Advanced Cardiac Life Support

See guideline 6, page 3.With 2 rescuers present, the person doing compressions should be changed over every 2 minutes with minimal delay. 2 minutes equates to about 5 cycles of 30:2 compression:ventilation.

See guideline 11.2 of the Australian Guidelines and page 44 of the UK Guidelines.There are no studies comparing 3 stacked shocks with a single shock, but some experimental studies show that interruptions in CPR are associated with reduced survival, and reduce the chances of converting VF to another rhythm.Combined wit the improved first shock efficacy (over 90%)of biphasic defibrillators for VF/VT, a single shock is recommended.Failure to terminate VF/VT indicates a need to improve myocardial oxygenation by CPR.For a monitored witnessed VF/VT arrest where a defibrillator is not immediately available, a pre cordial thump may be given. Most likely to be successful with converting VT to sinus rhythm within the first 10 seconds.

See guideline 6.The lower half of the sternum is deemed to correlate with the centre of the chest.The depth of compression should be 4-5cm

See Guideline 11.5 of the Australian Guidelines, and page 45 of the UK Guidelines.
For rectilinear biphasic waveforms the energy should be greater than 120J, and for truncated exponenetial waveforms it should be greater than 150J.Theefore, it isrecommended that the initial shock should be at least 150J, with 200J being within the effective range of first and subsequent biphasic shock energy levels.Every biphasic manual defibrillator available can deliver 200J.If there is clinical data to support the use of a different energy level for a specific device, then this may be used. The Phillips HeartStart XL has been shown to be effective at 150J.There is no evidence to suggest a clear benefit for either a fixed or escalating energy level.

See Guideline 11.5 of the Australian Guidelines, and page 45 of the UK Guidelines.
Due to the lower efficacy of monopahsic defibrillators for terminating VF/VT (54-63% for 200J), and the use of a single shock strategy, the first and subsequent shocks should be 360J. This contrasts with the previously recommended 200, 200, 360J stacked shock recommendations.

See page 46 of the UK Guidelines.
Fine VF that cannot be differentiated from asystole is unlikely to be converted successfully to a perfusing rhythm, and good quality CPR may improve the frequency and amplitude of VF (as the decrease in high energy phosphate stores in the myocardium can be slowed or reversed by CPR)and improve the success rate for defibrillation.Delivering repeated shocks for what is thought to be fine VF will damage the myocardium further.

See Guideline 11.6 page 3 of the Australian Guidelines and page 46 of the UK Guidelines.
The immediate resumption of CPR following a defibrillation attempt without pulse or rhythm check make it difficult to recommend when Adrenalineshould be given.Every 3-5 minutes equates to just before alternate shocks. The subsequent CPR will circulate the drug.The timing is the same for Asystole/PEA algorithm.
The initial sequence of actions would be for 2 minutes of CPR following attempted defibrillation of VF/VT, followed by rhythm check and further shock, followed by CPR, at which point adrenaline is given during the rhythm check.

See Guideline 11.5 of the Australian Guidelines and page 50 of the UK Guidelines.
In a mannikin study, there was no increase in oxygen concentration around the mannikin when the ventilation device was left attached to the ET tube.It is recommended that ICU type ventilators that deliver large oxygen flows are not disconnected or are turned off if being disconnected.

See Guideline 11.6 of the Australian Guidelines and page 47 of the UK guidelines.
There is no evidence that giving anti arrhythmic drugs routinely increases survival to discharge.On the basis of expert opinion, it is recommended to administer amiodarone after the 3rd shock in persistent VF/VT.
The only drugs recommended for endotracheal administration are Adrenaline, Lignocaine and Atropine.