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 and Blood Glucose Meters (2011):

http://www.mhra.gov.uk/home/groups/dts-pcc/documents/publication/con2015464.pdf

February 2013

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 in those who have a witnessed monitored arrest and are already connected to a manual defibrillator. Give amiodarone after the third shock. Give adrenaline during the third 2 min of CPR (after the fifth shock) if the patient remains in a shockable rhythm.

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 formula taught on Resuscitation Council UK and European Resuscitation Council courses for estimating the weight of a child has not changed.

(Age + 4) x  2 

This simple formula is taught because it is easy to remember and apply in an emergency setting. It is a useful first calculation, allowing treatment to be given quickly.

Complex calculations may provide greater absolute accuracy, but they increase the risks for error. Drug calculations can be altered subsequently depending on further information such as actual weight or length and the response to initial treatment.

It is important to appreciate that plasma levels of drugs will depend on numerous other factors such as age, lean body mass, method of administration, body temperature and the pathophysiology – so absolute, pinpoint accuracy is not essential.

For information, the APLS course calculates weight in a different way with separate charts for boys and girls.

July 2011

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 and Blood Glucose Meters (2011).

February 2013

Yes, 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  =  20 mL x 12 kg = 240 mL 0.9% saline
A   =  10 micrograms x 12 kg = 120 micrograms 1:10,000 = 1.2 mL
G   =  2mL 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 or error.

June 2016

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 extra uterine 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.

May 2015