Life support — DRS ABC
  • Urgent medical consult but do not delay starting resuscitation
  • If newborn — see Newborn resuscitation
  • If unsure of pulse — don't delay compressions
  • Person with narcotic overdose may at first have a pulse but not be breathing — they need respiratory support

This protocol is for people collapsed and unresponsive or drowned

  • If no signs of life — not responding, not moving, gasps/not breathing, pulseless or pulse not clearly felt in 10 seconds — DRS ABC
  • If unresponsive and breathing normally — assess for causes and manage as unconscious person
  • If deterioration or clinical change during assessment — return to start of this protocol
  • If more than one of you — declare who is in charge
  • Decision to stop CPR is very difficult — made by senior member of team after medical consult

Immediate defibrillation

  • If collapse is witnessed and defibrillator immediately available/attached (eg in clinic) — defibrillate if indicated — see Defibrillation

D – Danger

  • Make sure that you, person and place are safe
  • If outside — put on protective clothing (eg fluoro vest, sun protection PPE )
  • Check for hazards — chemicals, electrical sources, being trapped or burned
  • Check surface person is lying on

R – Response

  • Does person respond to voice or gentle shake

S – Send for help

  • Helper can
    • Collect needed equipment
    • Call for more help, call ambulance if access to hospital
    • Help with CPR

A – Airway

  • Clear airway and protect cervical spine (neck) — see Immobilising the spine
  • Adult or child
    • Use head tilt/chin lift — place one hand on the forehead. The other hand is used to provide chin lift. The head (not the neck) is tilted backwards. Grip chin and gently lift it up — Figure 2.1

OR jaw thrust if head or neck injury suspected. Hold jaw at point under ears, push upward and forward until chin juts out and airway opens — Figure 2.2

  • Infant (under 1 year)
    • Put folded towel or nappy under shoulders and back — Figure 2.3

Figure 2.1   

Figure 2.2   

Figure 2.3   
  • If visible foreign body — use forceps to remove OR if no other use 2 ‘hooked’ fingers in downward sweeping motion
  • If liquid (blood, vomit, water) — use suction if available OR gravity — roll onto side, open mouth and turn face downward 
  • Keep airway open — put in oropharyngeal or nasopharyngeal airway if needed

B – Breathing

  • Assess — look for chest rise and fall, listen for breath sounds, feel for breath
  • If person breathing but non-responsive — see Unconscious person
  • If not breathing — commence CPR
  • 2 breaths per 30 compressions for all ages except newborns — see newborn resuscitation
    • 2 breaths, delivered over 1 second each with bag-valve-mask using oxygen if available OR mouth-to-mouth with droplet barrier/filter
  • Watch chest rise and fall — don’t overinflate
  • If recovers and breathing normally
    • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD — 88–92%
  • Put in recovery position — Figure 2.4 — unless possible head or spinal injury possible

Figure 2.4   

C – Cardiopulmonary resuscitation - compressions (CPR)

  • Start CPR on firm surface
    • Centre of chest, ⅓ depth of chest
    • Allow chest recoil, minimise interruptions
  • 30 compressions then 2 breaths for 1 or 2 responders
  • 100 - 120 compressions/minute (2 compressions/second)
  • Pause compressions to allow for breaths — max pause 10 seconds

Defibrillation

  • Indications —  VF and Pulseless VT
  • As early as possible. If immediately available and adult patient — defibrillate before compressions
  • Infant or child less than 10kg
    • Use manual defibrillator if available
    • If no manual defibrillator — use AED

Pads

  • Press adhesive pads on firmly for best shock and to avoid burns
  • Do not place pad over ECG dots, leads or pacemakers
  • Adult — Figure 2.5
    • One pad on right parasternal area over 2nd intercostal space
    • One pad on left midaxillary line over 6th intercostal space
  • Child — use largest pad that allows at least 3cm pad separation
    • Over 10kg — usually 8–10cm adult pads
    • 10kg or under — dose-attenuated paediatric pads (deliver 50J) OR adult pads placed front and back — Figure 2.6

Figure 2.5   

Figure 2.6   
  • Defibrillator energy levels — Biphasic
    • Adult — 200J
    • Child — 4J/kg (doses)
  • AED — once attached pause compressions for rhythm analysis
  • Resume CPR immediately after shock delivered. Recheck rhythm after 2 minutes or return of responsiveness

Drugs (medicines)

Adrenaline (epinephrine)

  • Give if asystole (no heartbeat), , VF pulseless VT or pulseless electrical activity (PEA)
  • Adrenaline (epinephrine) dose
    • Adrenaline (epinephrine) IV/intraosseous — adult 1mg, child 0.01mg/kg/dose up to 1mg — doses — 1mg = 1mL of 1:1,000 or 10mL of 1:10,000 
    • Do not give if person already responding (breathing and moving)
    • Every 4 minutes during CPR

Amiodarone

  • If persistent VT or VF after 3 failed shocks — give amiodarone IV/intraosseous push as bolus — adult 300mg, child 5mg/kg up to 300mg — doses
  • If still persistent VT or VF — shock again
  • If still persistent VT or VF after fourth shock — medical consult about
    • Second amiodarone IV/intraosseous bolus — adult 150mg, child 5mg/kg up to 150mg
    • OR lidocaine (lignocaine) IV/intraosseous bolus — 1mg/kg
  • If normal rhythm restored — start amiodarone infusion 15mg/kg over 24 hours (usual adult dose 900mg), child 2.5mg/kg 6 hourly dose. Dilute in glucose 5%
  • ​Do not dilute amiodarone in normal saline
  • Diluting — need concentration of more than 0.6mg/mL for stable solution
    • Dose less than 225mg — use 100mL bag glucose 5%
    • Dose 225–449mg — use 250mL bag glucose 5%
    • Dose 450mg or more — use 500mL bag glucose 5%
  • Use volumetric pump
  • Do 12 lead ECG — look for evidence of ischaemia/infarct

Atropine

  • For severe bradycardia (very slow heart rate), some poisons
  • Do not give if asystole (no heartbeat)
  • Dose
    • Adult — IV/intraosseous — 1mg boluses (up to 3mg in total)
    • Child — IV/intraosseous — 0.02mg/kg (doses) OR ETT 0.03mg/kg

Flowchart 2.1  Advanced life support for adults

Flowchart 2.2 Advanced life support for infants and children

Unconscious person

Do first

  • Breathing and unresponsive
    • Call for help — medical consult
    • Clear airway and protect cervical spine (neck) — see Immobilising the spine
    • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD 88–92%
  • If breathing normally and no risk of head, face or spinal injury — put in recovery position — Figure 2.7, Figure 2.8

  • If suspected spinal injury and single responder — use Haines roll to protect the airway

Figure 2.7  

Figure 2.8   

Ask — friends and family

  • Did person become unconscious suddenly or slowly
  • Any symptoms before
    • Weakness, dizziness, fever, headache
    • Diarrhoea, vomiting — may cause shock, especially in child
  • Had person been drinking alcohol
  • Had person taken or injected medicines, drugs
  • Usual medicines
  • Injuries (eg hit over head, bled a lot)
  • Bites (eg snake, spider)
  • Has person been depressed
  • If person has
    • Fits (epilepsy)
    • High BP — may cause stroke, heart attack
    • Diabetes
    • Lung problems — high CO2 level, hypoxia (low oxygen)
    • Heart disease — heart attack, stroke
    • Liver or kidney disease
    • Thyroid disease
    • Asthma
    • Any allergies
  • Has person been

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • ECG and coma scale — pupils
  • Head-to-toe exam
    • Stroke — asymmetry (one side of body or face looks, moves, has reflexes different to other)
    • Injury — cuts, head injury, pupils different sizes, blood or clear fluid (CSF) from ear or nose
    • Dilated pupils (very large) — overdose anticholinergics
    • Pinpoint pupils (very small) — overdose opioids
    • Rash, neck stiffness — meningitis
    • Bite marks, bleeding — snake bite
    • Medical alert bracelet

Do

  • Put in IV cannula 
  • POC Test — electrolytes
  • Medical consult — IV fluids
    • Correct hypotension (low BP) — normal saline IV bolus— adult 500mL, child 20mL/kg up to 500mL
  • Assess/manage possible causes
    • If BGL less than 2.6mmol/L for child 10 years and under or less than 4mmol/L for child over 10 years or adult — do not delay, treat straight away — see Hypoglycaemia (low blood glucose)
    • Alcohol, drug overdose
    • Unconscious after a fit
    • Shock
    • Subarachnoid haemorrhage
    • Head injury
    • Infections, especially meningitis
    • If child — poisoning, infection, child abuse
    • Consider more than one cause — fit from low BGL AND being drunk/using drugs AND head injury from accident
  • Pressure area care
  • Consider IDC — U/A and pregnancy test