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Basic life support (BLS)
The goals of resuscitation interventions for patient in
respiratory or cardiac arrest to restore and support
effective oxygenation, ventilation, circulation with returnimpact neural functions.
Classification and recommendation and level of evidence
1.Class 1(benefits>>>risks): the procedure, treatment,
diagnostic test and assessment should be performed and
administered.
2.Class 2A (benefits>>risks): it is reasonable to perform and
administered procedure, assessment, diagnostic test, andtreatment.
3.Class 2B (benefits>= risks): the procedure and treatment,
assessment, and diagnostic test may be considered
4.Class 3 (risks>= benefits) : should not perform or
administer treatment, assessment and procedure..
Classification of survey:
1.Primary survey : include basic life support(BLS)
2.secondary survey: advance cardiac life support(ACLS)
The BLS primary survey
performed by any trained health care providers
without advanced interventions and depend on basic
ABCD
before contact of BLS should check the responsive of the
victims, activation EMS and get AED
health care provider should assess breathing before get
rescue breathing with mask
health care provider should assess pulse before initiate
chest compression
health care provider should assess shockable rhythm
before initiate DC shock
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Open airway by non invasive method (head tilt and chain
left) if patient with neck and head trauma thrust the jaw
without extension the head
Basic primary survey includes:
1)A(airway)
Open airway by non invasive method (head tilt and
chain left) if patient with neck and head trauma thrust
the jaw without extension the head
2)B(breathing)
Look, listen, feel if victims breathing or not, adequate
breathing or not If patient breath put he\she in recovery position
If victims absent breathing give two rescue breathing
each breath in one second and must observe it is rises the
chest
Do not ventilate fast(rate) or much(volume) to prevent
hyperventilation
3)C(circulations) Palpate in adult if carotid pulses are present or not by
apply three fingers on carotid artery in the groove area
behind the sternomastoid muscles, check should for 5
second and no more then 10 second and unilateral check.
Palpate in infant brachial or femoral pulses
If no pulses in adult or infant pulse less then 60
beat\min initiate chest compression with adult 30:2 and
infant with one rescuer 30:2 or 15:2 if have 2 rescuer Push hard, push fat 100 beat\min( in five cycle 150:10
in two minute)
Site of chest compression in adult between nipple in
below half of sternum and infant below the nipple level
Chest compression method: in adult put on heal of the
hand in the site of chest compression and other hand on
it. In infant used two thump and both adult and infant
make 1\4 depth or 3-5cm.
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During chest compression should avoid any
interruptions as check pulse, analysis rhythm, airway
management and switching the rescuer all of these aspect
done after 5 cycle or 2 min to provide adequate level of
circulation blood and oxygenation to brain and vital
organs
If pulses is present and absent breathing give adult 1
breath in 5-6 second and 1 breath in 3-5 second in infant
and check pulses every 2 minute
4)D(defibrillation)
If patient with shockable rhythm initiate and prepare
DC shock
Each DC shock or cardioversion must initiate CPR 5
cycle or 2 minute
Recovery positions
Recover position important in victims because it is
provide airway open, remove fluid in the mouth of
victims
This position called lateral position, and provide spinstraight, and put hand in position that maintain any chest
compression
1.during responsive victims
In adult
ask victims is shocking
give abdominal thrust (epigastrial thump) or chest thrust
if obese or pregnant victims
repeat technique until obstruction remove or victims
become un responsive
In infant
confirm infant difficult of breathing, silent cough,
cyanosis
give 5 back slaps and 5 chest thrust until remove
obstruction or victims become unresponsive
2.during unresponsive victims
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begin CPR in 5 cycles or 2 minute and look in mouth if
big foreign body causes obstruction and able to remove
it
ACLS secondary survey
1)A(airway)
Observe airway is patent and find indication of invasive
airway devices used
Maintain airway patent in unconscious patient by
noninvasive (head tilt and left chain) and invasive airway
as OPA (oropharyngeal airway) or NPA (nasopharyngeal
airway)Used laryngeal mask airway(LMA) or combitube or ETT
2)B(berating)
Observe: oxygen is adequate or not, proper placement of
airway devices, are exhaled CO2 or oxyhemoglobin
saturated.
Assessment adequate oxygenation depend on chest rises
during ventilation, oxygen saturation, capnometry orcapnography
Confirmation of airway placement through : physical
examination(5 point air entry, measure CO2 exhaled,
esophageal detector devices.
3)C(circulation)
Obtain IV, IO and attached monitors leads to analyze
rhythm , heart rateGive drug and fluid
Observe BP and take blood sample, cross matching
4)Defibrillations
Give patient DC or cardioversion is the rhythm is
shockable rhythm
5)Assess 6 H's and 6 T's
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H's: hypoxia, hypovolemia, hydrogen (acidosis),
hypo\hyper kalmeia, hypoglycemia, and hypothermia.
T's: toxin, tamponade(cardiac), tension( pneumothorax),
thrombosis, and trauma6)Assessment of disability
Assess GCS , mental status
Assess extremities injuries, excessive bleeding
Insert Foleys catheters and gastric tube
CODE of CPR
Role of team member:
1)Organize the group
2)Monitor individual performance of team member
3)Provide excellent team behaviors
4)Train and coach
5)Facilities and understanding all algorithms
6)Focus in competence patient care
Role of team member
1)Clear about role and take fulfill responsibilities about
her\his tasks
2)Well practiced in resuscitation skill and knowledgeable
about algorithm
3)Committed to success
Element of effective resuscitation team dynamics
1)Used close loop communications
Team leader give massage\order and assignment good
eye contact with team member
Team leader confirm order and the team member
confirm this order before done by repeat the order and
after the procedure done by say the procedure done, or
the drug given
2)Used clear massages
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All order which delivered by team leader must clear in
calm manner without shouting or yielding and speak
complete sentences
Team member repeat order before done and after doneclearly
3)Clear role and responsibilities
Each person must know her\his responsibilities to
prevent take many manner for one team member,
missing the primary role of team member, freelancing
one of team member
Team leader must clearly identify each team member
roleTeam member must ask if any difficult in her\his task
4)Know one's limitations
The team leader should be aware of limitation of each
team member
The leader should not practiced the team member for
new task during CPR to prevent any negative effect
Team member should not take new task during CPR
5)Knowledge sharing6)Constrictive intervention
Team leader must intervenes the actions in tactfully
manner
Team leader should not confront any team member and
after CPR criticism him
Team leader can suggest alternative drugs, and ask
about who is responsible of mistakes
7)Relevance of summarizingThe leader to reevaluate the patient status, make
massages friendly, and provide deferential diagnosis
8)Mutual respect
All team leader and team member must leave Ego
regardless any additional training or experienced that
the team leader or team member experienced or have it.
Leader speak friendly, and controlled of tone voice and
avoid shouting
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ACLS cases
Respiratory arrest
Respiratory arrest: complete absent or clearly inadequate
respiration to maintain effective oxygenation and
ventilations associated with present pulses
When patient com with respiratory arrest do the followingAsk the patient are you all right
Activate emergency responses 911 or AED
Patient with asphyxia arrest must do 5 cycle CPR then
contact with emergency responses
Initiate BLS
Patient with respiratory arrest give 1 oxygenation every
5-6 second but patient with respiratory arrest give 1
breath every 10-12 sec
Then check pulses in both cases after 2 minute
Increase rate (amount) of oxygenation or increase volume
lead to increase intra thoracic pressure (decrease venous
return and decrease CO), increase gastric inflation,
patient aspiration
Advance airway management:
Include 6 criteria:1. given and supply oxygen saturation 90%
2. open airway
3. provide basic ventilation management
4. used OPA or NPA management
5. suctions
6. provide ventilation with advance airway management
Opening airway
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Upper airway obstruction caused by loss of throat
muscles weakness or tongue fall back and occluded the
airway
Airway open by head tilt and chin left or jaw thrustwithout head extension if trauma occurs
Unconscious patient (no gag reflex, no cough) can
placement OPA or NPA to maintain airway potency
Is you seen foreign body obstruction airway able by used
finger to remove this foreign body
Basic air way management:
Various devices supplementary oxygen 21-100%
Divided to two type
1.non invasive : as oxygen supply cylinder, nasal
canula, face mask, ventori mask
2.invasive as OPA, NPA
Nasal canula:
low flow rate oxygenation provide oxygen up to 44% put
in patient nose
ratio describe as increase 1L\min increase concentration4% start at 1l\min maintain oxygen saturation 21-24%
1 L\min 2 L\min 3L\min 4L\min 5L\min 6L\min
12-24% 25-28% 29-32% 33-36% 37-40% 41-44%
Face mask
low rate oxygenation put in patient nose and mouth with
reservoir bag or without reservoir bag
with reservoir bag used when1. patient seriously ill and require high oxygenation
concentration
2. avoid ETT in acute intervention as pulmonary edema,
COPD , acute asthma
3. have indication of ETT but have high gag reflex , or
high clenched teeth
in case of high clenched teeth can used tight fitting mask
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Face mask supplement 60% oxygen concentration in flow
rate 6L\min(with ratio 1 L\min increase concentration
10%
6L\min 7 L\min 8 L\min 9L\min 10L\min
60% 70% 80% 90% 95-100
Ventori mask
More controlled of oxygenation delivery from 24-50%
concentration used for patient with COPD or chronic
increase CO2 level with sever hypoxemia
4-8L\min 10-12L-min
24-40% 40-50%
Bag mask ventilation
Consist of self inflating bag and non rebreathing valve
used when connect with advance airway tube or face
mask to provide positive ventilation pressure
Used of bag mask ventilations without advance airway
tube causes gastric inflations
Bag mask procedure1. fix on face and press against face
2. provide head tilt
3. mouth to mask ventilation (make C shape of thump
and index of one of your hand and press on mask )
Oropharyngeal airway(J shape)
used to prevent airway obstructions by the tongue and
facilitate suctioning used for unconscious patient after head tilt chain left or
thrust the jaw
should not used for conscious patient because it is
stimulate gag reflex and vomiting
technique of OPA insertion:
clear mouth and pharynx form secretions
select the size of the OPA by put the tip of airway on
the corner of the mouth and must reach the angle ofmandible and when you insert it must glottis opening
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insert airway that is turned backward then after
inserted rotate it 180 degree or same shape insertion by
used tongue blade
Nasopharyngeal airway
used when conscious or semiconscious patient or patient
with trauma in mouth or high gag reflex or cough
select the size and used lubricants
insert gently to prevent lacerate the adenoid tissue and
causes bleeding and aspiration
Advance airway management
Combitube
Alternative tube to provide adequate oxygenation and
have fetal risk complications
Consist of two inflatable tube(100cc and 15 cc) balloon
cuff and blind insertion without visualized vocal cord
(inserted in esophagus and trachea)
Laryngeal mask airway (LMA)
Composed of tube with cuffed mask , blind insertion untilfeel resistance
Not used for patient with regurgitation or aspiration
(class 3 survey)
Endotracheal tube (ETT)
during ETT insertion for patient without gagreflex or
cough or unconscious patient ask other team member to
cricoids pressure
Cricoids pressure maintain gastric regurgitation andfacilitate insertion of ETT, when pressure in cricoids used
thump and index fingers
Cricoids : the first prominent below thyroid cartilaginous
(Adam's apple)
Importance of ETT:
1. keep airway opening and deliver high oxygen rate
2. protect aspiration
3. facilitate suctioning
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4. alternate for medication if IV or IO impossible
indication of ETT
1. cardiac arrest and bag mask ineffective
2. responses patient but unable to oxygenation
3. patient unable to protect airway(coma, cardiac arrest
ETT medication administration protocol
1. Medication given to patient by ETT is: atropine,
vasopressin, epinephrine, and lidocain.
2. ETT medication must mixed with 10 cc saline or distal
water (saline increase liability absorption in airway
especially atropine drugs)
3. The dose of ETT medication high dose than IV or IO
equal 2-2.5*(IV or IO dose).
4. after ETT medication given 2 ventilation must be
performed to facilitate absorptions
Complication of ETT
If ETT insertion in esophagus causes patient suffer to brain
death and die
Confirmation of ETT
1. listen to the 5 point (2 apex, 2 base of the lung,epigastric region) associated with bag mask deliver
oxygenation
2. observe chest wall rises
3. gastric sound: gargling sound indicate of the ETT in
esophagus exhaled CO2 detectors devices
Purpose of defibrillations : to return spontaneous rhythmand maintain spontaneous perused rhythm
After defibrillation in the first minute the rhythm
spontaneously slowing and no create pulses so must
immediate initiate CPR cycle after defibrillation
Agonal gap it is a gap in the first minute after sudden
cardiac arrest (no responses, no pulses)
May used DC shock monphasic or biphasic or
AED(automated external defibrillators) if the DC shockmachine not known monphasic or biphasic used 200 j
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Monphasic start with 360j and biphasic constant used of
200j
VF and pulseless VTConsidered victims who unresponsive to BLS and no
responsive to the first shock
Drugs used in VF and VT vasopressin, epinephrine,
amidrone, lidocain, magnesium sulfate
VF and VT algorithm include
1. shockable : VT, VF
2. non shock able : PEA and a systole
algorithm start by BLS and call helpful team
Shockable rhythm (VT, VF)
1. shock : DC shock or defibrillators as protocol
2. immediate 5 cycle CPR and still CPR until
defibrillation is charge
3. give other one shock and perform 5 cycle CPR
4. give vasopressin and epinephrine as protocol
5. shock and 5 cycle CPR performed immediate andcheck rhythm
6. used anti arrhythmias drugs as amidrone, lidocain or
magnesium sulfate if torsad de pointes
7. then perform 5 cycle CPR
8. repeated if still VT or VF
9. move to other algorithm if change rhythm
Non shockable rhythm (PEA and a systole)
1. 5 cycle CPR
2. vasopressin and epinephrine as protocol
3. considered atropine
4. 5 cycle CPR and check rhythm
5. if still repeated same algorithm but if change used the
other algorithm depend on the new rhythm strip
produced
during CPR management H's, and T's
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the recommendation of shockable is 3 times
non shockable rhythm the QRS are narrowed and regular
if temperature less than 30 and patient with VF or VT
used hypothermia algorithm (rewarming procedure) theninitiate CPR because temperature 30 make unresponsive
body to drugs or pacing or defibrillation
drug given must followed by 20 cc fluid and rise hand for
10-20 second to facilitate delivery of drugs
hypovolemia is the most causes of PEA causes narrow
QRS and sinus tachycardia
causes of hypovolemia
1. hemorrhage, pulmonary embolism, cardiac
tamponade, ischemia
2. peripheral vascular dilation and myocardial
dysfunction after given over weighted drugs
if you face unclear situation as fine VF or asystole
differentiations considered fine VF is a prolong arrest so
must initiate 5 cycle CPR then can judged what is therhythm
asystole CPR continued 20 minute out side asystole no
need CRP if you witness a systole can perform CPR
immediate
Drugs of VF, VT
Vasopressin
Given IV\IO or in ETT
Vasopressin given as first or second dose not given as
third or more associated with epinephrine
Non adregenic peripheral vasoconstrictions
Epinephrine
Given in dose I mg and repeated it q 3- 5 min
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Alpha adregenic : effect to make vasoconstrictions of
cerebral and coronary artery to increase MAP and aortic
pressure
Amidrone:
Antiarrhythmia drugs used when patient un responsive to
shock
Affect of Na, K, Ca channel and considered alpha and
beta adregenic blocker
During CPR given 300 mg then 150 mg repeated every 3-5
min
Maximum amount of amidrone 2.2 gm\24 hr with
recurrent VF\ or VT based on cumulative toxicity
Recurrent VF\VT prescribed given amidrone as the
following
1. 150 mg in 10\min (bolus dose)
2. 360mg\nex 6 hr (1mg\min)and slow infusion
3. 540mg \18 hr (0.5 mg\min) as maintenance dose
During amidrone given observe hypotension, bradycardia,
GI toxicityLidocain
Antiarrhythmia drugs used if amidrone is not available
During CPR given 1-1.5 mg\kg first dose then 0.5-0.75
mg\kg (3 dose) repeated every 5-10 minute
The maximum dose of lidocain 3 mg\kg
Lidocain followed 1-4 mg\min after CPR
Magnesium sulfate
Used for patient with torsad de pointes and prolongation
of QT interval or patient with severe low magnesium level
Given in dose 1-2 gm diluted in 10 ml D5w need (5-20
minute)
Atropine
IV \IO or ETT given 1 mg every (3-5 min) and give just 3
doses
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Bradycardia
Bradydisarrhythmia : arrhythmia disorders with heart
rate less than 60 bpm, may found 40-50 bpm in athletes
persons
Bradycardia with escape rhythm : bradycardia dependant
of ventricle rhythm but considered normal myocardial
function but with abnormal conduction
Functional or relative bradycardia : heart rate 70 bpm in
case as cardiogenic shock or septic shock
Rhythm of bradycardia: sinus bradycardia, first \second
(1, 2)\ third heart block.
Complete heart block considered collapse and need TCP
Drug of bradycardia : atropine, dopamine(infusion),
epinephrine (infusion)
Symptoms of bradycardia
Chest discomfort and angina pain and SOB Decrease level of consciousness
H's Indicators Treatment
Hypovolemia Narrow complex,
rapid rate, flat
jugular vein
Volume infusion
Hypoxia Slow rate,
cyanosis, ABG
Oxygenation
Hydrogen ions
(acidosis)
DM, renal failure,
small amplitude
QRS complex
Sodium
bicarbonate
Hyperkalmeia T wave taller,
smaller p wave,
QRS wide, RF,DM, dialysis
glucose pulse
insulin, calcium
chloride, Sodiumbicarbonate,
dialysis
Hypokalemia U wave in ECG
QT prolong , QRS
wide
Infusion
potassium, added
magnesium
Hypothermia J or Osborn wave
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Dizziness, syncope, lighteners
Weakness, fatigue
Sing of bradycardia
Orthostatic BP
Diaphoresis
Pulmonary edema, CHF, PVC
Management of bradycardia
1. BLS primary survey and ACLS secondary survey
include:
A: maintain airway potency
B: give patient oxygen and monitor oxygen saturationC: IV access, ECG, Vitals sings
D: conduct with the problem and search with
contributing factors
2. If poor perfusion must prepare TCP(transcoetaneous
pacemaker ),
Sins and symptoms of poor perfusion: altered mental status,
hypotension, chest pain, and sings of shock.
3. if patient with adequate perfusion still monitored and
observation
4. if patient with poor perfusion must initiate the following
prepare TCP
give patient atropine as protocol of bradycardia
give patient epinephrine and dopamine as protocol of
bradycardia
5. treat causes under H's and T's and provide consultation
Transcoetaneous pacemaker (TCP)
TCP produce electrical depolarization and cardiac
contraction and impulses, it is also contain defibrillators
When apply TCP confirm it is mechanical and electrical
capture
Patient with hemodynamic instability and AV block type
2 and 3 with wide QRS complex must considered TCPimmediately.
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Ischemic patient should not increase heart rate in TCP to
not increase demand of oxygen and increase size of
ischemia and infarctions
Indication of TCP
1. Hemodynamic instability with bradycardia
(hypotension, altered mental status, angina, pulmonary
edema).
2. Sinus bradycardia, AV blocks, AMI. RBBB, LBBB
3. bradycardia with ventricular escape rhythm
4. tachycardia caused by drugs therapy or cardioversion to
organized heart rate
Contraindication of TCP
1.hypothermia, asystole
2.conscious patient until delay sedation( benzodiazepines,
analgesic)
3.carotid pulse not assess for patient with TCP because
TCP produce jerky movement and produce mimic
carotid pulse activity
When must used TCP
if ineffective atropine
patient become more symptomatic
IV access not quickly established
TCP technique
Connect the electrical way to machine and connect
electrode (one way toward patient and one toward themachine
Turn on
Put mood fixed(async) or demand(sync)
Select heart rate (60 bpm) or as order
Set cardiac output until capture occurs
Drugs for bradycardia
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Atropine:
Atropine is the first line given for symptomatic
bradycardia but also then can initiate TCP and other drugs
in atropine not respond
Atropine given in dose 0.5 mg until prepare TCP
If TCP ineffective can given atropine according (0.04*KG)
with maximum dose 3 mg
Atropine not give for patient with ischemia because it is
increase oxygen demand by increase heart rate and increase
ischemia and increase area of infarction
EpinephrineIf TCP is ineffective use Dose 2-10 mic\min
Dopamine
Dopamine alpha and beta adregenic action and can be
added to epinephrine or given alone
If TCP is ineffective use dose 2-10 mic\min (Chroutropic
or heart dose)
Pulmonary edema
1.assess BP and insert IV access and foleys catheter
2.give patient
morphine, oxygen, nitroglycerin, lasix
nitrocin given in dose 10-20 mic\min IV if systolic BP
more than 100mm.hg
dopamine or dobutamin to enhance pump action (2\10mic\min) IV
norepinephrine 0.5-3 mic\min IV
Hypothermia cases
Hypothermia patient who is temperature less then 36
1.remove wet garment
2.protect against heat lost and chills by use isolating blanket
3.put patient in horizontal position4.avoid rough movement and excess activity
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5.monitor cardiac rhythm, core temperature, responsive,
breath
If patient breathe and pulse present management as the
following:
1.mild hypothermia( T between 34-36 )
passive rewarming
active external rewarming: hot fluid, hot blanket)
2.moderate hypothermia (T between 30-34 )
passive rewarming
active external rewarming of the truncal area (trunk)
3.sever hypothermia (T
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Tachyarrhythmia : rhythm of the heart rate more than
100 bpm symptomatic or asymptomatic
Tachycardia may be considered stable or unstable
Tachycardia lead to decrease cardiac output and lead toCHF and pulmonary edema, and decrease blood flow to vital
organs
Rhythm of unstable tachycardia: atrial fibrillation, atrial
flutter, subraventricular tachycardia (SVT), monomorphic
VT, polymorphic VT and wide QRS complex tachycardia
with uncertain type.
Drugs used in case of unstable tachycardia: cardioversion,
sedationSymptoms of unstable tachycardia:
SOB, chest pain
Altered mental status
Weakness, fatigue
Fainting( pre syncope), syncope
Sins of unstable tachycardia
Hemodynamic instability (hypotension and sings
of shock)
Hypotension
Ischemia in ECG
PE and CHF
Poor peripheral perfusion manifested by: altered
mental status, cold extremities, decrease urine output
Management of unstable tachycardia:
1.maintain BLS and ACLS as the following
A: airway patent
B: give oxygen and suction and measure oxygen
saturation
C: vital sings, ECG, IV access
2.observe sings and symptoms of unstable tachycardia as the
following (altered mental status, hypotension, sings of shock,
syncope, fainting)
3.prepare cardioversion immediate( no choice)and
considered sedation
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4.some times patient with unstable tachycardia and wide
QRS complex as a complex situations so must considered as
case of VT
Stable tachycardia
Heart rate exceed 100 bpm and not exceed 180 bpm as
sinus tachycardia , also if heart rate 120-130 bpm when
patient rest
Sinus tachycardia considered physiological condition
increased by fever, blood loss, exercise
Drugs of stable tachycardia is adenosine and may used
Antiarrhythmia drugsManagement of stable
Management of stable tachycardia:
1.maintain BLS and ACLS as the following
A: airway patent
B: give oxygen and suction and measure oxygensaturation
C: vital sings, ECG, IV access
2.management as classification of stable tachycardia
A.stable with narrow QRS complex and regular HR
(QRS narrow
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If not conversion give patient 12 mg adenosine
(third dose) bolus dose with 20 cc normal saline and
rise the head and wait 2 minute)
If patient become unstable prepare immediatecardioversion
If patient conversion
It is probable to reentry SVT : treated with
adenosine or long AV bloke agent as diltazm or Beta
blocker
If patient not conversion
Possible to convert to atrial flutter , ectopic atrial
tachycardia, or junctional tachycardia can initiatedby long AV blocker as diltazm and B-blockers drugs
AV blocker not given to patient with CHF, PE
Then provide expert consultation
B.stable with narrow QRS complex and irregular HR(QRS narrow0.12 second)
As monomorphic VT or uncertain rhythm used
amidrone (150mg in 10 minute) and can repeat it
until maximum dose 2,2 g\day
Prepare elective cardioversion
If SVT occurs prepare adenosine
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If patient become unstable prepare immediate
cardioversion
D.stable with wide QRS complex and irregular HR
(QRS wide >0.12 second)As AF and WPW or polymorphic VT
Expert consultation
Avoid AV node blocker (adenosine, digoxine,
verpamil, diltazm
Considered amidrone
If torsades de pointes considered magnesium sulfate
(1-2 g in 5-60 min infusion
If patient become unstable prepare immediatecardioversion
Cardioversion and defibrillations
Not recommended in case junctional tachycardia, MAT,
ectopic because it is rising the depolarization and increase
rate
Mode of defibrillation is tow type
1. synchronized : used sensors
to deliver shock synchronized with QRS complex by
press sync bottom given in low energy
2. Asyncronized : shock deliver
any where In cardiac cycle but must given in high
energyAs case of polymorphic VT and VF or accelerate
tachycardia the sensors can not select QRS complex in
cardiac cycle so can not delivers cardioversion.
Indication of cardioversion:
1. Sinus tachycardia: physiological effect as responses to
extrinsic factors that need to increase CO, as person
with high sympathetic tones and high neural activity,
exercise
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2. atrial flutter : ( if person with heart rate 150 bpm and
under Antiarrhythmia drugs and complain of systemic
cardiac disease considered stable)
3. heart rate >150 bpm and unstable hemodynamic
4. patient seriously ill with cardiac disease and lower
heart rate
increase ventricular rate than 150 bpm not considered to
cardioversion
paddle can not used for synchronized just for monitoring
and fibrillation (not used in same time monitor and
cardioversion)
patient treat by cardioversion in the following cases1. patient with stable tachycardia with wide QRS complex
and regular rhythm
2. patient with unstable tachycardia with pulses
when patient become unstable initiate cardioversion as the
following(synchronized)
1. atrial fibrillation , SVT, monomorphic VT start at
100j-200j-300j-360j in monphasic
2. atrial flutter: start at 50j-100j-200j-300j-360j
in case of polymorphic VT and VF initiate defibrillations
Drugs of stable tachycardia
Adenosine
given in 3 doses 6g-12mg-12mg
Adenosine given and must followed by 20 ml directlynormal saline and rise the hand for 20 second
Adenosine not used to block AV and terminate
approximately 90% of reentry arrhythmia within 2 minutes
Adenosine not terminate atrial fibrillation and atrial
flutter but blocks AV conductions
Adenosine interaction with other drugs if given in large
dose as caffeine, theobromide, and theophillin
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Addsenosine start with 3 mg as minimal dose if patient
under treatment drugs as ( dipyrimadole or carbamazepine)
or patient with heart transplantation
Contraindication of adenosine :1.wide QRS complex
2.patient with airway disease( cause bronchial spasm)
Acute stroke cases
stroke : a general term refer to acute neurotically
impairment follow interruptions of blood supply to a
specific area in brain
type of stroke1. ischemic stroke : 85% of total case of stroke caused by
occlusion of an artery region in brains
2. hemorrhagic stroke : 15% of total cases where blood
vessels rupture into surrounding tissue hemorrhage
patient with hypertension or with atrial fibrillation
considered high risk and can not monitored sings of stroke
ECG is not take apriority over obtaining CT scan but
ECG can give resent MI or atrial fibrillation which may
lead to stroke
Do not delay CT because ECG just you can perform 12
ECG until CT is prepared
Drugs of stroke:
1. fibrinolytic therapy (tPA): tissue palsmogen activators
2. glucose50
3. labetol
4. nitropursside
5. nicardipine
6. aspirin
the main purpose of fibrinolytic therapy is reperfusion
acute ischemia (minimize brain injury and maximize patient
recovery)
diagnosis and treatment of stoke depend on 7 D's as thefollowing
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1. detection : onset sings and symptoms of stroke
2. dispatch of EMS
3. delivery: advanced pre hospitals notification
4. door : urgent triage in ED
5. data : computed tomography (CT) initiated
6. decision : treatment of fibrinolytic or not
7. during administration drugs and monitoring
period of assessment and management
1. 10 min :immediate general assessment in and order CT
2. 25 min :neurological assessment CT
3. 45 min :interpretation CT
4. 60min: administer fibrinolytic therapy after hospital
treatment and assessment
5. 3hr: treatment of fibrinolytic therapy after sings onset
appears
Algorithm of stroke:
1.identify the possible sings and symptoms:
sudden weakness and numbness in face, arm, leg in one
side
sudden confusiontrouble spelling or understanding
sudden trouble seeing in one or both eyes
sudden trouble walking
dizziness, loss balance and coordination
sever head ache without unknown causes
2.clinical assessment :
support ABC
give oxygen (maintain oxygen >92% to prevent
hypoxemia and increase ischemia brain injury
established timing
check glucose
alert hospital and bring witness from family or caregiver
clinical assessment depend on:
1. Cincinnati assessment
Dropped : ask patient to observe teeth or smile
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Arm weakness : ask patient to close eyes and
hold both arms out
Abnormal speech : ask patient to speak and
observe slurred or not2. Los Angeles assessment : ask about :
Age>45
History of seizure or epilepsy
Symptoms duration
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if no contraindication given , in have contraindication
give patient aspirin
do not give patient anticoagulant or antiplatelet before
24 hr until if fibrinolytic contraindicationif hemorrhagic stroke
consultation neurosurgery or transfer to other
hospitals
admit to the stroke unit and observe glucose level,
blood pressure , neurological status
Hypertension management:
1.systole >220 and diastole >121-140
able to reduction BP 10-15% of total BP
labetol 10-20 mg IV for 1-2 min and can be repeated to
maximum dose 300 mg
Nicardipine 5 mg\hr infusion (start at 2,5mg\hr and
repeated every 5 min until maximum dose 15mg\hr
2.diastole >140
Able to reduction BP 10-15% of total BP
Nitropursside 0.5 mic\min IV infusion with continuousmonitor BP
Care in intensive care unit:
1.support airway , oxygen, ventilation, nutrition
2.avoid GW fluid infusion
3.give patient 70-100 ml\hr normal saline
4.monitor hyperglycemia >200
5.treat fever ( Acetaminophen)
Fibrinolytic therapy:
tPA is given within 3 hr of onset symptoms
major complication of tPA is intracranial hemorrhage,
andioedema, transient hypotension
may be considered IV therapy or intra arterial therapy if
IV therapy have contraindication
tPA checklist
Inclusion criteria ( mean yes given)
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age > 18
clinically diagnosed stroke
time of onset symptoms 185\110
Aneurysm, neoplasm, male formation in arteriovenous
systemSeizure
Active internal bleeding or acute trauma
Acute bleeding disorder as ( platelet 1,7 or PT > 15
second
Intracranial or intraspinal surgery or serious head
trauma within 3 months
Relative exclusion criteria
Surgery within 14 days
GI or urinary bleeding
AMI within 3 months
Glucose level 400
Recommended