ALS Manual 2010.Version 1

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INFORMATION MANUAL FOR ALS TRAINING PROGRAMME

ALS Information Manual PAH 2010

ALS Information Manual PAH 2010

1

ALS Information Manual PAH 2010

CONTENTS INTRODUCTION

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1

7 7 8 8 9

PREREQUISITES 1.1 LEARNING GOALS PRIOR TO WORKSHOP 1.2 LEARNING OUTCOMES / OBJECTIVES 1.3 THE RAPID RESPONSE TEAM CRITERIA FOR CALLING THE RAPID RESPONSE TEAM 1.4 ROLES AND RESPONSIBILITIES OF THE ARREST TEAM AND ALS COMPETENT STAFF MEMBER

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2.0

AIRWAY MANAGEMENT OXYGENATION, VENTILATION AND AIRWAY MANAGEMENT OVERVIEW 2.1 PHARYNGEAL AIRWAYS Oropharyngeal Airways Technique for insertion Special considerations The Nasopharyngeal Airway (Nasal Trumpet) Technique for insertion Special considerations 2.2 MANUAL RESUSCITATION BAGS (MRBs) 2.3 LARYNGEAL MASK AIRWAY 2.3.1 POTENTIAL PROBLEMS 2.4 TRACHEAL INTUBATION 2.4.1 Indications for Intubation 2.4.2 Intubation Technique 2.4.3 Cricoid Pressure 2.5 ENDOTRACHEAL SUCTION 2.6 MECHANICAL VENTILATION DURING CPR 2.7 AUTOMATIC TRANSPORT VENTILATION (ATV) 2.8 TRACHEOSTOMY PROBLEMS REFERENCES

12 12 12 12 12 13 13 13 14 14 15 16 17 17 18 20 21 21 21 22 23

3.0

CARDIAC RHYTHMS 3.1 LETHAL ARRHYTHMIAS 3.1.1 VENTRICULAR FIBRILLATION Delivery of a Precordial Thump Treatment Causes of Ventricular Fibrillation 3.1.2 VENTRICULAR TACHYCARDIA Treatment 3.1.3 TORSADES DE POINTES Treatment Causes 3.1.4 ASYSTOLE Treatment 3.1.5 VENTRICULAR STANDSTILL Treatment 3.1.6 PULSELESS ELECTRICAL ACTIVITY (PEA) Treatment Causes 3.2 BRADYARRHYTHMIAS Treatment Causes 3.3 TACHYARRHYTHMIAS Supra-Ventricular Tachyarrhythmia Treatment Causes 3.4 COMPLETE AV BLOCK / COMPLETE HEART BLOCK Treatment Causes

24 25 25 25 25 26 27 27 28 28 28 29 29 30 30 31 31 31 32 32 32 33 33 33 33 34 34 34 2

ALS Information Manual PAH 2010

3.5

3.6

IDIOVENTRICULAR RHYTHM Treatment ASYMPTOMATIC Causes Rapid Idioventricular Rhythm Treatment PACED RHYTHM SPECIAL NOTES Recommended readings

36 36 36 36 36 37 38 39 39

4.0

DEFIBRILLATON INTRODUCTION 4.1 TWO METHODS OF DEFIBRILLATION EXTERNAL DEFIBRILLATION INTERNAL DEFIBRILLATION 4.2 SAFETY PRINCIPLES OF DEFIBRILLATION 4.3 EMERGENCY DEFIBRILLATION COMPLICATIONS OF DEFIBRILLATION 4.4 SYNCHRONIZED DEFIBRILLATION / CARDIOVERSION INDICATIONS FOR CARDIOVERSON SAFETY PRINCIPLES OF ELECTIVE CARDIOVERSION POST PROCEDURE 4.5 Types of Defibrillator’s at PAH Recommended readings

40 40 40 40 40 41 42 42 43 43 43 44 44 44

5.0

CARDIAC PACING Modes of Pacing Indications for Emergency Cardiac Pacing Routes for Temporary Pacing 5.1 EXTERNAL / TRANSCUTANEOUS PACING Method 5.2 MODES OF PACING 5.2.1 DEMAND MODE 5.2.2 FIXED MODE 5.2.3 PACED RHYTHM Characteristics of Paced Rhythm 5.3 SAFETY ASPECTS OF PACING 5.4 COMPLICATIONS OF PACING 5.5 TROUBLE SHOOTING PROBLEMS 5.5.1 FAILURE TO PACE 5.5.2 FAILURE TO CAPTURE 5.5.3 FAILURE TO SENSE 5.5.4 OVERSENSING 5.6 DOCUMENTATION OF PACING Recommended readings

45 45 45 45 46 46 47 47 47 47 47 48 48 49 49 50 51 52 53 53

6.0

PHARMACOLOGY 6.1 INTRAVENOUS DRUG ADMINISTRATION 6.2 ENDOTRACHEAL DRUG ADMINISTRATION 6.3 OXYGENATION 6.4 ADRENALINE Action Half-Life Indications Dose Adverse Effects Precautions ATROPINE 6.5 Action Half-Life Indications Dose

54 54 54 55 56 56 56 56 56 56 56 57 57 57 57 57 3

ALS Information Manual PAH 2010 Adverse Effects Precautions 6.6 LIGNOCAINE Action Half-Life Indications Dose Adverse Effects Precautions 6.7 AMIODARONE Action Half-Life Indications Dose Infusion Adverse Effects Precautions Drug Interactions 6.8 POTASSIUM Action Indications Dose Adverse Effects Precautions 6.9 MAGNESIUM SULPHATE Action Indications Dose Adverse Effects Precautions 6.10 SODIUM BICARBONATE Action Indications Dose Adverse Effects Precautions 6.11 CALCIUM CHLORIDE Action Indications Dose Adverse Effects Precautions 6.12 OTHER EMERGENCY DRUGS 6.12.1 ISOPRENALINE Action Indications Dose Adverse Effects Precautions 6.12.2 ADENOSINE Action Half-Life Indications Dose Adverse Effects Precautions 6.12.3 SALBUTAMOL Action Indications Dose Adverse Effects

57 57 58 58 58 58 58 58 58 59 59 59 59 59 59 59 59 59 60 60 60 60 60 60 61 61 61 61 61 61 62 62 62 62 62 62 63 63 63 63 63 63 64 64 64 64 64 64 64 65 65 65 65 65 65 65 66 66 66 66 66

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ALS Information Manual PAH 2010 6.13 NEUROMUSCULAR BLOCKERS 6.13.1 SUXAMETHONIUM Action Half-Life Indications Dose Adverse Effects Precautions 6.13.2 VECURONIUM Action Half-Life Indications Dose Adverse Effects Precautions Recommended readings

67 67 67 67 67 67 67 67 68 68 68 68 68 68 68 68

ADULT ALS ALGORITHM FLOWCHART

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7.0

ADULT ALS ALGORITHM 7.1 INITIAL MANAGEMENT OF CARDIAC ARREST 7.2 MANAGEMENT OF SPECIFIC ARRYTHMIAS Ventricular Fibrillation / Pulseless Ventricular Tachycardia (VF/VT)

70 70 71 71

8.0

MANAGEMENT AFTER CARDIAC ARREST 8.1 POST ALS ALGORITHM 8.2 CRITICAL INCIDENT DEBRIEFING

73 74 75

9.0

SPECIAL CASES PREGNANCY 9.1 PHYSIOLOGICAL CHANGES IN PREGNANCY 9.2 CAUSES OF CARDIOPULMONARY ARREST IN PREGNANCY 9.3 FACTORS AFFECTING RESUSCITATION IN PREGNANCY 9.4 OTHER CONSIDERATIONS

76 76 77 78 79

PAEDIATRIC CARDIORESPIRATORY ARREST ALGORITHM FLOWCHART

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REFERENCES AND FURTHER READINGS

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ALS Information Manual PAH 2010

INTRODUCTION This information package is specifically designed for medical staff at Registrar and Senior House Officer level and nursing staff currently employed in Critical Care areas of the Princess Alexandra Hospital. Nursing staff from the Coronary Care Unit, the Intensive Care Unit, the Cardiac-Surgical Unit, the Cardiac Catheter Laboratory, the Anaesthetic and Post Anaesthetic Care Unit, Trauma HDU and the Emergency Department are able to achieve the Advanced Life Support (ALS) Competency, after they have acquired 12 months experience in their critical care specialty and met the required knowledge / skill levels. The contents of this package describe the knowledge and skills required for the achievement of the ALS competency. Each section covers the basic material and knowledge required but readers are expected to undertake further readings relevant to their experience and background, to reinforce their knowledge. Each section has selected references for recommended readings. This manual was originally compiled in November 1994: Revised in: • March 1996 • June 1999 • August 2000 • September 2001 • April 2003 • June 2004 • August 2006 • June 2008 • January 2010

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ALS Information Manual PAH 2010

1

PREREQUISITES

Prior to attending the Advanced Life Support workshop, it is mandatory that nursing staff have the knowledge and skills to perform the following advanced clinical skills: •

Cardiac Arrest Procedure including competency in Basic Life Support – Semi Automatic External Defibrillator

Cardiac Monitoring, Recognition and Treatment of Arrhythmias

Defibrillation – demonstrate safe and appropriate defibrillation technique

External Cardiac Pacing – demonstrate safe and effective external pacing.

1.1

LEARNING GOALS

PRIOR TO WORKSHOP (a)

Cardiac Arrest Procedure Staff should be familiar with the Cardiac Arrest Procedure at the PAH. They should have achieved competency in Basic Life Support (BLS) including the use of the Semi Automatic External Defibrillator (SAED). Refer to the Policy and Procedure Manual.

(b)

Airway Management Staff should demonstrate the ability to perform intubation (medical staff) or assist with intubation and be able to manage an intubated patient. Staff should demonstrate effective manual ventilation techniques and be familiar with the portable ventilators available at the PAH. Refer to Section 2.

(c)

Cardiac Monitoring Staff should be familiar with how to operate cardiac monitors used at PAH. Staff should be able to recognise the arrhythmias described in Section 3 and outline the management of each arrhythmia.

(d)

Defibrillation Staff should demonstrate defibrillation technique, including the use of semiautomatic external defibrillators and outline the safety principles of defibrillation described in Section 4.

(e)

Emergency Drugs State the use, dosage and adverse effects of Adrenaline/Epinephrine, Atropine, Lignocaine, Amiodarone, Calcium, Magnesium, Potassium and Sodium Bicarbonate. Refer to Section 6. 7

ALS Information Manual PAH 2010

1.2

LEARNING OUTCOMES / OBJECTIVES

Staff competent in Advanced Life Support will be able to: (a)

State the emergency response procedure used at the PAH to advise of a Code Blue situation.

(b)

Outline the responsibilities of nursing, medical and allied health staff during a Code Blue situation.

(c)

State the location of emergency equipment – oxygen, suction, defibrillator / monitor, cannulation and intubation equipment.

(d)

Demonstrate effective Cardiopulmonary Resuscitation techniques (basic life support measures).

(e)

Demonstrate recognition of lethal arrhythmias and state the management of each arrhythmia according to the Australian Resuscitation Council Algorithm.

(f)

Demonstrate recognition of other potentially life-threatening arrhythmias and state the management of these arrhythmias.

(g)

Demonstrate safe defibrillation techniques and describe the safety precautions used.

(h)

Explain the indications for, the correct dose and the adverse effects of the primary emergency drugs – Adrenaline, Atropine, Lignocaine, Amiodarone, Magnesium, Calcium, Potassium and Sodium Bicarbonate.

(i)

Describe / demonstrate the steps required for intubation of the patient.

(j)

Discuss the indications for External Cardiac Pacing of the patient.

(k)

Demonstrate knowledge of the pacing functions of External Pacemakers.

(l)

Describe the management of the patient following a Code Blue situation.

(m)

Outline the variations in management for the paediatric and for the pregnant patient.

(o)

Identify the need for critical incident stress debriefing (CISD) and avenues for instigating CISD at PAH. 8

ALS Information Manual PAH 2010

1.3 THE RAPID RESPONSE TEAM A Rapid Response Team call system is in place at the PAH. The Rapid Response Team is summoned to any person (patient, visitor, and staff) who is in respiratory or cardiac arrest or has observations that meet any of the deteriorating patient calling criteria. If doubt exists about the presence of respirations or pulse, or if the patient meets the deteriorating patient criteria, CALL THE RAPID RESPONSE TEAM – DIAL 666 throughout the hospital.

CRITERIA FOR CALLING THE RAPID RESPONSE TEAM RAPID RESPONSE TEAM (RRT)

Acute Change In Airway

Physiology Noisy Laboured Breathing

Breathing

Respiratory arrest Respiratory Rate < 8 bpm Respiratory > 36 bpm Fall in SpO2 <90%

Circulation

Cardiac arrest Pulse Rate <40 Pulse Rate >140 Fall in systolic Blood Pressure <90 mmhg Significant blood loss

Neurology

Sudden Fall in level of consciousness Fall in GCS>2 points Repeated or prolonged seizures

Other

Any patient you are seriously worried about that does not fit into the above criteria particularly with changing parameters

To initiate a Rapid Response Team (RRT) call, dial 666 state “code blue” exact location and treating team (if known). Further information regarding RRT call criteria is available in the Princess Alexandra Hospital Health Service District Procedure Manual

EXCEPTIONS (AT THE PRINCESS ALEXANDRA HOSPITAL) •

ICU, CCU, ED, OT where the respective Registrar or Consultant is present and states that adequate personnel are already available. 9

ALS Information Manual PAH 2010

The procedure for conducting BLS is outlined in the Princess Alexandra Hospital Health Service District Procedure Manual (Procedure No. 80031/v7/10/2009) 1.4

ROLES AND RESPONSIBILITIES OF THE RAPID RESPONSE TEAM AND THE ALS COMPETENT STAFF MEMBER

The composition and skill mix of the team will vary from time to time but it is imperative that the Medical Registrar or ALS competent staff member assumes the role of the team coordinator. Team Coordinator: •

Undertakes clinical management of the resuscitation

Co-ordinates personnel and delegates duties.

Four tasks are assigned by the team leader at the start of the resuscitation: 1. airway and intubation management 2. chest compression 3. monitoring and defibrillation 4. intravenous access and blood sample collection

Ensures that treatments proceed as per the ALS algorithms derived from the Australian Resuscitation Council guidelines

Assesses the need for additional personnel

Ensures safety of patient and staff at all times

Determines appropriateness of patient treatment in consultation with the appropriate clinicians

Ensures that resuscitation documentation is completed

Undertakes debriefing and staff counselling as necessary

Other medical staff: •

Provide assistance with the clinical management of the resuscitation under the direction of the team coordinator

Ward nursing staff – Responsibilities: •

Ready the patient for BLS – SAED

Summon help from ward staff – press yellow staff assist button

Take the Ward Arrest Trolley, with the SAED, Drugs, portable suction and Manual Ventilation Bag to the bedside 10

ALS Information Manual PAH 2010

Summon the Rapid Response Team – Dial 666

Commence BLS procedures prior to the Rapid Response Team (RRT) arriving.

Ensure that wall suction and oxygen is available

Ensure that the Medical Records are at the bedside

Inform the RRT of any ‘Biohazard Control Procedures’ that may be required

Prepare and prime infusion line

Maintain documentation of the sequence of events during the arrest

Arrange for transport of urgent blood specimens

Notify the patient’s clinical team

Ensure Medical Officer notifies the patient’s relatives

Co-ordinate care and debriefing of other patients and relatives at the scene

A member of the ward staff must remain with the RRT throughout

Ancillary staff: •

Assist with patient transport

Answer the ward telephone

Be available to assist staff with any tasks as requested

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ALS Information Manual PAH 2010

2.0

AIRWAY MANAGEMENT

OXYGENATION, VENTILATION AND AIRWAY MANAGEMENT OVERVIEW Maintaining the patient’s airway is the first priority and ventilation with 100% oxygen should be commenced as soon as possible. During cardiopulmonary arrest, placement of a tracheal tube is only to be performed by those trained in tracheal intubation and advanced airway management. Maintenance of effective ventilation is essential until a medical officer skilled in advanced airway management arrives. The principles of basic life support airway maintenance should be observed initially: i) ii) iii) iv) v) 2.1

Jaw thrust and chin lift (or lateral positioning of spontaneously breathing patient) Pharyngeal airway Laryngeal mask airway Manual resuscitation bag Endotracheal intubation

PHARYNGEAL AIRWAYS

Oropharyngeal Airways The oral pharyngeal (oropharyngeal) airway is a semi-curved, tubular device which when properly positioned, holds the tongue forward of the posterior aspect of the pharynx. This prevents the tongue from occluding the airway and allows ventilation to occur through the lumen of the tube and around the airway. The oropharyngeal airway is only needed in the patient with a depressed conscious state, impaired gag reflex and loss of muscle tone, which results in airway obstruction. The chin-lift technique should be used in conjunction with the airway if not contraindicated. Insertion of this device in a conscious or semi-conscious patient, is likely to activate the gag reflex (when the back of the tongue or posterior pharyngeal wall is touched) and precipitate vomiting. Appropriate sizing of the device may be estimated at the bedside or in the field. Align the tube on the side of the patient’s face and choose an airway that extends from the centre of the lips to the angle of the mandible or to the bottom of the ear. Technique for insertion: There are two ways to position the oropharyngeal airway. The quickest method is to insert the device upside down into the mouth. As soon as the distal end reaches the hard palate, the airway is gently rotated 180o and slipped behind the tongue into the posterior pharynx. The second technique for insertion of the oral pharyngeal airway requires a tongue blade. The tongue is depressed and the airway is inserted right side up into the oral pharynx. With either technique, the flange of the tube should sit comfortably on the lips if the device has been properly inserted.

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ALS Information Manual PAH 2010

Special considerations: •

Although the second technique (i.e. direct visualisation with the use of a tongue blade) may seem intuitively easier, one must be sure that the airway is inserted deep enough so as to come to rest behind the tongue. Unless careful attention is paid to doing this, it’s all too easy to stop short – in which case the device may actually cause airway obstruction by pressing on the tongue and pushing it back to occlude the airway.

If the tube repeatedly comes out of the mouth, it is likely to be improperly seated (and compressing the tongue into the posterior pharynx). This may further obstruct the airway. Don’t continue to force the airway in. Remove it entirely and then try to insert it again.

Although the lumen of the tube is adequate for ventilating the patient, it should not be used for suctioning because the lumen is not large enough to allow passage of the suction catheter. The suction catheter is instead inserted adjacent to the airway. Suction is then performed in the usual manner.

The head tilt/chin lift should not be attempted if a known or high suspicion of cervical spine injury exists. Jaw thrust method can be used in this situation.

The Nasopharyngeal Airway The nasopharyngeal airway is an extremely compliant rubber tube approximately 15cm in length. The tube is designed so that its distal tip sits in the posterior pharynx while the proximal tip rests on the external nares. The lumen of this device permits the passage of air into the lower respiratory tract. Technique for insertion: Correct sizing of a nasopharyngeal airway is achieved by measuring from the patient’s nare, to the tip of the ear. It is important to size the tube prior to insertion to ensure a patent airway and to prevent advancement into the oesophagus. The tube should be lubricated with 2% lignocaine gel prior to insertion. The purpose of the lignocaine is two-fold. It anaesthetises the nasal mucosa in the posterior pharynx (so as to minimise sensitivity of the gag reflex), and lubricates the tube to facilitate insertion. Once inserted, a safety pin is attached to the end of the airway to prevent it migrating through the nare and into the nasal passage. Care should be taken to ensure that pressure from the pin is not exerted onto the nare. The nasopharyngeal airway is then advanced into the nares by placing the bevel against the septum of the nose and gently sliding the tube backward in line with the base of the ears. In that way the tube passes parallel to the floor of the nasal cavity. When completely inserted, the distal end is seated in the posterior pharynx. Special considerations: • Although in most cases proper insertion of the nasopharyngeal airway will result in correct position of the distal end in the posterior pharynx, on occasion the tube may be too short or too long. Be alert to the fact that if this happens, adequate ventilation may not be achieved. • While most conscious or semi-conscious patients are able to tolerate this device, the gag reflex of particularly sensitive individuals may still be activated.

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ALS Information Manual PAH 2010

• Forceful introduction of the airway into the nasal passage should be avoided, since this may cause abrasions or lacerate the nasal mucosa and produce significant bleeding. Cautious use of nasal airways in patients with deviated septum is warranted, to avoid nasal trauma and bleeding.

2.2 MANUAL RESUSCITATION BAGS (MRBs) Manual Resuscitation Bag Ventilation This is the preferred in-hospital technique for initial ventilation. It is recommended that 100% (15 litres) inspired oxygen is used as soon as possible during BLS and ALS. When the patient resumes adequate spontaneous ventilation, oxygen administration should be continued. Supplemental oxygen can be provided by any firmly fitting oxygen mask, but partialrebreathing or non-rebreathing systems deliver higher percentages of oxygen and are preferred. Manual resuscitation bags (MRBs) are not designed to deliver oxygen to spontaneous breathing patients. The one-way valve in the bag creates resistance that the patient must overcome to breathe in oxygen rich gas. If the patient has adequate spontaneous respirations then oxygen administration by a mask is more appropriate. MRBs can be used to deliver intermittent positive pressure ventilation (IPPV) via a mask, Endotracheal, Laryngeal Mask Airway or tracheostomy tube. MRBs consist of a self-inflating bag, a non-rebreathing valve and a supplemental oxygen reservoir, which should always be attached during CPR. The self-inflating bag allows breath delivery without a pressurised gas source, allowing the initiation of IPPV when wall or portable oxygen is not immediately available. Masks selected for resuscitation should be sized to provide an airtight seal for breath delivery. As a general guide in female patients use a size 3-4, and for males, size 5-6 mask. Masks should be made of transparent material to allow detection of regurgitation. An input oxygen flow rate of 15 litres per minute should be secured from wall or cylinder oxygen. Inexperienced operators may have difficulty providing a leak-proof seal to the face while ventilating the patient and maintaining an open airway. Effective ventilation is best achieved when two rescuers use these devices. One rescuer should hold the mask and one ventilate the patient by squeezing the bag. This will promote more effective breath delivery as assessed by the adequacy of chest wall movement. Potential operators must be familiar with the methods of checking these devices as faulty operation may cause barotrauma, hypoventilation or hypoxia. If there is a loose connection in the MRB, the selfinflating bag can be compressed without gas being delivered to the patient. High pressure in the circuit from jamming of the valves or too forceful manual ventilation can cause trauma to the patient’s lungs and / or reduce venous return. It is vital to know the detail of operating your MRB prior to a cardiac arrest situation. Make sure you familiarise yourself with the breathing circuit utilised in your clinical area. MRBs should always be available when transporting a ventilated patient post successful resuscitation, to enable manual ventilation in the event of loss of pressurized gas supply.

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ALS Information Manual PAH 2010

It is expected that to achieve Airway management competence, that the staff should be able to assemble MRBs and understand the principle underlying the one-way valve mechanism.

All staff should check their emergency equipment at the beginning of each shift and be familiar with handling, assembling, operation and cleaning of departmental emergency equipment.

Single rescuer bag mask ventilation

Two rescuer bag mask ventilation

Bag Mask Ventilation Images copyright: Kathy Mak June 2004 2.3 LARYNGEAL MASK AIRWAY (LMA) The LMA is only used where intubating skills are not available or in the event of failed intubation. The LMA is introduced into the pharynx and advanced until resistance is felt as the distal portion of the tube locates in the hypopharynx. The cuff is then inflated, which seals the larynx, leaving the distal opening of the tube just above the glottis, providing a clear airway. Please note that the airway is not fully protected. The potential advantage of the LMA is that it can provide a clear and relatively secure airway without the requirement for the skill of tracheal intubation. When correctly performed the insertion technique is simple and non-traumatic. The LMA should only be used when the patient is: • • •

profoundly unconscious and unresponsive; without glossopharyngeal reflexes; and has an identified need for an artificial airway eg. cardiac arrest.2

The LMA may be inserted by those trained in its use. It is not a superior alternative to tracheal intubation. Its use should be confined to those operators who do not possess intubation expertise and to patients in whom immediate intubation is not possible for anatomical or other reasons. The LMA provides a more secure and reliable means of ventilation than the facemask. It does not ensure absolute protection against aspiration. Even when the LMA is inserted, a small proportion of patients cannot be ventilated.

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ALS Information Manual PAH 2010

1

2

3

4

Laryngeal Mask Insertion Images copyright: Janet Fong June 2004 (Adapted) 2.3.1

POTENTIAL PROBLEMS

Three problems may be anticipated during use of the LMA: • • •

difficulty with insertion air leak around the cuff during positive pressure ventilation pulmonary aspiration of gastric or pharyngeal contents.2

Difficulty with insertion in profoundly unconscious patients may be minimised by scrupulous attention to use of the recommended technique. If a problem occurs, deflate the cuff, remove the LMA and try again using another correctly prepared and deflated mask.2 Air leak around the cuff may occur in 10-15% of cases.2 In the majority the leak is small and acceptable, provided the chest is seen to rise normally during inflation. If the leak is major, or the chest does not rise, the cuff should be deflated and the mask repositioned.2 Aspiration of regurgitated gastric contents is possible with the LMA in situ. The incidence is small and much less than occurs with the unprotected airway associated with other techniques. Regurgitation is more likely to occur if the stomach has already been inflated by mouth-to-mouth, mouth to mask or bag-valve-mask ventilation applied prior to insertion of the LMA.2 If regurgitation is suspected, aspirate the hypopharynx prior to LMA insertion. Aspiration may also occur after mask removal. Again, aspiration of the hypopharynx should be performed, preferably with the patient head down in the lateral recovery position, before the cuff is deflated and the LMA removed.2

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ALS Information Manual PAH 2010

Preparation for use: The LMA may be either disposable or reusable following autoclaving. The correct size is as follows: SIZE 3 Small adult; SIZE 4 Normal adult; SIZE 5 Large adult. If in doubt, choose a larger rather than smaller size. Equipment: 1. 50 ml syringe (for cuff inflation) 2. Lubricant 3. Surgical or cotton tape 4. Bite block (rolled gauze) Insertion and management of the airway can be achieved without items 2, 3, and 4 but they should be available when possible. Fully deflate the cuff ensuing there are no folds near the tip of the LMA. Apply lubricant only to the rear of the mask in the distal end of the tube (posterior surface).

2.4

TRACHEAL INTUBATION

Rationale In the absence of an endotracheal tube (ETT), lung inflation pressures may be high enough to cause gas to be forced into the stomach, resulting in gastric distension with subsequent risk of regurgitation and aspiration of gastric contents into the lung. 2.4.1

Indications for intubation

As soon as practicable during the resuscitation (usually the second or third shock sequence or when there is a medical officer present that is competent in intubation) the trachea should be intubated. The advantages of endotracheal tube (ETT) placement include: –

Provides a definitive patent airway Isolates the airway reducing but not eliminating the risk of aspiration Allows the delivery of IPPV and high oxygen concentration Enables tracheal suctioning Provides a route for the administration of emergency drugs (Atropine, Lignocaine, Adrenaline, Diazepam and Naloxone)

In addition, once an ETT is in place, ventilation need not be synchronised with chest compressions. Rather, it should be performed asynchronously at 8-10 ventilations per minute. In PULSELESS, witnessed and monitored Ventricular Tachycardia or Ventricular Fibrillation, intubation should only be attempted after the initial sequence of 3 DC shocks has failed (or after first shock with SAED if not witnessed and monitored). In the difficult to intubate patient, the resuscitation team should be mindful that greater harm will be caused by failure to ventilate than failure to intubate. 17

ALS Information Manual PAH 2010

2.4.2 Intubation Technique Prior to attempting intubation, all equipment should be quickly but thoroughly checked. During endotracheal intubation the maximum interruption to ventilation should be 20 seconds. Adequate ventilation and oxygenation must be provided between attempts. Preoxygenate the patient with 100% oxygen prior to any intubation attempt.

Collect all necessary equipment: – Suction source – occluding the suction tubing with suction turned on should result in a –ve 40 Kpa pressure change – Yankauer suction device and suction catheter (size 12-14 G for adult sized ETTs) – Laryngoscope – light source bright, bulb securely in position – ETT – correctly sized for the patient; check cuff and valve integrity by inflating cuff with a syringe filled with air – the inflated cuff should be concentric and not protrude over the tip of the tube – Introducer – ensure plastic coating intact; do not manipulate, allow MO to shape as required – Bougie – long flexible introducer used as a guide for placement of ETT. Will be supplied by ALS staff from CCU and ED – Water soluble lubricant – apply on request from MO only – Magill’s forceps – can be used to guide the position of the ETT into larynx or for removal of foreign bodies – 10ml syringe to inflate ETT cuff – Tape to secure ETT – End tidal CO2 detector (Oximax N-85) Typical tracheal tube sizes are: – Adult male 8.0 – 9.0 – Adult female 7.0 – 8.0 – Paediatric age + 4 4 Emergency intubation procedure:

• The patient should be positioned optimally to promote successful intubation. In an emergency situation this can mean ensuring the patient is supine and placed at a height that allows the operator optimal view of the vocal cords. A pillow or rolled towel underneath the shoulders (if not contraindicated) may assist the view of the cords.

• Preoxygenate the patient with 100% oxygen • The MO may request the application of Cricoid pressure (section 2.4.3) • Laryngoscopy is performed. Direct laryngoscopy involves the use of a laryngoscope to view the vocal cords, allowing placement of the ETT in the trachea. In the emergency setting an introducer may be used to assist with placement of the tube through the glottic opening. The introducer should not protrude beyond the end of the tube and is removed once 18

ALS Information Manual PAH 2010

the ETT is placed in the trachea. The ETT should be positioned so that the cuff comes to rest beyond the vocal cords and 2 cms above the carina. • Inflate the cuff with the minimum amount of air required to obtain a seal. • Ventilate the patient ensuring that the chest is rising and falling with each breath. Auscultate the lung fields for the presence of breath sounds. • Connection of the End-tidal CO2 detecting device between the ETT and manual ventilation bag, verifying tube placement • Secure the ETT using cotton tape. Note the position of the tube by recording the level of the tube markings at the patient’s lips or teeth. For Example, 21 cm for a male, 23 cm for a female. • A portable chest x-ray should also be performed after ROSC to confirm optimal ETT placement. Continual monitoring of oxygenation and ventilation is vital and is based on clinical assessment including patient colour, chest wall movement and auscultating air entry. End-tidal CO2 monitoring devices are used to assess tracheal tube placement. A failure to detect carbon dioxide usually means that the tube is in the oesophagus. However, occasionally carbon dioxide may not be detected in cardiac arrest patients with extremely low blood flow to the lungs or in those with a large amount of dead space (eg. significant pulmonary embolism).

Oximax N-85 Portable bedside Capnograph Images copyright: Nellcor 2006 (Adapted)

Capnograph Tubing Connection

The Oximax N-85 Capnograph is a portable monitor that continuously monitors end tidal CO2 (mmHg), respiratory rate, fractional inspired carbon dioxide, oxygen saturation and pulse rate. The monitor operates on batteries or on AC power. Before using the monitor in the field, ensure that the battery pack is fully charged. Operation Prior to start up: • • • •

Slide open the FilterLine input connector shutter and connect the appropriate FilterLine Turn the monitor on by sliding the on/of switch to the on position. When turned on, the monitor automatically performs a self test. Place the Filter Line between the Manual Resuscitation bag and the ETT. Monitor the end tidal CO2 (EtCO2) result displayed on the machine to ascertain ETT placement. 19

ALS Information Manual PAH 2010

EtCO2 monitoring should continue at all times while the patient is intubated to ensure the ETT is not dislodged. (Refer to Operators manual for further information)

Interpretation: Successful placement of the ETT into the trachea will result in an EtCO2 measurement being obtained (mmHg), as well as an appropriate waveform. If a failed intubation has occurred no EtCO2 will be present and thus, a numerical value and waveform will be absent. Pulse oximetry should be employed on return of spontaneous circulation (ROSC). A portable chest xray should also be performed after ROSC to confirm optimal ETT placement. NOTE: Paediatric tracheal tubes are uncuffed and require a small gas leak to be audible on positive pressure ventilation. Paediatric resuscitation equipment is kept in Emergency Department and Recovery.

2.4.3 CRICOID PRESSURE Cricoid pressure or Sellick’s manoeuvre should be applied during a tracheal intubation sequence. The Cricoid cartilage is a ring shape, not a ‘C’ shape like other tracheal rings. This shape allows compression of the oesophagus between the Cricoid cartilage and the spine. Correctly applied, Cricoid pressure prevents or controls passive gastric content regurgitation, minimizing the risks of pulmonary acid aspiration. In addition it decreases gaseous filling of the stomach and may provide a clearer view of the vocal cords during a difficult intubation. Cricoid pressure should not be performed at any time where there is active vomiting or where there is swelling of the front of the neck from recent trauma or if the anatomy is difficult to define. Cricoid pressure should only be used when the patient is unconscious or drug paralysed, otherwise vomiting may be stimulated.

Technique: Firm symmetrical pressure is applied with the index finger and thumb on the anterolateral aspect of the Cricoid cartilage, which is below the cricothyroid membrane. The effect is similar to applying 20

ALS Information Manual PAH 2010

pressure against the bridge of one’s nose that causes discomfort, or pressure against one’s cricoid that prevents swallowing. Pressure is not applied at the level of the Thyroid cartilage as this is ineffective, distorts the entire larynx and makes ventilation and intubation more difficult. Cricoid pressure must not be released until the medical officer performing the intubation requests its removal. This is usually after cuff inflation of the ETT and correct tube placement has been confirmed by auscultation.

2.5 ENDOTRACHEAL SUCTION To suction the tracheal airway, ensure the following: • suction catheter to be no greater than half the diameter of the tracheal tube; • suction pressure for adults to be between 100-150 mmHg (greater pressures may be needed, depending on secretion consistency); • suction time no greater than 10-15 seconds; • pre and post oxygenation (100%); • aseptic technique; • observe patent response; • observe hemodynamics, oxygenation/ventilation parameters.

2.6

MECHANICAL VENTILATION DURING CPR

Mechanical ventilators should not be used in the initial management of cardiac arrest in the intubated patient. The patient should be manually ventilated with 100% oxygen. (ARC Policy Statement 11.7) Rationale: this gives the operator complete control of ventilation and helps discern a differential diagnosis (eg. exclude tension pneumothorax and gas trapping). In the event of insufficient available rescuers, a temporary alternative to this is to leave the patient mechanically ventilated. This option should only be utilized until further assistance arrives. •

2.7

The oxygen setting should be increased to 100%, the pressure limit is increased to account for increased peak inspiratory pressures generated with cardiac compressions, and the minute ventilation should be appropriate for resuscitation (e.g. in the adult patient RR 12 bpm). This allows the bedside nurse to commence cardiac compressions until assistance arrives.

AUTOMATIC TRANSPORT VENTILATION (ATV)

The use of ATV in ALS is usually reserved for post-arrest situations when the cardiac rhythm is stable and supplementary ventilation support is required. ATVs can be used during CPR as outlined above. ATVs deliver set minute ventilation (volume of each breath x number of breaths delivered per minute) and provide information about the airway pressures generated with breath delivery. The ventilators free one team member for other tasks in the post-resuscitation period.

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The disadvantages of ATVs include the need for an oxygen source and in some models, a power source. ATVs should not normally be used in children under five. This is due to difficulty maintaining the subtle pressures and volumes required in young children. If mechanical ventilation is required for young children it is preferable to have a pressure cycle ventilator, rather than a volume cycle ventilator. The Dräger Oxylog 2000 and Oxylog 3000 ventilator is used for ATV in the Emergency Department and Intensive Care Unit.

2.8

TRACHEOSTOMY PROBLEMS

If called to see a patient with a tracheostomy problem, request senior assistance early. Consider calling the ENT registrar and calling switchboard (via ‘666’) and requesting urgent airway assistance. Accidental dislodgement of the tracheostomy 1. Apply 100% O2 via bag & mask to face and via the tracheostomy a. N.B Following a laryngectomy oxygenation via the upper airway is not possible 2. If the patient’s breathing is adequate – call for senior assistance to replace the tracheostomy 3. If the patient’s breathing is inadequate – call a code blue For suspected occlusion or malposition 1. Occlusion or malposition are suspected if the patient is in respiratory distress and there is an inability to pass a suction catheter 2. Apply 100% O2 via bag & mask to face 3. Attempt to pass a suction catheter down tracheostomy and suction trachea – if you are unable to pass a suction catheter, this is an emergency, call for urgent assistance 4. Being able to pass a suction catheter does not exclude a partial occlusion and if the patient is hypoxic or in respiratory distress call a code blue 5. In the case of a partially / blocked tracheostomy removing an ‘inner cannula’ or deflating the cuff (if either present) may improve the patients ability to ventilate adequately Removing the tracheostomy is indicated if 1. Total occlusion unrelieved by the above measures resulting in hypoxia or respiratory distress 2. You suspect the tracheostomy is not in the trachea but in the subcutaneous tissues of the neck. This is dangerous as attempts to ventilate the patient will be ineffective and result in subcutaneous emphysema. Apply 100% O2 via bag & mask to face If you remove the tracheostomy you may need to occlude the stoma with an occlusive dressing (eg Tegaderm) to achieve adequate bag-mask ventilation. In the case of a well established tracheostomy a new tracheostomy may be inserted if required.

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REFERENCES: Australian Resuscitation Council Guidelines – Policy Statements (2006): Basic Life Support Guidelines: 4 – Airway & 5 – Breathing. Australian Resuscitation Council Guidelines – Policy Statements (2006): Advanced Life Support Guidelines 11.1 – 11. Fong, J. (2004) Laryngeal Mask. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong. Retrieved 4/12/2006 http://www.aic.cuhk.edu.hk/web8/Laryngeal%20mask.htm

Joynt, G.M. (2003) Airway management and acute upper airway obstruction. In Bersten, A.D & Soni, N. editors. Intensive Care Manual (5th ed.). Butterworth Heinemann: Edinburgh: 283-296. Mak, K (2004) Bag mask Ventilation. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong. Retrieved 4/12/2006. http://www.aic.cuhk.edu.hk/web8/Copyright%20policy.htm Morley, P.T. and Walker, T. (2006) Australian Resuscitation Council: Adult advanced life support (ALS) guidelines 2006. Critical Care and Resuscitation. June. 8(2):129-131. Pierce, L. (2007) Management of the mechanically ventilated patient. 2nd Edition. Saunders: St. Louis. American Heart Association (2005) Part 7.1: Adjuncts for Airway Control and Ventilation. Circulation. Supplement. December 13. 112(24):IV-51 to IV-57.

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3.0

CARDIAC RHYTHMS

The following section contains examples of some of the important cardiac rhythms and the management of these rhythms. It is a mandatory requirement that ALS competent staff are able to recognise and treat lethal arrhythmias. The management is based on the ARC Guidelines and Algorithm (Guideline 11.2). Section 3.1 contains the Lethal Arrhythmias: •

Ventricular Fibrillation

Ventricular Tachycardia

Asystole

Ventricular Standstill

Electro Mechanical Dissociation (EMD) / Pulseless Electrical Activity (PEA)

Section 3.2 contains some other important arrhythmias that may lead on to cardiac arrest: •

Bradyarrhythmias

Tachyarrhythmias

Complete Heart Block

Idioventricular Rhythm

Torsades de pointes

Paced Rhythm

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3.1

LETHAL ARRHYTHMIAS

3.1.1

VENTRICULAR FIBRILLATION

Comment:

An erratic bizarre rhythm due to multiple foci in the ventricles rapidly discharging.

Results in ineffective ventricular contraction and no cardiac output. Delivery of a Precordial Thump A precordial thump is a single sharp blow to mid sternum of patient’s chest, delivered by the rescuer’s fist. It should only be done in a monitored and witnessed VF / pulseless VT arrest within the first 15 seconds if a defibrillator is not immediately available. It may also be done when cardiac arrest is caused by electrocution. It is contraindicated in recent sternotomy – post op cardiac surgery or chest trauma, or if the patient has a pulse. (A.R.C., Manual of Adult Advanced Life Support Skills) Treatment: ASSESS THE PATIENT – unconscious and pulseless • Precordial Thump as described above if witnessed and monitored DEFIBRILLATE IMMEDIATELY Biphasic Defibrillator – Philips Heartstart XL ¾ DCCS 150J

>150J

>150J

Biphasic Defibrillator – Medtronic Lifepak 12/20 ¾ DCCS 200J

>200J

>200J

• Check rhythm between defibrillation • If using paddles, keep insitu on chest • Commence CPR and obtain IV access • IV Adrenaline 1mg – Flush with 30ml saline and continue CPR for 2 minutes to circulate drug • Repeat DCCS 150j x 1

Biphasic Defibrillator – Philips Heartstart XL

• Repeat DCCS 200J x 1

Biphasic Defibrillator – Medtronic Lifepak 12/20

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ALS Information Manual PAH 2010

• Repeat IV Adrenaline 1mg every 3 minutes If no response – Intubate and Ventilate with 100% oxygen • Continue to repeat the single shock regime of DCCS @ 150J or 200J followed by 2 minutes of CPR and drug therapy • Consider Antiarrhythmic drugs: Amiodarone & Lignocaine • Amiodarone 300mg diluted in 20ml Dextrose slowly over 2 minutes (Nursing staff must have medical order to administer) • Lignocaine 1 – 1.5mg/kg • Find and treat the cause if possible Causes Predisposing Factors: Myocardial Infarction Acidosis Metabolic disturbances ? Diabetic Ketoacidosis Trauma Thromboembolism Hyperkalemia Hypoxaemia Hypothermia Hypovolaemia Drug overdose / Drug Toxicity ? Digitalis / ? Anti-arrhythmic Therapy Electrocution Trauma: Complications of CPR or MVA Tension Pneumothorax? Pericardial Tamponade Irreversible Causes: Massive Myocardial Infarction Ruptured Aortic Aneurysm

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3.1.2

VENTRICULAR TACHYCARDIA

Comment:

This is a rapid arrhythmia that results in reduced cardiac output. It can lead to haemodynamic instability and loss of consciousness.

Treatment: ASSESS THE PATIENT • Assess Pulse, BP and LOC If Asymptomatic • 12 Lead ECG, notify Doctor, monitor and observe patient If Symptomatic but conscious: • Lie flat & give oxygen, monitor patient, 12 Lead ECG if possible • Notify Doctors • Consider IV Amiodarone 300mg bolus • Consider IV Lignocaine 1-1.5mg/kg bolus (Nurses @ PAH trained in ALS can administer) • Consider Amiodarone or Lignocaine infusion • Consider Cardioversion • Find and treat the cause

If SYMPTOMATIC – Unconscious, Pulseless • Precordial Thump if appropriate

IMMEDIATE DEFIBRILLATION • Treat the same as Ventricular Fibrillation

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3.1.3

TORSADES DE POINTES

Comment:

This arrhythmia is Polymorphic Ventricular Tachycardia where the QRS axis is

changing. The changing axis causes the QRS complexes to be tall and then short. Torsades de Pointes literally means a "twisting of the points". The arrhythmia is often self-limiting, occurring for 5-10 seconds at a time. Treatment: ASSESS THE PATIENT • Stop all antiarrhythmic infusions • Defibrillate if prolonged and patient is compromised • Commence CPR if indicated • Consider IV Magnesium Infusion • Check the Biochemistry (K+, Ca++, Mg++) • Check Thyroid Function (TFTs) • Find and treat the cause • MO may consider overdrive pacing Causes:

Antiarrhythmic drugs Electrolyte Imbalances-

Hypokalaemia Hypocalcaemia Hypomagnesmia

Severe Bradycardia Hypothyroid Head Trauma and Subarachnoid haemorrhage Congenital Syndromes (prolonged QT interval) Psychotropic Drugs (eg Thioridiazine, Tricyclics) Corticosteroids Diuretics Organophosphate insecticides Liquid protein diets

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3.1.4

ASYSTOLE

Comment:

No Rhythm, No Pulse, No Cardiac Output

Treatment: • ASSESS THE PATIENT – pulseless and unconscious • Check rhythm in other leads • Commence CPR immediately • Obtain IV access and give Adrenaline 1mg, repeat every 3 minutes • Flush the IV line with at least 30ml saline and continue CPR for 2 minutes • Intubate & Ventilate with 100% oxygen • Find & Treat the cause if possible • Consider IV Atropine 1mg bolus dose, to a maximum of 3mg • Consider External Pacing • Consider Sodium Bicarbonate 1 mmol/kg if documented metabolic acidosis or prolonged cardiac arrest Causes:

Heart Disease (poor prognosis) Myocardial Infarction Drugs, Overdose, Hypothermia Acidosis, Hyperkalaemia, Hypoxaemia, Hypovolaemia Prolonged VF deteriorates into Asystole May result from a massive parasympathetic discharge

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3.1.5

VENTRICULAR STANDSTILL

Comment:

Atrial activity (P waves present) but no ventricular activity, therefore there is no cardiac

output. This rhythm can be intermittent if AV block is occurring but if it is sustained it must be treated as Asystole. Treatment: ASSESS THE PATIENT – pulseless and unconscious • Treat as Asystole • Commence CPR and obtain IV access • IV Adrenaline 1mg, repeat 3-5 minutely • Consider IV Atropine 1mg bolus dose to a maximum of 3mg • Consider IV Isoprenaline 20mcg bolus • Consider External Pacing Causes:

Heart disease

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3.1.6

PULSELESS ELECTRICAL ACTIVITY (PEA)

Comment:

This is a condition where there is electrical activity occurring in the heart, as evidenced

by any rhythm on the monitor. However, there is no associated mechanical activity. This means that no ventricular response or contraction occurs. The patient has no cardiac output. Some texts refer to this as Electromechanical Dissociation (EMD). PEA / EMD has a poor prognosis. Patient is collapsed and unresponsive. Treatment: ASSESS THE PATIENT – pulseless and unresponsive • Commence CPR and obtain IV access • IV Adrenaline 1mg, repeat every 3-5 minutes Find and Treat the cause if possible Causes: Circulatory Pericardial effusion with tamponade due to chest trauma, Pericarditis, Uremia or vigorous CPR Ventricular rupture or Aortic rupture Massive Pulmonary Embolism Hypovolaemia due to: • Acute blood loss • G.I. bleed • Dehydration Hypotension due to: Septic shock • Cardiogenic shock • Anaphylactic shock • Neurogenic shock Hypothermia Respiratory Intubation of the right main bronchus Hypoxia Tension Pneumothorax due to • Trauma • Asthma • Mechanical ventilation Metabolic Persistent Acidosis Diabetic Acidosis Lactic Acidosis Electrolyte Imbalance – hyperkalemia Overdose of cardiac depressant drugs

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3.2

BRADYARRHYTHMIAS

Comment:

Sinus Bradycardia is normal for fit and healthy persons. It is the physiological response

to sleep. Bradycardia causes problems when there is associated heart disease or heart failure, the heart rate slows and the heart cannot pump efficiently to maintain cardiac output. Treatment: ASSESS THE PATIENT • IF SYMPTOMATIC: • Lie flat and give Oxygen • IV Atropine 0.5mg bolus dose • Observe for any increase in heart rate • Notify the doctor • Wait 3-5 minutes for effect of Atropine • No response, repeat IV Atropine 0.5mg • Give IV Atropine up to a maximum 3.0mg • Consider IV Isoprenaline 20mcg • Consider External Pacing if no response to drugs • Find and Treat the cause Causes:

Acute Myocardial Infarction Beta Blockers, Calcium Channel Blockers Hypothermia Acute Hypertension Sick Sinus Syndrome Vagal Stimulation

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3.3

TACHYARRHYTHMIAS

Comment:

Ventricular Tachyarrhythmias have already been discussed under the Lethal

Arrhythmias. Supra-Ventricular Tachyarrhythmia: Sinus Tachycardia Atrial Fibrillation Atrial Flutter Paroxysmal Atrial Tachycardia SVT’s are not lethal arrhythmias as such, but they can compromise the patient’s haemodynamic status if they are prolonged. It is necessary to investigate and treat a tachycardia. Treatment: ASSESS THE PATIENT If Stable: • MO may attempt Vagal stimulation ( Carotid Sinus Massage) • Consider drugs: IV Adenosine, Beta Blockers, Digoxin, Sotalol If Unstable: • Sedate the patient and prepare for cardioversion • Usually cardioverted with 100 – 200Joules Causes:

Increased Sympathetic stimulation (fear, pain and exercise) Heart Failure Thyrotoxicosis Digoxin Toxicity Hypertensive Heart Disease Valve Disease Cardiomyopathy

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3.4

COMPLETE AV BLOCK / COMPLETE HEART BLOCK

Comment:

This rhythm shows atrial activity (P waves) occurring but it is not associated with the

ventricular response. The atrial impulse is not penetrating the AV node to activate the ventricles – there is complete AV block. The ventricles are activating themselves independently, either from a Junctional Pacemaker site or a ventricular pacemaker site. Junctional escape rhythm has a narrow QRS complex with a rate between 40 -60bpm. The Ventricular escape rhythm has a wider QRS with a slower rate between 15 – 40bpm. Treatment: ASSESS THE PATIENT If Asymptomatic: • 12 Lead ECG • Check electrolytes • Monitor and observe patient (dizziness, nausea) • Report to doctor If Symptomatic but maintaining BP Systolic > 90: • Lie flat and give oxygen • Notify the doctor • Consider IV Isoprenaline 20mcg • Commence External Pacing or Isoprenaline Infusion • Prepare for Transvenous Pacing Wire Insertion

If Symptomatic but BP Systolic < 90: • Lie flat and give oxygen • Give IV Adrenaline 0.1mg and flush line with a minimum of 30mls 0.9% NaCl 34

ALS Information Manual PAH 2010

• Notify medical staff urgently • Prepare IV fluids • Commence External Pacing • Prepare for insertion of Temporary Pacing Wire • Commence CPR if patient becomes pulseless Causes:

Myocardial Infarction Ischaemic AV Node Degeneration of the conduction system (elderly) Congenital

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3.5

IDIOVENTRICULAR RHYTHM

Slow Idioventricular Rhythm

Comment:

This ventricular rhythm is initiated by an ectopic focus in the ventricles because the

primary pacemaker sites have failed. It does not produce a cardiac output and therefore is a pulseless electrical activity situation. The rate is slow between 15 – 40bpm and is indicative of a dying heart. Treatment: ASSESS THE PATIENT Asymptomatic

Unconscious – no pulse

– 12 lead ECG

Symptomatic but conscious – lie flat, give O2

– frequent observation as

– obtain IV access

– CPR

condition may deteriorate

– Atropine 0.5 mgs IV

– obtain IV access

– check electrolytes

– notify MO

– Adrenaline 1mg every

– notify MO

– treat as PEA

3-5 mins consider external pacing find & treat cause if possible

Causes:

Massive Myocardial Infarction End Stage Heart Failure Hypovolaemia causing ischaemia Massive Pulmonary Embolism Cardiac Tamponade Tension Pneumothorax

Rapid Idioventricular Rhythm Comment:

This rhythm is quite a common reperfusion arrhythmia following Myocardial Infarction

treated with Thrombolysis. It is usually non – sustained. 36

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Treatment: ASSESS THE PATIENT If asymptomatic – monitor and observe patient Document in the patient’s notes the frequency Not treated unless patient is symptomatic (dizziness, nausea, blackouts) If symptomatic and increasing frequency may be treated with Lignocaine bolus Please Note: Rapid Idioventricular Rhythm with rate > 100 is VT and should be treated as Ventricular Tachycardia.

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3.6

PACED RHYTHM

Comment:

It is necessary for the achievement of the ALS competency that staff can recognise

paced rhythm. They must also demonstrate how to effectively externally pace a patient, how to achieve capture and how to recognise that pacing is effective. The above rhythm is recorded from a patient receiving external pacing. Capture means that there is a pacing spike on the monitor followed immediately by a widened QRS complex, indicating that the pacemaker is initiating ventricular depolarization. With every paced beat on the monitor there should be associated mechanical activity, which is evidenced by a palpable PULSE for each QRS complex. Specific pacemaker functions and troubleshooting are discussed in Section 5.0 Cardiac Pacing.

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SPECIAL NOTES: • Defibrillation takes priority over drugs and CPR in the management of VF and pulseless VT. • If there is no IV access available, then Adrenaline, Atropine and Lignocaine may be given via the EndoTracheal Tube. The dose is increased to 2 – 3 times the normal IV dose. • Minimise the interruptions to CPR between each DCCS and Intubation. • If there is return of spontaneous circulation, protect the patient’s airway and move to post arrest management. • Consider Calcium Chloride 10% for the treatment of overdose of Calcium Channel Blockers, hypocalcaemia and hyperkalaemia. • Consider Sodium Bicarbonate for the management of documented metabolic acidosis, hyperkalaemia, prolonged cardiac arrest and overdose of tricyclic antidepressants.

Recommended readings: Australian Resuscitation Council Guidelines- Policy statements, (2006) Section 11, Advanced Cardiac Life Support Conover, M.B. (2004), Pocket guide series, Electrocardiography 5th Ed. Mosby, St Louis. Conover, M.B. (1996), Understanding Electrocardiography 7th Ed. Mosby, St Louis; Chapters 11,13, 15 & 16)

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4.0

DEFIBRILLATION

INTRODUCTION In defibrillation, electrical energy is used to simultaneously depolarize all myocardial cells. The uniform depolarization of all cardiac cells facilitates the return of the normal electrical conduction pathways, via the primary pacemaker of the heart – the Sinus Node. The purpose is to stop the cells fibrillating and allow the normal conduction pathways to regain control. Restoration of sinus rhythm should improve the cardiac output.

4.1

TWO METHODS OF DEFIBRILLATION:

EXTERNAL DEFIBRILLATION a. Manual Defibrillation – requires the operator to be able to identify lethal arrhythmia and deliver appropriate defibrillation to the patient. External defibrillation can be facilitated by the use of hand held paddles or adhesive pads. •

Anterior – Anterior Method – This is the most effective pad/paddle placement for emergency defibrillation as the electrical current flows directly through the left ventricle. Place one pad/paddle to the right of the sternum directly under the clavicle in the 2nd to 3rd intercostal space. Place the second pad/paddle to the lower left anterior chest wall, in about the 5th to 6th intercostal space in the midaxillary line, over the apex of the heart.

Anterior – Posterior Method – This method is suited to atrial arrhythmias – Place one pad/paddle anteriorly, either to the left or the right of the sternum under the clavicle. Place the second pad/paddle posteriorly under the left scapula. If using hand held paddles, the patient must be lying on their right side for this method. Adhesive pads allow the patient to be supine.

b. Semi Automatic External Defibrillation – does not require the operator to have the skills to interpret ECG. The SAED uses computerised algorithm to detect arrhythmia and advises the operator ‘to shock or not to shock’

INTERNAL DEFIBRILLATION Internal defibrillators are available in Emergency Department, Recovery and Intensive Care. The chest cavity needs to be opened / reopened (thoracotomy) and the paddles are placed indirect contact with the heart. One paddle is placed over the right atrium and the second paddle over the apex of the heart. Internal defibrillation requires 20 joules regardless of the type of defibrillator.

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NOTE: There are two different defibrillators available for use at the PAH (Refer to Section 4.4). It is the responsibility of the staff member to be familiar with the machines used in their units. 4.2

SAFETY PRINCIPLES OF DEFIBRILLATION

IF USING PADDLES: • Moist gel pads should always be used to prevent or minimize burning to the skin. Gel pads or gel decrease the resistance between the electrode and the patient’s skin. Paddles should be placed over gel pads and should not extend out over the edges of the gel pads. Only use specific Defibrillator Gel. • Defibrillate from the left side of th

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