Immediate Life Support

Revision Lecture

Causes and Prevention of Cardiac Arrest

Early recognition prevents:

• Cardiac arrests and deaths• Admissions to ICU• Inappropriate resuscitation attempts

Chain of survival

Early recognition ofthe 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, SpO2, pulse, BP, GCS, temperature

ABCDE approachAirway

Causes of airway obstruction:

• CNS depression• Blood • Vomit • Foreign body • Trauma

• Infection • Inflammation • Laryngospasm • Bronchospasm

ABCDE approachAirway

Recognition of airway obstruction:

• Talking

• Difficulty breathing, distressed, choking

• Shortness of breath

• Noisy breathing• Stridor, wheeze, gurgling

• See-saw respiratory pattern, accessory muscles

ABCDE approachAirway

Treatment of airway obstruction:

• Airway opening• Head tilt, chin lift, jaw thrust

• Simple adjuncts

• Advanced techniques• e.g. LMA, tracheal tube

• Oxygen

ABCDE approachBreathing

Recognition of breathingproblems:• Look

• Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level

• Listen • Noisy breathing, breath

sounds

• Feel • Expansion, percussion,

tracheal position

ABCDE approachBreathing

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 approachCirculation

• 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

Causes of circulation problems:

ABCDE approachCirculation

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 approachCirculation

Treatment of circulation problems:

• Airway, Breathing• Oxygen• IV/IO access, take bloods• Treat cause• Fluid challenge

+

ABCDE approachCirculation

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 approachDisability

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 approachExposure

• Remove clothes to enable examination• e.g. injuries, bleeding, rashes

• Avoid heat loss

• Maintain dignity

Any questions?

• 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

Summary

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

• Patient response

• Open airway

• Check for normal breathing• Caution agonal breathing

• Check circulation

• Check for signs of life

To confirm cardiac arrest…Unresponsive?Not breathing or

only occasional gasps

Cardiac arrest confirmed

22222222

Unresponsive?Not breathing or

only occasional gasps

Call resuscitation team

Cardiac arrest confirmedUnresponsive?Not breathing or

only occasional gasps

Call resuscitation team

CPR 30:2Attach 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

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

START PAUSE

Assessrhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

CPR

• Uncoordinated electrical activity

• Coarse/fine• Exclude artefact

• Movement• Electrical interference

Shockable (VF)Shockable

(VF)

• Bizarre irregular waveform• No recognisable QRS

complexes• Random frequency and

amplitude

Shockable (VT)Shockable

(VT)

• Polymorphic VT• Torsade de pointes

• Monomorphic VT• Broad complex rhythm• Rapid rate• Constant QRS morphology

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 (VF / VT)

RESTARTCPR

Assessrhythm

Shockable

(VF / VT)

Shockable (VT)

CHARGE DEFIBRILLATOR

Assessrhythm

Shockable

(VF / VT)

Shockable (VF / VT)

DELIVER SHOCK

Assessrhythm

Shockable

(VF / VT)

Shockable (VF / VT)

IMMEDIATELY RESTART CPR

Assessrhythm

Shockable

(VF / VT)

Shockable (VF / VT)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Assessrhythm

Shockable

(VF / VT)

IMMEDIATELY RESTART CPR

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

• Vary with manufacturer

• Check local equipment

• If unsure, deliver highest available energy

• DO NOT DELAY SHOCK

• Energy levels for manual defibrillators on this course

Manual defibrillation energies

If VF / VT persists

CPR for 2 min

CPR for 2 minDuring CPR

Adrenaline 1 mg IVAmiodarone 300 mg IV

Deliver 2nd shock

Deliver 3rd shock

Non-Shockable

Assessrhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

• 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)Non-Shockable

(Asystole)

• Clinical features of cardiac arrest• ECG normally associated with an output• Adrenaline 1 mg IV then every 3-5 min

Non-shockable (Asystole)Non-Shockable

(PEA)

During CPRDuring 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?

• 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

Summary

Immediate Life Support Course Slide set

All rights reserved© Resuscitation Council (UK) 2010