Immediate Life Support Revision Lecture Causes and

Immediate Life Support Revision Lecture

Causes and Prevention of Cardiac Arrest

Chain of survival Early recognition prevents: • Cardiac arrests and deaths • Admissions to ICU • Inappropriate resuscitation attempts

Early recognition of the deteriorating patient • Most arrests are predictable • Hypoxia and hypotension are common antecedents • Delays in referral to higher levels of care

Recognition of the deteriorating patient Example escalation protocol based on Scottish early warning score (SEWS)

Recognition of the deteriorating patient • Several alternative systems to cardiac arrest team • e. g. Medical emergency team (MET) • Track changes in physiology • e. g. Early warning scores • Trigger a response if abnormal values: • Call senior nurse • Call doctor • Call resuscitation team

The ABCDE approach to the deteriorating patient Airway Breathing Circulation Disability Exposure

ABCDE approach Underlying principles: • Complete initial assessment • Treat life-threatening problems • Reassessment • Assess effects of treatment/interventions • Call for help early

ABCDE approach • Personal safety • Patient responsiveness • First impression • Vital signs • Respiratory rate, Sp. O 2, pulse, BP, GCS, temperature

ABCDE approach Airway Causes of airway obstruction: • CNS depression • Blood • Vomit • Foreign body • Trauma • Infection • Inflammation • Laryngospasm • Bronchospasm

ABCDE approach Airway Recognition of airway obstruction: • Talking • Difficulty breathing, distressed, choking • Shortness of breath • Noisy breathing • Stridor, wheeze, gurgling • See-saw respiratory pattern, accessory muscles

ABCDE approach Airway Treatment of airway obstruction: • Airway opening • Head tilt, chin lift, jaw thrust • Simple adjuncts • Advanced techniques • e. g. LMA, tracheal tube • Oxygen

ABCDE approach Breathing Recognition of breathing problems: • Look • Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level • Listen • Noisy breathing, breath sounds • Feel • Expansion, percussion, tracheal position

ABCDE approach Breathing Treatment of breathing problems: • Airway • Oxygen + • Treat underlying cause • e. g. antibiotics for pneumonia • Support breathing if inadequate • e. g. ventilate with bag-mask

ABCDE approach Circulation Causes of circulation problems: • Primary • • Acute coronary syndromes Arrhythmias Hypertensive heart disease Valve disease Drugs Inherited cardiac diseases Electrolyte/acid base abnormalities • Secondary • • • Asphyxia Hypoxaemia Blood loss Hypothermia Septic shock

ABCDE approach Circulation Recognition of circulation problems: • Look at the patient • Pulse - tachycardia, bradycardia • Peripheral perfusion - capillary refill time • Blood pressure • Organ perfusion • Chest pain, mental state, urine output • Bleeding, fluid losses

ABCDE approach Circulation Treatment of circulation problems: • • • Airway, Breathing Oxygen IV/IO access, take bloods Treat cause Fluid challenge +

ABCDE approach Circulation Acute Coronary Syndromes • Unstable angina or myocardial infarction • Treatment • • Aspirin 300 mg orally (crushed/chewed) Nitroglycerine (GTN spray or tablet) Oxygen guided by pulse oximetry Morphine (or diamorphine) • Consider reperfusion therapy (PCI, thrombolysis)

ABCDE approach Disability Recognition • AVPU or GCS • Pupils Treatment • ABC • Treat underlying cause • Blood glucose • If < 4 mmol l-1 give glucose • Consider lateral position • Check drug chart

ABCDE approach Exposure • Remove clothes to enable examination • e. g. injuries, bleeding, rashes • Avoid heat loss • Maintain dignity

Any questions?

Summary • Early recognition of the deteriorating patient may prevent cardiac arrest • Most patients have warning symptoms and signs before cardiac arrest • Airway, breathing or circulation problems can cause cardiac arrest • ABCDE approach to recognise and treat patients at risk of cardiac arrest

Advanced Life Support Algorithm

ALS algorithm • ILS providers should use those skills in which they are proficient • If using an AED – switch on and follow the prompts • Ensure high quality chest compressions • Ensure expert help is coming

Adult ALS Algorithm

Unresponsive? Not breathing or only occasional gasps To confirm cardiac arrest… • Patient response • Open airway • Check for normal breathing • Caution agonal breathing • Check circulation • Check for signs of life

Unresponsive? Cardiac arrest confirmed Not breathing or only occasional gasps Call resuscitation team 2222

Unresponsive? Cardiac arrest confirmed Not breathing or only occasional gasps Call resuscitation team CPR 30: 2 Attach defibrillator / monitor Minimise interruptions

Chest compression • 30: 2 • Compressions • Centre of chest • 5 -6 cm depth • 2 per second (100 -120 min-1) • Maintain high quality • • compressions with minimal interruption Continuous compressions once airway secured Switch compression provider every 2 min to avoid fatigue

Shockable and Non-Shockable START PAUSE Shockable (VF / Pulseless VT) CPR Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Shockable (VF) Shockable • Bizarre irregular waveform • No recognisable QRS • complexes Random frequency and amplitude • Uncoordinated electrical • • activity Coarse/fine Exclude artefact • Movement • Electrical interference

Shockable (VT) Shockable • Monomorphic VT • Broad complex rhythm • Rapid rate • Constant QRS morphology • Polymorphic VT • Torsade de pointes

Automated External Defibrillation • If not confident in rhythm recognition use an AED • Start CPR whilst awaiting AED to arrive • Switch on and follow AED prompts

AED algorithm

Manual defibrillation • Plan all pauses in chest compressions • Brief pause in compressions to check rhythm • Do chest compressions when charging • Ensure no-one touches patient during shock delivery • Very brief pause in chest compressions for shock delivery • Resume compressions immediately after the shock

Shockable/ VT) (VF Shockable RESTART CPR Assess rhythm

Shockable (VT) (VF / VT) Shockable CHARGE DEFIBRILLATOR Assess rhythm

Shockable/ VT) (VF Shockable DELIVER SHOCK Assess rhythm

Shockable/ VT) (VF Shockable IMMEDIATELY RESTART CPR Assess rhythm

Shockable (VF / VT) IMMEDIATELY RESTART CPR Shockable (VF / VT) Assess rhythm MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Manual defibrillation energies • Vary with manufacturer • Check local equipment • If unsure, deliver highest available energy • DO NOT DELAY SHOCK • Energy levels for manual defibrillators on this course

If VF / VT persists Deliver 2 nd shock CPR for 2 min Deliver 3 rd shock CPR for 2 min During CPR Adrenaline 1 mg IV Amiodarone 300 mg IV

Non-Shockable (VF / Pulseless VT) Assess rhythm Non-Shockable (PEA / Asystole) MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Non-shockable (Asystole) Non-Shockable • Absent ventricular (QRS) activity • Atrial activity (P waves) may persist • Rarely a straight line trace • Adrenaline 1 mg IV then every 3 -5 min

Non-shockable (Asystole) (PEA) Non-Shockable • Clinical features of cardiac arrest • ECG normally associated with an output • Adrenaline 1 mg IV then every 3 -5 min

During CPR · · · · Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Vascular access (intravenous, intraosseous) Give adrenaline every 3 -5 min Correct reversible causes

Reversible causes

Airway and ventilation • Secure airway: • Supraglottic airway device e. g. LMA, i-gel • Tracheal tube • Do not attempt intubation unless trained and competent to do so • Once airway secured, if possible, do not interrupt chest compressions for ventilation • Avoid hyperventilation • Capnography

Immediate post-cardiac arrest treatment

Resuscitation team • Roles planned in advance • Identify team leader • Importance of non-technical skills • • Task management Team working Situational awareness Decision making • Structured communication • SBAR or RSVP

Any questions?

Summary • Importance of high quality chest compressions • Minimise interruptions in chest compressions • Shockable rhythms are VF/pulseless VT • Non-shockable rhythms are PEA/Asystole • Use an AED if not sure about rhythms • Correct reversible causes of cardiac arrest • Role of resuscitation team

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