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Year 2 ALS OSCE > OSCE > Flashcards

OSCE Flashcards

1
Q

What are the 5 types of shock?

A

(1) Cardiogenic (heart)
(2) Hypovolaemic (loss of volume)
(3) Anaphylaxis (vascular)
(4) Neurological (vascular)
(5) Toxic/septic (vascular)

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2
Q

Why do we do CPR?

A

To build up Coronary Perfusion Pressure (CPP). CPR cleans out the pooled blood in the right atrium and gives the heart a chance to restart if combined with early defibrillation.

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3
Q

What is chest recoil and why is it important?

A

Allowing the chest to rise in between compressions, as it allows the chest to fully expand, which creates negative pressure that pulls blood back into the chest and cardiac tissues

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4
Q

What is Coronary Perfusion Pressure (CPP)?

A

The pressure gradient that drives blood flow in the heart. There needs to be a +15mmHg difference between the left ventricle and right atrium for blood to flow through the coronary arteries.

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5
Q

What is the pathophysiology of VF?

A
  • VF is a type of arrythmia where disorganised heart signals cause the ventricles to twitch uselessly.
  • As a result, the heart does not pump blood to the rest of the body.
  • It is caused by either a problem with the electrical system or a disruption of normal blood supply to the heart muscle.

A good analogy is thinking of the heart as a tube of toothpaste, if you squeeze the whole tube with your hand, the contents come out, whereas if you use fingers simultaneously, there is reduced output due to the irregularity.

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6
Q

What is the pathophysiology of pVT?

A

In pulseless ventricular tachycardia, the ventricles contract at a rate too rapid to allow for an adequate filling time during diastole, subsequently resulting in hemodynamic collapse from a diminished cardiac output causing insufficient blood supply to end organs.

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7
Q

What is the action of adrenaline?

A
  • A sympathomimetic that stimulates alpha and beta adrenergic receptors. This causes variable effects on vascular resistance.
  • During CPR , myocardial and cerebral flow is enhanced as it improves perfusion pressures.
  • Increases cardiac output
  • It stimulates the α1 receptors in vascular smooth muscle—causing vasoconstriction.
  • This increases coronary perfusion pressure (CPP) and cerebral perfusion pressure (CePP). The CPP is strongly associated with ROSC.
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8
Q

What is the action of amiodarone?

A

An antiarrythmic - lengthens cardiac action potential. Causes a delay in repolarisation by blocking potassium currents. Reduces the cardiac muscle excitability and prevents abnormal heart rhythms.

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9
Q

Why is shock dangerous?

A

It can result in inadequate blood flow to the cells, and causes an inability to deliver O2 and nutrients around the body. Reduction in blood flow also creates failure to rid the body of waste materials from the process of cellular metabolism.

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10
Q

What is the targeted temperature after ROSC?

A

Between 32 and 36 degrees celcius

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11
Q

When would you withhold or discontinue resuscitation attempts?

A
  1. The presence of a DNR or advanced directive
  2. Where a death is expected due to terminal illness
  3. Submersion of an adult for >1hr, paediatric >1.5hrs
  4. If all of the following exist together:
    - 15 minutes since the onset of collapse
    - No bystander CPR prior to crew arrival
    - Asystolic for >30 secs on ECG
    - No suspicion of: drowning, hypothermia,
    poisoning/toxins, pregnancy.
  • Massive cranial and cerebral destruction - Hemicorporectomy
  • Decapitation
  • Decomposition
  • Incineration
  • Rigor mortis
  • Hypostasis
  • Foetal maceration in newborns
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12
Q

Drowning management

A
  • Dry patient for defibrillation
  • 5 rescue breaths (to reverse hypoxia) before CPR (BOTH ADULTS AND CHILDREN)
  • CA will be secondary to hypoxia
  • Consider early ET intubation - foam will be generated to make sure to suction
  • Prolonged submersion will also likely be hypovolaemic due to cessation of hydrostatic pressure of water on body - fluid challenge
  • Prolonged resus attempts required
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13
Q

Pregnancy arrest management:

A
  • If over 20 weeks pregnant, manually displace the uterus to the left lateral position to relieve aortocaval compression
  • Give a fluid bolus if there is hypotension or evidence of hypovolaemia
  • Seek expert help early - obstetric, critical care etc
  • Give IV tranexamic acid for PPH
  • Consider early ET intubation by a skilled operator
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14
Q

Hypothermia management:

A
  • Check for the presence of vital signs for up to 60secs
  • If VF persists after 3 shocks, delay further shock attempts until core temp is >30
  • Do not give any cardiac arrest drugs if core temp is <30
  • Increase administration intervals for adrenaline to 6-10 minutes if the core temp is 30-34 (normothermia is >35 - normal drug intervals)
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15
Q

Describe and discuss when you would consider using fluids in a resuscitation and ROSC patient?

A

When BP is <90 systolic or when hypovolaemia is suspicious

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16
Q

What is the order of the stepwise airway management?

A
  1. Positioning
  2. Clear occlusion - forceps or suctioning
  3. HTCL/Jaw thrust
  4. OPA/NPA
  5. Supraglottic - iGel
  6. ET Intubation
  7. Needle cricothyroidotomy
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17
Q

What would your management be for an anaphylactic arrest?

A
  • Remove trigger to stop any infusion.
  • Establish IV or IO access
  • Give rapid IV fluid bolus and either convey to hospital or get critical care to start adrenaline infusion
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18
Q

If a patient with anaphylaxis has a cardiac arrest, is it better to give IM adrenaline rather than wait until someone arrives who can obtain IV access and give IV adrenaline according to the ALS guidelines?

A

Once cardiac arrest occurs it is important to ensure expert help is coming and start CPR immediately. Good quality CPR with minimal interruption for other interventions improves the chances of survival from cardiac arrest. Once cardiac arrest has occurred, the absorption of adrenaline given by IM injection may not be reliable, therefore IM adrenaline is not likely to beneficial. Attempts to give IM adrenaline may also interrupt CPR. Advanced life support according to current guidelines should start as soon as possible.

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19
Q

What is refractory anaphylaxis?

A

No improvement in respiratory or cardiovascular symptoms despite 2 appropriate doses of IM adrenaline

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20
Q

According to SWAST guidelines, normal capnography reading during ROSC is ….

A

4.0 - 5.7 kPa

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21
Q

What ETCO2 reading could indicate a PE?

A

<1.7 kPa

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22
Q

Hyperkalaemia in CA:

A
  • Consider hyperkalaemia or hypokalaemia in all patients with an arrythmia or CA
  • Hyperkalaemia is the most common electrolyte disorder to cause CA
  • Acute Hyperkalaemia is most likely to cause life-threatening cardiac arrythmias or CA
  • Caused by increase in potassium release from cells or impaired excretions by the kidneys
  • Main causes are renal failure and drugs, rhabdomyolisis, DKA or addison’s disorder
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23
Q

What normal BP would you like to see in ROSC?

A

> 90 systolic or a MAP of >65

24
Q

What SpO2 reading would you like to see in ROSC?

A

Between 94% - 98%

25
Q

What CA rhythm commonly presents with a PE?

A

PEA

26
Q

When performing high quality compressions, what reading may support a diagnosis of PE?

A

Low ETCO2 readings of <1.7 kPa

27
Q

When PE is the suspected cause of an arrest, what drug should be administered?

A

Thrombolytic drugs such as tenecteplase

28
Q

Sepsis cardiac arrest treatment:

A
  • Follow standard ALS guidelines, including administering the maximal inspired oxygen concentration
  • Intubate the trachea if able to do so safely, as they can aspirate due to iGel insertion
  • Commence IV fluid resus with an initial 500ml bolus
  • Control the source of sepsis, if feasible, and give antibiotics early, e.g. Meningitis and Ben-Pen
29
Q

What does hypokalaemia do?

A
  • Increases the incidence of arrythmias and sudden cardiac death
  • Risk is increased further in patients with pre-existing heart disease and those treated with digoxin
30
Q

How could you identify an MI from other thrombosis CA causes?

A
  • Chest pain prior to arrest
  • Known coronary artery disease
  • Initial CA rhythm: VF or pVT
  • Post resus 12-lead ECG showing ST-elevation
31
Q

Tension pneumothorax CA treatment:

A
  • Decompress chest immediately when it is suspected in the presence of CA or severe hypotension
  • Needle chest decompression serves as rapid treatment
  • Any attempt at needle decompression under CPR should be followed by an open thoracostomy or a chest tube if the expertise is available
32
Q

When do we need to consider ET intubation?

A

When our earlier stepwise approach fails, or when we are faced with a compromised and time critical/life-threatening airway that is in danger of being lost - e.g. burns/anaphylaxis/aspiration/trauma

33
Q

Examples of life-threatening airways for which ET intubation may be considered appropriate:

A
  • Burns
  • Maternal CA when pregnant
  • Prolonged or complicated extraction
  • Haemorrhaging
  • Drowning
  • Anaphylaxis
  • Risk of aspiration
  • Hanging/asphyxiation
  • Seizures or ROSC management need for RSI
34
Q

Which cartilages do you put the bougie between when intubating?

A

The cuniform and corniculate cartilages

35
Q

What confirmation do you have of successful ET intubation?

A
  1. Visualisation of the ET tube passing through the cords
  2. Waveform capnography (EtCO2) - patterns and values
  3. Auscultation of chest (no abdo sounds)
  4. Bilateral and equal chest movement
  5. Improvement in patients colour and pO2 values (94-98%)
  6. No resistance when bagging
36
Q

What is the location for a needle cricothyroidotomy?

A

Between the thyroid cartilage and the cricoid cartilage, in between the cricithyroid muscles: the “cricothyroid membrane”

37
Q

When do we need to use a needle cric?

A

According to the Das 2015 guidelines, when you have progressed up and down your stepwise airway management, and nothing previously is working at all. Pre-hospital needle cric is only a short term option to buy time.

38
Q

Technique for needle cric?

A
  1. Locate and palpate the crichothyroid membrane
  2. Clean the site
  3. Attach a large bore cannula to a syringe filled with 2-5ml sodium chloride
  4. Stabilise the larynx and advance the needle of cannula at a 45 degree angle towards feet. Advance until you hear a “pop”
  5. Push a small amount of SCL to blow plug and then aspirate syringe to see air bubbles in SCL to help confirm placement
  6. Connect 3 way tap to the cannula and the O2 tubing the other end of the 3-way tap
39
Q

What is a pneumothorax?

A

A collapsed lung, formed when air gets into the pleural cavity

40
Q

What is a tension pneumothorax?

A

If air continues getting into the pleural space as somebody breathes, this can start to compress the unaffected lung and the heart/aorta/vena cava - CVS becomes compromised

41
Q

Where is the primary site for chest decompression?

A

Midclavicular line (over effected side), 2nd intercostal space, above 3rd rib - to avoid vasculature that runs under the ribs

42
Q

What are the two alternative sites for chest decompression?

A

Anterior axillary line: 5th intercostal space, above 6th rib

Midaxillary line: 4th intercostal space, above 5th rib

43
Q

When would you consider decompressing the chest?

A

When a patient is demonstrating that their pneumothorax is progressing into a tension pneumothorax

44
Q

Signs and symptoms of a pneumothorax?

A

Pleuritic chest pain, tachypnoea, tachycardic, normotensive or hypertensive, hypocapnia (reduced EtCO2) reduced sats

45
Q

Signs and symptoms of a tension pneumothorax?

A

Pleuritic chest pain, bradypnoea, reduced breath sounds globally, bradycardic, hypotensive, increased EtCO2 levels, reduced GCS

46
Q

What is the desired resp rate for infants in ROSC?

A

25 breaths per minute

47
Q

What is the desired resp rate for children aged 1-8 in ROSC?

A

20 breaths per minute

48
Q

What is the desired resp rate for children aged 8-12 in ROSC?

A

15 breaths per minute

49
Q

What are the main causes of hypokalaemia?

A

Diarrhoea, vomiting, excessive use of diuretics, endocrine disorders

50
Q

What are the main causes of hyperkalaemia?

A

Renal failure, DKA (acidosis causes buildup of extracellular potassium)

51
Q

What are the changes to the paediatric guidelines 2021?

A
  • 1 breath every 3 seconds for under 8
  • 1 breath every 4 seconds for 8-12
  • 1 breath every 6 seconds for 12+
  • 2 person BVM 5 breath technique
52
Q

How does a PE cause an arrest?

A

When a pulmonary embolism blocks the blood vessels of the lung, there’s a sudden increase in pressure in the pulmonary artery.

This increases the afterload of the right ventricle, which is the pressure the heart must work against to pump blood.

As a result, the right ventricle has to work harder to keep pumping blood, but after a certain threshold it fails.

This disrupts blood flow to vital organs, leading to death - a process known as haemodynamic collapse.

53
Q

When would you give post-ROSC adrenaline?

A
  • If patient is over 18
  • Hypotensive despite fluids
  • HR <60
54
Q

What is the pathophysiology of PEA?

A
  • PEA occurs when a major cardiovascular, respiratory, or metabolic derangement results in the inability of cardiac muscle to generate sufficient force in response to electrical depolarization.
  • PEA is always caused by a profound cardiovascular insult (eg, severe prolonged hypoxia or acidosis or extreme hypovolemia or flow-restricting pulmonary embolus).
55
Q

What is the pathophysiology of asystole?

A

Asystole is a state of cardiac standstill with no cardiac output and no ventricular depolarization.

56
Q

What is the difference between a haemhorrhagic or ischaemic stroke?

A
  • A haemorrhagic stroke is caused by a bleeding in or around the brain.
  • An ischaemic stroke is caused by a blockage cutting off the blood supply to the brain. This is the most common type of stroke.
57
Q

Why do we give fluids for hypotension?

A

To increase the blood volume to keep the MAP high enough for essential organ perfusion

Year 2 ALS OSCE (1 decks)

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