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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
CARDIOPULMONARY RESUSCITATION
AND EQUIPMENT - CHW
PRACTICE GUIDELINE
©
DOCUMENT SUMMARY/KEY POINTS
The phone number for calling the Arrest Team is 444
•
On discovering a collapsed or seriously unwell person, use the DRSABCD approach to
Basic Life Support, call the Arrest Team for help and start Advanced Life Support when
appropriate staff arrive.
•
If you are in a ward area - dial 444 and state "Send the Arrest Team to …" and state
the ward, level and patient location.
•
If you are in a non-ward area - dial 444 and state "Send the Mobile Arrest Team to
…" and state the patient location and level.
•
The ward and mobile arrest trolleys all have the necessary equipment for Advanced Life
Support management of an arrested patient from a newborn through to an adult.
This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure and Guideline Committee
1st July 2014
Chair of CHW CERS Committee
Review Period: 3 years
Area/Dept: CERS Committee
Date of Publishing: 24 June 2014 4:34 PM
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Page 1 of 45
Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
CHANGE SUMMARY
•
Updated link to the CHW Ward Resuscitation Trolley checklist (Appendix 12)
•
Table 5, under mobile arrests, the anaesthetic registrar needs to only attend mobile
arrests during out-of-hours time periods (i.e. outside of Mon – Fri, 08:00 – 23:00).
READ ACKNOWLEDGEMENT
•
All staff should be familiar with the section on Basic Life Support and how to call for help
from the Arrest Team.
•
All clinical staff should be familiar with the whole document.
This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure and Guideline Committee
1st July 2014
Chair of CHW CERS Committee
Review Period: 3 years
Area/Dept: CERS Committee
Date of Publishing: 24 June 2014 4:34 PM
Date of Printing: 24 June 2014
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Page 2 of 45
Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
The phone number for calling the Arrest Team is 444
Algorithm A: BLS
Paediatric Basic Life Support (BLS) for Healthcare Workers
D
R
S
Check for DANGER - Hazards / Risks / Safety
Assess for RESPONSE
SEND (or call) for HELP
A
Open and Clear AIRWAY – Head tilt/chin lift, Jaw Thrust
B
Assess BREATHING – Look / Listen / Feel
If patient unresponsive and not breathing normally then GIVE 2 RESCUE BREATHS
C
Assess CIRCULATION - Commence COMPRESSIONS if:
patient is unresponsive and not breathing normally
AND
pulse not palpable within 10 seconds or < 60 beats/min (with poor perfusion)
Compression: Ventilation ratio 15:2
Compressions Depth: 1/3 of the chest wall
D
Compression Rate: 100 beats/min
Hand Position: lower half sternum
Attach monitor/DEFIBRILLATOR as soon as possible ASSESS RHYTHM
Refer to Section 1.1 for explanatory notes.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Algorithm B: ALS
Paediatric Advanced Life Support (ALS) for Healthcare Workers
Attach defibrillator/monitor
Assess rhythm
Shockable
VF/Pulseless VT
Non-shockable
Aystole/PEA
ADRENALINE DOSE
10 mcg/kg =
0.1 mL/kg 1:10,000
DC shock 4J/kg
immediately
2 min CPR then check
for ROSC
Ventilate with high flow
oxygen, consider
intubation I.V /I.O
DC shock 4J/kg
then ADRENALINE 10 mcg/kg IV/IO
Continue CPR, ventilate with high flow
oxygen, I. V. access & consider intubation
Consider and Correct
4Hs
Hypoxaemia
Hypovolaemia
Hypo/hyperkalaemia/metabolic
Hypo/hyperthermia
4Ts
ADRENALINE
10 micrograms/kg IV/IO
immediately then
every 4 mins
4 min CPR
Check rhythm &
ROSC every 2 min.
Tamponade, cardiac
Tension pneumothorax
Thromboembolism
Toxins/poisons/drugs
2 min CPR then check rhythm & ROSC
DC shock 4J/kg
then AMIODARONE 5 mg/kg IV/IO
2 min CPR then check rhythm & ROSC
Maximum / Adult Doses
DC shock 4J/kg
then ADRENALINE 10 mcg/kg IV/IO
2 min CPR then check rhythm & ROSC
2 min CPR then check
rhythm & ROSC
DC shock 4J/kg
Adrenaline: 1mg
Amiodarone: 300 mg
Joules: 1st dose 200J
2nd dose 300J
3rd & subsequent doses 360J
Adult BLS always 30:2
ROSC=Return of Spontaneous Circulation
Refer to Section 1.4 for explanatory notes.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
TABLE OF CONTENTS
Algorithm A: BLS .................................................................................................................. 3
Paediatric Basic Life Support (BLS) for Healthcare Workers ................................................... 3
Algorithm B: ALS .................................................................................................................. 4
Paediatric Advanced Life Support (ALS) for Healthcare Workers ............................................ 4
1
Cardiopulmonary Resuscitation in a Ward Area ...................................................... 7
1.1
BLS Algorithm Explanatory Notes ................................................................................. 7
Technique for External Cardiac Compressions ................................................................... 8
Table 1: Summary of CPR technique ................................................................................ 10
1.2
Nursing Roles in a Ward Arrest before Arrest Team arrives ....................................... 10
1.3
Ward Arrest Team Members & Roles .......................................................................... 10
Table 2: Ward Arrest Team Members and Roles .............................................................. 11
1.4
Advanced Life Support (ALS) ...................................................................................... 12
1.5
ALS Algorithm Explanatory Notes ............................................................................... 12
1. Shockable Rhythm: Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia
(VT) ....................................................................................................................................12
Table 3: Defibrillation Doses for Children .......................................................................... 13
Table 4: Defibrillation Doses for Adults.............................................................................. 13
2. Non-Shockable Rhythm: Asystole or Pulseless Electrical Activity................................. 13
1.6
Special Circumstances ................................................................................................ 14
Supraventricular Tachycardia (SVT).................................................................................. 14
Special Circumstances in PICU ......................................................................................... 14
1.7
Disposition Following Ward Arrest ............................................................................... 16
2
Resuscitation in a Non-Ward Area: 'Mobile Arrests' ............................................. 17
Disposition following Mobile Arrest .................................................................................... 17
Table 5: Mobile Arrest Team Members and Roles ............................................................ 18
3
The Deteriorating Child ............................................................................................. 19
4
References ................................................................................................................. 20
Appendix 1: Switchboard Flowchart for ‘444’ calls .......................................................... 21
Appendix 2: Contents of Resuscitation Trolleys .............................................................. 22
Appendix 3: Contents of Resuscitation Drug Kit .............................................................. 24
Adenosine (Adenocor®) ..................................................................................................... 24
Adrenaline .........................................................................................................................24
Anginine® ...........................................................................................................................25
Amiodarone (Cordarone®) ................................................................................................. 25
Aspirin (Aspro Clear®) ........................................................................................................ 25
Atropine Sulphate: ............................................................................................................. 25
Calcium Chloride 10% ....................................................................................................... 25
Glucose .............................................................................................................................25
Glyceryl Trinitrate (Anginine®) ........................................................................................... 25
Lignocaine .........................................................................................................................26
Naloxone (Narcan®) .......................................................................................................... 26
Sodium Bicarbonate .......................................................................................................... 26
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Sodium Chloride 0.9% (Normal Saline) “Posiflush” ........................................................... 26
Water for Injection.............................................................................................................. 26
ICU/ED Drug Pack ............................................................................................................ 27
Adrenaline .........................................................................................................................27
Midazolam .........................................................................................................................27
Propofol .............................................................................................................................27
Suxamethonium ................................................................................................................. 27
Thiopentone .......................................................................................................................27
Vecuronium........................................................................................................................27
Glucagon ...........................................................................................................................27
Hydrocortisone................................................................................................................... 27
Promethazine..................................................................................................................... 27
Appendix 4: Bedside Emergency Equipment Drawer Contents List ............................... 28
Appendix 5: Location and Features of Lifepak 20 Defibrillators ..................................... 29
Appendix 6: Resuscitation Trolley Action after an Arrest ................................................ 30
Appendix 7: Defibrillator: State of Readiness/ Use of Monitor ........................................ 31
A: State of readiness .............................................................................................................. 31
B: Use of Monitor on the LIFEPAK 20 .................................................................................... 31
Appendix 8: Manual Defibrillation ...................................................................................... 33
QUIK-COMBOTM Electrode Pad Placement ........................................................................... 33
Defibrillation Procedure .......................................................................................................... 34
Synchronised Cardioversion Procedure ................................................................................. 35
Appendix 9: Temporary Transthoracic Non-Invasive Cardiac Pacing ............................ 36
Procedure for Asynchronous (non-demand) Non-Invasive Transthoracic Pacing ............. 36
Procedure for Synchronous (demand) Non-Invasive Transthoracic Pacing ...................... 37
Appendix 10: Contents of Mobile Arrest Trolley/Pack ...................................................... 38
Appendix 11: CERS Protocol Flowchart ............................................................................ 40
Appendix 12: Resuscitation Trolley Maintenance ............................................................. 41
Daily Checks ..........................................................................................................................41
After an Arrest ........................................................................................................................42
Appendix 13: Defibrillator Maintenance and Warnings .................................................... 43
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
1
Cardiopulmonary Resuscitation in a Ward Area
In the event of a presumed cardiac arrest, resuscitative measures must be commenced
immediately by any nursing and medical staff present. The only exception to this is when the
patient’s medical records clearly state ‘not for resuscitation’ usually in an “Allow a Natural
Death” form (See CHW policy “Allow a Natural Death by Limiting the Use of Life-Sustaining Treatment”) .
On discovering a collapsed person, commence basic life support (BLS) as per the Paediatric
BLS Algorithm above.
1.1
BLS Algorithm Explanatory Notes
D: Danger
Approach cautiously checking for hazards, risks to your safety.
Remember standard precautions e.g. gloves
R: Responsiveness
Attempt to get a response from the patient by calling their name or
providing tactile stimulus. If there is no response, then
S: Send (or call) for Help by:
1. Pressing Emergency/Arrest button
o
o
On hearing the emergency / arrest call, all available ward nursing and medical staff
present should respond.
The first person to pass the resuscitation trolley should collect it and deliver the trolley to
the room. If assistance is slow in arriving, leave the patient briefly to collect the
resuscitation trolley and return to the patient to commence basic CPR until assistance
arrives.
2. Dialling 444 to summon the Arrest Team (see Appendix 1)
o
If you are in a ward area - dial 444 and state "Send the Arrest Team to …" and state the
ward, level and patient location. e.g.: "Send the arrest team to Clancy ward, level 3, bed
19". This arrest page should be put out for all arrests, adult or paediatric, which occur in
the ward area.
o
Except:
o
o
Airway
Breathing
Grace Centre for Newborn Care: In the event of a non-neonatal arrest summon a
mobile arrest team - dial 444 and state "Send the Mobile Arrest Team to Grace
Neonatal Nurseries, level 3, bed x"
Hall Ward: For all arrest calls dial 444 and state "Send the Mobile Arrest Team to
Hall Ward, level 1, bed x"
Clear the airway with simple airway manoeuvres (head tilt and chin lift
or jaw thrust) and suction the oropharynx as necessary. Consider
insertion of an appropriately sized oropharyngeal (Guedel) airway.
Check the breathing by looking for chest movement and listening and
feeling for breaths from the patient's mouth and nose for 10 seconds.
If the person is breathing spontaneously and effectively, but remains
unresponsive, continue to maintain an open airway, apply oxygen and
await the arrival of the arrest team.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
If the patient is not breathing normally, provide 2 rescue breaths.
These breaths should be delivered slowly over 1-1.5 seconds each in
order to reduce gastric distension.
Note: The Hospital recommends that a self-inflating resuscitation bag be used
to ventilate the patient. Mouth-to-mouth/mouth and nose is not recommended.
If a self-inflating resuscitation bag is not immediately available, pocket masks
can be obtained in fire hydrant cupboards marked by the symbol opposite.
Circulation
Check the pulse for 10 seconds. (The second nurse on the scene should perform this
duty). The pulse is best assessed in the following places:
o
Infants (<12 months) - femoral or brachial pulse.
o
Child/Adult (>12 months) – carotid, femoral or brachial pulse.
If there is an adequate pulse, recheck the breathing and, if spontaneous breathing
has not resumed, continue bag-valve-mask ventilation with a self-inflating
resuscitation bag connected to high flow oxygen (greater than 14L/min) at a rate of 12
-20 breaths per minute (1 breath every 3-5 seconds)
Start chest compressions if:
o
Patient unresponsive and not breathing normally, AND
o
No palpable central pulse, OR
o
A slow pulse (< 60 beats per minute with poor perfusion)
Technique for External Cardiac Compressions
1. Place a cardiac arrest board under the patient. Cardiac compressions should be
performed by the second nurse on the scene initially, but this role can be reassigned as
required.
2. To assist with resuscitation procedures the bed/cot needs to be pulled out from the wall
and the head of the bed/cot removed or lowered. Alternatively a patient in a cot can be
turned sideways across the mattress. The height of the bed may also need to be
adjusted to facilitate correct technique.
3. Method of Chest Compression.
o
For all age groups compress over the lower half of the sternum.
o
For all age groups compress approximately one third the anterior-posterior
diameter (depth) of the chest.
o
Infants and Neonates (0 to 12 months): Chest compressions for an infant can be
performed with the two-finger or the two thumbs encircling technique. In the latter,
the rescuers’ hands encircle the chest and the thumbs compress the sternum.
The two-thumb technique is the preferred technique for two healthcare rescuers.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
The two finger technique remains acceptable and may be used by a single
rescuer in order to minimise the transition time between chest compression and
ventilation.
o
Child (defined as all paediatric patients from 1 year to 18 years of age): Chest
compressions can be performed with the heel of one hand or the two handed
technique, whatever is required to compress the chest to one third the depth of
the chest.
o
Adult: Use the two handed technique i.e. the heel of one hand on the
compression site over the lower half of the sternum, with the other hand on top.
4. Compression Rate
o
For all age groups the compression rate is 100 compressions per minute (i.e. 1
compression every 0.6 seconds or nearly 2 compressions per second)
5. Ventilation to Compression Ratio
o
One or more healthcare rescuers
For all infant and paediatric patients: 15 compressions to every 2 ventilations
For all adult patients: 30 compressions to every 2 ventilations
o
The compressions should pause while the ventilation is delivered for a nonintubated patient. Compressions should restart during the second expiration.
(Note that with pauses for ventilation, the actual number of compressions will be
less than 100/min.) Once the airway is secured with an endotracheal tube there is
no need to pause for ventilations.
o
Ventilate at a rate of 10-12 /min during CPR to match ventilation with perfusion.
Increase ventilations to 12-20/min after Return of Spontaneous Circulation
(ROSC). Care should be taken to avoid hyperventilation which causes cerebral
vasoconstriction. Appropriateness of ventilation rate can be assessed with
endtidal CO2 monitoring or blood gases.
6. To achieve effective CPR:
o
Push hard
o
Push fast
o
Allow complete chest recoil between compressions
o
Minimise interruptions to compressions
If compressions are effective they should generate enough blood flow to enable a
central pulse to be palpated during compression.
Note: For a newborn within 2 hours of birth eg baby delivered in our Emergency Department,
use compression to ventilation ratio of 3:1 and compression rate of 120/min.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Table 1: Summary of CPR technique
INFANT
CHILDREN > 1YR
ADULTS
Airway Position
Neutral
Sniffing
Sniffing
Pulse check
Brachial or femoral
Carotid, femoral or
brachial
Carotid, femoral
or brachial
Chest Compression
Landmark
Chest Compression
Technique
Chest Compression
Depth
Chest Compression
Rate
Compression to
Ventilation Ratio
1.2
Lower ½ of sternum
2 fingers or 2
thumbs encircling
1 or 2 hands
2 hands
1/3 chest depth
100/min
15:2
15:2
30:2
Nursing Roles in a Ward Arrest before Arrest Team arrives
•
On hearing the emergency/arrest call all ward staff should respond.
•
The first person to pass the resuscitation trolley should collect it and bring to room (see
Appendix 2 & Appendix 3)
•
A limited supply of bedside emergency equipment is kept at the patient bedside in all
general wards. The equipment is located in the left hand drawer of the bedside locker
directly below the wall oxygen outlet. Equipment has been standardised (see Appendix
4) to support the commencement of basic life support until additional resources are
obtained.
•
First nurse on scene - assess patient responsiveness, press emergency / arrest button,
assess airway and breathing and commence bag-valve-mask ventilation if required.
•
Second nurse on scene – Call, or assign an assistant to call, '444' to activate the arrest
team. Then assess circulation and commence external cardiac massage if required
•
Third nurse on scene - Collects defibrillator from nearest defibrillator location (as
indicated on chart behind resuscitation trolley) (see Appendix 5). Ensures all monitoring
is connected (ECG, SaO2 and BP).
1.3
Ward Arrest Team Members & Roles
•
If arrest team members are unavailable, it is their responsibility to ensure they have
arranged appropriate cover should an arrest be called.
•
All team members must report to the arrest team leader when arriving at the arrest.
•
Refer to Table 2 below for role details.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Table 2: Ward Arrest Team Members and Roles
Ward Arrest Team
Member
Medical Registrar
(Advanced
Trainee Medical
Registrar - night
shift only):
Arrest Team Leader
PICU Registrar:
Circulation Doctor
Anaesthetic
Registrar: Airway/
Breathing Doctor
Medical Resident
PICU Nurse
Ward Nurse:
Nurse Team Leader (TL)
Ward Nurse:
Airway Nurse
Ward Nurse:
Circulation Nurse
(may require 2-3 nurses)
Ward Nurse:
Scribe
Senior Nurse
Manager
Social Worker
Roles
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Assume primary responsibility for resuscitation & direction of all individual personnel
Co-ordinate resuscitation efforts: Airway, Breathing, Circulation, Disability (CNS)
Liaise with Attending Medical Officer and team
Co-ordinate disposition of patient
Ensure completion of documentation on arrest form
On night shift (2230-0830hrs) the Advanced Trainee Medical Registrar will assume the team
leader role and delegate tasks to the Medical Registrar
Obtain IV access & blood specimens
Responsible for fluid administration
Monitor ECG and cardiac output
Push bolus medications during arrest sequence
Liaise with ICU to organise disposition of patient
Airway management
Ventilation
Monitor CNS status
Accompany patient to final disposition if ventilated
Obtain history & other information from clinical notes & attending staff & family
Assist with vascular access, blood sampling and documentation as designated
Bring arrest drug pack from ICU
Responsible for co-ordinating and overseeing nursing management of the resuscitation
Accompany patient during transport to final disposition
Handover to arrest team leader (may be done by nurse looking after patient)
In consultation with PICU nurse allocate nurses to primary roles of airway, circulation & scribe
Coordinate additional resources as required e.g. equipment, runner & personnel at local level
Maintain safe environment for patients/families/staff in consultation with Senior Nurse Manager
Ensure Resuscitation Trolley is restocked after the arrest (see Appendix 6)
Assemble necessary equipment for airway management from resuscitation trolley
Prepare suction & high flow oxygen
Ensure scribe is informed of ETT size, location & length at lips
Assist with chest compressions if required
Arrange for “Resus Drug Calculator” to be printed from intranet based on patient’s weight
Set up for IV cannulation/IO access
Prepare & label drugs for intubation & resuscitation as directed, with a 2nd RN check
Document all drugs & fluids administered, observations, interventions
Do not leave the foot of the bed to do other procedures unless instructed by TL
Reallocate nursing staff to ensure nursing care of patient throughout resuscitation & relocation
Provide communication link between resuscitation scene and rest of hospital
Maintain resuscitation nursing team to established number and roles.
Arranges ambulance transfer to Westmead hospital for adult arrests as required.
Designate nursing staff to accompany patient to receiving unit
In absence of Social Work staff performs functions described for Social Worker below.
Ensures documentation is completed and forwarded appropriately.
Ensures maintenance of patient privacy.
Assist family to a designated area
Counsel & support family throughout resuscitation
Ensure follow-up dependent on outcome of resuscitation
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Note:
•
PICU consultant /fellow (when available) – provide support for registrar
•
In the event of an arrest in the ED the Emergency Consultant / Fellow (when available)
will be Team Leader. In their absence the ED Registrar will be Team Leader.
1.4
Advanced Life Support (ALS)
Once BLS has been commenced, attach the monitor or LIFEPAK 20 (see Appendix 7) as
soon as available as advanced life support treatment is guided by the cardiac rhythm. The
choice and sequence of drugs, defibrillation and other therapy is indicated in Algorithm B on
page 4.
1.5
ALS Algorithm Explanatory Notes
1. Shockable Rhythm: Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT)
Defibrillation is a recommended means of terminating certain potentially fatal arrhythmias.
Defibrillation is only one aspect of the medical care required to resuscitate a patient with a
shockable electrocardiograph (ECG) rhythm. Other supportive measures include effective
CPR, administration of oxygen and drug therapy.
When the rhythm is assessed, if VF or pulseless VT is present, then a 4 J/kg shock should
be delivered as soon as possible (see Appendix 7 & Appendix 8). Whilst preparing to
defibrillate, chest compressions should be recommenced and continue whilst charging the
defibrillator. When the defibrillator is charged, the operator should clearly state "STAND
CLEAR" and confirm visually that everyone is clear of the patient and bed and that any
oxygen delivery device has been removed, then the first shock is delivered. Chest
compressions and ventilations should resume immediately WITHOUT rechecking the rhythm
at that point.
During CPR (near the end of the 2 min cycle) the defibrillator should be recharged so that, if
on reassessment of the rhythm, another shock is required, this can be given immediately
without a second pause to recharge. After the 2 minutes, chest compressions should be
briefly paused so reassessment of the rhythm can occur, with simultaneous check for Return
of Spontaneous Circulation (ROSC). If VF or pulseless VT is still present, then a second 4
J/kg shock should be delivered. If a second shock is not required, the charge should be
“dumped” by pressing the “Speed Dial” button or the “Energy Select” button.
After the second shock, adrenaline (dose 10 mcg/kg i.e. 0.1 mL/kg 1:10,000) should be
administered either intravenously (IV) or intraosseously (IO). Chest compressions should
continue for another 2 minutes, and the defibrillator should be recharged, then pause briefly
to reassess the rhythm and, if still in a shockable rhythm, a third 4 J/kg shock should be
delivered. Following the third shock, amiodarone (dose of 5 mg/kg) should be given IV or IO.
Lignocaine is second line treatment and should only be used if amiodarone is unavailable. If
a fourth shock is required, adrenaline should be given after the shock has been delivered
and then again after every subsequent second shock.
Occasionally other drugs may be considered e.g. magnesium for torsade de pointes.
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Table 3: Defibrillation Doses for Children
Mode
1st dose
2nd & all subsequent doses
VF, Pulseless VT
asynchronous
4 J/kg
4 J/kg
VT with pulse or SVT
synchronous
1 J/kg
2 J/kg
Rhythm
Table 4: Defibrillation Doses for Adults
(use these as maximum paediatric doses)
Rhythm
Mode
1st dose
2nd Dose
3rd Dose
VF, Pulseless VT
asynchronous
200J
300J
360J
VT with pulse
synchronous
100
200J
(4 and all subsequent doses
up to maximum of 360J)
SVT
synchronous
50J
100J
150J
300J
th
2. Non-Shockable Rhythm: Asystole or Pulseless Electrical Activity
If a non-shockable rhythm (asystole or pulseless electrical activity (PEA)) is present then
CPR should recommence. Adrenaline (dose of 10 mcg/kg ie 0.1 mL/kg 1:10,000) should be
given immediately either IV or IO. The rhythm should be reassessed every 2 minutes, with
simultaneous check for ROSC. Chest compressions must be paused briefly if a pulse check
is performed but do not delay returning to chest compressions by prolonged pulse check.
The key time to recheck the pulse is when there is a change in the rhythm, or when the
rhythm is one that could either have a pulse or not eg sinus rhythm & PEA, or VT. The same
dose of adrenaline should be given every 4 minutes (every 2nd loop of rhythm review). In the
absence of IV or IO access, only adrenaline may be given via the endotracheal tube (dose of
100 mcg/kg).
If the rhythm converts to a shockable rhythm then the VF/pulseless VT algorithm should be
followed.
It is fundamental that whilst performing CPR potential reversible causes are assessed for
and corrected if found. Causes include the classic “4Hs and 4Ts”: hypoxaemia,
hypovolaemia, hypo/hyperkalaemia, hypo/hyperthermia, tension pneumothorax, pericardial
tamponade, thromboembolism, and toxins/poisons/drugs. Intravascular volume expansion
with crystalloid (0.9% saline) or colloid (most commonly 4% albumin) 20 mL/kg should be
given. Bloods including a bedside glucometer reading and VBG should be taken and any
significant abnormalities corrected. Bicarbonate (dose 1 mmol/kg) may be used in certain
circumstances e.g. hyperkalaemia or tricyclic antidepressant overdose, or occasionally in a
prolonged arrest with severe acidosis once effective ventilation has occurred. A FAST
(Focused Abdominal Sonography in Trauma i.e. limited bedside ultrasound) looking for
pericardial fluid may be performed if appropriate.
Occasionally other drugs should be considered e.g. atropine (dose 20 mcg/kg) in bradycardia
with poor output that has been precipitated by vagal overactivity. Pacing may also be
required for bradycardia (see Appendix 9).
Resuscitation should continue until there is ROSC or a decision to terminate the resuscitation
is made. The question of when to terminate resuscitation is difficult. It depends on the patient
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and the cause of the arrest, but generally speaking, if there has been no ROSC after 20-30
minutes of good resuscitation efforts, the outcome will be extremely poor.
Post-Resuscitation Care
After successful resuscitation, ongoing management includes attention to oxygenation, CO2
control, temperature control, glucose, electrolytes and fluid balance.
1.6
Special Circumstances
Supraventricular Tachycardia (SVT)
SVT is the most common tachydysrhythmia seen in childhood. It can cause severe
hypotension and a state of shock, particularly in infants where presentation may be delayed.
This dysrhythmia is normally characterised by a relatively fixed rate, narrow QRS complex
and often a sudden onset and offset. In infants the rates are usually faster, around 220-300
beats per minute, compared with that seen in children who have rates of around 180 beats
per minute.
If the patient is cardiovascularly stable, vagal stimulation may be attempted to revert to a
sinus rhythm. In a neonate or young child this is achieved by application of a cloth soaked in
ice water to the face, whilst an older child may be asked to perform a Valsalva manoeuvre or
unilateral carotid massage. Pressure on the eye ball should NOT be performed to generate a
vagal stimulus.
Pharmacological cardioversion is typically required and adenosine is the drug of choice. As it
is a very short acting drug, a large bore cannula in the cubital fossa is required with a flush of
0.9% NaCl (2-5mL depending of the size of the child). The flush is needed to ensure that the
drug is rapidly administered into the circulation. Ideally a three-way tap should be placed at
the end of the cannula, both syringes loaded onto the three-way tap so the adenosine can be
immediately followed by the flush. The initial dose of adenosine is 0.1 mg/kg, but if ineffective
then the dose should be increased by 0.1 mg/kg increments to a maximum of 0.3 mg/kg
(may consider increasing to 0.5 mg/kg after consultation with cardiology). Of note adenosine
is contraindicated in patients with Wolf Parkinson White syndrome as it may precipitate VF or
“torsades de pointes”. The cardiology team should be informed of a patient in SVT and they
will aid in the management of this child.
If the patient is cardiovascularly unstable, severely hypotensive or pulseless, then
synchronised shock should be delivered immediately starting with 1 J/kg and increasing to 2
J/kg for the next and all subsequent doses. (see Table 3 & Table 4 and Appendix 8)
Special Circumstances in PICU
Witnessed VF or pulseless VT
If a patient in the PICU converts to VF or pulseless VT, with monitoring and a defibrillator at
the bedspace, a DC shock of 4 J/kg should be administered immediately, before CPR has
commenced. If the defibrillator is not at the bedspace or if there are any delays to the
delivery of the first DC shock, then CPR should be started and the ALS algorithm followed.
Cardiac Tamponade
Cardiac tamponade is a rare cause of cardiac arrest but may occur, particularly in the setting
of post-operative cardiac surgery. Tamponade may follow the recent removal of transthoracic
lines and may be preceded by a sudden change in chest drainage, either an increase or
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sudden cessation of flow. If an arrest has occurred secondary to tamponade then it needs to
be immediately relieved either by emergency reopening of the chest in the post-operative
cardiac surgical patient or needle pericardiocentesis in other patients. Discussion with the
intensivist and surgeon is mandatory.
Internal Cardiac Compression
Internal cardiac compression (open heart massage) may rarely be necessary in
postoperative cardiac patients who have had an emergency sternotomy before or during
cardiac arrest to diagnose and manage acute tamponade, cardiac perforation or
haemorrhage. It is more effective than external cardiac compression and may deliver near
normal perfusion to the brain and heart. Internal cardiac compression should ONLY be
performed by a cardiac surgeon. The ECG is obtained using chest leads or defibrillator
paddles. Pharmacotherapy or immediate DC shock is applied depending on the existing
arrhythmia, while cardiac compression and mechanical ventilation with oxygen are
maintained.
Internal Cardiac Defibrillation
If internal cardiac defibrillation is indicated, the internal therapy cable for internal defibrillation
is stored in the PICU Chest Opening Trolley and contains four defibrillator paddle sizes.
Internal defibrillation procedures are found in the guidelines: Internal Defibrillation Paddles:
Testing and Preparation in Operating Theatres.
Renal Replacement Therapy
If a cardiac arrest occurs while a child is on Continuous Veno-Venous Haemofiltration
(CVVH), this therapy should be continued except if hypovolaemia is suspected or confirmed
to be responsible for the cardiac arrest. For further details, consult the PICU CVVHDF
Practice Guideline.
Cessation of Resuscitation
Cardiac arrest in children has a particularly poor outcome. In the ICU, because of the rapidity
of intervention, some children who in other settings may have died, may be successfully
resuscitated. The decision to stop resuscitation is based on a number of variables including
the pre-arrest state, response to resuscitation, reversible factors, patient and parental
wishes, likely outcome and opinions of experienced staff. In the ICU the attending intensivist
is responsible for the decision to terminate resuscitation and should always be consulted
before resuscitative attempts are abandoned.
Documentation during a PICU Resuscitation
•
Documenting nurse enters the Resuscitation field of the CCIS record.
•
‘Chart Now’ and document commencement of cardiac massage (External Cardiac
Compressions, in cell attached to rhythm), rhythm and validate or enter other
observations. Rhythm should be documented at regular intervals.
•
Minutely observations are recorded during the resuscitation.
•
Drugs administered are recorded in appropriate cells (on the Medication Sheet field
after selecting the cardiac arrest button).
•
Information about change in respiratory support (i.e. intubation) is recorded.
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•
Following a resuscitation, nurse or medical officer verifies at least 5 minutely
observations for the half-hour prior to the cardiac arrest. Temperature and end-tidal CO2
prior to the cardiac arrest are useful parameters to include.
•
If deterioration is thought to have commenced prior to this half-hour, 15 minutely
observations are verified by nurse or medical officer.
1.7
Disposition Following Ward Arrest
Children
•
Inpatient - may be appropriate to remain on the ward after discussion with PICU. If
transfer to PICU is required the PICU nurse will organise suitable monitoring for
transport.
•
Outpatient - should be assessed by the arrest team and have emergency management
commenced and then be transferred to the Emergency Department for ongoing
management. The arrest team leader must notify the admitting officer on 52454.
Adults
•
Patients requiring ambulance transfer to Westmead Hospital (WMH)
o
Patient should be assessed and managed on the scene by the arrest team and
have urgent ambulance retrieval from the scene to WMH.
o
Senior Nurse Manager to arrange urgent ambulance retrieval to WMH.
o
The arrest team leader will alert the Admitting Officer at Westmead Emergency
Department 58222 and provide appropriate documentation.
o
In the event that WMH is only accepting life threatening only (LTO) cases, this can
be overridden if the case is discussed with and directly accepted by one of the
Emergency Physicians at WMH, phone Admitting Officer 58222.
o
If team require patient trolley, scoop or cervical spine collars the Senior Nurse
Manager to page the porter (pager number 6788) to collect them from the
Emergency Department and bring to scene.
•
Patient requiring non-ambulance transfer to WMH – patient should be assessed by the
arrest team and have their initial treatment at the scene and then be transferred to
WMH in a wheelchair with hospital porter and/ or nurse escort if appropriate, or by their
own transport if well enough.
•
Patient not requiring further hospital assessment – patient should be assessed by the
arrest team and then arrange own follow up with Local Medical Officer (LMO).
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2
Resuscitation in a Non-Ward Area: 'Mobile Arrests'
On discovering a collapsed person, commence basic life support (BLS) as per the BLS
algorithm using the DRSABCD approach (see Algorithm A). If there is any suggestion of
recent trauma (e.g.: fall from a height), when assessing responsiveness stabilise the cervical
spine by placing one hand on the forehead before gently shaking the person's hand or arm.
If patient is unresponsive, call for assistance by asking staff bystanders to dial 444.
If you are in a non-ward area - dial 444 and state "Send the Mobile Arrest Team to …" and
state the patient location and level (e.g.: "Send the mobile arrest team to the Bear Brasserie
on level 2"). This arrest page should be put out for all arrests, adult or paediatric, which occur
in a non-ward area.
One staff member should be sent out to the nearest communal area to direct the team to the
site of the arrest.
The Mobile Arrest Pack will be brought to the scene by the ED nurse. The Mobile Arrest
Pack contains the same equipment as the ward resuscitation trolleys, with the addition of a
Lifepak 20 defibrillator. (See Appendix 10)
If there is no immediate assistance available, leave the patient briefly to summon help and
then proceed as per the BLS algorithm.
Refer to Table 5 for details of roles
Disposition following Mobile Arrest
•
As outlined in “Disposition Following Ward Arrest” (Section 1.7) except it is the Mobile
Arrest Team that is responsible for the care of the patient until transfer to definitive care.
•
If arrest location is unsuitable for team to manage patient while awaiting ambulance
(e.g. patient privacy etc), transfer patient to the Emergency Department (ext 52454).
The patient’s movement to ED should be discussed with the Admitting Officer prior to
moving to ensure that a bed space is available.
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Table 5: Mobile Arrest Team Members and Roles
Mobile Arrest Team
Roles
Member
Medical Registrar:
Arrest Team Leader
Advanced Trainee Medical
Registrar (night shift only):
•
•
•
•
•
•
•
•
Assume primary responsibility for resuscitation & direction of all individual personnel
Obtain history from attending staff & family
Co-ordinate resuscitation efforts: Airway, Breathing, Circulation, Disability (CNS)
Monitor ECG and cardiac output
Liaise with attending medical officer and team
Co-ordinate disposition of patient
Ensure completion of documentation on arrest form
on night shift (2230-0830hrs) the Advanced Trainee Medical Registrar will assume the
Team Leader role and delegate tasks to the medical Registrar
Arrest Team Leader
ED Consultant/Fellow *
Anaesthetic Registrar:
Airway/ Breathing Doctor
(Does NOT need to attend
Mon-Fri 0800-2300hrs)
Medical Resident:
Circulation Doctor
ED Nurse
Senior Nurse Manager
Social Worker
Porter
Security
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Provides support for Medical Registrar
Airway management
Ventilation
Monitor CNS status
Accompany patient to final disposition if ventilated
Perform manual BP if patient has an output
Obtain IV access & blood specimens
Responsible for fluid and push bolus medication administration during arrest sequence
Assist with chest compressions if required.
Bring Mobile Arrest Trolley and drug pack from ED
Attach the ECG dots and connect the patient to the ECG monitor. A paper recording of
the patient's rhythm should be obtained.
Obtain a set of observations
Perform glucometer reading if appropriate
Prepare drugs & fluid as required
Accompany patient during transport to final disposition
Restock Mobile Arrest pack (see Appendix 10)
Readjust nurse staffing to ensure nursing care of patient throughout resuscitation & relocation
Provide communication link between resuscitation scene and rest of hospital
Maintain resuscitation nursing team to established number and roles.
Arranges ambulance transfer to Westmead hospital for adult arrests as required.
Designate nursing staff to accompany patient to receiving unit
In absence of Social Work staff performs functions described for Social Worker below.
Ensures documentation is completed and forwarded appropriately.
Ensures maintenance of patient privacy.
Assist family to a designated area
Counsel & support family throughout resuscitation
Ensure follow-up dependent on outcome of resuscitation
Brings oxygen cylinder, extraction equipment & patient trolley from ED to arrest scene
Assists with movement of patient
Assists with transfer of patient to appropriate unit for further management
Assists with movement of patient
Be available to assist ambulance paramedics to scene
Assists with bystander crowd control
Note: * When ED Consultant/Fellow unavailable (mainly on night shift) the ED cubes registrar will attend instead if able.
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3
The Deteriorating Child
•
The “deteriorating child” refers to any child whose clinical condition is felt to be
worsening; such “deterioration” will often be accompanied by alterations in one or
several of their clinical observations outside of the normal range for their age.
•
The Between the Flags program has been implemented to support clinical staff to better
recognise and manage children who are clinically deteriorating. This program involves
the implementation of five age-based Standard Paediatric Observation Charts (SPOC’s)
that incorporate a ‘track and trigger’ tool. A ‘track and trigger’ tool refers to an
observation chart that is used to record observations graphically so that trends can be
‘tracked’ visually. It also incorporates a threshold (a ‘trigger’ zone) beyond which a
standard set of actions is required if a patient’s observations breach this threshold.
•
The Clinical Emergency Response System (CERS) is the process for escalation of
concern and response required as a result of the breach. If a child’s observations are
tracked in the Blue, Yellow or Red zone on the SPOC, you should refer to the CERS
protocol ‘Recognition of the deteriorating child’ (Appendix 11) for instructions on what to
do next. When the CERS is activated, this must be documented in the child’s electronic
medical record in PowerChart.
•
Any member of the health care team may refer a child who is felt to be clinically
deteriorating on the ward to the PICU Outreach Service by paging 6664, regardless of
whether their observations are tracked in a coloured zone on the SPOC. Remember, for
children who are deteriorating acutely and who require immediate attention call 444 for
the Rapid Response Team or Arrest Team.
•
The PICU Outreach Service is coordinated by the PICU Nurse Practitioners. Referrals
will be triaged and children will be reviewed as soon as possible. The CHW policy for
Urgent Ward/ED Request for PICU Review outlines the service provided by the PICU
team. When a PICU review is requested, the PICU team will document the details of
this review in the child’s electronic medical record in PowerChart. The service also
provides ongoing follow-up for children who require close observation on the ward.
•
Additional guidelines including those whose management algorithms are laminated on
the arrest trolleys:
o
Emergency Seizure Management:
Appendix 2 in the CHW Seizure Management Practice Guideline:
http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2006-8037.pdf
o
Anaphylaxis algorithm:
http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2010-0013.pdf
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4
References
1.
2.
3.
4.
5.
6.
7.
8.
International Liaison Committee on Resuscitation (ILCOR) Resuscitation 81S (2010) e213-e287
Australian Resuscitation Council (ARC) Guidelines December 2010; www.resus.org.au
Advanced Life Support Group. Advanced Paediatric Life Support - The Practical Approach, 5th edition.
BMJ Publishing, 2010.
Medtronic Lifepak 20 Defibrillator/ Monitor with ADAPTIV Biphasic technology – Operating Instructions,
2004.
Perspectives on ADAPTIV Biphasic Technology, Medtronic 2004.
An Update on Biphasic external Defibrillation: Published Evidence from Clinical Research – April 2004,
Medtronic.
Is There a Need for Biphasic Energy Greater than 200 Joules? An Evidence – Based Approach,
Medtronic 2005.
New 2005 guidelines for Emergency Cardiovascular Care: What is the Role of escalating Energy in
Treating VF? Medtronic 2005.
Copyright notice and disclaimer:
The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in
whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done
everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. SCHN is not responsible for consequences arising
from the use of this document outside SCHN. A current version of this document is only available
electronically from the Hospital. If this document is printed, it is only valid to the date of printing.
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Appendix 1: Switchboard Flowchart for ‘444’ calls
‘444’ Phone Rings
What is the
emergency?
Rapid Response Call
Arrest Call
Who is the home team?
Non-ward Area
What is the
location?
Ward Area
Which Ward?
Which Level?
Which Department or Area?
Which Ward or Area?
Which level?
Which level?
Which Bed number?
Which Bed number?
YES
Is it in Business
Hours?
Send Message to Team Registrar:
“Rapid Response Team and XXX
(home) Team to Ward X, level Y Bed Z
NO
Send Message: “Mobile Arrest
Team to area X on level Y”
Send Message to appropriate After
Hours Registrar:
“Rapid Response Team and XXX
(home) Team to Ward X, level Y Bed Z
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Full documentation
Type of call, Date,
time, location, any
problems.
Page 21 of 45
Send Message: “Arrest Team
to Ward X on level Y Bed Z”
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Appendix 2: Contents of Resuscitation Trolleys
On Top or Attached to Rails
Description
Size
Portable oxygen cylinder, flow meter and tap
Mayo orange coloured disposable self-inflating bags Adult 1600mL & Child 500mL
Clipboard with documentation
Scissors - chained
Arrest board
Glucometer
Description
Airway Drawer
Size
Number
Small
Large
6,8,10,12 (long)
Sizes 00-4
Adult
Child
Infant
C
Yankauer suction head
Suction catheters
Guedel airways
Magill forceps
Spare batteries
Laryngoscope handles
Number
One each
One each
One each
One each
One each
One each
One each
Two each
One each
One each
Four each
Two each
Laryngoscope Straight blade
0
1
2
One each
Laryngoscope Curved blade
2
3
One each
Stethoscope
Description
Face masks -Non-latex; Laerdal type
Endotracheal introducer
One each
Breathing Drawer
Size
Sizes 0-4
Small
Medium
Large
size 2.5
size 3.0, 3.5, 4.0, 4.5,
size 5.0, 5.5, 6.0
size 6.0, 6.5, 7.0, 8.0
FG 8 & 10
Adult & child
Endotracheal tubes uncuffed
Endotracheal tubes uncuffed
Endotracheal tubes uncuffed
Endotracheal tubes cuffed
Intragastric tubes
Paedi – caps (Co2 detectors)
Lubricant
Leucoplast tape 2.5
Tincture Benz Co. swabs
Rebreathing bags with corrugated tubing, T piece
connector and O2 tubing attached
500mL and 1000mL
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Number
One each
One each
Two each
One each
One each
One each
Two each
One each
5 sachets
One roll
2 sachets
One each
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Circulation Drawer
Description
Syringes
Syringes
Syringes
Needles
Needles
Needles
Butterflies
Needle less IV caps with extension
Wide bore tubing (20-25cm long) with
attached 3-way tap
Minibore extension set with side clamp
Intraosseous needles 18g
Cannulae
Blood gas syringes
Tourniquets
Size
1ml, 2mL & 5mL,
10mL
20mL, 50mL
Blunt 18 gauge
drawing up needles
Standard 23 gauge
25 gauge needles
23g and 25g
Description
Drug Case
Fluids
152cm
18, 20, 22, 24 gauge
X-match, FBC, EUC
Drug Drawer
Size
Fluids
Decontamination plastic bag
Normal saline 1000ml
10% Glucose 500mL
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Ten each
Five each
Five each
Two each
Five each
Two each
Medi Swabs
Additive labels
Three way connectors
Blood tubes
Armboards neonatal, small & large
Blood pump sets
Burrette with IV Luer lock
Leucoplast 2.5cm
Clear tape
Medication additive labels
Number
Five each
Ten each
Two each
3 each
Two each
Five each
Five each
Two each
Twenty
each
Ten each
Two each
Two each
One each
One each
One each
One each
One each
ten
Number
One each
Two bags
One each
Two
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Appendix 3: Contents of Resuscitation Drug Kit
During an arrest the Resuscitation Doses for Children can be printed form the desktop computer, to do this:
•
Double click on the Resus drug calculator icon
on the Novell screen
Drug
Preparation on Trolley
Indications
Adenosine (Adenocor®)
3 x 6mg / 2mL ampoules
Antiarrhythmic agent - to treat
supraventricular tachycardia.
•
•
•
Enter patients weight
Click “calculate”
Click “print results
Dose
Increase in increments until
control achieved:
Dose 1: 0.1mg/kg
Route
Given as rapid IV
bolus followed by
rapid saline flush.
(Dose limit 3mg )
Dose 2: 0.2mg/kg
(dose limit 6mg )
Dose 3: 0.3mg/kg
(dose limit 12mg)
(Maximum single dose - 12mg)
Adrenaline
To treat asystole, pulseless
ARREST DOSES:
electrical activity and sinus
All doses in arrests - 0.1 mL/kg of
ETT only if IV or
bradycardia with shock (see
1:10,000 solution (10
IO unavailable
ALS Algorithm).
micrograms/kg) IV or IO
5 x 1mL ampoule of
To convert fine to coarse
Note all doses via ETT are 100
1:1000 solution
fibrillation before defibrillation.
micrograms/kg. (1mL/kg 1:10,000
(1mg/1mL)
(see ALS Algorithm)
or 0.1mL/kg of 1:1,000)
5 x 10mL ampoule of
1:10,000 solution
(1mg/10mL)
Arrests: IV/IO;
To raise the blood pressure and
improve myocardial contractility.
ANAPHYLAXIS DOSE:
Anaphylaxis: IMI
To treat anaphylactic shock.
10 micrograms/kg IMI given as
only
To treat electromechanical
0.01mL/kg of 1:1,000 solution
dissociation
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Comment
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Drug
Preparation on Trolley
Indications
Dose
Route
2 x 150mg / 3mL
Pulseless VF/VT during CPR
5 mg/kg rapid bolus during arrest
IV/IO
Link to ALS algorithm
(Maximum single dose = 300mg)
Comment
Anginine®
refer to Glyceryl Trinitrate
Amiodarone
(Cordarone®)
ampoule
For management of
arrhythmias only
administer on cardiology
advice and refer to CHW
Drug Dosages Guidelines
May cause
thrombophlebitis
Aspirin (Aspro Clear®)
Atropine Sulphate:
Calcium Chloride 10%
4 x 300mg dispersible
Suspected Myocardial
tablets
Ischaemia in adults
5 x 600 micrograms /
Sinus bradycardia which is
1mL ampoule
vagally mediated.
2 x 10mL ampoule of
10% solution
Only hyperkalaemia,
hypocalcaemia,
hypermagnesaemia and calcium
150mg (adult dose)
20 micrograms/kg
Oral
IV/IO; ETT only if
IV or IO
(Maximum Dose = 1 mg)
unavailable
0.15 mmol/kg (0.2 mL/kg)
IV/IO
NaCl before and after
(Maximum dose 10 mL)
administration.
channel blocker overdose
Glucose
1 x 50mL ampoule of
Hypoglycaemia.
Children and infants: 2-5 mL/kg
50% glucose
of 10% glucose (0.2-0.5 g/kg)
1 x 500mL bag of 10%
Adults: 25-50 mL of 50% glucose.
IV/IO
glucose (in drug drawer)
Glyceryl Trinitrate
(Anginine®)
600 microgram
Ischaemic chest pain in adults
0.5 -1 tablet sublingually, repeat in
sublingual tablets
5 minutes (adult dose).
Glyceryl trinitrate (30
ANNOTATE DATE OF OPENING,
tabs/bottle)
discard 90 days after opening
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Note: Flush IV lines with
Sublingual
Guideline No: 1/C/06:8239-01:06
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Drug
Preparation on Trolley
Indications
Dose
Route
Comment
Lignocaine
2 x 50mg/5mL ampoule
Second line treatment for
1mg/kg (0.1mL/kg of 1% solution).
IV/IO; ETT only if
Note: Flush IV lines with
(1% solution)
ventricular arrhythmias if
(Maximum dose = 100mg)
IV or IO
NaCl before and after
unavailable
administration.
amiodarone unavailable
Naloxone (Narcan®)
2 x 400 micrograms /
1mL ampoule
Narcotic overdose (post-
10 micrograms/kg
surgery).
Unconsciousness of
(Maximum dose = 2mg)
IV/IO; ETT only if
IV or IO
unavailable
undetermined origin.
Neonatal resuscitation (if mother
has been given narcotics;
NB: beware of using this in
neonates where the mother is a
chronic opiate user)
Sodium Bicarbonate
1 x 100mL vial of 8.4%
solution (1mEq/1mL)
To treat severe metabolic
acidosis of hypoxia or
1 mmol/kg (1 mL/kg)
ischaemia.
(Maximum dose = 50mL)
May be considered in prolonged
(Subsequent doses 0.5 mmol/kg)
IV/IO
NaCl before and after
administration.
arrest after adequate ventilation
with 100% 02 and external
cardiac compressions have
been established. (Poor
evidence for efficacy)
Sodium Chloride 0.9%
(Normal Saline)
“Posiflush”
5 x 10mL syringe
IV/IO
Water for Injection
5 x 10mL ampoule
IV/IO
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Note: Flush IV lines with
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Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
ICU/ED Drug Pack
These packs will be brought to the arrest scene by the ICU/ED nurse attending.
Drug
Preparation on Trolley
Indications
Dose
Route
Comment
Adrenaline
1 x 10mL ampoule of
As above
As above
As above
As above
sedation / seizures
0.15 mg/kg
IV/IO
Flumazenil is not routinely
(Maximum dose = 10mg)
Note: Respiratory
brought to the arrest
depression can
scene. It is readily
occur with I.V use.
available in PICU and
1:10,000 solution
(1mg/10mL)
4 x 1mL ampoule of
1:1000 solution
(1mg/1mL)
Midazolam
2 x 15mg/3mL ampoule
should be obtained without
delay for instances of
midazolam overdose.
Propofol
1 x 200mg/20mL
Sedation for rapid sequence
ampoule
induction (RSI)
1 – 4 mg/kg
IV
Suxamethonium
1 x 100mg/2mL ampoule
Muscle relaxant used in RSI
2mg/kg
IV
Thiopentone
1 x 500mg ampoule
Sedation for RSI
1 – 5 mg/kg
IV
Usually only used at CHW
by Anaesthetists or PICU
Beware if haemodynamically
unstable.
Vecuronium
1 x 10mg ampoule and
Longer acting muscle relaxant
1 x 4mg ampoule
for ongoing paralysis in
0.1mg/kg
IV
IMI
intubated patient.
Glucagon
1 x 1 mg ampoule
Hypoglycaemia
< 20kg – 0.5mg
Hydrocortisone
2 x 100mg ampoule
Asthma
4mg/kg
IV
0.125 – 0.5mg/kg
IM / IV
> 20kg – 1mg
Anaphylaxis
Promethazine
2 x 50mg/2mL ampoule
Antihistamine
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Appendix 4: Bedside Emergency Equipment Drawer Contents List
Non rebreather oxygen mask – child and adult
x1 each
Oxygen Tubing
Suction Catheters – FG 8,10, 12
x1
x1 each
Yankauer sucker
x1
Short size 12 suction Catheter
X1
Non-Sterile Gloves (singles)
x1
Gauze/Combine
X2
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Appendix 5: Location and Features of Lifepak 20 Defibrillators
LEVEL
Level 1
WARD
DEFIBRILLATOR
Hunter Baillie
1 standard unit
Camperdown
1 standard unit
1 standard unit + pacing
Emergency Department
Level 2
Level 3
1 standard unit + pacing on Mobile Arrest
Trolley
Cardiac Catheter Lab
(Radiology)
1 standard unit + pacing
CHISM
1 standard unit
Edgar Stevens
1 standard unit + pacing
Cardiac Theatre
1 standard unit + pacing + internal
defibrillation paddles
General Theatres
1 standard unit + pacing + internal
defibrillation paddles
Recovery
1 standard unit
Middleton Day Stay
1 standard unit
Cardiology (Stress Lab)
1 standard unit + pacing
GCNC
1 standard unit
PICU
2 standard unit + pacing + internal
defibrillation paddles
Biomedical Engineering
1 standard unit
NB: The defibrillator trolleys include the defibrillator, pads, leads and a razor.
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Appendix 6: Resuscitation Trolley Action after an Arrest
Resuscitation Trolley wiped down with 70% Chlorhexidine
All used disposable equipment discarded appropriately
Complete checklist for the trolley, identify all missing items.
Used Non disposable face masks placed in clear plastic bag
and sent to Inhalation Therapy
Used magill forceps and metal yanker sucker should be placed
in separate plastic bags and sent to CSSD
Used Laryngoscope handles if not worn and are working should
be wiped down with Chlorhexidine 70% and placed in red draw
insert
Yes
Does it occur in normal
working hours?
No
Step 1 - Contaminated re-usable equipment in
plastic bags taken to inhalation therapy or CSSD
Pharmacy box to be returned to pharmacy
Step 1 - Contaminated re-usable equipment in
plastic bags taken to inhalation therapy or CSSD
Pharmacy box to be returned to pharmacy
This can be done during normal working hours
Step 2 – Using checklist obtain the stock that is
available from the biomedical stockroom (Lvl3)
Sign and document all stock received
Step 2 – After hours biomedical stock room can be
accessed by getting keys from PICU staff Ph 51181
Using checklist obtain the stock that is available
from the biomedical stockroom (Lvl3)
Sign and document all stock received.
Step 3 –Using checklist obtain the stock that is
available from the ward area
Step 4 – Restock the trolley ensuring that all
stock is available re seal using the security tag
system.
Re seal using the security tag system.
Document the security tag number (Last 3 digits
then sign on checklist
Step 3 Using checklist obtain the stock that is
available from the ward area
Step 4 – Restock the trolley ensuring that all stock
is available re seal using the security tag system
Re seal using the security tag system.
Document the security tag number (Last 3 digits
then sign on checklist
Note: If an Arrest occurs on a ward while the resus trolley is
being restocked a Mobile arrest is to be activated
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Guideline No: 1/C/06:8239-01:06
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Appendix 7: Defibrillator: State of Readiness/ Use of Monitor
A: State of readiness
The LIFEPAK 20 should always be ready for use. This includes:
•
Defibrillator/monitor to be plugged into AC mains at all times.
•
The LIFEPAK 20 defibrillator uses QUIK-COMBO™ pacing/defibrillation /ECG electrode
pads in adult or paediatric sizes. The adult QUIK-COMBO™ electrode pads must be
connected to the therapy cable in a state of readiness at all times (except GNN);
Paediatric QUIK-COMBO™ electrode pads must be available with the machine for
patients under 15kg.
B: Use of Monitor on the LIFEPAK 20
Patients are monitored using the patient monitor cable. At CHW the LIFEPAK 20 default lead
setting is:
•
Channel 1- Lead 11
•
Channel 2- Paddles.
In an emergency situation the QUIK-COMBO™ electrode pads can be used to monitor the
patient until the cable has been attached. In this case the ECG trace will only appear on
Channel 2. To obtain trace on Channel 1, change lead select button to ‘Paddles’.
Monitoring with the Patient ECG cable
The patient can be monitored on leads I, II or III. Lead II is the default setting.
1. Press power on.
2. Patient cable should be attached to monitor at all times
3. Attach 3 electrodes to ECG dots and place on patient’s skin in positions LA, RA, LL.
(see Figure 1)
4. To print, press print (there is an 8 second delay)
Press again to stop.
Monitoring ECG with QUIK-COMBOTM electrode pads on LIFEPAK 20
Anterior –Lateral placement is the only placement that should be used for ECG monitoring
with electrodes (see Figure 2). Confirm package is sealed and use by date has not passed.
1. Place the ♥ therapy electrode lateral to the patient’s left nipple in the mid-axillary line
2. Place the other therapy electrode on the patient’s upper right torso, lateral to the
sternum and below the clavicle.
3. Connect the cable from the QUIK-COMBOTM electrode pads to the therapy cable.
4. Select paddle lead
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Figure 1:
ECG electrode placement
Figure 2:
Anterior-Lateral Placement
Selecting ECG Lead and Size
There are two methods for selecting or changing the ECG lead.
To change the ECG lead using the LEAD button:
1. Press the LEAD button
2. When the lead menu appears, press the LEAD button again or rotate the Speed Dial to
select another lead. The highlighted section shows the ECG lead.
To select or change the ECG lead using the Speed Dial.
1. Highlight and select Channel 1 and then Lead to obtain the primary ECG lead choices.
2. Change ECG lead by rotating the Speed Dial. The highlighted selection shows the ECG
lead.
3. Press the Speed Dial to activate the highlighted menu item.
4. Repeat steps 1 and 2 to select or change displayed waveforms for Channel 2.
Adjusting the Systole Tone Volume
1. Highlight and select heart rate in the monitoring area of the screen using Speed Dial.
2. Rotate the Speed Dial to the desired volume.
3. Press the home screen to exit.
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Appendix 8: Manual Defibrillation
•
The decision to deliver a shock is made by a medical officer. Only experienced and
appropriately trained staff are to prepare the LIFEPAK 20 for defibrillation and to deliver
the prepared shock.
QUIK-COMBOTM Electrode Pad Placement
Anterior-Lateral Placement
1. Place the ♥ therapy electrode pad lateral to the patients left nipple in the mid axillary
line.
2. Place the other therapy electrode pad on the patient’s upper right torso, lateral to the
sternum and below the clavicle as shown in Figure 2 above.
Anterior-Posterior Placement
The anterior-posterior placement is an alternative position for manual defibrillation,
synchronised cardioversion and non-invasive pacing, but not for ECG monitoring. The ECG
lead signal obtained through electrodes in this position is not a standard lead.
1. Place the ♥ therapy electrode pad over the precordium as shown in Figure 3. The upper
edge of the electrode should be below the nipple. Avoid placement over the nipple, the
diaphragm, or the bony prominence of the sternum if possible.
2. Place the other electrode behind the heart in the infrascapular area as shown in Figure
3. Do not place the electrode over the bony prominences
Figure 3:
Anterior- Posterior Placement
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Defibrillation Procedure
At CHW DO NOT use AED mode of LIFEPAK 20
The ANALYZE button should not be pressed as this will activate the AED mode. If the
ANALYZE button is pressed inadvertently please press ENERGY SELECT, CHARGE or
PACER buttons to return to MANUAL mode.
1. Press ON
2. Ensure appropriate size QUIK-COMBO™ electrode pads are connected to the therapy
cable; confirm cable connected to the device, position electrodes on patient as shown in
Figure 2 & 3 above. For patients < 15kgs use the paediatric size pads. For neonates
with very small chests, paediatric electrodes may be too large to place in the anteriorlateral position. In this situation place the paediatric QUIK-COMBO™ electrode pads in
the anterior – posterior position.
3. Conductive gel is not required when using QUIK-COMBO™ electrode pads.
4. Press ENERGY SELECT and adjust up or down as needed. (See Table 3 for
recommended Joules). Default energy setting is 5 joules at CHW.
5. Press CHARGE; when fully charged a message will appear on screen and loud alarm
will sound.
6. Operator to call loudly “Stand Clear”; make certain all personnel stand clear of patient,
bed and any equipment connected to the patient and remove any oxygen from patient.
7. Confirm ECG rhythm and available energy.
8. Press the SHOCK button to discharge energy to the patient.
9. Immediately recommence CPR for 2 minutes and recharge the defibrillator towards the
end of this 2 mins.
10. Pause chest compressions to recheck the patient’s ECG rhythm and pulse and, if an
additional shock is necessary, repeat the procedure beginning at step 6.
Note: If the charged electrodes are no longer required, the energy can be dumped by:
• Pressing the Speed Dial button.
• Pressing ENERGY SELECT button.
• Press the ON button which will turn the machine off.
• If charge is not delivered/dumped within 60 secs, stored energy is internally removed.
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Synchronised Cardioversion Procedure
1. Press ON.
2. Prepare the patient for therapy electrode application. Remove clothing and any
moisture; DO NOT apply alcohol. If possible place the patient on a firm surface.
3. Attach patient ECG cable and ECG electrodes.
4. Select lead II or the lead with greatest QRS complex amplitude (positive or negative).
Note: To monitor the ECG through QUIK-COMBO™ electrode pads, place the
electrodes in the anterior-lateral position and select paddles lead on channel 1.
5. Press SYNC and Confirm the SYNC LED blinks with each detected QRS complex.
Note: Press SYNC again to deactivate synchronous mode.
6. Observe the ECG rhythm. Confirm that a triangular sensor marker appears near the
middle of each QRS complex. If the sensor markers do not appear or are displayed in
the wrong locations e.g. on the T-wave, select another lead. It is normal for the sensor
marker location to vary slightly on each QRS complex.
7. Connect the therapy electrode pads to the therapy cable and confirm cable connection
to the device.
8. Apply therapy electrode pads to patient in the anterior-lateral or anterior-posterior
position. (Theatres only: if using standard paddles, apply conductive gel to the paddles
and place paddles on patient’s chest.)
9. Press ENERGY SELECT (Theatres only: rotate the energy select dial on the standard
paddles).
10. Press CHARGE
11. Operator to call loudly “Stand Clear”; make certain all personnel stand clear of patient,
bed and any equipment connected to the patient and remove oxygen from patient.
12. Confirm ECG rhythm and available energy.
13. Press and hold SHOCK button until discharge occurs with next detected QRS complex
and then release SHOCK button. If SHOCK button is not pressed within 60 seconds,
stored energy is internally removed.
Note: If you change the energy selection after charging has started, the energy is
removed internally. Press CHARGE to restart charging.
14. Observe patient; recheck ECG rhythm and pulse. Repeat procedure from Step 4 if
necessary.
Note: Synchronised cardioversion may not function if the R wave is not recognised. If
this is the case, use the ‘asynchronous’ mode.
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Appendix 9: Temporary Transthoracic Non-Invasive Cardiac
Pacing
•
Temporary non-invasive transthoracic pacing (NTP) is used primarily during emergency
situations for the treatment of haemodynamically significant arhythmias that are
unresponsive to resuscitative measures and pharmacology
•
NTP is not as reliable as other temporary pacing modes and can be uncomfortable. It
may be used as temporary supportive therapy until another method of pacing can be
established.
•
NTP is available on LIFEPAK 20s located in specialised areas (see Appendix 4).
•
NTP is implemented using the QUIK-COMBO™ electrode pads placed in either the
anterior-lateral or anterior-posterior positions (See Figure 2 and Figure 3). NTP may be
carried out as either synchronous (demand) or asynchronous (non-demand) mode.
CHW LIFEPAK 20 is defaulted to asynchronous so that pacing occurs regardless of the
patient’s own QRS being detected.
•
Should you require synchronous (demand) pacing, this can be set by pressing
OPTIONS and then using the speed dial to select PACING, MODE, DEMAND. ECG
monitoring via the LIFEPAK 20 must be in place in order for synchronous pacing to
occur.
Procedure for Asynchronous (non-demand) Non-Invasive Transthoracic Pacing
This is the default method of pacing.
1. Press ON.
2. Apply ECG electrodes to patient; connect ECG cable and select lead I, II or III. For
optimal signal ensure ECG electrodes and QUIK-COMBOTM therapy electrode pads
are adequately separated. Note you can pace a patient without the LIFEPAK 20 ECG
leads attached, but it will be asynchronous and you will not be able to view the ECG via
the paddles whilst the current is increased to capture. If the ECG leads become
dislodged, asynchronous pacing can continue, monitored via the paddles ECG on the
lower half of the screen only.
3. Prepare QUIK-COMBO™ electrode sites (anterior-lateral or anterior-posterior), remove
clothing and moisture. DO NOT apply alcohol.
4. Connect QUIK-COMBO™ electrode pads to cable if not already connected. Apply
QUIK-COMBO™ electrode pads to patient.
5. Press PACER -> LED illuminates.
6. Press RATE (increments of 10 bpm) or rotate Speed Dial (5 bpm increments) to select
desired pacing rate.
7. Press CURRENT (10 mA increments) or rotate Speed Dial (5 mA increments) to
increase current until electrical capture occurs: The PACER indicator flashes for each
delivered paced beat and the desired rate appears on the ECG monitor.
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8. Use the minimum current necessary to achieve this. Current and rate can continue to
be adjusted as above.
9. To interrupt and view patient’s native rhythm, press and hold PAUSE. This delivers
pacing at 25% of the set rate.
10. To stop pacing, reduce current to zero or press PACER. If the pacing electrodes are
dislodged, pacing ceases and delivered current resets to 0 mA.
11. If defibrillation is required during pacing, press ENERGY SELECT and then CHARGE
and pacing will automatically stop. Then proceed for defibrillation.
12. This is an uncomfortable and temporary method of pacing. Patient analgesia/sedation
should be considered.
13. Monitor patient continuously and arrange definitive pacing urgently.
Procedure for Synchronous (demand) Non-Invasive Transthoracic Pacing
•
This is not the default method of pacing. It requires some knowledge about pacing and
may be interfered with by CPR etc. However it may be undertaken following discussion
with cardiology/PICU.
•
The procedure is the same as for asynchronous pacing EXCEPT:
o
After turning the machine on, select for synchronous pacing by pressing
OPTIONS and then using the speed dial to select PACING, MODE, DEMAND
The LIFEPAK 20 ECG cable must be attached for demand pacing to occur.
o
After pressing PACER-> LED illuminates. Observe ECG and confirm triangular
sensor marker is near middle of each QRS complex. Select another lead if marker
position is not mid QRS. These are the sensed QRS complexes. Demand pacing
will only occur if a rate greater than this is selected and if adequate current is
selected to capture.
•
The rest of the procedure is the same as for asynchronous pacing as described above.
•
For full details on methods of pacing and for nursing management of paced children,
refer to CHW Cardiac Pacing – Patient Management Practice Guidelines:
http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2006-8137.pdf
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Appendix 10: Contents of Mobile Arrest Trolley/Pack
EQUIPMENT
MOBILE ARREST TROLLEY
Oxygen cylinder porter to bring
Scoop device porter to bring
Ambulance trolley porter to bring
ED drug pack from fridge:
• Suxamethonium 100mg/2mL – 2
amps
Defibrillator (Lifepak 20) with ECG dots,
pads & razor.
Sharps container tied to top of trolley
Mobile Arrest Trolley Checklist tied to top of
trolley
Arrest Team Access Card tied to top of
trolley
Mobile Arrest Pack
MOBILE ARREST PACK
OUTSIDE OF PACK
Sleeve Pocket Under Defibrillator
Top Pocket
Mobile arrest documentation form x2
Envelopes x2
Pens x2
Res-Q-Vac suction device, disposable
suction catheter and container
Self-inflating resuscitation bags – child and
adult
Laerdal masks – 00-4 - one each
Bottom Pocket
Right Side Pocket
1000mL Normal Saline –two
500mL Glucose 10% - one
Blood pump set – one
Giving set - one
pads 9x20 and 20x20 – five each
gauze swabs – five
steristrips
tegaderm
Left Side Pocket
Sphygmomanometer
Stethoscope
Neuro torch
Spare ECG dots
INSIDE LID OF PACK
Pocket 1
Pocket 2
Gloves – non-latex in a variety of sizes
Vomit bags
Pocket 3 (IO Needle Pack)
IO needle 16 gauge – one
IO needle 18 gauge – one
T-piece extension set with needleless injection
cap - two
Armboards – small/medium/large – one each
Brown Elastoplast
Alco wipes – five
INSIDE OF PACK
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Intubation Roll
Two laryngoscope handles
Straight blade 0, 1, 2 one each
Curved 3, 4, 5 one each
Spare battery and globes (small and large)
Endotracheal tubes:
size 2.5 (two)
size 3.0,3.5,4.0,4.5,5.0,5.5,6.0 uncuffed 1 each
size 6.0, 7.0, 8.0 cuffed one each.
Endotracheal introducer – small, medium &
lge
Magill forceps – adult, child and infant sizes
KY jelly – three
White tape for ETT
Brown elastoplast
Tinc Benz Co
Disposable CO2 detector – small (1-15kg)
and large (>15kg)
Airway (blue pack with green stripe)
Guedel airways 0-4 one each
NRB Oxygen mask (1 x adult; 1 x paed)
Nebuliser kit (1 x adult; 1 x paed)
Oxygen tubing
Intragastric tubes 8, 10 one each
Circulation (Orange Pack x 2)
Pack 1 - Cannulation
Blunt 19G drawing up needles - five
25 gauge needles - five
Butterflies 23 and 25 gauge – two each
T-piece extension set with needleless
injection caps – two
Cannulae sizes 16,18, 20, 22, 24 gauge 3
each
Tourniquets – one
Alco wipes – twenty
Blood gas syringes – two
Blood tubes – X-match, FBC, EUC – one each
Sodium Chloride 0.9% “Posiflush” 10mL – five
Steristrip packet – two
Tegaderm – two
Brown elastoplast
Bandaids – five
Cannula caps clearlink – two (NOT red combilock)
(armboards in IO needle pack inside lid of
pack)
Pack 2 – syringes: 2mL, 5mL, 10mL – three each
Drugs/Glucometer (yellow pack)
Adenosine 6mg / 2mL - 3 ampoules
Adrenaline 1:10,000 & 1:1000 -5 each
Amiodarone 150 mg– two amps
Anginine (see glyceryl trinitrate – 1 bottle)
Aspirin – 4 tablets
Atropine 600micrograms – two amps
Calcium chloride 10% 10mL – one amp
GlucaGen Hypokit (1mg) - one
Glucose 50% 50mL – one vial
Glyceryl Trinitrate 600 micrograms - 100 tabs
Hydrocortisone 100mg vials- two
Naloxone 400micrograms – two amps
Lignocaine 1% - two amps
Midazolam 15mg/5mL –two amps
Promethazine Hydrochloride 1 x 50mg/2mL
Propofol 200mg – one amp
Salbutamol 0.5% solution – one 30mL bottle
Sodium bicarbonate 8.4% 1x10mL amp
Thiopentone 500mg one.
Vecuronium 1x10mg amp; 1x 4mg amp
Water for injection 10mL – five
Syringes – 50mL – two each
Three way connector and minimal volume
extension tubing – one each
Additive labels – five
Red drawing up needles - ten
Scissors
Glucometer
For drug doses see Appendix 3: Contents of Resuscitation Drug Kit.
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Appendix 11: CERS Protocol Flowchart
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Appendix 12: Resuscitation Trolley Maintenance
Daily Checks
The resuscitation trolley must be checked on a daily basis and this check should be signed
for on the resuscitation checklist attached to the trolley. The following must be ensured:
•
The trolley should be sealed with the chain linked security tag (Seal) system this ensures that
the correct equipment is in place in the trolley.
•
To check the trolley contents break the security tag (Seal) by pulling the tag or by
opening a drawer using the checklist and check to ensure that all stock is present and
has not expired (http://chw.schn.health.nsw.gov.au/o/forms/clinical_emergency_response_systems__CERS/ward_resuscitation_trolley_-_checklist.pdf).
•
The drug drawer (bottom white drawer) contains a resuscitation drug kit which is sealed and has
not exceeded its expiry date. If seal is broken or kit is past its expiry date it must be replaced
through biomedical engineering store room or pharmacy (See Appendix 6: After an Arrest)
•
The drug drawer (bottom white drawer) also contains the following: two clear plastic bags; two
500mL bags of Normal Saline; two 500mL bags of Hartmann's Solution; one 500mL bag of 10%
Glucose. If any of these is missing or past their expiry date they should be replaced from ward
stock.
•
Once trolley contents have been checked and are correct re-seal security tag by feeding the
chain link through the trolley handles and clip the new security tag in place. Then add the
security tag number and sign on the appropriate space on the daily checklist. This helps to
identify if the trolley is sealed and when it was last sealed or if it has been tampered with.
Also check the presence of the following:
•
•
A functioning and full oxygen cylinder, flow meter and tap
Adult 1600mL and Child 500mL orange disposable self-inflating resuscitation bags. These
resuscitation bags are stored in plastic bags which are sealed with a white tamper evident seal –
if this seal is broken the resuscitation bag must be replaced with a new one.
•
Chained to the trolley rail: breathing circuit picture, drug dose chart, and trolley contents sheet
and scissors
•
•
•
•
•
On trolley bottom shelf: clipboard with resuscitation flowcharts and daily check sheet.
At back of trolley: an arrest board
On top of trolley: glucometer.
Areas that have an allocated defibrillator must complete a daily check.
A weekly check (as stated by Safety Alert 006/09) of the emergency alarm bell must be
performed and signed for on the resuscitation checklist attached to the trolley.
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Guideline No: 1/C/06:8239-01:06
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After an Arrest
(see Appendix 2 and Appendix 6 guide to guide restocking)
•
If an arrest occurs on a ward while the resuscitation trolley is unstocked, call a mobile
arrest
In normal working hours
•
During normal working hours replacement stock is available from the biomedical
stock room and ward area as indicated on the trolley check list
http://chw.schn.health.nsw.gov.au/o/forms/clinical_emergency_response_systems__CERS/ward_resuscitation_trolley_-_checklist.pdf
•
Follow steps documented in Appendix 6: Resuscitation Trolley Action after and Arrest
Outside of normal working hours
•
The same procedure applies as outlined in Appendix 6
•
After Hours Nurse Manager should be paged (pager 6056) if there is not any
pharmacy boxes left in supply in the biomedical stock room so that more can be
retrieved from the out of hours pharmacy.
•
On weekends and public holidays, the resuscitation equipment, is kept in the
biomedical engineering stock room which is routinely stocked and is the responsibility
of the biomedical engineering department. Should the existing stock be depleted to
only 1 pharmacy box available, the After Hours Nurse Manager should contact the
on-call Pharmacist. Inhalation therapy/biomedical engineering staff to organise
restocking out of hours once contacted by the After Hours Nurse Manager. If
restocking is not possible, the ward areas affected will need to utilise a mobile arrest
call as a temporary solution.
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Guideline No: 1/C/06:8239-01:06
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Appendix 13: Defibrillator Maintenance and Warnings
Report all Faults to Biomedical Engineering
Testing the LIFEPAK 20
The LIFEPAK 20 performs a daily self-test at 0300hrs. As the QUIK-COMBOTM electrode
pads will be connected and ready for use, the LIFEPAK 20 will recognize this and the
integrity of the therapy cables will not be tested. The automatic print out will then state “Selftest did not complete connect to test plug”. Therefore a daily “user test” needs to be
performed manually.
Daily User Test
This test must be performed at least daily and signed for on the arrest trolley daily checklist.
The LIFEPAK 20 defibrillator/monitor user test is a functional test and should not be
performed while using the defibrillator for patient care.
Speed Dial
O™ Test Plug
‘QUIK-COMBO™
Therapy cable
Figure 4: Lifepak 20 Defibrillator
1. Prior to performing the user test you need to ensure the therapy cable is connected to
the ‘QUIK-COMBO™ test plug see Figure 4.
2. Press ON
3. Press OPTIONS then turn Speed Dial to select USER TEST. Push the Speed Dial
button when USER TEST selected.
4. Message will be displayed:
Start user test? (This will end monitoring and close patient records)
Select YES and push Speed Dial button to confirm.
5. When selected the user test automatically performs the following tasks:
i.
Performs self-test
ii. Charges to a low energy level (approximately 1-3J) and then discharges through
a test load
iii. Tests pacing circuitry (if non-invasive pacing installed)
iv. Automatic print out of the result states “user test succeeded”
v. Turns itself off
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Guideline No: 1/C/06:8239-01:06
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If the LIFEPAK 20 defibrillator/monitor detects a problem during the user test, the service
LED lights and a printed report indicates that the test failed. Turn off the defibrillator and then
repeat the user test. If the Service LED remains lit, contact Biomedical Engineering
Department on extension 52594.
Once test is completed please ensure that the ‘Quick combo’ test plug is disconnected and
the adult QUIK-COMBO™ electrodes are reconnected.
If it is necessary to interrupt the user test, turn the power off and then on again. The test will
stop and the defibrillator will operate normally. A Pass/Fail report will not print.
During user test, all front panel controls (except ON) and standard paddle controls are
disabled.
Routinely testing the defibrillator consumes power; perform the user test with the device
plugged into ac power.
Defibrillator Checks After an Arrest
The LIFEPAK 20 must be returned to its location by the RN and left in a state of readiness.
Replacement QUIK-COMBO™ electrode pads are obtained from Biomedical Engineering
during normal working hours and from the after-hours pharmacy storeroom outside of normal
working hours.
In the event of a second arrest occurring in a ward area whilst the LIFEPAK 20 is in use
elsewhere, a mobile arrest call should be activated.
Loading Paper into the Recorder
The printer is equipped with an out-of-paper sensor to protect the print-head. The sensor
automatically turns off the printer if paper runs out or if the printer door is open.
Using other manufacturers’ printer paper may cause the printer to function improperly and/or
damage the print head. Use only the printer paper specified in these operating instructions.
Loading 50 mm Paper (PN 804700).
1. Pull the slotted edge of the front printer door to open the printer.
2. Remove the empty paper roll.
3. Insert the new paper roll, grid facing upwards.
4. Pull out a short length of paper.
5. Push the rear printer door in and push down on the front printer door to close.
Figure 5: Loading 50 mm paper into Lifepak 20
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Guideline No: 1/C/06:8239-01:06
Guideline: Cardiopulmonary Resuscitation and Equipment - CHW
Defibrillator WARNINGS!
1. Only experienced and trained staff are to use the LIFEPAK 20.
2. Report all faults to the Biomedical Engineering Department Ex 52594.
3. You must ensure all staff are not in contact with the patient, the bed or any connections
to the patient or bed when cardioversion or defibrillation is being attended.
The following are general warning and caution statements:
Shock hazard
The defibrillator delivers up to 360 J of electrical energy. Unless properly used as described
in these Operating Instructions, this electrical energy may cause serious injury or death. Do
not attempt to operate this device unless thoroughly familiar with these operating instructions
and the function of all controls, indicators, connectors, and accessories.
Possible fire or explosion
Do not use this device in the presence of flammable gases or anaesthetics. Use care when
operating this device close to oxygen sources (such as bag-valve-mask devices or ventilator
tubing). Turn off gas source or move source away from patient during defibrillation.
Possible defibrillator shutdown
When operating on battery power, the large current draw required for defibrillator charging
may cause the defibrillator to reach shutdown voltage levels with no low battery warning. If
the defibrillator shuts down without warning, or if a LOW BATTERY:CONNECT TO AC
POWER message appears on the monitor screen, immediately connect the AC power cord
to an outlet.
Possible failure to detect an out of range condition
Reselecting QUICK SET will reset the alarm limits around the patient’s current vital sign
values. This may be outside the safe range for the patient.
Note: Medtronic devices, electrodes, and cables are latex-free.
External Cleaning Procedures
WARNING! Shock or fire hazard
Do not immerse or soak any portion of this device in water or any other fluid. Avoid spilling
any fluid on the device or accessories.
CAUTION! Possible case damage
Do not clean any part of this device or accessories with bleach, bleach dilution, or phenolic
compounds. Do not use abrasive or flammable cleaning agents. Do not attempt to sterilize
this device or any accessories unless otherwise specified in accessory operating instructions.
Clean the exterior of the LIFEPAK 20defibrillator/monitor by wiping the surface with any of
the following solutions:
•
Soap and water
•
Isopropyl alcohol
Date of Publishing: 24 June 2014 4:34 PM
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