cardiac arrest & intraop myocardial ischaemia

Question 1

What’s the adult rate of compressions for CPR?

Answer 1

100-120/minute

Question 2

On the shockable cardiac arrest algorithm, after the first (300mg) amiodarone dose, what are subsequent doses of amiodarone?

Answer 2

150mg (? this may be old.. followed by an infusion of 900mg over 24hrs)

Question 3

What’s the first step in any crisis?

Answer 3

Simultaneous actions of communicating the problem (w appropriate level of urgency) to surgeons & team, calling for help & delegating tasks

Question 4

What level of hyperglycaemia should be treated during post-resus care?

Answer 4

> 10mmol/L

Question 5

What should the sats be during post resus care?

Answer 5

94-98% (avoid hyperoxia)

Question 6

What are the 4H’s 4HT’s reversible causes of cardiac arrest?

Answer 6

Hypoxia
Hypovolaemia
Hypothermia
Hypo/hyperkalemia
Thrombus
Toxins
Tamponade
Tension PTx

Question 7

What transthoracic echo view is useful during cardiac arrest? When should US (which may help diagnosis) be used?

Answer 7

Sub-xyphoid

During the brief pause for rhythm check (interruptions to CPR only <5secs)

Question 8

What’s the rate of ventilation during cardiac arrest?

Answer 8

10/minute

Question 9

What’s the goal maximum time for interruption between chest compressions?

Answer 9

<5secs

Question 10

What’s energy for biphasic shock during cardiac arrest? Monophasic? Kids?

Answer 10

200J, 360J, 4J/kg

Question 11

When should the drugs be given in cardiac arrest wrt defibrillation?

Answer 11

immediately after

Question 12

When are “stacked” shocks used? How many?

Answer 12

Up to 3 in a row, for witnessed VF/VT when defibrillator pads in situ (eg. after cardiac surg, in Cath lab, crit care environment)

Question 13

What’s the dose of Mg++ given for torsades or hypomagnesemia?

Answer 13

1-2g IV over 3 mins

Question 14

What’s the dose of Ca++ for hyperkalemia, hypocalcemia or OD of calcium channel blockers?

Answer 14

CaCl 10% IV 10mL

Question 15

What’s the dose of sodium bicarbonate for hyperkalemia or antidepressant overdose?

Answer 15

1-2mL/kg 8.4% IV

Question 16

How much adrenaline is given immediately (after commencing compressions) for non-shockable cardiac arrest? How often is it then given?

Answer 16

1mg IV

Every alternate cycle of CPR

Question 17

For what type of non-shockable cardiac arrest should pacing be considered?

Answer 17

Asystole w p waves present

Question 18

What are the roles which should be delegated in cardiac arrest?

Answer 18

Team leader
Compressions (alternate each rhythm check or as needed- quality of CPR vital)
Airway/ventilation
Defib & monitoring cardiac monitors
Time prompts & scribing
Drugs/access/samples/runner for 4Hs & 4T’s
-many hands useful ++

Question 19

What is a strong differential with PEA in surgical setting?

Other considerations?

Answer 19

hypovolaemia due to undiagnosed haemorrhage, esp w laparoscopic surgery
Other differentials include high spinal & anaphylaxis

Question 20

What’s the goal for fluids during cardiac arrest?

Answer 20

Normovolaemia

Unless hypovolemic, avoid excessive fluid

Question 21

What’s an ideal confirmation when placing an airway?

Answer 21

Confirm correct placement w CO2 detection

Question 22

What are the steps for paediatric ALS?

Answer 22

• Check pulse, oxygenation & confirm ecg rhythm
• Stop all vagal stimulation & switch to 100% O2
• Call for help, communicate & delegate
• Start CPR 100-120/min
• If VF/VT, give shock 4J/kg
• If asystole/PEA, given Adr 10mcg/kg IV
• Stop agent & consider intubation by most experienced operator (confirm w capnography) @ next rhythm check
• review 4Hs/Ts
• check rhythm/output @ CPR changeover
• consider TTE during brief (<5s) CPR interruption
• give Adr every 2nd cycle
• activate ECMO @ our institution (trained teams & protocols)

Question 23

What’s the dose of adrenaline for Paediatric ALS non-shockable? Frequency?

Answer 23

10mcg/kg- for PEA & asystole, give immediately, then every 2nd loop (every 2mins)

Question 24

With the exception of cardiac anaesthesia, what’s the rhythm for most anaesthetic-related paediatric cardiac arrests?

Answer 24

Asystole or PEA

Question 25

What are the 3 most frequent reversible causes of paediatric cardiac arrest? Are most paediatric arrests primary cardiac?

Answer 25

Hypoxia, hypovolaemia & vagal stimulation | No- they are most commonly asphyxial arrests from progressive resp failure or shock

Question 26

What's the rate of compressions & ventilations in paediatric cardiac arrest?

Answer 26

100-120/minute & 12-20 breaths/minute

Question 27

Is atropine recommended for paediatric cardiac arrest? If so, dose?

Answer 27

Not unless it's due to bradycardia ass'd w increased vagal tone, in which case, 0.02mg/kg

Question 28

What's given after the 2nd & 3rd shock in VF/VT arrest in paediatrics? How about non-shockable

Answer 28

adrenaline 10mcg/kg after the 2nd shock (then every 2nd loop), after the 3rd shock amiodarone 5mg/kg given For nonshockable, adrenaline 10mcg/kg immediately then every 2nd loop

Question 29

If the IV & IO routes are unsuccessful, how else can adrenaline be given & what dose?

Answer 29

100microg/kg via endotracheal route

Question 30

If using an AED in paediatric cardiac arrest, what special setting should be selected for children <8yo? What's the energy for paediatric shock?

Answer 30

"paediatric attenuated adult shock energy" | 4J/kg

Question 31

What are some considerations during post-resus care?

Answer 31

``` Consider thrombolysis Temperature management (consider 32-36 deg, AVOID hyperthermia, shivering) Avoid hyperglycaemia (treat if >10mmol/L) Aim SpO2 94-98%, avoiding hyperoxaemia Avoid hypercarbia ```

Question 32

:) What are the first 4 actions for managing myocardial ischemia intra-op?

Answer 32

- apply supplemental oxygen- goal normal SpO2 | - Ensure adequate ventilation, anaesthesia, analgesia

Question 33

:) If you've done the first 4 steps of management for intraop myocardial ischaemia, what are the next actions?

Answer 33

- Optimise myocardial O2 supply & minimise demand - Confirm ST changes (typically new horizontal or downsloping depressions) w expanded monitor view or 12-lead ecg - If ST elevation, consult cardiologist & surgeon immediately, have defibrillator readily accessible - If ST depression, aim to reduce O2 demand while increasing O2 supply by: - Ensuring maintain supplemental O2 (target normal SpO2 >=95%) - Control HR (aim 50-60bpm), deepen/analgese or if not improve, consider B blocker- correct arrhythmias- eg. could use lignocaine 1mg/kg IV for tachyarrhythmia - reduce shivering & fever- warm, paracetamol - afterload reduction- analgesia, anaesthesia, IV B blocker or consider nitroglycerin (titrate infusion 10-200microg/min; 0.1-3mcg/kg/min)- nitroglycerin dilates coronaries & decreases LV preload (ventilation)- balance against risk of hypoT & tachycardia (balance with alpha blocker) If the pt is hypERtensive: - cease stimulation (communicate w surgeon) - introduce a B-blocker - consider GTN infusion If the pt is hypOtensive (targets MAP 75, DBP 65) - correct any volume loss- check Hb, give blood if pt anaemic (target 90g/L in pts with ACS or signs of myocardial or other organ ischaemia, esp if ongoing bleeding) or crystalloid if need volume - treat any inappropriate vasodilation by adjusting anaes dose or carefully titrating vasoconstrictor to avoid adverse increased afterload - vasoplegia (eg. if septic or prior ACE-inhibitors) Rx with vasopressin (direct peripheral vasoconstrictor) or norepinephrine. Other considerations are: - invasive monitoring - echo to assess RWMAs, contractility & filling pressures - control filling pressure (CPP=ADP-LVEDP, avoid elevated LVEDP since the distal coronary pressures can be low++ w severe coronary artery obstruction) - support contractility- consider an inodilator or inotrope - once volume & BP corrected (maintain MAP >75mmHg to assist O2 supply), carefully titrate GTN infusion to dilate coronaries & reduce LVEDP - Consider anticoagulation, placement of IABP, PCI - manage of any electrolyte abnormalities - Aim SBP 100-120 & MAP >75 If myocardial ischemia persists, consider NSTE ACS & seek urgent cardio R/V

Question 34

What's the dose of lignocaine for managing tachyarrhythmia?

Answer 34

1mg/kg

Question 35

How is GTN useful for myocardial ischemia?

Answer 35

assists CPP by both: dilating coronaries and reducing LVEDP (reduces filling pressure as dilates venous capacitance vessels)

Question 36

What are the drug doses of sympathomimetic infusions for a 70kg pt?

Answer 36

Dobutamine: 250mg in 50mL 0.9% saline Adrenaline: 3mg in 50mL 0.9% saline NAdr: 4mg in 50mL 0.9% saline Commence @ 5mL/hr & titrate to response

Question 37

What are the doses of vasopressors/B-blockers/vasodilators to use in emergency?

Answer 37

Metoprolol: 2.5mg boluses Esmolol: 0.5mg/kg bolus, 50microg/kg/min infusion (titrate) Phenylephrine: 25-50microg bolus Metaraminol: 0.5-1mg bolus GTN: 50microg in 50mL 0.9% saline, commence @ 3-5mL/hr & titrate to response

Question 38

What are the steps for intra-op cardiac arrest (shockable)??

Answer 38

Check pt/monitors & confirm diagnosis Commence CPR 100-120/min & apply 100% O2 Call for help, communicate the emergency situation, delegate (as many hands as needed- team leader, CPR (& alternations every rhythm check), airway/ventilation, defibrillator, scribe/timekeeper, other jobs (eg. bloods, IVT) stop agent & secure airway (by most experienced operator, confirm w capnography) while applying pads deliver shock- back to CPR w minimal interruption (always <5secs) 4H's & 4T's every 2 mins- rhythm check+/- shock Adr 1mg after 2nd & immediately after every alternate shock Amiodarone 300mg IV after 3rd shock, 150mg IV after 5th shock Consider: activate Cath lab or ECMO

Question 39

What's the aim for diastolic BP & EtCO2 during compressions for both paeds & adults? What to do if spike in EtCO2 during compressions? What if EtCO2 drops to <10mmHg?

Answer 39

>20mmHg, >20mmHg. Continue compressions until end of cycle, quick rhythm check during next changeover Adjust technique & change compressor each cycle if EtCO2 <10mmHg

Question 40

Which IO routes could use?

Answer 40

humeral or tibial

Question 41

What are the goals of post-resus care?

Answer 41

``` TTM (32-36deg)- AVOID hypothermia SpO2 94-98%- avoid hyperoxaemia avoid hyperglycaemia (treat if BGL >10mmol/L) avoid hypercarbia consider thrombolysis ```

Question 42

What drug can be used in adult cardiac arrest if amiodarone n/a? how about paeds?

Answer 42

lignocaine 1mg/kg | This dose, followed by 20mcg/kg/min infusion, can be used for paeds

Question 43

What's the sequence of Mx for non-shockable cardiac arrest?

Answer 43

-Check monitors/confirm diagnosis- checking all (ECG, SpO2, ABP waveform, capnography) quickly distinguishes btwn artefact/calibration from asystole/PEA -Stop vagal stimulation & commence 100% O2 -Call for help, declare emergency, delegate (TL, compressions (alternate every rhythm check), airway/ventilation, scribe/timekeeper, drugs, bloods/runner- as many hands as need) Commence CPR 100-120/min & give 1mg Adr immediately Stop agent, consider intubation (by most experienced operator, confirm w capnography) @ next rhythm check 4H's, 4T's Consider TTE during brief interruption of CPR (<5secs) 1mg Adr IV every 2nd cycle If rhythm changes to VF/VT, shock & go to shockable algorithm consider pacing for asystole w p waves consider Cath lab or ECMO

Question 44

What's the optimal CPR compression depth for paeds?

Answer 44

1/3 chest depth, allow complete recoil

Question 45

What's EtCO2 useful for during arrest?

Answer 45

confirmation of airway placement, checking CPR effectiveness, monitoring CO

Question 46

What are causes of intraop myocardial ischemia?

Answer 46

ruptured atherosclerotic plaque or inadequate coronary perfusion pressure