IMMEDIATE LIFE

SUPPORT
 LEARNING OBJECTIVES

 What is ILS?

 Causes & Prevention of Cardiac arrest

 ABCDE approach

 Cardiac arrest

 Cardiac Arrest moulages

 WHAT IS ILS?

 Provides knowledge and skills needed to treat

adult patients in cardio-respiratory arrest for
the short time before the arrival of a
resuscitation team or more experienced
assistance

 Teaches the recognition and treatment of the

deteriorating patient using the ABCDE
approach.
 ABCDE APPROACH

 A – Airway

 B – Breathing

 C – Circulation

 D – Disability

 E - Exposure
CHAIN OF SURVIVAL
 CAUSES AND PREVENTION OF
CARDIORESPIRATORY ARREST
 WHY IS PREVENTION OF CARDIO-
RESPIRATORY ARREST IMPORTANT?

 Once cardiac arrest occurs, fewer than 20% of

patient having an in-hospital cardiac arrest will
survive to go home.

 Most in-hospital cardiac arrests are not sudden

or unpredictable events. In approximately 80%
of cases clinical signs deteriorate over the few
hours before arrest.
CHAIN OF PREVENTION
 EDUCATION
 How to observe patients

 Recognising signs of deterioration

 Using the ABCDE approach

 Simple skills to stabilise the patient pending the

arrival of more experienced help
 MONITORING

 Patient assessment

 Measurement and recording of vital signs

 RECOGNITION & CALL FOR HELP

 To identify patients in need of additional monitoring or

intervention (e.g Early Warning scoring system)

 Protocols for summoning a response to a deteriorating

patient (clear deterioration prompts early help)

 Using a structured communication tool such as SBAR or

RSVP to call for help
 EARLY WARNING SCORING SYSTEM

Score 3 2 1 0 1 2 3

<45 30 15% Normal for 15% >4

Systolic BP 30%
% % down patient up 5%

<4 101- 111- >1

Heart rate (BPM) — 41-50 51-100
0 110 129 30

Respiratory rate 15- >3

— <9 — 9-14 21-29
(RPM) 20 0

<3
Temperature (°C) — — 35.0-38.4 — >38.5 —
5

AVPU — — — A V P U
ESCALATION PROTOCOL BASED ON EWS
EWS Minimal Observation Escalation
frequency
Recorder’s action Doctor’s action

3-5 4 hourly Inform nurse in charge

6 4 hourly Inform doctor Doctor to see within 1 hour

7-8 1 hourly Inform doctor Doctor to see within 30

minutes and discuss with
senior doctor and / or
Consider continuous
monitoring outreach team

>9 30 minutes Inform doctor Doctor to see within 15

minutes and discuss with
senior doctor and ICU team
Start continuous monitoring
 CALL FOR HELP

SBAR RSVP

SITUATION REASON

BACKGROUND STORY

ASSESSMENT VITAL SIGNS

RECOMMENDATION PLAN
 RESPONSE

 Assured

 Specified speed

 Appropriate personnel (e.g. ICU team)

EXAMPLE
CAUSES OF DETERIORATION AND CARDIO-
RESPIRATORY ARREST

AIRWAY

BREATHING

CIRCULATION
 AIRWAY OBSTRUCTION

Causes
 CNS depression (loss of airway patency and
protective reflexes)
 Blood, vomitus, foreign body

 Trauma to face or throat

 Epiglottitis

 Pharyngeal swelling (e.g infection, oedema)

 Laryngospasm, bronchospasm

 Bronchial secretions

 Blocked teacheostomy or laryngectomy

 AIRWAY OBSTRUCTION (contd…)

Recognition

 Conscious patient Difficulty breathing, choking,

distressed

 Partial obstruction  NOISY

 Complete obstruction  SILENT, no air

movement at mouth

 Accessory muscle usage, see-saw respiration

 AIRWAY OBSTRUCTION (contd…)

Treatment

 Treat the cause (e.g suction)

 Protect airway
 airway opening manoeuvres (head tilt / chin lift
or jaw thrust)
 insertion of adjuncts (e.g. oropharyngeal)
 intubation

 Oxygen
 BREATHING PROBLEMS

Causes

 Acute or Chronic

 Lung disorder  infection, COPD, hemo /

pneumothorax, embolism

 Respiratory drive  CNS depression

 Respiratory effort  Spinal cord damage, diseases

(myasthenia gravis, GBS), pain
 BREATHING PROBLEMS (contd…)
Recognition

 Conscious patient  shortness of breath

 Irritability, confusion, lethargy, reduced consciousness

 Cyanosis – LATE sign

 Indicators:
 R/R
 Pulse Oximetry
 ABG’s
 BREATHING PROBLEMS (contd…)

Treatment

 Oxygen
 High flow to start
 Aim for 94-98% saturation on stability
 COPD – 88 – 92% saturation on stability

 Treat the cause

 Non-invasive ventilation

 Controlled ventilation (requiring intubation)

 CIRCULATION PROBLEMS

Causes

 Primary Heart Problems  ACS, valvular, etc

 Secondary Heart Problems

 Respiratory arrest causing lack of oxygenation
 Anemia

 Septic shock

 Hypothermia
 CIRCULATION PROBLEMS (contd…)

Recognition
 Chest pain
 Shortness of breath
 Syncope (fainting)
 Tachycardia / bradycardia
 Tachypnea
 Hypotension
 Poor peripheral perfusion
 Altered mental status
 Oliguria
 CIRCULATION PROBLEMS (contd…)
Treatment

 ECG

 Treat the cause  I/V fluids for hypotension

 For ACS:
 Sit patient up
 Aspirin 300mg
 Nitroglycerine (unless hypotensive)
 Oxygen
 Morphine for relief of pain
 If STEMI  decide for thrombolysis / PCI
ANY QUESTIONS?
 SUMMARY

 Causes of deterioration in patients

 Importance of vital observations

 Good and early communication

 Rapid initiation of treatment

ABCDE APPROACH
 A - AIRWAY
Assess
 see-saw respiration, accessory muscle usage
 cyanosis
 noisy / silent or no breath sounds
 depressed consciousness

Treat
 Airway opening maneuvres (head tilt, chin lift / jaw
thrust)
 Suction
 Insertion of airway adjunct / intubation (expert only)
 Oxygen
 B - BREATHING

Look, Listen, Feel

 R/R
 Depth, chest expansion

 Chest deformity

 sweating, central cyanosis, accessory muscle

usage, abdominal breathing
 Added sounds

 Percussion + Auscultation

 Tracheal position

 Chest wall palpation

 B – BREATHING (contd…)

Treat

 Oxygen (for COPD aim for 88-92%)

 Needle thoracosotomy, chest drain insertion
 C - CIRCULATION
Assess

 Colour and feel of hands

 Capillary refill time
 Pulse rate
 Character of peripheral and central pulses
 Blood pressure
 Auscultate the heart
 Conscious level
 Urine output (if catheterised)
 Ongoing bleeding, collections in drains
 C – CIRCULATION (contd…)
Treat

 Insert 14 or 16 G I/V cannula (one or more)

 Take blood samples for investigations and group and

save

 Rapid fluid challenge of N/saline or Hartmann’s:

 If normotensive - 500 ml

 If hypotensive – 1 liter

 If known cardiac failure - smaller volumes (250ml) with

closer monitoring
 C – CIRCULATION (contd…)

Treat

 Control bleeding

 Reassess and repeat fluid challenge if no

improvement

 Reassess and ask for help if no improvement

(inotropes or vasopressors maybe needed)

 Get ECG and follow ACS protocol if appropriate

 D - DISABILITY
Assess

 Review ABCs

 Consciousness level
 A – Alert
 V – responds to Vocal stimulus
 P – responds to Painful stimulus
 U – Unresponsive
 Or GCS

 Pupils

 Blood GLUCOSE

 Drug induced causes

 Lateral position if airway not protected

 E - EXPOSURE

 Full exposure of body

 Respect patient’s dignity

 Minimise heat loss

 ALWAYS

 Remain systematic in approach

 First initiate treatment for identified problem,
then move to next step
 Reassess and review your interventions
starting from A going to E
 Don’t Ever Forget Glucose
 Obtain history from patient, relative, staff,
notes
 Document assessment, intervention and
responses
ANY QUESTIONS?
 SUMMARY

 Systematic structured ABCDE approach

 Importance of treatment with identification

 DEF – Glucose

 Continuous re-assessments
CARDIAC ARREST
 CHEST COMPRESSIONS
 Correct hand position – middle of the lower half of
the sternum

 High quality compressions:

 Depth of 5-6 cm
 Rate of 100-120 compressions per minute
 Allow the chest to recoil completely after each
compression
 Minimise interruptions. Plan when and why to pause

 Do not feel for pulse to assess compression

effectiveness

 If intubated, continue compressions uninterrupted

 ADVANCED LIFE SUPPORT
 Standardised approach to patient with cardio-
respiratory arrest.

 Team members can predict and prepare for the next

stage in patient’s treatment

 Most important interventions that improve survival

after cardiac arrest are:
 Early, uninterrupted high quality chest compressions
 Early defibrillation for VF / VT

 Drugs and advanced airways are of secondary

importance
VENTRICULAR TACHYARDIA
VENTRICULAR FIBRILLATION
FINE VENTRICULAR FIBRILLATION
ASYSTOLE
PULSELESS ELECTRICAL ACTIVITY
 ADVANCED LIFE SUPPORT - SHOCKABLE

 Interval between stopping compressions and

delivering a shock must not be more than 5
seconds ideally

 Resume chest compressions immediately after

a shock without checking the rhythm or a pulse

 Give adrenaline 1mg (1:10000) I/V after 3 rd

shock. Repeat if arrest persists every alternate
cycle.
 ADVANCED LIFE SUPPORT – SHOCKABLE (contd…)

 Give amiodarone 300mg I/V after 3 rd shock.

Give further 150mg I/V if VF / VT persists.

 If amiodarone is unavailable, consider 100mg

Lidocaine. Give an additional 50mg if
necessary

 If rhythm is organised – check for pulse.

 ADVANCED LIFE SUPPORT – NON-SHOCKABLE

 Pulseless Electrical Activity: organised cardiac

‘electrical activity’ in the absence of palpable
pulses.

 Give adrenaline 1mg (1:10000) I/V as soon as

intravascular access is achieved. Repeat if
arrest persists every alternate cycle.
 DURING CPR

 Give good quality chest compressions

 Recognise and treat reversible causes

 Obtain a secure airway

 Obtain a vascular access

 AIRWAY AND VENTILATION

 Use a bag mask / supraglottic airway device

 Ventilate the lungs at 10 breaths / minute

 Tracheal intubation should only be attempted

by trained healthcare provider

 Once intubated  continue chest compressions

at a rate of 100-120 without pausing ventilation
 VASCULAR ACCESS

 Peripheral venous cannulation is quicker,

easier and safer.

 Give flush of 20 ml of fluid post drug

administration. Elevate the extremity for 10-20
seconds.

 If I/V access cannot be established, consider

intraosseous access.
 REVERSIBLE CAUSES

4 H’S

 Hypoxia

 Hypovolaemia

 Hypoglycemia / hypo- or hyper- kalemia /

hypocalcemia / acidaemia / metabolic disorders

 Hypothermia
 REVERSIBLE CAUSES (Contd…)

4 T’s

 Tension pneumothorax

 Tamponade

 Toxins

 Thrombosis (pulmonary or coronary thrombosis)

 SIGNS OF LIFE

 Respiratory effort

 Movement

 Check for organised rhythm

 Check for pulse

 If no pulse – continue CPR

 CONTINUE RESUSCITATION UNTIL

 Qualified / senior help arrives and takes over

 The patient starts to show signs of regaining

consciousness, such as coughing, opening his
eyes, speaking, or moving purposefully AND
starts to breathe normally

 You become exhausted.

 DISCONTINUING RESUSCITATION – DIAGNOSING
DEATH

 Absence of central pulse

 Absence of heart sounds

 Flatline – ECG

 Observe for 5 minutes

 Check for pupil response / corneal reflexes

 Involve a senior
ANY QUESTIONS?
 SUMMARY

 Identifying cardiac arrest

 ALS algorithm

 Shock able / Non-shock able rhythms

 Treatment of Reversible causes – 4 H’s & 4

T’s
CARDIAC ARREST
MOULAGES
 ACKNOWLEDGMENTS
 Prof. Farhat Jafri

 Prof. Tahir Husain

 Prof. Waqar Kazmi

 Dr.Wasim Siddiqui
THANK YOU ALL!