Adult Level 2 Resuscitation Training

Supporting Material

Resuscitation Services
The Princess Alexandra Hospital NHS Trust
 Cardiac arrest in adults is often preceded by a period of physiological deterioration (Resuscitation
Council (UK) 2010). Many in-hospital cardiac arrests are predicative events not caused by a primary
cardiac pathology, however the deterioration in a patient’s physiological condition is often poorly
recognised and treated (NCEPOD 2012). This marked deterioration is evident in approximately 73%
of patients who suffer a cardiac arrest (NCEPOD 2012). It is known that survival from an adult in-
hospital cardiac arrest is poor. It has been shown that fewer than 20% of patients who suffer an in-
hospital cardiac arrest with survive to hospital discharge (Meaney 2010).

Recent data collected regarding in-hospital cardiac arrests suggests that in the majority,
approximately 85%, the primary rhythm was non-shockable and therefore would not benefit from
defibrillation (NCEPOD 2012). Non-shockable rhythms are associated with a poorer prognosis
(Resuscitation Council (UK) 2010). The above data clearly suggests that healthcare institutions must
have systems in place to facilitate earlier recognition of patients who are deteriorating and must
have health professionals who are trained to respond to these situations and offer appropriate
interventions to prevent further deterioration.

Resuscitation Council (UK) 2021

ABCDE Approach
Assessment of the unwell adult patient is based on a structured systematic assessment incorporating
airway, breathing, circulation, disability and exposure, the ABCDE approach.

Airway:
Assessment of the airway should include:
• Airway patency- is the airway clear, is it obstructed or is it at risk of obstruction
Interventions to optimise a patient’s airway may include:
• Airway opening manoeuvres e.g. head tilt chin lift and/or the jaw thrust
• Insertion of an airway adjunct e.g. Oro-pharyngeal airway, nasopharyngeal airway or
Laryngeal Mask Airway
• Patients who have an obstructed airway should receive high flow oxygen therapy via either a
non-rebreathe mask, bag-valve-mask or any other appropriate oxygen delivery system to
reduce the risk of hypoxia associated with an airway obstruction
The immediacy of the situation should always be assessed and health care professionals of all grades
and experience are advised to have a low threshold for asking for additional help with a critically ill
patient. In the context of an airway obstruction this may be an Anaesthetist or the cardiac arrest
team.

Breathing:
Assessment of a patients breathing may include the following:
• Inspection - looking for the patient’s respiratory rate, evidence of symmetrical chest wall
movement, use of accessory muscles, peripheral or central cyanosis, and obvious chest wall
deformity/injuries. Oxygen saturation monitoring may be helpful, however health care
professionals should remember that oxygen saturation do not provide information on
ventilation but may be used as a guide to assist with oxygen therapy.
• Palpation - assessing for equal and adequate chest wall movement, chest wall tenderness,
insuring the trachea is central.
• Percussion - noting resonance or other sounds.
• Auscultation - ensuring the patient has equal air entry bilaterally, noting any additional sounds
and or the absence of sound
Interventions to help with breathing may include:
• Ensuring the airway is open and patent
• Oxygen therapy-in the critically unwell patient should be initiated at high flow. When
appropriate the patient’s oxygen therapy should be titrated to achieve target saturations as
outlined by the British Thoracic Society.
• Appropriate positioning to facilitate better chest wall movement
• Treatment of the underlying cause of the respiratory insufficiency
Circulation:
Assessment of the patient’s circulatory system may include the following:
• Palpation of the patients pulse and assessing their heart rate - the absence of distal pulses
may imply distal hypo perfusion
• Assessment of the patient’s blood pressure - this should ideally be undertaken manually.
• Capillary refill time.
• Urine output.
• 12 lead or 3 lead ECG-dependant on clinical presentation.
• Assessment for any obvious internal bleeding into cavities e.g. abdominal distension or
abdominal pain on palpation.
• JVP
Interventions to assist with circulation may include:
• Ensuring the patients airway and breathing has been optimised.
• Obtain or verify the presence of vascular access - either intravenous or Intraosseous. Heath
Care professionals should have a low threshold for consideration of intraosseous needle
placement in the critically unwell patient where obtaining intravenous access is either difficult
or impossible.
• Consider intravenous or intraosseous fluid therapy - crystalloids would be a suitable fluid to
use initially.
• Specific end goal therapy based on clinical presentation e.g. revascularisation for Acute
Coronary Syndromes, surgical opinion for surgical presentation.

Disability:
Disability assessment includes:
• Assessment of the patient’s level of consciousness - using either the GCS or the AVPU systems
• Assessing the patient’s pupillary reaction to a light stimulus - equal and consensual
• Assessment of the patient’s capillary blood sugar level
• Gross assessment of the patient’s neurological function - power and tone of limbs and facial
symmetry.
Interventions for disability may include:
• Reviewing what medications the patient has received or has taken-these may have an adverse
effect on their level of consciousness
• Restoration of a normal blood sugar level.
Exposure:
Exposure assessment includes:
• Full top-toe, front and back, assessment of the patient’s body looking for rashes, signs of
internal or external haemorrhage, limb deformities, bruising, degradation of skin integrity

Sepsis:
‘Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its
own tissues and organs. Sepsis can lead to shock, multiple organ failure and death especially if not
recognised early and treated promptly.’
(Merinoff, 2010).

“Sepsis Six First Hour care duties”

• Oxygen- via high concentration mask with reservoir bag to maintain target oxygen saturation
• Blood Cultures – prior to antibiotics where possible to identify causative organism
• Antibiotics – administer within one hour of recognition of sepsis. Do not delay antibiotics.
• Fluid Resuscitation- maintain MAP ≥65mmHg or systolic Bp ≥ 90 mmHg
• Lactate/Hb/Bloods- continued monitoring for organ dysfunction and failure to respond to
treatment
• Urinary monitoring – monitor end organ perfusion. Consider catheter

*Ensure you escalate this to the Nurse in Charge and ensure you have a conversation with Critical
Care Outreach on bleep 901*
ADULT SEPSIS SCREENING PROTOCOL
Adult in-hospital Basic Life Support:

• Safety - ensure safety of rescuer and patient - take any reasonably practicable steps to ensure
safety and/or reduce danger.
• Response - check for responsiveness of patient using a shake and shout/appropriate painful
stimuli.
• Ask for help - either shout and/or use local systems in place to obtain help from staff within
immediate vicinity.
• Airway - ensure the airway in clear and open -head tilt and chin lift manoeuvre.
• Breathing - look, listen and feel for up to 10 seconds for signs of breathing +/- signs of
circulation (dependant on competency and confidence of the health care professional this
may involve palpation of a central pulse). Ignore odd occasional agonal gasps.
• Ensure the cardiac arrest team has been activated by asking someone to dial 2222 and stating
"adult cardiac arrest team" the accurate location to include site, floor and ward.
• Commence chest compressions - hands to be in the centre of the patient’s chest-aiming for a
depth of 5-6cm and a rate of 100-120 per minute.
• When help arrives with a Bag-Valve-Mask attach this to high flow oxygen and commence 30:2
Compressions: Ventilations CPR until either the cardiac arrest team arrives and takes over
from you or the patient shows overt signs of life.
• Ensure that the person delivering chest compressions is rotated every two minutes to avoid
fatigue.
 Your Resuscitation trolley and checklist

Please read carefully

This system has been designed to be easy and quick to check, with the aim of improving Resuscitation
trolley compliance and patient safety. Stocking is aimed at incorporating only necessary equipment.

The Trolley Top and seal documentation are to be completed DAILY. Full trolley check and re-seal is
to be performed WEEKLY.
The Airway and Circulation drawers contain plastic wrapped trays. These trays are only to be opened
for emergency use. As long as they remain fully wrapped and in date you can consider the drawer
checked.

The Airway tray is wrapped in blue

The Circulation tray is wrapped in red

The spare stock of trays is kept in the Resuscitation Store and can be swapped if your tray is out of
date or has been opened. Return the tray, with its un-used contents, to the store room and we will
recycle them.

Do not leave any sharps or used equipment in your trays

Should you have any further queries, please contact the Resuscitation Service on 8562 or
[email protected]
 Anaphylaxis

Anaphylaxis is a potentially life-threatening allergic reaction. The recognition of anaphylaxis is based

on:

• Sudden onset and rapid progression of symptoms

• Airway, Breathing and/or Circulation problems
• Skin and/or mucosal changes.
Diagnosis is supported if a patient has been exposed to an allergen known to affect them.

Treat life-threatening features using the A-E approach as detailed above. Adrenaline is the first line
treatment for anaphylaxis. Give intramuscular adrenaline early, as detailed above. Intravenous
adrenaline must only be used in certain specialist settings by those skilled and experienced in its
use.

Follow the National Institute for Health and Care Excellence (NICE) guideline for the assessment and
referral of patients suspected to have had anaphylaxis. Specifically:

• All patients should be referred to a specialist clinic for allergy

assessment.
• Offer patients (or, if appropriate, their parent and/or carer) an
appropriate adrenaline injector as an interim measure before the
specialist allergy assessment (unless the reaction was drug induced)
• Patients prescribed adrenaline auto-injectors (and/or their
parents/carers) must receive training in their use, and have an
emergency management or action plan

Mast cell tryptase

There are several differential diagnoses for anaphylaxis, and an elevated serum tryptase
can be very useful to confirm anaphylaxis where the diagnosis is uncertain. Mast cell
tryptase should be measured in all patients with suspected anaphylaxis where the
diagnosis is uncertain.

The time of onset of anaphylaxis is the time when symptoms were first noticed. It is
important that this time is recorded accurately.

Sample timing

a) Minimum: one sample, ideally within 2 h (when peak tryptase levels generally occur)
and no later than 4 h after onset of symptoms.
b) Ideally: take three timed samples:
1) An initial sample as soon as feasible – but do not delay treatment to take sample.
2) A second sample 1 – 2 h (but no later than 4 h) after onset of symptoms.
3) A third sample at least 24 h after complete resolution, or in convalescence (for
Serial samples have better specificity and sensitivity than a single measurement in
confirming a diagnosis of anaphylaxis.

For more information on anaphylaxis and Mast cell tryptase testing, please see link below:

https://www.resus.org.uk/sites/default/files/2021-
05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf

DNACPR

“Cardiopulmonary resuscitation (CPR) was introduced in the 1960s as a treatment that for some
people may re-start their heart when they suffer a sudden cardiac arrest due to a heart rhythm
disturbance, most commonly triggered by acute myocardial infarction (‘heart attack’) from which
they would otherwise have been expected to make a good recovery. The context of sudden cardiac
arrest in a person with a heart condition remains the situation in which CPR is most likely to be
successful. The probability of success in any individual is influenced by other factors and in many
people with advanced chronic disease the likelihood of CPR being successful is relatively low. CPR
involves chest compressions, delivery of high-voltage electric shocks across the chest, attempts to
ventilate the lungs and injection of drugs”.

Adults with capacity may decide to refuse CPR, with or without giving a reason for their decision.
Decisions about CPR may be made following consideration of a balance of benefits and burdens. In
other cases, the decision not to attempt CPR is a clinical decision, if the clinical team has good reason
to believe that a person is dying as an inevitable result of advanced, irreversible disease or a
catastrophic event and that CPR will not re-start the heart and breathing for a sustained period. If
there is no realistic prospect of a successful outcome, CPR should not be offered or attempted.

Q. If we find an unresponsive patient and we are not sure if they are for resuscitation or not, what
should we do?
A. “In these circumstances initiating CPR will usually be appropriate, whilst all possible efforts are
made to obtain more information to guide further decision-making. There will be some situations in
which CPR is started on this basis, but during the resuscitation attempt further information becomes
available that makes CPR inappropriate. That information may include a fully documented DNACPR
decision, a valid and applicable advance decision to refuse treatment (ADRT), or clinical information
indicating that CPR will not be successful. In such circumstances, continuing attempted resuscitation
would be inappropriate”.

Q. What if a patient has a valid DNACPR form but suffers an arrest due to a reversible cause e.g.
choking or anaphylaxis?
A. “Occasionally, some people for whom a DNACPR decision has been made may develop cardiac or
respiratory arrest from a readily reversible cause such as choking, a displaced or blocked tracheal
tube, or blocked tracheostomy tube. In such situations CPR would be appropriate, while the reversible
cause is treated, unless the person has made a valid refusal of the intervention in these
circumstances. To avoid misunderstandings it may be helpful, whenever possible, to make clear to
patients and those close to patients that DNACPR decisions usually apply only in the context of an
expected death or a sudden cardiorespiratory arrest and not to an unforeseen event such as a blocked
airway”.

Ligature Cutters

What is a ligature?

It is anything that can be used to make a loop or a noose with the intention of deliberate or
accidental self-harm by hanging or asphyxiation e.g.

• Light/pull cords • Bedding (intact or torn into strips) • Clothing • Shoe laces • Electric cords/pull
bells/phone chargers • Plastic bags • Guitar strings • Plastic apron

Why are they necessary?

A requirement for anti-ligature cut down tools evolved from a PSI issued in June 2006 that
mandated the need for all uniformed staff within closed or semi open establishments to have
access to anti-ligature cut-down tools. Anti-ligature tools are a national requirement underpinned
by PSO 2700 (Suicide Prevention and Self Harm Management).

What can the ligature cutter be used for?

• Strapping • Bubble wrap • Tape • Rope • Some wires • Shrink wrap • Plastic ties

Ligature Cutting equipment

Must be available in all clinical areas • Stored on the Resus Trolley (bottom drawer) or Grab Bag •
They are replaceable via the centralised resuscitation store (Winter Ward OR call 8562)
What to do on finding someone who has used a ligature

GET HELP – pull the emergency buzzer dial 2222/9999 (state medical emergency and your exact
location) • Request ligature cutters from the Resus trolley • SUPPORT the persons weight (if safe to
do so) • As soon as possible release the tension on the ligature • Keep the body weight supported
or the tension off the ligature until cut • If the individual is unresponsive then attempt resuscitation
in line with Level 2 training.

References:

Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of
adult in-hospital cardiac arrest. Crit Care Med 2010;38:101-8

Resuscitation Council (UK) Adult in hospital Guidelines 2015

National Confidential Enquiry Patient Outcome and Deaths (NCEPOD) ‘Time to Intervene’ - A
review of patients undergoing cardiopulmonary resuscitation as a result of an in-hospital
cardiorespiratory arrest. 2012

Decisions relating to cardiopulmonary resuscitation – The British Medical Association (BMA),

Resuscitation Council UK, and the Royal College of Nursing (RCN) have issued updated guidance
regarding anticipatory decisions about whether or not to attempt resuscitation in a person when
their heart stops or they stop breathing.

Ligature cutter guidance – NHS England (Ligature and ligature point risk assessment tools and
policies)