term 1 test Flashcards
How to confirm cardiac arrest
Assess C-A-B to determine if pt is in cardiac arrest due to many presentations appearing initially as cardiac arrest
Check carotid/radial pulses and breathing in >10seconds
Is suspected apply pads immediately over chest leads
What does hypothermia present as
Cold, waxy skin, blanching of skin, locked extremities, not shivering
Medical TOR criteria in the ALS
Age >16 years old, altered LOA, arrest not witnessed by EMS and no ROSC 20 min of resuscitation and no defibrillation delivered
Trauma TOR conditions
> 16 years, no palpable pulses and no defibrillation delivered and rhythm asystole or no signs of life at any time since fully extricated, or signs of life when fully extricated with the closest ED >30 min transport time away, or rhythm PEA with the closest ED >30min away
Where do you transport a cardiac arrest
Closest ER, CTAS 1 code 4
What is the difference between a SCA and a heart attack
Patients die from the rhythm/arrhythmia that is unsustainable for the elctrophysiology of the heart not the STEMI
Medical cardiac arrest indications
Non-traumatic cardiac arrest
Airway obstruction in cardiac arrest
High instances in children, focus on high-quality CPR, consider very early transport (after 1 analysis and egress plan is organized), transport to closest ER since PT is CTAS 1
If airway obstruction is relieved prior to early transport, consider running a longer arrest on scene
TOR is contraindicated
Termination of resuscitation
Must call BHP and continue running arrest until receiving TOR order, ensure you recieve time of death from BHP
Causes of cardiac arrest
Atherosclerosis or underlying cardiac diseases, genetic disorders, cardiomyopathies, can occur after electrocution, drowning, trauma, drug overdose
SGA- King LT
Single lumen air device available in adult and peds sizes
Consists of a curved tube with ventilation ports between two inflatable cuffs
Medical cardiac arrest medical TOR contraindications
Known reversible cause of arrest unable to be addressed, pregnancy assumed to be >20 weeks’ gestation, suspected hypothermia, non-opioid drug overdose
Supraglottic airway medical directive conditions
Absent gag reflex
Advanced airways in cardiac arrest
Dont rush into advanced airways is BLS airways are adequate
King LT/ I Gel
What is the difference between a SAED and a manual defibrillation
Must pull over with a SAED, can stay enroute if able to analyze/defibrillate in that environment
What are the special cases of cardiac arrest
Trauma, pregnancy, hypothermia, airway obstruction, non-opioid toxicity, ROSC
Abnormal waveform- sudden increase in ETCO2
ROSC
Pre-arrival interventions with respect to TOR
Consult with BHP and advise them of interventions done by FD/other PTA and discuss
How to confirm placement for SGAs
ETCO2 reading, chest auscultation, chest rise, no wave form ETCO2, tube misting
Abnormal waveform- decreasing ETCO2
ET tube cuff leak
ET tube in hypopharynx
Partial obstruction
What is a vector change
Pads change from the front of the chest to the back
ETCO2 definition
Measures ventilation status- CO2 in the airway at the end of exhalation
Indications for the King LT
Alternative to bag-mask and OPA/NPA ventilation when an advanced airway device is required for airway management
Supraglottic airway medical directive contraindications
Airway obstruction by a foreign object, known esophageal disease (varices), trauma to oropharynx, caustic ingestion
What do you do if you obtain a ROSC
Complete assessment of CAB, 12 lead, full set of vitals, continually reassess and treat findings
Defibrillation in cardiac arrest
Heart is quivering but no blood is pumping so defib stuns heart muscles to allow the normal conduction to resume control
If not defibbed, VF/VT will deteriorate to asystole
Pt must be >24hrs
Why is there a shark-fin slope with a bronchospasm
The movement of the air at the alveoli is delayed and the rise to the plateau is more gradual and becomes sloped
SPO2 definition
Saturation of peripheral capillary oxygen- measures oxygen saturation levels
Supraglottic airway medical directive indications
Need for ventilatory assistance or airway control and other airway management is ineffective
Shockable rhythms in cardiac arrest
V tach, V fibb
ROSC- post arrest care
Fluid bolus- >2 years old
Ensure chest is clear and BP is hypotensive, 10ml/kg, max 1000ml, reassess every 100ml >2-<12 years and reassess every 250ml >12 years
Oxygenation- BVM ventilations are required, titrate SPO2 to 94-98%, avoid hyperventilation (ETCO2 30-40mmHg)
Monitoring CPR quality with ETCO2
Higher ETCO2: higher cardiac output (good CPR)
Lower ETCO2: change compressions or improve CPR quality
ETCO2 decreasing observe for chest compressor fatigue, hyperventilation, airway obstruction, or tracheal tube displacement
ETCO2 increasing: CPR is likely effective and ventilation appropriate; substantial rise can indicate ROSC
Where should the pt be during cardiac arrest
Hard flat surface with enough space- possibly stretcher and plan extrication
Move pt only if necessary and notify PD and document and do not move pt back
What causes high CO2 levels (hypoventilation)
Retaining CO2 due to the slow rate of breathing
Caused by overdose, sedation, intoxication, postictal states, head trauma, stroke, tiring CHF, fever, sepsis, SOB
What causes low CO2 levels (hyperventilation)
Blowing off large amounts of air from increased rate of breathing
Caused by anxiety, bronchospasm, pulmonary embolus, cardiac arrest, hypotension, decreased cardiac output, cold
Medical cardiac arrest manual defibrillation conditions
Age >24 hours, LOA altered, VF or pulseless VF
What are the signs of a ROSC
Sudden increase in ETCO2, spontaneous respirations, palpable pulses, change in colour, spontaneous movement
Oxygenation definition
Process of adding oxygen to the body system
DNR
Establish presence ASA, validity (if so, can be honoured without BHP call) if incomplete call BHP
What does a ETCO2 >45mmHg indicate
Hypoventilation/ hypercapnia
What is the life saving measures that are classified in a DNR in the BLS
Chest compressions, defibrillation, artificial ventilation, insertion of oropharyngeal/supraglottic airway, endotracheal tube, transcutaneous pacing, advanced resuscitation drugs- vasopressors, antiarrhythmic agents, and opioid antagonists
Medical cardiac arrest epinephrine contraindications
Allergy or sensitivity to epinephrine
What is cardiac arrest
Occurs when the heart unexpectedly and suddenly stops pumping often from a irregular heart rhythm
Blood stops flowing to the brain and other vital organs
Joule settings
> 24hours to <8 years
Initial dose: 2J/kg
Subsequent doses: 4J/kg
Interval: 2 min
> 8 years
Zoll: 120J, 150J, 200J
Lifepack: 200J, 300J, 360J
What are the reasons to prioritize an advanced airway
Vomit or airway full of secretions
Prolonged resuscitation or extrication
Poor seal with OPA/BVM
Trauma TOR contraindications
Age <16, defibrillation delivered, signs of life at any time since fully extricated medical contact, rhythm PEA and closest ED <30min transport time, patients with penetrating trauma to the torso/neck/ and lead trauma hospital <30min transport time
What do ETCO2 values indicate about a ROSC
ETCO2 values <10-15mmHG prompt close evaluation of CPR- if they remain low the prognosis of the ROSC is low
If the numbers rise into 20-30s the prognosis of the ROSC are high
If the numbers rise to extreme highs a ROSC is present so check rhythm and pulse at next rhythm check
What are the signs of an obviously dead patient
Decapitation, transection, visible decomposition, putrefaction, absence of vital signs and grossly charred body, an open head/torso wound with gross outpouring of cranial or visceral contents, gross rigor mortis, or dependent lividity
After 20mins what do ETCO2 levels indicate
ETCO2 levels <10mmHg are associated with futility (exceptions include hypothermia)
ETCO2 levels >25mmHg are associated with survival
How to secure King LT
Thomas tie is compatible, ensure to note and document depth prior to securing, tape if needed
Medical cardiac arrest manual defibrillation treatment
> 24 hours-<8 years: dose I defibrillation, initial dose 2j/kg, subsequent doses 4J/kj, dosing interval 2 min
> 8 years: dose 1 defibrillation, initial dose/ subsequent doses as per RBHP, dosing interval 2 min
What does fire do in cardiac arrests
Assist with patient care, can accompany to ER
What is PaCO2
Partial pressure of carbon dioxide in arterial blood gases thats measured by drawing the ABGs (also measure arterial PH)
Pregnancy in cardiac arrest
Pregnancy presumed to be >20 weeks’ gestation
Run as regular medical arrest and consider very ealy transport after a minimum 1 analysis and egress plan is organized
TOR contraindicated
Complications of King LT
Laryngospasm, vomiting, and possible hypoventilation may occur, trauma may also result from improper insertion technique, ventilation may be difficult if pharyngeal balloon pushes epiglottis over glottic opening
How does a pt respiratory rate change in conjunction with CO2
A patient’s respiratory rate increases as CO2 rises and decrease as CO2 falls
Definition of respiration
Process of oxygen and carbon dioxide diffuse in and out of the blood
What is the fourth phase of wave form
D-E: (0) start of inspiration
Medical cardiac arrest epinephrine conditions
Age >24 hours, LOA altered, anaphylaxis suspected as causative event
Abnormal wave forms- decreased ETCO2
Apnea, sedation
Pulse checks in cardiac arrest
Every 2 minutes and done in the last 15 seconds of the CPR cycle
Do not delay time off chest if unable to palpate pulse/ unsure of pulse presence
Also done if obvious signs of life is present
Abnormal wave form- sudden loss
ET tube disconnected, dislodged, or obstructed
Loss of circulatory function
Definition of ventilation
Pulmonary ventilation is the process by which oxygen enters, and carbon dioxide exits the alveoli ventilation is the process of in haling and exhaling- “movement of air”
Non-opioid drug cardiac arrest
Prioritize scene safety, determine ingested substance used and dose, consider early transport (min 1 analysis and exit plan is organized), transport to closest ER since pt is CTAS 1
TOR is contraindicated
I-Gel complications
Trauma to pharyngo-laryngeal framework, down-folding of epiglottis, gastric insufflation/ regurgitation and inhalation of gastric contents, nerve injuries, vocal cord paralysis, lingual or hypoglossal nerve injuries, if placed too high in the pharynx may result in poor seal and cause excessive leakage, laryngospasm
ETCO2 with a ROSC in cardiac arrest
Spikes are caused by large amount of acidic blood returning to the lungs and high amounts of CO2 diffuse into alveoli causing a sharp rise in ETCO2 levels that are higher than normal
If present complete pulse check and full assessment
ETCO2 in cardiac arrest
No CO2 production unless effective CPR, capnography gives feedback of CPR, ETCO2 <10mmHg indicates compressions are slow/deep enough, once circulation is restored there is a spike in ETCO2, ETCO2 <10mmHg suggests patients will not survive
Medical cardiac arrest medical TOR conditions
Age >16 years, LOA altered, arrest not witnessed by paramedic and no ROSC after 20 min of resuscitation and no defibrillation delivered
Interventions prior to EMS arrival
Pre-arrival interventions are not counted into patient care- it can be considered and documented
Sizes of King LTs
Yellow- size 3, 4-5ft tall, cuff volume 60ml, cuff pressure 60cmH20
Red- size 4, 5-6ft tall, cuff volume 80ml, cuff pressure 60cmH20
Purple- size >6ft tall, cuff volume 90ml, cuff pressure 60cmH20
I Gel- SGA
Medical grade thermoplastic elastomer that doesn’t require inflation
3 adult and 4 pediatric sizes- can be used between 2-90+kg, high seal pressures resulting in reduced trauma to the airway on insertion, alternative to OPA/BVM is unsuccessful or need for advanced airway, tip is designed to fit into proximal esophagus
Dead air space
Ventilated areas that do not participate in gas exchange
Total dead space= anatomic dead space (airways leading into alveoli) + alveolar dead space (ventilated areas in the lungs without blood flow) + mechanical dead space (artificial airways including ventilator circuits)
What are the causes of PEA
Hypovolemia, hypoxia, hyper/hypokalemia, hypothermia, H+ (acidosis), trauma, tension, tamponade, toxins, thrombosis
Airway management of cardiac arrest
OPA and BVM (15 LMP) ventilations, ETCO2 applied and aim for 45mmHg, suction as needed, SPO2 of 94-96
When advanced airway is placed compressions become asynchronous at a rate of 1 every 6 seconds (10 bpm)
Medical cardiac arrest epi treatment
dose 0.01mg/kg, max single dose 0.5mg, max # of doses 1
When do you insert an SGA
When BLS airways are ineffective or definitive need for a more advanced airway like prolonged extrication or ineffective management with other devices
Trauma cardiac arrest
Cardiac arrest secondary to severe blunt trauma
Treat the same as a medical cardiac arrest but maximum one shock/analysis
Medical cardiac arrest primary clinical considerations
Consider early transport after a minimum one analysis (and defib if indicated) once egress plan is organized: pregnancy >20weeks gestation, hypothermia, airway obstruction, non-opioid drug overdose/toxicology, or other known reversible cause of arrest
ROSC summary
A- Advanced airway if needed
B- provide optimal ventilation with waveform capnography (ETCO2 35-40mmhg and O2 sat 94-98%)
C- provide optimal perfusion what SBP >90 mmHg and treat hypotension with IV crystalloids, 12 with signs of ST elevation
D- consider raising the head of the bed by 30 degrees
Medical cardiac arrest CPR contraindications
Obviously dead, meet conditions of DNR standard
What do the police do in cardiac arrests
Manage spectators, protect scene, notify MD if TOR, notify coroner if needed, can help with family support
What is the second phase of the waveform
B-C: exhalation upstroke (deadspace gas mixes with lung gas)
What do you do if you have a ROSC then a re-arrest enroute
Resume CPR immediately, pull over, initiate immediate rhythm interpretation, treat accordingly, continue transport to closest ER, ensure rhythm analyses/ defibrillation can be done safely while enroute
Supraglottic airway medical directive treatment
Max number of attempts is 2
Primary method: ETCO2 (waveform capnography)
Secondary method: ETCO2 (non-waveform), auscultation, chest rise
Abnormal wave form- hypo/hyper ventilation
Hypoventilation: long slow wave forms
Hyperventilation: short fast wave forms
What is the first phase of the wave form
A-B: inspiratory baseline (low CO2 as its inspired air)
B is the start of alveolar exhalation
How does downtime in cardiac arrest management affect ETCO2
Short down time cause ETCO2 to give an accurate indication of quality of CPR
Long downtimes cause ETCO2 to remain low regardless of quality of CPR (vasodilation and sluggish blood flow prevent buildup of cardiac output)
Medical cardiac arrest manual defibrillation contraindications
Rhythms other than VF or pulseless VT
Medical cardiac arrest CPR conditions
LOA altered, performed in 2 min intervals
Abnormal waveform- bronchospasm
Shark-fin appearance
Asthma, COPD
Unshockable rhythms in cardiac arrest
Asystole, PEA (organized rhythm with no pulse)
When does the capnogram start and end
Begins before exhalation and ends with inspiration
Why is capnography important
Verification of proper tube placement
No waveform= no tube
5 main uses of ETCO2 in cardiac arrest
Verify tracheal tube placement, identify tracheal tube displacement, evaluate CPR quality, identify ROSC, determine when ROSC is unlikely
Definition of internal respiration
Gas exchange across the respiratory membrane in the metabolizing tissues like skeletal muscles
Definition of external respiration
Gas exchange across respiratory membrane in the lungs
What are the most common errors in prehospital defibrillation
Improper pad placement and poor adhesive contact
What is the third phase of waveform
C-D: continuation of exhalation (gas is alveolar now, rich in CO2)
D is the end tidal value at peak concentration
What does a ETCO2 <35mmHg indicate
Hyperventilation/ hypocapnia
How does a King LT work
Distal and proximal balloon to occlude esophagus and oropharynx (occludes esophagus to prevent gastric inflation/ aspiration), creates a direct route for ventilation/oxygen to the trachea and lungs
Abnormal waveform- CPR assessment
Attempt to maintain minimum of 10mmHg
ACR documentation for a cardiac arrest
CPR, PPV (BVM/rate), OPA (size/toleration), suction (how much/response), rhythm interpretations, advanced airway if placed (size/ tolerated), BHP patch (orders received), extrication (what was used), delays to CPR, scene delays, anything of note on scene, pt movement
Supraglottic airway medical directive clinical considerations
An attempt at an insertion is defined as the insertion of the supraglottic airway into the mouth, confirmation of SGA should use ETCO2 if unavailable/ not working then at least 2 secondary methods must be used
Contraindications for the King LT airway
Does not eliminate risk of vomiting and aspiration, high airway pressure can cause air to leak into stomach or out of mouth, do not use in patients with intact gag reflex, esophageal disease, or who have ingested caustic substance, airway obstructions
How does ETCO2 and cardiac output relate
when cardiac output is normal ETCO2 measures ventilation, when cardiac output is decreased ETCO2 measures cardiac output
Hypothermia in cardiac arrest
Consider environment and exposure time (remove pt from cold environment), consider early transport to closest ER as pt is CTAS 1
TOR contraindicated
Pulse checks every 10 sec
Focus on passive rewarming and gentle handling (excessive handling can cause lethal arrhythmias) and minimize movement of pt
Manage airways as needed (OPA/BVM over ETT)
