Cardiac arrest & emergency care

Question 1

What are the 4 patient categories of patients in an emergency care setting & simply put their management

Answer 1

1. Responsive (leave/get help)
2. Unconscious (recovery position/help)
3. Respiratory arrest (ventilation/help)
4. Cardiac arrest (help/CPR/ALS)

Question 2

Very simply how do you differentiate between a sleeping, unconcious, respiratory arrest or cardiac arrest patient ?

Answer 2

Question 3

Watch this video on how to put someone in the recovery position:

https://www.youtube.com/watch?v=TRQePNmR66w

Question 4

Define what a cardiac arrest is

Answer 4

This is the cessation of the heart (so no circulation and therefore no oxygen delivered) i.e. no pulse and not breathing

Question 5

What are the 2 categories of heart rhythms associated with cardiac arrest?

Answer 5

1. Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT))
2. Non-shockable rhythms (asystole and pulseless electrical activity (PEA))

Question 6

Define what is meant by pulsless electrical activity (PEA)

Answer 6

Pulseless electrical activity (PEA) is defined as cardiac arrest in the presence of electrical activity (other than ventricular tachyarrhythmia) that would normally be associated with a palpable pulse

Question 7

What are the signs of a cardiac arrest?

Answer 7

• Unresponsive patient
• Not breathing normally
• No pulse

Question 8

What deteriorating signs are common prior to a cardiac arrest ?

Answer 8

Preceding hypoxia and hypotension common

Question 9

What is the in-hospital management of someone who is collapsed/sick?

Answer 9

Question 10

During ABCDE what should you do when assessing someones airways and for how long ?

Answer 10

• Look for chest movement
• Listen for breath sounds
• Feel for expired air via mouth and nose
• Check nothing visibly obstructing airway
• Assess for no more than 10 seconds before deciding breathing is normal or not (doubt = NOT normal)
• Breathing = recovery position

Question 11

What can airways obstruction lead to and why is it important to correct?

Answer 11

• Airway obstruction can lead to hypoxia, which can cause cardiac arrest.
• It is important that this is recognised early, and treated with simple airway manoeuvres until skilled help arrives.
• Hypoxia is also a reversible cause of cardiac arrest and correcting hypoxia is important to restart the heart during cardiac arrest.

Question 12

When assessing ABCDE what are the signs someone has airway obstruction ?

Answer 12

• Difficulty breathing, distressed, choking
• Shortness of breath
• Noisy breathing (partially obstructed airway) - stridor, wheeze, gurgling, snoring. In a completely obstructed airway there will be silence (no airflow)
• See-saw respiratory pattern (normally in breathing as the chest expands the abdomen is pushed outwards, but in airway obstruction the abdo is drawn in as the chest tries to expand) , accessory muscles

Question 13

What are the treatment options for someone with airway obstruction ?

Answer 13

First thing to do is airway opening:

• 1st line = head tilt chin lift +/- suction
• 2nd line = jaw thrust +/- suction
• 3rd line = orophryngeal airway (gedel)
• 4th line = nasopahryngeal airway
• 5th line = Igel

Also increase Oxygen! (increase FiO2) - via bag and mask technique (2 person)

Question 14

Describe how to do a head tilt chin lift

Answer 14

• Head tilt - Place one hand on the patient’s forehead and tilt the head back gently
• Chin lift - Place the fingertips of your other hand under the point of the chin and gently lift to stretch the anterior neck structures.

Question 15

Describe how to perform a jaw thrust

Answer 15

• Identify the angle of the mandible
• Place you index and other fingers behind the angle of the mandible and lift upward
• Keep the mouth slightly open
• Recheck to see if there are any signs of airway obstruction

Question 16

When doing simple airway manoeuvres what is it important to remember to do ?

Answer 16

Look, listen and feel again to see if they alleviate the airway obstruction

Question 17

Sometimes airway manoeuvres alone are not enough to relieve airway obstruction and hence simple airway adjuncts are useful to maintain an open airway. A head tilt or jaw thrust may still be necessary.

How is a oropharyngeal or a nasopharyngeal airway inserted?

Answer 17

• Oropharyngeal - run the tip along the hardpalate then when in and cant go futher, turn it 180 degrees around
• Nasopharyngeal - insert into nose and direct it down towards the floor

Question 18

What are the contraindications to oropharyngeal and nasopharyngeal airways ?

Answer 18

• Oropharyngeal - vomiting or laryngospasm
• Nasopharyngeal - caution in suspected base of skull fractures

Question 19

Once you have managed to open up the airway with either simple airway manoeuvres or adjuncts what is then done ?

Answer 19

Correct hypoxia via 2 person bag and mask technique

Question 20

Describe how to do the bask and mask ventilation technique

Answer 20

• Bag mask ventilation is best performed with two people. One person holds the face mask and performs a jaw thrust, whilst the other person squeezes the bag ten times every minute.
• Oropharyngeal or nasopharyngeal airways can also be used, to help overcome soft tissue airway obstruction when using a self-inflating bag.

Question 21

What should you assess when checking someones breathing during ABCDE ?

Answer 21

Look:

• Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level

Listen:

• Noisy breathing, breath sounds

Feel:

• Chest expansion, percussion, tracheal position

Check O2 sats via pulse oximetry

Question 22

What is the main thing you should give as treatment during the B section of ABCDE ?

Answer 22

High flow O2 via a non-rebreather mask

Question 23

What should you assess when checking C on ABCDE?

Answer 23

• General exam – distress, pallor etc
• Indicators of organ perfusion - chest pain, mental state, urine output
• Blood pressure - BP cuff
• Pulse – tachycardia, bradycardia
• Peripheral perfusion - capillary refill time (CRT) - peripheral and if needed centrally
• Bleeding, fluid losses, JVP, CVP
• Listen to the heart in one or two areas

Question 24

What treatment may be provided during C section of ABCDE ?

Answer 24

• Bilateral arge bore IV access, take bloods & cultures
• Fluid challenge
• Inotropes/vasopressors
• Oxygen/Aspirin/Nitrates/ Morphine for ACS
• Haemodynamic monitoring

Question 25

What should be assessed during D section of ABCDE?

Answer 25

* AVPU or GCS + pupils * Check BG levels

Question 26

What should be assessed during the E section of ABCDE ?

Answer 26

Everything else: * Remove clothes to enable thorough examination (to avoid missing causes of problems) - e.g. injuries, bleeding, rashes * BUT! - Avoid heat loss & Maintain dignity

Question 27

What is the initial management steps of cardiac arrest when you dont yet know if the heart rhythm is shockable or non-shockable ?

Answer 27

1. Confirm cardiac arrest – check for signs of life and normal breathing, and if trained to do so check for breathing and a pulse simultaneously. 2. Call resuscitation team. 3. Perform uninterrupted chest compressions while applying self-adhesive defibrillation/monitoring pads 4. Stop chest compressions; confirm VF/pVT from the ECG (pause in chest compressions should be \< 5 secs)

Question 28

Following the initial management steps of cardiac arrest once you have confirmed a shockable heart rhythm what are the next steps ?

Answer 28

# 1. Resume chest compressions immediately - remove O2 delivery device and get everyone except the person doing chest compressions to stand clear 2. Choose an energy setting of at least 150J & press charge for the first shock, the same or a higher energy for subsequent shocks. If unsure of the correct energy level for a defibrillator choose the highest available energy. 3. Once the defibrillator is charged and the safety check is complete, tell the rescuer doing the chest compressions to “stand clear”; when clear, give the shock. 4. After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest compressions.The total pause in chest compressions \< 5 secs 5. Continue CPR for 2 min Pause briefly to check the monitor. If VF/pVT, repeat steps 1-5 above and deliver a second shock. If VF/pVT persists, repeat steps 1-3 above and deliver a third shock. Resume chest compressions immediately. Give adrenaline 1 mg IV and amiodarone 300 mg IV while performing a further 2 min CPR (after 3rd shock). Withhold adrenaline if there are signs of return of spontaneous circulation (ROSC) during CPR. Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/pVT persists. Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5 min on every second round of the CPR-shock cycle). If organised electrical activity compatible with a cardiac output is seen during a rhythm check, seek evidence of ROSC (check for signs of life, a central pulse and end-tidal CO2 if available). If there is ROSC, start post-resuscitation care. If there are no signs of ROSC, continue CPR and switch to the non-shockable algorithm. If asystole is seen, continue CPR and switch to the nonshockable algorithm.

Question 29

When is a pericordial thump used ?

Answer 29

Only used if defibrillator not immediately available in witnessed and monitored VF/pVT cardiac arrest

Question 30

Following the initial management steps of cardiac arrest once you have confirmed a non-shockable heart rhythm what are the next steps ?

Answer 30

1. Start CPR 30:2 2. Give adrenaline 1 mg IV as soon as IV access is achieved 3. Continue CPR 30:2 until the airway is secured – then continue chest compressions without pausing during ventilation Recheck the rhythm after 2 min: a) If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life * If a pulse and/or signs of life are present, start post resuscitation care. * If no pulse and/or no signs of life are present (PEA OR asystole) then: 1. Continue CPR 2. Recheck the rhythm after 2 min and proceed accordingly 3. Give further adrenaline 1 mg IV every 3–5 min (during alternate 2-min loops of CPR) b. If VF/pVT at rhythm check, change to shockable side of algorithm.

Question 31

During all cardiac arrests what potential causes or aggrevating factors for which specific treatments exist must be considered ?

Answer 31

4H's: * Hypoxia * Hypovolaemia * Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders * Hypothermia & the 4Ts: * Thrombosis (coronary or pulmonary) * Tension pneumothorax * Tamponade – cardiac * Toxins

Question 32

Prior to starting CPR what do you need to check someone does not have in hospital ?

Answer 32

DNACPR

Question 33

What is the use of waveform capnography ?

Answer 33

* Ensuring tracheal tube placement in the trachea (although it will not distinguish between bronchial and tracheal placement). * Monitoring ventilation rate during CPR and avoiding hyperventilation. * Monitoring the quality of chest compressions during CPR.

Question 34

When carrying out chest compressions what are the important technique points to remember i.e. depth, rate & position

Answer 34

* Ratio of 30:2 * Middle of lower ½ sternum * 5-6 cm depth * Allow full recoil * 100 - 120 min-1 * Change person every 2 minutes

Question 35

When carrying out the 2 rescue breaths during CPR what are the important technique points to remember ?

Answer 35

* Occlude victim’s nose * Maintain chin lift * Take a deep breath * Ensure a good mouth-to-mouth seal * Blow steadily (1 sec) into victim’s mouth * Watch for normal chest rise & fall * Overall time 2 breaths \<= 5 secs

Question 36

When applying the defibrillator pads what positions should they be in ?

Answer 36

One below the right clavicle & the other in the V6 mid-axillary line

Question 37

How do you assess someones airway obstruction if they are chocking and what is the subsequent treatment ?

Answer 37

Question 38

What is the post-resucitation management of someone who has had ROSC ?

Answer 38

* Note miantain SBP \> 100 * Unconscious adults with ROSC after arrest should be cooled to 32-36°C. Start as soon as possible and continue for 12 –24 h, using external or internal techniques