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Advanced life support algorithm Flashcards

1
Q

What 2 groups are heart rhythms associated with cardiac arrest divided into ?

A
  1. Shockable - ventricular fibrillation & pulseless ventricular tachycardia (VF/pVT)
  2. Non-shockable - asytole and pulseless electrical activity (PEA)
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2
Q

What is the key difference in the management of VF/pVT and asystole/PEA?

A

You shock/defibrilate patients with VF/pVT.

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3
Q

What are the 3 key things which improve survival after cardiac arrest?

A
  • Prompt & effective bystander CPR
  • Uninterupted CPR (or as minimal as possible)
  • Early defibrillation of VF/pVT
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4
Q

How often will VF/pVT occur at some point in a cardiac arrest when the inital documented rhythm is asystole or PEA?

A

25% of the time.

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5
Q

What is the standard positions to place the self-adhesive defibrillation/monitoring pads on a patient ?

A

1st below the right clavicle
2nd left side in V6 mid-axillary line

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6
Q

You should plan your actions prior to interupting chest compressions. When chest compression are paused for rhythm check how long should this pause be ?

A

< 5 secs.

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7
Q

Once rhythm is confirmed and it is a shockable rhythm what is the next step?

A

You should charge the defibrillator to appropriate energy (J). Whilst charging the person doing compressions should restart compressions, everyone else should be stood clear of the patient with oxygen removed.

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8
Q

What is the general range of energy which can be used for the intial shock of a person in VF/pVT?

A

120-150J. (same or higher used for subsequent shocks)

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9
Q

Prior to shocking a patient for VF/pVT what should be done? (remember person doing compressions is currently still in contact with the patient)

A

Carry out safety check and tell person doing compressions to stand clear. Ensure no oxygen is in contact with the patient.

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10
Q

After a shock is delivered to the patient what should immediately happen ?

A

CPR should be restarted.

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11
Q

After shocking a patient should you pause to assess the rhythm or for a pulse?

A

No! - continue with CPR

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12
Q

When should you give drugs in shockable cardiac arrest rhythms and what should you give?

A

You should give 1mg IV adrenaline and 300mg IV amiodarone after the 3rd shock (this is whilst fruther round of CRP is going, i.e. started the 4th round).

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13
Q

After giving the 1st dose of adrenaline and amiodarone is given in shockable (VF/pVT) cardiac arrests when should you next give them ?

A

Give 1mg adrenaline every 3-5 mins i.e. every 2nd/alternate shock thereafter. For as long as cardiac arrest persists.

Amidoarone may be given after a total of 5 shocks have been given at a dose of 150mg.

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14
Q

If organised electrical activity consistent with cardiac output seen, when should you check for signs of life/ROSC?

A

At the next rhythm check (check for signs of life, sudden increase in end tidal CO2 and check central pulse)

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15
Q

If on rhythm check despite previously being shockable (VF/pVT) the rhythm has changed to either asystole or PEA what should you do ?

A

**Switch to the non-shockable algorithm **

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16
Q

If at rhythm check there is ROSC what should you do ?

A

Start post-resuscitation care.

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17
Q

Go over this summary of the steps of shockable algorithm

A

Add photo

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18
Q

How often after defibrillating someone and resotring a perfusing rhythm might you not immediately be able to palpate a pulse?

`

A

It’s very rare to be able to immediately palpate a pulse after defibrillation. It takes > 2 mins in 25% of cases to feel a palpable pulse after shock.

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19
Q

If a perfusing rhythm has been restored but you still cannot feel a pulse does continuing to give chest compressions increase the chance of VF occuring ?

A

No - also you would have to assume PEA until pulse felt anyway.

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20
Q

The evidence for adrenaline/amiodarone in cardiac arrest is limited. However what does there use increase?

A

Short-term survival

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21
Q

Should you stop for a rhythm check before giving drugs during a cardiac arrest ?

A

No - only scenario you would is if there is clear signs of ROSC.

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22
Q

If there is no amiodarone available what alternate can be used in shockable rhythms ?

A

Lidocaine at 1mg/kg

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23
Q

When can lidocaine not be used as an alternate to amiodarone ?

A

If amiodarone has already been used.

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24
Q

The decision to continue a resuscitation attempt is a clinical judgement as a rough rule of thumb however what is thought about continuing resusication attempts in VF/pVT (shockable) rhythms?

A

That its worth continuing the resus attempt whilst they remain in these rhythms.

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25
In shock-refractory VF/pVT what should you consider doing?
You should check position and contact of the pads, if satisfactory, consider changing the defib pad placement to anterior-posterior.
26
Do you check for a pulse at each rhythm check?
No - only if you have a rhythm compatible with a pulse
27
When only should you interupt CPR to check for a pulse ?
When there is clear signs of ROSC
28
Sometimes it might be hard to distinguish fine VF from asystole, in this scenario what should you do i.e. what pathway should you follow?
Go with whichever pathway you think it is most likely, DONT debate.
29
A precordial thump has a very low success rate for cardioversion, when can it be used?
Only when it can be used without delay whilst awaiting for arrival of a defibrillator in a monitored VF/pVT arrest.
30
How does the ALS guideline differ for patients with a monitored arrest in the cath lab, CCU/ITU or whilst monitored after cardiac surgery AND a manual defibrillator is readily available?
* Confirm cardiac arrest and if initial rhythm is VF/pVT can give 3 successive stacked shocks. * After each defibrillation attempt rapidly check if appropriate for pulse/signs of ROSC * If 3rd shock is unsuccessful continue on normal ALS algorithm BUT treat the previous 3 shocks as if only one shock was given in the normal alogrithm i.e. adrenaline would be given after 2 more shocks. Amiodarone on the other hand is given after 3rd shock regardless so give following three stacked shocks.
31
Define PEA
This is electrical activity (other than ventricular tachycarrhythmia) that would normally be associated with a palpable pulse. These patients often have some mechanical myocardial contractions but they are too weak to produce a detectable pulse or BP.
32
Define asystole
This is the absence of electrical activity on the ECG trace
33
Whenever a diagnosis of asystole is made what should you double check for ?
That there is no p-waves suggesting ventricular standstill which might need treating with cardiac pacing. [https://www.youtube.com/watch?v=2pHNEiH4wFg](http://)
34
In non-shockable rhythms there is no difference in what you do aside from drugs and you DO NOT shock them. What is the difference in protocol for drugs given in non-shockable rhythm cardiac arrests?
Amiodarone is not given! 1mg IV Adrenaline is given immediately as soon as IV access is achieved.
35
After IV access is achieved and the 1st dose of adrenaline is given in non-shockable rhythms when is it next given?
Every 3-5 mins i.e. during alternate 2 min cycles of CPR.
36
During CPR when a defintive airway is not in place you will be giving compressions to ventilation breaths at 30:2. During these short breaks in compressions you might notice the rhythm has changed from non-shockable to VF (pVT doesnt count), should you stop and shock the patient or wait till the 2 min cycle of CPR has been completed?
Wait till the 2 min cycle has completed but prep the team that a shock will be immediately delivered. pVT doesnt could as you need to check for a pulse to confirm this.
37
Throughout the cardiac arrest (shockable or non-shockable alogrithm) what should you be checking for ?
Reversible causes. 4H's & 4T's
38
In the absence of personnel trainined in intubation what is the preferred airway during a cardiac arrest?
Preferrably a supra-glottic airway (SGA) i.e. i-gel. If unable to get an adequate seal with i-gel then bag-mask
39
If a SGA is secured, at what rate should you ventilate the patient?
10 breaths/min Compressions is at 100-120/min.
40
If whilst providing continuous compressions and ventilating a patient at 10 breaths/min there appears to be excessive gas leakage causing inadequate ventilation what should you do ?
Interupt chest compressions to provide adequate **ventilation** i.e. switch back to 30:2.
41
Have studies shown a benefit of intubation over bag-mask and SGA in cardiac arrests?
No
42
If the patient is intubated during an arrest how long can you pause compressions for whilst they are being intubated ?
No more than 5 secs.
43
How do you confirm correct palcement of the tracheal tube?
Waveform capnography Observation and asculatation to ensure both lungs ventilated
44
What clinical signs indicate ROSC and what if convincing do they require?
Breathing efforts, movements, eye opening and regaining conciousness. They then require rhythm and a pulse check. However these can occur in high quality CPR.
45
During arrests blood samples can be difficult to interpret, what samples might provide a better estimate of tissue pH?
Central venous blood samples.
46
Invasive blood pressure monitoring will help detect what during cardiac arrests?
Very low cardiac output/BP states when ROSC is achieved.
47
List the different ways you might monitor a patient in cardiac arrest
* Clinical signs of life * Pulse checks * Defibrillation pads i.e. heart rhythm * Waveform capnography - End-tidal CO2 * Feedback or prompt devices * Blood sampling and analysis * Invasive BP monitoring (arterial lines) * Focused echo/ultrasound.
48
If you suspect ROSC during a round of CPR, should you withold adrenaline ?
Yes, withold then finish 2 min cycle, check rhythm/pulse and if cardiac arrest still confirmed give the adrenaline during the next cycle.
49
If there is a combination of signs suggesting ROSC e.g. waking, purposeful movements, arterial BP waveform or sharp rise in end-tidal CO2 what should you do during CPR?
Consider briefly stopping to check rhythm and a pulse check. Note - if not convinced of ROSC then wait for next rhythm check and then assess rhythm and pulse.
50
If someone does not have vascular access and suffers a cardiac arrest what should you do?
1. Start the usual ALS alogrithm with compressions, airway management and defibrillation. 2. The gain vascular access through either PVC or if unable intraosseous route (IO).
51
How should drugs administered during an arrest be given ?
Drugs through a PVC or IO route should be followed by a min 20ml flush and then elevate the extremity for 10-20secs.
52
Does the IO route compared to PVC's achieve similar plasma concentrations of drugs ?
Yes & in a similar time
53
What are the 3 main sites for IO access?
1. The proximal humerus 2. The proximal tibia 3. The distal tibia Add photo.
54
What are the contraindications to IO access during an arrest?
Trauma to target site. Infection of target site. Joint replacement Recent IO access in the same limb, including failed attempts. Failure to identify anatomical landmark for insertion.
55
How do you confirm correct placement of IO access?
* Aspirate from needle, presence of IO blood confirms position. However abscence of blood does not necessarily imply failed insertion. * If no blood then extensively flush the needle and observe for leakage or extravasation.
56
Once IO access is confirmed you can give drugs, fluids an bood products as per the normal ALS protocol. What is the only difference to how you administer them ?
You will need extra pressure! - this is achieved through using a pressure bag or syringe (20ml flush)
57
What are the potential complications of IO access?
* Extravasation * Dislodgement of the needle * Compartment syndrome * Fracture or chipping of the bone * Pain * Fat emboli * Infection/OM
58
List the 4H's and 4T's for potential causes of cardiac arrest
4H's: 1. Hypoxia 2. Hypo/hyperthermia 3. Hypovolaemia 4. Hyper/hypokalaemia, hypoglycaemia, hypocalcaemia and other metabolic disorders. 4T's: 1. Thrombosis - coronary or pulmonary 2. Tamponade - cardiac 3. Tension pnuemothorax 4. Toxins
59
During an arrest how is hypoxia as a potential cause managed?
By securing the airway and giving 100% oxygen.
60
PEA cardiac arrest caused by hypovolaemia is usually caused by what?
Massive haemorrhage (this may be obvious e.g. trauma or occult e.g. GI bleeding or ruptured AAA).
61
What is the general mx of hypovolaemia ?
Replacement of circulating volume with fluids, blood products and cessation of bleeding source.
62
In any drowned patient what should you suspect?
Hypothermia
63
If ACS is suspected as the caused of a refractory cardiac arrest what could be considered ?
It may be feasible to perform angiogram + PCI This would however require transfer with either automated CPR device and/or Extracorporal CPR (ECPR).
64
If PE is thought to be the cause of cardiac arrest what could be given?
Consider thrombolysis with fibrinolytic drug
65
If fibrinolytic drug is given for cardiac arrest possibly secondary to PE, how does this influence duration of CPR afterwards and why?
Continue CPR for 60-90mins after before stopping resus attempt as good outcomes have been reported >60mins.
66
How is a tension pneumothorax treated ?
Decompression with needle thoracocentesis and then chest drain
67
What investigation during a cardiac arrest is useful for diagnosing cardiac tamponade ?
Focused cardiac ultrasound to ax for pericardial effusion.
68
Cardiac arrest following cardiac surgery or penetrating chest trauma should raise the suspicion of what?
Cardiac tamponade abd the need for resuscitative thoracotomy
69
In cardiac arrest caused by toxins if known then appropriate antidotes should be given but often the treatment is supportive, what should be considered ?
Extracorporal CPR.
70
List the thing focused ultrasound in cardiac arrest can help diagnose
Cardiac tamponade PE Ischaemia (RWMA) Aortic dissection Hypovolaemia Pnuemothorax
71
What position of ultrasound probe is recommended for focused ultrasound during a cardiac arrest?
Sub-xiphoid position
72
Placement of ultrasound probe prior to pausing chest compressions should allow an operator to obtain views within how long ?
10 secs.
73
When should the use of an automated mechanical chest compression device be considered?
* CPR in a moving ambulance - safety risk * Prolonged CPR * CPR during certain procedures e.g. PCI * Covid-19 infection
74
What is extracorporal CPR?
This is the combination of ALS + ECMO device. (bascially ECMO started during a cardiac arrest) In extracorporeal membrane oxygenation (ECMO), blood is pumped outside of the body to a heart-lung machine. The machine removes carbon dioxide and sends oxygen-rich blood back to the body. Blood flows from the right side of the heart to the heart-lung machine. It's then rewarmed and sent back to the body.
75
What are the general criteria for considering ECMO during cardiac arrest?
* Need vascular access * Can be useful for patients with a reversible cause e.g. MI, PE, hypothermia, toxins * Patient has minimal co-morbidities * Cardiac arrest is witnessed * Individual has recieved high quality CPR * ECMO is implemented early <1hr of collapse.
76
When considering duration of attempted resuscitation when is it generally accepted worthwhile continuing ?
When patient remains in VF/pVT and there is a potentially reversible cause that can be treated
77
As a rough rule of thumb when is it considered appropriate to stop a resus attempt?
When you have had asystole for >= 20mins in absence of reversible causes (although a shorter or longer time might be appropriate)
78
How long should you wait following discontinuing CPR efforts before confirming death ?
5 mins.
79
Add photo of the general ALS protocol.

ALS/GIC (14 decks)

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