RESUSCITATION

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Resuscitation in the ambulance service sophisticated programme (“Heartstart Scotland”) was initiated to review the outcome of every ambulance resuscitation attempt. Chain of survival The ambulance service is able to make useful contributions to each of the links in the chain of survival that is described in Chapter 1. Early awareness and early access The United Kingdom has had a dedicated emergency call number (999) to access the emergency services since 1937. In Europe, a standard emergency call number (112) is available and a number of countries, including the United Kingdom, respond to this as well as to their usual national emergency number. All ambulance services in the United Kingdom now employ a system of prioritised despatch, either Advanced Medical Priority Despatch or Criteria Based Despatch, in which the call-taker follows a rigorously applied algorithm to ensure that the urgency of the problem is identified according to defined criteria and that the appropriate level of response is assigned. Three categories of call are usually recognised: NHS Training Manual ● ● ● Category A—Life threatening (including cardiopulmonary arrest). The aim is to get to most of these calls within eight minutes Category B—Emergency but not immediately life threatening Category C—Non-urgent. An appropriate response is provided; in some cases the transfer of the call is transferred to other agencies, such as NHS Direct. Early ACCESS Early ACLS Having assigned a category to the call (often with the help of a computer algorithm), the call-taker will pass it to a dispatcher who, using appropriate technology such as automated vehicle location systems, will ask the nearest ambulance or most appropriate resource to respond. In the case of cardiorespiratory arrest this may also include a community first responder who can be rapidly mobilised with an automated defibrillator. The ambulance control room staff will also provide emergency advice to the telephone caller, including instructions on how to perform cardiopulmonary resuscitation if appropriate. The speed of response is critical because survival after cardiorespiratory arrest falls exponentially with time. The Heartstart Scotland scheme has shown that those patients who develop ventricular fibrillation after the arrival of the ambulance crew have a greater than 50% chance of long-term survival. The ambulance controller should ensure that patients with suspected myocardial infarction are also attended promptly by their general practitioner. Such a “dual response” provides the patient with effective analgesia, electrocardiographic monitoring, defibrillation, and advanced life support as soon as possible. It also allows pre-hospital thrombolysis. to get help Chain of survival Early CPR to buy time Early DEFIBRILLATION to restart heart to stabilize Early cardiopulmonary resuscitation The benefits of early cardiopulmonary resuscitation have been well established, with survival from all forms of cardiac arrest at least doubled when bystander cardiopulmonary resuscitation is undertaken. All emergency service staff should be trained in effective basic life support and their skills should be regularly refreshed and updated. In most parts of the United Kingdom ambulance staff also train the general public in emergency life support techniques. Ambulance dispatch desk 51
ABC of Resuscitation Early defibrillation Every front-line ambulance in the United Kingdom now carries a defibrillator, most often an advisory or automated external defibrillator (AED) that can be used by all grades of ambulance staff. The results of early defibrillation with AEDs operated by ambulance staff are encouraging. In Scotland alone, where currently over 35 000 resuscitation attempts are logged on the database, 16 500 patients have been defibrillated since 1988, with almost 1800 long-term survivors—that is, 150 survivors per year—an overall one year survival rate from out-of-hospital ventricular fibrillation of about 10%. The introduction of AEDs has revolutionised defibrillation outside hospital. The sensitivity and specificity of these defibrillators is comparable to manual defibrillators and the time taken to defibrillate is less. AEDs have high-quality data recording, retrieval, and analysis systems and, most importantly, potential users become competent in their use after considerably less training. The development of AEDs has extended the availability of defibrillation to any first responder, not only ambulance staff (see Chapter 3). It is nevertheless important that such first responder schemes, which often include the other emergency services or the first aid societies, are integrated into a system with overall medical control usually coordinated by the ambulance service. Early advanced life support The standardised course used to train paramedics builds on the substantial basic training and experience given to ambulance technicians. It emphasises the extended skills of venous cannulation, recording and interpreting electrocardiograms (ECGs), intubation, infusion, defibrillation, and the use of selected drugs. In 1992 the Medicines Act was amended to permit ambulance paramedics to administer approved drugs from a range of prescription only medicines. The paramedic training course covers, in a modular form, the theoretical and practical knowledge needed for the extended care of emergency conditions in a minimum instruction time of 400 hours. Four weeks of the course is provided in hospital under the supervision of clinical tutors in cardiology, accident and emergency medicine, anaesthesia, and intensive care. Training in emergency paediatrics and obstetric care (including neonatal resuscitation) is also provided. All grades of ambulance staff are subject to review and audit as part of the clinical governance arrangements operated by Ambulance Trusts. Paramedics must refresh their skills annually and attend a residential intensive revision course at an approved centre every three years. Opportunities are also provided for further hospital placement if necessary. The ability to provide early advanced life support techniques other than defibrillation—for example, advanced airway care and ventilation—probably contributes to the overall success of ambulance based resuscitation. The precise role of the ambulance service in delivering advanced life support remains controversial, but the overwhelming impression is that paramedics considerably enhance the professional image of the service and the quality of patient care provided. Coordination and audit Local enthusiasm remains a cornerstone for developing resuscitation within the ambulance service, but growing interest from the Department of Health and senior ambulance Equipment for front-line ambulance ● Immediate response satchel—bag, valve, mask (adult and child), hand-held suction, airways, laryngoscopy roll, endotracheal tubes, dressing pads, scissors ● Portable oxygen therapy set ● Portable ventilator ● Defibrillator and monitor and accessories, pulse oximeter ● Sphygmomanometer and stethoscope ● Entonox ● Trolley cots, stretchers, poles, pillows, blankets ● Rigid collars ● Vacuum splints ● Spine immobiliser, long spine board ● Fracture splints ● Drug packs, intravenous fluids, and cannulas ● Waste bins, sharps box ● Maternity pack ● Infectious diseases pack ● Hand lamp ● Rescue tools Drugs sanctioned for use by trained ambulance staff ● Oxygen ● Nalbuphine ● Entonox ● Syntometrine ● Aspirin ● Sodium bicarbonate ● Nitroglycerine ● Glucose infusion ● Adrenaline (epinephrine) ● Saline infusion 1:10 000 ● Ringer’s lactate infusion ● Lignocaine ● Polygeline infusion ● Atropine ● Metoclopramide ● Diazepam ● Frusemide ● Salbutamol ● Morphine sulphate ● Glucagon ● Benzyl penicillin ● Naxloxone Outline syllabus for paramedic training Theoretical knowledge Basic anatomy and physiology ● Respiratory system (especially mouth and larynx) ● Heart and circulation ● Central and autonomic nervous system Presentation of common disorders ● Respiratory obstruction, distress, or failure ● Presentations of ischaemic heart disease ● Differential diagnosis of chest pain ● Complications and management of acute myocardial infarction ● Acute abdominal emergencies ● Open and closed injury of chest and abdomen ● Limb fractures ● Head injury ● Fitting ● Burns ● Maxillofacial injuries ● Obstetric care ● Paediatric emergencies Practical skills Observing and assessing patient ● Assessing the scene of the emergency ● Taking a brief medical history ● Observing general appearance, pulse, blood pressure (with sphygmomanometer), level of consciousness (with Glasgow scale) ● Undertaking systemic external examination for injury ● Recording and interpreting the ECG and rhythm monitor Interventions ● Basic life support ● Defibrillation ● Intubation ● Vascular access ● Drug administration 52
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ABC OF RESUSCITATION Fifth edition
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ABC OF RESUSCITATION Fifth Edition
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Contents Contributors Introduction
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Introduction The modern era of resu
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