![www.cmft.nhs.uk/undergrad
Get expert help
• Send some one or leave
the victim to call the
resuscitation team
(2222)
• State clearly “Cardiac
arrest; [location]” and
repeat
• Return to the victim
GET HELP 2222 (or 999)](https://image.slidesharecdn.com/abcde-240917163448-ff142fe4/85/ABCDE-ATLS-guidelines-and-management-of-trauma-ppt-49-320.jpg)
ABCDE ATLS guidelines and management of trauma.ppt
- 1. www.cmft.nhs.uk/undergrad ABCDE - The approach to the critically ill patient DR. TALAT WASEEM CHIEF OF SURGERY SHL
- 2. www.cmft.nhs.uk/undergrad Objectives • The rational of ABCDE • The process of primary & secondary survey • Recognition of life threatening events • Treatment of life-threatening conditions • Handover
- 4. www.cmft.nhs.uk/undergrad The ABCDE approach Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination
- 5. www.cmft.nhs.uk/undergrad Ask 6 questions 1. Are they conscious? 2. Do they have a patient airway? 3. Is their breathing adequate? 4. Is their circulation adequate? 5. Are they neurologically intact? 6. Is the rest of them ok? If at any point the answer is NO then do something!
- 6. www.cmft.nhs.uk/undergrad The principles • Perform primary ABCDE survey (5 min) • Instigate treatment for life threatening conditions as you find them • Reassess when any treatment is completed • Perform more detailed secondary ABCDE survey including investigations • If condition deteriorates repeat primary survey
- 7. www.cmft.nhs.uk/undergrad The primary survey • ABCDE assessment • Treat life threatening conditions • Rapid intervention including – 15L O2 via a non-rebreathing mask – IV access & fluid challenge – specific treatment • Re-assess after any intervention
- 8. www.cmft.nhs.uk/undergrad The primary survey • No longer than 5 min • Repeated as necessary • Get experienced help • Delegate jobs – 1st person assess Airway, O2 & Breathing – 2nd person assesses Circulation – 3rd person IV access & fluids
- 9. www.cmft.nhs.uk/undergrad The secondary survey • Performed when patient more stable • Get a brief focused HPC & Hx • More detailed examination of patient (ABCDE) • Order investigations to aid diagnosis • IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY
- 10. www.cmft.nhs.uk/undergrad Airway - causes GCS • Body fluids • Foreign body • Inflammation • Infection • Trauma
- 11. www.cmft.nhs.uk/undergrad Airway - assessment • Talking patients have a patent airway! • Unresponsive patients have a threatened airway • Added sounds indicate partial obstruction – Snoring, gurgling, wheeze, stridor
- 12. www.cmft.nhs.uk/undergrad Airway – interventions (basic) • Head tilt chin lift • Jaw thrust • Suction • Oral airways • Nasal airways
- 13. www.cmft.nhs.uk/undergrad Airway – interventions (advanced practitioners) • GET HELP!!! • Nebulised adrenaline for stridor • LMA • Intubation • Cricothyroidotomy – Needle or surgical
- 14. www.cmft.nhs.uk/undergrad Once airway open... • Give 15 litres of oxygen to all patients via a non- rebreathing mask • For COPD patients re-assess after primary survey: keep SpO2 90-93%
- 15. www.cmft.nhs.uk/undergrad Breathing - causes GCS • Resp depressions • Muscle weakness • Exhaustion • Asthma • COPD • Infection • Pulmonary oedema • Pulmonary embolus • ARDS • Pneumothorax • Haemothorax • Open pneumothorax • Flail chest
- 16. www.cmft.nhs.uk/undergrad Breathing - assessment • Look – Rate (<10 or >20), symmetry, effort, SpO2, colour • Listen – Taking: sentences, phrases, words – Bilateral air entry, wheeze, silent chest other added sounds • Feel – Central trachea, Percussion, expansion
- 17. www.cmft.nhs.uk/undergrad Breathing - interventions • Consider ventilation with BVM + O2 if RR < 8 • Sit upright if conscious & SoB • Specific treatment – i.e.: β agonist for wheeze; chest drain for pneumothorax
- 18. www.cmft.nhs.uk/undergrad Circulation - assessment • Look at colour • Examine peripheries • Pulse, BP & CRT • Hypotension (late sign) – sBP< 100mmHg – sBP < 20mmHg below pts norm Urine output • Consider compensation mechanisms
- 19. www.cmft.nhs.uk/undergrad Circulation – shock • Loss of volume – Hypovolaemia • Pump failure – Myocardial & non- myocardial causes • Vasodilatation – Sepsis, anaphylaxis, neurogenic Inadequate tissue perfusion
- 20. www.cmft.nhs.uk/undergrad Compensation mechanism Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD
- 21. www.cmft.nhs.uk/undergrad Loss of volume 1 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 1
- 22. www.cmft.nhs.uk/undergrad Loss of volume 2 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 1 2
- 23. www.cmft.nhs.uk/undergrad Loss of volume 3 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 3 1 2
- 24. www.cmft.nhs.uk/undergrad Pump failure 1 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 1
- 25. www.cmft.nhs.uk/undergrad Pump failure 2 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 2 1
- 26. www.cmft.nhs.uk/undergrad Pump failure 3 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 3 2 1
- 27. www.cmft.nhs.uk/undergrad Vasodilatation 1 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 1
- 28. www.cmft.nhs.uk/undergrad Vasodilatation 2 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 2 1
- 29. www.cmft.nhs.uk/undergrad Vasodilatation 3 Fluid Volume (CVP/JVP) Vascular Diameter (SVR) Cardiac Output (SV x HR) PRE-LOAD AFTER-LOAD 3 2 1
- 30. www.cmft.nhs.uk/undergrad Circulation - interventions • Position supine with legs raised – Caution if DiB – Left lateral tilt in pregnancy • IV access - 16G or larger x2 – +/- bloods if new cannula • Fluid challenge – colloid or crystalloid? • ECG Monitoring • Specific treatment
- 31. www.cmft.nhs.uk/undergrad Disability - causes • Inadequate perfusion of the brain • Sedative side effects of drugs BM • Toxins and poisons • CVA ICP
- 32. www.cmft.nhs.uk/undergrad Disability - assessment • AVPU (or GCS) – Alert, responds to Voice, responds to Pain, Unresponsive • Pupil size/response • Posture • BM • Pain relief
- 33. www.cmft.nhs.uk/undergrad Disability - interventions • Optimise airway, breathing & circulation • Treat underlying cause – i.e.: naloxone for opiate toxicity – Caution if reversing benzo’s • Treat BM – 100ml of 10% dextrose (or 20ml of 50% dextrose) • Control seizures • Seek expert help for CVA or ICP
- 34. www.cmft.nhs.uk/undergrad Exposure • Remove clothes and examine head to toe; front and back – Haemorrhage (inc concealed), rashes, swelling etc • Keep warm (unless post cardiac arrest) • Maintain dignity
- 35. www.cmft.nhs.uk/undergrad Secondary survey • Repeat ABCDE in more detail • History • Order investigations – ABG, CXR, 12 lead ECG, Specific bloods • Management plan • Referral • Handover
- 36. www.cmft.nhs.uk/undergrad Handover • Grab their attention by telling them the Situation • Give them a little relevant Background on what's happened • Tell them your Assessment of the patient • Recommend to them what you want the to do
- 37. www.cmft.nhs.uk/undergrad Situation • Check you are talking to the right person • State your name & department • The headline grabber – “I think this patient is haemorrhaging internally”
- 38. www.cmft.nhs.uk/undergrad Background • Admission diagnosis and date of admission • Relevant medical history • Brief summary of treatment to date
- 39. www.cmft.nhs.uk/undergrad Assessment • Your assessment of the patient using the ABCDE approach
- 40. www.cmft.nhs.uk/undergrad Recommendation • I would like you to... • Determine the time scale • Is there anything else I should do? • Record the name and contact number of your contact
- 42. www.cmft.nhs.uk/undergrad Summary • Assess ABCDE in turn • Instigate treatments for life-threatening problems as you find them • Reassess following treatment • If anything changes go back to A
- 43. www.cmft.nhs.uk/undergrad CPR & Emergency Defibrillation For OSCEs Nick Smith Head of Clinical Skills
- 44. www.cmft.nhs.uk/undergrad Objectives • To be fully aware of the new CPR guidelines • To have knowledge of the new ALS guidelines • To be aware of the pitfalls
- 45. www.cmft.nhs.uk/undergrad The station • Could just be CPR • Could be just defibrillation • Could be combined CPR with defib • Maybe just you in the station or maybe an assistant (plus an examiner)
- 46. www.cmft.nhs.uk/undergrad Basic Life Support DANGER? RESPONSE? SHOUT 4 HELP OPEN AIRWAY CHECK BREATHING & CIRCULATION 30 CHEST COMPRESSIONS ATTEMPT 2 BREATHS GET HELP! 2222 (or 999) CONTINUE CPR 30:2 UNTIL DEFIB ARRIVES
- 47. www.cmft.nhs.uk/undergrad Assess the patient Ask the examiner if it is safe to approach Firmly shake the manikins shoulders and ask loudly “are you alright” Shout loudly for someone to assist you DANGER? RESPONSE? SHOUT 4 HELP
- 48. www.cmft.nhs.uk/undergrad Look for signs of life • An obvious head-tilt/chin lift • Get close to the patient & look listen and feel for breathing • At the same time feel for the carotid pulse • Count out 10 second OPEN AIRWAY CHECK BREATHING & CIRCULATION
- 49. www.cmft.nhs.uk/undergrad Get expert help • Send some one or leave the victim to call the resuscitation team (2222) • State clearly “Cardiac arrest; [location]” and repeat • Return to the victim GET HELP 2222 (or 999)
- 50. www.cmft.nhs.uk/undergrad Circulate oxygen • Heel of hands in middle of chest • Interlock fingers and keep elbows locked • Compress 5 – 6 cm • Rate of 100 - 120 per min • Allow chest to recoil 30 CHEST COMPRESSIONS
- 51. www.cmft.nhs.uk/undergrad Reoxygenate ATTEMPT 2 BREATHS • Assemble pocket mask • Create a seal around the nose & mouth • Open the airway • Attempt 2 breaths • If chest fails to rise go back to 30 chest compressions • Continue CPR 30:2 • Minimise interrutions
- 52. www.cmft.nhs.uk/undergrad Keep them going! • Get assistant to take over CPR where available • Connect defib • Turn defib on by turning the dial to ‘ON’ CONTINUE CPR 30:2 UNTIL DEFIB ARRIVES
- 53. www.cmft.nhs.uk/undergrad ALS algorithm Analyse Rhythm Non- shockable Asystole/PEA Shockable VF/Puleless VT 1 shock 150 joules Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated • Assess using ABCDE approach • Control oxygenation and ventilation • 12-lead ECG • Treat precipitating causes • Temperature control / therapeutic hypothermia Adrenaline 1mg & Amiodarone 300mg IV/IO after 3rd shock then repeat adrenaline after every alternate shock Adrenaline 1mg (IV/IO) as soon as access obtained and then every alternate loop Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated Return of spontaneous circulation Immediate post arrest treatment
- 54. www.cmft.nhs.uk/undergrad Decide what rhythm they are in • Briefly pause CPR to assess rhythm • Restart chest compressions • Verbalise the rhythm to the examiner • Shockable or non-shockable Analyse Rhythm
- 55. www.cmft.nhs.uk/undergrad Shockable • VF – Bizzare, irregular • Pulseless VT – Rapid, regular, broad QRS Analyse Rhythm Shockable VF/Puleless VT
- 56. www.cmft.nhs.uk/undergrad Deliver shock • Turn dial to 150 • “STAND CLEAR OXYGEN AWAY” • Push button 2 to charge • When charged stop compressions • “SHOCKING” • Press button 3 to shock Analyse Rhythm Shockable VF/Puleless VT 1 shock 150 joules
- 57. www.cmft.nhs.uk/undergrad Restart CPR • Immediately resume CPR for 2 min • Do not re-check rhythm! • Minimise interruptions to CPR • Only stop if patient shows obvious signs of life Analyse Rhythm Shockable VF/Puleless VT 1 shock 150 joules Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated
- 58. www.cmft.nhs.uk/undergrad • Time it out • Ensure quality CPR • Plan actions when interrupt CPR • IV Access +/- fluids • Ensure O2 via BVM • Prepare drugs • Consider reversible causes During 2 min CPR • Hypovolaemia • Hypoxia • Hypo/er kalaemia • Hypothermia • Tension pneumothorax • Tamponade (cardiac) • Toxins • Thrombus
- 59. www.cmft.nhs.uk/undergrad After 2 min CPR • Re-analyse the rhythm • If still shockable then repeat the process • If not VF or VT then move to non-shockable side of algorythm Analyse Rhythm Shockable VF/Puleless VT 1 shock 150 joules Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated
- 60. www.cmft.nhs.uk/undergrad After 3rd shock • Give 1mg adrenaline & 300mg amiodarone immediately after shock during CPR • Repeat adrenaline after every alternate shock Analyse Rhythm Shockable VF/Puleless VT 1 shock 150 joules Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated
- 61. www.cmft.nhs.uk/undergrad Non-shockable • Asystole – No electrical activity – Occasionally P waves • PEA – Any non-shockable rhythm with a QRS complex and no pulse Analyse Rhythm Non- shockable Asystole/PEA
- 62. www.cmft.nhs.uk/undergrad Signs of life (SoL) check • 10sec only • Don’t check in asystole • Only used to distinguish PEA from a perfusing rhythm Analyse Rhythm Non- shockable Asystole/PEA
- 63. www.cmft.nhs.uk/undergrad Restart CPR Analyse Rhythm Non- shockable Asystole/PEA Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated • Uninterrupted CPR for 2 min • Do not re-check rhythm! • Unless patient shows obvious signs of life
- 64. www.cmft.nhs.uk/undergrad Drugs • During CPR as soon as access available • Adrenaline 1mg • Repeat every alternate 2 min cycle Analyse Rhythm Non- shockable Asystole/PEA Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated
- 65. www.cmft.nhs.uk/undergrad After 2min CPR • Analyse rhythm • If still non-shockable then repeat the process • If shockable then go to shockable side of algorithm • If SoL then reassess using A-E approach Analyse Rhythm Non- shockable Asystole/PEA Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated
- 66. www.cmft.nhs.uk/undergrad ALS algorithm Analyse Rhythm Non- shockable Asystole/PEA Shockable VF/Puleless VT 1 shock 150 joules Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated • Assess using ABCDE approach • Control oxygenation and ventilation • 12-lead ECG • Treat precipitating causes • Temperature control / therapeutic hypothermia Adrenaline 1mg & Amiodarone 300mg IV/IO after 3rd shock then repeat adrenaline after every alternate shock Adrenaline 1mg (IV/IO) as soon as access obtained and then every alternate loop Immediately resume CPR 30:2 for 2 min Minimise interruptions Push drugs when indicated Return of spontaneous circulation Immediate post arrest treatment
- 68. www.cmft.nhs.uk/undergrad Summary • DRS ABC • Get help • CPR (minimise interruptions) • Attach defib • Analyse rhythm • Shock (or don’t) • 2 min CPR (minimise interruptions) • Reassess
- 69. www.cmft.nhs.uk/undergrad Acute severe asthma • Nebulised salbutamol (5mg) - O2 driven – Repeat as needed • Nebulised ipratropium (500mcg) - O2 driven • Hydrocortisone 100mg IV or Prednisolone 50 – 60mg po • MgSO4 IV 1.2 – 2g – Seek guidance first Any one of: • PEF 33 – 50% of best or predicted • RR> 24 • HR> 110 • Inability to complete sentences in 1 breath HR SVR
- 70. www.cmft.nhs.uk/undergrad Life threatening asthma • PEF <33% • SpO2 <92% • PaO2 <8 kPa • Normal PaCO2 – PaCO2 is a pre- terminal sign • Silent chest • Cyanosis • Poor respiratory effort • Arrhythmias • Exhaustion / GCS Severe asthma plus one of the following: Get expert help quickly and treat as for acute severe asthma HR SVR
- 71. www.cmft.nhs.uk/undergrad Sepsis Signs and symptoms of infection (SSI) or Systemic Inflammatory Response (SIRs) • Temperature > 38.2°C or <36°C • HR>90 beats/min • Respiratory rate >20 breaths/min • WBC count > 12,000 or <4,000/mL • Hyperglycaemia (in absence or DM) 2 or more SSI’s + suspicion of a new infection = SEPSIS HR SVR
- 72. www.cmft.nhs.uk/undergrad Severe Sepsis • Oxygen • Blood cultures • IV antibiotics (within 1 hour) • BP < 90 systolic • Acute alteration in mental status • O2 sats < 90% • UO < 0.5ml/kg/hr for 2 hours • Bilirubin >34µmol/L • Platelets <100 x 109 /L • Lactate>2 mmol/L • Coagulopathy – INR>1.5 or APTT>60sec SEPSIS + Organ dysfunction = SEVERE SEPSIS • Fluids +++ • Monitor lactate & Hb • Urinary Catheter & hourly monitoring HR SVR
- 73. www.cmft.nhs.uk/undergrad Anaphylaxis • Get expert help quickly • Oxygen • IM adrenaline 500mcg – repeat every 5 min if needed Highly likely if… 1. Sudden onset and rapid progression 2. Life threatening problem to airway &/or breathing &/or circulation 3. Skin changes (rash or angioedema) +/- Exposure to known allergen • Chlorphenamine 10mg IV • Hydrocortisone 200mg IV • +/- fluids +++ HR SVR
- 74. www.cmft.nhs.uk/undergrad Hypovolaemia Haemorrhagic • External • Drains • GI tract • Abdomen Trauma • On the floor and 4 more – Chest, abdo, pelvis, long bones Fluid loss • D&V • Polyuria • Pancreatitis Iatrogenic • Diuretics +++ • Inadequate fluid prescription HR SVR
- 75. www.cmft.nhs.uk/undergrad Hypovolaemia Responders Partial or transient responders Non-responders Patient improve and remains improved. Patient improves but shows a gradual deterioration on-going loss or re- equilibration No improvement. Exsanguination though severe dehydration & sepsis should be considered No further boluses maybe needed but investigate cause Further boluses and investigations Further boluses and get help quickly Give fluid challenge 250ml over 2 min and reassess after 5 min
- 76. www.cmft.nhs.uk/undergrad Haemorrhagic shock Class I < 15% <750ml Class II 15-30% 750 – 1500ml Class III 30 – 40% 1500 – 2000ml Class IV >40% >2000ml RR 14-20 20-30 30+ 35+ HR <100 >100 >120 >140 BP Normal Normal Decreased Decreased Pulse pressure Normal Decreased Decreased Decreased Neuro Slightly Anxious Mildly anxious Anxious or confused Confused or lethargic Urine Output > 30 20 – 30 5 - 15 Bladder sweat Use patients obs to estimate the blood loss then replace with crystalloid at 1.5 to 3ml for every 1ml of estimated blood loss Figures based on a young healthy adult with a compressible haemorrhage
- 77. www.cmft.nhs.uk/undergrad Bradycardia Adverse signs BP • HR < 40 • Heart failure • Ventricular arrhythmias compromising BP No adverse signs with a risk of asystole? • Recent asystole • Mobitz II AV block • 3rd degree HB w QRS • QRS pauses > 3 sec • Get expert help quickly! • Atropine 500 mcg IV – Repeat to a max total dose of 3mg • External cardiac pacing HR SVR
- 78. www.cmft.nhs.uk/undergrad Tachyarrhythmia • Get expert help quickly • Unstable* – Sedate and synchronised cardiovertion • Stable VT – Amiodarone 300mg 20 – 60 min • Stable SVT – Vagal manoeuvers – Adenosine 6mg, 12mg, 12mg • Stable tachy AF – Amiodarone 300mg 20 – 60 min if onset < 48hrs – Β-blocker IV or digoxin IV (*rate related symptoms are uncommon at less than 150 beats min-1 ) HR SVR