Adult Advanced Life Support

19/10/2017 Adult advanced life support
Adult advanced life support
1. The guideline process

2. Summary of changes in advanced life support since 2010 Guidelines
3. Introduction
4. ALS treatment algorithm
5. Treat reversible causes
6. During CPR
7. CPR techniques and devices
8. Duration of resuscitation attempt
9. Acknowledgements
10. References
Authors
Jasmeet Soar, Charles Deakin, Andrew Lockey, Jerry Nolan, Gavin Perkins
1. The guideline process

The process used to produce the Resuscitation Council (UK) Guidelines 2015 has been accredited by the National Institute for Health and Care
Excellence. The guidelines process includes:
Systematic reviews with grading of the quality of evidence and strength of recommendations. This led to the 2015 International Liaison
Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations.1,2
The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors.
Details of the guidelines development process can be found in the Resuscitation Council (UK) Guidelines Development Process Manual.
www.resus.org.uk/publications/guidelines-development-process-manual/
These Resuscitation Council (UK) Guidelines have been peer reviewed by the Executive Committee of the Resuscitation Council (UK), which
comprises 25 individuals and includes lay representation and representation of the key stakeholder groups.
2. Summary of changes in advanced life support since 2010 Guidelines

The 2015 Advanced life support (ALS) guidelines have a change in emphasis aimed at improved care and implementation of these guidelines in
order to improve patient outcomes.3 The key changes since 2010 are:
Increased emphasis on minimally interrupted high quality chest compressions throughout any ALS intervention.
Chest compressions must only be paused brie y to enable speci c interventions. This includes minimising interruptions in chest
compressions to less than 5 seconds when attempting de brillation or tracheal intubation.
There is a new section on monitoring during ALS.
Waveform capnography must be used to con rm and continually monitor tracheal tube placement, and may be used to monitor the quality
of CPR and to provide an early indication of return of spontaneous circulation (ROSC).
There are a variety of approaches to airway management during CPR and a stepwise approach based on patient factors and the skills of the
rescuer is recommended.
The recommendations for drug therapy during CPR have not changed, but there is equipoise for the role of drugs in improving outcomes
from cardiac arrest.
The routine use of mechanical chest compression devices is not recommended, but they may be useful in situations where sustained high
quality manual chest compressions are impractical or compromise provider safety.
Peri-arrest ultrasound may be used to identify reversible causes of cardiac arrest.
Extracorporeal life support techniques may be used as a rescue therapy in selected patients where standard ALS measures are not
successful.
https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/ 1/14
The ALS algorithm (Figure 1) has been modi ed slightly to show these changes.

Figure 1. Adult advanced life support algorithm
A4-size algorithm: http://resus.org.uk/_resources/assets/attachment/full/0/6442.pdf
3. Introduction
This section on adult advanced life support (ALS) adheres to the same general principles as Guidelines 2010, but incorporates some important
changes. The guidelines in this section apply to healthcare professionals trained in ALS techniques. Laypeople, rst responders, and automated
external de brillator (AED) users are referred to the Adult basic life support and automated external de brillation section.
www.resus.org.uk/resuscitation-guidelines/adult-basic-life-support-and-automated-external-de brillation/
Adult ALS includes advanced interventions after basic life support has started and when appropriate an AED has been used. The transition
between basic and advanced life support should be seamless as BLS will continue during and overlap with ALS interventions. Post-resuscitation
care guidelines are presented in a new section that recognises the importance of the nal link in the Chain of Survival.4
www.resus.org.uk/resuscitation-guidelines/post-resuscitation-care/
These guidelines are based on the International Liaison Committee on Resuscitation (ILCOR) 2015 Consensus on Science and Treatment
Recommendations (CoSTR) for ALS2 and the European Resuscitation Council 2015 Advanced Life Support Guidelines.5 These contain all the
reference material for this section.
4. ALS treatment algorithm

Heart rhythms associated with cardiac arrest are divided into two groups: shockable rhythms (ventricular brillation/pulseless ventricular
tachycardia (VF/pVT)) and non-shockable rhythms (asystole and pulseless electrical activity (PEA)). The main difference in the treatment of these
two groups is the need for attempted de brillation in patients with VF/pVT.
Other actions, including chest compression, airway management and ventilation, vascular access, administration of adrenaline, and the
identi cation and correction of reversible factors, are common to both groups. The ALS algorithm provides a standardised approach to the
management of adult patients in cardiac arrest.
Drugs and advanced airways are still included among ALS interventions, but are of secondary importance to early de brillation and high quality,
uninterrupted chest compressions. At the time of writing these guidelines, three large randomised controlled trials (RCTs) (adrenaline versus
placebo [ISRCTN73485024], amiodarone versus lidocaine versus placebo6 [NCT01401647] and supraglottic airway (i-gel) versus tracheal
intubation [ISRCTN No: 08256118]) are currently ongoing.
Shockable rhythms (VF/pVT)

The rst monitored rhythm is VF/pVT in approximately 20% of both in-hospital7 and out-of-hospital cardiac arrests (OHCAs).8 Ventricular
brillation/pulseless ventricular tachycardia will also occur at some stage during resuscitation in about 25% of cardiac arrests with an initial
documented rhythm of asystole or PEA.9,10
Treatment of shockable rhythms (VF/VT)

1. Con rm cardiac arrest – check for signs of life and normal breathing, and if trained to do so check for breathing and a pulse
simultaneously.
2. Call resuscitation team.
3. Perform uninterrupted chest compressions while applying self-adhesive de brillation/monitoring pads – one below the right clavicle and
the other in the V6 position in the midaxillary line.
4. Plan actions before pausing CPR for rhythm analysis and communicate these to the team.
5. Stop chest compressions; con rm VF/pVT from the ECG. This pause in chest compressions should be brief and no longer than 5 seconds.
6. Resume chest compressions immediately; warn all rescuers other than the individual performing the chest compressions to “stand clear”
and remove any oxygen delivery device as appropriate.
7. The designated person selects the appropriate energy on the de brillator and presses the charge button. Choose an energy setting of at
least 150 J for the rst shock, the same or a higher energy for subsequent shocks, or follow the manufacturer’s guidance for the particular
de brillator. If unsure of the correct energy level for a de brillator choose the highest available energy.
8. Ensure that the rescuer giving the compressions is the only person touching the patient.
9. Once the de brillator is charged and the safety check is complete, tell the rescuer doing the chest compressions to “stand clear”; when
clear, give the shock.
10. After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest compressions. Do not pause to reassess the rhythm
or feel for a pulse. The total pause in chest compressions should be brief and no longer than 5 seconds.
11. Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR.
12. Pause brie y to check the monitor.
13. If VF/pVT, repeat steps 6–12 above and deliver a second shock.
14. If VF/pVT persists, repeat steps 6–8 above and deliver a third shock. Resume chest compressions immediately. Give adrenaline 1 mg IV
and amiodarone 300 mg IV while performing a further 2 min CPR. Withhold adrenaline if there are signs of return of spontaneous circulation
(ROSC) during CPR.
15. Repeat this 2 min CPR – rhythm/pulse check – de brillation sequence if VF/pVT persists.
16. Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5 min).
17. If organised electrical activity compatible with a cardiac output is seen during a rhythm check, seek evidence of ROSC (check for signs of
life, a central pulse and end-tidal CO2 if available).
a. If there is ROSC, start post-resuscitation care.
b. If there are no signs of ROSC, continue CPR and switch to the non-shockable algorithm.
18. If asystole is seen, continue CPR and switch to the nonshockable algorithm.
The interval between stopping compressions and delivering a shock must be minimised. Longer interruptions to chest compressions reduce the
chance of a shock restoring a spontaneous circulation. Chest compressions are resumed immediately after delivering a shock (without checking
the rhythm or a pulse) because even if the de brillation attempt is successful in restoring a perfusing rhythm, it is very rare for a pulse to be
palpable immediately after de brillation. The duration of asystole before ROSC can be longer than 2 min in as many as 25% of successful
shocks.11 If a shock has been successful immediate resumption of chest compressions does not increase the risk of VF recurrence.12
Furthermore, the delay in trying to palpate a pulse will further compromise the myocardium if a perfusing rhythm has not been restored.13
The use of waveform capnography can enable ROSC to be detected without pausing chest compressions and may be used as a way of avoiding a
bolus injection of adrenaline after ROSC has been achieved. Several human studies have shown that there is a signi cant increase in end-tidal CO2
when ROSC occurs.5,14 If ROSC is suspected during CPR withhold adrenaline. Give adrenaline if cardiac arrest is con rmed at the next rhythm
check.
Regardless of the arrest rhythm, after the initial adrenaline dose has been given, give further doses of adrenaline 1 mg every 3–5 min until ROSC is
achieved; in practice, this will be about once every two cycles of the algorithm. If signs of life return during CPR (e.g. purposeful movement,
normal breathing or coughing), or there is an increase in end-tidal CO2, check the monitor; if an organised rhythm is present, check for a pulse. If a
pulse is palpable, start post-resuscitation care. If no pulse is present, continue CPR.
Give amiodarone 300 mg IV after three de brillation attempts irrespective of whether they are consecutive shocks, or interrupted by CPR, or for
recurrent VF/pVT during cardiac arrest. Consider a further dose of amiodarone 150 mg IV after a total of ve de brillation attempts. Lidocaine 1
mg kg-1 may be used as an alternative if amiodarone is not available but do not give lidocaine if amiodarone has been given already.
Witnessed, monitored VF/pVT
If a patient has a monitored and witnessed cardiac arrest in the catheter laboratory, coronary care unit, a critical care area or whilst monitored
after cardiac surgery, and a manual de brillator is rapidly available:
Con rm cardiac arrest and shout for help.

If the initial rhythm is VF/pVT, give up to three quick successive (stacked) shocks.
Rapidly check for a rhythm change and, if appropriate, ROSC after each de brillation attempt.
Start chest compressions and continue CPR for 2 min if the third shock is unsuccessful.
This three-shock strategy may also be considered for an initial, witnessed VF/pVT cardiac arrest if the patient is already connected to a manual
de brillator – these circumstances are rare. Although there are no data supporting a three-shock strategy in any of these circumstances, it is
unlikely that chest compressions will improve the already very high chance of ROSC when de brillation occurs early in the electrical phase,
immediately after onset of VF/pVT.
If this initial three-shock strategy is unsuccessful for a monitored VF/pVT cardiac arrest, the ALS algorithm should be followed and these three-
shocks treated as if only the rst single shock has been given.
Precordial thump
A single precordial thump has a very low success rate for cardioversion of a shockable rhythm.15-19 Its routine use is therefore not recommended.
Consider a precordial thump only when it can be used without delay whilst awaiting the arrival of a de brillator in a monitored VF/pVT arrest.
Using the ulnar edge of a tightly clenched st, deliver a sharp impact to the lower half of the sternum from a height of about 20 cm, then retract
the st immediately to create an impulse-like stimulus.
Non-shockable rhythms (PEA and asystole)

Pulseless electrical activity (PEA) is de ned as cardiac arrest in the presence of electrical activity (other than ventricular tachyarrhythmia) that
would normally be associated with a palpable pulse.20 These patients often have some mechanical myocardial contractions, but these are too
weak to produce a detectable pulse or blood pressure – this is sometimes described as ‘pseudo-PEA’ (see below). PEA can be caused by
reversible conditions that can be treated if they are identi ed and corrected. Survival following cardiac arrest with asystole or PEA is unlikely
unless a reversible cause can be found and treated effectively.
Treatment of PEA and asystole

1. Start CPR 30:2
2. Give adrenaline 1 mg IV as soon as intravascular access is achieved
3. Continue CPR 30:2 until the airway is secured – then continue chest compressions without pausing during ventilation
4. Recheck the rhythm after 2 min:
a. If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life
i. If a pulse and/or signs of life are present, start post resuscitation care
ii. If no pulse and/or no signs of life are present (PEA OR asystole):
1. Continue CPR
2. Recheck the rhythm after 2 min and proceed accordingly
3. Give further adrenaline 1 mg IV every 3–5 min (during alternate 2-min loops of CPR)
b. If VF/pVT at rhythm check, change to shockable side of algorithm.
Whenever a diagnosis of asystole is made, check the ECG carefully for the presence of P waves because the patient may respond to cardiac
pacing when there is ventricular standstill with continuing P waves. There is no value in attempting to pace true asystole.
5. Treat reversible causes

Potential causes or aggravating factors for which speci c treatment exists must be considered during all cardiac arrests.21 For ease of memory,
these are divided into two groups of four, based upon their initial letter: either H or T:
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
Thrombosis (coronary or pulmonary)

Tension pneumothorax
Tamponade – cardiac
Toxins
The four ‘Hs’
Minimise the risk of hypoxia by ensuring that the patient’s lungs are ventilated adequately with the maximal possible inspired oxygen during CPR.
Make sure there is adequate chest rise and bilateral breath sounds. Using the techniques described below, check carefully that the tracheal tube is
not misplaced in a bronchus or the oesophagus.
Pulseless electrical activity caused by hypovolaemia is due usually to severe haemorrhage. This may be precipitated by trauma, gastrointestinal
bleeding or rupture of an aortic aneurysm. Stop the haemorrhage and restore intravascular volume with uid and blood products.
Hyperkalaemia, hypokalaemia, hypocalcaemia, acidaemia and other metabolic disorders are detected by biochemical tests or suggested by the
patient’s medical history (e.g. renal failure). Give IV calcium chloride in the presence of hyperkalaemia, hypocalcaemia and calcium channel-
blocker overdose.
Hypothermia should be suspected based on the history such as cardiac arrest associated with drowning.
The four ‘Ts’

Coronary thrombosis associated with an acute coronary syndrome or ischaemic heart disease is the most common cause of sudden cardiac
arrest. An acute coronary syndrome is usually diagnosed and treated after ROSC is achieved. If an acute coronary syndrome is suspected, and
ROSC has not been achieved, consider urgent coronary angiography when feasible and, if required, percutaneous coronary intervention.
Mechanical chest compression devices and extracorporeal CPR can help facilitate this (see below).
The commonest cause of thromboembolic or mechanical circulatory obstruction is massive pulmonary embolism. If pulmonary embolism is
thought to be the cause of cardiac arrest consider giving a brinolytic drug immediately. Following brinolysis during CPR for acute pulmonary
embolism, survival and good neurological outcome have been reported, even in cases requiring in excess of 60 min of CPR. If a brinolytic drug is
given in these circumstances, consider performing CPR for at least 60–90 min before termination of resuscitation attempts. In some settings
extracorporeal CPR, and/or surgical or mechanical thrombectomy can also be used to treat pulmonary embolism.
A tension pneumothorax can be the primary cause of PEA and may be associated with trauma. The diagnosis is made clinically or by ultrasound.
Decompress rapidly by thoracostomy or needle thoracocentesis, and then insert a chest drain.
Cardiac tamponade is di cult to diagnose because the typical signs of distended neck veins and hypotension are usually obscured by the arrest
itself. Cardiac arrest after penetrating chest trauma is highly suggestive of tamponade and is an indication for resuscitative thoracotomy. The use
of ultrasound will make the diagnosis of cardiac tamponade much more reliable.
In the absence of a speci c history, the accidental or deliberate ingestion of therapeutic or toxic substances may be revealed only by laboratory
investigations. Where available, the appropriate antidotes should be used, but most often treatment is supportive and standard ALS protocols
should be followed.
Use of ultrasound imaging during advanced life support

When available for use by trained clinicians, focused echocardiography/ultrasound may be of use in assisting with diagnosis and treatment of
potentially reversible causes of cardiac arrest. The integration of ultrasound into advanced life support requires considerable training if
interruptions to chest compressions are to be minimised. A sub-xiphoid probe position has been recommended.22-24 Placement of the probe just
before chest compressions are paused for a planned rhythm assessment enables a well-trained operator to obtain views within 10 seconds.
Several studies have examined the use of ultrasound during cardiac arrest to detect potentially reversible causes.25-27 Although no studies have
shown that use of this imaging modality improves outcome, there is no doubt that echocardiography has the potential to detect reversible causes
of cardiac arrest. Speci c protocols for ultrasound evaluation during CPR may help to identify potentially reversible causes (e.g. cardiac
tamponade, pulmonary embolism, hypovolaemia, pneumothorax). Absence of cardiac motion on sonography during resuscitation of patients in
cardiac arrest is highly predictive of death although sensitivity and speci city has not been reported.28-31
6. During CPR
High quality chest compressions with minimal interruption

During the treatment of persistent VF/pVT or PEA/asystole, there should be an emphasis on giving high quality chest compression between
de brillation attempts or rhythm checks, whilst recognising and treating reversible causes (4 Hs and 4 Ts), and whilst obtaining a secure airway
and intravascular access. Aim for a chest compression pause of less than 5 seconds for rhythm checks, de brillation attempts, and tracheal
intubation. To achieve this rescuers must plan their actions before pausing compressions.
Monitoring during advanced life support

The following methods can be used to monitor the patient during CPR and help guide ALS interventions:
Clinical signs such as breathing efforts, movements and eye opening can occur during CPR. These can indicate ROSC and require
veri cation by a rhythm and pulse check, but can also occur because CPR can generate a su cient circulation to restore signs of life
including consciousness.32
Pulse checks when there is an ECG rhythm compatible with an output can be used to identify ROSC, but may not detect pulses in those with
low cardiac output states and a low blood pressure.33 The value of attempting to feel arterial pulses during chest compressions to assess
the effectiveness of chest compressions is unclear. A pulse that is felt in the femoral triangle may indicate venous rather than arterial blood
ow. There are no valves in the inferior vena cava and retrograde blood ow into the venous system can produce femoral vein pulsations.34
Carotid pulsation during CPR does not necessarily indicate adequate myocardial or cerebral perfusion.
Monitoring heart rhythm through pads, paddles or ECG electrodes is a standard part of ALS. Motion artefacts prevent reliable heart rhythm
assessment during chest compressions forcing rescuers to stop chest compressions to assess the rhythm, and preventing early
recognition of recurrent VF/pVT. We suggest that artefact- ltering algorithms are not used for analysis of ECG rhythm during CPR unless as
part of a research programme.35
End-tidal CO2 with waveform capnography. The use of waveform capnography during CPR has a greater emphasis in Guidelines 2015 and is
addressed in more detail below.
The use of CPR feedback or prompt devices during CPR should be considered only as part of a broader system of care that should include
comprehensive CPR quality improvement initiatives 36-38 rather than an isolated intervention.
Blood sampling and analysis during CPR can be used to identify potentially reversible causes of cardiac arrest. Avoid nger prick samples in
critical illness because they may not be reliable; instead, use samples from veins or arteries.
Blood gas values are di cult to interpret during CPR. During cardiac arrest, arterial gas values may be misleading and bear little relationship
to the tissue acid-base state.39 Analysis of central venous blood may provide a better estimation of tissue pH.
Invasive cardiovascular monitoring in critical care settings (e.g. continuous arterial blood pressure and central venous pressure monitoring).
Invasive arterial pressure monitoring will enable the detection of low blood pressure values when ROSC is achieved.
Ultrasound assessment is addressed above to identify and treat reversible causes of cardiac arrest, and identify low cardiac output states
(‘pseudo-PEA’).
Waveform capnography during advanced life support

Use waveform capnography whenever tracheal intubation is undertaken. Although the prevention of unrecognised oesophageal intubation is
clearly bene cial, there is currently no evidence that use of waveform capnography during CPR results in improved patient outcomes. The role of
waveform capnography during CPR includes:
Ensuring tracheal tube placement in the trachea (although it will not distinguish between bronchial and tracheal placement).
Monitoring ventilation rate during CPR and avoiding hyperventilation.
Monitoring the quality of chest compressions during CPR. End-tidal CO2 values are associated with compression depth and ventilation rate
and a greater depth of chest compression will increase the value.40 Whether this can be used to guide care and improve outcome requires
further study.41
Identifying ROSC during CPR. An increase in end-tidal CO2 during CPR can indicate ROSC and prevent unnecessary and potentially harmful
dosing of adrenaline in a patient with ROSC.14,41-43 If ROSC is suspected during CPR withhold adrenaline. Give adrenaline if cardiac arrest is
con rmed at the next rhythm check.
Prognostication during CPR. Precise values of end-tidal CO2 depend on several factors including the cause of cardiac arrest, bystander CPR,
chest compression quality, ventilation rate and volume, time from cardiac arrest and the use of adrenaline. Values are higher after an initial
asphyxial arrest, with bystander CPR, and decline over time after cardiac arrest.41,44,45 Low end-tidal CO2 values during CPR have been
associated with lower ROSC rates and increased mortality, and high values with better ROSC and survival.41,46,47 The inter-individual
differences and in uence of cause of cardiac arrest, the problem with self-ful lling prophecy in studies, our lack of con dence in the
accuracy of measurement during CPR, and the need for an advanced airway to measure end-tidal CO2 reliably limits our con dence in its
use for prognostication. The Resuscitation Council (UK) recommends that a speci c end-tidal CO2 value at any time during CPR should not
be used alone to stop CPR efforts. End-tidal CO2 values should be considered only as part of a multi-modal approach to decision-making for
prognostication during CPR.
De brillation
This section predominantly addresses the use of manual de brillators. Guidelines concerning the use of an automated external de brillator (AED)
are addressed in the Adult basic life support and automated external de brillation section. www.resus.org.uk/resuscitation-guidelines/adult-
basic-life-support-and-automated-external-de brillation The de brillation strategy for the 2015 Resuscitation Guidelines has changed little from
the former guidelines:
The importance of early, uninterrupted chest compressions remains emphasised throughout these guidelines, together with minimising the
duration of pre-shock and post-shock pauses – even 5–10 seconds delay will reduce the chances of the shock being successful.48-53
Continue chest compressions during de brillator charging, deliver de brillation with an interruption in chest compressions of no more than
5 seconds and immediately resume chest compressions following de brillation.
Place the right (sternal) electrode to the right of the sternum, below the clavicle. Place the apical paddle in the mid-axillary line,
approximately over the V6 ECG electrode position. This electrode should be clear of any breast tissue. It is important that this electrode is
placed su ciently laterally.
De brillation shock energy levels are unchanged from the 2010 Guidelines.
Deliver the rst shock with an energy of at least 150 J.
The shock energy for a particular de brillator should be based on the manufacturer’s guidance.
Those using manual de brillators should be aware of the appropriate energy settings for the type of device used, but in the absence
of this and if appropriate energy levels are unknown, for adults use the highest available shock energy for all shocks.
If an initial shock has been unsuccessful it is worth attempting the second and subsequent shocks with a higher energy level if the
de brillator is capable of delivering a higher energy but, based on current evidence, both xed and escalating strategies are
acceptable.
If VF/pVT recurs during a cardiac arrest (re brillation) give subsequent shocks with a higher energy level if the de brillator is capable
of delivering a higher energy.
There are no high quality clinical studies to indicate the optimal strategies within any given waveform and between different waveforms.2
Knowledge gaps include the minimal acceptable rst-shock energy level; the characteristics of the optimal biphasic waveform; the optimal
energy levels for speci c waveforms; and the best shock strategy ( xed versus escalating). It is becoming increasingly clear that selected
energy is a poor comparator with which to assess different waveforms as impedance-compensation and subtleties in waveform shape
result in signi cantly different transmyocardial current between devices for any given selected energy. The optimal energy levels may
ultimately vary between different manufacturers and associated waveforms. Manufacturers are encouraged to undertake high quality
clinical trials to support their de brillation strategy recommendations.
No one must touch the patient during shock delivery. Standard clinical examination gloves (or bare hands) do not provide a safe level of
electrical insulation.54
Use oxygen safely during de brillation by:
Removing any oxygen mask or nasal cannulae and place them at least 1 m away from the patient’s chest during de brillation.
Leaving the ventilation bag connected to the tracheal tube or other airway adjunct. Alternatively, disconnect the ventilation bag from
the tracheal tube and move it at least 1 m from the patient’s chest during de brillation.
Airway management and ventilation

The options for airway management and ventilation during CPR vary according to patient factors, the phase of the resuscitation attempt (during
CPR, after ROSC), and the skills of rescuers.55 They include: no airway and no ventilation (compression-only CPR), compression-only CPR with the
airway held open (with or without supplementary oxygen), mouth-to-mouth breaths, mouth-to-mask, bag-mask ventilation with simple airway
adjuncts, supraglottic airways (SGAs), and tracheal intubation (inserted with the aid of direct laryngoscopy or videolaryngoscopy, or via a
SGA).2,5,56,57
In comparison with bag-mask ventilation and use of a SGA, tracheal intubation requires considerably more training and practice and can result in
unrecognised oesophageal intubation and increased hands-off time. A bag-mask, a SGA and a tracheal tube are frequently used in the same
patient as part of a stepwise approach to airway management but this has not been formally assessed.56 Patients who remain comatose after
initial resuscitation from cardiac arrest will ultimately require tracheal intubation regardless of the airway technique used during cardiac arrest.
Anyone attempting tracheal intubation must be well trained and equipped with waveform capnography. Personnel skilled in advanced airway
management should attempt laryngoscopy and intubation without stopping chest compressions; a brief pause in chest compressions may be
required as the tube is passed through the vocal cords, but this pause should be less than 5 seconds. In the absence of these, use bag-mask
ventilation and/or an SGA until appropriately experience and equipped personnel are present.
There is no high quality evidence supporting one particular intervention over another. 2,57 Depending on the circumstances and the skills of the
rescuers, use either an advanced airway (tracheal intubation or supraglottic airway (SGA)) or a bag-mask for airway management during CPR.2,5
Basic airway manoeuvres and airway adjuncts

Assess the airway. Use head tilt and chin lift, or jaw thrust to open the airway. Simple airway adjuncts (oropharyngeal or nasopharyngeal airways)
are often helpful, and sometimes essential, to maintain an open airway. When there is a risk of cervical spine injury, establish a clear upper airway
by using jaw thrust or chin lift in combination with manual in-line stabilisation of the head and neck by an assistant.58,59 If life-threatening airway
obstruction persists despite effective application of jaw thrust or chin lift, add head tilt in small increments until the airway is open; establishing a
patent airway takes priority over concerns about a potential cervical spine injury.
Oxygen during CPR

During CPR, give the maximal feasible inspired oxygen concentration. There are no data to indicate the optimal arterial blood oxygen saturation
(SaO2) during CPR, and no trials comparing different inspired oxygen concentrations. In one observational study of patients receiving 100%
inspired oxygen via a tracheal tube during CPR, a higher measured partial pressure of arterial oxygen (PaO2) value during CPR was associated
with ROSC and hospital admission.60 The worse outcomes associated with a low PaO2 during CPR could, however, be an indication of illness
severity.
After ROSC, as soon as arterial blood oxygen saturation can be monitored reliably (by blood gas analysis and/or pulse oximetry), titrate the
inspired oxygen concentration to maintain the arterial blood oxygen saturation in the range of 94–98%.2 Avoid hypoxaemia, which is also harmful
– ensure reliable measurement of arterial oxygen saturation before reducing the inspired oxygen concentration.61 This is addressed in the Post-
resuscitation care section.
www.resus.org.uk/resuscitation-guidelines/post-resuscitation-care/
Ventilation
Provide arti cial ventilation as soon as possible in any patient in whom spontaneous ventilation is inadequate or absent. Expired air ventilation
(rescue breathing) is effective but the rescuer’s expired oxygen concentration is only 16–17%, so it must be replaced as soon as possible by
ventilation with oxygen-enriched air. A pocket resuscitation mask enables mouth-to-mask ventilation and some enable supplemental oxygen to be
given. Use a two-hand technique to maximise the seal with the patient’s face. A self-in ating bag can be connected to a face mask, tracheal tube,
or SGA. The two-person technique for bag-mask ventilation is preferable. Deliver each breath over approximately 1 second and give a volume that
corresponds to normal chest movement; this represents a compromise between giving an adequate volume, minimising the risk of gastric
in ation, and allowing adequate time for chest compression. During CPR with an unprotected airway, give two ventilations after each sequence of
30 chest compressions. Once a tracheal tube or SGA has been inserted, ventilate the lungs at a rate of about 10 breaths min-1 and continue chest
compression without pausing during ventilation.2,5
Alternative airway devices

The tracheal tube has generally been considered the optimal method of managing the airway during cardiac arrest.62 There is evidence that,
without adequate training and experience, the incidence of complications, such as unrecognised oesophageal intubation (2.4–17% in several
studies involving paramedics)63-67 and dislodgement, is unacceptably high.68 Prolonged attempts at tracheal intubation are harmful; the
cessation of chest compressions during this time will compromise coronary and cerebral perfusion. Several alternative airway devices have been
used for airway management during CPR.
There are published studies on the use during CPR of the Combitube, the classic laryngeal mask airway (cLMA), the Laryngeal Tube (LT) and the i-
gel, and the LMA Supreme (LMAS) but none of these studies has been powered adequately to enable survival to be studied as a primary endpoint.
Instead, most researchers have studied insertion and ventilation success rates. The SGAs are easier to insert than a tracheal tube and,69 unlike
tracheal intubation, can generally be inserted without interrupting chest compressions.70
Laryngeal mask airway (LMA)
An LMA is relatively easy to insert, and ventilation using an LMA is more e cient and easier than with a bag-mask. If gas leakage is excessive,
chest compression will have to be interrupted to enable ventilation. Although an LMA does not protect the airway as reliably as a tracheal tube,
pulmonary aspiration is uncommon when using an LMA during cardiac arrest. The original LMA (classic LMA [cLMA]) has been superseded by
several second generation SGAs that have more favourable characteristics, particularly when used for emergency airway management.71
I-gel
The cuff of the i-gel does not require in ation; the stem of the i-gel incorporates a bite block and a narrow oesophageal drain tube. It is very easy
to insert, requiring only minimal training and a laryngeal seal pressure of 20–24 cmH2O can be achieved.72,73 The ease of insertion of the i-gel
and its favourable leak pressure make it theoretically very attractive as a resuscitation airway device for those inexperienced in tracheal
intubation. In observational studies insertion success rates for the i-gel were 93% (n = 98) when used by paramedics for out-of-hospital cardiac
arrest (OHCA)74 and 99% (n=100) when used by doctors and nurses for in-hospital cardiac arrest (IHCA).75 The i-gel is in widespread use in the
UK for both IHCA and OHCA.
LMA Supreme (LMAS)

The LMAS is a disposable version of the Proseal LMA, which is used in anaesthetic practice. In an observational study, paramedics inserted the
LMAS successfully and were able to ventilate the lungs of 33 (100%) cases of OHCA.76
Tracheal intubation
Tracheal intubation should be attempted only by trained personnel able to carry out the procedure with a high level of skill and con dence. No
intubation attempt should interrupt chest compressions for more than 5 seconds. Use an alternative airway technique if tracheal intubation is not
possible.
Healthcare personnel who undertake prehospital intubation should do so only within a structured, monitored programme, which should include
comprehensive competency-based training and regular opportunities to refresh skills. Rescuers must weigh the risks and bene ts of intubation
against the need to provide effective chest compressions. The intubation attempt may require some interruption of chest compressions but, once
an advanced airway is in place, ventilation will not require interruption of chest compressions. Personnel skilled in advanced airway management
should be able to undertake laryngoscopy without stopping chest compressions; a brief pause in chest compressions will be required only as the
tube is passed through the vocal cords. Alternatively, to avoid any interruptions in chest compressions, the intubation attempt may be deferred
until ROSC;77,78 this strategy is being studied in a large prehospital randomised trial.79 The intubation attempt should interrupt chest
compressions for less than 5 seconds; if intubation is not achievable within these constraints, recommence bag-mask ventilation. After
intubation, tube placement must be con rmed and the tube secured adequately.
Videolaryngoscopy
Videolaryngoscopes are being used increasingly in anaesthetic and critical care practice.80,81 In comparison with direct laryngoscopy, they enable
a better view of the larynx and improve the success rate of intubation. Preliminary studies indicate that use of videolaryngoscopes improve
laryngeal view and intubation success rates during CPR 82-84 but further data are required before recommendations can be made for wider use
during CPR.
Con rmation of correct placement of the tracheal tube

The Resuscitation Council (UK) recommends using waveform capnography to con rm and continuously monitor the position of a tracheal tube
during CPR in addition to clinical assessment. End-tidal CO2 detectors that include a waveform graphical display (capnographs) are the most
reliable for veri cation of tracheal tube position during cardiac arrest.2,5
Clinical assessment includes observation of chest expansion bilaterally, auscultation over the lung elds bilaterally in the axillae (breath sounds
should be equal and adequate) and over the epigastrium (breath sounds should not be heard). Clinical signs of correct tube placement alone
(condensation in the tube, chest rise, breath sounds on auscultation of lungs, and inability to hear gas entering the stomach) are not reliable. The
reported sensitivity (proportion of tracheal intubations correctly identi ed) and speci city (proportion of oesophageal intubations correctly
identi ed) of clinical assessment varies: sensitivity 7–100%; speci city 66–100%.85-89
Based on the available data, the accuracy of colormetric CO2 detectors, oesophageal detector devices and non-waveform capnometers does not
exceed the accuracy of auscultation and direct visualisation for con rming the tracheal position of a tube in victims of cardiac arrest. Waveform
capnography is the most sensitive and speci c way to con rm and continuously monitor the position of a tracheal tube in victims of cardiac
arrest and must supplement clinical assessment (auscultation and visualisation of tube through cords). Waveform capnography will not
discriminate between tracheal and bronchial placement of the tube – careful auscultation is essential. Existing portable monitors make
capnographic initial con rmation and continuous monitoring of tracheal tube position feasible in almost all settings, including out-of-hospital,
emergency department and in-hospital locations where intubation is performed.
Cricothyroidotomy
If it is impossible to ventilate an apnoeic patient with a bag-mask, or to pass a tracheal tube or alternative airway device, delivery of oxygen
through a cannula or surgical cricothyroidotomy may be life saving. A tracheostomy is contraindicated in an emergency, as it is time consuming,
hazardous and requires considerable surgical skill and equipment.
Surgical cricothyroidotomy provides a de nitive airway that can be used to ventilate the patient’s lungs until semi-elective intubation or
tracheostomy is performed. Needle cricothyroidotomy is a much more temporary procedure providing only short-term oxygenation. It requires a
wide-bore, non-kinking cannula, a high-pressure oxygen source, runs the risk of barotrauma and can be particularly ineffective in patients with
chest trauma. It is also prone to failure because of kinking of the cannula, and is unsuitable for patient transfer. In the 4th National Audit Project of
the UK Royal College of Anaesthetists and the Di cult Airway Society (NAP4), 60% of needle cricothyroidotomies attempted failed.90 In contrast,
all surgical cricothyroidotomies achieved access to the trachea. While there may be several underlying causes, these results indicate a need for
more training in surgical cricothyroidotomy and this should include regular manikin-based training using locally available equipment.91
Drugs for cardiac arrest

The ILCOR systematic reviews found insu cient evidence to comment on critical outcomes such as survival to discharge and survival to
discharge with good neurological outcome with any drug during CPR.2 There was also insu cient evidence to comment on the best time to give
drugs to optimise outcome.
Thus,although drugs are still included among ALS interventions, they are ofsecondary importance to high quality uninterrupted chest
compressions and early de brillation.
Adrenaline
Despite the continued widespread use of adrenaline during resuscitation, there is no placebo-controlled study that shows that the routine use of
adrenaline during human cardiac arrest increases survival to hospital discharge, although improved short-term survival has been documented.92-
94
The current recommendation is to continue the use of adrenaline during CPR as for Guidelines 2010. We have considered the bene t in short-term
outcomes (ROSC and admission to hospital) and our uncertainty about the bene t or harm on survival to discharge and neurological outcome
given the limitations of the observational studies.2,95,96
The Resuscitation Council (UK) has decided not to recommend a change to current practice until there are high quality data on long-term
outcomes. Dose response and placebo-controlled e cacy trials are needed to evaluate the use of adrenaline in cardiac arrest. There is an
ongoing randomised study of adrenaline vs. placebo for OHCA in the UK (PARAMEDIC 2: The Adrenaline Trial, ISRCTN73485024).
Amiodarone
No anti-arrhythmic drug given during human cardiac arrest has been shown to increase survival to hospital discharge, although amiodarone has
been shown to increase survival to hospital admission.97,98 Despite the lack of human long-term outcome data, the balance of evidence is in
favour of the use anti-arrhythmic drugs for the management of arrhythmias in cardiac arrest. There is an ongoing trial comparing amiodarone to
lidocaine and to placebo designed and powered to evaluate for functional survival.6
Vascular access during CPR

The role of drugs during cardiac arrest is uncertain. Some patients will already have intravenous access before they have a cardiac arrest. If this is
not the case ensure CPR had started and de brillation, if appropriate, attempted before considering vascular access.
Peripheral versus central venous drug delivery

Although peak drug concentrations are higher and circulation times are shorter when drugs are injected into a central venous catheter compared
with a peripheral cannula,99 insertion of a central venous catheter requires interruption of CPR and can be technically challenging and associated
with complications. Peripheral venous cannulation is quicker, easier to perform and safer. Drugs injected peripherally must be followed by a ush
of at least 20 mL of uid and elevation of the extremity for 10–20 seconds to facilitate drug delivery to the central circulation.
Intraosseous route
If intravenous access is di cult or impossible, consider the intraosseous (IO) route. This is now established as an effective route in adults.100-108
Intraosseous injection of drugs achieves adequate plasma concentrations in a time comparable with injection through a vein.109,110 Animal
studies suggest that adrenaline reaches a higher concentration and more quickly when it is given intravenously as compared with the
intraosseous route, and that the sternal intraosseous route more closely approaches the pharmacokinetics of IV adrenaline.111 The recent
availability of mechanical IO devices has increased the ease of performing this technique.112 There are several intraosseous devices available as
well as a choice of insertion sites including the humerus, proximal or distal tibia, and sternum. The decision concerning choice of device and
insertion site should be made locally and staff adequately trained in its use.
7. CPR techniques and devices

Mechanical chest compression devices
We recommend that automated mechanical chest compression devices are not used routinely to replace manual chest compressions.
Automated mechanical chest compression devices are a reasonable alternative to high quality manual chest compressions in situations where
sustained high quality manual chest compressions are impractical or compromise provider safety.2
Interruptions to CPR during device deployment should be avoided. Healthcare personnel who use mechanical CPR should do so only within a
structured, monitored programme, which should include comprehensive competency-based training and regular opportunities to refresh skills.
Since Guidelines 2010 there have been three large RCTs enrolling 7582 patients that have shown no clear advantage for the routine use of
automated mechanical chest compression for OHCA using the Lund University Cardiac Arrest System (LUCAS)113,114 and AutoPulse devices.115
Ensuring high quality chest compressions with adequate depth, rate and minimal interruptions, regardless of whether they are delivered by
machine or human is important.116,117 Mechanical compressions usually follow a period of manual compressions;118 the transition from manual
compressions to mechanical compressions whilst minimising interruptions to chest compression and avoiding delays in de brillation is therefore
an important aspect of using these devices. The use of training drills and ‘pit-crew’ techniques for device deployment are suggested to help
minimise interruptions in chest compression.119-121
Extracorporeal cardiopulmonary resuscitation (ECPR)

Extracorporeal CPR (ECPR) should be considered as a rescue therapy for those patients in whom initial ALS measures are unsuccessful and, or to
facilitate speci c interventions (e.g. coronary angiography and percutaneous coronary intervention (PCI) or pulmonary thrombectomy for massive
pulmonary embolism).122,123 There is an urgent need for randomised studies of ECPR and large ECPR registries to identify the circumstances in
which it works best, establish guidelines for its use and identify the bene ts, costs and risks of ECPR.124,125
Extracorporeal techniques require vascular access and a circuit with a pump and oxygenator and can provide a circulation of oxygenated blood to
restore tissue perfusion. This has the potential to buy time for restoration of an adequate spontaneous circulation, and treatment of reversible
underlying conditions. This is commonly called extracorporeal life support (ECLS), and more speci cally extracorporeal CPR (ECPR) when used
during cardiac arrest. These techniques are becoming more commonplace and have been used for both in-hospital and out-of-hospital cardiac
arrest despite limited observational data in select patient groups. Observational studies suggest ECPR for cardiac arrest is associated with
improved survival when there is a reversible cause for cardiac arrest (e.g. myocardial infarction, pulmonary embolism, severe hypothermia,
poisoning), there is little comorbidity, the cardiac arrest is witnessed, the individual receives immediate high quality CPR, and ECPR is
implemented early (e.g. within 1 hour of collapse) including when instituted by emergency physicians and intensivists.126-132
The implementation of ECPR requires considerable resource and training. When compared with manual or mechanical CPR, ECPR has been
associated with improved survival after IHCA in selected patients.126,128 After OHCA outcomes with both standard and ECPR are less
favourable.133 The duration of standard CPR before ECPR is established and patient selection are important factors for
success.122,126,130,132,134-136
8. Duration of resuscitation attempt

If attempts at obtaining ROSC are unsuccessful the resuscitation team leader should discuss stopping CPR with the team. The decision to stop
CPR requires clinical judgement and a careful assessment of the likelihood of achieving ROSC. If it was considered appropriate to start
resuscitation, it is usually considered worthwhile continuing, as long as the patient remains in VF/pVT, or there is a potentially reversible cause
than can be treated. The use of mechanical compression devices and extracorporeal CPR techniques make prolonged attempts at resuscitation
feasible in selected patients. It is generally accepted that asystole for more than 20 minutes in the absence of a reversible cause and with ongoing
ALS constitutes a reasonable ground for stopping further resuscitation attempts.137
9. Acknowledgements
These guidelines have been adapted from the European Resuscitation Council 2015 Guidelines. We acknowledge and thank the authors of the
ERC Guidelines for Adult advanced life support:
Jasmeet Soar, Jerry P. Nolan, Bernd W. Böttiger, Gavin D. Perkins, Carsten Lott, Pierre Carli, Tommaso Pellis, Claudio Sandroni, Markus B. Skrifvars,
Gary B. Smith, Kjetil Sunde, Charles D. Deakin.
NICE has accredited the process used by Resuscitation Council (UK) to produce its Guidelines development Process Manual.
Accreditation is valid for 5 years from March 2015. More information on accreditation can be viewed at www.nice.org.uk/accreditation
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Adult Advanced Life Support

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19/10/2017 Adult advanced life support

Adult advanced life support

1. The guideline process

1. The guideline process

2. Summary of changes in advanced life support since 2010 Guidelines

Figure 1. Adult advanced life support algorithm

A4-size algorithm: http://resus.org.uk/_resources/assets/attachment/full/0/6442.pdf

4. ALS treatment algorithm

Shockable rhythms (VF/pVT)

Treatment of shockable rhythms (VF/VT)

Con rm cardiac arrest and shout for help.

Non-shockable rhythms (PEA and asystole)

Treatment of PEA and asystole

b. If VF/pVT at rhythm check, change to shockable side of algorithm.

5. Treat reversible causes

Thrombosis (coronary or pulmonary)

The four ‘Hs’

The four ‘Ts’

Use of ultrasound imaging during advanced life support

High quality chest compressions with minimal interruption

Monitoring during advanced life support

Waveform capnography during advanced life support

Airway management and ventilation

Basic airway manoeuvres and airway adjuncts

Oxygen during CPR

Alternative airway devices

Laryngeal mask airway (LMA)

LMA Supreme (LMAS)

Con rmation of correct placement of the tracheal tube

Drugs for cardiac arrest

Vascular access during CPR

Peripheral versus central venous drug delivery

7. CPR techniques and devices

Extracorporeal cardiopulmonary resuscitation (ECPR)

8. Duration of resuscitation attempt

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