CPR LECTURE SERIES-130911

RESUSCITATION LECTURES:
INTRODUCTION TO ACUTE CARE:
EMERGENCY MEDICINE,
ANAESTHESIA,
CRITICAL CARE

DR.ABDUL ALI BIN RAJA MOHAMED, ASA

◼ ASSOC PROF IN EMERGENCY MEDICINE, FACULTY OF MEDICINE, MAHSA UNIVERSITY.
◼DIRECTOR, MAHSA CENTRE OF CLINICAL SKILLS EDUCATION AND TRAINING
◼HEAD, PARAMEDICAL TRAINING
◼ NATIONAL CHAIRMAN FOR TRAINING, MRCS, NATIONAL EXECUTIVE BOARD MRCS MALAYSIA
◼ PRESIDENT, MEDICALERT FOUNDATION MALAYSIA.
◼ VICE CHAIRMAN-1, MRCS SELANGOR. MALAYSIA
◼ MQA, MSQH PANEL MEMBER FOR EMERGENCY MEDICINE
◼ (1989-2008 : HEAD OF TRAUMA & EMERGENCY CENTRE, UMMC, UNIVERSITY MALAYA)
◼ (DIRECTOR, ACADEMY OF PARAMEDICAL SCIENCES, CUCMS)
◼ (PRINCIPAL/CEO, CYBER PUTRA COLLEGE, CYBERJAYA)
◼ INTL. MEMBER-AMERICAN COLLEGE OF EMERGENCY PHYSICIANS (ACEP)
◼ INTL. MEMBER- NATIONAL ASSOCIATION OF EMS PHYSICIANS (NAEMSP)
◼ PREMIUM PROF. MEMBER, COUNCIL ON CARDIOPULMONARY & CRITICAL CARE, AMERICAN HEART ASSOCIATION
◼ AHA ECC ACCREDATED BLS AND ACLS INSTRUCTOR
 OBJECTIVES OF THE COURSE:

• 1. To develop the clinical knowledge in relevant taking history, physical

examination, investigation, differential diagnosis and management common
emergency and critical care situations.
• 2. To demonstrate the necessary skills and competencies in initiating and
maintain essential resuscitation skills and safe management of patients in
emergency and critical situations.
• 3. To acquire basic knowledge on preoperative assessment, monitoring and
conduct of anaesthesia and post-operative management.
• 4. Describe the triage and organisational structure, resources available and
team leadership roles in the emergency and anaesthesia and critical care
settings.
Critical Care Medicine (or ‘intensive care medicine’) is concerned predominantly with
the management of patients with acute life-threatening conditions (‘the critically ill’).

• ED: Emergencies,
• ICU: Intensive care units
• OT: High-risk patients before and after major surgery.
• HDU: High-dependency units offer a level of care intermediate between the general
ward and that provided in an ICU.
• WARDS: Monitoring and support for patients at risk of developing organ failure…
• ANYWHERE & ANYTIME: ??????

Equipped with monitoring and technical facilities

Compact and complex mechanical ventilators
Portable ultrasound and echocardiography
Patients receive continuous expert medical & nursing care
 BLOOMS TAXONOMY OF LEARNING

• COGNITIVE DOMAIN
• PSYCHOMOTOR DOMAIN
• AFFECTIVE DOMAIN
RESUSCITATION SKILLS

?
EM MED. Observe:-
PATIENT’S S/S
PROCEDURE
MONITORING
TECHNIQUES

EMERGENCY MEDICINE POSTING

RESUS 3 ABOUT AND FROM THE PATIENT
LEARN
 ?
ICU. Observe:-
PATIENT’S S/S
PROCEDURE
MONITORING
TECHNIQUES

INTENSIVE CARE POSTING

 Anaes. Observe:-
PROCEDURE
MONITORING
TECHNIQUES

ANAESTHESIA POSTING
4. AVOID MEDICAL
ERRORS-
NEVER EVER………..
PATIENT
SAFETY
 THERE WILL ALWAYS BE HISTORY,
SYMPTOMS AND SIGNS BEFORE A
PATIENT BECOMES CRITICAL !!!!

• 84% HAD SHOWN DOCUMENTED EVIDENCE

OF DETERIORATION 8 HOURS BEFORE
ARREST.
• 70% HAD SHOWN PHYSIOLOGICAL CHANGES
BEFORE ARREST.
• 70% ADMITTED LATE TO ICU British Medical Journal
 Copyright©The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

• Levels of Organization: I CANNOT

BREATH…

SIGNS HAD
STARTED HERE
8 HRS EARLIER
 How different?
•
•
Crisis Environment
Time Restriction
3
• Changing Clinical Environment
• Team Work
• Inter-professional Learning
• Clinical governance MEDICO-
LEGAL
• Professional Accountability
CASE
• Professional Regulation
• Patient Safety
• ? NO HISTORY
• ? LIMITED EXAMINATION
• ? NO INVESTIGATION
• ? UNSURE DIAGNOSIS
✓ TREAT & MANAGE

5
 SHOCK
Def:
A complex clinical syndrome
that results when tissue
oxygenation or nutrient
delivery are insufficient to
maintain the metabolic
needs of the cell
 CLASSIFICATION AND DIFFERENCIATION OF SHOCK
TYPE CAUSE PATHO SYMPTOMS SIGNS VITAL SIGNS
PHYSIOLOGY PR/ECG RR SKIN SPO2 GCS BP
1 HYPOVOLUMIC LOSS OF REDUCED VOLUME, GIDDINESS, LETHARGY, PALLOR COOL,
BLOOD, VENOUS RETURN, ANXIOUS, AMS,LOC SWEATING, COLD,
FLUIDS CARDIAC OUTPUT, BP ANXIOUS CHILL,
RESTLESS PEA CLAMMY,
MOTTLED
2 CARDIOGENIC MI,VALVE PUMP FAILURE CARDIAC CHEST PAIN, ANXIOUS,
FAILURE, VALVE FAILURE DIZZINESS, LETHARGY
TAMPONAD DIAPHORESIS,
E, DRUGS NAUSEA, VOMITING, ARRHYTHMA
PALPITATIONS,

3 ANAPHYLACTIC DRUGS BRONCHOSPASM SOB, ITCH, GIDDINESS, WHEEZING, N/ N/

BITES VASODILATION & EXUDATE URTICARIA, EARLY WARM,
STINGS POOLING OF BLOOD HIVES, LATE COOL
REDUCED VENOUS PEA
RETURN & BP
4 SEPTIC BACTERIA, VASODILATION, CAPILLARY SITES OF INFECTION ANXIOUS, EARLY WARM,
VIRUSES, LEAKAGE, POOLING OF FLUSHED, LATE COOL
FUNGI- BLOOD, RESTLESS,
LUNGS, UTI, REDUCED VENOUS LOC PEA
GIT, POST OP RETURN & BP

5 NEUROGENIC CERVICAL SPINAL CORD INJURY, TRAUMA, UNABLE TO PARALYSIS, N EARLY WARM, N N
INJURY, SYMPATHETIC DAMAGE, MOVE, NUMBNESS, PARAESTHESIA LATE COOL
SPINAL VASODILATION, POOLING TINGLING, ,WARM PINK
DRUGS OF BLOOD REDUCED NECK PAIN, UNABLE P.,PRIAPISM,
VENOUS RETURN & BP TO BREATH, INCONTINENC BRADYCARDIA
E, REDUCED
TONE COPYRIGHT- Dr AAli
 CLASSIFICATION OF HAEMORRHAGIC SHOCK
NO SIGNS CLASS I CLASS II CLASS III CLASS VI
1 Blood Loss:
Percentage < 15% 15 – 30% 30-40 % ➢ 40%
Volume < 750 ml 750 – 1500 ml 1500-2000 ml ➢ 2000 ml

2 Blood Pressure:
Systolic Unchanged Normal Reduced Very Low
Diastole Unchanged Raised Reduced Unrecordable
3 Pulse Rate 100 bpm 100-120 bpm > 120 bpm ➢ 120 bpm
➢ thready
4 Capillary Refill Normal Slow Slow Undetectable

5 Respiratory Rate Normal Normal > 20 /min > 20 /min

6 Urinary Flow Rate ml/h > 35 20-35 10-20 0-10

7 Extremities Normal Pale, Cool Pale, Cold Pale, Cold, Clammy

8 Complexion Normal Pale Pale Ashen

9 Mental Status Alert Anxious Confused, Drowsy, Stupor,

Restless Aggressive Unconscious
 COMPONENTS NECESSARY FOR ADEQUATE PERFUSION

• Composition of ambient air

• Patent Airway
• Mechanics of ventilation
• Regulation of ventilation
• Ventilation/perfusion ratio
• Transport of Oxygen,CO2, by the blood
• Blood volume
• Pump function of the myocardium
• Systemic vascular resistance
• Microcirculation
• Blood pressure
 Dynamics of Capillary Exchange

10 9

• Starling’s law of the capillaries is that the volume of fluid & solutes
reabsorbed is almost as large as the volume filtered
Tortora & Grabowski 9/e ©2000 JWS 21-22
 Arterioles
• Small arteries delivering blood to
capillaries
– tunica media containing few layers
of muscle
• Metarterioles form branches into
capillary bed
– to bypass capillary bed, precapillary
sphincters close & blood flows out
of bed in thoroughfare channel
– vasomotion is intermittent
contraction & relaxation of
sphincters that allow filling of
capillary bed 5-10 times/minute

Tortora & Grabowski 9/e

21-23
 Innervation of the Heart

• Speed up the heart with sympathetic stimulation

• Slow it down with parasympathetic stimulation (X)
• Sensory information from baroreceptors (IX)
Tortora & Grabowski 9/e ©2000 JWS 21-25
 Formation of Urine

Figure 15.5
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
What is the Pathogenesis of Hypoperfusion ?
How do you interpret the Symptoms & Signs ?
NO
VITAL SIGNS VALUE RANGE REMARKS
1 PULSE RATE
Infants <160 bpm
7 VITAL SIGNS
Preschool <140 bpm
School <120 bpm
Adult <100 bpm 60 – 80 bpm Volume?
2 RESPIRATION Rate, TV
Infant 25 – 50 bpm
School 15 – 30 bpm
Adult 12 – 20 bpm 12 - 30 bpm <10 , >30
3 TEMPERATURE 37C >38.5C Cool, Cold, Chill,
Warm, Hot Clammy, Mottled
4 GLASGOW COMA SCALE 3 - 15
5 OXYGEN SAT % > 97% <95% , <90%
6 BLOOD PRESSURE
Infant 70 mm Hg
School 80 (2 age in years)
Adult 120/80 mmHg MAP?
7 PAIN SCALE 0 - 10
 OTHER SIGNS VALUE
1 SKIN Pale, Cool, Cold, Clammy, Mottled
CAPILLARY REFILL < 2 sec

2 CARDIAC RHYTHM
3 CVP / VEINS 4 – 10 cm H2O pr
4 ABG Metabolic Acidosis: <pH, n/<PaCO2, >Base def, < Bicarb.
5 URINARY OUTPUT 0.5 – 1 ml / kg / hr
6 PAWP 6 – 12 cm H2O pr
7 ARTERIAL PRESSURE
8 JUGULAR/NECK VEINS
9 PUPILS
10 CYANOSIS
11 EYE MOVEMENT
12 SPEECH
13 SPECIFIC SIGNS
 FLOW DIAGRAM FOR MANAGEMENT OF UNDIFFERENTIATED SHOCK
HISTORY THINK
1 Trauma? Haemorrhagic Sh.
Tension Pneumothorax
Cardiac Tamponade
2 GIT haemorrhage, Diarrhea, Vomiting? Volume Resus
3 Fever?Hypothermia? Sepsis syndrome
4Infection?
TFT
4 ECG / s/sACS? MI ? Cardiogenic Sh.
Pulm Embolism
5 Bradycardia / Hypotension? Drug injestion-Neg inotrops
TFT
Addisonian Crisis
6 Hypoxemia? Pulm. Embolism
7 Abdominal/Low Backpain? Volume Resus
Abd U/S
8 Wheezing / Hives? Anaphylaxis Sh.

ROSEN’S EMERGENCY MEDICINE

EARLY WARNING SCORING SYSTEM
VITAL SIGN SCORE 3 2 1 0 1 2 3
SYSTOLIC BP < 70 71 - 80 81 - 100 101 - 179 180 - 199 200 - 220 > 220
(mm Hg)
HEART RATE - < 40 41 - 50 51 - 100 101 - 110 110 - 130 > 130
(beats/min)
RESPIRATORY - <8 8 - 11 12 - 20 21 - 25 26 - 30 > 30
RATE
(breaths/min)
OXYGEN SAT < 85 86 - 90 90 - 94 > 95 - - -
(%)
AVPU - - CONFUSION A V P U
URINE OUTPUT < 80 80 - 120 120 - 200 >800 - -
(Past 4 hours/mls)
TREATMENT with 60% 90 – ANY OTHER
O2 (NRFM) 94% THERAPY

SCORE 3 = ALERT # SCORE 5 = URGENT # SCORE 7 = IMMEDIATE

National Early Warning Score (NEWS) 2 | RCP
London

https://www.rcplondon.ac.uk/projects/outputs/natio
nal-early-warning-score-news-2
Dec 19, 2017 - NEWS2 is the latest version of the
National Early Warning Score (NEWS), first
produced in 2012 and updated in December 2017
58 Year-old male HT, with a Crushing chest pain.
What are you going to do?
 RESPIRATORY DISTRESS
• Tachycardia
• Increased respiratory effort
• Inadequate respiratory effort
• Abnormal airway sounds
• Tachycardia
• Pale, cool skin (warm, red, diaphoretic)
• Agitation/Changes in level of consciousness
• Use of Abdominal muscles to assist in breathing
 RESPIRATORY FAILURE
• Marked tachypnoea
• Bradypnoea, Apnoea
• Increased/Decreased/
• No respiratory effort
• Poor distal lung air movement
• Tachycardia (early)
• Bradycardia (late)
• Cyanosis
• Stupor/Coma (late)
 RESPIRATORY ARREST
• Absence of breathing
• Gasping <6/min, No chest movement
39
 Mx RESPIRATORY ARREST – BLS/ALS
• Giving supplementary Oxygen
• Opening the airway
• Providing basic ventilation-MM,MM,BVM
• Using basic airway adjuncts-OPA,NPA
• Suctioning
• Assess and Fix
 BASIC AIRWAY SKILLS
• Head tilt- Chin lift
• Jaw thrust without head extension
• Mouth-to-mouth ventilation
• Mouth-to-nose ventilation
• Mouth-to-barrier device ventilation
• Bag-mask ventilation
 ADVANCED AIRWAY DEVICE
• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal tube
• Endotracheal tube
 ◼ Preparation
– Team Assembly
– Equipment Check
◼ Triage
– Sort patients by level of acuity
◼ Primary Survey
– Designed to identify injuries that are
immediately life threatening and to treat them
as they are identified
◼ Resuscitation
– Rapid procedures and treatment to treat
injuries found in primary survey before
completing the secondary survey
◼ Secondary Survey

ATLS® – SAMPLE/Full History and Physical Exam to

evaluate for other traumatic injuries
◼ Monitoring and Evaluation, Secondary adjuncts
◼ Transfer to Definitive Care
Advanced Trauma Life Support – ICU, Ward, Operating Theatre, Another facility
TOPICS COVERED DURING THE COURSE:
By the end of 6 weeks posting, the student should have acquired the knowledge of the principles of management,
skills and attitude in managing the following:

1. Resuscitation techniques,
2. Management of multiple injured patients.
3. Principles of management of different shock syndromes.
4. Understand the principles of preoperative assessment of patients posted for elective surgery, basic monitoring,
conduct of different anaesthetic techniques, post op management in PACU, acute and chronic pain management.
5. Principles of management of acute abdominal pain.
6. Common respiratory emergencies like bronchial asthma, acute exacerbation of COPD and respiratory failure.
7. Acute poisoning.
8. Emergency wound management
9. Management of Acute coronary syndrome.
10. Transport of critically patient.
11. Disaster preparedness.
12. Common endocrine emergencies
13. Fluid and electrolyte management.
14. Arterial blood gas analysis
15. Management of sepsis and Septic shock
16. Management of anaphylaxis.
TEACHING AND LEARNING ACTIVITIES:

1. Observations of management of cases in the Emergency Department, Intensive

Care Unit and Operation Theatre
2. Series of Lectures and Tutorials
3. Interactive Seminars on common conditions
4. Interactive Seminars on equipment used in emergency and critical care setting
5. Demonstration of emergency procedures
6. High-Quality CPR Practical
7. Simulation Case Scenarios in MCCSET, SPC
Some students comments

◼ ‘most enjoyable posting’

◼ ‘loved every minute’
◼ ‘wish to stay longer’
◼ ‘resus room was great. Learnt a lot’
◼ ‘able to do a lot of things,……..more confident ‘
◼ ‘I stitched!’
◼ ‘so many acute….. So many things to observe’
◼ ‘learnt more here than back home’
◼ ‘loved the teaching’
◼ ‘good place’
◼ ‘stressful place…. but OK lah’
◼ ‘I don’t like resus’
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CARPE DIEM
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