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(Circulation. 1997;95:2180-2182.)
© 1997 American Heart Association, Inc.
Articles |
The Universal Advanced Life Support Algorithm
An Advisory Statement From the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation
Key Words: AHA Medical/Scientific Statements • ventilation • cardiopulmonary resuscitation • defibrillation
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Unequivocal Advanced Life Support Interventions |
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Top
Unequivocal Advanced Life...
Basis for RecommendationsValid scientific evidence supports only three interventions as unequivocally effective in adult cardiac resuscitation:
- Basic cardiopulmonary resuscitation (CPR)
- Defibrillation—if the rhythm is ventricular fibrillation or pulseless ventricular tachycardia
- Oxygenation and ventilation of the lungs through a patent secure airway such as a tracheal tube
The universal algorithm presents these interventions simplistically and recommends a specific sequence that rescuers should follow.
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Basis for Recommendations |
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The sequence of interventions is based, whenever possible, on sound scientific information. But there is a paucity of convincing human data on some aspects of resuscitation. Until such time as new information becomes available, the working group made no changes to well-established procedures but suggested some modifications on educational rather than scientific grounds.
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Only Two Arrest Rhythms |
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Cardiac arrest rhythms can be divided into two subsets: ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) and non-VF/VT. Non-VF/VT incorporates both asystole and pulseless electrical activity (PEA). The only difference in management between the two arrest rhythms is the need for rescuers to perform defibrillation for patients in VF/VT. Otherwise the actions and interventions are essentially the same: basic CPR, tracheal intubation, epinephrine administration, and correction of reversible causes.
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Basic CPR and the Precordial Thump |
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Basic life support (BLS) should be performed until advanced life support (ALS) becomes available. In the event of a monitored arrest, a precordial thump is considered a Class I recommendation by the ILCOR. (Note: The AHA considers the precordial thump an optional technique in a monitored arrest and a Class IIb recommendation when the patient is pulseless and a defibrillator is not immediately available.) For an unwitnessed arrest and in children, the thump is a Class IIb recommendation.
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Defibrillation |
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Defibrillation should be performed as soon as VF/VT is recognized. VF is defined as a pulseless, chaotic, disorganized rhythm characterized by an undulating irregular pattern that varies in size and shape with a ventricular waveform of >150 beats per minute.
Defibrillation energy levels should initially be 200 J (2 J/kg) for the first shock, 200 to 300 J (2 to 4 J/kg) for the second shock, and 360 J (4 J/kg) for the third and subsequent shocks (weight-based dosages are pediatric recommendations). Alternative waveforms and energy levels may be acceptable if demonstrated to be of equal or greater net clinical benefit in terms of safety and efficacy.
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Tracheal Intubation |
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Tracheal intubation is a Class I recommendation. If tracheal intubation is not possible, the laryngeal mask airway or Combitube are acceptable initial alternatives in adults.
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Intravascular Access |
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Intravascular access is a Class I recommendation. If intravascular access is not attainable, epinephrine may be administered via the tracheal tube using at least double the intravascular dosage.
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Epinephrine |
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Epinephrine should be administered using a dosage of at least 1 mg (0.01 mg/kg) every 3 minutes.
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Correction of Reversible Causes |
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The universal algorithm specifically directs rescuers to seek and treat reversible causes of the cardiac arrest. This recommendation is based on the appreciation that many people, especially those in non-VF/VT, have an identifiable cause for the cardiac arrest. Many of these causes can be reversed with specific interventions. As a teaching aide-memoire, the algorithm lists the most common reversible causes of cardiac arrest. Thus, we have moved from the former rhythm-based treatment approach to a more clinically relevant etiologic approach.
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Special Considerations |
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The use of buffers, antiarrhythmics, atropine, and pacing can be considered in certain special resuscitation situations. ILCOR has prepared an advisory statement on conditions that may require modifications in resuscitation procedures or techniques, based on the specific etiology of the arrest.
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Using the Universal Algorithm |
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Resuscitation algorithms are simple visual teaching tools and memory aids. They convey only a small portion of the knowledge needed to counter cardiopulmonary emergencies. The working group has resisted the temptation to construct all-inclusive algorithms that address most contingencies and possibilities. This would be complex and confusing. Instead, we have attempted to provide the framework for resuscitation while maintaining a simplified approach that will aid training and teamwork (Figure
).
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The Ultimate Simplicity of ALS Resuscitation |
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Our knowledge of effective therapy for cardiac arrest can be summarized as follows:
- Perform CPR at all times for pulseless patients (with the obvious exception of rhythm analysis and defibrillation shocks).
- Defibrillate VF/VT until it is no longer present.
- Gain control of the airway and provide adequate oxygenation and ventilation.
- Give intravenous boluses of epinephrine.
- Correct reversible causes.
To remember and provide these steps as rapidly and effectively as possible will serve our patients well.
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Footnotes |
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1 Resuscitation Councils of Southern Africa
3 European Resuscitation Council
4 Australian Resuscitation Council
5 Heart and Stroke Foundation of Canada.
`The Universal ALS Algorithm' was approved by the American Heart Association Science Advisory and Coordinating Committee in February 1997.
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