Recognising Deterioration and Preventing Cardiorespiratory Arrest

Question 1

In which situation do most people survive a cardiac arrest?

Answer 1

Initial primary myocardial ischaemia
Then VF arrest
Successful resuscitation in CCU

Question 2

What are to two most common vital signs that are noticed in patients who deteriorate during the few hours before a cardiac arrest?

Answer 2

Hypoxia and hypertension (I.e. ABC)

Question 3

What are the five rings in the chain of prevention of a cardiac arrest?

Answer 3

Education, monitoring, recognition, call for help, response

Question 4

If a COPD patient has a SpO2 of 93 and over on oxygen, is their EWS score 0 and why?

Answer 4

No, it is 1,2 or 3 as patient is on oxygen and therefore hypercapnic respiratory failure is occurring due to hypo ventilation

Question 5

What is the role of the critical care outreach team?

Answer 5

Usually highly qualified and experienced nurses
Prevent ward admissions to ITU
Identify when admission to ITU is necessary and look after patients who move from ITU back to wards
Share experienced knowledge with ward staff

Question 6

Name five causes of airway obstruction.

Answer 6

CNS depression 
Epiglottitis
Foreign body 
Laryngospasm
Pharyngeal swelling 
Vomitus
Blood 
Bronchial secretions 
Bronchospasm 
Blocked tracheostomy or laryngectomy 
Obstructive sleep apnoea

Question 7

Name 4 things that can be done to prevent airway obstruction.

Answer 7

• suck blood or gastric contents from airway
• place patient on side unless contraindicated
• give oxygen to reach sats of between 94-98%
• airway manoeuvres and adjuncts may be necessary (such as head tilt,chin lift, nasopharyngeal/oropharygeal airway and if expert is present, ET tube)
• consider Ng tube insertion to clear stomach and prevent aspiration

Question 8

Name 3 diseases that can cause respiratory arrest.

Answer 8

• Guillian Barre syndrome
• myasthenia gravis
• multiple sclerosis
• fractured rib or sternum
• chronic malnourishment
• kyphoscolliosis
• COPD exacerbation
• pulmonary embolism
• asthma
• ARDS
• pulmonary oedema
• pneumothorax/haemothorax
• tension pneumothorax (also Dec venous return to heart and lowers BP)

Question 9

Name three ways to recognise breathing problems

Answer 9

Resp rate of over 25/min
Pulse oximetry
ABG!!

Note that cyanosis, hypercarbia and low PH are late signs

Question 10

How do you treat an acutely ill patient with hypoxaemia?

Answer 10

Give oxygen via a high concn reservoir mask at 15L per min, measure O2 and then change mask. Aim for range of 94-98%
Treat underlying cause

Question 11

How do you treat patients with hypoxaemia who have pneumonia or asthma?

Answer 11

• IV abx asap

- bronchodilators (salbutamol nebs) and steroids

Question 12

In acutely unwell patients, what’s the most common cause of circulatory problems?

Answer 12

Hypovolaemia

Question 13

Which primary heart problem most commonly causes cardiac arrest and through what avenue?

Answer 13

Myocardial ischaemia secondary to MI causing VF

Question 14

What 2 things indicate that a patient is suffering from a STEMI?

Answer 14

• sustained chest pain for 20-30mins

- ST elevation on ECG

Question 15

If patients present with chest pain, and other ECG changes such as ST depression or T wave inversion, what test can be done and what does this indicate?

Answer 15

Troponin levels and high levels are suggestive of NSTEMI

Question 16

What is the initial treatment for an MI?

Answer 16

MONA
M-morphine given with anti emetics
O-oxygen (aim for 94-98% and 88-92% for COPD patients)
N-nitrates (GTN spray)
A-aspirin (300mg orally crushed or chewed)

Question 17

What is the preferred definitive treatment step of an MI and name 2 other long term treatments.

Answer 17

Primary PCI

• antithrombotics (clopidogrel)
• anticoagulation

Question 18

Name the top 3 causes of out of hospital sudden cardiac death (SCD).

Answer 18

• coronary artery disease
• non ischaemic cardiomyopathy
• valvular disease

Question 19

Name 5 signs or symptoms of cardiac disease.

Answer 19

• chest pain
• SOB
• tachypnoea
• bradycardia or tachycardia
• syncope
• hypotension
• poor peripheral perfusion
• oliguria
• altered mental state

Question 20

What are the 2 most common treatments for secondary heart problems?

Answer 20

Oxygen to treat hypoxia

IV fluids to treat hypovolaemia

Question 21

What should you do if a patient is unresponsive, unconscious and not breathing normally?

Answer 21

Commence CPR

Question 22

Which mask should be used to treat COPD patients with cardiac arrest? (B)

Answer 22

Venturi mask 4L/min

Question 23

In an emergency, what is the most likely cause of shock? (C)

Answer 23

Hypovolaemia

Question 24

What is the treatment for patients with cool peripheries and tachycardia? (C)

Answer 24

IV fluids

Question 25

What does a barely palpable pulse indicate and what does a bounding pulse indicate? (C)

Answer 25

Barely palpable=poor cardiac output | Bounding=SEPSIS

Question 26

What are the first 5 things that need to be done if circulatory compromise is suspected? (C)

Answer 26

1. Look at the colour of hands (blue, mottled, pale, pink) 2. Check capillary refill 3. Check pulse rate 4. Cool or warm peripheries? 5. Measure BP

Question 27

In circulatory compromise, if BP is normal, does this signify that the patient is well? (C)

Answer 27

No, peripheral resistance increases to compensate so normal BP does not signify that patient is well

Question 28

What does a low diastolic pressure indicate and give 2 examples. (C)

Answer 28

Arterial vasodilation which occurs in anaphylaxis and sepsis

Question 29

What does a narrow pulse pressure indicate in circulatory compromise(I.e. arterial vasoconstriction)? (C)

Answer 29

Cardiogenic shock (issue stems from hearts inability to pump blood efficiently) or hypovolaemia

Question 30

Name 3 things you’re listening for when auscultating the heart, to determine whether there is circulatory compromise. (C)

Answer 30

1. Pericardial rub indicating pericarditis 2. Murmurs/unequal heart rate and pulse rate=valvular disease 3. Diminished/quiet heart sound

Question 31

Apart from auscultation, BP and other vital signs, what 2 other factors signify reduced cardiac output? (C)

Answer 31

Reduced consciousness and oliguria

Question 32

What two sizes of cannula are suitable for circulatory restoration? What do you do before administering IV fluids?

Answer 32

Wide bore 14 or 16G for highest flow Take routine haematological, biochemical, coagulation and cross match bloods first

Question 33

When administering emergency fluids (500ml of NaCl over 15ml) , in which situation would you give 250ml? What do you do to monitor this? (C)

Answer 33

Heart failure patients | Listen for crackles after every bolus

Question 34

If patients normal BP is unknown, what value should you aim for? (C) if patient does not improve through multiple bolus infusions, what could be happening?

Answer 34

>100mmmg systolic Bleeding

Question 35

What 5 things should you do to treat disability (D) in the ABCDE protocol?

Answer 35

1. Treat ABC such as hypoxia hypotension 2. Reverse any drug toxicity (e.g naloxone for opiates) 3. Check status using AVPU (alert, voice response, painful stimuli response or unresponsive) 4. Check pupil reactions, size 5. Give glucose for hypoglycaemia (boluses of 10% glucose in 50ml)

Question 36

If an unconscious patients has a compromised airway, what position should you look after them in?

Answer 36

Lateral position