ResuscitationCME Fall 2011

• Morning– Welcome & Introduction– Housekeeping– CPR Recert– New Base Hospital Arrest Protocols

• Lunch & Flu shots

Agenda

• Afternoon– Autopulse rounds presentation (Base Hospital)– Dissection of Arrest ECGs– Lethal Rhythms– Manual Defibrillation– Autopulse Plus (shock / synch)– Skill Stations– Test

• Go Home

Agenda

• Audience Response Systems– ‘Clickers’– Will be used for games, challenges, tests

• SimMan 3G– State of the art patient simulator– Allows us to practice in a safe environment– Might seem spooky at first but great learning tool

New Training Tools

• Recent Changes in Resuscitation

– 2010 AHA ECC Guidelines• Reduce interruptions to compressions

– Base Hospital Arrest Protocols• Medical TORs

– Autopulse Plus (shock / synch)• Minimizes pauses in CPR

Background

• New Woodstock General Hospital– Emerg Patients enter through garage

• Garage holds 2 trucks• 1st truck in, clear out quickly for next vehicle• Caution leaving garage – blind corner to left

– Give report to RN at desk across from Trauma Rm• Do not go behind desk – patient confidentiality

– Non-Emerg / Transfers• Do Not Enter through Emerg / Garage• Use side entrance, park trucks outside

Housekeeping

• When patching in give:– Family MD (allows them time to contact doc)– MRSA / VRE status if known (from MARS sheet)

• When arriving:– Give health card to clerk with reason for visit

• Allows them to start registration• Can help expedite tests, labs, x-rays, etc• May not always be possible / practical (Code 4s)

TDMH

• When Patching give FRI status (+ve or –ve)– Any new or worsening cough– Shortness of Breath– Fever over 38 deg C.– Allows staff to prepare isolation precautions

All Hospitals

• Please refrain from pre-spiking IV bags– New drip set piece is sharp– Causes bags to leak if pre-spiked– Will most likely be switching to Baxter drip sets

• IV Locks– Will probably start stocking locks– Good for use when transporting to TDMH

IVs

• Doing a great job uploading ECGs• Procedures performed by 1 medic

– Unless its lifting, stairchair, extricate, etc

• Oxford policy – ACRs are completed for any call where you arrive scene (even if no pt)

• Please don’t use ‘Z’ procedure codes (ie Z301)• Will be placing OmniDrives in each truck soon• Working on having ability to upload calls from

hospital or on the road

ACRs

2012 Base HospitalNew Arrest Protocols

• Introduction of Medical TOR Protocol– ≥ 18 years– Unwitnessed Arrest– No ROSC– No Shocks Delivered

> BHP Patch for TOR

Medical Arrests

• Introduction of EPI where Anaphylaxis is suspected as the cause of arrest

– Give 0.01 mg/ kg to a max of 0.5 mg EPI 1:1000 IM

Medical Arrests

• Merging of Blunt and Penetrating Trauma protocols

• > 30 days old• VF/VT – 1 shock ER• Trauma TOR > 16 yrs• Asystole – Patch for TOR• PEA & Transport >30 mins – Patch for TOR

Traumatic Arrests

Autopulse RoundsDr. Sameer Mal - SWORBHP

Cardiac Arrest ECGs

Lethal RhythmsLethal Rhythms

• Review of the 4 lethal rhythm types

• Nothing new, reviewed annually during recerts

• Work on rapid recognition (5 seconds)

Lethal Rhythms & Manual Mode

Lethal Rhythm

Ventricular Tachycardia

• 3 or more consecutive ventricular complexes occurring at a rate of more than 100 bpm

• Could have an associated pulse or be pulseless

Ventricular Tachycardia

• Causes– Usually starts suddenly, triggered by a PVC– Usually a result of myocardial ischemia or

significant cardiac disease

Ventricular Tachycardia

• Other Causes– Electrolytic imbalance (Acid/Base, Na+, K+…)– CHF– Stimulants (ETOH, tobacco, C8H10N4O2)

– Drug Toxicity (digitalis, trycylics, antidepressants)– Sympathomimetics (cocaine, meth)– Prolonged QT

Ventricular Tachycardia

• Interpretation– QRS is WIDE– ≥ 0.12 seconds (same as LBB interpretation)– May appear distorted or bizarre– P waves may or may not be present – if present

usually dissociated from QRS– Rate > 100 bpm

Ventricular Tachycardia

• Types– Monomorphic

- one form, derives from one focus- every wave appears the same

Ventricular Tachycardia

• Types– Polymorphic

- generated by multiple foci- waveform appearance variable

Ventricular Tachycardia

• Types– Torsades de Pointes

- ‘twisting of the points’- conduction rotates, form of polymorphic

ALS Warning:Do NOT use antidysrhythmic drugs on Torsades

Ventricular Tachycardia

• Action – No Pulse?– Fast?– Wide?

SHOCK

Lethal Rhythm 2

Ventricular Fibrillation

• Chaotic ventricular rhythm results in ventricular ‘quivering’ and pulselessness

• Always pulseless

• Most common initial rhythm in sudden cardiac arrest

Ventricular Fibrillation• Causes

– Myocardial ischemia– AMI– 30 AV block with a slow ventricular escape rhythm– Cardiomyopathy– Digitalis Toxicity– Acidosis– Electrolyte Imbalance– Electrical Injury– Drug Overdose (cocaine, tricyclics)

Ventricular Fibrillation

• Interpretation– Chaotic– No discernible P waves or QRS complexes

Ventricular Fibrillation

• Types– Coarse VF

• Amplitude of > 3mm

– Fine VF• Amplitude < 3mm• May be very difficult to differentiate from asystole

Ventricular Fibrillation

• Action

SHOCK

Lethal Rhythm 3

Pulseless Electrical Activity

• Used to be called ‘Electromechanical Dissociation’

• Electrical activity is present but there are no resultant contractions

Pulseless Electrical Activity

• Causes – The 6 H’s and the 6 T’s– Hypothermia– Hypoxia– Hydrogen ions (Acidosis)– Hyper/Hypokalemia– Hypoglycemia– Hypothermia

Pulseless Electrical Activity

• Causes – The 6 H’s and the 6 T’s– Tablets / Toxins (Drug overdose)– Cardiac Tamponade– Tension pneumothorax– Thrombosis (MI)– Thrombosis (PE)– Trauma (Hypovolemia)

Pulseless Electrical Activity

• Interpretation– Patient is pulseless, apneic– Rhythm appears organized (anything from an escape rhythm to

normal sinus)– Slow & Wide -> PEA– Fast & Wide -> V Tach

Pulseless Electrical Activity

• Action– Ensure Pulselessness– Continue CPR

Lethal Rhythm IV

Asystole

• Flatline, absence of any electrical activity• Causes – 6H’s, 6 T’s, prolonged VF / VT / PEA

Asystole

• Interpretation– Flat line– Slow, wide, thin wave– May be fine V-Fib– Look at possible causes of death to help differentiate from VF

Continue CPR

Ventricular Escape Rhythms

Agonal Rhythms

Paced Rhythms

And now you know…

And Knowing is half the battle

Manual Mode

Do not be afraid

Using the E Series in Manual Mode• Turn on Defib as you normally would

– Press ‘Manual Mode’ soft key

Using the E Series in Manual Mode• Turn on Defib as you normally would

– Then press ‘Confirm’ soft key

Using the E Series in Manual Mode

• Ensure ‘Pads’ are selected (not Ld I,II or III…)

Using the E Series in Manual Mode• 120 Joules will be the default energy• After shock is delivered, energy will increase

– 150 J, 200 J

Using the E Series in Manual Mode• To evaluate a rhythm

– Stop CPR– Check Pulse– NOT MORE THAN 5 SECONDS– Press ‘Recorder’ button and print off strip (also marks event on

summary)

Using the E Series in Manual Mode• Resume CPR immediately then make your

defibrillation decision• (Shock / No Shock)

– You can use the rhythm strip you printed to make the decision after the pause

Using the E Series in Manual Mode

• If choosing to shock, press ‘Charge’ – (no need to press ‘Analyze’)– Confirm you have selected the proper

energy setting

Using the E Series in Manual Mode• Continue CPR until ready to shock then once all

rescuers are clear, press ‘Shock’ then resume CPR immediately.

– There should be a only very brief pause in compressions

Using the E Series in Manual Mode

To dump a shock, just hit the ‘Energy Select’ button (either arrow)

If really unsure whether to shock or not, the ‘Analyze’ button is always an option.

Using the E Series in Manual Mode

For PaedsKeep Defib in Semi Automatic and use pediatric attenuator pads

Autopulse Plus

AKA ‘Shock/synch’

Using Autopulse Plus

• The Autopulse now has the ability to coordinate defibrillation with the contraction cycle

• Allows for minimal interruption to compressions

• Can be hooked up initially or at any point in the call

Using Autopulse Plus

Using Autopulse Plus

• Connecting the Defib to the Autopulse– Connector site is located at the top of the

Autopulse next to the battery bay

Using Autopulse Plus

• Connecting the electrodes to the Autopulse

– Connect the defib pad electrodes by plugging them into the connector site (1)

– Ensure connector is firmly seated in the connector site

Using Autopulse Plus

• Connecting Defibrillator to Autopulse

– Connect defibrillator cable into connector site (marked ‘2’)

– Ensure cable is firmly seated

Using Autopulse Plus

Using Autopulse Plus

–When ready to interpret cardiac rhythm, pause compressions briefly for interpretation and pulse check if applicable

–Resume compressions immediately

Using Autopulse Plus

• Ensure appropriate energy and charge defibrillator if applicable

• Press ‘Shock’– Shock may be delayed as long as 800 ms to coordinate

with the upstroke of compressions from the Autopulse.

Using Autopulse Plus

Using Autopulse Plus

Using Autopulse Plus

Using Autopulse Plus