Cardiac Arrest

Question 1

In adults, what is the compression to ventillation ratio rate before an advanced airway is inserted?

Answer 1

30:2 with pause for ventillation; 1 sec inspiratory time.

Question 2

In adults, what is the compression to ventillation ratio rate AFTER an advanced airway is inserted?

Answer 2

15:1 or at a rate of 6-10 per minute with no pause for ventillation.

Question 3

Where should pads be placed in anterior-posterior configuration?

Answer 3

Anterior over patient’s precordium (i.e. portion of body over pts heart and lower chest)
Posterior to heart, just below left scapula

Question 4

Where should pads be placed in bi-axillary configuration?

Answer 4

On the lateral chest walls, one on the left and one on the right.

Question 5

What is refractory VF?

Answer 5

VF that persists beyond 3 shocks.

Question 6

When can stacked shocks be considered?

Answer 6

In a witnessed arrest where pads are already applied and the patient was well perfused and oxygenated pre-arrest.

Question 7

For timing of medication, how many shocks are counted in stacked shocks?

Answer 7

Stacked shocks are counted as one shock for medication timing.

Question 8

What are the reversible causes of cardiac arrest (4Hs 4Ts)

Answer 8

Hypoxia
Hypovolemia
Hypo/hyperthermia
Hypo/hyperkalemia (/ metabolic disorders)
Thrombosis (STEMI, PE)
Tension pneumothorax
Tamponade
Toxins

Question 9

How does identification of a reversible cause change cardiac arrest management?

Answer 9

When the cause of cardiac arrest is potentially reversible, consider aggressive and prolonged resuscitation efforts which may include clinical support or when the reversible cause is unable to be managed on scene, consider transport to hospital.

Question 10

What are the priorities in traumatic cardiac arrest?

Answer 10

All of
* Control haemorrhage
* Fluid resuscitation
* Open/control the airway (early SGA with capnography)
* Bilateral chest decomression

should take priority over standard interventions used to manage sudden cardiac death which is often related to coronary occlusion.

Chest compressions can be performed whilst reversible causes addressed if resources allow.

Question 11

Should adrenaline be used in traumatic cardiac arrest?

Answer 11

There is little evidence for the use of adrenaline in cardiac arrest due to trauma and as such is not recommended until after control and correction of reversible causes.

Question 12

What are the special circumstances for cardiac arrest that require a change in management?

Answer 12

Trauma
Hypothermia
Asthmatic arrest
Pregnancy with gestation > 20 weeks
Morbid obesity

Question 13

What changes in managment should occur in hypothermic cardiac arrest?

Answer 13

In hypothermic cardiac arrests, patients with a tympanic temperature <30C should receive a maximum of three defibrillations and all cardiac arrest drugs should be withheld.

Patients with a temperature of 30-35C should receive resuscitation as normal with the exception of drug administration intervals being doubled (e.g. adrenaline every 8 minutes).

Question 14

What changes in managment should occur in asthmatic cardiac arrest?

Answer 14

In cardiac arrests caused by asthma, ventilations will be difficult due to increased airway resistance. Appropriate ventilations with small tidal volumes and slow ventilation rates should occur as required to allow for adequate chest deflation.

Severe gas trapping may be relieved with a period of apnoea (disconnection of the BVM from the advanced airway) of up to 30 seconds between breaths.

Question 15

What changes in managment should occur in cardiac arrest pregnancy?

Answer 15

Pregnant patients in cardiac arrest with a known or suspected gestation >20 weeks should be resuscitated with manual displacement of the uterus to the left to minimise aorto-caval compression.
If manual displacement is not possible, then consider a 15°-30° tilt of the patient to the left if it is feasible and doesn’t interfere with high performance CPR.

IV/IO access should occur above the level of the diaphragm.

Early consult with the MedSTAR Medical Retrieval Consultant (MRC) via the EOC Clinician should occur to discuss management options, but this should not delay rapid transport.

Question 16

What changes in cardiac arrest managment should occur in obese patients?

Answer 16

Compressor fatigue may necessitate the need to change compressors more frequently than 2 minutes.

Significant increases in inspiratory airway pressures may be required during ventilations. This may result in excessive leakage with a supraglottic airway during uninterrupted compressions; and returning to a standard 30:2 compression-ventilation ratio may be required (interrupted compressions to ventilate).

Question 17

Which adult patients are most likely to benefit from transport under CPR?

Answer 17

Patients most likely to benefit from transport under CPR include:
* lived independently pre-arrest
* had chest compressions within 10 mins of arrest
* had initial rhythm of VF or VT
* have intermittent but unsustained ROSC or signs of life

Question 18

In adults, when should CPR be ceased?

Answer 18

If no signs of sustained response to treatment, continue reasonable treatment options for at least:
* 10 mins due to clinical futility (e.g. persistent asystole or traumatic arrest)
* 30 mins in all other cases

Question 19

What are the components of the charge and check script?

Answer 19

“Hands off” - after defibrilator is charged
“I’m safe” - compressor confirms hands are off
“Confirm shockable rhythm”, or “confirm non-shockable rhythm”

Question 20

When should IV/IO adrenaline be administered in adult cardiac arrest?

Answer 20

When resources allow:
* Shockable - after second shock then every second loop (4min)
* Non-shockable - ASAP

Question 21

When should IV/IO amiodarone be administered in adult cardiac arrest?

Answer 21

If shockable rhythm, amiodarone 300mg after 3rd shock

Question 22

What is the guideline for managing CPR induced consciousness?

Answer 22

Provide verbal reassurance

Unsuccessful reassurance:
* consider IV/IO midazolam 1 - 2 mg
* repeat every 5 mins prn
* total max dose 5 mg

Question 23

How much fluid should be administered in suspected hypovolemic or obstructive shock causes of arrest?

Answer 23

250ml aliquots, reassess, up to 30ml/kg

Question 24

What tools are available to control haemorrhage in traumatic arrest?

Answer 24

• Direct pressure
• Arterial tourniquet
• Arterial compression
• Pelvic binder
• Fracture management and splinting

Question 25

What are the most common causes of pediatric arrest?

Answer 25

Hypoxia, hypovolemia, or both.

Causative conditions include trauma, drowning, septicaemia, SIDS, asthma, upper airway obstruction, and congenital abnormalities of heart/lungs.

Question 26

What size orogastric tube is used for i-gel suctioning? How is the tube sized?

Answer 26

Size 10
Nose to earlobe, then earlobe to xiphisternum

Question 27

When should compressions be initiated in a pediatric?

Answer 27

Following ventilations, if the patient is unresponsive and not breathing normally and the heart rate is less than 60, or a palpable pulse cannot be detected within 10 seconds, external chest compressions should be commenced.

Question 28

What is the ratio of compressions to breaths in a pediatric? Should compressions be continued or stop?

Answer 28

15:2 and pause for ventillation. Advanced airway does not change this.

Question 29

What do low etCO2 levels suggest during pediatric cardiac arrest?
What does a high etCO2 suggest?

Answer 29

Low CO2 levels in expired breath from a patient receiving CPR may be due to inadequate external chest compressions or excessive ventilation.

Low CO2 levels may also indicate a treatable condition such as pneumothorax, hypovolaemia or cardiac tamponade.

A high CO2 level reading may indicate acidaemia or inadequate ventilations.

Question 30

Should adrenaline be used in traumatic pediatric arrest?

Answer 30

In cardiac arrest due to trauma, opening the airway, haemorrhage control, restoration of circulating blood volume and correcting obstructive shock states take priority.

There is little evidence for the use of adrenaline in cardiac arrest due to trauma, and as such is not recommended until after control and correction of reversible causes.

Question 31

How can gas trapping be relieved in an asthmatic arrest?

Answer 31

Gentle ventilations with small tidal volumes and slow ventilation rates should occur as required to allow for adequate chest deflation.

Severe gas trapping may be relieved with a period of apnoea (disconnection of the BVM from the advanced airway) to allow adequate chest deflation

Question 32

Should parents be allowed to be present during pediatric resuscitation?

Answer 32

Family members should be offered the opportunity to be present during the resuscitation of their child. Evidence suggests that the presence of parents at the child’s side during resuscitation enables them to gain a realistic understanding of the efforts made to save their child and they subsequently may show less anxiety and depression. A staff member must be designated to be the parents’ support and interpreter of events throughout the resuscitation as soon as sufficient resources are available.

Question 33

What head position should be used to ensure patent airway in 1) infants, 2) small pediatrics (1-8yrs, and 3) older pediatrics (9-16yrs)

Answer 33

Infants - neutral position (no extension)
Small children - slight neck extension
Older children - neck extension (same as adults)

Question 34

When is amiodarone indicated in pediatric arrest - when/how much administered?

Answer 34

Indicated for shockable rhythm refractory to 3x shocks.
5mg/kg after 3rd shock

Question 35

When is adrenaline indicated in pediatric medical (non-traumatic) arrest - when/how much administered?

Answer 35

Shockable rhythm - 10mcg/kg after 2nd shock, continue after every 2nd shock
Non-shockable rhythm - 10mcg/kg asap, then after every 2nd loop.

Question 36

When is fluid indicated in pediatric arrest (medical AND traumatic), and how much is administered?

Answer 36

Indicated in suspected hypovolaemic or obstructive cause of arrest
Administer IV saline 10 mL/kg aliquots (max 250 mL) and reassess up to 40 mL/kg

Question 37

What is the criteria for declaration of life extinct?

Answer 37

1 full minute of nil:
* heart sounds
* pulse
* respirations
and nil pupil reaction to light

Question 38

What are the criteria for non-initiation of CPR?

Answer 38

• Patient’s wishes (ACD, relative, substitute decision maker, etc)
• Obvious death
• Patient is pulseless, not breathing, with fixed dilated pupils, and unresponsive > 30 mins with no CPR prior to SAAS arrival

Question 39

How much fluid may be administered to hypotensive adults post ROSC?

Answer 39

250ml aliquots up to 10ml/kg (max 1000ml) until either
* radial pulse achieved
* SBP>=100

Consult SAAS Medical Practitioner via EOC Clinician if hypotension persists.

Question 40

How much fluid may be administered to hypotensive pediatrics post ROSC?

Answer 40

Consult SAAS Medical Practitioner via EOC Clinician for pediatrics (i.e. whatever they say).

Question 41

In post-ROSC adults who require ventillation, what rate is used? Pediatrics?

Answer 41

Adults - BVM with high flow O2 at rate 10-12bpm.
Pediatrics - as above, but normal age-appropriate respiratory rate per RDR.

Question 42

In post-ROSC patients who do not require ventillation, what is the target SpO2? rate is used? Why?

Answer 42

Target SpO2 for both adults and pediatrics is 94-98% - titrate O2 to achieve this.
Want to prevent hypoxia and hyperoxia, as both result in negative patient outcomes.

Question 43

What are the differences in post-ROSC management between adults and pediatrics?

Answer 43

In pediatrics early consult with a SAAS Medical Practitioner via the EOC Clinician must occur to ensure timely management of the anticipated physiological abnormalities.

Paediatric cardiac arrest is less likely to be precipitated by a cardiac cause (i.e. less likely to require Code STEMI activation).

Correction and avoidance of hypoxia is paramount to the outcome of paediatric patients.

Maintaining BP appropriate for age is important post-ROSC, and hypotension should be addressed. Refer to SAAS paediatric RDR chart for normative values.

Post-ROSC hyperthermia has increased prevalence in children, and is associated with poorer outcomes. Avoid hyperthermia accordingly.

There is an increased risk of hypoglycaemia. Greater emphasis must be placed on early post-ROSC BGL, and its management.

Question 44

What is the treatment for post-ROSC hypoglycemia (BGL< 3.5) in adults?

Answer 44

Adults - IV glucose 10% targeting BGL 3.5-10mmol/L.
Follow infusion with 100ml IV saline.

Question 45

What is the treatment for post-ROSC hypoglycemia (BGL< 3.5) in pediatrics?

Answer 45

Consult EOC clinician for IV glucose 10%, starting at 2ml/kg, targeting BGL 3.5-10mmol/L.
Max dose 5ml/kg.

Follow infusion with IV saline 1ml/kg.

Question 46

What is the target temperature in post-ROSC patients?

Answer 46

36.0-37.5C