — even 5—10 seconds delay will reduce the chances of the shock being successful.
Place the right sternal electrode to the right of the sternum, below the clavicle. Place the apical paddle in the mid-axillary line, approximately over the V6 ECG electrode position. This electrode should be clear of any breast tissue. It is important that this electrode is placed sufficiently laterally.
Defibrillation shock energy levels are unchanged from the Guidelines. Deliver the first shock with an energy of at least J.
Those using manual defibrillators should be aware of the appropriate energy settings for the type of device used, but in the absence of this and if appropriate energy levels are unknown, for adults use the highest available shock energy for all shocks.
If an initial shock has been unsuccessful it is worth attempting the second and subsequent shocks with a higher energy level if the defibrillator is capable of delivering a higher energy but, based on current evidence, both fixed and escalating strategies are acceptable. There are no high quality clinical studies to indicate the optimal strategies within any given waveform and between different waveforms.
It is becoming increasingly clear that selected energy is a poor comparator with which to assess different waveforms as impedance-compensation and subtleties in waveform shape result in significantly different transmyocardial current between devices for any given selected energy.
The optimal energy levels may ultimately vary between different manufacturers and associated waveforms. Manufacturers are encouraged to undertake high quality clinical trials to support their defibrillation strategy recommendations. No one must touch the patient during shock delivery. Standard clinical examination gloves or bare hands do not provide a safe level of electrical insulation. Leaving the ventilation bag connected to the tracheal tube or other airway adjunct.
Airway management and ventilation The options for airway management and ventilation during CPR vary according to patient factors, the phase of the resuscitation attempt during CPR, after ROSC , and the skills of rescuers. Videolaryngoscopy Videolaryngoscopes are being used increasingly in anaesthetic and critical care practice. Confirmation of correct placement of the tracheal tube The Resuscitation Council UK recommends using waveform capnography to confirm and continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment.
Cricothyroidotomy If it is impossible to ventilate an apnoeic patient with a bag-mask, or to pass a tracheal tube or alternative airway device, delivery of oxygen through a cannula or surgical cricothyroidotomy may be life saving. Adrenaline Despite the continued widespread use of adrenaline during resuscitation, there is no placebo-controlled study that shows that the routine use of adrenaline during human cardiac arrest increases survival to hospital discharge, although improved short-term survival has been documented.
Amiodarone No anti-arrhythmic drug given during human cardiac arrest has been shown to increase survival to hospital discharge, although amiodarone has been shown to increase survival to hospital admission. Peripheral versus central venous drug delivery Although peak drug concentrations are higher and circulation times are shorter when drugs are injected into a central venous catheter compared with a peripheral cannula, 99 insertion of a central venous catheter requires interruption of CPR and can be technically challenging and associated with complications.
Intraosseous route If intravenous access is difficult or impossible, consider the intraosseous IO route. CPR techniques and devices Mechanical chest compression devices We recommend that automated mechanical chest compression devices are not used routinely to replace manual chest compressions.
Duration of resuscitation attempt If attempts at obtaining ROSC are unsuccessful the resuscitation team leader should discuss stopping CPR with the team.
The use of mechanical compression devices and extracorporeal CPR techniques make prolonged attempts at resuscitation feasible in selected patients. It is generally accepted that asystole for more than 20 minutes in the absence of a reversible cause and with ongoing ALS constitutes a reasonable ground for stopping further resuscitation attempts. Acknowledgements These guidelines have been adapted from the European Resuscitation Council Guidelines.
Jasmeet Soar, Jerry P. Nolan, Bernd W. Skrifvars, Gary B. Smith, Kjetil Sunde, Charles D. Part I. Executive Summary: Resuscitation ; Part 4: Advanced life support: The formula for survival in resuscitation. The chain of survival. Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial. Am Heart J ; Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med ; Dynamic effects of adrenaline epinephrine in out-of-hospital cardiac arrest with initial pulseless electrical activity PEA.
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J Emerg Med ; Ineffectiveness of precordial thump for cardioversion of malignant ventricular tachyarrhythmias. Pacing Clin Electrophysiol ; Precordial thump efficacy in termination of induced ventricular arrhythmias.
Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: Antiarrhythmic effects of acute mechanical stiumulation. Cardiac mechano-electric feedback and arrhythmias: Elsevier Saunders; Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Pulseless electric activity: Circulation ; Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest.
Focused echocardiographic evaluation in resuscitation management: Echocardiography in cardiac arrest. Curr Opin Crit Care ; Advanced echocardiography for the critical care physician: Chest ; Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest.
Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram.
Acad Emerg Med ;8: Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med ; Impact of modified treatment in echocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressure during compression pauses.
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Resuscitation ;86C: Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: BMJ ; Connick M, Berg RA.
Femoral venous pulsations during open-chest cardiac massage. Part 3: Adult basic life support and automated external defibrillation: Debriefing to improve outcomes from critical illness: Intensive Care Med ; Mechanical devices for chest compression: European Resuscitation Council Guidelines for Resuscitation Section 2 Adult basic life support and automated external defibrillation. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation.
N Engl J Med ; Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support. J Am Heart Assoc ;3: Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.
Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics ; End tidal CO2 is a quantitative measure of cardiac arrest. Factors complicating interpretation of capnography during advanced life support in cardiac arrest-A clinical retrospective study in patients. The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: Crit Care ; Utstein style analysis of out-of-hospital cardiac arrest--bystander CPR and end expired carbon dioxide.
Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest.
Development of the probability of return of spontaneous circulation in intervals without chest compressions during out-of-hospital cardiac arrest: BMC Med ;7: Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation ROSC. Perishock pause: Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? Resistive properties of nitrile gloves.
Soar J, Nolan JP. Airway management in cardiopulmonary resuscitation. How do paramedics manage the airway during out of hospital cardiac arrest? Airways in out-of-hospital cardiac arrest: Prehosp Emerg Care ; Cervical spine movement during orotracheal intubation. Cervical spinal motion during intubation: J Neurosurg Spine ; Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission.
Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Field intubation of cardiac arrest patients: Emerg Med J ; Emergency physician-verified out-of-hospital intubation: Acad Emerg Med ; Out-of-hospital experience with the syringe esophageal detector device. Acad Emerg Med ;4: Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.
Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Nolan JP, Soar J. Airway techniques and ventilation strategies. Developing the skill of laryngeal mask insertion: Anaesthesist ; Effect of chest compressions on the time taken to insert airway devices in a manikin.
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Introduction of the I-gel supraglottic airway device for prehospital airway management in a UK ambulance service. Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation.
Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
JAMA ; Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. Anesth Analg ; Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: Video laryngoscopy improves the first-attempt success in endotracheal intubation during cardiopulmonary resuscitation among novice physicians.
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The assessment of three methods to verify tracheal tube placement in the emergency setting. The assessment of four different methods to verify tracheal tube placement in the critical care setting.
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Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study. Intraosseous vasopressin improves coronary perfusion pressure rapidly during cardiopulmonary resuscitation in pigs. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation.
An evidence-based review of epinephrine administered via the intraosseous route in animal models of cardiac arrest. Mil Med ; Comparison of two mechanical intraosseous infusion devices: Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Lancet ; Manual vs.
The randomized CIRC trial. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Quantifying the effect of cardiopulmonary resuscitation quality on cardiac arrest outcome: Circ Cardiovasc Qual Outcomes ;6: Manual chest compressions for cardiac arrest--with or without mechanical CPR? Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: Int J Cardiol ; Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department.
Emergency cardio-pulmonary bypass in cardiac arrest: Guidelines and guidance Introduction Adult basic life support and automated external defibrillation Adult advanced life support Paediatric basic life support Paediatric advanced life support Resuscitation and support of transition of babies at birth Prehospital resuscitation In-hospital resuscitation Post-resuscitation care Prevention of cardiac arrest and decisions about CPR Peri-arrest arrhythmias Education and implementation of resuscitation Contributors and conflict of interest G video summaries ABCDE approach.
Membership Full membership Associate membership Apply for membership. Adult advanced life support Adult basic life support and automated external defibrillation Education and implementation of resuscitation In-hospital resuscitation Paediatric advanced life support Paediatric basic life support Peri-arrest arrhythmias Post-resuscitation care Prehospital resuscitation Prevention of cardiac arrest and decisions about CPR Resuscitation and support of transition of babies at birth.
Adult Life Support. Paediatric Life Support. Newborn Life support. Free publications. Newsletter - Issue Course publications.
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