Advanced Life Support (ALS)

Question 1

What are the chances of surviving a cardiac arrest in the hospital?

Answer 1

In hospital, the chances of surviving to discharge are about 15-20%

Question 2

What are the components of the Chain of Survival? (4)

Answer 2

Question 3

What is the range of temperatures in Targeted temperature management?

Answer 3

• targeted temperature management (TTM) is now preferred to therapeutic hypothermia
• maintenance of a constant temperature between 33°C and 36°C for at least 24 hours

Question 4

ALS algorithm

Answer 4

Question 5

What else to do/consider during CPR? (4)

Answer 5

• give oxygen
• vascular access (IV or intraosseous)
• Adrenaline every 3-5 minutes
• Amiodarone after 3 shocks

Question 6

Reversible causes of cardiac arrest

Answer 6

Hs:

• hypoxia
• hypothermia
• hypovolaemia
• hyper/hypokalaemia (metabolic)

Ts:

• tamponade (cardiac tamponade)
• tension pneumothorax
• thrombosis (pulmonary or cardiac)
• toxins

Question 7

First (4) steps in assessment of a collapsed/unconscious person

Answer 7

1. Check the patient for a response
2. Open the airway with a head tilt or chin lift
3. Look, listen and feel for normal breathing* at the same time as checking for a carotid pulse for a maximum of 10 seconds
4. If there are no signs of life, i.e. no normal breathing or pulse, name an assistant to call the cardiac arrest team and start CPR

Question 8

How does agonal breathing look like?

Answer 8

Slow, sighing respirations

Question 9

How deep and at what rate the chest compressions should be performed?

Answer 9

• depressing the sternum by 5-6 cm
• at a rate of 100-120 compressions per minute

Question 10

Before obtaining a definite airway, how the ventilation should be provided (2)?

Answer 10

• A bag-valve mask

OR

• A pocket mask

Question 11

What to remember about when using a bag-valve-mask? (3)

Answer 11

• Ensure that it is attached to the oxygen outlet with a flow of 15 litres per minute and inflate the reservoir bag
• Administer two ventilations for every 30 compressions
• Be sure the chest is rising during the ventilations

Question 12

When should we attach a defibrillator?

Answer 12

As soon as possible → to determine the underlying rhythm

Question 13

What are shockable rhythms? (2)

Answer 13

The shockable rhythms are:

• Ventricular fibrillation (VF)
• Pulseless ventricular tachycardia (pVT)

Question 14

What are non-shockable rhythms?

Answer 14

The non-shockable rhythms are:

• Pulseless electrical activity (PEA)
• Asystole

Question 15

Describe this ECG

Answer 15

The ECG demonstrates a bizarre irregular waveform. No recognizable QRS complexes are present. The rhythm is random frequency and amplitude.

This rhythm is known as ventricular fibrillation (VF) and represents random uncoordinated ventricular electrical activity.

Question 16

Describe that rhythm

What’s the management?

Answer 16

• The ECG shows a broad complex tachycardia with uniform QRS morphology
• In the setting of a patient in cardiac arrest, this rhythm should be assumed to be ventricular in origin and treated as ventricular tachycardia
• Both ventricular fibrillation and pulseless ventricular tachycardia should be treated by defibrillation.

Question 17

Shockable rhythm defibliration algorithm

Answer 17

Question 18

What is that?

Management

Answer 18

This is asystole.

There are no p waves and no QRS complexes. The rhythm is rarely a completely flat line. A completely flat line would suggest lead disconnection.

Management:

Follow the non-shockable side of the algorithm:

1. Start or continue CPR
2. Administer 1 mg IV adrenaline
3. Check the leads are correctly attached during CPR
4. Look for and treat potentially reversible causes of the arrest

Question 19

Patient is confirmed to be in a cardiac arrest and this is his ECG

What’s the diagnosis?

Answer 19

• The patient is in PEA (Pulseless Electrical Activity)
• This occurs when clinical features of cardiac arrest are present with an ECG that is normally associated with an output

Question 20

Management of a non-shockable rhythm

Answer 20

1. Chest compressions immediately and 1 mg IV adrenaline is given
2. Continue CPR for 2 minutes then pause briefly for a second rhythm check

if electrical activity compatible with a pulse is seen, check for a pulse and signs of life:

• If no pulse or no signs of life are present continue CPR immediately and recheck the rhythm after a further 2 minutes. Give adrenaline 1 mg IV every 3-5 minutes or on alternate 2 minute cycles
• If a pulse or signs of life are present, start post resuscitation care
• If VF or pVT at rhythm check, change to the shockable side of algorithm
• If in asystole, check the ECG for the presence of p waves, because the patient may respond to cardiac pacing when in ventricular standstill with continuing p waves

Question 21

What’s End-tidal CO2 and waveform capnography are used for?

Answer 21

End-tidal CO2 and waveform capnography

This is useful for a number of reasons including:

• Ensuring correct tracheal tube placement
• Monitoring rate of ventilation
• Monitoring quality of CPR
• Identifying ROSC
• Making a prognosis, with caution

Question 22

Treatment of cardiac tamponade

Answer 22

needle pericardiocentesis or resuscitative thoracotomy

Question 23

Treatment of thrombosis

Answer 23

thrombolytic drug (given immediately if it’s a suspected cause of a cardiac arrest)

Question 24

Treatment for tension pneumothorax

Answer 24

Decompress rapidly by needle thoracocentesis, and then insert a chest drain

Question 25

Treatment of toxins as a cause of cardiac arrest

Answer 25

antidotes and/or supportive care

Question 26

What to do first when there is a witnessed, shockable cardiac arrest while a patient is on a monitor?

Answer 26

Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR