July 2004Richard Lake1 Resuscitation Protocols FFP Module 8

July 2004Richard Lake2 Background Information 40% of deaths under the age of 75yrs in Europe are due to cardiovascular disease 40% of deaths under the age of 75yrs in Europe are due to cardiovascular disease One third of people who suffer a myocardial infarction die before reaching hospital One third of people who suffer a myocardial infarction die before reaching hospital Most die within an hour of the onset of acute symptoms Most die within an hour of the onset of acute symptoms The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT) The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)

July 2004Richard Lake3 The only treatment for VF/ pulseless VT is attempted defibrillation The only treatment for VF/ pulseless VT is attempted defibrillation With each minute’s delay the chance of a successful outcome fall by 7-10% With each minute’s delay the chance of a successful outcome fall by 7-10% Once in hospital the incidence of VF after Myocardial Infraction is approximately 5% Once in hospital the incidence of VF after Myocardial Infraction is approximately 5% Most likely presentation of in hospital cardiac arrest is asystole or pulseless electrical activity (PEA). Most likely presentation of in hospital cardiac arrest is asystole or pulseless electrical activity (PEA).

July 2004Richard Lake4 The Chain of Survival

July 2004Richard Lake5 Early Access to emergency services or cardiac arrest team Early Access to emergency services or cardiac arrest team Out of hospital summon EMS Out of hospital summon EMS by dialling 999/112 by dialling 999/112 In hospital call cardiac arrest In hospital call cardiac arrest team ring 2222 (check team ring 2222 (check number when on placement) number when on placement)

July 2004Richard Lake6 External chest compressions and External chest compressions and ventilation will slow down the ventilation will slow down the rate of deterioration of the brain rate of deterioration of the brain and heart and heart Basic Life Support should be Basic Life Support should be performed immediately unless performed immediately unless AED and trained personnel AED and trained personnel available available

July 2004Richard Lake7 Basic Life Support Danger Danger Response Response Shout for Help Shout for Help Airway Airway Breathing Breathing If no help arrived leave victim, go for help If no help arrived leave victim, go for help Circulation Circulation

July 2004Richard Lake8 Danger Check for danger to: Check for danger to: Yourself Yourself Bystanders Bystanders Victim Victim Even clinical areas can have dangers, so ALWAYS CHECK Even clinical areas can have dangers, so ALWAYS CHECK

July 2004Richard Lake9 Response Check the victim for response Check the victim for response Ask a question, ‘hello are you alright?’ Ask a question, ‘hello are you alright?’ Give a command, ‘open your eyes!’ Give a command, ‘open your eyes!’ Give a painful stimulus; pinch the shoulder Give a painful stimulus; pinch the shoulder If no response shout for help If no response shout for help

July 2004Richard Lake10 Checking for response

July 2004Richard Lake11 Airway Check the airway Check the airway Open the airway, place one hand on the victims forehead and gently tilt head back Open the airway, place one hand on the victims forehead and gently tilt head back Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place DO NOT ATTEMPT ANY FINGER SWEEPS DO NOT ATTEMPT ANY FINGER SWEEPS

July 2004Richard Lake12 Opening the airway

July 2004Richard Lake13 Jaw thrust technique may be needed if C-spine injury

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July 2004Richard Lake15 If available use airway adjuncts

July 2004Richard Lake16 Nasopharyngeal airway insertion

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July 2004Richard Lake19 Oropharyngeal airway insertion

July 2004Richard Lake20 Laryngeal Mask Airways may be used in cardiac arrest for emergency airway management

July 2004Richard Lake21 The Laryngeal Mask Airway Latex-free, silicone rubber tube connected to an elliptical mask with an inflatable outer rim Standard 15 mm male adaptor Pilot tube and balloon attached to the inflatable outer rim Bars cover the connection between the tube and the mask Re-useable up to 40 times (Autoclave)

July 2004Richard Lake22 Breathing Keeping the airway open: Keeping the airway open: Look – for chest movements Look – for chest movements Listen – at the victims mouth for breath sounds Listen – at the victims mouth for breath sounds Feel – for air on your cheek Feel – for air on your cheek Look, listen and feel for no more than 10 seconds to determine if the victim is not breathing. Look, listen and feel for no more than 10 seconds to determine if the victim is not breathing.

July 2004Richard Lake23 If not breathing and no help has arrived Leave the victim and go to summon help Leave the victim and go to summon help

July 2004Richard Lake24 Turn the victim onto his back if he is not already in that position Turn the victim onto his back if he is not already in that position Give 2 effective rescue breaths, each of which should make the chest rise and fall Give 2 effective rescue breaths, each of which should make the chest rise and fall If you have difficulty achieving an effective breath: If you have difficulty achieving an effective breath: Recheck the victims mouth and remove any obstruction Recheck the victims mouth and remove any obstruction Recheck there is head tilt and chin lift Recheck there is head tilt and chin lift Make up to 5 attempts to achieve 2 effective breaths Make up to 5 attempts to achieve 2 effective breaths Even if unsuccessful move onto check circulation Even if unsuccessful move onto check circulation

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July 2004Richard Lake26 If available use a pocket mask

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July 2004Richard Lake28 Bag valve mask device may be used

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July 2004Richard Lake30 Circulation Look, listen and feel for normal breathing, coughing, swallowing, eye flickering, or any movement by the victim Look, listen and feel for normal breathing, coughing, swallowing, eye flickering, or any movement by the victim If you feel confident check for a carotid pulse If you feel confident check for a carotid pulse You should take no more than 10 seconds to do this You should take no more than 10 seconds to do this

July 2004Richard Lake31 Always check pulse same side as you

July 2004Richard Lake32 If no breathing but signs of circulation Continue rescue breaths at a rate of 10 breaths per minute Continue rescue breaths at a rate of 10 breaths per minute After every 10 breaths (every 1 minute) recheck for signs of circulation After every 10 breaths (every 1 minute) recheck for signs of circulation This should take no longer than 10 seconds to check This should take no longer than 10 seconds to check

July 2004Richard Lake33 If no breathing and no signs of circulation Commence CPR at a ratio of Commence CPR at a ratio of 15 Compressions 15 Compressions to 2 ventilations to 2 ventilations

July 2004Richard Lake34 Ensure correct hand position

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July 2004Richard Lake36 The Chain of Survival

July 2004Richard Lake37 Chain of survival

July 2004Richard Lake38 The need for defibrillation ventricular fibrillation: 80% of victims ventricular fibrillation: 80% of victims survival decreases: 10% per minute survival decreases: 10% per minute only treatment: electrical defibrillation only treatment: electrical defibrillation this means: delivering an electric shock with a device called an “Automated External Defibrillator” (AED) this means: delivering an electric shock with a device called an “Automated External Defibrillator” (AED)

July 2004Richard Lake39 Out of hospital the aim is to Out of hospital the aim is to deliver a shock within deliver a shock within 5 minutes of the EMS receiving 5 minutes of the EMS receiving a call a call In hospital the first healthcare In hospital the first healthcare responder should be trained and responder should be trained and authorised to use a defibrillator authorised to use a defibrillator immediately immediately

July 2004Richard Lake40 What is an AED? a device that delivers electric shocks to victims with cardiac arrest a device that delivers electric shocks to victims with cardiac arrest

July 2004Richard Lake41 all AEDs share the same operating principles all AEDs share the same operating principles  self-adhesive defibrillation electrodes  analyses the rhythm of the victim and decides when a shock is needed  accuracy is almost 100%

July 2004Richard Lake42 AED features voice prompts voice prompts memory memory analysing analysing ECG ECG

July 2004Richard Lake43 AED hands off pads

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July 2004Richard Lake45 Using an AED  three steps: 1.decide to use the AED 2.activate the AED 3.follow instructions

July 2004Richard Lake46 Check safety

July 2004Richard Lake47 Check response

July 2004Richard Lake48 Shout for help

July 2004Richard Lake49 Tilt head back Lift chin

July 2004Richard Lake50 Check for breathing

July 2004Richard Lake51 Raise the alarm

July 2004Richard Lake52 Check for signs of a circulation

July 2004Richard Lake53 Tilt head back Lift chin

July 2004Richard Lake54 Switch on the AED If NO signs of a circulation If NO signs of a circulation

July 2004Richard Lake55 Attach the electrodes

July 2004Richard Lake56 Follow directions

July 2004Richard Lake57 Analysis of the heart rhythm ensure that everyone is clear during analysis of the rhythm ensure that everyone is clear during analysis of the rhythm

July 2004Richard Lake58 If a shock is advised ensure that everybody is clear push shock button

July 2004Richard Lake59 If no shock is advised check for signs of a circulation check for signs of a circulation if none present: if none present:  start CPR  continue CPR until the AED tells you to stop  if signs of a circulation are present (including normal breathing):  recovery position  check regularly

July 2004Richard Lake60 Useful to know wipe skin dry before attaching electrodes wipe skin dry before attaching electrodes shave or cut excessive hair: only if necessary! shave or cut excessive hair: only if necessary! remove plasters remove plasters place electrodes away from pacemakers place electrodes away from pacemakers safety issues safety issues risk to the rescuer risk to the victim risk to the bystanders

July 2004Richard Lake61 Manual Defibrillator

July 2004Richard Lake62 Manual Defibrillator Paddles

July 2004Richard Lake63 Defibrillation

July 2004Richard Lake64 Defibrillation should be performed promptly

July 2004Richard Lake65 Often defibrillation restores a Often defibrillation restores a perfusing heart rhythm, this is perfusing heart rhythm, this is often inadequate to sustain often inadequate to sustain circulation and further circulation and further advanced life support is advanced life support is required to improve the required to improve the chances of long term survival chances of long term survival

July 2004Richard Lake66 Remember the chain of survival

July 2004 Richard Lake 67 The Universal Treatment Algorithm An important part of Advanced Cardiac Life Support

July 2004Richard Lake68 Objectives Recognise the four cardiac arrest rhythms Recognise the four cardiac arrest rhythms Identify correctly the appropriate algorithm for each of the rhythms Identify correctly the appropriate algorithm for each of the rhythms Discuss the potential reversible causes of cardiac arrest Discuss the potential reversible causes of cardiac arrest

July 2004Richard Lake69 BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm During CPR Correct reversible causes +/- Pulse Check VF / VT NON VF/VT DEFIB X 3 as necessary CPR 1 MIN CPR 3 min Re-assess one minute after defibrillation Check electrode / paddle positions Attempt/verify airway/0 2 /IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

July 2004Richard Lake70 BLS Algorithm if appropriate Attach Monitor/Defib Assess rhythm +/- Pulse Check VF / VTNon VF / VT ? Precordial Thump if appropriate

July 2004Richard Lake71 BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm During CPR Correct reversible causes +/- Pulse Check VF / VT DEFIB X 3 as necessary CPR 1 MIN Check electrode / paddle positions Attempt/verify airway/0 2 /IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

July 2004Richard Lake72 BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm During CPR Correct reversible causes +/- Pulse Check NON VF/VT CPR 3 min Re-assess one minute after defibrillation Check electrode / paddle positions Attempt/verify airway/0 2 /IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

July 2004Richard Lake73 Potentially Reversible Causes Hypoxia Hypovolemia Hyper/ Hypokalemia and metabolic disturbances Hypothermia Tension pneumothorax Tamponade Toxic/ therapeutic disturbances Thrombo-embolic/ mechanical obstruction

July 2004Richard Lake74 BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm During CPR Correct reversible causes +/- Pulse Check VF / VT NON VF/VT DEFIB X 3 as necessary CPR 1 MIN CPR 3 min Re-assess one minute after defibrillation Check electrode / paddle positions Attempt/verify airway/0 2 /IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

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July 2004Richard Lake79 Drugs used commonly during resuscitation Epinephrine (Adrenaline) Epinephrine (Adrenaline) Atropine Atropine Amiodarone Amiodarone Magnesium Sulphate Magnesium Sulphate Lidocaine (Lignocaine) Lidocaine (Lignocaine) Sodium Bicarbonate Sodium Bicarbonate Calcium Calcium

July 2004Richard Lake80 Epinephrine (Adrenaline) First line cardiac arrest drug, given after every 3 minutes of CPR First line cardiac arrest drug, given after every 3 minutes of CPR Dose 1mg (10ml of 1 in 10,000) IV Dose 1mg (10ml of 1 in 10,000) IV Causes vasoconstriction, increased systemic vascular resistance increasing cerebral and coronary perfusion Causes vasoconstriction, increased systemic vascular resistance increasing cerebral and coronary perfusion Increases myocardial excitability, when the myocardium is hypoxic or ischaemic Increases myocardial excitability, when the myocardium is hypoxic or ischaemic

July 2004Richard Lake81 Atropine Given for asystole or pulseless electrical activity with a rate less than 60 beats per minute Given for asystole or pulseless electrical activity with a rate less than 60 beats per minute 3mg is given as a single intravenous dose 3mg is given as a single intravenous dose It blocks the activity of the vagus nerve on the SA and AV nodes, increasing sinus automaticity and facilitating AV node conduction It blocks the activity of the vagus nerve on the SA and AV nodes, increasing sinus automaticity and facilitating AV node conduction

July 2004Richard Lake82 Amiodarone For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmias For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmias If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered. If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered. If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline) If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline) Should be given centrally but in an emergency can be given peripherally Should be given centrally but in an emergency can be given peripherally Increases the duration of the action potential in the atrial and ventricular myocardium Increases the duration of the action potential in the atrial and ventricular myocardium

July 2004Richard Lake83 Magnesium Sulphate For refractory VF when hypomagnesaemia is possible; ventricular tachyarrhythmias when hypomagnesaemia is possible For refractory VF when hypomagnesaemia is possible; ventricular tachyarrhythmias when hypomagnesaemia is possible In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) peripherally over 1 to 2 minutes. In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) peripherally over 1 to 2 minutes. Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutes Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutes

July 2004Richard Lake84 Lidocaine (Lignocaine) For Refractory VF/ pulseless VT (when Amiodarone is unavailable For Refractory VF/ pulseless VT (when Amiodarone is unavailable 100mg for VF/ pulseless VT that persists after three shocks. Another 50mg can be given if necessary 100mg for VF/ pulseless VT that persists after three shocks. Another 50mg can be given if necessary

July 2004Richard Lake85 Sodium Bicarbonate Given for severe metabolic acidosis and Hyperkalaemia Given for severe metabolic acidosis and Hyperkalaemia 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac arrest associated with Hyperkalaemia 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac arrest associated with Hyperkalaemia

July 2004Richard Lake86 Calcium Administered when pulseless electrical activity caused by: Administered when pulseless electrical activity caused by: Hyperkalaemia Hyperkalaemia Hypocalcaemia Hypocalcaemia Overdose of Calcium channel blocking Overdose of Calcium channel blocking drugs drugs Dose 10ml of 10% calcium chloride repeated according to blood results Dose 10ml of 10% calcium chloride repeated according to blood results

July 2004Richard Lake87 Summary Cardiac arrest can have a variety of causes Cardiac arrest can have a variety of causes The chain of survival is essential to improve outcome from cardiac arrest The chain of survival is essential to improve outcome from cardiac arrest

July 2004Richard Lake88 Awareness of the universal treatment algorithm is important Awareness of the universal treatment algorithm is important A knowledge of the drugs used in cardiac arrest, their routes and dilution is also essential A knowledge of the drugs used in cardiac arrest, their routes and dilution is also essential

July 2004Richard Lake89 Questions