14. Pre-hospital cardiac arrest

Question 1

how long should you remain on scene for at an arrest until you transport the pt to hospital

Answer 1

ideally until ROSC achieved or until skills/ interventions only possible in a hospital environment are encountered

Question 2

team approach to OHCA?

Answer 2

Position 1: airway at head of pt
Position 2: chest compressions + defib if needed at left side of pt
Position 3: chest compressions and access at pts right side
Position 4: team leader stands back and oversees only becoming involved if required

Question 3

T/F: evidence suggests survival from OHCA is improved if tracheal intubation is achieved

Answer 3

false - no evidence for this

simple techniques e.g. bag-mask, SGA produce as good if not better outcomes

Question 4

T/F: cricoid pressure should be used if tracheal intubation is being undertaken during CPR

Answer 4

false - do not routinely use, many pts have already aspirated and cricoid pressure can make intubation more difficult

Question 5

what sized laryngoscope blade is appropriate for most adults

Answer 5

size 4 MAC

Question 6

secure the tracheal tube at roughly what length?

Answer 6

approx 22cm

Question 7

possible complications of tracheal intubation?

Answer 7

hypoxaemia (oxygenate between intubation attempts)
unrecognised oesophageal intubation (use waveform capnography to exclude)
endobronchial intubation (insert tube no more than the appropriate length, listen to breath sounds in both axillae, monitor tube position)

Question 8

other sites that an oxygen probe can be placed it pt has cold extremities?

Answer 8

toes, nose, ear lobe, tongue or lip

Question 9

T/F: SGAs minimise the risk of gastric distention compared to bag-masks

Answer 9

true

Question 10

where is a chest drain for a tension pneumothorax usually inserted

Answer 10

5th IC space mid-axillary line

Question 11

in patients receiving positive pressure ventilation with a tension pneumothorax, what treatment is preferred pre-hospital

Answer 11

thoracostomy (5th IC space midaxillary line) - it is less invasive, quicker and avoids complications associated with the chest drain itself

Question 12

hypocarbia induced by ventilation (excess tidal volumes, RR, or both) can cause excessive cerebral vaso____

Answer 12

vasoconstriction and ischaemia

Question 13

T/F: defibrillation is one of the few interventions that improves outcome from sudden cardiac arrest

Answer 13

true
application is time critical
mortality increases 10% for every minute’s delay

Question 14

when attending OHCA as a solo responder, what should take priority: immediate rhythm assessment and defibrillation or airway and breathing interventions

Answer 14

immediate rhythm assessment and defibrillation

Question 15

VF recurs in ___% of pts within 2 mins of successful termination and ____% of pts during the entire cardiac arrest

Answer 15

50
75

(give amiodarone after 3 defib attempts, irrespective of whether those episodes are concurrent or separate)

Question 16

following any IV/IO drug given in cardiac arrest by a flush of what?

Answer 16

at least 20ml saline to facilitate drug delivery to the central circulation

Question 17

T/F: mechanical chest compression devices are superior to manual chest compressions

Answer 17

false - routine use is not superior

Question 18

examples of scenarios where mechanical chest compressions are needed?

Answer 18

acute MI and VF/ pVT refractory to 5 shocks where a decision is made to transport during arrhythmia to access PCI

hypothermic pt where prolonged resuscitation is considered

Question 19

roles of waveform capnography?

Answer 19

monitor tracheal tube placement
early indication ROSC
ensuring high quality CPR
helping prognostication

Question 20

criteria when it is appropriate to not start CPR in a cardiopulmonary arrest? (recognition of life extinct)

Answer 20

decapitation
massive cranial and cerebral destruction
hemicorporectomy
incineration (>95% full thickness burns)
decomposition/ putrefaction
rigor mortis and hypostasis
valid DNACPR in place

Question 21

if, following ALS interventions, the pt has been persistently and continuously asystolic for ___ mins and all reversible causes have been identified and corrected, resuscitation may be discontinued

Answer 21

20

Question 22

where practical, pts with what rhythms on ECG should be taken to the nearest cardiac arrest centre with ongoing CPR, minimising time on scene

Answer 22

VF/ pVT - because further treatment e.g. PCI may be successful

Question 23

T/F: you should allow relatives to be present during the resuscitation attempt

Answer 23

true - providing they do not interfere with the clinical care

Question 24

treat hypotension following ROSC with what

Answer 24

boluses of 250ml saline, repeated as necessary

Question 25

following ROSC, in the event of severe haemodynamic instability unresponsive to atropine and/ or fluids and/ or pacing, consider what intervention?

Answer 25

inotropic support > boluses of adrenaline 0.05-0.1mg IV/IO titrated against BP and repeated as necessary

aim for initial SBP >100

Question 26

during ventilation following ROSC, aim to maintain SpO2 at ___-___% and the end-tidal CO2 at ___-___kPa (values may be lower in pts with poor cardiac output)

Answer 26

94-98
4.6-6

Question 27

T/F: if pt is pyrexial post-ROSC, using rapid high-volume cold IVF immediately

Answer 27

false - associated with increased incidence of re-arrest and pulmonary oedema

use passing cooling (do not cover with blankets, keep ambulance temperature no higher than ambient)

Question 28

management of the combative pt post-ROSC (may be cerebrally irritated)

Answer 28

exclude hypoglycaemia
incremental doses of IV diazepam or IV midazolam may be indicated
anaesthetic support once in hospital

Question 29

T/F: should aim to achieve ROSC on scene rather than transporting pt with ongoing resuscitation attempts

Answer 29

true - resuscitation in a moving ambulance is likely to be suboptimal

in those who achieve ROSC, or those who have not achieved ROSC in 20 mins but in whom resuscitation is being continued, aim to leave the scene ASAP

Question 30

when transporting the pt to the hospital following ROSC, what position should they be in to optimise cerebral perfusio?

Answer 30

supine
feet first when coming down stairs
head up about 30 degrees

Question 31

structured method to handover information during a pre-alert?

Answer 31

ATMIST
- age
- time of onset
- medical complaint/ mechanism of injury
- investigations/ injuries
- vital Signs
- treatment
Finish with ETA