Advanced Life Support - Adult

Quick Answer

Critical: Advanced Life Support (ALS) for adult cardiac arrest follows the ARC/ANZCOR Guideline 11 algorithm, emphasising high-quality CPR, early defibrillation for shockable rhythms, and systematic consideration of reversible causes. Survival depends on the Chain of Survival: early recognition, early CPR, early defibrillation, and early advanced care with post-resuscitation optimisation.

Adult Advanced Life Support provides the framework for managing cardiac arrest beyond basic CPR and AED use. ALS incorporates advanced airway management, vascular access, pharmacotherapy, rhythm interpretation, and treatment of reversible causes. In Australia, out-of-hospital cardiac arrest (OHCA) affects 55-113 per 100,000 population annually, with survival to discharge of approximately 10-12%. The ARC/ANZCOR guidelines differ from AHA in several key areas, including adrenaline timing and algorithm structure. High-quality CPR (100-120/min, 5-6cm depth, full recoil, minimal interruptions) remains the cornerstone of successful resuscitation [1,2].

---

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Cardiac anatomy (coronary circulation, conduction system), chest wall anatomy for CPR mechanics, airway anatomy for intubation
• Physiology: Cardiac electrophysiology (action potentials, automaticity), oxygen-haemoglobin dissociation, acid-base balance during arrest, cerebral autoregulation
• Pharmacology: Adrenaline (alpha and beta effects), amiodarone (class III antiarrhythmic), sodium bicarbonate, calcium chloride, magnesium
• Pathology: Ischaemic myocardial injury, hypoxic brain injury, reperfusion injury

Fellowship Exam Relevance

• Written (SAQ/MCQ): Algorithm knowledge, drug doses and timing, reversible causes, post-resuscitation care, ECMO criteria, prognostication
• OSCE: Resuscitation leadership station (extremely high yield), team communication, breaking bad news post-arrest
• Key domains tested: Medical Expert (algorithm adherence), Leader (team coordination), Communicator (closed-loop, family communication)
• Hot topics: ECPR eligibility, double sequential defibrillation, targeted temperature management controversy

Exam Discrimination Points

• ARC algorithm timing differs from AHA - know Australian guidelines
• Adrenaline: after 3rd shock (shockable), immediately (non-shockable)
• Amiodarone dosing: 300mg then 150mg (not 150mg then 150mg)
• ETCO2 interpretation during arrest
• ECPR indications and contraindications

---

Key Points

---

Epidemiology

Australian/NZ Specific Data

• Aus-ROC Registry: National OHCA outcomes registry tracking approximately 20,000 cases annually [11]
• Indigenous populations: 2-3x higher OHCA incidence, younger age at arrest, lower survival rates [12]
• Metropolitan vs rural: Significant outcome disparity - metro survival 12%, rural 6-8% [13]
• Public AED programs: Increasing but variable coverage; higher in metro areas [9]
• RFDS coverage: Critical for remote areas; prolonged transport times affect viability

Temporal Trends

• Bystander CPR rates increasing (30% in 2010 to 55% in 2023) [8]
• Shockable rhythm proportion declining (35% in 2000 to 20% in 2023) [7]
• Overall survival improving despite declining shockable rhythms [5]
• COVID-19 pandemic: Transient decrease in bystander CPR and survival [14]

---

Pathophysiology

Mechanism of Cardiac Arrest

Electrical vs Mechanical Causes:

• Shockable rhythms (VF/pVT): Primary electrical disturbance; cardiac muscle capable of coordinated contraction if rhythm restored
• Non-shockable rhythms (PEA/Asystole): Usually metabolic, mechanical, or hypoxic cause; worse prognosis as underlying cause often irreversible

Phases of Cardiac Arrest

1. Electrical Phase (0-4 minutes)

• Immediate VF may respond to defibrillation alone
• Highest probability of successful conversion
• Minimal ischaemic injury
• CPR not essential if defibrillation immediate

2. Circulatory Phase (4-10 minutes)

• ATP depleted, myocardium ischaemic
• CPR essential before defibrillation (controversial)
• Coronary perfusion required for shock success
• Brain tolerating hypoxia but injury beginning

3. Metabolic Phase (greater than 10 minutes)

• Systemic ischaemia-reperfusion injury
• Multi-organ dysfunction developing
• Coagulopathy, acidosis, hypothermia
• Inflammatory cascade activation
• Irreversible neuronal injury progressing

Physiology of CPR

Cardiac Pump Theory:

• Direct cardiac compression between sternum and spine
• Generates forward flow through valves
• Produces approximately 25-30% normal cardiac output

Thoracic Pump Theory:

• Intrathoracic pressure changes
• Venous collapse prevents retrograde flow
• Arterial flow maintained during compression

Coronary Perfusion Pressure (CPP):

• CPP = Aortic diastolic pressure - Right atrial diastolic pressure
• Target: greater than 15-20 mmHg for ROSC probability
• Interrupted CPR causes CPP to drop rapidly
• Requires 30+ seconds of compressions to rebuild

End-Tidal CO2 Physiology

During Arrest:

• ETCO2 reflects pulmonary blood flow (cardiac output from CPR)
• Low ETCO2 (under 10 mmHg): Poor CPR quality OR poor prognosis
• ETCO2 10-20 mmHg: Adequate CPR, uncertain prognosis
• Sudden rise during CPR: Suggests ROSC (increased pulmonary blood flow)

Prognostic Value:

• ETCO2 persistently under 10 mmHg after 20 minutes: Very poor prognosis [15]
• ETCO2 cannot differentiate good vs poor CPR in all cases
• Affected by ventilation rate, sodium bicarbonate, pulmonary pathology

---

ARC/ANZCOR ALS Algorithm (Guideline 11)

Complete ANZCOR Guideline 11 Algorithm

┌─────────────────────────────────────────────────────────────────┐
│                    ADULT CARDIAC ARREST                         │
│                    ANZCOR Guideline 11                          │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│           CONFIRM CARDIAC ARREST                                 │
│  • Unresponsive                                                 │
│  • Not breathing normally (agonal gasps = arrest)               │
│  • No pulse (under 10 seconds check for healthcare providers)   │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│              CALL FOR HELP                                       │
│  • Call 000 (Australia) / 111 (New Zealand)                     │
│  • Activate hospital resuscitation team                         │
│  • Request defibrillator/AED                                    │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│           START HIGH-QUALITY CPR                                 │
│  • Rate: 100-120 compressions/minute                            │
│  • Depth: 5-6 cm (adult)                                        │
│  • Full chest recoil between compressions                       │
│  • Minimise interruptions (under 10 seconds)                    │
│  • 30:2 ratio (or continuous with advanced airway)              │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│           ATTACH DEFIBRILLATOR/MONITOR                          │
│  • Apply pads - anterior-lateral position                       │
│  • Analyse rhythm                                               │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
                    ┌─────────────────────┐
                    │   RHYTHM CHECK      │
                    │   (every 2 min)     │
                    └─────────────────────┘
                              │
              ┌───────────────┴───────────────┐
              ▼                               ▼
    ┌─────────────────┐              ┌─────────────────┐
    │   SHOCKABLE     │              │  NON-SHOCKABLE  │
    │   (VF / pVT)    │              │  (PEA/Asystole) │
    └─────────────────┘              └─────────────────┘
              │                               │
              ▼                               ▼
    ┌─────────────────┐              ┌─────────────────┐
    │  DEFIBRILLATE   │              │  ADRENALINE     │
    │  Biphasic:      │              │  1mg IV/IO      │
    │  150-200J       │              │  IMMEDIATELY    │
    │  (or as per     │              │  Then every     │
    │  device)        │              │  3-5 minutes    │
    │  Monophasic:    │              │                 │
    │  360J           │              │                 │
    └─────────────────┘              └─────────────────┘
              │                               │
              ▼                               ▼
    ┌─────────────────┐              ┌─────────────────┐
    │  RESUME CPR     │              │  RESUME CPR     │
    │  IMMEDIATELY    │              │  FOR 2 MINUTES  │
    │  for 2 minutes  │              │                 │
    └─────────────────┘              └─────────────────┘
              │                               │
              ▼                               │
    ┌─────────────────┐                       │
    │ After 3rd SHOCK │                       │
    │                 │                       │
    │ • Adrenaline    │                       │
    │   1mg IV/IO     │                       │
    │                 │                       │
    │ • Amiodarone    │                       │
    │   300mg IV/IO   │                       │
    └─────────────────┘                       │
              │                               │
              ▼                               │
    ┌─────────────────┐                       │
    │ After 5th SHOCK │                       │
    │                 │                       │
    │ • Amiodarone    │                       │
    │   150mg IV/IO   │                       │
    └─────────────────┘                       │
              │                               │
              └───────────────┬───────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│              DURING CPR - THROUGHOUT                             │
│                                                                  │
│  • Ensure high-quality CPR: rate, depth, recoil                 │
│  • Rotate compressors every 2 minutes                           │
│  • Establish IV/IO access                                       │
│  • Consider advanced airway (do not interrupt CPR)              │
│  • Continuous waveform capnography                              │
│  • Treat REVERSIBLE CAUSES                                       │
│                                                                  │
│     4 Hs                        4 Ts                            │
│     ─────                       ─────                           │
│     Hypoxia                     Tension pneumothorax            │
│     Hypovolaemia                Tamponade                       │
│     Hypo/Hyperkalaemia          Toxins                          │
│     Hypothermia                 Thrombosis (PE/coronary)        │
│                                                                  │
│  • Consider ultrasound during rhythm check                      │
│  • Consider mechanical CPR for transport/interventions          │
│  • Consider ECMO/ECPR if appropriate                            │
└─────────────────────────────────────────────────────────────────┘
                              │
                              ▼
┌─────────────────────────────────────────────────────────────────┐
│                         ROSC?                                    │
└─────────────────────────────────────────────────────────────────┘
                              │
              ┌───────────────┴───────────────┐
              ▼                               ▼
         ┌────────┐                    ┌─────────────┐
         │  YES   │                    │     NO      │
         └────────┘                    └─────────────┘
              │                               │
              ▼                               ▼
    ┌─────────────────┐              ┌─────────────────┐
    │ POST-ROSC CARE  │              │ CONTINUE CPR    │
    │                 │              │ OR              │
    │ • ABCDE         │              │ CONSIDER        │
    │ • SpO2 94-98%   │              │ TERMINATION     │
    │ • 12-lead ECG   │              │                 │
    │ • Treat cause   │              │ Termination     │
    │ • Target temp   │              │ criteria:       │
    │   management    │              │ • Asystole over 20  │
    │ • ICU admission │              │   min with ALS  │
    │                 │              │ • No reversible │
    │ STEMI? →        │              │   cause         │
    │ Emergent PCI    │              │ • ETCO2 below 10     │
    │                 │              │   persistently  │
    └─────────────────┘              └─────────────────┘

---

Shockable Rhythms Pathway (VF/pVT)

Ventricular Fibrillation (VF)

• Definition: Chaotic, disorganised ventricular electrical activity without coordinated contraction
• ECG appearance: Irregular, chaotic waveform; no identifiable P waves, QRS, or T waves
• Coarse vs Fine VF: Amplitude greater than 0.5mV (coarse) vs less than 0.5mV (fine); coarse may respond better to defibrillation
• Primary VF: Occurs as initial rhythm; better prognosis (typically ischaemic)
• Secondary VF: Develops during resuscitation; often indicates deterioration

Pulseless Ventricular Tachycardia (pVT)

• Definition: Wide complex tachycardia without palpable pulse
• ECG appearance: Regular, wide QRS (greater than 120ms), rate usually 150-250/min
• Monomorphic vs Polymorphic: Uniform QRS morphology (monomorphic) vs varying morphology (polymorphic/Torsades)
• Treatment identical to VF: Defibrillation + ALS algorithm

Defibrillation Protocol

Energy Levels (ARC/ANZCOR):

Defibrillation Technique:

1. Charge during CPR (minimise hands-off time)
2. "Stand clear"

• visual and verbal confirmation

3. Deliver shock
4. Immediately resume CPR - do not check rhythm/pulse
5. CPR for 2 minutes then rhythm check

Pad Position Options:

Shockable Rhythm Timeline

Refractory VF Strategies

If VF persists after 3+ shocks:

1. Verify pad position and contact
2. Change pad position (anterior-posterior)
3. Double sequential defibrillation (off-label but emerging evidence) [16]
4. Review reversible causes - especially electrolytes, toxins
5. Consider thrombolysis if PE or STEMI suspected [17]
6. Consider ECMO/ECPR if available and appropriate [18]
7. Lignocaine 1-1.5mg/kg as alternative antiarrhythmic [19]

---

Non-Shockable Rhythms Pathway (PEA/Asystole)

Pulseless Electrical Activity (PEA)

• Definition: Organised electrical activity on monitor without palpable pulse/cardiac output
• Wide complex PEA: Usually indicates myocardial damage/dysfunction
• Narrow complex PEA: May indicate mechanical cause (PE, tamponade, hypovolaemia)
• Pseudo-PEA: Organised rhythm with some cardiac contraction but output insufficient for palpable pulse; may respond to vasopressors

Asystole

• Definition: Complete absence of ventricular electrical activity
• ECG appearance: Flat line (must confirm in 2 leads, check connections)
• Fine VF vs Asystole: If uncertain, treat as VF (shock if any doubt)
• Prognosis: Worst arrest rhythm; less than 5% survival if initial rhythm

Key Management Differences from Shockable

PEA Reversible Causes - Focused Approach

Think "Cardiac Ultrasound" during rhythm check:

• Tamponade: Pericardial fluid, RV collapse
• PE: Dilated RV, D-sign
• Hypovolaemia: Empty hyperdynamic LV
• Wall motion abnormality: Ischaemia

Management by Cause:

---

Drug Protocols

Adrenaline (Epinephrine)

Pharmacology:

• Non-selective alpha and beta adrenergic agonist
• Alpha-1: Peripheral vasoconstriction → increased coronary and cerebral perfusion pressure
• Beta-1: Increased heart rate and contractility (less relevant during arrest)
• Half-life: approximately 2 minutes

Dosing Protocol:

Evidence:

• PARAMEDIC2 trial: Adrenaline improves ROSC (23.8% vs 8.0%) but no difference in favourable neurological outcome (2.2% vs 1.9%) [20]
• Role increasingly questioned but remains standard of care
• Earlier administration associated with better outcomes in observational studies [21]

Amiodarone

Pharmacology:

• Class III antiarrhythmic (potassium channel blocker)
• Also has sodium, calcium channel and beta-blocking properties
• Long half-life (40-55 days)

Dosing Protocol:

Evidence:

• ALPS trial: No survival benefit vs lignocaine vs placebo [19]
• Remains standard as may improve ROSC
• Consider for refractory VF

Lignocaine (Alternative)

Other Cardiac Arrest Drugs

Atropine - No Longer Recommended

Important: Atropine is NO LONGER part of the ARC/ANZCOR adult cardiac arrest algorithm. It was removed in 2010 as evidence showed no benefit in asystole or PEA. However, atropine remains useful for symptomatic bradycardia.

---

Advanced Airway Management

Airway Approach During Cardiac Arrest

Hierarchy of Priorities:

1. High-quality CPR with minimal interruptions
2. Basic airway manoeuvres (head tilt, chin lift, jaw thrust)
3. Basic adjuncts (OPA, NPA)
4. Bag-mask ventilation with two-person technique
5. Supraglottic airway (SGA) device
6. Endotracheal intubation (by experienced provider)

Key Principle: Do NOT interrupt CPR for intubation

Bag-Mask Ventilation (BVM)

Technique:

• Two-person technique preferred
• C-E grip for mask seal
• Rate: 10 breaths/minute (1 every 6 seconds with advanced airway)
• Avoid hyperventilation (reduces venous return)

Effectiveness:

• PART trial: BVM equivalent to ETT for survival [22]
• Reasonable first-line approach
• Avoids intubation complications

Supraglottic Airways

SGA Evidence:

• AIRWAYS-2 trial: SGA non-inferior to ETT for 30-day survival [23]
• Consider as first-line advanced airway
• Faster insertion, fewer interruptions

Endotracheal Intubation

Indications During Arrest:

• Inadequate oxygenation with BVM/SGA
• High aspiration risk
• Prolonged resuscitation expected
• Post-ROSC if ongoing airway concern

Technique in Arrest:

1. Prepare equipment during CPR (ETT, laryngoscope, drugs not usually needed)
2. Pre-oxygenate (if possible)
3. Attempt intubation during 10-second pause for rhythm check
4. If unsuccessful in 30 seconds, resume CPR with BVM/SGA
5. Confirm with waveform capnography

Confirmation:

• Waveform capnography - Gold standard
• Clinical: Chest rise, breath sounds, misting
• Do not rely on oesophageal detector alone

Ventilation with Advanced Airway

Capnography Targets:

---

Vascular Access

Intravenous Access

Preferred Sites:

1. Antecubital fossa (most accessible during CPR)
2. External jugular vein
3. Femoral vein (if experienced)

Considerations:

• Peripheral IV acceptable - follow with 20mL flush
• Do not interrupt CPR for IV access
• If IV unsuccessful after 2 attempts, proceed to IO

Intraosseous Access

Indications:

• IV access unsuccessful within 60-90 seconds
• Difficult venous access anticipated
• Time-critical situation

Sites:

Devices Available:

• EZ-IO (battery-powered drill)
• FAST1 (sternal)
• Manual IO needles

Drug Delivery:

• All resuscitation drugs can be given IO
• Equivalent efficacy to IV
• Flush with 10-20mL saline after each drug

Endotracheal Drug Administration

Not recommended in current guidelines

Previously used for adrenaline, atropine, lignocaine, naloxone (ALAN) when IV/IO unavailable.

Reasons for removal:

• Unreliable absorption
• Lower plasma levels
• IO access readily available
• May worsen outcomes

---

Rhythm Recognition

Four Arrest Rhythms

1. Ventricular Fibrillation (VF)

ECG Features:
• Chaotic, irregular waveform
• No identifiable P, QRS, or T waves
• Variable amplitude (coarse vs fine)
• Rate not measurable

Action: SHOCK + ALS algorithm

2. Pulseless Ventricular Tachycardia (pVT)

ECG Features:
• Wide QRS (greater than 120ms)
• Regular rhythm
• Rate 150-250/min
• No pulse palpable

Action: SHOCK + ALS algorithm (treat as VF)

3. Pulseless Electrical Activity (PEA)

ECG Features:
• Organised electrical activity
• May be narrow or wide complex
• May look "normal" sinus rhythm
• NO PULSE

Action: CPR + Adrenaline immediately + Treat cause

4. Asystole

ECG Features:
• Flat line (no electrical activity)
• May see P waves only (ventricular standstill)
• Confirm in 2 leads
• Check connections/gain

Action: CPR + Adrenaline immediately + Treat cause

Rhythm Check Protocol

10-Second Pause Every 2 Minutes:

1. Pause compressions
2. Assess rhythm on monitor
3. Pulse check only if organised rhythm
4. Charge defibrillator during pause if shockable
5. Resume CPR immediately (or shock then CPR)

Common Errors:

• Prolonged rhythm checks (greater than 10 seconds)
• Checking pulse for VF (unnecessary)
• Mistaking fine VF for asystole (if in doubt, shock)
• Not confirming asystole in second lead

---

Reversible Causes (4Hs and 4Ts)

Systematic Approach

Consider reversible causes throughout resuscitation, not just when initial rhythm fails to convert

4 Hs

4 Ts

Ultrasound in Cardiac Arrest

During Rhythm Check (10 seconds):

• Subxiphoid or parasternal view
• Assess for:
  • Cardiac activity (pseudo-PEA if contracting)
  • Pericardial effusion (tamponade)
  • RV dilation (PE)
  • Hypovolaemia (empty LV)

Limitations:

• Requires skilled operator
• May prolong pause if not rapid
• Should not delay interventions

---

CPR Quality Metrics

Compression Parameters

Quality Monitoring

Mechanical CPR Devices

Indications:

• Transport during arrest
• Prolonged resuscitation
• PCI during arrest
• Limited personnel

Evidence:

• LINC and PARAMEDIC trials: No survival benefit over manual CPR [24,25]
• Role is to maintain consistency during transport/procedures

---

Special Circumstances

Pregnancy

Key Modifications:

Perimortem Caesarean Section:

• Begin at 4 minutes of arrest
• Complete by 5 minutes
• Improves venous return for mother
• May save viable foetus (greater than 23 weeks)
• Perform in resuscitation bay
• Continue CPR during procedure

Drowning

Key Modifications:

Electrocution

Key Points:

• May cause VF or asystole
• Scene safety paramount
• Burns may indicate current path
• Myocardial injury common
• Standard ALS algorithm
• Monitor for arrhythmias post-ROSC

Hypothermia

Definitions:

Key Modifications:

• Continue CPR until core temp greater than 32 degrees C (or greater than 35 degrees C if ECMO available)
• Withhold drugs if temp less than 30 degrees C (delayed metabolism)
• Space drugs at longer intervals (6-10 min) if 30-35 degrees C
• Single shock reasonable; if VF refractory, defer further shocks until greater than 30 degrees C
• Consider ECMO for severe hypothermic arrest

Anaphylaxis Cardiac Arrest

Key Points:

• Adrenaline 1mg IV (same as standard arrest)
• Large volume fluid (anaphylaxis is distributive + hypovolaemic)
• Consider adrenaline infusion post-ROSC
• Prolonged CPR may be successful
• Glucagon if on beta-blockers

Asthma Cardiac Arrest

Key Points:

• Usually PEA or asystole (hypoxia, tension pneumothorax)
• Bilateral finger thoracostomies early
• Disconnect ventilator (auto-PEEP may impair venous return)
• Allow prolonged expiration
• Consider IV salbutamol, magnesium
• Higher ROSC rates with aggressive treatment

Poisoning/Overdose

Specific Antidotes:

---

Team Dynamics and CRM (Crisis Resource Management)

Resuscitation Team Roles

Closed-Loop Communication

Structure:

1. Leader gives order: "Give adrenaline 1mg IV now"
2. Team member confirms: "Adrenaline 1mg IV, giving now"
3. Team member completes and reports: "Adrenaline 1mg given"

Benefits:

• Ensures message received
• Confirms task completion
• Reduces errors

Team Leader Best Practices

Before Arrest (if possible):

• Brief team on roles
• Ensure equipment checked
• Identify expertise levels

During Arrest:

• Stand back - maintain situational awareness
• Avoid performing procedures (delegate)
• Verbalise thinking ("Rhythm check shows VF, we will shock")
• Summarise regularly ("This is a 55-year-old male, 4 shocks given, adrenaline x2...")
• Invite input ("Anyone see anything I'm missing?")

Common Team Leader Errors:

• Getting "hands on" and losing oversight
• Tunnel vision on one task
• Not rotating compressors
• Forgetting to consider reversible causes
• Inadequate communication

Quality Metrics to Verbalise

---

Post-Resuscitation Care

Immediate Post-ROSC (First 20 Minutes)

ABCDE Approach:

A - Airway:

• Confirm ETT position (waveform capnography)
• If no advanced airway, secure if needed
• Suction as required

B - Breathing:

C - Circulation:

D - Disability:

• GCS assessment (note may be sedated/paralysed)
• Pupil size and reactivity
• Blood glucose (target 7.8-10 mmol/L)
• Seizure management (common post-arrest)
• Avoid hyperthermia (37.5 degrees C or less)

E - Exposure:

• Core temperature
• Identify cause (look for clues)
• Injuries from CPR

Targeted Temperature Management (TTM)

Current ARC/ANZCOR Recommendations:

• Maintain constant temperature 32-36 degrees C for at least 24 hours
• TTM-2 trial: No benefit of 33 degrees C vs normothermia (37.5 degrees C or less) [26]
• Avoid fever (temp greater than 37.7 degrees C) for at least 72 hours
• Rewarming: 0.25-0.5 degrees C per hour (slow)

Methods:

Complications of Hypothermia:

• Shivering (treat with sedation, paralysis)
• Bradycardia (usually well-tolerated)
• Coagulopathy
• Electrolyte shifts (K+ changes during rewarming)
• Infection risk

STEMI Post-Arrest

Emergent Coronary Angiography Indications:

• ST-elevation on post-ROSC ECG
• High suspicion of coronary cause (witnessed VF, cardiac history)
• Consider even without ST-elevation in comatose survivors [27]

Timing:

• Immediate (under 2 hours) for STEMI
• Early (within 24 hours) for high suspicion without STEMI

Neurological Prognostication

When to Prognosticate:

• Minimum 72 hours after normothermia achieved
• Do NOT prognosticate in first 24-48 hours
• Multimodal approach essential

Prognostic Modalities:

Ethical Considerations:

• Avoid self-fulfilling prophecy
• Include family in discussions
• Palliative care involvement if poor prognosis

---

ECMO/ECPR

Extracorporeal CPR (ECPR)

Definition: Initiation of extracorporeal membrane oxygenation (ECMO) during cardiac arrest when conventional ALS fails.

Indications for ECPR

Potential Candidates:

• Witnessed arrest with good-quality bystander CPR
• Initial shockable rhythm (VF/pVT)
• Refractory VF (persists despite optimal ALS)
• Age typically under 70 years (varies by centre)
• No flow time under 5 minutes
• Low flow time (CPR) under 60-90 minutes
• Suspected reversible cause (PE, MI, hypothermia, toxins)

Contraindications:

• Unwitnessed arrest with unknown downtime
• Prolonged arrest (greater than 60-90 minutes) without good CPR quality
• Terminal illness
• Known severe neurological injury
• Severe frailty
• No consent/advance directive refusing

ECPR Evidence

• ARREST trial: Improved survival with ECPR for refractory OHCA VF (43% vs 7%) [18]
• Prague OHCA: ECPR improved survival with favourable neurological outcome (31% vs 22%) [28]
• Requires established program with rapid deployment capability

Practical Considerations

Availability:

• Metro tertiary centres only
• Requires interventional cardiology, CT surgery, perfusion support
• May require mechanical CPR for transport
• Pre-hospital ECMO developing in some systems

Australian Landscape:

• Available at major metropolitan centres
• Not currently available in most regional/rural settings
• Criteria vary by institution

---

Disposition

All ROSC Patients

• 100% require ICU/HDU admission
• No exception - all cardiac arrest survivors need critical care monitoring
• Minimum 24-hour continuous monitoring
• Specialist critical care input

Immediate Transfer Indications

Termination of Resuscitation

Consider Termination When:

• Asystole persisting greater than 20 minutes despite ALS
• ETCO2 persistently under 10 mmHg after 20 minutes [15]
• All reversible causes addressed/excluded
• No ROSC despite optimal resuscitation
• Patient factors (advanced directive, terminal illness)

Universal TOR Rules for OHCA:

1. Not witnessed by EMS
2. No bystander CPR
3. No shock delivered
4. No ROSC before transport (All four = very high probability of death)

Factors Supporting Continued Resuscitation:

• Witnessed arrest with short downtime
• Initial shockable rhythm
• Bystander CPR
• Signs of life during CPR
• Reversible cause not yet treated
• Hypothermia
• Young age
• Good pre-arrest function

Documentation Requirements

• Time of arrest recognition
• CPR initiation time
• Rhythm at each check
• Shocks delivered (number, joules)
• Medications given (drug, dose, time)
• Interventions (airway, access)
• ROSC time (or termination time and reason)
• Quality metrics if monitored

---

Pitfalls and Pearls

---

Viva Practice

---

OSCE Scenarios

Station 1: Resuscitation Leadership - VF Arrest

Format: Resuscitation leadership Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar. A 62-year-old male has arrived by ambulance in cardiac arrest. Paramedics have been performing CPR for 6 minutes and have given 2 shocks for VF. The rhythm on the monitor is VF.

Lead the resuscitation. Your team consists of two nurses and one junior doctor.

The examiner will provide clinical information as the scenario progresses.

Examiner Instructions:

• Rhythm sequence: VF → VF → VF → ROSC after 4th shock
• Post-ROSC: BP 78/50, HR 110, SpO2 96% on 100% O2
• 12-lead ECG: ST elevation in V1-V4
• Provide information when requested; prompt if candidate delays

Actor/Team Brief:

• Nurses competent but wait for instructions
• Junior doctor can perform procedures if directed
• Respond to closed-loop communication appropriately

Marking Criteria:

Expected Standard:

• Pass: 6/11 or greater
• Key discriminators: ARC algorithm adherence (adrenaline timing), team leadership (not doing procedures), recognising and acting on STEMI

Station 2: Resuscitation Leadership - PEA with Reversible Cause

Format: Resuscitation leadership Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar. A 45-year-old female who is 32 weeks pregnant has collapsed in the hospital corridor. CPR is in progress. The rhythm on the monitor shows organised electrical activity at 80bpm but there is no pulse.

Lead the resuscitation.

Examiner Instructions:

• Initial rhythm: PEA
• Without uterine displacement: Remains PEA
• With uterine displacement: Achieves ROSC after 4 minutes
• If candidate fails to apply uterine displacement, prompt at 4 minutes: "Is there anything specific about this patient that might affect your resuscitation approach?"

Marking Criteria:

Expected Standard:

• Pass: 6/11 or greater
• Key discriminators: Recognising pregnancy modification, manual uterine displacement, mentioning perimortem caesarean section

---

SAQ Practice

Question 1 (6 marks)

Stem: A 58-year-old male collapses at home. His wife calls 000 and commences CPR as instructed by the dispatcher. Paramedics arrive within 8 minutes and find him in ventricular fibrillation. They defibrillate twice and transport to your ED with CPR in progress.

Question: List 6 key components of high-quality CPR according to ARC guidelines.

Model Answer:

• Compression rate of 100-120 per minute (1)
• Compression depth of 5-6 cm in adults (1)
• Full chest recoil between compressions (1)
• Minimise interruptions to under 10 seconds (1)
• 30:2 compression to ventilation ratio (or continuous with advanced airway) (1)
• Rotate compressors every 2 minutes to prevent fatigue (1)

Examiner Notes:

• Accept: Avoid excessive ventilation, allow complete chest recoil, hard and fast
• Also accept: Place heel of hand on lower half of sternum; avoid leaning on chest
• Do not accept: Generic answers like "good compressions" without specifics

Question 2 (8 marks)

Stem: A 70-year-old female is in cardiac arrest with pulseless electrical activity (PEA). She has been receiving ALS for 15 minutes.

Question: (a) List 4 potential reversible causes from the "4 Hs" that could cause PEA (2 marks) (b) List 4 potential reversible causes from the "4 Ts" that could cause PEA (2 marks) (c) Describe 4 immediate bedside investigations or actions to identify reversible causes (4 marks)

Model Answer:

(a) 4 Hs (0.5 each, max 2):

• Hypoxia
• Hypovolaemia
• Hypokalaemia/Hyperkalaemia
• Hypothermia

(b) 4 Ts (0.5 each, max 2):

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary embolism or coronary)

(c) Investigations/actions (1 each, max 4):

• Point-of-care ultrasound/echocardiography - identifies tamponade, PE, hypovolaemia, cardiac activity
• VBG or ABG for potassium and pH
• Core temperature measurement for hypothermia
• Bilateral needle/finger thoracostomy if tension pneumothorax suspected
• Medication/history review for toxins (from family, paramedics)
• Point-of-care glucose
• Chest examination for breath sounds
• Review IV access and fluid status

Examiner Notes:

• Accept any reasonable investigation that addresses reversible causes
• Credit actions (e.g., thoracostomy) as investigations if framed as diagnostic/therapeutic

Question 3 (6 marks)

Stem: A 55-year-old male achieves ROSC after 12 minutes of CPR for VF arrest. He remains comatose.

Question: Outline 6 key components of immediate post-resuscitation care according to ARC guidelines.

Model Answer:

• Optimise oxygenation targeting SpO2 94-98%, avoiding hyperoxia (1)
• Maintain normocapnia with PaCO2 35-45 mmHg (1)
• Obtain 12-lead ECG to identify STEMI - emergent angiography if present (1)
• Maintain haemodynamic stability with MAP target greater than 65 mmHg (1)
• Initiate targeted temperature management (32-36 degrees C or avoid fever) (1)
• ICU admission for ongoing monitoring and care (1)

Examiner Notes:

• Accept: Avoid hyperthermia, neurological assessment, seizure management, glucose control
• Accept: Coronary angiography within 2 hours if STEMI, or early if high suspicion
• Do not accept: Vague answers without specific targets

Question 4 (8 marks)

Stem: Describe the key differences between the ARC/ANZCOR and AHA adult cardiac arrest algorithms.

Question: Outline 4 differences between ARC/ANZCOR and AHA guidelines (2 marks each).

Model Answer:

Alternative acceptable differences:

• Different guideline update cycles
• TTM temperature recommendations vary
• Atropine removed earlier in ARC

Examiner Notes:

• Must identify both the ARC and AHA approach for full marks
• Accept reasonable differences with accurate descriptions

---

Indigenous Health Considerations

Important Note: Aboriginal, Torres Strait Islander, and Maori Health in Cardiac Arrest:

Epidemiological Disparities:

• Indigenous Australians experience cardiac arrest at 2-3 times the rate of non-Indigenous Australians [12]
• Average age at cardiac arrest is 10-15 years younger
• Higher prevalence of risk factors: ischaemic heart disease, diabetes, hypertension
• Lower survival rates due to multifactorial causes including access and recognition delays

Barriers to Care:

• Remote community locations with prolonged response times
• Variable access to AEDs and trained responders
• Historical mistrust of healthcare services affecting help-seeking
• Communication barriers (language, cultural concepts)

Cultural Considerations During Resuscitation:

• Family presence during resuscitation - many families wish to be present
• Respect for cultural protocols regarding death and dying
• Awareness that some communities have specific beliefs about medical interventions
• Interpreter services should be offered when possible

Post-Arrest Communication:

• Involve Aboriginal Liaison Officers or cultural consultants
• Extended family may be involved in decision-making - identify key family members
• Allow time and space for cultural practices
• Be aware of "sorry business" and cultural obligations

End-of-Life Considerations:

• Some communities have specific preferences regarding where death occurs
• Discuss with family regarding body handling and autopsy
• Support return to country if appropriate
• Refer to Indigenous bereavement support services

Practical Steps:

1. Activate Aboriginal Liaison Service early
2. Ask family about cultural needs
3. Allow family presence if desired
4. Involve community elders if appropriate
5. Provide culturally appropriate bereavement support

---

Remote and Rural Considerations

Pre-Hospital Challenges

Bystander CPR in Remote Areas

• Critical importance: May be 30+ minutes before professional help
• Dispatcher-assisted CPR: 000 operators provide real-time CPR instructions
• Community training programs: First aid training in remote communities
• Public AED access: Variable - advocate for AEDs in community centres, schools, sporting facilities

Resource-Limited Resuscitation

When resources are limited:

• Focus on high-quality CPR (the most important intervention)
• BVM ventilation acceptable - do not delay for intubation equipment
• IO access if IV difficult - manual IO needles can be improvised
• Prioritise adrenaline if only one drug available
• Consider empiric treatments (thoracostomy, fluids) without imaging

Retrieval and Transport

Royal Flying Doctor Service (RFDS) Considerations:

• Notify early if ROSC expected or achieved
• Mechanical CPR enables safe air transport
• Pre-brief receiving hospital
• Consider rendezvous points for road-to-air transfer

Termination Decisions:

• Same principles apply, but consider:
  • Longer transport times meaning different risk-benefit calculation
  • Limited ICU resources at remote hospitals
  • Family presence often greater in small communities
  • Involve remote or retrieval consultation (e.g., TEMSU)

Telemedicine Support

Video-Assisted Resuscitation:

• Real-time specialist support via telehealth
• Quality feedback on CPR
• Guidance on advanced interventions
• Assistance with termination decisions

Services:

• TEMSU (Telehealth Emergency Medicine Support Unit) in some states
• State retrieval services
• Poison Information Centre (13 11 26)

---

Key Differences: ARC vs AHA vs ERC

---

References

ARC/ANZCOR Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 8: Cardiopulmonary Resuscitation. Melbourne: ARC; 2023. Available from: https://resus.org.au

2. Australian Resuscitation Council. ANZCOR Guideline 11: Adult Advanced Life Support. Melbourne: ARC; 2023.

3. Australian Resuscitation Council. ANZCOR Guideline 11.1: Medications in Adult Cardiac Arrest. Melbourne: ARC; 2023.

4. Australian Resuscitation Council. ANZCOR Guideline 11.2: Protocols for Adult Advanced Life Support. Melbourne: ARC; 2023.

5. Australian Resuscitation Council. ANZCOR Guideline 11.3: Management of Cardiac Arrest Due to Specific Causes. Melbourne: ARC; 2023.

6. Australian Resuscitation Council. ANZCOR Guideline 14: Post-Resuscitation Care. Melbourne: ARC; 2023.

Epidemiology and Outcomes

7. Bray JE, Di Palma S, Jacobs I, et al. Trends in the incidence of presumed cardiac out-of-hospital cardiac arrest in Perth, Western Australia, 1997-2010. Resuscitation. 2014;85(6):757-761. PMID: 24642404

8. Nehme Z, Andrew E, Bernard S, et al. Trends in survival from out-of-hospital cardiac arrests defibrillated by paramedics, first responders and bystanders. Resuscitation. 2019;143:85-91. PMID: 31398401

9. Beck B, Bray J, Cameron P, et al. Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: Results from the Aus-ROC Epistry. Resuscitation. 2018;126:49-57. PMID: 29477764

10. Cartledge S, Saxton D, Finn J, Bray JE. Australia's awareness of cardiac arrest and rates of CPR training: Results from the Heart Foundation's HeartWatch survey. BMJ Open. 2020;10(1):e033265. PMID: 31964662

11. Aus-ROC Steering Committee. Australian Resuscitation Outcomes Consortium (Aus-ROC) Epistry Annual Report 2022. Melbourne: Monash University; 2023.

Indigenous Health

12. Brown A, Walsh W. Cardiovascular disease in Indigenous Australians: a manifold problem. Heart Lung Circ. 2019;28(1):40-45. PMID: 30413360

13. Masterson S, Wright P, O'Donnell C, et al. Urban and rural differences in outcomes from out-of-hospital cardiac arrest: A systematic review. Resuscitation. 2015;94:107-116. PMID: 26092407

14. Bray JE, Straney L, Barger B, et al. Effect of the COVID-19 pandemic on bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2022;172:33-41. PMID: 35032576

Capnography and Monitoring

15. Touma O, Davies M. The prognostic value of end tidal carbon dioxide during cardiac arrest: A systematic review. Resuscitation. 2013;84(11):1470-1479. PMID: 23871864

16. Cheskes S, Wudwud A, Turner L, et al. The impact of double sequential external defibrillation for refractory ventricular fibrillation. Resuscitation. 2019;139:275-281. PMID: 31034940

Thrombolysis and Mechanical Causes

17. Javaudin F, Lascarrou JB, Le Bastard Q, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival. Chest. 2019;156(6):1167-1175. PMID: 31374209

ECPR Evidence

18. Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): A phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. PMID: 33197396

19. Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest (ALPS). N Engl J Med. 2016;374(18):1711-1722. PMID: 27043165

Adrenaline Evidence

20. Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest (PARAMEDIC2). N Engl J Med. 2018;379(8):711-721. PMID: 30021076

21. Hansen M, Schmicker RH, Newgard CD, et al. Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation. 2018;137(19):2032-2040. PMID: 29511001

Airway Management

22. Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest (PART): A Randomized Clinical Trial. JAMA. 2018;320(8):769-778. PMID: 30167701

23. Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome (AIRWAYS-2): The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791. PMID: 30167700

Mechanical CPR

24. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: The LINC randomized trial. JAMA. 2014;311(1):53-61. PMID: 24240611

25. Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015;385(9972):947-955. PMID: 25467566

Post-Resuscitation Care

26. Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (TTM2). N Engl J Med. 2021;384(24):2283-2294. PMID: 34133859

27. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation (COACT). N Engl J Med. 2019;380(15):1397-1407. PMID: 30883057

28. Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest (Prague OHCA): A Randomized Clinical Trial. JAMA. 2022;327(8):737-747. PMID: 35103762

International Guidelines

29. Soar J, Bottiger BW, Carli P, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation. 2021;161:115-151. PMID: 33773835

30. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 Suppl 2):S366-S468. PMID: 33081529

Prognostication

31. Sandroni C, D'Arrigo S, Cacciola S, et al. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med. 2022;48(4):389-413. PMID: 35254471

32. Nolan JP, Sandroni C, Bottiger BW, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation. 2021;161:220-269. PMID: 33773826

Australian-Specific Studies

33. Nehme Z, Andrew E, Bray JE, et al. The significance of pre-arrest factors in out-of-hospital cardiac arrests witnessed by emergency medical services: a report from the Victorian Ambulance Cardiac Arrest Registry. Resuscitation. 2015;88:35-42. PMID: 25534696

34. Bray JE, Bernard S, Cantwell K, et al. The association between systemic temperature and out-of-hospital cardiac arrest outcomes. Resuscitation. 2018;124:17-23. PMID: 29309816

35. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88-94. PMID: 25281189

CPR Quality

36. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation. 2013;128(4):417-435. PMID: 23801105

37. Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012;125(24):3004-3012. PMID: 22623717

38. Stiell IG, Brown SP, Nichol G, et al. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation. 2014;130(22):1962-1970. PMID: 25252721

Special Circumstances

39. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201. PMID: 26477412

40. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-S518. PMID: 26472998

Team Performance

41. Hunziker S, Johansson AC, Tschan F, et al. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol. 2011;57(24):2381-2388. PMID: 21658556

42. Fernandez Castelao E, Russo SG, Cremer S, et al. Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial. Resuscitation. 2011;82(10):1338-1343. PMID: 21757266