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July 2004July 2004 Richard LakeRichard Lake 11
Resuscitation ProtocolsResuscitation Protocols
FFP Module 8FFP Module 8
July 2004July 2004 Richard LakeRichard Lake 22
Background InformationBackground Information
40% of deaths under the age of 75yrs in 40% of deaths under the age of 75yrs in Europe are due to cardiovascular diseaseEurope are due to cardiovascular disease
One third of people who suffer a myocardial One third of people who suffer a myocardial infarction die before reaching hospitalinfarction die before reaching hospital
Most die within an hour of the onset of acute Most die within an hour of the onset of acute symptomssymptoms
The majority of these deaths the presenting The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)Ventricular Tachycardia, (VF/ pulseless VT)
July 2004July 2004 Richard LakeRichard Lake 33
The only treatment for VF/ pulseless The only treatment for VF/ pulseless VT is attempted defibrillationVT is attempted defibrillation
With each minute’s delay the chance With each minute’s delay the chance of a successful outcome fall by 7-of a successful outcome fall by 7-10%10%
Once in hospital the incidence of VF Once in hospital the incidence of VF after Myocardial Infraction is after Myocardial Infraction is approximately 5%approximately 5%
Most likely presentation of in hospital Most likely presentation of in hospital cardiac arrest is asystole or pulseless cardiac arrest is asystole or pulseless electrical activity (PEA).electrical activity (PEA).
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The Chain of SurvivalThe Chain of Survival
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Early Access to emergency services Early Access to emergency services or cardiac arrest teamor cardiac arrest team
Out of hospital summon EMSOut of hospital summon EMS
by dialling 999/112by dialling 999/112 In hospital call cardiac arrestIn hospital call cardiac arrest
team ring 2222 (check team ring 2222 (check
number when on placement)number when on placement)
July 2004July 2004 Richard LakeRichard Lake 66
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 heartand heart Basic Life Support should be Basic Life Support should be
performed immediately unlessperformed immediately unless
AED and trained personnel AED and trained personnel
availableavailable
July 2004July 2004 Richard LakeRichard Lake 77
Basic Life SupportBasic Life Support
DangerDanger ResponseResponse Shout for HelpShout for Help AirwayAirway BreathingBreathing If no help arrived leave victim, go for If no help arrived leave victim, go for
helphelp CirculationCirculation
July 2004July 2004 Richard LakeRichard Lake 88
DangerDanger
Check for danger to:Check for danger to: YourselfYourself BystandersBystanders VictimVictim Even clinical areas can have dangers, Even clinical areas can have dangers,
so so ALWAYS CHECKALWAYS CHECK
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ResponseResponse Check the victim for Check the victim for
responseresponse Ask a question, ‘hello are you Ask a question, ‘hello are you
alright?’alright?’ Give a command, ‘open your Give a command, ‘open your
eyes!’eyes!’ Give a painful stimulus; pinch Give a painful stimulus; pinch
the shoulderthe shoulder If no response shout for helpIf no response shout for help
July 2004July 2004 Richard LakeRichard Lake 1010
Checking for responseChecking for response
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AirwayAirway
Check the airwayCheck the airway Open the airway, place one hand on Open the airway, place one hand on
the victims forehead and gently tilt the victims forehead and gently tilt head backhead back
Remove any visible obstruction from Remove any visible obstruction from the victims mouth, including dislodged the victims mouth, including dislodged dentures. Leave well fitting dentures in dentures. Leave well fitting dentures in placeplace
DO NOT ATTEMPT ANY FINGER SWEEPSDO NOT ATTEMPT ANY FINGER SWEEPS
July 2004July 2004 Richard LakeRichard Lake 1212
Opening the airwayOpening the airway
July 2004July 2004 Richard LakeRichard Lake 1313
Jaw thrust technique may be Jaw thrust technique may be needed if C-spine injuryneeded if C-spine injury
July 2004July 2004 Richard LakeRichard Lake 1414
July 2004July 2004 Richard LakeRichard Lake 1515
If available use airway If available use airway adjunctsadjuncts
July 2004July 2004 Richard LakeRichard Lake 1616
Nasopharyngeal airway Nasopharyngeal airway insertioninsertion
July 2004July 2004 Richard LakeRichard Lake 1717
July 2004July 2004 Richard LakeRichard Lake 1818
July 2004July 2004 Richard LakeRichard Lake 1919
Oropharyngeal airway Oropharyngeal airway insertioninsertion
July 2004July 2004 Richard LakeRichard Lake 2020
Laryngeal Mask Airways may Laryngeal Mask Airways may be used in cardiac arrest for be used in cardiac arrest for
emergency airway emergency airway managementmanagement
July 2004July 2004 Richard LakeRichard Lake 2121
The Laryngeal Mask AirwayThe Laryngeal Mask Airway
Latex-free, silicone Latex-free, silicone rubber tube connected rubber tube connected to an elliptical mask with to an elliptical mask with an inflatable outer riman inflatable outer rim Standard 15 mm male Standard 15 mm male
adaptoradaptor Pilot tube and balloon Pilot tube and balloon
attached to the inflatable attached to the inflatable outer rimouter rim
Bars cover the connection Bars cover the connection between the tube and the between the tube and the maskmask
Re-useable up to 40 times Re-useable up to 40 times (Autoclave)(Autoclave)
July 2004July 2004 Richard LakeRichard Lake 2222
BreathingBreathing
Keeping the airway open:Keeping the airway open: Look –Look – for chest movements for chest movements Listen – Listen – at the victims mouth for breath at the victims mouth for breath
soundssounds Feel – Feel – for air on your cheekfor air on your cheek Look, listen and feel for Look, listen and feel for no more than 10 no more than 10
secondsseconds to determine if the victim is not to determine if the victim is not breathing.breathing.
July 2004July 2004 Richard LakeRichard Lake 2323
If not breathing If not breathing and no help has arrivedand no help has arrived
Leave the victim and go to summon helpLeave the victim and go to summon help
July 2004July 2004 Richard LakeRichard Lake 2424
Turn the victim onto his back if he is not Turn the victim onto his back if he is not already in that positionalready in that position
Give 2 effective rescue breaths, each of which Give 2 effective rescue breaths, each of which should make the chest rise and fall should make the chest rise and fall
If you have difficulty achieving an effective If you have difficulty achieving an effective breath:breath:
Recheck the victims mouth and remove any Recheck the victims mouth and remove any obstructionobstruction
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 Make up to 5 attempts to achieve 2 effective
breathsbreaths Even if unsuccessful move onto check Even if unsuccessful move onto check
circulationcirculation
July 2004July 2004 Richard LakeRichard Lake 2525
July 2004July 2004 Richard LakeRichard Lake 2626
If available use a pocket If available use a pocket maskmask
July 2004July 2004 Richard LakeRichard Lake 2727
July 2004July 2004 Richard LakeRichard Lake 2828
Bag valve mask device may be Bag valve mask device may be usedused
July 2004July 2004 Richard LakeRichard Lake 2929
July 2004July 2004 Richard LakeRichard Lake 3030
CirculationCirculation
Look, listen and feel for normal Look, listen and feel for normal breathing, coughing, swallowing, eye breathing, coughing, swallowing, eye flickering, or any movement by the flickering, or any movement by the victimvictim
If you feel confident check for a If you feel confident check for a carotid pulsecarotid pulse
You should take no more than 10 You should take no more than 10 seconds to do thisseconds to do this
July 2004July 2004 Richard LakeRichard Lake 3131
Always check pulse same side Always check pulse same side as youas you
July 2004July 2004 Richard LakeRichard Lake 3232
If no breathing If no breathing but signs of circulation but signs of circulation
Continue rescue breaths at a rate of Continue rescue breaths at a rate of 10 breaths per minute10 breaths per minute
After every 10 breaths (every 1 After every 10 breaths (every 1 minute) recheck for signs of minute) recheck for signs of circulationcirculation
This should take no longer than 10 This should take no longer than 10 seconds to checkseconds to check
July 2004July 2004 Richard LakeRichard Lake 3333
If no breathing and If no breathing and no signs of circulationno signs of circulation
Commence CPR at a ratio ofCommence CPR at a ratio of
15 Compressions 15 Compressions
to 2 ventilationsto 2 ventilations
July 2004July 2004 Richard LakeRichard Lake 3434
Ensure correct hand Ensure correct hand positionposition
July 2004July 2004 Richard LakeRichard Lake 3535
July 2004July 2004 Richard LakeRichard Lake 3636
The Chain of SurvivalThe Chain of Survival
July 2004July 2004 Richard LakeRichard Lake 3737
Chain of survivalChain of survival
July 2004July 2004 Richard LakeRichard Lake 3838
The need for defibrillationThe need for defibrillation
ventricular fibrillation: ventricular fibrillation: 80% of victims80% of victims
survival decreases: survival decreases: 10% per minute 10% per minute
only treatment: electrical only treatment: electrical defibrillation defibrillation
this means: delivering an this means: delivering an electric shock with a electric shock with a device called andevice called an “Automated External “Automated External Defibrillator” (AED)Defibrillator” (AED)
July 2004July 2004 Richard LakeRichard Lake 3939
Out of hospital the aim is toOut of hospital the aim is to
deliver a shock within deliver a shock within
5 minutes of the EMS receiving5 minutes of the EMS receiving
a calla call In hospital the first healthcare In hospital the first healthcare
responder should be trained andresponder should be trained and
authorised to use a defibrillatorauthorised to use a defibrillator
immediatelyimmediately
July 2004July 2004 Richard LakeRichard Lake 4040
What is an AED?What is an AED?
a device that a device that delivers delivers electric shocks electric shocks to victims with to victims with cardiac arrestcardiac arrest
July 2004July 2004 Richard LakeRichard Lake 4141
all AEDs share the same operating all AEDs share the same operating principlesprinciples
self-adhesive defibrillation electrodesself-adhesive defibrillation electrodes analyses the rhythm of the victim and analyses the rhythm of the victim and
decides when a shock is neededdecides when a shock is needed accuracy is almost 100%accuracy is almost 100%
July 2004July 2004 Richard LakeRichard Lake 4242
AED featuresAED features
voice promptsvoice prompts
memorymemory
analysinganalysing
ECGECG
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AED hands off padsAED hands off pads
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July 2004July 2004 Richard LakeRichard Lake 4545
Using an AEDUsing an AED
three steps:
1.decide to use the AED
2.activate the AED
3.follow instructions
July 2004July 2004 Richard LakeRichard Lake 4646
Check safetyCheck safety
July 2004July 2004 Richard LakeRichard Lake 4747
Check responseCheck response
July 2004July 2004 Richard LakeRichard Lake 4848
Shout for helpShout for help
July 2004July 2004 Richard LakeRichard Lake 4949
Tilt head backTilt head backLift chinLift chin
July 2004July 2004 Richard LakeRichard Lake 5050
Check for breathingCheck for breathing
July 2004July 2004 Richard LakeRichard Lake 5151
Raise Raise thethe alarm alarm
July 2004July 2004 Richard LakeRichard Lake 5252
Check for signs of a Check for signs of a circulationcirculation
July 2004July 2004 Richard LakeRichard Lake 5353
Tilt head backTilt head backLift chinLift chin
July 2004July 2004 Richard LakeRichard Lake 5454
Switch on the AEDSwitch on the AED
If NO signs of a If NO signs of a circulationcirculation
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Attach the electrodesAttach the electrodes
July 2004July 2004 Richard LakeRichard Lake 5656
Follow directionsFollow directions
July 2004July 2004 Richard LakeRichard Lake 5757
Analysis of the heart rhythmAnalysis of the heart rhythm
ensure that ensure that everyone is everyone is clear during clear during analysis of the analysis of the rhythmrhythm
July 2004July 2004 Richard LakeRichard Lake 5858
If a shock is advisedIf a shock is advised
ensure that ensure that everybody is everybody is clear clear
push shock push shock buttonbutton
July 2004July 2004 Richard LakeRichard Lake 5959
If no shock If no shock isis advisedadvised check for signs of a check for signs of a
circulationcirculation if none present:if none present:
start CPR start CPR continue CPR until the AED continue CPR until the AED
tells you to stoptells you to stop if signs of a circulation are if signs of a circulation are
present (including normal present (including normal breathing):breathing):
recovery positionrecovery position check regularlycheck regularly
July 2004July 2004 Richard LakeRichard Lake 6060
Useful to knowUseful to know wipe skin dry before attaching electrodeswipe skin dry before attaching electrodes shave or cut excessive hair: shave or cut excessive hair: only if necessary!only if necessary! remove plastersremove plasters place electrodes away from pacemakersplace electrodes away from pacemakers
safety issues safety issues risk to the rescuerrisk to the rescuer risk to the victimrisk to the victim risk to the bystandersrisk to the bystanders
July 2004July 2004 Richard LakeRichard Lake 6161
Manual DefibrillatorManual Defibrillator
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Manual Defibrillator PaddlesManual Defibrillator Paddles
July 2004July 2004 Richard LakeRichard Lake 6363
DefibrillationDefibrillation
July 2004July 2004 Richard LakeRichard Lake 6464
Defibrillation should be Defibrillation should be performed promptlyperformed promptly
July 2004July 2004 Richard LakeRichard Lake 6565
Often defibrillation restores a Often defibrillation restores a
perfusing heart rhythm, this isperfusing 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 survivalchances of long term survival
July 2004July 2004 Richard LakeRichard Lake 6666
Remember the chain of Remember the chain of survivalsurvival
July 2004July 2004 Richard LakeRichard Lake 6767
The Universal Treatment The Universal Treatment AlgorithmAlgorithm
An important part of An important part of
Advanced Cardiac Life Advanced Cardiac Life SupportSupport
July 2004July 2004 Richard LakeRichard Lake 6868
ObjectivesObjectives
Recognise the four cardiac arrest Recognise the four cardiac arrest rhythmsrhythms
Identify correctly the appropriate Identify correctly the appropriate algorithm for each of the rhythmsalgorithm for each of the rhythms
Discuss the potential reversible Discuss the potential reversible causes of cardiac arrestcauses of cardiac arrest
July 2004July 2004 Richard LakeRichard Lake 6969
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 defibrillationCheck electrode / paddle positions
Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
July 2004July 2004 Richard LakeRichard Lake 7070
BLS Algorithmif appropriate
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT Non VF / VT
?
Precordial Thumpif appropriate
July 2004July 2004 Richard LakeRichard Lake 7171
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/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
July 2004July 2004 Richard LakeRichard Lake 7272
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/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
July 2004July 2004 Richard LakeRichard Lake 7373
Potentially Reversible CausesPotentially Reversible Causes
HHypoxiaypoxia
HHypovolemiaypovolemia
HHyper/ Hypokalemia and metabolic yper/ Hypokalemia and metabolic disturbancesdisturbances
HHypothermiaypothermia
TTension pneumothoraxension pneumothorax
TTamponadeamponade
TToxic/ therapeutic disturbancesoxic/ therapeutic disturbances
TThrombo-embolic/ mechanical obstructionhrombo-embolic/ mechanical obstruction
July 2004July 2004 Richard LakeRichard Lake 7474
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 defibrillationCheck electrode / paddle positions
Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
July 2004July 2004 Richard LakeRichard Lake 7575
July 2004July 2004 Richard LakeRichard Lake 7676
July 2004July 2004 Richard LakeRichard Lake 7777
July 2004July 2004 Richard LakeRichard Lake 7878
July 2004July 2004 Richard LakeRichard Lake 7979
Drugs used commonly Drugs used commonly during resuscitationduring resuscitation
Epinephrine (Adrenaline)Epinephrine (Adrenaline) AtropineAtropine AmiodaroneAmiodarone Magnesium SulphateMagnesium Sulphate Lidocaine (Lignocaine)Lidocaine (Lignocaine) Sodium BicarbonateSodium Bicarbonate CalciumCalcium
July 2004July 2004 Richard LakeRichard Lake 8080
Epinephrine (Adrenaline)Epinephrine (Adrenaline)
First line cardiac arrest drug, given after First line cardiac arrest drug, given after every 3 minutes of CPRevery 3 minutes of CPR
Dose 1mg (10ml of 1 in 10,000) IVDose 1mg (10ml of 1 in 10,000) IV Causes vasoconstriction, increased Causes vasoconstriction, increased
systemic vascular resistance increasing systemic vascular resistance increasing cerebral and coronary perfusioncerebral and coronary perfusion
Increases myocardial excitability, when Increases myocardial excitability, when the myocardium is hypoxic or ischaemicthe myocardium is hypoxic or ischaemic
July 2004July 2004 Richard LakeRichard Lake 8181
AtropineAtropine
Given for asystole or pulseless Given for asystole or pulseless electrical activity with a rate less electrical activity with a rate less than 60 beats per minutethan 60 beats per minute
3mg is given as a single intravenous 3mg is given as a single intravenous dosedose
It blocks the activity of the vagus It blocks the activity of the vagus nerve on the SA and AV nodes, nerve on the SA and AV nodes, increasing sinus automaticity and increasing sinus automaticity and facilitating AV node conductionfacilitating AV node conduction
July 2004July 2004 Richard LakeRichard Lake 8282
AmiodaroneAmiodarone
For Refractory VF/VT; haemodynamically stable For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmiasVT and other resistant tachyarrhythmias
If VF or pulseless VT persists after the first 3 If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered.shocks then Amiodarone 300mg is considered.
If not pre-diluted, must be diluted in 5% dextrose If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline)to 20ml. (Will crystallise is mixed with saline)
Should be given centrally but in an emergency Should be given centrally but in an emergency can be given peripherallycan be given peripherally
Increases the duration of the action potential in Increases the duration of the action potential in the atrial and ventricular myocardiumthe atrial and ventricular myocardium
July 2004July 2004 Richard LakeRichard Lake 8383
Magnesium SulphateMagnesium Sulphate
For refractory VF when For refractory VF when hypomagnesaemia is possible; hypomagnesaemia is possible; ventricular tachyarrhythmias when ventricular tachyarrhythmias when hypomagnesaemia is possiblehypomagnesaemia is possible
In refractory VF – 1 to 2g (2-4ml of In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) 50% magnesium sulphate) peripherally over 1 to 2 minutes. peripherally over 1 to 2 minutes.
Other circumstances 2.5g (5ml of 50% Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutesmagnesium sulphate) over 30 minutes
July 2004July 2004 Richard LakeRichard Lake 8484
Lidocaine (Lignocaine)Lidocaine (Lignocaine)
For Refractory VF/ pulseless VT For Refractory VF/ pulseless VT (when Amiodarone is unavailable(when Amiodarone is unavailable
100mg for VF/ pulseless VT that 100mg for VF/ pulseless VT that persists after three shocks. Another persists after three shocks. Another 50mg can be given if necessary50mg can be given if necessary
July 2004July 2004 Richard LakeRichard Lake 8585
Sodium BicarbonateSodium Bicarbonate
Given for severe metabolic acidosis Given for severe metabolic acidosis and Hyperkalaemiaand Hyperkalaemia
50mmol (50ml of 8.4% solution), 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac where there is an acidosis or cardiac arrest associated with arrest associated with HyperkalaemiaHyperkalaemia
July 2004July 2004 Richard LakeRichard Lake 8686
CalciumCalcium
Administered when pulseless electrical Administered when pulseless electrical activity caused by: activity caused by:
HyperkalaemiaHyperkalaemia HypocalcaemiaHypocalcaemia Overdose of Calcium channel blocking Overdose of Calcium channel blocking drugsdrugs Dose 10ml of 10% calcium chloride Dose 10ml of 10% calcium chloride
repeated according to blood resultsrepeated according to blood results
July 2004July 2004 Richard LakeRichard Lake 8787
SummarySummary
Cardiac arrest can Cardiac arrest can have a variety of have a variety of causes causes
The chain of The chain of survival is essential survival is essential to improve to improve outcome from outcome from cardiac arrestcardiac arrest
July 2004July 2004 Richard LakeRichard Lake 8888
Awareness of the universal treatment Awareness of the universal treatment algorithm is important algorithm is important
A knowledge of the drugs used in A knowledge of the drugs used in cardiac arrest, their routes and cardiac arrest, their routes and dilution is also essentialdilution is also essential
July 2004July 2004 Richard LakeRichard Lake 8989
QuestionsQuestions