Question:
(1)   In relation to the three-stacked shocks, should the adrenaline and amiodarone be given after the third shock or delayed until after the fifth shock?
 
Answer:
Three initial stacked shocks are given only in very specific circumstances – in the cardiac catheter laboratory, in patients who have just had cardiac surgery, and those who have a witnessed monitored arrest and are already connected to a manual defibrillator. These 3 initial stacked shocks should be considered as the first shock in the ALS algorithm and both adrenaline and amiodarone should be given after a further 2 defibrillation attempts (i.e. delayed until after the fifth shock).
 

Question:
(2)   The first dose of amiodarone is given after the third shock. When is the second dose given?
 
Answer:
Following the first three shocks and amiodarone 300 mg, there are no data on when or if additional amiodarone is beneficial. A second dose of amiodarone 150 mg is often given to treat tachyarrhythmias and, on this basis, it is reasonable to give an additional 150 mg if VF/VT remains unresponsive to further shocks. The timing of this second dose is left to the discretion of the clinicians treating the patient.
 

Question:
(3)   The guidelines advocate the use of a normal saline flush when giving amiodarone in cardiac arrest. Isn’t this a ‘non-compatible’ mixture and the drug sheet still shows this?
 
Answer:
Our guidance is based on the limited available evidence, expert opinion and clinical experience in the use of amiodarone in cardiac arrest patients – there is limited science to base guidance in this area. Insistence on the use of 5% dextrose to flush amiodarone could cause significant delays in giving the drug to a cardiac arrest victim.

1. Amiodarone 300 mg IV from a 10 ml prefilled syringe can be given as a bolus injection into a peripheral vein during cardiac arrest – we do not see the value of further diluting this; this would defeat the whole point of having a prefilled syringe for emergency use.
    
2. This can be followed by a flush of 0.9% sodium chloride or by running 0.9% sodium chloride infusion (or 5% dextrose if available).
    
3. We are not aware of any cases of harm caused by this strategy of amiodarone in cardiac arrest patients. Any risk / benefit analysis has to factor in the very high risk of death from cardiac arrest.
    
4. The only published study found did not show a problem between 0.9% sodium chloride and amiodarone (see abstract below).
    
5. Any issues regarding product literature needs to be addressed by the manufacturer.
    
6. Some hospitals may wish to include 5% dextrose to dilute and flush an amiodarone IV injection.

Question:
(4)   If a change to a rhythm compatible with an output is noted following the 3rd shock (say in a pause to ventilate) is it reasonable to withhold adrenaline and amiodarone until the rhythm/pulse check at 2 minutes?
 
Answer:
Ideally, there should be minimal interruption in compressions (even for ventilations with a bag-mask) so rhythm assessment during the 2 min of CPR will not be easy. A change in the ECG may indicate return of spontaneous circulation (ROSC) but may require a long pause in compressions for confirmation. Signs that the patient has ROSC during the 2 min of CPR include clinical signs (waking, purposeful movement) or a sudden increase in end-tidal CO₂ in a patient who is intubated. If ROSC is likely, based on a combination of signs, but not a change in the ECG alone, withhold adrenaline.
 

Question:
(5)   What constitutes 'immediate' in the post op period of cardiac surgery? Or is this to be decided locally?
 
Answer:
‘Immediate’ is if the patient is still in hospital after having cardiac surgery (the highest risk is in the first few days).
 

Question:
(6)   As a trust we opted to use AEDs on most of our resuscitation trolleys with manual machines in critical care areas. Our AED takes at least 10-15s to analyse and charge. There are also delays in starting compressions immediately if there is a non-shockable rhythm (asystole for example) because of the time taken to analyse. When the arrest team arrives this frustrates ALS trained staff who are trained to be quicker. We have experimented with overriding the AED but it isn't well suited to that mode. We have contacted the company to see if they are able to improve the speed of analysis. Now that the recommendation is to have no more than 5s off the chest what are the Council's recommendations regarding the availability of a manual machine?
 
Answer:
The Resuscitation Council (UK) considers that the benefits of early defibrillation with an AED by those without rhythm recognition skills outweigh any problems caused when rescuers who can use a manual defibrillator arrive. In some hospitals a porter takes a manual defibrillator to arrests in non-critical care areas with AEDs. However, there will inevitably be some delay and the ideal solution is to use defibrillators that can be operated in either shock-advisory or manual mode.
 

Question:
(7)   The Life Support manuals show both vertical and horizontal placement of the apical defibrillation pad. Which of these is correct?
 
Answer:
Both apical pad configurations (horizontal or vertical) shown in the manuals can be used. The specific guidance for the apical pad to be vertical in the 2005 Guidelines has been removed in the 2010 Guidelines. Most self-adhesive pads have a diagram and instructions on them showing how they should be placed - when available and feasible (e.g. avoiding breast tissue, hairy chest) these should be followed.
 

Question:
(8)   I am a paramedic - when arriving at an arrest without CPR in progress should I give CPR prior to defibrillation?
 
Answer:
Several studies have examined whether a period of CPR before defibrillation is beneficial, particularly in patients with an unwitnessed arrest or prolonged collapse without resuscitation. A review of evidence for the 2005 guidelines resulted in the recommendation that it was reasonable for emergency medical services (EMS) personnel to give a period of about 2 min of CPR (i.e. about five cycles at 30:2) before defibrillation in patients with prolonged collapse (> 5 min). This recommendation was based on clinical studies in which response times exceeded 4-5 min and in which a period of 1.5 to 3 min of CPR before shock delivery, compared with immediate defibrillation, improved long-term outcome for adults with out-of-hospital VF/VT.
 
In contrast, in two more recent randomised controlled trials, a period of 1.5 - 3 min of CPR by EMS personnel before defibrillation did not improve ROSC in patients with out-of-hospital VF/VT, regardless of EMS response interval. Four other studies have also failed to demonstrate significant improvements in overall ROSC or survival to hospital discharge with an initial period of CPR.
 
The duration of collapse is frequently difficult to estimate accurately and there is evidence that performing chest compressions while preparing and charging a defibrillator improves the probability of survival. For these reasons, in any cardiac arrest that they have not witnessed, EMS personnel should provide good-quality CPR while a defibrillator is prepared, applied and charged, but routine delivery of a specified period of CPR (e.g. two or three minutes) before rhythm analysis and shock delivery is no longer recommended.
 

Question:
(9)   The ALS manual (page 29) recommends giving a loading dose of clopidogrel 600 mg to all patients receiving a fibrinolytic agent for STEMI. However, the current NICE guidelines and JRCALC recommend 300 mg for patients receiving fibrinolytic therapy. Which is correct?
 
Answer:
There is good evidence that patients who are treated by percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS), with or without ST elevation, have better outcomes if they are given a loading dose of 600 mg clopidogrel rather than 300 mg, followed by the standard maintenance dose of 75 mg daily. Many interventional cardiology centres use a 600 mg loading dose of clopidogrel routinely in this setting.
 
The purpose of giving a larger loading dose is to achieve platelet inhibition earlier, rather than greater platelet inhibition in the longer term, so the objective would be the same, regardless of whether reperfusion is achieved by fibrinolytic therapy or by PCI.
 
As many patients will undergo coronary angiography with a view to probable PCI as soon as possible after admission for any ACS, it makes good clinical sense to ensure that they are loaded quickly with effective platelet inhibition.
 
We recommend use of a 600 mg loading dose of clopidogrel in patients with ACS, as described in the ALS manual. In case of doubt, individual clinicians should seek advice from their local interventional cardiologists.
 

Question:
(10)   My Trust / Deanery wish to train F1 in ALS as well as ILS.
Is this acceptable?
 
Answer:
Yes. The ALS provider course is designed for healthcare professionals who would be expected to apply the skills taught as part of their clinical duties, or to teach them on a regular basis. Appropriate participants include doctors, and nurses working in critical care areas (e.g. ED, CCU, ICU, HDU, operating theatres, acute medical admissions units) or on the resuscitation / medical emergency teams, and paramedics. Completing either the ILS course or ALS fulfils the requirements of the F1 curriculum.
 
 
 
 
 
 
 

	© Resuscitation Council (UK)  2011   This page last updated: 15 July 2011