ILS pt.2

Question 1

How does VT appear on ECG and rate seen?

Answer 1

Ventricular tachycardia appears on a rhythm strip as a regular broad complex tachycardia, typically between 100-300 bpm

Question 2

How does VF appear on ECG?

Answer 2

• Ventricular fibrillation appears on a rhythm strip as chaotic and disorganised electrical activity with no identifiable QRS complexes
• VF is initially coarse and will progress to fine VF and eventually asystole if prompt defibrillation is not performed.

Question 3

What is important to do when VT is seen?

Answer 3

It is important to check for a pulse when this rhythm is seen. VT with a pulse is managed according to the ALS tachycardia algorithm

Question 4

What can VT show up as?

Answer 4

• VT can be monomorphic or polymorphic depending on the morphology of the QRS complexes.
• Torsade de pointes is a subtype of polymorphic VT where the axis of electrical activity rotates in a sinusoidal pattern. Torsade de pointes is associated with a long QT interval, and these patients often have low potassium and/or magnesium levels, which require replacement.

Question 5

VT ECG

Answer 5

Question 6

What can affect pulse oximetry?

Answer 6

Nail polish

Question 7

What does pulse oximetry assess?

Answer 7

It assesses arterial oxygen saturation

Question 8

Is pulse oximetry reliable during CPR?

Answer 8

In cardiac arrest, the patient’s peripheral circulation will be poor, and the pulse oximeter may not be able to measure the peripheral oxygen saturation.

Question 9

Adrenaline dose in cardiac arrest?

Answer 9

1mg in 10 ml of 1:10000

Question 10

What does adrenaline do during CPR?

Answer 10

Adrenaline can increase coronary and cerebral perfusion pressures.

Question 11

Routes in which cardiac arrest drugs can be given?

Answer 11

IV or the IO route.

Question 12

What dose of adrenaline during anaphalaxis?

Answer 12

500mcg of 1:1000 IM

Question 13

What can the Glasgow coma score range and what does it cover?

Answer 13

3-15, covering eyes, verbal and motor responses to assess a patient’s level of consciousness.

Question 14

What can pupillary and corneal reflexes be used as indicators for in CPR?

Answer 14

• Do not use the size of the pupils during CPR and immediately after resuscitation to try and predict if the person will survive
• If a patient remains comatose and has fixed dilated pupils 3 days after successful resuscitation, this indicates a poor prognosis.

Question 15

Glucose level target

Answer 15

Between 4 and 10

Question 16

Lenght of time for chest compressions

Answer 16

2 minute cycle of chest compressions followed by shock

Question 17

What is PEA?

Answer 17

• PEA is a condition in which cardiac contractions are absent in the presence of coordinated electrical activity.
• PEA encompasses a number of organized cardiac rhythms, including supraventricular rhythms (sinus versus nonsinus) and ventricular rhythms (accelerated idioventricular or escape)

Question 18

Where do most out of hospital cardiac arrests occur?

Answer 18

Most cardiac arrests (72%) occur in the home or a workplace (15%)

Question 19

Age and cardiac arrest

Answer 19

• OHCA: Most cardiac arrests occur in adults (98%), amongst whom one third (33%) were aged 15-64 years.
• INCA: The average age of those sustaining an IHCA is 70 years. A quarter (26.7%) are aged 16-64 years.

Question 20

Cause of cardiac arrest out of hospital?

Answer 20

8 out of 10 OHCA are due to a cardiac cause.

Question 21

Initial rhythm in OHCA

Answer 21

The initial rhythm is shockable in approximately 1 in 4 OHCA (22-25%)

Question 22

IHCA vs OHCA: How many patients have return of circulation following cpr and how many survive to hospital discharge?

Answer 22

• A return of spontaneous circulation (ROSC) is achieved in approximately 30% of attempted resuscitations. In the Utstein comparator group (presumed cardiac origin, bystander witnessed, initially shockable rhythm) the rate of ROSC is 54%.
• When resuscitation is attempted, just fewer than one in ten (9%) people survive to hospital discharge following OHCA. In the Utstein comparator group the rate of survival to discharge is 29%.
• ROSC is achieved in half (53%) of those who are treated by a hospital’s resuscitation team for IHCA.
• A quarter (23.6%) of those who are treated by a hospital’s resuscitation team for IHCA survive to hospital discharge.
• More than four out of five (83%) who survive to hospital discharge have a favourable neurological outcome (Cerebral Performance Category 1 or 2).

Question 23

How many OHCA are witnessed by bystanders?

Answer 23

Half of all OHCA are witnessed by a bystander.

Question 24

How many bystanders attempt CPR in OHCA and how many use defibrillator?

Answer 24

• Bystander CPR is attempted in 7 out of 10 OHCA.
• Public access defibrillator use is reported as being used in less than 1 in 10 OHCA.

Question 25

Incidence of IHCA

Answer 25

1 to 1.5 per 1,000 hospital admissions per year

Question 26

Where do cardiac arrests occur in the hospital?

Answer 26

Most cardiac arrests (85%) occur on wards and in patients admitted to hospital for medical reasons.

Question 27

Initial rythm in IHCA

Answer 27

The initial rhythm is shockable in 17% of cardiac arrests, pulseless electrical activity 52%, asystole 20% and the remainder are unknown or undetermined.

Question 28

Average length of stay in hospital following cardiac arrest

Answer 28

ROSC is achieved in half (53%) of those who are treated by a hospital’s resuscitation team for IHCA.

Question 29

Survival in critical care following cardiac arrest

Answer 29

Approximately half of those admitted to critical care following OHCA survive to hospital discharge whilst one third of those admitted to critical care following IHCA survive to hospital discharge.
Two thirds of patients who survive are discharged home.

Question 30

Who is targeted temperature management indicated for and how is it achieved?

Answer 30

Targeted temperature management (TTM) is recommended for adults after cardiac arrest (OHCA or IHCA) with any initial rhythm who remain unresponsive after ROSC. 
- Maintain a target temperature between 32 and 36 °C for at least 24 hours, and avoid fever for at least 72 hours after ROSC.

Question 31

Poor outcome indicators in those who have rosc

Answer 31

In a comatose patient with a Glasgow Motor Score of M ≤ 3 at ≥ 72 h from ROSC, in the absence of confounders, poor outcome is likely when two or more listed predictors are present:
- no pupillary and corneal reflexes at ≥ 72 h
- bilaterally absent N20 SSEP wave at ≥ 24 h
- highly malignant EEG (suppressed background or burst suppression) at ≥ 24h
- NSE > 60 mcg L-1 at 48 h and/or 72 h
status myoclonus ≤ 72 h
- Diffuse and extensive anoxic injury on brain CT/MRI.

Question 32

How many breath per minute if adult patient not breathing?

Answer 32

10-12 breaths per minute

Question 33

In how many cardiac arrest is the initial rhythm shockable?

Answer 33

About 20%

Question 34

How much electricity to pass through defibrillator when shocking?

Answer 34

In cardiac arrests, at least 150J for the first shock

Question 35

What causes pulseless electrical activity in hypovolemia and how to manage it?

Answer 35

• Usually due to severe bleeding such as that might be caused by trauma, GI bleeding, or a rupture aortic aneurysm
• Restore intravascular volume rapidly with fluid and blood, <15 mins

Question 36

What are emergency situations where calcium chloride is administered?

Answer 36

Severe hyperkalemia, hypocalcemia, or calcium channel blocker overdose leading to cardiac arrest

Question 37

Cardiac arrest due to coronary thrombosis management

Answer 37

• If initial resuscitation with advanced life support is not succesful, in some hospitals, it is feasible to perform percutaneous coronary angiography and percutaneous coronary intervention during ongoing CPR
• This usually requires an automated mechanical chest compression device or heart-bypass type machine (extra-corporeal life support) to maintain a circulation during the procedure

Question 38

What is the commonest cause of thromboembolic or mechanical circulatory obstruction and how is it managed?

Answer 38

• Massive pulmonary embolism
• Consider giving thrombolytic drug immediately

Question 39

How is tension pneumothorax diagnosed?

Answer 39

• Either clinically: Decreased air entry, decreased expansion and hyperresonance to percussion on the affect affected side, tracheal deviation away from the affected side
• Focus ultrasound of the chest

Question 40

Tension pneumothorax management

Answer 40

Decompress rapidly by thoracostomy or needle thoracentesis and then insert a chest drain

Question 41

Cardiac tamponade suspicion in context of cardiac arrest and management

Answer 41

• Difficult to diagnose because the typical signs of distended jugular veins and hypotension cannot be assessed during cardiac arrest
• Cardiac arrest after penetrating chest trauma or after cardiac surgery should raise strong suspicion of tamponade
• Needle pericardiocentesis or resuscitative thoracotomy should be considered

Question 42

Duration of resuscitation attempt

Answer 42

• If attempts at obtaining ROSC are unsuccessful, the resuscitation team leader should discuss stopping CPR with the team
• The decision to stop CPR requires clinical judgement and a careful assessment of the likelihood of achieving ROSC and long term-survival
• If it was considered appropriate to start resuscitation, it is usually considered worthwhile continuing, as long as the patient remains in VF/pVT, or there is a potentially reversible cause that can be treated

Question 43

Signs of life during CPR

Answer 43

• Regular respiratory effort or movement
• Readings from patient monitors compatible with ROSC such as sudden increase in end-tidal CO2 or arterial blood pressure waveform