Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

APLS > Management of Cardiac Arrest > Flashcards

Management of Cardiac Arrest Flashcards

1
Q

When has cardiac arrest occured?

A

When there is no effective cardiac output.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the non-shockable and shockable rhythms?

How do you distinguish between them?

A

CARDIAC ARREST RHYTHMS

Dinstinguish with ECG

  • NON-shockable (A’a)
    • Asystole
    • PEA (Pulseless Electrical Activity)
  • SHOCKABLE (V’s - Very Shockable)
    • VF
    • pulseless VT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the most common arrest rhythm in children and why?

A

Asystole.

Because the response of the young heart to prolonged hypoxia is:

  • Acidosis
  • Progressive bradycardia –>
  • Asystole
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Describe the appearance of asystole on ECG. What needs to be checked when you see this appearance?

A

ASYSTOLE

ECG

  • almost straight line
  • +/- P-waves occasionally

CHECK:

  • ARTEFACT e.g. loose wire, disconnected electrode
  • Turn up the GAIN on ECG monitor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is PEA?

A

PEA

Pulseless Electrical Activity

  • ECG monitor - recognisable complexes that NORMALLY produce perfusion
  • BUT
    • NO signs of life
    • NO pulse
  • Often a pre-asystolic state
  • Treated in the same way as asystole (Non-shockable rhythm pathway)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What causes PEA (Pulseless Electrical Activity)? In what types of patients/ what situations may it occur?

A

PEA

Pulseless Electrical Activity

Causes

4 H’s & 4 T’s

May be due to an identifiable and reversible cause

  • Hypoxia - most common
  • Hypovolaemia - “
  • Hypocalcaemia e.g. calcium channel blocker overdose (& hypo- hyper- K+)
  • Hypothermia
  • Trauma incl. cardiac tamponade
  • Tension PTX
  • Thromboembolism (massive PE - rarely)
  • (Toxins)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe the APLS cardiac arrest algorithm, including Mx for shockable and non-shockable rhythms.

A

APLS

CARDIAC ARREST

START WITH SSS –> ABC

  1. SAFETY (to approach, free from danger)
  2. STIMULATE
    • Are you alright?
    • hold head in place + shake arm
    • NEVER shake an infant
    • NB pre-verbal/ scared children will not reply meaninfully (may make sound or open eyes)
  3. SHOUT for HELP!
  4. A
    • airway opening manoeuvres - tongue may fall back and obstruct pharynx
      • HEAD TILT CHIN LIFT (may need to part lips gently, do not press chin too hard)
        • infant: NEUTRAL
        • child: sniffing the morning air)
      • JAW THRUST (C-spine injury suspected)
      • NB rest elbows on same surface as child’s head
      • can add head tilt if no C-spine issue
      • even in trauma A takes priority - MILS by an assistant + increasing head tilt applied by 1st rescuer
    • SUCTION if trache
    • NB let child adopt any position they like if conscious - best at maintaining own airway
    • assess success of airway opening manoeuvres w/ look/ listen/ feel
  5. B
    • LOOK - movement of chest and abdo
      • LISTEN - for breath
        • FEEL - for breath
    • 5 RESCUE BREATHS (BVM or mouth to mouth + 100% High flow O2)
      • whilst maintaining head tilt chin lift
      • pinch nose shut in children
      • slow exhalation 1 second
      • not too vigorous - gastric inflation –> regurgitation –> aspiration
      • check that the chest rises
    • failure? –> readjust head tilt chin lift –> try jaw thrust –> consider foreign body
    • note any GAG/ COUGH response (signs of life)
    • INTUBATE ASAP! + monitor ETCO2
      • –> Continuous compressions
      • –> ventilation rate 10-12 breaths per min
      • person during compressions must assess adequacy of ventilation (feel for chest rise)
  6. C – not > 10 secs
    • Check for SIGNS of LIFE
      • NORMAL BREATHING (following on from B) - ineffective, gasping, obstructed, agonal breathing, do NOT count!
      • COUGHING/ GAGGING (in response to rescue breaths)
      • MOVEMENT (spontaneous)
    • Check PULSE
      • Child: neck (carotid), groin (femoral)
      • Infant: antecubital fossa (brachial), groin (femoral)
    • IV / IO access (IO when unable to cannulate w/i 1 min)
  7. YES signs of life –> RECOVERY position
  8. NO - CPR 15 chest compressions: 2 ventilations – IF:
    1. NO signs of life
    2. NO/ ? pulse (central)
    3. PULSE < 60 bpm (+ no signs of life)
      • NB ‘unnecessary’ chest compressions are almost NEVER damaging
      • If in doubt, start compressions
      • pulse present but apnoeic –> continue exhaled air resuscitation but no compressions
  9. Continue for 2 min
  10. [[Call emergency services]] <– OOH (if alone - NB take child with you to a phone! OR ask another bystander to call LAS whilst you start CPR)
  11. ASSESS RHYTHM - attach cardiac monitor/ defibrillator pads ASAP - hands off during rhythm assessment :
    • NON-SHOCKABLE = Asystole + PEA
      1. ADRENALINE
        • immediately –> every 4 mins (every 2 cycles of CPR)
        • 10 mcg/kg IV/IO
        • 0.1 ml/ kg of 1 : 10,000
      2. Saline flush 2-5 ml
      3. Consider 4 H’s + 4 T’s
      4. Check RHYTHM every 2 MINS or if SIGNS OF LIFE
        1. Asystole –> Check electrode position + contacts –> Cont. CPR
        2. Organised /Perfusable rhythm? –> Check SIGNS of LIFE & PULSE
      5. ROSC? –> post cardiac arrest Tx
        • Increase ventilation rate 12-24 (age)
    • SHOCKABLE = VF + Pulseless VT
      1. DC shock 4 J/kg
        • asynchronous
        • use adhesive defib pads / manual paddles (or AED OOH)
        • Resistance to defib
          • diff. paddle positions
          • different defibrillatpr
          • infant - lager paddles
      2. 2 min CPR (immediately, do NOT reassess rhythm or check for pulse)
      3. Consider 4 H’s & 4 T’s
      4. Assess RHYTHM
        • after every 2 MINS of CPR
        • if SIGNS OF LIFE:
          • normal breathing (regular resp effort)
          • cough/ gag
          • movement
          • eye opening
          • sudden increase in ETCO2
        1. ​VF/ pVT –> continue
        2. asystole/ PEA OR –> non-shockable algorithm
        3. organised electrical activity –> check for SIGNS of LIFE + PULSE
          • (NO PULSE or bpm < 60) + NO SIGNS OF LIFE –> cont asystole/ PEA algorithm
          • ROSC –> Post cardiac arrest Tx
      5. Ongoing shockable rhythm –> Repeat until 3rd shock given
      6. ADRENALINE
        • 10 mcg/ kg IV/IO
        • after 3rd shock –>
        • every alternate DC shock (every 4 mins)
      7. AMIODARONE
        • 5 mg/ kg IV/ IO
        • after 3rd + 5th shock ONLY
        • only give 2 boluses total (but continue to cycle through rest of algorithm if rhythm corrects then deteriorates again)
        • Infusion if more necessary
          • 300 mcg/ kg/ hr
          • max 1.5 mg/ kg/ hr
          • max 1.2 g in 24 hrs
        • NOT in the event of OD on antiarrhythmic - d/w poisons centre
        • unhelpful in hypothermia but can use
      8. ​or LIGNOCAINE (LIDOCAINE)
        • 1 mg/ kg IV/ IO
      9. MAGNESIUM 25-50 mg/ kg (max 2g)
        • low magnesium
        • polymorphic VT (torsades de pointes) - regardless of cause
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Do procedures in cardiac arrest algorithm occur sequentially?

A

NO. They occur simultaneously with coordination by the team leader.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How does adrenaline work in cardiac arrest management?

A

ADRENALINE

  • a-adrenergic action
    • Vasoconstriction - aorta
    • increased aortic diastolic pressure during chest compressions
    • increased coronary perfusion pressure
    • increased delivery of oxygenated blood to the heart
  • Inotropic action
    • increased cardiac muscle contractility
    • stimulates spontaneous contractions of the heart
    • increased vigour and intensity of ventricular fibrillation (in shockable rhythms) - increased success of defibrillation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the ONLY indications for stopping compressions during cardiac arrest Mx?

A

CARDIAC ARREST

ONLY stop compressions to:

  1. Check the rhythm
  2. Deliver Shock

=> Continue uninteruppted compressions at ALL other times

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe the reversible causes of cardiac arrest.

A

CARDIAC ARREST

REVERSIBLE CAUSES

4 H’S & 4 T’s

  • Hypoxia - most common
  • Hypovolaemia - “ (e.g. trauma, anaphylaxis, sepsis)
  • Hypothermia e.g. drowning
  • Hypo/ Hyperkalaemia, Hypocalcaemia, other metabolic abnormalities e.g. in renal failure
    • Calcium gluconate 10% - 0.3 ml / kg
    • WHEN:
      • HYPERkalaemia
      • HYPOcalcaemia
      • calcium channel blocker OD
  • Trauma incl. cardiac tampanade (PEA)
  • Toxins e.g. accidental, deliberate OD, iatrogenic
  • Thromboembolism e.g. massive PE (rare)
  • Tension PTX (PEA)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Is there any role for the use of atropine in the management non-shockable cardiac arrest?

A

ATROPINE

CARDIAC ARREST

NON-SHOCKABLE RHYTHM

NO.

Used in PERFUSING pts to combat BRADYCARDIA

due to excessive vagal tone.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Is there any role for the use of calcium in non-shockable cardiac arrest?

A

CALCIUM

CARDIAC ARREST

NON-SHOCKABLE RHYTHMS

  • NO evidenc of efficacy
  • Evidence of HARMFUL effects - involved in REPERFUSION injury
    • following ischaemia
    • reperfusion of ischaemic organs
    • calcium enters cells
    • accumulates in cytoplasmic reticulum
    • cell death
  • Use ONLY if DOCUMENTED:
    • HYPOcalcaemia
    • Calcium channel blocker OD
    • HYPERkalaemia
    • HYPERmagnasemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Is there any role for the use of alkalinising agents in non-shockable cardiac arrest?

A

ALKALINISING AGENTS e.g. bicarbonate

CARDIAC ARREST

NON-SHOCKABLE RHYTHM

  • Bicarbonate
    • 1 mmol / kg
    • 1 ml/ kg of an 8.4% solution
  • Routine use - NO benefit
  • ONLY use if:
    1. PROLONGED cardiac arrest - following
      • effective BLS (more effective at raising myocardial pH)
      • assisted ventilation with O2 (increases intracellular CO2)
    2. PROFOUND ACIDOSIS
      • which is likely to affect the action of adrenaline
      • NB children w/ asystole will be acidotic as usually due to resp. arrest/ shock (i.e inadequate circulation - anaerobic respiration)
    3. HYPERkalaemia
    4. TCA OD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What should be used to guide further alkalinising therapy if such agents are used and why?

A

ALKALINISING AGENTS

CARDIAC ARREST

NON-SHOCKABLE RHYTHM

GUIDE TO FURTHER Tx - USE:

  • MIXED or CENTRAL venous pH
  • WHY?— ARTERIAL pH does not correlate well with TISSUE pH in arrest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What important considerations must be made when administering alkalinising agents e.g. sodium bicarbonate?

A

SODIUM BICARBONATE ADMINISTRATION

IMPORTANT POINTS

  • do NOT give in the same line as CALCIUM –> precipitation
  • FLUSH with SALINE before ADRENALINE/ DOPAMINE (inactivated by bicarbonate)
17
Q

What are the most common causes of VF and pulseless VT?

A

VF and pulseless VT

SHOCKABLE RHYTHMS

Causes:

  • Hypothermia
  • Toxins - TCA poisoning
  • Cardiac disease (usually congenital)

NB:

  • more likely if sudden witnessed collapse
  • less common + causes more varied than in adults
18
Q

Why is it imperative to immediately resume CPR following DC shock in the management of cardiac arrest with shockable rhythm?

A

CARDIAC ARREST

SHOCKABLE RHYTHM

  • VITAL to immediately resume CPR after shock
  • do NOT reassess rhythm/ feel for a pulse
  • BECAUSE
    • there is a pause b/w successful defibrillation and the appearance of a rhythm on the monitor
    • stopping compressions reduces the chance of successful CPR if a 2nd shock is needed
    • no harm from ‘unnecessary’ compressions
19
Q

What is the appropriate size, placement & type of defibrillator for different age groups?

A

DEFIBRILLATION PADS

  • SIZE
    • < 10 kg = 4.5 cm
    • > 10 kg = 8-12 cm
  • PLACEMENT
    • Usual = anterolateral
      • apex, midaxillary line, 1 finger below L nipple
      • to the R of the sternum, 1 finger below R clavicle
    • Only adult pads/ too large for child = Anteroposterior
      • just to the LEFT of the lower part of the sternum
      • below the tip of the LEFT scapula
    • Neonate
      • appropriate size pad
      • pad too large –> manual defib paddles w/ paediatric attachments
  • TYPE
    • adhesive defibrillation pads
    • manual defibrillator pads
      • first choice for < 1 yo
      • can be adjusted to give correct dose
    • AED (automatic external defbrillator)
      • > 8 years: standard adult shock
      • < 8 years: attenuated paeds pads
      • NB high degree of sensitivity & specificity for detecting shockable rhythms in all age groups
      • use with paediatric attenuation pads/ leads (decrease energy level)
      • NB both monophasic & biphasic wave form defibrillators acceptable
  • Neonates
    1. Manual defibrillator (first choice)
    2. AED WITH dose attenuator
    3. AED w/o dose attenuator
20
Q

What is the purpose of (1) DC shock and (2) the use of anti-arrhythmic drug in the management of shockable cardiac arrest?

A

CARDIAC ARREST

SHOCKABLE RHYTHMS

  • DC shock
    • converts the heart back to a perfusing rhythm
  • Anti-arrhythmic drug e.g. amiodarone, lidocaine
    • stabilises the converted rhythm
21
Q

What is the role of capnography in cardiac arrest Mx? What are its limitations and what can it be affected by?

A

CAPNOGRAPHY

ETCO2 MONITORING

CARDIAC ARREST

  • Absence of waveform
    • tube misplacement/ displacement
    • very poor or absent pulm. perfusion (more likely)
    • < 2 kPa –> ? chest compression adequacy
  • Prence of exhaled CO2 encouraging evidence of
    • good CPR
    • ROSC (if sudden rise)
  • Affected by medications
    • Adrenaline - reduced ETCO2
    • Bicarbonate - increased ETCO2
22
Q

What type/ amount of O2 should be used in the management of cardiac arrest? How should this be monitored and why?

A

OXYGEN USE

CARDIAC ARREST

  • 100% high flow O2
  • Monitor with pulse ox
  • AFTER ROSC aim 94-98%
  • Hyperoxia can be detrimental to recovering tissues
23
Q

What is the role of active temperature regulation in cardiac arrest management and what effects does fluctuation in temperature have?

A

CARDIAC ARREST

TEMPERATURE MANAGEMENT

  • Therapeutic (mild) hypothermia
    • cool to 32- 34 degrees for at least 24 hrs post arrest
    • may be beneficial for neurological recover in newborns
    • avoid shivering - increases metabolic demand (sedation +/- neuromuscular blockade)
  • Normothermia - actively maintain
    • 36 - 37.5 degrees
    • avoid Hyperthermia - 10-13% increase in metabolic demand for each degree above normal
    • treat with active cooling
24
Q

What is the role of glycaemic control in cardiac arrest?

A

HYPOGLYCAEMIA

CARDIAC ARREST

  • All children can become hypoG when ill esp. infants (low reserves)
  • Correct hypoG
  • Avoid hyperG - causes osmotic diuresis
  • Both hypoG and hyperG - worse neuro outcome in animal studies
25
Q

How should newborns be resuscitated (using which algorithm)?

A

NEWBORN RESUSCITATION

  • Use the resuscitation protocol with which you are most familiar (newborn or infant & child protocol)
  • If suspected cardiac cause –> INFANT + CHILD PROTOCOL
26
Q

When should resuscitation efforts be stopped in cardiac arrest?

A

WHEN TO STOP RESUSCITATION

CARDIAC ARREST

  • No single predictor for when to stop
  • Unlikely to be successful if no ROSC with up to 20 mins of cumulative life support + absence of recurring/ refractory VF/pVT
  • Exceptions to the 20 min rule where prolonged CPR occasionally successful:
    • poisoning
    • hypothermia
  • NB d/w PICU/ toxicologist

APLS (25 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions