Adults Resuscitation!

 



First of all, I am not a certified BLS trainer. Everything I outline here is based on my reading and experience working in Kementerian Kesihatan Malaysia (KKM) / Ministry of Health (MoH) facilities. However, I am a certified BLS provider. I will help you piece a picture out of this puzzle in layman terms.

It can be terrifying to bear witness a collapse in the ward, especially a general ward you man alone without proper equipment or guidance. (In fact, your principles would be the same in the public, minus the equipment) 

Everyone feels that way in the face of their first ward call. "Doctor! Patient collapse!" would prompt you to grab anything you have and rush over only to blankly stare at the patient. 


In summary, here are the tools: 

1. Few skills you need to know

  • Reading / Adjusting the cardiac monitor
  • Early defibrillation!
  • Effective chest compression
  • How much breath to give
  • IV cannulation 
  • Explaining the situation to family members

2. Few items you need to have

  • Monitors! Monitors! Monitors!
    • Cardiac Monitor
    • SpO2 monitor
    • BP monitor
  • Stethoscope 
  • Red trolly
    • IV Adrenaline 1mg per vial (1: 1000 = 1mg/cc)
    • ETT size
    • Pre-medications: Usually you would not need this

3. What to do?

  • Commence CPR = No pulse (in adults) = CPR!
  • Give oxygen
  • Draw the curtains and invite the family to wait outside - prevents overcrowding of the bedside so you can work
  • MONITORS!! 
    • I emphasis this because the patient is never on a monitor when I arrive.
    • Monitoring gives you a target goal you want to achieve, that is Return of Spontaneous Circulation! (ROSC)
  • Time & record
  • Inform MO on call
  • Set an IV cannula & DRAW bloods
    • I usually would send for everything under the sun, especially for investigations I believe could point towards the cause for the cardiac arrest
      • Hypokalaemia, Hyperkalaemia, Hypothermia, Hypoxia, Hypotension, Hydrogen
      • Toxin, Temponade, Tension pneumothorax, Thrombosis C, Thrombosis P


4. Chanting / No brainers

  • 2 minutes = Check pulse
  • 3 - 5 minutes = Adrenaline!
  • PEA / Asystole = Adrenaline + Chest Compressions (effective)
  • 30: 2 breaths (no airway secured, ie Guedel + Bagging)
    • You don't want 
  • Count to 10 = 1 breath (airway secured, at least LMA above)
  • I clear, you clear, everybody clear!


5. Good job! 

  • If your patient achieves ROSC, know that there is an increased risk of another rearrest. - HERE & HERE
  • The chances for ROSC for every subsequent resuscitation effort deteriorates 
  • TRY TO PREVENT an arrest if you can!
  • proceed with Cerebral protection
    • PaCO2 35 - 45mmHg
    • PaO2 94 - 98% / avoid hypoxia
    • Head up
    • Normothermia
    • Normoglycaemia
    • MAP~ 80mmHg
    • Sedation
    • Neuromuscular blockade - consider EEG montoring
    • Vt 6 - 8cc/kg / PEEP 4 - 8 cmH20
    • Anti-Seizure prophylaxis
    • Early PCI
  • Concept is reduce brain metabolism and reduce secondary brain damage after the primary insult. 

6. How should you utilise the algorithms?

You can google ANY algorithm throughout the world and the concept will ROUGHLY be the same. I typically practice guidelines from KKM, ESC and AHA because they are leading in these efforts. I highly suggest local guidelines as they are more relevant to your hospital setting. (due to training, equipment available, etc)

  • Types
    • "No pulse" - Shockable / Non-shockable rhythms 
    • Tachycardias - Stable / Unstable
    • Bradycardias - Stable / Unstable
  • Drugs - learn ALL the 1st lines & some 2nd / 3rd line good-to-knows 
    • Frequency & dosing differ by the type of resuscitation you are doing!  
    • Adrenaline (depends on type - 1cc fast push = 1mg/cc)
    • Amiodarone (depends on type)
    • Atropine (0.5mg fast push)
    • Adenosine (6, 12, 12)
    • Digoxin (depends on age, RP, etc - typically 0.25mg in 1hr then half dose t.d.s, keep K+ > 4!)
    • DC / AC cardioversion


7. If all else fails....

  • You did a good job, don't put the weight of the whole world on yourself.
  • Explain to the family members what we have done to prevent it, treat it. The salvageable goal is to care for the family and their emotions. Nothing you can do to bring the patient back. You have done your best.
  • I typically will not give up until I've done at least 30 minutes of non-stop CPR. I would push further if the patient has a good prognosis. 


Special situations - These situations require a tweak in the BLS / ALS. 

- COVID patients

- Pregnant women

- Children


Highlight - With the COVID era, major emphasis has been placed on limiting personnel and proper Personal Protective Equipment (PPE). Opinion based summary - HERE

At the moment, KKM is still using guidelines from 2015 with updates released with new Annexes. Major revisions are done every 5 years (not often we see groundbreaking changes are made every time). However, with the on-going pandemic, I suppose these efforts take a back seat.



Read also :

1. BLS - here

2. ALS - here

3. WHO - here

4. COVID KKM Annex - here

5. ERC - here

6. Malaysia ALS training manual - here 

7. When to stop CPR? Food for thought - here


Useful apps 

1. Anesthesiologist (android)

2. Airway Ex (game)

Comments

Post a Comment

Popular Posts