2019 ALS 1 Manual V4 Final

Adult Advanced Life
Support Level 1
Manual
(Immediate Life Support)
CSK12364
© South Western Sydney Local Health District, Centre for Education and Workforce Development
This work is copyright. It may be reproduced in whole or in part for study training purposes subject to
the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage
or sale. Reproduction for purposes other than those indicated above requires written permission from
the NSW Ministry of Health.
Published July 2019
South Western Sydney Local Health District (SWSLHD)
Centre for Education and Workforce Development (CEWD)

Ngara Education Centre
Liverpool Hospital, Eastern Campus
Elizabeth Street, Liverpool NSW 2170
Postal address: Locked Bag 7279
Liverpool BC NSW 1871
Email: SWSLHD-CEWD@health.nsw.gov.au
Intranet: http://intranet.sswahs.nsw.gov.au/CEWD_swslhd/
Internet: http://swslhd.nsw.gov.au/cewd/
Phone: (02) 8738 5920
Fax: (02) 8738 6858
Acknowledgements:
Australian Resuscitation Council Guidelines www.resus.org.au

V. Palmer & M. Boyd, Organ & Tissue Donation CNC SWSLHD
Developers:
J. Chalmers, Nurse Educator, SWSCEWD

A. Hooton, Nurse Educator, SWSCEWD
Reviewed by:
J. Ekholm, Clinical Manager, Cardiovascular and Medical Imaging, SWSLHD
S.Goodall, CNE, ICU/HDU Campbelltown Hospital
A.Herring, RN, Skills and Simulation Coordinator, Ingham Clinical Skills and Simulation Centre
E.Longhurst, CNE, HDU Bowral Hospital
K.Owen, CNE, CCU Campbelltown Hospital
D.Sanchez, CNC, ICU Campbelltown Hospital
Dr B Taylor, Conjoint Senior Lecturer UNSW, Simulation Educator, Ingham Clinical Skills and Simulation Centre, Emergency
Staff Specialist, Liverpool Hospital
K.Westwood, Nurse Educator, SWSLHD CEWD / HETI
L.Wright, A/CNC MET, Campbelltown Hospital
Version Control Table

Date Modified Version Number Reason for modification Requested by Approved by
August 2014 1.0 Document development A.Hooton, R. Leon
J.Chalmers
13.1.2015 2.0 Policy, brand and course A.Hooton, F. Lendon
code changes J.Chalmers
17.6.2015 2.1 Change to pre-requisite A.Hooton, F. Lendon
J.Chalmers
08.7.2016 3.0 Changes to the ANZCOR A.Hooton, F. Lendon
guidelines J.Chalmers
31.07.19 4.0 Course not scheduled for A.Hooton, F. Lendon
the past 18 months. J.Chalmers
Update references
Update MHL requirements
Adult ALS Manual Level 1 V4 / SWSCEWD 2 of 53

TABLE OF CONTENTS
TABLE OF CONTENTS .................................................................................................................................. 3
Introduction...................................................................................................................................................... 4
Chapter 1: Recognising the deteriorating patient ........................................................................................... 6
Chapter 2: Algorithms ..................................................................................................................................... 7
Chapter 3: Airway Management and Ventilation .......................................................................................... 14
Chapter 4: Shockable and non-shockable rhythms ...................................................................................... 22
Chapter 5: Defibrillation................................................................................................................................. 27
Chapter 6: Pharmacology ............................................................................................................................. 32
Chapter 7: Post Resuscitation ...................................................................................................................... 34
Chapter 8: Legal and ethical considerations ................................................................................................. 38
Chapter 9: Communication and Teamwork .................................................................................................. 40
Chapter 10: Questions for completion prior to workshop attendance ........................................................... 41
Reference / Bibliography ............................................................................................................................... 46
Appendix 1 .................................................................................................................................................... 50
Appendix 2 .................................................................................................................................................. 51

Introduction
This manual forms part of the requirements for the Adult Advanced Life Support (ALS) Level 1 course
in SWSLHD. ALS Level 1 is also known as Immediate Life Support.
“Basic Life Support (BLS) is the preservation of life by the initial establishment of, and/or
maintenance of, airway, breathing, circulation and related emergency care, including use of
an AED...Advanced Life Support (ALS) is the provision of effective airway management,
ventilation of the lungs and production of a circulation by means of techniques additional to
those of Basic Life Support. These techniques may include, but not be limited to, manual
defibrillation, advanced airway management, vascular access/ drug therapy and defibrillation”
(ARC Glossary 2014).
The SWSCEWD, Adult ALS Level 1 course consists of:

 Completion of
o Advanced Life Support Theory- Module A(Adult) (MHL)- course code: 67644403)
o Advanced Life Support Theory- Module B (Adult) (MHL – course code: 67644650)
o Advanced Life Support Theory – Module C Quiz (MHL- course code 197482978).
 Reading this manual (SWSLHD Adult ALS Manual) and completing the questions at the end
of the manual
 When the five activities above are completed, attendance at a SWSLHD Face-to-Face one
day Adult ALS workshop CSK12364
 Practical assessment CSK12365 by an accredited Adult ALS assessor (either at the one day
workshop, or at a later date in your facility).
The aim of this course is to enhance the knowledge and skills in ALS techniques for those responding
to cardiac arrests within critical care areas. It is suitable for Registered Nurses (RN’s) who work in
critical care areas and medical staff.
Pre-requisites for attendance at the Adult ALS workshop CSK12364
 Completion of Advanced Life Support Theory- Module A (Adult) (MHL - course code:
67644403), and Advanced Life Support Theory- Module B (Adult) (MHL - course code:
67644650) and Advanced Life Support Theory – Module C Quiz (MHL - course code
197482978) within the last 6 months.
 Basic Life Support Accreditation within the last 12 months
 For RN’s; currently working in a critical care area
 Working knowledge of the defibrillator and arrest/resuscitation trolley in their workplace
 Reading this manual (SWSLHD Adult ALS Manual) and completing the questions at the end
of the manual
 It is also expected that participants have completed Between the Flags - Tier 2 DETECT OR
Between the Flags - Tier 2 DETECT workshop (Mixed – Face-to-Face) –
Nursing and Medical – Half day.
In order to simplify treatment regimes, the Australian and New Zealand Committee on Resuscitation
(ANZCOR) has produced standardised treatment guidelines based on the recommendations of the
International Liaison Committee on Resuscitation (ILCOR). These can be found on the ANZCOR
website, at www.resus.org.au. This course is based on these guidelines.
At the end of this course the participant are able to:

 Discuss and demonstrate airway management with Bag-Valve Resuscitator (BV)
 Identify shockable and non-shockable rhythms and demonstrate appropriate management
 Demonstrate knowledge of first-line pharmacological treatment in a cardiac arrest.

Participants are encouraged to seek opportunities to practice their ALS skills and reinforce the
knowledge and skills they have learnt through the ALS course process. This should be taking place
before and after the workshop date.
You will need to maintain your BLS and ALS accreditation annually. Reaccreditation consists of:
 Practical accreditation in BLS with AED (Basic Life Support (Adult) Practical Assessment
 Completion of
o Advanced Life Support Theory- Module A (Adult) (MHL - course code: 67644403)
o Advanced Life Support Theory- Module B (Adult) (MHL – course code: 67644650)
o Advanced Life Support Theory – Module C Quiz (MHL- course code 197482978).
 Practical accreditation by an accredited Adult ALS assessor.
ALS accreditation and reaccreditation must be recorded in MHL, which enables a standardised and
accessible means of recording and reporting on courses, skills and competencies. For further
information on accreditation for ALS, contact your Clinical Nurse Educator (CNE) or the SWSCEWD
Nurse Educator (NE) below:
Amanda Hooton: amanda.hooton@sswahs.nsw.gov.au 8738 6089

Abbreviations used within this manual
AED Automated External Defibrillator * ILCOR International Liaison Committee
on Resuscitation*
AF Atrial Fibrillation ILS Immediate Life Support*
ALS Advanced Life Support * IO Intra Osseous* (official IO =
inferior oblique)
ANZCOR Australian and New Zealand Committee IV Intravenous
on Resuscitation*
AP Antero Posterior LMA Laryngeal Mask Airway* (official
LMA = Left Mento Anterior)
ARC Australian Resuscitation Council* LMS Learning Management System*
AV AtrioVentricular* (official AV = MET Medical Emergency Team
audiovisual)
BLS Basic Life Support* MHL My Health Learning
BV Bag Valve resuscitator NFR Not For Resuscitation
BTF Between The Flags* NSW New South Wales
CEC Clinical Excellence Commission OTDS Organ Tissue Donation Service*
CERS Clinical Emergency Response System PEA Pulseless Electrical Activity*
CPR Cardio Pulmonary Resuscitation PPM Permanent Pacemaker
CVAD Central Venous Access Device* RCUK Resuscitation Council United
Kingdom*
DBD Donation after Brain Death* RMS Roads & Maritime Services*
DCD Donation of tissue / organs after cardiac RN Registered Nurse
arrest
DETECT Detecting Deterioration, Evaluation, ROSC Return of Spontaneous
Treatment, Escalation and Circulation*
Communicating in Teams*
DNR Do Not Resuscitate SaNOK Senior available Next Of Kin*
DO Designated Officer* (official DO = Day SVT Supra Ventricular Tachycardia
Only)
DSN Donation Specialist Nurse SWSLHD South Western Sydney Local
Health District
EMD Electro Mechanical Dissociation* SWSCEWD South Western Sydney Centre
for Education and Workforce
Development*
ETT Endotracheal tube TdP Torsades de Pointes*
FBAO Foreign Body Airway Obstruction* VT Ventricular Tachycardia
ICD Implantable Cardioverter Defibrillator* VF Ventricular Fibrillation
ICU Intensive Care Unit
Abbreviations with an * are not listed in Approved List of Abbreviations Liverpool Hospital (2018)

Chapter 1: Recognising the deteriorating patient
Patients who require ALS often have poor outcomes. ‘Most in-hospital cardiac arrests are
not sudden or unpredictable events. In approximately 80% of cases clinical signs deteriorate
over the few hours before arrest’ (ARC & RCUK 2011, p.7).
Early recognition, appropriate escalation of care, and effective treatment of the patient who
is clinically deteriorating may prevent cardiac arrest, death or an unplanned Intensive Care
Unit (ICU) admission.
Early recognition of the deteriorating patient is vital. You should be familiar with the simple
assessment and management algorithm: ‘A to G assessment, give oxygen, position your
patient, call for help’ (CEC, 2014).
All public health organisations in New South Wales (NSW) are required to provide a Clinical
Emergency Response System (CERS). It includes the use of NSW Standard Observation
charts with standard calling criteria, an early warning system and rapid response/medical
emergency team, for prompt review and treatment of patients who are clinically deteriorating,
with referral to higher levels of care (escalation) when necessary. The aim is to reduce
cardiac and respiratory arrests and hospital mortality. Although ALS knowledge and skills as
taught in this course are vital, it is always better to prevent an arrest where possible.
As a result of Australian and International studies, reports and case reviews, the Between
the Flags (BTF) and Detecting Deterioration, Evaluation, Treatment, Escalation and
Communicating in Teams (DETECT) programs were implemented in NSW Health in 2010
(CEC, 2014). All facilities have policies which outline clinical review and rapid review criteria
so that signs and symptoms of clinical deterioration are recognised and appropriately
managed.
The A to G assessment is a structured approach to physical assessment. It is quick to use

and aims to assist in finding the cause for deterioration rather than just a diagnosis. Using
the A to G should also help to improve communication of changes in a patient’s condition.
A Airway
B Breathing
C Circulation
D Disability
E Exposure
F Fluids
G Glucose
All clinical staff should be familiar with assessing the patient and recording vital signs,
recognising the calling criteria and flagging those patients who need further help. If a patient
is deteriorating then there should be an escalation and management plan appropriate for the
facility and the patient.

The chain of survival (American Heart Association, 2014) is a series of actions that link to
each other. Increasing the strength of each link can improve the chances of survival and
recovery for victims of heart attack, stroke and other emergencies. These principles of early
access, early Cardiopulmonary Resuscitation (CPR), early defibrillation and early advanced
care are the foundation of ALS.
http://www.wikidoc.org/index.php/File:Chain_of_survival_large.jpg
Early access: Early recognition of the deteriorating patient, immediate recognition of cardiac
arrest, and activation of the emergency response system
Early CPR with an emphasis on chest compressions: Chest compressions and

ventilations will ensure there is some blood circulated to the patient’s brain, heart and lungs.
This helps to reduce further deterioration. DO NOT DELAY CPR in attempts to defibrillate,
and minimise interruptions to CPR.
Early defibrillation: Aim to deliver the first defibrillation attempt within three (3) minutes of
cardiac arrest onset. If manual defibrillation is not available, seek out an Automated External
Defibrillator (AED).
Early advanced care: ALS by well-trained staff includes good CPR, appropriate and
effective defibrillation, adequate ventilation, administration of relevant IV medications and
early recognition of reversible causes. Integrated post resuscitation care is vital after Return
of Spontaneous Circulation (ROSC). Interventions in the post resuscitation period can
significantly improve patient outcomes.
For further information, refer to your local policies on the deteriorating patient.
Chapter 2: Algorithms
On the following pages are the BLS and Adult ALS algorithms from the ANZCOR
http://www.resus.org.au/. The purpose of these algorithms is to provide a logical, step-by-
step procedure for the assessments and actions required for the person who has collapsed.
As an ALS provider, you must know both algorithms thoroughly.

(ANZCOR, 2016a, p.5)

BLS is the preservation or restoration of life by the initial establishment and/or maintenance
of airway, breathing and circulation, and related emergency care. Accreditation in BLS,
including the AED, is required before attending the ALS face-to-face workshop. If you are not
competent in BLS, then you cannot continue on to ALS.
In SWSLHD, the process for BLS accreditation is as follows:

 Update yourself on the theory of BLS. The MHL e-learning module, Basic Life
Support -Adult is required every 5 years, but can be repeated more often if desired.
 Practical accreditation in BLS on an adult manikin and with an AED. This is then
recorded in MHL as Basic Life Support (Adult) Practical Assessment. The SWSLHD
BLS assessment chart is Appendix 1 of this manual.
Each facility has a policy on BLS which is guided by the ANZCOR’s recommendations.
During ALS, good chest compressions are vital
‘The quality of chest compressions during in-hospital CPR is frequently sub-optimal.

The importance of uninterrupted chest compressions cannot be over-emphasized.
Even short interruptions to chest compressions are disastrous for outcome and every
effort must be made to ensure that continuous, effective chest compression is
maintained throughout the resuscitation attempt. The person providing chest
compressions should be changed every 2 minutes, but without causing long pauses
in chest compressions’ (Soar & Davies, 2012, p.56).
Good chest compressions for adults (ANZCOR, 2016d):

 Hand position: two hands on
the lower half of the sternum; At least 5 cm
 Rate: approx. 100-120
compressions per minute;
 Depth: at least 5 cms (approx.
1/3 of the antero-posterior [AP]
chest diameter);
 Allow complete recoil of the
chest after each compression,
but keep the hand in contact
with the chest;
 Duty cycle of 50% (ratio
between compression and
release);
 Minimise interruptions to chest CEWD Picture files
compressions;
 Alternate compressor duties frequently (i.e. every 2 minutes).
CPR for the pregnant woman: From third trimester, hand position for chest compressions
may need to be slightly higher on the sternum. From about 20 weeks pregnant: Manually
displace the uterus to the left, to relieve compression on the inferior vena cava. Add left
lateral tilt, between 15 and 30 degrees if this is feasible (ERC 2015). This can be achieved
by placing a pillow, a wedge or using rescuer’s knees (the human wedge), under the
woman’s right side (Morris & Stacey, 2003). ‘The angle of tilt used needs to enable high-

quality chest compressions and if needed, allow Caesarean delivery of the fetus’ (ERC 2015,
p.185). Urgent caesarean section may need to be performed, and CPR must be continued
throughout this procedure (Morris & Stacey, 2003).
The ALS algorithm (shown on the following page) was developed to simplify resuscitation
and recommend a specific sequence. The priority is to minimise “hands off time”. There are
two treatment arms for the ALS algorithm, SHOCKABLE and NON-SHOCKABLE.
More detail on the ALS for Adults algorithm is below.
 1st responder: Determine whether the patient is in cardiac arrest: Danger, Response,
Send for help, Airway, Breathing
 No response and no breathing, commence CPR whilst awaiting defibrillator
 1st responder continues with CPR at a ratio of 30 compressions: 2 breaths
 2nd responder attaches a manual defibrillator as soon as it arrives and prepares for
a rhythm check and shock.
DO NOT STOP CPR while defibrillator is charging
Attach and charge the defibrillator without stopping for a rhythm check,
so interruptions to CPR are avoided. Once the defibrillator is charged, CPR stops and
rhythm assessed. The rhythm cannot be accurately assessed while chest compressions
are performed.
To ensure that a shock is ready to go as soon as it is needed, the defibrillator is charged

whilst compressions continue, and compressions stop once the defibrillator is fully charged.
When should the rhythm be checked?
 As soon as the defibrillator is available and has been fully charged, and everyone is
prepared for a rhythm check
 After every 2 minutes of CPR, when the defibrillator has been fully charged and
everyone is prepared for a rhythm check
 At any other time if the victim becomes responsive and normal breathing is apparent
 If the patient is already monitored and the rhythm can be easily seen, the rhythm
should be checked as soon as the patient arrests, in the process of checking
DRSABCD.
Shockable rhythm – Go to shockable arm of the algorithm. Ensure safety; deliver shock,
straight to CPR for 2 minutes.
Non-shockable rhythm – Go to non-shockable arm of the algorithm. ‘Dump’ the charge

and continue with CPR for 2 minutes. The defibrillator should be charged during CPR as
the end of the 2 minute loop of CPR approaches, to minimise interruptions to CPR and
increase the likelihood of shock success.

ANZCOR 2018, p.8
Shockable arm of the algorithm:
Pulseless VT/VF: CPR in progress

When manual biphasic defibrillator available
Clearly perform defibrillation script as follows:
Compressions continue
Oxygen away
All else clear
Charging
Hands off/I’m safe
Evaluate rhythm
Deliver one (1) shock of 200 joules
Cycle continues: Continue compressions and ventilation (30:2) for 2 minutes

Clearly perform defibrillation script
nd
Adrenaline administration every 2 loop (around every 4 minutes)
Correct reversible causes
rd
Consider anti-arrhythmics: Amiodarone 300mg after 3 failed shock
ANZCOR 2018, p.8

Non-shockable arm of the algorithm:
PEA / Asystole: CPR in progress

When manual biphasic defibrillator available
Clearly perform defibrillation script as follows:
Compressions continue
Oxygen away
All else clear
Charging
Hands off/I’m safe
Evaluate rhythm
Disarm & dump charge
Cycle continues: Continue compressions and ventilation (30:2) for 2 minutes

st
Adrenaline 1mg administered immediately after 1 shock is dumped and then
nd
every 2 loop (around every 4 mins)
Correct reversible causes
During CPR, also consider

 IV/IO access
 Airway adjuncts
 Oxygen requirements
 Waveform capnography
 Plan actions before interrupting compressions
Potentially reversible causes

Consider and correct: The 4H’s and 4T’s
4 H’s 4 T’s
Hypo / Hyperkalaemia / metabolic Thrombosis (pulmonary and coronary)

disorders
Hypo / hyperthermia Tension pneumothorax
Hypovolaemia Tamponade
Hypoxia Toxins / tablets
For further information on reversible causes, refer to the ANZCOR Guidelines:
11.2 Protocols for Adult ALS
11.7 Post resuscitation therapy in adult ALS

Chapter 3: Airway Management and Ventilation
Airway Management
Airway management is necessary to provide an open airway in the following circumstances:
If the patient is unconscious

If the patient has an obstructed airway
If the patient needs rescue breathing.
Unconscious patients should be moved gently, avoiding twisting and bending of the neck.
Patients should only be rolled onto their side if the airway is obstructed with fluid, such as;
submersion injuries. In these cases the patient may be rolled onto their side to clear the
airway with the mouth open and turned slightly downwards to allow the fluid to drain. Well-
fitting dentures should be left in place, however loose fitting ones should be removed.
Head tilt / chin lift
For the purposes of ALS the chin lift is used in combination with a head tilt. The chin is
supported by the rescuers fingers to open the mouth and lift the tongue and soft tissues
away from the back of the mouth and throat.
(ARC, 2016)
Place one hand on the patient’s forehead while the other hand provides the chin lift. The
head is tilted back (this is the head tilt). A head tilt is NOT suitable for patients with
traumatic injuries where c-spine injuries are suspected.
Jaw thrust
Clasp the jaw with both hands and hold the mouth open with the thumbs. Pressure is applied
with the fingers behind the angles of the jaw gently pushing the jaw upwards and away from
the chest. This manoeuvre shifts the tongue away from the back of the throat. Jaw thrust is
the preferred method of opening the airway where c-spine injuries are suspected.

http://nairdafi.wordpress.com/emergency-medicine/
Obstruction
Airway obstruction may be partial or complete, may have a gradual or sudden onset, and
may be present in a conscious or unconscious patient. All obstructions are life threatening,
regardless of the cause. It is essential to assess and manage all airways.
Causes of airway obstruction can include:
 relaxation of airway muscles due to unconsciousness,

 inhaled foreign body,
 anaphylaxis,
 airway trauma or burns.
A conscious patient with airway obstruction may have extreme anxiety, agitation, gasping
sounds, cough, stridor, loss of voice and may clutch at their throat. In partial airway
obstruction breathing is laboured, may be noisy and some air can be felt escaping from the
nose or mouth.
In a complete airway obstruction there may be some effort made to breathe, but no sounds
of breathing or escape of air can be felt at the nose or mouth. In an unconscious, non-
breathing patient airway obstruction may not be obvious until a rescue breath is attempted.
Management of Foreign Body Airway Obstruction (FBAO)
Foreign body airway obstruction can be life threatening. When a foreign body irritates the
vocal cords, this can cause laryngeal spasm; a protective mechanism to prevent the material
from entering the lungs. This can lead to a partial or complete airway obstruction at the
entrance of the trachea.
First assess the severity of the obstruction.
Effective cough (Mild Airway Obstruction)
Patients with an effective cough should be re-assured and encouraged to cough until the
obstruction is cleared.
Ineffective cough (Severe Airway Obstruction)
Give 5 sharp back blows with the heel of one hand, in the middle of the back between the
shoulder blades. Rescuers should check after each back blow to see if the airway
obstruction is relieved, rather than administering all 5.

If back blows are unsuccessful, 5 chest thrusts should be performed. To deliver chest
thrusts the rescuer should locate the position on the chest where compressions for CPR are
given and then deliver 5 chest thrusts. These are similar to chest compressions, but sharper
and at a slower rate. Rescuers should check after each chest thrust to see if the obstruction
is relieved, rather than administering all 5.
Unconscious patients
Suction the airway, and if the obstruction is visible remove the material and commence CPR.
Regurgitation and inhalation of stomach contents is often unrecognised in an unconscious

patient. Regurgitation is a passive process and is managed by suctioning and/or rolling the
patient on their side.
Flow chart for management of Foreign Body Airway Obstruction
(ANZCOR 2016, p.7)

Oropharyngeal airways (Guedels airway)
Oropharyngeal airways should be the appropriate size and reserved for unconscious
patients, as vomiting and laryngeal spasm may occur in patients who have a gag reflex.
http://www.mayohealthcare.com.au/products/Resp_airManage_oropharyngeal.htm
The correctly sized oropharyngeal airway will measure from the

incisors to the angle of the jaw.
http://www.haworth21.karoo.net/BASIC%20AIRWAY%20MANAGEMENT.htm
Insert the oral airway upside down until the soft palate is
reached, then rotate the device 180 degrees and slip the
airway into place over the tongue.

Nasopharyngeal airways
(Liverpool Hospital 2018)
To size the nasopharyngeal airway; measure from the tip of the nose to the tragus. To insert
the nasopharyngeal airway check there are no obstructions in the nasal passage. Lubricate
the nasopharyngeal airway, insert the tip of the airway into the nostril and guide it towards
the ear with a slight rotating motion until the flange sits against the nostril.
If difficulty is experienced when advancing the nasopharyngeal airway, stop and try the other
nostril.
In patients with suspected basal skull fractures oral airways are preferred.
Laryngeal Mask Airway (LMA)
The LMA is a supraglottic airway device used during resuscitation. In the resuscitation
situation these airways are generally used when attempts of inserting an endotracheal tube
have been unsuccessful or when suitably skilled clinicians are not available. LMAs do not
protect the airway from aspiration. Sizes of LMAs used in adults are 3, 4 & 5.
LMA insertion is a skill that may be practiced as part of the ALS face-to-face day; however
there is no formal accreditation of this skill throughout the course.
http://www.brandianestesia.
it/english/genanesth.html

Advanced airway management such as insertion of endotracheal tubes and surgical airways
are beyond the scope of this course and therefore not covered in this manual.
Breathing / Ventilation
Ineffective or absent breathing may be due to:

 Direct depression of, or damage to, the breathing control centre of the brain
 Upper airway obstruction
 Paralysis or impairment of nerves/muscles of breathing
 Problems affecting the lungs
 Drowning
 Suffocation
 Cardiac arrest
Breathing assessment
LOOK – for movement of the chest or upper abdomen

LISTEN – for escape of air from the nose and/or mouth
FEEL – for movement of the chest and upper abdomen and escape of air from the nose
and/or mouth.
Rescue breathing
If the patient is still unresponsive and not breathing normally after the airway has been
opened and cleared, the rescuer must immediately commence chest compressions and then
rescue breathing at a ratio of 30:2 (30 compressions : 2 breaths).
Bag-Valve-Mask (BVM) ventilation
BVM ventilation is a skill which assists in oxygenating and ventilating a patient until a more
definitive airway can be obtained. The adult BVM device holds 1500-1600mls.
Proper positioning of the patient with either head tilt/chin lift or jaw thrust is essential when
performing BVM ventilation.
After selecting the appropriate size mask to fit the patient’s face, ensure the BVM device is
connected to 15 L/min of oxygen.
BVM ventilation can be performed by one or two

clinicians.
In the single person BVM ventilation technique, the thumb

and index finger of the clinician holds the mask over the
nose and chin of the patient, while the other three fingers
hold the mandible in a jaw thrust position.
http://www.acep.org/Clinical---Practice-Management/Focus-On---Bag-Valve-
Mask-Ventilation/

In the two person technique the first person applies the mask
to the patient’s face while performing a jaw-thrust manoeuvre
and maintaining a tight seal with both hands. The second
person squeezes the bag with both hands to ventilate the
patient.
Ventilation should be assessed by observing rise and fall of

the patient’s chest while gently squeezing the bag.
Complications of BVM ventilation include; gastric distention,
aspiration and risk of barotrauma.
Special considerations
Unless specified, the following section is adapted from “Bag-Valve (BV) Resuscitator
including oropharyngeal and nasopharyngeal airways” (LH_GL2018_P01.44).
Patients with a tracheostomy
A tracheostomy is an artificial opening into the trachea (NSW Agency for Clinical Innovation,
2013). The tracheostomy is usually located on the “midline anterior aspect of the neck”
(Liverpool Hospital, 2018, p. 7).
If a patient with a tracheostomy needs Bag-Valve ventilation, try the tracheostomy site first:
 Follow the BLS algorithm and suction if necessary

 If a fenestrated tube is in place, replace the inner cannula with a non-fenestrated
inner cannula
 If a cuffed tube is insitu, inflate the cuff
 Fenestrated tubes are normally cuffless, therefore, if ventilation is inadequate (due to
air escaping) the tube may need to be replaced
 Apply the Bag-Valve resuscitator directly to the tracheostomy tube and ventilate at a
rate of 10 breaths per minute
If unable to ventilate adequately, prepare to

either; remove the tracheostomy tube and set up
for either a new tracheostomy tube or an
endotracheal tube.
http://www.ems1.com/ems-products/medical-equipment/airway-management/articles/852294-How-to-convert-Resusci-Anne-into-a-tracheostomy-
training-manikin/

Patients with a laryngectomy
A laryngectomy is a permanent opening into the trachea, where the larynx has been
removed and a stoma formed, meaning there is no connection between the upper airway
and trachea (NSW Agency for Clinical Innovation, 2013 & Marcovitch, 2010). The
“laryngectomy stoma is located on the midline anterior aspect of the neck, above the
suprasternal notch” (Liverpool Hospital, 2018, p. 7).
All ventilation must involve the neck stoma, not the mouth and nose.
 Follow the BLS algorithm

 Expose the stoma and place a rolled towel between the patient’s shoulder blades
 Suction and remove dried secretions with forceps as necessary
 Connect the Bag-Valve resuscitator to the laryngectomy tube or use the mask over
the stoma in an inverted position

Chapter 4: Shockable and non-shockable rhythms
Patients who require ALS commonly have underlying problems, which may include heart
disease, respiratory disease, drug overdose, trauma, electrolyte imbalances, and a history of
arrhythmias.
Patients who arrest are defined by the criteria of not breathing and not responsive, and it is
vital that the ALS provider performs rhythm checks. Rhythm checks in ALS must be accurate
and fast, and the algorithm defines the basic management into shockable and non-
shockable rhythms.
In cardiac arrest, shockable rhythms are Ventricular Tachycardia (VT) and Ventricular
Fibrillation (VF).
In cardiac arrest, non-shockable rhythms are Asystole and Pulseless Electrical Activity
(PEA), which is also sometimes known as Electromechanical Dissociation (EMD). The term
PEA will be used in this manual.
The chance of successful defibrillation decreases with time. Therefore the

performance of good CPR and decreasing the time to defibrillation are the highest
priorities in resuscitation from sudden cardiac arrest (ANZCOR, 2018).
Electrocardiograph (ECG) monitoring may be via a standard hardwire ECG monitoring

system utilising 3 to 5 electrodes on the chest, or via the defibrillator pads. Whatever the
method used, ensure reliable tracings are obtained and that all those assessing the patient
are all looking at the right patient & the same rhythm.
A quick look at what is ‘normal’, so that abnormal is easily determined.
Normal Sinus rhythm is defined by the criteria of
Regular rhythm (equal RR intervals)
Normal P wave, Normal PR interval (less than 0.2 seconds, 1 large square)
Normal QRS for that patient Ventricular rate between 60 and 100 beats per minute.
80 bpm

Consistent and regular P waves followed by consistent and regular QRS complexes, with a
consistent PR interval.
A patient in sinus rhythm should also have a detectable pulse with each QRS complex.
In the critically ill / arrested patient, pulse checks should only be via central pulses i.e.
carotid, femoral and apex.
Should you check a pulse?
In BLS, the combination of unresponsiveness and absent or abnormal

breathing is used to identify cardiac arrest. Pulse checks have limitations,
but an ALS provider can check for a central pulse for up to 10 seconds
in the initial assessment of the collapsed patient.
“If trained and experiened in assessment of circulation in collapsed patients:
check for breathing and a central pulse at the same time. If there is any question
over the presence or absence of a pulse it must be treated as if it were absent”
(ANZCOR 2017, p.6).
During ALS, once the defibrillator is fully charged, the rhythm should be
checked. ‘If a rhythm compatible with spontaneous circulation is observed, the
defibrillator should be disarmed and the pulse checked’ (ANZCOR, 2018, p.2). If the
patient is unconscious, has no breathing and is in a shockable rhythm (VF or VT), no
pulse check is required.
Shockable rhythms
Ventricular tachycardia (VT)
VT is a rapid rhythm which originates in the ventricles. It is defined by:
 Regular, Rapid rate (more than 100 beats per minute, and most commonly more than
160)
 Wide QRS complex
As the ventricles are stimulated rapidly and abnormally, VT may produce a loss of cardiac
output. If there is no cardiac output the patient will have no pulse and be in cardiac arrest.
Patients in VT who are still conscious (have a pulse), are still in mortal danger and may
proceed to full cardiac arrest at any time. For patients who are in cardiac arrest, VT is the
rhythm generally associated with more favourable outcomes.
There are two basic types of QRS morphology (shape) associated with VT:

Monomorphic is the most common, with a regular, (mono) wide QRS. ‘Monomorphic VT is a
form of VT in which the QRS complex configuration is uniform from beat to beat in all the
surface ECG leads’ (Badhwar 2017). Here are two examples of monomorphic VT:
Polymorphic VT is less common, with a slightly irregular appearance and a beat-to-beat

variation in the QRS complexes, as shown in the rhythm strips below.
Torsades de Pointes (TdP) is a type of polymorphic VT which is French for ‘twisting around
the points’, as shown below. It is usually associated with long QT intervals / drug overdose
or toxicity / electrolyte imbalances. A short-long-short sequence between the R-R interval
occurs before the trigger response. It is a shockable rhythm.
Sustained and rapid Polymorphic VT can quickly degenerate into VF.
Badhwar 2017, Figure 13-13

Diagnosis between polymorphic VT and Monomorphic VT and even VF can be difficult with a
single ECG lead (Badhwar 2017).
A: Monomorphic VT B: Polymorphic VT
Badhwar 2017, Figure 13-4 (Reproduced, with permission, from Akhtar M. Circulation. 1990; 82:1561.)
Patients who have polymorphic VT may have a history of monomorphic VT which is being
treated with antiarrhythmic medications. In these cases, the antiarrhythmic medication may
be contributing to a long QT interval and can be a cause of polymorphic VT. In cardiac
arrest, treatment should include appropriate defibrillation plus withdrawal of the offending
agent and replacement of electrolytes; IV magnesium may be useful (Badhwar 2017).
Ventricular fibrillation (VF)
‘VF is in many situations the primary rhythm in sudden cardiac arrest. The vast majority of
survivors come from this group’ (ANZCOR, 2018, p.2). VF is an irregular, chaotic rhythm.
There is electrical activity in the heart but it is not effective. The ventricles do not pump, but
quiver like jelly, and produce no cardiac output. All patients in VF will have no pulse and
blood pressure and will not be conscious. ‘The amplitude and waveform of VF deteriorate as
high energy phosphate stores in the myocardium decrease. This rate of decrease can be
slowed, or even reversed by effective BLS’ (ANZCOR, 2018, p.2). It is not reversible without
a shock from a defibrillator.
Coarse VF has taller complexes, and is allied with better outcomes compared to fine VF.
Coarse VF

If not reverted by a shock, or if good CPR is not maintained, VF complexes will become fine
quite quickly, and will proceed to asystole.
Fine VF 
Non-shockable rhythms
Asystole
Asystole is also known as ‘flat line’. There is no atrial or ventricular activity, no electrical
activity in the heart. The patient will have no pulse, no normal respirations and will not be
conscious. Outcomes for patients in asystole are poor.
Asystole can closely resemble very fine VF. If it is hard to tell whether it is fine VF or
asystole, then the ECG amplitude on the monitor can be increased to confirm the diagnosis.
However, very fine VF should be treated as asystole (if you can’t tell whether there is
electrical activity then a shock will not be useful to convert it). Pacing and atropine are NOT
recommended treatments for asystole.
Note that asystole has a slight undulating baseline, and is not completely flat, as you would
see when a patient’s ECG leads have been removed.
If there are still regular P waves, but no QRS complexes, the terms ventricular standstill or P
wave asystole are used. It is a non-shockable rhythm. External pacing may sometimes be
utilised.
http://www.heartrhythmguide.com/irregular_rhythm.
php
Pulseless Electrical Activity (PEA)
PEA is a term which refers to any rhythm which is not VT or VF, and there is no detectable
cardiac output. There is a range of potential rhythms, and it generally has a very poor
prognosis unless the cause is quickly found and treated.
As patients with PEA do not have a shockable rhythm, defibrillation is not an option. Patients
with PEA are treated as asystole, with good CPR and adrenaline, whilst seeking a reversible
cause.

Below: rhythms which could be PEA, if the patient does not have a cardiac output / pulse.
Cardiac compressions can mimic activity on the monitor screen.
When performing a rhythm check, ensure compressions have ceased before

confirming the rhythm.
Chapter 5: Defibrillation
‘Following the onset of VF or Pulseless VT, cardiac output ceases and cerebral hypoxic
injury starts within 3 minutes. For complete neurological recovery, early successful
defibrillation with a Return Of Spontaneous Circulation (ROSC) is essential. The
shorter the interval between the onset of VF/VT and delivery of the shock, the
greater the chance of successful defibrillation and survival’ (ARC & RCUK
2011, p.49).
A defibrillation shock when applied through the chest produces simultaneous depolarisation
of a mass of myocardial cells and may enable resumption of organised electrical activity. For
a patient to then return to a ‘normal’ rhythm, the heart and conduction system must have the
capability to do so.
A defibrillation shock is indicated for treating VF and pulseless VT.
Cardioversion has the same mechanism and technique as defibrillation and uses a
defibrillator. The difference is that the delivery of the energy is synchronised with the R
wave. Cardioversion is employed when the patient has an R wave, and the shock will be
timed (synchronised) so that the shock does not occur on the T wave. The defibrillator must
be changed to synchronous defibrillation. Cardioversion is most commonly employed for
patients in Atrial Fibrillation (AF) or Supra Ventricular Tachycardia (SVT) and is a more
controlled procedure than emergency defibrillation. For patients in cardiac arrest, in VF or
Pulseless VT, the shock is Asynchronous. Asynchronous is the default mode for manual
defibrillators.

Defibrillation is more likely to be successful if:
 It occurs within 3 minutes of cardiac arrest

 Interruptions to cardiac compressions are minimised. Start cardiac compressions
immediately, and then apply the defibrillator as soon as it is available
 Adhesive pads are placed in the best possible positions as per manufacturer’s
instructions
 Biphasic defibrillators are used, with an energy level of 200 joules. Biphasic
defibrillators are more effective at terminating shockable rhythms and more likely to
do so on the first shock.
Pad placement
Defibrillator paddles are rarely used as they have been largely replaced by disposable self-
adhesive pads. Pads are safer, do not require firm pressure on the chest, and most pads
can be used for external pacing as well as defibrillation. Regardless of whether pads or
paddles are used, the positions are the same.
The chest must be exposed; the patient cannot be defibrillated safely with clothes on their
chest. This includes removing bras. When applied the pads or paddles must not be in
contact with each other.
During ALS, the usual position for paddles or pads in the anterior-lateral
position, as shown.
 Patient’s upper right chest just under the right clavicle. Also known
as the right parasternal area over the 2nd intercostal space.
 Patient’s lower left lateral part of the chest. Also known as
midaxillary line over the 6th left intercostal space.
Picture: http://en.wikipedia.org/wiki/File:Defibrillation_Electrode_Position.jpg
Alternative pad/paddle placement
Placement of pads should not delay defibrillation: for e.g., the anterior-
posterior and apex-posterior placements are not recommended in the emergency situation
as it can take longer to place the pads, as the patient is often required to be turned over.
Large-breasted individuals: Left pad lateral to or underneath the left breast, avoiding breast
tissue and enabling better adhesive contact with the skin.
Excessively hairy individuals: If the hair is so thick that the electrodes do not lie flat on the
surface of the chest, then hair should be removed. A gap between the paddle/pad and chest
wall is a spark hazard. If the pads do not have good adhesion to the skin, then the current
will be less effective, as the current may spread across the patient’s chest rather than
internally. Hair needs to be removed rapidly to decrease delays in shock delivery.
Patients with Internal CardioDefibrillator (ICD) or pacemakers: Most pacemakers and ICDs
are implanted into the patient’s left upper chest and so the normal pad/paddle placement can
be used. If they are implanted on the patient’s right upper chest, then the defibrillator

pad/paddle should be at least 8 cm from the generator position. The Anterior-posterior or
apex-posterior placement can also be used.
Obese individuals: The usual pad placement and energy levels applies. Transthoracic
impedance is the measure of opposition to current flow between the two pads on the thorax.
Modern biphasic defibrillators are impedance-compensated and adjust their output according
to the patient’s impedance, so the usual defibrillation protocols should be followed (ERC
2015, p.37). Even the super obese are unlikely to have transthoracic impedances that
preclude successful defibrillation (McFarlane 2012).
During open-heart surgery spoon-like paddles are used to defibrillate the patient.
Self-adhesive pads should be used for defibrillation, but if the only available option is
paddles:
 Apply firm pressure

 Use conductive gel pads for maximum electrical contact
 Charge the paddles on the patient’s chest
 Don’t wave charged paddles around in the air, this is dangerous.
Defibrillation procedure in ALS

Clear and confident instructions are required to ensure that defibrillation is a safe activity.
When you are the person who is performing defibrillation, use the procedure outlined below
including these recommended phrases to convey what you are doing to all involved.

It is recommended that a single shock strategy be used for patients in cardiac arrest
requiring defibrillation for VF or Pulseless VT.

A sequence of up to three (3) stacked shocks can be considered in critical care areas when
 a monitored and witnessed cardiac arrest occurs in a well oxygenated patient
the defibrillator is immediately available, AND
 first shock can be delivered within 20 seconds AND
 The time required for rhythm recognition and for recharging the defibrillator is short
(i.e. less than 10 seconds)
 After cardiac surgery: At any time in the immediate post-operative period, to minimise
the potential harm of chest compressions, and only if the defibrillator is immediately
available (within 20 seconds of arrest). (ANZCOR 2017, ARC 2011)
Know your defibrillator!

Each manufacturer has recommendations for pad size, position and energy levels, and
these should be followed.
Monophasic Defibrillators: Most facilities use Defibrillators that use Biphasic waveforms,
which recommend 200 joules. If you are using an older, monophasic defibrillator, then higher
energy levels of 360 joules are required. Higher energy levels can cause more myocardial
damage and skin burns.
It is not recommended to defibrillate patients in Asystole or PEA, as defibrillation will not

change their rhythm. Other management is required.
If the shock is not delivered when expected, consider:

 Defibrillator is in ‘synchronise’ mode
 Flat battery
 Charge dumped automatically, as decision to deliver shock took too long
 Lead fracture
Safety precautions when defibrillating

 Be aware of electrical hazards in the presence of water, metal fixtures (e.g. bed
rails), oxygen and flammable substances.
 Avoid charging paddles unless they are on the patient’s chest
 Minimise sparking by ensuring the pad/paddles are correctly placed.
 Avoid placing defibrillator paddles/pads over ECG electrodes, ECG leads, medication
patches, piercings, implanted devices (e.g. pacemaker, portacath), and CVAD
insertion sites.
 High-flow oxygen (e.g.; BV resuscitator attached to oxygen) should be removed, so
that the flow of oxygen is not directed across the chest during defibrillation.
 Minimise interruptions to CPR while defibrillating.
 Disarm or ‘dump’ the shock if it is not required.
 Manual chest compressions should not continue during shock delivery.
 Don’t defibrillate a patient if they, the operator or close bystanders are situated in an
explosive / flammable environment.
 Never shock a patient in VT until they are unconscious.

Chapter 6: Pharmacology
‘While the listed drugs have theoretical benefits in selected situations, no medication has
been shown to improve long-term survival in humans after cardiac arrest. Priorities are:
Defibrillation, Oxygenation and Ventilation together with External cardiac compression’
(ANZCOR, 2016c, p2).
The two main drugs used in cardiac arrest are Adrenaline and Amiodarone. Further
information on other drugs can be found in ANZCOR Guideline 11.5 Medications in Adult
ALS (2016c).
Adrenaline (Epinephrine)
Action: Sympathomimetic.
Alpha adrenergic effects  systemic vasoconstriction, increases coronary & cerebral
perfusion.
Beta adrenergic effects  may increase cerebral and coronary blood flow.
Dose in cardiac arrest 1mg IV or IO (10ml 1:10,000 or 1ml 1:1,000)
Indications in cardiac arrest
Shockable rhythm (VT/VF) Non-shockable rhythm (PEA/Asystole)
Given after the 2nd shock once compressions Given as soon as circulatory access is
have been resumed obtained
Repeated every alternate 2 minute loop Repeated every alternate 2 minute loop
(around every 4 minutes) (around every 4 minutes).
Give without interrupting chest compressions Give without interrupting chest compressions
Flush with 0.9% sodium chloride, minimum Flush with 0.9% sodium chloride, minimum
20mls 20mls
Contraindications
Nil. Usual contraindications become relative in cardiac arrest.
Side effects
 Increases myocardial oxygen consumption (increases workload of the heart).

 Induces ectopic ventricular arrhythmias, particularly in the presence of acidaemia.
 Transient hypoxaemia due to pulmonary arteriovenous shunting.
 Impaired microcirculation.
 Increased post-cardiac arrest myocardial dysfunction.
Amiodarone
Action
Membrane stabilising anti-arrhythmic drug (Class III antiarrhythmic).
Increases the duration of the action potential and refractory period in atrial & ventricular
myocardium.
AV conduction is slowed.
Peripheral vasodilatation.

Dose in cardiac arrest
300mg (6mls) IV or IO. Made up to a total of 20mls 5% dextrose and give as a bolus over 1
to 2 minutes (SWSLHD GL2016_021). An additional dose of 150mg could be considered. An
infusion may be ordered after bolus dose(s), e.g. 15mg/kg over 24 hours ( ANZCOR, 2016c,
p.6).
Flush with 5% dextrose or 0.9% sodium chloride, minimum of 20mls.

IV Amiodarone comes in glass vials of 150mg in 3mls (50mg / ml) and is oily; shaking will
cause bubbles and make it hard to draw up. It should be mixed with 5% dextrose to prevent
precipitation.
IV Amiodarone should be given via a large vein, preferably central access.
Indications in cardiac arrest

Shockable rhythm (VT/VF) Non-shockable
rhythm
(PEA/Asystole)
Given after the 3rd failed shock once compressions have been resumed Not indicated for
Further dose of 150mg if VF/VT persists, at least 15 minutes after 1st PEA or asystole
dose (MIMS Online).
May be followed by an infusion (15mg/kg over 24 hrs or as per hospital
protocol)
Give without interrupting chest compressions
May also be considered for prophylaxis of recurrent VF / VT

Further information on Intraosseous devices can be found in the ANZCOR Guideline 11.5
p2.
Contraindications
Relative in cardiac arrest. Includes bradycardias & conduction blocks; torsades de pointes
inducing drugs including other antiarrhythmics; known hypersensitivity; thyroid dysfunction;
hypotension. Do not mix with other drugs as interacts with a wide range of drugs.
Side effects
Hypotension, usually related to the rate of delivery

Bradycardia
AV blocks
Other drugs that may be used during a cardiac arrest include:

 Magnesium
 Potassium
 Lignocaine
 Calcium
 Sodium bicarbonate
Fluids: 0.9% Sodium Chloride or Hartmann’s solution is preferred for fluid resuscitation.
Avoid IV dextrose which is redistributed away from the intravascular space rapidly and

causes hyperglycaemia, which may worsen neurological outcome after cardiac arrest (ARC
& RCUK, 2011).
Chapter 7: Post Resuscitation
A to G
Resuscitation does not stop after ROSC. It is important that clinicians continue to assess
and maintain airway, breathing and circulation of the patient. “Hypoxic brain injury,
myocardial injury or subsequent organ failure are the predominant causes of morbidity and
mortality after cardiac arrest”
(ANZCOR, 2016e, p. 6). (ANZCOR 2018, p. 8)
The aims of post resuscitation care

are to:
 Continue respiratory support

 Maintain cerebral perfusion
 Treat and prevent cardiac
arrhythmias
 Determine and treat the cause of the arrest (including reversible causes – 4H’s & 4T’s).
A full A-G assessment should occur immediately after ROSC.
Airway & Breathing
After ROSC clinicians must ensure the airway is clear and the patient is adequately
oxygenated and ventilated.
After a brief period of cardiac arrest where the patient responded immediately to treatment,
the patient may immediately return to normal cerebral function. In these cases the patient
does not require tracheal intubation and ventilation, but should be given oxygen to maintain
normal oxygenation.
In other cases hypoxia and hypercarbia increase the risk of further cardiac arrest and
secondary brain injury. In these circumstances tracheal intubation, sedation and ventilation
should be considered. After ROSC, in the post-arrest period, hyper/hypoxia should be
avoided and inspired oxygen should be titrated to target oxygen saturations between 94-
98%. Arterial blood gas measurements should be used to assess ventilation in the post-
arrest period (instead of end tidal carbon dioxide levels) with clinicians aiming to maintain
normocarbia (PaCO2 35 – 40mmHg).
Assess the patient’s chest for symmetrical movement; listen for quality of chest sounds and
equal rise and fall of chest. Frequently monitor respiratory rate, SaO2 and where appropriate,
end tidal carbon dioxide level.
Circulation
After a cardiac arrest the cardiac rhythm and circulatory function may be unstable. For this
reason the patient should have continuous cardiac monitoring along with regular pulse, 12
lead ECG and blood pressure checks. The patient’s peripheral circulation should also be
assessed by checking for warmth and rapid capillary refill.

Disability & Exposure
Neurological function should be rapidly assessed by using a Glasgow Coma Scale and
recording the score in the patient’s clinical notes. To examine the patient properly the
patient should also be exposed.
Fluids
Assess input and output. Are IV fluids in progress? If not, do they need to be commenced? If
so, are they an appropriate fluid choice, check rate and amount?
Blood glucose control

Post cardiac arrest clinicians should monitor and treat hyperglycaemia (>10mmol/l) with
insulin, but should also avoid hypoglycaemia.
Temperature control
Targeted temperature management is recommended by ANZCOR (2016e) for the
management of adult patients who remain unresponsive post cardiac arrest (after ROSC).
Organ & Tissue Donation

When a resuscitation attempt progresses to death organ and tissue donation should be
considered. Donation of organs and tissues is an act of altruism that potentially benefits
those in medical need, and society as a whole. Although end of life care should routinely
include the opportunity to donate organs and tissue, the duty of care toward the dying
patients and their families remains the dominant priority of NSW Health staff. The decision of
people who choose not to donate must always be respected and the family shown
understanding for the decision.
Organs and tissues must be obtained for transplantation in accordance with the NSW
Human Tissue Act 1983. Organs and tissues for transplantation must be obtained in ways
that:
 Demonstrate respect for all aspects of human dignity, including the worth, welfare,
rights, beliefs, perceptions, customs and cultural heritage of all involved;
 Respect the wishes, where known, of the deceased;
 Give precedent to the needs of the potential donor and the family over the interest of
organ procurement;
 Organs and tissues must be allocated according to just and transparent processes;
 Protect, as far as possible, recipients from harm; and,
 Recognise the needs of the health professionals involved.
Before the request for Organ and Tissue Donation
 Organ and tissue donation should be considered in every end of life decision.
 In Donation after Brain Death (DBD), ensure that the family is informed of the
patient’s death and that brain death is explained and understood by the family.
 In Donation after Circulatory Death (DCD), ensure that the family and medical staff
have reached a consensual decision to withdraw futile life sustaining treatment.

 The family discussions on withdrawal of treatment, brain death and or imminent
death are led by a Staff Specialist and should always include the bedside RN, a
social worker, and the Donation Specialist Nurse (DSN). Inclusion of attendees is at
the discretion of the Treating Staff Specialist. A pastoral care worker may be involved
at the discretion of the family.
 The family donation conversation must (to the extent possible) be separate from and
follow the discussion and decision related to withdrawal of cardiorespiratory support.
Separating the discussion of withdrawal of cardiorespiratory support from organ
donation is important for bereaved families and helps minimise any potential
perception of conflict of interest on the part of any persons involved in the care of the
patient or by the patient’s family.
 The opportunity for donation should be discussed with families of potential organ
donors by skilled communicators, knowledgeable about donation, and who have
received specific training in this area (Designated Requestor).
 Family Donation conversations should be a collaborative approach, led by a
Designated Requestor (DR) (if the DR is also the treating Staff Specialist, a separate
DR must lead the conversation) and include the treating Staff Specialist, bedside RN,
social worker and the Donation Specialist Nurse (whom can also be the DR).
 Ideally all family donation conversations should include and/or be led by a Donation
Specialist Nurse (DSN).
 The on-call DSN should be contacted regarding a potential organ donor via the on-
call roster via hospital switchboard.
 Alternately, you may contact a Donate Life Donation Specialist Coordinator (DSC) on
(02) 9963 2801, which is a paging service. The DSC can access the Australian
Organ Donor Register (AODR) to ascertain consent or refusal of the potential donor.
The AODR MUST be checked in all potential donations to ascertain consent,
intention or refusal.
The RMS organ donor register, was decommissioned as of the 20th November 2017 and is
no longer accessed to ascertain consent, intention or refusal.
 All patients at end of life should be referred to the DSN or the DonateLife DSC to
assess for medical suitability for potential organ donation.
 Involve on-call social work support.
 Ascertain if religious support is required.
Consent
Consent needs to be obtained from the senior available next of kin (SaNOK), a Designated
Officer (DO) within your facility and if it is a Coroner’s Case, consent must be obtained from
the Forensic Pathologist and Coroner as well. A Designated Officer cannot provide consent
for organ and tissue donation in a Coroner’s Case without prior consent from the Coroner.
Process of Organ and Tissue Donation
A Donation Specialist Nurse (DSN) is present throughout the donation process, if the patient
is not already admitted to an ICU they will be transferred there as soon as a bed is available.
The family is informed of the donation process, duration / length of the procedure and that
organ retrieval surgery is performed with considerable respect for the donor. They ensure
social work involvement in all cases and ascertain if religious support is required.

Sudden and traumatic incident: shock, grief and reduced cognitive function – requires simple
and honest explanations. Avoid using terms such as: “Life support” – use instead “Ventilator”
“Harvest” - use instead “donation surgery”, “Organ retrieval surgery”, “surgical removal”
Coroner’s Cases: A family member must identify the donor with the police before or after an
organ donation and additional support may be required at this time.
The DSN will work closely with the Critical Care staff to ensure that the necessary tests &
assessments are carried out and to give advice and guidance on the management of the
potential organ donor. The DSN will also liaise with Operating Theatre staff to make
arrangements for retrieval surgery. They will also provide and organize for bereavement
aftercare and counseling for the family, as well as follow up and feedback for all of the
hospital staff involved.
Tissue –only donation
All deaths (including Coroner’s cases) occurring within or declared on arrival to hospital are
to be notified to the Lions NSW Eye Bank Coordinators through the Sydney Eye Hospital 24
hours a day on: 9382 7288.
Coroners Cases
In many cases a resuscitation attempt that progresses to death needs to be referred to the
Coroner. Examples of situations that should be referred to the Coroner include, but are not
limited to the following:
 A violent or unnatural death

 A sudden death where the cause is unknown
 Where a patient’s death was suspicious or unusual
 Where the patient had not been seen by a medical practitioner for the 6 month
period prior to their death
 A patient died while in a mental health facility (NSW Health, 2010)
When a patient is to be referred to the Coroner nothing should be done to the body. “All
intra-venous cannula, needles, endotracheal and intragastic tubes, all drains and airways
should be left in situ. Attached drip bags, bottles and feed lines must accompany the body.
All sharps or items of equipment left in situ should be firmly taped or secured to the body in
such a way that the risk of sharps injury or leakage is minimised” (NSW Health, 2010, p.7).
The body should not be washed as this may remove evidence that will be useful for the
forensic pathologist to examine. The body should be placed in a plastic body bag.
When a post mortem is to occur, the pathologist or medical officer performing the
examination must have access to the medical records. The release of these records should
be managed by the Medical Records department or designated responsible officer of the
facility.
For further information in relation to Coroner’s Cases please refer to (NSW Health, 2010).

Chapter 8: Legal and ethical considerations
Following is a summary of ANZCOR 2015, Guideline 10.5, Legal and ethical issues related
to resuscitation.
Duty to Rescue
‘Good Samaritans’ or volunteers are required to act in good faith and without recklessness,
maintaining a standard of care that is appropriate to their training, or lack of training.
The person, who has a duty of care to respond, such as a nurse or doctor trained in ALS, is
expected to have a higher duty of care and standard of care, than that of a volunteer or
Good Samaritan. If the nurse or doctor is trained in the skills of Advanced Life Support then
they must perform tasks to a standard expected of a reasonably competent person with their
training and experience.
Consent for treatment
Consent for treatment is normally required. However, if the person is unable to give consent
(e.g. they are in cardiac arrest) then the legal requirement to obtain consent before
assistance or treatment could be waived. If the situation is considered to be an emergency,
‘a doctor (and possibly other healthcare workers), may treat a patient if the doctor acts
reasonably and honestly believes on reasonable grounds that the treatment is necessary to
prevent a serious threat to the victim’s life or health’ (ANZCOR, 2015, p.5).
Refusal and discontinuation of treatment
‘Competent adults are legally entitled to refuse any treatment even if life-sustaining or their
own best interests’ (ANZCOR 2015, p. 9). In NSW, a person who has been given ‘enduring
guardianship’ for another person under the 1987 Guardian Act (NSW) can refuse treatment
on their behalf.
Do not attempt resuscitation orders and termination of resuscitation attempts
Not For Resuscitation (NFR) or Do Not Attempt Resuscitation (DNAR) orders must be
documented in the patient’s notes and signed by a doctor. The Resuscitation Plan as
outlined in the NSW Health PD2014_030 should be implemented after consultation with
relevant members of the healthcare team, the patient or legal guardian, and the family /
carer. It is a legally enforceable medical order and remains active during admission unless
cancelled ‘The legal status of such orders within institutions is not clear and probably void
between institutions and out-of-hospital unless signed by the victim when competent or by a
substitute decision-maker’ (ANZCOR 2015, p.13). Nurses and doctors should be aware of
local laws, regulations and policies concerning DNAR forms and advanced directives. Some
of the relevant policies are listed below:
NSW Health PD2014_030 Using Resuscitation Plans in End of Life Decisions.
NSW Health Guidelines GL2005_057 End-of-Life Care and Decision-Making Guidelines
SWSLHD_PD2013_035 Initiation and management of Advance Care Planning processes
Bowral Hospital BDH_PD2016_C01.08 Care Plan for the Dying Adult Patient

Liverpool Hospital LH_PCP2015_P01.20 Resuscitation Plan - Dying with Dignity –
withholding CPR and altered Medical Emergency team calling criteria.
The decision to terminate resuscitation may be difficult, and in the acute hospital setting, this
will be made by a medical practitioner. There are many factors to take into account, including
duration of cardiac arrest, if the arrest was witnessed, the patient’s known wishes, the
patient’s co-morbidities and whether immediate CPR was provided. The ‘BLS termination of
resuscitation rule’ (no shockable rhythm, unwitnessed by emergency services and no return
of spontaneous circulation) can be used to guide termination or pre-hospital CPR in adults
(ANZCOR 2015).
Care for families and significant others
Family members and significant others of patients who are undergoing resuscitation should
be given the option to be present at the resuscitation, this may assist the family to cope and
provide more positive emotional outcomes. Care of the family members/significant others
should include assigning an appropriate staff member to act as a support person (ANZCOR
2016f).

Chapter 9: Communication and Teamwork
A successful team is well organised with clearly defined roles and responsibilities, skilled
team members, effective leadership and team interactions.
The team leader is responsible for role allocation, gathering and distributing information, co-
ordinating the team and leading decision making and task prioritisation. A team leader can
only be effective if they are working with team members who take responsibility for their role,
pass on information to the team leader, perform allocated tasks and express concerns when
necessary.
An essential component of all successful teams is effective communication. Some features

of effective communication include:
 Use people’s names

 Confirm when you hear information
 Share information amongst the team and team leader
 Be specific and succinct
 Clarify team goals and acknowledge effort
 Remain calm and avoid conflict.
In ALS circumstances ISBAR is a useful tool to enhance the hand over process. This
process can be used when the Medical Emergency Team (MET) arrives at the bedside and
provides clinicians with a structure to clearly and concisely deliver relevant information to
other clinicians. Communicating effectively with the team will be incorporated as part of the
ALS face-to-face workshop in discussions and simulated scenarios.
Introduction
I State your name, role/position
Identify the patient
Situation
S State the patients current problem or diagnosis
Why did you call for help?
Background
B State the relevant clinical background and medical history of the patient
What treatment have you initiated and has this worked?
Assessment
A State the patient current observation or lack of spontaneous circulation
Any test or procedures you have done and what are the results?
What do you think the problem is?
Recommendation
R Clearly express what you would like to happen. What do you want the other
clinician to do?
CEC, In Safe Hands

Chapter 10: Questions for completion prior to workshop attendance
1. Indicate the shockable rhythms in ALS:
a)
b)
c)
d)
2. What is the recommended compression to ventilation ratio?
a) 30:2
b) 30:1
c) 15:1
d) 5:1
3. Which of the following are first line cardiac arrest drugs?
a) Atropine and amiodarone

b) Amiodarone and adrenaline
c) Potassium and magnesium
d) Adrenaline and adenosine
4. In the event of an arrest a patients dentures should always be removed:
True
False

5. Indicate the non-shockable rhythms in ALS:
a)
b)
c)
d)
6. What does ISBAR stand for:
(a) Investigate, Symptoms, Background, Assessment, Recognise
(b) Introduction, Situation, Background, Assessment, Recommendation
(c) Investigate, SAGO, Basic observations, Alert, Refer
(d) Introduction, Symptoms, Background, Assessment, Refer.
7. Opening the airway is necessary in which of the following circumstances:
a) If the patient is unconscious

b) If the patient has an obstructed airway
c) If the patient needs rescue breathing
d) a and c
d) (a), (b) and (c)
8. At what rate should the cardiac compressions be delivered in an adult?
a) 80 per minute
b) 140 per minute
c) 90 per minute
d) 100-120 per minute

9. Indicate the correct pad placement for defibrillation
10. Mr X is monitoring in the rhythm below.
What is this rhythm?
(a) Ventricular tachycardia
(b) Supraventricular cardiac
(c) Sinus tachycardia
(d) Ventricular fibrillation
11. Mr X is not responding and is not breathing, and continues to monitor in the above rhythm.
CPR is in progress. The resuscitation trolley has arrived. What is your next action?
(a) Administer Adrenaline 1mg immediately
(b) Continue compressions for 2 minutes and then administer Adrenaline 1mg
(c) Continue compressions for 2 minutes then defibrillate 200 joules
(d) Defibrillate with 200 joules immediately
12. Amiodarone 300mg bolus is administered if a patient is in:
(a) VT/VF
(b) Asystole
nd
(c) 2 degree AV Block
(d) Atrial fibrillation

13. Mrs K is in cardiac arrest. At the first rhythm check, the rhythm below is displayed. What is
your immediate action?
(a) Defibrillate at 200 joules
(b) Dump the charge, check for a central pulse
(c) Continue CPR
(d) Administer Amiodarone 300mg
14. What is the correct dose for Adrenaline in the ALS algorithm?
(a) 2mg
(b) 500mcg
(c) 10mg
(d) 1mg
15. What is the correct dose for Amiodarone in the ALS algorithm?
(a) 150mg
(b) 300mg
(c) 1mg/kg
(d) 1.5mg/kg
16. Which manoeuvre/s should be used for patients with a suspected c-spine injury:
(a) Head tilt
(b) Chin lift
(c) Jaw thrust
(d) Head tilt / chin lift

17. Which of the following is the best action for clinicians caring for a conscious patient with
an effective cough and FBAO:
(a) Give 5 chest thrusts
(b) Call for help and start CPR
(c) Reassure the patient and encourage coughing
(d) Give a total of 5 back blows, reassessing after each.
18. Treatment of the following rhythm is
(a) CPR, adrenaline immediately and then every 4 minutes
(b) CPR, defibrillate at 200 joules, adrenaline every 4 minutes
(c) External pacing at 80 per minute and intubate immediately
(d) Oxygen away, defibrillate immediately and continue compressions
19. What are the 4 H’s in the ALS algorithm?
1)
2)
3)
4)
20. What are the 4 T’s in the ALS algorithm?
1)
2)
3)
4)

Reference / Bibliography
th
American College of Surgeons. (2012). Advanced Trauma Life Support: Student Course Manual (9
ed.). Chicago, American College of Surgeons.
American Heart Association. (2014). Chain of Survival. Retrieved from

http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/ECCIntro/Chain-of-
Survival_UCM_307516_Article.jsp.
Australasian Transplant Coordinators Association (ATCA). (2008). ATCA National Guidelines for
Organ and Tissue Donation. Retrieved from http://www.atca.org.au/files/F.pdf
Australian and New Zealand Committee on Resuscitation (2018). ANZCOR Guideline 11.2: Protocols
for Adult Advanced Life Support. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2017). ANZCOR Guideline

11.1.Introduction to and Principles of In-hospital resuscitation Retrieved from
http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016). Guideline 4: Airway. Retrieved from
http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016a). Guideline 8. Cardiopulmonary

Resuscitation. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016b). ANZCOR Guideline 11.4:
Electrical Therapy for Adult Advanced Life Support. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016c). ANZCOR Guideline 11.5:
Medications in Adult Cardiac Arrest. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016d). Guideline 11.6: Equipment and
techniques in Adult Advanced Life Support. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016e). Guideline 11.7: Post-resuscitation
therapy in Adult Advanced Life Support. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Committee on Resuscitation (2016f). Guideline 10.6: Family Presence
during Resuscitation. Retrieved from http://resus.org.au/guidelines/
Australian and New Zealand Intensive Care Society (ANZICS) (2013). The ANZICS Statement on
Death and Organ Donation, Edition 3.2. Retrieved from https://www.anzics.com.au/wp-
content/uploads/2018/08/ANZICS_Statement_on_Death_and_Organ_Donation_Edition_3.2.pdf
Australian Resuscitation Council (ARC) & Resuscitation Council United Kingdom (RCUK) (2011).
rd
ARC Advanced Life Support Level 1: Immediate Life Support (Australian ed. 3 ed.). Melbourne,
Australian Resuscitation Council.
Australian Resuscitation Council (2011). Guideline 11.10: Resuscitation in special circumstances.

Retrieved from http://resus.org.au/guidelines/
Badhwar, N (2017). Chapter 13. Ventricular Tachycardia. In Crawford M.H. (Eds), Current Diagnosis
& treatment: Cardiology, 4e. Retrieved July 24, 2019 from CIAP/ Access medicine Books
Bowral Hospital (2016) Care Plan for the Dying Adult Patient (BDH_PD2016_C01.08)

Chain of Survival [Image] (2014, May 15). Retrieved July 24 2019 from
http://www.wikidoc.org/index.php/File:Chain_of_survival_large.jpg
Clinical Excellence Commission (CEC). Between the Flags: Keeping patients safe; Background.
Retrieved July 24, 2019 from http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-
safety/between-the-flags
Clinical Excellence Commission (CEC). In Safe Hands; Clinical handover. Retrieved July 30, 2019
from http://www.cec.health.nsw.gov.au/quality-improvement/team-effectiveness/insafehands/clinical-
handover
Colour-coded airways [Image] (2013, Nov 19). Retrieved Nov 19, 2013, from
http://www.mayohealthcare.com.au/products/Resp_airManage_oropharyngeal.htm
Donate Life (2017). Best Practice Guideline for Offering Organ & Tissue Donation in Australia.
Retrieved from https://donatelife.gov.au/resources/clinical-guidelines-and-protocols/best-practice-
guideline-offering-organ-and-tissue
European Resuscitation Council (ERC) 2015, Guidelines for Resuscitation Section 4: Cardiac arrest
in special circumstances, Retrieved 24 July 2019 from
https://cprguidelines.eu/sites/573c777f5e61585a053d7ba5/content_entry573c77e35e61585a053d7ba
f/573c78115e61585a053d7bce/files/S0300-9572_15_00329-9_main.pdf? Institute of Trauma and
Injury Management (2012), Australian Trauma Team Training Course: Participant Manual. Institute of
Trauma and Injury Management.
Jaw thrust [Image] (2013, Nov 19). Retrieved Nov 19, 2013, from
http://nairdafi.wordpress.com/emergency-medicine/
Laryngeal Mask Airway [Image] (2014, May 24). Retrieved May 24, 2014, from
http://www.brandianestesia.it/english/genanesth.html
Liverpool Hospital (2018). Approved list of abbreviations for use in health care records.
(LH_Proc2018_C02.14).
Liverpool Hospital. (2018a). Bag-Valve (BV) Resuscitator. (LH_PD2018_P01.44).
Liverpool Hospital (2016). Resuscitation Plan - Dying with Dignity –withholding CPR and altered
Medical Emergency team calling criteria. (LH_PCP2015_P01.20).
nd
Marcovitch, H (2010) Black’s Medical Dictionary – 42 ed. Bloomsbury Publishing
McFarlane, J. (2012). Defibrillating obese patients. Critical Care Nurse, 32(2), 73 – 74.
MIMS Australia Online (2019). Adrenaline. Retrieved through CIAP

https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
MIMS Australia Online (2019). Amiodarone. Retrieved through CIAP

https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
Morris, S & Stacey, M. (2003). ABC of Resuscitation: Resuscitation in pregnancy, BMJ, 327, 1277 –
1279.
NSW Agency for Clinical Innovation (2013). Care of Adult Patients in Acute Care Facilities with a
Tracheostomy: Clinical Practice Guideline. Retrieved from
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/ACI_Tracheostomy_CPG.pdf

NSW Consolidated Acts. (1983). Human Tissue Act 1983. (Act 164, 5 July 2013). Retrieved from
https://www.legislation.nsw.gov.au/inforce/dae79cae-8043-47df-9c37-fe8d1d7e38b3/1983-164.pdf
NSW Health. (2013) Recognition and management of patients who are clinically deteriorating.
(PD2013_049).
NSW Health (2013). Deceased Organ and Tissue Donation – Consent and other procedural
Requirements. (PD2013_001).
NSW Health. (2010). Coroners Cases and the coroners Act 2009. (PD2010_054).
NSW Health. (2014). Using Resuscitation Plans in End of Life Decisions (PD2014_030)
NSW Health. (2005). Guidelines for End of Life Care and Decision Making. (GL2005_057).
NSW Health. (2005). Human Tissue-Use/Retention including organ donation, post-mortem

examination and coronial matters. (PD2005_341)
Oropharyngeal airway insertion [Image] (2014, May 24). Retrieved May 24, 2014, from
Queensland Ambulance Service. (2012). Clinical Practice Procedures – Respiratory. Retrieved from
https://ambulance.qld.gov.au/docs/07_cpp_respiratory_300812.pdf
Queensland Ambulance Service. (2011). Clinical Practice Procedures – Airway Management.

Retrieved from https://ambulance.qld.gov.au/docs/02_cpp_airway.pdf
Resu4Kids (2016) COACHED algorithm. Resus4Kids Instructor resources
Sizing of an oropharyngeal airway [Image] (2014, May 24). Retrieved May 24 2014 from
Soar, J & Davies, R. (2012). In-hospital resuscitation. In Resuscitation Council (UK), Resuscitation
Guidelines 2010 (chapter 6, pp. 48 – 57). Retrieved from http://www.resus.org.uk/pages/inhresus.pdf
South Western Sydney Local Health District. (2018). SWSLHD Organ and Tissue Donation after
Death. (SWSLHD_Proc2018_038).
South Western Sydney Local Health District. (2016 Nov). Care Plan for the Dying Adult Patient
(SWSLHD_PD2016_015).
South Western Sydney Local Health District (2013)_ Initiation and management of Advance Care
Planning processes (PD2013_035)
The Society of Hospital Pharmacists Australia (SHPA). (2011). Australian Injectable Drugs Handbook
th
(5 ed.). e-ISBN: 978-0-9871103-1-2.
Traditionally, the ‘EC’ hand position [Image] (2014, May 26). Retrieved May 26, 2014, from Retrieved
http://www.acep.org/Clinical---Practice-Management/Focus-On---Bag-Valve-Mask-Ventilation/
The Transplantation Society of Australia and New Zealand (TSANZ) (2019) Clinical Guidelines for
Organ Transplantation from Deceased Donors (Version 1.3 - May 2019). Retrieved from
https://www.tsanz.com.au/TSANZ_Clinical_Guidelines_Version%201.3[6986].pdf
Ventricular asystole [Image] (2014). Retrieved May 20, 2014, from Heart Rhythm Guide
http://www.heartrhythmguide.com/irregular_rhythm.php

Ventilating a tracheostomy tube [Image] (2014, Jun 2). Retrieved Jun 2, 2014, from
http://www.ems1.com/ems-products/medical-equipment/airway-management/articles/852294-How-to-
convert-Resusci-Anne-into-a-tracheostomy-training-manikin/

Appendix 1
SWSLHD CEWD Life Support Assessment Tool, March 2016

Appendix 2
Adult Advanced Life Support - Level 1- Assessment

Checklist
This assessment relates to Standard 8: Recognizing & responding to acute deterioration.
For RN’s, currently working in a critical care area OR Medical Staff
Prior to the assessment the participant must have:
 Completed Between the Flags - Tier 2 DETECT OR Between the Flags- Tier 2 DETECT
workshop (Mixed – Face-to-Face) – Nursing and Medical – Half day
 Basic Life Support Accreditation completed within the last 12 months
 Completion of Advanced Life Support Theory- Module A(Adult) (MHL - course code:
67644403)
 Advanced Life Support Theory- Module B (Adult) (MHL - course code: 67644650)
 Advanced Life Support Theory – Module C Quiz (MHL - course code 197482978).
 Has previously attended the SWSLHD Face-to-Face Adult
Advanced Life Support (Level 1) workshop or equivalent
Assessors Signature: __________________________
Assessors Name: _____________________________
Designation: _________________________________
Accreditation entered into MHL
Plan of action if deemed not yet competent

Adult Advanced Life Support - Level 1- Assessment
Instructions to Assessors: Each activity must be demonstrated correctly by participants.
Mark each statement with:  = Observed OR  = Not Observed
Activity Observed
Danger: Check for Danger
Maintains WHS procedures throughout scenario
Response: Ascertains Response by appropriate verbal and tactile stimuli
Communicates clearly with all staff involved in the scenario
Send for Sends for help
help: Notes Time
Airway: Open Airway (Head tilt/Chin lift, Jaw thrust)
Clears airway (suction/remove visible objects)
Inserts airway adjuncts (without delaying compressions)
Breathing: Assesses for normal breathing for no more than 10 seconds (look, listen, feel)
CPR: Immediately commence chest compressions
 Correct hand position
 Depth 1/3 chest >5 cm
 100-120 per/min
 Ratio 30:2
Delivers breaths using BVM resuscitator
Defibrillation: Attaches manual defibrillator with minimal interruption to compressions
st
Immediately performs 1 rhythm check in the following sequence:
 Compressions continue
 Oxygen away
 All else clear
 Charging (at 200J)
 Hands off / I’m safe
 Evaluate rhythm
 Defibrillation or disarm & dump
If VT/VF defibrillates & immediately recommences 2 mins of CPR
If asystole/ PEA confirmed - dumps charge & immediately recommences 2 mins
of CPR
Performs rhythm check correctly every 2 mins
Asystole/ States IV access obtained & bloods taken
PEA: Administers IV Adrenaline 1 mg with 20ml flush immediately & on alternate loops
VF/VT: States IV access obtained & bloods taken
nd
Administers IV Adrenaline 1 mg with 20ml flush after 2 shock & on alternate loops
rd
Administers IV Amiodarone 300 mg with 20 ml flush after 3 shock
Reversible Verbalises and identifies potential reversible cause/s
causes:  Hypovolaemia  Tension pneumothorax
 Hypoxia  Tamponade
 Hyper/hypothermia  Thrombosis
 Hyper/hypokalaemia / metabolic  Toxins
disorders
Post Assesses pt using ABCDEFG
resuscitation: Discusses post resuscitation care
Comments:
Assessment Decision:  Competent  Not yet Competent

Participant Name: Participant Signature:
Employee No: Ward/Department:
Designation: Date:
Assessors Name: Assessors Signature:


2019 ALS 1 Manual V4 Final

Uploaded by

Copyright:

Available Formats

2019 ALS 1 Manual V4 Final

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2019 ALS 1 Manual V4 Final

Uploaded by

Copyright:

Available Formats

Adult Advanced Life

Published July 2019

South Western Sydney Local Health District (SWSLHD)

Centre for Education and Workforce Development (CEWD)

Phone: (02) 8738 5920

Fax: (02) 8738 6858

Australian Resuscitation Council Guidelines www.resus.org.au

J. Chalmers, Nurse Educator, SWSCEWD

Version Control Table

Adult ALS Manual Level 1 V4 / SWSCEWD 2 of 53

Adult ALS Manual Level 1 V4 / SWSCEWD 3 of 53

The SWSCEWD, Adult ALS Level 1 course consists of:

Pre-requisites for attendance at the Adult ALS workshop CSK12364

At the end of this course the participant are able to:

Adult ALS Manual Level 1 V4 / SWSCEWD 4 of 53

Amanda Hooton: amanda.hooton@sswahs.nsw.gov.au 8738 6089

Adult ALS Manual Level 1 V4 / SWSCEWD 5 of 53

The A to G assessment is a structured approach to physical assessment. It is quick to use

Adult ALS Manual Level 1 V4 / SWSCEWD 6 of 53

Early CPR with an emphasis on chest compressions: Chest compressions and

Adult ALS Manual Level 1 V4 / SWSCEWD 7 of 53

Adult ALS Manual Level 1 V4 / SWSCEWD 8 of 53

In SWSLHD, the process for BLS accreditation is as follows:

During ALS, good chest compressions are vital

‘The quality of chest compressions during in-hospital CPR is frequently sub-optimal.

Good chest compressions for adults (ANZCOR, 2016d):

Adult ALS Manual Level 1 V4 / SWSCEWD 9 of 53

More detail on the ALS for Adults algorithm is below.

DO NOT STOP CPR while defibrillator is charging

To ensure that a shock is ready to go as soon as it is needed, the defibrillator is charged

When should the rhythm be checked?

Non-shockable rhythm – Go to non-shockable arm of the algorithm. ‘Dump’ the charge

Adult ALS Manual Level 1 V4 / SWSCEWD 10 of 53

Pulseless VT/VF: CPR in progress

Cycle continues: Continue compressions and ventilation (30:2) for 2 minutes

ANZCOR 2018, p.8

Adult ALS Manual Level 1 V4 / SWSCEWD 12 of 53

PEA / Asystole: CPR in progress

Cycle continues: Continue compressions and ventilation (30:2) for 2 minutes

During CPR, also consider

Potentially reversible causes

Hypo / Hyperkalaemia / metabolic Thrombosis (pulmonary and coronary)

Hypo / hyperthermia Tension pneumothorax

Hypoxia Toxins / tablets

For further information on reversible causes, refer to the ANZCOR Guidelines:

11.2 Protocols for Adult ALS

11.7 Post resuscitation therapy in adult ALS

Adult ALS Manual Level 1 V4 / SWSCEWD 13 of 53

Airway management is necessary to provide an open airway in the following circumstances:

If the patient is unconscious

Head tilt / chin lift

Adult ALS Manual Level 1 V4 / SWSCEWD 14 of 53

Causes of airway obstruction can include:

 relaxation of airway muscles due to unconsciousness,

Management of Foreign Body Airway Obstruction (FBAO)

First assess the severity of the obstruction.

Effective cough (Mild Airway Obstruction)

Ineffective cough (Severe Airway Obstruction)

Adult ALS Manual Level 1 V4 / SWSCEWD 15 of 53