ACLS/ RHYTHMS/ ECG

Question 1

identify the components of the chain or survival

Answer 1

• Early recognition: look for signs of a cardiac arrest
• Call for help
• Early defibrillation: COACHED
• Early CPR → instead of ABC during cpr it is CAB
• Post resuscitation care

Question 2

what does COACHED stand for?

Answer 2

C= Compressions continue
O = Oxygen
A = Airway
C = Clear others/ charge defib
H = Hands off
E = Evaluating rhythm
D = Defib or disarm

Question 3

How is cardiac arrest diagnosed?

Answer 3

Normal rhythms
- Sinus rhythm
- Sinus bradycardia
- Sinus tachycardia
- Sinus arrhythmia

→ patient complains of chest pain, dizziness, shortness of breath, nausea
→ Check pulse
→ ECG to see wave patterns (VF or VT are shockable while PEA and asystole require CPR)

Question 4

What are the components of the ACLS algorithm?

Answer 4

• Start CPR
• Attach the defibrillator
• Assess rhythm :
  →If it is shockable → shock then continue CPR = if rhythm comes back commence post resus care
  → If it is non-shockable → continue CPR + 1mg IV adrenaline = if rhythm comes back commence post resus care

Question 5

Describe the various shockable rhythms

Answer 5

Ventricular fibrillation → characterised by chaotic waveforms and unrecognisable P-wave and QRS complexes → ventricular spasm often doesn’t have a pulse

Ventricular tachycardia → characterised by a heart rate of above 130 bpm, QRS complexes can be both narrow and wide (polymorphic). Abnormal electrical activity causes the ventricles to beat at a rapid rate → the patient may have or may not have a pulse

Question 6

Describe the various non-shockable rhythms

Answer 6

Pulseless electrical activity → there is a disconnection between the electrical conduction system and mechanical contraction → there is a presence of electrical activity on ECG but no cardiac output is observed → no detectable pulse

Asystole → cessation of electrical and mechanical activity of the heart → flatline waveform on ECG

Question 7

what do we need to consider as causes of non-shockable rhythems?

Answer 7

4 Hs
4 Ts

Question 8

what are the 4 Hs?

Answer 8

Hypoxia: pre-arrest SpO2, consider advanced airway and avoid hyperventilation (use capnography)

Hypovolaemia: caused by internal/external haemorrhage, wounds/surgical drains, sepsis, trauma, anaphylaxis and gastro (control the haemorrhage + replace blood)

hypo/hyperkalemia: diuretic use, kidney disease + hyperglycemia, medications, drug chart is required and fluid input and output chart

Hypothermia: ill patients have altered thermoregulation → re-warming, warm IV fluids and consider cardiopulmonary bypass
Hyperthermia: core temp is higher than 38.5 consider cause such as drug toxicity, dehydration or thyroid storm. Heat stroke can resemble septic shock. Treatment should be no quicker than 0.5 C/hr.

Question 9

what are the 4 Ts?

Answer 9

Tension pneumothorax: air in the intrapleural space → check position of tube, check for rise and fall of the chest, decreased breath sounds → needle decompression

Cardiac tamponade : blood or fluid in the pericardial space → chest pain, discomfort relieved when leaning forward → treatment is resuscitative thoracotomy, nurses role is to identify and escalate

Thrombosis: clot in the pulmonary vein often caused by DVT → characteristics include chest pain, SOB, hypoxia, and arrhythmia → treatment: heparin, percutaneous intervention and in cardiac arrest give fibrinolytic therapy.

Toxins: review medication charts, recreational drugs? → act early as specific antidotes may be needed

Question 10

What are the dose, route and MOA of adrenaline during a cardiac arrest?

Answer 10

Dose and route:
- 1mg in 10mls IV every 3-5 mins

MOA:
- Non-selective adrenergic agonist with potent B1 and moderate a1 + b2-receptor activity. Increases the myocardial force of contraction and heart rate

Question 11

What are the dose, route and MOA of lignocaine during a cardiac arrest?

Answer 11

Dose and route:
- 1-3mg/kg IV in 100mg bolus repeated every 5-10 mins

MOA:
1st choice in VT, an antiarrhythmic drug. Has no effect on SVT. Slows the rise of the cardiac action potential by causing negative inotropic effects and antiarrhythmic actions in the heart that weaken muscular contraction force

Question 12

What are the dose, route and MOA of atropine during a cardiac arrest?

Answer 12

Dose and route:
- 1mg IV every 3-5 mins (max 3mg)

MOA:
- NOTE: Avoid use in bradycardia secondary to hypothermia!
- Acts on the conduction system of the heart, accelerating electrical impulse transmission through cardiac tissue. Given to reverse asystole and severe bradycardia

Question 13

what does post-resus care include? how do we prevent complications?

Answer 13

• ECG monitoring
• Re-evaluate A-G assessment
• Oxygen therapy aim sat above 95%
• Assess patient LOC and GCS score.
• Re-assess pulse.
• Ensure defibrillator pads are attached to patients.

Question 14

What are the nursing responsibilities in ACLS and post-resus care?

Answer 14

• Oxygenation with stat goal >95%
• ECG monitoring
• Treat underlying cause (4H/TH)
• Achieve normocapnia (ensure the airway is a patent/consider ETT?)
• Optimise cerebral perfusion
• Treat and prevent cardiac arrhythmias
• Determine and treat the cause
• Resuscitation injuries → fractured ribs, tension pneumothorax, cardiac tamponade, ventilation