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In Hospital Resuscitation and Defibrillation. ABCDE approach Underlying principles Complete initial assessment Treat life-threatening problems Reassessment.

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Presentation on theme: "In Hospital Resuscitation and Defibrillation. ABCDE approach Underlying principles Complete initial assessment Treat life-threatening problems Reassessment."— Presentation transcript:

1 In Hospital Resuscitation and Defibrillation

2 ABCDE approach Underlying principles Complete initial assessment Treat life-threatening problems Reassessment Assess effects of treatment/ interventions Call for help early –e.g. Medical Emergency Team

3 A BCDE Talking Difficulty breathing, distressed, choking Shortness of breath Noisy breathing stridor, wheeze, gurgling See-saw respiratory pattern, accessory muscles

4 A BCDE Open The Airway Head Tilt, Chin Lift, Jaw Thrust Simple Adjuncts Oro-pharyngeal Airway Naso-pharyngeal Airway. Advanced Techniques LMA ETT O2 Nursing The Patient on his Side Naso-Gastric Tube

5 A B CDE Inspect Palpate Percuss Auscultate Chest Expansion Respiratory Rate Accessory Muscles Chest Deformities Cyanosis Tenderness Hyper-Resonance Equal Air Entry Adventitious Sounds

6 A B CDE Treat the Underlying Cause O2 To All Hypoxic Patients Respiratory Supports: Non invasive Face mask Bag-Mask-Valve Tracheal Intubation &Controlled Ventilation

7 AB C DE Look at the patient Pulse – tachycardia, bradycardia Blood pressure Peripheral perfusion - capillary refill time Organ perfusion – chest pain, mental state, urine output Bleeding, fluid losses

8 AB C DE Airway, Breathing Haemodynamic monitoring IV access Fluid challenge Inotropes/Vasopressors Treat Cause Oxygen/Aspirin/Nitrates/ Morphine for ACS

9 ABC D E AVPU Score GCS ABC Check Blood Glucose level & Pupils Check Drug Chart Consider Lateral Position

10 ABCD E Remove clothes to enable examination - e.g. injuries, bleeding, rashes Avoid heat loss Maintain dignity

11 In Hospital Resuscitation Sequence for collapsed patient in a hospital Check the patient for a response

12 In Hospital Resuscitation Sequence for collapsed patient in a hospital Shout for help.

13 In Hospital Resuscitation Sequence for collapsed patient in a hospital Look Listen Feel

14 In Hospital Resuscitation Sequence for collapsed patient in a hospital No pulse..... No Breathing for 10 Seconds Call Resuscitation Team

15 In Hospital Resuscitation Sequence for collapsed patient in a hospital Start CPR 30 : 2

16 In Hospital Resuscitation Sequence for collapsed patient in a hospital When Resuscitation Team Arrives

17 Open Airway Look for Signs of Life CPR 30:2 Until Defibrillator/Monitor Attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Call Resuscitation Team

18 Assess Rhythm Shockable ( VF/Pulseless VT ) 1 Shock J biphasic or 360 J monophasi c Immediately resume CPR 30:2 for 2 min Energy Level J biphasic 360 J monophasic

19 IF Shockable ( VF/Pulseless VT ) Persists Deliver 2 nd Shock CPR for 2 mins Adrenaline 1mg I.V Deliver 3 rd Shock After 2 min, assess rhythm: If organised electrical activity, check for signs of life: – if ROSC start post resuscitation care – if no ROSC go to non VF/VT algorithm 2 nd and subsequent shocks – J biphasic – 360 J monophasic Minimise Delays Between CPR and Shocks (< 10 s) Do not Delay Shock to Give Adrenaline Give Amiodarone Before 4 th Shock

20 Assess Rhythm Non-shockable (PEA/Asystole) Immediately resume CPR 30:2 for 2 min

21 Open Airway Look for signs of life Call Resuscitation Team CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseles VT) 1 Shock J biphasic or 360 J monophasic Immediately resume CPR 30:2 for 2 min Non-shockable (PEA/Asystole) Immediately resume CPR 30:2 for 2 min During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium ALS Treatment Algorithm During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium

22 Reversible Causes 4Hs 1)Hypoxia2) Hypovolemia 3)Hyper-Hypokalemia Hypocalcemia Hypoglycmia 4)Hypothermia Adequate Ventilation with 100% O2 Fluid Restoration Urgent Surgery to Stop Bleeding IV CaCl Low Reading Thermometer

23 Reversible Causes 4Ts 1)Tension Pneumothorax 2 ) Toxins 3)Thromboembolism 4)Tamponade Diagnosed Clinically Decompress by Needle Thoracocentesis Insertion of Chest Tube Specific History & Lab Investigations Supportive TTT & Antidotes Consider Thrombolytic Therapy Penetrating Chest Trauma Recent Cardiac Surgery Needle Pericardiocentesis Resuscitative Thoracotomy

24 Precodial Thumb Witnessed Shockable No Defilbrillator Monitored Ulnar Edge of a Tightly Clenched Fist 20 CM Height To the Lower ½ of Sternum

25 Mechanism of Defibrillation Defibrillation occurs by passage of electric current of sufficient magnitude across the myocardium to depolarize a critical mass of cardiac muscle simultaneously to enable the natural pace maker tissue to resume control.

26 Defibrillation Success Minimize Trans-Thoracic Impedance Electrode-Skin Contact Electrode Size Coupling Agent Paddle Force Phase of Ventilation Pads Versus Paddles One Shock Versus 3 Shock Sequence

27 Defibrillation Success Electrode Position Antero-Apical Antero-PosteriorBiaxillary

28 Synchronized Cardioversion If the Electric Cardioversion is Used to Convert Atrial or Ventricular Tachyarrhythmias, the Shock Must be Synchronized to Occur with the R-wave of the ECG Rather Than the T-wave to Avoid the Relative Refractory Period and Minimizing the Risk of Inducing VF.

29 Synchronized Cardioversion TachyarrhythmiaAdverse Signs Decreased Conscious Level Chest Pain Systolic B.P < 90 mmHg Heart Failure Regular Broad complex Tachycardia (Ventricular Tachycardia / SVT with Bundle branch block) Irregular Broad complex Tachycardia (Polymorphic VT = Torsade de pointes / AF with BBB) Irregular narrow complex tachycardia (AF) Regular narrow complex tachycardia (SVT)

30 Synchronized Cardioversion PRECAUTIONS Anticipating Slight Delay Sedation Energy Doses 200 J Monophasic J Biphasic 100 J Monophasic J Biphasic

31 Post Resuscitation Care Post Resuscitation Care Starts Where Return of spontaneous circulation is Achieved. ABCDE system-oriented approach to management should be followed in the immediate post resuscitation phase pending transfer to an appropriate high-care area. ABCDE system-oriented approach to management should be followed in the immediate post resuscitation phase pending transfer to an appropriate high-care area.

32 Ensure Clear Airway Adequate O2 & Ventilation Obtunded Cerebral Functions Immediate return of Normal cerebral Functions No Need For Tracheal Intubation O2 Mask Spontaneous Ventilation Tracheal Intubation controlled Ventilation Hypoxia & Hypercapnia: Further Cardiac Arrest 2ry Brain Injury Hyporcapnia Cerebral Ischemia Hypoxia & Hypercapnia: Further Cardiac Arrest 2ry Brain Injury Hyporcapnia Cerebral Ischemia Post Resuscitation Care

33 Pulse Bl.Pr. 1 Peripheral Perfusion 2 Capillary Refill Time < 2 Seconds Warm Pink Digits Neck Veins 3 Right Ventricular Failure Pericardial Tamponade Lung Bases 4 Left Ventricular Failure Post Resuscitation Care Maintain Normal Sinus Rhythm Maintain Adequate cardiac output

34 Post Resuscitation Care To Assess the Neurological Function. Ensure that Cardiac Arrest has not been Associated with Other Medical or Surgical Conditions Requiring Immediate Treatment

35 Post Resuscitation Care Monitor Defibrillator O2 Supply Suction Apparatus Cannulae, Tubes, Drains are Secured Aim: T o transfer the patient safely between the site of resuscitation and a place of definitive care Patient Transfere

36 Further Assessment Post Resuscitation Care History To Establish Regular Drug Therapy Before Cardiac Arrest Monitors ECG Pulse Oximetry Capnography C.V.P U.O.P Investigations C.B.C Biochemistry 12 Lead E.C.G Echocardiography Chest X.R A.B.G

37 Post Resuscitation Care Optimizing Organ Function Target Mean Arterial Pressure Adequate U.O.P Consider patient’s Usual Blood Pressure Maintain Normal Sinus Rhythm To Avoid decrease in C.O.P Correct Hypo-perfusion During Cardiac Arrest I.V Fluids Inotropes

38 Post Resuscitation Care Optimizing Organ Function Cerebral Perfusion Sedation Control of Seizures Treatment of Hyperthermia & Therapeutic Hypothermia Control of Blood Glucose

39 Prognosis Post Resuscitation Care No N eurological Signs C an Predict the Outcome in the F irst Hours after ROSC Poor Outcome P redicted at 3 Days by: – Absent Pupil L ight Reflexes – Absent M otor Response to Pain

40 Thank You


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