OSCE - Cardiac Arrest

Question 1

Management of the following ECG, no pulse

Answer 1

SAFE - shout for help, assess surroundings, free from danger, evaluate
Confirm cardiac arrest
Start CPR 30:2, attach cardiac monitoring and defibrillation pads

SHOCK 120-360 J
2 mins CPR - advanced airway management, assess 4H’s, 4T’s,

Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients in cardiac arrest with a shockable rhythm.

Repeat adrenaline 1 mg IV (IO) every 3-5 minutes whilst ALS continues.

Give amiodarone 300 mg IV (IO) for adult patients in cardiac arrest who are in VF/pVT after three shocks have been administered.
Give a further dose of amiodarone 150 mg IV (IO) for adult patients in cardiac arrest who are in VF/pVT after five shocks have been administered.

Question 2

Where can the defibrillation pads be attached?

Answer 2

Right upper sternum
5th intercostal space mid-clavicular line

OR

antero-posterior placement - left anterior chest, and behind left scapula
must be > 8cm away from pacemaker devices

Question 3

Management of atrial fibrillation with life threatening features

Answer 3

Sedation/ analgaesia

To convert atrial or ventricular tachyarrhythmias, the shock must be synchronised to occur with the R wave of the electrocardiogram (ECG).

For atrial fibrillation:
An initial synchronised shock at MAX defibrillator output rather than an escalating approach is a reasonable strategy based on current data.

Question 4

Management Atrial Flutter/ SVT

Answer 4

Sedation/ analgaesia

For atrial flutter and paroxysmal supraventricular tachycardia (140-280 bpm):

Give an initial shock synchronised of 70 - 120 J.

Give subsequent shocks using stepwise increases in energy.

Question 5

Management of VT with pulse

Answer 5

For ventricular tachycardia with a pulse:

Use energy levels of 120-150 J for the initial shock.
Consider stepwise increases if the first shock fails to achieve sinus rhythm.

Question 6

Management of pulseless VT in cardiac arrest situation

Answer 6

DC Shock: 150-360J Biphasic machine

Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients in cardiac arrest with a shockable rhythm.

Repeat adrenaline 1 mg IV (IO) every 3-5 minutes whilst ALS continues.

Give amiodarone 300 mg IV (IO) for adult patients in cardiac arrest who are in VF/pVT after three shocks have been administered.

Give a further dose of amiodarone 150 mg IV (IO) for adult patients in cardiac arrest who are in VF/pVT after five shocks have been administered.

Question 7

Management of Bradycardia with life threatening signs

Answer 7

ATROPINE 500mcg IV

Others:
Interim measures:
• Atropine 500 mcg IV repeat
to maximum of 3 mg
• Isoprenaline 5 mcg min-1 IV
• Adrenaline 2–10 mcg min-1 IV
• Alternative drugs*

or

Transcutaneous pacing

Question 8

What rhythms put a patient at risk of asystole and how would you manage them?

Answer 8

RISK FACTORS
- Recent asystole
- Mobitz II AV block
- Complete heart block with
broad QRS
- Ventricular pause > 3 s

Manage as per bradycardia algorithm

Question 9

Management PEA / Asystole

Answer 9

SAFE
Confirm cardiac arrest - pulse check 10 seconds
Cardiac monitoring
Defibrillation pads placed
CPR 30:2

Give adrenaline 1 mg IV (IO) as soon as possible for adult patients in cardiac arrest with a non-shockable rhythm.

Give adrenaline 1 mg IV after every alternate sequence of CPR/rhythm check (approximately every 3–5 minutes).
Rule out 4H’S, 4T’s

Continue CPR (30:2) until the airway is secured — once the airway is secured, ventilate the lungs at a rate of about 10 breaths per minute and continue chest compressions without pausing during ventilation.

Question 10

What is Wolf Parkinson White Syndrome?

Answer 10

WPW Syndrome refers to the presence of a congenital accessory pathway (AP) and episodes of tachyarrhythmias. The term is often used interchangeablely with pre-excitation syndrome.

Associated with a small increase in risk of sudden cardiac death.

Question 11

ECG features of WPW?

Answer 11

1. PR interval < 120ms (SHORT)
2. Delta wave: slurring slow rise of initial portion of the QRS
3. QRS prolongation > 110ms (WIDE)
4. Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
5. Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction)

Question 12

What type of tachyarrhythmias occur in WPW syndrome?

Answer 12

1. Atrial fibrillation or flutter. Due to direct conduction from atria to ventricles via an AP, bypassing the AV node.
2. Atrioventricular re-entry tachycardia (AVRT). Due to formation of a re-entry circuit involving the AP.