Lethal Cardiac Rhythms - Manual Defibrillation
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Transcript of Lethal Cardiac Rhythms - Manual Defibrillation
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ResuscitationCME Fall 2011
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• Morning– Welcome & Introduction– Housekeeping– CPR Recert– New Base Hospital Arrest Protocols
• Lunch & Flu shots
Agenda
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• Afternoon– Autopulse rounds presentation (Base Hospital)– Dissection of Arrest ECGs– Lethal Rhythms– Manual Defibrillation– Autopulse Plus (shock / synch)– Skill Stations– Test
• Go Home
Agenda
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• Audience Response Systems– ‘Clickers’– Will be used for games, challenges, tests
• SimMan 3G– State of the art patient simulator– Allows us to practice in a safe environment– Might seem spooky at first but great learning tool
New Training Tools
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• Recent Changes in Resuscitation
– 2010 AHA ECC Guidelines• Reduce interruptions to compressions
– Base Hospital Arrest Protocols• Medical TORs
– Autopulse Plus (shock / synch)• Minimizes pauses in CPR
Background
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• New Woodstock General Hospital– Emerg Patients enter through garage
• Garage holds 2 trucks• 1st truck in, clear out quickly for next vehicle• Caution leaving garage – blind corner to left
– Give report to RN at desk across from Trauma Rm• Do not go behind desk – patient confidentiality
– Non-Emerg / Transfers• Do Not Enter through Emerg / Garage• Use side entrance, park trucks outside
Housekeeping
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• When patching in give:– Family MD (allows them time to contact doc)– MRSA / VRE status if known (from MARS sheet)
• When arriving:– Give health card to clerk with reason for visit
• Allows them to start registration• Can help expedite tests, labs, x-rays, etc• May not always be possible / practical (Code 4s)
TDMH
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• When Patching give FRI status (+ve or –ve)– Any new or worsening cough– Shortness of Breath– Fever over 38 deg C.– Allows staff to prepare isolation precautions
All Hospitals
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• Please refrain from pre-spiking IV bags– New drip set piece is sharp– Causes bags to leak if pre-spiked– Will most likely be switching to Baxter drip sets
• IV Locks– Will probably start stocking locks– Good for use when transporting to TDMH
IVs
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• Doing a great job uploading ECGs• Procedures performed by 1 medic
– Unless its lifting, stairchair, extricate, etc
• Oxford policy – ACRs are completed for any call where you arrive scene (even if no pt)
• Please don’t use ‘Z’ procedure codes (ie Z301)• Will be placing OmniDrives in each truck soon• Working on having ability to upload calls from
hospital or on the road
ACRs
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2012 Base HospitalNew Arrest Protocols
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• Introduction of Medical TOR Protocol– ≥ 18 years– Unwitnessed Arrest– No ROSC– No Shocks Delivered
> BHP Patch for TOR
Medical Arrests
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• Introduction of EPI where Anaphylaxis is suspected as the cause of arrest
– Give 0.01 mg/ kg to a max of 0.5 mg EPI 1:1000 IM
Medical Arrests
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• Merging of Blunt and Penetrating Trauma protocols
• > 30 days old• VF/VT – 1 shock ER• Trauma TOR > 16 yrs• Asystole – Patch for TOR• PEA & Transport >30 mins – Patch for TOR
Traumatic Arrests
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Autopulse RoundsDr. Sameer Mal - SWORBHP
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Cardiac Arrest ECGs
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Lethal RhythmsLethal Rhythms
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• Review of the 4 lethal rhythm types
• Nothing new, reviewed annually during recerts
• Work on rapid recognition (5 seconds)
Lethal Rhythms & Manual Mode
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Lethal Rhythm
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Ventricular Tachycardia
• 3 or more consecutive ventricular complexes occurring at a rate of more than 100 bpm
• Could have an associated pulse or be pulseless
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Ventricular Tachycardia
• Causes– Usually starts suddenly, triggered by a PVC– Usually a result of myocardial ischemia or
significant cardiac disease
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Ventricular Tachycardia
• Other Causes– Electrolytic imbalance (Acid/Base, Na+, K+…)– CHF– Stimulants (ETOH, tobacco, C8H10N4O2)
– Drug Toxicity (digitalis, trycylics, antidepressants)– Sympathomimetics (cocaine, meth)– Prolonged QT
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Ventricular Tachycardia
• Interpretation– QRS is WIDE– ≥ 0.12 seconds (same as LBB interpretation)– May appear distorted or bizarre– P waves may or may not be present – if present
usually dissociated from QRS– Rate > 100 bpm
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Ventricular Tachycardia
• Types– Monomorphic
- one form, derives from one focus- every wave appears the same
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Ventricular Tachycardia
• Types– Polymorphic
- generated by multiple foci- waveform appearance variable
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Ventricular Tachycardia
• Types– Torsades de Pointes
- ‘twisting of the points’- conduction rotates, form of polymorphic
ALS Warning:Do NOT use antidysrhythmic drugs on Torsades
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Ventricular Tachycardia
• Action – No Pulse?– Fast?– Wide?
SHOCK
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Lethal Rhythm 2
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Ventricular Fibrillation
• Chaotic ventricular rhythm results in ventricular ‘quivering’ and pulselessness
• Always pulseless
• Most common initial rhythm in sudden cardiac arrest
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Ventricular Fibrillation• Causes
– Myocardial ischemia– AMI– 30 AV block with a slow ventricular escape rhythm– Cardiomyopathy– Digitalis Toxicity– Acidosis– Electrolyte Imbalance– Electrical Injury– Drug Overdose (cocaine, tricyclics)
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Ventricular Fibrillation
• Interpretation– Chaotic– No discernible P waves or QRS complexes
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Ventricular Fibrillation
• Types– Coarse VF
• Amplitude of > 3mm
– Fine VF• Amplitude < 3mm• May be very difficult to differentiate from asystole
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Ventricular Fibrillation
• Action
SHOCK
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Lethal Rhythm 3
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Pulseless Electrical Activity
• Used to be called ‘Electromechanical Dissociation’
• Electrical activity is present but there are no resultant contractions
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Pulseless Electrical Activity
• Causes – The 6 H’s and the 6 T’s– Hypothermia– Hypoxia– Hydrogen ions (Acidosis)– Hyper/Hypokalemia– Hypoglycemia– Hypothermia
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Pulseless Electrical Activity
• Causes – The 6 H’s and the 6 T’s– Tablets / Toxins (Drug overdose)– Cardiac Tamponade– Tension pneumothorax– Thrombosis (MI)– Thrombosis (PE)– Trauma (Hypovolemia)
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Pulseless Electrical Activity
• Interpretation– Patient is pulseless, apneic– Rhythm appears organized (anything from an escape rhythm to
normal sinus)– Slow & Wide -> PEA– Fast & Wide -> V Tach
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Pulseless Electrical Activity
• Action– Ensure Pulselessness– Continue CPR
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Lethal Rhythm IV
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Asystole
• Flatline, absence of any electrical activity• Causes – 6H’s, 6 T’s, prolonged VF / VT / PEA
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Asystole
• Interpretation– Flat line– Slow, wide, thin wave– May be fine V-Fib– Look at possible causes of death to help differentiate from VF
Continue CPR
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Ventricular Escape Rhythms
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Agonal Rhythms
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Paced Rhythms
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And now you know…
And Knowing is half the battle
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Manual Mode
Do not be afraid
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Using the E Series in Manual Mode• Turn on Defib as you normally would
– Press ‘Manual Mode’ soft key
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Using the E Series in Manual Mode• Turn on Defib as you normally would
– Then press ‘Confirm’ soft key
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Using the E Series in Manual Mode
• Ensure ‘Pads’ are selected (not Ld I,II or III…)
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Using the E Series in Manual Mode• 120 Joules will be the default energy• After shock is delivered, energy will increase
– 150 J, 200 J
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Using the E Series in Manual Mode• To evaluate a rhythm
– Stop CPR– Check Pulse– NOT MORE THAN 5 SECONDS– Press ‘Recorder’ button and print off strip (also marks event on
summary)
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Using the E Series in Manual Mode• Resume CPR immediately then make your
defibrillation decision• (Shock / No Shock)
– You can use the rhythm strip you printed to make the decision after the pause
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Using the E Series in Manual Mode
• If choosing to shock, press ‘Charge’ – (no need to press ‘Analyze’)– Confirm you have selected the proper
energy setting
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Using the E Series in Manual Mode• Continue CPR until ready to shock then once all
rescuers are clear, press ‘Shock’ then resume CPR immediately.
– There should be a only very brief pause in compressions
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Using the E Series in Manual Mode
To dump a shock, just hit the ‘Energy Select’ button (either arrow)
If really unsure whether to shock or not, the ‘Analyze’ button is always an option.
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Using the E Series in Manual Mode
For PaedsKeep Defib in Semi Automatic and use pediatric attenuator pads
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Autopulse Plus
AKA ‘Shock/synch’
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Using Autopulse Plus
• The Autopulse now has the ability to coordinate defibrillation with the contraction cycle
• Allows for minimal interruption to compressions
• Can be hooked up initially or at any point in the call
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Using Autopulse Plus
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Using Autopulse Plus
• Connecting the Defib to the Autopulse– Connector site is located at the top of the
Autopulse next to the battery bay
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Using Autopulse Plus
• Connecting the electrodes to the Autopulse
– Connect the defib pad electrodes by plugging them into the connector site (1)
– Ensure connector is firmly seated in the connector site
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Using Autopulse Plus
• Connecting Defibrillator to Autopulse
– Connect defibrillator cable into connector site (marked ‘2’)
– Ensure cable is firmly seated
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Using Autopulse Plus
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Using Autopulse Plus
–When ready to interpret cardiac rhythm, pause compressions briefly for interpretation and pulse check if applicable
–Resume compressions immediately
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Using Autopulse Plus
• Ensure appropriate energy and charge defibrillator if applicable
• Press ‘Shock’– Shock may be delayed as long as 800 ms to coordinate
with the upstroke of compressions from the Autopulse.
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Using Autopulse Plus
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Using Autopulse Plus
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Using Autopulse Plus
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Using Autopulse Plus