Post on 02-Jan-2016
CARDIAC ARREST
MANAGEMENT
Prepared by:
South West Education Committee
SWEC MEMBERS
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
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
Chain of Survival Review of the conduction system Cardiac Monitoring Protocols Special circumstances CPR & SAED reminders
CHAIN OF SURVIVAL Early Access (911)
– Someone must realize there is an emergency and 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
– First responder arrives with the training and equipment to defibrillate the heart. As time increases chances for survival decrease.
Early Advanced Life Support– ALS within minutes increases the chance of
survival.
CHAIN OF SURVIVAL
CAUSES OF CARDIAC ARREST
# 1 Cause = Conduction Disturbances # 2 Cause = AMI / ischemia
Other Causes include: Traumatic Hypoxia / Respiratory Metabolic
CARDIAC MONITORING
NORMAL ELECTRICAL CONDUCTION
RHYTHM INTERPRETATION 5 Steps Approach 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
LETHAL DYSRHYTHMIAS 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
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
Usually represented by a normal functioning electrical conduction system
Heart Rate average is 72 beats / minute
Pulseless Electrical Activity 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
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
No organized excitation of heart muscle
Heart is physically quivering compared to contracting (seizing)
No Cardiac Output
Defibrillation and Time 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
0
20
40
60
80
100
1 3 6 10
Survival
Minutes: collapse to 1st shock
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
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
~ 90 bpm
Irregular
P waves normal, extra beats haveassociated P wave
0.12 - 0.20 secYes
PACs
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal? Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
Variable < 100
Irregularly Irregular
No P waves
None
Yes
Atrial Fibrillation
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
Variable ~ 100
IrregularP waves Associated
with most QRS
Yes - not all
Yes - not all
PVC - unifocal
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
150
Regular
No P waves
N/A
Yes
Accelerated Juntional
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
40-70
IrregularP waves regular
Not always with a QRS
longer each beatYes
Second Degree AV Block Type 1
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
< 30 bpmRegular
P waves normal, not with QRS
None
Yes
3rd degree Heart Block
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
9 S H O C KS T O T AL 3 N O S H O C K SIN A R O W
R E T U R N O F A P U L SE
M ed ica l P ro to col w illE N D O N E O F T H R E E W A Y S
SHOCK VERSES NSI
3 N S I IN A R O WN o S h o ck P ro toco l is co m p le te
T ra n sp o rt
2 C on secu tive N S I on sce neP re p are T o T ra nsp o rt
P u lse C h e ck1 F u ll M in u te o f C P R
R e a na lyze
N o S ho ck Ind ica ted (P E A /A sys to le )
M a x im u m 9 S h ocks U n less R O S CT ra n sp o rt
P u lse C h e ck1 F u ll M in u te o f C P R
R e a na lyze
W a it 1 0 S e co n dsR e an a lyze an d S h ock A g a in
W a it 1 0 S e co n dsR e an a lyze an d S h ock A g a in
S h o ck (V F /V T)
Adult V -F ib , Pulseless V -TachAsysto le, PEA
Protocol
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
3 2 1 GO
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
When is the Defibrillator not attached to a VSA patient?
Age < 8 years old Penetrating trauma Obviously Dead
Criteria for Obviously Dead 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
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
Avoid placing pads directly over.
Apply pads at least 1 to 2 inches away.
Follow all protocols.
SPECIAL SITUATIONSWet patient
Victim lying in water.
Once on land, dry patient before applying SAED.
Remember, let the rescue experts do the rescuing.
SPECIAL SITUATIONS Medication patches
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
Age: victim <8 years old?
CPR only.
SPECIAL SITUATIONS Hypothermia
Hypothermia Definition: core body
temperature <35°C Causes: exposure to
extreme cold ( damp)
HYPOTHERMIA Clinical Signs and Symptoms
Lethargystuporcoma Muscle rigidity, cessation
of shivering Dilated pupils,
nonreactive pupils bradycardia, slow AF,
VF, or asystole
HYPOTHERMIA Initial Therapy
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
HYPOTHERMIACardiac Arrest
1 NO SHOCK
ANYWHERE
– Check pulse No Pulse
– CPR concurrent with transport
3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check Pulse
No Pulse– CPR transport
HYPOTHERMIAGeneral Approach
Maintain horizontal position – Vertical position may compromise cerebral
and systemic perfusion Avoid rough movements and activities Handle victim gently during CPR, BVM
ventilation and transport
SPECIAL SITUATIONSTraumatic Cardiac Arrest
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
Traumatic Cardiac Arrest
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 - VentilatePerform visualisation of airway q 15 compressions
If cleared start protocol minus shocks delivered
TAKE HOME POINTS
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 Integral component
of AED use CPR circulates
oxygen...– Prolongs heart’s
electrical activity– Minimizes brain
damage ...but defibrillation is
the definitive treatment
ADULTCompression / 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?