Faculty of Medicine Menoufia University

Advanced Life
Support
Course(ALS)

Emergency Department

Menofia University

2022
Advanced Life Support Course
*Course Manual edited by:
- Athar Fekry Lasheen
ALS and ERC instructor, M.D in Emergency
Medicine and Critical Care, Faculty of Medicine
Menoufia University

This manual is based on the ALS 2021 guidelines.

Index
1. Advanced Life Support Guidelines

1.1. Introduction…………………………………... 1
1.2. Prevention of in-hospital cardiac arrest……... 1
1.3. Prevention of out-hospital cardiac arrest……. 2
1.4. Treatment of in-hospital cardiac arrest……... 4
1.5. ALS considerations for out-of-hospital cardiac
arrest…………………………………………… 5
1.6. Resuscitation team …………………………... 6
1.7. ALS Treatment Algorithm………………….. 7
1.8. High quality chest compression…………….. 10
1.9. Manual defibrillator…………………………. 11
1.10. Airway and ventilation……………………… 14
1.11. Drugs and fluids……………………………... 15
1.12. Reversible causes of cardiac arrest………… 16
1.13. POCUS……………………………………….. 17
1.14. Peri-arrest arrhythmia……………………… 18
1.15. Debriefing…………………………………… 25
1.16. References……………………………………. 26
Adult advanced life support Guidelines
Introduction

Adult advanced life support (ALS) includes the advanced interventions

that follow basic life support (BLS) and use of an automated external
defibrillator (AED). Basic life support continues during and overlaps with
ALS interventions. This ALS section includes the prevention and
treatment of both in hospital cardiac arrest (IHCA) and out-of-hospital
cardiac arrest cardiac arrest (OHCA), the ALS algorithm, manual
defibrillation, airway management during cardiopulmonary resuscitation
(CPR), drugs and their delivery during CPR, and the treatment of peri-
arrest arrhythmias.

Prevention of in-hospital cardiac arrest

 The ERC supports shared decision making and advanced care

planning which integrates resuscitation decisions with emergency care
treatment plans to increase clarity of treatment goals and also prevent
inadvertent deprivation of other indicated treatments, besides CPR.
These plans should be recorded in a consistent manner.

 Hospitals should use a track and trigger early warning score system
for the early identification of patients who are critically ill or at risk of
clinical deterioration.

 Hospitals should train staff in the recognition, monitoring and

immediate care of the acutely ill patient.

 Hospitals should empower all staff to call for help when they identify
a patient at risk of physiological deterioration. This includes calls
based on clinical concern, rather than solely on vital signs.

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 Hospitals should have a clear policy for the clinical response to
abnormal vital signs and critical illness. This may include a critical
care outreach service and/or emergency team (e.g. medical emergency
team, rapid response team).

 Hospital staff should use structured communication tools to ensure

effective handover of information.

 Patients should receive care in a clinical area that has the appropriate
staffing, skills, and facilities for their severity of illness.

 Hospitals should review cardiac arrest events to identify opportunities

for system improvement and share key learning points with hospital
staff.

Prevention of out-of-hospital cardiac arrest

 Symptoms such as syncope (especially during exercise, while sitting

or supine), palpitations, dizziness and sudden shortness of breath that
are consistent with an arrhythmia should be investigated.

 Apparently healthy young adults who suffer sudden cardiac death

(SCD) can also have signs and symptoms (e.g. syncope/pre-syncope,
chest pain and palpitations) that should alert healthcare professionals
to seek expert help to prevent cardiac arrest.

 Young adults presenting with characteristic symptoms of arrhythmic

syncope should have a specialist cardiology assessment, which should
include an electrocardiogram (ECG) and in most cases
echocardiography and an exercise test.

 Systematic evaluation in a clinic specialising in the care of those at

risk for SCD is recommended in family members of young victims of

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 SCD or those with a known cardiac disorder resulting in an increased
risk of SCD.

 Identification of individuals with inherited conditions and screening of

family members can help prevent deaths in young people with
inherited heart disorders.

 Follow current European Society of Cardiology (ESC) guidelines for

the diagnosis and management of syncope.

Table (1): Causes of sudden cardiac arrest.

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Treatment of in-hospital cardiac arrest

 Hospital systems should aim to recognise cardiac arrest, start CPR

immediately, and defibrillate rapidly (<3 minutes) when appropriate.

 All hospital staff should be able to rapidly recognise cardiac arrest,

call for help, start CPR and defibrillate (attach an AED and follow the
AED prompts, or use a manual defibrillator).

 Hospitals should use a standard “Cardiac Arrest Call” telephone

number (2222).

 Hospitals should have a resuscitation team that immediately responds

to in hospital cardiac arrest (IHCA).

 The hospital resuscitation team should include team members who

have completed an accredited RCUK adult ALS course.

 Resuscitation team members should have the key skills and

knowledge to manage a cardiac arrest including manual defibrillation,
advanced airway management, intravenous access, intra-osseous
access, and identification and treatment of reversible causes.

 The resuscitation team should meet at the beginning of each shift for
introductions and allocation of team roles.

 Hospitals should standardise resuscitation equipment.

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Fig. 1: Chain of survival.

ALS considerations for out-of-hospital cardiac arrest

 Start ALS as early as possible.

 Emergency medical systems (EMS) should consider implementing

criteria for the withholding and termination of resuscitation (TOR)
taking into consideration specific local legal, organisational and
cultural context.

 Systems should define criteria for the withholding and termination of

CPR, and ensure criteria are validated locally.

 Emergency medical systems (EMS) should monitor staff exposure to

resuscitation and low exposure should be addressed to increase EMS
team experience in resuscitation.

 Adult patients with non-traumatic OHCA should be considered for

transport to a recognised centre of care for appropriate specialist
treatment, according to local protocols.

 Adult patients with a cardiac arrest of presumed primary cardiac

aetiology should be transported directly to a hospital with 24/7
coronary angiography capability.

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Resuscitation team

The resuscitation team may take the form of a traditional cardiac arrest
team that responds only to cardiac arrest events or a MET/RRT (medical
emergency team/ rapid response team) that responds to both cardiac
arrests and critically unwell patients.

• Roles planned in advance

• Identify team leader

• Importance of non-technical skills

– Task management

– Team working

– Situational awareness

– Decision making

• Structured
Communication

Fig.2: Non-technical skills ALS team.

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ALS treatment algorithm

Cardiac arrest is associated with either shockable rhythms (ventricular

fibrillation/pulseless ventricular tachycardia (VF/pVT)) or non-shockable
rhythms (asystole and pulseless electrical activity (PEA)). The main
difference in the treatment of shockable rhythms is the need for attempted
defibrillation. Other interventions, including high-quality chest
compressions with minimal interruption, airway management and
ventilation, venous access, administration of adrenaline and the
identification and treatment of reversible causes, are common for all
arrests. The ALS algorithm (Fig. 3) provides an overview of these key
interventions. These are based on the expert consensus of the writing
group. The ALS cardiac arrest algorithm is applicable to all cardiac
arrests.

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Fig. 3: ALS treatment algorithm

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To confirm cardiac arrest…

Put the unresponsive patient on his back and try to open his airway by
head tilt and chin left maneuver then apply the look, listen and feel
technique for 10 seconds:

• Patient response

• Open airway

• Check for normal breathing

• Check circulation

Fig. 4: Look, Listen, Feel technique for confirming cardiac arrest.

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High-quality chest compressions

High-quality CPR is defined as chest compressions that are of sufficient

depth and performed at a fast enough rate to generate enough blood flow
to the brain and other vital organs to delay cell death. Cells begin to die
within 4-6 minutes after cardiac arrest, so it is crucial that CPR be
performed immediately as possible.

Five critical components required for providing high-quality CPR:

1. Compressions should be delivered at a rate of 100–120

compressions per minute.

2. Compressing the chest to a depth of 5–6 inches in adults. This

depth is crucial to help blood flow to the vital organs.

3. Full chest wall recoil after each compression. This can be achieved
by not leaning or applying full weight on the patient.

4. Minimization of pauses in compressions. Interruptions in

compressions can decrease the success of a successful shock.

5. Avoid excessive ventilation by maintaining 2 breaths to every 30

compressions.

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Fig.5: High quality chest compression

Manual defibrillation

Defibrillation strategy

 Continue CPR while a defibrillator is retrieved, and pads applied.

 Give a shock as early as possible when appropriate.

 Deliver shocks with minimal interruption to chest compression and

minimise the pre-shock and post-shock pause.

 This is achieved by continuing chest compressions during

defibrillator charging, delivering defibrillation with an interruption
in chest compressions of less than 5 seconds and then immediately
resuming chest compressions.

 Immediately resume chest compressions after shock delivery. If

there is a combination of clinical and physiological signs of return
of spontaneous circulation (ROSC) such as waking, purposeful
movement, arterial waveform or a sharp rise in end-tidal carbon
dioxide (ETCO2), consider stopping chest compressions for rhythm
analysis, and if appropriate a pulse check.

Safe and effective defibrillation

 Minimise the risk of fire by taking off any oxygen mask or nasal
cannula and place them at least 1 m away from the patient’s chest.
Ventilator circuits should remain attached.

 Antero-lateral pad position is the position of choice for initial pad

placement. Ensure that the apical (lateral) pad is positioned
correctly (mid-axillary line, level with the V6 ECG electrode
position) i.e. below the armpit.

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  In patients with an implantable device, place the pad > 8 cm away
from the device, or use an alternative pad position. Also consider
an alternate pad position when the patient is in the prone position
(bi-axillary), or in a refractory shockable rhythm (fig.4).

 A shock can be safely delivered without interrupting mechanical

chest compression.

 During manual chest compressions, ‘hands-on’ defibrillation, even

when wearing clinical gloves, is a risk to the rescuer.

Fig. 6: Correct pad placement for defibrillation (© Charles Deakin).

Energy levels and number of shocks

 Use single shocks where indicated, followed by a 2 minute cycle of

chest compressions.

 A range of defibrillation energy levels have been recommended by

manufacturers and previous guidelines, ranging from 120-360 J. In
the absence of any clear evidence for the optimal initial and
subsequent energy levels, any energy level within this range is
acceptable for the initial shock, followed by a fixed or escalating
strategy up to maximum output of the defibrillator.

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Recurrent or refractory VF

 Consider escalating the shock energy, after a failed shock and for
patients where refibrillation occurs.

 For refractory VF, consider using an alternative defibrillation pad

position (e.g. anterior- posterior).

 Do not use dual (double) sequential defibrillation for refractory VF

outside of a research setting.

Additional interventions may be indicated for cardiac arrest caused

by special circumstances.

Fig. 7: Shockable (VF)

Fig. 8: Shockable (pVT)

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Fig. 9: Non-Shockable (Asystole)

Airway and ventilation

 During CPR, start with basic airway techniques and progress

stepwise according to the skills of the rescuer until effective
ventilation is achieved.

 If an advanced airway is required, only rescuers with a high

tracheal intubation success rate should use tracheal intubation.

 The expert consensus is that a high success rate is over 95% within
two attempts at intubation.

 Aim for less than a 5 second interruption in chest compression for

tracheal intubation.

 Use direct or video laryngoscopy for tracheal intubation according

to local protocols and rescuer experience.

 Use waveform capnography to confirm tracheal tube position.

 Give the highest feasible inspired oxygen during CPR.

 Give each breath over 1 second to achieve a visible chest rise.

 Once a tracheal tube or a supraglottic airway (SGA) has been

inserted, ventilate the lungs at a rate of 10 min-1 and continue chest

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 compressions without pausing during ventilations. With a SGA, if
gas leakage results in inadequate ventilation, pause compressions
for ventilation using a compression-ventilation ratio of 30:2.

Drugs and fluids

Vascular access

 Attempt intravenous (IV) access first to enable drug delivery in

adults in cardiac arrest.
 Consider intraosseous (IO) access if attempts at IV access are
unsuccessful or IV access is not feasible.
Vasopressor drugs

 Give adrenaline 1 mg IV (IO) as soon as possible for adult patients

in cardiac arrest with a non-shockable rhythm.
 Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients
in cardiac arrest with a shockable rhythm.
 Repeat adrenaline 1 mg IV (IO) every 3-5 minutes whilst ALS
continues.
Antiarrhythmic drugs

 Give amiodarone 300 mg IV (IO) for adult patients in cardiac

arrest who are in VF/pVT after three shocks have been
administered.
 Give a further dose of amiodarone 150 mg IV (IO) for adult
patients in cardiac arrest who are in VF/pVT after five shocks have
been administered.
 Lidocaine 100 mg IV (IO) may be used as an alternative if
amiodarone is not available or a local decision has been made to
use lidocaine instead of amiodarone. An additional bolus of
lidocaine 50 mg can also be given after five defibrillation attempts.

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Reversible causes of cardiac arrest
The reversible causes of cardiac arrest include four "H's":
 hypoxia
 hypovolaemia
 hyperkalaemia, hypokalaemia, other electrolyte disturbances
 hypothermia
and four "Ts":
 tension pneumothorax
 cardiac tamponade
 drug toxicity and therapeutics
 thromboembolism and other outflow obstructions

Fig.10: Reversible causes of cardiac arrest

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Thrombolytic drugs

 Consider thrombolytic drug therapy when pulmonary embolus is

the suspected or confirmed as the cause of cardiac arrest.
 Consider CPR for 60-90 minutes after administration of
thrombolytic drugs.
Fluids

 Give IV (IO) fluids only where the cardiac arrest is caused by or

possibly caused by hypovolaemia.

Waveform capnography during advanced life support

 Use waveform capnography to confirm correct tracheal tube

placement during CPR.
 Use waveform capnography to monitor the quality of CPR.
 An increase in ETCO2 during CPR may indicate that ROSC has
occurred. However, chest compression should not be interrupted
based on this sign alone.
 Although high and increasing ETCO2 values are associated with
increased rates of ROSC and survival after CPR, do not use a low
ETCO2 value alone to decide if a resuscitation attempt should be
stopped.
Use of ultrasound imaging during advanced life support

 Only skilled operators should use intra-arrest point-of-care

ultrasound (POCUS).
 POCUS must not cause additional or prolonged interruptions in
chest compressions.
 POCUS may be useful to diagnose treatable causes of cardiac
arrest such as cardiac tamponade and pneumothorax.

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  Right ventricular dilation in isolation during cardiac arrest should
not be used to diagnose massive pulmonary embolism.
 Do not use POCUS for assessing contractility of the myocardium
as a sole indicator for terminating CPR.
Mechanical chest compression devices

 Consider mechanical chest compressions only if high-quality

manual chest compression is not practical or compromises provider
safety.

 When a mechanical chest compression device is used, minimise

interruptions to chest compression during device use by using only
trained teams familiar with the device.

Peri-arrest arrhythmias

 The assessment and treatment of all arrhythmias addresses the

condition of the patient (stable versus unstable) and the nature of the
arrhythmia. Life-threatening features in an unstable patient include:

o shock – appreciated as hypotension (e.g. systolic blood pressure <

90 mmHg) and symptoms of increased sympathetic activity and
reduced cerebral blood flow

o syncope – as a consequence of reduced cerebral blood flow

o severe heart failure – manifested by pulmonary oedema (failure of

the left ventricle) and/or raised jugular venous pressure (failure of
the right ventricle)

o Myocardial ischaemia – may present with chest pain (angina) or

may occur without pain as an isolated finding on the 12-lead ECG
(silent ischaemia).

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Tachycardias

 Electrical cardioversion is the preferred treatment for tachyarrhythmia

in the unstable patient displaying potentially life-threatening adverse
signs.

 Conscious patients require anaesthesia or sedation, before attempting

synchronised cardioversion.

 To convert atrial or ventricular tachyarrhythmias, the shock must be

synchronised to occur with the R wave of the electrocardiogram
(ECG).

 For atrial fibrillation:

o An initial synchronised shock at maximum defibrillator output

rather than an escalating approach is a reasonable strategy based
on current data.

 For atrial flutter and paroxysmal supraventricular tachycardia:

o Give an initial shock of 70 - 120 J.

o Give subsequent shocks using stepwise increases in energy.

 For ventricular tachycardia with a pulse:

o Use energy levels of 120-150 J for the initial shock.

o Consider stepwise increases if the first shock fails to achieve

sinus rhythm.

 If cardioversion fails to restore sinus rhythm and the patient remains

unstable, give amiodarone 300 mg intravenously over 10–20 minutes
(or procainamide 10–15 mg kg-1 over 20 minutes) and re-attempt

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 electrical cardioversion. The loading dose of amiodarone can be
followed by an infusion of 900 mg over 24 hours.

 If the patient with tachycardia is stable (no life-threatening adverse

signs or symptoms) and is not deteriorating, pharmacological
treatment may be possible.

 Consider amiodarone for acute heart rate control in AF patients with

haemodynamic instability and severely reduced left ventricular
ejection fraction (LVEF). For patients with LVEF < 40% consider the
smallest dose of beta-blocker to achieve a heart rate less than 110 min -
1
. Add digoxin if necessary.

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 Fig.11: Tachycardia algorithm

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Bradycardia

 If bradycardia is accompanied by life-threatening adverse signs,

give atropine 500 mcg IV (IO) and, if necessary, repeat every 3–5
minutes to a total of 3 mg.

 If treatment with atropine is ineffective, consider second line drugs.

These include isoprenaline (5 mcg min−1 starting dose), and
adrenaline (2–10 mcg min−1).

 For bradycardia caused by inferior myocardial infarction, cardiac

transplant or spinal cord injury, consider giving aminophylline
(100–200 mg slow intravenous injection).

 Consider giving glucagon if beta-blockers or calcium channel

blockers are a potential cause of the bradycardia.

 Do not give atropine to patients with cardiac transplants – it can

cause a high-degree AV block or even sinus arrest – use
aminophylline.

 Consider pacing in patients who are unstable, with symptomatic

bradycardia refractory to drug therapies.

 If transcutaneous pacing is ineffective, consider transvenous

pacing.

 Whenever a diagnosis of asystole is made, check the ECG carefully

for the presence of P waves because unlike true asystole, this is
more likely to respond to cardiac pacing.

 If atropine is ineffective and transcutaneous pacing is not

immediately available, fist pacing can be attempted while waiting
for pacing equipment.

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 Fig.12: Bradycardia algorithm

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Debriefing

 Use data-driven, performance-focused debriefing of rescuers to

improve CPR quality and patient outcomes.

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References

1- Soar a J, Bernd W, Carli C , Keith D , Charles D, Deakin E ,

Lott G, Theresa O , Peter I , et al. European Resuscitation
Council Guidelines 2021: Adult advanced life support. J
Resuscitation. 2021.
2- ERC Guidelines 2021: [Link]

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