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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 Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. 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 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 3 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 4 of 45 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 5 of 45 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 6 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 7 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 8 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 9 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 10 of 45 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 11 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 12 of 45 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 13 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 14 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 15 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW • 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). Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 16 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 17 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 18 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 19 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 20 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. 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” Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. 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 Page 22 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. 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 Page 23 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 24 of 45 Comment Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 25 of 45 Note: Flush IV lines with Sublingual Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 26 of 45 Note: Flush IV lines with Guideline No: 1/C/06:8239-01:06 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 27 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 28 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 29 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 30 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 31 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 32 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 33 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 34 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 35 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 36 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 37 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 38 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 39 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW Appendix 11: CERS Protocol Flowchart Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 40 of 45 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 41 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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. Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 42 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 43 of 45 Guideline No: 1/C/06:8239-01:06 Guideline: Cardiopulmonary Resuscitation and Equipment - CHW 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 Date of Publishing: 24 June 2014 4:34 PM Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 44 of 45 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 Date of Printing: 24 June 2014 K:\CHW P&P\ePolicy\Jun 14\Cardiopulmonary Resuscitation & Equipment - CHW.docx This Guideline may be varied, withdrawn or replaced at any time. Page 45 of 45