Resuscitation and Cardiovascular Emergencies
What the board tests
This domain checks whether you can run a cardiac arrest to a decision, read a rhythm strip under time pressure, and commit to reperfusion and rate/rhythm control in ACS, dissection, bradyarrhythmia and tachyarrhythmia.
Cardiac arrest
- High-quality CPR: rate 100-120/min, depth 5-6 cm, full recoil, pauses under 10 s, chest compression fraction above 80%, compressor change every 2 min.
- VF/pVT: defibrillate immediately (biphasic 150-200 J or manufacturer setting; monophasic 360 J), then 2 min CPR. Adrenaline 1 mg IV/IO every 3-5 min after the second or third shock; amiodarone 300 mg after the third shock, then 150 mg.
- Asystole/PEA: adrenaline as early as possible, no shock, actively hunt the 5H and 5T causes.
- Confirm tube placement with continuous waveform capnography; a sudden ETCO2 rise suggests ROSC.
- Post-ROSC: SpO2 94-98%, PaCO2 35-45 mmHg, MAP at least 65 mmHg, 12-lead ECG, targeted temperature management 32-36 C in the comatose, urgent angiography if STEMI.
ACS and arrhythmia
STEMI means reperfusion: primary PCI within 90 min of first medical contact, or fibrinolysis within 30 min when PCI cannot be achieved in time and symptoms are under 12 h. Give aspirin 300 mg chewed, a P2Y12 inhibitor and anticoagulant; oxygen only if SpO2 is under 90%. Unstable tachyarrhythmia gets synchronized cardioversion; stable narrow-complex SVT gets vagal manoeuvres then adenosine 6 mg, then 12 mg. Bradycardia with adverse features gets atropine 1 mg (maximum 3 mg), then transcutaneous pacing or an adrenaline infusion. In aortic dissection, beta-block to a heart rate near 60 before adding a vasodilator, and never thrombolyse.
Worked example
A 58-year-old smoker has 90 minutes of crushing chest pain with ST elevation in II, III and aVF; BP 130/80. The nearest PCI centre is 3 hours away and local fibrinolysis can start in 25 minutes. There are no bleeding contraindications. Give aspirin, a P2Y12 inhibitor and heparin, then fibrinolysis with door-to-needle under 30 min and transfer for rescue or routine angiography. Reasoning: symptom onset under 12 h, PCI not achievable within 120 min, no contraindication.
Traps
Shocking asystole; pausing compressions to intubate; amiodarone before the third shock; routine 100% oxygen after ROSC; adenosine for an irregular wide-complex rhythm (think pre-excited AF); thrombolysis in suspected dissection.