chapter 6: advanced life support algorithm Flashcards
what are the shockable rhythms
VF
Pulseless VT
What are the non-shockable rhythms
PEA
Asystole
What are the key basic interventions required in all ALS scenarios to improve survival
continuous high-quality chest compressions
early defibrillation
what are the initial steps in ALS algorithm for a patient that is unresponsive and not breathing
call 2222, adult cardiac arrest team
cpr 30:2
attach defibrillator ( one below right clavicle, other in v6 mid-axillary line)
count assistant to take over chest compressions so you can see the rhythm on the monitor
what are the next stages in a shockable rhythm
perform 1st shock ( typically 200J)
Immediately resume CPR for 2 mins
After shocking the patient once, they remain in VF, what’s next?
deliver 2nd shock (300J)
Immediately resume CPR for 2 mins
After 2 shocks patient is in VF, what now?
3rd shock at 360J
1mg IV adrenaline (1:10,000)
300mg IV amiodarone
continue CPR 2 mins
How frequently to you give adrenaline
every 3-5 mins ( every alternate cycle)
continue for as long as there’s a cardiac arrest
if organised electrical activity is seen compatible with cardiac output following a shock, what then?
assess for ROSC
- check for signs of life
- check for a central pulse
-assess end-tidal co2
if there is organised electrical activity but no ROSC ?
The patient is in PEA
Switch to non-shockable algorithm
continue CPR
If there is ROSC and electrical activity after treating VF?
Post- resus care
- use A-E approach
- aim for SpO2 94-98%
- aim for normal pCO2
-12 Lead ECG
-Treat cause
- targeted temperature management
how frequently is amiodarone given following VF/pVT
300mg after 3rd shock
further 150mg after 5 shocks
lidocaine 1mg/kg given if no amiodarone
when are precordial thumps considered
very low success rate for cardioversion of shockable rhythm
when awaiting defibrillator
what is done when the patient has a witnessed and monitored cardiac arrest with VF/pVT?
Give 3 quick successive shocks
check rhythm change, pulse ,signs of life
start compressions, continue CPR for 2 mins if 3rd shock unsuccessful
continue normal ALS algorithm as if 1 shock had been given
when is adrenaline and amiodarone given if a patient has stacked shocks due to witnessed VF/pVT
Adrenaline- assume as if stacked shocks are first shock so after 2 further shocks
amiodarone- give immediately ( during CPR) it should be given regardless after 3 shocks
how are non-shockable rhythms managed
-CPR 30:2
-Adrenaline 1mg IV/IO, continued every 2 cycles regardless of whether it changes to shockable rhythm
- check rhythm at 2 minutes
what is a high quality chest compression
5-6 cm depth
100-120 bpm
full recoil after each compression
change individual every 2 mins to avoid fatigue
what should be used to ventilate the patient if tracheal intubation is not possible
laryngeal mask airway
supraglottic airway
what rate should the lungs be ventilated at
10 breaths per min
how do you confirm that a patient has been intubated successfully
waveform capnography
what do you monitor during CPR
Clinical signs- breathing effort, movement, eye opening, pulse
monitor heart rhythm
end tidal co2
feedback/prompt devices
blood samples/analysis
invasive cardiovascular monitoring
echo/ultrasound
what does the end tidal co2 show
cardiac output and pulmonary blood flow
ventilation minute volume
usually low during cpr=low cardiac output
if normalises, patient may be making resp effort on their own
what is the role of waveform capnography in cpr
confirm tracheal tube placement
monitor ventilation rate
monitor the quality of chest compressions
identify ROSC during CPR
What should be done if there is a rise in end-tidal co2 during CPR
Withhold adrenaline until next rhythm check
if there’s cardiac arrest, then give adrenaline
what is important to know about giving drugs during CPR
Best to use peripheral cannula, as don’t need to stop CPR
Flush drug with 20ml fluid
raise arm for 10-20s
consider IO if IV difficult
what are the main sites for IO assess
proximal humerus
proximal tibia
distal tibia
contraindications to IO
trauma
infection
prosthesis at target site
IO access attempt in same limb <48 hr
failure to identify landmarks
how is positioning of IO confirmed
aspirate- see blood
absence of aspirate doesn’t imply failed attempt
main complications of IO
Extravasation into soft tissue
dislodgement of needle
compartment syndrome
fracture
pain related to infusion
fat emboli
infection
4T
thrombus
toxin
tension pneumothorax
tamponade
4H
Hypovolemia
hypoxia
hypothermia
metabolic - hyper/hypokalemia
hypoglycemia/hypocalcemia, acidemia
why is tamponade difficult to diagnose as a cause for cardiac arrest and how is it diagnosed
hypotension and distended neck veins can’t be assessed
diagnosed with focused cardiac ultrasound
what would cause you to think of cardiac tamponade as the cause of cardiac arrest
penetrating chest trauma
post cardiac surgery
when is resus attempt typically terminated
asystole >20mins, no reversible cause found
usually worth continuing if shockable
how is death diagnosed after unsuccessful resus
observe patient for 5 mins:
- No central pulse AND no heart sounds
AND 1 of :
- asystole on continuous ECG
- No pulsatile flow using direct intraarterial pressure monitoring
- no contractile activity using echo
any activity prompt further 5 mins
assess pupillary response, corneal reflex. motor response, supra-orbital pressure
