1. Causes and prevention of cardiac arrest
Version: Jan 2016

2. 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

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

4. 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 events/bed annually)
survival to hospital discharge most common range being between 15% and 20%
shockable rhythms have best survival outcomes
% of patients presenting to hospital with cardiac arrest died in emergency department or ambulance (NSW government)

5. 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

6. 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

7. Early recognition of the deteriorating patient Modifications

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. Any questions?

25. 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

26. Advanced Life Support level 1 Course Slide set
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© Australian Resuscitation Council (January 2016)