QuestionSBA
QuestionChoice
Once establishing if the patient is conscious/rousable, an assessment of airway would be the next priority
33297
e
Check the patient's airway
QuestionChoice
After assessing for any airway compromise, an unconscious patient should be assessed for evidence of a pulse and respiratory effort to establish if they are in cardiac or respiratory arrest. This requires early identification so that appropriate management - with CPR or assisted ventilation - can be commenced. However you would first check for a response from the patient
33296
d
Look, listen and feel for a central pulse and respiratory effort for a minimum of 10 seconds
QuestionChoice
The patient may be in cardiac arrest - but this has not yet been identified. Chest compressions should be started as soon as possible following the identification of cardiac arrest
33294
b
Start cardiopulmonary resuscitation (CPR)
QuestionChoice
In any emergency situation, you should follow your DR ABC (danger, response, airway, breathing, circulation) approach. Ascertaining if the patient is conscious/rousable is the first step in the assessment
33293
a
Try to elicit a response from the patient
QuestionChoice
Simply putting the patient in the recovery position would not be an appropriate thing for the doctor to do given their level of training in assessing acutely unwell patients
33295
c
Put the patient in the recovery position
QuestionComment
I need to spend more time on the wards
23406
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subscriber
Intravenous Prone
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/)
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Advanced Life Support
Topic
39
Emergency Medicine
6659
A 39 year old woman collapses in the corridor of the cardiology ward. It is safe to approach and a nearby doctor goes to her aid.

From the options below, what is the next most appropriate action for the doctor to perform?
a