PCTH - Cardiac Arrest Special Considerations

Question 1

Supraglottic Airway Medical Directive Indications, Conditions, Contraindications

Answer 1

Indications: Need for ventilatory assistance or airway control AND other airway management is ineffective

Conditions: Other: absent gag reflex

Contraindications: CATE
* C: Caustic ingestion
* A: Airway obstructed by foreign object
* T: trauma to oropharynx - airway burns, swelling, blunt/penetrating trauma
* E: known esophageal disease (varices) - potential for massive hemorrhage

Question 2

Supraglottic Airway Medical Directive
Treatment, Clinical Considerations

Answer 2

Treatment:
* Consider supraglottic airway insertion (max attempts is 2)

• Confirm placement:
• Primary: ETCO2 w/ waveform capnography
• Secondary: ETCO2 (non-waveform), auscultation, chest rise

Clinical Considerations:
* An attempt at SGA insertion is defined as insertion of SGA into the mouth
* Confirmation of SGA should use ETCO2 (waveform). If not available/not working, then at least 2 secondary methods must be used.

Question 3

Signs of ROSC

Answer 3

• spontaneous/purposeful movement
• ETCO₂ spike
• gagging on airway
• pulse (during analyze NOT during CPR)

Question 4

What is the maximum number of times you can shock a patient under the Medical Cardiac Arrest Medical Directive?

Answer 4

5 (for re-arrest)

Question 5

In what cirucmstances would the Medical Cardiac Arrest Medical Directive be complete/discontinued?

Answer 5

1) Rhythm analysis has been performed by a paramedic 4 times OR
2) There has been a ROSC OR
3) The BHP has issued a TOR or directed you to transport (if they direct you to transport, you are likely still going to finish your last analyze because you wouldn’t get to the truck that quickly)

Question 6

Treatable causes of Cardiac Arrest (Hs and Ts)

Answer 6

H’s: Hypoxia, hypovolemia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia

T’s: tension pneumothorax, tamponade, thrombosis (pulmonary and coronary), toxins

Question 7

Special considerations for medical VSA where you would consider early transport (i.e. after the first analyze):

Answer 7

1) Pregnancy presumed to be ≥20 weeks gestation (fundus above umbilicus, ensure manual displacement of uterus to left)
2) hypothermia
3) airway obstruction
4) suspected PE
5) Medication overdose/toxicology
6) other known reversible cause of arrest not addressed

Question 8

Why is pregnancy presumed ≥20 weeks gestation requiring early transport, and how would you position them on transport?

Answer 8

• potentially pt’s baby can survive even if mother does not so you do not want to delay transport and care (you may be going to L&D/obstetrics facility
• position in L lateral recumbent position (lift up R side) - pushes baby off IVC to allow blood return

Question 9

What are the signs of suspected PE and why is early transport considered for these patients?

Answer 9

S/S:

• SOB (sudden)
• sharp pinpoint chest pain - worsens with deep breathing/changing positions like sitting up/bending forward
• coughing, hemoptysis
• Hx taking: recent travel, surgery, laying in bed for a long time, fractures, diving)

Why early transport: because it is a reversible cause. PE is caused by an obstruction in a lung artery which causes back up of blood in the RV (increased afterload) and ++pressure in RA. L side of heart is also not filling = cardiogenic shock and then cardiac arrest

Question 10

Specific to cardiac arrest secondary to medical overdose/toxicological cause being a special consideration, what med/drug is the exception that would not fall under this category?

Answer 10

opiates!

because VSA secondary to opiates is respiratory in nature so try to fix that first instead of early transport (And paramedics have the means to do this)

Question 11

What are other known reversible causes that would be considered as a special consideration and therefore you would consider early transport for?

Answer 11

anaphylaxis

ped VSA in a non-shockable rhythm

Question 12

Which patients would you plan for extrication and transport after the 3rd analysis?

Answer 12

1) patients with refractory v-fib (continuous v-fib or v-fib that keeps coming back)
2) patients in pulseless VT

*note: this DOES NOT MEAN leaving scene after your 3rd analysis, you are just considering starting to get everything ready and get going. Ensure that adequate CPR can be continued AND the directive has been completed

Question 13

You are called to a restaurant for a choking patient. On arrival, the patient appears to be alert and sitting up but holding onto his neck and coughing. Describe the appropriate steps to take on arrival, and what to do if the patient goes unconscious.

Answer 13

1) Introduce self, encourage patient to keep coughing (partial obstruction if you can hear them coughing)
2) One full body obstruction (no noise, pt starts to turn blue) - 5 back blows x 5 abdominal thrusts (or 5 chest thrusts if preggos or they’re large)
3) If they go unconscious, check AVPU and ABCs. Begin ventilating to see if breaths go in. NO OPA. If ventilations are met with resistance, then assume obstruction and begin chest compressions to push object out 30:2. After compressions, look into airway and ventilate x2 until object comes out or pt goes VSA.
4) If VSA, start FBAO directive, analyze x1 (if they are in a shockable rhythm, you still shock them)
5) If object relieved, confirm VSA and begin full medical cardiac arrest medical directive. If not relieved after first analysis, transport

Question 14

What is the maximum number of times you can shock a patient with an airway obstruction?

Answer 14

6

1 x FBAO

4 x Medical Cardiac Arrest Directive

1 x ROSC

Question 15

Hypothermia cardiac arrest

Answer 15

See medical cardiac arrest medical directive (compiled)

• NO TOR (Not dead until warm and dead)
• 1x interp/defib and GO (consider VERY early transport
• Passive rewarming only & handle with care (prone to dysrhythmias)

Question 16

What happens during hypothermia (physiologically)?

Answer 16

• severe hypothermia causes myocardium to become ↑ irritable leading to easily triggered VF/VT rhythms
• slows down metabolic rate so much that these patients are often viable for survival w/ intact neurological status

Question 17

Severe hypothermia is suspected by what signs/symptoms?

How do you differential between primary vs secondary hypothermia?

Answer 17

• History indicating prolonged exposure to a cold environment
• Central body temp cold to touch
• Skin appears white/waxy
• Stiff limbs

May be hard to differentiate between 1’ vs 2’ hypothermia (i.e. died from cold vs cold after death) so use environmental conditions/likelihood of exposure/other ax findings to make decision

Question 18

Why is it recommended when assessing and treating hypothermia patients to avoid aggressive treatment (i.e. during transport, suctioning, etc.)?

Answer 18

These patients can go into cardiac arrests from lethal rhythms

Question 19

You are called to a patient who has been outside for 4 hours, unconscious. You determine that the patient is VSA and begin your CPR and rhythm analysis. You analyze once and the patient is in PEA. You initiate transport but en route to the hospital, patient has a ROSC and re-arrests. What are your next steps?

Answer 19

Continue transport to the hospital. You do not pull over to do one more analyze. Continue transport with passive rewarming

Question 20

Methods of passive rewarming

Answer 20

methods that promote heat retention:

• heat on in the ambulance
• blanket
• removing clothes

Question 21

Conditions and contraindications for epinephrine in cardiac arrest.

Answer 21

Conditions:

• altered LOA
• Anaphylaxis suspected as causative event

Contraindications: allergy or sensitivity to epinephrine

Question 22

Epinephrine treatment parameters under the Medical Cardiac Arrest Medical Directive.

When would you deliver the epinephrine in your protocol (i.e. where in your flowchart)?

Answer 22

• Route: IM
• Concentration: 1mg/mL = 1:1000
• Dose: 0.01mg/kg* (can be rounded to the nearest 0.05mg)
• Max single dose: 0.5mg
• Dosing interval: N/A
• Max # of doses: 1

When to deliver? After your first analysis (this is the only durg we give VSA patients and we only give it ONCE)

Question 23

Why are you infusing 10ml/kg instead of 20ml/kg under the ROSC directive?

Answer 23

because you want to avoid fluid overload

Question 24

When transporting a ROSC patient, how are you transporting them?

Answer 24

30° elevation due to risk of cerebral edema (so promote cerebral venous drainage)

Question 25

ETCO₂ requires what two things to provide a reading?

Answer 25

blood flow

constant air movement

Question 26

Why would ETCO₂ readings be better than SpO₂ readings in cardiac arrest?

Answer 26

• because pulse ox is limited in the arrest situation due to its reliability on blood flow in the area where the probe is
• in patients who are cold/in shock, you will not get a reading

Question 27

What is a common mistake when ventilating cardiac arrest patients and how should they be ventilated?

Answer 27

• Common occurrence is overventilation leading to increase in intrathoracic pressure
• Leads to decrease blood circulated with compressions
• Excessive O2 leads to formation of free radicals and vasoconstriction
• 1 second/breath (1 sec to squeeze BVM, at least 2 seconds to let the air out)

Question 28

ETCO₂ values in cardiac arrest

Answer 28

ETCO₂ indicates the body’s response to CPR (lets us known if perfusion is happening)

• ≥15 mmHg indicates compressions are perfusing (so gas exchange is taking place in the lungs)
• <10 mmHg indicates poor compressions, low perfusion, long “down time”, shock
• The higher the value, the better the perfusion
• To get the best quality data to BHP, adequate CPR x advanced airway x 20 mins (since pt has been down), if <10 mmHg than patient will have a poor outcome
  
  • However, adequate CPR + advanced airway + x20 minutes (20 minutes of good CPR with ETCO2 >=15, you are probably not getting a TOR)

Question 29

A spike in ETCO₂ means what? What do you do in this situation?

Answer 29

• 1st sign of ROSC (body purging everything that has accumulated during resus)
• if you see this, do a pulse check to confirm ROSC and then ROSC care
• spike in ETCO₂ is usually seen before pulse is felt

Question 30

When defibrillating a pediatric patient, if you don’t have the exact joule setting that you calculated for the patient, do you round up or down to the next closest setting)

Answer 30

Go up to the next closest setting

Question 31

Describe the approximate weight, first and subsequent defib setting for the following age groups using a Zoll monitor.

1) 0 to 30 days

2) ≥1 month to <3 months

3) ​≥3 months to <1 year

Answer 31

1) 0 to 30 days: N/A (you don’t shock those <30 days)

2) ≥1 month to <3 months: <5kg; first shock 10J, subsequent shock 20J

3) ​≥3 months to <1 year: ≥5 to <12kg; first shock 15 J, subsequent shock 30J

Question 32

Describe the approximate weight, first and subsequent defib setting for the following age groups using a Zoll monitor.

1) ≥1 year to <5 years

2) ≥5 to <8 years

3) ​≥8 years

Answer 32

1) ≥1 year to <5 years: weight ≥12 to <20kg; first shock 30 J; subsequent shock 70 J

2) ≥5 to <8 years: weight ≥20 to <30kg; first shock 50 J; subsequent shock 100 J

3) ​≥8 years: adult manual defib settings!

Question 33

As per the Cardiac Arrest Standard in the BLS, in situations involving a patient with cardiac arrest, the paramedic shall:

Answer 33

1) position patient on firm surface

2) initiate CPR (including defibrillation)

3) establish a patent airway using authorized techniques

4) consider reversible causes of cardiac arrest and initiate further ax and management as required by the Standards

5) minimize disruptions to CPR

6) continue cardiac arrest resuscitation measures until a TOR order is received as per the ALS PCS

7) if the patient has a ROSC,

• a) continue to ventilate if pt remains apneic or respirations are inadequate
• b) administer O₂ to attempt to maintain pt’s oxygen saturation 94-98%
• c) in conjunction with the Patient Assessment Standard, obtain vitals signs,
  
  • at least every 15 mins after the patient’s ROSC for the first hour
  • at a minimum every 30 minutes thereafter or if a change in pt status occurs
• d) continue cardiac monitoring
• e) resume CPR if cardiac arrest recurs

Question 34

Additional guidelines when running a cardiac arrest, as per the Cardiac Arrest Standard in the BLS

Answer 34

• When 2+ CPR-certified rescuers are available, attempt to switch chest compressors ~every 2 minutes
• Have suction equipment readily available in preparation for emesis
• As per current Heart and Stroke Foundation of Canada Guidelines, use of mechanical CPR devices may be considered (if available) when limited rescuers are available, for prolonged CPR or in a moving ambulance
• ETCO₂ may be considered if available
• In cases where CPR must be interrupted, such as when going down a flight of stairs, plan to reinitiate CPR as quickly as possible at a predetermined point.
• When performing CPR on a pregnant patient with a uterine height at or above the umbilicus (approximately greater than 20 weeks gestation), have a second paramedic attempt to manually perform left uterine displacement.