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Fellowship revision > cardiac arrest & intraop myocardial ischaemia > Flashcards

cardiac arrest & intraop myocardial ischaemia Flashcards

1
Q

What’s the adult rate of compressions for CPR?

A

100-120/minute

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2
Q

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

A

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

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3
Q

What’s the first step in any crisis?

A

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

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4
Q

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

A

> 10mmol/L

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5
Q

What should the sats be during post resus care?

A

94-98% (avoid hyperoxia)

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6
Q

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

A 
Hypoxia
Hypovolaemia
Hypothermia
Hypo/hyperkalemia
Thrombus
Toxins
Tamponade
Tension PTx
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7
Q

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

A

Sub-xyphoid

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

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8
Q

What’s the rate of ventilation during cardiac arrest?

A

10/minute

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9
Q

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

A

<5secs

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10
Q

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

A

200J, 360J, 4J/kg

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11
Q

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

A

immediately after

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12
Q

When are “stacked” shocks used? How many?

A

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)

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13
Q

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

A

1-2g IV over 3 mins

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14
Q

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

A

CaCl 10% IV 10mL

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15
Q

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

A

1-2mL/kg 8.4% IV

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16
Q

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

A

1mg IV

Every alternate cycle of CPR

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17
Q

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

A

Asystole w p waves present

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18
Q

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

A

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 ++

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19
Q

What is a strong differential with PEA in surgical setting?

Other considerations?

A

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

20
Q

What’s the goal for fluids during cardiac arrest?

A

Normovolaemia

Unless hypovolemic, avoid excessive fluid

21
Q

What’s an ideal confirmation when placing an airway?

A

Confirm correct placement w CO2 detection

22
Q

What are the steps for paediatric ALS?

A
  • 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)
23
Q

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

A

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

24
Q

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

A

Asystole or PEA

25
Q

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

A

Hypoxia, hypovolaemia & vagal stimulation

No- they are most commonly asphyxial arrests from progressive resp failure or shock

26
Q

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

A

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

27
Q

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

A

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

28
Q

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

A

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

29
Q

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

A

100microg/kg via endotracheal route

30
Q

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

A

“paediatric attenuated adult shock energy”

4J/kg

31
Q

What are some considerations during post-resus care?

A 
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
32
Q

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

A
  • apply supplemental oxygen- goal normal SpO2

- Ensure adequate ventilation, anaesthesia, analgesia

33
Q

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

A
  • 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

34
Q

What’s the dose of lignocaine for managing tachyarrhythmia?

A

1mg/kg

35
Q

How is GTN useful for myocardial ischemia?

A

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

36
Q

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

A

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

37
Q

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

A

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

38
Q

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

A

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

39
Q

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?

A

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

40
Q

Which IO routes could use?

A

humeral or tibial

41
Q

What are the goals of post-resus care?

A 
TTM (32-36deg)- AVOID hypothermia
SpO2 94-98%- avoid hyperoxaemia
avoid hyperglycaemia (treat if BGL >10mmol/L)
avoid hypercarbia
consider thrombolysis
42
Q

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

A

lignocaine 1mg/kg

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

43
Q

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

A

-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

44
Q

What’s the optimal CPR compression depth for paeds?

A

1/3 chest depth, allow complete recoil

45
Q

What’s EtCO2 useful for during arrest?

A

confirmation of airway placement, checking CPR effectiveness, monitoring CO

46
Q

What are causes of intraop myocardial ischemia?

A

ruptured atherosclerotic plaque or inadequate coronary perfusion pressure

Fellowship revision (78 decks)

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