With respect to advanced cardiac life support (ALS), outline the modifications to the standard adult ALS algorithm needed in the management of cardiac arrest in the following clinical situations. Give the rationale for the modifications where appropriate.
a) A 72-year-old female ventilated in ICU 4 hours post-cardiac surgery. (40% marks)
b) A 66-year-old male with accidental hypothermia and core temperature< 24°C. (30% marks)
c) A 34-year-old 32/40 gestation pregnant female. (30% marks)
a) 72-year-old female ventilated in ICU 4 hours post cardiac surgery
Team composition |
|
Before-Ext cardiac massage |
|
Resternotomy |
and internal defibrillation post sternotomy. External cardiac massage no longer possible. |
Adrenaline |
|
Amiodarone |
|
Atropine |
|
IABP |
|
b) 66-year-old male with accidental hypothermia and core temperature < 24oC
Checking for signs of life |
Likely to need monitoring e.g. Echo rather than pulse or breathing check clinically. Monitor for up to 1minute |
Prolonged CPR with stiff chest wall |
May need mechanical chest compression devices and rotation of team members |
Defibrillation |
After initial 3 shocks as standard, delay till core temp >28-30C. Minimal shocking till rewarm |
Drug dosing & intervals |
With hold until temp >30C then double the usual interval between drug doses |
Rewarming |
Consider multiple strategies: space blanket, radiant heater, warm air blower, Warmed fluid irrigation of GIT and bladder, ECMO. Ensure rewarmed before declaring death |
Vascular access |
Use femoral route to avoid wires irritating heart and triggering VF/VT which may be shock resistant. |
c) 34-year-old 32/40 gestation pregnant female
Team composition |
Obstetrician, anaesthetist, paediatrician in event of needing resuscitative hysterotomy |
Resuscitative hysterotomy |
Needed if No ROSC in 4min |
Manual displacement of uterus to left / left lateral tilt |
To avoid IVC compression and decreased venous return |
Higher hand position for chest compressions |
Slightly higher on chest wall than for non-pregnant state |
Early Intubation |
Early as possible as higher risk of aspiration and diaphragmatic splinting by gravid uterus |
Defibrillation pads |
May need to be placed in bi-axillary position |
Examiners Comments:
Nil
This question is a concatenation of several older questions. Cardiac arrest following cardiac surgery came up in Question 30.2 from the second paper of 2017, cardiac arrest in extreme hypothermia appeared in Question 7 from the second paper of 2019, and cardiac arrest in the pregnant patient had been asked about at least four times since 2010. The college answer is refreshing in its approach, particularly the tabulated form of the answer and the emphasis on team composition (an excellent move).
a) Modification in the post-cardiac surgical patient:
b) Modification in hypothermia:
c) Modification in pregnancy:
Dunning, Joel, et al. "The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery." The Annals of Thoracic Surgery103.3 (2017): 1005-1020.
Dunning, Joel, et al. "Guideline for resuscitation in cardiac arrest after cardiac surgery." European Journal of Cardio-Thoracic Surgery 36.1 (2009): 3-28.
Paal, Peter, et al. "Accidental hypothermia–an update." Scandinavian journal of trauma, resuscitation and emergency medicine 24.1 (2016): 111.
Lee, Christopher H., et al. "Advanced cardiac life support and defibrillation in severe hypothermic cardiac arrest." Prehospital Emergency Care 13.1 (2009): 85-89.
Campbell, Tabitha A., and Tracy G. Sanson. "Cardiac arrest and pregnancy." Journal of emergencies, trauma, and shock 2.1 (2009): 34.