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ADULT ADVANCED

LIFE SUPPORT(ALS)

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GUIDELINES FOR PREVENTION OF IN-HOSPITAL CARDIAC ARREST

RECOGNISING THE CRITICALLY ILL PATIENTS

RESPONSE TO CRITICAL ILLNESSMedical emergency team (MET)

APPROPRIATE PLACEMENT OF PATIENTS

RESUSCITATION DECISIONSMany European countries have no formal policy for recording DNAR decisionsConsider ‘do not attempt resuscitation’ (DNAR) when the patient:

• does not wish to have CPR• will not survive cardiac arrest even if CPR is attempted

Marie Bártová

Recognising the critically ill patientIn general, the clinical signs of acute illness aresimilar whatever the underlying process, as theyreflect failing respiratory, cardiovascular and neurological systems. Abnormal physiology is common on general wards, yet the measurementand recording of important physiological observations of sick patients occurs less frequently than is desirable. This is surprising, as respiratory rate abnormalities may predict cardiorespiratory arrest. To assist in the early detection of critical illness, many hospitals now use early warning scores (EWS) or calling criteria. Early warningscoring systems allocate points to routine vital signs measurements on the basis of their derangement from an arbitrarily agreed ‘normal’ range. The weighted score of one or more vital sign observations, or the total EWS, may be used to suggest increasing the frequency of vital signs monitoring to nurses, or to call ward doctors or critical care outreach teams to the patient. Alternatively, systems incorporating ‘calling criteria’ are based on routine observations, which activate a response when one or more variables reach an extremely abnormal value.

Marie Bártová

medical emergency team (MET)responds, not only to patients in cardiac arrest, but also to those with acute physiological deterioration. The MET usually comprises medical and nursing staff from intensive care and general medicine. and responds to specific calling criteria. Any member of the healthcare team can initiate a MET call. Early involvement of the MET may reduce cardiac arrests, deaths and unanticipated ICU admissions

Marie Bártová

Study shows that higher nurse staffing is associatedwith reduction in cardiac arrest rates, as well asrates of pneumonia, shock and death

Marie Bártová

Guidelines for prevention of in-hospitalcardiac arrestThe following strategies may prevent avoidable inhospital cardiac arrests.1. Provide care for patients who are critically illor at risk of clinical deterioration in appropriateareas, with the level of care provided matchedto the level of patient sickness.2. Critically ill patients need regular observations:match the frequency and type of observations tothe severity of illness or the likelihood of clinicaldeterioration and cardiopulmonary arrest. Oftenonly simple vital sign observations (pulse, bloodpressure, respiratory rate) are needed.3. Use an EWS system to identify patients who are critically ill and or at risk of clinical eteriorationand cardiopulmonary arrest.4. Use a patient charting system that enables theregular measurement and recording of EWS.5. Have a clear and specific policy that requiresa clinical response to EWS systems. This shouldinclude advice on the further clinical managementof the patient and the specific responsibilitiesof medical and nursing staff.6. The hospital should have a clearly identifiedresponse to critical illness. This may includea designated outreach service or resuscitationteam (e.g. MET) capable of responding to acuteclinical crises identified by clinical triggers or other indicators. This service must be available24 h per day.7. Train all clinical staff in the recognition, onitoring and management of the critically illpatient. Include advice on clinical managementwhile awaiting the arrival of more experiencedstaff.8. Identify patients for whom cardiopulmonaryarrest is an anticipated terminal event and inwhom CPR is inappropriate, and patients whodo not wish to be treated with CPR. Hospitalsshould have a DNAR policy, based on nationalguidance, which is understood by all clinicalstaff.9. Ensure accurate audit of cardiac arrest, ‘falsearrest’, unexpected deaths and unanticipatedICU admissions using common datasets. Auditalso the antecedents and clinical response tothese events.

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IN-HOSPITAL RESUSCITATION

Marie Bártová

The unresponsive patientThe exact sequence will depend on the trainingof staff and experience in assessment of breathing and circulation. Trained healthcare staff cannot assess the breathing and pulse sufficiently reliably to confirm cardiac arrest. Agonal breathing (occasional gasps, slow, laboured or noisy breathing) is common in the early stages of cardiac arrest and is a sign of cardiac arrest and should not be confused as a sign of life/circulation.• Shout for help (if not already)Turn the victim on to his back and then open theairway:• Open Airway and check breathing:◦ Open the airway using a head tilt chin lift◦ Look in the mouth. If a foreign body or debrisis visible attempt to remove with forceps orsuction as appropriate◦ If you suspect that there may have been aninjury to the neck, try to open the airway usinga jaw thrust. Remember that maintaining anairway and adequate ventilation is the overridingpriority in managing a patient with a suspectedspinal injury. If this is unsuccessful, use just enough head tilt to clear the airway. Use manual in-line stabilisation to minimise head movement if sufficient rescuers are available. Keeping the airway open, look, listen, and feel for normal breathing (an occasional gasp, slow, laboured or noisy breathing is not normal):• Look for chest movement• Listen at the victim’s mouth for breath sounds• Feel for air on your cheekLook, listen, and feel for no more than 10 s todetermine if the victim is breathing normally• Check for signs of a circulation:◦ It may be difficult to be certain that there is nopulse. If the patient has no signs of life (lackof movement, normal breathing, or coughing),start CPR until more experience help arrives orthe patient shows signs of life.◦ Those experienced in clinical assessmentshould assess the carotid pulse whilst simultaneously looking for signs of life for not more than 10 s.◦ If the patient appears to have no signs of life, or if there is doubt, start CPR immediately. Delays in diagnosis of cardiac arrest and starting CPR will adversely effect survival must be avoided.If there is a pulse or signs of life, urgent medicalassessment is required. Depending on the localprotocols, this may take the form of a resuscitation team. While awaiting this team, give the patient oxygen, attach monitoring, and insert an intravenous cannula. If there is no breathing, but there is a pulse (respiratory arrest), ventilate the patient’s lungs and check for a circulation every 10 breaths.Starting in-hospital CPR• One person starts CPR as others call the resuscitation team and collect the resuscitation equipment and a defibrillator. If only one memberof staff is present, this will mean leaving thepatient.• Give 30 chest compressions followed by 2 ventilations.• Undertaking chest compressions properly is tiring;try to change the person doing chest compressions every 2 min.• Maintain the airway and ventilate the lungs withthe most appropriate equipment immediately tohand. A pocket mask, which may be supplemented with an oral airway, is usually readily available. Alternatively, use a laryngeal mask airway (LMA) and self-inflating bag, or bag-mask, according to local policy. Tracheal intubation should be attempted only by those who are trained, competent and experienced in this skill.• Use an inspiratory time of 1 s and give enoughvolume to produce a normal chest rise. Add supplemental oxygen as soon as possible.• Once the patient’s trachea has been intubated,continue chest compressions uninterrupted(except for defibrillation or pulse checks whenindicated), at a rate of 100 min−1, and ventilatethe lungs at approximately 10 breaths min−1.Avoid hyperventilation.• If there is no airway and ventilation equipmentavailable, give mouth-to-mouth ventilation. Ifthere are clinical reasons to avoid mouth-tomouthcontact, or you are unwilling or unable to do this, do chest compressions until help or airway equipment arrives.• When the defibrillator arrives, apply the paddles to the patient and analyse the rhythm. Ifself-adhesive defibrillation pads are available,apply these without interrupting chest compressions. Pause briefly to assess the heart rhythm. If indicated, attempt either manual or automated external defibrillation (AED).• Recommence chest compressions immediatelyafter the defibrillation attempt. Minimise interruptions to chest compressions.• Continue resuscitation until the resuscitationteam arrives or the patient shows signs of life.Follow the voice prompts if using an AED. If usinga manual defibrillator, follow the universal algorithm for advanced life support.• Once resuscitation is underway, and if there are sufficient staff present, prepare intravenous cannulae and drugs likely to be used by the resuscitation team (e.g. adrenaline).• Identify one person to be responsible for handover to the resuscitation team leader. Locate the patient’s records.• The quality of chest compressions during inhospital CPR is frequently sub-optimal. Theteam leader should monitor the quality of CPRand change CPR providers if the quality of CPRis poor. The person providing chest compressionsshould be changed every 2 min.

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ALS TREATMENT ALGORITHM

Marie Bártová

Pulseless electrical activity (PEA) is defined ascardiac electrical activity in the absence of anypalpable pulses. These patients often have somemechanical myocardial contractions, but these aretoo weak to produce a detectable pulse or bloodpressure.no rhythm is present = asystole

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AIRWAY MANAGEMENT AND VENTILATION

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BASIC AIRWAY MANAGEMENT

Head tilt and chin lift

Jaw thrust

Marie Bártová

Jaw thrustJaw thrust is an alternative manoeuvre for bringing the mandible forward and relieving obstruction by the soft palate and epiglottis. The rescuer’s index and other fingers are placed behind the angle of the mandible, and pressure is applied upwards and forwards. Using the thumbs, the mouth is opened slightly by downward displacement of the chin These simple positional methods are successful in most cases where airway obstruction results from relaxation of the soft tissues. If a clear airway cannot be achieved, look for other causes of airwayobstruction. Use a finger sweep to remove any solid foreign body seen in the mouth. Remove broken or displaced dentures, but leave well-fitting dentures as they help to maintain the contours of the mouth, facilitating a good seal for ventilation.

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ADJUNCTS TO BASIC AIRWAY TECHNIQUES

Oropharyngeal airways

Bag-mask ventilation

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OTHER AIRWAY DEVICES

Laryngeal Tube

Tracheal Tube

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DRUGS AND FLUIDS

- DRUGS Vasopressors Adrenaline

Anti-arrhythmics Amiodarone

Other drugs Atropine Theophylline

- INTRAVENOUS FLUIDS Hartmann’s solution, Ringer’s solution

Intravenous fluid to flush peripherally injected drugs into the central circulation

Marie Bártová

The alpha-adrenergic actions of adrenaline cause vasoconstriction, which increases myocardial and cerebral perfusion pressure.

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ELECTRICAL THERAPIES

DEFIBRILLATION Passage across the myocardium of an electrical current of sufficient magnitude to depolarise a critical mass of myocardium and restoration of coordinated electrical activity

USE OF DEFIBRILLATORS:- Adults- Children older than 8 years- NO defibrillation in children less than 1 year

Marie Bártová

The probability of successful defibrillation andsubsequent survival to hospital discharge declinesrapidly with time and the ability to deliverearly defibrillation is one of the most importantfactors in determining survival from cardiacarrest. For every minute that passes followingcollapse and defibrillation, mortality increases7%—10% in the absence of bystander CPR. EMSsystems do not generally have the capability todeliver defibrillation through traditional paramedicresponders within the first few minutes of a call,and the alternative use of trained lay responders The probability of successful defibrillation andsubsequent survival to hospital discharge declinesrapidly with time and the ability to deliverearly defibrillation is one of the most importantfactors in determining survival from cardiacarrest. For every minute that passes followingcollapse and defibrillation, mortality increases7%—10% in the absence of bystander CPR. EMSsystems do not generally have the capability todeliver defibrillation through traditional paramedicresponders within the first few minutes of a call,and the alternative use of trained lay responders The probability of successful defibrillation andsubsequent survival to hospital discharge declinesrapidly with time and the ability to deliverearly defibrillation is one of the most importantfactors in determining survival from cardiacarrest. For every minute that passes followingcollapse and defibrillation, mortality increases7%—10% in the absence of bystander CPR.EMSsystems do not generally have the capability todeliver defibrillation through traditional paramedicresponders within the first few minutes of a call,and the alternative use of trained lay responders to deliver prompt defibrillation using AEDs is nowwidespread.

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ELECTRICAL THERAPIES

AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

CARDIOVERSIONis used to convert atrial or ventricular tachyarrhythmias

PACINGConsider pacing in patients with symptomaticbradycardia

Marie Bártová

Electrode positionNo human studies have evaluated the electrodeposition as a determinant of return of spontaneous circulation (ROSC) or survival from VF/VT cardiac arrest. Transmyocardial current during defibrillation is likely to be maximal when the electrodes are placed so that the area of the heart that is fibrillating lies directly between them, i.e., ventricles in VF/VT, atria in atrial fibrillation (AF). Therefore, the optimal electrode position may not be the same for ventricular and atrial arrhythmias.For ventricular arrhythmias, place electrodes(either pads or paddles) in the conventional sternal—apical position. The right (sternal) electrode is placed to the right of the sternum, below the clavicle. The apical paddle is placed in the midaxillary line, approximately level with the V6 ECG electrode or female breast.Atrial fibrillation is maintained by functionalre-entry circuits anchored in the left atrium. Asthe left atrium is located posteriorly in the thorax,an anteroposterior electrode position may bemore efficient for external cardioversion of atrial

Marie Bártová

CardioversionIf electrical cardioversion is used to convert atrialor ventricular tachyarrhythmias, the shock must besynchronised to occur with the R wave of the electrocardiogram rather than with the T wave: VF can be induced if a shock is delivered during the relative refractory portion of the cardiac cycle.

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PAEDIATRIC BASIC LIFE SUPPORT

(PBLS)

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PEADIATRIC BASIC LIFE SUPPORT(PBLS)

MANY CHILDREN RECEIVE NO RESUSCITATION AT ALL BECAUSE THE RESCUERS FEAR DOING HARM.

APPLYING OF THE SAME GUIDANCE FOR ALL ADULTS AND CHILDREN ARE FEASIBLE ! ! ! ! ! !

ENHANCED TRAINING FOR HEALTHCARE PROFESSIONALS.

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PBLS

Marie Bártová

Rescue breaths for a child over 1 year are performed as follows :• Ensure head tilt and chin lift.• Pinch the soft part of the nose closed with theindex finger and thumb of your hand on his forehead.• Open his mouth a little, but maintain the chinupwards.• Take a breath and place your lips around themouth, making sure that you have a good seal.• Blow steadily into the mouth over about 1—1.5 s, watching for chest rise.• Maintain head tilt and chin lift, take your mouthaway from the victim and watch for his chest tofall as air is expelled.• Take another breath and repeat this sequencefive times. Identify effectiveness by seeing thatthe child’s chest has risen and fallen in a similarfashion to the movement produced by a normalbreath.Rescue breaths for an infant are performed asfollows:• Ensure a neutral position of the head and a chinlift.• Take a breath and cover the mouth and nasalapertures of the infant with your mouth, makingsure you have a good seal. If the nose and mouth cannot be covered in the older infant, the rescuer may attempt to seal only the infant’s nose or mouth with his mouth (if the nose is used, close the lips to prevent air escape).• Blow steadily into the infant’s mouth and noseover 1—1.5 s, sufficient to make the chest visiblyrise.

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RESCUE BREATHS

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carotid pulse / CHILD

brachial pulse / INFANT

Marie Bártová

Assess the child’s circulation. Take no more than10 s to• look for signs of a circulation. This includesany movement, coughing or normal breathing(not agonal gasps, which are infrequent, irregularbreaths);• check the pulse (if you are a health careprovider) but ensure you take no more than10 s.If the child is aged over 1 year, feel for thecarotid pulse in the neck.In an infant, feel for the brachial pulse on theinner aspect of the upper arm.

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PBLS

AGE C : V RATIO/RATE

POSITION RESCUE BREATHS

AED

Infant< 1 year of age 15:2 / 100 min

30:2 / 100 minlone rescuer

Tips of 2 fingers on the lower third of the sternum

Mouth-to mouth and nose ventilation

NO

Child1 year to puberty

The heel ofone hand over the lower thirdof the sternum,lift the fingers

Mouth-to mouth ventilation

YESpaediatric pads /programmes

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CHEST COMPRESSIONRESCUE BREATHS

Marie Bártová

Chest compressions are performed as follows.For all children, compress the lower third of thesternum. To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where the lowest ribs join in the middle. Compress the sternum one finger’s breadth above this; the compression should be sufficient to depress the sternum by approximately one third of the depth of the chest. Release the pressure and repeat at a rate of about 100 min.

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FOREIGN BODY AIRWAY OBSTRUCTION (FBAO)

Back blows, chest thrusts and abdominal thrusts all increase intrathoracic pressure and can expel foreign bodies from the airway

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PAEDIATRIC ADVANCED LIFE SUPPORT

(PALS)

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PALS

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REPETITION1. Name 3 causes of airway obstruction.2. Name 2 types of airway in-hospital devices.3. Name 2 drugs commonly used in ALS.4. What is the age limit 4 defibrillator usage? 5. What electrical therapies can be performed in the hospital?6. What is the C:V ratio in an infant life support?7. What is the major cause of cardio-pulmonary arrest in:

- children?- adult?

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