ACLS

Question 1

Vascular access typically

Answer 1

1. IV
   - use most proximal vein available
   - antecubital, external jugular
2. IO
   - non collapsible venous plexuses in bone marrow
   - rate of delivery similar to IV
   - proximal humerus, tibial tuberosity, distal femur, distal tibial
3. Intra-arterial

Question 2

Cardiac arrest drugs for:
- VFIB / Pulseless VT
- PEA
- Asystole

Answer 2

IV adrenaline 1mg dilute with 9mls of normal saline (1:10000) followed by 20mls NS flush given every 3-5mins (but standardise every 4 MINS)

Question 3

What is the effect of adrenaline?

Answer 3

Peripheral vasoconstriction -> improves cerebral and coronary blood flow

Question 4

ROSC amiodarone dose

Answer 4

1mg/min x 6h then 0.5mg/min x 18h

Question 5

Lignocaine max dose

Answer 5

3mg/kg

Question 6

How to administer adenosine?

Answer 6

IV adenosine 6mg given as a bolus with 20ml saline
Use a 3 way valve and raise the arm
If unsuccessful -> give 12mg followed by another 18mg

Question 7

VFIB / pulseless VT identified: how to react initially?

Answer 7

SHOCK immediately + CPR + IV adrenaline 1mg dilute in 9mls of saline (1:10000)

Defib in manual mode:
- Biphasic defib: 120J
- Monophasic defib: 360J

Question 8

ACLS cardiac arrest timeline

Answer 8

0 min starts when VF / pulseless VT first identified
- Rhythm and pulse check every 2 mins
0: SHOCK + CPR + IV adrenaline
2: SHOCK + CPR
4: SHOCK + CPR + IV adrenaline
6: SHOCK + CPR + IV amiodarone 300mg bolus
8: SHOCK + CPR + IV adrenaline + IV amiodarone 150mg bolus
10: SHOCK + CPR
12: SHOCK + CPR + IV adrenaline
etc

*IV adrenaline every 4 mins / every other pulse and rhythm check
*Once ROSC = first thing check BP
*If refractory after amiodarone, can consider 50-100g of IV lignocaine
*INTUBATE as soon as possible

Question 9

If asystole on defib, perform asystole check:

Answer 9

1. Check connection of leads
2. Check gain of the leads
3. Check other leads for asystole

Question 10

After confirming asystole check, what to do?

Answer 10

Proceed to continue CPR
(no need to shock)
Push IV adrenaline if due
Look for reversible causes

Question 11

what is PEA?

Answer 11

Pulseless electrical activity is any potentially perfusing rhythm or electrical activity that fails to general a palpable pulse

Question 12

During pulse and rhythm check, what to do?

Answer 12

PAUSE CPR
Assess for pulse and rhythm
Take no more than 10 seconds
- Must have both pulse and rhythm for ROSC, if just rhythm no pulse then it’s PEA

Question 14

For PEA/asystole, what is the underlying issue?

Answer 14

Look for 5H, 5T
Hypoxia
Hyper/Hypo K+
Hypothermia
H+ acidosis
Hypovolemia

cardiac Tamponade
pulmonary embolism
Tension pneumothorax
coronary Thrombosis (ACS)
Toxins

Question 15

PEA how to react?

Answer 15

Same as asystole
- continue CPR
- don’t shock
- IV adrenaline
- look for reversible cause

Question 16

Post ROSC: what to do?

Answer 16

1. Order relevant investigations (FBC, RP, ABG, ECG, CXR)
2. Monitoring and post rosc bundle targets
3. Definitive management (PCI as indicated or treat reversible causes)

Question 17

Post ROSC bundle

Answer 17

MOST IMPT: BP
- maintain MAP > 65mmHg (prevent hypotension -> hypoperfusion)

• maintain normocapnia (prevent cerebral vasoconstriction)
• maintain SpO2 94-98% (prevent hypoxia-induced inflammatory damage)
• targeted temperature management 32-36 degrees (reduce inflammatory response -> improve neurological outcome)
• glycemic control 6-10mmol/L (improve neurological outcome)
• neurological assessment after 72h (allow cerebral recovery)