Resuscitation Flashcards
Adult basic life support (out of hospital):
Management steps?
- Assess danger
- Assess breathing and responsiveness
- Call 999 and ask for an ambulance
- Send someone to fetch AED if ambulance dispatch identify one nearby
- CPR 30:2
- Attach AED and follow instructions
Adult advanced life support:
Initial steps of cardiac arrest management?
Patient unresponsive and not breathing normally:
- Call resuscitation team (delegate/ring 2222)
- CPR 30:2
- Attach defibrillator/monitor
- Assess rhythm - shockable (VF/pulseless VT), non-shockable (PEA/asystole), return of spontaneous circulation (ROSC)
ALSO:
- Gain IV or IO access
- Administer oxygen
- Identify and treat reversible causes of cardiac arrest
Adult advanced life support:
Specific management of VF/VT cardiac arrest?
- Give 1 shock, followed by 2 minutes of CPR. Repeat.
- After the 3rd shock, 1mg of adrenaline is given upon restarting compressions
- 1mg of adrenaline then given after alternating cycles of CPR (every 3-5 minutes)
- Give amiodarone after every 3 shocks
Adult advanced life support:
Specific management of PEA/asystole (non-shockable rhythms)?
- Adrenaline 1mg ASAP
- 2 minutes of CPR then reassess rhythm
- Intubation & ventilation (once intubated perform continuous compressions at โผ100bpm)
Adult advanced life support:
What are the reversible causes of cardiac arrest?
How are they managed?
4 Hโs:
- ๐๐๐ฝ๐ผ๐
๐ถ๐ฎ โ intubation and ventilation
- ๐๐๐ฝ๐ผ๐๐ผ๐น๐ฎ๐ฒ๐บ๐ถ๐ฎ โ stop bleeding, IV fluid/blood products
- ๐๐๐ฝ๐ผ-/๐ต๐๐ฝ๐ฒ๐ฟ๐ธ๐ฎ๐น๐ฎ๐ฒ๐บ๐ถ๐ฎ, ๐บ๐ฒ๐๐ฎ๐ฏ๐ผ๐น๐ถ๐ฐ โ mx varies
- ๐๐๐ฝ๐ผ-/๐ต๐๐ฝ๐ฒ๐ฟ๐๐ต๐ฒ๐ฟ๐บ๐ถ๐ฎ โ warm if hypo-, cool if hyper-, dantrolene if malignant hyperthermia.
NB: avoid IV drugs in ALS algorithm in hypothermic patients as may have a drastic response
4 Tโs
- ๐ง๐ฒ๐ป๐๐ถ๐ผ๐ป ๐ฝ๐ป๐ฒ๐๐บ๐ผ๐๐ต๐ผ๐ฟ๐ฎ๐ โ needle thoracostomy with a wide-bore cannula
- ๐ง๐ฎ๐บ๐ฝ๐ผ๐ป๐ฎ๐ฑ๐ฒ โ pericardiocentesis โ thoracotomy โ birth heart and remove the clot
- ๐ง๐ผ๐ ๐ถ๐ป๐ โ minimise absorption, antidote if available
- ๐ง๐ต๐ฟ๐ผ๐บ๐ฏ๐ผ๐๐ถ๐ (coronary or pulmonary) โ thrombolysis ยฑ embolectomy
Adult advanced life support:
What is the management after ROSC?
- ABCDE assessment
- Aim for SpOโ of 94-98% and normal PaCOโ
- 12 lead ECG
- Identify and manage cause if not yet done
Bradycardia:
Initial management?
- ABCDE
- IV access and Oโ if appropriate
- Monitor ECG, BP, SpOโ
- Evidence of life-threatening signs: shock, syncope, myocardial ischaemia, heart failure
- If non-life-threatening manage supportively and arrange for the patient to receive a pacemaker
Bradycardia:
Management of life-threatening bradycardia?
- Atropine 500micrograms IV
If bradycardia is still life-threatening, then:
- Repeat atropine doses up to a maximum of 3mg
- Isoprenaline 5micrograms/min IV infusion
- Adrenaline 2-10micrograms/min IV
If still life-threatening:
- Seek expert help
- Arrange for transvenous pacing
Tachycardia:
Initial management:
- ABCDE
- IV access and Oโ if appropriate
- Monitor ECG, BP, SpOโ
- Assess evidence of life-threatening signs: shock, syncope, myocardial ischaemia, severe heart failure
Tachycardia:
Management of life-threatening tachycardia?
- Synchronised DC shock, up to 3 attempts
If unsuccessful:
- Amiodarone 300mg IV over 10-20 minutes
- Repeat synchronised DC shock
Tachycardia:
Assessment of non-life-threatening tachycardia?
- Is the QRS narrow/broad?
- Is the QRS regular/irregular?
Tachycardia:
Causes and management of regular, narrow-complex tachycardia?
SVT:
- Vagal manoeuvres (carotid massage โ valsalva)
- Adenosine 6mg IV bolus โ 12mg bolus โ 18mg bolus (avoid in asthmatics)
- Verapamil/beta-blocker
- Electrical cardioversion
Tachycardia:
Causes and management of irregular, narrow-complex tachycardia?
Probable AF:
- Rate control with beta-blocker (verapamil/diltiazem if asthmatic)
- Consider digoxin or amiodarone if evidence of HF
- Anticoagulate if >48hrs
Tachycardia:
Causes and management of regular, broad-complex tachycardia?
If VT (or uncertain): - Amiodarone 300mg IV
If certain diagnosis of SVT with BBB:
- Treat as for SVT
Tachycardia:
Causes and management of irregular, broad-complex tachycardia?
Torsades des Pointes:
- IV magnesium 2g
Possible AF with BBB:
- Consider expert help for diagnosis
- Treat as for fast AF
Anaphylaxis:
Assessment?
- ABCDE
- Look for sudden onset ABC problems
- Usually also skin changes e.g. itchy rash
Anaphylaxis:
Management?
- Remove trigger if possible
- IM adrenaline (1:1000; 1mg/mL)
- ๐๐ฑ๐๐น๐ ๐ฎ๐ป๐ฑ ๐ฐ๐ต๐ถ๐น๐ฑ >๐ญ๐ฎ: ๐ฑ๐ฌ๐ฌ๐บ๐ฐ๐ด (๐ฌ.๐ฑ๐บ๐)
- Child 6-12 yrs: 300mcg (0.3mL)
- Child 6mo-6yrs: 150mcg (0.15mL)
- Child <6mo: 100-150mcg (0.1-0.15mL) - Establish airway โ high-flow Oโ
- Repeat IM adrenaline after 5 mins if no response
- Seek expert help for refractory anaphylaxis
Paediatric advanced life support:
Management of cardiac arrest?
- Call 2222 for help
- Commence CPR (5 rescue breaths โ 15:2)
- Assess rhythm
- Reassess rhythm every 2 minutes
Paediatric advanced life support:
Management of a shockable rhythm?
- 1 shock โ 2 mins CPR, repeat
- After 3rd shock IV adrenaline AND amiodarone bolus
- Repeat adrenaline every alternate cycle
- Repeat amiodarone once after 5th shock
Paediatric advanced life support:
Management of a non-shockable rhythm?
- Immediately resume CPR for 2 mins
- Give adrenaline IV ASAP then every alternate cycle (3-5mins)
Newborn life support:
Management algorithm?
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Shock:
What is shock?
A life-threatening disorder of the circulatory system that results in inadequate organ perfusion and tissue hypoxia, leading to metabolic disturbances and, ultimately, irreversible organ damage
Shock:
What is the shock index?
- Calculated by pulse rate รท blood pressure
- > 1 โ shock
Shock:
Types of shock?
- Hypovolaemic shock (inc. haemorrhagic shock)
- Cardiogenic shock
- Obstructive shock
- Distributive shock (inc. anaphylactic, neurogenic, and septic shock)
Shock:
How do you identify cardiogenic shock? Why is this important?
- Measure pulmonary capillary wedge pressure โ proxy for preload
- It is important as IV fluid should not be given in cardiogenic shock; it will cause rapid pulmonary oedema and will lead to the patient deteriorating
Shock:
Routine investigations?
- FBC
- U&E
- LFT
- coagulation panel
- ABG/VBG โ raised lactate (type A lactic acidosis)
Shock:
Immediate management of shock?
Fluid challenge:
- 500ml of crystalloid in less than 15 minutes
- Monitor BP and end-organ function to look for improvement, while auscultating and monitoring SpOโ to look for pulmonary oedema
- Repeat until BP normalised or until fluid is no longer tolerated
Transfusion:
Red cell transfusion threshold in patients without ACS?
- Hb โค 70g/L
- Target after transfusion = 70-90g/L
Transfusion:
Red cell transfusion threshold in patients with ACS?
- Hb โค 80g/L (transfuse earlier as higher risk)
- Target after transfusion = 80-100g/L
Transfusion:
What is autologous blood transfusion?
- When a patient has some of their own blood taken and stored, ready to be transfused back into them if needed
Transfusion:
What steps can be taken to reduce the risk of infection from blood transfusion?
- Removal of WBCs (reduces risk of CMV, EBV transmission)
- Blood samples are tested for many transmissible diseases in the blood bank
- Irradiation - this further depletes T-lymphocytes. Indications include immunodeficiency and Hodgkin lymphoma
Transfusion:
Threshold for platelet transfusion if there is active bleeding?
< 30 x 10โน if clinically significant bleeding
Transfusion:
Threshold for platelet transfusion if there is no/insignificant active bleeding?
< 10 x 10โน
Transfusion:
Contraindications for platelet transfusion?
- Chronic bone marrow failure
- Autoimmune thrombocytopenia (e.g. ITP)
- Heparin-induced thrombocytopenia
- Thrombotic thrombocytopenic purpura
Transfusion:
Indications for using fresh frozen plasma?
- โClinically significantโ but not โmajorโ haemorrhage
- PT ratio or APTT ratio > 1.5
Transfusion:
Indications for cryoprecipitate?
- Solution containing vWF, factor VIII:C, fibrinogen, fibronectin and factor XIII
- Used to replace fibrinogen
- Suited for patients with โclinically significantโ but not โmajorโ haemorrhage with fibrinogen levels < 1.5g/L
Transfusion:
Indications for prothrombin complex concentrate?
Reversal of anticoagulation in patients with severe haemorrhage (including any intracerebral bleeding)
Transfusion:
What to transfuse if the patientโs ABO and Rh status is unknown?
Use the universal donors:
- Packed red cells: O (Rh negative if possible)
- FFP: Blood type AB
- Platelets: less important but AB Rh -ve if possible
ABCDE:
Airways assessment?
- Can the patient speak?
- If yes, patent โ move on to B
- Inspect the airway for foreign bodies
- Check for signs of partial/complete obstruction
- Signs of partial obstruction = cough, hoarseness, stridor, snoring
- Signs of complete obstruction = inability to speak or cry out, absent breath sounds, cyanosis & profound hypoxia
- Aspirate the airway with a suction catheter (if appropriate)
- If no reflex response (coughing/gagging) or the breathing rate is less than 8 per-minute โ call anaesthetist to intubate
ABCDE:
Airways - what are the basic airway management manoeuvres?
- Head tilt chin lift (should be avoided if thereโs concern for c-spine injury)
- Jaw thrust (doesnโt require c-spine to be cleared)
- Bag-mask ventilation
- Indicated to preoxygenate before intubation or as part of CPR
- Insertion of a basic airway adjunct
- Oropharyngeal airway if patient is unconscious
- Nasopharyngeal if patient is conscious. Contraindicated in basal skull fractures (โpanda eyesโ, haemotympanum, mastoid bruising
ABCDE:
A - indications for intubation?
- Inability to maintain the airway: general anaesthetic, airway obstruction, reduced GCS, absent protective reflexes (gag/cough)
- Inability to maintain ventilation: severe acute COPD/asthma
- Conditions with a high risk of deterioration: anaphylaxis, severe septic shock, multisystem shock
ABCDE:
A - management of a CICV (cannot intubate, cannot ventilate) scenario?
- Needle cricothyrotomy
- A large-bore cannula is inserted through the cricoid membrane
- Indicated in young children (canโt have surgical cricothyrotomy)
- Indicated in adults when the practitioner is not comfortable performing a surgical cricothyrotomy
- Surgical cricothyrotomy
ABCDE:
Assessment of breathing?
Examination
- Inspection
- Appearance
- Apnoea
- Signs of lethargy or distress
- Speaking in full sentences?
- Vital signs
- Respiratory rate
- SpO2
- Specific signs
- Tracheal deviation
- Paradoxical chest wall movement
- Increased respiratory effort
- Appearance
- Auscultation
- Air entry
- Pathological breath sounds
- Percussion
- Hyperresonance/dullness
Rapid/bedside investigations
- ABG
- VBG is likely sufficient if no respiratory distress
- Consider bedside CXR and/or lung ultrasound
ABCDE:
Initial management of breathing?
- Apnoea/fulminant respiratory failure:
- Bag-mask ventilation
- Basic airway adjuncts
- Prepare for intubation and ventilation
- High-flow oxygen for all critically ill patients (except MI if theyโre maintaining saturations or known CO2-retaining COPD patients)
- If detected, provide emergency treatment of:
- Tension pneumothorax
- Needle thoracotomy decompression โ chest drain
- Massive haemothorax/pleural effusion
- Insert a chest drain
- Bronchospasm
- Administer bronchodilators (neb salbutamol & ipratropium, IV magnesium sulfate)
- Acute severe pulmonary oedema
- Administer diuretics
- Tension pneumothorax
ABCDE:
C - what are things to check when assessing a patientโs circulation?
- Assess skin appearance (e.g. pallor, mottling, cyanosis, diaphoresis)
- Check pulses
- Check HR and BP
- If shocked:
- Initiate sepsis six, record qSOFA score if Sepsis confirmed
- Check for signs of end organ damage
- Check for signs of active bleeding
- Take clotting screen, G&S and crossmatch if bleeding significant
- Auscultate the heart
- Muffled may indicate pneumothorax or tamponade
- Murmurs
- Friction rub suggests pericarditis
- Assess volume status
- Mucous membranes
- JVP
- CRT
- Obtain 12 lead ECG
- Consider other bedside tests such as a FAST scan, cardiac echo or CXR
ABCDE:
C - management of shock
- Establish (preferably x2) large-bore IV access
- Always give haemodynamic support*
- Fluid challenge (500ml IV crystalloid in < 5 minutes, 250ml if small & frail)
- Vasopressors if not responding to fluid
- The threshold depends on cause e.g. HHS may benefit from many litres of fluid while an elderly lady with cardiogenic shock may respond more poorly to small amounts.
- Haemorrhagic shock
- Blood transfusion
- Emergency haemostatic measures (e.g. pressure, packing wound)
- Obstructive shock
- Cardiac tamponade: pericardiocentesis/thoracostomy
- Tension pneumothorax: needle decompression โ chest drain
- Massive PE: thrombolysis
- Distributive shock
- Anaphylactic: IM adrenaline
- Septic shock: empiric IV antibiotics according to local policy
- Adrenal crisis: IV hydrocortisone
ABCDE:
C - other immediate management of C pathology (not shock)?
Very much depends on what was found during the assessment
- Hypertensive crisis
- Cautious use of IV antihypertensives
- Identify and manage any arrhythmias
- Identify and manage any cardiac ischaemia
- Treat any electrolyte disturbances that may compromise circulation
- Rapid vascular surgery transfer if ruptured AAA or aortic dissection
- etc. etc.
ABCDE:
D - what forms the components of a disability assessment?
- Evaluate consciousness
- GCS
- AVPU
- Identify readily-apparent possible underlying aetiology
- Head and neck trauma
- Hemiplegia
- Seizure activity
- Toxins on clothes/skin
- Check blood glucose level
- Examine pupils
- Evaluate for:
- Lateralising signs
- Signs of raised ICP
- Meningism
- Identify any classic toxidromes
- Consider:
- 12 lead ECG
- Toxicology screen
- Neuroimaging (e.g. CT head)
ABCDE:
D - what are some toxidromes?
ABCDE:
Management of D?
- โIf GCS โค 8 then intubateโโ
- Agitated or violent patients
- De-escalate if possible
- Consider the need to restrain and/or administer calming medication if the patient remains a risk to themself or others
- Suspected brain injury โ initiate protective measures
- Maintain adequate perfusion
- Optimise oxygenation & ensure normocapnia
- Provide emergency treatment for:
- Status epilepticus: IV lorazepam 5mg โ lorazepam 5mg โ phenytoin infusion
- Hypoglycaemia: IV glucose
- Intoxication/poisoning: administer antidote (search toxbase if unsure)
- Meningitis: IV antibiotics according to local policy
- Correct severe electrolyte abnormalities (beware overly rapid correction โ cerebral oedema)
- Consider need for escalation
ABCDE:
E - assessment of exposure?
- Fully undress patient
- Safely examine patientโs back (using c-spine precautions if necessary)
- Check for clues that may indicate the underlying condition:
- Triggers of anaphylaxis e.g. latex, insect stings
- Signs of trauma e.g. stab wounds, burns
- Rash e.g. petechiae
- Sources of sepsis e.g. infected wounds, gangrene
- Toxins and drugs - needle track marks, medication patches
- Other small wounds or foreign bodies e.g. insect bites, ticks
- Measure core body temperature
ABCDE:
E - management?
- Remove all potential causes for deterioration
- Allergens
- Transdermal medication patches
- Provide clean, dry clothing e.g. hospital gown
- Manage body temperature
- Hypothermia
- Warm IV fluid
- Active warming e.g. โbear-huggerโ
- Hyperthermia
- Begin surface cooling
- Consider cool IV fluids
- Antipyretics (not for environmental or malignant hyperthermia)
- Dantrolene for malignant hyperthermia
- Hypothermia
- Treat underlying pathology e.g. infection, trauma, intoxication etc.
