Causes and Prevention of Cardiac Arrest

• The importance of early recognition of the deteriorating patient

• The causes of cardiac arrest in adults

• The ABCDE approach

Learning outcomes

Early recognition prevents:

• Cardiac arrests and deaths• Admissions to ICU• Inappropriate resuscitation attempts

Chain of survival

Early recognition ofthe deteriorating patient

• Most arrests are predictable

• Hypoxia and hypotension are common antecedents

• Delays in referral to higher levels of care

Recognition of the deteriorating patient

• Several alternative systems to cardiac arrest team• e.g. Medical emergency team (MET)

• Track changes in physiology• e.g. Early warning scores

• Trigger a response if abnormal values:• Call senior nurse• Call doctor • Call resuscitation team

Recognition of the deteriorating patient -Early Warning Scoring Systems

Example of early warning scoring (EWS) systemFrom Prytherch et al. ViEWS—Towards a national early warning score for detecting adult in-patient deterioration. Resuscitation. 2010;81(8):932-7

Recognition of the deteriorating patient -Early Warning Scoring Systems

Example escalation protocol based on early warning score (EWS)

The ABCDE approach to the deteriorating patient

Airway

Breathing

Circulation

Disability

Exposure

ABCDE approach

Underlying principles:

• Complete initial assessment

• Treat life-threatening problems

• Reassessment

• Assess effects of treatment/interventions

• Call for help early

ABCDE approach

• Personal safety

• Patient responsiveness

• First impression

• Vital signs• Respiratory rate, SpO2, pulse, BP, GCS, temperature

ABCDE approachAirway

Causes of airway obstruction:

• CNS depression• Blood • Vomit • Foreign body • Trauma

• Infection • Inflammation • Laryngospasm • Bronchospasm

ABCDE approachAirway

Recognition of airway obstruction:

• Talking

• Difficulty breathing, distressed, choking

• Shortness of breath

• Noisy breathing• Stridor, wheeze, gurgling

• See-saw respiratory pattern, accessory muscles

ABCDE approachAirway

Treatment of airway obstruction:

• Airway opening• Head tilt, chin lift, jaw thrust

• Simple adjuncts

• Advanced techniques• e.g. LMA, tracheal tube

• Oxygen

ABCDE approachBreathing

• Decreased respiratory drive

• CNS depression

• Decreased respiratory effort

• Muscle weakness • Nerve damage• Restrictive chest defect• Pain from fractured ribs

• Lung disorders • Pneumothorax• Haemothorax • Infection• Acute exacerbation COPD• Asthma• Pulmonary embolus• ARDS

Causes of breathing problems:

ABCDE approachBreathing

Recognition of breathingproblems:• Look

• Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level

• Listen • Noisy breathing, breath

sounds

• Feel • Expansion, percussion

ABCDE approachBreathing

Treatment of breathingproblems:• Airway

• Oxygen

• Treat underlying cause• e.g. antibiotics for pneumonia

• Support breathing if inadequate • e.g. ventilate with bag-mask

ABCDE approachCirculation

• Primary (pump)• Acute coronary syndromes• Arrhythmias• Hypertensive heart disease• Valve disease• Drugs• Inherited cardiac diseases• Electrolyte/acid base

abnormalities

Causes of circulation problems:

• Secondary (Flow)• Asphyxia• Hypoxaemia• Blood loss• Hypothermia• Septic shock

Hypovolaemia

One of most common causes of crisis

Fluid loss not always obvious:•Haemorrhagic – blood loss within body•Distributive Shock - vasodilation•Cardiogenic Shock – myocardial insufficiency•Restrictive Shock – pericardial effusion•Obstructive Shock – Emboli•Relative Shock – anaemia

ABCDE approachCirculation

Recognition of circulation problems:

• Look at the patient• Pulse - tachycardia, bradycardia• Peripheral perfusion - capillary refill time• Blood pressure• Organ perfusion

• Chest pain, mental state, urine output

• Bleeding, fluid losses

ABCDE approachCirculation

Treatment of circulation problems:

• Airway, Breathing• Oxygen if needed• IV/IO access, take bloods• Call for help• Treat cause• Fluid challenge

ABCDE approachCirculation

Acute Coronary Syndromes

• Unstable angina or myocardial infarction

• Treatment• Aspirin 300 mg orally (crushed/chewed)• Nitroglycerine (GTN spray or tablet if first dose ever)• Oxygen (guided by pulse oximetry if uncomplicated)

- Give if in shock/heart failure/Saturations indicate• Morphine (or fentanyl)

• Consider reperfusion therapy (PCI, thrombolysis)

ABCDE approachDisability

(Drugs/Diabetes/Documentation)

Recognition

• AVPU or GCS• Pupils• Blood sugar • Check drug chart• Check for any history

(documentation, alert jewellery)

Treatment

• ABC• Treat underlying cause• Blood glucose

• If < 4 mmol l-1 give glucose

• Consider lateral position

ABCDE approachExposure

• Remove clothes to enable examination• e.g. injuries, bleeding, rashes

• Check all • Look at and examine surface, orifice, extremity and

cavity

• Avoid excessive heat loss

• Maintain dignity

Any questions?

• 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

• ABCDE approach to recognise and treat patients at risk of cardiac arrest

Summary

Immediate Life Support Course Slide set

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