Advanced Life Support (ALS)
1. Assess responsiveness, if none,
2. Outside hospital—activate EMS system. Inside hospital—call for defibrillator, or if on monitor and defribillator present and V-fib or pulseless V-tach defibrillate x 3 (200, 300 , 360 joules).
3. Open AIRWAY and assess BREATHING. If none, 2 slow breaths (in trauma, maintain cervical spine immobilization).
4. Assess PULSE. If present, mouth-to-mouth or bag-valve-mask or intubation at 12 breaths per minute (plus needle thoracentesis or chest tube if needed). If no pulse,
5. CPR: chest compressions 100 per minute. Compression/ventilation for 1 to 2 rescuers (15:2), with intubated patient 2 providers (5:1).
6. When DEFIBRILLATOR arrives and shows VF/pVT, defibrillate x 3. If another rhythm, continue CPR, intubate, IV access, determine rhythm and therapy.
7. DISABILITY: if adequate pulse and respirations, but comatose, use Coma Protocol.
Airway control is the critical first step in resuscitation. The head is tilted and either the jaw thrust or chin lift used to open the airway. Protection of the airway may require endotracheal intubation, often needed with respiratory distress and hypoventilation from any cause. It is also needed to prevent aspiration in the comatose patient or the patient with decreased level of consciousness and no gag reflex. The patient is ventilated with 100% oxygen using two assistants and a bag-valve-mask. Insertion of an endotracheal tube is performed orally (orotracheal intubation) or nasally (nasotracheal intubation).
Nasotracheal intubation is performed only on the breathing patient. It is useful in the immobilized patient, when the patient has clenched teeth or when cooperation is needed (i.e., the asthmatic or the patient with pulmonary edema). It is contraindicated with maxillofacial injuries or a basilar skull fracture.
In the trauma patient, the C-spine is protected with a cervical collar and the jaw thrust is used. The oral cavity is inspected for foreign bodies, vomitus, broken teeth and suctioned using a hard-tipped suction catheter. Examination of the neck and intubation in the trauma patient requires inline immobilization by an assistant in order to stabilize the neck when the cervical collar is removed.
Rapid Sequence Intubation
Intubation is sometimes necessary for an awake patient. The criterion is deterioration of vital signs so that the airway will be unprotected. Examples: head injury, a combative or agitated patient, a patient with clenched teeth, respiratory failure, impending cardiovascular collapse and a diminishing level of consciousness from any cause. Rapid sequence intubation (RSI) is performed using the following or a similar protocol:
- 1. Oxygen by nonrebreather mask for 5 minutes.
- 2. Induction with IV thiopental (Pentothal) 4 mg/kg or etomidate (Amidate) 0.3 mg/kg. Lidocaine 1 mg/kg IV is added to blunt the rise in intracranial pressure in head injuries.
- 3. An assistant applies pressure to the cricoid cartilage to occlude the esophagus and prevent esophageal reflux and aspiration (Sellick maneuver).
- 4. Paralysis with IV succinylcholine (Anectine) 1.5 mg/kg, or rocuronium (Zemuron) 1 mg/kg.
- 5. The tube is passed through the vocal cords (intubation).
- 6. Cricoid pressure is released.
- 7. Bag, listen for breath sounds, pulse ox/CO2 indicator.
- 8. X-ray for tube placement.
If intubation is not possible, a tracheostomy tube with an inflatable cuff (i.e., #6 Shiley), or a #6 or 7 endotracheal tube, is inserted through the cricothyroid membrane between the thyroid (“Adam’s apple”) and cricoid cartilages (cricothyrotomy). The patient is bagged through the ET or tracheostomy tube. If a tracheostomy tube is not available, a 14g angiocath may be inserted through the cricothyroid membrane (needle cricothyrotomy) while preparing for a surgical airway.
Choking from a foreign-body does not occur in the emergency department, but often takes place in a restaurant (“cafe coronary”). The person is drinking, the throat muscles are relaxed, he is talking while eating and inhales at the same time he is swallowing. The piece of food, usually meat, impacts against the vocal cords, obstructing breathing. The person grasps his neck with the thumb and fingers, a universally recognized sign of airway obstruction. The first thing to do is to ask if he can speak. If he can, he is not
obstructed. If he cannot, he is. Partial obstruction may occur, in which case coughing and stridor are present, but the person is exchanging air.
Treatment for obstruction is as follows :
1. The abdominal thrust (Heimlich maneuver) creates intrathoracic pressure and will expel almost any foreign body. The thumb side of the fist is placed against the person’s abdomen, slightly above the navel. The fist is grasped with the other hand and pressed upward quickly and forcefully as many times as needed to dislodge the object.
2. If the person becomes unconscious, he is placed on his back on the floor. With one hand on top of the other, abdominal thrusts are performed by the rescuer with the palms of the hands pushing upward.
3. Since hypoxic brain damage occurs in 7-10 minutes, after several failed attempts at abdominal thrusts the rescuer should open the mouth and perform finger sweeps. After this, rescue breathing should be attempted.
4. If attempts at abdominal thrusts, finger sweeps and rescue breathing are unsuccessful and the 7 minute point is approaching, an emergency cricothyrotomy may be life-saving: thrust anything, such as a knife or ballpoint pen, into the indentation between the
thyroid and cricoid cartilages (cricothyroid membrane). The force must be substantial or the trachea will not be penetrated. Remove the inner pen piece and keep the barrel in place, or keep the space open with two keys, or 2 to 3 straws. Stay with the person until
5. The Heimlich maneuver may be performed on oneself, as in 1.
Treatment for partial obstruction: remain with the person until he is transported to the nearest emergency facility, since complete obstruction may occur at any time.
After securing the airway, the lungs are auscultated for bilateral breath sounds. Breathing patients receive 100% oxygen by nonrebreather mask. Comatose patients are intubated to protect the airway. Nonbreathing patients are bagged with a bag-valve-mask (BVM) at 100% oxygen and are intubated.
If signs of tension pneumothorax or hemothorax are present or evolving (chest pain, dyspnea, decreased breath sounds on affected side, tracheal deviation, jugular venous distention), a 14g needle or angiocath is inserted in the 2nd interspace at the mid-clavicular line (needle thoracentesis) while preparing for chest tube (thoracostomy tube) placement, before a chest xray is taken. A 36F chest tube is inserted in the 5th intercostals space at the midaxillary line over the top of the rib (to avoid vessels) and connected to an underwater seal apparatus.
Paradoxic motion of the chest wall from moving rib segments (flail chest) may require intubation. An open wound of the chest wall (open pneumothorax) requires a sterile occlusive dressing taped on three sides, providing a flutter-type valve effect, followed by insertion of a chest tube.
Respiratory failure is seen in asthma, congestive heart failure, COPD, trauma (i.e., pulmonary contusion, pneumo-hemothorax) and occasionally pneumonia. Signs of hypoxia are dyspnea, tachypnea, tachycardia, restlessness, gasping respirations and use of accessory ventilatory muscles. Lethargy and confusion are seen with hypercapnia (see Chapter 6, Oxygen). ABGs show a PO2 <50 mmHg and/or a PCO2 >50 mmHg, implying impending respiratory failure, although patients with COPD may normally carry a PCO2
of 60-70 mmHg. A rectal temperature is taken, since the person is mouthbreathing.
endotracheal intubation is usually required, although some cases may respond to continuous positive airway pressure (CPAP). Initial settings on a volume-cycled respirator are: oxygen 100%, tidal volume 15 cc/kg, respiratory rate 16.
Hemorrhage is controlled by pressure. Blood loss is treated with 2 large bore IVs, 2 liters of normal saline and type-specific or O-neg packed red blood cells (RBCs).
Pulseless rhythms are ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity and asystole, the latter being often a terminal event. One must be careful to examine the patient and not the monitor. The monitor may show a normal sinus rhythm but the patient may be apneic or pulseless. Conversely, the monitor may show a chaotic rhythm or straight-line, but if the patient is alert and conversant, a lead is off. In ventricular fibrillation (VF), the electrical activity of the heart is chaotic and no heart-beat is present. Pulseless ventricular tachycardia (pVT) shows VT but without a pulse and is treated as VF.
CPR is begun and the patient is defibrillated as soon as possible
3 times in succession (200, 300, 360 J). If unsuccessful the patient is intubated
and CPR is continued. Epinephrine is given 1 mg q 5 min. Vasopressin 40 units may be given as one dose (vasopressin at this dosage is a vasoconstrictor, and is frequently used in Europe). It has been shown that antiarrhythmic agents possess minimal efficacy in VF/pVT. The usual protocol is to give the drug, followed by defibrillation. However, it is
acceptable to give the agent, followed by three shocks. Agents used, in order of preference, are:
- 1. Amiodarone 300 mg IV push. A second dose of 150 mg may be given,
- 2. Lidocaine 1 mg/kg IV push, and repeat in 5 minutes to a total of 3 mg/kg.
Defibrillation may be after each agent, or after each minute of CPR.
In pulseless electrical activity (PEA),
the monitor shows a rhythm, but the patient has no heart beat—the electrical activity is inadequate to stimulate contraction of the heart muscle, or the contraction is so weak as to be negligible. It is seen in several circumstances, the more common being hypovolemia and massive acute myocardial infarction.
this is a situation in which the patient may be mistakenly assumed to have a pulse. Always check for a pulse. Unfortunately, the reason for this lethal condition is often not known. CPR is begun, intubation is performed, IV access is obtained and epinephrine 1 mg IV push is given every 5 minutes. If electrical bradycardia is present, atropine 1mg IV is given every 5 minutes to a total of 0.04mg/kg. Because this condition is reversible in some circumstances, as a last resort bicarb 1 meq/kg and a 200 cc bolus x 2 of normal saline may be tried.
or a straight line on the monitor, is treated with CPR, transcutaneous pacing if the rhythm occurred suddenly, epinephrine 1 mg IV every 5 min and atropine 1 mg IV q 5 min (total 0.04 mg/kg). This is often a terminal nonrhythm, indicating death. Some bradycardias and tachycardias may require resuscitative measures.
4. DEFIBRILLATION and DISABILITY (Level of Consciousness)
In the hospital and emergency medical services (EMS) settings, “D” for Defibrillation is added to the ABCs. When a monitor or “quick look” paddles show ventricular fibrillation or pulseless ventricular tachycardia, the patient is defibrillated immediately as per the above protocol. In the trauma and other settings, “D” also represents “Disability”, or level of consciousness.