The sequence of cardiopulmonary resuscitation start with cireulation, airway and then breathing Circulation involves chest compressions which lead to ejection of blood from the heart as a result of actual compression of the neart between the stemum and vertebral column. Pearl #188: Adult Basic Life Support(BLS) Algorithm (Updated as per 2015 guidelines) BLS Healthcare Provider Adult Cardiac Arrest Algorithm—2015 Update By this time in all scenarios, emergency respone system or backup is activated, land AED and emergency equipment are retrieved or someone is retrieving therm, AED arrives.) Give 1 shock. Resume CPR immediately for about 2 minutos: (Until prompted by AED to ‘hythm check). Resume CPR immediately tor about 2 minutes (until prompted Pearl #2295: High quality CPR for adults Push nara: $.6em depin Push fast 100-120/mIn trequency Allow for complete chest reco! Minimize interruptions in compressions <10 seconds Rotate compressor every 2 min or earlier if fatigued Ino advanced airway. 30:2 compression-ventilation ratio Quantitative waveform capnography © I PETCO2 <1ommHg, attempt to Improve CPR quality + intra-arterial pressure © Ifrelaxation phase (diastolic) preseure <20mmbg, attempt to improve CPR qualityLaryngeat mask airway and other supragiottic airway devices are part of advanced ainway management, whien comes under advanced cardiac ife support (ACLS). Foreign ody Sirway obstruction, usually witheut the use Of equipment siner than automated extersat The GPR sequence Is as fotlows-circulation (chest compression), alrway ana then breathing: Chest compressions which lead to ejection of bioed trom the heart, as a result oF actu aasiated ventilation by giving rescus breathe ta tne patient using mouth to-mauth, mauth-t2- breathing or by using @ bag-mask device 2 Using automated extemal defibrillators (AED) ‘The first thing that needs to be done on witnessing a cardiac arrest is to verify the scene safety. ‘On ensuring that the scene is safe, the victim is checked for responsiveness. If unresponsive, call for help ana then check for breathing and pulse cimurancously taking not more than 10 secones. It Mere Is no breathing and no pulse, Immediate chest compression and rescue breaths are started at a ratio Ir mere Is @ pulse, Dut no breathing, GIVE one fescue breath every 8-6 seconds or about 10-12 breaths/min When an automated external defibrillator arrives. the rhythm is checked! if shockable, one shook is Sominictored and CPR fe resumed Immediately, Ir not snockable, then CPR Is resumed immeciatoy. Rotation of chest compressor Is done every 2 minutes oF earlier ifthe compressor Is fatigued High-quality cardiopulmonary resuscitation (CPR) refers to: Push nara (at least 5 em) andl fast (100-120/ min) and allew complete chest recoil Minimize interruptions in compressions (10 seconds or less) Rotate compressor every 2 minutes of earlier irratigued, Quantitative waverorm capnegraphy- If PetcO, <19 mm Hg, attempt fo improve CPR quality. Intravarterial pressure: If iciazation phase (dastolic) pressure <20 mm Mg. attemp! to improve CPR auaiity. = In children, the more common cause of cardiac arrest is asphyxia rather than ventricular fibrillation + Even though asphyxia Is the more common cause, pediatric resuscitation starts with chest compressions rather than rescue breaths as In adults for simplicity in traming + This Ig because the cycle of 80 chest compressions before fescus breathing delays ventilation for only 18 to 20 seconas, + Im aautts, tne ratio Is 30:2 respective oF the number of rescuers. 2 In intants and children, the depin of compression should be at least one-third of the anteroposterior Allow complete chest recoil after each compression. Minimize interruptions in compressions (10 seconds or tess) Rotate compressor every 2 minutes oF earlier If fatigued, ia 30:2 irrespective of the number of rescuers” + Flan quaity cardiopulmonary resuscitation involves adequate chest compressions te a depth of at Ha feedback device t= Used, then the compression depth can be increased to G em ‘Tne compression rate Shoula be 100-120/ minute. Allow complete chest recoil after each compression Minimize interruptions in compressions (10 seconds oF less) Rotate compressor every 2 minutes or earlier If fatigued.Intravenous route in order to deliver drugs and fluids, especially in oniiaren. + This Is Because an Intracsseous access can easily be mace In 30-60 seconds ana thus provide lan emergency vascular access. It Involves placing a catheter Imo the marrow venous plexus ana Boministerng. crystallolds, colloids, drugs ana blood which leads to rapid and rellable absorption Into 2 The nuids are aaministerea under prossure because of the resistance to Tluld low from the 1 catheter into the 1o space + The disadvantage with this route + 10 Access 1s superior to the endotracheal route. The American Heart Association dees not 1 rlok of osteomyelitis, compartment syndrome, Bone marrow or 14. A 45-year-old woman presented to the casualty with = dizziness. Her blood pressure is 80/60 mmHg with a pulse rate of 45/minute. Her ECG is shown below. What is the treatment of choice? + The ECG shown above Is the second-degree atrioventricular block type 1 Wenekebach = Treatment is incicated when braaycardia Is accompanied by any one of ine following > Hypotension 2 Acutely alterea mental status: Signs or sock + Treatment is iniuated with 0.5 mg atropine iv which may be repeated at 5-5 minute intervals to a maximum dose of 2 mg. = Along with auepine, the tranzeutaneous pacing i to be done + Intne bracycardia Is refractory to botn atropine and transcutaneous pacing, tnen IV infusions of dopamine (2 to 10 ug/kg/min) or epinephrine (2 te 10 wg/min) should be considered + Itine bradycardia still isn't responaing, then transvenous pacing Should be tried. If the patient is under spinal anesthesia. low-dose (0.2 mg) IV epinephrine can be given. + Epinephrine is the drug of choice for treating braclyarrhythmias in infants and children. 18. A 22-year-old man was brought to the casualty with = palpitations and dizziness. His heart rate was 160/min and blood pressure was 110/80 mm Hg. Given below Is his ECG. What is the first line of management? there Is no evidence of hemoaynamic deterioration, initial treatment consists of vagal maneuvers- Valsalva maneuver in awake patients. This is because vagal maneuvers alone can terminate approximately 20% to 25% of reentry supraventricular tachycardias (SVTs). + ITthis is unsuccessful, then IV adenosine 6 mg Is given. IT necessary another dose of adenosine 12 mg may be aaministered after 1-2 minutes. + ITthe arug is administered via a central venous catheter, then these doses are reduced to 2 mg and 6 mg, respectively. + ITthere is hemodynamic deterioration, then cardioversion is the treatment of choice.IV atropine is uses in the veatment of symptomatic bradvarrnytnmia starting at a dose oF 0.5 ma, whien can Auopine Is not used in adults at a dose loss than 0.5 mg because It can cause paradoxical siowing oF the Ir me braaycaraia fs refractory to both atropine ang transcutaneous pacing, then IV infusions of dopamine (2 16.20 Lg/kg/min) of epinephrine (2 to 10 igimin) shoula be Consideree Ir me braaycaraia fs stil not respenaing, then vansvenous pacing should! be ted. If the patient is uncer Spinal anesthesia, low-dose (0.2 ma) Iv epinephrine can bo given Epinephrine is the drug of cnoice for treating braayarrnyinmias in infants and chileren. + Sas stat nusion rato ts 3-20 meg/kg per minute. ‘Tirate to patient response; taper slowly Epinephrine 1V infusion: 2510 meg per minute infusion, Tata to patient 21. A 45-year-old known hyperthyroid was brought to the casualty with lightheadedness and palpitations. Her heart rate was Variable and blood pressure was 120/70mm Ha. Given below t= her ECG. What t= the treatment of choice? Tees Soe Se eee oe peice tele EEE COE SEES EE ee + The patient is in atriat tipniliation but her hemodynamic status Is normal. So ine treatment of choice is IV Ibutilie + Ibutilide is a class Ill antiarrhythmic drug which has a rapid onset of effect in restoring sinus rhythm. It acts by prolonging the action potential duration and effective refractory period. + itis administered at a dose of 1 mg over 10 minutes. If necessary, a second dose can be administered 10 minutes afer the first. + Ifthere is evidence of hemodynamic deterioration, immediate cardioversion is the treatment of choice. + The recommended initial dose for caraloversion Is "2 100 J to 200 J- if. a monophasic defibrillator is used © 100 J to 120 J - a bipnasic denpniiator+ Anon-snockaple rythm could be azyztole or pulzeles= electrical activity. Treatment for porn, involve: starting CPR immediately and administering 1 mg epinephrine I = Riynitie isthe compite and sustained absence of siecticar neiity. Iie usualy seen as a terminat fhyininin mrenuscltation atlermpt which starled with meiner rythm or ina patient wih unwitnessed or 1 Alpuitciess cicemen! aetwty involves 2 heterogeneous group of cardiac rhythms all without a pulse. thom fo aifferont ana PEA 1s likely to persist unt the Cause le treated, Hypoxia, Hydrogen ton caciaosis) Hypocaiemia or hyperkalemia Hypetnermnia Tanoponade (onrsitac) Thrombosis (pulmonary Thrombosis (coronas) ‘The patient is in ventricular tachycardia with hemodynamic stability. The next line of management is to acminister procainamide, class 1A antiarrhythmic drug. Antiarrhythmic therapy for stable wide QRS tachycardia include procainamide, amiodarone, or sotalol synchronized cardioversion Ia considered when the patient Is unstable. ‘Other Options: = Agenosine: Adenosine Is used in regular narrow complex tachycaraia. = Lidocaine: Lidocaine nas limiting side effects and, increase the overall mortality risk + Dojibritiation: itis the treatment for immediately life-threatening armythmias with which the patient does not nave a pulse, le ventricular fipnilation (VF) or pulseless ventricular tachycardia (VT) Adult Tachycardia With a Pulse Algorithm Te Stabe Wide'ans Tachyoardia RNAS cen ts Mein ‘Aebia'W prolonged Gt or CHE FSlow'by meantenancs intusion of SRS eae oat Sroiongedor In a peaiatnic cardiac arrest, tne initial energy for detipniliation Is set at 2 J/kg for botn monophasic ana biphasic waveforms. It is increased to 4 J/kg if a second shock is required. Ita pediatric denpnitator is not available. then an adutt denpriliator can be used. In children the most common cause of cardiac arrest is asphyxia. But a sudden witnessed collapse in a child Is usually due to ventricular nbriliation. For adult defibnitation, the energy that must be applied is. + Monophasie denbritiator 360 4 + Biphasic denpnitator- 120-200 J (manutacturer recommendea)ne © 41.17% answered this question correctly + IIs of utmost necessity to defipriliate at the earliest because of the chances of survival decreases by 710% every minute without efiballauon. interrupt disorganized cardiac activity and restore an organized cardiac rhythm oF asystole for at wast ‘s"Monophasie defibrillator 360 J = Chest compressions should be resume immediately following shock delivery. Pulse check and reanalysis of the cardiac rhythm Is performed only after 2 minutes of chest compression and rescue breathe. + This is because the neart Is temporarily stunned by a denbrillator snock and so cnest compressions: would benefit by providing coronary blood flow during this periog. = Denipnitation involves delivering an electrical current between two pads placed on ine chest so to Interrupt disorganized caraiac activity and restore an organized cardiac myihm of asystole for at least 5 seconds. It Is of utmost necessity to defibriliate Immediately because of ihe chances of survival decrease by 710% every minute without defibrillation. + Iraner 2 minutes, the mythm remains the same, then another shock is delivered. Chest compression and rescue breaths are resumed and 1 mg epinephrine is administered. Consideration Is given for an Bavanced airway placement. after 2 minutes the rhythm still remains the same, the first dose of amiodarone Soomg bolus is given. = With the next cycle of CPR, a shock is delivered and 1 mg of epinephrine Is given. And with the cycle Of CPR after that, shock is delivered and the second dose of amiodarone. 150mg l= given 26. Which electrolyte abnormality has to be considered in a a nt with the following ECG? Ke Zones ly depicts polymorphic ventricular tachycardio—torsades de pointes. Tersade ly Is seen in aasociation with hypomagnesemia and hypokalomie Torsades de pointes is a polymorphic ventricular tacnycardia meaning “twisting of the points Gharactonzea by twisting of the GRE axis around the baseline and @ polymorphic appearance. “The otner cause of torsades de pointes Include: procainamide, disopyramide and phenothiazine (amicdarone is rarely Wh induced by itis unForm). 2 Gonectolectrante abnormalities, pH and hypoxia 5 jum sulphate infusion Note: Although nypocaicemia je associated win prolongation of GT interval, there are only rare reports of Torsades de pointes associated with hypocalcemia So, among the above optins, the best answer would Be= The first dose of epinepnrine.7 mg IV, Ie aministered after the 2° aeripnilator shock Is delivered ana + Vasopressin was part of the resuscitation protocol in the 2010 American Heart Association (Atta) sardine arrest algorithm but it haz been removed from the latest 2078 guidelines. + Vasopressin cause intense penpheral vasoconstriction due to stimulation of V1 receptors in the endothelium but i causes limited increase In myocardial contractility, myocardial and cerebral oxygen Consumption, and metapolic demands Thus it doesn'thave much of a survival benefit + Epinephrine ana amiodarone are the two main drugs approved by the AMA for resuscitation of a cardiac arrest patient. = The frst dose of epinephrine, mg IV, Is administered aner the 2° denprillator shock Is delivered and itis continued every 5-5 minutes. + Itinis ts not effective, 300 mg IV bolus dose of amiodarone can be given and another dose of 150 mg, given innecessary Intravenous Adrenaline f= tne drug oF choice for CPR, but it can be given intrstracheslty also However, the concentration required ls 22.6 times mare than required for the 1V route ‘omer options: ‘@ption m: Intracaraiac injection is net recommended as it can cause myocaraial camage. Recommendes routes or adronatine are Intravenous, intraossoous (childran) ane intra-tracheal ‘option G: Adrenaline converts ine fo @ption B: Adrenaline 's avaliable as 1 mL injection containing 4. mg of adrenaline In 1:1000 concentration {ne dose used in cardiac arrest ia 1mg ot adrenaine every © minutes, usually given as tml in| 1000. concentration of 10m in 1-10.00 concentration (more preferred as in cardiac arrest peripyeral CHCUISUON 1S Siren hence larger volume is required for the drug to reach the cential cireulation) eee eee Ceres ae eee retreat eet (V7), pulseless electie activity (PEA), and asystole. Qutor thls, 2 are shockable and 2 are ROM Management of shockable rhythms (VF and VT): cary nigh-quallty CPR with prompt rapia Goefipritintion. Medications include mg epinephrine every a. min, Amiodarone or Lidaesine for retractor VE Management of nen-sheekable rhythms (PEA and Asystole): carly high-quality CPR with Tmo epinephrine every 3-0 mins. CPR forms one of the key constituents of any resuscitative care. Detailed knowledge about this is a must Know for any physician, Pearl #505: The drugs which can be given via the Endotracheal Route Atropine Epinephrine is used in cardiac arrest paticnts at a dose of 1 mg epinephrine, 10 mL of 1: 10,000 solution. Epinephrine is an adrenergic agonist: a-Adrenergie effects increase myocardial blood flow. B-Adrenergic effects incieases myocardial contracttty. Indication: VF/VT, electromechanical dissociation, ventricular asystole, severe bradycardia unresponsive to atropine or pacing, severe hypotension Dose: 1 mg IV Repeat doses every 3-6 min as necessary. Administration down a tracheal tube requires higher doses (22.5 mg in adults). + A pulseless electrical activity (PEA) Is a non-shockable rhythm. denipniliation Is of no benentt + Itinvolves a heterogeneous group of cardiac rhythms all without a pulse + The immediate treatment for this is giving chest compressions and 1 mg epinephrine at the earliest until more definitive therapy to the cause can be instituted. = Its essential to rule out the reversible causes oF cardiac arrest Because the treatment tor eacn of them is different and PEA is likely to persist until the cause is treated, + Reversible causes of cardiac arrestThe patient has an organized, apparently normal ECG without a pulze - Ls the patient nas pulzeles= them is different and PEA is likely to persist unl ine cause Is Weated Pearl #503: Reversible Causes of Cardiac Arrest 2 Hydrogen ton @ctostey Hypokatomia or nyperkatomia HYpatnermia, © Tension pneumotnerax Tamponade (enrdiae) Thrombosis (pulmonary) ‘Thrombosis (coronary) Targeted temperature management is the maintenance of a constant target temperature between 22- 26°C for at least 24 hours in post-cardiac resuscitation patients who have achieved return of Spontaneous circulation (ROSC), but are still comatose The entire body Is to be cooled using a combination of methods like Muid-flled cooling blankets, Ice packs. forced air blankets, cold IV fluids, and/or invasive devices or catheters. It has been found to be the only intervention whicn can improve neurological recovery after cardiac arrest — most beneficial in ventricular fiprilaiion and pulseless ventricular tachycardia patients. + Ina choking child (more than 1 year old) or an adult, the first thing to be clone Is to perform Heimiich maneuver which Involves delivering abdominal thrusts. + The rescuer should stand or knee! Dening the patient ancl wrap nis arms around the patient's waist. A ist Is made with one hana and using the other nang, te fist Is driven into the patient's abdomen with @ rapid, forceful upward thrust so as te dislodge the foreign body. This is continued until the foreign. boay Is expelled or If the patient becomes unresponsive. + Inachoking infant who is responsive, § back slaps between the shoulder blades and 5 downward thrusts on the chest are given in order to dislodge the foreign body. + Ifthe patient becomes unresponsive. immediately start CPR, Ita choking victim becomes unrespensive, call for heip and immediately start CPR, beginning wih chest compressions, For pediatric CPR, Ifa single rescuer Is present, then chest compression to ventilation Is performed in a ratio While giving rescue breaths, the alway is checked for a foreign body. If itis accessible, then the abject ean, be removed. Ifnot, then CPR is continued. Blind finger sweeping may be hazardous as it can push the ‘object further down the ainway. If ine child is responsive, then abdominal thrusts are performed to help relieve ainvay abstruction, Ina choking Infant who Is responsive, 5 back slaps belween the shoulder blades and 5 downward thrusts on the chest are given in order to dislodge the foreign body,+ Anesthetic bag or the bag-mask-valve system is a high flow fixed performance system - the delivered Fiz Ie not affected by changes in ventilatory lovel or breathing pattern of the patient and thus deliver accurate oxygen concentration. It ls of two types: the selfinflating bags with a reservolr of 1.5 Land the non-selt inflating bags with 2 reservow of 1,203 L + The alsacvantage Is nigh cost and poor patient tolerability due to high flow. 2 The other ted performance devices Include venturi mask, alr-entraining Nebulizers, and high flow air oxygen systems. + The nasal cannula, non-rebreathing mask, and nasal mask are low flow variable performance systems, oxygen Is delivered ata low. fixed flow which Is only @ portion of the Inspired gas Mixture. They are cheap with better patient tolerability. The disadvantage ts that the Fi. delivered cannot be accurately predicted, 20 they are suitable far patients win stable breathing pattems. + The nasal cannula is a low flow variable performance oxygen delivery system which can provide a maximum inspired oxygen concentration of 40-50 % at flow rates greater than 10L/ min for short periods. + Attlow rates of 5-4 L, it can provide inspired oxygen concentration of 30-35%. + Flow rates greater nan 5 Lmin are not tolerated because of the discomfort associated with this high Mow entering the nasal cavity and also due to drying and crusting of the nasal mucosa + In mouth-to-moutn resuscitation, te percentage of oxygen delivered Is 15%. + Anasal cannula is a low flow variable performance oxygen delivery system. It is not suited for patients: requiring high Fi2 of inspiratory oxygen flow rates greater than 40 Limin for whieh devices IIke Venture mask, anestnetic bag. alr-entraining nebulizers, or igh flow alr oxygen systems are prererrea, + Indications of a nasal cannula and other low-flow oxygen ai = Minute ventilation less than 8-10 L/min, © Breathing frequencies less than ~20 breaths/min > Tidal volumes (VT) less han ~0.5 L © Normal inspiratory flow (10-30 Limin). very systems include Venturi mask Is a high-flow, fxed-pertormance oxygen delivery system and provides the highest oxygen concentration (FIO>) of 60% ata flow rate of 15 Limin Its available In different colors, with the green one providing 60% FiO “This Is userut with patients wno require greater Fi» (like chronic obstructive pulmonary disease patients) than which can be provided by nasal cannulas. D Arterial oxygen tension =50 mm Hg on room air 2 Arenal Go 2 tension -S0 mm Mg in Ihe absence of Metabolic alkalosis, Ba © 2 fF IO 2 ratio ~300 mm Hg < Pacao 2 gragient “sso mm Ng o fidal Volume <6 mLska 3 iat capacity <15 mUKo + Tracheostomy in performed in an intubated patient after 2-3 weeks, + This is because if an orotracheal or nasotracheal tube is left insitu for more than 2-3 weeks, subglottic stenosis results. + Hence itis Ideal to replace the endotracheal tube with a eufted tracheostomy tube. + Ifon intubation, itis perceived that the patient may require intubation for a period longer than 2 weeks, then tracheostomy can be performed soon after intubation. + Tracheosomy has been found to reduce the incidence of pneumonia, the duration of mechanical ventilation, and the length of stay in patients with major head injuries.be present Won. Spinal cord function Below C1 may st Brain death eritena can be applied only in the absence of Hypotnermia, Hypotension Drugs Known to depress brain function. Generaty accepted clinical eriteria for brain death inclucie the following: Absent motor activity, incluciing ne decerebrate or decortcate posturing Absent brainstem reflexes, Including ho pupillary. corneal, vestibulocochiear (alone). or gag (or cougn) retiexos + Apsence of ventilatory emrort, with the arterial CO; tension at least GO mm Mg or 20 mm Hg above ne protest level (positive apnea test) Connrmatory test ndings (not mandatory but may assist In diagnosis) = lzoetectric electroencepnalogram + Avsence of cerebral perfusion as documented by angiographic, transcranial Doppler, oF radiosotopie Won Is Incieated when vital capacity Is > 10 mL/kg. All ine other options are correct Pearl #465: Mechanical Criteria for Weaning or Extubation Inspiratory pressure: -20-30em H20 aat votre: 4-omuKg Vital capacity: =10 mika Minute ventilation: 1OL/min Rapid shallow breathing index: <100 + The patient nas developed vasospasm (reflex sympathetic dystrophy). as indicated by tne development of swelling and discoloration of nana. + Stellate ganglion block will block upper thoracic and cervical ganglion. It is indicated in © Reflex sympathetic dystrophy © Vasospastic disorder of upper extremity 2 Head, neck, arm and upper chest pain.