ALS Protocols

So what modifications to the standard ALS protocol are required if your patient arrests, or is presented to you in cardiac arrest?

• Early intubation, particularly in the context of airway oedema, by the most experienced airway practitioner. As a competent RSI practitioner you’ll recognize the likelihood of a difficult airway. Ensure surgical airway equipment is immediately available
• IV adrenaline — ensure 1 mg is given every 3-5 minutes, given that it is the key agent that might effect recovery
• Large crystalloid challenges through large bore cannulae with pressure bags. Remember 4-8 litres
• Antihistamines and steroids? These have no role in cardiac arrest
• Additional vasopressors in refractory cases? The evidence-base is weak – case reports with potential flaws: you might question
  1. Was enough adrenaline/fluid given?
  2. Was recovery truly attributable to the additional agent?
• In beta-blocked patients, consider glucagon (1-2 mg every 5 minutes) in adrenaline-resistant cases
• Smaller doses of adrenaline in patients on tricyclic antidepressants, or some antihypertensive agents? This is theoretical, and thankfully not supported by the Resuscitation Council
• Be prepared for a prolonged resuscitation attempt — typically patients are young and previously well

Learning bite

• Antihistamines and steroids have no role in cardiac arrest.
• Early intubation by the most experienced airway practitioner is vital. Ensure you have equipment for a surgical airway immediately available