Page 680 - ACCCN's Critical Care Nursing

Resuscitation 657

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Early warning system calling criteria are widely displayed more anterior and acutely angled. The airway of an
around the hospital and the RRT is activated in the same infant is also more cartilaginous and can be easily
manner as the cardiac arrest team, ultimately resuscitat- occluded when the neck is hyperextended; in addition,
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ing patients earlier. Recent reviews of the literature and the large tongue can easily fall back to obstruct the
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meta-analyses show that in clinically unstable patients, pharynx. Hence, the head of an infant should be main-
early access – including early recognition and interven- tained in the neutral position, whereas a child aged 1–8
tion by a MET/rapid response system – can reduce the will require the ‘sniffing position’ with varying degrees
incidence of cardiac arrests outside ICUs, however there according to age. The chin-lift and head-tilt manoeuvres
are inconsistent findings regarding their impact on inten- may be used in children to obtain the appropriate amount
sive care admission rates and lowering hospital mortality of positioning for age. Jaw thrust may be used if head-tilt/
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rates. 35-37 To further facilitate earlier activation of the RRTs chin-lift is contraindicated. Do not use the finger sweep
family and patients have been provided with a means to to clear the airway of an infant, as this may result in
activate the team on a patient’s behalf. 38 damage to the delicate palatal tissues and cause bleeding,
which can worsen the situation. Use of finger sweep can
BASIC LIFE SUPPORT force foreign bodies further down into the airway.
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When a patient is identified as in potential or actual Suction is more useful for removing vomitus and
arrest, a primary and secondary survey should be con- secretions.
ducted in the DRSABCD sequence: 39
l Danger. Check for danger (hazards or risks or safety)
l Responsive. Check for response (if responsive/
unconscious) Practice tip
l Send. Send for help Infants are obligatory nose-breathers, so it is always important
l Airway. Open the airway. Airway assessment is under- to clear the nostrils.
taken to establish a patent airway while maintaining
cervical spine support (if injury is suspected)
l Breathing. Check breathing. Breathing includes the
assessment and establishment of breathing, noting Breathing
rate, pattern, chest movement and tissue oxygenation
l CPR. Start CPR. Give 30 chest compressions (almost To assess for the presence of breathing, look, listen and
two compressions/second) followed by two breaths. feel for breath sounds for no more than 10 seconds. If the
l Defibrillation. Attach an automated external defibril- person is unresponsive with absent or abnormal breath-
lator as soon as available and follow its prompts. ing, call for help and compressions should be com-
menced immediately. Agonal gasps are not to be
Continue CPR until responsiveness and normal breath- considered as normal breathing. Typically, the arterial
ing return. Ideally, these interventions are performed blood will remain saturated with oxygen for several
simultaneously or in rapid sequence and will take no minutes following the cardiac arrest and as cerebral and
longer than 60–90 seconds to complete. This systematic myocardial cell oxygenation is limited more by the
approach correlates closely with the principles of basic absence of cardiac output as opposed to the reduced
life support (BLS), in that where a life-threatening abnor- PaO 2 , effective compressions are more important than
mality is detected, immediate intervention is required rescue breaths. 27
before further assessment (see Figure 24.2).
Airway CPR
Recognition of airway obstruction includes listening for Individuals should commence cardiac compressions if
inspiratory (stridor), expiratory or grunting noises. The the victim is unconscious, unresponsive, not moving
work of breathing can be assessed by the respiratory rate, and not breathing normally. Where possible, change
intercostals, subcostal or sternal recession, use of acces- the person delivering the compressions every two
sory muscles, tracheal tug or flaring of the alae nasi. minutes. Pulse check by lay rescuers and health profes-
Nasal flaring is especially evident in infants with respira- sionals in BLS is not recommended. Assessment of effec-
tory distress. Noisy breathing is obstructed breathing, tive chest compression by healthcare professionals may
but the volume of the noise is not an indicator of the be made by continuous end tidal CO 2 (ETCO 2 ) moni-
severity of respiratory failure. Should obstruction to air toring. For CPR to be effective the patient should be
flow be detected, then the airway should be opened flat, supine and on a firm surface. The chest should be
using three manoeuvres: the head-tilt, chin-lift and jaw compressed in the midline over the lower half of the
thrust. The ARC recommends assessing a person’s airway sternum, which equates to the ‘centre of the chest’, at
without turning them onto the side unless the airway is a depth of more than 5 cm (in adults) and at a rate
obstructed with fluid (vomit or blood) or submersion of 100 compressions per minute for adults, infants and
injuries. 39 children, with the rate rising to 120/min for the
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newborn. CPR should be initiated when the heart rate
The airway of the infant differs from that of the older is 60 beats/min for the neonate, infant and the small
child or adult in that the infant has a large head and child and 40 beats/min for the large child. Performed
tongue, small mouth, and the larynx is narrower, shorter, correctly, external cardiac compressions (ECC) can