Advanced Life SupportGuidelines for
resuscitation of an
who is unconscious and not breathing, are given by the Resuscitation Council.
Anaphylactic shockA severe
hypersensitivity reaction to drugs or allergens, which can lead to asphyxia,
cardiovascular collapse, and cardiac arrest. The reaction is sudden, severe, and involves
the whole body.
Resuscitation Council ||
AspirationThe drawing of a substance, such as the
gastric contents, into the respiratory tract, during inhalation.
Also, the removal of fluid or gas from a body cavity, using suction equipment.
AsystoleAbsence of electrical
and mechanical activity in the heart - a non-shockable cardiac arrest.
Atrial FibrillationAn arryhthmia:
Rapid and asynchronous contractions of the atrium, causing irregular contraction
of the ventricles. The pulse will be irregular in rate and strength, and the
wrist and Apex pulse rates will
be asymmetrical. AF details
BarotraumaInjury due to excess pressure in tissues.
Beta (β) blockersNegative inotropic
drugs which block the affect of Adrenaline on the heart and blood vessels, by weakening
effects of the Sympathetic Nervous System on heart conductivity, and reducing blood
pressure and heart rate. Example
BradycardiaSlow heart rate/pulse.
Antimuscarinics, such as Glycopyrronium and Atropine, can be used to counter the
bradycardia caused by Neostigmine.
BronchospasmSudden difficulty in
breathing caused by constriction of plain muscle in the walls of the bronchi.
Spontaneously breathing patients may have an audible wheeze.
Can't intubate, can't ventilate
When intubation fails, and the patient suffers hypoxaemia and difficult
ventilation, a rescue algorithm must be followed, as described by the
Difficult Airway Society
Cardiac arrestThe heart stops
pumping blood around the body, resulting in unconsciousness and abnormal breathing,
which requires immediate cardiopulmonary resuscitation.
User manual ||
Dealing with an arrest
Cardiac (pericardial) tamponade
A condition in which gas or fluid, such as blood or pus, accumulates in the
pericardium faster than the pericardial sac can
stretch. If the fluid/gas significantly elevates the pressure on the heart, it will
prevent the heart's ventricles from filling properly, leading to a low stroke volume,
shock, and death. Actions
ChokingThe Resuscitation Council provides the algorithms for
treating choking in adults and
children over 1 year.
Code RedA protocol for managing massive haemorrhage. (
What to do
(Cricothyrotomy) An emergency procedure, to provide a temporary emergency
airway, via the cricothyroid membrane (in the adult: 10 mm high, 22 mm wide),
when there is obstruction at, or above, the larynx.
Action to take
routine intubation failure is unanticipated, any further attempts must be
made according to the algorithm provided by the
Difficult Airway Society.
Note: ventilating the patient has priority over intubation.
Hypertensive disorder of pregnancy and toxaemia of pregnancy. Pre-eclampsia is
characterized by high blood pressure and significant amounts of protein in the
urine, and this can develop into Eclampsia, where the patient may suffer tonic-clonic
Emergency airway Description
An emergency case, such as a ruptured aortic aneurysm, demands minimum delay to
anaesthetic induction (typically by RSI),
and surgical intervention. Equipment etc
Epileptic fitA neurological disorder marked by sudden
recurrent episodes of sensory disturbance, loss of consciousness, or convulsions.
Failed Rapid Sequence Induction
When routine RSI is unanticipated, follow the algorithm, as described by the
Difficult Airway Society.
Febrile convulsionA seizure (rarely serious)
which occurs in a child with a fever over 39°C (102.2°F).
Reflux of gastric contents. If the contents reach the lungs, permanent damage may
occur. If the contents are very acidic, death can result.
Considerations for surgery
Glasgow Coma Score
A system for rating a patient's level of consciousness, based on an assessment
of 3 response types: Eye opening, Motor response, and Verbal response.
Heart blockImpaired conduction between the
atria and ventricles.
Heart failure (congestive heart failure)Heart failure is a
global term for the state in which cardiac output is insufficient in meeting the
needs of the body. Most commonly caused when cardiac output is low, and the body
becomes congested with fluid.
Hypercapnia (hypercarbia)Increased level of carbon dioxide
in the blood.
HyperkalaemiaA high level of serum potassium: the
normal range is 3.5 – 5.3 mmol/L.
For raised levels, give 10ml of calcium gluconate
10% intravenously over 2-5 minutes; then 10 IU Actrapid + Glucose 50%, 50 mls.
ECG characteristics of hyperkalemia:
- P-waves are widened and low amplitude due to slowed conduction.
- Tall tented T waves.
- QRS widening
- Fusion of QRS-T
- Loss of the ST segment
HypertensionBlood pressure which is above the normal range
for a particular category of person, according to such factors as age and weight.
Typical treatment is by a Beta-blocker, such as Atenolol, Esmolol, or Labetalol.
Abnormally deep breathing or excessive ventilation of the lungs, usually
accompanying emotional stress.
HypokalaemiaA low level of serum potassium. Normal
range is 3.5 – 5.3 mmol/L. Treat with rapid infusion of potassium. ECG indications are:
- Flattened T waves
- Negative T waves
- Sometimes, prominent U waves
- ST depression
HypotensionBlood pressure which is below the normal range for a
particular category of person, according to such factors as age and weight. Typically treated
by a vasoconstrictor. Low diastolic pressure suggests arterial vasodilation, as with sepsis
or anaphylaxis. A small pulse pressure could be due to arterial vasoconstriction, such as
with hypovolaemia, or cardiogenic shock
HypothermiaCore body temperature below
(35°C). Consequences can vary from minor to severe.
Hypoventilation refers to inadequate breathing and impaired gas exchange, which
prevents the body from being able to remove carbon dioxide appropriately. As a
consequence, there develops an increase in the level of carbon dioxide
(hypercapnia) in the blood, together with a decreased level of oxygen.
HypovolaemiaReduced circulating blood volume,
typically caused by shock.
- Dry mouth
- Dry axillary skin
- Postural hypotension
The immediate goal is to raise systolic blood pressure to 100 mmHg, by administering
250-1,000 ml isotonic (0.9%) saline solution.
Low level of oxygen in the tissues (cellular level).
Low level of oxygen in arterial blood.
A reflexive prolonged contraction of the laryngeal muscles, and closing of the
vocal chords, characterised by noisy inspiration. If the vocal chords are completely
closed, there will not be any airway noise.
Dealing with Laryngospasm
Local anaesthetic toxicitySee
An abnormality of the muscle fibre membrane. The two most powerful triggers are
Suxamethonium and volatile agents (N2 has no effect). Also triggered by
Lignocaine, Atropine, Diazepam, Pancuronium, Phenothiazines, and stress.
Initial signs are tachycardia and increased CO2 production; spontaneously
breathing patient will deal with the CO2 by breathing more rapidly; IPPV
patients will have higher end tidal CO2.
Arterial Blood Gas shows hypercarbia, respiratory and metabolic acidosis.
Heart attack: Necrosis of part of the heart muscle, due to interrupted blood
supply, usually following a coronary thrombosis (artery occlusion).
G.A. Caesarian Section
Opioid overdoseCauses respiratory
depression, signified by a low minute volume, with resultant hypercapnia.
- Pin-point pupils
- Slow respiratory rate
Reverse with Naloxone, or stimulate respiration with eg, Doxapram.
Oxygen toxicityA condition resulting from the harmful effects
of breathing molecular oxygen at elevated partial pressures (hyperoxia). Severe
cases can result in cell damage and death, with effects most often seen in the
central nervous system, lungs and eyes. Oxygen toxicity is a concern for those
on high concentrations of oxygen (particularly premature babies), and those
undergoing hyperbaric oxygen therapy. Symptoms may include disorientation,
breathing problems, burning sensation with deep breathing, anxiety, vomiting,
and vision changes.
Paediatric Advanced Life Support
Paediatric Basic Life Support
Paediatric emergency treatment
Paediatric Immediate Life Support
Panic attackPsychological state, indicated by
hyperventilation, tachycardia, and erythematous rash (redness), but without
hypotension, pallor, wheeze, or urticarial rash.
Peri-arrestConditions which may precede or follow a cardiac arrest.
PericardiocentesisAspiration of fluid through fifth intercostal
Accumulation of air (or other gas) in the pleural cavity, which may lead to
collapse of the lung. Usually accompanied by sudden sharp pain in one side of the
chest, during inspiration. The pneumothorax can clear of it's own accord.
Post operative nausea and vomitingA side
effect of general anaesthesia, suffered by 1 in 4 patients. If unmanaged, can
lead to pulmonary aspiration of gastric contents. Younger patients are more
susceptible than older ones, as are gynaecological, urological,
strabismus correction, and middle ear surgery patients. Treatment is by
dispensing a combination of agents, until efficacy is achieved.
Drugs and actions
Postpartum Haemorrhage (PPH)The loss of 500 ml or more of
blood from the genital tract, within 24 hours of giving birth.
Precordial thumpAn attempt to interrupt an arrhythmia, such as
Ventricular Fibrillation or pulseless Ventricular Tachycardia, by making a single
strike, with the fist, to the centre of the patient's sternum. The thump is only
effective if made at the onset of a witnessed and monitored adverse rhythm
(VF/pVT), and a defibrillator is not immediately available. Latest resuscitation
guidelines de-emphasise use of the precordial thump.
Primary surveySteps to take when assessing an unconscious
Order of steps
|Danger||Assess Dangers to yourself and casualties|
|Response||Use the Glasgow Coma Scale to ascertain the level of
|Airway||Examine the Airway for obstructions|
|Breathing||Look, listen, and feel for adequate respiratory effort.
Supplement with oxygen to correct hypoxia, if saturations are below 95%|
|Circulation||If a carotid pulse is not palpable, then
resuscitation should be commenced|
Pulmonary embolismAn embolism
which usually originates from the proximal veins of the thigh and pelvis.
Pulmonary oedemaExcess of watery fluid in the lungs,
which collects in the air sacs, making it difficult to breathe. Pulmonary oedema is most often
caused by heart failure (cardiogenic pulmonary oedema), but it may be caused by other conditions,
which do not directly affect the heart (non-cardiogenic pulmonary oedema).
Pulseless Electrical Activity (PEA)A
cardiac arrest where the patient has cardiac electrical activity, which would
otherwise produce cardiac output and an obvious pulse. PEA usually has an
underlying treatable cause which, in emergency situations, is most often
hypovolemia. Performing a pulse check after a rhythm/monitor check will ensure
that PEA is identified. Cardiac issues
QuickTrach Cricothyrotomy kit
For making an airway opening during a "can't ventilate" emergency.
Respiratory failureWhen the respiratory
system fails in oxygenation and/or carbon dioxide (CO2) elimination.
Basic principles ||
In Hospital resuscitation
A more in depth survey of the patient than the primary survey.
Steps to take
ShockFailure of the cardiovascular system
to deliver adequate blood flow necessary to properly supply oxygen and nutrients to
vital organs, particularly to the kidneys and brain. This inadequate tissue perfusion
causes an accumulation of lactic acid in the tissues. If untreated, shock can lead to
multiple organ failure. Recognition and treatment
StridorA harsh vibrating sound, during inspiration, caused by tumour,
infection, or partial obstruction of the larynx or trachea.
• Oxygen and positioning the head of the bed 45 - 90 degrees.
• Nebulized racemic Adrenaline (0.5 to 0.75 ml of 2.25% racemic
Adrenaline added to 2.5 to 3 ml of normal saline) in cases where airway oedema
may be the cause of the stridor.
• Dexamethasone (Decadron) 4-8 mg IV q 8 - 12 h in cases where
airway oedema may be the cause of the stridor; note that some time (hours) may
be needed for dexamethasone to work fully.
• Inhaled Heliox (70% helium, 30% oxygen); the effect is almost
instantaneous. Helium, being a less dense gas than nitrogen, reduces turbulent
flow through the airways.
• Always ensure an open airway.
Suxamethonium apnoeaProlonged effect
of Suxamethonium, which means a patient may reverse from anaesthesia, but remain
paralysed. Anaesthesia protocol
SyncopeA brief period of unconsciousness, due to reduced
blood flow to the brain.
- Vagolytic drugs, such as Atropine
Adult treatment algorithm
Tension pneumothoraxPneumothorax due
to air escaping into the pleural cavity, typically as a consequence of a penetrating
injury. What to do
Thorax to aspirate pleural fluid or gas.
TracheotomyA procedure to make an
airway opening through the second or third tracheal ring, typically because of upper
- A lateral cut is made, superior to the sternal notch.
- The skin is separated and surrounding tissues dissected, exposing the trachea.
- The 2nd or 3rd tracheal ring is incised, and the tracheostomy tube placed.
- The tube cuff is then inflated (2-5 ml).
- The incision is sutured at the side of the tracheostomy tube.
Ventricular Fibrillation (VF)
Heart rhythm is chaotic -
the heart is in a state of electrical chaos. No blood is pumped from the heart,
and the patient has no pulse. The ECG trace lacks P-waves, QRS complexes, or
T-waves. Action is electrical defibrillation.
See Advanced Life Support
Ventricular Tachycardia (VT)
A regular and fast beating of the ventricles (120 beats/min), which is too fast
for them to fill with sufficient blood betweeen beats. Pulseless VT
can lead to Ventricular Fibrillation, which is a more serious condition. Action
for pulseless VT is electrical defibrillation.
See Advanced Life Support