Someone has collapsed. You must fix it.

Go!

Before you go in:


Read the vignette before you enter the station and think about these:

  • What’s the patient’s name? This is quite important
  • What are you (other than sweating)? Does it say you’re a doctor, student, or passer by? This is what you’re going to have to introduce yourself as.
  • Where are you? On a ward? On the street? What equipment are you likely to have?
    • is there likely to be any danger?
    • bag valve mask (instead of rescue breaths)?
    • auto defibrillator?
    • call 999 or 2222?
    • have you got someone to help you?
    • is it likely trauma was involved?
    • What are your four Hs and Ts of Cardiac arrest?
      • Hypoxia
      • Hypovolaemia
      • Hyper/po kalaemia (metabolic disturbance)
      • Hypothermia
      • Tamponade
      • Tension pneumothorax
      • Thromboembolism
      • Toxins

Deep breath. Check your own pulse so you know whether you’re feeling yours or theirs. Chill. It’s going to be just fine.

As you go in:


Grab a tiny squirt of hand gel and some gloves. Stick them on as you start talking to the patient.

DR CAB2

  • Danger
  • Response
    • call their name
    • shake their shoulders
    • squeeze trapezius
  • Call for help
    • If in a bed, lower it in case of needing to do CPR, and drag the bed clear of the wall, to ensure people can access both arms and the head
  • Airway
    • look in their mouth
    • head tilt, chin lift
    • jaw thrust if gurgling noises or risk of spinal injury
  • Breathing
    • listen for ten seconds, while watching their chest and feeling for carotid pulse
    • don’t let hair/necklace/dreads dangling into patient’s mouth
  • 2222 (or 999 if outside)
    • ask assistant to do this
    • “Please could you call 2222, adult cardiac arrest in the Plastic Dummies Ward, and on your way back could you bring the crash trolley, and let me know when it’s done”

CPR

  • Chest compressions – it’s all in the hips
    • heel of the right hand on patient’s sternum, 
    • fingers extended, wrists extended, elbows extended
    • left hand on top of right
    • 30 compressions, 5-6cm (1/3 of patient’s chest depth) at 100-120bpm
      • pretty much all house/electro music is 128bpm so if you have that in your head while you do it you won’t be far off
      • count the compressions out loud
    • 2 breaths
      • preferably with bag valve
      • watch the chest rise
      • preferably done by assistant if they’ve returned
        • they might hold mask on face and you use left hand to do the breaths (hence right hand on the bottom for compressions)
    • repeat until crash trolley and/or help arrives

HELP ARRIVES

Your first priority is to tag someone else in – ask them if they can take over compressions, and say you’ll count them in, and they should take over after the 2 breaths. Count on alternate compressions:

“3…press…2…press…1…press” —- 2 breaths —- they begin.

Now you’re clear to think. If there’s only 2 of you, you can take over airway.

DEFIBRILLATOR


Pads, pacemaker and piercings

  • one over apex, other just below right clavicle
  • >8cm from pacemakers
  • away from piercings and jewellery (doesn’t need removing, just move away)
  • one on the back if needed

Select, stop, shock?

  • select the ‘pads’ option for trace monitoring on the defibrillator
  • call to stop CPR and check the rhythm
    • you have 5 seconds to assess the rhythm, the first 3 are needed to let the rhythm settle after CPR stops
      • if it looks like a normal or vaguely organised trace, check for pulse 
        • if pulse, stop cpr
        • if no pulse, back on the chest
      • if not normal, decide if shockable
        • shockable – VF, pulseless VT
        • non-shockable – PEA, Asystole

Continue, Charge, Clear

  • While CPR is happening, say:
    • “Continue CPR, everyone else clear, oxygen away, I’m charging” and press charge
      • (150J biphasic)
  • Once charged:
    • “Stand clear, shocking”
    • CHECK EVERYONE IS CLEAR
    • Shock
    • Back on the chest

Time, think, treat

Ideally you would have these jobs delegated, with a system running like clockwork, allowing you to think.

Have someone timing (using the clock on the defibrillator) and counting the number of cycles

  • rhythm and shock check every 2 minutes

Think about your Hs and Ts and what might be causing this, and how you might treat it

  • Look at their drug chart
    • opiate painkillers
    • potassium sparing/losing diuretics
  • Listen to the chest
    • equal air entry? Tension pneumothorax? Tamponade?

Treat

TEST BLOOD GLUCOSE

  • during CPR:
    • establish a definitive airway
      • cuffed endotracheal tube in the trachea with the cuff inflated is the only secure airway
    • get IV access
      • if you can’t, get IO access
      • take bloods and send them off
        • FBC
        • U&E
        • Group and Save
        • VBG
    • have drugs at the ready
      • ADRENALINE 1mg IV – 10ml 1:10 000 pre-loaded syringe
        • every other cycle (3-5 mins)
      • AMIODARONE 300mg IV – after 3 shocks
        • if needed again, 150mg
        • infusion if still required
  •  Treat the cause:
    • Tamponade – pericardiocentesis
    • Tension pneumothorax – thoracocentesis (2 ICS Mid clavicular line)
    • Toxin – remove toxin/give antidote
    • Thrombus – thrombolysis
    • Hypothermia – warm patient
    • Hypoxia – 15l 100% oxygen
    • Hyper/po kalaemia – fix abnormal electrolytes
    • Hypovolaemia – IV fluid challenge

Continue until one of the following happens:

  • return of cardiac output
  • rhythm is no longer shockable, and a senior member of staff calls it

RETURN OF CARDIAC OUTPUT

  • ABCDE assessment
  • Oxygen (sats >94%)
  • consider therapeutic cooling

 

  • Thank your team!

 

  • CXR
  • 12 lead ECG
  • Echo
  • Blood pressure
  • Bloods
  • Transfer to ITU
  • Write everything down
  • Go talk to relatives

Things to remember:

ALWAYS DO CLOSED LOOP COMMUNICATION 

If you ask someone to do something, make sure you tell them to tell you when it’s done, to avoid confusion and help your thought process along.

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