ACLS Flashcards
What are the ACLS updates 2015 versus 2010
Any intervention: compression interruption < 5 seconds
Waveform capnography included
Stepwise airway management dependent on patient factors and rescuer skill
Is mechanical chest compression (LUCAS) indicated in the 2015 guidelines?
Some circumstances (patient transfer)
Is peri-arrest ultrasound indicated
In certain situations in providers with appropriate training
What do the guidelines say about Extracorporeal Life Support techniques
May be useful in certain patients where standard measures have failed
What two possible intra-operative conditions require deviation from standard cardiac arrest algorithm
Local anaesthetic toxicity
Anaphylaxis
What is the incidence of intraoperative cardiac arrest primarily attributable to anaesthesia
1 in 10 000
Classify the the major causes of perioperative cardiac arrest
Primary bleeding (Truama/coagulopathy/surgical vessel rupture)
Primary cardiac (MI/Dysrhythmia/block)
Other
- PE (air/fat/thrombus)
- Anaphylaxis
- Hypoxia (Airway/ventilatory complications
What circumstances constitutes cardiac arrest considered to be directly attributable to anaesthesia?
Immediate arrest following drug administration
Airway complications and mishaps
(Unstable patients arresting on induction were not considered having arrested primarily due to anaesthesia)
List in descending order the survival to hospital discharge the rhythms with best survival to hospital discharge
pVT/VF (41.8 %)
Asystole (30.5 %)
PEA (26.4 %)
What action should be taken if there is loss of SaO2 signal and ETCO2 reading diminishing
Pulse check (PEA arrest possible)
How is management of intra-operative VF different from the ALS algorithm
Stacked shocks - 2 x successive shocks –> CPR and algorithm
Precordial thump - if defibrillator not available
How is management of intra-operative asystole different from the ALS algorithm
EXCLUDE lead disconnection (completely straight line)
STOP VAGAL STIMULATION and TRY ATROPINE 0.5 MG
Most likely cause: excessive vagal tone
- Stop surgeon
- Administer atropine 0.5 mg titrated up to effect
If no immediate ROSC: CA algorithm
How is management of intra-operative PEA different from the ALS algorithm
Start CPR Give fluid (unless certain of normovolaemia) Vasopressor - Adrenalin 1mg is too much - give a small dose of adrenalin or another vasopressor initially --> if this fails to restore cardiac output, increase the dose
Cardiac arrest in a prone patient - how to do chest compressions
Compress on the back with or without sternal counter pressure
Describe the immediate management of a patient once anaphylaxis has been diagnosed
- Help
- Convert to ETT with FiO2 100%
- Adrenalin 0.5mg IM (50 ug titrated boluses IV anaesthetists)
Describe Early management (after immediate Rx) of a patient once anaphylaxis has been diagnosed
Fluid (500 ml or 20 ml/kg)
Chlorphenamine 10 mg IV
Hydrocortisone 200mg IV
If bronchospasm is significant -
Intravenous bronchodilators:
- Salbutamol (5 - 20 ug/min)
- Magnesium Sulphate (2g over 20 minutes)
- Aminophylline (load with 5.7 mg/kg if naive)
Describe late management (after early Rx) of a patient once anaphylaxis has been diagnosed
ICU
Tryptase levels: immediate, 2 hours and > 24 hours
Ensure allergy/immunology clinic referral
What is used in the treatment of cardiac arrest associated with local anaesthetic toxicity? Describe the proposed mechanism for its effect
Intralipid 20%
It has been suggested that the local anaesthetic partitions into the lipid which reduces the concentration in the myocardium.
What are the clinical findings suggestive of local anaesthetic toxicity
Precipitous CVS and or CNS disruption
CVS
Sinus brady/blocks/asystole/ventricular tachyarrhythmias
CNS
Severe agitation/LOC ± seizures
Does local anaesthetic toxicity occur immediately after administration of toxic dose?
There may be some delay after the initial injection
Describe the immediate management of LA toxicity
- Help and fetch intralipid bag
- ETT and FiO2 100%
- Rx seizures with increments of propofol/thiopental/benzo
- CPR if necessary ALS protocols (consider cardiopulmonary bypass if available)
- Administer Intralipid
What is the maximum cumulative dose of intralipid?
12ml/kg
How is intralipid administered in the setting of local anaesthetic toxicity?
- 1.5mg/kg bolus over 1 minute (3 boluses 5 minutes part if CVS not stabilized)
- 15mg/kg/hr infusion (double to 30 after 5 mins if CVS not stabilized)
For a 70 kg man
- 100ml bolus with infusion at 1000ml/hr for 40 mins
After 5 mins CVS instability remains - 100 ml bolus with infusion 2000 ml/hr for 20 mins
After 5 mins CVS instability remains - 100 ml bolus with infusion at 2000ml/hr for 16 mins
Maximum cumulative dose is 840 mls - this determines the infusion duration
How long should CPR continue in the setting of cardiac arrest caused by LA toxicity
Recovery from LA induced CA may take > 1 hour
Consider cardiopulmonary bypass
Is propofol a suitable substitute for 20% lipid emulsion
NO
How should hypotension/bradycardia and tachyarrhythmia be treated in the context of LA toxicity
Use conventional therapies and algorithms except exclude lidocaine as an antiarrythmic
What tests should be done in in the subsequent two days if ROSC is obtained
Exclude pancreatitis - Lipase and amylase daily
Summarize post-resuscitation care
Airway and breathing
- Advanced airway with waveform capnography
- SaO2 94 - 98%
- ETCO2 5 - 5.5kPa
Circulation
- SBP > 100 mHg (IABP/Vasopressor)
- Normovolaemia
- 12 lead ECG
Disability
- Rx seizures
- Optimize sedation
Exposure
- Tb: 32 -36 deg C
- Control shivering
Investigation
Likely Cardiac –> Coronary angiography/PCI
Unlikely cardiac –> CTB/CTPA
What is post cardiac arrest syndrome?
Comprised of 4 components
- Post CA brain injury (coma/seizures/myoclonus/neurocognitive dysfunction and brain death)
- Post CA myocardial dysfunction
- Systemic ischaemia and reperfusion response (Activation of immune and coagulation pathways –> multiple organ failure and risk of infection)
- Persistent precipitating pathology
Why is survival to hospital discharge significantly higher in patients who suffer CA in the perioperative setting
A reversible cause is more likely in this setting and intervention is often immediate
Considering the higher likelihood of survival from CA in the perioperative setting, how does this influence the management of the patient with a DNACPR order
Counsel patient beforehand to establish preference with regard to whether they would like to maintain DNACPR for the procedure or not
In what % of perioperative cardiac arrests is there a primary cardiac cause?
44%
What is the survival to hospital discharge for a perioperative cardiac arrest that occurs due to bleeding
10.3 % survival
What is the survival to hospital discharge for a perioperative cardiac arrest that occurs due to a primary cardiac cause
42%
What is the survival to hospital discharge for a perioperative cardiac arrest that occurs due to a ‘other’ causes (non bleeding and non cardiac)
> 57%
Of the cardiac arrests caused directly by drugs, which drugs are the most common cause
Neuromuscular blockers are the most common cause of drug-induced cardiac arrest directly attributable to anaesthesia.
What % of perioperative cardiac arrests survive to hospital discharge
34.5%
