Life support — DRS ABC

• Urgent medical consult but do not delay starting resuscitation
• If newborn — see Newborn resuscitation
• If unsure of pulse — don't delay compressions
• Person with narcotic overdose may at first have a pulse but not be breathing — they need respiratory support

This protocol is for people collapsed and unresponsive or drowned

• If no signs of life — not responding, not moving, gasps/not breathing, pulseless or pulse not clearly felt in 10 seconds — DRS ABC
• If unresponsive and breathing normally — assess for causes and manage as unconscious person
• If deterioration or clinical change during assessment — return to start of this protocol
• If more than one of you — declare who is in charge
• Decision to stop CPR is very difficult — made by senior member of team after medical consult

Immediate defibrillation

• If collapse is witnessed and defibrillator immediately available/attached (eg in clinic) — defibrillate if indicated — see Defibrillation

D – Danger

• Make sure that you, person and place are safe
• If outside — put on protective clothing (eg fluoro vest, sun protection PPE )
• Check for hazards — chemicals, electrical sources, being trapped or burned
• Check surface person is lying on
• If very hot — can cause burns
• If very cold — can cause hypothermia

R – Response

• Does person respond to voice or gentle shake

S – Send for help

• Helper can
• Collect needed equipment
• Call for more help, call ambulance if access to hospital
• Help with CPR

A – Airway

• Clear airway and protect cervical spine (neck) — see Immobilising the spine
• Adult or child
• Use head tilt/chin lift — place one hand on the forehead. The other hand is used to provide chin lift. The head (not the neck) is tilted backwards. Grip chin and gently lift it up — Figure 2.1

OR jaw thrust if head or neck injury suspected. Hold jaw at point under ears, push upward and forward until chin juts out and airway opens — Figure 2.2

• Infant (under 1 year)
• Put folded towel or nappy under shoulders and back — Figure 2.3

• If visible foreign body — use forceps to remove OR if no other use 2 ‘hooked’ fingers in downward sweeping motion
• If liquid (blood, vomit, water) — use suction if available OR gravity — roll onto side, open mouth and turn face downward 
• Keep airway open — put in oropharyngeal or nasopharyngeal airway if needed

B – Breathing

• Assess — look for chest rise and fall, listen for breath sounds, feel for breath
• If person breathing but non-responsive — see Unconscious person
• If not breathing — commence CPR
• 2 breaths per 30 compressions for all ages except newborns — see newborn resuscitation
• 2 breaths, delivered over 1 second each with bag-valve-mask using oxygen if available OR mouth-to-mouth with droplet barrier/filter

• Watch chest rise and fall — don’t overinflate
• If recovers and breathing normally
  
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Put in recovery position — Figure 2.4 — unless possible head or spinal injury possible

C – Cardiopulmonary resuscitation - compressions (CPR)

• Start CPR on firm surface
• Centre of chest, ⅓ depth of chest
• Allow chest recoil, minimise interruptions
• 30 compressions then 2 breaths for 1 or 2 responders
• 100 - 120 compressions/minute (2 compressions/second)
• Pause compressions to allow for breaths — max pause 10 seconds

Defibrillation

• Indications —  VF and Pulseless VT
• As early as possible. If immediately available and adult patient — defibrillate before compressions
• Infant or child less than 10kg
• Use manual defibrillator if available
• If no manual defibrillator — use AED

Pads

• Press adhesive pads on firmly for best shock and to avoid burns
• Do not place pad over ECG dots, leads or pacemakers
• Adult — Figure 2.5
  
• One pad on right parasternal area over 2nd intercostal space
• One pad on left midaxillary line over 6th intercostal space
• Child — use largest pad that allows at least 3cm pad separation
• Over 10kg — usually 8–10cm adult pads
• 10kg or under — dose-attenuated paediatric pads (deliver 50J) OR adult pads placed front and back — Figure 2.6

• Defibrillator energy levels — Biphasic
• Adult — 200J
• Child — 4J/kg (doses)
• AED — once attached pause compressions for rhythm analysis
• Resume CPR immediately after shock delivered. Recheck rhythm after 2 minutes or return of responsiveness

Drugs (medicines)

Adrenaline (epinephrine)

• Give if asystole (no heartbeat), , VF pulseless VT or pulseless electrical activity (PEA)
• Adrenaline (epinephrine) dose
  
• Adrenaline (epinephrine) IV/intraosseous — adult 1mg, child 0.01mg/kg/dose up to 1mg — doses — 1mg = 1mL of 1:1,000 or 10mL of 1:10,000 
• Do not give if person already responding (breathing and moving)
• Every 4 minutes during CPR

Amiodarone

• If persistent VT or VF after 3 failed shocks — give amiodarone IV/intraosseous push as bolus — adult 300mg, child 5mg/kg up to 300mg — doses
• If still persistent VT or VF — shock again
• If still persistent VT or VF after fourth shock — medical consult about
• Second amiodarone IV/intraosseous bolus — adult 150mg, child 5mg/kg up to 150mg
• OR lidocaine (lignocaine) IV/intraosseous bolus — 1mg/kg
• If normal rhythm restored — start amiodarone infusion 15mg/kg over 24 hours (usual adult dose 900mg), child 2.5mg/kg 6 hourly dose. Dilute in glucose 5%
• ​Do not dilute amiodarone in normal saline
• Diluting — need concentration of more than 0.6mg/mL for stable solution
• Dose less than 225mg — use 100mL bag glucose 5%
• Dose 225–449mg — use 250mL bag glucose 5%
• Dose 450mg or more — use 500mL bag glucose 5%
• Use volumetric pump
• Do 12 lead ECG — look for evidence of ischaemia/infarct

Atropine

• For severe bradycardia (very slow heart rate), some poisons
• Do not give if asystole (no heartbeat)
• Dose
• Adult — IV/intraosseous — 1mg boluses (up to 3mg in total)
• Child — IV/intraosseous — 0.02mg/kg (doses) OR ETT 0.03mg/kg

Unconscious person

Do first

• Breathing and unresponsive
• Call for help — medical consult
• Clear airway and protect cervical spine (neck) — see Immobilising the spine
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
• If breathing normally and no risk of head, face or spinal injury — put in recovery position — Figure 2.7, Figure 2.8

• If suspected spinal injury and single responder — use Haines roll to protect the airway

Ask — friends and family

• Did person become unconscious suddenly or slowly
• Any symptoms before
• Weakness, dizziness, fever, headache
• Diarrhoea, vomiting — may cause shock, especially in child
• Had person been drinking alcohol
• Had person taken or injected medicines, drugs
• Usual medicines
• Injuries (eg hit over head, bled a lot)
• Bites (eg snake, spider)
• Has person been depressed
• If person has
• Fits (epilepsy)
• High BP — may cause stroke, heart attack
• Diabetes
• Lung problems — high CO₂ level, hypoxia (low oxygen)
• Heart disease — heart attack, stroke
• Liver or kidney disease
• Thyroid disease
• Asthma
• Any allergies
• Has person been
• Outside in cold for too long — see Hypothermia
• In the heat, working, walking, exercising hard — see Hyperthermia (heat illness)

Check

• ECG and coma scale — pupils
• Head-to-toe exam
• Stroke — asymmetry (one side of body or face looks, moves, has reflexes different to other)
• Injury — cuts, head injury, pupils different sizes, blood or clear fluid (CSF) from ear or nose
• Dilated pupils (very large) — overdose anticholinergics
• Pinpoint pupils (very small) — overdose opioids
• Rash, neck stiffness — meningitis
• Bite marks, bleeding — snake bite
• Medical alert bracelet

Do

• Put in IV cannula 
• POC Test — electrolytes
• Medical consult — IV fluids
• Correct hypotension (low BP) — normal saline IV bolus— adult 500mL, child 20mL/kg up to 500mL
• Assess/manage possible causes
• If BGL less than 2.6mmol/L for child 10 years and under or less than 4mmol/L for child over 10 years or adult — do not delay, treat straight away — see Hypoglycaemia (low blood glucose)
• Alcohol, drug overdose
• Unconscious after a fit
• Shock
• Subarachnoid haemorrhage
• Head injury
• Infections, especially meningitis
• If child — poisoning, infection, child abuse
• Consider more than one cause — fit from low BGL AND being drunk/using drugs AND head injury from accident
• Pressure area care
• Consider IDC — U/A and pregnancy test