Causes and prevention of cardiac arrest Version: Jan 2016

Learning outcomes This lecture should enable you to: discuss the importance of early recognition of the deteriorating patient describe the causes of cardiac arrest in adults state how to assess a patient using the ABCDE approach

Chain of Prevention Assists in preventing: deterioration cardiac arrests and deaths admissions to ICU inappropriate resuscitation attempts

Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care establish recognition and response systems recognising clinical deterioration escalate care responding to clinical deterioration IHCA reporting is rare in the literature range between 1 and 5 events per 1,000 hospital admissions (or 0.175 events/bed annually) survival to hospital discharge most common range being between 15% and 20% shockable rhythms have best survival outcomes 2012 61% of patients presenting to hospital with cardiac arrest died in emergency department or ambulance (NSW government)

Early recognition of the deteriorating patient Common factors seen in cardiac arrests: most arrests are predictable deterioration in up to 80% of patients prior to cardiac arrest tachypnoea early sign - hypotension often later hypoxaemia and hypotension common pre-arrest in review of arrested patients

Track and trigger observation and response be aware of local charts and systems of escalation aggregate scoring system graded responses delays in referral to higher care increase mortality nurse concern is an important predictor of patient deterioration

Early recognition of the deteriorating patient Modifications

Causes of deterioration and cardiorespiratory arrest Airway obstruction Breathing problems Circulation problems

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

ABCDE approach Underlying principles: complete a prompt initial assessment treat life-threatening problems as they are found call for help early use all members of the team assess response to treatment/interventions effective communication – e.g. ISBAR

ABCDE approach personal safety first impression – ‘do they look unwell?’ assess from afar - ‘how are you?’ core physiological observations included: respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness ECG monitor

Causes of airway obstruction: ABCDE approach Airway Causes of airway obstruction: CNS depression foreign body solid blood vomit direct trauma infection inflammation laryngospasm bronchospasm blocked tracheostomy

Recognition of airway obstruction talking/not talking ABCDE approach Airway Recognition of airway obstruction talking/not talking difficulty breathing, distressed, choking Short of breath, tired see-saw respiratory pattern, accessory muscles partial obstruction - noisy breathing stridor, wheeze, gurgling complete obstruction - silence

Treatment of airway obstruction ABCDE approach Airway Treatment of airway obstruction high flow oxygen airway opening head tilt, chin lift, jaw thrust simple adjuncts oropharyngeal or nasal airway advanced techniques e.g. supraglottic airway device, tracheal tube

ABCDE approach Breathing Causes of breathing problems: decreased respiratory: drive CNS depression effort muscle weakness/tiring nerve damage restrictive chest defect pain lung disorders asthma infection acute exacerbation COPD pulmonary embolus pulmonary oedema pneumothorax haemothorax

ABCDE approach Breathing Recognition of breathing problems: RATES approach Look respiratory rate, rhythm and depth, use of accessory muscles, cyanosis, chest deformity, conscious level Listen noisy breathing, breath sounds/silence Feel expansion, percussion note, tracheal position, surgical emphysema Respiratory Rate Auscultate chest (listen) Trachea Effort of Breathing SpO2 Look respiratory rate, rhythm and depth, use of accessory muscles, cyanosis, chest deformity, conscious level Listen noisy breathing, breath sounds Feel expansion, percussion note, tracheal position, surgical emphysema

ABCDE approach Breathing Treatment of breathing problems: high flow oxygen guided by SpO2 (94 - 98% if measured) support breathing if inadequate e.g. bag-valve-mask, non-invasive ventilation treat/consider underlying cause

ABCDE approach Circulation Causes of circulation problems: hypovolaemia blood/fluid loss intravascular loss cardiogenic acute coronary syndromes arrhythmias hypertensive heart disease valve disease obstructive emboli pneumothorax tamponade distributive septic shock anaphylaxis drugs/toxins other hypoxaemia electrolyte/acid base abnormalities anaemia hyper/othermia asphyxia

ABCDE approach Circulation Recognition of circulation problems: shortness of breath syncope poor peripheral perfusion – temperature, capillary refill time pulse - tachycardia, bradycardia blood pressure organ perfusion - chest pain, mental state, oliguria bleeding, fluid losses

ABCDE approach Circulation Treatment of circulation problems: oxygen, if appropriate IV/IO access, take bloods fluid challenge fluid available consider transfusion for blood loss treat cause e.g. aspirin, oxygen (if appropriate), nitrates and opioid analgesia for acute coronary syndromes referral for higher care/monitoring

ABCDE approach Disability Documentation/Drugs/Diabetes Causes hypoxia drugs prescribed recreational hyper/hypoglycaemia intracranial haemorrhage cerebral hypo-perfusion hypothermia Recognition AVPU and pupils initially then GCS later bedside blood glucose core temperature check medication charts and notes

ABCDE approach Disability Documentation/Drugs/Diabetes Treatment ABC treatment oxygen if appropriate treat underlying cause achieve normoglycaemia consider lateral position

ABCDE approach Exposure remove clothes to enable examination surface, orifice, extremity, cavity, drains e.g. injuries, bleeding, rashes, bites and stings avoid heat loss record temperature 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 use the ABCDE approach to recognise and treat patients at risk of cardiac arrest

Advanced Life Support level 1 Course Slide set All rights reserved © Australian Resuscitation Council (January 2016)