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Resuscitation > Medical Arrest > Flashcards

Medical Arrest Flashcards

1
Q

ALS modifications in HYPOTHERMIA:

A

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.

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2
Q

Drugs via ETT:

A

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

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3
Q

Chain of Survival in cardiac arrest:
Components
Survival rates

A

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)

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4
Q

ECG in VF:

A

Chaotic
Varying amplitudes
No identifiable morphology
150-500 bpm

when very very fast, trace is fine.. may resemble asystole!

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5
Q

ECG in pulseless VT:

A

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

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6
Q

C- Defib pad placement and considerations:

A

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

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7
Q

C- Choice of defibrillation in arrest:

A

Biphasic (all modern)
UNsynchronised (VT, VF)
200J adults, 4J/kg (child)

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8
Q

C- ‘COACHED’ in ALS:

A

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

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9
Q

C- Utility of 3 stacked shocks:

A

Only when:
Witnessed
Delay <10sec to first shock, and between shocks

ie. only really in cath lab, or in cardiac OT

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10
Q

B- Ventilation technique in ALS:

A

100% O2
Rate 10 bpm
400-500ml tidal volume, 5-6 ml/kg

Too much inflation = hyperinflation and no ROSC

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11
Q

A- Choice of airway in ALS

A

Advanced airway = no further interruption to compressions

ETT, LMA equal

Don’t interrupt CPR for >20secs to insert

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12
Q

Adult ALS algorithm

A
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13
Q

4 Hs and 4 Ts:

A

The potentially reversible causes:

Hypoxia
Hypovolaemia
Hyper/o thermia
Hyper/o kalaemia (+other metabolic)

Thrombus (MI, PE)
Tension PTx
Tamponade
Toxins

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14
Q

CPR technique, rate and ratios by age:

A

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

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15
Q

D- Adrenaline in ALS

A

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

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16
Q

D- Amiodarone in ALS

A

Theory is for refractory VT/VF.

Nonshockable: -
Shockable: 300mg IV push (or 5mg/kg)
After 3rd shock as one-off.

MAY consider further 150mg +-

17
Q

D- General evidence for drugs in ALS:

A

None reliably shown to improve survival to discharge

  • Adrenaline/vasopressin and amiodarone improve ROSC rates only
18
Q

What ETCO2 indicates ineffective CPR?

A

<10mmHg

Airway obstruction, ineffective ventilation, poor flow

19
Q

D- Alternatives to adrenaline, amiodarone in arrest:

A

Vasopressin
Lignocaine

20
Q

Key interventions during arrest, beyond ALS algorithm:

A

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.

21
Q

Positive prognostic factors in arrest:

A

Witnessed or in-hospital
VF or VT
Immediate CPR
Rapid defib (within 3mins)
ROSC in <15mins or prehospital
Reversible cause

22
Q

Mean survival for OOHCA and IHCA:

A

Survival to discharge:

OOHCA 8%
IHCA 11%

Not nec neurologically intact

23
Q

When to stop ALS:

A

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

___________________________________

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

__________________________________

EXCEPTIONS: for prolonged efforts:
Hypothermia (30mins >32deg)
Overdose/poisoning (up to 4 hours)
Thrombolysis (up to 2 hours post)

24
Q

C- Praecordial thump:

A

Clenched fist strike to mid sternum.

Consider if:

Witnessed to go into pulseless VT and defib not immediately available

25
Q

Steps of post-ROSC care:

A

NEURO
Sedate and analgese
Eg. Morphine/ Midaz, 50mg in 50ml, 5-20ml/hr
Seek and treat seizure. No role for prophylaxis.
Nurse at 30 degrees
TARGETED TEMP MX FOR ALL ADULT ROSC WITHOUT CONSCIOUSNESS

RESP
Intubate and ventilate
Protective lung ventilation strategy
Sats 94-98%
Normocapnoea (35-45)
CXR for:
—> confirm tube/line placement
—> look for injuries

CVS
Art line
Central line
Haemodynamic targets:
—> MAP >65, SBP >100, PR <100, Cap refill <4, lactate <2, UO 0.5ml/kg/hr
Eg. adrenaline 6mg in 100ml, 5-20ml/hr
Consider anti arrythmic infusion
eg. Amiodarone 15mg/kg/day
ECG
IMMEDIATE PCI- definite if clin/ECG features, consider in most others unless clear alternative cause of arrest

METABOLIC
Glucose <10 and avoid hypo
Correct electrolytes

DISPOSITION
ICU
Cardio (PCI)

OTHER
Notify NOK
Document
Hot debrief / staff support

Prognosticate day 5

26
Q

Targeted temperature management (TTM) post ROSC:

A

Endorsed by ANZCOR for:
Any ADULT who remains COMATOSE after ROSC.

Evidence is for cardiac cause of arrest, but extrapolated to all causes.

Start ASAP.

32-36 deg target
as per ANZCOR. 2013 TTM2 trial showed no diff within this range

Usual cooling: icepacks, 4 degr IV fluids, cooling blanket, shiver control etc.

At least 24 hours
Then avoid fever for further 48h.

Rewarm no more 0.5 per hr

27
Q

Obstetric-related causes of arrest:

A

PE
Stroke
Cardiomyopathy
Amniotic fluid embolus
HELLP/ pre/eclampsia
High neuraxial block
Haemorrhage: abruption/ PPH

28
Q

Procedure: resuscitative hysterotomy (perimortem Caesar):

A

Primarily for Mum. Increases CO by 25%

INDICATIONS
Uterus above umbi (20ish/40 +)
Within 4mins of arrest optimises fetal outcome, but ANY time optimises maternal outcome.

No absolute contraindications.

PROCEDURE
Brief the room
Don’t worry about personnel/ USS/ prep- get going!
CONTINUE CPR

Scalpel from pubic symphysis to umbilicus (or higher)
Retract
Reflect bladder down, and empty it by big needle asp
5cm incision to lower uterus until through/gosh
Fingers in and lift off baby, then extend cut with curved scissors to fundus
Deliver baby, clamp and cut cord, resuscitaire
Deliver placenta via gentle traction
Pack uterus and abdomen
Suture
Oxytocin 5units IV

Baby to NICU if viable (24/40+ or unknown)

29
Q

Why is resuscitative hysterotomy recommended to occur within 4-5mins of arrest?

A

Optimises fetal outcome (20-30% survival)

Is still useful for Mum any time!
- Improves CO 25%
- Improves FRC by 20%

Resuscitation (10 decks)

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