ALS Flashcards
When must you check JRCALC during ALS?
Never, you are expected and permitted to memorise correct indications, dosages, routes, and intervals.
Which drugs do you have to cross check during ALS?
All of them, including fluids for flushes and drips
What are the history, assessments and management for the 4 Hs and 4 Ts of reversible causes for cardiac arrest during ALS?
Hypoxia
-Hx: Obstruction?, choking?, suffocation?, drowning?
-A&M: Check airway, ventilate
Hypovoleamia
-Hx: Internal/external haemorrhage?, D&V?, burns?, sepsis?, anaphylaxis?, severe dehydration?, DKA?
- A&M: S&S of above, fluid up to 2L should be rapidly infused if hypovolaemia known/suspected, HEMS for blood products
Hypo/hyperkalaemia
-Hx: Renal problems/dialysis/past DKA?, frail?, eating disorders?, gastric disease?, medications?
-A&M: Time critial transfer, fluids
(Hypoglycaemia is rarely a cause of cardiac arrest but is an important consideration, venous BM should be checked during ALS and after ROSC and corrected with IV glucose if necessary)
Hypothermia
- Hx: Consider environment, and conditions/age that may make patients more suseptable to hypothermia
A&M: Take a temperature, fluids should ideally be warmed, blankets can be used (slow cooling to <37.5ºC for hyperthermia)
Thrombosis
-Hx: Cardiac/pulmonary history?, PMHx?, sudden collapse?, ACS S&S?
A&M: Time critical transfer, thrombolysis, ECG for diagnosis and to aid decision for conveyence (cath lab)
Tamponade
-Hx: History of penetrating chest trauma? or recent cardiac surgery?, cardiac infection?
-A&M: Time critical transfer for hospital decompression, Beck’s triad (may not be present), ECG, echocardiography
Toxins
-Hx: Confirmed OD? (Substance(s) and dose, time since), IVDU?, Suspected? (History and environment)
-A&M: Time critical tranfer to ED, Naloxone can be given if opiod overdose suspected/confirmed, pupils can be assessed
Tension pneumothorax
-Hx: blunt/penetrating trauma?, DiB?, Chest pain?, air entry?
-A&M: Look for TENTION P-THORAX, NCD if indicated
For all reversible cuases as best a history as possible must be obtained
What must you do when first arriving at ongoing BLS before starting ALS?
Introductions
PRIMARY SURVERY
Confirm cardiac arrest (Check pulse - NOT DURING COMPRESSIONS)
Confirm airway (auscluate 4 chest points and stomach + capno (Attached behind filter)
Confirm pad positioning
History incl resus history (i.e. how many rhythm checks, what rhythms, how many shocks)
Which elements of time keeping are important for ALS?
Time down i.e. since collapse (estimated or confirmed)
Timing of rhythm checks (every 2 mins)
Timing of access
Timing of drugs
Intervals of drugs
What interventions can you continue during a rhythym check or charge?
NONE - best practice is complete hands off unless for compressions, trying to rush anything could be dangerous and it is acceptable to delay interventions in favour of timely and safe defibrilation
When do you give adrenaline during ALS?
If a CURRENT non-shockable rhythm - immediately
If continuous shockable rythms - After 3rd shock
Once adrenaline is first administered it can be given every 3-5mins regardless of rythm
When do you give amiodarone during ALS?
After the 3rd and 5th shocks (regardless of whether shockable rythms have been sequential or intermittent)
What dose of adrenaline is given during ALS for adults?
1mg(10ml) - THE WHOLE PREFILLED SYRINGE
What dose of amiodarone is given during ALS for adults?
Initial: 300mg(10ml)
Repeat: 150mg(5ml or 3ml)
How does hypothermia affect the administration of adrenaline and amiodarone during ALS?
Adrenaline:
Under 30º - Withold
Between 30º-35º - Double repeat dose interval
Amiodarone:
Under 30º - Withold
How much flush is needed for amiodarone and adrenaline?
20ml
When should IO access be attempted for ALS?
After 2 failed IV attempts or if IV unlikely to be succesful
What ETCO2 level should you aim for during ALS?
Between 1 and 2 mmHg
During ROSC what systolic BP should you aim for, how?
Above 100mmHg, in patients with an appropriate heartrate using fluids and adrenaline. (Atropine may be administered for bradycardic ROSC which may improve BP.)
For cardiac cause 250ml bolus of fluids can be used to counteract the loss of preload due to vasodilation. Plus a subsequent 250ml bolus for a total of 500ml.
For hypovolaemic arrests 250ml boluses of fluids should be administered up to 2L.
What is the maximum temperature should you aim for during ROSC, how?
No more than 37.5ºC, using no more blankets/layers than necessary. Reheating too quickly can be harmful.
What signs of spontaneous respiration can you look for during ROSC?
Mask misting
Gagging/intolerance of airway
Chest rise
Air entry on ausculation
Rise in ETCO2
In which ALS situations is it especially important to prioritise time critical transfer over continuing ALS?
Airway problem
Persistent VF
Penetrating Trauma
Pregnancy
PE / asthma / anaphylaxis
Electrolyte disturbance
Suspected Overdose/Poisoning
Hypothermia / drowning
When might you consider pausing mid cycle to check for a pulse?
If there are definitive signs of life, e.g.
-Waking
-Purposeful movement
-Sharp rise in EtCO2
What are the goals of post ressuscitation care?
To restore:
-Normal cerebral function
-Stable cardiac rhythm
-Adequate organ perfusion
-Quality of life
What complications can occur during post ressuscitation care?
Post-cardiac arrest brain injury:
-coma, seizures, myoclonus
Post-cardiac arrest myocardial dysfunction
Systemic ischaemia-reperfusion response
-‘sepsis-like’ syndrome
Persistence of precipitating pathology
How much flush do you use for ALS drugs?
20mls for all
What is normal CPR etCO2?
1.6-1.9
What is the difference between refractory and recurrent VF?
Refractory: VF that persists despite defibrillation attempts
Recurrent: VF that is cardioverted following each shock, but returns before the next rhythm check
