SAEDRecertification

Prepared by:

Program Co-ordinator:

Tim Dodd

Program Manager:

Ken Stuebing

Hamilton Health Sciences Base Hospital Program

Clinical Staff Medical Director

– Dr. Welsford Program Managers

– Steve Dewar– Ken Stuebing

Program Co-ordinator– Tim Dodd

Course Overview

Chain of Survival Pathophysiology Review

– Respiratory– Circulatory

Cardiac Monitoring Protocols Special Circumstances CPR & SAED Reminders

Chain of Survival Early Access (911)

– Someone must realize there is an emergency an act quickly to initiate the EMS.

Early CPR– A trained individual starts CPR at once to help

maintain a viable heart until help arrives. Early Defibrillation

– The first responder arrives with the training and equipment to defibrillate the heart. As time increases chances for survival decrease.

Early Advanced Life Support– ALS delivered within minutes also increases

the chance for survival.

Chain of Survival

RESPIRATORY SYSTEM

Respiratory SystemUPPER RESPIRATORY TRACT:Warms, Filters & Humidifies

»Nose / Mouth»Pharynx»Voice box

LOWER RESPIRATORY TRACT:Air Exchange

»Trachea»Bronchi»Bronchioles»Alveoli

LUNGSAir travels down the trachea until it enters alveoli.

GAS EXCHANGE ONLY HAPPENS IN THE

ALVEOLI!(STOP COMPRESSION &

give slow, gentle, deep breaths)

WHERETHE CIRCULATORY SYSTEM

ANDRESPIRATORY SYSTEM JOIN

How Air Enters The Lungs INSPIRATION:- Diaphram contracts. (drops)- Intercostal muscles contract.

(ribs go up & out)- Creates a negative pressure in the lungs (alveoli) in comparison to the atmosphere. - Atmospheric air rushes in to fill void. - Gas exchange occurs by diffusion.EXPIRATION:- Muscles relax Raises Pressure - Forces Air Out

QuickTime Movie

Oxygen Saturation

The paramedic will be able to initiate pulse oximetry monitoring and monitor the effectiveness of the patient’s respiratory status and treat to ensure that adequate and effective oxygenation is maintained.

How can the monitor be fooled?

Factors Affecting Oximetry Strong ambient light sources Poor circulation Cardiac arrest Hypothermia Shock Anemia CO poisoning Nail polish

Oxyhemaglobin Disassociation Curve

Take Home Points Oxygen saturation measurement may

be utilized to monitor a patient’s condition but should not be used to make decisions to restrict oxygen delivery when the patient appears ill or has a condition that may require supplemental oxygen.

Remember to treat the patient not the monitor. If the patient appears ill and you feel oxygen will benefit the patient, give oxygen! - it grows on trees.

Circulatory System

Expectation of the PCPKnowledge of Circulatory System

components (Pipes, Pump & Fluid)Knowledge of: heart conduction and

it’s relation to specific ECG waves as well as how these waves are related mechanically to the heart muscle

Specific rhythms

– NSR, VF, VT, PVC’s, Asystole, PEA, Artifact, Paced Beats.

The Heart (pump)

Echocardiography

Heart Valve Replacement

Blood Vessels - Pipes Arteries:

– carry blood away from the heart.– thick muscular walls. (3 layers)

Veins:– bring blood back to the heart.– thinner walls. (3 layers)

– have valves to stop back flow.– Is the spare blood reservoir.

Capillaries: 1 cell thick. (tissue paper)

– join arteries and veins together.– wraps cell & alveoli.– where diffusion takes place.

Blood Vessel Diseases Arteriosclerosis

– host of diseases which cause thickening & hardening of arterial walls.

– Plaque formation, calcium build up & occlusion of small branching blood vessels.

– Clots can dislodge and occlude smaller vessels.

Aneurysm– weakened area in the wall of

an artery will tend to balloon out & may burst.

Atherosclerosis

Angiogram

Angioplasty

Blood - Fluid Consists of:

– Red Blood Cells (RBC): which carries the oxygen from the lungs to the cells and carbon dioxide from the cells to the lungs.

– White Blood Cells (WBC): which is part of our immune system to fight against infection.

Blood - Fluid Consists of:

– Platelets: form the base for clots.– Plasma: water component which carries all

these components.– Clotting Factors: 12 factors which work in

a complicated cascade to form a clot. All 12 are needed and stored blood does not cave all 12.

Any factor affecting the ability of blood to carry oxygen to the heart and brain can cause tissue damage.

M.I. – Myocardial Infarction muscle / heart death

M.I. = death of the heart muscle

Death of the muscle is due to starvation of oxygen & nutrients.

Other causes . . .– disruption of blood

supply– blockage of a coronary

artery, aneurysm– asphyxiation– e.t.c.

Angina Pectoris Angina pain is caused

by an inadequate oxygen supply to heart.

Supply and demand– spasm, inability to open.

• stress, cold, MVO2. Pain is similar to that of

an MI– is usually relieved by:

rest, nitroglycerin, oxygen

STROKE or CVA CVA - Is very similar to an

MI, - irreversible damage is done to the brain by lack of blood supply.

Tissue death results from starvation of oxygen and nutrients.

Disruption of blood supply:– blockage of a cerebral

artery, aneurysm– asphyxiation,

strangulation– heart attack, e.t.c.

STROKE Oxygen and nutrients are

supplied to the brain by two arterial systems– carotid - left and right– vertebral - left and right

Blood is returned from the brain via two large veins (left and right jugulars)

Brain receives 20% of CO A Stroke occurs when the

brain is deprived of oxygen

Take Home Points

Stop compressions and allow time for diffusion of gasses.

Remember not all cardiac pain is the same.

If you are at risk for heart attacks you are at risk for stroke– a new stroke campaign is about to start in

our area

Cardiac Monitoring

Normal Electrical Conduction

Electrocardiogram

Dysrhythmia Interpretation: 5 Steps Approach Step 1: What is the rate?

– bradycardia < 60 bpm– tachycardia > 100 bpm

Step 2: Is the rhythm regular or irregular? Step 3: Is there a P wave - is it normal?

– are P waves associated with each QRS? Step 4: P-R Interval/relationship?

– PR interval (normal .12 - .20 sec) Step 5: Normal QRS complex?

– Normal QRS complex < .12sec

Lethal Dysrhythmias

There are four major life threatening Pulseless Dysrhythmias:– NON SHOCKABLE RYTHMS

1) Asystole - Flat Line

2) PEA - Pulseless Electrical Activity– SHOCKABLE RHYTHMS

3) VF - Ventricular Fibrillation

4) VT - Pulseless Ventricular Tachycardia

Asystole

No heart electrical activity

No excitation of the heart muscle

No Cardiac output

Normal Sinus Rhythm

Regular heart electrical conduction

Heart Rate avg. 72 beats / minute

Normal Cardiac Output

Pulseless Electrical Activity PEA is an electrical disturbance in

which an electrical stimulus is being generated but the muscle is NOT reacting.

DO NOT assume that since there is a rhythm on the screen that the patient has a pulse!!

Ventricular Tachycardia

Stimulus is originating from the ventricles

Heart (pump) is cavitating by beating too fast

Poor cardiac output, but may produce a pulse

The SAED will shock V.T. with-in preset limits.

Ventricular Fibrillation

No organized excitation of heart muscle

Heart is physically quivering compared to contracting (seizing)

No Cardiac Output

Chances of survival decline ~ 7 to 10 % for every minute that

defibrillation is delayed.

Defibrillation Defibrillation applies electrical energy

to the heart muscle This energy causes depolarization of

all heart cells at the same time. Therefore all repolarize at the same

time. We hope this starts an organized

perfusing rhythm We only apply a shock, via the

S.A.E.D, to the heart of a VSA patient

Other Rhythms

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

~ 90 bpm

Irregular

P waves normal, extra beats haveassociated P wave

0.12 - 0.20 secYes

PACs

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal? Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

Variable < 100

Irregularly IrregularNo P waves

None

Yes

Atrial Fibrillation

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

A = 300 bpmV = 75 - 150 bpm

Irregular -VariableSawtooth P waves - March through QRS

NA

Yes

Atrial Flutter

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

Variable ~ 100

Irregular

P waves Associatedwith most QRS

Yes - not allYes - but not all

PVC - unifocal

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

150

Regular

No P waves

NA

Yes

Accelerated Junctional

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

40-70

Irregular

P waves regularNot always with a

QRS

longer each beat

Yes

Second Degree AV Block Type 1

Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?

< 30 bpm

RegularP waves normal,

not associatedwith all QRS

None

Yes3rd degree Heart Block

Cardiac Monitoring and

Lead Placement3 & 5 Lead

RA (White): Place near right mid-clavicular line, directly below the clavicle.

LA (Black): Place near left mid-clavicular line, directly below the clavicle

LL (Red):Place between 6th & 7th

intercostal Space on left mid-clavicular line

RL (Green): Place between 6th and 7th intercostal Spac on right mid-clavicular line

V (Brown): Place to Right of sternum at the 4th

intercostal Space

Electrode Placement

BIPOLAR Leads or LIMB Leads (I,II,III)

BiPolar Leads I, II &III

Lead II

Lead III

Lead I

Take Home Points

Use the 5 step approach.– Remember where the lead is and what it

should look like. (lead placement can effect what you see)

– Use it or lose it. Remember Normal electrical

conduction path and rates. The monitor is a voltage gauge not a

pressure gauge - check the Pulse!

Protocols

Medical Protocol Completion

9 S H O C KS T O T AL 3 N O S H O C K SIN A R O W

R E T U R N O F A P U L SE

M ed ica l P ro to col w illE N D O N E O F T H R E E W A Y S

Guidelines 10 second pause between shock and

subsequent analysis to prevent accidentally missing a shockable rhythm

If Protocol ends with 3 “No Shocks” in a row If you receive:

• 3 “Check Patient” messages in a• 2 minute time frame • STOP the vehicle and Analyze• Result in:

–1 No Shock

–1 Stack of 3 Shocks

• Transport

3 2 1 Go

Hypothermia Cardiac Arrest

1 NO SHOCK

ANYWHERE

– Check pulse No Pulse

– CPR concurrent with transport

3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check Pulse

No Pulse– CPR transport

Blunt Trauma Protocol

This protocol does not include VSA patients as a result of penetrating trauma.

After adequate airway and c-spine management, apply AED and proceed with the following algorithm if Blunt Trauma is the suspected cause of the arrest.

Blunt Trauma Protocol 1 NO SHOCK

ANYWHERE– Check pulse– No Pulse CPR

concurrent with BTLS care

– Transport

3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check pulse– No Pulse CPR

concurrent with BTLS care

– Transport

Airway Obstruction 1 NO SHOCK

ANYWHERE– Check pulse– No Pulse– CPR– Transport

3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check pulse– No Pulse– CPR– Transport

Ventilate - Reposition - VentilatePerform visualisation of airway q 15 compressions

If cleared start protocol minus shocks delivered

Pulse Checks The defibrillator/monitor is a voltage meter

not a pressure gauge. It does not tell you if the patient has a pulse; it

is the operators responsibility to ensure the pulse is absent - it will defibrillate V-Tach >180 with a pulse into asystole!

Defibrillator pads are attached only to pulseless patients

Do not assume the patient has a pulse with the appearance of spontaneous respiration's

Defibrillator Errors If the defibrillator fails during a call,

complete the following actions. – Check the adherence of the pads;change

pads if required– Check the cables and connections– Change the battery– ALL these actions should take no longer

than 60 seconds– If you cannot solve the problem, abandon

the protocol and continue with BCLS only

Unusual Occurrences

Vomiting patient during charge up Pacemakers Automatic Implantable Cardioverter

Defibrillator(AICD) DNR orders

– unless the patient falls under the MOH Interfacility DNR directive, DNR orders will NOT be recognised in the field

When is the Defibrillator not attached to a VSA patient?

Age < 8 years old (new) Penetrating trauma Obviously Dead

Take Home Points

Complete one minute of CPR Initiate the appropriate protocol Complete the appropriate protocol Keep track of how many “No Shock

advised” in a row

CARDIOPULMONARY RESUSCITATIION

CPR

Role of CPR Integral component

of AED use CPR circulates

oxygen...– Prolongs heart’s

electrical activity– Minimizes brain

damage ...but defibrillation is

the definitive treatment

AdultCompression / Ventilation

Ratios 1 Rescuer:15:2

– 2 Rescuer: 15:2

Once airway is protected (ie. Intubated)

5:1 Ratio - pause compressions for ventilations to allow time for diffusion of gases!

Compressions Rates

Adult rate: 80-100 per minute Child rate: 100 per minute Infant rate: > 100 per minute Two Thumb method used for

infant compressions

QUESTIONS?