Advanced Cardiac Life Support

1.

To find the correct position for hand placement when delivering chest compressions, one should:
- A.
  
  Place the heel of the hand over the centre of the chest
- B.
  
  Place the heel of the hand 2 finger breaths above the xiphisternum
- C.
  
  Place the heel of the hand over the xiphisternum
- D.
  
  Place the heel of the hand 1 finger breath above the xiphisternum
- E.
  
  Place the heel of the hand over the nipple line
Correct Answer
A. Place the heel of the hand over the centre of the chest

Explanation
See guideline 6.The lower half of the sternum is deemed to correlate with the centre of the chest.The depth of compression should be 4-5cm

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2.

The rate of chest compressions per minute should be:
- A.
  
  60
- B.
  
  70
- C.
  
  80
- D.
  
  90
- E.
  
  100
Correct Answer
E. 100

Explanation
See guideline 6, page 3.With 2 rescuers present, the person doing compressions should be changed over every 2 minutes with minimal delay. 2 minutes equates to about 5 cycles of 30:2 compression:ventilation.

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3.

For an unwitnessed, in hospital VF/VT cardiac arrest, the sequence of actions is:
- A.
  
  3 'stacked' shock followed by a rhythm check
- B.
  
  3 'stacked' shocks followed by 2minutes of CPR (chest compressions/ventilation)
- C.
  
  1 shock followed by rhythm check
- D.
  
  1 shock followed by 2 minutes of CPR (chest compressions/ventilation)
- E.
  
  Pre cordial thump followed by 3 'stacked' shocks
Correct Answer
D. 1 shock followed by 2 minutes of CPR (chest compressions/ventilation)

Explanation
See guideline 11.2 of the Australian Guidelines and page 44 of the UK Guidelines.There are no studies comparing 3 stacked shocks with a single shock, but some experimental studies show that interruptions in CPR are associated with reduced survival, and reduce the chances of converting VF to another rhythm.Combined wit the improved first shock efficacy (over 90%)of biphasic defibrillators for VF/VT, a single shock is recommended.Failure to terminate VF/VT indicates a need to improve myocardial oxygenation by CPR.For a monitored witnessed VF/VT arrest where a defibrillator is not immediately available, a pre cordial thump may be given. Most likely to be successful with converting VT to sinus rhythm within the first 10 seconds.

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4.

When using an unfamiliar biphasic defibrillator, the initial energy level selected is:
- A.
  
  360J
- B.
  
  260J
- C.
  
  200J
- D.
  
  150J
- E.
  
  100J
Correct Answer
C. 200J

Explanation
See Guideline 11.5 of the Australian Guidelines, and page 45 of the UK Guidelines.
For rectilinear biphasic waveforms the energy should be greater than 120J, and for truncated exponenetial waveforms it should be greater than 150J.Theefore, it isrecommended that the initial shock should be at least 150J, with 200J being within the effective range of first and subsequent biphasic shock energy levels.Every biphasic manual defibrillator available can deliver 200J.If there is clinical data to support the use of a different energy level for a specific device, then this may be used. The Phillips HeartStart XL has been shown to be effective at 150J.There is no evidence to suggest a clear benefit for either a fixed or escalating energy level.

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5.

When using a monophasic deifbrillator, the initial energy level should be:
- A.
  
  150J
- B.
  
  200J
- C.
  
  260J
- D.
  
  300J
- E.
  
  360J
Correct Answer
E. 360J

Explanation
See Guideline 11.5 of the Australian Guidelines, and page 45 of the UK Guidelines.
Due to the lower efficacy of monopahsic defibrillators for terminating VF/VT (54-63% for 200J), and the use of a single shock strategy, the first and subsequent shocks should be 360J. This contrasts with the previously recommended 200, 200, 360J stacked shock recommendations.

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6.

If the monitored rhythm is believed to be fine VF, the recommended action should be:
- A.
  
  Defibrillate
- B.
  
  Commence CPR
- C.
  
  Administer Amiodarone
- D.
  
  Administer Adrenaline
- E.
  
  Change gain settings
Correct Answer
B. Commence CPR

Explanation
See page 46 of the UK Guidelines.
Fine VF that cannot be differentiated from asystole is unlikely to be converted successfully to a perfusing rhythm, and good quality CPR may improve the frequency and amplitude of VF (as the decrease in high energy phosphate stores in the myocardium can be slowed or reversed by CPR)and improve the success rate for defibrillation.Delivering repeated shocks for what is thought to be fine VF will damage the myocardium further.

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7.

In the protocol for VF/VT, adrenaline is administered:
- A.
  
  After every shock
- B.
  
  Before every shock
- C.
  
  Every 1-2 minutes
- D.
  
  Every 3-5 minutes
- E.
  
  After the second shock and with alternate shocks
Correct Answer(s)
D. Every 3-5 minutes
E. After the second shock and with alternate shocks

Explanation
See Guideline 11.6 page 3 of the Australian Guidelines and page 46 of the UK Guidelines.
The immediate resumption of CPR following a defibrillation attempt without pulse or rhythm check make it difficult to recommend when Adrenalineshould be given.Every 3-5 minutes equates to just before alternate shocks. The subsequent CPR will circulate the drug.The timing is the same for Asystole/PEA algorithm.
The initial sequence of actions would be for 2 minutes of CPR following attempted defibrillation of VF/VT, followed by rhythm check and further shock, followed by CPR, at which point adrenaline is given during the rhythm check.

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8.

In the protocol for VF/VT, Amiodarone is given:
- A.
  
  A bolus of 300mg, followed by 150mg and an infusion of 15mg/kg over 24 hours
- B.
  
  After the 3rd shock, during rhythm check prior to 4th shock
- C.
  
  After Lignocaine 1mg/kg
- D.
  
  Via the endotraceal tube if intravenous access is not available
- E.
  
  Via the intraosseous route if intravenous access is not available
Correct Answer(s)
A. A bolus of 300mg, followed by 150mg and an infusion of 15mg/kg over 24 hours
B. After the 3rd shock, during rhythm check prior to 4th shock
E. Via the intraosseous route if intravenous access is not available

Explanation
See Guideline 11.6 of the Australian Guidelines and page 47 of the UK guidelines.
There is no evidence that giving anti arrhythmic drugs routinely increases survival to discharge.On the basis of expert opinion, it is recommended to administer amiodarone after the 3rd shock in persistent VF/VT.
The only drugs recommended for endotracheal administration are Adrenaline, Lignocaine and Atropine.

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9.

During the resuscitation with an endotracheal tube in place,
- A.
  
  There is a pause for ventilation during CPR
- B.
  
  Oxygen should be turned off during defibrillation
- C.
  
  The ventilator or bag-valve device should be disconnected and moved 1m from the patient
- D.
  
  Nasal cannulae or oxygen mask should be moved 1m away from the patient during defibrillation attempts
- E.
  
  The use of self adhesive pads may minimise the risk of sparks compared to paddles
Correct Answer(s)
D. Nasal cannulae or oxygen mask should be moved 1m away from the patient during defibrillation attempts
E. The use of self adhesive pads may minimise the risk of sparks compared to paddles

Explanation
See Guideline 11.5 of the Australian Guidelines and page 50 of the UK Guidelines.
In a mannikin study, there was no increase in oxygen concentration around the mannikin when the ventilation device was left attached to the ET tube.It is recommended that ICU type ventilators that deliver large oxygen flows are not disconnected or are turned off if being disconnected.

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Advanced Cardiac Life Support

To find the correct position for hand placement when delivering chest compressions, one should:

The rate of chest compressions per minute should be:

For an unwitnessed, in hospital VF/VT cardiac arrest, the sequence of actions is:

When using an unfamiliar biphasic defibrillator, the initial energy level selected is:

When using a monophasic deifbrillator, the initial energy level should be:

If the monitored rhythm is believed to be fine VF, the recommended action should be:

In the protocol for VF/VT, adrenaline is administered:

In the protocol for VF/VT, Amiodarone is given:

During the resuscitation with an endotracheal tube in place,