Cardiac Arrest (ALS)

Question 1

A 65-year-old man is brought in by ambulance after collapsing and being defibrillated in a shopping centre. How would you manage him?

Impression/DDx/Goals

Answer 1

Cardiac Arrest:
Need to consider reversible causes of cardiac arrest
- 4H’s: hypoxia, hypovolaemia, hypothermia, hyperkalaemia/hypokalaemia
- 4T’s: thrombosis, tamponade, tension pneumothorax, toxins

Goals of management:
- Assemble team including senior colleagues to efficiently assess and manage patient
- commence ALS
- identify and treat underlying cause of arrest
- stabilise, arrange transfer to appropriate facility (ICU/CCU)

Pathway
- post-resuscitation care
- ALS algorithm

Question 2

Cardiac arrest (ALS) - History

Answer 2

History:
- MIST AMPLE
- collateral from family-members/ bystanders
If conscious, take

Question 3

Cardiac arrest (ALS) - Examination

Answer 3

Exam:
Would be conducted throughout ALS (post-resus care)
- A: patent, maintaining, suction for secretions, intubate pending GCS
- B: RR, SP02, supplemental as required
- C: HR, BP monitoring. Gain IV access (2xlarge bore), take initial bloods [VBG, UEC, LFT, FBC, BNP, serial trops]. Administer fluids, adrenaline as per ALS algorithm, further vasopressors/inotropic support with senior colleague input
- D: GCS - indication for intubation
- E: exposure for other injuries, Temp
- F:
- G: BSL

ALS algorithm
- chest compressions 30:2
- once defib on, run through coached, deliver shock if shockable, and check peripheral pulse
- non-shockable: adrenaline straight away and then every second cycle
- shockable: adrenaline after second shock, and after third then give amiodarone on 3rd, then adrenaline after every second

Question 4

Cardiac arrest (ALS) - Investigations

Answer 4

Investigations:
Would be conducted throughout ALS:
- Bedside: ECG, vital signs, VBG
- Bloods: trops (serial), FBC, UEC, BNP, coags
- Imaging: CXR, ECHO, coronary angiography (if indicated

Question 5

Cardiac arrest (ALS) - Management

Answer 5

Management:
1. Establish ALS team and assign roles (Scribe, airway, circulation, team leader, defibrillates, drugs etc)
2. Utilise ALS pathway, run through coached for use of defib
3. ensure pulse check after every shock delivered

Otherwise:
- Family consult
- Senior input into length of time/futility of ongoing ALS if non-responsive
- documentation

Disposition
- ICU if ROSC and requiring input
- retrieval to tertiary centre if stabilised and required further intervention
- Cardiac Cath lab for STEMI

Question 6

Shockable rhythms? Non-shockable?

Answer 6

Shockable rhythms:
- VT, VF

Non-shockable:
- PEA, asystole