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Early recognition of emergency and activation of EMS Early bystander CPR Early defibrillation: CPR plus defibrillation within 3 to 5 minutes of collapse can produce survival rates as high as 49% to 75%.
Early advanced life support followed by postresuscitation care delivered by healthcare providers.
BLS
Open Airway
Adequate Ventilation Mechanical Circulation
ACLS
Recognition of CP/CV Emergency Defibrillation
Advanced Airway Mgt
Rhythm Appropriate IV Meds
Judith Maely Kong-Tarrazona, RN
The Cause
- must be identified as quickly as possible to start appropriate therapy immediately
Judith Maely Kong-Tarrazona, RN
CPR
ACCESS
DEFIB
ACLS
Head-tilt, Chin-lift
The
fingers of one hand are placed underneath the mandible, gently lifting upward in an anterior direction.
Jaw-Thrust
Advantage: decreased risk of hyper-extending the neck. 1. Distinguish the edge of the jaw below the ears one hand on each side of the head. 2. Displace the mandible forward by applying a steady forward-andupwards movement to lift the jaw. 3. The thumbs are then utilised to slightly open the mouth by gently pressing downwards on the chin.
Judith Maely Kong-Tarrazona, RN
Breathing
LOOK (at rise and fall
of the chest)
Rescue Breaths
Pinch the nose Take 1 normal breath Make a good seal with your mouth Blow until there is visible chest rise
Judith Maely Kong-Tarrazona, RN
Airway Adjuncts
Face Mask
Airway Adjuncts
Airway Adjuncts
Laryngoscope
Judith Maely Kong-Tarrazona, RN
Intubation
No movement or response
2
Open AIRWAY
Check BREATHING
4
Give cycles of 30 Compressions and 2 Breaths Until AED arrives or ALS takes over Push HARD and FAST (100/min)
Judith Maely Kong-Tarrazona, RN
Check Rhythm
Shockable Rhythm?
Give 1 Shock
10
During CPR
Push
hard and fast (100/min) Ensure full recoil Minimize interruptions in chest compressions 1 cycle = 30 compressions : 2 breaths 5 cycles = 2 minutes Avoid hyperventilation
During CPR
Secure
airway and confirm placement After an advanced airway is in place, rescuers no longer deliver CPR in cycles Give continuous compressions without pausing for ventilations Give 8-10 ventilations per minute Check rhythm every 2 minutes Rotate compressors every 2 minutes within rhythm checks
Judith Maely Kong-Tarrazona, RN
During CPR
Search
for and treat possible contributing Toxins Tamponade (Cardiac) Tension pneumothorax Thrombosis Trauma
Defibrillation
1. 2. 3. 4.
The most frequent initial rhythm in witnessed SCA is VF The treatment for VF is electrical defibrillation The probability of successful defibrillation diminishes rapidly over time VF tends to deteriorate to asystole within a few minutes
Judith Maely Kong-Tarrazona, RN
Out-of-hospital SCA: Give 5 cycles of CPR then use AED (analyze rhythm)
DefibrillationProtocols
Single Shock at 360J followed by 5 cycles of CPR (ECC 2005) Sternal-apical electrode placement Charge and change sync settings Chant for clearance Deliver the shock with 20 lbs of weight Resume CPR immediately
Judith Maely Kong-Tarrazona, RN
ECG Recognition
Universal Steps for AED Operation: POWER ON Attach Electrode Pads Analyze the Rhythm Clear the victim and press the SHOCK button
1. 2. 3. 4.
AED Algorithm
1
Start ABCDs
NOT BREATHING
3B
YES, BREATHING
3A
AED Algorithm
NO CIRCULATION
4
Case 2: Pulseless
1
Arrest
BLS Algorithm: Call for Help, CPR O2 when available Attach to monitor Check Rhythm Shockable Rhythm?
SHOCKABLE NOT SHOCKABLE
9 2
VF/VT
Asystole / PEA
Judith Maely Kong-Tarrazona, RN
What is this?
What is this?
What is this?
SHOCKABLE
3A
VF/VT
SHOCKABLE
6
Continue CPR while charging Give 1 SHOCK Resume CPR immediately! Give EPINEPHRINE (1mg IV) q 3-5 min or 1 dose VASOPRESSIN 40 u IV
Give 5 cycles of CPR*
Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE
Epinephrine
Cardiac Arrest from VF or pulseless VT unresponsive to initial shocks Asystole PEA Initial Dose: 1mg IV; repeat every 3-5 min Infusion: 1mg/500ml NSS or D5W
Judith Maely Kong-Tarrazona, RN
Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE
Vasopressin
Alternative to Epinephrine PEA Shock 40 mg IV bolus single dose
SHOCKABLE
8
Continue CPR while charging Give 1 SHOCK, Resume CPR immediately! Consider antiarrhythmics AMIODARONE (300 mg IV once, then additional 150 mg IV once) or LIDOCAINE 1-1.5 mg/kg 1st dose then 0.50.75 mg IV [max=3mg/kg] Consider MAGNESIUM loading dose 1-2 g IV for Torsades de pointes After 5 cycles, go back to box 5
Judith Maely Kong-Tarrazona, RN
Persistent VF or VT after defibrillation SVT 150 mg IV bolus over 10 min followed by 1 mg/min infusion for 6 hours then 0.5 mg/min
Judith Maely Kong-Tarrazona, RN
ASYSTOLE / PEA
10
Resume CPR immediately for 5 cycles When IV/IO available Give EPINEPHRINE (1mg IV) q 3-5 min or 1 dose VASOPRESSIN 40 u IV (to replace 1st or 2nd dose of Epinephrine) Consider ATSO4 1mg IV/IO for asystole or slow PEA Repeat q 3-5 min up to 3 doses
Judith Maely Kong-Tarrazona, RN
Symptomatic bradycardia 1st degree AV Block Mobitz Type 1 AV Block Asystole or PEA
0.5-1 mg IV in 5-min interval TOTAL= 3mg
Judith Maely Kong-Tarrazona, RN
11
NOT SHOCKABLE
Go to Box 4
12
If Asystole go to Box 10 If with electrical activity, check pulse, no pulse, go to Box 10 If with pulse, proceed to postresuscitation care
Case 3: Bradycardia
Algorithm
Case 3: Bradycardia
Algorithm
Case 3: Bradycardia
1
Algorithm
Bradycardia Heart rate < 60 bpm and inadequate for clinical condition
2
Maintain patent airway, assist breathing as needed Give O2 Monitor ECG, BP, oximetry Establish IV line
ADEQUATE PERFUSION
4A
Observe / Monitor
Consider ATSO4 0.5 mg while awaiting pacer max dose = 3 mg Consider EPINEPHRINE 2-10ug/min or DOPAMINE 2-10 ug/kg/min
Judith Maely Kong-Tarrazona, RN
Cardiovascular Pharmacology
Agents to Optimize CARDIAC OUTPUT and BLOOD PRESSURE
Dopamine
Hypotension Post-resuscitation Shock 5-20 ug/kg/min
Dopaminergic Effect 2-4 ug/kg/min Inotropic Effect 5-10 ug/kg/min -receptor effect 10-20 ug/kg/min
Judith Maely Kong-Tarrazona, RN
Prepare for Transvenous Pacing Treat contributing causes Consider expert opinion
Case 4: Tachycardia
1
Algorithm
Tachycardia with pulses
Assess and support ABCs as needed Give O2 Monitor ECG, BP, oximetry Identify and treat reversible causes
SYMPTOMS PERSIST
3
Is patient stable? Unstable symptoms: altered mental status ongoing chest pain hypotension or signs of shock
STABLE UNSTABLE
Is QRS Narrow?
WIDE
6
NARROW
6
Is Rhythm Regular?
REGULAR
11
IRREGULAR
Irregular Narrow Complex Tachycardia (Afib, AF, MAT) Consider expert consultation Control rate: DILTIAZEM, BBLOCKERS
Judith Maely Kong-Tarrazona, RN
REGULAR
7
Attempt Vagal Maneuvers Give ADENOSINE 6mg rapid IV push with NSS flush If rhythm does not convert, give 12mg May repeat after 12 mg dose once
8
CONVERTS
Narrow complex tachycardias SVT 6mg IV bolus over 1-3 sec Followed by 20ml saline flush Repeat at 12 mg IV within 1-2 min
Judith Maely Kong-Tarrazona, RN
CONVERTS
9
Re-entry SVT
AF, Ectopic Atrial Tachycardia, or Junctional Tachycardia) Control rate: DILTIAZEM, B-BLOCKERS Treat underlying cause Consider expert consultation
Judith Maely Kong-Tarrazona, RN
10
WIDE
6
REGULAR
VT or uncertain rhythm AMIODARONE 150 mg IV over 10 mins Repeat as needed to maximum dose of 2.2g/24 hours Prepare for CARDIOVERSION
13
If Afib, with aberrancy, Go to Box11 If pre-excited atrial tachycardia avoid AV nodal blocking agents (ADENOSINE, DIGOXIN, DILTIAZEM, VERAPAMIL)
Judith Maely Kong-Tarrazona, RN
Case 5: Stroke
1
Management
EMS Assessment Support ABCs; Give O2 as needed Perform Pre-hospital Stroke Assessment * Establish time patient last known normal Alert hospital Check Glucose is possible
Judith Maely Kong-Tarrazona, RN
Immediate general assessment and stabilization * Assess ABCs, vital signs * Provide O2 if hypoxemic * Obtain IV access and blood samples * Perform neurologic screening assessment * Activate stroke team * Order emergent CT scan of brain * Obtain 12-lead ECG
Immediate neurologic assessment by stroke team or designee * Review patient history * Establish symptom onset * Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale
5 Does
NO HEMORRHAGE
6 Probable
Acute Ischemic
Stroke Consider FIBRINOLYTIC THERAPY * Check for fibrinolytic therapy * Repeat neurologic exams: are deficits rapidly improving to normal?
8 Patient
NOT A CANDIDATE
9 Administer
risks/benefits with patient and family: if acceptable * Give tPA * No anticoagulants or antiplatelet treatment for 24 hours
ASPIRIN