Advanced Life Support

Question 1

Cardiac Arrest

Answer 1

DC Shock 150j bipasic
Adrenaline 1mg IV (10ml of 1g in 10 000ml)
Amidoarone 300mg IV (if shockable rhythm)

Question 2

Anaphylaxis

Answer 2

Adrenaline 0.5mg IM (0.5ml of 1 in 1000)
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV

Question 3

Seizure

Answer 3

Lorazapam 4mg IV
(Benzodiazepam 10mg PR if no IV access)

Question 4

Hypoglycaemia

Answer 4

10% glucose 150ml IV /20% glucose 75ml IV over 5 mins (repeat as needed)

or glucagon 1mg IM if no IV access

Question 5

Hyperkalaemia

Answer 5

10% calcium gluconate 10ml IV over 5 mins

Then 10% glucose 250ml IV with 10 units Actrapid insulin over 30 minutes.

Question 6

Bradycardia

Answer 6

Atropine 500 micrograms IV
- repeat every 3 - 5 minutes to a max of 3mg if needed

Question 7

Supraventricular Tachycardia (SVT)

Answer 7

Adenosine 6mg IV ( followed by a further 12mg if unsuccessful)

NB must be given as quick bolus and flushed via large bore cannula in the antecubital fossa

Question 8

Ventricular Tachycardia (VT)

Answer 8

Amiodarone 300mg IV over 20-60mins

Question 9

Rapid tranquilization of patient at risk to self or others

Answer 9

Lorazepam 1-2mg PO (or 2-4mg IM)

or Haloperidol 1.5-3mg

Question 10

Benzodiazepine overdose

Answer 10

Flumazenil 300 micrograms IV

Question 11

Addison’s crisis

Answer 11

hydrocortisone sodium succinate: 50-100 mg intravenously every 6-8 hours for 1-3 days

Question 12

Opiate overdose

Answer 12

naloxone: 0.4 to 2 mg intravenously/intramuscularly/subcutaneously, repeat dose every 2-3 minutes.

Plus ventilation if required.

Question 13

Acute asthma

Answer 13

salbutamol nebuliser 5 mg every 20-30 minutes or when required

ipratropium nebuliser 500 micrograms every 4-6 hours when required

prednisolone: 40-50 mg orally once daily for at least 5 days

Consider a single dose of iv magnesium sulfate for the patient with asthma with PEF <50% of best or predicted who has not responded well to initial inhaled bronchodilator therapy.

Question 14

PE

Answer 14

Critically ill - thrombolyse

50g bolus of antiplase

otherwise LWMH

Question 15

MI

Answer 15

M morphine 5mg IV
O oxygen if required
N nitrates 400mg sub ling
A aspirin 300mg crushed dispersible

Metaclopramide 10mg

Question 16

ECG Method

Answer 16

Rule of Fours

Four variables
- how is the patient?
- rate
- rhythm
- axis

Four waves
- p waves
- QRS waves
- T waves
- U waves

Four intervals
- PR Interval
- QRS interval
- ST segment - elevated or depressed
- QT interval

Question 17

4 Hs and 4 Ts

Answer 17

Hypovolaemia
Hypothermia
Hypoxia / hyperthermia
Hypo/hyperkalaemia and other electrolyte imbalances
Tampanade - cardiac
Thrombus - pulmonary or cardiac
Toxins
Tension pnumothorax

Question 18

Shockable rhythms

Answer 18

Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (VT)

Question 19

non shockable rhythms

Answer 19

Pulseless electrical activity (PEA)
Asystole

Question 20

After the … shock give …

Answer 20

Adrenaline and amiodarone are indicated after the third shock in primary VF/pVT arrests. All drugs should be flushed into the circulation with at least 20 mls of fluid.

Question 21

Wave form capnography

Answer 21

The sudden rise in end-tidal CO2 suggests return of spontaneous circulation. When this is seen or when a patient starts displaying signs of life, chest compressions should be paused and patient should be reassessed.

Question 22

Do a pulse check when…

Answer 22

Pulse checks should be performed only when organised electrical activity compatible with a pulse is seen

Question 23

Give adrenaline….

Answer 23

In primary VF/pVT, adrenaline is withheld until after the third shock. Once given, adrenaline should be repeated every 3-5 minutes, irrespective of cardiac arrest rhythm.

Question 24

The initial dose of amiodarone

Answer 24

300mg

Question 25

When considering the treatment of PEA/Asystole…

Answer 25

give 1 mg adrenaline as soon as vascular access is achieved. There is no evidence that the routine use of atropine is effective in the treatment of asystole or PEA.

Question 26

What percentage of people survives after receiving CPR for in-hospital cardiac arrest?

Answer 26

~24%

Question 27

What percentage of people survives after receiving CPR for out of hospital cardiac arrest?

Answer 27

When CPR is attempted 30% make it to hosp but only 10% of those survive to go home from hosp - 3%

Question 28

Management you have determined that your patient’s ECG shows a regular, narrow-complex tachycardia

Answer 28

• attempt vagal manoeuvres
• if doest work give adenosine 6 mg IV, followed by 12 mg, and then 18 mg each as a rapid bolus and the narrow-complex tachycardia persists, you should seek expert help.
  -Among possible causes for this is atrial flutter. In the first instance, this may be treated with drugs to control the rate (for example, a ß-blocker).

Question 29

Drugs for rate control in AF

Answer 29

• the usual drug of choice is a beta-blocker.
• Diltiazem may be used in patients in whom beta-blockade is contraindicated (e.g. by asthma) or not tolerated. (However, this is not available in the UK as an intravenous preparation).
• Digoxin may be used in patients with heart failure.
• Amiodarone may be used to assist with rate control but is most useful in maintaining rhythm control.
  Beta-blockers, diltiazem and digoxin should be given orally in the first instance unless the patient has contraindications, is vomiting or is critically unwell. In these circumstances, the IV route may be used for beta-blockers and digoxin.

Question 30

Drugs for rhythm control in AF

Answer 30

Drugs such as flecainide may be used, but you should always seek expert help before using it. Do not use flecainide in the presence of heart failure, known left ventricular impairment, ischaemic heart disease, or a prolonged QT interval.
Amiodarone (300 mg over 20-60 min followed by 900 mg over 24 h) may be used to attempt chemical cardioversion but is less often effective than drugs like flecainide and takes longer to work.
Electrical cardioversion remains an option in this setting and will restore sinus rhythm in more patients than chemical cardioversion.

Question 31

Adverse features in tachycardia

Answer 31

Adverse features imply that a patient’s condition is unstable and at risk of deterioration. The following adverse features indicate that a patient is at risk of deterioration either wholly or partly because of their arrhythmia:
Shock
Syncope
Heart failure
Myocardial ischaemia