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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
Q

Severity assessment in asthma - severe asthma?

A

PEFR 33-50% best or predicted

RR >25

HR >110

Inability to complete full sentences

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26
Q

Severity assessment in asthma - life-threatening asthma?

A

Altered consciousness
Cyanotic
Hypotension
Exhaustion
Silent chest
Threatening numbers:
- PEFR <33%
- SpO2 92%
- PaO2 <8kPa
- Normal PaCO2

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27
Q

Severity assessment in asthma - near fatal asthma?

A

Raised PaCO2
Mechanical ventilation with raised inflation pressures

28
Q

Management of acute asthma to prevent cardiac arrest?

A

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
Q

ALS modifications in asthma?

A

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
Q

Management of anaphylaxis when identified?

A

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
Q

Management of refractory anaphylaxis (no improvement after 2 doses of IM adrenaline)?

A

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
Q

Modification of ALS in anaphylaxis?

A

Usual ALS algorithm

Treat with usual 1mg adrenaline IV/IO as per ALS

33
Q

When to take mast cell tryptase in anaphylaxis?

A

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
Q

Prevention of cardiac arrest in pregnancy?

A

Left lateral position or manually displace uterus to left

High flow oxygen

Fluid boluses for hypotension

Re-Evaluate need for drugs

Expert help

35
Q

Causes of cardiac arrest in pregnancy?

A

Cardiac disease

PE

Epilepsy and stroke

Sepsis

Mental health conditions

Bleeding

Malignancy

Hypertensive disorders of pregnancy

36
Q

Modifications of ALS in pregnancy?

A

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
Q

Reversible causes of collapse/arrest in pregnancy - haemorrhage?

A

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
Q

Reversible causes of collapse/arrest in pregnancy - pre-eclampsia and eclampsia?

A

Magnesium sulfate

39
Q

Reversible causes of collapse/arrest in pregnancy - amniotic fluid embolism?

A

At time of delivery, sudden collapse, breathlessness, cyanosis, hypotension with haemorrhage and DIC

40
Q

Perimortem C-Section - 20-23 weeks?

A

Emergency delivery of foetus to permit successful resuscitation of mother

Infant unlikely to survive

40
Q

Perimortem C-Section - <20 weeks gestation?

A

Not considered because fetal not viable

Unlikely to cause maternal cardiac compromise

41
Q

Perimortem C-Section - >24 weeks

A

Initiate emergency delivery to help save life of both mother and infant

42
Q

Definition of commotio cordis?

A

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
Q

Management of resuscitation in trauma - principles? (3)

A

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
Q

Management of cardiac tamponade in resuscitation?

A

Immediate decompression required

Thoracotomy with clamshell incision and opening of pericardium to relieve tamponade

Needle aspiration unreliable and likely to be clotted blood

45
Q

Treatment of tension pneumothorax in resuscitation?

A

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
Q

Which type of anaesthetic associated with increased cardiac arrest?

A

GA

47
Q

Common causes of perioperative cardiac arrest?

A

Hypovolaemia
Bleeding
Cardiac problems
Anaesthesia complications (airway management)

48
Q

Perioperative cardiac arrest - if pVT/VF?

A

Defbirillation

If not immediately available - precordial thump, if unsuccessful then CPR

49
Q

Perioperative cardiac arrest - adrenaline dosing?

A

Initial dose in increments (50-100mcg IV) rather than 1mg bolus, if no response to total 1mg then consider further boluses

50
Q

Cardiac surgery cardiac arrest - if pVT/VF?

A

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
Q

Initial Resuscitation in drowning patient once retrieved from water?

A

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
Q

Modifications of ALS after drowning - airway and breathing?

A

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
Q

Modifications of ALS after drowning - Circulation and defibrillation?

A

Check ECG and end tidal CO2 and consider Echo

Dry persons chest before applying defibrillator pads

Rapid IV fluid boluses

54
Q

Stages of hypothermia? (5)

A

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
Q

Resuscitation decisions in hypothermic patient?

A

Slow, small volume pulse, unrecoverable BP

Can tolerate periods of circulatory arrest (18 degrees 10x longer than 37 degrees)

Dilated pupils

56
Q

Intermittent CPR in hypothermia?

A

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
Q

Should CPR be given in hypothermic patients?

A

Yes - unless clear cause - lethal injury, fatal illness, prolonged asphyxia

In all others - no one is dead until warm and dead

58
Q

Modifications in ALS in hypothermia?

How long to check for signs of life?

When to intubate?

Drug changes in hypothermia?

A

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
Q

Rewarming in hypothermia?

A

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
Q

In hospital rewarming of hypothermia?

A

Warm IV infusions, warm air flow

ECMO preferable

61
Q

Risk factors of hyperthermia?

A

Elderly
Lack of acclimatisation
Dehydration
Obesity
Alcohol
Hyperthyroidism
Phaeochromocytoma
Medications (anticholinergics, diamorphine, cocaine, amphetamine, CCB, BB)

62
Q

Presentation of hyperthermia?

A

Mild - thirst, weakness, syncope, dizziness

Heat stroke - severe hyperthermia >40, neurological symptoms (confusion, seizure, coma), exposure to high temp or recent exercise

63
Q

Treatment of hyperthermia?

A

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
Q

Management of malignant hyperthermia?

A

Stop triggering agents

Give oxygen

Correct electrolytes and acidosis

Start active cooling

Dantrolene

ALS Theory (13 decks)

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