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Flashcards in Recognising the deteriorating patient and preventing arrest Deck (17):
1

Prognosis of inhospital cardiac arrest

Less than 20% survive to go home usually due to VF from myocardial ischaemia

2

Chain of prevention (5)

1) Education

2) Monitoring

3) Recognition

4) Call for help

5) Response

See EWS

3

Causes of deterioration: Airway

Can be complete (silent, no air movement and rapid arrest) or partial (Noisy breathing, strenuous resp movements, see saw breathing and abdo breathing). Causes:

- CNS depression
- Blood/vomitus
- Foreign body
- Epiglottitis
- Pharyngeal swelling
- Laryngospasm
- bronchospasm
- bronchial secretions
- Blocked tracheostomy

Check the patient’s responsiveness – talk to him and shake and shout if he does not respond.

4

Treatment of airway (3)

Turn patient onto side unless contraindicated

Suction to remove contents

Airway manouvres

Oxygen to achieve sats 94-98%

Monitor and record vital signs including respiratory rate, the oxygen saturation, the pulse, blood pressure, conscious level using the Glasgow coma score, and temperature

5

Breathing

Main breathing muscles are diaphragm (3rd,4th and 5th level) and intercostal muscles (innervated at level of ribs and paralysed by spinal cord lesion)

Pathology: myasthenia gravis, guillain barre, MS, kyphoscoliosis, fractured ribs.

Pneumo, haemo, tension, COPD, PE, asthma ARDS, pul oedema

6

Treatment

Oxygen 15l per min 94-98%

7

Circulation

Causes of VF:
ACS
HTN
valve disease
drugs

Circulation problems can be primary or secondary:
Primary problems include:

acute coronary syndromes
arrhythmias
hypertensive heart disease
valve disease
the effect of drugs on the heart
hereditary cardiac diseases
the effects of electrolyte and acid base abnormalities
Causes of secondary problems to the circulation include:

asphyxia
hypoxaemia
blood loss
hypothermia
septic shock

8

Features of arrhythmic syncope

Syncope in supine position
Syncope post exercise
Little to no prodrome
repeated unexpected syncope
FH of sudden cardiac death

9

Assessment airway:

Signs of airway obstruction
paradoxical chest movements (see saw)
noisy resp sounds

Airway manouvres
Give high flow O2
Maintain 94-98% or 88-92% as appropriate

10

Breathing

Look, listen, feel
Sweating, central cyanosis
RR, depth and pattern
chest deformity, raised JVP

COPD give 28% or 24% venturi

Non invasive ventilation in acute exac COPD helpful

11

Early recognition and a call for help to prevent cardiac arrest is the first link in the chain of survival.

For patients in-hospital this may prevent cardiac arrest and death, and prevent admissions to the intensive care unit.

Early identification can also identify patients who would not benefit from resuscitation or do not wish to be resuscitated. This will prevent inappropriate resuscitation attempts

Studies show that 50-80% of in-hospital cardiac arrest patients have a period of deterioration before the cardiac arrest.

Hypoxia and hypotension are common antecedents, and there are often delays in escalating treatments, or in referring the patient to intensive care or outreach teams.


Early identification can also identify patients who would not benefit from resuscitation or do not wish to be resuscitated. This will prevent inappropriate resuscitation attempts.

Studies show that 50-80% of in-hospital cardiac arrest patients have a period of deterioration before the cardiac arrest.

Hypoxia and hypotension are common antecedents, and there are often delays in escalating treatments, or in referring the patient to intensive care or outreach teams.

Once cardiac arrest occurs, survival after in-hospital cardiac arrest depends on the victim’s initial cardiac arrest rhythm and location of the arrest.

Survival to hospital discharge after a VF/VT cardiac arrest is 44%.

However most cardiac arrests, 82% in this data set, have non VF/VT arrests and survival to discharge is poor, about 7%.

12

Non VF/VT arrests or PEA and asystole tend to occur more commonly in ward areas and often have a period of deterioration before hand.

Prevention of cardiac arrest is very important for this group

13

Airway obstruction

Airway obstruction has a variety of causes.

A decreased conscious level is a common cause, for example after sedative drugs.

Other causes are listed.

Bronchospasm causes obstruction of the lower airways.

12. Airway obstruction is unlikely, for the time being at least, if the person can talk normally.

If a person has airway obstruction they will find it difficult to breath, may be distressed, or choking and there may be shortness of breath.

The breathing can also be noisy with stridor, wheeze or gurgling.

The victim may have a see-saw respiratory pattern and use his accessory muscles

14

Treatments for airway obstruction include:

airway opening manoeuvres such as the head tilt with chin lift, or the jaw thrust
the use of simple adjuncts such as oropharyngeal and nasopharyngeal airways
supraglottic airway devices, such as the laryngeal mask airway or igel
and finally, tracheal intubation

Remember to give oxygen – the amount of oxygen given should be adjusted so that the patient has a normal oxygen saturation.

15

Treating circulation problems

Treat circulation problems by first ensuring there are no airway or breathing problems.

Give oxygen if needed to maintain a normal oxygen saturation.

Obtain IV access and take bloods for lab tests.

Treat the underlying cause – for example, percutaneous coronary intervention after ST elevation myocardial infarction.

Give a fluid challenge and assess the response if the blood pressure is low.

Start haemodynamic monitoring.

Patients who remain hypotensive may benefit from inotropes and vasopressors.

If an acute coronary syndrome is suspected give aspirin/nitrates/oxygen, if appropriate, and morphine for the pain.

16

Disability problems are often caused by Airway, Breathing or Circulation problems, so ensure these have been recognized and treated.

Assess conscious level by using AVPU or the Glasgow Coma Scale score.

For AVPU, A stands for Alert, V for responds to Voice, P for responds to pain, and U for unresponsive.

The Glasgow Coma Scale score is based on the best score for eye opening, verbal response and motor response - a normal score is 15 and the lowest possible score is 3.

As mentioned earlier identify and treat any underlying ABC cause such as giving fluids for hypotension. Don’t forget to check the blood glucose and treat a low blood glucose with IV glucose.

An unconscious patient is at risk of aspirating gastric contents into his lungs – consider nursing the patient sitting up or in the lateral position to reduce this risk.

Always check the patient’s drug chart – ensure they are not on any drugs that decrease conscious level.

17

The E is for Exposure to ensure that you do a full assessment, including removing the patient’s clothes if necessary.

Look for injuries, rashes, evidence of bleeding.

Make sure you maintain the patient’s dignity at all times.