Transcript Shock - Hamilton Health Sciences

CARDIAC
ARREST
MANAGEMENT
Prepared by:
South West Education
Committee
SWEC MEMBERS
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Cambridge – Lori Smith
Grey Bruce – Andy Whittemore
Hamilton – Ken Stuebing, Tim Dodd
Lambton – Judy Potter
London – Tre Rodriguez
Niagara – Greg Soto
Windsor – Cathie Hedges
RTN – Peter Deryk
“The Power of 7”
Base Hospital Programs
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Goal: One single certification for all of
SouthWestern Ontario by Fall 2005!!
Recert process same across SW this year.
Notice, all paperwork will say SWEC.
Some information may not be specific to
Hamilton BH or Services in our area.
Pictures for data base in one of the stations
COURSE OVERVIEW
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Chain of Survival
Review of the conduction system
Cardiac Monitoring
Protocols
Special circumstances
CPR & SAED reminders
CHAIN OF SURVIVAL
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Early Access (911)
– Someone must realize there is an emergency
and act quickly to initiate the EMS.
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Early CPR
– A trained individual starts CPR at once to help
maintain a viable heart until help arrives.
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Early Defibrillation
– First responder arrives with the training and
equipment to defibrillate the heart. As time
increases chances for survival decrease.
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Early Advanced Life Support
– ALS within minutes increases the chance of
survival.
CHAIN OF SURVIVAL
CAUSES OF CARDIAC ARREST
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# 1 Cause = Conduction Disturbances
# 2 Cause = AMI / ischemia
Other Causes include:
Traumatic
Hypoxia / Respiratory
Metabolic
CARDIAC
MONITORING
NORMAL ELECTRICAL
CONDUCTION
RHYTHM INTERPRETATION
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5 Steps Approach
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Step 1: What is the rate?
– brady < 60 bpm, tachy > 100 bpm
Step 2: Is the rhythm regular or irregular?
Step 3: Is there a P wave - is it normal?
– are P waves associated with each QRS?
Step 4: P-R Interval/relationship?
– PR interval (normal 0.12 - 0.20 sec)
Step 5: Normal QRS complex?
– Normal QRS complex < 0.12sec
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LETHAL DYSRHYTHMIAS
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There are four major life threatening
Pulseless Dysrhythmias:
– NON SHOCKABLE RHYTHMS
1) Asystole - Flat Line
2) PEA - Pulseless Electrical Activity
– SHOCKABLE RHYTHMS
3) VF - Ventricular Fibrillation
4) VT - Pulseless Ventricular Tachycardia
Asystole
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No heart electrical
activity
No excitation of the
heart muscle
No Cardiac output
Usually the terminal
rhythm of a an
unsuccessful cardiac
resuscitation
Normal Sinus Rhythm
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Usually represented
by a normal
functioning electrical
conduction system
Heart Rate average is
72 beats / minute
Pulseless Electrical Activity
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A rhythm is determined to be PEA when
your pulseless patient presents with a
rhythm which you would normally expect to
produce some form of cardiac output.
DO NOT assume that since there is a
rhythm on the screen that the patient has a
pulse!!
Ventricular Tachycardia
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Stimulus is originating from
the ventricles
Loss of atrial kick may lead to
Inadequate ventricular filling
couple with the increased
rate causes:
Poor cardiac output, may or
may not produce a pulse
Most SAED units will only
shock if heart-rate is > 180
B.P.M.
Ventricular Fibrillation
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No organized
excitation of heart
muscle
Heart is physically
quivering compared
to contracting
(seizing)
No Cardiac Output
Defibrillation and Time
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Approximately 50% survival after 5 minutes
Survival reduced by 7% to 10% per minute
(with no CPR)
Rapid defibrillation is key
CPR prolongs VF, slows deterioration
100
80
60
Survival
40
20
0
1
3
6
10
Minutes: collapse to 1st shock
Defibrillation
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Defibrillation applies electrical energy to
the heart muscle.
This energy causes depolarization of all
heart cells at the same time.
Therefore all repolarize at the same time.
We hope this starts an organized
perfusing rhythm
We only apply a shock, via the S.A.E.D, to
the heart of a VSA patient
OTHER RHYTHMS
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~ 90 bpm
Step 1: Rate?
Irregular
Step 2: Regular or irregular?
Step 3: Is the P wave normal? P waves normal,
extra beats have
associated P wave
Step 4: P-R Interval/relationship? 0.12 - 0.20 sec
Yes
Step 5: QRS complex < 0.12 sec?
PACs
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Step 1: Rate? Variable < 100
Step 2: Regular or irregular? Irregularly Irregular
Step 3: Is the P wave normal? No P waves
Step 4: P-R Interval/relationship? None
Step 5: QRS complex < 0.12 sec? Yes
Atrial Fibrillation
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Step 1: Rate? Variable ~ 100
Step 2: Regular or irregular? Irregular
Step 3: Is the P wave normal? P waves Associated
with most QRS
Step 4: P-R Interval/relationship? Yes - not all
Step 5: QRS complex < 0.12 sec? Yes - not all
PVC - unifocal
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Step 1: Rate? 150
Step 2: Regular or irregular? Regular
Step 3: Is the P wave normal? No P waves
Step 4: P-R Interval/relationship? N/A
Step 5: QRS complex < 0.12 sec? Yes
Accelerated Juntional
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Step 1: Rate? 40-70
Step 2: Regular or irregular? Irregular
Step 3: Is the P wave normal? P waves regular
Not always with a
QRS
Step 4: P-R Interval/relationship? longer each beat
Step 5: QRS complex < 0.12 sec? Yes
Second Degree AV Block Type 1
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Step 1: Rate? < 30 bpm
Step 2: Regular or irregular? Regular
Step 3: Is the P wave normal? P waves normal,
not with QRS
Step 4: P-R Interval/relationship? None
Step 5: QRS complex < 0.12 sec? Yes
3rd degree Heart Block
TAKE HOME POINTS
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Use the 5 step approach.
– Remember where the lead is and what it
should look like. (lead placement can effect
what you see)
– Use it or lose it.
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Remember normal electrical conduction
path and rates.
The monitor is a voltage gauge not a
pressure gauge - check the Pulse!
PROTOCOLS
MEDICAL PROTOCOL
COMPLETION
Medical Protocol will
END ONE OF THREE WAYS
9 SHOCKS TOTAL
3 NO SHOCKS
IN A ROW
RETURN OF A PULSE
SHOCK VERSES NSI
Adult V-Fib, Pulseless V-Tach
Asystole, PEA
Protocol
No Shock Indicated (PEA/Asystole)
Shock (VF/VT)
Pulse Check
1 Full Minute of CPR
Reanalyze
Wait 10 Seconds
Reanalyze and Shock Again
Wait 10 Seconds
Reanalyze and Shock Again
2 Consecutive NSI on scene
Prepare To Transport
Pulse Check
1 Full Minute of CPR
Reanalyze
3 NSI IN A ROW
No Shock Protocol is complete
Transport
Maximum 9 Shocks Unless ROSC
Transport
GUIDELINES
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10 second pause between shock and
subsequent analysis to prevent
accidentally missing a shockable
rhythm
If Protocol ends with
3 “No Shocks” in a row
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If you receive:
• 3 “Check Patient” messages in a
• 2 minute time frame
• STOP the vehicle and Analyze
• Result in:
–1 no shock
–1 stack of 3 shocks
3 2 1 GO
DEFIBRILLATOR ERRORS
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If the defibrillator fails during a call,
complete the following actions.
– Check the adherence of the pads;change
pads if required
– Check the cables and connections
– Change the battery
– ALL these actions should take no longer
than 60 seconds
– If you cannot solve the problem, abandon
the protocol and continue with BCLS only
When is the Defibrillator not
attached to a VSA patient?
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Age < 8 years old
Penetrating trauma
Obviously Dead
Criteria for Obviously Dead
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Physical Findings:
– VSA
– Decapitation
– Transection
– Decomposition (Consider time frame of
arrest)
• lividity / mottling / putrefaction
– Gross rigor mortis
– Gross Charring
– Gross cranial or visceral contents.
SPECIAL SITUATIONS
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Vomiting patient during charge up
Pacemakers
Automatic Implantable Cardioverter
Defibrillator(AICD)
DNR orders
– unless the patient falls under the MOH
Interfacility DNR directive, DNR orders will
NOT be recognised in the field
SPECIAL SITUATIONS
Pacemaker or AICD
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Avoid placing pads
directly over.
Apply pads at least 1
to 2 inches away.
Follow all protocols.
SPECIAL SITUATIONS
Wet patient
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Victim lying in
water.
Once on land, dry
patient before
applying SAED.
Remember, let the
rescue experts do
the rescuing.
SPECIAL SITUATIONS
Medication patches
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Transdermal
medication patches:
blocking pad
placement?
While wearing
gloves, remove
patch and wipe area
with alcohol wipe
and dry.
Place AED pads and
follow protocol.
SPECIAL SITUATIONS
Paediatric Arrest
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Age: victim <8
years old?
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CPR only.
SPECIAL SITUATIONS
Hypothermia
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Hypothermia
Definition: core body
temperature <35°C
Causes: exposure to
extreme cold
( damp)
HYPOTHERMIA
Clinical Signs and Symptoms
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Lethargystuporcoma
Muscle rigidity, cessation
of shivering
Dilated pupils,
nonreactive pupils
bradycardia, slow AF, VF,
or asystole
HYPOTHERMIA
Initial Therapy
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Remove wet garments
Protect against heat loss and wind chill
(use blankets and insulating equipment)
Maintain horizontal position
Avoid rough movement and excess activity
Gradually re-warm
High flow oxygen via NRB
Monitor cardiac rhythm
HYPOTHERMIA
Cardiac Arrest
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1 NO SHOCK
ANYWHERE
– Check pulse
Pulse
No
– CPR concurrent
with transport
3 SHOCKS TOTAL
– Shock #1
– Shock #2
– Shock #3
– Check Pulse
No Pulse
– CPR transport
HYPOTHERMIA
General Approach
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Maintain horizontal position
– Vertical position may compromise cerebral
and systemic perfusion
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Avoid rough movements and activities
Handle victim gently during CPR, BVM
ventilation and transport
SPECIAL SITUATIONS
Traumatic Cardiac Arrest
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This protocol does not include VSA
patients as a result of penetrating trauma.
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After adequate airway and c-spine
management, apply AED and proceed with
the following algorithm if Blunt Trauma is
the suspected cause of the arrest.
Blunt Trauma Protocol
1 NO SHOCK
ANYWHERE
– Check pulse
– No Pulse CPR
concurrent with
BTLS care
– Transport
3 SHOCKS TOTAL
– Shock #1
– Shock #2
– Shock #3
– Check pulse
– No Pulse CPR
concurrent with
BTLS care
– Transport
Traumatic Cardiac Arrest
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If cardiac arrest is
caused by
penetrating trauma
Package the patient
and transport
immediately without
initiating SAED
protocols.
Airway Obstruction
1 NO SHOCK
ANYWHERE
– Check pulse
– No Pulse
– CPR
– Transport
3 SHOCKS TOTAL
– Shock #1
– Shock #2
– Shock #3
– Check pulse
– No Pulse
– CPR
– Transport
Ventilate - Reposition - Ventilate
Perform visualisation of airway q 15 compressions
If cleared start protocol minus shocks delivered
TAKE HOME POINTS
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Complete one minute of CPR
Initiate the appropriate protocol
Complete the appropriate protocol
Keep track of how many “No Shock
Indicated” IN A ROW
CARDIOPULMONARY
RESUSCITATIION
-CPR-
ROLE OF CPR
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Integral component
of AED use
CPR circulates
oxygen...
– Prolongs heart’s
electrical activity
– Minimizes brain
damage
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...but defibrillation is
the definitive
treatment
ADULT
Compression / Ventilation
Ratios
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1 Rescuer:15:2
2 Rescuer: 15:2
– Once airway is protected (ie. Intubated)
5:1 Ratio - pause compressions for
ventilations to allow time for diffusion
of gases!
COMPRESSIONS RATES
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Adult rate: 80-100 per minute
Child rate: 100 per minute
Infant rate: > 100 per minute
Two Thumb method used for
infant compressions
QUESTIONS?