Emergency Medicine - BLS, ACLS Flashcards

1
Q

Outline the Basic Life Support algorithm for adult cardiac arrest

A
  1. Check environment safety (e.g. for physical hazards)
  2. Immediate recognition and activation of emergency response system:
    → Call 999 if outside hospital
    → Call hospital arrest team if inside hospital
    → Should retrieve AED by 2nd rescuer (if witnessed) or by lone rescuer (if alone)
  3. Diagnose cardiac arrest within 10s
    → Unresponsive
    → No breathing or only gasping
    → No definite carotid pulse within 10s
  4. Start Basic Life Support
    → Recovery position if normal breathing
    → Ventilation alone if no breathing but normal pulse
    → Compression followed by ventilation at 30:2 (i.e. CAB approach) if no breathing + no pulse
  5. Early defibrillation (if indicated)
  6. Early advanced life support
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2
Q

Define high quality CPR

A

Chest compression:
□ Push fast: 100-120/min for both adults and kids
□ Push hard: 5-6cm
□ Allow complete recoil: ↓intrathoracic pressure to allow ↑VR
□ Avoid interruption: only acceptable for (1) rhythm analysis (2) rescue breaths (3) defibrillation
□ Switching of compressor: switching of provider every 2min to ensure chest compression quality

Ventilation:
□ Options:
→ Mouth-to-mouth ventilation
→ Mouth-to-mask ventilation
→ Self-inflating bag via bag-valve-mask or advanced airway
□ Rate: 30:2 unless advanced airway (then 10 breaths/min), Hyperventilation should be avoided

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3
Q

Treatment for shockable rhythm

  • Shockable rhythms
  • Energies/ types
  • Timing for successive shocks
  • Treatment
A

Shockable rhythms
→ VF: totally uncoordinated contraction of ventricles
→ Pulseless VT: LV rate too fast to pump blood effectively

Energy for cardiac defibrillation:
- 360J for monophasic; 120-200 for Biphasic
- Increase energy for subsequent shocks

Treatment timeline:
* Connect AED within 3-5min
* Give one shock ASAP
* Continue CPR immediately after shock for 2 min (or 5 cycles)
* Recheck rhythm every 2 minutes (not pulse)
* Secure IV/IO access without interrupting chest compression
* Give IV adrenaline 1mg every 3-5 minutes after 2nd shock
* Give IV amiodarone 300mg after 3rd shock, 150mg after 5th shock
* Consider IV lidocaine 1-1.5mg/kg if amiodarone unavailable
* Consider advanced airway
* Find reversible causes (5H 5T)

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4
Q

Define shockable and non-shockable rhythms

A

Shockable rhythms:
→ VF: totally uncoordinated contraction of ventricles
→ Pulseless VT: LV rate too fast to pump blood effectively

Non-shockable rhythms: more common in hospital settings
→ Asystole: flatline on ECG without any QRS complexes
→ Pulseless electrical activity (PEA): no pulse despite organized electrical activity (degenerates into asystole soon)

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5
Q

Airway protection and Advanced airway options for cardiac arrest

A

Airway protection
* Head tilt-chin lift, Jaw thrust
* Airway adjuncts: nasopharyngeal, oropharyngeal airway
* Advanced airway: Endotracheal intubation or supraglottic advanced airway

Breathing:
* Mouth to mouth or bag-valve-mask
* Deliver each rescue breath over 1 second
* Give a sufficient tidal volume to produce visible chest rise
* 30:2 (1 breath every 6 seconds (10 breaths per min)
* Avoid hyperventilation, keep continuous chest compressions

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6
Q

Assess return of spontaneous circulation

A

□ Breathing returns
□ Pulse with BP returns (in NIBP or arterial waveform)
□ Sudden rise in etCO2 to ~40mmHg
□ Should check and support vitals including SpO2 and BP

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7
Q

Define reversible causes of cardiac arrest

A
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8
Q

Advanced life support flowchart

A

Basic: Call for help, activate ERS

  1. Start CPR, give highest FiO2.
  2. Attach monitors or defibrillator: Separate into shockable and unshockable rhythm pathways
  3. Defibrillate and CPR, check pulse and rhythm every 2 minutes
  4. Add drug therapy if refractory
  5. Consider advanced airway
  6. Find reversible underlying cause: 5H and 5T
  7. Continue CPR for one more cycle after ROSC
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9
Q

Treatment for Non-shockable rhythm

A

Treatment:
* Perform high quality CPR ASAP
* Check rhythm/ pulse every 2 mintues
* Advanced airway
* Parenteral Access (IV/IO) w/o interrupting chest compression; try endotracheal or interosseous route if needed

Drug therapy:
* Adrenaline 1mg IV every 3-5 minutes
* Amiodarone 300mg for arrhythmia
* Lignocaine or MgSO4 if necessary

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10
Q

Adrenaline for non-shockable rhythm

MoA
Dosage
Timing
Effect

A

Mechanism:
α effect → constricts peripheral circulation → ↑↑aortic diastolic pressure (>40mmHg) → ↑coronary and cerebral perfusion pressure

Timing: ASAP if non-shockable; or after 2nd shock (but usu given asap) if shockable

Dose: 1mg (adults), 10μg/kg (paeds), higher dose if β-blocker or CCB overdose

Effect: improve ROSC rate but no difference in survival to discharge

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11
Q

Cardiac arrest

Causes
Definition

A

Cardiac arrest defined as sudden and complete loss of CO (life-threatening emergency!)

Causes:
□ Coronary artery disease (85%): myocardial ischaemia, AMI, prior MI with myocardial scarring
□ Structural heart disease (10%): AS, HCM, DCM, ARVD, congenital HD
□ Others (5%): LQTS, Brugada syndrome, WPWS, drug-induced TdP, severe electrolyte imbalance

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12
Q

Difference between children/ infant vs adult CPR

A

Children/ infants:
- If witnessed collapse, proceed with same BLS flow as adults
- If unwitnessed collapse and lone rescurer, give 2 minutes of CPR FIRST (c.f. leave to activate emergency response system and get AED before CPR for adults), then leave for ERS & AED, then return for CPR

Children/ infant:
- Compression-ventilation ratio without advanced airway: 30:2 if lone rescurer (same as adult), 15:2 if 2 or more rescurer

Children/infant:
- Chest compression depth: 1/3 AP diameter of chest, 5cm for children and 4cm for infants
- 2 fingers on chest or 2 thumb encircling chest for infant

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13
Q

Adjunctive treatments to CPR

Monitoring metrics

A

Airway and breathing management during CPR:
- Triple maneuver
- BVM for ventilation
- Airway adjuncts with BVM if possible
- Advanced airways (LMA, ETT) if refractory
- IPPV for prolonged ventilation
- High flow 100% O2 if possible

Continuous monitoring: capnography, arterial BP and SvO2

Ultrasound: help assess myocardial contractility and identify potentially treatable causes of cardiac arrest

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14
Q

Amiodarone for ACLS

MoA
Dose
Timing
Effect

A

Mechanism: affects Na, K, Ca channels with α- + β-blocking properties

Timing: usually after 3rd shock in VF or pulseless VT, give again after 5th shock if refractory

Dose: 300mg or 5mgkg in 20mL dextrose IV/IO bolus followed by one dose 150mg (5th shock)

Effect: termination of arrhythmia, ↓admission but does not improve long-term survival or survival with good neurological outcome

Alternatives: Lignocaine or MgSO4

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15
Q

List all drug options for ACLS

Indication and use

A

Adrenaline: ASAP for non-shockable, after 2nd shock if shockable

Amiodarone: after 3rd and 5th shock if shockable

Lignocaine: anti-arrhythmic alternative to amiodarone

Magnesium Sulphate: for shockable rhythm a/w Torsades de Pointes only

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16
Q

Advanced airway for ACLS
- Examples
- Indication and timing
- effect
- Confimation
- Advantage and disadvantage

A

Examples: SGA, ETT

Indication and timing: depends on scenario, change ventilation to 1 breath every 6 seconds when advanced airway is secured (c.f. 30:2 before)

Effect: No advantage in outcome compared to BVM

Advantage: free up hands of clinicians, allow IPPV and also facilitate post-arrest care
Disadvantage: risk of tube misplacement, requires elevation of bed, compromise CPR quality, tube obstruction or dislodgement

Confirmation by continuous waveform capnography

17
Q

List adjunct/ last-line treatments if routine ACLS fails

A

Mechanical chest compression device, eg. LUCAS machine

Extracorporeal CPR

Precordial thump: striking middle of sternum with ulnar aspect of fist → May rarely be effective in terminating ventricular arrhythmias

Steroid: methylprednisolone + vasopressin + adrenaline + post-ROSC hydrocortisone

Other options not routinely recommended:
(1) Na2CO3 – only for pre-existing metabolic acidosis, hyperK and TCA overdose
(2) Ca – only for hyperK, hypoCa, CCB overdose
(3) IV fluid – only if definitely hypovolemic

18
Q

Post-cardiac arrest care

  • Treatment for airway, breathing, circulation, neurological care
A

Airway: Definitive airway e.g. ETT

Breathing: Ventilation with waveform capnograph monitoring
- Oxygenation SpO2 ≥94%
- Normocarbia, peak etCO2 35-40mmHg

Circulation:
- Treat hypotension to above 90/65
- Use IV fluid + vasopressors ± inotropes (if cardiogenic)
- Monitor with 12-lead ECG after ROSC

Neurological:
- Targeted temperature management (32-36 degrees Celsius for 24 hrs) for all comatose pt with ROSC
- Manage seizures promptly using anticonvulsants
- Sedation/analgesia may be considered if mechanical ventilation or induced hypothermia

19
Q

(Symptomatic tachy and bradyarrhythmia treatment)

A

(TBC)