Resussitation and airway management

1. Resuscitation
and airway
management
By: Dr Basma Mohamed Ghoniem
Lecturer of Anesthesia and Surgical ICU
MD of Anaesthesia and Surgical ICU
Faculty of Medicine
Kafr El Sheikh University

2. Chain of survival
Early recognition prevents:
Cardiac arrests and deaths
Admissions to ICU
Inappropriate resuscitation
attempts

3. The ABCDE approach to
the deteriorating patient
Airway
Breathing
Circulation
Disability
Exposure

4. Airway
 The aim of the airway assessment is to establish
and maintain patent airway
 The patient’s airway can be clear (if the patient is
talking), partially obstructed (if air entry is
diminished and often noisy) or completely
obstructed (if there are no breath sounds at the
mouth or nose)

5. Airway
Causes of airway obstruction:
CNS depression
Blood
Vomit
Foreign body
Trauma
Infection
Inflammation
Laryngospasm
Bronchospasm

6. Assessing the Airway
Talking
Difficulty breathing, distressed, choking
Shortness of breath
Noisy breathing
– Stridor, wheeze, gurgling
See-saw respiratory pattern, accessory
muscles

7. Treatment of airway obstruction:
Airway opening:
• Head tilt, chin lift and jaw thrust.
• If suspect cervical spine injury :manual inline stabilization
• Maintain opening by simple adjuncts:
Supraglottic airway devices :Oropharyngeal airways
Nasopharyngeal airways
Laryngeal mask aiway
Infraglottic airway devices :endotracheal intubation

8. Head tilt chin left jaw thrust

9. Manual in line stabilization

10. Laryngeal mask

11. Oropharyngeal airway

12. Sizing of oropharyngeal airway

13. Nasopharyngeal airway

14. Endotracheal tube

15. Causes of breathing problems:
Decreased respiratory drive :CNS depression
Decreased respiratory effort
– Muscle weakness
– Nerve damage
– Restrictive chest defect
– Pain from fractured ribs
Lung disorders
– Pneumothorax
– Haemothorax
– Infection
– Acute exacerbation COPD
– Asthma
– Pulmonary embolus
– ARDS

16. Recognition of breathing problems
• Look
– Respiratory distress, accessory muscles, cyanosis,
respiratory rate, chest deformity, conscious level
• Listen
– Noisy breathing, breath sounds
• Feel
– Expansion, percussion
 For 10 seconds

17. Look ,listen and feel

18. Obstructed Airway
 A patient who is choking typically has a panicked,
confused or surprised facial expression.
 They may run about, flail their arms or try to get
another’s attention.
 The patient may place one or both hands on their
throat. This act of clutching the throat is commonly
referred to as the universal sign of choking

19. Obstructed Airway

20. Obstructed Airway
 Encourage coughing forcefully.
 If the patient cannot breathe or has a weak or
ineffective cough perform abdominal thrust or
back blows

21. Stand behind the patient, with one foot in front of the other and if possible,
between the patient’s feet. Place the thumb side of your fist against the
middle of the abdomen, just above the navel, and grab the fist with your
other hand.

22. For effective back blows, bend the patient forward at the waist so that the
patient’s upper body is parallel to the ground. Give 5 firm back blows
between the patient’s scapulae.

23. Causes of circulation problems:
Primary
– Acute coronary syndromes
– Arrhythmias
– Hypertensive heart disease
– Valve disease
– Drugs
– Inherited cardiac diseases
– Electrolyte/acid base abnormalities
Secondary
– Asphyxia
– Hypoxaemia
– Blood loss
– Hypothermia
– Septic shock

24. Recognition of circulation problems:
•Look at the patient
•Pulse - tachycardia, bradycardia
•Peripheral perfusion - capillary refill time
•Blood pressure
•Organ perfusion
–Chest pain, mental state, urine output
•Bleeding, fluid losses

25. Treatment of circulation problems:
Airway, Breathing
Oxygen if needed
IV/IO access, take bloods
Call for help
Treat cause
Fluid challenge

26. Acute myocardial infarction
 Refers to the necrosis (death) of heart
tissue as a result of insufficient delivery of
oxygenated blood to the heart.
 The sooner the signs and symptoms are
recognized and treated, the lesser the
degree of damage to the heart.
 Symptoms: chest pain, dyspnea ,nausea
,vomiting, sweating and dizziness

27. Treatment
 Morphin
 Oxygen
 Nitroglycrein
 Aspirin
 Withdrawal cardiac enzymes , 12 lead Ecg

28. Disability
AVPU or GCS
A: Alert
V: Responsive to verbal stimuli
P: Responsive to painful stimuli
U: Unresponsive
Pupils

29. Exposure
Remove clothes to enable examination
– e.g. injuries, bleeding, rashes
Avoid heat loss
Maintain dignity

30. After you finish:
• Investigations
• Consultation of
specialist
• Continuous assessment

31. SBAR
S: Situation
B: Background
A: Assessment
R: Recommendation

32. Cardiac arrest

33. CPR for Adults
Conduct a rapid assessment :
 check for responsiveness
 open the airway, and simultaneously check
for breathing and a carotid pulse for at least 5
seconds but no more than 10.
 If no pulse no breath , begin CPR

34. CPR for Adults

35. Chest compression
30:2
Compressions
– Centre of chest
– 5-6 cm depth
– 2 per second (100-120 min-1)
Maintain high quality compressions with minimal
interruption
Continuous compressions once airway secured
Switch compression provider every 2 min to
avoid fatigue

37. Shockable and Non-Shockable

38. Automated External
Defibrillators (AED)
 1st expose chest , remove hair
 Attach pads
anterior/lateral pad
• one pad on the upper right chest, below the right clavicle to the right of
the sternum.
• Place the other pad on the left side of the chest along the midaxillary line
a few inches below the armpit.
 anterior/posterior placement
 Place one pad to the center of the patient’s chest on the sternum.
 Place one pad to the patient’s back between the sc

39. AED

40. Prepare to let the AED analyze
the heart’s rhythm
 plug in the connector and push the analyze
button.
 Instruct everyone to stand clear while the AED
analyzes. No one, including you, should be
touching the patient.
 As the AED analyzes, switch positions if you are
working with a team. The provider giving
compressions should hover their hands above the
patient’s chest.

41. AED
 If the AED advises a shock, again instruct
everyone to stand clear.
 The compressor should continue to hover their
hands over the patient’s chest in preparation for
CPR.
 Press the shock button to deliver the shock.

42. AED

43. Shockable (VF)
Bizarre irregular waveform
No recognisable QRS
complexes
Random frequency and
amplitude

44. Shockable (VT)
Monomorphic VT
– Broad complex rythm
– Rapif rate
– Constant QRS morphology

45. Non-shockable (Asystole)
Absent ventricular (QRS) activity
Atrial activity (P waves) may persist
Rarely a straight line trace
Adrenaline 1 mg IV then every 3-5 min

46. Non-shockable
(pulsless electrical activity)

47. During CPR
 Ensure high-quality CPR: rate, depth, recoil
 Plan actions before interrupting CPR
 Give oxygen
 Consider advanced airway and capnography
 Continuous chest compressions when advanced airway
in place
 Vascular access (intravenous, intraosseous)
 Give adrenaline every 3-5 min
 Correct reversible causes

48. summary
 Early recognition of the deteriorating patient may
prevent cardiac arrest
 Most patients have warning symptoms and signs
before cardiac arrest
 Airway, breathing or circulation problems can
cause cardiac arrest
 ABCDE approach to recognise and treat patients
at risk of cardiac arrest
 Criteria of effective chest compression
 Shockable and non shockble rhythm