Adult BLS and ALS

Question 1

step 1 of BLS

Answer 1

1. check for a response (to voice, to pain (trapezius squeeze)

response = start ABCDE

no response = call for help

Question 2

what is the chain of survival

Answer 2

The chain of survival refers to a series of actions that, properly executed, reduce the mortality associated with cardiac arrest.

Early recognition and call for help
Early CPR
Early defibrillation
Early advanced cardiac life support

Question 3

what do you do next if there is no response

Answer 3

1. get help
2. position pt on their back and inspect airway
3. head-tilt chin lift
4. Assess for signs of life
   - carotid pulse
   - assess breathing for 10 seconds (check RR)

Question 4

what do you do if a pulse is present but the RR is low

Answer 4

If the respiration rate is below 12 – assist ventilation with bag valve mask (BVM) to maintain 10 breaths/min (re-checking the pulse every minute to ensure it is still present).

You will likely need two people to perform effective ventilation with a BVM (one ensuring a good seal over the face and the other compressing the bag to deliver the oxygen).

The BVM should ideally be connected to high-flow oxygen as soon as possible.

Question 5

what do you do if a pulse is present and the RR is fine

Answer 5

urgent ABCDE to stabilise before further deterioration

Question 6

what is agonal breathing

Answer 6

If the patient has occasional, irregular gasps of breath, this does not qualify as a sign of life as it commonly occurs in cardiac arrest and is referred to as agonal breathing.

Question 7

what do you do if there is no signs of life?

Answer 7

call for help from resuscitation team and commence CPR

if you are alone, you should leave the patient and get help first

Question 8

CPR ratios and speed asult

Answer 8

30 chest compressions followed by 2 ventilations

Perform compressions at approximately 100-120 compressions per minute.

Question 9

how often should you alternate who is perfoming chest compressions

Answer 9

Alternate the person performing chest compressions at 2-minute intervals (if enough team members are present).

Question 10

what do you do once AED arrives

Answer 10

Once an automated external defibrillator (AED) arrives, it is import to attach the 2 self-adhesive pads immediately to the patient’s chest (as labelled):

ADHESIVE PAD 1: the right of the sternum below the clavicle.
ADHESIVE PAD 2: the mid-axillary line, with its long axis vertical and sufficiently lateral.

Question 11

when does advanced life support commence

Answer 11

once the resuscitation team arrives.

Question 12

What is ALS?

Answer 12

ALS builds on BLS to increase liklihood of survival of cardiac arrest

it takes over from BLS once chest compressions have commenced and a defib is attached.

It focuses on more advanced airway management, adding in drugs for shockable and non-shockable rhythms and correcting reversible causes of cardiac arrest

Question 13

what airway adjuncts may you use in ALS

Answer 13

oropharyngeal

nasopharyngeal

i-gel/LMA

endotracheal intubation

Question 14

what defined roles are there in ALS

Answer 14

Team leader
Timer and scribe
Airway
CPR1/defib
CPR2
IV access/bloods/gases/Drugs

Question 15

what rhythms are shockable rhythms

Answer 15

pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF)

Question 16

what should the team leader do?

Answer 16

delegate tasks
ask people to say when theyve completed a task/cycle
coordiante tasks
go through reversible causes

Question 17

in what circumstances should chest compressions be continuous

Answer 17

Chest compressions should be continuous once the airway is secured with endotracheal tube

Question 18

under what circumstances/for what things do you pause compressions for

Answer 18

ONLY stop CPR for rhythm checks, electrical shocks, and the 2 rescue breaths. Ask the person doing compressions to tell the airway person each time 30 compressions are complete.

Question 19

what do you do with defib if pt has a pacemaker?

Answer 19

if a pacemaker is present, ensure pads are >8cm away from it (you can put the pads on AP if needed)

Question 20

what are the cycles of ALS, when do they start?

Answer 20

a cycle = 2 minutes of CPR/rescue breaths

Cycle 1 starts when the defibrillator is connected.

Perform a rhythm check ± shock every 2 minutes

Question 21

Management of a shockable rhythm

Answer 21

2 minute cycles of cpr followed by rhythm check

If the initial rhythm is shockable, provide one shock (at the recommended joules for your equipment)

resume cycles

After the third shock, give 300mg amiodarone and 1mg adrenaline IV/IO

Continue adrenaline every 3-5min

After the fifth shock, administer amiodarone 150mg

Question 22

How to manage a non-shockable rhythm?

Answer 22

2 minute cycles of cpr followed by rhythm check

Give adrenaline 1mg IV/IO every 3 – 5 minutes

Question 23

what is the dosing of adrenaline used in ALS

Answer 23

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

Question 24

what is the dosing of amiodarone used in ALS

Answer 24

Amiodarone 300mg IV after 3rd shock

Repeat 150mg IV after 5th shock if ongoing

Question 25

when should adrenaline be used in ALS

Answer 25

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

Shockable rhythm: give after 3rd shock (during CPR). Flush with 20ml saline.

Non-shockable rhythm: give as soon as IV access is established. Flush with 20ml saline.

Repeat adrenaline dose during every other CPR cycle thereafter (i.e. repeat every 3-5 minutes once given, regardless of rhythm)

Question 26

when should amiodarone be used in ALS

Answer 26

Amiodarone 300mg IV: if shockable rhythm only. Give after 3rd shock (during CPR). Repeat 150mg IV after 5th shock if ongoing.

Question 27

How should the team leader assess and treat hypoxia

Answer 27

assess: ventilation adequacy, o2 flow rate, abg

treat: 15L/min O2, good ventilation, i-gel

Question 28

what are the reverisble cuases of cardiac arrest taht should be identified and worked through by the team leader

Answer 28

Hypoxia
Hypovolaemia
Hypokalaemia/hyperkalaemia
Hypothermia/hyperthermia
Thrombosis
Tension pneumothorax
Tamponade (cardiac)
Toxins

Question 29

How should the team leader assess and treat hypovolemia

Answer 29

assess: history, drains, haemorrhage, fluid collections (expose pt)

treat: fluid resuscitation, blood if haemorrhage, stop bleeding

Question 30

how should the team leader assess and treat hypo/hyperkalaemia

Answer 30

ABG and latest blood results

if hyperkalaemic:
- Protect the heart: calcium chloride
- Shift K into cells: insulin and glucose, sodium bicarbonate
- Remove K from the body: consider dialysis for refractory hyperkalameic cardiac arrest

10 mL calcium chloride 10% IV by rapid bolus injection

10 units soluble insulin and 25 g glucose IV by rapid injection. Monitor blood glucose. Administer 10% glucose infusion guided by blood glucose to avoid hypoglycaemia.

50 mmol sodium bicarbonate (50 mL 8.4% solution) IV by rapid injection.

if hypokalaemic: 20mmol KCl over 10 mins

Question 31

how should the team leader assess and treat hypo/hyperthermia

Answer 31

assess: pts temp on recent obs, warmth to touch

treat:
hypo = warm pt, extracorporeal CPR

hyper: cool pt, IV fluids

Question 32

how does the team leader assess and treat tension pneumothorax

Answer 32

assess: tracheal deviation, unilateral hyper-resonance and decreased breath sounds

treat: insert cannula into second intercostal space mid clavicualr line

Question 33

how should the team leader assess and treat cardiac tamponade

Answer 33

assess: recent chest trauma/surgery/pacemaker insertion/PCI
cardias USS if there is a risk

treat: pericardiocentesis

Question 34

how should the team leader assess and treat toxins

Answer 34

assess: history, drug chart, capilalry glucose

treat: treat toxaemia eg naloxone for opiods

Question 35

when is ECMO considered

Answer 35

Extracorporeal CPR using extracorporeal membrane oxygenation (ECMO) device may be considered where available for select patients to facilitate other definitive treatments, e.g. PCI, pulmonary thrombectomy for massive PE, rewarming for hypothermia

Question 36

for how long should you do CPR? who decides when to stop?

Answer 36

In general, CPR should be continued as long as there is a shockable rhythm (mechanical compression device may be used)

Only stop if a registrar or above makes the decision with the team

Question 37

defibrilation vs cardioversion

Answer 37

Defibrillation vs cardioversion – defibrillation is a general term often used to describe the shock given to the heart, and more specifically it describes an ‘unsynchronised ‘shock. Cardioversion refers to this shock when it is applied at a specific time in the ECG cycle (a ‘synchronised’ shock).

Question 38

what are the shockable rhythms

Answer 38

Ventricular fibrillation
Pulseless ventricular tachycardia

Question 39

what are non-shockable rhythms

Answer 39

PEA – pulseless electrical activity – this means any electrical activity that appears on an ECG like it should be producing a pulse, but it is not. (all electrical activity except VF/VT, including sinus rhythm without a pulse) The most common cause is hypovolaemia.

Asystole – no rhythm present