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ALS Theory > Resus in Special Circumstances > Flashcards

Resus in Special Circumstances Flashcards

1
Q

What is most common electrolyte disorder associated with cardiac arrest?

A

Hyperkalaemia

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2
Q

Causes of hyperkalaemia?

A

Renal failure (AKI/CKD)

Drugs (ACEi, ARB, potassium sparing diuretics, NSAIDs, beta blockers, trimethoprim)

Tissue Breakdown (Rhabdomyolysis, tumour lysis syndrome)

Metabolic Acidosis (Renal Failure, DKA)

Endocrine (Addison’s Disease)

Diet (in advanced CKD)

Spurious

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3
Q

Symptoms of hyperkalaemia?

A

Weakness
Paralysis
Paraesthesia
Reduced tendon reflexes

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4
Q

ECG Changes in hyperkalaemia

A

1st degree heart block

Flattened or absent P waves

Tall, peaked T waves

ST segment depression

Sine wave pattern

Widened QRS

VT

Bradycardia

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5
Q

Management of hyperkalaemia - mild 5.5-5.9?

A

Address cause

If treatment indicated - potassium binders like lokelma/calcium resonium

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6
Q

Management of hyperkalaemia - moderate 6.0-6.4 without ECG changes?

A

10 units insulin in 25g glucose IV over 15-30 minutes

Followed by glucose infusion 10% at 50ml/hr for 5 hours if BM <7 initially

Remove potassium from body

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7
Q

Management of hyperkalaemia - moderate with ECG changes or >6.5?

A

Seek expert help

IV calcium gluconate 10mls 10% over 2-5 minutes

Glucose/insulin

Salbutamol nebuliser 10-20mg

Consider dialysis, Lokelma

May need continuous cardiac monitoring

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8
Q

Changes to ALS associated with hyperkalaemia?

A

Confirm with blood gas

10ml calcium chloride 10% IV rapid bolus injection, repeat if prolonged or refractory

10 units insulin in 25g glucose IV rapid injection

Sodium bicarbonate 50mmol (50ml 8.4%) IV by rapid injection

Consider dialysis

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9
Q

Causes of hypokalaemia?

A

GI losses (diarrhoea, vomiting)

Drugs (laxatives, diuretics, steroids)

Renal losses (RTA, DI, dialysis)

Endocrine (Cushing’s syndrome, hyperaldosteronism)

MEtabolic acidosis

Magnesium depletion

Poor diet

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10
Q

Symptoms of hypokalaemia?

A

Fatigue
Weakness
Muscle cramps
Constipation
Rhabdomyolysis

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11
Q

ECG changes in hypokalaemia?

A

U waves
T waves flattening
ST changes
Arrhythmias

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12
Q

Treatment of hypokalaemia

A

IV replacement

Maximum is 20mmol/hr, but is cardiac arrest imminent then 2mmol/minute for 10 minutes followed by 10mmol over 5-10 minutes

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13
Q

Modifications of ALS with dialysis patient?

A

OOH cardiac arrest 20x more likely

Assign trained dialysis nurse to operate haemodialysis machine

Stop dialysis and return patient’s blood volume with fluid bolus

Disconnect from dialysis machine (unless defibrillation proof)

Leave dialysis access open to use for drug administration

Dialysis may be required in early ROSC care

Prompt management of hyperkalaemia

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14
Q

Modification of ALS for toxins (poisoning)?

A

Avoid mouth-to-mouth when cyanide, hydrogen sulphide, corrosives, organophosphates

Correct electrolytes, acid base disorders

Cardioversion for tachyarrhythmias

Patient temperature

Consider extracorporeal life support

Consult TOXBASE

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15
Q

When is activated charcoal given?

A

Single dose when known ingestion of toxic dose within 1 hour

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16
Q

Management of salicylate toxicity?

A

IV sodium bicarbonate for urine alkalisation

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17
Q

Antidote for toxicity of - opioids?

A

Naloxone 400mcg IV, 800mcg IM, 800mcg SC

May require increments until breathing adequately, may need ongoing infusion if long acting opioid ingested

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18
Q

Antidote for toxicity of - benzodiazepines?

A

Flumazenil

Risk of SE (seizure, arrhythmia, hypotension, withdrawal syndrome)

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19
Q

Antidote for toxicity of - TCA?

A

Amitriptyiline, desipiramine, imipramine, nortryptiline, doxepine

Hypotension, seizures, coma, arrhythmia

Sodium bicarbonate

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20
Q

Antidote for toxicity of - local anaesthetic?

A

IV 20% lipid emulsion bolus followed by infusion

Up to 3 boluses at 5 minute intervals and continue infusion until patient stable

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21
Q
A
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22
Q

Antidote for toxicity of - stimulants?

A

Small doses of benzodiazepines first line

GTN second line if myocardial ischaemia

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23
Q

Antidote for toxicity of - drug induced bradycardias?

A

Atropine in organophosphate toxicity

Isoprenaline

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24
Q

Causes of cardiopulmonary arrest in asthma?

A

Severe bronchospasm and mucous plugging leading to asphyxia

Arrhythmias secondary to hypoxia

Dynamic hyperinflation (auto PEEP) - air trapping and breath stacking, reduces venous return and BP

Tension pneumothorax

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25
Severity assessment in asthma - severe asthma?
PEFR 33-50% best or predicted RR >25 HR >110 Inability to complete full sentences
26
Severity assessment in asthma - life-threatening asthma?
Altered consciousness Cyanotic Hypotension Exhaustion Silent chest Threatening numbers: - PEFR <33% - SpO2 92% - PaO2 <8kPa - Normal PaCO2
27
Severity assessment in asthma - near fatal asthma?
Raised PaCO2 Mechanical ventilation with raised inflation pressures
28
Management of acute asthma to prevent cardiac arrest?
Oxygen therapy aim 94-98% Salbutamol 5mg Nebuliser oxygen driven - Repeat every 15-30 minutes or continuous doses Ipratropium bromide 500mcg 4-6 hourly Steroids (prednisolone 40mg PO or hydrocortisone 100mg IV 6-hourly) early Single dose IV Magnesium Sulfate 2g (8mmol) over 20 minutes in acute severe asthma with no response Consider IV salbutamol + senior advice on IV aminophylline IV fluids ICU support and tracheal intubation
29
ALS modifications in asthma?
Intubate trachea early - risk of gastric inflation and hypoventilation If dynamic hyperinflation - compression of chest wall and period of apnoea - limited evidence Look for 4H's and 4T's - tension pneumothorax
30
Management of anaphylaxis when identified?
Call for help Remove trigger (stop infusion) Lie patient flat IM Adrenaline 1:1000 - Adult and child >12 = 500mcg - Child 6-12 years = 300mcg - Child 6 months - 6 years = 150mcg - Child < 6 months = 100-150mcg High flow oxygen Establish airway Monitor BP/ECG/SpO2 If no response: Repeat IM adrenaline after 5 minutes, IV fluid bolus 500ml - 1L If no response after 2 doses of adrenaline - follow refractory management algorithm
31
Management of refractory anaphylaxis (no improvement after 2 doses of IM adrenaline)?
IV/IO Access + Expert Help Rapid IV fluid bolus + Adrenaline infusion (titrate according to response) IM adrenaline every 5 minutes until infusion set up
32
Modification of ALS in anaphylaxis?
Usual ALS algorithm Treat with usual 1mg adrenaline IV/IO as per ALS
33
When to take mast cell tryptase in anaphylaxis?
Time of onset = time symptoms first noticed One sample 2-4 hours from start of symptoms 3 timed samples - asap, 1-2 hours, at 24 hours for baselinePre
34
Prevention of cardiac arrest in pregnancy?
Left lateral position or manually displace uterus to left High flow oxygen Fluid boluses for hypotension Re-Evaluate need for drugs Expert help
35
Causes of cardiac arrest in pregnancy?
Cardiac disease PE Epilepsy and stroke Sepsis Mental health conditions Bleeding Malignancy Hypertensive disorders of pregnancy
36
Modifications of ALS in pregnancy?
Obtain obstetric help and neonatologist Normal ALS applies After 20 weeks - uterus can compress IVC and aorta - manually displace uterus to left to minimise IVC compression Left lateral tilt if able Prepare for emergency C Section Early tracheal intubation
37
Reversible causes of collapse/arrest in pregnancy - haemorrhage?
Ectopic pregnancy, placental abruption, placenta previa, uterine rupture Fluid resus TXA Oxytocin, ergometrine, prostaglandins and uterine massage to correct uterine atony Uterine compression sutures, uterine packs IR for bleeding Surgical control
38
Reversible causes of collapse/arrest in pregnancy - pre-eclampsia and eclampsia?
Magnesium sulfate
39
Reversible causes of collapse/arrest in pregnancy - amniotic fluid embolism?
At time of delivery, sudden collapse, breathlessness, cyanosis, hypotension with haemorrhage and DIC
40
Perimortem C-Section - 20-23 weeks?
Emergency delivery of foetus to permit successful resuscitation of mother Infant unlikely to survive
40
Perimortem C-Section - <20 weeks gestation?
Not considered because fetal not viable Unlikely to cause maternal cardiac compromise
41
Perimortem C-Section - >24 weeks
Initiate emergency delivery to help save life of both mother and infant
42
Definition of commotio cordis?
Blunt impact to chest wall over heart Can cause VF/VT Occurs during sports (baseball) and usually teenage males Early defibrillation important for survival
43
Management of resuscitation in trauma - principles? (3)
Permissive hypotension (only enough to achieve radial pulse) until surgical haemostats achieved Duration of hypotension resuscitation <60 minutes TXA 1g IV followed by infusion
44
Management of cardiac tamponade in resuscitation?
Immediate decompression required Thoracotomy with clamshell incision and opening of pericardium to relieve tamponade Needle aspiration unreliable and likely to be clotted blood
45
Treatment of tension pneumothorax in resuscitation?
Needle decompression - 2nd intercostal space mid-clavicular space or 4th/5th in mid axillary line Open thoracostomy and chest drain as soon as ROSC Open thoracostomy - incision to chest wall (5th MA line) followed by dissection to pleural space
46
Which type of anaesthetic associated with increased cardiac arrest?
GA
47
Common causes of perioperative cardiac arrest?
Hypovolaemia Bleeding Cardiac problems Anaesthesia complications (airway management)
48
Perioperative cardiac arrest - if pVT/VF?
Defbirillation If not immediately available - precordial thump, if unsuccessful then CPR
49
Perioperative cardiac arrest - adrenaline dosing?
Initial dose in increments (50-100mcg IV) rather than 1mg bolus, if no response to total 1mg then consider further boluses
50
Cardiac surgery cardiac arrest - if pVT/VF?
3 quick stacked shocks If failed then emergency resternotomy with further defibrillation internally with paddles (20J) Adrenaline cautiously and titrate to effect up to 100mcg doses Emergency resternotomy indicated once reversible causes excluded and also in PEA/asystole when treatments failed (performed within 5 minutes)
51
Initial Resuscitation in drowning patient once retrieved from water?
5 initial ventilation breaths, supplemented with oxygen Place on firm surface and start CPR 30:2 (avoid compression only CPR as hypoxia common) Massive foam from mouth - needs intubation but ALS provider If regurgitation prevents ventilation - turn patient to side and remove regurgitated contexts using suction
52
Modifications of ALS after drowning - airway and breathing?
15L NRM to spontaneously breathing patient Consider early tracheal intubation and controlled ventilation (reduced pulmonary compliance limits supraglottic devices) Higher PEEPs at least 5-10cm H2O but can be up to 20 Decompress stomach with gastric tube
53
Modifications of ALS after drowning - Circulation and defibrillation?
Check ECG and end tidal CO2 and consider Echo Dry persons chest before applying defibrillator pads Rapid IV fluid boluses
54
Stages of hypothermia? (5)
Stage 1 - 35-32 - mild - conscious, shivering Stage 2 - 32-28 - moderate - impaired consciousness without shivering Stage 3 - 28-24 - severe - unconscious, vital signs present Stage 4 - <24 - cardiac arrest Stage 5 - <11.8 - death due to irreversible hypothermia
55
Resuscitation decisions in hypothermic patient?
Slow, small volume pulse, unrecoverable BP Can tolerate periods of circulatory arrest (18 degrees 10x longer than 37 degrees) Dilated pupils
56
Intermittent CPR in hypothermia?
If continuous cannot be delivered If <28 degrees - 5 mins CPR alternating with <5 mins without If <20 degrees - 5 mins CPR alternative with up to 10 minutes without
57
Should CPR be given in hypothermic patients?
Yes - unless clear cause - lethal injury, fatal illness, prolonged asphyxia In all others - no one is dead until warm and dead
58
Modifications in ALS in hypothermia? How long to check for signs of life? When to intubate? Drug changes in hypothermia?
Check for signs of life for up to 1 minute (central artery, ECG rhythm, capnography, echo) - if doubt then start CPR Mechanical chest compressions Early tracheal intubation Hold drugs until temp >30 degrees Once over 30 degrees - double intervals between doses (6-10 minutes) Once >35 degrees - normal drug protocols If VF persists after 3 shocks - delay until temp >30 degrees
59
Rewarming in hypothermia?
Rapid transfer to hospital Dry and insulate body, remove wet clothing Conscious people should exercise Temperature can drop further after removal from cold environment Mild - fully body insulation, shivering, aluminium foil, cap Moderate/Severe - chemical heat packs to trunk, arrange around recovery position Transfer to ECMO centre
60
In hospital rewarming of hypothermia?
Warm IV infusions, warm air flow ECMO preferable
61
Risk factors of hyperthermia?
Elderly Lack of acclimatisation Dehydration Obesity Alcohol Hyperthyroidism Phaeochromocytoma Medications (anticholinergics, diamorphine, cocaine, amphetamine, CCB, BB)
62
Presentation of hyperthermia?
Mild - thirst, weakness, syncope, dizziness Heat stroke - severe hyperthermia >40, neurological symptoms (confusion, seizure, coma), exposure to high temp or recent exercise
63
Treatment of hyperthermia?
Cool environment and laid flat Cool IV fluids, misting, fanning. OR if available cold water immersion/full body conductive cooling systems IV isotonic/hypertonic fluids, large volumes required Correct electrolytes Standard ALS care with continued cooling
64
Management of malignant hyperthermia?
Stop triggering agents Give oxygen Correct electrolytes and acidosis Start active cooling Dantrolene

ALS Theory (13 decks)

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