11/13/24, 7\:38 PM Guide | Pre-hospital ALS

Pre-hospital ALS

Table of contents

Introduction

This pre-hospital advanced life support (ALS) OSCE guide aims to provide an overview of performing ALS in a pre-hospital
environment for an out-of-hospital cardiac arrest (OOHCA). This guide is based on the Resuscitation Council (UK) guidance
and is intended only for students preparing for their OSCEs and not for patient care.

Advanced life support

Advanced life support (ALS) builds on basic life support (BLS) to provide patients with a higher level of care, increasing the
likelihood of survival in the event of a cardiac arrest.
To achieve this, ALS involves deintravenous or intraosseous access, drugs, and advanced airway management.
ALS is a team e
ALS can be performed by anyone with the appropriate training such as doctors, nurses, paramedics, and other allied health
professionals.

Initial assessment

The role of the initial assessment is
It needs to be careful and quick to give the patient the best chance of survival.

Safety

Initial patient assessment should always begin with ensuring both personal and scene safety.
Scene safety includes ensuring the environment is safe\: there needs to be a clear area around the patient to allow medical
sta
safe area to allow 360° access, and patients on chairs or beds should be moved onto the
compressions.
Personal safety must also be maintained through personal protective equipment (PPE). This will normally include gloves and a
type IIR facemask as a minimum, but may also include aprons, gowns, eye protection, an FFP3 mask, a respirator hood and a
high-visibility jacket.

Patient assessment

Once the scene is declared safe, approach the patient and begin the assessment\:
1. Assessing their level of consciousness. Are they alert or responsive to a verbal or painful stimulus? If they are unresponsive
to pain they can be deemed to be unconscious
2. Open and assess the patient's airway by using either a head-tilt chin-lift or jaw thrust
3. Look, listen, and feel for breathing and a carotid pulse for ten seconds
4. If there is ine
5. Start basic life support at a ratio of 30 compressions to 2 ventilations until a de
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De

safety should always be considered. To do this, consider the "6Ps"
\:
Perspiration\: excessive perspiration should be dried to allow pad adhesion
Pacemakers\: de
Patches\: de
placement altered
Piercings\: de
Puddles\: patients should be moved into a dry environment before de
Explosive environments\: for the safety of the patient and rescuers, de
environment
Considering these factors when de
bystanders.
Before de
charged, and then, a full top-to-toe sweep should be completed. Eyes should be kept on the patient as the shock is delivered
to ensure no one accidentally touches the patient. As soon as the shock is delivered, CPR should be restarted, minimising time
o

The ALS algorithm

ALS uses an algorithm with two distinct pathways to provide a systematic approach to managing cardiac arrest.
When following the ALS algorithm it is important to remember the basics, with high-quality CPR and early de
being the top priorities, quickly followed by gaining intravenous/intraosseous access and upgrading to an advanced airway.
Actions such as gaining IV/IO access, upgrading the airway, administering drugs and considering reversible causes should be
completed during the two minutes of CPR.
There are two sides to the ALS algorithm\: shockable and non-shockable.

Shockable rhythms

If the patient is in pulseless ventricular tachycardia (pVT) or ventricular
be used.
1. If the initial rhythm is shockable, provide one shock (at the recommended joules for your equipment)
2. Immediately resume CPR for 2 minutes before performing another rhythm check
3. Increase the joules with each shock in-line with your organisational guidance
4. After the third shock, give 300mg amiodarone and 1mg adrenaline IV/IO
5. Continue adrenaline every 3-5min
6. After the
7. Repeat until return of spontaneous circulation (ROSC) is achieved, or the patient moves into the non-shockable side of the
algorithm
Tip\: always check for a pulse if the monitor shows VT as this rhythm may be a pulsed, perfusing rhythm

Non-shockable rhythms

If the patient is in pulseless electrical activity (PEA), or asystole then the non-shockable algorithm should be used.
1. Immediately resume CPR for 2 minutes before performing another rhythm check
2. Give adrenaline 1mg IV/IO every 3 - 5 minutes
If the patient moves between shockable and non-shockable rhythms, then once the adrenaline has been administered, it
should be given every 3-5 minutes, regardless of the rhythm, until ROSC is achieved.
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Reversible causes of cardiac arrest
There are eight reversible causes of cardiac arrest, the four Hs and four Ts\:
Hypoxia
Hypokalaemia/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia
Tension pneumothorax
Tamponade (cardiac)
Thrombosis
Toxins
It is important to quickly identify and manage reversible causes during a cardiac arrest scenario. Successful
management and reversal of these causes will increase the likelihood of ROSC.

Airway management

Airway management and protection are vital in cardiac arrest to enable appropriate ventilation and oxygenation.
A stepwise approach should be taken towards airway management, with manual techniques being used
advanced equipment being utilised when appropriately trained sta
For more information on airway management devices, see the Geeky Medics guide to airway equipment.

Oropharyngeal airway (OPA)

An oropharyngeal airway (OPA) should be used during the initial phases of a cardiac arrest as they are quick and easy to
insert and work well with a bag valve mask for ventilation.

Nasopharyngeal airway

Nasopharyngeal airways can be used in place of an OPA in the event of trismus or an obstruction in the mouth.
Supraglottic airway / i-gel®
Supraglottic airways are inserted into the pharynx and enable higher-pressure ventilation and expiratory gas monitoring.
There are various supraglottic airways, including laryngeal mask airways (with either in
the i-gel ®
with a thermoplastic elastomer used to create a seal around the larynx.
The use of supraglottic airways is common in cardiac arrests due to their relatively simple insertion technique.

Endotracheal intubation

Endotracheal intubation is a specialist skill and should only be attempted by rescuers with a high success rate - 95%
achievement within two intubations.
An endotracheal tube is guided through the larynx and into the trachea before an in
This allows for high-pressure ventilation as well as signi
When an advanced airway is in place, the correct placement must be con
tidal CO₂ via waveform capnography.

Pit-stop model

When managing a cardiac arrest in a prehospital environment, the location of equipment and identi
vital to enable well-organised management and mitigate the negative impact of human factors.
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The 360/pit stop model
The 360° or pit stop model has been developed so that there is a standardised approach to each cardiac arrest. It enables
each member of the resuscitation team to have su
access to the equipment they need.
De
Airway\: the person at the very head of the patient with access to basic and advanced airway equipment. They are primarily
responsible for airway management but can provide CPR from their position if required.
CPR 1/de
de
members of the team.
CPR 2\: this role depends on the number of clinicians present. They are located to the patient's right and can alternate chest
compressions with CPR 1 or be the airway assistant.
Drugs\: positioned to the patient's lower right, they are responsible for gaining IV/IO access and administering medications
when necessary. They need access to equipment from the basic life support bag, IV/IO equipment and drugs.
Team leader\: should be positioned at the patient's feet and have a good view of the resuscitation. They should not become
directly involved with any particular aspect, but rather direct the team to complete tasks as appropriate. The team leader is
responsible for timing the arrest, as well as addressing any reversible causes. If available, the team leader should use
a checklist to ensure a systematic and standardised approach.
Should resourcing allow, two more team roles can be created - family liaison and runner. Family liaison works to gain as
thorough a history as possible whilst updating family members on what is occurring with the resuscitative e
will be in charge of collecting/replacing equipment (e.g. oxygen cylinders) from the site of the arrest to the ambulance.

Special circumstances

In some cardiac arrests, the ALS algorithm is adapted to provide more speci
survival.

Anaphylaxis

Anaphylaxis is a severe and life-threatening reaction to an antigen, presenting with rapid onset ABC problems or signi
skin/mucosal changes. It can cause global oedema resulting in hypovolemia, as well as swelling to the airway causing
signi
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Early intramuscular adrenaline should be administered in a patient with suspected anaphylaxis. This will signi
the likelihood of cardiac arrest.
Anaphylaxis leads to airway closure due to rapid swelling causing hypoxia, and hypovolemia due to anaphylactic shock.
These should be managed as reversible causes in an arrest.
Early intubation should be considered in the anaphylactic patient, as the rapid airway swelling will make management
increasingly di
For more information, see the Geeky Medics guide to the emergency management of anaphylaxis.

Asthma and COPD

COPD and asthma are extremely common in the UK, with 1 in 5 people having lung disease. These conditions can become
acutely exacerbated causing hypoxia, potentially leading to cardiac arrest.
The primary cause of cardiac arrest in COPD and asthma patients is hypoxia. Consider early tracheal intubation due to
increased intrathoracic pressure.
Provide manual ventilation over mechanical ventilation to reduce the risk of hyperin
Monitor constantly for signs of tension pneumothorax, and treat with thoracostomy as appropriate.
For more information, see the Geeky Medics guides to the emergency management of asthma and the emergency
management of COPD.

Drowning

In the UK, around 600 people die by drowning each year. Correctly managing a drowned patient is critical, as early
intervention can increase the chances of survival.
Drowning causes respiratory failure through immersion or submersion. As such, the leading cause of cardiac arrest is hypoxia.
However, hypothermia and arrhythmias should also be considered.
In water \<5°C, hypothermia is likely to be the primary cause, providing some protection against hypoxia.
Palpation of a pulse is unreliable in cold and wet patients. Therefore, ECG and waveform capnography should be utilised to
con
Give
may be required due to pulmonary oedema.

Hypothermia

Hypothermia occurs when the environment is too cold for a person’s body to regulate, and the core temperature drops. This
decreases cerebral out
To con
If the patient’s temperature is below 30°C and VF persists after three de
temperature rises above 30°C.
No cardiac arrest drugs should be given if the patient’s body temperature is below 30°C.
If the body temperature is 30-34°C, the timing of adrenaline intervals should be doubled to every 6-10 minutes.
All e
Where possible, patients should be warmed via extracorporeal life support (ECLS) and extracorporeal membrane
oxygenation (ECMO).

Maternal cardiac arrests

Pregnant women experience physiological changes and their bodies are placed under additional stress. Whilst maternal
cardiac arrests are relatively infrequent, the correct management is vital for patient survival. There are two patients, both of
whom need to be rescued.
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Maternal arrests are commonly caused by hypoxia or hypovolaemia. Consider the likelihood of concealed intrauterine
bleeding.
Call for specialist help immediately, including obstetrics and neonatology. Consider early intubation to help manage the
potentially oedematous airway.
If the patient is more than 20 weeks pregnant, the uterus should be displaced to the patient’s left side. This will reduce
aortocaval compression, potentially improving cardiac output.
If possible, apply left lateral tilt to the patient, either by angling the patient’s bed or by placing them on an angled scoop
stretcher.
If a ROSC is not achieved within four minutes of cardiac arrest, prepare for the emergency delivery of the foetus.

Obesity

With an increasingly obese population, it is important to recognise how to manage these patients in cardiac arrest situations.
The normal ALS algorithm should be followed. Chest compressions will be increasingly di
swapped more frequently to prevent fatigue. Anticipate di

Overdose

Intentional or accidental overdoses are becoming increasingly common, with potentially devastating e
Always maintain personal safety, especially if the cause is unknown or likely to be part of a CBRNE incident.
Use speci
Prolonged CPR may be appropriate for this cohort of patients, and a good neurological outcome is possible. Extracorporeal
cardiopulmonary resuscitation (ECPR) may be appropriate.
For more information, view our guides on benzodiazepine, opioid, salicylate, and tricyclic antidepressant overdose.
Opioid overdose
Of all drugs taken in overdose, opioids have been consistently shown to be the most likely to cause death. Respiratory
arrest usually leads to cardiac arrest, with hypoxia as the primary reversible cause.
In opiate overdoses, naloxone can be administered\:
Provide an initial dose of 400mcg IV/IO
Subsequent doses should be 800mcg IV/IO, every 60 seconds
Doses should be titrated until the patient can maintain their own airway
If there has been no response after 10mg of naloxone, another cause for the arrest should be considered
Naloxone administration should not compromise good quality CPR, early de
For more information, see the Geeky Medics guide to the emergency management of an opioid overdose.

Sepsis

Infection and sepsis are one of the leading causes of hospital admission, with patients being at high risk of deterioration into
septic shock. When this occurs, blood pressure drops and body systems fail to receive su
cardiac arrest.
When managing a cardiac arrest due to sepsis, follow the standard ALS algorithm and provide a 500ml
possible.
For more information, see the Geeky Medics guide to the emergency management of sepsis.

Return of spontaneous circulation (ROSC)

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s an advanced airway, it can be removed.

Breathing

Oxygen saturations should be maintained at 94 - 98% to prevent hypoxia or hyperoxia.
If the patient is breathing at a sustainable rate (above 10 breaths per minute) allow them to self-ventilate. Assistance may be
required if they are hypoventilating, which can be via bag-valve-mask or preferably a mechanical ventilator.
Measure end-tidal CO₂ and aim for a capnography reading of 4.6-6.0kPa (35-40mmHg), with a good waveform.

Circulation

elevation).
Following a cardiac arrest, repeat 12-lead ECGs should be performed to highlight any signi
Aim to maintain systolic blood pressure >100mmHg.

Disability

Most patients will have a signi
However, in some cases, they may become agitated and combative. In these situations, senior clinicians should be consulted
to consider sedation or anaesthesia.

Exposure

The patient’s temperature should be measured and appropriately managed, and they should be covered to maintain their
dignity.

Extrication

The decision to transport a cardiac arrest patient is complex, and decision-making should be based on clinical factors,
including\:
Presenting rhythm
Time without CPR
Response to treatment
Likelihood of a reversible cause that is unable to be identihyperkalemia)
Travel time to hospital
If the cardiac arrest occurred in a public location
The following patient groups should be conveyed to hospital\:
ROSC patients
Children
Pregnant women
Refractory/recurrent VF or pVT
Patients potentially suitable for primary percutaneous coronary intervention (PPCI)

Extrication method

Extrication of patients is a key skill for paramedics. Each situation will present challenges, such as tight corners, multiple

through experience.
If possible, the patient should be lifted onto the stretcher and wheeled to the ambulance. If this is not possible the stretcher
should be placed by the door to the property, and the patient should be extricated on a scoop stretcher and/or carry sheet
before being loaded onto the stretcher.
Consider using a mechanical ventilator or mechanical CPR device during extrication and conveyance to maximise free
resources and minimise the potential for falls and injury.
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Termination of resuscitation

In some cases of out-of-hospital cardiac arrest, patients will either be unresponsive to ALS or be in such a critical state that
resuscitation would be futile. Identifying these factors is essential for all clinicians to prevent unnecessary resuscitation
e

Recognition of life extinct (ROLE)

There are seven main criteria unequivocally associated with death commonly used by ambulance services. These are called
the Recognition of life extinct (ROLE) criteria\:
Incineration\: >95% full-thickness burns
Massive cranial destruction
Decapitation
Hemicorporectomy or similar massive injury
Rigor Mortis
Decomposition
Hypostasis
These include\:
Outside of the above criteria, there are other circumstances where resuscitation would be futile or inappropriate to o
The presence of a valid DNACPR/ReSPECT form
The presence of an advanced decision to refuse treatment
If a patient is deemed to be in the
neurological conditions and advanced frailty.
Submersion for over 90 minutes
>15 minutes since the start of the cardiac arrest with no evidence of bystander and 30 seconds of asystole on the ECG
monitor

Termination of resuscitation

Termination of resuscitation in the prehospital environment is a very complex decision balancing factors such as proximity to
hospital, availability of enhanced care teams, and the patient's condition.
There is varying guidance depending on the local ambulance service and presenting rhythm. It is essential to check and follow
any local guidelines.
Asystole
The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) advises that termination of resuscitation can occur after 30
minutes of ALS, provided all reversible causes have been addressed, and the patient has been asystolic throughout.
Low amplitude, irregular or wide QRS complexes with a rate under 10 beats per minute are not associated with e
cardiac output. If it has persisted for 30 minutes it can be treated as asystole.
Pulseless electrical activity (PEA)
Policy on termination of pulseless electrical activity varies across the UK and depends on local guidelines.
An increasing number of services utilise remote clinical support to aid crews in making these decisions, allowing discussions
between paramedics on scene and advanced paramedics or doctors. Factors that in
the community include\:
Time without CPR
Overall time in cardiac arrest
Absence of reversible causes
Comorbidities
Changes in presenting rhythm
The trend and value of ETCO2
Rate and width of QRS complex
Shockable rhythms
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Patients who present in a shockable rhythm will receive de
present this can indicate myocardial infarction, a potentially reversible cause requiring hospital intervention. As such it is not in
routine paramedic practice to terminate the resuscitation of this cohort of patients.

Handover

Ambulance pre-alerts follow a set structure to ensure accurate information is passed to the receiving area. Pre-alerts are
passed direct from the prehospital clinician or via the emergency operations centre (EOC).
Information passed will normally follow an ATMIST or SBAR structure. For more information, see our guide to pre-hospital
communication.
For an out-of-hospital cardiac arrest, the following information will normally be provided\:
Approximate age
Presenting rhythm of the arrest and current rhythm
Suspected aetiology of the arrest
Any ROSC and length of time maintained
Any requests for patient care on arrival (e.g sedation or advanced airway management)
Estimated time of arrival
Information may be limited depending on the circumstances and location of the out-of-hospital cardiac arrest.

Reviewer

Ashley Price

References

National Water Safety Available from\: [LINK]
Forum, 2015. A f u t u r e w i t h o u t d r o w n i n g \: T h e U K D r o w n i n g P r e v e n t i o n S t r a t e g y 2 0 1 6-2 0 2 6 . [Online].
Resuscitation Council UK, 2021. A d u l t a d v a n c e d l i f e s u p p o r t G u i d e l i n e s . [Online]. Available from\: [LINK]
Resuscitation Council UK, 2021. P o s t-r e s u s c i t a t i o n c a r e G u i d e l i n e s . [Online]. Available from\: [LINK]
Resuscitation Council UK, 2021. S p e c i a l C i r c u m s t a n c e s G u i d e l i n e s . [Online]. Available from\: [LINK]
The Sepsis Trust, 2022. Y e l l o w M a n u a l - 6 t h E d i t i o n . [Online]. Available from\: [LINK]
Hopkins, C., Burk, C., Moser, S., Meersman, J., Baldwin, C., & Youngquist, S. (2016). Implementation of Pit Crew Approach and
C di l R it ti M t i f O t f H it l C di A t I P ti t S i l d N l i l
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