EMERGENCY CARE AND RESUSCITATION
Final Objective: On completion of this module you will know how to manage a cardiopulmonary arrest.
Enabling Objective: To achieve this goal, you should know how to:
Reference Reading:
The resuscitation of a collapsed patient is usually divided into two phases:
PROTOCOLS FOR ADULT BASIC LIFE SUPPORT.
The initial steps of resuscitation are to check for danger (hazards/risks/safety), check for a response, call for help, open the airway, give two initial rescue breaths, and give 30 chest compressions followed by 2 breaths.
D check for danger
R responsive? If not, call for help.
A open airway, look for signs of life (unconscious, unresponsive, not breathing normally, not moving. Checking for a carotid pulse is an inaccurate sign.)
B give 2 initial breaths if not breathing normally
C give 30 chest compressions (almost 2 compressions/second followed by 2 breaths)
D attach defibrillator as soon as possible
Rescuers should start CPR if the victim has no signs of life (unconscious, unresponsive, not moving, and not breathing normally.
In most unconscious patients, all muscles relax and the airway will become obstructed. This occurs most often at the level of the hypopharynx as the reduced tone in the muscles of the tongue, jaw and neck allow the tongue to fall against the posterior pharyngeal wall. Other soft tissues of the airway may worsen this obstruction. The mouth tends to fall open but this tends to block, rather than open, the airway. If foreign material irritates the vocal cords, a protective reflex muscle spasm (laryngospasm) prevents the entry of material into the lungs. This may result in complete or partial airway blockage. Patients with incomplete laryngospasm will have stridor. Patients with complete laryngospasm will have a silent airway.
In an unconscious patient, care of the airway takes precedence over any injury, including the possibility of spinal injury however all unconscious victims should be handled gently with special care of the spinal column and neck.
This obstruction may be overcome by:
Backward Head Tilt plus Chin Lift. One hand is placed on the forehead or the top of the head. The head is tilted backwards (not the neck). It is important to avoid excessive force. The other hand is used to provide Chin Lift. The chin is held up by the rescuer’s thumb and fingers in order to open the mouth and pull the tongue and soft tissues away from the back of the throat. Jaw thrust may also be used to create an open airway. Applying pressure behind the angles of the mandible pushes the patient’s jaw forwards.
A child’s airway (age one to eight) should be managed as per adults. The airway of an infant (younger than one year) is easily obstructed. In infants the head should be kept neutral and maximum head tilt should not be used. The lower jaw should be supported at the point of the chin with the mouth maintained open. There must be no pressure on the soft tissues of the neck.
The mouth must be opened and turned slightly downwards to allow any obvious material to drain using gravity. Loose dentures should be removed, but well fitting ones can be left in place. The rescuer’s fingers with a finger sweep can remove visible material.
After an unconscious patient’s airway is cleared, the next step is to check whether or not the patient is breathing (more than the occasional gasp). Look and feel for movement of the upper abdomen and lower chest. Movement of the upper abdomen and lower chest does not necessarily mean the patient has a clear airway. Also listen and feel for breath from the nose and mouth.
If an unconscious patient is not breathing after the airway has been opened and cleared, then ‘mouth-to-mouth’ or more correctly expired-air ventilation. Common causes of inadequate mouth-to-mouth ventilation include: obstruction (failing to maintain head tilt, chin lift), leaks and unrecognised foreign bodies in the patient’s airway.
No human evidence has identified an optimal compression-ventilation ratio for CPR in victims of any age. Interruptions to compressions should be avoided. CPR should not be interrupted to check for signs of life. In order to increase the number of compressions and minimise interruptions to compressions, a universal compression-ventilation ratio of 30:2 is recommended for all ages. This ratio will also prevent excessive ventilation, simplify teaching and maximise skill retention. When providing 30 compressions (at approximately 100/min) and giving 2 breaths (each given over 1 second per breath), this should result in delivery of 5 cycles in approximately 2 minutes.
Compressions are delivered to the lower half of the sternum with the heel of the hand. The fingers are kept parallel to the ribs but raised above the ribs. The rescuers shoulders should be vertically over the sternum and the chest compressed with straight arms 4-5 cm.
Common errors with compressions include:
1. Wrong hand position
§ Too high: the heart is not compressed
§ Too low: the stomach is compressed and the risk of aspiration is increased
§ Too lateral: injuries to underlying organs
2. Too strong
§ Can cause cardiac damage, fractured ribs
3. Too weak
4. Failure to release between compressions.
PROTOCOLS FOR ADULT ADVANCED LIFE SUPPORT.
The algorithm is based on the following considerations:
Ventricular fibrillation is the most common primary rhythm in sudden cardiac arrest.
The chance of successful defibrillation decreases with time. The rate of decrease can be slowed, or even reversed by effective BLS. The time to delivery of the first shock is critical in determining the outcome.
There are interventions that are indicated in all causes of cardiac arrest.
There are a group of potentially reversible conditions that, if left untreated, may cause cardiac arrest or prevent resuscitation.
ADULT CARDIORESPIRATORY ARREST
Electrical defibrillation or cardioversion depolarises a critical mass of the myocardium allowing the natural pacemaker of the heart to take over and restore a normal co-ordinated contraction. Though defibrillation is critical for the treatment of VF/VT, a period of well-performed CPR can help maintain myocardial and cerebral viability. During CPR advanced life support interventions are applied and potential causes sought. After an unsuccessful attempt at defibrillation, a further 2-minute period of CPR is recommended. Interruptions to CPR should be minimal. Attempts to secure the airway should not interrupt CPR for more than 20 seconds. Despite the lack of human data it is reasonable to continue to use vasopressors and antiarrhythmic drugs on a routine basis. Adrenaline should be administered every 3 minutes. Consideration should be given to the administration of an antiarrhythmic after the second failed defibrillation attempt (s). Other drugs/electrolytes should be considered depending on the individual circumstances.
The prognosis of asystole and pulseless electrical activity (PEA) is much worse than VF/VT and defibrillation is not indicated. Before the diagnosis of asystole is made, it is important to exclude the possibility of VF having been misdiagnosed. This may be due to equipment failure or misinterpretation. If there is any doubt about the diagnosis, treatment should begin as for VF.
There is no evidence to support the routine use i.v fluids. Fluids should be given if hypovolaemia is suspected.
Energy levels for monophasic defibrillation for adults should be set at maximum (usually 360 Joules) for all shocks. Biphasic energy levels should be set at 200J for all shocks. Three stacked-shocks may be of benefit when the time required for rhythm recognition and recharging the defibrillator is short (i.e.: < 10 seconds). 1 shock strategy may improve outcome by reducing interruption of chest compressions.
Precordial Thump should be considered within the first 15 seconds of a monitored arrest, where the rhythm is VF/pulseless VT and a defibrillator is not immediately available. The inside of the fist is brought down sharply from 25-30 cm to make contact with the mid-sternum of the victim’s chest.
Defibrillation. The discharge of a defibrillator delivers enough current to cause VF. Several case reports describe fires ignited by sparks from poorly attached defibrillator paddles in the presence of an oxygen-enriched atmosphere. One paddle or pad is placed on the midaxillary line over the 6th left intercostal space and the other on the right parasternal area over the 2nd intercostal space. Once the defibrillator is charged, the paddles must be either in place on the patient’s chest or resting in the defibrillator. Avoid placing paddles over ECG electrodes or other medical equipment. Ensure that any rescuers are in not contact with the patient or trolley and that the patient is not in contact with metal fixtures (“stand clear”). Avoid delivering the shock with a gap between paddle and chest wall or with paddles touching each other.
Check that the patient has a motor response to the shock indicating delivery of the charge. If there is no motor response consider that the “synchronise” mode of the defibrillator may be on or there may be a flat battery, disconnected/broken lead etc.
If the attempt at defibrillation is unsuccessful:
Ventilation/oxygenation. High flow oxygen should be used if available. Attempts at endotracheal intubation must not interrupt CPR for more than 20 seconds. Laryngeal masks airways and other similar supraglottic airway devices may be used instead of an endotracheal tube when intubation is difficult however they should not replace mastery of bag and mask ventilation and endotracheal intubation remains the optimal technique to provide ventilation, limit aspiration deliver 100% oxygen and may be used for administration of some drugs.
PROTOCOLS FOR PAEDIATRIC BASIC LIFE SUPPORT.
Paediatric basic life support is not identical to adult basic life support. Although the general principles are the same, specific techniques are required and these techniques change with the size of the child. (An ‘infant’ is less than 1 year of age and a ‘small child’ is less than 8 years of age). The differences are due to the different causes of cardiorespiratory arrest and differences in the anatomy and physiology between children and adults.
Hypoxaemia or hypotension or both cause the majority of cardiorespiratory arrest in children. Causes include trauma, drowning, sudden infant death syndrome (SIDS), septicaemia, asthma, upper airway obstruction and congenital abnormalities of the heart and lungs. The initial cardiac rhythm is often severe bradycardia or asystole. Unlike adults, ventricular fibrillation is very uncommon, except with some congenital cardiac abnormalities, poisoning with cardiac drugs or during resuscitation.
Respiratory arrest may occur alone and not progress to cardiac arrest if treated quickly.
The same DR ABC (see above) approach for adult basic life support is used with children however hyperextension of the neck may cause airway obstruction in small children. In infants, chest compressions may be performed with two fingers or with two thumbs (the rescuer’s hand encircle the infants chest with the thumbs on the sternum). Chest compressions are performed with the heel of s single hand in young children.
The initial rates of compressions and ventilation are the same as for adult basic life support. 30:2 at a rate of 100 compressions/minute. With infant advanced life support and two rescuers the ratio is changed to 15:2 with a rate of 75 compressions/minute.
Drugs may be administered by intravenous, interosseous (io) or endotracheal routes. Endotracheal administration is less effective and should only be used for adrenaline, lignocaine or atropine.
PROTOCOLS FOR PAEDIATRIC ADVANCED LIFE SUPPORT.
PAEDIATRIC CARDIORESPIRATORY ARREST
Oropharyngeal (Guedel) or nasopharyngeal airways may improve ventilation. The correct size oropharyngeal airway should reach from the angle of the mandible to the centre of the mouth. The correct size nasopharyngeal airway should reach from the tip of the nose to the tragus of the ear. The appropriate un-cuffed endotracheal tube size may be calculated by age (years)/4 +4. The endotracheal tube should be inserted age (years)/2 +12 cm.
The bone marrow has a rich blood supply and forms part of the peripheral circulation. Drugs injected by the interosseous route are distributed as fast and reach the same peak levels as by intravenous injection. Many sites are suitable. The most common site is the antero-medial surface of the distal or proximal tibia. All intravenous and interosseous drugs should be flushed with a small volume of fluid. Although adrenaline, lignocaine and atropine are well absorbed from the respiratory tree the optimal doses are not known. Recommended doses are adrenaline 100 mcg/kg, atropine 30 mcg/kg and lignocaine 2-3 mg/kg. Volumes of drug preparations (normal saline) should be 0.7 ml for neonate, 1-2 ml for an infant, 2-5 ml for a small child and 5-10 ml for a large child.
The initial energy dose for VF and pulseless VT is 2 J/kg with both monophasic and biphasic defibrillators. Subsequent doses are 4J/kg.
If hypovolaemia is suspected as the cause of cardiorespiratory arrest, an initial of 20 ml/kg should be given. Sodium bicarbonate has a limited and unproven place in the management of cardiorespiratory arrest. Sodium bicarbonate produces carbon dioxide which mat re-enter cells causing increased intracellular acidosis. Other adverse effects include hypernatraemia and hyperosmolality. Hypokalaemia may cause a life threatening tachyarrhythmia. Emergency treatment is 0.03-0.07 mmol/kg by slow injection. The blood sugar should be checked with the aim of achieving normoglycaemia Hypoglycaemia may be treated with 0.5 g/kg
Asystole or pulseless severe bradycardia (less than 60 in infants and 40 in children) should be treated with adrenaline 10 mcg/kg.
THE CHOKING PATIENT.
The signs and symptoms of upper airway obstruction will depend on the cause, severity and duration of obstruction. Airway obstruction may be gradual or sudden in onset. It may be partial or complete. Some common causes include:
A foreign body airway obstruction is a life-threatening emergency. All patients with significant airway obstruction by a foreign body clutch their neck with the thumb and fingers. The severity of obstruction may be assessed by ability of the patient to cough. Patients with an effective cough usually have mild airway obstruction and may be managed by reassurance, encouraging coughing and continued observation. Victims with an ineffective cough usually have severe airway obstruction. Back blows, chest thrusts or abdominal thrusts are effective for relieving obstruction in conscious adults and children older than 1 year of age although injuries have been reported with abdominal thrusts. (The Heimlich manoeuvre is not recommended). In the conscious patient, initially five sharp back blows are given with the heel of the hand in the middle of the back between the shoulder blades. If the blows are unsuccessful the patient will need chest thrusts. A chest thrust is the same as chest compressions in CPR but are sharper and the airway is checked between each chest thrust. If the obstruction is not relieved, continue alternating five back blows with five chest compressions.
TRANSPORT OF THE CRITICALLY ILL
Transporting critically ill patients presents major problems, and adverse physiological changes occurring during transport can be life threatening. Thus transport of critically ill patients requires careful planning and strict attention to detail. The principles of achieving safe transport are:
§ Planning.
§ Personnel (correct number and correct skills).
§ Equipment.
§ Treatment to stabilise the patient before transport and treatments during transport.
§ Choice of route and type of transport.
Transport of critically ill patients may be within the hospital (for example between the intensive care unit and operating theatres), between hospitals (secondary transport) or from the site of the accident/onset of illness to the first hospital (primary transport).
There must be an adequate number of appropriately skilled personnel to ensure safe transport. Inexperienced or unskilled staff may not recognise or manage problems.
The type of equipment required depends on the stability of the patient. Basic monitoring is essential for all patients. More monitoring will be required for more complex and critical patients. All monitors must have adequate battery power. Emergency drugs, analgesics, sedatives, muscle relaxants and equipment to secure the airway must be available. Equipment should not be stored on the patient.
Immediately before transport begins the patient is checked and final preparations completed (e.g. giving bolus dose of muscle relaxant, analgesic or sedatives).
Transport preparations must not neglect the patient’s fundamental treatment.
Patient status check list
Airway secure and patent
Ventilation adequate
All drains are functioning and secure
Venous access is adequate and secure
Intravenous drips and infusions are functioning
Patient is safely secured to trolley
ECG, BP, Pulse oximeter, invasive monitors are functioning, alarms set
Manual resuscitator available and functioning
Suction device available and functioning
Oxygen cylinder is full
Spare oxygen cylinder available
Airway and intubation equipment available and functioning
Spare intravenous fluid
Additional drugs available
Patient notes, x-rays etc available
SELF-ASSESSMENT QUESTIONS
Develop guidelines for the resuscitation of the newborn infant. Consider anticipating the need for resuscitation, recommended equipment and drugs, assessment of the newborn infant, airway management and ventilation, chest compressions and medications.
EMERGENCY CARE AND RESUSCITATION CASE STUDIES
Case 1.1
Tungalag is found floating in a river.She is resuscitated by a tourist and brought to University Hospital by ambulance.
Draw a flow diagram (algorithm) for basic life support in an adult.
Outline the different aetiologies of adult and paediatric cardiac arrest.
What are the usual rhythms seen in adult and paediatric cardiac arrest?
When she arrives at the hospital her ECG shows a regular wide complex QRS with a rate of 180 bpm. What is the likely arrhythmia and how may you manage it?
Describe the physiological basis of blood flow during chest compression CPR.
Discuss the physiological requirements for a successful outcome of cardiopulmonary resuscitation.
Case 1.2
Tulga has inhaled a lump of buuz. He is clutching his throat and coughing weakly.
Draw a flow diagram for the management of an inhaled foreign body.
Case 1.3
A 26-year lady presents to the sum hospital with a one-day history of severe abdominal pain and a two-month history of amenorrhea. She collapsed when the doctor was taking her history. She had a weak pulse; pulse rate 140/min and her BP was unrecordable. She responded to 3 litres of intravenous fluid. Her haemoglobin was 60 g/l after fluid resuscitation. It is decided that she will need urgent operation at the Sum hospital.
What information do you want from the doctor at the sum hospital? What information/instructions do you give them?
List drugs and equipment you would take with you.
What are the anaesthetic options?
The most likely diagnosis is a ruptured ectopic pregnancy. You decide to take some blood with you. Which blood group and how much would you take?
There are a number of different oxygen cylinders available. How long will each last if you use 4l/min of oxygen?
What do you believe is the minimum anaesthetic/resuscitation equipment/drugs that should be available at a sum hospital?
Final Objective: On completion of this module you will know how to manage a cardiopulmonary arrest.
Enabling Objective: To achieve this goal, you should know how to:
- Identify the causes, symptoms and signs of impending cardiac or respiratory arrest.
- Demonstrate how to perform effective cardiopulmonary resuscitation.
- Know the principles of advanced life support.
- Demonstrate the safe use of the cardiac defibrillator.
- Know the principles of the safe transport of critically ill patients.
Reference Reading:
- Developing anaesthesia textbook chapters 32, 52 & 53.
The resuscitation of a collapsed patient is usually divided into two phases:
- Basic life support (BLS) is the description given to the technique of cardiopulmonary resuscitation (CPR) without the use of any equipment. CPR has 3 fundamental components: airway assessment and management, breathing assessment and management, and circulation assessment and management. BLS is performed to limit hypoxic damage of the vital organs by providing an artificial circulation; it rarely results in the return of spontaneous circulation, but is essential to maximise the chance of advanced life support achieving this. Effective external cardiac compressions provide a cardiac output of only 20-30% of the pre-arrest value. Expired air resuscitation provides ventilation with an inspired oxygen concentration of only 15-18%. The key treatment of ventricular fibrillation and pulseless VT is early electrical defibrillation.
- Advanced life support (ALS) is the description given to the use of defibrillation, intubation and the administration of drugs in an attempt to restore a spontaneous circulation.
PROTOCOLS FOR ADULT BASIC LIFE SUPPORT.
The initial steps of resuscitation are to check for danger (hazards/risks/safety), check for a response, call for help, open the airway, give two initial rescue breaths, and give 30 chest compressions followed by 2 breaths.
D check for danger
R responsive? If not, call for help.
A open airway, look for signs of life (unconscious, unresponsive, not breathing normally, not moving. Checking for a carotid pulse is an inaccurate sign.)
B give 2 initial breaths if not breathing normally
C give 30 chest compressions (almost 2 compressions/second followed by 2 breaths)
D attach defibrillator as soon as possible
Rescuers should start CPR if the victim has no signs of life (unconscious, unresponsive, not moving, and not breathing normally.
In most unconscious patients, all muscles relax and the airway will become obstructed. This occurs most often at the level of the hypopharynx as the reduced tone in the muscles of the tongue, jaw and neck allow the tongue to fall against the posterior pharyngeal wall. Other soft tissues of the airway may worsen this obstruction. The mouth tends to fall open but this tends to block, rather than open, the airway. If foreign material irritates the vocal cords, a protective reflex muscle spasm (laryngospasm) prevents the entry of material into the lungs. This may result in complete or partial airway blockage. Patients with incomplete laryngospasm will have stridor. Patients with complete laryngospasm will have a silent airway.
In an unconscious patient, care of the airway takes precedence over any injury, including the possibility of spinal injury however all unconscious victims should be handled gently with special care of the spinal column and neck.
This obstruction may be overcome by:
Backward Head Tilt plus Chin Lift. One hand is placed on the forehead or the top of the head. The head is tilted backwards (not the neck). It is important to avoid excessive force. The other hand is used to provide Chin Lift. The chin is held up by the rescuer’s thumb and fingers in order to open the mouth and pull the tongue and soft tissues away from the back of the throat. Jaw thrust may also be used to create an open airway. Applying pressure behind the angles of the mandible pushes the patient’s jaw forwards.
A child’s airway (age one to eight) should be managed as per adults. The airway of an infant (younger than one year) is easily obstructed. In infants the head should be kept neutral and maximum head tilt should not be used. The lower jaw should be supported at the point of the chin with the mouth maintained open. There must be no pressure on the soft tissues of the neck.
The mouth must be opened and turned slightly downwards to allow any obvious material to drain using gravity. Loose dentures should be removed, but well fitting ones can be left in place. The rescuer’s fingers with a finger sweep can remove visible material.
After an unconscious patient’s airway is cleared, the next step is to check whether or not the patient is breathing (more than the occasional gasp). Look and feel for movement of the upper abdomen and lower chest. Movement of the upper abdomen and lower chest does not necessarily mean the patient has a clear airway. Also listen and feel for breath from the nose and mouth.
If an unconscious patient is not breathing after the airway has been opened and cleared, then ‘mouth-to-mouth’ or more correctly expired-air ventilation. Common causes of inadequate mouth-to-mouth ventilation include: obstruction (failing to maintain head tilt, chin lift), leaks and unrecognised foreign bodies in the patient’s airway.
No human evidence has identified an optimal compression-ventilation ratio for CPR in victims of any age. Interruptions to compressions should be avoided. CPR should not be interrupted to check for signs of life. In order to increase the number of compressions and minimise interruptions to compressions, a universal compression-ventilation ratio of 30:2 is recommended for all ages. This ratio will also prevent excessive ventilation, simplify teaching and maximise skill retention. When providing 30 compressions (at approximately 100/min) and giving 2 breaths (each given over 1 second per breath), this should result in delivery of 5 cycles in approximately 2 minutes.
Compressions are delivered to the lower half of the sternum with the heel of the hand. The fingers are kept parallel to the ribs but raised above the ribs. The rescuers shoulders should be vertically over the sternum and the chest compressed with straight arms 4-5 cm.
Common errors with compressions include:
1. Wrong hand position
§ Too high: the heart is not compressed
§ Too low: the stomach is compressed and the risk of aspiration is increased
§ Too lateral: injuries to underlying organs
2. Too strong
§ Can cause cardiac damage, fractured ribs
3. Too weak
4. Failure to release between compressions.
PROTOCOLS FOR ADULT ADVANCED LIFE SUPPORT.
The algorithm is based on the following considerations:
Ventricular fibrillation is the most common primary rhythm in sudden cardiac arrest.
The chance of successful defibrillation decreases with time. The rate of decrease can be slowed, or even reversed by effective BLS. The time to delivery of the first shock is critical in determining the outcome.
There are interventions that are indicated in all causes of cardiac arrest.
There are a group of potentially reversible conditions that, if left untreated, may cause cardiac arrest or prevent resuscitation.
ADULT CARDIORESPIRATORY ARREST
Electrical defibrillation or cardioversion depolarises a critical mass of the myocardium allowing the natural pacemaker of the heart to take over and restore a normal co-ordinated contraction. Though defibrillation is critical for the treatment of VF/VT, a period of well-performed CPR can help maintain myocardial and cerebral viability. During CPR advanced life support interventions are applied and potential causes sought. After an unsuccessful attempt at defibrillation, a further 2-minute period of CPR is recommended. Interruptions to CPR should be minimal. Attempts to secure the airway should not interrupt CPR for more than 20 seconds. Despite the lack of human data it is reasonable to continue to use vasopressors and antiarrhythmic drugs on a routine basis. Adrenaline should be administered every 3 minutes. Consideration should be given to the administration of an antiarrhythmic after the second failed defibrillation attempt (s). Other drugs/electrolytes should be considered depending on the individual circumstances.
The prognosis of asystole and pulseless electrical activity (PEA) is much worse than VF/VT and defibrillation is not indicated. Before the diagnosis of asystole is made, it is important to exclude the possibility of VF having been misdiagnosed. This may be due to equipment failure or misinterpretation. If there is any doubt about the diagnosis, treatment should begin as for VF.
There is no evidence to support the routine use i.v fluids. Fluids should be given if hypovolaemia is suspected.
Energy levels for monophasic defibrillation for adults should be set at maximum (usually 360 Joules) for all shocks. Biphasic energy levels should be set at 200J for all shocks. Three stacked-shocks may be of benefit when the time required for rhythm recognition and recharging the defibrillator is short (i.e.: < 10 seconds). 1 shock strategy may improve outcome by reducing interruption of chest compressions.
Precordial Thump should be considered within the first 15 seconds of a monitored arrest, where the rhythm is VF/pulseless VT and a defibrillator is not immediately available. The inside of the fist is brought down sharply from 25-30 cm to make contact with the mid-sternum of the victim’s chest.
Defibrillation. The discharge of a defibrillator delivers enough current to cause VF. Several case reports describe fires ignited by sparks from poorly attached defibrillator paddles in the presence of an oxygen-enriched atmosphere. One paddle or pad is placed on the midaxillary line over the 6th left intercostal space and the other on the right parasternal area over the 2nd intercostal space. Once the defibrillator is charged, the paddles must be either in place on the patient’s chest or resting in the defibrillator. Avoid placing paddles over ECG electrodes or other medical equipment. Ensure that any rescuers are in not contact with the patient or trolley and that the patient is not in contact with metal fixtures (“stand clear”). Avoid delivering the shock with a gap between paddle and chest wall or with paddles touching each other.
Check that the patient has a motor response to the shock indicating delivery of the charge. If there is no motor response consider that the “synchronise” mode of the defibrillator may be on or there may be a flat battery, disconnected/broken lead etc.
If the attempt at defibrillation is unsuccessful:
- Recommence CPR
- Check paddle and electrode placement
- Check that there is adequate skin contact
- Check defibrillator settings.
Ventilation/oxygenation. High flow oxygen should be used if available. Attempts at endotracheal intubation must not interrupt CPR for more than 20 seconds. Laryngeal masks airways and other similar supraglottic airway devices may be used instead of an endotracheal tube when intubation is difficult however they should not replace mastery of bag and mask ventilation and endotracheal intubation remains the optimal technique to provide ventilation, limit aspiration deliver 100% oxygen and may be used for administration of some drugs.
PROTOCOLS FOR PAEDIATRIC BASIC LIFE SUPPORT.
Paediatric basic life support is not identical to adult basic life support. Although the general principles are the same, specific techniques are required and these techniques change with the size of the child. (An ‘infant’ is less than 1 year of age and a ‘small child’ is less than 8 years of age). The differences are due to the different causes of cardiorespiratory arrest and differences in the anatomy and physiology between children and adults.
Hypoxaemia or hypotension or both cause the majority of cardiorespiratory arrest in children. Causes include trauma, drowning, sudden infant death syndrome (SIDS), septicaemia, asthma, upper airway obstruction and congenital abnormalities of the heart and lungs. The initial cardiac rhythm is often severe bradycardia or asystole. Unlike adults, ventricular fibrillation is very uncommon, except with some congenital cardiac abnormalities, poisoning with cardiac drugs or during resuscitation.
Respiratory arrest may occur alone and not progress to cardiac arrest if treated quickly.
The same DR ABC (see above) approach for adult basic life support is used with children however hyperextension of the neck may cause airway obstruction in small children. In infants, chest compressions may be performed with two fingers or with two thumbs (the rescuer’s hand encircle the infants chest with the thumbs on the sternum). Chest compressions are performed with the heel of s single hand in young children.
The initial rates of compressions and ventilation are the same as for adult basic life support. 30:2 at a rate of 100 compressions/minute. With infant advanced life support and two rescuers the ratio is changed to 15:2 with a rate of 75 compressions/minute.
Drugs may be administered by intravenous, interosseous (io) or endotracheal routes. Endotracheal administration is less effective and should only be used for adrenaline, lignocaine or atropine.
PROTOCOLS FOR PAEDIATRIC ADVANCED LIFE SUPPORT.
PAEDIATRIC CARDIORESPIRATORY ARREST
Oropharyngeal (Guedel) or nasopharyngeal airways may improve ventilation. The correct size oropharyngeal airway should reach from the angle of the mandible to the centre of the mouth. The correct size nasopharyngeal airway should reach from the tip of the nose to the tragus of the ear. The appropriate un-cuffed endotracheal tube size may be calculated by age (years)/4 +4. The endotracheal tube should be inserted age (years)/2 +12 cm.
The bone marrow has a rich blood supply and forms part of the peripheral circulation. Drugs injected by the interosseous route are distributed as fast and reach the same peak levels as by intravenous injection. Many sites are suitable. The most common site is the antero-medial surface of the distal or proximal tibia. All intravenous and interosseous drugs should be flushed with a small volume of fluid. Although adrenaline, lignocaine and atropine are well absorbed from the respiratory tree the optimal doses are not known. Recommended doses are adrenaline 100 mcg/kg, atropine 30 mcg/kg and lignocaine 2-3 mg/kg. Volumes of drug preparations (normal saline) should be 0.7 ml for neonate, 1-2 ml for an infant, 2-5 ml for a small child and 5-10 ml for a large child.
The initial energy dose for VF and pulseless VT is 2 J/kg with both monophasic and biphasic defibrillators. Subsequent doses are 4J/kg.
If hypovolaemia is suspected as the cause of cardiorespiratory arrest, an initial of 20 ml/kg should be given. Sodium bicarbonate has a limited and unproven place in the management of cardiorespiratory arrest. Sodium bicarbonate produces carbon dioxide which mat re-enter cells causing increased intracellular acidosis. Other adverse effects include hypernatraemia and hyperosmolality. Hypokalaemia may cause a life threatening tachyarrhythmia. Emergency treatment is 0.03-0.07 mmol/kg by slow injection. The blood sugar should be checked with the aim of achieving normoglycaemia Hypoglycaemia may be treated with 0.5 g/kg
Asystole or pulseless severe bradycardia (less than 60 in infants and 40 in children) should be treated with adrenaline 10 mcg/kg.
THE CHOKING PATIENT.
The signs and symptoms of upper airway obstruction will depend on the cause, severity and duration of obstruction. Airway obstruction may be gradual or sudden in onset. It may be partial or complete. Some common causes include:
- Unconsciousness
- Inhaled foreign body
- Trauma
- Infection
A foreign body airway obstruction is a life-threatening emergency. All patients with significant airway obstruction by a foreign body clutch their neck with the thumb and fingers. The severity of obstruction may be assessed by ability of the patient to cough. Patients with an effective cough usually have mild airway obstruction and may be managed by reassurance, encouraging coughing and continued observation. Victims with an ineffective cough usually have severe airway obstruction. Back blows, chest thrusts or abdominal thrusts are effective for relieving obstruction in conscious adults and children older than 1 year of age although injuries have been reported with abdominal thrusts. (The Heimlich manoeuvre is not recommended). In the conscious patient, initially five sharp back blows are given with the heel of the hand in the middle of the back between the shoulder blades. If the blows are unsuccessful the patient will need chest thrusts. A chest thrust is the same as chest compressions in CPR but are sharper and the airway is checked between each chest thrust. If the obstruction is not relieved, continue alternating five back blows with five chest compressions.
TRANSPORT OF THE CRITICALLY ILL
Transporting critically ill patients presents major problems, and adverse physiological changes occurring during transport can be life threatening. Thus transport of critically ill patients requires careful planning and strict attention to detail. The principles of achieving safe transport are:
§ Planning.
§ Personnel (correct number and correct skills).
§ Equipment.
§ Treatment to stabilise the patient before transport and treatments during transport.
§ Choice of route and type of transport.
Transport of critically ill patients may be within the hospital (for example between the intensive care unit and operating theatres), between hospitals (secondary transport) or from the site of the accident/onset of illness to the first hospital (primary transport).
There must be an adequate number of appropriately skilled personnel to ensure safe transport. Inexperienced or unskilled staff may not recognise or manage problems.
The type of equipment required depends on the stability of the patient. Basic monitoring is essential for all patients. More monitoring will be required for more complex and critical patients. All monitors must have adequate battery power. Emergency drugs, analgesics, sedatives, muscle relaxants and equipment to secure the airway must be available. Equipment should not be stored on the patient.
Immediately before transport begins the patient is checked and final preparations completed (e.g. giving bolus dose of muscle relaxant, analgesic or sedatives).
Transport preparations must not neglect the patient’s fundamental treatment.
Patient status check list
Airway secure and patent
Ventilation adequate
All drains are functioning and secure
Venous access is adequate and secure
Intravenous drips and infusions are functioning
Patient is safely secured to trolley
ECG, BP, Pulse oximeter, invasive monitors are functioning, alarms set
Manual resuscitator available and functioning
Suction device available and functioning
Oxygen cylinder is full
Spare oxygen cylinder available
Airway and intubation equipment available and functioning
Spare intravenous fluid
Additional drugs available
Patient notes, x-rays etc available
SELF-ASSESSMENT QUESTIONS
- Outline the treatment for the reversible causes of cardiorespiratory arrest.
- How do adult and paediatric resuscitation protocols differ?
- Write a list of all equipment and drugs required for the transport of a critically ill patient from an aimag hospital to UB.
Develop guidelines for the resuscitation of the newborn infant. Consider anticipating the need for resuscitation, recommended equipment and drugs, assessment of the newborn infant, airway management and ventilation, chest compressions and medications.
EMERGENCY CARE AND RESUSCITATION CASE STUDIES
Case 1.1
Tungalag is found floating in a river.She is resuscitated by a tourist and brought to University Hospital by ambulance.
Draw a flow diagram (algorithm) for basic life support in an adult.
Outline the different aetiologies of adult and paediatric cardiac arrest.
What are the usual rhythms seen in adult and paediatric cardiac arrest?
When she arrives at the hospital her ECG shows a regular wide complex QRS with a rate of 180 bpm. What is the likely arrhythmia and how may you manage it?
Describe the physiological basis of blood flow during chest compression CPR.
Discuss the physiological requirements for a successful outcome of cardiopulmonary resuscitation.
Case 1.2
Tulga has inhaled a lump of buuz. He is clutching his throat and coughing weakly.
Draw a flow diagram for the management of an inhaled foreign body.
Case 1.3
A 26-year lady presents to the sum hospital with a one-day history of severe abdominal pain and a two-month history of amenorrhea. She collapsed when the doctor was taking her history. She had a weak pulse; pulse rate 140/min and her BP was unrecordable. She responded to 3 litres of intravenous fluid. Her haemoglobin was 60 g/l after fluid resuscitation. It is decided that she will need urgent operation at the Sum hospital.
What information do you want from the doctor at the sum hospital? What information/instructions do you give them?
List drugs and equipment you would take with you.
What are the anaesthetic options?
The most likely diagnosis is a ruptured ectopic pregnancy. You decide to take some blood with you. Which blood group and how much would you take?
There are a number of different oxygen cylinders available. How long will each last if you use 4l/min of oxygen?
What do you believe is the minimum anaesthetic/resuscitation equipment/drugs that should be available at a sum hospital?