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UNRESPONSIVE?
Open airway
Call 112*
30 chest compressions
Open airway Not breathing normally Send or go for AED Call 112* * or national emergency number
CPR 30:2
No shock advised
Continue until the victim starts to wake up: to move, opens eyes and to breathe normally
Fig 1.4_BLS-AED Final
Encourage cough Continue to check for deterioration to ineffective cough or until obstruction relieved
In Hospital Resuscitation
Collapsed/sick patient Shout for HELP & assess patient
No Signs of life? Yes
CPR 30:2
Assess rhythm
Non-shockable (PEA/Asystole)
1 Shock
During CPR
Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Vascular access (intravenous, intraosseous) Give adrenaline every 3-5 min Correct reversible causes
Reversible causes
Hypoxia Hypovolaemia Hypo-/hyperkalaemia/metabolic Hypothermia Thrombosis Tamponade - cardiac Toxins Tension pneumothorax
Synchronised DC Shock*
Up to 3 attempts
Unstable
Assess for evidence of adverse signs 1. Shock 2. Syncope 3. Myocardial ischaemia 4. Heart failure
Stable
Amiodarone 300 mg IV over 10-20 min and repeat shock; followed by: Amiodarone 900 mg over 24 h
Broad
Narrow
Irregular
Regular
Regular
Irregular
Use vagal manoeuvres Adenosine 6 mg rapid IV bolus; if unsuccessful give 12 mg; if unsuccessful give further 12 mg. Monitor ECG continuously
Irregular Narrow Complex Tachycardia Probable atrial brillation Control rate with: -Blocker or diltiazem Consider digoxin or amiodarone if evidence of heart failure Anticoagulate if duration > 48h
Possibilities include: AF with bundle branch block treat as for narrow complex Pre-excited AF consider amiodarone Polymorphic VT (e.g. torsades de pointes give magnesium 2 g over 10 min)
If Ventricular Tachycardia (or uncertain rhythm): Amiodarone 300 mg IV over 20-60 min; then 900 mg over 24 h If previously confirmed SVT with bundle branch block: Give adenosine as for regular narrow complex tachycardia
No
Yes
Probable re-entry PSVT: Record 12-lead ECG in sinus rhythm If recurs, give adenosine again & consider choice of anti-arrhythmic prophylaxis
Bradycardia Algorithm
Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, SpO2 ,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities)
Yes
Assess for evidence of adverse signs: 1 Shock 2 Syncope 3 Myocardial ischaemia 4 Heart failure
No
Satisfactory Response? No
Yes
Yes
Risk of asystole? Recent asystole Mbitz II AV block Complete heart block with broad QRS Ventricular pause > 3s
Interim measures: Atropine 500 mcg IV repeat to maximum of 3 mg Isoprenaline 5 mcg min-1 Adrenaline 2-10 mcg min-1 Alternative drugs* OR Transcutaneous pacing
No
Seek expert help Arrange transvenous pacing * Alternatives include: Aminophylline Dopamine Glucagon (if beta-blocker or calcium channel blocker overdose) Glycopyrrolate can be used instead of atropine
Fig 1.8_Bradycardia Final
Observe
0.1 mV in 2 adjacent limb leads and/ or 0.2 mV in adjacent chest leads or (presumably) new LBBB
High risk dynamic ECG changes ST depression haemodynamic/rhythm instability diabetes mellitus
Fig 1.9_ACS Definitons Final
non-STEMI-ACS
ECG
Pain relief Nitroglycerin sl if systolic BP > 90 mmHg Morphine (repeated doses) of 3-5 mg until pain free
Antiplatelet treatment
160-325mg Acetylsalicylic acid chewed tablet (or iv) 75 600 mg Clopidogrel according to strategy*
STEMI
Non-STEMI-ACS
Thrombolysis preferred if no contraindications and inappropriate delay to PCI Adjunctive therapy: UFH, enoxaparin or fondaparinux
PCI preferred if timely available in a high volume center contraindications for fibrinolysis cardiogenic shock (or severe left ventricular failure) Adjunctive therapy: UFH, enoxaparin or bivalirudin may be considered
Conservative or delayed invasive strategy# UFH (fondaparinux or bivalirudin may be considered in pts with high bleeding risk)
Open airway
5 rescue breaths
NO SIGNS OF LIFE?
30 chest compressions
2 rescue breaths 30 compressions After 1 minute of CPR call 112 or national emergency number
Fig 1.11_Paed BLS Final
Ineffective cough
Effective cough
Encourage cough Continue to check for deterioration to ineffective cough or until obstruction relieved
Assess rhythm
Non-shockable (PEA/Asystole)
1 Shock 4 J/kg
During CPR
Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Vascular access (intravenous, intraosseous) Give adrenaline every 3-5 min Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Correct reversible causes
Reversible causes
Hypoxia Hypovolaemia Hypo-/hyperkalaemia/metabolic Hypothermia Tension pneumothorax Toxins Tamponade - cardiac Thromboembolism
Dry the baby Remove any wet towels and cover Start the clock or note the time
Birth
30 sec
Recheck head position Consider two-person airway control or other airway manoeuvres Repeat inflation breaths
Consider SpO2 monitoring Look for a response
Acceptable* pre-ductal SpO2 2 min : 60% 3 min : 70% 4 min : 80% 5 min : 85% 10 min : 90%
When the chest is moving If the heart rate is not detectable or slow (< 60) Start chest compressions
3 compressions to each breath
Reassess heart rate every 30 seconds If the heart rate is not detectable or slow (< 60)
Consider venous access and drugs * www.pediatrics.org/cgi/doi/10.1542/peds.2009-1510 Fig 1.14 NLS Algorithm Final