WMAS Clinical Guidelines CLN PRO 026 I Version - 4 Guideline ID CLN PRO 026 Version Four Title WMAS Resuscitation Guidelines 2015 Approved by Clinical Steering Date Issued 4 May 2016 Review Date May 2019 Directorate Clinical and Quality Emergency Care Assistant X Student Paramedic X Technician X Critical Care Paramedic X Authorised Staff Advanced Technician X Nurse X Paramedic X Doctor X Specialist Paramedic - Urgent Care X Clinical Category Green Deviation permissible for registered healthcare professionals with application of clinical judgement 1 Scope 1.1 These guidelines are written to support clinicians management of patients requiring resuscitation from West Midlands Ambulance Service NHS Foundation Trust responders. 2 Background 2.1 The information contained within these clinical guidelines are provided to support clinicians utilising the UK Resuscitation Council Guidelines 2015 and provides information regarding the localisation of the guidelines for the West Midlands in order to provide a coordinated and seamless response.
3 Guidelines 3.1 Preventing Cardiac Arrest In many cases the ambulance service is only called following a patient s collapse, thus the first contact with many cardiac arrest patients is after the arrest has occurred. However, some patients may suffer a cardiac arrest in the presence of the ambulance crew. Therefore staff must be vigilant for clinical signs of deterioration and be aware of the measures to be taken to reduce the likelihood of cardiac arrest. The commonest clinical abnormalities witnessed before cardiac arrest are breathing problems, an increase in heart rate and fall in cardiac output. This may manifest itself as hypotension, confusion, restlessness, lethargy or a falling level of consciousness. Breathing difficulties are suggested by shortness of breath, an increase in respiratory rate, and a fall in oxygen saturation (SpO2). A fall in cardiac output should be suspected if the patient is cold, pale, clammy or cyanosed, or if their pulse is weak or impalpable. Any deterioration in mental status is usually secondary to inadequate cerebral perfusion as a result of diminished cardiac output. Wherever possible ambulance staff should initiate supportive treatment, for example oxygen therapy for those patients who are hypoxic, and, if indicated, administer treatments to correct the underlying cause, for example thrombolysis for AMI or nitrates and diuretics for acute cardiogenic pulmonary oedema. Prompt access to expert medical support and appropriate facilities such as those available in the emergency department, intensive care unit, high dependency unit or coronary care unit, is likely to decrease overall mortality, therefore ambulance staff must be conscious of minimising on scene delays so as to expedite transfer to definitive care 3.2 3.2.1 Every emergency ambulance and response care is equipped to enable clinicians to deliver advance life support. 3.2.2 In so far as is possible, equipment is standardised across the trust. Ambulance staff are responsible for checking the resuscitation equipment on their ambulance or response car and thus ensuring that they are able to deliver advanced life support where needed. 3.2.3 In the case of a vehicle or response bag being pre-checked and tagged by ambulance fleet assistants the lead clinician is responsible for checking the intact tag and date of the green first response bag and red ALS bag and check the defibrillator
3.2.4 The minimum equipment required to attempt resuscitation is as follows: Suction unit Airway adjuncts Bag valve mask (BVM) Monitor with defibrillator 3.2.5 This may be supplemented with additional equipment/procedures dependent on the skill level of the clinician or availability of the equipment: Supraglottic airway insertion Endotracheal intubation Mechanical ventilation Intravenous/intraosseous access (EZ-IO) Advanced life support medications A device for monitoring End Tidal CO2 Mechanical chest compression device 3.2.6 The continued availability of resuscitation equipment for each station is managed through the Distribution Centre, stations have minimum list of consumable equipment and where they reach this more equipment is urgently ordered by the Operational Manager from the Distribution Centre 3.3 3.2.7 The availability of resuscitation equipment on each Emergency Ambulance or Rapid Response Vehicle is the responsibility of the Area Manager and is delegated to the Ambulance Fleet Assistant. If the deployment site for the vehicle is not a make ready site then the senior clinician is responsible for that vehicle and all equipment should be checked and replenished from the station stores, where this is not possible or where the minimum/essential equipment is found to be defective this should be reported immediately to the Emergency Operations Centre to remove the vehicle from operational response until the vehicle has the minimum resuscitation equipment (see 3.2.4). 3.3.1 Basic life support (BLS) is the foundation of resuscitation and must be expertly delivered to improve outcomes and should be performed in line with UK Resuscitation Council BLS Guidelines. It is important to note however that the UK Resuscitation Council BLS guidelines are generally written for laypersons and that healthcare professionals are expected to perform some additional assessments.
3.3.2 Provided the environment and surroundings are safe, BLS for healthcare professionals commences with an assessment of level of consciousness on the AVPU scale. A patient who does not respond to the clinician s arrival at their side is not alert. The clinician must then assess for responsiveness to voice and pain, however these must not occur simultaneously, but rather in succession starting with response to voice and proceeding to pain. A patient who does not respond to voice or pain stimuli is unresponsive. 3.3.3 If the patient is deemed to be unresponsive, then assessment of the airway is the next priority. Clinicians should quickly assess the facial bones before opening the mouth for visual inspection. Obstructions e.g. vomit should be removed under direct vision and the head positioned with the head-tilt-chin-lift manoeuver provided there is no suspicion of cervical spine injury. Where spinal injury is suspected the head-tilt-chin-lift manoeuvre should be avoided if at all possible, and a jaw thrust manoeuvre used in preference. An appropriate airway adjunct should be inserted. 3.3.4 The next stage includes assessment of not just breathing but also signs of life. The presence of breathing does not rule out the possibility of cardiac arrest. Agonal respirations immediately before and shortly after cardiac arrest are common. Patients with a regular breathing pattern are unlikely to be in cardiac arrest, and if they are in cardiac arrest they will not retain this pattern for long. In addition to assessing breathing, ambulance clinicians should also seek other signs of life including checking for pulses, looking for movement of limbs, listening for gagging sounds or noting low level reflexes such as blinking or coughing. Patients with abnormal breathing and absent signs of life are deemed to be in cardiac arrest. 3.3.5 If the ambulance clinician is a solo responder: Ensure further assistance is en route Attach the defibrillator and if the rhythm is shockable; Press charge on the monitor Recommence CPR Safety checks should occur whilst the defibrillator is charging Once the defibrillator is charged advise any bystanders to stand clear and deliver the shock to the patient Immediately recommence CPR do not undertake pulse checks or rhythm analysis If the rhythm is non shock able continue CPR immediately
If part of an ambulance crew: One member immediately commences CPR whilst the other crew member attaches the defibrillator pads As soon as a reliable ECG rhythm is seen CPR should stop to allow analysis to occur If a shock is indicated CPR must continue whilst the defibrillator is charging; safety checks should occur in tandem whilst the defibrillator is charging Once the defibrillator is charged advise any bystanders to stand clear and deliver the shock to the patient Immediately recommence CPR do not undertake pulse checks or rhythm analysis. For patients under 12 years of age: ALL shocks to be delivered at 4J per kg, regardless of type or manufacturer of defibrillator. 3.3.6 Compression to Ventilation Ratios and Compression Depth Age Group New Born* Infant/Child Between new born and puberty First Action Dry and Stimulate 5 Inflation Breaths 5 Rescue Breaths Ratio Compressions: Ventilations Rate Compressions per minute 3:1 100-120 15:2 100-120 Depth At least 1/3 of the depth of the chest At least 1/3 of the depth of the chest Adult 30 Compressions 30:2 100-120 5-6cm *New born babies are defined as patients during the transition from birth to successfully breathing once separated from the placenta.
3.4 Defibrillation 3.4.1 All emergency and urgent ambulance clinicians and primary responders must be trained and equipped to provide defibrillation where indicated. Defibrillation is the delivery of electrical current to the myocardium in order to depolarise a critical mass of myocardial cells, to terminate ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Ventricular fibrillation is a life threatening arrhythmia characterised by electrical and mechanical chaos. Pulseless ventricular tachycardia is characterised by organised electrical activity without palpable cardiac output. Both arrhythmias are most commonly associated with cardiac disease but may also occur due to electrolyte or acid base disturbance, drug toxicity and electrocution. The only effective treatment for VF or pulseless VT is defibrillation. 3.4.2 WMAS NHS Trust uses a number of defibrillators across Automated External Defibrillators (AEDs) Cardiac Science Zoll AED Pro Manual Defibrillators Zoll M-series (biphasic) Zoll E-series (biphasic) Zoll X-series (biphasic) Lifepak 15 (biphasic) 3.4.3 Automated External Defibrillators (AEDs) Automated External Defibrillators (AEDs) are deployed throughout the trust in its buildings and are used by certain individuals who respond on behalf of the service e.g. Community First Responders. All AED s used throughout the trust are biphasic and the energy settings are programmed into the AED s. Clinicians will not be able to adjust the energy settings on AEDs, however they may override the embedded ECG analysis software and decide for themselves whether or not shocks are indicated. No formal training is required for these devices although an awareness where a single device is used is supported during training.
The UK Resuscitation Council indicates that: AEDs should not be used on patients under 1 year of age. Paediatric attenuated pads SHOULD be used for patients aged 1 to 8 years of age. Adult pads may only be used in this age range if paediatric attenuated pads are not available. Adult pads should be used for all patients over 8 years of age. If ambulance clinicians are responded to a cardiac arrest where an AED is in use then: In cases of paediatric cardiac arrest, the AED must be replaced with a manual defibrillator as soon as one is available, this will allow the clinician to set an age/weight appropriate energy setting for defibrillation. In cases of adult cardiac arrest, it is advisable to replace any AED with a manual defibrillator as soon as it is practicable. This ensures that the clinician can obtain an accurate reading of the ECG and can print copies of the ECG if required. Where an AED is in use by a trained responder that does not have a screen to display the underlying rhythm, then the AED should be replaced with a WMAS manual defibrillator as soon as it is practicable. Replacement of the AED with a WMAS defibrillator allows the ambulance clinician to view and print the ECG. 3.4.4 Manual Defibrillators WMAS NHS Trust primarily uses Zoll manual defibrillators. All recently acquired defibrillators are biphasic in nature; however crews may encounter a limited number of legacy defibrillators that are monophasic. The energy setting for shocks can vary between type of defibrillator (monophasic vs. biphasic) and manufacturer (Zoll vs. Physio control). Below describes the energy settings used by the different manual defibrillators: For adult patients (12 years of age and over): If a monophasic defibrillator is used, then all shocks should be delivered at 360J. If a Zoll biphasic defibrillator is used then an escalating energy shock sequence is used. The first shock is delivered at 120J, the second at 150J and all subsequent shocks delivered at 200J.
If a manual biphasic defibrillator is not manufactured by Zoll then the first shock should be delivered at 150J, with all subsequent shocks being delivered at 200J. For patients under 12 years of age: ALL shocks delivered at 4J per kg regardless of type of defibrillator or manufacturer. WMAS NHS Trust primarily uses Zoll manual defibrillators. All recently acquired defibrillators are biphasic in nature; however crews may encounter a limited number of legacy defibrillators that are monophasic. The energy setting for shocks can vary between type of defibrillator (monophasic vs. biphasic) and manufacturer (Zoll vs. Physio control). Below describes the energy settings used by the different manual defibrillators: For adult patients (12 years of age and over): If a monophasic defibrillator is used, then all shocks should be delivered at 360J. If a Zoll biphasic defibrillator is used then an escalating energy shock sequence is used. The first shock is delivered at 120J, the second at 150J and all subsequent shocks delivered at 200J. If a manual biphasic defibrillator is not manufactured by Zoll then the first shock should be delivered at 150J, with all subsequent shocks being delivered at 200J. For patients under 12 years of age: ALL shocks delivered at 4J per kg regardless of type of defibrillator or manufacturer. 3.4.5 Defibrillation: Safety Issues Wherever possible, safety issues should be addressed and appropriate plans made while chest compressions are being performed, before a shock is considered. Prior to delivering a shock: Ensure no one is touching the patient either directly or indirectly. Ensure the electrodes are firmly adhered to the patient s chest and only make contact with skin. Ensure the chest is not wet. Ensure high flow O2 is not in the zone of defibrillation (Bag valve mask respirators should be moved at least 1 meter from the patient). Ensure defibrillator pads are not placed over any pacemaker. Remove any medication patches (especially GTN) from the patient. Remove any jewellery in proximity to the defibrillator pads
3.4.6 In general, the likelihood of successful defibrillation decreases by 7-10% per minute from the time of arrest. Consequently, the timely delivery of defibrillation shocks is essential improve outcomes If the patient is being monitored through defibrillation pads and subsequently arrests in front of the ambulance clinician, then defibrillation should be attempted immediately (if indicated) before CPR commences. If the patient is not being monitored through defibrillation pads and subsequently arrests in front of the ambulance clinician, then a precordial thump should be attempted. While CPR is in progress, defibrillation should be attempted every 2 minutes if indicated. It is critical to minimise the delay between stopping chest compressions and delivering the shock. Where a shock is indicated ambulance clinicians should aim to deliver the shock within 10 seconds of stopping CPR as every 5 second delay reduces the likelihood of successful defibrillation by approximately 50%. If there are delays caused by difficulties in rhythm analysis or if individuals are still in contact with the patient, chest compressions should be restarted whilst plans are made to decide what to do when compressions are next stopped. Chest compressions should be resumed immediately following the delivery of a shock do not wait to see if the rhythm has changed or assess for the presence of a pulse. Resume CPR immediately. Pulse checks should only be undertaken when a previously lifeless patient shows signs of life, e.g. movement, or if coordinated electrical activity is noted on the monitor or in the case of sudden improvement of End Tidal Capnograph readings Pulse checks should only be undertaken when a previously lifeless patient shows signs of life, e.g. movement, or if coordinated electrical activity is noted on the monitor or in the case of sudden improvement of End Tidal Capnograph readings 3.5 Advanced Life Support (ALS) 3.5.1 Advanced Life Support (ALS) involves advanced airway management where indicated, and the delivery of resuscitation medications to supplement BLS and defibrillation. Research indicates that ALS does not significantly improve outcomes. The only interventions shown to improve outcomes in cardiac arrest are BLS, oxygen therapy and defibrillation. Consequently ALS must never be initiated at the expense of either BLS or defibrillation; ALS must always be deferred to ensure quality BLS and timely defibrillation.
3.5.2 ALS requires a minimum of two providers, one to deliver BLS and another to deliver the various elements of ALS for this reason it is not normally possible for a solo responder to deliver ALS. Where resources allow, ALS should occur in parallel with BLS, but should not interrupt BLS in any way. In particular, BLS must not be interrupted to perform cannulation, intubation or drug delivery. Refer to the UK Clinical Practice Guidelines and UK Resuscitation Council ALS guidelines for further detail regarding the delivery of advanced life support (ALS). 3.6 Reversible Causes Hypoxia Hypovolaemia Hypothermia/Hyperthermia Hypo-/hyperkalaemia/metabolic Tension pneumothorax Toxins Tamponade Cardiac Thrombosis Coronary or pulmonary 3.7 3.7.1 Advance Directives / Living Wills An Advance Directive is produced by a patient and identifies what treatment a patient is willing to receive in the future should they lack capacity at that time; they may be written by an individual with capacity and in whom a resuscitation attempt may have a good chance of success. It is well established both in law and in ethics that adults with capacity have the right to refuse any medical treatment, even if that refusal results in their death. Consequently, for an Advance Directive to be valid, the patient must have capacity at the time the advance directive is produced. Any Advance Directive produced where capacity is lacking is not legally binding. Advance Directives usually relate to specific treatments such as: Intubation Mechanical ventilation External chest compressions Defibrillation Administration of certain drugs (usually resuscitation drugs) Administration of food substitutes It is important to note that these treatment restrictions apply to all health care related issues i.e. the same restrictions apply regardless of whether or not the patient chokes on a piece of food, suffers a heart attack, is poisoned or is injured in a road traffic accident. In England and Wales, the Mental Capacity Act 2005 provides the legal framework for Advance Directives. The Act confirms that an advance decision refusing resuscitation will be valid, and therefore legally binding on the healthcare team, provided that: The patient was 18 years old or over and had autonomy, capacity and competency when the decision was made
The decision is in writing, signed and witnessed It includes a statement that the Advance Decision is to apply even if the patient s life is at risk The Advance Decision has not been withdrawn The patient has not, since the Advance Decision was made, appointed a welfare attorney to make decisions about CPR on their behalf The patient has not done anything clearly inconsistent with its terms The circumstances that have arisen match those envisaged in the Advance Decision. If an Advance Decision does not meet these criteria but appears to set out a clear indication of the patient s wishes, it will not be legally binding but should be taken into consideration in determining the patient s best interests. Although a valid Advance Directive must be respected, it is incumbent upon the patient to ensure that the Advance Directive is communicated to the treating health care professionals. In an emergency, if there is no time to investigate further and confirm that the patient has made a prior and specific request to refuse treatment, the presumption should be in favour of resuscitation if this has a realistic chance of prolonging life and staff should continue to provide all clinical care in the normal way, until such time as evidence is produced. If a WMAS clinician determines that the Advance Directive does not fulfill the criteria listed in 3.7.2.3 then the reasons why it is considered invalid or not applicable must be documented. 3.7.2 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) 3.7.2.1 When a patient is in the final stages of an incurable illness and death is expected within a few days, CPR is very unlikely to be clinically successful. In some cases it may prolong or increase suffering and subject the patient to traumatic and undignified death. In these circumstances, most patients want a natural death without unnecessary interventions that most consider to be undignified. Ambulance clinicians thus have an ethical and moral obligation to ensure that the patient s best interests are being served. 3.7.2.2 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is usually produced by the senior clinician in charge of a patient s medical care; however this task may be delegated to another competent clinician. There is no legal requirement for the DNACPR to be communicated to either the patient or their relatives however it is considered good practice, that wherever possible the patient, and if need be their family, are involved in the decision making process. It is important to note that patient capacity is not a prerequisite for a DNACPR to be valid.
3.7.2.3 There are no legal requirements concerning DNACPR, only good practice recommendations. As such the presentation of DNACPR varies considerably; there is no uniform template. Ideally a DNACPR should: Explicitly identify the patient Explicitly identify the circumstances in which the DNACPR applies Identify if the patient and their family are aware of the DNACPR Identify who produced the DNACPR Identify when the DNACPR was produced 3.7.2.4 A DNACPR decision applies solely to cardiopulmonary resuscitation. All other treatment and care that a patient requires is not precluded or influenced by a DNACPR decision e.g. provision of analgesia. Where a DNACPR is in place, a patient or their family cannot demand that health care professionals provide resuscitation health care professionals do however have an ethical, moral and professional responsibility to clinically justify withholding resuscitation. 3.8 Relatives witnessing resuscitation attempts 3.8.1 There is an increasing appreciation of the desire of close relatives to be present at resuscitation attempts. It is now agreed that such presence can reassure relatives that all necessary therapeutic steps were taken and can aid the process of bereavement. This practice has been routine for many years in paediatric medicine and is now relatively common in Emergency Departments around the country. Ambulance Clinicians should consider these facts when undertaking resuscitation in the presence of family members. 3.8.2 Relatives who wish to remain with the patient during resuscitation attempts should be allowed to do so unless their presence interferes with the resuscitation attempt. No relative should feel under any pressure to be present during CPR, and should be allowed to leave the vicinity of the resuscitation attempt if they so wish. Where resources allow (i.e. at least 4 ambulance staff are in attendance), it is best practice to appoint a single member of the resuscitation team to look after the relative and answer any questions that the relative may have. Reasonable efforts should be made to accommodate relatives requests; however clinical needs of the patient must take priority. The presence of relatives should be allowed provided that:
There is no reason to believe that the patient has already refused permission for relatives to be present if they require resuscitation. There is sufficient space to accommodate the presence of the relative without impact on the resuscitation effort. The presence of a relative will not compromise the potential success of the resuscitation attempt e.g. by asking questions that distract the clinicians or interfering with resuscitation attempts. No member of the resuscitation team objects to the presence of the relative. (If a member of the team does object, they must provide adequate justification as to why the relatives presence will compromise the resuscitation attempt before the relative is excluded). 3.8.3 The relative must be informed that if at any time during the resuscitation attempt it is believed that their continued presence compromises the best interest of the patient then they will be politely asked to leave. If relatives are prohibited from witnessing a resuscitation attempt for any of the preceding reasons then the team leader of the resuscitation should always confer with the relative afterwards, answering any questions they may have. 3.8.4 If the resuscitation attempt is successful, the surviving patient should be informed that their relative was present during the resuscitation attempt. 3.9 Outcome of Cardiac Arrest 3.9.1 Recognition of Life Extinct Refer to Recognition of Life Extinct procedure. 3.9.2 Return of Spontaneous Circulation (ROSC) Refer to Return of Spontaneous Circulation (ROSC) procedure (appendix 8) 3.9.3 Ongoing resuscitation attempt continued into hospital Resuscitation consistent with indicated guideline should continue. Continuous consideration of the safety of patient and rescuers and continue to dynamically assess and adapt to any risks that are identified. Pre-alert hospital to ensure that the hospital resuscitation team is on standby Following ROSC the patient should continue to be assessed as per 3.9.2 Patients that fit following ROSC can be due to reperfusion episodes, patients should only receive diazepam after 5 minutes of continuous fitting. The method for the movement of a patient immediately following ROSC should be carefully considered. The myocardium has a level of dysfunction following cardiac arrest which leaves the heart susceptible to further arrhythmia and reduced cardiac output which can lead to subsequent cardiac arrest if not handled appropriately.
3.10 Ambulance Quality Indicators (AQIs) Requirements The current national Ambulance Quality Indicators (AQIs) require Ambulance Trusts to report the following outcomes: ROSC at time of arrival at hospital Overall ROSC at time of arrival at hospital - Utstein Comparator Group Survival to discharge Overall survival rate Survival to discharge Utstein Comparator Group survival rate These are then compared against each other to identify achievement against the standard. 3.11 References Resus.org.uk, (2016). Resuscitation guidelines. [online] Available at: https://www.resus.org.uk/resuscitation-guidelines/ [Accessed 9 Feb. 2016]. Mental Capacity Act 2005 (c.9) London. OPSI
Appendix 1 Adult BLS and AED
Appendix 2 Adult Choking Algorithm
Appendix 3 Paediatric BLS
Appendix 4 Paediatric Choking Algorithm
Appendix 5 Adult ALS Algorithm (Medical)
Appendix 6 Adult ALS Algorithm (Trauma)
Appendix 7 Paediatric Advanced Life Support
Appendix 8 ROSC Procedure This procedure is to be undertaken following any case of Return of Spontaneous Circulation: Haemorrhage Control Continue to monitor effectiveness of haemorrhage control Airway Assess and manage using a stepwise approach Suction as required Breathing Monitor respiratory rate and maintain SPO2 at 95-98% Ventilation if required should undertaking using 10-15litres of O2 If available monitor ETCO2 and maintain at 3-5Kpa (Capnography) Circulation Undertake 12 Lead ECG If diagnostic of a STEMI discuss direct transfer with PPCI Centre Assess BP and remove patient keeping them as flat as possible Aim for 90-100 mmhg. (250ml boluses of fluids) Treat Symptomatic Bradycardia Disability Assess and record AVPU Do not actively re-warm patients that are unresponsive to pain Undertake a BM and treat hypoglycaemia In a combative patient consider Hypoxaemia and Hypoglycaemia in the first instance Secondly consider Rapid Sequence Induction (RSI) Evacuate Optimise cerebral perfusion utilise SUPINE position, FEET FIRST when down a stairs Consider head end of body raised 30 degrees (return to flat if further arrest occurs) Continue ABCDE on route to hospital. Provide a pre-alert message and convey to the appropriate centre of care Constantly monitor and treat any reversible cause: Hypoxia Tension pneumothorax Hypovolaemia Tamponade (Cardiac) Hypothermia Toxins Hypo/Hyperkalaemia/BM Thromboembolic
Date Change Authorised by Jan 2010 DRAFT Mike Smyth Medical Director Feb 2010 Reviewed and Amended - Matthew Ward Medical Director May 2010 Amended following external review Director of Nursing June 10 Approved Staff Side Policy Group July 10 Approved Clinical Governance Committee Nov 10 March 12 Amended following 2010 Resus Guidelines Reviewed by Head of Cardiac and Stroke Management Medical Director Medical Director July 13 Reviewed by Head of Cardiac and Stroke Management Medical Director Dec 13 Reviewed by Head of Clinical Practice, Research Paramedic and CPGM Medical Director 28 Jan 14 Approved by Clinical Steering Group Medical Director 04 May 2016 Approved Clinical Steering Group