Lecture 2: What is your role in a code? Flashcards
what is defibrillation
- terminates VF and pulseless VT
- passage of DC of electrical shock to depolarize cells of myocardium to allow SA node to resume role of pacemaker (monophasic defibrillators deliver energy in 1 direction, biphasic defibrillators deliver energy in 2 directions)
- after the initial shock, chest compressions (CPR) should be restarted
what is synchronized cardioversion
- choice of therapy for hemodynamically unstable ventricular or supraventricular tachydysrhythmias
- synchro circuit delivers counter shock on R wave of QRS complex of ECG
- synchronizer switch must be turned ON
defibrillation vs cardioversion
(when do we do both)
defibrillation:
- pulseless VT
- ventricular fibrillation
cardioversion
- unstable atrial fibrillation
- unstable atrial flutter
- unstable atrial tachycardia
- unstable supraventricular tachycardia
- medication failure
what is pacing
- used to pace the heart when normal conduction pathway is damaged or diseased
- pacing circuit consists of a power source, one or more conducting (pacing) leads, and the myocardium
- can be used to prevent bradycardia or tachycardia rhythms
for severe bradycardia, not for asystole, unstable
what is a pacemaker spike + when should it be
The electricity the pacemaker is sending.
Should be a complex after every pacer strike
types of pacemakers
- temporary transcutaneous pacemaker
- temporary transvenous pacemaker
- permanent pacemaker
- implantable cardioverter defibrillator (ICD)
what is cab - for is my patient stable
- circulation
- airway
- breathing
what are we looking for in the neurological re-check
alert x4
any abnormalities
tell me about glasgow coma scale
15 = fully alert and orientated
8 or less = endotracheal intubation to protect the airway (coma)
potential neuro causes of unresponsiveness
stroke
seizure
trauma
potential cardio causes of unresponsiveness
myocardial infarction
cardiac arrhythmia
cardiac arrest
potential resp causes of unresponsiveness
PE
respiratory arrest
potential endocrine causes of unresponsivenes
hypoglycemia
you walk into a pt room and you have a definite pulse + normal breathing
- vital signs
- assess responsiveness
- glasgow coma scale
- bloodwork/imaging tests
examples of definite pulse and normal breathing
- stroke/TIA
- slow brain bleed
- meds
you walk into a pt room and you have a definite pulse + no breathing
- “C” check for pulse; pulse is palpable, but no breathing or breathing is not normal
- “A” (airway): open airway
- “B” (breathing): bag valve mask
- 1 breath every 5-6 sec
- pulse check every 2 min
If we don’t have oxygenated blood to circulate our organs and such will fail.
examples of definite pulse and no breathing
obstruction, inadequate resp effort, meds
you walk into a pt room and you find no pulse for cardiac arrest
- “C” circulation
no pulse - IMMEDIATE CHEST COMPRESSIONS
push hard + fast (100-120 compressions/min)
depth of at least 2 inches (5cm)
allow chest recoil
minimize interruptions in compressions - “A” airway: open airway
- “B” breathing: bag valve mask (BVM) -> 30:2
if rhythm is shockable for cardiac arrest
VF/pVT - u shock then CPR for 2 min - shock - CPR and epi - until its not shockable
if rhythm is not shockable for cardiac arrest
asystole/PEA
- epi asap
then CPR (epi every 3-5 min)
- if YES pt has persistent tachyarrhythmia causing hypotension, ALOC, shock, chest pain, HF, etc… what do u do
- if refractory… consider
synchronized cardioversion
- consider sedation
- if regular narrow complex, consider adenosine
- underlying cause
- need to increase energy level for next cardioversion
- addition of anti-arrhythmic drug
- expert consultation
- underlying cause
If NO to persistent tachycardia causing etc, and no wide QRS greater than or equal to 0.12 sec…
- vagal maneuvers (if regular)
- adenosine (if regular)
- B blocker or calcium channel blocker
- consider expert consultation
- If NO to persistent tachycardia causing etc, and YES wide QRS greater than or equal to 0.12 sec…
- if refractory… consider
- consider
- adenosine only if regular and monomorphic
- antiarrhythmic infusion
- expert consultation - underlying cause
- need to increase energy level for next cardioversion
- addition of anti-arrhythmic drug
- expert consultation
- underlying cause
adenosine IV dose
1st and 2nd for tachycardia
1st: 6 mg rapid IV push
2nd: 12 mg if required
procainamide IV dose for antiarrhythmic IV for tachycardia
20-50 mg/min until better.maintanence 1-4 mg/min.
amiodarone IV dose for antiarrhythmic IV for tachycardia
first dos: 150 mg over 10 min. follow by maintenance infusion 1 mg/min for 1st 6 hours.
sotalol IV dose for antiarrhythmic IV for tachycardia
100 mg (1.5 mg/kg) over 5 min. avoid prolonged QT
pt is NOT having persistent bradyarrythmia causing: hypotension, ALOC, shock, chest pain, HF…
monitor and observe
pt is having persistent bradyarrhythmia causing: hypotension, ALOC, shock, chest pain, HF…
atropine
if atropine is ineffective: transcutaneous pacing and/or dopamine or epi IV
consider expert consultation and transvenous pacing
atropine dose IV for bradyarrhythmia
1st dose: 1 mg bolus
repeat every 3-5 min
max 3 mg
dopamine IV infusion dose for bradyarrhythmia
usual IV rate is 5-20 mcg/kg per min. titrate to pt response; taper slow
epinephrine IV infusion dose for bradyarrhythmia + causes
2-10 mcg/min IV.
causes: Myocardial ischemia/infarction, drugs/toxicologic (CCBs, digoxin), hypoxia, electrolyte abnormality (hyperkalemia)
reversible causes of cardiac arrest
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, coronary and pulmonary
what to do with advanced airways during cardiac arrest
- endotracheal intubation or supraglottic advanced airway
- waveform capnography or capnometry to confirm + monitor ET tube placement
- once advanced airway in place, give 1 breath every 6 sec (10 breaths/min) with continuous chest compressions
how to do good CPR quality
- push hard (2inch/5cm) + fast (100-120/min)
- change compressor every 2 min
- if no advanced airway 30:2
shock energy for defibrillation
1. biphasic
2. monophasic
- biphasic: dose of 120-200 K. subsequent doses are equivalent or higher.
- monophasic: 360 J
cardiac arrest epinephrine IV/IO dose
1 mg every 3-5 min
cardiac arrest amiodarone IV/IO dose
first dose: 300 mg bolus
second dose: 150 mg
cardiac arrest lidocaine IV/IO dose
first dose: 1-1.5 mg/kg
second dose: 0.5-0.75 mg/kg
