In Hospital Resuscitation and Defibrillation

In Hospital Resuscitation and Defibrillation

ABCDE approachUnderlying 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

ABCDE

Open The

Airway

•Head Tilt, Chin Lift, Jaw Thrust

•Simple Adjuncts

• Oro-pharyngeal Airway• Naso-pharyngeal Airway.

•Advanced Techniques • LMA• ETT

•O2•Nursing The Patient on his

Side•Naso-Gastric Tube

ABCDE

Inspect

Palpate

Percuss

Auscultate

•Chest Expansion•Respiratory Rate•Accessory Muscles •Chest Deformities•Cyanosis

•Tenderness

•Hyper-Resonance

•Equal Air Entry• Adventitious Sounds

ABCDE

Treatthe

UnderlyingCause

O2ToAll

Hypoxic Patients

RespiratorySupports:•Non invasive Face mask

•Bag-Mask-Valve

•Tracheal Intubation &Controlled Ventilation

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

ABCDE

•AVPU Score•GCS

•ABC•Check Blood Glucose level & Pupils •Check Drug Chart•Consider Lateral Position

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


Shout for help.


Look ...... Listen ...... Feel


No pulse ..... No Breathing for 10

Seconds

Call Resuscitation Team


Start CPR30 : 2


When Resuscitation Team Arrives

Open Airway Look for Signs of Life

CPR 30:2Until Defibrillator/Monitor

Attached

AssessRhythm

Shockable(VF/Pulseless

VT)

Non-shockable

(PEA/Asystole)

Call Resuscitation

Team

AssessRhyth

m

Shockable(VF/Pulseless

VT)

1 Shock150-360 J biphasic

or 360 J monophasic

Immediately resume

CPR 30:2 for 2 min

Energy Level• 150 - 200 J biphasic• 360 J monophasic

IF Shockable(VF/Pulseless

VT)Persists

Deliver 2nd Shock

CPR for 2 mins

Adrenaline 1mg I.V

Deliver 3rd 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

• 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

AssessRhyth

m

Non-shockable

(PEA/Asystole)

Immediately resume

CPR 30:2 for 2 min

Open Airway Look for signs of life Call

Resuscitation Team

CPR 30:2Until defibrillator/monitor attached

AssessRhythm

Shockable(VF/Pulseles VT)

1 Shock150-360 J biphasic

or 360 J monophasic

Immediately resume

CPR 30:2 for 2 min

Non-shockable

(PEA/Asystole)

Immediately resume

CPR 30:2 for 2 min

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

ALS Treatment Algorithm

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

Reversible Causes

4Hs

1) Hypoxia 2) Hypovolemia

3)Hyper-Hypokalemia Hypocalcemia Hypoglycmia

4) Hypothermia

•Adequate Ventilation with 100% O2

• Fluid Restoration• Urgent Surgery to Stop

Bleeding

• IV CaCl

• Low Reading Thermome-ter

Reversible Causes

4Ts

1) Tension Pneumothorax 2) Toxins

3) Thromboembolism 4) Tamponade

• Diagnosed Clinically

• Decompress by Needle Thoracocentesis

• Insertion of Chest Tube

•Specific History & Lab In-vestigations

• Supportive TTT & Anti-dotes

• Consider Thrombolytic Therapy

• Penetrating Chest Trauma

• Recent Cardiac Surgery

• Needle Pericardiocente-sis

• Resuscitative Thoraco-tomy

Precodial ThumbPrecodial Thumb

Witnessed Shockable

No Defilbrillato

r

Monitored

• Ulnar Edge of a Tightly Clenched

Fist

• 20 CM Height

• To the Lower ½ of Sternum

Mechanism of Defibrillation 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 SuccessDefibrillation 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 SuccessDefibrillation Success

Electrode Position

Antero-Apical

Antero-Posterior Biaxillary

Synchronized Cardioversion 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

•Decreased Conscious Level

•Chest Pain

•Systolic B.P < 90 mmHg

•Heart Failure

Regular Broad complex Tachycardia (Ventricular Tachycardia / SVT with Bundle branch

block)

Irregular Broad complex Tachycardia(Polymorphic VT = Torsade de pointes / AF with

BBB)

Irregular narrow complex tachycardia (AF)

Regular narrow complex tachycardia (SVT)


PRECAUTIONS

Anticipating Slight Delay

Sedation

Energy Doses

200 J Monophasic120-150 J Biphasic

100 J Monophasic70-120 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.

ABCDE system-oriented approach to management should be followed in the immediate post resuscitation phase pending transfer to an appropriate high-care area.

ABCDE

Ensure ClearAirway

Adequate O2 &

Ventilation

Obtunded CerebralFunctions

Immediatereturn of Normal cerebralFunctions

No Need ForTracheal

Intubation

O2 MaskSpontaneousVentilation

TrachealIntubation

controlledVentilation

•Hypoxia & Hypercapnia: • Further Cardiac Arrest• 2ry Brain Injury

•Hyporcapnia Cerebral Ischemia

•Hypoxia & Hypercapnia: • Further Cardiac Arrest• 2ry Brain Injury

•Hyporcapnia Cerebral Ischemia


Pulse

Bl.Pr.

1

PeripheralPerfusion

2 Capillary Refill Time < 2 SecondsWarm Pink Digits

Neck Veins

3 Right Ventricular FailurePericardial Tamponade

Lung Bases

4 Left Ventricular Failure


Maintain Normal Sinus Rhythm

Maintain Adequate cardiac output

ABCDE


ABC DE

•To Assess the Neurological Function.

•Ensure that Cardiac Arrest has not been Associated with Other Medical or Surgical Conditions Requiring Immediate Treatment


• Monitor

• Defibrillator

• O2 Supply

• Suction Apparatus

• Cannulae, Tubes, Drains are Secured

Aim:

To transfer the patient safely between the site of resuscitation and a place of definitive care

Patient Transfere Patient Transfere

Further AssessmentFurther Assessment


History To Establish Regular Drug Therapy Before Cardiac Arrest

Monitors•ECG•Pulse Oximetry

•Capnography

•C.V.P

•U.O.P

Investigations•C.B.C

•Biochemistry

•12 Lead E.C.G

•Echocardiography

•Chest X.R

•A.B.G


Optimizing Organ Function 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


Optimizing Organ Function Optimizing Organ Function

•Cerebral Perfusion

•Sedation

•Control of Seizures

•Treatment of Hyperthermia & Therapeutic Hypothermia

•Control of Blood Glucose

Prognosis 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

Thank You

Documents

In Hospital Resuscitation and Defibrillation