ALS and BTLS

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ALS and BTLS

  1. 1. ““And if anyone saved a life, it would be as if he saved allAnd if anyone saved a life, it would be as if he saved all mankind.” (Quran: 5:32).mankind.” (Quran: 5:32).
  2. 2.  DateDate 2020thth JUNE 2006JUNE 2006  Patient Lt Col XYZPatient Lt Col XYZ  Age 45 yearsAge 45 years  PlacePlace SSG CENTRE CHIRATSSG CENTRE CHIRAT  ActivityActivity Routine Morning ExerciseRoutine Morning Exercise Suddenly collapsed, became unresponsive with irregularSuddenly collapsed, became unresponsive with irregular gasping breathinggasping breathing  Rescuer Major. ABC surgical specialistRescuer Major. ABC surgical specialist  Diagnosis of Cardiac Arrest was madeDiagnosis of Cardiac Arrest was made  Airway maintained, mouth to mouth breathing and chestAirway maintained, mouth to mouth breathing and chest compressions were started. A bystander SSG officer wascompressions were started. A bystander SSG officer was involved in CPRinvolved in CPR  CPR continued and patient shifted to CMH Cherat in a militaryCPR continued and patient shifted to CMH Cherat in a military vehicle in 4-5 minutesvehicle in 4-5 minutes  CPR continued, patient intubated and 100% O2 givenCPR continued, patient intubated and 100% O2 given  I/V line established and defib. attached, (VF)I/V line established and defib. attached, (VF)
  3. 3.  360 J DC shock was immediately given but no effect360 J DC shock was immediately given but no effect  CPR continued and inj. Adrenaline 1 mg repeated every 3 minsCPR continued and inj. Adrenaline 1 mg repeated every 3 mins (3mg)(3mg)  360 J DC shock repeated and VF converted to sinus tachycardia360 J DC shock repeated and VF converted to sinus tachycardia  Carotid pulse was not palpableCarotid pulse was not palpable  CPR continued, after 5 mins rhythm again changed to VFCPR continued, after 5 mins rhythm again changed to VF  360 J DC shock repeated, VF changed to sinus tachycardia360 J DC shock repeated, VF changed to sinus tachycardia  Carotids became palpable and patient started breathing (irregularCarotids became palpable and patient started breathing (irregular gasps)gasps)  Chest compression stopped and breathing assistedChest compression stopped and breathing assisted  Heart rate 160/min, radial pulse became palpable, SpO2 72%Heart rate 160/min, radial pulse became palpable, SpO2 72%  80mg lignocaine and 60mmols soda bicarb. administered I/V and80mg lignocaine and 60mmols soda bicarb. administered I/V and dobutamine infusion starteddobutamine infusion started  Call was sent for a rescue helicopterCall was sent for a rescue helicopter  Patient opened his eyes but was confused and restlessPatient opened his eyes but was confused and restless  Inj. morphine sulphate 7.5 mg I/V was given for sedationInj. morphine sulphate 7.5 mg I/V was given for sedation
  4. 4.  Patient flown to AFIC in a military helicopter with O2Patient flown to AFIC in a military helicopter with O2 cylinder, emergency drugs, defib., and was accompaniedcylinder, emergency drugs, defib., and was accompanied by 2 doctorsby 2 doctors  Total flight time 45 mins, uneventfulTotal flight time 45 mins, uneventful  Admitted in CCU with mech. vent. SupportAdmitted in CCU with mech. vent. Support  IABP passed, supportive and symptomatic treatmentIABP passed, supportive and symptomatic treatment given, weaned off ventilator after 24 hoursgiven, weaned off ventilator after 24 hours  No neurological deficit notedNo neurological deficit noted  Angioplasty done after 39 days of cardiac arrestAngioplasty done after 39 days of cardiac arrest  Back on job, enjoying normal family lifeBack on job, enjoying normal family life  Total BLS ACLS time 94 minsTotal BLS ACLS time 94 mins
  5. 5. SEQUENCESEQUENCE  European resuscitation council (ERC) guidelinesEuropean resuscitation council (ERC) guidelines for resuscitation 2005for resuscitation 2005  BLSBLS  Chest compressionChest compression  Airway managementAirway management  AlgorithmsAlgorithms
  6. 6.  Basic life support (BLS)Basic life support (BLS)  Maintaining airway patency*Maintaining airway patency*  Supporting breathing *Supporting breathing *  Supporting circulation*Supporting circulation* **Without the use of equipmentWithout the use of equipment
  7. 7. IntroductionIntroduction  700,000 deaths/year in Europe (SCA)700,000 deaths/year in Europe (SCA)  Causes IHD (VF/VT/ Asystole)Causes IHD (VF/VT/ Asystole)  TraumaTrauma  Drug over doseDrug over dose  DrowningDrowning  AsphyxiaAsphyxia  Optimum treatment (Chest Compression,Optimum treatment (Chest Compression, Rescue Breathing and electrical defib)Rescue Breathing and electrical defib)
  8. 8.  SurvivalSurvival  Early recognition of SCAEarly recognition of SCA  Early bystander CPR improves survival (2 – 3 times)Early bystander CPR improves survival (2 – 3 times)  Early Defibrillation within 3 – 5 min of SCA (50 –Early Defibrillation within 3 – 5 min of SCA (50 – 75%)75%)
  9. 9. ABLS  Personal and patient safety  Check the victim for a response  Gently shake the patient for a response If he responds,  Leave him in position in which you found him  Try to find out what is wrong with him  Reassess him regularly
  10. 10.  If he does not respondIf he does not respond  Shout for helpShout for help  Turn the victim in supine positionTurn the victim in supine position  Open the Air way using head tilt andOpen the Air way using head tilt and chin liftchin lift  Look, listen and feel for normalLook, listen and feel for normal breathingbreathing  Look for chest movementLook for chest movement  Listen at the victims mouth for breathListen at the victims mouth for breath soundssounds  Feel for air on your cheekFeel for air on your cheek  Don’t waste more than 10 secsDon’t waste more than 10 secs
  11. 11. If he is breathing normallyIf he is breathing normally  Turn him into the recovery positionTurn him into the recovery position  Call for help/ ambulanceCall for help/ ambulance  Check for continued breathingCheck for continued breathing If he is not breathing normallyIf he is not breathing normally  Send someone for help/ ambulance serviceSend someone for help/ ambulance service  Kneel by the side of the victim.Kneel by the side of the victim.  Place the heel of one hand in the centre of the victim’s chestPlace the heel of one hand in the centre of the victim’s chest  Place the heel of the other hand on top of the first handPlace the heel of the other hand on top of the first hand  Interlock the fingers of your hands and ensure that pressure is notInterlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs or xiphisternumapplied over the victim’s ribs or xiphisternum  Position yourself vertically above the victim’s chest and withPosition yourself vertically above the victim’s chest and with your arms straight, press down the sternum 4 – 5 cmsyour arms straight, press down the sternum 4 – 5 cms  After each compression, release all the pressure on the chestAfter each compression, release all the pressure on the chest without losing contact between your hands and the sternum repeat at awithout losing contact between your hands and the sternum repeat at a rate of about 100/minrate of about 100/min  Compress and release for equal duration of timeCompress and release for equal duration of time
  12. 12.  Combine chest compression with rescue breaths. • After 30 compressions open the airway using head tilt and chin lift. • Pinch the soft part of the nose, using the index finger and thumb of your hand on the forehead. • Allow the mouth to open, but maintain chin lift. • Take a normal breath and place your lips around his mouth, making sure that you have a good seal.. • Blow steadily into the mouth while watching for the chest to rise, taking about 1 sec as in normal breathing; this is an effective rescue breath. • Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air passes out. * Blow another normal breath into the patients mouth and resume chest compressions * Continue with chest compressions and rescue breaths in a ratio of 30 – 2 * Stop to recheck if the victim starts breathing * If there are two rescuers they should take over CPR every two min * Not able/ unwilling to give rescue breaths (Continue chest compressions only)
  13. 13.  Continue resuscitation until • Qualified help arrives and takes over • The victim starts breathing normally • You become exhausted
  14. 14.  VentilationVentilation  Reduced blood flow to the lungs during CPR.Reduced blood flow to the lungs during CPR.  Ventilation/ perfusion ratio maintained Vt and RR.Ventilation/ perfusion ratio maintained Vt and RR.  Hyperventilation and large Vt are unnecessary and harmfulHyperventilation and large Vt are unnecessary and harmful increased intrathoracic pressure leads to reduced CO. andincreased intrathoracic pressure leads to reduced CO. and large Vt 1 ltr or more may cause gastric distention/large Vt 1 ltr or more may cause gastric distention/ regurgitationregurgitation  Interruptions in chest compression should be minimal.Interruptions in chest compression should be minimal.
  15. 15.  Chest CompressionChest Compression  Blood flow isBlood flow is generatedgenerated 1.1. IncreasedIncreased intrathoracic pressureintrathoracic pressure 2.2. Direct compression ofDirect compression of the heartthe heart 3.3. Systolic arterialSystolic arterial pressure peaks – 60 –pressure peaks – 60 – 80 mm Hg80 mm Hg 4.4. Low diastolic pressureLow diastolic pressure 5.5. Mean BP in carotid 40Mean BP in carotid 40 mm Hgmm Hg
  16. 16.  Airway Management and VentilationAirway Management and Ventilation  Airway obstructionAirway obstruction 1.1. Secondary to loss of consciousnessSecondary to loss of consciousness 2.2. Primary cause of cardio respiratory arrestPrimary cause of cardio respiratory arrest  Prompt assessment control of airway andPrompt assessment control of airway and ventilation will prevent secondary hypoxicventilation will prevent secondary hypoxic damage to the brain and other vital organsdamage to the brain and other vital organs  Airway obstruction in unconscious and obtundedAirway obstruction in unconscious and obtunded patientpatient 1.1. Decreased muscle tone/ posterior displacement of theDecreased muscle tone/ posterior displacement of the tongue and at the soft palate and epiglottis leveltongue and at the soft palate and epiglottis level 2. Vomitus, blood, foreign body, laryngeal oedema are2. Vomitus, blood, foreign body, laryngeal oedema are other causes of airway obstructionother causes of airway obstruction
  17. 17. RECOGNITION OF AIRWAYRECOGNITION OF AIRWAY OBSTRUCTIONOBSTRUCTION A Diagnosis often missed by Healthcare ProfessionalsA Diagnosis often missed by Healthcare Professionals  Look for Chest and Abdominal movementsLook for Chest and Abdominal movements  Listen and feel for Airflow at the Mouth and NoseListen and feel for Airflow at the Mouth and Nose 1) Diminished air entry and noisy breathing indicates partial airway1) Diminished air entry and noisy breathing indicates partial airway obstructionobstruction 2) Inspiratory stridor is caused by obstruction at the pharyngeal and supra2) Inspiratory stridor is caused by obstruction at the pharyngeal and supra glottic levelglottic level 3) Biphasic stridor in glottic or cervical tracheal obstruction3) Biphasic stridor in glottic or cervical tracheal obstruction 4) Expiratory wheeze implies obstruction of the lower airways4) Expiratory wheeze implies obstruction of the lower airways 5) Gurgling is caused by liquid or semisolid foreign material in the main5) Gurgling is caused by liquid or semisolid foreign material in the main airwaysairways 6) Snoring arises when the pharynx is partially occluded by the soft palate or6) Snoring arises when the pharynx is partially occluded by the soft palate or epiglottisepiglottis 7) Crowing is the sound of laryngeal spasm7) Crowing is the sound of laryngeal spasm
  18. 18. AIRWAY OBSTRUCTION cont…AIRWAY OBSTRUCTION cont…  Paradoxical breathingParadoxical breathing  Use of accessory muscles of respiration*Use of accessory muscles of respiration* **suprasternal, intercostal and subcostal recessionssuprasternal, intercostal and subcostal recessions  Listening for absence of breath soundsListening for absence of breath sounds  Failure to inflate the lungs during IPPVFailure to inflate the lungs during IPPV
  19. 19. BASIC AIRWAY MANAGEMENTBASIC AIRWAY MANAGEMENT  Head tilt and chin liftHead tilt and chin lift
  20. 20. BASIC AIRWAY MANAGEMENTBASIC AIRWAY MANAGEMENT cont…cont…  Jaw thrustJaw thrust  Suspected cervical spine injurySuspected cervical spine injury  Finger sweep and manual removal of foreign bodiesFinger sweep and manual removal of foreign bodies
  21. 21. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY TECHNIQUESTECHNIQUES  Oropharyngeal airwayOropharyngeal airway  SizesSizes  Vomiting and laryngospasmVomiting and laryngospasm
  22. 22. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY TECHNIQUES cont…TECHNIQUES cont…  Nasopharyngeal airwayNasopharyngeal airway IndicationsIndications 1) In patients who are not1) In patients who are not deeply unconsciousdeeply unconscious 2) Life saving in patients with2) Life saving in patients with clenched jaws, trismus orclenched jaws, trismus or maxillofacial injuriesmaxillofacial injuries ContraindicationsContraindications 1) Fracture or deformity of1) Fracture or deformity of the nosethe nose 2) Fracture base of skull2) Fracture base of skull 3) Coagulopathies3) Coagulopathies
  23. 23. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY TECHNIQUES cont…TECHNIQUES cont…  Oxygen inhalationOxygen inhalation  Oxygen masks with reservoir bagOxygen masks with reservoir bag  Oxygen flow / litre per minuteOxygen flow / litre per minute  SpO2 and ABGsSpO2 and ABGs  SuctionSuction  Blood, saliva and gastric contentsBlood, saliva and gastric contents  Intact gag reflex (vomiting)Intact gag reflex (vomiting)
  24. 24. VENTILATIONVENTILATION  Mouth to mouth breathingMouth to mouth breathing  Instant availability /no equipment requiredInstant availability /no equipment required  Oxygen content 16-17%Oxygen content 16-17%  Aesthetically unpleasantAesthetically unpleasant  Risk of acquiring infection (TB,SARS,HBV,HCV)Risk of acquiring infection (TB,SARS,HBV,HCV)  Pocket resuscitation masksPocket resuscitation masks  Transparent just like anesthesia masksTransparent just like anesthesia masks  Uni-directional valveUni-directional valve  Connection for addition of O2Connection for addition of O2  Large Vt or excessive inspiratory flow gastric distentionLarge Vt or excessive inspiratory flow gastric distention and regurgitationand regurgitation
  25. 25. SELF INFLATING BAGSELF INFLATING BAG  Can be connected to faceCan be connected to face mask/ETT/LMA/combitubemask/ETT/LMA/combitube  Oxygen deliveryOxygen delivery room air 21%room air 21% O2 attachment 45%O2 attachment 45% reservoir bag 85% (10 L/min flow)reservoir bag 85% (10 L/min flow)  Difficult for one person to ventilateDifficult for one person to ventilate  Two person techniqueTwo person technique
  26. 26. ENDOTRACHEAL TUBESENDOTRACHEAL TUBES  ADVANTAGESADVANTAGES  Optimal method of managing the airwayOptimal method of managing the airway  Maintenance of a patent airwayMaintenance of a patent airway  Protection from aspiration of gastric contents orProtection from aspiration of gastric contents or bloodblood  Provision of adequate tidal volume with uninterruptedProvision of adequate tidal volume with uninterrupted chest compressionschest compressions  Rescuers hand free for other tasksRescuers hand free for other tasks  Ability to suction airway secretionsAbility to suction airway secretions  Provision of a route for giving drugsProvision of a route for giving drugs  DISADVANTAGESDISADVANTAGES  Technically trained and experienced personnelTechnically trained and experienced personnel requiredrequired  Unrecognized esophageal intubationUnrecognized esophageal intubation  Dislodgment of the tubeDislodgment of the tube  Passage of tube in right main bronchusPassage of tube in right main bronchus  Laryngeal and upper airway traumaLaryngeal and upper airway trauma  Prolonged attempts( compromised coronary &Prolonged attempts( compromised coronary & cerebral flowcerebral flow
  27. 27. LARYNGEAL MASK AIRWAYLARYNGEAL MASK AIRWAY (LMA)(LMA)
  28. 28. LARYNGEAL MASK AIRWAYLARYNGEAL MASK AIRWAY (LMA) cont…(LMA) cont…
  29. 29. LARYNGEAL MASK AIRWAYLARYNGEAL MASK AIRWAY (LMA) cont…(LMA) cont…  Successful ventilation 72-98%Successful ventilation 72-98%  Better than bag mask ventilationBetter than bag mask ventilation  Inflation pressures less than 20 cm of H2OInflation pressures less than 20 cm of H2O  Interruption of chest compressions required forInterruption of chest compressions required for proper ventilation ( main disadvantage asproper ventilation ( main disadvantage as compared to ETT)compared to ETT)
  30. 30. THE COMBITUBETHE COMBITUBE
  31. 31. CRICOTHYROTOMY/CRICOTHYROTOMY/ LARYNGOTOMYLARYNGOTOMY
  32. 32. FBAOFBAO
  33. 33. FBAOFBAO
  34. 34. THANK YOUTHANK YOU

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