ALS

Question 1

ALS algorithm

Answer 1

Shockable
- adrenaline 1mg after second shock and every second loop
- amiodarone 300mg after 3 shocks
Non shockable
- adrenaline 1mg immediately and every second loop

During CPR

• airway
• oxygen
• monitoring
• IV/IO access
• 4Hs and 4Ts

Question 2

Hs and Ts

Answer 2

Hypoxia - 100% O2
Hypovolaemia - fluid/blood
Hyper/hypokalaemia/H+ ions, glucose and other metabolic disorders
- K >6.5 - calcium chloride 10% 10mL + 25g glucose + 10U novorapid +/- sodibic if severe acidosis or renal failure
- K <3.5 - 5mmol IV K + MgSO4 2g IV
- hypocalcaemia - calcium chloride 10% 10mL
- hypoglycaemia - IV dextrose
Hypo/hyperthermia

Tension pneumothorax - 2nd intercostal MCL 14G needle decompression, then chest drain
Tamponade - USS + pericardiocentesis
Thrombus (ACS/PE) - lysis (need to continue minimum 30 minutes)
Toxins - naloxone 100mg blouses, intralipid, flumazenil

Question 3

Airway problems

Answer 3

Symptoms/signs
- SOB
- coughing
- choking
- short sentences 
- distress/anxiety
- stridor
- accessory muscle use 
Look, listen, feel 
- abdominal see-sawing

100% oxygen

Causes
Resp depression
- intracranial pathology
- toxins - drugs, hypercarbia
Obstruction 
- blood, vomit - suction 
- foreign body - 5 back blows, finger sweep/laryngoscopy if unconscious  
- pharyngeal collapse - airway manoeuvres, adjuncts 
- epiglotitis - adrenaline neb
- layngospasm/oedema (anaphylaxis) 
- blocked tracheostomy - remove liner
- extrinsic compression
- airway oedema/secretions/plugging

Question 4

Breathing problems

Answer 4

Examination

• general appearance, positioning, WOB
• RR, Sats
• chest movement bilaterally
• tracheal position
• auscultation
• raised JVP in tension PTx/severe asthma
• difficulty bagging

Respiratory drive
- CNS pathology
- toxins (narcotisation)
Respiratory effort
- spinal cord lesion 
- incomplete reversal 
- exhaustion
- muscle disorders (GBS, myasthenia gravis)
- chest wall (broken ribs, kyohoscoliosis, pain)
Lung disorders 
- pneumothorax/haemothorax 
- infection, aspiration, COPD/asthma, pulmonary oedema, pulmonary contusion, ARDS, anaphylaxis 
- PE

Rx - O2 (15L non rebreather), ABG, CXR, specific treatment

Question 5

Circulation problems

Answer 5

Symptoms - chest pain/syncope
Signs 
- SOB, ALOC, evidence of bleeding 
- peripheral perfusion/CRT
- pulse/HR
- BP - narrow pulse pressure = vasoconstriction, wide = vasodilation
- JVP 
- auscultate chest 
- oliguria/fluid balance 
- wounds/drains 

Hypovolaemia
- blood
- fluid
Cardiogenic
- ACS
- arrhythmia - inherited disorders, electrolytes, drugs 
- valve disease 
- myocardial depression - drugs, electrolytes, acidosis, myocarditis, contusion, sepsis
- hypothermia 
- structural - HOCM, rupture, tamponade 
Obstructive
- PE, PTx 
- aortic dissection 
Distributive 
- septic
- neurogenic 
- anaphylaxis

Rx - O2, ECG, ABG, CXR, fluid challenge
Consider echo

Question 6

Disability assessment

Answer 6

AVPU
Pupils
BGL

Documentation:
Drug chart (e.g. sedatives)
Allergies 
Notes
Vitals trend

Question 7

Exposure assessment

Answer 7

Temperature 
Limbs/skin - rashes, wounds, oedema 
Abdo exam 
Drains/dressings
Patches, insulin pumps 
Log roll
ENT exam, PR

Question 8

ACS

Answer 8

STEMI - STE, new LBBB, ST depression V1-3 with dominant R wave
NSTEMI/UA

Initial Rx -
Aspirin, GTN, O2, fentanyl analgesia
Call cardio - PCI/lysis, second antiplatelet, anticoagulation
Nitrate infusion if unresolved pain

Complications

• Ventricular arrhythmia
• heart failure
• cardiogenic shock
• pericarditis
• ventricular rupture/papillary muscle rupture

Question 9

Collapsed patient

Answer 9

Danger - environment, PPE
Response
Send for help - shout, MET, emergency buzzer
A - open airway
B - look, listen, feel + pulse
CRP
Defib - 200-360J, COACHED, stacked shocks if witnessed and defib available

Question 10

Bradyarrhythmia

• causes
• management

Answer 10

Transcutaneous pacing

• explain to patient
• magnet over ICD
• Pads + monitoring
• rate (60-90)
• lowest milliamps and increase until electrical capture + 10
• check mechanical capture
• analgesia/sedation

Adverse features

• Shock (hypotension, ALOC, peripheral perfusion)
• Syncope
• Heart failure (pulm oedema/raised JVP)
• MI (typical chest pain/ECG evidence)
• HR <40

Causes

• Physiological
• Cardiac (AV block, sinus disease, MI)
• Non-cardiac (vasovagal, hypothermia, electrolytes)
• Drug induced

Presence of adverse features
Call senior
1. Pharmacotherapy - Atropine 500mcg IV bolus, repeat every 3-5 minutes if necessary
2. Transcutaneous pacing - 60-90bpm, 50-100mA, electrical and mechanical capture, clinical improvement

No adverse features: monitor, look for cause

Question 11

Tachyarrhythmia

Answer 11

Adverse features
- Shock (hypotension, ALOC, peripheral perfusion)
- Syncope
- Heart failure (pulm oedema/raised JVP)
- MI (typical chest pain/ECG evidence)
- HR >150
If instability likely to be due to tachyarrhythmia (unlikely if HR <150 and normal heart):
Call senior 
Synchronized cardioversion
- Conscious sedation/GA 
- Unsynchronized risks VF
- 120-150J --> repeat higher J --> amiodarone 300mg + infusion 900mg over 24 hours

No adverse features: pharmacotherapy
Call senior
- Regular broad complex –> amiodarone
- Irregular broad complex (AF with abberancy) –> correct electrolytes and other causes –> negative chronotropes (beta blockers, diltiazem, digoxin, amiodarone) +/- anticoagulation
- Regular narrow complex (except sinus) –> Vagal manoeuves, adenosine (6/12/12mg)
- Irregular narrow complex (AF) –> treat underlying cause, negative chronotropics +/- anticoagulation

Question 12

Potassium disorders

Answer 12

Hyperkalaemia
- Causes - renal failure, drugs, tissue breakdown, metabolic acidosis (DKA), addisons
- ECG - tall T waves, first degree heart block, bradycardia, ST depression, widened QRS, sine wave –> VT/arrest
Treatment in severe cases:
Call senior
Stabilise membrane - Calcium chloride 10% 10mLs IV over 2-5 minutes (if >6.5 + ECG changes)
Shift intracellularly - 10U novorapid + 25g glucose (e.g. 50ml 50%) or salbutamol +/- Sodium bicarb if acidosis or renal failure
Excrete - dialysis/resonium

Hypokalaemia
- Causes - GI loss, drugs, renal losses, cushings/hyperaldosteroneism, metabolic alkalosis, magnesium depletion
- ECG - T wave flattening, arrhythmia
PO/IV replacement + Magnesium. Rapid replacement periarrest or 5mmol bolus during arrest.

Question 13

Sepsis

• concerning features
• Rx

Answer 13

Concerning features following fluid replacement

• Hypotension
• Oliguria
• ALOC
• Lactate >4mmol/L

Sepsis 6
3 in - O2, Abx, Fluids
3 out - Cultures, lactate, urine output

Question 14

LA toxicity

Answer 14

- Following local injection 
CNS - Agitation/ALOC, seizures
CVS - sinus brady, conduction blocks, asystole, ventricular tachyarrhythmia 
Treatment 
- Call anaesthetist
- Stop LA injection
- Secure airway + O2
- Seizure control - benzo, propofol
- Arrest --> ALS + 20% lipid emulsion IV 1.5mL/kg bolus + 15mL/kg/hr (total dose 12mL/kg)

Question 15

Anaphylaxis

Answer 15

Diagnosis
- Acute onset skin/mucosa features + resp/CVS/GI
OR
- Acute onset of hypotension/bronchospasm/upper airway obstruction (even without skin features)

Airway - swelling, hoarse voice, stridor
Breathing - SOB, wheeze, fatigue, confusion (hypoxia), cyanosis
Circulation - hypotension, ALOC, peripheral perfusion, tachycardia, MI
Skin/mucosa - erythema, urticaria, angioedema

Treatment
- Early involvement of senior help
- Lie flat (no standing), may sit if breathing worse
- Remove trigger
- Monitoring
- O2
- Adrenaline 0.5mg IM
- Fluid bolus
- Upper airway obstruction –> nebulised adrenaline
- Consider early intubation with senior help
- Observe for minimum 4 hours (biphasic reaction)
- PO pred/antihistamine after
Arrest –> ALS (1mg IV adrenaline in protocol)