Cardiac Arrest (Adult)- Resuscitation

Question 1

Initial factors influencing the effectiveness of resuscitation (4)

Answer 1

1. Performing it at scene of collapse
2. Good quality chest compressions and defibrillation
3. Solo responders - only interupt chest compressions for ventilation and defibrillation
4. >1 responder - chest compression interruption kept to a minimum for IV access, drug admin, and advanced airway management.

Question 2

First action on confirmation of cardiac arrest? (4)

Answer 2

• Apply defib pads and ascertain presenting rhythm.
• >1 responder - 1 starts CPR, the other applies pads
• Shockable rhythm? Shock, CPR and ALS!
• Non-shocakble rhythm - CPR and ALS!

Question 3

Adult chest compressions (8)

Answer 3

1. Rate 100-120 per minute
2. Resume immediately, hands in centre of chest
3. Depth 5 - 6 cm
4. Allow full recoil
5. Time for compression = relaxation
6. Minimise interruptions
7. Compression:ventilation ratio 30:2
8. Rotate clinicians to avoid fatigue

Question 4

Adult airway and ventilation (9)

Answer 4

1. Inspiration phase over 1 second
2. No longer than 5 seconds pause in compressions
3. Stepwise approach to airway management
4. If suspected cause is asthma, COPD or anaphylaxis - early intubation and T-piece nebulisation.
5. If ET tube used follow tube verification procedure.
6. ETCO2 monitoring for all patients who are ventilated
7. ETI/SGA - uninterrupted compressions except for defibrillation and assessment
8. Ventiallte 10-12 pm - avoid hyperventilation
9. O2 ASAP

Question 5

Adult defibrillation (5)

Answer 5

1. Minimal interuption of compressions to assess rhythm
2. Use manual mode
3. Continue compressions while defib is charging
4. Shock given by clinician performing chest compressions
5. Post-shock - immediate compressions for 2 minutes

Question 6

Adult drugs (6)

Answer 6

1. Not via ET tube
2. Obtain IV access
3. Consider IO access
4. 1st adrenaline - in accordance with JRCALC, then every 3 - 5 minutes whilst in cardiac arrest
5. Atropine no longer indicated for asystole or pulseless activity
6. All drugs flushed with 20 mls N/saline via 500ml bag.

Question 7

Refractory/persistant VF (5)

Answer 7

1. Amiodarone 300mg after 3rd shock post-adrenaline, the 150mg after 5th shock
2. Consider early conveyance to ED if unable to manage reversible causes on scene.
3. Consider alternative pad position i.e anterior/posterior
4. Post-ROSC arrest - reset defib count
5. Hypothermia - 3 shocks single dose of adrenaline

Question 8

Witnessed monitored arrest (2)

Answer 8

1. Pre-cordial thump only if VT/VF whilst conected to monitor
2. If connected to defib - shock. Consider 3 stacked shocks before compressions start.

Question 9

Hypothermia (general) (6)

Answer 9

1. Often under-diagnosed
2. Caused by exposure to cold environments, immobilisation, cold water immersion, exhaustion, illness, injury, neglect, reduced LoC, drugs/alcohol
3. Common in eldery and very young.
4. Depresses cerebral blood flow, O2 requirement, cardiac output, blood pressure
5. Can appear dead, but full resuscitaton with intact neurological function is possible.
6. Peripheral pulses and resiratory effort may appear absent.

Question 10

Hypothermia management (6)

Answer 10

1. Palpate major artery, assess ECG and look for signs of life before concluding no output
2. If pulseless start CPR as normal
3. Can cause chest wall stiffness
4. Measure temperature early
5. Remove wet clothes, use blankets and insulating equipment
6. Maintain horizontal position, avoid rough movement and excessive activity

Question 11

Hypothermia - drugs and defibrillation (3)

Answer 11

1. Don’t repeat adrenaline or defibrillation until temperature >35C
2. Give drugs via large proximal vein or IO
3. Dont stop resuscitation! (unless cause is clearly attributed to fatal illness, prolonged asphyxia, lehal injury or chets uncompressible)

Question 12

Hyperthermia (general) (3)

Answer 12

1. Due to failure of body to thermoregulate - metabolic heat production or environemntal heat load
2. Follow standard procedures and cool rapidly to 39C
3. Poor prognosis, especially neurologically.

Question 13

Drowning (General) (2)

Answer 13

1. Defined as primary respiratory impairment from submersion/immersion in liquid
2. Near drowning - survival of drownign event involving inconsciousness and water inhalation - can cause pulmonary oedema up to 72hrs post. Convey all!

Question 14

Drowning management (9)

Answer 14

1. High flow O2
2. Don’d delay CPR
3. Pulse detection of cardiac arrest unreliable - ECG and ETCO2
4. Follow standard protocol
5. Consider early ETI - high pressure may help due to poor compliance due to pulmonary oedema
6. Stomach regurgitaion is common
7. Do not use abdo thrusts of head-down to remove water from lungs
8. Prolonged immersion may lead to hypovolaemia due to hydrostatic pressure - IV fluids
9. Manage hypothermia

Question 15

Drowning post-resuscitation care (4)

Answer 15

1. At risk of ARDS - adequate ventilation.
2. No difference between salt and freshwater
3. Hypothermia give some protection against hypoxia
4. If hypothermic continue to warm to 32-36C

Question 16

Opiate overdose (4)

Answer 16

1. Secondary to respiratory arrest and associated with severe brain hypoxia - poor prognosis
2. Naloxone IO, IV, IM or IN every 3 minutes (400mcg, total 4400 mg)
3. Acute withdrawal can cause sympathetic excess - arrythmia and severe agitation.
4. Do not withdraw resuscitation in pre-hospital setting.

Question 17

Asthma (general) (5)

Answer 17

1. Termial event after period of hypoxaemia linked to sever bronchospasm and mucous plugging - asphyxia
2. linked to cardiac arrhythmias due to hypoxia, stimulant drugs or electrolyte abnormalities
3. Dynamic hyperinflation - gradual pressure build up reducing venous return and BP
4. Tension pneumothorax often bilateral
5. 4Hs and Ts will help identify causes

Question 18

Asthma management (7)

Answer 18

1. If difficult ventilation use T-piece nebulisation
2. Intubate early due to gastric inflation and hypoventilation
3. Don’t cause gas trapping - RR =10 and minimal tidal volumes
4. Dynamic hyperinflation - compress the chest and period of apnoea may relieve gas trapping
5. Look for evidence of tension pneumothroax
6. Decompress suspected pneumothoraces
7. Standard guidelines for post-resus care.

Question 19

Anaphylaxis (4)

Answer 19

1. Severe, life-threatening allergic reaction resulting in generalised or systemic hypersensitivity reaction recognised by rapidly developing airway/breathing and circulation problems.
2. Consider steroids, antihistamines, and large volumes of fluids
3. Airway compromise may occur rapidly - angioedema, tongue and lip swelling, hoarseness and oropharyngeal swelling
4. Consider early intubation. SGAs may be difficult to insert. Neddle cric or surgical airway may be required.

Question 20

Blunt trauma (5)

Answer 20

1. Survival correlated to duration of CPR and pre-hospital time, the greater the worse. Focus on high quality CPR, ALS, and 4Hs/Ts
2. Commence on all patients regardless unless beyond help
3. Undertake only essential life saving inteventions - signs of life? Rapidly transfer, don’t delay for spinal immobilisation.
4. Effective airway management is essential
5. In low cardiac output conditions positive pressure ventilation may cause circulatory depression/arrest by impeding venous return. Monitor ventilation with capnography.

Question 21

Blunt trauma - reversible causes (4)

Answer 21

1. Hypoxaemia - O2, ventialion
2. Hypovolaemia - Compressible haemorrhage - compress, non-compressible - splints, conservative fluids
3. Tension pneumothorax - needle decompression
4. Cardiac tampanade - CCP - thoracotomy, transfer to MTC if poss. in 10 minutes.

Question 22

Trauma - general (3)

Answer 22

1. Conservative fluid replacement until bleeding controlled
2. Scoop and run in penetrating trauma
3. Resus discontinued if all reversible causes treated, patient is asytolic/agonal
4. No exclusion criteria are present.