ALS Flashcards
Outline the ALS algorithm
What drugs are given in shockable rhythms
Adrenaline 1mg IV every 3-5 mins
Amiodarone 300mg after 3rd shock, 150mg after 5th shock if shockable rhythms are seen
What are the 4Hs 4Ts
Hypoxia
Hypothermia
Hypovolaemia
Hypo/hypermetabolic
Thrombosis
Tamponade
Tension pneumo
Toxins
What drugs are given in non-shockable rhythms
Adrenaline 1mg IV as soon as IV access
Then every 3-5 mins
When can you give 3 successive shocks in VF/pVT?
Witnessed
Monitored on a manual defib
If unsuccessful commence typical ALS
What 5 things does waveform capnography assist with in ALS?
ET tube placement (alongside auscultation)
Ventilation rate
Chest compression quality
Identifying ROSC
Prognostication
How does a capnograph work?
Attach T piece to end of ET tubes / SGA device
What is the normal range for capnography
What etCO2 reading is associated with a poorer prognosis?
4.3-5.5kPa in a healthy patient
<1.33 kPa after 20 mins
What is needed alongside IV drug administration
20ml saline flush
What are the 3 main IO sites?
prox humerus
prox tibia
distal tibia
What are the 4 contraindications to IO access?
Trauma
Infection
Prosthesis
<48hr I/O access at that site inc failed attempts
How is IO access confirmed?
Blood on aspirate
How is death diagnosed in ALS
Following decision to stop ALS, wait 5 mins to confirm…
Absence of central pulse and heart sounds with
ONE of the following
a) asystole on ECG
b) no pulsatile flow on central arterial monitoring
c) absence of contractile activity on echo
How is USS used in ALS
Can help identify thrombosis or tamponade
Place probe just prior to ceasing of compressions to get a 10s analysis
How to clear airway in tracheostomy patient
- Check stoma/trache tube
- Change inner liner
- Pass suction catheter
- Remove and change trache tube
If trache tube removed can plug stoma and ventilate with mask or pass ET tube
OR
Place mask over stoma to ventilate
What is the choking pathway for ALS?
Mild (speaking, coughing)
Encourage coughing
Severe (cant speak, cough, not breathing)
Unconscious –> CPR
Conscious: 5 back blows –> 5 abdominal thrusts
What is the ‘hierarchy’ of airway aids
NP
OP
SGA
LMA
ET
What are the drawbacks of an i-gel (ET tube?
Gas leakage in poor lung compliance (COPD, oedema etc)
Some gas leak if uninterrupted compressions –> revert to 30:2 if inadequate
?Risk of aspiration
When should a tracheal intubation be used?
If a trained individual has a 95% chance of successful placement on 2 attempts
When should tracheal intubation be avoided
Acute epiglottitis
pharynx/larynx disease
Head injury
What do after tracheal tube placement
Confirm via auscultation and Capnography
What are the stages of ECG interpretation
- Electrical activity
- What is the ventricular rate
- Is the rhythm regular or irregular
- Is the QRS narrow or broad
- Is atrial activity present
- How is atrial activity related to ventricular activity
How to quickly calculate rate?
count R-Rs in 30 large squares (6S), multiply by 10
How can you distinguish ECGs by type of irregular rhythms
Irregularly irregular, consistently: AF
Mostly regular, interrupted by irregularity: Ectopic.
If QRS broad could be ventricular or
supraventricular + BBB
Can occur up to 3 times successively; more than this is tachyarrhythmia
Cyclical variation:
Examine P and QRS relationship
Which leads are good for assessing P wave activity
V1, II
How can P and QRS wave relationship determine rhythm?
Constant prolonged PR: 1st degree block
Progressive lengthening then drop: 2.1
Intermittent pairing of P and QRS: 2.2
No association between P and QRS: Total heart block
What 3 factors determine successful defibrillation
- Time from onset to shock
- Continuous, uninterrupted chest compressions
- Duration of stopping during ALS (every 5s halves the success rate of defibrillation)
What parts of the heart can pace rate and what is the general pacing these parts give?
SA node: 60-70
AV junctional region: 40-50
Distal purkinje-his fibres: 0-30
How is fist pacing performed
Raise fist to 20cm then hit L sternal praecordium
Check QRS on monitor
If no QRS, hit harder and augment site of landing
If no regular pulse quickly —> CPR
How to transcutaneous pace
Clear skin (shave and dry)
Place electrodes conventionally or AP (if defib still needed)
Select pacing rate ~60-90
Increase current until QRS spike followed by T wave - usually 50-100mA
What 3 ways can transvenous pacing fail
Increased voltage threshold
Connection failure
Lead displacement
Outline the tachyarrhythmia pathway
How is a regular broad complex tachycardia treated
Treat as VT
300mg amiodarone IV 10-60mins
900mg amiodarone IV 24 hr infusion post
+/- synchronised DC if persistent
How is an IRregular broad complex tachycardia treated
Seek expert advice as could be AF + BBB / WPW / polymorphic VT
If torsade des pointes: Give 2g MgSO4 over 10 min
What causes REGULAR narrow complex tachycardias
sinus
SVT
Atrial flutter
What is the treatment of regular narrow complex tachycardia
- Vagal manouvres: carotid/valsalva
- Adenosine 6mg
- Increase to 12mg then 18mg if no transient relief of tachycardia
what drugs are alternative to adenosine?
Verapamil 2.5-5mg IV over 2 mins
Metoprolol 2.5-15mg over 15 min given in 2.5mg bolus doses)
What do for rapid narrow complex tachys with no pulse
CPR
How to treat fast AF
Life threatening features: Cardiovert and LMWH
No life threatening features
Rate control with BBs or diltazem/amiodarone
If <48 hrs: chemical cardioversion
If >48 hours: Anticoagulate for 3 weeks then shock
If WPW presents with pre-excited AF: expert help
Outline the bradycardia algorithm
How to treat hyperkalaemia
10ml 10% Ca gluconate
10 units insulin in 25 glucose IV –> Glucose 10% infusion at 50ml/hr if <7 glucose
Remove potassium via binders (15-30g)
Consider dialysis if refractory
How to treat hypokalemia?
IV potassium replacement (20mmol hr)
Which electrolyte derangement gives confusion, weakness, short QT, prolonged QRS, flat T wave?
Hypercalcaemia
What is the treatment of hypercalcaemia
Fluids
furosemide
hydrocortisone
Pamidronate 30-90mg
How is hypocalcaemia treated
Ca chloride 10% 10-40ml IV
1-2g 50% MgSO4
How is hypermagnasaemia treated
Calcium chloride 10% 10ml
How is hypomagnasaemia treated
2g MgSO4 over 10-15 mins
How are opioids reversed
400ug IV / 800ug SC/IM / 2mg IN naloxone; lasts ~1hr
Up to 10mg
How are benzos reversed?
flumenazil
How are TCAs reversed?
bicarbonate if QRS widening
How is local anaesthetic reversed?
20% lipid emulsion 1.5ml/kg bolus
followed by 1.5ml/kg /hr up to 12ml/kg dose
Can give 3 bolus doses
How can asthma be classified into severe, life-threatening, near fatal?
Severe: PEFR 33-50%, RR >25, HR 110, incomplete sentences
Life-threatening: PEFR <33%, exhaustion, Pao2 <8
Fatal: Rising CO2
How to treat asthma attack
Salbutamol 5mg every 15 min
Ipratropium 500mcg 4-6 HOURLY
Pred 40mg orally / hydro 100mg I 6 hrly
MgSO4 IV 2g
Aminophylline under senior instruction
Outline anaphylaxis algorithm
Outline refractory anaphylaxis algorithm
How to investigate anaphylaxis cause
Mast cell tryptase
1. At event
2. 1-2 hours post
3. at 24 hours
How to modify cardiac arrest management in pregnancy
Place in L lateral position / displace uterus to L if >20 weeks
Prep for emergency C section if initial resuscitation efforts fail
Early tracheal intubation to reduce aspiration risk
What pregnancy specific reversible causes are there?
Haemorrhage: Give TXA, oxytocin/PGs/uterine massage, uterine compression, surgical/IR control
Drugs
MI
Pre-eclampsia/eclampsia: GIve MGSO4
Amniotic fluid embolism: Supportive
In traumatic cardioresp arrest, what constitutes damage control surgery
Permissive (radial pulse) hypotension (CI in brain injury) up to 60min
TXA 1g IV, then 1g over 8 hours
How to relieve cardiac tamponade
resuscitative thoracotomy NOT aspiration
What is the most common arrest reason perioperatively
Airwat
What modifications are made for peri-op arrest
Supine chest compressions
Adrenaline in 50-100mcg increments rather than bolus
Stop surgery unless can prevent cause
What are the specific timings involved in drowning
<10 mins associated with better outcomes
review rescue efforts at 30,60, 90 mins
What modifications to ALS are made in drowning patients
A/B: High flow, early intubation given increased pulm pressures, PEEP at 5-10cm H20
C/D: dont rely on pulse, hypovolaemia common once out of water
What are the post-resus care features of drowning
Ventilation strategies for ARDS
ECMO for refractory arrest
Pneumonia
What are the 5 stages of hypothermia
I: >32, conscious
II: >28, reduced conscious
III: >24, unconscious
IV: <24, arrest
V: <11.8, dead
How to measure hypothermia
Tympanic thermocoupled device
Lower third oesophagus measurement
How to resuscitate hypothermia
<28: 5 mins on 5 mins off
<20: 5 mins on 10 mins off
Check vital signs over 1 min
Can give drugs over double the time for temp 30-35 (eg 6-10 mins for adrenaline)
How to rewarm in hypothermia arrest
If >11.8 use heat packs, transfer to ECMO centre within 6 hours / warm on ward
How to treat hyperthermia
Cool and lay flat
hypertonic saline if <130 (3 x 100ml)
How to treat malignant hyperthermia
Dantrolene
outline post-resuscitation care
Outline steps of ABG analysis
- Clinical context
- Hypoxaemic?: is PaO2 = FiO2-10
- pH: <7.35 to 7.45
- PaCO2
- Compensation: The change in keeping with the pH is primary, the other will be compensatory
- Other changes
When is sodium bicarbonate appropriate?
Hyperkalaemia
TCA overdose
What implication does a DNACPR have on ICD function
CONSIDER removing the shock function
Is asystole a completely straight line?
No
This indicates a removed lead
What dose of adrenaline is given in bradycardia?
2-10mg
What is the initial shock dose for vFIB
120J
What are the absolute contraindications to fibrinolytic therapy
Prev haemorrhage past 6 months
<3 weeks major trauma/surgery
<1 month history of GI bleeding
Aortic dissection
Bleeding disorders
