adult and paediatric als - self-assessment in resuscitation ( deakin )

7/26/2019 Adult and Paediatric ALS - Self-Assessment in Resuscitation ( Deakin )

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Adult and Paediatric ALS

Self-assessment in Resuscitation

http://medical.dentalebooks.com


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Adult and Paediatric ALS

Self-assessment in ResuscitationCharles D. Deakin MA MD FRCP FRCA FERC FFICMHonorary Professor of Resuscitation and Prehospital Emergency Medicine, University of Southampton, UK

Consultant in Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, UK

Executive Committee, Resuscitation Council (UK)

Immediate Past Chair, Advanced Life Support Committee, European Resuscitation Council

Immediate Past Co-Chair, Advanced Life Support Committee, International Liaison Committee on Resuscitation



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Cambridge, New York, Melbourne, Madrid, Cape own,

Singapore, Sao Paulo, Delhi, Mexico City

Cambridge University Press

Te Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States o America by

Cambridge University Press, New York

www.cambridge.org

Inormation on this title:www.cambridge.org/

9781107616301

Charles Deakin 2012

Tis publication is in copyright. Subject to statutory

exception and to the provisions o relevant collective

licensing agreements, no reproduction o any part may

take place without the written permission o Cambridge

University Press.

First published 2012

Printed in the United Kingdom at the

University Press, Cambridge

A catalogue record for this publication is available from the

British Library

Library of Congress Cataloguing in Publication data

Deakin, Charles D.

Adult and paediatric ALS : sel-assessment in resuscitation /

Charles D. Deakin.

p. ; cm.

Adult and paediatric advanced lie support

Includes index.

ISBN 978-1-107-61630-1 (pbk.)

I. itle. II. itle: Adult and paediatric advanced lie support[DNLM: 1. Resuscitation Examination Questions. 2. Lie

Support Care Examination Questions. WA 18.2]

616.1025076 dc23 2011049190

ISBN 978-1-107-61630-1 Paperback

Cambridge University Press has no responsibility or the

persistence or accuracy o URLs or external or third-party

internet websites reerred to in this publication, and does not

guarantee that any content on such websites is, or will remain

accurate or appropriate.

Every effort has been made in preparing this book to provide

accurate and up-to-date inormation which is in accord withaccepted standards and practice at the time o publication.

Although case histories are drawn rom actual cases, every

effort has been made to disguise the identities o the individua

involved. Nevertheless, the authors, editors and publishers can

make no warranties that the inormation contained herein is

totally ree rom error, not least because clinical standards are

constantly changing through research and regulation. Te

authors, editors and publishers thereore disclaim all liability

or direct or consequential damages resulting rom the use o

material contained in this book. Readers are strongly advised

pay careul attention to inormation provided by the

manuacturer o any drugs or equipment that they plan to use



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Contents

Dedication pagevi

Preface viiAbbreviations viii

Paper 1 1

Questions 1

Answers 7

Paper 2 13

Questions 13

Answers 19

Paper 3 26

Questions 26

Answers 33

Paper 4 39

Questions 39

Answers 46

Paper 5 52

Questions 52

Answers 60

Paper 6 68

Questions 68

Answers 76

Paper 7 82

Questions 82

Answers 90

Paper 8 97

Questions 97

Answers 105

Paper 9 112

Questions 112

Answers 118

Paper 10 126

Questions 126

Answers 133

Index 141

v



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Dedication

o my daughter, Maddie, with apologies or her encounter with sevourane!o my parents, Mary and Davido all my riends at the Resuscitation Council (UK)

vi



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Preface

Basic and advanced lie support courses are under-taken by most NHS clinical staff and resuscitation isa mandatory area o knowledge. Tose preparing or aresuscitation course, or those wishing to maintain andupdate their knowledge, may enjoy an alternative tocourse manuals and resuscitation texts in the orm othese short test papers in resuscitation.

Te book covers the entire basic and advanced

lie support syllabus or both adult and paediatric

resuscitation, each section comprising 20 multiplechoice questions, ve photographic questions, vediagnostic questions and ve short answers. Tis bookis intended or all those taking advanced lie supportcourses and those taking higher medical examinationsthat include a resuscitation component, so covers coreknowledge needed by all specialist trainees and con-sultants in acute medical specialities.

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Abbreviations

AC Alternating currentACE Angiotensin-converting enzymeAED Automatic external debrillatorAICD Automatic implantable

cardioverterdebrillatorAIDS Aquired immunodeciency syndromeALS Advanced lie supportBLS Basic lie support

CNS Central nervous systemCPR Cardiopulmonary resuscitationCVC Central venous catheterCVP Central venous pressureCXR Chest radiographDC Direct currentECG ElectrocardiographyGN Glyceryl trinitrate (nitroglycerin)HIV Human immunodeciency virusIABP Intra-aortic balloon pumpICD Internal cardioverter device

IM IntramuscularIN Intranasal

IO IntraosseousIV IntravenousLMA Laryngeal mask airwayLUCAS Lund University Cardiac Assist SystemNICE National Institute or Clinical ExcellencePa2 Arterial partial pressure o carbon

dioxidePEA Pulseless electrical activity

Pa2 Arterial partial pressure o oxygenPEEP Positive end-expiratory pressurePco2 Partial pressure carbon dioxideP Partial pressure oxygenSa Arterial haemoglobin oxygen saturationSC SubcutaneousSp Arterial haemoglobin oxygen saturation

measured non-invasively by pulseoximetry

VF Ventricular brillationV Ventricular tachycardia

RALI ransusion-related acute lung injury

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Multiple choice questionsQuestion1

A 15:2 compression:ventilation ratio is recommendedor resuscitation o:

a. adults, i the rescuer is trained

b. adults, i the rescuer is untrained

c. children less than 8 years old, i the rescuer isuntrained

d. children less than 8 years old, i the rescuer istrained

e. adult drowning victims.

Question2

Which o the ollowing are correct doses or paediatriccardiac arrest?

a. atropine 10 g/kg

b. adrenaline (epinephrine) 10 g/kg

c. amiodarone 10 g/kg

d. debrillation (monophasic debrillator) 4 J/kg

e. debrillation (biphasic debrillator) 2 J/kg.

Question3

Which o the ollowing statements are correct?

a. in an adult male (7080 kg), the endotracheal tubeshould be 26 cm length at the lips

b. a size 4 laryngeal mask airway (LMA) is suitableor most adults

c. a size 9.0 mm nasopharyngeal airway is suitableor most adults

d. the size o an endotracheal tube, e.g. 7.0 mm,reers to its external diameter

e. a size 2 or 3 oropharyngeal airway is generallysuitable or an 8-year-old patient.

Question4

Which o the ollowing drugs cause pupillary dilation?

a. atropine

b. adrenaline

c. amiodarone

d. lignocaine

e. sodium bicarbonate.

Question 5With regard to cardiac arrest:

a. the commonest cause in adults is ischaemic heartdisease

b. home debrillators or high-risk patients doublesurvival rates

c. paediatric cardiac arrest is usually due to a nalcommon pathway causing hypoxaemia

d. bystander cardiopulmonary resuscitation (CPR)doubles the survival rate

e. sudden cardiac death accounts or about 15% oall deaths in Western countries.

Question 6

With regard to amiodarone:

a. hypotension results rom histamine release

b. should be administered i the patient remains inVF afer the second shock

c. the initial adult dose is 300 mg IV

d. may cause optic neuritis with prolonged use

e. precipitates with adrenaline.

Question 7

In diagnosing heat stroke in a pyrexial patient, the ol-lowing differential diagnoses should be considered:

a. neuroleptic malignant syndrome

b. phaeochromocytoma

c. hypothyroidism

d. anaphylaxis

e. CNS inection.

Question 8

Noradrenaline (norepinephrine):

a. is principally an -agonist

b. has some -agonist action

c. may cause a reex bradycardia

d. is synthesized primarily in the adrenalcortex

e. is broken down into various metabolites thatinclude adrenaline.

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Paper1 Questions

Question9

ECG changes o hypothermia include:

a. shortened PR interval

b. attened wave

c. J wave

d. movement arteact rom shivering

e. VF.

Question10

Suitable positions or sel-adhesive pad placement ordebrillation o VF include:

a. biaxillary

b. anterior (right sternal edge) and lef axilla

c. anterior (lef sternal edge) and lef axilla

d. anterior (lef sternal edge) and posterior

e. anterior (right sternal edge) and posterior.

Question11

Te ollowing drugs cause hypotension throughhistamine release:

a. atracurium

b. entanyl

c. morphine

d. amitriptyline

e. midazolam.

Question12

With regard to O2:

a. the concentration in exhaled breath is 18%

b. 30% O2doubles the rate o combustion

c. in most tissues o the body, the response tohypoxia is vasodilatation

d. in the lungs, the response to hypoxia isvasoconstriction

e. hyperventilation increases O2uptake.

Question13

Pulse oximetry:a. the presence o carbon monoxide in the blood

(COHb) results in an overestimation o oxygensaturation o haemoglobin (Sa2)

b. the presence o methaemoglobin in the blood(MetHb) results in an overestimation o Sa2

c. etal Hb results in an overestimation o Sa2d. a poor pulse oximetry trace may result in an

underestimation o Sa2e. diathermy may interere with waveorm detection.

Question 14

With regard to capnography:

a. normal range is approximately 4.56.0 kPa

b. absence o endotracheal end-tidal CO2during acardiac arrest is diagnostic o oesophagealintubation

c. end-tidal CO2that does not rise above 1.4 kPa(10 mmHg) during a resuscitation attempt isassociated with a poor prognosis

d. cooling increases end-tidal CO2e. Pa2is equal to end-tidal CO2.

Question 15

With regard to severe local anaesthetic toxicity assocated with cardiovascular collapse:

a. lignocaine is the commonest local anaesthetic

implicated in this conditionb. may benet rom administration o Intralipid

20%

c. propool (an intralipid emulsion) is a suitablealternative to Intralipid

d. the maximum recommended sae dose obupivacaine is 2 mg/kg IV

e. survival is uncommon.

Question 16

How should chest compressions be perormed on ainant?

a. with the heel o one hand and the other hand ontop o the rst

b. with the heel o one hand only

c. with 4 ngers o one hand

d. with 2 ngers o one hand

e. with the thumb o one hand.

Question 17

I an AED is available, but adult sel-adhesive pads aravailable, how should you manage a 5-year-old child icardiac arrest with a shockable rhythm?

a. AED use is unnecessary as shockable rhythms arrare in this age group

b. use the AED, but apply only one o the pads

c. use the AED with adult pads

d. perorm CPR, but do not use the AED

e. use the AED or a single shock only.2



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Paper 1 Questions

Question18

With regard to drug doses:

a. 1 ml 1:1000 adrenaline= 1 mg adrenalineb. 10 ml 0.25% bupivacaine= 25 mg bupivacainec. 100 g (mcg) adrenaline = 1 ml 1:10 000

adrenaline

d. 1 mg IV adrenaline has the same efficacy as2 mg IO (intraosseous) adrenaline

e. 10 ml 50% dextrose= 100 ml 5% dextrose.

Question19

A pacemaker programmed to:

a. AOO paces and senses the atrium only

b. VVI paces and senses the atrium only

c. DDD paces and senses both the atrium andventricle

d. DDDR has the capability to debrillate

e. DDD may be inhibited by diathermy current.

Question 20

With regard to haemorrhage:

a. circulating blood volume in an adult isapproximately 4% o body mass

b. patients who have an impaired level oconsciousness due to blood loss have generally

lost at least 40% o their circulating blood volumec. -blockers may mask the early signs o

hypovolaemic shock

d. the management o catastrophic haemorrhageshould take priority over airway management

e. venous bleeding is generally less serious thanarterial bleeding.

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Paper1 Questions

PhotographquestionsQuestion1

a. What is this?

b. What is the unction o the reservoir?

c. What O2ow rate delivers 100% O2to the patient?

Question2

a. What is thepercentage o O2inthe atmosphere?

b. What volume o gasis discharged romthis CD sizecylinder?

c. Why does thecylinder becomecold during use?

Question 3

a. What is this?

b. How is this device powered?

c. What hazards may be associated with its useduring debrillation?

Question 4

a. What class o medication is this solution?

b. What ECG changes does it cause when taken as aoverdose?

c. How is this overdose treated?

Question 5

Tis device can be placed over implanted pacemakeor cardioverterdebrillators.

a. What is it?

b. What is its effect on an implantable pacemaker?

c. What is its effect on an automated implantablecardioverterdebrillator (AICD)?

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Paper 1 Questions

Diagnostic questionsQuestion1

1

3

1

2

3

a. What is this image?b. Name structures 13.

Question2

Tis is a paced ECG. What mode is the pacemaker setto?

Question3

Te ollowing results have been obtained:

Na+ 135 mmol/l

K+ 7.2 mmol/lurea 33.4 mmol/l

creatinine 488 mmol/l

glucose 18.9 mmol/l

a. What is the most immediate priority in thispatient?

b. Which organ system is ailing?

c. What is the likely cause o this ailure?

Question 4

An arterial blood gas sample (on air) is taken rom anunresponsive patient, with the ollowing results:

pH 7.21

Pa2 11.0 kPa

Pa2 8.8 kPa

HCO3 15 mmol/l

a. What metabolic derangement is seen in this bloodgas?

b. Name three likely causes.

Question 5

a. What rhythm does this ECG show?

b. What non-pharmacological methods may be usedto terminate the arrhythmia?

c. What pharmacological methods may be used toterminate the arrhythmia?

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Paper1 Questions

Short answer questionsQuestion1

Draw the algorithm or paediatric ALS.

Question2

Explain why dextrose-containing solutions are contr-aindicated as resuscitation uids.

Question3

How quickly does manual external chest compressionatigue? How ofen should rescuers change?

Question 4

What are the risks o perorming a needle pericardiocentesis? How may these risks be minimized?

Question 5

Draw a cross-section o the heart to show the righ

atrium and ventricle, lef atrium and ventricle anpulmonary artery and aorta. Label each with normvalues or O2saturation (on air).

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Paper 1 Answers

MCQ answersAnswer 1

a. False. 30:2 is recommended in adults,irrespective o whether the rescuer is trained oruntrained.

b. False.c. False. 30:2 is recommended in children i therescuer is untrained.

d. False. rained rescuers should use 15:2.

e. True.

Answer 2

a. False. Atropine is not recommended orroutine use. When it is given, the correct dose is20 g/kg.

b. True. 100 g/kg should be considered in

children with cardiac arrest associated with severevasodilation, e.g. sepsis.

c. False. Amiodarone 5 mg/kg or both the rstand, i given, the second dose.

d. True.

e. False. Te recommended energy level orbiphasic debrillators is also 4 J/kg or all shocks.

Answer 3

a. False. For a 7080 kg adult, the endotrachealtube should be 2224 cm at the lips.

b. True.c. False. A size 6.07.0 mm airway is adequate or

most adults.

d. False. Te size reers to the internal diameter.

e. True.

Answer 4

a. True.

b. True.

c. False.

d. False.

e. False.

Answer 5

a. True. Among adults, ischaemic heart disease isthe predominant cause o arrest, with 30% opeople at autopsy showing signs o recentmyocardial inarction.

b. False. Home debrillators have not been shownto improve outcome rom cardiac arrest.

c. True.

d. True.

e. False. 30%.

Answer 6

a. False. Hypotension is thought to be caused bythe solvent in which amiodarone is dissolved.

b. False. Amiodarone is indicated immediatelyafer the third shock.

c. True.

d. True.

e. Frue.

Answer 7

a. True.

b. True.

c. False. Hyperthyroidism.

d. False.

e. True.

Answer 8

a. True.

b. True.

c. True.

d. False. Is synthesized primarily in the adrenalmedulla.

e. True.

Answer 9

a. False. Prolonged PR interval.

b. True.

c. True.

d. True.

e. True. Asystole and VF may begin spontaneouslyat core temperatures below 2528C.

Answer 10

a. True.

b. True.

c. False.d. True.

e. True.

Answer 11

a. True.

b. False.

c. True.

d. False.

e. False.7



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Paper 1 Answers

Answer 12

a. False. 15%.

b. False. 24% O2doubles the rate o combustion.30% increases the rate 10-old.

c. True.

d. True. Tis is known as hypoxic pulmonary

vasoconstriction.e. False.

Answer 13

a. True. At 660 nm (used by the pulse oximeter),COHb absorbs light in a similar manner to HbO2.

b. False. At 660 nm, MetHb has similar absorptionto reduced Hb. Sa2decreases with increasingMetHb levels, towards a Sa2o 85%. Below 85%,the presence o MetHb will, thereore, result in anincrease in Sa2towards 85%.

c. False. Fetal Hb has no signicant effect on pulseoximetry values.

d. True.

e. True.

Answer 14

a. True.

b. False. Also occurs with no cardiac output.

c. False. A threshold value o 10 mmHg (1.4 kPa)as a prognosticator or irreversible death inout-o-hospital cardiac arrest has been

demonstrated (Levine RLet al. N Engl J Med,1995;337:301306; Cantineau JPet al. Crit CareMed, 1996;24:791796).

d. False. Cooling reduces metabolic rate andcardiac output, subsequently reducing end-tidalCO2.

e. False. When ventilation and perusion areequal, Pa2is equal to end-tidal CO2. Inpractice, however, there is always a degree oshunting within the lungs, resulting inless-efficient gas transer. In conditions such as

cardiac arrest, chronic obstructive pulmonarydisease or adult respiratory distress syndrome, aneven greater ventilation/perusion abnormalityoccurs and high CO2gradients result.

Answer 15

a. False. Bupivacaine.

b. True. Some animal studies and human casereports suggest that Intralipid may be o benet inthese patients (Soar Jet al. Resuscitation,2010;81:14001433).

c. False. Propool is dissolved in Intralipid, but atinadequate dose to be in the therapeutic range.

d. True.

e. True. Bupivacaine is thought to bind strongly tmyocardial tissue and its effects are difficult toreverse.

Answer 16

a. False.

b. False.

c. False.

d. True.

e. False.

Answer 17

a. False.

b. False.

c. True.

d. False.

e. False.

Answer 18

a. True.

b. True. A 1% solution contains 10 mg/ml.

c. True.

d. False. IV and IO routes have the samebioavailability and, thereore, efficacy.

e. True.

Answer 19a. False. AOO paces the atrium only and is not

inhibited by atrial or ventricular activity.

b. False. VVI paces the ventricle and is inhibitedby ventricular activity.

c. True.

d. False. R means that the device is rateresponsive and can vary its rate.

e. True. Electrical activity rom diathermy devicecan be sensed by pacemakers, which thenmistakenly inhibit output.

Answer 20

a. False. 7%.

b. True.

c. True. achycardia may be masked by-blockers.

d. True. Te traditional ABC approach has beensuperseded by cABC, where the initial priority isto stop any torrential haemorrhage (e.g. rom limamputation) prior to moving on to ABC.

e. False.

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Paper 1 Answers

PhotographanswersAnswer 1

a. Oxygen rebreathing mask.

b. Te reservoir lls with O2to provide additionalO2to that delivered when the patient inhales.

c. A rate o 15 l/min O2results in the patientinhaling approximately 8590% O2; 100% O2isonly possible with sealed systems.

Answer 2

a. 21%.

b. Tis is a CD size O2cylinder, which stores 460litres.

c. Pressure o a gas (P) is related to its volume (V),given by the equationP/V= k, wherekis aconstant. Also,Pis proportional to the absolute

temperature (; measured in Kelvin) o the gas.Tereore, as gas escapes rom a pressurizedcylinder (137 bar when ull), the pressure alls andthe gas remaining in the cylinder expands. Tisall in pressure results in a proportionaltemperature decrease.

Answer 3

a. Lund University Cardiac Assist System (LUCAS)(Deakin CDet al. Resuscitation, 2010;81:13051352).

b. Te device is powered by compressed O2at>100 l/min. Later devices (LUCAS2) are poweredby battery.

c. Te exhaust O2gas discharged rom the deviceresults in high ambient O2concentrations,particularly in conned spaces. High ambient O2concentrations are a risk or re or explosion.

Answer 4

a. ricyclic antidepressant.

b. Prolonged Qc, widened QRS complex,ventricular brillation (VF).

c. In patients with a metabolic acidosis, sodiumbicarbonate (IV) is recommended. Te postulated

mechanism o action is two-old: tricyclics are protein bound but less so in acidic

conditions; reversing the acidosis increasesprotein binding and decreases bioavailability othe drug

sodium load may help to reverse the sodiumchannel blocking effects o the tricyclic drug

treatment is otherwise supportive.

Answer 5

a. Ring magnet.

b. Te magnet inhibits sensing by the pacemaker,converting to a xed output mode (e.g. AOO) at apreset rate (usually 50/min).

c. Te magnet will have the same effect on thepacing unction o an AICD as or an implantablepacemaker (b). It will also inhibit thedebrillation unction o the device.

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Paper 1 Answers

Diagnostic answersAnswer 1

a. Structures are:

(1) lef ventricle

(2) mitral valve

(3) lef atrium.

Te gure shows the orientation:

LA

LVRV

RA

Left

Answer 2

DDD. Both atrial (red arrows) and ventricular (bluearrows) pacing spikes can be seen.

Answer 3

a. Te immediate priority in this patient is thetreatment o hyperkalaemia (normal range3.55.0 mmol/l).

b. Te urea (normal range 3.07.0 mmol/l) andcreatinine (normal range 50118 mmol/l) are

both signicantly elevated, suggesting renalailure; the likely cause o this is hyperkalaemia.

c. Te high glucose level (normal range3.07.0 mmol/l) is suggestive o diabetes, acommon cause o chronic renal ailure.

Answer 4

a. Acute respiratory acidosis.

b. Respiratory depression, respiratory ailure, airwaobstruction, hypoventilation rom a low minutevolume o any cause.

Answer 5

a. Supraventricular tachycardia (with a rateapproximately 300/min).

b. Carotid sinus massage, sucking ice, cold annelover the ace.

c. Adenosine 36 mg IV; verapamil 2.55 mg IVboluses are an alternative i adenosine is notavailable.

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Paper 1 Answers

Short answersAnswer 1

Paediatric Advanced Life Support

CPR(5 initial breaths then 15:2)

Attach defibrillator / monitorMinimise interruptions

Shockable

(VF / Pulseless VT)

1 Shock4 J/kg

During CPR

Ensure high-quality CPR: rate, depth, recoil

Plan actions before interrupting CPR

Give oxygen

Vascular access (intravenous, intraosseous)

Give adrenaline every 3-5 min

Consider advanced airway and capnography

Continuous chest compressions when advanced

airway in place

Correct reversible causes

Reversible Causes

Hypoxia

Hypovolaemia

Hypo-/hyperkalaemia/metabolic

Hypothermia

Tension pneumothorax

Toxins

Tamponade - cardiac

Thromboembolism

Non-Shockable

(PEA/Asystole)

Callresuscitation team

(1 min CPR first,if alone)

Resuscitation2010 Guidelines

Unresponsive?Not breathing or

only occasional gasps

Return ofspontaneous

circulation

Immediately resume

CPR for 2 minMinimise interruptions

Immediately resume

CPR for 2 minMinimise interruptions

Resuscitation Council (UK)

Immediate post cardiacarrest treatment

Use ABCDE approach

Controlled oxygenation and

ventilation

Investigations

Treat precipitating cause

Temperature control

Therapeutic hypothermia?

Assessrhythm

Reproduced with permission from the Resuscitation Council (UK).

Answer 2

Solutions containing dextrose (sugar) are contraindi-cated in resuscitation because:

hyperglycaemia may exacerbate cellular ischaemicdamage; there is some evidence thathyperglycaemia caused by dextrose-containinguids given during resuscitation may worsenoutcome

dextrose is rapidly metabolized to leave ree water,which remains in the intravascular space or a veryshort period beore entering the extravascularspace; consequently its volume-expanding effectsare very limited, 1000 ml 5% dextrose will expandthe intravascular space by just 67 ml.

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Paper 1 Answers

Answer 3

Manual external chest compression atigues afer1 min, although rescuers do not perceive that theyare suffering atigue until approximately 3 min operorming chest compressions. Ideally, the individ-ual perorming chest compression should change afer

no more than 2 min (Javier OF, et al. Resuscitation,1988;37:149152).

Answer 4

Acute risks o needle pericardiocentesis include: myocardial puncture coronary artery puncture myocardial inarction needle-induced arrhythmias pneumopericardium pneumothorax accidental puncture o the liver, stomach or lung.

Risks can be minimized by using transthoracicecho or uoroscopy to ensure correct placement o theneedle. Use o an ECG injury potential when the nee-dle penetrates the myocardium is no longer a recom-mended technique.

Answer 5

Normal O2saturations (on air):

Right atrium

70%

70%

100%

100%

100%

70%

Right ventricle

Left ventric

Left atrium

Pulmonary arte

Aorta

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2PA

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With regard to potassium metabolism:

a. the normal potassium level is 3.05.5 mmol/l

b. hyperkalaemia is dened as K+>5.5 mmol/lc. hyperkalaemia is exacerbated by alkalosis

d. hyperkalaemia is common with acute renal ailure

e. hyperkalaemia may be caused by haemolysis o ablood sample.

Question2

Positive pressure ventilation causes:

a. decreased cardiac output

b. increased venous return

c. increased renal blood ow

d. raised intracerebral pressure

e. respiratory muscle atrophy.

Question3

Hard collars or cervical spine immobilization:

a. are contraindicated in patients with base o skullracture

b. may cause pressure sores

c. may decrease cerebral perusion pressure

d. should be tted afer the airway has been secured

e. can be loosened i a patients head is stabilized ona spinal board between head blocks.

Question4A childs weight (kg) can be estimated rom the ollow-ing equation:

a. Weight= 2(age+ 4)b. Weight= (age/4)+ 4c. Weight= 7(age)/3d. Weight= 3(age 4)e. Weight= 3(age)+ 7.

Question 5In the management o burns:

a. Body surace area calculations excludeerythematous areas

b. the whole hand represents 1% body surace area

c. children have proportionately larger heads thanadults

d. uid requirements are calculated rom the time othe burn occurring, not the time treatment starts

e. airway swelling rom respiratory tract burns is at

its worst 24 h afer the burn has occurred.

Question 6

Intraosseous access:

a. should be used when administration oendotracheal drugs is ineffective

b. is suitable or all crystalloids, colloids and IVdrugs

c. should be replaced by IV access as soon as ispractical

d. allows aspiration o bone marrow to estimate

haemoglobin, but not plasma electrolytese. is contraindicated i the limb in which access is

being considered is ractured.

Question 7

Adrenaline:

a. is an1-agonist

b. is a 1-agonist

c. is a GABA (gamma-aminobutyric acid) agonist

d. is synthesized by the adrenal cortex

e. is antagonized in patients taking -blockers.

Question 8

With regard to opioids:

a. all cause respiratory depression

b. entanyl and alentanyl are synthetic opioids

c. morphine is broken down into active metabolites

d. naloxone is a partial opioid agonist

e. pethidine is a partial opioid agonist. 13



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Paper2 Questions

Question9

Ventricular brillation:

a. may be triggered by atrial brillation

b. may be converted to sinus rhythm by theadministration o amiodarone

c. may convert to asystole ollowing debrillation

d. is associated with worse outcome than asystolewhen it is the presenting rhythm

e. may be triggered by direct mechanical irritationo the myocardium by an angiogram catheter orguidewire.

Question10

Te adult adrenaline autoinjector (Epipen):

a. delivers 0.5 mg adrenaline in a concentration o1:1000

b. contains a single dose o adrenaline

c. should be administered into a large orearm vein

d. should be used by a bystander once the patient isunconscious

e. should be stored in the ridge until needed.

Question11

During external chest compression (ECC) at 100/min,cardiac output is increased by the ollowing:

a. positive end-expiratory pressure (PEEP)

b. increasing the rate o compression.

c. changing rescuers perorming ECC every 2 mind. active decompression

e. ensuring complete chest wall relaxation byremoving hands rom the chest wall betweencompressions.

Question12

Physiological changes during pregnancy include:

a. an increase in blood volume by 20% at term

b. a all in haematocrit until the end o the secondtrimester, when levels return towards normal

c. an increase in cardiac output by 40% at termd. an increase in systemic vascular resistance

e. an increase in respiratory rate and decrease intidal volume.

Question13

With regard to VF:

a. the waveorm is entirely random

b. a ne waveorm is more likely to be cardiovertedto a perusing rhythm than a coarse waveorm

c. movement arteact may occasionally be mistakenby an AED or VF

d. the greater the area under the curve with spectrarequency analysis (Fourier analysis), the greaterthe chances o successul debrillation

e. the primary determinant o successul

debrillation is the duration o VF.

Question 14

Causes o pulseless electrical activity include:

a. respiratory arrest

b. acute pulmonary embolus, occluding 30% o thepulmonary vascular tree

c. auto-PEEP, as occurs during severe acute asthma

d. calcium channel blocker overdose

e. tricyclic antidepressant overdose.

Question 15

With regard to the ECG:

a. 1 large square= 0.5 sb. the normal PR interval is 0.12 to 0.20 s

c. the normal QRS duration is


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Paper 2 Questions

Question18

Factors avourable or survival romdrowning include:

a. water temperature


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Paper2 Questions


a. What is this?

b. How is it sized?

c. Why is it inserted in adults inverted and then

rotated?

Question2

A patient in a dental chair becomes unresponsive.

a. What is the most likely cause?

b. What is the treatment?

c. What is the differential diagnosis?

Question3

a. What is this implantable device?

b. How may it affect debrillation electrodeposition?

c. What are the risks to the rescuer rom this device

Question 4

You are called to the scene to provide medical care orpatient who has been trapped or 3 h by a crush injurto the legs at a serious road traffic accident.

a. What condition may cause collapse o this patienon extrication and why?

b. What treatment on-scene would you considerprior to extrication?

c. What additional hospital therapy may be obenet?

Question 5

a. What is this device?b. What is the advantage o a clear ace mask?

c. Where should the device be placed duringdebrillation?

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Paper 2 Questions


a. What does this rhythm strip show?

b. What conditions are associated with thisarrhythmia?

c. What is the treatment o this arrhythmia?

Question2

a. What rhythm is shown on this ECG rhythmstrip?

b. Is a pulse palpable in this patient?

c. What is the treatment?

Question3

Tis hypotensive patient has presented to the emer-gency department with central chest pain radiating tothe back.

a. What is the likely diagnosis?

b. What imaging investigations are required?


Question 4

Tis patient has become short o breath and hypoten-sive ollowing elective cardiac catheterization. Tetransthoracic echo is labelled to show the lef atrium(LA), lef ventricle (LV), right atrium (RA) and rightventricle (RV).

RV

RA

LA

LV

a. What structure is shown as ?b. What is the likely cause o this pathology?


Question 5

Tese arterial blood gases are taken rom an uncon-

scious patient with an unknown drug overdose:

pH 7.23

Pa2 13.0 kPa

Pa2 3.8 kPa

HCO3 14.9 mmol/l

a. What is the metabolic condition?

b. What drugs can cause this condition?

c. What other blood tests should be perormed?

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Paper2 Questions


Draw a biphasic debrillator waveorm, labelling the xandyaxes.

Question2List the causes o pulseless electrical activity, using the4Hs and our 4s as a guide.

Question3

List three common drugs causing anaphylaxis.

Question 4

What are the causes o an absent end-tidal COmeasurement?

Question 5

A post-arrest patient remains comatose and need

cooling. What methods are available to induce anmaintain hypothermia?

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Paper 2 Answers

MCQ answersAnswer 1

a. False. Te normal potassium level is3.55.0 mmol/l.

b. True.

c. False. Hyperkalaemia is exacerbated by acidosis.d. True.

e. True.

Answer 2

a. True.

b. False. Positive pressure ventilation causesincreased venous return.

c. False. Positive pressure ventilation decreasesrenal blood ow through decreased cardiacoutput.

d. True. By increasing venous pressure andsubsequently the venous drainage o the head.

e. True. In patients requiring long-termventilation.

Answer 3

a. False.

b. True.

c. True. By impairing venous drainage o the headand neck.

d. False. Should be tted in conjunction withairway management.

e. True.

Answer 4

a. True.

b. False.

c. False.

d. False.

e. True. Tis equation is more accurate than thatin (a).

Answer 5

a. True.

b. False. Te palm o the hand represents 1% bodysurace area.

c. True.

d. True.

e. False. Airway swelling rom respiratory tractburns is at its worst 2448 h afer the burn hasoccurred.

Answer 6

a. False. Endotracheal drug route is notrecommended. An IO access should be gainedpromptly i IV cannulation is not possible.

b. True.

c. True.

d. False. Blood and plasma electrolytes can all bemeasured using bone marrow aspirate.

e. True.

Answer 7

a. True.

b. True.

c. False.

d. False. Adrenaline is synthesized by chromaffincells o the adrenal medulla.

e. True.

Answer 8

a. True.

b. True.

c. True. Morphine is broken down byglucuronidation to morphine-3,6-diglucuronide,3-glucuronide and 6-glucuronide; the latter beingan opioid agonist.

d. False. Naloxone is a pure antagonist.

e. True.

Answer 9a. False.

b. False. Amiodarone alone will not cardiovert VF.Its membrane-stabilizing effects will increase theefficacy o subsequent debrillation.

c. True.

d. False. Patients presenting in asystole have alower survival rate than those in VF.

e. True.

Answer 10

a. False. Delivers 0.3 mg adrenaline in aconcentration o 1:1000.

b. True.

c. False. Te device is designed to deliver an IMdose; administration o adrenaline IV may causesevere tachyarrhythmias.

d. False. Should be used by the patient as soon ashe or she become symptomatic.

e. False. Should be kept with the patient at alltimes.

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Paper 2 Answers

Answer 11

a. False. PEEP will increase intrathoracicimpedance and reduce venous return, whichreduces subsequent cardiac output.

b. False. A rate o 100120/min is consideredoptimal to allow adequate myocardial lling

between compressions.c. True. Rescuer atigue occurs afer just 2 min o

ECC.

d. True. Active decompression (e.g. suction cupapplied to the chest wall to actively lif the chestwall during the relaxation phase o chestcompression) will increase cardiac output,although this has not been shown in clinicalstudies to improve survival.

e. True.

Answer 12a. False. Blood volume increases by 4550% at

term.

b. True.

c. True.

d. False. Systemic vascular resistance allsmarkedly as pregnancy progresses.

e. False. Respiratory rate increases slightly andtidal volume increases 40% at term.

Answer 13

a. False. Te VF waveorm is not entirely random,having a degree o predictability.

b. False. A coarse rhythm is more likely to becardioverted successully.

c. True. Tere are a number o case reports oautomatic debrillators mistaking movementarteact (vibration in an ambulance) or ashockable rhythm.

d. True.

e. True.

Answer 14a. True. Te commonest cause o pulseless

electrical activity, being implicated as the cause in2553% o cases.

b. False. Over 50% o the pulmonary vascular treeneeds to be occluded to cause haemodynamiccollapse.

c. True. Auto-PEEP occurs in acute asthma whenair trapping results in hyperination o the lungsAuto-PEEP may exceed 80 cmH2O in severecases, with the resulting increase in intrathoracicpressure impairing venous return and thehyperinated lungs compressing the heart, to

prevent lling.d. True. Calcium channel blockers can depress

myocardial unction and cause haemodynamiccollapse.

e. True. ricyclic antidepressants can depressmyocardial unction and cause haemodynamiccollapse.

Answer 15

a. False. 1 large square = 0.2 s.b. True.

c. False. Te normal QRS duration is


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Paper 2 Answers

Answer 18

a. True.

b. False. Salinity o water does not affect survival.

c. True. Aspiration o large quantities o waterhelps to induce rapid cooling.

d. False. Obese patients (high body mass index)

have excess adipose tissue, which acts as aninsulator and limits rapid cooling.

e. True.

Answer 19

a. True.

b. False.

c. False.

d. False. Digoxin tends to cause attened waves.

e. False.

Answer 20

a. False. Unlike the beating heart, myocardialblood ow occurs during both systole anddiastole.

b. True.

c. True. Although some studies have suggested a

greater risk o inducing VF.d. True.

e. False. When possible, tracheal intubationshould be perormed without interruption toexternal chest compression.

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Paper 2 Answers


a. Tis is an oropharyngeal (Guedel) airway.

b. It is sized by measuring against the patients head:the ange is aligned with the incisors and the tip

to the tragus o the ear.

c. Te Guedel airway is inserted inverted in order toavoid catching the tongue and pushing itbackwards during insertion. Once contact is madewith the back o the throat, the airway is rotated180, allowing or easy insertion.

Answer 2

a. A vasovagal collapse (aint) is the commonestcause o collapse in the dental chair. Also consideranaphylaxis, myocardial inarction.

b. Stop any stimulation, elevate the legs and give O2.

c. Other less common causes o collapse includeanaphylaxis, arrhythmia or cardiac arrest.

Answer 3

a. Automatic implantable cardioverterdebrillator(AICD).

b. Debrillation pads or paddles should be placed atleast 8 cm away rom this device to avoid escapecurrent damaging the device or being transmitteddown the debrillation electrode to damage themyocardium.

c. Te discharge rom an AICD may cause pectoralmuscle contraction in the patient, and shocks tothe rescuer have been documented. In view o thlow energy levels discharged by AICDs (30 min are atrisk o crush syndrome. Tis results romischaemic damage to limbs, with subsequentreperusion injury, and appears afer the release othe crushing pressure. Te mechanism is believedto be rhabdomyolysis (muscle breakdown causedby ischaemia) leading to the release into thebloodstream o breakdown products (e.g.myoglobin, potassium and phosphorus).

b. Prior to extrication, consider a saline inusion o10001500 ml/h, initiated during extrication.Sodium bicarbonate should also be considered inthese patients at the time o extrication. Considergradual release o the entrapped limb to limit thesudden release o toxins.

c. Forced alkaline diuresis, up to 8 l/24 h, should bemaintained (urine pH >6.5). Alkalinizationincreases the urine solubility o haematin and aidin its excretion. Tis should be continued untilmyoglobin is no longer detectable in the urine.Mannitol may also be o benet, both as ascavenger o oxygen ree radicals and through itsactions as an osmotic diuretic.

Answer 5

a. Sel-inating bag-valve-mask.

b. Allows the rescuer to see any blood or vomitcoming rom the mouth or nose.

c. At least 1 m away rom the patient.

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Paper 2 Answers


a. orsade de pointes. orsade is a polymorphicventricular tachycardia in which the morphologyo the QRS complexes varies rom beat to beat.

Te ventricular rate ranges rom 150 to 250/min.Because it is associated with regular variation othe morphology o the QRS vector rom positiveto net negative and back again, it was termedtorsade de pointes, or twisting o the point,about the isoelectric axis.

b. Brugada syndrome, Jervell syndrome,LangeNielsen syndrome and the RomanoWardsyndrome. Also akotsubo cardiomyopathy(stress-induced cardiomyopathy).

c. Stop amiodarone, which may worsen thecondition. Administer magnesium sulphate 24 gIV. Magnesium is usually very effective, even in apatient with a normal magnesium level. Othertherapies include overdrive pacing andisoprenaline inusion. Patients in extremis shouldbe treated with electrical cardioversion.

Answer 2

a. Acute aortic dissection.

b. ransoesophageal echocardiogram, Cangiogram (or MRI) o the heart and aorta.

c. Surgical repair or occasionally endovascularstenting may be possible.

Answer 3

a. P wave asystole.

b. Tere is no cardiac output and, thereore, no pulse.

c. Cardiac arrest ALS algorithm or non-shockablearrhythmias.

Answer 4a. Fluid in the pericardial space (i.e. cardiac

tamponade).

b. Peroration o the right atrium or right ventricleby the catheter.

c. Insertion o a pericardial drain to relieve thetamponade and possible surgery i the bleedingcontinues.

Answer 5

a. Uncompensated (acute) metabolic acidosis.

b. Salicylate (aspirin) intoxication, methanol,ethylene glycol, toluene (a solvent).

c. Blood levels should also be checked orparacetamol levels. Paracetamol is commonlytaken as an overdose, either separately orcombined with salicylate.

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Paper 2 Answers

Short answersAnswer 1

Tere are two main biphasic waveorms, both shownbelow:

0

30

25

20

15

10

5

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 1415 16 17

Time (ms)

(a) Biphasic truncated exponential

Current(amps)

Time (ms)

Current(amps)

0

30

20

10

0

10

20

1 2 3 4 5 6 7 8 9 10 11 12

(b) Rectilinear biphasic

Answer 2

4Hs: hypovolaemia hypoxia hypokalaemia/hyperkalaemia hypothermia.

4s: toxins tamponade (cardiac) thrombosis (pulmonary or coronary) tension pneumothorax.

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Paper 2 Answers

Answer 3

Drug types causing anaphylaxis: antibiotics: penicillin, cephalosporins (particularly

rst generation such as cealotin, cealexin,ceadroxil and ceazolin)

neuromuscular blockers (e.g. vecuronium,

pancuronium) anaesthetic induction agents (e.g. thiopental,

propool) opioids (morphine) non-steroidal anti-inammatory drugs colloids IV radiocontrast media.

Answer 4

Causes: aulty/disconnected capnography or breathing

circuit oesophageal intubation loss o cardiac output cessation o ventilation.

Answer 5

Initial cooling is acilitated by neuromuscular block-ade and sedation, which will prevent shivering.Magnesium sulphate reduces the shivering threshold.

External methods:

simple ice packs and/or wet towels cooling blankets or pads water or air circulating blankets water circulating gel-coated pads.

Internal methods: inusion o 30 ml/kg o 4C saline or Hartmanns

solution decreases core temperature byapproximately 1.5C (induction o hypothermiaonly)

intravascular heat exchanger, usually placed in theemoral or subclavian vein

cardiopulmonary bypass.

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3PA

PER


With regard to hyperkalaemia:

a. acute hyperkalaemia is less well tolerated thanchronic hyperkalaemia

b. glucose and insulin given together result inpotassium uptake into cells

c. calcium IV may protect against harmuleffects

d. all diuretics increase potassium loss and may

lower potassium levelse. renal dialysis may be indicated i severe.

Question2

With regard to endotracheal tube size:

a. adult sizes are usually appropriate or patientsaged >16 years

b. the appropriate size o a paediatric uncuffed tubeis given by the equation (Age/4)+ 4

c. the appropriate size o a paediatric cuffed tube isgiven by the equation (Age/4)

+3

d. tracheostomy tubes should be 1.0 mm smallerthan the corresponding endotracheal tubesize

e. tubes o smaller internal diameter reduce airwayresistance.

Question3

With regard to paediatric uid resuscitation:

a. a paediatric uid bolus is generally calculated as2030 ml/kg

b. maintenance uids can be calculated using the

4-2-1 rule, 010 kg: 4 ml/kg per h 1020 kg: +2 ml/kg per h >20 kg: 1 ml/kg per h

c. Children have higher body water content thanadults

d. children with 1520% dehydration have physicalndings that include tenting o the skin, weightloss, sunken eyes and ontanel, slight lethargy andry mucous membranes

e. crystalloids rather than colloids are the uid ochoice or volume resuscitation.

Question 4

Causes o a short PR interval include:

a. WolffParkinsonWhite syndrome

b. LownGanongLevine syndrome

c. Duchenne muscular dystrophyd. ype II glycogen storage disease (Pompe

disease)

e. ischaemic cardiomyopathy.

Question 5

With regard to electrical saety during externdebrillation:

a. paddles are saer than sel-adhesive pads

b. clinical gloves may reduce the risk o aninadvertent shock to the rescuer

c. sources o O2should be turned off duringdebrillation

d. electrode paste reduces the risk o arcing betweenelectrodes

e. 24% O2doubles the rate o combustion.

Question 6

Whole bowel irrigation or drug overdose:

a. is particularly effective or late presentingparacetamol or aspirin overdose

b. is an alternative to combined laxative and emetictherapy

c. may be considered or toxic ingestions osustained-release or enteric-coated drugs

d. is contraindicated in patients with hypothermia

e. is contraindicated in patients with haemodynaminstability.

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Paper 3 Questions

Question7

In the management o anaphylaxis:

a. the -agonist actions o adrenaline reverseperipheral vasodilation

b. the -agonist actions o adrenaline suppresshistamine release

c. the adult dose o adrenaline is 0.5 mg IMd. the adrenaline dose or children 612 years is

0.3 mg IM

e. adrenaline IM should be administered at 15 minintervals until an improvement is seen.

Question8

With regard to resuscitation during pregnancy:

a. the gravid uterus obstructs inerior vena cavalblood ow rom approximately 40 weeks ogestation

b. manual displacement o the uterus to the lefshould be perormed beore attempting lateral tilt

c. a tracheal tube 0.51.0 mm smaller than usualmay be required because o laryngeal oedema

d. increased transthoracic impedance means thatexternal debrillation should be perormedusing the highest debrillator energy settingspossible

e. external chest compressions should be perormedover the upper one-third o the sternum.

Question9Paediatric cardiac arrest:

a. is most commonly rom hypoxia-related causesrather than primary cardiac pathology

b. presents with asystole in approximately 80% oout-o-hospital cases

c. in hospital, most commonly is caused byrespiratory pathology

d. has sudden inant death syndrome (SIDS) as itsleading cause

e. can be accurately diagnosed by healthcareproessionals using a pulse check.

Question10

Causes o attened waves on the ECG include:

a. pulmonary embolus

b. right bundle branch block

c. lef bundle branch block

d. pericarditis

e. digoxin effect.

Question 11

Risks to rescuers during CPR are:

a. induction o VF caused by accidental contact withthe patient during debrillation

b. HIV inection rom needlestick injury

c. inection with swine u through droplet spreadd. reduced by using a barrier device ormouth-to-mouth ventilation

e. a cause o poor rates o bystander CPR.

Question 12

When summoning help at a cardiac arrest:

a. a crash call number is the internal hospitaltelephone number dialled to summon theemergency team ollowing a cardiac arrest in

hospitalb. 222 is the standard number or assistance in UKhospitals

c. 911 is the officially designated emergencytelephone number in Canada and the USA

d. 112 is the European emergency number in useacross the European Union

e. police and re are usually accessed using differentnumbers to 911 or 112.

Question 13

Causes o low-amplitude ECG complexes include:

a. poor lead connection

b. lead electrodes placed too close together

c. obesity

d. lef or right ventricular hypertrophy

e. myocardial stunning ollowing debrillation.

Question 14

Central venous catheters (CVCs):

a. when coated with chlorhexidine may be a cause oanaphylaxis.

b. are less o an inection risk when placed in theinternal jugular vein than when placed in theemoral vein

c. require antibiotic prophylaxis to cover insertion

d. are at greatest risk o causing a pneumothoraxwhen placed in the internal jugular vein

e. inserted by subcutaneous tunnelling reduces theincidence o catheter inection.

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Paper3 Questions

Question15

Cardiac arrest in electrocution:

a. is usually associated with higher voltages in adultsthan children

b. may occur as a result o respiratory arrest

c. may be caused by coronary artery spasm induced

by the electric currentd. is more likely with handoot current pathways

than handhand pathways

e. is a greater risk with moist skin, which decreaseselectrical resistance.

Question16

Naloxone:

a. can be administered by IV, IM, subcutaneous(SC), IO or intranasal (IN) routes

b. has an initial adult dose o 400 g by any route

c. has a duration o action o approximately 60 min

d. in large opioid overdoses may require titration onaloxone to a total dose o 610 mg

e. administration in chronic opioid abusers maycause acute withdrawal symptoms and iscontraindicated.

Question17

Causes o cardiac arrest in asthma include:

a. hyperventilation causing respiratory alkalosis

b. severe bronchospasm and mucous pluggingleading to asphyxia

c. tension pneumothorax

d. arrhythmias triggered by hypoxia

e. raised intrathoracic pressure (caused byauto-PEEP: gas trapped in the airways exerting apositive pressure) impairing venous return andsubsequent cardiac output.

Question 18

Hypermagnesaemia may present as:

a. conusion

b. weakness

c. respiratory ailure

d. cardiac arrest

e. hyperglycaemia.

Question 19

Urine alkalinization:

a. requires a blood pH o 7.5 or higher

b. is a rst line treatment or moderate-to-severesalicylate poisoning in patients who do not needhaemodialysis

c. may cause hyperkalaemia

d. may be effective in some orms o herbicidepoisoning

e. is induced using an IV bicarbonate inusion.

Question 20

With regard to the management o electrical injury:

a. compartment syndrome, cardiac arrhythmias ormyoglobinuria is uncommon in patients exposedto less than 500 V (low voltage)

b. patients ound in VF may have no external signso burn

c. high-voltage alternating current (AC) ofen cause

rapid muscle contraction that throws the victimaway rom the source, minimizing duration oelectrical contact

d. taser barbs rom police weapons discharging intothe chest wall may induce VF

e. sudden death rom VF is more common withlow-voltage AC, whereas asystole is more ofenassociated with high-voltage AC or DC.

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Paper 3 Questions


a. What does this sign indicate?

b. Where is it likely to be ound?

c. What training is required or a member o thepublic to use an AED?

Question2

a. What device has been inserted into this patientstibia?

b. What causes pain on injection o uids or drugsthrough this device.

c. What is the effect o lignocaine given through thisdevice on the pain o subsequent inusions?

Question 3

a. What is this device?

b. What are the indications or cooling post-arrest?

c. What is the target core temperature and durationor a period o therapeutic hypothermia?

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Paper3 Questions

Question4

A patient receiving a blood transusion becomeswheezy and hypotensive during the rst 30 min o ablood transusion.

a. What are the two most likely causes?

b. What is the immediate treatment?

c. Why is this unlikely to be transusion-relatedacute lung injury (RALI)?

Question 5

a. What procedure is being perormed?

b. What are the landmarks and needle direction orthis procedure?

c. What indicates accidental intraventricular ratherthan pericardial needle placement?

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Paper 3 Questions


Te ollowing arterial blood gas sample, rom a normalpatient breathing room air, has been drawn rom anarterial line. What is the likely diagnosis?

Hb 10.1 g/dl (101 g/l)

pH 7.39

Pa2 15.7 kPa

Pa2 3.5 kPa

HCO3 22.3 mmol/l

Question2

A member o the resuscitation team receives a needle-

stick injury rom a patient during a resuscitationattempt. Te patients blood shows the ollowingserology:

hepatitis B e antigen titre:low hepatitis B s antigen titre:high.

a. Is the rescuer at risk o being inected by hepatitisB virus and why?

b. What treatment is required?

Question5

a. What rhythm does this ECG show?b. What is the treatment?

Question 3

A 64-year-old patient presents with chest pain in theemergency department. Te ECG is shown below inquestion 5. What are the immediate priorities in treat-ing this patient?

Question 4A routine blood sample shows the ollowing results:

Na+ 131 mmol/l

K+ 2.9 mmol/l

urea 5.4 mmol/l

creatinine 120 mmol/l

Te patient is taking the ollowing drugs:

atenolol 50 mg PO once daily (o.d.)

ramipril 5 mg PO o.d.

urosemide 80 mg PO o.d.

aspirin 75 mg PO o.d.

What is the most likely cause o the hypokalaemia andwhy?

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Paper3 Questions


What is the treatment or inadvertent intra-arterialinjection o a vasoconstrictor?

Question2

Draw a monophasic debrillation waveorm and labelthexandyaxes.

Question3

Discuss the immediate management o Paraquatpoisoning

Question 4

What are the causes o a metabolic acidosis that malead to a cardiac arrest?

Question 5

Why does the paediatric BLS algorithm commenc

with ventilations, but the adult BLS algorithcommence with chest compressions?

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Paper 3 Answers

MCQ answersAnswer 1

a. True.

b. True.

c. True. However, there is no scientic evidence

or the benet o calcium in hyperkalaemia.d. False. Although most diuretics increase K+

excretion, some such as spironolactone arepotassium sparing and may cause hyperkalaemia.

e. True.

Answer 2

a. True.

b. True.

c. True.

d. False.

e. False. Larger internal diameter tubes reduceairway resistance.

Answer 3

a. True.

b. True.

c. True. Water makes up approximately 70% obody weight in inants, 65% in children and 60%in adults.

d. False. Te physical ndings are present with nomore than 610% uid loss.

e. False. In a 2004Cochrane Database Review,investigators examined a series o randomizedtrials o colloids compared with crystalloids inpatients who required volume replacement. Terewas no evidence to avour one type o uid overthe other (Roberts Iet al. Cochrane Database SystRev, 2004;(4):CD000567).

Answer 4

a. True.

b. True.

c. True.d. True.

e. False. ends to cause a prolonged PR interval.

Answer 5

a. False. Sel-adhesive pads provide better contactwith the skin and may reduce the risk o arcingbetween electrodes.

b. True. Although latex and non-latex gloves tendto disintegrate at relatively low currents and areofen torn during resuscitation.

c. False. Sources o O2should be at least 1 m awayrom the patient.

d. False. Electrode paste may smear over the chest

wall and increase the risk o arcing betweenelectrodes. Its use is no longer recommended.

e. True.

Answer 6

a. False.

b. False. Laxatives and/or emetics have no role inthe acute management o drug overdose.

c. Talse.

d. False.

e. True.

Answer 7

a. True.

b. True.

c. True.

d. True.

e. False. Adrenaline is recommended to be givenevery 5 min until improvement is seen.

Answer 8a. False. Obstruction is thought to occur rom

approximately 20 weeks o gestation.

b. True. Manual uterine displacement can beperormed quickly and easily. Lateral tilt is moredifficult to perorm, usually requires a wedge andmay make external chest compression lesseffective.

c. True.

d. False. Tere is no signicant change intransthoracic impedance during pregnancy and

standard debrillation energy settings should beused.

e. False. Although previous guidelines havesuggested that a higher than usual hand positionis required, there is no evidence to support thisrecommendation and standard hand positioningis recommended.

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Paper 3 Answers

Answer 9

a. True. Paediatric cardiac arrest is uncommon;progressive respiratory ailure accounts or 60% oall paediatric arrests.

b. True. Asystole has been documented in 78.9%cases, ollowed by pulseless electrical activity

(13.5%) and VF (3.8%) (Kuisma Met al.Resuscitation, 1995;30:141150).

c. False. Cardiovascular causes o cardiac arrestare the most common (41% o all arrests), withhypovolaemia rom blood loss and hyperkalaemiarom transusion o stored blood the mostcommon cardiovascular causes. Amongrespiratory causes o arrest (27%), airwayobstruction rom laryngospasm is the mostcommon. Medication-related arrests account or18% o all arrests. Vascular injury incurred during

placement o central venous catheters is the mostcommon equipment-related cause o arrest(Bhananker SM,et al. Anesth Analg,2007;105:344350).

d. False. SIDS is the leading cause o paediatriccardiac arrest, ollowed by trauma, airway-relatedcardiac arrest and (near) drowning.

e. False. In the paediatric studies, healthcareproessionals are able to accurately detect a pulseby palpation only 80% o the time and mistakenlyperceive a pulse when it is actually absent in

approximately 20% o cases.

Answer 10

a. True.

b. True.

c. False.

d. True.

e. True.

Answer 11

a. False. Tis has never been documented in theliterature.

b. True.

c. True.

d. True.

e. True.

Answer 12

a. True.

b. False. Te standard hospital number is 2222.

c. True.

d. True.

e. False. 911 or 112 are used to access all

emergency services.

Answer 13

a. False.

b. True.

c. True.

d. False.

e. False.

Answer 14

a. True.

b. True.

c. False.

d. False. Te subclavian route is the highest riskor a pneumothorax as the tip o the needle maypuncture the pleura over the apex o the lung.

e. True. Subcutaneous tunnelling o short-termCVCs is thought to reduce the incidence ocatheter inection by increasing the distancebetween the venous entry site and skin emergenc

Answer 15

a. True. Adult electrocution tends to occur morecommonly at work, in association with higherindustrial voltages, whereas children tend to beelectrocuted with domestic voltages (110240 V)

b. True. Respiratory arrest may be caused byparalysis o the respiratory centre or therespiratory muscles themselves.

c. True. Coronary artery spasm may result inmyocardial ischaemia and subsequent cardiacarrest.

d. False. Handhand pathways result in morecurrent traversing the myocardium comparedwith handoot pathways, and are more likely toinduce cardiac arrest.

e. True.

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Paper 3 Answers

Answer 16

a. True.

b. False. Te initial doses o naloxone are 400 gIV/IO, 800 g IM, 800 g SC or 2 mg IN.

c. True. Respiratory depression can persist or45 h afer opioid overdose, so repeated naloxone

doses may be necessary.d. True.

e. False. Although naloxone may cause acutewithdrawal, its administration is notcontraindicated in chronic opioid abusers.

Answer 17

a. False. Asthma causes hypoventilation withprogressive respiratory and metabolicacidosis.

b. True.

c. True.d. True.

e. True.

Answer 18

a. True.

b. True.

c. True.

d. True.

e. True.

Answer 19a. False. Requires a urine pH o 7.5 or higher.

b. True.

c. False. Hypokalaemia is the commonestelectrolyte disturbance.

d. True. For the herbicides2,4-dichlorophenoxyacetic acid andmethylchlorophenoxypropionic acid (Mecoprop).

e. True.

Answer 20

a. True. Although, patients sustaining burns rom2001000 V may have signicant local tissuedestruction.

b. True. As relatively little current is required toinduce arrythmias. VF can occur at currents o

50100 mA.c. False. High-voltage DC ofen causes rapid

muscle contraction, which throws the victim awayrom the source and minimizes duration oelectrical contact. In contrast, AC o the samevoltage is considered to be more dangerousbecause it causes tetanic muscle contractions,which render the victim unable to release theirhand rom the electrical contact.

d. False. asers deliver high-voltage currentthrough a series o DC shocks. Tey deliver

50 000 V, with an average current o 2.1 mA.Studies in healthy volunteers have ailed todemonstrate arrhythmias or cardiac damage.

e. True.

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Paper 3 Answers


a. Tis is the International Liaison Committee onResuscitation universal sign to indicate thepresence o an AED, the localization o an AED in

a room, a container with an AED or public use orthe direction to ollow in order to reach the AED.Its purpose is to assist in the rapid identication oan AED in cases o cardiac arrest.

b. Public places with large public gatherings such asshopping centres, airports, railway stations,erries, passenger planes and gyms.

c. In the UK, there are no legal requirements orusers to have had any training in order to use anAED.

Answer 2

a. Intraosseous needle.

b. Pain on injection results rom an increasedpressure within the bone marrow. It is, thereore,related to the rate at which uids are injected; theslower the rate, the less the pain.

c. Although lignocaine has been advocated as aneffective way o reducing pain on injectionthrough an intraosseous needle, it is ineffective asit has no effect on stretch receptors in the bonemarrow.

Answer 3a. Alsius CoolGard/Zoll Termoguard Management

device. (An intravascular countercurrent coolingdevice controlled through this trolley.)

b. Unconscious adult patients with spontaneouscirculation afer out-o-hospital VF cardiac arrest.Cooling should be considered or other rhythmsor in-hospital cardiac arrest.

c. Patients should be cooled to 3234C or 12 to24 h when the initial rhythm was VF. Such coolingmay also be benecial or other rhythms or

in-hospital cardiac arrest.

Answer 4

a. Acute haemolytic transusion reaction or severeallergic reaction/anaphylaxis.

b. Stop the transusion, then: check the patients identity and recheck agains

details on blood unit and compatibility label

give O2and IV uids as appropriate consider hydrocortisone 200 mg IV and

chlorphenamine 1020 mg IV i hypotension is severe, give adrenaline

0.51 mg IM and repeat every 10 min untilimprovement occurs.

c. RALI is characterized by acute respiratorydistress and bilaterally symmetrical pulmonaryoedema with hypoxaemia developing within 2 to8 h afer a transusion.

Answer 5a. Needle pericardiocentesis.

b. Te needle is inserted below the xiphisternum andirected towards the tip o the lef scapula. Teneedle track is at a 45angle to the abdominalwall and 45away rom the midline, as shown.Where possible, needle insertion should beperormed under direct ultrasound guidance.

c. Indications: intracardiac blood orms a clot, whereas

pericardial aspirate does not usually orm a clo

the pericardial aspirate should usually have alower haemoglobin level than the patientsperipheral blood

widening o the QRS complex, S segmentchanges or multiple ventricular dysrrhythmiasindicate myocardial puncture

unlimited aspiration o blood without clinicalimprovement indicates ventricular aspiration.

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Paper 3 Answers


Tis sample has low haemoglobin, normal pH, an ele-vated Pa2 and a lowered Pa2. Tese changes aretypical o accidental dilution with heparin. Te pH

will not change because o the large buffering capac-ity o haemoglobin and plasma proteins. Te Pa2willrise, while Pa2decreases: changes occurring in pro-portion to the relative differences in partial pressureo these gases between blood and the heparin. Telowered haemoglobin is a result o haemodilution.

Answer 2

Hepatitis B e antigen is a viral protein present inhepatitis B-inected cells. It is present in patients withacute or chronic hepatitis B inections. It is a markero active viral disease and the degree o inectious-ness o the patient. itres lag behind those o hepati-tis B s antigen (surace antigen). Hepatitis B s anti-gen appears early in the disease, peaks with the onseto symptoms and disappears 6 months post-inection.Patients who are positive or hepatitis B s antigen areconsidered inectious.

a. Te serology suggests that the patient has anactive hepatitis B inection and is, thereore, atrisk o inecting recipients.

b. I the individual with the needlestick injury hashigh levels o hepatitis B surace antibody (usuallyresulting rom hepatitis B vaccination), they areconsidered immune to the hepatitis B virus. An

individual with low hepatitis B surace antibodylevels may require immediate hepatitis Bvaccination, and hepatitis B immunoglobulinshould be considered. Screening should also beundertaken or HIV.

Answer 3

High-ow O2, aspirin 300 mg PO (unless contraindi-cated), glyceryl trinitrate (GN) 400 g sublingually,analgesia (morphine boluses, 12 mg IV, titratedagainst pain), alerting the duty cardiologist to reviewthe patient with possible need or percutaneous coro-nary intervention (PCI). Consider 300 mg clopidogrelPO and unractionated heparin (or a derivative, e.g.Fondaparinux), according to local protocol.

Answer 4

Furosemide (a loop diuretic) prevents the reabsorp-tion o Na+and Clchloride ions at the loop o Henlein the kidney. As a result, more Na+ and chloridereach the distal tubule andcollecting duct. Here, Na+ isreabsorbed in exchange or K+; the increased Na+ loadresulting in increased K+ excretion. Hydrogen ionsare also exchanged or Na+, resulting in a metabolicalkalosis.

Answer 5

a. Complete heart block (third-degree heart block).

b. A trial o atropine may be considered, but it is

usually ineffective and a temporary or permanentpacemaker is the treatment o choice.

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Paper 3 Answers

Short answersAnswer 1 Stop drug administration and i possible aspirate

rom the cannula to reduce the amount o drugpresent in the tissues (leave the cannula in place or

saline irrigation i indicated). Elevate the limb to reduce swelling and promotevenous drainage.

Heat may promote vasodilatation and increasedrug reabsorption and distribution.

Also consider the ollowing: saline washout

liposuction

steroids

hyaluronidase

phentolamine

regional sympathetic block. (For a good review, see Lake C, Beecrof CL

Contin Educ Anaesth Crit Care Pain,2010;10:109113.)

Answer 2

Monophasic damped sinusoidal (MDS) waveorm:

0

40

30

20

10

10

20

0

1 2 3 4 5 6 7 8 9 10

Time (ms)

Current(amps)

11 12

Answer 3

Tere is no specic treatment or Paraquat poisoninTe aims are to relieve symptoms and treat complications as they arise: remove all contaminated clothing gently wash any contaminated skin with soap and

water or 15 min (hard scrubbing risks abrasions,which may increase absorption)

give activated charcoal i oral absorption hasoccurred

consider haemoperusion or sicker patients do not routinely give supplementary O2, which

worsens pulmonary brosis; only give O2tomaintain adequate O2saturations i necessary.

Answer 4

Causes o metabolic acidosis include: lactic acidosis ketoacidosis intoxication:

salicylates

ethanol

methanol

ormaldehyde

ethylene glycol

paraldehyde massive rhabdomyolysis

intoxication: ammonium chloride

acetazolamide (Diamox)

toluene

isopropyl alcohol

glue sniffing.

Answer 5

Unlike adults, paediatric cardiac arrest is usualcaused by hypoxaemia. Giving rescue breaths beorchest compressions ensures that oxygenated blood

circulated when the chest compressions commencCommencing with chest compressions would only ciculate deoxygenated blood.

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4PA

PER


ECG changes o hyperkalaemia include:

a. increased PR interval

b. prominent U waves

c. inverted waves

d. reduced R wave amplitude

e. increased QRS duration.

Question2

Causes o a prolonged PR interval include:

a. rst-degree heart block

b. second-degree heart block (Mobitz type I)

c. second-degree heart block (Mobitz type II)

d. third-degree heart block

e. atrial brillation.

Question3

When rewarming a patient suffering rom severe acci-dental hypothermia:

a. i the core temperature is less than 30C, IVresuscitation drugs should be given every610 min rather than the standard 35 min

b. warm IV uids (40C) are an effective method oinitiating rewarming

c. active internal rewarming techniques includegastric, peritoneal, pleural or bladder lavage withwarmed uids at 60C

d. in a hypothermic patient with cardiac arrest,extracorporeal rewarming is the preerred methodo active internal rewarming

e. during rewarming, patients will require largevolumes o IV uids as vasodilation causesexpansion o the intravascular space.

Question4

Te atrioventricular node o the heart:

a. stimulates the sinoatrial node during normalsinus rhythm

b. discharges through the bundle o His.

c. conducts more slowly the aster it isstimulated

d. has an intrinsic ring rate o 4060/min

e. is stimulated directly by the ventricular lead o apacemaker.

Question 5

Te impedance threshold valve (ID):

a. generates a negative intrathoracic pressure duringpassive chest recoil

b. decreases venous returnc. increases spontaneous cardiac output

d. is not recommended to be used with supraglotticairway devices

e. is indicated or cardiac arrest o all aetiology.

Question 6

External chest compressions:

a. should be perormed at a rate o 100120/min inadults

b. should be perormed at a rate o 100120/min inchildren

c. may be more effective when perormed on ahospital mattress

d. may induce arrhythmias when perormed on apatient in sinus rhythm

e. may be more effective when rate is maintainedusing a metronome.

Question 7

Myocardial blood ow during CPR:

a. is determined by coronary perusion pressure: thedifference in aortic and right atrial pressure

b. occurs during both the compression anddecompression phases o external chestcompression

c. may be reversed i venous pressures are high

d. remains constant during good-quality CPR

e. is low because coronary perusion pressures areonly 1020 mmHg (compared with a threshold o4060 mmHg to generate adequate ow).

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Paper4 Questions

Question8

Atrial brillation (AF):

a. is dened as paroxysmal i recurrent episodessel-terminate in ewer than 7 days

b. doubles the risk o stroke i untreated

c. may occur secondary to carbon monoxide

poisoningd. may respond to unsynchronized electrical

cardioversion

e. usually results rom electrical oci arising rommyocytes in and around the base o thepulmonary veins.

Question9

orsade de pointes:

a. is a polymorphic ventricular tachycardia

b. may progress to VFc. may be treated with synchronized cardioversion

d. is more common in malnourished individuals andchronic alcoholics

e. may be precipitated by some antiarrhythmic drugssuch as sotalol, procainamide and quinidine.

Question10

Monophasic waveorms:

a. are extended in duration in patients with high

transthoracic impedanceb. should be delivered at 360 J or all ventricular

arrhythmias

c. have been shown to be less effective than biphasicwaveorms in achieving survival to hospitaldischarge

d. may deliver up to 5000 V

e. cause more severe cutaneous burns than biphasicwaveorms.

Question11Bystander CPR:

a. increases survival to hospital discharge rates by50%

b. is undertaken in 6070% o out-o-hospitalcardiac arrests

c. is more commonly perormed when the rescuerdoes not know the victim

d. should be undertaken without themouth-to-mouth component i the bystander isunwilling to perorm this

e. should not be perormed in traumatic cardiacarrest.

Question 12

With regards to opioid overdose:

a. heroin is an opioid

b. diamorphine is the same drug as heroin

c. diamorphine is metabolized to morphine

d. morphine is more lipid soluble than diamorphinso it is absorbed more rapidly across mucousmembranes

e. methadone is a partial opioid agonist.

Question 13Te Lund University Cardiac Assist System (LUCASdevice:

a. is battery powered

b. uses active decompression

c. compresses at a rate o 100/min

d. allows debrillation during chest compression

e. can be used during percutaneous coronaryintervention.

Question 14Hypocalcaemia may be caused by:

a. metabolic acidosis

b. calcium channel blocker overdose

c. hypothermia

d. asphyxial cardiac arrest

e. rhabdomyolysis.

Question 15

Adrenaline:

a. is given afer the third cycle o CPR ornon-shockable rhythms

b. is contraindicated in asphyxial arrests

c. should be given without interruption o chestcompressions

d. precipitates i mixed with bicarbonate

e. is less effective with poor-quality chestcompressions.

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Paper 4 Questions

Question16

Absolute contraindications to thrombolysis include:

a. previous haemorrhagic stroke

b. previous major surgery within 6 months

c. aortic dissection

d. CNS neoplasm

e. gastrointestinal bleed within the past month.

Question17

With regard to drug calculations:

a. 1 ml 1:1000 adrenaline= 10 ml 1% adrenalineb. 10 ml 50% dextrose= 5 g dextrosec. 5 ml 0.5% bupivacaine= 2.5 mg bupivacained. 1000 ml 0.9% saline= 9 g salinee. 10 ml 1% lignocaine= 100 mg.

Question18

Mouth-to-mouth ventilation without a protective bar-rier has resulted in transmission o the ollowingpathogens to the rescuer:

a. hepatitis A

b. hepatitis B

c. hepatitis C

d. HIV

e. cytomegalovirus (CMV).

Question 19

Terapeutic hypothermia ollowing cardiac arrest:

a. is recommended or all patients ollowingresuscitation rom a VF arrest

b. must be commenced within 30 min o return ospontaneous circulation

c. may induce VF in patients i the core temperaturealls below 32C

d. is most accurately monitored using rectaltemperature

e. should be continued or 2448 h.

Question 20

echniques o inducing therapeutic hypothermiainclude:

a. tepid sponging

b. administration o iced (4C) 0.9% saline IV at10 ml/kg

c. ice packs

d. cooling mattress

e. bladder irrigation using iced saline (4C).

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Paper4 Questions


a. What is the relationship between ow rate andcannula diameter?

b. What volume o uid should be used to ushresuscitation drugs given by this device in anadult?

c. Where is the optimal site or gaining IV accessduring cardiac arrest?

Question2

Tis patient is undergoing emergency thoracotomy or

a stab wound to the right ventricle.

a. What procedure is being perormed in thispicture?

b. What is the optimal energy or an adult patient?

c. What additional procedure can the paddles beused or?

Question 3

a. What diseases may be transmitted by needlestickinjury?

b. What are the risk actors or needlestick injury?

c. What are the risk actors or disease transmission

Question 4

a. What is this?

b. What are the advantages compared with trachealintubation?

c. What are the disadvantages compared withtracheal intubation?

Question 5

a. What procedure has been perormed

b. What are the indications?

c. What are the co

adult and paediatric als - self-assessment in resuscitation ( deakin )

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