Resuscitation policy. Document Author: Lead Paramedic for Clinical Development

Resuscitation policy Document Author: Lead Paramedic for Clinical Development Date Approved: April 2018 1

Document Reference Resuscitation policy Version V:6.0 Responsible Committee Clinical Governance Group Responsible Director (title) Executive Clinical Director Document Author (title) Lead Paramedic for Clinical Development Approved By Trust Management Group Date Approved April 2018 Review Date April 2020 Equality Impact Assessed Yes (EIA) Protective Marking Not Protectively Marked Document Control Information Version Date Author Status Description of Change (A/D) 2.1 15/10/13 Mark Millins D Minor amendments 2.1.1 23/10/13 Mark Millins D Minor amendments following CGG approval 3.0 06/11/13 Mark Millins A Approved SMG Addition of flowchart for 3.1 01/04/2014 Mark Millins, Steven making decisions about D Dykes resuscitation of pre-term babies 4.0 23/04/2014 4.1 24/03/2016 4.1.1 27/03/2016 5.0 15/06/2016 Mark Millins, Steven Dykes Kirsty Lowery-Richardson, Steven Dykes Kirsty Lowery-Richardson, Steven Dykes Kirsty Lowery-Richardson, Steven Dykes 5.1 11/10/16 Kirsty Lowery-Richardson A 5.2 April 2017 Kirsty Lowery-Richardson A 5.3 22.11.17 Kirsty Lowery-Richardson D A D D A Approved at SMG 23/04/2014 Reviewed against new guidelines; amendments and additions made Minor amendments following CGG approval Approved Amendment to NLS algorithm (appendix M) to reflect RCUK changes. Correction of minor typographical errors. To Clinical Governance Group for Information. Minor wording amendments and appendix additions due to procedural and legislation changes. Additional Guidance for non-clinical staff and volunteers. Updated AACE Best Clinical Practice Statements. Minor amendments/corrections 2

6.0 April 2018 Risk Team A A = Approved D = Draft Policy approved at April TMG Document Author = Lead Paramedic for Clinical Development Associated Documentation: Insert names of associated Policies or Procedures here Employee Wellbeing: Supporting Staff Involved in an Incident, Complaint or Claim Policy Policy on Paediatric Care v3 Oct 2014 Post Incident Care Guidance Resuscitation Plan 2015 2020 Statements of Best Clinical Practice (AACE 2017) Standard Operating Procedure (SOP) Red Arrest Team (RAT) Dispatch Protocol Section Contents Page No. Staff Summary 4 1.0 Introduction 4 2.0 Purpose/Scope 4 3.0 Process 4 4.0 Training Expectations for Staff 5 5.0 Implementation Plan 5 6.0 Monitoring compliance with this Policy 5 7.0 References 5 8.0 Appendices 5 Definitions 7 3

Staff Summary This section should be used to summarise the top 10 bullet points of the policy or strategy. It should highlight the key points in short, concise sentences placed into a table. To ensure that all clinical staff provide resuscitation in accordance with latest resuscitation council and JRCALC guidelines To recognise and improve the management of those patients presenting in a peri-arrest state To improve survival to discharge in patients suffering a cardiac arrest To improve clinical decision-making during the resuscitation attempt To recognise whether to initiate transport or remain on scene in a resuscitation To recognise when resuscitation would be futile and to empower staff to make the decision to not commence resuscitation in those cases To recognise when to terminate resuscitation To improve the management of those patients who have a return of spontaneous circulation To recognise the importance of ppci in those patients who have a return of spontaneous circulation and have signs of ST elevation To enable clinical staff to recognise and adhere to a do not attempt CPR (DNACPR), advanced decision or limitation of treatment arrangement (LOTA) To enable clinical staff to perform recognition of life extinct in appropriate cases 1.0 Introduction 1.1 This policy sets out the procedures for clinical staff in the management of those patients in or at high risk of cardiac arrest. It is designed to enable YAS clinicians to follow the latest guidance from both the Resuscitation Council (UK) and the latest JRCALC guidelines, with the core goals of preventing cardiac arrest or improving survival to discharge in those patients who suffer a cardiac arrest. 2.0 Purpose/Scope 2.1 The purpose of this policy is to enable all clinical staff within YAS to follow best practice when managing a patient in or at risk of cardiac arrest. It is based on the latest national guidance available and covers both the management and decision-making aspects of a cardiac arrest, as well as the recognition of life extinct (ROLE) and DNACPR/advanced decision orders. Its aim is to enable clinical staff to provide the best possible care for this patient group, with the primary goal of improving survival to discharge. 2.1.1 By following the guidance issued by the Resuscitation Council (UK) and the Clinical Practice Guidelines, and by initiating the Specialised Response Clinicians (Red Arrest Team) available within YAS, risks associated with this patient group can be safely managed whilst providing excellent clinical care to patients. 2.1.2 The application of this policy should be in conjunction with the current clinical scope of practice of each staff grade. 3.0 Process 3.1 This policy details the clinical response for those patients who have suffered a cardiac arrest, are presenting in a peri-arrest state or have achieved Return of Spontaneous Circulation (ROSC) following resuscitation. It also covers DNACPR orders, advanced decisions and LOTA, and circumstances where resuscitation would be futile. It also sets out the ROLE process, which are set out in appendices A-R. 4

3.2 The majority of equipment used during a resuscitation attempt is single use only and is disposed of following the resuscitation. Equipment that is not single use is maintained and cleaned under the Decontamination of Medical Devices and Vehicles procedure, and all equipment required is checked under the Managing Medical Devices Policy. Compliance with the checking and cleaning of the equipment is contained with those policy documents. 4.0 Training expectations for staff 4.1 Training for resuscitation is delivered as specified within the Trust s Training Needs Analysis (TNA). 4.1.1 RAT clinicians are subject to a specific training and refresher programme, recorded separately in the OLM system. 5.0 Implementation Plan 5.1 This policy will be disseminated to staff using a multi-factorial approach, including reference within all core training delivered in the Trust, the use of YAS 247, Clinical Catch-up and cascade by the Clinical Development Managers and Clinical Supervisors. 5.1.1 The latest approved version of this Policy will be posted on the Trust Intranet site for all members of staff to view. New members of staff will be signposted to how to find and access this guidance during Trust Induction. 6.0 Monitoring compliance with this Policy 6.1 The Head of Clinical Effectiveness will monitor the application of this policy through regular scheduled audit and will report back to the Clinical Governance Group. These audits form part of the reporting process for the National Ambulance Quality Indicators, which the Trust is fully compliant with. 7.0 References United Kingdom Resuscitation Council Resuscitation Council (UK) (2016) Advanced Life Support 7 th Ed. The latest UK Ambulance Services Clinical Practice Guidelines 7 Appendices Appendix A Definitions Appendix B Roles and responsibilities Appendix C The role of RAT Paramedics Appendix D Post incident care Appendix E Peri-arrest arrhythmias Tachycardia Bradycardia/ventricular Appendix F Cardiac arrest procedure Appendix G When to commence resuscitation (adults) Appendix H Basic life support Appendix I Advanced life support Appendix J Return of spontaneous circulation Appendix K Recognition of life extinct 5

Appendix L When to withhold resuscitation Appendix M Newborn life support Appendix N Resuscitation in pre-term babies Appendix O Paediatric basic life support Appendix P Paediatric advanced life support Appendix Q Death of a child, including sudden unexpected death in infants, children and adolescents (SUDICA) Appendix R Resuscitation for non-clinicians Appendix S Resuscitation Guidance for non-clinical staff and volunteers Appendix T - Statements of Best Clinical Practice (AACE 2017) 6

Appendix A Definitions Advanced decision Agonal breathing ALS Asystole BLS Cachexia Cheyne-stoke breathing CPR Decomposition/putrefaction DNACPR Hemicorporectomy Hypostasis ICD Incineration LOTA Massive cranial and cerebral destruction PEA Prolonged submersion Rigor mortis ROSC Glossary of Terms An advanced decision to refuse treatment; this is legally binding if valid and applicable to the circumstances at hand Slow and irregular gasping breathing that is common following a cardiac arrest; should not be mistaken for signs of life Advanced life support; the management of a cardiac arrest that utilises defibrillation, the use of drugs, advanced airway techniques and addresses any reversible causes The absence of electrical activity on an ECG or a BROAD complex PEA of less than ten per minute that could not produce effective myocardial contraction Basic life support; the immediate treatment for a patient in cardiac arrest using CPR A pronounced loss of body mass or body wasting in an individual who is not trying to lose weight A cyclical breathing pattern, alternating between deep and sometimes faster breathing through to a temporary cessation of breathing Cardiopulmonary resuscitation; emergency treatment that supports circulation in the event of a cardiac arrest The body has started to be reduced down to its component forms Do not attempt cardiopulmonary resuscitation; covers decisions about withholding CPR in the event of a future arrest and is completed by the senior clinician responsible for care, or their delegate Amputation of the lower half of the body The settling of blood in the lower half of the body Implantable cardioverter-defibrillator Full thickness burns or charring covering 95% of the body surface area Limitation of treatment arrangement; the paediatric equivalent of a DNACPR; note these are legally binding and occasionally these are in place for an individual in their 20 s who has had a long-term degenerative condition throughout their childhood Severe injuries to the brain that are incompatible with life Pulseless electrical activity; electrical activity displayed on the ECG that does not produce any myocardial contraction Where the body is completely beneath the water; note this is different from immersion, where the head may be above the water Rigidity of a body that, in normal conditions, commences two to four hours after death Return of spontaneous circulation following a resuscitation attempt 7

Terminal agitation Terminal illness VF VT A state of anguish, anxiety or agitation that a palliative care patient may experience when nearing death An illness that cannot be cured or adequately treated and is expected to result in the death of a patient within a short period of time Ventricular fibrillation Ventricular tachycardia; in cardiac arrest this is pulseless and is managed in the same way as VF 8

Appendix B Roles and Responsibilities The Executive Medical Director, supported by the Deputy Medical Director, has overall responsibility for the implementation of this policy. The Lead Paramedic for Clinical Development is responsible for ensuring that the policy complies with the latest clinical guidance from the Resuscitation Council (UK) and JRCALC Clinical Practice Guidelines, and for its dissemination to clinical staff. The Head of Clinical Effectiveness is responsible for auditing the outcomes of this policy and reporting them to the National Ambulance Service Framework. The Head of Education and Standards will produce a training plan for this policy in line with the Trust s Training Needs Analysis. Clinical Supervisors (and RAT Paramedics) will provide clinical leadership at cardiac arrests, support crews and initiate post incident care as appropriate. Clinical Development Managers and Clinical Managers will ensure that the CSs and RAT Paramedics are supported with regard to education and process relating to their role. CDMs will monitor RAT Paramedic education and PGD compliance via OLM data. Clinical staff will ensure that their practice is in line with this policy. 9

Appendix C The Role of RAT (Red Arrest Team) Paramedics RAT Paramedics oversee the safe and effective coordination of staff and tasks at an out of hospital cardiac arrest (OHCA). RAT provision is available in core areas spanning all of the Clinical Business Units in YAS. In the main, RAT Paramedics are CSs, however, in some areas, non-css have undertaken RAT training to ensure resilience of service provision. In order to undertake RAT duties an individual must have successfully completed the formal RAT training programme facilitated by the Clinical Development Manager team. RAT Paramedics are based on a response vehicle kitted with the additional equipment and drugs associated with the role. Function: The main function of the RAT is to ensure that OHCA runs as smoothly and effectively as possible in order to maximise positive outcomes. Ideally, when assigned to an OHCA, the RAT will not become too involved with practical tasks themselves but, instead, will assume a supporting and advisory role. Additional skills: The RAT has been trained in the Pit-Stop approach to cardiac arrest management, where each member has a specific role in the management of a patient in cardiac arrest. The RAT has also been trained in the use of the Automated CPR device used in YAS. Where a patient meets criteria for pacing, the RAT has been trained for this additional intervention. The RAT can administer (via PGD), post ROSC adrenaline, and midazolam for the sedation of patients undergoing transcutaneous pacing or to counteract agitation post ROSC. All RAT Paramedics that carry midazolam will also carry flumazenil, which is primarily used to reverse iatrogenic reactions to benzodiazepines. Hot debrief: Following each OHCA incident attended by a RAT, the aim is to provide a hot debrief immediately after the incident. This debrief is to discuss general management of the incident with a view to highlight areas of good practice and, conversely, areas where improvements could be made. It is also an opportunity for staff to ask questions and improve their understanding of OHCA. Post incident care: All CSs have the ability to record staff on the Trust s Post Incident Care (PIC) database, which will trigger a follow-up welfare meeting with a CS or Locality Manager. Collecting/auditing data: Both Lifepak 12/15 and Lifepak 1000 (AED) record data while in use. This data can be downloaded and reviewed after the event to provide staff with a better understanding of how effective their skills have been during the incident. Typically, download data will provide CPR rates, pre-shock pause duration, vital signs data and all cardiac rhythms observed during the time the defibrillator or AED was attached to the patient. Collected data will be used to inform the Clinical Scorecard; this will be used to audit cardiac arrest performance across the whole region and must be completed and sent back to the Clinical Directorate. Trends from this data may then be analysed and learning communicated to staff as a result. 10

Appendix D Post Incident Care YAS is committed to supporting and ensuring the welfare and well-being of all staff. The process for PIC allows any member of staff to complete a PIC form to highlight distressing/traumatic incidents, following which staff may benefit from support and monitoring. All CSs have the ability to record staff on the Trust s Post Incident Care (PIC) database, which will trigger a follow up welfare meeting with a CS or Locality Manager. The purpose of these meetings is to determine if staff experience any adverse effects from their attendance at traumatic incidents and to identify a strategy to support staff who are. For further information and guidance, please refer to: Employee Wellbeing: Supporting Staff Involved in an Incident, Complaint or Claim Policy Post Incident Care Guidance 11

Appendix E Peri-Arrest Arrhythmias (i) Tachycardia algorithm (adults) Ventricular rate >150 Assess using ABCDE approach Management Oxygen to saturation 94-98%, IV access, monitor ECG, BP, SpO 2, record 12-lead (Be alert peri-arrest condition) Narrow complex tachycardia Broad complex tachycardia Regular rhythm Attempt vagal manoeuvres Irregular rhythm No adverse features present Adverse feature(s) present: Shock Syncope Myocardial ischaemia Heart failure Continued monitoring of patient and convey to appropriate unit Administer amiodarone 300mg IV over 20-60 mins (as per YAS PGD) Regular rhythm Irregular rhythm Initiate rapid transport to appropriate ED Pre-alert, continue monitoring patient (Be alert peri-arrest condition) Synchronised DC shock (Up to three attempts) Cardioversion unsuccessful Cardioversion successful Administer amiodarone 300mg IV over 10-20 mins whilst enroute to hospital; Pre-alert Continued monitoring of patient, convey to appropriate unit 12

(ii) Bradycardia algorithm (adults) Bradycardia (including ventricular standstill) Assess using ABCDE approach Note: Bradycardia = ventricular rate <60 Adverse feature(s) present: Systolic BP <90 Reduced GCS Chest pain Shortness of breath No adverse features present Continued monitoring of patient and convey to appropriate unit Management Oxygen to saturation 94-98%, IV access, monitor ECG, BP, SpO 2, record 12-lead, administer atropine up to 3mg (in line with guideline) (Be alert peri-arrest condition) Commence BLS if indicated (ventricular standstill) Patient presentation stabilises Adverse features remain (unresponsive to atropine) RAT Paramedic Consider transcutaneous pacing Initiate rapid transport to appropriate ED: Pre-alert Consider requesting RAT Paramedic as appropriate Continue monitoring patient (Be alert peri-arrest condition) 13

Appendix F Cardiac Arrest Procedure 999 Cardiac arrest Dispatch CFR RRV/DCA + DCA Clinical Supervisor Note: Exceptions Immediate transfer to ED as a time critical transfer: <18 years old Pregnant Traumatic arrest Hypothermic Drowning Overdose Solo Responder Early defibrillation Concentrate on high quality CPR BLS only no ALS BVM or LMA only DCA/Dual Responders Early defibrillation ALS as per JRCALC/RCUK Ensure high quality CPR Three or more responders Team leader role (Clinical Supervisor) ALS 4Hs and 4Ts LMA and capnography (ETT as rescue technique only) Continuous chest compressions minimise hands off time Ensure appropriateness of continuing resuscitation VF/VT Remain on scene until ROSC or contact ppci centre for advice in refractory VF/VT. If VF/VT persists beyond 4 shocks consider transport to ED/pPCI PEA >10/min Consider early transfer to hospital or remain on scene Asystole or PEA<10/min Remain on scene until ROSC or 20 mins CPR and then ROLE Consider use of automated CPR device if refractory VF/VT or viable PEA arrest and transport to ED/pPCI required Return of Spontaneous Circulation (ROSC) Optimise ABC SpO 2 maintained 94-98% ETCO 2 maintained between 4.6-6kPa Fluid bolus IV to maintain radial pulse consider need for RAT interventions Blood sugar and 12-lead ECG and transfer to ppci if STEMI All other cases transport to ED with PREALERT Recognition of Life Extinct (ROLE) Follow ROLE protocol 14

DO NOT ATTEMPT RESUSCITATION Appendix G When to Commence Resuscitation (Adults) 3. No pulse No breathing, despite open airway Condition unequivocally associated with death: 1. Massive cranial and cerebral destruction 2. Hemicorporectomy or similar massive injury 3. Decomposition/putrefaction 4. Incineration 5. Hypostasis 6. Rigor mortis 7. Prolonged submersion (>60 minutes) DNACPR/advanced decision (LOTA) present? In the absence of a DNACPR or advanced decision, is the death expected, is it the result of a long-term condition and would resuscitation be futile? ** Registered HCP consideration** It is appropriate to commence BLS whilst the history and status of the patient are rapidly ascertained. Resuscitation efforts should not be delayed by history gathering where the circumstances are unclear. YES YES YES For further guidance, see appendices K and L In the absence of the above, start BLS and attach a monitor Is the patient asystolic? For BLS guidelines, see appendix H NO YES YES Is there evidence of CPR being performed in the past 15 minutes? NO Any suspicion of drowning, hypothermia, poisoning/ov erdose or pregnancy? Commence advanced life support; is the patient in a shockable rhythm? YES Continue with ALS For ALS guidelines, see appendix I NO If the patient is in asystole after 20 minutes of ALS, stop resuscitation except in cases of drowning, hypothermia, poisoning, overdose and pregnancy Stop resuscitation NO YES or? Commence ALS Asystole is defined as the absence of electrical activity on an ECG or a BROAD complex PEA of less than 10 per minute that could not produce effective myocardial contraction 15

Appendix H Basic Life Support (Resuscitation Council (UK), 2015) Unresponsive and not breathing normally Summon further resources if appropriate 30 chest compressions 2 rescue breaths Continue CPR 30:2 As soon as AED arrives, switch it on and follow instructions; 2 rescue breaths/30 compressions Key points: Good quality chest compressions are the key to successful resuscitation Agonal breathing is common following a cardiac arrest and should not be confused with signs of life, if you have any doubt whether breathing is normal, act as if they are not breathing normally and prepare to start CPR Use a bag valve mask with high flow oxygen to deliver rescue breaths as soon as available but do not interrupt chest compressions Once a defibrillator is available attach the electrode pads and commence ALS 16

Appendix I Advanced Life Support (Resuscitation Council (UK), 2015) Unresponsive and not breathing normally CPR 30:2 Attach defibrillator/monitor and minimise interruptions Call for additional resources as appropriate Assess rhythm Shockable (VF/pulseless VT) Non-shockable (PEA/asystole) One shock Minimise interruptions Immediately resume CPR for two minutes Minimise interruptions Return of spontaneous circulation (ROSC) Immediate post cardiac arrest treatment Use ABCDE approach Aim for SpO 2 of 94-98% Aim for normal PaCO 2 12-lead ECG Treat precipitating cause Do not actively warm or cool the patient Immediately resume CPR for two minutes Minimise interruptions During CPR Ensure high quality chest compressions Minimise interruptions to compressions Give oxygen Use waveform capnography Continuous compressions when advanced airway in place Vascular access (intravenous or intraosseous) Give adrenaline every three to five minutes Give amiodarone after shock number three and five. Consider changing pad position after 5 shocks. Reversible Causes Hypoxia Hypovolaemia Hypo/hyperkalaemia/metabolic Hypothermia Thrombosis coronary/pulmonary Tamponade cardiac Toxins Tension pneumothorax Key points: Mechanical chest compressions to facilitate transfer/treatment Coronary angiography and percutaneous coronary intervention 17

Ideally, at least three resources will be sent to a cardiac arrest; one of which will be a RAT Paramedic. One Paramedic should assume the role of team leader and manage the arrest situation, particularly at the decision-making points Remember that high quality chest compressions with minimal interruptions are the key to successful resuscitation The airway should be secured with a laryngeal mask; endotracheal intubation should only be used as a rescue technique Continuous chest compressions may be undertaken once the airway is secured appropriately, 30:2 may be continued where ventilation is not attained with asynchronous compressions End tidal CO 2 monitoring must be used whenever available (Normal values for ETCO 2 are 4.6 6.0 kpa, however it should be noted that it is possible that ETCO 2 will not fall within these parameters in peri-arrest or post ROSC patients whilst alveolar ventilation, pulmonary perfusion and cardiac output and CO 2 production are affected by the acute pathophysiology and hence the ETCO 2 may possibly read outside of these parameters); this gives a good indication of the quality of chest compressions, as well as an early indication of a return of spontaneous circulation. NB: ETCO 2 must be used where patients are intubated. There is no set time that chest compressions should be performed for prior to delivering the first shock; high quality chest compressions should be performed whilst the defibrillator is being set up and a shock delivered as soon as possible remember that the amount of time from stopping chest compressions to delivering the shock must be kept to a minimum Where the operator is trained in manual defibrillation, the defibrillator should be used in manual mode and not AED mode Any individual that recognises a shockable rhythm whilst treating a patient in cardiac arrest should initiate the appropriate treatment (shock). The recognition of rhythms should not be left to one individual; where a RAT paramedic is in attendance, they should ensure that they have sight of the defibrillator during rhythm checks. It is highly recommended that the metronome is used to ensure an optimum rate of chest compressions In the rare occurrence where a patient suffers a monitored arrest and is already attached to a defibrillator, three successive (stacked) shocks may be delivered. Where stacked shocks are administered, amiodarone 300mg should be administered after 3 shocks, adrenaline should be initiated after the 3 rd cycle of shocks (i.e 5 th shock). A second dose of amiodarone should be administered after 5 shocks and adrenaline every 3-5 minutes (every 2 nd cycle) as normal.# All presentations of Ventricular Fibrillation should be shocked as soon as possible, shocks should not be withheld where VF is considered fine. If there is any doubt whether a rhythm is fine VF or asystole following the printing of a rhythm strip, it should be treated as VF. 18

If VF/pVT recurs during a cardiac arrest (refibrillation), give subsequent shocks with a higher energy level if the defibrillator is capable of delivering a higher energy (i.e 360 joules with LP15) In a shockable rhythm, and where the standard shockable algorithm is initiated 1mg of 1:10,000 adrenaline should be given after the third shock, along with 300mg of amiodarone The administration of adrenaline should be repeated after every other shock, i.e. after the fifth then seventh etc; a repeat dose of 150mg amiodarone should also be given after the fifth shock In a non-shockable rhythm, 1mg of 1:10,000 adrenaline should be given as soon as IV access is gained and then every three to five minutes In a non-shockable rhythm, asystole is defined as no electrical activity or a broad complex PEA of less than ten per minute that could not produce myocardial output All reversible causes should be considered and, where possible, action taken to correct them The following group of patients will require transfer to hospital with resuscitation ongoing; aim for transfer within 10 minutes of arrival on scene: - <18 years old - Pregnant - Traumatic arrest - Hypothermic - Drowning - Overdose The decision to transfer should be made early in the resuscitation attempt and must take into account the ability to maintain high quality CPR, as evidence supports that effective CPR is key to survival If a shockable rhythm persists beyond 4 shocks, transportation to ED should be rapidly facilitated Repositioning of a fresh set of pads should be considered after 5 unsuccessful shocks. (The opportunity to reposition pads can be coincided with the application of a mechanical resuscitation device). Narrow complex PEA should be resuscitated with full ALS, and if high quality CPR can be maintained, the patient should be transferred to the ED If the patient is fitted with an ICD that is either not detecting the VF/pulseless VT or not converting it then provide external defibrillation, ensuring that the pads are placed at least 8cm from the ICD site Maternal resuscitation: Pregnancy is an indication for rapid transfer to hospital and should be initiated within four minutes if there is no response to CPR; the baby will need to be delivered by emergency caesarean section to facilitate the resuscitation of the mother 19

Manually displace the uterus to the left or tilt the patient to the left (15-30 o ) to remove compression of the inferior vena cava Maternal resuscitation should never be terminated in the pre-hospital setting Traumatic cardiac arrest: A patient who has suffered a traumatic cardiac arrest as a result of penetrating trauma should have full ALS and rapid transfer to an appropriate ED initiated, with minimum onscene time A patient who has suffered a traumatic cardiac arrest as a result of blunt trauma should have full ALS initiated for 20 minutes; if they have not responded after this, resuscitation can be terminated. The decision to transfer or remain on-scene with a blunt traumatic arrest must take into account the ability to maintain high quality CPR, as evidence supports that effective CPR is key to survival Attention should be paid to those patients with low flow state, where fluids/blood are required urgently; major haemorrhage management regimes should be commenced as a priority and consideration should be given to the administration of TXA. Chest compressions must be performed. If the patient has sustained injuries that are incompatible with life then resuscitation need not be started 20

Traumatic Cardiac Arrest Trauma Patient Cardiac Arrest START CPR Likely medical cause? YES NO Follow ALS Algorithm Treat Reversible Causes (Use 4Hs & 4Ts approach) Treat Reversible Causes HYPOVOLAEMIA HYPOXIA TENSION PNEUMOTHORAX * Control external bleeding CAT, Haemostatic agent * Splint pelvis/fractures * IV/IO fluid * TXA * Basic/advanced airway management * Oxygen * Decompress chest - bilateral (thoracostomy) Continue CPR Spontaneous Circulation? NO YES Immediate Transfer to appropriate hospital Consider Termination of Resuscitation 21

Special circumstances: Suspected hypothermia: Checks for signs of life should be undertaken for up to one minute Hypothermia can make ventilations and compressions difficult due to chest wall stiffness. Hypothermia can only be confirmed with a low reading thermometer Normal protocols should be followed Confirmed hypothermia <30 o C (it is unlikely that hypothermia can be confirmed in the pre-hospital setting) If VF persists after three DC shocks, withhold further shocks until core temperature 28-30 o C Cardiac arrest associated with asthma: Always consider bilateral pneumothoraces in cardiac arrest. Early needle decompression should be considered Cardiac arrest associated with anaphylaxis: Treat with standard 1mg dose of adrenaline as per ALS protocol 22

Appendix J Return of Spontaneous Circulation (ROSC) Return of spontaneous circulation (ROSC) Transfer All patients with ST elevation on ROSC following a non-traumatic cardiac arrest, and regardless of Glasgow Coma Score, should be considered for transport to a Primary Percutaneous Coronary Intervention (ppci) centre as a preferred destination Where possible, the patient should remain flat when being transferred to the vehicle On-going treatment/monitoring Continue to address any reversible causes Continue to use end tidal CO 2 monitoring (normal values 3.5-5 kpa) and assist ventilations where necessary Beware of over oxygenating the patient; aim for oxygen saturations of 94-98% Perform and analyse a 12-lead ECG Address cardiac arrhythmias in line with current YAS guidelines Monitor the patient s blood sugar levels Do not actively cool or warm the patient RAT specific considerations/interventions Is adrenaline 1:10,000 indicated? Is there a need to consider midazolam to address agitation/combative behaviour? 23

Appendix K Recognition of Life Extinct (ROLE) Recognition of life extinct Condition unequivocally associated with death? DNACPR, advanced decision, final stages of a terminal illness* (HCP), submersion >60minutes? Conditions unequivocally associated with death: Massive cranial and cerebral destruction Hemicorporectomy or similar massive injury Decomposition/putrefaction Incineration Hypostasis Rigor mortis NO YES Start BLS and attach defibrillator/aed, analyse rhythm; is a shock advised? DO NOT RESUSCITATE YES NO Evidence of CPR in last 15 minutes? NO Follow full ALS protocol YES or don t know Any suspicion of drowning, hypothermia, poisoning/overdose or pregnancy? NO If the patient is asystolic despite 20 minutes ALS, stop resuscitation except in cases of drowning, hypothermia, poisoning, overdose and pregnancy NO Note: Pregnancy is an indication for rapid transfer to hospital and should be initiated within four minutes if there is no response to CPR; the baby will need to be delivered by emergency caesarean section to facilitate the resuscitation of the mother Asystole for >30 seconds? YES STOP RESUSCITATION 24

(Appendix K continued Recognition of Life Extinct) Diagnose death (See previous flow chart) Are there any suspicious circumstances? YES NO Expected death Death at home or in normal place of residence? YES Relatives present? NO Unexpected death Seek identity and contact details; complete documentation and notify patient s GP if possible Take steps to preserve the scene; ask EOC to contact the police and remain on scene to complete documentation Contact police via EOC and await further instruction YES Offer condolences; complete documentation and discuss with relatives on their chosen undertaker; leave leaflet with relatives; notify EOC and patient s GP Clear scene Expected Death Those whereby the GP/Consultant/Medical Officer concerned has diagnosed the patient as suffering from an advanced, progressive, incurable disease and has died due to the consequences of the disease NB: not applicable when this is an unexpected cardio-respiratory arrest, such as suspected choking Patients subject to a Deprivation of Liberty (DoL) Order should be managed in the same way as any other patient and the police only notified when the cause of death is unknown or where there are concerns that the cause of death was unnatural or violent or where there is concern that the care given may have contributed to the person s death (Coroners and Justice Act 2009) 25

Appendix L When to Withhold Resuscitation - Peri-arrest patients on End Of Life Care pathway or with terminal illness. Is the patient in the final stages of a terminal illness? For example: Cachexia (pronounced loss of body mass) Not able to take oral medicines or food Confined to their bed Cheyne-stoke breathing Terminal agitation (anguish, anxiety and agitation) Care plan in place NO Commence treatment and rapid transport to the ED YES Is the current condition of the patient due to their terminal condition? NO For example: Choking Anaphylaxis Infection Poor nutrition Poor hydration Hypoglycaemia YES Is a DNACPR/ advanced decision in place? YES NO Immediately commence full treatment for any potentially reversible condition; your transport decision may depend on the patient s terminal illness, liaise with their GP/healthcare team if admission is avoidable Provide compassionate care and liaise with the GP/long-term care team to keep the patient at home Provide compassionate care and liaise with the GP/OOT/Clinical Hub to arrange treatment at home if possible If the patient suffers a cardiac arrest, do not start CPR 26

Key points: There is no need to ensure that a DNACPR is the original version, as there should only be one copy YAS clinicians should note that although most DNACPRs in this region are on a standard form, other formats exist and are equally valid. An advanced decision (formally known as a living will) is a legally binding document and staff must adhere to its contents If a patient has a DNACPR or an advanced decision and their clinical condition is a result of their terminal illness then withhold resuscitation If their clinical condition is not linked to their terminal illness then commence resuscitation If a patient is in the very final stages of a terminal illness and does not have an advanced decision or a DNACPR, and if any resuscitation attempt would be futile and their clinical condition is linked to their terminal illness then resuscitation can be withheld Asystole can be defined as no electrical activity or a BROAD complex PEA of less than ten per minute A patient in cardiac arrest with a narrow complex PEA should be resuscitated If a patient has been in cardiac arrest for more than 15 minutes with no bystander CPR, they are asystolic and there are no exclusion factors as indicated on the flow chart, then resuscitation can be withheld A patient in cardiac arrest who has a pacemaker fitted and where the pacemaker spike is producing electrical activity that could result in myocardial contraction, they should be resuscitated Where a pacemaker spike is not producing electrical activity and the underlying rhythm is asystolic, ROLE can be performed If the death is expected then there is no need to inform the police or request their presence, this includes patients that are subject to a DoL order The clinician should converse with relatives present to understand any wishes of the deceased that may require informing at this stage i.e. tissue donation 27

Appendix M Newborn Life Support Dry the baby, remove any wet towels and cover; start the clock or note the time Birth Assess (tone), breathing, heart rate 30 secs If gasping or not breathing, open the airway; give 5 inflation breaths; consider SpO 2 & ECG monitoring 60 secs Re-assess; if no increase in heart rate, look for chest movement during inflation If chest not moving, recheck head position, consider 2 person airway control and other airway manoeuvres, repeat inflation breaths, consider SpO 2 and look for a response Acceptable SpO 2 : 2 min 60% 3 min 70% 4 min 80% 5 min 85% 10 min 90% If no increase in heart rate, look for chest movement during inflation When the chest is moving, if the heart rate is slow (<60) or not detectable, ventilate for 30 seconds * It is essential that new babies are kept as warm as possible, every effort must be taken to ensure that the environment is kept warm Reassess heart rate; if still <60, start compressions three compressions to each ventilation breath Reassess heart rate every 30 seconds and initiate immediate transport 28

Appendix N Resuscitation in Pre-Term Babies Establish this is a pre-term baby Baby in cardiac arrest? NO Time critical transfer (wrap baby as below*) YES Accurate gestational age known YES YES NO Gestation age thought to be greater than 23+0 weeks then commence resuscitation Less than 24+0 weeks DO NOT ATTEMPT RESUSCITATION (Unless parents request and baby is between 23+0 and 23+6 weeks) Care and support for the parents, wrap baby in blanket and allow parents to hold the baby if they wish Complete ROLE Transport to hospital as per local guidelines; discuss with local midwifery team if parents wish to remain at home 24+0 weeks and older START RESUSCITATION (Unless care plan in place) Note: If any doubt about gestational age, commence resuscitation Foetal maceration is a contraindication to resuscitation at any gestation Follow JRCALC resuscitation of the newborn and don t stop until handover at hospital TIME CRITICAL transport to hospital as per local guidelines * Preterm babies of less than 28 weeks gestation should be kept warm and where interventions are not required should be nursed skin to skin 29

Appendix O Paediatric Basic Life Support Unresponsive? Summon further resources if appropriate Open airway Not breathing normally? Five rescue breaths No signs of life? 15 chest compressions Key points: Two rescue breaths/15 compressions; lone rescuers may use two rescue breaths/30 compressions The advanced life support algorithm is the same as for adults The aetiology of cardiac arrest in children is very different from adults; the primary requirements are basic life support, good oxygenation, fluids if necessary and a minimum on-scene time with very rapid transport to the ED Paediatric intubation has been withdrawn by Yorkshire Ambulance Service; a stepwise approach to opening and maintaining the airway should be adopted A newborn baby who has had a period of sustained life independent from the mother should be classed as a paediatric if they subsequently suffer a cardiac arrest An infant is a child under 12 months and a child is aged from 12 months to puberty A limitation of treatment arrangement (LOTA) should be treated in the same way as a DNACPR is for adults. Where possible, children should be defibrillated by a clinician able to reduce energy and deliver DC shocks manually When there is only an AED trained operator on scene, non-attenuated pads may be utilised in children >1 year; DC shocks should not be withheld when indicated 30

Appendix P Paediatric Advanced Life Support Unresponsive, not breathing or only occasional gasps Call for further resources as appropriate CPR (five initial breaths then 15:2), attach defibrillator/monitor, minimise interruptions Assess rhythm Shockable (VF/pVT) Return of spontaneous circulation Non-shockable (PEA/asystole) Immediate post cardiac arrest 1 shock 4 joules kg -1 treatment: Use ABCDE approach Controlled oxygenation and ventilation Immediately resume CPR for Treat precipitating cause two minutes Temperature control (minimise interruptions) Immediately resume CPR for two minutes (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 three to five minutes Consider advanced airway and capnography Continuous chest compressions if advanced airway in place Correct reversible causes Consider amiodarone after third and fifth shocks Reversible Causes Hypoxia Hypovolaemia Hyper/hypokalaemia, metabolic Hypothermia Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade (cardiac) Toxic/therapeutic disturbances 31

Appendix Q Death of a Child, including SUDICA Arrive at scene Expected child death Unexpected child death and questionable crime scene Unexpected child death but obvious crime scene Care plan available (LOTA) No care plan available Viable resuscitation? Condition unequivocally associated with death? Recognise life extinct YES NO YES NO Contact named clinician; leave child at home Commence resuscitation No obvious cause of death Obvious cause of death Commence resuscitation Transport child and parents to ED; inform EOC to direct police to hospital Ask EOC to contact police and await attendance or telephone advice death DI* and follow instruction Ask EOC to contact police *Child death DI = Detective Inspector trained in the management of child death incidents to ensure the multiagency investigation is commenced and evidence gathered to ascertain the full facts of the child s death Advised by child death DI* to take child and parents to ED Crime scene declared; leave child at scene and inform EOC All Sudden Unexplained Deaths in Infants, Children and Adolescents should initiate a safeguarding referral. Pre-alert and take to appropriate ED that is prepared to accept sudden deaths in children 32

Conditions unequivocally associated with death in children younger than 18 years: 1. Massive cranial and cerebral destruction 2. Hemicorporectomy or similar massive injury 3. Decomposition/putrefaction 4. Incineration The presence of rigor mortis and hypostasis should not preclude resuscitation in children, unless there is other substantial evidence to suggest that they are clearly beyond help. Where resuscitation of a child/adolescent under 18 years is not commenced the clinicians documentation must clearly articulate the rationale for this decision, referring to the specific history of events and presentation of the child. *Child death DI = Detective Inspector trained in the management of child death incidents to ensure the multi-agency investigation is commenced and evidence gathered to ascertain the full facts of the child s death. All children in cardiac arrest must be conveyed to hospital, unless they have a condition that is unequivocally associated with death or if the police request that the body remain on scene. If the child dies suddenly or unexpectedly at home or in the community, the child should normally be taken to an Emergency Department rather than a mortuary. In some cases when a child dies at home or in the community, the police may decide that it is not appropriate to move the child s body immediately, for example, because forensic examinations are needed. All children must be taken to ED and NOT the mortuary. All Sudden Unexplained Deaths in Infants, Children and Adolescents should initiate a safeguarding referral. 3

Appendix R Resuscitation for Non-Clinical Staff (Resuscitation Council (UK), 2015) The community response to cardiac arrest is critical to saving lives. Strengthening the community response to cardiac arrest by training and empowering more bystanders to perform CPR and by increasing the use of automated external defibrillators (AEDs) at least doubles the chances of survival and could save thousands of lives each year. Chain of Survival The Chain of Survival describes four key, inter-related steps which, if delivered effectively and in sequence, optimise survival from out-of-hospital cardiac arrest. 1. Early recognition and call for help If untreated, cardiac arrest occurs in a quarter to a third of patients with myocardial ischaemia within the first hour after onset of chest pain. Once cardiac arrest has occurred, early recognition is critical to enable rapid activation of the ambulance service and prompt initiation of bystander CPR. 2. Early bystander CPR The immediate initiation of bystander CPR can double or quadruple survival from out-of-hospital cardiac arrest. 3. Early defibrillation Defibrillation within 3 5 minutes of collapse can produce survival rates as high as 50 70%. Each minute of delay to defibrillation reduces the probability of survival to hospital discharge by 10%. 4. Early advanced life support and standardised post-resuscitation care Advanced life support with airway management, drugs, and the correction of causal factors may be needed if initial attempts at resuscitation are unsuccessful. 3

Adult Basic Life Support Algorithm (see also Appendix H) Unresponsive and not breathing normally Call 999 and ask for an ambulance 30 chest compressions 2 rescue breaths Continue CPR 30:2 As soon as AED arrives, switch it on and follow instructions Key points: Good quality chest compressions are the key to successful resuscitation Agonal breathing is common following a cardiac arrest and should not be confused with signs of life, if you have any doubt whether breathing is normal, act as if they are not breathing normally and prepare to start CPR If an AED is readily available seek to utilise it as soon as practicable 3

Sequence Description (Resuscitation Guidelines (UK), 2015) Sequence Safety Description Make sure you, the victim and any bystanders are safe Response Check the victim for a response Gently shake his shoulders and ask loudly: Are you all right?" If he responds leave him in the position in which you find him, provided there is no further danger; try to find out what is wrong with him and get help if needed; reassess him regularly Airway Open the airway Turn the victim onto his back Place your hand on his forehead and gently tilt his head back; with your fingertips under the point of the victim's chin, lift the chin to open the airway Breathing Look, listen and feel for normal breathing for no more than 10 seconds In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, slow and noisy gasps. Do not confuse this with normal breathing. If you have any doubt whether breathing is normal, act as if it is they are not breathing normally and prepare to start CPR Dial 999 Call an ambulance (999) Ask a helper to call if possible otherwise call them yourself Stay with the victim when making the call if possible Activate the speaker function on the phone to aid communication with the ambulance service Send for AED Send someone to get an AED if available If you are on your own, do not leave the victim, start CPR Circulation Start chest compressions Kneel by the side of the victim Place the heel of one hand in the centre of the victim s chest; (which is the lower half of the victim s breastbone (sternum)) Place the heel of your other hand on top of the first hand Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs Keep your arms straight Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone) Position your shoulders vertically above the victim's chest and press down on the sternum to a depth of 5 6 cm After each compression, release all the pressure on the chest without losing contact between your hands and the sternum; Repeat at a rate of 100 120 min -1 3

Give rescue breaths After 30 compressions open the airway again using head tilt and chin lift and give 2 rescue breaths Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead Allow the mouth to open, but maintain chin lift Take a normal breath and place your lips around his mouth, making sure that you have a good seal Blow steadily into the mouth while watching for the chest to rise, taking about 1 second as in normal breathing; this is an effective rescue breath Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air comes out Take another normal breath and blow into the victim s mouth once more to achieve a total of two effective rescue breaths. Do not interrupt compressions by more than 10 seconds to deliver two breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions Continue with chest compressions and rescue breaths in a ratio of 30:2 If you are untrained or unable to do rescue breaths, give chest compression only CPR (i.e. continuous compressions at a rate of at least 100 120 min -1 ) If an AED arrives Switch on the AED Attach the electrode pads on the victim s bare chest If more than one rescuer is present, CPR should be continued while electrode pads are being attached to the chest Follow the spoken/visual directions Ensure that nobody is touching the victim while the AED is analysing the rhythm If a shock is indicated, deliver shock Ensure that nobody is touching the victim Push shock button as directed (fully automatic AEDs will deliver the shock automatically) Immediately restart CPR at a ratio of 30:2 Continue as directed by the voice/visual prompts If no shock is indicated, continue CPR Immediately resume CPR Continue as directed by the voice/visual prompts Continue CPR Do not interrupt resuscitation until: A health professional tells you to stop You become exhausted The victim is definitely waking up, moving, opening eyes and breathing normally It is rare for CPR alone to restart the heart. Unless you are certain the person has recovered continue CPR Recovery position If you are certain the victim is breathing normally but is still unresponsive, place in the recovery position Remove the victim s glasses, if worn Kneel beside the victim and make sure that both his legs are straight Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm-up Bring the far arm across the chest, and hold the back of the hand against the victim s cheek nearest to you 3

With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground Keeping his hand pressed against his cheek, pull on the far leg to roll the victim towards you on to his side Adjust the upper leg so that both the hip and knee are bent at right angles Tilt the head back to make sure that the airway remains open If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth Check breathing regularly Be prepared to restart CPR immediately if the victim deteriorates or stops breathing normally 3

Appendix S Resuscitation Guidance for non-clinical staff and volunteers When to resuscitate When a patient is found to be unconscious and not breathing normally they are deemed to be in cardiac arrest and attempts to resuscitate should be made. For a non-clinical responder alone the AED should be attached immediately (if present). If there is more than one rescuer CPR should be started as the AED is being attached. Non-clinical responders should always act in the best interest of the patient. When not to resuscitate As a non-clinical responder you will want to do the very best for patients whilst always respecting their dignity. There are, however, circumstances when it is accepted that resuscitation of a patient in cardiac arrest may not be appropriate. These include; When a valid DNACPR is in place. Always ensure it is signed and in date (refer to specific DNACPR guidance). When the scene is not safe and to remain would put the non-clinical responder in danger. When any of the following are in evidence; o Patient is cold and stiff in a warm environment o Patient is decapitated, incinerated or decomposition has begun What if the family do not wish the patient to be resuscitated? If none of the above factors are present, and there is no valid DNACPR, resuscitation should commence regardless of the views of anyone present. We must work in the best interest of the patient and there should always be a presumption that CPR should be performed and the AED attached. This could, of course, be a challenging situation. Non-clinical responders should explain their protocols clearly and calmly and begin resuscitation if possible. Explain that the crew will be attending soon, will be able to analyse the situation more fully with their equipment and make the decision whether to cease resuscitation. If the atmosphere becomes aggressive or you feel threatened in any way you should withdraw from the scene and inform EOC. Be sure to document everything carefully and comprehensively on your Patient Care Record. When clinicians may decide to cease resuscitation attempts Even if resuscitation has been commenced, a clinician may decide to stop for a number of reasons. These include (but are not limited to); Consideration of Advance Care Plan (ACP), Advance Decision to Refuse Treatment (ADRT) or Lasting power of attorney for health and welfare. If the clinician feels that CPR would not be successful because o the patient is in the final stages of a terminal illness or dying as the inevitable result of an underlying disease o there are no exclusion factors present (e.g. drowning, hypothermia, poisoning, pregnancy) o the amount of time that has passed since the onset of cardiac arrest o whether or not bystander CPR was commenced when the patient first collapsed o the clinician believes attempts to resuscitate would be futile. 3

Appendix T Statements of Best Clinical Practice (AACE 2017) Statements of Best Clinical Practice Adult Cardiac Arrest Care November 2017- Version 4 These statements have been revised following a national ambulance cardiac leads meeting held on 26th September 2017. They form the consensus view from paramedic cardiac leads and medical leads of UK Ambulance services. We recognise that cardiac arrest situations can be highly stressful and the health and wellbeing of our staff is paramount. Each service should have in place appropriate systems, procedures and support mechanisms for all staff involved in managing cardiac arrests. 1. Taking the 999 call and responding a. When taking a call, the time taken to recognise a cardiac arrest MUST be minimal, with chest compressions started quickly. For patients with no signs of life or not breathing normally CPR instructions should be given. b. Provision of telephone instructions on compression only CPR and directed use of an AED by dispatchers is supported c. Community First Responders (CFR) and public access defibrillators (PAD) allow easy and early access to an AED and should be encouraged and developed. Public education is required to ensure anyone with an AED informs the ambulance service so that the location of the device can be logged to enable the dispatcher to advise any caller of their nearest AED. d. Ambulance services should actively establish if an AED is available at the time of the call, and be able to tell the public where an AED is located to ensure it is taken to the patient and can be used. e. Ambulance services should support a comprehensive national database of AED locations so that any AED that is near the patient can always be located. AEDs located at public buildings, GP surgeries and dental practices should be included as part of this database and they should be encouraged to place them at a suitable and visible location, for example on the outside of the building, for public access. f. Defibrillators should be placed in openly accessible (unlocked) cabinets that allow immediate access in an emergency. g. Where there is a single responder at a cardiac arrest, and no one else is present, they should be advised to stay and do compressions, call for help and not go to get a 4