Download Cardiorespiratory arrest

File 15 Cardiorespiratory arrest (adult and child)
Cardiorespiratory arrest (adults and child)
Recommend
 Defibrillate in a Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (VT)
arrest
 Witnessed arrest - check for pulse & connect patient to monitor - if shockable
rhythm, defibrillate
 Unwitnessed arrest – perform 2 minutes of uninterrupted CPR then assess for
shockable or non shockable rhythm
Background
 The aim of management is to restore a normal cardiac output as soon as possible
through CPR / defibrillation / airway management / vascular access and drug
administration
 In adults cardiac arrest may occur because of heart attack and/or cardiac arrhythmia.
Urgent defibrillation may be lifesaving
 In children, the majority of cardiorespiratory emergencies are due to either a primary
respiratory problem (eg. inhaled foreign body, anaphylaxis) or lack of adequate tissue
perfusion (eg. blood loss, severe dehydration). Once cardiorespiratory arrest has
occurred, the chances of survival for the child are low.
The aim therefore is to recognise and provide appropriate and rapid treatment to
the critically ill child to prevent cardiorespiratory arrest
 Management will be different according to quick accessibility of resuscitation
equipment including a defibrillator and drugs, and will either be based on: BLS
(Basic Life Support) or ALS (Advanced Life Support) as below
Related topics:
Basic life support, see DRABC Resuscitation / the collapsed patient, page 35
 Acute coronary syndrome, page 79
Cardiac arrhythmias, page 89
Electrocution / electric shock, page 90
1.
May present with:
 Sudden collapse
 As complication of heart attack
 As part of clinical picture of most conditions that can be regarded as
emergencies
2.
Immediate management:
 See Basic Life Support Flow chart
 Witnessed arrest - check for pulse & connect monitor and, if shockable rhythm,
defibrillate
 Unwitnessed arrest – 2 minutes uninterrupted CPR then assess for shockable
or non shockable rhythm
 If semiautomatic defibrillator follow instructions
 If manual defibrillator the most important initial assessment is a division of ECG
rhythm into shockable rhythm (VF or VT ) or non -shockable rhythm
File 15 Cardiorespiratory arrest (adult and child)
Shockable rhythm
Ventricular fibrillation
Non shockable rhythm
Asystole
Ventricular tachycardia
Pulseless electrical activity (PEA)
Sinus rhythm
3.
Clinical assessment:
 As per immediate management
 Monitor response to defibrillation, medication, improved oxygenation
4.
Management:
Call MO immediately if on site

Shockable rhythms: VF and pulseless VT
 defibrillation in witnessed arrest
o
this is best done as three (3) shocks in quick succession with brief
assessment of rhythm in between each shock
 defibrillation in unwitnessed arrest
o
commence 2 minutes of uninterrupted CPR then
o
subsequent single defibrillation attempt every 2 minutes (or as best
possible)
 airway and breathing
 bag and mask (as per basic life support) with high flow oxygen
 or Laryngeal Mask Airway (LMA)
 vascular access
 insert IV cannula
 drugs
 Adrenaline
child - Adrenaline 0.01 mg/kg IV (RN only)
adult - Adrenaline 1 mg IV (RN only) -can be repeated every 3
minutes
 Amiodarone (on MO order only)
adult – Amiodarone 300mg IV bolus - additional dose of 150mg
could be considered, followed by an infusion 15mg/kg over 24
hours (MO must order)
File 15 Cardiorespiratory arrest (adult and child)


Lignocaine
adult – Lignocaine IV first dose: 1 mg/kg bolus; second and last
dose 0.5 mg/kg (MO must order)
It is not recommended to commence Lignocaine infusion until
return of spontaneous circulation
Magnesium, Potassium
maybe ordered by MO
Cycles of CPR are 2 minutes before doing a rhythm check and shocking

Cessation of resuscitation may not always follow a definite timeframe but
will obviously be determined by response to treatment – usually asystole
will intervene and generally 20 minutes of asystole after resuscitative
efforts would be sufficient for a MO to advise stopping CPR

Non-shockable cardiac rhythms: asystole, bradycardiac arrest
 do not defibrillate
 airway & breathing
o
bag and mask (as per basic life support) with high flow oxygen
o
or Laryngeal Mask Airway (LMA)
 vascular access
o
insert IV cannula
 drugs
o Adrenaline
child - Adrenaline 0.01 mg/kg IV (RN only)
adult – Adrenaline 1 mg adult IV (RN only) can be repeated every 3
minutes if no response
o Atropine
child – Atropine 0.02 mg/kg IV (RN only)
adult – Atropine or up to a total of 3 mg IV(RN only) to completely
remove sinus node inhibition (MO must order)
 Usually 10 minutes in asystole after resuscitative efforts would be sufficient
for MO to advise stopping CPR

Non-shockable cardiac rhythm: Pulseless Electrical Activity (PEA)
Correct reversible causes (4 H’s and 4 T’s)
 hypoxaemia
 hypovolaemia
 hypo / hyperthermia
 hypo / hyperkalaemia (and other metabolic disorders)
 tamponade (cardiac)
 tension pneumothorax
 toxins / poisons / drugs
 thrombosis (pulmonary / coronary)
File 15 Cardiorespiratory arrest (adult and child)
File 15 Cardiorespiratory arrest (adult and child)
File 15 Cardiorespiratory arrest (adult and child)
Pulseless Electrical Activity (PEA)
This describes the presence of a cardiac rhythm on the monitor, but no
palpable pulse. In effect, no discernable cardiac output despite the presence of
electrical activity in the heart. Also known as Electromechanical Dissociation
(EMD)
PEA can either occur:

in a heart with little functional viable myocardium (ie. dying heart)

secondary to reversible medical conditions including the 4 H’s and 4 T’s
The history will often guide to the possible causes;

if trauma, eg. motor vehicle accident (MVA), hypovolaemia, tension
pneumothorax, pericardial tamponade should be considered early

if known to be on a calcium antagonist or beta blocker medication,
appropriate management needs to be considered early
Management in these situations involves working through and correcting the
possibilities outlined under non-shockable cardiac rhythm.






DO NOT DEFIBRILLATE
Airway and breathing
o bag and mask (as per basic life support) with high flow oxygen
o or Laryngeal Mask Airway (LMA)
vascular access
o insert IV cannula
o give IV fluid bolus of Normal Saline up to 20 mL/kg (adult and child)
drugs
o child - Adrenaline 0.01 mg/kg IV (RN only)
o adult – Adrenaline 1 mg (RN only)
o Adrenaline can be repeated every 3 minutes if no response
Further management even with an obvious reversible cause will certainly
be very difficult.
Consult MO and discuss what further intervention is reasonable and
feasible
File 15 Cardiorespiratory arrest (adult and child)
Asystole and PEA
Flowchart
Consider

Hypoxia

Hypovolaemia

Hyper/ Hypo
o electrolyte imbalance
o glycaemia

Hypothermia

Tension pneumothorax

Cardiac Tamponade

Toxins / Drug overdose

Thrombus MI / PE
and treat appropriately

Bag valve mask ventilate
high flow O2
Consider LMA or ETT
CPR 30:2
IV / IO access
IV or IO Adrenaline 1mg
every 3 minutes
IV Normal Saline 1 Litre
CPR 30:2
2 minutes
Symptomatic Bradycardia / Peri-Arrest Situation
Inadequate cardiac output in the presence of bradycardia
There may be a palpable pulse with each beat, but poor cardiac output
associated with slow heart rate

do not defibrillate

airway and breathing
o bag and mask (as per basic life support) with high flow oxygen
o or Laryngeal Mask Airway (LMA)

vascular access
o insert IV cannula
In a child with bradycardia – it is almost always a pre-terminal event. Airway,
breathing and circulation should always be assessed and treated if needed
before pharmacological management of bradycardia is given [1]

drugs
o child - Atropine 0.02 mg/kg IV (RN only) (MO must order)
o adult - Atropine 0.5mg – 0.6mg IV (RN only) (MO must order)
o can be repeated every 3 minutes on MO’s orders to a maximum of 3
mg (adult)
If still no response, but alive when evacuating/attending MO arrives, will require
external cardiac pacing (adult)
5.
Follow up:
 Provide support for family members
6.
Referral / Consultation:
 Always contact MO as soon as circumstances allow in cardiac arrest
File 15 Cardiorespiratory arrest (adult and child)
1.
Advanced Life Support Group, Advanced Paediatric Life Support - The Practical
Approach. 4th ed. 2003: Blackwell Publishing.
File 15 Cardiorespiratory arrest (adult and child)
The unconscious patient
(or patient with altered level of consciousness)
Recommend
 Never leave an unconscious patient alone
 The Glasgow coma scale or AVPU is a measure of consciousness, always act:

on Glasgow coma score less than 14

escalate immediately a drop of 2 or more in Glasgow coma score since the last
assessment interval

notify MO immediately of a score of 13 or less in a child

consider intubation less than 8
Background
 There are many causes of altered level or loss of consciousness
 Most clues to the cause will be gained through taking a thorough history from friends
or relatives
Related topics:
DRABC resuscitation / the collapsed patient, page 35
Collapsed patient (adult and child) summary, page 34
 Fits / convulsions / seizures, page 63
 Cardiac arrest, page 40
 Poisoning / overdose, page 182.
 Bites and stings, page 201
 Severe injury / head injury, pages 95, 107
TIA / Stroke, page, page 235
Meningitis, page 524
 Hypoglycaemia, page 68
1.
May present with:

Confused, drowsy, unconscious, not breathing, of unknown cause

As part of clinical picture of most conditions that can be regarded as
emergencies
2.
Immediate management:
DRABC resuscitation / the collapsed patient
Primary survey

Take emergency patient history from relatives / friends, if present

A. Assess airway patency (look, listen, feel)

Give high flow oxygen-see O2 Delivery systems to maintain O2 saturation >94%.
If >94% not maintained, consult MO

If possibility of cervical spine injury - maintain cervical spine in line and
if available have 2 people apply Stiff neck collar (appropriate to size)

B. Assess if breathing effectively

Check respiratory rate, effort, O2 saturation

C. Insert large bore IV cannula (14 g or 16 g, if possible). Insert the largest you
can in the circumstances

Check BP, heart rate, capillary refill

D. Dysfunction of the central nervous system = conscious state

Check Glasgow coma scale or AVPU, pupil size and reaction, BGL, temperature

Consult MO as soon as circumstances allow

Maintain temperature
File 15 Cardiorespiratory arrest (adult and child)
3.
4.
Clinical assessment:
Obtain a history from friend or relative including circumstances leading to
unconscious state. Look for clues which may indicate reason for unconscious
state e.g. medications taken

E. Expose and examine the patient systematically starting at the head and
progressing downwards to the toes. Remove all clothing as you move down,
maintaining privacy. Do not let the patient get cold, cover with a blanket after
examination. Whilst performing examination look for clinical signs which point to
reason for altered level of consciousness or unconsciousness (use diagram to
help with systematic approach)

Management:
 Consult MO who will advise further assessment and management depending on
clinical circumstances
 If BGL less than 3 mmol/L see Hypoglycaemia
 Use diagram to help with systematic approach to possible causes of
unconsciousness:

poisoning – deliberate or accidental, including alcohol

hypoglycaemia, see Hypoglycaemia

post-ictal (after fit). See Fit / convulsions / seizures

stroke. See TIA / stroke

head injury. See Head Injuries

subarachnoid haemorrhage

respiratory failure

acute cardiac arrhythmia / arrest
Less common:

meningitis or encephalitis. See Meningitis

liver or kidney failure

septicaemia

subdural haematoma

hyperglycaemia (high capillary BGL)

hypothermia
File 15 Cardiorespiratory arrest (adult and child)
5.
Follow up:
 According to possible cause for unconsciousness
 Patient will need evacuation / hospitalisation in suitably equipped facility
6.
Referral / Consultation:
 Always Contact MO as soon as possible if patient presents with altered level of
consciousness or unconscious or this occurs during the course of care

act on Glasgow coma score less than 14

escalate immediately a drop of 2 or more in Glasgow coma score since the
last assessment interval

notify MO immediately of a score of 13 or less in a child

remember less than 8 consider intubation
File 15 Cardiorespiratory arrest (adult and child)
Shock
Recommend
 The aim of management for someone in shock is to replace lost fluid to achieve
systolic BP > 100mm Hg and treat cause
 O2 saturation readings in shock can be unreliable due to peripheral shut down
Background
 Shock is a clinical state in which hypotension occurs due to haemorrhage / cardiac
failure or vascular tone and / or inadequate tissue perfusion. The patient in shock
looks pale and the body tries to make sure enough blood reaches vital organs
such as the brain, heart, and liver by diverting it from e.g. the skin and the kidneys.
Many organs can stop working
 There are different types of shock

hypovolaemic shock - due to a large amount of blood or fluid loss
from the circulation eg from blood loss, late stages of dehydration in
gastroenteritis [9]

cardiogenic shock - following heart pump failure after a massive heart
attack

septic shock – when the body is overwhelmed by infection the vessels
dilate and lose tone

obstructive shock - occurs with tension pneumothorax, massive
pulmonary embolism and pericardial tamponade

anaphylactic shock – caused by allergic reaction

spinal shock – follows transection of the spinal cord (warm shock)
Related topics:
DRABC resuscitation / the collapsed patient, page 35
 Cardiac arrest, cardiorespiratory arrest, adult / child, pages 40 - 44
 Severe injuries, chest injuries, abdominal injuries, spinal injuries, pages 95 - 113
 Burns, page 147
 Fractures, page 116
 Acute wounds, page 131
 Nosebleed, page 162
Upper gastrointestinal bleeding, page 171
 Anaphylaxis, page 60
 Heart attack, page 79
Tubal / ectopic pregnancy, page 406
 Gastroenteritis, page 565
1.
May present with:

Increased heart rate (tachycardia)

Increased respiration rate (tachypnoea) – “air hunger”

Poor capillary refill

Very low or high temperature

Low blood pressure (the level will vary)

Skin – pale and clammy (cool, moist) – in hypovolaemic shock, capillary return
> 2 seconds

Warm peripheries (hands and feet) – in septic shock

Decreased urine output

Anxious, confused, drowsy, unconscious
File 15 Cardiorespiratory arrest (adult and child)

2.
As part of clinical picture of most conditions that can be regarded as
emergencies e.g. Severe Injuries, Burns, Fractures, Acute Wounds, Nosebleed,
Upper Gastrointestinal Bleeding, Septicaemia, Heart Attack, Tubal/Ectopic
Pregnancy
Immediate management:
Call for help if available
Manage DRABC resuscitation / the collapsed patient

Take emergency history from patient, relatives / friends, if present

Give high flow oxygen (see O2 Delivery systems) to maintain O2 saturation
>94%. If >94% not maintained consult MO

In case of fracture or bleeding wound, stop any external bleeding by direct
pressure and pressure bandaging

Check and monitor BP and heart rate, respirations, O 2 saturation, BGL,
temperature

Check and monitor conscious state - Glasgow coma scale or AVPU

Insert large bore IV cannula (14 g or 16 g, if possible). See diagram for veins
most easily found and cannulated.

Insert the largest IV cannula you can in the circumstances, which may not be
very big, as the patient is often shut down with veins hard to find.
If intravenous access is unable to be established or is likely to be difficult and
time consuming, intraosseous infusion provides a route for the administration of
parenteral fluids and drugs in life threatening situations. This technique is
applicable to both adults and children. See Intraosseous infusion

If unable to access IV or intraosseous route consult MO immediately

For all causes of shock except for cardiogenic shock it is usual to start with IV
Normal Saline or Hartmann’s. MO will advise quantities and rate. The aim is to
keep:
Adults

Heart Rate <120/min

Systolic BP >90 - 100 mm Hg

Urine Output >0.5 ml/kg/hr

Children compensate very well in the early stages of shock, but can
decompensate rapidly

Consult MO as soon as possible

3.
Clinical assessment:

Obtain patient history including circumstances that may suggest the cause of
shock

Perform standard clinical observations with particular attention on BP, urine
output, temperature, Glasgow coma scale or AVPU, capillary refill
4.
Management:

Consult MO as soon as possible, who will organise evacuation / hospitalisation

Monitor clinical status and response to intervention - BP and heart rate,
respirations, O2 saturation, BGL, temperature, Glasgow coma scale or AVPU

If injured and shocked and not obvious where blood has been lost, suspect
internal bleeding:

chest (haemothorax), see Chest injuries

abdomen (ruptured spleen/liver/kidneys, fractured pelvis) see Abdominal
injuries

fractured humerus (forearm) or femur (thigh), pelvis, see Fractures
File 15 Cardiorespiratory arrest (adult and child)

Manage in consultation with MO as per:

severe injuries, chest injuries, abdominal injuries, spinal injuries

burns

fractures, acute wounds

nosebleed, upper gastrointestinal bleeding

anaphylaxis

heart attack

tubal / ectopic pregnancy

acute gastroenteritis
5.
Follow up:
 According to possible cause for shock
 Patient will need evacuation / hospitalisation in suitable equipped facility
6.
Referral / consultation:
 Consult MO on all occasions of shock
File 15 Cardiorespiratory arrest (adult and child)
File 15 Cardiorespiratory arrest (adult and child)
File 15 Cardiorespiratory arrest (adult and child)