In Hospital Resuscitation and Defibrillation

ABCDE approach Underlying principles Complete initial assessment Treat life-threatening problems Reassessment Assess effects of treatment/ interventions Call for help early e.g. Medical Emergency Team

ABCDE Talking Difficulty breathing, distressed, choking Shortness of breath Noisy breathing stridor, wheeze, gurgling See-saw respiratory pattern, accessory muscles

Nursing The Patient on his ABCDE Head Tilt, Chin Lift, Jaw Thrust Simple Adjuncts Oro-pharyngeal Airway Naso-pharyngeal Airway. Advanced Techniques LMA ETT Open The Airway O2 Nursing The Patient on his Side Naso-Gastric Tube

ABCDE Inspect Palpate Percuss Auscultate Chest Expansion Respiratory Rate Accessory Muscles Chest Deformities Cyanosis Inspect Palpate Tenderness Percuss Hyper-Resonance Auscultate Equal Air Entry Adventitious Sounds

O2 Treat the Underlying Cause ABCDE Respiratory Supports: Non invasive Face mask Bag-Mask-Valve Tracheal Intubation &Controlled Ventilation O2 To All Hypoxic Patients Treat the Underlying Cause

Pulse – tachycardia, bradycardia ABCDE Look at the patient Pulse – tachycardia, bradycardia Blood pressure Peripheral perfusion - capillary refill time Organ perfusion chest pain, mental state, urine output Bleeding, fluid losses

ABCDE Airway, Breathing Haemodynamic monitoring IV access Fluid challenge Inotropes/Vasopressors Treat Cause Oxygen/Aspirin/Nitrates/ Morphine for ACS

AVPU Score GCS ABC Check Blood Glucose level & Pupils Check Drug Chart ABCDE AVPU Score GCS ABC Check Blood Glucose level & Pupils Check Drug Chart Consider Lateral Position

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

In Hospital Resuscitation Sequence for collapsed patient in a hospital Check the patient for a response

In Hospital Resuscitation Sequence for collapsed patient in a hospital Shout for help.

In Hospital Resuscitation Sequence for collapsed patient in a hospital Look ...... Listen ...... Feel

In Hospital Resuscitation Sequence for collapsed patient in a hospital No pulse ..... No Breathing for 10 Seconds Call Resuscitation Team

In Hospital Resuscitation Sequence for collapsed patient in a hospital Start CPR 30 : 2

In Hospital Resuscitation Sequence for collapsed patient in a hospital When Resuscitation Team Arrives

Until Defibrillator/Monitor Attached Open Airway Look for Signs of Life Call Resuscitation Team CPR 30:2 Until Defibrillator/Monitor Attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole)

Energy Level 150 - 200 J biphasic 360 J monophasic (VF/Pulseless VT) Assess Rhythm Shockable (VF/Pulseless VT) 1 Shock 150-360 J biphasic or 360 J monophasic Energy Level 150 - 200 J biphasic 360 J monophasic Immediately resume CPR 30:2 for 2 min

(VF/Pulseless VT) Persists 2nd and subsequent shocks 150 - 360 J biphasic 360 J monophasic Minimise Delays Between CPR and Shocks (< 10 s) Do not Delay Shock to Give Adrenaline Give Amiodarone Before 4th Shock IF Shockable (VF/Pulseless VT) Persists Deliver 2nd Shock After 2 min, assess rhythm: If organised electrical activity, check for signs of life: if ROSC start post resuscitation care if no ROSC go to non VF/VT algorithm CPR for 2 mins Adrenaline 1mg I.V Deliver 3rd Shock

CPR 30:2 Assess Rhythm Non-shockable (PEA/Asystole) Immediately resume for 2 min

Until defibrillator/monitor attached ALS Treatment Algorithm Open Airway Look for signs of life Call Resuscitation Team CPR 30:2 Until defibrillator/monitor attached During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium Assess Rhythm Shockable (VF/Pulseles VT) Non-shockable (PEA/Asystole) During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium 1 Shock 150-360 J biphasic or 360 J monophasic Immediately resume CPR 30:2 for 2 min Immediately resume CPR 30:2 for 2 min

4Hs Reversible Causes Hypoxia 2) Hypovolemia Hyper-Hypokalemia Fluid Restoration Urgent Surgery to Stop Bleeding Adequate Ventilation with 100% O2 4Hs Hyper-Hypokalemia Hypocalcemia Hypoglycmia Hypothermia Low Reading Thermometer IV CaCl

4Ts Reversible Causes Tension Pneumothorax Diagnosed Clinically 2) Toxins Diagnosed Clinically Decompress by Needle Thoracocentesis Insertion of Chest Tube Specific History & Lab Investigations Supportive TTT & Antidotes 4Ts Thromboembolism Tamponade Penetrating Chest Trauma Recent Cardiac Surgery Needle Pericardiocentesis Resuscitative Thoracotomy Consider Thrombolytic Therapy

Ulnar Edge of a Tightly Clenched Fist To the Lower ½ of Sternum Precodial Thumb Ulnar Edge of a Tightly Clenched Fist 20 CM Height To the Lower ½ of Sternum Witnessed Monitored Shockable No Defilbrillator

Mechanism of Defibrillation Defibrillation occurs by passage of electric current of sufficient magnitude across the myocardium to depolarize a critical mass of cardiac muscle simultaneously to enable the natural pace maker tissue to resume control.

Defibrillation Success Minimize Trans-Thoracic Impedance Electrode-Skin Contact Electrode Size Coupling Agent Paddle Force Phase of Ventilation Pads Versus Paddles One Shock Versus 3 Shock Sequence

Defibrillation Success Electrode Position Antero-Apical Antero-Posterior Biaxillary

Synchronized Cardioversion If the Electric Cardioversion is Used to Convert Atrial or Ventricular Tachyarrhythmias, the Shock Must be Synchronized to Occur with the R-wave of the ECG Rather Than the T-wave to Avoid the Relative Refractory Period and Minimizing the Risk of Inducing VF.

Tachyarrhythmia Adverse Signs Synchronized Cardioversion Tachyarrhythmia Adverse Signs Regular Broad complex Tachycardia (Ventricular Tachycardia / SVT with Bundle branch block) Decreased Conscious Level Chest Pain Systolic B.P < 90 mmHg Heart Failure Irregular Broad complex Tachycardia (Polymorphic VT = Torsade de pointes / AF with BBB) Irregular narrow complex tachycardia (AF) Regular narrow complex tachycardia (SVT)

Anticipating Slight Delay Synchronized Cardioversion PRECAUTIONS Anticipating Slight Delay Sedation Energy Doses 200 J Monophasic 120-150 J Biphasic 100 J Monophasic 70-120 J Biphasic

Post Resuscitation Care Post Resuscitation Care Starts Where Return of spontaneous circulation is Achieved. ABCDE system-oriented approach to management should be followed in the immediate post resuscitation phase pending transfer to an appropriate high-care area.

Post Resuscitation Care Immediate return of Normal cerebral Functions Obtunded Cerebral Functions ABCDE Ensure Clear Airway No Need For Tracheal Intubation Tracheal Intubation Adequate O2 & Ventilation O2 Mask Spontaneous Ventilation controlled Ventilation Hypoxia & Hypercapnia: Further Cardiac Arrest 2ry Brain Injury Hyporcapnia Cerebral Ischemia

Post Resuscitation Care Pulse Bl.Pr. 1 Maintain Normal Sinus Rhythm Maintain Adequate cardiac output ABCDE 2 Peripheral Perfusion Capillary Refill Time < 2 Seconds Warm Pink Digits 3 Neck Veins Right Ventricular Failure Pericardial Tamponade Lung Bases 4 Left Ventricular Failure

Post Resuscitation Care ABC DE To Assess the Neurological Function. Ensure that Cardiac Arrest has not been Associated with Other Medical or Surgical Conditions Requiring Immediate Treatment

Post Resuscitation Care Patient Transfere Aim: To transfer the patient safely between the site of resuscitation and a place of definitive care Monitor Defibrillator O2 Supply Suction Apparatus Cannulae, Tubes, Drains are Secured

Post Resuscitation Care Further Assessment History To Establish Regular Drug Therapy Before Cardiac Arrest Monitors ECG Capnography U.O.P Pulse Oximetry C.V.P Investigations C.B.C 12 Lead E.C.G Chest X.R Biochemistry Echocardiography A.B.G

Post Resuscitation Care Optimizing Organ Function Target Mean Arterial Pressure Adequate U.O.P Consider patient’s Usual Blood Pressure Maintain Normal Sinus Rhythm To Avoid decrease in C.O.P Correct Hypo-perfusion During Cardiac Arrest I.V Fluids Inotropes

Post Resuscitation Care Optimizing Organ Function Cerebral Perfusion Sedation Control of Seizures Treatment of Hyperthermia & Therapeutic Hypothermia Control of Blood Glucose

Post Resuscitation Care Prognosis No Neurological Signs Can Predict the Outcome in the First Hours after ROSC Poor Outcome Predicted at 3 Days by: Absent Pupil Light Reflexes Absent Motor Response to Pain

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