Management of periarrest arrhythmias
A coordinated strategy to reduce death from cardiac arrest should include not only cardiopulmonary resuscitation but also measures to treat potentially malignant arrhythmias that may lead to cardiac arrest or complicate the period after resuscitation. The term peri-arrest arrhythmia is used to describe such a cardiac rhythm disturbance in this situation. Cardiac arrest should be prevented wherever possible by the effective treatment of warning arrhythmias. Ventricular fibrillation is often...
Defibrillation and drugs
Defibrillation and drug administration is in accordance with advanced life support recommendations. On a practical note, Alternative method for lateral position Alternative method for lateral position it is difficult to apply an apical defibrillator paddle with the patient inclined laterally, and great care must be taken to ensure that the dependant breast does not come into contact with the hand holding the paddle. This problem is avoided if adhesive electrodes are used. Increasingly,...
Abdominal thrusts
In children over one year deliver up to five abdominal thrusts after the second five back blows. Use the upright position Heimlich manoeuvre if the child is conscious Unconscious children must be laid supine and the heel of one hand placed in the middle of the upper abdomen. Up to five sharp thrusts should be directed upwards toward the diaphragm Abdominal thrusts are not recommended in infants because they may cause damage to the abdominal viscera Effective basic life support is a...
complete the following checklist
Ensure that the ET tube is correctly placed in the trachea, using direct laryngoscopy or end-tidal CO2 monitoring Ensure that the patient is being adequately ventilated with 100 oxygen. Listen with a stethoscope and confirm adequate and equal air entry. If pneumothorax is suspected insert a chest drain Measure arterial pH and gases, repeating frequently Measure urea, creatinine and electrolytes, including calcium and magnesium Insert a urinary catheter and measure the urinary output Insert a...
No neck pain No distracting injury
No localised tenderness Patient alert and oriented No neurological signs or symptoms contralateral tracheal deviation, absent breath sounds, and hyperresonance to percussion all indicate a significant tension pneumothorax. Initial treatment by needle decompression aims to relieve pressure quickly before insertion of a definitive chest drain. Needle decompression is performed by inserting a l4G cannula through the second intercostal space immediately above the top of the third rib in the...
Regular narrow complex tachycardia
Vagotonic manoeuvres, such as the Valsava manoeuvre or carotid sinus massage, should always be considered as first line treatment. Caution is required, however, as profound vagal tone may cause a sudden bradycardia and trigger ventricular fibrillation, particularly in the presence of acute ischaemia or digitalis toxicity. Carotid sinus massage may result in rupture of an atheromatous plaque and the possibility of a stroke. The drug of choice for the initial treatment of regular supraventricular...
Vom iting and regurgitation
Rescuers should always be alert to the risk of contamination of the unprotected airway by regurgitation or vomiting of fluid or solid debris. Impaired consciousness from anaesthesia, head injury, hypoxia, centrally depressant drugs opioids and recreational drugs , and circulatory depression or arrest will rapidly impair the cough and gag reflexes that normally prevent tracheal soiling. Vomiting is an active process of stomach contraction with retrograde propulsion up the oesophagus. It occurs...
Meconium aspiration
A recent large, multicentre, randomised trial has shown that vigorous babies born through meconium should be treated conservatively. The advice for babies with central nervous system depression and thick meconium staining of the liquor remains that direct laryngoscopy should be carried out immediately after birth. If this shows meconium in the pharynx and trachea, the baby should be intubated immediately and suction applied directly to the tracheal tube, which should then be withdrawn. Provided...
Physical principles of oxygen therapy devices
Typically these devices are driven from a pressurised oxygen source to which varying amounts of air are added by entrainment. Entrainment embraces actions ranging from simple patient activated inspiration to customised Venturi-operated devices. Non-reservoir masks that profess to deliver oxygen at greater than 40 will require high oxygen flows in excess of 10 l min. By way of example, a 60 Venturi style mask requires 15 l min oxygen flow to generate the required 50 50 oxygen air mixture to...
Alkalising drugs
The return of spontaneous circulation and adequate ventilation is the best way to ensure correction of the acid-base disturbances that accompany cardiopulmonary arrest. During cardiac arrest gas exchange in the lungs ceases, whereas cellular metabolism continues in an anaerobic environment this produces a combination of respiratory and metabolic acidosis. The most effective treatment for this condition until spontaneous circulation can be restored is chest compression to maintain the...
Acute MI
pacing may generate QRS complexes with an effective cardiac output, particularly when myocardial contractility is not critically compromised. Conventional cardiopulmonary resuscitation CPR should be substituted immediately if QRS complexes with a discernible output are not being achieved. Many defibrillators incorporate external pacing units and use the same electrode pads for ECG monitoring and defibrillation. Alternatively, pacing may be the sole function of a dedicated external pacing unit....
Transthoracic impedence
In adults transthoracic impedence averages about 60 Ohms, with 95 of the population lying in the range of 30-90 Ohms. Current flow will be highest when transthoracic impedence is at its lowest. To achieve this the operator should press firmly when using handheld electrode paddles. A conductive electrode gel or defibrillator pads should be used to reduce the impedance at the electrode and skin interface. Self-adhesive monitor or defibrillator electrodes do not require additional pressure. In...
Further reading Tdb
Adams S, Whitlock M, Higgs R, Bloomfield P, Baskett PJF. Should relatives be allowed to watch resuscitation BMJ 1994 308 1689. American Heart Association, Emergency Cardiac Care Committee. Baskett PJF. Ethics in cardiopulmonary resuscitation. Resuscitation 1993 25 1-8. Bonnin MJ, Pepe PE, Kimball KT, Clark PS. Distinct criteria for termination of resuscitation in the out of hospital setting. JAMA 1993 270 1457-62. Bossaert L. Ethical issues in resuscitation. In Vincent JL, ed. Yearbook of...
Classification of hypovolaemic shock and changes in physiological variables
Class I Class II Class III Class IV Class I Class II Class III Class IV Class III is blood loss of 30-40 1500-2000ml , which is associated with a thready tachycardic pulse, systolic hypotension, pallor, and delayed capillary refill Class IV blood loss is in excess of 45 more than 2000 ml and is associated with barely detectable pulses, extreme hypotension, and a reduced level of consciousness Some texts claim that the radial, femoral, and carotid pulses disappear sequentially as blood pressure...
Airway patency
Failure to maintain a patent airway is a recognised cause of avoidable death in unconscious patients. The principles of airway management during cardiac arrest or after major trauma are the same as those during anaesthesia. Airway patency may be impaired by the loss of normal muscle tone or by obstruction. In the unconscious patient relaxation of the tongue, neck, and pharyngeal muscles causes soft tissue obstruction of the supraglottic airway. This may be corrected by the techniques of head...