Advanced Life Support (ALS) for Paramedics

Advanced Life Support (ALS) for UK Paramedics

Advanced Life Support (ALS) sits at the very core of paramedic practice. Whether you are a student paramedic working through your degree or a newly registered clinician consolidating your skills, a thorough understanding of the ALS algorithm is non-negotiable. This guide walks through the key components of ALS in the pre-hospital UK context, aligned with Resuscitation Council UK (RCUK) guidelines and JRCALC clinical practice guidelines.

What Is Advanced Life Support?

ALS refers to the set of interventions used to treat cardiac arrest beyond basic life support (BLS). While BLS focuses on high-quality CPR and early defibrillation, ALS adds airway management, vascular access, pharmacological interventions, and systematic identification of reversible causes. In the pre-hospital environment, paramedics are often the most senior clinician on scene, making a sound grasp of ALS essential.

The ALS Algorithm: A Step-by-Step Overview

The Resuscitation Council UK ALS algorithm divides cardiac arrest rhythms into two broad categories:

• Shockable rhythms: Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (pVT)
• Non-shockable rhythms: Asystole and Pulseless Electrical Activity (PEA)

Regardless of the presenting rhythm, high-quality CPR with minimal interruptions remains the foundation. The ratio remains 30 compressions to 2 ventilations until an advanced airway is in place, at which point compressions are continuous at a rate of 100–120 per minute.

Shockable Rhythms (VF/pVT)

When a shockable rhythm is identified, a single biphasic shock is delivered (typically 150–200 J for the first shock, following manufacturer guidance for subsequent shocks). CPR is immediately resumed for two minutes before the rhythm is re-analysed. After the third shock, adrenaline 1 mg IV and amiodarone 300 mg IV are administered. Adrenaline is then repeated every 3–5 minutes (i.e., every alternate loop), and a further dose of amiodarone 150 mg can be given after the fifth shock if VF/pVT persists.

Non-Shockable Rhythms (PEA/Asystole)

For non-shockable rhythms, CPR is continued and adrenaline 1 mg IV is given as soon as vascular access is established, then repeated every 3–5 minutes. There is no role for amiodarone in non-shockable rhythms. The focus shifts firmly to identifying and treating the reversible causes of cardiac arrest.

The 4Hs and 4Ts: Reversible Causes of Cardiac Arrest

A key skill in ALS is systematically working through the reversible causes — often remembered as the 4Hs and 4Ts. In the pre-hospital environment, these causes must be considered continuously throughout resuscitation, not just at the end of a loop.

The 4Hs

• Hypoxia — Ensure effective ventilation with high-flow oxygen. Consider airway adjuncts or supraglottic airway devices (SGAs) such as the i-gel.
• Hypovolaemia — Common in trauma. Consider permissive hypotension post-ROSC and address haemorrhage control.
• Hypo/Hyperkalaemia and metabolic disorders — Obtain a history; consider calcium chloride for hyperkalaemia or dialysis patients.
• Hypothermia — Check core temperature if possible. "No one is dead until they are warm and dead" applies here.

The 4Ts

• Tension pneumothorax — Perform bilateral needle thoracocentesis if suspected; do not wait for confirmation.
• Tamponade (cardiac) — Difficult to treat pre-hospital; consider in penetrating trauma. Ultrasound-capable teams may identify this.
• Toxins — Consider naloxone for opioid overdose, specific antidotes where indicated, and activated charcoal in certain poisonings per JRCALC guidance.
• Thrombosis (pulmonary or coronary) — Thrombolysis may be considered for confirmed or strongly suspected PE causing cardiac arrest, with CPR continued for at least 60–90 minutes post-administration.

Airway Management in ALS

Advanced airway management is a key differentiator of ALS from BLS. In the pre-hospital setting, paramedics typically use supraglottic airway devices (SADs) such as the i-gel as a first-line advanced airway. Once an advanced airway is in place, end-tidal CO2 (EtCO2) monitoring via waveform capnography is essential — it confirms tube placement, monitors CPR quality, and may provide an early indicator of return of spontaneous circulation (ROSC). A sudden rise in EtCO2 is often the first sign that ROSC has occurred.

Vascular Access and Drug Delivery

Intravenous (IV) access is the preferred route for drug delivery in cardiac arrest. If IV access cannot be established quickly, intraosseous (IO) access should be used without delay — the JRCALC guidelines support the IO route as equivalent for drug and fluid delivery during resuscitation. Drug doses are the same regardless of whether IV or IO access is used.

Post-ROSC Care

Achieving ROSC is only part of the challenge. Pre-hospital post-resuscitation care includes:

• Targeting SpO2 of 94–98% and EtCO2 of 4.5–6.0 kPa
• 12-lead ECG to identify STEMI requiring primary percutaneous coronary intervention (PPCI)
• Avoiding hypotension — target systolic BP above 100 mmHg
• Consideration of targeted temperature management (TTM) in line with local STEMI/cardiac arrest pathway
• Rapid transfer to an appropriate receiving centre with pre-alert

Documentation and Communication

Accurate documentation of the arrest timeline — including the time of collapse, first rhythm, time of first shock, drug administration times, and time of ROSC — is critical for handover. Using the SBAR (Situation, Background, Assessment, Recommendation) framework ensures a structured and safe handover to the emergency department team.

Keeping Your ALS Knowledge Current

ALS guidelines are updated periodically by the Resuscitation Council UK, most recently in 2021. Student paramedics and registrants alike should ensure they are working from the most current version of both RCUK guidelines and the JRCALC Clinical Practice Guidelines. Regular scenario practice, self-assessment, and structured revision are the most effective ways to consolidate ALS knowledge ahead of OSCEs, clinical placements, and real-world practice.