Advanced Cardiac Life Support Procedures

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Questions and Answers

Which of the following is NOT a characteristic of unstable angina?

Increasing severity

Occurs at rest

Increasing frequency

Positive Troponin testing (correct)

What does a TIMI score of 0-2 indicate?

Critical Condition

High Risk

Medium Risk

Low Risk (correct)

In the management of NSTEMI, which of the following is NOT typically part of the plan?

Admit to a high care unit

Risk stratify the patient

Start immediate surgical intervention (correct)

Give Aspirin 300mg stat

Which of the following risk factors does NOT contribute to the TIMI risk score?

Diabetes Signup and view all the answers

What is the recommended daily dosage of Aspirin following the initial loading dose in NSTEMI management?

75mg Signup and view all the answers

What type of heparin is typically given subcutaneously in NSTEMI management?

Low molecular weight heparin Signup and view all the answers

Which heart condition is indicated by ST-segment depression or T-wave inversion with elevated cardiac biomarkers?

NSTEMI Signup and view all the answers

In the context of drowning cases, what should always be considered when assessing the victim?

Why the drowning occurred Signup and view all the answers

What is the recommended dosage of aspirin for rapid absorption?

300mg to chew immediately, followed by 150mg Signup and view all the answers

What should be monitored when administering nitrates?

Blood pressure and heart rate Signup and view all the answers

In which condition are statins contraindicated to start immediately?

Active liver disease Signup and view all the answers

Which medication should be initiated within the first 24 hours after symptom onset in myocardial infarction?

ACE inhibitors Signup and view all the answers

What is the maximum dose of nitrates that can be given sublingually?

3 doses Signup and view all the answers

Which of the following is NOT a contraindication for the use of morphine?

Persistent pain after nitrates Signup and view all the answers

What dosage of Clopidogrel is recommended for initial administration?

300 - 600mg stat orally Signup and view all the answers

What is a critical adverse effect to monitor for in a patient with asthma receiving beta-blockers?

Bronchospasm Signup and view all the answers

What is the primary route of administration for adenosine?

Intravenous bolus Signup and view all the answers

Which symptom is NOT a transient side effect of adenosine administration?

Severe hypertension Signup and view all the answers

In which scenario should a lower initial dose of adenosine be given?

Patient is on carbamazepine or beta blockers Signup and view all the answers

What is the recommended action if tachycardia recurs after adenosine termination?

Consult for alternative treatments like beta blockers Signup and view all the answers

When utilizing synchronized cardioversion, which of the following is essential?

Ensuring the 'sync' button is switched on Signup and view all the answers

What is the initial energy level recommended for synchronized cardioversion?

100J Signup and view all the answers

What condition makes the use of adenosine contraindicated?

Asthma Signup and view all the answers

Which of the following conditions requires the use of a higher initial dose of adenosine?

Patient using caffeine or theophylline Signup and view all the answers

What is the primary purpose of dedicating an area for patients to wait for up to 30 minutes after parenteral medication administration?

To monitor for early signs of anaphylaxis Signup and view all the answers

Which of the following is NOT a recommended action after a bee sting if anaphylaxis is suspected?

Squeeze the venom sac to expel the venom Signup and view all the answers

What critical aspect must be monitored to differentiate anaphylaxis from other medical emergencies?

The rapid progression of symptoms Signup and view all the answers

What is the significance of measuring mast cell tryptase levels during an anaphylactic emergency?

It confirms the anaphylactic reaction post-resuscitation Signup and view all the answers

What should be done at the first sign of anaphylactic symptoms during medication administration?

Stop further administration of the medication Signup and view all the answers

Why is it important to have the contact information for an ambulance service readily available?

To ensure rapid access to advanced life support Signup and view all the answers

Which condition can mimic the symptoms of anaphylaxis and must be differentiated during assessment?

Vasovagal syncope Signup and view all the answers

What is one of the key concerns for medical personnel when managing an anaphylactic emergency?

The safety of the rescuer and patient Signup and view all the answers

What is the initial volume of air recommended to inflate the tracheal tube cuff?

5ml Signup and view all the answers

Which method is recommended for confirming tracheal placement of the tube?

Utilizing an Oesophageal Detector Device (ODD) if available Signup and view all the answers

What is the recommended cuff pressure to indicate a possible return of spontaneous circulation?

40mmHg Signup and view all the answers

What is the preferred method of obtaining intravenous access during chest compressions?

Immediate intraosseous access if IV access is not available Signup and view all the answers

How often should adrenaline be administered if cardiac arrest persists?

Every 3-5 minutes Signup and view all the answers

After how many shocks should Amiodarone be administered if VF/VT persists?

After the third shock Signup and view all the answers

What dilution ratio is recommended for administering 1mg of Adrenaline?

1:1000 Signup and view all the answers

What is the maintenance infusion rate of Amiodarone following a loading infusion?

0.5mg/minute Signup and view all the answers

Study Notes

Tracheal Tube Placement

Inflate the tracheal tube cuff initially with 5ml of air.
Check tube placement with an Oesophageal Detector Device (ODD) if available.
Listen for breath sounds bilaterally.
Listen for absence of epigastric sounds.
Look for visible chest rise.
Look for humidification of the tracheal tube.
Attach an end-tidal CO2 device (colorimetric, digital or preferably waveform capnography) if available to confirm tracheal placement of the tube.
Secure tube in place and reconfirm tube placement again.
Maintain cuff pressure at 40 mmHg.

Intravenous/Intraosseous Access

Insert an intravenous line if not already in place, while chest compressions are continuing.
If intravenous access is not readily obtainable, immediate intraosseous access is recommended for both children and adults.
Tracheal administration of drugs is no longer recommended.

Vasopressors and Antiarrhythmics

Adrenaline (Epinephrine) indicated in cardiac arrest not responding to initial resuscitation or defibrillation.
Give 1mg IV/IO (1 ml of 1:1000 solution, diluted with 9 ml sterile water or saline) followed by a 20ml sterile water/saline flush after the 2nd shock (if the rhythm is VF/VT), or as soon as intravascular access is obtained (if the rhythm is PEA/asystole).
Repeat adrenaline 1mg IV every 3-5 minutes of CPR if cardiac arrest persists.
Elevate the limb for at least 10 seconds after each drug administration.
Amiodarone - 300mg IV/IO (diluted to 20ml with 5% D/W) is given after the first dose of Adrenaline (i.e. after the 3rd shock) if VF/VT persists.
One additional bolus of 150mg may be given after 3-5 minutes if VF/VT still present.
After return of spontaneous circulation, a loading infusion of 360mg may be administered over 6 hours at a rate of 1 mg/minute.
Thereafter, a maintenance infusion of 540 mg is administered over 18 hours at a rate of 0.5mg/minute.

Side Effects of Adrenaline

Cardiac: - Arrhythmias, Hypotension, Myocardial Depression
CNS: - Hypoxic brain damage, Convulsions
Renal: - Renal failure
Metabolic: - Acidosis, Electrolyte abnormalities
GIT: - Gastric distension, Foul diarrhoea
Haematological: - Haemolysis, DIC

Drowning

Always ask "Why did the drowning occur?".
The victim may have lost consciousness for some other reason (e.g. epilepsy, alcohol, drug overdose, spinal injury, acute myocardial infarction etc) - manage appropriately.

Acute Coronary Syndromes

Divided into: Unstable Angina, Non-ST-Elevation Myocardial Infarction, ST-Elevation Myocardial Infarction (classical Myocardial Infarction)

Unstable Angina

Angina which occurs at rest or that is increasing in frequency and/or severity.
Troponin testing is negative

Non-ST-Elevation Myocardial Infarction

Angina that is associated with typical rise/fall of cardiac biomarkers and ST-segment depression or T-wave inversion.

Management Plan

Admit patient, preferably to a high care unit or Coronary Care Unit.
Take bloods for cardiac markers and Troponin T or I (has prognostic value).
Treat aggravating factors (e.g. uncontrolled hypertension, cardiac failure, arrhythmias, infection, anaemia).

Risk Stratify the Patient

TIMI Risk Score (each risk factor scores 1 point):
- Age > 65 years
- _3 coronary artery risk factors
- Known coronary artery stenosis > 50%
- Aspirin use in the last 7 days
- Elevated cardiac biomarkers
- Severe angina (> 2 episodes in < 24 hours)
- ST-depression or elevation > 0.5mm
- (0 - 2 = Low Risk, 3 - 4 = Medium Risk, 5 - 7 = High Risk)

Drug Management (Non-ST-Elevation Myocardial Infarction)

Aspirin: 300mg stat (chewed) and then 150mg daily (unless allergic to aspirin). Do not use enteric-coated aspirins. Use with caution in patients with asthma or bleeding disorders.
Clopidogrel: 300 - 600mg stat orally and then 75mg daily. Alternatives are Prasugrel or Ticagrelor.
Anticoagulation: Either unfractionated heparin IV (keep PTT 2x normal) or low molecular weight heparin subcutaneously (Enoxaparin 1 mg/kg b.d.). Anticoagulate for at least 48 hours.
Beta blockers: If no contraindication is present.
Statins: High dose statin therapy should be started as soon as possible (e.g. Atorvostatin 80 mg)

ST-Elevation Myocardial Infarction

Also known as classical Myocardial Infarction

Management of Unstable Patient

If the patient has a pulse but shows signs of instability such as hypotension, acutely altered mental state, signs of shock, ischaemic chest discomfort and / or acute heart failure, and the signs are caused by the dysrhythmia, the patient will require immediate synchronized cardioversion.

Synchronized Cardioversion

Ensure that the “sync” button is switched on.
Locate “sync” marker on monitor screen. If necessary, increase the gain (ECG size).
Select appropriate energy level - 100J initially (monophasic or biphasic defibrillators).

Anaphylaxis

It is worthwhile asking patients to wait in a dedicated area for up to 30 minutes, especially following parenteral administration of medications.
Inform patients of the early symptoms of anaphylaxis, and to report these immediately if they occur.
Stop further administration at the first signs of anaphylaxis.
Severe reactions may occur (although rarely) even up to 24 hours after exposure.

Management of Anaphylaxis

It is essential to ensure the safety of the rescuer as well as the patient.
Do not squeeze the venom sac when removing the stinger; use a credit card or blunt end of a knife instead.
The symptoms and signs of an anaphylactic reaction must be differentiated from the non life-threatening features of a simple allergic reaction and from other conditions such as vasovagal attacks (syncope), hypoglycaemia, panic attacks, etc.
Confirmation of the anaphylactic reaction can be obtained by measuring mast cell tryptase levels after resuscitation has commenced.
In the pre-hospital setting, the rapid deployment of advanced life support paramedics will be required.
Knowledge of the telephone numbers of an appropriate ambulance service is fundamental.

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Description

This quiz covers critical procedures in Advanced Cardiac Life Support (ACLS), including tracheal tube placement and intravenous/intraosseous access techniques. Test your understanding of proper methodologies and confirmatory measures required during cardiac emergencies. Prepare to enhance your skills in delivering effective life-saving interventions.