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ALS/GIC > Advanced life support algorithm > Flashcards

Advanced life support algorithm Flashcards

1
Q

What 2 groups are heart rhythms associated with cardiac arrest divided into ?

A
  1. Shockable - ventricular fibrillation & pulseless ventricular tachycardia (VF/pVT)
  2. Non-shockable - asytole and pulseless electrical activity (PEA)
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2
Q

What is the key difference in the management of VF/pVT and asystole/PEA?

A

You shock/defibrilate patients with VF/pVT.

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3
Q

What are the 3 key things which improve survival after cardiac arrest?

A
  • Prompt & effective bystander CPR
  • Uninterupted CPR (or as minimal as possible)
  • Early defibrillation of VF/pVT
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4
Q

How often will VF/pVT occur at some point in a cardiac arrest when the inital documented rhythm is asystole or PEA?

A

25% of the time.

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5
Q

What is the standard positions to place the self-adhesive defibrillation/monitoring pads on a patient ?

A

1st below the right clavicle
2nd left side in V6 mid-axillary line

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6
Q

You should plan your actions prior to interupting chest compressions. When chest compression are paused for rhythm check how long should this pause be ?

A

< 5 secs.

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7
Q

Once rhythm is confirmed and it is a shockable rhythm what is the next step?

A

You should charge the defibrillator to appropriate energy (J). Whilst charging the person doing compressions should restart compressions, everyone else should be stood clear of the patient with oxygen removed.

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8
Q

What is the general range of energy which can be used for the intial shock of a person in VF/pVT?

A

120-150J. (same or higher used for subsequent shocks)

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9
Q

Prior to shocking a patient for VF/pVT what should be done? (remember person doing compressions is currently still in contact with the patient)

A

Carry out safety check and tell person doing compressions to stand clear. Ensure no oxygen is in contact with the patient.

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10
Q

After a shock is delivered to the patient what should immediately happen ?

A

CPR should be restarted.

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11
Q

After shocking a patient should you pause to assess the rhythm or for a pulse?

A

No! - continue with CPR

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12
Q

When should you give drugs in shockable cardiac arrest rhythms and what should you give?

A

You should give 1mg IV adrenaline and 300mg IV amiodarone after the 3rd shock (this is whilst fruther round of CRP is going, i.e. started the 4th round).

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13
Q

After giving the 1st dose of adrenaline and amiodarone is given in shockable (VF/pVT) cardiac arrests when should you next give them ?

A

Give 1mg adrenaline every 3-5 mins i.e. every 2nd/alternate shock thereafter. For as long as cardiac arrest persists.

Amidoarone may be given after 5 shocks at a dose of 150mg.

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14
Q

If organised electrical activity consistent with cardiac output seen, when should you check for signs of life/ROSC?

A

At the next rhythm check (check for signs of life, sudden increase in end tidal CO2 and check central pulse)

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15
Q

If on rhythm check despite previously being shockable (VF/pVT) the rhythm has changed to either asystole or PEA what should you do ?

A

**Switch to the non-shockable algorithm **

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16
Q

If at rhythm check there is ROSC what should you do ?

A

Start post-resuscitation care.

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17
Q

Go over this summary of the steps of shockable algorithm

A

Add photo

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18
Q

How often after defibrillating someone and resotring a perfusing rhythm might you not immediately be able to palpate a pulse?

`

A

It’s very rare to be able to immediately palpate a pulse after defibrillation. It takes > 2 mins in 25% of cases to feel a palpable pulse after shock.

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19
Q

If a perfusing rhythm has been restored but you still cannot feel a pulse does continuing to give chest compressions increase the chance of VF occuring ?

A

No - also you would have to assume PEA until pulse felt anyway.

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20
Q

The evidence for adrenaline/amiodarone in cardiac arrest is limited. However what does there use increase?

A

Short-term survival

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21
Q

Should you stop for a rhythm check before giving drugs during a cardiac arrest ?

A

No - only scenario you would is if there is clear signs of ROSC.

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22
Q

If there is no amiodarone available what alternate can be used in shockable rhythms ?

A

Lidocaine at 1mg/kg

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23
Q

When can lidocaine not be used as an alternate to amiodarone ?

A

If amiodarone has already been used.

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24
Q

The decision to continue a resuscitation attempt is a clinical judgement as a rough rule of thumb however what is thought about continuing resusication attempts in VF/pVT (shockable) rhythms?

A

That its worth continuing the resus attempt whilst they remain in these rhythms.

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25
Q

In shock-refractory VF/pVT what should you consider doing?

A

You should check position and contact of the pads, if satisfactory, consider changing the defib pad placement to anterior-posterior.

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26
Q

Do you check for a pulse at each rhythm check?

A

No - only if you have a rhythm compatible with a pulse

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27
Q

When only should you interupt CPR to check for a pulse ?

A

When there is clear signs of ROSC

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28
Q

Sometimes it might be hard to distinguish fine VF from asystole, in this scenario what should you do i.e. what pathway should you follow?

A

Go with whichever pathway you think it is most likely, DONT debate.

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29
Q

A precordial thump has a very low success rate for cardioversion, when can it be used?

A

Only when it can be used without delay whilst awaiting for arrival of a defibrillator in a monitored VF/pVT arrest.

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30
Q

How does the ALS guideline differ for patients with a monitored arrest in the cath lab, CCU/ITU or whilst monitored after cardiac surgery AND a manual defibrillator is readily available?

A
  • Confirm cardiac arrest and if initial rhythm is VF/pVT can give 3 successive stacked shocks.
  • After each defibrillation attempt rapidly check if appropriate for pulse/signs of ROSC
  • If 3rd shock is unsuccessful continue on normal ALS algorithm BUT treat the previous 3 shocks as if only one shock was given in the normal alogrithm i.e. adrenaline would be given after 2 more shocks. Amiodarone on the other hand is given after 3rd shock regardless so give following three stacked shocks.
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31
Q

Define PEA

A

This is electrical activity (other than ventricular tachycarrhythmia) that would normally be associated with a palpable pulse.

These patients often have some mechanical myocardial contractions but they are too weak to produce a detectable pulse or BP.

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32
Q

Define asystole

A

This is the absence of electrical activity on the ECG trace

33
Q

Whenever a diagnosis of asystole is made what should you double check for ?

A

That there is no p-waves suggesting ventricular standstill which might need treating with cardiac pacing.

https://www.youtube.com/watch?v=2pHNEiH4wFg

34
Q

In non-shockable rhythms there is no difference in what you do aside from drugs and you DO NOT shock them. What is the difference in protocol for drugs given in non-shockable rhythm cardiac arrests?

A

Amiodarone is not given!
1mg IV Adrenaline is given immediately as soon as IV access is achieved.

35
Q

After IV access is achieved and the 1st dose of adrenaline is given in non-shockable rhythms when is it next given?

A

Every 3-5 mins i.e. during alternate 2 min cycles of CPR.

36
Q

During CPR when a defintive airway is not in place you will be giving compressions to ventilation breaths at 30:2. During these short breaks in compressions you might notice the rhythm has changed from non-shockable to VF (pVT doesnt count), should you stop and shock the patient or wait till the 2 min cycle of CPR has been completed?

A

Wait till the 2 min cycle has completed but prep the team that a shock will be immediately delivered.

pVT doesnt could as you need to check for a pulse to confirm this.

37
Q

Throughout the cardiac arrest (shockable or non-shockable alogrithm) what should you be checking for ?

A

Reversible causes. 4H’s & 4T’s

38
Q

In the absence of personnel trainined in intubation what is the preferred airway during a cardiac arrest?

A

Preferrably a supra-glottic airway (SGA) i.e. i-gel.
If unable to get an adequate seal with i-gel then bag-mask

39
Q

If a SGA is secured, at what rate should you ventilate the patient?

A

10 breaths/min

Compressions is at 100-120/min.

40
Q

If whilst providing continuous compressions and ventilating a patient at 10 breaths/min there appears to be excessive gas leakage causing inadequate ventilation what should you do ?

A

Interupt chest compressions to provide adequate ventilation i.e. switch back to 30:2.

41
Q

Have studies shown a benefit of intubation over bag-mask and SGA in cardiac arrests?

A

No

42
Q

If the patient is intubated during an arrest how long can you pause compressions for whilst they are being intubated ?

A

No more than 5 secs.

43
Q

How do you confirm correct palcement of the tracheal tube?

A

Waveform capnography
Observation and asculatation to ensure both lungs ventilated

44
Q

What clinical signs indicate ROSC and what if convincing do they require?

A

Breathing efforts, movements, eye opening and regaining conciousness.
They then require rhythm and a pulse check.

However these can occur in high quality CPR.

45
Q

During arrests blood samples can be difficult to interpret, what samples might provide a better estimate of tissue pH?

A

Central venous blood samples.

46
Q

Invasive blood pressure monitoring will help detect what during cardiac arrests?

A

Very low cardiac output/BP states when ROSC is achieved.

47
Q

List the different ways you might monitor a patient in cardiac arrest

A
  • Clinical signs of life
  • Pulse checks
  • Defibrillation pads i.e. heart rhythm
  • Waveform capnography - End-tidal CO2
  • Feedback or prompt devices
  • Blood sampling and analysis
  • Invasive BP monitoring (arterial lines)
  • Focused echo/ultrasound.
48
Q

If you suspect ROSC during a round of CPR, should you withold adrenaline ?

A

Yes, withold then finish 2 min cycle, check rhythm/pulse and if cardiac arrest still confirmed give the adrenaline during the next cycle.

49
Q

If there is a combination of signs suggesting ROSC e.g. waking, purposeful movements, arterial BP waveform or sharp rise in end-tidal CO2 what should you do during CPR?

A

Consider briefly stopping to check rhythm and a pulse check.

Note - if not convinced of ROSC then wait for next rhythm check and then assess rhythm and pulse.

50
Q

If someone does not have vascular access and suffers a cardiac arrest what should you do?

A
  1. Start the usual ALS alogrithm with compressions, airway management and defibrillation.
  2. The gain vascular access through either PVC or if unable intraosseous route (IO).
51
Q

How should drugs administered during an arrest be given ?

A

Drugs through a PVC or IO route should be followed by a min 20ml flush and then elevate the extremity for 10-20secs.

52
Q

Does the IO route compared to PVC’s achieve similar plasma concentrations of drugs ?

A

Yes & in a similar time

53
Q

What are the 3 main sites for IO access?

A
  1. The proximal humerus
  2. The proximal tibia
  3. The distal tibia

Add photo.

54
Q

What are the contraindications to IO access during an arrest?

A

Trauma to target site.
Infection of target site.
Joint replacement
Recent IO access in the same limb, including failed attempts.
Failure to identify anatomical landmark for insertion.

55
Q

How do you confirm correct placement of IO access?

A
  • Aspirate from needle, presence of IO blood confirms position. However abscence of blood does not necessarily imply failed insertion.
  • If no blood then extensively flush the needle and observe for leakage or extravasation.
56
Q

Once IO access is confirmed you can give drugs, fluids an bood products as per the normal ALS protocol. What is the only difference to how you administer them ?

A

You will need extra pressure! - this is achieved through using a pressure bag or syringe (20ml flush)

57
Q

What are the potential complications of IO access?

A
  • Extravasation
  • Dislodgement of the needle
  • Compartment syndrome
  • Fracture or chipping of the bone
  • Pain
  • Fat emboli
  • Infection/OM
58
Q

List the 4H’s and 4T’s for potential causes of cardiac arrest

A

4H’s:
1. Hypoxia
2. Hypo/hyperthermia
3. Hypovolaemia
4. Hyper/hypokalaemia, hypoglycaemia, hypocalcaemia and other metabolic disorders.

4T’s:
1. Thrombosis - coronary or pulmonary
2. Tamponade - cardiac
3. Tension pnuemothorax
4. Toxins

59
Q

During an arrest how is hypoxia as a potential cause managed?

A

By securing the airway and giving 100% oxygen.

60
Q

PEA cardiac arrest caused by hypovolaemia is usually caused by what?

A

Massive haemorrhage (this may be obvious e.g. trauma or occult e.g. GI bleeding or ruptured AAA).

61
Q

What is the general mx of hypovolaemia ?

A

Replacement of circulating volume with fluids, blood products and cessation of bleeding source.

62
Q

In any drowned patient what should you suspect?

A

Hypothermia

63
Q

If ACS is suspected as the caused of a refractory cardiac arrest what could be considered ?

A

It may be feasible to perform angiogram + PCI

This would however require transfer with either automated CPR device and/or Extracorporal CPR (ECPR).

64
Q

If PE is thought to be the cause of cardiac arrest what could be given?

A

Consider thrombolysis with fibrinolytic drug

65
Q

If fibrinolytic drug is given for cardiac arrest possibly secondary to PE, how does this influence duration of CPR afterwards and why?

A

Continue CPR for 60-90mins after before stopping resus attempt as good outcomes have been reported >60mins.

66
Q

How is a tension pneumothorax treated ?

A

Decompression with needle thoracocentesis and then chest drain

67
Q

What investigation during a cardiac arrest is useful for diagnosing cardiac tamponade ?

A

Focused cardiac ultrasound to ax for pericardial effusion.

68
Q

Cardiac arrest following cardiac surgery or penetrating chest trauma should raise the suspicion of what?

A

Cardiac tamponade abd the need for resuscitative thoracotomy

69
Q

In cardiac arrest caused by toxins if known then appropriate antidotes should be given but often the treatment is supportive, what should be considered ?

A

Extracorporal CPR.

70
Q

List the thing focused ultrasound in cardiac arrest can help diagnose

A

Cardiac tamponade
PE
Ischaemia (RWMA)
Aortic dissection
Hypovolaemia
Pnuemothorax

71
Q

What position of ultrasound probe is recommended for focused ultrasound during a cardiac arrest?

A

Sub-xiphoid position

72
Q

Placement of ultrasound probe prior to pausing chest compressions should allow an operator to obtain views within how long ?

A

10 secs.

73
Q

When should the use of an automated mechanical chest compression device be considered?

A
  • CPR in a moving ambulance - safety risk
  • Prolonged CPR
  • CPR during certain procedures e.g. PCI
  • Covid-19 infection
74
Q

What is extracorporal CPR?

A

This is the combination of ALS + ECMO device. (bascially ECMO started during a cardiac arrest)

In extracorporeal membrane oxygenation (ECMO), blood is pumped outside of the body to a heart-lung machine. The machine removes carbon dioxide and sends oxygen-rich blood back to the body. Blood flows from the right side of the heart to the heart-lung machine. It’s then rewarmed and sent back to the body.

75
Q

What are the general criteria for considering ECMO during cardiac arrest?

A
  • Need vascular access
  • Can be useful for patients with a reversible cause e.g. MI, PE, hypothermia, toxins
  • Patient has minimal co-morbidities
  • Cardiac arrest is witnessed
  • Individual has recieved high quality CPR
  • ECMO is implemented early <1hr of collapse.
76
Q

When considering duration of attempted resuscitation when is it generally accepted worthwhile continuing ?

A

When patient remains in VF/pVT and there is a potentially reversible cause that can be treated

77
Q

As a rough rule of thumb when is it considered appropriate to stop a resus attempt?

A

When you have had asystole for >= 20mins in absence of reversible causes (although a shorter or longer time might be appropriate)

78
Q

How long should you wait following discontinuing CPR efforts before confirming death ?

A

5 mins.

79
Q

Add photo of the general ALS protocol.

A

ALS/GIC (14 decks)

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