Adult Advanced Life Support

Question 1

DRS ABCD

Answer 1

Danger 
Response - question, shake, command 
Shout - help and flat bed 
Airway 
Breathing 
CPR and Call cardiac arrest team - ask helper to call 2222 and explain there is an adult / pads / neonatal / trauma cardiac arrest and location - ask helper to bring RESUS trolley back 
Defibrillation

Question 2

What rate and depth should compressions be

Answer 2

100-120 per minute - 5-6cm

Question 3

When does cycle one begin and how often should you rhythm check

Answer 3

When defibrillator set up
Every two minutes - stop for 5 seconds to see if shockable (VF/VT) or non-shockable (PEA/asystole)

If rhythm that is compatible with pulse is seen (sinus or VT) - feel for carotid pulse and stop compressions if present

Question 4

Defibrillation steps to follow if shockable rhythm

Answer 4

Select correct energy level if not automatic ~150J biphasic
Ask for O2 to be REMOVED and everyone except compressions to move away - will tell them when shock about to be administered
Charge defib then move away
Once charged ask compressions to be stopped and shout CLEAR
Check CLEAR
Deliver shock
Immediately restart CPR

Question 5

What to consider with airway

Answer 5

Face mask with bag - 30 to 2
Consider OPA or NPA under mask
Once supraglottic airway or ETT placed - ventilate every 6 seconds with continuous compressions

Attach 15L/minute O2
Attach end-tidal CO2 monitoring if supraglottic mask or ETT attached
Avoid hyperventilation

Question 6

What drugs to consider

Answer 6

Obtain IV access and have drugs ready
If can’t get IV access after 2 attempts get IO
Bloods - VBG, FBC, U&E, LFT, G&S, Mg
IV fluids

Adrenaline 1mg IV (10ml of 1:10,000)

• shockable - give after 3rd shock (during CPR) and flush with 20ml saline
• non-shockable - give as soon as IV access and flush

Repeat adrenaline every other CPR cycle thereafter (~3-5 minutes) regardless of rhythm change
Adrenaline causes peripheral vasoconstriction to maximise cardiac blood flow

Amiodarone 300mg IV - if shockable

• give after 3rd shock
• stabilises the myocardium during VF and VT
• further 150mg after 5 shocks then infusion

Question 7

What are the reversible causes

• how to assess
• how to manage

Answer 7

Hypoxia

• ensure adequate ventilation, O2 flow rate, ABG
• 15L/M O2 and good ventilation

Hypovolaemia

• Hx, drains, haemorrhage, fluid collections (expose patient)
• Fluid resuscitation

Hypo/Hyperkalaemia

• ABG and latest blood results
• Hyper - 10ml 10% calcium chloride and 10U act rapid insulin in 50ml 50% dextrose
• Hypo - 20mmol KCL over 10 minutes

Hypothermia

• Temperature
• Warm patient

Thrombosis

• Hx, RF, Legs (DVT), post-op
• Thrombolysis if PE, call cardio if MI

Tension Pneumothorax

• Trachial deviation, hyper-resonance, decreased breath sounds
• Cannula into 2nd ICS mid clav line

Tamponade (cardiac)

• recent chest trauma / surgery, focussed USS
• Pericardiocentesis

Toxins

• Hx, drug chart, gather info, cap glucose
• treat toxaemia i.e. naloxone for opioids

Question 8

What to do if ROSC

Answer 8

Full A-E
Control O2 (94-98%)
Consider therapeutic hypothermia (32-36o)
Post-arrest Ix: cap glucose, full bloods, ABG, ECG, cardiac monitoring, CXR, ECHO
Treat cause
Consider HDU / ITU

Document

Question 9

What to do differently if pregnant

Answer 9

Manually displace uterus to left to avoid caval compression

Prepare for emergency C-section if >20 weeks gestation - within 5 mins of arrest

Question 10

Airway considerations in critically ill patient

• assessment
• management

Answer 10

Patent if talking
Non patent if secretions, aspirated, snoring, GCS<8
Look inside mouth

Remove dentures / debris 
Suction 
Airway manoeuvres 
OPA / NPA
Intubation if GCS<8
Treat cause - i.e. anaphylaxis, foreign body

Question 11

Breathing considerations in critically ill patient

• assessment
• management

Answer 11

Pulse oximetry 
RR
Chest exam - cyanosis, tracheal deviation, chest inspection (accessory muscles, deformities), expansion, percussion, auscultation
ABG - if low sats or low GCS 
CXR if lung pathology suspected 

15L/m O2 via non-rebreathe mask
If COPD - 24-28% Venturi for 88-92% sats
Consider NIV or invasive ventilation of hypoxaemic or hypercapnic respiratory acidosis despite maximal therapy
If resp effort inadequate - support with bag-mask ventilation

Treat cause - i.e. pneumothorax, asthma/COPD exacerbation, opiate OD, PE

Question 12

Circulation considerations in critically ill patient

• assessment
• management

Answer 12

Cap refill 
Pulse rate, rhythm, volume 
BP 
Auscultate heart, JVP
Fluid balance and organ perfusion - fluids, intake and catheter, drains, vomit 

Wide bore IV cannula - take bloods and VBG
Apply 3-lead cardiac monitoring
ECG if concerned
Catheter and fluid balance monitoring if hypotensive or unwell

Hypotension

• lay supine and elevate legs
• fluid challenge 0.9% saline STAT and monitor response - HR, BP, UO
• 250ml if significant heart failure hx

Shock

• 2 large bore IV cannula
• fluid challenge - 1L 0.9% saline STAT
• replace blood with blood (O neg or typing takes 15mins) - in massive blood loss - 2222 and call lab to activate massive blood loss protocol to get packed red cells + FFP +/- platelets

Further

• respond fully - consider maintenance fluids
• responds but BP falls again - may require further challenge
• No response - may be fluid overloaded or in cariogenic shock (avoid further fluids) or very deplete (requires further fluids)

Escalate

• If hypotensive and overloaded - need inotropes
• if still hypotensive despite fluid rhesus (20-30mg/kg quickly) need vasopressors

Treat cause
- arrhythmia, sepsis, bleeding etc.

Question 13

Disability considerations in critically ill patient

• assessment
• management

Answer 13

DEFG 
GCS / AVPU 
Temperature 
Pupils - reactivity and symmetry 
Pain assessment 

CT brain - if intracerebral pathology to be ruled out

Correct glucose
Give analgesia if pain - morphine 10mg in 10ml slow IV injection titrated to pain

Look for and treat cause
- Low GCS - morphine / sedative use, focal neuro, hypercapnia, post-octal

Question 14

Everything else considerations in critically ill patient

• assessment
• management

Answer 14

Exposure - bleeds, rashes, injuries, drain/catheter output, lines

Examine abdo
Focussed exam of relevant systems

Manage abnormal findings as appropriate

Question 15

Investigations to consider to find cause

Answer 15

BOXES

Bloods (mark as urgent

• ABG
• Venous bloods (FBC, U&E, LFT, CRP, G&S, VBG, amylase, clotting, troponin)
• Capillary glucose
• Blood cultures if fever

Orifice tests

• urine dip
• urnie / sputum / stool culture
• urine bHCG

X-ray / imaging
- Portable CXR, CT brain (if focal neuro or low GCS)

ECG +/- 3 lead cardiac monitoring

Special tests