Module 1: ALS algorithm Flashcards
The approach to the deteriorating (non dead) patient vs the dead patient?
Not dead: ABCDE
Dead: 4Hs and 4Ts
Describe ABCDE.
Airways
- McGill suction
- Forceps
- Head tilt-chin lift (jaw thrust if suspect C-spine injury)
- Basic adjuncts (OPA, NPA)
- Definitive airway (i-Gel)
Breathing
- Sats, RR, auscultate, percuss, expansion, trachea
- Give 100% oxygen 15L min-1 via bag-valve-mask
- Capnography to monitor airway
Circulation
- Pulse, BP, central CRT
- IV access (IO after 2 failed attempts) (consider ECPR if available)
Disability
- GCS, pupils, temp
Everything else
- Abdo, calves, bleeding/rashes
Why do you want access in A–E?
Give fluids
- 500ml boluses (250ml if elderly/HF)
- Up to 30 ml/kg
Take bloods, VBG, blood cultures
You are assessing a critically ill patient using the ABCDE approach, when suddenly you notice his oxygen mask is no longer misting. What is the first thing you do?
Confirm cardiac arrest!
1. Patient response
2. Open airway
3. Check for normal breathing (caution agonal) AND pulse simultaneously, for no longer than 10 SECONDS (count out-loud)
4. Start CPR in any unresponsive person with absent/abnormal breathing.
True/false: You should not start CPR in a patient who is unresponsive, but still breathing slowly and laboured.
False. Agonal breathing should be considered a sign of cardiac arrest
True/false: seizures are rare before cardiac arrest
False. Short periods of seizure-like movements can occur at the start of cardiac arrest. Assess the patient afterwards - if unresponsive and absent/abnormal breathing, start CPR.
Having confirmed cardiac arrest, what should you immediately do?
Start CPR 30:2 (attach defib/monitor at earliest opportunity to assess the rhythm shock/non-shockable, minimise interruptions)
Call resus team.
Follow the ALS algorithm + consider potentially reversible causes of the arrest.
Cardiac arrest mangement prior to team arrival:
- Confirm arrest and start CPR
- Call form help and request resus trolley
- Apply defib pads asap
- Minimise interruptions to chest compressions - Maintain airway and ventilation
- 100% oxygen using bag-valve-mask, 10-12 breaths min-1
- Waveform capnography - Rhythm check once defib connected
- Continue CPR as soon as rhythm check complete
- Prepare structured handover for emergency team when they arrive
How should chest compressions and ventilation be delivered?
30:2
High quality chest compressions:
- Position: centre of lower 1/3 chest
- Depth: total 1/3 (5cm)
- Rate: 100-120 min-1
- Recoil: between each
- MINIMISE HANDS-OFF TIME (<5s)
Ventilations:
- High flow (15L)
Continue compressions once airway secured.
Switch CPR provide every 2 min cycle to avoid fatigue.
What is the purpose of waveform capnography (ETCO2)?
Measures the amount of CO2 in a patient’s exhaled breath.
Used to confirm correct tracheal tube position (airway vs oesophagus) alongisde auscultation (to confirm tracheal vs bronchial placement)
Can indicate ROSC.
No trace = wrong place (assume oesophageal intubation)
Normal = 4.0–5.7 kPa
Rhythm check: what different rhythms may your monitor may display?
Shockable: VF and pVT
- Better prognosis
Non-shockable: PEA and asystole
- Worse prognosis
- Require 1mg IV adrenaline (10ml of 1:10,000) asap
- Survival unlikely unless reversible cause is identified and treated
Describe VF and your response.
ECG
- Chaotic and disorganised electrical activity
- NO identifiable QRS
- Initially coarse VF, will progress to fine VF and eventually asystole if prompt defib not performed
Give a shock
- Immediately resume CPR for 2 min
- Re-assess rhythm at 2 min
If VF/pVT persists: deliver SECOND shock
- Immediately resume CPR for 2 min
- Re-assess rhythm at 2 min
If VF/pVT persists: deliver THIRD shock and give 1mg adrenaline IV + 3mg amiodarone IV
Repeat the 2 min CPR/rhythm check sequence if VF/pVT persists
- Once given, 1mg adrenaline must now continue to be given after every other shock
- Identify reversible causes (4Hs and 4Ts)
Describe pVT and your response.
ECG =
- Regular broad complex tachycardia with recognisable QRS complexes
- 100-300 bpm
- Important to check for a pulse (VT with a pulse is Mx with ALS tachy algorithm)
- Can be monomorphic or polymorphic (TDP is a polymorphic VT
Give a shock
- Immediately resume CPR for 2 min
- Re-assess rhythm at 2 min
If VF/pVT persists: deliver SECOND shock
- Immediately resume CPR for 2 min
- Re-assess rhythm at 2 min
If VF/pVT persists: deliver THIRD shock and give 1mg adrenaline IV + 3mg amiodarone IV
Repeat the 2 min CPR/rhythm check sequence if VF/pVT persists
- Once given, 1mg adrenaline must now continue to be given after every other shock
- Identify reversible causes (4Hs and 4Ts)
Describe PEA and your response.
ECG = electrical activity (which you’d expect would produce CO) but absent pulse
Causes include: severe fluid depletion/blood loss, massive PE, cardiac tamponade, tension pneumothorax
Response = non-shockable rhythm
- Continue compressions
- Give adrenaline 1mg of 1:10,000 asap followed by 20ml saline flush
- Identify reversible causes (4Hs and 4Ts)
Describe asystole and your response.
ECG = no electrical activity (‘flat line’ though in reality may have slight undulations) **
Response = non-shockable rhythm
- Continue compressions
- Give adrenaline 1mg of 1:10,000 asap followed by 20ml saline flush
- Identify reversible causes (4Hs and 4Ts)
**Look out for regular P waves - important to distinguish from ventricular standstill with regular P waves - may benefit from cardiac pacing
Your resus team arrive. What should you do?
Allocate roles (specifically name/point to each person)
1. airway,
2. compressions 1-2 people (count them in to replace you),
3. defib,
4. drugs,
5. scribe
Maintain position as team leader at end of bed & ONLY move if you cannot see the monitor.
Defib machine - instructions to give to the team.
When charging: continue compressions, everyone else away (1m), including oxygen off
Charged: stop compressions, everyone off chest/away
Shocking: shock delivered, back on chest
Defib energies
Default = 200 J
During scenarios just specify ‘please give the maximum energy this machine can deliver’
4Hs
Hypoxia
- Pre-arrest SpO2?
- Tx: as much oxygen as poss (15L) but do not hyperventilate
Hypovolaemia
- Haemorrhage, surgery, anaphylaxis, sepsis?
- Tx: IVF / blood
Hyper/hypokalaemia
- VBG
- Tx hyperK: Calcium CHLORIDE, insulin/dex, IVF, consider sodium bicard
- HypoK: supplemental KCl, ?10mmol/1h
Hyperthermia
- Axillary temp
- Tx: ?rapid cooling measures / treat the cause
4Ts
Thromboembolism
- Suggestive Hx
- Tx: high clinical probability consider fibrinolysis (alteplase) - NB: IF GIVING FIBRINOLYSIS MUST COMMIT TO 30 MIN+ CPR or coronary/pulmonary percutaneous intervention
Tension pneumothorax
- Unilateral chest rise/fall, dec breath sounds, tracheal deviation, suggesive Hx e.g. trauma/asthmatic
Tamponade
- Need echo to Dx (request a FAST scan!!)
- Tx: needle pericardiocentesis or resuscitative thoracotomy
Toxins
- Drug chart
- Tx accordingly (specific antidotes)
What could indicate ROSC? What would you do if ROSC occurs?
Sudden rise in ETCO2 or sudden signs of life.
Stop CPR
Reassess ABCDE
Continue supporting ventilation at 10 min-1
Post-resuscitation care
- 12 lead ECG
- Tx precipitating cauases
- Aim: sats 94-98%, normo-capnia, -thermia, -glycaemia
Decisions to stop CPR e.g. no ROSC after 3 shocks in a frail, elderly, comorbid patient
Discuss decision with team
Wait until next rhythm check
