ALS Flashcards
A patient has received 5 shocks and is in VF/pulseless VT what should be given?
Amiodarone 150mg
Causes of constricted pupils (mitosis)
Opioid based medications such as morphine, codeine, fentanyl or recreational drugs such as heroin
Causes of dilated or blown out pupils (mydriasis)
injury to the brain from physical trauma, a stroke or may be an early sign of increased intracranial pressure.
Recreational drugs such as cocaine, marijuana, or amphetamines can also cause your pupils to dilate
Causes of stable broad complex tachycardia:
QRS Irregular - AF, polymorphic VT (torsades de points)
QRS Regular - VT, SVT with bundle branch block
Treatment of polymorphic VT (torsades de points)
IV Magnesium 2g over 10 mins
Treatment of regular QRS VT
Amiodarone 300mg IV over 10-60 mins
First line management of stable narrow complex tachycardia
Vagal manoeuvres:
Valsalva, modified valsalva, carotid sinus massage
What is the valsalva manoeuvre?
Commonly take a 20 ml syringe and get the patient to create a tight seal around the tip with their lips and blow forcefully as if they are trying to expel the plunger.
What is the modified valsalva manoeuvre?
20 ml syringe and get the patient to create a tight seal around the tip with their lips and blow forcefully as if they are trying to expel the plunger, with the patient in the semi-recumbent position, followed by supine repositioning with 15 seconds of passive leg raise at a 45-degree angle
Treatment of stable narrow complex tachycardia if vagal manoeuvres ineffective:
Give adenosine - 6mg rapid IV bolus
-If unsuccessful give 12mg
-if unsuccessful give 18mg
Monitor ECG continuously
If ineffective - verapamil or beta blocker
What is unstable tachycardia?
A Narrow or Broad Complex Tachycardia.
The Patient is presenting with life threatening features
That you consider the patient to be clinically unstable as a result
Tx of unstable tachycardia?
Synchronized DC Cardioversion
What can be used as sedation during tx of unstable tachycardia?
Midazolam and/or morphine
How to perform synchronised DC cardio version:
Ensure pads are placed correctly (usual place)
Open the door to put defibrillator in manual mode
Use the sync button to ensure shock is synchronised
Check the patients central pulse
Select the energy
Usual pre shock safety checks
Press and hold shock button
YOU MUST RESYNCHRONISE AFTER EACH SHOCK
Recheck patients central pulse before delivering another shock
Management of adult bradycardia?
ABCDE
Oxygen if appropriate, obtain IV access
Monitor ECG, BP, SpO2
Identify and treat reversible causes e.g. electrolyte abnormalities
If evidence of life threatening signs (shock, syncope, MI, HF) -> Atropine 500mcg IV
If no response -> Atropine 500mcg IV repeat to max 3mg
Isoprenaline 5mcg/min IV
Adrenaline 2-10mcg/min IV
Other alternative drugs : Aminophylline, Glucagon, Glycopyrrolate
Transcutaneous pacing
Seek expert help if still no satisfactory response
Risks of asystole
Recent asystole
Mobitz II AV block
Complete heart block with broad QRS
Ventricular pause > 3 seconds
If the patient has any of the above they should be treated as unstable
How is current adjusted in transcutaneous pacing?
As you increase the current you will see vertical lines appear on the screen at set intervals based on the “rate selected” these are termed “pacing spikes”
You need to increase the current (mA) until you see a QRS complex immediately following a Pacing spike. (electrical Capture)
Check the patient’s pulse to ensure it correlates with the rate set by the pacer, to ensure you have achieved Mechanical Capture.
Non-shockable rhythms
Pulseless electrical activity
Asystole
Shockable rhythms
Ventricular fibrillation
Pulseless VT
Team leader responsibilities in a cardiac arrest?
-Ensure continuing good quality chest compressions are provided
-Escalate airway management as required, ideally to allow for asynchronous CPR (continuous compressions and ventilations independent of each other)
-Consider waveform capnography
-If not already in place, ensure IV/IO access is obtained and any relevant blood sampling is carried out
-Reassess the rhythm every 2 mins cycle and decide treatment plan
-Consider the reversible causes and relevant treatments
Reversible causes of cardiac arrest:
4 H’s and 4 T’s
Hypoxia
Hypovolemia
Hypo / Hyperthermia
Hypo / Hyperkalemia
Thrombosis
Tension Pneumothorax
Cardiac Tamponade
Toxins
When should adrenaline be administered in ALS? What dose?
Dose:
1mg (10mls) of 1:10,000 Intravenous or Intraosseous as a rapid bolus.
When to be administered:
In shockable rhythms adrenaline is administered after the third shock during the 2 minutes of CPR. Do not delay recommencing CPR to administer adrenaline.
In non shockable rhythms adrenaline is given immediately after a non shockable rhythm is confirmed, and CPR recommenced. Do not interrupt chest compressions to give adrenaline.
Frequency of administration:
Once the first dose has been administered repeat the same dose every 3-5 minutes (every other 2 minute cycle) for all cardiac arrest rhythms.
When Stacked shocks are used:
They should be considered as giving the first shock and the first dose of adrenaline should be given after a further two shock attempts if VF/pVT persists.
Use of amiodarone in ALS?
Dose
300mg (10mls) Intravenous or Intraosseous
Frequency of administration:
Amiodarone is used in shockable rhythms only. 300mgs is administered after the third shock. 150mg may be considered after the 5th shock
When Stacked shocks are used:
Give Amiodarone after three shock attempts irrespective of when they are given during the cardiac arrest(i.e. give amiodarone during the 2 min CPR after the three stacked shocks.
When is intraosseous access indicated?
struggling to gain access or have failed twice and this is causing a delay to the administration of fluids or medications the insertion of an IO needle is indicated.
Equipment is carried by the DART team
