ALS =- specific scenarios Flashcards
ECG changes Hyperkalaemia?
Hyperacute T wave, Widened QRS, Flat/absent P, Tachycardia/bradycardia, 1st degree HB
Modifications to CPR?
- Confirm with VBG
- Protect the heart- 10ml CaCl IV bolus (can repeat)
- Glucose 25G/Insulin 2Units (K into cells)
- Sodium Bicarb 50 mmol IV if severe acidosis/RF
- Dialysis! - can use LUCAS if needed
?Signs Hypokalaemia
- U waves
- T wave flattening
- ST segment changes
- Arrythmias- especially if using dig.
Treatment Hypokalaemia
IV KCl in arrest:
- First bolus at 2mmol/min for 10 mins
- 10 mmol over 5- 10 mins
Hyper calcaemia
IVF
Furosemide 1 mg/kg IV
Hydrocortiosne 200-300 mg IV
Pamidronate 30-90 mg IV
Treat underlying cause
Hypocalcaemia
CaCl 10% 10-40 mL IV
1-2G IV MgSO4
Hyper magnesaemia
Treat when over 1.75
CaCl 10% 5-10mL and repeat as needed
Ventilatory support
Saline diuresis 0.9% saline with 1 mg/Kg furosemide
Haemodialysis
Hypomagnesaemia
Severe/symptomatic:
- 2G 50% MgSO4 (8mmol) IV in 15 mins
Torsades de pointes:
- 2G 50% MgSO4 (8mmol) IV in 1-2 mins
Seizure:
- 2G MgSO4 in 10 mins
CPR changes in dialysis?
- Trained dialysis nurse to operate haemodialysis machine
- Stop dialysis and return blood volume with a fluid bolus
- Disconnect the dialysis machine (unless defib proof)
- Leave dialysis port open for drug admin
- Dialysis may be needed early post ress
- Avoid large K+ and volume shifts in dialysis
Toxins mods to resus?
- PPE
- Avoid M-M or rescue breaths when- Cyanide, hydrogen sulphide, Corrosive, Organophosphates
- Treat anyarrythmias as per guidelines
- Once resus started try to identify cause- Pupils, Hx, LAS,
- Measure temp
- May need prolonged Resus
- Toxbase
Specific toxin management?
Opiates:
- 400 mcg IV stat (800 mcg IM/SC) Naloxone then titrate- need multiple doses due to half life
BDZ:
- Flumenazil but avoid in epilepsy/general as can cause seizures.
TCA:
- Wide QRS and Right Axis deviation – Treat with bicarb
Stimulants:
- GTN can relieve the coronary vasospasm
Alteration of ALS in asthma?
- Intubate early!
- If hyperinflated consider stopping vent and disconnecting IT tube and chest compression.
- May need high shock J
- ?PNEMOTHORAX
Anaphylaxis criteria?
When to start resistant treatment?
- Sudden Onset and Rapid porgression symptoms
- Life-threatening Airway/Breathing/ Circulation problems
- Skin and/or mucosal changes
After 2 doses IM adrenline
Cardiac arrest and anaphylaxis?
- Start CPR immediately
- 1 mg IV/IO adrenaline
- Mast cell tryptase 0, 1-2 then 24 hrs
- Use IM adrenaline boluses every 5 mins until IV access gained.
Managing peri-arrest in pregnancy?
- Left lateral position Manually displace the uterus
- High flow O2 guided by oxygen
- Fluid bolus if there is any evidence of hypotension
- Re-evaluate need for any current med
- Expert aid early
- Identify an treat cause
Managing Obs Arrest:
- Summon expert help immediately
- Start CPR as per ALS pathway.
- <20 week no need for displacement or E-Csection. Over this age prepare for emergency delivery in <5 mins. (best in 24-26 +)
- Access needs to be above the diaphragm
- Only if feasible perform left lateral
- Early intubation!
Reversible causes of arrest in pregnancy:
Haemorrhage;
- Extopic, abruption, placenta praevia, rupture
- Fluid resus and cell salvage- reverse coag issues, oxytocin, prostaglandins ergometrine and massage.
Drugs:
- Ca to treat Mg toxicity
CVD:
- Mostly congenital0 MI, anuerysm
- PCI is th treatment of choice
Pre-eclampsia + eclampsia:
- MgSo4 can prevent
Amniotic fluid embolism:
- Around labour collapse with breatjless cuampsos amd hypotension- can have DIC also.
- Treat supportively
PE: fibrinolysis if nil other option.
Traumatic arrest?
High mortality but if ROSC then good outcomes.
Damage control:
- Permissive hypotension (just enough for radial pulse) until surgical control of bleed
- If traumatic brain injury may need higher MAP
- Hypotensive resus should not last >60 mins
- TXA 1G loading dose- then 1G/8hr infusion. Within first 3 hours
Predicting outcome:
- Pupils
- Organised ECG
- Resp activity
In contrast to other Resus- bleed/tension/tamponade need to be resolved pre CPR
FAST!
Stop if at 20 mins nil reversible cause, no cardiac activity on US, no response.
May need aortic clamp - thoarcotomy aoe REBOA
CAREFUL with PEEP- can cause hypotension so adjust minute ventilation to be as low as possible whilst maintaining normocapnia
Management of Choking?
ineffective cough/RDS- 5 back blows then 5 abdo thrusts and repeat
If arrest then start ALS
What is Commotio Cordis?
Arrest caused by a blow to the chest. Blunt impact- early defib vital.
Signs of neurogenic shock?
Warm, vasodilated peripheries
Loss of reflexes
Severe Hypotension with bradycardia
Resus Thoracotomy?
Immediate indicated when penetrating chest trauma, less then 15 mins since loss of vitals.
- o pulse after penetrating chest injury, Short on scene to hospital time, Witnessed signs of life./ecg
Management of cardiac tamponade?
Clam shell thoractomy and Decompression- needle is unreliable due to clotted blood.
Tension pneumothorax
13% of trauma cases in arrest
Signs:
- Resp distress/hypoxia
- Haemodynamic compromise
- Absent breath sounds on auscaltation
- Chest crepitations
- SC emphysema
- Tracheal deviation
- Jugular venous distension
Treatment:
- Needle decompression 14G into 4th/5th intercostal space mid axillary line
- Open thoracostomy (preferable to above)- into the chest wall and dissect into the pleural space. - then drain
- Clamshell thoracostomy- traumatic and need extensive training
-
Perioperative?
Overall survival is high
Cmn causes:
- Failure of ventilation, medication related, complications of central access, perioperative MI
Types:
- 41.7% were asystole
- 35.4% VF/VT
- PEA 11.5%
Mx:
- Asystole and VF are noted almost immediately- however PEA may not be as clear- ETCO2 will be a good clue
- If surgery will not control consider early IR
Alertations:
- Can perform CPR with patient prone or cardiac massage
- VT/VF attatch defib and can give precordial thump.
- Brady: Stop surgery exacerbating this and give IV 0.5 mg atropine
- give micro doses 0.5 mcg- 100 mcg IV rather then stat 1 mg.
Cardiac arrest post cardiac surgery?
Early emergency resternotomy is key
- Other reversible causes adressed
- 3 shocks given
- Airway eastablished.
—> Within 5 mins
- VF/asystole defib at highest amplitude
- Start CPR - can use BP monitoring aim SBP>60 and DBP >25
resternotomy- use 20 J direct to heart via paddles
Use adrenaline very cautiously
Drowning:
Primary resp impairement from immersion/submersion in a liquid medium.
In immersion often hypothermic with open airway unless water splashes into mouth.
Bradycardia from hypoxaemia occurs pre arrest. (can reverse with just O2).
Try not to enter Water
Submersion for <5-10 mins better outcome. >25 mins v.poor prognosis
Review search and rescue at 30 and 60 mins
Modifications to ALS in drowning
5 resucue breaths first. Supplement with O2 if available.
Early Intubation
Aim 94-98% confirm with ABG. Also PEEP 5-10 cm at least may need up to 15-20
Pulse is not always reliable- use ETCO2 and trace
Rapid IV fluid and pressures –> Dehydration IV
V.poor outcome if CPR >30 mins
Hypothermia:
Stage I: 35-32- Conscious shivering- mild
Stage II: 32-28- Impaired conscious, No shivering: moderate
Stage III: 24-28: Unconscious, vital present. Severe
Stage IV: <24: no or minimal vitals. Arrest/no flow state
Stage V: <11.8 death due to irreversible hypothermia
Lower 1/3 of oesophagus- good temp for heart if airway present.
6% per degree reduction in metabolism
Dilated pupils do not mean brain death and pulse//rythm can be supressed.
Intermittent CPR can be of benefit..
Temp <28 then 5 mins CP with alternate 5 mins nil
Temp <20 5 mins CPR then 5-10 mins without.
‘No patient is dead, until warm and dead’
Decreased sensitivity and action of insulin
Mods to ALS in hypothermia?
_ Check for signs of life up to 1 min (central artery and assess cardaic rythm).- ETCO2 and US echo.
- Hypothermia can increase stiffness of the chest wall necessitating mechanical CPR use.
- Hypothermic metabolism and electical activity poor:
–> Limited efficacy for drugs
–> Hold adrenalin until >30
—> >30 double intervals
—> as reaching normothermia return to normal
–> VF persisting despite 3 shocks continue CPR until >30
- HOPE/ICE scores
principles of rewarming in hypothermia?
Remove from cold environment- transfer to hospital
Immobilise handle carefully apply O2
Remove wet clothing
Beware of cooling post removal from the environmnet can suddenly arrest/drop GCS
Extra Corpeal Life Support should be used in preference to CP bypass.
- Non ECLS if cant reach hospital in 6 hrs
- After ROSC use standard procedure
2 forms of heat stroke?
RF?
- Classic non exertional
- Exertional- high stress exercise in high temp/humidity- usually healthy young adults
RF: Elderly, unaclamatised, Obseity, dehydration, alcohol, CVD, Hyperthyroid, Meds
Triad of heat stroke?
- Core temp >37.5
- Neuro (confusion, seizures, coma)
- Exposure to high temp or exercise
Treatment of hyperthermia?
Cool enironment and lie flat
Start cooling and transfer to Hx
Colled to <39
Rapid coolling 0.2-0.3 degrees/min are achievable
Best - COld water immersion or conductive cooling system
Isotonic/hypertonic fluid If Na <130 can use 100ml 9% NaCl *3
May need high volume fluids to prevent hypotension
Management malignant Hyperthermia?
- Stop trigger immediately
- Give Oxygen
- Correct acidosis
- Cool actively
- Dantrolene can be used. relapse in 25% of people.
What number of presenting rythms in arrest?
Community: (50% witnessed bystander or ambulance)
25% VF/VT, 25% asystole, 50% PEA
(survive to home 9.7%- 30% ROSC)
Hx: (survie to home 23.9%)
- 18.1% VT/VF, 73% PEA/Asystole.
Bystander CPR at 60% now
Chain of survival?
- Early recognistion and call for help
- Start CPR
- Early Defib (within 3-5 min lead to 50-70% survival). Each minute delay decrease by 10-12%
- Post resus care
AED now used in 5% OOH arrest
All are equally important
Importance of comms?
Poor communication skills are a factor in up to 80% of AI or near miss events
Factors improving prognosis?
Witnessed,
VF/ pVT
MI related
Immediate and succesful defib
In 80% there is recognisable deterioration pre arrest
Common rythm in arrest due to hypoxia/hypotension?
PEA- 14% survival vs 24% general
When to think Aorta?
Sudden onset pain and marked hypotension with nil ECG changes
Chain of prevention?
Education
Monitorinf
Recognition
Calling for help
Response
Causes of VF:
- ACS
- HTN heart disease
- Valve disease
- Drugs
- Inhertied (prolonged QTc)
- Acidosis
- Abnormal electorolyte
- Hypothermia
- Electrocution
VF is likely to reccur if no reversal of underlying cause
Treating ACS:
Morphine 5-10 mg IV
Oxygen if sats <94%- aim 94-98%
GTN SL (unless hypotensive)
Aspirin 300 mg
ECG stat- then discuss with PCI lab.
Indication for fibrinolytic therapy
Attend wtho 12 hrs of AMI and PCI not possible plus:
- ST elevation >0.2 mm in adjacent leads or >0.1 mm in adjacent limb leads
-Dominant R wvee and ST depression in V1-3
- New LBBB
Why does transvenous pacing fail?
- High threshold: aim <1V usually 3-4 V initially- but if persistent may suggest not in contact with myocardium
- Connection failure:
- Bipolar one at tip and other 1 cm procimal/ Check connections immediately/ change connector. - Lead displacement. ?tamponade if sudden arrest and pulseless as migrates through RV.
ICD displacement less likely after 4-6 weekscan be caused by trauma to left arm
What factors affect the probability of success in Defib?
1,. Time fro onse to shock- every 1 min increase mortality by 7-10%
2. Continuous uninteruted and high quality compression
3. Durration between stopping and delivering shock. (every 5s halves chance of success
CI to flecanide/Peopafenone
HF
rLVEF
IHD
Prolonged QT
Post cardiac arrest components?
Post arrest brain injury
Post cardiac arrest myocardial dysfunction
Systemic ischaemia/reperfusion response
Persistant precipitating pathology
Heart recovers in 3-4 days
