In Hospital Resuscitation and Defibrillation. ABCDE approach Underlying principles Complete initial...
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Transcript of In Hospital Resuscitation and Defibrillation. ABCDE approach Underlying principles Complete initial...
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
In Hospital Resuscitation Sequence for collapsed patient in a hospital
Shout for help.
In Hospital Resuscitation Sequence for collapsed patient in a hospital
Look ...... Listen ...... Feel
In Hospital Resuscitation Sequence for collapsed patient in a hospital
No pulse ..... No Breathing for 10
Seconds
Call Resuscitation Team
In Hospital Resuscitation Sequence for collapsed patient in a hospital
Start CPR30 : 2
In Hospital Resuscitation Sequence for collapsed patient in a hospital
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.
Synchronized Cardioversion Synchronized Cardioversion
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)
Synchronized Cardioversion Synchronized Cardioversion
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
Post Resuscitation Care
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
Post Resuscitation Care
Maintain Normal Sinus Rhythm
Maintain Adequate cardiac output
ABCDE
Post Resuscitation Care
ABC DE
•To Assess the Neurological Function.
•Ensure that Cardiac Arrest has not been Associated with Other Medical or Surgical Conditions Requiring Immediate Treatment
Post Resuscitation Care
• 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
Post Resuscitation Care
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
Post Resuscitation Care
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
Post Resuscitation Care
Optimizing Organ Function Optimizing Organ Function
•Cerebral Perfusion
•Sedation
•Control of Seizures
•Treatment of Hyperthermia & Therapeutic Hypothermia
•Control of Blood Glucose
Prognosis Prognosis
Post Resuscitation Care
• 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