Week 9 Lecture Notes: Clinical Deterioration and BLS Notes

Chest Pain - Biological Differences

  • Classic cardiac pain symptoms:

    • Central chest pain or pressure

    • Radiation of pain

    • Shortness of breath

    • Sweating (diaphoresis)

    • Nausea or vomiting

    • Light-headedness or dizziness

  • Typical Presentation in Men:

    • Central or left-sided chest pressure or tightness

    • Radiating pain to left arm, jaw, or back

    • Diaphoresis, shortness of breath

  • Atypical Presentation in Women:

    • Fatigue

    • Shortness of breath

    • Nausea or vomiting

    • Dizziness or light-headedness

    • Pain in the neck, jaw, or back

  • Transgender Individuals:

    • Trans women (assigned male at birth) on oestrogen may have slightly elevated thromboembolic risk.

    • Trans men (assigned female at birth) on testosterone may have increased risk of hypertension or lipid changes.

Basic Life Support (BLS)

  • BLS involves:

    • Early recognition of critical signs

    • Activation of emergency services

    • Effective cardiopulmonary resuscitation (CPR)

    • Use of an Automated External Defibrillator (AED)

  • Chain of Survival:

    1. Early recognition and call for help

    2. Early CPR to maintain circulation

    3. Early defibrillation to restore heart rhythm

    4. Post-resuscitation care to stabilise and support recovery

CPR Techniques

  • Hand Positioning: Place the heel of one hand in the centre of the chest, on the lower half of the sternum (breastbone). Place the other hand on top, interlocking your fingers.

  • Compression Depth and Rate:

    • Compress the chest at least 5 cm (but no more than 6 cm).

    • Perform compressions at a rate of 100 to 120 per minute.

  • Bag and Mask Ventilation in CPR:

    • Give 2 ventilations after every 30 compressions.

    • Each breath should last about 1 second and cause visible chest rise.

Special Cases in CPR

  • Drowning Victims: Start with 5 initial rescue breaths before beginning chest compressions.

  • Trauma Cases: Use jaw thrust instead of head tilt–chin lift to open the airway.

  • Pregnant Individuals: Manually displace the uterus to the left side. Pad under the right hip to tilt the woman ~15–30° left.

Paediatric Basic Life Support (PBLS)

  • Main causes of Arrests in Children:

    • Hypoxia

    • Hypotension

    • Acidosis

  • CPR rate for all ages 100–120 bpm

  • Ratio for CPR is 2 breaths: 15 compressions

  • Compress the sternum 1/3 the depth of the chest

  • Key anatomical differences:

    • Smaller airway diameter

    • Larger tongue and adenoids

    • Higher and more anterior larynx

    • Shorter trachea

    • Larger occiput (back of head)

Normal and Common Cardiac Rhythms (Non-Emergent)

  • Normal Sinus Rhythm (NSR)

    • Rate: 60–100 bpm

    • Rhythm: Regular

    • P waves: Present, upright, one before each QRS

    • PR interval: 0.12–0.20 seconds

    • QRS complex: < 0.12 seconds

  • Sinus Bradycardia

    • Rate: < 60 bpm

    • Rhythm: Regular

    • P waves: Normal and precede each QRS

    • PR interval/QRS: Normal

  • Sinus Tachycardia

    • Rate: > 100 bpm (usually 100–160 bpm)

    • Rhythm: Regular

    • P waves: Present and precede QRS

    • PR interval/QRS: Normal

  • Atrial Fibrillation

    • Rate: 300–600 bpm (not directly visible on ECG)

    • Rhythm: Irregularly irregular

    • P waves: Absent – replaced by erratic fibrillatory waves

    • PR interval: Not measurable

    • QRS complex: Usually normal in width

Shockable Rhythms

  • Ventricular Fibrillation (VF):

    • ECG Appearance: Irregular, no identifiable P waves, QRS complexes, or T waves. —> No identifiable P or T waves

    • Think: heartbeat has no clear rhythm, ventricles cant pump blood properly

  • Pulseless Ventricular Tachycardia (VT):

    • ECG Appearance: Wide, regular QRS complexes at a fast rate; no pulse is present.

    • Heart rate above 100 beats per minute, originating in the ventricles.

    • Think: heartbeat is so fast that its not pumping blood effectively.

Non-Shockable Rhythms

  • Asystole:

    • ECG Appearance: Flat line or nearly flat with no electrical output.

    • Think: literally a flatline on the heart monitor

  • Pulseless Electrical Activity (PEA):

    • ECG Appearance: Can appear as any rhythm (sinus, bradycardia, tachycardia) without a pulse.

    • Think: no actual heartbeat and no pulse

Code Blue

  • A Code Blue is an emergency situation where a patient is experiencing a life- threatening condition, typically cardiac or respiratory arrest, requiring immediate resuscitation efforts.

  • Roles:

    • Permitted: Administering medication.

    • Not Permitted: Performing compressions, Operating a defibrillator.

The Deteriorating Patient

  • A – Airway Check if the airway is clear or obstructed.

  • B – Breathing Assess respiratory rate, depth, and effort.

  • C – Circulation Monitor heart rate, blood pressure, capillary refill, and peripheral perfusion.

  • D – Disability Assess level of consciousness (AVPU or GCS), pupil size/reactivity, and blood glucose levels.

  • E – Exposure Fully expose the patient to examine for rashes, wounds, swelling, or infection signs.

  • F – Fluids Review input/output, fluid balance charts, and signs of dehydration or overload.

  • G – Glucose (or \"Give comfort\") Check blood glucose again if not already done.

  • Fluid Resuscitation.

    • Key signs for initiating fluids include systolic BP < 85 mmHg, a rapidly falling BP, or unexplained changes in mental state

    • Help identify and treat reversible causes of cardiac arrest

  • The 5 H’s

    • Hypovolemia → Treat with Fluids or blood

    • Hypoxia → Ensure airway is open and oxygen given

    • Hydrogen ion → Check blood gases, might need bicarbonate

    • Hypo-/Hyperkalemia → ECG changes help, treat accordingly

    • Hypothermia → Warm the patient gradually

  • The 5 T’s

    • Tension pneumothorax → Look for unequal chest rise, tracheal deviation; treat with needle decompression

    • Tamponade → Look for muffled heart sounds, distended neck veins; treat with pericardiocentesis

    • Toxins → Clues from history, pupils, etc.; treat specific toxin

    • Thrombosis - Pulmonary → Sudden collapse, chest pain, right heart strain; may need thrombolytics

    • Thrombosis - Coronary → Often the cause of sudden arrest; treat with reprofusion

Critical Incident Debriefing

  • Critical incidents are unexpected or unplanned events that occur within a workplace or affect individual employees or the workplace as a whole.

  • Timely debriefing in health care is essential as it enhances the nurses and other team members’ ability to deal with such events, as well as to challenge what happened during the shift, especially if there has been an incident involving serious injury or death.

The Emergency - Healthcare Law

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  • Valid consent is generally needed before medical treatment can be provided to a competent adult.

  • Healthcare Law and Emergency Treatment Consent is not required in an emergency.

  • Good Samaritan Laws Good Samaritan legislation in Australia can protect the person rendering assistance from personal civil liability if they act in \"good faith\"