1. Agonal gasps
    • May be present in first minutes after sudden cardiac arrest
    • Pt who gasps usually looks like he is drawing air very quickly. Gasps may appear weak of forceful
    • Some time may pass between gasps as they usually happen at slow rate
  2. Quality compressions
    • Compress chest at least 2 inches
    • Rate btwn 100 to 120 per min
    • Allow complete chest recoil after each compression
    • Minimize interruptions to 10 sec
    • Avoid excessive ventilation
  3. What does defibrillation do?
    • DOES NOT restart heart
    • Rather, it stuns the heart and briefly terminates all electrical activity, including VF and pVT
  4. Primary assessment
    • Airway 
    • Breathing
    • Circulation
    • Disablility
    • Exposure
  5. Whats involved in airway (in primary assessment)?
    • Maintain patency in unconscious pt's
    • Use advanced airway if needed
    • Confirm proper integration of CPR & ventilation
    • Confirm proper placement of advanced airway devices by physical examination or quantitative waveform capnography
    • Secure device to prevent dislodgement
    • Monitor airway placement with continuous quantitative waveform capnography
  6. What's involved in breathing (primary assessment)
    • Give suppl O2 when indicated: cardiac arrest pt get 100%; others titrate O2 to achieve 94% or greater by pulse ox
    • Monitor adequacy of ventilation and oxygenation: chest rise and cyanosis, quantitative waveform capnography, O2 sat
  7. What's involved in circulation (primary assessment)
    • Monitor CPR quality: Quantitative waveform capnography
    • Attach monitor/defib for arrhythmia or cardiac arrest rhythms
    • Provide defib/cardioversion
    • Obtain IV/IO access
    • Give approp drugs to manage rhythm & BP
    • Check glucose & temp
    • Check perfusion issues
  8. When monitoring CPR, what to check for in:
    Quantitative waveform capnography
    Intra-arterial pressure
    If PETCO2 is less than 10 mmHg, attempt to improve CPR quality (PETCO2 is the partial pressure of CO2 in exhaled air at the end of the exhalation phase)

    Intra-arterial pressure : if diastolic pressure is less than 20mmHg, attempt to improve CPR quality
  9. Whats involved in Disability (Primary assessment)
    • Check for neurologic function
    • Quickly assess for responsiveness, levels of consciousness, and pupil dilation

  10. What's involved in exposure (Primary assessment)
    • Remove clothing to perform physical exam
    • Look for obvious trauma, bleeding, burns, unusual markings, or med alert bracelets
  11. What does secondary assessment consist of?
    involves differential dx, including med hx and H&T's

    Use SAMPLE along with H's & T's
  12. SAMPLE
    • Signs/Sx
    • Allergies
    • Medications (including last doses)
    • Past med hx
    • Last meal consumed
    • Events leading up to
  13. Most common causes of cardiac arrest
    H's and T's
  14. What are the H's
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion (acidosis)
    • Hypo/hyperkalemia
    • Hypothermia
  15. What are the T's
    • Tension pneumothorax
    • Tamponade (cardiac)
    • Toxins
    • Thrombosis (pulmonary)
    • Thrombosis (cardiac)
  16. What are the common underlying causes of PEA
    Hypovolemia and hypoxia, both potentially reversible
  17. Respiratory distress
    • clinical state characterized by abnormal respiratory rate or effort
    • Includes:
    • tachypnea
    • Increased resp effort (nasal flaring, retraction)
    • Hyperventilation/bradypnea
    • Tachycardia
    • Cyanosis
    • Change in LOC/agitation
    • Use of ab muscles in breathing
  18. Respiratory failure
    • Clinical state of inadequate oxygenation, ventilation, or both
    • Is end stage of respiratory distress
    • Includes:
    • Marked tachypenea
    • Bradypnea, apnea (late)
    • Increas, decre, or no resp effort
    • Tachycardia (early)
    • Bradycardia (late)
    • cyanosis
    • stupor, coma (late)
  19. Respiratory arrest
    • Absence of breathing
    • Usually caused by event such as drowning or head injury
  20. Most reliable way of confirming and monitoring correct placement of ET tube?
    continuous waveform capnography in addition to clinical assessment
  21. How to manage respiratory arrest
    • Give O2
    • Open airway
    • Provide basic vent
    • Use basic airway adjuncts
    • suction as needed
  22. How to properly measure OPA
    • Place OPA at side of face
    • When flange of OPA is a corner of mouth, and tip is at angle of mandible
    • Too large may obstruct larynx or cause additional trauma
    • Too small may push base of tongue posteriorly and obstruct airway
  23. How to properly measure NPA
    • Compare outer circumference with inner aperture of nares
    • NAP should be same distance from tip of nose to earlobe
  24. Acute Coronary Syndromes
    Any condition brought on by a sudden reduction or blockage of blood flow to the heart.
  25. Drugs for ACS
    • *Acute coronary syndrome - tx involves initial use of drugs to relieve ischemic discomfort, dissolve clots and inhibit thrombin and platelets:
    • MONA (Morphine, O2, Nitro, Aspirin)
    • Fibrinolytic therapy
    • Heparin
  26. Additional agents that are adjunctive to initial therapy for ACS
    • Beta-blockers
    • Adenosine diphosphate antagonists
    • ACE inhibitors
    • Statins (HMG-CoA inhibitors)
    • Glycoprotein llb/llla inhibitors
  27. In the prehospital setting, what steps does EMS take for ACS
    • Giving MONA (Morphine, Oxygen, Nitro, Aspirin)
    • Obtain initial 12 lead ECG
    • If EMS if trained, can give fibrinolytic therapy. If not, call ahead to ED
  28. Doses for MONA
    • If O2 <90, start oxygen at 4 L/min, titrate
    • Aspirin 160 to 325 mg
    • Nitro (subL or spray) 1once every 5 min, 3x max
    • Morphine by IV
  29. When trying to assess the EKG... what are the 5 questions???
    • 1. Whats the HR
    • 2. Is HR reg or irreg
    • 3. Is P wave present
    • 4. Is QRS present
    • 5. Is there a relationship w P + QRS
  30. What possible dx IF:
    HR is normal, btwn 60 -100 bpm...
    • Normal sinus rhythm
    • A flutter
    • A-fib
    • 1° block
    • 2° block type I
  31. What possible dx IF:
    HR is too fast @ 101 - 150 bpm...
    • Sinus tach
    • A flutter
    • A-fib
  32. What possible dx IF:
    HR is WAY too fast @ 150+ bpm...
    • V-tach
    • SVT/A-tach
  33. What possible dx IF:
    HR is too slow @ 30 - 59 bpm...
    • Sinus brady
    • A flutter
    • A-fib
    • 1° block
    • 2° block type I or II
  34. What possible dx IF:
    HR is WAY too slow @ <30 bpm...
    • V. Fib (no rate)
    • Asystole
    • 3° block
  35. "Sinus"
    relating to or denoting the sinoatrial node of the heart or its function as a pacemaker.
  36. Non-shockable rhythms
    • Asystole
    • PEA
  37. sinus bradycardia
    • a sinus rhythm with a rate that is lower than normal.
    • Generally resting HR btwn 30 - 59 bpm
    • Not necessarily life threatening, but could be a prob
  38. PVC
    • Premature ventricular contraction
    • Extra, abnormal heartbeats that begin in one of the heart's two lower chambers.
    • caused by an ectopic cardiac pacemaker located in the ventricle.
    • PVCs are wide & ugly
    • Characterized by premature and bizarrely shaped QRS complexes usually wider than 120 msec on with the width of the electrocardiogram (ECG)
    • Can be caused by caffeine, stress or meds
    • Something caused heart to be irritated & kicked off beat
  39. V-tach
    • Fast heart rhythm that starts in the lower part of the heart (ventricles). If left untreated, may get worse and lead to v-fib, which can quickly become lethal
    • Will go one way or another soon!

    • Regular rhythm
    • NO P WAVE
    • May or may not have a pulse = PEA
  40. V-fib
    The lower chambers quiver and the heart can't pump any blood, causing cardiac arrest.

    • Has no rate, no P-QRS complex
    • Irregular
    • No P Wave
    • Lethal!! Must be treated quickly
    • Shockable!

    Possible causes: hypothermic, electrical, electrolyte imbalance (hyperkalemia)
  41. Asystole
    • Nothingness
    • No rate, 
    • NEVER SHOCKABLE!! If you try to shock, you'll never bring back your pt
  42. PAC
    • Premature arterial contraction
    • Extra, abnormal heartbeat that starts in the upper chambers of the heart (atria).
    • look like normal rhythm
    • Can be caused by caffeine, stress, hot guy walks by...
    • Not prob unless symptomatic
    • Chronic PAC could need ablation
  43. SVT
    • Also called Atrial Tachycardia (A-Tach)
    • *this is the one that looks like P is cheating on QRS with T, T is humping P
    • Atria is no given time to completely fill up. 

    • Reg HR
    • P wave is present
    • QRS is present
    • Is a relationship w P-QRS, BUT unhealthy as it's moving too fast. Can't keep up for long
  44. S/S & tx for SVT
    • Can be caused from caffine, congenital heart disease
    • Will be SOB, increased HR, posturing due to oxygen deprivation

    #1 tx: vagal manuvers. Can also put pt face in ice water

    Pharm: ADENOSINE
  45. A-flutter
    • Problem with perfusing.
    • If perfusing, then overfilling ventricle before has chance to contract. 

    • Reg HR
    • No P wave 
    • QRS is present/ but not present
    • No relationship with P-QRS
  46. Tx for A-flutter
    • Cardiovert if symptomatic
    • Use drugs first, if that doesn't work shock

    *Concern is whether a clot is building with blood swirling in heart
  47. A-Fib
    Atria not contracting, blood just flowing. Clots can be developing

    • Reg rate
    • No P wave
    • QRS is present
    • No relationship
    • Narrow QRS
    • *can be lethal
    • People walk around in this rhythm all the type. They are put on coumadin used for prevention

    • Tx: Pharm first
    • Then shock
  48. 1° Block AV
    • Reg HR
    • P Wave is present
    • QRS is present
    • There is a relationship, but it is distant. 
    • They don't want to break up, but P & QRS is distant
    • Could be potential problem
  49. 2° Block AV Type I
    • Also called Winkie (Wenckebach)
    • Reg HR
    • Irregular P wave
    • QRS is present
    • No relationship!
    • It's a bad relationship as ventricular overfills and then a mega-bolus of blood gets pushed out
  50. 2° Block type II
    • Reg HR, but weird
    • P wave is present as is QRS
    • Bad relationship = Together/apart/together

    • Problem is volume is not being pumped out. 
    • Causes hypotension, clammy, pale, dizzy

    • Tx: fluids, meds to increase HR
    • Well ultimately need pacemaker
  51. 3° Block
    • Complete heart block
    • HR is too slow
    • Regular rhythm
    • P is present
    • QRS is present
    • No relationship btwn P-QRS. They are both individually reg, but not regularly together
    • Lethal!! Will code soon!
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