Transcript SAED Recert
SAED Recertification Prepared by: Program Co-ordinator: Tim Dodd Program Manager: Ken Stuebing Hamilton Health Sciences Base Hospital Program Clinical Staff Medical Director – Dr. Welsford Program Managers – Steve Dewar – Ken Stuebing Program Co-ordinator – Tim Dodd Course Overview Chain of Survival Pathophysiology Review – Respiratory – Circulatory Cardiac Monitoring Protocols Special Circumstances CPR & SAED Reminders Chain of Survival Early Access (911) – Someone must realize there is an emergency an act quickly to initiate the EMS. Early CPR – A trained individual starts CPR at once to help maintain a viable heart until help arrives. Early Defibrillation – The first responder arrives with the training and equipment to defibrillate the heart. As time increases chances for survival decrease. Early Advanced Life Support – ALS delivered within minutes also increases the chance for survival. Chain of Survival RESPIRATORY SYSTEM Respiratory System UPPER RESPIRATORY TRACT: Warms, Filters & Humidifies »Nose / Mouth »Pharynx »Voice box LOWER RESPIRATORY TRACT: Air Exchange »Trachea »Bronchi »Bronchioles »Alveoli LUNGS Air travels down the trachea until it enters alveoli. GAS EXCHANGE ONLY HAPPENS IN THE ALVEOLI! (STOP COMPRESSION & give slow, gentle, deep breaths) WHERE THE CIRCULATORY SYSTEM AND RESPIRATORY SYSTEM JOIN How Air Enters The Lungs INSPIRATION: - Diaphram contracts. (drops) - Intercostal muscles contract. (ribs go up & out) - Creates a negative pressure in the lungs (alveoli) in comparison to the atmosphere. - Atmospheric air rushes in to fill void. - Gas exchange occurs by diffusion. EXPIRATION: - Muscles relax Raises Pressure - Forces Air Out Oxygen Saturation The paramedic will be able to initiate pulse oximetry monitoring and monitor the effectiveness of the patient’s respiratory status and treat to ensure that adequate and effective oxygenation is maintained. How can the monitor be fooled? Factors Affecting Oximetry Strong ambient light sources Poor circulation Cardiac arrest Hypothermia Shock Anemia CO poisoning Nail polish Oxyhemaglobin Disassociation Curve Take Home Points Oxygen saturation measurement may be utilized to monitor a patient’s condition but should not be used to make decisions to restrict oxygen delivery when the patient appears ill or has a condition that may require supplemental oxygen. Remember to treat the patient not the monitor. If the patient appears ill and you feel oxygen will benefit the patient, give oxygen! - it grows on trees. Circulatory System Expectation of the PCP Knowledge of Circulatory System components (Pipes, Pump & Fluid) Knowledge of: heart conduction and it’s relation to specific ECG waves as well as how these waves are related mechanically to the heart muscle Specific rhythms – NSR, VF, VT, PVC’s, Asystole, PEA, Artifact, Paced Beats. The Heart (pump) Echocardiography Heart Valve Replacement Blood Vessels - Pipes Arteries: – carry blood away from the heart. – thick muscular walls. (3 layers) Veins: – bring blood back to the heart. – thinner walls. (3 layers) – have valves to stop back flow. – Is the spare blood reservoir. Capillaries: 1 cell thick. (tissue paper) – join arteries and veins together. – wraps cell & alveoli. – where diffusion takes place. Blood Vessel Diseases Arteriosclerosis – host of diseases which cause thickening & hardening of arterial walls. – Plaque formation, calcium build up & occlusion of small branching blood vessels. – Clots can dislodge and occlude smaller vessels. Aneurysm – weakened area in the wall of an artery will tend to balloon out & may burst. Atherosclerosis Angiogram Angioplasty Blood - Fluid Consists of: – Red Blood Cells (RBC): which carries the oxygen from the lungs to the cells and carbon dioxide from the cells to the lungs. – White Blood Cells (WBC): which is part of our immune system to fight against infection. Blood - Fluid Consists of: – Platelets: form the base for clots. – Plasma: water component which carries all these components. – Clotting Factors: 12 factors which work in a complicated cascade to form a clot. All 12 are needed and stored blood does not cave all 12. Any factor affecting the ability of blood to carry oxygen to the heart and brain can cause tissue damage. M.I. – Myocardial Infarction muscle / heart death M.I. = death of the heart muscle Death of the muscle is due to starvation of oxygen & nutrients. Other causes . . . – disruption of blood supply – blockage of a coronary artery, aneurysm – asphyxiation – e.t.c. Angina Pectoris Angina pain is caused by an inadequate oxygen supply to heart. Supply and demand – spasm, inability to open. • stress, cold, MVO2. Pain is similar to that of an MI – is usually relieved by: rest, nitroglycerin, oxygen STROKE or CVA CVA - Is very similar to an MI, - irreversible damage is done to the brain by lack of blood supply. Tissue death results from starvation of oxygen and nutrients. Disruption of blood supply: – blockage of a cerebral artery, aneurysm – asphyxiation, strangulation – heart attack, e.t.c. STROKE Oxygen and nutrients are supplied to the brain by two arterial systems – carotid - left and right – vertebral - left and right Blood is returned from the brain via two large veins (left and right jugulars) Brain receives 20% of CO A Stroke occurs when the brain is deprived of oxygen Take Home Points Stop compressions and allow time for diffusion of gasses. Remember not all cardiac pain is the same. If you are at risk for heart attacks you are at risk for stroke – a new stroke campaign is about to start in our area Cardiac Monitoring Normal Electrical Conduction Electrocardiogram Dysrhythmia Interpretation: 5 Steps Approach Step 1: What is the rate? – bradycardia < 60 bpm – tachycardia > 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 .12 - .20 sec) Step 5: Normal QRS complex? – Normal QRS complex < .12sec Lethal Dysrhythmias There are four major life threatening Pulseless Dysrhythmias: – NON SHOCKABLE RYTHMS 1) Asystole - Flat Line 2) PEA - Pulseless Electrical Activity – SHOCKABLE RHYTHMS 3) VF - Ventricular Fibrillation 4) VT - Pulseless Ventricular Tachycardia Asystole No heart electrical activity No excitation of the heart muscle No Cardiac output Normal Sinus Rhythm Regular heart electrical conduction Heart Rate avg. 72 beats / minute Normal Cardiac Output Pulseless Electrical Activity PEA is an electrical disturbance in which an electrical stimulus is being generated but the muscle is NOT reacting. DO NOT assume that since there is a rhythm on the screen that the patient has a pulse!! Ventricular Tachycardia Stimulus is originating from the ventricles Heart (pump) is cavitating by beating too fast Poor cardiac output, but may produce a pulse The SAED will shock V.T. with-in preset limits. Ventricular Fibrillation No organized excitation of heart muscle Heart is physically quivering compared to contracting (seizing) No Cardiac Output Chances of survival decline ~ 7 to 10 % for every minute that defibrillation is delayed. Defibrillation 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 ~ 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 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 A = 300 bpm Step 1: Rate? V = 75 - 150 bpm Step 2: Regular or irregular? Irregular -Variable Step 3: Is the P wave normal? Sawtooth P waves March through QRS Step 4: P-R Interval/relationship? NA Step 5: QRS complex < 0.12 sec? Yes Atrial Flutter Variable ~ 100 Step 1: Rate? 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 - but not all PVC - unifocal Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal? 150 Regular No P waves Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec? Accelerated Junctional NA Yes Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal? 40-70 Irregular 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 < 30 bpm Step 1: Rate? Step 2: Regular or irregular? Regular Step 3: Is the P wave normal? P waves normal, not associated with all QRS Step 4: P-R Interval/relationship? None Step 5: QRS complex < 0.12 sec? Yes 3rd degree Heart Block Cardiac Monitoring and Lead Placement 3 & 5 Lead Electrode Placement RA (White): Place near right mid-clavicular line, directly below the clavicle. LA (Black): Place near left midclavicular line, directly below the clavicle V (Brown): Place to Right of sternum at the 4th intercostal Space RL (Green): Place between 6th and 7th intercostal Spac on right mid-clavicular line LL (Red):Place between 6th & 7th intercostal Space on left midclavicular line BIPOLAR Leads or LIMB Leads (I,II,III) BiPolar Leads I, II &III Lead I Lead III Take Home Points 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. 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 Guidelines 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 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 • Transport Hypothermia Cardiac Arrest 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 Blunt Trauma Protocol This protocol does not include VSA patients as a result of penetrating trauma. 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 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 Pulse Checks The defibrillator/monitor is a voltage meter not a pressure gauge. It does not tell you if the patient has a pulse; it is the operators responsibility to ensure the pulse is absent - it will defibrillate V-Tach >180 with a pulse into asystole! Defibrillator pads are attached only to pulseless patients Do not assume the patient has a pulse with the appearance of spontaneous respiration's Defibrillator Errors 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 Unusual Occurrences 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 When is the Defibrillator not attached to a VSA patient? Age < 8 years old (new) Penetrating trauma Obviously Dead Take Home Points Complete one minute of CPR Initiate the appropriate protocol Complete the appropriate protocol Keep track of how many “No Shock advised” in a row CARDIOPULMONARY RESUSCITATIION CPR Role of CPR Integral component of AED use CPR circulates oxygen... – Prolongs heart’s electrical activity – Minimizes brain damage ...but defibrillation is the definitive treatment Adult Compression / Ventilation Ratios 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 Adult rate: 80-100 per minute Child rate: 100 per minute Infant rate: > 100 per minute Two Thumb method used for infant compressions QUESTIONS?