BLS

Question 1

What are the different oxygen masks?

Answer 1

Non-rebreather mask - 15L - delivers 85% inspired oxygen and one way valve means does not exhale into bag so only inhaling oxygen

Simple face mask - 10L delivers 40%

Venturi - draws in room air, useful for COPD

Nasal cannulae - 1-4L

Neb - salbutamol or ipratropium

Question 2

When is ventilation required?

Answer 2

Breathing inadequately e.g. slow RR or irregular pattern of respiration
Shallow breathing
Not breathing at all

Question 3

When does gastric distension happen?

Answer 3

High inflation - over inflating
Ventilating too fast
Partially obstructed airway - air going into stomach instead of lungs - can lead to aspiration

Question 4

How do we use BVM?

Answer 4

Neck slightly flexed and head extended to sniffing position
Jaw thrust performed - decreases leaks as more of a seal
C shape with thumb/index finger on top of mask, gently squeeze bag enough to see chest rise (1 second)

Question 5

Why do we always use a mask even if not connected to oxygen?

Answer 5

To prevent coming into contact with pt’s blood and secretions from mouth

Question 6

What increases survival in cardiac arrests?

Answer 6

Early recognition and call for help
Early CPR
Early defib
Good ROSC care
Early transportation if cannot treat ONS

Question 7

What are the four rhythms?

Answer 7

VF - rapid and disorganised
VT - wide-complex tachycardia, regular rhythm, may have pulse
Asystole - no electrical activity from heart
PEA - organised electrical activity without a pulse

Question 8

What circumstances do you not shock pt?

Answer 8

Non-shockable rhythm
In contact with pt and wet surface/metal surfaces that conduct currents
Near explosives e.g. oxygen not removed
Pt wearing jewellery

Question 9

What do we do for pregnant pt’s more than 20 weeks in CA?

Answer 9

Manually displace uterus to left or place pt on extrication board and tilt 15-30 degrees to left
Venous return restricted if not - cardiac output and uterine perfusion reduced

Question 10

What do we do for pregnant pt’s more than 28 weeks in CA?

Answer 10

Have hands 2-3cm higher on sternum when doing CPR
Use anterior-posterior pad placement

Question 11

What do we need to consider for pregnant pt’s in CA?

Answer 11

Early intubation as more likely to regurgitate stomach contents
Rapid transportation if no response to CPR within 5 minutes as baby could be saved with caesarean

Question 12

Where do we transport pregnant pt’s in CA?

Answer 12

To closest ED and request obstetrician in ED in advance

Question 13

What do we do if pt’s temp if less than 30 in CA?

Answer 13

Attempt to slowly warm pt - not dead till warm and dead
Can only give maximum of 3 shocks in VF or pulseless VT
No IV drugs can be administered

Question 14

What do we do if pt’s temp if between 30-35 in CA?

Answer 14

Can use defib as usual
IV drug administration time doubles

Question 15

What do we do if pt’s temp if over 35 in CA?

Answer 15

Resus is normal

Question 16

What is the difference between penetrating trauma CA treatment and blunt trauma CA treatment?

Answer 16

Penetrating trauma to chest and epigastrium must be rapidly conveyed to ED - scoop and run
Blunt trauma resus can remain on scene

Question 17

What do we do when we get ROSC?

Answer 17

Provide ventilation breaths at rate of 10-12 breaths/mins on high flow
Maintain capnography at 4.6-6
Check BM over 4
Keep core temp no higher than 36 - passively cool if higher - witnessed CA usually don’t need temp
Record 12 lead
Frequent BP checks - above 100mmHg, fluids 250ml required?
Transport - moving by 10 minutes - consider hospital with cardiac centre if believe caused by cardiac aetiology - stem showing on 12 lead)
Stop convulsions if occurring for more than 5 mins e.g. diazepam
Consider analgesia for management of pain
Head up 30 degrees when in back of ambulance as reduces cerebral pressure
ATMIST handover

Question 18

What are signs of ROSC?

Answer 18

Rhythm compatible with cardiac output + central pulse
Breathing?
Purposeful movement?
Significant increase in end tidal?

Question 19

What is considered good CPR?

Answer 19

Compress chest to depth of 5cm - no more than 6cm
Allow to recoil
Rate of 100-120 compressions/min
Swap over every 2 mins

Question 20

In what cases do we not start CPR (unlikely to be successful?

Answer 20

At least 15 mins have gone since CA and no CPR was provided and no excluding factors - hypothermia, poisoning, pregnancy
ECG asystole for more than 30 seconds
Pt been submerged more than 90 mins
Injuries/condition unequivocally associated with death e.g. massive cranial destruction, split in two at waist, full thickness burns on 95% of total body surface area, hypostasis - pooling of blood in part of body, rigor mortis (stiffening of limbs), decomposition (tissue damage suggesting dead for days, weeks etc)

Question 21

What do we do if an advance care plan states pt does not wish to be resuscitated?

Answer 21

Not legally binding so can use this when considering pt’s best interests - knowing their wishes and preferences

Question 22

What do we do if the pt has an advance decision to refuse treatment at a CA?

Answer 22

Check if it says ‘even if life is at risk’, if it’s signed, dated, and witnessed.
If so then legally binding so must follow.

Question 23

What do we do if the pt has a questionable DNAR at CA?

Answer 23

Can commence CPR is can justify actions
Not legally binding but do take into account pt’s best interests - DNAR usually in place as CPR unlikely to be successful or quality of life following CPR will not be in pt’s bests interests
Senior clinicians decision

Question 24

What do we do if pt is terminally ill and does not have DNAR?

Answer 24

Consider if CPR would be successful and if in final stages of terminal illness - senior clinicians can justify stopping

Question 25

What do we do if pt's ROLED and death is suspicious?

Answer 25

Preserve scene as much as possible Leave pt where they are and do not leave clinical equipment behind Ask EOC to contact police If outside and raining, cover body with foil blanket and not usual blanket

Question 26

What do we do when a child unexpectedly dies (under 18) (SUDICA)?

Answer 26

Resuscitate all children unless signs unequivocally associated with death Convey child and parent to ED - unless police want forensic evidence first Support family - majority of cases due to natural causes Use child's name whenever you can when referring to them Avoid placing infant in body bag

Question 27

What are reversible causes in trauma CA?

Answer 27

Hypovolaemia - control external haemorrhage, splint pelvic fractures, IV/IO fluid, early TXA Hypoxia - airway management, 100% oxygen Tension pneumothorax - decompress check Tamponade - consider enhanced skills/critical care intervention

Question 28

What are the 4Hs and 4Ts?

Answer 28

Hypoxia Hypovolaemia Hypo/hyperkalaemia + hypoglycaemia Hypothermia Toxins - check pupils/marks on skin indicating drug usage Tension Pneumothorax Thrombosis - coronary or pulmonary Cardiac Tamponade

Question 29

What do we do for pt who drowned in CA?

Answer 29

Start CPR if submerged for less than 90 mins for children and if in icy water - poor outcome past 25 mins Find out if anymore pts Consider c-spine injury in shallow water Use capnography to confirm CA as pulse as sole indicator is unreliable Early intubation Hypothermic as well? Dangerous rescue?

Question 30

How do we know it's CPR induced consciousness and not ROSC?

Answer 30

Absence of palpable pulses Rapid deterioration in consciousness when chest compressions are stopped Cardiac rhythm incompatible with life

Question 31

What do we do with an agonal rhythm?

Answer 31

Can treat it as systole - can be terminated if persisted continuously for more than 30 mins.

Question 32

What to do if ROLE pt and death expected?

Answer 32

Contact GP to certify death and issue certificate for medical cause of death

Question 33

What to do if ROLE pt and death unexpected?

Answer 33

Refer to HM coroner's office, possibly contact police.

Question 34

How do we handle bystanders in CA, including children?

Answer 34

Acknowledge situation is difficult, answer what questions they had, give welfare advice, signpost to GP Before leaving scene consider making GP referral for children - ask family if aware of death depending on age etc.

Question 35

What checks need to be done before assessing ABCDE?

Answer 35

Danger ONS - anything preventing me from entering? Any fire, multiple unconscious pt's (CBRN)? traffic? electricity? Do I require HART? Response - hello, can you hear me in both ears? check pain Background - unwitnessed? signs unequivocally associated with death? Mechanism of injury - trauma or medical? Ladders fallen from? Catastrophic haemorrhage?

Question 36

What do we do after declaring CA?

Answer 36

Call for backup, commence CPR, place pads on in double crew Pads on first, CPR after when single Considerations? - feel cold? hypothermic? - pregnant? require bystander to move belly to left Airway focus - positioning - mastoid process (behind ear) inline with sternal notch, adjuncts - OP and NP

Question 37

What pt's require transportation sooner than later?

Answer 37

Dialysis Drug overdose Pregnant Unable to manage airway Suspected PE Asthma or anaphylaxis

Question 38

What does our ATMIST handover involve?

Answer 38

Age and sex Time of arrest, bystanders cpr time, LAS ONS/BLS commenced, time of ROSC Medical complaint, CA Information, presenting rhythm, prodomal symptoms - first sign of symptoms S vital signs, best and current GCS Treatment and trends, number of shocks, total adrenaline, any other medications Allergies Medications Background history Other info, family's whereabouts, what they know Safeguarding referral following arrest?

Question 39

What do we do differently for child's CA?

Answer 39

Pad placement, LP1000 first instead, 5 rescue breaths