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The 9 ALS triads — an alphabetical checklist for advanced life support providers
Resuscitation 50 (2001) 57 – 60 www.elsevier.com/locate/resuscitation
The 9 ALS triads — an alphabetical checklist for advanced life support providers W.G.J. Kloeck * Resuscitation Council of Southern Africa, 72 Sophia Street, Fairland, 2195 Johannesburg, South Africa Received 7 July 2000; received in revised form 23 October 2000; accepted 7 November 2000
Abstract The successful outcome of a resuscitation attempt relies frequently on the performance of many advanced life support interventions. A checklist of 27 procedures, following an alphabetical sequence, is presented as an educational memory aid for healthcare providers. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiopulmonary resuscitation; Advanced life support; Education; Training; Memory aids
Resumo O sucesso de uma tentativa de reanimac¸a˜o assenta com frequeˆncia no desempenho de mu´ltiplas intervenc¸o˜es de Suporte Avanc¸ado de Vida. Apresenta-se uma lista, seguindo uma sequeˆncia alfabe´tica, como auxiliar de memo´ria educativo para confereˆncia de 27 procedimentos pelos prestadores de cuidados de sau´de. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Pala6ras cha6e: Reanimac¸a˜o Cardio-Pulmonar; Suporte Avanc¸ado de Vida; Ensino; Treino; Auxiliares de memo´ria
Ideal management of a cardiac arrest involves the performance of several interventions, simultaneously or in rapid sequence. Basic and advanced life support measures need to progress in an orderly manner, providing the patient with the best possible opportunity of recovery and restoration to pre-arrest physical and mental status. In any resuscitation attempt, team members will try their best to save a life. Debriefing sessions after resuscitation, whether the event was successful or unsuccessful, invariably lead to a discussion of modifications, alternative approaches and improvements which could be implemented in future events. Thinking clearly and systematically during a resuscitation is more easily said than done. It is always easier to identify errors and omissions retrospectively, when the stress and anxiety of active resuscitation has * Corresponding author. Tel.: + 27-11-4781874; fax: +27-116785087. E-mail address: [email protected] (W.G.J. Kloeck).
subsided. Most healthcare providers will readily admit that seldom is a resuscitation performed to perfection in every respect. In view of this, a simple alphabetical checklist is presented as a memory aid to allow resuscitation team members to review the resuscitation systematically while it is ongoing, and to implement corrective actions immediately upon recognition. Using the first nine letters of the alphabet (A–I), three interventions or assessments can be performed for each alphabetical symbol — an approach which could be termed ‘ The 9 ALS triads’ (Table 1) At the time this checklist review is being done, some or many of the interventions may already have been implemented, but seldom will all 27 procedures have been considered. Although an alphabetical sequence is presented as a memory aid, it is acknowledged and recommended that several of the interventions would be performed simultaneously, utilizing the expertise and experience of the team members present, and in the order of priorities indicated for that particular patient.
0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 0 ) 0 0 3 6 8 - 3
58
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
1. A — assessment/alignment of spine/airway? There are many facets to the assessment phase of a cardiac arrest. Assessment of the scene (Area — Hazards?) with respect to safety of the rescuer and patient is paramount, followed by assessment for responsiveness (Alertness – Hello?) and obtaining further assis-
Table 1 The 9 ALS triads
tance (Help!) (assessment of ‘Area, Alertness and Assistance’ or ‘Hazards — Hello — Help!’) If the patient is unresponsive, measures to obtain a patent airway must be taken in conjunction with maintaining alignment of the spine. For example, if a cervical spine injury cannot be excluded, the airway should be opened using the ‘jaw thrust’ manoeuvre rather than
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
the traditional ‘head tilt– chin lift’ technique. If the patient must be moved, this should be done carefully as a unit, avoiding any unnecessary rotation, flexion or extension of the spine.
2. B — breathing/bagging/bleeding? Once the airway and patient has been appropriately positioned, checking for the presence or adequacy of breathing is essential. If the patient is being ventilated, determine whether the bagging technique is optimal. Is the chest moving with each ventilation? Is there a large air leak? Are two rescuers required; one to hold the mask firmly in place while the other compresses the self-inflating bag? Is a reservoir attached, and is the oxygen flow rate adequate? Is there evidence or suspicion of active internal or external bleeding? Is this being adequately controlled?
3. C — circulation/compressions/cricoid pressure? Checking for the absence or return of spontaneous circulation or any other sign of life should be done at appropriate intervals. Any change in rhythm or pattern on the ECG, for example, should prompt a pulse check. If chest compressions are being done, are they at the correct rate, correct depth and with the correct hand position? Is the patient on a firm, flat surface? Prior to tracheal intubation, is cricoid pressure being applied and maintained?
4. D — defibrillation/drip/drugs? Rapid defibrillation of ventricular fibrillation or pulseless ventricular tachycardia is essential for successful conversion to a viable rhythm and return of spontaneous circulation. Assessment of the rhythm can be achieved using the ‘quick-look’ paddles of the defibrillator monitor, without requiring the application of ECG electrodes and cables. A repeated series of shocks may be required every minute for refractory ventricular fibrillation. Has intravascular access been achieved? Is the intravenous fluid running adequately? Are additional lines required or perhaps central venous access? Have the lines been properly secured? What therapeutic agents has the patient received so far? Is the patient on any drugs (e.g. cocaine, b-blockers) which may affect the resuscitation? Have the appropriate resuscitation medications been given, and at the appropriate time intervals?
5. E — endotracheal examination (‘etiology’)?
59
intubation/ECG
rhythm/
Is the airway adequately protected by a tracheal tube? Has the correct position of the tube been verified? Is the tube properly secured? Is the cuff, if present, adequately inflated? Is there any air leak? Has the chest been examined for adequate ventilation? Confirmation of the true rhythm must be assessed on all three lead views, particularly in the presence of suspected asystole. A loose lead can mimic asystole in two leads of a 3-lead ECG. Differentiation between asystole and very fine ventricular fibrillation may be possible by changing the axis of the ‘quick-look’ defibrillator paddles by 90°. View the rhythm obtained with one paddle placed over the left lower ribs in the mid-axillary line, and the other to the right of the sternum, just below the right clavicle. Then place one paddle over the right lower ribs, mid-axillary line, and the other to the left of the sternum just below the left clavicle; look for any change in the appearance of the rhythm. A search for reversible causes of cardiac arrest (‘etiology’) is fundamental in any resuscitation attempt. Various training aids and mnemonics have been described [1,2]. Hypoxia, hypovolaemia, hypothermia, hyperkalaemia and other metabolic disturbances should be corrected immediately upon recognition. Similarly the presence of tension pneumothorax, cardiac tamponade, thrombo-embolism, toxic or therapeutic disturbances should be considered and managed appropriately.
6. F — findings/fluids/follow-up? As soon as possible find out what happened to the victim. If available, speak to the first responders, whether they be lay persons, first aiders or emergency care professionals. Obtaining details from friends, family members and spectators regarding the events leading to the arrest, the past and present medical history, and allergies and medications that the patient may be taking, will expedite the search for reversible causes. With regard to the haemodynamic status, check that the fluid therapy and replacement rate is appropriate. In the presence of trauma, high intravenous flow sets and/or blood replacement therapy may be required. Protect against volume overload in renal and cardiac patients. Avoid rapid Ringers lactate infusions in patients with severe hyperkalaemia. Appointing a scribe or note-taker to keep a record of events, medications and interventions is essential for the orderly progression of a resuscitation. Recording the dose and time of administration of each drug, defibrillation shock, changes in ECG and vital signs, and results of special investigations as they become avail-
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
60
able, allows for interventions to be undertaken in appropriate sequence and analysis of the event at a later time.
7. G — gadgets/glucose/gases? Gastric tube insertion and placement of available vital sign instrumentation such as pulse oximetry, blood pressure monitoring, capnography, etc. enhances transition to haemodynamic stability. Serial determination of blood glucose level and blood gas abnormalities, particularly pH, pCO2, pO2 and potassium levels facilitates rapid corrective measures.
whether radiological, toxicological, serological or pathophysiological which may be appropriate. Additional invasive procedures such as central or arterial line insertion, tension pneumothorax decompression, intercostal drain insertion, emergency pericardiocentesis, diagnostic peritoneal lavage, urinary catheterization and so forth may be deemed necessary. Timely transfer to an intensive care unit, or arrangements for continued advanced life support care after resuscitation must be made to avoid deterioration or recurrence of the cardiac arrest.
10. J — ? 8. H — hypo-/hyper-/human mentation? Identification and correction of any major metabolic or physiological variable, whether in the form of a deficiency (e.g. hypoxia, hypovolaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, hyponatraemia, etc.) or excess (hyperkalaemia, hyperglycaemia, hypernatraemia, hyperthermia, etc.) should always be undertaken during a resuscitation attempt. Assessment of the higher functions and neurological state of the patient may further identify potential reversible or prognostic factors. Examination of pupil size, movement and reaction may lead to a suspicion of intracranial pathology, drug intoxication etc. Assessment of brainstem and cranial nerve function, such as the corneal and gag reflex, oculo-vestibular (caloric) reflex, pupil reaction to light, dolls eye movement and respiratory efforts in the absence of hypothermia and metabolic abnormalities may assist in the decision to continue or discontinue resuscitation efforts.
9. I — investigations/invasive procedures/intensive care? Consider
additional
diagnostic
investigations,
Having made the necessary arrangements for intensive care transfer (‘Journey’) the consequences of the resuscitation may lead to one of two outcomes. If the resuscitation was fraught with medicolegal consequences, the outcome may be very bleak indeed (‘Jail’)! On the other hand, a successful resuscitation with return to prearrest mental and physical status is always associated with great happiness (‘Joy’)! In applying the above 27-point checklist before, during and after resuscitations, it is the sincere intention of the author that the former outcome be avoided and that future resuscitation attempts be associated with a higher incidence of success.
References [1] Kloeck W. A practical approach to the aetiology of pulseless electrical activity. A simple10-step training mnemonic. Resuscitation 1995;30:157 – 9. [2] Kloeck W, Cummins R, Chamberlain D, et al. The universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee On Resuscitation. Resuscitation 1997;34:109 – 11.
The 9 ALS triads — an alphabetical checklist for advanced life support providers W.G.J. Kloeck * Resuscitation Council of Southern Africa, 72 Sophia Street, Fairland, 2195 Johannesburg, South Africa Received 7 July 2000; received in revised form 23 October 2000; accepted 7 November 2000
Abstract The successful outcome of a resuscitation attempt relies frequently on the performance of many advanced life support interventions. A checklist of 27 procedures, following an alphabetical sequence, is presented as an educational memory aid for healthcare providers. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiopulmonary resuscitation; Advanced life support; Education; Training; Memory aids
Resumo O sucesso de uma tentativa de reanimac¸a˜o assenta com frequeˆncia no desempenho de mu´ltiplas intervenc¸o˜es de Suporte Avanc¸ado de Vida. Apresenta-se uma lista, seguindo uma sequeˆncia alfabe´tica, como auxiliar de memo´ria educativo para confereˆncia de 27 procedimentos pelos prestadores de cuidados de sau´de. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Pala6ras cha6e: Reanimac¸a˜o Cardio-Pulmonar; Suporte Avanc¸ado de Vida; Ensino; Treino; Auxiliares de memo´ria
Ideal management of a cardiac arrest involves the performance of several interventions, simultaneously or in rapid sequence. Basic and advanced life support measures need to progress in an orderly manner, providing the patient with the best possible opportunity of recovery and restoration to pre-arrest physical and mental status. In any resuscitation attempt, team members will try their best to save a life. Debriefing sessions after resuscitation, whether the event was successful or unsuccessful, invariably lead to a discussion of modifications, alternative approaches and improvements which could be implemented in future events. Thinking clearly and systematically during a resuscitation is more easily said than done. It is always easier to identify errors and omissions retrospectively, when the stress and anxiety of active resuscitation has * Corresponding author. Tel.: + 27-11-4781874; fax: +27-116785087. E-mail address: [email protected] (W.G.J. Kloeck).
subsided. Most healthcare providers will readily admit that seldom is a resuscitation performed to perfection in every respect. In view of this, a simple alphabetical checklist is presented as a memory aid to allow resuscitation team members to review the resuscitation systematically while it is ongoing, and to implement corrective actions immediately upon recognition. Using the first nine letters of the alphabet (A–I), three interventions or assessments can be performed for each alphabetical symbol — an approach which could be termed ‘ The 9 ALS triads’ (Table 1) At the time this checklist review is being done, some or many of the interventions may already have been implemented, but seldom will all 27 procedures have been considered. Although an alphabetical sequence is presented as a memory aid, it is acknowledged and recommended that several of the interventions would be performed simultaneously, utilizing the expertise and experience of the team members present, and in the order of priorities indicated for that particular patient.
0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 0 ) 0 0 3 6 8 - 3
58
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
1. A — assessment/alignment of spine/airway? There are many facets to the assessment phase of a cardiac arrest. Assessment of the scene (Area — Hazards?) with respect to safety of the rescuer and patient is paramount, followed by assessment for responsiveness (Alertness – Hello?) and obtaining further assis-
Table 1 The 9 ALS triads
tance (Help!) (assessment of ‘Area, Alertness and Assistance’ or ‘Hazards — Hello — Help!’) If the patient is unresponsive, measures to obtain a patent airway must be taken in conjunction with maintaining alignment of the spine. For example, if a cervical spine injury cannot be excluded, the airway should be opened using the ‘jaw thrust’ manoeuvre rather than
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
the traditional ‘head tilt– chin lift’ technique. If the patient must be moved, this should be done carefully as a unit, avoiding any unnecessary rotation, flexion or extension of the spine.
2. B — breathing/bagging/bleeding? Once the airway and patient has been appropriately positioned, checking for the presence or adequacy of breathing is essential. If the patient is being ventilated, determine whether the bagging technique is optimal. Is the chest moving with each ventilation? Is there a large air leak? Are two rescuers required; one to hold the mask firmly in place while the other compresses the self-inflating bag? Is a reservoir attached, and is the oxygen flow rate adequate? Is there evidence or suspicion of active internal or external bleeding? Is this being adequately controlled?
3. C — circulation/compressions/cricoid pressure? Checking for the absence or return of spontaneous circulation or any other sign of life should be done at appropriate intervals. Any change in rhythm or pattern on the ECG, for example, should prompt a pulse check. If chest compressions are being done, are they at the correct rate, correct depth and with the correct hand position? Is the patient on a firm, flat surface? Prior to tracheal intubation, is cricoid pressure being applied and maintained?
4. D — defibrillation/drip/drugs? Rapid defibrillation of ventricular fibrillation or pulseless ventricular tachycardia is essential for successful conversion to a viable rhythm and return of spontaneous circulation. Assessment of the rhythm can be achieved using the ‘quick-look’ paddles of the defibrillator monitor, without requiring the application of ECG electrodes and cables. A repeated series of shocks may be required every minute for refractory ventricular fibrillation. Has intravascular access been achieved? Is the intravenous fluid running adequately? Are additional lines required or perhaps central venous access? Have the lines been properly secured? What therapeutic agents has the patient received so far? Is the patient on any drugs (e.g. cocaine, b-blockers) which may affect the resuscitation? Have the appropriate resuscitation medications been given, and at the appropriate time intervals?
5. E — endotracheal examination (‘etiology’)?
59
intubation/ECG
rhythm/
Is the airway adequately protected by a tracheal tube? Has the correct position of the tube been verified? Is the tube properly secured? Is the cuff, if present, adequately inflated? Is there any air leak? Has the chest been examined for adequate ventilation? Confirmation of the true rhythm must be assessed on all three lead views, particularly in the presence of suspected asystole. A loose lead can mimic asystole in two leads of a 3-lead ECG. Differentiation between asystole and very fine ventricular fibrillation may be possible by changing the axis of the ‘quick-look’ defibrillator paddles by 90°. View the rhythm obtained with one paddle placed over the left lower ribs in the mid-axillary line, and the other to the right of the sternum, just below the right clavicle. Then place one paddle over the right lower ribs, mid-axillary line, and the other to the left of the sternum just below the left clavicle; look for any change in the appearance of the rhythm. A search for reversible causes of cardiac arrest (‘etiology’) is fundamental in any resuscitation attempt. Various training aids and mnemonics have been described [1,2]. Hypoxia, hypovolaemia, hypothermia, hyperkalaemia and other metabolic disturbances should be corrected immediately upon recognition. Similarly the presence of tension pneumothorax, cardiac tamponade, thrombo-embolism, toxic or therapeutic disturbances should be considered and managed appropriately.
6. F — findings/fluids/follow-up? As soon as possible find out what happened to the victim. If available, speak to the first responders, whether they be lay persons, first aiders or emergency care professionals. Obtaining details from friends, family members and spectators regarding the events leading to the arrest, the past and present medical history, and allergies and medications that the patient may be taking, will expedite the search for reversible causes. With regard to the haemodynamic status, check that the fluid therapy and replacement rate is appropriate. In the presence of trauma, high intravenous flow sets and/or blood replacement therapy may be required. Protect against volume overload in renal and cardiac patients. Avoid rapid Ringers lactate infusions in patients with severe hyperkalaemia. Appointing a scribe or note-taker to keep a record of events, medications and interventions is essential for the orderly progression of a resuscitation. Recording the dose and time of administration of each drug, defibrillation shock, changes in ECG and vital signs, and results of special investigations as they become avail-
W.G.J. Kloeck / Resuscitation 50 (2001) 57–60
60
able, allows for interventions to be undertaken in appropriate sequence and analysis of the event at a later time.
7. G — gadgets/glucose/gases? Gastric tube insertion and placement of available vital sign instrumentation such as pulse oximetry, blood pressure monitoring, capnography, etc. enhances transition to haemodynamic stability. Serial determination of blood glucose level and blood gas abnormalities, particularly pH, pCO2, pO2 and potassium levels facilitates rapid corrective measures.
whether radiological, toxicological, serological or pathophysiological which may be appropriate. Additional invasive procedures such as central or arterial line insertion, tension pneumothorax decompression, intercostal drain insertion, emergency pericardiocentesis, diagnostic peritoneal lavage, urinary catheterization and so forth may be deemed necessary. Timely transfer to an intensive care unit, or arrangements for continued advanced life support care after resuscitation must be made to avoid deterioration or recurrence of the cardiac arrest.
10. J — ? 8. H — hypo-/hyper-/human mentation? Identification and correction of any major metabolic or physiological variable, whether in the form of a deficiency (e.g. hypoxia, hypovolaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, hyponatraemia, etc.) or excess (hyperkalaemia, hyperglycaemia, hypernatraemia, hyperthermia, etc.) should always be undertaken during a resuscitation attempt. Assessment of the higher functions and neurological state of the patient may further identify potential reversible or prognostic factors. Examination of pupil size, movement and reaction may lead to a suspicion of intracranial pathology, drug intoxication etc. Assessment of brainstem and cranial nerve function, such as the corneal and gag reflex, oculo-vestibular (caloric) reflex, pupil reaction to light, dolls eye movement and respiratory efforts in the absence of hypothermia and metabolic abnormalities may assist in the decision to continue or discontinue resuscitation efforts.
9. I — investigations/invasive procedures/intensive care? Consider
additional
diagnostic
investigations,
Having made the necessary arrangements for intensive care transfer (‘Journey’) the consequences of the resuscitation may lead to one of two outcomes. If the resuscitation was fraught with medicolegal consequences, the outcome may be very bleak indeed (‘Jail’)! On the other hand, a successful resuscitation with return to prearrest mental and physical status is always associated with great happiness (‘Joy’)! In applying the above 27-point checklist before, during and after resuscitations, it is the sincere intention of the author that the former outcome be avoided and that future resuscitation attempts be associated with a higher incidence of success.
References [1] Kloeck W. A practical approach to the aetiology of pulseless electrical activity. A simple10-step training mnemonic. Resuscitation 1995;30:157 – 9. [2] Kloeck W, Cummins R, Chamberlain D, et al. The universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee On Resuscitation. Resuscitation 1997;34:109 – 11.