ALS Paper 2018

Adult Advanced Life Support
CONTENTS
Objectives.................................................................................................................................... 7
Introduction.................................................................................................................................. 8
The aims of Adult Advanced Life Support.............................................................................. 8
Cardiopulmonary arrest (CPR).............................................................................................. 8
The deteriorating patient.......................................................................................................11
Conclusion........................................................................................................................... 16
ALS............................................................................................................................................. 17
The ALS flowchart................................................................................................................ 17
Sequence when responding to an arrest ............................................................................ 18
Responsibilities of team members....................................................................................... 22
Being organised and prepared............................................................................................. 24
Conclusion........................................................................................................................... 28
Rhythm Recognition................................................................................................................. 29
Rhythms are a picture.......................................................................................................... 29
Types of rhythms.................................................................................................................. 35
Conclusion........................................................................................................................... 36
Defibrillation............................................................................................................................... 37
What is defibrillation............................................................................................................. 37
Energy delivery.................................................................................................................... 40
Sequence for defibrillation................................................................................................... 42
Conclusion........................................................................................................................... 46
Advanced Airway Management................................................................................................ 47
Recognising an airway obstruction ..................................................................................... 47
Airway adjuncts.................................................................................................................... 48
Advanced airway devices.................................................................................................... 50
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Conclusion........................................................................................................................... 55
Drugs in Resuscitation............................................................................................................. 56
The action of first line drugs................................................................................................. 56
Adminstration....................................................................................................................... 57
Conclusion........................................................................................................................... 58
Cardioversion and Pacing........................................................................................................ 59
Synchronised cardioversion................................................................................................. 59
Temporary external transcutaneous cardiac pacing............................................................ 61
Conclusion........................................................................................................................... 64
Special Circumstances............................................................................................................. 65
Anaphylaxis.......................................................................................................................... 65
Pregnancy............................................................................................................................ 66
Hypothermia......................................................................................................................... 66
Electrocution........................................................................................................................ 67
Drug poisoning/toxicology.................................................................................................... 67
Near drowning...................................................................................................................... 68
Conclusion........................................................................................................................... 69
Post-resuscitation Care............................................................................................................ 70
Aims of therapy.................................................................................................................... 70
Once the patient has been successfully resuscitated.......................................................... 71
Conclusion........................................................................................................................... 75
Appendix 1 - Rhythms............................................................................................................... 76
Sinus.................................................................................................................................... 78
Sinus Bradycardia................................................................................................................ 79
Sinus Tachycardia................................................................................................................ 80
Ventricular Fibrillation........................................................................................................... 81
Pulseless Ventricular Tachycardia....................................................................................... 83
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Asystole............................................................................................................................... 85
Pulseless Electrical Activity (PEA)....................................................................................... 87
Ventricular Tachycardia with a pulse.................................................................................... 88
Torsades de Pointes............................................................................................................ 90
Supraventricular tachycardia............................................................................................... 92
Third Degree Block.............................................................................................................. 94
Idioventricular (Slow)........................................................................................................... 96
Accelerated idioventricular (fast).......................................................................................... 98
Atrial fibrillation..................................................................................................................... 99
Atrial flutter......................................................................................................................... 100
Agonal................................................................................................................................ 102
Appendix 2 - Resuscitation Drugs......................................................................................... 106
First line drugs................................................................................................................... 107
Second line and/or peri-arrest drugs.................................................................................. 109
Appendix 3 - Quiz Answers.....................................................................................................119
References............................................................................................................................... 123
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WELCOME
Welcome to the Ramsay Health Care Adult Advanced Life Support program.
The Australian Heart Foundation cites cardiovascular disease as accounting for 43,477 deaths
in Australia in 2017, including almost 20,000 deaths from ischaemic heart disease (ABS cat. no.
3303.0), more than any other single cause of death for both men and women. It also states that
of Australians aged 55-64 years of age, 8.8% are reported living with heart, stroke or vascular
disease, and that prevalence increases with age to 39% for those Australians aged 85 years and
over.
The aim of this program is to provide the knowledge and skills required to recognise and manage
the patient with a life threatening event, in line with current guidelines from the Australian
Resuscitation Council. The ANZCOR guidelines are available for free access at www.resus.org.au
About this course

This is not an ARC recognised/endorsed course. Ramsay hospitals accept the level
of training provided according to the standards of the face to face and assessment
components provided by each hospital. The Adult ALS program has been made possible with
the support and critical contribution of ALS educators from around the country.
Prerequisites
Prior to enrollment in this course you must be deemed competent in Basic Life Support within the
past 12 months
Structure
This program is divided into two undertakings:
1. The online module or equivalent document (this document)
2. Face-to-face training and practical assessment (according to site preferences e.g. case study
or simulation)
Assessment requirements
Completion of the online module and quiz (in print or interactive format) is not equivalent to an ALS
qualification.
It is a requirement of this program that you complete the online learning and achieve 100% in the
accompanying assessment before you can be enrolled in the face-to-face session.
At successful completion of the module and assessment, you will be instructed how to proceed
with enrolment in the face to face session.
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Duration
It is recommended that you spend a minimum of 4 hours on the learning contained within this
document. In order to register your completion of this document, you are required to log in to
your eLearning and complete the online assessment. This assessment is accessible on Ramsay
machines, personal computers, and iPads and tablets.
Additional resources
You will need your Athens login to access the recommended basic Anatomy and Physiology text:
• Essentials of Anatomy and Physiology – 6th Ed. (2011), Chapter 12: The Heart.
Note: You need to log in to Athens via the Ramsay Library website in order to access this
resource. If you do not already have an Athens login (this is NOT your eLearning password) you
should register at ramsaylibrary.com.au
Document Version Control

Version Date Rationale
2.1 20 April 2017 Added Athens login link to Rhythm Recognition
chapter introduction
3 20 November 2018 Updates based on changes in ARC Guidelines
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OBJECTIVES
At the end of this learning, you should be able to:
• Describe the concept of the Chain of Survival
• Discuss the importance of early recognition of potential cardiac arrests
• Describe the ethical and legal requirements of CPR
• Follow the Advanced Life Support algorithm
• Identify cardiac rhythms requiring defibrillation
• Describe the principles and application of defibrillation
• Discuss the choice and application of airway adjuncts
• Describe your role in assisting with advanced airway management
• Describe how to assist with a tracheal intubation
• Identify medication and doses used in resuscitation
• Describe the principles and application of synchronised cardioversion
• Describe the principles and application of non-invasive cardiac pacing
• Discuss the requirements of post resuscitation care
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Introduction
In this section, we’ll look at the aims of Advanced Life Support and the role of the nurse, as well as the
what, why, how and when of cardiac arrest and resuscitation
THE AIMS OF ADULT ADVANCED LIFE SUPPORT

When a patient suffers a cardiac arrest in a hospital their chances of survival should be optimal.
Advanced Life Support (ALS) aims to increase these chances through uniform procedure and early
recognition practices.
Advanced Life Support is defined by the Australian Resuscitation Council as:
“Basic Life Support with the addition of invasive techniques e.g. defibrillation, advanced airway
management, intravenous access and drug therapy.”
The role of the nurse in ALS

The role of the nurse has expanded to require the individual nurse to have a sound knowledge of
and be able to demonstrate skills in both the care of and management of the patient during a life
threatening emergency.
There is increased emphasis for the nurse regarding non clinical skills such as leadership,
teamwork and communication to improve CPR performance and patient outcomes. Your role will
not only be to undertake the clinical aspects of resuscitation but to act as role model and mentor to
junior staff during the arrest situation.
Nurses with ALS training, following the algorithm and working with the team may show improved
outcomes. However, “available research suggests that ALS knowledge and skills decay by 6
months to 1 year after training, and that skills decay faster than knowledge” (C.W.Yang et al,
2012). Regular education and assessment programs (3 – 4 times a year) based on scenarios allow
the nurse to reflect and update their practical skills in a non-threatening environment, providing an
opportunity to have hands on practice with the equipment.
The nurse involved in Advanced Life Support should be aware of and act within their scope of
nursing practice.
CARDIOPULMONARY ARREST
Cardiopulmonary arrest, also known as Cardiac arrest, is defined by the abrupt cessation of the
heart’s ability to contract effectively, resulting in loss of cardiac output and eventual death. In many
hospitalised patients, cardiopulmonary arrest is neither a sudden nor an unpredictable event.
Cardiopulmonary arrest is generally triggered by failure in either the respiratory system or the
cardiovascular system.
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The respiratory system
Arrest due to airway problems may be caused by (but is not limited to):
• CNS depression
• Bodily fluids
• Inflammation
• Foreign body
• Infection
• Laryngo or bronchospasm
Any condition that prevents the respiratory tract’s ability to function normally will have a profound
negative impact on the patient’s respirations and oxygen delivery to the tissues. Arrest due to
breathing problems may be caused by (but not limited to):
• CNS depression
• Muscle weakness
• Exhaustion
• Acute episodes of respiratory conditions
• Lung disorders e.g. pneumothorax
The Cardiovascular System

Circulation problems may be a primary cardiac condition caused by:
• ischaemia or infarction Secondary cardiac problems may be as a result

of:
• arrhythmia or cardiac failure due to
hypertrophy • respiratory obstruction
• tamponade myocarditis/cardiac tamponade • asphyxia
• tension pneumothorax
• severe blood loss
• hypoxaemia
• hypothermia
• septic shock
Signs
The cardiac arrests with the worst outcomes are usually neither sudden nor unpredictable. In hospital,
cardiopulmonary arrest usually presents as a final step in a sequence of progressive deterioration of
the presenting illness, involving hypoxia and hypotension.
Regular and complete sets of core physiological observations are vital to aid the detection of
the deteriorating patient. Often patients will not display noticeable physical signs that they are
deteriorating, particularly if they are relatively young and fit with efficient compensatory mechanisms.
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Young patients are able to compensate for disordered physiology efficiently and when their
compensation mechanisms fail (e.g. they become hypotensive), it is an ominous sign and an
indication of significant deterioration.
Signs of deterioration will include one or more of the following elements:

• Respiratory Rate
• Heart Rate
• Blood Pressure
• Temperature
• Glascow Coma Score - level of consciousness
• Pain
The Chain of Survival

In 1990, the American Heart Association developed the Chain of Survival. In Australia, a variation
of this has been developed by Professor Middleton of Take Heart Australia which describes 6
links. Like any chain, its only as strong as its weakest link. When each link in the chain works
successfully, the chances of surviving a sudden cardiac arrest suddenly decreases.
Early CPR Should be commenced and maintained

until a medical emergency team can arrive to lead the
event. Effective and quality compressions with minimum ALS A response by a trained medical emergency team
interruptions are the cornerstone of BLS/ALS to enable if available to provide Advanced Life Support measures
improved outcomes for the patient. for the patient by continuing ongoing CPR, defibrillation,
medication and reversal of the possible cause of the
Early Recognition of the deteriorating deterioration and/or arrest.
patient is vital
Early Access Calling for help using the process in place

within your work area to ensure that patient and staff Definitive care aims
have the adequate support through assistance of the to provide ongoing
medical emergency team or defibrillator arrives early. support of the patient
that may require
Early defibrillation Is a key factor in providing the patient with the best invasive ventilation,
chance of return of spontaneous circulation when the life threatening inotropic support
event has been caused by the shockable rhythm VF (Ventricular and active cooling to
Fibrillation) or Pulseless VT (Ventricular Tachycardia). The chance of protect vital organs.
successful defibrillation decreases with time. The majority or cardiac
arrest survivors come from the Pulseless VT shockable group.
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The chances of survival after an attack
Every minute the changes of survival reduce by 7-10%
Within 4 - 6 minutes, brain damage and permanent death start to

occur
After 10 minutes, few attempts at resuscitation succeed
THE DETERIORATING PATIENT

As you have already learned, recognising a deteriorating patient early on is the first critical step in
the Chain of Survival. Your hospital or work area will already have systems in place to ensure that
you are educated in the recognition of a deteriorating patient and have clear guidance on when to
call for help.
The approach to all critically ill patients is the same. Let’s now look at the underlying principles.
DRSABCD
Use the DRSABCD approach to assessing and treating
the patient. For a reminder on the correct procedure
for assessing and treating a patient, please refer to the
ANZCOR BLS Algorithm, or refer to the mandatory
eLearning module Basic Life Support, which you can find on
your eLearning Home page. See also the flowcharts page at
www.resus.org.au for the DRSABCD/BLS protocol.
Assess and reassess
Do a complete initial assessment and reassess regularly.
Prioritise problems
Treat life-threatening problems before moving to the next
part of the assessment.
Check back
Assess the effects of the treatment given.
Call for help early
Recognise when you will need extra help and call for it before you need it or as soon as you know
you will need it.
Use your resources
Use all members of the team. This enables interventions like assessment, attaching monitors and
intravenous access to be undertaken simultaneously.
Communicate
Ensure communication is clear and effective.
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Keep it simple
The aim of initial treatment is to keep the patient alive, and achieve some clinical improvement.
This will buy time for further treatment.
Effective Basic Life support is an essential component of Advanced Life

Support
Chest compressions
All rescuers should perform chest compressions for all those who are unresponsive and not
breathing normally. ANZCOR suggests that those who are trained and willing to give breaths do
so for all persons in cardiac arrest. If rescuers do continuous chest compressions they should
be at a rate of approximately 100 – 120/min (ANZCOR 2016 Guideline 8 - Cardiopulmonary
Resuscitation)
Minimise interruptions to chest compressions
CPR should not be interrupted to check for response or breathing. ANZCOR places a high priority
on minimising interruptions for chest compressions. We seek to achieve this overall objective
by balancing it with the practicalities of delivering 2 effective breaths between cycles of 30
chest compressions to the patient without an advanced airway. (ANZCOR 2016 Guideline 8 -
Cardiopulmonary Resuscitation)
Medical Emergency Teams

Medical Emergency Teams (MET) are an example of a rapid response system and have been
introduced in many hospitals to identify, review and treat patients at risk during the early phase of
their deterioration. The MET not only responds to patients in cardiopulmonary arrest, but also to
those with acute signs of deterioration.
Calling the team is reliant upon standardised criteria where staff are prompted to summon the
team, as in the escalation processes outlined in Track and Trigger charts. Once arrived, the
MET team will assess and treat the patient as required with the explicit aim of preventing further
deterioration. A guide to standard criteria may include some or all of the following determinants:
• Threatened airway
• All respiratory arrests
• Respiratory rate <4/min or >35/min (Code Blue criteria <8/min)
• Systolic BP <90 mmHg
• Pulse rate >140/min or <40/min (Code Blue criteria >140/min)
• Fall in GCS of >2 points or unresponsive on AVPU
• Seizures
• Fall in urine output <0.5mls/kg/hr
• Oxygen Saturation <90% (Code Blue criteria )
• All cardiac arrests (no pulse/cardiac output)
• Any patient you are seriously concerned about that does not fit into the above criteria
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Safety considerations
As a member of the ALS team, environmental awareness and safety should be paramount. It is
important to don Personal Protective Equipment (PPE) and ensure the surrounds are safe for all
team members prior to initiating any intervention.
Considerations may include:

• Environment free from potential hazards and risks – initial assessment and actioned
appropriately
• All interventions are practiced according to National Health and Safety guidelines
• Existing Multi-resistant Organisms (MRO) – PPE requirements
• Cytotoxic precautions - Cytotoxic PPE requirements
• Medical Radiology Imaging and exposure – Lead garments and PPE
• Cardiac Catheter Labs and radiation exposure – Lead garments and PPE
Please refer to your facility guidelines for specific PPE requirements.
For more information, check your hospital for calling

criteria and emergency response procedures
Ethical considerations
Law requires a collaborative approach between the health professional and patient and/or
substitutive decision-maker about providing, withholding or withdrawing any life-sustaining medical
measures. Please be aware that according to your Duty of Care, you are required to render
whatever assistance that lies within your scope of practice (ANZCOR 2015 Guideline 10.5 - Legal
and Ethical Issues related to Resuscitation).
Consent
Competent adults have the right to refuse treatment when it is life-saving, even if it is not in
their best interest. This right may be undermined if the person does not fully comprehend and
understand their options regarding the situation.
Where active treatment is no longer appropriate, this should be explained to patients and/their
substitutive decision maker.
In an emergency situation, reasonable efforts should be made to obtain consent, however there
may be need for an immediate decision to be made about maintaining the life and health of a
patient without proper consent.
When not to resuscitate
For out-of-hospital cardiac arrests little may be known about the previous medical condition of the
patient and the basic rule is to start CPR except when there are reliable criteria or certain death.
For cardiac arrests that occur in hospital, a patient’s medical condition may have been defined as
inappropriate to receive resuscitation if the patient is found to be pulseless.
Withholding CPR may then be appropriate if the prognosis is very poor, if the patient’s condition
would render the attempt futile, or if the patient has made an informed judgement that he or she
did not wish CPR to be attempted.
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NFR orders
An NFR (Not For Resuscitation) order means that in the event of a sudden deterioration in the
patient’s condition, or if that patient is found to be in a state of cardio/respiratory arrest, the
emergency response team within the hospital will not be activated. This order comes from the
patient or the patient’s family and must be clearly documented for each individual. NFR does not
mean not for escalation. It may still be appropriate to escalate to a MET (medical emergency) just
not for CPR / defibrillation.
It is important to understand that a decision ‘not to resuscitate’ does not mean that the standard
of general medical and nursing care is reduced in any way. It also does not mean that active
or supportive treatment will be withdrawn, such as chemotherapy, rehydration, antibiotics and most
importantly pain relief.
Refer to your hospital’s Not for Cardiopulmonary Resuscitation policy. The

primary response, however, must always be that resuscitation will be attempted
in the event of a cardiac arrest unless there are specific NFR orders. In the
absence of specific instructions, patients suffering cardiopulmonary arrest will
be assumed to require full CPR.
Advanced Health Directive

The Advanced Health Directive is a statement which can be made by any competent adult over
the age of 18 years of age. This form makes provision for directives concerning what medical
treatment the patient wants or does not want. It can also provide further instructions on life
sustaining measures, what the person is willing to accept and what they do not want done.
The life sustaining measures include CPR or any measures to keep the heart working, including
direction in mechanical ventilation, artificial feeding, use of blood products and/or hydration.
This form can be revised at any time or even revoked provided the adult is mentally competent.
The Advanced Health Directive does not constitute a NFR order. National Clinical Governance
policies are available on the National Clinical Governance Unit intranet site under Polices >
General. Please refer to your hospital’s Not for Resuscitation policy.
Legal requirements
Legally, healthcare staff are required to commence CPR promptly, to administer it effectively, and to
also know when such measures are contraindicated and when they should cease.
Failure to start
The consequences of failing to respond to a cardiac arrest may be significant and life threatening.
The reasons for such failure may be complex but are generally as a result of the following:
• Failure to recognise that a cardiac arrest has occurred
• Feelings of inadequacy by the rescuers
• Anxieties in connection with real or imagined risks as a result of undertaking resuscitation.
Failure to recognise that a patient is in need of CPR is a failure of training. Certainly this may be
excusable in the case of the lay public but for nursing and medical staff who owe a duty of care to
the patient, it could be regarded as negligent.
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When to stop
In hospital, it is the responsibility of the leader of the resuscitation team to make the decision to
stop CPR. The legal obligation rests with the most senior medically qualified doctor present.
Time should not be the major factor in the decision whether or not to continue. The size of the
pupils or their lack of response to light are not reliable guides to the activity of the central nervous
system or the likelihood of recovery. Factors influencing the decision to terminate resuscitation
efforts include clinical history and prognosis; the arrest rhythm that the patient is in; and
cardiovascular unresponsiveness to defibrillation, inotropic and stimulant drugs in the presence of
effective oxygenation and basic life support.
When it is appropriate, the decision to discontinue advanced cardiac life support should be made
by the doctor in charge, but all others involved in the attempt should be consulted, including the
patient’s consultant.
Documentation
A ‘real time’ record, such as a form called the ‘Cardiopulmonary Resuscitation Record’, should be
completed during the resuscitation and filed in the patient’s notes (a summary of the ‘code’ may be
printable from your defibrillator, and this may be useful for real time record keeping and accurate
documentation).
In addition to the real time record the team leader is to document events and outcomes in the
patients records or nominate a medical team member to undertake this role.
Any medications ordered and administered during the resuscitation should be documented and
signed for according to your local policy. The staff member responsible for the patient before the
emergency should document the events leading up to making the emergency call and use the
ISOBAR handover tool (or equivalent) if the patient requires transfer to a higher level of care.
Accurate and detailed descriptions of the resuscitation attempt may be invaluable if litigation is
ever sought. Documentation should not be left for a junior staff member as the accurate recording
of events is important to the legal processes.
Standard of care
A nurse or doctor who accepts a ‘duty of care’ for a patient in need of CPR is expected to provide a
reasonable standard of treatment.
A claim of inexperience or lack of training will not be successful as defence in an allegation

of negligence if a practitioner has been called upon only to work within the limits of their own
expected competence. It is important that practitioners should work within their Scope of Practice.
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
Let’s take a moment now to check what you’ve learned. This is not the final quiz, just practice to help you test your
knowledge so far. You’ll find the answers in Appendix 3.
1. What is the primary aim of the Chain of Survival?
a. To give you a simple means to remember the order of response when someone goes
into cardiac arrest
b. To highlight the relationship between early detection and defibrillation and the rates of
survival of cardiac arrests
c. To remind you to use the DRSABCD approach
d. To help you recognise a cardiac arrest
2. Every minute, the chances of survival after an arrest decreases by:
a. 3-5%
b. 5-7%
c. 7-10%
d. 10-15%
3. What are the ethical considerations that need to be adhered to as the ALS trained nurse in an
emergency?
a. NFR, DNR, current medical situation, Advanced Health Directive

b. Consultants orders, available equipment, family wishes, time of code, NFR
c. Advanced Health Directive, NFR, Medical situation, Consultants orders
d. Consent, NFR, Medical condition, Advanced Health Directive
4. The legal requirements which have to be considered in a cardiac arrest situation are:
a. Effective cardiac compressions, documentation, cessation of CPR, Standard of care

b. Medical prognosis, documentation, cessation of CPR, Standard of care
c. Failure to start, documentation, cessation of CPR, Standard of care
d. Standard of care, documentation, justice, empathy
CONCLUSION
In this chapter, we’ve looked at the aims of Advance Life Support, what a cardiac arrest is and how
the Chain of Survival can increase the chances of recovery. We’ve also looked at the role of the
nurse as well as the ethical and legal implications involved in resuscitation attempts.
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ALS
In this section, we’ll have a look at the ALS algorithm and the role of responders to an arrest event.
THE ALS FLOWCHART

The ALS flowchart has been developed as the recommended sequence of actions to be
undertaken once equipment and drugs are available. Several tasks in this flowchart may be
undertaken at the same time, enabling each member of the team to predict and prepare for the
next intervention or consideration. The ALS poster or flowchart (below) is a visual representation
of the algorithm.
The flowchart is based on the following considerations:
1. The importance of good CPR and early defibrillation in achieving successful outcomes.
Ventricular Fibrillation (VF) is in many situations the primary rhythm in sudden cardiac arrest.
The vast majority of survivors come from this group. The chance of successful defibrillation
decreases with time, therefore the performance of good CPR and decreasing the time to
defibrillation are the highest priorities in resuscitation from sudden cardiac arrest.
The amplitude and waveform of VF deteriorate as high energy phosphate stores in the
myocardium decrease. This rate of decrease can be slowed, or even reversed by effective
BLS.
2. Automated External Defibrillators (AEDs) can accurately diagnose cardiac rhythms and
separate them into two groups:
a. “Shockable” = those responsive to defibrillation
b. “Non-shockable” = those unresponsive to defibrillation
3. There are interventions that are indicated in all causes of cardiac arrest.
4. There is a group of
potentially reversible
conditions that, if
unrecognised or left
untreated during cardiac
arrest, may prevent
successful resuscitation.
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SEQUENCE WHEN RESPONDING TO AN ARREST

Please note that some of the details contained in the following process descriptions may be
different depending on your site.
1. The first responder

When an arrest occurs the first responder should follow the BLS Algorithm:
• D: Check for dangers
• R: Assess the patient’s responsiveness
• S: Send for help i.e. Call a code
• A: Open the airway
• B: Check for normal breathing
• C: Commence CPR
• Attached the defibrillator or AED if immediately available. All clinical staff should be BLS
trained and able to use an SAED (Semi-Automatic External Defibrillator) in automatic mode.
Remember:
Compressions require a significant amount of force and depth to ensure

quality and effectiveness and the person performing the compressions will
soon tire. It is recommended operators should change with another staff
member every 2 minutes (ANZCOR 2016 Guideline 6 - Circulation). This will
ensure that depth and rate are maintained at optimum levels.
Medical emergency call processes
Please refer to your own hospital policy and processes for how medical
emergency calls are managed/triggered/escalated and how you, as an ALS
trained staff member, will respond to that call. Be aware that it is possible you
may not be the first ALS trained staff member on the scene and that it is the
responsibility of ALS trained staff to ensure the ANZCOR flowchart is followed
until such time as an ALS team/MET can arrive.
2. Responding as an ALS-trained staff member

Ensure the BLS algorithm is being followed, or if you arrive at any point during that algorithm, your
role is then to:
1. Ensure effective CPR is in progress
2. Attach the defibrillator if this has not yet been done, by:
»» Exposing the patient’s chest quickly. If the patient has a lot of hair it may be advisable
to quickly clip hair for improved pad/skin contact as long as you have the necessary
equipment on hand. In addition, if the patient is diaphoretic, wipe their skin with a sheet
or towel quickly so that the defibrillator pads adhere.
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»» Attaching the pads. We’ll look at where the pads should go a little later.
»» Turning the defibrillator on ensuring it is in manual mode (depending on the type of
defibrillator you have at your site some may default to automatic mode). We’ll learn
more about this operation in a later chapter. Check the default function of the defibrillator
used in your area.
3. If an ALS/Medical Emergency team has not yet arrived, continue CPR and proceed along
the ALS flowchart, directing any other staff present to undertake tasks if they haven’t yet
been taken care of, e.g. ventilation, suction (if necessary), clearing the space around the
patient, recording the event on the Resuscitation record, drawing up drugs, obtaining IV
access and swapping with the person doing compressions.
Working with MET
MET and the on-call medical officer responding to a code will usually each take responsibility
for particular tasks, for example gaining IV access and maintaining the airway. Please refer to
your local policies for the roles of the emergency team.
Your job is to coordinate with these responders while simultaneously coordinating others.
3. Prepare for defibrillation

As an ALS provider, once you have a defibrillator connected, proceed according to the ALS
flowchart. Operating a defibrillator will be covered in the next chapter. For now, let’s focus on the
flow of events as outlined in the ALS flowchart.
There are a number of mnemonics that provide useful guidance in terms of moving from
compressions to charging the defibrillator and determining the patient’s rhythm. Here we will use
the COACHED mnemonic (see the Appendices for a printable flowchart version), but you may use
a different one at your site so please check your local policy and procedures. Remember, the
aim is to minimise interruption to compressions.
The person in charge of the defibrillator should coordinate as follows:
C Instruct compressions to continue
Ask that free-flowing oxygen be moved at least >1 meter away (staff on ventilation can place the bag
O and mask behind their back and step back). If a closed circuit is insitu (i.e. an ET or and LMA) leave
the oxygen connected.
A Request that all staff, other than the person undertaking CPR, stand clear. Do a visual check of the
room
C Charge the defibrillator to the appropriate joules
H
Once the defibrillator is charged, instruct the person on compressions to take hands off and stand
clear. Wait until they have responded accordingly (with “I’m safe” or similar)
E Evaluate the rhythm (shockable or not shockable) and articulate the result to the rest of the group
D Defibrillate patient or disarm/dump the charge
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A note about charging safety:
The ANZCOR 2016 Guidelines (11.4 Electrical Therapy for Adult Advanced Life
Support) state that biphasic defibrillators with self-adhesive defibrillation pads are
safe for compressions while charging, and recommend that compressions continue
while charging to minimise interruptions to compressions and increase likelihood
of shock success, however you should refer to your hospital’s policy for any ‘hands
off’ charging procedures.
4. Continue CPR
NON-SHOCKABLE RHYTHM (Non-VF/VT, Asystole/PEA)
• Asystole is characterised by the absence of any cardiac electrical activity.
• Pulseless Electrical Activity (PEA) (sometimes referred to as Electromechanical Dissociation
[EMD]) is the presence of a coordinated electrical rhythm without a detectable cardiac
output. Please see the section Rhythm Recognition, and Appendix 1: Rhythms for more
information.
• The prognosis in this group of cardiac rhythms or asystole is much less favourable than with
VF/VT.
• During CPR advanced life support interventions are applied and potential causes of arrest
sought.
• Defibrillation is not indicated and the emphasis is on CPR and other ALS interventions (e.g.
intravenous access, consideration of advanced airway, drugs and pacing).
If the rhythm was not shockable and the defibrillator has been disarmed, immediately asses for
return of spontaneous circulation. If there is no pulse or the rhythm is asystole/PEA, continue
with CPR and administer (or administer under the direction of the emergency medical team) 1mg
of Adrenaline immediately (ANZCOR 2018 Guideline 11.2 - Protocals for Adult Advanced Life
Support).
SHOCKABLE RHYTHM
• Ventricular fibrillation is asynchronous chaotic ventricular activity that produces no cardiac
output.
• Pulseless ventricular tachycardia is a wide complex regular tachycardia associated with
no clinically detectable cardiac output. Please see the section Rhythm Recognition, and
Appendix 1: Rhythms for more information.
• A defibrillator shock should be administered according to the algorithm.
• Administer a single shock and immediately resume CPR for 2 minutes after delivery of shock.
Do not delay recommencing CPR to assess the rhythm.
Energy levels
• Monophasic: the energy level for adults should be set at maximum (usually 360 Joules) for
all shocks.
• Biphasic waveforms: the default initial energy level for adults should be set at 200J. Other
energy levels may be used providing there is relevant clinical data for a specific defibrillator
that suggests that an alternative energy level provides adequate shock success (eg. usually
greater than 90%).
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ANZCOR suggests that if the first shock is not successful and the defibrillator is capable of
delivering shocks of higher energy, it is reasonable to increase the energy to the maximum
available for subsequent shocks (CoSTR 2015 weak recommendation, very low quality evidence).
Immediate CPR
Interruptions to CPR decrease the chance of survival from cardiac arrest. While defibrillation is of
paramount importance for VF/VT, a period of well performed CPR immediately after each shock
can help maintain myocardial and cerebral viability, and improves the likelihood of subsequent
shock success.
CPR should be recommenced immediately after the shock has been delivered. DO NOT PAUSE
COMPRESSIONS TO CHECK THE RHYTHM. The heart is slightly stunned when first defibrillated
and the chance the patient will rearrest due to low cardiac output is higher until a resonable blood
pressure is achieved with compressions.
Remember, the CPR ratio is 30:2, with 2 breaths at the completion of each 30 compressions
(without a secured airway). It should take 2 minutes to complete 5 cycles of 30:2.
While CPR is underway, towards the end of the 2 minute cycle and if your hospital policy permits,
charge the defibrillator again. Once charged, follow a mnemonic like COACHED again in order to
check the patient’s rhythm with minimal interruptions to compressions.
• If it becomes necessary to shock a second time, you should administer (or will be directed to
administer) 1mg of Adrenaline after the 2nd shock. This dose should then be administered
every second cycle.
• If it becomes necessary to shock a third time, proceed as above (CPR/charge > pause >
check rhythm > shock) and administer 300mg of Amioderone after the third shock.
• If the rhythm is not shockable, disarm the defibrillator, continue CPR, and return to the
Assess rhythm point in the algorithm. Follow the steps again.
Simultaneously while CPR continues, you and the team should be ascertaining the cause of the
arrest by considering the 4Hs and 4Ts and treating appropriately.
5. Return of spontaneous circulation

Has spontaneous circulation and normal breathing returned? If it has, proceed to post
resuscitation care.
If circulation has not returned, CPR should be continued until the patient is spontaneously
breathing. The patient should be reassessed every 2 minutes in regards to response to treatment
(drug administration, compressions or a shock).
• If the rhythm is shockable: deliver another shock as per the previous step
• If the rhythm is non-shockable: disarm the defibrillator and continue CPR as per the
previous step
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6. Post-resuscitation care
Once spontaneous circulation has returned, you should:
• Re-evaluate ABCDE
• Re-evaluate oxygenation and ventilation – aim for 94 -98% saturation/ normocapnia /
normoglycaemia
• Treat any precipitating causes - 4Hs and 4Ts
• Provide haemodynamic support through IV fluid administration
• Record a 12 lead ECG for analysis
• Escalate level of care and arrange safe transfer
• Initiate targeted temperature management (TTM) if appropriate
RESPONSIBILITIES OF TEAM MEMBERS

As the ALS trained staff member on scene, and until a medical officer has arrived, it is your role to
ensure the ALS flowchart is followed, and coordinate or ‘run’ the code. This means that you need
to maintain an awareness of the overall situation – who is where and doing what, and whether
the actions being taken are effective and following the ALS algorithm – regardless of what else you
are doing, and be able to coordinate everyone’s efforts. Refer to Human Factors training for more
information about this. The Human Factors program is available in your eLearning.
You will need to use your own judgement on what is needed, but be aware of everyone in the
room. Is the CPR person tiring? Has the person on ventilation responded appropriately to the
defibrillation call to stand clear? Who is investigating the cause of the arrest (4Hs & 4Ts)? Have the
recommended drugs been administered? These are only some of the considerations you will have
to take into account.
Above and beyond this, these are (commonly) the roles during a code:
• The team leader (responsible for allocating roles and running the Code)
• The person managing the patient’s airway (once the medical officer has arrived at the code,
this is often their role)
• The person operating the defibrillator
• The person performing compressions (2 to 3 people may need to rotate through this role as
a responder who is starting to tire may not be able to maintain good quality compressions)
• The person preparing access and administering any necessary drugs (this is often the
members of the MET)
• The person recording the event (i.e. the scribe)
Let’s now look at how these teams appear and function at different types of hospitals. Remember,
this is only a stereotypical view and teams may take different forms or function in slightly different
ways at your site.
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ALS trained, small hospital

You are an ALS trained staff member at a small hospital. With your training, you are
rostered on as part of a Medical Emergency Team on a regular basis.
In the event of a cardiac emergency, you will be called to respond with the rest of
your team and the on-call medical officer. Your role can be any one of the following:
• The person ‘running’ the code • The person performing compressions

(coordinating the resuscitation efforts) • The person preparing access and
• The person managing the patient’s administering any necessary drugs
airway • The person recording the event (i.e.
• The person operating the defibrillator the scribe)
ALS trained, large hospial

You are an ALS trained staff member at a medium to large hospital. With your
training, you are the nominated ALS person on your ward. You may or may not
be the only ALS person on your ward.
In the event of a cardiac emergency you may be the first or second person on
the scene. Your role is to coordinate other staff members present in resuscitation efforts until the
medical officer and/or MET arrive. Depending on the number of ward staff at the code, your role
may also include one of the following:
• The person managing the patient’s • The person preparing access and
airway administering any necessary drugs
• The person operating the defibrillator • The person recording the event (i.e.
the scribe)
• The person performing compressions
Once MET or a medical officer has arrived, your role may be to continue coordinating efforts in
conjunction with the MET and MO, or to act under direction from the MO.
ICU, CCU, ED/EU
You are a staff member working in ICU, CCU or Emergency. You are likely to already have ALS
certification and may have dealt with a number of cardiac arrests. You may
be rostered on to a Medical Emergency Team regularly.
In the event of a cardiac emergency, you will be called to respond with the
rest of your team and the on-call medical officer. Your role can be any one of
the following:
• The person ‘running’ the code • The person performing compressions

(coordinating the resuscitation efforts) • The person preparing access and
• The person managing the patient’s administering any necessary drugs
airway • The person recording the event (i.e. the
• The person operating the defibrillator scribe)
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BEING ORGANISED AND PREPARED

A code never runs according to plan. You must be organised and prepared to the best of your
ability even while adjusting to a changing situation. While CPR is underway, you will have a
moment to focus on the kinds of things that you and your team will need to consider.
During CPR you may have to be prepared to:

• Utilise available airway adjuncts
• Deliver oxygen
• Use waveform capnography
• Prepare or adjust IV/IO access
• Administer drugs
• Send to lab any blood and other tests
• Liaise with other medical staff
• Communicate with the medical officer and MET
Remember
You must plan your actions before interrupting

compressions (e.g. charge manual defibrillator as in
stated in the ALS algorithm).
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The 4Hs and 4Ts

We have discussed previously some common reasons why a cardiac arrest may occur. Cardiac
arrest maybe the result of potentially reversible causes requiring a specific treatment. During CPR
you will need to consider whether you are dealing with these causes – referred to as the 4Hs and
4Ts - and correct them.
Hypoxia
• Cause: Low oxygen levels in the blood
• Considerations: Prior to the arrest what was the respiratory pattern, rate, ABGs, O2
saturation?
• Treatment: Airway management and appropriate interventions need to be considered to
reverse the hypoxia. For example manual ventilation using the bag and mask, LMA or
intubation
Hypovolaemia
Hypovolaemia may be significant in arrests associated with trauma, GI Bleed, dehydration, fluids
shifts (burns), anaphylaxis, post-operative sepsis, surgery, and post-delivery complications/
miscarriage.
• Cause: Low amount of circulating blood, either absolutely due to blood loss or relatively due
to vasodilation
• Considerations: Look for signs of bleeding, severe dehydration (e.g. diarrhoea and
vomiting). Compensatory systemic release of catecholamines promotes peripheral
vasoconstriction, increased cardiac contractility and tachycardia. A low diastolic BP suggests
arterial vasodilation (as in anaphylaxis or sepsis) (ANZCOR 2016 Guideline 9.2.7 – First Aid
Management of Anaphylaxis)
• Treatment: Control bleeding and deliver appropriate fluid replacement e.g. crystalloid and
blood products.
Hyper/hypokalaemia/metabolic disorders
Metabolic abnormalities may be suggested by the patient’s underlying condition (e.g. renal failure),
tests taken during the resuscitation, or clues given in the ECG.
• Cause: Electrolyte imbalance, for example disturbances in the level of potassium/calcium/
magnesium in the blood. Also check patient history for issues e.g. hypoglycaemia
• Considerations: Look for conditions such as renal failure, diabetes, dehydration and check
patient medical history.
• Treatment: Aim of treatment is to reverse the disorder:
»» Hypokalaemia - 5mmol bolus KCL IV
»» Hyperkalaemia - to lower the potassium use shifting agents (glucose 25g + 10 units
of short acting insulin) and consider Sodium Bicarbonate. Cardio protective measures
include 5 -10ml of 10% calcium chloride IV or 10ml of 10% calcium gluconate as per
your hospital policy to stabilise cell membranes (this does not reduce serum potassium
levels)
»» Hypoglycaemia - 10-50% glucose IV
»» Hypomagnesia - 5mmol bolus of magnesium IV
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Hypothermia/hyperthermia
Hypothermia is associated with drowning incidents and drug overdose. Hyperthermia is associated
with dehydration, heart disease, fever, heat stroke, or drug use.
• Cause: Dramatic increase or decrease in body temperate
• Considerations: Look for signs of severely high or low body temperature such as skin
colour, cracked or blue lips
• Treatment: The patient should be actively warmed or cooled. Heat the patient using a
space blanket if hypothermia. Cool with fluids, ice packs in armpits and behind the neck for
hyperthermia. Specific modifications may be needed in cardiac arrest (refer to the Special
Circumstances chapter)
Tension pneumothorax
Tension pneumothorax results from the progressive build-up of air within the pleural space, usually
due to a lung laceration which allows air to escape the pleural space but not return.
• Cause: A tear in the lung leading to lung collapse and twisting of the large blood vessels,
including the insertion of invasive devices into the chest cavity
• Considerations: Observe and assess for tracheal deviation, unilateral air entry, and/or
unequal rise of the chest when ventilating. Also look for bruising around the rib area and
consider a thoracic assessment for broken ribs
• Treatment: Emergency chest decompression of the affected side by a skilled operator. Insert
a 14 gauge (or larger) needle /cannulae, into the 2nd intercostal space (midclavicular line).
Follow this with a chest drain when appropriate.
Tamponade
• Cause: Fluid or blood in the pericardium, compressing the heart and preventing its ability
to contract, due to thoracic trauma, recent cardiac surgery, insertion of central lines, recent
angiography, recent MI, recent pacemaker, mediastinal radiation therapy, known pericardial
effusion, renal failure, or pericarditis (ARC ALS 2 3rd Australian edition 2016)
• Considerations: Assess history for blunt trauma/stab wounds or for rapidly decreasing blood
pressure or complications from cardiac surgery/interventional procedures i.e. PPM insertion
• Treatment: Undertake cardiac ultrasound. Pericardial tap (pericardiocentesis) or emergency
open heart surgery may be required
Toxins/poisons/drugs
Toxic reaction is either a result of accidental or deliberate overdose.
• Cause: Dependent on the toxin
• Considerations: Look for symptoms of anaphylactic shock (rapidly decreasing vital signs) or
opiate induced respiratory arrest
• Treatment: Maintain basic and advanced life support and try to ascertain the source of the
reaction and reverse it (administer antagonist)
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Thrombosis (pulmonary/coronary)
Thrombosis is the blockage of blood vessels to the lungs or heart by a blood clot or other material.
• Cause: Post-surgical complications, Myocardial Infarction (MI), cardiac arrhythmias, blood
disorders
• Considerations: Patient history, e.g. chest pain, kidney failure (low molecular heparin),
signs of a stroke (level of consciousness) or signs of transient ischemic attack (TIA)
• Treatment: Thrombolytic therapy if there is a high likelihood of Pulmonary Embolus. MI is
treated by primary angioplasty. Increased risk of severe bleeding needs to be considered
particularly post-surgery / trauma / head injury
ANZCOR 2018 Guideline. 11.2 - Protocols for Adult Advanced Life Support
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. What is the correct response to recognition of a non-shockable rhythm?
a. Charge the defibrillator in case the rhythm changes

b. Ventilate the patient
c. Continue good quality CPR and reassess the rhythm after 2 minutes
d. Shock the patient then continue CPR
2. You are the ALS trained nurse responding to a call to resuscitate a patient on the surgical ward.
Ward staff found the patient collapsed, commenced CPR and attached the defibrillator. What is
your first priority?
a. Check the patient’s airway

b. Defibrillate the patient
c. Obtain IV access
d. Assess the effectiveness of the CPR being performed while planning for rhythm check/
defibrillation
3. Failure to perform a visual sweep of the room and call “stand clear” (or similar) before pressing
the Shock button constitutes a potential hazard to other staff members – True or False?
4. You should never charge the defibrillator pads on the patient’s chest wall as this may cause
accidental discharge – True or False?
CONCLUSION
In this chapter, we’ve looked at the ALS algorithm and the roles of the ALS nurse during a cardiac
arrest code. We’ve also looked at the 4Hs and 4Ts which may be causes of cardiac arrest.
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Rhythm Recognition
In this section, we’ll have a close look at the ECG and the components of a waveform, as well as what
constitutes a normal rhythm and how to recognise and interpret the abnormal.
RHYTHMS ARE A PICTURE

It is important to be able to recognise the cardiac rhythms that may compromise cardiac output,
precede cardiac arrest or complicate the recovery period after successful resuscitation.
Even if a definite ECG diagnosis cannot be made, it is important to be able to recognise that an
arrhythmia (an abnormality in the rhythm) is present so that you can assess the effects on cardiac
output and therefore act accordingly.
Cardiac Anatomy
The following content assumes that you understand the myocardial functions of the heart. If you need
to brush up on your cardiac anatomy and physiology, now’s the time to do so. You can use whatever
text you have at hand, or follow the link to our recommended online resource, Anatomy and Physiology
Essentials.
You will need your Athens login. See the RHC Library at http://ramsaylibrary.com.au for registration.
The electrocardiograph
Understanding of the basic principles of electrocardiograph (otherwise known as the ECG)
recording measurements and how this relates to the action of the heart will help you in
understanding how to read a rhythm strip.
About the ECG
The ECG is a diagnostic tool that reflects cardiac electrical activity. It is a record of the magnitude
and direction of the electrical current which is generated by depolarisation (contraction) and
repolarisation (relaxation) of the atria and ventricles.
• Rhythm strips – provide information relating to the rhythm and the rate.
• 12 lead ECG – provides information about rate, rhythm, impulse conduction, electrical axis,
hypertrophy, ischemia and infarction.
It’s important to remember that the ECG will only show you what is occurring electrically within the
heart, not how well it is pumping.
The measurement of the squares in an ECG strip is relevant to the ECG rhythm in that each part
of the ECG has an allocated time frame for each conduction, so knowing the measurement will
enhance your ability to interpret the rate and rhythm.
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Reading a rhythm strip

Let’s look at one simple way of reading a rhythm strip. All ECGs run at the same rate using the
same measurements. The paper speed of all ECGs is measured in 25mm per second.
This means that a 1mm square (also known as a small square) is equal to .04 of a second.
5 x 1mm square (also known as a large square) therefore equals .20 seconds
Now, this is the important part - the paper speed we were referring to earlier feeds 5 squares
through every 1 second.
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What you’ll find when you look at a rhythm strip is a mark every 6 seconds. That’s 30 x (.20
second) squares, or 5 x (1 second) squares.
Heart rates are based on beats per minute, i.e. the number of beats every 60 seconds. Rhythm
strips are marked every 6 seconds to make it easier for you to calculate how many beats there are
per minute. You look at the number of beats over a 6 second piece of the strip and then multiply by
10.
6 complexes (i.e. 1 second) x 10 = 60 beats per minute
Now let’s look at the units in the vertical direction on the graph. The vertical is used to measure
voltage. Voltage is also a set unit. On an ECG graph it is:
This enables you to determine types of electrical impulses. The bigger the muscle mass of the
heart, the higher the voltage on the ECG.
Parts of an ECG waveform

Now, that you understand the measurements mapped on an ECG, let’s look at the ECG wave form
itself and how it relates to the function of the heart. We’ll start with a sinus rhythm, which is the
normal (generic) rhythm of the human heart. As visualised by the ECG, it usually looks very much
like this:
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Each of these complexes represent something that the heart is doing electrically, which is how the
ECG turns the electrical activity of the heart into something you can see on a graph.
The P wave
The P wave reflects atrial depolarisation (atrial repolarisation is too small to see
reflected on the strip). This is when the electrical impulse spreads across the
atria from the Sinoatrial (SA) node. This should initiate contraction of the atria to
push blood through the open valves from the atria into both ventricles.
A normal P wave should be rounded and upright. A true P wave will look the
same at each complex.
PR Interval
The PR interval reflects the time it takes for an impulse to spread from the SA
node, through the atria and through to the AV node, where the impulse is held
briefly to allow the ventricles to fill. This is measured from the start of the P
wave to the start of the QRS complex. The normal amount of time this takes is
0.12 – 0.20 seconds (3 – 5 small squares).
QRS complex
The QRS complex reflects ventricular depolarisation.
Normal duration of a QRS complex is 0.04 – 0.12 seconds (1 – 3 small

squares)
The Q wave represents the depolarisation of the ventricular septum.
The R wave represents the depolarisation of the main mass of the ventricles
and the S wave represents the final depolarisation of the ventricles at the base
of the heart.
ST Segment
The ST segment represents a period of electrical inactivity after the whole
myocardium has depolarised.
T Wave
The T wave reflects ventricular repolarisation, that is, the point at which the
electrical signal has passed and the ventricles are relaxing.
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QT Interval
The QT interval is the distance from the beginning of the QRS to the end of the
T wave that represents the depolarisation and repolarisation of the ventricles.
Calculating the measurement is dependent upon heart rate and the length of
the QT interval. This is calculated by the ECG machine.
RR Interval
The RR interval represents the distance between 2 consecutive R waves.
Analysing rhythms
Now let’s learn how to analyse what we’re seeing on an ECG. Cardiac rhythm is identified through
the combination of several factors, some of which we have already touched upon.
Regularity and rate
Regularity refers to the predictability of the pattern. A regular pattern, where all complexes are
occurring as expected, indicates that the rhythm is normal. An irregular pattern, or one where
only certain complexes are occurring indicates that the rhythm is abnormal and that there is a
conduction issue somewhere within the heart (for reasons yet to be determined).
Rate similarly gives you an indication of ‘what the heart is doing’. Since we know what constitutes a
normal rate under general conditions, we can determine what issues potentially exist based on how
much faster or slower the patient’s rate is compared to the normal.
P waves
The P wave reflects whether the SA node – the heart’s natural pacemaker – is firing, so when you
look at the strip, ask yourself:
• Are there any? If not, why? • Is it upright or inverted?
• Is there one for every QRS? Is the signal • Is it rounded or peaked?
from the SA node always reaching the AV • Do they all look the same?
node, or only irregularly reaching it?
• Is it before, during or after the QRS? The absence or irregularity of P waves
indicates a problem with the SA node.
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PR Interval
The PR interval reflects the time it takes for the signal to spread from the SA node to the AV node.
A normal PR interval is 0.12 to 0.2 seconds (3-5 small squares). The interval should be consistently
the same for every beat. When the PR interval is longer than in sinus, it means that the signal from
the SA node is taking longer than expected to reach the AV node and there is a problem in that
area.
QRS complex
The QRS complex is usually the largest complex in a sinus rhythm, as it represents the
depolarisation of the ventricles (which are the strongest part of the heart).
A normally conducted beat will have a duration of between 0.04 and 0.12 seconds (1 to 3 small
squares). Anything longer implies that the beat was delayed in a bundle branch or it originated from
a site in the ventricles.
Note that the QRS can take on many forms.
ST segment and the T wave
The ST segment and T wave reflects the electrical inactivity in the heart after the whole
myocardium has depolarised. The ST segment should therefore normally be isoelectric (on the
baseline; abnormal may be elevation or depression) and the T wave should be minimal.
Looking at the T wave, ask these questions:

• Is there one?
• Is it too close to the preceding complex?
• Is it the same direction as the QRS?
• Is it tall, peaked, flattened, elevated, or depressed?
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Conduction
Conduction is illustrated in the P to QRS relationship. Look for random abnormalities or patterns.
Is there one P wave to every QRS? If not, are there too many? Or perhaps not every QRS has a P
wave?
Haemodynamics
This is perhaps the most important point – how is my patient?
Haemodynamic responses to rhythm changes will be different in all patients. It is vital to assess
your patient’s vital signs and haemodynamic responses to the changes and respond appropriately.
TYPES OF RHYTHMS
Now that we’ve looked at the parts of a wave form and how to translate what we’re seeing into
what’s happening in the heart, let’s finally look at types of rhythms.
There are two types of rhythms – sinus, or normal; and arrhythmic, in other words, abnormal.
Abnormal rhythms can be further categorised based on the presence or absence of cardiac output.
Rhythms with no cardiac output are known as arrest rhythms, or life-threatening arrhythmias.
Rhythms with cardiac output – however limited or dysfunctional – are known as non-life threatening
arrhythmias.
Life threatening arrhythmias

Life threatening (arrest) rhythms are specifically those rhythms with zero cardiac output. The
response to these rhythms is immediate CPR.
Arrest rhythms are categorised into two main types: shockable, and non-shockable.
• Shockable rhythms are defined as rhythms that can be reverted with an electrical shock. In
a shockable rhythm, the activity of the heart is such that cardiac output cannot be achieved.
A direct current (DC) electric shock will temporarily depolarise the cardiac tissue, essentially
stunning the heart. This then allows the heart’s natural pacemaker to initiate its normal
impulses. Shockable rhythms are either Ventricular Fibrillation (VF) or Pulseless Ventricular
Tachycardia (PVT).
• Non-shockable rhythms are those rhythms that cause circulatory collapse, yet would not
benefit from a single, depolarising shock. Non-shockable arrest rhythms are either Asystole
or PEA (Pulseless Electrical Activity).
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Non-life threatening arrhythmias

Non-life threatening rhythms are rhythms which may potentially cause decreased cardiac output.
These rhythms can be serious, and may lead to a cardiac arrest if untreated. In these cases
cardiac output will mean that the patient’s haemodynamic status is potentially compromised,
requiring immediate recognition of the rhythm and prompt treatment to prevent poor outcomes.
CONCLUSION
In this chapter, we’ve examined the ECG waveform and looked at how what you’re seeing on a
strip relates to the conduction in the heart.
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Defibrillation
In this section, we’ll look at defibrillation. We’ll also examine the factors that determine successful and
safe defibrillation.
WHAT IS DEFIBRILLATION
Defibrillation is the passage of electrical energy to the heart to simultaneously depolarise enough
myocardial cells to produce repolarisation and enable the natural pacemaker tissue to resume
control.
The Australian Resuscitation Council has determined that resuscitation outcomes show
improvement when a defibrillator is attached to the patient as soon as it is available and
shockable rhythms are immediately identified and shocked (ANZCOR 2016 Guideline 11.4 –
Electrical Therapy for Adult Advanced Life Support).
The importance of good CPR and early defibrillation in achieving successful outcomes. Ventricular
Fibrillation (VF) is in many situations the primary rhythm in sudden cardiac arrest. The vast majority
of survivors come from this group. The chance of successful defibrillation decreases with time.
Therefore the performance of good CPR and decreasing the time to defibrillation are the highest
priorities in resuscitation from sudden cardiac arrest.
The amplitude and waveform of VF deteriorate as high energy phosphate stores in the
myocardium decrease. This rate of decrease can be slowed, or even reversed by effective BLS.
Maintaining competency
Code of Practice for Registered Nurses states that it is the

responsibility of the Registered Nurse to maintain competency in any
procedures they undertake as part of their nursing practice.
With regard to defibrillation, nurses are evaluated in their competency

against the defibrillation policy in the department in which they work.
These may be set against the standards set through the ARC.
All defibrillators have the same functionality. Depending on the manufacturer, some of the controls
will look a little different. These are just some of types of defibrillators in use around Ramsay
Healthcare.
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Later, in the face-to-face session, you’ll get hands on experience with the device used in your
hospital, but right now we’ll just undertake a quick orientation with a Zoll defibrillator
Charge button
Energy select
Display
Pacing output MA
Synch on/off Shock button

Rhythm strip feed
Recorder Pacer rate
Power switch
Display
This is where the signal from the electrodes displays in a readable form.
This also displays the joules for shocking, pacing amplitude, time or duration of code.
Power switch
Switching to 1 DEFIB is a fully manual mode on this particular model of defibrillator. You can also
set the machine to monitor or Pace.
Note: Defibrillators which do not have pacing capabilities will default to automatic mode when
switched on and will have to be switched to manual elsewhere. The type of defibrillator you are
most likely to encounter at your hospital will be demonstrated fully in your face to face session.
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Energy Select
This controls the joules that the defibrillator will deliver and is used to increase/lower the joules or
dissipate the charge.
Charge button
This button will charge up the machine in preparation to deliver a shock.
Defibrillators produce a direct current (DC) discharge which passes between two electrodes.
• Monophasic defibrillators deliver a single burst of energy from one pad to another. The
energy on these defibrillators is set to 360J.
• Bi-phasic defibrillators send electricity from one pad to the other and then reverse direction.
This compensates for transthoracic impedance (which we’ll look at shortly) and therefore
uses less energy. The energy these defibrillators are capable of delivering is adjustable but
the ARC states that the default should be set to 200J unless otherwise recommended by the
manufacturer. If there is any doubt as to what the machine default is, it should be set to 200J.
Shock button Sync On/Off

This button delivers the shock to the This button is used in cardioversion and enables
pads. It lights up when the defibrillator the machine to preference R waves and trigger an
has charged to the set amount. impulse prior to the R wave in order to prevent an
“R on T”.
Pacing Output MA
In Pacer mode, this dial controls the You’ll learn more about cardioversion in a later
amount of milliamps delivered for the chapter.
purposes of capture of the pacing spike. Recorder
You’ll learn more about pacing in a later
chapter. Press this button to capture the arrest event on
the rhythm strip.
Pacer Rate
Strip
In Pacer mode, this dial controls the
rate at which you aim to pace the heart. This is where the defibrillator prints out the ECG
You’ll learn more about pacing in a later rhythm strip.
chapter.
Attached to the defibrillator machine are the pads and electrodes.

Pads Electrodes
The pads are adhesive gel The pads act as electrodes, however it is also
covered pads which stick to possible to hook up separate electrodes in view
the patient’s skin. of the patient requiring pacing.
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ENERGY DELIVERY
Delivery of a single shock is now the standard. There is no evidence to suggest that a single or
stacked regime of shock delivery improves outcome. There is evidence to show that effective
compressions and oxygenation during arrest improves outcome, hence the emphasis on effective
CPR.
Single shock
For biphasic defibrillators, a single shock of 200 joules is delivered.
All shocks for monophasic defibrillators, or where you are unsure of the recommended setting for a
specific device, should be 360 joules.
If the first shock is not successful and the defibrillator is capable of delivering a higher energy
shock, it is reasonable to increase the energy to maximum joules available for subsequent
shocks.
ANZCOR 2016 Guidelines section 11.4 - Electrical Therapy for Adult Advanced Life Support
Stacked shock
Stacked shocks are shocks that are delivered one after another. If the first shock does not have any
notable effect, another shock should be delivered within 20 seconds (ANZCOR 2017 Guidelines
Section 11.1 - Introduction to and Principles of In-hospital Resuscitation). The time required for
rhythm recognition and recharging the defibrillator is short (<10 seconds), and up to three shocks
are counted as the first shock in the ALS algorithm sequence.
The only situation where stacked shocks are now recommended is where:
1. The patient is previously well perfused and oxygenated;
2. The ECG is witnessed to change into a shockable rhythm;
3. The patient is non-responsive; and
4. A manual defibrillator (not a semi-automatic one) is already connected and ready for
use with qualified personnel to operate (for example, in a Cath Lab when the patient is
haemodynamically stable prior to the event, or with a patient who is immediately post-cardiac
surgery or has previously had a witnessed monitored arrest).
In this specific situation, a delivery of three stacked shocks may be given, followed immediately by
two minutes of CPR. The rationale for this is that successful reversion of the rhythm is proportional
to speed of defibrillation and length of time the patient has been in the shockable rhythm. If a
rhythm appears normally associated with an output after, for example, the second stacked shock,
there is no need to deliver the third shock. Subsequent shock delivery will be single.
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Successful defibrillation
You will normally recognise successful defibrillation by a change in the patient’s ECG rhythm.
Successful defibrillation depends on many patient and operational factors. These include:
• High quality CPR
• Pre-shock pause before defibrillation and post-shock resumption of chest compressions <5
seconds
• Pre-existing condition of the patient
• The duration of pre-shock ventricular fibrillation and CPR (i.e. “down time”)
• The functional state of the myocardium
• Acid/base balance
• Level of hypoxia and
• Antiarrhythmic drugs
The likelihood of successful defibrillation may be improved by the administration of certain drugs
such as Adrenaline. Time is the most important factor affecting defibrillation success. The aim is
to have the shortest possible pause between when compressions cease and delivery of shock –
under 5 seconds. Minimal interruption supports improved outcomes. (ANZCOR 2016 Guideline
11.4 – Electrical Therapy for Adult Advanced Life Support)
Transthoracic impedance
Transthoracic impedance is the resistance to current by the body. Skin, fat, muscle, bone and
internal organs all contribute to the magnitude of the current that actually reaches the heart.
Transthoracic impedance can be influenced by the following factors:
Body size
The range of weight in an adult’s body size does not greatly influence the energy requirements.
However, the time that the energy takes to transmit from the sternal to apex pads may be slightly
impeded.
Also consider breast size (male or female) in terms of positioning the pads. Pads placed directly on
a large breast will affect transmission of energy. Ensure pads are not placed over breast tissue.
Body hair
It’s often difficult to obtain good electrode to skin contact in patients with hairy chests. This
increases impedance, reduces defibrillation efficacy and may cause burns to the patient. If clippers
are available immediately, use them to remove the hair from the area where the electrodes are to
be placed. However, defibrillation should not be delayed if clippers are not immediately at hand.
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Placing the pads

Sternal/Apex
This position depolarises the largest amount of cardiac tissue. Incorrect positioning can mean the
heart is not correctly depolarised.
• Sternal pad placed to the right of the sternum and inferior to the right
clavicle
• Ensure pad is not over bone (conducts poorly)
• Apex pad is placed over the 6th intercostal space between left
midclavicular and mid-axillary line
• Ensure full contact of the pad by applying even pressure to whole surface of the pad
Anterior/Posterior
This position can be used if repeated defibrillation attempts have been
unsuccessful, the patient is morbidly obese or if there is an inability to place
the pads on the right side of the chest due to trauma or burns.
• Sternal pad placed over the 6th intercostal space on left anterior chest
wall to the left of the sternal border.
• Apex pad is placed on the left posterior wall, below the scapula and lateral to the spine.
Where not to place pads
Pads should NOT be placed over central lines, chest drains, surgical clips, drains, clothing, monitor
wires/cables, medication patches (such as GTN/HRT/Nicotine patches) with metal backing, or
wet skin. Pads should be placed at least 8cm away from pacemaker and brain stimulator pulse
generators (boxes), portacaths and other implantable devices.
SEQUENCE FOR DEFIBRILLATION

Now that we’ve looked at the defibrillator itself, and examined what can help or hinder its efficacy,
let’s take a look at how to use it.
Remember that the Anterior Posterior

pad position is an alternative if there is
damage to the chest or another reason why
the sternal pad cannot be placed in the
standard position.
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We’ll start by assuming that you have responded to a call for help and are ALS trained. CPR is
being administered when you arrive and it is being undertaken correctly. The defibrillator pads are
being attached correctly just as you arrive and the patient’s skin is dry. The first step is to turn the
defibrillator on.
1. Set the power switch to the ON position and ensure it is set to 200J. Certain defibrillators
require manually dialling the charge to the desired level. Please check the operation manual
for the defibrillator in use at your site.
2. Remember that interruption to compressions should be minimised, and that all other staff,
as well as the person ventilating, should stand clear. Commence your safe defibrillation
sequence, for example using the pneumonic COACHED.
Charge the defibrillator by pressing the CHARGE button. Defibrillators are designed to
withhold charge until the Shock button is pressed, so charging the pads while CPR is
underway is not considered dangerous and is recommended by the ARC to minimise
interruption to CPR, however, please check with your local policy with regards to hands on/off
charging. Perform visual sweep
3. Once the defibrillator is fully charged (an audible signal may be heard). advise the person on
compressions to stand clear or say “hands off”. Ensure you have clear acknowledgement
from the person performing compressions, before checking the rhythm. Ensure no-one is
touching the patient or anything that the patient is touching. Ensure that any oxygen is >1
metre away.
4. Check the rhythm and articulate it to the other staff attending the code. If the rhythm is
shockable proceed to shock by pushing the SHOCK button.
If the rhythm is non shockable, immediately disarm the defibrillator so the patient can be
checked for a pulse and chest compression can recommence if necessary. Please refer to the
manufacturer guidelines for machine-specific information on how to disarm the defibrillator in
use at your site.
5. If a pulse is not palpable or there are no signs of life, immediately continue CPR for 2
minutes.
6. At the end of the 2 minutes, repeat the process for rhythm assessment. During this time you
should also be determining the cause of the arrest (i.e. the 4Hs & 4Ts).
What to do in the event of failed defibrillation

A failed defibrillation occurs when there is an unsuccessful delivery of the electrical shock (joules)
for the intention of electrical defibrillation.
If the attempt at defibrillation is unsuccessful:

• Recommence CPR with oxygen
• Check pad position
• Check that there is adequate skin contact (clipping or shaving of body hair under the
defibrillator pad may be required)
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• Consider changing the defibrillator pads (pads could be expired)

• Consider anterior-posterior placement so that the maximum amount of current traverses the
myocardium
Failed defibrillation can fall into one of three categories:

Patient failure
Patient failure can be due to:
• Prolonged downtime before resuscitation is commenced
• Severe acid-base imbalance, myocardial hypoxia or severe electrolyte imbalance
• Terminal condition pre-arrest
• Severe drug toxicity, such as digoxin
Machine failure
Machine failure can be due to:
• A malfunction of the defibrillator
• Loss of battery charge during repeated defibrillation attempts. Always plug the defibrillator in
to the mains if repeated shocks are required.
• The synch button is on/active.
Operator failure
Operator failure can be due to:
• The defibrillator not being turned on
• The defibrillator not being charged
• Joules not being selected or the incorrect joules being selected
• The pads are not connected to the defibrillator
Process and documentation

The following forms of documentation are critical to both the ongoing care of the patient and your
hospital’s requirements for due process. Please check with your hospital policy for documentation
requirements.
Resuscitation record
The resuscitation record must be filled out by a member of the team during the event if possible.
This includes time of collapse, initial rhythm, number of shocks delivered, number of joules given
at each shock, drugs used and in what amounts, patient response to resuscitation efforts and
the duration of those efforts. If there were any failed attempts in interventions, as well as the
rationale behind the decisions made during resuscitation – e.g. two failed attempts at intubation
due to difficult or swollen airway therefore progressed to tracheotomy – then this also needs to be
included in the resuscitation record.
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The times on the record should match the time stamp on the defibrillator (be aware that some older
model devices do not have a time visible on the screen which will make it difficult to ensure this
correlation. Check with your local policy/procedure as to how to manage this if you have an older
device at your site). If the time on the strip is different to the manual records, there can be legal
implications. Also on the record must be the names of those staff members who attended the code.
A record sheet is attached to the resuscitation trolley. Part of the post-event checklist is to restock
this sheet along with any other items used from the trolley. Please refer to your hospital policy on
correct documentation.
Post-event print out
One of the most important pieces of documentation in a cardiac event is a printout of the rhythm
strip post-event.
If you are the person recording the arrest event on the resuscitation sheet it is also your
responsibility to obtain a print out of the rhythm strip at the end of the code. This must be included
with the resuscitation record in the patient’s file.
Post event count
The post-arrest count is conducted to correlate physically what has been used with the
resuscitation record, most importantly the drugs given, duration of the code, who attended the
code, shocks delivered, what equipment was used and what the next steps are. This is to both
confirm the notes on the record and to prepare for restocking.
Resuscitation trolley
The team leader or NUM will have allocated a staff member from the ward to restock the
resuscitation trolley after an arrest. It is also checked and restocked (if necessary) on a daily basis
as per hospital policy.
Team debrief
Post-resuscitation it is important that the team members have time to reflect and debrief on
the events, in addition to be able to discuss outcomes, processes, identify safety issues and
opportunities for improvement.
Family
Ensure family have been informed and relevant information material provided.
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. One of the conditions where it is recommended to deliver stacked shocks to a patient is:
a. Only when a previously well oxygenated, well perfused, witnessed and monitored patient
develops a pulseless, shockable rhythm
b. Only when a cardiac patient is witnessed to collapse in their bathroom
c. Only when you are called to an arrest
d. Only when a telemetry patient is seen to have collapsed
2. Time is a critical factor that affects defibrillation success – True or False?
3. Which of the following is NOT a factor that influences transthoracic impedance?
a. Pad contact and body hair

b. The patient’s chest wall size
c. Obesity
d. Correct pad placement
CONCLUSION
In this chapter, we’ve looked in detail at the defibrillation process and how to operate a defibrillator.
This should assist your learning when it comes time to practice these actions in the face-to-face
session.
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Advanced Airway Management

In this section, we’ll examine issues surrounding airway management during cardiac arrest. Choice of
adjunct is dependent upon the training and experience of the provider and the equipment available.
Early recognition and prompt treatment of the airway during an emergency is paramount in
preventing secondary hypoxic damage. When unconscious, all the muscles relax, therefore the
unprotected airway may easily be blocked by the tongue falling against the back wall of the throat.
In the unconscious patient the care of the airway will take precedence over any injury.
RECOGNISING AN AIRWAY OBSTRUCTION

Airway obstruction in a cardiac arrest patient may be the result of the loss of consciousness, or
the cause of the arrest. In both cases, it is vital to clear the obstruction. Airway obstruction may
be partial or complete. In the conscious patient, the signs and symptoms of obstruction will be
dependent upon severity. Partial obstruction may present as:
• Anxiety
• Laboured, noisy breathing
• Coughing
• Air can still be felt escaping from the mouth
Complete obstruction may present with:

• Respiratory effort without breath sounds or air escaping from the mouth
Common causes
Upper Airway
• Tongue
• Blood, vomit, secretions
• Foreign material
• Oedema from burns or anaphylaxis
• Infection
• Trauma
• Laryngeal spasm
Lower Airway
• Secretions, blood
• Pulmonary aspiration
• Bronchospasm, asthma
• Oedema (mucosal or pulmonary)
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Further complications
The unconscious patient is further at risk because of being unable to swallow or cough out foreign
material in the airway. This may potentially lead to airway obstruction, laryngeal irritation, or foreign
material entering the lungs. For this reason, the nurse should not give an unconscious patient
anything by mouth and should not attempt to induce vomiting.
AIRWAY ADJUNCTS
Gravity alone does not explain why airway obstruction by the base of the tongue may occur when
an unconscious patient is lying supine, prone or in the lateral position. Even when the head is in
the neutral or flexed position abnormal activity in various muscles of the tongue, pharynx, neck and
larynx may result in failure to maintain airway patency.
The use of an airway adjunct, such as an oropharyngeal airway, may be helpful as they overcome
the backward displacement of the tongue. A pharyngeal airway alone is not sufficient to prevent
obstruction hence they must be used in conjunction with a head tilt/chin lift or a jaw thrust.
For a reminder of how to action a head tilt

or jaw thrust, please refer to the Mandatory
eLearning module Basic Life Support, which
you can find in your eLearning
Pharyngeal Airway Oropharyngeal airway (Guedel) Nasopharyngeal airway

Used Unconscious patients As an alternative or when an oropharyngeal
airway cannot be inserted
• Conscious patients
• Not used in those with facial fractures
or a possible fractured base of skull
• Not used in patient with known
bleeding disorder due to increased
risk of bleeding
Size Measure the vertical distance Measure from the nostril to the tragus of
between the patient’s incisors and the ear or nares to the angle of the jaw or
the angle of the jaw (rather than suitable diameter for patient’s nostril
the corner of the mouth). Size 3,
• Small/medium: 6 - 7
4, or 5 is suitable in most adults
Insertion Insert upside down/inverted (with • Attempt insertion in largest nostril,
concave edge facing up) then ensure safety
rotate 180° to fit between the • Pin in flange if necessary (insert pin
tongue and hard palate, or slide in flange prior to insertion)
straight over the tongue • Lubricate with KY jelly
• If any resistance felt, try other nostril
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Bag/Valve/Mask
Bag/Valve/Mask (BVM) ventilation is recommended to be used as two-person technique. One
person holds the facemask in place using both hands and providing head tilt or chin lift, or jaw
thrust to open the airway and provide a seal (pictured below right), and the other person gently
squeezes the bag. In this way a better seal can be achieved, the jaw thrust manoeuvre is more
easily maintained, and the patient can be ventilated more effectively and safely. If there is not a
second person available, the recommended single-person technique using the C/E grip should be
employed (pictured below left).
On its own, the BVM system delivers via a reservoir bag approximately 15 litres of O2 per minute at
95-98%. ANZCOR recommends the highest possible O2 be used.
Indications for use
To ventilate patients who are apnoeic or not breathing normally.
Technique
Although the self-inflating BVM allows ventilation with high concentrations of oxygen, its use
requires a considerable degree of skill. When used with a face mask it is often difficult to achieve
an air-tight seal between the mask and the patient’s face, and simultaneously perform a jaw thrust
with one hand whilst squeezing the bag with the other. As a result the following may occur:
• An air leak from a poor face mask seal which will produce hypoventilation no matter how
energetically the bag is compressed.
• Excessive compression of the bag when attached to a face mask can result in air passing
into the stomach, which will further reduce the effective ventilation and greatly increase
the risk of regurgitation and aspiration (ANZCOR recommends End Tidal Volumes of 400-
500mls).
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ADVANCED AIRWAY DEVICES

Following placement of an advanced airway device (by experienced staff) chest compression can
continue without pausing to deliver ventilations. Ventilate the lungs at a rate of 6 to 10 ventilations
per minute avoid hyperventilation/excessive ventilation aim to provide one breath after each 15
chest compressions.
Supraglottic Airway devices (LMA, Laryngeal Tube, Oesophageal-Tracheal Combitute) are

generally considered easier to insert and can be inserted without interrupting chest compressions,
and their use has been increasing in cardiac arrest situations.
LMA
The laryngeal mask airway (LMA) is a common piece of airway management equipment used
throughout Ramsay hospitals. However, education and training in their use and insertion is
required before you can be deemed competent to insert in the patient (please be aware that
different brands of LMAs will require slightly different insertion techniques e.g. Laryngeal tube,
i-Gel, Combitube).
The LMA consists of a wide bore tube with an elliptical inflated cuff designed to oppose the
laryngeal opening. Although primarily for use in anaesthetised patients breathing spontaneously,
it can also be used for positive pressure ventilation, which has been demonstrated to be more
efficient and easier than with a bag/valve/mask.
Most LMAs are now single use. Drugs should not be administered via the LMA.
Advantages
• Rapid establishment of a patent airway
• Administration of 100% oxygen, can be inserted whilst CPR is in progress (minimising
interruption to compressions)
• Effective ventilation with one person
• Non-traumatic, does not require vigorous movements to align the head and neck
• Successful insertion by personnel with minimum training time
• Possible to minimise gastric inflation provided tidal volumes do not generate high inflation
pressures during intermittent positive pressure ventilation (> 20 cmH20) through the LMA.
• Provided there are no leaks, compression can continue without a pause (breaths can be
delivered at a ratio of 15:1 or 10 per minute)
Disadvantages
• Cannot administer medications via LMA
• Short term airway
• Aspiration of gastric contents is possible
Indications for use
Indications for use in hospital patients requiring resuscitation:
• Cardiac arrest situations
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• Profoundly unconscious patient with absent glossopharyngeal and laryngeal reflexes at

risk of airway obstruction and who may need artificial ventilation when tracheal intubation is
precluded by lack of available expertise or equipment
• Known or unexpectedly difficult intubation.
Essential equipment
Intubation equipment must be pre-prepared and ready to use:
• LMA sizes 3, 4 & 5. Backup/restock LMAs should be immediately available.
• 50/30ml syringe (luerlock connection)
• Gloves and other PPE
• BVM/Air Viva
• Oxygen-Powered Resuscitators (Mapleson Circuit)
• Stethoscope
• End tidal CO2 monitoring device
• Lubrication
• Bite block (rolled gauze or oropharyngeal airway)
• Tape/ties to secure tube
• Suction
Technique
Refer to your hospital policy for the type of LMA used in your hospital/MET. Different types of LMA
have different insertion techniques.
Ventilation
Ventilation can be commenced using any standard self-inflating bag in conjunction with high flow
oxygen. Inflation should be of adequate volume to allow the chest wall to rise. A small leak may be
heard, however if it is too large then the LMA should be removed and a larger one inserted.
The inflation pressure should be kept to a minimum. The aim is to allow chest wall to rise whilst
preventing potential gastric inflation or regurgitation.
Removal
Ensure that suction equipment is available prior to removal
Only remove the LMA if:

a. the patient demonstrates a return of airway protective reflexes;
b. the patient requires ongoing ventilation with an endotracheal tube (ETT) and the
attendant is skilled and competent in intubation; or
c. the resuscitation attempt is abandoned (and not a Coroners case)
If the patient is obviously regaining consciousness (i.e. after the patient can open their mouth on
command) then the tape and bite block may be removed.
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If the tube is to be removed prior to intubation then:

• Ensure suction equipment is available prior to removal of any airway adjunct
• Remove on exhalation
The cuff may remain inflated during removal. The rationale for this is that it will help draw out
secretions sat on top of the cuff rather than allowing those secretions to aspirate when the cuff is
deflated.
Tracheal intubation
Effective chest compressions deliver at maximum 30% of cerebral blood perfusion, therefore
in order to maximise cerebral oxygenation in a cardiac arrest the aim should be to deliver the
highest oxygen concentration effectively. CPR must be maintained and if endotracheal intubation
is attempted, laryngoscopy should be performed during chest compressions and attempts at
intubation should not interrupt compressions for more than 5 seconds (ANZCOR 2016 Guideline
11.6 - Equipment and Techniques in Adult Advanced Life Support).
For this reason tracheal intubation is the gold-standard in airway management as oxygen
concentrations of 100% can be achieved through a protected airway. It is indicated when personnel
who are able to carry out the procedure with a reasonable level of skill and confidence is present.
However, to avoid substantial interruptions in chest compressions providers may defer attempts
at intubation until return of spontaneous circulation if IV access is established and good bag
mask technique is in use. If tracheal intubation is attempted ongoing CPR must be maintained
and attempts at intubation should not interrupt cardiac compressions for more than 5 seconds
(ANZCOR 2016 Guideline 11.6 - Equipment and Techniques in Adult Advanced Life Support).
Advantages
• Isolation of the airway/maintenance of patent airway
• Allows suction/clearance of trachea
• Avoidance of gastric dilatation
• Prevents aspiration
• Facilitates intermittent positive pressure ventilation
• Delivery of high concentrations of oxygen
• Administration of first line drugs
• Allows uninterrupted chest compressions (ratio 15:1 including no pause) and approximately
8-10 breaths per minute
Disadvantages
• Training and experience essential, high failure rate if operator is inexperienced
• Aggravation of airway obstruction (e.g. epiglottis)
• Local injury (teeth, tongue, palate etc)
• Potential to exacerbate cervical cord injury
• Time without chest compressions (multiple attempts)
• Incorrect placement i.e. oesophageal/right main bronchus
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Complications - during
• Trauma
• Vagal stimulus  Bradycardia
• Hypoxia from misplaced tube
• Laryngospasm
• Substantial interruption to chest compressions
Complications whilst in place
• Blockage
• Dislodgment
• Laryngeal/ Tracheal strictures
• Mechanical ventilation complications
Complications post extubation
• Aspiration
• Obstruction
• Laryngospasm
• Stridor
• Respiratory failure
Essential equipment
Prior to intubation, the Medical Emergency Team must have the intubation tray ready (or direct
another staff member to do so).
• Laryngoscope: curved Macintosh blade - size 3 small adults – females - size 4 larger adults
- males
• Check light source: ensure bulb is secure and working (single use, disposable
Laryngoscope may be used), and if applicable, have spare bulbs and batteries available,
charge batteries, and if applicable check fibre optic blade
• Tracheal tubes: female size 7.0 - 8.0 mm male size 8.0 - 9.0 mm
• Syringe: for cuff inflation (10ml)
• Stethoscope: to confirm correct position of tube in trachea
• Tapes/ties: to secure tracheal tube
• Suction: Yankeur sucker and flexible catheters
• Lubricant jelly: water soluble KY jelly
• Magill’s forceps: to remove objects from the oropharynx
• Introducers: either soft bougies or semi-rigid stylets, intubation catheters
• PPE
• ETCO2 detection device (i.e. Easycap), ETCO2 monitoring device
• Gastric tube (naso/orogastric), Nasal Gastric Tube
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Waveform and colourmetric capnography

Waveform capnography measures end tidal CO2 in a non-invasive way. It is an effective method of
monitoring CO2 during an arrest and is recommended to confirm the position of the ET tube. It may
also be beneficial in providing feedback on the effectiveness of chest compressions and potential
patient outcomes. A lack of CO2 return may be due to lack of cardiac output to the lungs.
Disposable one-use only colourmetric CO2 detectors are effective and available for use in
emergency intubation where waveform capnography is not readily available on all arrest trolleys to
confirm correct tube placement.
Cricoid pressure
Cricoid pressure helps prevent regurgitation of gastric contents and consequent pulmonary
aspiration or to assist in viewing the vocal cords. It is not required on all patients. Please check
with the MO managing the airway as to whether cricoid pressure is required.
During intubation a trained assistant may carry out this manoeuvre if requested by the MO by
placing the thumb and forefinger on the cricoid cartilage (located below the thyroid cartilage).
The complete cricoid ring is forced backwards occluding the oesophagus against the body of the
cervical vertebrae.
Pressure is maintained until the operator instructs its release, after the tube has been placed
through the vocal chords, the cuff has been inflated and tube position confirmed. Although effective
at preventing passive regurgitation, cricoid pressure must be released when active vomiting occurs
as it may lead to oesophageal rupture.
Cricothyroidotomy
A Cricothyroidotomy is where a surgical airway is created by inserting a tube into the trachea. It is
an emergency airway undertaken by medical staff that has a limited life span. It is not a long-term
option. It is used when ventilation and intubation have both failed, when there is a supraglottic
obstruction or when there is laryngeal or palate trauma where the upper airway is completely
obstructed.
Needle cricothyroidectomy is a procedure that only allows oxygenation of the patient; carbon
dioxide is not eliminated and therefore its usefulness is limited to about 30 minutes, until intubation,
a tracheostomy or surgical cricothyroidectomy can be performed to maintain oxygen and
ventilation long term.
Complications include malpositioning of the catheter causing surgical emphysema, haemorrhage

and oesophageal perforation.
Only the doctor running the code will perform this procedure.
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. The size of the ET tube that you would expect to use for an average female during an arrest is:
a. 4.0 – 5.0
b. 7.0 – 8.0
c. 6.0 – 7.0
d. 9.0 – 9.5
2. The signs that an endotracheal intubation has been unsuccessful are:
a. A visible rise and fall of the chest wall

b. Increase in oxygen saturation
c. Absence of audible breath sounds through auscultation
d. Absence of expiratory wheeze
3. Which of the following statements regarding intubation during a cardiac arrest is false?
a. Endotracheal intubation can be performed by ALS trained nurses

b. Endotracheal intubation helps to prevent aspiration of stomach contents
c. The endotracheal tube provides a route for the administration of drugs if IV is absent
d. Endotracheal intubation improves lung inflation and allows administration of 100%
oxygen
CONCLUSION
In this chapter we’ve looked at airway management during a cardiac arrest.
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Drugs in Resuscitation
In this section we’ll look at the mode of administration of drugs used in resuscitation, as well as the
action of first line medications
A NOTE ABOUT NURSE INITIATED DRUGS
This section does not change your Scope of Practice, and not all sites are the same
concerning nurse-initiated drugs. Please check your local policy for guidance on what
drugs you may and may not administer without direct medical order.
The use of medications during cardiac arrest have been shown to be beneficial in certain
situations, improving patient outcomes and survival. Priorities are defibrillation, external cardiac
compression, and oxygenation together with ventilation.
ALS providers should have a good understanding of the first line drugs used during a cardiac
arrest as well as their action. First line drugs are Adrenaline and Amiodarone.
THE ACTION OF FIRST LINE DRUGS

The Sympathetic Nervous System (SNS) works when the body is stressed and reveals itself in
the fight or flight response, as opposed to the Parasympathetic Nervous System (PNS) which
is responsible for the body’s rest and digest function. The SNS has connections between the
brain and the Central Nervous System, including the heart, lungs, and blood vessels. The cell
membranes of the target organs have an alpha or a beta response. Adrenaline as the primary drug
in cardiac arrest is used for its alpha and beta effects.
Alpha response
Alpha response occurs in the blood vessels, producing vasoconstriction, which leads to an
increase in systemic arterial blood pressure.
Beta response
Beta response occurs at three different levels.
Beta 1 - Heart:
• Increases heart rate (chronotropic) by stimulating the SA node to fire faster. This is a positive
chronotopic effect.
• Improves conductivity (dromotropic) through the conduction pathways, such as the AV node
and the bundle branches.
• Increases contraction force (inotropic) by stimulating the myocardium. This is a positive
inotropic effect. However, it does also increase myocardical oxygen demand.
Beta 2 – Respiration:
The beta 2 effect is dilation of the bronchioles in the lungs, and a decrease in the Systemic
Vascular Resistance (SVR) in the blood vessels. This decreases the afterload of the heart, making
it easier for the heart to pump blood out, and decreases myocardial oxygen demand.
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Catecholamines
Some of the sympathetic fibres pass to the adrenal medulla, where they release catecholamines
into the bloodstream. They work on the target organs through the same mechanism as the
sympathetic pathway.
Naturally occurring catecholamines are Adrenaline, Noradrenaline, and Dopamine. Drugs that
have the same actions as these catecholamines are called sympathomimetics.
Amiodarone is a membrane stabilising anti-arrhythmic which increase refractory period in the

cardiac cycle, thereby slowing conduction at the AV node. It also has mild negative inotropic effect
(alpha blocking) which causes peripheral vasodilation.
ADMINSTRATION
The route for drug administration during a cardiac arrest will depend upon available access. If
central venous access is already established, this is the preferred route. If central venous is not
available, ideally, the peripheral intravenous route should be used due to the insertion of a central
venous catheter interrupting CPR and being associated with several potential complications.
If IV access fails the intraosseous route should be considered.
Intravenous
IV drug administration is the preferred route, via a large peripheral vein. This is a fast, reliable
method for drug administration, the taking of bloods and/or fluid administration during a cardiac
arrest.
If there are no visible peripheral veins, the external jugular vein may be considered. This vein is
often prominent during an arrest. Lower limb veins should be avoided due to impairment of venous
return below the diaphragm during cardiac arrest.
Intravenous drug administration must be followed by a fluid flush of (normal saline) at least 20-
30mls and external cardiac compression. In addition, elevating the limb may speed up delivery to
the central circulation.
Intraosseous
If IV access cannot be established, intraosseous (IO) access is safe and effective for fluid
resuscitation and drug delivery in all age groups.
The method of insertion will be dependent upon available equipment with the most common
sites for insertion being the proximal humerus, proximal tibia and distal tibia. It can be maintained
for 24–48 hours, after which another route of access should be obtained. Intraosseous access
has roughly the same absorption rate as IV access, and allows for blood sampling and fluid
resuscitation as well as administration of high-volume drugs and fluids.
Contra indication to IO includes infection above or below the insertion site or trauma to a limb
above or below the insertion site.
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About the Endotrachael route
The use of the endotracheal tube to administer medications is of limited benefit and its use
is not currently promoted. However, the following points using this method of administration
may be found in the ARC guidelines (11.5: 2016).
If access cannot be gained the priorities are defibrillation, oxygenation and ventilation
together with external cardiac compressions and this method of drug administration
considered as a last resort.
If IV or (IO) access cannot be attained and an endotracheal tube is present, endotracheal

administration of some medications is possible; although the absorption is variable and
plasma concentrations are substantially lower than those achieved when the same drug is
given by the intravenous route (increase in dose 3-10 times may be required).
Dilution with water instead of 0.9% normal saline may achieve better drug absorption.
Adrenaline, lignocaine and atropine are the only medications which may be instilled via the
endotracheal route, other cardiac arrest drugs should NOT be given endotracheally as they
may cause mucosal and alveolar damage.
To administer ETT drugs clear the ET tube with suctioning and remove the catheter, then
directly administer the drug via the syringe down the ET tube. Follow this by delivering 2-5
ventilations to disperse the drug into the alveoli.
For a list of rhythms management and drug dose and

administration, please see Appendix 1.
For a complete list drugs, their alpha and beta responses,

indications, effects, doses and dilutions, please see
Appendix 2.
CONCLUSION
In this chapter we’ve learned about the mode of administration of drugs used in resuscitation and
an overview of the action of the first line medications.
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Cardioversion and Pacing

In this chapter we’ll examine other ways in which an electrical impulse can be used to change the action
of the pacemaker of the heart.
Not all abnormal cardiac rhythms require full defibrillation. Many rhythms, as you have learned in
the chapter on Rhythm Recognition, are not immediately life threatening nor will they benefit from
defibrillation. If your patient is suffering from an arrhythmia, either fast or slow, that presents as an
adverse sign of deterioration (for example low blood pressure, periods of syncope, heart failure or
ongoing chest pain), techniques such as synchronised cardioversion and cardiac pacing may be
used.
We’ll look at each of these in detail now.
SYNCHRONISED CARDIOVERSION
In synchronised cardioversion, the SA node is “reset”. Cardioversion stuns excitable cells in
the atria (as in atrial fibrillation) that prevent the SA node from functioning normally rather than
stopping it altogether. To achieve this, a lower setting than that used for DC defibrillation is applied.
Cardioversion is used mainly for atrial arrhythmias associated with haemodynamic compromise or
other adverse signs. However it may also be undertaken as an elective procedure for patients in
long term AF, for example, cardioversion is undertaken in a controlled environment. The patient is
prepared and sedated for the procedure.
Indications
Cardioversion can be used for:
• Atrial fibrillation
• Atrial flutter
• Atrial tachycardia
• Supraventricular tachycardia (SVT)
It can also be used in VT where the patient is conscious and has a pulse, and drug therapy has
been ineffective or the patient is compromised.
Energy selection
Lower joules are required than when defibrillating the heart in an arrest situation. The aim is to
shock the SA node, not stop it altogether.
The following joule selection may be used (determined by the medical team) for each rhythm:
• Atrial Flutter and Atrial Tachycardia usually start at 50-100 joules
• Atrial Fibrillation starts at 100 joules
• SVT is commenced at 100 joules
The joules used can then be gradually increased depending on patient response. This should be
undertaken as per the Medical Officer’s orders.
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Pre-care
The patient should be fasted prior to the procedure and a 12 lead ECG should be obtained, as well
as an IV cannula inserted. You should also have gained formal patient consent.
Pre-procedure requirements:
• Results for U&Es, INR (if previously on Warfarin)
• Drugs for sedation – for example, Propofol, Midazolam, Fentanyl
• Resuscitation and suction equipment
Shave the patient’s chest if required and apply the pads. A different placement may be used for
atrial rhythms at the discretion of the cardiology team. Preoxygenate the patient during sedation.
Procedure for cardioversion

Please note, this process will vary according to the machine you are using.
1. Press the Synch button on defibrillator.
2. Ensure each complex is highlighted as per the defibrillator instructions with either a dot or
triangle above the R wave. There must be 100% recognition. Failure of loss of R wave
recognition may result in the patient converting to a life threatening arrhythmia.
3. Press the Energy Select button and select the energy level required as per the MO orders
(the default setting will be for defibrillation).
4. Charge the defibrillator
5. After following safety checks that all staff are standing clear, press and hold the Shock
button until the shock is delivered. The shock will only be delivered on the R wave of the
complex, therefore there may be a delay between pressing the button and the shock being
delivered.
6. Observe for return of normal rhythm.
If further shocks are required most defibrillators will require the synch button to be reset. This is a
safety feature in case a DC shock is required.
Post reversion
Once the rhythm has reverted, maintain the patient’s airway until they are self-ventilating.
Remove adhesive pads whilst patient unconscious and stay with the patient until they have
regained consciousness.
Continue to monitor them via ECG and perform a 12 lead ECG, making frequent haemodynamic
observations and ensure you document events as per hospital policy.
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TEMPORARY EXTERNAL TRANSCUTANEOUS CARDIAC PACING

Please note, this process will vary according to the machine you are using.
External transcutaneous cardiac pacing is the process by which the patient’s cardiac rhythm is
augmented to increase the heart rate and therefore their cardiac output.
To initiate pacing, the patient must be monitored utilising the ECG leads on the defibrillator
in addition to the pads so that it may sense and respond to the patient’s intrinsic rhythm on a
continuous, uninterrupted basis. On many machines the pads are not able to read the rhythm
and pace at the same time through one set of pads, therefore the defibrillator ECG leads must be
connected to the patient.
The defibrillator is able to act as a pacemaker to provide an artificial electrical stimulus to the
myocardium in order to initiate depolarisation of the atria, ventricle, or both. Pacing is the process
of initiating an electrical stimulus to the cardiac muscle and aims to achieve both electrical and
mechanical capture.
Capture
Capture – occurs both electrically and mechanically.
• Electrical capture is when an adequate electrical current has been delivered to the heart to
produce depolarisation of the ventricles. This is evidenced by a spike on the ECG which is
immediately followed by a wide QRS complex followed by a tall, broad T wave.
• Mechanical capture involves depolarisation of the ventricles and an adequate cardiac
output (i.e. a palpable pulse). Patients who are being paced should have mechanical capture
confirmed by palpating for the presence of a femoral pulse.
If there is a failure to capture:

• Increase the current
• Reposition the electrodes on the patient’s chest
• Consider a severe metabolic acidosis, hypoxia or drug toxicity
Sensing
This is when the pacemaker is sensing the patient’s intrinsic cardiac rhythm when in the demand
mode. The pacemaker can sense the atria or ventricles or both. The external pacemaker senses
the patient’s QRS complex (ventricular depolarisation), not the P wave. A mark appears on the
QRS complex when sensing occurs.
When there is failure to sense during pacing:

• Increase the ECG size so the pacer can detect the patient’s QRS complex
• Select a different ECG lead
• Reposition the electrodes on the patient’s chest
• If your site has access to a pacemaker technician, contact them immediately
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Non-demand/fixed pacing
The pacemaker delivers a pacing stimulus at a set rate completely independent of the patient’s
intrinsic heart activity. It can also be call Asynchronous Pacing. An indication for fixed mode maybe
during transport. Movement of the patient trolley during transport may cause sensing issues (over-
sensing). However, in general, this mode is rarely used, as competition between paced beats and
the patient’s intrinsic rhythm can lead to ventricular arrhythmias (Phillips Healthcare, 2013).
Demand pacing
The pacemaker senses the patient’s intrinsic cardiac activity, and delivers pacing stimuli to capture
only when the patient’s intrinsic rhythm falls below the set pacing rate or during prolonged pauses
in the patient’s rhythm. It can also be called Synchronous Pacing. This is the more commonly used
pacing mode.
Indications
External cardiac pacing is indicated for patients with symptomatic bradycardia and conduction
blocks such as complete heart block.
Bradycardia
Pacing is indicated in slow rhythms if the patient is haemodynamically compromised (SBP <
90mmHg) and has not responded to drug therapy, such as atropine or isoprenaline. In this situation
pacing aims to increase the patient’s heart rate and cardiac output.
Heart block
Pacing is usually the treatment of choice in 3rd degree heart block, possibly in conjunction with or
whilst awaiting additional medications to improve rate and contractility. Transcutaneous pacing may
sometimes be indicated in other conduction blocks, depending on the degree of haemodynamic
compromise.
Advantages and disadvantages

Transcutaneous pacing in a cardiac arrest situation has both its advantages and disadvantages
depending on the use of the pacing process and the current situation.
Advantages
There are numerous advantages to pacing. It is easy and quick to prepare the patient for the
procedure, and requires less training than internal pacing modes. There is also a lower risk to the
patient.
Disadvantages
Pacing can be quite uncomfortable for the conscious patient. Cutaneous nerve stimulation can
result in a tingling, stinging, pinching, or burning sensation. There can also be skeletal muscle
contraction that can cause tapping, twitching, or thudding sensations for the patient.
Skeletal muscle contractions can occur even with low energy levels, and patients often have
trouble tolerating currents above 50 milliamps. As capture threshold often occurs above this level,
analgesia and sedation should be considered for the conscious patient but only after adequate
cardiac output has been produced.
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Despite the discomfort for the patient, the administration of analgesia and sedation to a patient who
does not have an adequate cardiac output may result in a haemodynamic state that precipitates a
cardiac arrest.
Sequence for non-invasive cardiac pacing

Please note that this sequence is again based on the Zoll defibrillator and that the machine in use
at your site may differ. Please check your manufacturer’s instructions.
1. Connect the defibrillator/pacing pads and ECG leads and confirm the presence of a rhythm.
Check the pad expiry dates as all pads are pre-gelled and may dry out over time.
2. Record a rhythm strip.
3. Ensure the defibrillator pads are attached to the cable and place in the appropriate positions
on the chest. If there is time, shave hair from the site to improve conduction. Have the leads
pointing to the outside of the patient.
4. Turn on the Pacemaker.
5. Unless there is a default heart rate, select the required Heart rate. This will be determined by
the treating medical officer who will request an appropriate pacing rate as per the situation.
6. With the milliamps (or current, as terminology may differ) set at zero, start increasing the
milliamps until electrical capture is noted (where the artificial ‘spike’ triggers a response in the
myocardium). Check for a femoral pulse to confirm cardiac output and mechanical capture.
7. Once mechanical capture has been confirmed, increase the milliamps by 10% if tolerated by
patient as a margin of safety or as per your hospital policy.
8. Ensure patient comfort (e.g. administer analgesia or sedation).
9. Remember to record all observations including pacing mode, heart rate, threshold for
mechanical capture and set milliamps.
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. Synchronised counter shock is delivered:
a. On the Q of the QRS complex

b. On the P wave of the ECG
c. On the R wave of the ECG
d. On the T wave of the ECG
2. Which of the following arrhythmia is an indication for the delivery of synchronised

cardioversion?
a. Atrial fibrillation
b. Ventricular fibrillation
c. Pulseless ventricular tachycardia
d. Ventricular ectopic beat
3. To initiate pacing mode the patient must be connected to the defibrillator ECG leads and pads.
True or False?
CONCLUSION
In this chapter, we’ve looked at ways to electrically enhance a slow heart rate and revert a
tachyarrythmia to support the patient and prevent further deterioration.
There are additional options relating to the administration of medications which may also revert/
enhance tachy and brady arrhythmias. Refer to your hospital policy’s and practice for chemical
therapies.
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Special Circumstances
In this chapter we’ll look at other complicating factors to successful cardiac resuscitation
There are also certain difficulties to be faced when a cardiac arrest is complicated by other factors.
Knowing what these issues are and addressing them will increase success of resuscitation efforts.
ANAPHYLAXIS
Anaphylaxis, or anaphylactic shock, is a sudden, severe and potentially life-threatening allergic/
systemic hypersensitivity reaction characterised by rapidly developing, life-threatening airway/
breathing/circulation problems.
There are many triggers for anaphylaxis, but common causes are foods, drugs and venom.
A severe attack may develop very quickly from the time of exposure to allergen. Care should be
taken to monitor patients who have ingested food allergen as the time of onset and the duration of
the reaction increases due to ingestion time.
Common signs and symptoms

• Difficult/noisy breathing
• Wheezing
• Swelling of facial tissue of tightness in airways
• Haemodynamic compromise
• Loss of consciousness
• Hives/ rash
Signs of a severe reaction include two or more

systems showing signs of compromise, for example,
wheeze and falling blood pressure. Treatment
involves preventing further exposure to the allergen
and administering IM Adrenaline for adults. The
recommended dose is 500mcgs. If no improvement
is detected after five minutes or further deterioration
occurs, repeat the dose.
If cardiopulmonary arrest occurs, follow the

standard ALS protocol with fluid resuscitation.
The flowchart shows the First Aid management of
Anaphylaxis (ANZCOR 2016 Guideline 9.2.7 - First
Aid Management of Anaphylaxis) and the Peri-arrest
management of Anaphylaxis algorithm (ANZCOR
2017 Guideline 11.10 - Resuscitation in Special
Circumstances).
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PREGNANCY
In the obviously pregnant woman, the pregnant uterus causes pressure on the major abdominal
vessels when she lies flat, reducing venous return to the heart.
Maternal cardiac arrest can occur as the result of haemorrhage, amniotic or pulmonary embolism,
eclampsia or placental abruption, as well as the same causes of cardiac arrest as females of the
same age group. The physiological changes as a result of pregnancy, such as increased blood
volume, cardiac output, oxygen consumption and reduced lung volumes, can complicate the basic
ABC management. For example, intubation is more difficult and gastric reflux is more likely.
The principles of basic and advanced life support apply to the pregnant patient and the emphasis
is on the mother, as the foetus depends on her for survival. Without oxygen, the foetus will die and
this means oxygen and adequate circulation needs to be provided.
The main points when resuscitating a pregnant woman include:

• Summon expert help immediately
• Left lateral tilt: Manually displace pregnant uterus to the left to alleviate compression of
the major blood vessels. The angle of the tilt to the left still needs to allow for effective
compressions, i.e. shoulders flat, pelvis tilted to the left. A gravid uterus will occlude the
Vena Cava and the Aorta if the woman is left on her back. This can in itself produce ‘Supine
Hypotension Syndrome’ as the pressure of the uterus on the major abdominal vessels can
precipitate a cardiac arrest. The pregnant woman should be positioned on her back with her
shoulders flat and sufficient padding under the right buttock to give an obvious pelvic tilt to
the left.
• Aggressive airway management and early intubation: The foetus needs oxygen and
gastric emptying is poor in the pregnant woman with a subsequent risk of aspiration.
Further procedures: If the arrest is due to a ruptured uterus or eclampsia, or if initial resuscitation
efforts fail, then a peri-mortem emergency caesarean section is the only chance for delivery of the
infant and must take place within 5 minutes after the mother’s cardiac arrest. Advanced life support
must continue during and after surgery.
HYPOTHERMIA
Partly a protective mechanism, hypothermia will significantly reduce the basal metabolic rate
for every degree below 36°C. This therefore reduces oxygen requirements and will slow the
development of acidosis associated with anaerobic metabolism secondary to hypoxia. However,
hypothermia is also a barrier to effective resuscitation because it produces arrhythmias and
increases transthoracic impedance in defibrillation. The stiffness created by hypothermia in the
chest cavity will impede effective chest compressions and conduction of electrical impulse from
defibrillation.
To this end, it may be necessary to make modifications to ALS for the hypothermic patient:
• It is reasonable to withhold drugs until the core temperature >30°C – the intervals then
should be doubled until >35°C.
• If VF persists after 3 shocks – delay further attempts until the body temperature is 28 – 30°C
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Use all available resources e.g. active external methods like warm air, space blankets, warm
blankets or a ‘bear hugger’ for extra corporeal rewarming (cardio-pulmonary bybass/VA -ECMO);
and minimally invasive methods like warmed fluids. Patients should be rewarmed 1 to 1.5°C/hr to
avoid acute acidosis and other systemic complications resulting in ‘rewarming shock’.
ELECTROCUTION
Electricity will travel the path of least resistance, with resistance lowest in moist areas. Serious
internal damage occurs when the electricity is converted to heat, which occurs at the areas of
highest resistance, such as bone.
Low voltage
• Significant contact wounds and possible cardiac arrest, but little deep tissue damage.
• Commonly household current, which is Alternating Current (AC)
• Alternating Current (AC) can lead to cardiac arrhythmias, especially Asystole, VF and
hypoxia.
High voltage
Injury is caused by flash burns and Direct Current (DC) transmission.
• DC transmission will result in both full thickness cutaneous injury and deep tissue damage at
both entry and exit points. Deep muscle damage can occur along the path of the current and
may lead to Rhabdomyolosis with subsequent Acute Tubular Necrosis and renal failure.
• Overall damage is related to the combined effects of current, resistance and voltage.
Assessment and Management of Electrical Injuries

Ensure any power source is turned off and that it is safe to approach the victim. The priorities of
assessment are ABC and an ECG.
Avoiding hypoxia will improve the outcome. Defibrillation is the choice for VF arrest although
efficacy may be affected by the damage done to the heart from the electrical injury. With all
electrical burns you need to look for entrance and exit sites, as they can give an indication of the
pathway of the injury. The exit site is usually larger than the entry wound.
DRUG POISONING/TOXICOLOGY
The main consideration is for cardiotoxic poisons that inhibit conduction. Patients who experience
a cardiac arrest following poisoning by a substance that slows conduction are very difficult to
successfully resuscitate.
The focus should be on avoiding the cardiac arrest by neutralising or eliminating the poison.
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NEAR DROWNING
Initial immersion will elicit the diving reflex, which lowers the heart rate and respiratory rate;
followed by apnoea, producing hypoxia, tachycardia and subsequent acidosis. This will eventually
lead to bradycardia, arrhythmias and cardiac arrest.
The main problems with near drowning are hypoxia, hypothermia and acidosis, all three reducing
the effectiveness of resuscitation attempts.
Therefore, early airway management with intubation and ventilation is essential. Positive End
Expiratory Pressure (PEEP), which is the maintenance of alveolar pressure (keeping the alveoli
open), is often used to improve the relationship of ventilation to perfusion and therefore gas
exchange.
Assessing temperature is a critical factor in treating the hypothermia that frequently accompanies
immersion injuries.
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. The common signs of an anaphylaxis are:
a. Difficult/noisy breathing, hives/rash, loss of consciousness, muscle twitching

b. Hives/rash, welts and redness, loss of consciousness, thirst
c. Difficult/noisy breathing, hives/rash, wheezing, loss of consciousness
d. Difficult/noisy breathing, wheezing, thirst, headaches
CONCLUSION
In this chapter, we’ve looked at the special circumstances relevant to cardiac arrest, as well as how
to treat these complicating factors.
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Post-resuscitation Care
In this chapter we’ll look at considerations immediately following successful resuscitation
The aim of resuscitation is to ultimately have a patient with:

• A normal conscious level
• No neurological deficit
• A stable cardiac rhythm
• Adequate oxygen perfusion
However, the return of spontaneous circulation does not mark the achievement of these aims;
more likely it marks the start of a long and difficult post-resuscitation phase.
AIMS OF THERAPY
The aims of therapy after initial resuscitation are to:
• Determine and treat the cause of the cardiac arrest and prevent reoccurrence
• Continue respiratory support
• Maintain cerebral perfusion
• Treat and prevent cardiac arrhythmias
• Prevent secondary damage
This requires a range of assessments and observations to be undertaken following the cardiac
arrest. Let’s have a look now at an idealised timeline for events during a resuscitation attempt in
action.
While resuscitation is taking place

While resuscitation is taking place, if the patient has been critically ill, it is possible that there
may be family members present. Unless they are disrupting resuscitation efforts, they should be
permitted to stay if they so desire, as this has been shown to be beneficial in their adjusting to loss.
If a family member requests to stay in the room during resuscitation, a member of staff who can
adequately support them should be allocated to care for them. This member of staff needs to
be confident that they can explain what is occurring in a language the relatives will be able to
assimilate at this stressful time.
If the resuscitation is unsuccessful, the relatives should be allowed to be with the patient in private
as soon as is able.
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During a sudden, unexpected arrest

If an arrest is sudden and unexpected and relatives need contacting by phone, it is important that
this call is made by someone who has knowledge of the family dynamics, so that the appropriate
information can be communicated, whilst trying to minimise panic.
Normally this call will be made by the doctor in charge of the code, or the Nurse Unit Manager
of the ward. The person who makes that call should try to be available to receive those relatives
when they do arrive at the unit/ward.
Interpreter services
Consider that in certain circumstances you may need to contact an interpreter if the patient’s
family do not speak English or if they are culturally and linguistically diverse. This is an important
consideration as there can be culturally protocols that must be adhered to at the end of life.
ONCE THE PATIENT HAS BEEN SUCCESSFULLY RESUSCITATED

Once the patient has been successfully resuscitated, ventilation must be continued until the patient
is awake, alert and cooperative. The patient must be able to protect his or her own airway and
have a stable cardiovascular system before extubation. It is imperative that a full assessment
of your patient occurs post-resuscitation, reviewing airway, breathing, circulation, disability and
exposure to ensure optimum patient outcomes are achieved.
While in this stage, the medical officer running the code with the ALS nurse will check:
• Respiratory system:
»» Position and security of the ET tube if required
»» Assess for trauma to the chest wall/pneumothorax
• Cardiovascular system:
»» Listen for heart sounds, palpate major pulses
»» Look for grossly distended neck veins
»» Blood pressure
• Central Nervous system:
»» Perform an initial neurological assessment as a base line only
»» Assess pupillary size and reaction, limb movement and abnormal posturing
• Abdomen:
»» Examine for distension
»» Insert a urinary catheter and nasogastric tube
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Patient stabilisation is achieved

It is imperative to restore the patient’s usual blood pressure or at least a systolic pressure greater
than 100mmHg. Avoid hypoxia through use of 100% oxygen during cardiac arrest, and avoid
hyperoxia - it is reasonable to titrate inspired oxygen to maintain SpO2 between 94 – 98%. In
addition, maintain PaCO2 within normal range.
If the blood pressure falls, a vasopressor may be given by small increments (0.1mg) or an infusion
until fluid status and the need for volume expansion can be assessed. As soon as possible all
vasoactive drugs should be given by central access or dedicated central line lumen.
Hypo/hyperglycaemia and electrolyte disorders such as hypo/hypernatraemia may produce

continuing cerebral damage. Blood glucose level, biochemical screen, arterial blood gases and a
12 lead ECG should be performed to guide further management. Monitor blood glucose regularly
and treat any hyperglycaemia (>10mmol/L) and avoid hypoglycaemia
If ventricular fibrillation has been successfully reverted the anti-arrhythmic drug that was used may
be continued as an infusion under medical instruction.
There is no evidence that corticosteroids are beneficial. Anti-epileptic medication may be required
if seizures occur. Treat seizures if they occur and start maintenance therapy.
Targeted Temperature Management (TTM) describes the method and treatment of inducing a
mild hypothermia in patients post cardiac arrest who remain unresponsive. TTM been shown to
improve neurological outcomes in this cohort of patients. (ANZCOR 2016 Guideline 11.8 - Targeted
Temperature Management (TTM) after Cardiac Arrest)
If TTM is considered, then the method of cooling will be dependent upon equipment available.
Cooling methods include, ice packs, cool fluids, cooling blankets or Extra Corporeal Membrane
Oxygenation (ECMO) for example. The important factor is that a constant temperature be
maintained between 32 – 36°C, for a period of 12 – 24 hours (check hospital policy).
Additional considerations include avoiding hyperthermia and preventing the patient from shivering
which will increase metabolic demands.
Patient transfer is then determined

Only once the patient is stable should the decision to transfer be made. This decision should
come from the leader of the arrest situation and the receiving team. However, that being said, all
post arrest patients who are intubated and medically stable are transported to ICU or CCU as it is
assumed that they will require ventilation and further critical care treatment.
Having made the decision to transfer, continuous monitoring facilities need to be attached to the
patient. All lines, drains, catheters and tubing should be secured.
Staff attending to the patient during transfer should be satisfied before they leave, that they
have all equipment and skills necessary to deal with any complication or re-arrest during the
interdepartmental/hospital trip.
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Staff are debriefed

A debrief after the event is important for staff to examine what happened, how they felt about it and
accept loss in the event of a death. Usually this debrief is conducted by the NUM or team leader,
and includes all the staff on the ward who were present at the arrest, including ALS trained staff.
The MET team responders will likely have their own internal debrief elsewhere.
The debrief is not for criticism of performance but for positive feedback. The opportunity for
discussion about how and why events occurred should be included. Lastly, issues that may have
emerged for areas of educational activity or equipment availability and system/procedure changes
can be identified after debrief.
Often in the case of patients who have been on the ward for a while, staff might be interested in the
patient’s post arrest outcomes. Usually the NUM will obtain this information and disseminate it to
the interested staff members.
Sometimes arrest situations can be both stressful and traumatic. If you find that you are troubled
as a result of your invovlement in an arrest situation you may benefit from talking with someone
external to the event. If this is the case you can contact Ramsay’s EAS provider Benestar on 1300
360 364.
Keep in mind
Separate to the debrief, the NUM or team leader will open discussion with the attending staff
members to determine prior causes and issues leading up to the arrest and how effective
treatment and resuscitation efforts were. In this session the team will examine:
• The patient’s past medical history
• The patient’s current drug therapy
• Relevant events preceding the cardiac arrest
• Possibility of drug overdose/anaphylactic reaction
• Hypoglycaemia
• Neurological event such as a stroke
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
1. Once a successful resuscitation has been achieved which of the following post resuscitation
checks must be undertaken immediately?
a. Ensure that the patient is transferred to the ICU immediately

b. Clean the room and put all the furniture back, as well as check the resuscitation trolley
and restock whatever was used
c. Check that all staff are handling the event well and discuss how the code response went
d. Fully assess patient, ensure airway patency is maintained and aim to achieve normative
blood pressure
2. Which of the following is important during the immediate post resuscitation analysis? (note:
there is more than one correct answer)
a. Patient’s current drug therapy

b. Possibility of drug overdose/anaphylactic reaction
c. Patient’s past medical history
d. Relevant medical events leading up to the cardiac arrest
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Conclusion
The purpose of this analysis is to ensure that no aspect of nursing care was deficient.
Congratulations. You have reached the end of this component of the ALS programme. You should
now understand the concept of the Chain of Survival and understand the importance of early
recognition of potential cardiac arrests.
You should also be able to:

• Describe the ethical and legal requirements of CPR
• Follow the Advanced Life Support algorithm
• Identify cardiac rhythms requiring defibrillation
• Describe the principles and application of defibrillation
• Discuss the determination and application of airway adjuncts
• Describe your role in assisting in advanced airway management
• Describe how to assist with a tracheal intubation
• Identify medication and doses used in resuscitation
• Describe the principles and application of synchronised cardioversion
• Describe the principles and application of non-invasive cardiac pacing
• Discuss the requirements of post resuscitation care
Keep in mind that no two codes will run the same. The conditions that led to the arrest are different
in every patient. Resuscitation is one part routine and two parts adapting to changes.
Remember:
• Good CPR technique and early defibrillation increases chances of survival
• It is vital to know your rhythms and be able to recognise them immediately in

order to act quickly
• It is vital to know when drugs can be administered and where they are
required in the resuscitation process
• If you understand each person’s role in responding to a code and take a

proactive and communicative approach to your response you will help enable
the code to proceed smoothly.
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Appendix 1 - Rhythms
This resource lists the common rhythms you may see on an ECG.
Sinus.................................................................................................................................... 75
Sinus Bradycardia................................................................................................................ 76
Sinus Tachycardia................................................................................................................ 77
Ventricular Fibrillation........................................................................................................... 78
Pulseless Ventricular Tachycardia....................................................................................... 80
Asystole............................................................................................................................... 82
Pulseless Electrical Activity (PEA)....................................................................................... 84
Ventricular Tachycardia with a pulse.................................................................................... 85
Torsades de Pointes............................................................................................................ 87
Supraventricular Tachycardia............................................................................................... 89
Third Degree Block.............................................................................................................. 91
Idioventricular (Slow)........................................................................................................... 93
Accelerated Idioventricular (fast)......................................................................................... 95
Atrial Fibrillation................................................................................................................... 96
Atrial Flutter.......................................................................................................................... 97
Agonal.................................................................................................................................. 99
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SINUS
Rhythm strip
Classification Non-life threatening

Summary Sinus rhythm is normal conduction
Characteristics
Rate 60-100 bpm or 6-10 beats every 6 seconds
P waves Normal
PR interval Regular
QRS complex Normal
Conduction Regular
Rhythm Regular
Haemodynamics Patient is conscious, breathing is regular and cardiac output, pulse,
and blood pressure are normal
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SINUS BRADYCARDIA
Rhythm strip

Summary Sinus bradycardia is a regular slow sinus rhythm
Characteristics
Rate less than 60bpm or less than 6 beats every 6 seconds
P waves Normal
PR interval Regular
QRS complex Normal
Conduction Regular
Rhythm Regular
Haemodynamics Patient is conscious.
This is rate and patient-dependant. Some patients may be severely

compromised with a slow heart rate. The slower the rate the more
likely the haemodynamic compromise.
Other patients may have prescribed medications to slow the heart

rate to allow the heart to work more effectively and efficiently. In
addition, young fit people may also have a slow heart rate which is
quite normal for them.
Response
Treatment The aim of treatment in the compromised patient is to speed up the
heart and maintain cardiac output (blood pressure). Please refer to
Drugs in Resuscitation for further information.
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SINUS TACHYCARDIA
Rhythm strip

Summary Sinus tachycardia is a regular fast sinus rhythm
Characteristics
Rate greater than 100 bpm or more than 10 beats every 6 seconds
P waves Normal
PR interval Regular
QRS complex Normal
Conduction Regular
Rhythm Regular
Haemodynamics Patient is conscious.
Sinus Tachycardia (ST) is rate and patient-dependant. Some

patients may be severely compromised with a fast heart rate. The
higher the rate the more likely the haemodynamic compromise.
However the majority of patients with ST do not respond this way.
Sinus tachycardia tends not to present with exceedingly high rates,
and may be a precursor to a deteriorating patient with conditions
such as hypoxia or hypovolaemia equally, so symptoms such as
pain or fever may be the cause of the tachycardia, and are easily
reverted with simple treatments such as fever control or analgesia.
It is important to treat the patient as well as the heart rate.
Response
Treatment See Haemodynamics
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VENTRICULAR FIBRILLATION
Rhythm strip
Classification Life threatening - SHOCKABLE
VF is by far the most common primary rhythm, especially in victims

of sudden cardiac arrest. It produces a completely disorganised
ECG trace with impulses occurring irregularly at a rate of 300 - 500
per minute.
This arrhythmia is life threatening and requires immediate

treatment. Ventricular fibrillation is often a direct follow on from
untreated ventricular tachycardia.
Summary A condition in which the cardiac muscles of the ventricles
quiver, rather than contract properly. While there is activity, it
is undetectable by palpation at major pulse points (such as the
carotid or femoral arteries). You can only confirm VF via the ECG.
At the onset of VF the muscle fibres are usually still contracting

briskly and this is demonstrated by high amplitude deflections on
the ECG. If the VF is left untreated the muscle fibre contraction
rapidly deteriorates and the deflections on the ECG are reduced in
amplitude eventually deteriorating to asystole.
Characteristics
Rate So rapid that rate is not an effective determiner for VF. There is no
organised ventricular contraction.
P waves Nil
PR interval Nil
QRS complex Nil
Conduction Waves are rapid, small and chaotic. No organised atrial to
ventricular conduction. Check leads and patient
Rhythm Irregular due to multiple foci firing in the ventricles
Haemodynamics Patient will be unconscious with complete absence of cardiac
output
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Response
Nursing Ventricular Fibrillation always causes pulselessness and
unconsciousness. Commence CPR, administer O2 and prepare for
defibrillation.
Treatment Defibrillation with 200J biphasic shock. CPR
Recommended Adrenaline 1mg IV after the 2nd shock, repeated every 2nd cycle.
drugs Amiodarone 300mg IV after the 3rd shock and a second dose of
150mg may be given after the 5th shock.
Possible causes • Myocardial Infarction or Ischaemia
• Acid base imbalances
• Electric shock
• Severe hypothermia
• Electrolyte imbalances
Management The major determinant of survival of patients with VF or VT is the
speed of effective defibrillation.
When a defibrillator is not readily available, the major determinant

is adequate myocardial reperfusion and coronary perfusion
pressure (determined by the CPR technique and peripheral
vasoconstriction). To date, in the absence of or while awaiting a
defibrillator, nothing has been shown to be more effective than
good compressions.
Mortality Chance of successful defibrillation decreases with time. Amplitude
and waveform of VF deteriorate as high energy phosphate stores
in the myocardium decrease. This rate of decease of myocardial
energy reserves can be slowed, but not halted, by the provision of
effective CPR.
A defibrillatory shock should be attempted every 2 minutes

until VF no longer exists. Reversible causes such as hypoxia,
hyperkalaemia/hypokalaemia, hypothermia, acid/base disorders
must be identified and treated.
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PULSELESS VENTRICULAR TACHYCARDIA

Rhythm strip
Classification Life threatening - SHOCKABLE
Pulseless Ventricular Tachycardia (VT) often leads directly to

Ventricular Fibrillation, asystole and death.
Summary Pulseless VT originates in the ventricles which contract rapidly with
no corresponding cardiac output and will be followed rapidly by VF
if not reversed.
Characteristics
Rate Usually 140-200 beats per minute or 14-20 beats every 6 seconds
P waves Difficult to identify. Are often buried within the QRS complex as
there is complete dissociation between the atria and ventricles
PR interval Indeterminate
QRS complex Wide and bizarre
Conduction The rhythm originates from the ventricle. The atria and ventricle
beat independent of each other
Rhythm Regular, as one foci in the ventricles is often the sole pacemaker
for the heart
Haemodynamics Immediate substantial drop in cardiac output that often leads to
unconsciousness and pulselessness. Sometimes the patient may
remain conscious but will rapidly deteriorate if left untreated.
Response
Nursing Pulseless VT always causes pulselessness and unconsciousness.
Commence CPR and prepare for defibrillation.
Treatment Pulseless VT is a shockable rhythm. Prepare for defibrillation using
200J biphasic and commence CPR.
Recommended Adrenaline 1mg IV after the 2nd shock, repeated every 2nd cycle.
drugs Amiodarone 300mg IV after the 3rd shock
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• Cardiomyopathy
• Electrolyte imbalances (Hypokalaemia)
• Drug toxicity from digoxin
Management The major determinant of survival of patients with Pulseless VT is
the speed of effective defibrillation.
When a defibrillator is not readily available, the major determinant

is adequate myocardial reperfusion and coronary perfusion
pressure (determined by the CPR technique and peripheral
vasoconstriction). To date, in the absence of or while awaiting a
defibrillator, nothing has been shown to be more effective than
good compressions.
Mortality Chance of successful defibrillation decreases with time. Amplitude
and waveform of VF deteriorate as high energy phosphate stores
in the myocardium decrease. This rate of decrease of myocardial
energy reserves can be slowed, but not halted, by the provision of
effective CPR.
A defibrillatory shock should be attempted every 2 minutes until

VF/VT no longer exists. Reversible causes such as hypoxia,
hyperkalaemia/hypokalaemia, hypothermia, acid/base disorders
must be identified and treated.
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ASYSTOLE
Rhythm strip
Classification Life threatening - NON-SHOCKABLE
This rhythm is the most serious rhythm in an arrest situation as

it has the highest incidence of resuscitation failure. Without rapid
intervention, this arrhythmia becomes irreversible.
Summary No electrical activity, no contractions of any kind. This rhythm is
most commonly seen as the end result in patients with VF who
have not been resuscitated successfully.
A period of deteriorating vital signs is often a precursor to asystole.

Characteristics
Rate No ventricular rate
P waves P waves may be present, which indicates Ventricular Standstill,
as the atria are still working but are not conducting down the
ventricles. If there are no P waves, it is definitely asystole.
PR interval Nil
QRS complex No ventricular activity
Conduction No conduction through the ventricles
Rhythm Nil
Haemodynamics Complete loss of cardiac output and consciousness
Response
Nursing Assess the patient using DRSABC. If monitored, check for lead
disconnection.
Treatment Commence CPR and focus on treating the cause. Defibrillation is
ineffective as there is no rhythm.
Recommended Adrenaline 1mg IV immediately once access is obtained. Repeat
drugs every 2nd cycle.
Possible causes • Myocardial infarction
• Severe electrolyte imbalances
• Massive pulmonary emboli
• Prolonged hypoxaemia
• Drug overdoses
• Acid base imbalances
• Prolonged cardiac arrest (hypoxaemia and acidosis)
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Management An important consideration is the possibility of mistaken diagnosis.

The presence of fine ventricular fibrillation may not be recognised
for a number of reasons including equipment failure, excessive
artefact, lead disconnection or an incorrect gain setting.
Make every effort to interpret or improve the quality of the

recording of the rhythm. Be familiar with your equipment and how
it represents a lead disconnection, for example, does the trace
become a broken line?
If there is any uncertainty as to the rhythm, recommence CPR for 2

minutes to provide further effective compressions, then reassess.
Compressions may coarsen a very fine VF line, making it more
recognisable.
Mortality Recovery of patients who have primary cardiac disease that

leads to asystole is very unlikely to occur after 15 minutes of
unsuccessful CPR.
Important exceptions are cases of hypothermia, near drowning,

or poisoning, all of which should be remedied or excluded before
resuscitation attempts are abandoned.
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PULSELESS ELECTRICAL ACTIVITY (PEA)

Rhythm strip
Any rhythm has the potential to be PEA. This is a rhythm where

the conduction system is working, however due to a specific cause
(such as severe hypovolaemia or tampanade) the heart is unable
to pump.
Summary PEA can be applied to any rhythm where the tracing seen on
the monitor should represent a patient with a pulse, however the
patient is in full cardiac arrest.
Characteristics
Rate Dependent upon the rhythm
P waves Dependent upon the rhythm
PR interval Dependent upon the rhythm
QRS complex Dependent upon the rhythm
Conduction Dependent upon the rhythm
Rhythm Dependent upon the rhythm
Haemodynamics The patient is unresponsive, not breathing normally and has no
pulse.
Response
Nursing Immediately call for help and commence compressions
Treatment This is a non-shockable rhythm. Causes of cardiac arrest need
to be determined to reverse the PEA to a perfusing rhythm. If left
untreated this rhythm may deteriorate into ventricular fibrillation.
Recommended Adrenaline 1mg IV immediately once access has been gained
drugs
Possible causes 4Hs + 4Ts
Management Dependent upon the cause
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VENTRICULAR TACHYCARDIA WITH A PULSE

Rhythm strip
Classification Life threatening
Ventricular Tachycardia with a pulse has a different treatment plan

to Pulseless VT. The patient may or may not be compromised. VT
with a pulse if left untreated may deteriorate into Pulseless VT.
Summary VT originates in the ventricles. The patient with a pulse may have
a slower rate to the patient without a pulse. Faster rates (above
180bpm as a guide) decrease the time in which the ventricles fill
and the coronary arteries perfuse, hence these patients are more
likely to lose cardiac output rapidly and arrest.
Characteristics
Rate Rate may be as slow as 100-150bpm or 10-15 beats every 6
seconds
P waves Difficult to identify. Are often buried within the QRS complex as
there is complete dissociation between the atria and ventricles.
for the heart
Haemodynamics Instability may occur in the patient with pulsatile VT. Compromise
will be rate and patient-dependant.
Response
Nursing Rapid assessment of stability and haemodynamic status. Call for
help.
Treatment To prevent further deterioration, reversal of the rhythm is essential.
This may be achieved using cardioversion as described in the
chapter Cardioversion and Pacing if the patient is compromised
haemodynamically. In the more stable patient chemical
cardioversion may be initiated such as amiodarone.
Recommended Amiodarone in combination with cardioversion
drugs
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• Cardiomyopathy
• Electrolyte imbalances (Hypokalaemia)
• Drug toxicity from digoxin
Management Cardiac monitoring may occur for at least 24 hours to observe
patient does not revert back into VT. Cardiology review and a
treatment plan. Patient will require investigation into cause of VT
and may require a defibrillator pacemaker implant is recurrent
episodes occur.
Mortality Good outcomes if treated early.
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TORSADES DE POINTES
Rhythm strip
Classification Life threatening - SHOCKABLE IF PULSELESS
Torsades de Pointes is a French phrase which translates as

“twisting around a point”. Any condition that causes a prolongation
of the QT interval can cause torsades.
Summary Torsades is a form of VT where the QRS complexes gradually
change back and forth from one shape and direction to another
over a series of beats.
Characteristics
Rate 150 – 250 bpm or 15 – 25 beats every 6 seconds
P waves Nil
for the heart
Haemodynamics Instability may occur in the patient with Torsades de Point.
Compromise will be rate and patient-dependant.
Response
Nursing Rapid assessment of patient’s haemodynamic status. Call for help.
Treatment To prevent further deterioration of the patient if not in arrest,
reversal of the rhythm is essential.
Recommended During cardiac arrest, defibrillation/CPR and Adrenaline. During
drugs peri-arrest or post-arrest, a bolus of Magnesium 5mmol over
10 minutes with Doctors order (recommended for Torsades in
ANZCOR 2009 Guidelines 11.9 - Managing Acute Dysrhythmias).
Additionally, with expert help overdrive pacing or isoprenaline may
be utilised for peri or post-arrest for Torsades due to heart block or
bradycardia.
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Possible causes • Prolonged QT time

• Many drugs may cause this arrhythmia
• Electrolyte imbalance
• Genetic predisposition
Management Call for help. If pulseless, immediate defibrillation, CPR
and adrenaline to perfuse the brain. Lignocaine and other
antiarrhythmics are avoided as they may prolong the QT interval
and worsen the situation. Aim of therapy is to decrease the QT
interval and so magnesium sulphate and isoprenaline can be used.
Transcutaneous overdrive pacing may also be used.
Mortality Rapid reversal and correction of underlying cause improves
outcomes
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SUPRAVENTRICULAR TACHYCARDIA
Rhythm strip
Classification Not life threatening
SVT has the potential to cause haemodynamic compromise due to

the high heart rates often associated with this rhythm.
Symptoms can come on suddenly and may go away without

treatment. They can last for a few minutes or for as long as 1 or 2
days.
Summary SVT is a rapid atrial rhythm
Characteristics
Rate 150 to 250 bpm or 15-25 beats every 6 seconds
P waves Vary. Some P waves are normal, originating from the SA node, and
others are abnormal, originating from the escape foci. They also
may be hidden by the preceding T wave.
PR interval Normal when identifiable
QRS complex Normal, but they may have a slower rate than the atrial rate if there
is a block at the AV node (to protect the ventricles from the rapid
heart rate).
Conduction Usually normal, unless there is a block at the AV node
Rhythm Regular
Haemodynamics Patients with pre-existing disease may be compromised by their
inability to maintain adequate cardiac output.
Response
Nursing Monitor the patient closely for any signs of haemodynamic
instability and treat accordingly.
Treatment Vagal manoeuvres
These can be performed in order to attempt to slow the rate of the

heart and can comprise of:
• Valsalva technique, cough method, syringe blowing – ask the
patient to take a breath then hold the nose and mouth shut
and ‘blow out’. This method increases intrathoracic pressure,
which in turn stimulates baroreceptors in the carotid artery
• Chemical cardioversion – adenosine may be used to slow
the rhythm, to aid identification, or as a chemical cardioverter
to identify or restore a normal rhythm.
• Electrical cardioversion for the treatment of SVT especially if
the patient is showing signs of haemodynamic compromise
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Recommended Chemical cardioversion – adenosine may be used to slow

drugs the rhythm, to aid identification, or as a chemical cardioverter
to identify or restore normal rhythm. Please refer to Drugs in
Resuscitation for further information.
Possible causes Can be due to a rapid firing ectopic focus within the atria or a re-
entry circuit that lets the impulse travel rapidly within the atria.
Management Investigations to find cause. Medications may be prescribed
Mortality Good outcomes with treatment
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THIRD DEGREE BLOCK

Rhythm strip
Classification Potentially life threatening
This block can be either temporary or permanent and is potentially

life-threatening depending on the level of haemodynamic
compromise. Atrial kick is equal to about 15-30% of cardiac output,
and is instantly lost with this rhythm.
Summary Third Degree Heart Block is an Atrial-Ventricular block, where the
atrial impulses are blocked from conducting down through the
ventricles.
Characteristics
Rate Atrial rate is normal. The ventricular rate is regular and is
dependent on the site of the escape pacemaker.
P waves Normal
PR interval Varies from one complex to another as the P waves have no
relationship to the QRS complexes.
QRS complex This is dependent on the escape pacemaker. The QRS complex
will increase in duration (i.e. width) the lower down the conduction
pathway the escape focus is.
Conduction There is no conduction through the AV Node (indicating a complete
heart block). There is complete disassociation between the atria
and the ventricle.
Rhythm Regular. The P to P and R to R intervals are constant.
Haemodynamics Cardiac output is reduced due to the loss of atrial kick. Decreased
heart rate also decreases cardiac output.
Response
Nursing Observe the patient’s vital signs. The level of haemodynamic
compromise is dependent on cardiac output and ventricular heart
rate.
Perform a 12 lead ECG and note any ST segment changes. The

lower the heart rate, the lower down the conduction pathway is
the escape foci. Impulses originating from the Purkinjie fibres are
unreliable and the rhythm may deteriorate to ventricular standstill.
Treatment Treatment of Third degree heart block is dependent upon the level
of patient compromise. Initially IV atropine may be administered to
increase heart rate. IV isoprenaline as an infusion may be used to
improve cardiac output.
External pacing is commenced, generally, when the patient is

severely compromised and is used as an interim measure whilst
awaiting a temporary pacing wire.
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Recommended Atropine 600mcg is given as a starting dose. Rate response to

drugs the first dose will determine subsequent delivery and amount.
Isoprenaline may be also administered on medical instruction. See
Appendix 2.
Possible causes • Coronary artery disease
• Anterior or inferior wall myocardial infarction
• Degenerative changes in the heart
• Digoxin toxicity
• Lignocaine or amiodarone infusion
• Surgical injury
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IDIOVENTRICULAR (SLOW)
Rhythm strip
A ventricular rhythm with no atrial contraction

Summary Idioventricular rhythms are the “rhythm of last resort” and are a
type of escape rhythm. They are an inbuilt safety mechanism for
when the heart is unable to conduct impulses from the Bundle of
His to the ventricles.
Idioventricular rhythms prevent the heart going into ventricular

standstill. This arrhythmia signifies a serious conduction defect and
commonly occurs in dying patients.
Characteristics
Rate 20 – 40 bpm or 2 – 4 beats every 6 seconds
P waves Nil. This is an escape rhythm due to a lack of atrial activity
PR interval Nil
Conduction Impulse originates within the ventricles, therefore no P waves
Rhythm Ventricular, usually regular
Haemodynamics A slow heart rate and loss of atrial kick leads to a drop in cardiac
output and blood pressure. Haemodynamic effect is dependent on
the ventricular rate.
Response
Nursing Assess the patient’s vital signs, level of consciousness, and signs
of chest pain or dyspnoea. Notify a medical officer immediately if
deterioration occurs. The lower down the conduction pathway the
escape foci is, the slower the heart rate, and the less reliable the
pacemaker.
If the pacing focus deteriorates, the patient may go into a severe

bradycardia, or asystole.
Treatment Treatment should begin immediately. The aims of treatment are to
increase heart rate, increase cardiac output, and return to a more
reliable rhythm. Atropine and/or an external pacemaker are the
treatments often used.
It is important not to suppress the idioventricular rhythm, as this is

the safety mechanism that is keeping the heart functioning.
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Recommended Isoprenaline may be also administered (see Appendix 2). Never

drugs treat with Lignocaine as this will suppress this rhythm, and
ventricular standstill may occur.
Possible causes Idioventricular rhythms can accompany 3rd degree heart block,
and be caused by:
• Myocardial Ischaemia
• Metabolic imbalances
• Pacemaker failure
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ACCELERATED IDIOVENTRICULAR (FAST)

Rhythm strip

Summary Accelerated Idioventricular rhythm is the same as Idioventricular
rhythm except the rate is 40 - 100 BPM.
Accelerated Idioventricular rhythm is often better tolerated than

Idioventricular rhythm as the rate is higher and this leads to a
minimal drop in cardiac output. Regular assessment of the patient
and their vital signs is necessary in case the rhythm degenerates
into VT or a severe bradycardia.
Characteristics
Rate 40 - 100bpm or 4 - 10 beats every 6 seconds
P waves Nil. This is an escape rhythm due to a lack of atrial activity
PR interval Nil
Conduction Impulse originates within the ventricles, therefore no P waves
Rhythm Ventricular, usually regular
Haemodynamics Often better tolerated than the slower Idioventricular rhythm.
Monitor for deterioration.
Response
Nursing Assess the patient’s vital signs, level of consciousness, and signs
of chest pain or dyspnoea. Notify a medical officer immediately if
deterioration occurs.
Treatment It is important not to suppress the Idioventricular rhythm, as this is
the safety mechanism that is keeping the heart functioning.
Recommended Never treat with Lignocaine as this will suppress this rhythm, and
drugs ventricular standstill may occur.
Possible causes Accelerated Idioventricular rhythm may occur as a post reperfusion
arrhythmia after thromboytic therapy or in the patient receiving
inotrope.
Mortality Dependent on the underlying condition
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ATRIAL FIBRILLATION
Rhythm strip

Summary A condition where the electrical impulses in the atria are not
originating from the SA node but are firing throughout the atria
muscle. This is the second most common rhythm after Sinus
rhythm.
Characteristics
Rate Slow AF <60bpm or <6 beats every 6 seconds
Controlled AF 60-100bpm or 6 -10 beats every 6 seconds
Rapid AF >100bpm or >10 beats every 6 seconds

P waves Not identifiable, the isoelectric line appears to ‘quiver’
PR interval Unrecognisable/not measurable
QRS complex Usually narrow (approximately 0.4 - .12 seconds) but can be wide
Conduction Impulse originates from the atria
Rhythm Irregular
Haemodynamics Blood pressure may be low, patient will be conscious but may feel
faint and have heart palpitations.
Response
Nursing Assess the patient – Blood pressure, level of consciousness and
pulse.
Treatment If asymptomatic, obtain 12 lead ECG, doctor may order
antiarrythmics.
Recommended Digioxin, amiodarone, sotolol
drugs
Possible causes • Rheumatic fever
• Hypertension
• Cardiomyopathy
• Thyrotoxicosis
• CHF (Congestive Heart Failure)
• COPD (Congestive Obstructive Pulmonary Disease)
• Post cardiac surgery
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ATRIAL FLUTTER
Rhythm strip
Arises from an ectopic focus in the atria, usually low down towards
the AV node. Rapid atrial flutter can lead to a drop in stroke volume
from the decrease in ventricular filling time, but also has the
problem of loss of atrial kick.
Summary Atrial flutter is often described as 2:1, 3:1 or 4:1 block, which refers
to the ratio of atrial to ventricular waves. Note that 2:1 flutter can be
difficult to detect as the F wave is buried in the T wave.
Characteristics
Rate Rate is variable depending upon the degree of block: 75 – 150
bpm or 7 – 15 beats every 6 seconds
P waves P waves are replaced by F waves which can be described as ‘saw
tooth’. Atrial rates of up to 300 can be reached.
PR interval Not measurable
QRS complex Normal width
Conduction There will be more flutter waves than QRS waves. This is due to
the AV Node being unable to conduct rates over 220 bpm.
Rhythm Atrial flutter will be regular. If the rhythm has a varying block this
may give the illusion of being irregular.
Response
Nursing Monitor the patient closely for any signs of haemodynamic
instability and treat accordingly.
Treatment • Valsalva technique, cough method, syringe blowing – ask the
patient to take a breath then hold the nose and mouth shut
and ‘blow out’. This method increases intrathoracic pressure,
which in turn stimulates baroreceptors in the carotid artery
• Avoidance of excess caffeine and alcohol
• Cardioversion
• Radiofrequency ablation
Recommended Drugs used to slow the heart rate may be prescribed and may
drugs include beta blockers, calcium antagonists or digoxin.
Warfarin may be prescribed to prevent blood clots developing

leading to potential stroke.
Stronger medications to prevent or revert the rhythm such as

amiodarone may be used.
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Possible causes • Rheumatic heart disease

• Overactive thyroid
• Hypertension
• Coronary heart disease
• Cor pulmonale
• Pericarditis
• Hypoxia
• Digoxin toxicity
Mortality Haemodynamic status will be monitored in addition to further
investigation. An overactive thyroid can precipitate Atrial Flutter
therefore a thyroid function test should ideally be taken for new
onset Atrial Flutter.
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AGONAL
Rhythm strip
Classification Transition
An agonal rhythm represents the transition from slow VF into

asystole and is too quick to treat as an independent rhythm. It is
often indicative of a dying heart.
Summary Characterised by the presence of slow, irregular, wide ventricular
complexes of varying morphology. This rhythm is usually seen
during the late stages of unsuccessful resuscitation attempts.
The complexes are slow, progressively widening, before all
recognisable activity is lost.
Characteristics
Rate <20bpm or <2 beats every 6 seconds
P waves No P waves, wide bizarre ventricular beats present
PR interval Indeterminable
QRS complex Tendency to be irregular
Conduction Minimal
Rhythm Irregular
Haemodynamics Failing/decreasing cardiac output as the heart dies
Response
Nursing This rhythm precedes asystole. CPR is to be commenced
immediately.
Note: The nursing responsibilities for the patient who is Not For
Resuscitation is to provide dignity to the patient and support the
family.
Treatment CPR
Recommended Adrenaline 1mg immediately once access is gained.
drugs
Possible causes End of life
Management Nursing management
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
This quiz accompanies the information about rhyths, to help you practice identification and recall
the appropriate responses to them. You will find the answers in Appendix 3.
Identify the following rhythm:
ST
VT
SVT
VF
Ventricular fibrillation (VF):
Is NOT a common primary rhythm of cardiac arrest

Should be defibrillated as soon as possible
Is preceded by a period of pulseless ventricular tachycardia
Produces an irregular pulse in a major artery
Pulseless ventricular tachycardia:
Should be shocked with a biphasic defibrillator at 360J

Should be cardioverted (synchronised defibrillation) with 100J
Should be treated the same as ventricular fibrillation
Always has an irregular appearance
PEA:
Produces an ECG complex but has no palpable pulse

Does not require IV Adrenaline to be administered
Is treated by defibrillation
Has the worst possible outcome if the cause is mechanical e.g. tension pneumothorax
If the ECG rhythm appears to be Asystole, which of the following should occur? (Please note
there is more than one answer)
Check for ECG lead disconnection

Assess ECG size
Administer lignocaine
Commence CPR immediately for 2 minutes as per the ALS algorithm
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What is happening in the heart based on this information in this rhythm strip?
There is no atrial activity

There is no ventricular activity
There is regular, weak atrial activity
There is irregular, weak ventricular activity
Which drug may be administered in the initial management of a slow idioventricular rhythm?
Magnesium sulphate
Atropine
Defibrillation
Lignocaine
Adrenaline
Q8. Treatment for PEA does NOT include:
Prompt CPR
Securing an airway
Defibrillation
Adrenaline
What is this rhythm?
Sinus with premature atrial beats

Ventricular fibrillation
Atrial fibrillation
Atrial flutter
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During an emergency defibrillation, the energy level selected for the monophasic/biphasic
defibrillators are:
360/360 joules
200/200 joules
200/360 joules
360/200 joules
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Appendix 2 - Resuscitation Drugs
This resource lists the drugs used in resuscitation.
First line drugs......................................................................................................................... 105
Adrenaline.......................................................................................................................... 105
Amiodarone........................................................................................................................ 106
Second line and/or peri-arrest drugs.................................................................................... 107
Adenosine.......................................................................................................................... 107
Atropine.............................................................................................................................. 108
Calcium.............................................................................................................................. 109
Isoprenaline........................................................................................................................110
Lignocaine........................................................................................................................... 111
Magnesium.........................................................................................................................112
Potassium...........................................................................................................................113
Sodium Bicarbonate............................................................................................................114
Thrombolytics......................................................................................................................115
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FIRST LINE DRUGS

Adrenaline
Routes IV/IO or Endotracheal
Description This is a naturally occurring Catecholamine with alpha and beta
effects. It is administered in cardiac arrest to cause peripheral
vasoconstriction. It may facilitate defibrillation by improving
myocardial blood flow during CPR. Adrenaline has been and
is considered the standard vasopressor in all cardiac arrest
situations.
Alpha response Peripheral vasoconstriction directs available cardiac output to
myocardium and the brain
Beta response During cardiac arrest, cerebral blood flow may be enhanced. Post
return of spontaneous circulation, the beta response increases
heart rate and force of contraction.
• B1 – inotrope and chronotrope
• B2 – relaxes smooth bronchial muscle
Indications • Ventricular Fibrillation/Pulseless Ventricular Tachycardia after
2nd unsuccessful shock
• Asystole and PEA/EMD as initial treatment
Adverse effects • Tachyarrythmias
• Severe hypertension after resuscitation
• Tissue necrosis if extravasation occurs
Dose and The initial adult dose is 1mg (1ml of 1:1000 or 10ml of 1:10,000)
dilution and this should be repeated every 2nd loop of the algorithm (3-5
minutes) during CPR. Adrenaline may be required in repeated
small doses or by infusion to produce an adequate blood pressure
after return of spontaneous circulation. In this situation a dedicated
central line should deliver an infusion of Adrenaline 1 – 20 mcg/
min, as soon as able.
Should the dose be given via the ETT, it would be the decision of
the MO in attendance to decide the drug dose and dilution.
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Amiodarone
Routes IV/IO
Description Amiodarone is a Class III antiarrhythmic drug, and is a membrane
stabilising drug that prolongs the refractory period in all cardiac
tissues.
Amiodarone also has an effect on the AV node, causing a delay in

intranodal conduction.
Indications • Ventricular Fibrillation/Pulseless Ventricular Tachycardia
after the third shock. Usually administered when refractory to
defibrillator shocks and a vasopressor
• Prophylaxis of recurrent VF/VT
• Treatment of Atrial fibrillation, Atrial flutter and VT with a
pulse
Adverse effects • Hypotension
• Bradycardia
• 3rd Degree Heart block
Dose and • In cardiac arrest – 300mg diluted in 20mls 5% Dextrose as
dilution an IV push. An additional dose of 150mg may be considered
after the 5th shock.
• In unstable patients - 300mgs diluted in 100mls 5% Dextrose
over 30 - 60 minutes.
• In stable patients - 300mgs diluted in 100mls 5% Dextrose
over 1 hour followed by a maintenance infusion of 15mgs/kg
in 500mls 5% Dextrose over 24 hours. The volume of fluid
given to the stable patient will be as per hospital policy.
• If infusion required - The infusion must be in a non PVC
bag or glass bottle (500ml) and use low absorption infusion
tubing as the drug is absorbed into PVC over time.
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SECOND LINE AND/OR PERI-ARREST DRUGS

Adenosine
Routes IV
Description Adenosine causes transient heart block in the AV node. Adenosine
has an indirect effect on atrial tissue causing a shortening of the
refractory period.
Indications • Supraventricular Tachycardia – stable regular narrow
complex tachycardia
• Narrow complex tachycardias, for example, atrial flutter.
Adenosine may be used for its diagnostic properties. By
slowing the ventricular response the underlying rhythm may
be revealed.
Adverse effects • Facial flushing
• Light headedness
• Diaphoresis
• Nausea
• Severe bradycardia
• Sense of impending doom
(These symptoms are transitory, usually lasting less than one

minute)
Dose and The initial dose is 6 mg, given as a fast IV push into a fast running
dilution infusion. Ideally the arm should be elevated to speed delivery to
the heart.
Due to Adenosine’s extremely short half-life, start the IV line as

proximal to the heart as possible. If this first dose does not revert
the rhythm (e.g., no evidence of transient AV block), a 12mg dose
can be given 1-2 minutes after the first dose. If the 12mg dose has
no effect, a second 12mg dose can be administered 1-2 minutes
after the previous dose.
Administration of Adenosine must be undertaken in a monitored

environment due to potential for a transient period of ventricular
standstill.
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Atropine
Routes IV
Description Atropine is a parasympathetic antagonist that blocks the action of
the vagus nerve on the heart, therefore increasing rate of the sinus
node and conduction of the AV node.
Indications As a peri-arrest medication in severe bradycardia with
haemodynamic compromise
Adverse effects • Tachycardia, dilated pupils
• Excitement, delirium, hyperthermia in large doses
• Paradoxical bradycardia if administered as a low dose or
injected too slowly
• Contraindicated for cardiac transplant patients
Dose and Atropine is given as a bolus of at least 600mcg that may be
dilution repeated, to a maximum of 3mg with brady arrhythmias. Doses
larger than 3mgs may lead to a total blockade.
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Calcium
Routes IV/IO
Description Calcium is not recommended as a routine cardiac arrest drug
Calcium is essential for normal muscle and nerve activity. It

transiently increases myocardial excitability and contractility and
peripheral resistance.
Indications • Hyperkalaemia
• Hypocalcaemia
• Overdose of Calcium-Channel blocking drugs
Adverse effects • Possible increase in myocardial and cerebral injury by
mediating cell death
• Tissue necrosis with extravasation
Dose and The usual adult bolus dose in these settings is 5-lOmls of 10%
dilution Calcium Chloride. Calcium Chloride provides a higher dose of
Calcium than Calcium Gluconate.
• 10mls Chloride = 6.8mmolsCa ions
• 10mls Gluconate = 2.2 Ca ions
Please refer to your hospital policy on which strength to administer.
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Isoprenaline
Routes IV
Description Isoprenaline is a synthetic derivative of Noradrenaline
(sympathomimetric). Isoprenaline increases cardiac output and
heart rate.
Beta response Isoprenaline is a Synthetic Sympathomimetic Amine that is related
to adrenaline but acts almost exclusively on beta receptors,
positive inotrope and chronotrope, increased heart rate, increased
contractility, decreasing peripheral vascular resistance and causing
pulmonary vasodilation.
Indications • Bradycardia not responsive to atropine
•Haemodynamically compromised conduction disorders, e.g.
AV blocks
Adverse effects Adrenaline and Isoprenaline should not be administered
simultaneously.
• Cardiac arrhythmias – tachycardia may be severe enough to
produce pulmonary oedema
• Hypotension/hypertension
• Flushing of the skin/sweating
Dose and 1 mg/5ml ampoules
dilution
Dilute in 500ml 5% glucose
Administration via syringe pump/volumetric pump and intravenous

infusion at a rate of 0.5 to 5 microgram per minute (0.25 to 2.5 mL
of diluted solution). Please refer to your hospital policy.
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Lignocaine
Routes IV/IO
Description Lignocaine acts as a membrane stabiliser and sodium channel
blocker. It depresses automaticity of ventricular cells but has
little effect on the speed of conduction. It may be used when
Amiodarone cannot be used.
Indications • When Amiodarone not available
• For recurrent VT/VF prophylaxis
• When patient is allergic to Amiodarone
Adverse effects • Slurred speech
• Muscle twitching/seizures
• Hypotension
• Bradycardia/heart block
• Asystole
Dose and Initially 1mg/kg bolus
dilution
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Magnesium
Routes IV
Description Magnesium is an electrolyte essential for membrane stability.
Hypomagnesaemia causes myocardial hyperexcitability,
particularly in the presence of Hypokalaemia and Digoxin. Low
serum Magnesium may be caused by diuretic use, severe
diarrhoea and alcohol abuse.
Indications • Torsades de Pointes
• Cardiac arrest associated with Digoxin toxicity
• Refractory VF/pulseless VT
• Documented Hypokalaemia/Hypomagnesium
Adverse effects Excessive use may lead to muscle weakness, paralysis and
respiratory failure
Dose and Magnesium is given as a 5mmol bolus during cardiac arrest
dilution
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Potassium
Routes IV/IO
Description Potassium is an electrolyte essential for membrane stability.
Hypokalaemia, especially in conjunction with Digoxin therapy
and Hypomagnesaemia, may lead to life threatening ventricular
arrhythmias.
Indications Persistent VF due to documented or suspected Hypokalaemia
Adverse effects • Hyperkalaemia with bradycardia
• Extravasation may lead to tissue necrosis
Dose and A bolus of 5mmols of potassium chloride is given intravenously
dilution during cardiac arrest management
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Sodium Bicarbonate
Routes IV/IO
Description Routine Sodium Bicarbonate (NaHCO3) administration during an
arrest is not recommended. In most cardiac arrests early efficient
CPR negates the need for NaHCO3.
Indications • Overdose tricyclics antidepressants
• Hyperkalaemia
• Documented metabolic acidosis
• Protracted arrest – after arterial blood gas (ABG)
measurement
Adverse effects • Metabolic Alkalosis, Hypokalaemia, Hypernatraemia
• Paradoxical intracellular acidosis due to carbon dioxide being
liberated into the cells.
• When mixed with Adrenaline or Calcium the drugs are
inactivated and or precipitate in the line. A dedicated line
must be used during administration.
Dose and 1mmol/kg over 2 – 3 mins. Then guided by ABG results.
dilution
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Thrombolytics
Description Should be considered during a cardiac arrest in the patient with a
proven or highly suspected pulmonary embolism. (PE).
If administered CPR is to continue for at least 60 - 90 mins to allow

action of the drug to occur before terminating the resuscitation
attempt
Thrombolytics such as Tenectoplase are given as an IV bolus dose

during CPR
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Advanced
Adult Advanced
Life Support
Life Support
Quiz
This quiz accompanies the information about drugs used in resuscitation, to help you practice
identifying the appropriate drugs for the appropriate treatment. You will find the answers in
Appendix 3.
A bolus dose of intravenous adrenaline would be indicated in:
Unstable atrial fibrillation

Sinus bradycardia
Acute pulmonary oedema
Ventricular fibrillation
Which of the following drugs should NOT be given down the ET tube?
Adenosine
Adrenaline
Lignocaine
Atropine
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Appendix 3 - Quiz Answers
Quiz 1
Q1 What is the primary aim of the Chain of Survival?
b) To highlight the relationship between early detection and defibrillation and the
rates of survival of cardiac arrests
Q2 Every minute the chances of survival after an arrest decrease by:
c) 7-10%
Q3 The ethical considerations that need to be adhered to as an ALS trained nurse
in an emergency are:
d) Consent, NFR, Medical condition, Advanced Health Directive

Q4 The legal requirements which have to be considered in a cardiac arrest situation
are:
c) Failure to start, documentation, cessation of CPR, Standard of care
Quiz 2
Q1 The correct response to recognition of a non-shockable rhythm should be to:
c) Continue good quality CPR and reassess the rhythm after 2 minutes
Q2 You are the ALS trained nurse responding to a call to resuscitate a patient on
the surgical ward. Ward staff found the patient collapsed, commenced CPR and
attached the defibrillator. Your first priority is to:
d) Assess the effectiveness of the CPR being performed while planning for
rhythm check/defibrillation
Q3 It is TRUE that failure to perform a visual sweep of the room and call “stand
clear” (or similar) before pressing the Shock button constitutes a potential
hazard to other staff members.
Q4 It is false that you should never charge the defibrillator pads on the patient’s
chest wall as this may cause accidental discharge.
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Quiz 3
Q1 One of the conditions where it is recommended to deliver stacked shocks to a
patient is:
a) Only when a monitored, witnessed patient develops a pulseless, shockable

rhythm
Q2 It is true that time is a critical factor that affects defibrillation success.
Q3 The patient’s chest wall size (b) is NOT a factor that influences transthoracic
impedance.
Quiz 4
Q1 The size of the ET tube that you would expect to use for an average female
during an arrest is:
b) 7.0 – 8.0
Q2 The signs that an endotracheal intubation has been unsuccessful are:
c) Absence of audible breath sounds through auscultation

Q3 The following statement regarding intubation during a cardiac arrest is false:
a) Endotracheal intubation can be performed by ALS trained nurses
Quiz 5
Q1 Synchronised counter shock is delivered:
c) On the R wave of the ECG

Q2 The following arrhythmia is an indication for the delivery of synchronised
cardioversion:
a) Atrial fibrillation
Q3 It is True that to initiate pacing mode the patient must be connected to the
defibrillator ECG leads and pads.
Quiz 6
Q1 The common signs of an anaphylaxis are:
c) Difficult/noisy breathing, hives/rash, wheezing, loss of consciousness
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Quiz 7
Q1 Once a successful resuscitation has been achieved the following post
resuscitation checks must be undertaken immediately:
d) Assess patient chest wall trauma and secure the ET tube, and attempt to
restore normative blood pressure
Q2 The following are important during the immediate post resuscitation analysis:
a) Patient’s current drug therapy, b) Possibility of drug overdose/anaphylactic

reaction, c) Patient’s past medical history & d) Relevant medical events leading
up to the cardiac arrest
Quiz - Appendix 1
Q1
This rhythm is a b) VT
Q2 Ventricular fibrillation (VF):
b) Should be defibrillated as soon as possible

Q3 Pulseless ventricular tachycardia:
c) Should be treated the same as ventricular fibrillation

Q4 PEA:
a) Produces an ECG complex but has no palpable pulse

Q5 If the ECG rhythm appears to be Asystole, the following should occur:
a) Check for ECG lead disconnection, b) Assess ECG size & d) Commence
CPR immediately for 2 minutes as per the ALS algorithm
Q6
This rhythm is showing that a) There is no atrial activity

Q7 The following drug may be administered in the initial management of a slow
idioventricular rhythm:
b) Atropine
Q8 Treatment for PEA does NOT include:
c) Defibrillation
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Q9
This rhythm is c) Atrial fibrillation

Q10 During an emergency defibrillation, the energy level selected for the
monophasic/biphasic defibrillators are:
d) 360/200 joules
Quiz - Appendix 2
Q1 A bolus dose of intravenous Adrenaline would be indicated in:
d) Ventricular Fibrillation
Q2 The following drug should NOT be given down the ET tube:
a) Adenosine
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C.O.A.C.H.E.D.
Compressions Continue
C Person in charge of the defibrillator to say, ‘compressions continue’
Oxygen away
O Person in charge of the defibrillator to say, ‘remove free flowing oxygen’.

Any free flowing oxygen at this point is to be removed from the patient.
All else clear

A Person in charge of the defibrillator to say, ‘everyone else stand clear’
Everyone other than the person doing compressions is to stand clear of the
patient.
Charging
C Charge the defibrillator to the appropriate joules
Hands off/ I’m safe
H Person in charge of the defibrillator to tell the compression person ‘hands

off’. At this point the person doing compressions is to stop compressions
step away from the patient raise their hands in the air and respond ‘I’m
safe’
Evaluate rhythm
E Evaluate the patient’s rhythm. Is this a shockable or non-shockable
rhythm and vocalise this to the team
Defibrillation or disarm and dump

D Either defibrillate the patient if they are in a shockable rhythm or disarm
and dump the shock if the child is in a non-shockable rhythm, prior to
checking ROSC
© RESUS4KIDS April 2016 COACHED

References
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2012, CAP Summary.
[ONLINE] Available at: http://www.ncepod.org.uk/2012report1/downloads/CAP_summary.pdf,
[Accessed 19 October 2016].
3303.0 - Causes of Death, Australia, 2017. ABS cat. no. 3303.0 - September, 2018. [ONLINE]
Available at: http://www.abs.gov.au/AUSSTATS/[email protected]/mf/3303.0/[Accessed 19 October 2018].
National Heart Foundation of Australia, Australian heard disease statistics 2015, [ONLINE]
Available at: https://heartfoundation.org.au/images/uploads/publications/RES-115-Aust_heart_
disease_statstics_2015_WEB.PDF [Accessed 20 October 2016].
The Australian Resuscitation Council Guidelines 2016, [ONLINE] Available at: https://resus.org.au/
guidelines/ [Accessed 19 October 2016].
Yang, C,. Yen, Z., McGowan, J., Huiju, C., Chiang, W., Mancini, M., Soar, J., Lai, M. & Ma, M., A
systematic review of retention of adult advanced life support knowledge and skills in healthcare
providers, Resuscitation, vol. 83 (9), 2012, pp1055-1060 [ONLINE] Available via Athens @
Ramsay at: http://www.sciencedirect.com.proxy1.athensams.net/science/journal/03009572
[Accessed 19 February 2014]
Philips Healthcare Non-Invasive Transcutaneous Pacing – Application Note. 2013. Koninkliijke

Philips Electronics N.V. [ONLINE] Available at: http://incenter.medical.philips.com/doclib/enc/fet
ch/2000/4504/577242/577243/577245/577817/577869/Non-Invasive_Transcutaneous_Pacing.
pdf%3fnodeid%3d8615795%26vernum%3d-2 [Accessed 03 November 2016]
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Adult Advanced Life Support

The aims of Adult Advanced Life Support.............................................................................. 8

Cardiopulmonary arrest (CPR).............................................................................................. 8

The deteriorating patient.......................................................................................................11

The ALS flowchart................................................................................................................ 17

Sequence when responding to an arrest ............................................................................ 18

Responsibilities of team members....................................................................................... 22

Being organised and prepared............................................................................................. 24

Rhythms are a picture.......................................................................................................... 29

Sequence for defibrillation................................................................................................... 42

Advanced Airway Management................................................................................................ 47

Recognising an airway obstruction ..................................................................................... 47

Advanced airway devices.................................................................................................... 50

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The action of first line drugs................................................................................................. 56

Cardioversion and Pacing........................................................................................................ 59

Temporary external transcutaneous cardiac pacing............................................................ 61

Once the patient has been successfully resuscitated.......................................................... 71

Pulseless Ventricular Tachycardia....................................................................................... 83

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Pulseless Electrical Activity (PEA)....................................................................................... 87

Ventricular Tachycardia with a pulse.................................................................................... 88

Third Degree Block.............................................................................................................. 94

Accelerated idioventricular (fast).......................................................................................... 98

Atrial flutter......................................................................................................................... 100

Appendix 2 - Resuscitation Drugs......................................................................................... 106

First line drugs................................................................................................................... 107

Second line and/or peri-arrest drugs.................................................................................. 109

Appendix 3 - Quiz Answers.....................................................................................................119

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About this course

1. The online module or equivalent document (this document)

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Document Version Control

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THE AIMS OF ADULT ADVANCED LIFE SUPPORT

Advanced Life Support is defined by the Australian Resuscitation Council as:

The role of the nurse in ALS

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The Cardiovascular System

• ischaemia or infarction Secondary cardiac problems may be as a result

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Signs of deterioration will include one or more of the following elements:

The Chain of Survival

Early CPR Should be commenced and maintained

Early Access Calling for help using the process in place

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The chances of survival after an attack

Every minute the changes of survival reduce by 7-10%

Within 4 - 6 minutes, brain damage and permanent death start to

After 10 minutes, few attempts at resuscitation succeed

THE DETERIORATING PATIENT

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Effective Basic Life support is an essential component of Advanced Life

Medical Emergency Teams

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Considerations may include:

Please refer to your facility guidelines for specific PPE requirements.