ALS Manual.pdf

Advanced Life Support 7th Edition January 2016 Reprinted in April 2017 ISBN - 978-1-903812-30-3 ADVANCED LIFE SUPPORT i  Advanced Life Support...

Advanced Life Support 7th Edition January 2016 Reprinted in April 2017 ISBN - 978-1-903812-30-3 ADVANCED LIFE SUPPORT i  Advanced Life Support 7th Edition January 2016 - Reprinted in April 2017 Editors Jerry Nolan David Gabbott Jasmeet Soar Carl Gwinnutt Sue Hampshire Andrew Lockey Sarah Mitchell Gavin Perkins David Pitcher Contributors Annette Alfonzo James Fullerton Oliver Meyer Mike Scott Matthew Cordingly David Gabbott Sarah Mitchell Gary Smith Ron Daniels Carl Gwinnutt Jerry Nolan Jasmeet Soar Robin Davies Sue Hampshire John Pawelec Andrew Wragg Charles Deakin Tony Handley Gavin Perkins Joyce Yeung Sarah Dickie Andrew Lockey David Pitcher Joel Dunning Kevin Mackie Susanna Price Acknowledgements We thank and acknowledge the members of the ERC 2015 Guidelines Writing Group who have contributed directly or indirectly to this ALS Manual: Gamal Eldin Abbas Khalifa, Annette Alfonzo, Hans-Richard Arntz, Helen Askitopoulou, Abdelouahab Bellou, Farzin Beygui, Dominique Biarent, Robert Bingham, Joost J.L.M. Bierens, Bernd W. Böttiger, Leo L. Bossaert, Guttorm Brattebø, Hermann Brugger, Jos Bruinenberg, Alain Cariou, Pierre Carli, Pascal Cassan, Maaret Castrén, Athanasios F. Chalkias, Patricia Conaghan, Charles D. Deakin, Emmy D.J. De Buck, Joel Dunning, Wiebe De Vries, Thomas R. Evans, Christoph Eich, Jan-Thorsten Gräsner, Robert Greif, Christina M. Hafner, Anthony J. Handley, Kirstie L. Haywood, Silvija Hunyadi-Anticevic, Rudolph W. Koster, Anne Lippert, David J. Lockey, Andrew S. Lockey, Jesús López-Herce, Carsten Lott, Ian K. Maconochie, Spyros D. Mentzelopoulos, Daniel Meyran, Koenraad G. Monsieurs, Nikolaos I. Nikolaou, Jerry Nolan, Theresa Olasveengen, Peter Paal, Tommaso Pellis, Gavin D. Perkins, Thomas Rajka, Violetta I. Raffay, Giuseppe Ristagno, Antonio Rodríguez-Núnez, Charles Christoph Roehr, Mario Rüdiger, Claudio Sandroni, Schunder-Tatzber, Eunice M. Singletary, Markus B. Skrifvars, Gary B. Smith, Michael A. Smyth, Jasmeet Soar, Karl-Christian Thies, Daniele Trevisanuto, Anatolij Truhlár, Philippe G. Vandekerckhove, Patrick Van de Voorde, Kjetil Sunde, Berndt Urlesberger, Volker Wenzel, Jonathan Wyllie, Theodoros T. Xanthos, David A. Zideman. We thank Mike Scott for taking and digitally preparing all the photographs in this manual. We also thank the Nuffield Hospital, Guildford, for the use of their facilities, Oliver Meyer for digital preparation of the 12-lead ECGs and rhythm strips, Correen Cleggett for help with the final preparation for printing, and the models who gave up their time to help with the photographs. Environmental friendly paper has been used. 15% recycled, elemental chlorine free fibre sourced from well managed forests. © Resuscitation Council (UK) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior written permission of the Resuscitation Council (UK). Permission must also be obtained before any part of this publication is stored in any information storage or retrieval system of any nature. Chain of Prevention © Gary Smith ECGs © Oliver Meyer Electrical conduction of the heart (Figure 8.6 and 10.1) © LifeART image (1989-2001) Wolters Kluwer Health, Inc.-Lippincott Williams & Wilkins. All rights reserved. Photographs © Mike Scott Published by Resuscitation Council (UK) 5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR Tel: 020 7388 4678 Fax: 020 7383 0773 E-mail: [email protected] Website: http://www.resus.org.uk Printed by: TT Litho Printers Limited Units 3 & 5 Northpoint, Enterprise Close, Medway City Estate, Rochester, Kent ME2 4LX Tel: 01634 845397 Email: [email protected] Website: http://www.ttlitho.co.uk The Resuscitation Council (UK) guidelines are adapted from the European Resuscitation Council guidelines and have been developed using a process accredited by The National Institute for Health and Care Excellence. The UK guidelines are consistent with the European guidelines but include minor modifications to reflect the needs of the National Health Service. This Advanced Life Support (ALS) manual is written by the Resuscitation Council (UK) ALS Subcommittee and forms part of the resources for the Resuscitation Council (UK) ALS course, which is delivered in accredited course centres throughout the UK. ADVANCED LIFE SUPPORT ii Contents Chapter 1 Advanced Life Support in perspective................................................ 1 Chapter 2 Non-technical skills in resuscitation.................................................. 7 Chapter 3 Recognising deterioration and preventing cardiorespiratory arrest.......... 13 Chapter 4 Cardiac causes of cardiac arrest....................................................... 23 Chapter 5 In-hospital resuscitation................................................................ 43 Chapter 6 Advanced Life Support algorithm..................................................... 51 Chapter 7 Airway management and ventilation................................................. 63 Chapter 8 Rhythm recognition...................................................................... 77 Chapter 9 Defibrillation................................................................................ 95 Chapter 10 Cardiac pacing.............................................................................. 103 Chapter 11 Peri-arrest arrhythmias.................................................................. 111 Chapter 12 Resuscitation in special circumstances.............................................. 121 Chapter 13 Post-resuscitation care................................................................... 153 Chapter 14 Prehospital cardiac arrest............................................................... 163 Chapter 15 Blood gas analysis and pulse oximetry............................................... 171 Chapter 16 Making decisions about CPR............................................................ 181 Chapter 17 Supporting relatives in resuscitation practice..................................... 189 Appendix A Drugs used during the treatment of cardiac arrest............................... 193 Appendix B Drugs used in the peri-arrest period.................................................. 195 Appendix C Useful links.................................................................................. 199 ADVANCED LIFE SUPPORT iii Glossary Throughout this publication: The masculine pronouns he, him and his are used generically. The terms cardiopulmonary arrest, cardiorespiratory arrest and cardiac arrest have been used interchangeably. Adrenaline is the preferred term for adrenaline/epinephrine. A Amperes AC alternating current ACEI angiotensin converting enzyme inhibitor ACS acute coronary syndrome AED automated external defibrillator AF atrial fibrillation ALS advanced life support AMI acute myocardial infarction AV atrioventricular as in atrioventricular node AVNRT AV nodal re-entry tachyarrhythmia AVRT AV re-entry tachyarrhythmia BLS basic life support- no equipment is used except protective devices BP blood pressure CABG coronary artery bypass grafting CCU coronary care unit CK creatine kinase CHB complete heart block CPR cardiopulmonary resuscitation - refers to chest compressions and ventilations CVP central venous pressure DC direct current DNACPR do not attempt cardiopulmonary resuscitation ECG electrocardiogram ED emergency department EMS emergency medical services (e.g. ambulance service) h hour HDU high dependency unit ICD implantable cardioverter-defibrillator ICU intensive care unit IM intramuscular IO intraosseous IV intravenous JVP jugular venous pressure LBBB left bundle branch block LMA laryngeal mask airway LT laryngeal tube LV left ventricular MET medical emergency team MILS manual in-line stabilisation NSTEMI non-ST-elevation myocardial infarction PCI percutaneous coronary intervention PPCI primary percutaneous coronary intervention PEA pulseless electrical activity PLMA ProSeal laryngeal mask airway ROSC return of spontaneous circulation RV right ventricular s second SA sino-atrial as in sino-atrial node SBP systolic blood pressure STEMI ST-elevation myocardial infarction SVT supraventricular tachycardia TDP torsade de pointes VF ventricular fibrillation VT ventricular tachycardia VF/pVT ventricular fibrillation/pulseless VT WPW Wolff-Parkinson-White syndrome ADVANCED LIFE SUPPORT iv Advanced Life Support in Chapter perspective 1 The problem Coronary heart disease (CHD) is the biggest single cause of death in the UK. In 2012, 16% of male deaths and 10% of female deaths were from CHD, a total of around 74,000 deaths. There are nearly half a million hospital admissions associated with CHD in the UK each year. English ambulance services initiate resuscitation on about 28,000 patients who sustain an out-of-hospital cardiac arrest each year (52 cases per 100,000 inhabitants). Most cardiac arrests occur in the home and are presumed to have a cardiac cause. Around two-thirds of cardiac arrests are witnessed by either a bystander or ambulance staff. The presenting rhythm is shockable (ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT)) in about a quarter of cases and non-shockable in the remainder – asystole in about 50% and pulseless electrical activity (PEA) in about 25% of cases. Amongst those in whom resuscitation is attempted, 25–30% initially achieve a return of spontaneous circulation (ROSC) but only approximately 8% survive to go home from hospital. The incidence of in-hospital cardiac arrest is difficult to assess because it is influenced heavily by factors such as the criteria for hospital admission and implementation of do not attempt cardiopulmonary resuscitation (DNACPR) decisions. Data from 144 hospitals contributing data to the UK National Cardiac Arrest Audit showed that during 2011–2013 the overall incidence of adult in-hospital cardiac arrest was 1.6 per 1000 hospital admissions. The incidence varied seasonally, peaking in winter. The overall survival to hospital discharge was 18.4%. The presenting rhythm was shockable (VF/pVT) in 16.9% and non-shockable (asystole or pulseless electrical activity) in 72.3% of cases, and rates of survival to hospital discharge associated with these rhythms were 49.0% and 10.5%, respectively, but varied substantially across hospitals. All these individuals received chest compressions and/or defibrillation and were attended by the hospital resuscitation team in response to a 2222 call. Many patients who have an in-hospital cardiac arrest have significant comorbidity, which influences the initial rhythm and, in these cases, strategies to prevent cardiac arrest are particularly important. The Chain of Survival The interventions that contribute to a successful outcome after a cardiac arrest can be conceptualised as a chain - the Chain of Survival (Figure 1.1). The chain is only as strong as its weakest link; all four links of the Chain of Survival must be strong. They are: Early recognition and call for help Early cardiopulmonary resuscitation (CPR) Figure 1.1 Chain of Survival ADVANCED LIFE SUPPORT 1 Chapter 1 Advanced Life Support in perspective Early defibrillation reasonable health at minimum risk of a further cardiac arrest. The quality of treatment in the post-resuscitation Post-resuscitation care. period influences the patient’s ultimate outcome. The post-resuscitation phase starts at the location where ROSC Early recognition and call for help is achieved. The ALS provider must be capable of providing Out of hospital, early recognition of the importance of high quality post-resuscitation care until the patient is chest pain will enable the victim or a bystander to call the transferred to an appropriate high-care area. ambulance service so that the victim can receive treatment that may prevent cardiac arrest. Once cardiac ALS algorithm arrest has occurred, early recognition is critical to enable The ALS algorithm (Figure 1.2) is the centre point of the rapid activation of the ambulance service and prompt ALS course and is applicable to most CPR situations. Some initiation of bystander CPR. In the UK, the ambulance modifications may be required when managing cardiac service can be contacted by dialing 999. arrest in special circumstances (Chapter 12). In hospital, early recognition of the critically ill patient who Improving outcomes from cardiac is at risk of cardiac arrest and a call for the resuscitation team or medical emergency team (MET) will enable arrest treatment to prevent cardiac arrest (Chapter 3). A universal High quality care is safe, effective, patient-centred, timely, number for calling the resuscitation team or MET should be efficient and equitable. Hospitals, resuscitation teams and adopted in all hospitals - in the UK this number is 2222. If ALS providers should ensure they deliver these aspects of cardiac arrest occurs, do not delay defibrillation until quality to improve the care of the deteriorating patient and arrival of the resuscitation team – clinical staff should be patients in cardiac arrest. We describe below some of the trained to use a defibrillator. strategies to improve outcomes. Early CPR Evidence based guidelines Chest compressions and ventilation of the victim’s lungs will Improving outcomes from cardiac arrest depends on the implementation of evidence based guidelines. The slow down the rate of deterioration of the brain and heart. contents of this ALS provider manual are consistent with After out-of-hospital cardiac arrest, bystander CPR extends the Resuscitation Council (UK) Guidelines. The process used the period for successful resuscitation and at least doubles to produce the Resuscitation Council (UK) Guidelines has to quadruples the chance of survival after VF/pVT cardiac been accredited by the National Institute for Health and arrest. Performing chest-compression-only CPR is better than Care Excellence. The guidelines process includes: giving no CPR at all. Despite the well-accepted importance of CPR, bystander CPR rates are only approximately 40%. After Systematic reviews with grading of the quality of in-hospital cardiac arrest, chest compressions and evidence and strength of recommendations. This led to ventilation must be undertaken immediately, but should not the 2015 International Liaison Committee on delay attempts to defibrillate those patients in VF/pVT. Resuscitation (ILCOR) Consensus on Cardiopulmonary Interruptions to chest compressions must be minimised and Resuscitation and Emergency Cardiovascular Care should occur only very briefly during defibrillation attempts Science with Treatment Recommendations. and rhythm checks. The involvement of stakeholders from around the world including members of the public and cardiac arrest Early defibrillation survivors. Defibrillation within 3–5 min of collapse can produce Collaboration with the European Resuscitation Council, survival rates as high as 50–70%. This can be achieved and adapting its guidelines for use in the UK. through public access defibrillation, when a bystander uses a nearby AED to deliver the first shock. Each minute of The current Resuscitation Council (UK) Guidelines for cardiopulmonary resuscitation can be found at delay to defibrillation reduces the probability of survival to www.resus.org.uk hospital discharge by 10–12%. In the UK, an AED is deployed to fewer than 2% of out-of-hospital cardiac arrests (OHCA) before ambulance arrival. In hospitals, Quality standards sufficient healthcare personnel should be trained and Healthcare organisations have an obligation to provide a authorised to use a defibrillator to enable the first high quality resuscitation service, and to ensure that staff responder to a cardiac arrest to attempt defibrillation as are trained and updated regularly and with appropriate frequency to a level of proficiency appropriate to each rapidly as possible and certainly within 3 min. individual’s expected role. The same core standards apply to all health care settings: Post-resuscitation care Return of a spontaneous circulation is an important phase The deteriorating patient is recognised early and there is in the continuum of resuscitation; however, the ultimate an effective system to summon help in order to prevent goal is to return the patient to a state of normal cerebral cardiorespiratory arrest. function, a stable cardiac rhythm, and normal haemodynamic function, so that they can leave hospital in ADVANCED LIFE SUPPORT 2 Figure 1.2 Adult Advanced Life Support algorithm ADVANCED LIFE SUPPORT 3 Chapter 1 Advanced Life Support in perspective Cardiorespiratory arrest is recognised early and CPR is allowing a comparison of to be made not only within, but started immediately. also between, hospitals locally, nationally and internationally. Emergency assistance is summoned immediately, as soon as cardiorespiratory arrest is recognised, if help has not been summoned already. Safety incident reporting In England and Wales, hospitals can report patient safety Defibrillation, if appropriate, is attempted within 3 min incidents to the National Reporting and Learning System of identifying cardiorespiratory arrest. (NRLS) (http://www.nrls.npsa.nhs.uk/report-a-patient- Appropriate post-cardiorespiratory-arrest care is safety-incident/). A patient safety incident is defined as ‘any received by those who are resuscitated successfully. This unintended or unexpected incident that could have harmed includes safe transfer. or did lead to harm for one or more patients being cared for Implementation of standards is measured continually by the National Health Service (NHS)’. Resuscitation related and processes are in place to deal with any problems incidents are associated with equipment problems, identified. communication, delays in the resuscitation team attending, and failure to escalate treatment. Staff receive at least annual training and updates in CPR, based on their expected roles. The ALS course Staff have an understanding of decisions relating to CPR. The Resuscitation Council (UK) ALS course provides a Appropriate equipment is immediately available for standardised approach to cardiopulmonary resuscitation in resuscitation. adults. The course is targeted at doctors, nurses, and other healthcare professionals who are expected to provide ALS The Resuscitation Council (UK) Quality standards for in and out of hospital. The multidisciplinary nature of the cardiopulmonary resuscitation practice and training provide course encourages efficient teamwork. By training further detailed information. together, all ALS providers are given the opportunity to gain experience as both resuscitation team members and Measuring patient outcomes team leaders. The ALS course teaches the knowledge and Continuous measurement of compliance with processes, skills required to: and patient outcomes at a national and local level provides information on the impact of changes in practice, recognise and treat the deteriorating patient using a structured ABCDE approach identifies areas for improvement, and also enables comparison in outcomes between different organisations. deliver standardised CPR in adults Uniform definitions for collecting data for cardiac arrest manage a cardiac arrest by working with a exist. multidisciplinary team in an emergency situation The National Out of Hospital Cardiac Arrest Outcomes use non-technical skills to facilitate strong team leadership and effective team membership. project measures patient, process and outcome variables from out-of-hospital-cardiac arrest in the UK. The project The Resuscitation Council (UK) offers the option for a two- is run in collaboration with the National Ambulance Service day face-to-face ALS course, or the eALS course that Medical Directors Group with support from the British Heart consists of one day of e-learning that can be done in the Foundation, Resuscitation Council (UK) and University of participants own time and one day of face-to-face Warwick. The project is designed to measure the teaching at an ALS course centre. A large multi-centre epidemiology, and outcomes of cardiac arrest and to randomised-controlled trial showed that the learning serve as a national resource for continuous quality outcomes were similar for these two courses. The face-to- improvement initiatives for cardiac arrest. face component of both courses includes workshops, skill stations, cardiac arrest simulation (CAS) training, and The National Cardiac Arrest Audit (NCAA) is an ongoing, lectures. Candidates’ knowledge is assessed by means of a national, comparative outcome audit of in-hospital cardiac multiple choice question paper. Practical skills in airway arrests. It is a joint initiative between the Resuscitation management and the initial approach to a collapsed Council (UK) and the Intensive Care National Audit & patient (including defibrillation where appropriate) are Research Centre (ICNARC) and is open to all acute hospitals assessed continuously. There is also assessment of a in the UK and Ireland. The audit monitors and reports on simulated cardiac arrest (CASTest). Candidates reaching the incidence of, and outcome from, in-hospital cardiac the required standard receive a Resuscitation Council (UK) arrest in order to inform practice and policy. It aims to ALS Provider certificate. identify and foster improvements in the prevention, care delivery and outcomes from cardiac arrest. Resuscitation knowledge and skills deteriorate with time and therefore recertification is required for those who have Data are collected according to standardised definitions not recently undertaken the course to maintain ALS and entered onto the NCAA secure web-based system. Provider status. Recertification provides the opportunity to Once data are validated, hospitals are provided with refresh resuscitation skills and to be updated on activity reports and risk-adjusted comparative reports, ADVANCED LIFE SUPPORT 4 resuscitation guidelines, and can be undertaken by attending a provider course or an accredited recertification course. All ALS providers have a responsibility to maintain their skills in resuscitation and to keep up to date with changes in guidelines and practice, and the requirement for recertification should be seen as an absolute minimum frequency of refreshing skills and knowledge. Further reading Brace-McDonnell S, Perkins GD, OHCAO Collaborators. Out-of-Hospital Cardiac Arrest Outcomes. BMJ Open 2015. Cardiovascular disease statistics 2014. British Heart Foundation Centre on Population Approaches for Non Communicable Disease Prevention. Nuffield Department of Population Health, University of Oxford. December 2014. www.bhf.org.uk Monsieurs K, Nolan JP, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 1 Executive Summary. Resuscitation 2015;95:1-80. National Out of Hospital Cardiac Arrest Outcomes Project www.warwick.ac.uk/ohcao Nolan JP, Hazinski MF, Aicken R, et al. Part I. Executive Summary: 2015 International Consensus on cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e1-e32. Nolan J, Soar J, Eikeland H. The chain of survival. Resuscitation 2006;71:270-1. Nolan JP, Soar J, Smith GB, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014;85:987-92. Perkins GD, Handley AJ, Koster KW, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 2 Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81-98. Perkins GD, Kimani PK, Bullock I, et al. Improving the efficiency of advanced life support training: a randomized, controlled trial. Ann Intern Med. 2012;157(1):19-28. Resuscitation Council (UK). Quality standards for cardiopulmonary resuscitation and training. https://www.resus.org.uk/quality-standards/ Soar J, Callaway CW, Aibiki M, et al. Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2015;e71-e122. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 3 Adult Advanced Life Support. Resuscitation 2015;95:99-146. United Kingdom National Cardiac Arrest Audit https://www.icnarc.org/Our-Audit/Audits/Ncaa/About ADVANCED LIFE SUPPORT 5 Chapter 1 Advanced Life Support in perspective ADVANCED LIFE SUPPORT 6 Non-technical skills in Chapter resuscitation 2 Contents Non-technical skills Situational awareness Decision making Team working, including team leadership Task management The importance of communication Resuscitation teams Learning outcomes To enable you to: Be an effective team leader and team member Consider the role of non-technical skills during resuscitation Effectively use structured communication tools such as SBAR and RSVP Non-technical skills The skills of chest compressions, defibrillation, and rhythm recognition are considered typically to be important aspects of cardiac arrest management. These are all technical skills that are learnt from books, lectures, courses and peers. Although they are important for the successful resuscitation of a patient, there is another group of skills that is becoming increasingly recognised in medicine – non-technical skills. Non-technical skills can be defined as the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance. More simply, they are the things that affect our personal performance. Non-technical skills of leadership and teamwork have been identified as important contributory factors to technical skill performance in both simulated settings and poor clinical outcomes in acute medical settings. The importance of non-technical skills in emergencies is now widely accepted across many acute medical specialties including surgery, anaesthesia, critical care and acute medicine. Examples of poor non-technical skills include unwillingness to help, poor communication, poor leadership, poor decision-making, and no clear roles, all of which can lead to system errors. Episodes of cardiac arrest with documented system errors are associated with poor clinical outcomes such as decreased rates of return of spontaneous circulation and worse survival. Previous research has demonstrated that leadership behaviour is correlated with quality of CPR, with shorter hands-off time, pre-shock pauses and time to first shock. Understanding and improving non-technical skills may help to reduce human errors, creating more effective teams and improve patient safety. An effective team leader can help focus the team members, improve team commitment and act as the role model for the others. The key non-technical skills are situational awareness, decision making, team working and leadership, and task management. ADVANCED LIFE SUPPORT 7 Chapter 2 Non-technical skills in resuscitation Situational awareness Team working, including team This can be described as an individual’s awareness of the leadership environment at the moment of an event and the analysis This is one of the most important non-technical skills that of this to understand how an individual’s actions may contribute to successful management of critical situations. impact on future events. This becomes particularly A team is a group of individuals working together with a important when many events are happening common goal or purpose. In a team, the members usually simultaneously, for example, at a cardiac arrest. High have complementary skills and, through coordination of information input with poor situational awareness may effort, work synergistically. Teams work best when lead to poor decision making and serious consequences. everyone knows each other’s name, when they are doing At a cardiac arrest, all those participating will have varying something they perceive to be important, and when their degrees of situational awareness. In a well-functioning role is within their experience and competence. Optimal team, all members will have a common understanding of team function mandates a team leader. There are several current events, or shared situational awareness. It is characteristics of a good resuscitation team member: important that only the relevant information is shared otherwise there is too much distraction or noise. Competence – has the skills required at a cardiac arrest and performs them to the best of their ability. At a cardiac arrest, important situational awareness factors include: Commitment – strives to achieve the best outcome for the patient. consideration of the location of the arrest, which can give clues to the cause Communicates openly – being able to articulate their findings and actions taken, raise concerns about clinical obtaining information from staff about the events or safety issues, and listens to briefings and instructions. leading up to the arrest Supportive – enables others to achieve their best. confirmation of the diagnosis determining who is present – including names, roles, Accountable – for their own and the team’s actions. and who is leading Prepared to admit when help is needed. noting the actions already initiated (e.g. chest Creative – suggests different ways of interpreting the compressions) situation. checking that a monitor has been attached and Participates in providing feedback. interpreting what it shows communicating with the team, gathering information Team leadership implementing any immediate action necessary A team leader provides guidance, direction and instruction to the team members to enable successful completion of consideration of the likely impact of interventions their stated objective (Figure 2.1). They lead by example determining the immediate needs. and integrity. Team leaders need experience not simply seniority. Team leadership can be considered a process; it Decision making is available to everyone with training and not restricted to those with leadership traits. This is defined as the cognitive process of choosing a specific course of action from several alternatives. At a cardiac arrest, the many decisions to be made usually fall to the team leader. The leader will assimilate information from the team members and from personal observation and will use this to determine appropriate interventions. Typical decisions made at a cardiac arrest include: diagnosis of the cardiac arrest rhythm choice of shock energy to be used for defibrillation likely reversible causes of the cardiac arrest how long to continue resuscitation. Once a decision has been made, clear unambiguous communication with the team members is essential to ensure that it is implemented. Figure 2.1 Team leader ADVANCED LIFE SUPPORT 8 There are several attributes recognisable in a good team leader: Knows everyone in the team by name and knows their capability. Accepts the leadership role. Is able to delegate tasks appropriately. Is knowledgeable and has sufficient credibility to influence the team through role modelling and professionalism. Stays calm, keeps everyone focused and controls distractions. Is a good communicator – not just good at giving instructions, but also a good listener and decisive in action. Figure 2.2 Task management Is empathetic towards the whole team. Is assertive and authoritative when required. Identifying the resources required - ensuring that equipment is checked and specifics organised and Shows tolerance towards hesitancy or nervousness in delegated. the emergency setting. Has good situational awareness; has the ability to Prioritising actions of the team. constantly monitor the situation, with an up-to-date Watching out for fatigue, stress and distress amongst overview, listening and deciding on a course of action. the team. During a cardiac arrest, the role of team leader is not Managing conflict. always immediately obvious. The leader should state early Communicating with relatives. on that they are assuming the role of team leader. Specifically, at a cardiac arrest the leader should: Communicating with experts for safe handover both by telephone and in person. Follow current resuscitation guidelines or explain a reason for any significant deviation from standard protocols. Debriefing the team. Consult with the team or call for senior advice and Reporting untoward incidents, particularly equipment or assistance if unsure about an intervention. system failures. Play to the strengths of team members and allow them Participation in audit (Chapter 1). some autonomy if their skills are adequate. To illustrate the importance of non-technical skills, a Allocate roles and tasks throughout the resuscitation modified team performance tool, the Team Emergency and be specific. This avoids several people or nobody Assessment Measure (TEAM) tool, is used during scenario attempting the task! teaching on the ALS Course. This tool is used as a teaching Use the two-minute periods of chest compressions to instrument and discussion point for both instructors and plan tasks and safety aspects of the resuscitation candidates throughout the face-to-face teaching and attempt with the team. during teaching scenarios. (Figure 2.3). Thank the team at the end of the resuscitation attempt and ensure that staff and relatives are being supported. The importance of communication Complete all documentation and ensure an adequate when managing a sick patient handover. Communication problems are a factor in up to 80% of adverse incidents or near miss reports in hospitals. This Task management failure of communication is also evident when a medical emergency occurs on a ward and a doctor or nurse During the resuscitation of a patient, either in full cardiac summons senior help. The call for help is often suboptimal, arrest or peri-arrest, there are numerous tasks to be carried with failure by the caller to communicate the seriousness of out by the team members, either sequentially or the situation and to convey information in a way that simultaneously. The coordination and control, or informs the recipient of the urgency of the situation. The poor management, of these tasks is the responsibility of the quality information heightens the anxiety of the person team leader (Figure 2.2). They include: responding to the call, who is then uncertain of the nature of Planning and, where appropriate, briefing of the team the problem they are about to face. A well-structured process (e.g. prior to arrival of the patient in the emergency that is simple, reliable and dependable, will enable the caller department). to convey the important facts and urgency, and will help the Being inclusive of all team members. recipient to plan ahead. It was for similar reasons that the ABCDE approach was developed as an aide memoire of the Being prepared for both the expected and the unexpected. key technical skills required to manage a cardiac arrest. ADVANCED LIFE SUPPORT 9 Chapter 2 Non-technical skills in resuscitation Figure 2.3 Team Emergency Assessment Measure (TEAM) tool ADVANCED LIFE SUPPORT 10  SBAR RSVP Content Example SITUATION REASON Introduce yourself and check you Hi, I’m Dr Smith the medical F2 are speaking to the correct person I am calling about Mr Brown on acute Identify the patient you are calling medical admissions who I think has a about (who and where) severe pneumonia and is septic Say what you think the current problem He has an oxygen saturation of 90% is, or appears to be despite high-flow oxygen and I am very worried about him State what you need advice about Useful phrases: - The problem appears to be cardiac/ respiratory/neurological/sepsis - I’m not sure what the problem is but the patient is deteriorating - The patient is unstable, getting worse and I need help BACKGROUND STORY Background information about the He is 55 and previously fit and well patient He has had fever and a cough for 2 Reason for admission days Relevant past medical history He arrived 15 minutes ago by ambulance ASSESSMENT VITAL SIGNS Include specific observations and vital He looks very unwell and is tiring sign values based on ABCDE approach Airway - he can say a few words Airway Breathing - his respiratory rate is 24, he Breathing has bronchial breathing on the left side. His oxygen saturation is 90% on Circulation high - flow oxygen. I am getting a blood gas and chest X-ray Disability Circulation - his pulse is 110, his blood Exposure pressure is 110/60 The early warning score is… Disability - he is drowsy but can say a few words Exposure - he has no rashes RECOMMENDATION PLAN State explicitly what you want the I am getting antibiotics ready and he is person you are calling to do on IV fluids What by when? I need help - please can you come and see him straight away Useful phrases: - I am going to start the following treatment; is there anything else you can suggest? - I am going to do the following investigations; is there anything else you can suggest? - If they do not improve; when would you like to be called? - I don’t think I can do any more; I would like you to see the patient urgently Table 2.1 SBAR (Situation, Background, Assessment, Recommendation) and RSVP (Reason, Story, Vital signs, Plan) ADVANCED LIFE SUPPORT 11 Chapter 2 Non-technical skills in resuscitation The use of the SBAR (Situation, Background, Assessment, Recommendation) or RSVP (Reason, Story, Vital signs, Plan) Summary learning tool enables effective, timely communication between individuals from different clinical backgrounds and Non-technical skills are important during hierarchies (Table 2.1). resuscitation. Resuscitation teams Use SBAR or RSVP for effective communication. The resuscitation team may take the form of a traditional cardiac arrest team, which is called only when cardiac arrest is recognised. Alternatively, hospitals may have strategies to recognise patients at risk of cardiac arrest and My key take-home messages to summon a team (e.g. medical emergency team) before cardiac arrest occurs (Chapter 3). The term resuscitation from this chapter team reflects the range of response teams. As the team may change daily or more frequently, as shift pattern working is introduced, members may not know each other or the skill mix of the team members. The team should therefore meet at the beginning of their period on duty to: Introduce themselves; communication is much easier and more effective if people can be referred to by their name. Identify everyone’s skills and experience. Allocate the team leader. Skill and experience takes precedence over seniority. Allocate responsibilities; if key skills are lacking (e.g. nobody skilled in tracheal intubation), work out how this deficit can be managed (Figure 2.4). Review any patients who have been identified as ‘at risk’ during the previous duty period. Further reading Finally, every effort should be made to enable the team Andersen PO, Jensen MK, Lippert A, et al: Identifying non-technical skills and members to meet to debrief (e.g. difficulties or concerns barriers for improvement of teamwork in cardiac arrest teams. about their performance, problems or concerns with Resuscitation 2010; 81:695–702. equipment and submit incident reports). It may also be possible to carry out a formal handover to the incoming Cooper S, Cant R, Porter J, et al: Rating medical emergency teamwork team. performance: Development of the Team Emergency Assessment Measure (TEAM). Resuscitation 2010; 81:446–452. Featherstone P, Chalmers T, Smith GB. RSVP: a system for communication of deterioration in hospital patients. Br J Nurs 2008;17:860-64. Flin R, O’Connor P, Crichton M. Safety at the Sharp End: a Guide to Non- Technical Skills. Aldershot: Ashgate, 2008. Yeung J, Ong G, Davies R, Gao F, Perkins GDP. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med 2012; 40:2617–2621. Acknowledgment TEAM tool adapted and modified from Cooper et al (2010) to be used in ALS training courses. See http://medicalemergencyteam.com/ for full details. Figure 2.4 Team briefing ADVANCED LIFE SUPPORT 12 Recognising deterioration Chapter and preventing cardiorespiratory arrest 3 Contents Prevention of in-hospital cardiac arrest: the Chain of Prevention Recognising the deteriorating patient Response to critical illness Causes of deterioration and cardiorespiratory arrest The ABCDE approach Learning outcomes To enable you to: Understand the importance of early recognition of the deteriorating patient Consider the relevant causes of cardiorespiratory arrest in adults Identify and treat patients at risk of cardiorespiratory arrest using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach Introduction Early recognition of the deteriorating patient and prevention of cardiac arrest is the first link in the Chain of Survival. Once cardiac arrest occurs, about 20% of patients having an in-hospital cardiac arrest will survive to go home. Prevention of in-hospital cardiac arrest requires staff education, monitoring of patients, recognition of patient deterioration, a system to call for help, and an effective response. Survival after in-hospital cardiac arrest is more likely if the arrest is witnessed and monitored, the rhythm is ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT), the primary cause is myocardial ischaemia, and the patient is successfully defibrillated immediately. Most cardiorespiratory arrests in hospital are not sudden or unpredictable events: in approximately 80% of cases there is deterioration in clinical signs during the few hours before cardiac arrest. These patients often have slow and progressive physiological deterioration, particularly hypoxia and hypotension (i.e. Airway, Breathing, Circulation problems) that is unnoticed by staff, or is recognised but treated poorly. The cardiac arrest rhythm in this group is usually non-shockable (pulseless electrical activity (PEA) or asystole) and the survival rate to hospital discharge is very low. Early recognition and effective treatment of the deteriorating patient might prevent cardiac arrest, death or an unanticipated intensive care unit (ICU) admission. Hospitals with the lowest incidence of in-hospital cardiac arrest have the highest cardiac arrest survival, perhaps suggesting better selection of patients suitable for cardiopulmonary resuscitation (CPR) or better prevention of cardiac arrest. Closer attention to patients who have a false cardiac arrest (i.e. a cardiac arrest team call when the patient has not had a cardiac arrest) may also improve outcome, because up to one-third of these patients die during their in-hospital stay. Early recognition will also help to ADVANCED LIFE SUPPORT 13 Chapter 3 Recognising deterioration and preventing cardiorespiratory arrest identify individuals for whom CPR is not appropriate or who Recognising the deteriorating do not wish to be resuscitated. patient Prevention of in-hospital cardiac In general, the clinical signs of critical illness are similar whatever the underlying process because they reflect arrest: the Chain of Prevention failing respiratory, cardiovascular, and neurological The Chain of Prevention can assist hospitals in structuring systems (i.e. ABCDE problems) (see below). Abnormal care processes to prevent and detect patient deterioration physiology is common on general wards, yet the and cardiac arrest. The five rings of the chain represent: measurement and recording of important physiological staff education; the monitoring of patients; the recognition observations of acutely ill patients occurs less frequently of patient deterioration; a system to call for help; and an than is desirable, especially at night. The assessment of effective response (Figure 3.1): very simple vital signs, such as respiratory rate, may help to predict cardiorespiratory arrest. To help early detection Education: how to observe patients; interpretation of of critical illness, many hospitals use early warning scores observed signs; the recognition of signs of deterioration; (EWS) or calling criteria. Early warning scoring systems and the use of the ABCDE approach; simple skills to allocate points to measurements of routine vital signs on stabilise the patient pending the arrival of more the basis of their derangement from an arbitrarily agreed experienced help; knowledge of rationale for and role in ‘normal’ range. The weighted score of one or more vital the rapid response system in use in the hospital. sign observations, or the total EWS, indicates the level of Monitoring: patient assessment and the measurement intervention required (e.g. increased frequency of vital and recording of vital signs, which may include the use signs monitoring, or the need to call ward doctors or of electronic monitoring and/or documentation devices. resuscitation teams to the patient). In the UK, the National Early Warning Score is recommended (Table 3.1). Recognition encompasses the tools available to identify patients in need of additional monitoring or Early warning scores are dynamic and change over time intervention, including suitably designed vital signs and the frequency of observations should be increased to charts and sets of predetermined ‘calling criteria’ to track improvement or deterioration in a patient’s condition. ‘flag’ the need to escalate monitoring or to call for more If it is clear a patient is deteriorating call for help early expert help. rather than waiting for the patient to reach a specific Call for help protocols for summoning a response to a score. deteriorating patient should be universally known and understood, unambiguous and mandated. Doctors and The patient’s EWS is calculated based on Table 3.1. An nurses often find it difficult to ask for help or escalate increased score indicates an increased risk of deterioration treatment as they feel their clinical judgement may be and death. There should be a graded response to scores criticised. Hospitals should ensure all staff are according to local hospital protocols (Table 3.2). empowered to call for help. A structured communication tool such as SBAR (Situation, Alternatively, systems incorporating calling criteria are Background, Assessment, Recommendation) or RSVP based on routine observations, which activate a response (Reason, Story, Vital signs, Plan) should be used to call when one or more variables reach an extremely abnormal for help. value. Recent research suggests that EWS may be better discriminators of outcomes than calling criteria. Some Response to a deteriorating patient must be assured, of hospitals combine elements of both systems. specified speed and by staff with appropriate acute or critical care skills, and experience. Figure 3.1 The Chain of Prevention ADVANCED LIFE SUPPORT 14  PHYSIOLOGICAL PARAMETERS 3 2 1 0 1 2 3 Respiration Rate ≤8 9 - 11 12 - 20 21 - 24 ≥25 Oxygen ≤91 92 - 93 94 - 95 ≥96 Saturations Any Supplemental Oxygen Yes No Temperature ≤35.0 35.1 - 36.0 36.1 - 38.0 38.1 - 39.0 ≥39.1 Systolic BP ≤90 91 - 100 101 - 110 111 - 219 ≥220 Heart Rate ≤40 41 - 50 51 - 90 91 - 110 111 - 130 ≥131 Level of A V, P, or U Consciousness Table 3.1 National Early Warning Score (NEWS) Nurse concern may also be an important predictor of example, the MET usually comprises medical and nursing patient deterioration. Even when doctors are alerted to a staff from intensive care and acute medicine and responds patient’s abnormal physiology, there is often delay in to specific calling criteria (Table 3.3). Any member of the attending to the patient or referring to higher levels of care. healthcare team, and in some cases the patient or their relatives, can initiate a MET call. Early involvement of the Response to critical illness MET may reduce cardiac arrests, deaths and unanticipated The traditional response to cardiac arrest is reactive: the ICU admissions, and may facilitate decisions about name ‘cardiac arrest team’ implies that it will be called limitation of treatment (e.g. do not attempt only after cardiac arrest has occurred. In many hospitals cardiopulmonary resuscitation (DNACPR) decisions). the role of the cardiac arrest team is incorporated into that Medical emergency team interventions often involve of other teams (e.g. rapid response team, critical care simple tasks such as starting oxygen therapy and outreach team, medical emergency team (MET)). These intravenous fluids. The benefits of the MET system remain teams are usually activated according to the patient’s EWS to be proved, but evidence is increasing of their worth. (see above) or according to specific calling criteria. For NEWS Minimum score observation Clinical response frequency 0 12 hourly Continue routine NEWS monitoring with every set of observations. 1–4 4–6 hourly Inform registered nurse, who must assess the patient. Registered nurse to decide if increased frequency of monitoring and/or escalation of clinical care is required. 5,6 or a 1 hourly Registered nurse to urgently inform the medical team caring for the patient. score of 3 in any single Urgent assessment by a clinician with core competencies to assess acutely ill patients. variable Clinical care in a monitored setting. ≥7 Continuous Registered nurse to immediately inform the medical team caring for the patient – this should be at monitoring of least at Specialist Registrar level. vital signs Emergency assessment by a clinical team with critical care competencies, which also includes a practitioner/s with advanced airway skills. Consider transfer of clinical care to a level 2 or 3 care facility (i.e. high dependency or critical care unit). Table 3.2 Example escalation protocol based on early warning score (EWS) ADVANCED LIFE SUPPORT 15 Chapter 3 Recognising deterioration and preventing cardiorespiratory arrest Airway obstruction Call MET if For a detailed review of airway management see Chapter 7. Acute change in: Physiology: Causes Airway Threatened Airway obstruction can be complete or partial. Complete Breathing All respiratory arrests airway obstruction rapidly causes cardiac arrest. Partial Respiratory rate < 5 min-1 obstruction often precedes complete obstruction. Partial Respiratory rate > 36 min-1 airway obstruction can cause cerebral or pulmonary oedema, exhaustion, secondary apnoea, and hypoxic brain Circulation All cardiac arrests injury, and eventually cardiac arrest. Pulse rate < 40 min-1 Pulse rate > 140 min-1 Central nervous system depression may cause loss of Systolic blood pressure < 90 mmHg airway patency and protective reflexes. Causes include head injury and intracerebral disease, hypercarbia, the Neurology Sudden decrease in level of depressant effect of metabolic disorders (e.g. diabetes consciousness mellitus), and drugs, including alcohol, opioids and general Decrease in GCS of > 2 points anaesthetics. Laryngospasm can occur with upper airway Repeated or prolonged seizures stimulation in a semi-conscious patient whose airway reflexes remain intact. Other Any patient causing concern who does not fit the above criteria In some people, the upper airway can become obstructed when asleep (obstructive sleep apnoea). This is more Table 3.3 Medical emergency team (MET) calling criteria common in obese patients and obstruction can be worsened in the presence of other factors (e.g. sedative drugs). In the UK, a system of pre-emptive ward care known as critical care outreach, has developed. Outreach services exist in many forms ranging from a single nurse to a Causes of airway obstruction 24-hour, seven days per week multiprofessional team. An outreach team or system may reduce ward deaths, Central nervous system depression postoperative adverse events, ICU admissions and readmissions, and increase survival. Rapid response teams, Blood such as outreach teams or METs, play a role in educating Vomitus and improving acute care skills of ward personnel. Foreign body (e.g. tooth, food) All critically ill patients should be admitted to an area that Direct trauma to face or throat can provide the greatest supervision and the highest level Epiglottitis of organ support and nursing care. This is usually in a critical care area (e.g. ICU, high dependency unit (HDU), or Pharyngeal swelling (e.g. infection, oedema) resuscitation room). These areas should be staffed by Laryngospasm doctors and nurses experienced in advanced resuscitation and critical care skills. Bronchospasm – causes narrowing of the small airways in the lung Hospital staffing tends to be at its lowest during the night Bronchial secretions and at weekends. This influences patient monitoring, Blocked tracheostomy treatment and outcomes. Admission to general wards in the evening, or to hospital at weekends is associated with increased mortality. Studies have shown that in-hospital Recognition cardiac arrests occurring in the late afternoon, at night or Assess the patency of the airway in anyone at risk of at weekends are more often non-witnessed and have a obstruction. A conscious patient will complain of difficulty lower survival rate. Patients discharged at night from ICUs in breathing, may be choking, and will be distressed. With to general wards have an increased risk of ICU readmission partial airway obstruction, efforts at breathing will be and in-hospital death compared with those discharged noisy. Complete airway obstruction is silent and there is no during the day and those discharged to HDUs. air movement at the patient’s mouth. Any respiratory movements are usually strenuous. The accessory muscles Causes of deterioration and of respiration will be involved, causing a ‘see-saw’ or cardiorespiratory arrest ‘rocking-horse’ pattern of chest and abdominal movement: the chest is drawn in and the abdomen expands on Deterioration and cardiorespiratory arrest can be caused inspiration, and the opposite occurs on expiration. by primary airway and/or breathing and/or cardiovascular problems. ADVANCED LIFE SUPPORT 16 Treatment failure of gas exchange, a reduction of venous return to The priority is to ensure that the airway remains patent. the heart, and a fall in cardiac output. Severe lung disease Treat any problem that places the airway at risk; for will impair gas exchange. Causes include infection, example, suck blood and gastric contents from the airway aspiration, exacerbation of chronic obstructive pulmonary and, unless contraindicated, turn the patient on their side. disease (COPD), asthma, pulmonary embolus, lung Give oxygen as soon as possible to achieve an arterial blood contusion, acute respiratory distress syndrome (ARDS) and oxygen saturation by pulse oximetry (SpO2) in the range of pulmonary oedema. 94–98%. Assume actual or impending airway obstruction in anyone with a depressed level of consciousness, regardless Recognition of cause. Take steps to safeguard the airway and prevent A conscious patient will complain of shortness of breath further complications such as aspiration of gastric contents. and be distressed. The history and examination will usually This may involve nursing the patient on their side or with a indicate the underlying cause. Hypoxaemia and hypercarbia head-up tilt. Simple airway opening manoeuvres (head can cause irritability, confusion, lethargy and a decrease in tilt/chin lift or jaw thrust), insertion of an oropharyngeal or the level of consciousness. Cyanosis may be visible but is a nasal airway, elective tracheal intubation or tracheostomy late sign. A fast respiratory rate (> 25 min-1) is a useful, may be required. Consider insertion of a nasogastric tube to simple indicator of breathing problems. Pulse oximetry is an empty the stomach. easy, non-invasive measure of the adequacy of oxygenation (Chapter 15). However, it is not a reliable indicator of Breathing problems ventilation and an arterial blood gas sample is necessary to obtain values for arterial carbon dioxide tension (PaCO2) and Causes pH. A rising PaCO2 and a decrease in pH are often late signs Breathing inadequacy may be acute or chronic. It may be in a patient with severe respiratory problems. continuous or intermittent, and severe enough to cause apnoea (respiratory arrest), which will rapidly cause cardiac Treatment arrest. Respiratory arrest often occurs because of a Give oxygen to all acutely ill hypoxaemic patients and treat combination of factors; for example, in a patient with the underlying cause. Give oxygen at 15 L min-1 using a chronic respiratory inadequacy, a chest infection, muscle high-concentration reservoir mask. Once the patient is weakness, or fractured ribs can lead to exhaustion, further stable, change the oxygen mask and aim for a SpO2 in the depressing respiratory function. If breathing is insufficient range of 94–98%. For example, suspect a tension to oxygenate the blood adequately (hypoxaemia), a pneumothorax from a history of chest trauma and confirm cardiac arrest will occur eventually. by clinical signs and symptoms. Early needle decompression (thoracocentesis), or thoracostomy, followed by chest drain Respiratory drive insertion is needed (Chapter 12). Central nervous system depression may decrease or abolish respiratory drive. The causes are the same as those for Patients who are having difficulty breathing or are airway obstruction from central nervous system depression. becoming tired will need respiratory support. Non-invasive ventilation using a face mask or a helmet can be useful and Respiratory effort prevent the need for tracheal intubation and ventilation. For patients who cannot breathe adequately, sedation, The main respiratory muscles are the diaphragm and tracheal intubation and controlled ventilation is needed. intercostal muscles. The latter are innervated at the level of their respective ribs and may be paralysed by a spinal cord Circulation problems lesion above this level. The innervation of the diaphragm is at the level of the third, fourth and fifth segment of the Causes cervical cord. Spontaneous breathing cannot occur with severe cervical cord damage above this level. For a detailed review of cardiac causes of cardiac arrest see Chapter 4. Inadequate respiratory effort, caused by muscle weakness Circulation problems may be caused by primary heart or nerve damage, occurs with many diseases (e.g. disease or by heart abnormalities secondary to other myasthenia gravis, Guillain-Barré syndrome, and multiple problems. Most often, circulation problems in acutely ill sclerosis). Chronic malnourishment and severe long-term patients are due to hypovolaemia. The heart may stop illness may also contribute to generalised weakness. suddenly or may produce an inadequate cardiac output for a period of time before stopping. Breathing can also be impaired with restrictive chest wall abnormalities such as kyphoscoliosis. Pain from fractured Primary heart problems ribs or sternum will prevent deep breaths and coughing. The commonest cause of sudden cardiac death (SCD) is an Lung disorders arrhythmia caused by either ischaemia or myocardial infarction. Cardiac arrest can also be caused by an Lung function is impaired by a pneumothorax or arrhythmia due to other forms of heart disease, by heart haemothorax. A tension pneumothorax causes a rapid block, electrocution and some drugs. ADVANCED LIFE SUPPORT 17 Chapter 3 Recognising deterioration and preventing cardiorespiratory arrest Sudden cardiac arrest may also occur with cardiac failure, In patients with a known diagnosis of cardiac disease, cardiac tamponade, cardiac rupture, myocarditis and syncope (with or without prodrome - particularly recent or hypertrophic cardiomyopathy. recurrent) is as an independent risk factor for increased risk of death. Apparently healthy children and young adults who have SCD may also have symptoms and signs (e.g. Causes of ventricular fibrillation syncope/pre-syncope, chest pain, palpitation, heart murmur) that should alert healthcare professionals to seek Acute coronary syndromes (Chapter 4) expert help to prevent cardiac arrest. Features that indicate Hypertensive heart disease a high probability of arrhythmic syncope include: Valve disease syncope in the supine position Drugs (e.g. antiarrhythmic drugs, tricyclic antidepressants, digoxin) syncope occurring during or after exercise (although syncope after exercise is often vasovagal) Inherited cardiac diseases (e.g. long QT syndromes) syncope with no or only brief prodromal symptoms Acidosis repeated episodes of unexplained syncope Abnormal electrolyte concentration (e.g. potassium, magnesium, calcium) syncope in individuals with a family history of sudden death or inherited cardiac condition. Hypothermia Electrocution Assessment in a clinic specialising in the care of those at risk for SCD is recommended in family members of young victims of SCD or those with a known cardiac disorder resulting in an Secondary heart problems increased risk of SCD. Specific and detailed guidance for the The heart is affected by changes elsewhere in the body. care of individuals with transient loss of consciousness is For example, cardiac arrest will occur rapidly following available (http://guidance.nice.org.uk/CG109). asphyxia from airway obstruction or apnoea, tension pneumothorax, or acute severe blood loss. Severe hypoxia Treatment and anaemia, hypothermia, oligaemia and severe septic Treat the underlying cause of circulatory failure. In many shock will also impair cardiac function and this may lead to sick patients, this means giving intravenous fluids to treat cardiac arrest. hypovolaemia. Assess patients with chest pain for an acute coronary syndrome (ACS). A comprehensive description of Recognition the management of ACS is given in Chapter 4. Most The signs and symptoms of cardiac disease include chest patients with cardiac ischaemic pain will be more pain, shortness of breath, syncope, tachycardia, comfortable sitting up. In some instances lying flat may bradycardia, tachypnoea, hypotension, poor peripheral provoke or worsen the pain. Consider using an anti-emetic, perfusion (prolonged capillary refill time), altered mental especially if nausea is present. state, and oliguria. Survivors of an episode of VF are likely to have a further Although the risk of SCD is greater for patients with known episode unless preventative treatment is given. These severe cardiac disease, most SCDs occur in people with patients may need percutaneous coronary intervention, unrecognised disease. Asymptomatic or silent cardiac coronary artery bypass grafting, or an implantable disease may include hypertensive heart disease, aortic defibrillator. valve disease, cardiomyopathy, myocarditis, and coronary disease. Treating the underlying cause should prevent many secondary cardiac arrests; for example, early goal-directed Recognition of risk of sudden cardiac death out of therapy to optimise vital organ perfusion decreases the risk hospital of death in severe sepsis. Cardiovascular support includes Coronary artery disease is the commonest cause of SCD. correction of underlying electrolyte or acid-base Non-ischaemic cardiomyopathy and valvular disease disturbances, and treatment to achieve a desirable cardiac account for some other SCD events. A small percentage of rate, rhythm and output. Advanced cardiovascular SCDs are caused by inherited abnormalities (e.g. long and monitoring and echocardiography may be indicated. short QT syndromes, Brugada syndrome, hypertrophic Appropriate manipulation of cardiac filling may require cardiomyopathy, arrhythmogenic right ventricular fluid therapy and vasoactive drugs. Inotropic drugs and cardiomyopathy), and by congenital heart disease. vasoconstrictors may be indicated to support cardiac output and blood pressure. ADVANCED LIFE SUPPORT 18 The ABCDE approach Airway (A) Airway obstruction is an emergency. Get expert help Underlying principles immediately. Untreated, airway obstruction causes The approach to all deteriorating or critically ill patients is hypoxia and risks damage to the brain, kidneys and heart, the same. The underlying principles are: cardiac arrest, and death. 1. Use the Airway, Breathing, Circulation, Disability, Exposure 1. Look for the signs of airway obstruction: (ABCDE) approach to assess and treat the patient. 2. Do a complete initial assessment and re-assess Airway obstruction causes paradoxical chest and regularly. abdominal movements (‘see-saw’ respirations) and the use of the accessory muscles of respiration. 3. Treat life-threatening problems before moving to the Central cyanosis is a late sign of airway obstruction. next part of assessment. In complete airway obstruction, there are no breath sounds at the mouth or nose. In partial obstruction, 4. Assess the effects of treatment. air entry is diminished and often noisy. 5. Recognise when you will need extra help. Call for In the critically ill patient, depressed consciousness appropriate help early. often leads to airway obstruction. 6. Use all members of the team. This enables 2. Treat airway obstruction as a medical emergency: interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously. Obtain expert help immediately. Untreated, airway obstruction causes hypoxaemia (low PaO2) with the 7. Communicate effectively - use the SBAR or RSVP risk of hypoxic injury to the brain, kidneys and heart, approach (Chapter 2). cardiac arrest, and even death. 8. The aim of the initial treatment is to keep the patient In most cases, only simple methods of airway alive, and achieve some clinical improvement. This will clearance are required (e.g. airway opening buy time for further treatment and making a diagnosis. manoeuvres, airways suction, insertion of an oropharyngeal or nasopharyngeal airway). Tracheal 9. Remember – it can take a few minutes for treatments intubation may be required when these fail. to work, so wait a short while before reassessing the patient after an intervention. 3. Give oxygen at high concentration: First steps Provide high-concentration oxygen using a mask 1. Ensure personal safety. Wear apron and gloves as with oxygen reservoir. Ensure that the oxygen flow is appropriate. sufficient (usually 15 L min-1) to prevent collapse of the reservoir during inspiration. If the patient’s 2. First look at the patient in general to see if the patient trachea is intubated, give high concentration oxygen appears unwell. with a self-inflating bag. 3. If the patient is awake, ask “How are you?”. If the In acute respiratory failure, aim to maintain an patient appears unconscious or has collapsed, shake oxygen saturation of 94–98%. In patients at risk of him and ask “Are you alright?” If he responds normally hypercapnic respiratory failure (see below) aim for he has a patent airway, is breathing and has bra