Causes of Deterioration and Cardiorespiratory Arrest

Airway problems
Airway obstruction can be partial or complete.
Partial airway obstruction may lead to cerebral or pulmonary oedema, exhaustion, secondary apnoea, and hypoxic brain
damage, and eventually to cardiac arrest.

Possible causes
 CNS depression causes loss of airway patency and protective reflexes (head injury - intracerebral disease –
hypercarbia - metabolic disorders depressant effect e.g. hypoglycemia - drugs e.g. alcohol, opioid - general
anaethetic agents)
 Foreign body in airway (tooth, food, blood, vomitus)
 Bronchial secretions
 Blocked tracheostomy or laryngectomy
 Pharyngeal swelling
 Bronchospasm or laryngospasm

Assessment
 Conscious patient will complain of breathing difficulty or choking. And will be distressed.
 Partial airway obstruction leads to noisy breathing efforts.
 Complete airway obstruction is silent, and there is no air movement at the patient’s mouth. Any respiratory
movement will be strenuous (see-saw or rocking horse pattern of chest and abdominal movement)
 Cyanosis.

Treatment
 Assume actual or impending airway obstruction in anyone with a depressed consciousness, regardless of cause.
 Suction blood and gastric content from airway.
 Unless contraindicated, use simple airway opening manoeuvers such as turn the patient on their side or head
tilt/chin lift or jaw thrust.
 Insert oropharyngeal or nasopharyngeal airway.
 Tracheal intubation or tracheostomy.
 Consider insertion of nasogastric tube to empty the stomach.
 Give oxygen as soon as possible to achieve arterial blood oxygen saturation by pulse oximetry (Spo2) in the range
of 94-98%.

Breathing problems
Breathing inadequacy may be acute or chronic.
It may be continuous or intermittent.
It can be severe enough to cause the person to stop breathing (apnea or respiratory arrest)
If breathing is insufficient to oxygenate the blood adequately, lack of oxygen to the vital organs will lead to loss of
consciousness and eventually cardiac arrest.
The main respiratory muscles are the diaphragm and intercostal muscles.

Causes
 CNS depression (head injury - intracerebral disease – hypercarbia - metabolic disorders depressant effect e.g.
hypoglycemia - drugs e.g. alcohol, opioid - general anaethetic agents)
 Muscle weakness or nerve damage (Chronic malnourishment - Myasthenia Gravis – Guillain-Barre Syndrome –
Multiple Sclerosis)
 Restrictive chest wall abnormalities (Kyphoscoliosis)
 Fractured ribs (Pain will prevent deep breaths and coughing)
 Impaired Gas exchange (Chest infection – COPD exacerbation – pulmonary embolus – lung contusion – ARDS –
Pulmonary oedema – pneumothorax - hemothorax)
 Tension pneumothorax (Rapid impaired gas exchange, reduction of venous return to the heart, fall in blood
pressure)
 Severe long-term illness

Assessment
 Conscious patient will complain of shortness of breath and be distressed.
  Fast respiratory rate over 25
 Pulse oximetry to check adequacy of oxygenation but not a reliable measurement of ventilation.
 Arterial blood gases to assess adequate ventilation
 High PaCo2 (arterial carbon dioxide tension) indicates hypoventilation
 Hypoxia and hypercarbia can cause irritability, confusion, lethargy, and depressed consciousness.
 Cyanosis is a latter sign.

Treatment
 Give oxygen at 15 L/Min using high concentration reservoir mask. Once the patient is stable, change the Oxygen
Mask and aim for SpO2 in the range of 94-98%.
 Give early IV antibiotic to patient with severe pneumonia
 Start bronchodilator and steroid treatment for patient with severe asthma.
 Non-invasive ventilation using facemask can help patient with difficult breathing and prevent tracheal intubation.
 ICU admission for sedation and tracheal intubation and controlled ventilation may be needed.

Circulation problems
Circulation problems maybe caused by primary heart disease or by heart abnormalities secondary to other problems
The heart may stop suddenly or may produce and inadequate cardiac output for a while before stopping.
The commonest initial cardiac arrest rhythm is VF.

Causes
 Sudden cardiac arrest is caused by an arrhythmia secondary to myocardial ischaemia or myocardial infarction
 Primary respiratory arrest will result in a secondary cardiac arrest due to lack of oxygen
 Severe anemia, hypothermia, severe shock will impair cardiac function which eventually lead to a cardiac arrest.
 Acute coronary syndrome (Unstable angina – NSTEMI – STEMI)
 Asymptomatic or silent cardiac disease (Hypertensive heart disease, aortic valve disease, cardiomyopathy,
myocarditis, coronary disease)
 Heart valve disease
 Inherited cardiac disease (Long QT Syndromes)
 Drugs (antiarrhythmic drugs, tricyclic antidepressant, digoxin)
 Abnormal electrolyte concentration (potassium, magnesium, calcium)
 Hypothermia
 Electrocution
 Acidosis

Assessment
 Cardiac disease symptoms (chest pain, shortness of breath, syncope/presyncope, tachycardia, bradycardia,
palpitations, heart murmur, tachypnea, hypotension, poor peripheral perfusion/prolonged capillary refill time,
altered mental state, oliguria)
 Discomfort accompanied by belching (misinterpreted as evidence of indigestion)
 ECG that shows STEMI with a history of chest pain for 20-30 minutes or more.
 Substantial release of troponin with less specific ECG abnormalities (e.g. ST depression, T wave inversion)
 Unstable angina should be considered when there is an unprovoked and prolonged episodes of chest pain without
definite ECG or laboratory evidence of AMI.
 Features that indicate a high probability of arrhythmic syncope:
o Syncope in the supine position (fainting when already lying down)
o Syncope occurring during or after exercise (syncope after exercise is usually vasovagal)
o Syncope with no or only brief prodromal symptoms (sudden collapse without warning signs)
o Repeated episodes of unexplained syncope
o Syncope in individuals with a family history of sudden death or inherited cardiac condition

Treatment
 Treat hypovolemia by giving intravenous fluids
 Immediate general ACS treatment
 Aspirin 300 mg crushed or chewed
 Nitroglycerin as sublingual glyceryl trinitrate (tablet or spray), unless patient is hypotensive or extensive right
ventricular infarction is suspected
 Oxygen to keep PaO2 94-98% (or 88-92% in presence of COPD)
 Relief of pain using IV morphine to control symptoms but avoid sedation and respiratory depression