Chapter 6 Flashcards
(22 cards)
Appropriate energy setting for shocks in VF/VT
120-150J for the first shock. Same or higher for subsequent shocks.
ALS management of shockable rhythms
CPR 30:2
Attach defib pads
Rhythm check - confirm VF/VT
Deliver shock
Resume CPR for 2 minutes
After 3rd shock give IV adrenaline 1mg and IV amiodarone 300mg
Give further IV adrenaline every 3-5 minutes (alternate shocks)
Give 150mg amiodarone after 5th shock
Signs of ROSC
Sudden increase in end-tidal CO2
Palpable pulse
Breathing effort
Movement
Eye opening
Evidence of cardiac output on invasive monitoring
Some signs e.g. movement may be because CPR is providing good circulation to allow for signs of life
How is a witnessed VF/VT arrest managed?
Confirm cardiac arrest and shout for help
If rhythm is confirmed to be VT/VF give up to 3 successive (stacked) shocks
Check for rhythm change and signs of ROSC if appropriate after each shock
Start chest compressions and continue CPR for 2 minutes if third shock unsuccessful
Start usual ALS algorithm after three shocks - considered to be one shock i.e. give adrenaline after two more shocks but give amiodarone after three stacked shocks
ALS management of non-shockable rhythms
CPR 30:2
Attach defib pads
Give adrenaline 1mg IV as soon as IV access
Recheck rhythm after 2 minutes - if electrical activity compatible with a pulse check for pulse and signs of life
Give adrenaline every 3-5 minutes (alternate cycles)
Amiodarone not indicated
What to do if rhythm becomes shockable during 2 minute CPR cycle?
Do not give shock until end of 2 minutes
If clearly shockable, prepare team to give shock after 2 minutes
How should airway be managed during ALS?
Bag-mask or preferrably supraglottic airway (i-gel) should be used if no one present able to perform tracheal intubation
Once SGA inserted give continuous chest compressions
Ventilate at 10 breaths/minute
Try to avoid interruptions to chest compressions for intubation - if required can pause while passing vocal cords but should be <5 seconds
Can confirm correct tube position with waveform capnography
Is palpation of arterial pulses a reliable method of assessing effectiveness of chest compressions?
No
Define end-tidal CO2 and explain its use during CPR
Partial pressure of CO2 at the end of an exhaled breath
Reflects cardiac output, pulmonary blood flow and ventilation minute volume
Will be low during CPR as low cardiac output generated by chest compressions
Most reliable in tracheal intubation, can also be used with SGA and bag-valve mask
Uses:
Ensure tracheal tube placement in the trachea
Monitoring ventilation rate during CPR and avoiding hyperventilation
Monitoring the quality of chest compressions - increased is better
Identifying ROSC - will increase, prevents harmful administration of adrenaline
Prognostication - lower end-tidal CO2 associated with lower ROSC rates and increased mortality. Should not be used alone for prognostication.
What to do re adrenaline if ROSC suspected?
Withhold adrenaline if ROSC suspected
Give adrenaline if cardiac arrest confirmed at next rhythm check
How does end-tidal CO2 compared to arterial CO2?
Slightly lower
What to do if there are signs of life during CPR?
If combination of physiological and clinical signs e.g. waking, purposeful movement, arterial blood pressure waveform, sharp rise in end-tidal CO2 - consider stopping chest compressions for rhythm analysis/pulse check
Sites for IO access
Proximal humerus
Proximal tibia
Distal tibia
Contraindications to IO access
In the target limb:
Trauma
Infection
Prosthesis
Recent IO access (within 48 hours) including a failed attempt
Or failure to identify anatomical landmarks
Complications of IO access
Extravasation into soft tissues
Dislodgement of needle
Compartment syndrome due to extravasation
Fracture of chipping of bone during insertion
Pain due to infusions
Fat emboli
Infection/osteomyelitis
How to use IO access once inserted
Try to confirm position by aspirating - if no aspirate not necessarily in wrong place
Try to flush needle to ensure patency and assess for extravasation/leakage
Give resus drugs, can also give IVF/blood products but need pressure to acheive reasonal flow rates
What reversible cause is often associated with PEA arrest?
Hypovolaemia
Management of suspected coronary thrombosis and pulmonary thrombosis as the cause of cardiac arrest during ALS
Coronary - may benefit from PCI during ongoing CPR, requires automated mechanical chest compression device/extracorporeal CPR
Pulmonary - fibrinolysis, consider continuing CPR for at least 60-90 minutes before termination of resuscitation attempt
If available consider extracorporeal CPR, surgical/mechanical thrombectomy
How can USS be used during ALS?
Can detect reversible causes e.g. cardiac tamponade, PE, ischaemia, dissection, pneumothorax, hypovolaemia
Need to minimise interruptions to compressions
Sub-xiphoid probe position recommended
How is death diagnosed after unsuccessful resuscitation?
Observe for minimum 5 minutes before confirming death
Confirm absence of mechanical cardiac function - absence of central pulse, absence of heart sounds, asystole on ECG, absence of pulsatile flow on intra-arterial monitoring, absence of contractile activity on echo
If any cardiac/respiratory activity during 5 minutes should observe for further 5 minutes from next arrest. After 5 minutes continued arrest check for absence of pupillary reflexes, corneal reflexes, response to supra-orbital pressure
What tasks must be completed following completion of resuscitation?
Ongoing care of patient
Handover to other teams
Documentation of resus
Communication with relatives
Post-event debriefing - hot + cold
Restock trolleys
Complete audit forms
