QuestionSBA
QuestionChoice
300mg of amiodarone is used in cardiac arrest secondary to VF or VT. However, it is only given after the 3rd shock
32351
d
Administer 300mg of amiodarone (IV)
QuestionChoice
Along with amiodarone, adrenaline is given after the 3rd shock in patients with cardiac arrest secondary to VF or pVT
32350
c
Administer 10mg of 1 in 10,000 adrenaline (IV)
QuestionChoice
Amiodarone and adrenaline are given in cases of cardiac arrest secondary to VF or VT; however, only after the 3rd shock
32352
e
Administer 300mg of amiodarone (IV) and 10mg of 1 in 10,000 adrenaline (IV)
QuestionChoice
This patient has a shockable rhythm, so it is important to administer a shock before recommencing chest compression
32349
b
Continue CPR for 2 minutes
QuestionChoice
In the context of a patient in cardiac arrest, a regular broad-complex tachycardia is suggestive of pulseless ventricular tachycardia (pVT). Along with ventricular fibrillation (VF), pVT is an indication for defibrillation (unsynchronised cardioversion) at a setting of 200J
32348
a
Unsynchronised cardioversion at an energy setting of 200J
QuestionComment
The question needs to make it clear whether he does or does not have a pulse at this point - this would determine whether or not we follow the ALS algorithm. 
7747
QuestionComment
Exactly!
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MannyOA
QuestionComment
I don't think you need to know he has a pulse at this stage, from the stem you know he's in VT and receiving CPR - whether or not he has a pulse he's going to need a shock. Although I do agree the stem should probably make it clearer he's in VT and not another rhythm. 
21050
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Axillary Gas
QuestionComment
if he has no pulse, you'd do shock. if he does have a pulse, it becomes VT so you wont do ALS.
22359
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Syndrome RNA
QuestionComment
“A man has a cardiac arrest in hospital” means no pulse chief, VT with pulse is not a cardiac arrest 
23166
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Liam
QuestionComment
tachycardia outpatient out here doing CPR on people with pulses...
43011
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Ale
QuestionComment
The stem says he's in cardiac arrest, i.e. pulseless... It could be clearer but that's absolutely clear enough to me. Also the option of synchronised cardioversion (treatment of choice for VT with a pulse with haemodynamic compromise - like collapse in this patient) is not an option. You're really missing the point of the question if you got this wrong guys
43904
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Gastro Complement
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Tachycardia Outpatient
QuestionComment
VT needs a synchronised shock not unsycn
26952
QuestionComment
That's VT WITH a pulse, the case is describing WITHOUT a pulse as he has "had a cardiac arrest" and is "receiving CPR". Unsynchronised cardioversion is another way of saying defibrillation
43906
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Gastro Complement
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Serotonin Embolism
QuestionComment
Questioning why they couldn't have just labelled this as "requires shock", in a real life situation I'm not going to state he needs unsynchronised cardioversion at 200j 
38572
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SimbaStatin
QuestionComment
You guys need to read the question properly and stop disliking questions you just get wrong lmao
43907
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Gastro Complement
Concept
Chapter
# Summary

Advanced Life Support (ALS) describes an algorithmic approach to the management of a cardiac arrest by those trained in delivering it. It involves early recognition, taking steps to secure the airway and initiate high quality chest compressions and obtaining intravenous or intraosseous access promptly. Cardiac monitoring should be applied to identify if the rhythm is shockable or non-shockable, which determines what treatment is given. Shockable rhythms require defibrillation, with adrenaline and amiodarone given later on; non-shockable rhythms are treated with adrenaline. 

# Definition

Advanced Life Support is a guideline-based approach to treating patients who have had a cardiac arrest to improve the chances of successful resuscitation and survival. 

# Epidemiology

Cardiac arrests can be categorised into those that occur out of hospital and those that occur in hospitals. Most out of hospital cardiac arrests occur at home (72%) and 8 out of 10 are due to a cardiac cause. In 7 out of 10 cases resuscitation is attempted, however only 9% of these patients survive to hospital discharge.

In hospital cardiac arrests tend to occur in older patients (average age 70), with return of spontaneous circulation (ROSC) achieved in 53% of patients. However, only 24% of patients survive to hospital discharge. 

# Aetiology

Causes of cardiac arrest can be remembered using the 4Hs and 4Ts mnemonic:

- Hypoxia
- Hypovolaemia
- Hypo/hyperkalaemia (and other electrolyte abnormalities)
- Hypo/hyperthermia
- Thromboembolism (pulmonary embolism or coronary artery thrombosis)
- Tamponade
- Tension pneumothorax
- Toxins 

# Classification

Cardiac arrests are managed differently depending on whether the rhythm is **shockable** or **non-shockable**.

**Shockable** rhythms are:

- **Pulseless Ventricular Tachycardia (pVT)** - regular broad complex tachycardia
- **Ventricular Fibrillation (VF)** - chaotic irregular deflections of varying amplitude

**Non-shockable** rhythms are:

- **Pulseless Electrical Activity (PEA)** - electrical activity that should produce a pulse, but doesn't due to absent or insufficient cardiac output 
- **Asystole** - no detectable electrical activity 

# Management

## Management for all cardiac arrests

- **Rapid recognition** of cardiac arrest (ineffective breathing or absent central pulse) is key 
- The first responder should start **cardiopulmonary resuscitation (CPR)** immediately and **call for help**, for example by asking for a cardiac arrest call (2222) to be put out
- Every two minutes CPR should be stopped for a **rhythm check**
- Secure the **airway**
    - Oropharyngeal or nasopharyngeal airways may be used initially with a bag valve mask for ventilation
    - Either a supraglottic airway (laryngeal mask airway or i-gel) or an endotracheal tube should be inserted
    - Tracheal intubation should only be attempted by those with a high success rate
    - Confirm the position of the endotracheal tube with waveform capnography (measuring end-tidal carbon dioxide)
- Give **high-flow oxygen**
- Gain IV access - if not possible the intraosseous (IO) route can be used
- Consider reversible causes (as above) and treat as appropriate
    - IV or IO fluids if secondary to hypovolaemia
    - Thrombolysis if secondary to pulmonary embolism
    - Point of care ultrasound (POCUS) may be used to investigate for cardiac tamponade and pneumothorax
        
## Management of shockable rhythms

- **Defibrillation** should be delivered as early as possible
    - Remove oxygen (ventilator circuits can remain attached)
    - Ensure no one is touching the patient before the shock is delivered
    - No specific energy is specified in guidelines; anything from 120 to 360 joules is suitable
- Immediately resume CPR after the shock is delivered for two minutes
- After 3 shocks, give 300mg amiodarone and 1mg adrenaline IV or IO
- Give repeat doses of adrenaline every 3-5 minutes (i.e. every other cycle)
- After 5 shocks, give a further dose of amiodarone 150mg

## Management of non-shockable rhythms 

- Give adrenaline 1mg IV or IO as soon as possible
- Give repeat doses of adrenaline every 3-5 minutes (as per shockable rhythms)
- Defibrillation and amiodarone are not used unless the rhythm changes to a shockable one

# NICE Guidelines

[NICE CKS - Advanced Life Support](https://cks.nice.org.uk/topics/cardiac-arrest-out-of-hospital-care/management/advanced-life-support-adult/)

# References

[Resuscitation Council UK - Adult Advanced Life Support Guidelines](https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines)
 
[Resuscitation Council UK - Epidemiology of Cardiac Arrest](https://www.resus.org.uk/library/2021-resuscitation-guidelines/epidemiology-cardiac-arrest-guidelines)

[BNF Treatment Summaries - Cardiopulmonary Resuscitation](https://bnf.nice.org.uk/treatment-summaries/cardiopulmonary-resuscitation/)
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Advanced Life Support
Topic
39
Emergency Medicine
6470
Pulseless ventricular tachycardia (VT) is a shockable cardiac arrest rhythm, and defibrillation with unsynchronized cardioversion at an energy setting of 200J is used to deliver an electrical shock to attempt to restore a normal heart rhythm.
A 56-year-old man has a cardiac arrest in hospital. Following prompt commencement of cardio-pulmonary resuscitation (CPR), he is found to have a regular broad-complex tachycardia at the first rhythm check.

Which of the following is the next best step in management?
a