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Adult and Paediatric ALS
Self-assessment in Resuscitation
Charles D. Deakin MA MD FRCP FRCA FERC FFICM
Honorary 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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 cambrid ge universit y press
Cambridge, New York, Melbourne, Madrid, Cape Town,
Singapore, São Paulo, Delhi, Mexico City

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by

Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/
9781107616301

c Charles Deakin 2012



This publication is in copyright. Subject to statutory

exception and to the provisions of relevant collective
licensing agreements, no reproduction of any part may
take place without the written permission of 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 : self-assessment in resuscitation /
Charles D. Deakin.
p. ; cm.
Adult and paediatric advanced life support
Includes index.
ISBN 978-1-107-61630-1 (pbk.)
I. Title. II. Title: Adult and paediatric advanced life support.
[DNLM: 1. Resuscitation – Examination Questions. 2. Life
Support Care – Examination Questions. WA 18.2]
616.1 025076 – dc23 2011049190

ISBN 978-1-107-61630-1 Paperback

Cambridge University Press has no responsibility for the

persistence or accuracy of URLs for external or third-party
internet websites referred 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 information which is in accord with
accepted standards and practice at the time of publication.
Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals
involved. Nevertheless, the authors, editors and publishers can
make no warranties that the information contained herein is
totally free from error, not least because clinical standards are
constantly changing through research and regulation. The
authors, editors and publishers therefore disclaim all liability
for direct or consequential damages resulting from the use of
material contained in this book. Readers are strongly advised to
pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
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Contents
Dedication page vi
Preface vii
Abbreviations viii

Paper 1 1 Paper 7 82
Questions 1 Questions 82
Answers 7 Answers 90
Paper 2 13 Paper 8 97
Questions 13 Questions 97
Answers 19 Answers 105
Paper 3 26 Paper 9 112
Questions 26 Questions 112
Answers 33 Answers 118
Paper 4 39 Paper 10 126
Questions 39 Questions 126
Answers 46 Answers 133
Paper 5 52
Questions 52
Answers 60
Index 141
Paper 6 68
Questions 68
Answers 76

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 Dedication

To my daughter, Maddie, with apologies for her encounter with sevoflurane!

To my parents, Mary and David
To all my friends at the Resuscitation Council (UK)

vi

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Preface

Basic and advanced life support courses are under- resuscitation, each section comprising 20 multiple
taken by most NHS clinical staff and resuscitation is choice questions, five photographic questions, five
a mandatory area of knowledge. Those preparing for a diagnostic questions and five short answers. This book
resuscitation course, or those wishing to maintain and is intended for all those taking advanced life support
update their knowledge, may enjoy an alternative to courses and those taking higher medical examinations
course manuals and resuscitation texts in the form of that include a resuscitation component, so covers core
these short test papers in resuscitation. knowledge needed by all specialist trainees and con-
The book covers the entire basic and advanced sultants in acute medical specialities.
life support syllabus for both adult and paediatric

vii

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 Abbreviations

AC Alternating current IO Intraosseous

ACE Angiotensin-converting enzyme IV Intravenous
AED Automatic external defibrillator LMA Laryngeal mask airway
AICD Automatic implantable LUCAS Lund University Cardiac Assist System
cardioverter–defibrillator NICE National Institute for Clinical Excellence
AIDS Aquired immunodeficiency syndrome Paco2 Arterial partial pressure of carbon
ALS Advanced life support dioxide
BLS Basic life support PEA Pulseless electrical activity
CNS Central nervous system Pao2 Arterial partial pressure of oxygen
CPR Cardiopulmonary resuscitation PEEP Positive end-expiratory pressure
CVC Central venous catheter Pco2 Partial pressure carbon dioxide
CVP Central venous pressure Po Partial pressure oxygen
CXR Chest radiograph Sao Arterial haemoglobin oxygen saturation
DC Direct current SC Subcutaneous
ECG Electrocardiography Spo Arterial haemoglobin oxygen saturation
GTN Glyceryl trinitrate (nitroglycerin) measured non-invasively by pulse
HIV Human immunodeficiency virus oximetry
IABP Intra-aortic balloon pump VF Ventricular fibrillation
ICD Internal cardioverter device VT Ventricular tachycardia
IM Intramuscular TRALI Transfusion-related acute lung injury
IN Intranasal

viii

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 1
PAPER

Multiple choice questions Question 5

With regard to cardiac arrest:
Question 1
A 15:2 compression:ventilation ratio is recommended a. the commonest cause in adults is ischaemic heart
for resuscitation of: disease
a. adults, if the rescuer is trained b. home defibrillators for high-risk patients double
b. adults, if the rescuer is untrained survival rates
c. children less than 8 years old, if the rescuer is c. paediatric cardiac arrest is usually due to a final
untrained common pathway causing hypoxaemia
d. children less than 8 years old, if the rescuer is d. bystander cardiopulmonary resuscitation (CPR)
trained doubles the survival rate
e. adult drowning victims. e. sudden cardiac death accounts for about 15% of
all deaths in Western countries.
Question 2
Which of the following are correct doses for paediatric Question 6
cardiac arrest? With regard to amiodarone:
a. atropine 10 µg/kg a. hypotension results from histamine release
b. adrenaline (epinephrine) 10 µg/kg b. should be administered if the patient remains in
c. amiodarone 10 µg/kg VF after the second shock
d. defibrillation (monophasic defibrillator) 4 J/kg c. the initial adult dose is 300 mg IV
e. defibrillation (biphasic defibrillator) 2 J/kg. d. may cause optic neuritis with prolonged use
e. precipitates with adrenaline.
Question 3
Which of the following statements are correct? Question 7
a. in an adult male (70–80 kg), the endotracheal tube In diagnosing heat stroke in a pyrexial patient, the fol-
should be 26 cm length at the lips lowing differential diagnoses should be considered:
b. a size 4 laryngeal mask airway (LMA) is suitable
a. neuroleptic malignant syndrome
for most adults
b. phaeochromocytoma
c. a size 9.0 mm nasopharyngeal airway is suitable
c. hypothyroidism
for most adults
d. anaphylaxis
d. the size of an endotracheal tube, e.g. 7.0 mm,
refers to its external diameter e. CNS infection.
e. a size 2 or 3 oropharyngeal airway is generally
suitable for an 8-year-old patient. Question 8
Noradrenaline (norepinephrine):
Question 4 a. is principally an α-agonist
Which of the following drugs cause pupillary dilation? b. has some β-agonist action
a. atropine c. may cause a reflex bradycardia
b. adrenaline d. is synthesized primarily in the adrenal
c. amiodarone cortex
d. lignocaine e. is broken down into various metabolites that 1
e. sodium bicarbonate. include adrenaline.

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 Paper 1 – Questions

Question 9 Question 14
ECG changes of hypothermia include: With regard to capnography:
a. shortened PR interval a. normal range is approximately 4.5–6.0 kPa
b. flattened T wave b. absence of endotracheal end-tidal CO2 during a
c. J wave cardiac arrest is diagnostic of oesophageal
d. movement artefact from shivering intubation
e. VF. c. end-tidal CO2 that does not rise above 1.4 kPa
(10 mmHg) during a resuscitation attempt is
Question 10 associated with a poor prognosis
Suitable positions for self-adhesive pad placement for d. cooling increases end-tidal CO2
defibrillation of VF include: e. Paco2 is equal to end-tidal CO2 .
a. biaxillary
b. anterior (right sternal edge) and left axilla Question 15
c. anterior (left sternal edge) and left axilla With regard to severe local anaesthetic toxicity associ-
d. anterior (left sternal edge) and posterior ated with cardiovascular collapse:
e. anterior (right sternal edge) and posterior. a. lignocaine is the commonest local anaesthetic
implicated in this condition
Question 11 b. may benefit from administration of Intralipid
The following drugs cause hypotension through 20%
histamine release: c. propofol (an intralipid emulsion) is a suitable
a. atracurium alternative to Intralipid
b. fentanyl d. the maximum recommended safe dose of
c. morphine bupivacaine is 2 mg/kg IV
d. amitriptyline e. survival is uncommon.
e. midazolam.
Question 16
Question 12
How should chest compressions be performed on an
With regard to O2 : infant?
a. the concentration in exhaled breath is 18% a. with the heel of one hand and the other hand on
b. 30% O2 doubles the rate of combustion top of the first
c. in most tissues of the body, the response to b. with the heel of one hand only
hypoxia is vasodilatation c. with 4 fingers of one hand
d. in the lungs, the response to hypoxia is d. with 2 fingers of one hand
vasoconstriction e. with the thumb of one hand.
e. hyperventilation increases O2 uptake.

Question 13 Question 17
Pulse oximetry: If an AED is available, but adult self-adhesive pads are
available, how should you manage a 5-year-old child in
a. the presence of carbon monoxide in the blood
cardiac arrest with a shockable rhythm?
(COHb) results in an overestimation of oxygen
saturation of haemoglobin (Sao2 ) a. AED use is unnecessary as shockable rhythms are
rare in this age group
b. the presence of methaemoglobin in the blood
(MetHb) results in an overestimation of Sao2 b. use the AED, but apply only one of the pads
c. fetal Hb results in an overestimation of Sao2 c. use the AED with adult pads
d. a poor pulse oximetry trace may result in an d. perform CPR, but do not use the AED
underestimation of Sao2 e. use the AED for a single shock only.
2
e. diathermy may interfere with waveform detection.

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 Paper 1 – Questions

Question 18 Question 20
With regard to drug doses: With regard to haemorrhage:
a. 1 ml 1:1000 adrenaline = 1 mg adrenaline a. circulating blood volume in an adult is
b. 10 ml 0.25% bupivacaine = 25 mg bupivacaine approximately 4% of body mass
c. 100 µg (mcg) adrenaline = 1 ml 1:10 000 b. patients who have an impaired level of
adrenaline consciousness due to blood loss have generally
d. 1 mg IV adrenaline has the same efficacy as lost at least 40% of their circulating blood volume
∼2 mg IO (intraosseous) adrenaline c. β-blockers may mask the early signs of
e. 10 ml 50% dextrose = 100 ml 5% dextrose. hypovolaemic shock
d. the management of catastrophic haemorrhage
Question 19 should take priority over airway management
A pacemaker programmed to: e. venous bleeding is generally less serious than
a. AOO paces and senses the atrium only arterial bleeding.
b. VVI paces and senses the atrium only
c. DDD paces and senses both the atrium and
ventricle
d. DDDR has the capability to defibrillate
e. DDD may be inhibited by diathermy current.

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 Paper 1 – Questions

Photograph questions Question 3

Question 1

a. What is this?
b. How is this device powered?
c. What hazards may be associated with its use
during defibrillation?

Question 4

a. What is this?
b. What is the function of the reservoir?
c. What O2 flow rate delivers 100% O2 to the patient?
Question 2
a. What is the
percentage of O2 in
the atmosphere?
b. What volume of gas
a. What class of medication is this solution?
is discharged from
b. What ECG changes does it cause when taken as an
this CD size
overdose?
cylinder?
c. How is this overdose treated?
c. Why does the
cylinder become Question 5
cold during use?
This device can be placed over implanted pacemakers
or cardioverter–defibrillators.

a. What is it?
b. What is its effect on an implantable pacemaker?
4 c. What is its effect on an automated implantable
cardioverter–defibrillator (AICD)?

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 Paper 1 – Questions

Diagnostic questions Question 4

An arterial blood gas sample (on air) is taken from an
Question 1
unresponsive patient, with the following results:

pH 7.21
Pao2 11.0 kPa
1
Paco2 8.8 kPa
2 HCO3 − 15 mmol/l

a. What metabolic derangement is seen in this blood

gas?
3 b. Name three likely causes.

Question 5

a. What is this image?

b. Name structures 1–3.

Question 2 a. What rhythm does this ECG show?

b. What non-pharmacological methods may be used
This is a paced ECG. What mode is the pacemaker set
to terminate the arrhythmia?
to?
c. What pharmacological methods may be used to
terminate the arrhythmia?

Question 3
The following results have been obtained:

Na+ 135 mmol/l

+
K 7.2 mmol/l
urea 33.4 mmol/l
creatinine 488 mmol/l
glucose 18.9 mmol/l

a. What is the most immediate priority in this

patient?
b. Which organ system is failing?
5
c. What is the likely cause of this failure?

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 Paper 1 – Questions

Short answer questions Question 4

What are the risks of performing a needle pericardio-
Question 1
centesis? How may these risks be minimized?
Draw the algorithm for paediatric ALS.
Question 5
Question 2
Draw a cross-section of the heart to show the right
Explain why dextrose-containing solutions are contr- atrium and ventricle, left atrium and ventricle and
aindicated as resuscitation fluids. pulmonary artery and aorta. Label each with normal
values for O2 saturation (on air).
Question 3
How quickly does manual external chest compression
fatigue? How often should rescuers change?

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 Paper 1 – Answers

MCQ answers d. True.

e. False. 30%.
Answer 1
a. False. 30:2 is recommended in adults, Answer 6
irrespective of whether the rescuer is trained or a. False. Hypotension is thought to be caused by
untrained. the solvent in which amiodarone is dissolved.
b. False. b. False. Amiodarone is indicated immediately
c. False. 30:2 is recommended in children if the after the third shock.
rescuer is untrained. c. True.
d. False. Trained rescuers should use 15:2. d. True.
e. True. e. Frue.
Answer 2 Answer 7
a. False. Atropine is not recommended for a. True.
routine use. When it is given, the correct dose is
b. True.
20 µg/kg.
c. False. Hyperthyroidism.
b. True. 100 µg/kg should be considered in
d. False.
children with cardiac arrest associated with severe
e. True.
vasodilation, e.g. sepsis.
c. False. Amiodarone 5 mg/kg for both the first
Answer 8
and, if given, the second dose.
a. True.
d. True.
b. True.
e. False. The recommended energy level for
biphasic defibrillators is also 4 J/kg for all shocks. c. True.
d. False. Is synthesized primarily in the adrenal
Answer 3 medulla.
a. False. For a 70–80 kg adult, the endotracheal e. True.
tube should be 22–24 cm at the lips.
Answer 9
b. True.
c. False. A size 6.0–7.0 mm airway is adequate for a. False. Prolonged PR interval.
most adults. b. True.
d. False. The size refers to the internal diameter. c. True.
e. True. d. True.
e. True. Asystole and VF may begin spontaneously
Answer 4 at core temperatures below 25–28◦ C.
a. True.
b. True. Answer 10
c. False. a. True.
d. False. b. True.
e. False. c. False.
d. True.
Answer 5 e. True.
a. True. Among adults, ischaemic heart disease is
the predominant cause of arrest, with 30% of Answer 11
people at autopsy showing signs of recent a. True.
myocardial infarction. b. False.
b. False. Home defibrillators have not been shown c. True.
to improve outcome from cardiac arrest. d. False. 7
c. True. e. False.

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 Paper 1 – Answers

Answer 12 c. False. Propofol is dissolved in Intralipid, but at

a. False. 15%. inadequate dose to be in the therapeutic range.
b. False. 24% O2 doubles the rate of combustion. d. True.
30% increases the rate 10-fold. e. True. Bupivacaine is thought to bind strongly to
c. True. myocardial tissue and its effects are difficult to
d. True. This is known as hypoxic pulmonary reverse.
vasoconstriction. Answer 16
e. False. a. False.
b. False.
Answer 13 c. False.
a. True. At 660 nm (used by the pulse oximeter), d. True.
COHb absorbs light in a similar manner to HbO2 . e. False.
b. False. At 660 nm, MetHb has similar absorption
to reduced Hb. Sao2 decreases with increasing Answer 17
MetHb levels, towards a Sao2 of 85%. Below 85%, a. False.
the presence of MetHb will, therefore, result in an b. False.
increase in Sao2 towards 85%. c. True.
c. False. Fetal Hb has no significant effect on pulse d. False.
oximetry values. e. False.
d. True.
Answer 18
e. True.
a. True.
Answer 14 b. True. A 1% solution contains 10 mg/ml.
a. True. c. True.
b. False. Also occurs with no cardiac output. d. False. IV and IO routes have the same
c. False. A threshold value of 10 mmHg (1.4 kPa) bioavailability and, therefore, efficacy.
as a prognosticator for irreversible death in e. True.
out-of-hospital cardiac arrest has been
demonstrated (Levine RL et al. N Engl J Med,
Answer 19
1995;337:301–306; Cantineau JP et al. Crit Care a. False. AOO paces the atrium only and is not
Med, 1996;24:791–796). inhibited by atrial or ventricular activity.
d. False. Cooling reduces metabolic rate and b. False. VVI paces the ventricle and is inhibited
cardiac output, subsequently reducing end-tidal by ventricular activity.
CO2 . c. True.
e. False. When ventilation and perfusion are d. False. ‘R’ means that the device is rate
equal, Paco2 is equal to end-tidal CO2 . In responsive and can vary its rate.
practice, however, there is always a degree of e. True. Electrical activity from diathermy devices
shunting within the lungs, resulting in can be sensed by pacemakers, which then
less-efficient gas transfer. In conditions such as mistakenly inhibit output.
cardiac arrest, chronic obstructive pulmonary Answer 20
disease or adult respiratory distress syndrome, an
a. False. 7%.
even greater ventilation/perfusion abnormality
occurs and high CO2 gradients result. b. True.
c. True. Tachycardia may be masked by
Answer 15 β-blockers.
a. False. Bupivacaine. d. True. The traditional ABC approach has been
b. True. Some animal studies and human case superseded by cABC, where the initial priority is
reports suggest that Intralipid may be of benefit in to stop any torrential haemorrhage (e.g. from limb
8 these patients (Soar J et al. Resuscitation, amputation) prior to moving on to ABC.
2010;81:1400–1433). e. False.
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