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In Hospital Resuscitation and Defibrillation
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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
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ABCDE
•Talking•Difficulty breathing, distressed, choking•Shortness of breath•Noisy breathing
stridor, wheeze, gurgling •See-saw respiratory pattern, accessory muscles
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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
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ABCDE
Inspect
Palpate
Percuss
Auscultate
•Chest Expansion•Respiratory Rate•Accessory Muscles •Chest Deformities•Cyanosis
•Tenderness
•Hyper-Resonance
•Equal Air Entry• Adventitious Sounds
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ABCDE
Treatthe
UnderlyingCause
O2ToAll
Hypoxic Patients
RespiratorySupports:•Non invasive Face mask
•Bag-Mask-Valve
•Tracheal Intubation &Controlled Ventilation
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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
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ABCDE
• Airway, Breathing• Haemodynamic monitoring• IV access• Fluid challenge• Inotropes/Vasopressors• Treat Cause• Oxygen/Aspirin/Nitrates/
Morphine for ACS
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ABCDE
•AVPU Score•GCS
•ABC•Check Blood Glucose level & Pupils •Check Drug Chart•Consider Lateral Position
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ABCDE
• Remove clothes to enable examination
- e.g. injuries, bleeding, rashes
• Avoid heat loss
• Maintain dignity
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
Check the patient for a response
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
Shout for help.
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
Look ...... Listen ...... Feel
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
No pulse ..... No Breathing for 10
Seconds
Call Resuscitation Team
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
Start CPR30 : 2
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In Hospital Resuscitation Sequence for collapsed patient in a hospital
When Resuscitation Team Arrives
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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
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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
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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
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AssessRhyth
m
Non-shockable
(PEA/Asystole)
Immediately resume
CPR 30:2 for 2 min
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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
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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
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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
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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
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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.
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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
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Defibrillation SuccessDefibrillation Success
Electrode Position
Antero-Apical
Antero-Posterior Biaxillary
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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.
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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)
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Synchronized Cardioversion Synchronized Cardioversion
PRECAUTIONS
Anticipating Slight Delay
Sedation
Energy Doses
200 J Monophasic120-150 J Biphasic
100 J Monophasic70-120 J Biphasic
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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.
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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
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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
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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
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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
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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
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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
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Post Resuscitation Care
Optimizing Organ Function Optimizing Organ Function
•Cerebral Perfusion
•Sedation
•Control of Seizures
•Treatment of Hyperthermia & Therapeutic Hypothermia
•Control of Blood Glucose
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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
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Thank You