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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 100 80 60 Survival 40 20 0 1 3 6 10 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 ~ 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 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 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 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 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 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 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 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 SITUATIONS Wet 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 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 HYPOTHERMIA General 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 SITUATIONS Traumatic 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 - Ventilate Perform 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 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?