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SC Multidisciplinary > Anaesthesiology: Advanced Life Support Course > Flashcards

Anaesthesiology: Advanced Life Support Course Flashcards

1
Q

Cardiac arrest

A 
- Heart stopped beating
—> No CO
—> No blood flow to vital organs (***Brain, ***Heart), tissues
- Life-threatening emergency
- Time is crucial

Management:
- Resuscitation

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2
Q

Resuscitation

A
  • Maintain adequate **Oxygen + **Blood flow to vital organs
    —> Buy time for more definitive therapeutic management
  • Need to support ABC
    —> Airway
    —> Breathing
    —> Circulation
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3
Q

Guidelines on Resuscitation

A
  • **American Heart Association guidelines (latest in 2021)
  • used by most centres in HK

ILCOR (International Liaison Committee on Resuscitation)

  • review latest scientific evidence in 5-yearly cycle
  • individual organisations publish guidelines consistent with local needs
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4
Q

Basic Life Support (BLS) and Advance Life Support (ALS)

A 
Basic Life Support (BLS):
- What you can do with just:
—> Hands
—> Mouth
—> AED
- Can be done in any settings
- Backbone of resuscitation

Advance Life Support (ALS):

  • What you can do with more equipment, drugs, health care providers
  • Depends on ongoing BLS
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5
Q

Main goals of resuscitation

A
  1. Immediate recognition + activation of emergency response system (call for help)
  2. High quality CPR
    - Chest compression
    - Bag valve mask ventilation
  3. Rapid defibrillation
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6
Q

***Basic Life Support algorithm

A
  1. Verify scene safety
    - check if scene is safe for provider
    - physical threats such as toxic / electrical hazards
  2. Immediate recognition of cardiac arrest
    - Check responsiveness
    - ***Call for nearby help if person not responsive (叫左先)
  3. Assess breathing + pulse simultaneously
    - Pulse check ***<=10s
    - Look at chest movement / gasping
  4. Activate emergency response system
    - Full activation
    - 999 (if outside hospital)
    - Hospital arrest team (if in hospital)
    - Get AED + emergency equipment (or send someone to do so)
  5. Start CPR (if no pulse + no breathing / only gasping)
    - Start with Cardiac compressions —> Airway —> Breathing (**CAB, ∵ initial physiological deficit is lack of blood flow rather than lack of oxygenation)
    - Compression : Rescue breath ratio = **    30:2
    - if 2 rescuers: one do CPR, one do rescue breaths —> 5 cycles (2 mins) —> swap
  6. AED
    - Check rhythm —> Shockable rhythm?
    —> Shockable: deliver 1 shock, resume CPR immediately for 2 mins until rhythm check by AED, continue until ALS provider take over / patients start to move
    —> Non-shockable: resume CPR immediately for 2 mins until rhythm check by AED, continue until ALS provider take over / patients start to move
    - NB: NO need to check pulse every 2 mins if AED not available
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7
Q

Pulse checking

A
  • Check for definite ***carotid pulse
  • Can be difficult + inaccurate
  • Use ***<=10s
  • If in doubt —> Assume patient in arrest —> Activate emergency response system
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8
Q

Chest compressions

A

Directly compress the heart
—> ↑ Intrathoracic pressure
—> ↑ Perfusion pressure
—> ↑ Blood flow + O2 to brain & heart

  • Heel of hand on centre of chest (lower half of sternum, X ribs, X epigastrium)
  • Heel of other hand on top of first hand
  • Arms straight + 90o
  • ***Rate: 100-120 bpm
  • ***Depth: 5-6 cm
  • Allow complete recoil of chest after each compression —> avoid leaning on patient in between compressions —> allow heart to fill up
  • Minimise frequency + duration of interruptions (esp. unintended reasons)
    —> more compressions associated with higher survival rates
    —> aim for compression fraction >=60%
    —> pause for required care: **Rescue breaths, **Rhythm analysis, ***Defibrillation

Rate too fast:
- associated with inadequate depth (<3 cm)

Compression too deep
- ↑ non-fatal injury (e.g. rib fractures)

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9
Q

Airway maneuvers

A

Triple maneuvers:

  1. Head tilt-Chin lift
  2. Jaw thrust
  3. Airway adjuncts (give routinely unless CI)
    - Nasopharyngeal
    - Oropharyngeal
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10
Q

Breathing

A
  • Mouth to mouth / Bag mask
  • Deliver each rescue breath over ***1 second
  • Give sufficient tidal volume to produce ***visible chest rise
  • 30:2 —> avoid hyperventilation
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11
Q

Automated external defibrillator (AED)

A
  • Simple to use —> step by step voice instruction
  • AED analyse victim’s heart rhythm (accuracy >90%)
  • Gives instructions on whether to deliver shock / continue CPR after rhythm analysis
  • Pause CPR (no matter which cycle) whenever AED arrives
    —> priority should be given to ***early + rapid defibrillation
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12
Q

Defibrillation

A
  • ***Ventricular fibrillation: common + treatable initial rhythm in adult witnessed cardiac arrest
  • Rapid defibrillation is treatment of choice for **VF + **Pulseless VT
  • Highest survival when defibrillation given within ***3-5 mins of collapse
  • Connect to AED as soon as available
  • Give one shock asap if indicated
  • Continue CPR immediately after shock for 2 mins / 5 cycles
  • Recheck rhythm every 2 mins (NOT pulse)
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13
Q

***Advanced life support algorithm

A
  1. Start CPR
    - give ***highest FiO2 possible (i.e. 100%) (Ambubag + O2 >15L)
    - ∵ low blood flow state —> need to maximise O2 content
  2. Attach monitors / defibrillators
    - rhythm analysis
    - 2 pathways: Shockable vs Non-shockable rhythm (can jump from one to another)
  3. Non-shockable rhythm
    - High quality CPR
    - Adrenaline 1mg IV / IO (ASAP) every **3-5 mins
    - Advanced airway
    - Recheck rhythm after **    2 min CPR —> decide if shockable or not —> non-shockable —> continue
    - Find + treat reversible causes: 5H + 5T
  4. Shockable rhythm
    - Immediate defibrillation
    - Followed by 2 min CPR
    - Rhythm check after 2 min CPR
    - Adrenaline after **2nd shock every 3-5 mins
    - Advanced airway
    - Antiarrhythmic drugs after **    3rd shock (Amiodarone / Lignocaine)
    - Find + treat reversible causes: 5H + 5T
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14
Q

Rhythm in ALS

A

Shockable rhythm:

  • VF
  • Pulseless VT

Non-shockable rhythm:

  • Asystole
  • Pulseless electrical activity (PEA)

Can jump from one to another

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15
Q

Non-shockable rhythm

A
  1. Asystole
    - no QRS complex
  2. Pulseless electrical activity
    - heart rhythm that usually produce a pulse (e.g. narrow complex tachycardia: AF, SVT, Sinus tachycardia etc.)

Management:

  1. High quality CPR
  2. Adrenaline 1mg IV / IO (ASAP) every 3-5 mins
  3. Advanced airway
  4. Recheck rhythm after 2 min CPR —> decide if shockable or not —> non-shockable —> continue
  5. Find + treat reversible causes: ***5H + 5T
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16
Q

Adrenaline

A
  • Parenteral access: IV / IO
    —> Drug administration is of secondary importance —> do NOT interrupt / delay chest compression to establish IV / IO access
- ***1mg every ***3-5 mins
—> 1ml of 1:1000
—> 10ml of 1:10000
—> paediatrics: 10 mcg/kg
—> Higher dose may be indicated if β blocker / CCB overdose
  • improve ROSC (return of spontaneous circulation) + survival to hospital discharge
  • ***NO advantage of using vasopressin —> removed from guidelines

**MOA:
- α1 + β1 agonist
—> Primary beneficial effects via α1 effects
—> Peripheral vasoconstriction
—> **↑ Aortic diastolic pressure (>40 mmHg)
—> ↑ Coronary + Cerebral perfusion pressure (while ↓ perfusion to other organs (i.e. divert blood from other organs to brain + heart))

—> NOT via β1 effects to ↑ HR / contractility (∵ heart already not functioning)

17
Q

Advanced airway

A
  1. Supraglottic airway (Laryngeal mask airways)
  2. Endotracheal tube
    - most common form of in-hospital advanced airway
    - risks: tube misplacement (e.g. esophagus), ↑ hands off time
    - avoid multiple attempts (∵ affect quality of CPR + can inadvertently cause bleeding / edema in upper airway)
  • ***NO difference in outcomes between bag mask ventilation / advanced airway devices
  • No agreed ideal timing for placement of advanced airway

Compression: Ventilation ratio with advanced airway (X 30:2):

  • 1 breath every ***6 seconds (10 breaths per min) (∵ already ensure all air will go into lungs rather than stomach)
  • ***Continuous chest compression
  • Avoid hyperventilation —> may have worse outcomes

Assessment of tube placement:
- Risks with ETT: esophageal placement, obstruction, dislodgement
- **Continuous CO2 waveform capnography (End-tidal CO2)
—> most reliable method of confirming + monitoring correct ETT placement
—> also monitor CPR quality (EtCO2 during CPR: at most 10 mmHg, consistently **<10 mmHg: poor CPR quality ∵ not returning enough CO2 back out)
—> also detect return of spontaneous circulation (EtCO2 back to ***40 mmHg)

18
Q

5H + 5T

A

H:

  1. Hypoxia
  2. Hypovolaemia
  3. Hydrogen ion (Acidosis)
  4. Hypo/Hyperkalaemia
  5. Hypothermia

T:

  1. Tamponade
  2. Tension pneumothorax
  3. Thrombosis, Coronary
  4. Thrombosis, Pulmonary
  5. Toxins
  • History + P/E (***auscultation to rule out tension pneumothorax)
  • Blood tests (POC / Lab): Glucose, Hb (blood loss), Electrolytes (K), Cardiac markers
  • Ultrasound: Bedside echocardiogram (pericardial effusion / tamponade)
19
Q

Shockable rhythm

A
  1. VF
    - coarse / fine (can be similar to asystole)
  2. Pulseless VT

Management:

  1. Immediate Manual defibrillation
  2. Followed by 2 min CPR
  3. Rhythm check after 2 min CPR
  4. Give Adrenaline after ***2nd shock
  5. Advanced airway
  6. Antiarrhythmic drugs after ***3rd shock (Amiodarone / Lignocaine)
  7. Find + treat reversible causes: 5H + 5T
20
Q

Safety measures in electrical therapy

A
  • Check for ***indication: it is invasive!
  • Ensure good ***contact
  • Choose the right ***mode (e.g. Synchronisation in Cardioversion)
  • Make sure ***no one touching —> do not defibrillate / cardiovert yourself / any bystander
  • Handle the defibrillation paddle with care:
    —> Do NOT short circuit (pads must not touch each other + one hand one paddle)
    —> Put back to original position when not in use
21
Q

Manual defibrillation

A
  • X AED, ∵ manual much faster to analyse rhythm
  • delivery of ***large direct current over a very short interval
  • ***Unsynchronised manner

Aims:
Depolarise the heart
—> Abolish all prevailing abnormal rhythm
—> Hope that SA node will take over again as pacemaker

Indications:

  • VF
  • Pulseless VT
  • Biphasic: 120-***200J
  • Monophasic: 360J
    —> Biphasic better than Monophasic —> Higher chance of terminating arrhythmia + Less collateral damage
  • First shock:
    —> manufacturer recommended dose
    —> max dose (200J) if unknown
  • Higher energy for subsequent shock
22
Q

Antiarrhythmic drugs

A
  1. Amiodarone
    - **300mg IV bolus —> then 150mg IV (no guideline on when give 2nd dose)
    - max. **    450mg
  2. Lignocaine
    - Alternative to Amiodarone (e.g. CI to Amiodarone e.g. allergy)
    - 1-1.5 mg/kg —> then 0.5-0.75 mg/kg
  • Do ***NOT improve long term survival / survival with good neurological outcome
  • NO evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge
  • Amiodarone: shown to increase ***short-term survival to hospital admission when compared with placebo / lignocaine
23
Q

Amiodarone

A

MOA:

  1. Affect Na, ***K (affect repolarisation phase), Ca channels
  2. α + β blocking properties
    - Vasodilation + Bradycardia —> can cause hypotension although less pronounced as β blockers / CCB

Indication:
- Recommended for VF + Pulseless VT unresponsive to shock delivery, CPR and a vasopressor

Dose:

  • 300mg or 5mg/kg in 20ml dextrose IV / IO bolus
  • can be followed by one dose 150mg
24
Q

Interventions not routinely recommended

A
  1. NaHCO3
  2. Ca
  3. IV fluids
  4. Precordial thump (rarely, for termination of witnessed monitored unstable VT when defibrillator not available)
25
Q

NaHCO3

A

Reverse acidosis

  • multiple unwanted effects
    1. Compromise CPP (Coronary perfusion pressure) by reducing SVR
    2. ***Extracellular alkalosis
  • shift O2 dissociation curve (ODC) to **left —> inhibit O2 release
    3. **    HyperNa, **Hyperosmolarity
    4. Excess CO2 production —> **    Paradoxical intracellular acidosis
    5. May inactivate simultaneously administered catecholamine

Can be beneficial in special circumstances:
1. Pre-existing acidosis
2. HyperK
3. Tricyclic antidepressant overdose
—> esp. if these are underlying causes of cardiac arrest (e.g. ESRF)

26
Q

Calcium

A

Inotrope

  • routine use not recommended
  • not supported by clinical trials
  • acceptable, probably helpful in HyperK, HypoCa, Drug overdose with CCB
  • can exacerbate cell injury (toxic to myocyte)
27
Q

Mechanical chest compression device

A
  • No benefit compared with manual chest compressions
    —> Manual compressions: Standard of care
  • Free up people to do other stuff
  • Alternative in challenging situations e.g. dangerous environment for provider, angiography suite
28
Q

Extracorporeal CPR (ECPR)

A
  • Pump with oxygenator to oxygenate blood + remove waste from patient

Indication:
- If expected cardiac arrest will be prolonged but still reversible
—> buy more time

  • Not routinely used
  • Highly trained team, specialised team (ICU physicians)
  • Cannulation of large veins + artery —> venoarterial extracorporeal circulation + oxygenation
  • Select patients: suspected etiology potentially reversible during limited period of mechanical support (e.g. LA toxicity)
  • Setting: ***need rapidly implemented, need quickly prime machine + heparin
  • Still can only be used for short period of time
29
Q

Return of Spontaneous Circulation (ROSC)

A

Return of:

  1. Pulse
  2. BP
  3. Breathing

If NO signs of ROSC
—> continue CPR, Adrenaline
—> consider appropriateness for continued resuscitation

If ROSC —> Post-cardiac arrest care

30
Q

Post-cardiac arrest care

A

Aim:

  1. Brain + Cardiac status major determinant of survival
  2. ***Optimise cardiopulmonary function + vital organ perfusion after ROSC
  3. Transport / transfer to an appropriate hospital / ICU / CCU
    - have better monitoring + intensive support
  4. Identify + treat ACS and other reversible causes (e.g. ACS)
  5. Control temperature to optimise ***neurologic recovery
  6. Anticipate, treat, prevent multiple organ dysfunction
  7. ***Prevent going back to cardiac arrest again

2 Phases:

  1. Initial stabilisation (ABC)
  2. Continued management + additional emergent activities
31
Q

Post-cardiac arrest care: 1. Initial stabilisation (ABC)

A
  1. Airway
    - Early placement of ***ET tube (Definitive airway ∵ still breathing poorly / unconscious —> still need ventilatory support)
  2. Manage respiratory
    parameters
    - Titrate FiO2 to achieve SaO2 **92-98% (X 100% (unlike during cardiac arrest care): oxygen free radicals released —> toxic to brain)
    - **    Normocarbia: PaCO2: ***35-45 mmHg (too low: cerebral blood vessels constricted —> inadequate cerebral perfusion; too high: cerebral edema)
    - RR: 10 breaths / min
  3. Manage haemodynamic parameter
    - ***Avoid Hypotension
    - SBP >90 mmHg
    - MAP >65 mmHg
    —> By Inotropes (Adrenaline / NE ∵ some degree of myocardial ischaemia during resuscitation + support BP), Fluids (fluid overload if no inotropes given at the same time)
  4. 12-lead ECG
    - to rule out ACS
  5. Actively treat cause of cardiac arrest
    - Review 5Hs + 5Ts —> Take blood
32
Q

Post-cardiac arrest care: 2. Continued management + additional emergent activities

A
  1. Consider for emergent ***cardiac intervention if:
    - STEMI present
    - Unstable cardiogenic shock
    - Mechanical circulatory support required
  2. If Comatose
    - **Targeted temperature management (TTM)
    —> Avoid **    hyperthermia to protect brain (↓ workload for brain cells)
    —> May improve neurological outcome
    —> For ALL comatose patients with ROSC
    —> Constant temp between **32-36oC for **24 hours
    - Brain CT
    - EEG monitoring —> for ***seizures
    - Other critical care management
  3. If Awake
    - Other critical care management
  4. Evaluate + Treat rapidly reversible etiologies, involve expert consultation for continued management
33
Q

Summary

A
  • Cardiac arrest: No blood flow to tissue (esp. Brain + Heart)
  • Time is critical
  • Immediate recognition of cardiac arrest + activation of emergency response
  • Effective CPR
  • Early defibrillation for shockable rhythm

SC Multidisciplinary (10 decks)

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