Advanced Life Support

Question 1

name the

1. shockable
2. non-shockable

cardiac rhythms

Answer 1

1. shockable: VF, pVT
2. non-shockable: PEA, asystole

Question 2

Treating Shockable Rhythms

1. Confirm cardiac arrest
2. Call resus team
3. Perform uninterrupted chest compressions while applying pads: descibe the placement of these
4. Stop compressions: confirm VF/ pVT from ECG. This pause should be ≤?secs
5. Immediately resume compressions. Warn all other than the individual performing chest compressions to ‘stand clear’ and remove any oxygen devices
6. Select the appropriate energy on the defib (at least __J for first shock) and press charge
7. Tell individual performing chest compressions to ‘stand clear’ then deliver shock immediately resume CPR (30:2) starting with chest compressions. This pause should be ≤5s
8. Continue CPR for how long?
9. Brief pause to check monitor for rhythm. If VF/ pVT repeat as before
10. After 3^rd shock deliver what medications while performing a further 2 min CPR.
11. Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/pVT persists.
12. Give further ____ 1 mg IV after alternate shocks (i.e. approx. every 3–5 min) for as long as cardiac arrest persists. If VF/pVT persists, or recurs, further 150 mg amiodarone may be given after how many defibrillation attempts.
13. If organised electrical activity compatible with a cardiac output is seen during a rhythm check, seek evidence of ROSC such as?
14. If ROSC, start post-resus care. If no signs of ROSC, continue CPR and switch to the non-shockable algorithm.
15. If asystole is seen, do what?

Answer 2

1. .
2. .
3. one below the right clavicle and the other in the V6 position in the midaxillary line.
4. 5
5. .
6. 150
7. .
8. 2 minutes
9. .
10. adrenaline 1 mg IV and amiodarone 300 mg IV (NB: Withhold adrenaline if there are signs of ROSC)
11. .
12. adrenaline. 5 (lidocaine, 1 mg kg-1 may alternatively be used if amiodarone unavailable)
13. check for signs of life, a central pulse and end-tidal CO2 if available
14. .
15. continue CPR and switch to the non-shockable algorithm

Question 3

what is pulseless electrical activity? (PEA)

Answer 3

cardiac arrest in the presence of electrical activity (other than ventricular tachyarrhythmia) that would normally be associated with a palpable pulse

Question 4

Treating non-shockable rhythms

1. Start CPR 30:2
2. Give what medication as soon as access achieved
3. Continue CPR 30:2 until airway is secured then continue chest compressions at what ratio?
4. Recheck the rhythm after 2 min

• If EA compatible with a pulse is seen, check for a pulse and/ or signs of life
• If none, do what?
• Change to shockable algorithm if VT/pVT detected at rhythm check

Answer 4

1. .
2. adrenaline 1mg IV/IO
3. without pausing during ventilation
4. continue CPR, check rhythm after 2 min and proceed accordingly, give further adrenaline 1mg IV every alternate 2 min CPR loop

Question 5

describe high quality compressions

Answer 5

5-6cm depth, 100-120/ min, full recoil at the end of each

Question 6

what airway device should be used for ventilation in the absence of personnel skilled in tracheal intubation?

Answer 6

A bag-mask, or preferably, an SGA (e.g. LMA, i-gel)

Question 7

Once an SGA has been inserted, attempt to deliver continuous chest compressions, uninterrupted during ventilation.

Ventilate at __ breaths per min

If there is excessive gas leakage leading inadequate ventilation?

Answer 7

10

interrupt chest compressions to enable ventilation (30:2)

Question 8

T/F: chest compressions should be stopped in order to perform laryngoscopy and intubation

Answer 8

false - avoid stopping chest compressions during laryngoscopy and intubation (brief pause <5s may be needed when passing the tube between the vocal cords)

Once the patient’s trachea has been intubated, continue compressions without pausing during ventilation

Question 9

After intubation, how should correct position by confirmed?

Answer 9

with waveform capnography

Question 10

what sort of invasive cardiovascular monitoring can be used to monitor CPR in critical care settings?

Answer 10

• continuous arterial blood pressure
• central venous pressure monitoring

Will enable detection of even very low blood pressure values when ROSC achieved

Question 11

PCO2 vs PaCO2?

Answer 11

• PCO2 = concentration of CO2 in the blood
• PaCO2 = concentration of CO2 in arterial blood

Question 12

what information does end-tidal CO2 provide?

Answer 12

it reflects cardiac output and pulmonary blood flow (CO2 is transported by the venous system to the right side of the heart and then pumped to the lungs by the right ventricle) as well as the ventilation minute volume

Question 13

During CPR, end-tidal CO2 values are low/ high

Answer 13

low (reflecting the low cardiac output generated by chest compression)

Question 14

Waveform capnography works best in patients with what airway devices?

Answer 14

tracheal tube

but can also be used with SGA or bag mask

Question 15

what does waveform capnography measure?

Answer 15

end-tidal CO2

Question 16

what is the role of waveform capnography in CPR?

Answer 16

• ensures tracheal tube placement
• Monitors ventilation rate during CPR
• Monitors quality of chest compressions
• Identifying ROSC (allowing adrenaline to be withheld)
• Prognostication

Question 17

Main sites used for intraosseous access in adults?

Answer 17

• proximal humerus
• proximal tibia
• distal tibia

Question 18

contraindications to using intraosseous access?

Answer 18

• trauma, infection or a prosthesis at the target site
• IO access in last 48h in the same limb

Question 19

complications of IO access?

Answer 19

• extravasation
• needle dislodgement
• compartment syndrome due to extravasation
• fracture or chipping of the bone during insertion
• pain during infusion
• fat emboli
• infection/ osteomyelitis

Question 20

name the reversible causes of cardiac arrest (4 Hs and 4 Ts)

Answer 20

• Hypoxia
• Hypovolaemia
• Hypo/hyperkalaemia, hypoglycaemia/calcaemia, acidaemia, other metabolic
• Hypothermia
• Thrombosis
• Tension pneumothorax
• Tamponade (cardiac)
• Toxins

Question 21

Hypoxia

• How to manage this during CPR?

Answer 21

• Ensure lungs ventilated with 100% oxygen during CPR
• Ensure adequate chest rise and bilateral breath sounds
• Check tracheal tube not misplaced in a bronchus or oesophagus
• If ROSC achieved, adjust the inspired oxygen to target of 94-98%.

Question 22

IV ___ ___ is indicated in the presence of hyperkalaemia, hypocalcaemia and CCB overdose

Answer 22

calcium chloride

Question 23

Hypothermia

• Suspect this in any incident involving ____
• Use a __ __ thermometer

Answer 23

• drowning
• low reading

Question 24

Thrombosis

• Coronary thrombosis is a common cause of cardiac arrest
• If an ACS is the expected cause, ___ ___ ___ and coronary intervention during ongoing CPR may be feasible to perform
• Commonest cause of thromboembolic or mechanical circulatory obstruction is massive ___. If suspected, consider giving a ____ drug immediately. If given, consider performing CPR for at least ____ mins before terminating

Answer 24

• percutaneous coronary angiography
• PE
• fibrinolytic
• 60-90

Question 25

Cardiac tamponade is difficult to diagnose because typical signs of distended neck veins and hypotension cannot be assessed during cardiac arrest

What might raise suspicious/ Ix that migt help

*

Answer 25

• Penetrating chest trauma or post-cardiac surgery should raise strong suspicious
• Focussed cardiac US can diagnose a pericardial effusion

Question 26

what is Extracorporeal CPR (ECPR)?

What is it used?

Answer 26

• passes the patient’s blood through a machine in a process to oxygenate it
• Can provide a circulation of oxygenated blood to restore tissue perfusion
• Has potential to buy time for restoration of adequate spontaneous circulation and treatment of reversible causes

Question 27

• Generally accepted that asystole for >__ min in the absence of a reversible cause and with ongoing ALS is reasonable grounds for stopping
• After stopping, observe patient for minimum of __ min before confirming death

Answer 27

• 20
• 5