Mandatory Training - Basic Life Support (BLS)

welcome to your online mandatory resuscitation training your medical emergency training we've had to change how we deliver our education in light of the current covid crisis so what we would like you to do is enjoy this presentation take what you can from it in terms of learning points and we'll expect you to answer a little questionnaire at the end of it and you need to do this before you come to us for a practical session so once you've completed this online section we will see you in the resuscitation training room to make sure that you've got the practical resuscitation skills that you need for the next 12 months my name is pat on the leap resuscitation here at poole and also delivering this training session will be dave and ingrid and you'll get to hear and see them shortly within this presentation okay so what we're going to discuss is the chain of survival we talk about this every time you come to training with us and it's the resuscitation council's logo and they like to use this logo because the chain is only as strong as its weakest link so there are four elements in the chain of survival and we're going to talk a little bit about each of those there'll be some focus on the initial link which is early deterioration in patients and recognizing that quickly because that's when we can really make a difference the point at which a patient deteriorates that we can either decide to intervene and escalate them fully into critical care or we can make decisions that actually they're reaching the end of their life and it may be appropriate to limit the care and treatment that we give them and make them comfortable towards the end of their life so calling for help early is always really important we're going to talk a bit about that the second link is early cpr this is your chest compressions and there have been some changes in what we need to do in terms of resuscitation in light of the guidelines with related to covid and so we're going to present the resuscitation to you in that sense the biggest risk to us is through aerosol generating procedures so we need to be very mindful of our own safety when dealing with a collapsed patient and we should really be in ppe and we will talk about that more as we go through early defibrillation is still a very key treatment in resuscitation we know that defibrillation works for some patients and defibrillators should be applied to all patients in cardiac arrest if they're shockable the gold standard for delivering that shock is within three minutes of collapse or three minutes of cardiac arrest so again it's very important that we get that early call for help out and a team with the skill to defibrillator on their way to you if you have an ils or als certificate then feel free to defibrillate obviously you've had that training and that's something that we can deliver to any patient in cardiac arrest coping positive or negative post resuscitation care that would be where we're talking about moving that patient into a critical care environment for ongoing organ support this is a really important and sometimes neglected link in the chain of survival and we have to consider if our patients have treatment escalation plans that state they would not be for escalation to critical care then actually is the rest of the chain of survival appropriate for that patient because if we don't give them that good ongoing organ support their chance of a good outcome and a discharge home with a good quality of life are greatly reduced so we need to consider whether cpr is appropriate in those patients that would be for ward based care only and that's a good time to start thinking about making dna cpr decisions and we'll talk a bit about that at the end so in terms of what happens here at pool hospital we want to just show you our statistics and this is a slide i'm really quite proud of particularly in the sense of the cardiac arrest data because we've got an ongoing trend of a reduction in cardiac arrests and this is despite the fact that we believe our patients are generally sicker than they have been in the past few years so this is all a testament to the fact that we do have a really good system for early detection that's our new system we have a good response team that's our news team and our medical emergency team and we have really good decision making with regards to treatment escalation and dna cpr decision making and also it's to the care the patients receive on the wards it is that early recognition and that good input at an early stage so that's always a reassuring thing and our aim is to keep those cardiac arrest figures as low as they are now so in the last year we had 56 arrests in our whole hospital and i think that's a really low number but it also means it's something we don't see that often so it makes training much more important because we're not exposed to cardiac arrest on a regular basis the non-arrest medical emergency calls you can see they're going up and again that's a fairly positive figure because it means that we are recognizing that deterioration and we're not afraid to put out that shout for help and that's what we always want we want staff to feel confident that if they have concerns about a patient they can pick up the phone call the team and the team will respond so last year there were 407 times the team responded to people that were either collapsed having a seizure having some chest pain looking acutely unwell maybe anaphylaxis those are the kind of things that will generally trigger a non-arrest medical emergency call the news calls are fairly static over the past few years but what we can say is since the introduction of news 2 there has been a fairly significant rise in the number of news calls because we dropped the trigger score from nine to seven uh news calls we will talk about in a little bit more detail later but again the fact that we have so many of those that's the majority of our emergency calls is recognition that we have that group of deteriorating patients out there on the walls the next slide is looking at the outcomes from cardiac arrests now the national average is reported at being 18 to 22 survival to discharge from in hospital events so we had a rather good year in 2019 with 27 of our patients that had a cardiac arrest of surviving to discharge that's 27 of those 56 patients we mentioned before about half the patients survive the cardiac arrest and by definition that means their heart rate started for about 20 minutes but they did not survive to discharge from hospital so the green figures that survive to discharge are probably the most important figures on that slide and again we it's about appropriate selection of those patients where resuscitation will be a good benefit and i think our 27 reflects that so if we're shouting for help we know that the emergency number within the hospital is double two double two if you call that number switchboard will answer usually very very quickly indeed and the information that you need to give to switchboard is which team you would like and where you want that team to go and it's important to be very clear in your instructions so you will want the adult medical emergency team and if you can give your award and a bed space number even better the team will come to you as quickly as possible if you're in a non-clinical area or i happen to be away from an internal phone there is a way of activating the met team from a mobile phone so you would dial the pool area code of o1202 and then 4-4 gets you through to the hospital switchboard and then you do your double 2.2 so you can pop your phone onto speaker and you can manage your patient and you can be activating the medical emergency team at the same time some areas of the hospital may also need a 999 call so if we have a collapse in the car park for example um it may be difficult to extricate that person with our lifts don't take trollies and we might need our paramedics to support us with the removal of a patient to a place of safety such as the emergency department there are plenty of medical emergency teams and about 16 teams that we actually can activate on double 2.2 so again it's really important that you tell switchboard who you want so the purposes of medical emergencies we have the adult team the pediatric team the trauma team obstetric team and the neonatal team stroke pre-alerts major hemorrhage protocol security fire all of those things are also activated on double 2.2 so please be very specific to switchboard the adult medical emergency team please when the met team arrive they will come to you within two minutes hopefully it is a running response and you will usually have at least nine people that will respond to that adult medical emergency call one of the ways of determining whether you might need a medical emergency or a news call would be whether this patient has airway or breathing difficulties so if they have airway or breathing difficulties or are unconscious then the choice the call of choice should be the adult medical emergency team because that team contains anaesthetic staff so we at the moment have two anesthetists although that may well change to one in the near future the team leader on both the met team and the news team is the medical registrar on call for that day and he she will be supported by the junior medical doctors the sho and the house officer you also get the clinical practitioners on for outreach and a porter and the resuscitation team coming to the mecca during daytime hours the news team is a slightly smaller team and they're responding to patients who meet the critical risk criteria in a ward-based environment again the same medical registrar will respond to that team along with the junior support and an outreach nurse and that is a five-minute response time if you work in a department and you have a patient that needs help the call should be medical emergency not news the only areas of the hospital grounds or site that we don't cover as a team are parkstone house which is the accommodation block and that's because the majority of people in that building have nothing to do with pool hospital so that is a 999 call and also forest home because again that's away and out of our remit really so if something happens over in forest home that would be a 999 call there too but remember from forest home from an internal phone you'd have to dial four nines to get your outside line first so just to update you if you're not aware the national early warning score changed last year that it was a mandate from nhs england that news 2 would be used by all hospitals within england whereas previously there was probably over 40 different kind of scoring systems used within hospital trusts which meant that medical staff on rotation had to learn a new scoring system every time they moved and there would be no big bits of evidence that could be used for research when all patients are being scored differently so it is now mandated that all trusts use news2 so we are now compliant with that as of december and then there were some changes when we implemented news 2. so the nursing staff will enter the observations using the ipad and the ipad will then calculate a score and give you a message at the end of that to tell you what you need to do about that score so it's all very well completing the observations fully uh the most important bit really about news is that you do something about the score that you have and we don't just use it as a way of recording we need to react to what we do one of the mantras that came out with news 2 was a way of thinking about sepsis slightly differently to try and simplify that so any patient now with a new score of five or more we should automatically think is this sepsis do they have evidence of infection and if the new score is five and they have evidence of infection we should complete the sepsis screening tool and call the appropriate people to come and start instituting the sepsis six management news 2 also has a scale 2 for saturations and this is for patients very specifically with hypercapnic respiratory failure so that's copd patients who retain carbon dioxide and have that documented it shouldn't be used for other patients where we're trying to run them on lower oxygen saturation levels if there's no evidence of co2 retention they should be on scale one from a safety point of view we want a registrar or above to make that prescription for scale 2 and it needs to be documented in the notes and then there are senior level nurses on the ward that can select scale 2 from within the news 2 software it also comes up as a little flag on on the uh eobs that we can see on the screen which patients have been put on scale too the other change with news 2 was the avpu score scale changed to aquafu which is a lot harder to say and that c stands for new confusion so if a patient becomes newly or acutely confused then they will get a score of three to add up to their overall new score when new confusion is new confusion is a bit of a remains new is a bit of a question and at the moment what we're saying as an organization is once we've recognized and treated the cause of this new confusion we can then start scoring the patient as alert again so the news 2 scoring system as you see it there you can see what the difference between scale one and scale two whereas previously a copd patient with saturations that we'd normally be happy with at 89 would have scored three they would now score zero so it makes their score much more appropriate to them we continue to score patients two points for being on oxygen even if that is long term and the rest of the schools haven't adjusted at all what has changed however is what we do about the score and the trigger as i mentioned earlier so we've moved from a trigger score of nine to a trigger score seven for initiating a new school there is a whole a teaching education package on the royal college of physician sites and this is an example of one of the scenarios so we have a patient admitted to the emergency department and these are the observations that that patient presents with when you calculate their new score on the basis of that that will give you a new score of six the advantage of the whole of the nhs using this means that when the patient is seen at home by the gp the gps are also using news2 so this patient might have had a new score of four when the gp assessed them paramedics then collect that patient and bring them into hospital and they might have scored them as a news of five on route to hospital they now arrived in the emergency department and have a score of six and we know that everyone is using exactly the same tool we can see that the trend is this patient is deteriorating and equally we can see improvements when schools get better so this patient on our graded response would be classed as high risk so if a patient has a score of five or six they're in the high-risk category which means they should have a medical review or an outreach review if this is out of hours and this should happen within 30 minutes you might want to repeat their observations more frequently in that time certainly if you're concerned about them and if they've actively got chest pain and look very acutely unwell you may want to escalate them to critical risk even though their score is five so we can put out a news call or a medical emergency call to any patient we have concern about regardless of what their new score is this escalation is the minimum requirement unless they have a treatment escalation plan documenting that they are not for news or those very clearly documented set different parameters for this patient we should be adhering to this graded response this is sliders just showing us our audit that we perform annually and what we can see where we a vital pac was implemented back in 2015 we have seen a significant improvement in patients being escalated because that escalation message pops up at the end of each set of observations and this again is really positive feedback for you guys on the wards and if we're not escalating a patient it's really important that you document in your nursing or the medical notes as to why we've made a decision not to escalate for example bob with copd has just walked out to the toilet he's come back sat in his chair you've done his set of observations he's really short of breath because he's just worked a bit hard and his sats might have dropped a little bit and given 10 minutes time bob will settle down and his new school will drop that's a reasonable reason not to put out a news call however if they're lying in bed nothing's changed their news has gone from zero to seven then this patient needs to be escalated and they need to follow that protocol unless stated otherwise so we've had a 90 compliance to those patients with high or critical scores having evidence of escalation or appropriate documentation that they were not for escalation in the first place and that's amazing and we need to maintain that standard all right i'm dave i'm one of the resuscitation officers i'm going to be carrying on from pat's very good lecture and we're just going to talk about the a2e approach the atv approach is extremely important it's the same assessment that's carried out on every patient regardless of what's wrong with them within the hospital and regardless of whether you're a support worker or whether you are a consultant it's the same assessments the only difference is what you can do within each area so the most important thing to remember is that the idea of the aoe assessment is that actually we're trying to identify the thing that's potentially going to kill you first the most serious injury or disease that you've got that we need to treat and that's a principle of all times once we find something wrong with you we don't move on until we've actually treated it so the a3 approach is basically based around airway breathing circulation disability and exposure on the airway part of it essentially what we need to know is is the airway obstructed is it patent or is it at risk so have we got a patient whose conscious levels reducing or say for example a hypo patient who may reduce their conscious level the railway may be fine initially but then become at risk breathing we need to know whether it's effective are we managing to get oxygen from the outside to the inside of the body and then that's circulating around the body so regardless of respiratory rate it may well be somebody can have a normal respiratory rate but actually not be effectively breeding so we need to assess their rates we need to look at the depth of breeding we need to look at things like oxygen saturations to see if it has been effective circulation we need to know that's adequate adequate tissue per perfusion is the brain and the major organs being diffused properly and we're going to do this by doing something we call the circle of circulation which we'll cover when we do our patient assessment on disability it's really just a quick neurological check so we're going to do look at a patient's conscious level using the hack for poo scale which pat talked about we're going to check a patient's blood sugar all patients regardless of whether you think they're diabetic or not should have their blood sugar taken and then we're going to check pupillary response just to see how fast uh they're reacting and whether they're reacting the same size so we can have an idea about what's going on within the brain and then finally we're going to do um exposure so we're going to check our patient from head to toe front and back to ensure that we can find any deformity bruising patient may have chest frames in that we're not sure about or surgical drains that we've not seen but the idea is to do a full head-to-toe examination to make sure we haven't missed anything and we find anything new such as rashes this part will also include looking at things like the patient's medical notes their computer record would check a patient's blood sugar all patients regardless of whether you think they're diabetic or not should have their blood sugar taken and then we're going to check pupillary response just to see how fast they're reacting and whether they've reacted the same size so we can have an idea about what's going on within the brain and then finally we're going to do exposure so we're going to check our patient from head to toe front and back to ensure that we can find any deformity bruising patient may have chest strains in that we're not sure about or surgical drains that we've not seen but the idea is to do a full head-to-toe examination to make sure we haven't missed anything and we find anything new such as rashes this part will also include looking at things like the patient's medical notes their computer records to see if there's anything in there that could give us an idea about what's happening to the patient okay i'm now going to carry out an a3 assessment on ingrid i can hear some snoring hello english you're all right okay you're just an award so i'm happy you've got an airway because you're talking to me and i know that you're breathing so i'm just going to go on to a breeding check now so i'm just going to count your respiratory rate and just have a look at the depth i'm going to do that over a minute okay and you've got a rate of about 20 and i'm just going to check expansion okay and that's fine as well that's all normal let's get some oxygen saturations let's see what they're doing pop this on your finger [Music] okay so i'll just wait for that to come off but i'm happy with the breathing normal right depth and rhythm good chest expansion we just need to know what sats are no cyanosis okay so it's up to 96. so i'm not going to put any oxygen on it happy with breathing so angry i'm just going to check your circulation now okay i'm just going to take your pulse okay so just checking for a rate and regularity how strong it is we do that over a minute okay and that confirms what the machine says around about 63 skin feels nice and warm so obviously we're checking there for the temperature and whether they're warm dry cold or sweaty whatever moving up the arm just checking for any iv access we haven't got any access at the moment so i might consider that i'm just going to take your blood pressure ingredients okay do you know what your normal food pressure is [Music] i can look at your notes for that that's fine okay while that cuffs going up i can do more temperature [Music] okay that's fine 3072. and also i'm going to do a capillary refill time so i'm just going to press on your chest for five seconds five one two and it's come back within two seconds so that's normal anything over two would be show that there's some sort of compromise there [Music] do we need ecg if she's become acutely unwell then yeah get a 12-leading cpg organized systolic 115 over 80. so that's fine that is normal for her so circulation wise i'm happy i think we'll organize to get cannula in get some blood taken off uh we don't need to give any fluids at the moment because the blood pressure is fine um moving on to disability so i'm gonna assess the conscious state so hello you're right there oh yeah okay so you're responding to voice okay where's george he's at home for you [Music] the other thing i'm going to check is her pupillary response i'm just going to shine a light into your eye okay just to see what's going on [Music] normal size normal reaction normal sort of shape ingrid i just need to give you a little check all over to make sure um george get george we'll sort that out for you so we'll now need to go on to exposure so looking where i am now have you got any pain anywhere no no okay something unusual there i'm gonna look at the car so it can't normal size not painful at all no there's no heat on the normal uh moving up i'm just gonna have a look to see if there's any anything under there and obviously keep maintaining dignity if you're trying to do it you can also examine the abdomen at this point but actually i can't find anything wrong with ingrid apart from the fact she's responding to voice so if she's only responding to voice that will give her a new score of three but actually i'm still quite concerned about it because this is fairly new so i think what i'll do is contact the average practitioners hello are you calling outreach i know yeah it's um it's dave from the recess team oh hi it's pakistan on average today hi uh i'm up on b4 um that's space 13 with a patient ingrid she she was brought into hospital with acute abdominal pain which just been watched by the surgeons i've gone up to her today and she's only seems to be responding to voice which is deteriorating in her condition i've done an assessment on her um her airway is patent although she's only responding to void she does still maintain it when she needs to um her respiratory rate is around about 20 she's got good air entry good chest expansion um so that's effective the sats at the moment are 94 but that's normal for her uh circulation wise is she on any oxygen to get those saturations no she doesn't know she's 94 on there 94 yeah the circulation wise and she's got a nice strong radial pulse which has gone round about sort of low 60s at the moment at the moment 63. um i've got a cannula in now tucker the normal bloods fbc's using these there's no evidence of infection so i haven't done anything with regard to sepsis i've also took a venus blood gas as well her blood pressure is 115 over 80 which is normal for her the temperature is 37.2 she's got a normal capillary refill time of less than two seconds i've looked at a chart and a urine output is normal there's no deterioration in that so i'm happy with the circulation i don't think we need to give her any fluids disability wise normal pupil response and like i say she's only responding to voice the venus blood gas came back and showed she had a blood sugar of 5.6 so that was all fine and then on exposure i've found nothing abnormal to detect i've not found any swelling in the calves any rooms deformities or anything like that and i'm just concerned although she's got a new score of three um because of her only responding to voice i'm obviously concerned that she could deteriorate and become worse and i'm not sure why she's deteriorated okay yeah that's uh sounds unusual so does she make sense when you talk to her is she uh alert when you wake her up um yeah she yeah she doesn't want to wake her up she does open her eyes to me she does talk to me she's not complaining of pain anyway you said she came in with abdominal pain no i asked if she was complaining of pain and she said she wasn't and has she had any recent analgesia that might account for her drowsiness the staff nurse said she had five milligrams about two hours ago milligrams of she was fine after that right well i'll just i'll have a quick look on epma and to see how much she's had over the last period of pupil size she said was normal though yeah pupil science was normal and reacting normally as well okay so um if we can just uh check out on her drop charts make sure she hasn't had anything else on top of that and we'll come up and review her in a few minutes okay in the meantime if you've got any concerns please do put out a news call okay thank you all right okay you've just got some help coming for your ingredients okay she's just going to list her a toy approach so how i felt her airway was which i felt that airway was at risk but she was maintaining it but breathing there wasn't any particular problems in breathing circulation i'm going to tell the average practitioner exactly what i found in circulation from pulse blood pressure how the patient felt to touch urine output and i'll make sure that there's an ecg been done before they get there and then the recommendation which is really important so this is your opportunity to tell them how fast you need them to get there so if you've got a patient you need to be seen straight away that's exactly what you tell them um if that person then can't attend that patient that's when we think about escalating further so when you use team or a mental depending on what the situation is but the idea is that actually you're telling that person how quickly you need that help and you need to find out whether they can attend or not when you do phone you have problems occasionally where people phone somebody to hand the patient over and don't necessarily have the right information so please make sure that you've got the right information to hand over about the patient so obviously your eighth way assessment so you've got all the observations something about the background you know and exactly what's happened um and make sure that if you've been told to phone someone but you're actually the clinical person changing that patient how fast you need that team and that would be less smart approach um we're now going to move on to sepsis which is um quite a a serious problem in hospital obviously we have lots of patients come in with sepsis but also patients develop sesame sepsis while we're in hospital things like hospital are quite pneumonias so it is quite a major thing to be looking for we've looked at how the news 2 system works so anyone with a score over five should be getting assessed the way we assess it is to use the sepsis screening tool so this is the separatist screening tool that we use for um non-pregnant adults um the idea being that actually you go through this this tip box approach and basically [Music] it will give an assessment for you and tell you whether your patient is suffering from sepsis if they're not suffering from sepsis it also gives an indication as to what things you could do so with regards to blood tests with regards to treatment if we do think our patient has got sepsis then on the back of the page um he's got the sepsis six pathway which is really simple it's in a really effective way of treating sepsis it can be done in the majority of clinical areas and essentially we're going to give three things and take three things we're going to give high flow oxygen we're going to give fluids and we're going to give antibiotics the three things we're going to take are an arterial blood gas or a venous blood gas to find out what their lactate is uh we're going to take some blood cultures um to try and identify what the organism is and we can also look at the urine output so obviously some of these patients may not be on a fluid balance chart already but if they aren't we should start one at that point to try and multiply the fluids on if you work in other areas we've got different charts that can be used for them so we've got a maternity chart we've got neutropenics such as a screening tool and we've got a pediatric sepsis screening tool so regardless of where you work there will be some screening tool that you can use so wherever you are working please make sure you're familiar with it and you know how to use it it has been proven to be a really effective way of identifying these patients and it takes less than a minute to do in reality we'll now move on to anaphylaxis obviously in hospital we still get people allergic to different things and also we administer lots and lots of medications to patients and they may not be aware that they're allergic to them so occasionally we do get patients who have a reaction to it when we talk about anaphylaxis we're talking about that life-threatening response to whatever they've had a reaction to so we're not talking about somebody who gets a bit of a rash or feels a bit itchy we're talking about about a systemic life-threatening problem so if we use our eight-week approach and we can see what the sort of things we're looking for so we're gonna look for swelling so we're going to look for swelling around the lips and the mouth and also some facial swelling as well um obviously make sure you get them to open their mouth look at their tongue and see if there's any swelling inside the mouth as well as outside look listen to their voice sometimes their voice will start to change as the railway swells up um so that might be fairly noticeable they may start to develop the wheat as their airways start to close over and they'll sort of develop breaking problems so they'll develop a weeds they'll start to look like they're starting to struggle to breed as well and then ultimately they'll develop stridor which is a sort of a sound while they're trying to breathe we know at this point that their airway is massively closed off so it is a medical emergency it may well be if they've been doing that for a prolonged period of time actually those sounds die off you need to ensure that actually that's because you've treated them well and not because they've become exhausted at that point we then move on to breeding so they're gonna look like they're having difficulty breeding if the railway's swelling up struggling harder to breathe so you'll start to see them using their accessory muscles so the neck muscles and the chest muscles to try and breathe properly they may well be trying to sit up and put themselves in a better better position if they are doing that as long as they're safe let them do that let them sit up and let them get themselves in a position they feel comfortable in their respiratory bets going to increase the amount of oxygen they're taking into their bodies being reduced so they're trying to compensate for that so their actual respiratory rate will increase chronic quite dramatically their oxygen saturations obviously will start to drop if they're not getting oxygen in obviously with these if you do notice any airway breathing problems we want you to pull high flow oxygen straight away if we look at circulation the blood pressure is going to start to drop so as the blood vessels vasodilate and fluid leaks up into the tissues as well the blood pressure is going to drop so alongside that they're going to become quite sweaty and shut down the heart rate's going to increase um and they may well start to feel sort of dizzy faint they may become agitated because obviously their brain's not being confused properly so there we're going to look at getting the lining we're going to look at getting fluids in um if they're able to you can lie them down and put the feet in the air that will help them with their blood pressure when we come to disability obviously their conscious level will change so as they get less and less oxygenating as their brains not being confused properly then their conscious level will sort of start to go down so they may start off alert but then end up to the point where they're unresponsive and then on exposure you may see um and depending on the patient some it comes fairly early some it's a bit late so you may see just a widespread rate red rash over the body importantly for anaphylaxis uh we need to know when to give the adrenaline so if at any point we find something that is life-threatening that is when we give the adrenaline so if we have a patient who's got a swollen airway and he's not breathing properly that's when we give the adrenaline we don't move on to the next stage if we go to breathing and they are having real difficulty eating breathing and a fast respiratory rate then we may give it there if we have a shocked patient so we find it circulation out there shocked we may give it at that point the key thing is when you identify something life-threatening that's when it should be administered you don't need to complete the whole eight-way assessment before you give the adrenaline we follow the resuscitation council guidelines for anaphylaxis and that's the algorithm there and it's quite a good algorithm it tells you exactly what to look for for life-threatening problems in airway breathing and circulation so just make sure you're familiar with them for all adults we give 0.5 milligrams of adrenaline at one in 1 000 and that's always given intramuscularly it is not to be given intravenously so any drugs during anaphylaxis with regards to adrenaline should be given intramuscularly if you work with pediatrics then obviously essentially the algorithm is the same it's just a change in drug doses so make sure you're familiar with those changes the adrenaline we have available at the moment comes in ampoules so you'll get an ampoule a syringe and a needle in the blue crash box which is in the bottom of the red emergency trolleys and you basically draw the full amount the one mill squirt out the half of it and then with the other half into the patient's stomach some patients will come in with um auto injectors so if they have got an auto injector they're fairly easy to use just remove the glue cap on the top and then basically you just administer it into the thigh and hold it there for around about three to five seconds okay now we're going to talk about choking we do get patients who choke on the wards obviously we have patients who have difficulty swallowing patients who have reduced levels of consciousness and sort of obstructed on various different things so we're just going to go through the algorithm on choking the first thing we need to do is assess our patient and that's really important so we do a really simple check we talk to them we ask them at the okay are they choking if somebody turns around and says yes i'm choking clearly they're not choking because we know by talking that they're airways patent that they get an opportunity into the lungs of the breeding effectively if we have a patient like that then we just encourage them to sit forward and to cough if they've got an effective cough so those patients are fairly easy to to deal with but just make sure you keep an eye on them because if they have got something in the railway and they're coughing at all we don't want them to obstruct and then nobody be around um our second group of patients are the ones that haven't got an effective cough and are obviously sore choking so the sort of things you will see is that they might be clawing at the throat or pointing at the throat when you talk to them they might just be silent because it's completely obstructed they'll not be able to get any words out and you're going to get facial changes so the colour of their face is going to change they're going to go all sorts of colours so they'll get congested they'll go red blue and purple and obviously look at history as well you know most of these cases happen with somebody around so somebody normally can tell you that they haven't been choking so what i'm going to do is demonstrate what to do on john here so basically johnny's our mannequin that we're going to use to sort of demonstrate the choking algorithm like i say if i turn around to john and say you're right there johnny you're choking and he goes yeah i'm choking he's not really choking leaning forward and encouraging to cough if i look at the patients they can't speak to me i can see they've got changes in colour in the face um and also you know somebody's just said he was eating something and he's just started choking then i need to take some fairly effective action so what i'm going to do is stand at the side of the patient and i'm just going to let them rest on my arm and support them in between the shoulder blades with the heel of my hand i'm going to give up to five back blows okay so tell your patient what you're doing i'm just going to hit you on the back try and get this out once see if it comes out twice see if it comes out three check again four check again five check again if it does come out at any point during this then obviously you can stop doing the backlogs and then we should carry out a to the assessment on the patient to make sure that actually it hasn't affected them in any other way if we're unlucky and it doesn't come out at that point we then need to do abdominal thrusts so this time we're going to stand behind the patient and i'm basically just going to make a nice flat fist with my hand and i'm going to place it between the umbilicus and as if he's stirred up so that soft part so i'm going to reach around the patient and then bring my other arm around and then i'm going to basically make a j motion so i'm going to go in and up at the same time okay so i'm just going to do an abdominal thrust so we'll do one see if it's come out so see if it's come out see if it's come out see if it's come out or we'll see if it's coming out obviously if it does come out again if the airways we then carry out an a3 assessment to make sure our patient's okay if it hasn't come out we're then just going to alternate between five back blows and five abdominal thrusts the patient's only gonna be able to sustain not getting up oxygen for a short period of time so we should be thinking about what happens if it's not going to come out so if we're in an area where there's lots of things around we should clear the area because our patient's going to have to go on the floor if they do become unresponsive then essentially we're going to do our basic life support which we'll look at in a minute um the only difference will be is that when we actually do the head touch and lift and look in the airway we're going to take a little bit longer just to check to see if there's anything there if we try backing the patient and the air's not going in then you just you just check every two breaths to see if anything shifted the abdominal thrusts um normally work pretty well the idea of doing the cpr is to mimic those abdominal thrusts it's not to keep the heart going um if the obstruction hasn't come out immediately then please make sure you've called the adult medical emergency team if you're outside the hospital make sure you've called an ambulance straight away there are a couple of groups that we're not going to do the abdominal thrusts on firstly we're not going to do it on pregnant ladies apart from the actual logistical side of getting your arms around and doing an effective thrust there's a chance we can damage the baby so we don't want to do that so no pregnant ladies and we're not going to do abdominal thrust on anything under one year old most of their organs are actually in their abdomen so we don't damage any of them and we'll cover what to do with pediatrics later on there are some situations as well if you've got a patient who's absolutely huge and you can't get your arms around them then obviously you can't do the abdominal thrust you just need to continue doing back blows and then if they become unresponsive do chest compressions hello there i'm ingrid i'm one of the resuscitation officers here um we're now going to look at early cpr to buy time we're going to look at the second link in the chain of survival to demonstrate how important good quality chest compressions are and we will be demonstrating that to you um in one moment we're also bringing in the current guidelines at the moment with the covid19 epidemic fred can you hear me can you hear me can i have some help in here please it's angry what's matter i'm at freddy's in cardiac arrest can you that will come okay we'll down so okay right i've just demonstrated to you what would happen in real time now i'm going to talk through each stage as we go and so the first thing that you need to do is to make sure that your area is safe that there are no trip hazards no hysterical relatives no fluid you're going to slip on and that you have your appropriate infection control um outfit on um the next thing i want to do is to approach the patient and stimulate them so i'm going to say fred fred can you hear me so i want to shake him fred fred can you hear me um the next thing i'm going to do because he hasn't responded to me is shout for help so really really clearly can i have some help in here please and push your button if um you're on the ward if nobody's coming you must go and get help for this patient and not begin um anything and so i'm called for help um the next uh thing i need to do is to assess the patient and in our current covered climate i am not going to go near the airway at all so i am going to arm's length feel for a pulse any normal signs of life and i have 10 seconds to do that my assessment now is because of i had my surgical mask on my visor my gloves and my um apron that you would have in all areas i can begin cpr and my help has now arrived are you all right angry and i'm going to be very very clear and state exactly which team i want and where so pat could you put out an adult medical emergency call please on double two double two toward b4 room six come back with the crash trolley and anybody else that will come i will do that okay so i've made very very clear um instruction there i know help is now on on its way the next thing i'm going to do is to start my cpr so i need to make sure that i'm at least mid thigh above the patient if they're on the floor leave them on the floor if they're in a chair put them on the floor if they're in their bed then obviously you can leave them in their bed pulling the cpr pressure relieving mattress cord if necessary so you've got a nice firm surface the next thing i need to make sure is that i put the heel of my hand in the correct position on the patient which means mid nipple line lower third of the sternum i'm going to use the heel of my hand i'm placing my other hand how i feel comfortable i'm locking my arms and i am going to start chest compressions now my compressions need to be 100 to 120 a minute i'm gonna press as hard as i can which is five to six centimeters when i press down i need to make sure i recoil so the heart can refill again very important and i am going to carry on doing this until my help arrives okay so that's a demonstration of really really good chest compressions it's absolutely imperative so it's five to six centimeters deep as hard as you can push ensuring that you have that recoil back off the chest so that the heart can refill you're going to do 100 to 120 a minute and you are going to carry on till your team arrive you are not going to touch the airway at all in these current situations but you must continue to do really high quality chest compressions right what might make you stop your chest compressions so during a resuscitation attempt um to analyze the rhythm once the defib monitor is attached to the patient you would need to stop while the rhythm is being analyzed and that's a really good time to actually swap over because one round of cpr is a really good round so continually swapping over to ensure that quality is high is absolutely imperative and you may stop if somebody finds a dna ar form that is pertinent to this patient so you could stop because don't forget if you are not sure whether this patient is dnar or not you must start chest compressions and call for the team um you will stop um when um the team have decided that um it's futile and that will be a team decision and you will all be asked what you think about that you would also stop if you were on your own and absolutely exhausted or in danger in course if your patients show signs of life then you will go on to your abcde assessment thank you as you can see i have just demonstrated a covid 19 negative or patient without any symptoms so it's starting your chest compressions only and you're leaving a face mask on a patient if it's present on the patient and that will protect you um the first team member in full ppe as per action card one arrives and you will hand over the chest compressions and then remove yourself from the room leave the area and don full ppe if required so any doubt confirmed or suspected covered 19 you are only going to take the defibrillator into the room you are not going to start chest compressions so that needs to be passed you in the room while an adult medical emergency call is going out as quickly as possible if there is somebody around that is ils or als trained they are to don full ppe and go into the room where they can assess for a shockable rhythm and start chest compressions um leave the face mask on the patient again and once the first responder arrives they will have level three ppe on anaesthetics are to manage the airway and breathing so nobody is to get a bag valve mask and start anything to do with the airway whatsoever that will be part they will be part of the team and when they arrive they will manage the airway completely a really good point to make is if you are on a ward and working as a team identify who is ils and als trained at the beginning of a shift so you know that they will be first responder and can have the defibrillator pass to them the packs can go on and a shot can go into the place patient prior to the team arriving that might negate all of the other interventions that we might need to do at that point early defibrillation uh really importantly if a patient is in a shockable rhythm we get a shock in within three minutes um as you can see um all of our um defense machines are used in this trust in automated mode so if you are ils or als trained you can safely deliver a shock uh to the patient um the energy levels are 200 joules 300 joules and 360. compressions during charging but in our covered patients or suspected um covid you need to make sure that you're in level three ppe before compressions begin um pad placement is really important so make sure the patient is dry make sure that they are shaved so that the pads can get a really really good adherence to them and as you can see you can place the plants below the right clavicle midaxilla and sandwich alternatively you can do anterior and posterior or you can do lateral lateral this is our inhospital algorithm and as you can see as they've mentioned before the abcde when a patient is alive and going through that systematic matically trying to reverse anything that is happening once a patient becomes unresponsive and there are no signs of life we are going to go through our inhospital algorithm for cardiac arrest and apply the pads and and then hand over to the team as they arrive and um they will come into the room and take over um post resuscitation care and documentation and communication so our emergency record sheets are on the computer um they're uh on epr so um they will be filled out by the team leader who will um enter that in for our records and for audit as you can see there are three lots of chest compressions there one shows chest compressions in the center that were done by a lucas machine in our ed department it then shows a very weak chest compression and then it shows a very frantic chest compression where um the heart will not refill so it's very very important you remember to swap regularly so those compressions are of a really good quality our emergency trolleys so we have our emergency trolleys and really important the daily checks that are done on our emergency tries is to ensure that our suctioning is working well because most patients will have an event and it's not always conveniently by a bed it could be in a corridor or by a toilet and so you want to have your full compliment ready to go for that patient and so we're making sure that our suction is ready and works well and we make sure that our d-fib is checked regularly by self-test every day and sign form and we want to make sure that we have a full oxygen bottle and that it's in date and that we have gloves and other equipment on our crush trolley our monthly checks are to open up the crash trolley and make sure that every draw is checked make sure that everything is in date and that it's going to be in date by the end of the month if it isn't send it to a department where they can use it so we save resources but that must be in fully functioning um order when we present that for a cardiac arrest our top up cupboard is on the lower ground floor porter's lodge will have the key on level -1 and there is a gray cupboard where you can replenish your crush trolley as you wish um audit results we audit the crash trolleys regularly within the trust to make sure that they are up to standard so please ensure that your crash trolley is up to standard in-date and ready to go um remote equipment we have equipment in um the main multi-story car park so if somebody had a cardiac arrest on level g there is a defense machine on level c there is also a red phone if your mobile phone wasn't working and to call for help we also have a dfi machine by the main reception on the wall so if there was a cardiac arrest within that area there is a defend machine that you can grab very very quickly in an emergency okay so just to talk a little bit now about allowing a natural death and do not attempt to cardiopulmonary resuscitation um you should know by now that we have a pandorsip policy so all of our hospitals in the region care homes gps etc all use the same policy and same form the only difference here at poole hospital is our form is created electronically where elsewhere the form is still hand written so we will accept a resuscitation status decision that's brought in with a patient from the community but there are still some checking procedures that we have to do to ensure that that decision is relevant for the patient at that time so it's quite easy when we make a decision during the patient's admission so if we've made a decision this patient's status is as such that they would not survive a cardiac arrest it's usually a team decision that resuscitation would not be appropriate for them it's a consultant-led decision but we allow the registrar's to make that decision in the out-of-hours period but consultants should validate that within 48 hours the form is created on epr and when the doctors create the form they have the options of making the decision indefinite which means this will go home with a patient they can put a review date on it so if this patient is acutely unwell but we think they may or may not get better the problem with review dates is they very rarely get reviewed so if you see a form with a review date on it please make sure the team update that or you can make it cancel on discharge so this would be the patient's decision would no longer be valid at the point they go home and which guess we need to do no more so if they come into hospital with a form and it's a paper form a gp has written we'd still require the doctors to put that onto epr and all they would need to document was this is a gp decision it's already been made by a consultant so they're just transferring that information onto our system so that we have a record of that in the future it would then be printed out on red board of paper and put in the front of the patient's medical notes and we therefore know that decision has been reviewed on admission at the point of discharge if the patient has an indefinite decision that has been signed by a consultant then that decision should go home with them the patient should take the red-bordered form from the front of their notes we shouldn't photocopy it we shouldn't print out other versions that original copy is the patient's copy to take home with them the form should be checked though because we do still see on many forms in the communication section that the communication is to still happen and there's no evidence that the patient is therefore aware of this decision having been made and that's not very good practice so the recommendation legally is that patients should be fully aware that they have a resuscitation status decision and they should be involved in that conversation they don't necessarily get a choice on being for resuscitation but they certainly have a choice of being not full resuscitation but we need to have those conversations in a timely fashion and by somebody that's able to hold that conversation appropriately so patients must be aware that they have a dna cpr decision and if they have dementia are not able to understand that decision then at least they're next to kin or a carer who is going to be going home with them at the point of discharge when the doctors complete the inpatient discharge summary they will be asked if this patient has a dna cpr form in their notes if the answer is yes they will then be asked has a consultant sign this off and agreed that it is indefinite if they answer yes to that there is an automatic process set into place the gp will be informed automatically via the ids and an email gets sent to southwest ambulance that's fired off automatically every two hours from the trust and they are then made aware of those patients that are discharged home with an indefinite dna cpr decision this enables them to then have a flag on their system so when a call goes out to that address they can go into our epr they can see the form print out a copy send it straight to the paramedic via their electronic system whichever they need to do so even if the form isn't present in the house the the paramedics will have had sight of it and can and prevent them from doing inappropriate cpr in end-of-life situations in an ideal world the patient should always have the form with them so if they have a dna cpr form in the community it should come with them to hospital and wherever else they may go decisions can be cancelled so nothing is permanent so if a decision has been made to be not for resuscitation even if it has been listed as indefinite it can be reversed if for whatever reason and the medics would go on to epr and make that form cancelled the one that's therefore in the front of the patient's notes needs to be ripped up and put into confidential waste and then it becomes clear on epr that that form is a cancelled decision any patients that has a form written we can see there is an orange folder that appears on the epr tree so that includes treatment escalation plans and so if they've had a dna cpr form at any time in the past that orange folder will now be visible but it's really important to open that orange folder and see the contents of what's in there because cancelled forms will also still live in an orange folder there is a patient information leaflet which we can give to reinforce the conversations that we have these are available to be ordered via the printed stationery and they are very useful for explaining what resuscitation is we often find that patients that insist on being full resuscitation really don't understand what that means and they think that they will have their life prolonged and they will have good quality and what we're saying when we make somebody not for resuscitation is their quality of life is either not going to be maintained or they are very unlikely to survive that cardiac arrest so this information leaflet will give some idea as to what resuscitation actually means to them so we're now going to cover pediatric basic life support this isn't a full pediatric basic life support course if you are working regularly with children and you need to attend a pediatric ils course or pediatric bls course this is just an overview to highlight the differences between adults and children firstly the majority of cardiac arrests with children and normally due to the fact that they not getting enough oxygen in the body um and there's some reason that's been interrupted so we're going to go through um how we do basic life support and then just very quickly look at chunking so we classify children in different things so anyone under one is classed as a an infant anyone above one is classed as a child if you're not sure when their date of birth was then just use a bit of common sense if you look at them and think they look like a baby treat them as a baby if you look at them and think actually they're a bit older then treat them as a child so first of all differences in pediatric basic life support we still do our sss approach or making sure it's safe for us to actually get there to do something because the reason that child might be collapsed in that area is because there's a problem in that area we still shake them we still try and stimulate them so with the baby i'm going to hold the head still and i can sort of tap them i can tap the bottom of the feet if they've got some hair you can pull the hair as well but basically something just to try and sort of make them respond to you if there is no response the difference now between this and adult basic life support is that i'm going to assess the airway so the airway unlike an adult shouldn't be tilted back they should be in a neutral position basically looking directly up into the sky support their chin with your finger on the bony part so you're not pressing the bottom of the mouth in and then we do a look listen feel the same way we would with an adult so we're trying to feel any breath on our face hear any noises and look at the chest to look for what we think is normal chest movements and we can do that for up to 10 seconds if there is no signs of life then at this point we're going to give five rescue breaths so with a child with a baby sorry we need to make sure we cover their mouth and their nose when we blow in we give five short breaths but only until the chest rises please don't try and empty your entire lung volume into a small baby after we've given five rescue breaths we then reassess the abc if that's been successful then we can carry on and do our eight-week approach on them if it's not this is when we're going to carry out chest compressions um so locations for a baby to do chest compressions is between the nipples and you can hold them in your arm if you're sort of moving anywhere two fingers and then we're going to do 30 compressions okay [Music] up to 30 and then we do two breaths so the same as uh the abdomen basic life support once we've done that 30 compressions to two breaths if we have a baby that's choking then again we can do back bloat so use a bit of gravity hold them in your arm or hold them down somehow and just hit them between the shoulder blades remember it's a baby so you're not going to use the same force as you would on a an adult so again one two three four five if that doesn't work remember we said we don't do abdominal thrusts on anyone under one so we're going to do chest rust so exactly the same place you would have done chest compressions for cpr between the nipples and it's a really quick um push in and sort of upwards at the same time so we can do up to five of them one two three four five and again we just continue doing back blows and then chest thrusts but if it's a pediatric case um obviously in hospital make sure you've called the pediatric medical emergency team if it's outside hospital just make sure you've got an ambulance coming straight away because they won't tolerate having no oxygen for very long if it's a child so over overwhelmed it is fairly much the same as an adult so the only difference is is really when we do the chest compressions we do our sss abc if they're not breeding no signs of life we give five rescue breaths and then reassess again and then this time if we do chest compressions depending on the size the child will depend on whether you use one hand or two hands and the size of yourself as well so again with this child between the nipples on the breastbone i'm going to use one hand and we want to compress about a third of the chest so so i'm going to do up to 30 of them once i've done 30 compressions then we can do two breaths so in the current coving situation with children we just carry on and do everything as normal the difference this time is i need to pinch the nose and cover the mouth and blow in again just till the chest rises um choking wise we can do back blows and we can do abdominal thrust but remember what we don't want is children being lifted off the floor and people are attempting abdominal thrusts like that you need to get down to their level so you may need to sit or kneel down on the floor if they're old enough you can have them over your knee to assist you to do the back close but again make sure that you have got help coming straight away with regards to cpr on pediatrics if you haven't got help coming then we do cpr for one minute and then we call for help but remember use your mobile phones put one speaker you can carry on doing resuscitation while you're talking to the ambulance service but if that's not possible do one minute of resuscitation and then go make sure you call for help okay so you've come to the end of your online learning for resuscitation um and so just to summarize it's absolutely essential that we do that first check that we actually recognize our patients are sick we use the tools that are in place things like the news scoring system and actually we call the white people in to deal with our patients of utilizing the right teams the news teams and the met teams so making sure you get those people in early nobody's going to get in trouble for calling the team in early that's exactly what we want and that's why our figures are going in the right direction secondly cpr cpr is absolutely essential but good quality cpr is what we're looking for so please make sure that you're doing really good quality cpr you've got the right depth the right rates the right compression if you see your colleagues flagging they're getting tired or they're not doing it properly please tell them or swap around but what we want is that really effective chest compressions to try and perfuse the brain on the other organs early defibrillation if you train to do it then actually please do it if you've got the right qualifications and you're allowed to do it then do it and you can do that before the resuscitation team arrive and if you're patient in the shockable rhythm actually that might be the thing that brings them out of it but also if you're not trying to do it make sure that equipment is in the room with the patients and ready for us to use when we get there the post resuscitation care is something that as a team will take care of between ourselves and intensive care and outreach and make sure that actually that patient who has been resuscitated is being looked after properly resuscitation is only a temporarily measure if you like you know we've got them back we've got retainer spontaneous circulation but there's still clearly a big insult going on that we need to deal with um and there'll be people around that can help you deal with that for that patient make sure you enjoy coming to your half hour session i will teach your practical skills

Channel: Poole Hospital

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Length: 72min 5sec (4325 seconds)

Published: Thu Jun 25 2020