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return of spontaneous circulation
First step in assessment of pt?
first determine if pt is conscious
- conscious - do ACLS survey
- unconscious - do BLS survey then ACLS survey
Deliver each rescue breath over ___ second(s).
Indication breaths are effective?
Steps of BLS survey?
- Make sure scene is safe
- 1. "Are you OK?" & look for breathing
- 2. Activate emergency response system/get AED or send someone
- 3. Circulation - check carotid pulse for <10 seconds & start CPR if no pulse. If there is a pulse start rescue breaths.
- 4. Defibrillation - If no pulse, check for shockable rhythm as soon as defibrillater arrives. Provide shocks as indicated then resume CPR.
Compress at _____ compressions per minute at a depth of at least ____ inches.
Interruptions in compression should be ___ seconds or less.
Switch breaths/compressors every ____ minutes.
Rescue breaths should be given every ____ seconds/_____ breaths per minute. Pulse should be checked every ____ minutes.
5 - 6 seconds / 10-12 breaths per minute
ACLS survey steps?
- 1. airway
- 2. breathing
- 3. circulation
- 4. differential diagnosis
- 1. is airway patent
- 2. advanced airway indicated?
- 3. advanced airway secured & placement reconfirmed frequently?
Ways to maintain patent airway?
- 1. head-tilt-chin lift
- 2. oropharyngeal airway (OPA)
- 3. nasopharyngeal airway - NPA
- 4. advanced airway - ET tube, other
Check and monitor placement of ET tube?
- 1. are ventilation & oxygenation adequate?
- 2. are quantitative & oxyhemoglobin saturation monitored?
How much O2 should be given?
cardiac arrest -100% O2
others- titrate for O2 sat >/= 94%
3 ways to monitor adequacy of ventilation & oxygenation?
- 1. chest rise & cyanosis
- 2. waveform capnography
- 3. O2 sat
- 1. effective compressions? - monitor
- 2. cardiac rhythm? - attach defib
- 3. defib/cardioversion indicated? - use prn
- 4. IV/IO access - establish access
- 5. ROSC? -
- 6. pulse but unstable?
- 7. meds needed for BP or rhythm? - give prn
- 8. need volume replacement? - give prn
2 indications CPR quality is not good?
1 waveform capnography PETCO2 is <10mmHg
2. intra-arterial pressure/diastolic pressure <20mmHg
partial pressure of CO2 in exhaled air at the end of exhalation phase
Differential diagnosis phase of ACLS?
why pt developed s/s or arrest & is there a reversible cause that can be TX
make sure everything done at right time & monitor performance of team members
Closed loop communications?
- 1. give msg or order
- 2. confirm msg received by clear response & eye contact
- 3. don't give new tasks until receive confirmation of first task given
METs & RRT's
MET - medical emergency team
RRT - rapid response team
When is therapeutic hypothermia indicated and how is it done?
- 1. comatose adult pt with ROSC after out of hospital VF cardiac arrest
- 2. consider for comatose adult pt with
- ROSC after in-hospital cardiac arrest of any initial rhythm of out of hospital with intitial rhythm of PEA or asystole
cool pt to 32 to 34 degrees C (89.6 - 93.2 F)
O2 after resusitation?
titrate to lowest level required to have O2 sat of >/= 94%
Ventilations may be titrated to acheive PETCO of ______ or PaCO2 of _____.
Goal for BP after cardiac arrest?
mean arterial pressure >/= 65 mmHg
Intervention that may be done for coronary cause of cardiac arrest?
PCI - coronary reperfusion
Goal BS for ROSC pt?
144 - 180
acute coronary syndrome
ED protocols for ACS?
- 1.activation of cardiac cath lab
- 2. Admission to coronary ICU
S/S of respiratory arrest?
- 1. unconscious, unresponsive
- 2. respirations absent or inadequate
- 3. Pulse is presentj
BLS then ACLS
BLS survey of respiratory arrest pt?
- 1. pt has a pulse - no compressions or defib
- 2. no/inadequate respirations
- 3. unconscious/unresponsive
- 4. need to assess & reassess for changes - may need to start CPR later
Tx of respiratory arrest?
- 1. give rescue breaths 1 q 5-6 seconds / 10-12 per minute
- 2. Recheck pulse about q2min - tk at least 5 sec but less than 10
- 1. consider advanced airway
- 2. admin O2 for 94% O2 sat or up
- 3. Monitor for chest rise and fall, waveform capnography, & O2 sat
- 4. other ACLS survey actions
- 5. may require OPA & NPA or suctioning
Ventilations with an advanced airway?
1 ventilation q 6-8sec (8-10 breaths/min)
Most reliable method of confirming & monitoring correct placement of an ET tube?
What to do if pt in resp arrest & known to be choking?
open mouth & look for object & remove with fingers if possible
When are OPA's used?
never used in conscious pt - must be pt without a gag reflex
- 1. during respirations
- 2. during suctioning
- 3. pt with ET tube
How to insert OPA?
- 1. get correct size - from corner of mouth to curve of jaw
- 2. insert
When are NPA's used?
pt with cough or gag reflex/ conscious or semi-consciuos pt
pt that cannot have OPA
- 1. size: look at circumference of nostrils - from tip of nose to earlobe
- 2. Lubricate with water-soluble lubricant or anesthetic
- 3. Insert through nostril - resistance: rotate and/or attempt other nostril
When should NPA not be used?
give 100% O2 before and after and suction <10 sec
Monitoring during suctioning?
- 1. HR
- 2. O2 sat
- 3. clinical appearance
Stop suctioning if bradycardia occurs, O2 sat drops, or clinical appearance deteriorates
Precautions for possible spinal injury?
- 1. jaw thrust
- 2. manual stabilization of cervical spine
- 3. mobilization devices during transport
Lone rescuer BLS with AED for Vfib & pulseless Vtach?
- 1. Check responsiveness & breathing
- 2. Activate emergency response
- 3. Check for pulse for 5-10 seconds
- - no pulse -> start compressions
- - pulse -> rescue breath q5-6 seconds
- 4. Defib as soon as AED available
- - shock or not then resume CPR & recheck rhythm q2min
Criteria for using AED?
- 1. no response
- 2. absent or abnormal breathing
- 3. no pulse
Steps of operating AED?
- 1. Power on
- 2. Attach electrodes - wipe off sweat/liquids,
- - 1 pad on upper-right side of chest below clavicle & other to left of nipple with top margin of pad below left armpit
- 3. Analyze rhythm & shock prn