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ILS Pre Course Handbook
ILS Pre Course Handbook
Sarah Hope
Produced by ECG Ltd, December
2019
LIFE SUPPORT
PRE-COURSE
HANDBOOK
Contents
Introduction ..................................................................................................................... 3
Non-Technical Skills .......................................................................................................... 3
Leadership.................................................................................................................... 3
Teamwork .................................................................................................................... 4
Situational Awareness .................................................................................................... 4
Communication Skills ..................................................................................................... 4
Debrief ......................................................................................................................... 5
Reporting Incidents ....................................................................................................... 5
Signs of Deterioration ....................................................................................................... 6
Chain of Prevention ....................................................................................................... 6
National Early Warning Score ......................................................................................... 7
Causes of patient deterioration ....................................................................................... 8
The A-E Assessment ......................................................................................................... 9
Airway (A) .................................................................................................................. 10
Breathing (B) .............................................................................................................. 11
Circulation (C)............................................................................................................. 12
Disability (D)............................................................................................................... 14
Exposure (E) ............................................................................................................... 15
Basic Life Support ........................................................................................................... 17
Chain of Survival ......................................................................................................... 17
Recovery position ........................................................................................................... 23
Choking ......................................................................................................................... 24
Advanced Life Support .................................................................................................... 26
Cardiac Arrest Rhythms ............................................................................................... 26
Cardiac Arrest Drugs.................................................................................................... 28
Causes of Cardiac Arrest and their reversal .................................................................... 28
Ending a Resuscitation Attempt .................................................................................... 30
Opening the Airway ........................................................................................................ 30
Head Tilt & Chin Lift .................................................................................................... 30
Jaw Thrust ................................................................................................................. 30
Oropharyngeal Airways (OPA) ...................................................................................... 31
Patients are increasingly seen for both consultation and diagnostic services in non-acute hospital
locations that do not always have access to rapid emergency response teams. Our ageing popu-
lation has an ever-expanding list of existing medical problems and public awareness of health,
wellbeing and illness has become more prevalent. As such, the likelihood of Health Care Profes-
sionals seeing unwell patients and being involved in cardiac arrests is higher than ever.
This course has been aligned to the Resuscitation Council UK (RCUK) guidelines on Immediate
Life Support. The RCUK develop and publish guidelines on resuscitation based on scientific evi-
dence, which is reviewed every five years. This pre-course handbook is based upon the most
recent guidelines published in January 2015. The primary objective of the RCUK is to promote
high-quality practice in all aspects of cardiopulmonary resuscitation to improve survival rates.
Non-Technical Skills
Before we learn about the life-saving technical skills of Immediate Life Support (ILS) such as
airway management and defibrillation, it is essential to consider the significance of non-technical
skills.
Non-technical skills are of a huge importance in an emergency. Three of the most important non-
technical skills are:
• Leadership
• Teamwork
• Awareness of the situation
Leadership
A leader is someone who gives instruction and takes control of the situation.
• To make clinical decisions according to RCUK guidelines, including the initial decisions
of calling the resuscitation team, starting CPR and using a defibrillator
• Ideally know team members by name
• Communicate information clearly to both the team and any relatives present
• Ensure all necessary equipment is available
• Delegate tasks playing to the strengths of team members individual skills
• Remain calm and potentially manage conflict
• Take control of the situation/ be authoritative when needed
• Show understanding and patience towards team members who may be nervous
• Ensure a post incident debrief takes place to support the team
Situational Awareness
Situational awareness is an understanding of what is happening and how your actions can
impact the situation and outcome. There are various ways to increase awareness of the situation:
• Ensure personal safety and the safety of those around you is a priority
• Observe the surroundings – could this help to identify a cause of the emergency?
• Know who is present (team members, relatives, bystanders etc.)
• Gather information from team members, relatives, bystanders etc.
• Prioritise the various needs the emergency demands
• Gather equipment that is needed
Communication Skills
Problems with communication contribute to 80% of adverse incidents in hospitals (1).
You should communicate any concerns about a patient using SBAR (2).
Situation – introduce yourself, confirm who you are speaking with and who about, and say
what you need advice about.
“I am (name) calling about (name) and I am concerned that (observations, NEWS score)”
Background – brief background information about the patient (past medical history, reason
for admission)
“Patient was admitted with (…) their last set of observations were (…)”
“He is speaking but his respiratory rate is (…) his oxygen saturation is (…), his pulse (…) BP
(…), he has new confusion and on exposure his skin is (…). I think the problem is (…)”
“I have given (…) but I need you to come and see the patient within (…) minutes and can I do
anything in the meantime?”
Debrief
It is essential to debrief after an emergency event. It has been found that debriefing staff is an
effective strategy in helping them deal with such stressful events and is a useful strategy to im-
prove resuscitation performance. Ideally this should be soon after the event has occurred, but
where this is not possible it is acceptable to have this any time after the event. It is most im-
portant that the debrief is facilitated at some point following the event. This gives individuals
the opportunity to offer support to team members and discuss any concerns that may have
arisen during the event.
Reporting Incidents
It is essential to report all emergency incidents and any potential safety incidents according to
local policy.
Every healthcare professional must be open and honest with patients (or where appropriate,
the patient’s advocate) when something goes wrong with their care which has the potential to
cause harm or distress. A healthcare professional must inform the patient when something has
gone wrong, apologise, offer a remedy or support to put matters right (if possible) and explain
any effects of what has happened. Healthcare professionals must be honest and open with their
colleagues and employers. They must support and encourage each other to be open and honest,
and not prevent others from raising concerns.
All in-hospital cardiac arrests are reviewed and audited. The National Cardiac Arrest Audit (NCAA)
is a UK-wide database of in-hospital cardiac arrests and is supported by the Resuscitation Council
(UK) and the Intensive Care National Audit & Research Centre (ICNARC).
• Patient's details
• Date, time and location of cardiac arrest
• Who attended
• Interventions such as CPR, rescue breaths, use of pocket mask/bag valve mask
• Time of AED arrival, analysis and shock (if advised), any subsequent shocks
Chain of Prevention
The chain of prevention is a tool from the RCUK to help ensure deterioration is identified in order
to prevent progression into a cardiac arrest.
• Education
Educating staff in the assessment and identification of signs of deterioration and how to
escalate any concerns about the patient appropriately.
• Monitoring
Healthcare staff should perform patient monitoring and assessment using the A-E ap-
proach to assessment.
• Recognition
Healthcare staff must be able to put their training into practice in order to identify dete-
rioration or any ‘red flags’. One way to assist with staff recognition is through the use of
systems such as the National Early Warning Score.
Healthcare staff must understand how to appropriately escalate any concerns to senior
clinicians and relay the relevant information required (for example using SBAR to effec-
tively communicate the urgency of the situation).
• Response
The appropriate clinicians/medical teams must respond to the situation within a reason-
able time frame depending on the urgency of the situation. They must be sufficiently
trained to provide an effective response and have appropriate equipment available.
The National Early Warning Score (NEWS) is a system to assist in the identification of signs of
patient deterioration. The patient receives a score based on their observations (Figure 1) which
will advise on the appropriate action to take (escalation and increased frequency of monitoring
the patient) (Figure 2). The higher the NEW score, the higher the risk of deterioration.
Figure 2. The recommended response to a patient based on their NEW score (5) (Royal Col-
lege of Physicians, 2017)
Table 1. Causes of patient deterioration and cardiac arrest relating to airway, breathing
and circulation.
The end outcome of cardiac arrest is undoubtedly influenced by the quality of resuscitative care
that is provided. In the peri-arrest period, the aim is to identify the deteriorating patient and
instigate treatments with the aim of preventing the person deteriorating further. In cardiac
arrest, the provision of high-quality basic life support and prompt defibrillation coupled with
early mobilisation of emergency resources all contribute to survival and ongoing quality of life.
Airway
Breathing
Circulation
Disability
Exposure
No stridor
No wheeze
Exposure No bleeding
No injury
• The tongue
• Blood
• Vomit
• Food
• Trauma
• Epiglottitis
• Swelling of the pharynx
• Laryngospasm
• Depression of the central nervous system
• Bronchospasm
• Bronchial secretions
• Infection
For the immediate treatment of an obstructed airway use the recognised guidance for the treat-
ment of choking. We will look at this later in the pre-course book.
Figure 3. Images of airway problems – jaw injury, deformity of the jaw, obesity and
swelling of the tongue.
• Opening the airway with a head tilt chin lift or jaw thrust (we will cover this in more
detail in the airway management chapter)
• Various airway adjuncts can be used to support the airway (we will cover this in more
detail in the airway management chapter)
• Putting the patient into the recovery position to protect their airway
Breathing (B)
Breathing problems can be acute or a result of a long-term condition. Respiratory arrest or in-
sufficient respiration will lead to inadequate oxygenation of the blood which will affect vital or-
gans. This will result in a loss of consciousness and ultimately a cardiac arrest.
Problems with the lungs (such as chronic obstructive pulmonary disease, asthma, pulmonary
embolus, pulmonary oedema and pneumothorax) can restrict gas exchange.
Other causes of breathing problems include depression of the central nervous system, spinal
cord injury, muscle weakness/nerve damage (e.g. Guillain-Barre syndrome) and kyphoscolio-
sis (which can restrict the chest movements).
To assess breathing problems, look, listen and feel for breathing to identify signs of respiratory
distress. You may notice the patient is sweating, using accessory muscles and has central cya-
nosis.
• Count the respiratory rate. The normal adult rate is 12 -20 breaths min-1. A high respir-
atory rate is a strong indicator of deterioration which may occur rapidly.
• Assess breathing for the depth of each breath, the rhythm/regularity of respiration and
look for equal chest expansion on both sides.
• Note the inspired oxygen concentration given to the patient (ideally 15L min-1) and the
oxygen saturation reading of the pulse oximeter (if SpO2 monitor unavailable observe
for evidence of peripheral or central cyanosis). Remember that a patient receiving high
flow oxygen may have a normal Sp02 even if they have insufficient ventilation.
• Listen to the patient’s breath sounds (by listening close to their face). If a patient is
unable to cough/take a deep breath, they may have airway secretions which can be
heard as rattling noises. A partial airway obstruction may be heard as a stridor, and
constriction of the bronchial tree may be heard as a wheeze.
• Continue with the highest possible concentration of inspired oxygen using a mask with
an oxygen reservoir. Ensure high flow oxygen (15L min-1) to prevent collapse of the
reservoir bag during inspiration. It is important to note that individuals with COPD are
• Hyperventilation and panic attacks may happen. In most cases, these will resolve with
simple reassurance.
Circulation (C)
Causes of circulatory problems include problems with the heart itself or heart abnormalities
secondary to other conditions.
Cardiac problems include:
• Arrhythmia
• Acute coronary syndrome i.e. myocardial infarction
• Hypertensive heart disease
• Valve disease
• Cardiomyopathies/Long QT syndrome
In the case of acute coronary syndromes (ACS), they usually present as central chest pain,
although atypical presentations can be seen. ACS can be divided into categories based on the
result of a 12-lead ECG and the troponin concentration in their blood.
- ST-segment-elevation myocardial infarction (STEMI)
- Non ST-segment-elevation myocardial infarction (NSTEMI) (where troponin levels are
raised but we do not see ST elevation on the ECG)
- Unstable Angina (a lack of ECG or troponin level changes in the presence of chest pain).
Secondary heart problems occur when changes elsewhere in the body affect the heart. The
heart can be affected by the following:
• Electrolyte imbalances
• Drugs
• Hypervolemia
• Septic shock
• Hypothermia
• Touch/hold and observe the patient’s hand and feel for the radial pulse (located in the
wrist at the base of the thumb). A warm hand with a present pulse will suggest they
likely have an acceptable blood pressure. A cool or pale/mottled hand with a weak or
absent radial pulse will suggest inadequate organ perfusion.
• Measure the capillary refill time. Apply gentle pressure for five seconds on a fingertip
held at the level of the heart. Time how long it takes for the blanched skin to return to
the colour of the surrounding skin after releasing the pressure. The normal refill time is
less than two seconds. A prolonged time suggests poor peripheral perfusion. Other fac-
tors (e.g. age of the patient and surrounding temperature) can prolong the time.
• Count the rate and feel the character of the radial and carotid pulse (is it regular, strong,
equal). A normal adult heart rate is 60-100 per min with a good volume. Fast, slow,
weak or thready pulses are abnormal in most people.
• Measure the patient’s blood pressure (comparing this to their usual if known). Note that
a patient in shock may have a normal blood pressure due to the compensatory mecha-
nisms of the body increasing peripheral resistance.
• Note the patient’s urine output if they have a catheter, a low urine output known as
oliguria is a urine volume of less than 0.5mL kg-1h-1.
• Insert a cannula if trained to enable fast delivery of fluids where fluid replacement is
required. This should be given in the form of a 500mL rapid bolus of warmed crystalloid
solution over less than 15 minutes.
• Reassess the pulse rate and blood pressure every 5 minutes, aiming for the patient‘s
normal blood pressure. If this is unknown, in adults aim for a systolic blood pressure
greater than 100 mmHg.
• If ACS is suspected (e.g. the patient has central chest pain) perform a 12-lead ECG and
treat with aspirin, GTN and oxygen as described previously.
No circulation:
• Call for help
• Commence CPR
• Send for defibrillator
• Consider IV access
Disability (D)
Disability refers to the level of consciousness and neurological condition of the patient. Possible
causes of reduced levels of consciousness include:
• Hypoxia
• Low blood pressure
• Drugs
• Hypoglycaemia
• Stroke
• Always review and treat problems with airway, breathing and circulation.
• Examine the pupils using a pen torch for their size, equality and reaction to light.
• Assess the patient’s level of consciousness rapidly using the AVPU method.
• Treat unconscious patients in the lateral position if their airway is not protected.
Exposure (E)
• Exposing the patient by loosening or removing clothing allows the healthcare profes-
sional to identify problems such as bleeding, swelling, rashes (e.g. anaphylaxis), bruis-
ing, deformity, evidence of trauma and any medical-alert jewellery.
• Dignity must be maintained where possible and exposure kept to a minimum to avoid
heat loss.
Summary
• Most patients will have signs of deterioration prior to an in-hospital cardiac arrest.
• Early identification of deterioration and treatment will help to prevent a cardiac arrest.
• Airway, breathing and circularity problems can cause a cardiac arrest.
• The A-E assessment should be used to assess and treat patients who are deteriorating.
Chain of Survival
The 'Chain of Survival' concept is internationally recognised as summarising the important
components of successful resuscitation
Early Recognition- If untreated, a quarter to a third of patients having a heart attack will go
on to have a cardiac arrest within the first hour after onset of chest pain.
Early CPR - Prompt cardiopulmonary resuscitation (CPR) can help to buy time until a defibril-
lator can attempt to restore a normal heartbeat. The rescue breaths and chest compressions
help oxygenated blood flow to the person's brain and heart. This can double or quadruple sur-
vival from out-of-hospital cardiac arrest.
Early defibrillation - For every minute the patient doesn’t have a defibrillator attached to
their chest, their chances of survival reduce by 10%.
Early advanced life support - Advanced life support will be delivered by either an ambu-
lance crew or an emergency medical team. This care can include basic life support, defibrilla-
tion, administration of intravenous cardiac drugs and the insertion of airway adjuncts.
When a patient has a cardiac arrest, immediate life support (ILS) can be provided to help the
patients chance of survival.
As in Basic Life Support (BLS) essentially you are providing chest compressions to pump blood
around the body, ensuring the tissues and brain maintain an oxygen supply. Compressions
alone are highly unlikely to result in recovery for a patient in cardiac arrest, but it is crucial in
order to buy time prior to a defibrillator arriving. Failure of the circulation for three to four
minutes (less if the victim is initially hypoxic) will lead to irreversible cerebral damage. Delay,
even within that time, will lessen the eventual chances of a successful outcome. At ILS level
we expect to see additional actions to be taken in the identification of deterioration, the mini-
mising of interruptions to compressions and in airway management.
1. Make sure the victim, any bystanders and you are safe.
If there are no dangers or they have been dealt with it is safe to approach the patient to
carry out the assessment.
• Within the hospital environment, consider Personal Protective Equipment (PPE), be cau-
tious of sharps and consider your manual handling training.
• If they respond you should call for help according to your local protocols.
• Assess the patient using the A-E approach and continue to reassess them regularly.
• Start monitoring their vitals such as oxygen saturations, blood pressure and consider
recording an ECG. Give the patient oxygen (level dependent on their Sp02).
• Consider venous access/blood samples if trained.
• Consider the SBAR communication model to hand over to the relevant healthcare
professional.
• Look for chest movement. In the first few minutes after car-
• Listen at the victim's mouth for breath sounds. diac arrest, a victim may be barely
• Feel for air on your cheek. breathing, or taking infrequent,
• If in doubt about whether the breathing is normal, noisy, gasps. This is often termed
continue as if the patient is not breathing normally. agonal breathing and must not be
• If you are trained, at ILS level we expect healthcare confused with normal breathing.
professionals to feel for a carotid pulse at the same
time as checking for breathing.
• NOTE: Immediately following cardiac arrest, blood flow to the brain is reduced
which may cause a seizure-like episode that can be confused with epilepsy. There-
fore, assess for cardiac arrest in any patient presenting with seizures by checking
for breathing once any tonic-clonic movements have stopped.
• Turn them into the recovery position to protect their airway (see below).
• Summon appropriate help by calling the emergency team (or if out of hospital this
may be the ambulance service by mobile phone, use the speaker phone if necessary.
If this is not possible, send a bystander. Leave the victim only if there is no other
way of obtaining help).
• While awaiting help perform an A-E assessment, give oxygen and attach available
monitoring.
• Continue to assess that breathing remains normal. If there is any doubt about the
presence of normal breathing, start CPR.
5b. If they are not breathing normally and you cannot feel a pulse:
• After 30 compressions open the airway again using head tilt and chin lift (or other
manoeuvre as previously described).
• For mouth to mouth: pinch the soft part of the victim’s nose closed, using the index
finger and thumb of your hand on his forehead.
• Allow their mouth to open but maintain chin lift.
• Take a normal breath and place your lips around their mouth, making sure that you
have a good seal.
• Blow steadily into their mouth whilst watching for their chest to rise; take about one
second to make the chest rise as in normal breathing; this is an effective rescue
breath.
• Maintaining head tilt and chin lift, take your mouth away from the victim and watch
for the chest to fall as air comes out.
• Take another normal breath and blow into the victim’s mouth once more to give
two effective rescue breaths. The two breaths should not take more than 5 seconds.
Then return your hands immediately to the correct position on the sternum and give
a further 30 chest compressions.
• Continue with chest compressions and rescue breaths in a ratio of 30:2.
• In the person where ventilations are not desirable or possible (e.g. due to vomit or
blood where no resuscitation aid is available) then perform chest compression only
CPR until the arrival of more equipment or the emergency services.
• Use any airway equipment available such as a bag valve mask or a supraglottic
airway. If these are unavailable, you may consider performing mouth to mouth or
using a pocket mask to deliver rescue breaths.
• Resuscitation aids such as face shields or pocket masks are preferable for adminis-
tering breaths as they avoid direct patient contact. To use a pocket mask perform
a head tilt and chin lift to open the airway then ensuring there is a tight seal between
the pocket mask and the patients face blow into the inlet tube to deliver the breath.
• If a supraglottic airway (i-gel or LMA) is available and you are adequately trained,
you should insert this device. Upon the insertion of a supraglottic airway, it may be
possible to ventilate the victim’s lungs by delivering breaths at a rate of 10 min⁻¹
whilst performing continuous chest compressions.
• Stop to recheck the victim only if he starts to show obvious signs of regaining con-
sciousness, such as coughing, opening his eyes, speaking, moving purposefully and
starting to breathe normally; otherwise do not interrupt resuscitation.
If the initial rescue breath of each sequence does not make the chest rise as in normal
breathing, then, before your next attempt:
• Check the victim's mouth and remove any visible obstruction using suction/magills
forceps as appropriate.
• Recheck that there is adequate head tilt and chin lift.
• Do not attempt more than two breaths each time before returning to chest com-
pressions.
7. Defibrillation
• As soon as the defibrillator arrives apply the pads to the patient’s chest and turn on
the defibrillator.
• If you have an automated external defibrillator (AED) simply follow the voice in-
structions.
8. Continue resuscitation
• In the meantime, continue cycles of 30:2 unless a supraglottic airway has been placed
which may allow the delivery of 10 breaths min⁻¹ and continuous compressions.
• Make every possible effort to minimise interruptions to chest compressions wherever
possible. This can have a significant impact on the outcome.
• Continue to use the defibrillator available to you.
• Consider gaining IV access with a cannula and preparing any drugs likely to be used by
the resuscitation team (if trained to do so).
• The patient should be given ventilated breaths as described above at a rate of 1 breath
every 5 seconds.
• The pulse should be reassessed every minute.
• If there are any uncertanties about the presence of a pulse chest compressions should
be started immediately.
• If a respiratory arrest is not adequately treated with oxygen and rescue breaths it will
rapidly develop into a cardiac arrest.
10. You are trained in manual defibrillation and the patient has a witnessed cardiac
arrest.
• Where a manual defibrillator is rapidly available and cardiac arrest has been confirmed.
• When a shockable rhythm is confirmed, three initial shocks can be given in quick
succession.
• A rapid check should be made for a rhythm change and if appropriate a pulse check
after each attempt.
• After the third shock we can begin CPR.
NOTES
• Remove the victim’s glasses and sharp objects from pockets, if present.
• Kneel beside the victim and with the person lying on their back make sure that both
their legs are straight.
• Place the arm nearest to you out to the side with the elbow bent and the hand
palm-up.
• Take their other arm and hold the back of the hand against the victim’s cheek near-
est to you.
• With your other hand, grasp the far leg just below the knee and pull it up, keeping
the foot on the ground.
• Keeping their hand pressed against their cheek, pull on the far leg to roll the victim
towards you on to their side.
• Adjust the upper leg so that both the hip and knee are bent at right angles.
• Tilt the head back to make sure that the airway remains open.
• If necessary, adjust the hand under the cheek to keep the head tilted and facing
downwards to allow liquid material to drain from the mouth.
• Stay with the person and monitor them including checking their breathing regularly.
If the victim must be kept in the recovery position for more than 30 min turn them to the
opposite side to relieve the pressure on the lower arm.
Pregnant woman should be placed on their left side.
Figure 10. Identifying a mild and severe airway obstruction (Resuscitation Council
UK, 2015).
Chest compressions are often inadequately performed by healthcare professionals, despite be-
ing essential for a positive outcome. Once a patient’s airway is secured, we can perform con-
tinuous compressions (as opposed to the 30:2 ratio where we stop to deliver the rescue
breaths). We can secure an airway using tracheal intubation (if trained) or a supraglottic air-
way such as an i-gel. Once the airway is secured, we can attach a bag and deliver breaths at
a rate of 10 min⁻¹. It is important not to hyperinflate the lungs. We can also consider patient
monitoring including; pulse checks, clinical signs of life, heart rhythm monitoring, waveform
capnography (which is used to measure end-tidal C02), blood analysis, invasive cardiovascular
monitoring and echocardiography.
There are four possible cardiac arrest rhythms, split into shockable and non-shockable rhythms.
These are:
• Shockable
o Ventricular Fibrillation
o Pulseless Ventricular Tachycardia
• Non-Shockable
o Pulseless Electrical Activity
o Asystole
Patients with a shockable rhythm require defibrillation whilst those in a non-shockable rhythm
will not respond to defibrillation. All cardiac arrest patients (regardless of rhythm) require
chest compressions, airway management, adrenaline administration and the investigation and
treatment of the cause of the arrest.
After a shock is delivered, we perform 2 minutes of CPR before reassessing the rhythm – this
ensures the interruptions to chest compressions are kept to a minimum. If we identify a non-
shockable rhythm which appears in an organised manner, the responders should try to feel
for a central pulse and look for any signs of cardiac output from the patient themselves or
from any monitoring equipment.
Figure 14. The Advanced Life Support algorithm (Resuscitation Council UK, 2015).
It is recommended that a 1mg dose of Adrenaline is given intravenously after the delivery of
the third shock whilst the subsequent CPR is being performed. Amiodarone 300mg is recom-
mended after three shocks, and 150mg after 5 shocks. Once adrenaline is given it should be
administered every 3-5 minutes to the patient if they remain in cardiac arrest.
Figure 15. Causes of a cardiac arrest which can potentially be reversed (Resuscita-
tion Council UK, 2015).
Hypoxia can be treated by ventilating the patient’s lungs with 100% oxygen whilst performing
CPR, and by placing airway tubing to allow the delivery of ventilation breaths at a rate of
10min⁻¹.
Hypovolaemia
Severe blood loss can be a cause of PEA. Using fluid/blood transfusions in conjunction with
stopping the bleeding (whether it be from trauma or problems such as an aortic aneurysm
rupture requiring urgent surgery).
Hyperkalaemia
Hypothermia
Hypothermia should always be considered, and the patients temperature measured using a
thermometer capable of reading low temperatures.
Thrombosis
Tension Pneumothorax
Tension pneumothorax can be identified by decreased chest expansion and tracheal deviation
away from the affected lung. It can cause PEA and is treated with needle thoracocentesis and
a chest drain.
Cardiac Tamponade
Cardiac tamponade should be suspected after cardiac surgery or chest trauma but is often
hard to diagnose during a cardiac arrest.
Toxins
Again, this is difficult to diagnose unless there is a known history of ingestion of a substance.
Antidotes appropriate to the toxin should be used where possible, otherwise healthcare pro-
fessionals can only provide supportive treatment.
Following the resuscitation attempt, there must be ongoing care of the patient (or monitoring
to confirm death), delegating tasks to team members, documentation of the event including
times, communication with family members/friends, a post-event debrief to allow all team
members to communicate any concerns, restocking of equipment and completing audit forms.
Jaw Thrust
If your patient is between sizes, it is more beneficial to choose the larger size. However, as a
rough rule of thumb, the following sizes can be used:
• 00 = Babies
• 0 = Infants
• 1 = Children
• 2 = Small Adults
• 3 = Large Adults
• 4 = V Large Adults
Insertion of an OPA
Check the mouth to ensure it is clear. Size the airway to
ensure a good fit. The correct size should match the dis-
tance from the angle of the jaw to the incisors.
Insertion of an NPA
• Check the design of the airway. Some brands
require a safety pin to be inserted through the
flange to ensure it remains in situ. If your air-
ways do require a safety pin, do this BEFORE
you insert It.
• Check you have the correct size; it should reach
from the tragus of the ear to the tip of the nos-
tril.
• Lubricate the airway thoroughly.
• Insert the bevel end first vertically along the
floor of the nose with a slight twisting action. Try
the right nostril first. If there is an obstruction,
then try the left.
• Once in place, check for airway patency.
• If the airway meets an obstruction in one nos-
tril, withdraw it and try to pass it
Figure 21. Insertion of a
up the other nostril.
nasopharyngeal airway
The i-gel is a supraglottic airway device which reduces the risk of gastric inflation and often
provides more effective ventilation. It sits just above the larynx. The cuff is made of jelly like
material and does not need to be inflated. It can be inserted without stopping CPR and forms
a good laryngeal seal. They come in various sizes for both adults and children (see table 3).
Insertion of an i-gel
• Remove the i-gel from the packaging and place a small
bolus of lubrication on the middle of the cradle. Lubri-
cate the i-gel on the back and sides of the cuff.
• Hold the i-gel firmly along the bite block and position
it so the cuff outlet is facing towards the chin of the
patient. The patient should be in the “sniffing the
morning air” position. Gently press the chin down. In-
troduce the leading soft tip into the mouth in the di-
rection of the hard palate.
Table 3. Sizes of i-gels and the patient/patient weight appropriate for each size.
Size Patient Patient
Weight (kg)
2 Small Paediat- 10-25
rics
2.5 Large Paediat- 25-35
rics
3 Small Adult 30-60
4 Medium Adult 50-90
5 Large Adult 90+
The pocket mask is a device which enables a rescuer to provide ventilation breaths whilst
keeping a barrier between the patient (and any vomit, blood etc) and the rescuer.
Breaths should be given by making an airtight seal between the mask and the face using both
hands and delivering a rescue breath over a second, watching for the chest to rise/fall and
giving a second breath. The breaths should be provided at a rate of 30 compressions to two
rescue breaths.
The bag-valve-mask can be used on its own or attached to an i-gel. As the bag is squeezed,
the air is forced into the patient’s lungs. On release the exhaled air is released into the atmos-
phere via a one-way valve. When used without supplemental oxygen, this will provide atmos-
pheric oxygen concentrations (21%) but this is increased to 45% when attaching high flow
oxygen directly to the bag. If a reservoir bag is used, oxygen concentrations of 85% are
achieved when supplementing oxygen by 15L min⁻¹.
The use of this equipment requires skill to ensure a good seal. This should be used with a
two-person technique where one person holds the mask in place using both hands and a
jaw thrust, and the other squeezes the bag.
When squeezing the bag, care must be taken not to over-inflate the lungs. A gentle squeeze
to ensure a chest rise is enough.
Using a Bag-Valve-Mask
Suction
Suction should be used by those who are trained in order to remove any potential obstruc-
tions from the airway (e.g. saliva, blood, vomit). Larger pieces may need to be removed using
Magill’s forceps is the wide-bore rigid catheter is not sufficient. Suction should be performed
gently focussing on the sides of the mouth and drawing the catheter outwards. The catheter
should not be placed further than is visible in the mouth.
There are two key types of suction unit; the manual & mechanical suction units.
Manual
This has a soft large catheter, only insert it as
far as you can see and only suction for a maxi-
mum of 10 seconds.
Pulse Oximetry is a simple, non-invasive tool which provides an instant measure of the arterial
blood oxygen saturation. Its main uses are; to detect hypoxaemia, targeting oxygen therapy,
for general monitoring and as a diagnostic tool. When targeting oxygen therapy, we aim for a
range of 94-98% SpO2 (with the exception of those with hypercapnic respiratory failure from
COPD where the target range is 88-92%). In a cardiac arrest the pulse oximeter is not reliable
to deliver an accurate reading and we should deliver 100% inspired oxygen.
The pulse oximeter probe is designed as a clip to be placed on the finger, having LEDs on one
side and a photoreceptor on the opposite. The amount of light transmitted through the tissue
is used to calculate the oxygen levels in the blood. It is important to note that pulse oximetry
only measures oxygen saturation, so we cannot be sure of adequate oxygen levels in the tis-
sues. Furthermore, a patient may have a high carbon dioxide level from insufficient breathing,
yet their oxygen saturation can be normal. For this reason, arterial blood gas should be used
to assess ventilation and oxygenation. Pulse oximetry results are not affected by anaemia,
skin colour or jaundice.
• Haemoglobins such as those present in sickle cell disease or carbon monoxide poison-
ing.
• Nail varnish
• Motion artefact
• Hypotension/vasoconstriction
• Shockable
o Ventricular Fibrillation
o Pulseless Ventricular Tachycardia
• Non-Shockable
o Pulseless Electrical Activity
o Asystole
• Rhythm – Irregular
• Rate – indeterminate - chaos
• QRS – nor recognisable
• P wave - not seen.
Ventricular Tachycardia
This results from tissues in the ventricles generating a rapid and irregular heart rhythm. Poor
cardiac output is usually associated with this rhythm thus causing the patient to go into cardiac
arrest.
This is defined as any ECG waveform that may be compatible with a pulse where no pulse
exists. This is a common arrest rhythm and is often associated with trauma, blood and fluid loss
and certain medical conditions (i.e. asthma).
Defibrillation
There are approximately 30,000 people in the UK who sustain a cardiac arrest outside hospital
and are treated by the ambulance service each year. Electrical defibrillation is the only definitive
therapy for shockable cardiac arrests; caused by ventricular fibrillation (VF) or pulseless ven-
tricular tachycardia (VT). The delay from collapse to delivery of the first shock is the single most
important determinant of survival. If defibrillation is delivered promptly, survival rates as high
as 75% have been reported. The chances of successful defibrillation decline at a rate of about
10% with each minute of delay. Basic life support will help to maintain coronary and cerebral
perfusion but is not a definitive treatment.
Safety
Defibrillators are potentially dangerous, so some safety aspects should be considered.
A severe allergic reaction may follow oral or parenteral administration of a drug. In general,
the more rapid the onset of the reaction the more profound it tends to be. Symptoms may de-
velop within minutes and rapid treatment is essential.
Management
First-line treatment includes securing the airway, restoration of blood pressure (laying the pa-
tient flat and raising the feet, or in the recovery position if unconscious or nauseous and at risk
of vomiting), and administration of adrenaline (epinephrine) injection. This is given intra-
muscularly in a dose of 500 micrograms (0.5 mL adrenaline injection 1 in 1000). The dose is
repeated if necessary, at 5-minute intervals according to blood pressure, pulse, and respiratory
function. Oxygen administration is also of primary importance. Arrangements should be made
to transfer the patient to hospital urgently.
Paediatric Doses
Fainting
Insufficient blood supply to the brain results in loss of consciousness. The most common
cause is a vasovagal attack or simple faint (syncope) due to emotional stress.
Lay the patient as flat as is reasonably comfortable and, in the absence of associated breath-
lessness, raise the legs to improve cerebral circulation
Postural hypotension can be a consequence of rising abruptly or of standing upright for too
long; antihypertensive drugs predispose to this. When rising, susceptible patients should take
their time. Management is as for a vasovagal attack.
Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faint-
ness but does not usually result in syncope. In most cases reassurance is all that is necessary;
rebreathing from cupped hands may be helpful but calls for careful supervision.
Seizures
It is not uncommon for epileptic patients not to volunteer the information that they are epilep-
tic but there should be little difficulty in recognising a tonic-clonic (grand mal) seizure.
Management
During a convulsion try to ensure that the patient is not at risk from injury but make no at-
tempt to put anything in the mouth or between the teeth (in mistaken belief that this will pro-
tect the tongue). Give oxygen to support respiration if necessary.
After convulsive movements have subsided place the patient in the recovery position and
check the airway.
After the convulsion the patient may be confused (‘post-ictal confusion’) and may need reas-
surance and sympathy. The patient should not be sent home until fully recovered. Seek medi-
cal attention or transfer the patient to hospital if it was the first episode of epilepsy, or if the
convulsion was atypical, prolonged (or repeated), or if injury occurred.
Asthma
Most attacks will respond to 2 puffs of the patient's short-acting beta2 agonist inhaler such as
salbutamol 100 micrograms/puff; further puffs are required if the patient does not respond
rapidly. If the patient is unable to use the inhaler effectively, further puffs should be given
through a large-volume spacer device (or, if not available, through a plastic or paper cup with
a hole in the bottom for the inhaler mouthpiece). If the response remains unsatisfactory, or if
further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst
awaiting transfer, oxygen should be given; if a nebuliser is unavailable, then 2–10 puffs of
salbutamol 100 micrograms/metered inhalation should be given (preferably by a large-volume
spacer) and repeated every 10–20 minutes if necessary. If asthma is part of a more generalised
anaphylactic reaction, an intramuscular injection of adrenaline (as detailed under Anaphylaxis
above) should be given.
Hypoglycaemia
Measure the blood glucose to exclude hypoglycaemia using a rapid finger-prick testing method.
If the patient does have hypoglycaemia (blood glucose
of less than 4.0 mmol L) and is still conscious, initially
glucose 10–20 g is given by mouth either in liquid form
or as granulated sugar or sugar lumps. Approximately
10 g of glucose is available from non-diet versions of
Lucozade® Energy Original 55 mL, Coca-Cola®
100 mL, Ribena® Blackcurrant 19 mL (to be diluted), 2
teaspoons sugar, and from 3 sugar lumps. If necessary,
this may be repeated in 10–15 minutes.
Figure 27. A blood glucose
If glucose cannot be given by mouth, if it is ineffec- monitor.
tive, or if the hypoglycaemia causes unconsciousness,
glucagon 1 mg (1 unit) should be given by intramus-
cular (or subcutaneous) injection. Once the patient regains consciousness oral glucose should
be administered as above. If glucagon is ineffective or contra-indicated, the patient should be
transferred urgently to hospital.
Nurse unconscious patients in the lateral position if their airway is not protected.
Table 5. Drugs for use in a cardiac arrest (based on Resuscitation Council UK guid-
ance).
Not everyone wants to receive CPR, so it is important to respect people's wishes and to make
sure that they are offered a chance to make choices that are right for them.
ReSPECT
The DNACPR process is being superseded by ReSPECT.
ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment and is
not just a replacement for a DNACPR form. The aim is to promote recording an emergency
care plan by many more people, including many whose ReSPECT forms will recommend active
treatment, including attempted CPR if it should be needed.
There is a gradual transition from DNACPR to ReSPECT documentation by locality so until the
ReSPECT process has been introduced locally the DNACPR documentation remains valid.
The DNACPR or ReSPECT decision should be reviewed whenever the patient's condition
changes and prior to any proposed move between care settings. A timeframe for review
should be stated on the form when it is first signed.
Healthcare professionals must start CPR without delay to have the best chance of success.
They will start CPR unless they have immediately available, clear documentary information to
show them that this is not appropriate.
2) https://improvement.nhs.uk/documents/2162/sbar-communication-tool.pdf
3) https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-
do-i-check-someones-pulse/
4) https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/read-
the-professional-duty-of-candour/
5) https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
6) https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/pulse-oximetry