cardiac arrest (google docs)

Question 1

outline the guideline management of

Answer 1

Compressions while being attached to pads/ charging
If VT or VF shock immediately, max joules or 4j per kg for pead
Perform 2 minute cycles of CPR between each rhythm check
Place a SGA (Igel or better)
Administer IV adrenaline every 4 minutes
Administer amiodarone if rhythm is VF or VT any time after the first dose of adrenaline
fluids
Once arrest established go over checklist + discuss reversible causes

Question 2

If VF or VT recurs or persists beyond three shocks delivered by ambulance personnel:

Answer 2

Change pad placement to the anterior/posterior vector when only one manual defibrillator is present.

Perform double sequential defibrillation in manual mode when two manual defibrillators are present.

Withhold further adrenaline and administer a further dose of 150 mg amiodarone IV after 15 minutes for an adult.

Seek clinical advice if the rhythm persists.

Question 3

management if PEA persists

Answer 3

1-2 litres of 0.9% sodium chloride IV for an adult.
20-40 ml/kg of 0.9% sodium chloride IV for a child.

Question 4

what is a primary cardiac arrest

Answer 4

one where the cardiac arrest is clearly caused by a cardiac problem, or there is no obvious cause.

Question 5

what is a secondary cardiac arrest

Answer 5

where there is an obvious non-cardiac cause, for example asthma, drowning, trauma or poisoning.

Question 6

what is rosc

Answer 6

the presence of a palpable pulse, or clear signs of spontaneous circulation (such as non-agonal breathing, normal ETCO2 or active movement) in the absence of CPR.

Question 7

Resuscitation should start unless there is a clear reason not to. Clear reasons for not starting resuscitation include:

Answer 7

• Signs of rigor mortis or post-mortem lividity.
• A clear advance directive not to receive resuscitation for cardiac arrest.
• Scenarios where resuscitation is futile or clearly not in the best interest of the patient. Examples include unwitnessed cardiac arrest with asystole as the initial rhythm, patients who are dying from cancer and patients with severe life-limiting disease.

Question 8

considerations when stopping a resuscitations

Answer 8

The cause of the cardiac arrest.
Whether or not the cardiac arrest was witnessed.
Whether or not there was bystander CPR.
The response time.
The initial rhythm.
The total estimated time in cardiac arrest.
Whether ROSC has occurred at any time.
The patient’s comorbidities.

Question 9

when is it usually appropriate to stop a resuscitation

Answer 9

20 minutes after the onset of resuscitation by ambulance personnel in poor prognosis scenarios.

40 minutes after the onset of resuscitation by ambulance personnel in good prognosis scenarios.

Earlier than described above, if it becomes clear that it was inappropriate to have commenced resuscitation, or the rhythm has deteriorated into asystole for more than a few minutes despite resuscitation.

Question 10

movement In arrest is indication of

Answer 10

good cerebral perfusion

Question 11

poor prognostic factors in arrest

Answer 11

Secondary cardiac arrest
Unwitnessed
No bystander CPR
Response time > 8 minutes
Initial rhythm asystole or PEA
Time in cardiac arrest > 30 minutes
Severe comorbidities
Living in aged residential care
Age > 85 years
ETCO2 < 15 mmHg or falling despite CPR

Question 12

good prognostic factors in arrest

Answer 12

Primary cardiac arrest
Witnessed
Bystander CPR
Response time < 8 minutes
Initial rhythm VT or VF
Time in cardiac arrest < 30 minutes
No severe comorbidities
Living independently
Age ≤ 85 years
ETCO2 > 25 mmHg with CPR

Question 13

ventilation ratio for adults

Answer 13

For an adult the CPR compression to ventilation ratio is 30:2. This ratio prioritises chest compressions on the basis that an adult is most likely to have had a primary cardiac arrest. If an adult has had a cardiac arrest secondary to asphyxiation or respiratory failure, alter the ratio to 15:2.

Question 14

paediatric ventilation ratio

Answer 14

For a child the CPR compression to ventilation ratio is 15:2 (exception – the ratio is 3:1 for neonates). The 15:2 ratio reduces the priority of chest compressions on the basis that a child is most likely to have had a cardiac arrest secondary to respiratory failure. If a child has had a primary cardiac arrest, alter the ratio to 30:2.

Question 15

what is End tidal CO2 (ETCO2)

Answer 15

is a marker of the blood flow being achieved during CPR. With good CPR an ETCO2 of greater than 20 mmHg should usually be achieved, unless there is an obstruction to blood flow, for example from a pulmonary embolus or tension pneumothorax.

Question 16

a sudden increase in ETC02 indicates

Answer 16

A sudden increase in ETCO2 is usually an indicator that ROSC has occurred.

Question 17

falling ETCO2 indicates

Answer 17

A falling ETCO2 despite CPR is a poor prognostic factor and must prompt a focus on ensuring high performance CPR is being provided and the ventilation rate is at or below 10/minute.

Question 18

circumstances where pads should immediately placed posterior and anterior

Answer 18

in morbidly obese and paediatric

Question 19

when in an arrrest to move too posterior/ anterior pads

Answer 19

Place pads in the anterior/posterior position for patients in persistent VF or VT, as this may help to terminate the rhythm by changing the direction of the electrical vector through the heart.

Question 20

use of adrenaline in patients with persistent VT and why

Answer 20

Some patients with persistent VF will have an inherited abnormality of the ion channels within their heart. In this setting repeated doses of adrenaline may reduce the likelihood of successful defibrillation.

Question 21

what is end tidal C02 and its normal range

Answer 21

The level of carbon dioxide that is released at the end of an exhaled breath is called End Tidal CO2 (ETCO2) , normal range in conscious person 35-45

Question 22

PEA is often secondary too….

Answer 22

a non-cardiac problem. The history immediately prior to cardiac arrest is very important in helping to determine what the cause may be.

Question 23

what is PEA

Answer 23

PEA is present when a patient in cardiac arrest has a rhythm that should be associated with cardiac output but is not. PEA is a clinical condition and not an abnormal rhythm.

Question 24

define refractory VF/VT

Answer 24

To be refractory to defibrillation there must be no ROSC between shocks. For example, if a patient receives three or more shocks but has achieved ROSC between shocks, this is recurrent VF/VT and not refractory VF/VT.

Question 25

outline the reversible causes of arrest

Answer 25

Hypoxia.
Hypothermia.
Hypovolaemia (including anaphylaxis).
Hyper/hypokalaemia (and other metabolic abnormalities).

Tension pneumothorax.
Tamponade (cardiac).
Toxins (poisoning).
Thrombosis (pulmonary and coronary).

Question 26

criteria for treating PEA assystole in arrest

Answer 26

It is common for PEA to degenerate into asystole with time. During this process slow (less than 30/minute) broad complexes may be present. This is treated as asystole and not PEA.

Question 27

deterioration from PEA to assystole indicates

Answer 27

poor prognosis

Question 28

management of a patient who remains in PEA despite resuscitation attempt

Answer 28

consider the possibility that there is cardiac output that cannot be detected clinically. In this setting stop chest compressions and observe the ETCO2 for one minute while ventilating at a rate of 10/minute:

If the ETCO2 rapidly falls to below 10 mmHg the patient is in cardiac arrest.

If the ETCO2 is maintained at or above 10 mmHg, the patient has low cardiac output and should be treated accordingly.

Question 29

prognosis for arrests initial rhythm asystole

Answer 29

Survival from cardiac arrest with an initial rhythm of asystole is rare and prolonged resuscitation attempts in this setting are usually inappropriate, particularly if the cardiac arrest was unwitnessed.