All the medical procedures and drug administration
mentioned in this text should be done only under a senior
doctor’s consultancy.
IN HOSPITAL CPR/AED
ALGORITHM
Safety first!
Assess for unresponsiveness: ‘Are you Ok’?
No response
Ask for help and assess the patient!
Open airway (head tilt & chin lift
or jaw thrust, on trauma only jaw thrust)
Breathing assessment (look, listen feel)
& simultaneously check for carotid
pulse (all these for 10 sec)
A)
The
patient breaths and has pulse:
Assess ABCDs, give
oxygen, obtain IV access (keep it open with NS normal saline
and also take blood for Labs), connect to monitor &
take a 12 Lead ECG. Recognize & treat any abnormality. If unconscious,
place on recovery position and ask for help (activate EMT
Emergency medical Team / call blue code & ask for defibrillator).
B)
The
patient has pulse, but is not breathing (apnoea):
Activate EMT Emergency medical Team /
call blue code & ask for defibrillator.
Give
1 rescue breath / 5-6 sec (10 – 12 breaths/ min). Recheck pulse
every 2min.
C)
In case the patient breaths
and has pulse, place the patient on a recovery position,
if unconscious and check ABCs.
D)
The patient is pulseless: activate
EMT Emergency medical Team / call blue code & ask for
defibrillator (standard or AED Automated External Defibrillator).
Start with 30 chest compressions and next give 2 rescue breaths.
Resume CPR (CPR compressions : rescue breaths ratio 30:2),
until AED arrives.
Compressions 100/min (depth 4 – 5 cm) in the middle of the chest.
Ventilations 1 breath/ 5 – 6 sec or 10 – 12 breaths/ min. The duration of each ventilation is 1 sec. The
tidal volume is about 500 ml/breath (6 – 7 ml/kg). Ensure full chest recoil with the compressions.
When the patient is intubated, then ventilations and compressions
are performed asyncronized.
Attach monitor/standard defibrillator/ AED. In case of an AED you
will hear the message of analyzing the rhythm. During analyzing
ensure that no one touches the patient!
Check Rhythm on the monitor of the standard defibrillator.
A)
Shockable rhythm (VF Ventricular
Fibrillation, pulseless VT ventricular Tachycardia)
1st shock:
Gel
(Place gel on the patient’s chest for the standard defibrillator)
Joules
(For a standard defibrillator Start with 120 J for biphasic defibrillator
and increase until 200 J at next shocks; In case you don’t
know the Joules, then start with the Joules that the device
opens on ‘defibrillator’. For monophasic give 360 J). For
an AED you don’t need to choose the Joules.
Before each shock remove oxygen supply
(nasal cannulae or oxygen mask or self inflating bag) 1
meter away or close the ventilator! Ensure no one touches
the patient including yourself and the person that ventilates
the patient!
Next say: ‘I am going to shock
on three. One, I am clear. Two, you are clear. Three, everyone
is clear’! Check visually that everyone is clear!
Then defibrillate.
Paddles (1st paddle below the right clavicle, 2nd
on the left axilla at the left mid-axillary line)
In case you have an AED just apply the
pads on the patient’s chest.
In case of a patient with a pacemaker or
an ICD (implantable cardiac defibrillator), place the defibrillator’s
pads or paddles at least 12 – 15 cm away from the pacemaker
or the ICD to avoid burning the myocardium!
A few sec before and also during the defibrillation check the monitor
(ensure that rhythm hasn’t changed and also that the defibrillation
has commenced)
Resume immediately CPR for 5 cycles of 30:2 (2 min)
Reassess rhythm & pulse, and so on.
B)
Non – shockable rhythm (asystole, PEA Pulseless
Electrical Activity). In
case of an AED you will hear the message of continuing (resuming)
CPR.
Resume immediately
CPR for 5 cycles of 30: 2 (2 min)
Check rhythm
NOTES:
·
When AED is analyzing
the rhythm and also during the defibrillation ensure that
no one touches the patient (including yourself and also
the person that ventilates the patient).
ACUTE CORONARY SYNDROME (ACS)
It is classified to STEMI (ST elevation Myocardial Infarction)
and NSTEMI (Non ST Elevation
MI)/ UA (Unstable angina). Chest pain on MI lasts usually > 15 min, but pts with DM (Diabetes Mellitus)
may not have pain!
Unstable angina is characterized by angina of effort with increasing
frequency over a few days and provoked by less exertion.
ECG may be normal, however ST depression and/or Troponin
release suggest high risk patient.
Initial therapy on ACS, after the ABCs, is MONA, but
as OANM.
·
O (Oxygen): Give Oxygen
nasal cannula at 1 – 4 L/min. For more severe cases give
O2 with non rebreathing mask at 15 L/min. Keep SpO2 oxygen
saturation > 90%.
·
A (ASA, Aspirin): Give
aspirin 160 – 325 mg, CHEWED. CI (contraindications) are
hypersensitivity to salicylates, known bleeding disorder
(e.g. hemophilia), active peptic ulcer and recent GI (gastrointestinal)
bleeding.
Assess vitals, apply cardiac monitor,
obtain a 12 lead ECG, initiate a IV line of normal saline
and take blood for Labs including cardiac enzymes (e.g.
CK – MB) and cardiac markers (Troponin I & T), electrolytes
and coagulation studies.
·
N (NTG , Nitroglycerine): give up to 3 NTG tablets
(each tablet 0.3 – 0,4 mg) OR 3 sprays (each puff of 0.4
mg), 5 min APPART.
CI (contraindications) to NTG is SBP (systolic
BP) < 90 mmHg or BP< 30 mmHg below baseline, HR <
50 or > 100, erectile drugs (Sildenafil – Viagra or Vardenafil
– Levitra the last 24 h or tadafil – Cialis the last 48
h), intracranial bleeding, aortic or mitral stenosis or
HOCM and also on Right Ventricular Infarction.
·
M (morphine) 2 – 4 mg
slowly IV push. CI are hypersensitivity to it or other opiates
and also signs of CNS depression (e.g. respiratory depression,
decreased BP or decreased HR). Give morphine only if 3 NTG
treatments fail to relieve COMPLETELY the patient’s chest
pain/ discomfort.
Inclusion criteria for fibrinolytic therapy include:
·
ST segment elevation > 0.2 mV in 2 adjacent chest
leads or > 0.1mV in 2 or more adjacent limb leads (ACLS protocol: ST elevation >_ 1 mm in >_
2 contiguous leads).
·
New or presumably
new LBBB.
·
Dominant R waves &
ST depression in V1 – V3 (posterior infarction).
The above 3 signs are conclusive only
with a 12 lead ECG.
·
Signs and symptoms of
ACS.
·
Onset of symptoms <
12 h ago.
·
Exclude CI (contraindication) for thrombolytic therapy!
Absolute
contraindications are previous haemorrhagic stroke, ischemic
stroke during the last 6 months, CNS damage (and also AV
malformation, aneurysm, tumour, surgery) or neoplasm, recent
(within 3 weeks) major surgery, head injury or other major
trauma. Also CI are active internal bleeding (not menses)
or GI (gastrointestinal) bleeding within the last month,
known or suspected aortic dissection, known bleeding disorder
e.g. haemophilia.
·
Relative contraindications are: refractory hypertension (systolic BP> 180,
diastolic BP > 110), TIA (transit ischemic attack) the
last 6months, oral anticoagulation, pregnancy or < 1
week postpartum, traumatic CPR (prolonged > 10 min with
evidence of thoracic trauma), non compressible vascular
(especially arterial) puncture, active peptic ulcer, infective
endocarditis, advanced liver disease or advanced cancer
or severe renal disease and previous allergic reaction to
the thrombolytic to be used. If streptokinase has been given
> 4 days previously, give a different thrombolytic (because
of antibodies to it).
·
ACS: ABCs, vitals,
MONA (as OANM), monitor, 12 lead ECG, establish IV access
(keep it open with NS normal saline, take blood for Labs
including coagulation, electrolytes, CK – MB and Troponins
I &T), CXR (< 30 min).
STEMI ACLS algorithm (ST elevation or new or presumably new LBBB)
β’ blocker
ASA (aspirin)
clopidogrel
< _12 h from symptoms onset
PCI (ER/ ED emergency room/ department door to PCI goal time 90min)
or fibrinolytics (ER/ ED emergency room/ department door to fibrinodolysis
goal time is 30 min).
Also within 24 h give ACE inhibitors or ARBs (angiotensine receptor
blockers) and statins.
NSTEMI (ST depression or T inversion)/ high risk UA ACLS algorithm
NTG
β’ blockers
clopidogrel
UFH or LMWH
Glycoprotein IIb/IIIa (eptifibatide or tirobifan)
Admit to monitored bed
Assess risk
High Risk (refractory chest pain, recurrent/ persistent ST deviation,
VT ventricular tachycardia, signs of cardiac failure, hemodynamic
instability)
Early invasive strategy including catheterization and revascularization
for shock, within 48 h of MI (Myocardial Infraction).
Also aspirin (ASA), ACE inhibitors or ARBs & statins.
Intermediate/ low risk UA (normal or non diagnostic changes on ST/
T waves) ACLS algorithm
ST depression or increased Troponins?
If Yes, go to NSTEMI/ high risk UA algorithm (above)
If No, admit to ED chest unit or ER monitored bed with ECG monitoring
& repeated 12 lead ECG and serial cardiac markers.
NOTES
·
On
chest pain/ discomfort with a non diagnostic ECG and with
negative troponins, take a targeted history, establish continue
monitoring, take serial 12 lead ECGs (every 3, 6 and 12
h, or sooner if indicated), check vitals frequently and
repeat cardiac markers and enzymes (CK- MB
and Troponins I & T). Don’t discharge if you don’t exclude
ACS.
·
On
chest pain ask if pain is pleuritic (on inspiration) and
also if deteriorates with patient’s movements are with palpation.
However, these can’t exclude an ACS! Also patients with
DM (diabetes mellitus) may have MI without chest pain. Also
on these patients DKA (diabetic Ketoaxidosis) may be ought
to MI (Myocardial Infraction).
PULSELESS ARREST, ALS (Advanced life support) ALGORITHM
For initial steps see above ‘in hospital CPR/AED’ algorithm.
Attach monitor/ defibrillator
a.
Shockable rhythm (VF, pulseless
VT).
1st shock:
Gel
(Place gel on the patient’s chest for the standard defibrillator)
Joules
(For a standard defibrillator Start with 120 J for biphasic defibrillator
and increase until 200 J at next shocks; In case you don’t
know the Joules, then start with the Joules that the device
opens on ‘defibrillator’. For monophasic give 360 J). For
an AED you don’t need to choose the Joules.
Before each shock remove oxygen supply
(nasal cannulae or oxygen mask or self inflating bag) 1
meter away or close the ventilator! Ensure no one touches
the patient including yourself and the person that ventilates
the patient!
Next say: ‘I am going to shock
on three. One, I am clear. Two, you are clear. Three, everyone
is clear’! Check visually that everyone is clear!
Then defibrillate.
Paddles (1st paddle below the right clavicle, 2nd
on the left axilla at the left mid-axillary line)
In case you have an AED just apply the
pads on the patient’s chest.
In case of a patient with a pacemaker or
an ICD (implantable cardiac defibrillator), place the defibrillator’s
pads or paddles at least 12 – 15 cm away from the pacemaker
or the ICD to avoid burning the myocardium!
A few sec before and also during the defibrillation check the monitor
(ensure that rhythm hasn’t changed and also that the defibrillation
has commenced)
1st shock
Biphasic 120 – 200 Joule.
or Monophasic 360 J.
Resume immediately CPR for 2 min (5 cycles
of 30:2 CPR)
Check monitor/rhythm
Shockable rhythm
2nd shock
Biphasic 200 Joule
or monophasic 360 J.
Immediately resume CPR for 2 min
Epinephrine (adrenaline) 1mg rapid IV/IO
push
Check monitor/ rhythm
Shockable rhythm
3rd shock
Immediately resume CPR for 2 min
Amiodarone 300 mg (diluted in 20 – 30
ml D5W 5% dextrose) rapid IV/IO push
ACLS: Repeat amiodarone at dose of 150
mg (diluted in 20 – 30 ml D5W rapid IV/IO push 3 – 5 min
after the initial dose.
4th shock
etc.
ΝΟΤΕS:
·
Give epinephrine (adrenaline)
every 3 – 5 min (after alternating shocks or every 2nd loop).
According to ACLS, alternative to 1st dose of
adrenaline is vasopressin 40 units once (in this case give
epinephrine 10 min after vasopressin).
·
Rotate compressors every
2 min.
·
Alternative to amiodarone
is lidocaine 1 – 1.5 mg/kg rapid IV/IO push which may be
repeated at 0.5 – 0.75 mg/kg every 5 – 10 min. Max total
dose of amiodarone is 2.2 gr/ 24h.
·
For
refractory VF ventricular fibrillation with hypomagnesaemia
you should give 2 gr bolus (4ml, 8 mmol) of 50% MgSO4 (magnesium
sulphate) diluted in D5W (5% dextrose). For VT ventricular
tachyarrhythmias with hypomagnesaemia, Torsades de pointes,
AF (atrial fibrillation) and digoxin toxicity; give 2 g
MgSO4 over 10min IV.
b.
Non shockable rhythm (asystole
or PEA)
In case of asystole
1.
Check another lead.
2.
Check if electrodes are
detached.
3.
Increase Gain and sensitivity
of the monitor.
On asystole or PEA:
·
Resume CPR.
·
Perform ET (endotracheal)
intubation and establish IV/IO access.
·
Give epinephrine 1mg
rapid IV/IO push. Repeat every 3 – 5 min (every 2nd
loop. According to ACLS, alternative to 1st dose
of adrenaline is vasopressin 40 units once (in this case
give epinephrine 10 min after vasopressin).
·
Also give atropine 3
mg once rapid IV push, on asystole or PEA with HR < 60.
·
On PEA ACLS suggests
to give 500 ml bolus normal saline (hypovolaemia is the
commonest cause of PEA).
·
Check also reversible
causes (6 Hs and 6Ts).
TERMINATION OF ALS
Consider termination of ALS (advanced life support) if acceptable
BLS (basic life support) was provided, advanced airway was
placed and successfully maintained, shockable rhythms were
defibrillated, IV/IO access was established, al the appropriate
drugs were administered, potentially reversible causes were
ruled out or corrected and the family has been updated on
the probable negative outcome of continued ALS.
NOTES ON ARREST:
·
Epinephrine (adrenaline)
dose is 1 ml of 1: 1000 or 10 ml of 1: 10.000 solution.
·
Every drug administration
should be followed by 20 ml flush of normal saline and extremity
elevation for 10 – 20 sec.
REVERSIBLE CAUSES OF ARREST TO RULE OUT OR CORRECT
Reversible causes to be excluded and corrected in arrest are the
6 Hs & 6 Ts.
The 6 Hs include Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia,
Hypoglycemia and Hypothermia.
The 6 Ts include Toxins/Tablets
(poisoning), Tamponade cardiac, Tension pneumothorax, Thrombosis
coronary, thrombosis pulmonary and Trauma.
·
Hypovolaemia causes narrow
QRS tachyarrhythmia.
·
Hypoxia causes narrow
QRS bradyarrhythmia.
·
Acidosis usually causes
bradyarrhythmia or other arrhythmias.
·
Hyperkalemia causes very
tall (tended) peaked T waves (T waves larger than R waves
in > 1 lead !), 1st degree AV (atrioventricular)
block, sinus bradycardia, AV blocks, flattened or absent
P waves, ST depression (!), S & T waves merging, wide
QRS, VT, arrest (pulseless VT, VF, asystole, PEA).
·
Hypokalemia causes QT
prolongation (such as hypomagnesaemia), flat T wave, 1st
degree AV block, U waves (!), ST elevation (!), variable
arrhythmias, VT, arrest (pulseless VT, VF, asystole, PEA).
·
Hypoglycemia causes tachycardia
(may not appear if on β’ blockers).
It also may cause ST depression or AV block. It also (as
well as liver failure) may cause hemiplegia and other focal
neurological signs and seizures.
·
Cardiac tamponade causes
narrow QRS tachyarrhythmia or PEA.
·
Tension pneumothorax causes narrow complex tachyarrhythmia
or bradyarrhythmia (because of the hypoxia) or may cause
PEA.
·
Οn hypovolemia
give 500 ml normal saline bolus and reassess.
·
Except trauma, suspect
hypovolemia from dehydration (e.g. high fever and/or severe/
prolonged diarrhea and/or vomiting).
·
On hypoxia and acidosis
ensure effective oxygenation and ventilation. Then consider
on acidosis sodium bicarbonate.
·
Sodium bicarbonate is indicated
in metabolic acidosis (check ABGs arterial
blood gases) – e.g. on hyperkalaemia, TCAs tricyclic antidepressants,
aspirin, phenobarbital, diphenydramine and cocaine) OD (overdose)
and also on prolonged (>10min) arrest. Don’t give it
in patients with hypercarbic acidosis.
Bicarbonate’s dose is 1 mEq /kg (1mMole/Kg
or 1 ml/kg) of 8.4% solution IV/IO. Ventilate the patient
after bicarbonate administration. Don’t give it with catecholamines
(e.g. adrenaline or dopamine) at the same IV line (at least
flush the line first with normal saline).
·
Suspect electrolyte abnormalities
on history (renal failure, recent dialysis, diuretics, severe
diarrhea or vomiting etc).
·
On hypothermia do only
1 defibrillation and withhold drugs until core body temperature
is > 30 degrees C (86 degrees F).
·
On poisoning/ overdose
consider decontamination, gastric lavage, active charcoal,
whole bowel irrigation, dialysis, antidotes.
·
Tension pneumothorax
is characterized by JVD (jugular vein distension – if not
hypovolemic), absent breath sounds and hyper- resonance
on the affected side, decreased compliance on ventilating.
Late sign is contralateral tracheal shift.
·
Massive pulmonary embolism
is characterized by sudden onset of
dyspnea, pleuritic (on inspiration) chest pain, cyanosis,
and JVD. It may cause PEA.
·
Tension pneumothorax,
cardiac tamponade and pulmonary thrombosis are obstructive
causes of PEA.
ABCs ASSESSMENT
A: airway (and C spine immobilization on suspected injury):
Is the airway patent and safe (e.g. the patient talks) or
threatened (e.g. stridor or ‘snoring’) or obstructed?
B: Breathing: RR (respiratory rate) and depth. Shallow or
labored breaths? Increased breathing labor?
Bilateral normal thoracic expansion or not (e.g. on flail chest)?
Auscultation (bases and apices, check if breath sounds are bilaterally
normal or decreased or absent), percussion (normal, hyper-
resonant – tympanic, decreased resonance, stony), SpO2 (oxygen
saturation).
Give Oxygen (see below).
C (circulation): Pulse (radial and then carotid).
Weak, fast, slow, thready? Regular or irregular?
BP.
Attach monitor.
Perform 12 lead ECG.
IV/IO access. keep it open with normal saline.
Take blood for CBC/ FBC (full/ complete blood count), biochemistry
(glucose, BUN blood urea nintrogen, creatinine, LFTs liver
function tests), electrolytes, coagulation studies (Platelets,
PT, aPTT, D’ dimmers, INR), cardiac enzymes (e.g. CK – MB)
and markers (Troponin I & T),
pregnancy test, urinalysis, amylase, lipase, toxicology
(medications, illicit drugs, alcohol). Consider also TFTs
(thyroid function tests) on arrhytmias.
On suspected hypovolemia ask type & crossmatch and ask for
e.g. 4 units P-RBCs.
On women at reproductive age ask pregnancy test.
Glucose finger stick and urine dip stick.
Capillary refill (normal < 2 sec on 5 sec finger pulp pressure).
Skin color and temperature. Cyanosis?
Cardiac failure signs such as JVD (also in tension pneumothorax
and cardiac tamponade and PE pulmonary embolism) , ankle
edemas, lungs bases crepitations,
pulsus alterans and on children liver distension).
Also ABGs.
D: Disability: AVPU or better GCS, pupils (size and reaction
to light) and abnormal body postures (stereotypical flexion
if decorticate, or stereotypical extension if
decerebrate).
E: Expose/environment: Expose, Log Roll, check
for trauma or other signs (rash, angioedema etc). Next,
prevent hypothermia (with blankets).
PRIMARY SURVEY AT A GLANCE
·
Primary
survey.
·
On
A (airway)
we check the airway’s patency. A is also C Spine immobilization
(on suspected injury). We open airway with jaw thrust or
chin lift (we use jaw thrust on suspected C – spine injury),
we do suction (e.g. of vomits), we place an oropharengeal
airway (if the airway is endangered and also if no gag reflex)
and consider a permanent airway (e.g. ET intubation). On
A we also check tracheal position and also for JVD (jugular
vein distension).
·
Traps
on A (airway) are cribiform and face trauma and base skull
fracture with ear or nose leakage of CSF, racoon eyes and
Battle sign with haematoma behind the ears and also blood from the ear. In the
above cases the nasal airway or the nasogastric tube may
enter to the brain so its use is contraindicated!).
·
On
B (breathing) we check RR (respiratory rate), chest expansion
(if it is equal bilaterally, otherwise suspect e.g. flail
chest), we ausculate the chest (is breathe sound bilaterally
equal?), we percuss the chest (any tympany?) and take oxygen
saturation (SpO2). If RR is < 10 or > 30 (in adults)
and/or GCS <_ 8 we ventilate with BMV (bag mask ventilation)
or intubate (we use RSI rapid sequence intubation if GCS
is >3).
·
Traps
on B (breathing) are vulnerable ages (on children rib fractures are rare, if they occur
they indicate severe lung injury;
the elderly are vulnerable and they may also suffer
from pulmonary oedema after a high fluid resuscitation (e.g.
on lung contusion).
·
On
C (circulation) we check pulse (radial and carotid; Is it fast and thready?), BP, pulse
pressure (SBP systolic BP – DBP diastolic BP). We obtain
vascular (IV/IO) access (2 wide IV lines – grey or orange).
On hypovolemia we give 500 ml NS (normal saline) or RL (Ringers
- Lactated) and reassess (we may give e.g. 1 – 2 Lt fluids)
and also consider early to transfuse blood (if not type
available give Group O Rh negative). Fluids should be warm
(39 degrees C). On children we give 20 ml/kg fluids. On
no response, we repeat 20 ml/kg and if shock still remains
we give 15 ml/kg packed red blood cells PRC to 10 ml/kg
crystalloids or we give 10 ml/kg whole warmed blood. On
hypovolaemic newborn we give10 ml/kg fluids over 5 – 10
min.
After IV access
we also take blood for Labs (including pregnancy test on
women, toxicology, coagulation and blood type and crossmatch
– we ask blood units for transfusion). We also look the
color and temperature of the skin (a cold clammy skin may
indicate shock, however exclude low ambient temperature!),
the capillary refill timer (normal is when < 2 sec, on
5 sec finger nail pressure) and LOC (level of consciousness).
We also connect
to a monitor, and – if indicated (e.g. heart contusion)
– we take a 12 lead ECG. If there is time, we may also take
ABGs to check for
acidosis.
·
On
D (disability) we check AVPU (Alert, React to voice, Reacts to pain, Unresponsive), or
if there is time (and always on head trauma) we check GCS
(Glasgow comma scale). We also check pupil’s size & reaction to light and also
for abnormal postures of flexion (decorticate) or extension
(decerebrate).
·
Traps
on D (disability) are intoxicated patient, or under illicit
drugs influence. On a patient with head trauma do not attribute
the decreased level of consciousness on drugs or alcohol,
unless you exclude head pathology (e.g. increased ICP intracranial
pressure). This is also the case in general for a patient
with trauma. Other traps is the lucid interval on epidural
hematoma, brain’s vasoconstriction from hyperventilation
and also ICP increasing with intubation (prevent it with
lidocaine as premedication of RSI rapid sequence intubation,
and etomidate as an anaesthetic– the last is contraindicated
on hypotension – in that case stabilize the patient e.g.
with fluids and perhaps with surgery).
·
Ο E (Expose, Environment) we expose the patient (from his/her clothes) and check the
skin for clues (wounds, rash, belt sign etc). We also perform
log roll and check the back. Next we prevent hypothermia
e.g. with blankets. E is also to call
Expert!
·
Traps on E are hypothermia
which complicates clotting.
·
Aids on ABCDs are ABGs (arterial
blood gases), SpO2 (oxygen saturation), capnographer (CO2
detector after intubation), Foley, Levine (nasogastric tube),
ECG, DPL (diagnostic peritoneal lavage) and FAST.
·
Don’t forget to check
the patient’s temperature!
·
‘TREAT
FIRST WHAT KILLS FIRST’!
·
‘TREAT
AS YOU GO’!
·
Secondary survey is the examination
from head to toes. We check pulses and also check for lacerations,
edema, deformity, paleness, tenderness, crepitation, surgical
(subcutaneous) emphysema, joints mobility, sensory examination,
reflexes and neurological examination etc. We use X’ Rays,
Doppler, CT etc.
·
The
emergency needs to be transferred to the nearest APROPRIATE (trauma) medical centre/
hospital.
·
TRIAGE
is based to factors such as ABCs, the available
means (personnel and devices), if we have a mass destruction,
the number of victims, the time and distance for definite
care, the severity of the injury and the bigger chance for
survival (in case of a patient with a very serious injury
that is not compatible with life, or in a case of no pulse,
we go on with the rest patients and ‘flag’ this patient
black – or blue in some countries – i.e. expectable to die).
Triage is continuing (dynamic).
·
We
do not forget log roll.
·
On
secondary survey always we ask AMPLE (Allergy, Medication, Past medical history, Last meal and Environment/Events),
however many prefer to ask it from the very first.
OXYGEN ADMINISTRATION
On patients WITHOUT significant
hypoxia (SpO2 Oxygen saturation) and WITH ADEQUATE breathing
give oxygen with nasal cannula 2 – 4 L/min.
On patients WITH significant
hypoxia but ADEQUATE breathing give O2 (oxygen) with non
rebreathing face mask with reservoir bag and flow 15 L/min.
In case of INADEQUATE breathing
or APNEA perform BMV bag mask ventilation with self inflating
bag with reservoir and oxygen supply and flow 15 L/min.
Keep always SpO2 oxygen
saturation > 90%.
STROKE ACLS ALGORITHM
Possibility for stroke
1)
Confusion, decreased LOC
(Level of consciousness).
2)
Cincinnati Prehospital Stroke Scale:
1 of the following suggests possibility for stroke:
a)
Facial droop (‘smile’)
b)
Arm drift (‘raise both
arms with your eyes CLOSED’)
c)
Speech (slurred, mute,
inappropriate words, dysarthria).
3)
Symptoms NOT improving
spontaneously (differential diagnosis with TIA transit ischemic
attack).
The above criteria are
also criteria for fibrinolytic therapy (alteplase rTPA)
Plus
Intracranial hemorrhage
ruled out with head CT.
·
ABCDs. Give
oxygen. Initiate IV line of normal saline NS. Perform ECG. Transport/ transfer patient for definite care
(stroke unit).
·
Perform a non contrast
CT. Don’t give any drug before the CT.
·
CT initially may not
show ischemic stroke.
·
On Lab tests don’t forget
to ask for glucose and also coagulation studies. However,
do as soon as possible a glucose finger stick test to exclude
hypoglycemia which may mimic stroke.
·
Don’t give D5W (5%dextrose)
on stroke! Give normal saline NS.
·
The goal time for fibrinodolysis
is < 3 h from symptoms onset and < 60min from ER –
ED (emergency room/ department) arrival (door to treatment
time).
·
Fibrinolytic therapy
has as complication about 6% brain hemorrhage.
·
Do not decrease the BP
fast. Call Expert.
·
Correct glucose if high
or low (with symptoms).
·
Correct electrolytes.
·
Treat cardiac dysrhythmias
if unstable, but don’t treat immediately AF (atrial fibrillation).
Call an expert.
·
Check CI (contraindications)
for thrombolysis e.g. a SBP > 185 or a DBP> 110 are
CI.
LARYNGEAL MASK
It has many advantages.
We put it with normal saline, not gel. We place it holding it as
a pen (with our index and thumb), until we feel resistance
(our index finger enters completely in the mouth following
the tongue’s rout. On the end of the tongue’s rout we may
enter the tube a little
bit more with the fingers of our other hand). Then we inflate
the cuff. We remove it inflated!
Size is for women and small men 3 – 4 (usually 4), and for men
4 – 5 (usually 5). We inflate the cuff with tube’s size
x 10 – 10 e.g. for tube size 4 we inflate with 4 x 10 –
10 = 30 ml air.
ET (ENDOTRACHEAL) INTUBATION
On adults we use curved blade size 3 or 4. Initially we preoxygenate
the patient for 2 – 3 min. We assemble the equipment (ET
endotracheal tube, syringe, gel, laryngoscope, SUCTION,
exhaled CO2 detector, Magill’s forceps) and we insure that
the light of the laryngoscope is OK and that the cuff inflates.
We insert the laryngoscope at the right angle of the mouth,
holding it with our left hand, and visualize the vocal cords.
We don’t flex our wrist during laryngoscopy. Then, we insert
the ET (which we have been lubricated with gel). We inflate
the cuff with 5 – 10 cc air (usually 8 – 10cc). We ausculate
both lungs (axillae) and epigastrium (ensuring bilateral
normal breath sounds and absence of gastric bubbles, if
breath sounds are less on the left we deflate the cuff,
withdraw a few cm the tube, inflate the cuff and recheck)
and attach an end tidal CO2 (carbon dioxide) detector (capnographer
or oesophagal detector). Then we secure the tube and ventilate.
When we extubate, we do not forget to deflate the cuff.
The insertion depth of the ET is about 22 cm on women and 24 cm
on men.
The size of ET tube on adults is 8 – 9 mmID on men and 7 – 8 mmID
on women.
Nover forget to deflate the cuff before extubating.
In case you have another rescuer, you can perform Sellick maneuver
during intubation, in order to prevent aspiration. However,
if aspiration occurs release the Sellick maneuver, otherwise
you may cause oesophagal perforation. In that case turn
the patient on his/her size and perform suction.
The duration of intubation is 1 breath holding (30 sec). In case
this time lapses and we haven’t intubated, we stop intubation
and continue BMV.
The positive pressure ventilations rate is 10 – 12 breaths /min
or 1 breath every 5 – 6 sec with BMV (bag mask ventilation).
The duration of each ventilation is 1 sec. The tidal volume
is about 500 ml/breath (6 – 7 ml/kg).
Alternative device for detecting correct tube placement is the
oesophagal detector. However the safest method is a CXR
(chest X’ Ray) where we see the ET just above the level
of the carina.
ITD DEVICE
ITD device is Impendence Threshold Device. It attaches to the self
inflating bag mask or the tracheal tube. It let the patient
to exhale if spontaneous breathing returns. It also does
not permit the equalization of negative intra-thoracic pressure
in case of hyperventilation. When we use it with BMV (bag
mask ventilation), two rescues need to perform ventilation.
When we open the ITD it has lights that open 10 times/min.
During each light we ventilate.
FOREIGN BODY AIRWAY OBSTRUCTION ACLS ALGORITHM
a. The patient is conscious.
·
On a patient that chokes
from a foreign body:
1.
If the patient is conscious
and the cough is effective, we encourage the patient
to cough.
2.
If the patient is conscious
and the cough isn’t effective we give with our palm
(thenar) 5 back blows between the patient’s scapulae &
5 abdominal thrusts (Heimlich maneuver). On pregnant and
obese patients we give chest thrusts and not abdominal.
We reassess. We open the patient’s airway and remove any visible
object (or use suction, if available).
If still not adequate breathing, we call for help.
b. The patients is unconscious
Safety first
Check for unresponsiveness. ‘Are you OK’?
No response
Call blue code and ask a defibrillator
Open airway
Remove any visible object (or perform suction, if available)
Check for breathing (look, listen feel, 10 sec)
No breathing
Give 2 ventilations
Unsuccessful
Reposition the patients head (increase the extension) and ventilate
again
Unsuccessful
Give 30 chest compressions
Check mouth for foreign body and remove it if visible
Unsuccessful
Visualize vocal cords with a laryngoscope and remove the foreign
object with a Magill’s forceps.
WHAT TO CHECK ON MONITOR/
ECG
1.
Is there electrical activity
and recognizable QRS?
2.
Which is the ventricular
rhythm? It is 300/ large squares between RR waves.
3.
Are the QRS regular?
If not, exclude e.g. AF (atrial fibrillation) or ectasystoles.
4.
Which is the QRS width?
If > 0.12 sec (3 small squares) it is wide. Then exclude
ventricular arrhythmia or BBB (bandle branch block).
5.
Is there atrial activity?
Check for P waves on II and V1 leads. If not exclude e.g.
AF.
6.
Which is the relationship
between atrial and ventricular activity? Is it 1:1 each
P followed by QRS) as normal, or is it variable (e.g. atrial
flutter) or there is no relationship (e.g. AF)?
UNSTABLE WIDE COMPLEX
TACHYCARDIA ALGORITHM
Generally, we treat wide complex tachycardia as VT, as it is far
likely the rhythm that occurs on a wide complex tachycardia.
AN UNSTABLE wide complex
tachycardia is characterized by one or more of the following:
decreased LOC (level of consciousness), SBP (systolic BP)
<90 mmHg, chest pain, heart failure, dyspnea, shock,
AMI (acute MI myocardial infraction), pulmonary edema.
UNSTABLE WIDE COMPLEX
TACHYCARDIA ALGORITHM
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available
·
We take a 12 lead ECG
We open the monitor on II lead. Wide complex tachycardia. The patient
is unstable (see above).
In case the patient isn’t unconscious you need to sedate with
1.
Midazolam 1 – 2.5 mg
slowly IV
OR
2.
Diazepam 5 – 10 mg slowly
IV.
We ensure nobody touches
the patient!
We push the ‘synchronized’
(‘synch’) button on the defibrillator. If we don’t do it,
we may cause R on T phenomenon and cause a VF! (I personally,
in order not to forget to remove oxygen and push synchronized
button, I say ‘Jel – O (oxygen) – Joule – synch – paddles’.
Other push again ‘synch’ button after each cardioversion,
however, don’t forget to perform asynchronized defibrillation
shock on a shockable arrest – pulseless VT or VF).
On synchronized mode
we see on the monitor arrows above the R waves.
Jell – Joule – paddles:
We put Jell on the patient’s
chest
We remove oxygen supply
1 meter away (or close the ventilator)!!!
In
case of a patient with a pacemaker or an ICD (implantable
cardiac defibrillator), place the defibrillator’s pads or
paddles at least 12 – 15 cm away from the pacemaker or the
ICD to avoid burning the myocardium!
We choose Joules (from
‘lead’ we go to ‘defibrillation’ and choose Joules).
We push the synch button!!!
We say ‘I am about to
shock on 3. One, I am clear. Two, you are clear. Three,
we are all clear’.
Check that everyone is
clear, no one touches the patient (including you and the
person providing ventilations, and ensure that oxygen is
removed. A few sec before and during defibrillation look
on the monitor and ensure that the rhythm hasn’t changed
and also that the defibrillation has commenced.
For a monophasic defibrillator
(old), for monomorhpic VT we start with 100 J (next subsequent
shocks are with increasing Joules: 200, 300 & 360 J).
Monomorphic VT is characterized by QRS all of same size,
shape and direction. For polymorphic we give 360 Joule defibrillation.
Polymorphic VT is characterized by QRS of varying shape,
size and direction and one form of this rhythm is Torsades
de pointes.
For a biphasic defibrillator,
for a monomorphic VT we start with 75 J and continue next
shocks with 120, 150 and 200J. For a polymorphic VT we start
with 120J and continue the next shock with 200J.
The above Joules are
not indicative. Check each device’s manual for the specific
Joule of defibrillation or cardioversion.
We place the paddles (1st paddle below the right clavicle,
2nd on the left axilla at the left mid-axillary
line)
After the 1st cardioversion we check monitor and pulse
(we check pulse to exclude PEA).
If needed (the arrhythmia
hasn’t cardioverted) we follow with 2nd shock with the same
pattern, but we just increase the Joules e.g. if the 1st
shock was with 75 J, and was unsuccessful, we repeat the
shock with 120J. If needed (the arrhythmia hasn’t cardioverted)
we give a 3rd shock (increasing the Joules as
mentioned before).
After the 3rd shock we administer amiodarone 300 mg
IV/IO (diluted in D5W 5% dextrose) over 10 – 20 min. If
needed (the arrhythmia hasn’t cardioverted) we repeat the
shock (4th). Next we administer 900mg amiodarone
IV/IO over 24 h. Max total dose of amiodarone is 2.2 gr/
24h.
STABLE WIDE COMPLEX
TACHYCARDIA
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available.
·
We take a 12 lead ECG
Generally, we treat wide complex tachycardia as VT, as it is far
likely the rhythm that occurs on a wide complex tachycardia.
A)
REGULAR Broad complex stable
tachycardia of unknown rhythm: amiodarone 300 mg IV push over 20 – 60 min (diluted
in D5W 5% dextrose). Repeat it at 900 mg over 24 h. Max
dose of amiodarone is 2.2 gr IV / 24h.
According to ACLS, alternatives
to amiodarone are:
1.
Lidocaine 1 – 1.5 mg/kg
rapid IV/IO push which may be repeated at 0.5 – 0.75 mg/kg
every 5 – 10 min. Max dose is 3 mg/kg.
2.
Procainamide 20 mg/min
IV INFUSION until ONE of the following occurs:
a)
The arrhythmia is converted.
b)
Hypotension occurs.
c)
QT interval prolongs
(increases) or QRS widens by > 50% of its pre – treatment
width.
d)
Max dose of 17 mg/kg.
B)
IRREGULAR WIDE COMPLEX TACHYCARDIA
a.
Polymorphic VT (QRS have
varying size, shape and direction):
i.
According to ACLS, in case
of a polymorphic VT with a normal QT interval:
·
Treat ischemia.
·
Correct electrolytes.
·
Give amiodarone 150 mg
IV push diluted to D5W (5% dextrose),
over 10 min OR
Lidocaine 1 – 1.5 mg/kg IV push.
ii.
If prolonged QT interval
or VT with hypomagnesaemia:
·
Correct electrolyte abnormalities
and especially hypo/hyperkalemia or hypomagnesaemia.
·
For
VT ventricular tachyarrhythmias with hypomagnesaemia, Torsades
de pointes, (and also in
AF atrial fibrillation and digoxin toxicity); give 2 g MgSO4 (magnesium
sulphate) diluted to D5W (5% dextrose), over 10min IV.
·
ACLS: also consider overdriving
pacing.
b.
Pre – excited tachycardia
e.g. on WPW syndrome:
Call Expert! For pre – excited tachycardia (WPW) all antiarrhythmics
are contraindicated (especially adenosine, digoxin, Calcium
channel blockers and β’ blockers)
because they may induce VT! Consider administrating amiodarone
(150 mg IV diluted to 20 – 30 ml D5W 5% dextrose, over 10min)
or (ACLS) procainamide (20 mg/min).
c.
AF with BBB (Bundle Bunch
Block):
Treat as for a narrow complex tachycardia.
NOTE
·
Don’t combine antiarrhythmics
that both prolong the QT (e.g. amiodarone and procainamide),
because they may induce polymorphic VT and especially Torsades.
ANTIARRHYTHMIC MAINTENANCE INFUSION AFTER THE TERMINATION OF A WIDE
COMPLEX TACHYCARDIA
In case a wide complex tachycardia was terminated pharmacologically,
start a maintenance infusion of the antiarrhythmic that
you used for the chemical cardioversion (e.g. amiodarone
or lidocaine or procainamide).
In case a synchronized cardioversion was used to terminate a wide
complex tachycardia and an antiarrhythmic wasn’t administered,
give a bolus of an antiarrhythmic and start a maintenance
infusion. The infusion prevents the recurrence of the wide
complex tachycardia.
1.
According to ACLS:
a.
Amiodarone maintenance
infusion: 360 mg IV infusion the first 6 h (1 mg/min) and
next 540 mg IV infusion the remaining 18 h (0.5 mg/ min).
Max total dose of amiodarone is 2.2 gr/ 24h.
b.
Lidocaine maintenance
infusion: 1 – 4 mg/min titrated to desired effect.
c.
Procainamide maintenance
infusion: 1 – 4 mg/min
titrated to desired effect.
NOTE: each drug has contraindications e.g. don’t give amiodarone
on a patient with bradycardia and hypotension, but stabilize
first the patient.
2.
ACCORDING TO ALS (ERC)
the loading dose of amiodarone on a wide complex tachycardia
is 300 mg IV/IO diluted to D5W (5% dextrose), over 10 – 20 min for
an unstable wide or narrow complex tachycardia (after the
3rd shock) or over 20 – 60 min at a stable wide complex
tachycardia or an irregular stable narrow complex tachycardia;
and then the maintenance dose in all the above cases is
900 mg over 24 h. Max
total dose of amiodarone is 2.2 gr/ 24h.
UNSTABLE NARROW COMPLEX
TACHYCARDIA
AN UNSTABLE narrow
complex tachycardia is characterized by one or more of the
following: decreased LOC (level of consciousness), SBP (systolic
BP) <90 mmHg, chest pain, heart failure, dyspnea, shock,
AMI (acute MI myocardial infraction), pulmonary edema.
UNSTABLE NARROW COMPLEX
TACHYCARDIA ALGORITHM
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available.
·
We take a 12 lead ECG
We open the monitor on II lead. Narrow complex tachycardia. The
patient is unstable (see above).
In case the patient isn’t unconscious you need to sedate with
1.
Midazolam 1 – 2.5 mg
slowly IV
OR
2.
Diazepam 5 – 10 mg slowly
IV.
We ensure nobody touches
the patient.
We push the ‘synchronized’
(‘synch’) button on the defibrillator. If we don’t do it,
we may cause R on T phenomenon and cause a VF! I personally,
in order not to forget to remove oxygen and push synchronized
button, I say ‘Jel – O (oxygen) – Joule – synch – paddles’.
Other push again ‘synch’ button after each cardioversion,
however, don’t forget to perform asynchronized defibrillation
shock on a shockable arrest (pulseless VT, VF).
On synchronized mode
we see on the monitor arrows above the R waves.
Jell – Joule – paddles:
We put Jell on the patient’s
chest
We remove oxygen supply
1 meter away (or close the ventilator)!!!
In
case of a patient with a pacemaker or an ICD (implantable
cardiac defibrillator), place the defibrillator’s pads or
paddles at least 12 – 15 cm away from the pacemaker or the
ICD to avoid burning the myocardium!
We choose Joules (from
‘lead’ we go to ‘defibrillation’ and choose Joules).
We push the synch button!!!
We say ‘I am about to
shock on 3. One, I am clear. Two, you are clear. Three,
we are all clear’.
Check that everyone is
clear, no one touches the patient (including you and the
person providing ventilations, and ensure that oxygen is
removed. A few sec before and during defibrillation look
on the monitor and ensure that the rhythm hasn’t changed
and also that the defibrillation has commenced.
For a monophasic defibrillator
(old), we give initially for AF (atrial fibrillation) 100
J. If unsuccessful, we repeat at 200, 300 and 360 J respectively.
For atrial flutter or PSVT (paroxysmal supraventricular
tachycardia) we start with 50 Joule and, if unsuccessful,
we repeat at 100, 200, 300 and 360 J respectively.
For a biphasic defibrillator,
for PSVT, AF or atrial flutter we start with 30 J and, if
unsuccessful, we repeat with 50, 75 and 120J, respectively.
The above Joules are
not indicative. Check each device’s manual for the specific
Joule of defibrillation or cardioversion.
We place the paddles (1st paddle below the right clavicle,
2nd on the left axilla at the left mid-axillary
line)
After the 1st
cardioversion we check monitor and pulse (we check pulse
to exclude PEA).
If needed (the arrhythmia hasn’t cardioverted) we follow with 2nd
shock with the same pattern, but we just increase
the Joules e.g. if the 1st shock was with 75
J, and was unsuccessful, we repeat the shock with 120J. If needed (the arrhythmia hasn’t cardioverted)
we give a 3rd shock (increasing the Joules as
mentioned before).
After the 3rd shock we administer amiodarone 300 mg
IV/IO (diluted in D5W 5% dextrose) over 10 – 20 min. If
needed (the arrhythmia hasn’t cardioverted) we repeat the
shock (4th). Next we administer 900mg amiodarone
IV/IO over 24 h. Max total dose of amiodarone is 2.2 gr/
24h.
STABLE NARROW COMPLEX
TACHYCARDIA
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available.
·
We take a 12 lead ECG
We open the monitor on II lead.
A.
REGULAR STABLE NARROW COMPLEX
TACHYCARDIA:
We perform vagal maneuvers such as Valsava maneuver (we ask the
patient to blow the outlet of a syringe in order to expel
the plunger) or perform ipsilateral carotid sinus massage
(for 5 sec, contraindicated if carotid bruits or known carotid
stenosis), or placed a cold ice pack on the face (not immediately
up on the skin, but on a towel) (however prefer the above
2 methods on adults).
If unsuccessful we give adenosine 6 mg rapid IV push (over 1 –
3 sec). If unsuccessful, we repeat after 1 – 2 min at 12mg.
If still unsuccessful, we repeat after 1 – 2 min at 12 mg
(to total dose of 30 mg). Each dose should be followed by
20 cc saline flush and arm elevation for 10 – 20 sec. The
injection should be performed on a close to heart vein (e.g.
antecubital fossa).
1.
If rhythm hasn’t converted,
we call Expert! The rhythm may be probable atrial flutter.
In that case control rate, e.g. with β’ blockers.
2.
If normal sinus rhythm
is restored, the previous rhythm was probable PSVT (Paroxysmal
Supra – Ventricular Tachycardia): we monitor ECG. If it
recurs we administer again adenosine and consider antiarrhytmic
prophylaxis, such as Calcium channel blockers.
Calcium
channel blockers Indications are: control of
ventricular rate in AF atrial fibrillation and atrial flutter
(consider anticoagulation!). Also, for stable narrow
complex tachycardia that is not terminated by vagal manoeuvres
or adenosine. Also,
verapamil is used in ectopic atrial tachycardias.
Verapamil 2.5 – 5 mg IV over 2 min.
It may be repeated 15 – 30min later at 5 – 10 mg, to a max
dose of 20 mg.
Alternative
is
Diltiazem
15 – 20 mg (0.25 mg/kg) IV over 2 min. It may be repeated
after 15 min at 20 – 25 mg (0.35 mg/kg) over 2 min. Maintenance
dose is 5 – 15 mg/h titrated to HR and BP.
To
control ventricular rate in patients with AF (atrial fibrillation)
or atrial flutter (usually when the arrhythmia is < 48h)
give Diltiazem 15 – 20mg IV over 2 min.
CI
(contraindications) to calcium blockers are wide complex
tachycardia of uncertain origin, poison or drug induced
tachycardia, pre – excited tachycardia e.g. rapid atrial
flutter or AF in patients with WPW, SN sinus nodus disease,
AV (atrioventricular) block without pacemaker, and perhaps
on CHF (congestive heart failure), because of negative inotropic
action (especially of verapamil). Give them with caution
if LV (left ventricular) dysfunction. Use sustained long acting formula, because
short acting increase the risk for ACS/ MI (acute coronary
syndrome/ myocardial infarction)!
Verapamil
is a negative inotropic agent so avoid it in patients with
left ventricular impairment or heart failure, even they
are stable! Also, avoid it on 2nd or 3rd
degree heart block, sick sinus syndrome.
Don’t
give concomitantly a Calcium blocker with a β’ blocker, because they
may cause severe hypotension and bradycardia.
B.
IRREGULAR STABLE NARROW COMPLEX
TACHYCARDIA:
It is probable AF (Atrial Fibrillation). Call expert. The expert
will deside also if coagulation will be administered in
high risk patients < 48h or on patients > 48 h from
AF onset (an ECHO may be needed to exclude intracardial
thrombus that may cause stroke).
Control rate with β’ blocker or digoxin
IV.
a.
β’ blockers:
β’ blockers are indicated for narrow complex regular
tachycardia uncontrolled by vagal maneuvers and adenosine
on patient with preserved ventricular function. Also to
control rate in AF (atrial fibrillation) and atrial flutter
with duration < 48h and with preserved the ventricular
function (don’t give it in rapid ventricular rate caused
by accessory pathway in pre-excited arrhythmias such as
WPW).
Atenolol (β1) 5mg over 5 min. May be repeated 10 min later at same dose.
Metoprolol (β1) 2 – 5 mg slow IV at 5 min intervals. Total dose 15mg.
Propanolol (β1&β2) 100 mcg (μg) (=0.1 mg)/kg in 3 divided doses at 2 min intervals. It is
usually used in hyperthyroidism (there exclude AF atrial
fibrillation!).
Esmolol (β1 short acting!) 500 mcg (μg) (=0.5mg)/kg
over 1 min followed by infusion of 50 – 200 mcg/kg/min.
CI
(contraindications) to β’ blockers are: heart failure (IV category), bronchospasm/
COPD (with bronchospasm), asthma, AV block/ bradycardia
and brittle insulin depended DM (IDDM).
Don’t
give concomitantly a Calcium blocker with a β’ blocker, because they
may cause severe hypotension and bradycardia.
b.
Digoxin:
Digoxin’s
dose for AF (atrial fibrillation) or atrial flutter with fast ventricular response is 500 mcg (=0.5
mg) IV over 30 min.
Contraindications
to digoxin are: VF, VT, HR < 60 bpm and pre – excited tachycardia e.g. WPW. Use with
caution in renal failure
·
If onset is < 48 h consider
amiodarone 300 mg IV/IO over 20 – 60 min (diluted in D5W
5% dextrose). Then give maintenance dose 900mg IV over 24
h. Max total dose of amiodarone is 2.2 gr/ 24h.
·
If rhythm hasn’t converted,
we call Expert! The rhythm may be probable
atrial flutter. In that case control rate e.g. with β’ blockers.
NOTE
High risk patients and patients with AF> 48 h may need anticoagulation
before chemical or electrical cardioversion (unless a cardiac
Echo excludes intra-cardial thrombus).
NOTE FOR AMIODARONE
Indications of amiodarone
are VF ventricular fibrillation and pulseless VT ventricular
tachycardia (refractory to defibrillation), polymorphic
VT ventricular tachycardia, wide complex tachycardia of
uncertain origin, stable VT (when cardioversion is unsuccessful),
as an adjunct to synchronized cardioversion in SVT supraventricular
tachycardia, termination of ectopic atrial tachycardia,
rate control in AF atrial fibrillation and atrial flutter
resistant to other therapies. Also used in pre-excitation
tachycardia e.g. in WPW.
CI
(contraindications) to amiodarone are known sensitivity,
SN (sinus node) disease with severe bradycardia, and 2nd
or 3rd degree AV atrioventricular block.
UNSTABLE BRADYCARDIA
Adverse signs on bradycardia are SBP (systolic BP)<90, HR<40,
heart failure, ventricular arrhythmias compromising BP.
Risk factors for asystole are recent asystole, type II (Mobitz
II) 2nd degree AV (atrioventricular) block, complete
heart block with broad QRS and ventricular pauses > 3
sec. In the above factors perform TCP (Transcutaneous Pacing)
a.s.a.p (as soon as possible). TCP is also indicated on
denervated (e.g. transplanted) heart where drugs will not
work.
Relative bradycardia is the phenomenon where HR is faster than
the one that would expected for the patient’s condition.
For example a patient with HR 65 bpm and BP 80/ 50 has relative
bradycardia because HR is too slow, relative to (regarding
to) the BP.
ALGORITHM FOR UNSTABLE BRADYCARDIA:
·
Administer oxygen.
·
Put on monitor. Chose
II lead.
·
Establish IV/IO access,
initiate normal saline to keep open and take blood for labs.
Check especially the electrolytes.
·
Take a 12 lead ECG.
a.
ΟΝ ADVERSE SIGNS
(see above):
·
Give atropine 0.5 mg
rapid IV push. Repeat every 3 – 5 min to max 3 mg.
On satisfactory response to atropine check
if there is risk for asystole (see above).
b.
IF NO SATISFACTORY RESPONSE
ON ATROPINE OR ON RISK OF ASYSTOLE (see above):
·
Initiate epinephrine
(adrenaline) infusion at 2 – 10 mcg/min.
Alternative to adrenaline is dopamine
infusion at 2 – 10 mcg/kg/min. Consider 500ml NS normal
saline bolus before dopamine. Other alternative drugs include
aminophylline, isoprenaline (better avoid it, as it may
be arrhytmogenic), glucagon (used on β’ blocker or Calcium channel blocker OD overdose).
·
Seek expert help and
arrange transvenous pacing.
NOTES
·
If no immediately available
TCP, we give drugs.
·
Glycopyrronium may be
used instead of atropine.
·
To differentiate complete
AV block from idioventricular rhythm
we increase the GAIN of the defibrillator to check
for P waves (no P waves on idioventricular rhythm, but on
complete AV block there is dissociation between P and QRS).
TCP (TRANSCUTANEOUS PACING):
Indications are:
1.
Symptomatic bradycardia
with signs and symptoms related to it, when atropine is
unavailable or unsuccessful.
2.
2nd degree
type II (Mobitz II) AV block.
3.
3rd degree
(complete) AV block (with broad QRS)/ Ventricular pause
> 3 sec.
4.
Bradycardia with ventricular
escape complexes.
5.
Recent asystole.
6.
Denervated heart (heart
transplantation).
Contraindications are
severe hypothermia and also prolonged bradyasystoloc arrest.
The patient may need
sedation and/or analgesia.
Energy setting:
1.
Set pacing rate at 80
bpm (range 60 – 90 bpm).
2.
Increase output (mA)
from the minimum setting, until consistent electrical capture
is achieved (wide QRS and broad T wave after each pacer’s
spike). Increase 2 mA further after the previous point.
Note: the pacing rate
width is 60 – 90bpm, however for same circumstances (e.g.
complete AV block with idioventricular rhythm 50 bpm), a
slower rate of 40 or even 30 bpm may be required.
The position of the pads
on arrest is as in defibrillation. Otherwise you can choose
the AP placement with the anterior electrode on the left
anterior chest wall (beside the sternum, overlying the V2
& V3 ECG positions) and the posterior electrode between
the lower part of the left scapula and the spine (at the
same horizontal level as the anterior).
NOTES
·
If there is a need for
TCP and the pacemaker is not immediately available, we give
drugs (atropine etc).
·
In case the TCP is unsuccessful
and the IV pacemaker isn’t immediately available, we give
drugs such as atropine and adrenaline or dopamine infusion.
AVOIDING PITFALLS IN ALS
·
On a patient with COPD
on respiratory distress do not forget to taka ABGs (arterial
blood gases). In case of type II respiratory insufficiency
with hypoxemia and hypercapnia, call an expert! Then max
28% oxygen is needed. That occurs because in some cases
of COPD the patients rely on their hypoxic drive to breathe, so oxygen more than 30% may lead
to reduced RR (respiratory rate) and hypercapnia which will
cause decreased conscious level and respiratory failure
with cardiac arrhythmias. So, in case on ABGs is evidence of CO2 retention, start with 24 – 28% oxygen in the above
patients and reassess after 30 min. In case the patient
has not evidence of CO2 retention, then start with 28 –
40% oxygen and monitor next the ABGs.
·
On operated patients
check the tubes for blood and the Foley for urine.
·
In
case of suspected hypovolemia, on ABCs place also a
Foley.
·
On
ethical problems consult your hospital’s legal team. In
case e.g. of a kid with an end stage disease (such as CF
cystic fibrosis or cancer) that is intubated and the parents
ask to be extubated, consider that you aren’t covered by
the law. Just say that next time they should avoid bringing
the kid to the hospital, or seek a court’s decision. Also
comfort them that in the future there may be a therapy for
the disease. There are many other legal problems such as
parents – Jehovah martyrs that refuse their child to be
transfused with blood, in case of trauma with hypovolaemia.
·
In
any interference we check the outcome by repeating the ABCs e.g. on a patient
with shortness of breath and SpO2 oxygen saturation 89%
we place a not rebreathing mask with reservoir and check
then if the saturation improves.
·
In
any change (deterioration) on the patient we recheck ABCs!
·
After
cardioversion we check monitor and pulse (we exclude PEA).
If the arrhythmia is converted we check again ABCs.
·
We
do not forget antiarrhythmic (e.g. amiodarone) maintenance
infusion after a successful cardioverted or defibrillated
wide complex tachycardia (we start with loading dose if
already hasn’t given).
·
In
case the algorithm changes, we take the Joules from the
beginning and forget what we gave previously e.g. if now
we have a pulseless VT, we start with e.g. 120 J (for biphasic).
·
In
any change from an arrest
rhythm to another arrest rhythm (e.g. from VF to
asystole) we give adrenaline following the new algorithm
(e.g. immediately on asystole) irrespectively the time we
gave it previously (on our previous algorithm). However,
this is not the case for atropine or amiodarone (these have
max dose).
·
On
a change from an arrest rhythm to a viable rhythm, we check
the monitor and for pulse (to exclude PEA).
·
On
a change from an arrest rhythm to another arrest rhythm
we check the monitor. In case the new rhythm is VT, we check
also for pulse.
·
On
a change from a viable rhythm to an arrest rhythm (e.g.
VT) we recheck ABCs and specifically
if the patient is conscious.
If the patient is unconscious we call
for help and check for breathing and pulse simultaneously.
In case the patient has no pulse we
go on with the ALS algorithm. We call blue code, ask for
a defibrillator and start CPR.
In case the patient has pulse, but does not breathe or breaths
inadequately (e.g. RR respiratory rate is >30 or <
10) or if the GCS is <_8 we call blue code, ask for a
defibrillator and perform BMV with self inflating bag with
reservoir or we intubate (with RSI rapid sequence intubation
if GCS > 3).
In case the patient breaths and has pulse, we place the patient
on a recovery position, if unconscious. We check ABCs and specifically
airway patency (airway is patent if the patient talks),
respiratory rate, bilateral normal chest expansion, we perform
chest auscultation and percussion, we check SpO2 oxygen
saturation of hemoglobulin, we check the pulse (radial and
carotid), the BP, connect to monitor, establish IV/IO access
(keep it patent with normal saline
and take blood for Labs), take a 12 lead ECG and
ABGs, check AVPU
or GCS (with size and reaction of both pupils – also notice
any abnormal posture such as stereotypical flexion or extension),
expose the patient (remove clothes) and perform log roll
(especially on trauma, scheck for trauma, rash, petechiae
etc) and next we prevent hypothermia (blankets). We also call expert! When the patient has been
stabilized, we transfer to ICU (ITU).
·
If
an intubated patient improves and we have a little difficulty
on ventilating or he/she bites the ET tube, we consider
extubation. However, extubation should be performed rather
in the ICU, rather than in the ER/ ED (emergency room/ department).
However,
don’t forget that difficulty on ventilation may suggest
tension pneumothorax.
·
Every drug has contraindications
e.g. don’t give amiodarone on a patient with bradycardia
and hypotension, but stabilize first the patient (e.g. if
the patient had initially sinus bradycardia and then VF
and eventually was successfully defibrillated but now has
still bradycardia and hypotension we may stabilize the patient
with TCP and then, when the patient is haemodynamically
stabilized, we give amiodarone infusion).
·
To see if an intubated
patient with a VT is unstable, we check e.g. the BP
for hypotension.
·
We don’t rely only on monitor,
but if available, we perform 12 lead ECG. Monitor is unreliable
to show AMI (acute myocardial infarction)/ ACS (acute coronary
syndrome).
·
Sodium bicarbonate is indicated
in metabolic acidosis (check ABGs arterial
blood gases) – e.g. on hyperkalaemia, TCAs tricyclic antidepressants,
aspirin, phenobarbital, diphenydramine and cocaine) OD (overdose)
and also on prolonged (>10min) arrest. Don’t give it
in patients with hypercarbic acidosis.
Bicarbonate’s dose is 1 mEq /kg (1mMole/Kg
or 1 ml/kg) of 8.4% solution IV/IO. Ventilate the patient
after bicarbonate administration. Don’t give it with catecholamines
(e.g. adrenaline or dopamine) at the same IV line (at least
flush the line first with normal saline).
NEVER FORGET:
·
Safety first.
·
Push ‘sync’ synchronized
button on cardioversion.
·
Remove oxygen 1 meter away
or close the ventilator before the defibrillation or cardioversion.
·
Take finger stick glucose
on suspected stroke (also on seizures).
·
Call blue code and ask
for a defibrillator on an unconscious patient.
·
Don’t forget IV/IO access
on C – circulation (take blood for labs, keep it open with
normal saline).
·
Rule out and treat 6Hs
& 6Ts reversible causes of arrest (especially in asystole
or PEA).
·
On an unconscious patient
follow the intra hospital CPR/ AED algorithm. Before checking
for breathing, open the airway (chin lift or jaw thrust,
jaw thrust only on trauma).
·
Do not interrupt the
chest compressions (a very common mistake) for any reason.
However, if needed (e.g. for intubation) interrupt it just
for a few seconds. There are special devices that perform
automatically chest compressions. Subclavian IV rout is also contraindicated on
cardiac arrest (another common mistake) because it will
interrupt the chest compressions and also may cause undetectable
complications such as pneumothorax or subclavian artery
puncture. Prefer femoral IV rout. If no fast access to
IV rout, go on with IO (intraosseous) rout.
APPENDIX
(I): COMMON CAUSES OF SHOCK
What to rule out on a shock:
a)Traumatic blood loss. Check for bleeding
in chest. Perform CXR, FAST. Check for pelvic or long bone
fracture. If so, do immobilization and consider PAST antishock
trousers.
b)Non traumatic blood loss. Rule out abdominal
aortic aneurysm (e.g. palsatile abdominal mass). Do USS/
FAST. Is there hematemesis or melena? Is fluid on Levine
(NG tube) bloody? Perform endoscopy if high suspected GI
bleeding.
c)Dysrhythmia. Perform an ECG.
d)Tension pneumothorax. Are there any decreased
unilateral breath sounds, tracheal deviation (away from
the pneumothorax), hyper-resonant hemithorax on percussion
or distended neck veins (if not hypotensive with blood loss)?
Don’t wait CXR. Perform needle decompression and next insert
a chest tube.
e)Cardiac Tamponade.Are there distended
JVD (jugular veins distension), muffled heart sounds, low
ECG voltage and electrical alterance, or pulsus paradoxus?
Perform FAST/ USS (ultrasound).
f)Massive
pulmonary embolism. Is there hypoxemia with right ventricular strain on
ECG?
g)Anaphylaxis. Is there angioedema,
laryngeal edema with stridor, wheezing, hives on skin?
h)Spinal Cord Injury – Neurogenic shock with decreased HR.
Check for a motor/ sensory level of paralysis and anesthesia.
Take cervical spine protections. Check rectal tone and check
for blood.
i)Warm skin? If so, consider sepsis, neurogenic
shock, anaphylactic shock, medication overdose (e.g.β’ or Ca
blockers).
j)Also rule out Poisons/ medication overdose
or SEs (Side Effects)/ illicit drug abuse, Sepsis and Adrenal
Insufficiency.
• PH of venous blood is usually 0,01
– 0,03 lower than the arterial blood PH. Also PCO2 is 6
mmHg higher and bicarbonate is 2 meq/L higher by using venous
blood.
• Anion gap is ([Na] + [K])
– ([Cl] + [HCO3]) and normal values are 12 – 16 mEq/L (usually
10 -1 2mEq/L). Increased anion gap occurs on
DM (diabetes melitus), alcoholics, starvation, lactic acidosis,
renal failure, exogenous toxins metabolized to lactate (cyanide
– CN, CO, ibuprofen, strychnine, toluene, iron – Fe and
INH - isoniazide), or exogenous toxins metabolized to acids
(aspirin, methanol, ethanol, ethylene glucol, paraaldeyde
and rarely with isopropanol), severe hypotension, seizures
and hypoxemia.
• Increased osmolar gap may occur in DKA,
ethylene glycole or methanol or ethanol or isopropanol poisoning.
Osmolar gap ΔOsm = measured Osm
– Calculated O.
APPENDIX
(II): GCS
Eye
Opening (E4)
4 0 – 1
years old: spontaneously; > 1 years old: spontaneously
3 0 – 1 years old: to shout; > 1 years old:
to verbal command
(not
necessarily to ‘open your eyes’)
2 all ages: to pain
1 all ages: no response
Response to pain is checked
by pressing the patient’s nail’s bed with a pen. If not
response, try supraorbital pressure and sterna pressure.
Best
Verbal Response (V5)
5 0 – 2 years old: appropriate cry, smiles;
2 – 5 years old: appropriate words and phrases; >
5 years old: oriented,
converses
4 0 – 2 years old: cries; 2 – 5years old: inappropriate words; > 5 years old: confused
3 0 – 2 years old: inappropriate cry; 2 – 5 years
old: cries, screams; > 5 years old: inappropriate words
2 0 – 2 years old: grunts; 2 – 5 years old: grunts,
sounds; > 5 years old: incomprehensible e.g. moans
1 all ages: no response
Best
Motor Response (M6)
6 0 – 1 years old: moves spontaneously and adequately;
> 1 years old: obeys
command
5 all ages: localizes pain
4 all ages: flexion withdrawal
3 all ages: decorticate (stereotypical flexion)
2 all ages: decerebrate (stereotypical extension)
1 all ages: no response
Motor response may be e.g.
‘raise your hand’. It is the better response of any limb.
Decorticate posture is characterized by flexion of upper
extremities. Decerebrate posture is characterized by internal
rotation of shoulder & arm pronation and limb extension.
Score: min 3,
max 15. If GCS<_8 the patient needs intubation (RSI rapid
sequence intubation if GCS > 3). GCS <_8 severe injury,
GCS 9 –12 moderate injury, GCS 13–15 minor injury.
APPENDIX:
SIGNS OF HYPOVOLAEMIC SHOCK
Signs of hypovolaemic shock (haemorrhage - external or internal
blood loss; or severe dehydration e.g. on severe diarrhea
or vomiting) include: tachycardia (if not on β' blockers
or pacemaker!), fast thready pulse, narrowed pulse pressure
(Systolic BP - diastolic BP), weak peripheral pulses, tachypnea,
decreased level of concioussness (LOC), decreased urine
output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants
2 ml/kg/h), decreased capillary refill time (>2 sec),
hypotension (late, with > 30% volume loss on adults and
> 40% on children), cool pale skin, diaphoresis (not
on dehydration); also decreased skin turgor (unreliable
on the elderly) and dry mucus membranes (e.g. dry tongue)
on dehydration.
NOTE
Some
information in this text is empirical and its reliability
can't be ascertained. It is suggested to search official
medical articles, books and guidelines in order to ascertain
the medical information of this text.
All
the medical procedures and drug administration mentioned
in this text should be done only under a senior doctor's
consultancy.
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