Police statements Do not provide information to the police until patient consent has been o btained. Writing a police statement requires thought and care. Write the statement yourself . Keep statements brief and try to avoid hearsay, conjecture, or opinion on the likely outc ome. List injuries using both medical and non-medical language, explaining terminology in d etail as necessary. State the investigations and treatment provided as accurately as possib le (eg what sutures and how many were used). Having written the statement, ask your consult ant to read it and comment on it. Get the statement typed (a friendly ED secretary may help if you cannot type yourself, and will also know how you can claim the relevant fee). Havin g checked it, sign and date the statement, and give it to the of \201 cer concerned. Alway s keep a copy of the statement and the ED notes, so that they are easily available if you a re called to court. Court appearances In advance Discuss the case with your consultant, and review the notes, t he questions that you might be asked, and the likely court procedures. Get a good copy of t he notes and any investigations. Ask whether you should take the original records to court. On the day Dress smartly, arrive early, and behave professionally. Be prepared for a long w ait, so take a book to read. Turn off your mobile phone. Once in court, you have the option of taking an oath before God or af \201 rming without religious connotation. You are equa lly bound to tell the truth whichever you choose. Use the same form of address that others have already used (eg \200\230My Lord \200\231, \200\230Your Honor \200\231). Answer dire ctly and simply. Use comprehensible language, free of medical jargon. Remember that you are a professional witness, not an expert. Therefore, con \201 ne the expression of opinion t o within the limits of your knowledge and experience \200\224 if asked something outside t his, say so! Inquest/fatal accident inquiry If you are called to give evidence at an inquest (in Scotlan d, a fatal accident inquiry), discuss the case with your consultant and also with your medi cal defense society. Further information and advice about reports and appearing in court The medical defense org anizations ( b p.29) have useful advice sheets for their members about writing reports and appearing in court. 32 CHAPTER 1 General approach Infection control and prevention Staff in the ED have an important role in preventing and c ontrolling infection, which can be a serious risk to patients, relatives, and staff. Organi sms such as Staph. aureus , including MRSA ( b p.235), can readily be transmitted by contam inated hands or equipment, causing infection of wounds, fractures, and in-dwelling devices (eg catheters or chest drains). Infected blood can transmit many infections, including hepa titis B and C ( b p.239) and human immunode \201 ciency virus (HIV; b p.242). Viral gas- t roenteritis is usually spread by the fecal-oral route, but vomiting may cause widespread vi ral contamination of the surroundings and equipment, with a risk of transmission to other p atients and staff. Coughing and sneezing produces small droplets of infected secretions, which could involve v iruses such as in \202 uenza ( b In \202 uenza pandemics, avian \202 u, and swine \202 u, p.252), severe acute respiratory syndrome (SARS; b p.251), and respiratory syncytia l virus (RSV; b p.682). A nebulizer used on an infected patient may spread respiratory viru ses widely, as occurred in the outbreak of SARS in Hong Kong in 2003 which involved many ED staff. Standard precautions for preventing infection Standard precautions (also known as \200\230 universal precautions \200\231) should be used at all times and with all patients to reduce the risks of infection. Blood and body \202 uids from all patients should be treated as infected. These standard precautions include: \200 Hand hygiene Essential, but often negl ected. Decontaminate your hands before and after every patient contact, and after any activ ity that might contaminate hands, including removing gloves. Hands that are visibly dirty o r possibly grossly contaminated must be washed with soap and water, and dried thoroughly. A lcohol hand gel can be used if the hands look clean. Cover broken skin with a waterproof dr essing. Personal protective equipment (PPE) Wear suitable disposable gloves for any contact with bl ood, body \202 uids, mucous membranes, or non- intact skin. Latex gloves are widely used, but cause allergic reactions in some patients and staff, who need special nitrile gloves. Use a disposable plastic apron if there is a risk of blood or body \202 uids contaminatin g clothing. After use, dispose of it and wash your hands. Impervious gowns are needed if th ere is a high risk of contamination. Use a mask , face shield, and eye protection if blood or body \202 uids might splash in your eyes or mouth. Protection against respiratory viru ses, eg SARS or in \202 uenza requires special masks or respirators (eg FFP3), which must be \201 tted and used properly. Powered air-purifying respirators should be used for high -risk procedures such as intubating patients with serious viral infections. Safe handling and disposal of sharps Avoid handling needles directly or using hand-held nee dles. Never re-sheathe needles. Place used needles and blades immediately into a \200\230s harps bin \200\231. If possible, use safety needles and cannulae, which reduce the risk of needlestick injury. If, despite all precautions, a needlestick injury does occur follow loc al approved 33 INFECTION CONTROL AND PREVENTION procedures to minimize the risk of infection and look after the people involved (see b Need lestick injury, p.418). Managing blood and bodily \202 uids Samples of blood or other body \202 uids must be ha ndled safely, with care not to contaminate request forms or the outside of the container. F ollow local approved procedures for dealing with spillages of blood or body \202 uids: we ar suitable PPE (usually a disposable apron and gloves) and disinfect the spillage with an appropriate agent such as diluted bleach. Planning for outbreaks of infectious diseases Planning to cope with an outbreak of a seriou s infectious disease such as SARS or pandemic \202 u ( b p.252) is a considerable challen ge for ED staff and for the whole community. The ED must be organized so that patients can be assessed properly with a minimum risk of infecting staff or other patients. If possible, patients with serious airborne diseases should be treated in negative pressure isolation r ooms by staff in appropriate PPE who are fully trained to minimize the risks of spreading a nd acquiring the infection. In high risk situations a \200\230buddy \200\231 system for st aff may be helpful, with each doctor or nurse being watched closely by another person to ch eck that full safety precautions are maintained. Assessment of febrile patients Hospitals in Hong Kong with experience of SARS use the FTOCC criteria when assessing febrile patients for potentially serious infectious diseases: \200 F \200\224 fever ( > 38 C). \200 T \200\224 travel history. \200 O \200\224 occupational history. \200 C \200\224 clustering of cases. \200 C \200\224 contact h istory (eg someone with SARS or avian \202 u). Similar criteria are used in the UK Health Protection Agency \200\231s algorithm: www.hpa.org.uk/Topics/InfectiousDiseases/Infections AZ/AvianIn \202 uenza/ Further information Standard precautions www.rcn.org.uk/downloads/publications/public_pub/0 02725.pdf Masks and respirators www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SevereAcute Res piratorySyndrome/Guidelines/sars040Facemasksand respiratorsFAQ/ Pandemic in \202 uenza/avian \202 u b In \202 uenza pandemic, avian \202 u, and swine \202 u, p.252. SARS b SARS, p.251. 34 CHAPTER 1 General approach What to carry in your car If you are interested in out of hospital work, join the British A ssociation for Immediate Care (BASICS: www.basics.org.uk ), which is a valuable source of i nformation and expertise. It can give advice on clothing, medical and protective equipment and their suppliers, and Immediate Care courses. The equipment that could be carried is extensive. In the UK, except in the most remote situ ations, it is likely that an ambulance will be on scene quickly. Emergency ambulances carry many items of equipment, eg for intubation, volume infusion and splintage, and also some d rugs. There is a risk of carrying too much equipment in your car and getting diverted from the primary aims of pre-hospital care, which are to perform only relevant life-saving techn iques, and to transfer the patient rapidly and safely to the nearest appropriate hospital. The equipment listed below is a personal choice based on experience attending out-of-hospit al calls over the past 20 years: Personal equipment \200 High quality wind/waterproof re \202 ective jacket and over-trou sers. If your \201 nances do not run to this, at least have a re \202 ective \200\230Do ctor \200\231 tabard. Protective helmet. \200 Protective footwear \200\224 leather boots with steel toecaps ar e ideal. \200 2 pairs of latex gloves. \200 1 pair of protective gloves (eg leather gar dening gloves). General equipment \200 Re \202 ective warning triangle. \200 Fire extinguisher. \200 Heavy-duty waterproof torch. \200 Clothes-cutting scissors. \200 Mobile phone. 35 WHAT TO CARRY IN YOUR CAR Medical equipment The equipment listed is only of value if you know how to use it, it is se cure (ie locked in a case in a locked vehicle), and it is in date: \200 Stethoscope. \200 Hand-held suction device + Yankauer and soft \202 exible suckers. \200 Laryngosco pe, adult curved blade, spare batteries, and bulb. \200 Selection of tracheal tubes of va rying sizes + syringe to in \202 ate cuff. \200 Magill \200\231s forceps. \200 Selecti on of oropharyngeal and nasopharyngeal airways. \200 Laerdal pocket mask. \200 Venous t ourniquet. \200 Selection of IV cannulae (2 each of 14G and 16G) and syringes. \200 2 \227 IV-giving sets. \200 2 \227 1000mL 0.9 % saline bags. \200 1 roll of 1-inch zinc oxide tape. \200 1 roll of 3-inch Elastoplast. \200 Small selection of dressings and ba ndages. \200 Cervical collar. \200 Cricothyrotomy kit. \200 Intercostal chest drain s et. \200 2 \227 0/0 silk suture on a hand-held cutting needle. \200 Local anesthetic, eg lidocaine 1 % (for nerve blocks). \200 Splints for IV cannulation sites. 36 CHAPTER 1 General approach At the roadside Priorities It is easy in an emergency to forget the simplest, most life-sav ing procedures. At worst, an individual trying to help can aggravate the situation, slow th e process of care, and even become a casualty themselves. If you arrive \201 rst at the s cene of a collision, the initial priority is to ensure your own safety and that of other re scuers. \200 Park safely so your car will not obstruct other vehicles (including emergenc y vehicles), preferably where its presence will alert other road users to the collision. Pu t your hazard warning lights on. If you have a warning beacon, put it on the roof of the ca r and switch it on. If you have a mobile phone, dial \200\230999 \200\231 and request ambulance, \201 re, an d police to attend. Remember to give the exact location, a brief description of the inciden t, and number of casualties. Tell the emergency service operator who you are, as well as th e number of your mobile phone. Switch off the engine of your car and of any other vehicles. \200 Ensure that no-one is s moking or displays a naked \202 ame. \200 Events involving electricity or chemicals have speci \201 c hazards. Involvement of overhead or u nderground electric cables poses risks, compounded if water is involved or sparks produced. The risk from high tension cables extends for several meters. Phone the power company to ensure that the source is turned off before approaching. Electri \201 ed rail lines may be short-circuited by a trained individual using a special bar carried in the guard \200\231s compartment. Chemical incidents Do not approach a chemical incident until declared safe by the Fire Serv ice. Lorries carrying hazardous chemicals must display a \200\230Hazchem \200\231 board (s ee Fig. 1.2 ). This has: \200 Information on whether the area should be evacuated, what p rotective equipment should be worn, aspects relating to \201 re- \201 ghting, and if the chemical can be safely washed down storm drains (top left). A white plate means that the l oad is non-toxic. A 4-digit UN product identi \201 cation number (middle left). \200 A pictorial hazard di amond warning (top right). \200 An emergency contact number (bottom). The European \200 \230Kemler \200\231 plate contains only the UN product number (bottom) and a numerical haza rd code (top) \200\224 a repeated number means intensi \201 ed hazard. Mixed loads <500kg may only be identi \201 ed by a plain orange square at the front and rear of the vehicle. The transportation emergency card (TREM card) carried in the driver \200\231s cab gives in formation about the chemical for use at the scene of a crash. The \201 re tender may be e quipped with CHEMDATA \200\224 a direct link with the National Chemical Information Center at Harwell. Alternatively, contact a Poisons Information Center or the transportation comp any. Helicopters If helicopters are used for transportation/evacuation, remember: \200 Communi cations in or near helicopters are dif \201 cult because of the noise. \200 Ensure any l oose objects are secured to prevent them being blown away. 37 AT THE ROADSIDE Never enter the landing space area during landing or take-off. \200 Never enter or leave the rotor disc area without the pilot \200\231s permission. \200 Duck down in the rotor d isc area and only approach in full view of the pilot. \200 If the helicopter cannot land and the winch is used, do not touch the cable before it has touched the ground to earth any static electrical charge. Hazchem advice for the control of the chemical Hazard symbol and description in a diamond on white square background (rest of label is bla ck lettering on an orange backround) 4WE 2513 Substance identification number and name Corrosive Bromoacetyl bromide Specialist advice Pace transportation 0705 826435 Specialist advice and telephone number Suppliers name (optional) Danger labels 2 7 0 OxygenO 2 1 U . N . Marine pollutant Compressed gas 9 Other dangerous substance Multiload White Red Red Green Flammable liquid 2 Compressed gas 2 Flammable gas 2 Poision gas 2 Red/white stripes White Blue Yellow Oxidizing agent Spont aneously combustible 4.1 Flammable solid 4.1 5.1 Red Yellow White White Harmful stow a way from foodstuffs 6.1 Organic peroxide Toxic Corrosive 8 Black 5.2 6.1 Fig. 1.2 Hazchem advice and danger labels. 38 CHAPTER 1 General approach Major incidents A major incident involves a lot of people. The casualties may have multiple injuries, minor injuries/burns, or other emergencies such as food poisoning or chemical in halation. Every hospital accepting emergencies has a Major Incident plan to use when the no rmal resources are unable to cope and special arrangements are needed. There will be action cards for key staff detailing their duties. All staff need to familiarize themselves with their roles in advance. Call-in lists must be up to date and available at all times. Major incident practices must be held regularly to check arrangements and contact details a nd to remind staff what they should do. Alert The ambulance service or the police should warn the hospital of a possible or de \201 nite major incident. Initial messages are often inaccurate because they are based on c onfused and incomplete information from the scene. Occasionally, patients arrive without wa rning from a major incident near the hospital. Ensure that the ED consultant on duty is informed immediately of any suspected major incide nt, enabling them to participate in the decision to start the major incident procedure. Sen ior medical, nursing, and administrative staff will set up the hospital \200\231s Control C enter and prepare for action. If the major incident is con \201 rmed, the full hospital re sponse is initiated, following the procedures in the plan. Communications are vital, but switchboards rapidly become overloaded. Staff should therefor e be called in using non-switchboard phones if possible. All staff should wear their identi \201 cation badges. Action in the ED \200 Check that the ED consultant and hospital switchboard know about th e incident and that the major incident procedure has been started. \200 Inform all ED staff on duty (doctors, nurses, receptionists, porters). \200 Call in other ED staff in accord ance with the Major Incident plan. \200 Clear the ED of any patients who are not seriousl y ill or injured. Prepare the department to receive patients from the incident. Doctors and nurses arriving to help should be given appropriate action cards. Staff should have labels or tabards so that ED staff and other specialties (eg anesthetists) can be iden ti \201 ed easily. Prepare a triage point at the ambulance entrance. This should be staffed by a senior doctor and nurse who direct patients to the most appropriate area of the department. If possible, a nurse should stay with each patient until he/she is discharged or admitted to a ward. All patients should be labeled immediately with a unique Major Incident number, which is us ed on all notes, forms, blood samples, property bags, and lists of patients. Collect names, addresses, and other details as soon as possible, but this must not delay triage or emerge ncy treatment. Keep lists of anyone leaving the ED. Ensure that the hospital Control Center is regularly updated regarding the situation in the ED. 39 MAJOR INCIDENTS Wards and theaters Beds must be cleared to receive patients, preferably on 1 or 2 wards, ra ther than many different wards. A senior surgeon should triage patients needing operations and co-ordinate theater work. Relatives and friends Relatives and friends of casualties should be looked after by social workers and chaplaincy staff in an area near to, but separate from, the ED, perhaps in the outpatient department. Keep relatives informed as soon and as much as possible. Security st aff at each entrance to the ED should direct relatives and friends of casualties to the app ropriate area and not allow them into the ED. Press Journalists and television crews will arrive rapidly after a major incident. Keep the m out of the ED \200\224 direct them to a pre-arranged room to be briefed by a press of \201 cer and senior staff. Arrangements at the site of a major incident The police are in overall command. The \201 re service take control of the immediate area if there is a \201 re or chemical risk. The police, \201 re, and ambulance services will each have a control vehicle, with an Incide nt Of \201 cer to co-ordinate their staff and the rescue work. There may be a Medical Incident Of \201 cer (MIO) and also a Mobile Medical Team of doctor s and nurses, who should if possible be sent from a supporting hospital, rather than the ho spital receiving the \201 rst casualties. These staff must be properly clothed (yellow an d green high-visibility jacket marked \200\230Doctor \200\231 or \200\230Nurse \200\231, over trousers, green helmet with visor and chin strap, safety boots, gloves, knee pads, tor ch, ID badge), and must be trained and equipped with suitable medical supplies and action c ards. The mobile medical team must report to the MIO, who is in charge of all medical and nursing staff on site and works closely with the Ambulance Incident Of \201 cer (AIO). The MIO sh ould record the names of the mobile medical team and brief them about their duties and the site hazards and safety arrangements. The MIO is responsible for supervising the team, arra nging any necessary equipment and supplies, and making sure that the team are relieved when necessary. The MIO and AIO relay information to the hospitals and distribute casualties ap propriately. Debrie \201 ng staff Debrie \201 ng is important after a major incident, so that staff ca n discuss what happened and express their feelings. Mutual support of the team is essential . Counseling may be required. Senior staff should prepare a report on the incident and revi ew the major incident plan. Further information NHS Emergency Planning guidance www.dh.gov.uk/en/Managingyourorganisati on/Emergencyplanning/index.htm CBRN (Chemical, Biological, Radiological and Nuclear) incidents b Decontamination of patien ts, p.211. This page intentionally left blank 41 Chapter 2 Life-threatening emergencies Anaphylaxis Treatment algorithm for adults with anaphylaxis Choking Cardiac arrest In-hospi tal resuscitation algorithm Adult basic life support Cardiac arrest management Advanced lif e support algorithm Notes on using the advanced life support algorithm Post-resuscitation c are Central venous access Severe sepsis and septic shock Shock 42 44 45 46 47 48 50 52 53 54 56 59 60 Life-threatening emergencies in children are considered in Chapter 15, Pediatric emergencie s 631 b Pediatric basic life support 646 b Choking from a foreign body 648 b Anaphylaxis in children 650 b Pediatric advanced life support 652 42 CHAPTER 2 Life-threatening emergencies Anaphylaxis ( Anaphylaxis in children is covered in b p.650) Anaphylaxis is a generalized i mmunological condition of sudden onset, which develops after exposure to a foreign substanc e. The mechanism may: \200 Involve an IgE-mediated reaction to a foreign protein (stings, foods, streptokinase), or to a protein \200\223hapten conjugate (antibiotics) to which the patient has previously been exposed. Be complement mediated (human proteins eg G -globulin, blood products). Be unknown (aspirin, \200\230idiopathic \200\231). Irrespective of the mechanism, mast cel ls and basophils release mediators (eg histamine, prostaglandins, thromboxanes, platelet ac tivating factors, leukotrienes) producing clinical manifestations. Angio-oedema caused by A CE inhibitors and hereditary angio-oedema may present in a similar way to anaphylaxis. Here ditary angio-oedema is not usually accompanied by urticaria and is treated with C1 esterase inhibitor. Common causes \200 Drugs and vaccines (eg antibiotics, streptokinase, suxamethonium, aspi rin, non-steroidal anti-in \202 ammatory drugs (NSAIDs), intravenous (IV) contrast agents) . Hymenoptera (bee/wasp) stings. \200 Foods (nuts, shell \201 sh, strawberries, wheat). \200 Latex. Clinical features The speed of onset and severity vary with the nature and amount of the st imulus, but the onset is usually in minutes/hours. A prodromal aura or a feeling of impendi ng death may be present. Patients on B -blockers or with a history of ischaemic heart disea se (IHD) or asthma may have especially severe features. Usually two or more systems are inv olved: Respiratory Swelling of lips, tongue, pharynx, and epiglottis may lead to complete upper ai rway occlusion. Lower airway involvement is similar to acute severe asthma \200\224 dyspno ea, wheeze, chest tightness, hypoxia, and hypercapnia. Skin Pruritus, erythema, urticarial, and angio-oedema. Cardiovascular Peripheral vasodilati on and i vascular permeability cause plasma leakage from the circulation, with d intravascu lar volume, hypoten- sion, and shock. Arrhythmias, ischaemic chest pain, and electrocardiog ram (ECG) changes may be present. GI tract Nausea, vomiting, diarrhea, abdominal cramps. 43 ANAPHYLAXIS Treatment \200 Discontinue further administration of suspected factor (eg drug). Remove stings by scraping them carefully away from skin. Give 100 % oxygen (O 2 ). \200 Open and maintain airway. If upper airway oedema is presen t, get specialist senior help immediately. Emergency intubation or a surgical airway and ve ntilation may be required. In patients with shock, airway swelling, or respiratory dif \201 culty give 0.5mg (0.5mL o f 1:1000 solution) adrenaline intramuscular (IM). Repeat after 5min if there is no improvem ent. In adults treated with an adrenaline auto- injector (eg EpiPen ) the 300mcg dose is usually suf \201 cient, but additional doses may be required. Give only 50 % of the usual dose of adrenaline to patients taking tricyclic antidepressants, MAOIs, or B \200\223bloc kers. In profound shock or immediately life-threatening situations, give CPR/ ALS as necessary, a nd consider slow IV adrenaline 1:10,000 or 1:100,000 solution. This is recommended only for experienced clinicians who can also obtain immediate IV access. Note the different strengt h of adrenaline required for IV use. If there is no response to adrenaline, consider glucag on 1 \200\2232mg IM/IV every 5min (especially in patients taking B -blockers). Give a B 2 -agonist (eg salbutamol 5mg) nebulized with O 2 for bronchospasm, possibly with the addition of nebulized ipratropium bromide 500mcg. Give IV \202 uid if hypotension does not rapidly respond to adrenaline. Rapid infusion of 1 \200\2232L IV 0.9 % saline may be required, with further infusion according to the clini cal state. Antihistamine H 1 blockers (eg chlorphenamine 10 \200\22320mg slow IV) and H 2 blockers (eg ranitidine 50mg IV) are commonly given. They are second line drugs that, with hydrocortiso ne 100 \200\223200mg slow IV, may reduce the severity/duration of symptoms. Admit/observe after initial treatment: prolonged reactions and biphasic responses may occur . Observe for at least 4 \200\2236hr after all symptoms have settled. Report anaphylactic reactions related to drugs/vaccines to the Committee on Safety of Medic ines. Further investigation of the cause (and possibly desensitization) may be indicated. W here identi \201 ed, the patient and GP must be informed and the hospital records appropri ately labeled. Medic-Alert bracelets are useful. Notes on treatment algorithm on b p.44 1 A n inhaled B 2 -agonist such as salbutamol may be used as an adjunctive measure if bronchosp asm is severe and does not respond rapidly to other treatment. 2 If profound shock judged immediately life-threatening give CPR/ALS if necessary. Consider slow IV adrenaline (epinephrine) 1:10,000 solution. This is hazardous and is recommended o nly for an experienced practitioner who can also obtain IV access without delay. Note the d ifferent strength of adrenaline (epinephrine) that may be required for IV use. 3 If adults are treated with an EpiPen the 300mcg will usually be suf \201 cient. A sec ond dose may be required. Half doses of adrenaline (epinephrine) may be safer for patients on amitriptyline, imipramine, or B -blocker. 4 A crystalloid may be safer than a colloid. 44 CHAPTER 2 Life-threatening emergencies Treatment algorithm for adults with anaphylaxis 1 Anaphylactic reaction? Airway, Breathing, Circulation, Disability, Exposure Diagnosis - look for: Acute onset of illness \200 Life-threatening airway and/or breathing and/or circulation p roblems1 \200 And usually skin changes Call for help \200 Lie patient flat \200 Raise patient \200\231s legs Adrenaline2 When skills and equipment available: Establish airway \200 High flow oxygen \200 IV fluid challenge3 \200 Chlorphenamine4 \200 Hydrocortisone5 Monitor: \200 Pulse oximetry \200 ECG \200 Blood pressure 1 Life-threatening problems: Airway: Swelling, hoarseness, stridor Breathing: Rapid breathi ng, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion Circulation: Pale, clammy, low blood pressure, faintness, drowsy/coma 2 Adrenaline (give IM unless experienced with IV adrenaline) IM doses of 1:1000 adrenaline (repeat after 5 min if no better) \200 Adult: 500 micrograms IM (0.5 mL) \200 Child mor e than 12 years: 500 micrograms IM (0.5 mL) \200 Child 6 \200\22312 years: 300 micrograms IM (0.3 mL) \200 Child less than 6 years: 150 micrograms IM (0.15 mL) Adrenaline IV to b e given only by experienced specialists Titrate: Adults 50 micrograms; Children 1 microgram /kg 3 IV fluid challenge: Adult - 500 \200\2231000 mL Child - crystalloid 20 mL/kg Stop IV colloid if this might be the cause of anaphylaxis 4 Chlorphenamine (IM or slow IV) 10 mg 5 mg 2.5 mg 250 micrograms/kg 5 Hydrocortisone (IM or slow IV) 200 mg 100 mg 50 mg 25 mg Adult or child more than 12 years Child 6 \200\22312 years Child 6 months to 6 years Child less than 6 months See also: Anaphylactic reactions \200\223 Initial treatment Fig. 2.1 Anaphylaxis algorithm. 1 Resuscitation Council (UK) guidelines , 2008 . See: www.resus.org.uk 45 CHOKING Choking The management of choking is rightly taught as part of \201 rst aid. Recognition of the problem is the key to success. Clues include a person experiencing a sudden airway p roblem whilst eating, possibly combined with them clutching their neck. Severity of airway obstruction Victims with severe airway obstruction may be unable to spea k or breathe and become unconscious (see Fig. 2.2 ). Assess severity Severe Airway obstruction (ineffective cough) Mild Airway obstruction (effective cough) Unconscious Conscious Encourage cough Continue to check for deterioration to ineffective cough or until obstruction relieved Start CPR 5 back blows 5 abdominal thrusts Fig. 2.2 Adult choking algorithm. 1 1 Resuscitation Council (UK) guidelines, 2010 ( www.resus.org.uk ) 46 CHAPTER 2 Life-threatening emergencies Cardiac arrest Clinical features and recognition Follow resuscitation algorithm ( www.resus .org.uk ) shown opposite. Cardiac arrest is a clinical diagnosis: \200 Suspect cardiac ar rest in any patient who is unconscious and who does not have signs of life. If you check a pulse, examine only for a major (carotid or femoral) one and take no longer than 10sec. Oth er \200\230con \201 rmatory \200\231 clinical features (eg color, pupil size/response) wa ste time and do not help. Note that some respiratory efforts, such as gasping, may persist for several minutes after the onset of cardiac arrest. Occasionally, an arrest may present as a grand mal \201 t of short duration. \200 Most patients have had a sudden and unexp ected out-of-hospital event. Prior warning to the department is usually relayed by radio or direct telephone link from the Ambulance Service. While resuscitation is continued, ensure that accompanying relatives/friends are met and taken to an appropriate room, which has a telephone, facilities for making tea and coffee, and where privacy is possible. Arrange for a member of staff to stay with the relatives to act as a link with the Resuscitation Team. Information to obtain from ambulance crew/relatives \200 Patient details : including age, past medical history, current medication, chest pain before event Times of : collapse (often an approximation), 999 (or 112) call, arrival on scene, start of cardiopulmonary resuscitation (CPR), \201 rst de \201 brillating shock (if appropriate) , other interventions (eg advanced airway management, drugs), restoration of spontaneous ci rculation (ROSC) Was there any bystander CPR ? Where a patient in cardiac arrest is brought to hospital by a mbulance, the cardiac arrest team (ED staff, the hospital team, or a combination of both) s hould already be present in the resuscitation room with all equipment ready to receive the patient. The team leader The team leader controls, co-ordinates, organizes the team and makes treatm ent decisions. 4 \200\2236 team members are optimal. Each should know their role. Perform r esuscitation in a calm, quiet, con \201 dent manner with minimal interruption to the perfo rmance of basic life support (BLS) or de \201 brillation. Start the following procedures simultaneously: \200 Continue BLS. \200 Remove/cut cloth ing from the upper body to allow de \201 brillation, ECG monitoring, chest compression, and IV access. Obtain the ECG trace (through de \201 brillator pads or monitor leads). If already attache d to an ECG monitor, note (print out if possible) the rhythm. Beware movement artifact, dis connected leads, electrical interference, etc. Follow the ALS algorithm ( b p.52). \200 Do not interrupt CPR except to perform de \201 brillation. 47 IN-HOSPITAL RESUSCITATION ALGORITHM In-hospital resuscitation algorithm 1 Collapsed/sick patient Shout for HELP and assess patient Signs of life? YES NO Assess ABCDE Recognize and treat Oxygen, monitoring, IV access Call resuscitation team CPR 30:2 with oxygen and airway adjuncts Call resuscitation team if appropriate Apply pads/monitor Attempt defibrillation if appropriate Advanced life support when resuscitation team arrives Handover to resuscitation team Fig. 2.3 1 Resuscitation Council (UK) guidelines , 2010 ( www.resus.org.uk ). 48 CHAPTER 2 Life-threatening emergencies Adult basic life support Airway and ventilation Usually in the ED, advanced airway techniqu es will be used from the outset. If basic techniques are used (Fig. 2.4 ): \200 With the patient on his/her back, open the airway by tilting the head and lifting the chin. (Use jaw thrust instead if neck trauma suspected.) \200 Remove any visible obstructions from the mouth, but leave well- \201 tting dentures in place. Aim for each breath to last 8 1sec and make the chest rise. After each breath, maintain the head tilt/chin lift, take your mouth away from the patient \200\231s and watch for the che st to fall as the air comes out. Fig. 2.4 Mouth to mouth ventilation. 1 1 Colquhoun MC et al . (1999). ABC of Resuscitation , 4th edition. BMJ Books, London. 49 ADULT BASIC LIFE SUPPORT Technique for chest compression (Fig. 2.5 ) \200 Place the heel of one hand over the midd le of the lower half of the patient \200\231s sternum, with the other hand on top. Extend o r interlock the \201 ngers of both hands and lift them to avoid applying pressure to the patient \200\231s ribs. Positioned above the patient \200\231s chest and with arms straight, press down to depress the sternum 5 \200\2236cm. Release all the pressure and repeat at a rate of 100 \200\223120/min. \200 Compression an d release phases should take the same time. \200 Use a ratio of 30 chest compressions to 2 ventilations (30:2). \200 Aim to change the person providing chest compressions every 2 min, but ensure that this is achieved without causing signi \201 cant pauses. Fig. 2.5 Chest compressions. 1 1 Colquhoun MC et al . (1999). ABC of Resuscitation , 4th edition. BMJ Books, London. 50 CHAPTER 2 Life-threatening emergencies Cardiac arrest management De \201 brillation \200 Most survivors have an initial rhythm of VF/VT. The treatment for this is de \201 brillation. With time, the chances of successf ul de \201 brillation and survival d dramatically. Adhesive de \201 brillator pads have r eplaced manual paddles in most hospitals. Place one pad to the right of the upper sternum b elow the clavicle, the other in mid-axillary line level with V 6 ECG electrode position. Av oid placement over the female breast. To avoid problems with pacemakers, keep pads > 15cm a way from them. \200 With biphasic de \201 brillators, use shock energy of 150J, for (mos tly older) monophasic de \201 brillators, select 360J energy. Plan for chest compressions to be as continuous as possible, with minimal delays. Having pa used brie \202 y to assess the rhythm, recommence compressions until the de \201 brillato r is charged. Pause brie \202 y to deliver a shock (removing O 2 sources and transdermal g lycerol trinitrate (GTN) patches), then immediately restart CPR with 30:2 compressions: ven tilation, and continue for 2min before reassessing the rhythm or feeling for a pulse. In monitored patients with pulseless ventricular tachycardia/ \201 brillation (VT/VF) wher e de \201 brillation is not immediately available, give a single precordial thump . With a tightly clenched \201 st, deliver one direct blow from a height of 820cm to the lower ha lf of the sternum. Airway management Techniques for securing the airway, providing oxygenation and ventilation are covered in b Airway obstruction: basic measures, p.324. Although tracheal intubation h as long been considered to be the gold standard de \201 nitive airway, only attempt this i f suitably experienced. Laryngeal mask airway is a readily available, rapid alternative, wh ich is easy to insert. Whatever method is used, aim to ventilate (preferably with 100 % O 2 ) using an inspiratory time of 1sec, a volume suf \201 cient to produce a normal rise of the chest, at a rate of 10/min. For patients with tracheal tubes or laryngeal mask airways, ventilate without interrupting chest compressions, which should be continuous (except for de \201 brillation or pulse checks as appropriate). End-tidal CO 2 monitoring is very usef ul to con \201 rm correct tracheal tube placement and indirectly measure cardiac output du ring CPR. Drugs There is little evidence that any drug improves outcome. Central venous cannulation i s dif \201 cult, has risks and interrupts CPR. Peripheral access is easy and quick. Having given a peripheral IV drug, give a 20mL saline bolus and elevate the limb for 10 \200\2232 0sec. If IV access is impossible, consider intraosseous route ( b p.640). It is no longer r ecommended for any drugs to be given by tracheal tube. Similarly, do not attempt intracardi ac injections. The \201 rst drug used in cardiac arrest (after oxygen) is adrenaline. In the case of VF/ VT, administer adrenaline after three shocks, whereas in asystole/PEA, give it as soon as p ossible (see b Adult life support algorithm, p.52). 51 CARDIAC ARREST MANAGEMENT Non-shockable rhythms: PEA and asystole Pulseless electrical activity ( PEA ) is the clinic al situation of cardiac arrest with an ECG trace compatible with cardiac output. PEA may be caused by: \200 Failure of the normal cardiac pumping mechanism (eg massive MI, drugs su ch as B -blockers, Ca 2 + antagonists or electrolyte disturbance, eg hypokalaemia, hyperkal aemia). Obstruction to cardiac \201 lling or output (eg tension pneumothorax, pericardial tampona de, myocardial rupture, pulmonary embolism (PE), prosthetic heart valve occlusion, and hypo volaemia). Prompt and appropriate correction of these can result in survival. Remember potentially rev ersible causes as the 4H \200\231s and 4T \200\231s (see Table 2.1 ). Table 2.1 4H \200\231s 4T \200\231s Hypoxia Tension pneumothorax Hypovolaemia Tamponade (cardiac) Hyper/hypokalaemia/metabolic disorders Toxic substances (eg overdose) Hypothermia Thromboembolic/mechanical obstruction Asystole is the absence of cardiac (particularly ventricular) electrical activity. If unsur e if the rhythm is asystole or \201 ne VF, continue chest compressions and ventilation in an attempt to increase the amplitude and frequency of VF, and make it more susceptible to de \201 brillation.