ALS algorithm Flashcards
ALS algorithm.
a) When should ALS algorithm be started?
b) 4 main rhythms in an arrest (2 classifications)
c) Initial management of arrest in adults
d) Adjuvant management
a) - Patient unresponsive and not breathing normally (eg. agonal breathing - occurs in up to 40% of arrests)
- Respiration (look, feel, listen) and circulation (feel for carotid pulse) should be assessed simultaneously for 10 seconds
b) - Shockable: pulseless VT, VF
- Non-shockable: PEA, asystole
c) - Call for help (crash team alert on 2222)
- Start uninterrupted CPR 30:2
- Attach defibrillator pads
- Stop CPR (< 5 secs) to assess rhythm
- If shockable, deliver shock
- Continue CPR for 2 mins
d) - Airway management (SGA, ETT), oxygen, IV access
- Waveform capnography (if intubated)
- Blood samples - venous and arterial (for reversible causes)
- Adrenaline (1 mg IV - ASAP and every 3 - 5 mins in non-shockable rhythm; after 3rd shock and then after alternate shocks [every 3 - 5 mins] in shockable rhythm)
- Amiodarone (single dose of 300 mg IV after 3rd shock in shockable rhythm)
Shockable rhythm:
- Assessing rhythm and delivering a shock
- Stop chest compressions and assess rhythm (< 5 secs) If shockable... - Resume chest compressions - Tell everyone else to "stand clear" - Charge for shock (~ 150 J) - Stop oxygen delivery to patient - When charged, tell person on chest to "stand clear" - Deliver 1 shock - Continue CPR for 2 mins
Shockable rhythm:
- Management for pVT/VF persisting after 1st shock
- After 1st shock, continue CPR for 2 mins
- Repeat rhythm check and deliver second shock
- After 2nd shock, continue CPR for 2 mins
- Repeat rhythm check and deliver third shock
- After 3rd shock:
a. IV amiodarone 300 mg (single dose), and
b. IV adrenaline 1 mg (1 in 10,000)* - Continue with CPR and shocks
- Administer IV adrenaline 1 mg after alternate shocks (every 3 - 5 mins)
- Adrenaline doses:
- 1 mg IV of 1 in 10,000 in ALS
- 500 mcg IM of 1 in 1,000 in anaphylaxis
ROSC.
a) How is it assessed?
b) Management
c) Problems in the post-arrest patient
a) - Pulse / signs of life
- Increase in etCO2 on waveform capnography in intubated patients: approaching 35 - 45 kPa
b) Immediate post-cardiac arrest treatment:
- Use ABCDE approach
- Aim for SpO2 of 94-98%
- Aim for normal PaCO2
- 12-lead ECG
- Treat precipitating cause (eg. 4 Ts and 4 Hs)
- Targeted temperature management - aim for core temperature no higher than 36.0 C*
*Passive cooling acceptable, don’t infuse cold IV fluids for cooling alone
c) - Post-arrest brain anoxia/hypoxia
- Myocardial damage
- Ischaemia and reperfusion injury
- Multi-organ failure
- Ongoing effects of the cause of arrest
Non-shockable rhythms.
a) What are PEA and asystole?
b) Management
c) True asystole vs. ventricular standstill
a) - PEA: cardiac arrest in the presence of electrical activity (other than ventricular tachyarrhythmia) that would normally be associated with a palpable pulse.
- Asystole: total cessation of electrical activity from the heart, resulting in zero cardiac output (usually irreversible; very poor prognosis)
b) - Start CPR 30:2
- Gain IV access (or IO), administer adrenaline 1 mg IV
- Continue CPR 30:2 until airway is secure 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
i. If a pulse and/or signs of life are present, start post resuscitation care
ii. If no pulse and/or no signs of life are present (PEA OR asystole), continue CPR
b. If VF/pVT, change to shockable rhythm algorithm
- Recheck the rhythm after 2 min and proceed accordingly
- Give adrenaline 1 mg IV after alternate CPR cycles (every 3–5 min)
c) Asystole:
- Check ECG for P waves - patient may respond to cardiac pacing if P waves but no ventricular activity
- True asystole will not respond to pacing
Reversible causes of cardiac arrest. (4 Ts and 4 Hs) - diagnosis - treatment - which has the best prognosis?
Hypoxia.
- Diagnosis: low SpO2
- Rx: support airway - ideally iGel or ETT and give high-flow oxygen (15 L/min via NRB)
Hypovolaemia.
- Diagnosis: clinical, low BP, etc.
- Rx: IV fluids STAT (and O-negative blood if major haemorrhage), stop any haemorrhage if present
Hypothermia.
- Diagnosis: low temp
(drowning often causes sudden-onset hypothermia)
- Rx: Dry patient (if wet), blankets, cover extremities, IV warm fluids, monitor temp (aim for at least 35.0 C)
Hypo/hyperkalaemia/ other metabolic (Ca2+, Mg2+, hypoglycaemia, hypothyroidism).
- Diagnosis: ABG values for K+, BM for glucose, venous sample lab results for others
- Rx (for hyperK+ and ): IV insulin/dex + calcium chloride/ gluconate + salbutamol, etc.
- Rx (for hypoCa2+): IV calcium chloride
- Rx (for hypoglycaemia): IV glucose
- Rx (for hypokalaemia): NaCl 0.9% + 40 mmol/L KCl (at infusion rate of 10 mmol/L)
- Rx (for metabolic acidosis): sodium bicarbonate*
*Note: NEVER give sodium bicarbonate and calcium compounds through same line as it will form calcium carbonate (chalk)
Thromboembolism (PE most likely, then MI).
- Diagnosis: clinical (+/- ECHO)
- Rx: Urgent thrombolysis/thrombectomy
- Rx: Urgent angio and PCI for MI (once ROSC achieved?)
- Rx: Continued CPR via mechanical chest compression or extra-corporeal CPR
Tension pneumothorax.
- Diagnosis: clinical
- Urgent decompression via needle thoracostomy 2nd ICS mid-clavicular line (insert cannula during CPR and observe for a ‘hiss’ of air. Ensure it is not knocked out or kinked - if it is, insert another)
- Chest drain inserted after ROSC
Tamponade.
- Diagnosis: Transthoracic ECHO (TTE) to confirm
- Pericardiocentesis
Toxins.
- Diagnosis: look at drug chart, consider common causes (eg. TCA, opiate, naloxone, benzo) and anaphylaxis
- Rx: Antidotes where available (eg. naloxone, flumazenil*, NAC)
- Routine use of flumazenil not indicated in benzo overdose as it can cause seizures in those dependent on benzos. Used in accidental/iatrogenic overdose
- Coronary thrombosis has a relatively good survival compared to the others
Waveform capnography.
a) what does it assess?
b) when should it be used?
c) why is it useful? (2 reasons)
d) Values in normal patients (or ROSC), effective chest compressions and ineffective chest compressions
a) Non-invasive continuous assessment of end-tidal (expired) CO2
b) - Any intubated patient in arrest situation
c) - Indicator of cardiac output: assesses quality of chest compressions and ROSC
- Indicator of ventilation: assesses tracheal tube placement (though doesn’t distinguish bronchial from trachel placement) and hyper/hypoventilation
d) - Bad chest compressions: < 10 mmHg
- Good chest compression: 10 - 20 mmHg
- ROSC: rising etCO2 to normal range (35 - 45 mmHg)
Decision to stop CPR.
a) Who should decide?
b) What factor should be considered?
c) How long should you continue CPR for?
a) Resuscitation team leader
b) Assessment of the likelihood of achieving ROSC
c) - In the presence of VT/VF or a potentially reversible cause to be treated, continue until deemed futile
- Asystole for more than 20 minutes in the absence of a reversible cause
ALS in children.
a) Differences to adult algorithm
b) Adrenaline and amiodarone doses
c) Parental presence
d) Mnemonic for a collapsed child
a) - Start with 5 rescue breaths
- CPR ratio 15:2
- If alone, do 1 minute of CPR before calling for help
b) - Adrenaline: 10 mcg/kg
- Amiodarone: 5 mg/kg
c) - Parents may want to be present during CPR
- Someone should be present to explain to the parents what is happening throughout
- Parents present during CPR attempt show reduced levels of depression and anxiety in the months following bereavement
d) WETFLAG:
W Weight (Age + 4) x 2 (kg)
E Energy/electricity 4 x weight (kg) = Joules
T Tube (ETT) (Age / 4) + 4 = diameter in mm
F Fluids (bolus) 20 ml/kg NaCl 0.9%
L Lorazepam 0.1 mg/kg
A Adrenaline 10 mcg/kg of 1:10,000 = 0.1 ml/kg
G Glucose 2 ml/kg (10% Dextrose)
ALS in pregnant women.
a) At what gestational age does the uterus become clinically relevant in ALS and why?
b) Pregnancy-related causes of arrest
c) ALS management in pregnancy
d) When should peri-mortem CS take place?
a) ~ 20 weeks - gravid uterus extends above umbilicus and can compress the IVC (may occur before this in polyhydramnios)
b) - Haemorrhage: APH (praevia, abruption)
- VTE (massive PE)
- Eclampsia
- Amniotic fluid embolism
c) - Obstetric input sought immediately
- Also paediatric input if gestational age 23 weeks+
- Uterus should be manually moved to the left
- Woman should be tilted left by 15 - 30 degrees, ONLY if on stable tilt table surface
- Then CPR as normal 30:2 (may need to be higher up the chest in gravid uterus due to displacement of intra-thoracic contents)
- Consider peri-mortem CS
d) If there is no response to CPR within 4 minutes of maternal collapse in women beyond 20 weeks gestation
Chest compressions.
a) Rate and depth
b) Ratio of chest compressions to breaths. (Exceptions?)
c) When should they be stopped?
a) - Rate: 100 - 120/minute
- Depth: 5 - 6 cm
b) 30: 2
- If airway (ETT or LMA) in place, give continuous chest compressions
- In children - 5 rescue breaths, then 15: 2
c) - Obvious signs of life
- Rhythm check at start and every 2 minutes
- When delivering shock
- If team leader decides futile to continue
If patient vomits / regurgitates gastric contents during CPR, what should be done?
- Stop CPR briefly
- Roll patient onto side to drain contents (suction what you can see if necessary)
- Roll onto back and restart CPR
Shockable vs. non-shockable rhythms.
a) What % cases are initially shockable vs asystole vs PEA
b) What % of initial PEA/asystole convert to VF/pVT?
c) Drugs used in each and timing
d) When may magnesium sulfate be used?
a) 25% shockable
50% asystole
25% PEA
b) 25%
c) Shockable:
- Adrenaline 1 mg IV (1 in 10,000) after 3rd shock, then every 3 - 5 mins (roughly after every alternate shock)
- Amiodarone 300 mg IV single-dose after 3rd shock
Non-shockable:
- Adrenaline 1 mg IV as soon as IV access is gained
- Then every 3 - 5 mins
d) Persistent VF/VT where hypomagnesaemia is suspected (eg. hypokalaemia secondary to diuretics - often have low Mg2+ also)*
* Low Mg2+ can aggravate hypokalaemia - as magnesium is needed for cellular uptake of K+ (Mg2+ deficiency leads to potassium-wasting)
Give likely cause and adjuvant management of the following cardiac arrest case vignettes.
a) 30 year old man found in street with track marks on arms
b) 22 year old man arrests in critical care after central line insertion
c) 54 year old woman recently started on spironolactone
d) 68 year old woman recently started on indapamide
a) Opiate overdose - Rx: naloxone
b) Tension pneumothorax - Rx: needle decompression, then chest drain after ROSC
c) Hyperkalaemia (spiro = potassium sparing diuretic)
Rx:
- IV insulin (10 U) + IV dextrose (50 mls of 50%) infusion - IV calcium gluconate (10 mls of 10% over less than 5 mins)
d) Hypokalaemia (indapamide = thiazide-like diuretic)
Rx:
- IV NaCl plus 40 mmol/L of KCl
- Generally give over 4 hours (KCl should not be given quicker than rate of 10 mmol/hr)
- May sometimes be given at 20 mmol/hr
When are 3 stacked shocks given instead of one?
- VF/pVT occurring after cardiac catheterisation or surgery
