ABCDE ATLS guidelines and management of trauma.ppt
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Sep 17, 2024
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About This Presentation
ABCDE ATLS guidelines and management of trauma.ppt
Slide Content
www.cmft.nhs.uk/undergrad
ABCDE - The approach to the
critically ill patient
DR. TALAT WASEEM
CHIEF OF SURGERY SHL
ABCDE - The approach to the
critically ill patient
DR. TALAT WASEEM
CHIEF OF SURGERY SHL
www.cmft.nhs.uk/undergrad
Objectives
•The rational of ABCDE
•The process of primary & secondary survey
•Recognition of life threatening events
•Treatment of life-threatening conditions
•Handover
Objectives
•The rational of ABCDE
•The process of primary & secondary survey
•Recognition of life threatening events
•Treatment of life-threatening conditions
•Handover
www.cmft.nhs.uk/undergrad
Traditional medical approach
Traditional medical approach
www.cmft.nhs.uk/undergrad
The ABCDE approach
Airway & oxygenation
Breathing &
ventilation
Circulation &
shock
management
Disability due to
neurological
deterioration
Exposure &
examination
The ABCDE approach
Airway & oxygenation
Breathing &
ventilation
Circulation &
shock
management
Disability due to
neurological
deterioration
Exposure &
examination
www.cmft.nhs.uk/undergrad
Ask 6 questions
1.Are they conscious?
2.Do they have a patient airway?
3.Is their breathing adequate?
4.Is their circulation adequate?
5.Are they neurologically intact?
6.Is the rest of them ok?
If at any point the answer is NO then do something!
Ask 6 questions
1.Are they conscious?
2.Do they have a patient airway?
3.Is their breathing adequate?
4.Is their circulation adequate?
5.Are they neurologically intact?
6.Is the rest of them ok?
If at any point the answer is NO then do something!
www.cmft.nhs.uk/undergrad
The principles
•Perform primary ABCDE survey (5 min)
•Instigate treatment for life threatening
conditions as you find them
•Reassess when any treatment is completed
•Perform more detailed secondary ABCDE
survey including investigations
•If condition deteriorates repeat primary
survey
The principles
•Perform primary ABCDE survey (5 min)
•Instigate treatment for life threatening
conditions as you find them
•Reassess when any treatment is completed
•Perform more detailed secondary ABCDE
survey including investigations
•If condition deteriorates repeat primary
survey
www.cmft.nhs.uk/undergrad
The primary survey
•ABCDE assessment
•Treat life threatening conditions
•Rapid intervention including
–15L O
2 via a non-rebreathing mask
–IV access & fluid challenge
–specific treatment
•Re-assess after any intervention
The primary survey
•ABCDE assessment
•Treat life threatening conditions
•Rapid intervention including
–15L O
2 via a non-rebreathing mask
–IV access & fluid challenge
–specific treatment
•Re-assess after any intervention
www.cmft.nhs.uk/undergrad
The primary survey
•No longer than 5 min
•Repeated as necessary
•Get experienced help
•Delegate jobs
–1
st
person assess Airway, O
2 & Breathing
–2
nd
person assesses Circulation
–3
rd
person IV access & fluids
The primary survey
•No longer than 5 min
•Repeated as necessary
•Get experienced help
•Delegate jobs
–1
st
person assess Airway, O
2 & Breathing
–2
nd
person assesses Circulation
–3
rd
person IV access & fluids
www.cmft.nhs.uk/undergrad
The secondary survey
•Performed when patient more stable
•Get a brief focused HPC & Hx
•More detailed examination of patient (ABCDE)
•Order investigations to aid diagnosis
•IF PATIENT DETERIORATES RETURN TO
PRIMARY SURVEY
The secondary survey
•Performed when patient more stable
•Get a brief focused HPC & Hx
•More detailed examination of patient (ABCDE)
•Order investigations to aid diagnosis
•IF PATIENT DETERIORATES RETURN TO
PRIMARY SURVEY
www.cmft.nhs.uk/undergrad
Airway - causes
GCS
•Body fluids
•Foreign body
•Inflammation
•Infection
•Trauma
Airway - causes
GCS
•Body fluids
•Foreign body
•Inflammation
•Infection
•Trauma
www.cmft.nhs.uk/undergrad
Airway - assessment
•Talking patients have a patent airway!
•Unresponsive patients have a threatened
airway
•Added sounds indicate partial obstruction
–Snoring, gurgling, wheeze, stridor
Airway - assessment
•Talking patients have a patent airway!
•Unresponsive patients have a threatened
airway
•Added sounds indicate partial obstruction
–Snoring, gurgling, wheeze, stridor
www.cmft.nhs.uk/undergrad
Airway – interventions
(basic)
•Head tilt chin lift
•Jaw thrust
•Suction
•Oral airways
•Nasal airways
Airway – interventions
(basic)
•Head tilt chin lift
•Jaw thrust
•Suction
•Oral airways
•Nasal airways
www.cmft.nhs.uk/undergrad
Airway – interventions
(advanced practitioners)
•GET HELP!!!
•Nebulised adrenaline
for stridor
•LMA
•Intubation
•Cricothyroidotomy
–Needle or surgical
Airway – interventions
(advanced practitioners)
•GET HELP!!!
•Nebulised adrenaline
for stridor
•LMA
•Intubation
•Cricothyroidotomy
–Needle or surgical
www.cmft.nhs.uk/undergrad
Once airway open...
•Give 15 litres of
oxygen to all patients
via a non-
rebreathing mask
•For COPD patients
re-assess after
primary survey: keep
SpO
2 90-93%
Once airway open...
•Give 15 litres of
oxygen to all patients
via a non-
rebreathing mask
•For COPD patients
re-assess after
primary survey: keep
SpO
2 90-93%
www.cmft.nhs.uk/undergrad
Breathing - causes
GCS
•Resp depressions
•Muscle weakness
•Exhaustion
•Asthma
•COPD
•Infection
•Pulmonary oedema
•Pulmonary embolus
•ARDS
•Pneumothorax
•Haemothorax
•Open pneumothorax
•Flail chest
Breathing - causes
GCS
•Resp depressions
•Muscle weakness
•Exhaustion
•Asthma
•COPD
•Infection
•Pulmonary oedema
•Pulmonary embolus
•ARDS
•Pneumothorax
•Haemothorax
•Open pneumothorax
•Flail chest
www.cmft.nhs.uk/undergrad
Breathing - assessment
•Look
–Rate (<10 or >20), symmetry, effort, SpO
2, colour
•Listen
–Taking: sentences, phrases, words
–Bilateral air entry, wheeze, silent chest other added
sounds
•Feel
–Central trachea, Percussion, expansion
Breathing - assessment
•Look
–Rate (<10 or >20), symmetry, effort, SpO
2, colour
•Listen
–Taking: sentences, phrases, words
–Bilateral air entry, wheeze, silent chest other added
sounds
•Feel
–Central trachea, Percussion, expansion
www.cmft.nhs.uk/undergrad
Breathing - interventions
•Consider ventilation
with BVM + O
2 if RR < 8
•Sit upright if conscious
& SoB
•Specific treatment
–i.e.: β agonist for
wheeze; chest drain for
pneumothorax
Breathing - interventions
•Consider ventilation
with BVM + O
2 if RR < 8
•Sit upright if conscious
& SoB
•Specific treatment
–i.e.: β agonist for
wheeze; chest drain for
pneumothorax
www.cmft.nhs.uk/undergrad
Circulation - assessment
•Look at colour
•Examine peripheries
•Pulse, BP & CRT
•Hypotension (late sign)
–sBP< 100mmHg
–sBP < 20mmHg below pts
norm
Urine output
•Consider compensation
mechanisms
Circulation - assessment
•Look at colour
•Examine peripheries
•Pulse, BP & CRT
•Hypotension (late sign)
–sBP< 100mmHg
–sBP < 20mmHg below pts
norm
Urine output
•Consider compensation
mechanisms
www.cmft.nhs.uk/undergrad
Circulation – shock
•Loss of volume
–Hypovolaemia
•Pump failure
–Myocardial & non-
myocardial causes
•Vasodilatation
–Sepsis, anaphylaxis,
neurogenic
Inadequate tissue perfusion
Circulation – shock
•Loss of volume
–Hypovolaemia
•Pump failure
–Myocardial & non-
myocardial causes
•Vasodilatation
–Sepsis, anaphylaxis,
neurogenic
Inadequate tissue perfusion
www.cmft.nhs.uk/undergrad
Compensation mechanism
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
Compensation mechanism
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
www.cmft.nhs.uk/undergrad
Loss of volume 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
Loss of volume 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
www.cmft.nhs.uk/undergrad
Loss of volume 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
2
Loss of volume 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
2
www.cmft.nhs.uk/undergrad
Loss of volume 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3
1
2
Loss of volume 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3
1
2
www.cmft.nhs.uk/undergrad
Pump failure 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
Pump failure 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
www.cmft.nhs.uk/undergrad
Pump failure 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
2
1
Pump failure 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
2
1
www.cmft.nhs.uk/undergrad
Pump failure 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3 2
1
Pump failure 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3 2
1
www.cmft.nhs.uk/undergrad
Vasodilatation 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
Vasodilatation 1
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
1
www.cmft.nhs.uk/undergrad
Vasodilatation 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
2 1
Vasodilatation 2
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
2 1
www.cmft.nhs.uk/undergrad
Vasodilatation 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3
2 1
Vasodilatation 3
Fluid
Volume
(CVP/JVP)
Vascular
Diameter
(SVR)
Cardiac
Output
(SV x HR)
PRE-LOAD AFTER-LOAD
3
2 1
www.cmft.nhs.uk/undergrad
Circulation - interventions
•Position supine with legs raised
–Caution if DiB
–Left lateral tilt in pregnancy
•IV access - 16G or larger x2
–+/- bloods if new cannula
•Fluid challenge
–colloid or crystalloid?
•ECG Monitoring
•Specific treatment
Circulation - interventions
•Position supine with legs raised
–Caution if DiB
–Left lateral tilt in pregnancy
•IV access - 16G or larger x2
–+/- bloods if new cannula
•Fluid challenge
–colloid or crystalloid?
•ECG Monitoring
•Specific treatment
www.cmft.nhs.uk/undergrad
Disability - causes
•Inadequate perfusion of the brain
•Sedative side effects of drugs
BM
•Toxins and poisons
•CVA
ICP
Disability - causes
•Inadequate perfusion of the brain
•Sedative side effects of drugs
BM
•Toxins and poisons
•CVA
ICP
www.cmft.nhs.uk/undergrad
Disability - assessment
•AVPU (or GCS)
–Alert, responds to Voice, responds to Pain,
Unresponsive
•Pupil size/response
•Posture
•BM
•Pain relief
Disability - assessment
•AVPU (or GCS)
–Alert, responds to Voice, responds to Pain,
Unresponsive
•Pupil size/response
•Posture
•BM
•Pain relief
www.cmft.nhs.uk/undergrad
Disability - interventions
•Optimise airway, breathing & circulation
•Treat underlying cause
–i.e.: naloxone for opiate toxicity
–Caution if reversing benzo’s
•Treat BM
–100ml of 10% dextrose (or 20ml of 50% dextrose)
•Control seizures
•Seek expert help for CVA or ICP
Disability - interventions
•Optimise airway, breathing & circulation
•Treat underlying cause
–i.e.: naloxone for opiate toxicity
–Caution if reversing benzo’s
•Treat BM
–100ml of 10% dextrose (or 20ml of 50% dextrose)
•Control seizures
•Seek expert help for CVA or ICP
www.cmft.nhs.uk/undergrad
Exposure
•Remove clothes and examine head to toe;
front and back
–Haemorrhage (inc concealed), rashes, swelling etc
•Keep warm (unless post cardiac arrest)
•Maintain dignity
Exposure
•Remove clothes and examine head to toe;
front and back
–Haemorrhage (inc concealed), rashes, swelling etc
•Keep warm (unless post cardiac arrest)
•Maintain dignity
www.cmft.nhs.uk/undergrad
Secondary survey
•Repeat ABCDE in more detail
•History
•Order investigations
–ABG, CXR, 12 lead ECG, Specific bloods
•Management plan
•Referral
•Handover
Secondary survey
•Repeat ABCDE in more detail
•History
•Order investigations
–ABG, CXR, 12 lead ECG, Specific bloods
•Management plan
•Referral
•Handover
www.cmft.nhs.uk/undergrad
Handover
•Grab their attention by telling
them the Situation
•Give them a little relevant
Background on what's happened
•Tell them your Assessment of the
patient
•Recommend to them what you
want the to do
Handover
•Grab their attention by telling
them the Situation
•Give them a little relevant
Background on what's happened
•Tell them your Assessment of the
patient
•Recommend to them what you
want the to do
www.cmft.nhs.uk/undergrad
Situation
•Check you are talking to the right person
•State your name & department
•The headline grabber
–“I think this patient is haemorrhaging internally”
Situation
•Check you are talking to the right person
•State your name & department
•The headline grabber
–“I think this patient is haemorrhaging internally”
www.cmft.nhs.uk/undergrad
Background
•Admission diagnosis and date of admission
•Relevant medical history
•Brief summary of treatment to date
Background
•Admission diagnosis and date of admission
•Relevant medical history
•Brief summary of treatment to date
www.cmft.nhs.uk/undergrad
Assessment
•Your assessment of the patient using the
ABCDE approach
Assessment
•Your assessment of the patient using the
ABCDE approach
www.cmft.nhs.uk/undergrad
Recommendation
•I would like you to...
•Determine the time scale
•Is there anything else I should do?
•Record the name and contact number of your
contact
Recommendation
•I would like you to...
•Determine the time scale
•Is there anything else I should do?
•Record the name and contact number of your
contact
www.cmft.nhs.uk/undergrad
Questions
?
Questions
?
www.cmft.nhs.uk/undergrad
Summary
•Assess ABCDE in turn
•Instigate treatments for life-threatening
problems as you find them
•Reassess following treatment
•If anything changes go back to A
Summary
•Assess ABCDE in turn
•Instigate treatments for life-threatening
problems as you find them
•Reassess following treatment
•If anything changes go back to A
www.cmft.nhs.uk/undergrad
CPR & Emergency Defibrillation
For OSCEs
Nick Smith
Head of Clinical Skills
CPR & Emergency Defibrillation
For OSCEs
Nick Smith
Head of Clinical Skills
www.cmft.nhs.uk/undergrad
Objectives
•To be fully aware of the new CPR guidelines
•To have knowledge of the new ALS guidelines
•To be aware of the pitfalls
Objectives
•To be fully aware of the new CPR guidelines
•To have knowledge of the new ALS guidelines
•To be aware of the pitfalls
www.cmft.nhs.uk/undergrad
The station
•Could just be CPR
•Could be just defibrillation
•Could be combined CPR with defib
•Maybe just you in the station or maybe an
assistant (plus an examiner)
The station
•Could just be CPR
•Could be just defibrillation
•Could be combined CPR with defib
•Maybe just you in the station or maybe an
assistant (plus an examiner)
www.cmft.nhs.uk/undergrad
Basic Life Support
DANGER?
RESPONSE?
SHOUT 4 HELP
OPEN AIRWAY
CHECK BREATHING & CIRCULATION
30 CHEST COMPRESSIONS
ATTEMPT 2 BREATHS
GET HELP!
2222 (or 999)
CONTINUE CPR 30:2
UNTIL DEFIB ARRIVES
Basic Life Support
DANGER?
RESPONSE?
SHOUT 4 HELP
OPEN AIRWAY
CHECK BREATHING & CIRCULATION
30 CHEST COMPRESSIONS
ATTEMPT 2 BREATHS
GET HELP!
2222 (or 999)
CONTINUE CPR 30:2
UNTIL DEFIB ARRIVES
www.cmft.nhs.uk/undergrad
Assess the patient
Ask the examiner if it is safe
to approach
Firmly shake the manikins
shoulders and ask loudly
“are you alright”
Shout loudly for someone
to assist you
DANGER?
RESPONSE?
SHOUT 4 HELP
Assess the patient
Ask the examiner if it is safe
to approach
Firmly shake the manikins
shoulders and ask loudly
“are you alright”
Shout loudly for someone
to assist you
DANGER?
RESPONSE?
SHOUT 4 HELP
www.cmft.nhs.uk/undergrad
Look for signs of life
•An obvious
head-tilt/chin lift
•Get close to the patient
& look listen and feel
for breathing
•At the same time feel
for the carotid pulse
•Count out 10 second
OPEN AIRWAY
CHECK BREATHING & CIRCULATION
Look for signs of life
•An obvious
head-tilt/chin lift
•Get close to the patient
& look listen and feel
for breathing
•At the same time feel
for the carotid pulse
•Count out 10 second
OPEN AIRWAY
CHECK BREATHING & CIRCULATION
www.cmft.nhs.uk/undergrad
Get expert help
•Send some one or leave
the victim to call the
resuscitation team
(2222)
•State clearly “Cardiac
arrest; [location]” and
repeat
•Return to the victim
GET HELP 2222 (or 999)
Get expert help
•Send some one or leave
the victim to call the
resuscitation team
(2222)
•State clearly “Cardiac
arrest; [location]” and
repeat
•Return to the victim
GET HELP 2222 (or 999)
www.cmft.nhs.uk/undergrad
Circulate oxygen
•Heel of hands in middle
of chest
•Interlock fingers and
keep elbows locked
•Compress 5 – 6 cm
•Rate of 100 - 120 per
min
•Allow chest to recoil
30 CHEST COMPRESSIONS
Circulate oxygen
•Heel of hands in middle
of chest
•Interlock fingers and
keep elbows locked
•Compress 5 – 6 cm
•Rate of 100 - 120 per
min
•Allow chest to recoil
30 CHEST COMPRESSIONS
www.cmft.nhs.uk/undergrad
Reoxygenate
ATTEMPT 2 BREATHS
•Assemble pocket mask
•Create a seal around the
nose & mouth
•Open the airway
•Attempt 2 breaths
•If chest fails to rise go back
to 30 chest compressions
•Continue CPR 30:2
•Minimise interrutions
Reoxygenate
ATTEMPT 2 BREATHS
•Assemble pocket mask
•Create a seal around the
nose & mouth
•Open the airway
•Attempt 2 breaths
•If chest fails to rise go back
to 30 chest compressions
•Continue CPR 30:2
•Minimise interrutions
www.cmft.nhs.uk/undergrad
Keep them going!
•Get assistant to take
over CPR where
available
•Connect defib
•Turn defib on by turning
the dial to ‘ON’
CONTINUE CPR 30:2
UNTIL DEFIB ARRIVES
Keep them going!
•Get assistant to take
over CPR where
available
•Connect defib
•Turn defib on by turning
the dial to ‘ON’
CONTINUE CPR 30:2
UNTIL DEFIB ARRIVES
www.cmft.nhs.uk/undergrad
ALS algorithm
Analyse
Rhythm
Non- shockable
Asystole/PEA
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Assess using ABCDE
approach
•Control oxygenation and
ventilation
•12-lead ECG
•Treat precipitating
causes
•Temperature control /
therapeutic hypothermia
Adrenaline 1mg & Amiodarone
300mg IV/IO after 3
rd
shock
then repeat adrenaline after
every alternate shock
Adrenaline 1mg (IV/IO) as
soon as access obtained and
then every alternate loop
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Return of
spontaneous
circulation
Immediate post arrest
treatment
ALS algorithm
Analyse
Rhythm
Non- shockable
Asystole/PEA
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Assess using ABCDE
approach
•Control oxygenation and
ventilation
•12-lead ECG
•Treat precipitating
causes
•Temperature control /
therapeutic hypothermia
Adrenaline 1mg & Amiodarone
300mg IV/IO after 3
rd
shock
then repeat adrenaline after
every alternate shock
Adrenaline 1mg (IV/IO) as
soon as access obtained and
then every alternate loop
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Return of
spontaneous
circulation
Immediate post arrest
treatment
www.cmft.nhs.uk/undergrad
Decide what rhythm they are in
•Briefly pause CPR to assess rhythm
•Restart chest compressions
•Verbalise the rhythm to the examiner
•Shockable or non-shockable
Analyse
Rhythm
Decide what rhythm they are in
•Briefly pause CPR to assess rhythm
•Restart chest compressions
•Verbalise the rhythm to the examiner
•Shockable or non-shockable
Analyse
Rhythm
www.cmft.nhs.uk/undergrad
Shockable
•VF
–Bizzare, irregular
•Pulseless VT
–Rapid, regular, broad
QRS
Analyse
Rhythm
Shockable
VF/Puleless VT
Shockable
•VF
–Bizzare, irregular
•Pulseless VT
–Rapid, regular, broad
QRS
Analyse
Rhythm
Shockable
VF/Puleless VT
www.cmft.nhs.uk/undergrad
Deliver shock
•Turn dial to 150
•“STAND CLEAR OXYGEN
AWAY”
•Push button 2 to charge
•When charged stop
compressions
•“SHOCKING”
•Press button 3 to shock
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Deliver shock
•Turn dial to 150
•“STAND CLEAR OXYGEN
AWAY”
•Push button 2 to charge
•When charged stop
compressions
•“SHOCKING”
•Press button 3 to shock
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
www.cmft.nhs.uk/undergrad
Restart CPR
•Immediately resume CPR
for 2 min
•Do not re-check rhythm!
•Minimise interruptions to
CPR
•Only stop if patient shows
obvious signs of life
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Restart CPR
•Immediately resume CPR
for 2 min
•Do not re-check rhythm!
•Minimise interruptions to
CPR
•Only stop if patient shows
obvious signs of life
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
www.cmft.nhs.uk/undergrad
•Time it out
•Ensure quality CPR
•Plan actions when
interrupt CPR
•IV Access +/- fluids
•Ensure O
2 via BVM
•Prepare drugs
•Consider reversible
causes
During 2 min CPR
•Hypovolaemia
•Hypoxia
•Hypo/er kalaemia
•Hypothermia
•Tension pneumothorax
•Tamponade (cardiac)
•Toxins
•Thrombus
•Time it out
•Ensure quality CPR
•Plan actions when
interrupt CPR
•IV Access +/- fluids
•Ensure O
2 via BVM
•Prepare drugs
•Consider reversible
causes
During 2 min CPR
•Hypovolaemia
•Hypoxia
•Hypo/er kalaemia
•Hypothermia
•Tension pneumothorax
•Tamponade (cardiac)
•Toxins
•Thrombus
www.cmft.nhs.uk/undergrad
After 2 min CPR
•Re-analyse the rhythm
•If still shockable then
repeat the process
•If not VF or VT then
move to non-shockable
side of algorythm
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
After 2 min CPR
•Re-analyse the rhythm
•If still shockable then
repeat the process
•If not VF or VT then
move to non-shockable
side of algorythm
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
www.cmft.nhs.uk/undergrad
After 3
rd
shock
•Give 1mg adrenaline &
300mg amiodarone
immediately after shock
during CPR
•Repeat adrenaline after
every alternate shock
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
After 3
rd
shock
•Give 1mg adrenaline &
300mg amiodarone
immediately after shock
during CPR
•Repeat adrenaline after
every alternate shock
Analyse
Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
www.cmft.nhs.uk/undergrad
Non-shockable
•Asystole
–No electrical activity
–Occasionally P waves
•PEA
–Any non-shockable
rhythm with a QRS
complex and no pulse
Analyse
Rhythm
Non- shockable
Asystole/PEA
Non-shockable
•Asystole
–No electrical activity
–Occasionally P waves
•PEA
–Any non-shockable
rhythm with a QRS
complex and no pulse
Analyse
Rhythm
Non- shockable
Asystole/PEA
www.cmft.nhs.uk/undergrad
Signs of life (SoL) check
•10sec only
•Don’t check in asystole
•Only used to distinguish
PEA from a perfusing
rhythm
Analyse
Rhythm
Non- shockable
Asystole/PEA
Signs of life (SoL) check
•10sec only
•Don’t check in asystole
•Only used to distinguish
PEA from a perfusing
rhythm
Analyse
Rhythm
Non- shockable
Asystole/PEA
www.cmft.nhs.uk/undergrad
Restart CPR
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Uninterrupted CPR for 2
min
•Do not re-check
rhythm!
•Unless patient shows
obvious signs of life
Restart CPR
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Uninterrupted CPR for 2
min
•Do not re-check
rhythm!
•Unless patient shows
obvious signs of life
www.cmft.nhs.uk/undergrad
Drugs
•During CPR as soon as
access available
•Adrenaline 1mg
•Repeat every alternate
2 min cycle
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Drugs
•During CPR as soon as
access available
•Adrenaline 1mg
•Repeat every alternate
2 min cycle
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
www.cmft.nhs.uk/undergrad
After 2min CPR
•Analyse rhythm
•If still non-shockable
then repeat the process
•If shockable then go to
shockable side of
algorithm
•If SoL then reassess
using A-E approach
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
After 2min CPR
•Analyse rhythm
•If still non-shockable
then repeat the process
•If shockable then go to
shockable side of
algorithm
•If SoL then reassess
using A-E approach
Analyse
Rhythm
Non- shockable
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
www.cmft.nhs.uk/undergrad
ALS algorithm
Analyse
Rhythm
Non- shockable
Asystole/PEA
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Assess using ABCDE
approach
•Control oxygenation and
ventilation
•12-lead ECG
•Treat precipitating
causes
•Temperature control /
therapeutic hypothermia
Adrenaline 1mg & Amiodarone
300mg IV/IO after 3
rd
shock
then repeat adrenaline after
every alternate shock
Adrenaline 1mg (IV/IO) as
soon as access obtained and
then every alternate loop
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Return of
spontaneous
circulation
Immediate post arrest
treatment
ALS algorithm
Analyse
Rhythm
Non- shockable
Asystole/PEA
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
•Assess using ABCDE
approach
•Control oxygenation and
ventilation
•12-lead ECG
•Treat precipitating
causes
•Temperature control /
therapeutic hypothermia
Adrenaline 1mg & Amiodarone
300mg IV/IO after 3
rd
shock
then repeat adrenaline after
every alternate shock
Adrenaline 1mg (IV/IO) as
soon as access obtained and
then every alternate loop
Immediately resume
CPR 30:2 for 2 min
Minimise interruptions
Push drugs
when indicated
Return of
spontaneous
circulation
Immediate post arrest
treatment
www.cmft.nhs.uk/undergrad
Questions
?
Questions
?
www.cmft.nhs.uk/undergrad
Summary
•DRS ABC
•Get help
•CPR (minimise interruptions)
•Attach defib
•Analyse rhythm
•Shock (or don’t)
•2 min CPR (minimise interruptions)
•Reassess
Summary
•DRS ABC
•Get help
•CPR (minimise interruptions)
•Attach defib
•Analyse rhythm
•Shock (or don’t)
•2 min CPR (minimise interruptions)
•Reassess
www.cmft.nhs.uk/undergrad
Acute severe asthma
•Nebulised salbutamol
(5mg) - O
2 driven
–Repeat as needed
•Nebulised ipratropium
(500mcg) - O
2
driven
•Hydrocortisone 100mg
IV or Prednisolone 50 –
60mg po
•MgSO
4
IV 1.2 – 2g
–Seek guidance first
Any one of:
•PEF 33 – 50% of best or predicted
•RR> 24
•HR> 110
•Inability to complete sentences in 1 breath
HR
SVR
Acute severe asthma
•Nebulised salbutamol
(5mg) - O
2 driven
–Repeat as needed
•Nebulised ipratropium
(500mcg) - O
2
driven
•Hydrocortisone 100mg
IV or Prednisolone 50 –
60mg po
•MgSO
4
IV 1.2 – 2g
–Seek guidance first
Any one of:
•PEF 33 – 50% of best or predicted
•RR> 24
•HR> 110
•Inability to complete sentences in 1 breath
HR
SVR
www.cmft.nhs.uk/undergrad
Life threatening asthma
•PEF <33%
•SpO2 <92%
•PaO2 <8 kPa
•Normal PaCO2
–PaCO2 is a pre-
terminal sign
•Silent chest
•Cyanosis
•Poor respiratory effort
•Arrhythmias
•Exhaustion / GCS
Severe asthma plus one of the following:
Get expert help quickly and treat as for acute severe
asthma
HR
SVR
Life threatening asthma
•PEF <33%
•SpO2 <92%
•PaO2 <8 kPa
•Normal PaCO2
–PaCO2 is a pre-
terminal sign
•Silent chest
•Cyanosis
•Poor respiratory effort
•Arrhythmias
•Exhaustion / GCS
Severe asthma plus one of the following:
Get expert help quickly and treat as for acute severe
asthma
HR
SVR
www.cmft.nhs.uk/undergrad
Sepsis
Signs and symptoms of infection (SSI) or
Systemic Inflammatory Response (SIRs)
•Temperature > 38.2°C or <36°C
•HR>90 beats/min
•Respiratory rate >20 breaths/min
•WBC count > 12,000 or <4,000/mL
•Hyperglycaemia (in absence or DM)
2 or more SSI’s + suspicion of a new infection = SEPSIS
HR
SVR
Sepsis
Signs and symptoms of infection (SSI) or
Systemic Inflammatory Response (SIRs)
•Temperature > 38.2°C or <36°C
•HR>90 beats/min
•Respiratory rate >20 breaths/min
•WBC count > 12,000 or <4,000/mL
•Hyperglycaemia (in absence or DM)
2 or more SSI’s + suspicion of a new infection = SEPSIS
HR
SVR
www.cmft.nhs.uk/undergrad
Severe Sepsis
•Oxygen
•Blood cultures
•IV antibiotics (within 1
hour)
•BP < 90 systolic
•Acute alteration in mental
status
•O2 sats < 90%
•UO < 0.5ml/kg/hr for 2
hours
•Bilirubin >34µmol/L
•Platelets <100 x 10
9
/L
•Lactate>2 mmol/L
•Coagulopathy – INR>1.5 or
APTT>60sec
SEPSIS + Organ dysfunction = SEVERE SEPSIS
•Fluids +++
•Monitor lactate & Hb
•Urinary Catheter &
hourly monitoring
HR
SVR
Severe Sepsis
•Oxygen
•Blood cultures
•IV antibiotics (within 1
hour)
•BP < 90 systolic
•Acute alteration in mental
status
•O2 sats < 90%
•UO < 0.5ml/kg/hr for 2
hours
•Bilirubin >34µmol/L
•Platelets <100 x 10
9
/L
•Lactate>2 mmol/L
•Coagulopathy – INR>1.5 or
APTT>60sec
SEPSIS + Organ dysfunction = SEVERE SEPSIS
•Fluids +++
•Monitor lactate & Hb
•Urinary Catheter &
hourly monitoring
HR
SVR
www.cmft.nhs.uk/undergrad
Anaphylaxis
•Get expert help quickly
•Oxygen
•IM adrenaline 500mcg
–repeat every 5 min if
needed
Highly likely if…
1.Sudden onset and rapid progression
2.Life threatening problem to airway &/or breathing &/or
circulation
3.Skin changes (rash or angioedema)
+/- Exposure to known allergen
•Chlorphenamine 10mg
IV
•Hydrocortisone 200mg
IV
•+/- fluids +++
HR
SVR
Anaphylaxis
•Get expert help quickly
•Oxygen
•IM adrenaline 500mcg
–repeat every 5 min if
needed
Highly likely if…
1.Sudden onset and rapid progression
2.Life threatening problem to airway &/or breathing &/or
circulation
3.Skin changes (rash or angioedema)
+/- Exposure to known allergen
•Chlorphenamine 10mg
IV
•Hydrocortisone 200mg
IV
•+/- fluids +++
HR
SVR
www.cmft.nhs.uk/undergrad
Hypovolaemia
Haemorrhagic
•External
•Drains
•GI tract
•Abdomen
Trauma
•On the floor and 4 more
–Chest, abdo, pelvis, long
bones
Fluid loss
•D&V
•Polyuria
•Pancreatitis
Iatrogenic
•Diuretics +++
•Inadequate fluid
prescription
HR
SVR
Hypovolaemia
Haemorrhagic
•External
•Drains
•GI tract
•Abdomen
Trauma
•On the floor and 4 more
–Chest, abdo, pelvis, long
bones
Fluid loss
•D&V
•Polyuria
•Pancreatitis
Iatrogenic
•Diuretics +++
•Inadequate fluid
prescription
HR
SVR
www.cmft.nhs.uk/undergrad
Hypovolaemia
Responders Partial or transient
responders
Non-responders
Patient improve and
remains improved.
Patient improves
but shows a gradual
deterioration
on-going loss or re-
equilibration
No improvement.
Exsanguination
though severe
dehydration &
sepsis should be
considered
No further boluses
maybe needed but
investigate cause
Further boluses and
investigations
Further boluses and
get help quickly
Give fluid challenge 250ml over 2 min and reassess after 5 min
Hypovolaemia
Responders Partial or transient
responders
Non-responders
Patient improve and
remains improved.
Patient improves
but shows a gradual
deterioration
on-going loss or re-
equilibration
No improvement.
Exsanguination
though severe
dehydration &
sepsis should be
considered
No further boluses
maybe needed but
investigate cause
Further boluses and
investigations
Further boluses and
get help quickly
Give fluid challenge 250ml over 2 min and reassess after 5 min
www.cmft.nhs.uk/undergrad
Haemorrhagic shock
Class I < 15%
<750ml
Class II 15-30%
750 – 1500ml
Class III 30 – 40%
1500 – 2000ml
Class IV >40%
>2000ml
RR 14-20 20-30 30+ 35+
HR <100 >100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressureNormal Decreased Decreased Decreased
Neuro Slightly AnxiousMildly anxiousAnxious or
confused
Confused or
lethargic
Urine Output > 30 20 – 30 5 - 15 Bladder sweat
Use patients obs to estimate the blood loss then replace with crystalloid at 1.5
to 3ml for every 1ml of estimated blood loss
Figures based on a young healthy adult with a compressible haemorrhage
Haemorrhagic shock
Class I < 15%
<750ml
Class II 15-30%
750 – 1500ml
Class III 30 – 40%
1500 – 2000ml
Class IV >40%
>2000ml
RR 14-20 20-30 30+ 35+
HR <100 >100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressureNormal Decreased Decreased Decreased
Neuro Slightly AnxiousMildly anxiousAnxious or
confused
Confused or
lethargic
Urine Output > 30 20 – 30 5 - 15 Bladder sweat
Use patients obs to estimate the blood loss then replace with crystalloid at 1.5
to 3ml for every 1ml of estimated blood loss
Figures based on a young healthy adult with a compressible haemorrhage
www.cmft.nhs.uk/undergrad
Bradycardia
Adverse signs
BP
•HR < 40
•Heart failure
•Ventricular arrhythmias
compromising BP
No adverse signs with a risk of
asystole?
•Recent asystole
•Mobitz II AV block
•3
rd
degree HB w QRS
•QRS pauses > 3 sec
•Get expert help quickly!
•Atropine 500 mcg IV
–Repeat to a max total dose of 3mg
•External cardiac pacing
HR
SVR
Bradycardia
Adverse signs
BP
•HR < 40
•Heart failure
•Ventricular arrhythmias
compromising BP
No adverse signs with a risk of
asystole?
•Recent asystole
•Mobitz II AV block
•3
rd
degree HB w QRS
•QRS pauses > 3 sec
•Get expert help quickly!
•Atropine 500 mcg IV
–Repeat to a max total dose of 3mg
•External cardiac pacing
HR
SVR
www.cmft.nhs.uk/undergrad
Tachyarrhythmia
•Get expert help quickly
•Unstable*
–Sedate and synchronised
cardiovertion
•Stable VT
–Amiodarone 300mg 20 –
60 min
•Stable SVT
–Vagal manoeuvers
–Adenosine 6mg, 12mg,
12mg
•Stable tachy AF
–Amiodarone 300mg 20 –
60 min if onset < 48hrs
–Β-blocker IV or digoxin IV
(*rate related symptoms are uncommon at less than 150 beats min
-1
)
HR
SVR
Tachyarrhythmia
•Get expert help quickly
•Unstable*
–Sedate and synchronised
cardiovertion
•Stable VT
–Amiodarone 300mg 20 –
60 min
•Stable SVT
–Vagal manoeuvers
–Adenosine 6mg, 12mg,
12mg
•Stable tachy AF
–Amiodarone 300mg 20 –
60 min if onset < 48hrs
–Β-blocker IV or digoxin IV
(*rate related symptoms are uncommon at less than 150 beats min
-1
)
HR
SVR
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