Chapter 6 ALS algorithm Flashcards
On the ALS support for adults algorithm, what is under “During CPR”
Airway adjuncts (ETT, LMA) Oxygen Waveform capnography IV/IO access Plan actions before interrupting chest compression
What drugs are standard given during ALS?
SHOCKABLE
- Adrenaline 1mg after 2nd shock (then ever 2nd loop)
- Amiodarone 300mg after 3 shocks
NON-SHOCKABLE
- Adrenaline 1mg immediately (then every 2nd loop)
What are the 4 H’s?
Hypoxia
Hypovolaemia
Hyper/hypokalaemia/metabolic disorders
Hypothermia/hyperthermia
What are the 4 T’s?
Tension pneumothorax
Tamponade
Toxins
Thrombosis (pulmonary, coronary)
What is needed for “Post-resuscitation Care” according to ALS algorithm
Re-evaluate ABCDE 12 lead ECG Treat precipitating cause Aim for SpO2 94 - 98%, normocapnea and normoglycaemia Targeted temperature management
What is the COACHED acronym for defibrillation stand for?
C: Continue CPR
O: Oxygen away (1 meter, can leave if airway secure)
A: All others away (visual check)
C: Charging (top clear, middle clear, bottom clear)
H: Hands off (state “I’m safe”)
E: Evaluate rhythm
D: Defibrillate or disarm
What do you do if you see organised electrical activity compatible with cardiac output during a rhythm check?
Dump charge
Seek evidence of ROSC (check for signs of life, central pulse, end-tidall CO2)
If no signs of ROSC, switch to non-shockable algorithm)
How many joules should be provided during a shock?
200J biphasic for first shock for
Can increase up to 360J biphasic for second
Why is it not needed to check for a pulse during every rhythm check?
1) Even if defibrillation has worked, it takes time for ROSC
2) Delay to continued CPR dangerous
3) If perfusing rhythm is restored, doing CPR won’t increase changes of VF recurring
4) In presence of post-shock asystole, chest compressions may usefully induce VF
When would you consider a second (150mg) dose of amiodarone?
When VT/VF persists or recurs after 5 shocks
What dose of lignocaine could be given if there was no amiodarone available
1mg/kg
Do not give if amiodarone has already been given
What is important to check in shock refractory VT/VF
The position and the contact of the pads
During a VT/VT arrest, you do a rhythm check and it is now organised electrical activity. What should you do?
Look for signs of life
Check for a pulse
Look for sudden increase end-tidal CO2
You are unsure of the rhythm is asystole or very fine VF. Do you deliver a shock?
Do not attempt defibrillation
Continuing effective CPR may increase the amplitude and frequency of the VF and improve changes of of subsequent successful defibrillation
When would you give 3 stacked shocks?
Witness and monitored VT/VF
Can be delivered within 20 seconds
Patient was well oxygenate and perfused prior to arrest
(3 shocks counts as 1st shock)
What would you do if you saw ventricular standstill (P waves over a flat trace)
Consider attempting cardiac pacing
What settings on the defibrillator would you check if the rhythm was asytole?
Ensure ECG pads are attached to the chest and correct monitoring mode is selected
Ensure gain setting is appropriate
Look for P waves and consider cardiac pacing
During a pause to provide ventilation, you see the rhythm is VT/VT. Should you provide a shock now?
No, wait till 2 minutes has elapsed
During the first rhythm check you see electrical activity that could be consistent with a cardiac output, but there is no pulse and you confirm PEA. Do you need to keep checking for a pulse each rhythm check?
No, assume PEA
You have inserted an LMA/ETT and are ventilating at a rate of 10 breaths per minute with continuous CPR, but you notice significant air leaking. What do you do?
Go back to 30:2 allowing a pause for two breaths
There are no studies that show tracheal intubation increases survival after cardiac arrest and incorrect placement is frequent if done by unskilled personnel during CPR. What is an alternative?
Supra-glottic airway
When may a brief pause be acceptable during ETT placement?
While passing the ETT between the vocal cords
How do you confirm ETT position placement is correct?
End tidal CO2
Does the pH of an arterial blood gas correlate well with tisssue pH?
No
But central venous blood provides better estimation
Can end tidal CO2 be used with a SGA?
Yes, but it’s more accurate with an ETT
You are not sure if you have ROSC (subtle signs, but not enough to stop CRP to check), the nurse is about to give adrenaline, what do you do?
Without adrenaline until cardiac arrest if confirmed at next rhythm check.
1mg of adrenaline in a patient with ROSC could be harmful
What are the benefit of end-tidal CO2 montioring?
1) ensuring ETT placement in trachea
2) monitoring ventilation and CPR (CO2 values are high in effective CPR)
3) identifying ROSC (sudden increase)
4) Prognostiation (low CO2 = worse prognosis)
What are the four phases of the capnography waveform?
1) flat part = end of inspiration
2) upstroke = start of expiration (alveoli air mixed with dead space)
3) plateau = expiration of alveoli air only
4) down stroke = start of inspiration
Failure to achieve and end-tidal co2 > 10mmHg after 20 minutes of CPR is associated with a poor prognosis. True/false?
True
What volume should drugs be flushed with?
20 ml. It may be easier to have continuously running IVF
What sites can be used for IO access?
Proxial tibial
Distal tibia
Proximal humerus
Distal femur
What are contraindications for an IO?
Trauma/fracture Infection Prosthesis IO at same site within 48 hours Failure to identify anatomical landmarks
How can you confirm successful IO placement
Aspiration, if blood drawn back, success.
However may not always bleed so identifying anatomical landmarks and feeling it pass through bone is important
What are the possible causes of hypovolaemia?
Haemorrhage - trauma or occult
Distributive shock (anaphylaxis, shock)
N&V, diarrhoea
In addition to H for hypo/hyperkalaemia, what else would you check when thinking of electorlyte/chemical disturbances?
Hypoglycaemia
Hypocalcaemia
Acidaemia
The patient has hyperkalaemia what specific doses would you give of the following:
Calcium chroride
Glucuse & insulin
Sodium bicarbonate
Calcium chloride 10ml of 10% Glucose 25g (50ml 50%) + 10 units novorapid Sodium bicarbonate 50mmol (if acidotic)
Consider dialysis on obtaining ROSC
What is the benefit and draw-back of calcium gluconate?
Benefit: less irritating to veins
Draw-back: 3 x less calcium than calcium chlroide
Needs hepatic metabolism to release calcium – this will be slowed in cardiac arrest or liver failure
What are the uses of IV calcium? Name 3
1) Hypocalcaemia
2) Hyperkalaemia
3) Calcium channel blocker overdose
What are the causes of acute hypocalcaemia?
Shock
Sepsis
Pancreatitis
Drug toxcities
You suspect the patient arrested due to hypokalaemia, the level is 2. How much potasium and how much magnesium shoud you give?
5mmol IV potassium bolus
10mmol/2.5g magnesium
Match the condition to the symptoms/signs:
1) Heat stroke
2) Heat exhaustion
3) Hyperthermia
a) Temperature > 40.6
b) condition of fatigue caused by prolonged exposure to high temperature +/- humitidy, exercise. Symptoms include: headache, nausea, vomiting, malaise. Often recover quickly. Core temp usually < 40
c) Systemic inflammatory reponse with core temperature >40.6, accompanied by altered mental status, collapse of varying levels of organ dysfunction. Sweating often ceases (though may be profuse), hot dry skin
1 = c 2 = b 3 = a
Dantrolene is used in maligant hyperthermia due to anaesthetic agents. Can it be used in malignant hyperthermia from other drugs? Which ones?
Ecstacy
Amphetamines
You presume a cardiac arrest is caused by a masissive PE and give a fibrinolytic agent. How long should you continue CPR for?
At least 30 minutes, up to 60 -90 minutes. Survival with good neurological outcome has been reported in excess of 60 minutes CPR.
When would you consider using a fibrinolytic agent in an arrest?
Coronary thrombosis
Pulmonary embolism
When would you consider transfer with ongoing CPR in a patient with suspected coronary thrombosis? What factors a favour a good outcome. Name 3.
Witnessed cardiac arrest
Bystander CPR
Intermittent ROSC
Initial shockable rhythm
Name 3 conditions that increase the risk of tension pneumothorax. Consider the categories trauma, iatrogenic, diseaeses
Trauma:
- thoracic trauma (penetrating or blunt)
- pulmonary barotrauma
Iatrogenic -recent thoracic procedures:
- insertion temporary pacing wire
- existing chest drain (misplaced or blocked)
- premanent pacemakrer/ICD insertion
- transthoracic needle aspiration or biopsy
- subclavian or jugualar vein catherterisation
- thoracocentesis
- closed pleural biopsy
Diseases
- asthma
- COPD
In an awake patient with tension pneumothorax the signs and symptoms are more obvious ( chest pain, trachynpoea/air hunger, terminal decreasing RR, hypoxia, tachycardia, hypotension, altered GCS).
In an intubated patient, what would point to the diagnosis of tension pneumothorax?
Progression may be rapid High ventilation pressure Hypoxia Hypotension Tachycardia
Abnormal chest rise and fall on affected side
Decreased breath sounds on affected side
Hyper-expanded chest, increased percussion note
Tracheal deviation away from affected side (late sign)
What investigations will help to investigate for tension pneumthorax (stable patient)
CXR
USS
What are the complications/causes of failure of emergency needle thoracocentesis for a pneumothorax?
Obstruction by:
- blood
- tissue
- cannula kinking/compressed
Missing a localised tension pneumothorax (needle too short)
Inability to drain large air leak
Moving, dislodging, falling out
Requirement for repeated needle decompression
What location and what needle would you use emergency needle thoracocentesis for a tension pneumothorax?
14 g LONG needle
2nd intercostal space mid-clavicular line
Name 3 situations when cardiac tamponade may be a likely differential
Thoracic trauma (blunt/penetrating) Recent thoracic/cardiac surgery Insertion of central lines Temporary pacing wire Recent angiography/PCI Recent myocardial infarction Recent permannet pacemaker/defibrilator insertion Thoracic neoplasm or mediastinal radiation therapy Known pericardial effusion Renal failure (uraemia) Pericarditis Infectious disease e.g tuberculosis
What is Beck’s triad for cardiac tamponade?
Elevated JVP
Muffled heart sounds
Hypotensoin (with narrow pulse pressure)
May only be breifly present before cardiac arrest
What are the signs and symptoms of cardiac tamponade?
Tachypnoea Dyspnoea Pulsus paradoxus Low voltage QRS or electrical alternans Kussmauls sign (rise of JVP with inspiration)
A patient has had cardiothoraic surgery and arrested. You are wanting to do re-sternotomy. Should you withold CPR while preparing for this?
No
In patient with cardiothoracic surgery, when should re-sternotomy be considered?
Cariac arrest
In appropriately staff ICU
Poor outcomes outside of this setting
A patient has cardiac tamponade and are hypotensive. Should you give fluid while preparing for pericardiocentesis?
Yes
You need to do a pericariocentesis for cardiac tamponade but do not has access to an USS. What other monitoring can help you?
Telemetry
Watch for arrhythmias indicating needle is contacting myocardium
What the most common complications of pericardiocentesis?
Cardiac dysrhythmia Cardiac puncture Pneumothorax Coronary vessel injury Diaphragmatic injury Death
Name the antidotes to the following drugs Digoxin Opioids Benzodiazapines Cyanide Tricyclic antidepressant Amphetamines
Digoxin specific antibody (digibind) 38mg (one vial) over 30 minutes
Naloxone 100mcg to 2mg
Flumazenil 100 -200mcg
Hydroxycobalmin 5mg up to 15mg
Sodium bicarbonate 50 - 150 mmol
Benzodiazapines, dantrolene 2.5mg/kg if malignant hyperthermia
How can amphetamines cause a cardiac arrest?
Induce myocardial ischaemia/necrosis due to coronary artery spasm
Directly induced myocardial necrosis
Massive efflux of K+ due to necrosis inducing arrhythmia
Where should your probe be and when should you look for a pericarial effusion during CPR?
Subxiphoid
Just prior to rhythm check (brief pause in chest compressions)
When would you consider prolonged CPR?
Patient remains in VT/VF
Identified/treating reversible cause
A patient has been a asystole for more than 20 minutes with no reversible casue found. Should you continue CRP?
Probably not
How long should you wait to confirm death after CPR has ceased?
5 minutes
