1.4 Copyright UKCS #284661815

Management of Surgical Emergencies Part 1 : Critical Care Advanced Life Support: Principles & Recent Changes Copyright UKCS #284661815

Aims Principles Changes in ALS Post-resuscitation care BLS demonstration Copyright UKCS #284661815

Resuscitation - Futile or not? May be inappropriate due to injury, pre- existing conditions or lack of available resources – senior clinician involvement Not always futile Potentially reversible and treatable conditions especially in context of trauma Good quality ALS buys time…............. Copyright UKCS #284661815

Principles of ALS Early recognition of the deteriorating patient Early decision making – appropriate? Usually predictable Structured assessment – A,B,C,D,E Good quality BLS - chest compressions, oxygenation and ventilation Reversible causes? Post-resuscitation care - A,B,C,D,E Copyright UKCS #284661815

Copyright UKCS #284661815

Copyright UKCS #284661815

BLS Collapsed patient - SAFE approach Unresponsive - get help Responsive - A,B,C,D assessment Open airway - head tilt, chin lift / jaw thrust Airway adjunct Look, listen, feel 10s. Signs of life? No signs of life - start chest compressions Copyright UKCS #284661815

Recent changes Check for signs of life or breathing Compressions: Centre of chest 5-6cm depth - allow chest to expand fully Rate 100-120 per minute Ratio 30:2 i.e. 30 compressions to two breaths Ventilation: Ideally with airway adjunct and BVM; pocket mask Once definitive airway inserted: Continuous compressions -10 breaths per minute Copyright UKCS #284661815

Adult ALS Algorithm Copyright UKCS #284661815

Monitor or Defibrillator (if available) Assess Rhythm Shockable (VF/VT) Single DC shock (360J mono, 150J biphasic), CPR 1mg Adrenaline & 300mg Amiodarone (after 3rd shock) Adrenaline every 4 mins Copyright UKCS #284661815

Monitor or Defibrillator (if available) Assess Rhythm Non-shockable (PEA/Asystole) Continuous CPR. Rhythm check every 2 minutes Adrenaline every 4 minutes During CPR: Secure airway; Consider reversible causes Copyright UKCS #284661815

Reversible causes 4 H’s Hypoxia Hypovolaemia Hypothermia Hypo/hyperkalaemia 4 T’s Tension Pneumothorax Tamponade Thromboembolism Toxicity Copyright UKCS #284661815

Special Circumstances Poisoning Hyperkalaemia Hypothermia Drowning Electrocution Anaphylaxis Asthma Pregnancy Copyright UKCS #284661815

Difficult Decisions Continue or stop Clinical judgement - past medical history Assessment of likelihood of achieving ROSC Confirm death - absence of central pulse on palpation. Absence of heart sounds on auscultation. Copyright UKCS #284661815

Post-resuscitation Care Aims: Brain – prevention of secondary injury Heart - stabilise rhythm and function Organs - optimise perfusion Anticipate SIRS type response Management of precipitating pathology Reduce morbidity Consider active cooling (reduce secondary injury) Copyright UKCS #284661815

Post-resuscitation Management Airway Protected? Consider intubation Breathing & ventilation Ensure adequate Oxygenation. Ventilate to Normocapnia Circulation Manage Arrhythmias. Optimise cardiac dysfunction Monitoring Disability Sedation and seizure control Exposure Temperature Glucose control Cooling - out of hospital VF arrest Copyright UKCS #284661815

Quality & Human Factors Quality cardiac arrest management requires: Leadership Task identification, delegation & prioritisation Task familiarisation Team work Manage conflict Manage relatives Debrief Audit & Quality Improvement Copyright UKCS #284661815

QUESTIONS? Copyright UKCS #284661815

Summary Deterioration usually predictable Structured approach to assessment Quality BLS & ALS may be appropriate and buy time Changes in delivery of BLS Consider reversible causes Post-resuscitation care Copyright UKCS #284661815

BLS Demonstration Copyright UKCS #284661815