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ALS and BTLS

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ALS and BTLS ALS and BTLS Presentation Transcript

    • “ And if anyone saved a life, it would be as if he saved all mankind.” (Quran: 5:32).
    • Date 20 th JUNE 2006
    • Patient Lt Col XYZ
    • Age 45 years
    • Place SSG CENTRE CHIRAT
    • Activity Routine Morning Exercise
    • Suddenly collapsed, became unresponsive with irregular gasping breathing
    • Rescuer Major. ABC surgical specialist
    • Diagnosis of Cardiac Arrest was made
    • Airway maintained, mouth to mouth breathing and chest compressions were started. A bystander SSG officer was involved in CPR
    • CPR continued and patient shifted to CMH Cherat in a military vehicle in 4-5 minutes
    • CPR continued, patient intubated and 100% O2 given
    • I/V line established and defib. attached, (VF)
    • 360 J DC shock was immediately given but no effect
    • CPR continued and inj. Adrenaline 1 mg repeated every 3 mins (3mg)
    • 360 J DC shock repeated and VF converted to sinus tachycardia
    • Carotid pulse was not palpable
    • CPR continued, after 5 mins rhythm again changed to VF
    • 360 J DC shock repeated, VF changed to sinus tachycardia
    • Carotids became palpable and patient started breathing (irregular gasps)
    • Chest compression stopped and breathing assisted
    • Heart rate 160/min, radial pulse became palpable, SpO2 72%
    • 80mg lignocaine and 60mmols soda bicarb. administered I/V and dobutamine infusion started
    • Call was sent for a rescue helicopter
    • Patient opened his eyes but was confused and restless
    • Inj. morphine sulphate 7.5 mg I/V was given for sedation
    • Patient flown to AFIC in a military helicopter with O2 cylinder, emergency drugs, defib., and was accompanied by 2 doctors
    • Total flight time 45 mins, uneventful
    • Admitted in CCU with mech. vent. Support
    • IABP passed, supportive and symptomatic treatment given, weaned off ventilator after 24 hours
    • No neurological deficit noted
    • Angioplasty done after 39 days of cardiac arrest
    • Back on job, enjoying normal family life
    • Total BLS ACLS time 94 mins
  • SEQUENCE
    • European resuscitation council (ERC) guidelines for resuscitation 2005
    • BLS
    • Chest compression
    • Airway management
    • Algorithms
    • Basic life support (BLS)
    • Maintaining airway patency*
    • Supporting breathing *
    • Supporting circulation*
    • * Without the use of equipment
  • Introduction
    • 700,000 deaths/year in Europe (SCA)
    • Causes IHD (VF/VT/ Asystole)
    • Trauma
    • Drug over dose
    • Drowning
    • Asphyxia
    • Optimum treatment (Chest Compression, Rescue Breathing and electrical defib)
    • Survival
        • Early recognition of SCA
        • Early bystander CPR improves survival (2 – 3 times)
        • Early Defibrillation within 3 – 5 min of SCA (50 – 75%)
    • 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
    • If he does not respond
      • Shout for help
      • Turn the victim in supine position
      • Open the Air way using head tilt and chin lift
      • Look, listen and feel for normal breathing
      • Look for chest movement
      • Listen at the victims mouth for breath sounds
      • Feel for air on your cheek
      • Don’t waste more than 10 secs
    • If he is breathing normally
        • Turn him into the recovery position
        • Call for help/ ambulance
        • Check for continued breathing
      • If he is not breathing normally
      • Send someone for help/ ambulance service
      • Kneel by the side of the victim.
      • Place 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 hand
      • Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs or xiphisternum
      • Position yourself vertically above the victim’s chest and with your arms straight, press down the sternum 4 – 5 cms
      • After each compression, release all the pressure on the chest without losing contact between your hands and the sternum repeat at a rate of about 100/min
      • Compress and release for equal duration of time
    • 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)
  •  
  •  
  •  
    • Continue resuscitation until
    • • Qualified help arrives and takes over
    • • The victim starts breathing normally
    • • You become exhausted
    • Ventilation
      • Reduced blood flow to the lungs during CPR.
      • Ventilation/ perfusion ratio maintained Vt and RR.
      • Hyperventilation and large Vt are unnecessary and harmful increased intrathoracic pressure leads to reduced CO. and large Vt 1 ltr or more may cause gastric distention/ regurgitation
      • Interruptions in chest compression should be minimal.
    • Chest Compression
      • Blood flow is generated
        • Increased intrathoracic pressure
        • Direct compression of the heart
        • Systolic arterial pressure peaks – 60 – 80 mm Hg
        • Low diastolic pressure
        • Mean BP in carotid 40 mm Hg
  •  
  •  
    • Airway Management and Ventilation
        • Airway obstruction
      • 1. Secondary to loss of consciousness
      • 2. Primary cause of cardio respiratory arrest
        • Prompt assessment control of airway and ventilation will prevent secondary hypoxic damage to the brain and other vital organs
        • Airway obstruction in unconscious and obtunded patient
        • 1. Decreased muscle tone/ posterior displacement of the tongue and at the soft palate and epiglottis level
        • 2. Vomitus, blood, foreign body, laryngeal oedema are other causes of airway obstruction
  •  
  • RECOGNITION OF AIRWAY OBSTRUCTION
    • A Diagnosis often missed by Healthcare Professionals
    • Look for Chest and Abdominal movements
    • Listen and feel for Airflow at the Mouth and Nose
    • 1) Diminished air entry and noisy breathing indicates partial airway obstruction
    • 2) Inspiratory stridor is caused by obstruction at the pharyngeal and supra glottic level
    • 3) Biphasic stridor in glottic or cervical tracheal obstruction
    • 4) Expiratory wheeze implies obstruction of the lower airways
    • 5) Gurgling is caused by liquid or semisolid foreign material in the main airways
    • 6) Snoring arises when the pharynx is partially occluded by the soft palate or epiglottis
    • 7) Crowing is the sound of laryngeal spasm
  • AIRWAY OBSTRUCTION cont…
    • Paradoxical breathing
    • Use of accessory muscles of respiration*
    • * suprasternal, intercostal and subcostal recessions
    • Listening for absence of breath sounds
    • Failure to inflate the lungs during IPPV
  • BASIC AIRWAY MANAGEMENT
    • Head tilt and chin lift
  • BASIC AIRWAY MANAGEMENT cont…
    • Jaw thrust
    • Suspected cervical spine injury
    • Finger sweep and manual removal of foreign bodies
  • ADJUNCTS TO BASIC AIRWAY TECHNIQUES
    • Oropharyngeal airway
    • Sizes
    • Vomiting and laryngospasm
  • ADJUNCTS TO BASIC AIRWAY TECHNIQUES cont…
    • Nasopharyngeal airway
    • Indications
    • 1) In patients who are not deeply unconscious
    • 2) Life saving in patients with clenched jaws, trismus or maxillofacial injuries
    • Contraindications
    • 1) Fracture or deformity of the nose
    • 2) Fracture base of skull
    • 3) Coagulopathies
  • ADJUNCTS TO BASIC AIRWAY TECHNIQUES cont…
    • Oxygen inhalation
    • Oxygen masks with reservoir bag
    • Oxygen flow / litre per minute
    • SpO2 and ABGs
    • Suction
    • Blood, saliva and gastric contents
    • Intact gag reflex (vomiting)
  • VENTILATION
    • Mouth to mouth breathing
    • Instant availability /no equipment required
    • Oxygen content 16-17%
    • Aesthetically unpleasant
    • Risk of acquiring infection (TB,SARS,HBV,HCV)
    • Pocket resuscitation masks
    • Transparent just like anesthesia masks
    • Uni-directional valve
    • Connection for addition of O2
    • Large Vt or excessive inspiratory flow gastric distention and regurgitation
  •  
  • SELF INFLATING BAG
    • Can be connected to face mask/ETT/LMA/combitube
    • Oxygen delivery
    • room air 21%
    • O2 attachment 45%
    • reservoir bag 85% (10 L/min flow)
    • Difficult for one person to ventilate
    • Two person technique
  •  
  • ENDOTRACHEAL TUBES
    • ADVANTAGES
    • Optimal method of managing the airway
    • Maintenance of a patent airway
    • Protection from aspiration of gastric contents or blood
    • Provision of adequate tidal volume with uninterrupted chest compressions
    • Rescuers hand free for other tasks
    • Ability to suction airway secretions
    • Provision of a route for giving drugs
    • DISADVANTAGES
    • Technically trained and experienced personnel required
    • Unrecognized esophageal intubation
    • Dislodgment of the tube
    • Passage of tube in right main bronchus
    • Laryngeal and upper airway trauma
    • Prolonged attempts( compromised coronary & cerebral flow
  • LARYNGEAL MASK AIRWAY (LMA)
  • LARYNGEAL MASK AIRWAY (LMA) cont…
  • LARYNGEAL MASK AIRWAY (LMA) cont…
    • Successful ventilation 72-98%
    • Better than bag mask ventilation
    • Inflation pressures less than 20 cm of H2O
    • Interruption of chest compressions required for proper ventilation ( main disadvantage as compared to ETT)
  • THE COMBITUBE
  • CRICOTHYROTOMY/ LARYNGOTOMY
  •  
  • FBAO
  • FBAO
  •  
    • THANK YOU