ALS Flashcards
Peri-arrest:
Initial Ix?
Adverse signs?
UNSTABLE tx?
Bradycardia?
@Adverse Sx
@NOadverse sx
ABCDE
- Bloods = electrolytes
- IV x 2
- SpO2
- T12-ECG 24 Holter
- O2
Adverse signs? -Shock -HF -AF >48hrs Not DC sync shock TOE*/AC* -MI -Syncope
*TOE = excl Left Atrial Appendage Thrombus AC = 3wb4 cardioversion
UNSTABLE:
-Sync DC shock x3 Repeat
-Amiodarone–300mg/10-20mins–900mg/24hr
@VF=NONsync-DC shock
Bradycardia? @Adverse Sx: -Atrop 500 mic -> Atrop 500mic/3mg -> -TransCut Ext Pacing -Isoprenaline -Adr-Aminophyline/ -Dopamine/Glucagon @ Bblockers
@NOadverse sx = RCMV –> ATIAD
- Recent Asystole
- Complete HB
- Mobitz 2
- Vent pause > 3sec
Peri-arrest:
@Stable = QRS < ? ms
Narrow SVT
-Reg: V? A? -@H?/A? /S? = ?Tx M?
Y=ProbParoxRe-entryAF
- SVT=?
- ?Ix
N=Probable AFlutter
?
-Irreg: Probable AF =? -@HF=? Assx VTE - AC tx \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Broad VT
-Reg:
VT/?Rhythm
SVT+RBBB=?
-Irreg: Pre-Excited AF =? AF+BBB=? POLYMORPHIC= -T-invert =? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SpO2, Thermia, Vol, K-high/low
Tamponade, Px, Toxin, Thrombosis
*Thrombosis/Tamp - Px-poxin
_________________
4H 4T
@Stable = QRS < 120 ms
Narrow SVT
-Reg: Vagal - Valsalva/CSM Adenosine 6mg 12mg/repeat -@HB/Asthma/SinoAtrialDx=Verap Monitor ECG --> SINUS RHYTHM?
Y=ProbParoxRe-entryAF
- SVT=AntiArrhythmics
- T12-ECG
N=Probable AFlutter
-Bblocker
-Irreg: Probable AF = Bblock/Dilit -@HF=Amiod/Digox Assx VTE - AC tx \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Broad VT
-Reg:
VT/?Rhythm
-Amiod 300mg/20-60mins
-Amiod 900mg/24 hrs
SVT+RBBB=NarrowRegSVT-tx
-Irreg: Pre-Excited AF = Amiodarone AF+BBB=NarrowSVT-tx POLYMORPHIC= -T-invert = low K + Alco = MgSO4 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SpO2, Thermia, Vol, K-high/low
Tamponade, Px, Toxin, Thrombosis
*Thrombosis/Tamp - Px-poxin
Arrest Rhythm? 1 2 3
VF
VT puseless
1 shock / ? shock @CCU #stacked/monitored
? min CPR + Adr ? mg alt CPR cycles = 3-5mins #?/?
? /+ shock:
- ? ?dosemg -> ? mg @5
- Adr ? mg alt CPR cycles = 3-5mins
SpO2, Thermia, Volume, K high/low
Thrombosis/Tamp-Px/Poxin
VF
VT puseless
1 shock / 3 shock @CCU #stacked/monitored
2minCPR + 1mgAdr
alt CPR cycles - 3-5mins
#PEA/Asystole
3/+ shock:
- Amiod 300mg -> 150mg @5
- Adr 1mg alt CPR cycles = 3-5mins
Before delivering a ?
you should check that all team members are
? of the patient and bed.
?
should be removed, at least
? metre away from the patient’s chest.
? should be connected when available.
Once a secure airway is in place, give:
? at a rate of 100-120 min-1, and
? at a rate of about 10 min-1.
Following the onset of
VF/ pulseless VT
-? ceases, and
-? starts within 3 minutes.
If there are enough rescuers
the person performing CPR
should be changed every ? minutes.
Correct hand position for chest compression:
middle of
lower half of
sternum
Reduction of the
? and ?-shock pause
can influence the likelihood of success.
It is usually worthwhile
continuing/stopping resuscitation
whilst the patient
remains in ?
delivery of each drug
with a flush of at least
20 mL of fluid
Tx of PEA/Asystole
-give 1mg adrenaline
Survival from cardiac arrest is
unlikely unless
? cause ? AND ?
Chest compressions:
- depth of ? cms
- allowing the chest wall to ? completely in between each compression
- a rate of ? min-1
- minimising any ? (minimising ? time)
What percentage of people survives after receiving CPR for IN-hospital cardiac arrest?
? %
-Prognosis for these patients is more favourable, around ? % surviving to hospital discharge.
What percentage of people survives after receiving CPR for OUT-of-hospital cardiac arrest?
? %
(DNACPR) decision may be made because the person is dying from an ? advanced condition
- I.E. attempting CPR when heart stops would ? prevent their death -> harm
When a person is at clear risk of dying
as a result of an advanced condition
in which CPR would not prevent their death,
CPR should NOT be offered or attempted.
Attempting CPR @EoL could:
- ? the person of dignity
- ? their heart temporarily,
- ? the process of dying and
- ? suffering.
If the patient and/or those close to them refuse to accept a decision a ? opinion should be offered and arranged.
Clear and honest provision of ? and explanation, (i.e. gillick competent) is crucial.
Many people ?estimate the likelihood of success from CPR
-give accurate and realistic information about the likelihood of success in their specific situation.
important to recognise EoL, so can switch from -trying to prolong life/cure TO -symptom control + QoL
Advance care plans
are not ?
but provide valuable guidance to support
good clinical decision-making in emergency situations.
If a person with capacity refuses CPR, this must be ?
In England & Wales,
if a person lacking capacity
has a valid and applicable
Advance Decision to Refuse Treatment (ADRT) specifically refusing CPR, this is ? binding.
If the person lacks capacity,
those close to them
must be involved in discussions,
to reach a ‘best-interests’ decision.
It is important to ensure that loved-ones understand that they are not being asked to make a decision about CPR. (unless there is an applicable power of attorney or similar authority)
purpose of documentation is to ensure that
the decision
the reasons for it
discussions that led to it
Situational awareness: Awareness of the ? Awareness of the ? Awareness of the immediate ? Awareness of what is ?
? % of patients who suffer a cardiac arrest
whilst in hospital
have a period of deterioration before the arrest.
? are common antecedents of cardiac arrest
Patients commonly have a period of ?
in the hours prior to cardiac arrest
The cardiac arrest rhythm for most in-hospital cardiac arrests is ?
Post cardiac-arrest syndrome Cx:
- brain injury/myocardial dysfunction
- ischaemia-reperfusion response
- Persistence of the precipitating pathology e.g. PE
cause of death in 68% of patients who have suffered an OUT-of-hospital cardiac arrest who have survived to ITU admission = Post-cardiac-arrest ? injury
‘myocardial stunning’ aka myocardial ?
-reduced EF for ? days only
cardiac arrest –> ?coag dx –> ? failure
Seizures occur in ? % of those who remain comatose.
Hyperthermia (> 37°C) is associated with a worse/better neurological outcome and it should be avoided.
- period of mild ? improves neurological outcome
- target temperature is ? °C.
Hypercarbia leads to cerebral blood vessel dilatation/constriction and an increased blood flow
VF –>
?-of-hospital cardiac arrest –>
in comatose survivors of –>
use of induced mild ? @ROSC
External and/or internal cooling -An infusion of ? mL/kg of ice cold 0.9% sodium chloride / Hartmann's decreases core temperature by approximately ?°C. -i.e. approx 2L in a 70kg person
Rewarming should take place after 24 h
of induced hypothermia
@ 0.25-0.5°C / h
hypothermia causes V - arrythmias / DIC I - immunity fuck up ND - reduced sedative drug clearance I - shivering CATE - HYPERglycemia / Electrolyte dx / HYPERamylasemia
Once arterial blood oxygenation saturation can be monitored reliably, the oxygenation saturation is maintained ideally in the range ? %.
In the patient requiring mechanical ventilation, the aim is to achieve ?capnia
In the first 24 h after ROSC, most of the patients will require sedation to enable ?
After resus, Not all patients require intubation
In the unconscious patient, it is normally at least ? days before clinical assessment provides a reliable indication of neurological outcome.
After ROSC, myocardial contractility:
- is often temporarily impaired for ? days
- is usefully assessed with ?
- can be increased by infusing an ?
neurological outcome is optimised by maintaining the blood glucose in the range ? mmol L-1.
cardiac arrest in pregnancy
- Can be associated with ?
- May necessitate the infusion of IV ? if cardiac arrest occurs after an epidural infusion has been started Correct option
Before delivering a SHOCK,
you should check that all team members are
CLEAR of the patient and bed.
Free flowing oxygen
should be removed, at least
one metre away from the patient’s chest.
Capnography should be connected when available.
Once a secure airway is in place, give:
- continuous chest compressions at a rate of 100-120/min, and
- continuous ventilations at a rate of about 10/min
Following the onset of
VF/ pulseless VT
-cardiac output ceases, and
-cerebral hypoxic injury starts within 3 minutes.
If there are enough rescuers
the person performing CPR
should be changed every 2 minutes.
Correct hand position for chest compression:
middle of
lower half of
sternum
Reduction of the
pre and post-shock pause
can influence the likelihood of success.
It is usually worthwhile
CONTinuing resuscitation
whilst the patient
remains in VF
delivery of each drug
with a flush of at least
20 mL of fluid
Survival from cardiac arrest is
unlikely unless
reversible cause found AND treated.
Chest compressions:
- depth of 5-6 cms
- allowing the chest wall to recoil completely in between each compression
- a rate of 100-120 min-1
- minimising any interruptions (minimising hands-off time)
What percentage of people survives after receiving CPR for IN-hospital cardiac arrest?
20%
-Prognosis for these patients is more favourable, around 40-50% surviving to hospital discharge.
What percentage of people survives after receiving CPR for OUT-of-hospital cardiac arrest?
10%
(DNACPR) decision may be made because the person is dying from an IRREVERSIBLE advanced condition
- I.E. attempting CPR when heart stops would NOT prevent their death -> harm
When a person is at clear risk of dying
as a result of an advanced condition
in which CPR would not prevent their death,
CPR should NOT be offered or attempted.
Attempting CPR @EoL could:
- deprives the person of dignity
- restart their heart temporarily,
- prolong the process of dying and
- increase suffering.
If the patient and/or those close to them refuse to accept a decision a SECOND opinion should be offered and arranged.
Clear and honest provision of information and explanation, (i.e. gillick competent) is crucial.
Many people OVERestimate the likelihood of success from CPR
-give accurate and realistic information about the likelihood of success in their specific situation.
Advance care plans
are not legally binding
but provide valuable guidance to support
good clinical decision-making in emergency situations.
If a person with capacity refuses CPR, this must be respected.
In England & Wales,
if a person lacking capacity
has a valid and applicable
Advance Decision to Refuse Treatment (ADRT) specifically refusing CPR, this is legally binding.
purpose of documentation is to ensure that
the decision
the reasons for it
discussions that led to it
Situational awareness: Awareness of the history Awareness of the team Awareness of the immediate needs Awareness of what is relevant
50-80% of patients who suffer a cardiac arrest
whilst in hospital
have a period of deterioration before the arrest.
Hypoxia and hypotension are common antecedents of cardiac arrest
Patients commonly have a period of deterioration
in the hours prior to cardiac arrest
The cardiac arrest rhythm for most in-hospital cardiac arrests is pulseless electrical activity (PEA)
cause of death in 68% of patients who have suffered an OUT-of-hospital cardiac arrest who have survived to ITU admission = Post-cardiac-arrest BRAIN injury
‘myocardial stunning’ aka myocardial dysfunction
-reduced EF for 2-3 days only
cardiac arrest –> DIC –> organ failure
Seizures occur in 10% to 40% of those who remain comatose.
Hyperthermia (> 37°C) is associated with a worse neurological outcome and it should be avoided.
- period of mild hypothermia improves neurological outcome
- target temperature is 32 - 36°C.
Hypercarbia leads to cerebral blood vessel dilatation and an increased blood flow
VF –>
OUT-of-hospital cardiac arrest –>
in comatose survivors of –>
use of induced mild hypothermia @ROSC
External and/or internal cooling
-An infusion of 30 mL/kg of ice cold
0.9% sodium chloride / Hartmann’s
decreases core temperature by approximately 1.5°C.
Rewarming should take place after 24 h
of induced hypothermia
@ 0.25-0.5°C / h
Once arterial blood oxygenation saturation can be monitored reliably, the oxygenation saturation is maintained ideally in the range 94 - 98%.
In the patient requiring mechanical ventilation, the aim is to achieve normocapnia
In the first 24 h after ROSC, most of the patients will require sedation to enable controlled mechanical ventilation.
After resus, Not all patients require intubation
In the unconscious patient, it is normally at least 3 days before clinical assessment provides a reliable indication of neurological outcome.
After ROSC, myocardial contractility:
- is often temporarily impaired for 2-3 days
- is usefully assessed with echocardiography
- can be increased by infusing an inotrope
neurological outcome is optimised by maintaining the blood glucose in the range 4 - 10 mmol L-1.
cardiac arrest in pregnancy
- Can be associated with sepsis
- May necessitate the infusion of IV lipid if cardiac arrest occurs after an epidural infusion has been started Correct option
STEMI:
During the acute phase, there is a substantial risk of ?
When using transcutaneous pacing:
-Capture typically occurs with a current of ? mA (i.e. ? times less).
- Hyperkalaemia may prevent successful pacing.
- ? artefact may inhibit the pacemaker.
- A QRS complex does not guarantee ? Absence of a pulse in the presence of good electrical capture constitutes PEA.
With regard to the ECG:
-Adhesive defibrillator pads should only be used in ? to assess the cardiac rhythm.
-The normal PR interval is between
? (i.e. ? small squares).
-The normal QRS complex interval is < ? s
( < ? small squares).
In drowning:
- There is initially ?spasm and ?-holding preventing entry of water into the victim’s lungs.
- Submersion durations of less than 10 min are associated with a very high chance of a ?good/bad outcome and
- Submersion durations of more than 25 min are associated with a SHIT outcome
- Following submersion, respiratory arrest usually precedes cardiac arrest.
STEMI:
During the acute phase, there is a substantial risk of VF.
When using transcutaneous pacing:
-Capture typically occurs with a current of 50‒100 mA (i.e. 100 times less).
- Hyperkalaemia may prevent successful pacing.
- Movement artefact may inhibit the pacemaker.
- A QRS complex does not guarantee myocardial contractility. Absence of a pulse in the presence of good electrical capture constitutes PEA.
With regard to the ECG:
-Adhesive defibrillator pads should only be used in an emergency to assess the cardiac rhythm.
-The normal PR interval is between 0.12 and 0.20 s (3‒5 small squares).
-The normal QRS complex interval is < 0.12 s
(< 3 small squares).
In drowning:
- There is initially laryngospasm and breath holding preventing entry of water into the victim’s lungs.
- Submersion durations of less than 10 min are associated with a very high chance of a GOOD outcome and
- Submersion durations of more than 25 min are associated with a SHIT outcome
- Following submersion, respiratory arrest usually precedes cardiac arrest.
