TEACHING BASIC LIFE SUPPORT (& ALS) Anton Koželj, R.N., B. Sc., lecturer Faculty of Health Sciences, University of Maribor Žitna ulica 15, 2000 Maribor, Slovenia
Fact s To know-how to perform basic life support can save a life s!! As a health care workers we should know how, and be able to implement this knowledge in real situation. (Without excuse!?) How do we really know perform CPR? 2
Students of Faculty of Health Sciences, should get good knowledge, during the study, and as soon as possible. 3
For that reason all our students have course to learn how to perform CPR (BLS) in first year of study. They have additional, extensive class in last year (BLS, ALS, ATLS, APLS). General idea is, that all health care workers should have courses to refresh their knowledge every year. Can this be achieved? 4
Because of all this facts Faculty of Health Sciences, University of Maribor assure funds and open contemporary Simulation centre: Field of education: emergency medicine, (trauma, surgery emergency, paediatric emergency, intensive medicine and nursing, etc.) anaesthesia, reanimathology. 5
General idea: to get knowledge, perform skill s and go to the patience prepared (100 %). Tell me and I forget Show me and I remember Involve me and I understand. (Confucius ) 6
Universal ALS Algorithm Open Airway Look for signs of life Call for help Cardiac Arrest Precordial Thump if appropriate BLS if appropriate Attach Defib-Monitor Assess Rhythm VF/VT 1 Shock 150-360 J biphasic or 360 J monophasic Immediately resume CPR 30:2 for 2 min +/- Check Pulse During CPR: Correct reversible causes Check electrode position and contact Attempt / verify: IV access airway and oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, Non-VF/VT Immediately resume CPR 30:2 for 2 min Potential reversible causes: Hypoxia Tension pneumothorax Hypovolaemia Tamponade Hypo/hyperkalaemia & metabolic disorders Toxic/therapeutic disorders Hypothermia Thrombo-embolic & mechanical obstruction r: ERC 7
Airway, ventilation and chest compression Secure airway: tracheal tube LMA Combitube Once airway secured, do not interrupt chest compressions for ventilation 8
Recognising the sick patient and preventing cardiac arrest Objectives: To understand: The causes of cardiorespiratory arrest in adults How to identify patients at risk The role of a Medical Emergency Team The initial management of patients at risk of a cardiorespiratory arrest r: ERC 9
Most arrests are predictable Deterioration prior to 50-80% of cardiac arrests Hypoxia and hypotension are common antecedents Delays in referral to higher levels of care 10
Recognition of critically ill patients Modified Early Warning System (MEWS) 3 2 1 0 1 2 3 Pulse < 40 41-50 51-100 101-110 111-130 > 130 Systolic BP mmhg < 70 71-80 81-100 101-199 > 200 Respiratory Rate < 8 9-14 15-20 21-29 > 30 Temp C < 35 35.1-36.5 36.6-37.4 > 37.5 CNS A V P U Track score - a score of > 4 triggers a review by doctor 11
Medical Emergency Team (MET) Calling Criteria 1. Airway threatened: 2. Breathing: - Respiratory arrest - RR < 5 or RR >36 3. Circulation: 4. Neurology: - cardiac arrest - pulse < 40 or >140 - systolic BP < 90 mmhg - sudden fall in GCS > 2 - (AVPU is P od U) 5. Any other worries 12
The ABCDE approach to the critically ill patient A airway B breathing C circulation D disability E exposure 13
Complete initial assessment Treat life-threatening problems Reassessment Assess effects of treatment/ interventions Call for help early e.g. Medical Emergency Team Personal safety Patient responsiveness Vital signs pulse, respiratory rate, BP, SpO 2, ECG, temperature 14
Recognition of airway obstruction ABCDE approach Airway Talking Difficulty breathing, distressed, choking Shortness of breath Noisy breathing stridor, wheeze, gurgling See-saw respiratory pattern, accessory muscles Treatment of airway obstruction Airway opening - i.e. head tilt, chin lift, jaw thrust Simple adjuncts Advanced techniques - e.g. LMA, tracheal tube Oxygen 15
ABCDE approach Breathing Recognition of breathing problems Look respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level Listen noisy breathing, breath sounds Feel expansion, percussion, tracheal position Treatment of breathing problems Airway Oxygen Treat underlying cause - e.g. drain pneumothorax Support breathing if inadequate - e.g. ventilate with bag mask 16
ABCDE approach Circulation Recognition of circulation problems Look at the patient Pulse tachycardia, bradycardia Peripheral perfusion - capillary refill time Blood pressure Organ perfusion chest pain, mental state, urine output Bleeding, fluid losses 17
Treatment of problems Airway, Breathing Oxygen IV access, take bloods Treat cause Fluid Haemodynamic monitoring Inotropes/vasopressors Oxygen/Aspirin/Nitrates/ Morphine for ACS 18
ABCDE approach Disability Recognition AVPU or GCS, and pupils (P = GCS 8) Treatment - ABC Treat underlying cause Blood glucose if < 3 mmol l -1 give glucose Consider lateral position Check drug chart 19
ABCDE approach Exposure Remove clothes to enable examination - e.g. injuries, bleeding, rashes Avoid heat loss Maintain dignity 20
DEFIBRILLATION Early defibrillation!! Why? Delay each minute: reduction of chances for 7-10% ECG Heart conduct system 21
DEFIBRILLATION Shockable: (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Uncoordinated electrical activity Monomorphic: VT(no pulse) broad complex rhythm rapid rate constant QRS morphology Polymorphic VT torsade de pointes (low potassium ) 22
VF/VT 1. Defibrilacija 150 200 360J 2 min CPR 30: 2 VF/VT 2. Defibrilacija 200 360 J VF/VT 4. Defibrilacija 200 360 J Amiodaron 300 mg 2 min CPR 30: 2 2 min CPR 30: 2 VF/VT 3. Defibrilacija 200 360 J Adrenalin 1 mg + Amiodarone 300 mg 2 min CPR 30: 2 VF/VT 5. Defibrilacija 200 360 J Adrenalin 1 mg + Amiodarone 150 mg 2 min CPR 30: 2 23
Non-shockable: Asystole EMD Clinical / cardiac arrest TH: Adrenaline 1 mg IV every 3-5 min Atropine 3 mg if PEA with rate < 60 min-1 24
PEA/asistolija 2min CPR 30:2 Adrenalin 1 mg + Atropin 3 mg / not in protocol any more PEA/asistolija 2min CPR 30:2 PEA/asistolija 2min CPR 30:2 Adrenalin 1 mg 25
Use of AED What is AED? When to use it? Who should us it? How to use it?? 26
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r: ERC Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths Approach safely Check response Shout for help Open airway Check breathing Call 112 Attach AED Follow voice prompts 28
This is not OK!! 29
Summary Cardiovascular disease remains a major cause of cardiac arrest in adults Earlier recognition of patients at risk may reduce the number of cardiac arrests The ALS course teaches a standardised approach using several educational formats and assessment tools (by patronage ERC) Health care workers (starting with students) should know what to do and how to help! 30
Conclusion It is necessarily for health worker to know how to perform CPR because we are obligate to perform this procedure then they are needed. (legal and moral obligation). Our student are very satisfied with course in the first year and object in the last year. (They estimate this topics as a indispensable knowledge) We had course for all our teachers. (They share the same opinion as a students, and they express the need to have refreshing course every year. ) Personally I totally agree, and I am happy that I can teach this topic, that we have good conditions to teach and transmit my theoretically and practically knowledge to students and my colleague. r: ERC 31
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No need for CPR, just resting. But thanks for your care!!! 33