In order to respond urgently and yet retain thoroughness, effective emergency management demands a systematic, prioritised approach. Care can be structured into the following phases.
Primary assessment
This consists of a rapid “physiological” examination to identify immediately life-threatening emergencies. It should be completed in less than a minute. It is prioritised as shown in the box.
From the respiratory viewpoint, do the following:
• Look, listen and feel for airway obstruction, respiratory arrest, depression, or distress.
• Assess the effort of breathing.
• Count the respiratory rate.
• Listen for stridor and/or wheeze.
• Auscultate for breath sounds.
• Assess skin colour.
If a significant problem is identified, management should be started immediately.
After appropriate interventions have been performed, primary assessment can be resumed or repeated.
Resuscitation
During this phase, life-saving interventions are performed. These include such procedures as intubation, ventilation, cannulation, and fluid resuscitation. At the same time, oxygen is provided, vital signs are recorded, and essential monitoring is established.
From the respiratory viewpoint, do the following:
ADVANCED SUPPORT OF THE AIRWAY AND VENTILATION
Airway Breathing Circulation
Disability (nervous system) Exposure
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• Consider jaw- and neck-positioning manoeuvres.
• Administer oxygen.
• Consider suction and foreign body removal.
• Consider mask ventilation, and pharyngeal or tracheal intubation.
• Consider chest decompression.
• Consider needle cricothyroidotomy, if unable to oxygenate by alternative means.
• Initiate pulse oximetry and other monitoring at this time.
Secondary assessment
This consists of a thorough physical examination, together with appropriate invest-igations. Conventionally, examination is from head to toe, and represents an “anatomical”
assessment. Before embarking on this phase, it is important that the resuscitative measures are fully under way.
From the respiratory viewpoint, do the following:
• Perform a detailed examination of the airway, neck, and chest.
• Identify any swelling, bruising, or wounds.
• Re-examine for symmetry of breath sounds and movement.
• Do not forget to inspect and listen to the back of the chest.
Emergency treatment
All other urgent interventions are included in this phase.
If at any time the patient deteriorates, care returns to the primary assessment, and recycles through the system.
In the very sick or critically injured child, the primary assessment and resuscitation phases become integrally bound together. As a problem is identified, care shifts to the relevant intervention, before returning to the next part of the primary assessment. The simplified airway and breathing management protocol illustrates how this integration can be achieved.
ADVANCED SUPPORT OF THE AIRWAY AND VENTILATION
Airway and breathing management protocol
Begin primary assessment. . . . Assess the airway . . .
If evidence of blunt trauma
then protect the cervical spine from the outset
If any evidence of obstruction and altered consciousness then optimise the head and neck positioning
and administer oxygen
and consider chin lift, jaw thrust, suction, foreign body removal If obstruction persists
then consider oro- or nasopharyngeal airway If obstruction still persists
then consider intubation and check the position of the tracheal tube If intubation impossible or unsuccessful
then consider cricothyroidotomy
ADVANCED SUPPORT OF THE AIRWAY AND VENTILATION
If stridor but relatively alert
then allow self-ventilation whenever possible
and encourage oxygen but do not force to wear mask and do not force to lie down
and do not inspect the airway (except as a definitive procedure under controlled conditions) and assemble expert team and equipment
Assess the breathing . . .
If respiratory arrest or depression
then administer oxygen by bag-valve-mask
and consider intubation and check the position of the tracheal tube If sedative or paralysing drugs possible
then administer reversal agent If respiratory distress or tachypnoea
then administer oxygen If lateralised ventilatory deficit
then consider haemopneumothorax and inhaled foreign body and also consider lung consolidation, collapse, or pleural effusion If chest injury
then consider tension pneumothorax and massive haemothorax and consider flail segment and open pneumothorax
If evidence of tension pneumothorax
then perform immediate needle decompression and follow up with chest drain
If evidence of massive haemothorax then consider simultaneous chest drain and blood volume replacement
If wheeze or crackles
then consider asthma, bronchiolitis, pneumonia, and heart failure but remember inhaled foreign body as a possible cause
If evidence of acute severe asthma
then consider inhaled or intravenous ß-agonists and consider intravenous steroids and aminophylline Continue the primary assessment . . . .
. . . . proceed to assess the circulation and nervous system If deteriorating from whatever cause
then reassess the airway and breathing and be prepared to intubate and ventilate
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6
The management of cardiac arrest
INTRODUCTION
Cardiac arrest has occurred when there are no palpable central pulses. Before any specific therapy is started effective basic life support must be established as described in Chapter 4.
CHAP TITLE
Stimulate and assess response
Open airway
Check breathing
Two effective breaths
Check pulse
Compress chest and ventilate
Assess rhythm VF/VT
algorithm
Non VF/VT Asystole or
PEA algorithm
Figure 6.1. Initial approach to cardiac arrest
Three cardiac arrest rhythms will be discussed in this chapter:
1. Asystole.
2. Ventricular fibrillation and pulseless ventricular tachycardia.
3. Pulseless electrical activity (including electro mechanical dissociation).
The initial approach to cardiac arrest is shown in Figure 6.1 but for the purpose of teaching the arrest rhythms will be discussed separately.