FAQs: Advanced Life Support

The Human Medicines Regulations 2012 came into force on 14 August 2012. This new legislation applies to non-prescribers and allows holders of a current Resuscitation Council UK ‘Advanced Life Support’ provider certificate to administer adrenaline and amiodarone without prescription to adults in cardiac arrest. The legislation refers only to these drugs as they are recommended in the resuscitation guidelines for the specific treatment of cardiac arrest.   

The legislation does not extend to children in cardiac arrest, nor does it include holders of certificates from ‘in-house’ ALS courses, European Resuscitation Council (ERC) courses, or Australian Resuscitation Council (ARC) courses.

It is important to remember that the use of drugs during cardiac arrest is less important than ensuring good-quality CPR with minimal interruption, and early defibrillation when appropriate.

Ultimately it is responsibility of each individual to ensure that they:

1. work within their clinical role and responsibility as decided by their employer,
2. keep-up to date and maintain their clinical skills and knowledge regarding current guidance on the use of drugs in cardiac arrest,
3. maintain their professional registration/licence for their clinical role,
4. have indemnity either through their employer or directly with an indemnity organisation that covers their clinical practice.

The Human Medicines Regulations 2012 are available with explanatory material at: http://www.legislation.gov.uk/uksi/2012/1916/contents/made

October 2012

The rapid bedside evaluation of blood glucose as part of the ABCDE assessment is designed to identify hypoglycaemia as a cause of disordered conscious level as early as possible in the clinical assessment of a patient.

Whilst finger prick capillary blood samples and point-of-care ("bedside") blood glucose meter/strip readings can be inaccurate in certain clinical situations, waiting for the results of a venous or arterial blood sample takes time. If the patient is hypoglycaemic, this delay risks short and long-term neurological damage. The benefits of a rapid bedside diagnosis and early
 
treatment of hypoglycaemia, even if some inaccuracies in measurement are present, generally outweigh the dangers presented by these inaccuracies. Therefore, do not delay the treatment of ‘suspected’ hypoglycaemia whilst awaiting a formal laboratory venous or arterial blood sample result.

All staff using blood glucose test strips and/or meters must understand how to perform the test accurately and must also be aware of the many potential sources of error.

Conditions where there may be inaccuracies with point-of-care testing with blood glucose meters include hypotension, shock, and severe dehydration. The Medicines and Healthcare Products Regulatory Agency (MHRA) provides detailed advice in point-of-care testing.

Three stacked shocks may be considered in a witnessed and monitored cardiac arrest, only when the patient is already connected to a manual defibrillator. For the purposes of medicine administration, these three shocks should be treated as the first shock in the ALS algorithm.

Give the first dose of amiodarone after three shocks, and the second dose after five shocks, irrespective of whether the associated shockable rhythms are sequential (refractory) or intermittent (recurrent).

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 may be given after 5 defibrillation attempts.

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.

Adenosine is predominantly a hospital-based treatment, although it would be reasonably safe and potentially effective for use in pre-hospital settings (e.g. GP surgeries, paramedics).
The relevant points to consider are:

• Wherever adenosine is used it must be within a system that ensures safety. This relates principally to the need for clinical judgement in relation to any history of asthma. Provocation of an acute, severe asthma attack is a rare but well-documented side-effect and can probably be treated more effectively/safely in a hospital setting, if necessary, by treatment that includes early ventilation on an ICU.
• Whoever gives adenosine must be competent in its delivery (by very rapid bolus injection into a large relatively proximal vein). That applies to hospital staff as well as any pre-hospital personnel. They should be competent in recording a continuous 12-lead ECG during adenosine administration and interpreting the response. If adenosine fails to terminate the arrhythmia (because the arrhythmia is a regular atrial arrhythmia such as atrial flutter with 2:1 conduction) it will increase the AV block transiently and show the underlying atrial rhythm, so that must be recorded and recognised. The effect will be very transient (elimination half-life around 15 sec) so this should be understood in order to record and interpret the response appropriately. It is not uncommon to hear 'adenosine didn't work' when in fact it showed clearly (for maybe 1–3 sec) that the arrhythmia was atrial flutter and therefore will not be terminated by blocking the AV node.
• In contrast, if adenosine does terminate the tachyarrhythmia, that is diagnostic of atrioventricular or atrioventricular nodal re-entry tachycardia (AVRT or AVNRT) and in most cases the 12-lead ECG in sinus rhythm will distinguish which of those it was by the presence or absence respectively of delta waves.
• It is a decision for local Ambulance Medical Directors to decide whether, under a Patient Group Directive, ambulance paramedics carry and administer adenosine.
• If adenosine is kept available in multiple locations, each with a very low frequency of needing it, a lot will be wasted. Keeping adenosine in defined select locations (such as the local hospital ED and maybe carefully selected rural community hospitals or general practices) minimises waste and allows development of relative expertise in its use in those locations.

The International Liaison Committee on Resuscitation consensus on science and treatment recommendations conditionally recommend the use of termination of resuscitation rules to aid decision-making about when to stop resuscitation in out-of-hospital cardiac arrest. The review highlights the evidence base is of very low certainty.
 
The European Resuscitation Council and Resuscitation Council UK guidelines describe that persistent asystole despite 20 minutes of advanced life support (ALS) in the absence of any reversible cause is associated with poor prognosis. The decision to stop resuscitation needs to balance the chances that ongoing resuscitation will achieve a meaningful outcome for the patient with the risks of continuing resuscitation to the patient and those providing resuscitation, the resources required to do so and the values and preferences of wider society.
 
Observational studies have shown that survival, although rare, is possible after more than 20 minutes of advanced life. The chances of survival with a favourable outcome are small. Therefore, it is possible that increasing the duration of resuscitation beyond 20 minutes may increase survival in a small number of cases. A key point in our guidelines and those of JRCALC is that termination based on the duration of resuscitation should only ever be considered where no reversible cause has been identified. If there is a potentially reversible cause, then resuscitation efforts should be continued.
 
Resuscitation Council UK and JRCALC are collaborating with researchers funded by the National Institute for Health and Care Research (NIHR) to review the evidence relating to termination of resuscitation rules and model the effect of different termination roles on survival outcomes in the UK. The study is also exploring the views and opinions of paramedics, hospital clinicians, patients and family members. An update to our guidelines is likely to follow the conclusion of this research programme. For further information, see https://fundingawards.nihr.ac.uk/award/17/99/34
 
References
 
ILCOR Consensus on Science and Treatment Recommendations https://costr.ilcor.org/document/out-of-hospital-cardiac-arrest-termination-of-resuscitation-tor-rules-eit-642-tf-sr
 
Resuscitation Council UK Guidelines https://www.resus.org.uk/library/2021-resuscitation-guidelines/ethics-guidelines
 
Nagao K, Nonogi H, Yonemoto N, et al. Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest. Circulation 2016;133:1386-96.
 
Drennan IR, Case E, Verbeek PR, et al. A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation 2017;111:96-102
 
Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation 2016;134:2084-94.
 
Matsuyama T, Kitamura T, Kiyohara K, et al. Impact of cardiopulmonary resuscitation duration on neurologically favourable outcome after out-of-hospital cardiac arrest: A population-based study in Japan. Resuscitation 2017;113:1-7.

The rapid bedside evaluation of blood glucose as part of the ABCDE assessment is designed to identify hypoglycaemia as a cause of disordered conscious level, as early as possible in the clinical assessment of a patient. Whilst finger prick capillary blood samples and point-of-care ("bedside") blood glucose meter/strip readings can be inaccurate in certain clinical situations, waiting for the results of a venous or arterial blood sample takes time.

If the patient is hypoglycaemic, this delay risks short and long-term neurological damage. The benefits of a rapid bedside diagnosis and early treatment of hypoglycaemia, even if some inaccuracies in measurement are present, generally outweigh the dangers presented by these inaccuracies. Therefore, do not delay the treatment of ‘suspected’ hypoglycaemia whilst awaiting a formal laboratory venous or arterial blood sample result.

All staff using blood glucose test strips and/or meters must understand how to perform the test accurately and must also be aware of the many potential sources of error.

Conditions where there may be inaccuracies with point-of-care testing with blood glucose meters include hypotension, shock, and severe dehydration. The Medicines and Healthcare Products Regulatory Agency (MHRA) provides detailed advice in point-of-care testing.
 

Medications are prescribed based on a child’s body weight. In an emergency situation, it is often impractical to weigh the child; therefore, an alternative method of estimating weight as accurately as possible is required. In order of preference:

1. use the child/infant’s body weight for drug calculations if known
2. use a body length tape with pre-calculated drug doses
3. use a paediatric emergency drug chart
4. use an age-based weight calculation formula. For the age group between one and 10 years, the following formula provides an approximation of weight:
   • Weight (kg) = (Age in years + 4) x 2
   • An infant weighs approximately 3 kg at birth and 10 kg at one year of age.

The EPALS course uses the simple acronym W E T Fl A G for children over the age of 1 year and up to 10 years old. This equates to:
 

Example

For a 2-year-old child:
W = (2 + 4) x 2 = 12 kg
E  = 12 x 4 = 48 J
T = 2/4 + 4 = 4.5 mm ID tracheal tube uncuffed
Fl = 10 mL x 12 kg = 120 mL 0.9% saline
A = 10 micrograms x 12 kg = 120 micrograms 1:10,000 = 1.2 mL
G = 2 mL x 12 kg = 24 mL 10% Dextrose

Whilst this is not evidence-based, it provides a simple, easy-to-remember framework in a stressful situation reducing the risk of error.

Beware of exceeding the adult doses of drugs and fluids in older children.

In the majority of babies born with a slow heart rate, this will usually increase within the 30–60 seconds it takes to complete five effective inflation breaths and 30 seconds of effective ventilation breaths. It is, therefore, logical to start compressions only if the heart rate remains less than 60 min^-1 after this period of 30 seconds of effective ventilation. This hopefully clarifies previous confusion.
 
This change to the guidelines means that lung expansion and ventilation is established. There is more opportunity for the heart rate to respond, which usually occurs within 30 seconds of effective ventilation and avoids the potential compromise of ventilation by compressions.
 
If the heart rate remains below 60 min^-1 or absent after this period, synchronised compressions should be commenced at 3 compressions:1 ventilation before reassessing heart rate.
 
The heart rate should be reassessed every 30 seconds and once the heart rate exceeds 60 min^-1 the compressions should be stopped.

In the rare cases where there is an undetectable heart rate and the resuscitator is certain they have seen chest movement through the 5 inflation breaths, it is acceptable for the resuscitator to start 3:1 ventilations to compressions immediately though this remains a professional judgement. 30 seconds of ventilation breaths prior to starting compressions in any circumstances will optimise lung aeration and thus ensure subsequent compressions have best chance of working. In practice, when auscultating the heart rate after five inflation breaths when two resuscitators are present, ventilation breaths are usually continued as a matter of course during this period.

Effective inflation breaths and ventilation will help the majority of babies; it is therefore essential to ensure that this has occurred before instituting compressions. Compressions without effective ventilation are ineffective and may even impede ventilation.

The NLS guidelines are specifically intended for resuscitation at birth. They deal with warming and drying and assessment of the newborn followed, if necessary, by resuscitation, which is mainly concerned with the initial inflation of the lungs and establishing stable respiration. This is different to resuscitation at any other time of life. In addition, the questions of oxygen administration, airway blockage, meconium aspiration and umbilical venous catheterisation are considered which are also usually only applicable to babies in the first hours of life.

The major difference between newborn guidelines and paediatric is in the ratio of compressions to ventilations in CPR. The ILCOR evaluation of the evidence for these two groups arrived at different conclusions. Newborn babies and those on medical neonatal units, special care units and postnatal wards should usually receive 3 compressions to 1 ventilation as the reason for resuscitation is most likely to be respiratory and this ratio is most likely to deliver an appropriate ventilation rate. If a baby is thought to have a primary cardiac cause for arrest, consideration should be given to 15 compressions to 2 ventilations.

A baby who has successfully adapted to extrauterine life and has subsequently collapsed and presented to A&E or collapsed on a joint neonatal/paediatric medical and surgical intensive care unit should be resuscitated according to paediatric life support algorithms with a 15:2 compression to ventilation ratio.

Read our updated FAQ here.

May 2015, reviewed January 2023

LMAs were prioritised in the 2021 guidelines as there was increasing evidence around their ease of use and efficacy. At the time the LMAs available were more suitable for >34 weeks and >2kg. More recently smaller LMAs have been manufactured and we would now advise following the manufacturers guidance in relation to which gestations or size baby that those LMAs can be used in.

Guedel airways were deprioritised in 2021 as there was some evidence that they might contribute to airway obstruction in babies <34 weeks and the evidence base for their use in term babies was lacking. However, they are still discussed in the NLS manual and remain an option for people with trained to use them. The time constraints of the NLS course mean that not all skills can be taught, and content needs to be prioritised. As Guedel airways are more likely to be used by more senior staff who are called to help, rather than by staff who attend initially, they are taught on the RCUK ARNI course. Local neonatal services may also train their staff in Guedel insertion if that is felt to be suitable for the staff within their service and the babies they look after.