Note:breathing and pulse can be assessed simultaneously for no more than 10 seconds. You will also get an impression of whether the patient is breathing normally or not when assessing responsiveness.
Notes: *Complete primary survey consists of Airway, Breathing, Circulation, Disability and Exposure. Problems with the primary survey should be corrected as they are discovered:
- Airway should be opened, suctioned and maintained
- SpO2 should be titrated to 94% using nasal prongs or face mask if the patient is self-ventilating, or bag-valve-mask ventilation with O2 attached if ventilations are inadequate or absent
- Circulation can be quickly assessed by observing the patient's colour, capillary refill and by feeling for central and peripheral pulses. Pallor or cyanosis is clearly problematic. Capillary refill should be <2 seconds. Normal pulse in an adult is between 60-100 beats per minute, should be regular and good volume.
- Disability can be rapidly assessed using the AVPU scale, where A= alert, V=responds to voice, P= responds to pain, and U= unconscious. Pupillary assessment can similarly be done rapidly using a pen torch. Pupils should be equal and responding to light (PEARL)
- Exposure is important to identify trauma, rashes, scars and other evidence of pathology.
BP = blood pressure
RR = respiratory rate
SpO2 = oxygen saturation (as measured by pulse oximeter)
ECG = electrocardiogram
IV = intravenous
CVS = cardiovascular system: examination constitutes general impression, position of trachea and whether jugular venous distension is present; pulses central and peripheral, BP, apex beat location, auscultation of heart sounds and identification of any added sounds; identification of any murmurs or bruits; any evidence of peripheral or sacral oedema; any ascites or enlarged intra-abdominal organs. More about this in later blogs.
SOB = shortness of breath
LVF = left ventricular failure, usually associated clinically with shortness of breath and crackles at the lung bases on auscultation,
Tx = therapy or management
General approach and the unresponsive patient
The things to bear in mind when approaching an individual with a potential cardiac condition are as follows:
- we treat the patient, not the machine: so assess your patient in the first instance
- having ascertained the condition of the patient, we then consider the cardiac rhythm
- we then apply the appropriate algorithm
The patient will fall into one of three broad categories:
- "Dead" - having just suffered cardiac arrest
- Alive and unstable
- Alive and stable
It is therefore important to assess these patients in a systematic way
- If relevant, make sure that your scene is safe, and that body substance isolation is used (eg gloves; face shield or resuscitation mask for delivering breaths)
- ASSESS FOR RESPONSIVENESS - tap and shout
- If unresponsive and doesn't appear to be breathing: ACTIVATE EMERGENCY RESPONSE and specifically ask for the automated external defibrillator (AED)
- CHECK PULSE AND RESPIRATIONS FOR NO MORE THAN 10 SECONDS. These can be checked simultaneously. If unable to feel a central pulse or unsure whether pulse is present, commence cardiopulmonary resuscitation (CPR)
- DELIVER COMPRESSIONS at a rate of 100-120 per minute and a depth of 5-6cm
- FOLLOW WITH 2 BREATHS if BVM available each delivered over approximately 1 second
- REPEAT FOR 5 CYCLES OF 30:2 (APPROXIMATELY 2 MINUTES) then reassess pulse.
As soon as an AED is delivered, this takes top priority....either instruct the person who delivers the AED to take over CPR while you apply the AED, or if they are unable to do so, stop CPR briefly to activate and apply the AED. The reason for this is because the best chance of retrieving a patient with a shockable rhythm is delivery of an early defibrillation shock. Shockable arrest rhythms deteriorate to asystole at the rate of approximately 10% per minute, and asystolic arrests have a very poor prognosis.
With many older AEDs, you will not be able to resume CPR during charging as this may interfere with rhythm interpretation. Newer AEDs may allow you to go back on the chest, and will instruct you to do so if this is an option. Therefore, the first step when the AED arrives is TURN THE AED ON. The AED will then clearly instruct the rescuer what to do and the sequence in which to perform the steps in defibrillation. The usual sequence is "apply pads to patient's bare chest - plug in pad connector at flashing light". Once the connector is plugged in, the next instruction is "analysing heart rhythm - do not touch the patient" or similar. At this stage, the rescuer should clear all bystanders from touching patient so that an accurate rhythm analysis can be made. Once the rhythm is analysed, either "no shock advised - commence CPR" or "shock advised - charging" will be stated by the machine. Unless specifically told to recommence CPR by the machine, stay clear of the patient during charging. The amber light on the charge button will flash when charging is complete, the rescuer should again clear the patient, then deliver the defibrillation shock. Immediately after the shock is delivered, CPR should be recommenced and the above 30:2 sequence should be followed for 2 minutes, at which point the AED will again request clearance of the patient so that the rhythm can be analysed.
If a monitored patient develops what appears to be an arrest rhythm on the screen, it is important to ascertain in the first instance that the clinical picture matches the monitor....interference patterns from certain types of muscular activity or electrical appliances may mimic ventricular fibrillation, and a loose lead may appear as asystole in certain types of monitor. Therefore, assessment of responsiveness and a pulse / breathing check should be performed to confirm that the patient is in fact in cardiac arrest before proceeding to arrest management
Whilst patients in cardiac arrest fall into the following 4 broad categories.....
· Ventricular Fibrillation (VF)
· Pulseless Ventricular Tachycardia (pVT)
· Asystole
· Pulseless Electrical Activity (PEA)
......they can be dealt with in one of two ways, by dividing the rhythms into “shockable” or “non-shockable”, with VF and pVT in the “shockable” algorithm, and asystole and PEA in the “non-shockable” algorithm.
The "Live" Patient
Dealing with the “live” patient presents the candidate with a different set of problems. The “live” patient may present in many different ways, however. The important thing to remember is
The "Live" Patient
Dealing with the “live” patient presents the candidate with a different set of problems. The “live” patient may present in many different ways, however. The important thing to remember is
The systematic approach is always the same.
Once you have checked responsiveness and established that the patient has a pulse, you are now dealing with the “live” patient, and your next priorities are the primary survey ABCDE, and secondary survey which will subdivide these patients into “stable” or “unstable”.
PRIMARY SURVEY ABCDE
If a patient is pulseless, the BLS survey dictates that you proceed with C-A-B: commence CPR, then open the airway and deliver breaths. In the “live” patient, the priorities become A-B-C-D-E.
· The airway should be opened, cleared and maintained
· Breathing should be supported by administration of supplementary oxygen if the patient is self-ventilating, titrating to an SpO2 of 94%, or ventilations supported using the bag-valve-mask if ventilations are absent or inadequate. The patient should be ventilated at the rate of one breath every 6 seconds, with each breath delivered over 1 second, approximately 4-500ml (sufficient to make the chest rise)
· Circulation should be checked in the primary survey by noting patient colour, capillary refill and pulse characteristics. If there is any significant external bleeding, it should be dealt with immediately. Additional assessment and management of the circulation will be completed in the secondary survey.
· Disability should be rapidly assessed using the Alert-Vocal response-Pain response-Unresponsive (AVPU) scale. In addition, pupils may be checked in the primary survey for PEARL, and if the patient is responsive and co-operative, a quick assessment of equality of power may be done by asking the patient to “squeeze my fingers” to complete the mini-neurological examination
· Exposure is important to identify trauma, scars, rashes and other features that might provide a clue to the patient’s condition
SECONDARY SURVEY
This involves complete head-to-toe examination of the patient, but the trick with the secondary survey is knowing where to start. Important assessments that quickly divide these patients into “stable” or “unstable” can be remembered using the mnemonic “VOMIT SAMPLE”
· VITALS: BP, RR, Pulse, Temperature
· OXYGEN: titrate to SpO2 94%
· MONITOR: 3-lead ECG to see rhythm
· IV: intravenous access; send bloods
· TWELVE LEAD ECG and Targeted examination: CVS, lungs, oedema
· SYMPTOMS: Chest pain? Shortness of breath? Palpitations? Etc.
· ALLERGIES
· MEDICATIONS
· PAST HISTORY
· LAST MEAL
· EVENTS leading to presentation
Those of you offended by the word “VOMIT” (what are you doing in healthcare?) can use the alternative mnemonic “MOVIE”
· MONITOR: 3-lead ECG to see rhythm
· OXYGEN: titrate to SpO2 94%
· VITALS: BP, RR, Pulse, Temperature
· IV: intravenous access; send bloods
· ECG and targeted examination
The patient should be clinically assessed for signs of distress and of right- and left-ventricular dysfunction: examination constitutes general impression, position of trachea and whether jugular venous distension is present; pulses central and peripheral, BP, apex beat location, auscultation of heart sounds and identification of any added sounds; identification of any murmurs or bruits; any evidence of peripheral or sacral oedema; any ascites or enlarged intra-abdominal organs.
The critical signs dividing stable from unstable patients include:
· Altered level of consciousness
· Shock or hypotension
· Shortness of breath
· Evidence of left ventricular dysfunction / failure
· Ischaemic chest pain
Once the condition of the patient has been established, the rhythm should be analysed
· Fast or slow?
· Regular or irregular?
· Is there a normal P-wave? Abnormal P-waves are associated with certain types of atrial and junctional tachycardias.
· Is there a normal QRS complex? QRS complex in the adult is <0.12s. Broad QRS is associated with rhythms generated by the ventricles, or with bundle branch blocks.
· Is there a P before every QRS? Lack of normal P waves may occur with atrial fibrillation or flutter, or junctional rhythms. QRS complexes may also appear to occur independently of P waves in certain types of heart block.
· Is there a QRS after every P? Similarly, P waves occurring intermittently without a following QRS complex may indicate heart block.
· Is the relationship of the P-wave to the QRS complex normal? Abnormal relationship between the P wave and QRS complex occurs with the various degrees of heart block. Normal PR interval in the adult is 0.12-2s (3-5 small boxes)
