Systematic Approach Flashcards
Describe the systematic approach.
- Determine the scene is safe.
- Determine the patient’s level of consciousness
3a. If unconscious -> BLS Assessment for initial evaluation, then proceed to Primary/Secondary Assessments
3b. If conscious -> Primary Assessment
What should you do if you are not sure about the presence or absence of a pulse?
Begin cycles of compressions and ventilations. Unnecessary compressions are less harmful than failing to provide them.
How should agonal gasps be interpreted?
They are not normal breathing and may be present in the first minutes after sudden arrest
Steps in BLS assessment?
- Check responsiveness (tap and shout, “Are you okay?”)
- Shout for nearby help/activate the emergency response system and get the AED/defibrillator
- Check breathing and pulse for 5-10 seconds. If no pulse within 10 seconds, start CPR (chest compressions). If pulse, start rescue breathing (1 breath every 5-6 minutes), check pulse every 2 minutes
- If no pulse, check for shockable rhythm ASAP and provide as indicated. Continue CPR.
Components of quality compressions?
2-2.4” depth
100-120/min
Allow complete recoil after each compression
Steps in the Primary Assessment?
Airway Breathing Circulation Disability Exposure
Components of airway assessment?
Is the airway patent? [If unconscious, use head tilt-chin lift, oropharyngeal airway, or nasopharyngeal airway
Is an advanced airway indicated?
If using - is proper placement of the airway device confirmed? Is the tube secured and placement reconfirmed frequently (via physical exam or quantitative waveform capnography)? Also, confirm proper integration of CPR and ventilation
Components of breathing assessment?
Are ventilation and oxygenation adequate? [If arrest, give 100% O2. Otherwise, titrate to 94+%]
Are quantitative waveform capnography and oxyhemoglobin saturation monitored? [Monitors the adequacy of ventilation and oxygenation; can also look at chest rise and cyanosis]
Avoid excessive ventilation
Components of circulation assessment?
Are chest compressions effective [monitor via capnography - PETCO2 >10, intra-arterial pressure diastolic pressure >20 mmHg]
What is the rhythm? [Attach monitor/defibrilator]
Is defibrillation or cardioversion indicated? If yes, provide.
Obtain IV/IO access, give appropriate drugs, fluids
Check glucose and temperature
Check for perfusion issues
Is ROSC present? Is the patient with a pulse unstable?
Components of disability assessment?
Check for neurologic function
Quickly assess for responsiveness, levels of consciousness, and pupil dilation
AVPU - Alert, Voice, Painful, Unresponsive
Components of Exposure assessment?
Do an exam (remove clothing), look for obvious signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets
Steps in the Secondary Assessment?
DDx Focused medical history Consider using the mnemonic SAMPLE: Signs and symptoms Allergies Medications (last dose taken) PMHx Last meal consumed Events Search for and treat underlying causes (most common causes of cardiac arrest): Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypothermia Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis (pulmonary) Thrombosis (coronary)
2 most common underlying and potentially reversible causes of PEA?
Hypovolemia
Hypoxia
What are key steps in searching for underlying causes?
- Consider H’s & T’s
- Analyze EKG for clues to the underlying cause
- Recognize hypovolemia
- Recognize drug OD/poisonings
Explain how hypovolemia can cause PEA.
You will initially see rapid, narrow-complex tachycardia with increased diastolic and decreased systolic pressures. As loss of volume continues, BP drops, eventually becoming undetectable, although the narrow QRS complexes and rapid rate continue (ie, PEA)
Common non-traumatic causes of hypovolemia?
Occult internal hemorrhage
Severe dehydration
When should you consider volume infusion?
PEA associated with narrow-complex tachcyardia
ACS involving a large amount of heart muscle can present as PEA - how does it present before the arrest?
Occlusion of the left main or proximal LAD can present w/cardiogenic shock rapidly progressing to arrest and PEA
Should routine fibrinolytic therapy be used for cardiac arrest thought to be due to ACS?
No (no benefit)
Should fibrinolytic therapy be given in patients w/arrest due to presumed or known PE?
Yes
Cardiac tamponade, tension, pneumothorax, and massive PE cannot be treated unless recognized. How is this done?
Bedside US
Certain drug overdoses and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction with resultant hypotension. The approach to poisoned patients should be aggressive because the toxic effects may progress rapidly and may be of limited duration. In these situations, myocardial dysfunction and arrhythmias may be reversible. Numerous case reports confirm the success of many specific limited interventions that buy time. List such treatments.
- Prolonged basic CPR in special resuscitation situations
- Extracorporeal CPR
- Intra-aortic balloon pumping
- Renal dialysis
- IV lipid emulsion
- Specific drug antidotes (digoxin immune Fab, glucagon, bicarbonate)
- Transcutaneous pacing
- Correction of severe lyte disturbances (K, Mg, Ca, acidosis)
- Specific adjunctive agents
Define normal and abnormal breathing.
Normal: average RR for an adult is 12-16/min, normal TV of 8-10 mL/kg
Tachypnea: >22/min
Bradypnea: <12/min
Hypoventilation: <6/min, requires assisted ventilation w/bag-mask device or advanced airway w/100% O2
Typical causes of respiratory arrest?
Drowning or head injury
What should be used in patients with respiratory arrest and airway obstruction or poor lung compliance?
Pressure-relief valve on a resuscitation bag-mask device
BLS assessment in a patient who is in respiratory arrest w/pulse?
Ventilations Q5-6 seconds w/bag-mask or any advanced airway device (each breath should take 1 second and achieve visible chest rise)
Pulse check Q2 minutes (at least 5 seconds, no more than 10)
Primary assessment in a patient who is in respiratory arrest w/pulse?
If BMV is adequate, may defer insertion of advanced airway (decide during primary assessment) - options include laryngeal mask airway, laryngeal tube, esophageal-tracheal tube, and ET tube
What is the most reliable method of confirming and monitoring correct placement of an ET tube?
Continuous waveform capnography + clinical assessment
Steps in management of respiratory arrest?
Give supplemental O2 (titrate to 100% O2) Open the airway Provide basic ventilation Use basic airway adjuncts (OPA and NPA) Suctioning
Why is hyperventilation potentially harmful?
Increases intrathoracic pressure -> decreases venous return -> decreases CO
Gastric inflation -> predispose to vomiting and aspiration
Cerebral vasoconstriction -> reduce blood flow to brain
Most common cause of upper airway obstruction in an unconcious/unresponsive patient?
Loss of tone in the throat muscles -> tongue falls back and occludes the airway at the level of the pharynx
Basic airway opening techniques?
Head tilt-chin lift; if trauma patient w/suspected neck injury, use a jaw thrust without head extension; if this does not work, use head tilt-chin lift
In patients who are unconscious (and only unconscious) with no cough or gag reflex, insert OPA or NPA to maintain airway patency
If chocking, open the mouth wide to look for a foreign object and remove it w/your fingers. If you do not see an object, CPR. Each time you open the airway to give breaths, repeat this process.
Options for basic ventilation?
Mouth-to-mouth
Mouth-to-nose
Mouth-to barrier device
Bag-mask
Steps in inserting OPA?
- Clear the mouth and pharynx of secretions, blood, vomit if possible
- Select proper OPA size (when flange is at the corner of the mouth, the tip is at the angle of the mandible)
- Insert so that it curves upward toward the hard palate, then rotate 180 degrees
Problems with too large OPAs?
May obstruct the larynx of cause trauma
Problems with too small OPAs?
May push the base of the tongue posteriorly and obstruct the airway
Who should get an NPA?
Conscious, semiconscious, or unconscious (intact cough/gag reflex); indicated when insertion of OPA is technically difficult or dangerous
Steps in inserting NPA?
- Proper size - length should be the same distance from the tip of the patient’s nose to the earlobe
- Lubricate the airway
- Insert through the nostril in a posterior direction perpendicular to the plane of the face, pass gently along the floor of the NP
What should you be cautious about when using an NPA?
- Insert gently to avoid causing bleeding -> aspiration of clots into trachea
- Improperly sized may enter the esophagus
- May cause laryngospasm and vomiting
- Use cautiously in facial trauma, can be misplaced into cranial cavity if cribriform plate is fractured
What two presentations can occur with acute MI?
Sudden cardiac death
Hypotensive bradyarrhythmias
Drugs used in ACS?
- O2
- ASA
- Nitroglycerin
- Opiates (eg, morphine)
- Fibrinolytic therapy
- Heparin (UFH, LMWH)
- Beta-blockers
- ADP (adenosine diphosphate) antagonists (clopidogrel, prasugrel, ticagrelor)
- ACEIs
- HMG-CoA reductase inhibitors (statins)
- G2b3a inhibitors
