Download SAED Recert - Hamilton Health Sciences

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?