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Advanced Life Support (ALS) > Chapter 6: Advanced Life Support Algorithm > Flashcards

Chapter 6: Advanced Life Support Algorithm Flashcards

1
Q

What are the shockable rhythms?

A

VF and pVT

Pulseless VT

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2
Q

What are the non-shockable rhythms?

A

Asystole and PEA

PEA

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3
Q

What are the key basic interventions required in all ALS scenarios to improve survival?

A

Continuous high quality chest compressions

Early defibrillation

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4
Q

You notice a patient is unresponsive and not breathing. What are the initial steps in the ALS algorithm?

A

Call the resus team
CPR 30:2
Attach defibrillator/cardiac monitor
- one below right clavicle, other in V6 position in mid axillary line

Count assistant in to take over chest compressions so you can assess the rhythm

STOP CHEST COMPRESSIONS BRIEFLY - to assess rhythm. Start CPR again whilst charging then shock.

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5
Q

You see a shockable rhythm. What are the next stages of management?

A

Perform 1 shock (safely) at 150J

Immediately resume CPR for a further 2 minutes minimising interruptions

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6
Q

You have shocked a patient once but after 2 minutes, the patient remains in VF. What do you do?

A

Safely deliver second shock - typically 300J

Immediately resume CPR for further 2 minutes

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7
Q

Following 2 shocks, the patient remains in VF. What should you do?

A

Shock again at 360J

Give 1mg IV adrenaline (1:10,000) and 300mg IV amiodarone while performing further 2 minutes CPR

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8
Q

How frequently is adrenaline given once it has been started?

A

Every 3-5 minutes (every alternate cycle)

Continue for as long as cardiac arrest persist

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9
Q

If organised electrical activity is seen compatible with cardiac output following a shock, what should be done?

A

Assess for ROSC

  • check for signs of life
  • check for central pulse
  • assess end-tidal CO2

If there is ROSC - ABCDE

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10
Q

If there is organised electrical activity but no return of spontaneous circulation, what should be done?

A

Continue CPR and switch to the non-shockable algorithm - the patient is in PEA

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11
Q

If there is return of spontaneous circulation and electrical activity following treatment for VF, what should be done?

A

Start post-resus care

  • Use A-E approach
  • Aim for SpO2 of 94-98%
  • Aim for normal pCO2
  • 12 lead ECG
  • Treat precipitating cause
  • Targeted temperature management
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12
Q

How frequently can amiodarone be given following VF/pVT?

A
  • 300mg after 3rd shock
  • further 150mg after 5 shocks

Lidocaine 1mg/kg can be given if no amiodarone available but don’t mix

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13
Q

When should precordial thumps be considered?

A

Very low success rate for cardio version of shockable rhythm

Not recommended routinely

Use when awaiting arrival of defibrillator

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14
Q

How is a precordial thump given?

A

Use ulnar edge of fist

Strike sternum from height of 20cm and immediately retract fist

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15
Q

If a patient has a witnessed and monitored cardiac arrest with VF/pVT, what should be done?

A

Give 3 quick successive shocks

Rapidly check rhythm change and if appropriate check for pulse and signs of life

Start compressions and continue CPR for 2 mins if 3rd shock unsuccessful.

Continue normal ALS algorithm as if 1 shock has been given.

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16
Q

When is adrenaline and amiodarone given if a patient has stacked shocks due to witnessed VF/pVT?

A

Adrenaline - assume as if stacked shocks are first shock so after 2 further shocks (3 in total)

Amiodarone - give immediately (during CPR) as it should be given regardless after 3 shocks.

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17
Q

How are non-shockable rhythms managed according to the ALS algorithm?

A
  • CPR 30:2
  • Give adrenaline 1mg IV/IO - must be continued every 2 cycles from here on regardless of whether it changes to a shockable rhythm
  • Check rhythm at 2 minutes and respond as according to this

If shockable rhythm, give shock then 2 mins of cpr then assess rhythm then if shockable shock then adrenaline every 2 cycles.

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18
Q

What classifies as a high quality chest compression?

A

Adequate depth - 5/6cm
Adequate rate - 100-120 bpm
Ensure full recoil of chest after each compression

Aim to change individual doing compression every 2 minutes to avoid fatigue

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19
Q

What should be used to ventilate the patient if tracheal intubation is not possible?

A

Laryngeal mask airway

Supraglottic airway

20
Q

What rate should the lungs be ventilated at?

A

10 breaths per min

21
Q

What does the evidence suggest regarding intubation and survival?

A

No studies have shown tracheal intubation increases survival

22
Q

What takes priority, tracheal intubation or continuing chest compressions?

A

Tracheal intubation should only be attempted by trained providers

Avoid stopping chest compressions but can pause for upto 5s when passing through vocal cords

Can defer intubation until after ROSC

23
Q

How would you confirm that a patient has been intubated successfully?

A

Waveform capnography

24
Q

What do you monitor during CPR?

A

Clinical signs - breathing effort, movement, eye opening
Pulse checks
Monitor heart rhythm
End tidal CO2 on waveform capnography
Feedback or prompt devices
Blood samples and analysis
Invasive cardiovascular monitoring - e.g. cont. BP
Focused echo/ultrasound can be used

25
Q

What does the end tidal CO2 give a reflection of?

A

Cardiac output and pulmonary blood flow

Ventilation minute volume

Usually low during CPR - reflect low cardiac output. If it normalises, indicate patient may be making resp. effort of own

26
Q

What is the role of waveform capnography in CPR?

A

Confirm tracheal tube placement

Monitor ventilation rate - avoid hyperventilation

Monitor quality of chest compressions - increase depth of compression, higher CO2

Identify ROSC during CPR - Rise in end tidal CO2 may indicate ROSC

Prognostication during CPR

27
Q

What equipment may be needed for waveform capnography?

A

Portable monitors that measure end-tidal CO2

Side-stream sampling - connector req. in breathing piece
Mainstream sampling

28
Q

What are the stages of a waveform capnograph?

A

A-B = baseline - end of inspiration (CO2 in air)
B-C = start of expiration (start with no CO2 as from anatomical deadspace then increase)
C-D = alveolar plateau
D - end-tidal CO2 = maximal CO2 (normally 4.3-5.5)
D-E = inspiration begin

29
Q

What should be done if there is a rise in end-tidal CO2 during a CPR cycle?

A

Withhold adrenaline until the next rhythm check. If cardiac arrest is confirmed, give adrenaline then.

30
Q

Can end tidal CO2 be used to terminate CPR?

A

While failure to achieve end tidal CO2 >1.33 in 20 mins is associated with a poor outcome, it should not be used alone to terminate CPR efforts

31
Q

What is important to know about giving drugs during CPR?

A

Best to use peripheral cannula as don’t need to stop CPR

Flush drug with 20ml fluid

Raise arm for 10-20 seconds

Can consider IO if IV is difficult to obtain

32
Q

What are the main sites recommended for IO access in adults?

A

Proximal humerus
Proximal tibia
Distal tibia

33
Q

What are the contraindications to IO access?

A

Trauma
Infection
Prosthesis at target site
Recent IO access attempt (<48hr) in same limb
Failure to identify landmarks

34
Q

How is positioning of an IO confirmed?

A

Aspirate - should see blood.

Absence of aspirate doesn’t imply failed attempt

35
Q

What are the main complications associated with IO access?

A

Extravasation into soft tissues - needs flushed as a result
Dislodgement of needle
Compartment syndrome due to extravasation
Fracture or chipping of bone
Pain related to infusion
Fat emboli
Infection/osteomyelitis

36
Q

What are the 4H’s and 4T’s of cardiac arrest?

A

Reversible causes of cardiac arrest:

  • Hypovolaemia (blood/fluid bolus)
  • Hypoxia (o2 and bag valve)
  • Hypothermia (themometer and blankets)
  • Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, academia, other metabolic (via vbg and treat via protocol)
  • Thrombus (PE - fibrinolysis/ MI - PCI/Fibrinolysis)
  • Toxin (antidote if available)
  • Tension pneumothorax (needle thoracotomy)
  • Tamponade (thoracotomy)
37
Q

Why is a tamponade difficult to diagnose as a cause for cardiac arrest and how is it diagnosed?

A

Typical signs such as hypotension and distended neck veins can’t be assessed

Focused cardiac ultrasound performed to diagnose pericardial effusion

38
Q

What would raise suspicion of cardiac tamponade as a cause for cardiac arrest?

A

Penetrating chest trauma
Post cardiac surgery

May req. resuscitative thoracotomy

39
Q

What probe position is recommended for focused ultrasound in cardiac arrest?

A

Sub-xiphoid

<10s pause in compressions

40
Q

When may automated chest compression devices be useful?

A 
CPR in moving ambulance where safety is at risk
Prolonged CPR
CPR during certain procedures:
- Coronary angiography
- Prep for extracorporeal CPR
41
Q

What do extracorporeal CPR techniques require?

A

Vascular access

Circuit with pump and oxygenator

42
Q

Where may extracorporeal CPR be associated with improved survival?

A 
Reversible cause of cardiac arrest:
- MI
- PE
- Hypothermia
- Poisoning
Little comorbidity
Cardiac arrest witnessed
Receive high quality CPR and ECPR
43
Q

When is a resus attempt typically terminated?

A

Clinical decision based on patient status and likelihood for improvement

If shockable, usually worth continuing

If asystole for >20 mins in absence of reversible cause and ongoing ALS constitute reasonable grounds for stopping further resus attempts

If fibrinolysis given - have to go for 60-90 mins

44
Q

How is death diagnosed after unsuccessful resuscitation?

A

Observe patient for minimum 5 mins
- no central pulse on palpation AND
- no heart sounds on auscultation
AND 1 of :
- asystole on continuous ECG
- absence of pulsatile flow using direct intra-arterial pressure monitoring
- absence of contractile activity using echo

Any activity prompt further 5 mins observation
After this assess pupillary response, corneal reflex, motor response to supra-orbital pressure

45
Q

What are the post even tasks for CPR?

A
  • Ongoing care for patient and allocation of roles and handover
  • Document
  • Communicate with relatives
  • Immediate post event debrief + delated debrief may be useful
  • Ensure equipment and drug trolley replenished
  • Audit forms completed

Advanced Life Support (ALS) (9 decks)

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