Emergencies
Advanced Life support
Chain of survival
1.
2.
3.
4.
Early recognition
Early CPR
Early defibrillation
Post resuscitation care
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Acute Coronary Syndromes
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Advanced Life Support Algorithm (2008)
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Airways adjuncts
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Cardiac monitors
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Collapsed patient
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Drug Delivery
Peri-arrest arrythmias - Bradyarrythmias
Peri-Arrest arrythmias
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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
o
1mg 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
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5.
6.
Ensure personal safety
Check for response: shake + shout
Open airway, head tilt + chin lift
Look into mouth (MILS)
Look, listen, feel (10 seconds)
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
Pneumothorax
Pulmonary
embolus
Pulmonary oedema
Foreign body
Anaphylaxis
Acute
Anxietyhyperventilation
Hypovolaemia
Asthma
LVF
Foreign body
Pneumonia
Pulmonary infiltrates
Pulmonary haemorrhage
Poisoning
Subacute
Abdominal
distension
Pulmonary infiltrates
Pleural effusion
Carcinoma
Management
1.
2.
3.
4.
5.
ABC
Oxygen
History
Examination
Support - O2, bronchodilators, ventilation
Decide whether help is required early on +/- critical care outreach
Oxygenation
PaO2 = from ABG (arterial oxygenation)
Chronic
COPD
Pulmonary
fibrosis
Non-pulmonary
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
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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