Life Support

Question 1

For adult basic life support, how do you assess the unconscious patient?

Answer 1

DRS ABCD

• Danger → check around pt + environment
• Response → question, shake + command
• Shout → ‘help, help help’
• Airway → head-tilt/chin-lift or jaw thrust, look/remove obstructions
• Breathing → assess for up to 10s by listening + feeling w/ ear, while watching chest movements and palpating carotid
• CPR + Call ambulance → if not breathing, start CPR; ask helper to call 999, if no helpers then you must call 999
• Defibrilator → find AED, attach pads to pt’s bare chest, continue CPR while attaching electrodes, follow prompts

Question 2

What is involved in CPR for BLS?

Answer 2

• 30:2 chest compressions to resuce breaths
• 30 chest compressions → perform at 100-120/min, depth 5-6cm
• 2 rescue breaths

Question 3

Adult Advanced Life Support (ALS) follows the same DRS ABCD assessment as BLS. What is the algorithm for ALS?

Answer 3

Question 4

How are chest compressions given in ALS?

Answer 4

• 30:2 chest compressions to ventilations (until airway secure)
• Perform at rate 100-120/min (ie 2/s)
• Depth of 5-6cm

Question 5

When should chest compressions be stopped?

Answer 5

• 5 second rhythm checks
• Electrical shocks
• When giving 2 rescue breaths (before airway is secure)
• Ask person doing compressions to tell airway person each time 30 are complete
• Switch CPR provider during rhythm check every 2 mins (or earlier if they tire)

Question 6

When should chest compressions be continuous?

Answer 6

Once the airway is secured with either a supraglottic airway or endotracheal tube

Question 7

How do you set up defibrilation?

Answer 7

• Work around person performing compressions
• Place two pads: under right clavicle + over cardiac apex
• Shave/dry chest
• Leave jewellery on but move it out of way
• If pacemaker → move pads >8cm away
• Connect pads to defib and set monitoring trace to ‘pads’
• Delegate someone to manage timing + say when 2 min cycles are up, remember cycle number
• Cycle 1 starts when defib is connected

Question 8

When should rhythm checks be performed?

Answer 8

• Perform rhythm check +/- shock every 2 mins
• When pads in place and defib on, ask for CPR to be stopped for 5s rhythm check
• Determine if rhythm shockable vs non-shockable
• If rhythm compatible w/ pulse during check, also feel for central pulse and stop compressions if present
• Then immediately continue CPR

Question 9

What are the shockable vs non-shockable rhythms?

Answer 9

• Shockable → VF + pulseless VT
• Non-shockable → PEA + asystole

Question 10

What happens next if a shockable rhythm is identified?

Answer 10

• Select correct energy level for device, if unsure then give highest energy level shock
• Ask for O₂ to be removed
• Everyone (except compression person) to move away
• Compressions continue until you alert them to move away
• Charge defib and then move hand away from machine
• Once charged, ask compressions to stop and shout “everybody stand clear”
• Check area is clear (incl oxygen)
• Deliver shock by pressing ‘shock’
• Immediately restart CPR

Question 11

What are management options for airway?

Answer 11

• Face mask w/ bag (30:2) → consider also placing oropharyngeal / nasopharyngeal airway under mask if struggling
• Supraglottic airway (laryngeal mask, i-gel) → once placed, ventilate every 6 seconds with continuous compressions, providing seal is good
• Intubation w/ ET tube (gold standard) → once placed, ventilate every 6 seconds w/ continuous compressions
• Attach 15L/min O2
• Attach end-tidal CO2 monitoring (i-gel or ET)
• Avoid hyperventilation

Question 12

ALS: When is IV access needed?

Answer 12

• Obtain IV access + drugs ready
• After 2 IV attempts → intraosseous access via head of humerus / tibial tuberosity
• Take bloods from cannula → VBG, FBC, U+Es, Mg, G+S
• Give IV fluids

Question 13

Which drugs are important to give during CPR?

Answer 13

• Adrenaline 1mg IV (10ml of 1:10,000)
  
  • Shockable → give after 3^rd shock (during CPR) + flush
  • Non-shockable → give as soon as IV established + flush
  • causes peripheral vasoconstriction + maximises cardiac blood flow
  • repeat during every other CPR cycle thereafter
• Amiodarone 300mg IV
  
  • if shockable rhythm only
  • give once after 3 shocks have been administered (during CPR)
  • is given to stabilise myocardium in VF and T
  • usually single dose, but further 150mg bolus may be given

Question 14

What are the reversible causes of cardiac arrest?

Answer 14

• 4 Hs + 4 Ts

Question 15

ABCDE is used for the critically ill patients.

What is involved in assessing‘A’?

Answer 15

• If patient can talk → patent
• Not patent if:
  
  • secretions
  • aspirated
  • snoring / GCS < 8
• Look inside mouth - any obstructions?

Question 16

How can you manage airway?

Answer 16

• Consider → suction, airway opening manouvres (jaw thrust, head-tilt/chin-lift), oropharyngeal/nasopharyngeal airways, intubation if GCS < 8
• Cricothyroidotomy required in upper airway obstruction where intubation not possible
• Treat any evident causes (eg. anaphylaxis, foreign body)

Question 17

How do you assess‘B’?

Answer 17

• Pulse oximetry
• RR
• Chest exam → cyanosis, tracheal deviation, chest inspection, accessory muscles, expansion, percussion, auscultation
• Calves
• Send for → ABG + CXR

Question 18

How do you manage breathing?

Answer 18

• 15 L/min O₂ via non-rebreathe mask
• Take care in COPD unless in resp distress/critically unwell + need high flow O₂, start at 24-28% ie 2-4L venturi, aim for sats 88-92%
• Consider NIV or invasive ventilation if hypoxic or hypercapnic despite max therapy
• If resp effort inadequate, must be supported → ventilate with mask
• Treat evident causes (pneumothorax, astham/COPD exacerbation, opiate OD, PE)

Question 19

How do you assess‘C’ (circulation)?

Answer 19

• Cap refill (central)
• Pulse rate, rhythm + volume
• Blood pressure (look at trend)
• Temperature
• Auscultate heart, check JVP + look for signs of fluid overload
• Assess fluid balance + organ perfusion → catheter
• Place wide-bore IV cannula + take bloods, VBG first if required
• Apply 3-lead cardiac monitoring + ECG

Question 20

Circulation: How do you manage the hypotensive patient?

Answer 20

• Lay supine and elevate legs
• Fluid challenge = 500ml 0.9% saline/Hartmann’s solution STAT and monitor by HR, BP + urine output
• Take care if significant heart failure history (use 250ml challenge)

Question 21

Circulation: How do you manage the patient in shock?

Answer 21

• 2 large bore IV cannulas
• Fluid challenge → 1L 0.9% saline/Hartmann’s solution STAT
• Replace blood w/ blood (can give O neg or typing takes 15 mins)
• If massive blood loss → call 2222/lab and activate massive blood loss protocol to get packed red cells + FFP +/- platelets

Question 22

What is further management of ‘C’ (circulation)?

Answer 22

• Respond fully → give maintenance fluids
• Responds but BP falls again → more fluids (adequate resuscitation depends on patient and degree of deficit but is usually 20-30ml/kg given quickly)
• No response → pt is either fluid overloaded (don’t give any more fluids) or v depleted (give lots of fluids)

Treat underlying causes (eg. arrhythmia, sepsis, bleeding)

Question 23

Circulation: What does the patient need if they are hypotensive and overloaded?

Answer 23

Inotropes

Question 24

Circulation: What does the patient need if they are still hypotensive despite adequate fluid resuscitation (30ml/kg)?

Answer 24

Vasopressors

Question 25

How do you assess‘D’ (disability)?

Answer 25

• Glucose
• GCS / AVPU
• Pupils reactivity and symmetry
• Pain assessment
• CT brain if intracerebral pathology

Question 26

How can you manage‘D’ (disability)?

Answer 26

• Correct glucose
• Give analgesia if pain (eg. morphine 10mg in 10ml slow IV injection titrated to pain)
• Look for + treat causes of low GCS (eg. morphine/sedative use, focal neurology to suggest intracranial pathology, hypercapnia, post-ictal)

Question 27

What can be done in ‘E’ (everything else)?

Answer 27

• Exposure → bleeds, rashes, injuries, drain/catheter putput, lines
• Examine abdomen
• Focussed exam of relevant systems
• Manage any other abnormal findings as appropriate

Question 28

BOXES

ABCDE: Which investigations can be done to find causes of acute illness?

Answer 28

• Bloods → ABG if low sats/GCS, venous bloods (G+S, FBC, U+Es, CRP, LFTs +/- amylase, clotting, troponin, VBG etc), capillary glucose, blood cultures (if pyrexial)
• Orifice tests → urine dip, urine/sputum/faeces culture, urine b-hCG
• X-rays/imaging → portable CXR, CT brain (if neurology or low GCS in absence of other causes)
• ECG → +/- 3-lead cardiac monitoring
• Special tests → depending on likely cause