QuestionSBA
QuestionChoice
PEA is a non-shockable rhythm and therefore shocks are not indicated
31850
c
Give 1 shock, immediately resume CPR and reassess rhythm in 2 minutes
QuestionChoice
Rhythm should be reassessed in 2 minutes
31849
b
Immediately resume CPR and then reassess rhythm in 5 minutes
QuestionChoice
This patient has pulseless electrical activity (PEA), which is a non-shockable rhythm. The management should include immediate resumption of CPR, with a rhythm check in 2 minutes
31848
a
Immediately resume CPR and then reassess rhythm in 2 minutes
QuestionChoice
This should only be attempted after ROSC
31852
e
Examine the patient using an ABCDE approach
QuestionChoice
This should only be done after return of spontaneous circulation (ROSC)
31851
d
12 lead ECG
QuestionComment
you would give Adrenaline as soon as possible- question is wrong
14643
QuestionComment
That's not an option. Also, high quality BLS always takes priority over ALS
23344
User
subscriber
Yellow Nightshift
QuestionComment
However, it is the next step according to advanced life support guidelines as per question.
28229
User
subscriber
Amnesia Transplant
QuestionComment
Not true. After checking the rhythm, if it is non shockable, the next step is resume cpr. Giving adrenaline comes after cpr has been restarted and in practice would be done by another person to prevent interruption. Question is right.
42883
User
subscriber
Ale
User
subscriber
Loose Contusion
QuestionComment
adrenaline
44512
User
subscriber
Transplant Myotonia
Concept
Chapter
# Summary

Advanced Life Support (ALS) describes an algorithmic approach to the management of a cardiac arrest by those trained in delivering it. It involves early recognition, taking steps to secure the airway and initiate high quality chest compressions and obtaining intravenous or intraosseous access promptly. Cardiac monitoring should be applied to identify if the rhythm is shockable or non-shockable, which determines what treatment is given. Shockable rhythms require defibrillation, with adrenaline and amiodarone given later on; non-shockable rhythms are treated with adrenaline. 

# Definition

Advanced Life Support is a guideline-based approach to treating patients who have had a cardiac arrest to improve the chances of successful resuscitation and survival. 

# Epidemiology

Cardiac arrests can be categorised into those that occur out of hospital and those that occur in hospitals. Most out of hospital cardiac arrests occur at home (72%) and 8 out of 10 are due to a cardiac cause. In 7 out of 10 cases resuscitation is attempted, however only 9% of these patients survive to hospital discharge.

In hospital cardiac arrests tend to occur in older patients (average age 70), with return of spontaneous circulation (ROSC) achieved in 53% of patients. However, only 24% of patients survive to hospital discharge. 

# Aetiology

Causes of cardiac arrest can be remembered using the 4Hs and 4Ts mnemonic:

- Hypoxia
- Hypovolaemia
- Hypo/hyperkalaemia (and other electrolyte abnormalities)
- Hypo/hyperthermia
- Thromboembolism (pulmonary embolism or coronary artery thrombosis)
- Tamponade
- Tension pneumothorax
- Toxins 

# Classification

Cardiac arrests are managed differently depending on whether the rhythm is **shockable** or **non-shockable**.

**Shockable** rhythms are:

- **Pulseless Ventricular Tachycardia (pVT)** - regular broad complex tachycardia
- **Ventricular Fibrillation (VF)** - chaotic irregular deflections of varying amplitude

**Non-shockable** rhythms are:

- **Pulseless Electrical Activity (PEA)** - electrical activity that should produce a pulse, but doesn't due to absent or insufficient cardiac output 
- **Asystole** - no detectable electrical activity 

# Management

## Management for all cardiac arrests

- **Rapid recognition** of cardiac arrest (ineffective breathing or absent central pulse) is key 
- The first responder should start **cardiopulmonary resuscitation (CPR)** immediately and **call for help**, for example by asking for a cardiac arrest call (2222) to be put out
- Every two minutes CPR should be stopped for a **rhythm check**
- Secure the **airway**
    - Oropharyngeal or nasopharyngeal airways may be used initially with a bag valve mask for ventilation
    - Either a supraglottic airway (laryngeal mask airway or i-gel) or an endotracheal tube should be inserted
    - Tracheal intubation should only be attempted by those with a high success rate
    - Confirm the position of the endotracheal tube with waveform capnography (measuring end-tidal carbon dioxide)
- Give **high-flow oxygen**
- Gain IV access - if not possible the intraosseous (IO) route can be used
- Consider reversible causes (as above) and treat as appropriate
    - IV or IO fluids if secondary to hypovolaemia
    - Thrombolysis if secondary to pulmonary embolism
    - Point of care ultrasound (POCUS) may be used to investigate for cardiac tamponade and pneumothorax
        
## Management of shockable rhythms

- **Defibrillation** should be delivered as early as possible
    - Remove oxygen (ventilator circuits can remain attached)
    - Ensure no one is touching the patient before the shock is delivered
    - No specific energy is specified in guidelines; anything from 120 to 360 joules is suitable
- Immediately resume CPR after the shock is delivered for two minutes
- After 3 shocks, give 300mg amiodarone and 1mg adrenaline IV or IO
- Give repeat doses of adrenaline every 3-5 minutes (i.e. every other cycle)
- After 5 shocks, give a further dose of amiodarone 150mg

## Management of non-shockable rhythms 

- Give adrenaline 1mg IV or IO as soon as possible
- Give repeat doses of adrenaline every 3-5 minutes (as per shockable rhythms)
- Defibrillation and amiodarone are not used unless the rhythm changes to a shockable one

# NICE Guidelines

[NICE CKS - Advanced Life Support](https://cks.nice.org.uk/topics/cardiac-arrest-out-of-hospital-care/management/advanced-life-support-adult/)

# References

[Resuscitation Council UK - Adult Advanced Life Support Guidelines](https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines)
 
[Resuscitation Council UK - Epidemiology of Cardiac Arrest](https://www.resus.org.uk/library/2021-resuscitation-guidelines/epidemiology-cardiac-arrest-guidelines)

[BNF Treatment Summaries - Cardiopulmonary Resuscitation](https://bnf.nice.org.uk/treatment-summaries/cardiopulmonary-resuscitation/)
697
725
Advanced Life Support
Topic
39
Emergency Medicine
6370
In pulseless electrical activity (PEA), immediate CPR resumption is crucial, followed by rhythm reassessment after two minutes.
A cardiac arrest is called to a medical ward. On arrival, the patient is unresponsive and not breathing. Nursing staff on the ward have already commenced cardiopulmonary resuscitation (CPR) at a rate of 30:2 and attached the defibrillator. An ECG shows normal sinus rhythm, but central pulses cannot be felt.

According to the advanced life support (ALS) guidelines, what is the next step in this instance?
a