This document provides information on cardiovascular emergencies and procedures for manual defibrillation, cardioversion, artificial pacemakers, and cardiac arrest treatment algorithms. It discusses defibrillation, synchronized cardioversion, manual vs automated defibrillation, safety measures, energy levels, and indications. Cardiac arrest treatment involves assessing CABs, starting CPR, attaching an AED/defibrillator, analyzing rhythms, delivering shocks if indicated, administering medications, and considering termination of resuscitation or transport depending on the patient's condition and response to treatment.
3. • Defibrillation
• Surge of electric energy is delivered to
the heart
• Current depolarizes hearts muscle cells.
• When cells repolarize after the shock,
they should respond to an impulse from
SA node.
• Needs to be done as soon as possible
for:
• Ventricular fibrillation
• Pulseless ventricular tachycardia
• Not useful in asystole
4. • Manual defibrillation
• Automated external defibrillator (AED): interprets cardiac rhythm
• Manual defibrillation: paramedic interprets cardiac rhythm
• Switch an AED to manual mode when:
• All electrical therapy functions are needed.
• Patient is in cardiac arrest.
5. • Manual defibrillation (cont’d)
• Follow safety measures.
• Make sure no one is touching the patient.
• Do not defibrillate a patient in pooled water.
• Do not defibrillate a patient who is touching metal.
• If implanted pacemaker or internal defibrillator, place the pad below, or in anterior and
posterior positions.
6. • To perform manual defibrillation:
• Attach pads to the patient’s chest.
• Dry the chest if necessary.
• Check the instructions.
• Set energy level to 200 J.
• Charge the defibrillator.
• Apply a conductive gel and apply pressure.
7. • To perform manual defibrillation (cont’d):
• Follow recommended placement.
• Position the negative pad right of the upper part of the sternum and the
positive pad just below.
• Clear the area.
• Discharge the defibrillator.
8. • To perform manual defibrillation (cont’d):
• Contraction of the chest will be evident.
• Resume CPR immediately and continue for
2 minutes/5 cycles before checking pulse.
• If the rhythm does not require a shock and there is a pulse, check the
breathing.
10. • Patients who do not regain a pulse on the scene usually do not
survive.
• Transport when one of the following occurs:
• The patient regains a pulse.
• Six to nine shocks have been delivered.
• Defibrillator gives three consecutive messages that no shock is advised.
11. • Automated external defibrillator (AED)
• Charge pads and deliver countershocks.
• Semiautomated AED prompts rescuer.
• If you witness cardiac arrest, attach AED as soon as available.
• If not witnessed, perform five cycles of CPR first.
12. • AED (cont’d)
• After AED protocol:
• Pulse is regained
• No pulse regained and AED indicates no shock
• No pulse regained and AED indicates shock is advised
13. • Cardiac arrest during transport
• If pulse is not present:
• Stop vehicle.
• If defibrillator is not ready, perform CPR.
• Analyze the rhythm.
• Deliver one shock and resume CPR.
• Continue resuscitation.
14. • Cardiac arrest during transport (cont’d)
• If adult patient loses consciousness:
• Check for a pulse.
• Stop the vehicle.
• If defibrillator is not ready, perform CPR.
• Analyze the rhythm.
• Deliver one shock and resume CPR.
• Continue resuscitation.
15. • Synchronized cardioversion: use of the defibrillator to terminate
hemodynamically unstable tachydysrhythmias.
• Involves energy delivery at peak of R wave
• Increases probability of depolarizing myocytes
• Allows SA to resume pacemaker function
16. • Synchronized cardioversion (cont’d)
• Performed just as defibrillation except the user selects the synchronize setting
first.
• Done only with severely impaired CO
• When done on a conscious patient, he or she must be sedated.
17. • Artificial pacemakers deliver
repetitive electric currents to the
heart.
• Passes through the skin across the
heart
• Pacer is set for a specific rate
• Energy is increased until heart
responds
18. • Several applications in prehospital care:
• Interhospital transfer needing pacemaker implantation
• Artificial pacemaker failure
• Bradydysrhythmias or blocks associated with severely reduced CO
19. • Must increase heart rate and improve CO.
• Support airway and breathing, then:
• Establish IV line with normal saline.
• Administer atropine.
• If no response to atropine, begin TCP immediately.
• If unsuccessful, consider a sympathomimetic drug.
• Transport to a hospital.
20.
21. • Decide on seriousness of symptoms.
• Unstable tachycardia:
• Chest pain
• Dyspnea
• Hypotension
• Altered mental status
22. • Decide if signs and symptoms indicate tachycardia or another
condition.
• Rates of 150 beats/min rarely cause serious signs of tachycardia.
• Slowing heart rate of patient compensating for a medical condition may be
fatal.
23. • If unstable signs and symptoms result from tachycardia, cardioversion
is needed.
• If signs and symptoms are mild, slower but safer treatment is
recommended.
• Determine origin or pacemaker site of rhythm.
25. • Never massage
both carotid
arteries
simultaneously.
• May cause
significant
bradycardia or
asystole
26. • Consider patient’s history.
• Patients at risk of thromboembolism include:
• Advanced age
• Coronary artery disease
• High cholesterol
• If successful, transport anyway.
27. • Administer adenosine.
• 6 mg, by rapid IV push
• Insert syringe of adenosine and syringe of at least 20 mL of normal saline
solution.
• Be prepared for a short run of asystole.
28. • Administer adenosine (cont’d).
• If first dose is unsuccessful, administer again.
• If still unsuccessful, transport immediately.
• If patient becomes unstable, move to cardioversion algorithm.
• If the rhythm is ventricular and patient is stable, transport to the hospital.
29.
30. • Warnings of cardiac arrest:
• Atherosclerosis
• Underlying cardiac disease
• Electrocution, drowning, or other trauma
• Cardiac arrest management requires a systematic approach that is
rehearsed.
31. • CPR should now be initiated prior to airway and breathing
assessment.
• Concentrate on high-quality compressions.
• Avoid excessive volume and inflation pressure.
• Keep compressions smooth, regular, and uninterrupted.
32. • Maintain compression for
at least half the
compression-release cycle.
• Avoid jerky compressions.
• Keep shoulders over
patient’s sternum, keep
elbows straight.
• Maintain proper hand
position.
• Rotate compressors every
2 minutes.
33. • Single rescuer: give 30 compressions and
2 ventilations at rate of at least 100 per minute.
• Do not interrupt CPR compressions except for:
• Advanced airway placement
• Defibrillation
• Moving the patient
• Do not stop for more than 10 seconds.
34. • Minimally interrupted
chest compression
• Use of adjunctive
equipment
• Cardiac monitoring for
dysrhythmia
• Establishment and
maintenance of IV
• Use of definitive therapy
to:
• Prevent cardiac arrest
• Establish an effective
cardiac rhythm and
circulation.
• Stabilize patient’s condition.
35. • Administer hypothermia therapy for patients in a coma after return of
spontaneous circulation.
• Transport to an appropriate facility.
• Monitor closely.
36. • As you approach the scene, bring:
• Defibrillator
• Portable oxygen cylinder
• Jump kit with airway management equipment
• Intubation kit
• IV equipment
• Drug box
• If alone, do not take time to carry everything.
37. • Assess circulation.
• If no pulse, start CPR.
• Second paramedic should
attach defibrillator.
• After 2 minutes, proceed.
• Assess responsiveness.
• If not responsive:
• Open airway and assess
breathing.
• If not breathing:
• Give two slow breaths
using a bag-mask or
barrier device.
38. • Check pulse and rhythm on
monitor.
• If ventricular fibrillation or
tachycardia is present:
• Follow algorithm.
• If not present, resume CPR.
• If still in cardiac arrest, may
be:
• Ventricular fibrillation or
tachycardia
• PEA
• Asystole
39.
40. • Address CAB issues.
• Begin CPR and attach
defibrillator.
• Confirm ventricular
fibrillation or tachycardia.
• Confirm absence of pulse.
• Resume CPR.
• Clear patient and then
defibrillate.
• Biphasic: 120 to 200 J
• Monophasic: 360 J
• Resume CPR after
discharge.
41. • On monitor:
• Identify rhythm.
• No pulse: move to asystole-
PEA pathway.
• Pulse: move to appropriate
algorithm.
• If ventricular fibrillation or
tachycardia: resume CPR.
• Clear the patient, then
defibrillate.
• Resume CPR.
• Insert advanced airway if
airway is not adequate.
42. • Start IV line.
• If unable, establish IO
access until IV is
established.
• Administer a vasopressor
drug.
• Epinephrine
• Vasopressin
• At end of 2 minutes of CPR,
check for circulation and
rhythm.
• If ventricular fibrillation or
tachycardia, resume CPR.
• Clear the patient, then
defibrillate.
43. • Resume CPR for 2 minutes.
• Consider an
antidysrhythmic
medication.
• After CPR, check for
circulation and rhythm on
monitor.
• If ventricular fibrillation or
tachycardia:
• Resume CPR.
• Clear patient and
defibrillate.
• Resume CPR for 2 minutes.
• If still present, consider
transport.
44.
45. • If spontaneous circulation returns:
• Assess vital signs.
• Support airway and breathing, as necessary.
• Provide medications as indicated.
• Consider hypothermia protocol and transport to appropriate center.
46. • Organized cardiac rhythm not accompanied by a detectable pulse
• Heart beat so weak from:
• Cardiogenic or hypovolemic shock
• Cardiac tamponade
• Massive pulmonary embolism
• Electrolyte imbalance disturbances
• Drug overdose
47. • Resume CPR.
• Insert an advanced airway
if airway is not adequate.
• Start an IV line.
• If access cannot be
established, consider IO
access.
• Administer a vasopressor
drug.
• At end of CPR, check
circulation and rhythm.
• If PEA still present:
• Continue CPR.
• Search for causes.
48. • Flat line may or may not be asystole.
• Rule out other causes:
• Leads not attached to patient or monitor
• Incorrect monitor setting
• Very-low-voltage ventricular fibrillation
• True asystole
49. • Resume CPR.
• Check for other causes of
flat line.
• Switch to another lead to
detect low-voltage
fibrillation.
• Insert an advanced airway
if airway is not adequate.
• Start an IV line.
• If unable to establish,
consider IO access.
• Administer a vasopressor
drug.
• Epinephrine
• Vasopressin
50. • At end of 2 minutes of CPR,
check for circulation and
rhythm.
• If asystole is still present:
• Resume CPR.
• Search for/treat possible
causes.
• Consider termination of
resuscitation.
51. • Heart rate should be stabilized.
• Stabilize cardiac rhythm.
• If ventricular fibrillation or ventricular tachycardia, consider antidysrhythmic
drug.
• If severe bradycardia, atropine or TCP may be necessary.
52. • Lessen effects on the brain:
• Correct marked hypotension.
• Avoid tracheal suctioning in an intubated patient.
• Consider elevating the patient’s head.
• If effective rhythm is restored, transport.
• If comatose, begin hypothermia treatment.
53. • In the past, once CPR was started, it had to continue until a physician
pronounced death.
• In some jurisdictions, pronouncement of death may be permitted by a
paramedic.
54. • Coronary artery disease (CAD) is the most common form of heart
disease.
• If coronary arteries are blocked, cardiac muscle will be deprived of
oxygen (ischemia).
• If not restored, area will die (undergo infarction).
55. • Atherosclerosis
• Affects inner lining of aorta and cerebral and coronary blood vessels
• Leads to narrowing and blood flow reduction
• Area provides a locus for the formation of a fixed blood clot (thrombus)
• May cause arteriorsclerosis