Resuscitation

Resussitation and airway management

1. Resuscitation and airway management By: Dr Basma Mohamed Ghoniem Lecturer of Anesthesia and Surgical ICU MD of Anaesthesia and Surgical ICU Faculty of Medicine Kafr El Sheikh University

2. Chain of survival Early recognition prevents: Cardiac arrests and deaths Admissions to ICU Inappropriate resuscitation attempts

3. The ABCDE approach to the deteriorating patient A irway B reathing C irculation D isability E xposure

4. Airway The aim of the airway assessment is to establish and maintain patent airway The patient’s airway can be clear (if the patient is talking), partially obstructed (if air entry is diminished and often noisy) or completely obstructed (if there are no breath sounds at the mouth or nose)

5. Airway Causes of airway obstruction: CNS depression Blood Vomit Foreign body Trauma Infection Inflammation Laryngospasm Bronchospasm

6. Assessing the Airway Talking Difficulty breathing, distressed, choking Shortness of breath Noisy breathing Stridor, wheeze, gurgling See-saw respiratory pattern, accessory muscles

7. Treatment of airway obstruction: Airway opening: Head tilt, chin lift and jaw thrust. If suspect cervical spine injury :manual inline stabilization Maintain opening by simple adjuncts: Supraglottic airway devices : Oropharyngeal airways Nasopharyngeal airways Laryngeal mask aiway Infraglottic airway devices :endotracheal intubation

8. Head tilt chin left jaw thrust

9. Manual in line stabilization

10. Laryngeal mask

11. Oropharyngeal airway

12. Sizing of oropharyngeal airway

13. Nasopharyngeal airway

14. Endotracheal tube

15. Causes of breathing problems: Decreased respiratory drive : CNS depression Decreased respiratory effort Muscle weakness Nerve damage Restrictive chest defect Pain from fractured ribs Lung disorders Pneumothorax Haemothorax Infection Acute exacerbation COPD Asthma Pulmonary embolus ARDS

16. Recognition of breathing problems Look Respiratory distress, accessory muscles, cyanosis, respiratory rate, chest deformity, conscious level Listen Noisy breathing, breath sounds Feel Expansion, percussion For 10 seconds

17. Look ,listen and feel

18. Obstructed Airway A patient who is choking typically has a panicked, confused or surprised facial expression. They may run about, flail their arms or try to get another’s attention. The patient may place one or both hands on their throat. This act of clutching the throat is commonly referred to as the universal sign of choking

19. Obstructed Airway

20. Obstructed Airway Encourage coughing forcefully. If the patient cannot breathe or has a weak or ineffective cough perform abdominal thrust or back blows

21. Stand behind the patient, with one foot in front of the other and if possible, between the patient’s feet. Place the thumb side of your fist against the middle of the abdomen, just above the navel, and grab the fist with your other hand.

22. For effective back blows, bend the patient forward at the waist so that the patient’s upper body is parallel to the ground. Give 5 firm back blows between the patient’s scapulae.

23. Causes of circulation problems: Primary A cute coronary syndromes Arrhythmias Hypertensive heart disease Valve disease Drugs Inherited cardiac diseases Electrolyte/acid base abnormalities Secondary A sphyxia Hypoxaemia Blood loss Hypothermia Septic shock

24. 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

25. Treatment of circulation problems: Airway, Breathing Oxygen if needed IV/IO access, take bloods Call for help Treat cause Fluid challenge

26. Acute myocardial infarction Refers to the necrosis (death) of heart tissue as a result of insufficient delivery of oxygenated blood to the heart . The sooner the signs and symptoms are recognized and treated, the lesser the degree of damage to the heart . Symptoms: chest pain, dyspnea ,nausea ,vomiting, sweating and dizziness

27. Treatment Morphin Oxygen Nitroglycrein Aspirin Withdrawal cardiac enzymes , 12 lead Ecg

28. Disability AVPU or GCS A: Alert V: Responsive to verbal stimuli P: Responsive to painful stimuli U: Unresponsive Pupils

29. Exposure Remove clothes to enable examination e.g. injuries, bleeding, rashes Avoid heat loss Maintain dignity

30. After you finish: Investigations Consultation of specialist Continuous assessment

31. SBAR S: Situation B: Background A: Assessment R: Recommendation

32. Cardiac arrest

33. CPR for Adults Conduct a rapid assessment : check for responsiveness open the airway, and simultaneously check for breathing and a carotid pulse for at least 5 seconds but no more than 10. If no pulse no breath , begin CPR

34. CPR for Adults

35. Chest compression 30:2 Compressions Centre of chest 5-6 cm depth 2 per second (100-120 min -1 ) Maintain high quality compressions with minimal interruption Continuous compressions once airway secured Switch compression provider every 2 min to avoid fatigue

36. Shockable and Non- Shockable

37. Automated External Defibrillators (AED) 1 st expose chest , remove hair Attach pads anterior/lateral pad one pad on the upper right chest, below the right clavicle to the right of the sternum. Place the other pad on the left side of the chest along the midaxillary line a few inches below the armpit. anterior/posterior placement Place one pad to the center of the patient’s chest on the sternum. Place one pad to the patient’s back between the sc

38. AED

39. Prepare to let the AED analyze the heart’s rhythm plug in the connector and push the analyze button. Instruct everyone to stand clear while the AED analyzes. No one, including you, should be touching the patient. As the AED analyzes, switch positions if you are working with a team. The provider giving compressions should hover their hands above the patient’s chest.

40. AED If the AED advises a shock, again instruct everyone to stand clear. The compressor should continue to hover their hands over the patient’s chest in preparation for CPR. Press the shock button to deliver the shock.

41. AED

42. Shockable (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude

43. Shockable (VT) Monomorphic VT Broad complex rythm Rapif rate Constant QRS morphology

44. Non- shockable ( Asystole ) Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace Adrenaline 1 mg IV then every 3-5 min

45. Non- shockable ( pulsless electrical activity)

46. During CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Vascular access (intravenous, intraosseous ) Give adrenaline every 3-5 min Correct reversible causes

47. summary Early recognition of the deteriorating patient may prevent cardiac arrest Most patients have warning symptoms and signs before cardiac arrest Airway, breathing or circulation problems can cause cardiac arrest ABCDE approach to recognise and treat patients at risk of cardiac arrest Criteria of effective chest compression Shockable and non shockble rhythm