ALS Revision Flashcards
What does the acronym DRSABCDE stand for?
Danger Response Send for help Airway (+ Cspine) Breathing Circulation Disability Exposure
What is the ALS algorithm?
Start CPR
Attach Defib/monitor
Assess the rhythm - is it shockable or non shockable?
Shockable → Shock and continue CPR for 2 minutes
Non shockable → no shock → continue CPR for 2 minutes
Assess for ROSC
If ROSC → Post resuscitation care
What additional tasks should be performed during CPR?
Airway adjuncts Oxygen Waveform capnography (ETCO2) IV/IO access Plan actions before interrupting compressions
What are the 4 H’s?
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypo/hyperthermia
How do you treat the 4 H’s?
Hypoxia → O2 therapy
Hypovolaemia → IVT or blood products
Hypo/hyperkalaemia → K+ replacement/Calcium Gluconate or IV insulin & dextrose
Hypo/hyperthermia → Bair hugger, warm fluids/undress patient, cooled fluids
What are the 4 T’s?
Tamponade
Toxins
Thrombus
Tension pneumothorax
How do you treat the 4 T’s?
Tamponade → Pericardiocentesis
Tension pneumonothorax → ICC
Toxins → reversal if able
Thrombus → anticoagulant - herapin
What is included in post resuscitation care?
Re-evaluate ABCDE 12 lead ECG Treat precipitating causes Re-evaluate O2 and Ventilation Temperature (cool)
Name the 12 causes of airway obstruction
(FIT PELVIC BBB)
Foreign body
Inflammation
Trauma
Pharangeal Swelling Epiglottitis Laryngospasm Vomit Infection CNS depression
Bronchial Secretions
Blood
Bronchospasm
How do you assess a patients airway?
Look for any foreign bodies, vomit or blood
Listen for inspiratory stridor or expiratory grunting
What is the triple airway manoeuvre?
Head tilt
Chin lift
Jaw thrust
What are the 4 airway adjuncts?
OPA
NPA
LMA
ETT
What are the causes of ineffective breathing?
Decreased respiratory drive
- CNS depression
Decreased respiratory effort
- Muscle weakness
- Nerve damage
- Restrictive chest defect
- Pain
Lung disorders
- Pneumothorax
- Haemothorax
- Infection
- Acute exacerbation of COPD
- Asthma
- PE
- ARDS
How do you assess a patients airway?
Look
- Respiratory distress
- Use of accessory muscles
- Cyanosis
- Incr RR
- Chest deformity
- Conscious level
Listen
- Noisy breathing
- Auscultate
Feel
- Expansion of chest
- Percussion
- Tracheal position
- Subcut emphysema
What are the 6 primary causes of ineffective circulation?
(AHHEAD) ACS Hypertensive heart disease Hereditary heart disease Electrolyte/acid base abnormalities Arrythmias Drugs
What are the 5 secondary causes of ineffective circulation?
(BASHH) Blood loss Asphyxia Septic Shock Hypothermia Hypoxia
What are the 5 different types of shock?
(CORRD) Cardiogenic Obstructive Restrictive Relative Distibutive
How do you assess a patients circulation?
HR Caprefill BP Organ perfusion (chest pain, mental state, urine output) bleeding or fluid loss
What causes altered conscious state?
Hypoxia
Hypercapnia
Cerebral hypo perfusion
Recent administration of analgesia and sedatives
What assessments are used to assess CNS?
AVPU
GCS
Pupils
Limb Strength
How do you elicit a response?
Grab and squeeze trapezius
“open your eyes”
“squeeze my hand”
Response - maintain ABCDE
No response - call for help, place pt on back, ABCDE
What do you do if the patient has no signs of life?
Commence compressions (30:2) Middle lower half of sternum High quality compressions 5cm depth of chest Rate 100-120/min Allow full recoil of chest Minimise interruptions Place pads on Change operator every 2 mins to avoid fatigue Recommence compressions immediately post defib
Bradycardia Algorithm (write out)
Tachycardia Algorithm (write out)
What are some considerations for trans thoracic impedence?
Dry skin Shave chest if required Chest pads are moist Do not use open pads Ensure pads are adhered to chest
What are the two different types of pad placement?
Aterior-posterior (AP)
Postero-lateral
What do we need to consider when using a defib with a pacemaker?
Place pads at least 8cm away from PPM. As it can cause burns to where wires meet myocardium
What is a synchronised cardioversion?
Synchronisation of a shock to occur on a R wave. This avoids refractory period and decreases risk of VF
What are the indications of synchronised cardioversion?
VF with pulse
SVT
AF
When can we administer 3 stacked shocks?
When a patient who is previously well and cardiac monitored with defib attached is observed to go into a shockable rhythm.
3 stacked shocks can be given (within 20 seconds of rhythm change). If nil sign of ROSC after 10 seconds post - commence CPR.
What are the 13 steps in the ALS shockable rhythm?
- Confirm cardiac arrest
- Call for help
- Commence CPR/apply defib
- Plan actions/avoid interruptions of CPR
- C, O, A
- C
- H
- E, D
- Recommence CPR
- CPR 2 mins
- Repeat steps 4-10
- Adrenaline 1mg second shock then every 2nd loop
- Amiodarone 300mg after 3rd shock
What are the 11 steps in ALS of a Non-Shockable Rhythm
- Confirm cardiac arrest
- Call for help
- Commence CPR/apply defib
- Plan actions/avoid interruptions of CPR
- C, O, A
- C
- H
- E, D
- Recommence CPR
- Give adrenaline 1mg immediately then every second loop
- Repeat steps 4-10
Some key points during ALS
Emphasis on high quality uninterrupted CPR
Recognising and treating reversible causes
Attempts to secure airway must be completed with minimal interruptions to CPR
When airway is secured continue CPR with nil pause for ventilation. Aim 6-8bpm
Airway adjuncts
- OP 1st instance
- LMA no longer than 30 second attempt
- ETT no longer than 10 sec interruption of CPR
O2
- HR O2 until ABG measurable
- BVM
- when airway secured confirm with end tidal
IV
- peripheral preferred
- 20ml flush and elevate limb
IO
- If unable to establish IV in 2 mins of resus
What are the 2 shockable rhythms?
VT
VF
How would you describe VF?
An asynchronous chaotic ventricular rhythm
No regular pattern
No cardiac output
No P waves
How would you describe VT?
Wide complex tachycardia
May or may not produce cardiac output
No pwaves
What are the non-shockable rhythms?
Asystole
PEA
How would you describe Asystole?
Absence of any electrical activity of the heart
No pattern
No cardiac output
No pwaves
How would you describe PEA?
A presence of coordinated electrical rhythm
Can be regular
No Q waves
P waves can be present
What are the actions of Adrenaline?
Catecholamine
Vasoconstricts vessels
Directs blood flow towards Brain and heart
What are the indications of adrenaline?
VF
VT
Asystole
PEA
What is the dosage of adrenaline in an arrest? Shockable VS Non-shockable
1mg NEAT
Shockable - 1mg NEAT 2nd shock, then every second loop
Non-Shockable - 1mg NEAT immediately, then every second loop
What are the adverse effects of adrenaline?
Tachyarrythmias
Tissue necrosis at site
Post resuscitation HTN
What are the actions of Amiodarone?
Class III antiarrythmic
Prolongs action potential
Reduces rate through AV node
What are the indications of Amiodarone?
VT
VF
What is the dosage and administration requirements of Amiodarone?
300mg IV in 20mls Glucose over 10-20 mins
If required - follow by 900mg/24 hours
Pre and post flush with glucose 20ml
In an arrest give Amiodarone after 3rd shock if shockable rhythm
What are the adverse effects of Amiodarone?
Bradycardia
Prolonged QT
What is the action of Atropine?
Anticholinergic
Increases firing rate of SA node
What are the indications of atropine?
Severe bradycardia
2nd and complete heart block
What is the dose and administration requirements of Atropine?
500-600mcg NEAT
Repeat 5 minutely up to 3mg
What are the adverse effects of Atropine?
Tachyarrythmias
Dilated pupils
Increased ICP
What are the actions of Adenosine?
Transiently blocks conduction through AV node
What are the indications of adenosine?
Haemodynamically stable SVT
Paroxysmal SVT
What is the dose and administration requirements of Adenosine?
6mg IV, then repeat 12mg and 12mg if required
Followed by a rapid flush as it has a short half life of 0.6-10 seconds
What are the adverse effects of Adenosine?
Impending doom
Chest pain
Sinus arrest
What are additional drugs not mentioned that can be used in ALS
Metoprolol Potassium Digoxin Magnesium Lignocaine Sodium Bicarbonate
What is the defibrillation algorithm?
(COACHED) Continue compressions Oxygen away All others clear Charging defib Hands off Evaluating rhythm Defibrillate/disarm
What are the steps for non-invasive transcutaneous pacing?
(MRS Milliamps) Mode Rate Synch Milliamps (output)
Start pacing
Increase amplitude to 30mA
Slowly increase amps until capture is achieved (pacing spike before every QRS)
Increase slightly above capture to avoid loss of capture
Check mechanical capture (palpate pulse)
Monitor haemodynamic responsiveness
Explain the different pacing modes.
Synch and Demand
Synch (Demand) - preferred as paces when pts HR falls below set level avoiding R on T
Asynch (Fixed) - paces at set rate. Can be used for transport to avoid artefact and unnecessary pacing
Explain the procedure of Synchronised Cardioversion.
Place electrodes on patient
Turn mode selector to defib
Press SYNC on/off soft key
Verify that you see the word SYNC before the joules setting
Once in the SYNC mode the divide will display a down arrow markers above the R wave
(These markers indicate points in the cardiac cycle where discharge can occur)
Follow -OACHED algorithm (no compressions)
Select energy (200 joules)
Press charge
Shock
The defib will automatically revert to defib
Repeat process with starting SYNC soft key
