In accordance with the Resuscita- tion Guidelines, 2015

IMMEDIATE Sarah Hope Produced by ECG Ltd, December LIFE SUPPORT 2019 PRE-COURSE HANDBOOK

Contents

Introduction ...... 3 Non-Technical Skills ...... 3 Leadership ...... 3 Teamwork ...... 4 Situational Awareness ...... 4 Communication Skills ...... 4 Debrief ...... 5 Reporting Incidents ...... 5 Signs of Deterioration ...... 6 Chain of Prevention ...... 6 National Early Warning Score ...... 7 Causes of patient deterioration ...... 8 The A-E Assessment ...... 9 Airway (A) ...... 10 Breathing (B) ...... 11 Circulation (C) ...... 12 Disability (D) ...... 14 Exposure (E) ...... 15 Basic Life Support ...... 17 Chain of Survival ...... 17 Recovery position ...... 23 Choking ...... 24 Advanced Life Support ...... 26 Cardiac Arrest Rhythms ...... 26 Cardiac Arrest Drugs ...... 28 Causes of Cardiac Arrest and their reversal ...... 28 Ending a Resuscitation Attempt ...... 30 Opening the Airway ...... 30 Head Tilt & Chin Lift ...... 30 Jaw Thrust ...... 30 Oropharyngeal Airways (OPA) ...... 31

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Nasopharyngeal Airways (NPA) ...... 32 i-gels ...... 33 Pocket Mask ...... 34 Bag-Valve-Mask (two-person technique) ...... 34 Suction ...... 35 Oxygen ...... 36 Oxygen and Pulse Oximetry ...... 36 Cardiac Rhythms ...... 37 Normal cardiac conduction ...... 37 Cardiac Arrest Rhythms ...... 37 Ventricular Fibrillation ...... 38 Ventricular Tachycardia ...... 38 Asystole ...... 39 Pulseless Electrical Activity ...... 39 Defibrillation ...... 39 Automated External Defibrillators (AED) ...... 40 Safety ...... 40 Manual Defibrillation ...... 41 Post Resuscitation Care ...... 42 If the patient regains consciousness ...... 42 If the patient remains unconscious ...... 42 Anaphylaxis ...... 43 Fainting ...... 43 Seizures ...... 44 Asthma ...... 45 Hypoglycaemia ...... 45 Summary of Drugs for Medical Emergencies ...... 46 Do Not Attempt CPR ...... 47 ReSPECT ...... 47 References...... 49

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Introduction

The need for clinicians to be trained in high-quality resuscitation is essential. The term ‘Healthcare Professional’ is now considered to have a much wider scope and the expectations that are placed on a wider variety of healthcare professionals have undoubtedly increased.

Patients are increasingly seen for both consultation and diagnostic services in non-acute hospital locations that do not always have access to rapid emergency response teams. Our ageing popu- lation has an ever-expanding list of existing medical problems and public awareness of health, wellbeing and illness has become more prevalent. As such, the likelihood of Health Care Profes- sionals seeing unwell patients and being involved in cardiac arrests is higher than ever.

This course has been aligned to the Resuscitation Council UK (RCUK) guidelines on Immediate Life Support. The RCUK develop and publish guidelines on resuscitation based on scientific evi- dence, which is reviewed every five years. This pre-course handbook is based upon the most recent guidelines published in January 2015. The primary objective of the RCUK is to promote high-quality practice in all aspects of cardiopulmonary resuscitation to improve survival rates.

Non-Technical Skills Before we learn about the life-saving technical skills of Immediate Life Support (ILS) such as airway management and defibrillation, it is essential to consider the significance of non-technical skills.

Non-technical skills are of a huge importance in an emergency. Three of the most important non- technical skills are:

• Leadership • Teamwork • Awareness of the situation Leadership

A leader is someone who gives instruction and takes control of the situation.

The roles of a team leader are:

• To make clinical decisions according to RCUK guidelines, including the initial decisions of calling the resuscitation team, starting CPR and using a defibrillator • Ideally know team members by name • Communicate information clearly to both the team and any relatives present • Ensure all necessary equipment is available • Delegate tasks playing to the strengths of team members individual skills • Remain calm and potentially manage conflict • Take control of the situation/ be authoritative when needed • Show understanding and patience towards team members who may be nervous • Ensure a post incident debrief takes place to support the team

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Teamwork

Teamwork is one of the most important non-technical skills.

The qualities of a good team member are:

• Works up to their level of competency, asking for help when needed • Performs to the best of their ability • Communicates confidently and listens to others • Are supportive to other team members • Raises any concerns about safety or the clinical situation • Are accountable for their actions Situational Awareness

Situational awareness is an understanding of what is happening and how your actions can impact the situation and outcome. There are various ways to increase awareness of the situation:

• Ensure personal safety and the safety of those around you is a priority • Observe the surroundings – could this help to identify a cause of the emergency? • Know who is present (team members, relatives, bystanders etc.) • Gather information from team members, relatives, bystanders etc. • Prioritise the various needs the emergency demands • Gather equipment that is needed

Communication Skills Problems with communication contribute to 80% of adverse incidents in hospitals (1).

You should communicate any concerns about a patient using SBAR (2).

Situation – introduce yourself, confirm who you are speaking with and who about, and say what you need advice about.

“I am (name) calling about (name) and I am concerned that (observations, NEWS score)”

Background – brief background information about the patient (past medical history, reason for admission)

“Patient was admitted with (…) their last set of observations were (…)”

Assessment – include current observations using A-E assessment

“He is speaking but his respiratory rate is (…) his oxygen saturation is (…), his pulse (…) BP (…), he has new confusion and on exposure his skin is (…). I think the problem is (…)”

Recommendation – what action is requested/recommended

“I have given (…) but I need you to come and see the patient within (…) minutes and can I do anything in the meantime?”

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SBAR enables an individual to communicate all relevant information and the urgency of the sit- uation in a concise way. It is also important to remember to delegate tasks to specific team members (using name where possible) to avoid confusion.

Debrief

It is essential to debrief after an emergency event. It has been found that debriefing staff is an effective strategy in helping them deal with such stressful events and is a useful strategy to im- prove resuscitation performance. Ideally this should be soon after the event has occurred, but where this is not possible it is acceptable to have this any time after the event. It is most im- portant that the debrief is facilitated at some point following the event. This gives individuals the opportunity to offer support to team members and discuss any concerns that may have arisen during the event.

Reporting Incidents

It is essential to report all emergency incidents and any potential safety incidents according to local policy.

Remember you have a professional duty of candour (4).

Every healthcare professional must be open and honest with patients (or where appropriate, the patient’s advocate) when something goes wrong with their care which has the potential to cause harm or distress. A healthcare professional must inform the patient when something has gone wrong, apologise, offer a remedy or support to put matters right (if possible) and explain any effects of what has happened. Healthcare professionals must be honest and open with their colleagues and employers. They must support and encourage each other to be open and honest, and not prevent others from raising concerns.

All in-hospital cardiac arrests are reviewed and audited. The National Cardiac Arrest Audit (NCAA) is a UK-wide database of in-hospital cardiac arrests and is supported by the Resuscitation Council (UK) and the Intensive Care National Audit & Research Centre (ICNARC).

For out-of-hospital cardiac arrests, data is collected by the UK Ambulance Services.

Information you should gather:

• Patient's details • Date, time and location of cardiac arrest • Who attended • Interventions such as CPR, rescue breaths, use of pocket mask/bag valve mask • Time of AED arrival, analysis and shock (if advised), any subsequent shocks

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Signs of Deterioration

At ILS training level it is expected that you will not just respond to a cardiac arrest but have the capability to recognise and respond to signs of deterioration in order to potentially prevent a cardiac arrest occurring. Up to 80% of in-hospital cardiac arrests have signs of deterioration prior to the event. Where cardiac arrest is sudden, it is usually due to a catastrophic event such as a myocardial infarction (heart attack), sudden lethal dysrhythmia or major trauma.

Chain of Prevention

The chain of prevention is a tool from the RCUK to help ensure deterioration is identified in order to prevent progression into a cardiac arrest.

• Education

Educating staff in the assessment and identification of signs of deterioration and how to escalate any concerns about the patient appropriately.

• Monitoring

Healthcare staff should perform patient monitoring and assessment using the A-E ap- proach to assessment.

• Recognition

Healthcare staff must be able to put their training into practice in order to identify dete- rioration or any ‘red flags’. One way to assist with staff recognition is through the use of systems such as the National Early Warning Score.

• Call for help

Healthcare staff must understand how to appropriately escalate any concerns to senior clinicians and relay the relevant information required (for example using SBAR to effec- tively communicate the urgency of the situation).

• Response

The appropriate clinicians/medical teams must respond to the situation within a reason- able time frame depending on the urgency of the situation. They must be sufficiently trained to provide an effective response and have appropriate equipment available.

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National Early Warning Score (5)

The National Early Warning Score (NEWS) is a system to assist in the identification of signs of patient deterioration. The patient receives a score based on their observations (Figure 1) which will advise on the appropriate action to take (escalation and increased frequency of monitoring the patient) (Figure 2). The higher the NEW score, the higher the risk of deterioration.

Figure 1. The National Early Warning Score System (RCUK, 2016)

Figure 2. The recommended response to a patient based on their NEW score (5) (Royal Col- lege of Physicians, 2017)

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Causes of patient deterioration

Patient deterioration can be caused by problems with the airway, breathing and/or circulation.

Table 1. Causes of patient deterioration and cardiac arrest relating to airway, breathing and circulation.

Airway Breathing Circulation

Obstruction may cause a Respiratory inadequacy Primary and secondary rapid deterioration in may be due to an acute causes of cardiac respiratory function. Causes or chronic problem. These abnormalities include: of obstruction include: causes include:

Central Nervous System Infection Myocardial infarction depression

Foreign body Asthma Ischaemia

Blood, vomit and other Aspiration Hypovolaemia (can be associ- secretions ates with blood loss, sepsis, metabolic conditions, anaphy- laxis, other fluid loss)

Maxillo-facial trauma Pneumothorax Hypertensive heart disease

Local swelling due to infection Exacerbation of Chronic Drugs Obstructive Pulmonary Disease

Laryngospasm or bronchospasm Pulmonary embolus Acidosis

Trauma Electrolyte abnormalities

Haemothorax Hypothermia associated with drowning

Pulmonary oedema Electrocution

The end outcome of cardiac arrest is undoubtedly influenced by the quality of resuscitative care that is provided. In the peri-arrest period, the aim is to identify the deteriorating patient and instigate treatments with the aim of preventing the person deteriorating further. In cardiac arrest, the provision of high-quality basic life support and prompt defibrillation coupled with early mobilisation of emergency resources all contribute to survival and ongoing quality of life.

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The A-E Assessment

Early identification of the deteriorating patient and prevention of cardiorespiratory arrest is the first link in the chain of survival. Once cardiac arrest occurs, fewer than 20% of in-hospital cardiac arrests will survive to go home. In approximately 80% of cases, clinical signs deteriorate over the few hours before arrest. These patients often have slow, progressive physiological deterioration; often hypoxia and hypotension are either not noticed or are treated poorly. In general, the clinical signs of critical illness are similar whatever the underlying process because they reflect failing respiratory, cardiovascular and neurological systems. We use the A to E assessment as it is a systematic way to ensure we don’t miss anything and eliminate anything life threatening before moving on to the next most important section. We prioritise from A to E treating as we go – for example, if someone has an obstructed airway and cannot breath, we must treat this immediately – we would not move on to assessing their circulation.

ABCDE assessment looks at the below:

Airway Breathing Circulation Disability Exposure

Table 2. A normal A-E assessment. Airway Clear

No stridor

Breathing Respiratory rate 12-20 min⁻¹

No wheeze

No use of accessory muscles

Sp02 94-98% (or 88-92% in individuals with COPD)

Circulation Heart rate 60-100bpm

Blood pressure 120/80

Capillary refill time <2 seconds

Disability Alert on AVPU

PEARL (pupils equal and reactive to light)

Blood sugar levels normal

Exposure No bleeding

No injury

No swelling, rashes etc.

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Airway (A)

The main airway complication is obstruction. Noisy breathing efforts indicate a partial obstruc- tion, whilst silence indicates a complete obstruction. Noisy sounds include snoring (tongue ob- structing the pharynx) and stridor (laryngeal oedema – i.e. anaphylaxis). Strenuous respiratory movements may be observed such as the use of accessory muscles or see-saw respirations; where the chest and abdomen move in opposite directions. Other signs of an airway problem include patient distress and swelling to the lips and tongue. We must also consider any deform- ities or injuries affecting the upper airway/jaw.

There are multiple potential causes of an obstructed airway:

• The tongue • Blood • Vomit • Food • Trauma • Epiglottitis • Swelling of the pharynx • Laryngospasm • Depression of the central nervous system • Bronchospasm • Bronchial secretions • Infection

For the immediate treatment of an obstructed airway use the recognised guidance for the treat- ment of choking. We will look at this later in the pre-course book.

Figure 3. Images of airway problems – jaw injury, deformity of the jaw, obesity and swelling of the tongue.

Treatment to prevent an obstructed airway includes:

Identifying signs of airway obstruction:

- What sound can you hear? - Is there increased respiratory effort? - Is there any cyanosis (such as blue lips)?

Treatments for airway obstruction:

• Opening the airway with a head tilt chin lift or jaw thrust (we will cover this in more detail in the airway management chapter)

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• Suction (if trained)

• Various airway adjuncts can be used to support the airway (we will cover this in more detail in the airway management chapter)

• Putting the patient into the recovery position to protect their airway

• Give oxygen at high concentration: • Give high concentration oxygen using a mask with an oxygen reservoir bag to ensure higher inspired oxygen concentrations. High flow oxygen (at 15L min⁻¹) should avoid collapse of the reservoir bag during inspiration. • Use pulse oximetry to guide oxygen therapy. • Aim for an oxygen saturation of 94-98%. In patients with chronic obstructive pulmonary disease (COPD) we aim for an Sp02 of 88-92% to prevent hypercapnic respiratory fail- ure.

Breathing (B)

Breathing problems can be acute or a result of a long-term condition. Respiratory arrest or in- sufficient respiration will lead to inadequate oxygenation of the blood which will affect vital or- gans. This will result in a loss of consciousness and ultimately a cardiac arrest.

Problems with the lungs (such as chronic obstructive pulmonary disease, asthma, pulmonary embolus, pulmonary oedema and pneumothorax) can restrict gas exchange. Other causes of breathing problems include depression of the central nervous system, spinal cord injury, muscle weakness/nerve damage (e.g. Guillain-Barre syndrome) and kyphoscolio- sis (which can restrict the chest movements).

Assessing breathing problems

To assess breathing problems, look, listen and feel for breathing to identify signs of respiratory distress. You may notice the patient is sweating, using accessory muscles and has central cya- nosis.

• Count the respiratory rate. The normal adult rate is 12 -20 breaths min-1. A high respir- atory rate is a strong indicator of deterioration which may occur rapidly.

• Assess breathing for the depth of each breath, the rhythm/regularity of respiration and look for equal chest expansion on both sides.

• Note the inspired oxygen concentration given to the patient (ideally 15L min-1) and the oxygen saturation reading of the pulse oximeter (if SpO2 monitor unavailable observe for evidence of peripheral or central cyanosis). Remember that a patient receiving high flow oxygen may have a normal Sp02 even if they have insufficient ventilation.

• Listen to the patient’s breath sounds (by listening close to their face). If a patient is unable to cough/take a deep breath, they may have airway secretions which can be heard as rattling noises. A partial airway obstruction may be heard as a stridor, and constriction of the bronchial tree may be heard as a wheeze.

• Continue with the highest possible concentration of inspired oxygen using a mask with an oxygen reservoir. Ensure high flow oxygen (15L min-1) to prevent collapse of the reservoir bag during inspiration. It is important to note that individuals with COPD are

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at risk of hypercapnic respiratory failure – so giving high concentrations of O2 can cause respiratory depression. It is advised these patients are given 4L min-1 and their target range kept to 88-92% O2. • If the patient’s depth or rate of breathing is inadequate or the patient has stopped breathing, use a pocket mask or two-person bag-mask ventilation while calling ur- gently for expert help.

• Hyperventilation and panic attacks may happen. In most cases, these will resolve with simple reassurance.

Summary of breathing problems:

• Patient has shortness of breath • Breath sound • Fast respiratory rate (>25 min-1) • Use of accessory muscles/see-saw breathing • Sp02 <94% • Confusion • Cyanosis (i.e. blue lips or tongue) • Chest deformities

Circulation (C)

Causes of circulatory problems include problems with the heart itself or heart abnormalities secondary to other conditions. Cardiac problems include: • Arrhythmia • Acute coronary syndrome i.e. myocardial infarction • Hypertensive heart disease • Valve disease • Cardiomyopathies/Long QT syndrome

In the case of acute coronary syndromes (ACS), they usually present as central chest pain, although atypical presentations can be seen. ACS can be divided into categories based on the result of a 12-lead ECG and the troponin concentration in their blood. - ST-segment-elevation myocardial infarction (STEMI) - Non ST-segment-elevation myocardial infarction (NSTEMI) (where troponin levels are raised but we do not see ST elevation on the ECG) - Unstable Angina (a lack of ECG or troponin level changes in the presence of chest pain).

Initial treatment for suspected ACS includes: • 300mg aspirin chewed • Sublingual glyceryl trinitrate (unless patient hypotensive) • Oxygen if patient Sp02 < 94% (or <88-92% with COPD) • Immediate escalation to cardiology for percutaneous coronary intervention

Secondary heart problems occur when changes elsewhere in the body affect the heart. The heart can be affected by the following:

• Electrolyte imbalances • Drugs • Hypervolemia • Septic shock • Hypothermia

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Assessing a patient for circulatory problems:

• Touch/hold and observe the patient’s hand and feel for the radial pulse (located in the wrist at the base of the thumb). A warm hand with a present pulse will suggest they likely have an acceptable blood pressure. A cool or pale/mottled hand with a weak or absent radial pulse will suggest inadequate organ perfusion.

• Measure the capillary refill time. Apply gentle pressure for five seconds on a fingertip held at the level of the heart. Time how long it takes for the blanched skin to return to the colour of the surrounding skin after releasing the pressure. The normal refill time is less than two seconds. A prolonged time suggests poor peripheral perfusion. Other fac- tors (e.g. age of the patient and surrounding temperature) can prolong the time.

• Count the rate and feel the character of the radial and carotid pulse (is it regular, strong, equal). A normal adult heart rate is 60-100 per min with a good volume. Fast, slow, weak or thready pulses are abnormal in most people.

• Measure the patient’s blood pressure (comparing this to their usual if known). Note that a patient in shock may have a normal blood pressure due to the compensatory mecha- nisms of the body increasing peripheral resistance.

• Note the patient’s urine output if they have a catheter, a low urine output known as oliguria is a urine volume of less than 0.5mL kg-1h-1.

• Look for signs of bleeding or injury.

• Insert a cannula if trained to enable fast delivery of fluids where fluid replacement is required. This should be given in the form of a 500mL rapid bolus of warmed crystalloid solution over less than 15 minutes.

• Reassess the pulse rate and blood pressure every 5 minutes, aiming for the patient‘s normal blood pressure. If this is unknown, in adults aim for a systolic blood pressure greater than 100 mmHg.

• If ACS is suspected (e.g. the patient has central chest pain) perform a 12-lead ECG and treat with aspirin, GTN and oxygen as described previously.

Figure 4. A demonstration of assessing Capillary Refill Time

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Summary of circulatory problems Circulatory problems can be identified from a range of features, including: • Chest pain • Pale complexion • Cyanosis • Slow capillary refill time (CRT) • Abnormal blood pressure (high or low) • Anormal heart rate (tachycardia or bradycardia) • Increased respiratory rate • Oliguria (low urine output)

No circulation: • Call for help • Commence CPR • Send for defibrillator • Consider IV access

Disability (D)

Disability refers to the level of consciousness and neurological condition of the patient. Possible causes of reduced levels of consciousness include:

• Hypoxia • Low blood pressure • Drugs • Hypoglycaemia • Stroke

The AVPU scale can be used to identify reduced levels of consciousness. • Alert • Vocal Stimuli (responds to voice) • Painful stimuli (responds to pain) • Unresponsive to all stimuli *The painful stimuli should be administered by squeezing the trapezius muscle between the neck and shoulder.

We can also consider signs of neurological injury: • Stroke (FAST – face arm speech time) • PEARL – pupils equal and reactive to light

There are several potential causes of a reduced level of consciousness. • Hypoglycaemia • Suspected stroke – call 999 • Hypoxia – give oxygen at 15L min⁻¹ • Cerebral hypoperfusion – i.e. faint – lie patient on floor and raise their legs.

Treating causes of disability

• Always review and treat problems with airway, breathing and circulation.

• Examine the pupils using a pen torch for their size, equality and reaction to light.

• Assess the patient’s level of consciousness rapidly using the AVPU method.

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• Measure the blood glucose, using a glucose meter or stick method, to exclude hypogly- caemia (this should be done in all unwell patients where possible – not just diabetic ones). When the blood sugar is below 4mmol L⁻¹, give glucose at a dose of 50mL of 10% glucose solution intravenously. Consider administration of glucose as intramuscu- lar or intravenous for unconscious patients or orally for conscious patients. Ensure you repeat blood glucose measurement to monitor the treatment and if no improvement is seen consider further doses of 10% glucose.

• Treat unconscious patients in the lateral position if their airway is not protected.

Exposure (E)

• Exposing the patient by loosening or removing clothing allows the healthcare profes- sional to identify problems such as bleeding, swelling, rashes (e.g. anaphylaxis), bruis- ing, deformity, evidence of trauma and any medical-alert jewellery. • Dignity must be maintained where possible and exposure kept to a minimum to avoid heat loss.

• Wet clothes should be removed as soon as practical.

Figure 5. An example of a skin rash.

Summary • Most patients will have signs of deterioration prior to an in-hospital cardiac arrest. • Early identification of deterioration and treatment will help to prevent a cardiac arrest. • Airway, breathing and circularity problems can cause a cardiac arrest. • The A-E assessment should be used to assess and treat patients who are deteriorating.

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NOTES

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Basic Life Support

Chain of Survival The 'Chain of Survival' concept is internationally recognised as summarising the important components of successful resuscitation

Figure 6. The chain of survival (Resuscitation Council UK 2016)

Early Recognition- If untreated, a quarter to a third of patients having a heart attack will go on to have a cardiac arrest within the first hour after onset of chest pain.

Early CPR - Prompt cardiopulmonary resuscitation (CPR) can help to buy time until a defibril- lator can attempt to restore a normal heartbeat. The rescue breaths and chest compressions help oxygenated blood flow to the person's brain and heart. This can double or quadruple sur- vival from out-of-hospital cardiac arrest.

Early defibrillation - For every minute the patient doesn’t have a defibrillator attached to their chest, their chances of survival reduce by 10%.

Early advanced life support - Advanced life support will be delivered by either an ambu- lance crew or an emergency medical team. This care can include basic life support, defibrilla- tion, administration of intravenous cardiac drugs and the insertion of airway adjuncts.

When a patient has a cardiac arrest, immediate life support (ILS) can be provided to help the patients chance of survival.

As in Basic Life Support (BLS) essentially you are providing chest compressions to pump blood around the body, ensuring the tissues and brain maintain an oxygen supply. Compressions alone are highly unlikely to result in recovery for a patient in cardiac arrest, but it is crucial in order to buy time prior to a defibrillator arriving. Failure of the circulation for three to four minutes (less if the victim is initially hypoxic) will lead to irreversible cerebral damage. Delay, even within that time, will lessen the eventual chances of a successful outcome. At ILS level we expect to see additional actions to be taken in the identification of deterioration, the mini- mising of interruptions to compressions and in airway management.

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The Resuscitation Council Guidelines were last updated on the 16th October 2015.

Basic life support consists of the following sequence of actions:

1. Make sure the victim, any bystanders and you are safe.

The first steps in any emergency is to ensure personal safety. Before going to assess someone, it is important to check that you, the patient or any by- standers are safe.

Potential threats to your safety include: • Traffic • Sharp objects • Electricity • Slip and trip hazards • Gases or chemicals

If there are no dangers or they have been dealt with it is safe to approach the patient to carry out the assessment.

• Within the hospital environment, consider Personal Protective Equipment (PPE), be cau- tious of sharps and consider your manual handling training.

2. Check the victim for a response

• If the patient appears unconscious or collapsed, shout for help. • Gently shake their shoulders and ask loudly “Are you all right?”

3a. If they respond

• If they respond you should call for help according to your local protocols. • Assess the patient using the A-E approach and continue to reassess them regularly. • Start monitoring their vitals such as oxygen saturations, blood pressure and consider recording an ECG. Give the patient oxygen (level dependent on their Sp02). • Consider venous access/blood samples if trained. • Consider the SBAR communication model to hand over to the relevant healthcare professional.

3b. If they do not respond:

• Shout for help • Turn the victim onto their back and then open the airway using head tilt and chin lift o Place your hand on the forehead and gently tilt the head back. o With your fingertips under the point of the victim's chin, lift the chin to open the airway • If there is a risk of cervical spine injury you may consider using a jaw-thrust or chin lift whilst stabilising the head and neck. If airway obstruction persists, it may be necessary to add a head tilt a small amount at a time to establish a patent airway which ultimately takes priority over the spine.

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4. Keeping the airway open, look, listen, and feel for normal breathing for no more than 10 seconds.

• Look for chest movement. In the first few minutes after car- • Listen at the victim's mouth for breath sounds. diac arrest, a victim may be barely • Feel for air on your cheek. breathing, or taking infrequent, • If in doubt about whether the breathing is normal, noisy, gasps. This is often termed continue as if the patient is not breathing normally. agonal breathing and must not be • If you are trained, at ILS level we expect healthcare confused with normal breathing. professionals to feel for a carotid pulse at the same time as checking for breathing. • NOTE: Immediately following cardiac arrest, blood flow to the brain is reduced which may cause a seizure-like episode that can be confused with epilepsy. There- fore, assess for cardiac arrest in any patient presenting with seizures by checking for breathing once any tonic-clonic movements have stopped.

5a. If they are breathing normally and have a pulse:

• Turn them into the recovery position to protect their airway (see below). • Summon appropriate help by calling the emergency team (or if out of hospital this may be the ambulance service by mobile phone, use the speaker phone if necessary. If this is not possible, send a bystander. Leave the victim only if there is no other way of obtaining help). • While awaiting help perform an A-E assessment, give oxygen and attach available monitoring. • Continue to assess that breathing remains normal. If there is any doubt about the presence of normal breathing, start CPR.

5b. If they are not breathing normally and you cannot feel a pulse:

• Ask someone to call for an ambulance and bring an AED if available. If you are on your own, use your mobile phone on speaker phone to call for an ambulance. Leave the victim only when no other option exists for getting help. • Start chest compressions as follows: o Kneel by the side of the victim. o Place the heel of one hand in the centre of the victim’s chest (which is the middle of Figure 7. A demonstration of hand the lower half of the victim’s sternum placement and position to deliver (breastbone)). chest compressions. o Place the heel of your other hand on top of the first hand. o Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not apply any pressure over the upper abdomen or the bot- tom end of the sternum. o Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum 5 - 6 cm. o After each compression, release all the pressure on the chest without losing con- tact between your hands and the sternum. o Repeat at a rate of 100 - 120 min⁻¹. o Compression and release should take an equal amount of time. o Keep any interruptions to compressions to a minimum. o Try to change the person performing chest compressions at least every 2 minutes, with minimal interruption when changing over.

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6. Combine chest compression with rescue breaths: 6.a Mouth-to-mouth

• After 30 compressions open the airway again using head tilt and chin lift (or other manoeuvre as previously described). • For mouth to mouth: pinch the soft part of the victim’s nose closed, using the index finger and thumb of your hand on his forehead. • Allow their mouth to open but maintain chin lift. • Take a normal breath and place your lips around their mouth, making sure that you have a good seal. • Blow steadily into their mouth whilst watching for their chest to rise; take about one second to make the chest rise as in normal breathing; this is an effective rescue breath. • Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air comes out. • Take another normal breath and blow into the victim’s mouth once more to give two effective rescue breaths. The two breaths should not take more than 5 seconds. Then return your hands immediately to the correct position on the sternum and give a further 30 chest compressions. • Continue with chest compressions and rescue breaths in a ratio of 30:2. • In the person where ventilations are not desirable or possible (e.g. due to vomit or blood where no resuscitation aid is available) then perform chest compression only CPR until the arrival of more equipment or the emergency services.

6.b. Airway equipment

• Use any airway equipment available such as a bag valve mask or a supraglottic airway. If these are unavailable, you may consider performing mouth to mouth or using a pocket mask to deliver rescue breaths. • Resuscitation aids such as face shields or pocket masks are preferable for adminis- tering breaths as they avoid direct patient contact. To use a pocket mask perform a head tilt and chin lift to open the airway then ensuring there is a tight seal between the pocket mask and the patients face blow into the inlet tube to deliver the breath. • If a supraglottic airway (i-gel or LMA) is available and you are adequately trained, you should insert this device. Upon the insertion of a supraglottic airway, it may be possible to ventilate the victim’s lungs by delivering breaths at a rate of 10 min⁻¹ whilst performing continuous chest compressions.

• Stop to recheck the victim only if he starts to show obvious signs of regaining con- sciousness, such as coughing, opening his eyes, speaking, moving purposefully and starting to breathe normally; otherwise do not interrupt resuscitation.

If the initial rescue breath of each sequence does not make the chest rise as in normal breathing, then, before your next attempt:

• Check the victim's mouth and remove any visible obstruction using suction/magills forceps as appropriate. • Recheck that there is adequate head tilt and chin lift. • Do not attempt more than two breaths each time before returning to chest com- pressions.

7. Defibrillation

• As soon as the defibrillator arrives apply the pads to the patient’s chest and turn on the defibrillator. • If you have an automated external defibrillator (AED) simply follow the voice in- structions.

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• If you have a manual defibrillator and are appropriately trained in rhythm recogni- tion you may use this to deliver a shock when appropriate. We will discuss both AED and manual defibrillators in an upcoming section.

8. Continue resuscitation

• In the meantime, continue cycles of 30:2 unless a supraglottic airway has been placed which may allow the delivery of 10 breaths min⁻¹ and continuous compressions. • Make every possible effort to minimise interruptions to chest compressions wherever possible. This can have a significant impact on the outcome. • Continue to use the defibrillator available to you. • Consider gaining IV access with a cannula and preparing any drugs likely to be used by the resuscitation team (if trained to do so).

8a. Continue resuscitation until:

• Qualified help arrives and takes over. • The patient shows obvious signs of regaining consciousness, such as coughing, opening his eyes, speaking, moving purposefully and starting to breathe normally. • You become physically exhausted.

9 . If the patient is not breathing but has a pulse (respiratory arrest)

• The patient should be given ventilated breaths as described above at a rate of 1 breath every 5 seconds. • The pulse should be reassessed every minute. • If there are any uncertanties about the presence of a pulse chest compressions should be started immediately. • If a respiratory arrest is not adequately treated with oxygen and rescue breaths it will rapidly develop into a cardiac arrest.

10. You are trained in manual defibrillation and the patient has a witnessed cardiac arrest.

• Where a manual defibrillator is rapidly available and cardiac arrest has been confirmed. • When a shockable rhythm is confirmed, three initial shocks can be given in quick succession. • A rapid check should be made for a rhythm change and if appropriate a pulse check after each attempt. • After the third shock we can begin CPR.

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Figure 8. The Resuscitation Council UK, 2015 NOTES

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Recovery position

A reminder of the recovery position – this is appropriate for patients who are unconscious and breathing normally.

• Remove the victim’s glasses and sharp objects from pockets, if present. • Kneel beside the victim and with the person lying on their back make sure that both their legs are straight. • Place the arm nearest to you out to the side with the elbow bent and the hand palm-up. • Take their other arm and hold the back of the hand against the victim’s cheek near- est to you. • With your other hand, grasp the far leg just below the knee and pull it up, keeping the foot on the ground. • Keeping their hand pressed against their cheek, pull on the far leg to roll the victim towards you on to their side. • Adjust the upper leg so that both the hip and knee are bent at right angles. • Tilt the head back to make sure that the airway remains open. • If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth. • Stay with the person and monitor them including checking their breathing regularly.

Figure 9. The recovery position.

If the victim must be kept in the recovery position for more than 30 min turn them to the opposite side to relieve the pressure on the lower arm. Pregnant woman should be placed on their left side.

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Choking

Foreign bodies can cause airway obstruction which can be mild or severe. Figure 10 summarises the key differences between signs of a mild and severe airway obstruction.

Figure 10. Identifying a mild and severe airway obstruction (Resuscitation Council UK, 2015).

Sequence for the treatment of a choking adult

1. If the patient shows signs of mild airway obstruction: • Only encourage them to continue coughing.

2. If the patient shows signs of severe airway obstruction and is conscious: • Give up to five back blows. • Stand to the side and slightly behind the victim and support their chest with one hand whilst leaning the patient forward. This means that when the obstructing object is dislodged it comes out of the mouth rather than goes fur- ther down the airway. • Give up to five sharp blows between the shoul- der blades with the heel of your other hand. • Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the ob- struction with each blow rather than necessarily to give all five.

Figure 11. Demonstration of delivering

back blows.

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If five back blows fail to relieve the airway obstruction move on to deliver up to five abdominal thrusts (in older children and adults). • Stand behind the victim and put both arms round the upper part of his abdomen. • Lean the victim forwards. • Clench your fist and place it between the umbilicus (navel) and the bottom end of the sternum (breast- bone). Grasp this hand with your other hand and pull sharply inwards and upwards. • Repeat up to five times.

If the obstruction is still not relieved continue alternating five back blows with five abdominal thrusts.

Figure 12. Demonstration of delivering abdominal thrusts.

Figure 13. Recommended actions for responding to a choking patient (Resuscitation Council UK, 2015).

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Advanced Life Support

We can take additional actions above the level of basic life support in order to perform the best quality compressions with the least amount of interruption, provide a shock (where ap- propriate) in the most efficient way and furthermore we can investigate the cause of cardiac arrest and attempt to reverse the problem.

Chest compressions are often inadequately performed by healthcare professionals, despite be- ing essential for a positive outcome. Once a patient’s airway is secured, we can perform con- tinuous compressions (as opposed to the 30:2 ratio where we stop to deliver the rescue breaths). We can secure an airway using tracheal intubation (if trained) or a supraglottic air- way such as an i-gel. Once the airway is secured, we can attach a bag and deliver breaths at a rate of 10 min⁻¹. It is important not to hyperinflate the lungs. We can also consider patient monitoring including; pulse checks, clinical signs of life, heart rhythm monitoring, waveform capnography (which is used to measure end-tidal C02), blood analysis, invasive cardiovascular monitoring and echocardiography.

Cardiac Arrest Rhythms

We will look at cardiac arrest rhythms in detail in the Cardiac Rhythms section of this manual, but we will now discuss them briefly in the context of understanding the ALS algorithm.

There are four possible cardiac arrest rhythms, split into shockable and non-shockable rhythms. These are:

• Shockable o Ventricular Fibrillation o Pulseless Ventricular Tachycardia

• Non-Shockable o Pulseless Electrical Activity o Asystole

Patients with a shockable rhythm require defibrillation whilst those in a non-shockable rhythm will not respond to defibrillation. All cardiac arrest patients (regardless of rhythm) require chest compressions, airway management, adrenaline administration and the investigation and treatment of the cause of the arrest.

After a shock is delivered, we perform 2 minutes of CPR before reassessing the rhythm – this ensures the interruptions to chest compressions are kept to a minimum. If we identify a non- shockable rhythm which appears in an organised manner, the responders should try to feel for a central pulse and look for any signs of cardiac output from the patient themselves or from any monitoring equipment.

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If we have a patient with a non-shockable cardiac arrest rhythm, we can perform the following actions:

• Commence CPR at a ratio of 30:2 • Administer adrenaline 1 mg IV as soon as possible • Secure the airway to enable continuous chest compressions to be performed alongside ventilation breaths being administered every 5 seconds. • Following 2 minutes of CPR reassess the rhythm: - If an organised rhythm is seen, check for a pulse and signs of life and perform post resuscitation care or continue CPR. - If a shockable rhythm is identified move to the shockable algorithm which is discussed in the section on manual defibrillation.

Figure 14. The Advanced Life Support algorithm (Resuscitation Council UK, 2015).

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Cardiac Arrest Drugs

It is recommended that a 1mg dose of Adrenaline is given intravenously after the delivery of the third shock whilst the subsequent CPR is being performed. Amiodarone 300mg is recom- mended after three shocks, and 150mg after 5 shocks. Once adrenaline is given it should be administered every 3-5 minutes to the patient if they remain in cardiac arrest.

Causes of Cardiac Arrest and their reversal Causes of cardiac arrest can be divided into 4 Hs and 4Ts (as in figure 15). These specific causes are important to be aware of because they each have potential treatments which can be used to achieve the return of circulation.

Figure 15. Causes of a cardiac arrest which can potentially be reversed (Resuscita- tion Council UK, 2015).

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Hypoxia

Hypoxia can be treated by ventilating the patient’s lungs with 100% oxygen whilst performing CPR, and by placing airway tubing to allow the delivery of ventilation breaths at a rate of 10min⁻¹.

Hypovolaemia

Severe blood loss can be a cause of PEA. Using fluid/blood transfusions in conjunction with stopping the bleeding (whether it be from trauma or problems such as an aortic aneurysm rupture requiring urgent surgery).

Hyperkalaemia

Hyperkalaemia (or other electrolyte imbalances such as hypokalaemia, hypocalcaemia, acidae- mia or hypoglycaemia) can be detected by testing the blood or potentially picked up through changes to the 12-lead ECG.

Hypothermia

Hypothermia should always be considered, and the patients temperature measured using a thermometer capable of reading low temperatures.

Thrombosis

Coronary thrombosis causing a myocardial infarction needs to be treated with percutaneous coronary intervention (which can be performed during a cardiac arrest). Pulmonary embolism is another thrombosis which can be treated with thrombolytic drugs.

Tension Pneumothorax

Tension pneumothorax can be identified by decreased chest expansion and tracheal deviation away from the affected lung. It can cause PEA and is treated with needle thoracocentesis and a chest drain.

Cardiac Tamponade

Cardiac tamponade should be suspected after cardiac surgery or chest trauma but is often hard to diagnose during a cardiac arrest.

Toxins

Again, this is difficult to diagnose unless there is a known history of ingestion of a substance. Antidotes appropriate to the toxin should be used where possible, otherwise healthcare pro- fessionals can only provide supportive treatment.

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Ending a Resuscitation Attempt The resuscitation team leader should discuss with team members whether to stop CPR. Whilst a patient is in a shockable rhythm or has an identified cause of cardiac arrest which has the potential to be reversed, CPR should be continued. If the team leader after discussion decides that CPR should be stopped, then death can be confirmed only after the patient is observed for a minimum of 5 minutes. During this time the following should be noted; no heart sounds on auscultation, no central pulse on palpation and asystole on the ECG display and absence of cardiac activity echocardiography. Tests for motor reactions and pupil responses will be per- formed before the time of death is recorded.

Following the resuscitation attempt, there must be ongoing care of the patient (or monitoring to confirm death), delegating tasks to team members, documentation of the event including times, communication with family members/friends, a post-event debrief to allow all team members to communicate any concerns, restocking of equipment and completing audit forms.

Opening the Airway

Head Tilt & Chin Lift

The head tilt-chin lift manoeuvre is the primary method used to open the airway. To perform the head tilt-chin lift manoeuvre, place one of your hands on the patient’s forehead and apply gentle, firm, backward pressure us- ing the palm of your hand. Place the fingers of the other hand under the bony part of the chin. Lift the chin forward and support the jaw, helping to tilt the head back. This manoeuvre will lift the patient’s tongue away from the back of the throat and provide an adequate airway. Figure 16. Demonstration of a head-tilt chin-lift.

Jaw Thrust

The jaw-thrust manoeuvre is considered an alternative method for opening the airway. This manoeuvre is accom- plished by holding the sides of the head (keeping clear of the ears so the patient can hear you). Find the angle of the man- dible. Apply upward/forward pressure with the index fingers placed behind the angle of the mandible. Use the thumbs to open the mouth slightly and put downwards pressure to lower the chin. This manoeuvre is useful if you believe the patient may have a neck injury. Figure 17. Demonstration of a jaw thrust.

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Oropharyngeal Airways (OPA)

This is a mechanical device that prevents the tongue from obstructing the airway. An OPA is a plastic tube (see figure 18) which can be placed in the mouth of unconscious patients. The tube is available in various sizes, and the appropriate size can be identified by measuring the distance between the incisors and the an- gle of the jaw and comparing this to the OPA itself. It can be used in conjunction with Bag Valve Mask ventilation. Figure 18. Oropharyngeal airways of varying sizes.

If your patient is between sizes, it is more beneficial to choose the larger size. However, as a rough rule of thumb, the following sizes can be used:

• 00 = Babies

• 0 = Infants

• 1 = Children

• 2 = Small Adults

• 3 = Large Adults

• 4 = V Large Adults

Insertion of an OPA Check the mouth to ensure it is clear. Size the airway to ensure a good fit. The correct size should match the dis- tance from the angle of the jaw to the incisors.

Introduce the airway into the mouth in the upside down position and rotate 180 degrees into the correct position as it passes the hard palate and into the oropharynx.

Correct placement means the flange at the tip of the airway should sit between the front teeth and the lips. Check the airway to ensure patency. If the patient gags, remove it immediately.

Figure 19. Insertion of an oro- pharyngeal airway.

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Nasopharyngeal Airways (NPA)

An NPA is a long plastic tube for inserting into the nose and may be used on a conscious, re- sponsive victim or an unconscious victim. Unlike the oral airway, the nasal airway does not cause the victim to gag. NPAs should not be used on victims with suspected head trauma or skull fracture. It is most useful on patients with tris- mus (clenched jaw) or facial injuries. Figure 20. Nasopharyngeal airways of Caution using an NPA – around 30% of patients varying sizes. will have a nosebleed and if we select too large a size this can cause the patient to gag.

Insertion of an NPA • Check the design of the airway. Some brands require a safety pin to be inserted through the flange to ensure it remains in situ. If your air- ways do require a safety pin, do this BEFORE you insert It. • Check you have the correct size; it should reach from the tragus of the ear to the tip of the nos- tril. • Lubricate the airway thoroughly. • Insert the bevel end first vertically along the floor of the nose with a slight twisting action. Try the right nostril first. If there is an obstruction, then try the left. • Once in place, check for airway patency. • If the airway meets an obstruction in one nos- tril, withdraw it and try to pass it Figure 21. Insertion of a up the other nostril. nasopharyngeal airway

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Supraglottic airways can be used during CPR to en- able more effective ventilation than with a bag valve mask alone. They can be inserted without in- terrupting chest compressions and once in place al- low the responders to provide breaths every five seconds and perform continuous chest compres- sions. Figure 22. i-gels of varying sizes.

The i-gel is a supraglottic airway device which reduces the risk of gastric inflation and often provides more effective ventilation. It sits just above the larynx. The cuff is made of jelly like material and does not need to be inflated. It can be inserted without stopping CPR and forms a good laryngeal seal. They come in various sizes for both adults and children (see table 3).

Insertion of an i-gel • Remove the i-gel from the packaging and place a small bolus of lubrication on the middle of the cradle. Lubri- cate the i-gel on the back and sides of the cuff.

• Hold the i-gel firmly along the bite block and position it so the cuff outlet is facing towards the chin of the patient. The patient should be in the “sniffing the morning air” position. Gently press the chin down. In- troduce the leading soft tip into the mouth in the di- rection of the hard palate.

• Glide the device down and backwards along the hard palate with a continuous but gentle push until a defin- Figure 23. Insertion of an i-gel. itive resistance is felt. The incisors should be resting on the integral bite block. Tape down from maxilla to maxilla.

Table 3. Sizes of i-gels and the patient/patient weight appropriate for each size. Size Patient Patient

Weight (kg) 2 Small Paediat- 10-25 rics 2.5 Large Paediat- 25-35 rics

3 Small Adult 30-60 4 Medium Adult 50-90 5 Large Adult 90+

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Pocket Mask

The pocket mask is a device which enables a rescuer to provide ventilation breaths whilst keeping a barrier between the patient (and any vomit, blood etc) and the rescuer.

Breaths should be given by making an airtight seal between the mask and the face using both hands and delivering a rescue breath over a second, watching for the chest to rise/fall and giving a second breath. The breaths should be provided at a rate of 30 compressions to two rescue breaths.

Bag-Valve-Mask (two-person technique)

The bag-valve-mask can be used on its own or attached to an i-gel. As the bag is squeezed, the air is forced into the patient’s lungs. On release the exhaled air is released into the atmos- phere via a one-way valve. When used without supplemental oxygen, this will provide atmos- pheric oxygen concentrations (21%) but this is increased to 45% when attaching high flow oxygen directly to the bag. If a reservoir bag is used, oxygen concentrations of 85% are achieved when supplementing oxygen by 15L min⁻¹.

The use of this equipment requires skill to ensure a good seal. This should be used with a two-person technique where one person holds the mask in place using both hands and a jaw thrust, and the other squeezes the bag.

When squeezing the bag, care must be taken not to over-inflate the lungs. A gentle squeeze to ensure a chest rise is enough.

Using a Bag-Valve-Mask

A self-inflating bag can be connected to a face mask. The two-person technique for bag-mask ventilation is preferable. Deliver each breath over approximately one second and give a vol- ume that corresponds to normal chest move- ment; this represents a compromise between giving an adequate volume, minimising the risk of gastric inflation, and allowing adequate time for chest compression. During CPR with an un- protected airway, give two ventilations after each sequence of 30 chest compressions. Figure 24. Using a bag-valve-mask using a If the patient is breathing but insufficiently, we two-person technique. can support their ventilations. The rate of ven- tilation for an adult is 10-12 breaths per minute or, approximately 1 bag squeeze every 5-6 seconds (try to go with the patient’s own breathing effort and enhance the depth if required but add additional breaths if the rate is not sufficient).

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The bag should be depressed for a full 1-2 seconds and then released. Chest rise should be seen with adequate tidal volumes, approximately 400-600 ml. Appropriate oxygenation and ventilation should be reflected by pulse oximetry readings. Providers tend to hyperventilate patients. The emergency medicine literature has demonstrated that hyperventilation can be harmful by increasing intra-thoracic pressure, which decreases venous blood to the heart and subsequently decreases cerebral and coronary perfusion pressures. Be mindful of the potential harmful effects of hyperventilation when bagging your patient.

Suction Suction should be used by those who are trained in order to remove any potential obstruc- tions from the airway (e.g. saliva, blood, vomit). Larger pieces may need to be removed using Magill’s forceps is the wide-bore rigid catheter is not sufficient. Suction should be performed gently focussing on the sides of the mouth and drawing the catheter outwards. The catheter should not be placed further than is visible in the mouth.

There are two key types of suction unit; the manual & mechanical suction units.

Table 4. Manual and Mechanical suction.

Manual This has a soft large catheter, only insert it as far as you can see and only suction for a maxi- mum of 10 seconds.

Mechanical If there is a substantial amount of fluid, you may find a mechanical unit more effective. Insert the catheter, starting at the back, turn unit on and sweep from side to side as you withdraw from the mouth. Keep suction going until catheter is out of the mouth.

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Oxygen When performing resuscitation, the lungs should be ventilated with 100% oxygen until there is a return of spontaneous circulation. From there, a non-rebreathing mask should be used to deliver oxygen concentrations of up to 85% from rates of 10-15L min⁻¹. Oxygen should then be monitored using pulse oximetry to maintain the ideal range of 94-98% or 88-92% in the context of COPD as previously described.

Oxygen and Pulse Oximetry (6) Pulse Oximetry is a simple, non-invasive tool which provides an instant measure of the arterial blood oxygen saturation. Its main uses are; to detect hypoxaemia, targeting oxygen therapy, for general monitoring and as a diagnostic tool. When targeting oxygen therapy, we aim for a range of 94-98% SpO2 (with the exception of those with hypercapnic respiratory failure from COPD where the target range is 88-92%). In a cardiac arrest the pulse oximeter is not reliable to deliver an accurate reading and we should deliver 100% inspired oxygen.

The pulse oximeter probe is designed as a clip to be placed on the finger, having LEDs on one side and a photoreceptor on the opposite. The amount of light transmitted through the tissue is used to calculate the oxygen levels in the blood. It is important to note that pulse oximetry only measures oxygen saturation, so we cannot be sure of adequate oxygen levels in the tis- sues. Furthermore, a patient may have a high carbon dioxide level from insufficient breathing, yet their oxygen saturation can be normal. For this reason, arterial blood gas should be used to assess ventilation and oxygenation. Pulse oximetry results are not affected by anaemia, skin colour or jaundice.

Pulse oximetry inaccuracies can be the result of:

• Haemoglobins such as those present in sickle cell disease or carbon monoxide poison- ing. • Nail varnish • Motion artefact • Hypotension/vasoconstriction

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Cardiac Rhythms Normal cardiac conduction Under normal circumstances, contraction of the heart muscle is initiated in a specialised group of cells in the right atrium called the sinoatrial node. This contraction spreads across the atrial myocardium with each cell’s contraction initiating the contraction of the next. This wave spreads to the ventricles via the atrioventricular node, located in the septum of the heart and close to the junction between atria and ventricles. Beyond this, the impulse travels rapidly through the ventricular myocardium via purkinje fibres, which ensure that contraction is co-ordinated.

Figure 25. The cardiac conduction system.

Normal Sinus Rhythm

Cardiac Arrest Rhythms There are four possible cardiac arrest rhythms, split into shockable and non-shockable rhythms. These are:

• Shockable o Ventricular Fibrillation o Pulseless Ventricular Tachycardia

• Non-Shockable o Pulseless Electrical Activity o Asystole

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Ventricular Fibrillation

Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious, as blood is not pumped to the brain. Immediate treat- ment by defibrillation is indicated.

Looking at the ECG you will see:

• Rhythm – Irregular • Rate – indeterminate - chaos • QRS – nor recognisable • P wave - not seen.

Ventricular Tachycardia

This results from tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the patient to go into cardiac arrest.

Looking at the ECG you'll see that: • Rhythm - Regular • Rate – Rapid – usually >160bpm • QRS Duration - widened • P Wave - Not seen

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Asystole

This is a terminal rhythm with poor prognosis for resuscitation.

Looking at the ECG you'll see that: • Rhythm – Flat (undulating or ‘wavy’ baseline) • Rate - 0 • QRS Duration - None • P Wave - None

Pulseless Electrical Activity

This is defined as any ECG waveform that may be compatible with a pulse where no pulse exists. This is a common arrest rhythm and is often associated with trauma, blood and fluid loss and certain medical conditions (i.e. asthma).

Defibrillation

There are approximately 30,000 people in the UK who sustain a cardiac arrest outside hospital and are treated by the ambulance service each year. Electrical defibrillation is the only definitive therapy for shockable cardiac arrests; caused by ventricular fibrillation (VF) or pulseless ven- tricular tachycardia (VT). The delay from collapse to delivery of the first shock is the single most important determinant of survival. If defibrillation is delivered promptly, survival rates as high as 75% have been reported. The chances of successful defibrillation decline at a rate of about 10% with each minute of delay. Basic life support will help to maintain coronary and cerebral perfusion but is not a definitive treatment.

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Automated External Defibrillators (AED)

AEDs are sophisticated, reliable, safe, computerised devices that de- liver electric shocks to victims of cardiac arrest when the ECG rhythm is one that is likely to respond to a shock. Simplicity of operation is a key feature: controls are kept to a minimum, voice and visual prompts guide rescuers. Modern AEDs are suitable for use by both lay rescuers and healthcare professionals. All AEDs analyse the vic- tim’s ECG rhythm and determine the need for a shock. The semi- automatic AED indicates the need for a shock, which is delivered by the operator, while the fully automatic AED administers the shock without the need for intervention by the operator. Some semi-auto- matic AEDs have the facility to enable the operator (normally a healthcare professional) to override the device and deliver a shock Figure 26. An Automated manually, independently of prompts. External Defibrillator.

Safety

Defibrillators are potentially dangerous, so some safety aspects should be considered.

Items to consider for safety with the use of an AED: • Great care must be exercised where there is water. • Oxygen delivery devices (Bag-Valve-Mask or pocket mask) must be moved away from the patient. Oxygen does not itself burn but it does support combustion. • Defibrillation pads should be placed away from metal or conductive objects. This may include jewellery, medicinal patches (including GTN), 12 lead ECG electrodes. • Internal pacemakers are a special case. For some time, pacemakers have em- ployed internal protection circuitry to minimise pacemaker malfunction after defib- rillation. Even with these protective circuits, however, defibrillation may infrequently cause pacemaker disturbances including loss of pacemaker output, improper sens- ing, inadvertent reprogramming, and endocardial burns which may increase the pacing threshold and cause loss of capture. To minimise complications following defibrillation position the defibrillator electrodes at least 10-15cm from pacemaker (approximately the length of a paddle). The patient should have a pacemaker checked in hospital following defibrillation • Ensure ALL people are away from the patient when defibrillating. Shout clearly and loudly “Stand Clear” as you are about to deliver the shock. • Adult pads can be used in the absence of paediatric pads for children aged 1-8 years old • Ensure the pads go on as soon as possible as this will increase the chance of sur- vival and that interruptions to CPR should be minimised whilst using the AED.

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Manual Defibrillation Manual defibrillators enable the user to recognise the rhythm on a display and deliver (where appropriate) a shock rapidly without having to wait for the analysis of the rhythm that is per- formed by the AED. This minimises any interruptions to the chest compressions. The most im- portant factor in using manual defibrillation is the user who must be skilled enough to recog- nise a shockable rhythm and safely and quickly use the defibrillator to deliver a shock.

Using a manual defibrillator

• Confirm cardiac arrest as per the basic life support sequence. • Call for help – the resuscitation team. • Perform uninterrupted chest compressions whilst applying the pads to the patient’s chest, in the positions indicated on the pads (one under the right clavicle with the other on the right side of the chest on the midaxillary line) • Communicate effectively with the team to keep interruptions to compressions to a minimum – plan actions for rhythm analysis. • Stop compressions, confirm VF/pVT from the ECG monitor and after a maximum of 5 seconds resume compressions. • Ask all team members apart from the individual performing compressions to stand clear and to remove oxygen. • The individual using the manual defibrillator should select the energy (minimum of 150J for the first shock) and press the charge button. • Once the defibrillator is charged, the operator must have a final safety check that all team members and oxygen are away, before instructing the individual performing chest compressions to now also stand clear. • When this individual is clear, the operator should deliver the shock. • CPR should be immediately restarted and continued for 2 minutes before the operator warns the team to prepare for the next pause in CPR in order to assess the rhythm. • If VF/pVT is detected, repeat steps as above to deliver further shocks as necessary. • If electrical activity considered fitting with a normal cardiac output is seen during a rhythm check, the team should check for a central pulse and signs of life. • If there are signs of return of spontaneous circulation, post resuscitation care should be started. • If there are no signs of return of spontaneous circulation, change to the non-shocka- ble algorithm.

If the patient has a witnessed cardiac arrest: • Where a manual defibrillator is rapidly available and cardiac arrest has been confirmed. • When a shockable rhythm is identified, three initial shocks can be given in quick succession. • A rapid check should be made for a rhythm change and if appropriate a pulse check after each attempt. • After the third shock we can begin CPR.

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NOTES

Post Resuscitation Care

If the patient regains consciousness • Do not leave the patient where possible. • Encourage patient to remain lying down with feet raised in the air. • Monitor observations regularly (at least at 5-minute intervals). • Document all actions including history, duration of BLS, number of shocks delivered. • Prepare to recommence BLS again should the patient deteriorate. • Arrange emergency transfer to A&E.

If the patient remains unconscious ▪ Keep the patient in the recovery position and stay with them where possible. ▪ Monitor observations regularly (at least at 5-minute intervals). ▪ Document all actions including history, duration of BLS, number of shocks delivered. ▪ Prepare to recommence BLS again should the patient deteriorate. ▪ Arrange emergency transfer to A&E.

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Anaphylaxis

A severe allergic reaction may follow oral or parenteral administration of a drug. In general, the more rapid the onset of the reaction the more profound it tends to be. Symptoms may de- velop within minutes and rapid treatment is essential.

Signs and Symptoms

A – stridor, swelling to lips and tongue B – shortness of breath, increased respiratory rate, wheeze, increased work of breathing C – increased heart rate, low blood pressure, pale, sweaty, cyanosis D – reduced level of consciousness, confusion, agitation, sense of impending doom E – skin and / or mucosal changes (seen in 80% of cases)

Management

First-line treatment includes securing the airway, restoration of blood pressure (laying the pa- tient flat and raising the feet, or in the recovery position if unconscious or nauseous and at risk of vomiting), and administration of adrenaline (epinephrine) injection. This is given intra- muscularly in a dose of 500 micrograms (0.5 mL adrenaline injection 1 in 1000). The dose is repeated if necessary, at 5-minute intervals according to blood pressure, pulse, and respiratory function. Oxygen administration is also of primary importance. Arrangements should be made to transfer the patient to hospital urgently.

Paediatric Doses

• <6 yrs: 150 micrograms (0.15 mls 1:1000) IM • 6-12 yrs: 300 micrograms (0.3 mls 1:1000) IM • >12 yrs: 500 micrograms (0.5 mls 1:1000) IM

May be repeated at 5-minute intervals if no improvement.

Fainting

Insufficient blood supply to the brain results in loss of consciousness. The most common cause is a vasovagal attack or simple faint (syncope) due to emotional stress.

Symptoms and signs

• Patient feels faint • Low blood pressure & bradycardia • Pallor and sweating • Yawning and slow pulse • Nausea and vomiting • Dilated pupils • Muscular twitching

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Management

Lay the patient as flat as is reasonably comfortable and, in the absence of associated breath- lessness, raise the legs to improve cerebral circulation

Loosen any tight clothing around the neck

Once consciousness is regained, give sugar in water or a cup of sweet tea

Other possible causes

Postural hypotension can be a consequence of rising abruptly or of standing upright for too long; antihypertensive drugs predispose to this. When rising, susceptible patients should take their time. Management is as for a vasovagal attack.

Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faint- ness but does not usually result in syncope. In most cases reassurance is all that is necessary; rebreathing from cupped hands may be helpful but calls for careful supervision.

Seizures

It is not uncommon for epileptic patients not to volunteer the information that they are epilep- tic but there should be little difficulty in recognising a tonic-clonic (grand mal) seizure.

Symptoms and signs

• There may be a brief warning (this is variable). • Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanotic (tonic phase). • After 30 seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase). • There may be frothing from mouth and urinary incontinence. • The seizure typically lasts a few minutes; the patient may then become flaccid but re- main unconscious. After a variable time, the patient regains consciousness but may remain confused for a while.

Management

During a convulsion try to ensure that the patient is not at risk from injury but make no at- tempt to put anything in the mouth or between the teeth (in mistaken belief that this will pro- tect the tongue). Give oxygen to support respiration if necessary.

Do not attempt to restrain convulsive movements.

After convulsive movements have subsided place the patient in the recovery position and check the airway.

After the convulsion the patient may be confused (‘post-ictal confusion’) and may need reas- surance and sympathy. The patient should not be sent home until fully recovered. Seek medi- cal attention or transfer the patient to hospital if it was the first episode of epilepsy, or if the convulsion was atypical, prolonged (or repeated), or if injury occurred.

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Focal seizures similarly need very little active management. Again, the patient should be ob- served until post-ictal confusion has completely resolved.

Asthma

Most attacks will respond to 2 puffs of the patient's short-acting beta2 agonist inhaler such as salbutamol 100 micrograms/puff; further puffs are required if the patient does not respond rapidly. If the patient is unable to use the inhaler effectively, further puffs should be given through a large-volume spacer device (or, if not available, through a plastic or paper cup with a hole in the bottom for the inhaler mouthpiece). If the response remains unsatisfactory, or if further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst awaiting transfer, oxygen should be given; if a nebuliser is unavailable, then 2–10 puffs of salbutamol 100 micrograms/metered inhalation should be given (preferably by a large-volume spacer) and repeated every 10–20 minutes if necessary. If asthma is part of a more generalised anaphylactic reaction, an intramuscular injection of adrenaline (as detailed under Anaphylaxis above) should be given.

Hypoglycaemia

Measure the blood glucose to exclude hypoglycaemia using a rapid finger-prick testing method. If the patient does have hypoglycaemia (blood glucose of less than 4.0 mmol L) and is still conscious, initially glucose 10–20 g is given by mouth either in liquid form or as granulated sugar or sugar lumps. Approximately 10 g of glucose is available from non-diet versions of Lucozade® Energy Original 55 mL, Coca-Cola® 100 mL, Ribena® Blackcurrant 19 mL (to be diluted), 2 teaspoons sugar, and from 3 sugar lumps. If necessary, this may be repeated in 10–15 minutes. Figure 27. A blood glucose If glucose cannot be given by mouth, if it is ineffec- monitor. tive, or if the hypoglycaemia causes unconsciousness, glucagon 1 mg (1 unit) should be given by intramus- cular (or subcutaneous) injection. Once the patient regains consciousness oral glucose should be administered as above. If glucagon is ineffective or contra-indicated, the patient should be transferred urgently to hospital.

Nurse unconscious patients in the lateral position if their airway is not protected.

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Summary of Drugs for Medical Emergencies

Table 5. Drugs for use in a cardiac arrest (based on Resuscitation Council UK guid- ance).

Drug Shockable Rhythm Non-shockable Rhythm pVT/VF Asystole/PEA Adrenaline 1mg (10mL 1:10,000) given via IV 1mg (10mL 1:10,000) given via IV route. route.

Administer following the third shock Administer as soon as is possible. when chest compressions have been continued. Further doses should be given on al- ternating rounds of CPR (3-5 Further doses should be given on minutes intervals). alternating rounds of CPR (3-5 minutes intervals). Administering adrenaline should not cause any disruption to chest com- pressions. Adrenaline is the primary drug used in cardiac arrest. Vasocon- striction resulting from the alpha-adrenergic effects of adrenaline helps to improve both coronary and cerebral perfusion pressures. The beta-adren- ergic effects of adrenaline can improve coronary and cerebral blood flow, however, can also cause increases in myocardial oxygen consumption, ventricular arrhythmias and increased post cardiac arrest myocardial dys- function. There are studies which have shown improvement in short-term survival which justifies its continued use, despite having no proven long- term benefit. Amiodarone 300mg bolus diluted in 5% dex- Not recommended for use with non- trose to a volume of 20mL given shockable rhythms. via IV route.

Administer following the third shock when chest compressions have been continued.

Further dose of 150mg should be given following 5 defibrillation at- tempts if pVT/VF persists. Amiodarone acts to increase both the duration of the action potential and refractory period in the myocardium. This slows atrioventricular conduc- tion. Amiodarone also causes peripheral vasodilation. Amiodarone may im- prove short-term survival which justifies its continued use, despite having no proven long-term benefit. Amiodarone should be flushed with 0.9% so- dium chloride or 5% dextrose.

Should amiodarone be unavailable, lidocaine (100mg (1-1.5mg kg⁻¹)) should be considered for persistent pVT/VF following three shocks. An ad- ditional bolus of 50mg may be given if needed. No more than 3mg kg⁻¹ should be given within the first hour. Fluids In the context of hypovolaemia, fluids should be infused rapidly as 0.9% sodium chloride, Hartmann’s solution or PlasmaLyte. Blood transfusions should also be used in the context of major haemorrhage. Dextrose should not be given as this can cause hyperglycaemia which can impair neurological outcome and survival following a cardiac arrest.

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Do Not Attempt CPR Not every patient who suffers a cardiac arrest should receive resuscitation. In certain patients, this is an inappropriate action and the requirement for ‘Do Not Attempt CPR’ (DNACPR) status should always be considered to provide the patient with the most appropriate and dignified care.

Not everyone wants to receive CPR, so it is important to respect people's wishes and to make sure that they are offered a chance to make choices that are right for them.

A DNACPR decision may be made and recorded:

• At the request of the person themselves. • As a shared decision (made by the person themselves and their doctor and/or other healthcare team members) that the likelihood of CPR being beneficial in their current situation would not outweigh the potential burdens and risks of receiving attempted CPR. • By the healthcare team, because CPR should not be offered to a person who is dying from an advanced and irreversible condition and therefore CPR will not prevent their death. • By the healthcare team because the person themselves is not able to contribute to a shared decision and a decision must be made in their best interests.

ReSPECT

The DNACPR process is being superseded by ReSPECT.

ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment and is not just a replacement for a DNACPR form. The aim is to promote recording an emergency care plan by many more people, including many whose ReSPECT forms will recommend active treatment, including attempted CPR if it should be needed.

There is a gradual transition from DNACPR to ReSPECT documentation by locality so until the ReSPECT process has been introduced locally the DNACPR documentation remains valid.

The DNACPR or ReSPECT decision should be reviewed whenever the patient's condition changes and prior to any proposed move between care settings. A timeframe for review should be stated on the form when it is first signed.

Healthcare professionals must start CPR without delay to have the best chance of success. They will start CPR unless they have immediately available, clear documentary information to show them that this is not appropriate.

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ECG The Gatehouse, Bradwell Abbey, Alston Drive, Milton Keynes MK13 9AP Tel: 0845 423 8993 www.ecgtraining.co.uk

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References

1) Resuscitation Council (UK), Immediate Life Support Fourth Edition, (2018).

2) https://improvement.nhs.uk/documents/2162/sbar-communication-tool.pdf

3) https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how- do-i-check-someones-pulse/

4) https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/read- the-professional-duty-of-candour/

5) https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

6) https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/pulse-oximetry

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