ALS

Question 1

A patient has received 5 shocks and is in VF/pulseless VT what should be given?

Answer 1

Amiodarone 150mg

Question 2

Causes of constricted pupils (mitosis)

Answer 2

Opioid based medications such as morphine, codeine, fentanyl or recreational drugs such as heroin

Question 3

Causes of dilated or blown out pupils (mydriasis)

Answer 3

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

Question 4

Causes of stable broad complex tachycardia:

Answer 4

QRS Irregular - AF, polymorphic VT (torsades de points)
QRS Regular - VT, SVT with bundle branch block

Question 5

Treatment of polymorphic VT (torsades de points)

Answer 5

IV Magnesium 2g over 10 mins

Question 6

Treatment of regular QRS VT

Answer 6

Amiodarone 300mg IV over 10-60 mins

Question 7

First line management of stable narrow complex tachycardia

Answer 7

Vagal manoeuvres:
Valsalva, modified valsalva, carotid sinus massage

Question 8

What is the valsalva manoeuvre?

Answer 8

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.

Question 9

What is the modified valsalva manoeuvre?

Answer 9

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

Question 10

Treatment of stable narrow complex tachycardia if vagal manoeuvres ineffective:

Answer 10

Give adenosine - 6mg rapid IV bolus
-If unsuccessful give 12mg
-if unsuccessful give 18mg
Monitor ECG continuously

If ineffective - verapamil or beta blocker

Question 11

What is unstable tachycardia?

Answer 11

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

Question 12

Tx of unstable tachycardia?

Answer 12

Synchronized DC Cardioversion

Question 13

What can be used as sedation during tx of unstable tachycardia?

Answer 13

Midazolam and/or morphine

Question 14

How to perform synchronised DC cardio version:

Answer 14

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

Question 15

Management of adult bradycardia?

Answer 15

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

Question 16

Risks of asystole

Answer 16

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

Question 17

How is current adjusted in transcutaneous pacing?

Answer 17

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.

Question 18

Non-shockable rhythms

Answer 18

Pulseless electrical activity
Asystole

Question 19

Shockable rhythms

Answer 19

Ventricular fibrillation
Pulseless VT

Question 20

Team leader responsibilities in a cardiac arrest?

Answer 20

-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

Question 21

Reversible causes of cardiac arrest:

Answer 21

4 H’s and 4 T’s
Hypoxia

Hypovolemia

Hypo / Hyperthermia

Hypo / Hyperkalemia

Thrombosis

Tension Pneumothorax

Cardiac Tamponade

Toxins

Question 22

When should adrenaline be administered in ALS? What dose?

Answer 22

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.

Question 23

Use of amiodarone in ALS?

Answer 23

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.

Question 24

When is intraosseous access indicated?

Answer 24

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

Question 25

Contraindications for IO access?

Answer 25

• Infection at site of insertion
• Previous orthopaedic surgery at the site of insertion.
• Fracture/Trauma in target bone proximal to the insertion site.
• Excessive tissue (severely obese) resulting in the inability to identify anatomical landmarks.
• IO access or attempted IO access in target bone within previous 48 hours.

Question 26

Complications of IO access?

Answer 26

-Penetration through the bone either by wrong needle size selection or incorrect angle of insertion
-Failure to enter the bone marrow and extravasation or sub periosteal infusion.
-Epiphyseal plate injury.
-Localised infection around the insertion site.
-Skin necrosis, it is important to ensure the IO needle is inserted as recommended and not compressing the skin.
-Pain
-Compartment syndrome
-Fat and bone micro emboli are rare.
-Rarely Osteomyelitis.

Question 27

Common insertion sites for IO access?

Answer 27

Humeral head
Proximal tibia

Question 28

What is a common ABG result after prolonged cardiac arrest?

Answer 28

There is a mixed metabolic and respiratory acidosis. The predominant component is metabolic, caused by anaerobic respiration.

Question 29

What adjustments should be made in maternal cardiac arrest?

Answer 29

After 20 weeks gestation (earlier in multiple pregnancies) the uterus can compress the inferior vena cava (IVC) which limits the effectiveness of CPR.

The uterus should be displaced to the left manually. Left lateral tilts can be used but requires a firm surface.

IV/IO access should be placed above the diaphragm due to potential for IVC compression

Early intubation is recommended due to the increased risk of aspiration - however this is often more difficult and should be attempted by an experienced practitioner.

Preparation for peri-mortem section should be initiated immediately with a view to removing the infant at 5 minutes if ROSC is not achieved.

Defibrillation should be delivered as normal - be aware that any lateral tilt and larger breasts can make placement of the apical pad more difficult.

Question 30

Common causes of cardiac arrest in pregnancy:

Answer 30

Cardiac disease

Embolism - pulmonary, amniotic

Epilepsy and stroke

Bleeding e.g. ectopic pregnancy/placental abruption/uterine rupture

Mental health issues leading to self harm

Question 31

Adjustments for asthmatics in cardiac arrest?

Answer 31

Ventilation will be difficult due to acute bronchospasm - avoid gastric inflation and hypoventilation where possible with early intubation

Monitor for hyperinflation (gas trapping) - if the patient receives the recommended 10 breaths per minute, this is less likely.

The risk of tension pneumothorax is greater in the asthmatic patient in cardiac arrest - consideration must be given to the presence of bilateral pneumothoraces.

The use of ECMO should be considered if available.

Question 32

Adjustments in cardiac arrest due to hypothermia:

Answer 32

Check for signs of life for up to 1 min
CPR can be difficult due to stiffness of chest wall - early intubation, mechanical chest compression devices
Low reading thermometer
Rewarming liquid
ECMO
Heart is less responsive to drugs and defib - adrenaline held until temp >= 30
Give 3 shocks as usual but if temp under 30 after 3 then delay until temp increased

Question 33

Adjustments for hyperthermia as a cause of cardiac arrest:

Answer 33

Correct electrolyte abnormalities

Actively cool patient and follow standard advanced life support procedures.

Question 34

What must be completed after every 2222 call?

Answer 34

DATIX to monitor and respond to any concerns around the event,
Monitor the activity of the arrest team
Monitor our cardiac arrest/medical emergency rates