1
Q
what are 1st steps on Initial assessment of a patient?
A
Call out to the individual -> conscious/ unconscious?
Make sure scene is safe before approaching the individual
2
Q
what is the chain of survival?
A
1) Recognise symptoms and activate EMS
2) Perform early CPR
3) Defibrillate with AED
4) Advanced life support
5) Post cardiac arrest care
6) Recovery
3
Q
BCLS: What are the 4 things to do before carrying on with assessment of the patient?
A
1) check pt for responsiveness
2) shout for nearby help
3) activate emergency response system
4) send someone to get AED/ defibrillator
4
Q
BCLS: What to do after you assess the patient and there is normal breathing and a pulse felt?
A
Monitor until advanced care arrives
5
Q
BCLS: what to do when you assess a patient and there is a pulse felt but abnormal breathing such as gasping?
A
- provide breaths. 1 breath every 6s = 10 breaths/min
- check pulse every 2 mins: if no pulse -> start CPR
- if suspected opioid overdose, administer naloxone
6
Q
BCLS: what to do if no breathing or only gasping, pulse not felt?
A
start CPR: cycles of 30 compressions: 2 breaths
use AED as soon as it is available
if suspected opioid overdose, consider naloxone
7
Q
BCLS: once AED arrives and you check rhythm-> Shockable rhythm found. what do you do?
A
Give 1 shock. resume CPR immediately for 2 minutes until next rhythm check.
repeat until ROSC
8
Q
BCLS: non shockable rhythm found on AED. what do you do?
A
resume CPR for 2 minutes until next rhythm check. keep repeating cycles until ROSC
9
Q
treatment of symptomatic sinus bradycardia?
A
atropine, dopamine, adrenaline
10
Q
tx of sinus tachycardia?
A
reverse underlying condition (Fever, anxiety, exercise)
beta blockers
11
Q
tx of VT?
A
defibrillation
12
Q
Tx of VF?
A
defibrillation, adrenaline, amiodarone, lidocaine
13
Q
What ETCO2 reading should be produced with high quality CPR?
A
10-20 mmHg
14
Q
If ETCO2 reading <10mmHg during CPR, what to consider?
A
confirm quality of CPR and placement of advanced airway.
if still <10mmHg after 20 mins of CPR for intubated individual, consider stopping resuscitation attempts
15
Q
A/B in ACLS?
A
- maintain airway: ie. head tilt/chin lift + bag mask ventilation vs intubate/ oro or nasopharyngeal airway with bagging
- give 100% oxygen + assess effective ventilation with capnography
- suction secretions
16
Q
C in ACLS?
A
Evaluate rhythm and pulse
-> defib/ cardioversion where appropriate
obtain IV access (Class I) -> if fails, go for intraossesous access (Class 2a)
give rhythm-specific meds
give IV fluids when appropriate
17
Q
D in ACLS? (ie. Differential Diagnosis)
A
identify and treat reversible causes
cardiac rhythm and pt history are keys to differential diagnosis
assess when to shock vs medicate
18
Q
steps to remember when inserting an OPA?
A
1: suction
2: select appropriately sized airway device (corner of mouth to earlobe)
3: insert OPA facing upwards then turn it at the end
19
Q
what is a normal ETCO2 reading?
A
35-45 mmHg
20
Q
how to manage airway during cardiac arrest?
A
bag mask ventilation with 100% O2
with either head tilt/ chin lift
or advanced airway (ETT)
21
Q
contraindications to OPA?
A
conscious or semiconscious individual bc it can stimulate gagging, vomiting and possible aspiration.
22
Q
contraindications to NPA?
A
usu carefully in individuals with facial trauma due to risk of displacement
23
Q
how often to bag / deliver breaths during cardiac arrest?
A
once every 6 seconds
24
Q
Dosage of adenosine to give in SVT in ACLS?
A
Adenosine
6mg then 12 mg then 12mg (every 1 to 2 min)
25
how to give adenosine ?
rapid IV push followed by saline bolus
continuous cardiac monitoring following administration
26
Cardiac arrest: if VF/ VT, how to shock?
usually start at 120J, up to 200J
27
Cardiac arrest: what drugs do you have to give if PEA/asystole?
Adrenaline: given 1mg every 2 cycles (3-5 mins)
28
Cardiac arrest: VT/VF arrest, what medications to give?
Adrenaline: 1mg every 2 cycles (3-5 mins)
Amiodarone: 300mg bolus
Or Lidocaine: First dose 1-1.5mg/kg
29
What are your reversible causes in cardiac arrest?
5Hs and 5Ts:
- Hypovolaemia
- Hypoxia
- H+ (acidosis)
- Hypo/HyperK
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
30
what are your 5Hs?
hypovolaemia
hypoxia
H+ (Acidosis)
Hypo/HyperK
Hypothermia
31
what are your 5 Ts?
Tension pneumothorax
Toxins
Tamponade, cardiac
Thrombosis, pulmonary
Thrombosis, coronary
32
when do you give adrenaline after cardiac arrest?
asap
33
cardiac arrest: shockable rhythm at rhythm check? ie VF, pulseless VT
shock immediately, then continue CPR 2 mins
then pulse check
34
when to start amiodarone or lignocaine in cardiac arrest?
after 2 shocks
35
Indications for amiodarone infusion?
- VF/pulseless VT
- VT with pulse
- Tachycardia rate control
36
Dose of amiodarone in conscious VT/VF?
Amiodarone 150mg bolus over 10 mins, followed by a continuous infusion 1mg/min for 6h, then 0.5mg/min for 18h
37
Dose of amiodarone in unconscious VF/ pulseless VT?
IV amiodarone 300mg first dose, add 150mg as 2nd dose if not effective (max dose 450mg)
38
when to not use amiodarone?
dont use in 2nd or 3rd degree heart block
- look out for hypotension, bradycardia, GI toxicity
39
Dose of atropine in symptomatic bradycardia?
IV Atropine 0.5 or 1mg, repeat every 3-5 mintues (max dose 3mg)
40
Dose of atropine in specific toxins/overdose e.g. organophosphate?
2- 4mg may be needed
41
when to avoid atropine?
glaucoma or tachyarrhythmias
42
Management of adult tachyarrhythmia with a pulse?
Initial assessment
A/B: maintain airway, Oxygen if hypoxia
C: continuous cardiac monitoring to identify rhythm. monitor BP
IV access.
12 lead ECG
43
Mx of persistent tachyarrhythmia causing hypotension/ altered mental status/ signs of shock/ ischaemic chest discomfort/ acute heart failure?
synchronised cardioversion
- sedate wherever feasible
- if regular narrow complex, consider adenosine
44
mx of persistent tachyarrhythmia causing haemodynamic instability, refractory to synchronised cardioversion?
- treat underlying cause
- may need to increase energy level for next cardioversion
- addition of anti-arrhythmic drug
45
mx of persistent tachyarrhythmia with no signs of shock or haemodynamic instability + wide QRS complex >/=0.12s
- anti arrhythmic infusion
- consider adenosine only if regular and monomorphic
46
mx of persistent tachyarrhythmia with no signs of shock or haemodynamic instability + narrow QRS complex
- vagal manoeuvres (if regular)
- adenosine (if regular)
- beta blocker or CCB
47
If about to electrically cardiovert, what are some things to have available by bedside?
- oxygen sats + continuous cardiac monitoring
- suction device
- intubation equipment
- IV line
- sedate with fentanyl
48
energy for synchronised cardioversion of AF with haemodynamic instability?
200 J
49
energy for synchronised cardioversion of Atrial flutter with haemodynamic instability?
200 J
50
energy for synchronised cardioversion of Narrow complex tachycardia with haemodynamic instability?
100J
51
energy for synchronised cardioversion of monomorphic VT with haemodynamic instability?
100J
52
energy for synchronised cardioversion of polymorphic VT with haemodynamic instability?
unsynchronized high energy shock (defibrillation)
53
dosage of lignocaine to give in cardiac arrest due to VF/pVT?
initial dose: 1-1.5mg/kg loading dose
second dose: half of first dose 0.5-0.75mg/kg in 5-10 mins
maintenance: 1 - 4mg/min infusion
54
dose of lignocaine to give in wide complex tachycardia with pulse?
initial dose: 0.5-1.5mg/kg IV loading
second: half of first dose in 5-10 min
maintenance: 1-4mg/min
55
what to be aware of with lignocaine infusion?
may cause hypotension and bradycardia
use with caution in renal failure
56
mx of bradycardia with pulse but with evidence of haemodynamic instability (hypotension, signs of shock, altered mental status, acute heart failure, ischaemic chest discomfort)
A/B: maintain airway, o2
Atropine IV 1mg, repeat up to 3mg
if remains ineffective:
- transcutaneous pacing
and/or
- dopamine or adrenaline infusion
then: consider transvenous pacing
57
mx of bradycardia without evidence of haemodynamic instability?
identify and tx underlying cause
- support ABC
- obtain 12 lead egg
- observe
58
dopamine dosage in symptomatic bradycardia or in shock/CHF
5 to 20mcg/kg/min infusion
- titrate to desired BP and/or HR
max dose 20mg
59
dosage of adrenaline in anaphylaxis?
IM adrenaline 0.3-0.5mg
repeat every 5 minutes as needed
60
dosage of adrenaline in cardiac arrest?
IV Adrenaline 1mg (1:10,000) in 10ml of normal saline
every 3-5 mins
maintenance infusion: 0.1-0.5mcg/kg/min (ie.
61
dosage of adrenaline in symptomatic bradycardia/ shock?
2-10mcg/min infusion
- titrate to response
62
what infusions can you give in symptomatic bradycardia with shock?
dopamine infusion or adrenaline infusion
63
possible underlying causes of symptomatic bradycardia?
- MI
- drugs: e.g. CCB/ BB/ digoxin
- Hypoxia
- electrolyte abnormalities e.g. HyperK
64
when to give IV MgSO4?
torsades de pointes with pulse
cardiac arrest/ pulseless torsades
65
dose of IV MgSo4 to give in cardiac arrest / pulseless torsades?
1-2g diluted in 10ml D5W
ie 1-2 cycles IV MgSO4
66
Dose of IV MgSO4 in torsades de pointes with a pulse?
IV MgSO4 1-2g over 5-60 mins
maintenance: IV MgSo4 0.5-1g/hr
67
dosage of sotalol to give in tachyarrhythmia/ monomorphic VT/ as a 3rd line anti-arrhythmic?
100mg IV (1.5mg/kg) over 5 min
68
when not to give Sotalol
prolonged QT
69
Post cardiac arrest care starts with?
Airway/ Breathing: ETT. FiO2 100%. Target SpO2 94-98% (PaO2 60-105mmHg)
Circulation: inotropes to Target MAP >/=65 +/- fluid resuscitation PRN
consider when to cath+/-PCI
Cause of arrest:
- obtain 12 lead ECG to assess for MI/arrhythmia
- consider diagnostic imaging where indicated: CT head/ TAP to determine cause of arrest.
- POCUS or TTE
70
what diagnostic testing to consider post ROSC?
12 lead ECG: look for STEMI, arrhythmia
POCUS/ TTE: can look for tension pneumothorax, tamponade
CT brain/ TAP to determine cause of arrest
71
Post cardiac arrest with ROSC, ECG showing persistent ST elevation, cardiogenic shock, refractory or recurrent ventricular arrhythmias, severe myocardial ischaemia?
emergency PCI +/- mechanical circulatory support (IABP)
72
Post cardiac arrest: temperature control
if pt not following commands off sedation/ neuromuscular blockade, aim hypothermia / normothermia for at least 24h
73
Post cardiac arrest care: when to consider EEG?
evaluate for any clinical seizures
obtain EEG to evaluate for seizures in pts not following commands
AEDs e.g. keppra
74
Post cardiac arrest: when to neuroprognosticate?
multimodal approach with delayed impressions
>/=72h from ROSC or achieving normothermia
75
if pulse present but pt has abnormal/ agonal breathing?
start rescue breathing with bag mask
- deliver 1 breath every 5-6 seconds (ie 10-12 breaths per min)
check pulse every 2 min
76
what are the 2 most common causes of PEA collapse?
hypovolaemia and hypoxia
77
1st line inotrope in pts
noradrenaline
78
2nd line inotropes?
vasopressin
consider phenylephrine
79
3rd line inotrope?
adrenaline
80
temperature control in an OHCA pt who is unresponsive?
temperature control for at least 24 h
aim core body temp 32-37.5 degrees with a cooling device with a feedback loop
81
pt presents with OHCA, when to consider emergency PCI/ cath lab activation?
- STEMI present
- unstable cardiogenic shock
- mechanical circulatory support required
82
what other monitoring to do in CCU when pt presents with OHCA and is comatose?
- temperature control, monitor core temp w oesophageal or bladder probe
- cEEG monitoring
83
Neurological assessment in OHCA pts?
GCS per shift
pupillary response: check for reactive pupils
84
ix to send in cardiac arrest pts?
- FBC electrolytes glucose ABG + other pertinent labs
- CXR: to evaluate for pulmonary complications, confirm tube placements
- Echo to assess cardiac fn
85
signs/symptoms of haemodynamic instability?
hypotension
altered mental status
signs of shock
chest pain
acute heart failure
86
contributing factors to bradycardia?
rmb Hs/Ts
hypoxia
hypothermia
hypovolaemia
hyper/hypoK
toxins
tamponade
tension pneumothorax
thrombosis (coronary/pulmonary)
87
anti arrhythmics for stable pts with wide QRS complex tachyarrhythmias
- IV amiodarone 150mg over 10 mins (repeat as needed if ventricular tachycardia recurs), maintenance 1mg/min for first 6h
- IV procainamide: avoid if prolonged QT/ congestive heart failure
- IV sotalol: avoid if prolonged QT
88
dose of sotalol used?
IV sotalol 100mg (1.5mg/kg) over 5 min
89
precautions in using procainamide?
avoid if prolonged QT or congestive HF present
90
dosage of procainamide for tachyarrhythmia
loading dose: 20-50 mg per minute until arrhythmia suppressed/ hypotension ensues/ QRS increases by >50% for max dose 17mg/kg is reached
maintenance: 1-4mg/min
91
mx for any wide complex tachycardia of unknown type?
synchronised cardioversion
92
mx of irregular narrow complex tachycardia?
probable A fib
control rate with IV diltiazem 15-20mg (0.25mg/kg) over 2 minutes
or beta blockers
93
mx of probable VT with pulse?
IV amiodarone 150mg over 10 minutes
elective cardioversion
94
Biphasic vs monophasic waveform defibrillation?
biphasic preferred over monophasic (Class 2a)
95
single shock vs stacked shocks for defibrillation?
single shock is preferred to stacked shocks (Class 2a)
96
what to do about airway in ACLS?
even if on ventilator, take off ventilator.
give 1 breath every 6 seconds via bagging with 100% O2
97
vector change usefulness in refractory VF?
vector change in persistent VF/pVT after 3>/= consecutive shocks not been established (Class 2b)
*Class 2b: benefit>/=risk, weak. may be reasonable/ considered
98
double sequential defibrillation in refractory VF?
double sequential defibrillation in persistent VF/pVT after 3>/= consecutive shocks has not been established (class 2b: weak benefit >/=risk, can be considered)
99
Central venous access in cardiac arrest?
if IV or IO access unsuccessful or not feasible, can use CVC (Class 2b)
100
optimal anatomical location for IO access?
tibial or humeral
101
adrenaline in cardiac arrest?
recommended for ALL patients in cardiac arrest (Class 1)
-> 1mg every 3-5 mins (ie. every 2 cycles) : class 2a
-> administer adrenaline immediately in non shockable rhythm (class 2a)
-> administer adrenaline after initial defibrillation attempts have failed (class 2a)
102
vasopressin in cardiac arrest?
vasopressin alone or vasopressin + adrenaline offers no advantage as substitute for adrenaline in cardiac arrest (Class 3: no benefit)
103
Amiodarone/Lidocaine in cardiac arrest with shockable rhythms?
class 2b evidence.
amiodarone / lidocaine may be considered for VF/pVT that is unresponsive to defibrillation
104
Magnesium in adults in cardiac arrest?
routine administration of Mg not recommended (Class 3: no benefit)
105
sodium bicarbonate in cardiac arrest?
routine administration of sodium bicarbonate not recommended (class 3: no benefit)
106
calcium in cardiac arrest?
routine administration of calcium not recommended (Class 3- no benefit)
107
how can ETCO2 help identify ROSC?
sudden increase of 10mmHg in ETCO2 may indicate ROSC
108
when to terminate resuscitation?
failure to achieve ROSC after 20 mins of ALS resuscitation
109
which criteria should be present in which to consider termination of resuscitation efforts in OHCA?
- arrest not witnessed by emergency medical services personnel
- no ROSC (before transport)
- no AED shock delivered (before transport)
- no bystander CPR
110
what is the most reliable method of confirming and monitoring correct placement of an ETT in adults with cardiac arrest?
continuous waveform capnography (Class 1)
111
mx of haemodynamically unstable wide complex tachycardia?
synchronised cardioversion (Class 1)
112
mx of haemodynamically stable patients with wide complex tachycardia when vagal manoeuvres and pharmacological therapy is ineffective/ contraindicated?
synchronised cardioversion (class I)
113
pharmacological mx of adult with wide complex tachycardia when haemodynamically stable?
IV amiodarone, procainamide, sotalol (Class 2B)
114
when can you use adenosine in wide complex tachycardia?
in haemodynamically stable pt with regular monomorphic wide complex tachycardia, can use IV adenosine for treatment or aiding rhythm diagnosis when cause of rhythm cannot be determined (Class 2b)
115
what medications not to give to pt with wide complex tachycardia?
verapamil and diltiazem (Class 3- causes harm)
116
when to NOT give adenosine in pts with wide complex tachycardia?
if haemodynamically unstable, irregularly irregular, or polymorphic wide complex tachy
(Class 3- HARM)
117
definition of wide complex tachycardia?
>150bpm, QRS >/=0.12s
118
what are the 4 means of achieving a wide QRS complex?
1. conduction of ventricular origin
2. left or right BBB
3. conduction through a bypass tract
4. ventricular pacing
119
causes of wide complex tachycardias?
could be ventricular (VT/VF)
or SVTs resulting from:
2. left or right BBB
3. conduction through a bypass tract
4. ventricular pacing
120
what presents as polymorphic wide complex tachycardias?
torsades de pointes
VF
AF with a bypass tract
121
adenosine effect on a wide complex tachycardia of ventricular origin?
will not terminate
may cause profound hypotension leading to shock, or precipitate VF or cardiac arrest
122
mx of pts with sustained polymorphic ventricular tachycardia (ie torsades de pointes)?
immediate unsynchronised shock (defibrillation)
Class 1
123
mx of adults with recurrences of polymorphic VT Assoc w long QT >500ms (torsades de pointes)?
Magnesium (Class 2b)
+ correct hypoK
124
mx of adults with recurrences of polymorphic VT WITHOUT long QT?
IV lidocaine, amiodarone (Class 2b)
Measures to treat myocardial ischaemia ie PCI (class 2b)
routine use of Mg not recommended if QT normal (class 3: no benefit)
125
most common cause of polymorphic VT not associated with Long QT?
acute myocardial ischaemia
126
potential causes of polymorphic VT not associated with long QT?
- most common: acute myocardial ischaemia
- genetic abnormality where polymorphic VT is provoked by exercise or emotion
- short QT syndrome (QTc <330-370ms)
- idiopathic RVOT polymorphic VT
- bidirectional VT seen in digitalis toxicity
127
all forms of polymorphic VT are considered?
haemodynamically and electrically unstable
128
tx of bradycardia or pause-precipitated torsades de pointes?
consider additional measures such as overdrive pacing or isoproterenol
129
Mx of SVT/ regular narrow complex tachycardias?
- vagal manoeuvres (Class I)
- adenosine (Class I)
- synchronised cardioversion if haemodynamically unstable (Class 1)
130
when to consider synchronised cardioversion in SVT/narrow complex tachycardia?
- if haemodynamically unstable (Class I)
- if vagal manoeuvres or pharmacological tx is ineffective or contraindicated (Class I)
131
what 2nd line treatments may be considered in adults with haemodynamically stable narrow complex tachycardias?
IV diltiazem or verapamil (Class 2a)
IV Beta blockers (class 2a)
132
what rhythms are encompassed under narrow complex tachycardias?
sinus tachycardia, A flutter, AVNRT, AVRT, atrial tachycardia
133
what are examples of vagal manoeuvres?
- pt to blow into 10cc syringe
- bearing down
- carotid massage
134
adenosine in asthma?
can cause bronchospasm and is contraindicated
135
mx of AF/A flutter with RVR and haemodynamic instability?
immediate electrical cardioversion (Class I)
136
mx of new onset AF/A flutter with RVR in the setting of ACS with haemodynamic compromise, ongoing ischaemia, or inadequate rate control?
urgent direct-current (DC) cardioversion
137
medical tx for AF with RVR without pre excitation?
- IV beta blocker (e.g. metoprolol, esmolol) or non dihydropyridine CCB e.g. diltiazem/ verapamil (Class 1)*
- IV amidoarone (Class 2a)
*should not be used in adults with LV systolic dysfunction and decompensated heart failure as can lead to further haemodynamic compromise (Class 3-harm)
138
medical tx for AF RVR in pts with heart failure?
IV amiodarone
139
dose of diltiazem in mx of AF RVR?
Diltiazem IV 0.25mg/kg bolus over 2 mins (ie 12.5mg)
then infusion 5-10mg/hr
*Avoid in hypotension, HF, CMP, ACS
140
dose of verapamil in AF RVR?
bolus: 0.075-0.15mg/kg IV bolus over 2 min
can give additional dose after 30 min if no response
infusion 0.005mg/kg/min
*avoid in hypotension, HF, CMP and ACS
141
dose of IV metoprolol in AF RVR?
bolus: 2.5-5mg over 2 min, up to 3 doses
*avoid in decompensated HF
142
dose of IV esmolol in AF RVR?
bolus: 500mcg/kg IV over 1 min
infusion: 50-300mcg/kg/min
*short duration of action, avoid in decompensated HF
143
dose of propranolol in AF RVR?
bolus 1mg IV over 1 min, up to 3 doses
*avoid in decompensated HF
144
Amiodarone dose in AF RVR?
can given IV bolus 150mg
or 300mg over 1h
then infusion: 1mg/min for 6h then 0.5mg/min for 18h
145
management of acute symptomatic bradycardia?
evaluate and treat reversible causes (Class 1)
if haemodynamically unstable, give atropine (class 2a)
if persistently haemodynamically unstable + refractory to medical tx, temporary transcutaneous pacing (Class 2a)
146
potential causes of symptomatic bradycardia?
- MI
- hypoxaemia
- hypothyroidism
- infections
- structural heart disease
- increased vagal tone
- metabolic derangement, electrolyte abnormalities
- toxins/ meds
147
mx of anaphylaxis cx cardiac arrest?
- reasonable to fluid resuscitate with isotonic IV fluids (Class 2A)
- reasonable to use extracorporeal CPR in those refractory to pharmacological interventions (Class 2A)
- administer glucagon IV 1-5mg if there is suspected/confirmed concurrent Beta blocker use (Class 2b)
- effectiveness of standard anaphylaxis IM adrenaline dose is uncertain (Class 2b) -> ie. just use standard ACLS IV adrenaline dose
148
tx of anaphylaxis peri-arrest
IM adrenaline
bronchodilators
corticosteroids
glucagon
discontinuation / removal of the trigger
149
in adults and children with life threatening asthma, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for?
tension pneumothorax (Class 1)
150
ventilatory strategy for pts with life threatening asthma?
low RR and TV (Class 2A)
and ideally increased expiratory time> minimise risk of intrinsic PEEP and barotrauma
-> to avoid air trapping and thus decreased effective ventilation
151
extracorporeal life support in pts with life threatening asthma refractory to standard therapies?
reasonable class 2b
> venovenous ECMO for respiratory failure
> in the setting of haemodynamic instability as well, may require VA ECMO support
152
how may asthma lead to cardiac arrest?
increased lower airway obstruction -> hypoxaemia, hypercarbia, respiratory acidosis, and increased intrathoracic pressure -> decreased cardiac output
153
pts in cardiac arrest in ICL should receive?
- mechanical CPR devices (Class 2A)
- extracorporeal life support (Class 2A)
- intracoronary adrenaline (Class 2b)
-> ideally to allow performance of lifesaving interventions ie PCI or placement of mechanical circulatory support
154
VF cardiac arrest after cardiac surgery if a trained professional witnesses the cardiac arrest?
immediate 3 stacked defibrillation (Class 1) within 1 min
and CPR if defibrillation is not successful within 1 min
155
mx of patients in asystole or bradycardia arrest after cardiac surgery if a trained professional witnesses the arrest and temporary pacing wires alr in place?
immediate pacing and CPR initiated within 1 min if pacing unsuccessful (Class 1)
156
post cardiac surgery cardiac arrest?
- if shockable, shock 3 times
- start with external chest compressions if emergency resternotomy is not immediately available (class 1)
- rapid sternotomy in an appropriately staffed and equipped ICU if refractory (for at least 10 days post surgery) (Class 2a)
- internal cardiac massage if chest/abdomen is open or when chest can be reopened rapidly (Class 2a)
if refractory to standard resus, ECLS ( e.g. ECMO, VAD, CPB) can be effective (class 2a)
157
ventilation post drowning cardiac arrest?
- by first means available (mouth-to-mouth, pocket mask, bag valve ventilation) to avoid delay in ventilation (class 2a)
- can use advanced airways (class 2a)
158
Cardiac Arrest + HyperK
- what special things to give?
- IV calcium gluconate (Class 2b)
- IV sodium bicarbonate (Class 2b) - shifts K intracellularly
- IV insulin 10 units and glucose (D50% 40ml bolus) (Class 2b)
159
cardiac arrest + hyperthermia (Core Temp >40)
- what special things
- active cooling alongside standard resuscitation (Class 1)
- immersion in ice water (2a)
- can stop active cooling when core temp reaches 38.6 (2a)
160
cardiac arrest + hypothermia
- what special things to do ?
- rewarming concurrently (Class 1)
- can use ECLS (class 2a)
- may be reasonable to defibrillate once and if unsuccessful, defer further defibrillation until core temp >/=30 degrees (2b)
- may be reasonable to defer adrenaline until core temp >/=30degrees (2b)
161
how to detect cardiac arrest in patients with durable LVADs?
durable LVADs have continuous rather than pulsatile flow, so most pts do not have a palpable pulse
perfusion assessed if any are present:
1. normal skin colour /temp
2. normal cap refill
3. MAP >/=50mmHg
4. ETCO2 >20mmHg
if unresponsive without adequate perfusion, likely in cardiac arrest
162
special mx in cardiac arrest 2' PE?
systemic fibrinolysis vs surgical embolectomy vs percutaneous mechanical embolectomy (class 2a)
if only suspected PE, systemic fibrinolysis is class 2b
reasonable to use ECLS (VA-ECMO) (2a)
163
cardiac arrest due to beta blocker poisoning
- high dose insulin 1U/kg or euglycaemia therapy in those with hypotension (class 1)
- vasopressors (class 1)
- glucagon bolus 2-10mg then infusion 0.05-0.15mg/kg in tx of symptomatic bradycardia (2a)
- consider ECLS (VA-ECMO) if in cardiogenic shock refractory to pharmacological interventions (2a)
consider HD if atenolol, nadolol, sotalol (2b)
IV lipid emulsion (2b)
164
mx of cardiac arrest 2' CCB poisoning?
- high dose insulin (1U/kg) for hypotension (class 1)
- vasopressors for hypotension (class 1)
- ECLS (VA-ECMO) if refractory (2a)
- calcium chloride IV 2g or Ca gluconate 6g (2a)
2b:
- glucagon
- methylene blue
- ILE
165
life threatening local anaesthetic poisoning?
intravenous lipid emulsion
benzos for seizures
sodium bicarb for life threatening wide complex tachycardia
ECLS if refractory cardiogenic shock
166
how does CO2 affect brain blood flow?
high CO2 causes vasodilation (may worsen elevated ICP through increased cerebral blood volume), whereas low CO2 causes vasoconstriction and may lead to cerebral ischaemia
167
what is the physiologic rationale for considering a higher MAP after cardiac arrest?
CPP = MAP - ICP
impaired cerebral blood flow auto regulation post cardiac arrest may impair ability of the brain to maintain perfusion even at normal MAP
168
CT scan post cardiac arrest?
reasonable to consider CT head to pelvis to investigate aetiology of cardiac arrest and complications from resuscitation (2b)
169
why may shock occur after cardiac arrest?
often multiple aetiologies
may evolve from initial low output cardiogenic shock from post cardiac arrest myocardial dysfunction to a later vasodilatory shock from inflammatory vasoplegia
170
when to activate ICL for cardiac arrest patients?
- persistent STE on ECG (suspected STEMI as cause of arrest)
- electrical instability (recurrent ventricular arrhythmias) or haemodynamic instability (cardiogenic shock)
- or evidence of significant ongoing myocardial ischaemia
Cardiology 101
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