Emergencies Emergencies Advanced Life support

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Emergencies Emergencies Advanced Life support Powered By Docstoc
					                            Emergencies
Advanced Life support
Chain of survival

   1.   Early recognition
   2.   Early CPR
   3.   Early defibrillation
   4.   Post resuscitation care

       Acute Coronary Syndromes
   
       Advanced Life Support Algorithm (2008)
   
       Airways adjuncts
   
       Cardiac monitors
   
       Collapsed patient
   
       Drug Delivery
       Peri-arrest arrythmias - Bradyarrythmias
       Peri-Arrest arrythmias

Acute Coronary Syndromes
Acute coronary syndromes comprise

   1. Unstable Angina
   2. Non-ST segment elevation MI
   3. ST segment elevation myocardial infarction

Fissure of atheromatous plaque > Haemorrhage into plaque > contraction of lumen of
wall + thrombus formation in wall

Diagnosis

History
Clinical examination
12-Lead ECG: ST elevation, TWI, posterior MI
Lab tests: Troponins, CK, LDH, AST
Echocardiography
Treatment (OMAN)
Oxygen
Morphine + Metoclopramide
Aspirin 300mg
Nitrates (titrate to BP)

A - STEMI: Reperfusion (1) Percutaneous coronary intervention - PCI (2)
Thrombolysis
B - NSTEMI: Prevent further thrombus (1) LMWH (2) Clopidogrel
300/600/900mg (3) GpIIb/IIIa - Tirofiban

Reduction in O2 demand (1) B-blockers (2) ACEi

Complications (Sudden Death on PRAED ST)
Sudden death
Pericarditis
Ruptured
Aneurysm
Embolus
Dressler's
Heart failure
Cardiogenic Shock
Arrythmias

Cardiac Rehabilitation

Secondary prevention
Anti-thrombotic therapy (Asp/Clopi)
Preseveration LV function - ACEi (incl echo)
Reduction of cholesterol
Avoidance of smoking
Anti-hypertensives


Advanced Life Support Algorithm
(2008)
Ensure safe to approach
Gowns/barriers/gloves

?Unresponsive
Open airway + Look for signs of life
Call for help - put bed down
CPR 30:2 if no signs of life
Assess rhythm

   1. Shockable rhythm (VF/Pulseless VT)
         o 1 shock 150-360J Biphasic
         o CPR 30:2 for 2 mins
           o1mg 1:10000 (10mls) Adrenaline before 3rd shock (then every 2nd
            cycle)
        o 300mg Amiodarone or 100mg iv lidocaine before 4th shock
   2. Non-shockable rhythm
        o CPR 30:2
        o 1mg 1:10000 (10mls) when access established (then every 2nd cycle)
        o 3mg Atropine when asystole

Once airway secured, ventilate at 10/min + 100/min chest compressions
IV access + bloods + blood sugar

Reversible causes

Hypovolaemia
Hypoxia
Hypo/hyperkalaemia/Metabolic
Hypothermia

Tension pneumothorax
Tamponade: pericardiocentesis, echo
Toxic
Thrombosis (coronary or pulmonary)


Airways adjuncts
Airways obstruction

   1. Neurological
         o Decreased level of consciousness
   2. Above larynx
         o Max-Fax trauma
         o Infection - tonsillary hypertrophy
         o Foreign bodies
         o Neoplasms
   3. Larynx
         o Laryngeal fracture
         o Infection
         o Laryngeal oedema: smoke inhalation, radiotherapy
   4. Below larynx
         o Congenital - subglotting stenosis
         o Neck trauma - haemorrhage
         o Infection - acute laryngotreachobronchitis




Headlift
Chin lift / Jaw thrust (due to attachment of tongue to mandible via genioglossus
muscle)
C-spine immobilisation
Oxygen
Venturi mask
Non-rebreathe mask ~85%
Bag-valve mask

Suction
Yankeur sucker
Can promote vomiting/spasm
Suck only what you can see



Simple Airway

   1. Oropharyngeal airway
      Sizes 2,3,4
      Sized from incisors to angle of mandible
      Inserted upside down and rotated
   2. Nasopharyngeal airway
      Bevelled one end, flanged other end
      Insert with safety pin in end to prevent "loss"
      Sized according to internal diameter: 6-7mm adults (used to be size of little
      finger)
      Contraindicated in basal skull fracture
   3. Laryngeal mask airway
      Sizes 3,4,5
      Insufflated with (size x 10) - 10mls: ie size 4 gets 30mls air
      Tube should lift 1-2cm out of mouth if cuff in correct position
      + insert bite block (ie OPA)
      Risk of leakage of air + aspiration

Definitive airway

"Tube in trachea with an inflated cuff"

Prevents aspiration



Indications; relief of obstruction, protects from aspiration, ventilatory requirement,
facilitates suction/toilet



   1. Endotracheal tube
      Needs: x2 laryngoscopes, stethoscope, magils, bougie, tubes, lube, suction
      Detected with CO2 detector or (in arrest) oesophageal suction detector - can
      detect collapse
      Check (1) epigastrium (2) mid axillary line
      + insert bite block (oropharyngeal airway)
        Pre-oxygenate
        Position head
        Thio / Sux / Tube

   2. Cricothyroidotomy
      Needle - between cricothyroid membrane, aim 45' down
      Surgical - extend head, dissect down

        Results in good oxygenation, but poor ventilation - results in hypercarbia (and
        thus limited to ~45 minutes usage)
        Contraindicated in children (under 12) - risk of damage to cricoid cartilage
        which is the only support for the paediatric trachea


   3. Tracheostomy


Cardiac monitors
Electrode positioning
Place electrodes over bone
Monitor in lead 2
Skin dry, not greasy, shave hair

Emergency monitoring
Self-adhesive electrodes
Quick-look paddles


Collapsed patient
   1. Ensure personal safety
   2. Check for response: shake + shout
   3. Open airway, head tilt + chin lift
   4. Look into mouth (MILS)
   5. Look, listen, feel (10 seconds)
   6. Start CPR + get help
      Compress middle of sternum / lower half sternum / 4-5cm depth / 100
      compressions per min
      LMA / Bag-mask / intubate - inspiratory time 1sec, avoid rapid breaths
      (barotrauma, pneumothorax, stomach insufflation)
   7. Attach defibrillator
      Apply pads (infra clavicular, anterior axillary / A-P / Transthoracic)
      Check rhythm


Drug Delivery
Intravenous
Intraosseous
Can be used for adults as well as children
2cm below tibial tuberosity

Tracheal (NAVAL)
Naloxone
Atropine
Vasopressin
Adrenaline x3-10 higher than IV dose
Lignocaine
Usually requires x3 iv dose of drug
Unpredictable concentrations
Unknown ideal dosing


Peri-arrest arrythmias -
Bradyarrythmias
Bradyarrhythmias

Rate < 60
Physiological/fit, B-blockers, pathological

1st Degree Heart block
Prolonged PR (>0.2s/five "squares")
AV conduction delay - Atheletes, drugs, conduction pathway fibrosis
Rarely needs treatment

2nd Degree Heart block
Some, but not all P-waves conducted
Mobitz I: Wenckebach AV block - progressive prolonged PR
Mobitz II: 2:1, 3:1 block

3rd Degree Heart block
Atria and ventricles beat independently
High risk of asystole


Peri-Arrest arrythmias -
Tachyarrythmias
Arise from atria (NCT) or ventricles (BCT)

Narrow Complex Tachycardia
Atrial fibrillation
Atrial flutter
Broad Complex Tachycardia
Below Bundle of His
SVT + aberrant conduction system (eg WPW)
VT can degenerate to VF

Breathless patient
Respiratory failure
Failure to maintain adequate oxygen exchange

   1. Type 1: PaO2 <8kPA with normal or low pCO2
         o Shunt: intracardiac
         o V/Q mismatch: pneumonia, PE, ARDS, bronchiectasis
   2. Type 2: PaO2 <8kPA with PaCO2>6kPA
         o Brain - head injury, brainstem stroke, drugs
         o Spine - cervical trauma
         o Nerve - MND, GBS
         o NMJ - Myasthenia
         o Muscle - exhaustion / myopathy
         o Thorax - flail chest


Dramatic            Acute                     Subacute                Chronic
Pneumothorax        Anxiety-                  Abdominal               COPD
Pulmonary           hyperventilation          distension              Pulmonary
embolus             Hypovolaemia              Pulmonary infiltrates   fibrosis
Pulmonary oedema    Asthma                    Pleural effusion        Non-pulmonary
Foreign body        LVF                       Carcinoma
Anaphylaxis         Foreign body
                    Pneumonia
                    Pulmonary infiltrates
                    Pulmonary haemorrhage
                    Poisoning

Management

   1.   ABC
   2.   Oxygen
   3.   History
   4.   Examination
   5.   Support - O2, bronchodilators, ventilation

Decide whether help is required early on +/- critical care outreach



Oxygenation

PaO2 = from ABG (arterial oxygenation)
PAO2 = From alveolar gas equation (alveolar oxygenation)

PAO2 = (760-47) x FiO2 - PaCO2/0.8



Venturi Masks

Venturi Valve Flow rate (l/min) Oxygen delivered
Blue          2                 24
White         4                 28
Yellow        6                 35
Red           8                 40
Green         12                60

Work of breathing

Compliance (change in volume per unit change in pressure)
Force to overcome viscosity of lung and chest wall
Airways resistance

      Normally breathing requires <5% oxygen delivery
      Requirements can increase to >25% total oxygen delivery
      Ventilatory support will reduce work of breathing and decrease oxygen
       delivery demands

				
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posted:11/30/2011
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