cardiac arrest management prepared by: south west education committee

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?