BASIC LIFE SUPPORT THEORY Before reading this, you should watch the 5 minute film found on Youtube titled ERC BLS WITH AED
Objectives By the end of this session you will have an awareness of: Importance of the the Chain of Survival Current guidelines for: Basic Life Support (BLS) Use of the recovery position Dealing with a choking victim Trust Emergency Equipment (including Automated external defibrillator or AED) Trust Documentation in relation to resuscitation
European Resuscitation Council Please click the link below to watch a short video by the European Resuscitation Council before continuing to the next page ERC BLS Video
Objectives (continued) After reading this presentation, you must arrange an appointment via resuscitation training department to be observed delivering BLS and using an AED to be marked as compliant with trust mandatory training. You will be assessed using the following assessment sheet: NB: by attending the practical assessment you are inferring that you have read and understood all of the content of this presentation
The steps that contribute to successful outcome after cardiac arrest form the chain of survival. The chain is only as strong as the weakest link, all links should be strong to give the best outcomes for patients. The 4 stages of this chain are described over the next slides.
Stage 1: recognition of deterioration and calling for help Cardiac arrests in hospital are often preventable. Signs that patients are deteriorating may include signs such as chest pain, acute confusion or drop in level of consciousness and a rise in national early warning score (NEWS) when recording observations. Implementation of NEWS has reduced cardiac arrests by roughly a third as staff are prompted to escalate sick patients early Calling for help early can prevent further deterioration, which in turn can prevent cardiac arrest and therefore death. Help may include colleagues with a different skill set, doctors or medical emergency team (MET). If recording observations, then NEWS escalation policy MUST be followed
National Early Warning Score (NEWS) When recording observations, this escalation must be followed as a minimum
Stage 2: Early CPR Once cardiac arrest has been confirmed cardiopulmonary resuscitation (CPR) must be commenced immediately after calling for help. CPR slows down the rate of deterioration of the heart and brain by supplying oxygen. CPR must be performed to a high standard and with minimal interruptions to be effective. High quality CPR is only equivalent to around a third of the work the body would have done normally, unfortunately CPR is often not of a good standard due to lack of practice, which can lead to nervousness and poor technique. Very few people will respond to CPR alone, the aim of CPR is to buy time for the victim until further interventions can be made. Chance of survival from cardiac arrest is generally less than 20%.
Stage 3: Early defibrillation Defibrillation within 3-5 minutes of collapse can give survival rates as high as 50-70%, however the chances of defibrillation being effective are reduced if CPR is not performed to a high standard Chance of survival drops by around 10-12% with every passing minute that defibrillation is delayed. This is one of the many reasons why staff should be familiar with where their emergency equipment is, ensure that it is promptly brought to the collapsed patient and always ready for use.
Stage 4 : Post-resuscitation care While CPR and defibrillation aim to restore a pulse, the ultimate goal is to restore the patient to a stable condition and restore health to the point where they can safely leave hospital with minimal risk of further deterioration. In terms of BLS, we need to handover the event to the rescuers that have come to give support, the handover tool we use is SBAR which is a nationally recognised communication tool: S Situation prompting call for help B Background including any change prior to collapse A Assessment or what is happening now R Recommendations (can be given or requested) For example; This patient was seen to collapse and I have confirmed cardiac arrest. They were admitted with chest pain and complained of breathlessness prior to collapse. We have just started CPR and are setting up the defibrillator, please can you take over, what can I do to help?
D R S A B C (approach to confirm cardiac arrest) Danger Response Shout for help Airway Breathing / Signs of life Call 2222 / 999 / 112 Start CPR 30:2 This sequence will now be described in detail
Danger Check if it is safe for you to approach, are bystanders safe, is the victim safe? If you cannot make an environment safe to approach you should wait for further support Our biggest hazard in hospital is slips, trips and falls, particularly if there is lots of equipment around the patient don t put yourself at risk by being complacent!
Response Gently shake the shoulder Give a simple command eg open your eyes
Is the patient responsive? YES NO Check for injuries Reassess Get help Shout for help, press buzzer Continue assessment
Open the Airway Turn the victim onto their back Look in the mouth for foreign body and remove what you safely can (don t do blind finger sweeps as this can convert a partial airway obstruction to complete). Turn to head to drain secretions or perform suction if immediately available. Leave well fitting dentures in place Open the airway with an airway opening manouvre head tilt/chin lift (as in picture) if cervical spine injury suspected use jaw thrust
Open the Airway jaw thrust Consider jaw thrust when patient has suffered head/neck injury, as keeping the head and neck still minimises the risk of further injury Keeping head and neck still, place fingers behind the angle of the jaw and lift upwards If this doesn t open the airway, apply a head tilt gently until airway is open
Is the patient breathing notmally with signs of life (+ / - Pulse)? YES If safe, use recovery position Go for help Reassess at intervals
Recovery Position Assists with the drainage of secretions Maintains an open airway Considered safer position to leave the casualty, in order to gain help Remember that when a patient is in the recovery position, their airway is safer than if they were on their back, however patients in the recovery position can also deteriorate to the point of cardiac arrest, so continue to assess
Place arm nearest the rescuer at a right angle Place other hand against the cheek, palm outwards
Lift up behind the knee furthest away and push downwards The patient should roll over quickly and easily towards you
To prevent nerve and tissue damage turn the patient side to side every 30 minutes. If the patient has significant injuries, place on the unaffected side first if possible
Is the patient breathing normally with signs of life (+ / - Pulse)? NO - Call for help: Call 2222 within trust stating medical emergency followed by your precise location (state paediatric medical emergency if it is a child) If there is a cardiac arrest or a medical emergency where the airway is compromised (Eg choking, anaphylaxis), on the Royal site only you should also state anaesthetic team On external Trust areas state medical emergency, hospital grounds followed by location and nearest building (9)999 or 112 off trust premises to summon ambulance services
Chest compressions Place heel of the hand on the lower third of sternum Compress chest 100-120 per minute, or 2 per second Depth 5-6 cm Deliver 30 compressions
Start chest compressions From the side of the victim put your hands on the lower third of the sternum Place heel of hand in centre (crosswise) of chest with other hand on top Interlock fingers and pull fingers up ensuring you re not leaning on the victims ribs. Keep your arms straight with shoulders above hands Press down on the sternum aiming to depress between 5 and 6 cm, after each compression, release all the pressure on the chest without loosing contact with the sternum. Repeat at a rate of 100-120 per min or 2 compressions per second Swap rescuers every 2 minutes where possible to maintain quality
Rescue Breaths After every 30 compressions aim to deliver 2 breaths Pinch patient s nose Maintain chin lift Ensure a good mouth-to-mouth seal Blow steadily (1 sec) into patient s mouth Make chest rise as in normal breathing then repeat a second time Remember delivering breaths is safe there is no recorded cases of Hep B/C or HIV transmission from this intervention Breaths are important as they top up the supply of oxygen that compressions push around the body
Ventilation Use the most appropriate equipment to ventilate Use pocket mask if available bag valve mask if trained to do so Add Oxygen as soon as possible Consider Insertion of an oropharangeal airway
Rescue mask Position the mask over the nose and mouth, pointed end over the nose Press the mask to the face to minimise air leaks Pull the chin upwards to open the airway Blow into the one way valve to make the chest rise and fall as in normal breathing Attach oxygen tubing turned up to 15 litres once available
Continue resuscitation at a ratio of 30 compressions to 2 breaths: This ratio stays the same no matter how many rescuers there are Consider 1 minute of CPR before leaving to get help if the victim is a child or have drowned they are more likely to need oxygen from CPR than a defibrillator You can stop CPR when: Qualified help arrives and takes over The patient shows signs of life (if breathing normally consider recovery position) You become exhausted
Compression-only CPR Should be considered if reluctance or inability to perform mouth-to-mouth ventilation and no equipment available Chest compressions alone are better than no CPR If possible combine with head tilt, there is some evidence that shows this will generate artificial breathing to a small degree
Neck breathers If a patient breathes through a stoma to their neck breaths should be delivered through this stoma rather than their mouth (upper airway may not be connected) Cover/close nose and mouth Don t do head tilt chin lift Deliver rescue breaths via stoma aiming to make the chest rise and fall as in normal breathing Use a neck breather mask when available (found in airway drawer on emergency trolley)
How to deal with a choking victim: Initial assessment Choking may be recognised by coughing, colour changes, agitation, pointing to the throat, or the victim may say I m choking! Encourage coughing until signs of cyanosis or cough is ineffective/silent (when the victim is coughing, they are the best person to dislodge the obstruction!). Once we recognise either of these signs, we should intervene
First choking manouvre is to deliver up to 5 back blows. Position the victim upright and leaning forwards to deliver a sharp blow between the shoulder blades, assessing for effectiveness after each blow If not effective deliver up to 5 abdominal thrusts. Make a fist in front of the abdomen pulling inwards and upward sharply, assessing for effectiveness Alternate between both choking manouvres until airway is cleared If the victim is pregnant or <1 yr perform chst thrusts instead of abdominal thrusts
Patient loses consciousness If not already done, call 2222 or 999 / 112 Then commence CPR at a ratio of 30:2 Until patient starts to breathe normally
In Summary Danger Response Shout for Help Airway Breathing / Signs of Life Call 2222 or 999 / 112 Start CPR 30:2
Trust Documentation
Reporting Electronic incident report (DATIX) should be completed for EVERY call to 2222 summoning MET including: MET calls for both deteriorating patients and cardiac arrest Call triggered by raised NEWS False alarms It is everybody s responsibility to complete DATIX which should be completed as near to the time of the event as possible
Transfer policy When moving patients around the trust, this should be planned to ensure a safe journey for the patient. This should include ensuring the receiving area is ready before you set off and an assessment of what equipment and personnel are necessary. If you don t think you have enough resources to safely move the patient, this should be escalated
Do not attempt Cardiopulmonary Resuscitation (DNACPR) Many in-hospital cardiac arrests occur following a period of decline due to co-morbidities It is vital to recognise this and make pro-active decisions Making a DNACPR decision allows a person to die with dignity (inappropriate CPR can prolong death rather than extending life) Patients can remain for active treatment and have a DNACPR decision (do not resuscitate does not mean do not treat) Providing active treatment is not a reason not to consider and document what to do in event of cardiac arrest You should ensure you know the resuscitation status of your patients, and if unsure, ask. If a patient arrests and there is lack of clarity around resuscitation status you should start CPR
Who do we discuss DNACPR with? All patients with capacity must be consulted unless it is believed that the discussion is likely to cause harm or the patient indicates that they do not want to participate. Document this on the red card The decision is a clinical one based on assessment and consideration of the patient s best interests The Guardian, 17 June 2014
RLBUHT DNACPR document At present we are using this red card system to communicate resuscitation status Can only be completed by senior doctors, but may be updated by a junior doctor Expiry date should be checked at the beginning of every shift and this should be communicated with all staff who come into contact with the patient This document is only valid for one hospital admission and is voided by discharge from the trust
udnacpr is the document used in community to communicate that a patient is not for CPR If a patient is admitted to our trust with this document, doctors in the admission areas will complete the trust DNACPR to acknowledge this decision is in place. Consultants can discharge a patient into community with this order completed if appropriate to do so
Emergency equipment Bottom door must be opened fully before top drawers will unlock Picture 679 from desktop
Daily checklist (front) Daily checklist must completed at least once every 24 hours, this will be audited and fed back to trust board Yes or no should be completed for each box as appropriate Four weeks of records only should be kept on the trolley
Daily checklist (back) If you have to record no for any part of the daily checklist your actions must be completed on the reverse of the checklist. Any issues you cannot rectify should be escalated
Weekly checklist: A full trolley check should be made: Every 7 days as a minimum If the trolley has been`opened for any reason including training If on a daily check it is noted that the last recorded security seal number doesn t match the one on the trolley
Top of trolley Each 24 hours as a minimum the trolley must have a daily check. This is to ensure that the trolley is clean and servicable, the defibrillator passes it s test, the security seal matches the last recorded number, and the following items are available and in date: 1x Oxygen cylinder at least 3/4 full 1x Self- inflating bag (Ambu) with reservoir, Oxygen tubing 1x pocket mask - Disposable 1x box of gloves (medium) 1x sharps container 1x Multifunction defibrillator pads NB test blocks MUST be removed from defibrillator cable after testing
Top of trolley: portable suction machine (runs on mains or battery if charged). Suction is part of emergency equipment and must also be checked on a daily basis
Top drawer: equipment to take bloods, cannulate etc (checked each time seal is broken or every 7 days) 6x Sodium Chloride 0.9% flush 10 ml pre-drawn syringes 4x Safety Needles - (blue/green/white/blunt) 2x Each size Ported B-Braun Venflons - (14g - orange, 16g grey, 18g green) NB NO OTHER TYPE TO BE ADDED 2x 3-Way taps 2x Gauze swabs 1x Tape 4 x IV dressings 10x alcohol swabs 2x disposable tourniquets 2x Cling bandages 2x Syringes - (5, 10, 20ml) 2x Arterial blood gas syringes
Second drawer: equipment for airway and breathing support (checked each time seal is broken or every 7 days) 1x Adult non-rebreather O2 mask 1x Guedal airways - size 2, 3 & 4 1x Nasopharangeal airway size 6mm or 28F + 7mm or 32F 4x sachets Lubricant 1x Resuscitation mask for neck breathers with one way valve 1x Cuffed endotracheal tubes - size 6, 7, 8 & 9 (All tubes low pressure, uncut and sealed) 1x Catheter Mount 1x Mac 3 Laryngoscope single use. 1X mac 4 Laryngoscope single use 1x intubation stylet - 1x Bandage/tape to secure 1x Stethoscope 1x Magills forceps Disposable 1x Bandage/tape to secure ET tube 1x Adult Yankauer 1x strong scissors1 x Bougie 1x 20ml Syringe 1x 10,12,14,16 F, Fine Bore Suction Catheter BGH only 1x LMAs size - 3,4 & 5 1x 50ml syringe
Third drawer: Fluids and giving sets (checked each time seal is broken or every 7 days) 2x Blood giving set 1x IV giving set 1x 500ml Glucose 10% 1x 1000ml Hartmans 1x 1000ml Sodium Chloride 0.9% 1x 500ml Gelofusine
Bottom drawer (checked each time seal is broken or every 7 days) 2x packs of ECG electrodes-(3 in each pack) 2x Leadercath central line (14 + 16G) 1x Emergency drug box - in date 1x Spare ECG roll 1x Multifunction pads in date
BLS with AED algorithm (as seen in ERC film)
Use of AED Use of AED/PAD: Turn machine on and follow voice prompts Pads must be placed on the clean, bare dry chest of victim avoiding jewellery/implanted devices by 8-10cm Minimise unnecessary interruptions to CPR If prompted to press shock button, ensure nobody is touching the patient and immediately return to CPR NB It is not expected that staff use the manual mode of defibrillators unless trained to do so (ILS or ALS trained)
Additional Learning For additional information and learning please click on the link below to watch the Resuscitation Council Life Saver video http://www.life-saver.org.uk/ And visit www.resus.org.uk
For any other training or enquiries contact; Department of Resuscitation Training Extension 2045 Email resus.courses@rlbuht.nhs.uk