A set of procedures provided by trained medical staff. In our environment, it is performed by EMS crews and in healthcare facilities by specialized teams.

It differs from Basic Life Support by its presence of:

• airway management equipment
• vascular access
• pharmacotherapy
• ECG monitoring
• defibrillation
• trained team

Nevertheless, providing high-quality CPR stays a priority = high quality, minimally interrupted chest compressions and effective oxygen therapy and ventilation.

As in the basic life support algorithm, we use the acronym SSS ABC to detect SCA.

If the patient is unresponsive to addressing and shaking, we open the airway and check for the presence of breathing for 10 seconds while checking the pulse at the carotid artery.

If a cardiac arrest is detected, we alert the staff present with a loud announcement, e.g. "Cardiac arrest, starting CPR". During ongoing compressions, we start monitoring the patient with an ECG. As soon as possible, when compressions are interrupted, we check the ECG rhythm while detecting the central pulse at the carotid artery.

According to the assessed rhythm, the algorithm is divided into two main branches:

• shockable
• nonshockable.

Shockable rhythm

Early defibrillation is a priority in this branch in addition to quality CPR.

Ventricular fibrillation (VF)

Pulseless ventricular tachycardia (pVT)

Nonshockable rhythm 

In this branch, in addition to providing quality CPR, the priority is to provide early IV/IO access and administration of Adrenaline 1 mg IV (every 3-5 mins).

Asystole

Pulseless electrical activity (PEA)
+ no pulsations on the carotid artery

Reversible causes of cardiac arrest – 4H's/4T's

The presence of reversible causes of arrest should be considered during any CPR. Intervention to remove the present reversible cause should also be performed if possible.

4H	4T
hypoxia	thrombosis  -(coronary, pulmonary)
hypovolemia	tension pneumothorax
hyper-/hypokalemia + other iont disorders	tamponade
hyper-/hypothermia	toxins

Both branches of the ALS algorithm, including reversible causes of circulatory arrest, are described in more detail in the available presentations.

In addition to the content of the presentations, a detailed knowledge of the ERC algorithms is assumed before coming to Lesson 3.

In the text below, we provide key points on each component of ALS.

QUALITY CHEST COMPRESSIONS

The quality of chest compressions is defined by their depth (5-6 cm), frequency (100 -120/min) and minimal interruption. Intermittent compressions are only tolerable during rhythm control, defibrillation and airway management, always for the shortest time possible.

OXYGENATION AND VENTILATION IN ALS

ALS always includes effective ventilation. The first choice method is to use a face mask and a self-expanding bag connected to an oxygen source. Another option is a laryngeal mask or orotracheal intubation. Securing the airway using orotracheal intubation is not the focus of this course. Orotracheal intubation should only be undertaken by an experienced healthcare professional who is safe with this technique.

More about securing airway - Lecture 2.

DEFIBRILLATION + ECG MONITORING

A defibrillator and self-adhesive electrode pads are recommended to allow both ECG monitoring and defibrillation.
If the patient is already being monitored, e.g. in an ICU bed, we can also use a 3- or 5-lead ECG to monitor the ECG.

VASCULAR ACCESS IN ALS

The first method of securing vascular access is using a peripheral venous catheter (PVC), which may be difficult to obtain in patients suffering from SCA. If the PVC insertion is impossible, we immediately proceed to intraosseous access.

PHARMACOTHERAPY

Adrenaline

• Nonshockable rhythm - 1 mg IV/IO every 3 – 5 minutes
• Shockable rhythm – 1 mg IV/IO after 3rd shock, then every 3-5 minutes
• Every drug application is followed by 10 - 20 ml bolus of fluids (saline or balanced crystalloid)

Amiodarone

• Used during shockable rhythm only. Bolus of 300 mg IV/IO after 3rd shock, bolus of 150 ml  IV/IO after 5th shock