chapter 6: advanced life support algorithm

Question 1

what are the shockable rhythms

Answer 1

VF
Pulseless VT

Question 2

What are the non-shockable rhythms

Answer 2

PEA
Asystole

Question 3

What are the key basic interventions required in all ALS scenarios to improve survival

Answer 3

continuous high-quality chest compressions
early defibrillation

Question 4

what are the initial steps in ALS algorithm for a patient that is unresponsive and not breathing

Answer 4

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

Question 5

what are the next stages in a shockable rhythm

Answer 5

perform 1st shock ( typically 200J)
Immediately resume CPR for 2 mins

Question 6

After shocking the patient once, they remain in VF, what’s next?

Answer 6

deliver 2nd shock (300J)
Immediately resume CPR for 2 mins

Question 7

After 2 shocks patient is in VF, what now?

Answer 7

3rd shock at 360J
1mg IV adrenaline (1:10,000)
300mg IV amiodarone
continue CPR 2 mins

Question 8

How frequently to you give adrenaline

Answer 8

every 3-5 mins ( every alternate cycle)
continue for as long as there’s a cardiac arrest

Question 9

if organised electrical activity is seen compatible with cardiac output following a shock, what then?

Answer 9

assess for ROSC
- check for signs of life
- check for a central pulse
-assess end-tidal co2

Question 10

if there is organised electrical activity but no ROSC ?

Answer 10

The patient is in PEA
Switch to non-shockable algorithm
continue CPR

Question 11

If there is ROSC and electrical activity after treating VF?

Answer 11

Post- resus care
- use A-E approach
- aim for SpO2 94-98%
- aim for normal pCO2
-12 Lead ECG
-Treat cause
- targeted temperature management

Question 12

how frequently is amiodarone given following VF/pVT

Answer 12

300mg after 3rd shock
further 150mg after 5 shocks
lidocaine 1mg/kg given if no amiodarone

Question 13

when are precordial thumps considered

Answer 13

very low success rate for cardioversion of shockable rhythm
when awaiting defibrillator

Question 14

what is done when the patient has a witnessed and monitored cardiac arrest with VF/pVT?

Answer 14

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

Question 15

when is adrenaline and amiodarone given if a patient has stacked shocks due to witnessed VF/pVT

Answer 15

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

Question 16

how are non-shockable rhythms managed

Answer 16

-CPR 30:2
-Adrenaline 1mg IV/IO, continued every 2 cycles regardless of whether it changes to shockable rhythm
- check rhythm at 2 minutes

Question 17

what is a high quality chest compression

Answer 17

5-6 cm depth
100-120 bpm
full recoil after each compression
change individual every 2 mins to avoid fatigue

Question 18

what should be used to ventilate the patient if tracheal intubation is not possible

Answer 18

laryngeal mask airway
supraglottic airway

Question 19

what rate should the lungs be ventilated at

Answer 19

10 breaths per min

Question 20

how do you confirm that a patient has been intubated successfully

Answer 20

waveform capnography

Question 21

what do you monitor during CPR

Answer 21

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

Question 22

what does the end tidal co2 show

Answer 22

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

Question 23

what is the role of waveform capnography in cpr

Answer 23

confirm tracheal tube placement
monitor ventilation rate
monitor the quality of chest compressions
identify ROSC during CPR

Question 24

What should be done if there is a rise in end-tidal co2 during CPR

Answer 24

Withhold adrenaline until next rhythm check
if there’s cardiac arrest, then give adrenaline

Question 25

what is important to know about giving drugs during CPR

Answer 25

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

Question 26

what are the main sites for IO assess

Answer 26

proximal humerus
proximal tibia
distal tibia

Question 27

contraindications to IO

Answer 27

trauma
infection
prosthesis at target site
IO access attempt in same limb <48 hr
failure to identify landmarks

Question 28

how is positioning of IO confirmed

Answer 28

aspirate- see blood
absence of aspirate doesn’t imply failed attempt

Question 29

main complications of IO

Answer 29

Extravasation into soft tissue
dislodgement of needle
compartment syndrome
fracture
pain related to infusion
fat emboli
infection

Question 30

4T

Answer 30

thrombus
toxin
tension pneumothorax
tamponade

Question 31

4H

Answer 31

Hypovolemia
hypoxia
hypothermia
metabolic - hyper/hypokalemia
hypoglycemia/hypocalcemia, acidemia

Question 32

why is tamponade difficult to diagnose as a cause for cardiac arrest and how is it diagnosed

Answer 32

hypotension and distended neck veins can’t be assessed
diagnosed with focused cardiac ultrasound

Question 33

what would cause you to think of cardiac tamponade as the cause of cardiac arrest

Answer 33

penetrating chest trauma
post cardiac surgery

Question 34

when is resus attempt typically terminated

Answer 34

asystole >20mins, no reversible cause found
usually worth continuing if shockable

Question 35

how is death diagnosed after unsuccessful resus

Answer 35

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