Advancd life support inservice


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For All the Nursing Students and Teachers

Advancd life support inservice

  1. 1. Bsc.Nsg 4th year 1 4/6/2013
  2. 2. Objectives At the end of this educational program, participants will be able to: - Review cardiac arrest - Review basic life support - Describe Advanced Life Support - Demonstrate - Basic life support - Airway insertion - DefibrillationBsc.Nsg 4th year 2 4/6/2013
  3. 3. TOPIC TIME SPEAKER Welcome note 2 min Divya Labh Background 2 min Divya Labh Pretest 5 min Review of cardiac arrest 5 min Divya Labh Review of basic life support 10 min Divya Labh Anu Aryal Advanced life support(ALS) 5min Anu Aryal Defibrillation and nurses role 5min Anita Gurung Drugs used in ALS 5 min Anita Gurung Flowchart of adult ALS sequence 15 min Hricha Neupane Post resuscitation care 2 min Hricha Neupane Break for refreshment 15 min Demonstration on 30 min All BLS, airway insertion, defibrillation Post test 10 min Hricha Neupane Vote of thanksBsc.Nsg 4th year 3 4/6/2013
  4. 4. Bsc.Nsg 4th year 4 4/6/2013
  5. 5. Cardiac arrest Cardiac arrest is the abrupt cessation of cardiac pump function, which may be reversible by a prompt intervention but will lead to death in its absence. It is due to asystole, pulseless electrical activity, ventricular tachycardia or fibrillation.Bsc.Nsg 4th year 5 4/6/2013
  6. 6. CAUSES OF CARDIAC ARREST CARDIAC: Coronary artery OTHERS disease Severe anaphylaxis M.I. Suffocation Arrhythmia Electrocution Low Trauma C.O.,failure,shock Stroke Cardiomyopathy Exsanguinations Myocarditis Drowning Massive pulmonary emboliBsc.Nsg 4th year 6 4/6/2013
  7. 7. REVERSIBLE CAUSES OF CARDIAC ARREST: 4 Ts:  Thromboembolism 4Hs: Tension Hypoxia pneumothorax Hypovolemia Tamponade Hypo/hyperkalemia Toxicity(TCAs,b- Hydrogen ions blockers,ca channel blocker,dogoxin)Bsc.Nsg 4th year 7 4/6/2013
  8. 8. CLINICAL MANIFESTATIONS: Consciousness , pulse ,and blood pressure are lost immediately. Pupil start dilating within 45 seconds. Seizure may or may not occur. ! Nursing alert The most reliable sign of cardiac arrest is absence of pulse. In adult &child carotid pulse is assessed while in infant brachial pulse is assessed. Valuable time not to be wasted taking BP, listening for heartbeat, or checking proper contact of electrode.Bsc.Nsg 4th year 8 4/6/2013
  9. 9. MANAGEMENT : Basic Life Support (BLS)  Advanced Cardiac Life Support (ACLS)  Post Resuscitation Care The urgency of cardio respiratory arrest & the fact that brain damage can occur within 4-6 mins without circulation (except in hypothermia)make it necessary to start early BLS within 4 mins and rapid ACLS within 8 min to establish neurological recovery and survival.Bsc.Nsg 4th year 9 4/6/2013
  10. 10. Chain of survivalBsc.Nsg 4th year 10 4/6/2013
  11. 11. Bsc.Nsg 4th year 11 4/6/2013
  12. 12. BASIC LIFE SUPPORT (BLS) It comprises of cardiopulmonary resuscitation(CPR) which is a series of measures aimed at delivery of oxygenated blood to the heart and brain until further therapy can restore spontaneous and effective circulation.Bsc.Nsg 4th year 12 4/6/2013
  13. 13. Bsc.Nsg 4th year 13 4/6/2013
  14. 14. WHY C-A-B ?Bsc.Nsg 4th year 14 4/6/2013
  15. 15. ADULT BLS Sequence • Recognize unresponsive adult with no breathing or no normal breathing (ie, only agonal gasps)Bsc.Nsg 4th year 15 4/6/2013
  16. 16. Activate emergency response, retrieve AED (or send someone to do this)Bsc.Nsg 4th year 16 4/6/2013
  17. 17. • Check for pulse (no more than 10 seconds) • If no pulse, begin sets of 30 chest compressions and 2 breaths • Use AED as soon as availableBsc.Nsg 4th year 17 4/6/2013
  18. 18. Bsc.Nsg 4th year 18 4/6/2013
  19. 19. Before you begin Check for: Is the person conscious or unconscious? If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?“ If the person doesnt respond and two people are available, one should begin CPR another should call Emergency team.Bsc.Nsg 4th year 19 4/6/2013
  20. 20. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR immediately.Bsc.Nsg 4th year 20 4/6/2013
  21. 21. Chest compressions Put the person on his or her back on a firm surface. Kneel next to the persons neck and shoulders. Place the heel of one hand over the center of the persons chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.Bsc.Nsg 4th year 21 4/6/2013
  22. 22. Chest compressions Use your upper body weight (not just your arms) as you push straight down on (compress) the chest at least 2 inches (approximately 5 centimeters). Push hard at a rate of about 30compressions:2 breath.Bsc.Nsg 4th year 22 4/6/2013
  23. 23. Chest compressions If you havent been trained in CPR, continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR, go on to checking the airway and rescue breathing.Bsc.Nsg 4th year 23 4/6/2013
  24. 24. Airway: Clear the airway After 30 chest compressions, open the persons airway using the head-tilt, chin-lift maneuver.Bsc.Nsg 4th year 24 4/6/2013
  25. 25. Jaw thrustBsc.Nsg 4th year 25 4/6/2013
  26. 26. Breathing: Breathe for the person Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or cant be opened.Bsc.Nsg 4th year 26 4/6/2013
  27. 27. RESCUE BREATH Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesnt rise, repeat the maneuver and then give the second breath. 30 chest compressions followed by 2 rescue breaths is considered one cycle. Resume chest compressions to restore circulation.Bsc.Nsg 4th year 27 4/6/2013
  28. 28. If the person has not begun moving after five cycles (about two minutes) and an automatic external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR — starting with chest compressions — for two more minutes before administering a second shock.Bsc.Nsg 4th year 28 4/6/2013
  29. 29. Continue CPR until there are signs of movement or until the patient is taken to emergency.Bsc.Nsg 4th year 29 4/6/2013
  30. 30. Key Issues and Major Changes • “Look, listen, and feel for breathing” has been removed from the algorithm. • Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression minimizing interruptions in compressions, and avoiding excessive ventilation).Bsc.Nsg 4th year 30 4/6/2013
  31. 31. To initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). Compression rate should be at least 100/min (rather than “approximately” 100/min). Compression depth for adults has been changed from the range of 1½ to 2 inches to at least 2 inches (5 cm).Bsc.Nsg 4th year 31 4/6/2013
  32. 32. BLS only provides 15 to 20% of normal cardiac output and should be regarded as “buying time” until the commencement of ALS. If there is more than one rescuer present , another should take over the CPR every 1 to 2 minute to prevent fatigue.Bsc.Nsg 4th year 32 4/6/2013
  33. 33. ADVANCED LIFE SUPPORT Advanced life support (ALS) includes use of adjunctive equipment and techniques for  assisting ventilation and circulation  ECG monitoring with dysrrhythmia recognition and defibrillation  establishment of I.V. access and pharmacologic therapy in addition to BLS skills.Bsc.Nsg 4th year 33 4/6/2013
  34. 34. ALS ALGORITHMBsc.Nsg 4th year 34 4/6/2013
  35. 35. ALS includes:  Circulation by cardiac compression Airway management by equipments  Breathing by advanced techniques  Defibrillation by manual defibrillator  Drugs.Bsc.Nsg 4th year 35 4/6/2013
  36. 36. Circulation Chest compression: - rate- 100/min - Place- mid of sternum - Depth- at least 5 cm (2inches) - or 1/3rd of AP diameter of chest - No synchrony with respirationBsc.Nsg 4th year 36 4/6/2013
  37. 37. Precordial Thump • The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest. • The precordial thump may be considered for patients with witnessed, monitored, unstable VT (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery.Bsc.Nsg 4th year 37 4/6/2013
  38. 38. A. Airway management 1) Guedel’s airways- Most commonly usedBsc.Nsg 4th year 38 4/6/2013
  39. 39. Airway management 2) Laryngeal Mask AirwaysBsc.Nsg 4th year 39 4/6/2013
  40. 40. Airway management 3) Endotracheal tubeBsc.Nsg 4th year 40 4/6/2013
  41. 41. B. Breathing: Breathing can be accomplished by 1.Bag and mask ventilation 2.Ventilation by advanced method: a.ET tube: Intubation is most definitive and best method for ventilation. b.LMA c.Tracheostomy tube 3. Ventilation by automatic ventilators.Bsc.Nsg 4th year 41 4/6/2013
  42. 42. Bag and Mask VentillationBsc.Nsg 4th year 42 4/6/2013
  43. 43. Artificial Manual Breathing Unit(AMBU) It consists of self inflating bag made up of rubber or silicon, connector, safety valve, mouth piece.100% oxygen can be delivered by AMBU bag by attaching oxygen source and oxygen reservoir.Bsc.Nsg 4th year 43 4/6/2013
  44. 44. Defibrillation These are the treatment for tachydysrhythmias. Defibrillation depolarize the critical mass of myocardial cell at once. When they repolarize the sinus node recapture its role as the pacemaker . Is treatment of choice for pulseless VT/VF.Bsc.Nsg 4th year 4/6/2013
  45. 45. Ventricular tachycardiaBsc.Nsg 4th year 45 4/6/2013
  46. 46. Ventricular fibrillationBsc.Nsg 4th year 46 4/6/2013
  47. 47. Defibrillator Defibrillators can be classified as : Monophasic(delivers current of one polarity only and Biphasic (deliver current of 2 polarity)Bsc.Nsg 4th year 47 4/6/2013
  48. 48. Position of defibrillator paddle: 1st paddle - on the right side of the chest just below the clavicle 2nd at precordial, region. Paddle should be applied with pressure equivalent to 10 kg.Bsc.Nsg 4th year 48 4/6/2013
  49. 49. Paddle size Adult: 13cm Children:8cm Infants:4.5cmLatest Recommendation for shock protocol ;Previous recommendation of 3 successive shock (200,300,360J)Now a days only single shock is recommended .i.e. 360J by monophasic 150-200J by biphasicBsc.Nsg 4th year 49 4/6/2013
  50. 50. Nurses role while performing defibrillation Apply conducting jelly between the paddle and the skin. Place the paddle so that they dont touch patient’s clothing and bed linen and arent near medication and direct oxygen flow. Ensure that defibrillator is not in synchronized mode. Dont charge the device until ready to shock; then keep the thumbs and fingers off discharge button until paddle are on the chest.Bsc.Nsg 4th year 50 4/6/2013
  51. 51. Nurses role in defibrillation Before pressing the discharge button call “ all clear” 3 times 1st clear: Ensures you aren’t touching patient,bed, equipment 2nd clear: Ensures no one is touching patient, bed , equipment 3rd clear: Ensures you and everyone else are clear off the patient and anything touching the patient.Bsc.Nsg 4th year 51 4/6/2013
  52. 52. Nurses role in defibrillation Record the delivered energy and the results (cardiac rhythm and pulse). After the event is complete inspect the skin under the pads and paddles for burns , and if any detected consult about the treatment.Bsc.Nsg 4th year 52 4/6/2013
  53. 53. DRUGS 1. Adrenaline(all types of cardiac arrest)- 1mg every 3-5 mins 2. Amidarone(VF,VT)- 1st dose:300mg IV bolus, 2nd dose 150 mg 3. Lidocaine(If Amidarone isn’t available) 4. Sodium bicarbonate(only if cardiac arrest is associated with hyperkalemia or tricyclic anti- depressent overdose) 5. Calcium gluconateBsc.Nsg 4th year 53 4/6/2013
  54. 54. Adrenaline (Epinephrine): Class : Adrenergic MOA : Causes Cardiac stimulation Indication : cardiac arrest Dose : Adults – 0.5-1 mg IV - repeat every 5min - Children – 10 mcg/kg Adverse reaction : nervousness , tremor, headache, drowsiness , palpitation , tachycardia , dyspnea .Bsc.Nsg 4th year 54 4/6/2013
  55. 55. Amiodarone: Class : Ventricular antiarrhythmic MOA : abolishes ventricular arrhythmia Indication : recurrent VF , unstable VT , atrial fibrillation Dose : 300mg IV ; further 150mg may be given , followed by an infusion of 900mg for 24 hour.Bsc.Nsg 4th year 55 4/6/2013
  56. 56. FLOWCHART OF ACLSBsc.Nsg 4th year 56 4/6/2013
  57. 57. Unresponsive Call for help(monitor/defribillator) Start BLS algorithm Attach monitor & defibrillator when available Check rhythmBsc.Nsg 4th year 57 4/6/2013
  58. 58. Rythm Non- Shockable shockable VT Asystole VF PEABsc.Nsg 4th year 58 4/6/2013
  59. 59. VF and VTBsc.Nsg 4th year 59 4/6/2013
  60. 60. Asystole and PEABsc.Nsg 4th year 60 4/6/2013
  61. 61. SHOCKABLE(pulseless VF/VT) 1stShock (150-200 biphasic, 360 monophasic) CPR 30:2(2min) If VF,VT persists 2nd Shock( 150-360 biphasic, 360 monophasic) CPR30:2(2 min)Bsc.Nsg 4th year 61 4/6/2013
  62. 62. Check monitor(if VT,VF persists) Adrenaline 1mg IV every 3-5min 3rd Shock CPR 30:2(2 min) Check monitor(if VT,VF persists) Amidarone(300 mgIV) 4th Shock CPR 30:2 (2 min)Bsc.Nsg 4th year 62 4/6/2013 Adrenaline 1mg IV
  63. 63. 5th shock Further shock after each 2 min period of CPR If organised electrical activity seen,check for pulse If pulse present:start post resuscitation care If no pulse and asystole seen :continue CPR and switchBsc.Nsg 4th year on to non shockable rhythm 63 4/6/2013
  64. 64. Management of Asystole and PEA Start CPR 30:2 Give adrenaline 1mg as soon as intravascular access is achieved. Continue CPR 30:2 until the airway is secured, then continue chest compressions without pausing during ventilation Consider possible reversible causes and correct any that are identifiedBsc.Nsg 4th year 64 4/6/2013
  65. 65. Management of Asystole and PEA Recheck the patient after 2 min: If there is still no pulse and no change in the ECG appearance: - Continue CPR. - Recheck the patient after 2 min and proceed accordingly. - Give further adrenaline 1 mg every 3-5 min (alternate loops). - If VF/VT, change to the shockable rhythm algorithm. - If a pulse is present, start post-resuscitation care.Bsc.Nsg 4th year 65 4/6/2013
  66. 66. WHEN TO STOP RESUSCITATIONBsc.Nsg 4th year 66 4/6/2013
  67. 67. POST RESUSCITATION CARE Optimizing vital organ perfusion Maintain o2 saturation more than or equal to 94% Transport to comprehensive post arrest system of care Emergent coronary reperfusion for high suspicion of STEMI or AMI Temperature control Aniticipation, treatment and prevention of multi organ dysfunctionBsc.Nsg 4th year 67 4/6/2013
  68. 68. Bsc.Nsg 4th year 68 4/6/2013
  69. 69. References: American Heart Association “Guidelines for CPR and ECC, 2010” Aitkenhead AR, Rowbotham DJ, Smith G. Textbook of Anesthesia, 4th Edition Churchill Livingstone:2001;748-757 Barash PG, Cullen BF, Stoclting RK, Clinical Anesthesia, 5th Edition, Lippincott, Williams and Wilkins:2006; 1390-1404 Stoclting Rk, Miler RD. Basics of Anesthesia, 4th Edition, Churchill Lvingstone:2000479-492 Harrisons, Principle of internal medicine, 16thBsc.Nsg 4th year 69 4/6/2013 Edition, Vol II, 1621-1622.