ALS Algorithm update 2020.pptx

Updated 2020 AHA algorithms

1. Advanced Life Support Course (updated 2020)

2. ,

3. 2015 2020

4. 2020 Lignocaine IV/IO 1 st dose 1 – 1.5mg/kg 2 nd dose 0.5 – 0.75mg/kg

5. Shockable rhythm!

6. Non-Shockable rhythm

7. NEW

8. Reversible Causes • Hypovolemia  is the IV drip running? Any bleeding? Sign of dehydration • Hypoxia  O2 connected? How’s bagging? Chest rise? • Hydrogen ion (acidosis)  VBG/ABG? • Hypo-/ hyperkalemia  RP/K+ level? • Hypothermia  Temperature? • Tension pneumothorax  trachea central? Hyper-resonance? No air entry? • Tamponade , cardiac  Ultrasound? Beck’s triad? • Toxins  history from witness? • Thrombosis, pulmonary  history? Risk factor? Ultrasound? • Thrombosis, coronary  history? ECG prior (if any)?

9. Emphasis on Early Adrenaline 2020 (Unchanged/Reaffirmed): NON-SHOCKABLE RHYTHM: It is reasonable to administer epinephrine as soon as feasible . SHOCKABLE RHYTHM: It may be reasonable to administer epinephrine after initial defibrillation attempts have failed

10. Importance of Early Defibrillation

11. Double Sequential Defibrillation – Not Recommended 2020 (New): 2020 ILCOR systematic review found no evidence to support and recommended against its routine use. A recent pilot RCT suggests that changing the direction of defibrillation current by repositioning the pads may be as effective & avoiding the risks of harm from increased energy and damage to defibrillators.

12. RR 10bpm Spo2 92 – 98% PCo2 35 – 45mmHg or ETCO2 30 – 40mmHg SBP >90mmHg MAP >65mmHg

13. Standard dose adrenaline Standard-dose epinephrine (1 mg every 3 to 5minutes) may be reasonable for patients in cardiac arrest (Class IIb , LOE B-R). • High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III: No Benefit,LOE B-R).

14. Early adrenaline? For initial non- shockable rhythm: It may be reasonable to administer adrenaline as soon as feasible after the onset of cardiac arrest (Class IIb,LOE C-LD). • For initial shockable rhyhtm : There is insufficient evidence to make a recommendation as to the optimal timing of adrenaline, particularly in relation to defibrillation

15. Amiodarone & Lidocaine Amiodarone may be considered for VF/ pVT that is unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb , LOE B-R). • Lidocaine may be considered as an alternative to amiodarone for VF/ pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb , LOE C-LD).

16. IV access “…none (of the antiarrhythmics ) have yet been proven to increase long term survival or survival with good neurologic outcome. Thus establishing vascular access to enable drug administration should not compromise the quality of CPR or timely defibrillation, which are known to improve survival .”

17. F OCUS E CHOCARDIOGRAPHIC E VALUTION IN L IFE SUPPORT = FEEL Ultrasound (cardiac or noncardiac )may be considered during the management of cardiac arrest, although its usefulness has not been well established (Class IIb , LOE CEO). If a qualified sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation (Class IIb , LOE C-EO).

18. Hypothermia post ROSC “…..Nevertheless, it is important to acknowledge that there may be a clinically relevant benefit of controlling the body temperature at 36°C, instead of allowing fever to develop in patients who have been resuscitated after cardiac arrest .” - No fever please.

19. Synchronized Cardioversion

20. Updated 2020: Dr Sazwan RS Dr Lim See Choo