Adult Basic Life Support

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2 Adult Basic Life Support UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? Call 112* 30 chest compressions 2 rescue breaths 30 compressions *or national emergency number Fig 1.2_Adult BLS Final

3 Automated External Defibrillator Algorithm unresponsive? Call for help Open airway Not breathing normally Send or go for AED Call 112* CPR 30:2 until AED is attached * or national emergency number AED assesses rhythm Shock advised No shock advised 1 Shock Immediately resume: CPR 30:2 for 2 min Immediately resume: CPR 30:2 for 2 min Continue until the victim starts to wake up: to move, opens eyes and to breathe normally Fig 1.4_BLS-AED Final

4 Adult Foreign Body Airway Obstruction Treatment Assess severity Severe airway obstruction (ineffective cough) Mild airway obstruction (effective cough) Unconscious Conscious Encourage cough Start CPR 5 back blows 5 abdominal thrusts Continue to check for deterioration to ineffective cough or until obstruction relieved Fig 1.3_Adult FBAO Final

5 In Hospital Resuscitation Collapsed/sick patient Shout for HELP & assess patient No Signs of life? Yes Call resuscitation team Assess ABCDE Recognise & treat Oxygen, monitoring, iv access CPR 30:2 with oxygen and airway adjuncts Call resuscitation team Apply pads/monitor If appropriate Attempt defibrillation if appropriate Advanced Life Support when resuscitation team arrives Handover to resuscitation team Fig 1.5_InHospital Resuscitation Final

6 Advanced Life Support unresponsive? Not breathing or only occasional gasps Call Resuscitation Team CPR 30:2 Attach defibrillator/monitor Minimise interruptions Assess rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Return of 1 Shock spontaneous circulation Immediately resume: CPR for 2 min Minimise interruptions Immediate post cardiac arrest treatment use ABCDE approach Controlled oxygenation and ventilation 12-lead ECG Treat precipitating cause Temperature control / therapeutic hypothermia Immediately resume: CPR for 2 min Minimise interruptions During CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Vascular access (intravenous, intraosseous) Give adrenaline every 3-5 min Correct reversible causes Reversible causes Hypoxia Hypovolaemia Hypo-/hyperkalaemia/metabolic Hypothermia Thrombosis Tamponade - cardiac Toxins Tension pneumothorax Fig 1.6_Adult ALS Final

7 Tachycardia Algorithm (with pulse) Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, SpO2,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities) Synchronised DC Shock* Up to 3 attempts Unstable Assess for evidence of adverse signs 1. Shock 2. Syncope 3. Myocardial ischaemia 4. Heart failure Stable Is QRS narrow (< 0.12 sec)? Amiodarone 300 mg IV over min and repeat shock; followed by: Amiodarone 900 mg over 24 h Broad Narrow Irregular Broad QRS Is QRS regular? Regular Regular Narrow QRS Is rhythm regular? Irregular Seek expert help Use vagal manoeuvres Adenosine 6 mg rapid IV bolus; if unsuccessful give 12 mg; if unsuccessful give further 12 mg. Monitor ECG continuously Irregular Narrow Complex Tachycardia Probable atrial fibrillation Control rate with: ß-Blocker or diltiazem Consider digoxin or amiodarone if evidence of heart failure Anticoagulate if duration > 48h Possibilities include: AF with bundle branch block treat as for narrow complex Pre-excited AF consider amiodarone Polymorphic VT (e.g. torsades de pointes - give magnesium 2 g over 10 min) *Attempted electrical cardioversion is always undertaken under sedation or general anaesthesia If Ventricular Tachycardia (or uncertain rhythm): Amiodarone 300 mg IV over min; then 900 mg over 24 h If previously confirmed SVT with bundle branch block: Give adenosine as for regular narrow complex tachycardia Normal sinus rhythm restored? Yes Probable re-entry PSVT: Record 12-lead ECG in sinus rhythm If recurs, give adenosine again & consider choice of anti-arrhythmic prophylaxis No Seek expert help Possible atrial flutter Control rate (e.g. ß-Blocker) Fig 1.7_Tachycardia Final

8 Bradycardia Algorithm Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, SpO2,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities) Assess for evidence of adverse signs: 1 Shock Yes 2 Syncope 3 Myocardial ischaemia 4 Heart failure No Atropine 500 mcg IV Satisfactory Response? Yes No Risk of asystole? Recent asystole Yes Möbitz II AV block Complete heart block with broad QRS Ventricular pause > 3s Interim measures: Atropine 500 mcg IV repeat to maximum of 3 mg No Isoprenaline 5 mcg min -1 Adrenaline 2-10 mcg min -1 Alternative drugs* OR Transcutaneous pacing Seek expert help Observe Arrange transvenous pacing * Alternatives include: Aminophylline Dopamine Glucagon (if beta-blocker or calcium channel blocker overdose) Glycopyrrolate can be used instead of atropine Fig 1.8_Bradycardia Final

9 Patient with clinical signs and symptoms of ACS 12 lead ECG ST elevation 0.1 mv in 2 adjacent limb leads and/ or 0.2 mv in adjacent chest leads Other ECG alterations (or normal ECG) or (presumably) new LBBB = NSTEMI if troponins (T or I) positive = UAP if troponins remain negative STEMI non-stemi-acs High risk dynamic ECG changes ST depression haemodynamic/rhythm instability diabetes mellitus Fig 1.9_ACS Definitons Final

10 ECG Pain relief Nitroglycerin sl if systolic BP > 90 mmhg ± Morphine (repeated doses) of 3-5 mg until pain free Antiplatelet treatment mg Acetylsalicylic acid chewed tablet (or iv) mg Clopidogrel according to strategy* STEMI Non-STEMI-ACS Thrombolysis preferred if PCI preferred if Early invasive strategy# Conservative no contraindications and timely available in a high volume center UFH or delayed invasive strategy# inappropriate delay to PCI contraindications for fibrinolysis Enoxaparin or bivalirudin may be considered UFH (fondaparinux or bivalirudin may be cardiogenic shock (or severe left considered in pts with high bleeding risk) Adjunctive therapy: ventricular failure) UFH, enoxaparin or fondaparinux Adjunctive therapy: UFH, enoxaparin or bivalirudin may be considered # According to risk stratification Fig 1.10_ACS Treatment Final

11 Paediatric basic life support UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? 5 rescue breaths NO SIGNS OF LIFE? 30 chest compressions 2 rescue breaths 30 compressions After 1 minute of CPR call 112 or national emergency number Fig 1.11_Paed BLS Final

12 Paediatric Foreign Body Airway Obstruction Treatment Assess severity Ineffective cough Effective cough Unconscious Conscious Encourage cough Open airway 5 breaths Start CPR 5 back blows 5 thrusts (chest for infant) (abdominal for child > 1 year) Continue to check for deterioration to ineffective cough or until obstruction relieved Fig 1.12_Paed FBAO Final

13 Paediatric Advanced Life Support unresponsive? Not breathing or only occasional gasps CPR (5 initial breaths then 15:2) Attach defibrillator/monitor Minimise interruptions Call Resuscitation Team (1 min CPR first, if alone) Assess rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Return of 1 Shock 4 J/kg spontaneous circulation Immediately resume: CPR for 2 min Minimise interruptions Immediate post cardiac arrest treatment use ABCDE approach Controlled oxygenation and ventilation Investigations Treat precipitating cause Temperature control Therapeutic hypothermia? Immediately resume: CPR for 2 min Minimise interruptions During CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Vascular access (intravenous, intraosseous) Give adrenaline every 3-5 min Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Correct reversible causes Reversible causes Hypoxia Hypovolaemia Hypo-/hyperkalaemia/metabolic Hypothermia Tension pneumothorax Toxins Tamponade - cardiac Thromboembolism Fig 1.13 Paed ALS Final

14 Newborn Life Support At all stages ask: Do you need HELP? Dry the baby Remove any wet towels and cover Start the clock or note the time Assess (tone), breathing and heart rate If gasping or not breathing Open the airway Give 5 inflation breaths Consider SpO2 monitoring Re-assess If no increase in heart rate Look for chest movement If chest not moving Recheck head position Consider two-person airway control or other airway manoeuvres Repeat inflation breaths Consider SpO2 monitoring Look for a response If no increase in heart rate Look for chest movement When the chest is moving If the heart rate is not detectable or slow (< 60) Start chest compressions 3 compressions to each breath Reassess heart rate every 30 seconds If the heart rate is not detectable or slow (< 60) Consider venous access and drugs * Fig 1.14 NLS Algorithm Final Birth 30 sec 60 sec Acceptable* pre-ductal SpO2 2 min : 60% 3 min : 70% 4 min : 80% 5 min : 85% 10 min : 90%