Medical Arrest Flashcards
ALS modifications in HYPOTHERMIA:
REWARMING TRUMPS EVERYTHING
Avoid excessive movement (VF trigger)
Act on ABG as it is- do not correct gases for temp, machine warms blood
Prolonged until 32deg for 30mins- not dead until warm and dead
Pulse check for full minute- may need help of cardiac USS, Doppler
Initial 3x stacked shocks, then defer rest until 30deg. Don’t pace until 30deg.
No drugs until 30deg, ineffective, accumulation.
Then, double the dose interval until 34deg
Don’t correct biochem- hyperglyc, K+, acidosis, coagulopathy. WARMING IS TREATMENT.
Drugs via ETT:
Use 3-10x IV dose
Dilute to 10ml in saline
Squirt down ETT
NAVEL
Naloxone
Atropine
Valium
Epinephrine (adrenaline)
Lignocaine
Give a few forceful breaths post
Chain of Survival in cardiac arrest:
Components
Survival rates
1-Medical assistance
2- BLS/CPR
3- Defib
4- Advanced care
When all immediately: 67% survival overall
Survival declines 5% every minute without these
(BLS 2, defib 1, ALS 2)
ECG in VF:
Chaotic
Varying amplitudes
No identifiable morphology
150-500 bpm
when very very fast, trace is fine.. may resemble asystole!
ECG in pulseless VT:
Regular, broad
Uniform (monomorphic) OR Polymorphic OR Torsades
Rate >100, 150
+- ‘VT features’
A Northwest axis
B Broad >200ms (1large)
C Concordance, Capture beats
D Dissociation
E Early part QRS - delayed R wave upstroke
F Fusion beats
C- Defib pad placement and considerations:
Anteroapical
OR
AP
—> Equally effective for Defib
—> AL more accurate rhythm trace
Avoid over:
- Medication patch
- ECG dots
- Large breast
- PPM
Avoid air pockets (incl hair)
Compatible with PPM
C- Choice of defibrillation in arrest:
Biphasic (all modern)
UNsynchronised (VT, VF)
200J adults, 4J/kg (child)
C- ‘COACHED’ in ALS:
At 2mins:
Compressions continue
Oxygen away
All else clear
Charging
Hands off incl compressions
Evaluate rhythm
—> if organised, do pulse check
Dump
If organised and pulse, or,
nonshockable
OR, Defib
+- restart CPR
+- drugs
C- Utility of 3 stacked shocks:
Only when:
Witnessed
Delay <10sec to first shock, and between shocks
ie. only really in cath lab, or in cardiac OT
B- Ventilation technique in ALS:
100% O2
Rate 10 bpm
400-500ml tidal volume, 5-6 ml/kg
Too much inflation = hyperinflation and no ROSC
A- Choice of airway in ALS
Advanced airway = no further interruption to compressions
ETT, LMA equal
Don’t interrupt CPR for >20secs to insert
Adult ALS algorithm
4 Hs and 4 Ts:
The potentially reversible causes:
Hypoxia
Hypovolaemia
Hyper/o thermia
Hyper/o kalaemia (+other metabolic)
Thrombus (MI, PE)
Tension PTx
Tamponade
Toxins
CPR technique, rate and ratios by age:
Adult
30:2
C: 100
B: 4-500ml, rate 8-10
Child and Infant
15:2
C: 100-120
Smaller child: palm of one hand
B: 5-6ml/kg, rate 10-25
Neonate
3:1
C: 120
Thumbs encircling, or, 2 finger
B: 5-6ml/kg, rate 40-60
D- Adrenaline in ALS
1mg IV push
1ml 1:1000, or, 10ml 1:10,000- both are fine
Give:
- Nonshockable: immediately, then every 2nd cycle
- Shockable: after 2nd shock, then every 2nd cycle
D- Amiodarone in ALS
Theory is for refractory VT/VF.
Nonshockable: -
Shockable: 300mg IV push (or 5mg/kg)
After 3rd shock as one-off.
MAY consider further 150mg +-
D- General evidence for drugs in ALS:
None reliably shown to improve survival to discharge
- Adrenaline/vasopressin and amiodarone improve ROSC rates only
What ETCO2 indicates ineffective CPR?
<10mmHg
Airway obstruction, ineffective ventilation, poor flow
D- Alternatives to adrenaline, amiodarone in arrest:
Vasopressin
Lignocaine
Key interventions during arrest, beyond ALS algorithm:
100% O2
Advanced airway
-LMA or ETT
- ETT can be drug route
Access
-PIVC - upper limb, EJV. Poor venous return from legs in CPR)
-IO (any site)
-via ETT if no IV access (3-10x dose in 10ml)
Arterial line
-Aim diastolic 40 (coronary perfusion)
Waveform capnography
Seek and treat 4 Hs and 4 Ts
Eg. Obs, echo, gas.
Seek NOK/GOC
MINIMISE INTERRUPTION TO COMPRESSIONS at all times. <20secs.
Positive prognostic factors in arrest:
Witnessed or in-hospital
VF or VT
Immediate CPR
Rapid defib (within 3mins)
ROSC in <15mins or prehospital
Reversible cause
Mean survival for OOHCA and IHCA:
Survival to discharge:
OOHCA 8%
IHCA 11%
Not nec neurologically intact
When to stop ALS:
No absolutes.
CONSIDER:
-Ceiling of care
Age, QOL, comorbidities, ACD found
-Prognostic features of Arrest
?Witnessed, ?Rhythm, Time to CPR, Time to defib (?3mins), ROSC at any time, Reversible cause, severe biochemical derangement
-Have best efforts been made?
Effective ALS, Hs and Ts optimised
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Generally stop if:
No ROSC or viable rhythm for 20-30 mins of effective ALS (Restart clock if ROSC)
K>10
pH <6.5
Lactate
ETCO2 persistently <10
Reversible causes addressed
Injuries not compatible with life
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EXCEPTIONS: for prolonged efforts:
Hypothermia (30mins >32deg)
Overdose/poisoning (up to 4 hours)
Thrombolysis (up to 2 hours post)
C- Praecordial thump:
Clenched fist strike to mid sternum.
Consider if:
Witnessed to go into pulseless VT and defib not immediately available
